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Increasing the availability and acceptability of contraceptives through community-based outreach in Bas Zaire Programme d'Education Familiale (PRODEF). Original.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (ZAI-01)The Tulane Family Planning (FP) Operations Research (OR) Project in Bas Zaire (known locally as PRODEF) aims to increase the availability and acceptability of modern contraceptives in an urban and a rural area. The urban program offers FP only, whereas the rural program integrates FP with 3 interventions for children under 5 years of age: anti-malarial drugs, anti-helminthic drugs, and rehydration salts. The objectives of this project, which cost US $623,504, were to: increase knowledge and use of modern contraceptives; improve attitudes toward FP; decrease "ideal" family size; and increase appropriate treatment for children under 5 years of age who have malaria, intestinal helminths, and dehydration due to malaria. The project tests 2 alternative strategies for the delivery of FP services. In treatment area A, dispensaries distribute contraceptives (and the rural children's drugs) and outreach activities are conducted. In area B, dispensaries distribute contraceptives (and the rural children's drugs), but there are no outreach activities. In the rural villages that do not have a dispensary, a matrone selected by the villagers is trained by PRODEF to serve as a distributor. Pre/post-intervention surveys were conducted in all project areas to measure changes in FP knowledge and practice and the relative effectiveness of the 2 approaches. Service statistics were used to monitor project activity, and cost/couple month of protection (CMP) was compared. The promotion of modern contraceptives was found to be culturally acceptable. Offering FP services only was acceptable in the urban area. The number of ever-married women who had ever used a modern contraceptive rose from 10 to 48% among women in area A and to 44% among women in area B. The child health interventions greatly enhanced the value of the program for the rural communities. Ever use of modern contraceptives increased from 8 to 34% in area A and from 7 to 27% in area B. The matrones were an efficient and culturally acceptable distribution channel. Simply making the contraceptives available increased contraceptive prevalence. However, the level of contraceptive prevalence was greater in area A, which also received outreach. Current use of modern methods in the urban area increased from 4 to 19% in area A and from 5 to 16% in area B. In the rural area, modern method use increased from 5 to 14% in area A, and from 2 to 10% in area B. The number of women using a traditional method decreased from 60 to 48% in area A and from 65 to 53% in area B; however, traditional methods are still used more than modern methods by a factor of 2:1 in the urban area and by over 3:1 in the rural area. The baseline survey showed that 95% of all women know at least one traditional fertility control method and about 80% had heard of at least one modern method. At follow-up, almost all urban respondents knew at least one modern and one traditional method. In the rural area, 90% knew at least one modern method. In the urban region, cost per CMP was US $7.11 in area A and $6.18 in area B; in the rural region the respective costs were US $11.22 and $7.95.
Community-based distribution (CBD) of low cost family planning and maternal and child health services in rural Nigeria (expansion).
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (NGA-02)A community-based distribution (CBD) project has been in operation since 1980 in Oyo State, Nigeria. As a result of word-of-mouth communication among health professionals, television coverage of graduation ceremonies, and positive political feedback from the pilot area, the state government requested assistance in expanding the program. In collaboration with the State Health Council, the Pathfinder Fund, University College Hospital, and the Center for Population and Family Health of Columbia University, the program was expanded in 1982 at a cost of US $237,517. In each of the 4 health zones of the expansion area, a Primary Health Center (PHC) became the training and supervisory center. The expanded program was modified in light of experience in the pilot area. Monthly stipends to CBD workers were eliminated and, because of government policy, no fees were to be charged for services. (This policy was later reversed.) Also, a full-time CBD supervisor was assigned to each zone, rather than relying on individual maternity staff members for supervision. Each zone was limited to 100 CBD workers. Data collection included baseline and post-intervention knowledge, attitudes, and practice surveys and a village documentation survey to estimate the service population. The project also carried out in-depth CBD worker interviews, structured observations of training, mini-surveys, analyses of supervision records and service statistics, and a case study of the impact of the CBD program in which villagers were interviewed about the educational and clinical roles of the CBD workers. Although initial family planning (FP) acceptance was low, ever use of a modern method has increased from 2 to 25% in the pilot area. About half of the married women of reproductive ages in the project area are not sexually active at any one time because of postpartum abstinence. Most of the acceptance of modern contraceptives replaces use of traditional abstinence. Male promoters have proved to be an asset to male acceptance of FP services. Individual monetary incentives are not required to motivate CBD workers; however, once incentives are given, difficulties are created if they are stopped, as they were in the pilot area. The CBD approach has changed the concept of health care from that of providing services to clients who come to a fixed site to reaching out to provide services to all people living within a particular catchment area. The expanded project was subsequently extended into additional areas of Oyo State by the State Health Council. In addition, a conference to discuss the project, held in January 1985, was attended by health program managers and policymakers from all parts of Nigeria. The conference stimulated planning by State and Federal Ministries of Health to undertake CBD as a major strategy for primary health care in rural areas.
