Contraceptive introduction reconsidered: a new methodology for policy and program development.

Although new contraceptive technology has the potential for providing women with expanded options for fertility control, the historical record of international family planning shows that, in practice, introduction of new methods has not always broadened reproductive choice. Using the example of introduction of intrauterine devices into the Indian family planning program in the 1960s, we show that an exclusive focus on the technology itself is problematic and argue that methodologies are needed that relate introduction of new methods to user needs and program capacities. We summarize key findings from the Indonesian experience with Norplant introduction. Although an effort was made to address problems with previous approaches, major deficiencies in both the technical and interpersonal dimensions of care arose when the implants were made broadly available within the program. We subsequently present a methodology for contraceptive introduction developed by the World Health Organization. This methodology emphasizes the social and institutional context in which technology is used and suggests a participatory and research-based approach to program and policy development. We illustrate results from this new approach in its implementation in Vietnam and suggest areas for further evaluation.

Factors related to condom use among four groups of female sex workers in Bali, Indonesia.

This article tests a behavioral model of condom use for four groups of female commercial sex workers. Data were drawn from a study of 614 female sex workers conducted in Bali, Indonesia. AIDS knowledge, risk behaviors, and factors related to condom use varied substantially among the four groups of women and reflect the social context of their work. Interventions for each group need to reflect these differences. Important factors to consider include the level of AIDS and STD knowledge in their environment, the characteristics of the clients served, and the degree of supervision that they receive.

PIP: The efficacy of a behavioral model of condom use was evaluated in 4 groups of commercial sex workers in Bali, Indonesia, in 1992-93: 1) women working in low-price complexes supervised by a pimp in the Denpasar area (n = 407); 2) mid-price women who rent rooms within family complexes or bungalows (n = 77); 3) women working at high-price houses in and around Denpasar (n = 50); and 4) independent workers at the Kuta tourist resort (n = 80). Mean knowledge scores among the 614 prostitutes ranged from 8.3 to 11.6 out of a possible 19. Common misconceptions were that an HIV-infected person could appear healthy and that AIDS can be cured with medicine or injections. The mean number of clients in the week preceding the interview was 15.8 at low-price brothels, 10.5 in the bungalow group, 4.7 at high-price houses, and 3.2 at the resort. Condom use with clients was 19%, 68%, 71%, and 90%, respectively. The effects of independent variables on condom use were evaluated through multiple regression analysis. Among women in the low-price and bungalow groups, condom use was significantly associated with beliefs about condoms' ability to prevent sexually transmitted disease (STD) and pregnancy, the belief condoms enhance sexual pleasure, perceived susceptibility to STDs (but not HIV), self-efficacy, number of clients in the past week, and pregnancy history. For women in the resort area, condom use was related to beliefs about the ability of condoms to protect against STDs and AIDS, perceived susceptibility to HIV infection, and experience with an STD. Finally, among high-price prostitutes, condom use was associated with the belief condoms prevent AIDS and increase pleasure, self-efficacy, and pregnancy experience. These findings indicate that levels of AIDS knowledge and the extent of risky behaviors are related to the particular social context in which sex work is practiced.

The strategic approach to contraceptive introduction.

The introduction of new contraceptive technologies has great potential for expanding contraceptive choice, but in practice, benefits have not always materialized as new methods have been added to public-sector programs. In response to lessons from the past, the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP) has taken major steps to develop a new approach and to support governments interested in its implementation. After reviewing previous experience with contraceptive introduction, the article outlines the strategic approach and discusses lessons from eight countries. This new approach shifts attention from promotion of a particular technology to an emphasis on the method mix, the capacity to provide services with quality of care, reproductive choice, and users' perspectives and needs. It also suggests that technology choice should be undertaken through a participatory process that begins with an assessment of the need for contraceptive introduction and is followed by research and policy and program development. Initial results from Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Vietnam, and Zambia confirm the value of the new approach.

