pathfinder international
authors: Elizabeth Oliveras,
Caroline Nalwoga, Lucy Shillingi
Addressing Unmet Need for
Contraception among HIV-Positive Women:
Endline Survey Results and Comparison
with the Baseline
Foreign Affairs, Trade and
Development Canada
Affaires étrangères, Commerce
et Développement Canada
ARISE
Enhancing HIV prevention for at-risk populations
Addressing Unmet Need for
Contraception among HIV-positive
Women
Endline Survey Results and Comparison
with the Baseline
Elizabeth Oliveras, Caroline Nalwoga, and
Lucy Shillingi
Submitted by
Pathfinder International
9 Galen Street
Watertown, MA 02472
Phone: (617) 924-7200
Fax: (617) 924-3833
Submitted to
PATH
April 2014
*Correspondence to: Margaret Waithaka, [email protected]
Pathfinder Research and Evaluation Working Paper Series
The purpose of the Working Paper Series is to disseminate work in progress by Pathfinder International
staff on critical issues of population, reproductive health, and development.
Unless otherwise indicated, working papers may be quoted and cited without permission of the author(s),
provided the source is clearly referenced as a working paper. Full responsibility for the content of the paper
remains with the author(s). Comments from readers are welcomed and should be sent directly to the
corresponding author.
Published by Pathfinder International. Copyright by the author(s). ©2014.
Pathfinder International
Pathfinder International places reproductive health services at the center of our work around the world,
providing women, men, and adolescents access to a range of quality health services—from contraception
and maternal care to the prevention and care of sexually transmitted infections. Pathfinder strives to halt
the spread of HIV and AIDS, strengthen access to family planning, advocate for sound reproductive health
policies, and, through all of our work, improve the rights and lives of the people we serve.
Pathfinder International/Headquarters
9 Galen Street, Suite 217
Watertown, MA 02472 USA
Tel: 617-924-7200
Fax: 617-924-3833
www.pathfinder.org
Acknowledgements
This study was conducted under Arise—Enhancing HIV Prevention for At-Risk-Populations. Arise
implements innovative HIV prevention initiatives for vulnerable communities with a focus on
determining cost-effectiveness through rigorous evaluations.
Many thanks to the dedicated team of interviewers and the women who participated in the
surveys, NACWOLA Project Officers, and the Pathfinder International Uganda Team, as well as to
Frederick Makumbi, Makerere University School of Public Health, for his assistance with the two
surveys. Thanks also to Pathfinder Research and Metrics staff, Patricia David and Margaret
Waithaka, who provided extensive comments on earlier drafts of this report, and Emma Morse,
who finalized the text and formatted the report.
Table of Contents
Table of Figures .......................................................................................................................................................................... 1
Abbreviations ............................................................................................................................................................................. 3
Executive Summary .................................................................................................................................................................. 4
Section 1. Background .............................................................................................................................................................. 6
Integrating Family Planning into HIV Services ............................................................................................................. 6
Project Background .............................................................................................................................................................. 6
Survey Methodology ........................................................................................................................................................... 9
Response Rates ................................................................................................................................................................... 10
Section 2. Results ..................................................................................................................................................................... 11
Respondent Characteristics.............................................................................................................................................. 11
Use of HIV Services ........................................................................................................................................................... 18
Integration of Family Planning with HIV Services...................................................................................................... 21
Contraceptive Use............................................................................................................................................................. 26
Dual Method Use .............................................................................................................................................................. 30
HIV Risk Behaviors at Last Sex ....................................................................................................................................... 31
Unmet Need for Family Planning ...................................................................................................................................33
Effect of Exposures on Outcomes ................................................................................................................................. 39
Section 3. Discussion and Conclusions ............................................................................................................................ 44
References ............................................................................................................................................................................... 46
Appendix A: Endline Survey Questionnaire .................................................................................................................... 49
Appendix B: Survey Team Members ................................................................................................................................. 61
Appendix C: IATT Tool for assessing unmet need for family planning among women living with HIV......... 62
Table of Figures
Table 1. Percent distribution of women 15–49 by selected background characteristics, baseline and endline
surveys ....................................................................................................................................................................................... 12
Figure 1. Comparison of timing of last sex at baseline and endline ............................................................................ 13
Table 2. Comparison of reported timing of last sexual activity, baseline and endline surveys .......................... 13
Table 3. Timing of last sex by characteristics of the respondents, endline survey ................................................14
Table 4. Percent distribution of women who ever gave birth at endline, by age and cumulative frequency . 15
Table 5. Percent distribution of women, by number of living children, among women who ever gave birth, at
endline ........................................................................................................................................................................................16
Table 6. Percent distribution of currently married women age 15–49 years by desire for children, according
to number of living children, endline survey .................................................................................................................... 17
Table 7. Desire for children among women aged 15-49 years, baseline and endline surveys ........................... 17
Table 8. Months since HIV diagnosis by district of residence, at baseline and endline.......................................18
Figure 2. Time in treatment, comparison of baseline and endline .............................................................................18
Table 9. Duration of receipt of care or treatment at endline, by characteristic .....................................................19
Table 10. HIV services currently recevied among women receiving any treatment, comparison of baseline
and endline ................................................................................................................................................................................19
Table 11. HIV services currently received among women receiving any treatment at endline, by
characteristic ...........................................................................................................................................................................20
Table 12. Participation in support groups and receipt of FP information at endline, by characteristic ............ 21
Figure 3. Use of ANC at last pregnancy, among births in the past 2 years, comparison of baseline and
endline surveys........................................................................................................................................................................ 22
Table 13. Distribution of ANC utilization at last pregnancy, Among births in the 2 years before endline, by
characteristic ........................................................................................................................................................................... 22
Table 14. HIV testing during last pregnancy, among women with a birth in the past 2 years, comparison of
baseline and endline .............................................................................................................................................................. 23
Figure 4. Percent of women with a birth in the past 2 years receiving recommended information during
antenatal care, comparison of baseline and endline ..................................................................................................... 23
Table 15. Information received by women pregnant in the past 2 years, by characteristic, at endline ........... 24
Figure 5. Experience of integrated services among FP users and women recieving care and support,
comparison of baseline and endline .................................................................................................................................. 25
Table 16. Experience of integrated services, among FP users and women receiving care and support, by
characteristic at endline ....................................................................................................................................................... 25
Figure 6. Current contraceptive use among women living with HIV, comparison of baseline and endline ... 26
Table 17. Percent distribution of current use of contraception among women, endline ..................................... 27
Arise: endline survey results and baseline comparison | 1
Table 18. Source of contraception among contraceptive users, comparison of baseline and endline ............ 28
Table 19. Source of contraception, among current users of modern methods at endline .................................. 28
Table 20. Percent of modern contraceptive users experiencing integration, endline ......................................... 29
Table 21. Percent distribution of contraception decision making, by FP use, at endline ..................................... 29
Figure 7. Partner knowledge of FP use by marital status, among women using contraception, comparison of
baseline and endline .............................................................................................................................................................. 30
Table 22. Percent distribution of partner knowledge and discussion of FP use, by marital status, among
current contraceptive users at endline ............................................................................................................................. 30
Table 23. Percent distribution of dual method use, by characteristic, among current modern contraceptive
users and all women, endline ............................................................................................................................................... 31
Figure 8. Condom use at last sex among women who reported sex in the past year, comparison of baseline
and endline ............................................................................................................................................................................... 32
Table 24. Condom use at last sex and having had a non-regular partner in the past year at endline, by
characteristic ........................................................................................................................................................................... 32
Table 25. Confidence in future condom use at endline, by characteristic .............................................................. 33
Figure 9. Need for family planning calculated using the modified-survey appraoch, comparison of baseline
and endline ............................................................................................................................................................................... 34
Table 26. Need for family planning calculated using the standard household survey approach, among
women who have ever had sex, by background characteristic, endline .................................................................. 35
Table 27. Unmet need calculated using the IATT approach ...................................................................................... 36
Figure 10. Partner counseling and testing, comparison of baseline and endline ................................................... 37
Table 28. Partner counseling and testing at endline, by characteristic, among women who are married or
living with a partner ............................................................................................................................................................... 38
Table 29. Partner’s HIV status at endline, by characteristic, among women who are married or living with a
partner ....................................................................................................................................................................................... 38
Figure 11. Exposure to Arise interventions among women attending ART or pre-ART services ...................... 39
Table 30. Exposure to Arise project interventions by backround characteristics .............................................. 40
Table 31. Odds of contraceptive use by key exposures at endline .............................................................................41
Table 32. Odds of having demand for family planning by key exposures at endline ........................................... 42
Table 33. Odds of having unmet need for contraception by key exposures at endline ....................................... 43
2 | Pathfinder international
Abbreviations
ANC
Antenatal care
CI
Confidence interval
CPR
Contraceptive prevalence rate
FP
Family planning
HBC
Home based care
HIV
Human immune-deficiency virus
IQR
Interquartile range
NACWOLA
National Community of Women Living with HIV/AIDS
OI
Opportunistic infections
PEPFAR
President’s Emergency Plan for AIDS Relief
PLHIV
Persons living with HIV
PMTCT
Prevention of mother to child transmission
SD
Standard deviation
VCT
Voluntary counseling and testing
Arise: endline survey results and baseline comparison | 3
Executive Summary
A facility-based endline survey was conducted as part of a program evaluation to assess the Arise—
Enhancing HIV Prevention for At-Risk-Populations project in Uganda. Arise is integrating family planning
services into HIV services in 11 districts in Northern and Eastern Uganda. The project, funded by the
Foreign Affairs, Trade and Development Canada (DFATD) through the Arise project, was designed to
address the high unmet need for family planning that had been reported in past studies in Uganda, in order
to prevent HIV infections by ensuring that HIV-positive women do not have unintended pregnancies,
providing counseling to women who do become pregnant about how to limit transmission to their babies,
and by encouraging partner counseling and testing and dual method use to prevent infections in uninfected
partners of women infected with HIV.
The baseline and endline surveys used the same approach, interviewing women aged 15–49 years who
sought HIV care and treatment at a sample of health facilities covered by Arise. The baseline survey was
conducted in October 2011 and included 1,221 respondents; the endline survey was conducted in March
2013 and included 1,231 respondents. For each survey, four districts were randomly selected from among
the eight districts covered by the research arm of the project. Three districts were included in both surveys
while one of the districts changed. Within those districts, a sample of facilities was selected using
probability proportional to client volume. Thirteen facilities were included in the baseline survey and
seventeen in the endline survey. Both surveys used the same instrument to collect data on respondent’s
characteristics, their reproductive history, use of contraceptive methods, marriage and sexual activity,
fertility preferences, and experience of integrated FP and HIV/AIDS services. Some minor changes were
made between baseline and endline to capture additional information on some key topics. The surveys
were conducted by Pathfinder International in collaboration with the National Community of Women
Living with HIV/AIDS (NACWOLA), a local partner to Pathfinder for Arise, and were approved by the
Institutional review boards at PATH and Makerere University.
Overall, the results of the surveys suggest a positive change in terms of services received and in the key
outcomes of the project, namely use of family planning by women living with HIV. With regard to services,
while the percent of survey respondents who received counseling on FP did not change (81%), the
proportion given information on special considerations for women with HIV increased from 93.6% to
99.1% and the proportion that had discussed their desire for children with their provider increased from
75.8% to 80.5%. This suggests that while coverage may not have changed, the quality of the counseling
provided did improve. Improvements were also seen in coverage of pregnant women living with HIV. The
percent of PMTCT clients who received postpartum follow-up visits that include FP counseling increased
from 51.0% to 72.4%. This is substantial improvement, but over one quarter of pregnant women did not
receive information in the postpartum period. This finding suggests that this is an area for further
improvement.
Most importantly, the key project outcomes improved. The modern method contraceptive prevalence rate
(CPR) among women living with HIV increased from 38.4% at baseline to 54.2% at endline, a change of
15.8%. At the same time, unmet need for family planning declined significantly from 17.0% at baseline to
14.8% at endline, despite a significant increase in overall demand for family planning (from 56.1% to
67.9%). In addition to use of family planning, dual method use also improved, increasing from 44% to
51.8%.
Male involvement, which was also an important focus for Arise has improved in some areas but not others.
In particular, the proportion of clients whose partners had been tested for HIV was unchanged but the
percentage of women who knew their partners status increased slightly from 76.3% to 81.3%. Thus male
involvement is another area where further improvements are possible.
In summary, the comparison of the findings from the baseline and endline surveys suggest that the Arise
project successfully contributed to increasing demand for and use of family planning by women living with
HIV in northern Uganda. The Arise project cannot take full credit for the changes that were seen, given that
4 | Pathfinder international
the Government of Uganda and other projects have also been implementing integration of services.
However, despite the project’s short time frame, when these survey findings are viewed alongside the
project monitoring data that show the large number of women who were provided with counselling and/ or
family planning services through Arise, it is reasonable to conclude that the project did contribute to these
changes. The findings support the importance of integrating family planning into HIV services so that
women living with HIV can make informed choices about whether or not to have children and can use
appropriate methods to delay or limit births if they do not wish to have more children.
Key Messages




Women who received information from a community support group were more likely to
use contraception than those who had not received information in this way, highlighting
the importance of linking facility interventions to community-based ones.
At endline, the percentage of women who received information about family planning
during antenatal care and postpartum increased, but fewer women reported receiving
information during the postpartum period than during pregnancy. This suggests a
continuing gap in service provision, despite substantial improvement over the two years
of project intervention.
Dual method use increased from baseline, but was no more common among women in
discordant couples than in concordant positive couples, and partner testing did not
significantly increase. HIV positive women still practiced risky sexual behaviors, as
evidenced by only half who were sexually active reporting using a condom at last sex.
These findings suggest that efforts to increase male involvement need to be more
vigorous, in order to increase disclosure and enhance condom use.
Concerted efforts to improve access to family planning information and services for
women living with HIV by integrating them into other services can increase
contraceptive use, and as a result prevent unintended pregnancies and new HIV
infections.
Arise: endline survey results and baseline comparison | 5
Section 1. Background
Integrating Family Planning into HIV Services
Integration of family planning (FP) and HIV services has been widely promoted as an effective approach to
ensuring the reproductive rights of persons living with HIV (PLHIV) and to preventing HIV infections by
preventing unintended pregnancies (Wilcher and Cates 2009; Guttmacher Institute and UNAIDS 2006).
From a rights perspective, integrated services provide a means of ensuring that HIV-positive women are
able to safely pursue their reproductive intentions whether they wish to become pregnant or to avoid
pregnancy. In the case of HIV-positive women who are pregnant or wish to become pregnant, integrated
services can help a woman to reduce risks of transmission to her baby. That HIV-positive women have a
range of reproductive intentions is well documented (Chen 2001, Cooper 2007, Homsy 2009, Nakayiwa
2006, Peltzer 2008, Stanwood 2007). For example, studies in Uganda show that around 7% of women
wish to become pregnant in the future but among those who do not wish to become pregnant, many are
practicing behaviors that put them at risk for pregnancy and use of contraceptives is uncommon (Homsy
et al 2009; Nakayiwa 2006). Beyond the immediate benefit to women, integrated services may provide
additional benefits in terms of addressing overlapping health needs (e.g., for STI treatment as well as FP)
and in reducing stigma for clients seeking services (Ringheim et al 2009).
In terms of HIV prevention, integrated FP and HIV services have long been one of the key elements of
strategies to prevent mother-to-child HIV transmission (PMTCT) (WHO 2003) and this is reiterated in a
new strategy document for 2010–2015 (WHO 2010). Particular importance is given to MTCT because it is
a leading mode of HIV transmission worldwide, accounting for 430,000 new infections in 2008 (Joint UN
Programme 2009). Integration is seen as an important means for preventing HIV infections by enabling
HIV-positive women to prevent or delay pregnancies through improved access to and availability of
contraception (WHO 2006).
The impact of FP/HIV integration has been explored in a number of studies in multiple countries and the
results are generally positive (Spaulding 2009). Efforts to model the impact suggest that FP contributes
“as much or more than ARV-PMTCT in mitigating pediatric HIV” (Hladik 2009, Sweat 2004). However,
the evidence base is limited. Most of the available studies did not employ rigorous designs and the range of
outcomes assessed is limited and no studies have looked at HIV incidence or unintended pregnancy
(Spaulding 2009). Rather, studies have looked at uptake of HIV testing, condom use, contraceptive use,
quality of services and cost. Of those studies that reported on contraceptive use, the results were not
consistent; 2 studies reported positive effects while two reported mixed effects (Spaulding 2009). In
addition, because of the various types of integration possible (e.g., family planning integrated into VCT,
HIV VCT provided to family planning clients), the evidence on any given approach is based on a handful of
studies at most. Thus, while integration is the recommended standard of care, the evidence base for this
recommendation could be stronger.
