Offering family planning services in factory settings in Egypt: Examining feasibility, acceptability, and cost I.	Project Summary  

The Population Council/Egypt is conducting a project to address family planning / reproductive health (FP/RH) needs of Egyptian factory workers through raising their awareness of FP/RH and providing them with on-site FP services. The project objectives are to: (1) improve knowledge, attitudes and behaviors of male and female factory workers related to FP/RH in selected factories (2) assess the feasibility, acceptability, and effectiveness of offering on-site FP information and services to factory workers, (3) documenting lessons learned from implementing this model of public – private partnership, i.e., between Ministry of Health and Population (MOHP) and private factories. The intervention focuses on male and female factory workers (both married and unmarried) and is implemented in the Industrial Zone of El Amreya, Alexandria governorate. The project is implemented in partnership with the Egyptian Chamber of Apparel and Home Textile Industries (ECAHT) and in coordination with the Population and Family Planning sector at the Ministry of Health and Population. II.	Activities completed during the reporting period (January – December 2022):

The following activities were completed during the reporting period:

•	Introductory meetings with ECAHT and MOHP senior management: Meetings were held with the two entities to gauge their interest in the project. A subaward was granted to ECAHT to take a lead role in implementing activities inside the factories.  MOHP expressed full interest and support for the project. 

•	Finalizing the selection of factories and components of the intervention: In the first quarter of 2022, we finalized the selection of partnering factories in El Amreya (n=11) and comparison factories in Borg El Arab (n=3). We also selected the health committees’ (HC) members from each factory, and we held an introductory meeting in early February 2022 to explain the program goals and HC responsibilities.  In addition, meetings were held with the Ministry of Health and Population (MOHP) to agree on the role of MOHP on components of the intervention and feasibility of using the MOHP operated mobile clinics in offering FP services to factory workers in Amereya. We also developed selection criteria for peer educators and shared them with HCs.  In addition, we adapted and updated the existing FP/RH training package for peer educators and factory nurses and identified key health messages to be shared with factory workers.   

•	Diagnostic Qualitative Study: This study was conducted in February – March 2022, with 20 female and 10 male factory workers, 10 factory managers, 5 nurses, and 2 doctors. This study aimed to inform the program design and better understand the program’s target audience in the intervention factories; their FP/RH knowledge, attitudes, behaviors, and FP needs. The study showed that workers needed correct FP information as they currently rely on inadequate sources or do not have access to any information. Factory workers supported the idea of receiving FP services through the mobile Family Planning clinic provided that certain precautions are maintained along with proper coordination with factory management. In addition, workers welcomed receiving FP messages through WhatsApp groups and peer educators. Factory managers expressed their support for the above components so long as messages are delivered to workers without disrupting work in the factory. Results of the diagnostic study were shared with HC members as well as MOHP officials and were used in fine tuning the intervention.  A presentation summarizing results of the diagnostic study is sent through e-mail. 

•	Visit by Netherlands Ministry of Social Affairs team: On March 28, 2022, a team from NL Ministry of Foreign Affairs along with Population Council staff visited one of our intervention factories (Garment textile) at El Amreya. They took a tour inside the factory halls and discussed components of the intervention with select HC members. NL Ministry of Foreign Affairs team Representatives from the Netherlands Embassy were Marjolein Jongman, and Caroline Nassif (based in Cairo), and Annemarie Elise, and Lizelotte Johanna (based in the NL).   

•	The Baseline Survey: The survey was conducted from April through August 2022.  It included a sample of 1,559 male and female workers (806 from intervention factories and 753 from comparison factories), between the ages 18-49. The questionnaire included questions on respondents’ background information such as education, marital status, and the number of children; basic knowledge, attitudes, and use of FP/RH methods; and use of mobile phones and social media. A presentation summarizing key results of the baseline assessment is sent through e-mail. Baseline survey results were shared with HC members and our partner NGO, ECAHT. Key baseline results are presented below:
o	32% of married non pregnant workers are not using the FP method.
o	26% of married respondents who are not currently using any FP methods reported that they do not intend to use FP methods in the future. 
o	14% of respondents could not name any FP methods, 28% could name only 1 or 2 modern methods, 22 % could name 3, and 36% could name 4 or more methods. 
o	More than 70% of workers agreed with the statement that "a woman must leave at least one child before using a family planning method" which indicates misconceptions about FP. 
o	44.5% of the respondents did not know whether birth control pills could cause cancer or not while 43% believed that they did not cause cancer.
o	21% believe that an IUD can move into the abdomen and even reach the heart, while 37.5% did not know if this was true or not.
o	93% of female workers that are currently using any method (or intend to use FP in the future) reported their willingness to receive a family planning service from the MOPH mobile clinic.
o	85% of workers indicated ownership of a smart phone while 96% of workers who had a smart phone reported use of WhatsApp. 

•	Finalizing the design of the intervention: Based on the results of the baseline and diagnostic study, components of the intervention were fine tuned in consultation with our ECAHT partners, MOHP and HC members. It was agreed that awareness raising will be done by PEs using WhatsApp messages for workers who have smart phones. Each WhatsApp group will have 50-60 workers of the same sex and will receive biweekly FP/RH messages from the PE.  WhatsApp groups will be set up in a way that only PEs can post messages while workers can ask address questions privately to the PE.  In addition, PEs will use face to face communication and SBC materials to reinforce messages. Workers will be encouraged to share SBC materials with their families.  The factory nurse will provide FP counseling to factory workers and will coordinate the visits of the mobile clinic which will come to each factory once every two weeks, or more often depending on workers needs. 

