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Integrating health promotion to improve maternal and newborn health in El Salvador

Author(s) Janet Perkins1, Nicole Répond2, Cecilia Capello3, Ana Ligia Molina Araniva4, Carlo Santarelli 5.
Affiliation(s) 1Health Department, Enfants du Monde, Geneva, Switzerland, 2Health Department, Enfants du Monde, Lausanne, Switzerland, 3Health Department, Enfants du Monde, Geneva, Switzerland, 4Health Deparment, Concertación de Educación of El Salvador , San Salvador,El Salvador, 5Enfants du Monde, Enfants du Monde, Geneva, Switzerland.
Country - ies of focus El Salvador
Relevant to the conference tracks Women and Children
Summary Women and newborns in El Salvador continue to face elevated risks related to pregnancy and birth. Historically, the Ministry of Health (MoH) has focused primarily on strengthening the health services while neglecting the critical role that women, men, families and communities play in improving maternal and newborn health (MNH). Our project integrates a Health Promotion component (Ottawa Charter) in the broader MNH strategy in order to empower women and communities to improve MNH, increase access to quality MNH services and incorporate community participation in the health system. As a result of our project, we have seen important changes at both the national and local level towards improving MNH.
What challenges does your project address and why is it of importance? Women and newborns living in El Salvador face among the greatest risks related to pregnancy and childbirth in Central America and the Caribbean. With a maternal mortality rate of 81/100,000, a woman living in El Salvador faces a 1 in 490 lifetime risk of death due to maternal causes, compared to the 1 in 3,900 risk of a woman living in a developed country. In addition, 15 out of every 1,000 infants fail to survive the first year of life, with a high proportion of these deaths occurring before the end of the first month. Risks related to pregnancy and birth are magnified in rural areas where the utilization of health services, and institutional birth in particular, remains low.
Achieving real improvement in MNH requires not only improving and expanding health services but also action with the community to improve care in the home of women and newborns as well as increase demand and utilization of health services. However, historically action aiming to improve MNH in El Salvador has been directed primarily at the health services, with only marginal emphasis accorded to the role of individuals, families and communities within the health system. Our efforts aim to address this gap by empowering women, men, families and communities to improve MNH.
How have you addressed these challenges? Do you see a solution? The World Health Organization’s framework for Working with Individuals, Families and Communities (IFC) to improve MNH is designed to facilitate the inclusion of Health Promotion in national MNH strategies. Its primary aims are to empower women, men, families and communities to improve MNH and increase access to MNH services. The IFC framework was integrated into the Pan-American Health Organization’s (PAHO) regional MNH strategy in 2004 and El Salvador was selected as one of four countries for pilot implementation.
Since 2005, Enfants du Monde (EdM), a Geneva-based NGO, in collaboration with the Concertación de Educación of El Salvador (CEES), a consortium of local NGOs, has been supporting Ministry of Health (MoH) to implement the IFC framework. Initially, a national IFC coordinating body was established to oversee IFC implementation in the country and assure that the framework is integrated in broader health initiatives. This IFC committee includes representatives from MoH and CEES, with technical support by EdM and the PAHO country office. This committee collaborates with and supervises IFC coordinating bodies at sub-national and local levels.
The national committee selected eight municipalities, covering approximately 100,000 women of reproductive age, for initial implementation of the framework at the local level for validation. Participatory community assessments (PCAs) were conducted in each municipality at the outset in order to guide planning. These PCAs consist of a series of roundtable discussions with community members and leaders where they discuss priority MNH needs and participate in designing interventions to tackle identified challenges. Results of these discussions were used to develop IFC action plans which were integrated into broader district action plans and implemented. Interventions vary by municipality, but include in general: birth preparedness; strengthening interpersonal skills of health providers; community oversight of health services; sensitizing men to MNH needs and their roles; and promoting rights to health.
At the national level, efforts have focused on institutionalizing health promotion and community participation in the national health strategy. Notably, due to the success of the program, the IFC committee has been invited to participate in elaborating a number of policies related to reproductive health. In addition, actors at the municipal level were consulted by MoH in the revision of the national birth preparedness strategy.
How do you know whether you have made a difference? The actions undertaken at both national and local levels have been successful at reaching their objectives. At the national level, the IFC committee participated in drafting the Strategic Plan for Reducing Maternal and Neonatal Mortality 2011-2015, the Sexual and Reproductive Health Policy, and the Technical Operational Guidelines for the Birth Preparedness Strategy. Largely as a result of their participation, each of these documents contains lessons from the implementation of the IFC framework, thereby highlighting Health Promotion and community participation in each one. These documents have now been finalized and endorsed by MoH. Furthermore, the IFC committee is now participating in drafting the Technical Guidelines for Promoting the Right to Health.
The PCA has elicited a great deal of enthusiasm by MoH at national and local level. Stakeholders have witnessed the benefit of working with communities using this tool and as a result MoH has adopted it for use beyond MNH for analyzing and planning health action more broadly. A range of actors at national, sub-national and local level are being trained to use it, contributing its institutionalization.