Finally, one of the reasons most cited for such integration is the potential cost effectiveness of integrated
services although this is largely based on logic rather than evidence. Reynolds et al (2006) estimated the
cost per infection averted by FP to be $663 compared to a cost of $857 per infection averted by a singledose nevirapine regimen. More recently, Reynolds et al (2008) estimated the cost savings from adding
contraception to HIV services in countries with funding from the Presidents Emergency Plan for AIDS
Relief (PEPFAR). They report that preventing unwanted pregnancies among HIV-positive women would
lead to annual savings of between $26,000 and $2.2 million, depending on the country. However, both of
the above studies provide model-based estimates and costing data from actual interventions would
provide stronger evidence for the cost-effectiveness of integrating services.
Project Background
Pathfinder International, Uganda is working with health facilities and a community group, the National
Community of Women Living with HIV/AIDS (NACWOLA) to integrate family planning into HIV services
6 | Pathfinder international
in eleven districts in northern Uganda. The project, Arise, began in 2011 and builds on identified bestpractices, providing counseling as well as service provision, bolstering commodity supply, and including a
community-based component. Integration of HIV into family planning services is the standard of care per
Ugandan government policy, but it has not been fully implemented in all areas, particularly in the project
areas. Pathfinder’s approach aims to ensure that HIV-positive women are supported in their decision
making around childbearing and fertility intentions regardless of whether they would like to stop or delay
having children or would like to have a child. The intervention also includes couple counseling, which can
support the use of family planning by HIV-positive women.
The program is being implemented in Northern Uganda, a post-conflict, underserved area where FP is
currently not offered in PMTCT or ART services, and where FP availability is limited to the general
population. The intervention is being implemented in 11 districts (technically located in the north and
eastern regions): Kaberamaido, Amolatar, Dokolo, Lira, Apac, Katakwi, Amuria, Oyam, Gulu, Pader and
Amuru which have a total population of approximately 3.6 million people. According to the national AIDS
Indicator Survey, adult HIV prevalence among women in the north central region1 is 9.0% while it is 3.6%
in the north eastern region (MOH and ORC Macro 2006). 85% of the population in the eleven districts
covered by this project lives in the higher prevalence north central region and given the proximity of these
districts to one another, the degree of variation is likely to be less than the national figures suggest. In
terms of CPR for modern methods, it is 23.4 in the northern region where HIV prevalence is higher, and
23.2 in the eastern region (Uganda Bureau of Statistics 2012).
HIV and AIDS services are provided through the local government as well as through several partners
including the Northern Uganda Malaria, AIDS and TB Project, which supports PMTCT in 5 of the 8
proposed project districts. Other organizations provide PMTCT services in hospitals and level III and IV
health centres. These include Protecting Families against AIDS and Canadian Physicians for Aid and Relief;
and ART programs such as the TREAT project and The AIDS Support Organization. Additional
organizations provide community-level services including NACWOLA, AIDS Information Centre, Network
of HIV-positive People, Uganda Young Positives, and district local governments.
After over 20 years of conflict, Northern Uganda falls behind the nation as a whole on a range of socioeconomic indicators and continues to suffer the effects of the prolonged conflict. In parts of the region,
90% of the population (a total of close to 2 million people), were displaced, many for long periods of time.
A 2007 survey of displaced and returned populations showed limited access to health services, markets,
and secondary schools, especially among people who had returned from camps (UNDP 2007). The region
as a whole suffers from high levels of poverty, low literacy and high school dropout, and few employment
opportunities. A recent report by the Uganda Bureau of Statistics showed that most Ugandans in absolute
poverty (31% of the national population) live in the northern and eastern parts of the country. Over 40% of
females aged 15–35 are illiterate and 19% of them have never attended school (Annan 2008). Most
employment in the region is subsistence agriculture and small trading although there has been a
substantial investment in micro-credit.
Women in Northern Uganda are particularly likely to face sexual and reproductive health challenges in the
aftermath of two decades of violent conflict and internal displacement. Gender norms limit women’s ability
to earn independent incomes making them dependent on their spouses and families and leading to
prostitution. High levels of sexual and gender-based violence lead to poor health. According the
Demographic and Health Survey 2012 (UBOS 2012) in Northern Uganda, only 23.9% of women aged 15 to
49 were using a form of contraception; unmet need is estimated to be 42.5% (UDHS 2012). One of the
most common reasons women give for not using contraceptives is fear of disapproval by their husbands.
Women in post conflict northern Uganda are further denied services due to distance, inability to pay for
services, inability to make individual decisions on when to seek health services, and denial of access to
services by their male partners or other decision makers in the family.
1
The AIDS Indicator Survey 2006 used regions that were delineated for the survey; they are not consistent with the
9 districts used in the DHS 2006 or with the four administrative regions.
Arise: endline survey results and baseline comparison | 7
Education levels are low for women in northern Uganda. 22.7% of women have not had any formal
education and 48.8% are illiterate (UBOS 2012). Young women aged 15–19 are not employed, early
marriage is common, and polygamy, as in most rural communities in Uganda, is still practiced. Married
women in such unions do not make decisions for themselves and consent is usually sought from husbands.
In the UDHS 2006, 78% of married women reported that they did not make independent health care
decisions. Likewise, while 15% of women in northern Uganda earn more than their husbands or partners,
only 36% of women in this region make independent decisions on their earnings.
Women with HIV may also face stigma in their homes and communities if their HIV-positive status is
known. Unfortunately, the documentation of stigma in Uganda is weak but one study suggests that PLHIV
can become socially disenfranchised, with community members unwilling to interact with them. An HIV
diagnosis can also have serious financial implications if the person infected with HIV is engaged in
business, and can limit participation in politics (Muyinda et al 1997). However, the article was published in
1997 and even then noted some lessening of stigma as people’s awareness of HIV increased. In other
countries, the availability of ARV has also been linked to a decline in stigma (Wolfe et al 2009). So while
there is the potential for stigma to affect women who are HIV-positive, the extent to which this is possible
and the potential ramifications are difficult to determine. Discussion with NACWOLA suggests that there
is stigma. However this is one of the issues that is addressed seriously with their members because it
affects access to services. The Executive Director reported reduced or lack of stigma among NACWOLA
members as a result of the work of the community mobilizers during awareness and education activities.
Survey Objectives
The overall program evaluation aims to answer two key questions about integration of FP into HIV service
delivery:


Does improved availability of quality FP counseling and services to HIV-positive women reduce
unmet need for contraception among this group?
Does increased emphasis on couple counseling and testing, and on male involvement among
PMTCT and ART clients result in increased use of contraception, particularly dual method use?
The research objectives related to the surveys are:
1.
Determine whether the contraceptive prevalence rate (CPR) among HIV-positive women changes
following integration of FP into HIV service delivery
2. Determine whether levels of dual method use change among HIV-positive women and their
partners following integration of FP into HIV service delivery
Three key outcomes were assessed in the evaluation and measured through the baseline and endline
surveys:
 The contraceptive prevalence rate (CPR) among HIV-positive women. This will provide a direct
measure of the effectiveness of this intervention in increasing use of contraception among HIVpositive women, which should lead to a reduction in fertility among HIV-positive women and a
decrease in the number of HIV-positive children.
 Dual method use. This will provide a measure of the effect of the program in increasing preventive
behavior among discordant couples.
 Unmet need for contraception. This is a more direct measure of the impact of the intervention,
which aims to decrease unmet need.
Secondary outcomes included: the percent of program participants who have received counseling on FP,
the percent of PMTCT clients receiving postpartum follow-up visits that include FP counseling, and the
proportion of clients whose partners have had an HIV test.
The full report of results from the baseline survey are reported elsewhere (Oliveras and Makumbi 2013).
This report focuses on results of the endline survey and compares key findings with the baseline, as stated
in the research objectives.
8 | Pathfinder international
Survey Methodology
Survey Design & Sample
Three-stage cluster sampling was used. Four districts were randomly selected: two in the Northern region
and two in the north eastern region. This was in order to ensure that the focus of the data collection was in
the Northern region where the majority of the population covered by the intervention is located. Then all
67 accredited ART and pre-ART service delivery sites in the selected districts were listed. The estimated
number of female clients served by each site was documented through a facility needs assessment and
through available data from facility registers. A sample of 13 facilities was chosen for the baseline and 17
for the endline using systematic sampling with probability proportional to size, using the volume of female
clients served as the measure of size.2 The total target sample size was allocated to facilities proportionate
to client volume (QIQ 2001).
All female clients of the participating HIV services (ART or pre-ART facility services) aged 15-49 years
were eligible to participate. The number of clients interviewed per site varied with the number of clients
served. The number of clients needed per facility was estimated and the number of days required to obtain
that number was calculated (# interviews/# interviews per day). The interviewers were asked to conduct
as many interviews as possible during the allotted number of days, with the interviewer team starting with
the first client who registered for services on a given day and then choosing subsequent women to
interview based on when preceding interviews were completed. In other words, once an interviewer
completed an interview, she invited the next available woman to participate. They continued in this way
over the course of the day. The interviewers were trained and supervised to avoid biased selection of
clients.
Survey Instrument
The survey was conducted using a questionnaire (Annex A) that was developed based on Demographic
and Health Survey and AIDS Indicator Survey tools. The questionnaire was translated into the two local
languages used in the study areas: Ateso and Langi.
Data Collection & Management
All survey tools, including instruments and manuals, were pre-tested and validated prior to training for the
baseline survey. The research staff (Annex B) were trained on the questionnaire, client selection, informed
consent, confidentiality, and interviewing techniques. Training for the baseline included an initial 1-week
training and pilot test and a 2-day refresher training that was held just prior to the start of data collection;
training for the endline survey was a 3-day refresher training because all of the interviewers and
supervisors had participated in the baseline survey. Ethical considerations were stressed and highlighted in
materials development, interviewer training, and field work. All interviews were conducted in a private
setting by same-sex interviewers. Written informed consent was obtained from all participants. The survey
was approved by the Research Ethics Committee at PATH and the Makerere University School of Public
Health Higher Degrees and Research and Ethical Committee. The initial training and pilot testing for the
baseline took place in May 2011 and the baseline data collection was conducted between 28 September
and 11 October 2011; training and data collection for the endline survey were conducted in March 2013.
Data management differed between baseline and endline. For both surveys, questionnaires and consent
forms were collected by the survey supervisors and were transported each day to the Pathfinder office in
2
The number of sites varied because the intervention was never implemented in one district. As a result, that district
(which had a large facility) was removed from the list of eligible facilities for the endline survey.
Arise: endline survey results and baseline comparison | 9
Lira for storage. For the baseline, the completed questionnaires were then packaged and sent to Kampala
for data entry by the study collaborators at Makerere University School of Public health. Data were
entered into EPIDATA capture screens by two well-trained data entry staff. For the endline, the data were
entered the following day into EPI-INFO data capture screens by three trained data entry operators. A
random sample of 5% of the questionnaires were re-entered and checked for consistency so as to make a
decision on 100% double data entry. Inconsistency between the first and second re-entry was below 2%,
and so the 100% double entry was not done as earlier determined by the entry guidelines. Inconsistencies
were reviewed by the data editor and were corrected after comparison to the questionnaire. The electronic
data were then transferred into Stata format for analysis. Both the EPIDATA and Stata data files were
backed up and archived.
Data Analysis
Data analysis was completed in Stata, Release 11, Copyright © 2009 StataCorp LP. Frequencies and means
were calculated for the sample as a whole and for sub-groups as detailed below.
Limitations of the Study
These surveys had some limitations that may affect the results. First, the estimates of unmet need
excluded pregnant women at baseline and thus differ from the calculation commonly reported in surveys
like the DHS and MICS. Second, the findings at baseline may not reflect a true baseline because providers
had already been trained at the time that the baseline was conducted. Other project inputs (i.e., the
community-based interventions, direct support to facilities to encourage integration) had not begun, so
this would likely have had a minimal effect. This potential bias would minimize the differences between
baseline and endline findings so the true effects of the project may have been greater than what is shown
here.
Response Rates
The baseline survey was conducted in 13 facilities and the endline survey was conducted in 17 facilities.
Eight facilities were common to both surveys and clients from these facilities comprised 69.3% of the
endline sample. One large facility, the Lira Regional Referral Hospital comprised 36.2% of respondents in
the baseline and 24.8% of respondents in the endline survey.
In total, 1,238 women were approached for interview at baseline and 1,259 at endline. Of all the women
approached, over 99.7% at baseline and 99.3% at endline completed the interview. At endline, two women
were not eligible, two refused to participate and two did not complete the interview. In all, 1,221 women at
baseline and 1,231 women at endline provided complete information on key background characteristics
(age, marital status and education) and were included in the analysis.
10 | Pathfinder international
Section 2. Results
Respondent Characteristics
Demographic Characteristics
Table 1 summarizes the characteristics of the women who participated in the baseline and endline surveys.
In general, there were few differences between the respondents in the two surveys. The mean age of
respondents at baseline was 33.0 years (95% CI: 32.6, 33.4) while at endline it was 32.7 years (95% CI:
32.3, 33.1). In both the baseline and endline surveys, the majority of the respondents were formally married
or living with a partner in informal union (over 60% at baseline and over 70% at endline, p<0.01), although
the proportion married was 10% higher at endline. At endline, 4.3% of women had never been married.
Notably, 43.6% of women in informal union said that their partner was living elsewhere as did 20.8% of
married women (data not shown); this is an increase relative to the baseline survey. These women may be
at increased risk for exposure to sexually transmitted infections or HIV reinfection if their partners are
having sexual relations outside of their partnership. In both surveys, half of the participants were Catholic,
approximately 40% were Protestant, and less than 10% were Pentecostal, Muslim or another religion.
Approximately one-quarter of women reported never attending school while most of the rest (over 60%)
reported primary schooling only.
Arise: endline survey results and baseline comparison | 11
Table 1. Percent distribution of women 15–49 by selected background characteristics, baseline and
endline surveys
Background characteristics
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Current marital status
Married
Living together
Not living with a partner
District
Amuria
Dokolo
Lira
Oyam
Katakwi
Religion
Catholic
Protestant
Pentacostal
Muslim
Other/None
Missing
Education Level
No education
Lower primary
Upper primary
Secondary or higher
Total
Baseline
(%)
#
Endline
(%)
#
3.0
10.5
19.8
23.3
23.0
13.0
7.4
37
128
242
284
281
159
90
3.1
10.8
22.7
24.2
18.0
14.4
6.8
38
133
279
298
222
177
84
39.1
23.4
37.5
458
477
286
49.6
22.3
28.0
611 0.00*
275
0.41
345 0.00*
8.7
14.7
64.3
12.3
NA
106
180
785
150
NA
44.5
21.5
16.3
NA
17.6
548 0.00*
265 0.00*
201 0.00*
NA
NA
217
NA
49.7
37.4
9.1
3.0
0.6
0.3
607
456
111
36
7
4
48.8
40.3
8.4
1.4
1.1
0.0
601
496
103
17
14
0
0.80
0.18
0.48
0.01*
0.10
281 20.8 256
288
27.9 343
462
35.7 439
190
15.7 193
1,221 100% 1,231
0.17
0.02*
0.28
0.84
23.0
23.6
37.8
15.6
100%
0.88
0.75
0.30
0.48
0.01*
0.38
0.71
*Two-sample comparison of proportions for baseline vs endline
Recent Sexual Activity
Three quarters of the respondents reported that they had been sexually active in the past year (Figure 1);
this is a significantly higher proportion than at the baseline (p<0.01) and significantly fewer women
reported last sex more than 1 year before the survey (22.6% at endline vs 29.3% at baseline, p<0.01). Over
thirty percent had last had sex within the past week, 20% between 1 week and one month ago, and 19%
more than one month ago (Table 2). The proportion of women that reported sex in the past year was
inversely related to age. As expected, women who were not married were least likely to have had sex;
whereas 90% of women who were married or living in informal union reported sex in the past year, only
33% of women not living with a partner did so (Table 3).
