Running head: FAMILY PLANNING ON WHEELS

Family Planning on Wheels: A Program to Reduce Unplanned Pregnancies in Rural

Ecuador
Kaylee Blankenship, Alyssa Cardinal, LeAnna Ceglia, Maggie Fabry and Noel Silveira
California State University, Stanislaus

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Executive Summary
A prevalent issue in Ecuador is the high incidence of unplanned pregnancy, particularly
within the rural, adolescent population. According to Bremner, Bilsborrow, Feldacker and Lu
Holt, this results from a lack of access to contraceptive measures and a knowledge deficit in
regards to family planning (2009). According to research by Yoost, Hertweck and Barnett,
implementing educational clinic visits may lower the incidence of pregnancy (2014). Integrating
an educational intervention into these rural locations has the potential to increase residents
knowledge of family planning while decreasing unplanned pregnancy.
A proposal for a Family Planning on Wheels program has been created in an effort to
overcome this issue in Ecuador. The program consists of a staff of nurses and volunteers that
travel throughout rural areas of Ecuador. The mission of this program is to evaluate individual
needs, provide education related to family planning and provide contraceptives in order to
prevent unplanned pregnancies. Educational topics include abstinence, safe sex practices, proper
use of contraceptives, self-esteem, peer pressure avoidance, and how parents should approach
sexual education with their children. Through the implementation of this program, it is estimated
that there will be an increased knowledge of family planning, increased acceptance toward
various methods of birth control, and a decrease in unplanned pregnancies.
Background
Countries in the Andean region of Latin America have exceptionally high adolescent
fertility rates in comparison to both individual country and global averages (Goicolea, 2010).
Ecuador, in particular, has the highest rate among Latin American countries with a staggering
100 out of every 1,000 adolescent girls currently or recently impregnated (Goicolea, Wulff,
Ohman, & San Sebastian, 2009). According to Goicolea, Wulff, Ohman and San Sebastian, of

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all Ecuadorian women age 15 to 19, 20% get pregnant before age 20 (2009, p. 221). Due to the
physical and mental health complications associated with early childbearing, as well as the high
risk for poverty bestowed on these young mothers, Ecuadors high adolescent fertility rate is a
huge concern. The offspring of these adolescents are also at an increased risk for abuse and
neglect, and the majority are forced to become accustomed to lifestyles of hardship (Goicolea,
Wulff, Ohman, & San Sebastian, 2009). In Latin America, it has been shown that infants born
to mothers 15 to 19 years old are nearly 80 percent more likely to die during the first year of life
than infants born to mothers 20 to 29 years old (Herdman, 2008). This is problematic for the
entire country because the adolescent population, in the bigger picture, is the future of Ecuador.
According to Goicolea, Wulff, Ohman and San Sebastian, risk factors for unintended
pregnancies include not only being an adolescent, but also having poor contraceptive knowledge
and use, poor communication among family members, low education levels, early sexual debut,
and low socioeconomic status (2009). To address these concerns, Ecuador created a national
pregnancy prevention plan in 2007 that is based on the assumption that in order for adolescents
to exercise their reproductive rights they not only need access to a network of services but also
must be empowered to take control of their sexuality (Goicolea, Wulff, Ohman, & San
Sebastian, 2009, p. 222). Aside from accessibility, education on the proper use of contraceptives
is also important for this population. The most paramount task, however, is reaching out to the
most vulnerable and neglected populations. More specifically, the task at hand involves
providing family planning education to indigenous individuals or those living in rural Ecuador.
Due to a lack of research and attention to the alarmingly high Ecuadorian adolescent fertility
rates, the number of pregnancies continues to increase. Goicolea explains that while total
fertility rates have been declining, adolescent fertility rates have experienced little change, and in

