Effectiveness of a community based health educational intervention in reducing unmet need for modern methods of family planning among ever married reproductive age women in the Kalutara district, Sri Lanka

Malwenna; L.I'.; Jayawardana; P.L.; Balasuriya; A

Effectiveness of a community based health educational intervention in reducing unmet need for modern methods of family planning among ever married reproductive age women in the Kalutara district, Sri Lanka

Malwenna, L.I'., Jayawardana,P.L. , Balasuriya,A

Malwenna, L.I^1*., Jayawardana,P.L. ², Balasuriya,A³

Senior Registrar-National Institute of Health Sciences, Kalutara
Professor in Community Medicine, University of Kelaniya
Senior Lecturer, Faculty of Medicine, Defense University, Rathmalana

Corresponding Author: Malwenna, L, Email: indrani.malwenna@yahoo.com

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Abstract

Introduction: Unmet need is defined as the percentage of all fecund women who are married or living in union and thus presumed to be sexually active but are not using any method of contraception, either do not want to have any more children or want to postpone their next birth at least for two more years or do not know when or if they want another child1. Unmet Need for Modern Methods includes all in the unmet need group and those who are using natural and traditional methods at the time of survey (The Westoff Model) 2. It describes the discrepancy between sexual and contraceptive behaviors and stated fertility preferences of women in the reproductive age.

Objective: This study was designed to evaluate the effectiveness of a health educational intervention in improving the knowledge and attitudes on family planning (FP) among Public Health Midwives (PHMM) who function as community health workers and acceptance of modern FP methods planning which eventually reduce the Unmet Need (UMN) and thereby reducing the risk of unintended pregnancy among 15 - 49 year old married women in in the Kalutara district.

Method: Initially the perceptions on unmet need in community service providers was assessed by three Focus Group Discussions conducted among Medical Officers of Health, Public Health Nursing Sisters and PHMM. It was followed by assessment of the baseline knowledge and attitudes on FP and UMN among all the PHMM and a group of married women in reproductive age (15-49) with unmet need for modern methods selected from cluster sampling of PHM areas in the district using PPS technique, allocating 22 clusters of 12 women in each Intervention (IA) and Control Area (CA).The developed health education intervention was applied on PHMM followed by the selected group of women with unmet need for modern methods only to the IA. The effectiveness was assessed in terms of the change in knowledge and attitudes of PHMM after 2 months of intervention, of target group of women after 6 months of intervention and the reduction of unmet need for modern methods in the IA compared to CA.

Result: In PHMM, overall percentage mean knowledge score in IA at pre and post intervention were 29.9% and 65.7% respectively with a statistically significant difference (p<0.001) but with no such difference (p=0.10) in CA between pre (20%) and post (30%) scores. Median attitude scores were 37.5% and 86% in IA at pre and post intervention with a statistically significant difference (p<0.001). For CA respective figures were (40%) and (41%) with no significant difference (p=0.09) Regarding the target group, in IA had pre (37.6%) and post (70.6%) mean knowledge scores with a statistically significant difference (p<0.001); but with no significant difference (p=0.06) in CA between pre (39.0%) and post (40.2%) scores. Similarly, between groups comparison shows statistically significant difference (p<0.001) between IA and CA in post intervention, the scores being 70.6% and 40.2% respectively.

Conclusion: The training conducted on PHMM revealed a significant impact on knowledge and attitudes in both service providers and clients leading to change in the FP practice and reduction in unmet need for modern methods of FP.

Keywords

Family Planning, Unmet need, Married women, Reproductive age, Health Education Intervention

INTRODUCTION

Unmet need is defined as the percentage of all fecund women who are married or living in union and thus presumed to be sexually active but are not using any method of contraception, either do not want to have any more children or want to postpone their next birth for at least two more years or do not know when or if they want another child1. Unmet need for modern methods includes the above category and those who are using natural and traditional methods at the time of survey2.

