Improving sexually transmitted disease management in the private sector: the Jamaica experience.

OBJECTIVES: To improve the quality of sexually transmitted disease (STD) case management in Jamaica by providing comprehensive continuing medical education to private practitioners who manage 60% of all STDs on the island. METHODS: Six half-day STD seminars were presented at 3-4-month intervals and repeated in three separate geographic locations. All Jamaican practitioners received invitations. The subjects were as follows: urethritis, genital ulcer disease, HIV infection, vaginal discharge syndrome, STDs in children and adolescents, and a review seminar. The program effectiveness was evaluated with a written, self-reported pre-test and a telephone post-test that measured changes in clinical management. RESULTS: Six hundred and twenty eight practitioners attended at least one seminar. Comparing pre- versus post-test scores, there were practitioner improvement trends in all four of the general STD management categories: counseling/education (69.8-73.3%; P > 0.05); diagnostics/screening (57.2-71.0%; P= 0.042); treatment (68.3-74.5%; P> 0.05); and knowledge (66.4-83.2%; P= 0.002). Obtaining syphilis serologies during pregnancy rose from 38.3 to 83.8% (P= 0.001), and providing effective treatment for gonorrhea rose from 57.8 to 81.1 % (P= 0.002), but correct responses on treatment for mucopurulent cervicitis at the post-test was a low 32.4%. CONCLUSION: The introduction of continuing medical education for improved STD care targeting private physicians in Jamaica was successful based on high attendance rates and self-reported STD management practices. However, efforts should continue to address the weaknesses found in STD management and counseling and to reach the providers who did not participate. In the global effort to reduce HIV transmission by improving STD care services, continuing education programs that target the private sector can be successful and should be included as a standard activity to improve care and provide a public/private link to STD/HIV control.

PIP: The Jamaican Ministry of Health has estimated that over 60% of all sexually transmitted diseases (STDs) are managed within the private sector, where 800 (66%) of the country's 1200 registered physicians practice. To improve the quality of STD case management provided by these practitioners, the Medical Association of Jamaica organized a series of 6 half-day seminars repeated at 3-4 month intervals in three geographic locations between December 1993 and July 1995. Topics addressed included urethritis, genital ulcer disease, HIV/AIDS, vaginal discharge, pelvic inflammatory disease, and STDs in children and adolescents. A total of 628 private practitioners attended at least one seminar and almost half the physicians attended two or more. Comparisons of scores on a written pretest completed before the seminar and those from a post-test conducted by telephone after the seminar revealed significant improvements in all four general STD management categories: counseling/education, diagnostics/screening, treatment, and knowledge. The proportion of practitioners who obtained syphilis serologies during pregnancy rose from 38.3% to 83.8% and those providing effective treatment for gonorrhea increased from 57.8% to 81.1%. Overall, 96% of practitioners were providing some level of risk-reduction counseling at the time of the post-test and 74% were prescribing correct treatment regimens. Ongoing education and motivation by the national STD control program or the Medical Association are recommended to improve STD case management even further.

Breast-feeding training for health professionals and resultant institutional changes.

Assessed is a breast-feeding training course that was attended by health professionals at the Santos Lactation Center (SLC), Santos, São Paulo, Brazil, as well as its impact on the implementation of breast-feeding programmes in maternity hospitals. Eight maternity hospitals were studied--four were randomly allocated to the experimental group and sent three health professionals to attend an 18-day course at SLC; the remaining four institutions constituted the control group. The compliance of all eight hospitals with WHO/UNICEF's "Ten steps for successful breast-feeding" was determined using scores obtained before and 6 months after the training course. Institutions in the experimental group had an improved score, but those in the control group did not. The SLC training course was efficient since it enabled the participants to promote breast-feeding practices. However, in order to succeed in implementing breast-feeding programmes, health professionals require also to develop skills to apply the knowledge they acquire in the course, as well as to involve the whole maternity unit team in the activities.

