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									Production Coordinator:
nguyen bich hang
Country Representative
Marie Stopes International Vietnam

Drafting Group:
Margaret Irene Braddock
International Consultant
Ole Schack Hansen
International Consultant
Editing Group:
Be Quynh Nga
National Consultant
Dang Viet Phuong
National Consultant
Dinh Thi Nhuan
Project Manager
Marie Stopes International Vietnam
Tran Thi Nga
Project Officer
Marie Stopes International Vietnam
Design & Layout:
Bui Viet Dzung
Graphic Designer
This document has been developed by Marie Stopes Internationnal Vietnam(MSIVN),
in association with the Vietnam Family Planning Association (VINAFPA), and partners
participating in the RHIYA programme.
    The RHIYA programme is funded by European Union (EU) and the United Nations
                                Population Fund (UNFPA).



   4
                Background and Acknowledgements

This ARH Toolkit has been developed by the staff and consultants of Marie
Stopes International in Viet Nam (MSIVN) through discussions and working ses-
sions with many people and organisations who are participating in the
Reproductive Health Initiative for Youth in Asia (RHIYA), including United
Nations Population Fund (UNFPA) and Umbrella Programme Support Unit
(UPSU), the Executing and Implementing Agencies of RHIYA Output Project 2 -
Vietnam Family Planning Association (VINAFPA), the Centre for Reproductive
and Family Health (RaFH) and Vietnamese Association of Midwives (VAM), the
Ministry of Health at Central level and at District and Commune level in the pilot
sites in Hai Phong and Hoa Binh, the Implementing (IAs), Executing (EAs) and
Technical Assistance Agencies of RHIYA Output Project 1 (Vietnam Youth Union,
CARE International, World Population Foundation (WPF), community leaders,
organisations, village health volunteers, Vietnam Committee for Population,
Family and Children (VCPFC) collaborators, Women's Union staff and not least
courageous young people in the pilot sites. Marie Stopes International Australia
has also provided support and important input to the process and the product.
We would like to thank all the people involved for their active participation and
the time and ideas which they contributed to the development of the Adolescent
Reproductive Health Toolkit (ARH Toolkit).
The ARH Toolkit was conceived as a set of programme development tools and
procedures which can be used as the basis for programming and implementing
special youth-friendly services for young people. It was to be aimed specifically
at Commune health stations who are interested in planning youth-friendly serv-
ices and youth-friendly corners in their health facilities. To take into account the
differences in infrastructure, human resources and the social environment in dif-
ferent communes, the ARH Toolkit had to be designed as a flexible instrument
which can be used in a wide variety of situations.
The process of development of the ARH Toolkit was based on the principle of
"not re-inventing the wheel". Adolescent Reproductive Health (ARH) has been a
major focus of work in Asia and elsewhere for a number of years, and there is a
considerable amount of materials, instruments and tools already available for


                                                                               3
designing and developing youth-friendly services for young people. It was decid-
ed in discussion with all RHIYA participants that the ARH Toolkit would draw on
this body of existing material, choosing instruments and methods which are rel-
evant and appropriate for provision of youth-friendly services in Vietnam, and
adapting them to local conditions. Where suitable materials were not already
available they were developed by the MSIVN team. The first stage of RHIYA was
a rich source of material and ideas.
An initial draft ARH Toolkit was prepared by a team of MSIVN staff and consult-
ants. The draft was discussed with UNFPA, UPSU and the Implementing and
Executing Agencies of both RHIYA output projects and adjustments were made
to the content and text. Staff from the implementing and executing agencies
were trained in the ARH Toolkit instruments and methods, which were piloted
with support from the IA, EA and MSIVN in three Commune health stations in
rural areas of Hai Phong province and one in Hoa Binh province. The pilots were
monitored and evaluated by MSIVN, and feedback was sought from the IAs,
EAs and staff of the health stations. Written comments from a wide range of
stakeholders, feedback from the health stations, and discussions by stakehold-
ers in a special workshop were incorporated into the final version of the ARH
Toolkit, which is presented in this document.
The materials in the ARH Toolkit come from a range of sources which are
acknowledged in the text. Sources included publications, materials from
Vietnam and elsewhere, and materials downloaded from the Internet. All these
have been adapted to take into account the specific needs of young people in
Vietnam, the human and material resources available in Commune health sta-
tions, the policy framework of the Ministry of Health and its guidelines for RH
service provision, and the social and cultural environment in Vietnam. Principle
sources include the Vietnamese Ministry of Health, United Nations Population
Fund (UNFPA), Pathfinder, International Family Health, the Nicaraguan Ministry
of Health, Asia Pacific Development Communication Centre in Bangkok and
Marie Stopes International. Among the existing IEC materials consulted to make
recommendations on communication were materials produced by the following
agencies: Marie Stopes International in Vietnam (MSIVN), CARE international in
Vietnam (CARE), Vietnam Family Planning Association (VINAFPA), Centre for



  4
Reproductive and Family Health (RaFH), Research Centre for Gender, Family
and Environment in Development (CGFED), Centre for Counselling on Love,
Marriage and Family (LMF), United Nations Population Fund (UNFPA),
UNESCO Centre for Non-formal Education (UCNEV), the United Nations
Children’s Fund (UNICEF), the UN system in Vietnam, Supporting Centre for
HIV/AIDS/STIs (SUCECON), Hochiminh Welfare (HCVF), Vietnamese Youth
Union (WYU), and the Vietnamese Association of Midwives (VAM) in Hue.


               Marie Stopes International Vietnam - MSIVN
                2nd Floor, No.1 Nguyen Dinh Chieu Street
                  Hai Ba Trung District, Hanoi, Vietnam

           Tel: + 84 4 9439860/ 943 9861 * Fax: + 84 4 943 9858
                     Email: info.msivn@mariestopes.org




                                                                    5
                                                CONTENT


Introduction
                . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Page
Part A:    introduction
Tool T1    Youth-Friendly Services - an Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Part B:    Implementation tools
Tool T2    Self-Assessment of Knowledge and Attitudes of Service Providers . . . . . .15
Tool T3    Gender Awareness - Teaching Materials . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Tool T4    Gender Awareness - Teaching Materials . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Tool T5    MoH National Guidelines on RH services . . . . . . . . . . . . . . . . . . . . . . . . . .40
Tool T6    MoH Regulations on Technical Responsibilities in RH Care . . . . . . . . . . .184
Tool T7    Teaching Material on STI/HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179
Tool T8    Communications with Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209
Tool T9    Description of Target Groups from YU BCC Strategy . . . . . . . . . . . . . . . .219
Tool T10   Key and Specific Communication Messages . . . . . . . . . . . . . . . . . . . . . .228
Tool T11   Changing Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242
Part C:    Monitoring and evaluation
Tool T12   UPSU Monitoring Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254




                                                                                                                       7
INTRODUCTION


This volume of the ARH Toolkit provides additional reference material which may
be useful to you in development of your YFC.
The materials included are:
Tool T1   Youth-friendly services - an overview
Tool T2   Self-Assessment of knowledge and attitudes of service providers
Tool T3   Gender awareness - teaching materials
Tool T4   Gender awareness - teaching materials
Tool T5   MoH National Guidelines on RH services
Tool T6   MoH regulations on technical responsibilities in RH care
Tool T7   Teaching material on STI/HIV/AIDS
Tool T8   Communications with adolescents
Tool T9   Description of target groups from YU BCC Strategy
Tool T10 Key and Specific Communication Messages
Tool T11 Changing Behavior of Service Providers
Tool T12 UPSU Monitoring Checklists




                                                                         11
TOOL T1
                   YOUTH-FRIENDLY SERVICES -
                   AN OVERVIEW

                                   Source: Meeting the Needs of Young Clients.
                                             Family Health International (2000)


This is background information for self-study which you may find useful in plan-
ning your youth-friendly services.
To meet the needs of adolescents you should consider ways to attract and better
serve young people. There are strategies to make services more "youth-frienly".
Youth-friendly programs:
   S Actively involve adolescents in program design and service delivery.
   S Consider how adolescents needs differ from those of adults and provide
     services that specifically meet the needs of young people.
Providing youth friendly services does not necessarily mean building a new
clinic. It can mean adding adolescent-only hours or offering services in places
where adolescents congregate, such as youth centers, sporting events or work
sites. For community case - workers, it can mean including young people in
home visits. And for all health workers, it means establishing or working within a
referral network. While family planning - reproductive health programs may not
be able to offer all methods and services to young people, they can link with
other organizations that offer services to young people, including educational
and social service programs.
What you can do?
How far you can go to meet the needs of adolescents depends on your
resources, interest and motivation.

1. At a minimum should do the following:



                                                                            15
  S Involve young people in planning and implementing health services.
  S Make all staff-receptionists, nurses, physicians - aware that they should
    treat adolescents with respect and dignity.
  S Revise clinic policies and procedures that prevent youth from receiving
    services and information. For example revise age requirements for
    contraceptive use, or requirements that clients must be married.
  S Ensure that young clients have privacy and that clinic policies emphasize
    confidentiality.
  S Train staff in counseling techniques and make sure they have the most
    current information on contraceptives.
  S Allow enough time for counseling.
  S Develop referral systems. Find out about other services in your community
    for adolescents. Keep a list of these services readily available.

2. If you have some resources for improving adolescent services, you
can also add these components:
  S Offer separate services for adolescents and adults.
  S Offer services at hours that are convenient for adolescents, such as after
    school or on weekends.
  S Make the clinic attractive to adolescents (bright colors, posters, popular
    music).
  S Offer information and education to young clients, both at the clinic and as
    part of community outreach. For example, hold education sessions at your
    clinic at times convenient for adolescents such as after school, or meet
    with adolescents at local youth clubs to answer their questions about
    reproductive health.
  S Reduce prices for young clients. Provide services free or based on a
    sliding scale.
  S Involve young people by creating a young advisory board.

3. Programs with more resources can do more, possibilities include:
  S Advocate to improve national policies and service delivery guidelines for


 16
      adolescents.
   S Develop community outreach programs and off-site clinics health at
     schools, in factories or on the streets.
   S Reach adolescents through educational talks before they need reproductive
     health services. Target parents too.
   S Train peer educators to provide information, education, and contraceptive
     methods to youth.
   S Work with mass media to communicate reproductive health messages.
     Use billboards, soap operas, videos, radio dramas, comic books, popular
     songs, or plays.
   S Create or work with "youth development programs" - programs that
     improve socioeconomic status such as literacy programs or job training.
   S Evaluate your program. Examine quality, gender equity, and respect for
     adolescent rights. Evaluations may include:
   - Simple observations.
   - Review of clinic statistics to determine if more young people are attending
     clinics and returning for follow-up visits.
   - Collection of data to compare services before and after youth-friendly services are
     implemented.
   - Outcome evaluations to assess whether the project met its goals.

General guidelines for all adolescent programs
If you decide to offer services to adolescents, you can take several steps to
ensure that programs are effective:
   S Identify which specific target groups will be served. The group can be
     defined by age, school status, marital status, or place of residence (e.g..
     urban versus rural).
   S Establish specific objectives and indicators to measure whether these
     objectives were achieved. For example, an objective might be to increase
     awareness about STIs. An indicator might be that 10 peer educators were
     trained and then they reached 100 young people with safer sex messages.



                                                                                  17
   S Involve young people in program planning, implementation, and evaluation.
   S Consider the potential effects of gender, culture, and tradition on service
     delivery.
   S Offer short waiting times and welcome drop-in clients.
   S Welcome boys and develop programs targeting them.
To be successful, you also may need to consider approaches to service delivery
that involve the community, such as:
   S Peer motivators and educators.
   S Contraceptive information at schools, sports events, youth clubs, concerts
     or other places where young people congregate.
   S A parents day at the clinic to provide information to adults about adolescents'
     reproductive health needs.
   S A young people's day at the clinic to provide information about good
     health. Children of all ages, not just adolescents, could be invited.
   S Community feedback sessions to solicit ideas from young people about
     the types of health services they want, their satisfaction with current
     services, and their ideas for changes and improvements.
The key to providing quality services for adolescents is to treat clients with
courtesy and dignity. Above all, young people who seek reproductive health
information and services deserve respect.




 18
TOOL T2:            SELF-ASSESSMENT OF KNOWLEDGE
                    AND ATTITUDES OF SERVICE PROVIDERS

                                                 Family Health International
     Contraceptive Technology and Reproductive Health Series: Reproductive
   Health of Young Adults: Contracepton, Pregnancy and Sexually Transmitted
                                                       Infections/HIV(2003)


This is a self-assessment tool for service providers. health workers may like to
try it themselves. Directors of health stations may also find it useful for
identifying staff with suitable attitudes to work with young people. It can also be
used to identify training needs.


Contraceptive Technology and Reproductive Health
Series: Reproductive Health of Young Adults
Test of Knowledge and Attitudes
of Service Providers


Section 1. Reproductive Health Issues of Young Adults
1. Please indicate whether the following statement is True (T) or False (F).
Young people have many problems and hence offer little help      True False
in addressing reproductive health problems.
2. Check all that apply. Sexually active youth face the following reproductive
health risks:
   a) Unintended and early pregnancy.
   b) Sexual violence and unwanted sexual activity.
   c) Too much influence on peers.
   d) Sexually transmitted infections, including HIV.
   e) Lack of communication with parents.




                                                                             21
3. Please indicate whether the following statements regarding gender and
HIV/AIDS among youth are True (T) or False (F)
   a) Risk of infection varies because of gender.                True    False
   b) Girls purchase condoms as easily as boys.                  True    False
   c) Girls see condoms as a sign of promiscuity.                True    False
   d) Boys use condoms most often with regular partners.         True    False
4. What are the main reasons that unmarried, sexually active youth report they
do not use contraception? Check all below that apply :
   a) Did not have permission from their parents.
   b) Did not expect to have sex.
   c) Lacked information about contraception.
   d) Lacked access to resources.
5. Please indicate whether the following statements are True (T) or False (F)
   a) Using contraception can reduce the risk of unsafe         True     False
      abortion among youth.
   b) More than one-third of women seeking abortion in          True     False
      Vietnam are under age 20.
   c) Medical complications from abortion are not serious.      True     False

6. Check all that apply. Youth are at high risk for STIs/HIV due to which of the
following factors:
   a) Non-use or incorrect use of condoms.
   b) Failure to seek treatment.
   c) Lack of communication among peers.
   d) Having multiple partners.




 22
Section II. How to Reach Young Adults
7. Please indicate whether the following statements are True (T) or False (F)

   a) Sex education leads to earlier or increased sexual        True      False
      activity.
   b) Sex education tries to give young people skills to        True      False
      delay sexual activity.
   c) Sex education can lead to increased use of                True      False
      contraceptive.

8. Check all that apply. The most important elements in designing programs for
young adults:
   a) Are designed by the Ministry of Health.
   b) Involve youth.
   c) Make services accessible, as identified by youth.
   d) Identify target groups, their assets and their needs.
   e) Work with community, including parents.

Section III. Contraceptive Methods
9. Please indicate whether the following statement is True (T) or False (F)
Some contraceptive methods are not appropriate for              True      False
adolescents or young adults for medical reasons.

10. Check all that apply. Why are barrier methods considered particularly
appropriate for young people?
   a) Many young adults are at high risk for STIs.
   b) Many young people have easier access to barrier methods than to other
      contraceptives.
   c) They are good methods for couples in long-term relationships.
   d) They can be easily initiated and discontinued.
   e) All of the above.


                                                                              23
11. Check all that apply. When using the male condom you should:
   a) Open the package carefully to avoid tearing the condom.
   b) Unroll the condom directly onto the erect penis.
   c) Hold onto the rim of the condom while withdrawing the penis from the
      vagina.
   d) Use oil-based lubricants, such as petroleum jelly.
   e) All of the above.
12. Please indicate whether the following statements about oral contraceptive
are True (T) or False (F)
   a) Oral contraceptives are very safe for young women.        True   False
   b) Progestin-only pills are the best type of oral
      contraception for most young women.                       True   False

   c) Oral contraceptives offer protection against some
      STIs.                                                     True   False


13. Please indicate which of the following statements about injectables and
implants are True (T) or False (F)
   a) Young people can safely use injectables.                  True   False
   b) Injectables and implants are easy to use without a
                                                                True   False
      partner's knowledge.
14. Please indicate whether the following statements about traditional contra-
ceptive methods are True (T) or False (F)
   a) Traditional methods can promote reproductive
                                                              True     False
      health awareness.
   b) They have low pregnancy rates in typical use.           True     False
   c) Traditional methods offer no protection against STIs.   True     False
   d) Periodic abstinence is particularly appropriate for
                                                              True     False
      young women just after including fertility.




 24
15. Dual protection refers to:
   a) Use of a highly effective contraceptive method for pregnancy prevention
      along with condoms for STI prevention.
   b) Use of condoms to prevent pregnancy and STI transmission.
   c) Choices a and b.
   d) None of the above.
16. Please indicate whether the following statements are True (T) or False (F) in
terms of when emergency contraception can be used to prevent pregnancy
   a) After unprotected intercourse.                              True    False
   b) Anytime during cycle.                                       True    False
   c) As a regular method.                                        True    False
   d) As a backup method after contraceptive failure.             True    False
   e) Anytime within a week after unprotected intercourse.        True    False
17. Which of the following methods are considered appropriate for young
people? Check all that apply :
   a) Complete abstinence.
   b) Oral contraceptives.
   c) Condoms.
   d) IUDs.
   e) Sterilization.

Section IV: STI/HIV Prevention and Treatment: Priority for
Young Adults
18. Please indicate whether the following statement is True (T) or False (F)
Young adults may be a high risk for STIs due to both             True    False
behavioral and biological susceptibility.




                                                                           25
19. Check all that apply. High-risk behavior for contracting STIs include:
   a) Having multiple partners.
   b) Having one partner who has multiple partners.
   c) Drug and alcohol use.
   d) Using condoms inconsistently or incorrectly.
20. Check all that apply. HIV is transmitted in which of the following ways?
   a) Air.
   b) Semen.
   c) Vaginal fluids.
   d) Blood.
   e) Breastmilk.
21. Which three of the following are good examples of effective behavior by a
provider during voluntary counseling and testing?
   a) Discussion of disclosure of HIV status.
   b) Preventive counseling.
   c) Shouting at the client.
   d) Providing social and medical support.
22. The consequences of untreated STIs can include:
   a) Painful urination.
   b) Complications with pregnancy.
   c) Infertility.
   d) Death.
   e) All of the above.
23. Please indicate whether the following statement is True (T) or False (F)
Counselors need to pay special attention to young women,         True        False
since HIV rates are increasing most rapidly among this
group.


The following section shows the correct answers to each question


 26
   Contraceptive Technology and Reproductive Health
Series: Reproductive Health of Young Adults - Answer Key

Section 1. Reproductive Health Issues of Young Adults.
1. Please indicate whether the following statement is True (T) or False (F)
Young people have many problems and hence offer little help in addressing
reproductive health problems :                           True       False
2. Check all that apply. Sexually active youth face the following reproductive
health risks:
   a) Unintended and too-early pregnancy.
   b) Sexual violence and unwanted sexual activity.
   c) Too much influence on peers.
   d) Sexually transmitted infections, including HIV.
   e) Lack of communication with parents.
3. Please indicate whether the following statements regarding gender and
HIV/AIDS among youth are True (T) or False (F).
   a) Risk of infection varies because of gender.                True    False
   b) Girls purchase condoms as early as boys.                   True    False
   c) Girls see condoms as a sign of promiscuity.                True    False
   d) Boys use condoms most often with regular partners.         True    False
4. Please indicate whether the following statement is True (T) or False (F).
   The length of time when women are fertile prior to          True    False
   marriage has been increasing due to nutrition and
   health in developed countries but not in developing
   countries.
5. What are the main reasons that unmarried, sexually active youth report they
do not use contraception? Check all below that apply :
   a) Did not have permission from their parents.
   b) Did not expect to have sex.



                                                                          27
   c) Lacked information about contraception.
   d) Lacked access to resources.
6. Please indicate whether the following statement is True (T) or False (F)

   As many as half of pregnancies among unmarried               True     False
   women in many developing countries are unintended.

7. Please indicate whether the following statements are True (T) or False (F)
   a) Using contraception can reduce the risk of unsafe         True     False
      abortion among youth.
   b) More than half of women seeking hospital care for         True     False
      unsafe abortion in developing countries are under
      age 20.
   c) Medical complications from abortion are not serious.      True     False
8. Check all that apply. Youth are at high risk for STIs/HIV due to which of the
following factors:
   a) Non-use or incorrect use of condoms.
   b) Failure to seek treatment.
   c) Lack of communication among peers.
   d) Having multiple partners.

Section II. How to Reach Young Adults
9. Check all that apply. Communication skills needed by providers working with
youth include which of the following:
   a) Reflective listening.
   b) Superior knowledge.
   c) Closed-ended questions.
   d) Honesty.
   e) Nonjudgmental attitude.




 28
10. Please indicate whether the following statements are True (T) or False (F)
   a) Sex education leads to earlier or increased sexual        True    False
      activity.
   b) Sex education tries to give young people skills to       True      False
      delay sexual activity.
   c) Sex education can lead to increased use of               True      False
      contraceptive.

11. Check all that apply. The following are outcomes of effective sex education
programs:
   a) Strengthens individual and group values against unprotected inter-
      course.
   b) Provides clear lecture notes for teachers.
   c) Involves students in teaching methods.
   d) Maintains discipline in classroom.
   e) Focuses on reducing sexual risk-taking.
12. Check all that apply. The most important elements in designing programs for
young adults:
   a) Are designed by the Ministry of Health.
   b) Involve youth.
   c) Make services accessible, as identified by youth.
   d) Identify target groups, their assets and their needs.
   e) Work with community, including parents.
13. Check all that apply. Elements of good youth-adult partnerships include:
   a) Organizational commitment and capacity.
   b) An equal number of youth and adults on all projects.
   c) Attitude shifts among adults and youth.
   d) Substantive levels of youth participation.
   e) Youth working equal hours as adults.


                                                                          29
Section III. Contraceptive Methods
14. Please indicate whether the following statement is True (T) or False (F)
   Some contraceptive methods are not appropriate for            True    False
   adolescents or young adults for medical reasons.
15. Check all that apply. Complete sexual abstinence can include a range of
which following sexual expressions?
   a) Hugging.
   b) Massage.
   c) Mutual masturbation.
   d) Withdrawal.
   e) Oral sex.
16. Check all that apply. Why barrier methods are considered particularly
appropriate for young people?
   a) Many young adults are at high risk for STIs.
   b) Many young people have earlier access to barrier methods than to
      other contraceptives.
   c) They are good methods for couple in long-term relationships.
   d) They can be easily initiated and discontinued.
   e) All of the above.
17. Check all that apply. Which of the following is true of the spermicidal
nonoxynol-9?
   a) Is more effective against pregnancy when used with another barrier
      method.
   b) Offers protection against HIV.
   c) Is an appropriate method of contraception for women at low risk of
      STIs.
   d) May increase the risk of HIV transmission in some circumstances.
   e) All of the above.



 30
18. Check all that apply. When using the male condom, you should:
   a) Open the package carefully to avoid tearing the condom.
   b) Unroll the condom directly onto the erect penis.
   c) Hold onto the rim of the condom while withdrawing the penis from
      the vagina.
   d) Use oil-based lubricants, such as petroleum jelly.
   e) All of the above.
19. Please indicate whether the following statements about oral contraceptives
are True (T) or False (F)
   a) Oral contraceptives are very safe for young women ado-       True    False
      lescents or young adults for medical reasons.
   b) Oral contraceptives can protect against entopic preg-        True    False
      nancy, benign breast disease, ovarian and endometrial
      cancer, and some forms of pelvic in flammatory dis-
      ease.
   c) Fertility usually returns ten months to a year after         True    False
      women stops taking the pill.
   d) Oral contraceptives are usually available only through a     True    False
      clinic or other trained provider.
   e) Progestin-only pills are the best type of oral contracep-    True    False
      tion for most young women.
   f) Oral contraceptives offer protection against some STIs.      True    False

20. Please indicate which of the following statements about injectables and
implants are True (T) or False (F).
   a) Young people can safely use injectables and implants.       True    False
   b) Injectables and implants have pregnancy rates of less       True    False
       than 1 percent after one years of use.
   c) Injectables and implants are easy to use without a          True    False
       partner's knowledge.




                                                                          31
   d) Injectables and implants are inexpensive.                True     False
   e) Using implants and progestin-only injectables reduces    True     False
      estrogen levels, which theoretically could predispose
      women who use them before age 16 to osteoporosis
      late in life; however definitive studies have not been
      completed.
21. For the lactational amenorrhea method to be effective, a woman must be:
   a) Fully or nearly fully breastfeeding.
   b) Amenorrheic.
   c) Within the first six months postpartum.
   d) Choices a and b only.
   e) Choices a, b and c.
22. Please indicate whether the following statements about traditional contra-
ceptive methods are True (T) or False (F).
   a) Traditional methods can promote reproductive health      True     False
      awareness.
   b) They have low pregnancy rates in typical use.            True     False
   c) Traditional methods offer no protection against STIs.    True     False
   d) Periodic abstinence is particularly appropriate for      True     False
      young women just after menarche.
   e) Natural family planning requires knowledge of            True     False
      reproductive physiology, including fertility.

23. Dual protection refers to:
   a) Use of a highly effective contraceptive method for pregnancy prevention
      along with condoms for STI prevention.
   b) Use of condoms to prevent pregnancy and STI transmission.
   c) Choices a and b.
   d) None of the above.




 32
24. Please indicate whether the following statement is True (T) or False (F) in
terms of when emergency contraception can be used to prevent pregnancy.
   a) After unprotected intercourse.                              True       False
   b) Anytime during cycle.                                       True       False
   c) As a regular method.                                        True       False
   d) As a backup method after contraceptive failure.             True       False
   e) Anytime within a week after unprotected intercourse.        True       False
25. Which of the following methods are considered appropriate for young peo-
ple? Check all that apply:
   a. Complete abstinence.
   b. Oral contraceptives.
   c. Condoms.
   d. IUDs.
   e. Sterilization.

Section IV: STI Prevention and Treatment: Priority for Young
Adults
26. Please indicate whether the following statement is True (T) or False (F).
   Young adults may be at high risk for STIs due to both          True       False
   behavioral and biological susceptibility.
27. Check all that apply. High risk behavior for contracting STIs include:
   a) Having multiple partners.
   b) Having one partner who has multiple partners.
   c) Drug and alcohol use.
   d) Using condoms inconsistently or incorrectly.
28. Please indicate whether the following statement is True (T) or False (F).
   Most curable STIs are caused by bacteria and can be            True       False
   treated effectively with antibiotics.



                                                                             33
29. Please indicate whether the following statement is True (T) or False (F)
      The most common curable STI is HIV.                           True    False
30.      Check all that apply. HIV is transmitted in which of the following ways?
      a. Air.
      b. Semen.
      c. Vaginal fluids.
      d. Blood.
      e. Breastmilk.
31. Which three of the following are good examples of effective behavior by a
provider during voluntary counseling and testing?
      a. Discussion of disclosure of HIV status.
      b. Preventive counseling.
      c. Shouting at the client.
      d. Providing social and medical support.
32. Check all that apply. Viral STIs include the following?
      a. HIV.
      b. Syphilis.
      c. Herpes.
      d. Hepatitis B.
33. A full STI management program involves:
      a. Training providers.
      b. Diagnosing STIs.
      c. Treating STIs with antibiotics.
      d. Tracing partners for treatment.
      e. All of the above.
34. The consequences of untreated STIs can include:
      a. Painful urination.


 34
   b. Complications with pregnancy.
   c. Infertility.
   d. Death.
   e. All of the above.
35. Please indicate whether the following statement is True (T) or False (F).
   Counselors need to pay special attention to young             True     False
   women, since HIV rates are increasing most rapidly
   among this group.




                                                                          35
TOOL T3
    GENDER AWARENESS - TEACHING MATERIALS


                              Sex and Gender

                           Cited from : The Training Manual for Peer Educators.
                                                       Marie Stopes Nicaragua.


What are sexual relations?
Before talking about sexual relations, we should define sex and gender.
Sex: Is the biological characteristics that distinguish between boys and girls at
birth.
Gender: is behaviours, values and roles developed after one is born, through
the influence of the family and society in general.
Almost all societies have different values for men and women. Often these
different sets of values renders... the relation between the two sexes inequitable.
There are many unjust attitudes toward women in many aspects in life, for
example, the differences in males and females' health, education, responsibility
and work.
The education that we have received since a young age shows males are
valued more highly than females. This situation occurs and exists, and is
demonstrated in many people's behavior and actions in the family, school, and
social relationships.
We may still remember when we were young, our parents often assigned roles
to each person in games, which reflect the expected role of each person in
society. For instance:
In some families, there is a big difference in buying toys for boys and girls: girls
play with dolls, cooking sets, and boys participate in physical games, fighting,
self-defence.




                                                                              39
Girls are taught to wear clothes which are different from boys, follow orders, be
gentle and responsible with family, quit school to take care of household tasks
when necessary, take care of older and younger brothers and other family
members, practice being a good housewife, and above all, train to be good
future mothers and be able to please their future husbands.
   S Boys are taught to be independent, courageous, risk-taking, and strong.
     They cannot be weak and especially cannot show their feelings. In
     contrast, boys need to learn how to give an order so that they can control
     and maintain their power because they will become the owners of the
     house in the future.
   S Some female adolescents are forced to stop schooling when they get
     pregnant while male adolescents can continue their education even
     though they are fathers.
   S Female adolescents are not allowed to receive sexual information to avoid
     encouraging them to fnd a sexual partner, while male adolescents are
     encouraged to find out about sexual relations.
   S Females are limited in the right to decide whether or not to have a child,
     therefore there are many unwanted pregnancies that affect women's
     health and their personal and social development.
This inflexible thinking and actions about males and females may cause some
difficulties in life and may affect overall health of adolescents.
Inequity between the sexes is an issue which must be debated in society and in
the family. Men need to set some active male models, support the protection of
women's rights and women's reproductive health. This helps to build up
awareness about this issue in young males' minds so that they will be more
sensitive and supportive in the future.
Men's support is a major factor that helps to empower women. Men need to
accept women's power and not take it as a threatening sign but as a positive
change for the family and society.




 40
Activity 1
Seeking the balance between males and females.
Through the two-branch diagram, we will analyze current relations between the
sexes in order to suggest behaviour changes.
Time: 1 hour 30 minutes.

Materials needed.
   S Pen.
   S Paper.
   S Marker.
   S Draw a picture of a "Tree of unfairness and injustice" on a flipchart. Divide
     the tree into 3 parts as following: dry tree branches, tree-trunk, and tree-
     root.
   S Draw a picture named "Tree for fairness and justice" in another flipchart.
     Divide the tree into three parts as following: fresh tree branches, tree-
     trunk, and tree-root.

Detailed steps.
Step 1 :
   S Start a short discussion using the following questions:
      -    Do you think that there are models or inflexible rules for male and
           female behaviour in your community?
      -    Do you think there are differences between men and women?
      -    Do you think these differences between men and women are fair and
           valid for both sexes?
   S After taking notes on the group's answers, you need to stress…
When there is an unfair issue, it's important that each individual changes his/her
attitudes in order to bring about changes in the community and hence improve
health.




                                                                            41
Step 2 :
   S Divide the group into 3 teams. Give each team a part of the "tree for
     unfairness and injustice".
   S The first team receives the part of dry tree branches. They should write on
     that part the general situation and examples of the different behaviour of
     men and women.
   S The second team writes some other examples of organisations which
     maintain unfair relations between males and females in the tree-trunk
     part.
   S The third team notes some different values and attitudes in the society
     which contribute to the strengthening of current sex relations or unfair
     relations on the tree-root part.
   S After that the three teams get together and join 3 parts of the "tree for
     unfairness and injustice". The first team will stick their informative dry tree
     branches on the flipchart, then the tree-trunk team does the same, and
     lastly the tree-root team.
   S Give guidelines for discussion on different actions which contribute to the
     strengthening of various thinking ways and actions, based on different
     existing values of the society which affect sexual relations.
Start the discussion: Which part of the tree is easiest to change and what needs
to be done to make these changes? The facilitator provides more information if
it is needed for the discussion.
Step 3 :
   S Distribute one part of the "tree for fairness and justice" to each team.
   S On this new tree, the team having the fresh tree branches will write
     related actions and issues which may result in fairer and more legitimate
     relations.
   S The second team will write on the tree-trunk the names of organizations
     which are able to make changes in the relation between males and
     females so that this relation can be more legitimate and fairer.
   S The third team will write on the tree-root the values and collaborative and
     respectful attitudes on relations between males and females which make


 42
      this relation more legitimate and fairer.
   S In the three-team meeting, request the whole group to put together the
     different parts of the tree, starting with the root of the tree and ending with
     the fresh branches of the tree.
   S Ask everyone to read the information on the tree for one minute, then
     invite one volunteer to give comments on the information. Based on what
     this person says, end the discussion by giving a summary.
All forms of the tree relate to each other to some extent (tree branches, tree
trunk and tree root). It's important that you do not wait for things to be changed
by other people. In order to make some changes at personal level, you have to
make proposals and set up new forms of relation between males and females
which are more legitimate and fairer for both sexes.
Step 4 :
   S To finish the exercise, ask each team to write a message showing what
     needs to be done to reduce the above-mentioned differences in each
     family and put this message in eye-catching places in the community.




                                                                              43
TOOL T4
     GENDER AWARENESS - TEACHING MATERIALS

The following tools are exercises to highlight problems related to the different
ways of treating boys and girls, and the different values put on them in some
societies. Although there is equality of the sexes in Viet Nam according to the
law, society's attitudes are slower to change and we still come across a
significant level of discrimination in some communities.
The material is designed for group discussion.


            The Value Of A Son, The Value Of A Daughter

                                                  Source: Choose a Future!
                The Centre for Development and Population Activities (CEDPA).
                                                          Washington, 1996.


Objective
By the end of the session, participants will be able to examine the benefits of pro-
viding educational opportunities to daughters as well as to sons.

Materials.
"Mai's Story"

Activity.
  1. To begin, ask the girls to think of common sayings about girls or women.
     For example: "A woman's place is in the home".
  2. Ask the group whether they agree or disagree with these sayings and why.
  3. Explain that you are going to read a story about a girl named Mai and some
     problems she faces.
  4. Read "Mai's Story".




                                                                              47
Discussion guidelines
1. Ask the girls for their ideas about how Mai can solve her problem, with
questions such as:
   S What are Mai's problems? What are her concerns?
   S What are the concerns of Mai's mother-in-law? Why is it important to her
     to have a grandson? Is she concerned about the effect on her
     granddaughters of another baby in the family? What does this say about
     how she values her granddaughters?
   S Did Mai make a good decision to start practicing family planning? Why?
   S How will it benefit Mai and her family if she has no more children?
   S What should Mai do about her mother-in-law and her wish to have more
     grandsons? How could her husband help?
   S What about Mai's concern that her daughter, Thom, be allowed to
     continue her studies?
   S What might happen to Thom if she is not able to continue school?
2. After discussing the story, ask the girls:
   S Do you have any similar situations in your home, families, or
     communities?
   S If so, what do you think you can do about them?