Millions of females, mostly in developing countries who prefer to postpone or avoid their pregnancies do not use contraceptives. This unmet need is a disconnection between women’s fertility preferences and their contraceptive behavior, which indicates the failure to take necessary action to prevent unwanted conceptions. The concept of Unmet Need for Family Planning (FP) is usually applied to married women but can also be applied to sexually active unmarried females and to men as well. It can also be applied to those whose current method is inappropriate or inadequate3.

The one and only sequel of unmet need is unintended and thus unwanted pregnancy with its disastrous consequences to the individual woman, the unborn fetus, the rest of the children in the family and the spouse. These squeals may be broadly classified as health, social and economic; the extremes being resorting to induced abortions of the unborn child or infanticide and neglect or abandonment of the child after the birth.

According to the WHO estimates in 2003, a woman dies every 8 minutes due to complications arising from unsafe abortions. Worldwide, approximately 42 million pregnancies are voluntarily terminated, 22 within the national legal system and 20 outside4. In 1987, an estimated 26-31 million legal and 10-22 million clandestine abortions were performed worldwide with a rate of 35 per 1000 women in the 15-44 year age group4. Even by 1995, the situation has not changed5. In 2003, Casterline, El-Zantary and El-Zeini have reported that more than 80% of unintended pregnancies in Upper Egypt occur in women with unmet need and hence unmet need for FP remains a useful tool for identifying and targeting women at high risk of unintended pregnancies6.

All of the above signifies the consequences of unmet need. Although abortion is a method of preventing a birth, all service providers should know the essential difference between preventing a birth by the use of a contraceptive method and, preventing it by resorting to an induced abortion7.

Contraceptive use in Sri Lanka

In Sri Lanka, the Total Fertility Rate (TFR) has declined from 3.4 children in early 1980 s to 1.9 by 2000. Fertility decline has taken place within marriage mostly due to the increased use of contraceptives, with the contribution of high rate of induced abortions8.

However, the TFR has increased from1.9 in 2000 to 2.3 in 2007 although the Wanted Fertility Rate remains as 2.1. At the same time unmet need has decreased to 7.3% in 2007 from its value of 18.2% in 2000 creating a big puzzle in achieving and maintaining the replacement level of fertility9. This high TFR may be attributed to change in attitudes in the community to have bigger families or to the reduced Total Abortion Rate (TAR) from 0.147 to 0.087 experienced in the recent past in the country, due to unavailability of facilities and the cost of it8.

Although the contraceptive prevalence rate has increased from 57.8% in 1982 to 70.0% in 2000, 20.5% was traditional methods which are well known to have high failure rate10. Similerly, the incorrect use of modern methods, especially oral contraceptive pills and condoms resulted in unwanted pregnancies contributing to 39% of total induced abortions11.

However, 20% of pregnancies within previous 5 years were unintended accounting for about 43% of maternal deaths13. Either through lack of awareness or mere neglect, women do not consider the use of an effective FP method to prevent unwanted pregnancies. All of this emphasizes the need for motivating clients towards using modern FP methods ffectively, thus decreasing the unmet need. Hence the dire emergency to strengthen the planning of FP services in future9.

DHS 2006/7 reveals that the use of permanent methods has decreased from 23.15% to 17% and the discontinuation of the accepted methods is also high (32% within the first year) with high rates for pills (43%) and condoms (40%)9. To increase the uptake and continuity of modern contraceptive methods, it is important to stress their beneficial health effects and address the misconceptions as well. Hence, the likely benefits of a successful intervention will extend beyond the unborn fetus, the neonate and the infant to the individual mothers, the family members, the community and the country at large. Therefore, in the event of the intervention being effective, its use may be recommended island wide.

This is a community based experimental study to assess the effectiveness of health education intervention in improving the knowledge and attitudes on FP and unmet need among PHMM and in improving the knowledge, attitudes and practices on modern methods of FP and in reducing the unmet need in the target population. Implementation of the intervention was done only in the IA during the period from 12.10.2008 to 30.03.2009.