At the local level, IFC action plans have been implemented in the eight selected municipalities. Trust has been built between women and families and healthcare providers. Women have been empowered to demand quality health services which have been defined as their right. For example, women mobilized to obtain the right to be accompanied by a companion of choice when receiving MNH services at health facilities, notably during birth, and were successful in this goal. In addition, MoH responded to the community when they demanded that certain positions which had been vacant (i.e., gynecologist, pediatricians) be filled in rural health facilities.
Women and families report seeking health services to a greater extent and high satisfaction with services received. Women take action to prepare for birth and potential obstetrical and neonatal complications. However, challenges still exist in terms of women following through on their plan. Utilization of both routine and emergency MNH services is increasing. Men are increasingly participating in MNH by accompanying women to health facilities, though not to the extent anticipated. Promisingly, in each of the implementation municipalities maternal, perinatal and neonatal death has decreased and no maternal death has been reported in 7 of 8 municipalities for 3 years.
Have you or the project mobilized others and if so, who, why and how? We recognized from the outset of our project that long term success and real integration of the project in national policies and programs can only occur when a variety of actors across different sectors are mobilized. Notably, each year a team of 10 actors from national and local MoH, NGO’s and members of the IFC committee participate in the PAHO/EdM diploma awarding course on the IFC framework at the University of Antioquia in Colombia. This course helps actors from Latin-American understand the critical nature of working with and empowering individuals, families and communities and how to institutionalize mechanisms allowing them to participate to reach the goals laid out in the national MNH strategy. Following the training, these actors support implementation of the framework at national, sub-national and local level.
The national IFC committee’s participation in the Alliance for Sexual and Reproductive health has also served to mobilize others. This intersectoral alliance operates under MoH and includes a number of organizations such as PAHO, UNFPA, Save the Children, Plan International, and World Vision. This alliance has helped to increase visibility of the IFC component and encourage the interest of other members. For example, as a result of this alliance, Save the Children has become financially engaged to support the implementation of certain interventions of the IFC program.
Moreover, efforts have been undertaken to strengthen the system of community health teams at the national and local levels. At the local level these teams include community health workers as well as trained doctors and nurses. They visit under-served communities providing services. Within our program we are training them to integrate health promotion and community participation into their work and conduct PCAs. As a result, their capacities are reinforced to work with and empower communities.
In addition, community members, leaders and groups have been mobilized to participate in MNH action. Links have been created between communities and health facilities allowing for meaningful community participation to be institutionalized in the health system. Mayors and religious groups have become involved in funding the implementation of local interventions. Perhaps most importantly, the community, notably women, their partners and mothers-in-law, have mobilized to improve the care of women and newborns and increase access to health services, for example in facilitating transport.
When your donor funding runs out how will your idea continue to live? Sustainability of the program has been a priority since its inception and has therefore been implemented with a long term vision and the constant search for alliances. To begin with, a central priority of implementation process has been to institutionalize the IFC framework and community participatory processes into the national MNH strategy as well as in other policies at various levels. As highlighted earlier, we have made a great deal of progress in this domain, as components of the IFC framework have been integrated into some of the most important sexual and reproductive health documents and policies recently elaborated.
In addition, the IFC framework is being implemented by MoH, with the support of outside actors, including NGOs and PAHO. As a result MoH is directly responsible and accountable for its implementation. It has been institutionalized within the MNH program at all levels, ensuring that participatory processes themselves are integrated as well. MoH is now planning a strategy for scaling up to new municipalities.
In addition, at its core, our project focuses on building the capacities of in-country actors. Notably EdM has no expatriate staff on the ground. Rather, locals are staffed as coordinators in existing offices (of PAHO and MOH). Likewise, CEES is composed of a consortium of local NGOs, based and operating in El Salvador. Moreover, at every phase of IFC implementation, the focus remains on building the capacities of State and other local actors to implement the framework and assume primary responsibility for interventions. This focus on capacity building of in-country stakeholders prevents an over reliance on outsiders and ensures local ownership of initiatives, thereby promoting sustainability.
Finally, the program has also launched processes of empowering women, men, families and communities. This empowerment is considered not only a means to an end, but also an end in and of itself. These exercises of working together have built the capacities of community members to collaborate to identify their needs and design methods of addressing these needs. The capacities of the health services have simultaneously been reinforced to include the participation of community members in health planning and services action. This bodes well for the sustainability of the idea as local actors have the capacity to participate and the health sector is better equipped with the capacity to integrate and promote community participation.

