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.

Caring for people with HIV in Zambia: are traditional healers and formal health workers willing to work together?

This study of traditional healers and formal health workers determined their knowledge and practices in the field of HIV/AIDS and examined their training needs and attitudes to collaboration, in preparation for planning joint training workshops. Several misconceptions concerning symptoms and transmission of HIV disease were found in both groups, particularly among traditional healers. Twenty healers (51%) and four formal health workers (15%) claimed a cure existed for AIDS. The majority of traditional healers interviewed expressed difficulties discussing a diagnosis of HIV directly with patients, mainly due to fear of the patient becoming depressed and suicidal. Most interviewees wanted more training--the majority of traditional healers in recognizing symptoms of HIV/AIDS and their treatment, and the majority of formal health workers in HIV counselling. Most were interested in supplying condoms. Almost all healers and half of the formal health workers were keen to collaborate in training and patient care. The study indicates that there is willingness amongst Zambian traditional healers and formal health workers to collaborate in training and patient care in the field of HIV/AIDS. As well as covering symptoms, transmission and prevention of HIV/AIDS, training should aim to increase ability to openly discuss HIV with patients, which many traditional healers and some formal health workers find difficult. Involving traditional healers in supplying condoms may improve acceptability and availability, particularly in rural areas.

PIP: A knowledge questionnaire and a semistructured interview was conducted with 39 traditional leaders (22 males and 17 females) and 27 formal health workers (4 men and 23 women) to determine their knowledge and practices in the field of HIV/AIDS; additionally, their training needs and attitudes to collaboration, in preparation for planning joint training workshops, were examined. Areas explored included symptoms and transmission of HIV/AIDS, treatment, personal risk, condom use and distribution, traditional practices, education and prevention, HIV counseling and testing and collaboration between healers and health workers. Results showed that misconceptions and gaps concerning transmission and symptoms existed in both groups, particularly among the traditional healers. 20 traditional healers (51%) and 4 formal health workers (15%) claimed that a cure for AIDS existed. Most health workers and traditional healers found discussing a diagnosis of HIV directly with patients difficult because of fears that it might make them depressed or suicidal. However, many healers were keen to participate in condom distribution. There was more support for collaboration among traditional healers than among formal health workers; almost all formal health workers but only 8 traditional healers knew of voluntary HIV counseling. Both traditional healers and formal health workers have significant and complementary roles in the field of HIV/AIDS in Zambia, but there is much debate concerning the relationship between them.

[Memisa and home care for AIDS patients in Zambia]. / Memisa en de thuiszorg voor aidspatiënten in Zambia.

Health care in Zambia has since long been receiving support from non-governmental organizations (NGOs) like Memisa. Church organizations bear responsibility for a considerable part of the national health services. During the last 15 years, growing attention has been given to improvement of basic services in the villages and to recruitment and organization of groups in the community active in the field of health care. The combat against AIDS is a major focus. Many NGOs give health education on HIV and AIDS, are coaching HIV-positive individuals and are trying to organize support for AIDS patients and their relatives and relief for women and children after the death of husband or father. The community home care projects established in the urban areas of Copperbelt province in Zambia provide a decent terminal phase for AIDS patients and assist the surviving families in maintaining a certain socioeconomic level of existence.

PIP: In Zambia more than 1.2 million people have been infected with HIV since the beginning of the epidemic in 1983-84, and approximately 300,000 people have developed AIDS since then. Home care for such patients has been organized either through health care institutions (involving visits once every two weeks or a month to the home by medical and nursing personnel) or through the community with outside support, mainly from a nongovernmental organizations (NGOs) such as Memisa. In 1991 a home care program for chronically ill patients was launched by the bishopric of Ndola in the province of Copperbelt. In 5 towns with 400,000-450,000 inhabitants, home care projects were initiated for these patients, who constitute more than 90% of cases of symptomatic HIV infections. Palliative care has evolved over the years toward a holistic form of care consisting of a combination of medical treatment, psychological and pastoral support, counseling and, in some cases, material assistance. The results of the home care are that the quality of the lives of terminal patients have improved, the community has fully accepted the projects, the volunteers and nurses are more alert to the symptoms of serious opportunistic infections, the treatment of tuberculosis has improved, and more openness about AIDS and HIV infection has made possible a positive life concept for many patients. The project also provides support (school fees, clothes, food for children) for the families of patients. Income-generating projects also provide sources of income--mainly for women whose income has been lost as a result of AIDS. In 1996 this project assisted approximately 6000 patients and their families.