Material and Method

The study was conducted in two randomly selected Medical Officer Health (MOH) areas in the Kalutara district, Sri Lanka. MOH area is the health unit delivering public health services for about 50,000 populations, free of charge and headed by a qualified medical officer, called Medical Officer Health (MOH). His staff consisted of Public Health Nursing Sisters (PHNSS) who are supervisors in function, Public Health Midwives (PHMM) who are the grass root level workers providing domiciliary care in relation to maternal and child health, Public Health Inspectors (PHI) providing field services in relation to environmental and occupational health. MOH area Horana was assigned as the Intervention Area (IA) and MOH area Matugama as the Control Area (CA).

The study consisted of four phases.

Phase I: Situation analysis: Three Focus Group Discussions were conducted among MOHH, PHNSS and PHMM in the district on unmet need for FP to identify the perception of the public health staff on unmet need, deficiencies of the existing FP programme leading to unmet need, their suggestions to improve the coverage and the quality of FP services and thereby to reduce the unmet need and to design the intervention.

Phase II - Baseline survey: Pre intervention assessments of Knowledge and Attitudes on FP and unmet need among PHMM using a self administered questionnaire for which all PHMM in both areas participated.

The knowledge, attitudes and practices on FP and unmet need was assessed in target group women using an interviewer administered questionnaire administered by trained PHNSS.

The target group women consisted of

All women, married or living in union, sexually active, fecund, but expecting to postpone their next pregnancy at least for 2 years or do not know when or if they want another child but not using any method of contraception,

All pregnant women whose current pregnancies are unintended and was not using any FP method before the conception,

All amenorroiec women within first 6 weeks of delivery whose recent births were unintended and were not using any FP method before the conception,

All amenorroiec women after first 6 weeks of delivery and were not using any FP method and not expecting to have a child at least for 2 years,

Those who are using traditional methods of contraception (periodic abstinence and withdrawal) and natural methods of contraception (calendar method and basal body temperature method) at the time of survey.

Out of all, who had no plans to move out of the area within the period of next twelve months were included. The widowed, separated or whose husbands were abroad and not having any form of sexual contact at present were excluded. The calculated sample size of 264 of eligible women from each MOH area were selected by Cluster sampling with 12 individual in one cluster.

Phase 111-Intervention phase: Development and implementation of Health Education Intervention for both PHMM and target group women carried out with objectives of improving the knowledge and attitudes of PHMM in providing FP services and improving that of the target community in using FP services. For that, trainers’ guide for the trainers conducting training workshop for PHMM, a hand book on FP for PHMM, health learning materials (flip chart and a brochure) for women and a training module for the target group were developed.

A two day workshop was conducted for PHMM to update the knowledge, to facilitate acquisition of favorable attitudes and practices and to improve the skills of counseling the target community. The full “Health Education Package” for the clients consisted of four sessions of which the first one was conducted by the principal investigator (PI) and the PHM. The rest three were conducted by the PHM during home visits, at clinics and at any suitable place where she came in contact with the selected women. A referral card was given to the individual woman (to be used when she decides to seek FP advice and services) with written information containing clients name, MOH area and PHM area and name of the FP clinic with details of the appointment. The brochure with information on FP services and methods were distributed among all selected women. Despite the health education sessions, no changes in service provision were made to ensure that all women who wanted to receive FP services were provided through routine clinic services.

For the control group, no specially arranged educational activities in relation to unmet need and FP carried out. However, they were subjected to their routine FP services.

Phase 1V - (Post Intervention Phase): This was conducted in two steps. Initially, evaluation of the effectiveness of intervention in improving knowledge and attitudes on the PHMM after two months and on target group after six months of intervention using same questionnaires both in IA and CA.

Finally, the percentage of women who accepted a modern method of FP and the reduction of unmet need at the end of six months of intervention in IA and without intervention in CA was assessed and compared. In cases of pregnant and post partum mothers (26 in IA and 17 in CA), data collection was continued until the last mother in the group completed 6 weeks post partum to assess the acceptance of a FP method, if the period exceeded six months from the last date of the intervention.

