Evaluation of Community Education Interventions 
in Sexual and Reproductive Health Services 
in Urban-Marginal Areas of La Paz, Bolivia
María Dolores Castro Mantilla
Máriel Loayza Antezana
April 2004
 CIDEM
This study was funded by the U.S. Agency for International Development (USAID) 
under the terms of Cooperative Agreement Number HRN-A-00-98-00012-00 and 
Population Council Subagreement A199.74 A. The opinions expressed herein are those 
of the authors and do not necessarily reflect the views of USAID.
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in Sexual and Reproductive Health Services, La Paz, Bolivia
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SUMMARY
The purpose of this study was to strengthen community strategies to improve quality of 
care services first implemented as part of a Ministry of Health and Prevention (MSPS) 
and World Health Organization (WHO) project in 1997-98. That intervention focused on 
health facilities, and the accompanying community interventions were found to be 
insufficient. Groups that do not regularly attend health facilities, such as adolescents, 
men, and women with older or no children, remained out of reach. To reach these target 
audiences and improve community demand for services, CIDEM implemented a 
community education intervention focusing on sexual and reproductive health and rights. 
Research was carried out in public health centers of urban and marginalized rural areas in 
La Paz.
CIDEM collected both qualitative and quantitative data for this study with a quasi￾experimental design. Four health centers were selected, with two assigned to receive the 
intervention and two monitored as control sites. All four centers previously participated 
in the MSPS/WHO quality improvement program. 
A baseline analysis was conducted during the first phase of the project. Using this 
information, researchers designed and implemented educational community strategies 
and interventions in the health service centers. They also developed information, 
education, and communication (IEC) materials to support the educational sessions and 
the orientation activities in the health centers. After 15 months, staff conducted a post￾intervention impact evaluation. Informed consent was obtained from all participants. 
Results showed that the interventions improved access to and utilization of sexual and 
reproductive health services among men, women, and adolescents. They also increased 
beneficiaries’ reproductive health knowledge, and improved client attitudes and 
satisfaction with services. Researchers found that efforts to increase knowledge of and 
demand for reproductive health services must be accompanied by service strengthening 
measures.
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TABLE OF CONTENTS
Summary..............................................................................................................................ii
List of Tables and Figures...................................................................................................iv
Acronyms.............................................................................................................................v
Acknowledgements.............................................................................................................vi
I. Background...................................................................................................................... 1
II. Problem Statement ......................................................................................................... 3
III. Research Methodology ................................................................................................ 5
IV. Description of the Intervention..................................................................................... 9
1. Community Education Sessions ................................................................................ 9
2. Health Center Interventions ..................................................................................... 10
3. IEC Materials ........................................................................................................... 10
V. Challenges................................................................................................................... 12
VI. Results........................................................................................................................ 13
1. Women...................................................................................................................... 13
2. Men .......................................................................................................................... 20
3. Adolescents.............................................................................................................. 24
VII. Dissemination and Sustainability............................................................................. 31
VIII. Conclusions and Recommendations……………………………………………….32
Bibliography...................................................................................................................... 34
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LIST OF TABLES AND FIGURES
Tables
Table 1. Catchment Populations of Participating Health Centers......................... 1
Table 2. Intervention Design................................................................................. 5
Table 3. Health Center Quality of Care Observations........................................... 32
Figures
Figure 1: Health Center Visits by Women 20 Years and Older.............................. 15
Figure 2: Ratio of Health Center Visits by Women 20 Years and Older to Total 
Population................................................................................................
15
Figure 3: Clinic Visits by Women 50 and Over...................................................... 16
Figure 4: Number of New Contraceptive Users in Each Health Center, by 
Method..................................................................................................... 17
Figure 5: New Modern Method Use: Experimental versus Control....................... 18
Figure 6: New Natural Method Use: Experimental versus Control........................ 18
Figure 7: Visits for Pap Cytology by Women Aged 25 – 59.................................. 19
Figure 8: Health Center Visits by Men 20 Years and Older................................... 22
Figure 9: Ratio of Health Center Visits by Men 20 Years and Older to Total 
Population................................................................................................ 22
Figure 10: Number of Health Center Visits by Adolescent Girls 14-19................... 26
Figure 11: Ratio of Health Center Visits by Adolescent Girls 14-19 to Total 
Population................................................................................................ 26
Figure 12: Number of Health Center Visits by Adolescent Boys 14-19.................. 26
Figure 13: Ratio of Health Center Visits by Adolescent Boys 14-19 to Total 
Population................................................................................................ 26
Figure 14: Number of Adolescent (14–19 years old) Users of Contraceptives, by 
Method..................................................................................................... 28
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ACRONYMS
CIDEM Centro de Información y Desarrollo de la Mujer
(Center for Information and Development of Women)
ENDSA Encuesta Nacional de Demografía y Salud
(National Demographic and Health Survey) 
FGD Focus group discussion
HC Health center
HCPB Historia Clínica Perinatal Base
(basic perinatal history form)
IEC Information, education, and communication
INE Instituto National de Estadística
(National Institute of Statistics)
IUD Intrauterine contraceptive device
MSPS Ministerio de Salud y Previsión Social
(Ministry of Health and Prevention)
NGO Non-governmental organization
PAHO Pan-American Health Organization
SEDES Servicio Departamental de Salud
(Departmental Health Service)
SNIS Sistema Nacional de Información en Salud
(National Health Information System)
SRH Sexual and reproductive health
STI Sexually Transmitted Infection
WHO World Health Organization
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ACKNOWLEDGEMENTS
This research would not have been possible without the efforts of many people and 
institutions that generously joined the activities and supported the achievement of the 
objectives established.
We want to recognize CIDEM for providing the institutional background to carry out this 
work. We’d like to express our special thanks to the Executive Director, Ximena 
Machicao, researcher Mary Marca, and the whole CIDEM team for the administrative 
support given. 
Additionally, the support of researcher Angela Caballero was vital to reaching 
participants in different areas. Angela participated in the interviews, focus groups, and 
educational sessions, giving technical as well as logistical support. 
We also want to express our gratitude to Silvia Salinas, who was responsible for the 
English translations of the reports presented to the institution, and to Zilka Loayza for her 
support in the data processing of the statistics gathered in the services. We also thank 
María Rosa Aguilar for helping us with expenditure reports and support.
We share our sincere appreciation with Martha Barrientos, Director of District I of the 
Garita de Lima; to Roseyva Sivautt, Director of the Health Center La Portada; to Eliana 
Abad, Director of the Health Center Chamoco Chico; to María Luz Terrazas, Director of 
the Health Center Obispo Indaburo; and to Yuko Hiramatzu, Director of the Health 
Center Alto Mariscal Santa Cruz. 
The financial support for this investigation was possible thanks to the Population 
Council’s USAID-supported Frontiers in Reproductive Health (FRONTIERS) Small 
Grants Program. We thank John Townsend, Celeste Marin, and Ricardo Vernon for their 
orientation and valuable opinions. FRONTIERS’ Bolivia office, headed by Fernando 
Gonzáles, supported the follow-up of some of the project activities.
We cannot conclude without recognizing Ruth Simmons of the University of Michigan, 
Juan Díaz of the Population Council, and Virginia Camacho of the Pan American Health 
Organization. They were the creators and initiators of this project.
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I. BACKGROUND
This research project was carried out by the Centro de Información y Desarrollo de la 
Mujer (CIDEM) with financial support from the Frontiers in Reproductive Health 
(FRONTIERS) Small Grants Program. The investigation was initiated in February 2000 
and had a two-year duration. The project was developed to continue support of a series of 
reproductive health interventions to improve quality of care in Bolivia initiated by the 
Ministry of Health and Prevention (MSPS), with a methodology proposed by the World 
Health Organization (WHO) entitled: Strategic Approach for the Introduction of 
Contraceptive Technologies. This approach was pilot-tested between 1995-98 in areas 
throughout Bolivia, including Health District I of the city of La Paz. The interventions to 
improve quality of care focused on adaptations in health centers, training providers, and 
increasing the range of contraceptive methods offered. During that time, significant work 
was carried out with people of the community, but it focused mainly on women who 
already frequented health facilities. 
