1
Private Sector Project for 
Women’s Health 
Evaluation Report 
Evidence-Based Medicine (EBM) for 
Family Planning Program 
Submitted to: 
Dr. Basma Khraisat 
Contracting Officer’s Technical Representative (COTR)
USAID/Jordan 
Submitted by: 
Reed Ramlow 
Chief of Party 
Private Sector Project for Women’s Health 
Abt Associates Inc. 
Prepared By: 
Dr. Nadia Al-Alawi 
December 2010 
Private Sector Project for Women’s Health-Jordan 
PSP Task number 802 
Contract number: GPO-I-802-04-00007-00
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A. Executive Summary 
One of the main activities of the Private Sector Project (PSP) for Women’s Health, funded by 
the United States Agency for International Development (USAID), is to address provider bias 
and negative attitudes and behaviors towards hormonal family planning (FP) methods and to 
increase knowledge of modern contraceptive methods among physicians providing family 
planning (FP) services to Jordanian women. To do this, PSP enacted an Evidence Based 
Medicine (EBM) for Family Planning/Reproductive Health program, in which PSP 
collaborated with Bayer Schering Pharma to organize 16 “roundtable” seminars for 247 
physicians to disseminate best research evidence on combined oral contraception (COC) 
methods through a Critically Appraised Topic (CAT) format. PSP then reinforced knowledge 
though individual visits to doctors, providing specific messages and materials on key COC 
topics. 
PSP conducted an assessment of knowledge, attitudes, and practices of physicians 
participating in its 2009/2010 EBM program both before and after participation in the 
program. The assessment found that the PSP-Jordan EBM program was an effective method 
for improving private sector provider knowledge, attitudes, and practices on FP. Following 
participation in the EBM program, participating physicians: 
 Improved reported FP discussion practices. Physicians discussed FP with patients 
more often after participating in the program. 
 Improved reported COC pill prescription practices. Physicians were more willing to 
prescribe COC pills to appropriate clients and less likely to inappropriate clients after 
participating in the program. 
 Improved reported attitudes on the importance of patient preferences. Participants 
were more likely to state that a woman’s preference for a method was the most 
important factor and the provider’s preference for a method the least important factor 
when deciding which FP method to suggest to a woman after participating in the 
program. 
 Increased knowledge of COC pills. More physicians were able to dispel myths and 
correctly identify specific risks and benefits of the COC pills after participating in the 
program. 
Participating physicians felt the EBM program was more beneficial than traditional 
continuing medical education programs because it was more likely to change their clinical 
behavior. Unlike the EBM program (which improved several measures of knowledge, 
attitudes, and practices), the only differences in knowledge, attitudes, or practices on FP 
between physicians attending non-EBM trainings, workshops, or conferences and those not 
attending was an increase in frequency of discussing FP with patients. The EBM program 
therefore, may be more effective at changing knowledge, attitudes, and practices on FP than 
other training programs. 
Based on assessment results, it is recommended that PSP:
1. Continue to use the EBM program to improve provider knowledge, attitudes, and 
practices on COC pills. 
2. Increase the number of male physicians participating in the EBM program because 
many FP providers in Jordan are male, and the knowledge, attitudes, or practices of 
male physicians is generally not as good as female physicians. 
3. Expand the EBM program to reach more physicians. 
4. Expand the EBM program to include other modern contraceptive methods. 
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B. Introduction 
The Private Sector Project (PSP) for Women’s Health, funded by the United States Agency 
for International Development (USAID) 2005 - 2012, has a mandate to improve the health of 
Jordanian women and families. The project uses an integrated approach to increase demand 
for modern contraception and related women’s health services, increase availability of quality 
private sector health care services, increase early detection of breast cancer, and address 
domestic violence against women. One of the project’s major activities is to increase 
knowledge of modern contraceptive methods among physicians providing family planning 
(FP) services to Jordanian women. 
Evidence Based Medicine (EBM) is the process of systematically reviewing, appraising, and 
using clinical research findings to aid in clinical decision making, to ensure the best medical 
care for patients. PSP-Jordan is addressing provider bias and negative attitudes and behaviors 
towards hormonal FP methods by integrating the EBM approach into training programs for 
FP practitioners. PSP partnered with Bayer Schering Pharma in organizing “roundtable” 
seminars to disseminate updated research on combined oral contraception (COC) pills in 
Critically Appraised Topic (CAT) format. PSP then reinforced the knowledge learned 
through “detailing” of physicians. During detailing, PSP and Bayer Schering Pharma visit the 
doctors, providing specific messages on key program topics and materials such as the FP 
Global Handbook. 