Adapting traditional healing practices.

PIP: The Aboriginal people in Canada have been noted to have low self-esteem, subsequently increasing their risk of HIV. To this effect, two traditional healing practices are being used to help these people avoid HIV infection, and to live more healthily and positively if they are infected. The first method is the Medicine Wheel, which is a traditional model used to represent the complex interrelationship among all living things and show how their immune system is physically affected by their emotions and worries. Many Aboriginal AIDS Organizations, counselors and others are now using this AIDS teaching Wheel model. Meanwhile, the second method is the Sharing Circles, which provide an environment where people feel safe to talk about HIV and give participants a sense of support and a means for expression without stigma or judgement. As a result, many people who attend HIV circles begin to take better care of themselves and of others. Overall, it is emphasized that these traditional healing practices can be effectively adapted for use in HIV counseling and education.^ieng

An assessment of care provided by a public sector STD clinic in Cape Town.

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

PIP: In South Africa's Western Cape Province, where sexually transmitted disease (STD) rates are high but HIV prevalence remains low, syndromic STD management in the public health services has been proposed as a strategy for curbing development of an AIDS epidemic. This study, conducted prior to the formal introduction of such a program, evaluated the quality of STD management at a local health authority clinic in Cape Town. 170 male and 161 female new clients presenting during the 6-week study period were enrolled. 76% of men and 81% of women reported they had never used a condom. Only 21% of male and 37% of female clients received health education concerning STD prevention during their visit. Contact slips to facilitate partner notification were provided to 28% of men and 25% of women. Condom use was discussed with just 25% of male and 36% of females. The most common clinical diagnosis made by staff was gonorrhea. According to the research physician's findings, 51 patients (40 men and 11 women) had genital ulcers, the majority of which were not detected by staff. Of 32 men and women diagnosed by staff clinicians as having no infections, 58% of men and 75% of women had at least 1 STD confirmed by laboratory testing. Overall, at least 16% of men and 61% of women left the clinic with 1 or more STD inadequately treated. These findings indicate that introduction of syndromic protocols in South Africa's public health services will not automatically improve STD diagnosis and treatment. Health education to correct misinformation about STDs, condom promotion and distribution, partner notification, and the validity of clinical diagnoses must be addressed.

Quality of care in reproductive health programmes: education for quality improvement.

The provision of high quality maternity care will make the difference between life and death or lifelong maiming for millions of pregnant women. Barriers preventing access to affordable, appropriate, acceptable and effective services, and lack of facilities providing high quality obstetric care result in about 1600 maternal deaths every day. Education in its broadest sense is required at all levels and sectors of society to enhance policy formulation that will strengthen programme commitment, improve services with a culturally sensitive approach and ensure appropriate delegation of responsibility to health staff at peripheral levels. This paper is the second in series of three which addresses quality of care. The first (Kwast 1998) contains an overview of concepts, assessments, barriers and improvements of quality of care. The third article will describe selected aspects of monitoring and evaluation of quality of care.