12 | Pathfinder international
Figure 1. Comparison of timing of last sex at baseline and endline
75.0 *
80
66.7
70
Percent of clients
60
50
40
29.3
30
22.6 *
20
10
1.0
0.7
*
0
Never
Last year
Baseline
> 1 year
*p<0.05
Endline
Table 2. Comparison of reported timing of last sexual activity, baseline and endline surveys
Baseline
(%)
#
Timing of last sex
Never had sex
Sex in the past week
Sex in the past month
Sex in the past year
Last sex > 1 year ago
Don’t know
Total
1.0
30.6
16.6
19.5
29.3
3.0
100%
Endline
(%)
#
12
0.6
7
374 36.2 445
203 20.0 246
238 18.9 232
358 22.6 278
37
1.8
22
1,221
1,231
p-value*
0.94
0.01
0.04
0.61
<0.01
<0.01
*Two-sample comparison of proportions for baseline vs endline
Arise: endline survey results and baseline comparison | 13
Table 3. Timing of last sex by characteristics of the respondents, endline survey
Background
characteristic
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a
partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not married
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Never
had
sex
<1
week
Timing of last sex
<1
<1
≥1
month
year
year
Baseline Survey
Don’t
know
Sex in
past 12
months
Number
of
women
8.1
2.3
1.7
0.4
0.0
0.6
0.0
32.4
35.9
38.8
32.0
32.4
18.2
12.2
16.2
17.2
18.2
19.4
17.8
9.4
12.2
27.0
28.1
21.9
22.9
16.4
12.6
8.9
10.8
14.1
18.2
22.9
31.3
53.5
60.0
5.4
2.3
1.2
2.5
2.1
5.7
6.7
75.7
81.3
78.9
74.3
66.6
40.3
33.3
37
128
242
284
281
159
90
1.1
0.7
47.2
42.0
23.7
22.0
17.4
26.6
8.6
6.6
2.1
2.1
88.3
90.6
1.1
6.3
5.9
17.3
65.1
4.4
29.5
477
286
458
0.0
1.0
1.5
1.1
1.0
24.2
35.4
32.7
27.9
30.6
14.2
21.7
14.2
18.1
17.3
19.3
22.1
19.0
16.6
19.5
Endline Survey
37.4
28.5
26.0
26.8
29.3
2.5
2.8
3.3
3.2
3.0
60.1
67.7
69.3
69.0
66.8
13.2
0.8
0.0
0.0
0.0
0.6
0.0
18.4
46.6
39.8
39.3
35.6
28.8
21.4
15.8
21.1
19.7
22.8
23.9
15.3
10.7
36.8
19.6
25.1
19.8
16.2
10.7
9.5
13.2
11.3
13.3
16.8
22.1
43.5
53.6
2.6
0.8
2.2
1.3
1.8
1.1
4.8
71.1
87.2
84.6
81.9
75.7
54.8
41.7
38
133
279
298
222
177
84
0.0
0.0
2.0
48.8
44.0
7.5
23.9
25.8
8.4
18.5
20.7
18.0
7.7
8.4
60.3
1.0
1.1
3.8
91.2
90.6
33.9
611
275
345
0.0
0.3
0.9
1.0
0.6
32.8
36.2
38.7
34.7
36.2
18.8
19.2
21.6
19.2
20.0
16.8
19.0
19.4
20.2
18.9
29.3
24.2
17.1
23.3
22.6
2.0
1.2
2.3
1.6
1.8
68.4
74.3
79.7
74.1
75.0
256
343
439
193
1,231
281
288
462
190
1,221
Reproductive History
Understanding the reproductive histories of the respondents is important because it is likely to be related
to their demand for and use of contraception. As shown in Table 4, almost all of the women in both
samples (95%) had given birth (n=1,155 at baseline, n=1,173 at endline). At least 90% of women in each
age group above 15–19 years had given birth before the survey. In all but one age group (25–29 years),
there was no significant difference in the percentage that had given birth at baseline and endline. Although
14 | Pathfinder international
a significantly smaller proportion of women age 25–29 years had given birth at endline, the difference was
small 95.5% vs. 98.6%, p=0.03.
Table 4. Percent distribution of women who ever gave birth at endline, by age and cumulative frequency
Ever Given Birth
Ever Given Birth
(in Age Group)
(Cumulative by Age Group)
Baseline
Endline p-value*
Baseline
Endline
(n=1,221) (n=1,231)
(n=1,221)
(n=1,231)
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Total
*
54.1
89.8
95.5
97.2
96.8
96.9
96.7
94.6
68.4
91.7
98.6
96.3
96.4
96.1
90.5
95.0
0.21
0.60
0.03
0.54
0.80
0.69
0.09
0.66
54.1
81.8
89.9
92.9
94.0
94.4
94.6
68.4
86.6
94.0
94.9
95.3
95.4
95.0
Two-sample comparison of proportions for baseline vs endline
Respondents were asked how many living children they had, in particular about children they had borne.
While women may also have foster children or adopted children, children born to them are more likely to
affect their fertility desires and decisions regarding contraception. Only women who reported ever giving
birth (n=1,155 at baseline and 1,171 at endline) were asked the number of living children. Women who
reported ever giving birth had an average (SD) of 3.8 (2.2) living children at baseline and 3.9 (2.1) children
at endline; half of these children were boys and half of them were girls (Table 5). Over one-third of women
had five or more living children. The proportion of women with three or more living children tended to be
higher among women with primary or no education. Thus the average number of living children decreased
with increasing level of education, from 4.6 children among women with no education to 2.9 children
among women with secondary or higher education at endline.
Arise: endline survey results and baseline comparison | 15
Table 5. Percent distribution of women, by number of living children, among women who ever gave
birth, at endline
Number of Living Children
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women who ever gave
birth
3
4
5+
Baseline Survey
Mean number of living
children
Boys
Girls
Total
Number of
women
0
1
2
30.0
5.2
2.2
0.4
1.8
2.6
6.9
50.0
29.6
15.2
8.3
4.8
5.8
11.5
10.0
34.8
27.7
13.4
9.6
9.7
11.5
10.0
20.9
23.8
19.6
8.8
13.6
8.1
0.0
7.0
16.4
21.4
22.8
15.6
12.6
0.0
2.6
14.7
37.0
52.2
52.6
49.4
0.5
1.0
1.5
2.0
2.2
2.4
2.0
0.5
1.1
1.4
2.0
2.4
2.4
2.2
1.0
2.1
2.9
4.0
4.6
4.8
4.2
20
115
231
276
272
154
87
0.7
2.2
4.4
3.4
2.9
8.5
9.4
10.4
22.7
11.6
13.3
14.5
17.3
24.4
16.8
12.2
16.0
20.7
11.4
16.2
15.9
18.6
18.9
14.8
17.4
49.3
39.3
28.3
23.3
35.1
2.2
2.0
1.7
1.5
1.9
2.2
2.0
1.8
1.4
1.9
4.4
4.0
3.5
2.9
3.8
270
275
434
176
1,155
Endline Survey
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women who ever gave
birth
3.9
4.1
1.8
2.4
1.4
1.8
2.6
57.7
32.0
8.7
5.2
2.8
8.2
4.0
15.4
34.4
21.5
11.9
10.3
5.3
9.2
7.7
17.2
28.0
19.2
14.0
7.7
2.6
7.7
7.4
21.2
28.9
18.2
14.7
17.1
7.7
4.9
18.9
32.4
53.3
62.4
64.5
0.7
1.0
1.6
1.9
2.2
2.5
2.5
1.1
1.0
1.7
2.0
2.5
2.6
2.8
1.8
2.0
3.3
3.9
4.7
5.1
5.3
23
123
278
282
218
165
82
1.2
1.2
2.6
4.6
2.2
4.5
4.8
11.5
23.4
9.9
11.8
11.2
17.9
20.6
15.1
13.4
15.7
20.3
17.1
17.1
17.6
23.3
19.4
15.4
19.6
51.2
43.8
28.2
18.9
36.1
2.3
2.1
1.7
1.3
1.9
2.3
2.3
1.9
1.5
2.0
4.6
4.4
3.6
2.8
3.9
246
331
419
175
1,171
Fertility Desires
Most women (over 63%) in both surveys wanted no more children (Table 6). At endline this increased
with number of living children, from 28% among women with one child to 85% among women with 5 or
more children. Conversely, 20.9% of women with no children wanted a child soon (within the next 2
years) compared to less than 2% of women with 5 or more children. Overall, 23.3% of women wanted to
have another child but wanted to delay the birth of their next child for 2 or more years. Thus, 87% of all
women surveyed wished to either limit or space their births. The proportion of women who wanted to have
another child did not differ between the two surveys although the proportion that wanted to have another
child soon was lower (4.0% vs 7.4%, p<0.01) at endline than at baseline , and the proportion that wanted
to have another after 2 or more years was higher (23.6% vs 16.6%, p<0.01) (Table 7).
16 | Pathfinder international
Table 6. Percent distribution of currently married women age 15–49 years by desire for children,
according to number of living children, endline survey
Desire for children
Number
Have
Have
Have another,
Undecided Want no
At
of living
another
another
undecided when
more
marriage
children
soon*
later**
0
20.9
32.6
7.0
11.6
23.3
4.7
1
6.9
54.3
2.6
4.3
27.6
1.7
2
4.5
35.0
1.7
7.9
49.2
0.6
3
2.0
25.0
1.5
9.0
61.5
0.0
4
2.2
19.6
1.3
5.7
70.0
0.0
5+
1.4
9.2
0.2
3.6
84.6
0.2
Total
4.0
23.3
1.5
6.1
63.4
0.7
* Wants next birth within 2 years ** Wants to delay next birth for 2 or more years
Missing
Number of
women 15–
49
0.0
2.6
1.1
1.0
1.3
0.7
1.1
86
116
177
200
230
422
1,231
Table 7. Desire for children among women aged 15-49 years, baseline and endline surveys
Baseline
(%)
#
Endline
(%)
#
Desire for children
Have another soon
7.4
90
4.0
49
Have another later
16.6
203
23.3 287
Have another, undecided when
3.2
39
1.5
19
Undecided
6.1
74
6.1
75
Want no more
63.7
778
63.4 780
At marriage
0.7
9
0.7
8
Missing
2.3
28
1.1
13
Total
100%
1,221 100% 1,231
*
Two-sample comparison of proportions for baseline vs endline
p-value
*
<0.01
<0.01
<0.01
1.00
0.88
1.00
0.02
Time since Diagnosis
Respondents at endline had been diagnosed anywhere from less than one month before the survey to over
25 years before. Ninety five percent had been diagnosed within 10 years of the survey and 99% within 14
years. The mean number of months since diagnosis was 44.9 (standard deviation, SD=35.9) at baseline
and 51.4 (SD=37.7), significantly longer at endline (p<0.01). The median (interquartile range, IQR) was 36
(IQR=24, 60) months at baseline and 48 (IQR=24, 72) months at endline. Although mean time since
diagnosis tended to vary by district of residence, these differences were not statistically significant and the
mean time since diagnosis varied less by district at endline than it did at baseline.
Arise: endline survey results and baseline comparison | 17
Table 8. Months since HIV diagnosis by district of residence, at baseline and endline
Baseline
Months since HIV diagnosis
District
Number
of
women
105
178
775
150
NA
1,208*
Amuria
Dokolo
Lira
Oyam
Katakwi
Total
Mean
SD
Median
50.5
47.3
44.3
41.3
NA
44.9
33.9
41.0
34.2
38.8
NA
35.9
48
36
36
36
NA
36
Inter
quartile
range
24, 72
15, 72
24, 60
12, 60
NA
24, 60
Number
of
women
199
264
542
NA
216
1,221**
Endline
Months since HIV
diagnosis
Mean
SD Median
48.7
51.3
53.0
NA
50.3
51.4
33.5
36.6
40.8
NA
34.5
37.7
48
48
48
NA
48
48
Inter
quartile
range
24, 72
24, 72
24, 72
NA
24, 72
24, 72
pvalue
0.68
0.25
<0.01
NA
NA
<0.01
* 13 women did not provide information on time since diagnosis ** 10 women did not provide information on time since diagnosis
Use of HIV Services
As expected most of the women interviewed (99%) were receiving care or treatment at the time of the
survey. The average duration of treatment at endline was 49 months (versus 39 months at baseline) and
38% of all women had been on treatment for 5 or more years (Table 9). Duration on treatment was
positively associated with age. Women not living with a partner had a substantially longer duration of
treatment than women who were married or living with a man. Significantly more women had been on
treatment for more than 5 years at endline than at baseline (Figure 2).
Figure 2. Time in treatment, comparison of baseline and endline
45
38.1 *
40
Percent of clients
35
30
26.4
25
20
15.6
15
10.4*
14.1
15.0 15.2
15.1
12.4
12.3 *
11.8 11.0
10
5
0
<1 year
1 year
2 years
Baseline
18 | Pathfinder international
3 years
Endline
4 years
5 years
*p<0.05
Table 9. Duration of receipt of care or treatment at endline, by characteristic
Background characteristic
Receiving
care or
treatment
Number
of
women
<1
Time on treatment (years)*
1
2
3
4
5+
Age
15–19
97.4
38 18.9 24.3
20–24
100.0
133 19.6 21.8
25–29
100.0
279 14.7
15.1
30–34
99.3
298 10.1
9.5
35–39
99.6
222
3.6 10.4
40–44
99.4
177
5.1
8.5
45–49
100.0
84
7.1
7.1
Marital status
Married
99.5
611 10.5 14.0
Living together
99.3
275 13.2 11.0
Not living with a partner
100.0
345
7.8 10.7
Education Level
No education
99.2
256
8.7 10.2
Lower primary
99.7
343
9.7 12.0
Upper primary
99.8
439 12.1 14.2
Secondary or higher
99.5
193
9.9 12.0
All women
99.6
1,231 10.4 12.4
* 7 women were missing information on duration on treatment
13.5
21.8
17.9
17.2
14.0
6.8
9.5
5.4
12.0
13.6
15.9
11.8
9.7
6.0
5.4
8.3
11.1
12.5
9.5
13.6
10.7
32.4
16.5
26.2
34.5
49.8
55.1
59.5
16.5
18.0
10.7
14.3
9.9
10.7
11.2
10.6
11.0
33.1
37.0
47.5
13.8
14.6
17.1
13.5
15.2
15.0
11.7
12.1
10.4
12.3
11.0
13.5
11.2
6.3
11.0
40.6
38.0
32.7
46.9
38.0
Number
of
women on
treatment
37
133
279
296
221
176
84
100
608
273
345
100
254
342
438
192
1,226
Almost all women on treatment reported that they were taking cotrimoxazole (Table 10) and this was
consistent across groups (Table 11). In both surveys, fewer women were taking ART than cotrimoxazole
but the percentage taking ART increased from 51.9% at baseline to 59.9% at endline (p<0.01). At endline,
the proportion of women on ART increased from 40.5% among women under age 19 years to over 80%
among women over age 45 years. Women not living with a partner, who were generally older, were more
likely to be on ART. Treatment of opportunistic infections (OI) increased from 44% at baseline to 74.7% at
endline and the percentage of clients receiving home based care (HBC) almost tripled from 11.5% to 31.7%
(p<0.01).
Table 10. HIV services currently recevied among women receiving any treatment, comparison of
baseline and endline
Baseline
(%)
Care and support currently received
Home based care
11.5
Cotrimoxazole
98.6
ART
51.9
Treatment of opportunistic infections
44.0
Total number of women receiving care or support 1,209
*
Two-sample comparison of proportions for baseline vs endline
Endline
(%)
p-value*
31.7
99.2
59.9
74.7
1,226
<0.01
0.16
<0.01
<0.01
Arise: endline survey results and baseline comparison | 19
Table 11. HIV services currently received among women receiving any treatment at endline, by
characteristic
Background characteristic
HBC
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Services received
Cotrimoxazole ART
OI
29.7
36.1
26.9
26.0
33.5
38.1
44.1
100.0
99.3
98.9
99.3
99.1
98.9
100.0
40.5
43.6
48.8
56.4
68.3
78.4
82.1
81.1
69.2
73.8
71.3
75.1
80.1
83.3
31.1
36.3
29.3
99.5
98.2
99.4
55.8
63.0
64.6
76.3
71.4
74.5
30.3
31.0
32.4
33.3
31.7
99.6
98.8
99.1
99.5
99.2
57.9
58.2
58.5
68.8
59.9
67.7
76.9
76.3
76.6
74.7
Number
of
women
37
133
279
296
221
176
84
100
608
273
345
100
254
342
438
192
1,226
The percentage of pregnant women that reported receiving ART to prevent transmission of HIV to their
child was not significantly different at endline than it had been at baseline. At endline, 70.9% of pregnant
women were receiving ART to prevent transmission (data not shown).
The percentage of women currently attending support group meetings increased from just over one
quarter (26.1%) at baseline to 43.1% at endline (Table 12).While older women and married women were
somewhat more likely to attend meetings at baseline, this was less apparent at endline. However in both
surveys, women with secondary or higher education were more likely than women with less education to
attend groups. In both surveys, more women reported receiving information from support groups than
reported attending group meetings; as with participation, the percentage receiving information increased
between the two surveys. While just half of all women reporting receiving information about family
planning from a support group at baseline, 74.3% reported this at endline (p<0.01).
20 | Pathfinder international
Table 12. Participation in support groups and receipt of FP information at endline, by characteristic
Currently attend group
Info on FP from group in
past 6 months
Baseline Endline p-value*
Background characteristic
Baseline Endline p-value*
Age
15–19
21.6
44.7
0.03
59.5
73.7
20–24
19.5
36.8
0.43
48.4
75.2
25–29
26.0
43.4
0.38
47.9
70.3
30–34
24.7
38.3
<0.01
47.2
72.2
35–39
30.0
41.9
<0.01
53.0
77.5
40–44
27.7
50.3
<0.01
49.7
76.8
45–49
34.7
56.0
<0.01
53.3
81.0
Marital status
<0.01
Married
32.3
43.9
<0.01
54.9
76.4
Living together
18.9
42.6
<0.01
43.0
75.6
Not living with a partner
25.8
42.0
<0.01
49.1
69.6
Education Level
<0.01
No education
22.1
40.6
<0.01
46.3
70.3
Lower primary
20.4
38.5
<0.01
48.3
72.3
Upper primary
29.2
45.1
<0.01
53.0
75.4
Secondary or higher
36.8
49.7
0.01
50.5
80.8
All women
26.7
43.1
<0.01
50.0
74.3
*
Two-sample comparison of proportions for baseline vs endline
Number of women
Baseline
Endline
0.19
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
37
128
242
284
281
159
90
38
133
279
298
222
177
84
<0.01
<0.01
<0.01
477
286
458
611
275
345
<0.01
<0.01
<0.01
<0.01
<0.01
281
288
462
190
1,221
256
343
439
193
1,231
Integration of Family Planning with HIV Services
Use of Antenatal Care
At endline, 63% of respondents (n=768) reported that they had their last child within 5 years of the
survey; these women were asked about their use of antenatal care during the pregnancy. Only women with
a birth in the past 2 years (n=353 at baseline and 413 at endline) are included below because this coincides
with the timing of the interventions. Almost all women with a birth in the past 2 years used ANC (Table 13)
and most of them received it from a nurse or midwife or clinical officer (85.0% at baseline and 94.0% at
endline, p-value<0.00; Figure 3). The proportion of women seeking ANC from doctors was notably higher
among women with secondary or higher education at baseline but not at endline, when fewer women
overall used doctors for ANC. At endline almost all women who used ANC (n=410) received services at a
public facility (98.1%).