Validity of data was maintained gaining thorough knowledge on the subject by literature review, using simple and clear operational definitions for all the relevant variables, using close ended questions clearly in simple, local language, permitting the flow of discussion and asking sensitive questions indirectly at the end, pre testing questionnaires and training data collectors. All the records were inspected just after the data collection for inconsistencies and incompleteness. Both pre and post intervention assessments were standardized and conducted in a uniform manner. Non response rate was minimized by collecting data with minimal disturbances to the daily activities of both data collectors and participants and paying repeated three attempts in data collection for one individual.

In order to maintain reliability of data, 25 subjects from each area were interviewed in two weeks of the initial survey to assess the test - re test reliability. Agreements between the responses in the two questionnaires were measured using Cohen’s Kappa for categorical variables. A Kappa value of ≥0.75 represents excellent agreement and 0.40-0.74 represents fair to good agreement14. All surveys in the present study had Kappa values of >0.75 representing excellent agreement.

Analysis: The concept related to “Grounded Theory” with necessary modifications was used in analysis of FGDs. In the analysis, primary data consisted of transcripts of audiotapes and written down notes. Two experts developed coding categories independently by indexing and sorting primary data and identifying dominant themes and categories. Then they met and came to a consensus on those themes and categories. Finally, results were presented in a narrative form. Whenever relevant, direct quotes of the participants were used. The findings of three FGDs were not similar and were compiled separately for analysis.

Attitude was marked using a 4 - point Likert scale: very favorable (+2), favorable (+1), unfavorable (-1) and very unfavorable (-2). Percentage scores for individual components of attitude and the overall score was calculated. For nominal data, Chi-squire test was used in independent samples to test the significance of difference between IA and CA. The standard error of difference between percentages for two proportions (SND test) was used to assess difference between intervention and control area in relation to the method of known by respondents.

For continuous data with normal distributions, such as mean knowledge scores the “t test” was applied to detect any significant difference. Here “t test for individual samples” used for analysis of significance of deference between IA and CA in pre and post interventions. “Paired t test” was used for paired samples in comparison of within IA and within CA in comparing the knowledge components in pre and post intervention.

In this study the attitudes scores were not normally distributed. Therefore non parametric tests were used to assess the significance of the intervention between IA and CA. For unpaired samples Mann Whitney U test was applied (in comparison of IA and CA in pre and post intervention), while Wilcoxan Signed Rank test was applied for paired samples (in comparison of IA in pre and post intervention and CA in pre and post intervention).

Results

In all 4 FGDs, the needs of addressing unmet need were identified as to prevent unintended pregnancies, induced abortions and their complications.

The identified suggestion were training of all the working categories on unmet need supported by provision of simple and clear guide lines in basic training as well as in in-service training followed by regular supervisions, improve quality and quantity of service provision, conducting client friendly service outlets and regular follow-ups to prevent discontinuation of accepted methods and strengthening the coordination between preventive and curative sector to attend the needs of referred clients to hospitals.

At the end, 68.7% (n=180) of the IA and 21% (n=54) had started a modern method of FP, reducing the unmet need with a statistically significant difference. OR=8.25 (95% CI; 5.44-12.54). Among those who accepted, DMPA was the method accepted by most in the IA (43.3%; n=78) as well as in the CA (38.9%; n=21).When the source of the accepted method was considered, majority of in the IA (72.8%; n=131) and in the CA (70.4%; n=38) had selected the government sector for their source of FP method.

Discussion

The intervention was effective in improving the knowledge and attitudes of both service providers as well as the clients and in reducing the unmet need for modern methods for FP among the latter.

