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Stud Fam Plann. 2011 June ; 42(2): 67–82.

What works in family planning interventions: A systematic

review of the evidence
Lisa Mwaikambo, MPH1, Ilene S. Speizer, PhD2, Anna Schurmann, MPH3, Gwen Morgan,
PhD4, and Fariyal Fikree, MD, DrPH5
1Center for Communication Programs, Johns Hopkins University Bloomberg School of Public

Health
2Carolina Population Center and Department of Maternal and Child Health, University of North
Carolina at Chapel Hill Gillings School of Global Public Health
3Sukshema Project, Karnataka Health Promotion Trust/Intrahealth
4African Population and Health Research Center, Nairobi, Kenya
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5Independent Consultant, Global Health, Washington DC

Abstract
This study presents findings from a systematic review of evaluations of family planning
interventions published between 1995 and 2008. Studies that used an experimental or quasi-
experimental design or had another way to attribute program exposure to observed changes in
fertility or family planning outcomes at the individual or population levels were included and
ranked by strength of evidence. A total of 63 studies were found that met the inclusion criteria.
The findings from this review are summarized in tabular format by the type of intervention
(classified as supply-side or demand-side). About two-thirds of the studies found were on demand
generation type-programs. Findings from all programs revealed significant improvements in
knowledge, attitudes, discussion, and intentions. Program impacts on contraceptive use and use of
family planning services were less consistently found and less than half of the studies that
measured fertility or pregnancy-related outcomes found an impact. Based on the review findings,
we identify promising programmatic approaches and propose directions for future evaluation
research of family planning interventions.
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BACKGROUND
By the early 1970s, international efforts to reduce rapid population growth in the developing
world were well advanced. The vast majority of countries adopted voluntary family planning
programs, which in most cases were part of their maternal and child health or primary health
care systems (Sinding 2007). A golden era of family planning from 1970 to 1990—during
which a reproductive revolution occurred in every region of the world except sub-Saharan
Africa—was underway (Donaldson 1990; Donaldson and Tsui 1990).

Corresponding Author: Ilene S. Speizer, Department of Maternal and Child Health, Gillings School of Global Public Health,
University of North Carolina at Chapel Hill, 206 W. Franklin St., CB 8120, Chapel Hill, NC 27516, Tel: 919-966-7411, Fax:
919-966-2391, [email protected].
A previous version of this paper was presented in October, 2009 at the International Conference on Urban Health in Nairobi, Kenya
and in November, 2009 at the International Conference on Family Planning: Research and Best Practices in Kampala, Uganda. At the
time this work was undertaken, LM, AS, and FF were part of the MLE project team.
 Mwaikambo et al. Page 2

Between the mid-1960s and the mid-1990s, average fertility in the developing world,
including China, fell from around six children per woman over her reproductive lifetime to
around three, a 50 percent decline. During the same period, the prevalence of contraceptive
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use among women increased from less than 10 percent to nearly 60 percent, but the rise was
uneven (Sinding 2007).

Despite decades of research on the subject, considerable uncertainty exists about the
processes and factors that motivate couples to limit their family size; this is related to
variations in the adoption of birth control in different societies at different times (Bongaart
et al. 1990). There is general agreement that socioeconomic development and organized
family planning programs both play significant roles in bringing about changes in
reproductive behavior; however identifying independent effects of family planning programs
proves more difficult (see United Nations 1979, 1986, and Lloyd and Ross 1989 for a review
of this work).

Lapham and Mauldin (1985) showed that it is the combination of improved socioeconomic
conditions and greater family planning program effort that leads to the strongest associations
with increased use of contraception. These findings were used to demonstrate to economic
and social development policymakers that consideration of ways to initiate or improve
family planning delivery systems should be an integral part of any development strategy.
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Family planning programs have varied widely in their emphasis on demand generation
activities and supply-side activities such as increasing contraceptive method choice and
using varying service delivery approaches. Despite such differences in their characteristics,
Bongaarts, Mauldin, and Phillips (1990) outline certain key issues that are relevant for
strengthening program performance in a variety of settings:
1. Passive clinical approaches are less successful than programs that make services
available to couples in their villages and home.
2. The quality of services is a crucial but often neglected element of programs; this
entails choice among a number of methods, to be well informed about alternative
methods, to have competent and caring providers of services, to have follow-up
exchanges with knowledgeable program staff.
3. No single formula for program design suits all needs. It is imperative to develop
culturally appropriate, sensitive approaches and monitor and adjust programs as a
result of lessons learned.
4. Political support for family planning is often critical to establishing strong program
effort.
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The Matlab Project from rural Bangladesh exemplifies the importance and ultimate success
of taking into account all of the above mentioned issues. It is one of the most well-
documented experimental projects on family planning in developing countries as a result of
the Demographic Surveillance System (DSS) developed by the International Centre for
Diarrhoeal Disease Research, Bangladesh (ICDDR,B). The experimental design of Matlab
has allowed researchers to examine the differences between the special services invested in
the treatment areas against the standard government services provided in the comparison
areas. These areas are similar culturally and socioeconomically allowing researchers to
conclude that the Matlab Project has succeeded in raising contraceptive prevalence and
reducing child mortality substantially even in an environment that is economically and
socially unfavorable to these developments (Nag 1992).

The longitudinal, experimental study design of Matlab has allowed researchers to study a
variety of inputs and outcomes as a result of the interventions. The very nature of the study

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design allows researchers to draw conclusions on cause and effect. Unfortunately, this is not
always the case in public health research. Although randomized controlled trials are the gold
standard, a number of real-world issues are encountered that often prevent the use of
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randomized trials in public health research; these include feasibility and ethical concerns
among others. Randomized controlled trials are “primarily a vehicle for evaluating
biomedical interventions, rather than strategies to change human behavior. Altering the
norms and behaviors of social groups can sometimes take considerable time….” (Global
HIV Prevention Working Group, 2008).

From the available evidence that varies in strength, Bongaarts, Mauldin, and Phillips (1990)
estimated that without the effects of family planning programs in the 1970s-1980s, fertility
in developing countries would have been 5.4 births per women during 1980 to 1985 rather
than the actual 4.2. These program effects reflect the buildup of program strength over the
preceding years. Ironically, this success, in combination with increased attention to the
AIDS epidemic, has led to reduced funding for contraceptive research and most importantly,
investment in family planning services in the mid-1990s (UN Population Fund 2005). And,
despite the positive effects that family planning programs have had, in much of the
developing world and particularly in sub-Saharan Africa, fertility remains well above the
level observed in the developed world, where women average about two births.

INTRODUCTION
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Worldwide, there is a large and empirically verified demand for family planning services to
space or limit childbearing. Currently, about 201 million women have an unmet need for
modern contraception (PRB 2008), that is, they are sexually active, they want to delay or
stop childbearing, and are not using a modern method of contraception. Notably, more than
80 million mistimed or unwanted pregnancies (unintended pregnancies) occur each year
worldwide, contributing to high rates of induced abortions, maternal morbidity and
mortality, and infant mortality (Cleland et al. 2006). Furthermore, family planning has been
found to be an essential approach for countries to achieve their Millennium Development
Goals (MDGs), particularly goals four and five for improved child and maternal health
outcomes (Cleland et al. 2006; Potts and Fotso 2007; Allen 2007; Moreland 2006). Family
planning is a cost-effective public health and development intervention. The cost of averting
unwanted births is miniscule compared to the costs to the family and country of unwanted
births (Cleland et al. 2006). Few public health interventions are as effective as family
planning programs at reducing the mortality and morbidity of mothers and infants and have
such a breadth of positive impacts (Cleland et al. 2006; Bongaarts et al. 2009).

In the 1970s-1980s, family planning programs were on the rise, leading to important impacts
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on increasing voluntary family planning use and reducing fertility in many parts of the
world. During this same period, numerous family planning program evaluations were
undertaken to demonstrate the impact of demand generation and service delivery
improvements on contraceptive use and fertility-related outcomes (Bauman, Viadro, Tsui
1994; Samara, Buckner, Tsui 1996; Cuca and Pierce 1977). Evaluations undertaken in this
period included small-scale evaluation efforts to test novel service delivery approaches as
well as evaluations of community- and national-level mass media, community-based
delivery, and policy change initiatives (Samara, Buckner, Tsui 1996). The family planning
evaluations used varying study designs, especially in terms of the outcomes measured, the
assumptions required, and the strength of the conclusions (Bertrand, Magnani, Rutenberg
1996). The more rigorous family planning evaluations used randomized experiments
(experimental designs), quasi-experiments, and multilevel regression methods. Notably,
examining the period through the end of 1992, Bauman (1997) found sixteen family
planning evaluations that were considered to be randomized experiments (i.e., random

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assignment of individuals or groups). Thus, while many authors at the time acknowledged
the difficulties in undertaking randomized experiments of family planning programs (Cuca
and Pierce 1977), Bauman’s analysis demonstrated that this was not impossible. That said,
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even the most widely recognized family planning evaluation, the Matlab study mentioned
above, did not randomly assign participating villages; a strong advantage of Matlab,
however, was the use of longitudinal data and multivariate analyses to demonstrate program
impacts.

Although significant gains have been made since the 1970s, the potential benefits of family
planning programs have not been realized for millions of women (Cleland et al. 2006). To
revitalize political will and funding for a new era in the promotion of family planning and
reproductive health (FP/RH) services, robust evidence-based strategies must continue to
demonstrate research-driven best practices and outline the logistics of implementation. A
recent report by the Center for Global Development (CGD) Evaluation Gap Working Group
concluded that missed opportunities for the collection and analysis of program impacts have
led to continued funding of ineffective and inefficient programs (William 2006). Impact
evaluation studies are imperative in providing critical evidence to decision makers on how to
effectively spend scarce resources. As a result, the objective of this review is to provide an
update on family planning program effectiveness since 1994 when there was less attention
and funding for family planning programs. In particular, we a) synthesize recent research on
family planning program effectiveness, focusing on experimental and quasi-experimental
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impact evaluation studies; b) discuss program approaches that are successful (and those that
are less successful); c) identify gaps in family planning evaluation research; and d)
recommend future research and evaluation directions.

METHODOLOGY
We undertook a systematic search of journal databases for peer-reviewed articles as well as
a companion search of gray literature through funder clearinghouse websites, project
websites, and correspondence. In addition, we utilized a ‘snowball’ sampling approach
through searching the reference lists of identified articles. The search strategy included word
combinations that incorporated evaluation or outcomes with the following terms: family
planning, contraceptive use, child spacing, fertility, unmet need, maternal health, quality of
care, private sector family planning services, adolescent pregnancy, unintended pregnancy,
abortion, cost effectiveness, male involvement, breastfeeding and lactational amenorrhea
method (LAM), and family planning/reproductive health policy.

The inclusion criteria for the review focused on studies of family planning interventions that
took place in developing countries, assessed changes in outcomes that are directly
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attributable to a program (causality), and included the following family planning outcomes
of interest: use of family planning services, knowledge and/or attitudes about family
planning, discussions around family planning, intentions to use family planning,
contraceptive use, unmet need, total fertility rate, unintended pregnancies, and abortion.
These outcomes were selected as they provide both short-term and longer term perspectives
of family planning program achievements. While the long-term outcomes (fertility,
unintended pregnancies, and abortion) are the most important, few evaluations have a long
enough follow-up period to observe changes at this level. Thus, using the short-term
outcomes provides an understanding of whether programs are on track for achieving their
intended impacts; a program that is unable to affect short-term outcomes is unlikely to have
long-term impacts. The systematic search covered published and unpublished papers from
1995 to 2008.

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Studies identified were categorized based on their study methodology as experimental

designs, quasi-experimental designs, and non-experimental designs. Studies that included
experimental designs, that is, the groups or individuals were randomly assigned and quasi-
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experimental designs with non-random assignment to groups were included in this review.
Most of these studies used a pre-test and post-test study design or a panel/longitudinal
design. A small number of included studies used a post-test only design with an
appropriately defined comparison group. Finally, a few of the included studies were non-
experimental and thus did not include a comparison group but were able to attribute changes
in outcomes to program exposure through multivariate analyses.

The studies included in this review meet the above criteria; however, they still vary widely
in strength of design and robustness of the findings. For this reason, we further ranked the
studies by the methodological quality, creating a rating scale based on the strength of the
research design, scope of the study (i.e., ability to generalize results), and the control of
confounders and selection bias. As a result, three categories of strength of evidence
emerged:
• High – This includes randomized cluster designs that included details on the
randomization process and where necessary, controlled for differences in the small
number of groups randomized. Also included in this category are studies that
randomized individual-level participants; many of these often first randomized sites
and then randomized participants within sites. A small number of studies met the
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high quality criteria by using a longitudinal design with a low loss to follow-up, a
long follow-up period, and a comparison group (e.g., Matlab and Navrongo); most
of these studies also controlled for differences in groups.
• Medium – Most of the studies in this category used a pre-post test with comparison
group design that had a follow-up period of at least six months. All of the studies in
this category controlled for possible selection bias between the groups through
multivariate analyses. This category also included longitudinal studies without a
control group and with low loss to follow-up as well as a small number of studies
that used a randomized cluster design but either did not provide details on the
randomization process and/or did not control for differences between the small
number of intervention and control groups;
• Low – These studies were quasi-experimental designs that often included a pre-
post test control group design with no control for differences between the groups
and/or a very short follow-up period (e.g., <6 months). Also in this category are the
post-test only comparison group design studies and the longitudinal studies with
high loss to follow-up and no comparison group.
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Two individuals (the first two authors) independently assessed the studies for inclusion and
rated the studies according to the inclusion criteria and above rating scale. The majority of
the studies in this review fall into the medium strength of evidence category.

No attempt was made to conduct a meta-analysis and reanalyze the data from the studies, as
is done in the Cochrane Collaboration. As noted in the Cochrane Handbook for Systematic
Reviews of Interventions, “Public health and health promotion interventions are broadly-
defined activities that are evaluated using a wide variety of approaches and study designs.
For some questions, the best available evidence may be from non-randomized studies”
(Armstrong R et al., 2008). Thus merging study designs and observations from multiple
studies would not provide useful information to summarize the varying types of family
planning program activities.

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Search results (as of August 2009) yielded 225 studies that consisted of a family planning
intervention. Of these, 63 studies met the above methodological criteria for rigor of
evaluation. A number of studies were excluded due to their lack of multivariate analysis
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with non-randomized study designs, focus on reproductive health outcomes other than the
family planning outcomes of interest (e.g., HIV prevention programs and youth programs
focusing on delayed sexual debut and condom use), or being strictly operations research
(e.g., feasibility and acceptability studies) that did not go on to examine population-based
family planning and fertility outcomes. Notably, many of the operations research studies
were undertaken as part of the FRONTIERS Project led by the Population Council and can
be found on the Frontiers Legacy website (http://www.popcouncil.org/publications/
FRONTIERSLegacy/index.asp).