PIP: A breast-feeding training course was assessed that was attended by health professionals at the Santos Lactation Center (SLC), Santos, Sao Paulo, Brazil, as well as its impact on the implementation of breast-feeding programs in maternity hospitals. Eight maternity hospitals were studied, 4 were randomly allocated to the experimental group with 3 health professionals to attend an 18-day course at SLC; the remaining 4 institutions constituted the control group. The course consisted of 45 units that covered theoretical and practical aspects of breast-feeding over a 133-hour period. The compliance of all 8 hospitals with the World Health Organization (WHO)/UNICEF's 10 steps for successful breast-feeding was determined using scores obtained before and 6 months after the training course. Individual interviews were held 6 months after the SLC course with directors in participating institutions, with administrative managers, and with professionals in charge of antenatal, nursery, and outpatient services. 16 focus group sessions were also held with 6-15 persons of the staff 6 months after the course. Pre- and postcourse test results showed that in general there was improvement in the students' knowledge on breast-feeding (the average number of correct answers were 20.27 precourse and 26.92 postcourse). Institutions in the experimental group had an improved score, but those in the control group did not. Changes were more particularly in relation to steps 2 (train all health care staff in skills necessary to implement this policy) and 10 (foster the establishment of breast-feeding support groups and refer mother to them upon discharge from hospital). Among graduate-level professionals interpersonal conflicts limited the possibilities for change. The SLC training course enabled the participants to promote breast-feeding practices. However, in order to succeed in implementing breast-feeding programs, health professionals also have to apply the knowledge they acquire in the course as well as involve the whole maternity unit team in the activities.

Integrating the Lactational Amenorrhea Method into a family planning program in Ecuador.

This paper reports the results of a 12-month implementation study documenting the process of integrating the Lactational Amenorrhea Method (LAM) into a multiple-method family planning service-delivery organization, the Céntro Médico de Orientación y Planificación Familiar (CEMOPLAF), in Ecuador. LAM was introduced as a family planning option in four CEMOPLAF clinics. LAM was accepted by 133 breastfeeding women during the program's first five months, representing about one-third of postpartum clients. Seventy-three percent of LAM acceptors were new to any family planning method. Follow-up interviews with a systematic sample of 67 LAM users revealed that the method was generally used correctly. Three pregnancies were reported, none by women who were following LAM as recommended. Service providers' knowledge of LAM resulted in earlier IUD insertions among breastfeeding women. Relationships with other maternal and child health organizations and programs were also established.

PIP: The aim of this inquiry was to describe the planning and process of integration of the Lactational Amenorrhea Method (LAM), as a viable contraceptive option, into an existing family planning service network. LAM was introduced as a demonstration project in 1991 in 4 out of 20 available clinics nationwide operated by the private, nonprofit Centro Medico de Orientacio y Planificacion. Study sites included Quito in an urban mountainous area, Latacunga in a mixed urban/rural mountainous area, Cajabamba in an isolated area with indigenous populations, and Santo Domingo in a mixed urban/rural coastal area. A needs assessment of clients, staff, and organizational information system factors was conducted 4 months prior to introducing LAM into the pilot clinics. Organizational materials were prepared for clients, and a staff training program was implemented. Baseline information was obtained from 58 clients and 24 staff on the prevailing knowledge, attitudes, and practices of breast feeding and contraception. The educational materials included a wall chart on breast feeding promotion, a wall poster on contraception including LAM, a 12 page booklet for LAM clients, and a desk-size flip chart for one-to-one instruction. Record keeping was improved. LAM was introduced to all mothers with infants 6 months old, who were fully or nearly fully breast feeding and were amenorrheic, and identified by intake staff. Follow-up was after 3 months, unless there was a change in desires or a change in the LAM requirements. After 6 months of implementation, a qualitative evaluation was made. 50% of acceptors were interviewed (67, of which 23 were still using LAM). The results showed that 73% used LAM as their first ever contraceptive method. Compliance with follow-up and LAM instructions varied with each clinic. 87% of users and 67% of Quechua users expressed satisfaction with LAM. A number of observations were made about clinic operations. A refined training model was developed, and there was consensus that the 12-page booklet was the most useful. A well child program was integrated into the LAM program. A surprise finding was the low use among rural traditional ethnic groups. LAM is being included in outreach efforts and the expertise passed along to other health programs. The Pearl pregnancy index was 6.8%, which was comparable to other temporary methods in Andean countries.

Family planning goes public.

PIP: The Center for Family Orientation (COF), a private family planning agency with clinics in 8 provinces of Bolivia, initiated a bold, scientifically planned, and successful mass media campaign in 1986. As late as 1978 the Bolivian government had been hostile to COF. The Johns Hopkins University/Population Communication Services helped COF determine that the Bolivian public and its leaders were open to more information about family planning. Bolivia, the poorest Latin American country, then had 7 million people, expected to double in 27 years. There are 2 distinct indigenous groups, the Aymara and the Quechua, and Spanish-speaking people, centered in the cities of La Paz, Cochabamba, and Santa Cruz, respectively. Only 4% of couples use modern family planning methods. Initial surveys of 522 opinion leaders, 300 family planning users, focus groups of users, and a population survey of 1300 people in 8 provinces showed that 90% wanted modern family planning services. Radio was chosen to inform potential users about COF's services, to increase clinic attendance, and to involve men. To obtain support from public leaders, 10 conferences were held. The 1st series of radio messages focused on health benefits of family planning and responsible parenthood; the 2nd series gave specific benefits, information on child spacing, breast feeding, and optimal ages for childbearing. Besides 36,800 radio spots broadcast on 17 stations, booklets, posters, calendars, promotional items, and audiotapes to be played in public busses, were all designed, pretested, and revised. New acceptors increased 71% during the 11-month campaign. Success of the project influenced the start of the National Reproductive Health Project and new IEC efforts planned through cooperation of public and private institutions.^ieng