Evaluation of the MSPS/WHO project showed that the interventions improved services 
but did not increase demand among underserved populations. It was concluded that the 
intervention’s impact would continue to be low unless the project could reach community 
members and create more demand for services. The purpose of the new research was to 
evaluate the impact of a community intervention on utilization of and community 
satisfaction with sexual and reproductive health (SRH) services. Both qualitative and 
quantitative data were collected for this study using a quasi-experimental design. Four 
health centers were selected, two as intervention sites and two as control sites. All four 
centers originally participated in the MSPS/WHO program. 
The health centers’ population catchment areas are presented in Table 1, below.
Table 1. Catchment Populations of Participating Health Centers
Intervention Sites Control Sites
La Portada Chamoco 
Chico
Obispo 
Indaburo
Alto Mariscal 
Santa Cruz
1999 Population* 10,100 17,980 10,115 6,646
* Health District 1: Garita de Lima
The majority of the residents in the neighborhoods targeted by the intervention are rural 
migrants of Aymara culture with a fixed urban residence of more than 10 years. Many 
inhabitants still have migratory practices, either due to the strong linkages with their 
places of origin (for example some have rural farms), or because they are minor 
tradesmen who migrate temporarily between neighborhoods or cities. In general, they are 
people with low incomes, low education, and poor nutritional status. Some tradesmen 
with high incomes are also found in the areas, but they are not typical. The basic 
infrastructure and services are poor, and there are no local NGOs supporting the 
population (WHO Project, 1998).
Evaluation Of Community Education Interventions 
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Churches have an important influence in the neighborhoods, with Protestant institutions 
growing to outnumber Catholic ones in recent years. Also, traditional Andean medicine is 
practiced in this area and is thought to reduce demand for modern health center services. 
There has also been a proliferation of unlicensed health consultants in considerable 
demand by the population (WHO Project, 1998).
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II. PROBLEM STATEMENT
Bolivia faces a series of challenges in the area of sexual and reproductive health (SRH). 
Among other problems, the Bolivian government is confronting a maternal mortality ratio 
of approximately 390 deaths per 100,000 live births (National Demographic and Health 
Survey, 1994). Abortion is a leading cause of maternal mortality, and service providers 
lack basic resources to diagnose and treat sexually transmitted infections. Clients have 
limited access to contraception, and providers often have inadequate or outdated 
reproductive health information. To confront these problems, the government is 
emphasizing improvements in capacity and quality of care in sexual and reproductive 
health services.
Despite the government’s efforts, access to SRH services remains low. However, 
inadequate coverage cannot only be explained in terms of unavailability. There are other 
factors that must be considered. For example, SRH programs have focused on maternal 
and child health, but have left out other important target populations including men, 
adolescents, and women who are not pregnant or mothers. On the other hand, in addition 
to delivery limitations (i.e. problem with infrastructure, logistics, supplies, and human 
resources), demand for services is low because traditionally, the population is distrustful 
of modern health centers. Furthermore, people do not know their rights regarding access 
to health services.
It is important to note that it has been difficult to formulate broad sexual and reproductive 
health public policy in such a diverse social, cultural, and geographic context as exists in 
Bolivia. Thus, past efforts have had varying impacts in different regions, and among 
ethnic groups and social classes. A large portion of the population lives in inaccessible 
rural areas in the highlands, and many people migrate to urban and semi-urban areas in 
La Paz and El Alto. In these cities they live under marginal conditions, without basic 
services or access to education or health care (National Statistic Institute, 2001).
Public health facilities offer primary care and SRH services, including contraception, in 
many urban neighborhoods. However, these services are often underutilized. For 
example, family planning is often discussed or provided only during antenatal and 
postnatal visits. As a consequence, adolescents, men, and non-pregnant women without 
children are excluded from these services (WHO Project, 1998). 
Since 1997, the Bolivian government has promoted the fundamental right of free access 
to health services. Efforts have been made to increase the range of contraceptive 
methods offered and emphasize clients’ rights to informed choice. Despite this, the 
population is not well informed about the changes in public policy and people remain 
largely unaware of their rights.
A review of the literature shows that interventions in Bolivia to improve quality of care 
have focused on health services, and have largely left out education, prevention, and 
community participation. Health providers have not been trained to interact with the 
Evaluation Of Community Education Interventions 
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community. Consequently, fear, distrust, and discrimination characterize the relationship 
between many health providers and their beneficiaries (Camacho et al, 1996). 
Quality of care models present two distinct approaches to addressing the above problems: 
(1) interventions aimed to improve provision of services; and (2) interventions to 
stimulate client demand for services. In the first approach, interventions are focused on 
improving quality of care by changing provider attitudes and improving their capacity to 
interact with clients and offer services that take into account ethnic, gender, and 
generational diversity, thus not adhering to a rigid model (NETWORK en Español, 1993). 
Interventions to address service provision are important. However, if only these 
interventions are emphasized, their potential is limited and their impact may be low. 
Such interventions need complementary programs that simultaneously address client 
demand for services.
There are several different strategies to address demand for services. Social marketing 
campaigns inform the public about SRH, including contraception and basic rights to 
access to services, through mass media channels (e.g. radio, newspapers, television, and 
posters). Another strategy focuses on community education and information with an 
emphasis on social groups typically out of reach of SRH programs. Information is 
gathered on community perceptions of the barriers to SRH service use and how people 
evaluate their own SRH needs. These interventions are designed to improve 
communities’ access to and demand for services. Even though the social marketing 
approach can play an important role in community education, diagnosis of community 
needs and perspectives is needed to evaluate the effectiveness of messages, and to 
determine which are the most accessible and appropriate media in each community.
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III. RESEARCH METHODOLOGY
This study employed a quasi-experimental design with two experimental health centers 
and two comparison sites (see Table 2). All four centers participated in the MSPS/WHO 
program and continued to receive support for improving the quality of their services. 
Researchers collected both qualitative and quantitative data to evaluate the effects of the 
intervention. 
Intervention sites were chosen based on characteristics of the health centers and their 
surrounding communities. For example, La Portada made notable improvements in 
quality of services during the MPSP/WHO project, but did no work with the community 
to increase access to and demand for services. The population there is more marginalized 
than in some other areas (i.e. large proportions of the population are Aymara, an ethnic 
minority, and there is a large migrant population). Chamoco Chico Health Center had by 
far the largest catchment area of the study sites. It was chosen because it was well known 
as a good health facility but the area it serves is very spread out with a diffuse population 
and little community organization.
In the first phase of the project, researchers conducted a baseline analysis. Using this 
information, they designed educational community interventions and developed 
information, education, and communication (IEC) materials to support educational 
sessions and orientation activities in the health centers. During the third phase, a post￾intervention evaluation was conducted to determine the impact of the activities. 
Researchers obtained informed consent from all participants at all stages of the project.
Table 2. Intervention Design
Support for 
interventions
addressing service 
provision
Interventions to 
create new demand 
for services
La Portada: Intervention ¸ ¸
Chamoco Chico: Intervention ¸ ¸
Alto Mariscal Santa Cruz: Control ¸ --
Obispo Indaburo: Control ¸ --
1. Data Collection
Data was collected for both the diagnostic phase and the endline evaluation through focus 
group discussions (FGDs), in-depth interviews, and health center service statistics using 
quantitative and qualitative methods. The FGDs and interviews were conducted with the 
target population to evaluate their knowledge of and attitudes about reproductive health, 
as well as their access to and satisfaction with services. Researchers conducted informal 
interviews with providers and observed client-provider consultations. Service statistics 
were also collected from each of the health centers.
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Focus Group Discussions
Three populations were targeted for focus group discussions: 
1. Priority audiences who do not regularly use reproductive health services (i.e. 
adolescents, men 20-40 years old, and women in the same age range who had not 
been pregnant in the past 12 months); 
2. Traditional leaders (i.e. elders, both women and men, who influence community 
views on reproductive health); 
3. Other leaders who influence reproductive health opinions (i.e. formal and 
informal leaders including nuns, teachers, neighborhood committees, traditional 
healers, religious leaders, and traditional midwives).
In total, researchers conducted eight focus group discussions (FGDs) with key 
community members. The FGDs took place in health center community rooms or in 
places chosen by the groups involved. 
The principal researcher conducted focus group sessions, after obtaining participants’ 
informed consent, using interview guides designed for the project. Additionally, each 
participant completed a registration sheet identifying demographic characteristics (e.g. 
age, work, schooling, knowledge and use of contraceptives, and number of children). A 
social researcher made audio recordings of each session and recorded contextual 
information in a field notebook. 