Together, PSP-Jordan and Bayer Schering Pharma implemented 16 EBM roundtable 
discussions on combined oral contraceptives over a one year period starting in April 2009, 
reaching a total of 247 physicians with roundtable discussions, and detailing messages on 
COC pills. 
International research and private sector experience reveal detailing to be a major source of 
learning and behavior change for doctors. PSP-Jordan assessed the impact of its 2009/2010 
COC EBM program on the knowledge, attitudes, and practices on FP of private health care 
providers. This report presents findings from the assessment. 
C. Methodology 
Physicians participating in the EBM roundtable education activities for COC pills each 
received a study identification number. Physicians completed baseline questionnaires (see 
Annex 1 for baseline questionnaire) prior to participating in the education session. Physicians 
arriving after the start of the education session did not complete the baseline questionnaire. 
Project staff entered data from 180 completed questionnaires into Excel spreadsheets. 
Approximately three months after the completion of the COC EBM program PSP-Jordan 
detailers or Bayer Schering Pharma representatives visited participating doctors and asked 
them to fill in an endline questionnaire (see Annex 2 for endline questionnaire). The endline 
questionnaire included all questions from the baseline questionnaire, with some additional 
questions on physicians’ opinions on the EBM program. Project staff entered data from 148 
completed endline questionnaires into Excel spreadsheets. 
PSP hired a consultant, Nadia Al-Alawi, to analyze and write a report on the evaluation. The 
consultant analyzed data from 113 paired data sets (baseline and endline) using SPSS
software. 
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D. Results 
Usefulness of EBM Approach in Improving FP Practices and Attitudes 
The EBM program was useful in improving overall private sector provider FP knowledge, 
attitudes, and practices. Following the EBM roundtables and detailing visits, responding 
providers (113 in total) discussed family planning significantly more frequently with their 
patients than prior to participation in EBM program (see Figure 1 below). 
Figure 1: Percentage of providers discussing FP with patients during the past week 
Participation in the EBM program also improved reported prescription habits. After 
participation in the EBM program, private sector providers were significantly more willing to 
prescribe COC pills to newly married young women who wished to delay childbirth, than 
prior to participation in the EBM program. Physicians were also significantly less willing to 
prescribe COC pills to 24 year olds who recently gave birth and were breastfeeding. See 
Figure 2 below for details. There was no significant change in willingness of the provider to 
prescribe COC pills to older women who desire no more children and who smoke. 
Figure 2: Percentage of providers willing to prescribe COC pills to specific patients 
0%
10%
20%
30%
40%
50%
60%
Always Often Sometimes Occasionally Never
Baseline
Endline
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Newly married 21
year old who wishes
to delay childbirth
24 year old who
recently gave birth
and who is
breastfeeding
38 year old woman
who desires no
more children and
who is a smoker
Baseline
Endline
5
Participation in the EBM program also improved physicians’ attitudes on the importance of 
specific factors when deciding which FP method to suggest to a woman. Notably, 
participation in the program increased the percentage of physicians who believed a woman’s 
preference was the most important factor when deciding which FP method to suggest to a 
woman. Participation also increased the percentage of physicians who identified their own 
preference for method as the least important factor when deciding which FP method to 
suggest to a woman. 
There were other differences between baseline and endline data in physicians’ beliefs on the 
most important factor (see Figure 3 below) and least important factor (see Figure 4 below) 
when deciding which family planning method to suggest to a woman. 
Figure 3: Percentage of physicians who belief specific factors are MOST important when 
deciding which family planning method to suggest to a woman 
Figure 4: Percentage of physicians who belief specific factors are LEAST important when 
deciding which family planning method to suggest to a woman 
0% 20% 40% 60% 80%
Patient's preference for a method
Patient has a medical condition which is a
contraindication for a method
Provider's preference for a method
Patient's future fertility plans
Baseline
Endline
0% 20% 40% 60% 80%
Patient's preference for a method
Patient has a medical condition which is a
contraindication for a method
Provider's preference for a method
Patient's future fertility plans
Baseline
Endline
6
Participation in the EBM program also significantly increased physician knowledge of some 
of the risks and benefits of COC pills (see Figure 5 below). 
Figure 5: Percentage of respondents able to correctly identify specific risks and benefits of 
COC pills 
Participation in the EBM program did not significantly change physician perceptions on the 
ability of COC pills to reduce severe symptoms of dysmenorrhea (awareness of this was 
already very high at 92% and 94% awareness before and after participation in the EBM 
program respectively), protect against ovarian cancer (awareness for this was fairly high, at 
75% and 74% before and after participation respectively), or change in incidence of breast 
cancer (53% in both cases). The research presented for breast cancer gave no definitive 
answer to whether use of COC pills is associated with breast cancer. 
