Family Planning

on Wheels
By: Kaylee Blankenship, Alyssa Cardinal, LeAnna
Ceglia, Maggie Fabry & Noel Silveira

Background
What is the concern?
Ecuador has highest adolescent
fertility rate among Latin American
countries, and one of the highest
rates worldwide.
20% of Ecuadorian women age 15
to 19 will get pregnant before age
20
Although fertility rates have been
declining overall, indigenous
people living in rural areas are still
experiencing high fertility rates
and lack access to reproductive
health services
A

Some of the most common

reasons reported for not using
modern contraceptive methods
were lack of knowledge, fear
of side eects, cost,
misconceptions, and fears.

Background
Why are high rates of unplanned
pregnancy a concern?
Children born to adolescents
in Ecuador are 80% more likely
to die during the rst year of
life
Ospring of adolescents are
at increased risk for abuse and
neglect
Increased likelihood that
mothers will experience
poverty and low
socioeconomic status
M

LITERATURE
REVIEW

Literature Review
The Eect of an Educational
Approach to Pregnancy
Prevention Among High-Risk
Early and Late Adolescents
Researchers sought to use
educational clinic visits as a
means of pregnancy
prevention
The educational approach
used may decrease adolescent
pregnancy among high-risk
adolescents that continue to
use the clinic system
(Yoost, J. Hertweck, S. & Barnet, S.,
2014)
N

Literature Review
Risk Factors for Pregnancy Among
Adolescent Girls in Ecuador's Amazon
Basin: A Case-Control Study
Various risk factors were analyzed for pregnancy
among the population of adolescent girls living in
the Amazon basin of Ecuador
All participants were surveyed on three dierent
categories of risk factors for pregnancy among
adolescent women including socio-demographic
indicators, adverse events during childhood-
adolescence, and sexual and reproductive health
variables
Six factors found to be statistically signicant
(p< 0.05) in adolescent pregnancies included:

sexual abuse during childhood-adolescence

early sexual debut
living in a very poor household
experiencing life periods of a year or longer without a
mother and father
married or being in a union
not being enrolled in school at the time of the
interview

(Goicolea, I., Wul, M., hman, A., & San Sebastian, M., 2009)

Ingapirca, Ecuador- January 2014

Literature Review
Unintended Pregnancy in the
Amazon Basin of Ecuador: A
Multilevel Analysis
This study investigated the eects
of both individual and contextual
factors on unintended pregnancies
in Ecuador (2014)
Signicant risk factors found for
unintended pregnancies included
being single, young, and
indigenous as well as having more
than two children and little access
to education
(Goicolea, I., & San Sebastian, M.,
2014)
L

Literature Review
Women's Reproductive Rights in the
Amazon Basin of Ecuador: Challenges
for Transforming Policy into Practice
The study gathered information and
data on reproductive health factors
such as delivery care, adolescent
pregnancy, and contraception
Women in urban areas had a higher
percentage of planned pregnancies,
modern contraceptive use and skilled
delivery attendance compared to the
women living in rural areas
Indigenous women had the lowest
percentage of planned pregnancies, use
of modern contraceptives, and skilled
delivery attendance

(Goicolea, I., San Sebastin, M. & Wul, M., 2008)

Ingapirca, Ecuador- January 2014

Literature Review
Beyond the Clinic Walls: Empowering Young
People Through Youth Peer Providers
Programmes in Ecuador and Nicaragua
This study evaluated the eectiveness of Youth
Peer Provider programs in Ecuador and Nicaragua
using three evaluations over a seven-year period.
1st survey revealed: 3/4 of respondents were
currently sexually active, 95% of sexually active
individuals were using contraception, and 3/4 of
respondents reported ever having used a condom
with the intention of preventing sexually
transmitted infections (STIs)
2nd and 3rd evaluations revealed: biggest
program impact was an increase in knowledge and
the second most common was personal growth
A signicant number reported that there was an
improvement in their relationships with their
family and friends

(Redwine, D. & Tebbets, C., 2013)

Literature Review
Fertility Beyond the Frontier:
Indigenous Women, Fertility, and
Reproductive Practices in the
Ecuadorian Amazon
Purpose of study was to estimate
fertility rates in Ecuador for rural
indigenous women, analyze
reproductive health intentions and
the use of contraceptives, and
contemplate why fertility rates
remain high among lowland tropic
indigenous populations
The results of this study conrmed
that fertility rates are high and that
the need for dierent types of
contraceptives are unmet