In numerous cases, the interventions consist of various activities using both demand- and
supply-side strategies. However, for this review, we have categorized each intervention
study as predominantly demand or predominately supply. Forty-two of the included articles
are classified as demand-side interventions, while the remaining twenty-one are classified as
supply-side interventions. Within the demand generation activities, we further classified
programs as mass media, interpersonal communication, and development approaches. The
development approaches that included conditional cash transfer programs and a savings and
credit program tended to be the most integrated in terms of demand- and supply-side
strategies and four out of five of them had high quality evidence (see details below). Among
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the supply-side interventions, we further classified programs into access, quality, and cost
approaches. The one cost approach identified (a voucher program) had features of both a
supply-side and a demand generation activity and was classified in the low quality of
evidence category.

RESULTS
Among the 63 studies included, the strength of the evidence varies widely. In particular,
among the 42 studies that were in the demand category, 7 were of low quality, 27 were of
medium quality, and 8 were considered to be of high quality (see Table 1 for citations by
category). Half of the high quality studies were of studies and interventions classified as
development approaches - conditional cash transfer programs and a savings and credit
program (Stecklov et al. 2007; Steele et al. 2001). Among the remaining high quality
demand programs, two were interpersonal communication programs with an instructor/
facilitator (Cabezon et al. 2005; Walker et al. 2006) and two were community-level
interpersonal communication programs (Lou et al. 2004; Ross et al. 2007). Among the
programs in the supply-side interventions, 8 were considered low quality, 7 were considered
medium quality, and 6 were considered high quality. Among those supply-side programs of
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high quality, three are access/community outreach programs that were undertaken in large
demographic surveillance sites (Bangladesh and Ghana), permitting long-term follow-up of
a longitudinal sample (Rahman et al. 2001, Sinha 2005, Debpuur et al. 2002). The three
others were quality of care/integrated service programs (Bashour et al. 2008; Bolam et al.
1998; Xiaoming et al. 2000), two of which were able to randomize individuals at the clinic
level. Notably, the remaining demand-side and supply-side interventions were of medium or
low quality but still met the inclusion criteria of being quasi-experimental designs (or having
another way to attribute program exposure to outcomes).

Table 2 summarizes the findings of the 63 rigorously evaluated studies included in this
review. Generally speaking, the available evidence over the last 15 years suggests that
family planning programs have positively impacted individuals’ family planning knowledge,
attitudes, discussion, intentions, and to a smaller degree, contraceptive use. Seventy-five
percent of the studies that measured contraceptive use as an outcome reported positive

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findings for increased contraceptive use or reduced unmet need, while the outcomes of
knowledge, attitudes, discussion, and intentions were more commonly found to be
significant. Increased service use and changes in fertility-related outcomes were less
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consistently evident. All of the supply-side interventions that measured fertility outcomes (4
studies - Rahman et al. 2001; Sinha 2005; Debpuur et al. 2002; Sherwood-Fabre et al. 2002)
were positive and significant, revealing either a decrease in fertility rates, reduced
unintended pregnancies, or a decrease in abortion rates, while only 2 (Askew et al. 2004
(sites A & C); Cabezon et al. 2005) out of 9 demand-side intervention studies (Rogers et al.
1999; Vernon et al. 2004; Mathur et al. 2004; Stecklov et al. 2007 (included as 3 separate
studies – Honduras, Nicaragua, and Mexico); Signorini et al. unpublished, PAA 2009) that
measured fertility-related outcomes revealed statistically significant, positive findings on
this outcome.

As shown in Table 3, the majority of the evaluation studies reported on interventions that
took place in Africa (n=25 studies), while 21 studies reported on data from Asia, 14 studies
from the Americas, 2 study from Eurasia, and 2 studies from the Middle East.1

To facilitate synthesis and presentation, studies are presented based on their categorization
as demand-side or supply-side interventions below. More detailed summaries of the
intervention type, program description, research design/analytic methods, and results may be
found in the Appendix.
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The next three sections outline specific demand-side approaches that the articles from our
review broadly fall within – mass media, interpersonal communication, and development
approaches. The subsequent three sections divide the supply-side studies from our review
into the three broad supply-side categories – access, quality of care, and cost. The article
concludes with a discussion of gaps and directions for future evaluation research.

Demand-side approaches
Mass media—The central goals of family planning demand-side interventions include
changing women’s, men’s, and couples’ knowledge and attitudes about family planning
methods, increasing their knowledge of sources of contraceptives, and increasing their use
of family planning to meet their fertility desires (Salem et al. 2008). As an intervention,
mass media through the radio, television, or print media is an appealing strategy for the
promotion of family planning because of its potential reach and ability to address often
culturally taboo issues in an entertaining way. The use of media to deliver primarily social
development messages has been employed in family planning (FP) and reproductive health
(RH) programs for over five decades (Salem et al. 2008). As FP/RH programs have grown
and evolved so have the communication approaches. These approaches are referred to by
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many names such as entertainment-education (EE); edutainment; information, education,

and communication (IEC); and behavior change communication (BCC), to name a few
(Salem et al. 2008).

Nine articles (Rogers et al. 1999; Kincaid 2000a; Meekers et al. 1997; Meekers et al. 1998;
Van Rossem et al. 1999a; Van Rossem et al. 1999b; Kim et al. 2001; Magnani et al. 2000a;
Sood et al. 2004) evaluating the impact of mass media interventions that met our inclusion
criteria for rigorous evaluation were found in the literature search. Often, in the case of mass
media interventions, evaluations must use creative methods to compare those exposed to the
intervention to those not exposed given that the programs tend to be full coverage programs.
In cases where a comparison group is not feasible, researchers sometimes divide the sample

1The total does not equal 63 studies because the Brieger 2001 article reports on data from Nigeria and Ghana.

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into groups based on exposure to the various components of the intervention. Comparing the
groups based on exposure experience or extent of exposure, controlling for background
differences, provides researchers with an opportunity to measure dose response effects on
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the fertility or family planning outcomes of interest (Kincaid 2000a; Magnani et al. 2000a;
Sood et al. 2004). Given these methodological challenges with evaluating mass media
approaches, all but one of these studies were considered to be of medium quality; this last
study was considered of lower quality because it used a post-test only comparison group
design (Sood et al., 2004).

Of the nine mass media intervention evaluations we reviewed, results usually focused on
short-term outcomes such as changes in knowledge, attitudes, beliefs, and discussion
patterns either between partners or between parents and their children. Few behavioral
outcomes were measured. However, when behavioral outcomes such as contraceptive use
were measured among the study population, results were positive (Rogers et al. 1999;
Kincaid 2000a). Most positive behavioral results emerged from studies where mass media
was combined with other intervention components, such as social marketing (Meekers et al.
1998; Van Rossem et al. 1999a; Van Rossem et al. 1999b) or interpersonal communication
interventions (Kim et al. 2001; Magnani et al. 2000a; Sood et al. 2004).

In Tanzania, Rogers and colleagues (1999), which was considered to be a medium quality
study, measured married women’s use of contraceptives as a result of exposure to an
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entertainment-education radio soap opera, “Twende na Wakati” (Let’s Go with the Times).
The authors used a quasi-experimental design since the soap opera was broadcasted on
seven mainland stations of Radio Tanzania and not on the eighth station covering the
Dodoma area. While the seven stations were broadcasting the soap opera twice a week, the
Dodoma area station was broadcasting locally produced programs at the same time.
Consequently, it was able to serve as the comparison site. In addition to triangulating a
number of different data sources, the authors used a repeat cross-sectional design, in which
they surveyed individuals in the same 35 wards in two regions of the Dodoma comparison
area and seven regions in the treatment area at one-year intervals from 1993 to 1997. The
authors found that all statistical tests supported a significant effect of exposure to “Twende
na Wakati” from 1993 to 1995 on married women’s use of contraceptives. As a result of the
positive findings from the 1993-1995 analysis, Radio Tanzania began broadcasting the soap
opera in the Dodoma area. The authors found this statistically significant effect between
exposure to the soap opera and contraceptive use of married women replicated in the
Dodoma comparison area from 1995 to 1997.

Interpersonal communication—Interpersonal communication approaches including

one-on-one discussions, small-group sessions, and facilitator-led curriculum-based programs
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are another demand-side strategy used to influence knowledge, attitudes, intentions, and
behaviors related to FP and RH. Interpersonal communication interventions take place in
varying settings including schools, workplaces, and the community. These interventions are
often facilitated by peers, teachers, or expert trainers. Twenty-eight articles using
interpersonal communication approaches met our inclusion criteria. Of these articles, 11
reported on peer-led interventions (Agha et al. 2004; Magnani et al. 2000b; Brieger et al.
2001; Speizer et al. 2001; Cartagena et al. 2006; Askew et al. 2004; Diop et al. 2004;
Vernon et al. 2004; Bhuiya et al. 2004; Mathur et al. 2004; Ozcebe et al. 2003); 12 were
instructor/facilitator-led (Cabezon et al. 2005; Eggleston et al. 2000; Magnani 2001; Mbizvo
et al. 1997; Murray et al. 2000; Martiniuk et al. 2003; Mba et al. 2007; Rusakaniko et al.
1997; Shuey et al. 1999; Stanton et al. 1998; Walker et al. 2006; FOCUS/CARE
International - Cambodia 2000); and, 5 were community-based (Levitt-Dayal et al. 2001;
Erulkar et al. 2004; Lou et al. 2004; Tu et al. 2008; Ross et al. 2007).

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Within these categories, the overwhelming majority were of medium quality with the
exception of two of the peer-led interventions that were lower quality (Cartagena et al. 2006;
Ozcebe et al. 2003); two of the instructor/facilitator led that were of high quality (Cabezon
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et al. 2005; Walker et al. 2006); two of the instructor/facilitator led of low quality (Mba et
al. 2007; Shuey et al. 1999); two of the community-based that were high quality (Lou et al.
2004; Ross et al. 2007); and one of the community-based that was low quality (Levitt-Dayal
et al. 2001). Notably, none of the articles compared the different types of facilitators to help
inform whether one approach is more effective than another. However, Table 2 reveals that
the peer-led and adult-led intervention studies had similar outcomes.

The interpersonal communication interventions almost exclusively targeted adolescents and

young adults (the age range included 10 year olds to 26 year olds), and the evaluations all
included short-term outcomes (knowledge, attitudes, and beliefs) and only a few included
behavioral outcomes (contraceptive use and unintended pregnancies). Most studies (86% -
18 studies out of 21) reported improved knowledge and attitudes, while about two-thirds of
the studies (12 studies out of 19) measuring family planning use found a positive effect
(Magnani et al. 2000b; Brieger et al. 2001; Speizer et al. 2001; Askew et al. 2004; Murray et
al. 2000; Stanton et al. 1998; Walker et al. 2006; Levitt-Dayal et al. 2001; Erulkar et al.
2004; Lou et al. 2004; Tu et al. 2008; Ross et al. 2007) and half of those measuring fertility
outcomes (2 studies out of 4) led to declining fertility (Askew et al. 2004; Cabezon et al.
2005).
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Askew and colleagues (2004) compared three intervention sites in the Western Providence
of Kenya. Interventions to create a supportive environment at the community level and
strengthen the health system’s ability to meet the reproductive health information and
service needs of adolescents were introduced into Site A locations. Site B locations
consisted of the same intervention activities as in Site A plus an in-school life-skills and
development curriculum and parent sensitization, so that the additional effect of educating
school children on reproductive health issues could be assessed. Site C locations were
identified as comparison sites, where no interventions were introduced. This was considered
to be a medium quality study. For most socio-demographic characteristics, there were no
differences, between the sites nor between baseline and endline cross-sectional
characteristics. Where differences did occur for a characteristic, it was taken into account in
the analysis and interpretation of the findings. This indicates that any differences in
measures of the key indicators found between baseline and endline are most likely due to the
influence of the interventions themselves. Among the never married girls living in Site B
there was no change over time in terms of experiencing pregnancy, with about one quarter
of sexually active girls reporting a pregnancy. In intervention Site A and the comparison
site, however, large and significant reductions in pregnancy were reported over time. This
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may be a result of the fact that approval of contraception and condom use improved in the
comparison site and in Site A but not in Site B. This finding is particularly interesting
because Site B, which offered exposure to the largest number of program components, had
the least effect.

Alternatively, Cabezon and colleagues (2005), in their high quality study, found that a
school-based intervention taught by teachers had a protective effect in preventing
unintended pregnancies. Three cohorts of first year high school students were enrolled in a
randomized control trial in which some students received no intervention and other students
received the TeenSTAR abstinence-centered sex education program which consisted of 14
units taught over a school year. The cohorts represent the years 1996, 1997, and 1998; the
1996 cohort did not experience any intervention program. No interventions were received by
any of the cohorts during their second, third, or fourth years. All cohorts were followed up
for four years; pregnancy rates were recorded and subsequently contrasted in the

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intervention and control groups. Pregnancy rates for the intervention and control groups at
four year follow-up in the 1997 cohort were 3.3% and 18.9%, respectively; while pregnancy
rates for the intervention and control groups at four year follow-up in the 1998 cohort were
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4.4% and 22.6%, respectively. The pregnancy rate for the 1996 cohort that was not exposed
to the program was 14.7%. The differences between intervention and control group by
cohort were statistically significant demonstrating an impact of the TeenSTAR program
using a high quality study design.

Development approaches—The development approaches, which included four

conditional cash transfer programs and a savings and credit program, all focused on
intermediate and long-term behavioral outcome indicators, such as contraceptive use and
fertility. Four out of five of these studies were of high quality (Stecklov et al. 2007 –
counting for three studies; Steele et al., 2001) and the remaining one was of medium quality
(Signorini et al. unpublished, PAA 2009). In the case of Stecklov and Signorini, they used
population-level secondary data for the evaluation. In particular, by relying on large,
nationally representative surveys that are infrequently available, the authors were able to
examine longer-term outcomes than what is usually available immediately following the
intervention activities. Stecklov and colleagues (2007) explored the possible association
between conditional cash transfer (CCT) programs in three Latin American countries
(Mexico, Nicaragua, and Honduras) and fertility. The authors compared three sets of panel
data from experimental CCT programs in these countries to assess the impact of these
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programs on childbearing. Each program first identified a set of communities eligible for the
program and then randomly assigned them into control and treatment groups. The treatment
groups were provided payments conditional on the household’s behavior, such as enrolling
children into public schools, getting regular check-ups at the doctor’s office, and receiving
vaccinations.