PIP: In response to difficulties associated with the introduction of new contraceptive technologies to public sector service systems, the UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction has formulated a new model. The strategic approach to contraceptive introduction shifts the emphasis from the promotion of a particular technology to quality of care issues, a reproductive health focus, and users' perspectives and needs. It further entails a participatory approach with collaboration among governments, women's health groups, community groups, nongovernmental providers, researchers, international donors, and technical assistance agencies. The underlying philosophy is that method introduction should proceed only when a system's ability to provide high-quality services exists or can be generated. Since 1993, WHO has provided support for the implementation of this perspective in public sector programs in Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Viet Nam, and Zambia. Preliminary assessments in these countries revealed major structural, managerial, and philosophical barriers to high-quality family planning services. In cases where assessments have indicated the feasibility of new method introduction, this has been implemented through a carefully phased, research-based process intended to encourage the development of appropriate managerial capacity and to promote a humanistic philosophy of care.

Correlates of condom use among female prostitutes and tourist clients in Bali, Indonesia.

This study examines the commercial sex activity of both tourist client and local prostitute groups in the host country of Indonesia. The study provides a profile of social and behavioural characteristics of foreign tourist men and Indonesian women engaging in commercial sex, using cross-sectional data gathered in the tourist resort town of Kuta, Bali. Univariate statistical analysis and multiple logistic regression are used to assess psychosocial and other factors associated with consistent condom use in commercial sex encounters, drawing from the Health Belief model and social cognitive theory. Results from both respondent groups indicate that condom use is high between tourist clients and female Indonesian sex workers, although not 100% consistent. Beliefs about condom efficacy and effects on pleasure, as well as susceptibility to STD infection were related to condom use for female sex workers. Beliefs about condoms being too much trouble, and self-efficacy were related to condom use for tourist clients.

PIP: This study examines the commercial sexual activity of both male tourist clients and local female prostitutes in the host country of Indonesia. The study provides a profile of social and behavioral characteristics of male tourists and Indonesian women engaging in commercial sex using cross-sectional data gathered in the tourist resort town of Kuta, Bali. Univariate statistical analysis and multiple logistic regression are used to assess psychosocial and other factors associated with consistent condom use in commercial sex encounters, drawing from the Health Belief model and social cognitive theory. Results from both respondent groups indicate that condom use is high between tourist clients and female Indonesian sex workers, although not 100% consistent. Beliefs about condom efficacy and effects on pleasure, as well as susceptibility to STD infection, were related to condom use for female sex workers. Beliefs about condoms being too much trouble and self-efficacy were related to condom use for male tourist clients.

Behavioral interventions for reduction of sexually transmitted disease/HIV transmission among female commercial sex workers and clients in Bali, Indonesia.

OBJECTIVE: To describe and evaluate a behavioral intervention targeted to low-price female commercial sex workers (CSW) in large brothel complexes, their pimps, and their male clients. DESIGN AND METHODS: Fieldwork was conducted during 1994 in Bali, Indonesia. Intervention activities included an education program for CSW, pimp training, condom sales and distribution, and client media. Theoretical perspectives guiding the intervention were the Health Belief Model and social cognitive theory. Baseline and evaluation surveys were conducted to evaluate the intervention. RESULTS: Both AIDS and sexually transmitted disease (STD) knowledge increased significantly over the intervention period. Condom use for vaginal sex with paid partners the day before the interview increased substantially in the two intervention areas: 18-75% and 29-62%. Condom use also increased in the control area, although the difference between baseline and evaluation measures was smaller. Multivariate analyses indicated that programmatic factors such as attendance at education sessions and reading the project brochure were related to condom use. CONCLUSIONS: Increasing community knowledge and awareness among low-price CSW, pimps, and clients regarding AIDS and STD using trained outreach workers is feasible and effective. In summary, this study has documented the effectiveness of a behavioral intervention for CSW and their clients.

AIDS knowledge, risk behaviors, and condom use among four groups of female sex workers in Bali, Indonesia.

