Posters were used widely in an educational campaign throughout Taichung. The caption reads: "A wise grandmother says: 'Look! My son and his wife have

only three children. How healthy and happy they are!' If you have any question, go to the nearest health station"

Taichung has a population of about 300,000, including about 36,000 married women from 20 to 39 years old, of whom 60 percent have had three or more children. Most of the people live in a central region of shops, offices, and residences, but there are also rural areas within the city's administrative limits. A number of Government health stations and hospital clinics provide focal points for the action program.

The city as a whole was exposed to only two aspects of the program: a general distribution of posters pointing out the advantages of family planning and a series of meetings with community leaders to inform them about the program, get their advice and enlist their support. That was the extent of the communitywide effort; the remainder of the program was designed as a differentiated experiment involving various kinds and degrees of effort. The objective was to learn how much family planning could be achieved at how much cost in money, personnel, and time. To this end the local health authorities and a cooperating team from the United States devised four different "treatments," and applied one of them to each of the 2,389 lin's, or neighborhoods of 20 to 30 families, into which Taichung is divided. In order of increasing effort, the treatments were designated "nothing," "mail,” “everything (wives only)” and “everything (wives and husbands)."

In the "nothing" lin's there was no activity beyond the distribution of posters and the meetings with leaders. In the "mail" lin's there was a direct-mail campaign addressed to two groups: newlywed couples and parents with two or more children. It was in the "everything" neighborhoods that the major effort was made to increase family planning. The primary procedure was a personal visit to the home of every married woman from 20 to 39 years old by a specially trained staff of nurse-midwives. The fieldworkers made appointments for people at the health stations, provided contraceptive supplies, answered questions and did whatever else was necesssary to satisfy a couple's desire for family planning guidance. In half of the "everything" lin's the visits were made to wives only; in the other half the visits were extended to both husbands and wives, who were seen either separately or together.

Rather than apply each of these treatments to a different part of the city, the investigators decided to arrange matters so as to test a central economic issue. How much "circulation effect" can one expect in a program of this kind? To what extent can one depend on the population itself to spread the desired innovation, and how large an initial effort is required to prime the process? There has been substantial testimony that word-of-mouth diffusion played a large role in spreading ideas about family planning in the West and Japan; any such effect would clearly be of major importance to national efforts in the underdeveloped countries, which must influence large numbers of people and do so with limited

resources.

In order to investigate this question of "spread" it seemed advisable to apply the four treatments in different concentrations in different parts of the city. Taichung was divided into three sectors roughly equivalent in urban-rural distribution, socioeconomic status and fertility, and designated as areas of heavy, medium, and light "density." In the heavy density sector the two “everything" treatments were administered to half of the lin's, in the medium sector to a third of them and in the light sector to a fifth. In each sector the remaining lin's were assigned equally to the "nothing" and the "mail" treatment groups (see illustration following). The lin's were assigned at random, although always

Matrix shows the allocation of various "treatments" among the lin's in the three density sectors. The figures in parentheses give the total number of women 20 to 39 years old

in the proper proportion, and those designated for a particular treatment received exactly the same program regardless of their location in the city. They differed only in their environment; in the heavy density sector, for example, "nothing" lin's were much more closely surrounded by "everything" lin's than were the "nothing" neighborhoods in the two lighter density sectors."

The program got underway in mid-February of 1963: the posters went up, meetings were held, 18 fieldworkers fanned out through the "everything" lin's and the health stations prepared to receive inquiries. A set of educational materials was prepared for group and individual discussion, primarily visual aids dealing with the elementary facts about the physiology of reproduction, the reasons for practicing family planning and the major methods of contraception. The fieldworkers offered a wide choice of methods, encouraging couples to select whichever seemed most suitable: jelly, foam tablet, diaphragm, condom, rhythm, withdrawal, the oral pill and the new intrauterine device. (The last is a recent development that holds great promise for mass programs to reduce fertility because it does not require continued supply, sustained motivation or repeated actions on the part of the user. A plastic ring or coil is inserted in the uterus by a physician and remains there; it is extremely effective as a contraceptive, although its mode of action is still unclear.) Contraceptive supplies were provided at or below cost, or free if necessary; the pills sold for the equivalent of 75 cents for a cycle of 20. The same charge was made for the insertion of an intrauterine device.