Ideas for action
To conclude, ask the girls to tell the ideal number of children they would like to
have and why.

Mai's Story.
Mai is a mother with five children: one son An, and four daughters.
Her husband, Hung, is a reliableman and a good father. He works hard as a
farmer and Mai helps him in the field.
They all live together with Hung's mother, who is a widow. She is a good woman,
but she is always critical and nags at Mai. It fact, she talks from early morning
until she goes to bed : "When are you going to light the fire? It is broad daylight


  48
already!", "Wives should obey their husbands". Sometimes she criticizes Mai for
work not done, and sometimes for spending too much money. And she always
complains that Mai has produced only one son and burdened her dear Hung
with one daughter after another!
Mai has learned to live with her mother-in-law and to keep her mouth closed. In
this way, she is a very dutiful daughter-in-law. But last month she did something
in secret - well, it was a secret between her and Hung. They didn't tell Hung 's
mother was that she wasn't feeling very well. Having five children in 9 years can
make a woman feel unwell. She has a backache and she is tired most of the
time. But she also has so much work to do - when can she rest?
But there was another reason Mai started using family planning. It was because
of her eldest daughter, Thom. She is the first child - and a lovely little girl, a joy
to everyone. Thom goes to school along with An. Every afternoon she brings her
exercise book home and proudly reads to her mother what she has written. She
is so happy in school. But Mai knows that if she has another baby, Thom must
leave her school to care for the new baby while Mai works in the field. There is
simply no other way all the work can be managed. In a way Th¬m knows this too
- because she has seen this happen to her little friends. Almost all of them no
longer go to school, but instead care for younger brothers and sisters.
Today there is a terrible scene in the house when the family gathers to eat. The
old women is wailing and pulling her hair. The family is alarmed and gather
around her where she sits on the floor. Between sobs, she finally tells them. At
the village well this morning, she talked with an old friend who told her someone
had seen Mai at the family planning clinic.
"You are very bad" she shouts at Mai. "And you will pay! You will pay for such
wicked-ness. Now you will have no more sons. And who will care for you in your
old age? An is a good boy, but he is only one. A family needs many sons. Think
of our name. Who will help Hung in the fields? Who will take care of me, if God
forbid, something happens to Hung?"
Hung sits next to his mother and comforts her. He looks at Mai as if he doesn't
know that to do. Thom is also looking at Mai. She knows that this is all
about - at least she knows what is will mean to her. There are also tears in her
eyes.
Mai really has a problem. What would you do if you were Mai?


                                                                                49
                Gender And Family Decision Making.

Objective.
By the end of the session, participants will be able to examine the role of gender
in distributing resources in the family.

Materials.
Six posters of a girl and boy in a family (use the drawings in this session or draw
your own).

Activity.
1. Post or pass around the first four posters. Ask:
   S What do you see in these pictures?
   S How do you thinks the boy and girl feel in each situation?
2. Now post or pass around the two "ideal" pictures (5 and 6).
Ask the same questions as in 1. Have the girls describe how the two pictures
differ.

Discussion guidelines.
1. Ask the girls:
   S What causes situations like those in the first four posters?
   S Which set of posters - the first or second - is most similar to what you see
     in your community?
   S What opportunities, resources, and responsibilities do girls have? What
     about boys?
2. Ask the girls to think about themselves as wives:
   S What responsibilities do wives have? What kinds of opportunities do they
     have? What sort of resources do wives have available to them?
   S Who in the family makes decisions about how resources are shared,
     including food, money, etc.?



  50
Ideas for action.
Point out that the girls have identified an important and widespread problem.
You'd like them to talk about what can be done about it:
   S What can you do to help your own girl children have the same
     opportunities and resources as your boy children?
   S When you become a wife, what can you do to share decisions with your
     husband about how resources and opportunities are shared among your
     children?




                                                                       51
TOOL T5
MINISTRY OF HEALTH NATIONAL GUIDELINES FOR
REPRODUCTIVE HEALTH CARE SERVICES

                                    Source: National Standards and Guidelines
                                       for Reproductive Health Care Services.
                                            Vietnam Ministry of Health (2002).



                          CHAPTER I
                      GENERAL GUIDELINES


       The relationship between health care provider
                      and community


1. The commune level.
  -   The health care providers should work with the community to improve the
      mothers and newborn baby's health.
  -   Explain the factors that can affect the mothers' health in an
      understandable way to the community.
  -   Define necessary steps that need to be taken to help the community
      resolve their reproductive health-related problems (go to village, hamlet).
  -   Facilitate and share with the community the problems that they are facing,
      and make a plan to address those problems.
  -   Help the community to find effective solutions and necessary resources.
  -   Work with the community to explore ways they can resolve the problems.

2. The district level.
  -   Receive the patients, their relatives, and health care staff from lower
      levels warmly.


                                                                           55
   -   Encourage and thank the staff from lower levels for their efforts in
       transferring the patients to the health care centre.
   -   Provide appropriate clinical instructions and recommendations to
       strengthen the community's reliance on the commune health care
       providers.
   -   Communicate with and recognize the key persons of the community, to
       support them to realize their role and functions as well as their difficulties
       and limitations.
   -   Meet and exchange experience with the providers of the commune level
       to enhance their prestige in the community. Set up a specific plan to visit
       periodically the commune level to provide support supervision.
   -   Respect and ensure the patients' privacy, make them and their relatives
       comfortable.

3. Relationship between commune, district and provincial
health care facilities.

3.1 General relationship.
-     Patients (and their relatives) are normally transferred from the commune
health care centre to the district hospital, where facilities will be available for
operative intervention and neonatal care. In some instances, onward referral to
provincial or central hospitals will be necessary.

3.2 Practice.
Lower level:
   -   When referring a patient to the higher level, make sure that the relevant
       instruments are prepared.
   -   Provide necessary information such as the patient's name, age, address,
       obstetric history, reasons for referral and other special reasons, treatment
       conducted and results.
Higher level:
   -   Encourage and thank the staff of lower level for their efforts in transferring
       patients to the health care centre.


 56
   -   Feedback: the health care providers at the higher level should inform if
       possible the refering service about the patient's treatment and results.

3.3 Supportive supervision and regular training.
   -   Review the diagnosis and management of the lower level, health leath
       workers to provide technical support.
Meet and exchange experience and information with the providers of the lower
level health service to enhance their prestige in the community. Provide the
commune health care staff with retraining in high quality clinical skills. Support
the relationship between the district health centre and the commune health
centres.




                                                                            57
            Counselling in Reproductive Health Care.


1. General Principles in Reproductive Health Care (RHC)
Counselling
   -   Counselling is very important and necessary in RHC services. It is a
       communication process between a RH counsellor and a client.
   -   The counselling service needs to be conducted on the basis of
       confidentiality and mutual respect in order to help the client understand
       RH information correctly, know how to manage, and make good decisions
       about personal RH-related problems.
   -   The counsellor needs to have good knowledge of RHC and understand
       the counselling process and skills.
   -   RHC counselling should be based on the client's needs and desires.
   -   RHC counselling can be divided into different levels (commune and
       higher levels):
Health workers who provide counselling at the commune level provide clients
with RH information and knowledge, help them understand their health status
(normal or at risk), tell them what they need to do to improve or protect their RH
and if necessary, where to find further counselling or treatment.
Counselling at the higher levels is a specialized service requiring advanced
training:
   -   Depending on the context, each counselling session may have different
       objectives, content and methods; however they all have to follow the
       same skills, requirements and steps to conduct a counselling session.

2. Requirements for a Quality Counselling Session.

2.1 Respect for the client:
   -   Keep the client's information confidential; do not reveal client's information
       without his/her consent.
   -   Respect the client regardless of their problems and who they are; accept
       his/her ideas without any judgement .


 58
   -   Be patient, listen carefully to understand the client's needs and desires.
   -   Place oneself in the client's "shoes" to understand what he/she thinks,
       needs, and how to help him/her.
   -   Establish a comfortable, open, respectful and trusting relationship with
       the client to ensure the effectiveness of the counselling service.

2.2 Provision of clear and correct information:
   -   Provide the client with appropriate RH information that he/she needs and
       wants to know, including both disadvantages and risk factors.
   -   Use simple language and avoid using technical terms. Encourage the
       client to ask questions, then answer clearly or tell them to return for an
       answer.
   -   Before closing the session, the counsellor must check if the client
       understands correctly the information given to him/her or if the client is
       unclear about anything. Repeat or summarize what the client needs to
       know or do. Make an appointment if necessary.

3. The basic counselling skills

3.1 Establishing rapport skills
   -   Greet the client and introduce oneself to create a close relationship
   -   Use verbal and non-verbal language to communicate with the client

3.2 Listening skills
   -   Listen to the client patiently to understand the causes of his/her
       RH-related problems, concerns and expectations.
   -   Listen carefully to make the client feel that his/her ideas are recognized,
       respected, sympathised with. In this way, his/her anxiety and discomfort
       can be reduced.
   -   Accept what the client has said. Do not reject or criticize but try to
       understand the client's concerns.
   -   Be patient when the client asks questions or queries, hesitates, cries or is
       upset.


                                                                             59
     3.3. Communication skills
        -   Respond appropriately to the client's story by using gestures (such as eye
            contact, nodding).
        -   Counsellor should observe the reactions of the client. Try to uderstand the
            reasons lead to the attitutes of the client (for example: embarassment,
            worry, anger or despair).
        -   Share with the client some practical RH cases to provide him/her with
            opportunities to talk.
        -   The counsellor should have the skills to use information, education and
            communication (IEC) aid materials.

     3.4. Problem solving skills
        -   Identify the nature of the problem.
        -   Identify risks or improper behaviours, encourage the client to reconsider
            his/her beliefs, thoughts and perceptions and to change his/her ways of
            thinking and behaviour, if necessary.
        -   Explore different solutions to the client's problems
        -   Support the client to consider each solution and decide which may be the
            best one.
        -   Assure the client that they will always receive ongoing support while
            he/she is trying to reach a solution.
        -   Sometimes, the counsellor should help the client to acquire new skills
            such as communication skills for safe sex.

     4. Counselling steps

     4.1. Greeting
        -   Greet the client openly and ask him/her to take a seat.
        -   Introduce oneself.
        -   Talk to the client in a friendly manner, so that he/she feels comfortable.




60
4.2. Asking
   -   Ask about the client's needs, desires and reasons for coming. Try to
       explore his/her RH needs at present as well as in the future.
   -   Ask about related information that is useful for counselling (for example
       the client's family history, medical history, living conditions, concerns, and
       knowledge).
   -   Ask open questions, observe and listen attentively to the client's
       responses.

4.3. Telling
   -   Must provide the client with the correct, appropriate and necessary
       information (including both positive and negative information).
   -   Use communication (IEC) aids.
   -   Do not impose personal ideas on the client.

4.4. Helping
   -   Help the client understand the nature of his/her problems to make
       appropriate decisions.
   -   Provide specific guidance to the client to help him/her solve his/her own
       problems.

4.5. Explaining
   -   Explain to the client clearly what he/she still wonders about or
       misunderstands.
   -   Provide the client with IEC materials relating to his/her issues.

4.6. Making appointment
   -   Make appointment with the client to return for further counselling, follow
       up changes and recommend higher level for further treatment if
       necessary.




                                                                                        61
5. Counselling facility
  -   The counselling place needs to ensure the client's privacy and confiden-
      tiality.
  -   There should also be RH issues related posters, information, instructions,
      and materials at the counselling units.




 62
Blood and Fluid Transfusion in Obstetrics & Gynaecology.


1. Blood Transfusion.

1.1. Indications
   -   Severe bleeding during obstetric and gynaecological (OBG) care.
   -   Severe anaemia, especially in the last trimester of pregnancy.

1.2. Basic principles of blood transfusion
   S The most important principle is to transfuse the blood or blood products to
     the patient only when she has severe loss of blood in order to restore
     blood and fluid volume quickly.
   S For physicians:
       + Use blood transfusion only if it is necessary for treatment.
       + Follow the national guidelines for blood transfusion.
       + If the patient has severe loss of blood, infuse fluid and give her oxygen
         while waiting for blood.
       + The health care providers must be aware of the potential risks
         associated with blood transfusion.
       + Monitor the patient during the transfusion process to recognize early
         the possible complications

1.3. Effects
   -   A correctly indicated and safe blood transfusion can save a patient's life
       and restore the patient's health.

1.4. Risks of blood transfusion
Consider carefully the risks related to blood transfusion or the risks without a
blood transfusion before deciding to transfuse blood or blood products to the
woman:
   -   Blood transfusion can cause short-term or long-term complications.




                                                                                     63
   -   Possible reactions of the recipient during blood transfusion: shock,
       shivering, rash, etc,
   -   A whole blood transfusion can infect the recipient with pathogens, such as
       HIV, HBV, HCV, syphilis, or malaria.
   -   Plasma transfusion can transfer the same pathogens like the whole blood
       transfusion and can also cause reactions in the recipient.
   -   Over transfusion.
   1.5. Monitoring during blood transfusion
1.5.1. Monitoring
   S Prior to the procedure: Take the patient's pulse, temperature and
     measure the blood pressure.
   S At the beginning of the procedure:
       -   Give an antihistamine (usually promethazine 10 mg IM) before the
           transfusion.
       -   Confirm the required input (number of drops/minute).
   S During infusion: monitor closely the general status, skin colour and
     temperature changes, take the pulse and blood pressure every 15
     minutes.
   S After infusion: monitor for at least two hours afterwards.
   S Record starting time, completing time, the volume of blood and other
     fluids transfused.
1.5.2. Possible reactions during transfusion and management
If reactions such as red skin, itchiness, anaphylactic shock occur: stop the
transfusion immediately; keep the IV in situ by infusing some fluids such as
saline or Ringer's lactate and call for help.
   S Minor reaction: give promethazine 10mg orally.
   S Anaphylactic shock:
       -   Adrenaline 1%, (use 0.1 ml mixed with 10 ml of saline or Ringer's lac-
           tate solution), give it IV and slowly.




 64
       -   Promethazine 10 mg IV.
       -   Depersolone 30-90 mg (1-3 ampoules) slowly - IV or IV infusion with
           IV fluid, repeat as indicated.
   S If dyspnoea due to bronchial contraction occurs: give Aminophylline 250
     mg mixed with 10 ml of saline or Ringer's lactate solution intravenously.
   S Monitor the heart, lung, and kidney function.
   S When neccessary, timely referral to the higher level.
   S Cross-check again the transfused blood specimen right after the reaction
     occurs.
   S If septic shock is suspected due to infected blood transfusion, stop the
     blood transfusion immediately and conduct bacterial culture of the blood
     in the container.

1.6. Safe blood transfusion
The risks of blood transfusion can be reduced if the regulations below are
followed:
   -   Select carefully the blood donors.
   -   Do not use date expired blood.
   -   Screen for communicable diseases (such as HIV/AIDS, HBV, syphilis,
       malaria) among the blood donors.
   -   Choose blood from appropriate and matched blood group, high quality
       (before expired date, no precipitation); perform the cross-reaction test;
       store and transport the blood safely.
   -   Use blood and blood products correctly in accordance with clinical
       indications.
1.6.1. Blood screening:
   -   Must follow the national regulations.
   -   Screen all sources of blood:
       HIV-1; HIV-2
       HBV, HCV.



                                                                          65
       Syphilis, malaria.
   -   Blood and blood products can be used for transfusion only when all the
       tests are negative.
   -   All sources of blood from donors that are not screened for transmittable
       pathogens as required by national regulations must not be used for
       transfusion.
1.6.2. Sources of blood:
   -   Blood bank.
   -   At the district hospital, blood can be given by the relatives and stored for
       use when necessary, especially with blood group O, Rh negative. The
       screening of the blood donors must be carried out as required by
       national regulations.
Auto-transfusion: the blood must be fresh and it must be assessed to ensure that
it is not coagulated and infected. Use 8 liners of gauze to remove coagulated
blood, store it in a bottle with an anti-coagulation agent and transfuse the patient.

2. Replacement Fluid Infusion
Intravenous replacement fluids are the first-line treatment for hypovolaemia.
Initial treatment with these fluids may be life-saving and provide more interval
time to control bleeding and to obtain blood for transfusion, if necessary.

2.1. Indications
   -   Restore the fluid that the body loses due to operation, or delivery, or other
       disorders.
   -   Maintain the blood pressure while waiting for blood.

2.2. Replacing fluids
2.2.1. Crystalloid solutions
   -   Saline (sodium chloride) 0.9% is the best fluid to use. In addition, Ringer's
       lactate is often used.
   -   Dextrose is ineffective as replacement fluid, and it is not recommended for
       replacing blood in hypovolaemia except when there are no other fluids


 66
        available.
2.2.2. Colloid solutions
    -   These solutions include suspension fluids with bigger molecular
        components than crystalloid fluids, they tend to remain within the
        vascular compartment and mimic plasma proteins to maintain blood
        pressure or to increase the colloid and osmotic pressure of blood.
    -   Plasma should not be used as a colloid solution because it can carry a
        similar risk of transmitting infections, such as HIV and hepatitis as in
        whole blood.
    -   Colloid solutions have a limited function in intensive care for life-saving.

2.3. Checking procedures of fluid infusion
    -   Check if the seal at the bottom of the bottle or plastic packet remains
        intact.
    -   Check the expiration date.
    -   Check if the solution is clear.
2.4. Monitoring the IV fluid infusion:
    -   Prior to the infusion: take pulse, blood pressure, temperature,
        respirations, and urinary volume.
    -   During the infusion: monitor the pulse, blood pressure every 15 minutes,
        urinary volume, and possible reactions (shivers, shock).
    -   If severe blood loss occurs, infuse saline or Ringer's lactate solution at the
        speed of 1 litre in 20 minutes to elevate the blood pressure.
-       After the infusion: continue to monitor the patient for at least 1 more hour.




                                                                                67
       Usage of Antibiotics in Obstetrics & Gynaecology

Infection during pregnancy or after delivery can be caused by many different
micro-organisms including aerobic and anaerobic bacteria. Use of antibiotics
should be based on the monitoring of the woman. If there is no clinical response,
it is required to test for antibiotic sensitivities in order to select the appropriate
antibiotic. In addition, blood culturing needs to be done if septicaemia is
suspected. If urinary tract infections occur after abortion or delivery, broad
spectrum antibiotics should be provided. The serum anti tetanus prophylaxis
should be provided to women in case of unsafe abortion or non-institutional
delivery.

1. Providing Prophylactic Antibiotics
   -   Use prophylactic antibiotics to prevent infection during some obstetric
       procedures (such as Caesarean section, manual removal of placenta). If
       infection is suspected or diagnosed, therapeutic antibiotic is appropriate.
   -   Mode of use: give antibiotics, IV, 30 minutes before operation or
       procedure in order to have enough time for antibiotic to be circulated into
       the blood when starting operation or procedure.
   -   In caesarean section, give one dose of prophylactic antibiotics at the cord
       clamping stage. If operation lasts longer than 6 hours or a large amount
       of blood is lost (estimated about 1,000ml), give second dose to maintain
       adequate antibiotic concentration in blood during operation.

2. Providing Therapeutic Antibiotics
   -   Three kinds of antibiotics can be given during pregnancy within ordinary
       dosage and administration rules; they are Beta-lactamin, Macrolit and
       Polypeptide.
   ­   Tetracycline is contraindicated because it can effect the development of
       baby's bones and teeth and it may have toxic effects on the mother's liver.
   ­   Chloramphenicol is contraindicated because it can cause bone marrow
       aplasia of the foetus.
   ­   Aminoglycosit is contraindicated because it may have toxic effects on the



  68
                 foetus.
            ­    It is not advisable to use Sulfamit, particularly in the last trimester,
                 because it may cause severe haemolytic jaundice of the baby.
            ­    It is not advisable to use Imidazol, pyrimethamin and trimethoprim ,
                 because of their anti-folic acid effect and they can cause foetal
                 deformity, especially in the first trimester.
            ­    Quinolon should not be used during pregnancy.

         2.1. Commune level
            ­    Base on the essential drugs for treatment.
            ­    If the patient's condition has not improved after 2 days of antibiotic
                 treatment, transfer patient to the higher level.

         3. District level:
         To treat primary infection, combine two antibiotics in the following way:
            + Gentamicin 5mg per kg of body weight, IV every 24 hours.
            + Metronidazole 500 mg, IV infusion every 8 hours.
         Guidelines for using antibiotics in pregnancy and during breast-feeding:
                         First        Second            Third
   Antibiotics                                                    Breast-feeding
                      trimester      trimester       trimester
Penicillin               Yes            Yes              Yes           Yes
Cephalosporin            Yes            Yes              Yes           Yes
Macrolite                Yes            Yes              Yes           Yes
Colistine                Yes            Yes              Yes           Yes
Tetracycline              No             No              No            No
Chloramphenicol           No             No              No            No
Aminosit                  No             No              No            No
Rifampicin                No            Yes              Yes           No
Sulfamid                  No             No              No            No
Sulfamethoxazol/
                           No           No              No              No
Trimethoprim
Quinolon                   No           No             No               No
Metronidazole              No           Yes            Yes              No



                                                                                     69
      Aseptic Principles in Reproductive Health Services


1. Clean Environment of the Technical Facilities
  ­    In a health care facility, the surgical and procedure room needs to be
       located in a clean and dry place and far from the kitchen, toilet, and
       infectious department.
  ­    This room must have a floor and walls that are waterproof so that they can
       be washed easily with water and soap. There should be a closed waste
       discharge system.
  ­    The room needs to be equipped with air conditioner and/or table fans
       (ceiling fan is not allowed). The windows must be covered with glass and
       at a level of 1.5m higher than the floor or if glass is not available, net can
       be used to prevent flies and mosquitoes.
  ­    When technical procedures are not in progress, the room must be closed
       and inaccessible. It must absolutely not be used for other purposes.
  ­    After each surgical procedure, change the operative cover; clean the
       cover carefully before reuse.
  ­    Operating room: all equipment in the operating room needs to be cleaned
       and cleaning need to be done regularly.

2. Clients (Users of Reproductive Health Services)

2.1. Prior to conducting a surgical procedure or operation
  ­    Before the surgical procedure or operation, the client needs to bath, and
       wear clean clothes.
  ­    The client should urinate or the bladder should be emptied.
  ­    The health care provider has to check the operation area for wounds,
       furuncle, scabies, or any other infection. If present, the operation should
       be postponed, except in an emergency.
  ­    The body area for operation (e.g. abdomen, genital area) must be
       washed; apply aseptic solution such as organic iodine 10%.




 70
2.2. After an operation or procedure
   ­   After the operation, the client must wear clean clothes, keep the incision
       clean and dry, and avoid making the incision wet if having a bath.
   ­   If the incision is dry, clean and without blood, it is not necessary to change
       the bandage daily. The bandage will be changed on the day that the
       sutures are removed (5-7 days after operation).

3. Providers (health care workers)
   ­   Shoes and slippers must be placed outside the surgical room (use the
       designated slippers or wooden clogs for operating room). Cap must cover
       hair; mask must cover nose. Medical staff who have infectious diseases
       are not allowed to enter the surgical area. Change the sterile gown,
       gloves, mask after each operation.
   ­   Surgeon and assistants must wear a sterile gown, cap, and mask.
       Fingernails must be short; ring and bracelet should be removed before
       scrubbing up. Wash hands with aseptic solution such as chlohexidine
       gluconate solution, if wash hands with soap and brush, dry hands with a
       sterile cloth then wear sterile gloves.
   ­   Note: washing hands is the most important step to prevent infection in
       providing reproductive health services.
   ­   Process of using gloves:
Gloves are used for most of the MCH/FP services. The principle of using gloves
for each type of service is shown in the table as following:




                                                                               71
Note: (-)                                                              Highly
                                                          Needs                     Sterile
u n n e c - No         Name of service
                                                          gloves
                                                                     disinfected
                                                                                    gloves
                                                                       gloves
e s s a r y,
( + ) 1. Gynaecological examination                          +            +             -
required 2. Vaginal exam, birth attending                    +            +             -
             3. Insertion or removal of IUD                  +            +             -
4.           4. Menstrual regulation                         +            +             -
             5. Induced abortion                             +            -             +
             6. Insertion and removal of Norplant            +            -             +
                Operation, uterine cavity inspection,
             7.                                              +            -             +
                manual removal of placenta
             8. Neonatal intensive treatment                 +            -             +
             9. Blood withdrawal and transfusion             +            +             -
            10. Decontamination of instruments               +            -             -
             11. Washing instruments and clean the body      +            -             -

Instrument and Equipment Used in Surgical Procedures and
Operations:
     ­   Equipment such as: operating table, obstetric table, etc. should be
         cleaned after conducting every procedure and should be washed weekly
         with soap and clean water, and the gynaecological examination table
         must be cleaned daily. Change the table-cover after each procedure.
     ­   Instruments made of metal, rubber, plastic, linens, and glass must be
         sterilized following the specific sterilization process applied to each type
         of instrument.
     ­   Contraceptives such as: IUDs, pills, and implants must be kept in the
         manufacturer's packets. If the packet is broken, do not use.




 72
                   Instrument Sterilization Process
                   in Reproductive Health Services


1. Sterilization Process:

1.1. Decontamination
   ­   This is the first step of the sterilization process.
   ­   Equipment needed: a large plastic bucket with handle and more than 35
       cm in height and a smaller plastic basket with handle to put it inside the
       bucket.
   ­   Chemical decontamination solution: Chloramine or Glutaraldehyde
       solution. These solutions should be changed after each working session.
   ­   Instruments that were used in the operation are placed in the bucket,
       soaked in the decontamination solution for 10 minutes; then they are
       washed and cleaned.

1.2. Cleaning
   ­   Equipment required: a plastic basin, running water, soap, and a brush.
   ­   While washing, the worker needs to wear rubber gloves and mask to
       prevent infection. Use brush and soap to clean the instruments until all
       blood stains and tissue are removed.
   ­   Clean carefully the dirty areas such as teeth and apex of the instruments;
       then wash with soap and dry with a clean cloth. Cleaning under running
       water is better than cleaning with water in the bucket.
   ­   Requirement: no blood, pus, or tissue such as placental fragments,
       adipose or muscular remnants should remain on the instruments.

1.3. High-level disinfection (HLD):
1.3.1. Soaked in chemicals
   ­   Requirement: the instruments should be soaked in chemicals used for
       high-level disinfection such as : glutaraldehyde 2%, or other solutions
       such as chlorine 0.5% for 20 minutes.



                                                                           73
   ­   This method is applied to instruments made of plastic and rubber; it is not
       relevant for those made of metal or linen.
Make sure that the instruments are totally steeped in the solution. Remove the
instruments and rinse with sterilized water, then place them in a sterile tray with
cover, wait until dry before use or store.
1.3.2. Boiling
­     Equipment: metal pot rectangular in shape, large enough to contain
equipment with an electric heater at the bottom or use a separate heater such
as electric, gas or kerosene stove.
­       Requirement: cleaned instruments must be placed promptly into the pot,
then clean water poured on to cover all the instruments. Boil the instruments for
20 minutes at 100c. Remove the instruments then use immediately, do not store
for later use.

1.4. Sterilization:
1.4.1. Steam sterilization
   -   This method is appropriate for all equipment except those made of
       plastic (gowns, gauze, drapes, caps, and masks...) and rubber (catheter,
       gloves). Linen and rubber materials must be processed separately
       because the time, temperature, and pressure required for each kind of
       material is different.
   -   Equipment: autoclave.
   -   Requirement: raise the temperature to 121c (pressure at 1.5 kg/cm2).
       Maintain this temperature for 30 minutes for the wrapped instruments, and
       20 minutes for the unpacked instruments.
1.4.2. Dry heat sterilization
   -   This method is applied only to metal medical instruments
   -   Equipment: dry heat sterilizer.
   -   Requirement:
       + At 170c, maintain for 60 minutes
       + At 160c, maintain for 120 minutes.


  74
       + At 150c, maintain for 150 minutes.
       + At 140c, maintain for 180 minutes.
       + At 121c, maintain for 8 hours.
1.4.3. Checking the sterilization
   -   Soaking in chemicals: sonde, aspiration tubes should be soaked for 10
       hours. The soaked instruments should then be washed in sterilized water.
   - Check equipment:
       + Before sterilization, stick a white indicator paper on the container or the
         wrapping.
       + After sterilization, observe if the paper changes to black. This means the
          instruments inside are sterilized.
After checking: Record the date and name of the worker who sterilized the
instruments on the container or packets.

2. Storage of the Sterilized Instruments:
   -   The storage place must be clean, dry, and with a door that closes.
   -   There should also be shelves and a cabinet, and books to record the date
       of sterilizing the instruments, the date of putting them in storage and
       taking them out (Note: first in first out).
   ­   The sterilized instruments must not be mixed with the non-sterilized ones.
   -   Duration of storage:
       + Sterilized unpacked instruments (which need to be used immediately)
         should not be stored.
       + Highly-disinfected instruments can only be used within 3 days.
       + Sterilized instruments which are packed or placed into a sterile
         container can be stored up to 1 week. If they are not used within 1
         week, they must be sterilized again.
   ­   When transferring sterilized instruments from the storage to the operation
       room, they must be covered to avoid contamination.




                                                                              75
             Essential Drugs at the Commune Level


1. Essential Drugs Criteria for Treating Reproductive Health
Related Problems
  -   The drugs should be appropriate for the provision of essential
      reproductive health care services.
  -   Be available in necessary quantity, safe quality and at reasonable price
  -   Be safe, appropriate and effective.
  -   Be affordable in terms of production capacity, storage, supply and usage.

2. Analgesics and Anaesthetics

2.1. Without opium
  -   Ibuprofen 200mg, po
  -   Paracetamol 100mg, 500mg, po
  -   Atropine 0.25mg/ml, injectable
  -   Lidocaine (Novocain) 1%, injectable
  -   Diazepam 5mg/ml, injectable (where doctor is available)

2.2. With opium
  -   Morphine 10 mg/ml, injectable
  -   Pethidine (Dolosal, Dolargan) 50mg/ml, injectable (where doctor is
      available)

3. Antibiotics
  -   Ampicillin 250mg, 500mg, po
  -   Erythromycin 250mg, po
  -   Doxycycline 100mg, po
  -   Tetracycline 250mg, po
  -   Cotrimoxazole 480mg, po



 76
   -   Metronidazole 250mg, 500mg, po, per vaginal
   -   Chlotrimazole 500mg, per vaginal
   -   Nystatin 100.000IU, per vaginal
   -   Benzyl penicillin 1.200.000IU - 2.400.000IU, injectable
   -   Benzyl penicillin procaine: 1.000.000IU - 3.000.000IU, injectable
   -   Chloramphenicole 1g, injectable
   -   Gentamycine 80mg/ml, injectable

4. Antihypertensives
Treatment of hypertension is not the responsibility of the commune level.
However, if there are signs of severe pre-eclampsia that requires referral, give
the patient antihypertensives in combination with Diazepam.
   -   Aldomet (methyldopa) 250mg, po
   -   Nifedipine: capsule 10mg (sustained release)

5. Aseptics and antiseptics
   -   Chlorhexidine 5% (liquid), external use
   -   Alcohol 70o : external use
   -   Iodine 0,5%: external use
   -   Chloramine 0,5% - 1% (liquid): high antiseptic
   -   Polyvidon iodine 10% (betadine): external use

6. Antispasmodics
   -   Atropine 0.25mg, po or 0,25mg/ml injectable (under doctor's supervision)
   -   papaverin 40mg, po or 40mg/ml injectable (under doctor's supervision)
   -   salbutamol 2mg, po

7. Oxytocics
   -   Ergometrine 0.2mg/ml, injectable



                                                                           77
   -   Oxytocin 5IU, injectable
   -   Salbutamol 5mg

8. Sedatives
   -   Diazepam 5mg, po or injectable (5mg/ml) (injectable under doctor's
       supervision)
   -   Seduxen 5mg

9. Vitamins and Minerals
   ­   Vitamin A, capsule 200.000IU
   ­   Vitamin B1, ampoule 25mg/ml or tablets 10 mg
   ­   Vitamin C, ampoule 100mg or tablets 100mg
   ­   Vitamin K, ampoule 5mg/ml
   ­   Vitamin K1, ampoule 20 mg/ml (with syringe 1 ml)
   ­   Folic iron tablet 60mg iron and 0.5mg folic acid

10. Contraceptives
The commune level needs to have at least 3 kinds of contraceptives:
   -   Combined oral contraceptive pills need to have 2 kinds of pills available
       such as Rigevidon and Ideal
   -   Progestin only contraceptive pills: Exluton
   -   Injectable contraceptive: DMPA 150mg

11. Other Drugs

11.1. Intravenous fluids
Fluid is indispensable for treatment of hypotension, bleeding, exhausted from
prolonged labour, or foetal distress.
   -   Glucose 5%, 20% iv solution.
   -   Sodium chloride 0,9% iv solution.



 78
   -   Ringer's lactate: iv solution

11.2. Antimalarial: (malaria regions)
   -   Artemisinine 250mg, po
   -   Chloroquine 150mg, po
   -   Mefloquine 250mg, po

12. Storage of Essential Drugs

12.1. A medicine cabinet must be provided.
Groups A and B toxic drugs must be locked inside

12.2. Provide a list of drugs
   -   Group A toxic
   -   Group B toxic
   -   Group A and B toxic reduced
   -   Common drugs

12.3. For each kind of drug
   -   The ampoules need to be contained in boxes with correct labels.
   -   Tablets need to be contained in jars with correct labels.
       + Drugs must be kept in the correct place.
12.4. Daily matching:
   -   The quantity of drugs on the list must match those in the cabinet and the
       amount used during the day.




                                                                          79
 Essential Instruments and Equipment for Reproductive
           Health Care at the Commune Level


  ­   Set of instruments for delivery                            03
  ­   Set of instruments for episiotomy and suturing             01
  ­   Set of instruments for cervix inspection                   01
  ­   Set of instruments for neonatal resuscitation              01
  ­   Set of instruments for insertion and removal of IUDs       01
  ­   Set of instruments for gynaecological examination          03
  ­   Set of instruments for MVA                                 01
  ­   Other instruments.

