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In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (KEN-13)For the past 20 years, Chogoria Hospital has run a steadily expanding clinic and community-based health service program in Meru District. This hospital, with its 32 satellite clinics and its catchment area, has been renowned for its high contraceptive prevalence and low fertility rate compared to the Kenyan national average and that of many sub-Saharan countries. Several factors have contributed to this success, including community-based distribution by family health educators (FHEs) and community health workers (CHWs). Through these community-based distributors, family planning (FP), child welfare, and antenatal clients who fail to turn up for appointments within a month after the default date are followed-up and encouraged to visit a clinic. Financial support for this default tracking system has been ensured through donor funds. Lately, however, the longterm sustainability and usefulness of the tracking system have been questioned. In response to this concern, the management at Chogoria Hospital asked The Population Council to evaluate the default tracking system. This study, which cost US $15,080, determined the extent to which the default tracking system is effective in identifying, tracking, and bringing defaulters back to the program. In addition, the cost of tracking down and bringing back a client was determined. A third component involved assessing the attitude of clients towards this activity and their consequent behavior when they visit Chogoria or other clinics. Data were collected from interviews with 654 defaulting clients using a general questionnaire and 3 other ones specific to FP, child welfare, and antenatal issues. 4 teams composed of local school teachers, with heads of schools acting as supervisors, identified and interviewed the defaulters over a period of 13 days. The teams, who had substantial previous experience in interviewing and data collection, received a week-long training session which included 2 days of fieldwork. A different questionnaire was used to collect information from CHWs. These data were supplemented by information received from field team observations. True defaulters were few, and the impact of CHWs and FHEs in bringing back these clients was low (11-17%). The benefits derived from bringing back a defaulter were negligible compared to the high cost of deploying the CHWs and FHEs. As a result, it was recommended that the default tracking system be discontinued. In addition, it was suggested that the CHWs and FHEs be supervised more effectively and that they concentrate their efforts on other community health activities such as primary health care counseling.
[Unpublished] 1993. Presented at the 8th International Conference on AIDS and African Congress on Sexually Transmitted Diseases in Africa, Marrakech, Morocco, December 16, 1993.  p.New national and community structures must be developed to ensure that the concerns and problems of young people are heard and that their potential as a resource rather than as a problem are fully realized. This conclusion can easily be reached after reviewing concerns voiced by an international group of young people from African countries convened by UNICEF and the World Health Organization to describe the needs and problems of youth in health and development and what can be done about them. The following insights were offered by the youths: there is widespread ignorance of AIDS in rural areas, among young people, and especially among homeless street children; there is an overwhelming lack of access to information about sexuality, misinformation on the subject, and a lack of communication with parents about sex, HIV, and AIDS; youths learn from peers and experience considerable peer pressure; they are worried about teen pregnancy and cultural practices which force young women to have sex with older men; homosexuality is practiced in schools, but often denied or not acknowledged; youths fear the violence of the military killing them and of men raping women; and they complained about negative images and messages in the international media, political corruption, an inadequate educational system, a discriminatory health system, social and religious taboos against seeking STD and family planning services, and the lack of confidence given to their ability to behave responsibly and contribute to the development of society. The youths recommend that young people be involved in making policy and implementing programs to rectify these problems. They call for government and donor agencies to fund youth initiatives, confront poverty, and in collaboration with nongovernmental organizations, youth clubs, and social workers solve the plight of street children. Family life education programs should be organized by youth and targeted at youth; sex and health education programs should be integrated at all educational levels; youths infected with HIV and people with AIDS should be counselled and cared for by their peers; adults who feel comfortable talking to youth should be identified and trained to deal with matters relating to sexuality among youth; many young people should be trained as peer educators; communication between parents and children should be improved through the development of proper communication skills in the appropriate fora; teachers and health workers should be trained to have warm and welcoming attitudes, and to listen nonjudgementally to young people; and religious leaders should be mobilized to discuss sexuality with young people, hopefully advocating condom use.
JOURNAL OF FAMILY WELFARE. 1993 Mar; 39(1):33-5.In 1960-70, right-wing, authoritarian governments in Latin America condoned the raping of female political prisoners, thereby setting the tone for civil police to do so. Police officers in Venezuela often rape sex crime victims who seek their help. Caracas' police chief has fired officers for being sexist and taking advantage of women. In 1984, a psychologist formed the Venezuelan Association for an Alternative Sexual Education (AVESA) to give rape victims somewhere to go for counseling. Its sex education programs target diverse groups. Funding from the UN Development Fund for Women launched AVESA's sex education program for police officers in April 1990, which attempts to sensitize police to rape victims. It has trained 450 police officers, 20% of whom are female police officers. A graduate claims that this AVESA training is responsible for him treating a rape victim with dignity which he would not have done before the course. A female police officer says that, before the AVESA course, she would have asked a rape victim what she did to provoke the rape. She credits the course for showing her how deeply ingrained sexism is in society. For example, men in the course blamed women for becoming less desirable after having children and for not wanting to have sexual intercourse anymore, thereby justifying their right to beat them. Statistics confirm that women are indeed afraid of reporting sex crimes to the police. In January-June 1990, there were 37 reported cases of sexual violence, but AVESA provided help to 146 rape victims. A mother of a 5-year old rape victim reported to the media the undignified way the police treated her, resulting in the arrest and conviction of the middle-aged physician who raped her daughter. AVESA also lobbies for changes in the inherently sexist legal system (e.g., it allows men to rape their wives).
