Community Education Interventions in Sexual and Reproductive Health Services

According to organisers, this intervention sought to improve quality of care not merely by taking steps to improve provision of services but, rather by using communication strategies to stimulate client demand for those services. Information gathered on community perceptions of the barriers to SRH service use and how people evaluate their own SRH needs was used to develop communication strategies to increase demand for services. These strategies included the provision of community education and information with an emphasis on social groups typically out of reach of SRH programmes.

To that end, the research began with a baseline study that featured focus group discussions (FGDs), in-depth interviews, and collection of health centre service statistics. The FGD's focused on 3 populations:

1. Priority audiences who do not regularly use reproductive health services (i.e., adolescents, men 20-40 years old, and women in the same age range who had not been pregnant in the past 12 months)
2. Traditional leaders (e.g., male and female elders)
3. Other leaders who also influence reproductive health opinions (i.e., formal and informal leaders including nuns, teachers, members of neighbourhood committees, traditional healers, religious leaders, and traditional midwives).

Participatory, face-to-face community educational sessions were developed based on this research. The idea here is that community members, especially those who cannot read, can be educated (e.g., about the importance of going to the doctor) in a more personalised medium - akin to the way many people learn about health from their friends. The project team conducted a total of 32 two-and-a-half to 3-hour educational sessions. Community leaders and key decision makers were also included in the sessions, which included 7 to 15 people per session. Adult men and women chose evenings and weekends to meet, while adolescents preferred afternoons and mornings. In various sessions, male and female participants were introduced to SRH issues, as well as identified their sexual and reproductive rights and discussed ways to exercise them. They were also sensitised to the issue of family violence and its impact on health. Participants learned about specific contraceptive methods, including the benefits, side effects, and correct use for each method. In an effort to improve information and access to services for uterine and breast cancer, women were also taught about breast cancer and learned how to perform a self-exam.

A second project component focused on health care centre interventions, and included 1) group analysis of new systems to reporting of service statistics and 2) training of health care providers. To focus on the latter activity, CIDEM conducted a workshop entitled "Recognizing and Respecting Differences and Rights in Sexual and Reproductive Health" for providers from each of the 4 participating health centres. The following topics were discussed:

• gender, sexuality, and diversity
• sexual and reproductive rights
• quality of care and institutional management
• contraception (an update - discussion focused on those methods offered by the Basic Health Insurance system). Each provider received a copy of the WHO Medical Eligibility Criteria for Contraceptive Use, which CIDEM translated from English to Spanish as a tool to reinforce the information discussed.

Third, the research team reviewed existing IEC materials distributed by community organisations and the ministry of health (MOH). New IEC materials were developed, with technical assistance from CIDEM, to meet the needs expressed by FGD participants and individual interviewees. The researchers designed materials on 3 topics: sexual and reproductive rights, services offered by the health centres, and contraceptive methods. The materials were field-tested and printed after changes were made. They are brightly coloured, use simple language, and include pictures of indigenous women. The contraceptive methods packet contains a series of cards, one for each method offered, with a picture of the method and a description of how it works, who should and should not use it, and possible side effects. The materials were distributed in each community after the educational sessions and provided to both the intervention and control health centres to support SRH services.

CIDEM organised workshops to disseminate the information gleaned through these interventions in June 2002 in the main cities of the country: La Paz, Cochabamba, and Santa Cruz.

Sexual and Reproductive Health, Gender, Rights, Domestic Violence, Youth, Women.

The majority of the residents in the neighbourhoods addressed by this project are rural migrants of Aymara culture, many of whom still have migratory practices. In general, they are people with low incomes, low education, and poor nutritional status. Churches have an important influence in the neighborhoods. Traditional Andean medicine is practiced in this area and is thought to reduce demand for modern health centre services.

Bolivia has one of the highest maternal mortality rates in Latin America. Approximately 390 women per 100,000 live births die from pregnancy-related causes. According to evaluators, a review of the literature shows that interventions in Bolivia to improve quality of care have focused on health services, and have largely left out education, prevention, and community participation. Health providers have not been trained to interact with the community. Consequently, again according to evaluators, fear, distrust, and discrimination characterise the relationship between many health providers and their beneficiaries.

The project was developed to continue support of a series of reproductive health interventions to improve quality of care in Bolivia initiated by the Ministry of Health and Prevention (MSPS), with a methodology proposed by the World Health Organization (WHO).