Arise: endline survey results and baseline comparison | 21
Figure 3. Use of ANC at last pregnancy, among births in the past 2 years, comparison of baseline and
endline surveys
94.0 *
100
85.0
90
Percent of clients
80
70
60
50
40
30
20
10
13.3
4.8
*
0.6
0.5
0
Doctor
Nurse/Midwife
Baseline
None
Endline
*p<0.05
Table 13. Distribution of ANC utilization at last pregnancy, Among births in the 2 years before endline,
by characteristic
Background characteristic
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women who gave birth in the past 2 years
Health Professional
Doctor
Nurse/
Midwife
None
Number of
women
10.5
5.1
4.7
5.6
1.8
4.6
0.0
84.2
92.3
94.6
94.4
96.4
95.5
100.0
0.0
2.6
0.0
0.0
0.0
0.0
0.0
19
78
129
107
55
22
3
4.0
6.2
3.1
8.2
4.8
94.7
93.8
95.1
90.2
94.0
1.3
0.0
0.6
0.0
0.5
75
113
164
61
413
HIV testing and counseling during antenatal care was also assessed. Of women who had a birth in the past
2 years, 88.4% reported that they were offered HIV testing during their pregnancy (Table 14). Among all
women with a pregnancy in the past 2 years, regardless of whether they received ANC, a similar
percentage (87.2%) took an HIV test. Almost all of the women (98.6%) who were tested (n=360)
received their result. No clear pattern in testing was observed by level of education, marital status and age
for HIV testing at either baseline or endline (results not shown).
22 | Pathfinder international
Table 14. HIV testing during last pregnancy, among women with a birth in the past 2 years, comparison
of baseline and endline
Baseline
(%)
79.6
Endline
(%)
88.4
p-value*
Offered HIV test during last pregnancy
<0.01
HIV testing status during last pregnancy**
Tested and received result
81.6
86.0
0.10
Tested but did not receive result
0.9
1.2
0.69
Not tested
16.7
12.8
0.12
Total number of women
353
413
*
Two-sample comparison of proportions for baseline vs endline; ** At baseline, 3 women (0.9)
were missing information on their testing status at last pregnancy.
Provision of Family Planning Information During Pregnancy and PostPartum Care
Women who had been pregnant in the 2 years before the survey were asked about the information they
received at the time of the pregnancy. In particular, they were asked about whether or not they had
received information about HIV services for expectant mothers, about use of family planning after birth
and whether or not they had received information about family planning within the first 6 weeks after the
birth. While most women (95.9%) at endline received information on HIV services for expectant mothers
(Table 15), fewer (90.3%) received information on using family planning after the birth and even fewer
(72.4%) received information about family planning within 6 weeks of the birth. Significantly more women
received each type of information at endline than had at baseline (Figure 4). However, the lower
percentage of women receiving information after the birth suggests a continuing gap in service provision,
despite substantial improvement over the 2 years of project intervention.
Figure 4. Percent of women with a birth in the past 2 years receiving recommended information during
antenatal care, comparison of baseline and endline
95.9
100
90
87.8
*
90.3 *
77.3
80
72.4 *
70
60
51.0
50
40
30
20
10
0
ANC: Information on HIV
services
ANC: Information on FP after Postpartum: Information about
birth
FP
Baseline
Endline
*p<0.01
Arise: endline survey results and baseline comparison | 23
Table 15. Information received by women pregnant in the past 2 years, by characteristic, at endline
Background characteristic
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Received info on
HIV services for
expectant mothers
Received information
on using family
planning after birth
Received information
about family planning
postpartum
Number
of
women
89.5
97.4
94.6
98.1
92.7
100.0
100.0
94.7
89.7
90.7
86.9
90.9
100.0
100.0
73.7
68.0
74.4
68.2
74.6
86.4
100.0
19
78
129
107
55
22
3
94.9
98.0
96.3
91.9
87.8
89.0
72.1
72.5
73.2
233
98
82
90.7
95.6
97.6
98.4
95.9
88.0
89.4
90.9
93.4
90.3
64.0
71.7
76.2
73.8
72.4
75
113
164
61
413
Provision of Family Planning Information During HIV Care and Support Services
Women who were using HIV care and support services at the time of the survey were asked whether or
not they had received integrated services. The majority (81%) had seen an HIV provider who discussed
family planning with them and this was consistent across groups (Table 16). Among these women, almost
all of them (99.1%) had discussed special considerations for use of contraception by women living with
HIV. Specific messages that these women were given included how to reduce risk of transmission from
mother to child (53.1%), the importance of health status before pregnancy (34.4%), and risk of
transmission to the baby (33.0%).
24 | Pathfinder international
Figure 5. Experience of integrated services among FP users and women recieving care and support,
comparison of baseline and endline
100
93.6
90
80
75.8
80.5*
80.8
99.1 *
80.5
70
60
50
40
30
20
10
0
Discussed desire for children
Discussed use of FP
Baseline
Discussed special
considerations for HIV+
women
Endline
*p<0.01
Table 16. Experience of integrated services, among FP users and women receiving care and support, by
characteristic at endline
Background characteristic
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Discussed
desire for
children
Discussed
use of FP
Number of
women
receiving
care/support
Discussed
Number
special
of women
considerations who talked about FP
for HIV+
women
73.0
85.0
76.3
84.1
83.3
78.4
75.0
70.3
85.0
76.7
82.8
84.2
80.1
73.8
37
133
279
296
221
176
84
100.0
100.0
99.1
98.4
98.9
99.3
100.0
26
113
214
245
186
141
62
81.7
82.8
76.5
81.9
84.3
75.1
608
273
345
99.4
98.3
99.2
498
230
258
76.8
78.1
84.0
81.8
80.5
77.2
78.1
82.9
83.9
80.5
254
342
438
192
1,226
98.5
98.5
100.0
98.8
99.1
196
267
363
161
987
Arise: endline survey results and baseline comparison | 25
Contraceptive Use
Contraceptive Prevalence
Almost 38.7% of respondents at baseline and over half of all respondents at endline (54.6%, p<0.01)
reported that they were currently doing something to delay or avoid getting pregnant (Figure 6). The most
commonly used methods were injectables (22.6%), implants (18.2%), and male condoms (7.2%); while
these methods were also the most popular methods at baseline, the proportion of women using injectables
and implants increased significantly (injectables from 16.2% to 22.6%, p<0.01; implants from 9.7% to
18.2%, p<0.01). Women who were married or living in union were significantly more likely to report
modern contraceptive use (61%) compared to women not living with a partner (37.1%, p<0.01). Use of
modern contraceptives was positively related to level of education (Table 17).
Figure 6. Current contraceptive use among women living with HIV, comparison of baseline and endline
60
54.6*
54.2 *
Percent of clients
50
40
38.7
38.4
30
20
10
0
Any method
Any modern method
Baseline
26 | Pathfinder international
Endline
*p<0.01
Table 17. Percent distribution of current use of contraception among women, endline
Background
characteristics
Any
method
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a
partner
Education Level
No education
Lower primary
Upper primary
Secondary or
higher
All women
Any
modern
method
Female
sterilization
Intrauterine
device
(IUD)
Implants Injectables
Pill
Condoms
Any
Number
tradi- of women
tional
method
39.5
52.6
56.6
57.1
64.4
48.0
36.9
39.5
52.6
56.6
56.7
64.0
47.5
34.5
0.0
0.0
1.1
1.3
5.9
5.1
7.1
0.0
0.0
1.1
2.4
4.5
4.5
2.4
7.9
15.8
24.4
19.5
17.6
15.8
8.3
18.4
26.3
24.4
24.8
25.2
17.0
9.5
2.6
0.8
1.8
1.0
3.6
1.1
1.2
10.5
9.0
3.9
7.4
7.2
4.0
6.0
0.0
0.0
0.0
0.3
0.5
0.6
2.4
38
133
279
298
222
177
84
61.1
61.8
60.6
61.5
2.3
4.0
3.1
2.6
20.8
17.1
24.7
27.3
1.3
3.6
8.2
6.6
0.5
0.4
611
275
37.4
37.1
2.9
1.2
14.5
15.1
0.9
2.6
0.3
345
49.2
54.8
55.4
48.4
54.5
55.1
3.1
4.7
1.1
3.9
2.3
1.8
20.3
17.5
18.7
17.2
22.7
23.2
1.2
1.8
2.1
2.7
5.3
8.0
0.8
0.3
0.2
256
343
439
59.6
59.1
3.1
2.1
15.5
28.0
1.6
8.8
0.5
193
54.6
54.2
2.8
2.4
18.2
22.6
1.7
6.3
0.4
1,231
Source of Contraception
The majority of modern contraceptive users obtained their method from public sector sources at both
baseline and endline, particularly government hospitals and health centers (Table 18). At baseline, a
smaller proportion of single women (6.3%) used private sector sources than did married women (12.8%)
or women living in informal union (9.6%) (Oliveras and Makumbi 2013). A smaller proportion of women
obtained their contraceptive method from a private sector source at endline than at baseline (5.3% at
endline vs. 9.4% at baseline, p<0.01) (Table 18) and this was true for all methods. This may be due in part
to the fact that the baseline survey included one mission hospital and the endline only included public
sector facilities. However, given that the proportion obtaining each method at a private sector source
declined, it may be that the projects efforts to ensure the provision of contraceptives at the public sector
facilities through outreach services, particularly for long-acting methods, resulted in the change. It is
important to note that Arise partnered with Marie Stopes International, which provides outreach services
at public sector facilities. Thus, the fact that women reported that services were received at a public sector
facility does not necessarily mean that they were provided by a public sector provider.
Arise: endline survey results and baseline comparison | 27
Table 18. Source of contraception among contraceptive users, comparison of baseline and endline
Baseline Endline p-value*
(%)
(%)
Public sector
87.4
94.2
<0.01
Public hospital
22.8
24.0
0.64
Public health center
57.6
66.3
<0.01
Other public
7.0
3.9
0.02
Private sector
9.4
5.3
<0.01
Total number of women
469
667
*
Two-sample comparison of proportions for baseline vs endline
Table 19. Source of contraception, among current users of modern methods at endline
Background
characteristic
Public
sector
Public
hospital
Public
health
center
Age
15–19
86.7
33.3
46.7
20–24
88.6
28.6
54.3
25–29
95.6
26.6
65.8
30–34
91.7
21.3
68.1
35–39
94.4
15.5
73.2
40–44
100.0
28.6
66.7
45–49
100.0
37.9
62.1
Marital status
Married
95.1
23.0
68.7
Living together
92.9
29.0
58.6
Not living with a
93.0
20.3
69.5
partner
Education Level
No education
93.6
19.4
71.0
Lower primary
94.7
18.2
73.3
Upper primary
94.2
25.6
64.5
Secondary or higher
93.9
35.1
53.5
Contraceptive method
Female sterilization
100.0
37.1
60.0
IUD
93.3
33.3
60.0
Implants
96.0
23.2
71.9
Injectables
90.3
19.4
63.3
Pill
100.0
28.6
61.9
Condoms
98.7
32.5
66.2
All women
94.2
24.0
66.3
* 2 women were using the diaphragm and are not shown in the table
Other
public
Private
sector
Missing
Information
Number
of
women
6.7
5.7
3.2
2.4
5.6
4.8
0.0
13.3
10.0
2.5
8.3
5.6
0.0
0.0
0.0
1.4
1.9
0.0
0.0
0.0
0.0
14
69
161
167
140
83
33
3.5
5.3
4.1
7.1
0.8
0.0
370
169
3.1
6.3
0.8
128
3.2
3.2
4.1
5.3
5.7
4.8
5.0
6.1
0.8
0.5
0.8
0.0
124
187
242
114
2.9
0.0
0.9
7.6
9.5
0.0
3.9
0.0
6.7
3.1
9.0
0.0
1.3
5.3
0.0
0.0
0.9
0.7
0.0
0.0
0.6
35
30
224
278
21
77
667
Integration with HIV: Source of Contraception
Among women who were using contraception, 68.7% at baseline and 80.7% at endline (p <0.01) had
received family planning at an HIV service site. However, the survey did not ask whether they received the
method from an HIV provider or from an FP provider. Compared to women who were married or in union, a
smaller proportion of women not living with a partner received contraception from an HIV site and a larger
proportion of women with secondary or higher education received their method at an HIV service site than
did women with lower levels of education (Table 20).
Most of the women (80% at baseline and 87.1% at endline, p <0.01) received the method from a provider
who knew her HIV status. This was not related to age, marital status or educational attainment.
28 | Pathfinder international
Table 20. Percent of modern contraceptive users experiencing integration, endline
Background characteristic
Received
FP provider
Number of
method at an knew her
women
HIV service site HIV status using modern
methods
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
Total
80.0
82.9
82.3
75.7
81.7
83.3
82.8
86.7
88.6
90.5
83.4
86.6
86.9
89.7
15
70
158
170
143
85
31
84.3
76.9
75.0
88.9
85.8
83.6
370
170
129
75.8
81.8
81.8
81.6
80.7
83.9
87.7
87.2
89.5
87.1
126
188
243
115
672
Both women who were and were not using contraception were asked who made the decision about family
planning. Overall, as shown in Table 21, over half of all respondents at endline (54.2%) reported that the
decision to use contraception was a joint decision with her partner. This was a significant increase from
baseline when just 41.9% reported that the decision to use contraception was a joint decision (p<0.01)
(Oliveras and Makumbi 2013). However, in both surveys the person who made the decision about
contraceptive use differed among users and non-users of family planning. Joint decision-making about FP
use was significantly higher at endline among women who were using contraception compared to women
not using contraception (75.2% vs 28.9%, p<0.00). Overall, just 3.0% of women in both surveys reported
that the decision was mainly made by her husband or partner.
Table 21. Percent distribution of contraception decision making, by FP use, at endline
Mainly
Respondent
Mainly
Joint
Other
husband/ Decision
partner
FP user
22.3
2.4
75.2
0.0
Non user
59.6
4.4
28.9
6.4
All women
39.3
3.3
54.2
2.8
*9 women were missing information on contraceptive use
Missing
Information
0.2
0.7
0.4
Number
of
women
672
550
1,231
Among contraceptive users, in most cases, the woman’s partner knew about her use of contraception
(Table 22). However, partner knowledge was most common among married women (92.2%), less
common among women living with a partner (89.4%), and least common among women who were
sexually active but not currently living with a partner (54.7%). Among women who were married and
unmarried women living with their partners, the percentage of women who said their partner knew about
her use of contraception increased between baseline and endline (Figure 7). Over half (56.3%) of all
respondents reported that they had talked about family planning with their partner more than twice in the
past year; this percentage did not change significantly between the baseline and endline survey.
Arise: endline survey results and baseline comparison | 29
Figure 7. Partner knowledge of FP use by marital status, among women using contraception,
comparison of baseline and endline
100.0
90.0
92.2*
89.4*
86.8
76.7
80.0
70.0
59.7
60.0
52.0
50.0
40.0
30.0
20.0
10.0
0.0
Married
Living together
Baseline
Not married
Endline
*p<0.05
Table 22. Percent distribution of partner knowledge and discussion of FP use, by marital status, among
current contraceptive users at endline
Partner
Knows*
Marital status
Married
Living together
Not living with a partner
All women
Frequency of discussion in the past year
Once or
More
Never
Twice
Often
92.2
89.4
59.7
85.3
7.5
10.0
41.1
14.6
28.4
27.7
24.8
27.5
63.8
58.8
31.0
56.3
Number of
women-current
FP users
373
170
129
672
Dual Method Use
Dual method use (use of condoms and another method of contraception) was reported by 44% of
contraceptive users at baseline and 51.8% of women at endline (p <0.01). At endline this was over half of
all contraceptive users; dual method use was most common among married women and those living in
union and among those with secondary or higher education (Table 23). Dual method use was no more
common among women in discordant couples than among women in concordant positive couples (35.1%
vs 34.1%, p=0.85). Among the 348 women who reported dual method use at endline, just 9.5% reported
challenges to dual method use compared to 22.7% at baseline (p <0.01) (data not shown).