Findings, based on difference-in-difference models, show that the program in Honduras,

which inadvertently created large incentives for childbearing, may have raised fertility by
between 2 and 4 percentage points. The Honduras program created incentives by
establishing different targeting and eligibility criteria and transfer amounts. For example, the
Honduras’ Family Allowance Program (PRAF, after its Spanish acronym) allowed parents
to join or obtain increased benefits by bearing children after the program had begun
(Stecklov et al. 2007). The CCT programs in the two other countries, Mexico and
Nicaragua, did not have the same unintended incentives for childbearing; however, they also
did not have a net impact on fertility (Stecklov et al. 2007). The data were more positive
when examining contraceptive use, where it was measured. The data from the PROGRESA
program in Mexico revealed significant increases in contraceptive use, while the Nicaragua
data illustrated an increase, albeit one that was not significant. Similarly, an evaluation of a
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similar conditional cash transfer project in Brazil, called Bolsa Familia Program, was found
to have no impact on the fertility of program beneficiaries (Signorini et al. unpublished,
PAA 2009).

Likewise, evidence from a high quality evaluation of a Save the Children USA program
examining the characteristics of women who choose to join a women’s savings or a credit
group in rural Bangladesh and the impact of their participation on contraceptive use revealed
mixed results (Steele et al. 2001). The credit approach required more stringent criteria for
membership based on credit worthiness, an admission fee, and there were individual and
group expenses for meeting rooms. In addition, the group funds were managed by a credit
officer who collects weekly savings and loan payments to deposit at a government bank. The
savings groups were more autonomous than the credit groups, and set their own rules with
regard to frequency of meetings, savings contributions by members, size of group, and how
group savings were managed. To evaluate the impact of the credit program, the authors

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compared credit members with eligible nonmembers in the same village communities. The
savings group members were compared with eligible nonmembers in the same village
communities as well as in village communities in which the savings program was not
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introduced. The use of a longitudinal design for this evaluation controlled for two types of
endogeneity that often threatens evaluation research: self selection and non-random program
placement (Steele et al. 2001). Increased contraceptive use was found among participants of
the credit program but not among participants of the savings group.

Supply-side approaches
The overarching strategy of successful supply-side family planning programs is to make
contraceptive methods as accessible as possible to clients in a good quality, reliable fashion.
This includes offering a wide range of affordable contraceptive methods, making services
widely accessible through multiple service delivery channels, making sure potential clients
know about services, following evidence-based technical guidelines that promote access and
quality, and providing client-centered services (Richey et al. 2008). These types of supply-
side interventions ensure that women and couples are able to effectively use family planning
when the need arises. Understanding which supply side interventions lead to increased
contraceptive use and reductions in unmet need and unintended pregnancy is important for
making recommendations to program managers and policy makers on how to expend finite
resources. Much of the research to date on supply-side interventions has been undertaken
through operations research that has generally focused on outcomes such as improved
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service quality, increased client satisfaction, and increased service use. Fewer recent
evaluation studies of supply-side strategies examine whether changes in family planning
availability, accessibility, quality, and costs lead to increased contraceptive use and reduced
unintended pregnancy at the population level. The studies that we sought for this assessment
of rigorous evaluations did just this; they examined the impact of supply-side activities on
fertility and family planning outcomes. In total, we found twenty-one articles that evaluated
the population-level impact of supply-side interventions.

Access—Nine studies focusing on issues of accessibility met our inclusion criteria; three
of these (two with medium quality and one with low quality) evaluated the impact of
fractional social franchising programs (Agha et al. 2007, Hennink and Clements 2005,
Babalola et al. 2001) and six focused on community-based distribution or outreach programs
(high quality: Rahman et al. 2001, Sinha 2005, Debpuur et al. 2002; medium quality:
Phillips et al. 1996; low quality: Douthwaite et al. 2005, Kincaid 2000b). Social franchising
typically entails the creation of networks of private medical practitioners (doctors, nurses,
midwives, pharmacists) that offer a standard set of services at lower costs under a shared
brand name. Franchise members are offered training, commodity advertising, inter-franchise
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referrals, a branding that shows high-quality standards, and other benefits. Fractional social
franchises are businesses that add a franchised service or product to the existing operations
(LaVake 2003). Among the three studies that used this approach, one with medium quality
and one with low quality (Hennink and Clements 2005; Babalola et al. 2001) had a
significant effect on family planning outcomes in the intended direction, while the Agha et
al. 2007 article found a marginally significant effect on current use of family planning (p=.
067). None measured an effect on fertility-related outcomes. Similarly, those that examined
knowledge, attitudes, and intentions also demonstrated positive effects. One study, however,
that examined whether fractional social franchising leads to increased service use in Nepal
failed to show the hypothesized effect and showed only a marginally significant effect for
contraceptive use (Agha et al. 2007). This may be a result of the fact that clients had other
sources of reproductive health services available to them that they felt comfortable using;
10-12% of the population in the intervention district went to a medical store/pharmacy for

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reproductive health services. In addition, the project was implemented for less than a year
(Agha et al. 2007).
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Hennick and Clements (2005) found that the introduction of new family planning clinics in
urban Pakistan resulted in increased knowledge of family planning methods, distinct effects
on contraceptive uptake, and decline in unmet need. However, the impacts were different by
provinces, which represent different cultural contexts. The new clinics in Sargodha and
Gujranwala in the Punjab province contributed to a significant decline in unmet need for
family planning; most of this change was comprised of a decline in unmet need for limiting
births. In the more culturally conservative cities of Hyderabad and Shikarpur in the Sindh
province, the operation of the new clinics led to no reduction in overall unmet need but led
to increases in the demand for family planning. This study highlights the importance of
taking into account the socio-cultural context of the study location.

Among the six community outreach/distribution studies, positive findings were found for all
outcomes measured, including three studies that measured fertility related outcomes. The
three studies that measured fertility outcomes were all of high quality and used longitudinal
study designs – Matlab and Maternal and Child Health-FP Extension projects in Bangladesh
(Rahman et al. 2001; Sinha 2005) and Navrongo project in Ghana (Debpuur et al. 2002)
over long follow-up periods. This reflects the fact that it is often difficult to report on
changes in fertility-related outcomes in the absence of datasets that cover a long period of
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time. In addition, the Matlab and Maternal and Child Health-FP Extention and Navrongo
projects include a combination of demand- and supply-side activities, which may explain the
positive FP and fertility outcomes.

These long follow-up periods also provided the time necessary to compare different
intervention approaches on the outcomes of interest. For example, Debpuur and colleagues
(2002) examined approaches to mobilizing Ghana’s Ministry of Health outreach program
and compared this with mobilizing traditional community-based organizations as well as
mobilizing both sectors simultaneously. Their study had four arms: a comparison site with
no intervention, a nurse outreach only site, a traditional community organization (zurugelu)
site, and a combined zurugelu plus nurse outreach site. They found that contraceptive use
remained the same when analyzing the effects of the approaches separately. However, when
examining the combined zurugelu plus nurse outreach approach, they found that
contraceptive use increased significantly and fertility decreased significantly.

Quality of care—Programs that seek to improve quality of services often focus on the
various components of quality as defined by Bruce (1990) in her seminal article. These
include choice of methods, information given to users, technical competence, interpersonal
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relations, follow-up or continuity mechanisms, and appropriate constellation of services.

Quality is inconsistently defined across different studies, and between different stakeholders.
This makes it difficult to draw larger conclusions about studies that seek to improve family
planning service quality.

Eleven articles to improve quality of care met the inclusion criteria for this review. One
article of lower quality focused on increased method options (Khan et al. 2004 - introducing
emergency contraceptive pills into the method mix); another of lower quality focused on
client provider interactions (Nawar et al. 2004). Nine reported on various quality
improvement approaches (high quality: Bashour et al. 2008, Bolam et al. 1998, Xiaoming et
al. 2000; medium quality: Khan et al. 2008, Kunene et al. 2004, Sherwood-Fabre et al. 2002,
Sanogo et a. 2003; low quality: Varkey et al. 2004, Speizer et al. 2004).

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Studies that sought to improve quality were not consistently successful; six studies (Sanogo
et a. 2003; Xiaoming et al. 2000; Speizer et al. 2004; Bolam et al. 1998; Khan et al. 2008;
Varkey et a. 2004) out of ten revealed a significant increase in contraceptive use. Five of the
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seven integrated service delivery studies focused on postpartum contraceptive use (Bashour
et al. 2008; Bolam et al. 1998; Khan et al. 2008; Kunene et al. 2004; Varkey et al. 2004),
and of these, three reported significant results (Bolam et al. 1998; Khan et al. 2008; Varkey
et a. 2004). The one integrated service delivery study that provided family planning to post-
abortion clients in Russia (Sherwood-Fabre et al. 2002) found a reduction in abortion rates
but no corresponding increase in contraceptive use. The authors explained that this situation
may be a result of the fact that the intervention was unevenly implemented; the survey
indicated that there were many missed opportunities to reinforce and personalize the family
planning information that women received. In addition, it was found that there was an
increase in the proportion of unintended pregnancies that resulted in live births during the
study period; this affected the abortion rates (Sherwood-Fabre et al. 2002). Finally, one
study investigated the impact of integrating an HIV prevention intervention into a well-
established family planning network of services in China. The authors found that at 12-
months follow-up, significantly more respondents from the experimental sites were using
condoms as their main contraceptive method (p<.05) (Xiaoming et al. 2000) as compared to
in the comparison sites.

The feasibility of male involvement in antenatal care (ANC) counseling sessions and the
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effectiveness of their involvement in postpartum contraceptive use was evaluated by two

studies – one of medium quality from South Africa (Kunene et al. 2004) and one of lower
quality from India (Varkey et al. 2004). In KwaZulu-Natal, South Africa, the study team
matched facilities by size and rural/urban status and then randomly assigned six clinics as
the intervention sites and six as the comparison sites. Implementing joint couple counseling
was challenging for this program because the population being served was mostly
unmarried. One-third of the couples invited attended the joint counseling sessions, and
communication among them was reported to improve with male partners more likely to
provide support in the event of pregnancy complications; however, postpartum family
planning use and overall risk behavior did not change (Kunene 2004). The other study that
examined male involvement had positive effects; however, did not randomly assign sites or
control for differences between the groups (Varkey et al. 2004).

Cost—The issue of cost of family planning methods is often discussed as both a supply-
side and demand-side issue. From the supply-side perspective, the direct cost of a family
planning method is seen as a barrier to use. From the demand-side perspective, many family
planning programmers and advocates have pointed out that there are many indirect costs
associated with access to family planning, such as large, unofficial payments to staff and
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long waiting times to see service providers; each of these affects demand (Ensor and Cooper
2004).

Only one article evaluating a cost-based intervention was found that met our inclusion
criteria. Although Meuwissen and colleagues (2006) used a quasi-experimental design to
evaluate the impact of a competitive voucher pilot program on adolescents’ use of sexual
and reproductive health care (SRHC) services and contraceptives in urban Managua,
Nicaragua, the authors used a post-test only design so the study design is considered lower
quality. Self-administered questionnaires were distributed randomly among female
adolescents 3 to 15 months after the vouchers had been distributed in their area. The voucher
receivers were considered the intervention group to be compared at a group level with the
control group, the non voucher receivers. Voucher receivers demonstrated significantly
higher use of SRHC services and knowledge of contraceptives and sexually transmitted
infections compared with non-receivers. There was no change in overall contraceptive use

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between the two groups – receivers and non-receivers. However, effects were modified by
place of survey – school versus neighborhood. Focus group discussions and interviews with
adolescents during the intervention suggest that the factors that contributed to the success of
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the voucher program were the removal of practical obstacles (e.g., financial, the need to
make an appointment, the lack of information on clinic location, and opening times) plus the
guarantee of confidential access to a service provider of their choice. These results reveal the
interplay between demand-side and supply-side barriers.

DISCUSSION
The available evidence on the effectiveness of family planning interventions in developing
countries over the last fourteen years reveals a positive picture with no one size fits all
approach. Both demand- and supply-side interventions led to improvements in knowledge,
attitudes, discussion of family planning and sexuality, and intentions to use family planning.
Results were less consistent in terms of effects on fertility and family planning outcomes.

The examination of mass media interventions illustrated positive results on contraceptive

use and/or unmet need, while the wealth of interpersonal communication interventions less
consistently demonstrated these effects. A notable example is the quasi-experimental study
by Rogers and colleagues (1999) that showed a significant effect of exposure to an
entertainment-education radio soap opera on contraceptive use by married women, which
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led to the scale-up of the program nationwide throughout Tanzania.

Only two (Askew et al. 2004; Cabezon et al. 2005) out of the four studies from the
interpersonal communications category that measured fertility related outcomes found
significant reductions in unintended pregnancies. For example, Askew and colleagues
(2004) found differential effects by exposure arm such that those with the greatest exposure
had the least fertility and family planning impacts. Askew and colleagues acknowledged that
their multi-sectoral approach reached adolescents with reproductive health information;
however, they cautioned that the findings need to be interpreted with care in light of the fact
that the community-based intervention was more intensively implemented in varying sites.
They also pointed to the fact that the teachers who implemented the school-based
intervention were more comfortable with providing the abstinence messages than the safer
sex messages to their students. These challenges are representative of similar challenges
experienced by all programs working with adolescents on issues of sexual and reproductive
health.

Contrary to Askew’s findings, Cabezon and colleagues (2005) revealed a protective effect in
preventing unintended pregnancies from a school-based intervention taught by teachers. The
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authors reported that the success of their teacher-led program was due to the accurate and
comprehensive information provided and the focus on developing assertiveness and
negotiation skills. The authors also acknowledged that the implementation of the program
over an academic year was ideal and found the teachers to be effective implementers of the
program. This example along with the example provided by Askew highlights the
importance of the program facilitators’ comfort with the subject matter and their
commitment to the program.

Once demand for contraceptive use is achieved, it is imperative that the supply is readily
available and accessible. Our review found that supply-side interventions that addressed
access to family planning led to positive effects on family planning use, whereas improved
quality less consistently showed positive effects on family planning behaviors. Notably, few
studies measured fertility-related outcomes such as reduced unintended pregnancies and
abortions; however, the supply-side intervention studies that did measure fertility showed

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the most consistent and positive findings, generally using the strongest study designs (Khan
et al. 2008; Debpuur et al. 2002; Rahman et al. 2001; Sherwood-Fabre et al. 2002).
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It is also notable that even in some places where the findings were positive; results were not
necessarily consistent across different locations or target groups. For example, the voucher
program in urban Nicaragua found different effects among school-going youth and youth
who participated from community-based sites (Meuwissen et al. 2006). Hennick and
Clements (2005) reported differential changes in unmet need as a result of introducing new
family planning clinics in two culturally distinct provinces of Pakistan. Debpuur and
colleagues (2002) found a significant increase in contraceptive use and decrease in fertility
when they examined the combined approach of two different community-based outreach
interventions in contrast to when they analyzed the effects of the interventions separately.