Human papillomavirus vaccination acceptability among university students in South Africa.

Author(s) Muhammad Hoque1, Shanaz Ghuman2, Guido Van Hal3.
Affiliation(s) 1Graduate School of Business and Leadership, University of KwaZulu-Natal, Durban, South Africa, 2Department of Community Health Studies, Durban University of Technology, Durban, South Africa, 32Medical Sociology and Health Policy, University of Antwerp, Antwerp, Belgium, 4.
Country - ies of focus South Africa
Relevant to the conference tracks Women and Children
Summary Very few students were aware of the link between HPV and cervical cancer. The majority were willing to accept HPV vaccination. University students needs to be educated regarding cervical cancer and effectiveness of HPV vaccine.
Background Cervical cancer is the second most common cancer after breast cancer in South Africa. Every year, over 3,000 women in South Africa die from cervical cancer. It is reported that 21.0% of women in the general population are estimated to harbor cervical HPV infection at any given time in South Africa. The incidence of cervical cancer is unacceptably high and most cases of invasive carcinoma present late with a high case-fatality. In South Africa the two vaccines (Gardasil® and Cervarix®) are registered but are not freely available. The effectiveness of vaccination programs against HPV will largely depend on how different population groups have been oriented.
Objectives The objectives of this present study are to assess the awareness of cervical cancer and its risk factors among female undergraduates in South Africa, and to determine the level of acceptability of HPV vaccination among these students.
Methodology This was a cross-sectional study which was conducted in March 2013 among 440 full time undergraduate female students using a self-administered anonymous questionnaire.
Results Results indicated that of those students who had never had sex (n=163), 96 (58.9%) hadn't heard of cervical cancer and only 12 students (12.5%) knew that HPV causes cervical cancer. More than a third (35.4%) of the students correctly stated that sexual intercourse before age of 18 years is a risk factor for cervical cancer and 55.2% of the students knew about Pap smear tests which is used for screening cervical cancer. The majority (77.3%) were willing to accept HPV vaccination. Results revealed that students who knew about the Pap smear test knew that having multiple sex partners, sexual intercourse before the age of 18 years, smoking and having contracted any STDs are risk factors for cervical cancer and were more likely to accept HPV vaccination compared to other groups.
Conclusion The general knowledge of South African female university students about cervical cancer is not sufficient but they have positive attitudes toward getting vaccinated against HPV.

Risk Factors of Inappropriate Birth Weight for Gestational Age: Thailand

Author(s) Dittakarn Boriboonhirunsarn1, Tripop Lertbunnaphong2, Rujirote Chainara3.
Affiliation(s) 1Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 2Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 3Obstetrics and Gynecology, Srisaket, Srisaket, Thailand.
Country - ies of focus Thailand
Relevant to the conference tracks Women and Children
Summary Inappropriate gestational weight gain, but not pre-pregnancy BMI, was an independent risk factor for inappropriate birth weight for gestational age infants. Controlling gestational weight gain within the appropriate range could help improving both maternal and neonatal outcomes.
Background Delivery of infants with an appropriate birth weight for gestational age is one of the ultimate goals in obstetric care. However, inappropriate fetal growth is still one of the important public health problems worldwide. Infants with inappropriate birth weight for gestational age are more likely to develop many complications during the antepartum, intrapartum and postpartum period, as well as increased long term health risks.
Objectives This study aimed to determine the prevalence and risk factors of infants with inappropriate birth weight for gestational age.
Methodology A total of 820 low-risk, term, singleton pregnant women who delivered live born infants were enrolled in this cross-sectional study. Obstetric information was extracted from medical records, including maternal age, parity, gestational age at delivery, pre-pregnancy body mass index (BMI), gestational weight gain and infant birth weight. Prevalence of small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational age (LGA) were estimated using the 10th and 90th percentile cutoff values. Pre-pregnancy BMI was used to classify pregnant women into underweight, normal weight, overweight, and obese. Gestational weight gain was categorized into inadequate, adequate, and excessive weight gain according to the Institute of Medicine (IOM) guideline. Comparison of variables between the groups was carried out to assess the possible associated factors for inappropriate birth weight.
Results Prevalence of SGA and LGA was respectively 2.6% (95%CI 1.7 – 3.9%) and 10.5%(95%CI 8.6 – 12.8%). Pre-pregnancy BMI and gestational weight gain was significantly higher in LGA than AGA group (p=0.04)
Conclusion Inappropriate gestational weight gain, but not pre-pregnancy BMI, was an independent risk factor for inappropriate birth weight for gestational age infants. Since gestational weight gain is modifiable these findings should be applied to the clinical practice of antenatal care, especially in terms of nutritional surveillance, support, and monitoring, in order to minimize the risk of inappropriate fetal growth and related complications.

Would you Terminate a Pregnancy Affected by Sickle Cell Disease? Views of Doctors, Parents and Patients in Cameroon.

