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The USAID-funded flagship family planning service delivery project named Evidence to Action (E2A) worked from 2011 to 2021 to improve family planning and reproductive health for women and girls across seventeen nations in sub-Saharan Africa using a “scaling-up mindset.” The paper discusses three key lessons emerging from the project’s experience with applying ExpandNet’s systematic approach to scale up. The methodology uses ExpandNet/WHO’s scaling-up framework and guidance tools to design and implement pilot or demonstration projects in ways that look ahead to their future scale-up; develop a scaling-up strategy with local stakeholders; and then strategically manage the scaling-up process. The paper describes how a scaling-up mindset was engendered, first within the project’s technical team in Washington and then how they subsequently sought to build capacity at the country level to support scale-up work throughout E2A’s portfolio of activities. The project worked with local multi-stakeholder resource teams, often led by government officials, to equip them to lead the scale-up of family planning and health system strengthening interventions. Examples from project experience in the Democratic Republic of the Congo, Kenya, Nigeria, and Uganda illustrating key concepts are discussed. E2A also established a community of practice on systematic approaches to scale up as a platform for sharing learning across a variety of technical agencies engaged in scale-up work and to create learning opportunities for interacting with thought leaders around critical scale-up issues.

OBJECTIVE: To describe the declining trend in maternal mortality observed in Mongolia from 1992 to 2007 and its acceleration after 2001 following implementation of the Maternal Mortality Reduction Strategy by the Ministry of Health and other partners. METHODS: We performed a descriptive analysis of maternal mortality data collected through Mongolia's vital registration system and provided by the Mongolian Ministry of Health. The observed declining mortality trend was analysed for statistical significance using simple linear regression. We present the maternal mortality ratios from 1992 to 2007 by year and review the basic components of Mongolia's Maternal Mortality Reduction Strategy for 2001-2004 and 2005-2010. FINDINGS: Mongolia achieved a statistically significant annual decrease in its maternal mortality ratio of almost 10 deaths per 100 000 live births over the period 1992-2007. From 2001 to 2007, the maternal mortality ratio in Mongolia decreased approximately 47%, from 169 to 89.6 deaths per 100 000 live births. CONCLUSION: Disparities in maternal mortality represent one of the major persisting health inequities between low- and high-resource countries. Nonetheless, important reductions in low-resource settings are possible through collaborative strategies based on a horizontal approach and the coordinated involvement of key partners, including health ministries, national and international agencies and donors, health-care professionals, the media, nongovernmental organizations and the general public.

Objective To assess the effectiveness, side effects, and acceptability of copper uter-ine cavity - shaped intrauterine devices (UCD) with and without indomethacin. Methods We used electronic search and hand search to identify relevant literatures. Included papers were systematically reviewed according to previous established guidelines. Results A total of 39 related papers were identified. Of them, 9 papers were included in this review: 4 associated with medicated or non-medicated UCD200 (containing copper 200 mm2) and 5 associated with medicated or non-medicated UCD300 (containing copper 300 mm2). The contraceptive effectiveness, cumulative one-year and two-year continuation rates were similar between medicated UCD200, non-medicated UCD200 and TCu220C. The effectiveness of non-medicated UCD300 was similar to that of TCu220C and TCu200. The effectiveness of medicated UCD300 was similar to that of MLCu375 and TCu220C but lower than that of TCu380A. The cumulative one-year, three-year and five-year continuation rates were similar between medicated, non-medicated UCD300 and TCu380A or MLCu375. The problem of bleeding was less common among medicated UCD users than among non-medicated devices. Conclusions Uterine cavity-shaped devices should continue to be used in the National Family Planning Proramme. However, priority should be given to the 300 mm 2 copper containing device. A large multicenter randomized comparative trial of UCD300 and TCu380A is needed.