The study was confined to two MOH areas from the Kalutara district due to logistical, financial as well as time constraints. The random allocation of study and control groups facilitated equal distribution of the background variables among both groups. To minimize contamination, MOH areas that were situated apart were selected as IA and CA. Although the classical experimental trial is based on random allocation of individuals to experimental and control subjects, the community surveys are conducted targeting a group of participants in a given defined community. Unlike administration of drugs which has to be at individual level, preventive programmes are feasible and more effectively carried out through mass administration.

the PHMM were targeted in the intervention because they are the most appropriate service providers to conduct the intervention, being responsible for providing FP services at the grass root level. The experience in relation to previous studies on weaning practices15 breast feeding16 and cervical cancer screening17 conducted in the same district provide evidence of their capabilities and success in getting the relevant message across to the target community. The use of a SAQ was justified based on their same educational level and helped save time and gave them the freedom to provide genuine responses, which would not have been the same in the presence of an interviewer. Anonymity ensured the validity and reliability of responses. Since the response rate was 100%, the findings can be generalized to two selected MOH areas. Since those two were selected randomly, the findings can be applied to other MOH areas in the district as well reflecting high external validity of the study. This is considered as a strength of this study

In the second study group, the required samples (264 in each arm) were selected by cluster sampling with 12 in one cluster, while clusters were selected by PPS technique from all the PHM areas in each respective MOH area allowing all socio demographic variables to distribute evenly. Data collection instrument was an IAQ with questions on knowledge and attitudes which required more time in the pre test and achieved by limiting the cluster size to 12.

In order to ensure reliability and accuracy of data collected by PHNSS, they were not allocated to their duty assigned areas. Training of them on the subject and the data collection procedure enhanced the reliability. Providing Interviewer’s Guide assured anonymity and confidentiality, with minimizing non response bias.

The intervention was conducted as a two way communication process, which has more influence the behavioral change following attitude change in the target group. First session was conducted by the PI with the PHM while the next three were by the PHMM. The involvement of the PI in the sessions facilitated clarification of most of the misconceptions that were influencing the participants’ behavior.

The post intervention assessment was conducted six months after the intervention, minimizing the effect of maturation which could affect the validity of the data. The same IAQ was used as in the pre intervention. The Hawthrone effect caused by application of same study instrument repeatedly was controlled by using the CA. Data collection was done by changing the allocated areas of the data collectors assigned during the pre intervention to minimize the intra observer bias.

During the procedure, special measures related to service provision such were not adopted, except the provision of a referral to the FP clinics Since the primary objective was motivation of women for increased uptake of FP, provision of additional services temporarily which may not be sustainable in the future would like to lead to a decline in seeking FP services.

The method of triangulation was achieved by way of FGDs, allowing qualitative approach to complement the quantitative approach in the present study.

The findings of FGDs which were conducted in three different working categories compatible with that of the base line survey on PHMM and the target group with agreement of existence of unmet need and its’ serious but avoidable consequences. Similarly, the need of basic and in service training for all the working categories providing simple and clear guide lines, improving the knowledge and the awareness of the community on the subject were highlighted.

Among PHMM in IA and CA, all other socio demographic variables had no significant difference except the marital status which showed a significant difference between IA and CA (p=0.006) where 62% of PHMM in IA and 88% in CA were married, but practical relevance cannot be attached to it as majority in the two groups were married.

In the pre intervention assessment of knowledge, the difference in overall scores between study groups (P=0.38) were not statistically significant.

With regard to post intervention assessment of knowledge, all the scores related to individual items increased along with the increasing of mean overall score for IA from 29.9% to 67.7% ,compared to that of CA which increased from 28.1% to 30.8% having highly significant (p<0.001) difference between IA and CA.

In the CA knowledge pertaining to female reproductive tract (P=0.01) and emergency contraception (P=0.008) showed a significant increase in the post intervention which can be attributed to the Hawthrone and maturation effects which are well known biases related to intervention studies.