Author(s) Ambroise Wonkam1, Jantina de Vries2, Charmaine Royal3, Dora MBanya 4, Jeanne Ngongang 5, Fru Angrafo III6
Affiliation(s) 1Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, 2Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, Institute for Genome Sciences & Policy, Duke University, Durham, United States, 4Department of Medicine, Faculty University of Yaoundé I, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon, Biochemestry, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon, Surgery, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.
Country - ies of focus Cameroon
Relevant to the conference tracks Women and Children
Summary We studied the views of 110 doctors, 130 parents with one living child with SCD (Sickle Cell Disease), and 89 adults patients suffering from SCD, regarding prenatal genetic diagnosis and termination of a SCD-affected pregnancy.
The majority accepted the principle of prenatal genetic diagnosis for SCD (78.7%, 89.8% and 89.2%). The majority of parents accepted the principle of termination of SCD-affected pregnancy (62.5%) as opposed to doctors and patients where this group were in the minority (36.1%, and 40.9 %). Parents and patients who rejected termination of pregnancies claimed ethical reasons (69.1 and 78.1%) while those who accepted it feared having another SCD-affected child (98.1 and 88.9%) with a poor quality of life (92.6% and 81.5%).
Background Patients with Sickle Cell Disease (SCD) can suffer from anemia, painful episodes, susceptibility to infection, stroke, and chronic organ damage (kidneys, lungs, heart, brain). There is currently no cure available for SCD, but the condition can be managed using a variety of therapies. When the condition is not managed patients tend to die in early childhood as occurs in many African countries.
In Cameroon it is possible to test for sickle cell homozygosity before birth, and in fact Prenatal Genetic Diagnosis (PND) represents one type of preventive strategy, as it is offered as a reproductive option to at-risk parents. PND provides parents with a reproductive option to test at-risk pregnancies and make decisions regarding medical abortion.
However, legal bans on abortion exist in virtually all African countries and when allowed medical abortion is often restricted to direct threats to maternal health. This raises important ethical questions regarding the desirability of terminating affected pregnancies.
Many parents currently caring for a child with SCD opt to abort a fetus that is also suffering from SCD. What has not yet been investigated is the comparative views of parents to those of health care providers and patients living with SCD.
Objectives We examined the attitudes of a sample of Cameroonian medical doctors, parents with at least one SCD-affected child, adult SCD patients towards PND and TAP. There were two major research questions: (1) their agreement with prenatal genetic diagnosis and pregnancy termination in general (2) their agreement with prenatal genetic diagnosis for SCD, and pregnancy termination for SCD, and the reasons for their attitudes.
Methodology Design
This research was a quantitative social science study administered by structured questionnaires.
Sample Population and Eligibility Criteria.
The sampling methods used included both purposeful and convenience sampling.
Medical doctors were recruited from a National Medical Conference for continue medical education. In an attempt to ensure inclusion of parents and adult SCD-affected patients and incorporate the entire spectrum of this illness, we issued a call for participation using the national Cameroonian media. We also approached two SCD Patients’ Associations in Cameroon. Participants needed to be at least 18 years old with a diagnosis of SCD that was confirmed by a laboratory documentation of their hemoglobin electrophoresis.
Questionnaire Format.
The data were collected by means of a structured questionnaire consisting of three sections of closed-ended questions. These were (1) Socio-demographic characteristics; (2) Attitudes towards SCD screening policies; and (3) Attitudes about principles of SCD- prenatal diagnosis and termination of an affected pregnancy if the participant’s unborn child were proven to be affected. Response options were “Yes,” “No” or “Undecided”.
Research Setting and Data Collection.
The study was conducted at the Yaoundé Central Hospital where face-to-face questionnaires interviews were conducted. Informed consent was also obtained at this stage. In addition to the introductory explanation, each patient was given full non-directive genetic counseling with neutral information concerning PND and its reproductive options. Images were used to explain the obstetric procedure of PND and risks (specifically 1% induced miscarriages). Information on the available therapeutic options and follow up for patients with SCD was reviewed and the participants were given an opportunity to ask questions. The information provided during this counseling session was equivalent to the information that prospective parents would have received had they been seeking PND for SCD.
Data Analysis.
Data were analyzed using SPSS (Statistical Package for Social Sciences, Chicago). A comparison between two or more variables was evaluated by non-parametric tests (H test of Kruskal-Wallis or Z test of Kolmogorov-Smirnov, when applicable). The p values were considered significant if they reached 95%.
Results The majority of parents participants lived in urban areas (89%), were female (80%), Christian (93%), married (60.2%) in monogamous households (81.1%), were employed (61.7%), and had at least a secondary or tertiary education (82%). Similarly, the majority of the patient participants were urban dwellers (84.3%), female (57.3%), Christian (95.5%), single (90.9%), with a secondary/tertiary education (79.5%).
The clinical profile of participant children and patient participants indicated that they suffered from (relatively) severe forms of SCD. The majority of research participants received poor treatment for their SCD. Only 4.4% of participants received hydroxyurea treatment, the only treatment currently available to manage SCD. Nearly 90% (89.7%) had received traditional medicine for their conditions on at least one occasion in the past.
The majority accepted the principle of prenatal genetic diagnosis for SCD (doctors: 78.7%; parents: 89.8% and patients: 89.2%). The majority of parents accepted the principle of termination of SCD-affected pregnancy (62.5%), but doctors and adults patients were less comfortable with this principle (36.1%, and 40.9 % acceptance, respectively). The acceptance of the principle of medical termination for SCD increased with unemployment status. (missing data here)
Conclusion Differential views regarding medical abortion for SCD in Cameroon could lead to societal, ethical and legal conflicts. Our finding may well reflect the failure of professional stakeholders to provide adequate care services to patients with SCD in Cameroon.
The patient participants in this study indicated a surprisingly high (40.9%) rate of acceptability of TAP. This is surprising as one could argue that a decision to terminate a pregnancy where the future child would suffer from the same condition that is affecting the parent seems to imply a value judgment about the individuals’ quality of life. Patients who participated in this study presented with severe forms of SCD. We wonder whether our results mean that approximately 4 out of 10 of the patients included in this study did not find their quality of life worth living and did not want to allow a child to experience it. This is a disturbing finding that requires the further attention of policy makers and medical professionals in Cameroon.
Our finding may well reflect the failure of professional stakeholders to provide adequate care services to patients with SCD in Cameroon. For instance, the average late diagnosis of the condition in our participants leads to greater clinical severity. In addition, the very low number of people who receive adequate medical care to manage their condition, as well as the large number of people who received traditional medicine, may also indicate the failure of medical professionals in Cameroon to adequately manage SCD. Many patients with SCD require the expertise of specialized centers. Lifelong medical care and surveillance are not yet available in Cameroon where provision of healthcare services is hampered by major economic, organizational and infrastructural difficulties.These differential views of patients, physicians and parents also indicate potential ethical conflicts between various components of the Cameroonian society regarding TAP for SCD. Additional studies among various groups may provide detailed insight into the range of moral, legal and social perspectives held by the public and the healthcare community regarding genetic technology and prenatal diagnosis in Cameroon.