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countries such as Colombia and Ecuador, they have even increased (2010). Immediate action is
required for this country in order to decrease fertility rates and prevent the negative outcomes
associated with pregnancies, specifically in regards to the rural and adolescent populations.
Literature Review
Researchers Yoost et al. recently conducted a study to evaluate a new approach on
adolescent pregnancy prevention (2014). The study utilized a retrospective chart review design
held at the Center for Adolescent Pregnancy Prevention, which is a privately funded clinic
located in an urban setting in Kentucky. Subjects were between the ages of 11 and 18 years and
were seen from January 2007 to December 2010. The outcomes studied were 12- and 24-month
continuation rates of birth control options, total length of follow-up, time until gaps in follow-up,
and incident pregnancies. Results were based on age at the initial visit and were split into two
groups: early adolescents (aged 11-15 years) or late adolescents (aged 16-18 years). There were
121 patients and seven incident pregnancies, all in the late adolescent group. The early
adolescents had a greater rate of continuation of birth control at 12 months and 24 months
compared with late adolescents. The educational approach used may decrease adolescent
pregnancy among high-risk adolescents that continue to use the clinic system. This model may
be more effective for early adolescents than late adolescent (Yoost et al., 2014)
A major strength of this study involves the extensive education provided by a nurse that
covers female anatomy, the menstrual cycle, vaginal health, and birth control options. Another
strength is encouraging the patients to follow through with follow up appointments every 3
months. The study contained a couple of limitations. The first is classifying patients with
continued contraception use with the condition of not discontinuing their form of birth control
for one month or longer. This puts the patient at risk for pregnancy because methods could be

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stopped and then resumed within that month and still considered continued. Another
limitation includes not recording demographic information such as drug and alcohol use that can
contribute to high-risk activity. Pregnancy ambivalence was also not assessed; all pregnancies
were recorded as unintended. Reasons for discontinuation of birth control methods were not
recorded. All of these limitations affect internal validity. The external validity or generalizability
is affected by the fact that participants were not randomly assigned to participate in the study.
In a recent study conducted by Goicolea, Wulff, Ohman, and San Sebastian, varying risk
factors were analyzed for pregnancy among the population of adolescent girls living in the
Amazon basin of Ecuador (2009). The study was a match case-control study with 140 cases and
262 participants in the control group. Cases included females between the ages of 10 and 19
living in Orellana, who were pregnant at the time of the interview or had been pregnant in the
previous two years. The control group included adolescents of the same age group and location,
who had never been pregnant. All participants were surveyed on three different categories of risk
factors for pregnancy among adolescent women including socio-demographic indicators, adverse
events during childhood-adolescence, and sexual and reproductive health variables. The study
uncovered that six factors were statistically significant (p< 0.05) in adolescent pregnancies;
sexual abuse during childhood-adolescence, early sexual debut, living in a very poor household,
experiencing life periods of a year or longer without a mother and father, married or being in a
union, and not being enrolled in school at the time of the interview (Goicolea, Wulff, hman, &
San Sebastian, 2009).
The strengths of this study included a high number of participants and also follow-up
with resources for individuals who claimed to have experienced some sort of abuse. There were
many limitations to this study. First, the study focused on a small fraction of the country, with

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participants residing in only a single province of Ecuador. A huge limitation to the study was the
unreliability of reported abortions due to fear in relation to Ecuadors law forbidding abortions.
This inaccuracy, in addition to the fear of sharing information in the presence of parents, could
have affected the studys overall results by potentially excluding the most vulnerable population
of girls. Another limitation was the use of the Adverse Childhood Experiences questionnaire,
which was created for the American population and not the Ecuadorian population. The external
validity was also negatively affected by the lack of random assignment of participants for the
study.
Additional research, by Goicolea and San Sebastian, investigates the effects of both
individual and contextual factors on unintended pregnancies in Ecuador (2010). Women
between the ages of 15 and 44 years old were selected with an ongoing community-based crosssectional survey. The survey was conducted between May and December 2006 in the Orellana
province. Survey questions were issued as an interview in the participants home and in the
participants native language. The data was fitted and translated by using a multilevel logistic
regression in which individual-level and community-level factor were adjusted as fixed effects
and allowing for heterogeneity between communities (Goicolea & San Sebastian, 2010). The
sample included a total of 1,002 women between the ages of 15 and 44 years old who lived in the
Orellana province of Ecuador. This sample excluded women who were either pregnant or
breastfeeding to avoid respondent bias and only included the women who actually delivered a
child. The results of this study showed that the overall occurrence of unintended pregnancy was
62.7% of the population. A total of 73.7% of indigenous women reported having at least one
pregnancy that was unintended. The significant risk factors found for unintended pregnancies
included being single, young, and indigenous as well as having more than two children and little

