Integration of prevention and care of sexually transmitted infections with family planning services: what is the evidence for public health benefits?

It has been widely believed that, by combining the services for preventing and treating sexually transmitted infections (STI) with those for family planning (FP), STI coverage would increase and the combined service would be of higher quality and more responsive to the needs of women. So far, there is little concrete evidence that integration has had such an impact. Besides the absence of documentation, a clear definition of integration is lacking. We therefore carried out a comprehensive review of concrete experiences with integrated services, and present a summary of our findings in this article. The results indicate that the tasks of STI prevention, such as education for risk reduction and counselling, have been integrated into family planning services much more frequently than the tasks of STI diagnosis and treatment. Some STI/FP integration efforts appear to have been beneficial, for instance when the integration of STI/HIV prevention had a positive impact on client satisfaction, and on the acceptance of family planning. Less clear is whether STI prevention, when concentrated among traditional FP clients, is having a positive impact on STI risk behaviours or condom use. A few projects have reported increases in STI caseloads following integration. In some projects, FP providers were trained in STI case management, but few clients were subsequently treated.

STDs, pregnancies affect women's health.

PIP: Many family planning (FP) programs are integrating services to treat and control sexually transmitted diseases (STDs). Educating women about risks associated with sexual intercourse and about ways to protect themselves helps them control their fertility as well as their health. Programs throughout the world illustrate this approach. In Nepal, integrating STD services at a FP clinic led to a dramatic increase in demand for these services and caused the clinic to expand hours, staff, and locations. Education about STD/HIV prevention is integrated with other components of FP service provision, and condoms are provided for FP and STD/HIV prevention. In Latin America, the International Planned Parenthood Federation (IPPF) is conducting pilot programs to integrate FP and STD services, including HIV prevention counseling. The first priority for these programs in Brazil, Honduras, and Jamaica was to prepare staff for expanded responsibilities. Staff training led to a significant increase in client condom use to prevent STDs. One of the IPPF goals is to use group discussions to help women learn how to communicate about sexual issues with their partners and to negotiate for condom use. In Nigeria, focus group discussions are being used to determine how to develop programs to improve partner discussions on reproductive health and HIV/AIDS. Training for AIDS workers incorporates family planning information, and peer education programs have been expanded to cover AIDS, abortion, and pregnancy. Discussion groups are being used effectively to discuss reproductive health topics in a nonthreatening way.^ieng

The integrated management of childhood illness.

PIP: Each year, at least 4 million African children die before they reach their fifth birthday, and 70% of the deaths are caused by pneumonia, diarrhea, malaria, measles, malnutrition, or, more commonly, a combination of these. Despite the fact that sick children often have more than one condition, busy clinics tend to treat only the one that is most obvious. With much of the effort of the past two decades directed to diarrhea, health workers have been taught their clinical skills in a piecemeal, rather than an integrated, fashion. In response to this problem, the World Health Organization and the UN Children's Fund developed a training course for the integrated management of childhood illnesses (IMCI) in 1993. IMCI is now being used in Uganda, Tanzania, and Zambia, and other African countries are preparing to institute it. IMCI relies on a straightforward clinical assessment and classification of illness that does not require the use of a laboratory. IMCI identifies general danger signs that may call for hospitalization of the child and then bases its assessment on the presence of 1) cough and difficulty breathing, 2) diarrhea, 3) fever, 4) measles, 5) ear infection, and 6) malnutrition. All sick children are screened for all of these conditions because IMCI capitalizes on the presence of the child in the clinic (vaccinations are also given if necessary). Training for IMCI involves 11 days, half of which are spent in clinical practice and demonstration and half in the classroom. Each country must adapt the IMCI guidelines and training course to meet its specific needs. Such adaptation provides an opportunity for collaboration among disease-specific programs; it stimulates a review of technical and clinical guidelines; and it provides an opportunity for the health system to focus on its essential drug needs, referral care, and supervisory system.^ieng

Sexually transmitted diseases control in developing countries.

Sexually transmitted diseases (STDs) are a major public health problem now compounded by the advent of AIDS and HIV infection. The size of the problem represented by STDs and HIV is unknown however it is estimated that there are 333 million new cases of STD per annum and currently 15-20 million people infected worldwide with HIV. Control programmes for STDs must prevent the acquisition of STDs, their complications and sequelae and interrupt and reduce transmission. They can also reduce the incidence of HIV infection. Such programmes must place emphasis on health education, condom usage, altering health seeking behaviour and providing case management. The syndromic approach currently offers the most realistic, and cost effective, way in which to treat patients.