By the end of June fieldworkers had visited each of the nearly 12,000 designated homes at least once and more than 500 neighborhood metings had been held. Between then and the middle of October followup visits were made to women or couples who had indicated interest and to women who had been pregnant or had been nursing infants earlier in the year. A final phase began in late October and is still continuing; direct action has been terminated, but services and supplies are still available at the health stations, and the momentum of the program is continuing to have effect as of this writing.

There are three ways in which the effectiveness of the whole program will be measured. One is through case records kept for all couples who were visited in their homes or came to clinics as a result of the action program. The second is a before-and-after survey of a random sample of 2,432 women of childbearing age. The final story will be told in fertility statistics to be compiled eventually from the official register.

So far one result has emerged from the before-and-after survey, and it is a key measure of the outcome; at the end of 1962, 14.2 percent of the women in the sample were pregnant, and at the end of 1963, 11.4 percent were pregnant, a decline of about a fifth.

Aside from this one statistic, only the case records are available. Even for the people directly involved it is too early to measure the effect of the program on fertility; an immediate effect would take at least 9 months to begin to show up. A presumptive effect, however, can be gaged from the record of "acceptances," defined as the insertion of an intrauterine device or the receipt of instructions and the purchase of supplies for other methods, together with expressed intent to practice contraception. In the 13 months ending in midMarch of this year the action program was responsible for a total of 5,297 acceptances of family planning, 4,007 of which were from women living within Taichung proper. (The remainder came from outside the city even though no direct action was carried on there.)

How good is that record? There are different ways to appraise the figure of 4,000-odd acceptances within the city. First, the accepters constitute 11 percent of the married women from 20 to 39. Not all the women in that age group, however, were "eligible" to accept family planning as a result of this program. About 16 percent were already practicing contraception to their own satisfaction. Another 16 percent had been sterilized or were believed to be sterile. Nine percent were pregnant, 3 percent lactating and 1 percent experiencing menstrual irregularities of one kind or another. If these women are eliminated, only about 55 percent of the 36,000 in the age group were "eligible." Of these 20,000 or so women, the program secured about 20 percent as family planners. Included in that definition of eligibility, however, are women who actively want another child-young wives who have not completed their families or those who want a son. If they are considered not really eligible for contraception at this time, the "currently eligible" category is reduced to some 10,000 women, and those who have taken up contraception in the first 13 months come to about 40 percent of this truly eligible population.

See illustration, p. 35, top, op. cit.

54-459-66-pt. 3B- -18

This arithmetic helps to define a "success" in the spread of family planning in the underdeveloped countries. At any given time somewhere between half and three-fourths of the target population is simply out of bounds for the purpose. If a program can get as many as a half-or even a third or a fourth-of the remaining group to begin practicing contraception within a few years, it has probably achieved a good deal. In this kind of work, then, having an impact on 10 percent of the target population in a year or so is not a disappointing failure but a substantial success: one should report "fully 10 percent," not "only 10 percent." Another way to appraise the Taichung results to date is to recognize that whereas in February 1963, about 16 percent of the married women from 20 to 39 were practicing contraception, by March of this year about 27 percent were doing so, an increase of nearly 70 percent.

