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C-Channel Issue 3

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C-Channel header  November 2008

Dear Colleagues,

This issue of C-Channel focuses on research on behavior change communication and health issues in Eastern Europe and Eurasia. Albania currently has one of the lowest rates of modern contraceptive use in Europe. To address this issue, the C-Change program is implementing a USAID-funded family planning behavior change communication program to shift contraceptive behaviors from dependency on traditional methods to an increase in the use of modern family planning methods. In addition, C-Change recently published a report of an assessment in Eastern Europe and Eurasia (specifically Kyrgyzstan, Albania, and Armenia) that looked at how USAID and other donors can be more effective in assisting countries in the region to engage health care consumers to take more responsibility for their health care and that of their families. C-Change presented the findings at the "WHO International Conference on Primary Health Care: Alma-Ata Declaration 30 Years" in Almaty, Kazakhstan in October 2008. The assessment was spurred by the fact that the Eastern Europe and Eurasia region is struggling to address the enormous burden of both infectious diseases and the growing burden of non-communicable diseases and injuries, which account for 85 percent of adult mortality there. To address non-communicable diseases that are often the result of lifestyle choices such as diet, smoking, and drinking alcohol, consumers will need to take a more active role in their health. The assessment found that empowered consumers demand better primary health care (PHC), request more information from health care workers, and are spurred to take action to protect their health. Participants at the conference echoed this sentiment, when they endorsed one of the conclusions of the C-Change presentation "Without empowerment, progress in primary health care (PHC) is not possible."

Two journal articles presented in this C-Channel issue are from the Lancet special issue on the state of primary health care (in recognition of the 30th anniversary of the Alma-Ata Declaration on Primary Health Care and the recent WHO conference in Kazakhstan): one looks at chronic disease prevention and management, which is a critical issue in the Eastern Europe and Eurasia region; and the other examines community participation in maternal and child health and asks whether community participation is critical to the success of large-scale primary health care programs. Other journal articles explore the importance of social networks and their leaders to bring about changes in sexual behavior among a Roma male population in Bulgaria; the use of condoms among Croatian young adults and the relation to their knowledge and attitudes of HIV and AIDS; how the attitudes and practices of gynecologists in Serbia toward modern contraceptives affect the counseling of clients on family planning; and the findings from an assessment of a program in Kazakhstan that looked at patient behaviors and improving clinical practices of providers to enhance management of hypertension. See the table of contents below for additional articles on behavior and social change around primary health care and family planning.

We welcome your feedback and ideas that can be sent to c-channel@healthnet.org.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit http://c-changeprogram.org/c-channel


 

PRIMARY HEALTH CARE

1. Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care

2. Community participation: lessons for maternal, newborn, and child health

3. Increasing recreational and leisure time physical activity in Poland - how to overcome barriers of inactivity

4. Improving the management of hypertension in Kazakhstan: implications for improving clinical practice, patient behaviours and health outcomes

5. Patterns of motivations and ways of quitting smoking among Polish smokers: a questionnaire study
 

FAMILY PLANNING/REPRODUCTIVE HEALTH

6. Husband-wife agreement, power relations and contraceptive use in Turkey

7. Sexual behaviour and contraceptive use among youth in the Balkans

8. Are Serbian gynaecologists in line with modern family planning?
 

HIV/AIDS

9. Prevention of HIV and sexually transmitted diseases in high risk social networks of young Roma (Gypsy) men in Bulgaria: randomised controlled trial

10. HIV/AIDS-related knowledge, attitudes and sexual behaviors as predictors of condom use among young adults in Croatia
 


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PRIMARY HEALTH CARE

1. Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care

Authors: Beaglehole, R; Epping-Jordan, J; Patel, V; Chopra, M; Ebrahim,S; Kidd, M; Haines, A
Source: The Lancet 13 September 2008, 372(9642): 940-949.

