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This report comprehensively summarizes the FHI/AIDSCAP program in Senegal (1993-1997). The report includes a discussion of accomplishments, outcomes, implementation and management issues, as well as a series of lessons learned and recommendations.
Table of Contents I. Country Program Description C. Accomplishments and Outcomes D. Implementation and Management Issues II. Lessons Learned and Recommendations III. Subproject Highlights III. Subproject Highlights (continued) Strengthening STI Services Strengthening STD Services in Senegal
Background and Scope of the Intervention The Programme National de Lutte Contre le SIDA (PNLS) was the implementing agency for this project which sought to reduce STI/HIV transmission through improved case management of STIs at the primary health care level. Principal Accomplishments A baseline needs assessment of 12 health facilities in the four AIDSCAP regions was conducted at the beginning of the project. The study assessed the number and type of clinic staff, types of treatment available, quantities of condoms, training needs of staff and the prevalence of STIs at each clinic. A census of the 419 health facilities (public, private catholic and NGO) in 6 regions of Senegal (the 4 AIDSCAP regions plus Louga and Fatik) was also conducted, as well as an inventory to determine what materials and equipment existed in the laboratories and clinics. Essential equipment and supplies for STI prevention and case management were subsequently purchased and distributed to select health facilities. STI training modules, pocket guides and wall posters with national STI case management guidelines were developed and reproduced and 492,000 condoms were provided to the 6 regions each trimester. The development of national guidelines for the management of STIs integrated into the primary health care delivery system was also completed during this project. A consensus meeting was held in May 1995 to adopt national guidelines and announce plans for health worker training. Throughout the life of the project 12 laboratory technicians were trained in STI laboratory techniques and 1,167 health care workers (38 doctors, 781 nurses, 312 midwives and 36 others) were trained and supervised in STI case management. Written tests were administered at the beginning and end of each training to measure comprehension and identify areas for follow-up training. The project also supervised 6 health posts for which 54 other health structures were dependent. Supervision was done to verify the usage of algorithms, record keeping, notification forms, and for the correction of errors. Supervisors also offered encouragement and positive reinforcement to health workers to "keep up the good work". Operations research to validate national algorithms for women presenting to health facilities with vaginal discharge or lower abdominal pain was conducted in collaboration with the University of Washington. This research allowed AIDSCAP to verify the prevalence of STIs in the regions surveyed, evaluate the STI algorithms being used at the time of the survey and test the sensitivity of N. gonorrhoeae to antibiotics being used. The study revealed the following:
An evaluation of STI case management using an adapted version of the WHO methodology (PI6/PI7) at baseline (2 regions) and following training (6 regions) was completed with the following results:
Important Constraints
Lesson Learned and Recommendations Follow-up training for and increased supervision of health care workers in the clinics and laboratories is necessary to ensure continued use of STI algorithms. As resource constraints prevented the acquisition of all equipment needed, efforts should be made to provide the necessary equipment to the remaining health facilities which did not receive supplies. In addition, training should be provided for the systematic testing of syphilis in pregnant women, STI patients and CSWs. Workshops focusing on counseling would also be beneficial for health care workers. IEC about STIs for the general population should be increased focusing on symptoms, related complications, utilization of health structures, prevention methods, and partner notification. IEC particularly directed at men should also be undertaken in an effort to increase the usage of health facilities for the treatment of STIs by men.