1. Set of Instruments for Delivery
  ­   Straight toothed forceps                                   02
  ­   Straight scissors                                          01
  ­   Metal box with cover                                       01
  ­   Long sterilization forceps                                 02

2. Set of Instruments for Episiotomy and Suturing
  ­   Long d forceps for antiseptic                              02
  ­   Blunt -ended scissors for cutting perineum                 01
  ­   Stitch removal scissors                                    01
  ­   Vaginal retractor                                          02
  ­   Toothed dissecting forceps                                 01
  ­   Needle holder forceps                                      01
  ­   Rounded needle (used for suturing muscle and epithelium)   01
  ­   Triangle needle (used for suturing skin)                   01



 80
  ­   Metal container with cover                         01
  ­   Suture (catgut, flax)

3. Set of Instruments for Cervix Inspection.
  ­   Long forceps for antiseptic                        01
  ­   Vaginal retractor                                  02
  ­   28-cm long heart shaped forceps                    02
  ­   Dissecting forceps                                 01
  ­   Needle holder                                      01
  ­   Rounded needle                                     01
  ­   Metal container with cover                         01
  ­   Suture (catgut)                                    01

4. Set of Instruments for Neonatal Resuscitation
  ­   Suction tube for mucus                             01
  ­   Vacuum aspirator (manual or electric)              01
  ­   Tube connecting vacuum machine with suction tube   01
  ­   Connectors used to assemble the connecting tubes   01
  ­   Metal container with cover                         01
  ­   Form of heating (a bulb of at least 150W)          01

5. Set of Instruments for Insertion and Removal of IUDs.
  ­   Long forceps for antiseptic                        02
  ­   Vaginal retractor or vaginal speculum              01
  ­   Tenaculum                                          01
  ­   Uterine sound                                      01
  ­   Scissors                                           01
  ­   Metal container with cover                         01




                                                           81
     6. Set of Instruments for Gynaecological Examination
       ­   Speculum                                              03
       ­   Long straight forceps for antiseptic                  03
       ­   Metal container with cover                            01

     7. Set of Instruments for MVA
       ­   Long forceps for antiseptic                           02
       ­   Speculum                                              01
       ­   Tenaculum                                             01
       ­   Cannula sized #4                                      01
       ­   Cannula sized #5                                      01
       ­   Cannula sized #6                                      01
       ­   Vacuum syringe (Karmann)                              01

     8. Other Instruments:
       ­   Drug cabinet
       ­   Delivery table
       ­   Table for providing services
       ­   Gynaecological examination table
       ­   Instrument table
       ­   Bed (with poles for holding mosquito net)
       ­   Boiler for instrument sterilization (electric)
       ­   Dry heat sterilizer
       ­   Autoclave
       ­   Plastic container with cover for cold sterilization
       ­   Sheet (nylon)
       ­   Container of gauze and cotton




82
   ­   Container of sheets and drapes
   ­   Table for newborn resuscitation and umbilical care
Note: It is possible to have a specific separate box to contain long sterilized
forceps to use for all procedures.




                                                                         83
                Reproductive Health Care Facilities
                      at the Commune Level

The facility should consist of 6 rooms as follows if possible:
   ­   Antenatal care (pregnancy examination) room
   ­   Gynaecological examination room
   ­   Family planning room
   ­   Delivery room
   (Wash basin must be available in each room)
   ­   Post-delivery room
   ­   Counselling and communication room
Otherwise, the facility should have at least 4 rooms:
   ­   Gynaecological examination room
   ­   Family planning room
   ­   Delivery room
   ­   Post-delivery room
   ­   Pregnancy examination, counselling and communication will take place
       in the general examination room of the centre.

1. Pregnancy Examination (Antenatal Care) Room

1.1. Criteria
   ­   Pregnancy examination and management are the functions.
   ­   If the designated room is not available:
       + Pregnancy examination can be arranged in the general examination
         room with a single bed
       + Pregnancy management can be provided in the communication room.

1.2. Equipment:
   ­   For pregnancy examination:


 84
      + Clock with a second hand (for palpation and auscultation of the foetal
        heart rate)
      + Scales (for weighing adult)
      + Sphygmomanometer
      + Stethoscope
      + Foetal stethoscope
      + Quick stick (for urine pregnancy test)
      + Proteinuria test (quick stick or tube and spirit-lamp)
      + Haemoglobin, haematocrit, HIV and syphilis tests (if possible)
      + Height measurer
      + Tape measurer (to measure the height of uterus, abdominal circumfer-
        ence)
  ­   For pregnancy management:
      + Home-based mother's card
      + Pregnancy examination record
      + Pregnancy monitoring and management chart
      + Appointment card box

2. Gynaecological Examination Room

2.1. Examination room
  ­   Must be separated from the delivery room
  ­   The area should be at least 9 m2
  ­   Gynaecological table with steps and leg-holders
  ­   Desk for recording and book-keeping
  ­   Instrument table
  ­   Examination light
  ­   Clothes hanger for patients' use




                                                                         85
2.2. Instruments
   ­   Generally need 3 sets of instruments and sterile gloves.
   ­   Other instruments:
   ­   Cotton in small pieces, immersed in sterile solution for cleaning the
       vagina and cervix.
   ­   Acetic acid 3% to differentiate inflammatory conditions from glandular
       ectopia.
   ­   Lugol 3% for detecting suspected injury of the cervix.
   ­   Betadine for disinfection if needed.

3. Family Planning Room.
Refer to the FP section.

4. Delivery Room

4.1. Minimum standards
   ­   The area should be at least 16 m2
   ­   Clean ceiling: the walls are covered by ceramic tiles at least 1.6m high.
   ­   The door protects the room from dust, flies and wind.
   ­   The floor is covered by ceramic tiles and is waterproof, with water
       drainage.
   ­   Clean floor and wall after each delivery.
   ­   The room is equipped with electric lamp with safe wiring.
   ­   It has a wash basin that is convenient for delivery attendance, but does
       not wet the floor.
   ­   The room is located far from polluted areas.
   ­   An intact system for waste water discharge must be available.
   ­   The delivery room must not be used for gynaecological examination.

4.2. Minimum equipment



 86
   ­   01 clean delivery table.
   ­   01 cabinet with sufficient medicine and instruments (according to the
       regulations).
   ­   01 instrument table for delivery and episiotomy.
   ­   01 table for umbilical care and neonatal resuscitation.
   ­   01 lamp for suturing the perineum, assisting delivery.
   ­   Heater or a lamp at least 150W to keep the baby warm.
   ­   Boxes containing thread, bandages, gauze, sterile drapes unexpired.
   ­   Clogs and slippers should be separated.

5. Patient Room (for women in labour, early postnatal period and post-
abortion)
   ­   The number of beds is based on the reproductive health care demands.
       Bed sharing or unnecessary beds should be avoided.
   ­   The room must be clean, free from dust and spider webs, and painted
       regularly.
   ­   Clean beds with poles, sheets must be changed for new patients.
   ­   The place is comfortable and easy to follow up the patient
   ­   Well-designed windows and door that keep the room warm in winter, cool
       in summer and is a peaceful resting place at night.
   ­   The room must have clean water, convenient bathroom and toilet.

6. Communication & Counselling Room

6.1. The room should:
   ­   Be a private room in a convenient location.
   ­   Have enough chairs for group counselling.
   ­   Be cleaned daily, ready to serve the clients.
   ­   Maintain privacy, warmth for counselling.
   ­   If room is not available, this service can be arranged in a corner of the



                                                                          87
       general examination room.

6.2. Equipment
   ­   Leaflets relating to counselling information.
   ­   Posters (hung neatly on the walls, remain intact, not mould).
   ­   Picture illustrated book.
   ­   Specimens.
Presentation of contraceptive samples such as IUDs, pills and condoms.




 88
                             CHAPTER II
                          FAMILY PLANNING


                   Counselling on Family Planning

Family planning counselling needs similar skills and follows the steps of
Counselling in reproductive health care . This section deals only with the
specific issues relating to counselling on family planning.

1. Counselling on Family Planning
Counselling helps the client to make decisions about using an appropriate
contraceptive method at a certain reproductive period. The client's needs, rather
than the counsellor's intentions must be the focus of the counselling session.

2. Role of Family Planning Counselling
   ­   Help the client to choose the appropriate contraception and to use it cor-
       rectly.
   ­   Increase the rate of continuing users of contraception and reduce the
       number of discontinued clients.
   ­   Increase the number of contraceptive users.
   ­   Contribute to health promotion and make the family planning programme
       less expensive.
   ­   Explain the interrelationships of safe sex in order to decrease unwanted
       pregnancies and client's risk of contracting STIs.

3. Ten Rights of Clients
   ­   To have information
   ­   To have access to the health care and information services
   ­   To be free to choose and refuse or stop any contraceptive methods
   ­   To receive safe services



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  ­   To have confidentiality
  ­   To enjoy privacy
  ­   To be comfortable while receiving the service
  ­   To be respected
  ­   To continue the service
  ­   To express their ideas

4. The Essential Qualities of a Family Planning Counsellor

4.1. Respecting the clients:
  ­   Respect the client regardless of their social status
  ­   Listen to their needs and ideas.

4.2. Understanding the clients:
  ­   Be sensitive about their needs. Understand their wishes.
  ­   Receive them in a separate and quiet room so that they can enjoy
      privacy.

4.3. Being honest with the clients when counselling
  ­   Tell the truth about all contraceptive methods, including disadvantages,
      side effects, and risks of such methods.
  ­   Do not refuse to provide the client with information. If the information is not
      clear, remember to answer later.

4.4. Informing the clients clearly and simply and paying attention to the
client's interest
  ­   Use simple and short sentences. Do not use professional terms.
  ­   Use words with the support of additional materials such as pamphlets, posters,
      and models and encourage the clients to touch and observe directly.
  ­   Request the client's feedback.
  ­   Summarize, emphasize the key points and ask the client to repeat before
      ending the counselling.


 90
5. The Six Counselling Steps for Family Planning

5.1. Greeting (communicating)
­      Greet the client warmly, ask him/her to sit down, be friendly in order to
build a close relationship.
­       Introduce yourself.

5.2. Asking
    ­   Ask for information about the client's health and contraception needs.
    ­   Listen carefully, be patient, avoid speaking too much.
    ­   Identify the client's misperceptions and explain the right way.

5.3. Telling
    ­   Introduce and display the contraceptive methods available at the facility
        and in the market.
    ­   Provide proper information, both advantages and disadvantages; possible
        side effects and complications of such methods.
    ­   Focus on the client's interests; and explain when the client misundstands.

5.4. Helping
    ­   Help the client to select the most appropriate method.
    ­   Do not influence the client's choice.
    ­   If the client selects a method that could be inappropriate or contra-indi-
        cated, the counsellor should give him/her advice on alternatives.

5.5. Explaining
    ­   When the client selects a method, explain properly how to apply it.
    ­   Tell him/her the procedure (especially with some clinical methods such as
        IUD and sterilization).
    ­   Explain the reasons that could cause failure and how to prevent them.
    ­   Tell the client the symptoms of side effects and how to deal with it at
        home.


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  ­   Tell the client the warning signs and how to deal with it.
  ­   Explain clearly the degree of reversibility of the contraceptive method.
  ­   Explain why regular examination is needed and encourage the client to
      follow this advice.
  ­   Explain adequately the incorrect understanding of the client.
  ­   After the explanation, ask the client for feedback.

5.6. Return
  ­   Before saying good-bye, tell the client that he/she can make regular visits
      as scheduled or if abnormal signs appear she/he may come back at any
      time.
  ­   Provide communication materials.




 92
            Intrauterine Contraceptive Device (IUD)


1. Indications
  ­   Any woman of reproductive age who wants to use long-term and
      reversible contraception and who is not subject to any contra-indications
      can use an IUD.
  ­   An IUD can be used as an emergency contraceptive.

2. Contraindications
  ­   Menstruation: Prolonged, severe bleeding, menstrual pain, menorrhagia
      due to any cause .
  ­   Gynaecological history: Unresolved reproductive tract infection (vaginitis,
      cervicitis, uterine infection, tubal infection, ovarian infection, PID), uterine
      prolapse, benign or malignant tumour in the uterus or cervix, and uterine
      deformity.
  ­   Obstetric history: no birth, ectopic pregnancy, or suspected pregnancy,
      uterine scar within the last 6 months. After 6 months, the IUD insertion can
      be conducted at hospital, if necessary.
  ­   Medical history: cardiac diseases, coagulation disorders, severe anaemia,
      diabetes, leukocyte reduction, and prolonged corticoid therapy, vulnerable
      woman with infection. Clients with these disorders should be referred to
      higher level for further assessment.

3. IUD Insertion and Removal Procedure

3.1 Examine and evaluate the client's condition before applying the
method.
  ­   Ask thoroughly about history to identify contra-indication (use a checklist).
  ­   Perform appropriate examination to rule out pregnancy or unexplained
      bleeding or contraindications.




                                                                                         93
3.2 When the IUD insertion can be conducted
   ­   Principle: An IUD can be inserted at any time during the menstrual cycle,
       provided that the client is not pregnant.
   ­   Postpartum. Insertion can be performed at the following points of time:
       + At 6 weeks after delivery (after postpartum period) at district health
         centre (DHC) and higher level or at Commune Health Station by DHC
         outreach team
          NOTE: IUD should not be inserted by the commune health station
          staff, because the uterus is still soft and can be perforated easily.
       + Within 6 months after delivery, if menstruation has not returned and the
         mother is exclusively breast-feeding.
       + In cases where pregnancy is suspected, a pregnancy test should be
         carried out.
   ­   After induced abortion: IUD can be inserted after an abortion procedure if
       the uterine cavity is clear of products of conception and not infected.
   ­   IUD Insertion for emergency contraception: The earlier the IUD is insert-
       ed, the better it is. The insertion takes best effect within 5 days after
       unprotected sexual intercourse except in cases of rape, because of the
       risks of STIs.

3.3. Insertion of IUD, TCu-380A type
3.3.1. Preparation:
   -   Check the instruments and IUD packet (within expiry date and intact).
   -   Ask the client to empty her bladder.
   -   Ask the client to lie on the examining table in the gynaecological position.
   -   Explain to the client about the on-going procedure.
   -   Perform a bimanual exam to identify the position of the uterus, its volume
       and check the ovaries.
   -   Wear sterile gloves.
   -   Swab the perineum with an aseptic solution (using the first forceps).



 94
   -   Cover with the sterile drape.
   -   Provider's position: sitting on a chair, between the client's thighs. If there
       is a assistant, the assistant sits or stands on the left of the provider (wear
       sterile gloves on the hand that holds the valve or other instrument).
3.3.2. Procedure of IUD insertion
   ­   Revealing the cervix:
       + Open the vagina with a vaginal retractor or a speculum.
       + Swab the cervix and the fornices with betadine (using 2nd forceps).
       + Grasp the cervix with a tenaculum and pull down slightly.
   ­   Sounding the uterus:
       + Insert the uterine sound in the correct direction without touching the
         vaginal wall.
       + Determine the depth of uterus.
   ­   Loading the IUD into the insertion tube:
       + Load the IUD into the insertion tube inside package.
       + Set the green depth-gauge of the insertion tube in the correct direction
         and corresponding to the uterine depth.
   ­   Inserting the IUD into the uterus:
       + Hold the tube in correct position and direction, hold the tenaculum in
         other hand and pull the cervix up, gently push through the cervical os
         until the tube touches the fundus.
       + Hold the rod to withdraw the insertion tube to release the arms.
       + Push the insertion tube slightly until the IUD touches the fundus.
       + Hold the insertion tube to withdraw the rod.
       + Withdraw the rod.
       + Cut the string at 3 cm from the cervical os, fold the end into the poste-
         rior fornix.
   ­   Removal of the instruments:
       + Remove the tenaculum.


                                                                               95
       + Disinfect the cervix and vagina with betadine, stop bleeding (if neces-
         sary).
       + Remove the vaginal retractor or speculum.
       + Tell the client that procedure ends.

3.4. Insertion of Multiload type
3.4.1. Preparation:
       + As in TCu-380A
3.4.2 Insertion of IUD:
   ­   Revealing the cervix (as in TCu-380A).
   ­   Sounding the uterus (as in TCu-380A).
   ­   Inserting the IUD
       + Tear the packet off; set the depth-gauge of the insertion tube to the cor-
         rect direction and corresponding to the uterine depth.
       + Hold the tenaculum in one hand and pull the cervix up, hold the inser-
         tion tube in the other hand (with IUD inside), push the IUD gently
         through the cervical os following the uterine direction until it touches
         the fundus.
       + Withdraw the insertion tube.
       + Cut the string at 3cm from the cervical os, fold the end into the poste-
         rior fornix.
   ­   Removing the instruments (as in TCu-380A).

3.5. Removal of IUD
3.5.1. Indications:
   ­   Medical reasons:
       + Pregnancy (removal can be done only if the strings are seen).
       + Excessive bleeding.
       + Severe lower abdominal pain.
       + Uterine infection or pelvic inflammatory disease (PID).


 96
       + Uterine or cervical cancer suspected or defined.
       + IUD expulsion.
       + Menopause (12 months after finishing periods).
       + IUD expired (8 - 10 years with TCu-380A, 3 - 5 years with Multiload).
         After removing the IUD, another one can be inserted at the client's
         request.
   ­   Personal reasons:
       + Wishes to become pregnant.
       + Wishes to change to other contraceptive method.
       + Contraception is unnecessary.
3.5.2. How to conduct the removal:
   ­   If the IUD does not have a string, use a designated hook to remove. It
       must be performed by a specialist and in a hospital, not at the commune
       health station.
   ­   TCu and Multiload have strings so they can be removed by using forceps
       to grasp both of the strings and pulling it out.
   ­   If the string can not be found, ultrasound imaging should be conducted to
       identify if the IUD is in the uterine cavity and refer to the higher level for
       IUD removal.

4. Counselling
   ­   Provide the client with information about an IUD:
       + Listen and explore the client's needs for IUD.
       + Let the client look at the different types of IUDs available, but mainly
         give information on the specific IUD that will be used by the client.
       + Use picture or model to explain the IUD position in the uterus and how
         it will be inserted.
Tell the client the advantages and disadvantages of an IUD. The client should be
told that an IUD can not prevent STIs. Infertility is highly possible if the client
cotracts an STI while using this contraception method.



                                                                               97
     + Tell the client when the IUD expires and needs to be removed.
­    Instruct the client to self follow-up: Tell the client how to take the drugs
     provided after insertion.
­    Tell the client to come back for re-examination after 1 month, return for
     annual screening visit or for removal if abnormal signs appear, as
     examination is needed immediately.
­    The client has the right to request IUD removal and to use another method
     if she does not want to continue with an IUD.
­    Ask questions on the key counselling issues and check for her response.
­    Ensure privacy and confidentiality of the client.




98
                                    Condom

Condom use is an effective, safe and cost-effective method of contraception, as
well as a method for protection against STIs, including HIV/AIDS. There are 2
types of condoms that can be used exclusively by males and females.

1. Indications
   ­   Those who wish to use contraception.
   ­   For use as a supportive method (e.g. after vasectomy, missed pills).
   ­   For use as a protective method against STIs, including HIV/AIDS.

2. Contra-indications
   ­   Those who are allergic to latex.

3. Usage and Storage
   ­   The client should have condoms at his/her disposal; check the expiry date
       before use.
   ­   Use an unused condom for each sexual intercourse.
   ­   Male condom: Wear condom when the penis is erect and before putting
       into the vagina. Keep the ring outside. Roll the ring up to the penis' base
       and the condom should not be stretched. After ejaculation, withdraw the
       penis while it is still erect, keep the ring at the penis' base and withdraw
       the penis to prevent semen from running out.
   ­   Female condom: insert into the vagina by hand before intercourse. Bend
       the small ring and place it into the vagina, right behind the pubis. This
       small ring will cover the cervix entirely; the bigger external ring will cover
       the labia majora. The female condom should be removed after the
       intercourse is over or before sitting up or standing up to prevent the semen
        from flowing out.
   ­   Storage: avoid sunlight and high temperature.




                                                                                        99
4. Counselling
  ­   Listen and explore the client's needs for contraception.
  ­   Show the client condoms and tell him/her how to use them.
  ­   Explain the advantages and disadvantages of the method. It provides pro-
      tection against STIs.
  ­   If the condom is broken, emergency contraception should be used. If con-
      doms are used with spermicides the method is more effective. No other
      lubrications should be used.




100
                   Combined Oral Contraceptives

The combined oral contraceptive (COC) is a reversible contraceptive method,
containing 2 kinds of hormones, oestrogen and progestin.

1. Indications
Women who need an effective contraceptive method and who are not subject to
any contraindications in the use of COCs.

2. Contra-indications
   ­   Known or suspected pregnancy.
   ­   Breast-feeding an under-6-month child.
   ­   Don't use a COC within 21 days after delivery even for the mother who is
       not breastfeeding.
   ­   Aged over 35 and smoking (10 or more cigarettes/day).
   ­   Hypertension, cardiac diseases, liver diseases, diabetes, and coagulation
       disorders.
   ­   Presence or history of breast cancer.
   ­   Migraine.
   ­   Unexplained abnormal vaginal bleeding.
   ­   Treatment of tuberculosis or mycosis.

3. Procedures

3.1. Examine and evaluate the client's condition before applying the
method.

   ­   Ask thoroughly about history to identify any contra-indication (use
       a checklist).
   ­   Perform appropriate examination to rule out pregnancy or unexplained
       abnormal bleeding.




                                                                                   101
3.2. Timing of use
   ­   From the 1st to the 5th day of the cycle, 1st day is the best.
   ­   Postpartum period if the client does not breastfeed: from 4 weeks after
       delivery.
   ­   After induced abortion or miscarriage: start early within 5 days.

3.3. Modes of use
   ­   Take the first pill on any day of the first 5 days of the menstrual cycle; it is
       best to start on the first day; take one pill daily at the same time and fol-
       low the arrows shown on the packet.
   ­   If using the 28-pill packet, and after finishing one packet, use the first pill
       of the next packet on the next day despite ongoing bleeding.
   ­   If using the 21-pill packet, after finishing one packet, stop for 7 days before
       using the next packet despite ongoing bleeding.

3.4. Management of missed pills, nausea or delayed period
   ­   If one pill is missed: take it immediately at the time of remembering and
       take another at the regular time.
If two pills are missed, take two pills immediately then another two tablets on the
next day then continue the others at the regular time. Use an additional
contraceptive method for 7 days if having sexual intercourse.
   ­   If three pills are missed: give up the used packet, start with the new
       packet. Use an additional contraceptive method for 7 days if having
       sexual intercourse.
   ­   If the client has vomiting or diarrhoea within 4 hours after taking pill, take
       the remaining pills as usual and use an additional method for 7 days after
       the symptoms stop.
   ­   If the cycle is delayed, the client needs to be examined for possible preg-
       nancy.

4. Counselling
   ­   Listen and explore the client's needs for COC.



 102
­   Show the client the packet of COCs and tell her how to use it.
­   Tell her about the advantages and disadvantages of the method. It should
    be noted that COC cannot protect against STIs.
­   Tell her about possible side effects.
­   Follow-up while COCs are being used:
    + The client can revisit for examination and counselling at any time.
    + During the first 3 months of taking the drug, she should return for
      general examination, BP and weight measurement.
    + The client should return for re-examination annually as scheduled.




                                                                      103
                Progestin Only Contraceptive Pills

The progestin only contraceptive pill (POP) is a reversible method of
contraception, containing a little amount of progestin and no oestrogen.

1. Indications
  ­   All women can use a POP effectively, except if contraindicated.
  ­   It is especially safe for breastfeeding women.
  ­   Women who are subject to the contraindications of COCs.

2. Contra-indications
  ­   Past or present breast cancer.
  ­   Present hepatitis or cirrhosis.
  ­   Unexplained abnormal bleeding.
  ­   Treatment with anti-convulsion drugs such as phenyltoin, carbamezapine,
      barbiturates or antibiotics such as griseofulvin, rifampicine.
  ­   Pregnant or suspected pregnant women .

3. Procedure

3.1. Examine and evaluate the client's physical condition before
applying this method
  ­   Ask carefully about her medical history to rule out the contra-indications
      (use a checklist).
  ­   Perform necessary examination to rule out pregnancy or unexplained
      abnormal bleeding.

3.2. Timing of use
  ­   Postpartum and breastfeeding: Start at the 6th week after delivery.
  ­   Postpartum and not breastfeeding: Any time within the first 4 weeks after
      delivery.
  ­   After abortion/miscarriage: Immediately or within 7 days.


104
  ­   After periods start again: Within the first 5 days of the cycle, the best is the
      first day. If this method is used after the first 5 days, POP can be started
      with an additional method such as condoms or spermicides or abstinence
      for two days.
  ­   If the client switches from another modern method, POP can be used
      immediately without waiting for a period.

3.3. Mode of use
  ­   Take a pill everyday at the same time.
  ­   A few hours delay in taking pills can reduce its effectiveness.
  ­   Continue the next packet right after finishing the previous one without an
      interval between the two packets.

3.4. Management of missed pills
  ­   If 1 pill is missed, take it at the time of remembering. The other pills are
      taken regularly as usual.
  ­   For a mother who is not breast-feeding or whose menstruation has
      returned, if she missed 1 pill or took pill 3 hours late, she should use addi-
      tional methods for 2 days.
  ­   If 2 or more pills are missed, the risk of pregnancy is rather high, so use
      additional methods such as condoms, spermicides; or avoid sexual
      intercourse for 7 days while continuing to take pills.

4. Counselling
  ­   Listen and explore the client's needs for POP.
  ­   Show the client the packet of POP and give instructions on how to use.
  ­   Effects, advantages and disadvantages when using POP. They do not
      protect against STIs.
  ­   Potential side effects.
  ­   Follow up during using this method:
      + Client can come back at any time.




                                                                                         105
      + Within first 3 months of taking POP, client needs to come to the health
        facility to have a general examination, blood pressure checked and
        body weight.
      + Appointment for annual checking.
NOTE: POP is less effective than COC and it causes more menstrual disorders
then COC.




106
                Emergency Contraceptive Methods

Emergency contraceptive methods used after unprotected sexual intercourse
includes contraceptive pills and the IUD.

1. Indications
   ­   Women after having unprotected sexual intercourse.
   ­   Contraceptive failure such as perforated condom, missed pill etc.
   ­   Rape.

2. Contra-indications

2.1. Contraceptive pills
   ­   Pregnancy or suspected pregnancy.

2.2. Emergency IUD insertion

   ­ See IUD section.

3. Procedure

3.1. Examine and evaluate the client's physical condition before apply-
ing this method
   ­   Ask carefully about her medical history to rule out the contra-indications
       (use a checklist).
   ­   Perform necessary examination to rule out pregnancy or unexplained
       abnormal bleeding.

3.2. Mode of use
Select one of the three following ways
3.2.1. Emergency contraceptive pill with progestin only:
   ­   The trade name is POSTINOR. The active ingredient is 0.75mg of
       Levonorgestrel.



                                                                                    107
   ­   Take 1 pill as soon as possible and within 72 hours after first unprotected
       intercourse. The next pill is taken 12 hours after the first one.
3.2.2. Combined oral contraceptive: (Ideal, Choice, New Choice)
   ­   First dose: within 72 hours after intercourse, take 4 pills (each contains
       30g ethinyl oestradiol and 0.15mg levonorgestrel). 12 hours afterward,
       take another 4 pills.
3.2.3. Emergency IUD insertion:
   ­   Insert the IUD within 5 days after unprotected intercourse. After rape, if the
       risk of STI is evident, do not insert an IUD. (See the section on IUD).

4. Counselling
   ­   Listen and explore the client's needs for emergency contraceptive
       methods.
   ­   Show the client the packet and tell her how to use it.
   ­   Tell the client about advantages and disadvantages of emergency contra-
       ception. It should be noted that the method cannot protect against STIs.
   ­   Counsel on the use of other reliable methods if regularly sexually active.
   ­   Explain potential side effects of this method. For example, she can have
       nausea after taking COC and spotting and cramping after IUD insertion.
   ­   Counselling on emergency IUD insertion.
   ­   Follow-up visit:
       + If the client has delayed period, she should be re-examined immedi-
         ately.
       + Severe or prolonged vaginal bleeding also requires re-examination.
       + If the client vomits within 2 hours after taking the pill, repeat the dose.
       + This method should not be used more than twice a month and should
         not be used regularly.




108
                   Injectable Contraceptive (DMPA)

A dose of injectable contraceptive DMPA contains progestin 150 mg and has a
contraceptive effect for 3 months.

1. Indications
   ­   Women of reproductive age who want long-term, reversible and effective
       contraception and who do not want to use pills daily.

2. Contra-indications
   ­   Pregnancy or suspected pregnancy.
   ­   Unexplained abnormal vaginal bleeding.
   ­   Jaundice.
   ­   Breast cancer.
   ­   Cardiac diseases.

3. Procedures of DMPA injection

3.1. Examine and evaluate the client's physical condition before applying
this method
   ­   Ask carefully about her medical history to rule out the contra-indications
       (use a checklist).
   ­   Perform necessary examination to rule out pregnancy or unexplained
       abnormal bleeding.

3.2. Timing of the first injection
   ­   Within the first 7 days of the menstrual cycle. It can be injected later if
       there has been no intercourse since the last period. Condoms must be
       used or no intercourse for 2 days after injection.
   ­   Within 7 days after pregnancy termination.
   ­   Postpartum.
       + Inject after 6 weeks if breast feeding.



                                                                           109
       + Inject after 3 weeks if not breast feeding.
   ­   The next injections can be given every 3 months (possibly 2 weeks
       earlier or later).

3.3. Injection technique
   ­   Disinfect the area to be injected (deltoid muscle, shoulder, or buttock)
       with iodine.
   ­   Use disposable syringe and needle.
   ­   Check DMPA for expiration. Shake the DMPA vial carefully before with-
       drawing from the vial.
   ­   Inject deeply, intramuscularly. Push the solution in slowly to make sure
       that the whole 150 mg DMPA is absorbed.
   ­   After removing the needle, do not rub the injection site to prevent the drug
       from spreading early and quickly.

3.4. Follow-up after injection
Look for:
   ­   Local infection, pain, and redness in the injected site.
   ­   Abscess.

4. Counselling
       ­    Listen and explore the client's needs for an injectable contraceptive.
       ­    Tell her about advantages and disadvantages of injectable contracep-
            tive. Note: due to slow return of fertility after discontinuation of DMPA,
            do not recommend this method for clients wanting to become pregnant
            in the coming year.
       ­    Tell the client about potential side effects.
       ­    Client can return for re-examination follow-up at any time.
       ­    When and where the next injection will be done.




110
                        Contraceptive Implants

There are two kinds of contraceptive implants:
   ­   Norplant, an implant with 6 soft capsules enclosed in synthetic mem-
       branes; each capsule contains 36 mg levonogestrel. The hormone infil-
       trates through the membrane into the blood continuously ensuring reliable
       prouding contraceptive effect for 5 years.
   ­   Implanon, which has only one capsule containing 68 mg etonogestrel
       providing contraceptive effect for 3 years.

1. Indications
Women who want long-term, reversible and effective contraception and who do
not want to take a pill daily or have an injection every 3 months.

2. Contra-indications
   ­   Pregnancy or suspected pregnancy.
   ­   Unexplained abnormal vaginal bleeding.
   ­   Liver disease (acute hepatitis, benign or malignant tumours).
   ­   Breast cancer.
   ­   Thrombo-embolic diseases, phlebitis.
   ­   Systemic diseases such as diabetes, kidney disease, migraine or severe
       headache.

3. Procedure of inserting and removing implant

3.1. Examine and evaluate the client's physical condition before apply-
ing this method
   ­   Ask carefully about her medical history to rule out the contra-indications
       (use a checklist).
   ­   Perform necessary examination to rule out pregnancy or unexplained
       abnormal bleeding.




                                                                          111
3.2. Timing of implanting During the menstrual period or within the first
7 days of the menstrual cycle.
   ­   Three weeks after delivery if not breastfeeding or not exclusively
       breastfeeding.
   ­   Right after or within 7 days after abortion.
   ­   After removal of previous implant.
   ­   At any time if ensure not pregnant.

3.3. Place of implanting
   ­   Interior aspect of the upper-arm (usually the left arm).
   ­   Insert sub-cutaneously.
   ­   Norplant: the capsules are arranged in a sector shape.
   ­   Implanon: the capsule is inserted in the middle of the interior aspect of the
       upper arm.

3.4. Implanting technique
3.4.1. Norplant
   ­   Swab the incision area with an antiseptic solution.
   ­   Cover the area with a drape.
   ­   Anaesthetize the place of insertion, for each capsule apply 1 ml xylocaine
       1%.
   ­   Incise the skin (2mm long).
   ­   Insert the trocar (with a capsule loaded) through the incision.
   ­   Load each capsule one by one as above. Arrange the capsules in a sec-
       tor shape, the angles between 2 capsules and the first and the last cap-
       sule are 150 and 750 respectively. The outer end of the capsules must be
       5mm inside the incision.
   ­   Do not rub the skin after implanting. Apply sterile gauze and a bandage.
3.4.2. Implanon
   -   Swab the implant area with antiseptic solution.


112
  -   Cover the area with a drape.
  -   Anaesthetize the place of insertion with 1 ml lidocaine 1%.
  -   Remove the trocar from the sterile packet.
  -   Check the presence of the capsule in the trocar.
  -   Insert the trocar, always pushing it subcutaneously.
  -   Holding the piston, remove the trocar and the capsule will be left behind.
  -   Verify the presence of the capsule by touching.
  -   Bandage with sterile gauze.

3.5. Removal technique (applied to Norplant and Implanon)
  ­   Disinfect the implanted area.
  ­   Cover the incision area with a drape.
  ­   Anaesthetize with local anaesthetic .
  ­   Incise the skin 2 mm like when inserting.
  ­   Use fingers to squeeze capsules out at the incision.
  ­   Use designated forceps to grasp the capsule and withdraw it. Remove
      capsules one by one lightly.
  ­   After removal, clean the incision with an aseptic solution and apply a
      bandage.

4. Counselling
  ­   Listen and explore the client's needs for implant contraceptive.
  ­   Tell her about advantages and disadvantages of implant contraceptive
      (difficult to remove). It does not protect against STIs.
  ­   Tell her about potential side effects.
  ­   The client can return for re-examination and follow-up at any time.
  ­   This method is not permanent, Norplant has a 5 years contraceptive effect
      and Implanon has a 3 years contraceptive effect.
  ­   Using anti tuberculosis drugs, anti epilepsy drugs and tranquillizers can
      reduce the effect of Norplant and Implanon.


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             Male Sterilization With the Method of Vasectomy


      1. Indications
      Applicable to men who:
         ­   Voluntarily wish to use a permanent, non-reversible contraceptive
             method.

      2. Contra-indications
         ­ Local infection(scrotum infection, STI, testitis, or epididymis inflammation).
         ­   Hydrocele.
         ­   Local disease such as: inguinal hernia, scrotal mass, scrotal varicose.
         ­   Coagulation disorders.

      3. Procedure

      3.1. Surgeon
      Surgeon should be trained in male sterilisation.

      3.2 Pre-operation assessment
             ­   Rule out contraindications.
             ­   Check carefully the medical and surgical history; examine thoroughly
                 and locally (heart, lung, and abdomen). Examine carefully the genital
                 area (scrotum, testicles, epididymis).
             ­   Laboratory tests required: coagulation and bleeding time.
             ­   The client should fill in and sign the voluntary sterilization form.

      3.3. When the procedure can be conducted
         ­   At any time.

      3.4. Client and provider preparation
         ­   Clean the operation area: shave the hair; wash the genital area with an




114
       antiseptic solution.
   ­   The client wears clean clothing, lies on his back comfortably. Cover the
       client with a sterile drape; expose the scrotum through the drape's win-
       dow.
   ­   Surgeon and assistant: wash hands, wear gown and gloves and follow
       strictly aseptic requirements.