The burden of chronic diseases, such as heart disease, cancer, diabetes, and mental disorders is high in low-income and middle-income countries and is predicted to increase with the ageing of populations, urbanisation, and globalisation of risk factors. Furthermore, HIV/AIDS is increasingly becoming a chronic disorder. An integrated approach to the management of chronic diseases, irrespective of cause, is needed in primary health care. Management of chronic diseases is fundamentally different from acute care, relying on several features: opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; and long-term follow-up with regular monitoring and promotion of adherence to treatment. To meet the challenge of chronic diseases, primary health care will have to be strengthened substantially. In the many countries with shortages of primary-care doctors, non-physician clinicians will have a leading role in preventing and managing chronic diseases, and these personnel need appropriate training and continuous quality assurance mechanisms. More evidence is needed about the cost-effectiveness of prevention and treatment strategies in primary health care. Research on scaling-up should be embedded in large-scale delivery programmes for chronic diseases with a strong emphasis on assessment.

To link to the website containing this article, click here. Full Text is freely available.

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2. Community participation: lessons for maternal, newborn, and child health

Authors: Rosato, M; Laverack, G; Grabman, LH; Tripathy, P; Nair, N; Mwansambo, C; Azad, K; Morrison, J; Bhutta, Z; Perry, H; Rifkin, S; Costello, A
Source: The Lancet 13 September 2008, 372(9642): 962-971.

Primary health care was ratified as the health policy of WHO member states in 1978. Participation in health care was a key principle in the Alma-Ata Declaration. In developing countries, antenatal, delivery, and postnatal experiences for women usually take place in communities rather than health facilities. Strategies to improve maternal and child health should therefore involve the community as a complement to any facility-based component. The fourth article of the Declaration stated that, “people have the right and duty to participate individually and collectively in the planning and implementation of their health care”, and the seventh article stated that primary health care “requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care”. But is community participation an essential prerequisite for better health outcomes or simply a useful but non-essential companion to the delivery of treatments and preventive health education? Might it be essential only as a transitional strategy: crucial for the poorest and most deprived populations but largely irrelevant once health care systems are established? Or is the failure to incorporate community participation into large-scale primary health care programmes a major reason for why we are failing to achieve Millennium Development Goals (MDGs) 4 and 5 for reduction of maternal and child mortality?

To link to the website containing this article, click here. Full Text is freely available.

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3. Increasing recreational and leisure time physical activity in Poland - how to overcome barriers of inactivity

Authors: Drygas, W; Kwasniewska, M; Kaleta, D; Ruszkowska-Majzel, J
Source: Journal of Public Health 2007, 16:31-36.

International experts recognize that a lack of physical activity is a major risk factor for chronic diseases and is a primary health care issue. This review paper examined studies and innovative programs that focused on the recreational and leisure time physical activity of adults and youth in Poland. Data showed that almost 1/3 of adults are sedentary in their free time and another 17% engage only occasionally in regular exercise. Children under 14 years spend over 3 hours per day watching TV or using the computer, and among older youth more than 50% do not engage in any physical activity. Results from several innovative, large-scale physical activity campaigns implemented in Poland in the last 5 years showed significant improvement in the physical activity of Polish society.

To link to the website containing this article, click here.

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4. Improving the management of Hypertension in Kazakhstan: implications for improving clinical practice, patient behaviours and health outcomes

Authors: Authors: Nugmanova, A; Pillai, G; Nugmanova, D; Kuter, D
Source: Global Public Health April 2008, 3(2): 214-231.

This paper presents findings from the assessment of a strategy aimed at improving case-finding and management of hypertension patients. Study findings suggest that providers' orientation to clinical guidelines, public information on hypertension risks, promotion of yearly blood pressure screening, and universal access to an outpatient drug benefit package, improve case-finding and management. In addition, training of providers at pilot sites resulted in a substantial and significant difference in patient care and health outcomes. Provider training and tools, especially focused on effective patient counselling, made a significant contribution to increased case-finding, patient adherence to prescribed drugs, reducing salt, and increasing regular exercise. However, further refinements are required to achieve the expected adherence of patients to medication and lifestyle advice. In the pilot area, we compared two samples of patients before and after the initiation of the intervention. We found an increase in the proportion of patients with blood pressure <140/90 mmHg, and a significant decrease in the proportion of patients with blood pressure ≤160/100 mmHg. The strategy involved the joint efforts of the Research Institute of Cardiology and Internal Diseases, Karaganda Drug Information Centre, Karaganda Oblast Health Department, Kazakhstan Association of Family Physicians, Almaty Postgraduate Institute for Physicians, and USAID ZdravPlus Project in Central Asia.