30 | Pathfinder international
Table 23. Percent distribution of dual method use, by characteristic, among current modern
contraceptive users and all women, endline
Modern contraceptive users
Dual Condom Contracep- Number
of
method use only tive use
only
women
use
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a
partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
All women
No
Dual Condom ContracepNumber
method use only tive use Method
of
only
women
use
71.4
55.1
46.0
52.4
52.8
58.3
41.7
21.4
15.9
5.0
12.5
9.2
6.0
19.4
7.1
29.0
48.5
34.5
37.3
35.7
38.9
14
69
161
168
142
84
36
27.8
28.6
26.1
30.2
33.0
28.5
16.5
8.3
8.3
2.8
7.2
5.7
2.9
7.7
2.8
15.8
27.5
19.9
23.4
17.4
16.5
61.1
47.4
43.3
42.3
37.4
51.2
59.3
38
133
279
298
222
177
84
53.7
55.3
11.8
10.0
34.0
34.7
374
170
32.8
34.2
7.2
6.2
20.7
21.5
39.0
38.2
611
275
41.5
5.4
52.3
130
15.6
2.0
20.2
61.9
345
50.4
50.0
50.4
59.1
51.8
3.9
8.5
13.5
12.2
10.1
44.1
41.5
36.1
27.8
37.7
127
188
244
115
674
24.9
27.3
28.0
35.2
28.3
2.0
4.7
7.5
7.3
5.5
21.8
23.3
20.0
16.6
20.8
50.6
44.8
44.6
40.4
45.2
256
343
439
193
1,231
HIV Risk Behaviors at Last Sex
Less than half of all women who had sex in the past year reported using a condom at last sex (Table 24).
Condom use was related to educational attainment, with women with secondary or higher education more
likely to have used condoms. Only 4.5% of women who had sex in the year before endline and 3.1% of such
women at baseline reported having more than one partner. This was highest among women not living with
a partner at endline (12.8% vs. 2.8% among women living in union and 1.3% among married women) and
among women with no education.
Arise: endline survey results and baseline comparison | 31
Figure 8. Condom use at last sex among women who reported sex in the past year, comparison of
baseline and endline
60
50.6
50
40
47.2
46.3
46.0
41.0*
38.5
41.9
44.1
30
20
10
0
Married
Living together
Unmarried
Baseline
All women
*p<0.05
Endline
Table 24. Condom use at last sex and having had a non-regular partner in the past year at endline, by
characteristic
Background characteristic
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Condom
use at last sex
Had a
non-regular partner
Number
of women
40.7
41.4
37.7
48.8
47.6
43.3
51.4
3.7
2.6
3.0
4.1
2.4
2.1
5.7
27
116
236
244
168
97
35
46.0
41.0
41.9
1.3
2.8
12.8
557
249
117
40.0
42.8
43.4
53.2
44.1
4.6
1.6
3.7
2.8
3.1
175
255
350
143
923
The respondents were also asked about how confident they felt that they would use a condom next time
they had sex with their regular partner (Table 25). Close to 40% of all respondents in both surveys
reported that they were very confident that they would use condoms. The percentage that said they were
not at all confident they would use condoms increased from 12.2% at baseline (Oliveras and Makumbi
2013) to 18.3% at endline (p<0.00). There were few differences by age, marital status or educational
32 | Pathfinder international
attainment although women not living with a partner were less likely than other women to say that they
were very confident that they would use condoms at next sex.
Table 25. Confidence in future condom use at endline, by characteristic
Background characteristic
Very
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a
partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Confidence
Confident Somewhat
Not
at all
Number
of
women
18.5
38.8
34.3
43.9
38.1
37.1
42.9
55.6
36.2
36.4
27.9
37.5
27.8
22.9
7.4
10.3
9.8
9.8
6.0
13.4
5.7
18.5
13.8
19.1
17.6
18.5
20.6
25.7
27
116
236
244
168
97
35
41.3
39.8
30.0
37.0
9.5
7.2
18.9
15.7
557
249
20.5
42.7
12.8
21.4
117
30.9
34.9
40.0
49.0
38.2
34.3
34.5
33.1
31.5
33.5
7.4
9.8
10.3
8.4
9.3
26.9
20.0
15.7
11.2
18.3
175
255
350
143
923
Unmet Need for Family Planning
Calculating Unmet Need Using the Approach Used in Household Surveys
Per the Demographic and Health Surveys (DHS), “Women who indicate that they either want no more
children (limiters) or want to wait two or more years before having another child (spacers), but are not
using contraception constitute a group that has unmet need for family planning. Women who are currently
using a family planning method are considered to have a met need for family planning. The women with
unmet need and those who are currently using a family planning method form the total demand for family
planning.”3 In the Demographic and Health Surveys and other surveys like the UNICEF Multiple Cluster
Indicator Surveys, unmet need is assessed based on answers to over 15 survey questions. Using data from
the endline survey we calculated unmet need following the household survey approach. However, because
the Arise baseline survey did not include questions about whether or not women who were currently
pregnant wanted to become pregnant at the time that they did, the household survey approach could not
be used for the baseline data. First, therefore, we calculated a modified measure of unmet need that
considered all pregnant women as not having any need for family planning (modified household survey
approach) in order to allow for comparison between the baseline and endline surveys. These results are
shown in Figure 9 only.
When using the modified household survey approach, total unmet need decreased (from 17.0% to 14.8%)
with a significant decline in the unmet need for limiting (12.3% at baseline vs. 9.6% at endline; p<0.01) but
no change in unmet need for spacing (Figure 9). The reduction in total unmet need occurred despite a
significant increase in demand for family planning (from 56.1% to 69.7%) because more of the demand
was met [69.7% at baseline and 82.2% at endline (data not shown)].
3
P.103, Uganda Bureau of Statistics (2007)
Arise: endline survey results and baseline comparison | 33
Figure 9. Need for family planning calculated using the modified-survey approach, comparison of
baseline and endline
80
69.7 *
70
56.1
60
50
41.6 *
40
28.3
30
20
10.9
14.3*
12.3
10
9.6*
4.7 5.2
0
Met need for
spacing
Met need for
limiting
Unmet need for
spacing
Baseline
Endline
Unmet need for
limiting
Total demand for
FP
*p<0.05
Using the endline data, we also calculated an unmodified (standard) measure of unmet need that took into
account desire for pregnancy at the time of a pregnancy, which could not be calculated using the baseline
data (see Table 26). The resulting estimate of 16.1% is higher than the 14.8% from the modified measure.
Although this unmodified measure cannot be compared to the baseline survey results, it is more
comparable to other survey-based estimates of unmet need and is reported here for that reason.
Calculating Unmet Need Using a Clinic-Based Approach
The approach to calculating unmet need from survey data is complicated and is not well suited to
assessing unmet need among individuals in clinical settings. Thus, an alternative tool for assessing unmet
need among women living with HIV was developed by the Interagency Task Team on the Prevention and
Treatment of HIV Infection in Pregnant Women, Mothers and Children (IATT). The tool (Annex C) was
designed to be used in clinic settings as a means to assess levels of unmet need for family planning among
women living with HIV. The Arise project used the tool for assessment and counseling as well as for
monitoring unmet need on an ongoing basis over the course of the project. The IATT tool includes far
fewer questions than standard surveys so the results are not directly comparable. It focuses on three
questions: 1) Are you currently pregnant?, 2) Do you want to become pregnant within the next year4? , and
3) Are you currently using a family planning method? Women who are currently pregnant are asked: At
the time you became pregnant, did you want to become pregnant then? And women who are currently not
using family planning are asked: Can you tell me why you are not using a method? This approach divides
women into three groups, those with no need for family planning, those with met need for family planning,
and those with unmet at need for family planning. It does not distinguish between need for spacing and
need for limiting.
Both estimates of unmet need (standard, unmodified household survey approach and clinic-based
approach) resulted in similar estimates of unmet need. The unmodified household method resulted in
4
The standard survey approach considers women to have a need for spacing if they want to wait more than 2 years to
have a next birth.
34 | Pathfinder international
unmet need of 16.1% (Table 26) while the IATT approach found unmet need of 16.7% (Table 27);
estimates for met need were also similar (54.9% vs. 54.0%).
Relationship between demand for family planning and personal characteristics
When calculated in the standard way for household surveys, the need for family planning at endline
differed with the characteristics of the women (Table 26). Total need for family planning was highest
among those with the lowest levels of education (17.2% among women with no education and 17.7%
among women with lower primary education) and thereafter decreased with increasing education to 15.1%
among women with upper primary and 13.8% among women with at least secondary education. The need
for spacing decreased with age whereas the need for limiting increased with age. Women not living with a
partner had the highest level of unmet need at 21.6%.
Table 26. Need for family planning calculated using the standard household survey approach, among
women who have ever had sex, by background characteristic, endline
Background
characteristic
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a
partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Met need for family
1
planning
For
For
Total
spacing limiting
Unmet need for family
2
planning
For
For
Total
Spacing limiting
Total demand for family
planning
For
For
Total
spacing Limiting
Percent
of
demand
satisfied
Number
of
women
40.0
41.2
25.5
19.9
13.6
7.1
1.2
6.7
9.9
31.3
37.3
50.2
42.3
37.2
46.7
51.1
56.8
57.2
63.8
49.4
38.4
10.0
13.7
8.3
2.4
1.4
1.2
1.2
0.0
7.6
11.9
11.9
12.7
15.5
5.8
10.0
10.0
20.2
14.3
14.1
16.7
7.0
40.0
48.9
37.4
31.7
26.2
22.6
7.0
16.7
23.7
39.6
39.7
51.6
43.5
38.4
56.7
72.5
77.0
71.4
77.8
66.1
45.3
82.4
70.5
73.8
80.1
82.0
74.7
84.8
32
131
273
294
217
174
80
23.5
23.9
37.3 60.8
37.1 61.0
4.8
6.3
8.6
9.2
13.4
15.5
32.1
33.1
42.1
43.4
74.2
76.5
81.9
79.7
604
272
9.2
29.9
39.1
3.4
18.2
21.6
27.4
33.2
60.6
64.5
10.8
19.8
22.1
26.1
19.7
38.8
36.1
32.9
34.0
35.2
49.6
55.9
55.0
60.1
54.9
3.2
5.6
5.7
3.2
4.8
14.0
12.1
9.4
10.6
11.3
17.2
17.7
15.1
13.8
16.1
24.8
32.0
31.5
36.7
31.1
42.0
41.7
38.6
37.2
40.0
66.8
73.7
70.1
73.9
71.0
74.3
75.8
78.5
81.3
77.3
325
250
338
425
188
1,201
Regardless of the calculation method, unmet need was higher among women with less education and
lower among those with higher levels of education. Using the household survey approach it was highest
among women not living with a partner and lowest among married women, whereas using the IATT
approach there was little variation by marital status (Table 27).
Arise: endline survey results and baseline comparison | 35
Table 27. Unmet need calculated using the IATT approach
Background
characteristic
Total
demand for
family
planning
No need for
family
planning
Met need
for family
planning
Unmet need
for family
planning
Percent of
demand
satisfied
Number
of
women
20.0
32.8
24.8
27.2
24.9
35.7
46.5
46.7
51.9
55.8
55.8
62.4
48.2
38.4
33.3
15.3
19.4
17.1
12.7
16.1
15.1
80.0
67.2
75.2
72.8
75.1
64.3
53.5
58.3
77.3
74.2
76.6
83.1
75.0
71.7
30
131
278
287
221
168
86
23.5
23.9
59.6
59.2
16.9
16.9
76.5
76.1
77.9
77.8
604
272
44.3
39.4
16.3
55.7
70.7
325
31.2
28.7
30.1
25.5
29.2
48.4
55.0
54.1
59.6
54.0
20.4
16.3
15.8
14.9
16.7
68.8
71.3
69.9
74.5
70.8
70.3
77.2
77.4
80.0
76.3
250
338
425
188
1,201
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a
partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
Knowledge of Partner’s HIV Testing Behavior and Couple’s Counseling
Women were asked about whether or not they had been counseled with their partners at any time since
their diagnosis. We did not assume that having attended couple’s counseling indicated disclosure or
knowledge of the partner’s status. Two-thirds of women who were married or in union (67%) reported
that their partner had attended HIV counseling with them and this had not changed since baseline (Figure
10). The percentage of women whose partners had attended counseling with them differed with time
since diagnosis (Table 28). It was lowest among women diagnosed within the past year (58.0%) and
highest among those diagnosed 5 or more years before the survey (69.5%). A higher percentage of
married women reported that their partner had attended counseling (71.9 %) than did women living with a
partner (56.4%). Among those whose partners had not attended counseling with them, only about 40%
gave a reason for why their partner had not attended (data not shown). The most commonly reported
reasons were concerns about stigma and discrimination (28.2%), that the partner was in denial (23.5%)
and that the partner was not living in the same location as the woman (19.1%).
Women were also asked whether or not their partner had been tested and if so, if they knew their partner’s
HIV status. Among women who were married or in union, 84.8% reported that their partner had been
tested (unchanged from baseline), 9.7% said that their partner had not been tested, and 4.2% did not
know.
However, simply being tested is not enough; it is more important to learn the result of the test to influence
negotiation of safer sex and to initiate joint decision-making about sexual and reproductive health
behaviors. At endline, just over 80% of all women who were married or in union reported that their partner
had tested for HIV and received the result; although this was a slight increase from baseline (82.4% vs
78.9%) the increase was not significant (p=0.07). As with counseling, partner testing was more
commonly reported by married women (86.8%) than by women living with a partner (72.7%). Over 80%
of women who were married or in union knew their partner’s status, but almost all of them (93.4%)
reported that their partner knew their status. There was a slight increase in the percentage of women that
reported knowing their partner’s status, from 76.3% at baseline to 81.3% at endline (p=0.01).
36 | Pathfinder international
As at baseline, whether or not the woman’s partner knew her status was strongly related to his counseling
and testing behavior. Whereas 70.9% of women whose partner knew her status had been counseled with
her partner, only 10% of those women whose partner did not know her status had been counseled together
(Table 28). These results need to be interpreted with caution due to the small sample of women whose
partners did not know their status (n=30) but these findings reinforce the importance of facilitated
disclosure during couples counseling and testing for both the woman and her partner.
Figure 10. Partner counseling and testing, comparison of baseline and endline
95.2 93.4
100.0
83.0 84.8
90.0
78.9
80.0
70.0
82.4
76.3
81.3 *
67.6 67.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Attended
Partner tested for
counseling with
HIV
husband
Partner tested
and received
result
Baseline
Endline
Woman knows
partner's status
Partner knows
woman's status
* p <0.01
Arise: endline survey results and baseline comparison | 37
Table 28. Partner counseling and testing at endline, by characteristic, among women who are married
or living with a partner
Partner has
attended HIV
counseling
with the
woman*
Partner has
been tested
for HIV
71.9
56.4
88.9
75.6
86.8
72.7
86.1
70.6
95.9
87.6
613
275
58.0
64.8
67.9
68.1
69.5
77.3
75.0
85.5
87.9
88.9
76.1
73.2
82.8
85.6
86.3
71.6
70.4
82.8
85.1
85.4
85.2
92.6
95.6
95.7
92.0
88
108
250
208
226
5
70.9
10.0
67.0
88.6
10.0
84.8
86.1
10.0
82.4
84.9
10.0
81.3
NA
NA
829
30
888
Marital Status
Married
Living with a man
Time since diagnosis
Within past year
1 year
2-3 years
4-5 years
5+ years
Don’t know
Partner knows her status*
Yes
No
Total
Partner
tested and
received
result
Woman
knows
partner’s
status
Partner
knows
woman’s
status*
Number of
women
93.4
*4 women were missing information on whether or not their partner attended counseling with them; 4 women were also missing
information on whether or not their partner knew their status
Over two-thirds of women who were married or in union reported that their partner was positive. Of all
women in union, approximately one in five at baseline (21.9%) and somewhat fewer (17.3%) at endline did
not know their partner’s status (Table 29). At endline, the percentage of women whose partners’ status
was unknown was higher among women living with a partner than among married women (26.6% vs.
13.2%), and higher among women whose partners did not know their status than among women whose
partners knew their status (90% vs. 14.8%). The proportion whose partner’s status was unknown
decreased with time since diagnosis. These same patterns were also seen at baseline.