PIP: This review of educational efforts to improve maternity care opens by noting that education extends beyond training and is required at all levels to enhance policy formulation and improve service delivery. The first section of the article credits the Safe Motherhood Initiative (SMI) with initially advocating education as a strategy for achieving safe motherhood and traces the origins of the SMI to actions of international groups representing midwives and obstetricians/gynecologists. The next section briefly describes the midwifery training modules developed by the World Health Organization and the American College of Nurse Midwives and mentions the few distance learning manuals for midwives that are available. The article continues with an overview of clinical-skills training developed for midwives, for physicians and assistant physicians, and for traditional birth attendants. Next, the article considers the incorporation of interpersonal communication and counseling skills into training efforts and notes that newly integrated family planning/sexually transmitted disease services will require differing applications of counseling skills and, thus, will pose a challenge to medical education. The article then reviews how the provision of management and leadership training can improve quality of care as newly-formed leadership qualities provide health personnel with the initiative to tackle minor problems and improve information management. Finally, the article reviews "excellent" examples of community participation achieved in SMI programs and notes that health workers need training on how to establish successful community partnerships.

Survey of subfertility patients attending a community clinic over a two year span, before and after national folate campaigns.

PIP: Findings are presented from a retrospective survey of two cohorts of new patients seeking subfertility advice who presented to the subfertility and preconception service of the Croydon Community Health Trust. The first cohort of 40 women presented between April 1, 1995, and March 31, 1996, and the second cohort of 36 women presented between April 1, 1996, and March 31, 1997. The national folate supplementation campaign was conducted in March-April 1996, during which local activities were held to increase awareness among health professionals. The women in cohorts 1 and 2 were aged 21-42 and 19-43 years, respectively, and had been attempting to become pregnant for 2-96 months. 45% of women in the first cohort and 36% in the second cohort had never been pregnant, while 12.5% and 27% of women in the two cohorts, respectively, had a prior history of pregnancy termination. A low incidence was observed at the clinic of correct usage of folate at the time of first attendance throughout the entire period and although folate supplementation had been discussed with some of the women upon their referral to Croydon, 100% uptake of such supplementation had not been achieved. Family planning patients at community services in Croydon should be offered routine rubella testing within 1 year of first attendance if they have not previously given birth in the UK since 1980. Furthermore, couples who are attempting to conceive must be urged to stop smoking preconceptually.^ieng

Health-seeking behaviour of patients with sexually transmitted diseases in Zambia.

The aim of this paper is to describe health-seeking behaviour, time with symptoms and sexual activity during symptom period among patients attending the public health sector in urban and rural Zambia for treatment of an STD. The study was conducted at two urban health centres and at one rural mission hospital during four months in 1994 and 1995. Four hundred and seventy nine patients seeking health care for STD symptoms were interviewed. The patients had experienced STD symptoms for one to two weeks before they came to the clinic. During this period two thirds in the urban and one third in the rural setting had had sex. Sixty per cent of the patients in the urban and 50% in the rural setting had taken some kind of medicine before they came to the clinic. More people had used modern compared to traditional medicine, especially in the urban area. Market places, other clinics and doctors, friends, and relatives were common treatment sources. Ten per cent had received medicine from a traditional healer. Thus, a majority of the patients had received medication from other sources before they came to the clinic. Sex during periods with STD symptoms was common. This has serious implications for STD as well as HIV transmission.

PIP: A number of factors influence which treatment sources people seek when symptoms of morbidity occur and a person alone, or with the advice of others, decides that the condition warrants additional attention. Some such factors are related to social structures such as kinship, social networks, gender, and economic status, while others are related to belief systems which define how people conceptualize the etiology of disease. Service quality, the introduction of user fees, and the cost of treatment can also affect health-seeking behavior (HSB). One highly important factor affecting HSB for sexually transmitted diseases (STD) is social stigma. For example, in Zambia, where STDs are a major public health problem, it is considered highly shameful to have an STD, especially for women. This paper describes the HSB, time with symptoms, and sexual activity during symptom period among patients attending 2 urban public health centers and 1 rural mission hospital in Zambia during 4 months in 1994 and 1995 to receive treatment for their STDs. 479 patients seeking health care for STD symptoms were interviewed. The patients had experienced STD symptoms for 1-2 weeks before coming to the clinic. During that period, two-thirds in the urban and one-third in the rural areas had had sexual intercourse. 60% of the patients in the urban and 50% in the rural settings had taken some kind of medicine before coming to the clinic. However, more people had used modern rather than traditional medicine, especially in the urban area. Marketplaces, other clinics, physicians, friends, and relatives were common treatment sources, although 10% had received medicine from a traditional healer.