A minimum of seven and a maximum of 12 people participated in each FGD session. 
The adolescent groups were comprised of males and females between the ages of 15 and 
20. Most were currently in school or studying a technical career; few were employed. 
The married men who participated in the FGDs 
represented associations or neighborhood 
committees, as well as independent workers (e.g. 
tradesmen and bus drivers). Some of the men were 
unemployed. Almost all of them migrate to rural 
areas during harvest and cultivation periods, as well 
as during traditional celebrations in their 
communities of origin. Men’s average schooling is 
between nine and 12 years.
Women’s FGDs were mainly made up of 
housewives, with some peddlers and market 
saleswomen. The owner of a drugstore located near 
the health center also participated in a group. The 
majority of women were married and belonged to a 
mothers’ club, but few were members of the 
neighborhood committee. In La Portada and 
Chamoco Chico, the experimental areas, men have 
more opportunities than women to join 
neighborhood groups. It is typical for one woman to 
Evaluation Of Community Education Interventions 
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participate for every five men on a neighborhood committee. Women also migrate 
(usually more frequently than men) to their communities of origin during harvest periods. 
The average female FGD participant ended her formal education in primary school.
In-Depth Interviews
Researchers conducted 10 in-depth individual interviews in the homes or workplaces of 
interviewees using a flexible guide with open-ended questions. The same form was used 
for men and women. Interviews were conducted with the presidents of neighborhood 
committees, school directors, a midwife, and a Catholic nun.
Heath Center Service Statistics
The quantitative component in the baseline survey was based on routine service statistics 
for the following indicators:
· Contraceptive service users
· New contraceptive service users
· Sexually transmitted infection (STI) and reproductive tract infection service users
· Antenatal and postnatal service users
· Pap smear tests performed
· Women under 20 years old who seek contraceptive consultation
· Men under 29 years old who seek contraceptive consultation
Data was obtained from the daily registration books of the National Health Information 
System (SNIS) and other health center registers. Instruments with similar reporting 
formats for each population group (i.e. men, women, and adolescents) were used to 
standardize the information collection process. 
Qualitative health center data were collected through observations of reproductive health 
consultations following a format prepared by REPROLATINA, a Brazilian NGO that 
works with the WHO strategy. Informal interviews with health providers were also 
carried out and recorded in field notes.
Impact Evaluation (endline survey)
The same qualitative and quantitative methodology used for the baseline survey was 
applied for the impact evaluation. When possible, researchers interviewed the same 
focus groups and individuals who participated in the baseline survey and educational 
sessions; however, migration caused some variation in both the participants reached and 
the methodology. For example, researchers were unable to hold focus group discussions 
with men during the post-intervention evaluation because the timing coincided with the 
harvest, and many men had temporarily migrated to rural areas. Instead, individual 
interviews were conducted with the male participants who could be reached.
Ethical Considerations
All participants in focus group discussions and in-depth interviews completed informed 
consent forms during both the baseline survey and the impact evaluation. The completed 
Evaluation Of Community Education Interventions 
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forms, as well as the tape recordings and transcriptions, were kept locked in the office in 
a confidential archive. 
2. Data Recording and Analysis
Tape recordings and field notes were transcribed using a word processor, with a number 
assigned to each line. 
The themes originally considered for the analysis include:
· Attitudes and knowledge about the health centers
· Attitudes and knowledge about sexual and reproductive health services
· Needs and demands for contraceptive services
· Knowledge of sexual and reproductive rights
In addition, the interviewees brought up the following topic:
· Barriers and access to health care
Other topics that appeared during the research were:
· Knowledge about sexually transmitted infections, including HIV/AIDS
· IEC strategies in the community
· Community organization and participation
Participants’ gender and ethnicity were taken into consideration during data collection 
and analysis, as well as during the educational interventions, as these characteristics can 
influence individuals’ opinions. More inquiring was necessary to obtain information 
from women and girls, and from participants of Aymara or Quechua origin, for example. 
Researchers collected socio-demographic data on all participants, and recorded 
observations of behavior and gestures during the focus group discussions to provide 
further contextual information for analyzing transcripts. Results are presented without 
individual identifiers in separate sections for women, men, and adolescents, as there were 
substantial differences in the results among the groups.
Quantitative data were entered into Microsoft Excel spreadsheets and researchers 
analyzed routine service statistics for each health center to determine statistical trends in 
the indicators listed above. Additionally, national and regional data from the National 
Health Information Service and the National Statistics Institute provided a comparative 
framework for the analysis.
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IV. DESCRIPTION OF THE INTERVENTION
The objective of this operations research study was to implement and evaluate 
community educational interventions to increase client utilization of, and satisfaction 
with, reproductive health services.
1. Community Education Sessions
The project team conducted a total of 32 educational sessions, four sessions for each key 
audience group. Community leaders and key decision makers were also included in the
sessions. Men and women chose evenings and weekends to meet, while adolescents 
preferred afternoons and mornings. The number of participants varied between seven 
and 15 for each session. The topics addressed were:
· Sexual and reproductive health
· Sexual and reproductive rights
· Contraceptive methods
· Family violence and gender
Each theme was addressed as a module using a participatory teaching methodology and 
lasted two-and-a-half to three hours. The principal investigator was responsible for the 
modules about sexual and reproductive health and rights and the medical advisor 
conducted the educational sessions on contraceptive methods. A researcher from CIDEM 
developed and initiated the module on violence and gender. 
A female participant commented on the importance of the sessions:
“There are people who cannot read, so that another form of teaching has 
to be applied. There are people that do not like to go to the doctor’s, but 
still they learn about health from their friends who do go... It is good 
when people participate in these meetings, when people get together, so 
they can learn.”
The principle results of the educational interventions were the following:
· Both male and female participants were introduced to sexual and reproductive health 
issues.
· Participants identified their sexual and reproductive rights and discussed ways to 
exercise them.
· Male and female participants were sensitized to the issue of family violence and its 
impact on health.
· Participants broadened their SRH knowledge and learned about specific contraceptive 
methods, including the benefits, side effects, and correct use for each method.
Developing the relationships with community members and organizations necessary to 
bring people together was a more time-consuming and demanding process than 
Evaluation Of Community Education Interventions 
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anticipated. Thus, it was not possible to organize more extensive educational sessions 
during the project period.
2. Health Center Interventions
As an additional component of this project, CIDEM continued to support and monitor 
interventions to improve the quality of care initiated by the MSPS/WHO in 1997. The 
specific elements of the OR project were:
Training
CIDEM conducted a workshop entitled “Recognizing and Respecting Differences and 
Rights in Sexual and Reproductive Health” for providers from each of the four 
participating health centers. A total of 22 providers attended, including some from district 
health centers not participating in the study. The following topics were discussed:
· Gender, sexuality, and diversity
· Sexual and reproductive rights
· Quality of care and institutional management
· Contraceptive update
During the workshop, participants discussed all available contraceptive methods, giving 
priority to those offered by the Basic Health Insurance system. Each provider received a 
copy of the WHO Medical Eligibility Criteria for Contraceptive Use, which CIDEM 
translated from English to Spanish as a tool to reinforce the information discussed.
Record Keeping
During the project implementation, the Bolivian Ministry of Health (MOH) introduced a 
new format for reporting service statistics in their national health information system 
(SNIS). Because health personnel were not familiar with the format, project staff 
carefully reviewed the new notebooks to verify information. Some deficiencies were 
discovered, for example, there was no place to register clients’ first and last names or 
addresses on the form. Also, specific age groups could not be identified (i.e. to 
distinguish adults from adolescents) because the SNIS used broad age ranges (e.g. 15-45 
years old). After a joint review by providers and project team staff, transitional solutions 
were established. They were evaluated in the experimental health centers and afterwards 
the Directorate of District 1 transmitted proposals and recommendations to the MOH 
SNIS unit.
3. IEC Materials
As a third component of the intervention, the research team reviewed existing 
information, education, and communication (IEC) materials distributed by community 
organizations and the MOH and found them to be inadequate. Notably, materials on some 
issues (e.g. contraceptive methods) did not exist or were only being issued by the MOH. 
Project researchers designed new IEC materials, with technical assistance from CIDEM, 
to meet the needs expressed by focus group discussion participants and individual 
interviewees. 