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access to education. There was no correlation found between use of contraceptives and
socioeconomic status. All of the variations between the 34 province communities were
explained by individual factors (Goicolea & San Sebastian, 2010).
The strengths of this study included using a large population of participants, having the
interview conducted in the participants native language, and obtaining informed consent before
the study was conducted. Also, to avoid respondent bias, the interview excluded women who
were either pregnant or breastfeeding. Limitations of this study include having only interviewed
women between the ages of 15 and 44. Also, the study was conducted in only one province of
Ecuador, limiting their data to only a single population.
A study by Goicolea, San Sebastian, and Wulff gathered information and data on
reproductive health factors such as delivery care, adolescent pregnancy, and contraception
(2008). The data was gathered from a local community based survey as well as from policy and
official sources from the Health Rights of Women Assessment Instrument (HRWAI). The
design was a community-based cross sectional survey that began in 2006. The survey was
conducted as an interview that evaluated three areas of reproductive health including family
planning, delivery care, as well as pregnancy among adolescent girls between the ages of 10 and
19 years. The participants partook in a two-stage cluster sampling procedure. The population
targeted included a total of 2,025 women who were between the ages of 10 and 44 years old and
live in the Orellana province. Of those 2,025 women participants, 1,631 lived in households, 524
were from indigenous communities and 1,107 were from non-indigenous communities. As a
result of the survey, it is evident that women who live in Orellana face lower quality of
reproductive health services compared to other women who live in other areas of the country.
The study also brought forth a wide gap of inequity amongst the women living in Orellana. For

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instance, women in urban areas had a higher percentage of planned pregnancies, modern
contraceptive use and skilled delivery attendance compared to the women living in rural
areas. Indigenous women had the lowest percentage of planned pregnancies, use of modern
contraceptives, and skilled delivery attendance (Goicolea, San Sebastian, and Wulff, 2008).
Strengths of this study include using a large population of participants and using a
credible tool to measure their findings. The researchers also used literature reviews of
international and governmental documents as research on the topics in addition to their
community surveys. However, some limitations of this study included not obtaining any form of
consent from its participants and conducting the survey and research in one province of Ecuador,
limiting their data to a single population.
A qualitative study conducted by Tebbets and Redwine evaluated the effectiveness of
Youth Peer Provider programs in Ecuador and Nicaragua (2013). Three evaluations were used
over a seven-year period to analyze the various programs effectiveness. In 2004, the first
evaluation was conducted in both Ecuador and Nicaragua and used a 33-item survey containing
questions about pregnancies, births and contraceptive use and history. For this evaluation, 597
program participants were randomly selected. These respondents had been participants of the
program for an average of three years. The second evaluation took place in Ecuador between
2007 and 2009 and utilized the Most Significant Change Technique. This evaluation was
qualitative and assessed the impact of the program on 92 individuals using a six-question survey
tool. The third and final evaluation took place in 2010 and included 15 in-depth interviews
assessing the interviewees thoughts regarding the programs strengths, weaknesses, impacts and
operational issues. The sample of 107 individuals included in the last two evaluations consisted
of past and present Youth Peer Providers or coordinators, organizational staff, staff at

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participating schools, students receiving training through the program, youth receiving methods,
counseling through the program, and parents of the participants. The 2004 survey revealed that
three-quarters of the respondents were currently sexually active and 95 percent of those sexually
active individuals were using contraception. This survey also found that three-quarters of
respondents reported ever having used a condom with the intention of preventing sexually
transmitted infections (STIs). These results compared favorably to the general populations in
Nicaragua and Ecuador. The final two evaluations responses revealed that the most commonly
mentioned program impact was an increase in knowledge and the second most common was
personal growth. In addition, twenty-two percent of participants stated an increase in selfesteem, leadership skills and self-confidence and twenty-three percent of participants mentioned
that their communications skills were improved as a result of the program. Lastly, a significant
number of respondents reported that there was an improvement in their relationships with their
family and friends (Tebbets & Redwine, 2013).
The study had many strengths including the ability of the reader to follow the
researchers reasoning. Not only was confidentiality of each client kept and the services
provided in the local language, but participants were able to recognize the experience as their
own. This study had Youth Peer Providers monitor contraceptive records for all of their
clients. Another strength included using a large sample size over a course of 10 years. Ongoing
monitoring and evaluating of the effects was also provided from this program by obtaining
voluntary personal feedback from clients. A limitation of this study, however, was a failure to
mention obtaining consent forms from the participants.
Bremner et al. conducted a study to estimate fertility rates in Ecuador for rural indigenous
women, analyze reproductive health intentions and the use of contraceptives, and contemplate