Lancet. 1995 Nov 11; 346(8985):1304-5.The military deployment of members of the 21-nation United Nations Transition Authority Cambodia (UNTAC) was unconventional in nature (largely non-combatant peacekeeping where soldiers stayed in garrison, were well paid, had an abundance of free time, and were encouraged to mix with the local inhabitants). The high reported prevalence of human immunodeficiency virus (HIV) infections among local prostitutes prompted the Indonesian military to screen the 3627 soldiers participating in UNTAC. 1658 soldiers were pre- and postscreened, and 1929 were postscreened only. Specimens that were found to be positive twice by Pasteur enzyme-linked immunoabsorbent assay (ELISA) were confirmed by western blot. Overall prevalence was 3.3 per 1000 (12 out of 3627 soldiers). The annualized seroconversion rate (negative pretest, positive posttest) resulting from 6 months (mean) of peacekeeping experience in Cambodia was 2.2 per 1000 soldier-years. In the population screened only after their return to Indonesia (in the absence of predeployment data), the prevalence was 3.62 per 1000 soldiers screened. Only 1 soldier (0.5 per 1000) was HIV-1 reactive before departing for Cambodia. Prescreened soldiers served as historical controls for comparing prevalence among those postscreened only. The negligible prevalence found in predeployment testing and the low level transmission of HIV-1 within high risk groups in Indonesia indicated that the 7 HIV cases found in post-only screening acquired the virus in Cambodia. Follow-up testing using polymerase chain reaction genotyping and ELISA serotyping with confirmatory DNA sequencing in 6 of the 7 cases indicated subtype E, which is found in Thailand, the likely source of the HIV-1 spread into Cambodia. The predominate subtype found in Indonesian risk groups is subtype B. The actual seroconversion rate (including the 7 only-postscreened HIV-1 positives as probable seroconverters) was 6.3 per 1000 soldier-years.
[Unpublished] 1979 Jul 16. 23, , 5 p. (EGY-02)Building on previous AID-supported research by the American University in Cairo, specifically a study of household contraceptive delivery, the Social Research Center (SRC) expanded a household distribution system tested in Shanawan to 38 rural villages in the Menoufia Governorate. The project, which cost US $919,440, was designed to test the effectiveness of the household-based approach to delivery of family planning (FP) services. Like the earlier project, this study was based on the assumptions that there was an unmet demand for contraceptives and that this demand could be systematically identified and met in a culturally acceptable way, using lay women as distributors. Once a community is systematically exposed to FP information and services, a community-based resupply system can effectively meet the ongoing demand for services. The project tests 4 different FP systems, where a first round of free household distribution is followed by: 1) free resupply at the clinic; 2) free resupply in the village; 3) resupply sold at the clinic; and 4) resupply sold at a village depot. Distribution and resupply agents were local women. The study employed a quasi-experimental design. Villages were matched as far as possible on sociodemographic characteristics and contraceptive usage and were randomly assigned to one of the 4 types of delivery systems. Data were collected through a baseline survey conducted at the same time as the household distribution of contraceptives to assess contraceptive behavior. A follow-up survey conducted 9 months later with eligible women only (married, fecund, and age 15-44) was designed to evaluate the household delivery system and focused on contraceptive and fertility behavior. Prevalence increased from 19.1% at the baseline to 27.7% 8 months after the distribution (relative increase of 45%). The delivery system proved to be culturally, logistically, and administratively feasible. There was no significant difference in prevalence between those groups who were charged for a resupply of contraceptives and those who were not. Prevalence increased from 19.5 to 28.5% in the former group and from 18.7 to 26.9% in the latter. Based on this study, a modified version of the tested delivery system was implemented in collaboration with the Governorate of Menoufia among the entire rural population of 1.4 million. The modified system included a wider range of contraceptive methods as well as health and community development components.
