Mexico: informing service providers and factory workers about emergency contraception

Mexico: Informing Service
Providers and Factory Workers
about Emergency Contraception
Ricardo Vernon
Frontiers in Reproductive Health
Population Council
Final report of the project, Dissemination of Knowledge of Emergency Contraception among Service Providers and Factory Personnel, conducted in Mexico during January-March 1999. 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, Subproject number 5801.13003.421. The opinions expressed herein are those of the author and do not necessarily reflect the view of USAID. Mexico: Informing Service Providers
and Factory Workers about
Emergency Contraception
The goal of this project was to inform physicians, pharmacists, and female factory workers about emergency contraception through mailings of booklets and posters. These materials had been developed in a previous operations research project conducted by the Instituto Mexicano de Investigación de Familia y Población (IMIFAP) and supported by the Population Council INOPAL III project. Both activities were funded by the U.S. Agency for International Development. This dissemination project consisted of distributing the following print materials: § A four-page booklet to inform physicians about emergency contraception (EC), which was inserted into a magazine sent to 15,000 physicians as well as mailed to a separate list of 3,065 private physicians; § A four-page booklet to give pharmacists basic information about EC, which was inserted into a magazine sent to 15,500 pharmacies as well as mailed to a separate list of 1,075 pharmacies; and § A booklet and poster mailed to 2,107 assembly plants located near the U.S./Mexico border. The impact of the mailings was assessed by analyzing responses to three questionnaires mailed to the three major audiences. Questionnaire respondents generally liked the print materials and welcomed information about EC. Within three weeks of receiving the materials, many respondents reported that they had taken immediate action to make EC available and/or to educate others about EC: § Nearly all physicians said that they had already given information to women in need of EC; § Most physicians had discussed EC with their colleagues; § Some physicians had given a talk about EC to their medical colleagues or had consulted them about § Most pharmacists had already provided information about EC to women and had discussed EC § Nearly all of the respondents from assembly plants said that they had discussed the materials with § One in five of the physicians and respondents from assembly plants stated that they had disseminated information about EC through the mass media. Most respondents wanted more information about EC. Only a few respondents were opposed to EC. This project showed that targeted mailings to key audiences can increase awareness of emergency contraception at a relatively low cost. The booklets reached more than 18,000 physicians and 16,500 pharmacists. The booklets and posters sent to 2,107 assembly plants reached an estimated audience of 1.1 million reproductive-age women. The project cost $27,978, of which the major components were printing and postage. This experience indicates that reproductive health organizations can be effective in making information about EC and related services widely available. Public and private agencies in Mexico and other Spanish-speaking countries should replicate or modify the existing materials and distribute them widely. Mexico: Informing Service Providers
and Factory Workers about
Emergency Contraception
TABLE OF CONTENTS
Mexico: Informing Service Providers
and Factory Workers about
Emergency Contraception
BACKGROUND