Although the findings presented in this review categorized studies as demand-side and
supply-side interventions, a small number of studies explicitly included a multi-component
approach, such as undertaking mass media and interpersonal communication (Kim et al.
2001; Magnani et al. 2000a; Sood et al. 2004), mass media and social marketing (Meekers et
al. 1998; Van Rossem et al. 1999a; Van Rossem et al. 1999b), fractional social franchising
with strong media promotional presence (Agha et al. 2007; Babalola et al. 2001), and
fractional social franchising and community-based outreach (Hennick and Clements 2005).
These studies generally found positive family planning outcomes and, when measured,
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positive fertility outcomes as well. The importance of multi-component programs has been
demonstrated in other reviews that have examined rigorous evaluations of adolescent
reproductive health programs (Speizer et al. 2003; Ross et al. 2006).

It is also worth noting where the evidence was weak or non-existent in this review. While
male involvement programs are becoming increasingly important in the international family
planning arena, there is limited evidence on the effectiveness of this approach on
population-based fertility and family planning outcomes. A small number of operations
research studies have been undertaken and reveal that approaches to increase male
involvement in prenatal and postpartum care lead to increased attendance at these critical
events; these studies with medium to low quality of quasi-experimental design, however,
have shown mixed results in regards to behavioral outcomes such as contraceptive use and
unintended pregnancies (Kunene et al. 2004; Varkey et al. 2004).

In addition to the limited evidence provided on evaluations of male involvement programs,

only one study of lower quality (Meuwissen et al. 2006) was found that examined the effect
of a voucher program on increased contraceptive use behaviors; this is an important gap
because voucher programs are an increasingly popular approach in public health
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programming. Several developing countries, with international donor support, are

considering or in the process of implementing a voucher program (examples include India,
Tanzania, Uganda, Kenya and Bangladesh) (Arur et al. 2009). However, more research is
needed to inform the design and expansion of voucher programs throughout the developing
world. Important areas for further voucher studies include: impact evaluations, cost and
cost-effectiveness studies, and the effect of using technology to simplify implementation and
reduce overhead costs. Vouchers are a relatively untested approach in low-income countries.
Although results from these early experiences are positive, there is a clear need for rigorous
research that can conclusively establish that voucher programs can increase coverage and
use of FP/RH and other health services among underserved target populations (Arur et al.
2009).

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Limitations
There are a number of limitations to this type of systematic review. First, depending on the
level of depth provided in each study, it is not always possible to extrapolate the features of
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each intervention and the corresponding evidence as to which components were the most
effective. Second, most studies of multi-component programs examined overall program
effects and did not separate out the effects of the different components. Third, the majority
of studies considered were written in English although the authors also reviewed studies in
French. Fourth, as expected for the outcomes of interest, most of the studies were based on
self-reported sexual and health-seeking behaviors; previous studies have demonstrated
potential biases of self-reported behaviors (Curtis and Sutherland 2004). Fifth, service
utilization statistics were included but only as a complement to individual level data; this
limited the inclusion of most of the operations research studies. Sixth, there is likely to be a
publication bias with this type of review whereby studies with positive findings are more
likely to be published (and found) whereas studies with non-significant or negative findings
are unavailable. Finally, given the diversity in study methods and implementation strategies,
it was not possible to do a formal meta-analysis that joins the samples and compares the
odds ratios. Therefore, a limitation of this study is that while all studies included met the
experimental or quasi-experimental (or another form of attribution) criteria, there was still
variability across the rigor of the studies. We have categorized the identified studies into
three quality categories: low, medium, and high to help clarify these types of distinctions
across the multiple approaches. Where appropriate, we have identified which findings come
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from those studies with a higher study quality (e.g., are from a randomized cluster design
and/or use longitudinal data with a comparison group to determine attribution).

Conclusions
In spite of limited funding for family planning programs during the period 1995 to 2008, this
systematic review reveals that both demand- and supply-side interventions that have been
rigorously evaluated have been found to be generally successful in increasing knowledge,
attitudes, beliefs, and discussions around family planning as well as increasing contraceptive
use. These impacts are often a result of programs that have taken into account the
importance of various approaches to reaching women and couples with family planning
products and services, providing quality information and service delivery, addressing
cultural norms and barriers to contraceptive use, and seeking community support.

That said, a number of gaps and directions for future research have also been identified. In
particular, there is a need to undertake evaluations of broader development approaches and
supply-side interventions measuring population-level outcomes (beyond operations
research) and their long-term impacts on family planning and fertility. Likewise, there is a
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need for more research around the impact of male involvement, integrated services, public-
private partnerships, and voucher programs, especially in light of the recent push and
funding for these approaches. There is also a need for information on the effectiveness and
cost-effectiveness of alternative implementation approaches for both demand and supply-
side interventions. For example, there are gaps in our understanding of the impact of a peer-
led versus instructor or facilitator led program as well as gaps in the understanding of
intervention costs and the comparison of costs for alternative implementation approaches.

Most evaluations are of small-scale interventions and implemented over relatively brief
periods of time (often a pilot test). There is little evidence on the long-term behavioral
effects of the interventions that would provide us the evidence required to make decisions
about scale-up or replication. The strongest evidence to support reaching long-term fertility
measures comes from long-standing longitudinal studies, such as Maternal and Child
Health-FP Extension projects in Bangladesh (Rahman et al. 2001; Sinha 2005) and the

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Navrongo project in Ghana (Debpuur et al. 2002). This reflects the need for long-term
follow-up in measuring and observing such changes in fertility-related outcomes. A number
of Demographic Surveillance Systems coordinated through the INDEPTH network (http://
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www.indepth-ishare.org/) are now currently available and could possibly serve as data for
these types of long-term evaluations of existing models in varying sites.

Furthermore, lacking in most studies is an assessment of the differential impact of

interventions across target audiences. For example, it is important to consider the impacts of
programs on the populations most in need of services, such as high risk subgroups, migrants,
and the urban poor, to name a few. The examination of differential impacts by subgroups
was rarely examined within the studies found. More specific information on the actual
beneficiaries of interventions is still needed by policy makers wishing to target scarce
resources to those most in need. The study by Hennick and colleagues (2005) highlights the
importance of not only understanding the cultural backgrounds of the various populations
that are being studied, which helps in explaining the different results in unmet need and
where these two distinct populations are in terms of acceptance and intentions to use family
planning methods, but also the importance of looking at the socio-demographic
characteristics of beneficiaries. They found that women who live outside of the catchment
areas are often married with four or more children and are of low socioeconomic status.
They also found that young (aged 16-19), poor women who are separated or unmarried were
seeking services from outside the catchment areas. These findings reveal that women who
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are poor were willing to travel some distance to obtain services for which they pay fees.

The findings of this review reveal that all of the intervention approaches have some benefit
at least on short-term outcomes. The main program approaches that led to increases in
contraceptive use included development approaches and supply-side interventions. Whether
the other approaches did not have an effect or did not measure one is a different issue.
Notably, only a small number of studies had an impact on fertility outcomes; most of these
were high quality studies of supply-side approaches working in supportive, long-term
settings using multi-component, integrated programs. As interventions are designed, it is
imperative that planning goes into monitoring and evaluating the activities, so that programs
can be refined and lessons learned can be shared widely. Particular attention needs to be
paid to undertaking rigorous impact evaluations that can attribute program activities to
changes in outcomes of interest. Randomized controlled trials will not be feasible for most
FP program activities; thus evaluators need to identify alternative study designs (quasi-
experimental; longitudinal) that are appropriate for the varying settings where programs are
being implemented (Victora, Habicht, and Bryce, 2004). This attention to rigor of family
planning evaluations will increase accountability, improve program decision making, and in
the end, improve maternal and infant health outcomes.
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Acknowledgments
This work was made possible with support from the Bill & Melinda Gates Foundation for the Measurement,
Learning & Evaluation (MLE) Project for the Urban Reproductive Health Initiative. The authors’ views expressed
in this publication do not necessarily reflect the views of the donor, the Bill & Melinda Gates Foundation.

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Table 1
Strength of Evidence of Included Family Planning Evaluation Studies by Type of Intervention and Strength of
NIH-PA Author Manuscript

Evidence

Strength of Evidence

Low Medium High

Demand-side interventions
• Mass media Sood et al. 2004 Rogers et al. 1999
Kincaid 2000a
Meekers et al. 1997
Meekers 1998
Van Rossem et al. 1999a
Van Rossem et al. 1999b
Kim et al. 2001
Magnani et al. 2000a
• Interpersonal communication
• Peer Cartagena et al. 2006 Agha et al. 2004
NIH-PA Author Manuscript

Ozcebe et al. 2003 Magnani et al. 2000b

Brieger et al. 2001
Speizer et al. 2001
Askew et al. 2004
Diop et al. 2004
Vernon et al. 2004
Bhuiya et al. 2004
Mathur et al. 2004
• Instructor/facilitator Mba et al. 2007 Eggleston et al. 2000 Cabezon et al. 2005
Shuey et al. 1999 Magnani 2001 Walker et al. 2006
FOCUS/CARE International, 2000 Mbizvo et al. 1997
Murray et al. 2000
Martiniuk et al. 2003
Rusakaniko et al. 1997
Stanton et al. 1998
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• Community-based Levitt-Dayal et al. 2001 Erulkar et al. 2004 Lou et al. 2004
Tu et al. 2008 Ross et al. 2007
• Development approaches Signorini et al. no date Stecklov et al. 2007*
Steele et al. 2001

Supply-side interventions Babalola et al. 2001 Agha et al. 2007 Rahman et al. 2001
• Access Douthwaite et al. 2005 Hennink and Clements, 2005 Sinha 2005
Kincaid 2000b Phillips et al. 1996 Debpuur et al. 2002
• Quality Khan et al. 2004 Khan et al. 2008 Bashour et al. 2008
Nawar et al. 2004 Kunene et al. 2004 Bolam et al. 1998
Varkey et al. 2004 Sherwood-Fabre et al. 2002 Xiaoming et al. 2000

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 Mwaikambo et al. Page 24

Strength of Evidence

Low Medium High

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Speizer et al. 2004 Sanogo et al. 2003

• Cost Meuwissen et al. 2006

*
Included as 3 separate studies
NIH-PA Author Manuscript
NIH-PA Author Manuscript

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Table 2
Evaluation Studies of Family Planning Interventions on Knowledge, Attitudes and Behaviors

Impact on Key Behaviors

No. of Programs Showing Significant Impact/Total Number of Programs Studied

Fertility-related
Mwaikambo et al.

measures -
Increased Increased Reduced
relevant intentions to use Increased unintended
Improved discussion FP; decreased contraceptive use; pregnancy;
knowledge and/ around fertility Reduced unmet Reduced
Type of Program Number of Studies Increased service use or attitudes sexuality/FP preferences need abortions
All programs 63 4/8 34/38 18/20 6/7 36/49 6/13
Demand side interventions 42 3/5 26/30 14/15 3/4 21/30 2/9

Mass media/BCC 9 1/1 8/9 7/7 1/2 7/8 0/1

Mass media only (2) - 2/2 2/2 1/1 2/2 0/1

Mass media + social marketing (4) - 3/4 3/3 - 2/3 -

Mass media + interpersonal (3) 1/1 3/3 2/2 0/1 3/3 -

communication (IPC)

Interpersonal communications 28 2/4 18/21 7/8 2/2 12/19 2/4

Peer led (11) 2/3 9/10 3/4 1/1 5/9 1/3

Instructor/facilitator led (12) 0/1 8/10 3/3 1/1 3/5 1/1

Community based (5) - 1/1 1/1 - 4/5 -

Development approaches 5 - - - - 2/3 0/4

Conditional cash transfer (4) - - - - 1/2 0/4

Savings/credit group (1) - - - - 1/1 -

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
Supply side interventions 21 1/3 8/8 4/5 3/3 15/19 4/4

Access 9 0/1 4/4 2/2 2/2 7/7 3/3

Fractional social franchising (3) 0/1 2/2 1/1 - 3/3 -

Community outreach/distr (6) - 2/2 1/1 2/2 4/4 3/3

Quality of care 11 0/1 3/3 2/3 1/1 7/11 1/1

Method options (1) - - - - 1/1 -

Provider/integrated servs (10) 0/1 3/3 2/3 1/1 6/10 1/1

Cost 1 1/1 1/1 - - 1/1 -

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Impact on Key Behaviors

No. of Programs Showing Significant Impact/Total Number of Programs Studied

Fertility-related
measures -
Increased Increased Reduced
relevant intentions to use Increased unintended
Improved discussion FP; decreased contraceptive use; pregnancy;
Mwaikambo et al.

knowledge and/ around fertility Reduced unmet Reduced

Type of Program Number of Studies Increased service use or attitudes sexuality/FP preferences need abortions
Vouchers (1) 1/1 1/1 - - 1/1 -

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Table 3
Regional Distribution of Studies

Africa Asia Americas Eurasia Middle East INTERVENTION-TYPE TOTALS

Demand 19 9 13 1 1 43*
Mwaikambo et al.

Supply 6 12** 1 1 1 21

REGIONAL TOTALS 25 21 14 2 2

*
The total does not equal 63 because the Brieger 2001 article reports on data from Nigeria and Ghana.
**
Of the 10 Asian studies, 5 are from Bangladesh - Matlab program.

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A.1
Research on Effectiveness of Demand-side Interventions

Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
Mwaikambo et al.