Objective A review of evidence was conducted to assess the safety, effectiveness and continuation of once-a-month contraceptive pills. Methods Papers were identified by electronic searches in Chinese and international databases and manual searches of Chinese journals and index of family planning literature. Data on pharmacokinetics, clinical performance and laboratory examinations were extracted from 17 papers of mixed quality on pills containing quinestrol 3 mg and norgestrel 12 mg (Quin-Ng) or levonorgestrel 6 mg (Quin-Lng) used by women in China. Results Quin-Lng pills gave steady-state serum levels of ethinylestradiol between 0.20–0.25 and 0.15 ng/mL. The 1-year perfect use pregnancy rate was 1.1 per 100 women-years. Nausea and increased leukorrhea were common; bleeding control was good. Hypertension developed in 5.8% of Quin-Ng pill users during the first year of use. For Quin-Ng and Quin-Lng once-a-month pills, 1 year continuation rates were 73.6 and 82.1 per 100, respectively. Conclusions Lack of good quality data prevents confident assessment of the safety and efficacy of once-a-month pills. Short-term safety information indicates a high incidence of bothersome side effects and hypertension. The high monthly estrogen and progestogen doses raise questions about the safety of the once-a-month pills.

This paper describes how the Urban Reproductive Health Initiative in Kenya, the Tupange Project (2010-2015), successfully applied the ExpandNet approach to sustainably scale up family planning interventions, first in Machakos and Kakamega, and subsequently also in its three core cities, Nairobi, Kisumu and Mombasa. This new focus meant shifting from a "project" to a "program" approach, which required paying attention to government leadership and ownership, limiting external inputs, institutionalizing interventions in existing structures and emphasizing sustainability. The paper also highlights the project's efforts to prepare for the future scale up of Tupange's interventions in other counties to support continuing and improved access to family planning services in the new context of devolution (decentralization) in Kenya.

The history of fertility regulation in Romania illustrates the complex interactions between politics, women's reproductive health and rights and access to high quality care. This paper describes the current situation of abortion and contraception in Romania, based on national statistics, recent reproductive health surveys and the findings of a strategic assessment led by the Ministry of Health in late 2001. This rapid assessment employed a participatory, qualitative methodology. Over 500 people were interviewed from 145 institutions in 25 cities, towns and villages in Romania, about the range of actions needed to prevent unwanted pregnancies, reduce abortion-related morbidity and mortality and improve the quality, accessibility and availability of abortion and contraceptive services. Although much progress has been made in contraceptive services over the past ten years, improvements in abortion care have lagged considerably. The assessment played an important role in raising team members' awareness and motivation to take action. Some of the issues identified are already being addressed by the institutions that took part. National standards and guidelines for comprehensive abortion care have been developed, contraceptive services have been expanded at primary health care level, sexual and reproductive health education provided by classroom teachers has been introduced in schools, and a study to test a model of comprehensive abortion care services for Romania is planned.

Small-scale pilot projects have demonstrated that integrated population, health and environment approaches can address the needs and rights of vulnerable communities. However, these and other types of health and development projects have rarely gone on to influence larger policy and programme development. ExpandNet, a network of health professionals working on scaling up, argues this is because projects are often not designed with future sustainability and scaling up in mind. Developing and implementing sustainable interventions that can be applied on a larger scale requires a different mindset and new approaches to small-scale/pilot testing. This paper shows how this new approach is being applied and the initial lessons from its use in the Health of People and Environment in the Lake Victoria Basin Project currently underway in Uganda and Kenya. Specific lessons that are emerging are: 1) ongoing, meaningful stakeholder engagement has significantly shaped the design and implementation, 2) multi-sectoral projects are complex and striving for simplicity in the interventins is challenging, and 3) projects that address a sharply felt need experience substantial pressure for scale up, even before their effectiveness is established. Implicit in this paper is the recommendation that other projects would also benefit from applying a scale-up perspective from the outset.