The impact of such a program is not felt immediately or at one time or evenly. At the outset the acceptance rate was remarkably constant, but after some 7 weeks, when 40 percent of the home visits had been made and wordof-mouth reports of the program were well established, the curve began to climb steadily (see illustration below). It hit a plateau in about 4 weeks and stayed there for about a month before declining. This was the height of the program, when two-thirds of the home visits had been completed and interest was strong. By the beginning of June, when nearly all the visits had been made, the cream had been skimmed: the women who were strongly motivated toward family planning had heard of the program and had decided what they would do about it. By the end of the summer followup visits were reaching less motivated women and the curve returned to its starting point. In the fall, when home visits ended but supplies and services were still available, the acceptances settled to a lower but steady rate.

A program of this kind, then, apparently starts off reasonably well, builds up quite rapidly and achieves roughly half of its first year's return within the first 4 months. The important thing is to develop a "critical mass" that can generate enough personal motivation and social support to carry on without further home visits. A poor country simply cannot afford visits to the entire population, so any realistic plan must rely heavily on personal and informal contacts from trusted sources; it may be that the job will have to be done by relatives, neighbors and friends or not at all. The task of a planned program will thus be to develop enough knowledgeable and convinced users of contraceptives to start a movement that reaches out to the ill-informed and unconvinced.

Progress of action program is traced by a curve showing the trend of "acceptances" of contraception in Taichung each week from the end of February 1963, to mid-January 1964. The three heavy vertical grid lines show (left to right) the points at which 40 percent, 62 percent, and 85 percent of the home visits had been completed. The program reached a peak, then leveled off.

The indirect effects were extremely important in Taichung. The most dramatic indication is the fact that by the end of 1963 some 20 percent of the acceptances had come from women who did not even live in the city. (That figure has since risen to almost 25 percent.) Within the city about 60 percent of the acceptances were from "Everything" lin's; the other 40 percent were divided about equally between the "Nothing" and the "Mail" lin's. Even in the "Everything" neighborhoods about a sixth of those who accepted contraceptives actually came forward before their scheduled home visits had been made. Direct home visits, in other words, accounted for only some 40 percent of the acceptances by the end of December.

As for the effectiveness of various concentrations of effort, the proportion of those who accepted contraceptives was indeed higher in the heavy-density sector, but this effect was almost completely within the "Everything" lin's themselves (see illustration below). The indirect effect-the "ruboff" from the home-visit areas to the "Nothing" and "Mail" lin's-was remarkably constant in the three sectors. Our tentative conclusion is that the maximum return for minimum expenditure can be obtained with something less than the heavy-sector degree of concentration. Finally, the added effect of visiting husbands as well as wives was not worth the expense, perhaps because in this program the preferred contraceptive method was one involving the wife alone.

Results of the program are given as of the end of last December. The figures show the accepters as a percent of the married women aged 20 to 39, by "treatment" and density sector.

The nature of the contraceptive method, as a matter of fact, has more of an effect on the success of a program than may have been generally recognized. A "onetime" method requires far less field effort over a long term than a method dependent on resupply and sustained motivation. In Taichung the choice turned out to be overwhelmingly for the intrauterine devices, which were preferred by 78 percent of those who accepted contraceptives; 20 percent selected one of the more traditional methods (mainly foam tablets or condoms) and 2 percent chose the oral pill (which was, to be sure, the most expensive method). The women themselves, in other words, elected the onetime method. This was particularly significant in view of the method's high effectiveness and what might be called its accountability through scheduled medical followups. The 6-month checkup shows that only some 20 percent of the devices have been removed or involuntarily expelled, whereas about 30 percent of the women who chose the traditional methods are no longer practicing contraception regularly.

The Taichung study revealed another significant advantage of the intrauterine device: a striking tendency for information about it to be disseminated indirectly by word of mouth, obviating much of the task of communication and persuasion. Nearly 75 percent of the new devices were accepted without the necessity of a home visit, compared with only 15 percent in the case of the traditional methods. The intrauterine devices "sold" themselves; what the home visits did, in effect, was to secure acceptance of the traditional methods. Since last October, when the action program proper was terminated, more than half of those who have

See illustration, p. 36, lower, op. cit.