Table 29. Partner’s HIV status at endline, by characteristic, among women who are married or living
with a partner
Positive
Marital Status
Married
Living with a man
Time since diagnosis*
Within past year
1 year
2-3 years
4-5 years
5+ years
Don’t know
Partner knows her status
Yes
No
Total
Baseline
Negative Unknown
Number of
women
Positive
Endline
Negative Unknown
Number of
women
73.6
57.7
6.7
9.4
16.8
30.4
477
286
77.3
56.4
8.2
13.8
13.2
26.6
613
275
56.3
53.3
74.4
65.4
71.8
100.0
5.8
3.7
6.8
8.9
13.0
0.0
36.9
28.4
16.7
23.4
12.2
0.0
103
109
234
179
131
3
56.8
63.9
73.2
76.9
71.2
100.0
14.8
6.5
8.8
8.2
12.8
0.0
27.3
28.7
16.0
14.4
12.4
0.0
88
108
250
208
226
5
70.8
6.1
67.6
8.0
3.0
7.7
18.7
90.9
21.9
726
33
763
73.9
6.7
70.8
10.4
3.3
9.9
14.8
90.0
17.3
829
30
888
38 | Pathfinder international
Effect of Exposures on Outcomes
Women had the potential to be exposed to project interventions in two ways, through contact with
providers at the participating facilities who talked to the woman about her fertility intentions and through
contact with community support agents in their community. As shown in Figure 11, almost 80% of the
women were exposed through at least one source. More than half of those women (43.3% of all women),
were exposed through both a facility-based provider and a community support agent.
Figure 11. Exposure to Arise interventions among women attending ART or pre-ART services
18.3%
None
43.3%
6.6%
Group only
Facility only
Both
31.7%
Exposure to the Arise interventions varied with the characteristics of the clients (Table 30). A larger
proportion of married women (85.3%) had been exposed to interventions than had either single women
(78.6%) or women living with their partners (80.4%). Women with more education were also somewhat
more likely to have been exposed, with 83% of women with upper primary or more education exposed
compared to 80% of women with lower primary or no education.
Arise: endline survey results and baseline comparison | 39
Table 30. Exposure to Arise project interventions by background characteristics
Type of exposure
Background characteristic
None
Group only: Heard
about FP from an HIV
support group in the
past 6 months
Facility only: HIV
provider talked about
desire for children
Both
Any
exposure
Number
of
women
Age
15–19
20–24
25–29
30–34
35–39
40–44
45–49
Marital status
Married
Living together
Not living with a
partner
Education Level
No education
Lower primary
Upper primary
Secondary or higher
All women
21.6
26.6
19.0
16.6
16.0
15.7
21.1
8.1
4.7
6.6
5.6
6.1
9.4
8.9
18.9
25.0
33.1
36.3
31.0
34.6
25.6
51.4
43.8
41.3
41.6
47.0
40.3
44.4
78.4
73.5
81.0
83.5
84.1
84.3
78.9
36
133
284
291
227
172
91
14.7
19.6
6.3
4.2
30.4
37.4
48.6
38.8
85.3
80.4
613
275
21.4
8.5
29.5
40.6
78.6
346
19.9
20.1
16.7
17.4
18.4
6.4
7.3
6.5
6.3
6.6
33.8
31.6
30.3
32.1
31.7
39.9
41.0
46.5
44.2
43.3
80.1
79.9
83.3
82.6
81.6
257
344
440
193
1,234
To further explore project effects, we looked at whether key outcomes related to exposure to project
interventions using logistic regression. In particular, we looked at whether contraceptive use and unmet
need for family planning were related to having discussed fertility desires with a provider, having heard
about family planning from a support group in the past 6 months, and being exposed via either means (i.e.,
had discussed fertility desires with a health care provider OR from had heard about family planning from a
support group). We also looked at the relationship between these exposures and demand for family
planning. We assessed potential confounders, assessing variables that are theoretically related to the
outcome, and included those in the model that had a p-value of 0.15 or less.
With regard to contraceptive use, women who had discussed their fertility desires with a provider were
40% more likely to be using contraception after adjusting for marital status, education and number of
living children (Table 31). Contraceptive use was also significantly related to educational attainment with
women who had attended upper primary school being 40% more likely to use contraception than those
with no education and women with secondary or higher education being more than twice as likely to use
contraception. Having heard about family planning from an HIV support group had a stronger effect, with
women who did being almost twice as likely (Adjusted OR 1.9, 95% CI: 1.4, 2.5) to be using contraception.
Overall, women who had been exposed to one or both interventions were more than three times (3.3, 1.96
5.6), as likely to be using contraception. In all of these models, there was a slight increase in the odds of
contraceptive use for each additional living child.
40 | Pathfinder international
Table 31. Odds of contraceptive use by key exposures at endline
Un-adjusted Model
Discussed fertility desires with a provider
Adjusted Model
Discussed fertility desires with a provider
Marital status
Married
Living together
Not living with a partner
Education
No education
Lower primary
Upper primary
Secondary or higher
Number of living children
Un-adjusted Model
Heard about FP from an HIV support group
Adjusted Model
Heard about FP from an HIV support group
Marital status
Married
Living together
Unmarried
Education
No education
Lower primary
Upper primary
Secondary or higher
Number of living children
Un-adjusted Model
Talked to a provider about fertility desires or heard about
family planning for an HIV support group or exposed to both
Adjusted Model
Talked to a provider about fertility desires OR heard about
family planning for an HIV support group OR exposed to both
Marital status
Married
Living together
Unmarried
Education
No education
Lower primary
Upper primary
Secondary or higher
Number of living children
OR (95% CI)
p-value
1.4 (1.1, 1.9)
0.02
1.4 (1.0, 1.9)
0.04
1.0
1.1 (0.8, 1.5)
0.4 (0.3,0.5)
0.40
0.00
1.0
1.3 (0.9, 1.8)
1.4 (1.0, 1.9)
2.1 (1.4, 3.2)
1.2 (1.1, 1.2)
0.14
0.05
0.00
0.00
2.1 (1.6, 2.7)
0.00
1.9 (1.4, 2.5)
0.00
1.0
1.1 (0.8, 1.5)
0.4 (0.3, 0.5)
0.45
0.00
1.0
1.3 (0.9, 1.8)
1.4 (1.0, 1.9)
2.0 (1.3, 3.0)
1.1 (1.1, 1.2)
0.12
0.06
0.00
0.00
3.8 (2.2, 6.5)
0.00
3.3 (1.9, 5.6)
0.00
1.0
1.2 (0.9, 1.6)
0.4 (0.3, 0.5)
0.30
0.00
1.0
1.4 (1.0, 1.9)
1.4 (1.0, 1.9)
2.1 (1.4, 3.2)
1.1 (1.1, 1.2)
0.08
0.05
0.00
0.00
A similar pattern was seen in terms of overall demand for family planning (Table 32) although the
relationships were not as strong. Women whom who had talked to a provider were 40% more likely to
have demand for contraception, those who attended support groups were 60% more likely to have
demand, and those who had any exposure (to one or both interventions) were over twice as likely
(adjusted OR 2.3, 95% C.I. 1.5, 3.7) to have demand for contraception.
Arise: endline survey results and baseline comparison | 41
Table 32. Odds of having demand for family planning by key exposures at endline
Un-adjusted Model
Discussed fertility desires with a provider
Adjusted Model
Discussed fertility desires with a provider
Marital status
Married
Living together
Not living with a partner
Education
No education
Lower primary
Upper primary
Secondary or higher
Number of living children
Un-adjusted Model
Heard about FP from an HIV support group
Adjusted Model
Heard about FP from an HIV support group
Marital status
Married
Living together
Not living with a partner
Education
No education
Lower primary
Upper primary
Secondary or higher
Number of living children
Un-adjusted Model
Talked to a provider about fertility desires OR heard about
family planning for an HIV support group OR exposed to both
Adjusted Model
Talked to a provider about fertility desires OR heard about
family planning for an HIV support group OR exposed to both
Marital status
Married
Living together
Not living with a partner
Education
No education
Lower primary
Upper primary
Secondary or higher
Number of living children
OR (95% CI)
p-value
1.5 (1.1, 2.0)
0.02
1.4 (1.1, 2.0)
0.02
1.0
1.2 (0.8, 1.6)
0.7 (0.5, 0.9)
0.37
0.01
1.0
1.4 (1.0, 2.0)
1.3 (1.0, 1.9)
2.3 (1.5, 3.6)
1.1 (1.1, 1.2)
0.04
0.09
0.00
0.00
1.7 (1.3, 2.3)
0.00
1.6 (1.2, 2.1)
0.00
1.0
1.1 (0.8, 1.5)
0.7 (0.5, 0.9)
0.50
0.00
1.0
1.4 (1.0, 2.0)
1.3 (0.9, 1.8)
2.1 (1.4, 3.3)
1.1 (1.1, 1.2)
0.05
0.12
0.00
0.00
2.7 (1.7, 4.2)
0.00
2.3 (1.5, 3.7)
0.00
1.0
1.2 (0.8, 1.6)
0.7 (0.5, 0.9)
0.37
0.01
1.0
1.5 (1.0, 2.1)
1.3 (1.0, 1.9)
2.2 (1.5, 3.5)
1.1 (1.1, 1.2)
0.03
0.09
0.00
0.00
As expected, exposure to project interventions was associated with a decreased likelihood of having unmet
need for contraception (Table 33). Women who talked to a provider were no less likely to have unmet
need compared to those who had not discussed family planning, while those who heard about family
planning from a support group were 60% less likely to have unmet need. After controlling for age, marital
status and number of living children, those who were exposed through either or both sources were 70%
less likely to have unmet need relative to women who had neither discussed family planning with a
provider nor heard about family planning from a support group,. Unlike the other models, inclusion of
education did not affect the relationship between exposure to project interventions and unmet need.
42 | Pathfinder international
Table 33. Odds of having unmet need for contraception by key exposures at endline
Un-adjusted Model
Discussed family planning with a provider
Adjusted Model
Discussed family planning with a provider
Age
Marital status
Married
Living together
Not living with a partner
Number of living children
Un-adjusted Model
Heard about FP from an HIV support group
Adjusted Model
Discussed family planning with a provider
Age
Marital status
Married
Living together
Not living with a partner
Number of living children
Un-adjusted Model
Talked to a provider about fertility desires OR heard about
family planning for an HIV support group OR exposed to both
Adjusted Model
Talked to a provider about fertility desires OR heard about
family planning for an HIV support group OR exposed to both
Age
Marital status
Married
Living together
Not living with a partner
Number of living children
OR (95% CI)
p-value
0.9 (0.6, 1.3)
0.47
0.9 (0.6, 1.4)
1.0 (0.9, 1.0)
0.70
0.02
1.0
1.1 (0.7, 1.6)
2.5 (1.7, 3.6)
1.0 (0.9, 1.1)
0.77
0.00
0.68
0.4 (0.3, 0.5)
0.00
0.4 (0.3, 0.6)
1.0 (0.9, 1.0)
0.00
0.05
1.0
1.1 (0.7, 1.6)
2.4 (1.6, 3.5)
1.0 (0.9, 1.1)
0.77
0.00
0.99
0.2 (0.1, 0.4)
0.00
0.3 (0.1, 0.5)
0.00
1.0 (0.9, 1.0)
0.06
1.0
1.0 (0.7, 1.5)
2.4 (1.7, 3.5)
1.0 (0.9, 1.1)
1.00
0.00
0.89
Arise: endline survey results and baseline comparison | 43
Section 3. Discussion and Conclusions
The respondents at baseline and endline were largely quite similar but they differed with regard to marital
status, timing of last sex and fertility desires. More specifically, a larger proportion of the endline
respondents was married and a smaller proportion was not in union than at baseline. Timing of last sex,
which was related to marital status (p<0.01), also differed. A higher percentage of women at endline
reported sex in the past year and fewer reported last sex more than 1 year before the survey. The
percentage of women who said they wanted to wait 2 or more years before having a child was higher at
endline than at baseline and the percentage that said they wanted to have a child within 2 years decreased.
Finally, the time since diagnosis had increased as had time on treatment, likely because of the elapsed time
between baseline and endline.
In general, exposure to the project interventions increased between baseline and endline. The percentage
of women that had participated in support groups in the past 6 months increased from 26.1% to 43.1% and
the percentage that had received information from a support group increased from 50% to 74%. This is
likely the result of the increased activity by NACWOLA which included both community dialogues and
outreach visits. In addition, the percentage of women with a birth in the past 2 years that had received
antenatal care increased from 85% to 94%. The results highlight the effect of providing information about
family planning through support groups in the community. Women who had received information from a
support group had higher odds of having a demand for family planning and were also more likely to be
using contraception than women who had not received information from a support group. This highlights
the importance of linking interventions in facilities with community based interventions.
The survey results also suggest that service delivery improved in a manner consistent with the project aims
and training. Significantly more women who had a birth in the 2 years before the endline reported receiving
information during and after their pregnancy than women interviewed at baseline. A smaller, but also
significant increase was seen in the content of family planning counseling for ART and pre-ART clients. The
percentage of women who discussed family planning with their provider was unchanged from baseline to
endline, but the percentage of women who had discussed their fertility desires with their HIV provider
increased, as did the percentage that had discussed special considerations for women living with HIV. This
suggests that although the high levels of counseling coverage did not change, the quality of counseling did.
The results also show that women who discuss their fertility desires with a provider are more likely to both
have demand for family planning and use contraception. Reaching the 20% of women who have not yet
discussed their fertility desires with their providers will be important to further increasing use of family
planning by women living with HIV.
In addition, the results suggest better integration of services, given that 80.7% of respondents at endline
said they had received family planning from an HIV site compared to just 69% at baseline. The results do,
however, suggest that women who were married or living with a partner were more likely to receive FP
counseling as part of HIV care and treatment, and so were more likely to benefit from integration. In terms
of contraceptive use, integration of services (a provider discussing family planning) was also related to
contraceptive use.
Most importantly, the survey results show a clear improvement in the outcomes expected from the
project. Contraceptive prevalence increased by 16% and dual method use increased by 8%. Unmet need
for family planning decreased but to a small degree (from 17.0% to 14.8%). As in the baseline, the levels of
unmet need in this survey were substantially lower than in past studies in Uganda and unmet need was
lower than the 34% found in the general population of women of reproductive age (Uganda Bureau of
Statistics and ICF International, 2012). That said, there remains substantial room for improvement in
condom use by women with HIV, given that only 50% of women reported condom use at last sex and the
percentage was lower among women not living with a partner.
Another important finding is that use of contraception is related to who makes the decision about whether
to use contraception; women who were using contraception were more likely to say that they had made
44 | Pathfinder international
the decision about contraceptive use with their partner.
As noted above, the results also suggest some areas for improvement. In particular, the proportion of
women reached with postpartum family planning information was low and could be improved. In Uganda,
just 33% of women receive postnatal care within 2 days of birth (UBOS 2012) but many women take their
babies for well-baby care within the first 6 weeks of birth. These visits provide a way to reach more
postpartum women with information about family planning. In order to address the issue of postpartum FP,
it may be necessary to address the commonly held belief that women who were recently pregnant cannot
become pregnant again soon. It is likely that this belief is found among both community members and
providers. Community groups could also be trained to identify pregnant or postpartum women so that they
can ensure that they receive information during the postpartum period. Services could also be targeted to
more effectively reach women most in need, particularly less educated women and women not living with
a partner, a group that currently lags behind women who are married or living with a man in terms of
access to and use of contraception.
Taken together the improvements in the proportion of clients receiving integrated services either in
facilities or in the community, the improvements in quality of care and the improvement in outcomes
suggest that Arise likely contributed to improved results. It shows that concerted efforts to improve access
to family planning information and services for women living with HIV can increase use of contraception
and, therefore, prevent HIV infections by preventing unintended pregnancies among these women.
Key Messages




Women who received information from a community support group were more likely to
use contraception than those who had not received information in this way, highlighting
the importance of linking facility interventions to community-based ones.
At endline, the percentage of women who received information about family planning
during antenatal care and postpartum increased, but fewer women reported receiving
information during the postpartum period than during pregnancy. This suggests a
continuing gap in service provision, despite substantial improvement over the two years
of project intervention.
Dual method use increased from baseline, but was no more common among women in
discordant couples than in concordant positive couples, and partner testing did not
significantly increase. HIV positive women still practiced risky sexual behaviors, as
evidenced by only half who were sexually active reporting using a condom at last sex.
These findings suggest that efforts to increase male involvement need to be more
vigorous, in order to increase disclosure and enhance condom use.
Concerted efforts to improve access to family planning information and services for
women living with HIV by integrating them into other services can increase
contraceptive use, and as a result prevent unintended pregnancies and new HIV
infections.
Arise: endline survey results and baseline comparison | 45
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48 | Pathfinder international
Appendix A: Endline Survey Questionnaire
Pathfinder International, Uganda
Addressing Unmet Need for Contraception among HIV-Positive
Women
1. IDENTIFICATION
No. QUESTIONS AND FILTERS
CODING CATEGORIES
101
SERVICE DELIVERY SITE OR
CLUB/GROUP (all selected sites will be
coded prior to interview)
102
DISTRICT CODE
103
SUB-COUNTY NAME
104
URBAN/RURAL
105
Interviewer ID
106
RESULT OF INTERVIEW
107
Date of Interview
__________________________
URBAN ....................................... 1
RURAL ........................................ 2
d
Result codes:
1 Completed
2 Refused
SKIP
d
3 Partly completed
m
m
y
y
Y
y
4 Not eligible
Arise: endline survey results and baseline comparison | 49
2. BACKGROUND CHARACTERISTICS
No.
201
QUESTIONS AND FILTERS
RECORD THE START TIME.
USE 24 HOUR CLOCK.