Rogers et al. 1999 • Tanzania Radio soap opera program, • RCS-C: 7 1993-1995 • Knowledge of FP: 0
(mass media only) Twende na Wakati (Let’s be intervention areas
• Five annual surveys modern/let’s control out lives), and 1 comparison • Attitudes toward FP
of about 2,750 was broadcasted on seven area (measured by self efficacy):
households in the mainland stations of Radio +
comparison and the Tanzania. An eighth station • Regression models;
treatment areas ANOVA • Attitudes toward FP
broadcast alternative
(measured by ideal number
programming from 1993 to
• Plus, a sample of new • Strength of of children): 0
1995, its listenership serving as a
family planning evidence: medium
comparison area. The program • Attitudes toward FP
adopters in 79 health
was designed based on a values (measured by ideal age at
clinics
grid containing 57 statements, marriage for women): +
such as not favoring male
children over female children • Attitudes toward FP
and encouraging couples to use (measured by approval of
FP methods. FP): +
• Discussed FP with spouse:
+
• Contraceptive use: +
• Currently pregnant: 0

Kincaid 2000a (mass • Philippines National Communication • PS: Longitudinal 6 months • Knowledge of modern
media only) Campaign of 1995/1996 design with lagged contraceptive methods: +
• Intact panel of 1,253 (NCC-95/96) used six method- variables and
married women ages specific TV spots developed for comparable • Attitudes toward the
15-49 the first campaign and added measures at Time 1. practice of FP: +
four new ones, two to promote
• Conditional change • Attitudes toward
breast-feeding and injectables
regression analysis; contraceptive methods: +
and two others to involve men in
decisions about FP. structural equation
• Discussion of FP with one’s
modeling

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
husband: +
• Strength of
• Discussion of FP with other
evidence: medium
women: +
• Advocacy of FP to others: +
• Exposure to campaign: +
• Intention and contraceptive
use: +
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
Meekers et al. 1997 • Lobatse, Botswana Youth friendly outlets for RH • RCS-C: 1 16 months after • Believe that condoms
(mass media + social (treatment); information and products that intervention and 1 baseline, 8 months reduce AIDS and pregnancy
marketing) Francistown, referred adolescents to Tsa comparison site after implementation risk: Males: 0 Females: +
Botswana Banana clinics; multi-media of project
(comparison) campaign; social marketing of • Logistic regression • Believe AIDS is not
Mwaikambo et al.

condoms; peer sales outreach to curable: Males: 0 Females:

• Males and females • Strength of +
community; and education
aged 13-18 evidence: medium
sessions in school.
• Believe sex leads to
Communications: radio, print
• n=1002 at baseline; marriage: Males: 0 Females:
media, and information targeted
n=2396 follow-up +
to parents, teachers, and
community leaders. • Believe sex increases one’s
status: Males: - Females: 0
• Believe sex is an AIDS risk:
0
• Believe abstinence is
protective: Males: 0
Females: +
• Attitude toward female’s
initiating condom use: 0

Meekers 1998 (mass • Soweto, South Africa Participatory media development • RCS-C: 1 1 year after pretest • Awareness about risks of
media + social (treatment - live weekly talk shows; mass intervention and 1 becoming pregnant: +
marketing) community); Umlazi, media campaign; peer education; comparison site
South Africa (control and targeted condom • Perceived susceptibility to
community) (both distribution. 70 adolescents • Logistic regression sexual risk: 0
locations are urban) trained in participatory media
• Strength of • Believe condom use is best
development process, peer
• Females only aged evidence: medium way to protect against HIV/
education, and condom
17-20 AIDS: +
distribution. 300 condom
distribution outlets opened to • Believe condom use is best
• n=226 pretest; n=204
support intervention. way to protect against
posttest
Communications: television, pregnancy: +
print media, radio (limited
reach). • Believe other contraceptives

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
are the best way to protect
against pregnancy: +
• Perception of barriers to
pregnancy prevention: 0
• Discussed contraceptives/
self-efficacy for pregnancy
prevention: +
• Discussed STD/HIV
prevention: 0
• Sexual experience: 0
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
• Current use of condoms to
prevent pregnancy: 0
• Condom use at last sex: +
(but at p=.10)
Mwaikambo et al.

Van Rossem et al. • Edea, Cameroon Peer education (28 adolescents • RCS-C: 1 15 months after • Knowledge of preventive
1999a (mass media + (treatment trained as peer educators), youth intervention and 1 pretest, 13 months of behavior: +
social marketing) community); Bafia, clubs in schools, mass media comparison site intervention
Cameroon (control campaign, behavior change • Knowledge of FP methods:
community) communication, social • Logistic regression +
marketing of condoms.
• Males and females • Strength of • Perceived risk for STI/
Communications: brochures,
aged 12-22 evidence: medium AIDS: Males: + Females: 0
posters, and community radio
and live talk shows targeting • Perceived risk for unwanted
• n=1606 pretest;
youth with messages about RH pregnancy: 0
n=1633 posttest
and condom use.
• Awareness of responsibility
for use of protection: +
• Discuss sexuality and
contraceptive use: +
• Ever visited health center
for contraceptive
information: 0
• Onset of sexual activity
<15: Males: 0 Females: +
• Use of modern method to
prevent pregnancy: Males: +
Females: 0
• Ever tried condoms: Males:
0 Females: +
• Condom use at last sex: 0
• 2+ sexual partners in last 30

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
days: Males: + Females: 0

Van Rossem et al. • Conakry and Kankan, Peer education; media materials; • RCS-C: selected 13 months after • Awareness of risk for HIV:
1999b (mass media Guinea intense, targeted marketing effort neighborhoods in pretest, about 8 0
+ social marketing) in context of broader social each city were months of
• Males and females marketing activity; distributed chosen for the intervention period • Awareness of risk for
aged 12-19 free contraceptives to intervention while pregnancy: +
adolescents; developed logo others were chosen
• n=2016 pretest; • Knowledge of condoms as
“My Future First” to identify as comparison sites
n=2005 posttest contraception: + (males
youth-friendly retail outlets.
• Logistic regression only)
Small youth-friendly service
component (certain clinics held
special hours for youth);
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
recreational activities. • Strength of • Knowledge of other forms
Communications: brochures and evidence: medium of contraception: + (females
posters. Also added theater, only)
dance, and discussion groups to
existing social marketing • Visited a health center in
program. past year: + (females only)
Mwaikambo et al.

• Discussed sex often: +

(males only)
• Sexually experienced: 0
• Onset of sexual activity by
age 15 or earlier: + (males
only)
• 2+ sexual partners during
past 4 weeks: + (marginally
significant for both at .08)
• Usually uses condoms: +
(males only)
• Used condom during last
sexual encounter: +

Kim et al. 2001 • Zimbabwe: Mutare Youth multi-media campaign to • RCS-C: 5 Follow-up 1 year after • Knowledge of FP: +
(mass media + IPC) (urban), Maphisa, education about RH issues. intervention and 2 pretest, 3 months after
Tongogara, Nzvimbo, Trained providers in “youth control sites completion of • Knowledge of RH: 0
and Nemanwa (all friendly services,” encouraged intervention
• Chi-square tests • Sexual decision-making: 0
towns at the center of parental involvement, and
rural districts) included peer educators. • Discussion with anyone
• Logistic regression
Communications: posters, about RH topics: +
• Males and females leaflets, peer educators, radio, • Strength of
aged 10-24, with half drama, campaign launch events, • Refused sex: +
evidence: medium
the sample between hot line, training programs for
15-19 drama, seminars to solicit media • Use of contraception: +
and local leaders.
• n=1426 at pretest • Have only one partner: +
n=1400 at follow-up

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
• Start using condoms: +
• Use of RH services: +

Magnani et al. 2000a • Asuncion, San Adolescent-specific mass media • RCS (reflexive 30 months between • Knowledge that condoms
(mass media + IPC) Lorenzo and product development and controls) pretest and follow-up prevent STI: +
Fernando de la Mora, placement and peer educators.
Paraguay Designed to (a) increase the • Chi-square tests; F- • Believe both partners are
media’s understanding and tests; Student’s t- responsible for protection: +
• Males and females coverage of adolescent RH tests; logistic
from in-school and regression • Believe that girls who use
issues, (b) increase knowledge of
out-of-school sites, protection are responsible:+
SRH issues to promote
aged 15-19 • Strength of
responsible sexual behavior • Ever had sex: 0
evidence: medium
among adolescents, and (c)
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
• n=947 pretest, improve communication and • Condom use at first sex: +
n=1575 follow-up negotiation skills related to SRH
issues among young adults. Peer
educators received 80 hours of
training.
Mwaikambo et al.

Sood et al. 2004 • Nepal (rural): Fulbari Radio Communication Project • PT-C: Three groups • Knowledge of FP
(mass media + IPC) VDC (intervention); (RCP) combines mass media - Group 1: radio (spontaneous recall of 5 or
Parbatipur VDC messages, distance education, program + the more methods): + (Group 1
(control) and interpersonal listening groups & 2)
communication and counseling (n=204); Group 2:
• n=408 (IPC/C) training programs radio program only • Discussed FP with spouse:
featuring workshops, radio-based (n=73); Group 3: no + (Group 1 only)
health worker training in FP and exposure (n=131)
• Discussed FP with others: +
a national drama. First phase
• Logistic regressions; (Group 1 & 2)
aired between 1995 and 1996;
three more phases aired between service statistics
• Current use of any modern
1996 and 2001. Fourth phase of were also collected
method: + (Group 1 only)
project was on the air when from the sub-health
Fulbari VDC Listening Groups posts. • Approval of FP: 0
were being formed. Participants
• Strength of • Recommending method: 0
get together to listen to the 15
evidence: low
minute program and then discuss
• Future use: 0
the episode.

Agha et al. 2004 • Zambia (urban Single session school-based peer • PS-C: 3 schools First follow-up: 1 • Normative beliefs about
(IPC - peer secondary, boarding sexual health intervention - were randomly week; Second follow- abstinence: + (sustained
education) schools) included discussions, condom assigned to the up: 6 months after until 6 months)
demonstration, drama skits, and intervention & 2 to intervention
• n=416 respondents leaflet. the control condition • Approval of condom use
aged 14-23 (at (session on water and intention to use: + (not
baseline) were purification). sustained at 6 months)
interviewed in all
three survey rounds • Mixed effects • Normative beliefs about
(86% follow-up rate) logistic regression condom use: + (only at 6
growth curve; months follow-up)
adjusted odds ratios
• Condom use: 0
• Strength of

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
• Multiple regular partners: +
evidence: medium
(only at 6 months follow-
up)

Magnani et al. 2000b • Peru: 6 departments: Third year secondary school • RCS-C: Pilot project 18 month follow-up • Knowledge of correct day
(IPC - peer Lima, Lambayeque, students selected as peer leaders period of ovulation: +
education) Ica, San Martin, and trained by health • Chi-square tests;
Arequipa, and Tacna professionals over a 2-month logistic regression • Knows that woman can get
period. Each leader was pregnant at first sex: +
• n=6962 secondary • Strength of
responsible for making at least
school males and evidence: medium • Believe could convince
25 youth contacts in 6-month
females partner to use a condom: 0
period. Content of Peer Leader
Workshops: sexual development, • Ever had sex: + (only
body consciousness, self-esteem, measured among boys)
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
assertiveness, anatomy and • Contraceptive use at last
physiology, values, STIs/HIV, sex: + (among boys only)
parenthood, relationships,
adolescent pregnancy.

Brieger et al. 2001 • 8 Nigerian Worked with youth serving • RCS-C: 10 18 months • Knowledge of AIDS/STI,
Mwaikambo et al.

(IPC - peer communities organizations to develop intervention and 10 pregnancy prevention, SRH:
education) activities for youth. All sites control sites + (in school)
• 2 Ghanaian developed peer education
communities programs. Some sites worked in • Logistic regression • Contraceptive opinion: 0
schools (secondary or post-
• In and out of school • Strength of • Contraceptive self-efficacy:
secondary). Others worked with
males and females evidence: medium + (in school-males)
out-of-school youth.
aged 12-24
• Willingness to buy
• n=1714 at pretest; condoms: + (in school-
n=1801 at posttest males)
• Willingness to buy foaming
tablets: + (in school)
• Used modern
contraceptives: + (in school)

Speizer et al. 2001 • Cameroon: Peer education program to • RCS-C: 1 17 months after • Knowledge of
(IPC - peer Nkongsamba and increase contraceptive intervention and 1 pretest, 3 months after contraceptives: +
education) Mbalmayo prevalence and reduce control site intervention
prevalence of STIs and completion • Knowledge of female STI
• Males and females unwanted pregnancies. • Logistic regression symptoms: +
aged 10-25 Activities: trained peer educators
• Strength of • Knowledge of male STI
provide information to peers in
• n=802 pretest; n=818 evidence: medium symptoms: Males: +
communities and refer them
posttest Females:0
through discussion groups, one-
on-one meetings and • Use of modern method: +
development of health
associations. Developed and • Condom use at last sex: +
distributed promotional materials
(calendars, comic strips,
posters).

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
Cartagena et al. 2006 • Mongolia A sexual health peer education • PT-C: 16 schools – 8 3 years • Knowledge, attitudes, and
(IPC – peer program for secondary school intervention and 8 self-efficacy∷ +
education) • Males and females students was launched in 2001. control
aged 150=-19 Peer educators (boys and girls) • Consistent condom use
were chosen by local GTZ • Multilevel during last 3 months: 0
• n=647 regression
coordinators and teachers based
on: openness, student interest,
• Strength of
grades, expressiveness,
evidence: low
communication skills, and
friendliness. They were trained
for 3 days in: reproductive
health, AIDS and STI
transmission, symptoms and
prevention, safe sex, and
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
discussions and interactive
communication skills.

Askew et al. 2004 • Kenya (rural) Multi-sectoral approach: • RCS-C: cluster 42 months • Received RH information: +
(IPC - peer community-based included randomization of
education) • Total baseline n=3653 mobilization for engaging local sites; 2 intervention • Knowledge of
Mwaikambo et al.

adolescents (87%) civic and religious leaders and sites: site A = contraception: +
and n=1192 parents parents and reaching out of community- +
(93%); Total endline • Knowledge of STIs: +
school youth with peer facility-based
n=3774 adolescents educators, training them in interventions; site B • Awareness of preventive
(89%) and n=1143 adolescent health and sexuality = community-, behaviors: + (site A -
parents (93%) (also issues, and holding sessions facility- + school- abstinence & condoms; site
included cost during religious and community based interventions; B males - abstinence)
analysis) meetings - drama, theater, video and 1 control site =
shows and targeted public site C. • Knowledge of reproductive
events; facility-based included physiology: 0
training staff, creating • Two-sample, two-
designated spaces within the tailed test of • Disapproval of male
clinic for adolescents, and differences premarital sex: + (site A)
inviting out-of-school peer
• Strength of • Disapproval of premarital
educators to hold group and
evidence: medium childbearing: + (site A)
individual meetings; school-
based included training teachers, • Approval of condom use: +
establishing extracurricular
classes, recruiting, training, • Sex: 0
supervising school-based peer
educators. • Delay of onset: + (site A
boys & site B)
• Secondary abstinence: +
• Discuss RH issues with
their parents: + (those who
met with a peer educator)
• Use of protection at last sex:
+ (sites A & C girls) - (site
B for boys)
• Pregnancy: + (site A & C)

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
Diop et al. 2004 (IPC • Senegal (urban): Multi-sectoral approach: • RCS-C: 2 April 2000-July 2002 • Parents’ approval of
- peer education) Louga and Saint- Community-based included intervention sites: adolescents receiving RH
Louis (treatment); sensitization of adults, peer Louga = community- services: +
Diourbel (control) educators using a life skills + facility-based
curriculum, IEC activities - interventions; Saint- • Communication between
• Baseline festivals, sports events, theater – Louis = community-, parents and adolescents: +
adolescents=2893 and radio programming; facility- facility- + school-
parents=1683; • Knowledge of risks of early
based included training staff, based interventions;
Endline sexuality, pregnancy, and
infrastructure modifications and Diourbel =
adolescents=2738 and abortion: +
when possible, and information control site
parents=1409 (also campaigns led by peer educators; • Knowledge of contraceptive
school-based included training • Logistic regression
methods: Males + Females
teachers, establishing
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
included cost extracurricular classes, • Strength of + (for Louga and only 15-19
analysis) recruiting, training, supervising evidence: medium Saint-Louis)
school-based peer educators.
Focus on abstinence and values • Attitudes regarding
clarification. contraceptive use: 0
Mwaikambo et al.