This paper presents the strategic approach to the introduction of depot medroxyprogesterone acetate (DMPA) as an opportunity to improve quality of care for all contraceptive methods in Viet Nam. Testing of the strategic approach developed by the Development and Research Training in Human Reproduction initiative with a variety of other institutions comprised three stages. Stage I involves a strategic assessment of the need for contraceptive introduction carried out in 1994. Several conclusions were derived from the activity: 1) priority should be given to improving the provision of the methods already available; 2) there is no need for removal of existing methods from the public sector family planning program; and 3) introduction of fertility regulation technology should be approached with great caution. Stage II of the test developed a strategy for DMPA introduction in Viet Nam within the context of broad method choice and improved quality of care for all family planning methods. The final program of the test Stage III assists in the wider introduction of DMPA through scaling up of Stage II program interventions. Overall the strategic approach shows that it can be effectively utilized to introduce contraceptive technologies and at the same time improve the quality of care for all methods in the FP program.

This paper presents the strategic assessment of reproductive health (RH) in the Lao Peoples Democratic Republic conducted in February-June 1999. Designed to identify RH needs within the existing delivery models and to set priorities for intervention this assessment addressed four major RH issues: maternal health birth spacing reproductive tract infections (RTIs)/sexually transmitted infections (STIs) and HIV/AIDS and adolescent health. Overall results note that there remains a need to strengthen existing RH programs in the areas of safe motherhood birth spacing RTIs/STIs and adolescent RH. The existing strategies of each of these programs need to be further developed to address the issues arising out of the strategic assessment. These findings provide a road map for long-term policy and program development towards the provision of integrated RH care. This road map can form the basis for a dialogue to build consensus for a coordinated and integrated approach to RH program development as many international agencies are collaborating with the nations government in implementing various programs for specific components of RH.

In 1991 the Development and Research Training in Human Reproduction in collaboration with other institutions developed a strategic approach to contraceptive introduction. The approach shifts attention from promotion of a particular technology to an emphasis on the role of technology in enhancing quality of care and reproductive choice. In doing so it recognizes the implications of technology introduction for changes in program management. This paper describes this strategic approach and experience with its implementation. It also reviews the application of the approach to reproductive health (RH) program development and raises some issues concerning the methodology that needs to be addressed during the application process. Overall an evaluation of the strategic approach in 1998 concluded that the strategy has contributed to a more integrated holistic and client-centered approach to the introduction of fertility regulation technologies. It found the approach to be highly effective flexible and adaptive creates a high degree of county ownership and is an important tool for policy change. However the application of the strategy was labor intensive and required time and substantial local and international technical assistance to be implemented successfully.

The implementation of a strategic approach in contraceptive introduction in Myanmar has catalyzed a process of assessment pilot testing and scaling-up of successful program interventions as an evidence-based systematic process of moving towards reproductive health (RH) programs in the country. The assessments provided vital information for informing the development of many components of the RH program in a context where such a program was just starting. They have also proven to be a useful tool for providing critical information in the design of RH programs and interventions as well as being instrumental in identifying areas that require focused operations research-type activities. In this regard reports from both the contraceptive method mix assessment and the reproductive health needs assessment have been particularly important for advocating internally to decision makers in Myanmar and to the international donor community the need for resources and for effort to be put into the RH program. Moreover the process has led to the increased empowerment of technical staff within the Department of Health and to greater collaboration between the various groups working in RH in Myanmar.

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.