Emergency contraception (EC) is a method that women can use to prevent pregnancy following
unprotected sexual intercourse (sex without contraception or a contraceptive accident). Emergency
contraception uses contraceptives that are widely available and accepted in most countries. The two
contraceptive methods most commonly used for emergency contraception are:
§ Combined oral contraceptives. Women who have unprotected intercourse may avoid an
unwanted pregnancy by taking oral contraceptives as soon as possible and within 72 hours after intercourse. The usual dose is two contraceptive pills with 50 mcg ethynil estradiol/150 mcg levonorgestrel, followed by two additional pills after 12 hours. In the case of low-dose pills (30 mcg ethynil estradiol/250 mcg levonorgestrel), four pills must be taken in the first 72 hours after unprotected intercourse, followed by four additional pills after 12 hours. There are no known contraindications for these regimes. Studies have found that 98 percent of the women who take them as instructed do not become pregnant. Side effects include nausea (in approximately 50% of the cases), irregular uterine bleeding and breast tenderness.
§ Intra-uterine devices (IUDs). Copper-medicated IUDs may also be used as an emergency
contraceptive. They should be inserted within the first five days following unprotected intercourse. Studies have found the effectiveness of this treatment to be as high as 99 percent in preventing pregnancy. The contraindications for IUD use as emergency contraception are the same as those for regular IUD use (IPPF, 1994). Until recently, most family planning and reproductive health programs in Mexico have not offered counseling on emergency contraceptive methods. Some program directors may be concerned about public criticism because of the misconception that EC is an abortifacient. As a result, most service providers and reproductive-age women in Mexico do not know about EC. In Latin America, the Population Council and other partners recently conducted three emergency contraception projects that tested: 1. The acceptability of EC as an element in the care of rape victims, conducted by the Attorney General’s Office in Mexico City (Vernon, Schiavon and Llaguno, 1997). 2. The acceptability of EC as a contraceptive method in outpatient clinics, programs for adolescents, and centers that care for rape victims, conducted by four organizations in Ecuador with technical assistance from the International Center for Research on Women (Paolisso et al., 1998). Mexico: Information about Emergency Contraception 1 3. Strategies to disseminate information on EC through various mass and interpersonal media, conducted by the Instituto Mexicano de Investigación de Familia y Población (IMIFAP) in Mexico City, funded by the Population Council INOPAL III project (Givaudan et al., 1998).
See Vernon (1998) for information on other EC programs in Latin America conducted by the
Population Council and other organizations.
These projects have shown that emergency contraception is well-accepted by providers and clients who
need the method for a variety of reasons (such as rape, condom breakage, and unforeseen sexual
relations). The IMIFAP study in Mexico (Givaudan et al. 1998) demonstrated that targeted
communication interventions did raise knowledge about EC. The proportion of private physicians who
knew about EC increased from 38 percent in the baseline survey to 61 percent in the endline survey,
while knowledge among pharmacists rose from 5 percent to 26 percent. After posters were displayed
on the campus of the National University of Mexico, the proportion of students who reported knowing
about EC increased from 37 percent to 50 percent.
II.
OBJECTIVES

The objective of this project was to expand the use of the results of the IMIFAP project to inform
service providers and female factory workers in U.S./Mexico border towns about emergency
contraception through mailings of booklets and posters. This project was designed to address
Intermediate Result 2 of the FRONTIERS project, OR results disseminated and utilized for policy and
program improvement.
III.
INTERVENTIONS AND RESULTS

Mailing of Booklets to Physicians and Pharmacists

The booklets that IMIFAP had printed and distributed in the INOPAL III project were reviewed by
three reproductive health experts (Rafaella Schiavon, Consultant; Emma Ottolenghi, Population Council;
and Jeffey Spieler, USAID). The revised versions – 40,000 copies of the four-page booklet for
physicians and 87,500 copies of the four-page booklet for pharmacists – were printed by
FRONTIERS.
To identify potential recipients of the mailings, PC/FRONTIERS staff searched for lists of physicians
and pharmacies. The process was slow and difficult. Pharmaceutical companies and commercial editors
would not agree to give or sell their lists. Through personal contacts, staff found a solution. A business
editor who edits two courtesy magazines for physicians and pharmacists agreed to insert booklets within
the magazines. Two copies of the EC booklet for physicians were included inside one issue of the
magazine DIVERSION, which is mailed to 15,000 physicians. Five copies of the booklet for
pharmacists were included inside one issue of Pasatiempo Farmaceutico, which is mailed to 15,500
Mexico: Information about Emergency Contraception 2 pharmacies. Thus, a total of 30,000 booklets for physicians and 77,500 booklets for pharmacists were
distributed as magazine inserts.
In addition, one booklet was mailed to 3,065 private physicians whose names and addresses were
collected through other sources (such as the National Federation of Obstetricians/Gynecologists) and to
1,075 pharmacies that are members of the National Chamber of Commerce (CANACO). A few
booklets – 48 booklets for physicians and 77 for pharmacists – were returned due to incorrect
addresses.
Mailing of Booklets and Posters to Assembly Plants in Mexico