3. 5. Anaesthesia
   ­   Local anaesthesia is used lidocaine 1%.
   ­   Give 5mg diazepam if patient is nervous.

3.6. No-scalpel vasectomy technique
3.6.1. Occluding and cutting the right vas.
   ­   Apply the three-fingers technique to locate the vas.
   ­   Grasp the vas with forceps through the scrotal skin.
   ­   Puncture the scrotal skin with dissecting forceps.
   ­   Disclose and elevate the right vas.
   ­   Grasp the vas with the ringed clamp.
   ­   Strip the sheath.
   ­   Occlude and cut the vas.
   ­   Place a piece of sheath to separate the two cut ends of the vas.
3.6.2. Occluding and cutting the left vas: apply a similar technique.
NOTE:
   ­   It is not necessary to suture the scrotal skin. Just apply a bandage over
       the puncture site .
   ­   Ensure haemostasis carefully during the entire procedure.

3.7. Post-operative follow-up
   ­   Ensure the client has a rest for several hours. It is not necessary to stay




                                                                                     115
      in the hospital.
  ­   Client can go home after having rested for some hours at the health
      facility.
  ­   Take antibiotics for 5 days.
  ­   Take pain relief drugs such as paracetamol.

4. Counselling
  ­   Listen to the client to understand his needs for male sterilization.
  ­   Tell him the advantages and disadvantages of vasectomy, emphasizing
      that this is an irreversible method. The possible causes of pregnancy after
      sterilization. This method does not protect against STIs.
  ­   Explain the procedure of male sterilization.
  ­   Teach the client how to take care of himself:
      + The client may feel uncomfortable and some pain in his scrotum (wear
        tight underwear for the first few days to feel more comfortable).
      + Avoid heavy physical work for the first 1-2 days.
      + Sexual intercourse is permitted after the first week, but there is a risk
        of pregnancy.
      + Use condoms for at least the first 20 ejaculations or for 3 months after
        vasectomy.
      + Recognize the signs of local infection.




116
       Female Sterilization by Tubal Ligation & Tubectomy


1. Indications
   ­    Women of reproductive age who have enough healthy children as desired
        and voluntarily wish to use an irreversible permanent contraceptive
        method.
   ­    Have diseases that pregnancy is contraindicated and cannot use other
        methods.

2. Contra-indications:
   ­    Have the following diseases: heart failure, lung failure, endocrine or clot-
        ting disorders, mental disorder, benign and malignant tumour in genitalia,
        urogenital infection (including pelvic inflamation diseases).

3. Procedure:

3.1. Surgeon:
Surgeon should be trained in female sterilisation.

3.2. Pre-operation medical assessment
   ­    Rule out any contraindications.
   ­    Healthy women who wish to use a definitive contraceptive method.
   ­    Check carefully medical, surgical, obstetric and gynaecological history.
        Examine thoroughly and locally (heart, lungs, and abdomen). Perform
        gynaecological examination to check if the reproductive organs are nor-
        mal and the client is not pregnant.
   ­    Compulsory laboratory tests: coagulation and bleeding time.
   ­    The client should fill in and sign the voluntary sterilization form.

3.3. When to perform female sterilization
   ­    No pregnancy.
   ­    After normal delivery (within 48 hours or 6 weeks after delivery).



                                                                               117
   ­   Post abortion/menstrual regulation.
   ­   Conduct sterilization during abdominal operation (at the client's request).

3.4. Preparation
   ­   The client lies on her back on the operating table, legs apart, her knees
       are flexed and the knee joints are on the supports higher than the table
       surface. This position helps the abdomen soften and is convenient for
       using the fundal elevator.
   ­   Catheterize the bladder or ensure client has passed urine before
       the operation.
   ­   If using the fundal elevator, put it in before operating.
   ­   Surgeon stands on the left of the client. The assistant stands on
       the opposite side.
   ­   The instrument table is within the reach of the assistant.
   ­   An anaesthetist is employed to monitor the vital status.
   ­   Another assistant is available outside.

3.5. Anaesthesia
Give 10mg diazepam by injection or 5mg diazepam orally if the patient
is nervous.
Depending on the available equipment and experience, use one of the
three following techniques:
   -   Local anaesthesia: lidocaine 1%.
   -   Peridural (extradural) anaesthesia with lidocaine.
   -   Endotracheal anaesthesia.
The last two must be performed by anaesthetists in hospital.

3.6. Tubectomy technique
3.6.1. Incision of the abdominal wall.
   ­   Small incision (minilap): vertical or horizontal. If the incision is vertical, it
       starts at the highest point of the fundus downward, the uterine elevator


 118
        can be used. Length of the incision is less than 5cm. If tubectomy
        is performed within 48 hours after delivery, use the curb incision right
        below the umbilical plies. Minilap is contra-indicated in women who have
        previous incisions or who are overweight.
    ­   A larger incision may be applied when performing another operation
        combined with tubectomy.
3.6.2. Pomeroy technique:
    ­   Seek and define the tube starting from the uterus. In order to distinguish
        the round ligament (anterior), the infundibulo-pelvic-ovarain ligament
        (posterior), and the fatty tissue of the colon, it is necessary to see the
        pavilion of fallopian tube. The use of fingers or instruments to find the tube
        is dependent on the practice of the surgeon.
    ­   Using Allis forceps raise and move the tube 'waist' out.
    ­   Using catgut, do the ligation of one end 1.5cm below the Allis pick- up
        point and then the other.
    ­   Cut the 'elbow' above the ligation.
    ­   Do the same with the other tube.
    ­   Close the abdomen in layers after making sure that nothing remains
        inside the abdomen.

4. Immediate post operative care:
    ­   Monitor the vital signs (general condition, pulse, blood pressure, and
        respiration... within the first 6 hours)
    ­   The client can go home when the general status is stable .
    ­   Give antibiotics for 5 days when there is a risk of infection.
    ­   Give pain relief drugs (paracetamol).

5. Counselling
    ­   Listen to the client to understand her needs for female sterilization.
    ­   Tell her about the advantages and disadvantages of tubal ligation.
­       It does not protect her against STIs.


                                                                               119
 ­    Explain the procedure of female sterilization.
 ­    Teach the client how to take immediate care of the wound by herself:
      + Have the stitches removed on the 6th day at home or at the commune
        health station.
      + Keep the incision dry and clean. Do not have a bath for the first two
        days. Avoid touching the incision.
      + Avoid hard work for a week.
 ­    Complications and guidance on monitoring warning signs: Call for a
      doctor or send the client to the health centre if one of the following signs
      appears:
      + High temperature.
      + Abdominal pain.
      + Bleeding or pus coming out from the incision.
      + Swollen incision.
      + Suspected pregnancy.




120
        Traditional (natural) Methods of Contraception

Traditional (natural) methods of contraception are those which do not require the
use of any device, medicine or operation to prevent fertilization.

1. Indications
   ­   All couples that want to avoid pregnancy can use this method.

2. Contra-indications
   ­   There is almost no contra-indication but the menstrual cycle based
       methods cannot be used if the woman has irregular menstrual cycle or
       amenorrhoea (secondary or lactational amenorrhoea).
   ­   These methods should not be recommended for women who have
       a contraindication to pregnancy due to health reasons (because the
       effectiveness of these methods is not high).

3. Instructions on Using the Methods

3.1. The rhythm method:
   ­   Depending on the menstrual cycle, instruct the client to calculate the
       expected date of the next period.
   ­   From the date of expected period, count back for 14 days for the
       expected time of ovulation.




       NOTE:       * expected ovulation
          +....+ with risk of pregnancy


                                                                                    121
        ­   From the expected date of ovulation, count forward for 4 days and back-
            ward for 5 days, the period between these points is called the "unsafe
            period" (fertile period). It is necessary to avoid sexual intercourse during
            this period, otherwise, additional contraception needs to be used.

      3.2. Withdrawal method
        ­   When the male partner is about to ejaculate, he must quickly withdraw his
            penis to release the semen outside the vagina.
        ­   Do not let any semen leak out while the penis is still inside the vagina, or
            let any semen drop into the vagina after being ejaculated.

      4. Counselling
        ­   Listen to the clients to understand their needs.
        ­   Tell the client about advantages and disadvantages of traditional methods
            of contraception (they are difficult to apply if the woman does not have a
            regular cycle or the couple fails to cooperate with one another). These
            methods cannot protect from STIs.
        ­   It should be noted that these traditional contraception methods are not
            highly effective. It is therefore advised to combine them with other meth-
            ods to enhance the contraception effect.

      4.1. The rhythm method:
            ­   During the period prior to ovulation, effectiveness is not high because
                ovulation may occur earlier and sperm can live longer.
            ­   It is difficult to apply effectively for women whose cycle is not regular.
            ­   It is advisable that intercourse should be avoided except within the one
                week prior to the next period.

      4.2. Withdrawal:
        ­   The biggest disadvantage of this method is to decrease the excitement of
            both, especially the male; therefore the effectiveness is usually low.
        ­   Also, couples who have lived together for a long time may accept this
            method. It is not appropriate for the young or for those who have just got
            married or who have intercourse very often.


122
             Lactational Amenorrhoea Method (LAM)

The lactational amenorrhoea method uses breastfeeding as a temporary con-
traceptive method.

1. Indications
Women who are exclusively breastfeeding, without the return of menstruation
and have a less than 6 month old baby can use this method.

2. Contraindications:
Include all contraindications to breastfeeding, such as.
   -   mother who is not exclusively breastfeeding, more than 6 months after
       delivery or whose menstruation has returned.
   ­   acute infectious diseases of the mother (including acute viral hepatitis).
   ­   mother infected with HIV.
   ­   mother treated with some drugs that are contraindicated during breast-
       feeding period.
   ­   mother who has not enough breastmilk and is not exclusively
       breastfeeding.

3. Procedure
   ­   Feed the baby 8 - 10 times a day including at least one time at night. The
       interval is no more than 4 hours during the day time and 6 hours during
       the night time.
   ­   Provide the client with correct technical instructions on breastfeeding.
   ­   Baby should not be fed anything except breastmilk.

4. Counselling and Follow-Up
   ­   Listen to the client to understand her needs for contraception.
   ­   Tell her about advantages and disadvantages of LAM. This method
       cannot protect the client against STIs.



                                                                            123
 ­    Tell her to come back to receive other effective contraception if she starts
      to feed her baby with supplementary food, her baby is more than 6
      months or her menses return.
 ­    Revisit the client at least 1 time in 3 months. The information to be
      explored includes:
      + Return of period.
      + Other food the infant takes other than mother's milk.
      + Difficulties in breastfeeding in order to provide assistance.
      + Use of some drugs.
      + Disease recently contracted, such as hepatitis, HIV..
      + Advise the woman to start using another method if this method
        becomes inappropriate (mother does not exclusively breastfeed the
        baby).




124
                   The Family Planning Service Facility

The family planning procedure room should meet the following criteria:

1. Infrastructure

1.1. Location
   ­   Located in a well ventilated and bright place.
   ­   Far from toilet facilities, polluted area.

1.2. Area and structure
   ­   Area from 10 - 16m2.
   ­   Built with glass windows, shutter for dust proofing, net to prevent insects.
   ­   Wall covered with tiles 1.6m high at least.
   ­   Ceiling covered with whitewash or white paint.
   ­   Floor is waterproof, sloping down for draining water.
   ­   No ceiling fan should be used, a ventilator should be installed.
   ­   Well lit.
   ­   The sink with clean water and boiled water at a relevant height, conven-
       ient for washing hands.

2. Staffing
Maternal-Child Health/Family Planning specialized staff:
   ­   Midwives.
   ­   Assistant doctors in obstetrics and paediatrics.
   ­   Obstetric/Gynaecological doctors.
   ­   General doctors who are trained and certified.
   ­   Laboratory workers.




                                                                                      125
3. Equipment and instruments
   ­   Operating table: clean, stainless steel.
   ­   Instrument trolley: stainless steel, mobile.
   ­   Lights.
   ­   2 chairs.
   ­   Other necessary sterilized equipment, sufficient for family planning proce-
       dures.

4. Activities
   ­   The technical procedures are designated by MOH following the decision
       385/2001/ QD BYT on the technical regulation at different levels of health
       care.

5. Logistics

5.1. Equipment
   ­   Heat sterilizer.
   ­   Autoclave.
   ­   Electric boiler.

5.2. Means for asepsis
   ­   Containers for instruments sterilized by Chloramine in the operation room
   ­   Other containers, long gloves, apron, soap, brush, and protecting uniform
       used for washing instruments.
   ­   Safety goggles, aprons for physicians, enough clean slippers.
   ­   Table cover: Nylon sized 50 x 50cm. Cotton cloth sized 80 x 80cm,
       changed after each procedure.
   ­   Designated uniform.

5.3. Essential drugs
(As in MOH regulations)



126
5.4. Contraceptives
Condoms, hormonal contraceptives, IUD.

5.5. Documentation:
  ­   Follow-up registers.
  ­   Contraceptive supply records.
  ­   Client's contraception records.

6. Counselling area
  ­   Situated in a separated area.
  ­   Provided with counselling notebooks and materials.

7. Designated area for medical waste processing




                                                           127
                        CHAPTER III
          REPRODUCTIVE TRACT INFECTIONS (RTI) AND
           SEXUALLY-TRANSMITTED INFECTIONS (STI)


                                    General Issues

      Reproductive tract infections includes 3 types of infections:
       1) Sexually transmitted infections such as chlamydia, gonorrhoea, genital
          trichomonas, syphilis, chanchroid, genital herpes, genial warts and the
          complications of genital wart virus infection and HIV infection.
       2) Endogenic infection due to the overgrowth of normal vaginal micro-
          organisms such as bacterial vaginitis and vulvo-vaginitis caused by
          candida albicans.
       3) Infection caused by contaminated septic procedures. These infections can
           be prevented.
      These infections may result in infertility, ectopic pregnancy, cervical cancer,
      abortion, low birth weight new-born, infant blindness, pneumonia and slow men-
      tal development of the new-born. Furthermore, some RTIs can increase the risk
      of HIV transmission.
      Both men and women can be infected by a STI. When a patient has a STI, the
      treatment should be given to both the patient and his/her partner in order to
      avoid re-infection of the patient if he/she has sex with her/his partner again.
      Endogenic infections caused by bacteria and vaginitis and vulvitis caused by
      candida albicans are not STIs, so treatment for his/her partner is not required.
      Management of RTIs and STIs requires expertise of providers and co-ordination
      of patients. The provider must maintain ethical and professional standards and
      be respectful to all clients, ensuring confidentiality. Examination rooms must be
      private and clean to provide quality RTI and STI management. With female
      patients, the clinical examination includes vaginal examination by sterile
      speculum to check the cervix and the vagina. Prevention is crucial to all STI




128
management. Counselling on safer sexual behaviour including monogamy as
well as proper condom use and treatment for partners is always necessary.
These RTI and STI guidelines are predominantly intended for first level of care
(commune and district levels). However, they are applicable to every level of
care, so the management at secondary and tertiary care levels has been
included as well. If recommended medications or treatment procedures are not
readily available at commune level, referral of patients to a higher level
is recommended.
These guidelines contain limited information on laboratory diagnosis and
treatment regimens to fit with the limited of laboratory equipment at first level, so
the syndrome approach is introduced. Recommended antibiotics will be modi-
fied according to sensitivity patterns. Users of these guidelines are encouraged
to be updated with new information regularly.

1. Medical history taking
The following information needs to be asked:
   -   Current symptoms.
   -   When did the symptoms start and how long has disease existed?
   -   Medicines or other methods currently being used?
   -   History of allergy to medicine.
   -   When was the last sexual intercourse?
   -   The relationship between the symptom and intercourse, e.g. any pain?
       Are the symptoms getting worse?
   -   Menstruation history and prior pregnancies.
   -   Does the client have regular partners? How many partners? Type of part-
       ners (sex workers).
   -   Do sexual partners have similar symptoms or have they been diagnosed
       with any STIs?
   -   Any history of vaginal or urethral discharge or STIs, if yes, how many
       times?
   -   A past or current drug user, tattoos any?


                                                                              129
2. Clinical examination

2.1. Principles and requirements
   -   The examination room should have sufficient light, privacy, and confiden-
       tiality during examination.
   - The provider must keep ethical and professional standards, be respectful
     to the clients and their customs/traditions.It is preferable that the provider
     is the same sex as client. Otherwise, there must be an assistant of the
     same sex as client
   -   Give psychological support to patient before examination.
   -   Sterile gloves should be worn during the procedure.
   -   Prepare sterile instruments: speculum, pincers, gloves, instruments for
       taking specimens, microscopic slides, cotton, alcohol.

2.2. Examination
2.2.1. Examination for female client
General examination: to find out the pathological changes. Attention should be
paid to the body areas where changes frequently can be seen such as mouth,
axillary glands in armpits, groin, anus, palms of hand and foot.
External genital examination:
   -   Position: adjust the patient's position to the gynaecological position.
       Other body areas should be covered, except genital area.
   -   Examine the external genitalia and anal areas, urethra, anus, for ulcers,
       warts, swollen glands, scabies lesions, pubic lice and nits.
   -   Notice vaginal or urethral discharge for colour, smell, appearance (clear,
       clear with mucous, mucous, frank pus, bloody).
Vaginal examination:
   -   Using a sterile speculum to examine: put speculum into the vagina, open
       and fix the cervix between the 2 blades, examine the cervix and vaginal
       walls thoroughly.
   -   Assess the characteristics and features of the discharge (colour, amount,



130
       smell). Assess the discharge in the cervical os: clear or purulent, with
       blood?
   -   Look for lesions like ulcers, or a mass in the cervix or vagina.
   -   Bi-manual examination: insert two fingers into the vagina; press on
       urethra to check whether there is pus or discharge. With the other hand
       gently palpate the lower abdominal area trying to feel for a mass or
       tenderness. Identify whether there is any pain or tenderness when
       pressing or moving the cervix. If yes, pelvic inflammatory disease (PID)
       is highly suspect.
2.2.2. Examination for male client:
   -   Position: standing
   -   Examine the skin of the whole body; pay more attention to face, body,
       arms, hands and feet to identify abnormalities, areas of changed colour.
       Check mouth, armpits, groin, anus, and palms of hand and foot to
       identify any abnormal changes.
   -   Examine the penis, urethral opening, retract the foreskin and check along
       urethra for "milking" (colour, quantity, and other characteristics).
   -   Check scrotum, testes, and epididymis for their firmness and size, any
       abnormal changes.
   -   Examine anal area and anus.

3. Risk assessment for STI
A person is likely to have high risk of an STI if she/he has any one of the fol-
lowing characteristics:
   -   The partner has symptoms of STI or.
   -   There are two out of the 3 following conditions.
       Aged around 20 years and unmarried and is sexually active,
       Has more than one sexual partner or his/her partner has other partner/s,
       Has changed partner within 3 months or,
   -   Has unprotected sex.



                                                                          131
   -   Has sex with sex workers or has partner who has sex with high risk
       groups (e.g.: sex workers and IDUs)

4. When to suggest HIV testing
   -   All STI patients should be assessed for the risk of contracting and trans-
       mitting HIV, therefore all STI patients should be counselled and request-
       ed to have HIV test.
   -   Cases of syphilis, extensive or pervasive herpetic ulcers, chancroid,
       extensive or pervasive genital warts and other STIs with slow response to
       recommended therapy, oral/pharyngeal fungal infections, repeated/recur-
       rent cervical or vaginal infections are strongly recommended to seek HIV
       counselling and testing.

5. Counselling for effective treatment and prevention

5.1. Information and counselling on STIs
Education and counselling for safe sexual behaviours must be provided to all
STI clinic clients. The main issues to be counselled for STI cases are:
   -   Consequences of STIs, especially when proper and complete treatment is
       not provided.
   -   Emphasise the importance of treatment and strictly conform to the doses
       recommended even when the symptoms disappear and patient comes
       back for reassesment as appointed.
   -   Possibility of transmitting STI to current sex partners.
   -   Identify the sex partners and treat them even without clinical symptoms.
   -   Adolescents and young people should be informed of the risk of
       contracting STI's, of more complications safe sex, the need of visting
       health facilities early to have examination, and treatment if getting
       intection.
   -   Safer sex and condom use to prevent STIs and HIV and also to prevent
       unwanted pregnancy.
   -   Risk of HIV infection, counselling for voluntary HIV testing (see above).
       Provide information on the counselling and HIV testing facilities that


132
       clients can use.

5.2. Safer sex and condom use
   -   Condoms are the most efficient way to prevent STIs and HIV. Every STI
       case should be encouraged to learn about and use condoms, male and
       female, properly for safer sex and for the prevention of unwanted preg-
       nancy.

5.3. Partner notification
   -   Health care workers should encourage client with STIs to notify their part-
       ners. Health care workers should explain to clients about the conse-
       quences of STIs if not treated.




                                                                           133
                     Vaginal discharge syndrome

Vaginal discharge syndrome is a clinical syndrome, which is characterised by
the complaint of vaginal discharge, and other accompanying symptoms such as
itching, burning pain in genital areas, discomfort on passing urine, painful sexual
intercourse if not treated, complications can occur, especially gonorrhoea and
chlamydia which may cause PID, infertility, and ectopic pregnancy.
   -   Common causative agents of vulvitis, vaginitis and cervicitis:
       + Candida albicans causing vaginitis and vulvitis.
       + Trichomonas vaginalis causing vaginitis.
       + Bacterial vaginosis causing vaginitis.
       + Neisseria gonorrhoea causing endocervicitis and urethritis.
       + Chlamydia trachomatis causing endocervicitis and urethritis.

1. Clinical symptoms:
   -   Vaginal discharge of various quantity, colour or smell, clear or opaque and
       other signs.
   -   Itching in the vulva and vaginal areas especially with candida albicans.
   -   Burning pain in the vaginal and vulval areas especially with candida albi-
       cans.
   -   Swelling of the vulva .
   -   Painful sexual intercourse.
   -   Discomfort on passing urine.

2. History taking:
   ­   See General Issues
   ­   Endocervicitis risk assessment
A person has a high risk of endocervicitis (usually caused by gonococci or
chlamydia) if he/she has one of the following conditions:
   -   The partner has symptoms of STI or:



 134
  -   There are two out of the 3 following conditions:
      + Aged around 20 years and unmarried and is sexually active,
      + Has more than one sexual partner or her partner has other partner/s,
      + Has changed partner within 3 months, or
  -   Has unprotected sex,
  -   Has sex with or has partner who has sex with high risk groups (e.g.: sex
      workers or IDUs)

3. Clinical examination:
See General Issues.

4. Supportive testing:
  -   Vaginal smear test (wet mount) to identify trichomonas and candida infec-
      tions.
  -   Gram stain for Neisseria gonorrhoea.
  -   Quick Sniff test (test smelling with KOH 10%) for bacterial vaginosis.

5. Diagnosis:
  -   Endocervicitis caused by gonococcus and chlamydia: the discharge in the
      cervical os is muco-purulent, pus or bloody pus. Infection of Skene or
      Bartholin's glands can be accompanied.
  -   Vaginitis: vaginal discharge has the following characteristics:
      + Caused by candida: white discharge, bound to the vaginal walls, abun-
        dant or moderate in amount, often accompanied by itchy and burning
        feeling at the vulva and vagina.
      + Caused by trichomonas: green, foaming, abundant discharge, smelly
        and it can cause intensive cervicitis (strawberry shaped
        cervix).Confirmed diagnosis by wet mount when identifying tri-
        chomonas.
      + Caused by bacteria: grey-white, uniform, bound to the vaginal wall, few
        amount. Sniff test positive.



                                                                          135
6. Treatment protocols:
   -    If the cause is identified, then treat the cause. If not, use syndromic
        approach.
   -    For all cases of vaginal discharge syndrome, the health provider needs to
        identify and treat sex partners, except for vaginitis and vulvitis caused by
        candida albicans and bacteria.

6.1. Treatment protocol for endocervicitis: treat both gonorrhoea and
chlamydia:
   -    Ceftriaxone 250mg, IM. single dose + Doxycycline 100mg po 2 times/day
        in 7 days, or
   -    Spectinomycin 2g, IM. single dose + Doxycycline 100mg po 2 times/day
        in 7 days.
   -    Cefotaxime 1 g, im single dose + Doxycycline 100mg po 2 times/day in 7
        days.
Note:
   -    Doxycycline can be replaced by Tetracycline 500 mg po 4 times/day, in 7
        days.
   -    Doxycycline and Tetracycline should not be used for pregnant and breast
        feeding women, replace as follows:
        + Erythromycin base 500mg po 4 times/day in 7 days, or
        + Amoxicillin 500mg po 3 times/day in 7 days, or
        + Azithromycin 1g po single dose.
   -    Treat the sex partners even if they do not have symptoms of gonorrhoea
        or chlamydia with similar dose.

6.2 Treatment protocol for vaginitis
   -    Treat for trichomonas, bacteria and candida.
6.2.1. Treatment for trichomonas, bacteria .
Use 1 of the following:




 136
   -   Metronidazole 2g or Tinidazole 2g po single dose.
   -   Metronidazole 500mg po 2 times/day for 7 days.
   -   In case of trichomonas vaginitis, treat the partners with the similar dose.
6.2.2. Treatment for candida.
   -   Use 1 of the following:
       + Nystatin vaginal pessary 100,000 IU, 1or 2 tab/day for 14 days, or
       + Miconazole or Clotrimazole vaginal pessary 200mg, 1 tab/day for 3
         days, or
       + Clotrimazole 500mg, vaginal pessary single dose, or
       + Itraconazole (Sporal) 100mg po 2 tab/day for 3 days.
       + Fluconazole (Diflucan) 150mg po single dose.
   Note: treatment for partners is not required.
6.2.3. Refer the patient to the higher level if:
   -   The above medicine/drugs are not available.
   -   Symptoms do not reduce after one course of treatment.
   -   If PID suspected, the patient should be treated at DHC or higher level.

7. Counselling and education
All cases of vaginal discharge should be educated and counselled on safe sex-
ual behaviour, except when caused by candida albicans and endogenic infec-
tion. Major topics for counselling especially with confirmed gonorrhoea or sus-
pected gonorrhoea, Chlamydia and Trichomonas are:
   -   Consequences of vaginal discharge-ascending infection, ectopic preg-
       nancy, infertility.
   -   Follow strict treatment protocols, revisit for examination as scheduled,
       even if symptoms disappear.
   -   Possibility of transmission to sex partner.
   -   Avoid sexual intercourse until therapy is completed.
   -   Safe sex and proper condom use.


                                                                            137
 -    Partner treatment.
 -    Risk of HIV infection. Clinics which provide counselling and HIV testing.
 -    If the disease is not resolved or abdominal pain occurs, sexual intercourse
      is painful, patient should be re-examined to detect other diseases or
      complications.




138
                  Lower abdominal pain syndrome

Lower abdominal pain is a symptom observed in both RTIs and STIs, which
often accompanies vaginal discharge and fever. However, lower abdominal pain
can be a symptom of some obstetric-surgical emergency conditions such as
appendicitis, ectopic pregnancy, twisted ovarian cyst, and ruptured ovarian cyst,
Therefore, the patient must be carefully examined to determine proper indica-
tion.
Pain characteristics:
Pain may be acute or chronic.
   -   Acute pain: refer to some obstetric-surgical emergency conditions:
       appendicitis, twisted ovarian cyst, and ectopic pregnancy, etc.
   -   Chronic pain: not periodical, often related to PID or gynaecological
       infections.
Causative agents of lower abdominal pain related to PID:
   -   Neisseria gonorrhoeae.
   -   Chlamydia trachomatis.
   -   Anaerobic bacteria.

1. Clinical symptoms:
   -   Lower abdominal pain, continual or intermittent, mild to severe.
   -   Pain during intercourse.
   -   Vaginal discharge.
   -   Fever.

2. Medical history
   -   See General issue.
   -   Focus on menstrual period, contraception, pregnancy.




                                                                                    139
      3. Clinical examination
        -   See General issues
        -   Some special attention should be paid when examining the patient:
            + Two hand examination: Insert 2 fingers of one hand into vagina and
              place another hand on the abdomen to determine uterine size, move-
              ment, tenderness and any abnormal condition of the adnexae, or blood
              seen on fingers.
            + Signs: lower abdominal tenderness, pain on cervical motion, palpable,
              tender masses, cervical discharge and fever.

      4. Additional testing (at district level)
        -   Complete Blood Count (CBC).
        -   Ultrasound.
        -   Urinalysis.
        -   Pregnancy test.

      5. Diagnosi
        -   Firstly, differential diagnosis should be made to rule out surgical emer-
            gencies. Such as:
            + Appendicitis.
            + Intestinal obstruction.
            + Torsion of ovarian cyst.
            + Ectopic pregnancy.
        -   For adnexitis/PID.
            + Cervix motion tenderness or painful sexual intercourse.
            + Pain in both sides, more pain on one side.
            + Abundant discharge.
            + Tenderness in lower abdomen and lateral to the uterus.
            + Swelling, mass attached to uterus or ovary .
            + Fever.

140
Patient should be examined to identify other STIs and causes if laboratory tests
are available.

6. Treatment
   -   If causative agent can be identified, the causative treatment should be
       provided.
   -   For every case of PID, partners are required for assessment and treat-
       ment especially in suspected gonorrhoea or Chlamydia.
   -   If causes can not be identified, simultaneous treatment of all causes of
       PID/adnexitis as below.

6.1. Treatment for Gonorrhoea

Use one out of three antibiotics below :
   -   Ceftriaxone 250mg, IM. single dose.
   -   Spectinomycin 2g, IM. single dose.
   -   Cefotaxime 1g, IM. single dose.

6.2. Treatment for Chlamydia
Use 1 out of 3 antibiotics below:
   -   Doxycycline 100mg po 2 times/day in 7 days.
   -   Tetracycline 500mg po 4 times/day in 7 days.
   -   Azythromycin 1g po single dose.
Note: For pregnant women, replace by :
   -   Erythromicine stearate 500mg po 4 times/day in 7 days.
   -   Amoxycycline 500mg po 3 times/day in 7 days.

6.3. Treament for anaerobic infection:
   -   Metronidazole 500 mg p.o. 2 times/day for 14 days.
Note: Metronidazole is not recommended for the first trimester of pregnancy and
alcohol is not allowed during treatment period.



                                                                         141
6.4. Refer the patient to the higher level if:
   -   The above medicine/drugs are not available.
   -   Symptoms do not reduce after 3 days of treatment.
   -   Suspected lower abdominal pain results from surgical causes.
   -   The patient has delayed period, just had delivery, miscarriage or vaginal
       bleeding.

7. Information and counselling
   -   Comply strictly with described treatment regimes even when symptoms
       reduce after some days of taking drugs and return as scheduled for re-
       examination. It is necessary to have a timely re-examination if the symp-
       toms do not reduce or increase.
   -   Complications of STIs, especially ectopic pregnancy risk and infertility if
       the treatment is improperly given.
   -   Partner should be informed and treated, especially cases of Gonorrhoea
       or Chlamydia Trachomatis.
   -   Counselling and education on safe sex and condom use to prevent
       reoccurrence as well as transmission of other STIs/HIV/AIDS.
   -   Suggested place for counselling and HIV test.




142
                      Urethral Discharge Syndrome

Urethral discharge is the term used to indicate urethritis of the male. It is the
most common STI encountered in males. Urethral discharge is a syndrome,
characterised by the discharge from the urethral opening and other symptoms
such as painful urination, dysuria. Urethral discharge usually happens with ure-
thritis.
   -   Most common causative agents: Neisseria gonorrhoea, Chlamydia tra-
       chomatis.

1. Clinical symptoms
   -   Pus or mucus discharge from urethral openning.
   -   Dysuria.
   -   Pollakiuria.
   -   Difficult urination.
   -   Feeling of constant urethral itching.
   Signs often accompanied by:
   -   Conjunctivitis, gonorrhoeal pharyngitis
   -   Swelling and tenderness in testicles

2. History taking:
See general issues, in addition; ask the following questions:
       -   When did the problem start? Did it start abruptly or gradually? Duration
           of incubation period?
       -   Did the symptoms appear at the same time and acutely or gradually?
       -   Is the urethral discharge abundant or scarce, what are the
           characteristics of the discharge?

3. Clinical examination
How to examine: see General issues (Examination).
In addition, clinical examination should be conducted to find out:


                                                                                      143
  -   Amount of discharge: abundant or scarce, discharging automatically or
      when pushing.
  -   Characteristics of discharge: clear or not, purulent, mucoid.
  -   Testicles and epididymis: swelling, tenderness.
  -   Other symptoms: arthritic pain, conjunctivitis.
  -   Other STI syndromes: genital ulcers, genital warts, inguinal nodes.

4. Laboratory tests:
  -   Gram staining for negative gram diplococci and number of white blood
      cells in the urethral discharge.

5. Diagnosis

5.1. Gonococcal urethritis:
  -   Acute onset of disease, dysuria associated with purulent discharge which
      caused the patient to go to the clinic.
  -   Short incubation period (2 - 6 days).
  -   Abundant, purulent discharge, sticky, yellow or greenish discharge.
  -   Testing: negative gram diplococci found and intra and extra cellular
      granulocytes.

5.2. Non-gonococcal urethritis:
  -   Longer incubation period (1 - 5 weeks).
  -   Less striking symptoms, no dysuria, less and non-purulent discharge.
  -   Testing: no gram negative and more than 4 WBCs per field magnified
      1000 times.

6. Treatment protocol
  -   It is necessary for the health care provider to treat the sex partners of all
      patients who have urethral discharge syndrome.
  -   If the causative agents are identified, provide the cause-based treatment.
      Otherwise, use the syndromic approach.


144
6.1. Gonococcal urethritis:
   -   Combination of treatment for both Gonococcal and non gonoccocal ure-
       thritis using 1 out of 3 below:
       + Ceftriaxone 250mg, IM. single dose + Doxycycline 100mg po,
         twice/day for 7 days.
       + Spectinomycin 2g, IM. single dose + Doxycycline 100mg po, twice/day
         for 7 days.
       + Cefotaxime 1g, IM. single dose. + Doxycycline 100mg po, twice/day for
         7 days.

6.2. Non-gonococcal urethritis:
   -   Use 1 of 3 below:
       + Doxycycline 100mg po 2 times/day in 7 days.
       + Tetracycline 500mg po 4 times/day in 7 days.
       + Azythromycin 1g po single dose.
Note: Treat partner with similar dose. Do not use Doxycycline, Tetracycline for
pregnant or breast feeding women.

6.3. Refer the patient to the higher level if:
   -   The above medicine/drugs are not available.
   -   Symptoms do not reduce after one course of treatment.
   -   Gonorrhoea with complications such as orchitis.

7. Counselling and information
Counselling and education on safe sexual behaviour needs to be provided for all
patients who have urethral discharge. The health care provider must adhere to
all the counselling principles mentioned in these guidelines. The main
counselling contents include:
   -   Consequences of infection: risks of PID in partner, infertility, conjunctivitis
       resulting in blindness of new-born, pneumonia of new born, etc.
   -   Follow the treatment protocols and return for re-examination.