The objectives of this study were to discover the AIDS knowledge, risk behaviors, and condom use of four groups of female professional sex workers (n = 614). Personal interviews were conducted with women working in low-price brothels, mid-price and high-price houses, and tourist areas. Only 51% of women in the low-price brothels had heard of AIDs, although most of the women in the other groups had heard of it. Knowledge of transmission and symptoms was weak in all groups, and most women were unaware of asymptomatic transmission. Most women felt safe from HIV due to ineffective strategies such as taking medications or client selection practices. Condom use with clients varied widely by group. Women in the low-price brothels reported the lowest levels of use (19% of encounters in the previous week), with women from the mid- and high-price groups reporting higher levels (68% mid-price; 71% high-price). Women working in the tourist areas reported the highest levels of use (90%). Interventions for each group need to reflect these differences in knowledge as well as the contexts of their work; important contextual factors to consider include the level of AIDS and STD knowledge in their environment, the characteristics of the clients served, and the degree of supervision that they receive.

AIDS knowledge and risk behaviors among domestic clients of female sex workers in Bali, Indonesia.

This study investigated AIDS and STD knowledge, risk behaviors and condom use among clients of female commercial sex workers in Bali, Indonesia. Although these clients were varied in their socioeconomic status, they all tended to have low levels of knowledge concerning HIV and STD transmission and prevention, multiple sexual partners, low frequencies of condom use with these partners, and experienced frequent STDs. Although HIV sero-prevalence rates are currently low in Indonesia, clients of CSWs are at high risk of HIV transmission. Given their high mobility and frequent sexual encounters with CSWs in other parts of Indonesia, these men could well be agents of rapid spread of the virus throughout Indonesia. Interventions to prevent the spread of the HIV virus must be targeted not only to CSWs, but also to their clients. These interventions should include educational activities concerning AIDS and STD transmission and prevention, condom promotion, efforts to improve condom availability, and activities to strengthen the health sectors' STD diagnosis and treatment capabilities for both CSWs and their clients.

AIDS knowledge, risk behaviors, and factors related to condom use among male commercial sex workers and male tourist clients in Bali, Indonesia.

OBJECTIVES: To describe the AIDS/sexually transmitted diseases (STD) knowledge and risk behaviors, and to determine factors related to condom use among male commercial sex workers (CSW) and male tourist clients in Bali, Indonesia. DESIGN: Individual survey interviews were conducted with a sample of 80 male CSW and 100 tourist clients in the Kuta area of Bali. METHODS: Survey interviews included detailed questions on AIDS/STD knowledge, sexual behavior, and psychosocial measures related to risk taking. RESULTS: Most of the male CSW had heard about AIDS and other STD, although some misconceptions about transmission and risks of different sexual practices remained. Both oral and anal intercourse with tourists were common and condom use was far from consistent. Factors related to condom use for anal intercourse with tourist clients were condom beliefs, self efficacy, susceptibility to STD infection, and STD knowledge. Tourist clients were mainly from Australia and Europe and many had paid for sex in other parts of Indonesia as well as in high prevalence countries. Knowledge of AIDS/STD was very good among the tourists and previous experience with STD was common. Factors related to condom use with male CSW were condom beliefs and self efficacy. CONCLUSION: There is a very active and mobile group of male CSW and tourist clients present in Bali. Interventions with these men are needed due to the low level of knowledge about AIDS among CSW, their experience with STD and STD symptoms, and their level of risky sexual behavior.