FRONTIERS staff contacted various institutions and professional associations to obtain a list of
assembly plants in Mexico. A directory compiled by the National Chamber of the Transformation
Industry (CANACINTRA) was found. Since an electronic version of the directory was not available,
addresses for 2,107 assembly plants were keyed in to produce a mailing list. Five copies each of the
booklet for physicians, the booklet for rape victims, and the poster were mailed to each of the assembly
plants. Eighty-one envelopes were returned due to address changes and other reasons. Since the 2,107
assembly plants have an average of 534 employees each, more than 1.1 million people, mostly women
of reproductive age, were exposed to the message.
IV.
EVALUATION
To evaluate the impact of the mailings, PC/FRONTIERS staff sent three questionnaires to physicians,
pharmacists and assembly plants on the mailing/distribution lists (see Appendix A for the three
questionnaires). By the project’s end on April 30, 1999 (just three weeks after the mailings),
PC/FRONTIERS had received 40 responses from physicians, 14 responses from pharmacists, and 75
responses from representatives of assembly plants.
Physicians

All 40 physicians who responded to the questionnaire had a private office. In addition, 23 physicians
worked at public health facilities and 27 at private health facilities. All of them had read the booklet.
Nearly all respondents (37 out of 40) rated it “very good” or “good.” The booklet led to other
important dissemination behaviors:
Mexico: Information about Emergency Contraception 3 § All but one of the physicians said that they had already given information to women in need of EC. § 60 percent reported that they had given a talk on EC to colleagues in their clinic or hospital, and 35 percent had given a talk for colleagues in another clinic or hospital. § 87 percent had discussed the booklet with other colleagues. § 35 percent had trained other health staff members in EC service delivery. § Nearly one in four physicians said that they had consulted their colleagues about implementing EC § 22 percent had disseminated information on EC through the mass media (only one specified a § 40 percent had searched for more information about EC. Of the physicians who added comments, several mentioned the acceptability of EC and the lack of information about it. Some physicians requested further information.
Pharmacists

Of the 14 pharmacists who had contacted PC/FRONTIERS by the project’s end, 12 answered the
questionnaire, one requested more materials, and one confirmed receipt of the booklets. All of the
questionnaire respondents had read the booklet. Nine respondents considered the booklet “very good,”
and three rated it “good.” Major behavioral outcomes were:
§ Ten pharmacists said that they had given information about EC to women who needed it.
§ Eleven pharmacists had shared the booklet and discussed it with other staff members
§ Six pharmacists had asked questions or sought more information on EC.
The most frequent comments from pharmacists were congratulations on the initiative, reports of sharing
the information with staff members, family and friends, and agreement with the use of EC, especially in
cases of rape. Only one respondent reported any difficulties; he had received a complaint from a
woman who had used EC without the desired effect.
Assembly Plant Workers

Of the 2,107 assembly plants, 79 company representatives contacted PC/FRONTIERS before the
project end; 60 people filled out questionnaires and 19 requested further information. All respondents
had read the materials. Eight in 10 respondents said they had displayed the posters in their plants. About
one half of the respondents considered the booklet “very good” and the rest (with one exception)
considered it “good.” Half (51%) of the respondents said that the poster was “very good,” and 36
percent considered it “good.”
Mexico: Information about Emergency Contraception 4 Following are some of the behavioral outcomes: § Ninety-five percent of the plant representatives said that they had discussed the materials with other § 80 percent had shared the materials with others.
§ 21 percent said they had disseminated information on EC through the media.
§ 15 percent said they had searched for more information on EC.
In addition, three respondents reported that they had given talks on EC to all of their employees.
Nearly 40 percent of the plant representatives requested additional information and materials. One
person asked for samples of the pills. Three respondents remarked that the information was very useful
at their plants, since the great majority of employees were women of fertile age. Many respondents
congratulated the project for sending the information.
Three respondents reported that the materials had caused problems, but they did not specify the nature
of these problems. Two respondents stated that they did not agree with the method.
V.
CONCLUSIONS AND RECOMMENDATIONS
This project showed that targeted mailings to key audiences can increase awareness of emergency contraception at a relatively low cost. The materials had sufficient information to enable recipients to take immediate action and to discuss EC authoritatively. The booklets reached more than 18,000 physicians and 16,500 pharmacists. The booklets and posters sent to 2,107 assembly plants reached an estimated audience of 1.1 million reproductive-age women. The project cost $27,978, of which the major components were printing and postage. Initial reactions from physicians, pharmacists and representatives of assembly plants were overwhelmingly positive. Respondents expressed strong interest in knowing more about EC and had already discussed EC with their colleagues, clients, customers, and peers. This experience indicates that reproductive health organizations can be effective in making information about EC and related services widely available. Public and private agencies in Mexico and other Spanish-speaking countries should replicate or modify the existing materials and distribute them widely. Mexico: Information about Emergency Contraception 5 VI. REFERENCES
Givaudan, Martha, R.Vernon, C. Fuertes, and S. Pick. 1998. Testing Strategies to Disseminate
Information on Emergency Contraception. INOPAL III Final Report. Mexico, The Population Council.
International Planned Parenthood Federation, 1994. IMAP Statement on Emergency Contraception.
IPPF Medical Bulletin. Volume 28, No. 6, December 1994.
Paolisso, Michael, E. Pinto, M.L. Carrillo, M. Yépez, M. Arellano, and M. Macieira. 1998. Providing
Emergency Contraception in Ecuador: Assessing the Impacts of Training and Practice. ICRW,
Washington, D.C.
Vernon, Ricardo, Rafaella Schiavon, and Silvia E. Llaguno. 1997. Emergency Contraception as an
Element in the Care of Rape Victims. INOPAL III Final Report. Mexico, The Population Council.
Vernon, Ricardo (ed.). 1998. Ampliando el Acceso a la Anticoncepción de Emergencia. Memorias del
Taller Regional. Quito, Ecuador, 27-29 de abril.
Mexico: Information about Emergency Contraception 6 APPENDIX A