SAFO – The Strategic Alliance for the Fortification of edible Oils and Other Staple Foods.

Author(s) Andreas Bluethner1
Affiliation(s) 1Food Fortification, BASF SE, Ludwigshafen, Germany.
Country - ies of focus Germany
Relevant to the conference tracks Women and Children
Summary SAFO (Strategic Alliance for the Fortification of edible Oils and Other Staple Foods) is a Strategic Alliance within the DeveloPPP partnership scheme of the German Government that seeks to reduce vitamin A deficiency of 100 million people at risk of undernutrition. It was implemented by the following partners: BASF, a leading supplier of high-quality, cost-effective vitamin A, the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the German Federal Ministry of Economic Cooperation and Development (BMZ) and local food producers and fortification alliances, including academia, UN, NGO's and the public sector.
Background BASF has chosen food fortification as an area for partnership engagement because it has been ranked by the Copenhagen Consensus as a top developmental priority due to its outstanding cost-benefit ratio.
For BASF, food fortification is part of the company's commitment to the Global Compact LEAD initiative of the United Nations. BASF's activities in food fortification is a strategic Shared value project, as the company becomes part of the solution to the global malnutrition challenge. Through effective communications this results in measured gains for branding (employer), sustainability reporting, serving as a partnership model for other divisions, and last but not least access to future markets.
Objectives The aim of the Strategic Alliance is to reduce vitamin A deficiency of 100 million people at risk of undernutrition in 8 Target countries within Latin America, Africa and Asia. In order to achieve this, SAFO builds local capacity in the food industry to deliver cost-effective interventions in food fortification which is the addition of essential nutrients to staple foods that are affordable for those groups with limited purchasing power and risk of micronutrient deficiencies.
Methodology National fortification programmes are typically based upon four components: policy advice and
advocacy, legislation, economic and technical implementation and testing arrangements. SAFO supports local partners to build upon these components. SAFO demonstrates that food fortification is a cost efficient and effective way of reducing hidden hunger and, to that end, brings all relevant actors together in the partner countries. Within SAFO, BASF empowers local food producers through technical training, analytical support, mobile laboratory equipment (with the German SME BioAnalyt as the partner for mobile analytics) and other in-kind start-up support that enables the cost-effective fortification of staple foods with essential micronutrients. Moreover, BASF assists local producers in the development of business plans that affordably supply enriched foods to low-income populations at high risk of micronutrient deficiencies.
GIZ supports capacity development by facilitating multi-stakeholder dialogues, advising government authorities, and supporting locally embedded food fortification NGOs. GIZ advises the public sector on the development of industry standards for fortification and credible labeling schemes that inform consumers about the health benefits of nutrient-rich foods and also supports M&E trainings of food and drug authorities.
This objective is not always a strictly linear process as local partners work in different countries at the same time with the support of BASF and GIZ.
Results SAFO has obtained its goal to reach about 150 million people at risk of malnutrition with fortified staple foods thereby contributing to reduce the prevalence of vitamin A deficiency in vulnerable populations.
Conclusion SAFO has reached its goal to reduce the prevalence of vitamin A deficiency in a self-sustainable and scalable way through a transformational public-private partnership approach. In terms of population reach one may assume, that the SAFO program, in conjunction with 150+ Mio. beneficiaries, is among the largest partnership and ‘shared value’ project that addresses an essential need.
Based on a ‘shared value’ business model, BASF's food-fortification engagement grew significantly over the 10 years of experience. Within BASF as a whole the overall turnover appears marginal, but the business model receives growing interest and support, including R&D efforts, on the basis of its needs-oriented engagement with  low income nutrition populations.

Linking Health And Educations Measures To Improve Early Childhood Development Programmes: Kyrgyzstan.