                                                                               145
 -    Increased risk of transmission of other STIs and HIV to partners.
 -    Discuss safe sex and how to use condom properly and regularly.
 -    Inform and treat partners.
 -    Asymptomatic cases are common (more than 50%), but they can be
      transmitted to partners and the disease is still active and it can result in
      complications.
 -    Risk of contracting other STIs and HIV, counselling before HIV test.
 -    Place for counselling and HIV test.




146
                         Genital ulcer syndrome

Genital ulcer syndrome is the term used to indicate the condition in both males
and females. It is a pathological condition featuring an ulcer in the genitalia, anus
or other location (lips, tongue, throat) caused by an STI causative agent, often
accompanied by swollen surrounding nodes.
Common causes:
   S Syphilis.
   S Chancroid.
   S Genital Herpes types I, II.

1. Clinical symptoms
   -   An ulcer or many ulcers in the anus or genitalia or lips, tongue, throat with
       or without pain.
   -   Swollen lymph nodes, on one or two sides, with or without pain, abscess,
       that has ruptured may lead to ulcer or not, moveable or not.
   -   General condition: the patient may be normal or may have mild fever or
       fatigue.

2. History taking
See General Issues

3. Clinical examination
       -   Examination of genitalia (see General Issues: Examination).
       -   In addition: examination of the ulcer(s):
       + Number, site.
       + Size, form.
       + Characteristics: hard, soft; clean or pus at base; smooth or rough mar-
          gin, surface.
   -   Examination of the nodes: large or small, fixed or mobile, pain, redness,
       fistula.


                                                                              147
   -   Examination of the skin lesion: rash, pus, etc. It is strongly recommended
       to carefully examine palms of hands to detect syphilitic symptoms.
   -   Examine mucous membrane of rectal and oral cavity, nose to detect
       lesions of mucous membrane and semi-membrane in syphilis and herpes.
   -   Other symptoms: alopecia, pain in joints, fatigue.

4. Testing:
   -   Serological test for syphilis (RPR, VDRL).
   5. Diagnosis
   -   Syphilitic ulcer: usually single, not painful, no itching. Smooth surface,
       solid infiltration (important), self-healed after 6-8 weeks, associated with
       inguinal, unilateral, painless, non-suppurating swollen nodes.
   -   Chancroid ulcer: multiple due to self-expansion. Bottom rough, margins
       rough, abundant pus. Very painful (important). Groin nodes swollen on
       one side (unilateral), which may result in abscess, fistula.
   -   Herpes ulcer: small, multiple rashes having grapes shape. Burning, itch-
       ing. Becomes superficial lesion, soft, curved margin, may disappear spon-
       taneously, but usually re-occurs in same site. Bilateral small non-suppu-
       rating swollen inguinal nodes.
   -   If ulcer does not fall under the above, refer to higher level for definitive
       diagnosis.
Note: The ulcer may not be typical as described above.

6. Treatment protocol
The health care provider should treat the sex partners of all patients who have
genital ulcer syndrome.
If the causative agents are identified, provide the cause-based treatment.
If the ulcer could not be identified as syphylis or chancroid, treat both.
For detail therapy regime, please refer to the list of drug table for RTIs/STIs
treatment.simultaneously.




 148
6.1. Treatment for Syphilis:
Use one of the following drugs:
   -   Benzathine Pen G 2.4ml IM single dose, or
   -   Procaine Pen G 1.2ml IM 1 time per day in 10 consecutive days, or
   -   Doxycycline 100mg po 4 times/day in 15 days.
Note: Do not use Doxycycline for pregnant or breastfeeding women, or children
below 7 years old.

6.2. Treatment for Chancroid:
Use one of the following drugs:
   -   Ceftriaxone 250mg IM single dose, or
   -   Azythromycin 1g po single dose, or
   -   Erythromicine 500mg po 4 times /day in 7 days, or
   -   Spectinomicine 2g IM single dose, or
   -   Ciprofloxacine 500mg, po 2 times/day in 3 days.
Note: Ciprofloxacine must not be used for pregnant, breastfeeding women and
persons under 18.

6.3. Treatment for Genital herpes:
Use one of the following drugs:
   -   Acyclovir 400mg po 3 times/day in 7 days for first clinical episode, 5 days
       for recurrent infection, or
   -   Acyclovir 200mg po 5 times/day 7 days for first clinical episode, 5 days for
       recurrent infection, or
   -   Famicyclovir 250mg po 3 times/day 7 days for first clinical episode, 5 days
       for recurrent infection, or
   -   Valacyclovir 1g po 2 times/day 7 days for first clinical episode, 5 days for
       recurrent infection.
Drugs used in treatment of Genital Herpes cannot kill the virus. They are only
effective in reducing the severity of symptoms and shortening the time of the



                                                                                      149
      herpes infection. The treatment should be conducted as soon as possible in
      case of primary herpes infection.

      6.4. Refer the patient to the higher level if:
         -   The above medicine/drugs are not available.
         -   Symptoms do not reduce after one course of treatment.
         -   Herpes recurs 6 times in one year.
         -   Symptoms of Syphilis and Chanchroid do not reduce after treatment or
             Genital Herpes with clinically severe and extended symptoms suspected
             due to HIV infection.
         -   Pregnant women at term with primary Genital Herpes have a high risk
             for transmission to the child. It is possible to treat the infection 4 hours
             within, or prior to, the rupture of membranes.

      7. Information and counselling
      Apart from general information and counselling (see General Guidelines),
      attention should be paid to the following:
         -   It is highly recommended for patients, especially those with Syphilis and
             Chanchroid, to comply with the treatment course.
         -   Re-examine as arranged and according to schedule.
         -   Genital herpes possess a high risk of HIV transmission; the foetus can
             easily become infected during labour.
         -   Syphilis can be transmitted from the mother to the baby through the
             placenta, resulting in serious consequences such as miscarriage, still
             birth or congenital syphilis.
         -   Currently, there are no courses of treatment that can cure genital herpes;
             patients become life-time virus carriers. The condition recurs very often. If
             recurrences occur more than 6 times per year, refer the patient to the
             upper level for treatment. It is critical to counsel the patient about the high
             risk of transmission to their partners; therefore, preventive methods are
             very important.
         -   Safe sex and regular and proper condom use. It should be noted that the



150
    genital herpes ulcers can transmit the infection if the condom does not
    cover the lesions.
-   Notify and treat the partners.
-   Place for counselling and HIV test.




                                                                    151
                       Swollen Inguinal Nodes Syndrome

      Swollen Inguinal Nodes Syndrome can occur in both males and females.
      Pathological characteristics featuring swollen nodes in the groin, which may be
      painful or painless, solid or soft, intact or broken with pus, caused by STI
      causative agents.
      Common causative agents:
         -   Treponema pallidum, causing syphilis.
         -   Hemophilus ducreyi, causing chancroid.
         -   Chlamydia trachomatis type L1, L2, L3, causing LGV (Nicolas-Favre)

      1. Symptoms
         -   Possible fever or not.
         -   Swollen nodes on one or two sides
         -   Ulcers, vesicles or rashes in the anus or genitalia
         -   Other signs on skin or mucous membranes: papule, eruption, roseola,
             especially lesions on palms of hands and feet.

      2. History taking
      See General issues, in addition, history taking can reveal:
         -   Causes of swollen nodes which are related to injuries, skin lesions lead-
             ing to acute infection of the lower extremity of the same side.
         -   Pain, tenderness of the nodes, fistula, suppurating discharge.

      3. Clinical examination

      3.1. Examination of adenitis
         -   Unilateral or bilateral swollen nodes.
         -   Painful or not, acute or chronic adenitis.
         -   Number of nodes: many or few, size: large or small.




152
   -   Characteristics, solid or fluctuating, hard or soft, adhering to underlying
       tissue, fistula or sinus.

3.2. Examination of genital ulcers, rashes, mucous membranes lesions
   -   These lesions often appear in genital perineal areas, oral cavity and nose.
3.3. Examination of other signs in skin or mucous membranes
   -   Common signs are papule, pus or vesicles, roseola, sores on the skin of
       the body, palms of hands and feet, membranes of oral cavity, nose, geni-
       tal-perineal area.

4. Diagnosis

4.1. Syphilis-caused adenitis
Often appears with syphilis chancre. Nodes are varied in size, not painful, no
abscess, not fluctuant, not adherent to surrounding tissue. For primary syphilis,
there is often a large node on one side. For secondary syphilis, nodes are sym-
metrical and there are enlarged nodes at axillary, neck, sub-mandibular areas,
accompanying other symptoms of skin/mucous membranes. (e.g. roseola,
papule, Biette, hair loss).

4.2. Chancroid-caused adenitis
Appears 2 weeks after chancroid ulcers. There usually is a single node in either
side. Swollen nodes are hot, red, inflamed, and usually progress to suppurating
adenitis. Enlarged nodes usually rupture to drain brownish pus and transform to
a deeply ulcerative lesion which is difficult to heal.

4.3. LGV adenitis (Nicolas-Favre disease)
Appears several days or weeks after ulcers, rashes, or vesicles. Enlarged
nodes are usually on one side. They usually come together in one single mass,
which is fixed to surrounding tissues, becomes softer with pus like "lotus seed"
with interconnected sinuses. Prolonged progress may result in the infection of
anus, rectum, and cause anal constriction, anal fistula.
If swollen nodes do not fall into above categories, look for other causes.




                                                                             153
5. Additional testing:
Serological test for Syphilis (RPR, VDRL).

6. Treatment
   -   In all cases of swollen inguinal nodes that are suspicious of STIs, the sex-
       ual partners should be identified and treated.
   -   If the cause is identified, give specific treatment.
   If the cause is unable to be detected, give a combined protocol of treatment
   for Syphilis and Chanchroid
   6.1. Treatment for Syphilis
Use one of the following drugs:
   -   Benzathine Pen G 2.4 ml im every week in 3-4 weeks, or
   -   Procaine Pen G 1.2 mll im 1 time per day in 20 consecutive days, or
   -   Doxycycline 100mg po 4 times/day for 30 days.
Note: Doxycycline should not be used for pregnant and breastfeeding women.

6.2. Treatment for Chancroid
Use one of the following drugs:
   -   Ceftriaxone 250mg im single dose, or
   -   Azythromycin 1g po single dose, or
   -   Erythromicine 500mg po 4 times /day for 7 days, or
   -   Spectinomicine 2g im single dose, or
   -   Ciprofloxacine 1g po once daily for 3 days.
Note: Ciprofloxacine must not be used for pregnant, breastfeeding women and
persons under age 18.

6.3. Treatment for LGV
Use one of the following drugs:
   -   Doxycycline 100mg po 2 times/day for 21 days. or


154
   -   Tetracycline 500mg po 4 times/day for 21 days, or
   -   Erythromicine 500mg po 4 times/day for 21 days.
Note: Doxycycline and Tetracyclin should not be used for pregnant or breast-
feeding women.
Refer the patient to the higher level if:
   -   The above medicine/drugs are not available.
   -   Symptoms do not reduce after 1 course of treatment.
   -   Suspect that swollen inguinal nodes are caused by other agents rather
       than syphilis, chancroid, and LGV.

7. Information and counselling
   -   Possible consequences if appropriate treatment is not provided.
   -   The patient should follow the treatment protocol and return for re-exami-
       nation as scheduled.
   -   Safe sex and condom use.
   -   Partner's notification and treatment.
   -   Promotion and guidance on condom use for STI/HIV/AIDS prevention.
   -   Counsel on HIV test, especially for those with Syphilis and Chanchroid as
       these conditions increase risk of HIV transmission. Place for counselling
       and HIV test.




                                                                         155
                                       Genital warts

      Genital warts, a sexually transmitted disease in both male and female, are
      caused by Human Papilloma Virus (HPV). The lesion represents a papilloma of
      light pink colour, soft, not painful, that bleeds easily at its site in the vulva, anus,
      penis, urethral opening etc. HPV is a risk factor for cancers of cervix, penis or
      rectum. Most people infected with this virus do not have any symptoms.

      1. Clinical symptoms
      Usually the patients discover the signs by themselves and then go to a clinic.
      The disease presents with a papilloma of light pink colour, soft, not painful, easy
      to bleed. Lesions also can be flat to the skin, which is difficult for detection. In
      women, warts usually occur on the clitoris, labia minor, peri-urethral or perineal
      areas. Warts also can be found in the cervix or anus. In men, warts are often
      seen on the penis foreskin's circumference, body of the penis, sometimes at the
      urethral opening or anus.

      2. History taking
      See General Issues.

      3. Clinical examination
      See General Issues. In addition, special attention should be paid to assess:
         -   Male patients: carefully examine the genito-anal area for wart lesions in
             the prepuce, foreskin, circumference of the penis, urethral opening and
             anus.
         -   Female patients: look thoroughly at the external genito-anal area, using
             speculum to identify warts on the cervix and vaginal wall.
         -   Check for any other signs of STIs.

      4. Diagnosis
         -   Characteristics of warts are very specific, thus diagnosis is predominant-
             ly based on clinical symptoms.




156
   -   Female patients with warts on the cervix need to have regular (annual)
       check up (e.g. PAP smear) for early signs of cervical cancer.

5. Treatment
   -   Currently, there are no courses of treatment that can cure genital warts;
       patients become life-time virus carriers and the disease can occur with
       either symptomatic or asymptomatic conditions. The following regimes
       are effective only in reducing symptoms or making lesions disappear but
       the disease is not completely eradicated.
   -   All genital warts cases must be treated at the district level and higher.
   -   For every case diagnosed and treated, health care providers must iden-
       tify the possibly infected partners and provide appropriate treatment.

5.1. Warts in the external genitalia and anus:
   -   Trichloro acetic acid 30% applied locally once a day, or
   -   Podophyllin 10 - 25% applied locally once a day or 2 - 3 times per week.
   -   Cryotherapy using liquid nitrogen, or electric cauterization, laser.
   -   Surgical intervention such as resection or curettage.

5.2. Intravaginal warts:
   -   Cryotherapy by liquid nitrogen, electric cauterization, laser surgery, or
   -   Podophyllin 10 - 25% applied locally once a day or 2 - 3 times per week,
       or
   -   Resection.

5.3. Cervical warts
   -   Cryotherapy with liquid nitrogen.
   -   Electric cauterization, laser surgery.

5.4. Warts in the urethral opening
   -   Resection or curettage, or
   -   Cryotherapy by liquid nitrogen, electric cauterization, or



                                                                              157
   -    Trichloro acetic acid 30% locally.

5.5. Warts in the anus
   -    Cryotherapy by liquid nitrogen, electric cauterization, or
   -    Podophyllin 10 - 25% applied locally once a day or 2 - 3 times per week.
   -    Resection.
Note:
   -    Podophyllin must not be used for pregnant and breastfeeding women, and
        must not be applied to the cervix. Tell the patient to wash him/herself after
        using the medicine for 4 - 5 hours.

6. Counselling and education
There is no drug to kill HPV, so the patients will carry HPV with or without
symptoms all the time. There is a risk of cancer and a risk of transmission to
partners.
   -    Consequences of genital warts contraction, especially genital cancer may
        occur if appropriate treatment is not provided. PAP smear tests are
        advised.
   -    Sex partners should be informed to have an examination, treatment and
        counselling as the disease is likely to occur in the asymptomatic manner.
   -    Cases diagnosed with genital warts should be recommended for HIV test-
        ing especially large, multiple warts since these indicate immune deficien-
        cy.
   -    Promote condom use.
   -    Suggest place for counselling and HIV test.




158
                        Recommended drugs for RTI/STI
                        Ordered by a,b,c in Vietnamese
   Diagnosis                 1st line                2nd line                3rd line        Remarks

                       Doxycycline 100mg       Tetracycline 500mg      Azithromycin
1. Chlamydia RTI
                       po bid 7 days           po qid 7 days           1gm po single
                       Erythromycin
2. Chlamydia RTI       stearate or ethylsuc- Amoxycillin 500mg         Azithromycin 1 g
(pregnancy)            cinate 500mg x qid tid 7 days                   single dose
                       7 days
3. Chlamydia           Erythromycin syrup
neonatal conjunc-      50mg/kg divided         n/a                     n/a
tivitis                into qid 14 days
                                                                       Famciclovir
4. Primary Herpes      Acyclovir 400mg po      Acyclovir 200mg po                         Start as soon as
                                                                       250mg, tid 7
infection,             tid 7 days              5 times a day 7 days                       possible
                                                                       days
                                                                       Famciclovir        Best when start-
5. Herpes infec-       Acyclovir 400mg po      Acyclovir 200mg po
                                                                       250mg, bid 5       ed at prodromal
tion, recurrent        tid 5 days              5 times a day 7 days
                                                                       days               stage
                                                                                          Consider
6. Herpes infec-       Acyclovir 400mg po      Acyclovir 200mg 5
                                                                       n/a                Caesarean sec-
tion, pregnancy        tid 5 days              times/day for 7 days
                                                                                          tion
7. Neonatal expo-
                       Acyclovir 10 mg/kg
sure, Herpes at                                n/a                     n/a
                       iv tid 21 days
delivery
8. Herpes infec-       Acyclovir 400mg po
tion, with HIV         3 - 5 times/day until   n/a                     n/a
infection              recovered
                                              Procaine Pen G 1.2       Doxycycline
9. Syphilis, early     Benzathine Pen G
                                              million im od 10 con-    100mg po qid 15
(less than 2 years)    2.4 million IM. single
                                              secutive days            days
                       Benzathine Pen G
10. Syphilis, latent                           Procaine Pen G 1.2      Doxycycline
                       2.4 million IM.,
(more than 2                                   million IM od 20 con-   100mg po qid 30 Clients
                       weekly for 3 - 4
years)                                         secutive days           days
                       weeks
11. Syphilis, preg-                           Procaine Pen G 1.2
                       Benzathine Pen G
nancy, early (less                            million im od 10 con-    n/a
                       2.4 million IM. single
than 2 years)                                 secutive days




                                                                                                             159
Note: n/a 12. Syphilis, preg- Benzathine Pen G Procaine Pen G 1.2 Erythromycin
not avail- nancy, latent (more 2.4 million IM.,                                            Erythromycin is with
                                                  million IM od 20 500mg po qid
                                                                                           high failure rates
able.      than 2 years)       weekly for 3 weeks consecutive days 30 days
                                                                                           Information on antibiot-
                                                                          Ciprofloxacin
                              Ceftriaxone          Azithromycin 1 gm                       ic resistance of the
           13. Chancroid                                                  500mg bid for
                              250mg. IM. single    po single                               bacteria to ciprfloxacin
                                                                          3 days
                                                                                           is unavailable
           14. Gonococcal
                              Ceftriaxone          Spectinomycin          Cefotaxime     40% resistant to
           RTI Without com-
                              250mg, IM. single    2gm, IM. single        1gm IM. single quinolones
           plications
           15. Gonococcal     Ceftriaxone          Spectinomycin          Cefotaxime
           RTI pregnancy      250mg, IM. single    2gm, IM. single        1gm IM. single
           16. Disseminated                        Spectinomycin 2
                              Ceftriaxone 1 gm,                                            Endocarditis, treat up
           (systemic) GC                           gm, IM. bid. for 3 -
                              IM. daily for 7 days                                         to 6 weeks
           infection                               7 days
                              Ceftriaxone
           17. Gonococcal     125mg, IM. single Spectinomycin             Azithromycin 2 40% resistant to
           conjunctivitis     (for neonate         2gm, IM. single        gm, p.o. single quinolones
                              50mg/kg, IM)
                              Nystatin 100,000
                                                                          Fluconazole
                              units, 2 vag supp    Itraconazole 100mg
           18. Candidiasis                                                150mg po sin-
                              per day for 14       bid 3 days
                                                                          gle
                              days
           19. Genital wart   Trichloroacetic      Cryotherapy or         Podophyllin      Podophyllin is
           (HPV) general      acid 80%-90%         electric cautery       10% - 25%        absorbable, toxic
           20. Genital wart
           (HPV) with preg-   Cryotherapy          n/a                    n/a
           nancy
           21. Trichomonas
                                                                                           Avoid alcohol Not in
           vaginalis and       Metronidazole 1gm Metronidazole 2gm        Tinidazole
                                                                                           1st trimester of gesta-
           vaginitis caused by po/day 7 days     po single dose           2gm po single
                                                                                           tion
           bacteria
                                                                                           Doxycycline and
                              Doxycycline                                 Erythromycin     Tetracycline is contra-
                                                   Tetracycline 500mg
           22. LGV            100mg po bid 21                             500mg po qid     indicated for pregnant
                                                   qid 21 days
                              days                                        21days           and breastfeeding
                                                                                           women




 160
                     CHAPTER IV
           ADOLESCENT REPRODUCTIVE HEALTH


                            General guidelines

When providing reproductive health care services to adolescents, health care
service facilities should:
   ­   Provide reproductive health services (preventive and curative) to adoles-
       cents (married and unmarried). This includes counselling on sexual and
       reproductive health, contraceptive services, care for pregnant adoles-
       cents, safe abortion, family planning, and management of reproductive
       tract infections and sexually transmitted infections.
   ­   Adhere to standards/guidelines for reproductive health care included in
       the specific adolescent sexual and reproductive health clinical
       guidelines,and the other reproductive health guidelines.
   ­   Provide counselling for adolescents as an integral part of services.
   ­   Be adolescent-friendly. This can be achieved by treating adolescents with
       respect, understanding and responding to their needs, providing adoles-
       cent-friendly information and education materials, and where possible,
       providing a separate space/time for adolescents.
   ­   Ensure privacy and maintain confidentiality when providing services and
       counselling.

1. Counselling on adolescents reproductive health
The principles of adolescent counselling are similar to those of adults. Special
attention should be paid to the following issues when providing adolescent
reproductive health (ARH) counselling:
   ­   Counselling on ARH is an important and indispensable component of ARH
       care services.
   ­   Counselling on ARH is a communication process between the counsellor
       (trained person, who has qualifications and knowledge on the psycho-



                                                                              161
       somatic characteristics of adolescence and possesses counselling skills)
       and client-adolescent (who currently has problems which can not be
       solved by him/herself) on the basis of mutual confidence and respect,
       aiming to help the latter to respond effectively to his/her own problem.
   ­   The counsellor needs to understand psycho-somatic characteristics of
       adolescence, while maintaining privacy, and understanding without judg-
       ment. The counselling process can only be conducted thoroughly and
       fruitfully once a confidential, open and respectful relationship is built
       between the counsellor and adolescent. Telephone counselling is effec-
       tive and welcomed by adolescents.
   ­   In order to make the consultation effective and attract more adolescents
       to come for counselling, it is necessary to use different forms of IEC mate-
       rials and resources. Some particular days should be reserved for adoles-
       cent counselling. The information must be clear and accurate and appro-
       priate for adolescents.
   ­   ARH counselling is based on the needs of the adolescent and depends on
       the level of care (community level or upper). Health care at community
       level mainly helps the adolescent to identify his/her own current health
       status (normal or at risk) and how to improve it. They can also recommend
       places for counselling or further treatment.
Depending on the actual situation, the objective and content of a counselling
session will be different. However, each session should follow the same steps
and basic skills described below.

1.1. Basic counselling steps
   ­   Greet in a warm, friendly, equal way.
   ­   Build a comfortable and trusting relationship.
   ­   Listen and explore information.
   ­   Identify the topic of counselling.
   ­   Explain, convince, help, and provide treatment (help the adolescent find
       appropriate solutions).
   ­   Set up next session for follow-up or refer for further counselling and treat-
       ment.


162
1.2. Topics of counselling
   ­   Anatomical, physiological       and   psychological   characteristics   of
       adolescence.
   ­   Normal and abnormal menstruation in adolescence.
   ­   Pregnancy and childbirth in adolescence.
   ­   Contraception in adolescence.
   ­   Discharge (urethral or vaginal) in adolescence.
   ­   Wet dreams, masturbation, safe and healthy sexual behaviour.

1.3. Basic counselling skills
   ­   Greeting skills.
   ­   Listening skills.
   ­   Communication skills.
   ­   Problem solving skills.
When working with adolescents the counsellor needs to have special skills and
to be more patient to help them identify their problems and seek solutions them-
selves.

2. Management of reproductive tract infections and sexually
transmitted infections in adolescents
The guidelines on the management of RTIs and STIs for adolescents (married
and unmarried) are similar to those for adults. Refer to the RTIs and STIs guide-
lines. The following should be addressed during counselling:
   ­   Explore the history of infection.
   ­   Allow adolescents to have more time to ask questions.
   ­   Ensure confidentiality.
   ­   Provide condoms to prevent re-infection.
   ­   Discuss how the adolescent can inform his/her partner(s) about STI
       status.




                                                                          163
                      Examination for female adolescents

      Adolescent girls go to the clinic mainly for the following reasons:
         ­   Menstruation problems.
         ­   Pregnancy, childbirth.
         ­   Abortion.
         ­   Vaginal discharge.
         ­   Personal concerns about physical development.
      Adolescents should be provided with information and counselling associated
      with the above reasons. They may also need to be examined and provided with
      clinical care if necessary.

      1. Asking
      Based on the reasons for the visit, select from the following questions those that
      are relevant to ask the adolescent:
         ­   When did you have your first period?
         ­   How long is your longest, shortest, and average cycle?
         ­   How long is your period? Too much or too little bleeding? Is it painful when
             the period is about to occur or during the period?
         ­   When was your last period? How many days late is it compared to your
             longest period?
         ­   Are there any abnormal signs, such as sleepiness, nausea, eating strange
             food?
         ­   Are you married? Have you had sexual intercourse? If so, when? When
             was the most recent time? Sexual abuse? Contraception used? Multiple
             partners, drug usage, already counselled about STIs?
         ­   Have you ever been pregnant? Have you had a child? Ever had an
             induced abortion?
         ­   When did the discharge appear, before or after the sexual intercourse?




164
   ­   Vaginal discharge characteristics: amount, scant or thick, colour, with
       vulvo-vaginal itching or burning, frequent urination, dysuria?
   ­   Have you been examined? Ever received gynaecological treatment?

2. Examination
If an examination is necessary, explain the procedure and seek the adolescent's
agreement to the examination.
Procedure:
   ­   Generally observe and assess for growth and development against the
       age of adolescent.
   ­   Breast examination if indicated.
   ­   Observe the external genitalia: vulva, labia majora, labia minora, and
       hymen.
   ­   Observe the discharge characteristics (if present).
   ­   Vaginal examination: can be performed only when the adolescent already
       has had intercourse, and she agrees. If she is accompanied by a relative,
       it is necessary to ask her relative for informed consent.
   ­   If the patient does not consent to a vaginal examination explain the rea-
       son for the examination and suggest a rectal examination as an alterna-
       tive.
   ­   If pregnancy is suspected, the hymen is not intact and the patient agrees:
       + Use a small speculum to check the vagina and cervix for signs of infec-
         tion, cervical ectopy, and cervical polyp.
       + Insert a finger in the vagina to check the uterine position, density,
         mobilization and tenderness. Check the adnexa if they are palpable,
         soft, painless, or have cyst or tumour.

3. Laboratory tests
   ­   Pregnancy suspected: hCG (quick stick).
   ­   Discharge: fresh vaginal smear test, if there is a microscope.




                                                                                    165
        ­   Anaemia: determine the amount of the haemoglobin (Hb).

      4. Diagnosis
        ­   Make a diagnosis based on the clinical findings and laboratory tests.
            Refer to higher level if necessary.

      5. Management
        ­   Irregular menstrual cycle, dysmenorrhea (refer to the guidelines on ado-
            lescent menstruation).
        ­   Pregnancy (refer to the guidelines on care of pregnant adolescent and
            guideline for antenatal care).
        ­   Discharges (refer to the guidelines for management of RTIs/STIs).

      6. Counselling
        ­   Refer to counselling for adolescents section.
        ­   Give adolescents more time to develop confidence in the counselling
            provider and encourage her to ask questions.
        ­   Help the adolescent to deal with anxieties, encourage her to provide accu-
            rate information and cooperate with the health provider.
        ­   Explain to the adolescent about her health status.
        ­   Encourage her to discuss her health status with her relatives. The health
            provider can offer to help her with this if necessary.
        ­   Counsel on sexual negotiation between partners and how to say 'no'.
        ­   Counsel on safe and healthy sex, on condom use, and other
            contraceptive methods.
        ­   Ensure confidentiality.
        ­   Give her a confidential address if she needs further counselling or
            intensive treatment.




166
                 Examination for male adolescents

Male adolescents go to the clinic mainly for the following reasons:
   ­   Masturbation.
   ­   Wet dream, nocturnal emissions, premature ejaculation.
   ­   Personal concerns about an abnormality of the penis or scrotum, or dif-
       ferent to other people of the same age.
   ­   Swelling or discharge of pus from the penis or the foreskin cannot be
       retracted.
   ­   Frequent, painful urination, opaque urine or urine mixed with blood or pus.
   Some less common complaints:
   ­   Differences in physical development between adolescents.
   ­   Abnormality in the secondary sexual characteristics: pubic hair, axillary
       hair, beard, acne, and breasts.
   ­   Seeking help in contraception.
Male adolescents should be provided with information and counselling related to
the above reasons. They may also need to be examined and provided with clin-
ical care, if necessary.

1. Asking
   ­   Age, education, puberty.
   ­   Sexual activity, sexual abuse.
   ­   Wet dream/nocturnal emission, masturbation.
   ­   Abnormalities: discharge, itches, pains in genitals.
   ­   Any questions that need to be explained.

2. Examination
When an examination is necessary, explain the procedure and seek the adoles-
cent's agreement to the examination.
   ­   Observing: body size and development, hair, and breasts.


                                                                           167
   ­   Measure height, weight, compare with normal development.
   ­   Examine genital organ: scrotum, penis, pubic hair.
   ­   Check the heart and lungs, urinary system, teeth (if necessary).

3. Laboratory tests
It is not necessary to perform tests unless there are signs of sexual and repro-
ductive disease, such as urethral discharge.

4. Management
   ­   Urethral discharge (refer to the guidelines for management of RTIs/STIs).
   ­   Treat infection if foreskin of penis infected.
   ­   For other abnormalities, refer to the higher level or specialists.

5. Counselling
   ­   Male adolescents have many different concerns and ideas due to the
       differences in development between males and females and among
       males. They should be reassured that this is normal.
   ­   Wet dream/nocturnal emission is a normal physiological phenomenon.
       However, keeping busy studying, doing exercise, and working can reduce
       the frequency. Medicine usually does not help.
   ­   Masturbation can be a normal activity. It mitigates sexual tension without
       creating a risk of disease or pregnancy.
   ­   Safe and healthy sexual behaviour is a responsibility that adolescents
       should consider, including avoidance of transferring diseases and
       causing unwanted pregnancy.
   ­   Adolescent family planning: combined oral contraception and emergency
       contraception for woman & condoms for males (for prevention of STIs and
       unwanted pregnancy).
   ­   If suffering from STIs, adolescents should be treated early. Stricture of the
       urethra and infertility result from delayed or missed or incomplete
       treatment.




168
                      Menstruation in adolescents

Menstruation is normal bleeding from the uterus due to the detachment of the
endometrium. It occurs each month as a result of the changes in ovarian hor-
mones in the body.
The adolescent menstrual cycle can be irregular because the ovarian function is
not stable in the first 1 - 2 years of the reproductive life.

1. Clinical signs and symptoms

1.1 Normal menstruation:
       ­   The onset is from 11 to 18 years of age.
       ­   The cycle is from 22 to 35 days, 28 - 30 days on average.
       ­   The period lasts from 3 to 7 days.
       ­   The amount of blood loss is from 3 - 5 changes of blood-soaked sani-
           tary pads a day.
       ­   The menstrual blood is light reddish, uncoagulated, with no fishy smell.

1.2 Abnormal menstruation - menstrual disorders
   ­   Primary amenorrhoea: no period occurs until after 18 years of age.
   ­   Secondary amenorrhoea: no period occurs within 3 months but there
       have been regular periods before, or no period occurs within 6 months if
       periods were irregular previously.
   ­   Pseudo- amenorrhoea: menstrual bleeding occurs but it is not discharged
       due to an abnormal hymen or adhered cervix.
   ­   Menorrhagia: prolonged period, period lasts over 7 days.
   ­   Hypomenorrhea: the amount of blood loss for the period is too little to
       change the pads.
   ­   Hypermenorrhea: the amount of blood loss is more than 60ml for the
       whole period.
   ­   Oligomenorrhea: the cycle is over 35 days.



                                                                            169
  ­   Short cycle: the cycle is less than 21 days.
  ­   Metrorrhagia: Excessive menstrual bleeding: the amount of blood loss is
      greater than 150 ml within a very short duration. It can cause dizziness,
      fatigue, or fainting.
  ­   Spotting: bleeding that is not related to the period.
  ­   Spotting and menorrhagia: prolonged period, the bleeding lasts over 7
      days associated with abnormal bleeding without relation to period.
  ­   Dysmenorrhea: abdominal pain during the period, possibly resulting in
      tiredness.
  ­   Precocious puberty (early onset of menstruation under 10 years old).

2. Management
  ­   Treat the dysmenorrhea with pain relief medication (ibuprofen, paraceta-
      mol) and tocolytics (spasmaverin, papaverine).
  ­   Monitor the cases of oligomenorrhea, short cycle, hypomenorrhea that do
      not impact on health.
  ­   Amenorrhoea may be caused by nutrition and psychological disorders.
      Counsel the client about the possible negative effects on development.
  ­   The COC can help provide relief from heavy and painful menstrual peri-
      ods, and regulate the cycle.
  ­   Spotting or irregular bleeding may be caused by infection or cervical
      abnormal changes. Examine and treat if there is infection and refer for
      Pap smear if necessary (refer to RTI/STD guidelines).
  ­   In other cases such as excessive menstrual bleeding, amenorrhea, pro-
      longed period and spotting, or if the adolescent is very concerned about
      her periods, counsel and refer to higher level for diagnosis and treatment.

3. Counselling
  ­   Explain to an adolescent that periods are natural, caused by the normal
      anatomical and physiological changes at puberty. Reassure her that this
      is not a disease so she should not worry. During the menstrual period she
      may feel pain or discomfort in the lower abdomen, dizziness.


170
­   Check her understanding of the menstrual cycle and conception, clarify
    anything misunderstood. Explain especially clearly that since her period
    starts, it is easy to get pregnant if she has sexual intercourse.
­   If an adolescent is concerned about irregular cycles, reassure her that this
    can be normal for 1 - 2 years.
­   Explain that abnormal psychological states such as difficult breathing,
    headache, anxiety, insomnia and poor appetite can happen when having
    period.
­   Explain how to carry out menstrual hygiene and the use of sanitary nap-
    kins.
­   Explain and guide how to prevent pregnancy. If adolescents are sexually
    active provide them with appropriate contraceptive methods (condoms
    and combined oral contraceptive). Also explain emergency contraception.
­   Explain about safe sex and use of condoms for STI prevention.
­   It is possible to invite the parents and relatives to be involved in coun-
    selling on menstruation so that they (family members) can provide support
    to adolescents.




                                                                         171
                          Adolescent pregnancy

If a pregnant adolescent comes to seek support for a decision about whether to
continue with the pregnancy or to have an abortion, the health care providers
should discuss the possible solutions and the implications of her choices.
Pregnancy can be determined by asking questions, examination and a labora-
tory test.
Babies born to adolescent mothers and adolescent mothers themselves are like-
ly to have higher morbidity and mortality rates.