202
In what month and year were you born?
CODING CATEGORIES
SKIP
HOUR.....................................
MINUTES ...............................
MONTH..................
DON’T KNOW MONTH ................ 98
YEAR ......................
DON’T KNOW YEAR ..... ........... 9998
203
How old were you at your last birthday?
AGE IN COMPLETED YEARS
204
Have you ever attended school?
YES ..............................................................1
NO..............................................................2
205
What is the highest level of school you
attended?
LOWER PRIMARY .................................1
UPPER PRIMARY ....................................2
‘O’ LEVEL ..................................................3
‘A’ LEVEL...................................................4
TERTIARY ................................................5
UNIVERSITY ............................................6
TECHNICAL/VOCATIONAL ............7
206
What is your religion?
CATHOLIC ..............................................1
PROTESTANT ........................................2
MUSLIM .....................................................3
PENTECOSTAL ......................................4
SDA ............................................................5
ORTHODOX..........................................6
JEHOVA’S WITNESS .............................7
OTHERS ....................................................8
50 | Pathfinder international
GOTO 206
3. REPRODUCTION
No.
301
QUESTIONS AND FILTERS
Now I would like to ask about all births you
have had during your life. Have you ever
given birth?
302
To how many children have you given birth?
303
Do you have any sons or daughters to whom
you have given birth who are now living with
you?
304
How many sons live with you?
And how many daughters live with you?
CODING CATEGORIES
YES ............................................................. 1
NO ............................................................. 2
MALE
FEMALE
SKIP
GOTO 401
TOTAL
YES ............................................................. 1
NO ............................................................. 2
GOTO 305
SONS AT HOME ................
DAUGHTERS AT HOME .
IF NONE, RECORD ‘00’.
305
306
Do you have any sons or daughters to whom
you have given birth who are alive but do not
live with you?
How many sons are alive but do not live with
you?
YES ............................................................. 1
NO ............................................................. 2
GOTO 307
SONS ELSEWHERE..............
DAUGHTERS ELSEWHERE
How many daughters are alive but do not live
with you?
IF NONE, RECORD ‘00’.
307
In what month and year was your last child
born?
MONTH..................
DON’T KNOW MONTH ................ 98
YEAR ......................
DON’T KNOW YEAR ..... ........... 9998
308
309
Did you ever go for antenatal care during this
pregnancy?
YES ............................................................. 1
NO ........................................................... 2
Whom did you see for antenatal care?
HEALTH PERSONNEL
DOCTOR................................................A
NURSE/MIDWIFE ................................. B
MEDICAL ASSISTANT/ CLINICAL
OFFICER ............................................. C
NURSING AIDE ................................... D
GOTO 312
OTHER PERSON
TRADITIONAL BIRTH
ATTENDANT .................................... E
OTHER(Specify)
__________________________ X
Arise: endline survey results and baseline comparison | 51
No.
QUESTIONS AND FILTERS
310
Where did you receive antenatal care for this
pregnancy?
Anywhere else?
PROBE TO IDENTIFY TYPE(S) OF
SOURCE(S) AND CIRCLE THE
APPROPIRATE CODE(S).
IF UNABLE TO DETERMINE IF A
HOSPITAL, HEALTH CENTER, OR CLINIC
IS PUBLIC OR PRIVATE, WRITE THE NAME
OF THE PLACE.
CODING CATEGORIES
SKIP
PUBLIC SECTOR
GOVT. HOSPITAL ..........................A
GOVT. HEALTH CENTER ........... B
GOVT. HEALTH POST ................ C
OTHER PUBLIC ___________ D
(Specify)
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC ............... E
OTHER PRIVATE MEDICAL
(Specify) __________________ F
OTHER (Specify) _____________ X
(NAME OF PLACE(S))
311
Were you offered an HIV test during the
pregnancy for your last born child?
YES ............................................................ 1
NO ............................................................ 2
312
Did you take an HIV test during the
pregnancy for your last born child?
YES ............................................................ 1
NO ............................................................ 2
GOTO 315
Did you receive your results?
YES ............................................................ 1
NO ............................................................ 2
GOTO 315
314
What was your result?
POSITIVE…………………………..1
NEGATIVE .............................................. 2
DON’T WANT TO TELL ............…..3
315
Did you receive any information during your
pregnancy about HIV services for expectant
mothers?
YES ............................................................ 1
NO ............................................................ 2
316
Did you receive any information during your
pregnancy about using a family planning
method after giving birth?
YES ............................................................ 1
NO ............................................................ 2
317
Within the first 6 weeks after the birth, did a
health provider or community health worker
talk to you about starting a family planning
method?
YES ............................................................ 1
NO ............................................................ 2
318
At the time that you became pregnant with
your last child, did you want to get pregnant
at that time?
YES ............................................................ 1
NO ............................................................ 2
319
Did you want to have a baby later on, or did
you not want any (more) children?
LATER ...................................................... 1
NO MORE .............................................. 2
320
Has your menstrual period returned since
the birth of your last child?
YES ............................................................ 1
NO ............................................................ 2
313
52 | Pathfinder international
GOTO 320
4. CONTRACEPTION
No.
QUESTIONS AND FILTERS
401
Are you currently doing something or
using any method to delay or avoid getting
pregnant?
YES .......................................................................1
NO .......................................................................2
GOTO 403
402
Can you tell me why you are not using a
method?
NOT MARRIED .............................................. A
TRYING TO BECOME PREGNANT ...... B
ALL
GOTO 415
Any other reasons?
CIRCLE ALL MENTIONED.
CODING CATEGORIES
SKIP
FERTILITY-RELATED REASONS
NOT HAVING SEX ....................................... C
INFREQUENT SEX ........................................D
MENOPAUSAL/HYSTERECTOMY ............E
CAN’T GET PREGNANT ............................. F
NOT MENSTRUATED SINCE LAST BIRTH
.............................................................................G
BREASTFEEDING ...........................................H
FATALISTIC ....................................................... I
OPPOSITION TO USE
RESPONDENT OPPOSED ............................ J
HUSBAND/PARTNER OPPOSED ............ K
OTHERS OPPOSED ....................................... L
RELIGIOUS PROHIBITION ....................... M
LACK OF KNOWLEDGE
KNOWS NO METHOD ............................. N
KNOWS NO SOURCE ............................... O
METHOD-RELATED REASONS
DRUG INTERACTIONS ..............................P
HEALTH CONCERNS................................. Q
FEAR OF SIDE EFFECTS .............................. R
LACK OF ACCESS/TOO FAR .................... S
NOT AVAILABLE ......................................... T
COSTS TOO MUCH .................................... U
INCONVENIENT TO USE .......................... V
INTERFERES WITH BODY’S NORMAL
PROCESSES .................................................... W
OTHER (Specify) _________________ X
DON’T KNOW .............................................. Z
403
Which method are you using?
CIRCLE ALL MENTIONED.
404
Current Method. ENTER THE FIRST
METHOD LISTED, NOT THE FIRST
MENTIONED.
FEMALE STERILIZATION............................ A
MALE STERILIZATION ................................ B
IUD ..................................................................... C
IMPLANTS ........................................................D
INJECTIBLES .....................................................E
PILL ..................................................................... F
CONDOM........................................................G
FEMALE CONDOM ......................................H
DIAPHRAGM ..................................................... I
FOAM/JELLY ...................................................... J
LACTATIONAL AMEN.
METHOD ...................................................... K
RHYTHM METHOD ...................................... L
WITHDRAWAL ............................................ M
OTHER (Specify) _________________ X
________________________________
Arise: endline survey results and baseline comparison | 53
No.
QUESTIONS AND FILTERS
405
Since what month and year have you been
using (CURRENT METHOD) without
stopping?
PROBE: For how long have you been
using this method without stopping?
CODING CATEGORIES
MONTH..................
DON’T KNOW MONTH ................ 98
YEAR ......................
DON’T KNOW YEAR ..... ........... 9998
406
LOOK AT Q403. IS THE WOMAN
USING ONLY CONDOMS? DO NOT
ASK HER THIS QUESTION.
YES .......................................................................1
NO .......................................................................2
407
Are you currently using condoms and
another method of family planning?
YES .......................................................................1
NO .......................................................................2
If yes, what is the main reason you are
using both condoms and a FP method?
AVOID INFECTION/TRANMISSION AND
PREVENT PREGNANCY ..............................1
AVOID INFECTION ......................................2
AVOID HIV INFECTION ............................3
PREVENT PREGNANCY ..............................4
PREVENT HIV TRANSMISSION .................5
408
CIRCLE ONLY ONE RESPONSE.
SKIP
GOTO 411
GOTO 411
OTHER (Specify) _________________ 6
DON’T KNOW ...............................................8
409
410
Have you had any challenges/problems
with using both condoms and a FP
method?
YES .......................................................................1
NO .......................................................................2
If yes, what challenges/problems?
CONSISTENT USE DIFFICULT ..................1
OPPOSITION FROM PARTNER ................2
CONDOMS ARE SOMETIMES
UNAVAILABLE ................................................3
OTHER (Specify) _________________ 6
411
Last time you or your partner obtained
the method you are currently using,
where did you get it?
IF UNABLE TO DETERMINE IF
HOSPITAL, HEALTH CENTER OR
CLINIC IS PUBLIC OR PRIVATE
MEDICAL, WRITE THE NAME OF THE
PLACE.
(NAME OF PLACE)
PUBLIC SECTOR
GOVT. HOSPITAL ....................................... 11
GOVT. HEALTH CENTER ........................ 12
FAMILY PLANNING CLINIC ................... 13
OUTREACH .................................................. 14
GOVT COMMUNITY BASED
DISTRIBUTOR .......................................... 15
OTHER PUBLIC (Specify)
_________ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPTIAL/CLINIC ................... 21
PHARMACY/DRUG SHOP ....................... 22
PRIVATE DOCTOR/NURSE/MIDWIFE 23
OUTREACH .................................................. 24
NGO COMMUNITY BASED
DISTRIBUTOR .......................................... 25
OTHER PRIVATE
MEDICAL (Specify) ______________ 26
OTHER SOURCE
SHOP................................................................ 31
RELIGIOUS INSTITUTION ....................... 32
FRIEND/RELATIVE....................................... 33
OTHER (Specify)............................................ 96
412
Was this an HIV service point?
54 | Pathfinder international
YES .......................................................................1
NO .......................................................................2
GOTO 411
No.
413
QUESTIONS AND FILTERS
Did the provider who gave you the
method know your HIV status?
CODING CATEGORIES
SKIP
YES .......................................................................1
NO .......................................................................2
PROBE: Did you disclose your HIV status?
414
Does your husband/partner know that
you are using a method of family planning?
YES .......................................................................1
NO .......................................................................2
DON’T KNOW ...............................................8
415
Does your husband/partner support you
in using method of family planning?
YES .......................................................................1
NO .......................................................................2
DON’T KNOW ...............................................8
416
Would you say that the decision about
whether or not to use contraception was
mainly your decision, mainly your
husband’s/partner’s decision, or did you
both decide together?
MAINLY RESPONDENT ...............................1
MAINLY HUSBAND/PARTNER .................2
JOINT DECISION ...........................................3
417
How often have you talked with your
husband/partner about Family Planning in
the past year?
NEVER ................................................................1
ONCE OR TWICE .........................................2
MORE OFTEN..................................................3
418
Have you ever used anything or tried in
any way to delay or avoid getting
pregnant?
YES .......................................................................1
NO .......................................................................2
OTHER (Specify) _________________ 6
5. CURRENT PREGNANCY
No.
QUESTIONS AND FILTERS
CODING CATEGORIES
501
Are you pregnant now?
YES....................................................................... 1
NO ..................................................................... 2
UNSURE ........................................................... 8
502
Do you think you are physically able to
get pregnant at this time?
YES........................................................................ 1
NO ...................................................................... 2
UNSURE ........................................................... 8
503
Were you using anything or trying in any
way to delay or avoid getting pregnant at
the time that you became pregnant?
YES........................................................................ 1
NO ..................................................................... 2
504
Are you currently receiving ART to
prevent transmission of HIV to your child?
YES....................................................................... 1
NO ..................................................................... 2
UNSURE ........................................................... 8
505
When you got pregnant, did you want to
get pregnant at that time?
YES....................................................................... 1
NO ..................................................................... 2
506
Did you want to have a baby later on or
did you not want any (more) children?
LATER ................................................................ 1
NO MORE ........................................................ 2
507
After the birth of the child you are
expecting now, would you like to have
another child or would you prefer not to
have any more children?
HAVE (A/ANOTHER) CHILD .................... 1
NO MORE/NONE ......................................... 2
UNDERCIDED/DON’T KNOW .............. 8
SKIP
GOTO 503
ALL
WOMEN
GOTO 601
GOTO 507
GOTO 701
GOTO 701
Arise: endline survey results and baseline comparison | 55
No.
508
QUESTIONS AND FILTERS
After the birth of the child you are
expecting now, how long would you like
to wait before the birth of another child?
CODING CATEGORIES
MONTHS ................................... 1
YEARS ......................................... 2
SOON/NOW...............................................993
AFTER MARRIAGE.....................................995
OTHER (Specify) ________________ 996
DON’T KNOW ..........................................998
SKIP
ALL
WOMEN
GOTO 701
ALL
WOMEN
GOTO 701
6. FERTILITY PREFERENCES (ONLY FOR NON-PREGNANT WOMEN)
No.
QUESTIONS AND FILTERS
601
Now I have some questions about the
future. Would you like to have (a/another)
child, or would you prefer not to have any
(MORE) children?
602
How long would you like to wait from
now before the birth of (a/another) child?
CODING CATEGORIES
HAVE (A/ANOTHER) CHILD ......................1
NO MORE/NONE ...........................................2
UNDECIDED/DON’T KNOW....................8
SKIP
GOTO 701
GOTO 701
MONTHS .................................... 1
YEARS .......................................... 2
SOON/NOW ............................................... 993
AFTER MARRIAGE ..................................... 994
OTHER (Specify) ________________996
DON’T KNOW........................................... 998
7. MARRIAGE AND SEXUAL ACTIVITY
No.
QUESTIONS AND FILTERS
CODING CATEGORIES
701
Are you currently married or living
together with a man as if married?
YES, CURRENLTY MARRIED ......................1
YES, LIVING WITH A MAN ........................2
NO, NOT IN UNION ...................................3
702
Have you ever been married or lived
together with a man as if married?
YES, FORMERLY MARRIED .........................1
YES, LIVED WITH A MAN ...........................2
NO .......................................................................3
703
What is your marital status now: are you
widowed, divorced, or separated?
WIDOWED ......................................................1
DIVORCED .......................................................2
SEPARATED ......................................................3
704
Is your husband/partner living with you
now or is he staying elsewhere?
LIVING HERE....................................................1
STAYING ELSEWHERE .................................2
705
Now I would like to ask you about your
(first) (husband/partner). In what month
and year did you start living with him?
SKIP
GOTO 704
GOTO 704
GOTO 714
GOTO 714
ALL
GOTO 714
MONTH..................
DON’T KNOW MONTH ................ 98
YEAR ......................
DON’T KNOW YEAR ..... ........... 9998
706
Has your husband/partner attended HIV
counselling with you since your diagnosis?
56 | Pathfinder international
YES .......................................................................1
NO .......................................................................2
GOTO 708
No.
QUESTIONS AND FILTERS
CODING CATEGORIES
SKIP
707
If not, why not?
NEGATIVE .........................................................1
STIGMA/DISCLOSURE CONCERNS .......2
LIVING ELSEWHERE......................................3
TOO BUSY ........................................................4
DENIAL ..............................................................5
OTHER (Specify) _________________ 9
708
Does your husband/partner know your
HIV status?
YES .......................................................................1
NO .......................................................................2
709
Has your husband/partner ever tested for
HIV?
YES .......................................................................1
NO .......................................................................2
DON’T KNOW ...............................................8
GOTO 714
GOTO 714
710
Do you know if he received the results of
his last test?
YES .......................................................................1
NO .......................................................................2
DON’T KNOW/REMEMBER .......................8
GOTO 714
GOTO 714
Do you know your husband/partner’s HIV
status?
YES .......................................................................1
NO .......................................................................2
GOTO 714
712
What is your husband/partner’s HIV status?
HIV-POSITIVE ...................................................1
HIV NEGATIVE ................................................2
DO NOT WANT TO TELL.........................3
713
Did your husband/partner tell you of his
HIV-test results?
YES .......................................................................1
NO .......................................................................2
714
When was the last time you had sexual
intercourse?
NEVER HAD SEX ....................................... 990
DO NOT WANT TO TELL.................... 997
DON’T REMEMBER................................... 998
711
IF LESS THAN 12 MONTHS, ANSWER
MUST BE RECORDED IN DAYS, WEEKS
OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE,
ANSWER MUST BE RECORDED IN
YEARS.
GOTO 801
GOTO 801
GOTO 801
DAYS AGO ............................. 1
WEEKS AGO .......................... 2
MONTHS AGO ..................... 3
YEARS AGO............................ 4
715
The last time you had sexual intercourse
was a condom used?