• Sexual debut: + (positive

delays/increases in age for
younger boys and older
girls)
• Use of services: +
(excluding all girls in Louga
and older boys in Saint-
Louis)

Vernon et al. 2004 • Mexico (small cities) A Young People Coordinator • RCS-C: 2 21 months • Use of contraceptive
(IPC - peer (YPC) for each experimental city experimental groups method at last sexual
education) • n=2191 adolescents was hired and trained. A YPC and 1 nonequivalent intercourse: -
(10-19 years old) and space was opened in each city; control of 4 cities
950 parents at meeting space, IEC materials, each: 2-Int = • Knowledge of FP methods:
baseline; n=1915 video and film showings; school community + 0
adolescents and 850 teachers, service providers, peer facility-based
parents at endline. • Aware of EC: + (2-Int
promoters, and other adult interventions; 3-Int =
group)
community volunteers were community, facility
trained as multipliers. Schools + school-based • Talked with partner about
and clinics in each city given a interventions; sexual relations: - (3-Int
set of materials including a sex control group = no group only)
education training manual, 7 activities.
videos, 6 flipcharts, brochures, • Felt trust to clarify doubts: -
and pamphlets on adolescent • Logistic or multiple (2-Int group only)
SRH. Sport events, graffiti regressions
sessions, parades, rock concerts, • Use of services: 0
• Strength of
etc. were organized to promote
evidence: medium • Pregnant: 0
IEC materials and
contraceptives.

Bhuiya et al. 2004 • Bangladesh (urban) Strategy I (Site A) provided RH • RCS-C: Pabna (Site Baseline conducted in • Knowledge of HIV/AIDS:
(IPC - peer education to out-of-school A), Dinajpur (Site Feb-April 2000 and Males + (Site B)

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
education) • n=about 6000 adolescents linked with B), and Rangpur endline April-June
adolescents (aged adolescent-friendly services at (Site C). Sites A & B 2002 • Knowledge of three routes
13-19) and about health facilities as well as were intervention of transmission: Males +
3000 parents were community support activities. sites while Site C Females + (Site B)
interviewed in total Strategy II (Site B) provided RH served as a control.
(from baseline & • Knowledge of
education to both in-school and
endline) • Bivariate and contraceptives: Males +
out-of-school adolescents linked
multivariate analyses (Site B) Females + (Site A)
with adolescent-friendly services
at health facilities and • Knowledge of fertile period:
• Strength of
community support activities. Males + Females: (Site B)
evidence: medium
• Knowledge of potential
health risks of early
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
pregnancy: Males + (Site B
& C) Females (Site C)
• Attitudes towards RH
education and services:
Males 0 Females - (older
Mwaikambo et al.

girls in Site A)
• Attitudes toward
contraceptive use: Males +
(Site B & older boys of Site
A) Females + (Site A)
• Condom use: 0
• RH service utilization: +

Mathur et al. 2004 • Nepal At the control sites, traditional • RCS-C: 2 12-24 months • Correctly identified at least
(IPC - peer RH research and interventions - intervention sites 2 modes of HIV
education) • Baseline: n=724 adolescent-friendly services, (one rural and one transmission: + (urban &
adolescents aged peer education and counseling urban) and 2 control rural females)
14-21; Endline: and teacher training - were sites (one rural and
n=979 adolescents employed. At intervention sites, one urban). • Ever discussed sex with
aged 14-25 youth and adult community Quantitative, anyone: + (rural females)
members identified a broader set qualitative, and
• Had premarital sex: +
of 8 integrated interventions: participatory
(urban unmarried males)
adolescent-friendly services, methods were
peer education and counseling, employed. • Contraceptive use: 0
IEC campaign, adult peer
education, youth clubs, street • Multivariate • Ever visited an organization
theater, livelihood opportunities, regressions; odds for FP advice: + (marginally
teacher education. ratios significant at .06 for rural
married females)
• Strength of
evidence: medium • Knowledge of at least one
serious problem during
childbirth: + (rural males)
• Experience of pregnancy: 0

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
• Currently in school: + (rural
females)
• Membership in group
activities: + (rural females)

Ozcebe et al. 2003 • Turkey (rural) Volunteers, who were married or • RCS-C: Peer • Knowledge level for
(IPC - peer unmarried women and men aged education females: +
education) • Treatment: n=113 15-24 years were designated as intervention was
females and n=109 peer educators and trained on conducted in 2 • Knowledge level for males:
males aged 15-24; reproductive health issues. villages, while +
Control: n=108 another 2 villages
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
females and n=201 served as a control
males aged 15-24 group.
• One-way variance
analysis
Mwaikambo et al.

• Strength of
evidence: low

Cabezon et al. 2005 • Santiago, Chile TeenSTAR abstinence-centered • RCT: 3 cohorts: the 4 years of • Pregnancy rates: +
(IPC - Instructor/ (peripheral sex education program consists 1996 cohort of 425 observations
facilitator led) community, San of 14 units; each was developed students (no
Bernardo) in one or more 45-minute class, intervention), the
allows a full year course in a one 1997 cohort (210
• N=1259 girls from an class per week schedule. Each students received
all-girls high school unit is interactive, comprised of intervention; 213 did
group discussions, not), and 1998
brainstorming, fertility cohort (328 received
awareness instruction, intervention; 83 did
homework, videotapes, and not).
skills building. Focuses on
biological and physiological • Risk ratio; chi-
aspects of fertility - mentions square tests
contraceptive methods but
• Strength of
stresses abstinence. No
evidence: high
interventions were received by
any of the cohorts during their
2nd, 3rd, or 4th years of high
school.

Eggleston et al. 2000 • Jamaica Specially developed family-life • PS-C: 5 intervention 9 months after • Knowledge of pregnancy
(IPC - Instructor/ education curriculum. Content: school and 5 control baseline and 21 prevention and condom use:
facilitator led) • n=945 female and Reproductive anatomy and schools (who months after baseline + (not sustained at follow-
male 7th grade physiology, benefits of sexual received regular sex (76% of baseline) up 2)
students, age 11-14 abstinence, negative education program)
from “new consequences of sexual activity • Knowledge of when
secondary” and “all and pregnancy, transmission, • Chi-square tests; pregnancy occurs: -
age” schools symptoms and treatment of STI, Student’s t-tests;
logistic regression • Attitudes about sexual

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
FP, and peer pressure. Sessions
using generalized activity: + (not sustained at
once per week throughout the
estimating equation follow-up 2)
academic year (about 9 months).
The sessions were coeducational methods
• Attitudes about parenthood:
and each lasted about 45 + (not sustained at follow-
• Strength of
minutes. up 2)
evidence: medium
• Sexual initiation: 0
• Use of contraception: 0

Magnani 2001 (IPC - • Salvador, Bahia, Sexual reproductive health • RCS-C: 6 30 months after • Received SRH-related
Instructor/facilitator Brazil education program with the intervention and 6 pretest information from school
led) provision of adolescent- control sites
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
• n=4777 male and appropriate RH services at • Logistic regression sources or health
female youth linked public health facilities professional: +
• Strength of
evidence: medium • SRH knowledge: 0
• Ever had sex: 0
Mwaikambo et al.

• Condom use: 0
• Utilization of clinics: 0

Mbizvo et al. 1997 • Zimbabwe: selected Health education program • RCT: 5 intervention 5 months after • Knowledge of menstruation:
(IPC - Instructor/ urban and rural consisting of IEC materials and 3 control baseline +
facilitator led) secondary schools (leaflets, pamphlets, posters) and schools; cross-
(exact location not lectures. Content: Male sectional samples • Knowledge of wet dreams:
reported) reproductive function, sexuality, +
HIV/AIDS, female reproductive • Chi-square tests;
• n=1689 males and Wilcoxon two- • Knowledge of pregnancy: +
function, anatomy, STIs, human
females with a mean sexuality, unwanted pregnancy, sample tests; trend
• Knowledge of family
age of 14.5 at contraception, and career goals analysis
planning: +
baseline; 1605
participants at 5- • Strength of
• Ever had sex: 0
month follow-up evidence: medium

Murray et al. 2000 • Santiago, Chile School and health facility • PS-C: 2 intervention 3 rounds of data • Knowledge on human
(IPC - Instructor/ (urban) education. Content: Healthy and 3 control sites collection: baseline, reproduction & STIs
facilitator led) relationships, sexuality, STIs, 8-month, and 20- (index): +
• n=4238 male and gender, risk-taking behaviors. • Life table techniques month follow-up
female 7th-12th grade Information and referrals to • Knowledge about STIs: +
students • Strength of
clinic.
evidence: medium • Knowledge on
contraception: 0
• Attitudes (teen pregnancy,
sexual relationships of
youth): 0
• Sexual activity: 0

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
• Contraceptive use: Males: 0
Females: +
• Method use at last sex: 0

Martiniuk et al. 2003 • Belize (urban) Responsible Sexuality Education • RCT: 8 classrooms No information • Knowledge: +
(IPC - Instructor/ Program (RSP) based on were randomized to
facilitator led) • n=399 adolescents Bandura’s Social Learning the intervention arm • Attitudes: 0
between the ages of Theory is a 3-hour scripted and 11 classrooms to
13-19 • Behavioral intent: 0
responsible sexuality education the control arm
intervention which provides a
framework for adolescents’ • Regression analysis
decision-making in relationships
and provides unbiased
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
information about sex and • Strength of
sexuality. evidence: medium

Mba et al. 2007 (IPC • Nigeria (rural) Intervention consisted of a 3- • RCS-C: 1 Same subjects • Knowledge about STIs,
- Instructor/ hour workshop on STIs, HIV/ intervention interviewed 6 weeks HIV/AIDS, and FP
Mwaikambo et al.

facilitator led) • n=360 students AIDS and FP. secondary school after the workshop methods: +
participated in both and one control
the pre- and post- secondary school • Sexual activity: 0
tests; mean age was
14.3 years • Chi-square tests
• Strength of
evidence: low

Rusakaniko et al. • Zimbabwe (rural and Intervention package included • RCT: 8 secondary 5-months and 9- • Knowledge of reproductive
1997 (IPC - urban) lectures, videos, and IEC schools were months after biology: +
Instructor/facilitator materials in the form of leaflets randomized to implementation
led) • Baseline: n=1689 and pamphlets which cover: receive a health • Knowledge of
students, 5 month male reproductive function, education contraception: +
follow-up: n=1605; 9 sexuality, STDs/AIDS; female intervention and 3
month follow-up: • Knowledge of pregnancy
reproductive function, anatomy (one urban and two
n=1589 risk: +
and STDs; human sexuality and rural) were chosen to
responsible sexual behavior; and serve as controls.
unwanted/unplanned pregnancy
and contraception. • Chi-square tests
• Strength of
evidence: medium

Shuey et al. 1999 • Soroti District, Activities: 1-day sensitivity • RCS-C: 10 students 2 years after pretest • Knowledge of AIDS: 0
(IPC - Instructor/ Uganda training for local leaders and from each of 38
facilitator led) headmasters; supervision of primary schools • Communication between
• n=400 males and school health program; meetings selected. peers & teachers about sex:
females, average age with parents, teachers, and +
13-14 community leaders, training for • Chi-square tests;
cross tabulation • Perceive peers are sexually
“senior women” and science
active: 0
teachers’ college in school health
• Strength of

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
and AIDS curriculum. • Agree that abstinence is
evidence: low
good: +
• Sexual activity: +
• Number of partners: 0

Stanton et al. 1998 • Omusati and Caprivi, Adaptation of US-based • RCT: 10 schools 2-month, 6-month, • Perceive could find
(IPC - Instructor/ Namibia “FOCUS on Kids” program, with random and 12 month follow- condoms: Males: + (2&6
facilitator led) based on social cognitive theory; assignment of up (after baseline) months) Females: + (12 mo)
• n=515 males and program called “My Future is individuals within
females age 15-18; 12 My Choice.” 14 after-school school • Perceive could ask for
month follow-up sessions with groups of 15-20 condoms at clinic: 0
students. Sessions were 2 hours a • Chi-square tests
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
sample was 340 week for 7 weeks. Content: • Strength of • Believe they can put
(66%) emphasis on abstinence and safer evidence: medium condom on: Males: 0
sex practices. Facilitator training Females: + (2, 6, & 12 mo.)
lasted 40 hours.
• Intention to use condoms:
Males 0 Females: + (2 mo.)
Mwaikambo et al.

• Delay of sexual initiation:

Males 0 Females: + (12
mo.)
• Condom use if sexually
active: Males: + (2 mo.)
Females: 0
• Discussed past sexual
relationships and other HIV
risk behaviors with partners:
+ (2 & 6 mo.)
• Number of sex partners: 0
• Could refuse sex without a
condom: 0

Walker et al. 2006 • Morelos, Mexico Schools were randomized to one • RCT: 15 schools Baseline, four months, • Knowledge on EC: +
(IPC – Instructor/ of three arms: an HIV prevention randomly assigned and 16 months after (condom promotion + EC
facilitator led) • n=10,954 students (at course that promoted condom to each of the intervention began group) (at 16 mo)
baseline), 9,371 use, the same course with intervention courses (which last 15 weeks)
(immediately after emergency contraception as and 10 randomly • Attitudes about condom use:
intervention), 7,308 back-up, or the existing sex assigned to control + (females at 16 mo)
(one year after); mean education course. The (existing course)
age 16.7 • Condom use at last sex: +
curriculum was based on
• Logistic regressions (condom promotion + EC
teaching life skills and followed
group but only at 4 mo, not
the guidelines of the UN
• Strength of at 16 mo)
programme on HIV/AIDS for
evidence: high
effective school based • Used EC: + (condom
programmes. promotion + EC group but
only for females at 16 mo)

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
FOCUS/ CARE • Phnom Penh, Reproductive health education • PS-C 18 months after • Knowledge of STI/HIV/
International - Cambodia provided to young garment baseline AIDS: 0
Cambodia 2000 (IPC factory workers using a • Chi-square tests
- Instructor/ • 1072 mostly female Participatory Learning and • Knowledge of contraceptive
(92%) factory • Strength of method: +
facilitator led) Action (PLA) approach.
workers with a mean evidence: low
age of 20 years • Knowledge of the risks of
pregnancy: +
• Discussed condoms with
friends: +
• Worry about getting AIDS:
0
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
• Knowledge of modes of
HIV/AIDS prevention: 0
• Knowledge of condom
source: 0
Mwaikambo et al.

