Published by the CORE Group, this 23-page case study documents the sustainable activities and interventions of an initiative that was implemented by the Johns Hopkins Bloomberg School of Public Health, Center for Communications Programs (JHU/CCP) through Save the Children/US in Nepal. Valued Behavior for Healthy Families was funded by the United States Agency for International Development (USAID) and carried out in 4 districts by selected Village Development Committees (VDCs) with the District Health Office, the District Public Health Office, and partner non-governmental organisations (NGOs).

Launched in October 2003, the 3-year project aimed to help women and couples from disadvantaged groups in Nepal realise their reproductive intentions through: a) increased knowledge of and interest in family planning services through participatory learning and action/radio listening groups (PLA/RLG); b) improved quality of family planning (FP) services facilitated by community involvement in defining, implementing, and monitoring the quality improvement process (partnership-defined quality (PDQ) approach); c) increased community access to FP services through voluntary surgical contraception (VSC) outreach; and d) improved social and policy environment for FP and reproductive health (RH) services and behaviour through capacity building and the NGO Institutional Capacity Tool (NICAT).

Data on the sustainable activities/practices of the project were collected (one-year post project) from the PLA participants, facilitators, and communities where the project was implemented and analysed in 2008. Field visits to each of the 4 districts and health facilities within each district were conducted, as well as interviews with the partner NGOs, PLA participants, and health workers.

Sustainable activities are defined here as those practices that have been continued or improved after the project ended. Here are some examples from the report:

• Access:
  • The project covered 94% of the marginalised (Dalit, Muslim, and other disadvantaged group) population in the 4 project districts. Working with the support of Muslim Imam and other religious leaders, the project was able to create continued support for the use of FP practices within the Muslim community.
  • A radio health message developed in the local language continued to air in the Banke District with technical support from the United Nations Educational, Scientific and Cultural Organization (UNESCO) Club. A commercial company named Ruchi Noodle adapted the messages and aired on local FM radio complete episodes of the Ministry of Health's FP radio programme (via JHU/CCP), which had been adapted to local languages. The messages were also aired by the National Health Education, Information, and Communication (NHEICC), Ministry of Health and Population (MoHP) nationwide.
• Knowledge:
  A pre- and post-test was conducted among a random selection of 34% of participants from each PLA/RLG centre to assess increases in knowledge of FP. The proportion of participants who could mention at least 3 modern FP methods increased three-fold - from 26% (2003) to 94% (2006).
  • A literacy test, which was conducted at the end of the 7-month course, showed that 99% of the PLA participants could read and write simple words and sentences.
  • A majority of the PLA/RLG facilitators were Female Community Health Volunteers (FCHVs). The PLA/RLG facilitators said that working as a facilitator helped to develop their confidence, which helped them in their roles as FCHVs. Working on the project gave them an in-depth knowledge of village women and non-formal education skills, which helped them succeed in their roles. All participants interviewed were able to name child immunisations and knew the timing of when children should receive them. According to some of the health facility records observed, women who delivered children after the project formally ended showed an increase in the number of antenatal check-ups during their new pregnancies.
• Increased discussion:
  • After completion of the project, some PLA members remained functional as members of mothers groups and some of them organised themselves into income generation groups called "saving/credit groups"; as part of these latter groups, some women share the RH/FP messages with the other women in the village.
  • NGO partners catalysed community participation in all aspects of the project, encouraging family dialogue about family planning through radio listening groups, peer dialogue through literacy groups, and dialogue with health facility staff through Quality Improvement Teams. Community members who participated in the project have taken new leadership jobs where they use these skills (such as the FCHV), and partner NGOs are continuing to utilise these tools and techniques in their ongoing work in communities.
  • All NGOs initially involved in the project continue to regularly participate in the Reproductive Health Coordination Committee meetings at district levels. FP/RH issues, such as preparing for mobile VSC events, are discussed among the stakeholders, who work to solve issues together.
• Attitude shifts:
  • Support for use of FP services among the Muslim community continues to grow.
• Practices:
  • Use of health facilities has increased. The register from the Haripur Sub Health Post indicated that on an average, 30 patients come to the clinic every day for different services and treatment. In May-June 2008, a total of 800 patients were seen by the clinic. Out of 800 clients, 32 women received injectable FP (Depo) services and 31 pregnant women received antenatal care services from the health facility.
  • VSC services provided in the Muslim communities increased in the year following the end of the project. Comprehensive FP and VSC services are well accepted and continue to be available year-round, not only in the winter months. There continue to be requests for expanded VSC services from District Public Health Offices to serve as a complement to their own services.
• Other impacts:
  • BCC tools continue to be used by partner NGOs. For instance, Kirat Yakthung Chumlung (KYC), a local NGO in the Sunsari District, with support from the United Nations Children's Fund (UNICEF), has implemented a Youth Friendly Multipurpose Service Center for youth with HIV/AIDS. Building on the experiences of the Valued Behavior PLA/RLG sessions, KYC developed a radio programme called Naya Goreto (New Path) for youth with HIV/AIDS. As in the Valued Behavior project, KYC formed radio listeners' groups and launched issue discussions after each radio programme.
  • The project improved tracking of FP services provided to marginalised groups by implementing a system that records clients by caste, ethnic, and religious group. The more detailed record keeping is designed to help programmes better understand their impact and outreach to marginalised communities.

One key conclusion was that the PLA/RLG technique proved to be "an effective approach for sustaining community dialogue about family planning and spreading family planning knowledge. Through family dialogue and peer support, discussion around family planning issues continues in these marginalized communities, along with overall improved health care seeking behavior. Facilitation skills and health knowledge learned through this program have been used by Female Community Health Workers in their day-to-day work in other community programs, like the mother group meetings. Local NGOs have also been able to adapt the approach in other health and education programs. The Partnership Defined Quality (PDQ) approach continues to be used by selected health facilities to improve the quality of health and family planning services....The capacity of local NGOs, built through the project, continues to be utilized by other donors to deliver a broad set of health and education services. The Reproductive Health Coordination Committee platform continues to be utilized as a forum for district government officers and NGOs to share ideas and concerns and plan together."

CORE Group listserv, March 20 2009.