Author(s) Anara Doolotova1, Jypara Ergeshbaeva2
Affiliation(s) 1Health department, Aga Khan Foundation, Bishkek, Kyrgyzstan, 2Health, Mountain Society Development Support Program, Osh, Kyrgyzstan.
Country - ies of focus Kyrgyzstan
Relevant to the conference tracks Women and Children
Summary Since 2005 AKF has been implementing an early childhood development (ECD) program targeting caregivers and preschool age children in three districts of Osh province. The focus of the programme has been to provide different models of preschool education, from government kindergartens to private, home-based care facilities and even yurt-based kindergartens in high pastures during the summer (jailoo). This programme develops cognitive, social and intellectual skills of children 0 to 8 but mainly focuses on the older age group, from 4 to 8. Beginning in 2013 the Health Program introduced health components in the education formats to protect and promote the health of pregnant women and children under 5.
What challenges does your project address and why is it of importance? According to DHS-KG (2012), only 56% of infants are exclusively breastfed, more than 18 % of children under 5 are stunted, and 33 percent of women of reproductive age and 39% of children age 6 to 59 months have some level of anemia. The integration of health elements with the cognitive components of education is designed to increase health promoting practices and to reduce the prevalence of poor health practices. The Kyrgyz Republic has not recognized a formal ECD agenda for children 0 to 3 years old. Policy-makers and caregivers/parents are not fully aware that promoting the health of the mother and investing in the early years of a child’s development generate a substantial return later in life. While such an investment is a rational for a low-income country like the Kyrgyz Republic, most communities believe that children do not need to be educated in the early years because they are too young to learn. Also, while women generally support measures to promote the development of the young child through health and education initiatives, most men do not understand and are not involved in the care and development of the young child.
How have you addressed these challenges? Do you see a solution? AKF implements programs in 35 pilot villages of three districts. It is a community based approach and relies on involving volunteers of parent support groups and health providers. Integrating the health initiatives in the existing early child development programmes enables women and their families to have full knowledge of the care needed during pregnancy, delivery and the postpartum period, and promotes practices such as exclusive breastfeeding, proper nutrition, parenting and nurturing that promote the development of the young child. To address these challenges AKF, KR has adapted an integrated health and education model that uses a multi-partner approach based on community involvement and innovative implementation techniques such as home-visits of parent support groups, involving instructors of mothers schools to work with young parents, addressing ECD and health issues to men and partners, developing IEC materials on ECD and other initiatives which were not presented in the country.
How do you know whether you have made a difference? The study will measure the project implementation results between ECD indicators of integrated health and education programs in 35 pilot village communities and non-pilot villages where only the education component is being implemented.
Annual M&E data will be compared against the baseline. The following indicators will be tracked to monitor progress and impact: % of caregivers practicing at least five responsive parenting techniques; % of families with access to Parent Resource Centers (PRC) services; % of M/F children 0-6 months who are exclusively breastfed in project areas; and % of mothers with children under 5 who know at least 3 ways to prevent enteric infections which includes the % of M/F community members who know that breastfeeding should be initiated at birth.
Have you or the project mobilized others and if so, who, why and how? To reach mothers-to-be, new mothers and very young children, AKF KR works through Mother Schools. These are ‘sessions’ that take place largely in health facilities where the ’pregnancy to parenting approach’ is provided for pregnant women and family members during antenatal visit at birth preparedness schools (Mother schools) which are a part of primary health care facilities. Mothers Schools teach couples about antenatal, childbirth and postpartum care but also the early needs of the young child during the first days of life. Mother schools instructors will be trained on measures to ensure proper growth and development in the earliest years of a Child’s life. Parents will be educated by trained physicians to take proper care of the young child, not only physical development but cognitive and social development as well. Trained health providers provide sessions to young parents. Parental Resource Centres address the developmental needs of somewhat older children, i.e., 0 to 8 years. The families of these children are encouraged to visit a village-based centre in village or school libraries where trained facilitators, e.g. librarians and facilitators, provide special learning sessions for parents. Health messages and other interventions are incorporated. These measures inform parents about good health and nutrition practices and contribute to the healthy development of children between 4 to 8 years old. The material developed reaches parents with children aged 0 to 8 and a wide range of topics are included as breastfeeding and complementary feeding, danger signs during first years of childhood, immunization, how to take properly care of children in addition to ECD day to day development. To improve the health status of WRA the following topics are presented: postpartum nutrition, contraception and depression, danger signs of postpartum period and the role of family members. Finally, all parents with children 0-8 are informed of methods to prevent anemia and micronutrient deficiency, which is very common among local communities, how to adopt good nutrition habits, how to use safe water and maintain proper hygiene and sanitation in the family. The libraries of the PRCs have a space where parents and children can have access to information and can adopt/adapt practical lessons and plays, read IEC materials and watch DVDs. The health unit will provide health IEC materials to complement Education program. Home Visits will be carried out to reach families who cannot attend the PRCs.
When your donor funding runs out how will your idea continue to live? When the AKF program ends, the community will continue to implement the activities because the local personnel of the parent resource centers, mother schools, community leaders, district authorities will have already built their capacity and will continue their duties in order to benefit families.

Working in Partnership to Improve Child Survival: Red Cross Support to the Ministry of Health During the Mali Integrated Campaign

Author(s): M. M. Erskine1, D. Adama*2, J. Peat1, O. I. Toure3
Affiliation(s): 1Health and Care Department, International Federation of Red Cross and Red Crescent Societies, Geneva, Switzerland, 2Governance Committee, Mali Red Cross Society, 3Ministry of Health, Bamako, Mali
Keywords:

Child survival, Mali, Ministry of Health, Red Cross, integration, vaccination, malaria, civil society, partnership

Background:

In 2007, the Malian Ministry of Health worked with its financial and technical partners to plan and implement one of the largest child survival campaigns to date. The Mali Child Survival campaign targeted over 2.8 million children under the age of five throughout the country. In one week, children received vaccination against measles and polio, supplementation with vitamin A, deworming treatment and long-lasting insecticide treated nets for malaria prevention. Together, the integrated package addresses a number of diseases that contribute to a high disease burden among African children.  A central part of the campaign planning was the communications and social mobilization strategy, to ensure that all segments of society were informed and motivated to promote and participate in the activities. One organization that played an important role was the Mali Red Cross Society, which trained 2,500 volunteers in six regions of the country. The partnership between the Malian Ministry of Health and the Malian Red Cross is an example of how civil society organizations can play a supportive role to improve healthcare delivery. The Malian Red Cross continues to play this auxiliary role for community- and household-based promotion of routine health services to work towards sustaining the high coverage rates attained during the integrated campaign.