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why fertility rates remain high among lowland tropic indigenous populations (2009). The authors
hypothesized that, high fertility is, in large part, due to unmet need for reproductive health
services, and this hypothesis was tested using primary survey data regarding reproductive
practices. Data collection took place in 2001 in two phases. The first phase was an ethnographic
study of eight communities while the second phase was a survey of 36 communities collecting
data about the household and the community. Qualitative and quantitative data was collected
from both households and certain community leaders. The sample was 564 households from a
two-stages and the sampling was controlled. The interviews of the male and female heads of the
households were lead separately using questionnaires. The questionnaires included questions
about migration history, age, sex, education level, marital status, languages spoken, assets and
health of the household. The second part of the survey also asked females about their family
planning methods used, the desire for more children, and their own reproductive history. For this
data, only the women of reproductive age were used making the sample size 510 households and
648 women. The Brass-Cole methods were used and estimations were calculated for fertility
rates. Univariate and bivariate descriptive analysis was used in order to compare the reproductive
attitudes, preferences, and contraceptives used among 369 females and the results were then
further compared with the national ENDEEMAIN II survey. Cross-ethnic comparisons were
made using a binary logistic regression model. The results of this study confirmed that fertility
rates are high and that the need for different types of contraceptives are unmet. They found that
there is only one health center in the Ecuadorian amazon that actually focuses on providing
reproductive health services and family planning. This fact helps explain why knowledge and use
of contraceptives are so low and misconceptions are commonplace. There is a lack of access and
a lack of information or education on family planning and contraceptives (Bremner et al., 2009).

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The strengths in this study included having a large sample size in which the sample
population represented multiple communities in an area of Ecuador. To avoid any bias or
misleading answers, men and women were given separate, individual surveys/interviews. Also,
the tools used to measure the surveys were reliable and the same questionnaires were used for
each subject.

However, there were also many limitations found in this study. For instance,

there was no mention of any forms of consent obtained from the participants. The survey was
conducted only in the northernmost provinces of Ecuador, limiting their data to only a selected
population. Also, some locations had every household surveyed, while other locations had
households chosen at random, therefore, providing an inconsistency in the obtained data. With
that being said, this study is not very generalizable since it is focused specifically on indigenous
women of Ecuador, therefore, the external validity is limited.
Project Goals and Objectives
The overall desired impact for Family Planning on Wheels is a decrease in the number of
unplanned pregnancies in rural Ecuador by 2% in five years (See Appendix A: Figure 1).
According to Planned Parenthood, approximately 30% of Ecuadors population lives in rural
areas, and one in ten adolescents from this rural population give birth each year (2014).
Therefore, this programs desired impact is to reduce the adolescent birth rate from 10% to 8%.
The implementation of this program is vital for not only the health of this population, but also the
economic prosperity of Ecuador as a whole. Unplanned pregnancies, especially those in
adolescents, increase the likelihood that mothers will experience poverty and low socioeconomic
status (Goicolea, Wulff, hman & San Sebastian, 2009, p. 222). This study also communicates
that globally, early childbearing is associated with higher risk of adverse reproductive outcomes

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and, among the youngest mothers and their newborns, increased maternal and infant mortality
(Goicolea, Wulff, hman & San Sebastian, 2009).
Although Latin American countries have seen a decline in fertility rates, there are still
rural areas and sub-populations that are experiencing high fertility rates and generally, a lack of
access to family planning and reproductive health services (Bremner, Bilsborrow, Feldacker &
Holt, 2009). In a study conducted by Jennie L. Yoost, it was found that education and multiple
clinic visits decreased the number of pregnancies in adolescents (2014). Due to the limited
availability and occurrence of transportation to higher populated areas with health clinics,
indigenous and rural communities will greatly benefit from the proposed clinic on wheels. The
program aims to decrease the number of unplanned pregnancies by increasing knowledge related
to family planning and increasing accessibility to contraceptives. The following section will
elaborate on the overall plan, including key stakeholders and end beneficiaries, inputs, activities,
outputs, effects, and assumptions that contribute to the overall desired impact; all of which are
outlined in Appendix A: Figure 1.
Key Stakeholders and End Beneficiaries
The end beneficiaries of this program, or those who will benefit from the services
provided, include the individuals and families of rural communities in Ecuador, health care
providers, and the local governments economy. The residents in these communities will be the
ones who experience the most benefits from this program. This is because they will gain the
knowledge and resources necessary to prevent unplanned pregnancies and create a family plan
that is specific to their own individual wants, needs, and beliefs. Through referrals, clients will
have a direct line to physicians closest to their homes.