1. Signs and Symptoms

1.1. Ask
   ­   Sexually active?
   ­   Late period?
   ­   Morning sickness?

1.2. Clinical symptoms
   ­   Breasts: tender, areola with dark colour and small pigments.
   ­   Vaginal examination: cervix is soft and purple, uterus is enlarged and soft.

2. Lab tests
   ­   Urinary hCG (+) (quick stick).

3. Diagnosis
   ­   Based on hCG test (+) and signs and symptoms (at commune level).
   ­   If ectopic pregnancy is suspected, refer to higher level for ultrasound.

4. Counselling for adolescents
   ­   The objective of counselling is to assist the adolescent to make her own
       decision about whether to continue with the pregnancy or to terminate,
       and to provide support for the adolescent if necessary.



172
   ­   Ensure adequate time to exchange information and discuss her concerns.
   ­   Explore the client's attitude to the pregnancy and possible alternative
       options.
   ­   Explain all the possible risks of continuing or terminating the pregnancy.
   ­   If the pregnancy continues, the potential risks and problems could be:
       + During pregnancy: spontaneous abortion, premature delivery,
         anaemia, pre-eclampsia are more likely to occur
       + During delivery: difficult delivery due to small pelvis, operative delivery
         (by forceps/vacuum extraction or caesarean section) is more likely to
         occur.
       + Post-partum period: haemorrhage, infection.
       + The above complications lead to the higher maternal mortality rate in
         adolescent mothers than that in the mature ones. The infant mortality
         and morbidity rates are also much higher.
       + The family are more likely to be separated, which can have an adverse
         effect on their future; high rate of divorce, discrimination.
       + Their future education, career and economic opportunities are badly
         affected.
       + Early motherhood can be stressful.
       + Discuss the possible social, financial and psychological implications of
         adolescent pregnancy with the client. Where possible, involve family
         for support.
   ­   Potential risks of pregnancy termination - increased risks of infections and
       future fertility problems. (Refer to safe abortion guidelines for more
       details.)
   ­   Counsel adolescent to make final decision as appropriate.

5. Management

5.1. If the adolescent decides to terminate the pregnancy:
Counselling before abortion/menstrual regulation:



                                                                             173
   ­   Allow the adolescent to have more time to ask questions and consider her
       decision.
   ­   Reassure and support the adolescent to decrease her worrying and
       stress. Explain the procedure.
   ­   Allow more time for discussion if she has not made a decision. Encourage
       her to talk with a family member or trusted adults.
   ­   Refer adolescent to the appropriate facility.
   Procedures: Refer to safe abortion guidelines for clinical standards.
   Counselling after abortion/MR:
   ­   Explain the importance of antibiotic treatment.
   ­   Describe signs of infection and haemorrhage and explain the need for fol-
       low-up.
   ­   Explain and provide post-abortion contraceptives. Using condoms can
       protect from both pregnancy and STIs.
   ­   Counselling on emergency contraceptive methods.
   ­   Help the adolescent to avoid psychological breakdown or crisis.

5.2. If the adolescent decides to continue with the pregnancy
Counselling attention should be paid to the following:
   ­   Explain normal pregnancy and labour. Encourage and answer any ques-
       tions she may have.
   ­   Encourage the adolescent to seek regular antenatal care (at least 3 times
       during pregnancy). Provide information on health facilities.
   ­   Recommend place for safe delivery.
   ­   Give counselling on the way of working, dressing, resting, life style, psy-
       chological well-being and what needs to be done to avoid spontaneous
       abortion/preterm labour.
   ­   Reinforce the support of families for adolescent mothers.
   ­   Post delivery: Provide information on contraception, breastfeeding, child-
       care skills.



174
             Contraceptive methods for adolescents

These are contraceptives methods used for both male and female adolescents
to prevent pregnancy when having sexual relations. The number of adolescents
who have knowledge and who use contraceptives is still limited. Thus many
adolescent girls become pregnant, which can impact on their physical and
psychological health, work and education.

1. Asking
The following questions can be asked to determine the appropriate contracep-
tion for adolescents.
   ­   What do think about sexual relations? Have you got a sexual partner? Do
       you have sex regularly? How many sexual partners do you have? When
       was the last sexual intercourse?
   ­   Are periods regular? Is the period late?
   ­   Is she/he using any contraception methods, any problems with this?
   ­   Are there abnormal signs e.g. sleepiness, nausea, vomiting, breast
       tenderness?
   ­   Vaginal and urethral discharge? Dysuria, frequent urination, difficult
       urination?

2. Provision of contraceptives for adolescent

2.1. Contraceptive methods that are suitable for adolescents:
   ­   Delay sexual activity.
   ­   Condoms and combined oral contraceptives (if there is no
       contraindication), condoms with spermicides, emergency contraception if
       necessary
   ­   Other methods according to needs/situation.

2.2. Assessment before providing contraceptives
   ­   Ensure that the adolescent is not pregnant before providing contracep-
       tives.



                                                                                 175
        ­   Provision of contraception should be based on need.
        ­   If the adolescent is not pregnant, counsel the adolescent about
            contraceptives an safe sex, particularly condoms and the combined oral
            contraceptive.
        ­   If the adolescent has an STI, refer to the guidelines on management of
            RTIs/STIs.

      3. Key issues to be counselled
        ­   Explain about healthy and safe sex.
        ­   Encourage the adolescent to accept and apply a suitable contraceptive.
        ­   Discuss the consequences of not using contraceptives (pregnancy, STIs).
        ­   Counsel on proper contraception if sexual violence, coercion, or rape is
            disclosed during discussion.
        ­   If the adolescent chooses the COC, instruct on how to take the COC and
            address the following:
            + The Pill (COC) does not protect her from sexually transmitted infec-
              tions. Encourage the use of condoms.
            + She must take the pill daily. Tell her what to do if she misses taking the
              pill. See the guidelines on family planning.
            + Adolescents can purchase the pill at the pharmacy and at the CHS.
        ­   Counselling about emergency contraceptive can be provided for
            pre-marriage adolescents.
        ­   For high-risk adolescents (drug users, sex workers, those with STIs) con-
            dom use must be emphasized.
        ­   Counselling provision for male adolescents on contraception methods
            needs to be mentioned.
        ­   Adolescents can get contraceptive pills and condoms at health facilities or
            buy them at pharmacies.
        ­   Counselling provided for adolescents who fail to use contraception.
        ­   When an adolescent seeks advice for failed contraception, unprotected
            sexual intercourse, or when sexual abuse has occurred, health care
            providers should explain and provide the emergency pill.


176
                              CHAPTER V
                            SAFE ABORTION


                            General guidelines

Surgical methods of abortion
This is the use of transcervical procedures for terminating pregnancy, including
vacuum aspiration, dilatation and curettage (D&C), and dilatation and
evacuation (D&E).
Medical methods of abortion
This is the use of pharmacological drugs to induce abortion.         Sometimes'
non-surgical' is also used to describe this procedure.
Gestational age
This is the number of completed days or weeks since the first day of a woman's
last menstrual period (LMP) to the day of pregnancy termination.
   ­   Methods to be used for up to and including 12 weeks since the first day
       of the last menstrual period.
       + The preferred methods are manual or electric vacuum aspiration, or
       + Medical methods using a combination of mifepristone followed by
         misoprostol for up to 7 weeks (49 days) LMP only. The use of medical
         abortion requires the back up of vacuum aspiration (or curettage where
         vacuum aspiration is not available).
       + Dilatation and curettage (D&C) should be replaced by vacuum aspira-
         tion whenever possible.
   ­   Methods to be used after 12 weeks since the first day of the last menstrual
       period.
       + The preferred surgical method is dilatation and evacuation (D&E)
         using vacuum aspiration and forceps.




                                                                                     177
This document covers the following national standards regarding induced abor-
tion:
   ­   Counselling on abortion.
   ­   Surgical methods up to 12 weeks LMP:
       + Vacuum aspiration (VA).
       + Dilatation and curettage (D&C).
   ­   Medical methods up to 7 weeks LMP (mifepristone and misoprostol).
   ­   Surgical methods from 13 to 18 weeks LMP (dilatation and evacuation).
   ­   MVA instrument processing for reuse.




178
                           Abortion counselling

Counselling for abortion clients is to help the client to decide about the abortion
and to choose an appropriate method for pregnancy termination, based on
sufficient and accurate information about available methods, procedures,
possible complications and risks, post procedure care and contraceptive meth-
ods.

1. Requirements of counsellor

1.1. Knowledge
   ­   Be aware of client's needs.
   ­   Understand the policies, regulations on reproductive health and social
       norms.
   ­   Be familiar with the 6 steps of counselling.
   ­   Have basic knowledge of available abortion methods: process, complica-
       tions, post-procedure care.
   ­   Have sound knowledge of contraceptive methods.
   ­   Understand the referral system.

1.2. Counselling skills
   ­   Welcoming skills.
   ­   Listening skills.
   ­   Communication skills.
   ­   Problem solving skills.

2. Place for counselling
There should be a separate counselling room. However, counselling can be
done anywhere, as long as it can be:
   ­   Confidential, private.
   ­   Comfortable.



                                                                            179
        ­   Quiet.
        ­   Free from interference or interruptions.

      3. Counselling process
        ­   Counselling on physical examination:
            + Explain about the examination process and its purpose.
            + The laboratory investigations and administrative formalities.
            + Ask about the medical and obstetric and gynaecological history.
        ­   Counselling on the pregnancy termination decision: provide 2 options to
            the client to choose from:
            + continue with pregnancy and give birth.
            + terminate the pregnancy by induced abortion.
        ­   If the client makes the decision to have an abortion, counselling on abor-
            tion methods that are available at the health facility, discussion to help the
            client to choose the appropriate method, and how to conduct the required
            administrative process is needed.
        ­   Counselling on clinical procedure:
            + Required duration.
            + Pain management method.
            + Steps of the procedure.
            + Introduce the service provider.
            + Possible side effects and complications.
        ­   Counselling on contraceptive methods after abortion.
            + Emphasize that the ability to conceive may resume very soon,
              therefore it is necessary to use a contraceptive method right after the
              abortion.
            + Introduce contraceptive methods; help client to choose an appropriate
              method that can be used right after the procedure.
            + Introduce service delivery points for getting contraceptive methods.
        ­   Counselling on post-abortion care and follow-up.


180
       + Administer drugs as prescribed by physician.
       + Abstain from sexual intercourse until bleeding has completely stopped
         (usually 1 week).
       + Self-care regarding personal hygiene, nutrition.
       + Danger and warning signs that require re-examination right away.
       + Repeat counselling on contraceptive methods.
       + Make an appointment for revisit.
   ­   Timing of counselling: counselling should be done in all 3 phases of an
       abortion but the most effective times are pre- and post-procedure.
       + Pre-procedure: counselling on all of the above 5 contents.
       + During procedure:
          Talk, encouraging client's cooperation.
          Repeat some points relating to the procedure.
       + Post-procedure:
          Emphasise self-care and follow-up.
          Repeat counselling on the contraceptive method that the client has
          chosen or has changed to.
          Provide information about when client will require treatment or referral.
          Confirm the appointment for return visit.

4. Counselling for special groups

4.1. Adolescents
When counselling adolescents on abortion, health care providers should give
special care to:
   ­   Allow more time for adolescents to ask questions and make a decision.
   ­   Ensure confidentiality.
   ­   Provide post-abortion contraceptives that protect from pregnancy and
       sexually transmitted infections (condoms)



                                                                            181
4.2. Women who have experienced violence:
When counselling women on abortion who have experienced violence in some
form, health care providers should take special care to:
  ­   Provide empathetic counselling recognising that she may be fearful and
      upset.
  ­   Establish good rapport and build trust with the abused woman.
  ­   Refer her to available social service contacts to help her deal with her
      situation.
  ­   Provide post-abortion contraception that she can control herself.




182
           Abortion using vacuum aspiration method

Vacuum aspiration is a method to terminate a pregnancy by evacuating products
of conception from the uterus. This method should be used for pregnancies from
6 weeks up to 12 weeks inclusive, as calculated from the first day of the last
menstrual period (LMP).

1. Level of application
   ­   Central, provincial and district levels: termination of pregnancies from 6
       weeks to 12 weeks inclusive.
   ­   Commune level: termination of pregnancies at 6 weeks (gestational age
       from 36 to 42 days) only.­ Doctors; assistant doctors (specialized in
       obstetric and paediatric);    secondary and college-level midwives who
       are trained in vacuum aspiration.

2. Authorized procedure providers
   ­   Doctors; assistant doctors (specialized in obstetric and paediatric);
       secondary and college-level midwives who are trained in vacuum
       aspiration.

3. Indications4. Contra-indications
   ­   Termination of pregnancies between 6 and 12 weeks inclusive (LMP).

4. Contra-indications
   ­   Acute reproductive tract infections. These cases need to be treated or be
       referred to an appropriate level for treatment.

5. Clinical procedures

5.1. Counselling
To be done during all 3 phases: before, during, and after the abortion procedure
(See counselling section).

5.2. Facilities


                                                                          183
         ­   Procedure room: must meet the MOH standards.
         ­   Instruments and supplies:
             + Vacuum aspiration apparatus.
             + Equipment and supplies for instrument processing and waste
               disposal.
             + Medications for anaesthesia, analgesia, shock management, and uter-
               ineaugment drug.

      5.3. Preparation for clients
         ­   Record medical and obstetric history. A client who has a chronic disease
             (such as cardio-vascular diseases, hypertension) or a deformity of the
             reproductive tract needs to have the procedure done in a facility with
             emergency and intensive care services.
         ­   General examination.
         ­   Gynaecological examination to confirm pregnancy and exclude con-
             traindications.
         ­   Gestational age estimation based on LMP.
         ­   Pregnancy test.
         ­   Use ultrasound - if required.
         ­   Client signs informed consent for abortion.

      5.4. Procedure provider
         ­   Wash hands with soap under running water.
         ­   Put on surgical clothes, including cap and mask and protective glasses.

      5.5. Clinical procedure
         ­   Give oral analgesia half an hour before the procedure.
         ­   Bi-manual examination to determine size and position of the uterus.
         ­   Change to sterile gloves.
         ­   Disinfect vulval area, place clean sheet under client's bottom.
         ­   Place speculum, expose cervix, clean cervix and vagina with antiseptic.


184
  ­   Place tenaculum.
  ­   Administer paracervical block.
  ­   Measure uterine depth by cannula.
  ­   Dilate cervix further (if required).
  ­   Aspirate.
  ­   Examine the products of conception (POC).
  ­   Evaluate the completeness of the procedure.
  ­   Process instruments and dispose of waste.

5.6. Complications and management
  ­   Early complications: shock, excessive bleeding, uterine perforation, and
      cervical laceration.
  ­   Late complications: infection, retained placenta/products of conception.
Management:
  ­   Treat clients according to each complication (see training manual).
  ­   Refer clients to an appropriate facility.

5.7. Follow-up and care
  ­   Follow-up pulse, blood pressure and vaginal bleeding for at least 30 min-
      utes after procedure.
  ­   Prescribe antibiotics.
  ­   Post-abortion counselling.
  ­   Make appointment for follow-up examination for after 2 weeks.

6. Counselling
  ­   Discussion about the decision to terminate the pregnancy.
  ­   Discussion on available abortion methods at health facility.
  ­   Steps in vacuum aspiration procedure.
  ­   Possible complications.



                                                                            185
 ­    Self monitoring signs after aspiration.
 ­    Danger signs requiring client's return to hospital.
 ­    Normal recovery signs of health and fertility.
 ­    Information on contraceptive methods and assist client to choose
      appropriate method to avoid repeat abortion.




186
             Medical abortion for up to 7 weeks LMP

Medical abortion is the termination of pregnancy using mifepristone and
misoprostol to cause the expulsion of the foetus from the uterus. It may be used
for pregnancies up to 7 weeks (49 days) LMP.

1. Level of application
   ­   Central, provincial levels.
   ­   Distance between client's home and the abortion facility should not be
       further away than 30 minutes travel by any means.

2. Authorized service provider
   ­   Obstetric and gynaecological doctors who are trained in medical abortion.

3. Indications
   ­   Women who opt to use medicine to terminate their pregnancies.
   ­   Pregnancies of up to 49 days LMP.

4. Contra-indications
   ­   Those with adrenal gland pathologies.
   ­   Those with coagulation disorders.
   ­   Those treated with cortico-steroids or anti-coagulants.
   ­   Known allergy to misoprostol or mifepristone.
   ­   Women who are breast-feeding.

5. Technical procedures

5.1. Counselling
(See counselling section)

5.2. Preparation for clients
   ­   Record medical history to rule out contra-indications.



                                                                         187
         ­   General examination.
         ­   Gynaecological examination to confirm pregnancy.
         ­   Gestational age estimation based on LMP.
         ­   Pregnancy test.
         ­   Use ultrasound - if required.
         ­   Client signs informed consent for abortion.

      5.3. Procedures
         ­   Give 1 tablet of mifepristone of 200mg to the client orally at the clinic
             under observation; follow-up pulse, blood pressure, general condition of
             the client for 15 minutes, after that the client can be allowed to go back
             home.
         ­   After 48 hours, give 400mcg of misoprostol orally to the client at the
             clinic under observation; follow-up pulse, blood pressure, general condi-
             tion of the client for 4 hours.
         ­   Give analgesia such as paracetamol or ibuprofen.

      5.4. Complications and management
         ­   Excessive bleeding.
      Management: aspirate or curette the uterus to stop bleeding.

      5.5. Follow-up care
      Follow-up examination after 2 weeks:
         ­   If the product has been expelled and there is no bleeding: good result,
             follow-up completed.
         ­   If the product has been expelled but there is still bleeding: continue to
             follow-up.
         ­   If the pregnancy is still viable: use aspiration (or curettage) method for
             abortion.




188
6. Counselling
  ­   Discussion about decision of pregnancy termination.
  ­   Discussion about available abortion methods.
  ­   Provide information on medical abortion.
  ­   Possible complications and side effects.
  ­   Danger signs of complications that require immediate return to health
      facility.
  ­   Importance of follow-up examination after 2 weeks.
  ­   Normal signs when taking the medicine.
  ­   Normal signs of health and fertility recovery.
  ­   Information on contraceptive methods and help client to choose
      appropriate method and to avoid repeat abortion.




                                                                     189
         Abortion using dilation and curettage method

Dilation and curettage (D&C) is a procedure that combines mechanical dilatation
of the cervix followed by evacuation of products of conception from the uterus
using forceps and then curette to empty the uterus.

1. Level of application
Central, provincial and district level hospital.

2. Authorized Service Providers
   ­   Doctors, Obstetric and Paediatric Assistant Doctors and secondary and
       college-level midwives who are trained in D&C.

3. Indications
   ­   Termination of pregnancies between 8 and 12 weeks inclusive (LMP) in
       places where vacuum aspiration is not available.

4. Contraindication
   ­   Acute reproductive tract infections. These cases need to be treated or
       referred to an appropriate level for treatment.

5. Technical procedures

5.1. Counselling
To be done in all 3 phases: before, during and after abortion procedure (see
counselling section).
5.2. Facilities
   ­   Procedure room: must meet the MOH standard.
   ­   Instruments and supplies:
       + Set of D&C instruments.
       + Instruments and supplies for decontamination and waste disposal.
       + Medications for anaesthesia, shock management and uterine atony.



 190
5.3. Preparation for clients
   ­   Refer to vacuum aspiration.

5.4. Procedure Provider
   ­   Refer to vacuum aspiration.

5.5. Clinical procedure
   ­   Give analgesia.
   ­   Bimanual examination to determine size and position of the uterus.
   ­   Change to sterile gloves.
   ­   Clean vulval area with antiseptic; place a clean sheet under client's
       bottom.
   ­   Place speculum and clean cervix and vagina with antiseptic.
   ­   Place tenaculum.
   ­   Administer paracervical block.
   ­   Measure uterine depth.
   ­   Dilate the cervix.
   ­   Use sponge forceps to grasp products of conception.
   ­   Use curette to empty uterus.
   ­   Measure again uterine depth (if required).
   ­   Remove tenaculum.
   ­   Clean cervix, vagina and vulva with antiseptic.
   ­   Remove speculum.
   ­   Process instrument and dispose of waste.

5.6. Complications and management
   ­   Early complications: shock, excessive bleeding, uterine perforation, and
       injury to abdominal organ.
   ­   Late complications: infection, retained placenta/products.




                                                                        191
Management:
  ­   Treat client based on cause (see training manual).
  ­   Refer clients to an appropriate facility.

5.7. Follow-up care
  ­   Follow-up pulse, blood pressure and vaginal bleeding every 15 minutes in
      the first hour and every half hour over the next two hours.
  ­   Prescribe antibiotic.
  ­   Post-abortion counselling.
  ­   Make appointment for follow-up examination after 2 weeks.

6. Counselling
  ­   Discussion about decision of pregnancy termination.
  ­   Discussion about available abortion methods.
  ­   Steps in D&C procedure.
  ­   Possible complications during D&C.
  ­   Danger signs that require re-examination right after D&C.
  ­   Normal recovery signs of health and fertility.
  ­   Information on contraceptive methods and help client to choose
      appropriate method to avoid repeat abortion.




192
 Abortion using dilation and evacuation method for 13 to
                   18 weeks gestation

D&E is a method to terminate pregnancy by using misoprostol and dilators to
prepare the cervix, followed by vacuum aspiration together with forceps to
evacuate products of conception. This may be used for gestational ages
between 13 and 18 weeks.

1. Level of application
   ­   Central and provincial level hospitals.

2. Authorized Providers
   ­   Obstetric & Gynaecology Doctors who are skilled in first trimester D&C
       and trained in D&E.

3. Indications
   ­   Termination of pregnancies between 13 and 18 weeks inclusive (LMP or
       ultrasound).

4. Contraindications
   -   Acute medical problem.
   -   Deformities of reproductive tract.
   -   Acute reproductive tract infection - needs to be treated before performing
       the procedure.
   -   Known allergy to misoprostol.
CAUTION: Special care should be paid to cases associated with uterine fibroma
or uterine scar.

5. Technical procedures

5.1. Counselling
-     To be done in all 3 phases: before, during and after abortion procedure
(see counselling section).


                                                                                    193
      5.2. Facilities:
         -   Procedure room: must meet the MOH standard.
         -   Instruments and supplies:
             + Set of D&E instruments: forceps for disinfecting, tenaculum, dilators
               size 5 to 17, Sopher and Bierre forceps, and postpartum curette.
             + VA apparatus with cannula size 12-14.
             + Emergency facilities.
             + Ultrasound machine.
             + Container for products of conception.
             + Equipment and supplies for instrument processing and waste
               disposal.
         ­   Medications for anaesthesia and shock management.

      5.3. Preparation for clients
         ­   Record medical history and parity.
         ­   General examination.
         ­   Estimation of gestational age based on LMP.
         ­   Gynaecological examination to rule out contraindications.
         ­   Ultrasound.
         ­   Blood tests include: blood count, blood group and coagulation.
         ­   Informed consent for abortion (For those under 18 years, there must be
             consent of parents or guardian).
         ­   Administer 400mcg misoprostol sub-buccally; follow-up the client in the
             waiting room for 4 - 6 hours. Repeat the dose if needed.

      5.4. Procedure provider
         ­   Wash hands with soap under running water.
         ­   Put on surgical clothes, including cap and mask and protective glasses.




194
5.5. Clinical procedure
   ­   Give analgesia.
   ­   Bimanual examination to determine size and position of the uterus.
   ­   Change to sterile gloves.
   ­   Clean vulval area with antiseptic; place a clean sheet under client's
       bottom.
   ­   Place speculum and clean cervix and vagina with antiseptic.
   ­   Place tenaculum.
   ­   Administer paracervical block.
   ­   Dilate the cervix (if required).
   ­   Use VA and cannula to aspirate amniotic fluid and bring the product to the
       lower part of the uterus.
   ­   Evacuate products of conception using forceps.
   ­   If it is difficult to grasp the products, use ultrasound to guide.
   ­   Examine the POC to make sure that the procedure is complete.
   ­   Process instruments and dispose of waste.

5.6. Complications and management
   ­   Shock, excessive bleeding, uterine perforation, retained product, infec-
       tion, cervical laceration, blood accumulation inside the uterus.
Management: follow protocols (see training manual).

5.7. Follow-up and care
   ­   Follow-up pulse, blood pressure, vaginal bleeding and uterine contraction
       for 4 hours after the procedure.
   ­   Prescribe antibiotic.
   ­   Post-abortion counselling.
   ­   Make appointment for follow-up examination after 2 weeks.




                                                                            195
6. Counselling
  ­   Discussion about the decision to have an abortion.
  ­   Possible dangers, complications and consequences of second trimester
      abortion.
  ­   Methods for second trimester abortion.
  ­   Steps in D&E procedure.
  ­   Warning signs after D&E that require immediate re-examination.
  ­   Normal recovery signs and fertility after D&E.
  ­   Information on contraceptive methods and help client to choose appropri-
      ate method and to avoid repeat abortion.
  ­   Early signs of pregnancy which can be easily recognized to avoid D&E
      abortion.




196
   Processing of Manual Vacuum Aspiration Instruments


1. Decontamination Before Cleaning
Immediately after the MVA procedure, draw Chlorine 0.5% or equivalent solution
into the syringe and cannula and gloves. Completely immerse all reusable items
in the container. Soak for 10 minutes. Use gloves or forceps to remove instru-
ments. Change solution at least daily.

2. Clean
Clean all instruments and gloves after decontamination by washing all items
thoroughly in warm water and preferably detergent, not soap. If tissue is trapped
in the tip of a cannula, flush water through the cannula repeatedly or use a
cotton-tipped probe, soft brush or soft cloth to gently remove material. Wear
gloves
   ­   Disassemble all parts of the syringe. Clean all parts thoroughly, using a
       soft brush.
   ­   Do not use sharp items to remove O-ring. Instead, while wearing gloves,
       squeeze or use a blunt lever or instrument to gently pry O-ring off. If
       unable to clean off all blood or tissue from an instrument, discard the
       instrument.

3. Sterilisation and High Level Disinfection
The MVA syringe only needs to be high level disinfected. Cannulae need to be
sterilized or high-level disinfected. Do not process the MVA instruments using an
autoclave or oven.

3.1. Sterilisation
Cannula: soak in a Cidex solution (Glutaraldehyde) for 10 hours. Make sure that
instruments are completely immersed. Remove with sterile forceps or sterile
gloves. Rinse with sterile water. Dry.

3.2. High-level disinfection
   ­   Syringe and cannula: soak fully immersed in a Cidex solution


                                                                          197
      2%(Glutaraldehyde) or a 0.5% Chloramin for 20 minutes. Remove from
      solution using HLD or sterile forceps or gloves. Rinse with boiled or ster-
      ile water. Dry with sterile cloth.
  ­   Change Chloramin at least daily; change Cidex every two weeks or follow
      manufacturer's recommendation.
  ­   Cannula: instead of using chemicals, cannula can be boiled (but syringe
      can not). Boil cannula fully immersed for 20 minutes. Remove using HLD
      or sterile forceps or gloves. Dry with sterile cloth. Using disposal syringe
      is best.
  ­   Syringe: Use after decontamination, cleaning, HLDing, drying and lubri-
      cating.

3.4. Storage and use
  ­   Storage: Instruments should be stored in dry, covered sterile or HLD
      containers with tight-fitting lids.
  ­   Should not store more than an amount of instruments to be used within
      the day. To remove cannula from the container, grasp the non-aperture
      end with HLD or sterile forceps or gloves.
  ­   Before use: reassemble, lubricate and check vacuum capacity of the
      syringe.




198
TOOL T6
MINISTRY OF HEALTH REGULATIONS ON TECHNICAL
RESPONSIBILITIES IN REPRODUCTIVE HEALTH CARE

                      Source: Annex III, National Strategy on reproductive health care
                                                            For the 2001 - 2010 period
                                                      Vietnam Ministry of Health(2001)



               Regulation of tecnical responsibilities
         in reproductive health care within health facilities


A - Village Health Worker

Function                                         Task
               a. Collect the following numbers:
                  -    Women of reproductive age (aged 15 0 49), married women of
                       reproductive age, current contraceptive users.
                  -    Pregnant women, high-risk pregnancies, births, obstetric com-
                       plications, maternal deaths.
  MANAGEMENT




                  -    Number of children under 1 year, under 5 years, infant deaths,
                       malnourished children under-5, fully vaccinated children.
               b. Early identification of pregnancies, keep pregnancy register,
                  motivate mothers to have at least 3 antenatal visits and to give
                  birth at commune health station or at any health station.
               c. Give instruction and motivation on women's hygiene, proper
                  hygiene and nutrition during pregnancy, avoiding practices that
                  are harmful for mother and child health.
               d. Motivate and monitor mothers to breast feed. Provide counseling
                  on proper breastfeeding practice and warning food.




                                                                               201
                            e. List the children for the immunization programmed, motivate
                               mothers to have their children vaccinate against diseases follow-
                               up to detect any complications of vaccination.
                            f. Promotion of family planning methods.
                            g. Management of child health according to child health
                               programmers, integrated with the commune health station.
                            h. Keep and use the village health worker medicine bag.
                            i. Mobilization and preparation of transportation means for referral to
                               nearest health facility.
                            j. Report monthly as required by commune health station.

                            a. Identify and provide first aid for common obstetric and pediatric
                               conditions, as well as side effects of contraceptives and assist
                               quick referral.
                            b. Periodically visit mother and new-born after birth.
                            c. Assist in normal delivery, and in cases of delivery en route, or if
                               woman is unable to go to the health station. Give guidance on and
      TECHNICAL FUNCTIONS




                               use a Clean Delivery Kit.
                            d. Coordinate with various programmes are required.
                            e. Distribute condoms, oral contraceptive pills using checklist from
                               second use onward.
                            f. Identify, manage acute diarrhoea, acute respiratory infections and
                               make prompt referral.
                            g. Provide home treatment using herbal medicine for common
                               diseases, such as cough, cold, diarrhoea (without sung antibiotics)
                            h. Measure, weigh children, use growth chart for children per
                               regulations and instruct mother on using the growth chart. Identify
                               malnourished children under 5 and refer them to the commune
                               health station.




202
                B - Commune Health Center

Function                                         Task
                a. Collect the number of births and deaths (general), maternal
                   deaths, infant deaths, deaths of children under 5, and the courses
                   within the commune.
                b. Besides the numbers indicated for village health workers, collect
                   the following numbers:
                   -   Live births, low birth weight (under 2500g), adolescents.
                   -   Pregnant women receiving 1 to 3 or more antenatal care check
                       ups, tetanus toxoid (TT) immunsation and number of times,
   MANAGEMENT




                       deliveries attended by trained health worker, deliveries at
                       health station, total abortions, and adolescent abortions/
                       menstrual regulations (MR).
                   -   Couples using contraceptives by method, infertile and
                       sub-fertile couples.
                   -   RTI and STD cases.
                c. Report to the District Health Centre on a regular basis using the
                   date forms promulgated by MOH.
                d. Collaborate with other programmes/ projects.
                e. Provide educating and counseling on reproductive health issues.
                f. Supervise village health workers' activities.
                g. Monitor the HIV/AIDS prevalence in the commune.
                   -   Apply national standards on asepsis.
                   -   Provide at least 3 antenatal care check-ups iron and folic acid
                       to pregnant women.
                   -   Keep home-based mother records, identify high risk pregnan-
                       cies for referral to higher level.
                   -   Provide TT immunization for pregnant women following exist-
                       ing regulations.



                                                                                         203
                                                     -   Perform normal delivery, ensure 3 cleans and use pantograph.
                                                     -   Perform episiotomy when indicated and suture 2nd degree tear
                                                         of perineum.
      TECHINICAL FUNCTIONS




                                                     -   Manage 5       obstetric   complications   following    existing
                                                         regulations.
                             A. OBSTETRICS




                                                     -   Five instruction to mother on proper breast-feeding
                                                         immediately after birth and on weaning food after 4 or 6 months.
                                                     -   Visit mother and new-born twice within 42 days after delivery.
                                                     -   Provide umbilical care and detect early signs of umbilical
                                                         infection.
                                                  Perform menstrual regulation under 6 weeks (7 - 14 day menstrual
                                                  delay and positive pregnancy test) by single-valve Karman syringe.
                                                     -   Examine, diagnose and treat common RTIs such as vulvitis
                                                         vaginitis, cervicitis, pelvic inflammatory diseases, including
                             B.GYNECOLOGY




                                                         STDs when indicated by upper level, paying attention to
                                                         treatment of sex partners.
                                                     -   Diagnose breast tumour, uterine fibrome, cervical cancer and
                                                         conduct direct microscopy if available.
                                                     -   Perform PAP smear if available.
                                                     -   Provide full information on available contraceptives.
                             C. FAMILY PLANNING




                                                     -   Provide condoms, emergency contraceptives and injectables.
                                                     -   Check and provide oral contraceptive pills by checklist at first
                                                         use.
                                                     -   Insert and remove IUDs.
                                                     -   Follow-up and provide first care for contraceptive complications
                                                         and slide-effects.
                                                     -   Provide care for full-term new-borns. Refer cases of deformity
                                                         and illness.
                                                     -   Provide first care and refer low birth weight (LBW) new-borns.




204
                                    -   Neonatal resuscitation: management of asphyxia (assisted res-
                                        piration, mouth-to-mouth respiration) and refer if the condition
                                        does not improve.
                                    -   Provide umbilical care.
             D. CHILD HEALTH CARE




                                    -   Instruct mother how to prevent conditions such as malnutrition,
                                        diarrhoea, acute respiratory infections, rickets, vitamin A
                                        deficiency, malaria.
                                    -   Implement EPI programme: give sufficient and proper
                                        vaccination to prevent childhood diseases.
                                    -   Provide first care for diarrhoea, acute respiratory infections,
                                        toxicosis, fever, and refer if the condition does not improve.
                                    -   Treat common diseases and refer if do not improve.
                                    -   Implement Integrated Management of Childhood Illnesses
                                        (MSICI) if a doctor is available at the commune health station.
                                    -   Provide IEC and counseling for adolescents on safe and
REPRODUCTIVE HEALTH




                                        healthy sexual relations.
   E. ADOLESCENT




                                    -   Provide necessary services, such as oral contraceptive pills,
                                        emergency contraceptives and condoms for protection against
                                        unwanted pregnancy and STDs.




                                    -   Examine and identify early signs of reproductive health
CARE FOR OLDER PEOPLE
F. REPRODUCTIVE HEALTH




                                        disorders in older people, such as breast cancer, cervical
                                        cancer, etc.




