Adalat Ahmad Hamad Al Wazaneh, a 38 year old resident of East Amman, received a visit from a community health worker in the morning. Later the same day she put into practice the instructions received on breast self-examination; Adalat discovered a lump which further screening determined was malignant. Now in remission, she credits the timely appearance of the outreach worker with saving her life.

There is little argument that the most effective form of communication is interpersonal. The trick in a middle income country such as Jordan is to make it cost-effective. The USAID/Jordan health project for the private sector (Commercial Market Strategies – CMS) has, over the last two and a half years, reached over 70 percent of married women in their homes. During the two to four home visits made to each woman the outreach worker:

• assesses maternal risk and discusses contraceptive options,
• refers pregnant women for antenatal care, and
• promotes early detection of breast cancer.

Effect

Thanks to superb management of the outreach activity by two NGOs, the results have been consistently excellent.

Family planning. The initial focus of the outreach activity was on reproductive health. Discontinuation of modern methods was high, dependence on traditional methods was high, consequently the failure rate (unwanted pregnancies) was also high, and adoption of modern methods had plateaued after years of steady increase. After two full years of outreach activity, the following had been achieved.

• Total clients reached = 388,959 or 63 percent of all married women of reproductive age
• Total new modern method adopters (new adopters and switchers from traditional) = 52,765
• Average cost per new adopter = US$18.23 (US$14.07 in year two)
• Imputed increase in the national prevalence rate of modern contraceptive methods = 8.5 percentage points

Breast cancer. The work on breast cancer – a leading killer of Jordanian women – has been especially challenging. Hospital data show that 70 percent of detected cases of breast cancer have already advanced to late stages; by this point the five year survival rate is less than 20 percent. USAID/Jordan has been working with the government and other donors to improve access to screening and treatment but there is a long way to go. Not only are resources lacking, breast cancer assumes such dread proportions in the minds of Jordanian women that denial is common. An illustration of the problem comes from the data of the past three months:

• 248 women were referred by outreach workers for screening;
• 195 went
• Of these, the results for 26 were sufficiently worrisome to warrant biopsy (fine needle aspiration).

• 14 women showed up for the procedure and three were found to have malignant masses requiring surgery.
• The other 12 have dragged their feet. Two are newly married and don’t want to upset their husbands; two are engaged and are afraid their fiancés will walk out; and so on.

Despite this resistance the wins exceed the losses. A recent survey of knowledge of screening methods among clients of the outreach program found that 97 percent knew when and how to conduct breast self-examination; 61 percent reported having conducted self-examination; the national average is 17 percent.

Cost-effectiveness. Beyond the cost-per-adopter figure reported above, it is instructive to compare the cost of outreach with mass media. The costs to “talk” to a woman for one minute are as follows:

• Outreach – US$0.045
• Evening news on Jordan TV – US$0.016
• Regional satellite broadcast – US$0.098

The cost data from TV are based on the numbers of women who watch programs on these channels; unknown is the number of women who also sit through the commercials. As a consequence, the cost-per-minute to reach a woman via television may be understated.

The diffusion of viewership further strengthens the claim of outreach on cost-effectiveness. Thanks to the explosive proliferation of satellite channels, no broadcaster commands more than 16 percent of the viewing market. USAID’s community outreach program will connect with 40 percent of the women in Jordan every year for the foreseeable future.