Evaluation Of Community Education Interventions 
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The researchers designed IEC materials on three topics: sexual and reproductive rights, 
services offered by the target health centers, and contraceptive methods. The materials 
were field tested and printed after changes were made. They are brightly colored, use 
simple language, and include pictures of indigenous women. The contraceptive methods 
packet contains a series of cards, one for each method offered, with a picture of the 
method and a description of how it works, who should and should not use it, and possible 
side effects. The materials were distributed in each community after the educational 
sessions and provided to both the intervention and control health centers to support SRH 
services.
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V. CHALLENGES
· Migration posed a major challenge to sustained educational services and investigation 
follow-up. It was necessary to adjust intervention time frames to the migratory 
patterns of the participants. 
· The communities involved in this project previously participated in various 
ineffective interventions, so many community members were apprehensive of 
interviewers. Project staff had to spend extra time earning the communities’ trust.
· A maternal death occurred in the La Portada health center during the educational 
sessions and generated conflicts between the community and the health center, once 
again affecting, to a certain extent, the credibility of the health center in the eyes of 
the population. 
· In April and May 2001 there were medical strikes and social conflicts that caused a 
two-month delay in project activities.
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VI. RESULTS
Key Findings on Client Perceptions and Use of Services
1. Women 
The educational interventions broadened women’s knowledge about SRH, but some of 
them still considered it to be important only for pregnant women or those with newborn 
babies. This perception results from messages broadcast by the official health sector, 
which promoted antenatal and delivery services under the title of “reproductive health” 
and, more recently, “sexual and reproductive health.” 
Service statistics show that few women visit clinics for reasons other than pregnancy 
related services. However, researchers observed a meaningful increase in the number of 
women who sought consultation for cancer prevention, family planning, and sexually 
transmitted infections. The number of consultations related to sexuality, menopause, and 
infertility are still very low. But, as can be seen in Figure 3 below, the number of clients 
in the older age groups increased notably during the intervention.
Perceptions of Service Quality
Women defined a good health center as one that not only provides good services, but also 
has medical equipment, medicine, and other modern supplies. It is important to note that 
despite the fact that many women give birth at home, they value ultrasound scanning. 
This is an example of the coexistence of traditional and Western medicine in these areas. 
Women perceive modern equipment like an ultrasound scanner as important, but few 
expect to deliver at the health center. One woman observed:
“There is no equipment, things are missing. They tell us to come here, but there 
is nothing to provide us attention. There is no ultrasound scanning; how will 
they have their children if they do not see how they are? There are no 
medicines. It should have a pharmacy.”
The lack of equipment and medicines and a delay in returning test results motivates 
women of La Portada to seek services at private clinics or more complex public service 
facilities. This lack of confidence also reinforces use of traditional medicine. For 
example, many women use herbs in place of modern medications that are too expensive 
or not available at all. One woman commented on the conflict between doctor-prescribed 
medicine and traditional herbs:
“With herbs there are women who have their babies in their homes with 
midwives. They only give them herbal teas. Also, urinary infections are healed 
with chamomile baths. This has also been addressed at school. Herbs, however, 
are even growing down the street. But the doctors do not want this because we 
reduce the pharmacist’s sales. There is no money, this does not help.”
Even if it is not expressed in technical language, technical competency is another 
influence on women’s perceptions of services provided. One woman reported:
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
14
“I suffered when a doctor could not put in an IUD correctly. They were not 
able to insert it and sent me to many places they said would be able to put it in 
better. They were not successful, and they caused me much pain. In five years I 
have not returned.”
Project staff noted a change in attitudes toward health centers and services in post-test 
interviews and focus group discussions, particularly in Chamoco Chico. However, this 
change is attributable primarily to women’s improved feelings of empowerment 
regarding their health, rather than improved perception of services. Researchers 
performed periodic observations of client-provider interaction at all of the clinic sites and 
observed no significant differences in the quality of services offered.
In accordance with previous research findings in the region, women indicated that even 
though they may have been satisfied with their own service, friends’ and relatives’ 
experiences weighed heavily in forming their overall opinions. One woman recounted a 
friend’s negative experience:
“I will tell you what happened to my friend here in the center. She was going to 
have her baby…She was admitted to the center but she received bad care...They 
did nothing for her. The delivery was getting complicated, but they did not 
transfer her to another facility where she could get better care. Her husband 
told them: ’Let me take her, please, she will die.’ He begged them but they 
would not let her go.”
Some women stated that male leaders 
influence whether or not women go to the 
health centers.
 “I did not go (to the health center) 
anymore, but I have now returned 
because (a male community leader) has 
begged me. He told me ’they are nice, 
you have to go, one has to take care of 
oneself.’ He begged me a lot. I went to 
the doctor.”
In La Portada, some women said they 
noticed the services improving: “Before they 
did not give us attention, they told us off.” 
Other women do not seek services at health 
centers because they are afraid of male 
attendants. However, they indicated being 
less afraid after the educational sessions.
Figure 1 below shows that the number of 
client visits to the health centers in Chamoco 
Chico and La Portada increased dramatically 
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
15
while there were no significant changes in the number of visits to the two control clinics. 
While it is true that both health centers had more visits prior to the intervention, and 
Chamoco Chico covers a much larger catchment area, figure 2 shows that the number of 
visits increased even in proportion to the population. One possible reason for the greater 
increase in visits in the experimental clinics than the control was that women trusted 
these health centers more, as evidenced by the focus group discussions. 
Figure 1: Health Center Visits by Women 20 Years 
and Older
0
500
1000
1500
2000
2500
3000
3500
Jan-June
2000
July-Dec
2000
Jan-July
2001
July-Dec
2001
Number of Visits
Chamoco Chico
La Portada
Alto Mcal. Sta. Cruz
Obispo Indabur
Figure 2: Ratio of Health Center Visits by Women 20 
Years and Older to Total Population
0
20
40
60
80
100
120
Jan-June
2000
July-Dec
2000
Jan-July
2001
July-Dec
2001
Ratio of Visits
Chamoco Chico
La Portada
Alto Mcal. Sta. Cruz
Obispo Indabur
Community Organization Plays an Important Role
Because community organizations are so influential in Bolivia, service delivery managers 
use them to generate participation in activities and educational sessions. In La Portada, 
community solidarity is a value that has not been diluted by urbanization. Economic, 
social, and cultural activities represent socializing opportunities for women and stores, 
marketplaces, schools, churches, and health centers are appropriate places to address 
diverse issues of daily life, including health.
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
16
This situation is different, however, in Chamoco Chico, where faster urban growth has 
occurred and solidarity and neighborhood linkages are weaker. For the women of this 
neighborhood, it is more difficult to organize moments to share their experiences and 
knowledge. So, the women who attended the educational sessions there assigned 
fundamental importance to community organization. For them, belonging to an 
organization is an important way to remain informed and to make friends with female 
neighbors. These women have since organized, forming a women’s health group with 
the objective of communicating health information to more women in the community.
Figure 3: Clinic Visits by Women 50 and Over
0
20
40
60
80
100
120
140
160
Jan - June
2000
July - Dec
2000
Jan - June
2001
July - Dec
2001
Number of visits
Chamoco
Chico
La Portada
Alto Mcal.
Sta. Cruz
Obispo
Indaburo
Contraceptives
There was an important change in women’s perceptions and use of contraception. Before 
the educational interventions, few women reported using a contraceptive, and others did 
not know about or had not even heard about particular methods. Due to experiences 
recounted by friends and relatives, many participants thought that contraceptives caused 
health problems. For example, amenorrhea caused by contraceptive injections was 
perceived to be unhealthy. One woman reported:
“One does not know the consequences [contraceptive use] can have. 
For example, a friend said there is a monthly and quarterly injection, but 
the quarterly stops menstruation. Others have told me that it is 
dangerous for it to stop.”
The educational sessions increased women’s knowledge about contraceptive methods 
with health facility data showing changed use patterns (see Figure 4, below). Also, 
women became less fearful of side effects, although some concerns remained. The main 
concern cited was the return to fertility, suggesting that patient orientation and counseling 
sessions should focus carefully on providing clients with correct information.
Post-intervention interviews in La Portada revealed that some women received 
misinformation about certain methods. Some commented:
“It is frightening because they told my friend that when the IUD is taken out, 
she will not be able to have children.”
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
17
“I had pus in my breast, and they told me that it was because of the IUD that I 
had for more than four years.”