YES .......................................................................1
NO .......................................................................2
716
What is your relationship to the man with
whom you last had sexual intercourse?
HUSBAND.........................................................1
COHABITING PARTNER ............................2
BOYFRIEND .....................................................3
CASUAL ACQUAINTANCE .......................4
GOTO 801
OTHER (Specify) _________________ 6
Have you had sex with any other man in
the last 6 months?
YES .......................................................................1
NO .......................................................................2
718
The last time you had sexual intercourse
with this other man, was a condom used?
YES .......................................................................1
NO .......................................................................2
719
What is your relationship to this man?
HUSBAND.........................................................1
COHABITING PARTNER ............................2
BOYFRIEND .....................................................3
CASUAL ACQUAINTANCE .......................4
717
GOTO 722
OTHER (Specify) _________________ 6
720
Other than these two men, have you had
sex with any other man in the last 6
months?
YES .......................................................................1
NO .......................................................................2
GOTO 722
Arise: endline survey results and baseline comparison | 57
No.
QUESTIONS AND FILTERS
721
In total, with how many different men have
you had sex in the last 6 months?
CODING CATEGORIES
NUMBER OF PARTNERS
722
How confident do you feel that you will
use a condom next time you have sex with
your spouse/cohabitating
partner/boyfriend?
VERY CONFIDENT ........................................1
CONFIDENT ....................................................2
SOMEWHAT CONFIDENT ........................3
NOT CONFIDENT AT ALL ........................4
723
If you have sex in the future with someone
who is not your spouse/cohabitating
partner/boyfriend:
WILL NOT HAVE SEX WITH A PERSON
WHO IS NOT A SPOUSE/ COHABITATING PARTNER/BOYFRIEND
.......................................................................0
VERY CONFIDENT ........................................1
CONFIDENT ....................................................2
SOMEWHAT CONFIDENT ........................3
NOT CONFIDENT AT ALL .......................4
How confident do you feel that you will
use a condom next time you have sex with
a man who is not your spouse/cohabitating
partner/boyfriend?
SKIP
8. FP/HIV INTEGRATED SERVICES
No.
QUESTIONS AND FILTERS
801
How long ago did you find out that you are
HIV-positive?
IF LESS THAN 12 MONTHS, RECORD
ANSWER IN MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE,
RECORD ANSWER IN YEARS.
802
803
Do you currently attend meetings or
receive services from an HIV support
group/club or network?
How long have you been a member of the
group/club/network?
IF LESS THAN 12 MONTHS, RECORD
ANSWER IN MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE,
RECORD ANSWER IN YEARS.
CODING CATEGORIES
MONTHS ..................................... 1
YEARS............................................ 2
DON’T REMEMBER ..............888
YES ........................................................................... 1
NO ........................................................................... 2
GOTO 804
MONTHS ..................................... 1
YEARS............................................ 2
DON’T REMEMBER ..............888
804
Have you ever received information about
family planning through an HIV support
group/club/network?
YES ........................................................................... 1
NO ........................................................................... 2
DON’T REMEMBER ............................................ 8
805
In the last 6 months have you heard
anything about family planning from an HIV
support group/club/network?
YES ........................................................................... 1
NO ........................................................................... 2
DON’T REMEMBER ............................................ 8
806
Are you currently receiving care or
treatment for HIV?
YES ...................................................................... 1
NO ...................................................................... 2
58 | Pathfinder international
SKIP
GOTO 813
No.
807
808
QUESTIONS AND FILTERS
What services are you receiving?
How long have you been receiving any
form of care or treatment services?
IF LESS THAN 12 MONTHS, RECORD
ANSWER IN MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE,
RECORD ANSWER IN YEARS.
809
When receiving HIV care or treatment, has
a provider talked with you about whether
or not you would like to have (more)
children?
CODING CATEGORIES
a) ARVs TO PREVENT
MTCT
c) HOME-BASED CARE
d) COTRIMOXAZOLE
e) ART
f) TREATMENT OF
OPPORTUNISTIC
INFECTIONS
x) OTHER _____________
(Specify)
SKIP
Yes
1
No
2
1
1
1
1
2
2
2
2
1
2
MONTHS ..................................... 1
YEARS............................................ 2
DON’T REMEMBER ..............888
YES ...................................................................... 1
NO ...................................................................... 2
DON’T REMEMBER ....................................... 8
GOTO 813
GOTO 813
PROBE: Did s/he talk with you about
whether you wanted to become pregnant?
810
What did the provider tell you to consider
about getting pregnant as a woman living
with HIV?
RISK OF HIV AND STI TRANSMISSION
TO PARTNER .......................................... A
RISK OF TRANSMISSION TO BABY ....... B
HEALTH STATUS BEFORE PREGNANCY
......................................................................C
HOW TO REDUCE RISK OF
TRANSMISSION TO PARTNER ....... D
HOW TO REDUCE RISK OF MOTHERTO-CHILD TRANSMISSION .............. E
OTHER (Specify) _________________ X
811
When receiving HIV care or treatment, has
a provider talked with you about use of
family planning?
YES ...................................................................... 1
NO ...................................................................... 2
DON’T REMEMBER ....................................... 8
812
Did the provider talk with you about
special considerations for using a
contraceptive method when receiving HIV
care or treatment?
YES ...................................................................... 1
NO ...................................................................... 2
DON’T REMEMBER ....................................... 8
813
Can women with HIV safely use family
planning?
YES ...................................................................... 1
NO ...................................................................... 2
DON’T REMEMBER ....................................... 8
GOTO 813
GOTO 813
GOTO 815
GOTO 815
Arise: endline survey results and baseline comparison | 59
No.
814
QUESTIONS AND FILTERS
What family planning methods can a
woman with HIV use?
PROBE FOR EACH METHOD LISTED
(e.g., ASK: Can an HIV-positive woman use
female sterilization? Can the partner of an
HIV-positive use male sterilization?)
815
RECORD THE END TIME.
USE 24 HOUR CLOCK.
60 | Pathfinder international
CODING CATEGORIES
FEMALE STERILIZATION ............................ A
IUD...................................................................... B
IMPLANTS ........................................................C
INJECTIBLES ................................................... D
PILL .................................................................... E
CONDOM .........................................................F
FEMALE CONDOM ..................................... G
DIAPHRAGM .................................................. H
FOAM/JELLY ......................................................I
LACTATIONAL AMEN.
METHOD ........................................................J
RHYTHM METHOD...................................... K
WITHDRAWAL...............................................L
OTHER (Specify) _________________ X
HOUR ....................................
MINUTES...............................
SKIP
Appendix B: Survey Team Members
Survey Logistics Manager
Stella Ekatan Ajore
Project Reproductive Health officer
Florence Naiga
Pathfinder International Country Director
Lucy Shilingi
Survey Advisor
Elizabeth Oliveras
Project M&E Specialist
Caroline Nalwoga Ssekikubo
Data Analysis and Report Writing
Elizabeth Oliveras
Review and Review
Frederick Makumbi, Makerere University School of Public Health
NACWOLA Project Officers
Martina Starace – Regional Manager
Onang Geoffrey – PO Lango
Inyokoit Betty – PO Teso
FIELD STAFF
Field Supervisors
Agnes Akello
Francis Ojara
Interviewers
Kia Ketty
Akao Ursula
Akello Betty Irene
Adongo Hellen Keller
Angom Mildren Rose
Lapyen Margaret Juliet
Adong Jane Margaret
Apiyo Milly
Auma Dessuretter
Apiny Florence
Imalingat Veronica
Igung Betty Anselah
Alungat Stella Rose
Data Entry Officers
Suzan Aneno
Sylvia Kyomuhendo
Carol Ogwang
Arise: endline survey results and baseline comparison | 61
Appendix C: IATT Tool for assessing unmet need for family planning among women living with HIV
Core indicator 10: Unmet need for family planning (Note: This indicator is being field-tested.)
Percentage of women of reproductive age attending HIV care and treatment services with unmet need for family
planning
What it measures
Unmet need for family planning among women of reproductive age (15–49 years) living
with HIV who are attending care and treatment services. It provides information on
whether women living with HIV have the opportunity to control their fertility if and when
they want to, thereby preventing unintended pregnancies.
Rationale
Preventing unintended pregnancies in women living with HIV is a critical step towards
reducing mother-to-child transmission and is a core component of the international
standards for a comprehensive approach to prevention of mother-to-child transmission
of HIV.
All women, irrespective of HIV status, need services that can help them make informed
reproductive decisions and provide them with contraceptive options, if and when they
are desired. By enabling women living with HIV to prevent or delay pregnancy, access
1
to these services could avert HIV infection in infants.
Numerator
Number of women of reproductive age living with HIV and attending HIV care and
treatment services who have an unmet need for family planning at the time of the
assessment and number of women who are pregnant and whose pregnancies were
unwanted or mistimed
Women with an unmet need for family planning are defined as all fecund, sexually
2
active women who do not want to become pregnant in the next year but are not using
any family planning method. Also included are pregnant women whose pregnancies
were unintended or mistimed (at the time of the assessment).
Denominator
Total number of women of reproductive age (15–49) living with HIV who are attending
HIV care and treatment
Epidemic type
All
Frequency
Annual
How to measure and
measurement tools
The information should be collected at HIV care and treatment sites. To calculate the
indicator, information is needed about women’s fecundity, sexual activity, pregnancy
status, pregnancy intentions and current contraceptive use. Such information can be
collected from the answers to a series of questions that lead to one of three
assessments: “No need for family planning”, “Unmet need for family planning” or “Met
need for family planning”.
Pregnancy status
1. Are you pregnant?
(a) Yes → question 2
(b) No → question 3
Pregnancy intention/assessment of needs
2. At the time you became pregnant, did you want to become pregnant then?
(a) Yes → classify as “No need for family planning” → end of questioning
(b) No → classify as “Unmet need for family planning” → end of questioning
3. Would you like to have a/another child or would you prefer not to have any (more)
children?
62 | Pathfinder international
(a) Have a (another) child → may have need → question 4
(b) No more/none → need → question 5
(c) Can’t get pregnant (infecund) → classify as “No need for family planning” →
end of questioning
(d) Undecided → Need → question 5
4. How long would you like to wait from now before becoming pregnant with a/another
child?
(a) More than 1 year → question 5
(b) Less than 1 year → classify as “No need for family planning” → end of
questioning
(c) Can’t get pregnant (infecund) → classify as “No need for family planning” →
end of questioning
(d) Other → need unclear → question 5
(e) Do not know → need → question 5
Family planning use
5. Are you doing something or using any method to delay or avoid getting pregnant?
(a) Yes → classify as “Met need” → question 6
(b) No → question 7
6. Which method(s) are you using? (Do not read response categories; classify woman’s
3
response(s) as one of the following.)
(a) Female sterilization
(b) Male sterilization
(c) Pill
(d) Intrauterine contraceptive device
(e) Injectables
(f)
Implants
(g) Condom
(h) Female condom
(i)
Diaphragm
(j)
Foam/jelly
(k) Lactational amenorrhoea method
(l)
Rhythm method
(m) Withdrawal
(n) Other
Go to end
7. If you are not using a family planning method but want to delay or prevent a future
pregnancy, can you tell me why are you not using a method? (Do not read response
categories, classify women’s responses as one of the following.)
(a) Cannot get pregnant → classify as “No need for family planning”
(b) Menopausal → classify as “No need for family planning”
(c) Has had hysterectomy → classify as “No need for family planning”
(d) No sex → classify as “No need for family planning”
(e) Other response → classify as “Unmet need for family planning”
This indicator can be measured by routine data collection or patient exit interviews. If
using exit interviews, unmet need for family planning should be monitored in a sample
of nationally representative facilities representative once a year and, where possible, in
an integrated manner with other, similar data collection. Standardized, systematic
sampling procedures should be used in establishing the sampling frame. Aggregated
Arise: endline survey results and baseline comparison | 63
national figures should be reported annually.
If using routine data, individual outcomes can be summarized in patient registers or
charts, and summary information can be tallied and aggregated to measure the
indicator. One should establish, however, the feasibility of capturing information from
the answers to the above questions during clinical care, while following
recommendations for good quality sexual and reproductive health counselling.
Strengths and
weaknesses
This indicator provides critical information for countries on both the unmet need for
family planning among women living with HIV and the extent to which their family
planning needs are addressed. This will show whether the integration and provision of
family-planning services for women living with HIV as part of HIV care and treatment
should be strengthened.
As the indicator is measured in women attending HIV care and treatment only, it does
not capture unmet need among women whose HIV status is unknown and among those
who are not known to providers of HIV care and treatment.
Family planning needs can also be assessed at other sites, such as clinics for HIV
testing and counselling or antenatal care. It is impractical, however, to include
information from these sites, owing to the risk for double-counting and because women
attending these sites are more likely to have known about their HIV infection only
recently. In addition, most women accessing antenatal care and testing and counselling
who are HIV infected will not necessarily receive long-term follow-up at these antenatal
care and testing and counselling sites. As more women living with HIV are enrolled in
long-term care and treatment programmes, collecting the information for this indicator
at care and treatment facilities will cover a larger proportion of the women targeted by
the indicator.
While this indicator is partly derived from demographic and health surveys, the modified
questions do not directly assess sexual activity and fecundity. These can be estimated
indirectly, however, from the responses to relevant questions.
Please note: This indicator is being field-tested. The recommendations for use of this
indicator may change after pilot testing and implementation in the field. Despite the lack
of extensive testing, it is included as a core indicator because of the need to expand
family planning to prevent mother-to-child transmission of HIV.
Additional
considerations for
countries
Some countries with a high prevalence of HIV have incorporated biomarkers, including
HIV-test status, into demographic and health and other population-based surveys.
Demographic and health surveys also measure unmet need for family planning. The
indicator in this guide could be interpreted with the data from these population-based
surveys, although the populations being surveyed are not comparable. In countries that
have added biomarker measures for HIV, unmet need for family planning among
women testing positive in demographic and health surveys can be analysed, but one
cannot determine whether the HIV status was known. As demographic and health
surveys are conducted every 3–5 years, the period between measurements is not
sufficient for programme monitoring.
The figures for unmet need in some settings might appear low because there is a low
demand for family planning, partly because larger families are desired and partly
because of limited information on the availability of family planning methods and
services. High unmet need emerges when family planning services and supplies cannot
keep up with the demand. The reasons for unmet need should, therefore, be examined
in specific analyses to address both low demand (if due to insufficient information about
family planning) and high demand by enhancing supply.
When measuring this indicator, countries may wish to conduct periodic assessments at
other service delivery points, as HIV-positive women might have received services at
associated family planning units.
While this indicator measures fertility intentions and unmet need for family planning
specifically, countries may wish to track uptake and acceptance of family planning
methods among women living with HIV through services for the prevention of motherto-child transmission of HIV, care, treatment and other services.
IATT FP – Screening Tool
64 | Pathfinder international
This tool is intended to be incorporated into the facility based patient file/chart in HIV care and treatment programs.
Women of reproductive age (15-49 years) will be surveyed regarding pregnancy intentions and their need for family
planning. Based on responses to questions posed, conclusion can be drawn. The information in the conclusion box
would then be transferred into pre-ART and/or ART registers for monthly aggregation purposes.
PATIENT ID:
Date of visit:
(DD/MM/YY):
1. Are you currently
pregnant?
2. Do you want to
become pregnant within
the next year?
 Yes  At the time you
became pregnant, did you
want to become pregnant
then?
Yes  MET FP NEED
 Yes  No FP Need
 Yes  NO FP NEED
Action: Counsel on
PMTCT and tick “No
FP Need” in Column 4
Action: Counsel
regarding safe
pregnancy and tick “No
FP Need” in Column 4
 No FP NEED
 No UNMET FP
NEED
Action: go to Question
#3
Action: Counsel on
FP and tick “Unmet FP
Need” in Column 4
 No 
Action: go to Question
#2
3. Are you currently using a
family planning method?
 Don’t know 
Action: go to Question
#3
4. Conclusion:
 No FP Need
Action: Tick “Met FP
Need” in Column 4 and
document FP method
currently in use
 Met FP Need
No  Can you tell me
why you are not using a
method? (check one)
Infecundity reasons 
No FP Need
Action: Counsel and tick
“No FP Need” in Column
4
 Unmet FP Need
Action: Transfer
to FP column on
ART card
Also tick
Sterile/Infecund on ART
card
Not sexually active
No FP Need
Action: Counsel and tick
“No FP Need” in Column
4
OtherUNMET FP
NEED
Action: tick “Unmet FP
Need” in Column 4
Arise: endline survey results and baseline comparison | 65
Met need is defined as women of reproductive age (15-49 years) living with HIV attending care and treatment
services who want(ed) to delay or avoid a/another pregnancy who are currently using a family planning method of
their choice
No need is defined as (a) women that are not at risk of pregnancy or (b) women at risk for pregnancy and not wanting
to space or limit their childbearing
Unmet need is defined as


All pregnant women whose pregnancies were unplanned at the time of conception.
All fecund, sexually active women who are not pregnant and who do not want to become pregnant in the next year
but are not using any contraceptive
66 | Pathfinder international
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