PIP: Interviews conducted in 1992-93 with 80 male commercial sex workers in Bali, Indonesia, and 100 of their tourist clients revealed low levels of accurate knowledge about acquired immunodeficiency syndrome (AIDS) and widespread high-risk sexual behaviors. Although most male sex workers were aware of AIDS, 30% did not know that healthy-appearing persons could be infected. The mean number of clients in the week preceding the interview was 2.8 (range, 0-12); 61% had engaged in anal intercourse in that period. Condom use with clients averaged 48% for receptive anal intercourse, 55% for insertive anal intercourse, and 14-17% for oral intercourse; these rates were 19%, 33%, and 0%, respectively, for unpaid partners. Only 30% of clients serviced by male prostitutes insisted on condom use. Factors related to condom use with commercial clients were condom beliefs, self-efficacy, perceived susceptibility to infection, and knowledge of sexually transmitted diseases. The tourist clients, 60% of whom were from Europe and 25% from Australia, were significantly older (mean age, 38.4 years) than the sex workers. 64% reported a history of STD infection, primarily gonorrhea. In the week before the interview, clients had an average of 1.7 paid and 0.3 unpaid partners and 53% engaged in anal intercourse. Condom use was 75% for receptive and 69% for insertive anal intercourse. Although 87% of tourists brought condoms to Bali, only 62% knew of a local source. Factors related to condom use with a commercial sex worker were condom beliefs and self-efficacy.

Contraceptive introduction and the management of choice: the role of Cyclofem in Indonesia.

This paper presents a programmatic perspective on the relationship between the introduction of new contraceptive technology and expanding contraceptive options, using the example of Cyclofem in Indonesia. Past approaches to contraceptive introduction have considered only the characteristics of the new method in the decision-making process. In assessing whether the introduction of a new method actually expands contraceptive choice for women and whether the program has the managerial capabilities to assure quality of care in this process, the authors argue that consideration must be given to all methods within a delivery system and how new technology relates to the management of contraceptive choice. Using this perspective, the authors suggest that choice would not necessarily be expanded with scaled-up service delivery of a new once-a month injectable in the Indonesian public sector context.

PIP: After observation and in-depth interviews within the Indonesian Family Planning Service Delivery System, it was concluded that the introduction of new contraceptives such as the injectable Cyclofem administered once a month would be advantageous only if changes were made in operations and program management. Changes were needed in counseling and information provision, technical provision of care, training of staff, supervision, record keeping, logistics and supplies, and policy support. Informed choice was jeopardized in the prior introduction of the new method Norplant, and wide scale introduction of Cyclofem would stretch the ability of the system to respond with assurances of quality of care. Expanding the method mix would be appropriate in settings where the service delivery system is stronger, where injectables are not currently available, and where Cyclofem could replace high-dose injectables already dispensed. This study included observations of 241 individual provider-client interactions and 107 in-depth interviews among national leaders, provincial and district program managers, public and private sector providers, community leaders, and clients in Cyclofem trial and non-trial areas. Promotional activities were not performed for Cyclofem. The introduction of Cyclofem expanded women's options and in a way that included additional information not usually provided. Cyclofem has the advantage of easy reversibility, regular bleeding patterns, and high efficacy. This method, however, was not promoted as a spacing method, in part because spacing methods are generally promoted within the service delivery system. The system already provide two other injectables, DMPA and NET-EN, with very different side effects. The policy and management obstacles to planned expansion of choice in the public sector of the Indonesian Family Planning Program included the following: the emphasis on long-acting methods, charges for injectables and limited supplies, the lack of identification of specific injectables in the record-keeping system, inadequate information dissemination and counseling, and the added burden to staff time. The private sector is more suitable for introduction of all injectables.

Maintaining technical quality of care in the introduction of Cyclofem in a national family planning program: findings from Indonesia.

This paper discusses the technical dimensions of "quality of care" in contraceptive service delivery in both the Cyclofem Introductory Trial, as well as in routine service delivery of other injectables in Indonesia. Although the quality of care in the Cyclofem trial was generally acceptable, substantial weaknesses in screening, clinical technique, the management of side-effects, and knowledge concerning re-injection time frames were identified in the provision of injectable contraceptives in routine service delivery. The findings suggest that in order for Cyclofem and other injectables to be delivered in the routine program with an adequate standard of care, considerable managerial adaptation and strengthening of providers' technical capabilities would be necessary prior to actual introduction. This would include providing training and updated technical guidelines concerning both Cyclofem and other contraceptives to providers, with an emphasis on technical issues including contraceptive indications and contraindications, re-injection time frames, maintenance of asepsis and the management of side-effects. Strengthening the existing management information system and logistics systems to facilitate differentiation between injectable contraceptives provided by the program so as to ensure sufficient supplies of both contraceptives and associated materials such as needles and syringes will also be necessary.