Joint contraceptive decision-making needs to be addressed more thoroughly with both 
men and women. Even after the intervention, many women reported that men should 
decide how many children the couple should have. Joint decision-making was discussed 
with both men and women in informational sessions, and continued attention must be 
paid to this matter to affect changes in attitudes.
Figure 4: Number of New Contraceptive Users in Each Health Center, by Method
 
0
50
100
150
200
250
Number of users
July￾Dec
1999
Jan￾June
2000
July￾Dec
2000
Jan￾June
2001
July￾Dec
2001
Chamoco Chico Health Center
IUD Pill DMPA Condom Natural
 
0
50
100
150
200
250
300
350
400
Number of users
July￾Dec
1999
Jan￾June
2000
July￾Dec
2000
Jan￾June
2001
July￾Dec
2001
La Portada Health Center
IUD Pill DMPA Condom Natural
 
0
20
40
60
80
100
120
140
160
180
Number of users
July￾Dec
1999
Jan￾June
2000
July￾Dec
2000
Jan￾June
2001
July￾Dec
2001
Alto Mcal. Sta. Cruz Health Center
IUD Pill DMPA Condom Natural
 
0
50
100
150
200
250
300
350
400
450
Number of users
July￾Dec
1999
Jan￾June
2000
July￾Dec
2000
Jan￾June
2001
July￾Dec
2001
Obispo Indaburo Health Center
IUD Pill DMPA Condom Natural
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
18
Figure 5: New Modern Method Use: 
Experimental versus Control
0
200
400
600
800
1000
1200
1400
July-Dec
1999
Jan-June
2000
July-Dec
2000
Jan-June
2001
July-Dec
2001
Number of users
Experimental Control
Figure 6: New Natural Method Use: 
Experimental versus Control
0
200
400
600
800
1000
1200
1400
July-Dec
1999
Jan-June
2000
July-Dec
2000
Jan-June
2001
July-Dec
2001
Number of users
Experimental Control
As can be seen in Figures 4-6 above, modern method use in the experimental clinics 
increased dramatically during the intervention period, compared to the control. Important 
to note, the increase in new modern method users did not diminish the number of clients 
using natural methods. Instead, natural method use also improved during the 
intervention, in both experimental and control clinics, presumably due to the increased 
number of clients seeking services and the quality of care activities implemented in each 
of the sites.
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
19
Cancer 
Women were very interested in learning more about breast and cervical-uterine cancer. 
Although aware of cancer, many knew little about it and some had misinformation. A 
common belief was that uterine cancer is due to blood clots caused by an injury or by 
carrying heavy things. The link between the human papilloma virus and cervical cancer 
was identified, but poorly understood as a cause of cancer. One woman stated:
“[Cancer] develops because one has relations with many men, or if the husband 
himself has relations with other women and afterwards he is with his wife again 
and infects her with some illness.”
Women reported that although health providers perform Pap smear tests to screen for 
cervical cancer, few performed breast exams or taught patients how to do self￾examinations. During the educational sessions, women were taught about breast cancer 
and learned how to perform a self-exam. Improving information and access to services 
for uterine and breast cancer is an important part of this intervention.
Beginning in January 2001, the national basic health insurance system (SBS) 
incorporated Pap smear testing into its services. As expected, the number of clients 
increased, particularly in the intervention clinics. But as Figure 7 shows, the figures were 
not consistent from one semester to the next. Among possible explanations, women 
mentioned that even though the service is now offered for free they were charged for the 
associated consultation. Many women mentioned that their Pap smear test results arrived 
late or were lost, and that the exam did not lead to a timely diagnosis.
Figure 7: Visits for Pap Cytology by Women Aged 25 – 59
Family Violence and Women’s Rights
Evaluation results show that women were interested in further exploring issues of family 
violence and gender equity addressed in the educational sessions. Continued efforts must 
be made to inform women of their rights and provide them support in exercising them.
0
50
100
150
200
250
300
350
400
450
Jan. - June
2000
July - Dec.
2000
Jan. - June
2001
July - Dec.
2001
Semester
Number of Visits
Chamoco
Chico
La Portada
Alto Mcal.
Sta Cruz
Obispo
Indaburo
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
20
In one of the educational workshops, participants discussed human rights and how they 
apply to both men and women. The workshop facilitator posed the following question:
“There are laws for women’s as well as for men’s rights, but men exercise their 
rights much more often than women. What can we do to promote equity?”
There is little knowledge about institutions that can support women who experience 
domestic violence, and women don’t know how to access support. They suggested that 
women should be taught about these institutions and the mechanisms they should follow 
to be sure their accusations are effective. While the women agreed that information and 
education are important, they also said that joining together would help them demand 
their rights. For them, being organized was fundamental.
2. Men
Adult men reported that general illnesses including tuberculosis and malnourishment are 
the most frequent problems in the area. They said that for men, as well as for women and 
adolescents, the key factor affecting health is poverty. They also argued that other 
problems like alcoholism influence their general health, but that the effect on women and 
children is greater because of associated increases in domestic violence.
When sexual and reproductive health was addressed before the interventions, men hardly 
spoke about themselves, arguing that this issue was more relevant with adolescents. One 
man observed:
“Well, men’s health, the drama of young men who do not take care of their 
health, the drinking...People that drink three or four days [per week], this 
damages them. They turn very bad and catch all kinds of illnesses.”
Men said they know little about their sexual and reproductive health because they do not 
have access to education and do not speak about these issues with their parents, wives, or 
relatives. The majority of men mentioned that they acquire knowledge about sexuality 
and reproduction through experience and observation. Generally, this happens during 
adulthood, a social age marked by fatherhood and other symbols related to heritage and 
authority that occurs from age 15 on. One man reported:
“My parents brought me up in a very conservative manner. I learned almost 
naturally. But I raised my children in a different way because here in the city, 
everything is visible, we could say. I think that one has to move ahead to address 
the issues so that the children do not get confused...” 
Before the interventions, some men mentioned that they had heard about SRH through 
their children, who had learned about it in school. However, many said they did not 
agree with these lessons taught in school because they might encourage children to 
initiate sexual activity too early. After the educational sessions, however, many men 
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
21
mentioned that it was very important for them to know and speak about these issues. 
Nevertheless, some of them were skeptical about the changes that this process could 
generate. In fact, one man stated, “We have been motivated with talks…but they have 
made us dream because everything remains the same.”
Other men said that their attitudes have changed. Now they can speak openly and with 
more information about sexual and reproductive health topics with their wives, children, 
and friends. Despite the change, adults still consider adolescents to be the most at risk for 
sexual and reproductive health problems and maintain that they should be the main target 
group for educational actions. 
Perceptions of Service Quality
Men’s concerns with health services centered on infrastructure and specialty services like 
ophthalmology, cardiology, and general surgery. They identified personnel turnover as 
an important factor affecting service quality. In Chamoco Chico the men explained that 
having the same doctor on staff for more than 10 years increased client trust.
Men continued to assert that sexual and reproductive health services were only for 
women and newborns, but they believe they are good services because they perceived 
that women use them often. They said they do not go to health centers for services 
because of fear, lack of information, or orientation. One man reported:
“Men often do not come because they lack orientation and fear consultation. 
Men come when they are ‘one step away from death,’ not when they are fine, 
walking.”
Others mentioned that some men who want to consult clinic staff for treatment of 
sexually transmitted infections (STIs) feel ashamed and invent other symptoms while 
being treated:
“Men seek general medical services for cough, cold, stomach ache; nobody 
consults for gonorrhea, syphilis. Sometimes because we feel embarrassed we 
want to consult a male doctor because we do not trust a female doctor. The 
same happens with women.”
Men know that STIs exist, but often don’t believe they are at risk of contracting them. 
Many mentioned that they had heard about STIs including HIV and syphilis, but always 
commented that young men are more likely to become infected. One man observed:
“I think it is important to talk about venereal diseases, AIDS. Youth have the 
right to have sexual relations if they are not married, but they must take care of 
themselves.”
Older men reported that they do not go to health centers because they do not believe they 
are at risk for STIs. Furthermore, infections are considered a confidential issue, so men 
prefer to be treated by doctors who don’t know them. This may be one of the reasons so 
few men seek STI consultations at the La Portada health center. Many men reported that 
they would travel to distant health centers for treatment because word would get around if 
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
22
they attended their neighborhood clinic, particularly in La Portada. It is important to 
guarantee confidentiality and to follow up with men who attend clinics from far away.