To link to the website containing this article, click here.

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5. Patterns of motivations and ways of quitting smoking among Polish smokers: a questionnaire study

Authors: Sieminska, A; Buczkowski, K; Jassem, E; Lewandowska, K; Ucinska, R; Chelminska, M
Source: BMC Public Health 4 Aug 2008, 8:274.

Background: The majority of Polish smokers declare their will to quit smoking and many of them attempt to quit. Although morbidity and mortality from tobacco-related diseases are among the highest in the world, there is a lack of comprehensive cessation support for smokers. We aimed to investigate how Poles, including the medically ill, cope with quitting cigarettes and what their motivations to quit are.

Methods: Convenience sampling was used for the purpose of the study. Individuals attending several health care units were screened for a history of quit attempts. Ex-smokers were defined as smoking previously at least one cigarette/day but who have no longer been smoking for at least one month. Attempts at quitting were defined as abstaining from cigarettes for at least one day. Data on socio-demographics, tobacco use, quitting behaviors and reasons to quit from 618 subjects (385 ex- and 233 current smokers) who fulfilled these criteria were collected with the use of a questionnaire. For the comparison of proportions, a chi-square test was used.

Results: In the entire study population, 77% of smokers attempted to quit smoking on their own and a similar proportion of smokers (76%) used the cold turkey method when quitting. Current smokers were more likely than former smokers to use some form of aid (p = 0.0001), mainly nicotine replacement therapy (68%). The most important reasons for quitting smoking were: general health concern (57%), personal health problems (32%) and social reasons (32%). However, 41% of smokers prompted to quitting by personal health problems related to tobacco smoking did not see the link between the two. A small proportion of ex-smokers (3%) abstaining from cigarettes for longer than a year were not confident about their self-efficacy to sustain abstinence further.

Conclusion: The majority of Polish smokers, including patients with tobacco-related diseases, attempt to quit without smoking cessation assistance, thus there is a need for a broader professional help for them. There is also a lack of general information on hazards related to tobacco and further anti-tobacco campaigns in media are needed. Finally, former smokers should be given more attention and periodic inquiries regarding the smoking habit are worthwhile.

To link to the website containing this article, click here. Full Text is freely available.

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FAMILY PLANNING/REPRODUCTIVE HEALTH

6. Husband-wife agreement, power relations and contraceptive use in Turkey

Authors: Kulczycki, A
Source: International Family Planning Perspectives 2008, 34(3): 127-137.

In this study, data from the 1998 Turkish Demographic Health Survey (DHS) was used to better understand contraceptive use among couples, their agreement on issues related to fertility and family planning methods, and the influence of variables such as communication, decision-making, and power between spouses. Data analysis was based on wives', husbands', and joint reports from 1,546 married couples on their current use of contraception. Overall, analysis showed high concurrence on fertility and contraceptive use but only moderate agreement on family planning methods. Based on individual reports, perception of a spouse's approval had a positive impact on the use of contraception. However, contraceptive use was negatively associated with couples wanting more than three children or only wives wanting less than three. The study concludes that the differences in spousal reports were significant enough to say that attitudes and preferences of wives' and husbands' do influence contraceptive use.

To link to the website containing this article, click here. Full Text is freely available.

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7. Sexual behaviour and contraceptive use among youth in the Balkans

Authors: Delva W, Wuillaume F, Vansteelandt S, Claeys P, Verstraelen H, Temmerman M.
Source: PubMed [European Journal of Contraception and Reproductive Health Care Dec 2007, 12(4): 309-16.]