PIP: The aim was to examine the implications for service delivery in Indonesian national family planning programs introducing a new method, the injectable Cyclofem. Observations were made in 28 clinics and with in-depth interviews in Jakarta, West Java, and West Sumatra. The clinics included introductory trial clinics, nontrial health centers, community-based health posts, and private sector settings. Observations focused on the logistics of clients moving through the clinic and on all methods provided. In-depth interviews were conducted among national leaders, provincial and district program managers, public and private providers of services, community leaders, and clients. Quality of care issues focused on indications and contraindications, clinical technique, management of side effects, and appropriate follow-up in service delivery. Observations revealed that the clinical record form K-IV was not used very well for ascertaining client's needs for spacing methods. The form also did not differentiate between injectables and oral pills. Screening for contraindications was limited. Several patterns emerged on use of syringes and needles, including single use and multiple use. All used alcohol to swab the injection site, but one center reused cotton swabs. Hands were rarely washed before providing services. Many service centers were without running water in the service area. Gloves were reused without disinfection. Insertion instruments for IUDS were not properly sterilized. Written materials were only in one language. Side effects discussions were taken out of context and used to motivate clients. When symptoms were reported, complaints were dismissed, and assessment of the seriousness of bleeding or amenorrhea was not made. Clients were told to come back on a specific day. Mistiming of returns for injection resulted in mistiming of injections and a variety of inappropriate responses for assurance of contraceptive coverage. Most clients were responsible and returned on the appointed date. There were management problems that interfered with quality of care delivery: supply shortages, inadequate knowledge by staff of the importance of asepsis and technical information, heavy case loads, provider fears of discussing side effects with clients, lack of technical supervision, and general lack of attention to quality of care issues. Recommendations were to provide technical guidelines and instructions that are periodically updates, training for all service providers, written manuals or guidelines, a functional supervisory system, revision of reporting forms, refinement of logistics to assure one syringe and needle per client, and balanced staff and equipment for case load management.

STD knowledge and behaviours among clients of female sex workers in Bali, Indonesia.

This study investigated knowledge, beliefs, and practices related to STDs and AIDS among clients of low price sex workers in Bali, Indonesia. These men are at high risk of STD and HIV transmission. They have poor knowledge of the basic concepts of STD and HIV transmission and prevention, and they practice a variety of ineffective prevention strategies including partner selection and the prophylactic use of antibiotics. They report a mean of 1.9 paid sexual partners in the previous week and very low frequencies of condom use. Over 25% had experienced an STD symptom in the previous 6 months, with self treatment with antibiotics reported by a third. Recent experience of an STD was related to the number of sex worker partners in the previous month and to ever having used a condom with a sex worker. The implications of the study findings for the development of comprehensive STD control programs including educational campaigns, condom promotion, and the strengthening of STD case management by health care providers are discussed.

