0 Georgetown University’s Institute for Reproductive Health and Save the Children AUGUST 2018 WALAN PILOT Final Evaluation Report Assessing the effectiveness of a group counseling model for couples on Fertility Awareness Method (FAM) in Northern Uganda 1 © 2018, Institute for Reproductive Health, Georgetown University Recommended Citation: Institute for Reproductive Health. 2018. WALAN Pilot Final Evaluation Report: Assessing the effectiveness of a group counseling model for couples on Fertility Awareness Methods (FAM) in Northern Uganda. Fertility Awareness for Community Transformation (FACT) Project, Washington, DC. Institute for Reproductive Health, Georgetown University. This report was authored by Jeannette Cachan, Lillian Ojanduru, and Esther Spindler on behalf of the Fertility Awareness for Community Transformation Project (FACT) Project. The authors would like to acknowledge the commitment of the community leaders, Community Development Officers (CDOs) and WALAN youth facilitators from Gulu, Amuru and Nwoya who carried out the implementation of the WALAN pilot activities. We also recognize the many consultants and organizations responsible for data collection and analysis, including Robert Okeny, Barbra Aciro, Florence Nambooze and Annette Nabuduwa from Akili Foundation. The authors gratefully acknowledge Victoria Jennings, Rebecka Lundgren, and Dominick Shattuck for shaping and guiding the study and Danielle McCadden and Sam Okello for their contribution to the M&E guidelines and tools. For their support with field implementation, stakeholder engagement and monitoring of the intervention, we thank Shannon Pryor, Dr. Sarah Naikoba, Dickens Ojamuge, Jolly Awor Grace and Sophie Akere from Save the Children, and Thomas Odong, Jennifer Langoya, Sam Okello and Emily Arach from IRH/Uganda. Lauren DuComb, Hanley Futz, Darya Dokshina and Tori Stevens for their programmatic and research support; and Sophie Savage and Sammie Hill from IRH’s Communications team provided valuable support with multiple dissemination events and products. We also thank Jessica Velcoff for spearheading the initial formative research and concept design phases over four years ago. This report was prepared by IRH under the Fertility Awareness for Community Transformation (FACT) Project. This report and the FACT Project are made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement No. AID-OAA-A-13-00083. The contents are the responsibility of the authors and do not necessarily reflect the views of Georgetown University, USAID, and the United States Government. FACT Project Institute for Reproductive Health | Georgetown University 1825 Connecticut Avenue, N.W., Suite 699 Washington, DC 20009 USA irhinfo@georgetown.edu www.irh.org/projects/FACT_Project 2 TABLE OF CONTENTS TABLE OF FIGURES ...............................................................................................................3 TABLE OF TABLES..................................................................................................................4 ACRONYMS ...........................................................................................................................5 EXECUTIVE SUMMARY .........................................................................................................6 1. INTRODUCTION................................................................................................................9 2. WALAN’S SOLUTION DEVELOPMENT.......................................................................11 3. PILOT IMPLEMENTATION.............................................................................................13 4. PILOT EVALUATION METHODOLOGY......................................................................19 5. FEASIBILITY RESULTS .....................................................................................................30 6. EFFECTIVENESS RESULTS..............................................................................................46 7. ACCEPTABILITY RESULTS..............................................................................................71 8. CONCLUSION AND RECOMMENDATIONS..............................................................79 REFERENCES ........................................................................................................................83 ANNEX .................................................................................................................................85 3 TABLE OF FIGURES Figure 1. Map of Northern Uganda ......................................................................................................... 11 Figure 2. WALAN Solution Components................................................................................................... 14 Figure 3. WALAN Flow of Activities.......................................................................................................... 17 Figure 4. Flow chart showing number of FAM users contacted and in/eligible at first interview. 25 Figure 5. Community learning sessions delivered, by topic from May 2016 to March 2017 (n=123) .......................................................................................................................................................... 31 Figure 6. Profile of Community Learning Participants........................................................................... 31 Figure 7. Interest in FP methods during community learning sessions, by method type (n=1,521)32 Figure 8. Number of clients seeking FP counseling services at district health facilities, 2015 - 2017 ............................................................................................................................................................... 32 Figure 9. Proportion of Youth Facilitators meeting the 75% competency threshold (n=13).......... 34 Figure 10. Example of questions and answers during observed group counseling sessions.......... 36 Figure 11. SDM users who show how to use the method correctly, at first and second interview 50 Figure 12. SDM users’ use of method during fertile days, at first and second interview............... 52 Figure 13. SDM female users’ reasons for discontinuing SDM use, at second interview (n=20)... 56 Figure 14. SDM female users’ self-reported reasons for pregnancies, at second interview (n=6) ......................................................................................................................................................................... 56 Figure 15. TwoDay Method users who demonstrate how to use the method correctly, at first and second interview ........................................................................................................................................... 57 Figure 16. TwoDay Method users’ reported actions to take if experiencing unhealthy secretions (correct answers in green)............................................................................................................................ 59 Figure 17. TwoDay Method users method use during fertile days, at first and second interview 60 Figure 18. Correct use of TwoDay Method by means of verification, at first and second interview ......................................................................................................................................................................... 61 Figure 19. FAM users who initiated a conversation about what to do on fertile days, at first and second interview ........................................................................................................................................... 65 Figure 20. Proportion of SDM users who reported “always true to me” when asked if they felt comfortable about…................................................................................................................................... 66 Figure 21. Proportion of TwoDay Method users who reported “always true to me” when asked if they felt comfortable about…................................................................................................................... 67 4 TABLE OF TABLES Table 1. Fertility Awareness-Based Methods defined .......................................................................... 10 Table 2. Community Learning and Group Counseling Training Schedule.......................................... 16 Table 3. WALAN study timeline ................................................................................................................ 20 Table 4. Feasibility data collection methods, by sample achieved .................................................... 21 Table 5. Effectiveness data collection methods, by sample achieved................................................ 23 Table 6. Acceptability data collection methods, by sample achieved............................................... 27 Table 7. Type and number of FGD conducted with community members ......................................... 27 Table 8. Type and number of KIIs conducted with service providers and community leaders...... 28 Table 9. Number of Group Counseling Sessions and Participants, May 2016 – March 2017..... 33 Table 10. Competency Scores for Youth Facilitator Pairs for SDM and TwoDay Method group counseling (n=13) ......................................................................................................................................... 35 Table 11. Competency scores by counseling category, for SDM and TwoDay Method group counseling (n=13) ......................................................................................................................................... 35 Table 12. FAM user demographics at first interview, by SDM and TwoDay Method samples..... 47 Table 13. FAM user FP history at first interview, by SDM and TwoDay Method samples............. 48 Table 14. FAM user reasons for using FAM at first interview, by SDM and TwoDay Method samples........................................................................................................................................................... 49 Table 15. FAM users’ exposure to WALAN activities at first interview, by SDM and TwoDay Method samples............................................................................................................................................ 50 Table 16. Correct knowledge of SDM use by demonstration steps, at first and second interview ......................................................................................................................................................................... 51 Table 17. Percentage of SDM users reporting correct management of fertile days, at first and second interview ........................................................................................................................................... 51 Table 18. Correct use of SDM by method verification, at first and second interview.................... 53 Table 19. SDM users’ self-reporting of out of range cycles, at first and second interview........... 54 Table 20. Action taken by SDM users with out of range cycles, at first and second interview..... 54 Table 21. SDM Male Partner Role, at first and second interview ...................................................... 55 Table 22. Correct Knowledge of TwoDay Method Use by step, at first and second interviews.. 58 Table 23. TwoDay Method users correct management of fertile days............................................. 59 Table 24. TwoDay Method male partner roles, at first and second interview................................. 61 Table 25. FAM users who feel their opinion is taken into account about what to do on fertile days, first & second interview.................................................................................................................... 65 Table 26. FAM female users comfortable discussing topics with other couples, at first interview 71 Table 27. FACT WALAN monitoring data collection process .............................................................. 86 Table 28. Competency scores for youth facilitator pairs during group counseling sessions (n=13) ......................................................................................................................................................................... 87 Table 29. Youth facilitator pairs meeting competency criteria, by measure and observation point (n=13)............................................................................................................................................................. 88 Table 30. FAM users’ comprehensive fertility awareness knowledge, at first and second interview ......................................................................................................................................................................... 90 5 ACRONYMS CDO Community Development Officer DHS Demographic and Health Survey FA Fertility Awareness FACT Fertility Awareness for Community Transformation FAM Fertility Awareness-Based Methods FGD Focus Group Discussion FP Family Planning ICRW International Center for Research on Women IDI In-Depth Interviews IRH Institute for Reproductive Health, Georgetown University KII Key Informant Interview LAM Lactational Amenorrhea Method MoH Ministry of Health M&E Monitoring & Evaluation ODK Open Data Kit REAL Fathers The Responsible, Engaged and Loving Fathers Initiative SDM Standard Days Method USAID United States Agency for International Development VHT Village Health Team WALAN Wake ki Lago Nywal (Be proud with family planning) 6 EXECUTIVE SUMMARY SOLUTION OVERVIEW The community-based group counseling approach described in this report was tested in Northern Uganda, relying on non-health volunteers to (a) spread fertility awareness and family planning (FP) information within their communities, and (b) deliver counseling in FAM to couples, while (c) supporting linkages to the health systems for other FP options. From 2014 to 2017, IRH and Save the Children, researched and developed the framework for this approach, through formative research, and solution testing and development. The resulting model was a group counseling model delivered by community volunteer facilitators specifically for couples. Community members branded this approach “WALAN” which stands for Wake ki Lago Nywal (Be proud with family planning) in Acholi. Under WALAN, trained Youth Facilitator pairs, with the support of Community Development Officers (CDOs), mobilized the community to attend community learning sessions on fertility and FP topics, subsequently delivering the community learning sessions to groups of 30-40 men and women. Following the community learning sessions, youth facilitators delivered group counseling sessions in FAM to small groups of couples (two to six couples per session) who opted for either SDM or TwoDay Method as their family planning choice. For members interested in non-FAM methods, the facilitator pair provided an invitation card as a form of referral to FP services at the health facilities and to community Village Health Team (VHT) members. Community engagement activities were also conducted with health service providers and community leaders. STUDY DESIGN A prospective mixed methods evaluation design was used to describe the feasibility, acceptability and effectiveness of the Group Counseling Model. Data points included survey interviews with 175 female FAM users (122 SDM; 53 TwoDay Method), and 96 male partners (60 SDM; 36 TwoDay); in-depth interviews with seven couples who used either SDM or TwoDay Method; key informant interviews with nine health service providers and community leaders; focus group discussions with 25 youth facilitators and 38 community members; competency checklist observations of 12 facilitator pairs at two different time points; attendance monitoring data; and FP service statistics of local health facilities. KEY RESULTS The pilot evaluation findings suggest that the WALAN community group counseling model is feasible to implement, but supportive supervision is necessary to ensure quality of FP counseling by non-health workers. Results also suggest that the majority of couples who learn about FAM in a group counseling model are able to use the method correctly. Results, grouped by feasibility, effectiveness and acceptability, are highlighted below. 7 (1) Feasible to be implemented by trained non-health community agents, with strong supportive supervision and mentoring. Over the 10-month implementation period, the 15 trained youth facilitator pairs delivered a total of 123 community learning sessions to the community at large and 95 group counseling sessions (67 SDM and 28 TwoDay Method sessions) to groups of couples. Over time, Youth facilitators improved their counseling skills in both methods. The percentage of youth facilitators receiving a high competency score increased from 33% to 75% over four months. Gains in accurate counseling was linked with increased practice time and a booster training. Most youth facilitators delivered group counseling sessions when provided the adequate mentoring and supervision. (2) Acceptable to participating couples and to the community at large. Attendance to community learning sessions—which were intended to sensitize community members about HTSP / FP, LAM, and fertility more broadly—as well as FAM counseling for couples-was high, reaching both men and women. Qualitative results suggest that community members were generally excited about having access to FAM, and they highly valued having easier access to hormonal method alternatives not typically offered at health facilities. Across 15 villages, a total of 288 couples started a FAM (214 SDM; 74 TwoDay Method). Interest from both women and men in other FP methods offered at health facilities was observed during community learning sessions, as measured by the distribution of invitation cards to visit those facilities. Evaluation data reflect a high degree of interest and enthusiasm for continued counseling on FAM. Couples who attended sessions on FAM reported not only returning to multiple method support sessions, but also that method use was a joint effort involving both the female and male partners. (3) Couples learned and used SDM and TwoDay Method correctly, as identified through follow-up surveys and interviews with couples who chose to use a method:  80% of SDM users demonstrated correct method use at the first follow up (demonstrating all 5 steps correctly); at the second follow up the percentage of correct demonstrations increased to 87%.  84% of TwoDay Method users accurately demonstrated correct use at the first follow up; and 89% correctly demonstrated using the method at the second follow up.  Management of the fertile days is central to successfully utilizing a FAM (defined as reporting either abstaining, using condoms, or both abstaining and using condoms during fertile days). 96% and 93% of women using SDM and TwoDay Method users, respectively, reported managing their fertile days effectively.  21% of SDM users discontinued using the method at the second follow up (six to seven months after method initiation). However, 26 of the 27 TwoDay Method users continued to use the method at the second interview point. Reasons for discontinuation included: changes in fertility desires (wanting to become pregnant), interest in using a more effective method, and difficulties or issues in using the method (e.g. losing the CycleBeads; tired of moving the ring; forgetting the CycleBeads during seasonal migration; and pregnancy). In three cases, SDM female users became pregnant as a 8 result of improper method use (failure to manage fertile days; forgetting CycleBeads while moving to a relative’s house). Interestingly, findings suggest that in some cases, users simply wanted to “try” out the method since it was readily available in the community. LESSONS LEARNED Overall, acceptance for learning about FP methods and receiving counseling for FAM among couples in a group setting was very high and effective within these Northern Ugandan communities. The group counseling in FAM as delivered by the community youth facilitator pair—who are non-health workers—was found effective after two rounds of training and reinforcement through supportive supervision as facilitators were learning the ropes of counseling over time. The findings suggest that while couples are able to learn how to use FAM correctly, one in five female SDM user discontinued method use seven to eight months after method initiation. This is consistent with other IRH studies which have shown higher SDM use drop-out within the first few months. As well, qualitative findings suggest that in some cases, users simply wanted to try out a new method. We found that the men who participated in the couple counseling sessions were active participants in both counseling sessions and method use; and that couples reported improved communication and trust in their relationship as a result of method use, a finding that also is consistent with studies in other contexts. Lastly, our findings describe strong interest and demand for FAM as part of the FP method mix. This is a key finding as these Northern Uganda communities are frequently challenged with limited FP options, stock-outs and high FP discontinuation rates due to side effect concerns. Overall, this intervention shows there is demand for FAM counseling among couples in a group setting, but quality counseling requires strong support and supervision, in addition to health service linkages. 9 1. INTRODUCTION 1.1 BACKGROUND In this report, the Georgetown University Institute for Reproductive Health (IRH) describes activities carried out and results of the WALAN community-based group counseling model under the “Fertility Awareness for Community Transformation (FACT) Project” (Cooperative Agreement No. OAA-A-13-00083). FACT is a five-year United States Agency for International Development (USAID)-funded project implemented by IRH in partnership with the International Center for Research on Women, Population Media Center, and Save the Children (SC). FACT aims to foster an environment where women and men can take actions to protect their reproductive health throughout the life-course. FACT is a research, intervention, and technical assistance project that is developing and testing unique solutions in India, Nepal, Rwanda and Uganda to investigate two primary hypothesis:  Increased fertility awareness improves family planning (FP) use  Expanded access to fertility awareness-based methods (FAM) increases uptake of FP and reduces unintended pregnancies As part of the second hypothesis, the goal of the Wake ki Lago Nywal (WALAN) “Be Proud with Family Planning” intervention is to increase access to and uptake of FAM specifically, and FP in general, through existing community groups outside of the health system. Under this solution, two FAMs developed by IRH - Standard Days Method® (SDM) and TwoDay Method® - were offered through a community-based group learning and counseling model to couples in selected districts in the Acholi region in Northern Uganda. WALAN leveraged the Youth Initiative for Employment and sustainable Livelihoods Development (YIELD) project, implemented by Save the Children. This program aims to foster socio-economic empowerment of vulnerable youth in Northern Uganda. YIELD works with youth ages 15-24 in the districts of Amuru, Gulu and Nwoya, and focuses on agricultural, vocational, and apprenticeship training. Facilitators selected from YIELD received training in fertility awareness, FP, and FAM as well as an orientation in group facilitation to strengthen their interpersonal skills. In each community, a WALAN facilitator pair conducted community learning sessions on fertility awareness and FP topics, followed by small group counseling sessions on either SDM or TwoDay Method to interested couples and women. 10 1.2 RATIONALE Both SDM and TwoDay Method were developed by IRH to respond to the need for simple, accurate ways for women to identify the fertile window and avoid unprotected intercourse to prevent pregnancy (see Table 1). Given their ease of use and lack of side effects, SDM and TwoDay Method may appeal in particular to couples who are currently not using any method, are relying on some form of “rhythm” or withdrawal, or are dissatisfied with their current method. In addition, since SDM and TwoDay Method are knowledge-based methods, they can be offered by a provider outside of the health system. Because they are both information-based methods they can easily be offered directly to consumers through community-based approaches. Table 1. Fertility Awareness-Based Methods defined FERTILITY AWARENESS METHODS (FAM) Standard Days Method® (SDM) identifies a fixed fertile window in the menstrual cycle when pregnancy is most likely and is typically used with CycleBeads®, a visual tool that helps women track their cycle to know when they are fertile. Results of an efficacy trial showed SDM to be more than 95% effective with correct use and 88% effective with typical use, well within range of other user-dependent methods (Arevalo, Jennings, Sinai 2002). TwoDay Method® relies on cervical secretions as the fertility indicator. Results of the efficacy trial published in 2004 showed it to be 96% effective with correct use and 86% effective with typical use (Arévalo, Jennings, Nikula, Sinai 2004). FAM – including SDM and TwoDay Method -- are traditionally offered in a one-on-one provider-client interaction similar to other FP methods. However, research suggested that FAM can successfully be taught in groups, but had seldom been tried outside of small-scale service delivery initiatives(Seidman 1997). Furthermore, IRH research on FAM provided robust evidence that these methods can be offered successfully by low-literacy community-level workers (in and out of the health system), including a significant amount of tools and resources already developed and tested for these settings (High-Impact Practices in FP [HIPs], 2015). In the context of low resource settings—where women may not have access to health services—a group learning approach meets both the local need and cultural context for sharing key information. Community learning sessions provide an important opportunity to disseminate information about fertility and FP methods and generate demand for FP use. As an information-based and natural FP method, FAM are uniquely positioned to be offered within group settings, unlike other FP methods. Therefore, increasing access to and use of FAM through existing groups and social networks offers an ideal opportunity to go beyond the health system to address unmet need for FP in areas that desperately need services. Given the existing evidence and IRH’s experience with FAM, WALAN was designed as a community-based solution, offering both SDM and TwoDay Method (and LAM during community learning sessions) directly to consumers in a group counseling model in which couples came together to learn the method of their choice. 