Summary/Objectives:

The objectives of the Integrated Child Survival campaign in Mali were to reach more than 95% of children with measles vaccination and more than 80% of children with all other interventions. Additional objectives included ensuring adequate social mobilization to persuade caretakers of the importance of the campaign, undertaking micro-planning for logistics and management of all campaign supplies and implementing an effective system for monitoring and supervision during the week of activities. The campaign will be evaluated in late January/early February using PDA technology.

Results:

Results for this presentation are divided into two components, one related to process and the other related to impact. In terms of process, a strong collaboration and cooperation existed amongst partners, with the Ministry of Health leading and coordinating all activities. Strong relationships with civil society organizations, including the Mali Red Cross, allowed for successful mobilization of parents and organization of sites for the child survival campaign. The role of the Red Cross as a civil society organization is highlighted here to emphasize the need for community-based volunteers to ensure that the most vulnerable, and the most resistant, households receive these necessary interventions. In terms of impact, data were collected daily during the seven days of campaign activities and information was relayed from the health centre level to the national level through telephones, computers and radios. The results of the campaign indicate that all objectives set at the outset of the campaign were not only reached but also exceeded. A cluster survey, using PDA technology, will be used to confirm the daily tally results from health facilities with household level data regarding under fives and their participation in the campaign.

Lessons learned:

The Mali Integrated Child Survival campaign was an enormous undertaking for the country. The importance of partnership, at both international and national levels, is highlighted as a major reason for the success of the initiative. Within the vast country, the contribution of community-based organizations is central, as demonstrated by the role of the Red Cross in mobilizing caretakers before, during and after the campaign. The importance of ongoing messaging to parents to ensure that health facilities are accessed for routine vaccination services, and to contribute to positive behaviour change at the household and community level, are retained as major lessons for sustaining achievements.

A Gender Perspective Study of HIV Positive Cases Attending Voluntary Counselling and Testing Center (VCTC), Vadodara

Author(s): M. G. Shaikh*1, S. Mishra1
Affiliation(s): 1Preventive and Social Medicine, Medical College Baroda - Maharaja Sayajirao University, Vadodara, India
Keywords: HIV/AIDS, gender, VCTC
Background:

A semi-structured and pre-tested pro-forma is used to interview HIV positive patients attending VCTC located at SSG Hospital, Vadodara. Prior verbal and written consent was taken before starting each interview. This cross-sectional study included HIV positive 50 male and 50 female (>13 yrs) cases attending VCTC during April-July 2007. Analysis is done by Epi info 6.04 d statistical package.

Summary/Objectives:

1 – To understand the epidemiological profile of HIV positive patients attending VCTC;
2 – To find out the possible high risk behaviour of having acquired HIV/AIDS among HIV positive patients studied;
3 – to understand the social support system and gender discrimination if any, in HIV positive patients;
4 – to find out health-seeking behaviour and ability to access health services in HIV positive patients.

Results:

Study found, almost 60 % of married HIV positive patients with significant higher percentage of males (58 %) as compared to females (42 %). Whereas total no. of widow/widower found is 23 % with almost 87 % of females as compared to males (13 %). Majority of female patients (80 %) were housewives while majority of males were involved in high risk occupations like truck driving, auto driving, call centre job, sales work etc. In 45 % cases, spouses were HIV positive while 31 % cases didn’t know of the HIV status of their spouse. 26 % HIV positive patients had a past history of Blood transfusion. More males presented with history of premarital sex (83 %), extramarital sex (64 %), multiple sex partners (84 %) and sexual activity (85 %) even after HIV infection. More number of females experienced careless behaviour/neglect (65 %) after HIV status disclosure to their spouse while 71 % females experienced careless behaviour from their family. Out of 9 % cases 75 % females were the culprit of domestic violence. Majority of males (59 %) had contacted private clinic/hospital initially for their health problems while 70 % female patients contacted government hospital for their problems. 3 females were forced to contact quack by their spouse.

Lessons learned:

Males were mainly involved with high risk occupations while females in household work. More males were presented with premarital, extramarital sex and multiple sex partners and females were more vulnerable. Health seeking behaviour of females was affected by male dominance and their economic dependency on others.

Gender Inequality and HIV/AIDS: Double Jeopardy of Women

Author(s): B. Joshi*1, B. Shahi1
Affiliation(s): 1Sociology and Rural Development, Tribhuwan University, Nepal, 2Community Health, All India Institute of Medical Sciences, New Delhi, India
Keywords: Gender, HIV/AIDS, women, vulnerability, rights
Background:

Current statistics indicate that 6.1 million people in South Asia are infected with Human Immunodeficiency Virus (HIV). HIV is an extraordinary kind of crisis. It requires an exceptional response that remains flexible, creative and vigilant on the one hand and on the other hand those who are affected need a multi-dimensional approach to their lives. Now HIV infection in Nepal has a female face because of it growing fastest in this subpopulation. How do gender and HIV/AIDS make women jeopardized? Gender is a crucial element in health inequalities in developing countries. Gender can be conceptualized as a powerful social determinant of health, which interacts, with other determinants such as age, family structure, income, education and social support and a variety of behavioural determinants. In a patriarchal system, men dominate women and exercise control over their lives including their sexuality and reproductive choices. Nepalese women’s vulnerability for HIV is further fragmented by a combination of factors such as biological, social- class, caste, urban/rural location, sexual orientation, culture, economic and legal factors, etc. These factors have an impact on women’s access to services, resources and information.