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The key stakeholders in this program include registered nurses, peer support volunteers,
local government officials, community leaders, physicians and potential clients. With the support
of community leaders, potential clients will be more willing to take part in these educational
family planning meetings, thus making the program more effective. Registered nurses will be the
stakeholders providing family planning education and resources necessary to reduce unplanned
pregnancies. The key to this programs success, however, depends on the participation of the
clients. Without their involvement, registered nurses are unable to make home visits, thereby
affecting the anticipated outcome.
Inputs
There are several resources needed in order to carry out the necessary activities for
Family Planning on Wheels. American registered nurses will be needed to train all staff, while
Ecuadorian nurses will be needed to provide family planning education, distribute condoms,
orient volunteers and make referrals to physicians. Peer support volunteers will be needed for
assisting in program activities. Tebbets and Redwine claim youth who discuss sexual and
reproductive health with peers are more likely to display positive health-seeking behaviours than
youth who discuss it with adults (2013, p. 144). Based on this knowledge, young adults will be
hired as volunteers to create a more comfortable atmosphere for clientele in order to enhance
learning.
Contracts with local health care facilities and physicians will need to be made in order to
make referrals for family planning methods and related health assessments. Materials, including
pamphlets and reproductive models, are needed to illustrate and explain different family
planning methods. Vehicles, insurance, registration, and fuel for travel are also essential. These
vehicles will contain all supplies necessary for making home visits and provide transportation for

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nurses and volunteers. Information and maps for clinics closest to the area that provide different
types of contraceptives will also be needed. Lastly, funds for all essential materials and activities
are necessary for implementation.
Activities
In order to reach the overall impact, there are a number of activities that need to be
carried out in a specific order. The first activity that needs to be performed in the Family
Planning on Wheels program is an assessment of attitudes and knowledge on family planning
among rural Ecuadorian residents. This will be done by visiting individual homes, providing
information about the program, inquiring about the residents interest in program services,
quickly assessing family planning needs using questioning, pre-tests and surveys, and
encouraging them to spread the word to the rest of the community. A meeting should be held
with local officials and community leaders to communicate the family planning issues in each
community and establish rapport in order to develop a partnership (A. Aleman, personal
communication, November 4, 2014). In the Ecuadorian culture, sex and family planning are not
always openly discussed and religious beliefs often play a role in attitudes and behaviors
regarding contraceptive use (Bremner, Bilsborrow, Feldacker and Holt, 2009). Therefore, it is
important to have community leaders in support of the initiative to aid in gaining the trust of the
community. American nurses will interview and hire qualified Ecuadorian nurses and peer
support volunteers. A teaching plan and schedule will be created specific to each rural
community and its needs. Next, nurses and volunteers will be trained on program guidelines and
how to effectively present family planning education to rural communities. Family planning
educational materials, including pamphlets and reproductive models, need to be purchased for in
home teaching sessions. The next activity is to purchase 20 vehicles in Ecuador and stock them

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with educational materials. The vehicles will require insurance, registration, and fuel. After all
necessary supplies are gathered and the staff is trained, initial visits will begin, and will be
followed by monthly visits. The initial visit will determine the households family planning
needs, knowledge deficits, and will last no longer than one hour. A general pre-test, post-test and
survey, in the familys primary language, will be distributed for evaluation of teaching methods.
Follow-up visits will elaborate on the previously determined needs of the household and last
approximately thirty minutes to one hour. Pre-tests, post-tests and surveys will be distributed at
each home visit and will be specific to the topic for that particular visit. Topics for education will
include abstinence, safe sex practices, proper use of contraceptives, promotion of self-esteem,
peer-pressure avoidance, and how best to foster communication regarding sexual practices
between children and their parents. Education is one of the essential elements of this program.
Research shows that among indigenous women, the most common reasons for not using modern
contraceptive methods were lack of knowledge, fear of side effects, and cost. The ethnographic
study also revealed widespread misconceptions and fears about negative impacts of modern
family planning methods on womens health (Bremner, Bilsborrow, Feldacker and Holt, 2009).
Referrals may also need to be provided to doctors or nurse practitioners concerning family
planning, as well as providing information on health clinics closest to each community.
Throughout the progression of this program, the effectiveness of visits will be evaluated by
monitoring birth rates, comparing pre and post-test scores for each visit, and reviewing survey
feedback.
Outputs
One expected output is a partnership between program members, community leaders, and
clientele. Ecuadorian nurses and peer support volunteers will be equipped with the necessary