This study is based on data collected during February 1992-November 1993 in Bali Indonesia as part of the Udayana-Michigan AIDS Behavioral Study. Interviews were conducted among 614 female sex workers. Another part of the study included analysis of interviews from male sex workers and clients of female sex workers. Interviews are representative of the three types of establishments (low- mid- and high-priced groups). A sample of female workers who worked independently in Kuta are included. The sample underrepresents short term workers and women with long-term relationships with clients. Information was obtained about knowledge of AIDS STDs and condoms; socioeconomic and demographic characteristics and migration history; sexual history; attitudes and beliefs about condoms; and other health practices. The results reveal a sample population ranging in age from 15 to 44 years. Kuta women were slightly older. Most had a primary school education. Most women came from East Java. Only 51% of women from low-priced brothels had heard of AIDS. Almost all of the other women knew about AIDS. Mean knowledge scores ranged from 8.3 to 11.6 out of a possible 19. There was a clear need for more and better information particularly for dispelling myths about transmission of protection against and treatment of AIDS. Almost all workers had heard of sexually transmitted diseases (STDs) but 15% of women in low-priced brothels were unaware. Syphilis was used interchangeably with STD. Symptoms knowledge was deficient. Most women did not consider themselves at risk. Protection was considered assured because of the practice of taking medicines and injections and because of the type of clients (few tourists and careful selection of clients). Except for Kuta women all had been sex workers for a year or less. 40% of the high-priced workers had worked outside of Bali. Clients represented a variety of occupations. The Kuta area and all groups except low-priced groups served tourists who had the highest levels of condom use. All but 10% in low-priced groups had heard of condoms. Over 50% preferred clients use of condoms. Condom use was lowest in low-priced groups which had the largest number of clients. Indonesian prostitution is complex and requires different approaches for different groups.

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.

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.Individual survey interviews were conducted with a sample of 80 male CSW and 100 tourist clients in the Kuta area of Bali.Survey interviews included detailed questions on AIDS/STD knowledge, sexual behavior, and psychosocial measures related to risk taking.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.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.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.

We have made important progress toward achieving Millennium Development Goals 4 and 5, with an estimated 47% decrease in maternal deaths and 28% decrease in newborn deaths globally since 1990. However, rapidly accelerating this progress is vital because far too many maternal and newborn deaths still occur each day. Fortunately, there are major initiatives underway to enhance global efforts in preventing these deaths, including the United Nations Secretary General's Global Strategy for Women's and Children's Health. We know why maternal and newborn deaths occur, where they occur, and how they occur, and we have highly effective interventions for preventing them. Nearly all (99%) maternal and newborn deaths occur in developing countries where the implementation of life-saving interventions has been a major challenge. Determining how best to meet this challenge will require more intensive interrelated efforts that include not only science-driven guidance on effective interventions, but also strategies and plans for implementing these interventions. Implementation science, defined as "the study of methods to promote the integration of research findings and evidence into healthcare policy and practice," will be key as will innovations in both technologies and implementation processes. We will need to develop conceptual and operational frameworks that link innovation and implementation science to implementation challenges for the Global Strategy. Likewise, we will need to expand and strengthen close cooperation between those with responsibilities for implementation and those with responsibilities for developing and supporting science-driven interventions. Realizing the potential for the Global Strategy will require commitment, coordination, collaboration, and communication-and the women and newborns we serve deserve no less.

Public sector health systems that provide services to poor and marginalized populations in developing countries face great challenges. Change associated with health sector reform and structural adjustment often leaves these already-strained institutions with fewer resources and insufficient capacity to relieve health burdens. The Strategic Approach to Strengthening Reproductive Health Policies and Programs is a methodological innovation developed by the World Health Organization and its partners to help countries identify and prioritize their reproductive health service needs, test appropriate interventions, and scale up successful innovations to a subnational or national level. The participatory, interdisciplinary, and country-owned process can set in motion much-needed change. We describe key features of this approach, provide illustrations from country experiences, and use insights from the diffusion of innovation literature to explain the approach’s dissemination and sustainability.

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.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.

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.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.

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.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.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.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.

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.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.

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.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.

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.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.

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.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.

Heavy smokers and light smokers of marijuana were compared for general psychological health, stable personality traits, changes in personality induced by long-term use of marijuana, effects of multiple drug use, and the "amotivational syndrome" that is said to result from heavy use of the drug. Results did not indicate any overall pattern of excess psychopathology for either group, although significant differences were found in levels of depression and organicity and in various personality traits. The findings suggest that heavy use of marijuana may be related to already existing depression and that impaired motivation may be a manifestation of depression rather than a consequence of frequent mairjuana use.