Levitt-Dayal et al. • India: Peri-urban Better Life Options (BLO) • PT-C: 1 intervention 1-4 years after • Awareness of HIV: +
2001 (IPC - slums of New Delhi; program that seeks to empower and 1 control group program participation
community) rural Madhya young women to make better • Age at marriage: +
Pradesh; and rural choices for the future. Activities: • Risk-ratios
generated from MV • Completion of secondary
and urban slums of income-generating activities,
analyses education: +
Gujarat formal and non-formal
education, FLE, vocational skills • Employed and earning
• n=1693 unmarried • Strength of
training, health education and money: +
and married women evidence: low
services, public awareness
aged 15-26 creation and advocacy. Also • Contraceptive use: +
works with parents, community
leaders, and decision-makers to • Utilization of ANC and
raise awareness about the need PNC services: +
for girls’ empowerment.
• Utilization of hospital for
Content: decision-making,
delivery: +
mobility, self-esteem/
confidence/ empowerment, • Utilization of ORS for
childbearing and spacing, children’s diarrhea: +
contraceptive use and health
seeking behavior. • Number of children: +
• Child mortality: +
• Children vaccinated: +

Erulkar et al. 2004 • Nyeri Municipality, Nyeri Youth Health Project, • RCS-C: 1 36 months • Sexual debut: Males: +
(IPC - community) Kenya (treatment); community based project that intervention (marginally significant .8)
Nyahururu uses Kikuyu tradition and well- municipality and 1 Females: 0
Municipality, Kenya known and respected young control municipality
(control) parents as counselors who were • Secondary abstinence:
trained for one month in the life • Logistic regression Males: 0 Females: +
• At baseline, skills curriculum “Life Planning or Cox proportional

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
unmarried young hazard models • Condom use: Males: +
Skills for Adolescents in
people aged 10-24: Females: 0
Kenya.” Used group discussions,
N=1544; at endline, • Strength of
role playing, drama, lectures, • Number of sex partners:
young adults aged evidence: medium
worked with adults, referred Males: 0 Females: +
10-26: N=1865 (only youth to trained service
respondents aged providers. Content: community, • Communication with
10-24 in this analysis) family and individual values, parents: Males: - Females: +
adolescent development,
sexuality, gender roles, • Communication with other
relationships, pregnancy, HIV/ adults: Males & Females: +
STIs, harmful traditional
practices, substance abuse,
planning for the future,
children’s rights and advocacy.
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
Lou et al. 2004 (IPC • Shanghai, China Three main activities: building • PS-C: A 20 months after the • Used contraceptive at onset
- community) (suburban) awareness, disseminating nonrandomized intervention of sexual intercourse: +
educational materials, playing community trial with
• n=2227 unmarried instructional videos, giving one intervention • Ever contraceptive use,
young people (aged lectures, conducting small group group and one regular contraceptive use,
Mwaikambo et al.

15-24) were recruited activities; a youth health control group and condom use: +
at baseline (about counseling center was set up and
92% were • Chi-square tests; • Jointly decided on
contraceptives were distributed
successfully logistic regression contraception: + (males
free of charge; community
followed-up) models; Generalized only)
activities
Estimating
Equations (GEEs)
• Strength of
evidence: high

Tu et al. 2008 (IPC - • Shanghai, China Intervention was designed to • RCS-C with a panel: First follow-up at 20 • Use of withdrawal method:
community) (suburban) increase knowledge and enhance A nonrandomized months; second +
access to services related to community trial with follow-up 28 months
• 2,227 unmarried sexuality and reproduction one intervention after first follow-up • Consistent contraceptive
youth aged 15-24 among unmarried youth. group and one (cross-sectional use: 0
interviewed at Involved 3 activities: IEC - control group sample at second
baseline; 2,042 were • Contraceptive use ever, use
building awareness through follow-up)
interviewed • x2; logistic of contraceptive at each
dissemination of educational
immediately after the regression intercourse combined with
materials, instructional videos,
intervention (91.7% frequent use, condom use
lectures, and small group
of baseline); 2,249 at • Strength of ever, and withdrawal use
educational activities; provision
long-term follow-up evidence: medium ever: 0
of counseling - a youth health
(28 mos. later) counseling center was set up;
(32-34% of baseline enhancing access to services
and posttest samples) specifically contraceptives
through local FP units, youth
counseling center, and
educational activities

Ross et al. 2007 (IPC • Mwanza, Tanzania MEMA kwa Vijana (Good • RCT: Community 3 years • Knowledge of pregnancy
- community) (rural) things for young people) randomized trial of prevention: +
intervention - Four components: 20 communities;

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
• Baseline cohort: community activities; teacher- panel sample • Attitudes to sex: + (males
n=9645 adolescents - led, peer-assisted sexual health only)
all those aged 14 education in years 5-7 of primary • Biomarkers; two-
years and older in late way ANOVA; t- • More than one sexual
school; training and supervision
1998, who were in statistics; Logistic or partner: Males: + Females:
of the health workers to provide
years 4-6 of primary Poisson regressions; 0
‘youth-friendly’ sexual health
school in 20 services; and peer condom social random effects
• Condom use: +
communities; marketing. model
Endline: n=7040 • Condom use at last sex:
(73%) • Strength of
Males: + (marginally at .06)
evidence: high
Females: 0
• STI symptoms: 0
• HIV incidence: 0
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
• HSV2 seropositive: 0
• Protective effect of the
intervention on syphilis, C.
trachomatis, gonorrhea,
vaginalis, and pregnancy: 0
Mwaikambo et al.

Stecklov et al. 2007* • Select poor Households in the treatment • RCT/PS-C: 2-year period under • Fertility: Honduras -
(Development communities in group benefitted from the PROGRESA in examination after Nicaragua & Mexico 0
approaches - CCT) Mexico, Honduras, Conditional Cash Transfer Mexico, PRAF in each program was
* Included as 3 and Nicaragua programs and received transfers Honduras, and RPS undertaken • Contraceptive use: Mexico:
separate studies under the condition that their in Nicaragua. In + Nicaragua 0
• All women aged children enroll in and attend each case,
12-47 in the baseline school and that family members communities
sample (1997 for obtain health care. randomly assigned
PROGRESA and to treatment and
2000 for PRAF and control groups. For
RPS), who would PROGRESA, 302
have been aged 14-49 communities were
in the follow-up randomly assigned
(1999 PROGRESA to treatment and 186
and 2002 PRAF and to control. For
RPS). PRAF, 40 eligible
communities were
• N=8,817 women for
assigned to treatment
PROGRESA;
and 30 to control.
n=6,456 for PRAF;
For RSP, 21
n=2,409 for RPS
treatment and 21
control communities.
• Difference in
difference models;
probit models
• Strength of
evidence: high

Signorini et al. • Brazil The Bolsa Familia program • RCS-C: Using the 2 year comparison • Fertility: 0

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
unpublished began in 2003, uniting pre- Household Sample
(Development • In 2004, n = 24,338 existing social programs directed National Survey
approaches - CCT) (6.17% of the sample) at poor families. In one (PNAD) for the
households receiving component, families below the years 2004 and 2006
Bolsa Familia poverty line (which is R$50,00 and estimate the
benefits. In 2006, n = per capita) would be provided a first-differences for
87,800 (21.42% of monthly minimum income of R each year, to find the
the sample) $50.00 (US$21). Additional average treatment
households receiving benefits given to each pregnant effect on treated
Bolsa-Familia woman, infant or school-aged (ATT). To find
benefits. child. The program’s comparable groups
conditionalities include of treatment and
children’s school attendance and control, used
the fulfillment of basic health
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Design/Analytic
Methods/Strength of Period of
Reference Location/Sample Program Description Evidence Observation Results: Change in Outcome
care measures (immunization, Propensity Score
going to the health clinic, Matching methods.
prenatal care, and others). The
most vulnerable families can • Regression model -
receive up to R$172.00 monthly first differences
(about US$72). The transfer approach
Mwaikambo et al.

benefits vary by situation of

• Strength of
family, household income per
evidence: medium
capita, children, pregnant
women, and breastfeeding
women.

Steele et al. 2001 • Bangladesh (rural) SC-ASA credit groups: require • PS-C • Contraceptive use: + (SC-
(Development an admission fee, mandatory ASA credit group only)
approaches - credit/ • n=6,456 women in weekly meetings are held, and • Latent trait analysis;
savings) 1993; in 1995, members must save in a group binary logit
n=5,695, of whom fund from which they can regression;
4,333 were re- withdraw only if they leave the multinomial logit
interviewed group. SC savings groups: more regression; logistic
autonomous than SC-ASA credit regression; fixed-
groups, set their own rules with effects and random-
regard to frequency of meetings, effects models
savings contributions by
• Strength of
members, size of group, and how
evidence: high
group savings are managed. 4
groups: (a) members of savings
groups in old area; (b) poor
women in the new area where
Save the Children (SC) had not
yet introduced a program, but
who would be eligible for
membership; (c) women in the
same area who did not fulfill
SC’s eligibility criteria for group
membership; and (d) the control
group where no intervention was
introduced.

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
No significant difference 0; significant desirable difference +; significant undesirable difference - RCT=randomized cluster trial; PS-C=panel study with comparison group; PS=panel study; RCS-C=repeat
cross-sectional study with comparison group; PT-C=posttest only with comparison group
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A.2
Research on Effectiveness of Supply-side Interventions

Period of
Reference Location/Sample Program Description Design/Analytic Methods Observation Results: Change in Outcome
Agha et al. 2007 • Nepal (rural): A pilot fractional franchise network of • RCS-C: 1 intervention Baseline surveys: • Overall client
Mwaikambo et al.

(Access - Rupandehi district 64 nurses and paramedics was and 1 control district April-May 2001; satisfaction: +
fractional social (intervention); launched to improve quality of RH Follow-up surveys:
franchising) Nawalparsi district services under brand name Sewa. To • Random effects logit December 2002- • Returning clients: +
(comparison) join franchise, franchisees paid one- model January 2003
• Current use of FP: +
time registration fee and annual
• Providers=70 (at • Strength of evidence: (marginally
membership fee. They were given 7
baseline) and 64 (at medium significant net effect
days of training in FP service delivery
follow-up); Clients of at p=.067)
training by EngenderHealth &
70% of interviewed JHPIEGO. Network was supported by • Use of ANC during
providers’ clinics marketing activities. last pregnancy: 0
were interviewed
during a 2-day
period; Married
women 15-45 - 480
from intervention and
480 from
comparison; and
service delivery
statistics

Hennink et al. • Pakistan (urban) Four new FP clinics were opened as • RCS-C: 4 study sites 18 months • Knowledge: +
2005 (Access - part of a national franchise of RH (urban secondary cities of
fractional social • Ever married women clinics. Each clinic was similar in size Gujranwala, Hyderabad, • Sterilization: +
franchising) aged 15-45 residing and located in its own building. All Sargodha, and Shikarpur)
within 2-3 kilometer • Condom: -
clinics adhere to the same service and 2 control sites (urban
radius of each clinic delivery protocols and provide secondary cities of Gujrat • Overall CPR: 0
(in study areas) or identical services, including and Larkana)
within a poor urban contraceptives (pill, condoms, • Unmet need: +
area of similar size in injectables, IUD, female sterilization), • Factor analysis; logistic
control sites. pregnancy testing, pregnancy regression
termination, and advice about sexual
• Baseline N=5338; • Strength of evidence:
health. Each operates both clinic-based
Endline N=5502 medium
and outreach services. A fee is charged

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
but less than private health facilities;
subsidized treatment fund is available
to poor clients.

Babalola et al. • Cameroon (8 Gold Circle (GO) campaign rewarded • PS: using household 1998-1999 • Ideation: +
2001 (Access - provinces - targeting and promoted FP quality improvements survey, supplemented by
fractional social urban residents) through a certification process and a service statistics from GO • Contraceptive use: +
franchising) quality of care diagnostic tool. On the clinics and non-GO
• Baseline - N=1,367 supply side, the campaign attempted to clinics
women. Follow-up increase the availability of FP methods,
N=1,150 of which improve clinic management, client- • Interrupted time-series
571 (42%) from provider interactions and infection analytic method for
baseline. prevention practices. The campaign service stats; conditional
also used mass media (TV and radio change model; logistic
regression analysis;
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Period of
Reference Location/Sample Program Description Design/Analytic Methods Observation Results: Change in Outcome
• Service statistics jingles as well as print materials) and Poisson regression
from 8 of 12 GO sites community activities to create demand. analysis
and data from non-
GO sites within same • Strength of evidence: low
region.
Mwaikambo et al.

Rahman et al. • Bangladesh (rural) Married women in the comparison • PS-C: longitudinal data 1979-1998 • Abortion rate: +
2001 (Access - group received standard visits every 2 from Matlab which
community • n=147,753 pregnancy months from FWA, including provision includes data on • Unintended
outreach/ outcomes between of pills and condoms. In treatment pregnancy outcomes from pregnancies: +
distribution) 1979 and 1998, areas, community health workers two similar areas -
including 4100 visited married women of reproductive treatment and comparison
abortions. age every 2 weeks to provide areas - since 1966.
counseling about FP services, deliver
injectables, pills and condoms at the • Relative risks; Ω2
doorstep, and ICDDR, B subcenters
provide integrated MCH and FP • Strength of evidence:
services. high

Sinha 2005 • Bangladesh (rural) Married women in the comparison • PS-C: longitudinal data 18 year period from • Fertility: +
(Access - group received standard visits every 2 from Matlab covering start of program until
community • n=4892 ever-married months from FWA, including provision 139 villages, with 70 the MHSS was • Labor force
outreach/ women and n=2520 of pills and condoms. In treatment villages in the treatment fielded in 1996 participation: Boys: +
distribution) boys & girls (10-16) areas, community health workers area and 69 in the control Girls: 0
in the children visited married women of reproductive area.
sample. • Schooling: 0
age every 2 weeks to provide
counseling about FP services, deliver • Regression analysis
injectables, pills and condoms at the
• Strength of evidence:
doorstep, and ICDDR, B subcenters
high
provide integrated MCH and FP
services.
Debpuur et al. • Ghana (rural) Nurse outreach: Relocating nurses to • PS-C: longitudinal 1993-1999 • Knowledge of
2002 (Access - villages trained, equipped with register of all 139,000 contraceptive
community • n=8998 currently motorbikes, and provided with a individuals - augmented methods: + (separate
outreach/ married women management information system for with an open-cohort of txs & combined)
distribution) gathered in an monitoring doorstep service delivery. 1,900 compounds in
average of 2.4 panel Services included doorstep and which all married women • Knowledge of supply
years for each points: +

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
community-based curative care and of reproductive age have
respondent over a supplies of oral contraceptive and been interviewed
maximum of 6 panel • Fertility preference
condoms. Zurugelu community-based annually since 1993
years. for limiting or
outreach: Community health (analysis of six panel data
spacing: +
volunteers, also called health aides, sets)
trained to provide basic health care • Contraceptive use: 0
services, RH education, outreach to • Regression models; logit
(for separate txs) +
men, and contraceptive supplies. models; odds ratios
(for combined)
Utilize community gatherings and
• Strength of evidence:
other structures to get their messages • Fertility: +
high
and services across. Treatment areas
included nurse outreach, Zurugelu
community-based outreach targeting
men, and a combination of both.
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Period of
Reference Location/Sample Program Description Design/Analytic Methods Observation Results: Change in Outcome
Douthwaite et al. • Pakistan (rural) LHW deliver a range of services • PT-C: 1 intervention and 6 years after the • Contraceptive use/
2005 (Access - related to maternal and child health 1 control group program began Ever-use of modern
community • n=4277 currently including immunizations, growth reversible methods: +
outreach/ married rural women monitoring, FP, health promotion and • Logistic regression
distribution) aged between 15-49 education. FP responsibilities include
(931 from non- • Strength of evidence: low
motivating women to practice FP,
Mwaikambo et al.

intervention control providing pills and condoms and

areas and 3346 from referrals for injections, IUD, and
LHW areas) sterilization. Each LHW is attached to
a government health facility.