HEALTH FOR THE MILLIONS. 1993 Jun; 1(3):8-10.India has massive problems and is in need of improving and expanding non governmental organization (NGO) programs by broadening the scope of NGO activities, identifying successful NGO activities, and by moving closer to the community to participate in their activities. The problems and experience in the last few decades indicate that with expansion bureaucratization takes place. The institution begins to depend on donors and follows donor-driven agendas. As more money is given by the government, many more so called GONGO or Government-NGO projects materialize. Another problem is that the government almost always approaches the NGOs for the implementation of a project, and there is complete lack of cooperation at the planning stage. The government is considering a loan from the World Bank and UNICEF to launch a mother and child health program, but there has not been any discussion with the dozens of people who have worked on issues concerning mother and child health issues for many years. There is a need to be more demanding of the government about the various programs that are implemented for the government. Very few NGO health and family welfare projects are run by ordinary nurses or ordinary Ayurvedic doctors under ordinary conditions. Since successful NGO work has to be extended to other parts of the country, they will have to be run by ordinary people with very ordinary resources. Over the years, the NGO community has become preoccupied with its own agenda. Today, despite very sophisticated equipment and infrastructure, they are not able to reach the 60,000-70,000 workers and employees. Some of the ideas with respect to the strengthens and weaknesses of community participation have to be shared. NGOs should include all the existing non governmental organizations throughout the country, and have a dialogue with other nongovernmental bodies such as trade unions. The challenge is to adjust the current agenda, prevailing style, and present way of operating and move closer to the people.
ADVANCES IN CONTRACEPTION. 1993 Jun; 9(2):129-39.Quality of care means that the needs of the clients should be the major determinant of the behavior of the providers and the goal of the programs. Quality of care can be considered a right of the clients, defining clients not only as those who approach the health care system for services but also as everyone in the community who is in need of services. Any member of the community who is of reproductive age should be considered a potential client for family planning (FP) services. The International Planned Parenthood Federation (IPPF) has outlined 10 rights of FP clients: rights to information, access, choice, safety, privacy, confidentiality, dignity, comfort, continuity, and opinion. Program managers and service providers should achieve fulfillment of the rights of the FP clients. This goal is directly related to the availability and quality of FP information and services. The responsibilities for quality of care are distributed throughout the whole FP program, but those who are actually seen as most responsible are the ones who are in direct contact with the clients; the service providers. The needs of the service providers can be enumerated as a need for training, information, infrastructure, supplies, guidance, back-up, respect, encouragement, feedback and self-expression. The interaction between clients and providers of contraceptive services could be an exchange of knowledge, needs, and experience that contributes to the personal growth of both. Quality of care involves physical, technical, and human aspects. When fulfilling the rights of the clients and needs of the service providers, both technical and human aspects should be taken into account.
Social Science and Medicine. 1993 Jul; 37(1):97-103.Dehydration from diarrheal disease is the leading cause of infant and child mortality in many developing countries. World Health Organization (WHO) policy recommends oral rehydration solution (ORS) for its treatment and prevention. In concordance with this recommendation, many community-based oral rehydration therapy programs have been implemented since the late 1960s, making ORS widely available and affordable. The solution, however, has not been incorporated universally where needed into people's health-seeking practices. A study was conducted on the household management of childhood diarrhea in a poor, urban neighborhood of Managua, Nicaragua, over the period February 1987 - April, 1988. Results are based upon data collected from interviews with 8 key informants and 109 mothers, and 44 reported cases of diarrhea. Despite the provision of ORS by state health facilities, pharmacies, and informal drug vendors, and health education efforts to change mothers' beliefs and practices, the appropriate use of ORS was not common in the household management of diarrhea. Mothers knew about dehydration and diarrhea, but their explanatory models and actual practice reflected heavy reliance upon self-prescribed pharmaceuticals and home remedies; ORS use was associated with clinic attendance. These findings underscore the existing obstacles to changing people's explanatory models for illness and illness management. To best effect positive, healthy change, the context in which treatment options are assessed and used must be understood.
NETWORK. 1993 Mar; 13(3):6-10.70 million women worldwide now use oral contraceptives (OCs), but many more women could use them if it were not for some medical attitudes, regulations, or practices preventing them from using OCs. For example, in the US, adolescents may need their parent's permission, even though the services cost nothing. 30 years of research on OCs, the most studied family planning method ever, show that they are a convenient, effective contraceptive. These medical practices and attitudes which limit access to OCs cannot be justified scientifically, particularly when weighing the risk of pregnancy. In fact, the only group of women at high risk of using OCs are smokers older than 35 years. Prescribing practices and safeguards when OCs were first marketed were necessary because the medical community knew little about them, but today they are needless barriers to access. Some unnecessary precautions are restricting OCs to women who have already experienced childbirth and OC users needing a rest period. Today's OCs have much lower doses than the earlier OCs. Many conditions once considered to be absolute contraindications should now be considered signs to closely monitor OC users. Moreover, present US guidelines for progestin-only OCs list contraindications which actually apply to combined OCs that contain estrogen and not to progestin-only OCs, e.g., lactation, yet progestin-only OCs are ideal for lactating women. WHO and other groups have joined together to standardize eligibility criteria for OCs at the international level. INTRAH has already produced some guidelines to get rid of the complicated method of classifying contraindications. Other barriers to OC use are requirements of undergoing a physical examination of having blood drawn. Adequate counseling can screen for contraindications as well as, or perhaps better than, exams and blood tests.