Compliance, counseling and satisfaction with oral contraceptives: a prospective evaluation.

CONTEXT: Oral contraceptive users' risk of accidental pregnancy may be higher than it should be, because of inconsistent pill-taking. However, few reliable data are available on pill users' everyday experiences with their method, especially characteristics that may affect consistency of use. METHODS: Two months after initiating or resuming oral contraceptive use, a nationwide sample of 943 women completed questionnaires examining their compliance with instructions for proper use, the quality of their interactions with their provider, their satisfaction with the method, and the frequency and costs of visits or calls to their providers because of pill-related side effects. Regression analyses were used to determine the factors associated with compliance difficulties and method dissatisfaction. RESULTS: In all, 47% of users missed one or more pills per cycle, and 22% missed two or more. Women who lacked an established pill-taking routine, who did not read and understand all of the informational material accompanying the pill package, or who experienced spotting or heavy bleeding had increased odds of missing two or more pills per cycle. Method satisfaction was most likely among women who were aware of the pill's noncontraceptive benefits, were satisfied with their relationship with their provider, had used the pill in the past and experienced few side effects. Some 22% of users called their provider at least once about pill-related side effects, and 9% made at least one visit for this reason; these women spent $25 and $62, respectively, to treat side effects. CONCLUSIONS: Improving pill use is a shared responsibility of the provider, the patient and, to a lesser degree, pill manufacturers. Awareness of potential difficulties such as inadequate counseling is a key step in helping women use oral contraceptives effectively.

PIP: The Organon Contraceptive Use Study, a prospective cohort study (1994-96) of 943 US women (mean age, 25 years) recruited through private medical practices, Planned Parenthood clinics, and a health maintenance organization, examined oral contraceptive (OC) use patterns. 95% of study participants began or switched to a new OC brand at study enrollment. At follow up 2 months after enrollment, 47% of pill users reported missing 1 or more pill per cycle and 22% missed 2 or more pills in each cycle. Those who missed 1 or more pill were significantly more likely than those who did not to lack an established pill-taking routine, not to have read or understood the informational material accompanying the pill, and to have experienced spotting or heavy bleeding. 34% rated the OC as a very good method and another 30% considered it a good method. Method satisfaction was significantly higher among OC users who were aware of the pill's noncontraceptive health benefits, had a good relationship with their OC provider, had used the pill in the past, and experienced few side effects. 22% of OC recipients called their provider at least once about pill-related side effects and 9% visited at least once for this reason; these women spent US$25 and $62, respectively, to treat side effects. Recommended, to increase patient compliance and satisfaction with OCs, are measures such as counseling on potential side effects, evaluations of consistency of use at all follow-up contacts, and attention to the quality of the provider-client relationship.

Providing affordable sanitary latrines to low-income urban communities in Mozambique.

PIP: Rapid population growth in developing countries, especially in urban areas, will produce an unprecedented sanitation crisis in the next century. A self-help latrine construction program initiated in 1976 by Mozambique's Ministry of Health offers important lessons for other African countries. Although thousands of latrines were constructed in low-income urban communities in a short time period, the campaign largely failed because of a lack of technical guidance in latrine design and construction and chronic shortages of appropriate building materials. In response, a research project was commissioned in 1979 to identify and develop a suitable technology and methodology for large-scale implementation of improved sanitation in peri-urban areas. This led, in turn, to creation in 1985 of the National Program for Low-Cost Sanitation funded by donors, the central government, and user communities. The technology is based on the concept of a simple, unreinforced domed concrete slab placed over a lined or unlined pit. Employment of community members in local production units enhanced poverty alleviation. Community members also served as animators, assessing the individual needs of those without sanitation, monitoring and evaluating program performance, and promoting hygienic behavior practices. Existing communication channels were used to publicize the program. Despite adverse economic and political conditions, 170,496 improved latrines were installed in 1979-96. The success of this program is attributed to the identification of a simple technological solution, affordability, and an integrated health and hygiene education package.^ieng

Funding women's health work -- no easy answers.