Figure 8: Health Center Visits by Men 
20 Years and Older
0
50
100
150
200
250
300
350
Jan-June
2000
July-Dec
2000
Jan-July
2001
July-Dec
2001
Number of Visits
Chamoco Chico
La Portada
Alto Mcal. Sta. Cruz
Obispo Indabur
Figure 9: Ratio of Health Center Visits by Men 20 
Years and Older to Total Population
0
2
4
6
8
10
Jan-June
2000
July-Dec
2000
Jan-July
2001
July-Dec
2001
Ratio of Visits
Chamoco Chico
La Portada
Alto Mcal. Sta. Cruz
Obispo Indabur
Contraception
At the beginning of the intervention, men said that family planning is a topic that 
concerns women and that the researchers should speak to them about it. Only one man 
interviewed said that he and his wife use an IUD because they decided only to have two 
children. Most men knew they could get contraceptives at the drug store or health center 
but said they did not because they were afraid of rumors.
Men agreed that health providers should be consulted when choosing a contraceptive 
method because of the effects on the woman’s health. They reported that they and their 
wives had heard the IUD has the fewest side effects, as one man observed:
“My wife used Depo-Provera injections two years ago for two years, but she 
gained a lot of weight. She switched to an IUD because we do not want children 
yet...Doctors said that the injection is not always convenient because it makes 
one gain weight...My wife did not feel good being fat. Now she uses the IUD, 
one week, and she is fine.”
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
23
In the post-intervention interviews, men mentioned:
“Many people need contraceptive 
methods, not only women. Women are 
willing but their husbands become 
jealous.”
“I still think it is the man who decides 
how many children he wants, even though 
we said in the talks that the woman also 
has the right to say she does not want 
anymore and can use the IUD or another 
method.”
“It is a problem with the husbands. One 
has to recognize that we are male 
chauvinists, we also want to control the 
women, so I think that to speak more with 
the husbands in other talks like this is 
important.”
“I have learned a lot. For example, 
earlier I distrusted the IUD because of 
what I had heard…that it made the womb 
rotten, that it made women turn crazy. 
But with the talks, I have been convinced 
that it is not like they say.” 
Despite the attitudes reflected in the post-intervention interviews, statistical information 
shows that few men go to health service centers for contraception. However, there has 
been an increase in couple consultations at the clinics.
Cancer
Although men consider cancer to be an important topic, they know little about it. Like 
women, they believe that cancer is caused by injury. After the interventions, men said 
they would like providers to be trained on these topics so they can better meet their 
educational and service needs. 
Sexual and Reproductive Rights
Men were generally unaware of sexual and reproductive rights issues. In the post￾intervention interviews men reported that sexual and reproductive rights refer to having 
sexual relations with protection to avoid an STI or an unwanted pregnancy. They spoke 
about the right to decide how many children to have and when to have them. Like 
women, they agreed that these issues must be addressed because there is a lot of sexual 
violence in their neighborhoods.
“From 18-30 years old....is the most dangerous age for men. Because there is 
not opportunity to study, they finish school and begin work in mechanical 
workshops. The majority…work among men, they start to drink every weekend 
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
24
and look for girls to satisfy the drunken man’s desires. Women start to work in 
restaurants and are paid little, 50 to 100 bolivianos, and the bosses tell them if 
you let me touch you or have relations with me, I will increase it to 150, and if 
she refuses he fires her. So the solution for the girls is to get married fast, 
because once they have finished school, they will not receive support in their 
homes, and if they get married their bosses will respect them more.”
Men thought that sexual abuse could be decreased through educational interventions. 
One commented:
“I also think that rape would diminish if men were informed, because many men 
do not have a conscience, especially when they are drunk, and this should 
change. Women should also denounce (sexual abuse) even from their own 
husbands, and so men would be afraid and I think would watch themselves 
more.”
3. Adolescents
Adolescents generally have more information than adults about sexual and reproductive 
health, but they are not used to talking about these issues. In the post-intervention 
evaluations, almost all adolescents mentioned that they were exposed to the presentations 
on sexual and reproductive health.
Male adolescents were more outspoken than females about sexual and reproductive 
health topics. Many mentioned they had heard about sexuality and reproduction in school 
and in HIV/AIDS public awareness campaigns. They initiated discussions and, in some 
sessions, became competitive in voicing their knowledge and opinions.
In La Portada, the adolescents said that some males buy contraceptives or talk about 
sexual issues to show off and project a macho image. They also said that youth in the 
neighborhood are “conservative, good people” and many abstain from sex.
Female adolescents had greater difficulty than males speaking about sexual and 
reproductive health topics in mixed-gender focus group discussions. Some expressed 
their opinions, however, said they did not want to speak in front of the males for fear that 
the boys might “think bad things about them.” One girl said:
“Generally we do not speak about the issue because it is taboo, as my 
companions said. At our age nobody gives it much importance, and it is not 
discussed in our homes. Well, at least nobody has talked to me about these 
topics. Only when I was in 10th grade were we given a presentation, and I 
learned about abortion and sexual relations.”
Focus group participants asserted that sexual and reproductive health information is 
transmitted more effectively among peers of the same gender, and that very little 
information is transmitted from parents to children. The adolescents gave examples of 
topics they address with their peers including menstruation, decision-making power, 
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
25
respect during sexual relations, fear of pregnancy, and use of contraceptives. Males 
highlighted peer pressure to have sex.
Perceptions of Service Quality
Both male and female adolescents felt excluded from health center services. They said 
that medical staff assume youth do not get sick, and that the health centers only offer 
services for mothers, children, and old people. 
Parents’, doctors’, and teachers’ opinions about sexual and reproductive health influence 
adolescents’ attitudes toward and access to sexual and reproductive health care. The 
teachers interviewed said that adolescents often come to them with questions about 
sexual and reproductive health instead of going to the health centers. Because many 
adults are misinformed about the safety and side effects of contraceptives, adolescents 
are, by extension, biased against them as well. 
Some adolescents who had good experiences at the health center said that it is important 
to be informed by clinical staff rather than by drugstore employees or friends. One 
observed:
“In the health center they have given us this information about sexual union 
because I didn’t know anything about that. The doctor and nurse informed me 
about safe sex and contraception, and I shared this with my classmates. I told 
them why they have to protect themselves, and how they have to protect 
themselves, and when to do it because they have to plan ahead. Nowadays, if they 
do not want to have a child there are so many contraceptives they can use. I tell 
them to go to the center – to ask the doctor, the nurses – that they will tell them 
correctly.”
After the educational sessions the adolescents of Chamoco Chico and La Portada had 
broader knowledge about the health centers in their neighborhoods and the services they 
offer. In La Portada a community health fair publicized health center services; however, 
the adolescents demand for services remains low. In contrast, adolescents in Chamoco 
Chico gained trust in the health center, reflected in the increased number of consultations 
(see Figures 10 and 12 below). They said the health center “opened its doors to 
adolescents” as a result of the intervention. In fact, the educational sessions and other 
adolescent project activities occurred at the Chamoco Chico health center.
Figures 10-13 (below) show that more adolescents visited health centers in the 
intervention sites than in the control sites. Figures 11 and 13 show the ratio of visits in 
terms of population size in the health center catchment areas to avoid bias by population 
size. Although improvements in service utilization are less dramatic when considered as 
a ratio to all adolescents, both intervention health centers outperformed the control 
centers serving male adolescent clients (Figure 13), and the La Portada health center has 
a substantially higher number of visits by female adolescents (Figures 10 and 11). 
Despite the increase in consultations, some adolescents in La Portada maintain that their 
health center fails to offer youth-friendly services, mainly due to the cost of consultations 
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
26
and medicines. They also mentioned that the center does not offer privacy to adolescents. 
One adolescent recounted a story about a 15-year-old girl who was scolded in the clinic 
waiting area for coming for a pregnancy consultation. Discussions suggest that many 
adolescents are fearful of reproach if they seek services at the health clinic.