                                                                                                           205
                                            -    Benefits of family planning and safe motherhood.
                                            -    Benefits, effects, side effects of contraceptives and where to
C-
                                                 obtain them.
        G. COUNSELLING AND EDUCATION ON




                                            -    Prevention of unwanted pregnancy and counseling on safe
                                                 abortion.
              REPRODUCTIVE HEALTH




                                            -    Benefits of pregnancy examination, encourage the client to
                                                 have antenatal care, instruction on hygiene and nutrition during
                                                 pregnancy and promote breast feeding.
                                            -    Instruction on menstrual hygiene, prevention of RTIs and STDs.
                                            -    How to prevent and identify early female reproductive tract
                                                 conditions, especially cervical cancer and breast cancer
                                                 (instruction on self-examination of the breasts for older women).
                                            -    Education on reproductive health for adolescents.
                                            -    Ensure there is a counseling site and trained counseling
                                                 personnel available.

Maternity Home and Inter-commune Polyclinic



      Function                                                             Task
                                          1. Provide all techniques permitted at the commune health station.
                                          2. When an obstetrician and appropriate equipment and drugs are
                                             available, the following functions are permitted:
               MATERNITY HOME




                                             -   Abortion/MR under 12 weeks.
                                             -   Remove retained placenta after abortion and delivery.
                                             -   Perform suture of 2nd, 3rd degree perinea lacerations.
                                             -   Laboratory diagnosis of cases of vertical transmission, such as
                                                 HIV, HBV etc.
                                             -   Diagnose infertility cases and treat those due to infections.




206
                     -   Perform PAP smear, diagnose reproductive tract cancer.
                     -   Provide counseling and FP services after delivery and abortion.
                                                                                              D-
                     -   Perform obstetric ultrasound diagnostics.
                 1. Provide all techniques permitted at commune health station.
                 2. When an obstetrician is available, the following functions are
 INTERCOMMUNE
   POLYCLINIC




                    permitted:
                     -   Treatment of primary threatened abortion.
                     -   Abortion /MR under 12 weeks as standard.
                     -   Removal of retained placenta after delivery if there is no sign of
                         infection.
                 District Health center



Function                                            Task
                 -   Organize the MCH/FP network down to the communes and
                     villages under the management of the district.
                 -   Identify the Reproductive Health disease pattern of the district.
                 -   Provide technical monitoring and supervision to lower levels.
                 -   Conduct training and retraining in Reproductive Health for lower
                     level health workers.
    MANAGEMENT




                 -   Provide IEC on Reproductive Health and Reproductive Health
                     Care for people.
                 -   Manage Reproductive Health indicators and submit reports to
                     higher level as regulated.
                 -   Conduct situation analysis and evaluation of Reproductive Health
                     in the district.
                 -   Develop annual action plan on Reproductive Health/Family
                     Planning.




                                                                                               207
                                            -   Provide management of high risk pregnancies.
                                            -   Provide treatment of pre-eclampsia and eclampsia.
                                            -   Conduct delivery of normal and abnormal presentations such as
                                                face, breech presentations
                                            -   Provide management of transverse lie (shoulder presentation)
                                                brow and compound presentation.
                                            -   Provide management of referred abnormal labor from lower level.
                                            -   Perform produces, such as forceps, ventouse, induction of labour.
                                            -   Provide examination, diagnosis and treatment of infertility due to
                                                severe.
                                            -   Identify early and test vaginal and vulval haematoma.
                                            -   Perform caesarean section, as an emergency operation in case of
      TECHNICAL FUNCTIONS




                                                uterine rupture.
                            A. OBSTETRICS




                                            -   Perform partial hysterectomy in case of postpartum emergency,
                                                perform total hysterectomy in case of life threatening situation.
                                            -   Perform operation for ectopic pregnancy.
                                            -   Provide treatment of post-abortion and postpartum endometriosis,
                                                including curettage of retained placenta after complicated abortion
                                                or delivery.
                                            -   Conduct HIV, HBV laboratory tests for pregnant women as
                                                stipulated by the MOH.
                                            -   Provide treatment for HIV transmission to new-born from mother.
                                            -   Conduct imaging diagnosis and laboratory tests for reproductive
                                                health.
                                            -   Perform under 12-weeks pregnancy termination procedures by
                                                D&C or aspiration with bi-valve Karman syringe.
                                            -   Provide counseling on pregnancy termination in case of
                                                suspected foetal deformity.




208
                          -   Conduct laboratory tests, diagnosis and treatment of RHIs and
                              STDs including HIV.
                          -   Carry out PAP smear, and/or colposcopy to identify early
B - GYNECOLOGY
 INCLUDING RTI




                              cancerous changes (including referred cases from lower level).
                          -   Provide breast examination and instructions for self-examination
                              of the breasts.
                          -   Perform partial or total hysterectomy for uterine fibroma.
                          -   Perform operation on twisted ovarian cyst.
                          -   Perform cystectomy and send for pathology analysis.
                          -   Provide family planning services: make and female sterilization,
                              IUD insertion and removal, implant, injectables. Provide new
                              contraceptive methods when approved and instructed by provicial
                              health service.
   C. FAMILY PLANNING




                          -   Provide phostparstum and post-abortion counseling and
                              contraceptives.
                          -   Follow - up after contraceptive use.
                          -   Identify and manage side effects and complications of contraceptives.
                          -   Organize mobile team to assist commune level in delivering FP
                              services as standard.
                          -   Manage logistics system of contraceptives.
                          -   Provide care for pre-term babies, low birth weight babies over
                              1800g and common diseases of the new-born.
   D. CHILD HEALTH CARE




                          -   Provide emergency care and treatment of common diseases in
                              children, such as food poisoning, dehydration and diarrhoea,
                              bronchitis.
                          -   Treat common chronic diseases, such as mild and moderate
                              malnutrition, rickets, anaemia.
                          -   Manage and provide periodic examinations for well-babies,
                              identify early common diseases.
                          -   Implement Integrated Management of Childhood Illnesses (IMCI).



                                                                                                      209
                                     -   Benefits of family planning and safe motherhood.
                                     -   Benefits, effects, side effects of contraceptives and where to
                                         obtain them.
      E. COUNSELLING AND EDUCATION




                                     -   Prevention of unwanted pregnancy and counseling on safe
         ON REPRODUCTIVE HEALTH




                                         abortion.
                                     -   Benefits of pregnancy examination, encourage the client to have
                                         antenatal care, instruction on hygiene and nutrition during
                                         pregnancy, and promote breast feeding.
                                     -   Instruction on menstrual hygiene, prevention of RTIs and STDs.
                                     -   How to prevent and identify early female reproductive tract
                                         conditions, especially cervical cancer and breast cancer
                                         (instruction on self-examination of the breasts for older women).
                                     -   Education on reproductive health for adolescents.
                                     -   Ensure there is a counseling site and trained counseling
                                         personnel available.




210
                                       E - Health Facilities under Provincial Health Service

Function                                                                            Task
                                                   -   Perform full range of common obstetric and gynecological
GENERAL HOSPITALS OR REGIONAL GENERAL HOSPITALS




                                                       technical functions. Perform obstetric, gynecological and
 PAEDIATRIC HOSPITALS, OBSTETRIC/ GYNAECOLOGICAL




                                                       paediatric operations and procedures as stated in Decision No
    PROVINCIAL OBSTETRIC/ GYNAECOLOGICAL AND

    AND PAEDIATRIC DEPARTMENTS OF PROVINCIAL




                                                       1904/1998/QDD-BYT of 10th August 1998 regarding the list of
                                                       technical operations and procedures.
                                                   -   Examine and treat infertility cases; perform In-vitro Fertilization
                                                       where it is approved by MOH.
                                                   -   Perform laboratory tests for cases of vertical transmission of
                                                       HIV, hepatitis B (HBV) etc.
                                                   -   Early identification of pregnancies at risk of foetal malformation,
                                                       and provide counselling for pregnancy termination.
                                                   -   Perform imaging and laboratory diagnostics for reproductive
                                                       health problems.
                                                   -   Perform surgical endoscopy in obstetrics and gynaecology.




                                                   -   Perform all functions and responsibilities of provincial MCH/FP
                                                       centre as stated in Decision No 22792/ 1999/QD-BYT of 16th
                                                       September 1999 regarding the promulgation of "Stipulation of
                                                       functions, responsibilities and organisation of the MCH/FP
                                                       centre under Provincial health Services and the MCH/FP Team
                                                       under the District Health Centre".
                                                   -   Provide management and supervision of reproductive health
                                                       care activities for local health facilities.
                                                   -   Provide information-education-communication (IEC) and
                                                       counselling on reproductive health.




                                                                                                                             211
                            .- Provide out-patient, in-patient examination and treatment of
                               obstetric/gynecological conditions, common diseases of children,
                               and family planning complications
                            -   Conduct antenatal care, pregnancy examination, normal delivery
                                (and delivery of difficult cases in a well-equipped facility).
                            -   Provide examination and diagnosis of reproductive tract cancers.
                            -   Conduct imaging diagnosis and laboratory tests in reproductive
                                health.
                            -   Conduct clinical trials and applications of new contraceptive, new
                                methods of pregnancy termination, following the guidance of the
 PROVINCIAL MCH/FP CENTRE




                                Ministry of Health.
                            -   Examine and treat infertility cases in a well-equipped facility.
                            -   Conduct laboratory tests, diagnosis and treatment of RTIs and
                                STIs (including HIV in relation to pregnancy and childbirth).
                            -   Conduct laboratory tests and diagnosis of vertical transmission for
                                such as: HIV, hepatitis B (HBV).
                            -   Provide family planning methods such as IUD insertion
                                injectables, implant, male and female sterilization.
                            -   Conduct pregnancy termination under 12 weeks by dilatation and
                                curretage (D&C) or aspiration with bi-valve Karman syringe.
                            -   Provide management and monitoring of healthy children and
                                malnourished children.
                            -   Execute and manage logistics system, provide contraceptives and
                                essential drugs for reproductive health.
                            -   Utilize a management information system (MIS) for reproductive
                                health.
                            -   Conduct scientific research in reproductive health.




212
TOOL T7
TEACHING MATERIAL ON STI/HIV/AIDS

                                                 Family Health International
    Contraceptive Technology and Reproductive Health Series: Reproductive
  Health of Young Adults: Contraception, Pregnancy and Sexually Transmitted
                                                       Infections/HIV (2003)


This tool is a teaching guide for group work with young people. It can also be
used for self-study.


               STI/HIV Prevention and Treatment:
                    Priority for Young Adults

The incidence of STIs in youth has increased dramatically in the last 20 years.
Due to the high incidence of STIs, and the increasing spread of HIV infection,
prevention and treatment of STIs are health priorities for young people. The
information that follows discuss STI risks and consequences, STIs common in
young adults, STI prevention issues, STI counseling and risk assessment
including voluntary counseling and testing, and STI management and treatment.
Providers who are serving youth need to learn about STIs and how they affect
young people.
Activity: STI Risk and Young Adults
   S Ask participants to answer the question, "What are some of the reasons
     why young adults may be at risk for STIs? Examples could include: they
     may have multiple partners, and they may not be able to negotiate
     condom use.
   S Write the responses on a flipchart.
   S Ask participants to answer the question, "What are some of the
     consequences of STIs for young adults? Examples could include they
     may be painful, and they are dangerous to one's health.
   S Write the responses on a flipchart.


                                                                        215
STI Risk Higher in Young Adults
Young adults may be at high risk for STIs due to both behavioral and biological
susceptibility. While AIDS awareness campaigns have alerted youth in general
to the dangers of HIV, many still believe "it can't happen to me" and continue
high-risk behaviors. Also, many lack knowledge of other STIs. Many youth, even
if they know about the risks of STIs, do not use condoms consistently or
correctly. Young adults may lack communication and negotiation skills, making
condom use difficult. When youth are coerced into having sexual relations, they
cannot negotiate condom use.
Other high-risk behaviors include having multiple partners or a partner with
multiple partners. This can include either having multiple partners at the same
time, or having a series of monogamous relationships. Those who are married
may be knowingly or unknowingly at increased risk for STIs due to extramarital
sexual activities of either partner. Other factors that appear to increase the
incidence of high-risk behavior include drug and alcohol use.
Women appear to be more susceptible to STIs than men, due to biological
factors. Young women may be even more susceptible because of cervical
ectopy. This is a normal condition that is present in most female adolescents and
becomes less common with age. Cervical ectopy develops when the cells that
line the inside of the cervical canal extend onto the outer surface of the cervix.
These cells are more vulnerable to infections, such as chlamydia and gonorrhea.
Also, theoretically, the cervical mucus in young women is less thick, possibly
making them more susceptible to infection.

STI Consequences for Young Adults
STIs may result in such symptoms as vaginal or penile discharge, painful
urination, abdominal pain or genital sores. STIs can be transmitted from mother
to infant during pregnancy, delivery, or breastfeeding, and can result in
miscarriages, stillbirths, premature delivery, low infant birth weight or infection.
If left untreated, STIs can result in chronic disease, infertility or even death.
Young adults and their children may also have severe psychological and social
consequences. Economically, years of productive life are often lost, especially
with HIV/AID, affecting one's family, children, and the larger society.




 216
Activity: Local Prevalence of STIs
   S Ask participants to identify the STIs most prevalent in their areas/clinics.

Most Common STIs
The number of new cases of STIs is rising globally, but prevalence varies
significantly by region. Hence, providers need to learn which STIs are most
prevalent in their areas. STIs can be divided into those that can be cured and
those that cannot be cured. The most common curable STIs are mostly
bacterial, and include trichomonicasis, chlamydia, gonorrhea and syphilis. The
incurable STIs are viral. The most devastating of these is HIV/AIDS. AIDS
develops from infection by HIV the "human immunodeficiency virus", and is
almost always fatal without expensive and often unavailable, antiretroviral
medication. Other major viral STIs are human papilloma virus or HPV, hepatitis
B, and herpes.

Curable STIs
Most curable STIs are caused by bacteria and can be treated effectively with
antibiotics. With access to services, young people can get the treatment they
need to prevent these infections from getting worse. In addition, treatment is an
opportunity for youth to learn more about preventive measures.
However, some bacteria infections tend to be asymptomatic and, hence, difficult
to diagnose. If left untreated, these infections can lead to pelvic inflammatory
disease, or PID, which can lead to infertility. Some can be transmitted from
mother to infant during pregnancy or childbirth, or can cause adverse
pregnancy outcomes. The presence of some STIs also increases the likelihood
of HIV transmission.

Most Common Curable STIs
The most common STI that can be cured with antibiotics is trichomoniasis, a
protozoan infection. Globally, trichomoniasis is estimated to account for more
than half of all STI infections. If untreated, trichomoniasis has been associated
with adverse outcomes of pregnancy and facilitating HIV transmission.
Two bacterial STIs that are particularly common among young adults are



                                                                           217
chlamydia and gonorrhea. In 1995, it was estimated that more than 30 million
new cases of chlamydia and 20 million new cases of gonorrhea occurred among
young adults - about one-third of the total cases worldwide. Chlamydia and
gonorrhea may lead to PID, and they can be transmitted from mother to infant
during delivery.
In many countries, syphilis is a problem for young adults. Although syphilis can
be diagnosed and treated, young adults do not generally go to clinics where this
can be done. Pregnant women with syphilis have a high risk of transmitting the
disease to the child during pregnancy. A simple test that does not require
expensive laboratory equipment can determine if a woman or man has syphilis.
All pregnant women should be tested for syphilis since treatment prevents
transmission to the unborn child.

HIV: High Risk for Young Adults
Approximately half of all HIV infections worldwide occur among youth under 25
years of age. In some countries, as many as 60 percent of all new HIV infections
are among young adults, which twice as many in young women as in young
man.
HIV is transmitted by an infected person through semen vaginal fluids, blood,
breast milk or in utero. Between one-fourth and one-third of infants born to
women infected with HIV becomes infected (called vertical or perinatal
transmission). This can occur in utero, during birth or through breast milk. The
percentage of infected infants is substantially lower when HIV - infected
pregnant women take the drug nevirapine, which is relatively simple to use and
inexpensive.
HIV infection leads to AIDS, or "acquired immunodeficiency syndrome", a severe
depression of the immune system resulting in various opportunistic infections.
AIDS typically occurs several years after infection and is almost always fatal.
Several new drug treatments show promise in delaying the onset of AIDS but
they are expensive and are generally not available in developing countries. No
vaccine against AIDS is available at present.
The most potent weapon against HIV/AIDS is prevention. Anyone who works
with youth must remember the urgent need for effective HIV prevention
strategies.


218
Other viral STIs
Other viral STIs widespread among young adults are HPV, hepatitis B and
herpes. HPV causes genital warts and asymptomatic cervical infections. Certain
strains of HPV are highly associated with cervical cancer, which is the leading
type of cancer among women in many developing countries. In some
populations, HPV has been found to be the most prevalent STI.
Hepatitis B causes liver damage and can lead to liver cancer. It can be
transmitted sexually or at birth. A vaccine is available, and its use should be
strongly encouraged. Herpes can be either symptomatic with painful blisters or
asymptomatic. Widespread among the adolescent population, it can enhance
the transmission of HIV.

Addressing the HIV Epidemic: Youth Central to Strategies
There is still hope for the HIV epidemic, fueled by declines in HIV/AIDS in a few
countries. Young people are taking fewer risks as well. To preserve their health
and their lives, youth must be at the center of any strategy to control HIV/AIDS.
A comprehensive approach must be undertaken to address youth and HIV. This
involves:
S   Building support for AIDS prevention
Until more leaders speak out about the AIDS crisis among youth and give it top
priority for funding and action there is little hope of a solution.
S   Offering education and communication
Young people need help to become aware of risks for HIV/AIS and how to avoid
them. Education and communication programs must go beyond merely offering
information to fostering risk -avoidance skills as well, such as delay of sexual
debut, abstinence and negotiation with sex partners. HIV/AIDS education should
begin early, even before adolescents become sexually active.
S   Addressing cultural and social norms
Many traditions and cultural practices increase risks for young people more than
adults and for young women even more than young man. Efforts to involve
communities and to change social and gender norms are as crucial as efforts to
reduce individual risk-taking.


                                                                          219
S   Promoting condoms for dual protection
Condoms, the only contraceptive method that can protect against HIV as well as
against pregnancy, are vital to controlling HIV/AIDS among youth. Condoms
should be widely accessible, and their use promoted among sexually active
people of all ages.
S   Making services youth-friendly
To serve young people better, health care providers must do more to make
young people feel welcome and comfortable. Services, including treatment of
STIs and voluntary HIV counseling testing and referral, should be provided
confidentially and sensitively.
S   Reaching out to vulnerable youth
Programs need to reach out to street children, sex workers and other vulnerable
youth, including millions of young people orphaned by AIDS. Most programs for
youth work better when young people help plan and run them. Programs must
also find more effective ways to reach parents and other adults who can
influence young people's lives.

Orphans and Vulnerable Children (OVC)
The safety, health and survival of all children in many countries, especially in
Africa, are increasingly jeopardized due to the effects of AIDS on families and
communities. Increasing numbers of children are living in households with sick
or dying parents or in households that have taken in orphans. The impact of
AIDS on children is complex. Children suffer psychosocial distress and
increasing material hardship due to AIDS. They may be required to care for ill or
dying parents. Many are forced to drop out of school to work at home or to make
up for the economic loss suffered when a parent is too ill to work. They
experience declining access to food and medical care. They are at risk of
exclusion, abuse, discrimination, and stigma.
There are other issues to consider regarding OVC as well. For example, if a
parent is sick or has died from AIDS, should their children be tested for HIV as
well? In order to best address the care and support needs of children as they
relate to knowledge of one's serostatus, the following critical areas must be
considered:


220
   S Motivation for testing
   S Obtaining consent
   S Disclosure between parent and child
   S Counseling for OVC and parents
Orphans and other vulnerable children are at an increased risk for sexual
exploitation because of economic and social factors. Some may engage in sex
work out of economic necessity. Others are at risk of sexual abuse. Particular
attention should be given to OVC to ensure that their reproductive health needs
are met and that they are protected.

Activity: STI Transmission
Before the presentation: Prepare enough blank cards so that each participant
can have one.
      -   On the back of one card, write an "X" so that it is not very noticeable.
      -   On the back of another card, write an "C" so that it is not very
          noticeable.
      -   On the back of a third card write an "A" so that it is not very noticeable.
      -   On the front of this card write "Do not sign anyone else's card and do
          not let anyone sign your cards!"
   S Ask participants to stand. Give each participant a card.
   S Tell participants that they have 10 minutes to greet three other participants
     individually (one at a time). Each participant, when in conversation with
     the other three, should:
      -   Find out where the other person currently works.
      -   Find out of she or he is married.
      -   Tell the other person one thing that they like about them.
      -   Have the other person sign their card.
   S At the end of the 10 minutes have everyone sit down. Each person
     (except one) should have three signatures on their card.




                                                                              221
 S Tell the participants: "Signing the card represents a sex act. In other
   words, if you signed a card or had someone sign your card, it means you
   had sex with that person".
 S Ask the following processing questions:
      -   "Did everyone get three signatures?" Ask everyone with signed cards
          to stand.
      -   "Who has the card with the "A" on the back?" The person with the card
          with the "A" should not have any signatures. Tell the group that the "A"
          symbolizes abstinence. (The person with the "A" card will often
          succumb to peer pressure and accept signatures. If this happens,
          make the point that "abstinence is talked about as a way to prevent
          STIs, but in the real world it is extremely difficult for young adults to be
          abstinent!) If the person with the "A" card has not collected signatures,
          she or he should remain sitting; otherwise she or he should stand.
      -   "Who has the card with the "X" on the back?" The "X" symbolizes an
          STI. This person has an STI. This person should remain standing. Tell
          the participants that they should remain standing if this person signed
          their card, otherwise they should sit down.
      -   "Who has a card signed by any person standing up?" The people still
          standing should include the person with the "X" and the people she or
          he "infected". Now additional people should stand up.
      -   Ask the same question again, "Who has a card signed by any person
          NOW standing up?" Everyone or almost everyone should now be
          standing.
      -   "Who has the card with the "C" on the back?" The "C" represents a
          condom used correctly for every sex act. This person may sit down.
 S Tell participants that only the people still sitting are not infected with an
   STI. This should include the person with the unsigned "A" card and the
   person with the "C" card.
 S The message that this activity emphasizes is that STIs spread widely
   unless precautions, such as abstinence or using a condom correctly and
   consistently, are taken.




222
STI Prevention
All reproductive health programs for youth need to include basic STI/HIV
prevention services. This includes providing information on STIs, counseling
clients about safer sexual behaviors, assessing client's risk for STIs, and the
promotion and distribution of condoms. If a client might be a risk for infection, he
or she should be referred to a clinic that can diagnose and, if necessary, treat an
infection.

STI Counseling
Counseling for STIs prevention is essential. Youth should be informed and
understand that sexual activity, both heterosexual and homosexual, puts them at
risk for STI/HIV transmission and that they are particularly vulnerable. They
need to understand that the safest sexual behavior is abstinence. For those who
choose to be sexually active, safer behaviors include assessing if their partner
is infected, mutual monogamy, reducing the number of partners, engaging in
low-risk sexual practices such as mutual masturbation, and using condoms.
Condoms need to be made readily available to young adults, even those who
are not yet sexually active, so that they are prepared for future sexual activity.
Young adults need to understand the importance of consistent condom use and
be shown how to use condoms correctly.

Voluntary Counseling and Testing: (VCT)
Many young people in countries where HIV prevalence is high have indicated
they want to know their HIV status. VCT services can address young people's
HIV prevention and care needs. Program planners for VCT services face
numerous challenges: they need to establish policies and bolster support
services, develop adequate training for counselors for working with young
people, make existing services youth-friendly, and address the problem of
stigma. But the impact on behavior is great. VCT can help young adults use
safer sexual practices and even reduce their rates of STIs.

The VCT Model
The VCT model begins with a young adult's decision to seek testing. This is
followed by pretest counseling, in which the counselor discusses with the youth



                                                                             223
the test process, the implications of testing, risk assessment and risk prevention
and coping strategies for whatever the test result may be. After this counseling
session, the youth then decides whether or not to proceed with an HIV/AIDS
test.
If the youth decides not to be tested, the counselor advises the youth of ways to
protect him or herself and his or her future partners.
If the youth decides to be tested, the test is followed up with post test counseling
based on the result of the test. Regardless if the test is positive or negative for
HIV infection, the test result is giving, a risk-reduction plan is made, and the
youth and counselor discuss a risk-reduction plan. This is followed up with
appropriate medical care and emotional and social support. It is important to
remember that both positive and negative test results warrant counseling. A
youth who tests negative for HIV may be relieved, but also needs to understand
how to preserve their negative serostatus. A youth who tests positive for HIV
needs to be informed of the best ways to preserve his or her own health, and
how to protect the health of others. Youth who test positive for HIV also require
emotional counseling. It is important for the counselor to be non-judgemental, to
establish rapport, and to instill hope in young people, especially those who test
positive.

Assessment of STI Risk
Many youth do not know if they are at risk for STIs. Various techniques have
been developed to help youth and others determine if they rare at increased risk.
Especially helpful are individual or group counseling sessions. Young men and
women may feel more comfortable when they are in groups of the same sex.
Counselors can discuss the symptoms of STIs, which include vaginal or penile
discharge, painful urination, abdominal pain or genital sores. Many women
regard most vaginal discharge as normal and do not realize that some
discharge may be a sign of infection that needs treatment. Hence, women need
to be educated on the differences in normal and abnormal vaginal discharge.
Counselors can also point out factors that put young people at high risk for STIs.
These risk factors include the number of sexual partners, age, whether he or she
has had a new partner in recent months, history of previous STI infection,
whether their partner has STI symptoms. It is difficult for many women to know



 224
if the are at risk because they do not know whether their husband or boyfriends
have multiple partners. The behavior of male partners may be the greatest risk
factor for women. Current research is exploring whether such risk factors
demographic, behavioral and related factors, called a risk assessment tool, and
whether use of this tool can help to manage contraceptive choices and STI
diagnosis and treatment.

STI Management: Diagnosis and Treatment
The only way to be certain if someone has an STI is to identify the disease-
causing microbe with laboratory tests. Laboratory tests are expensive and
require a client to return for results and treatment. Hence, WHO has developed
an approach for diagnosing and treating STIs called syndromic management,
which is based on a person's symptoms and signs in the context of the local
epidemiology of STI infection.
This syndromic management approach works well in some situations, for
example when treating men with genital ulcers or urethral discharge for
gonorrhea and chlamydial infection. However, the syndromic approach has not
worked well in diagnosing vaginal discharge. In addition, about three of every
four women with gonorrhea or chlamydia infection have no symptoms in the
early stages, so syndromic management is not helpful these cases. In fact, the
main causes of vaginal discharge globally are trichomoniasis and bacterial vagi-
nosis.
Research is under way to determine if various types of risk assessment tools
can be used to make STI diagnosis and treatment of cervical infections more
effective. Findings thus far are inconclusive, indicating that any risk assessment
tool must be modified to individual countries and regions within countries. These
tools must take into account prevalence rates for various STIs and cultural
factors such as whether women are willing to report having multiple partners or
are likely to know if their husbands have had multiple partners.
A full STI management program involves training providers, diagnosing STIs,
treating STS with antibiotics and tracing of partners for treatment. During treatment,
counseling should emphasize the importance of partner notification and treatment
in order to prevent reinvention. If programs decide they cannot afford to offer all of
these services, they can at least offer STI/HIVS preventive services and develop a


                                                                               225
referral system for diagnosis and treatment with another clinic. They can then
counsel youth about the need for treatment and refer them to the other clinic.

Summary of STI/HIV
STI prevention and treatment is priority for those working with youth. Young
adults are at high risk of STIs, which can result in chronic illness, infertility or
even death. Bacterial STIs such as chlamydia and gonorrhea, both common
among youth, can be cured. Given the STI/HIV epidemic among youth anyone
who works with youth, including family planning providers, must remember the
urgent need for effective STI/HIV prevention strategies.
Special attention needs to be paid to young women, since HIV rates are
increasing most rapidly among this group. Counseling about prevention can help
all youth avoid infection. Good counseling includes discussions of symptoms of
STIs, risk factors for infection, safe sexual behaviors and condom use. Where
STI infection rates are high, voluntary counseling and testing is important to
educate youth and reduce the risk of infection in the community. Diagnosing and
treating STIs may require referral to a clinic specializing in STIs.

Youth Are Our Future
Youth hold the future in their hands, and the entire society needs to be invested
in their progress. With opportunities to learn and explore their curiosity, young
people have much to offer. However, they face many challenges as well.
The HIV pandemic has become a youth epidemic, which poses huge barriers for
many youth. In the face of AIDS, many young people have learned to change
their behavior. Adults can support youth in these efforts by encouraging more
open conversations about sexuality, working to reduce stigma regarding those
infected with HIV, and supporting youth involvement in programs that affect their
lives.
As children become adults, all youth need to learn about their sexuality and
reproductive health issues. This includes a wide range of issues, including
delayed sexual debut, limited number of sexual partners and condom use for
those who are sexually active.




 226
TOOL T8
COMMUNICATIONS WITH ADOLESCENTS

                                     Source: Adolescent Health Care Principles
                                                  Centre for Adolescent Health
                               Royal Australian College of General Practitioners


This reference material on counselling is included for self-study by staff involved
in counselling provision. You may like to discuss it in groups with your
colleagues.


                 Communicating with adolescents


1. Introduction
This session focuses on the principles and practice of communicating
successfully with young people.
You will find there are many different styles of effective communication but the
underlying concepts are identical. Many of these concepts of communication
also form good advice for parents of teenagers.
You may find you already practice these techniques or may disagree with them.
It may be worth sharing ideas with colleagues or others about these techniques.
In this session you will work through the self-directed notes which will help to put
into practice some of the concepts we will cover.

2. The Medical Interview - framework and aims
Always explain to a young person what you are doing, why and the reasons for
taking a certain line of questioning. This proves a more collaborative framework
and keeps the young person empowered.
The main aims of a medical interview consultation with an adolescent are to:
   S Facilitate communication



                                                                             229
   S Negotiate time alone with young person
   S Discuss confidentiality
   S Screen for health risk and protective factors
   S Provide health promotion where appropriate
   S Negotiate a management plan


Facilitating communication
An important step toward improving adolescents' access to medical services is
to improve the communication in the relationship between doctor and young
person. Some important points regarding communication include:
   S Introduce yourself to the adolescent first in the waiting room, and ask
     them to introduce accompanying adults to you.
   S Be yourself during consultation, whilst maintaining a professional manner.
     Avoid using adolescent jargon unless they use it first, as this can be
     viewed as patronizing. Such jargon also tends to change frequently.
   S Avoid using medical jargon.
   S Interview in an interactive style.
   S Be relaxed, open, flexible and unhurried.
   S Be warm, sincere and non-judgmental, without condoning risk-taking
     behavior which is not developmentally appropriate.
   S Normalize and explain the process of asking questions of a young
     person's health, e.g. "I ask all my teenage patients... to understand how
     their lifestyle may be affecting their health". This approach can also be
     used when negotiating time with adolescent alone and introducing
     confidentiality. The aim is to keep the adolescent as comfortable as
     possible.
   S Take a "one-down" approach. The adolescent is an expert on their own
     life-let them educate you, e.g. "I'm not sure if I've got this right... was it a
     bit like....?"




230
Negotiating time alone with the young person
Many adolescents will be brought along to your practice by anxious or
concerned parents. It can be a challenging but necessary skill for the health
worker to hear the parent's concerns, reflect that you have understood their
position, then negotiate some time alone with the adolescent to establish rapport
and hear her/his side of the story.
In interviewing the adolescent alone, important questions that you may want to
start with include how he/she feeds about coming along to the clinic, his/her
parent's version of the issue that the young person is presenting with, and how
he/she feels about them. Many adolescents may not perceive that they have a
problem at all, or may define it differently from their parents.
This time alone further allow an opportunity to assess developmental stage,
screen for health risk behaviors and provide preventive health information/edu-
cation. Statements which normalize this practice as protocol can make it easier
for the health worker. For example:
"It has been important for me to hear what you have to say Mrs. Mai (mother has
stated her concerns). It is my usual practice with adolescents to spend some
time chatting with them alone to build up an understanding of where they are at
so I can best help them. I'd like to chat with An for awhile, then we can wrap up
together at the end".
It may also appropriate to spend some time alone with parents. Families are inte-
gral to the healthy development of young people and may need counseling or
advice to help them deal with their teenager's issues. It is preferable that his
occurs after you have spent time alone with the adolescent, so as to avoid the
perception that some level of collusion is going on between yourself and the
adolescent's parents in terms of his/her care.
Discussing Confidentiality
Once you are alone with the young person, it is important to discuss the terms
of confidentiality with them as early as possible. This can help facilitate rapport
and lessen discomfort in talking about private concerns. The following is an
example:




                                                                            231
"An, I like to explain to all my teenage patients that what we talk about in this
consultation is confidential. That means, for example, that I'm not going to tell
your parents or teachers what you tell me without your permission. There are
three exceptions to this, however; if you told me that you were going to
seriously endanger your life, such as by suicide, if you were going to seriously
endanger someone else's life, or if someone was physically or sexually abusing
you. In these cases I would need to involve others to keep you safe. I would try
to talk to you about it first and we could contact the safe people together. Is that
OK?"
Whilst this seems like a monologue, we have found that it really only takes 30 -
90 seconds to cover and can be stated with some humor if that's your style and
the situation is appropriate. Some doctors prefer to explain the terms of
confidentiality with parents and adolescents together.
Screen for health risk and protective factors
The reasons for undergoing an opportunistic screen should be explained to the
young person, for example:
"An, I know you've come in for a sore throat but as I haven't caught up with you
for over a year and you are embarking on some pretty heavy study soon, I'd like
to check out with you how life is going in general. If you have anything you'd like
to discuss about your health, we could do that now. If there are any areas or
questions that you don't feed happy to talk about or answer that is also fine - just
let me know. I do this with all my teenage patients yearly, because life can
change so rapidly."
This step of explaining the process is crucial if you are to avoid alienating the
young person. Young people don't appreciate being asked personal questions if
they can't see the reasons for them. As outlined above, it is also important to
give them permission to refuse to answer if they so wish.
Even if they are not at risk of serious morbidity or mortality, young people are
undergoing many changes that they may find confusing or worrying. They may not
have an adult in their lives who they relate to well, so chatting to an easily
accessible and empathetic health professional may help them clarify issues and
discover a range of different ways to tackle a problem. If they perceive you as
someone who is happy to talk about issues which are important to them, they will



 232
be more likely to return with other questions; particularly when they are having
difficulties.
Discussing sensitive issues
It is best to start with the generally least sensitive areas of a young person's life
that should be easier to talk about, and move towards the more sensitive. It is
important to bear in mind, however, that "home" or other areas may be highly
sensitive, and the practitioner may need to exercise some discretion.
Before asking about drug and alcohol use, sexuality and depression/suicide risk,
it is helpful to warn the teenager that you are about to ask some more personal
questions that they may feel uncomfortable about and are free to not answer if
they wish. Additionally, it is worth reiterating the confidentiality clause, as it is
often in discussing these areas that dangerous risk taking behavior may be
disclosed.
Asking sensitive questions of adolescents can often meet with no-verbal
reactions such as looking down or away. This may mean the adolescent is
embarrassed, engaged in the behavior when they say they are not or it may be
a painful area that is difficult to talk about. Indeed this may be the case for the
so-called no-sensitive areas such as home and school.
Encountering this reaction does not mean we should drop the inquiry like a hot
cake - in fact, it may be just the area where the adolescent patient need the most
assistance. Rather it means we would trap very gently and explores the area
more indirectly, e.g. "Some teenagers find that if they drink more then they feel
sad or lonely, do you ever feel that way?"
It may be more appropriate to move on to another area to continue building
rapport whilst in a comfortable zone and return to the sensitive area later. You
may choose to comment that you can see this is difficult for the adolescent to
discuss and that you would be available for them if they wished to talk about it
another time.
If some areas of discussion end up taking some time, a few consultations may
be necessary. Explain to the young person that you believe what they are telling
you is important and that you would like to explore it further with them, and make
another appointment.