PIP: An integrated STD (sexually transmitted disease) and HIV control program is vital to tackling the major public health problem of STDs and HIV/AIDS. The World Health Organization estimates that there are 333 million new STD infections and 15-20 million new HIV infections each year. The two basic principles common to all STD control programs worldwide include prevention of STDs, their complications, and sequelae and the interruption and reduction of their transmission. These principles also apply to bringing about the reduction of the incidence of HIV infection. Primary prevention strategies, which should be accessible to all sexually active adults and youth, include health education and information, education, and communication (IEC). Secondary prevention strategies include promotion of health care seeking behavior, case management of people with an STD, and early detection and treatment of asymptomatic infections through case finding and screening. In developing countries especially, the most realistic and cost effective way to treat STD patients is the syndromic approach. This approach uses algorithms based on common signs and symptoms (e.g., genital ulcer, urethral and vaginal discharge). It can be used either with or in the absence of laboratory support. The two most common causes for genital discharge are syphilis and chancroid, so, given no laboratory support, the health provider would provide treatment for both STDs. The algorithm for urethral discharge is similarly clear cut. That for vaginal discharge is not so discriminating, since this symptom is very common and non-specific with multiple non-sexually acquired etiologies possible. Since most chlamydial and gonococcal infections in women are asymptomatic, active case finding, screening, and partner notification are very important in women-focused STD control programs.

Integrating child development with health and nutrition.

PIP: The relationship between health and nutrition is well known. A similar relationship exists between child development and health and between child development and nutrition. Actions favoring child development should be combined with health and nutrition actions that promote child growth. There is accumulating evidence showing the important interplay between nutrition and activities that strengthen a child's environment and the child's interaction with the caregiver. This research suggests that: children's physical growth and development can be improved both by nutrition and by nonnutritional interventions. The interaction between a child's nutritional status and psychosocial development suggests that child feeding should be viewed as a social, developmental, and nutritional process. Opportunities exist within nutrition programs for linkages with child development activities. In the first 4-6 months of life, much of the mother-infant interaction is focused on breastfeeding. During feeding, the child's relationship with the mother grows; the mother can also observe the development of her child's capacities. Other nutrition programs that could be combined with psychosocial components include weaning, center-based supplementary feeding, nutritional recuperation, growth monitoring, and nutrition education. The first 6 years are critical in the formation of intelligence, personality and social behavior and the negative effects of early child deprivation are cumulative. There are many options available for complementary programming that will promote children's development, beginning from early childhood, including: providing direct attention to children through support to child care and development centers, training and supporting parents and other child caregivers, promoting change in community conditions that adversely affect child development, supporting strategies to strengthen national resources and capacities, e.g., strengthening institutions devoted to improving early childhood development, influencing policy and planning through direct advocacy with policy makers, and providing information to the public to create demand and awareness.^ieng

Integration and family planning programme performance: an interpretive summary of research projects in Malaysia and the Republic of Korea on the determinants and impact of integration in family planning programmes.

PIP: Results are presented of research undertaken in the Republic of Korea and Malaysia to determine how far integration affects the performance of family planning and allied programs and to identify organizational determinants of clinic level interactive linkages. The report discusses the background of the research, provides overviews of the country programs, outlines research methodologies and procedures, and presents findings. 41 clinics with high, medium, and low performance ratings in Korea and 17 main health centers, 31 sub-health centers, and 49 midwife stations in Malaysia, (some of them intensive input demonstration areas) were assessed on performance, interaction measures, and organizational determinants. The overall finding was that integration affects program performance, but the direction of the impact depends on how the integrated programs are organized. In Malaysia, where the program is specifically organized to integrate family planning with maternal and child health, the integration appears to have increased service delivery and resulted in larger numbers of family planning acceptors. No spill-over was found from the inputs of the 2 components to each other. The overall positive impact and lack of service reduction due to integration appears to result from specific planning for a limited degree of integration. In Korea, a mild negative relationship was found between clinic level performance in the family planning and community development, or Saemaul Undong (SU) components. In the field SU was observed to be more favored and powerful, and was not fully integrated with family planning. The major conclusion of the study was that integration works best when family planning is linked to similar services, and does not work as well with services that are different in character or in degree of government support.^ieng