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skills and knowledge to educate rural residents on family planning matters. Teaching topics and
itineraries for home visits will be created and distributed to each staff member and client. Twenty
vehicles will be purchased, insured, registered and outfitted with all required supplies. It is
anticipated that through the efforts and cohesiveness of this programs interdisciplinary team,
communication will be improved between family members and peers, as well as between clients
and staff.
Effects
This program hopes to change the knowledge, attitudes, and practices of rural
Ecuadorian communities in relation to family planning practices. Desired effects of this program
are specific, measurable, achievable, realistic and time-specific (SMART). One of the desired
objectives is by year five of the program, the clients will demonstrate increased knowledge of
family planning and contraceptive methods as evidenced by higher scores on post-tests. By year
five, clients will demonstrate enhanced awareness of which contraceptive method best suits their
lifestyle as evidenced by attitudes reflected through survey responses. This is relevant because
total fertility rates for Ecuador have been steadily declining, and this has been regarded as a
direct indicator of the success of interventions aimed at improving access to contraception across
the country (Goicolea & San Sebastian, 2010). Another desired outcome is that by the end of
the program, clients will demonstrate an increased awareness of facilities that provide family
planning methods and related healthcare services, which will be demonstrated through the use of
survey responses. In addition to increasing knowledge, this program aims to develop progressive
attitudes among rural residents and community leaders regarding various family planning
methods. Furthermore, the program hopes to foster more open-mindedness of parents and
children toward discussing family planning and sexual practices in the home. By year five, the

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increase in accepting attitudes toward family planning practices will be measured through survey
feedback. The practices that will theoretically change due to the implementation of this program
include: prolonging abstinence among adolescents, increasing proper and consistent use of
contraceptives among all sexually active individuals, and increasing communication between
parents and children regarding sexual practices and family planning. By year five of the program,
the change in these practices will be determined by evaluating the change in birth rates among
adolescents living in rural Ecuador.
Assumptions
Certain assumptions or beliefs were made about the programs interventions and
resources utilized through its development. Assumptions were made based on research, best
practices, past experience and common sense (Department of Health and Human Services,
Centers for Disease Control and Prevention, 2013). The following assumptions were made: there
will be an adequate number of volunteers, educational content will be presented consistently,
laws and policies will support the program, funding will be remain secure, all supplies will be
delivered without error, staff will possess necessary skills and abilities, and the clientele and
community leaders will be receptive to the education and care provided. An awareness and plan
of action in regard to these assumptions is essential in order for the Family Planning on Wheels
program to be successful.
Technical Approach and Gantt Chart Work Plan
This program is scheduled to start on January 1st of 2015. The first task will involve five
American nurses hiring and facilitating the training of twenty Ecuadorian nurses. After this
training has been completed, these five nurses will be responsible for evaluating successes and
failures through statistical data analysis for the remainder of the program. Eleven days have been