Kincaid 2000b • Bangladesh Government field workers were trained • PS-C Follow-up of the • Elements of ideation:
(Access - to organize group discussions with same respondents +
community • n=860 married women in the homes of opinion leaders • Logistic regression from baseline was
outreach/ women age 14-49 (satisfied current adopters) who are conducted 2.5 years • Contraceptive use/
(65.5% of the original • Strength of evidence: low Prevalence of modern
distribution) geographically dispersed to cover the after baseline.
baseline survey) entire village network. The jiggasha method use: +
meetings or network approach in which
• Continuation rate of
this discussion occurs provide an
FP use: +
opportunity for social comparison,
support, and influence. This approach
was compared to home visits by FWA,
and no visits.

Phillips et al. • Bangladesh (rural) In the MCH-FP Extension Project • PS – Results assess the Data collected over • Change in
1996 (Access - study areas, service-outreach contribution of outreach an 8-year period reproductive
community • A brief questionnaire encounters are routinely monitored by to contraceptive preferences: +
outreach/ was added to 2 research workers who visit households prevalence for successive
distribution) rounds of SRS in 90-day rounds and record 18-month periods at the • Contraceptive use: +
system in 1993 to respondents’ recall of the dates of beginning of the project
elicit responses about household visits from government and period (1982-1984), at
exposure to the other outreach workers. the middle (1986-1988),
overall regimen of and in the most recent
services. period (1990-1992).
• Generalized logit
regression; logit
regression
• Strength of evidence:

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
medium

Khan et al. 2004 • Bangladesh (two On-demand model provided all FP • PT-C: Two intervention • EC use: +
(Quality of care - districts in the Dhaka clients (except IUD, implant and groups - 4 clinics offered
method options) division: Tangail and sterilization acceptors) with counseling educational brochure plus
Mymensingh) and a brochure on EC. Prophylactic prophylactic EC
group provided the same information (prophylactic) and 4 other
• n=1,300 married services but in addition provided clinics just provided the
women each from the women with two packets of EC to use brochure and a referral
3 groups were chosen in case of an emergency. The control (on-demand) and 4 clinics
at random. group received no EC services. served as controls.
• Logistic regression
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Period of
Reference Location/Sample Program Description Design/Analytic Methods Observation Results: Change in Outcome
• Strength of evidence: low

Nawar et al. • Egypt (4 Intervention clinics received a • PS-C: A cohort of new Client outcomes were • Contraceptive use: 0
2004 (Quality of governorates were comprehensive intervention package FP acceptors was enrolled measured at 7 and 13
care - provider / selected from Lower for 6 months. This included: system- and follow-up for a 13 months through home • Knowledge about FP:
integrated Egypt) related, provider-related, and client- month period after the interviews. + (at 7 months)
Mwaikambo et al.

services) related factors intended to increase index visit.

• n=300 women in providers’ technical knowledge and
each study group attitudes about FP counseling as well • Chi-square test; t-test;
(intervention and as provider motivation. multiple regression
control) at 7 month analysis; life table
follow-up and 295 in analysis; multiple logistic
each for the 13 month regressions
follow-up
• Strength of evidence: low

Sanogo et al. • Senegal (5 regions) The government of Senegal created • PS-C: longitudinal survey Client outcomes were • Quality of care: +
2003 (Quality of reference centres for family planning of first time users of measured 16 months
care - provider / • n=1,320 women at based on notions of improving quality contraception, first time after initial interview/ • Contraceptive use: +
integrated baseline and n=1,110 of care. The strategy included users of specific method, visit.
services) at 16 months follow- substantial inputs to improve switchers, and those re-
up infrastructure, equipment, supplies and starting after hiatus;
personnel skills. interviewed 16 months
later
• Two analyses -
differences in care – chi-
square & multivariate
logistic model; outcomes
at client level –
multivariate logistic
regression models
• Strength of evidence:
medium

Bashour et al. • Damascus, Syria Registered midwives with special • RCT (individual-level 4 months • Current contraceptive
2008 (Quality of training made a home visit or series of randomization): 3 groups use: 0

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
care - provider / • n= 876 women home visits providing information, of new mothers were
integrated education, and support to women. randomly allocated to • Postpartum care
services) Visits included postnatal care, physical either (group A) 4 uptake: 0
exams, counseling on breastfeeding postnatal home visits,
• Breastfeeding: +
and family planning. (group B) one visit, or
(group C) no visits. • Impressions about
home visits: +
• Chi-square tests;
ANOVA
• Strength of evidence:
high
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Period of
Reference Location/Sample Program Description Design/Analytic Methods Observation Results: Change in Outcome
Bolam et al. • Urban and periurban 20 minute, one to one health education • RCT (individual-level Women were • Contraceptive use/
1998 (Quality of Kathmandu, Nepal at birth and 3 months later. Key randomization): 4 groups followed up at 3 and Uptake of FP: + (at 6
care - provider / messages given by health educators of new mothers were 6 months postpartum months for groups A
integrated • n=540 mothers, 135 included advantages of breastfeeding, randomly allocated to at their homes. & B)
services) to each of the four dangers of diarrhea, symptoms and (group A) health
groups, and followed response to acute respiratory infection, education just after birth • Exclusive
Mwaikambo et al.

up 403 (75%) at 3 and importance of restarting FP no and 3 months later, breastfeeding: 0

months and 393 later than 8 weeks after birth. (group B) at birth only,
(73%) at 6 months. (group C) at 3 months
only, or (group D) none
• Odds ratios; ANOVA
• Strength of evidence:
high

Khan et al. 2008 • India (rural Meerut Educational campaign by 267 • PS-C: The experimental Interviewed at • Discussions on LAM,
(Quality of care - district) community workers (CWs) addressing (24 villages) and control recruitment (3-6 STIs and HIV/AIDS:
provider / pregnant women, their husbands, (24 villages) groups months pregnant), 4 +
integrated • Baseline n=605 mothers-in-law, and community recruited 600 women at 3 months postpartum,
services) experimental & 592 leaders; using IEC materials (leaflets, to 6 months pregnancy and 9 months • Discussions on FP
control; at 4 months posters, wall paintings, and pocket with parity of 0 or 1 postpartum with husbands: +
n=554 experimental booklet on HTSP. CWs (ANMs,
& 541 control; at 9 • Logistic regression • Correct knowledge
ASHAs, and AWs) were trained on all
months n=570 for all methods: +
educational topics. Coordination and
experimental & 560 • Strength of evidence:
support among the district authorities • Contraceptive use: +
control medium
of the two departments and village (at 9 months)
level CWs was enhanced. A printed
work register was given to CWs to • Pregnant: + (at 9
ensure systematic coverage of all months)
relevant topics.

Kunene et al. • South Africa Two components: improving existing • RCT: Randomized cluster 6 months • Contraceptive use at 6
2004 (Quality of (Ethekwini district) ANC services including information, matched paired design months postpartum: 0
care - provider / education, communication and was used with 6 clinics
integrated • Baseline n=2082 dissemination of an information leaflet implementing the • Knowledge of dual
services) women (1087 control and a booklet for couples to read and intervention and another protection provided
and 995 intervention) discuss (“Ukuba umzali”) and 6 control clinics •follow- by condoms: +
and 584 intervention introducing strengthened individual up interview with woman

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
male partners; at • Discussed topics
and group counseling for pregnant and partner at 6 months
follow-up n=1423 related to STI, sexual
women and their partners. Men were
women (694 control • t-test relations,
invited to participate in 3 counseling
and 729 intervention) immunizations, and
sessions through the maternity period.
and 1166 male • Strength of evidence: breastfeeding: +
Two were to take place during
partners (558 control medium
pregnancy and the other 6 weeks post • Discussed topics
and 608 intervention) delivery. Each clinic developed its own related to FP: 0
plan to conduct couple counseling.

Varkey et al. • New Delhi, India Intervention included training • RCS-C: Non-equivalent 2 year intervention • Knowledge of
2004 (Quality of providers to conduct brief counseling control group study period; 6-9 month breastfeeding as
care - provider / • Baseline n=581 sessions and behavior change design in which six ESIC between baseline and pregnancy
integrated pregnant women communication (CBB), new IEC dispensaries with highest follow-up of sample prevention: +
services) (10-26 weeks materials and some new clinical antenatal clinic
pregnant) and 488
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Period of
Reference Location/Sample Program Description Design/Analytic Methods Observation Results: Change in Outcome
husbands at practices. Main components included: attendance were • Knowledge of dual
intervention and 486 an individual or group counseling purposively selected - protection provided
women at control session in the antenatal clinic, three assigned to the by condoms: 0
sites; 6-9 month separately for men and women; couple intervention and three
follow-up n=327 counseling sessions during antenatal acted as controls. • Intention to use FP: +
women and their and postnatal clinics; screening of all Consistency of
husbands from the pregnant women for syphilis; and • Analysis of variance; z- condom use: +
Mwaikambo et al.

intervention group syndromic management of men statistics

• Contraceptive use at
and 302 women and reporting urethral discharge and men
• Strength of evidence: low postpartum: +
their husbands from and women reporting genital ulcers as
the control group part of the individual counseling. • Knowledge of STI/
HIV/AIDS: 0
• Knowledge that
condoms protect
against STI: + (men)
0 (women)
• Spousal
communication on FP
and breastfeeding: +
(women)
• Spousal
communication on
HIV/AIDS: 0
(women)
• Joint decision
making: +
• Levels of
immunization: 0
• Spouse present at
labor/delivery: +
• Breastfeeding
practices: -
• Danger signs during

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
pregnancy: +

Sherwood-Fabre • Russia Intervention goal was to reduce • RCS-C: Two project 3 years • Discussing various
et al. 2002 abortion-related maternal mortality by cities (Yekaterinburg and methods with a
(Quality of care - • n= 6000 women ages changing physicians’ and women’s Ivanovo) and 1 control provider: 0
provider / 15-44 knowledge and practices concerning city (Perm)
integrated FP. Components: Physician training - • Women’s attitudes
services) 2-day introductory contraceptive • Logistic regression about FP became
technology update seminar; IEC more favorable: 0
• Strength of evidence:
activities - brochures, mass media
medium • Contraceptive use: 0
campaign, radio, TV, articles in
regional newspaper; Contraceptive • Abortions: +
supplies - provided 6-month supply of
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Period of
Reference Location/Sample Program Description Design/Analytic Methods Observation Results: Change in Outcome
contraceptives to participating
facilities.

Xiaoming et al. • China Integrate AIDS prevention intervention • RCT: Two townships 12 month follow-up • Using condoms as
2000 (Quality of at the community level into the existing randomly assigned to main contraceptive
care - provider / • n= 748 young adults family planning services. The experimental or control method: +
integrated at baseline; 710 at experimental township received a conditions – 2 villages in
Mwaikambo et al.

services) follow-up ages 18-30 multifaceted 12-month intervention each randomly selected
that included written materials, videos,
radio programs, small group • Chi-square; t-test (no
discussions, home visits, individual differences between
counseling, and a free supply of groups)
condoms. The intervention providers
• Strength of evidence:
included family planning workers,
high
village doctors, and women’s leaders.

Speizer et al. • Lome, Togo Establishment of a youth center in • PS-NC (reflexive Follow-up 1: 16 • Sexuality knowledge:
2004 (Quality of March 1998, to offer ARH clinical controls) months after baseline; 0
care - provider / • 2083 males and services, recreational services, Follow-up 2: 1 year
integrated females aged 10-24 counseling, IEC, and vocational and • Logistic regression after first follow-up • Knowledge of
services) (817 of baseline literacy classes. condoms: +
found at follow-up 1; • Strength of evidence: low
893 of baseline found • Contraceptive or
at follow-up 2) condom use at last
sex: +
• Utilization of health
services: 0

Meuwissen et al. • Managua, Nicaragua Vouchers gave free access to SRH care • PT-C 3 to 15 months after • Utilization of
2006 (Cost - (urban) in 20 health centers, were distributed to the vouchers were services: +
vouchers) adolescents in 4 markets, outside 19 • Crude odds ratios; distributed
• n=3009 12-20 year public schools, in clinics, and on streets adjusted Mantel-Haenszel • Knowledge of
old female and house to house in 221 poor odds ratios; logistic contraceptives: +
adolescents (n=904 neighborhoods. Vouchers were not regressions
voucher receivers; • Knowledge of STIs: +
bound to the person who originally
n=2105 non- • Strength of evidence: low
received them and could be passed to • Prevention through
receivers) another adolescent (voucher traveling). condom use: +
Also, vouchers were only valid for 3

Stud Fam Plann. Author manuscript; available in PMC 2013 September 03.
months and could be used for 1 • Condom use at last
consultation and 1 follow-up visit. contact: +
• Use of modern
contraceptives: 0
(overall) + (for school
receivers)

No significant difference 0; significant desirable difference +; significant undesirable difference - RCT=randomized cluster trial; PS-C=panel study with comparison group; PS=panel study; RCS-C=repeat
cross-sectional study with comparison group; PT-C=posttest only with comparison group
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