Introduction: The impact of cervical cancer prevention programs depends on persuading women to go for screening and, if needed, treatment. As part of an evaluation of a pilot project in Indonesia, qualitative research was conducted to explore the factors that influence women's decisions regarding screening and treatment and to generate practical recommendations to increase service coverage and reduce loss to follow up. Methods: Research was conducted at 7 of the 17 public health centers in Karawang District that implemented the pilot project. Interviews and focus group discussions were held with 20 women, 20 husbands, 10 doctors, 18 midwives, 3 district health officials, and 16 advocacy team members. Results: Free services and mobile outreach events encouraged women to go for screening, along with promotional efforts by community health workers, advocacy teams, and the mass media. Knowledge and perceptions were the most important barriers to screening: women were not aware of cervical cancer risks, did not know the disease was treatable, and were fatalistic. Factors facilitating treatment were social support from husbands, relatives, and friends and the encouragement and role modeling of health workers. Barriers to prompt treatment included limited access to services and the requirement for husband's consent for cryotherapy. Conclusion: As cervical cancer prevention services are scaled up throughout Indonesia, the findings suggest three strategies to expand screening coverage and ensure prompt treatment: strengthening community mobilization and advocacy activities, modifying the service delivery model to encourage a single visit approach to screening and treatment, and working to gain men's support.

C o n t ex t : A 1997-1998 multimedia campaign promoted sexual responsibility among young people in Zimbabwe, while strengthening their access to reproductive health services by tra i n i n g providers. M e t h o d s :Baseline and fo l l ow-up survey s, each involving approximately 1,400 women and men aged 10-24, were conducted in five campaign and two comparison sites. Logistic regr e s s i o n analyses were conducted to assess exposure to the campaign and its impact on young people's reproductive health knowledge and discussion, safer sexual behaviors and use of services. R e s u l t s :The campaign reached 97% of the youth audience. Awareness of contra c e p t i ve methods increased in campaign areas, but general reproductive health knowledge changed little. As a result of the campaign, 80% of respondents had discussions about reproductive health-with f riends (72%), siblings (49%), parents (44%), teachers (34%) or partners (28%). In response to the campaign, young people in campaign areas were 2.5 times as likely as those in comparison sites to report saying no to sex, 4.7 times as likely to visit a health center and 14.0 times as likely to visit a youth center. Contraceptive use at last sex rose significantly in campaign areas (from 56% to 67%). Launch eve n t s, leaflets and dramas were the most influential campaign comp o n e n t s. The more components respondents were exposed to, the more likely they were to take action in response. C o n cl u s i o n s :A multimedia approach increases the reach and impact of reproductive health int e rventions directed to young people. Building community support for behavior change also is essential, to ensure that young people find approval for their actions and have access to serv i c e s.

BackgroundResuscitation with bag and mask is a high-impact intervention that can reduce neonatal deaths in resource-poor countries. This study assessed the capacity to perform newborn resuscitation at facilities offering comprehensive emergency obstetric and newborn care (EmONC) in Afghanistan, as well as individual and facility characteristics associated with providers’ knowledge and clinical skills.MethodsAssessors interviewed 82 doctors and 142 midwives at 78 facilities on their knowledge of newborn resuscitation and observed them perform the procedure on an anatomical model. Supplies, equipment, and infrastructure were assessed at each facility. Descriptive statistics and simple and multivariate regression analyses were performed using STATA 11.2 and SAS 9.1.3.ResultsOver 90% of facilities had essential equipment for newborn resuscitation, including a mucus extractor, bag, and mask. More than 80% of providers had been trained on newborn resuscitation, but midwives were more likely than doctors to receive such training as part of pre-service education (59% and 35%, respectively, p < 0.001). No significant differences were found between doctors and midwives on knowledge, clinical skills, or confidence in performing newborn resuscitation. Doctors and midwives scored 71% and 66%, respectively, on knowledge questions and 66% and 71% on the skills assessment; 75% of doctors and 83% of midwives felt very confident in their ability to perform newborn resuscitation. Training was associated with greater knowledge (p < 0.001) and clinical skills (p < 0.05) in a multivariable model that adjusted for facility type, provider type, and years of experience offering EmONC services.ConclusionsLack of equipment and training do not pose major barriers to newborn resuscitation in Afghanistan, but providers’ knowledge and skills need strengthening in some areas. Midwives proved to be as capable as doctors of performing newborn resuscitation, which validates the major investment made in midwifery education. Competency-based pre-service and in-service training, complemented by supportive supervision, is an effective way to build providers’ capacity to perform newborn resuscitation. This kind of training could also help skilled birth attendants based in the community, at private clinics, or at primary care facilities save the lives of newborns.

CONTEXT:The World Health Organization (WHO) has developed a decision-making tool to be used by providers and clients during family planning visits to improve the quality of services. It is important to examine the tool's usability and its impact on counseling and decision-making processes during family planning consultations. METHODS:Thirteen providers in Mexico City were videotaped with family planning clients three months before and one month after attending a training session on the WHO decision-making tool. The videotapes were coded for clientprovider communication and eye contact, and decision-making behaviors were rated. In-depth interviews and focus group discussions explored clients' and providers' opinions of the tool. RESULTS:After providers began using the decision-making tool, they gave clients more information on family planning, tailored that information more closely to clients' situations and more often discussed HIV/AIDS prevention, dual protection and condom use. Client involvement in the decision-making process and client active communication increased, contributing to a shift from provider-dominated to shared decision making. Clients reported that the tool helped them understand the provider's explanations and made them feel more comfortable talking and asking questions during consultations. After one month of practice with the decision-making tool, most providers felt comfortable with it and found it useful; however, they recommended some changes to the tool to help engage clients in the decision-making process. CONCLUSIONS:The decision-making tool was useful both as a job aid for providers and as a decision aid for clients.

Context: Family planning programs have long endorsed the principle of informed choice as a way of ensuring that clients select a method that best meets their needs. There has been little research, however, that examines how, or whether, family planning clients make informed decisions. Methods: Interactions between female family planning clients and clinic-and community-based providers at 25 service delivery sites in Kenya were audiotaped over a 9-15 day period. Transcripts of 176 counseling sessions were analyzed to identify key counseling behaviors and assess the completeness of information provided to the clients. Results: Providers collected information about a new client's marital and reproductive history in 60% of counseling sessions, but asked women about their childbearing intentions in only 7%. In 55% of sessions with continuing clients, providers asked whether the woman was experiencing any problems with her current contraceptive method; providers raised the issue of switching methods in 27% of these sessions, and inquired about a continuing client's reproductive intentions in 17%. Providers discussed an average of four contraceptive methods with new clients, while with continuing clients they typically discussed fewer than two. Providers seldom tailored their discussion of contraceptive methods to the client's reproductive intentions, prior knowledge of family planning, contraceptive preferences, personal circumstances or heatlh risks. In addition, while they emphasized a woman's right to make the final decision as to method choice, they rarely assisted women in fully weighing alternatives or ascertained that they understood completely the personal implications of their choices. Conclusions: Family planning providers could enhance the quality of women's contraceptive decisionmaking if they took a more active role in contraceptive counseling-for example, by relating information on specific methods to women's personal circumstances and helping clients weigh the advantages and disadvantages of various methods.