Summary/Objectives:

A study was conducted with PLWHA women during 2005-2007. To examine the complexity of HIV/AIDS and to learn more about the specific problems faced by women living with HIV - how the concept of gender & HIV/AIDS make their life vulnerable. Case studies and Informal Interviews with HIV infected women. Data was analysed with EPI info programme.

Results:

Case studies and interviews with women from the study illustrate that low status in family, sexual violence, economic and social problems such as poverty, lack of education are some of the primary reasons to get infection. Cultural orientation inhibits them to talk about sex to their partners, which results in infectious status. In the middle-aged women, after sterilization they do not practice regular use of condoms, because they think it is primarily for family planning. Among the newly-married women they know their status only at time of pregnancy, which results in psychological trauma and other related aspects. Most of them are widows and they know their sero status at a later stage of their partner’s HIV infected life. After the death of their partner, some of them are being expelled from their home and undergo various violations of human rights.

Lessons learned:

This study revealed the need to develop appropriate programme would be emphasizing the target communities. Due to illiteracy, poverty, gender inequality women and girls are facing with spousal battering, sexual abuse of female children, dowry related violence, rape including marital rape, traditional practices harmful to female, no spousal violence, sexual harassment and intimidation at work and in school, trafficking of women, forced prostitution, rape in war, female infanticide, constant belittling includes controlling behaviours such as isolation from family & friends, monitoring her movements, restrict her access to resources. Social workers can minimize these issues by giving empathy and psychosocial support, change behaviours and attitude providing medical treatment, offer counselling ,documents injuries and refer their clients to legal assistance and support services, family planning and other mental and reproductive healthcare. Peer-educators (healthcare workers and medical students) approaches for prevention of violence are cost effective, sustainable, easy access to-hard-to reach groups. Governments, NGOs, INGOs also have crucial role to work hand in hand on these issues by empowering women, law and policy, equal education and equal economic opportunities.

Women and HIV/AIDS in Sierra Leone

Author(s): Y. G. Golley-Morgan*1
Affiliation(s): 1Ministry of Health and Sanitation, Freetown, Sierra Leone
Keywords: HIV/AIDS, WLWHA, triple jeopardy, poverty, voice of women, care and support
Background:

More than two decades after its identification, AIDS has become far more widespread, affecting all members of society. Women continues to bear the brunt of the epidemic as they are faced with many other health, social and economic issues and has to struggle with the challenges poised by the epidemic. Thus, they carry a triple jeopardy of AIDS, i.e. as people infected with the virus, as mothers of children infected and as carers of partners, parents and orphans with AIDS. This has resulted in further impoverishment, increase in gender-based violence, threat to women’s livelihood, devastation, extra burden of care, and inaccessibility to health services.

Summary/Objectives:

Women living with HIV/AIDS in Sierra Leone are increasing. The prevalence rate is 1.7% for ages 15-19yrs (Aug 2006) and the age group most affected is 20-24yrs. Some of the causes of this increase in post war Sierra Leone ranges from lack of autonomy of women, pervasive poverty, sexual violence and gender based violence, illiteracy, ignorance or low knowledge of the virus, unwillingness to change behaviour, cultural norms, and patriarchy and gender inequality. HIV affects both their sexual health and well-being. Addressing the health and other needs of women living with HIV/AIDS is fundamental to women’s wellbeing, their partner and children. Organization and institutions addressing WLWHA are essential in the fight against poverty and contributes in promoting social and economic development.

Results:

Increase in the number of services (both community and national) that addresses the sexual, reproductive and other health, social and economic needs of these women. Formation of a sound HIV/AIDS workplace policy that addresses HIV/AIDS issues has resulted in increased support for WLWHA. The ‘Voice of women’ initiative of HIV positive women was set up to empower women living with and affected by HIV/AIDS. 80% of healthcare in the country now has trained personnel for HIV testing, with free ASRV for all HIV positive women that require them. The development of manuals on STDs for healthcare workers and booklets on guidelines on lab diagnostic procedures of HIV infections.

Lessons learned:

Breaking the silence among women needs implementation of sound and collective initiatives from victims themselves and women must be encouraged to be central to the HIV/AIDS response to break the patriarchy trend. Implementation of the principle of GIPA is moving in a rather slow pace as a result of poor partnership and lack of proper strategic framework. Cultural practices, e.g. FGM, early marriage etc., cannot be addressed by HIV/AIDS programmes alone but rather on sound policies and legislation. Well chosen volunteers and family members including traditional healers and leaders are essential for community and home based care. Capacity building through skills training is an important and alternative source of income. Nutritional support is essential for ART adherence. Involvement of existing health institutions in admission and further clinical management of WLWHA have contributed in reducing stigma among health staff and other family members and promote psychological healing.