PIP: This article discusses a community's solution to improving women's health in Guatemala. Indigenous women from the highland community of Cajola formed the Asociacion Pro-Bienestar de la Mujer Mam (APBMM). The APBMM identified a need for women health promoters and good, low-cost medicines. The Instituto de Educacion Integral para la Salud y el Desarrollo (IDEI) helped train 16 women as health communicators or promoters in 1996. The health communicators learned about setting up community medicine distribution. The mayor bypassed APBMM's efforts to set up medicine distribution and set up a community pharmacy himself. Someone else opened a private pharmacy. The 200-member group was frustrated and redirected their energies to making natural herbal medicines, such as eucalyptus rub. The group set up a community medicine chest in the IDEI medical clinic and sold modern medicine, homemade vapor rubs, and syrups. The group was joined by midwives and other volunteers and began educating mothers about treatment of diarrhea and respiratory diseases. The Drogueria Estatal, which distributes medicines nationally to nongovernmental groups, agreed to sell high quality, low cost medicine to the medicine chest, which was renamed Venta Social de Medicamentos (VSM). The health communicators are working on three potential income generation projects: VSM, the production and sale of traditional medicines and educational materials, and an experimental greenhouse to grow medicinal plants and research other crops that can be grown in the highlands.^ieng

Cape fearless.

PIP: This article describes the Ilita Labantu (IL) group in South Africa, that is working to reduce child abuse and violence against women. The group started in 1989, with the aim of reducing child rape and sexual assaults in five townships in Cape Town. Child rape is perpetuated by myths sustained by witch doctors and indigenous medicine that promote child rape as a cure-all for symptoms ranging from poverty to AIDS. IL has four satellite groups that educate rape and abuse victims and potential victims. It is assumed that girls are potential victims because of their early unawareness that gender is tied to some patterns of behavior. IL trained mass media groups to educate the general public. IL distributes public information materials on how to identify domestic violence and abuse and how to identify potential rapists within households. Materials are distributed to individuals in community programs and in training programs. Child survivors make presentations in playgroups in a nonthreatening way. IL interacts with courts of law, police stations, hospitals, and schools. The group refers 25-35 cases per day. The group is working on setting up private rooms in police stations where rape victims can make confidential complaints without public attention. IL also works to promote the use of alternative strategies for solving family conflicts.^ieng

Rural and indigenous women speak out on the impact of globalization.

PIP: This article describes approach papers, proposed strategies, and closing agreements among those attending the May 1998 Asian Pacific Forum on Women, Law, and Development (APWLD) among rural, indigenous women (IW). IW spoke of their experiences with globalization. The aim was to examine the effects of deregulation and privatization, liberalization, and global market and foreign monopoly capital on rural, IW in Asia. The expected outcome was an advocacy directive for APWLD in the forthcoming APEC and People's Summit in November 1998. Approach papers included F. N. Burnad's paper on the "Impact of Globalization on Rural Women" and V. Tauli-Corpuz's paper on "Globalization and its Impacts on Indigenous Women: The Philippine Experience." These papers emphasized the multiple roles of women, their increasing resourcefulness which leads to their enslavement, links between globalization and continuing colonization by transnationals and international institutions, access to ancestral resources, and promotion of export led production that threatens food security. Suggested strategies were to mobilize opposition to globalization and greater control over traditional resources and knowledge by IW. Several important questions were raised about nation states, dominant cultures, human rights violations, technology, and the close link between militarization and globalization. Participants agreed to mobilize for effectively resisting and eliminating unjust and unequal systems that exploit and oppress rural, poor, and indigenous people, especially women.^ieng

Reducing risky pregnancies in Somalia.