The study, conducted in Bosnia, Macedonia, and Serbia and Montenegro, examined the relationship between the determinants of sexual behaviour and contraceptive use and sexual and reproductive health (SRH) care among 2,150 urban high school students. A self-administered questionnaire was used to gather data. The results show that in this group of students with a mean age of 16.7 years, sexual debut had already occurred.. Condoms were used at first sex by almost 70% of the students but then declined with no uptake in other available contraceptive methods. While students had a high desire for information on SRH care, they did not actively seek it because of shame, fear and insecurity. Mass media should be explored as a vehicle to disseminate information on contraceptive methods and address the challenges faced by youth in seeking SRH care.

To link to the website containing this article, click here.

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8. Are Serbian gynaecologists in line with modern family planning?

Authors: Sedlecky K, Rasevic M
Source: PubMed [European Journal of Contraception and Reproductive Health Care Jun 2008, 13(2): 158-63.]

All 1,139 Serbian gynecologists of the Serbian Medical Society Gynecology and Obstetrics Section were sent a questionnaire to explore their knowledge, attitudes and personal practices regarding family planning. The response rate was 27%. The majority of the respondents (61.8%) reported use of abortion one or more times by themselves or their partner while 37.6% used coitus interrupts or no contraceptive method at all. Almost half refused to prescribe combined oral contraceptives to women under the age of 18 and 76.5% advised women against using combined oral contraceptives beyond two years. Inaccurate knowledge about health risks surrounding contraceptive use was high. This study identifies the urgent need for further training of Serbian gynecologists on family planning methods to ensure quality contraceptive counseling in Serbia.

To link to the website containing this article, click here.

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HIV/AIDS

9. Prevention of HIV and sexually transmitted diseases in high risk social networks of young Roma (Gypsy) men in Bulgaria: randomised controlled trial

Authors: Kelly, JA; Amirkhanian, YA; Kabakchieva, E; Vassileva, S; Vassilev, B; McAuliffe, TL; DiFranceisco, WJ; Antonova, R; Petrova, E; Khoursine, RA; Dimitrov, B
Source: British Medical Journal 25 November 2006, 333(7578): 1098.

This study was done to assess the effects of a behavioral intervention on the prevention of sexually transmitted diseases and HIV among Roma (gypsy) men in Bulgaria. First tested for STD and treated and counseled, 286 Roma men were randomised to an intervention or control group. The intervention groups were counseled by Roma leaders from their social networks who had been taught to counsel members on risk prevention of HIV and STDs. Groups were assessed at 3 and 12 months after the intervention. A significant decrease in unprotected intercourse was reported in the intervention groups. The results showed that information on HIV/AIDS prevention provided by social network leaders can effectively maintain change in sexual behavior, most significantly in men with casual partners. The study highlights the benefit of using this approach among groups that do not trust outsiders.

To link to the website containing this article, click here.

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10. HIV/AIDS-related knowledge, attitudes and sexual behaviors as predictors of condom use among young adults in Croatia

Authors: Stulhofer, A; Graham, C; Bozicevic, I; Kufrin, K; Ajdukovic, D
Source: International Family Planning Perspectives 2007, 33(2): 58-65

Using data from a probability sample of 1,093 Croatian men and women (aged 18-24 years), regression models were used to examine the relationship between HIV-related knowledge, attitudes and sexual behavior and the predictors of condom use at first and last intercourse. It was found that condom use at first intercourse and positive attitudes toward condom use were the best predictors of condom use at last intercourse and consistent condom use. Among women, consistent condom use was also positively associated with having peers with modern attitudes about sex. This study advised targeting youth before they become sexually active with pragmatic sex education programs given that risky sexual behavior is common among Croatian young adults.

To link to the website containing this article, click here. Full Text is freely available.

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C-Change, managed by AED, is USAID's flagship program to improve the effectiveness and sustainability of communication programs for behavior and social change in low and middle income countries.
To contact us, please send an email to c-channel@healthnet.org
Additional information about the project is available at the website www.c-changeprogram.org/