11 1.3 CONTEXT After two decades (1986-2006) of armed conflict that engulfed residents in the Northern Region of Uganda in violence and displacement (Akumu, Amony, and Otim 2004; Branch 2008), the Acholi sub-region has been undergoing a period of rehabilitation and transition that is influencing the acceptability of FP. People in this region are striving to rebuild their livelihoods as well as the traditional familial and social structures that were eroded during 20 years of internal conflict. At the same time, unintended pregnancies are very common in Uganda, with more than four in 10 births being unplanned. On average, women have approximately 6.2 children, but desire only 4.5 children (Uganda DHS 2011). Unplanned births are the highest in Northern Uganda, with 54% of all births being unplanned, compared to the national average of 43% (Guttmacher Institute 2013). The gap between women’s desired and actual births suggests that women in the Acholi sub-region are unable to achieve their fertility goals. The high levels of fertility also pose serious limitations to plans for improving lives of the Acholi people. 2. WALAN’S SOLUTION DEVELOPMENT A solution design process informed the development of a solution aimed at fertility awareness information broadly to men and women throughout the community, as well as group counseling sessions on FAM to interested couples. The concept also involved establishing a supportive environment through sensitizations of health facility personal, Village Health Teams (VHTs) and community leaders. In addition, referrals for other FP methods were considered as part of the solution design. 2.1 CONCEPT DEVELOPMENT WORKSHOP A concept development workshop was held in Gulu with participation from key stakeholders who were well placed to inform the design of the solution and may have been potentially interested in supporting the solution implementation. The workshop provided an opportunity to disseminate, validate and discuss formative research findings and begin development of a concept for the solution. Objectives for the workshop were to share and discuss findings from the formative research; define the core components, principles, and requirements of the solution; identify factors that could affect implementation of the solution; and identify the most feasible mechanism of delivery for FAM within the existing YIELD groups as well as ancillary components that would complement the solution. Figure 1. Map of Northern Uganda 12 2.2 PROTOTYPE TESTING Rapid prototype testing was conducted to test components of the solution with community members and obtain their input. A series of sessions were observed, where a facilitator from the YIELD platform led sessions on fertility awareness and FAM. These sessions were followed by focus group discussions with participants and facilitators to solicit their reactions to the session as well as suggestions for changes and improvements. This feedback was subsequently incorporated into the concept design, as part of an iterative process that involved development of components of the solution to achieve the group teaching objectives. Prototyping also involved illustrations development and testing through an iterative process of focus group discussions with community members to solicit their ideas and suggestions for culturally appropriate ways to depict key fertility awareness and FAM messages. The final illustrations were incorporated in the facilitators’ job aids and client materials. 2.3 MAPPING OF FP SERVICE PROVIDERS AND FACILITIES Save the Children conducted a mapping of FP providers and facilities in settings where both proof of concept and pilot implementation took take place. The purpose of the mapping was to identify FP service delivery points where youth facilitators could refer community members if they wished to obtain an FP method other than a FAM. The preliminary analysis of the mapping indicated that FP services were very limited and poorly stocked with FP commodities. Efforts were made to encourage local private sector partners to support the health facilities with commodity gaps and referrals also were made to private outlets and Marie Stopes mobile services. 2.4 STAKEHOLDER SUPPORT ADVOCACY AND BUILDING STAKEHOLDER SUPPORT One-day workshops were conducted with district and sub-county officials in Gulu, Nwoya and Amuru districts to introduce the FACT Project to these stakeholders and generate buy￾in for the solution. Participating stakeholders included political officials, traditional leaders, and representatives from the religious communities. SCI and IRH presented an overview of the FACT project, provided an introduction to fertility awareness and FAM, and facilitated a discussion of the Group Counseling solution. The group discussed and came to an agreement on the roles and expected support from each district, and ways to link to other FP programs in the district. FORMATION OF LOCAL ADVISORY COMMITTEE A local technical advisory committee was established in Gulu to play an advisory role, provide local technical expertise, and offer guidance on concept design throughout the concept development and pilot implementation. Committee members included local district and sub-county council members, representatives of Christian and Muslim faith￾based organizations, FP service providers, and a community representative. The committee’s first meeting was held on January 22, 2015. IRH and SCI introduced the FACT Project and Group Teaching solution to the committee. Formative research findings and the preliminary solution design were shared, and committee members provided input on these. The committee established their expected role as an advisory body, their terms of reference, 13 and selected a Chairperson, Vice Chairperson, and Secretary to serve as the Executive Committee. The Advisory Committee remained involved throughout all phases of the project, from formative research to proof of concept to final pilot testing of the intervention. PROOF OF CONCEPT PHASE A 3-month proof of concept testing phase was conducted to refine the solution. The proof of concept results showed that participants were highly satisfied and comfortable learning about FAM with other couples and satisfied with both methods (FACT_WALAN_POC_Report_October_2016). However, some TwoDay Method users cited lack of support from other community members in using the method. As well, local leaders and group facilitators shared that TwoDay Method can be perceived as unhygienic and culturally inappropriate if women did not use toilet paper were to use their fingers to check secretions. As a result, the IRH research team decided to reduce the TwoDay Method sample size for the program evaluation, described below. Finally, the proof of concept phase tested the provision of group counseling sessions to couples only. However some participants expressed the importance of providing sessions to both women (only) and couples. As a result, the subsequent pilot model offered sessions to both couples and women alone, although our results described below suggest that sessions were mostly attended by couples. Lastly, the proof of concept phase results facilitated the further development and refinement of the training and intervention materials for group sessions. 3. PILOT IMPLEMENTATION The Group Learning and Counseling solution comprises three facilitator-led components: community learning, FAM group counseling, and referrals to FP services (see Figure 2). During community learning sessions, facilitators conduct brief, interactive lessons with community members to teach about human fertility, HTSP, and LAM and provide accurate information about FP methods, including FAM. At the end of this session, community members interested in receiving additional information are referred to a local health center for FP services or to a group counseling session on FAM. Couples are also encouraged to participate in method support sessions where they can discuss their experiences using the method, seek advice on potential challenges, and encourage one another to use the method correctly. 14 3.1 IDENTIFYING, SENSITIZING AND EQUIPPING KEY SOLUTION ACTORS There were several actors involved in all phases of the group couples counseling model, including:  Youth facilitators, recruited through existing youth groups, receive training in group facilitation skills and content materials that prepare them to deliver fertility awareness community learning and FAM counseling sessions to interested community members. In WALAN, youth facilitators selected by their peers were female and male volunteer members of their local YIELD Program and ranged in age from 18 to 30 years old. They worked in pairs (male and female) and were able to read and write in Acholi, the local language. Having a male and female facilitator pair was intentional to address cultural sensitivities addressing topics of human fertility among women and couples.  District and sub-county Community Development Officers (CDOs) received training by program staff that equip them to support the youth facilitators’ work through mentoring, mobilization, and problem-solving.  Local stakeholders (community, opinion, religious and cultural leaders) provided ongoing support of CDOs, and participate in awareness-raising events that promote acceptance of fertility awareness and FAM activities. Stakeholders were integral in raising awareness and promoting acceptance of fertility awareness and FAM activities. In WALAN, program staff engaged with a range of civic, religious and cultural leaders informed and sensitized at community meetings. Once these leaders agreed to lend their Figure 2. WALAN Solution Components 15 support, they integrated discussions about WALAN into their ongoing activities. For example, during community gatherings and meetings they informed about WALAN learning sessions. A poster that promoted FP was designed with input from these leaders and was used to prompt community discussions about child spacing and FP methods. Religious leaders would initiate discussions about WALAN during services, and youth facilitators would submit information about an upcoming WALAN activity to be read as part of the weekly notices during church.  A Technical Advisory Group (TAG) was formed to provide technical guidance and advice to the project throughout the course of implementation in addition to generating interest and buy-in to WALAN. The TAG was composed of key health stakeholders including representatives from the line departments of Health, Community Development and Planning and Population. It also included political representatives, cultural and religious leaders and community representatives. The TAG provided guidance to ensure that the project was culturally and socially sensitive and in line with the government policies and guidelines, technically. It provided input to the concept design (prototype testing) and refinement of the solution concepts. Members provided valuable input to the Group Teaching illustrations and materials. TAG members had the opportunity to interface with the Group Facilitators and beneficiaries and provided input in the packaging and delivery of the counselling sessions. In the last year of the project, members provided input to activities related to positioning WALAN for scale. 3.2 ESTABLISHING LINKAGES WITH THE HEALTH SYSTEM While WALAN operated outside the health system, strong linkages were established with the local facility and community health workers to facilitate a supportive environment for the youth facilitators work and ensure proper referrals of community members to FP services other than FAM. In addition to orientation sessions on fertility awareness and FAM for health care workers, reflection meetings with service providers were held twice during the pilot intervention to foster communication with FACT, encourage facilitators’ referral to the facilities and collect service statistics. Health workers and VHTs were integral to WALAN, and worked in concert with youth facilitators to provide FP information and services. For example, clients who required additional information on fertility awareness or FAM were referred to youth facilitators for community learning and group counseling sessions. Similarly, youth facilitators distributed FP invitation cards to community members who were interested in additional FP methods and services (e.g. obtaining hormonal contraception). In some instances, youth facilitators were invited by health workers and VHTs to local health fairs during the antenatal clinic days to discuss fertility awareness and FAM. 16 3.3 CONDUCTING YOUTH FACILITATOR TRAINING Trainings of Youth Facilitators were conducted by Community Development Officers (CDOs), who were trained as trainers and served as supervisors over the course of implementation. A total of 30 Youth Facilitators from five sub-counties (Bungatira, Anaka, Atiak, Gulu and Patiko) were trained at two points during the pilot phase (Table 2). At the first training Youth Facilitators were trained to offer community learning sessions on Human Fertility, HTSP and FP, and LAM and counseling in SDM. The facilitator pairs were then trained in counseling for SDM or TwoDay Method to couples in a group setting. FAM training was done in a phased process, first learning group counseling in SDM and later on TwoDay Method. Facilitators received a guide with the lesson plans they implemented in both community learning sessions as well as group counseling. Supporting job aids included flip chart on key topics, activity cards, and a FP methods board. Youth Facilitators were introduced to the counseling approach for FAM, tools and content and message delivery and working as a team. Each training included group work, role plays, and demonstrations on methods of message delivery. For each training the trainees also had the opportunity of a practicum for one day in the field, and the last day of the training was dedicated to drawing lesson plans for their work in their community and learning about completing forms to keep records of their activities. All training and intervention materials were endorsed by the Uganda Ministry of Health (MoH). Table 2. Community Learning and Group Counseling Training Schedule Date Content April / May 2016 (5 days)  Community learning in Human Fertility, HTSP and FP, and LAM  Counseling in SDM and method support  Field Practice in community learning  In-classroom practice in SDM counseling  Facilitation, orientation to WALAN, work planning and reporting July 2016 (3 days)  Review SDM counseling and facilitation  Counseling in TwoDay Method and method support  Field Practice in SDM and TwoDay Method counseling  Review experience with community learning and SDM counseling December 2016 (2 days)  Refresher on TwoDay counseling  Classroom practice  Review overall facilitators experience, work planning and reporting 17 3.4 DELIVERING COMMUNITY LEARNING AND GROUP COUNSELING The elements of community learning sessions are a series of facilitator-initiated tasks. Trained Youth Facilitator pairs, with the support of CDOs, mobilized the community to attend community learning sessions, subsequently delivering the community learning sessions to groups of 30-40 men and women. Following the community learning sessions, Youth Facilitators delivered group counseling sessions in FAM to small groups of couples (between two to six) who opted for either SDM or TwoDay Method. For members interested in non-FAM methods, the facilitator pair provided an invitation card as a form of referral to FP services at the health facilities and community VHTs. Mobilizing the community is the first task in preparing to implement Community Learning sessions. Facilitators, with the support of local stakeholders and CDOs, mobilize their communities to attend Community Learning sessions. Facilitators may choose to invite community members in many different ways, including announcing at water well, posting a note in a public area, telling friends and family, phone calls, asking religious leaders to announce sessions at the pulpit or during congregation meetings. The Community Learning sessions involve a trained male-female facilitator pair engaging their community members in reflection, discussion and information sharing on fertility awareness and FP topics. The sessions are open to all community members, including those who are not part of the facilitators’ group. The trained Youth Facilitators pair rely on lesson plans in a guide to deliver the sessions which are supported with job aids used by both facilitators and participants. These sessions are organized around three general topics addressed in sessions lasting approximately one and a half hour. Community members are invited to participate in the discussion topics that include:  Session 1 - Fertility Awareness (male and female fertility, menstrual cycle) Method Support Sessions Group Couples Counseling Sessions Figure 3. WALAN Flow of Activities 18  Session 2 - Healthy Timing and Spacing of Pregnancies (HTSP) and FP, including FAM (myths and misconceptions around FP)  Session 3 - Lactational Amenorrhea Method (LAM) Individuals and couples who are interested in learning about a FAM are referred to a FAM session specific to the method that they are interested in. Individuals and couples interested in other FP methods are referred to a FP service provider in their area. The Group Counseling sessions involve the same pair of trained facilitators delivering counseling, in either SDM or TwoDay Method, to interested couples in a group setting. For women who are interested in attending alone, facilitators schedule a separate session. FAM sessions are designed for 1 hour and involve the following tasks:  Screening – asking questions to know if the method is appropriate for the woman and the couple  Teaching – teaching the couple how to use CycleBeads to prevent pregnancy  Supporting the couple – helping the couple decide how they would manage condom use or abstinence during the fertile days when the woman can conceive (white beads) if they want to prevent a pregnancy. The FAM counseling followed by youth facilitators also ensures participants’ privacy and confidentiality and engaging the couple in discussing their FP plans and how they will manage the fertile days, using interactive and culturally appropriate methodologies. Couples who are interested in other methods or do not meet the methods criteria, receive a FP invitation card to visit with a healthcare provider or VHT to obtain the method of their choice. Couples who start using a FAM method are invited to attend a support session in which users can discuss with peer couples their experience using the method, any challenges they face, and receive or share advice for using the method correctly. These sessions which are optional, are held monthly by the Youth Facilitators, also involve a review of method use with couples, answering questions and referring users who decide to switch to a non-FAM method. 3.5 SOLUTION MONITORING Monitoring of the WALAN pilot was conducted through a collaborative process among youth facilitators, CDOs and FACT project staff. Youth Facilitators and CDOs were trained on the monitoring forms and process as part of the aforementioned WALAN training workshops. They practiced completing the forms both using a hypothetical scenario during the classroom portion, and as part of a practical activity that was incorporated into the training. Youth Facilitators completed attendance registries at the beginning of each Group Counseling session in addition to the Monthly Supply Form for materials distributed to group members, including condoms, CycleBeads, TwoDay Method client cards and FP invitation cards. Group Couples Counseling Sessions 19 CDOs collected forms from facilitators during monthly supervisory visits. During these visits, the CDOs observed the facilitators delivering a session using a checklist, and gave feedback to improve the facilitators’ performance. This was also an opportunity for facilitators to ask questions and bring up challenges or issues with the CDO. CDOs reviewed the monitoring forms with facilitators before collecting them, to identify and correct errors in completion or missing information. A reflection meeting with CDOs was held about once a month. This provided a space for CDOs to share successes and challenges, discuss issues they were facing, and collectively generate solutions. CDOs brought all of the forms that they had collected from facilitators to these meetings and gave them to the program coordinator. The data was useful in identifying issues in implementation, and the discussions promoted collective problem solving. A table of the monitoring data collection process can be found in Annex 2. 4. PILOT EVALUATION METHODOLOGY 4.1 EVALUATION PURPOSE AND RESEARCH QUESTIONS The purpose of the WALAN pilot study was to determine if a group counseling solution for couples could be an effective model for teaching, learning and using FAM in a community￾based setting. The study objectives and research questions of this study were: 1) Describe the delivery and feasibility of the group counseling model at the community level 2) Assess the effectiveness of the WALAN group counseling model vis-à-vis correct method use among women and couples1 who learn a FAM in a group couples counseling setting 3) Describe the acceptability of the group counseling model among participating couples and wider community members 4.2 EVALUATION DESIGN AND METHODS A prospective descriptive study design using mixed methods was conducted to assess whether a community-based group couples counseling is feasible, effective and acceptable for FAM counseling. The study was conducted in three districts in the Acholi Region in Northern Uganda. These districts were selected in collaboration with Save the Children and the district officials from the Community Development Office. The study was conducted in 15 sites in five sub counties (Bungatira, Patiko, Pabbo, Atiak, and Anaka) within Gulu, Amuru and Nwoya Districts between April 2016 and April 2017. Ethical clearance for 1 “Women” refers to any woman who participates in the group counseling intervention without a male partner; and “couples” refers to female and male partners who participate in the group counseling intervention together. 20 this study was obtained from the Georgetown University Institutional Review Board, The AIDS Support Organization (TASO) review Board, and the Uganda National Council of Science and Technology (UNCST). Local authorities in Northern Uganda were also informed and approved of study activities. Methods included FAM user survey interviews with 120 SDM and 53 women using TwoDay Method, and a sub-set of 60 SDM and 36 TwoDay Method male partners. These FAM users were interviewed at two different time points: first at approximately one to two months after attending a group counseling session and beginning to use a FAM, and second, again 4-6 months after the first interview. Qualitative data were collected at endline, through 11 in￾depth interviews with select couples who took up a FAM; sex-disaggregated FGDs with 36 community members; 25 youth facilitators and 10 CDOs; interviews with 12 key informants. Finally, attendance and competency checklist observations of group counseling sessions on SDM and TwoDay Method were conducted; and; service statistics from 19 local health facilities were collected routinely through the course of the intervention (see WALAN study timeline below). Table 3. WALAN study timeline Study Activities 2016 2017 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May INTERVENTION ACTIVITIES - Training 1: Community learning + SDM group counseling sessions - Training 2: SDM refresher + TwoDay Method group counseling sessions - Implementation of community learning + SDM group counseling sessions - Implementation of TwoDay Method sessions STUDY ACTIVITIES - Competency checklist observations - SDM user interviews - TwoDay Method user interviews - FGDs with youth facilitators / CDOs - FGDs with community learning participants - IDIs with FAM dis/continued couples - KIIs with leaders and providers - Service statistics - Dissemination of preliminary results among participating communities Data collection methods and sources, sampling and analyses procedures are explained in more detail below by 1. Feasibility; 2. Acceptability, and; 3. Effectiveness evaluation methods. 