Comparison with Other Information Sharing Methods 
Physicians felt the EBM program was extremely beneficial when compared with traditional 
continuing medical education programs. Virtually all physicians agreed that: 
 An EBM continuing medical education program is more likely to change their clinical 
behavior (100% of respondents agreed). 
 The EBM program with the use of CATS is more convincing since they have the data 
available for their immediate review (100% agreed). 
 They have more confidence in the speaker because they can see the research on which 
they base their conclusions (100% agreed). 
 The EBM program is more helpful because it includes not only the research, but also 
the attitudes of the physicians attending the seminar (99% agreed). 
 The EBM program is more helpful because it includes not only the research, but also 
the attitudes of the patients they see in their practice (94% agreed). 
Participating physicians also readily shared EBM information with colleagues. Eighty-five 
percent shared the EBM talk with colleagues outside of the EBM training. Seventy-nine 
percent used the CATs in talks or speeches they gave. Fifty-five percent of physicians gave 
CATs to colleagues outside of the EBM training. 
Prior to participation in the EBM program, physicians who had attended other FP trainings 
(63 in total), workshops, or conferences discussed FP with patients more frequently than 
93%
96%
78%
81%
73%
82%
83%
59%
55%
43%
0% 20% 40% 60% 80% 100%
Decreased menstrual blood flow is a benefit
of using COC pills
COC pills are a safe treatment for moderate
acne
COC pills are safe for most women
COC pills can be prescribed to nulliparous
women who wish to delay childbirth
Women who use COC pills are not at an
increased risk to gain weight
Baseline
Endline
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those who had not (49 in total). After participating, however, there were no differences in 
frequency of discussion of FP with patients between physicians who attended FP trainings, 
workshops, or conferences and those who had not. 
After participation in the EBM program, there were no differences in physician knowledge, 
attitudes, and practices on FP when comparing physicians who attended other FP trainings, 
workshops, or conferences with those who had not. 
There were no differences in willingness to prescribe COC pills to specific women, in beliefs 
in the most or least important factors when deciding which FP method to suggest to a woman, 
and in knowledge of the risks and benefits of COC pills between physicians who attended 
other FP trainings, workshops, or conferences and those that did not either prior to or 
following participation in the EBM program. 
Gender of Physician 
Female physicians generally had better knowledge, attitudes, and practices on family 
planning than did male physicians. Participating female physicians (85) discussed FP patients 
more frequently than did male physicians (28), both before and after the EBM roundtable 
discussions (see Figure 6 below for endline data). 
Figure 6: Frequency of discussing FP with patients during the past week, by gender (endline 
data only) 
Female physicians also had better reported prescription habits than male physicians. Female 
physicians expressed more willingness to appropriately prescribe COC pills when compared 
with male physicians, both before and after participation in the EBM program. They were 
more willing than male physicians to prescribe COC pills to newly married young women 
who wished to delay childbirth, and less willing than male physicians to prescribe COC pills 
to 24 year olds who recently gave birth and were breastfeeding, or older women who desire 
no more children and who smoked (see Figure 7 below for endline data). 
0%
10%
20%
30%
40%
50%
60%
Always (100%) Often (75%) Sometimes
(50%)
Occasionally
(25%)
Never (0%)
Male
Female
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Figure 7: Frequency of willingness of provider to prescribe COC pills to specific patients, 
by provider gender (endline data only) 
Female physicians also expressed more appropriate attitudes, when compared with male 
physicians, on the importance of specific factors when deciding which FP method to suggest 
to a woman. More female than male physicians believed the most important factor when 
deciding which FP method to suggest to a woman was either a female patient’s medical 
condition which was a contraindication for a specific method (51% for female physicians and 
39% for males, endline data) or that a woman’s preference was the most important factor 
(31% and 25% female and male physicians respectively, endline data). There were no 
significant differences between female and male physicians’ views on the least important 
factors when deciding which FP method to suggest to a woman. 
There were no significant differences between female and male physician’s knowledge of the 
risks and benefits of COC pills either before or after participation in the EBM program. 
E. Conclusions and Recommendations 
The PSP-Jordan EBM program was an effective method for improving private sector 
provider knowledge, attitudes, and practices on FP. Following participation in the EBM 
program, participating physicians: 
 Improved reported FP discussion practices. Physicians discussed FP with patients 
more often during the previous week after participating in the program. 