Strengthening STD Services in Catholic Health Posts in Senegal
Background and Scope of the Intervention The objective of this project was to strengthen STI case management and HIV prevention at the primary health care level at private Catholic health facilities throughout Senegal. The APSPCS collaborates closely with Ministry of Health disease control programs and the PNLS. With 72 health facilities in the 10 regions of Senegal, the Catholic health posts are believed to see 40 percent of all medical consultations. A total of 21 health posts were chosen on the basis of determined criteria, such as being situated along major transportation routes or large markets, migration patterns, socioeconomic status of the area and strength of surrounding health infrastructure, to participate in this project. The project consisted of training in STI syndromic management for APSPCS staff, provision of equipment, development of an IEC program on STI/AIDS prevention, and the supervision of health posts. Principal Accomplishments A baseline assessment of material and training needs was conducted at the health posts and laboratories at the start of the project. The laboratory capabilities at 18 health posts were upgraded with emphasis on antenatal syphilis screening. Laboratory technicians received an intensive 45 day training at the National STD Reference Laboratory at the Institut d'Hygiène Sociale (IHS) in Dakar and equipment and supplies were procured. In addition, equipment for the health clinics was procured according to the PNLS standard list of required material for STI treatment. Forty-three health workers, mostly nurses, were also trained in STI case management and monthly supervision of health workers at project sites was carried out. Didactic materials including training modules, pocket guides and wall charts with national guidelines for clinicians were adapted and distributed, as well as brochures and flipcharts which were supplied for patient education. Eighty-four peer educators were trained during the project and IEC activities were carried out with community educators, including religious, traditional and political leaders, to educate the communities about STI/AIDS prevention, the existence of the clinics for STI treatment, and the importance of partner notification and treatment. As a result of this project, project staff reported witnessing an increased awareness at the community level of the consequences of STIs, and the importance of treatment and partner referral. Important Constraints Some heads of clinics refused to participate in the project claiming an excess of work. Political instability in Ziguinchor reduced the number of days of training in that region to only 3 days, however material supports and training modules were supplied. In the regions of Louga and Fatick, equipment requirements still remain unsatisfied, particularly for the laboratories. A request is being submitted to the PNLS by the Medical Director of Louga to address this problem. Lessons Learned and Recommendations The necessity to involve religious, political and other community leaders in AIDS prevention programming was recognized in the implementation of this project. As such leaders often have great influence over their communities, it is essential to have their support and participation in prevention activities in order to increase the effectiveness of interventions and induce positive behavior change.
Training NGOs, Policy Seminars, and Conference Support
Background and Scope of the Intervention This multisectoral project was implemented by African Consultants International (ACI) over a period of 2.5 years. The primary objective of ACI's project was to encourage nongovernmental organizations (NGOs) to effect policy dialogue seminars within the four main regions of the AIDSCAP/Senegal program in order to sensitize opinion leaders about the AIDS epidemic and involve them in the search for responses. Principal Accomplishments ACI organized and conducted 7 training programs for 137 representatives of over 100 Senegalese NGOs and associations, six regional seminars for 270 opinion leaders, and a two-day seminar for the National Assembly, including both formal sessions and a two-day exhibition in the Hall of the National Assembly that mobilized more than 30 NGOs, associations and other AIDS organizations. In addition, ACI identified 20 organizations or associations already executing AIDS projects and which had proven themselves capable of being leaders in guiding other AIDS groups in the implementation of projects after the end of AIDSCAP. These groups were called "poles of excellence" and ACI conducted reinforcement activities for them through additional training sessions, follow-up and support, and provision of IEC materials. Reinforcement activities with an emphasis on information exchange and collaboration were also conducted for secondary groups in the four regions which had distinguished themselves with their AIDS activities, however had not yet reached the scope to be "poles of excellence". These reinforcement activities also involved the development, adaptation and production of IEC materials, the development of curricula for specialized mini training programs, the identification and refinement of films on local AIDS activities and the adaptation of three international AIDS films into Wolof. A case study on the evolution of political dialogue on AIDS in Senegal over the course of the AIDSCAP program was also completed. In addition, ACI carried out several related activities for AIDSCAP over the life of the project:
During the life of the project ACI produced the following documents:
In addition, the reprinting and distribution of the six-part series entitled "AIDS is Our Problem" in French and Wolof that ACI had previously developed with Arid Lands Information Network (ALIN) assisted by Plan International, Lutheran World Relief (LWR) and UNDP, was completed. Results Pre- and post-training tests were administered during the training sessions with the objectives of obtaining a rapid assessment of the change in attitudes of the participants by the end of the training, to measure the impact of this particular training approach, and to determine any changes needed in the training design itself. Overall results showed a net increase in knowledge of the basic facts about AIDS and the epidemic in both the NGO and regional seminars, though a prior "AIDS culture" was in evidence, particularly among the NGO representatives. In addition, open-ended written evaluations confirmed the success of the combined intellectual and affective approach used by ACI to affect attitude change and foster commitment and initiative in the search for responses to the epidemic. Follow-up evaluations of training and reviews of activities were carried out both formally in structured interviews with past participants of training and informally in ACI's daily contact with individuals and