21 4.3 FEASIBILITY METHODS To understand WALAN’s feasibility and potential for scalability, data were collected to better understand the following solution aspects: 1) Youth facilitator competence in delivering the sessions; and 2) the reach and targeting of solution activities. Table 4. Feasibility data collection methods, by sample achieved Type of Data Participant / Data Source Monitoring Attendance Data  123 Community Learning Sessions  95 Group Counseling Sessions  51 Method Support Sessions Observational Competency Checklist  24 Youth Facilitators (12 pairs of M/F) Qualitative Focus Group Discussions  25 Youth Facilitators (12M / 13F)  10 CDOs and Assistant CDOs Quantitative Service Statistics (routine)  19 Facilities: Hospitals, Health Centers (HC) III, HCII, HCI, drug shops Attendance data were collected and analyzed for each community learning, group counseling and method support session to understand the intervention reach and participant demographics. At each community learning session, group counselling sessions and method support sessions, youth facilitators were trained to collect de-identified attendance data covering basic demographic information, which included; number attended, age, education level, marital status, number of children. Attendance forms were submitted to CDOs and SC staff during quarterly reflection meetings. Attendance data were then entered into an excel database, and frequencies of attendance numbers and demographics were tabulated quarterly. Attendance frequencies were subsequently presented at the quarterly team M&E meetings between IRH and Save the Children to inform the intervention targeting and processes. Competency checklist. A competency checklist was used by two external data collectors to observe and score of 13 facilitator pairs delivering SDM and TwoDay Method group counseling sessions at two different time points: 2 months post training (July/August 2016) and 9-10 months post training (February/March 2017). A standard competency checklist was used which collected information on: 1) counselling principles; 2) facilitation skills; 3) screening for method eligibility; 4) method teaching; and 5) couples support using the method. In total, 48 sessions were observed (12 SDM sessions observed twice and 12 TwoDay Method sessions observed twice). During each observed group counseling session, external observers observed and listened to the group counseling session, following the competency checklist and recording a “yes (1)” or “no (2)” according to different competency measures (e.g. Counseling principles – Youth Facilitator pair ensured privacy for the session: Yes [1] or No [0],) Measures were nested in one of five counseling categories: 22  counseling principles;  facilitation skills;  screening for method eligibility;  method teaching; and  couple support using the method. In addition, data collectors recorded open-ended qualitative notes to add any other contextual or process-related observations. Competency checklist data for SDM and TwoDay Method sessions were entered and analyzed separately in an excel database. Competency scores were analyzed as a dichotomous outcome variable for each competency measure. A total percentage competency score was tabulated for each youth facilitator pair for both observed sessions. Based on previous IRH studies, a score of 75% or higher was considered the threshold for a “competent” counseling performance. Qualitative observation notes were entered in a separate matrix and analyzed thematically to help explain the competency score results and better understand competency strengths and gaps. Focus group discussions. Sex-disaggregated FGDs were conducted with 25 youth facilitators and 10 CDOs, separately, at endline to understand their experiences in delivering and supporting the WALAN activities, respectively. Participants were systematically recruited from the WALAN implementation sites in the Gulu, Nwoya and Amuru districts with guidance from SC staff. All participants were consented and focus groups were conducted in a private location, where the conversation cannot be overheard. FGDs were conducted by a trained facilitator and observer. Responses were translated from Acholi and transcribed into English, synthesized and coded into an Excel matrix for processing and analysis. Content analysis was conducted in excel, with the following specific themes of interest: overall experiences facilitating WALAN community learning and group counseling sessions in FAM, referrals and linkages to FP services at health centers, and recommendations for program improvements. Anonymous, un-linked FP service statistics were collected from 19 health facilities covering the catchment areas of the WALAN solution activities, these included regional hospitals, district, sub-county and local health centers, and local drug shops before, during and after the period of the intervention. These data captured the number and types of FP methods provided, women and couples counseled on FP, and referrals for FP related services. This was done in collaboration with local health officials and with the approval of the Ugandan MOH. 23 4.4 EFFECTIVENESS METHODS STUDY SITE AND POPULATION The primary study participants were new FAM users [having started method use within 30-60 days] who voluntarily consented to participate in the study. Women and their male partners who participated in the FAM group counseling sessions were invited to participate in the study. The study was open only to adults or emancipated adults. Since the intervention targets women and men 15 – 35 years of age, women and men 15-17 years old were only included and consented to participate in the study if they were parents or married and therefore considered emancipated adults per Ugandan law. METHODS FAM user interview data from SDM and TwoDay Method FAM users were collected at two time points. At the first data collection point, FAM users were interviewed approximately one to two months after attending a group counseling session and beginning to use a FAM. Then FAM users were followed-up for a second interview again four to six months after the first interview. At the first interview point, a total of 122 SDM and 53 TwoDay Method female users were interviewed who took up the method after attending the WALAN group couples counseling sessions. A male partner subset of interviewed female users were also interviewed separately at the first data collection point (60 SDM; 36 TwoDay Method). At the second interview time point, 101 SDM female users and 27 TwoDay Method female users participated in a second interview, in addition to 41 SDM and 21 TwoDay Method partners. In-depth interviews (IDIs), were conducted at endline with a small sample of female users and male partners. A total of 11 interviews were conducted, including four couples who continued FAM use; two couples who discontinued FAM use; and one couple who switched from SDM to TwoDay Method. Interviews were done separately for females and male partners. Table 5. Effectiveness data collection methods, by sample achieved Type of Data Participant / Data Source First Interview Second Interview Follow-up (4-6 months later) Quantitative FAM User Interviews (two time points)  122 SDM Female Users  60 SDM Male Partners  53 TwoDay Method Female Users  36 TwoDay Method Male Partners → 101 SDM Female Users → 41 SDM Male Partners → 27 TwoDay Method Female Users → 21 TwoDay Method Male Partners Qualitative In-depth Interviews (endline)  Continued Users: 1 SDM Couple; 1 TwoDay Method Couple; 1 SDM Male Partner  Discontinued Users: 1 SDM Couple; 1 TwoDay Method Couple  Switched Users: 1 SDM couple switched to TwoDay Method 24 SAMPLING FAM User Interviews. Correct use of SDM and TwoDay Method was measured using a sample of 150 SDM and 100 TwoDay Method female participants counseled in a group setting (total n = 250). Based on the proof of concept findings, we reduced the TwoDay female sample size to 100, rather than 150, to account for lower expected participation and recruitment numbers. We estimated a 33% loss to follow-up based on previous research under the USAID￾funded AWARENESS (2002 – 07) and FAM (2007 – 13) projects, which studied the introduction and scale-up of SDM and TwoDay Method across multiple countries. As a result, we expected a final sample of at least 100 women in SDM and 67 in the TwoDay Method group at the second interview follow-up. Women meeting eligibility criteria were identified and recruited from the 24 identified villages in the district sites of Gulu, Nwoya, and Amuru. IDIs with couples. A sub-set of women and male partners enrolled in the study and interviewed as part of the FAM user sample were systematically selected and asked to participate in an IDI interview at endline. The IDIs were conducted with both SDM and TwoDay FAM users, in addition to female discontinued users and their male partners. STUDY RECRUITMENT Only female users and male partners who met the study eligibility criteria were interviewed. Criteria for female users included:  Being between 15-35 years old (adults or emancipated adults),  Participated in a FAM group counseling session and having gone home with SDM or TwoDay Method,  Not self-reported as pregnant  Have used either SDM or TwoDay Method for at least 30 days  Agreed to participate in the study Male partners were eligible to participate if they had either participated in a group counseling session with a female partner; or had a female partner who attended the group counseling session without him. The study participant selection process and sample size for both SDM and TwoDay Method users is presented in Figure 4. A total of 540 potential FAM users – defined as couples who began using a method after attending a group counseling session - were contacted to participate in the study. Of the 540 potential study participants contacted, 269 of them did not meet eligibility criteria (49.8%). Reasons for ineligibility included being above 35 years, having not started using the method or in the case of SDM, having been using SDM for less than 30 days. Fewer males were interviewed due to difficulties in finding men at home during interview times. Fewer interviews were done with TwoDay Method users due to the lower overall community demand for TwoDay Method. 25 Figure 4. Flow chart showing number of FAM users contacted and in/eligible at first interview ANALYSIS Descriptive statistics were used to obtain simple frequencies and proportions for selected variables. All analyses were gender disaggregated. FAM user interviews primary outcomes comprised of correct knowledge of method use and continued and discontinued method use. Secondary outcomes included male partner participation in method use, couple communication, self-efficacy in FP use, comprehensive knowledge of fertility awareness, attitudes toward FP, and perceptions of group counseling and method support sessions. A composite indicator was calculated for correct knowledge of SDM use determined through demonstration of all the 5 steps of SDM use (Steps: 1- move ring to red bead when period starts, 2 – move ring to next bead every day, 3 – use condoms or abstain when ring is on white beads to avoid pregnancy, 4 – brown beads are safe days of no pregnancy, and 5 – when period starts again move ring to read bead to begin again). A composite score was calculated for correct knowledge of all five steps (showing all five steps correctly during demonstration). An average percentage score was also computed for correct knowledge of method use, based on the average of showing each individual step correctly. Correct knowledge of TwoDay Method was assessed using two survey measures. During interviews, TwoDay Method users were shown a filled-in TwoDay Calendar example and asked two questions: 1. When is it safe to have sex with no risk of pregnancy?, and; 2. What Total contacted: 540 couples (AUGUST - OCTOBER 2016) Eligible: 271 couples SDM: 182 couples 122 female users 101 female users 60 male partners 41 male partners TwoDay Method: 89 couples 53 female users 27 female users 36 male partners 21 male partners Ineligible: 269 Reasons: 1. Above 35 years 2. Not used method at least 30 days before interview 3. Not started using method (due to pregnancy, breastfeeding, or had not received Cycle Beads or TwoDay Method calendar) 4. Spouse did not approve interview 5. Relocated to another village or location not found 6. Not at home during the time of interview 7. Still using a hormonal method 1st Interview (AUGUST – NOVEMBER 2016) 2nd Follow-up Interview (FEBRUARY – MARCH 2017) 1st Interview (SEPTEMBER - DECEMBER 2016) 2nd Follow-up Interview (MARCH – APRIL 2017) 26 does it mean if you notice secretions today or yesterday? We calculated correct answers for the two questions and reported: 1) the percentage of respondents who answered both questions correctly, and; 2) the average percentage score of the questions answered correctly. Qualitative interview data were translated from Acholi to English, synthesized, coded and enumerated for processing and analysis. Transcripts were coded and organized into thematic matrices in Excel. Further, data reduction techniques were used to examine codes in detail for sub-themes and patterns across the IDIs. For the IDIs with couples, excerpts were summarized according to the following themes: overall experience as a FAM user; couple communication and decision-making around FAM use and management of fertile days, and; experiences with community learning and group counseling sessions. QUALITY ASSURANCE A research firm was hired under the supervision of IRH to collect FAM user interviews, IDIs and FGD qualitative data. Research assistants received a 3-4 day training prior to each data collection event, including prior to: 1. SDM user interviews; 2. TwoDay Method user interviews; and 3. Endline qualitative data collection for IDIs and FGDs. Trainings focused on technical knowledge of FAM, recruitment and data collection procedures, consent and ethical considerations, in addition to data management and security protocols. Local language (Acholi) was used during all interviews and data collection points. Participants study enrolment criteria was strictly adhered to in selecting study participants and all participants were consented into the study. Respondent codes were assigned to the FAM users to ease identification and follow-up of SDM and TwoDay Method users at the second interview time point. All completed interviews were reviewed for completeness and coherence before submission to the server. All qualitative interviews were recorded for back up and quality monitoring purposes. Open Data Kit (ODK) application was used to pick data to ease data collection and minimize errors. All data were backed up at the end of each day. LIMITATIONS Obtaining the desired sample for FAM user interviews was challenging due to the study eligibility criteria. Specifically, at the time of data collection some participants had not yet used SDM for at least 30 days, or had not started using the method (e.g. waiting for next period to start using the method). Interview schedules did not always match with the users’ availability. Some had gone farming far from their residences for the periods of data collection. In such cases, several return visits were made in an attempt to find them. TwoDay Method was less popular in the community and as a result, obtaining users to participate in the interviews was more challenging. A few of the TwoDay Method calendars held by participants at second interview were outdated (2016, rather than 2017), as a result correct method use could not be verified for those interviewees. 27 The study team also experienced challenges screening study participants. Research assistants were trained to properly screen potential participants prior to enrollment, including any potential study participants who may be pregnant. However, in some cases, potential study participants stated that they had begun using the method, even though it was later disclosed in the interview that the user was in fact pregnant, rendering her ineligible for the interview. 4.5 ACCEPTABILITY METHODS To measure acceptability of the WALAN activities, information was triangulated with perceptions about FAM from different audiences: 1.) community participant experiences with community learning sessions and group counseling sessions; 2.) community leaders engaged in WALAN activities; and 3.) service providers’ perceptions of WALAN activities. Table 6. Acceptability data collection methods, by sample achieved Type of Data Participant / Data Source Qualitative Focus Group Discussions  38 Community Learning Session Participants (18 M /20 F) Qualitative Key Informant Interviews  3 Health Service Providers  3 Village Health Team (VHT) members  3 Community Leaders FGDs with a sex-disaggregated sample of 18 female and 18 male community members who participated in community learning sessions. The purpose of the focus group discussions was to understand community members’ reception and understanding of HTSP/FP, human fertility and LAM topics diffused by the community learning sessions, while also understanding their exposure and perceptions of other WALAN group counseling and method support sessions. Participants were systematically recruited from the WALAN implementation sites in the Gulu, Nwoya and Amuru districts with guidance from SC staff. All participants were consented and focus groups were conducted sex-disaggregated in a private location, where the conversation cannot be overheard. FGDs were segmented by younger (15-25 years) and older community members (26-35 years). FGDs were conducted by a trained facilitator and observer. Responses were translated from Acholi and transcribed into English, synthesized and coded into an Excel matrix for processing and analysis. The FGD participant breakdown is found in Table 7 below. Table 7. Type and number of FGD conducted with community members Gender Total Number of FGDs Age Female Male 15 to 25 Years 14 6 3 26 to 35 Years 6 12 3 TOTAL 20 18 6 28 Key informant interviews (KIIs). Nine key informant interviews with six service providers (three males and three females) and three male local leaders were also conducted to explore their perceptions of the WALAN activities in their community. Similar to the above FGDs, participants were systematically recruited from the WALAN implementation sites in the Gulu, Nwoya and Amuru districts with guidance from SC staff. Service providers comprised of VHTs and health workers from both public and private facilities; Service providers including those from private facilities were oriented on the project and fertility awareness in general. All participants were consented and KIIs were conducted in a private location, where the conversation cannot be overheard. The KII participant breakdown is found in Table 8 below. Table 8. Type and number of KIIs conducted with service providers and community leaders Respondent Type Female Male Religious Leaders 0 1 Cultural Leader 0 1 Political Leader 0 1 Health Service Providers 2 1 VHTs 1 2 TOTAL 3 6 Analysis. For both FGD and KIIs responses were translated from Acholi and transcribed into English, synthesized and coded into an Excel matrix for processing and analysis. Further, data reduction techniques were used to examine codes in detail for sub-themes and patterns across the IDIs. Excerpts were summarized according to the following themes: experiences with community learning sessions; perceptions of the WALAN activities; feedback for orientation and sensitization meetings (in case of service providers and community leaders), and; recommendations for program improvement. 29 WALAN FEASIBILITY RESULTS 30 5. FEASIBILITY RESULTS The findings below describe the reach and targeting of the WALAN solution, including profiles of community members participating in WALAN activities; competency results of observed group counseling session on SDM and TwoDay Method, and; youth facilitators and CDO’s experiences implementing and supporting the intervention. 5.1 COMMUNITY LEARNING SESSION PARTICIPATION Delivery of community learning sessions. Community learning sessions covered three topics:  Fertility awareness  LAM  FP / HTSP Across 15 villages, a total of 123 community learning sessions were delivered from May 2016 to March 2017 which lead to 3,387 points of contact with the community (non-unique individuals). 1 Figure 5 shows the frequency of session delivery by topic module, highlighting that most sessions were delivered on HTSP and FP, with very few delivered on human fertility. The frequency of delivery may have been due to facilitator’s comfort and ease with different topics. For instance, during FGDs, youth facilitators shared that the topic of human fertility was the most difficult to facilitate because participants would ask many technical questions, such as “What is the speed of both sperm and ova in terms of reaching the uterus? Why does the ovary look like fingers?” Some also reported that community elders found the topic too sensitive to discuss openly in the community. At the same time, youth facilitators reported that the topic of HTSP and FP was the easiest to facilitate. Interestingly, a number of community learning session topics were not marked by the youth facilitators on their reporting forms, suggesting that stronger training support may be needed to reinforce quality assurance of M&E data collection by youth facilitators. Also, the fact that community members asked many questions during the relatively few session on human fertility indicates a strong interest in this topic, with people desiring more information than is likely to be conveyed by a community volunteer. Strategies to provide this information, while taking into account the sensitivities involved, should be further explored. 1 This number reflects individuals who returned to multiple sessions, and do not reflect individual, unique participants 31 Figure 5. Community learning sessions delivered, by topic from May 2016 to March 2017 (n=123) (Source: Attendance records) Each community learning session was attended by approximately 28 community members, although size of participant audience varied greatly (min six; max 70). Of the total 3,387 points of contact among community members, approximately 58% were female and 42% male, with just over half 15-25 years of age. Community interest in FP methods. At the end of the community learning sessions on HTSP/FP, participants were asked about their interest in FP methods. Across the 15 villages, a total of 1,521 individuals were recorded as having an interest in a method of FP. An individual was considered interested in a FP method if s/he raised their hand affirmatively at the end of the community learning session when youth facilitators asked about interest. (It is not known how closely this reflects actual interest. People could have been reluctant to publicly express interest in an FP method, or they could have felt pressure to do so given the topics being discussed.) Figure 7 below shows that of the 1,521 individuals interested in FP methods, most were interested in SDM (43%), followed by LAM (20%), and TwoDay Method (10%). About 15% were interested in other methods provided by health facilities (228 individuals). Youth Facilitators also recorded the number of FP invitation cards handed out to community learning participants which provided information about other FP methods from health facilities. Across the 15 villages, a total of 256 FP invitation cards were handed out to participants, both during and after the community learning sessions. 