 Improved reported COC pill prescription practices. Physicians were more willing to 
prescribe COC pills to appropriate clients and less likely to inappropriate clients after 
participating in the program. 
 Improved reported attitudes on the importance of patient and provider preferences. 
Participants were more likely to state that a woman’s preference for a method was the 
most important factor and the provider’s preference for a method the least important 
factor when deciding which FP method to suggest to a woman after participating in 
the program. 
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Newly married 21
year old who wishes
to delay childbirth
24 year old who
recently gave birth
and who is
breastfeeding
38 year old woman
who desires no more
children and who is a
smoker
Male
Female
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 Increased knowledge of COC pills. More physicians were able to dispel myths and 
correctly identify specific risks and benefits of the COC pills after participating in the 
program. 
Participating physicians felt the EBM program was more beneficial than traditional 
continuing medical education programs because it was more likely to change their clinical 
behavior. Unlike the EBM program (which improved several measures of knowledge, 
attitudes, and practices), the only differences in knowledge, attitudes, or practices on FP 
between physicians attending non-EBM trainings, workshops, or conferences and those not 
attending was an increase in frequency of discussing FP with patients. The EBM program 
therefore, may be more effective at changing knowledge, attitudes, and practices on FP than 
other training programs. 
Based on assessment results, it is recommended that the PSP: 
1. Continue to use the EBM program to improve provider knowledge, attitudes, and 
practices on COC pills. Focus programming topics on understanding the importance 
of discussing FP frequently with patients, reducing inappropriate prescription 
practices, increasing provider belief in patient preferences as an important factor in 
decision making, and dispelling myths on the risks of using COC pills. 
2. Increase the number of male physicians participating in the EBM program because 
many FP providers in Jordan are male, and the knowledge, attitudes, or practices of 
male physicians is generally not as good as female physicians, particularly on 
willingness to prescribe COC pills to inappropriate clients. 
3. Expand the EBM program to include more physicians. 
4. Expand the EBM program to include other modern contraceptive methods. 
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Annex 1 
Roundtable Baseline Evaluation: 
This questionnaire asks for information about your practice and your professional experiences 
in providing family planning services. The information collected is confidential and will be 
used to evaluate the training program. The information you provide will have no impact on the 
trainings, services, or incentives which you receive. 
1. Date: 
2. Sex: Male Female 
3. In which type of facility is your primary practice? 
Private center Clinic Hospital Other, specify:
4. Where is your primary practice located? 
City/town: 
Neighborhood: 
5. Specialty: General practitioner Obstetrician/Gynecologist Other: 
6. Are you a member of the PSP Jordan network of private providers? 
Yes No
7. Have you been certified in the quality assurance family planning program under PSP Jordan? 
Yes No
8. In the past 12 months, have you attended any other trainings, workshops, or conferences about 
family planning? 
Yes. Please specify where, when (month and year), and the topics covered:
 
No
The following questions are related to your practices regarding family planning. Your 
responses are confidential. 
9. In the past week, how frequently did you discuss family planning with patients who were married 
women of reproductive age? 
Always (100% of visits) 
Often (75% of visits)
Sometimes (50% of visits) 
Occasionally (25% of visits)
Never (0% of visits)
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10. Would you prescribe a COC to the following women? Please mark yes or no for each scenario. 
Yes No
A newly married woman, aged 21 who wishes to delay childbearing for 
one year
A woman, aged 24, who has recently given birth and who is breastfeeding
A woman, aged 38, who desires no more children and who is a smoker
11. Looking at the factors below, please put mark with an “X” the most important factor when 
deciding which family planning method to suggest to a woman. 
____Female patient’s preference for a method 
____Female patient has medical condition which is a contraindication for a 
 method 
____The provider’s (your) preference for a method 
____Female patient’s future fertility plans 
12. Looking at the factors below, please put mark with an “X” the least important factor when 
deciding which family planning method to suggest to a woman. 
____Female patient’s preference for a method 
____Female patient has medical condition which is a contraindication for a 
 method 
____The provider’s (your) preference for a method 
____Female patient’s future fertility plans 
13. For the following questions, please mark if you Strongly Agree, Agree, are Uncertain, Disagree, 
or Strongly Disagree with the statement. 
Strongly 
Agree Agree
Do not 
agree or 
disagree Disagree
Strongly 
Disagree
a. COCs have been shown to reduce severe 
symptoms of dysmenorrhea.
b. The use of COCs is associated with an increased 
incidence of breast cancer.
c. The use of COCs has a protective effect against 
ovarian cancer.
d. Decreased menstrual blood flow is a benefit of 
using COCs.
e. COCs are a safe treatment for moderate acne.
f. COCs are safe for most women.
g. I should not prescribe COCs to nulliparous 
women who wish to delay childbirth.
h. For some oral contraceptives there is a slightly 
increased risk of a myocardial infarction
i. Women who use a COC are at an increased risk 
to gain weight
j. I know what is best for women who wish to use a 
modern method of contraception.