In PHMM, attitudes were assessed in relation to the statements: 1). Selection of the appropriate method for every couple by the PHM, 2). A couple should be informed only about the most suitable family planning method for them, 3). Traditional family planning methods can be eliminated from the society with good performance of the PHM, 4). Emergency contraception is suitable even for unmarried females, 5). Women doing heavy work should not select female sterilization as a family planning method, 6). Natural family planning methods are more suitable for a country like ours because there is no cost involved, 7). Induced abortion is harmful even if performed by a qualified person, 8). Discussion about sexual problems with unmarried people is not compatible with our culture, 9). Unmet need can be reduced by insisting women to do female sterilization and 10). It is not possible to change the contraceptive behavior of the people with unmet need. In the pre intervention assessment of PHMM, all the median scores of IA were either higher or same as that of CA except for the statement “traditional family planning methods cannot be completely removed from the society”, for which the CA scored higher. In the post intervention, all the items in the attitude score showed a significant improvement as well as in the overall score (p<0.001) in the IA.

In post intervention, the overall median attitude score for the IA increased from 37.5 to 86, whereas that of CA increased only from 40 to 41, indicating a highly significant improvement in attitudes in IA compared to CA (P<0.001). This is an important finding that with improvement in knowledge the attitudes are also likely to improve. This phenomenon should be capitalized on and focus should be directed towards more training in FP which will be beneficial in motivating the target group to reduce unmet need. The knowledge and attitudes of the target group were assessed using an IAQ which is considered as suitable for data collection in a heterogeneous group like women in reproductive age with different socio demographic characteristics ensuring the accuracy and reliability of the responses received.

Out of 264 women participated in the pre intervention assessment, only 262 women from the IA (MOH area Horana) and 257 from the CA (MOH area Matugama) were available for the post intervention assessment. However there was no significant difference in losses to follow up (p=0.88) in the two groups. The presence of loss to follow up may have affected both external and internal validity of the study.

When compared to pre assessment, women of the IA (p<0.001) showed a significant improvement in the post assessment and had higher mean scores for all the items on knowledge. On the contrary, those of CA (P=0.29) had shown only a slight increase over time, which was not large enough though to reach statistical significance.

The significant increase in the IA can be attributed to the intervention because all factors that would have led to a similar increase due to other extraneous factors have been taken control by having the control group. The slight improvement observed in the CA may be attributed to the Hawthrone and maturation effects as for the PHMM because among the community too, most of the respondents were educated.

With regard to attitudes, all the items as well as the overall attitude scores (IA: Median score=70.0%; IQR: 50.0-70.0 versus CA: Median= 30%; IQR= 10-50) were significantly higher in IA in the post intervention phase.

With regard to attitude within groups, attitudes were assessed in relation to following statements: 1).Induced abortion for an unwanted pregnancy is not accepted, 2).No harm in using oral contraceptives just after marriage, 3).Insertion of Intra Uterine Device is painful, 4).Sexual satisfaction is reduced when the condom is used and 5).Sterilization is not suitable for women doing heavy work. All the attitude scores of the IA showed an increase in the post intervention phase with statistically significant difference. However statistically significant increase was seen in the attitudes related to “insertion of an IUD is painful” and “the sexual un satisfaction of the condom” in the CA too in the post intervention.

Acceptance of modern FP methods by the participants was assessed after follow up of six months after intervention. With respect to pregnant and post partum women whose proportions in the IA was 9.8% (n=26) and CA 6.4% (n=17), their assessment of acceptance was confined to the end of the post partum period which is considered the ideal time to commence FP after a delivery. Missing this opportunity translates into practical difficulties in excluding a pregnancy in the presence of lactational amennorrhoea.

At the end of the follow up period, 68.7% (n=180) of the IA and 21% (n=54) in the CA had started a modern method of FP, reducing the unmet need in IA by 68.7% and in CA by 21% with a highly significant difference (p<0.001) which can be attributed to the intervention itself. This reflects the need and the effectiveness of a special intervention to address the unmet need and to fill the gap between the desire and the practice of FP in the community.