0 10 20 30 40 50 60 HTSP and FP LAM Topic not marked Human Fertility GULU AMURU NWOYA Figure 6. Profile of Community Learning Participants 32 Figure 7. Interest in FP methods during community learning sessions, by method type (n=1,521) (Source: Attendance records) To understand use of facility-based FP services in the catchment areas, the study team also collected service statistics from 19 health facilities from April 2015 to March 2017. The purpose of collecting these service statistics was to under the general time trends and patterns of FP uptake in the health centers where facilitators referred clients after community learning sessions. Figure 8. Number of clients seeking FP counseling services at district health facilities, 2015 - 2017 (Source: Service Statistics from Catchment Area Health Facilities) Overall, there were general increase in number of clients seeking FP services at the time of the WALAN pilot implementation (July 2016-March 2017), in particular in Gulu District health facilities. However, we are unable to attribute the causality of this increase exclusively to the WALAN community learning session activities, as other factors may have also intervened (presence of other projects, seasonality, etc.). However, these data also suggest that the community-based offering of SDM and TwoDay Method counseling described below did not affect clients’ up-take of other methods and facility-based FP services. SDM 43% TwoDay Method 10% LAM 20% Pills 5% Injection 6% Implant 4% 0 500 1000 1500 2000 2500 April - June 2015 July - Sept 2015 Oct- Dec 2015 Jan- March 2016 April - June 2016 July - Sept 2016 Oct- Dec 2016 Jan - March 2017 Nyoya Amuru Gulu WALAN Implementation 33 5.2 PARTICIPATION IN GROUP COUNSELING SESSIONS ON FAM Participation in group counseling sessions. After community learning sessions, youth facilitators delivered counselling sessions on SDM and TwoDay Method to couples interested in either method. Over 10 months, 94 counseling sessions on FAM were delivered across 15 villages. As seen in Table 9, more counseling sessions were delivered on SDM (67) than TwoDay Method (27), highlighting a higher demand for SDM. On average, four couples attended each session as per WALAN guidelines. The number of couples at each session ranged from one to 15. Most couples (91%) who attended the group counseling sessions on FAM and began method use (288 out of 315 couples). Of these couples, 214 began using SDM and 74 began using TwoDay Method. In a few cases, couples switched between FAMs, typically from SDM to TwoDay Method, if the method was not suitable for them (cycle too short/long-for SDM) and/or if the method was easier for them to use. Table 9. Number of Group Counseling Sessions and Participants, May 2016 – March 2017 SDM TwoDay Method Total number of group counseling sessions 67 27 Total number of couples who attended group counseling sessions 237 78 Total number of couples who began method use 214 74 Number of couples returning to more than one group counseling session 43 16 Mean number of couples per group counseling session (min, max) 4.3 (1, 15) 3.6 (1, 7) (Source: Attendance records) Group counseling session participants. Female participants in both SDM and TwoDay Method support sessions were on average 26 years of age (min 16, max 47), with an average of three children (min 0, max 11). Not surprisingly, male participants were older, averaging about 30 years of age in both group counseling session groups (min 20, max 53). The majority of group counseling participants reporting either having some level or completed primary education (over 60%) for both women and men. Distribution of education levels were similar across both SDM and TwoDay Method group counseling sessions. Participation in method support session. Method support sessions were provided to couples to reinforce method use after initiation. While follow-up visits are not required for FAM use, support groups were formed to provide a forum for couples to share their strategies for negotiating sex and handling fertile days and to review correct method use with the facilitators. Attendance data show that approximately 49 method support sessions were offered (26 SDM Group Couples Counseling Sessions 34 and 23 TwoDay Method). Approximately 98 couples returned to SDM method support sessions, and 79 couples returned to TwoDay Method sessions, with an average of four couples per each session (min 2; max 7). 5.3 YOUTH FACILITATOR COMPETENCE To assess youth facilitator competency, 13 facilitator pairs were observed and scored for competency delivering SDM and TwoDay Method group counseling sessions at two time points: two months post training (July/August 2016) and nine-10 months post training (February/March 2017). A standard competency checklist was used to collect information on: 1) counselling principles; 2) facilitation skills; 3) screening for method eligibility; 4) method teaching; and 5) couples support using the method. Facilitator were rated as pairs, rather than individual performances Proportion of Youth Facilitator pairs who achieved a competency score of 75%. Based on previous IRH studies, we defined youth facilitator pair competency as receiving a 75% score or higher for an observed session (meeting at least 75% of the individual criteria specified in the competency checklist). Figure 9 shows that at the first observation point, one out of three facilitators met the 75% competency threshold. The proportion of youth facilitators meeting the competency criteria more than doubled seven months later with two out of every three youth facilitators meeting the competency threshold for SDM counseling and three out of four for TwoDay Method counseling sessions. Figure 9. Proportion of Youth Facilitators meeting the 75% competency threshold (n=13) (Source: Competency checklist observations) Youth Facilitator Counseling Scores by District. Table 10 shows the overall counseling scores by each of the three intervention districts for each facilitator pair for SDM counseling sessions, followed by TwoDay Method sessions at first and second observation time points. Average counseling scores for the 13 observed facilitator pairs increased over the seven-month time period from 54% to 77% for SDM group counseling sessions and 68% to 82% for TwoDay Method sessions. Youth facilitators in Gulu district performed the most competently, while 33.3% 66.7% 33.3% 75.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% First Observation Second Observation First Observation Second Observation SDM TwoDay Method 35 those in Nwoya performed the least competently (see Annex 3 for a full list of scores by each of the 13 facilitator pair). Table 10. Competency Scores for Youth Facilitator Pairs for SDM and TwoDay Method group counseling (n=13) Sub-county SDM First Observation SDM Second Observation TwoDay Method First Observation TwoDay Method Second Observation GULU DISTRICT (3 facilitator pairs) 75.0% 94.4% 83.4% 92.9% AMURU DISTRICT (8 pairs) 53.0% 80.0% 66.3% 81.6% NWOYA DISTRICT (2 pairs) 27.1% 48.0% 48.2% 69.7% TOTAL AVERAGE % 54.2% 77.1% 67.6% 82.1% (Source: Competency checklist observations) Improvements by counseling category. As seen in Table 11 below, youth facilitators improved substantially from first to second observations points, with the largest improvements observed during observed SDM group counseling sessions. Facilitators performed best in facilitation skills (encouraging male and female practice in pairs) and explaining how to use the methods correctly. The qualitative observations showed that facilitators had dynamic teaching styles, properly used visual aids, and encouraged active participation. Youth facilitators scored lowest in screening for method eligibility, in particular during SDM group counseling sessions (54% of youth facilitators asked if women have periods about once a month and if women and partners are able to abstain or use a condom on fertile days), although this score improved substantially by the second observation point (75%). As well, significant improvements were found in ensuring counseling principals around stating group rules and ensuring privacy (46% at first SDM time point, to 88% at second SDM time point). Table 11. Competency scores by counseling category, for SDM and TwoDay Method group counseling (n=13) Observation Categories SDM First Observation SDM Second Observation TwoDay Method First Observation TwoDay Method Second Observation COUNSELING PRINCIPALS (Stating group rules; ensuring privacy) 45.8% 87.5% 70.8% 91.7% FACILITATION SKILLS (Encouraged male + female participation; practice in pairs) 77.8% 97.2% 95.8% 95.8% SCREENING METHOD ELIGIBILITY (SDM: asked if women have periods once a month; TDM: women with healthy secretions; Both: able manage fertile days) 54.2% 75.0% 83.3% 95.8% METHOD TEACHING (Explains method use step by step) 68.8% 93.8% 89.6% 99.0% SUPPORT COUPLE USE (asked how couples will be able to handle fertile day; management of fertile days) 37.5% 58.3% 41.7% 54.2% (Source: Competency checklist observations) 36 Qualitative observation notes indicate that this initial low score may have been due to youth facilitators’ difficulties in ensuring privacy of the group (e.g. curious neighbors, children, etc.) in beginning stages of implementation, a challenge that youth facilitators mastered seven months later. Scores were lowest for supporting couples in method use, where youth facilitators at the end of the group counseling session reinforced that method success depends on the couple’s ability to abstain or use condoms during fertile days. A full list of scores by individual measures in each of the counseling categories can be found in Annex 3. The qualitative data from the observations also confirmed the improvement over time, including facilitator’s ability to achieve active participation among couples and answer the couples’ questions. In particular, common questions during SDM sessions were on method eligibility, and possibilities in switching between SDM and other methods. The higher performance scores during TwoDay Method sessions may have been due to the timing of the TwoDay Method observations, which occurred approximately one month after the first SDM group counseling session observations. The TwoDay Method observations also occurred after a second training on TwoDay Method counseling, which reinforced overall counseling skills. In addition, youth facilitators shared during focus group discussions that TwoDay Method was relatively easier to teach in comparison to SDM. Qualitative data shows that competency factors may have been dependent on the presence of both youth facilitator partners during the counseling sessions. Observations conducted when only one youth facilitator was present was generally associated with a lower competency score. In addition, while not taken into account in the competency scoring, the observations showed that methods were not always given out during each counseling session, and in some cases couples returned to multiple group counseling sessions before deciding to start method use. 5.4 EXPERIENCES OF YOUTH FACILITATORS AND CDOs Four sex-disaggregated FGDs were conducted after 10 months of implementation to understand the experience of the WALAN youth facilitators in delivering the couples counseling activities; identify lessons and challenges WALAN youth facilitators faced in Question: “Most of the time women are wet in their private parts. How do we know that this is the secretion that brings about pregnancy?” Answer: Normal secretions are healthy, whitish without smell, they do not itch. They start to come some days after monthly bleeding. Question: “If someone starts to use SDM and wants to change, is that possible?” Answer: Yes, it is possible to change. It is your choice. Question: “Does one have to move with the beads? Answer: You do not have to put the beads on yourself, but keep them in a private and safe place where only the couple can see them so that the ring is not moved mistakenly. Figure 10. Example of questions and answers during observed group counseling sessions 37 carrying out WALAN activities and ways that these could be addressed for future scale-up activities. In addition a FGD was conducted with 10 A/CDOs to understand their experiences in supporting WALAN activities as trainers and supervisors. Social and personal benefits of becoming a WALAN youth facilitator. Youth facilitators mentioned that becoming a youth facilitator had helped their professional development, established them as leaders in the community and boosted their knowledge and confidence to talk in public. In many cases, youth facilitators reported receiving newly given community names such as “teacher,” or “health worker.” Youth facilitators pointed out that working with CDOs had helped legitimize their roles since CDOs are recognized as leaders within their given community. Youth facilitators also shared that the technical knowledge around fertility and FAM helped them improve their own RH and FP decisions in their personal lives. “Before the project, I used to not talk in public but now I am able to do that. Secondly, I am known in about three sub parishes. My dream is that I will be able to stand as a Counselor for this parish.” - Male Youth Facilitator, Nwoya District “It has changed my life because personally I didn’t even know my body parts. And now I know myself very well. I know what happens in my body, I can tell when I want to conceive or not and I know the period I can conceive. I know when I can conceive and when I will deliver” – Female Youth Facilitator, Nwoya District CDOs also reported an increased knowledge about FP methods, including FAM, as a result of their participation in WALAN. CDOs reported enjoying becoming resource persons and “FAM consultants.” One CDO shared how he became a FAM user: “WALAN project has widened our knowledge in areas where we never knew. Especially in the natural methods of FP and the materials used…because we have been hearing about CycleBeads or LAM but when it came to the practical training we really enjoyed and we learnt. The knowledge is now there and we are transferring the knowledge home.” - CDO Supervisor “Me personally, I even took one method; after learning I went home and introduced the idea to madam (wife) and I taught her how to use it, we are using CycleBeads. So that is how WALAN has impacted my life.” - CDO Supervisor Another CDO shared that being involved in WALAN helped ease his work as a CDO in conflict resolution among couples, stating that the increased couple communication as a result of method use helped reduce conflict among couples. Experiences of CDOs with WALAN activities. The primary responsibilities of the CDOs included: 1. Train youth facilitators; 2. Observe and mentor the youth facilitators; 3. Distribute youth facilitator materials (e.g. forms; CycleBeads; TwoDay Method pamphlet), and; 4. Mobilize 38 and sensitize community leaders about WALAN activities. The FGD with CDOs showed that their liaising with community leaders enabled community support for the WALAN activities, and that in many cases CDOs served as linkages between youth facilitators and health services to obtain other methods and information, such as condoms for larger distribution. CDOs cited the WALAN training and teaching to be the easiest part of the WALAN activities, given their experiences training other youth groups, VSLA groups, and farmer groups, among others. Relative to other trainings and projects, CDOs reported the WALAN project training and materials to be well designed, aiding in the training and support of the youth facilitators: “The WALAN materials are already good materials that actually made our work easier Tin training the facilitators. They had already properly developed materials. That is what actually impressed me, sometimes you find if it is a new project, the materials are not good enough, it also becomes a challenge to the trainers; but this was okay, following was easy.”– CDO Supervisor However, CDOs also noted a few challenges related to the WALAN activities, including dropouts by youth facilitators, citing that CDOs should be part of the selection process to avoid similar attrition. CDOs also reported difficulties time managing their role in WALAN with their other competing roles and responsibilities with other projects, particularly when receiving short notice of WALAN activities. “We were brought on board to train and we carried out the training of the facilitators but the challenge was we didn’t participate in the choosing of the facilitators so that became a challenge because we had a number of dropouts from the facilitators.” – CDO Supervisor “Where it became difficult was because after the training we came up with the work plan on how WALAN should run. But there came a time when we received information on short notice and this became very difficult because we had already planned our own activities but we managed although it was a challenge to us. We managed amidst these trying moments. We never wanted to fail this program but sometimes you find (long pause), it was difficult but we managed.” – CDO Supervisor CDOs concurrently agreed that improvements in the quarterly reflection meetings were crucial in helping to resolve and “manage” challenges related to attrition and scheduling. During such reflection meetings, CDOs would discuss and reflect on lessons learned in the last month, and plan together how to troubleshoot any issues. Youth Facilitators’ experiences implementing community learning sessions. Most youth facilitators reported feeling confident with community learning sessions, in particular because the information needed to facilitate the session was directly available in the WALAN job aids. The facilitators generally felt that mobilization for community learning sessions was easy because the sessions were open to everybody in the community. However, 39 some youth facilitators noted difficulties in managing the large crowds, citing that “when everyone comes,” managing and responding to all the questions can be difficult. Consistent with the community learning session attendance numbers highlighted earlier, youth facilitators reported that the LAM and HTSP/FP were the easiest topics to deliver. Youth facilitators reported that youth typically liked the topics of discussion on fertility (e.g. on reproductive organs), but were hesitant to discuss the topics openly in front of other elderly community members. “For human fertility, the moment you show people the pictures, they automatically start to laugh (…) people are afraid to mention some words. You know that session involves every one [in the community], including elderly women. So mentioning these words cause a bit of fear and shyness.” – Female Youth Facilitator, Nwoya District In general, the topic on human fertility was most difficult to facilitate due to elders’ apprehension and the range of difficult questions asked by community members. In some cases during those sessions, community members wanted more information about the female and male reproductive organ physiology, which youth facilitators were unable to answer fully. When it came to answering difficult questions, youth facilitators were trained to write down any questions they were unable to answer and submit them to a CDO or SC staff. However, youth facilitators reported not receiving the responses to all the questions. This process was facilitated when a CDO was present during the community learning session, during which difficult questions were answered by the CDO. Youth Facilitators’ experiences implementing group counseling sessions. Consistent with the competency checklist results which showed initial challenges in delivering the group counseling sessions, youth facilitators shared having initial challenges following the group counseling session guide. However youth facilitators cited that comprehension of materials improved with time, repeated use and counseling experience. Youth facilitators cited that understanding of materials and delivery improved after a refresher training. One youth facilitator explained that the first training had been rushed: “…when we came back from the training, we had difficulties in reading the guide but when it became part of my work it was now easy because I would just look at the heading of the topic and know what to say.” - Male Youth Facilitator, Nwoya District “…the first time was not very easy but following the guide we were able to do it but the reality is that the training was rushed and when we went for the refresher training there was an improvement.” - Male Youth Facilitator, Amuru District Whereas youth facilitators reported both methods were easy to offer, facilitators cited they liked and felt more comfortable offering SDM, as per the community demand and familiarity with the local branding of CycleBeads, locally known as “MoonBeads” in Uganda. In some 40 cases, youth facilitators also reported that community members liked the physical design of the CycleBeads. Youth facilitators handling of period regularity and pregnancy screening during group counseling sessions. As part of the FGDs, a few youth facilitators shared that during group counseling sessions on SDM, some women did not know always know or disclose accurately whether they had regular periods, making the SDM screening counseling requirements for using SDM more challenging for youth facilitators. These findings are consistent with the competency checklist results, which also showed that only half of observed youth facilitator pairs followed the SDM screening protocol at the first observation point, which improved to 75% of observed youth facilitator pairs by the second observation point. “It has been difficult for women to know whether their cycle is too short or too long. Some of them will tell you that they have bleeding once a month but in actual sense it might have been too short and when they come back for the method support session you realize that.” - FGD Male Youth Facilitator, Nwoya District During FGDs, male and female youth facilitators shared that some women attended the group counselling while pregnant. These women typically fell into categories: 1. They were unaware of their pregnancy, or; 2. They knew of the pregnancy but wanted to try the method anyway. If they knew of their pregnancy, some wanted expressed the desire to take CycleBeads home to use the method after their pregnancy. “First, they were not sincere with me, they had so much interest for CycleBeads because they say it is difficult to find. There were three people who I followed-up with (…) because they were not yet having menstrual period, not knowing that one person was already 1 and half months pregnant and she had already taken home the method, yet she did not tell me about it [her pregnancy]”. - Male Youth Facilitator, Amuru District “There are some people that you offer a method to because they tell you they are not pregnant but you see her pregnant after three months, and [if known] you would have not offered the method to her.” – Female Youth Facilitator, Amuru District Although certainly not universal, the qualitative FGD results suggest that youth facilitators did not always receive clear and reliable information from potential FAM users about their eligibility for method use. As a result, youth facilitators grappled with meeting couples’ demand for CycleBeads in the community, while also ensuring that the couples were appropriately screened. Given these emerging results, a refresher training was conducted in December 2016 to reinforce screening protocol and problem-solving misinformation about method eligibility from interested couples. 41 Demand for TwoDay Method. TwoDay Method was reported as easy to understand, however less popular compared to SDM. In particular, youth facilitators cited that checking secretions could be considered unhygienic and that men, in particular, mistrusted the method. As well, youth facilitators cited that women do not have time to check secretions during the day since they are always working in the garden. Youth facilitators also reported that some users cited writing on the TwoDay Method marking calendar as difficult, and perceived it was for “educated people.” “At one point the women thought that it was easy to use TwoDay Method but did not use it because they said they do not have the time to check (secretions). They are always in the garden. Some say that it is dirty to check for secretions. When you compare the users, CycleBeads are more but when it comes to understanding, it is easier to understand TwoDay Method.” - Male Youth Facilitator, Nwoya District “TwoDay Method requires politics, and you have to convince people. The counselling takes a longer time because you have to start with some jokes. The CycleBeads takes a shorter time because the people coming for the CycleBeads already like the method.” - Male Youth Facilitator, Nwoya District “Men tend to look down on TwoDay Method. With TwoDay Method, you only go back with the calendar and with a pen. TwoDay Method women can cheat men [give them the wrong information] but the CycleBeads is easier because a man is able to check the beads…” - Male Youth Facilitator, Nwoya District Referral for other FP methods. Youth facilitators referred couples to both VHT and health workers for different reasons. Facilitators shared that they referred couples to facilities for preferred use of other methods like pills, and IUDs. Other couples were referred due to failure to meet screening criteria, either due to menstrual cycle irregularity or inability to manage fertile days. Youth facilitators also reported challenges related to lack of condoms, which was mitigated by referrals to health centers and through CDOs, whom linked youth facilitators to health facilities for condom supplies. “…some of them you get them from the screening and one of them told me that she experiences a lot of pain when she is bleeding and I referred her to the health center. Secondly some women had husbands who drink a lot of alcohol and knew that their husbands would not cooperate and I gave them invitation card.” - Male Youth Facilitator, Amuru District “…I have given invitation cards to six people. One of them said she feels a lot of pain in the abdomen when having sex and then I referred her to the health centre. The other people said they have smelly secretion and we gave them invitation to go to the health centre and for the others the men were drinking a lot of alcohol.” - Male Youth Facilitator, Nwoya District 42 Youth facilitators reported having a good working relationship with VHTs and health workers. Youth facilitators shared that both VHTS and providers would periodically attend sessions; supporting both through mobilization and teaching. In some cases, youth facilitators shared that they received referrals from facility providers for FAM, and in particular SDM. “The health worker referred a woman who needed CycleBeads to me immediately after the health worker had attended the orientation meeting, she is the one whose drug shop is nearby.” - Female Youth Facilitator, Amuru District “So if we found those who need other methods such as injectable, implant, pills then we refer to them and they also refer those who need the CycleBeads and the rest to us. So we relate well” – Female Youth Facilitator, Nwoya District Youth Facilitator’s experiences working in male and female pairs. Overall, youth facilitators reported working well in pairs, pointing to mutual support and sharing of responsibilities during sessions. Youth facilitators reported correcting each other in a respectful way about session contents, and encouraged each other to talk about sensitive topics. Youth facilitators also cited that working in pairs also helped to facilitate and amplify participant mobilization. Both male and female youth facilitators also felt that their experience with WALAN had improved their confidence and skills in public speaking and facilitation. Not surprisingly, there were also gendered differences and experiences. In the separate FGDs, female facilitators reported enjoyed working as a pair more frequently than their male counterparts. Male youth facilitators more frequently discussed challenges and taken on more workload, noting that female youth facilitators had lower literacy levels than their male counterparts, which affected their ability to fill out the attendance forms and answer difficult audience questions during counseling sessions. Some of the FGD results suggest that inequitable gender attitudes and norms influenced the way that male facilitators viewed the performance of their female counterparts. Youth male and female facilitators, just like in any other society, were raised and socialized to have certain gendered expectations of how and why women and men behave. They applied this lens in a way that men viewed their female counterparts during WALAN activities. In a few cases, male facilitators complained that their female counterparts were often ‘distracted’ with commitments elsewhere, ‘lazy,’ ‘weak,’ and less helpful when they were pregnant. “My first colleague left the WALAN work and teaching was not easy and she went without any information. The person who came to replace the other person is also not good, either she is lazy or maybe she is not well prepared, sometimes she does not appear for the teaching and also many times, I do the teaching alone. I had challenges with my group, sometimes you mobilize them but they end up not turning up.” - Male Youth Facilitator, Nwoya District 43 In some cases, refresher training helped improve women’s comfort levels and ability to speak up and actively facilitate during the counseling sessions. “This was common during the training when we realized that the female facilitators...most of them but not all, most of them were a little bit weak but of course after that we had another refresher training, most of them improved although still we had some few who could not come to the expected standard. When you go for these observations you will find that the male participant is the one dominating.”