Influence of village level health and birth spacing conducted by religious leaders on contraceptive acceptance and continuation rates.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (GAM-02)Although awareness of family planning (FP) in rural Gambia is relatively high for West Africa, contraceptive use remains low because of the belief among many in this strongly Islamic country that Islam opposes the practice of FP. To increase the acceptability of FP, a social mobilization project using Islamic religious leaders (Imams) was launched by Save the Children Federation USA (SCF), in collaboration with the Africa operations research/technical assistance (OR/TA) project at a cost of US $68,114. The OR study tested whether village meetings led by local Imams can overcome perceived religious objections to FP and increase the acceptability of contraceptive services. Specific objectives were to: 1) orient village Imams to the benefits of birth spacing through the use of modern contraceptives; 2) hold 2 meetings in each of the 22 villages, over a year, on FP health topics led by Imams; and 3) measure the effect of these activities on the awareness and use of FP services by rural Gambians. The campaign identified and promoted the ways in which Islam clearly supports birth spacing for maternal and child health (MCH). Local and national Imams joined with SCF staff to present talks and films about FP. Baseline and impact sample surveys and focus group discussions were conducted. Immediately after each round of village meetings, a mini-survey and focus group discussions were carried out. This approach raised the awareness of both Imams and villagers about the relevance of teachings in the Koran and other holy texts about MCH. In particular, the open discussion of fertility regulation, which was previously regarded as taboo, encouraged more women to seek FP advice and services from community health nurses. In the post-intervention survey, almost all respondents were aware of FP, and more than 90% of the respondents (both men and women) were able to define the term correctly. After the village meetings, levels of contraceptive knowledge rose considerably for virtually all methods. On average, prompted knowledge was higher than unprompted knowledge (by 25% for men and 18% for women). At the initial survey, 20% of men and 13% of women knew of Islamic teachings related to FP. At the post-intervention survey, these proportions had risen to 50%. Focus group discussions revealed many qualitative data regarding attitudes towards FP, with noticeable shifts in reasons for using and not using contraception. Current use rose from 11% for both sexes to 24 and 30% for males and females, respectively. The project is being expanded, and SCF is continuing to support Imam village meetings about FP. As recommended at the dissemination seminar, a delegation of scholarly Imams from Egypt visited local Imams to provide leadership. Some local Imams are still skeptical about the use of contraception by unmarried couples, but, on the whole, this project generated a great deal of support for the use of FP.
Implementing a counseling training program to enhance quality of care in family planning programs in Ecuador.
[Unpublished] 1989. Presented at the 117th Annual Meeting of the American Public Health Association [APHA], Chicago, Illinois, October 22-26, 1989. 9,  p.To address the need to improve and expand the level of counseling offered trough family planning programs in Latin America, the Asociacion Pro-Bienestar de la Familia Ecuatoriana (APROFE), an affiliate of the International Planned Parenthood Federation, provided counseling and interpersonal communication training to its 149 staff members in 1988- 89. Before the workshops were held, 724 clients at 6 APROFE clinics were surveyed to provide a baseline assessment of the quality of care from the client's point of view. The 2-day workshops focused on counseling skills, values clarification activities in the area of human sexuality, and the importance of informed choice to the quality of client care. A KAP test was administered to staff before and after the training. The client surveys indicated overall satisfaction with APROFE in the areas addressed--cost, hours, privacy, informed consent, and attitudes of personnel--but pinpointed areas for change, including a preference for specific appointment times, more information on sexually transmitted diseases and acquired immunodeficiency syndrome, and a failure of some staff to provide information on the entire range of contraceptive choices. The clinic's director of counseling has become involved in the selection and training of new staff members. Workshop participants have expressed a need for additional training about ways to counsel clients on matters related to human sexuality and to overcome the sociocultural barriers to such discussions.