•	Developing SBC materials and WhatsApp messages: 16 fliers were developed in consultation with HCs and MOHP officials.  The fliers covered key FP information as well as other health topics such as child marriage, female genital mutilation, breast cancer, nutrition and non- communicable diseases.   
In addition, 40 WhatsApp messages were developed. The messages cover basically the same topics as the fliers as they are meant to complement each other. Copies of the WhatsApp messages and fliers are sent through email. 

•	Peer educators and nurses training in intervention factories: We adapted and updated the existing FP/RH training package for peer educators and the key health messages for factory workers. We also updated factory nurses’ FP/RH counseling training materials. The material was revised and approved by the MOHP. Trainers were mostly MOHP doctors from the Health Directorate.  A total of 16 nurses were trained in Al-Amreya intervention factories over six separate days.  In addition,11 training sessions were held with 227 Peer Educators in November 2022.  Following the training each PE started to collect around 50 phone numbers to create WhatsApp groups.  

Peer educators and nurses were very satisfied with the training.  Testimonials by some PEs are captured in the video sent through e-mail.  In addition, pre and post tests were conducted before and after training to evaluate the success of the training in increasing the FP/RH knowledge. Key results of the pre and post tests are presented below:
o	In the PEs pre-test the average score was 54%, which increased to 75% in the post-test.  
o	In the nurses’ pre-test the average score was 59%, which increased to 79% in the post-test.  
Some of the reasons for the relatively low increase in knowledge will be discussed in the monthly refresher sessions to be held with PEs and nurses.  

•	Nurses training in comparison factories: As part of our agreement with the partnering comparison factories in Borg Al Arab, nurses in comparison factories were to receive training and SBC materials. However, they will not receive PE training, WhatsApp messages or visits by MOHP mobile clinic. As yet, only one of the comparison factories in Borg el Arab received training where two nurses were trained at the Shahander factory in November. 

•	Providing factory clinics with basic equipment: Factory clinics were provided with basic equipment to enable nurses to offer FP counseling and to guide workers to more appropriate FP methods for their needs.  The equipment included stethoscope and sphygmomanometer, scale and blood sugar kits.  

III.	Challenges and lessons learned:

•	The baseline data collection took much longer than planned. This was mainly due to the nature of the factory’s production work orders. Although the actual baseline questionnaire did not take more than 15 minutes to complete per factory worker, some of the factories could not afford any delays in the production line at certain times. The field coordinator at ECAHT was in constant communication with the factory management to coordinate the best dates for the factory to receive data collectors. 

•	The following challenges were faced during PE and nurses training: 
o	Training of peer educators was postponed several times because factories had work orders that they had to deliver and hence would not release workers for the training.
o	It was difficult in some factories to take PEs and nurses for two hours to attend training and hence we had to reduce the duration of training to one hour and consequently some of the training content was not adequately covered. Additional training sessions will be offered to Pes and nurses.  
o	PEs training sessions that were held outside the factory premises after work hours proved to be more successful however, not all factory managers accepted this arrangement. 
o	Some of the selected PEs were not adequately informed by ECAHT about their role in advance before attending the training. As a result, some of the selected PEs chose to drop out of the training.

•	ECAHT has been reluctant to hire full time for the project for various reasons. Lack of dedicated staff resulted in delay in implementation of several of the project activities.  PC team held several meetings with ECAHT and discussed possible increases to staff salaries given recent devaluation of the Egyptian pound.  Finally, PC team indicated to ECAHT that we might consider contracting a different local NGO to complete the work in factories if ECAHT fails to hire full time staff for the project by March 2023. 

IV.	Activities to be completed in 2023 and 2024:

•	Implementation of the Intervention: based on the results of the diagnostic study and the baseline survey the below activities will be held in intervention factories starting January 2023 to September 2023:
o	Peer educators in each factory will provide FP/RH messages to their colleagues through separate WhatsApp groups that will be created for male and female workers. 
o	Monthly meetings will be held with peer educators to provide them with monthly messages and to respond to their questions or any challenges they met.
o	The PEs will only spread the FP messages and any questions or consultations will be referred to the factory nurse. 
o	Social Behavior Communication Change (SBCC) materials will be distributed by the factory nurse to workers who will visit the clinic and ask for FP counseling and by peer educators to workers who do not have internet connections or smartphones or cannot read and write. 
o	On-site FP services will be offered through the mobile clinics that are operated by MOHP. The factory workers will be informed by the PEs about the mobile clinic visits schedule to be prepared and to register their names with the nurses. 

•	End-line Survey and Impact Analysis: After finalizing the planned intervention program, the end-line survey will be conducted to assess the impact of the implemented components on the factory workers’ knowledge and attitudes about FP/RH and FP use. The impact analysis will utilize several output indicators to measure the increased knowledge and improved attitudes. These output indicators are measured by % of factory workers with the correct knowledge and favorable attitudes: (1) the percentage of factory workers who can name at least 3 FP methods, (2) the % who can name one place where they can obtain FP services, (3) % of workers who are aware that they could obtain FP services at the factory clinic, and (4) the % who express positive attitudes about FP, and (5) the % who express willingness to use FP in the future (among those not currently using). This information will be collected through the analysis of the baseline and end-line data to quantify comparisons and measure increases. The endline survey will be conducted in October – December 2023. 

•	Conducting qualitative assessment: A second qualitative study will be conducted towards the end of the project to solicit factory workers, managers and MOHP officials’ views of the intervention. 

•	Production of publications and conducting dissemination activities: Results of the study will be disseminated through policy briefs, English peer-reviewed journal article, round table discussions, and a final dissemination event. The above dissemination activities will be undertaken in 2024.