– CDO Supervisor In many cases, male partners dominated the session facilitation, attributed the reasons to their female counterparts “shyness.” One CDO explains how this shyness could be directly attributed to cultural taboos around discussing sex openly, let alone by and among women. “Some women were shy because; yeah it is true culturally that women will not be able to talk about sex in public, they will say you are spoilt, disrespectful. So WALAN wanted them to start speaking about these things to the community that did not expect such things from a lady…talking about how to put on a condom...all those things, it becomes a problem to them. So sometimes much as they have the confidence to speak but that culture and the fear to mention such things in public, they would not allow” – CDO Supervisor 5.5 LESSONS LEARNED ABOUT FEASILIBITY High acceptance of community learning sessions. The findings suggest high demand and community participation in community learning sessions on fertility, LAM, HTSP and FP. Most of the sessions delivered were around HTSP and FP, suggesting a high demand for FP information in these communities. Interestingly, fewer sessions were delivered on fertility, and findings suggest that the use of male and female organ posters may have been viewed as taboo by some community elders. During community learning sessions on HTSP and FP, community members expressed interest in different types of methods, although the vast majority were interested in SDM or TwoDay Method specifically. The higher demand for FAM can be explained by general excitement surrounding the introduction of new side effect￾free FP alternatives directly within the community. Community members interested in other FP methods were given FP invitation cards to receive FP services at the health facility. However, the study team could not follow-up with such clients to confirm use of other FP services. Yet service statistics collected in the health center catchment areas suggest that use of FP counseling services increased during the same time of the WALAN intervention activities. While we are unable to ascertain causality, 44 these results suggest that the implementing the FAM group counseling model in the communities did not negatively affect use of FP methods offered in facilities. Demand among couples for FAM as part of the method mix. The results show that across the 15 villages, close to 300 couples took the method home. There was stronger demand for SDM than TwoDay Method. Yet TwoDay Method was described as an easier method to use. In some cases, youth facilitators described that FAM users switched from SDM to TwoDay Method, due to method ineligibility and/or method preference. Youth facilitators often described the reasons behind the demand for FAM as being side-effect-free methods that were easy to use. Finally, the process findings suggest that group counseling sessions were in the vast majority attended by couples, highlighting demand for FAM not only by women, but their male partners as well. Youth facilitators are able to deliver group counseling on FAM for couples, but need strong supervision and support to improve their competency. Youth facilitator scores improved over the intervention period in all counseling aspects for both SDM and TwoDay Method. This improvement came at a time after a refresher training was done in December 2016 and after organized efforts for supportive supervision and mentoring were implemented, with an emphasis on addressing facilitator gaps in counseling, particularly around method screening and eligibility. At the on-set, youth facilitators’ competency gaps included method screening (e.g. period regularity for SDM; able to manage fertile days for SDM and TwoDay Method; screening out pregnant women) and supporting couples to use the method (e.g. stating either couples should abstain or use condoms during fertile days; asked how they will handle fertile days). These skills significantly improved by the second observation point. Handling screening of couples interested in FAM during group counseling sessions. Consistent with the competency checklist findings, FGDs with youth facilitators shared that screening participants could be challenging during the group counseling session. For instance, at times women did not disclose or know that they were pregnant. Moreover, findings suggest that a few pregnant women wanted to CycleBeads use after their pregnancy. Future solution adaptation and research should explore other ways – perhaps by including a pregnancy checklist, job aide or smaller counseling component to advise pregnant women to come back for CycleBeads after their pregnancy to ensure proper screening and eligibility for method use. Strengthening male and female youth facilitators’ collaboration. The findings suggest that male youth facilitators, in particular, felt overburdened by the workload they took on, relative to their female counterparts. However, they attributed workload imbalance to what they perceived as women’s laziness, lack of education or distractedness in facilitating the sessions. These findings suggest that more time and support needs to be integrated into the trainings and support visits to deconstruct facilitators’ notions and beliefs around masculinity and femininity, and how this relationship may affect their working relationship in delivering the WALAN activities. 45 WALAN EFFECTIVENESS RESULTS 46 6. EFFECTIVENESS RESULTS The results section below describes whether women and couples who learn about FAM in a group counseling model are able to use the method correctly. The section also explores changes in couple communication and relationship as a result of method use, and continuation of method use at the second interview time point. 6.1 FAM USERS BACKGROUND FAM User Demographics The descriptive results in Table 12 show that interviewed SDM female users are slightly older than the TwoDay Method users (24.8 years versus 22.8 years, respectively). This trend is similar for SDM and TwoDay Method male partners. About 63% of SDM female users have some level of primary education, compared to 77% of TwoDay Method female users. Not surprisingly male partners have higher education levels than female users for both SDM and TwoDay Method groups. Approximately 47% of TwoDay Method male partners had some level of secondary education, compared to 37% SDM male partners. Consistent with the Northern Uganda’s livelihood and economy, the majority of female users and male partners reported working in farming and harvesting. Consistent with the different age trends, SDM female users reported being married longer (7.9 years) than TwoDay Method users (5.7 years). About 30.8% of SDM and 35.9% of TwoDay Method female users reported that their male partner had other wives (defined as ‘co-wives’ in table below). Finally, SDM and TwoDay Method female users had an average of 3 and 2.5 children, respectively, by the time of the first interview. TwoDay Method users reported having younger children than SDM users, with close to 1/3 reporting having a child under 1 year of age (32.7%). This is not surprising given that unlike SDM, TwoDay Method can be used by women with irregular menstrual cycles after giving birth. Interestingly, four SDM female users reported having a child under six months (3.4%), suggesting that these four users may have been ineligible for SDM use (postpartum women should wait until she has had at least four periods, or three regular menstrual cycles, after giving birth to start method use). 47 Table 12. FAM user demographics at first interview, by SDM and TwoDay Method samples SDM Female Users (n= 120) SDM Male Partners (n= 60) TwoDay Method Female Users (n= 53) TwoDay Method Male Partners (n= 36) Age in years Mean (min, max) 24.8 (17.0, 35.0) 28.9 (19.0, 45.0) 22.8 (15.0, 35.0) 25.9 (20.0, 41.0) Education No Education 13.3% 5.0% 7.5% 0.0% Some primary 63.3% 28.3% 77.4% 19.4% Completed Primary 14.2% 25.0% 11.3% 19.4% Some Secondary 6.7% 36.7% 1.9% 47.2% Completed Secondary 1.7% 1.7% 1.9% 11.1% More than Secondary 0.8% 3.3% 0.0% 2.8% Have a job Yes 87.5% 100.0% 98.1% 100.0% No 12.5% 0.0% 1.9% 0.0% Job type Farming 89.5% 91.6% 92.3% 77.8% Formal paid work 0.0% 1.7% 0.0% 5.6% Informal paid work 3.8% 0.0% 3.9% 16.6% Other 6.7% 6.7% 3.8% 0.0% Marriage duration in years Mean (min, max) 7.9 (0.5, 30.0) 8.3 (2.0, 20.0) 5.7 (0.08, 20.0) 4.2 (0.25, 17.0) Male partner has more than 1 wife Yes 30.8% 21.7% 35.9% 27.8% No 69.2% 78.3% 64.1% 72.2% Number of living children Mean (min, max) 3 (0, 7) 3.8 (1, 26) 2.5 (0, 7) 2.6 (0, 9) Age of youngest child 0-6 months 3.4% 5.0% 10.2% 20.6% 7-11 months 10.1% 8.3% 22.5% 23.5% 1-2 years 70.6% 65.0% 46.9% 38.2% 3-5 years 14.3% 21.7% 14.3% 11.8% 6 years + 1.7% 0.0% 6.1% 5.9% (Source: FAM User Interviews) FAM Users’ Family Planning History Table 13 shows FAM users’ FP history and reason for choosing their FAM of choice at first interview. Female users and male partners were asked if they had ever used a modern method of FP, followed by whether they had used a modern method of FP in the last three months. Around half of female users (45.0% SDM and 54.7% TwoDay Method) reported never having used a FP method prior to their current FAM use. When asked about which methods women were using in the last three months prior to the first interview point, 36.7% of SDM (44) and 17.0% of TwoDay Method female users (9) reported using a method of FP. Of the 44 SDM female users reporting a method of FP in the last three months, 34 were using a hormonal 48 method of FP (30 injectable; 2 implants; 2 pills). For TwoDay Method, four of the nine women were recently using injectables. Qualitative IDI interviews suggest that concerns over side effects were a common reason for switching to FAM. Overall, this data point suggest potential gaps in screening criteria, given that women must wait until they have at least one regular cycle – or two or more periods – before starting SDM use. This data point, triangulated with the competency checklist results, suggests that screening potential SDM users for previous FP method history and menstrual cycle regularity needs to be strengthened in the training as well as in supportive supervision. One possible option is to have facilitators refer these cases to a healthcare provider. Table 13. FAM user FP history at first interview, by SDM and TwoDay Method samples SDM Female Users (n= 120) SDM Male Partners (n= 60) TwoDay Method Female Users (n= 53) TwoDay Method Male Partners (n= 36) Ever used FP method Yes 55.0% 61.7% 45.3% 66.7% No 45.0% 38.3% 54.7% 33.3% Using another FP method 3 months prior Yes 36.7% 45.0% 17.0% 47.2% No 62.5% 55.0% 83.0% 52.7% No response 0.8% 0 0 0 FP method used in last 3 months Condom 3.3% 18.4% 1.9% 22.2% Pills 1.7% 1.7% 0 5.6% Injectable 25.0% 13.4% 7.5% 5.6% Implant 1.6% 5.0% 0 0 IUD 0 0 0 2.8% CycleBeads 0.8% 1.7% 5.7% 11.1% TwoDay Method 0.8% 0 0 0 LAM 1.6% 0 0 0 Withdrawal 0.0 1.7% 0 0 Abstinence 0.8% 3.3% 0 0 Other 0.8% 0 1.9% 0 (Source: FAM User Interviews) Female users and male partners were asked about their reason for using either SDM or TwoDay Method during their first interview. The results show that the majority of FAM users, both women and their male partners, cited the desire to prevent pregnancy, although in some cases respondents also cited the desire to track their menstrual cycle and/or plan a pregnancy as a secondary reason. No female users cited the desire to plan a pregnancy as 49 the sole reason for using their FAM of choice. Notably, 19.4% of TwoDay Method male partners cited the desire to plan a pregnancy as a reason for choosing TwoDay Method. Table 14. FAM user reasons for using FAM at first interview, by SDM and TwoDay Method samples SDM Female Users (n= 120) SDM Male Partners (n= 60) TwoDay Method Female Users (n= 53) TwoDay Method Male Partners (n= 36) Prevent pregnancy 99.2% 98.2% 90.6% 77.8% Plan Pregnancy 0.0% 1.8% 0.0% 19.4% Track menstrual cycle 0.0% 0.0% 7.5% 2.8% Don’t know 1.8% 0.0% 1.9% 0.0% (Source: FAM User Interviews) FAM User Exposure to WALAN activities Table 15 shows interviewed FAM users’ exposure to the WALAN community learning, group counseling and method support sessions at their first interview. Approximately 85% of SDM users (male and female) attended these community learning sessions, which included awareness raising sessions on fertility awareness, LAM, HTSP and FP to the entire community. Community learning sessions were attended less frequently by female TwoDay Method users (66%) than male partners (81%). Of the FAM users interviewed, over 90% of SDM and TwoDay Method female users reported attending the group counseling session on FAM. Notably, only 83% of TwoDay Method male partners reported attending a group counseling session. These data suggest that not all interviewed users attended the session, and instead may have had their partner attend on their behalf. As well, qualitative data suggest that in a few cases, youth facilitators conducted individual counseling upon request, despite not being part of the original WALAN protocol. As a result, a small number of users may have received this method outside of the group counseling sessions. After group counseling sessions, FAM users were also given the option of attending a follow￾up method support session to strengthen their method use. Results suggest that a larger proportion of SDM male partners attended the method support sessions (83%), relative to SDM female users (74%). In contrast, a smaller proportion of TwoDay Method male partners reported attending at least one method support session (67%), compared to TwoDay Method female users (85%). 50 Table 15. FAM users’ exposure to WALAN activities at first interview, by SDM and TwoDay Method samples SDM Female Users (n=120) SDM Male Partners (n=60) TwoDay Method Female Users (n=56) TwoDay Method Male Partners (n=36) Attended a community learning session on fertility, HTSP, FP 85.8% 85.0% 66.0% 80.6% Attended group counselling session on FAM 90.0% 93.3% 96.2% 83.3% Attended a method support session on FAM 74.2% 83.3% 84.9% 66.7% (Source: FAM User Interviews) 6.2 SDM KNOWLEDGE AND METHOD USE Correct Knowledge of SDM use Figure 11 shows correct knowledge of method use by SDM female users and male partners at approximately 1-2 months after method initiation. Correct knowledge of SDM use was measured through a structured observation of the user demonstrating how to use CycleBeads. The research assistant used a checklist of five key points necessary for method use. Composite indicators were then calculated to show; 1) the percentage of respondents who demonstrated all 5 steps (listed above) correctly during the demonstration and 2) the average % score from each of the five individual measures. When asked to show how to use CycleBeads, 80.9% of SDM female users (97 out of 120) reported all five points correctly, which increased to 87% of SDM female users approximately 6-7 months after method initiation (see Figure 11). SDM male partners experienced a drop in correct knowledge of method use, decreasing from 80% to 71% from first to second interview point. Figure 11. SDM users who show how to use the method correctly, at first and second interview (Source: FAM User Interviews) 80.9% 87.1% SDM Female 1st Interview (n=120) SDM Female 2nd Interview (n=101 ) 80% 70.7% SDM Male Partner 1st Interview (n=60) SDM Male Partner 2nd Interview (n=41) 51 Table 16 shows the percentage of participants who mentioned each of the steps correctly during the demonstration, in addition to the average percentage score of correct steps. The table shows that nearly nine out of ten female SDM users demonstrated all steps correctly. The step most frequently demonstrated was ‘move the ring to the red bead on the first day of period.’ The least frequently mentioned step ‘brown beads are safe days’—though the difference between the two was marginal. Knowledge of key method demonstration steps improved between the first and second interview for women but decreased for men. Specifically, men scored lowest in showing that brown beads are safe and moving the ring back to the read bead. Table 16. Correct knowledge of SDM use by demonstration steps, at first and second interview Female User 1st Interview (n=120) Female User 2nd Interview (n=101) Male Partner 1st Interview (n=60) Male Partner 2nd Interview (n=41) Average question score from 5 method steps: 91.3% 91.3% 90.3% 82.4% 1. Move ring to red bead 95.8% 95.1% 95.0% 90.2% 2. Move ring to next bead 90.8% 92.1% 95.0% 87.8% 3. Abstain on white beads 91.7% 90.1% 86.7% 82.9% 4. Brown beads safe 88.3% 89.1% 85.0% 75.6% 5. Move ring back to red bead 90.0% 90.1% 90.0% 75.6% (Source: FAM User Interviews) SDM Management of Fertile Days In addition to correct knowledge of method use, the other key criterion for using SDM correctly is the ability to either abstain and/or use condoms during fertile days. Table 17 shows correct management of fertile days, reported separately by female users and male partners at first and second interview points. The results show high compliance with management of fertile days in the previous month – as confirmed by both female users and male partners - about one to two months after method initiation, and again six to seven months post-method initiation (98% to 99% for female users from first to second interviews respectively). Table 17. Percentage of SDM users reporting correct management of fertile days, at first and second interview 1st Interview 2nd Interview * WOMEN ( 1st interview n=120) ( 2st interview n=77) 97.5% 98.7% MEN ( 1st interview n=60) ( 2st interview n=34) 98.3% 97.1% (Source: FAM User Interviews; *Note: Users no longer using SDM excluded from analysis at second interview) SDM users were asked how they manage fertile days with their partner. The majority correctly reported use of condoms or abstinence. Just over a third of female SDM users (37%) reported using condoms as the primary way they managed fertile days with their partner. Another third of female users (34%) reported abstinence as the primary way to manage fertile days. 52 Approximately 26% reported using both condoms and abstinence. A very small number of respondents reported an “other” method of managing fertile days, including one female user who stated she “swallowed tablets.” Men were more likely to report abstinence as the primary way of managing fertile days. Slightly fewer women and men reported using abstinence as their primary way of managing fertile days six to seven months after method initiation. Qualitative data show that couples managed fertile days vis-a-vis male partners going “for a visit” to a relative’s house; if in polygamous union, sleeping at a second wife’s home, separating beds, and/or sleeping in the kitchen or with children during fertile periods. Only two women at first interview reported not using protection nor abstaining during fertile days in the last month. Qualitative data suggest that reasons for not having unprotected sex during fertile days included not having condoms available, male partner insisting on having sex, and trying to become pregnant. Figure 12. SDM users’ use of method during fertile days, at first and second interview (Source: FAM User Interviews; *Note: Users no longer using SDM excluded from analysis at second interview) SDM Method Use Verification During the FAM user interviews, SDM users’ calendars and CycleBeads were verified to assess whether the ring was placed on the correct bead as per correct method use. The research assistant asked to check the user’s calendar and checked “yes” if the period start date was marked on the calendar and also “yes” if the ring was on the correct bead based on the marked period start day on the calendar. Table 18 shows method verification at first and second interview points for female users, by three measures: 1. Having an SDM marking calendar; 2. If having a calendar, marking period date; 3. And If marking period date, ensuring that the ring is on correct bead. The results show that approximately 97.5% of SDM users had their calendar at first interview point, 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Female Users 1st Interview (n=120) Female Users 2nd Interview (n=77) Male Partners 1st Interview (n=60) Male Partners 2nd Interview (n=34) Abstinence Condoms Both abstaining and condoms Not using protection or abstaining Other 53 dropping to 85.7% of interviewed female users at second interview point. Of those female users with a calendar, 78.6% had their period start date marked at the time of first interview, compared to 71.2% at second interview date. Finally, of those who had marked the start date of their period, 65.2% had the ring on the correct bead as verified by the data collector, compared to 46.8% at second interview point. While the results suggest decreased correct method use, as defined by the method verification conducted, qualitative data suggest that most users stopped using the calendar once they were able to memorize their menstrual cycle and use the method correctly without the calendar. This is consistent with anecdotal data from other SDM studies conducted by IRH. Table 18. Correct use of SDM by method verification, at first and second interview Female Users 1st Interview Female Users 2nd Interview Have SDM calendar? (n=120) (n=77)* Yes 97.5% 85.7% No 2.5% 14.3% If have SDM calendar, marked period date? (n=117) (n=66) Yes 78.6% 71.2% No 21.4% 28.8% If marked period date, Ring on correct bead? (n=92) (n=47) Yes 65.2% 46.8% No 34.8% 53.2% (Source: FAM User Interviews; *Note: Users no longer using SDM excluded from analysis at second interview) Reported Menstrual Cycle Ranges In order to use SDM, women must have menstrual cycles between 26 and 32 days long. To assess menstrual cycle range and user eligibility, SDM female users were asked if their menstrual period had ever come: 1. Before the darker brown bead (proxy for 26th day of menstrual cycle, and; 2. After the last brown bead (proxy for 32nd day of menstrual cycle). Table 19 shows that at first interview, 14% of women (17 out of 120) reported a short or long range cycle, compared to 16% of women at the second interview time point (12 out of 77). 