Research in Kenya in the mid-1990s suggested poor quality family planning services and limited access to services. Clinical guidelines for family planning and reproductive health were published in 1991 and updated in 1997, but never widely distributed. Managers and trainers chose intensive, district-level training workshops to disseminate guidelines and update health workers on guideline content and best practices. Training workshops were held in 41 districts in 1999. Trainees were instructed to update their untrained co-workers afterwards. As a reinforcement, providers in randomly selected areas received a 'cascade training package' of instructional materials and training tips. Providers in 15 randomly selected clinics also received 'supportive supervision' visits as a second reinforcement. A cluster-randomized experiment in 72 clinics assessed the overall impact of the training and the marginal benefits of the two reinforcing activities. Researchers and trainers created several dozen indicators of provider knowledge, attitudes, beliefs and practices. Binomial and multivariate analyses were used to compare changes over time in indicators and in aggregated summary scores. Data from patient interviews were analysed to corroborate provider practice self-reports. Cost data were collected for an economic evaluation. Post-test data collected in 2000 showed that quality of care and access increased after the intervention. The cascade training package showed less impact than supportive supervision, but the former was more cost-effective. Service delivery guidelines, when properly disseminated, can improve family planning practices in sub-Saharan Africa.