(Bilsborrow, R., Bremmer, J., Feldacker, C., & Lu

Holt, F., 2009)

Ingapirca, Ecuador- January 2014

PROGRAM GOALS
AND OBJECTIVES

PROGRAM GOALS AND

OBJECTIVES
Overall desired impact:
Decrease the prevalence of
unplanned pregnancies in rural
Ecuador by 2% in 5 years
(a reduction from 10% to 8%)

PROJECT GOALS &

OBJECTIVES (contd)
Research has proven that
education and clinic visits
decrease the number of
adolescent pregnancies
(Yoost, 2014)
Lack of clinics in rural
Ecuador
Family Planning on
Wheels will bring the
necessary resources and
education to rural
residents
K

KEY STAKEHOLDERS &

END BENEFICIARIES
STAKEHOLDERS
Registered nurses
Peer support volunteers
Local government ocials

END BENEFICIARIES
Individual adolescents and
families
Health care providers
Local governments economy

Community leaders
Physicians
Potential clients
The key to this programs success heavily depends on client participation.
Without client participation RNs are unable to make home visits,
and the anticipated outcome becomes unattainable.
L

INPUTS

Necessary resource

Role

American Registered Nurses

Train all sta

Ecuadorian Registered Nurses

Provide family planning education

Distribute condoms
Orient volunteers
Make referrals to physicians

Peer Support Volunteers (young adults)

Create a more comfortable

atmosphere for clients to enhance
learning

Contracts with local health care facilities

& physicians

Referrals for extended health care

services regarding family planning
and related health assessments

Pamphlets and reproductive models

Visuals to aid in education and

enhance learning

Vehicles and associated requirements

(insurance, registration, & fuel)

Transportation of sta and supplies

Local clinic brochures and maps

Educate clients on locations of clinics

and services oered

Funds

To cover the costs of all

aforementioned resources

Tebbets and Redwine claim youth who discuss sexual and reproductive health with peers are more
likely to display positive health-seeking behaviours than youth who discuss it with adults (2013).

Expenses

Cost per
unit

Total
One
number of time
unit needed cost

American Nursing Salaries

30,000

140,000

Ecuadorian Nursing Salaries

30,000

20

600,000

Vehicles

10,000

20

Vehicle Insurance

639

20

12,780

Vehicle Registration

114

20

2,280

Fuel Cards

2,000

20

40,000

Additional funds for vehicle

maintenance

$500

20

10,000

Reproductive Models

20

40

Hotels for nurses and volunteers

12,000

20

240,000

Rent for main oce space

$400

4,800

Utilities for main oce space

60

720

Computers

1,000

5,000

Oce printer

200

200

Filing cabinets

100

300

Paper, pens, and ink

1,000

Varies

Folders

300

Multiple

Annual
Cost

200,000

800

X
X

Total yearly
expenses

1,000
300

ACTIVITIES
American nurses will interview
and hire Ecuadorian nurses and
peer support volunteers
Nurses and volunteers will be
trained on:
Program guidelines
How to eectively present family
planning education to rural
communities

Purchase 20 vehicles (in Ecuador)

Purchase insurance, registration,
and fuel cards for vehicles
K

ACTIVITIES (contd)
Community assessment

Visit individual homes

Establish rapport
Provide info about program
Inquire residents interest in program services
Assess family planning needs using questioning, pre-tests
and surveys

Encourage families to spread the word

Meet with local ocials and community
leaders

Establish rapport
Discuss local family planning issues

Teaching plan and schedule created

specic to each rural community and its
needs
Purchase family planning educational
materials- pamphlets and reproductive
models and stock vehicles
N

ACTIVITIES (contd)

Initial visits will begin

Monthly follow up visits will elaborate on the familys

needs

Determine family planning needs and knowledge decits

Distribute general pre-test, post-test, and survey
No > 1 hr

Approximately 30 minutes to one hour

Dierent topic for each visit covering:

Abstinence
Safe sex practices
Proper use of contraceptives
Promotion of self-esteem
Peer pressure avoidance
How to communicate as a family regarding sexual
practices

Distribute pre-tests, post-tests and surveys at each

home visit-- specic to that visits topic

Educate families on location of nearest clinic

Make referrals to physicians if necessary

To evaluate eectiveness of program, continuously

monitor birth rates, pre- and post-test scores and
survey feedback

Research shows that

among indigenous
women, the most
common reasons for
not using modern
contraceptive
methods were lack
of knowledge, fear
of side eects, and
cost [] also
revealed widespread
misconceptions and
fears about negative
impacts of modern
family planning
methods on
womens
health (Bremner,
Bilsborrow,
Feldacker and Holt,
2009).