54 Table 19. SDM users’ self-reporting of out of range cycles, at first and second interview Female Users 1st Interview Female Users 2nd Interview Out of Range Cycles (n=120) (n=77)* Experience period before darker brown bead or after last brown bead 14.2% 15.6% Ever experience period before darker brown bead? (n=120) (n=77)* Yes 8.3% 10.4% No 85.0% 88.3% Don’t know 4.2% 1.3% No response 2.5% 0.0% Ever experience period after last brown bead? (n=110) (n=69)* Yes 6.4% 5.8% No 86.4% 92.8% Don’t know 5.5% 1.4% No response 1.8% 0.0% (Source: FAM User Interviews; *Note: Users no longer using SDM excluded from analysis at second interview) As seen in Table 20, out of the 17 women self-reporting out of range cycles at first interview, about 35% reported talking to someone about their out of range cycle. This increased to close to 42% of the 12 SDM female users six to seven months after method initiation (second interview point). The majority of women reported discussing this issue with their male partner, or a friend. Table 20. Action taken by SDM users with out of range cycles, at first and second interview Female Users 1st Interview Female Users 2nd Interview Talk to someone about out of range cycle? (n=17) (n=12) Yes 35.3% 41.7% No 64.7% 58.3% Who did you talk to? (n=6) (n=5) My partner 83.3% 20% Youth Group Facilitator 0 40% Friend 16.7% 40% (Source: FAM User Interviews) SDM Male Partner Participation in Method Use Approximately 92% of male partners reported participating in method use in the last month at first interview point, dropping slightly to 88% at second interview point. In Table 21, male partners reported multiple roles in method use in the previous month. The majority reported moving the ring or reminding their female partner to move the ring, followed by marking the first day of period on the calendar. 55 Table 21. SDM Male Partner Role, at first and second interview (Source: FAM User Interviews; multiple response options; *Note: Users no longer using SDM excluded from analysis at second interview) SDM Continuation At the second interview point – or approximately six to seven months after method initiation -- 79% of SDM female users reported still using SDM (77 out of 97 SDM users). This is similar to other multi-country studies on SDM conducted by IRH showing method discontinuation trends over time. For instance, one study found the percentage of women continuing to use SDM after one year ranged from 23 to 61% (IRH 2008). As seen in Figure 13, the 20 SDM female users cited different reasons for no longer using the method at the second interview (21% of female users interviewed). Reasons include being pregnant (six), wanting a more effective method such as injectables or IUD (four), and separating or moving away from their male partner (three). Two women cited male partner disapproval, while other cited difficulty in using CycleBeads (2), and losing CycleBeads while moving between houses (2). Interestingly, one of the women who discontinued for a more effective method further explained in her interview that she just “wanted to try out” CycleBeads. Of the 14 non-pregnant discontinued users, over half reported currently using another method of modern FP (57%), including injectables (three), condoms (two), implant (one), IUD (one) and progesterone pill (one). Male Partners 1st Interview (n=60) Male Partners 2nd Interview (n=34)* Moves the ring 66.7% 55.9% Reminds partner to move ring 43.3% 55.9% Marks first day of period on calendar 20.0% 11.8% Abstains on fertile days 11.7% 2.9% Uses condoms on fertile days 6.7% 2.9% Asks partner if they can have sex 3.3% 2.9% Buys condoms 0 2.9% Other 1.1% 5.9% 56 Figure 13. SDM female users’ reasons for discontinuing SDM use, at second interview (n=20) (Source: FAM User Interviews) Of the six reported pregnancies, three women reported wanting to become pregnant, while three other women reported becoming pregnant unintentionally while using the method (see Figure 14 below). Two of the three unintended pregnancies were attributed to failure in managing fertile days. As one SDM female user noted, “we never intended to have another child but my husband insisted that we have unprotected sex.” The third unintended pregnancy is attributed to stopping CycleBeads use, as the female user cited that she was using the method correctly since method initiation, but forgot her set of CycleBeads once she traveled away to her parent’s home. Figure 14. SDM female users’ self-reported reasons for pregnancies, at second interview (n=6) It should be noted that in addition to the six pregnant female respondents, four other interviewed SDM female users cited that they were already pregnant when they received CycleBeads, despite incorrectly notifying the data collector at the first interview point that they were using CycleBeads. These include women who both knew and did not know they were pregnant when they received the method at a group counseling session. This result was corroborated by FGDs with youth facilitators, who reported difficulties in screening for early pregnancy during counseling. Given that a woman cannot start using CycleBeads without the start of her period, these four women were excluded from the discontinued sample above (resulting in total sample of n=97, rather than n=101). Of the 77 women still using SDM at the second interview time point, 98.7% of them reported intent to continue use of FAM. Reasons for method continuation included that the method 6 4 3 2 2 2 1 0 1 2 3 4 5 6 7 Pregnant Wanted more effective method Away / separated from partner Male partner disapproves Difficult to use CycleBeads Lost CycleBeads No response 3 Wanted to become pregnant 3 Became pregnant using CycleBeads 57 was side effect free and easy to use. Only one woman cited plans to discontinue method use, citing irregular menstrual cycle as a reason to discontinue SDM in the near future. This suggests correct learning about SDM and eligibility, as this user expressed understanding to discontinue the method due to her cycle irregularity. Overall, the SDM user results suggest that the users learned how to use the method correctly, but for various reasons, one fifth of SDM users decided to discontinue method use six to seven months after method initiation. 6.3 TWODAY METHOD KNOWLEDGE AND METHOD USE Correct knowledge of TwoDay Method use Two measures were used to assess users’ knowledge of TwoDay Method. Users were shown a filled-in TwoDay Calendar example and asked two questions: 1. When is it safe to have sex with no risk of pregnancy? and; 2. What does it mean if you notice secretions today or yesterday? We calculated correct knowledge for the two questions and identified: 1) the percentage of respondents who answered both questions correctly, and; 2) the average percentage score of the questions answered correctly. Figure 15 shows that the proportion of users who demonstrated how to use TwoDay Method correctly was relatively high between sexes and time points. Approximately 79% of TwoDay Method female users and 81% of male partners were able to answer both questions correctly at first interview point, compared to 82% of female users and 77% of male partners followed￾up at the second interview time point. Figure 15. TwoDay Method users who demonstrate how to use the method correctly, at first and second interview (Source: FAM User Interviews) As seen in Table 22, 83% of TwoDay Method female users and male partners correctly identified when it was safe to have sex with no risk of pregnancy (two dry days in a row) one 79.2% 81.5% 80.6% 76.5% 0% 20% 40% 60% 80% 100% TDM Female 1st Interview (n=53) TDM Female 2nd Interview (n=27) TDM Male Partner 1st Interview (n=36) TDM Male Partner 2nd Interview (n=17)* 58 to two months after method initiation. Female users scored higher than men on all indicators of method knowledge except for the questions “what does it mean if you notice sections today or yesterday’ during the second interview. Table 22. Correct Knowledge of TwoDay Method Use by step, at first and second interviews Female User 1st Interview (n=53) Female User 2nd Interview (n=27) Male Partner 1st Interview (n=36) Male Partner 2nd Interview (n=17) Average question score from 2 method questions: 84.9% 88.9% 83.3% 85.3% When is it safe to have sex with no risk? (Points to 2 dry days in a row ) 83% 88.9% 83.3% 76.5% What does it mean if you notice secretions either today or yesterday? (I am fertile/ should use condoms / should abstain) 86.8% 88.9% 83.3% 94.1% (Source: FAM User Interviews) Understanding the difference between healthy and unhealthy secretions is another key knowledge component to correct TwoDay Method use. At the first interview, about 64% of TwoDay Method female users correctly answered that secretions are unhealthy if they smell bad, itch, or cause pain at first interview time point, compared to 88.9% of female users at the second interview time point (relative to 72% and 77% of male partners at first and second interview time points, respectively). TwoDay Method users were asked what action they should take if they are experiencing unhealthy secretions, with the correct answer options, including: 1. Go to a health center; 2. Go to a VHT and/or 3. See a youth facilitator. Figure 16 shows correct answers in the green bars, highlighting that the majority of respondents answered correctly to ‘go to a health center’ (59% at first interview and 74% at second interview for female users) or see a youth facilitator (8% to 15% at first and second interview respectively for female users). No one respondent answered with ‘seeing a VHT.” Overall the proportion of female users answering this question correctly increased from one to two months, to six to seven months after method initiation (from 66% to 89%). Incorrect answers are shown in the orange bars in Figure 16. Specifically, during their first interview, four female respondents answered that users “should take a bath” if they are experiencing secretions. 59 Figure 16. TwoDay Method users’ reported actions to take if experiencing unhealthy secretions (correct answers in green) (Source: FAM User Interviews) TwoDay Method Management of Fertile Days Table 23 shows the proportion of users reporting correct management of fertile days, defined as having either used abstinence, condoms or both methods during fertile days in the last month. The results show high compliance, with 94% of TwoDay Method female users reporting correct management of fertile days, slightly increasing to 96% at the second interview time point. A slightly lower proportion of men reported correct management of fertile days, which increased to all men at the second interview time point. Table 23. TwoDay Method users correct management of fertile days Female User 1st Interview (n=53) Female User 2nd Interview (n=27) Male Partner 1st Interview (n=36) Male Partner 2nd Interview (n=17) 94.3% 96.2% 88.6% 100% (Source: FAM User Interviews; *Note: Excludes users interviewed, but no longer using the method at interview time point) Figure 17 shows TwoDay Method users’ reports of method used during fertile days. The vast majority of female users and male partners reported using either abstinence, condoms and/or a combination of both methods. Only two women reported not abstaining or using condoms in the last month during fertile days during their first interview. A small proportion of female users and male partners also reported using “other” methods during their fertile days, 7.5% 14.8% 8.3% 58.5% 74.1% 72.2% 82.4% 15.1% 7.4% 5.6% 18.9% 11.8% 3.7% 13.9% 5.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TDM Female 1st Interview (n=53) TDM Female 2nd Interview (n=27) TDM Male Partner 1st Interview (n=36) TDM Male Partner 2nd Interview(n=17)* See group facilitator Got to a health center Other Don’t know 60 including one female user who reported that her partner had been away for five months, and another user stating that they “check out our calendar and know where we stand.” Figure 17. TwoDay Method users method use during fertile days, at first and second interview (Source: FAM User Interviews) TwoDay Method Use Verification During the interview, female users and male partners were asked to present their TwoDay Method calendar to verify if they were marking their calendars daily. One to two months after method initiation, 90% of female users presented their calendar, compared to 31% of female users at the second interview, four to five months later. The primary reason given for not having a calendar at the second interview point was not having the new 2017 marking calendar (follow-up interviews were conducted in early 2017); and not having the calendar on hand if the interview was conducted outside the home. Interview participants reported several improvisation techniques, including using a CycleBeads calendar and marking the days in a personal book. Process-level data also suggest a delay in delivering TwoDay Method calendars to youth group facilitators after the 2017 New Year. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Female user 1st interview (n=52) Female users 2nd interview (n=26) Male partners 1st interview (n=35) Male partners 2nd interview (n=16) Abstinence Condoms Both abstaining and condoms Not using protection or abstaining Other 61 Figure 18. Correct use of TwoDay Method by means of verification, at first and second interview (Source: FAM User Interviews) TwoDay Method Male Partner Participation in Method Use Approximately 69% of male partners reporting helping their female partner use TwoDay Method at first interview point, which increased to 77% at second interview. Table 24 shows that male partners played multiple roles in method use, including marking the calendar (58% at first interview) and reminding their partners to mark the calendar (36% at first interview). One male partner cited buying a handkerchief for his female partner for checking secretions. Table 24. TwoDay Method male partner roles, at first and second interview (Source: FAM User Interviews; Note: multiple response options) TwoDay Method Continuation Of the 26 female users and 17 male partners followed-up at the second interview point, all but one female user and one male partner reported continuing method use. The one discontinued female user cited her husband’s desire for pregnancy as a reason for discontinuation. 90.4% 30.8% 97.1% 75% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Female users 1st interview (n=52)* Female users 2nd interview (n=26)* Male partners 1st interview (n=35)* Male partners 2nd interview (n=16)* Male Partners, 1st Interview (n=36) Male Partners, 2nd Interview (n=17) Marks the card 58.3% 35.3% Reminds me to mark the card 52.8% 58.8% Checks the secretions 2.8% 0 Asks if we can have sex 8.3% 0 Abstains on fertile days 11.1% 17.6% Uses condoms on fertile days 8.3% 5.9% Buys condoms 2.8% 0 Other: Bought a handkerchief 2.8% 0 62 IDIs with continued method users indicated that method continuation could be attributed to ease with which TwoDay Method is used, male partner involvement while using the method, and improved communication among couples. 6.4 COUPLE DECISION-MAKING AND COMMUNICATION ABOUT FAM USE Results from both FAM user interviews and IDIs were used to explore the intervention’s effect on improving couple decision-making and communication around FAM use. Specifically, the study team was interested in answered the following questions: 1. How do couples make the decision to use FAM? 2. And how does FAM use affect the couple relationship and communication? 3. What are couples’ experiences in using FAM and management of fertile days? Couples’ Decision to Use FAM The FGD and IDI qualitative data collected from community members and users provide a window into the decision-making processes of choosing FAM. The results show that the decision to attend a group counseling session and use a FAM was typically a joint decision made by the couple together, although the decision-making process varied among couples. In certain instances, one partner typically let the other partner know of the group counseling sessions first, and often returned to the group counseling session with the other partner prior to deciding on FAM use. “She is actually the one who came and told me about it because I was not around. She told me about a method of FP using the MoonBeads. I told her I needed to attend one of the meetings which I did and later got the moon beads and began using it. That’s how we were taught.” – SDM Male Partner, 24 years old, Amuru District “My husband first approached me one evening and told me he wanted to share something with me but will only share it on one condition that I accept. And I said I will accept if it will be of help so he told me and I told him to first give me time to attend one of the sessions as I make up my mind. So I accepted and we went for the group counseling together and that’s when we were given the beads”. – SDM Female User, 20-25 years old, Gulu District In other cases, both partners attended the community learning session together and then decided to attend the session on their FAM of choice. While communication and decisions about method use involved the couple together, qualitative data suggest that in some cases, the final decision was made by the male partner. 63 “We both attended the community learning and my husband seemed satisfied more with use of cycle beads so we decided to attend the group counselling on CycleBeads.” – SDM Female User, 15-25 years old, Amuru District Couple Relationship Improvements FAM female users and male partners reported relationship improvements over the course of method use. Reported improvements included less conflict, and increased trust and communication between them as a result of using a FAM together. A few interviewed users shared that the ability of spacing children enabled relationship improvements, and reduction of tension and violence. “My relationship with my wife before was not good and full of tension. This was because we had a child the shortly after we had another. The children being too close in age created violence between us. There were so many issues between us and sometimes my wife decide to go away. Today we do not have tension or acts of violence between the two of us. We are also practicing child spacing or family planning well with no secrets.” – SDM Male Partner, 24 years old, Amuru District Specifically both female users and male partners pointed to secrecies around covert FP use as a source of tension prior to FAM use. Female users and male partners cited the increasing presence of “trust” as a basis for relationship and intimacy improvements. As one 19-year￾old TwoDay Method female user stated, “there is no issue now of accusing some one of lying [about FP method use] because we both trust the method.” Both female users and male partners also pointed to shared “respect” as a contributor to their relationship improvement. Respect was cited in terms of both FAM use and management of fertile days, in addition to respecting each other’s decisions and decision￾making processes within the couple relationship. In some cases, couples pointed to improved conflict mitigation and communication as a result of attending WALAN sessions and using FAM. “Using CycleBeads improved our relationship in a way that we respect each other especially when one is going through a challenge. We respect each other’s decisions and do not change our minds on things already decided upon. We agree on many things like separating beds or using condoms when one of us is not ready. And this we learned as a result of using this method, respect!” - SDM Male Partner, 33 years old, Nwoya District “They said that once you have started using these methods there should be love between you and your partner so that when you forget to circle [the calendar days] he can do it for you; I mean that there is respect in your practice of family planning.” – TwoDay Method User, 26-35 years old, Amuru District 64 Interviewed female users in particular reported experiencing and observing positive changes in the behavior of their male partners. Specifically, they reported experiencing more love in their relationship and reduced violence from their partners, in addition to having more partner support with domestic chores such as bathing children, and accompanying their female partners to the hospital in case the children fell sick. These changes may have also been due to the combination of WALAN and the Responsible, Engaged and Loving Fathers Initiative (REAL) intervention activities in certain parishes of Amuru and Gulu districts, whereas some young fathers participating in REAL violence prevention intervention activities also started using FAM with their partners under WALAN activities. “For me I realized that there was no respect in my house because all the time we were quarreling. So we sat down and started to look at other people who respect themselves. After attending this session we started respecting each other for example when he gets back from his journey I go and greet him and he also greets me, bathe the children and take for me water to bathe when am sick so I am now free and happy” – Female Community Member, 26 – 35 years old, Amuru District (WALAN and REAL intervention site) Consistent with the earlier quantitative findings, female users also reported increased male partner support in method use, helping the female partner to move the ring or remind them to move the ring and use condoms or abstain during fertile days. Couples cited the importance of being able to work together to use the method correctly. Examples given during interviews included reminding one another to move the ring, or reminding to check for secretions. “If I am away he needs to move the ring. He shows me and tells me not to move the ring again.” – SDM Female User, 24 years old, Gulu District “When we reach the fertile days I tell her that she may get pregnant, I remind her how it is not easy to take care of six children and how we have to struggle to educate them. She usually responds that no problem with that and she agrees with what I say. (…) We abstain and I support her. When she is done she monitors her secretions using a hankie and we are both comfortable we go on together.” – TwoDay Method Male Partner who switched to TwoDay Method, 35 years old, Amuru District Couple Communication around Management of Fertile Days As highlighted in the above qualitative results, couple communication is key to correct use of FAM, especially during management of fertile days. Couples have to jointly decide on what to do on fertile days and agree if the method is suitable for them. The study team explored couple communication processes around management of fertile days through both quantitative and qualitative data. 65 Table 25 below shows the proportion of female users and male partners who felt that their opinion was taken into account about what to do on fertile days. One to two months after method initiation, a high proportion of SDM female users (95%) and male partners (97%) felt that their opinions were taken in to account on fertile days. Slightly fewer TwoDay Method female users (91%) and male partners (89%) reported feeling that their opinion was taken in to account during fertile days one to two months after method initiation. Table 25. FAM users who feel their opinion is taken into account about what to do on fertile days, first & second interview TWODAY 1st Interview 2nd Interview * TwoDay Method Female User 90.6% 100% TwoDay Method Male Partner 88.9% 100% (Source: FAM User Interviews; *Note: Users no longer using SDM excluded from analysis at second interview) Figure 19 shows the proportion of FAM users reporting initiating a conversation with their partner about what to do on fertile days at both interview points. Interestingly by the second interview (orange bar), fewer females and male partners – across SDM and TwoDay Method groups - reported initiating a conversation on fertile days, in comparison to the first interview time point. This decrease may be due to prolonged method use, whereas couples may already know what to do on fertile days six to seven months after initiating method use. Figure 19. FAM users who initiated a conversation about what to do on fertile days, at first and second interview (Source: FAM user interviews) The study team was also interested in understanding couples’ level of comfort discussing topics around management of fertile days. A Likert scale was used to understand couples’ comfort in discussing different topics related to management of fertile days. Respondents 84.4% (n=103) 81.7% (n=49) 69.8% (n=37) 61.1% (n=22) 62.4% (n=63) 56.1% (n=43) 66.7% (n=18) 41.2% (n=7) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% SDM Females SDM Males TwoDay Female TwoDay Male 1st interview 2nd Interview SDM 1st Interview 2nd Interview * SDM Female User 95.1% 94.1% SDM Male Partner 96.7% 97.6% 66 were given four choices: always true for me (1), sometimes true for me (2), rarely true for me (3), and never true for me (4). The Likert scale was used across five different measures: a) telling/asking partner if I am/she is on a fertile day, b) telling my partner we should use condoms, c) telling partner we should not have sex today, d) telling partner what to do on a fertile day, e) consoling partner when s/he is upset, and f) talking about disagreements. Only respondents who answered ‘always true to me’ were categorized as being comfortable discussing that topic. Figure 20 shows the proportion of respondents who reported feeling comfortable discussing different topics, segmented by SDM female users (blue bars) and male partners (orange bars) at first and second interviews. Female users were most comfortable telling their partner when fertile days occur (78% SDM) but less comfortable telling their partner not to have sex (40% SDM). Overall, male partners felt generally more comfortable than female partners to discuss the different topics related to management of fertile days, although the proportion of men reporting the same level of comfort slightly decreased by