Evaluation Questionnaires
CUESTIONARIO EVALUACIÓN ANTICONCEPCIÓN DE EMERGENCIA
(Médicos)
¿En cuáles de los siguientes tipos de establecimientos presta sus servicios? Atención en clínica, centro de salud u hospital del sector salud .1 Atención en clínica u hospital privado .2 Desde que recibió el folleto informativo ¿ha llevado a cabo alguna de las siguientes ACTIVIDAD
Dar una plática informativa para otros colegas/otro personal de mi consultorio/clínica/hospital sobre los contenidos del folleto Dar una plática sobre el tema para colegas/otro personal de otros Comentar con colegas sobre la información del folleto Capacitar a otros médicos, consejeros u otro personal para que proporcionen esta información a mujeres que la requieran. Difundir por algún medio de comunicación el tema de la anticoncepción Proporcionar información verbal sobre anticoncepción de emergencia a Investigar a sobre el tema en la bibliografía anexa o en otras Llevar a cabo reuniones con otros colegas/otro personal para discutir la conveniencia o posibilidad de implantar actividades de anticoncepción de emergencia en el consultorios/clínicas/hospitales. En caso de que haya llevado alguna de estas actividades, ¿ha tenido algunos problemas, o han CUESTIONARIO EVALUACIÓN ANTICONCEPCIÓN DE EMERGENCIA
(Farmacias)
Desde que recibió el folleto informativo ¿ha llevado a cabo alguna de las ACTIVIDAD
Comentar con otro personal de la farmacia sobre la Compartir con otro personal de la farmacia la información Proporcionar información verbal sobre anticoncepción de En caso de que haya llevado alguna de estas actividades, ¿ha tenido algunos problemas, o han sido bien recibidas las actividades? Si tiene algún comentario sobre problemas o reacciones a favor, escríbalo en este _____________________________________________________________________________ _____________________________________________________________________________ Escriba en el siguiente espacio cualquier comentario que desee hacer. _____________________________________________________________________________ _____________________________________________________________________________ CUESTIONARIO EVALUACION ANTICONCEPCION DE EMERGENCIA
(Maquiladoras)
Desde que recibió los materiales ¿ha llevado a cabo alguna de las siguientes ACTIVIDAD
Pegar los carteles en las instalaciones de su empresa Comentar con otro personal de su empresa sobre la Compartir los materiales con otro personal de la empresa Difundir por algún medio de comunicación el tema de la Preguntar/investigar a sobre el tema en otras fuentes Por favor, califique los materiales que haya leído. En caso de que haya exhibido o repartido los materiales ¿ha tenido algunos Por favor comente al respecto en este espacio: ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Escriba en el siguiente espacio cualquier comentario que desee hacer. ___________________________________________________________________________ _____________________________________________________________________________

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