OUTPUTS
Partnership between program employees,
community leaders, and clientele
Ecuadorian nurses and volunteers equipped
with the necessary skills and knowledge to
educate rural residents on family planning
matters
Teaching topics and itineraries for home visits
will be created and distributed to each sta
member and client
20 vehicles will be purchased, insured,
registered and outtted with supplies

Through the eorts and cohesiveness of this

programs interdisciplinary team,
communication will be improved between
family members and peers, as well as
between clients and sta

EFFECTS
Goal
Increased knowledge of family
planning and contraceptive methods
Enhanced awareness of which
contraceptive method best suits the
clients lifestyle preferences
Increased awareness of facilities that
provide family planning methods and
related healthcare services
Develop progressive attitudes among
rural residents and community leaders
regarding various family planning
methods
Foster open-mindedness of parents
and children toward discussing family
planning and sexual practices in the
home
Prolonged abstinence among
adolescents in rural Ecuador
Increase proper and consistent use of
contraceptives among all sexually
active individuals

Increasing communication between

parents and children regarding sexual
practices and family planning

Time frame Method for evaluation

5 years

Higher scores on post-tests

5 years

Attitudes reected through

survey responses

5 years

Attitudes reected through

survey responses

5 years

Attitudes reected through

survey responses

(continuous)

(continuous)
(continuous)

(continuous)

5 years

(continuous)

Attitudes reected through

survey responses

5 years

Evaluation of rural Ecuadors

birth rates

5 years

Evaluation of rural Ecuadors

birth rates

5 years

Evaluation of rural Ecuadors

birth rates

(bi-annually)
(bi-annually)

(continuous)

ASSUMPTIONS

Adequate number of volunteers

Educational content will be presented consistently
Laws and policies will support the program
Funding will remain secure
All supplies will be delivered without error
Sta competence
N

Clientele and community leaders will be receptive to the

education and care provided

Logic Model

TECHNICAL
APPROACH

TECHNICAL APPROACH

Scheduled to start on January 1st of 2015

11 days for hiring and training 20 Ecuadorian nurses and 20

Ecuadorian peer support volunteers

15 days for purchasing 20 vehicles, insurance, registration, and fuel

cards.

4 weeks to explore rural areas of Ecuador, assess communities, and

establish rapport with community leaders and members

Communicate with community leaders in order to gain support and

understanding will continue throughout the duration of the
program

Select specic communities for initial visits

Develop, change and nalize schedule for community visits

10 days for purchasing and stocking vehicles with educational

materials, condoms, and referral paperwork

5 days for ensuring team is fully prepared for community visits

Home visits will begin Monday, March 16th and continue for the
remainder of the 5 year initiative

Provide education with each visit and referrals as needed

Evaluate eectiveness of program, gather data, and begin to

construct written program evaluation.

Gantt Chart
Family Planning on Wheels
Tasks

Start and End Dates

1/1/15

Conduct interviews for Ecuadorian registered nurses

Hire nurses
Train and educate nurses on goals, plans and routine
Interview and select volunteers
Train and educate volunteers
Select and purchase vehicles
Purchase insurance, registration and fuel cards for all vehicles
Explore rural communities of Ecuador
Evaluate family planning attitudes and knowledge base of communities
Communicate with community leaders (gain support and establish/maintain rapport)
Select communities for initial visits and group according to location
Develop, change and nalize schedule for community home visits
Purchase all materials including condoms, informational pamphlets, referral paperwork, models,
ect
Outt vehicles with supplies and materials
Ensure all materials are ready and orderly. Ensure that volunteers and nurses are ready to begin
work
Conduct rst year of home visits
Provide clients with referrals as needed

Evaluate eectiveness of program/gather data/begin to construct written program evaluation

3/3/15

5/3/15

7/3/15

9/2/15

11/2/15

1/2/16

EVALUATION

EVALUATION
Evaluation Measure
Pre-test at initial visit to establish clients baseline
knowledge of family planning on contraceptive
methods

Pre-test at the start of each visit, specic to that

days educational topic, to determine clients
baseline knowledge

Short answer and multiple choice survey questions

at the end of every visit to allow clients an
opportunity to voice their opinions on the session.
Determines if attitudes regarding contraceptive use
and family planning were changed as a result of the
interventions provided.