the second interview point. A larger proportion of SDM Female users, rather than male partners, reported feeling more comfortable communicating about the different topics together at second interview point. Figure 20. Proportion of SDM users who reported “always true to me” when asked if they felt comfortable about… (Source: FAM user interviews) Figure 21 shows TwoDay Method users who reported feeling comfortable discussing different topics, segmented by TwoDay Method female users (blue bars) and male partners (orange bars) at first and second interviews. Similar to SDM, male partners felt generally more comfortable than their female counterparts with the different topics, although the gender differences were smaller than SDM couples. Unlike SDM male partners, TwoDay Method male partners’ levels of comfort discussing different topics increased over time (e.g. 81% to 100% 0% 20% 40% 60% 80% 100% Telling partner am on fertile day Telling partner to use condoms Telling partner not to have sex Talking about what to do on fertile days Consoling my partner when s/he is upset Talking about disagreements SDM Female Users 1st interview (n=122) SDM Female Users 2nd interview (n=101) SDM Male Partners 1st interview (n=60) SDM Male Partners 2nd interview (n=41) 67 for talking about what to do on fertile days). While TwoDay Method female users level of comfort increased over time across most categories, a smaller proportion of female users felt comfortable telling their partner to use a condom (66% to 63% at first and second interviews, respectively), and talking about disagreements (83% to 78%). The largest improvements over time among TwoDay Method female users over time included comfort telling partner that she is on a fertile day (68% to 89% first to second interview), and talking about what to do on fertile days (72% to 85%). Figure 21. Proportion of TwoDay Method users who reported “always true to me” when asked if they felt comfortable about discussing the following topics with their partner (Source: FAM user interviews) 6.5 LESSONS LEARNED ABOUT EFFECTIVENESS Women and men can learn how to use SDM and TwoDay Method correctly when taught in a group counseling setting. Between 80% to 84% of female SDM and TwoDay Method users, respectively, showed how to use FAM correctly at the first observation point. The proportion of users showing correct method use increased to 87% and 89% of SDM and TwoDay method users respectively, a few months later at the second time point. As well, both SDM and TwoDay Method female users, in addition to their male partners, reported high compliance in managing fertile days (ranging from 89% to 100% among FAM samples). The correct knowledge of method use – combined with the correct management of fertile days – suggest that the group counseling model for couples can be effective in teaching couples how to use FAM correctly. FAM users managed fertile days using either condoms or abstinence or a combination of both, including sleeping in different houses. Female users reported improved comfort discussing how to manage fertile days and negotiating the use of condoms on fertile days. Male partner support for FAM was key in women gaining confidence to discuss what to do on fertile days. Men were willing to abstain or use condoms during fertile days but some 0% 20% 40% 60% 80% 100% Telling partner am on fertile day Telling partner to use condoms Telling partner not to have sex Talking about what to do on fertile days Consoling my partner when s/he is upset Talking about disagreements TDM Female Users 1st interview (n=52) TDM Female Users 2nd interview (n=26) TDM Male Partners 1st interview (n=35) TDM Male Partners 2nd interview (n=21) 68 expressed concerns because condoms were not readily available. Future adaptation or replication should ensure that condoms be available, given the method requirement that couples need to either abstain or use condoms during fertile days. Half of interviewed women who started using FAM had never used a method of FP, while close to one third were previous hormonal method users. Half of interviewed FAM users reported never using a method of FP in their lifetime (45% SDM; 55% TwoDay Method). This result suggests that half of those FAM users sampled may have been new users to FP and that FAM may be attractive to couples who may want to prevent a pregnancy but have never used a FP method. On the other hand, the findings suggest that some women may have switched to SDM from hormonal methods: close to 3 in 10 surveyed female FAM users were using a type of hormonal method in the last three months preceding the first survey point (28%). Not all SDM users continued method use seven months after method initiation. Approximately one fifth of SDM female users followed up with at the second interview point were no longer using SDM (20 of 97 women). Reasons for SDM discontinuation included: wanting a more effective method such as injectable or IUD, wanting to become pregnant, either separation or having moved away from their male partner, and male partner disapproval. Of those who discontinued method use, over half decided to switch to another method of FP - including injectables, IUD and condoms - suggesting that for some users, SDM may have been an entryway toward the use of other FP methods. The reports of losing CycleBeads when traveling in between houses suggests that in similar contexts with high migration and mobility – especially during harvest season –FAM providers may need additional training and support to support couples with loss of CycleBeads and remembering to bring the method with them. Youth facilitators’ and study team’s handling of pregnancies before and during CycleBeads. Similar to the feasibility competency checklist results, a very small number of women reported a pregnancy prior to taking a FAM home at the second interview point, despite confirming method use with the data collector previously. While unanticipated, this finding confirms that pregnant women took FAM home after attending a group counseling session, either aware or unaware of their pregnancy. In some cases, women took the method home to start using the method after childbirth. It should be noted that it is not harmful to educate a pregnant woman about FAM, but future models should support facilitators with the use of job aide on assessing pregnancy and/or following up with pregnant women after the counseling session. Of the larger SDM sample, only three women reported becoming pregnant while using the method – two of which resulted from failure to manage fertile days, and another because she forgot the method when moving between houses. While the team included additional probing questions on the second interview guide, especially for pregnant users, we were limited in getting more detailed information about discontinuation since these interviews were not designed to be exit interviews. Men were engaged and involved in method use. The findings show that men can and want to be actively involved in FP use. Male partner support was evident. In most cases, SDM male partners either moved the ring or reminded their partners to move the ring. Qualitative findings show that the decision to attend the group counseling sessions and using FAM was 69 typically made jointly, although the process of decision-making and how information was sought varied among couples. In some cases, one partner attended a group counseling session without the partner, then returned back to another group counseling session with their partner, while in other cases couples attended the initial group counseling session together after one partner attended a community learning session. Couple communication improved couple relationship and decision making on FAM. FAM users reported improved relationships with their spouses and freedom in discussing about method use especially management of fertile days. Couple communication resulted in respect for one another and reduction of couple conflict, although the latter may have also been affected with site overlap with the REAL violence prevention intervention activities. Couples discussed economic challenges associated with raising children (feeding and school fees) and agreed to space their children by using FAM. FAM users stated that because the success of the method depends on management of fertile days, couples must communicate and use the method together and agree on what to do on fertile days. Couples reported taking into consideration spouse’s views and making joint decisions. Qualitative findings also show improved couple communication and relationship as a result of FAM use, including increased “trust” among couples (some couples described previous conflict and distrust due to FP covert use by female partner). The majority of couples attended group counseling sessions and returned to method support sessions, but not all couples attended together. The proportion of SDM and TwoDay Method users attending at least one group counseling session ranged from 83% to 96%, suggesting that not all couples attended the sessions together. Furthermore, the qualitative findings suggest that in some cases, one partner attended a group counseling session and then returned back to a following session with their partner. This finding suggests a different couple attendance pattern than the consistent number of couples recorded by youth facilitators in group counseling session attendance sheets (presented under the feasibility results section). One potential explanation for this discrepancy could be that youth facilitators always recorded couple attendance, regardless of whether only one partner attended the session. Other results suggests that in some cases, youth facilitators also did individual visits and counseling and gave out methods when requested. This suggests that some FAM users, although very few, may have received SDM through individual counseling sessions, rather than group counseling sessions. Overall, these findings suggests that future trainings on the group couples counseling model should place stronger focus on how to handle and record partners who attend and return with and without their partners. Lastly, the results highlight that FAM users returned to method support sessions to improve on their method use. Approximately one to two months after method initiation, 67% to 85% of FAM users had attended a method support session to strengthen their method use. This finding shows multiple points of contact between users and youth facilitators throughout method use, unlike the typical service delivery setting where points of contact may be limited to a one time counseling session. 70 WALAN ACCEPTABILITY RESULTS 71 7. ACCEPTABILITY RESULTS This section describes results related to WALAN’s acceptability. Specifically, the study team was interested in understanding new FAM users’ perceptions of their group counseling experience, including benefits and challenges of learning about FAM with other couples in a group, discussing sensitive topics, and sharing personal information. The study also sought to better understand the experiences of community members who attended the initial community learning sessions on fertility awareness, HTSP, LAM and FP methods, regardless of whether or not they later attended group counseling sessions. Finally, the team explored the perceptions of key community opinion leaders, health workers, and VHTs regarding FAM counseling by non-health youth facilitators. 7.1 COUPLES SHARING OF INFORMATION IN GROUPS During FAM user interviews, female users and male partners were asked if they were comfortable discussing the following topics in a group with other couples: a) using condoms during fertile days; b) talking about when to have sex; c) talking about intimate topics that are personal to me and or my partner; and d) menstruation for SDM users or secretions for TwoDay Method users only. As seen in Table 26, both SDM and TwoDay Method female users reported high level of comfort discussing the topics with other couples in a group counseling session. Qualitative data suggest that couples appreciated sharing their experiences with others during group counseling sessions and again later on during method support sessions, when couples shared their experiences with method use. Table 26. FAM female users comfortable discussing topics with other couples, at first interview Topics SDM (n=120) TwoDay Method (n= 57) Intimate topics personal to my partner and I 88% 88% When to have sex 89% 88% Condom use during fertile days 80% 96% Menstruation for SDM 96% -- Secretion for TwoDay Method -- 96% (Source: FAM user interviews) Qualitative results suggest that FAM users shared information about their method use beyond the group counseling sessions with other couples. FAM users reported sharing information they learned during group counseling and method support sessions with others in their community, specifically family members, friends, neighbors and parents-in-law. The type of information shared typically included about how to use CycleBeads, including the marking calendar, how to check for secretions (for TwoDay Method), and strategies to manage fertile days. 72 Qualitative data show that FAM users also recommended that their friends and relatives come to a group counselling sessions. The reasons they cited for recommending their friends or relatives for a group counselling session included ease of method use, that the methods are side-effect free, and that the methods encourage couple communication and cooperation in the family. 7.2 COMMUNITY LEARNING PARTICIPANTS’ PERCEPTIONS OF WALAN Community members who participated in FGDs felt the community learning sessions had valuable information to support the practice of spacing children in their community. Overall, FGD participants were very enthusiastic about learning new topics related to fertility awareness, in addition to learning about new, side-effect free methods. Both younger and older women expressed the desire to use FP methods that are side-effect-free, which led to a high interest in attending the group counseling sessions delivered by the youth facilitators following the community learning sessions. “For me I was very opposed to family planning due to the non-stop bleeding that made me ask so many questions [about FP methods]. But now I understood and this has helped my life. Because I realized that having many children will bring issues related to school fees, hospital bills and others. They showed us this using a FP method mix board, which was very good.” – Male Community Member, 20-25 years old, Gulu District In general, FGD male participants, and in particular in the older age cohort, reported attending the sessions out of curiosity about the specific teachings, in addition to the desire to learn more about child spacing and FP. Youth facilitators were trained to discuss HTSP / FP topics during community learning sessions, focused on providing informed choice, and information on all FP methods. This was strategically conducted to provide community members with all the necessary information to make a choice on either FAM or accessing another FP method either through a VHT and local health facility. “They put us together, then talked about FP that is, pills, IUDs, implants. Later they introduced the three other ways of FP that is, LAM, CycleBeads and TwoDay Method” – Male community member, 20 - 25 years old, Gulu District While FGD participants described receiving information about all FP methods, as highlighted in the below quote, the majority of participants were more interested in attending a group counseling session consider FAM is a side-effect-free option. In fact, the majority of respondents among the community members participating in the FGDs reported attending a group counseling session, and in some cases, having started FAM use. 73 FGD respondents, regardless of age or sex, reported telling others in the community about the WALAN community learning sessions and encouraged others to attend. In general, participants told their neighbors, friends and family about the community learning sessions. Women more frequently reported sharing topics with their friends, sisters and parents-in-law. During FGDs, men reported sharing about community learning sessions by word of mouth. “I told very many people. When I went to the center, other communities would ask why vehicles come to our community. So I told them about it, and they followed us and attended the teachings”. – Male community member, 20 - 25 years old, Gulu District Some interviewed community members reported some resistance from a few peers in the community. Specifically, some peers cited the need to have more children to replace the lives claimed by the war, confirming similar formative research findings conducted prior to intervention design. However, this resistance was small relative to the large acceptance and excitement over the WALAN activities, both through new teaching about fertility awareness and FP method during community learning sessions, and the introduction of new side effect￾free FAM alternatives. Overall, the overwhelming support of the WALAN project by FGD community members suggest wide acceptability of the community learning sessions, in addition to the group counseling and method support sessions 7.3 COMMUNITY LEADERS’ PERCEPTIONS OF WALAN Community leaders were oriented about the project and later invited for periodic sensitization meetings. Findings from the KIIs suggest that community leaders were particularly receptive to being engaged on topics related to FP in their community. Similar to the FGDs with community members, leaders expressed being very supportive of the youth facilitators’ work due to the availability of side-effect-free methods directly within the community. “I accepted the use of FAM and the idea of us [leaders] taking back the information received from the meeting to the community. I also liked learning that FP improves the lives of both men and women because of child spacing.” – Male Clan Leader, 63 years old, Gulu District “I got the message on child spacing, I learnt this and most times this is what I sensitize the community on. To use the different methods of family planning; I emphasize the use of these MoonBeads [CycleBeads] methods. However, for those who cannot handle use of CycleBeads, I advise couples to try other FP methods that are medicinal [hormonal] if they are comfortable with the method.” – Male Religious Leader, 28 years old, Amuru District 74 After their first sensitization meeting, leaders reported targeting young couples specifically to attend WALAN activities to improve their family health and well-being. However, some leaders complained that the project was covering a small area. “I think it’s (community learning session) a good session but should only be improved to cover wide area. It (community learning) has improved relationship between couples for instance my wife and I. The sessions have also given me a better understanding of the SDM.” – Male Political leader, 43 years old, Nwoya District In a few cases, leaders participated in WALAN community learning sessions and group counseling for couples and in one case, became a method user. Community leaders accepted community learning sessions and described the session as helpful to improving couple knowledge on correct method use and improving their couple relationship. Religious leaders generally supported WALAN activities but one leader had concerns with non-cooperation of management of fertile days among couples, stating that success of method use can be difficult if couples and/or a partner uses alcohol and when men do not “respect” women. The interviewed leaders also provided several recommendations for program improvement, including one recommendation that youth facilitators should be given refresher courses every one to two months to enable them to strengthen their facilitation and counseling skills. One leader also suggested that youth facilitators “should be able to assess whether both couples consented to the use of CycleBeads” and to “not rush the process” in order to avoid giving the method to couples who are not ready to use it. Overall the qualitative findings suggest that community leaders were very supportive, active and instrumental in passing information about WALAN to people in their community. All leaders expressed continued interest and support in continuing the WALAN activities in their communities. 7.4 SERVICE PROVIDERS’ PERCEPTION OF WALAN Interviewed health providers reported that the periodic orientation meetings they attended changed their perceptions about FAM and how the methods are used. At their health facilities, only hormonal methods are offered and WALAN’s offering of non-hormonal alternatives to the communities was a welcomed addition. As well, health providers shared that clients referred from youth facilitators typically came with FP information already learned from the youth facilitators, easing the counseling burden on facility-based service providers. 75 “Cases when clients have been referred by the facilitators are easy because that means they already have some information from the facilitators. So when they come and ask about methods, they will be able to give you the information they have and it’s easier to help them. It’s not like the new clients who come where you have to begin the health education from zero.” – Health Service Provider, Amuru District Since WALAN’s model emphasized a group counseling approach outside a facility setting, facilitator-provider linkages were important especially in situations where couples either preferred other FP methods or were ineligible for FAM. In such cases, couples were given invitation cards by facilitators for referral to health facilities. Overall, health workers accepted WALAN approach’s to working outside the health system while providing linkages to health facilities. Some providers mentioned serving some clients who were referred by the youth facilitators. In some cases, providers also referred facility clients interested in FAM to the youth facilitators within their given community. “They (women) came with the card (invitation card), which I kept in my home. They (women) wanted Depo, the injectable. The invitation cards are usually with the facilitator and are only given to women. These women came but were alone [with the FP invitation card]. I gave them the method.” - Male Health Provider, Gulu district “I also like WALAN because it has enabled us refer some people to whom we are not able to give our services. Yes, the group facilitators who are in our village who provide information on moon beads here; since we know them, we refer clients because the facilitators are the people living with them (clients). So if someone talks of maybe moon beads, I refer that person to the other side (facilitator) but we don’t have the referral forms to direct them.” - Male Health provider, Gulu District As highlighted in the above two quotes, FP invitation cards were not usually retained by the health provider at the health center, but providers acknowledged and recognized these cards as referral cards from the WALAN youth facilitators. On the other hand, when health providers or VHTs referred clients to youth facilitators for FAM, these providers did not have and as a result, use a referral card or form for their clients. A few of the interviewed providers confirmed that clients tend to prefer “natural methods” such as FAM due to the absence of side effects. The majority of the providers cited that community members still “fear” going to the health center to seek FP information and services. Specifically, a few providers stated some women fear their husbands cutting out implants out of their arm, and fear of any financial costs associated with accessing and/or receiving health services. 76 “You know some women fear, they fear to come to us direct or they fear to also go to the hospital. They feel like that thing is can be a shame to their self, but this thing is not a shame.” VHT Worker, Amuru District Although interviewed health workers agreed that counseling men and women on FAM together is best because both partners should be equally involved, one VHT recognized that counseling couples separately may also be important. Specifically, the VHT highlighted the need for separate sessions for women who are very shy in front of their partners and/or afraid to speak up in a mixed sex setting. While generally receptive to FAM, one service provider expressed concerns over management of fertile days, especially if a couple does not communicate well on what to do during fertile days which can lead to a pregnancy that has not been planned for. Overall, service providers described an open collaboration in referring potential clients back and forth to the youth facilitators, and cited that the educational activities by youth facilitators “deep in the community” had alleviated their health education and counseling workload. Finally, health service providers – similar to community leaders - reported positive perceptions of activities and suggested that the activities be expanded to other communities. 