Figure 10: Number of Health 
Center Visits by Adolescent Girls 
14-19
50
100
150
200
250
300
350
400
450
500
Jan-June
2000
July-Dec
2000
Jan-June
2001
July-Dec
2001
Number of Visits
Chamoco Chico La Portada
Alto Mcal. Sta. Cruz Obispo Indaburo
Figure 11: Ratio of Health Center 
Visits by Adolescent Girls 14-19 to 
Total Population
0
5
10
15
20
Jan-June
2000
July-Dec
2000
Jan-June
2001
July-Dec
2001
Ratio of Visits
Chamoco Chico La Portada
Alto Mcal. Sta. Cruz Obispo Indaburo
Figure 12: Number of Health 
Center Visits by Adolescent Boys 
14-19
0
10
20
30
40
50
60
Jan-June
2000
July-Dec
2000
Jan-June
2001
July-Dec
2001
Number of Visits
Chamoco Chico La Portada
Alto Mcal. Sta. Cruz Obispo Indaburo
Figure 13: Ratio of Health Center 
Visits by Adolescent Boys 14-19 to 
Total Population
0
1
2
3
Jan-June
2000
July-Dec
2000
Jan-June
2001
July-Dec
2001
Ratio of Visits
Chamoco Chico La Portada
Alto Mcal. Sta. Cruz Obispo Indaburo
Contraception
Focus group discussions showed that male and female adolescents use contraception with 
doubts and lack information on correct usage. The females, and a few males, had heard 
about almost all contraceptive methods (e.g. IUD, pills, condom, monthly and quarterly 
injectables, natural family planning, breastfeeding, and vasectomy). One of the boys 
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
27
referred to withdrawal as a method, describing it as “when one’s penis is tied“ (making a 
face and moving his hands as if cutting). One female commented:
“I think [contraception] is very important because it is us women who suffer the 
consequences, not men in the majority of cases...One can always get pregnant or 
something like that. It is women who suffer contempt by people, mainly by men, 
if they have had relations, if they have their baby -- I think mainly because of 
that. If they have an abortion, they can never become mothers. I think this is 
important.”
Misinformation was common among both males and females. They were suspicious of 
the pill’s side effects and had heard their mothers and other people in the neighborhood 
say that the IUD causes cancer. It is also commonly believed that babies are born with 
birth defects if contraceptives are used for a long time.
Condoms were the method they were most interested in learning more about and the 
method used most often by adolescents. Many adolescents do not know how use it, 
including when to put it on and how to remove it from the penis.
The number of adolescent contraception users increased in all four health centers during 
the intervention (see Figure 14 below). Improvements at the Alto Mariscal Santa Cruz 
control site can be attributed in part to efforts by the youth center, which had been 
operating there since 2001 with the support of an NGO specialized in working with this 
age group. The contraceptive mix offered in the intervention centers also improved 
considerably in the second semester of 2001. However it is important to note that the 
Catholic Church, which is located on the same public square as the health center, has a 
very strong influence in La Portada, and may contribute to the limited method mix and 
low use among adolescents there. This health center was also influenced by a project 
introducing the Standard Days Method (i.e. using a necklace to keep track of fertile days 
and abstaining on them). They also said that it is difficult for them to obtain 
contraceptives at health centers because they still feel ashamed, so they often go to the 
drug store. This probably accounts for the low rates of condom use among adolescents 
attending health centers.
Even though youth still believe some family planning methods are harmful, they believe 
using a method without clinical supervision causes many of the problems. Males and 
females said that they obtained information on contraception from different sources, 
including the educational sessions by CIDEM, at school, and at the health center. They 
also mentioned the church as an important reference. However, they said that the church 
speaks about marriage and not about contraception. One participant in the Chamoco 
Chico area remarked:
“What I have seen is that the church cares that a child is welcomed and is not a 
nuisance. They want a child to be born within a marriage so he/she has the love 
of their parents. But it also happens that some young women have been raped; 
who are victims of assaults and get pregnant, and they feel pressured to reject 
their babies. I think that the church should welcome them too and teach them 
about family planning, but instead they reject them.”
Evaluation Of Community Education Interventions 
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Figure 14: Number of Adolescent (14–19 years old) Users of Contraceptives, by 
Method
0
5
10
15
20
25
30
35
Number of users
July￾Dec
1999
Jan￾June
2000
July￾Dec
2000
Jan￾June
2001
July￾Dec
2001
Chamoco Chico Health Center
IUD Pill DMPA Condom
0
5
10
15
20
25
Number of users
July￾Dec
1999
Jan￾June
2000
July￾Dec
2000
Jan￾June
2001
July￾Dec
2001
La Portada Health Center
IUD Pill DMPA Condom
0
5
10
15
20
Number of users
July￾Dec
1999
Jan￾June
2000
July￾Dec
2000
Jan￾June
2001
July￾Dec
2001
Alto Mcal. Sta. Cruz Health Center
IUD Pill DMPA Condom
0
5
10
15
20
Number of users
July￾Dec
1999
Jan￾June
2000
July￾Dec
2000
Jan￾June
2001
July￾Dec
2001
Obispo Indaburo Health Center
IUD Pill DMPA Condom
Source: Health Center service statistics
Sexually Transmitted Infections
Before the interventions, male adolescents spoke more than females about sexually 
transmitted infections including HIV/AIDS. They reported that STIs are transmitted 
through sexual relations, poor hygiene, and contaminated syringes and they think that 
having sex too frequently and with multiple partners are the main risks for contracting 
infection.
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
29
Girls mentioned that STIs affect women more than men and can be recognized because 
“there is pain in the womb,” “women cannot walk properly,” and “there are violet marks 
in the woman’s parts.” In the post-intervention interviews, female adolescents expressed 
more clarity about STIs and how they are transmitted. They referred to blood and 
unprotected sexual relations.
The discussions suggested that many adolescents in the area had experienced symptoms 
of STIs and had purchased medication at the pharmacy rather than at the health center. 
Health center statistics confirm that although the frequency of STIs in men and women is 
one of the main reproductive health problems, consultations to prevent or treat STIs are 
low relative to the estimated number of cases. 
It is important to mention that, according to the adolescents, gang hazing is very common 
in these neighborhoods. These youth are often required to initiate sexual relations, 
usually unprotected, under the influence of alcohol. Adolescents observed that STIs are 
common among the gangs. However, they say that gang members often do not recognize 
the symptoms of an STI or know how to prevent them, and they do not go to health 
centers for testing and treatment because they fear reproach, shame, and lack of 
confidentiality. 
Sexual and Reproductive Rights
Before the interventions, adolescents related sexual and reproductive rights to the right to 
love, children’s rights, the right to live, and the rights to have an education, parents’ love, 
freedom, and free choice. In the post-intervention interviews, they mentioned that sexual 
and reproductive rights refer to having correct and adequate information about all 
contraceptive methods, avoiding STIs due to unprotected sexual relations, being 
conscious about how many children to have, having sexual relations without violence 
against women, and not subordinating women. Others mentioned that, in their opinions, 
access to family planning is still poor and thus related to the number of aborted 
pregnancies resulting from sexual violence. Family violence is a major concern. 
Adolescents said they did not realize that family violence could affect sexual and 
reproductive health. One participant said:
“I know a family with 11 children, and it is not the only family that I know like 
this. The husband drinks and hits his wife. The wife is a laundress and makes 
skirts, and the husband has abandoned them. I met her when she had nine 
children, and every time he returned to the house...he was drunk. I do not know 
what else happened, but I heard a racket, and some time after she appeared with a 
baby. So I assume he forced her. She had babies and appeared beaten. She even 
has a small baby now and is old.”
An adolescent in La Portada said sexual and reproductive rights are the choice to have 
sexual relations and enjoy sexuality, but said there is no place for adolescents to “enjoy 
their sexuality.” Youth are often prohibited from having sex at home, cannot afford a 
hotel, and are deterred by policemen in the parks.
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
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Ideal family size
Adolescent focus group participants said families in their neighborhoods have an average 
of five or six children. They questioned policies that encourage contraceptive use as a 
means to reduce poverty. Several youth said they thought that many large, poor families 
were “happy families,” suggesting that the cultural preference for large families could 
contribute to low contraceptive use.
Evaluation Of Community Education Interventions 
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VII. DISSEMINATION AND SUSTAINABILITY
This research is part of the Ministry of Health and Prevention’s efforts to improve the 
quality of care, and, more specifically, to continue to support health centers where 
injectable contraceptives were recently introduced. The research experience and results 
were presented to health authorities at the district, departmental, and national levels. The 
lessons learned from this project will provide useful examples for future experiences in 
other regions and results will be disseminated through local publications and, if possible, 
national workshops.