PIP: In Somalia, the International Planned Parenthood Federation, in consultation with the UN Population Fund, has implemented a successful project to improve reproductive health among the 120,000 residents of the town of Bosasso, most of whom migrated to the town to escape the civil war. A fully-equipped clinic was created in the center of the town in February 1997 and is supplemented by community-based services in rural areas. A husband and wife team of physicians began service delivery by offering prenatal care and general reproductive health counseling. As the women in the community began to learn about the positive aspects of birth spacing and avoiding births at an early or older age, they began to accept family planning (FP) services. After approximately a year of service, the health center is serving about 450 new clients per month. In order to improve attitudes about FP, the clinic held more than 40 community seminars where participants could discuss reproductive health issues. The project also involved training of 11 physicians, 25 nurses, 60 traditional birth attendants, and 120 drug retailers in the town in the delivery of reproductive health and FP services.^ieng

Empowerment at village level through a workshop method.

PIP: This article describes the activities and lessons learned of a 2-day workshop held in Sheikhupura District in Punjab, Pakistan. The project aim was to strengthen primary health care and to include the community in health development. The pilot program established Village Health Committees (VHCs) to promote local participation. Villagers decided that VHCs should be representative of the community. The community elected traditional birth attendants, teachers, holy men, and village activists. Workshops were held with VHCs in order to provide basic concepts of community awareness, organization, and development. Each workshop included 3-4 VHCs. Groups were comprised of up to 6 people. Workshops were held near villages and had access to lavatories. The workshop aims were identified throughout individual sessions and linked with each other. Facilitators kept discussions relevant, objective, and interesting. Participants introduced each other, which provided an opportunity to establish comfort and trust. Initial discussions centered on health issues that were introduced as interrelated. The health system issues was related to the village situation. Participants were asked to develop a health system model. The aim of the sessions was to reinforce the importance of the role of community. An exercise was conducted to illustrate the importance of dialogue and collective work. Participants discussed the nature of community organization and means of development, threats to the village, and empowerment. The workshops created awareness of the process of community involvement in development and were ongoing.^ieng

Providing sexual health services for men in Bangladesh.

PIP: International health advocates, planners, and policymakers agreed at the 1994 International Conference on Population and Development (ICPD) that special efforts should be made to stress men's responsibility in family planning and reproductive health, and to promote their involvement in preventing HIV/STDs and unwanted and high-risk pregnancies. Bangladesh is one of many countries now trying to control reproductive tract infections (RTIs) and STDs by establishing public health programs. Bangladesh's system of primary health care (PHC) has long focused upon maternal and child health and family planning (MCH-FP) rather than the delivery of comprehensive care for all. This exclusive focus has led to the almost total exclusion of men as recipients of reproductive health care services at the PHC level. Following consultations with the community, 4 male sexual health clinics were established and opened between August 1995 and January 1996 for 1 afternoon/week, with opening hours later expanded to 1 day/week. The first such services opened in either the public or nongovernmental organization sectors, the clinics were located in existing MCH-FP buildings and open to all men in the communities free of charge. Male staff were trained according to WHO guidelines on the syndromic management of STDs. By the time they opened, awareness of the clinics' existence had been spread in the served communities through word-of-mouth and interpersonal communication networks. To better serve the large proportion of men with psychosexual problems such as impotence, premature ejaculation, and sexual dissatisfaction, 1 staff member studied male sexual health services in India for 3 months, after which he returned to train his 3 male colleagues.^ieng

World Bank oil-pipeline project designed to prevent HIV transmission.