Evaluation of clinical management training programme for diarrhoea.

We report the evaluation of a training programme on clinical management of infantile diarrhoea. The training programme was delivered through a series of on-site clinical courses offered to a selected group of physicians and nurses from 16 health units in Peru and a series of local workshops conducted in their own health units. The outcome of this training programme was assessed by pre- and post-tests, knowledge, attitude, and practice (KAP) questionnaires, and observational surveys. A significant improvement in medical knowledge about diarrhoea, in particular about the use of ORT and drug therapy, was observed. Although the observational surveys showed significant improvement in the use of ORT at health facilities (2.9% to 23.6%, p = 0.007) the rate observed was still low compared to the high level of knowledge on ORT that was demonstrated by the KAP questionnaires. A reduction of antibiotic prescription for inpatients with diarrhoea (85.7% to 64.8%, p = 0.025) was observed. The training programme was also effective in promoting the establishment of Oral Rehydration Units in the participants' health facilities.

PIP: Physicians designed a training program on clinical management of diarrhea which consisted of 11 clinical training courses at the Cayetano Heredia University Hospital in Lima, Peru for 37 physicians and 37 nurses from 16 hospitals in 20 various cities in Peru; a number of local workshops on overall features of clinical management of diarrhea cases; and supervisory pre- and posttraining visits to the hospitals. Health workers treated only 2.9% of dehydration cases and 25.7% of inpatient diarrhea cases before dehydration set in and 7.7% of similar outpatients with oral rehydration therapy (ORT) during the pretraining observational survey. After the training, these corresponding figures increased to 23.6% (p=.007), 57.6% (p=.002), and 88.9% (p.0001). The 23.6% rate was still low compared with the high level of knowledge about diarrhea treatment, however. Before training, they prescribed antibiotics to 85.7% of inpatients and 50% of outpatients. After the training, health workers still prescribed antibiotics to 50% of outpatients even though 95% knew correct drug prescription practices. On the other hand, they prescribed antibiotics to a lower percentage of inpatients (64.8%; p=.025). Before the course, they recommended breast feeding and weaning foods in 25.7% and 28.6% of inpatients, respectively, and in 47.1% and 41.2% of outpatients, respectively. Following the course, health workers were more likely to advise breast feeding and weaning foods for outpatients (p=.015 and p=.001, respectively), but tended not do so for inpatients. They were less likely to recommend breast feeding (25.7% vs. 19.4%). This evaluation helped promote creation of rehydration units in 12 of the participating hospitals. The results showed a need for continuous medical education for the health workers in the new units.

Planning and pre-testing: the key to effective AIDS education materials.

PIP: The steps in designing and producing effective AIDS prevention educational materials are outlines, using as an example a brochure originated in St. Lucia for clients at STD clinics. The brochure was intended to be read by clients as they waited for their consultation, thus it was targeted to a specific audience delimited by age, sex, language, educational level, religion and associated medical or behavioral characteristics. When researching the audience, it is necessary to learn the medium they best respond to, what they know already, what is their present behavior, how they talk about AIDS, what terms they use, how they perceive the benefits of AIDS prevention behavior, what sources of information they trust. The minimum number of key messages should be selected. Next the most appropriate channel of communication is identified. Mass media are not always best for a target audience, "little media" such as flyers and give-always may be better. The draft is then pre-tested by focus groups and interviews, querying about the text separately, then images, color, format, style. Listen to the way the respondents talk about the draft. Modify the draft and pre-test again. Fine-tune implications of the message for realism in emotional responses, respect, self-esteem, admiration and trust. To achieve wide distribution it is a good idea to involve community leaders to production of the materials, so they will be more likely to take part in the distribution process.^ieng

Brazilian popular healers as effective promoters of oral rehydration therapy (ORT) and related child survival strategies.

PIP: 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.^ieng