To guarantee the sustainability of the experience, researchers based the interventions on 
resources already existing in the health system and produced educational materials for 
distribution in the community. Activities initiated during this study will continue to be 
supported by the National Quality of Care Improvement Strategy of the Ministry of 
Health and Prevention, with funds provided by DFID and with technical assistance from 
the Population Council. Educational activities will be strengthened so that the centers 
can be used as models for educational experiences for the rest of the country. 
CIDEM organized workshops to disseminate the information in June 2002 in the main 
cities of the country: La Paz, Cochabamba, and Santa Cruz. The dissemination activities 
reached an audience composed of representatives from the Departmental Health Services 
(SEDES), international agencies, NGOs that work in sexual and reproductive health, and 
women’s organizations that work to promote human and sexual and reproductive rights.
Evaluation Of Community Education Interventions 
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VIII. CONCLUSIONS AND RECOMMENDATIONS
This research showed that educational activities play an important role in improving 
access to sexual and reproductive health services. Consequently, it is important to 
incorporate participative educational strategies in quality of care intervention approaches 
based on increasing demand for services.
However, the study also demonstrated that it is necessary to reexamine which educational 
strategies are most appropriate and effective in this social and cultural context. The 
economic, social and cultural situation, power relations, gender inequity, discrimination, 
and sexual and domestic violence were shown to be factors that influence sexual and 
reproductive health in the urban and semi-urban areas of La Paz. This research 
penetrated very complex cultural environments that cannot be impacted with educational 
activities alone. 
Lessons Learned
· Educational interventions have to be tailored to meet the needs of the community.
· It is important to show gratitude to training participants. Each person who attended 
an educational session received a certificate and was made to feel important. For 
some of them, it was the first time they had ever received a certificate 
· Groups established during the intervention can be motivated to take further action in 
the community, as seen among the adolescents of La Portada and the women of 
Chamoco Chico. In both settings the educational sessions motivated them to organize 
and become part of neighborhood committees.
· Participants were surprised by and distrustful of the informed consent forms. Many 
had never encountered them before and did not understand their meaning. Others 
were afraid to sign because they felt they were committing to something or accepting 
an obligation.
· Involving community leaders is necessary to gain trust and motivate community 
members. Many of the women and men interviewed were contacted through 
storekeepers, market leaders, presidents of civil organizations, health center doormen, 
teachers, and nuns.
· Health center assessments showed that care was inadequate and needs improvement. 
Community members want clinic staff to be trained, and increases in service 
utilization will require providers to use their time more efficiently. 
Results showed that pedagogic methodologies based in popular education, which 
emphasize “knowledge dialogue,” are very useful to promote changes in health behaviors 
and knowledge. Improving knowledge based on the subjects’ own experiences with 
sexual and reproductive health was an important mechanism to introduce new concepts, 
clarify doubts, and sensitize the participants to the importance of SRH. The educational 
sessions on SRH, rights, knowledge of contraception, violence, and gender were 
important channels to improve clients’ access to SRH services and help them make 
informed decisions. 
Evaluation Of Community Education Interventions 
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The intervention’s impact on client demand for services were clear in the health center 
statistics, but this does not mean that they were satisfied with the services they received. 
Many participants believe that treatment and confidentiality remain inadequate. 
Adolescents still do not have a separate counseling area; resolution of this issue is still in 
progress. Client orientation services have been consolidated and will continue to be 
strengthened. Intervention strategies based on increasing demand, such as educational 
activities, must be complemented by improvements in the quality of health care services. 
Improvements are being made in the health services sector as problem areas are 
identified. This research supports the theory that improvement in quality of care have to 
be addressed in an integral manner, taking into account clients and those not using health 
services, health center conditions, and existing technologies.
The impact of community educational sessions should not only be measured in terms of 
demand for services. Qualitative observations of how community members reflect and 
discuss their own values and practices in SRH should also be considered. For example, 
adolescents’ discussions about their lifestyles showed increases in their awareness of 
STIs. Some men changed their attitudes considering SRH issues as taboo; now they are 
more open and show interest in other themes such as prostate cancer and sexual 
dysfunction. Initially men reluctant to discuss sexual and reproductive health and had 
many fears due to lack of information. After the interventions it was often fathers who 
sent their sons to educational sessions. Women in the communities learned that it is 
necessary to get organized to contribute themselves to changes in health. 
In general, the importance of introducing community education and participation 
strategies based on demand became clear for officials in the health district and health 
center staff. This process requires support from the introduction of methodologies 
through the process of institutionalizing them in the health system. It is important to train 
teams in charge of community extension in these strategies to achieve sustainability.
In terms of cost and benefits, participative educational strategies demand time and 
confront a series of limitations, depending on the social dynamics of the participant 
subjects and changes desired in the health center. However, in the medium and long￾term, benefits of such projects are much greater when compared to other demand-based 
strategies, such as social marketing. These benefits are related to two fundamental issues 
that arose in this research: 
· Participants are potential actors to support initiatives or actions by the health center 
or other organizations working in favor of health care improvements; and
· Although still incipient, organizations of groups of adolescents and women were 
created. These organizations can become forums for individuals to exercise their 
sexual and reproductive rights effectively.
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BIBLIOGRAPHY
Albo Xavier, 1999. Iguales Aunque Diferentes. La Paz: Reforma Educativa, UNICEF, 
CIPCA.
Altobelli Laura. 1998. Identificación de la demanda insatisfecha para servicios de salud 
Reproductiva en Huancavelica, Perú. Resultados de una encuesta de salud a mujeres 
rurales. Population Council. Documentos de Trabajo, núm. 27.
Araujo, G y Fernández, L 1996. ‘La Entrevista Grupal: Herramienta de la Metodología 
Cualitativa’ in Szasz, I y Lerner, S (eds.) Para comprender la subjetividad: investigación 
cualitativa en salud reproductiva y sexualidad. Mexico, D.F. El Colegio de México, pp. 
243 – 256.
Bradby, B 1996. "La Investigación a Nivel de Comunidad dentro de un programa de 
salud reproductiva: de la participación al diálogo". Workshop presentation "Género, 
Salud Reproductiva y Política de Población. La Paz, April 22, 1996.
Calidad de Atención, 1993. NETWORK en Español, Vol. 8 Nº 4.
Camacho V. et al, 1996. Diagnóstico Cualitativo de la Salud Sexual y Reproductiva en 
Bolivia, Revisión Bibliográfica, Secretaria Nacional de Salud. 
Council of International Organizations of Medical Sciences (CIOMS) 1993. 
‘Antecedentes’; ‘Introducción’ en Pautas Eticas Internacionales para la Investigación y 
Experimentación Biomédica en Seres Humanos. Geneva: CIOMS/WHO.
Instituto Nacional de Estadística. Encuesta Nacional de Demografía y Salud (ENDSA) 
1994, Bolivia, 1994.
Instituto Nacional de Estadística, INE. 2001 Bolivia: Distribución de la Población. Censo 
Nacional de Población y Vivienda.
Instituto Nacional de Estadística, INE. 2001. Distribución de la Población por 
municipios. Censo Nacional de Población y Vivienda
Lamas, M. 1997. ‘Usos, Dificultades y Posibilidades de la Categoría de Genero’ in 
Lamas, M (eds.) El Género, La Construcción Cultural de la Diferencia Sexual, pp. 327-
366. Mexico, D.F.: UNAM, PUEG
Pando, M y Villaseñor, M 1996. ‘Modalidades de entrevista grupal en la investigación 
social’ in Szasz, I y Lerner, S op. cit.
Rodríguez Gómez, G, Gil Flores, J, García Jiménez, E 1996. ‘Capítulo III. Proceso y 
Fases de la Investigación Cualitativa’ in Metodología de la investigación cualitativa, pp. 
61-77. Pavia (Málaga, Spain): Ediciones Aljibe
Evaluation Of Community Education Interventions 
in Sexual and Reproductive Health Services, La Paz, Bolivia
35
Schrijvers, J 1991. ‘Dialéctica de un Ideal Dialógico: Estudiar Hacia Abajo, Estudiar 
Lateralmente y Estudiar Hacia Arriba’ in Nencel, L y Pels, P (eds.) Constructing 
Knowledge: Authority and Critique in Social Science. London: SAGE. Translation: 
Gonzalo Araoz 1999, La Paz
Sistema Nacional de Información en Salud, SNIS, Ministerio de Salud y Previsión Social. 
Información Estadística de los años 1999, 2000 y 2001.