HYGIE. 1989 Mar; 8(1):26-9.Activities of the WHO-Shanghai Collaborating Center in Health Education are described. The Center is a joint venture between WHO and the Shanghai Health Education Institute, and as such it is intended to have international significance. Its aims are to strengthen the impact of health education in primary care and to utilize effective health education technologies. Since 1956 the Center has provided guidance to districts and counties in the form of promotional materials for basic medical units, trained health personnel and conducted health promotion activities. There are 70 staff in 5 divisions: publications, art, publicity, administration and audiovisuals. Methodologies are both tested and used as a vehicle for human resource development, by training health staff on the job. Some current projects include anti-smoking educational programs for workplaces incorporating baseline and follow-up assessments, and production of media programs such as documentaries, TV series, short spots, and video cassettes, approximately 1 every 3 weeks. Several productions won national awards in 1986. An international exchange program with the University of California at Los Angeles was held to explore how the Chinese apply health education in the community. Consultation services are provided through WHO. Progress in health education in China is limited by the lack of translated literature on health education.
Brazilian popular healers as effective promoters of oral rehydration therapy (ORT) and related child survival strategies.
BULLETIN OF THE PAN AMERICAN HEALTH ORGANIZATION. 1988; 22(4):335-54.In Ceara State in northeastern Brazil in 1986 infant mortality reached 110-139 per 1000 live births, and 50% of those deaths were due to diarrhea and dehydration. Diarrheal deaths can be prevented by oral rehydration therapy (ORT), which replaces lost fluids and electrolytes with oral rehydration salts (ORS) and water. ORT was known in the 1830s, but only in the 1960s was the importance of sugar, which increases the body's ability to absorb fluid some 25 times, realized. In northeastern Brazil access to ORT has been severely limited by poverty, official incompetence, and bureaucratic restrictions. In 1984 a 2-year research project was initiated in the village of Pacatuba to test the theory that mobilizing and training popular healers in ORT would 1) increase awareness and use of ORS, 2) promote continued feeding during diarrhea, 3) increase breast feeding, and 4) reduce the use of costly and nonindicated drugs. 46 popular healers, including rezadeiras and oradores (prayers), Umbandistas (priests), espiritas (mediums), an herbalist, and a lay doctor, were recruited and trained. Most of these people practiced a mixture of folk medicine and religion and were highly respected in the community. For purposes of survey, Pacatuba was divided into 3 groups, each containing houses at 4 different income levels. The mothers in 204 Group 1 homes were interviewed concerning ORT and diarrhea-related knowledge before intervention, and 226 households in Group 2 were interviewed after intervention. The healers were taught the basic biomedical concept of rehydration and how to mix the ORS -- 7 bottle cap-fulls of sugar and 1 of salt in a liter of unsweetened traditional tea. The healers were also taught how to use the World Health Organization's (WHO) ORS packets (2% glucose, 90 mmol/1 of sodium chloride, 1.5 gm potassium chloride, and 2.9 gm sodium bicarbonate) for cases of moderate to severe dehydration. In addition, the healers were taught the 5 basic health messages: give ORS-tea for diarrhea and dehydration (or any similar folk illness, such as evil eye, fallen fontanelle), continue feeding, encourage breast feeding, eliminate drugs, and ask people to seek the healer quickly at the onset of diarrhea. The healers continued to perform all the popular rites and prayers traditionally associated with curing diarrhea. The healers distributed approximately 7400 liters of ORS-tea in 12 months at a unit cost of 48 cents (US). A post-intervention survey of diarrhea-related knowledge was then carried out among the 226 Group 2 households. Before the intervention 2.9% of the mothers knew about ORS; 71.2% did afterward. All of the healers demonstrated that they knew exactly how to mix the ORS-tea. Knowledge of the WHO packets also increased. The number of mothers who continued feeding their children during diarrhea increased to 92%. Following the introduction of the ORS-tea, purchases of the more costly WHO packets and other commercial medications and antibiotics fell off significantly. The people's belief in folk etiologies remained unchanged, showing that traditional healers can be successfully integrated into an effective health care program. The success rate of the ORT program in Pacatuba, carried out entirely by word of mouth, compares favorably with expensive mass media campaigns other places.