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Annex 2 
Roundtable Endline Evaluation: 
This questionnaire asks for information about your practice and your professional experiences 
in providing family planning services. The information collected is confidential and will be 
used to evaluate the training program. The information you provide will have no impact on the 
trainings, services, or incentives which you receive. 
1. Date: 
2. Sex: Male Female 
3. In which type of facility is your primary practice? 
Private center Clinic Hospital Other, specify:
4. Where is your primary practice located? 
City/town: 
Neighborhood: 
5. Specialty: General practitioner Obstetrician/Gynecologist Other: 
6. Are you a member of the PSP Jordan network of private providers? 
Yes No
7. Have you been certified in the quality assurance family planning program under PSP Jordan? 
Yes No
8. In the past 12 months, have you attended any other trainings, workshops, or conferences about 
family planning? 
Yes. Please specify where, when (month and year), and the topics covered:
 
No
The following questions are related to your practices regarding family planning. Your 
responses are confidential. 
9. In the past week, how frequently did you discuss family planning with patients who were married 
women of reproductive age? 
Always (100% of visits) 
Often (75% of visits)
Sometimes (50% of visits) 
Occasionally (25% of visits)
Never (0% of visits)
13
10. Would you prescribe a COC to the following women? Please mark yes or no for each scenario. 
Yes No
A newly married woman, aged 21 who wishes to delay childbearing for 
one year
A woman, aged 24, who has recently given birth and who is breastfeeding
A woman, aged 38, who desires no more children and who is a smoker
11. Looking at the factors below, please put mark with an “X” the most important factor when 
deciding which family planning method to suggest to a woman. 
____Female patient’s preference for a method 
____Female patient has medical condition which is a contraindication for a 
 method 
____The provider’s (your) preference for a method 
____Female patient’s future fertility plans 
12. Looking at the factors below, please put mark with an “X” the least important factor when 
deciding which family planning method to suggest to a woman. 
____Female patient’s preference for a method 
____Female patient has medical condition which is a contraindication for a 
 method 
____The provider’s (your) preference for a method 
____Female patient’s future fertility plans 
13. For the following questions, please mark if you Strongly Agree, Agree, are Uncertain, Disagree, 
or Strongly Disagree with the statement. 
Strongly 
Agree Agree
Do not 
agree or 
disagree Disagree
Strongly 
Disagree
a. COCs have been shown to reduce severe 
symptoms of dysmenorrhea.
b. The use of COCs is associated with an 
increased incidence of breast cancer.
c. The use of COCs has a protective effect 
against ovarian cancer.
d. Decreased menstrual blood flow is a 
benefit of using COCs.
e. COCs are a safe treatment for moderate 
acne.
f. COCs are safe for most women.
g. I should not prescribe COCs to 
nulliparous women who wish to delay 
childbirth.
h. For some oral contraceptives there is a 
slightly increased risk of a myocardial 
infarction
i. Women who use a COC are at an 
increased risk to gain weight
14
Strongly 
Agree Agree
Do not 
agree or 
disagree Disagree
Strongly 
Disagree
j. I know what is best for women who wish 
to use a modern method of contraception.
14. For the following questions, please mark if you Strongly Agree, Agree, are Uncertain, Disagree, 
or Strongly Disagree with the statement. 
Compared to traditional continuing medical education programs, 
Strongly 
Agree Agree
Do not 
agree or 
disagree Disagree
Strongly 
Disagree
a. An EBM continuing medical 
education program is more likely to 
change my clinical behavior.
b. The EBM program with the use of 
CATs is more convincing since I have 
the data available for my immediate 
review.
c. I have more confidence in the 
speaker because I can see the research 
on which they base their conclusions.
d. The EBM program is more helpful 
because it includes not only the 
research, but also the attitudes of the 
physicians attending the seminar.
e. The EBM program is more helpful 
because it includes not only the 
research, but also the attitudes of the 
patients we see in our practice.
15. Did you share the EBM talk with any of your colleagues outside of the EBM training? 
Yes No
16. Did you give the CATs to any of your colleagues outside of the EBM training? 
Yes No
17. Did you use the CATs in any talk or speech you gave to others? 
Yes No Not Applicable (did not give any talk or speech)