PIP: A World Bank-funded oil pipeline project, in Chad and Cameroon, is the first large-scale construction project in sub-Saharan Africa to incorporate an HIV/AIDS prevention component. The project entails the development of oil fields in southern Chad and construction of 1100 km of pipeline to port facilities on Cameroon's Atlantic coast. 3000 construction workers from the two countries will be employed between 1998 and 2001, including about 600 truck drivers. In some areas along the pipeline route, 50% of the prostitutes (who are frequented by truck drivers) are HIV-infected. The HIV/AIDS intervention aims to prevent HIV and sexually transmitted diseases (STDs) among project workers through social marketing of condoms, treatment of STDs in prostitutes along the route, and health education to modify high-risk behaviors. The program is considered a test case for African governments and donors interested in whether the integration of a health component in major construction projects can avoid AIDS epidemics in affected countries.^ieng

Understanding lay perspectives: care options for STD treatment in Lusaka, Zambia.

Understanding lay persons' perceptions of STD care is critical in the design and implementation of appropriate health services. Using 20 unstructured group interviews, 10 focus group discussions and 4 STD case simulations in selected sub-populations in Lusaka, we investigated lay person perspectives of STD services. The study revealed a large diversity of care options for STD in the communities, including self-care, traditional healers, medicine sold in the markets and streets, injections administered in the compounds, private clinics, health centres and hospital. The factors identified as influencing care seeking behaviour are: lay referral mechanisms, social cost, availability of care options, economics, beliefs, stigma and quality of care as perceived by the users.

PIP: Lusaka's health system is comprised of 4 hospitals, 22 government urban health centers, 144 private for-profit clinics, and more than 1000 traditional healers and traditional birth attendants. The authors explored laypeople's perspectives of sexually transmitted disease (STD) care services using 20 unstructured group interviews, 10 focus group discussions, and 4 STD case simulations in selected subpopulations of the city. People of differing age and sex were sampled. A large diversity of care options for STD was found in the communities, including self-care, traditional healers, medicine sold in the markets and streets, and injections administered in the compounds, private clinics, health centers, and hospitals. Lay referral mechanisms, social cost, the availability of care options, economics, beliefs, stigma, and the quality of care as perceived by users influence care-seeking behavior in this population.

Gender and advocacy in Indonesia.

PIP: The Centre for Development and Population Activities (CEDPA) and the Indonesian Midwives Association (IBI) have developed a two-phase training program regarding gender issues for the association's midwives. The first phase focuses on the leadership, management, and advocacy skills necessary to articulate program needs and to take part in making decisions regarding family planning and reproductive health. The second phase concerns the integration of gender into project design. Proposals developed by the midwives include the following: 1) to improve counseling services for women in a district where 70% of the women using contraception do not decide for themselves which methods to use; 2) to reduce maternal mortality in a district where it has increased by 20% and where women have died while waiting for husbands or fathers-in-law to make the decision to bring them to hospitals; 3) to develop gender-sensitive materials concerning HIV/AIDS; and 4) to expand gender training to all levels of IBI, to provide follow-up technical support, and to integrate gender into the mission statement of the organization. Dr. Nafsiah Mboi (member of Parliament and vice chair of the Global Commission on Women's Health), Dr. Widyastuti Wibisana (director of community participation in the Ministry of Health), Dr. Kokila Vaidya (WHO Medical Officer), Carla Bianpoen (gender specialist with the World Bank), and Titi Sumbung (director of the Melati Foundation) helped to develop and to conduct the program. IBI, which has 65,000 members, provides family planning, reproductive health, and maternal and child health services throughout Indonesia.^ieng

"Operation REACH". Building public-private partnerships for public health.

PIP: The Society for Family Health (SFH) has embarked on an ambitious program entitled "Operation REACH," which aims to utilize the large volunteer network of community health workers and traditional birth attendants who are attached to almost all rural health centers to distribute socially marketed products. These volunteer community-based distributors (CBDs) attached to the Ministry of Health are an important source of distribution of the SFH products, particularly SafePlan oral contraceptive pills, in areas where traditional private sector outlets are limited. As part of Project REACH, CBDs will be trained to distribute MAXIMUM, SafePlan, and Prolact VFTs--the three products that are socially marketed by SFH. This distribution mechanism could also be utilized when new products, such as the female condom, are added to the SFH portfolio.^ieng