groups. Results are encouraging, as in the interviews persons characterize themselves and/or their organizations as either engaged in responding to the epidemic (i.e. involved in prevention or education activities) or having had their capacities reinforced in three cases out of four. Furthermore, in its interactions with these groups, ACI has observed extraordinary displays of energy, creativity, and dynamism, as well as numerous examples of groups working together in genuine partnerships. Further evaluations by ACI have shown that many associations and organizations have improved their ability to organize programs, lead effective group discussions on AIDS-related topics and films, and use various IEC materials to the best advantage. Perhaps one of the most important results of the initial and reinforcement activities is the networking and exchange of ideas that have become ever-present dynamics within the NGO community. ACI consultant and caseworkers have fostered communication, information exchange, sharing of materials, collaborative activities, and exchange visits all of which have reinforced the natural networking affinities of Senegalese culture and have worked against the type of "territoriality" that can be so detrimental to meaningful responses to the epidemic. Important Constraints The Regional Committees which ACI relied upon to ensure follow-up of regional training programs for opinion leaders proved to be less developed than originally believed and, therefore, unable to provide the required support. Since this follow-up had not been included in the subagreement, many participants felt they had been abandoned. Requests from former participants that could not be met or were partially met by the voluntary activities of ACI consultants, placed additional stress on the ACI team. Requirements for traditional pre- and post-tests included in the subagreement proved to be time consuming and largely meaningless in measuring the important mid- and longer-term effects of the training. A more participatory, collaborative approach woven into a program of ongoing support and follow-up for participants and their activities would have been less time-consuming for ACI trainers, more appropriate to the spirit of the training, and more meaningful in contributing to sustainable results. Lessons Learned and Recommendations ACI identified the following three categories of needs in its contacts with opinion leaders, nongovernmental actors and government leaders: additional training, support materials for IEC activities, and follow-up and support. It is recommended to seek future investment in strengthening organizations that have proven themselves well-organized, dynamic and effective in their prevention or care initiatives. Developing these groups as resources for others involved in the fight against AIDS will help to ensure the sustainability of vital activities begun in the AIDSCAP/Senegal program. Political dialogue should be deepened by expanding training to members of the government and other key decision makers and by devoting resources to encouraging exchanges with other countries such as Côte d'Ivoire and Uganda that have developed effective national policies and political will as well as nationally coordinated multisectoral approaches. Closer cooperation with UNDP in this area is also recommended. In order to promote and expand the involvement of religious leaders, the more liberal elements of Muslim and Christian religious communities should be identified and supported and efforts made to sensitize the more conservative elements to the dangers Senegal faces and to the unique role that religious leaders can play in promoting traditional values of abstinence and fidelity and assuring a compassionate response to those directly affected by the epidemic. In addition, every effort should be made to involve religious and political opinion leaders in the planning and activities in each region and to encourage dialogue between community groups and these leaders. Efforts at decentralization of the national program should be reinforced through the expansion, training and strengthening of regional and district AIDS committees, and support for consortia of AIDS NGOs and associations. Special attention needs to be given to the involvement of people living with HIV/AIDS in dialogue and decision-making processes at all levels, and should be built into any future programming. This will require more flexibility in allowing for investment in both prevention and care, which are inextricably linked in the process of involving those most directly concerned in effective prevention efforts and the search for responses to the epidemic.
NGO Grants for Combat AIDS
Background and Scope of the Intervention JAMRA is a religious NGO involved in different social and health problems, such as prostitution and drug abuse. Working in a country where 95 percent of the population practices an established religion (90 percent are Muslim), JAMRA has developed an original strategy to deal with social problems. Through the inspiration of religious values, JAMRA works to sensitize the general population, mobilize religious leaders and solicit positive reactions to fight the AIDS epidemic and the discrimination faced by persons infected by HIV/AIDS. This project intervened in the four regions of AIDSCAP/Senegal -- Dakar, Kaolack, Thies and Ziguinchor -- with the following objectives:
Principal Accomplishments Religious authorities and headmasters of Koranic schools are highly respected in the community and have the potential to play an important role in the fight against AIDS. Sixteen religious leaders were trained in AIDS prevention who in turn trained 805 other leaders. 786 teachers of Koranic schools were also trained, who in turn trained approximately 1,500 other teachers and headmasters. One training session was held for 6 JAMRA staff who organized 2 IEC sessions with the projection of a film and discussions about HIV/AIDS prevention. Approximately 209 youth between the ages of 20 and 35 years participated in these activities. Eleven information kiosks were established in different strategic locations in Dakar. These kiosks were open three days a week provided information on STIs/HIV/AIDS as well as other common health issues such as diarrhea, malaria, family planning, vaccination programs, tuberculoses and drug abuse. 2,041 people consulted the kiosks for information during the life of the project and 3,783 IEC materials on the prevention of HIV/AIDS were distributed. In addition, 473 IEC brochures concerning other health problems were distributed. Important Constraints Delays in financing resulted in the non-execution of certain aspects of the project, specifically, only 2 of the 4 conferences planned actually took place. In addition, the numbers of IEC sessions and therefore persons educated was lower than expected. Late financing also resulted in delays in the construction of kiosks.
