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Reported are the results of a randomized controlled trial to assess the effectiveness of the WHO/UNICEF 40-hour course "Breastfeeding counselling: a training course". The course was conducted in a maternity hospital which provides care to a low-income population in a metropolitan area in São Paulo, Brazil. Health workers from 60 health units were randomly assigned to be either participants (20) or controls (40), and their breastfeeding knowledge and skills were assessed before and immediately after the course, as well as 3 months later. Immediately after the course the participants' knowledge of breastfeeding had increased significantly compared to controls. Both their clinical and counselling skills also improved significantly. When assessed 3 months later, the scores remained high with only a small decrease. The implementation of the course was also evaluated. The methods used were participatory observation, key interviews and focus group discussion. In the 33 sessions of the course, the average score was 8.43 out of 10. Scores were highest for content and methodology of the theory sessions, and lowest for "use of time", "clinical management of lactation", and "discussion of clinical practice". "Breastfeeding counselling: a training course" therefore effectively increases health workers' knowledge and their clinical and counselling skills for the support of breastfeeding. The course can be conducted adequately using the material and methodology proposed, but could be more satisfactory if the time allocated to exercises and clinical practice sessions were increased.

PIP: This document presents a report which assesses the effectiveness of the WHO/UNICEF 40-hour course "Breastfeeding counseling: a training course" (BFC). The course was conducted in a maternity hospital which provides services to a low-income population in Sao Paulo, Brazil. The randomized controlled trial was composed of 60 health professionals divided into an "exposed" group (20) and a control group (40). The participants' breastfeeding knowledge and skills were assessed before, immediately after, and 3 months after the course. Results showed that the participants' knowledge of breastfeeding together with their clinical and counseling skills had markedly improved by the period immediately after the course. Three months after the course, their knowledge skills remained high with only a slight decrease. Participatory observation, key interviews and focus group discussions were used in evaluating the course implementation. The content and methodology of the theory sessions received the highest scores whereas "use of time", "clinical management of lactation", and "discussion of clinical practice" got the lowest scores. In general, BFC was effective in increasing the health workers' clinical and counseling skills for the support of breastfeeding. The course, however, does need to be improved with regard to the time allocated for exercises and clinical practice sessions.

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PIP: The JOICFP team evaluates the progress and achievements of the Health Education Project in Bahamas. Additionally, the team prepared comprehensive plans for the next phase. The project leaders made a plan for the next phase through the production of printed and audiovisual information, education and communication materials. These would include revised manuals and guides for teachers and workshop facilitators, which would focus more on the practical aspects of adolescent RH and sexuality education. Furthermore, the project involved the creation of separate workshops for students, out-of-school individuals, teachers, nurses and community leaders. The JOICFP mission was a collaborative effort with the Bahamas Family Planning Association, overseeing the positive impact of the project and to the Bahamian society.^ieng

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PIP: In December 1998, JOICFP and the Inter-American Development Bank entered into a contract to implement the Adolescent Reproductive Health Education Project in the Bahamas. Soon thereafter, three experts visited the Bahamas to provide short-term assistance in project development. Chizuko Ikegami, from Positive Living and Community Empowerment in Tokyo, evaluated the current status of HIV infection and responding national prevention activities. She concluded that the project should develop audiovisual material on HIV/AIDS/STDs (sexually transmitted diseases) using music popular with adolescents; expand on the available HIV/AIDS telephone counseling service; and incorporate material prepared by the World Health Organization for use in schools. Shirley Oliver-Miller, from the Margaret Sanger Center International, conducted a training course for project partners using an Experiential Learning Model. The training also involved choosing which existing materials could be adapted for field training in the Bahamas and adapting a prototypical "Christian Family Life Education" resource guide for facilitators. Hiroyuki Tanemoto, a computer consultant, determined which office equipment suppliers in the Bahamas could fulfill project requirements and conducted a computer training course for the project team. These consultations were coordinated by Harumi Kodama, acting JOICFP Coordinator, who also visited Mexico to observe programs there.^ieng

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PIP: This paper presents an interview with Miguel Sabido, a writer-producer-director of theater and soap operas in Mexico concerning the social uses of commercial soap operas. According to Sabido, television soap operas can play multiple roles in educating the public: 1) melodramatic soap operas represent a mediation between good and bad; 2) soap operas allow people to gossip on different characters, their dilemmas, and create a climate for social change, especially if it centers on key social issues; and 3) soap operas provide role models to emulate. Sabido stressed the importance of a theory-based method for producing drama and mentioned how theoreticians Bentley, Bandura, Maclean, and Jung influenced his writing and production of soap operas. According to Sabido, the social uses of commercial television are possible with socially responsible soap operas.^ieng

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PIP: The Mexican Family Planning Association (MEXFAM) started the Gente Joven program in 1986, targeting young people in the neediest urban and rural areas of Mexico to counteract the lack of sexual and reproductive health information and services for the youth. This lack of information has led to over half a million children being born to teenage mothers each year in Mexico. Studies also show that only 1 in 6 sexually active teenager uses some kind of protection against unwanted pregnancies and sexually transmitted diseases. To address this problem, the Gente Joven program disseminates adolescent sexual health information, produces IEC materials, provides adolescent health services and trains health and education professionals in human sexuality. As part of the program, audiovisual equipment was purchased and used since it has shown to be very effective in disseminating information. The purchase of audiovisual equipment for 36 MEXFAM clinics and centers would mean that field level staff would be able to carry out their duties more effectively.^ieng