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dedicated to hiring and training nurses, as well as 20 peer support volunteers on educational
content and program goals. The same amount of time has been given for training volunteers as
nurses because their role is, perhaps, equally important. As peers of rural Ecuadorian
communities, volunteers will play an important role as young individuals are greatly influenced
by their peers in relation to matters of sexuality and reproductive health (Tebbets & Redwine,
2013). After the training process is complete, almost a month will be devoted to purchasing the
20 vehicles and obtaining registration, insurance and fuel cards. At this point, four weeks will be
devoted to exploring the rural areas of Ecuador, assessing communities, and evaluating the
knowledge base and attitudes of the residents who live in these areas in regards to family
planning. A month has been devoted to this evaluation process due to its importance as
evidenced by the deficiency in knowledge of the indigenous population in Ecuador (Bilsborrow,
Bremmer, Feldacker & Holt, 2009). At this point, specific communities will be selected for
initial visits and a rough schedule will be drafted based on location. Time has been allotted for
revising and finalizing the schedule, which may be necessary as nurses and volunteers are hired
and trained. Due to the anticipated increase and fluctuation of clientele, the schedule will remain
flexible. From February 16th to February 26th, materials such as reproductive models, pamphlets,
referral paperwork and condoms will be purchased and organized within the vehicles. The next
two weeks will be allotted for ensuring that the team and the materials are organized and ready
for community visits. This extra time can be used to account for any of the above items that take
longer than expected or can be used as last minute preparation time. In the event that program
coordinators face resistance from community leaders or individual community members,
difficulty arises in finding and hiring nurses and volunteers, or there is a failure to obtain
necessary materials, additional time will be allotted and community visits will be delayed

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accordingly. On Monday March 16th, community visits will commence. Although the Gantt
chart only conveys the first year of the program, community visits, in-home meetings and client
referrals will continue for five years. In addition to the on-going evaluation process beginning at
the start of community visits, two months will be dedicated to constructing a written program
evaluation after the completion of this initiative. Refer to Appendix B: Figure 2 for the detailed
Family Planning on Wheels Gantt Chart.
Evaluation Summary
Previous studies have highlighted that being raised in an environment with little chance
of social and economic advancement can cause adolescents to be uneducated about pregnancy
and have unintended pregnancies at a young age (Yoost et al., 2014). This alone implies that
education is crucial in decreasing pregnancy rates in young populations. The Family Planning
on Wheels program is able to provide this needed education. However, participation in this
program does not guarantee that learning will occur or that attitudes about birth control use will
change. Measures must be implemented to evaluate whether the program is effective and
accomplishes the impact that it intended.
The Family Planning on Wheels program will be evaluated using both qualitative and
quantitative measures. Before any education on family planning can be implemented, the nurses
must first assess their clients baseline knowledge regarding family planning and contraceptive
methods. A pretest will be distributed at the start of each visit and will be specific to the
education provided that day. At the end of each visit, a post-test will be distributed and later
compared to the pre-test in order to determine the effectiveness of teaching. Comparing the
average scores of these tests for each client will indicate whether learning took place and if the
intervention or teaching was effective. Pregnancy rates of clients before, during and following

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participation in the program will be monitored and compared to overall pregnancy rates in rural
areas of Ecuador. Monitoring changes biannually will determine whether the program has
affected, or more specifically, lessened the number of unplanned pregnancies as intended.
Qualitative measures will be implemented using short answer and multiple choice survey
questions that allow patients to voice their opinions on the educational content presented to them.
They will also have the opportunity to provide advice on how the program or their individual
experience could have been improved. In this survey, clients will share whether or not their
attitudes regarding contraceptive use and family planning were changed as a result of the
interventions of this program.
Extensive literature exists depicting interventions that have been effective in lowering the
rates of unintended pregnancies. This proposal was designed with the intent to incorporate
components that have been proven effective through extensive research. Family Planning on
Wheels was modified to reflect this populations particular culture and inhabitance across the
rural regions of Ecuador. This program has the potential to make improvements in Ecuador by
decreasing birth rates and can only be put in to action if adequate funding is granted. In short, the
ability to lower birth rates in Ecuador is in your hands.

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References

Bilsborrow, R., Bremmer, J., Feldacker, C., & Lu Holt, F. (2009). Fertility beyond the frontier:
indigenous women, fertility, and reproductive practices in the ecuadorian amazon.
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Department of Health and Human Services, Centers for Disease Control and Prevention (2013).
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http://www.cdc.gov/dhdsp/programs/nhdsp_program/evaluation_guides/docs/logic_mode
l.pdf
Goicolea, I (2010). Adolescent pregnancies in the Amazon Basin of Ecuador: A rights and
gender approach to adolescents sexual and reproductive health. Global Health Action, 3.
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among adolescent girls in Ecuador's Amazon basin: A case-control study. Revista
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Herdman, C. (2008). The impact of early pregnancy and childbearing on adolescent mothers and
their children. Retrieved from
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222-227. doi:10.1016/j.jadohealth.2014.01.017

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Appendices:
Logic Model and Gantt Chart