Condom Promotion: Training Pharmacists in Senegal
Background and Scope of the Intervention Social Marketing for Change (SOMARC) is a pilot condom social marketing project run by the Futures Group and funded by USAID. In complement to this project, FHI agreed to finance a training of trainers (TOT) workshop for pharmacists to be conducted by SOMARC. The objective of this project was to train pharmacists, pharmacy clerks and depot managers in promoting the use of condoms for STI/AIDS prevention. In addition, pharmacists were trained to provide information about methods of contraception, STI prevention and correct condom use. The association, Conseil pour l'Action, a local NGO, was responsible for the administrative, financial and logistical arrangements for the workshop. Principal Accomplishments The workshop was conducted by SOMARC and trained 18 pharmacists from the following locations: Dakar, Diorbel, Fatick, Joal, Kaolack, Kolda, Louga, Mbacké, Mbour, Ourossogui, St. Louis, Tambacounda, Thies and Ziguinchor. Each of these pharmacists were then responsible for conducting six to nine one-day training sessions for other pharmacists, pharmacy clerks and depot managers. A total of 88 persons were trained in Dakar and 61 in other regions. A questionnaire was administered at the beginning of the training to assess the trainers present level of knowledge. Responses showed a good level of knowledge relative to condoms and the quality of service expected from a pharmacy. In terms of methods of contraception some misconceptions were identified and addressed during the training. A post-training test was administered to measure trainers knowledge and attitudes after completion of the workshop. The results of this test were very positive with few incorrect responses indicating the training was successful and trainers would be capable of disseminating correct information on STI prevention, contraception methods and condom use. In addition, trainers gained insight into the impact of STI/HIV/AIDS on a national level, demographic and epidemiological information relative to STIs/AIDS in Senegal and gained positive interpersonal communication skills to assist them in their roles as public health agents. Other topics covered during the training included marketing, supplying and stocking of condoms, negotiating the use of condoms with partners, training techniques to be used in their subsequent training courses with other pharmacists, clerks and warehouse managers, and identifying and managing rumors about condoms. Fourteen secondary one-day training sessions were conducted by the primary trainers -- 7 in Dakar and 7 in the regions of Kaolack (covering Kaolack and Fatick), Ziguinchor (covering Ziguinchor and Kolda), Saint-Louis (covering Saint Louis and Louga), Thies, Diourbel, Mbour and Tambacounda. Of the total number of pharmacists in Dakar 76 percent participated in the training and in the other regions 53 percent of the pharmacists received training. Post-training tests indicated a high level of success in the pharmacists ability to provide information about condom use and STI prevention. Post-training evaluations also indicated pharmacists desire to reinforce their capacities to provide advice concerning other forms of contraception, to increase their knowledge of STIs/AIDS and to improve their skills in condom marketing and promotion. In addition to the pharmacists training sessions, 5 sessions in Dakar and 7 sessions in other regions were held for pharmacy clerks. A total of 67 clerks in Dakar and 76 in the other regions were trained representing a total participation rate of 68 percent and 65 percent respectively. Of the 255 pharmaceutical warehouses officially registered with the government, only 68 are actually supervised by a pharmacy. Of those 68, 29 warehouse managers attended one of three training sessions held. Lessons Learned and Recommendations A post-training evaluation by participants indicated the training of trainers and secondary workshops were too short and that more role playing, case studies and simulations would be beneficial to reinforce the messages and allow them to improve on their skills as trainers. As the TOT workshop was conducted in two days, it is recommended that future workshops be increased to three days to include additional activities as mentioned above, and increase the secondary training sessions to two days. As the role of pharmacists in the prevention of STIs/HIV/AIDS is very important to the overall AIDS program in Senegal, it is recommended that communications and relations between the Programme National de Lutte Contre le SIDA (PNLS) and the network of professional pharmacists be maintained and strengthened. Three constraints affected the participation rates of the secondary training sessions held in the various regions, excluding Dakar:
Two constraints affected the training sessions for warehouse managers:
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