7.5 LESSONS LEARNED ABOUT ACCEPTABILITY Couples are comfortable sharing sensitive topics with other couples in a group counseling setting. Findings from FAM user interviews and FGDs suggest that both women and men felt comfortable sharing personal information around menstruation, fertile days and other topics in a group setting with other couples. These findings suggest that the group counseling model is an acceptable counseling model to teach FAM among groups of couples in the Northern Ugandan context. There is very high community demand for fertility awareness, FP and FAM information. Qualitative findings suggest that community learning session participants felt that the topics around FP were relevant and needed information in order to help couples and families in their communities to better space children. As well, most women and men who attended group counseling sessions and then started FAM use recommended the method to their peers and friends in the community. The high interest in learning about FAM in participating communities were primarily driven by the fact that FAM provided a side-effect free alternative to other FP methods in the health center, are cost-free, and were easily accessible within the community. Community leaders accepted the WALAN model and offered mobilization support to youth facilitators. Cultural leaders, religious leaders and political leaders were in support of the 77 community learning and group counseling activities. Community leaders actively participated by mobilizing and sensitizing community members about the WALAN activities, attending some on the sessions and in one case, using FAM with their partner. Using community resource persons was viewed positively by both the leaders and community members because the services were brought closer to them, having access to the trained facilitators. Community leaders shared a sense of ownership over the activities, due to their involvement at the onset of the intervention and their routine engagement through reflection meetings, in addition to the selection and use of youth facilitators directly from their community. Health workers viewed the WALAN activities positively. Because of the orientation they received, health workers understood the intervention processes, including referral mechanisms, very well. As a result, the idea of working outside of the health system using non-health professionals was received well by service providers acquainted with the WALAN activities. They described the youth facilitators’ work as important to the community and as reducing their workload within their day to day work in and out of the health facilities. The referrals made by the youth facilitators for other FP methods to the health providers were perceived positively by the service providers and in some cases, health providers referred clients interested in FAM to the community-based WALAN youth facilitators. 78 CONCLUSION So What? 79 8. CONCLUSION AND RECOMMENDATIONS This section ties in final conclusions based on the findings from the three results, with the purpose of informing future programming and research. Suggestions and recommendations for potential adaptation and replication are highlighted below. 8.1 KEY TAKE AWAYS Feasibility. Non-health community agents can deliver group counseling for couples on FAM, provided strong supportive supervision is part of the capacity building effort to strengthen their counseling skills. Delivering these counseling session directly within the community enabled repeated interaction between community-based youth facilitators and couples, reinforcing method use and support (as opposed to one time interaction when method is offered in regular service delivery at a health facility). The percentage of youth facilitators receiving a high competency score increased from 33% to 75%, from first to second observation point eight months later. The significant improvement can be explained by the fact that youth facilitators had more time to practice and therefore, improve their counseling skills, and by a refresher training that was delivered to youth facilitators between 1st and 2nd observation time points. This suggests that most youth facilitators who are non￾health agents can deliver the group counseling sessions but need strong and consistent training, supervision, and time to develop their skills in delivering FAM counseling. Like many other settings and counseling interventions, practice makes perfect: this finding is perhaps no different from what might be found in other health interventions in which community volunteers or health facility providers are trained. Effectiveness. About half of interviewed FAM users had never used a method of modern FP prior to starting the method. Findings show that couples who learn about FAM in a group counseling format with other couples can learn how to use FAM correctly. FAM users managed fertile days using either condoms or abstinence or a combination of both. Female users reported improved comfort discussing how to manage fertile days, including negotiating the use of condoms on fertile days. Men were willing to abstain or use condoms during fertile days, but some expressed concerns because condoms were not readily available. Like other studies conducted by IRH, our qualitative findings strongly suggest the improvement of couple communication and ‘trust’ among couples using FAM. Our findings show that most women continued FAM use seven to eight months after method initiation (about four in five SDM female users). About one out of five SDM female users had discontinued the method. Reasons for discontinuation included the desire for more effective methods, desire for pregnancy, partner disapproval, and difficulty of use and/or losing CycleBeads while moving between family houses. Out of the total 20 discontinued users, eight had switched over to another modern method of FP (injectables, IUD, condoms). Only three SDM female users – that is about less than 3 in 100 women - reported a pregnancy as a result of method failure. Acceptability. The study findings show that there is high acceptability and demand for FAM as part of the method mix in Northern Uganda. Perceived benefits of FAM included that they 80 were side-effect free, and a non-hormonal alternative to other FP methods. There was high demand for community learning sessions on fertility awareness, HTSP, LAM and FP. For those who attended community learning sessions on FP, most expressed interest FAM methods, especially SDM. They described FAM methods as side-effect-free and easy to use. Group counseling was found to be an acceptable model to teach about FAM, and participating couples felt comfortable sharing personal information about menstruation, and management of fertile days with other couples. Notably there was lower demand for TwoDay Method, and cases of switching between methods. 8.2 RECOMMENDATIONS The WALAN pilot evaluation has shown that a group counseling model for couples is effective in teaching couples how to use FAM correctly, acceptable for community members and couples, and feasible to implement by non-health community volunteers properly trained and supervised. The model has potential for future adaptation, replication and further research. Recommendations for future implementation and research are below. RECOMMENDATIONS FOR FUTURE MODEL IMPLEMENTATION Ensure early and ongoing community and stakeholder engagement. The WALAN group counseling model as implemented—outside the health system but with strong linkages to local facilities and community health workers—facilitated a supportive environment for the youth facilitators’ work and supported informed choice through referrals to FP services for non-FAM methods. Securing the buy-in of community influentials and engaging health workers from the onset as well as keeping them in-the-loop is essential for effective model implementation. Consider the individual vs couple group counseling modalities. The model was designed for couples to attend group counseling sessions together, and individual counseling was the exception. Despite this, the implementation of the model in Northern Uganda allowed for one-on-one individual counseling for women interested in attending group counseling without their partner. The WALAN evaluation showed:  The benefits of both partners attending the counseling sessions, and that the effectiveness of the model is also tied to male partner involvement in method use. The findings showed that men can and want to be actively involved in FP use. Male partner support was evident. FAM users reported improved relationships with their spouses and freedom in discussing method use, especially management of fertile days, an essential aspect of successful method use.  Screening for method eligibility and discussion of sensitive topics such as couples’ strategies for managing fertile days was acceptable in this context. The counseling protocol, which includes securing confidentiality and privacy, was feasible to implement in a group setting. Couples attendance—as well as men alone and 81 women alone at times—to follow-up support sessions confirmed the value that participants gave to sharing of their individual method use experience within the group. Building youth facilitator capacity. Similar to other health interventions, strong training and supervision of community health agents are essential. This was also relevant for the WALAN model since it was implemented by volunteer youth facilitators.  Given that the youth facilitators are not trained as health workers, training them in phases (e.g. on one FAM method at a time during each training), allows for familiarization and strengthening of skills in delivering one method (SDM) before learning how to provide other methods (TwoDay Method in this case).  For quality FAM group counseling for couples, it is critical to include opportunities to refresh the youth facilitators’ knowledge of counseling procedures and their skills in problem-solving situation with clients, record keeping and timely liaising with health workers. Hence, phased training paired with strong supportive supervision and mentoring - either to groups of facilitators during monthly/quarterly events, or individually to each pair of facilitators - is highly recommended. In WALAN, while the training was phased, gaps in supervision during the early implementation stage hindered youth facilitators’ ability to advance in their learning curve as well as resolve issues that emerged, including appropriate client screening for method eligibility. Ensuring coordination with health facilities. Youth facilitator coordination with health facilities is a necessary component of the model which programs interested in replicating it must determine how to implement. This coordination facilitates: (1) referrals to other FP methods, (2) guarantees resupply of condoms, (3) ensures recording of FP users is integrated into the health system; and (4) helps boosts support from health workers and VHTs to address issues that are beyond the volunteer youth facilitators scope and competencies—such as assistance with special cases, e.g. screening of recent user of hormonal methods or recent pregnancy and breastfeeding. Learnings from model adaptations in Uganda. Programs in Northern Uganda which have a strong community engagement and/or service delivery component received the tools and resources as well as training in the group counseling model at the completion of the WALAN study. These programs—which varied from youth livelihoods to FP, RH and/or HIV services, to women’s economic empowerment as well as women’s groups—determined which FAM to integrate in their FP offerings, which community agents in their program was most suitable to deliver the group counseling and how supportive supervision would be implemented. Adaptation plans were developed during a training workshop however, these adaptations maintained the essential component of convening couples to offer them the FAM counseling jointly in a group. Implementation guidelines, and facilitator and program materials used in the WALAN intervention are available in the links found under Annex 1. 82 RECOMMENDATIONS FOR FUTURE RESEARCH  The study team collected FP service statistics from health facilities and saw an increasing trend in FP services during the WALAN implementation period. The team also documented the use of FP invitation cards for community members interested in other FP methods at the health center. However, the evaluation design was limited in attributing causality for this uptake of FP services to WALAN, despite some evidence of FP service linkages and referrals. Future research could be conducted to quantify and/or qualify the community-based group counseling model’s potential impact on use of other FP methods within catchment area health facilities.  The prospective component of this study only followed FAM users up to eight months after method initiation. Future research could explore a longitudinal study follow-up of these FAM users a couple years after starting method use to explore evolution and potential changes in FAM use, including for example, dis/continuation, switching to other FP methods, and any other improvements in couples’ relationships as a result of participating in the WALAN group counseling sessions and other activities.  While WALAN was purposely tested and evaluated as a task-sharing model outside of the health system, there is potential to study the use and adaptation of the group counseling model to other contexts. One potential space to test and evaluate the model could be in a health facility-based setting, where convening groups of couples at once for counseling may be an attractive alternative to the typical one-on-one counseling typically conducted within standard FP services. Evaluation tools found in the annex of this report could be used and modified to evaluate such a model adaptation in other settings. Overall, WALAN tested a number of new innovative approaches to FAM counseling. WALAN not only tested the delivery of FP methods in a group setting, but it was also carried out among couples, and furthermore delivered by youth who had never been trained in health￾related topics. Despite the number of new innovations, our findings suggest the approach is acceptable and effective in teaching couples how to use FAM correctly. Finally, the findings strongly suggest a demand for FAM as part of the method mix in Northern Uganda, pointing to the value of integrating FAM as part of the larger method mix among FP-focused programs and services. 83 REFERENCES Arévalo M, Jennings V, and Sinai I (1999a). The twoday algorithm: a new algorithm to identify the fertile time of the menstrual cycle. Contraception 60(2): 65-70. Arévalo M, Jennings V, and Sinai I (1999b). A fixed formula to define the fertile window of the menstrual cycle as the basis of a simple method of natural FP. Contraception 60(6): 357-360. Arévalo M, Jennings V, and Sinai I (2002). Efficacy of a new method of FP: the Standard Days Method. Contraception 65(5):333-338. Arévalo M, Jennings V, Nikula M, and Sinai I (2004). Efficacy of a new method: the TwoDay Method of FP. Fertility and Sterility 82(4):885-892. Georgetown University’s Institute for Reproductive Health. 2008. AWARENESS Project: Peru Country Report 2002-2007. AWARENESS Project. Washington, D.C.: Institute for Reproductive Health, Georgetown University. Georgetown University’s Institute for Reproductive Health. 2015. Formative Research Report: Group Teaching through Community Organizations (Acholi-Sub Region, Uganda). FACT Project. Washington, D.C.: Institute for Reproductive Health, Georgetown University. Gribble JN et al (2008). Being strategic about contraceptive introduction the experience of the Standard Days Method. Contraception 77(3):147-154. High-Impact Practices in FP [HIPs] (2015). Community health workers: bringing FP services to where people live and work. Washington (DC): USAID. Available from: http://www.fphighimpactpractices.org/resources/ community-health-workers￾bringing-family- planning-services-where-people-live-and-work Hoddinott P, Allan K, Avenell A, and Britten J (2010) Group interventions to improve health outcomes: a framework for their design and delivery. BMC Public Health 10:800 Lebetkin, E. 2015. Situation Analysis of Community-Based Referrals for Family Planning: A Review of the Evidence and Recommendations for Future Research and Programs. Arlington, VA: Advancing Partners & Communities. Long-Term Use of Standard Days Method ®: Experience of Operations Research Study Participants. February 2008. Washington, D.C.: Institute for Reproductive Health, Georgetown University for the U.S. Agency for International Development (USAID). 84 Manandhar, D, Osrin D, Shrestha B, Mesko, N, Morrison, J, Tumbahangphe, K, Tamang, S, Thapa, S, Shrestha, D, Thapa, B, Shrestha, J, Wade, A, Borghi, J, Standing, H, Manandhar, M, and Costello, A (2004). Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trial. The Lancet 364 (9438): 970-979. Oddens, BJ (1996). Determinants of contraceptive use: national population-based studies in various Western European countries. Eburon, Delft. Schwandt, H, Creanga, A, Danso, K, Adanu, R, Agbenyega, T, and Hindin, M (2013). Group versus individual FP counseling in Ghana: a randomized, noninferiority trial. Contraception 88(2): 281-288. Seidman, M (1997). Requirements for NFP service delivery: an overview. Advances in Contraception 13(2): 241-247. Uganda Bureau of Statistics and ICF International (2011). Demographic and Health Survey: Uganda 2011. Available from: http://dhsprogram.com/publications/publication￾fr264-dhs-final-reports.cfm. 85 ANNEX ANNEX 1. FACT WALAN RESOURCES 1. WALAN Website and Resources  WALAN Implementation Guidelines  WALAN Facilitator Tools 2. WALAN Evaluation Tools 3. WALAN Solution brief 4. WALAN Blog 5. WALAN Proof of concept report 86 ANNEX 2. INTERVENTION TABLES Table 27. FACT WALAN monitoring data collection process Actor Process Timeframe WALAN Facilitators  Complete Attendance Forms at each Community Learning Session, Group Counseling Session, and Couples Support session  Forms are stored in dark colored, sealed envelope for confidentiality  Give all completed forms to CDO when CDO visits once per month Ongoing, whenever a session is conducted CDOs  Once per month, CDOs visit each WALAN site and meet with Facilitators to provide support and supervision. This should occur prior to meeting with Save the Children Senior Officer.  CDOs collect all Attendance Forms completed during previous month from Facilitators during this meeting.  CDOs complete Supplies Inventory Form with Facilitators during the meeting  Forms are stored in dark colored, sealed envelope for confidentiality Once per month. Timing will depend on observation schedule Save the Children Senior Officer (SO)  Meets with CDOs on a monthly basis for Reflection Meeting  Collects forms from CDOs at this meeting  Give Attendance Forms to IRH upon return to office  Use Supplies Inventory Form to determine upcoming supply needs  Back-up plan: If Attendance Forms and Supplies Inventory Form are not brought to Reflection Meeting, SO will call CDOs and/or Facilitators to understand what the issue is. If needed, the SO will send a vehicle to the site with someone who can support Facilitators in completing the forms. Alternately, SO can ask Observers to collect the forms if they are scheduled to visit that site. 4th Week of the month IRH  Upon receipt of forms from Save the Children Senior Officer, Data Entry Assistant enters all data into database  Data Entry Assistant or Research Monitoring and Evaluation Coordinator (RMEC) runs tabulations and produces summary reports: o Full report on all indicators for review by WALAN Project Manager, M&E Lead, Save the Children and GMEAL  RMEC and Qualitative Research Coordinator review reports  RMEC and Qualitative Research Coordinator sends reports to Save the Children and to WALAN Project Manager and M&E Lead 1st Week of the month GMEAL Committee  Meets monthly to review data, identify areas for programmatic improvement or M&E systems improvement based on data 2nd Week of Month 87 ANNEX 3. FEASIBILITY RESULTS TABLES Table 28. Competency scores for youth facilitator pairs during group counseling sessions (n=13) Pair Sub county SDM First Observation SDM Second Observation TwoDay Method First Observation TwoDay Method Second Observation GULU DISTRICT 75.0% 94.4% 83.4% 92.9% 1 Patiko 95.8% 95.8% 92.9% 89.3% 2 Patiko 79.2% 91.7% 78.6% 96.4% 3 Patiko 50.0% 95.8% 78.6% 92.9% AMURU DISTRICT 53.0% 80.0% 66.3% 81.6% 4 Pabbo 79.2% 79.2% 60.7% 67.9% 5 Pabbo 62.5% 79.2% 71.4% 70.5% 6 Atiak 50.0% 91.7% 67.9% 89.3% 7 Pabbo 37.5% 70.8% 64.3% 75.0% 8 Pabbo 41.7% 75.0% 53.6% 85.7% 9 Atiak 75.0% 91.7% 89.3% 89.3% 10 Atiak 25.0% 58.3% N/A N/A 11 Atiak N/A N/A 57.1% 89.3% NWOYA DISTRICT 27.1% 48.0% 48.2% 69.7% 12 Anaka 12.5% 54.2% 60.7% 85.7% 13 Anaka 41.7% 41.7% 35.7% 53.6% TOTAL AVERAGE % SCORE 54.2% 77.1% 67.6% 82.1% (Source: Competency checklist observations) 88 Table 29. Youth facilitator pairs meeting competency criteria, by measure and observation point (n=13) Observation categories SDM First Observation SDM Second Observation TwoDay Method First Observation TwoDay Method Second Observation Counseling principles 1. Completed the group norming by stating rules and obtaining the group’s pledge 50.0% 83.3% 75.0% 83.3% 2. Ensured privacy for the session 41.7% 91.7% 66.7% 100% Facilitation skills 3. Established this counseling session is for SDM [or] TwoDay Method 91.7% 100% 100% 100% 4. Encouraged both male and female participants to participate. 83.3% 91.7% 91.7% 91.7% 5. Asked participants to practice using CycleBeads and explain to each other how the method works. 58.3% 100% N/A N/A Counseling - Screening women for method eligibility 6. Asked if women have periods about once a month 58.3% 75.0% N/A N/A 7. Asked if women and partner are able to abstain or use a condom on days when she can get pregnant 50.0% 75.0% 83.3% 91.7% 8. Stated that TwoDay Method is for women whose secretions are healthy N/A N/A 83.3% 100% Counseling – Teaching SDM, Youth Facilitator Pair Explains Method Use… 9. Red bead is for first day of bleeding, brown for infertile and white for fertile days. 83.3% 91.7% N/A N/A 10. On the day you start your period, move ring to the RED bead. 75.0% 100% N/A N/A 11. Move ring one bead every day, even on days you are having your period. 83.3% 100% N/A N/A 12. Pregnancy is unlikely when the ring is on a BROWN bead. 91.7% 91.7% N/A N/A 13. Abstain or use a condom when ring is on any WHITE bead. You CAN get pregnant on these days. 75.0% 91.7% N/A N/A 14. When your period starts again, move ring to the RED bead to start again. 75.0% 100% N/A N/A 15. If your period comes before the DARK brown bead, your period has come too soon to use this method. Return to the facilitator or talk to VHT or provider to switch to another method. 50.0% 91.7% N/A N/A 16. If your period does not come by the day after you reach the last brown bead, your period has come too late to use this method. Return to the 16.7% 83.3% N/A N/A 89 Observation categories SDM First Observation SDM Second Observation TwoDay Method First Observation TwoDay Method Second Observation facilitator or talk to VHT or provider to switch to another method. Counseling – Teaching TwoDay Method, Youth Facilitator Pair Explains Secretions… 17. Secretions appear a few days after your period. N/A N/A 91.7% 100% 18. Secretions are whitish and/or clear N/A N/A 100% 100% 19. At first they can be scant, they then become more abundant and are easier to see and feel. N/A N/A 58.3% 50.0% 20. Once they begin they continue for several days in a row until they disappear. N/A N/A 58.3% 58.3% Counseling – Teaching TwoDay Method Youth Facilitator Pair Explains Method Use… 21. By seeing them on your underwear or on the toilet paper when you wipe after urinating, by touching them with your fingers, or sensing them. N/A N/A 100% 100% 22. You must check starting at midday, at least two times before going to bed. N/A N/A 91.7% 100% 23. If you had secretions today or yesterday, you are fertile TODAY and can get pregnant. N/A N/A 83.3% 100% 24. You won’t get pregnant if you did not have secretions today or yesterday. Two consecutive days without secretions. N/A N/A 83.3% 100% 25. You and your partner must use condoms or not have sex on identified fertile days to avoid pregnancy. N/A N/A 91.7% 91.7% 26. Explained meaning of symbols N/A N/A 91.7% 100% 27. Explained combination of symbols when woman is fertile and can get pregnant N/A N/A 75.0% 100% 28. Explained combination of symbols when woman is not fertile and cannot get pregnant N/A N/A 75.0% 100% Support couple to use method 29. Stated success of method depends on couple’s ability to use condoms or avoid sex on fertile days. 50.0% 75.0% 41.7% 58.3% 30. Asked how couples will be able to handle fertile days 25.0% 42.0% 41.7% 50.0% 90 ANNEX 4. EFFECTIVENESS RESULTS TABLES Table 30. FAM users’ comprehensive fertility awareness knowledge, at first and second interview Measure SDM Female User SDM Male Partner TwoDay Method Female User TwoDay Method Male Partner 1st Interview (122) 2nd Interview (n=101) 1st Interview (n=60) 2nd Interview (n=41) 1st Interview (56) 2nd Interview (n=27) 1st Interview (n=36) 2nd Interview (n=21) High FA score (high vs. low binary) 37.7% 56.4% 71.7% 73.2% 58.5% 63.0% 66.7% 61.9% Days from period to next when woman might conceive 69.7% 76.2% 86.7% 85.4% 60.4% 74.1% 63.9% 57.1% Can woman get pregnant if not on FP 86.9% 96.0% 95.0% 95.1% 96.2% 96.3% 100% 81.0% What are healthy vaginal secretions 64.8% 74.3% 63.3% 73.2% 69.8% 70.4% 88.9% 81.0% Do secretions come during menstrual cycle 77.9% 85.2% 68.3% 68.3% 92.5% 96..3% 69.4% 90.5% What age should a woman get pregnant 73.0% 82.2% 85.0% 95.1% 77.4% 81.5% 83.3% 76.2% How long should a woman wait to get pregnant 54.9% 80.2% 71.7% 87.8% 50.9% 51.9% 88.9% 76.2% (Source: FAM User Interviews)