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PIP: This article presents an overview of the Chilean program for assuring health service (HS) quality. The National Program for the Evaluation and Improvement of Quality (EMC) was established by the Ministry of Health (MOH) in 1991. The aims were to raise awareness about the importance of quality in HS delivery; to develop a structure for supporting quality; to achieve improvements in quality of health care and service delivery; and to improve patient satisfaction. During 1991-94, EMC received technical assistance, undertook to develop quality assurance (QA) capacity, and to motivate health workers to engage in QA activities. One full-time staff member at the national level provides training and technical support to the country's 29 HS facilities. Quality Committees at the HS level operate within 79% of the country's 29 facilities. HS entities are encouraged to develop their own policies and action plans. Quality monitors at the local level were trained by MOH staff. Over 6500 health professionals and 615 quality monitors were trained in QA methods. The central office of QA control now has a new role in regulation. The office reviews existing laws, decrees, regulations, norms, and protocols that affect quality of care. It is studying how to appoint groups of experts to develop norms in specialized areas. Over 400 QA improvement projects were undertaken during 1991-96. The MOH sponsors a National QA Conference and identifies October as Quality Month for focused activities. External technical assistance ended in 1994.^ieng

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PIP: This article presents an overview of Ecuador's efforts to maintain quality assurance (QA) in the care and delivery of health services. The Ministry of Health (MOH) established the National QA Program (QAP) in March 1996. Most of the efforts have been directed toward 7 of the 21 provinces. QAP's permanent resident advisor has coached teams in implementing QA microprojects. QAP has worked with district level officials in development of action plans and to define basic quality standards. MOH is moving to incorporate QA within a larger health sector reform process. New draft policies include ways to improve quality of care. A coordinator provides supervision and support to pilot projects and will strengthen the integration of QA within health sector reforms. QA pilot projects in Azuay and Bolivar have led to formation of QA teams at provincial, hospital, and health district levels. The first year of GAP was spent developing capacity by training QA facilitators at the national level. Azuay and Bolivar provinces have held provincial level training in problem solving, process improvement, strategic planning for quality, and standards development. Technical assistance was provided by JHPIEGO to revise national norms and clinical standards for reproductive health (RH). The MOH is piloting a training program in the new RH standards in Cotopaxi province. QAP conducted QA design efforts and development of local quality indicators under a new World Bank funded project. A newsletter was started in 1997 to disseminate QA information and progress reports. QA has been institutionalized within MOH.^ieng

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PIP: This article discusses the improvement of HIV counseling services in El Salvador despite the existence of the continuing stigma of HIV infection. In the past, the knowledge and inclination of health care personnel dictated whether or not HIV patients receive any kind of counseling. It was unfortunate that most hospital members did not know how to counsel or even recognize the need for counseling. As such, the Ministry of Health recognized this need, and requested assistance from the Implementing AIDS Care and Prevention project of the Family Health International, which resulted in voluntary counseling and testing training among health care professionals. This change and improvement in the quality of handling by health professionals ensures that other HIV positive patients are spared from the trauma and shame that one HIV positive patient experienced.^ieng

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Emergency contraception promises to reduce Mexico's high unwanted pregnancy and unsafe abortion rates. Because oral contraceptives are sold over-the-counter, several emergency contraceptive regimens are already potentially available to those women who know about the method. Soon, specially packaged emergency contraceptives may also arrive in Mexico. To initiate campaigns promoting emergency contraception, we interviewed health care providers and clients at health clinics in Mexico City, ascertaining knowledge, attitudes, and practices concerning the method. We found limited knowledge, but nevertheless cautious support for emergency contraception in Mexico. Health care providers and clients greatly overestimated the negative health effects of emergency contraception, although clients overwhelmingly reported that they would use or recommend it if needed. Although providers typically advocated medically controlled distribution, clients believed emergency contraception should be more widely available, including in schools and vending machines with information prevalent in the mass media and elsewhere.

PIP: An interview was conducted to ascertain knowledge, attitudes, and practices concerning emergency contraception (EC) among health care providers and potential EC users in metropolitan Mexico. Findings showed that there was a limited knowledge about EC per se and its method, but nevertheless, most of the participants were cautious to support EC in Mexico. Health care providers and clients greatly overestimated the negative health effects of EC, although clients overwhelmingly reported that they would use or recommend it if needed. Although providers typically advocated medically controlled distribution, clients believe EC should be more widely available, including in schools and vending machines, with information prevalent in the mass media and elsewhere.

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PIP: As part of a 10-year health sector reform effort, the government of Bolivia is collaborating with the Pan American Health Organization and the World Bank to increase coverage of vaccines included in the national immunization program and to introduce other important vaccines (such as yellow fever vaccine in affected areas and vaccination against hepatitis B in endemic areas) into the program. Financing will be covered by a World Bank loan of US $6.5 million, grants from international agencies ($4.5 million), and $9 million from the government. A 5-year plan offers specific strategies to 1) strengthen the national immunization program to improve adoption and implementation of immunization policies, 2) strengthen health services to improve coverage and introduce other vaccines, and 3) strengthen the information and surveillance systems. Indicators to monitor implementation of the project will include 1) coverage of DPT3 dose in 1999 and coverage with pentavalent 3 vaccine by the year 2000; 2) the number of municipalities with DPT3 coverage less than 80% and the number with pentavalent 3 coverage less than 80% by 2000; and 3) national financing of immunization programs.^ieng

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