Among those who accepted, DMPA was the method accepted by most in both areas (IA: 43.3%; n=78 and CA:38.9%; n=21). It is consistent with the usual practice of FP in the community; the injectables are the most popular. Since any modification of the service provision was not done during the intervention this outcome reflects the usual trend in the community in selecting FP methods.

When the source of the accepted method was considered, majority of the IA (72.8%; n=131) and of CA (70.4%; n=38) had selected the government sector for their source of FP method. This highlights the fact that if the correct information is given to the community through an accepted channel, the community has the tendency to obtain the services through the government sector. Therefore a concerted effort should be made to sustain the services and ensuring availability of all resources required.

With regard to limitations, the period of follow up for PHMM was only limited to two months due to practical reasons. The sustainability of the gained improvement in knowledge and attitudes could not be measured during such a short period. Ideally it should be assessed at different follow up periods and this information is essential to decide on the frequency of conducting in service training programmes. Due to time constraints this was not feasible within this study and thus it is also considered a limitation of this study. However, it may be done through the routine services and therefore, the feasibility of further assessments needs to be explored.

The follow up period for women with unmet need was limited to six months which again limited the ability to measure the long standing retention of knowledge and attitudes so gained. Even though a reduction of unmet need was observed over these six months, the degree of sustainability is an issue related to practices too. The common experience of trouble shooting occurs not at the commencement but with continuation of FP. Another important aspect that needs assessment is the scrutiny of correct use of the chosen method. Having the feasibility to assess all above would have added more meaning to the study but practical constrains limited these assessments.

Ethical considerations

The area of research was on FP which deals with very sensitive personal issues and the conduct of the intervention, where the benefits if any are directly applied to only one arm of the study.

Informed consent was a must for enrolling participants to the study and they were free not to participate or to leave the study at any point they wished to, without any restrictions being imposed to the routine services they entitled to otherwise. All the sensitive questions were dealt carefully by introducing smoothly incorporating preambles, placing them at the bottom of the questionnaire which allowed adequate time for the respondent to develop confidence in the interviewer by the time these questions were reached. Confidentiality was ensured and implemented by making the questionnaires anonymous. Data were kept with the principal investigator with no access to others once the data until collection was completed.

After the completion of the study, the complete course of training was given to the PHMM in the CA. In view of the success of the intervention as observed from the results, a strong request was made to make use of this training for the benefit of the community who should be the ultimate beneficiaries of this whole programme.

Ethical clearance for the study was granted by Ethical Review Committee of Faculty of Medical Sciences, University of Kelaniya, Ragama, Sri Lanka.

Conclusions

The mean overall knowledge scores of PHMM of the IA were 29.9 (SD=8.1) at pre intervention improved to gain overall mean scores of 65.7(SD=7.2) at 2 months post intervention. Median overall attitude scores of the IA were 50% (IQR: 50-50) at pre intervention which improved to median of 100 (IQR: 100-100) after two months of intervention. The mean overall knowledge scores of women with unmet need for modern methods of FP of the IA were 37.6% (SD=14.3%) at pre intervention improved to gain overall mean scores of 70.6 (SD=11.8) at 6 months post intervention. Median overall attitude scores of the IA were 20% (IQR: 0-50%) at pre intervention which improved to median of 70% (IQR: 50-70%) after six months of intervention.

Acceptance of modern methods of FP, hence reduction of unmet need in IA was 68.7% and in the CA was 21%. The difference in reduction of unmet need for modern methods of FP between IA and CA was highly significant (p<0.001) at six months of intervention.

Acknowledgements

I’m grateful to my supervisors Professor Pushpa Jayawardana, Department of Public Health, Faculty of Medical Sciences, University of Kelaniya, Ragama, Sri Lanka and Dr. Ayendra Balasooriya, Consultant Community Physician, Health Education Bureau,No.2, Kensy road.cColombo 08, Sri Lnka.

Recommendations

Conducting regular in service training to upgrade knowledge and to sustain favorable attitudes among PHMs can be utilized to motivate the target community in adopting favorable behavior towards FP.

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