Qualitative Quantitative

Post-test distributed at the end of initial visit and

subsequent visits that compares answers to pre-test
and determines eectiveness of teaching

Monitor changes in pregnancy rates from start of

program and biannually throughout the duration of
the 5 year program

EVALUATION

Being raised in an environment with little chance of

social and economic advancement can cause
adolescents to be uneducated about pregnancy and
have unintended pregnancies at a young age
(Yoost et al., 2014)

Education is CRUCIAL to decreasing pregnancy rates in

young populations

Education, especially by peers of similar ages, has been

proven to decrease pregnancy rates in adolescents

This proposal was designed with the intent to

incorporate components that have been proven
eective through extensive research

Family Planning on Wheels was modied to reect this

populations particular culture and inhabitance across
the rural regions of Ecuador

Solution= FAMILY PLANNING ON WHEELS!

CHALLENGES
Finding times to meet
as a whole
Agreeing on the details
of the program
Dividing up the work
load

WHAT WORKED BEST

It worked better when we got together as a group versus
working separately on individual sections
Google Docs
Reviewing/editing each others sections

LESSONS LEARNED
Start sooner rather
than later!
GETTING THE DETAILS
OF THE PROJECT
AGREED UPON BEFORE
STARTING THE
PAPER!!!

Bilsborrow, R., Bremmer, J., Feldacker, C., & Lu Holt, F. (2009). Fertility beyond the frontier: Indigenous
women, fertility, and reproductive practices in the ecuadorian amazon. Population Environment. 30, 93113.
doi:10.1007/s11111-009-0078-0
Department of Health and Human Services, Centers for Disease Control and Prevention (2013). Evaluation
guide: Developing and using a logic model. Retrieved from http://www.cdc.gov/dhdsp/programs/
nhdsp_program/evaluation_guides/docs/logic_model.pdf
Goicolea, I (2010). Adolescent pregnancies in the Amazon Basin of Ecuador: A rights and gender approach to
adolescents sexual and reproductive health. Global Health Action, 3. doi:10.3402/gha.v3i0.5280
Goicolea, I., & San Sebastian, M. (2010). Unintended pregnancy in the amazon basin of ecuador: A
multilevel analysis. International Journal for Equity in Health. 9:14. Retrieved from http://
www.equityhealthj.com/content/9/1/14
Goicolea, I., San Sebastin, M. & Wulff, M. (2008). Women's reproductive rights in the amazon basin of
ecuador: Challenges for transforming policy into practice. Harvard School of Public Health/Franois-Xavier
Bagnoud Center for Health. 10, 91-103. Retrieved from http://www.jstor.org/stable/20460105
Goicolea, I., Wulff, M., hman, A., & San Sebastian, M. (2009). Risk factors for pregnancy among
adolescent girls in Ecuador's Amazon basin: A case-control study. Revista Panamericana De Salud Publica,
26(3), 221-228. Retrieved from http://web.b.ebscohost.com.ezproxy.lib.csustan.edu:2048/ehost/pdfviewer/
pdfviewer?sid=25b3f36e-9372-4a2f-9dd9-562d38fb1596%40sessionmgr112&vid=4&hid=106
Herdman, C. (2008). The impact of early pregnancy and childbearing on adolescent mothers and their
children. Retrieved from http://www.advocatesforyouth.org/publications/publications-a-z/432-the-impact-ofearly-pregnancy-and-childbearing-on-adolescent-mothers-and-their-children.html
Planned Parenthood (2014). Ecuador country program. Retrieved from http://www.plannedparenthood.org/
about-us/planned-parenthood-global/ecuador-country-program.html
Redwine, D. & Tebbets, C. (2013). Beyond the clinic walls: Empowering young people through youth peer
providers programmes in ecuador and nicaragua. RHM Journal. 21, 143-153. doi:10.1016/
S0968-8080(13)41693-2
Yoost, J., Hertweck, S., & Barnet, S. (2014). The effect of an educational approach to pregnancy prevention
among high-risk early and late adolescents. Journal of Adolescent Health. 55, 222-227. doi:10.1016/
j.jadohealth.2014.01.017

References

Any Questions?