PIP: In Indonesia, interviews with 401 16-65 year old clients of low-price sex workers in Bali were conducted to examine knowledge, beliefs, and practices related to sexually transmitted diseases (STDs) and AIDS. They had had a high number of paid sexual partners (mean, 1.9) in the week before the survey. They rarely used condoms (8%). The level of a history of STDs among the clients was high (50%). For example, 34% reported urethral discharge, 20% a genital ulcer, and 25% had a history of syphilis. Almost 20% had had intercourse with a sex worker while experiencing symptoms during their most recent episode. The most common treatment was self-treatment with antibiotics (35-46%). Perceived STD and AIDS prevention strategies were partner selection based on cleanliness or lack of mouth or body odor and prophylactic medications. Most clients (95%) were familiar with STDs. High level of education and previous experience with an STD were positively correlated with STD knowledge (p 0.01 and 0.05, respectively). Most clients (almost 75%) had heard of AIDS, but few had accurate knowledge about HIV transmission. For example, 33% believed that medication would prevent HIV infection. AIDS knowledge level was positively associated with age (p 0.001), education (p 0.001), and never having been married (p 0.05). Five or more sex worker partners in the previous month and never use of a condom with a sex worker were positively associated with having recent STD symptoms (relative risk = 3.34 (for syphilis) and 2.41, respectively; p 0.01). These findings indicate a need for developing a comprehensive STD control program consisting of educational campaigns, condom promotion, and improving case management by health providers. Specific messages for campaigns should revolve around recognition of STD symptoms, possibility of asymptomatic infection, need for medical consultation at onset of STD symptoms, inefficacy of existing STD prevention strategies, and consistent use of condoms.

Issues in the assessment of nutritional status using anthropometry.

Four issues in the use and interpretation of anthropometry are discussed at the level of the population and of the individual. The first issue is the index or indices of choice: weight-for-height versus height-for-age versus weight-for-age. The selection of an index or indices depends upon many factors, and no one index is completely adequate in all situations. Proposed criteria are provided to assess the severity of low anthropometry within populations. The second issue is the scale of the index: z-scores (or standard deviations) versus percentiles versus percent-of-median. z-Scores have several properties that make them superior to the other two scales. A third issue deals with limitations in the current growth reference; one of these is the disjunction between the growth curves at 2 years of age, resulting from the use of two different populations in the reference. It is important that this disjunction be recognized by researchers so that the anthropometric findings are interpreted correctly for this age range. Lastly, some issues to do with the collection of single versus multiple anthropometric measurements on children are discussed.

AIDS and STDs: risk behaviour patterns among female sex workers in Bali, Indonesia.

This study investigated AIDS and STD knowledge, risk behaviour patterns and condom use among three distinct groups of female commercial sex workers (CSWs) in Bali, Indonesia. Individual in-depth interviews were conducted with 71 female CSWs. These CSW groups differ in the prices they charge, their places and modes of employment, educational backgrounds, levels of AIDS and STD knowledge, number of clients served and levels of condom use. Knowledge of the routes of transmission and appropriate prevention practices is low among all groups, and despite significant differences in their number of clients and their condom use, all groups report high levels of STD symptoms. Although HIV seroprevalence rates are currently low in Indonesia, high risk sexual behaviour patterns place all three groups of CSWs and their clients at great risk of infection. Interventions targeted to specific groups of CSWs and clients should be undertaken as soon as possible, including educational activities utilizing peer educators, condom promotion and distribution, together with improved STD diagnosis and treatment for CSWs and their clients.

PIP: The World Health Organization projects that by the year 2000 Asia will have the largest number of people infected with HIV in the world. HIV is spread most frequently through sexual contact, so concern exists over the role of female sex workers and their clients in the spread. This paper attempts to describe knowledge about AIDS and other sexually transmitted diseases (STD), risk behavior patterns, and condom use among 3 distinct groups of female prostitutes in Bali, Indonesia, with the goal of ultimately discussing the implications. The groups differ in the prices they charge, their places and modes of employment, educational backgrounds, levels of AIDS and STD knowledge, the number of clients served, and levels of condom use. On the basis of interviews with 71 of the women, it was determined that women in all groups had low knowledge of transmission routes and appropriate prevention practices. All reported high levels of STD symptoms. Although current levels of HIV seroprevalence in Indonesia are low, the frequent high-risk sex behavior of these prostitutes puts them and their clients at high risk of infection. Interventions should therefore be targeted to specific groups and their clients as soon as possible, and include educational activities which employ peer educators, condom promotion and distribution, along with improved STD diagnosis and treatment for the workers and their clients.