                                                                              233
It is important to actively listen and explore areas of ambiguity. For example:
Doctor: "Sometimes when people feed very unhappy they may consider hurting
themselves. Have you ever felt like harming yourself?"
Young Person: "No... not really" (looking down at feet)
Doctor: "I can see that talking to you about this is difficult for you... is it okay?
OR "What do you mean by "not really"?"
Young person: "Well I once cut my leg with a razor but then I got scared..."
To have left the questioning after the young person had said "not really", may
have resulted in an important issue being missed. This may seem obvious but is
the kind of thing that does happen when someone is intent on getting through a
list. Similarly, you may need to get the teenager to explain what they mean by
common "teen terms"; for example, "Can you tell me what you actually get up to
when you are "hanging out" with friends"?
Gaining additional information on sensitive areas
When a risk is identified, particularly in a sensitive area of questioning, it is
important to explore it in more detail. Below are some examples:
Drug use:
   S Explore not only use of illicit drugs but the more easily accessible licit
     drugs such as paracetamol and prescription items.
   S Ask about how much the person is taking, how often and in what
     circumstances, effects of the drug use and any regrets.
   S Explore knowledge of and use of harm minimization strategies.
Sexual activity
   S Ensure this subject is explored in gender neutral terminology; in this way,
     a young person dealing with sexuality issues, or who identifies as
     same-sex attracted, will be more likely to feel comfortable and listened to.
   S Ask about their knowledge and practice of contraception, STI protection.
   S Explore whether they are happy in a relationship and whether sex is
     consensual or whether there is force or coercion occurring. Are they in




 234
      need of strategies to be more assertive about not having sex?
Depression and suicide risk assessment
   S This is also an opportunity to exclude other mental health symptoms such
     as anxiety, anger or psychosis.
   S Ask about general stress coping mechanisms and thoughts, past attempts
     or plans for any self-harm.
Depression and suicide risk will be explored in more details in a later module
which will specifically look at these issues in relation to young people.
Providing health promotion/health education
The doctor should provide health promotion or education when appropriate, for
example, discussing contraception and protection against STIs under the
heading of sexuality. There is also a range of harm minimization strategies with
regard to young people and risk-taking, such as drug taking behaviors that you
may want to explore and incorporate in your practice on these issues.
A possible trap is lecturing or proving advice before fully exploring the young
person's history of risk taking, their perceptions or their risk taking and what they
already know of the harms and harm minimization strategies.
After this information is evaluated, health promotion is more meaningful as it can
be targeted according to individual behavior and characteristics.
Making health messages relevant to the adolescent's immediate lifestyle is more
useful than those outlining how it will affect them in the future. This is
particularly true for younger adolescents; you may recall that they may not yet
be cognitively mature enough to have a future time perspective, that is, connect
with how their behavior may impact on their future.
It is great if you can help young people reflect on their risk taking behavior and
weigh up the perceived benefits, and disadvantages. There are obvious
perceived benefits in any health risk behaviors, for adults as well as adolescents.
These need to be acknowledged and the adolescent encouraged to think about
how the/she views the balance of benefit and risk, e.g. belonging to a peer group
vs. the risks of using drugs dangerously. Helping the young person to move
through a problem solving exercise or to brainstorm other options to achieve the
same benefits with less/no risk may be useful.


                                                                              235
If adolescents have told you about risk taking behaviors that are worrying it pays
to feedback your concern. It is NOT normal adolescent behavior to be taking
unreasonable health risks and it IS okay for us to highlight our concern to them.
If anything, this imparts a sense that we care about them. You may find relief in
their face they are often just as concerned and may be looking for help to
consider other options for dealing with problems. The often find it easier to admit
to a doctor that they are engaging in risky behavior than to admit/explain that
they are worried about it.
Offering some education about the risk in a non-judgmental fashion is important
and may explode some myths adolescents hold such as “smoking marijuana is
not as harmful as cigarettes". Posing questions such as "What would you do if
you were with your friends, all had alcohol to drink and wanted to drive home?"
is an effective non-judgmental way of providing anticipatory guidance as the
process of "cognitive rehearsals allow the young person to consider various
strategies with you. Saying something like, "you wouldn't drink and drive would
you?" is more condescending and judgmental and does not allow for the same
interaction with the teenager.
How the adolescent receives this approach depends largely on how we deliver
it. It is usually best to avoid lecturing and lengthy monologues at all cost. Rather,
speak in short segments of about two sentences at a time, check the young
person's non-verbal reactions to what you are saying as you speak, pause and
allow time for them to reflect, make a comment and ask a question. Check to see
that they understand your words and explanations.
Feedback and negotiating a management plan
Feeding back your impressions of the consultation to adolescents and
negotiation of a management plan together, in a developmentally appropriate
fashion, shows respect for them as people and encourages their emerging
independence. The following points are important:
   S Reflect back to the young person what you think they were trying to tell
     you, not only in terms of content but also in terms of the feelings
     portrayed. They will usually feel quite comfortable about correcting you if
     you have it wrong, thus giving you a more accurate perception of their
     situation. Reflection also illustrates to the young person that you were
     listening to what they were saying.



 236
   S Compliment areas in their life that are going well and highlight the areas that
     may be of concern and need further discussion at some point. Problems
     can be "normalized" to reduce any negative stress e.g. "Many people
     experience these feelings when... happens". This can incorporate some of
     the strategies outlined above for giving health promoting messages.
   S It is important in the feedback to give an impression of what you think is
     going on for that young person. For example, if they have presented with
     recurrent headaches and you have found a number of psychosocial
     stressors which could contribute to these, it is important to help them
     understand the possible connection.
   S Also, young people are worried about being labelled as "mad", which is
     particularly important in dealing with mental health issues, so it is worth-
     while providing some reassurance. Again, an example of "normalizing"
     the problem is "Some people hear voices/imagine "weird" things when
     they are much stressed or depressed..."
Adolescents prefer a straight forward, honest approach. They question what we
as doctors are thinking about their presentation. It helps to verbalize our
reasoning. If, for example, you are investigating pelvic pain and comment to the
teen girl that everything is normal on examination but then go and order an
ultrasound without explaining why, she will be left bewildered and may not
comply. An example of a better way to approach this situation is as follows:
"Everything seems normal to physical examination but sometimes these pains
are caused by things you cannot easily feel and I'd line to check for these. An
ultrasound is a type of test that enables us to see if there is anything internally
that may be causing the pain. A cyst on the ovary is a common cause of this sort
of discomfort and is most often nothing to worry about - they can come and go.
It may help explain your pain if we do this test".
You may also need to explain what is involved in an ultrasound if they haven't
had one before. Giving young people some sense of choice and control
maintains our efforts to empower them and show positive regard.
Involving others
It may also be important to see how family, teachers or others perceive the
teenager's behavior.


                                                                             237
It helps to negotiate with the adolescent which areas should be discussed with
parents or others and how this should be done. No other person should be
contacted about their situation unless they give permission, and they must give
permission before any part of their history is divulged.
At times when the teen is seriously at risk, however, they may need someone
else to offer control, safety and containment until things improve. It is still
important to offer them some input into the series of events and enlist their
support, providing it does not delay life saving procedures/processes.
It is also important to check the best way of contacting a young person if you
need to after the consultation. They may not want people with whom they live to
know that they have seen a doctor.
Physical examination
Another important aspect of consultation with teenagers is the physical examination.
Adolescents often have a focus on body image and preoccupation about
normality. Protecting modesty, offering a chaperone, explaining the examination
as you go along and commenting on morality are important strategies to relax
the adolescent and reassure them. Be sensitive and straightforward in
explaining any negative findings and exactly what these mean in simple terms.
The first pap smear is important - explain the reasons and processes first, be
gentle, warm the speculum with hot tap water, reassure about process and
normality and offer to stop if the young woman finds it too difficult. Some young
women may like to see their anatomy in a mirror/ have it explained - others
would be uncomfortable with this.
There is no requirement to routinely examine genitalia or other secondary sex
characteristics unless there is a strong suspicion of an endocrine disorder of
growth or the teenager would like reassurance on parts of their body.
Examination of these areas is highly embarrassing for teenagers and usually of
doubtful benefit for most other conditions in the general practice setting.
Keep in mind some of the common variations of development such as unequal
breast size in girls, gynaecomastia in boys and the relative timing of the stages
of growth and development relative to each other. Plotting growth charts is often
useful, especially in variations of height and weight.



 238
TOOL T9
                   DESCRIPTION OF TARGET GROUPS
                   FROM YOUTH UNION BCC STRATEGY

                                    Source: Vietnam Youth Union BCC Strategy
                                                                - RAS/03/P51


1. Segmentation of Young People Into Target Groups
The overall target group under RHIYA Vietnam as well as for the BCC strategy
includes whole the population of young people at the age of 10-19 and 20 -24,
respectively defined as adolescents and young people according the World
Health Organization (WHO).
To be able to tailor interventions to the needs of different target groups of A/Ys
(adolescents/young people) and to effectively communicate with them
appropriate communication messages, segmentation into specified target
groups is required, based on:
   -   Characteristics in demographic variables, like societal position, gender,
       educational level, residence, age, ethnicity, etc.
   -   Characteristics of lifestyles, like risky behavioural factors related to
       individuals, biological and mental development and influences of society
       and environment.
   -   Characteristics of needs, demands and the SRH problems, different
       target groups are facing.
Together with the IAs (implementing agencies) during the development of the
BCC strategy, the overall target group of A/Ys has been analyzed and divided
into 3 main, specified target groups of the 7 provinces where the project is
implemented. These main target groups were further segmented into sub-target
groups, based on common characteristics:




                                                                           241
                                                       PLHA and their Social
    In-School Youth         Outside-School Youth
                                                          Environment
S Pupils of secondary      S Street children       S PLHA
  and high schools         S Young people working S People in the social
S Students in college        in restaurants/hotels   environment of PLHA
  and university           S Young people working
                             in factories
                           S Young people working
                             as farmers
                           S Ethnic young people


1.1 The sub-target group in school includes:

a) Pupils of secondary and high schools
Though some differences in age, biological and mental development and
sexual needs between pupils of secondary and high schools exist, they have
enough similarities to group them into one sub-target group, to be approached
with same communication messages.
   S Taking the research data on sexual behaviours in mind, for pupils of
     secondary schools SRH problems like pregnancy, abortion, HIV, etc are
     not very pressing issues. However, their knowledge is limited and their
     attitude and behaviours towards related SRH problems often are
     inappropriate. Therefore, it is essential to focus on providing them
     information on their own biological and mental development and already
     prepare them, so that they will have adequate knowledge, positive
     attitudes and skills in order to take healthy decisions whenever they will
     have sexual contact and face SRH problems.
      Main characteristics of this sub target group are:
      -   Age: 12 - 15 years old
      -   Living with parents
      -   Going to school, carrying out activities with their peers (Youth Union
          branch, etc); and being influenced by their teachers.



242
      -   Starting to enter puberty, but do not yet have concrete sexual needs in
          how to cope with sexual relationships. This means that knowledge on
          puberty, and other SRH issues should be provided to them.
   S Pupils of high schools are in the period of a growth spurt and fast
     development, both physically and mentally, during this puberty period.
     They have needs for information on their own development and on how to
     cope with friendship with the opposite sex. Some of them may already
     face SRH problems such as unintended pregnancy, abortion, RTIs and
     STIs, including HIV, etc.
This sub-target group does yet not realistically perceive risks of SRH problems
and may therefore take sexual health risks, because of which they need to be
provided with SRH information, education and services.
The main characteristics of this sub-group are:
      -   Age: 16 - 19 years old
      -   Living with parents
      -   Going to school, carrying out activities with their peers (Youth Union
          branch, etc); and being influenced by their teachers
      -   Gradually finishing the puberty period, still rapidly changing,
          physically and mentally.
      -   Founding friendship with peers of the opposite sex, they may fall in
          love and may be confused on friendship and love.
      -   Eager to find information.
Apart from the above-mentioned characteristics of pupils of secondary and high
schools in general, ethnic pupils are specifically characterised with the following
additional, own features:
      -   Having difficult living conditions.
      -   Having difficulties in accessing mass media.
      -   Being not self-confident and lacking life skills, including communication
          skills.
      -   Often forced to drink wine, may lead to lack of controlling their sexual
          behaviour.


                                                                            243
b) Students in Colleges and Universities
In general, university students have certain knowledge on SRH problems and
insight in themselves. However, often living far from their family without parental
guidance, having financial constraints, and increasingly experimenting with a
"trial living style as spouses before marriage", easily confront them with SRH
problems (including unintended pregnancy, abortion, STIs, HIV, etc). But if they
are equipped with relevant information, attitudes and skills, they may become
good advocates in the area of SRH for their peers and for the society as well.
Main characteristics of this sub-target group are:
      -   Age: 19 - 24 years old
      -   Most of them live alone, far from their family, without parental guidance
      -   Having some understanding on SRH, easily accessing both
          comprehensive information as well as fragmented, one-sided and explicit
          information via Websites on the Internet.
      -   Think that life should be more "modern, open"
      -   Taking SRH risks
1.2       The out- of- school target group includes:

1.2.1. Street children
This sub-target group is an extraordinary group within society, living far from the
family, mostly without any adult guidance and support and in poor inns. They
face many and high SRH risks, like sexual abuse, drug use and needle sharing,
unintended pregnancy and abortion, etc. Due to financial constraints, they are
easily involved in drug use, drug dealing and prostitution. Most of them are
uneducated or low educated, have a low self-esteem, lack even basic
knowledge on SRH and do not know (and are unable to know) where, when and
how to access SRH information and services.
The main characteristics of this sub-target group are:
      -   Age: 10 - 18 years old.
      -   Low education, low self-esteem, lack of even basic knowledge on SRH.
      -   Mostly coming from poor families, and living far from family to earn their



 244
       own livings, without parental guidance.
   -   Having difficulties in accessing SRH information and services.
   -   Are easily exploited/involved in high-risk behaviours (drug use, drug
       dealing, prostitution, sexual abuse).

1.2.2 Young people working in restaurants, hotels
This sub-target group has also to be included in the high-risk target groups, as
they are easily confronted with guests who have sexual requests/needs.
Therefore, some of them become commercial sex workers.
Besides risks on sexual abuse, they are easily infected with STIs, including HIV,
due to lack of knowledge on SRH. Therefore, interventions and communication
messages should guide them in awareness on sexual abuse and in preventing
STIs, HIV, unintended pregnancy and abortion as well as training them in how
to avoid and escape risky situations, negotiate with sex partners, to consistent-
ly use condoms during sexual intercourse, and to look for health services in-time
in case of having an SRH problem.
Main characteristics of this subgroup are:
   -   Age: 19 - 24 years old.
   -   Low education.
   -   Working in restaurants, hotels in which they easily face SRH problems
       because of sexual contacts with guests.
   -   Particularly in need of knowledge on prevention of RTIs, STIs and HIV,
       signalling signs of STIs in order to have examination and treatment in
       time; refusal skills, negotiation skills on using condoms, etc.

1.2.3. Young people working at factories
Most young people of this sub-target group come from the countryside. This sub-
target group consists of more females than males. Because of working in
crowded industrial zones and living from their family, they are in need of intima-
cy and love, easily leading to unprotected sexual intercourse. Hence, they are
easily facing SRH problems such as unintended pregnancy, abortion, RTIs,
STIs, HIV, etc.



                                                                           245
Providing SRH information, skills, counselling and services to them is necessary,
especially to the female workers so that they can protect themselves.
Main characteristics of this sub-target group are:
   -   Age: 18 - 24 years old.
   -   Low education.
   -   Often living alone in worker-crowded residences, without adult guidance.
   -   Having not much chance to access information on SRH and be reached
       by mass media, due to shifts in working,.
   -   Female workers should be paid more attention to, as they account for a
       large numbers of workers and are more vulnerable and at risk of SRH
       problems.

1.2.4. Young people working as farmers
Most of these young people live in rural areas. Due to their social norms, culture
and pressure to move to urbanized regions, they get married early, have many
children and some of them move to cities to earn their livings, getting easily
involved in social evils. It is necessary to provide them knowledge, skills and
services on SRH care, integrated into family planning activities as well as on
hunger eradication and poverty reduction in order to protect their own health and
the health of their families.
Main characteristics of this sub-target group are:
       -   Age: 18 - 24 years old.
       -   Low education.
       -   Mostly living in rural areas, moving to cities beyond harvest time.
       -   Not having chances to access IEC materials.
       -   Easily involved in social evils.

1.2.5. Ethnic young people
Though this sub-target group accounts for only a small proportion of the total
population A/Ys of RHIYA, more attention should be paid to them as they live in
poor, mountainous areas. Some of them are not good at speaking the national



 246
language, often only speaking ethnic minority language and many are illiterate
(or do not know to write). Thus, they lack chances to access (written) SRH infor-
mation and health services.
Main characteristics of this sub-target group are:
   -   Age 10 -24 years old.
   -   Low education, some of them are illiterate.
   -   Living with their family in poor living conditions, getting married early.
   -   Having difficulties to access (written) SRH information and services.

1.2.6. PLWHA
If we take this sub-target group into consideration in the project sites, PLWHA do
not account for a large proportion. However, in terms of the increasing
proportion of young people infected with HIV/AIDS among the rapidly rising
figures on the total of PLWHA, there should be paid more attention to this group
and their social environment. They may be living isolated from communities,
having to hide their infection to prevent discrimination while they are working in
factories, offices, or studying at school or university. However, because of lack
of knowledge and irrational fear to become infected they are discriminated by
the society, communities, their families, their peers, and often even their friends.
Most of them live in poor living conditions, having difficulties in accessing SRH
information and services due to fear of stigma and/or lack of friendliness of serv-
ices for them.
The main characteristics of this sub-group are:
   -   Age 18 - 24 years old.
   -   Low education, lack of SRH knowledge.
   -   Live in poor conditions, do not have and get work, and are discriminated
       by people around them.
   -   Always live with fear and have a low self-esteem due to social attitudes
       and having often to face disappointment, rejection, etc.
   -   Can be unique information sources and can be very convincing in
       communicating with their peers. If they can be involved in prevention
       programs, they may become good and powerful peer educators.


                                                                              247
1.3. Overview of SRH problems per target group in RHIYA

                                                                                                                                        SRH PROBLEMS


SN                       Target groups                                   Project site
                                                                                                         Unintended preg-   Abortion                  RTIs/STIs/   Discrimination against
                                                                                                                                       Sexual abuse
                                                                                                              nancy         (unsafe)                  HIV/AIDS           PLWHA*



1.     In school


       Both secondary and high school pupils (includ-   Hoa Binh, Hanoi, Hue, Khanh Hoa, Hai Phong, Da

       ing ethnic people)                               nang, Ho Chi Minh city
                                                                                                                +              +           ++             +                  +




1.2    Students (University, colleges)                  Ha Noi, Hai Phong, Dang, Ho Chi Minh city

                                                                                                               +++            +++          ++            +++                 +
                                                        (HCMC)



2.     Out of school


2.1    Street children                                  HCMC, Hanoi, Hai phong, Danang

                                                                                                                +              +           ++            +++                ++



2.2    People working in factories, offices             Hue, Khanh Hoa, Hai Phong, Danang

                                                                                                               +++            +++          ++            +++                ++


2.3    People working in restaurants, hotels            Hue, Khanh Hoa

                                                                                                               ++             ++           ++            +++                ++


2.4    People working as farmers                        Hai Phong, Danang

                                                                                                               ++              +           ++            ++                  +


2.5    Etnic people living in mountainous areas         Hoa Binh

                                                                                                               ++              +            +             +                  +




3.     PLWHA


3.     PLWHA                                            HCMC
                                                                                                                +              +            +            +++                +++




Note:
-     Sign (+) indicates the degree, in which a target group faces an SRH problem. These
      are no hard figures, but estimated, using data from research and reports and input of
      IAs
-     The more signs (+), the more importance in addressingf the SRH problem is required
-     More or less signs (+) is defined on data from qualitative and quantitative published
      reports on ARH,, discussions and findings of partners under RHIYA Vietnam, and the
      Baseline Survey of UPSU, conducted in July 2004 in 7 project provinces by UPSU
(*) The problems of discrimination with PLWHA is urgent among PLWHA, however this problems is
caused by discriminatory attitude of people in the community



    248
      TOOL T10
251




                                KEY AND SPECIFIC COMMUNICATION MESSAGES
                                                          Source: RAS/03/P51 - Behaviour change communication strategy
      The following tables show the recommended messages to young people to help solve these priority RH prob-
      lems.
      Two common health promoting behaviours contributing to minimise five sexuality and reproductive
      health problems
           Health
                                Key communication                                                             Specific communication
         promoting                                              Intervention objectives
                                    messages                                                                         messages
         behaviours
      1.     Seeking SRH " Modern youth know to seek      Knowledge: A/Y:                                  " You will not engage in unwilling
         information   to  information to avoid SRH       " Have correct information on YFSs and             parenthood if you have adequate
         prevent unwanted  problems:unwanted/teenage          professional SRH services for A/Y (where,      knowledge on SRH
         pregnancy         pregnancy, abortion and            what services provided, who are providers,   " Counselling centres and YFCs are
                           unsafe             abortion,       when…) and place providing safe abortion       always willing to explain how to use
                           RTIs/STIs/HIV/AIDS, sexual                                                        condoms and the ECP
                                                          " Knowledge on advantages of in-time
                           abuse, and stigma with
                                                              examination, test, and treatment of          " Receiving SRH services in a
                           people with HIV/AIDS
                                                              RTIs/STIs/HIV                                  professional health center will protect
      2.Use reliable and " For your health, happiness,
                                                          Risk perception                                    your      health     and        ensure
         professional SRHC and future, use YFCs or                                                           confidentiality.
         services and YFCs in
                           profesional health services    " A/Y are aware of risks to SRH problems
         time                                                                                              " Our professional health centres and
                           for counseling and sexual      Atitude: A/Y:
                                                                                                             YFCs can provide correct information
                           and reroductive care.
                                                                                                             on pregnancy and abortion.
                                                                                                           " Come to YFCs, you wll receive
      " If pregnant, come to the        " Aware of advantages of SRH services, be      counseling,         condom         and
        YFC: we are here for all your      ready to look for YFCs and share            contraceptive pills free of charge
        questions!                         information on YFSs to the others         " When you have any sign of
      " If you decide for abortion,     " Be willing to look for and access health     RTIs/STIs/HIV, come to counselling
        come to the professional           services and YFCs                           centres and YFCs n time
        SRH services to receive         Aware of social norms: A/Y:
        counseling and quality
                                        " Expect the community to support the use of
        service
                                           SRH quality services and counselling cen-
      " Come to our youth-friendly         tres
        services immediately if you
                                        Skills:A/Y have:
        are sexually abused or
        harassed to receive support     " Skills to access and request health care
        and a health check.                services in YFCs and professional health
                                           centres meeting 10 clients rights
252
      " Be willing to denounce rapists
259




      " Be aware of your rights to protection and
        support from relatives, authority, police and
        health services
      Aware of social norms: A/Y:
                                                        " Sexual abuse is a violation of your
      " Expect other people to respect your right to      rights; absolutely condemn it!
        protect bodily integrity and be willing to cope
                                                        " Victims of harassment or rape are
        with the opponents
                                                          never guilty!
      " Trust in the community ‘s empathy towards
                                                        " Responsible men only have
        women who lost their "virginity" because
                                                          consensual sex.
        they were sexually abused
      " Expect support from the community for
        using counselling, health care and SRH
        care services
      Skills: A/Y have:                                " Girls, if in remote areas, sexual
      " Skills to identify risky situations that may     abuse lies in wait, have a friend with
         lead to sexual abuse                            you as bodyguard
      " Skills to refuse sex and protect him/herself " Talk about sexual abuse; it helps you
         from risky situations that may lead to sexual   and the fight against this violation of
         abuse                                           rights
      " Skills to access supports after being sexual- " If someone touches you against your
         ly abused                                       will, say NO and call for help
      BCC goal No. 4: Minimise RTIs/STIs/HIV among A/Y
           Health
                                Key communication                                                           Specific communication
         promoting                                                Intervention objectives
                                    messages                                                                       messages
         behaviours
      12.Keep reproductive " Daily hygiene of your Knowledge: A/Y have:                                 "   Being Equipped with adequate
         organ     hygienic  reproductive organs helps " Knowledge on reproductive organs, puber-           knowledge on RTIs/STDs/HIV/AIDS is
         during menstruation you to prevent RTIs           ty, sexuality, STIs/HIV, RTIs (risks, conse-     an effective weapon to protect
         hygiene                                           quences and prevention methods)                  yourself from these problems
                                                         " Knowledge about the consequences of "            Female students need to know about
      13.Practise safe sex. "                              sharing needles related to HIV and               menstruation hygiene to protect their
                             Condoms kill two birds with
         Use         condoms                               hepatitis B                                      health
                             one stone: pregnancy and
         correctly during allHIV! If you have sex, use " Knowledge on harms of alcohol and drug "           Safe sex - being faithful with one
         sexual intercourse  them!                         abuse related to risks of unsafe sex             sexual partner and using condoms
                                                                                                            when having sex – protects you from
                                                                                                            RTIs/STIs/HIV
      14.Do nor have many " Be faithful with one sexual
         sexual partners                                                                                "   Use separate and clean disposable
                              partner is a possible choice
                                                                                                            syringes and needles
                              to protect yourself from
                              STIs/HIV                                                                  "   More recycling of syrings and needles
                                                                                                            results in, more risks of contracting
      15. When needed, use " Use disposable syringes to                                                     HIVto HIV/Hepatitis B
         disposable syringes  prevent HIV and hepatitis B
                                                                                                        "   Youth friendly corners answer all your
         and needles and do
                                                                                                            concerns and worries on RTIs/
         not share these with
                                                                                                            STIs/HIV
         other people
                                                                                                        " Come to commune health centre, and
                                                                                                          the YFC at your place, you will receive
                                                                                                          free counselling and condoms
260
      16.Do not abuse
                             " Don't let alcohol
        alcohol and drugs   damage your youth and         Risk perception: A/Y:                              " Everyone can be infected with HIV
261




      that     lead    to   your health                   " Are aware of what the consequences early           do not use condoms during or if they
      unexpected sexual   " Come to YFCs or reliable          sexual intercourse and unsafe sex will have      share when having sex, and share
      intercourse           SRHC services immediate-          on health and future                             needles when injecting
                            ly if you have any signs      " Fully aware of risks of sharing needles and      " Too much Alcohol easily leads to
                            relating to RTIs/STDs and         how this will effect health.                     unprotected sex.
                            have 2 health check and
                                                          " Fully aware of consequences of alcohol
                            treatmentin time to protect
                                                              abuse related to unsafe sex risks
                            your health and your future
                                                          Attitude: A/Y:                                     " Know how to prevent yourselves
                                                          " Be aware of their rights on making own             from RTIs/STIs/HIV
                                                              decisions and respect the rights to decision   " Condoms may cause you one
                                                              making of their partners                         minute with less pleasure, but they
                                                          " Express positive attitude toward virginity         also contributes to safe, healthy
                                                                                                               and happy life of your lover and you
                                                          " Express positive attitude toward love-based
                                                              sexuality and faith
                                                          " See condom use in sexual intercourse; and
                                                              disposable needles/syringes use responsi-
                                                              ble behaviours
                                                          Aware of social norm: A/Y:                     "     Sharing needles is not about
                                                          " Feel supported by community in regarding           friendship, but about HIV; always
                                                            virginity as an important value; are willing       use clean disposable needles and
                                                            and able to cope with peer pressure of             do not share them!
                                                            having sexual intercourse before they are
                                                            ready for it
                                                          " Expect community’s objections towards
                                                            having many sexual partners
                                                          " Trust in support from the community in using
                                                            clean/disposable syringes and needles; and
                                                            health care/SRHC services
      BCC goal No. 5: Minimise discrimination against A/Y living with HIV/AIDS
        Health promot-          Key communication                                                                 Specific communication
                                                                     Intervention objectives
       ing behaviours               messages                                                                             messages
      For A/YLWH
      17.Avoid self-stigma if " Do not isolate yourself if Knowledge: PLWHA have:                             "   Equip yourself with adequate
         living with HIV,        infected with HIV; actively " Knowledge on HIV/AIDS (transmission                knowledge on RTIs/STIs/HIV as an
         actively participate in integrate yourself into the       routes, prevention methods, essential care     effective weapon to fight these
         social activities       community: accept, be open        and follow-up)                                 problems
                                 and live more effectively for
                                 yourself, for your family, and Risk perception:                              "   Do not close yourself when being HIV
                                 the community                  " PLWHA are aware of situation in which they      infected. You have right to be
                                                                   might need support from their surrounding      supported!
                                                                   and health services
                                                               Attitude: PLWHA:                               " Do not close yourself when being HIV
                                                               " Trust in support from the community            infected. You need support and have
                                                                                                                the right to support!
                                                               " Are open and willing to seek support form
                                                                   outsiders their surroundings
                                                               " Are aware of their right to receive support
                                                                   and protection and are willing to look for
                                                                   YFSs, YFC, health services to pass on
                                                                   information and about the use of services
                                                               Aware of social norms: PLWHA:
                                                                                                         " HIV is a virus that you, me and our
                                                               " Are willing to look for support           relatives can be infected with Be
                                                               " Are willing to deal with discriminative   empathetic and support PLWHA
262

                                                                 attitudes and isolated situation
                                                             Skills: PLWHA:                                  " Accept the fact, be open, look for
263




                                                             " Have skills to persuade other people            support and try to live longer with HIV
                                                                against their irrational fears of being " Live actively, prevent transmission
                                                                infected through contact with PLWHA            actively, and seek treatment actively,
                                                             " Know how to cope with their HIV/AIDS            and actively integrate into community.
                                                                status
                                                             " Have skills to communicate with their
                                                                surroundings
                                                             " Have skills to seek support, including skills
                                                                to access YFCs
      For people around PLWH
      18. Treat PLWHA as " HIV infected people have Knowledge:                                               " Equip yourself with adequate
         equals            the right to live and work as " A/Y have knowledge on HIV transmission              knowledge on RTIs/STIs/HIV as an
                           other people                      routes and prevention methods                     effective weapon to fight these
                         " HIV is a virus that you, me                                                         problems
                           and our relatives can be Risk perception:                                         " Do not discriminate PLWHA as you,
                           infected        with.     Be " A/Y are aware of risks related to HIV                me and our relatives can be infected
                           sympathetic and support           infection                                         with this virus.
                           PLWHA
                                                         Attitude: A/Y:
                                                         " Trust that HIV is not transmitted by contact      " HIV is transmitted by blood, unsafe
                                                             with PLWHA                                        sex, and by mother to child during
                                                                                                               birth. It is not transmitted by normal
                                                         " Are aware of PLWHA needs and rights to
                                                                                                               daily communication
                                                             receive support of PLWHA
                                                         Aware of social norms:
                                                                                                             " Do not discriminate against PLWHA
                                                         " A/Y are aware that PLWHA are like any
                                                                                                               as you, me and our relatives also can
                                                             others in the community and treat them
                                                                                                               get infected
                                                             equally
                                                         Skills:
                                                                                                             " You can support PLWHA in any way
                                                         " A/Y have skills to support PLWHA
                                                                                                               you like, start by talking with them.
TOOL T11
                    CHANGING BEHAVIOURS
                    OF SERVICE PROVIDERS

 Source: Changing Behavious of Service Providers Toward the Implementation
                  of National Standards and Guidelines for RH Care Services
                                           Vietnam Ministry of Health (2004)




 Current Status and The Necessity of Behavioral Change
       for Reproductive Health Service Providers


1. The Behavior Concept in Reproductive Health Services
Provision
Behavior in reproductive health services provision is understood as the
professional practices and attitude of service providers towards customers.
These practices and attitude may or may not comply with the National Standards
on reproductive health services.
For example:
   -   Correct behavior of service providers: keep confidential all information
       related to the health status of people living with HIV/AIDS, comply with the
       procedure of infant umbilical care, counseling patients contaminated with
       sexually transmitted diseases and their sex partners on treatment and
       prevention.
   -   Incorrect behavior of services providers: unwelcoming attitude,
       inattentive, noncompliant with the sterilization process, incomplete
       antenatal checks process, inducing clients to use contraceptive methods
       available at the clinic, not forewarning clients about dangerous health
       symptoms, not using partographs for antenatal checks, etc.




267
2. Current Status of Behaviors According to The National
Standards

2.1. Some achievements in terms of the behavior of health workers
Changing service provider behavior is an important factor enabling in service
providers to carry out the assigned tasks effectively and in line with his/ her
professional discipline. Over the past years, service providers at various levels
have made a lot of efforts to comply with professional and technical disciplines
and also to have appropriate attitude towards clients and service provision.
Some achievements have been recorded such as:
   -   Perform technical procedures in compliance with professional regulations:
       At many health centers, the IUD placement procedure has been
       performed technically correctly. Many midwives and birth-related medical
       staff fully comply with the antenatal check process. Others have become
       proficient at using the partographs.
   -   Many service providers show respect for clients, fully implementing the
       counseling process.
   -   Despite difficulties, many service providers willingly pay visits to patients'
       homes especially in areas far from health facilities
   -   In spite of numerous difficulties in their own daily life, many health officers
       have set bright examples of ethics, just as Uncle Ho has taught us:
       “Doctor must be as kind as beloved mother"
   -   These good behaviors have been instrumental in improving people's
       health, reducing diseases and the mother mortality and infant mortality
       rates as well as the number of complication in delivery during recent
       years.

2.2. Some emerging behaviors in reproductive health services provision
Besides the good achieved in providing reproductive health services and
existing regulations on the responsibilities and technical process of service
providers, recent surveys indicate that the behaviors of some services providers
remain inappropriate as compared to the public health standards and the
national standards on reproductive health service provision. There remain many
health centers and service providers that do not fully comply with the


                                                                               268
professional regulations and show lack of respect for clients. The mentioned
inappropriate behaviors are categorized as follows:
S Urgent behaviors in infection prevention
   -   Many medical staffs either do not follow or even skip the required sterili-
       zation procedures for medical instruments, for example, service providers
       often dip metal medical instruments in boiling water prior to using them
       instead of going through the regulated instrument treatment process.
   -   Many commune health centers do not follow sterilization procedures for
       medical instruments on periodical basis to be always in the position to
       provide health services to clients.
   -   Some health centers do not comply with regulations of waste
       management causing pollution to the surrounding environment.
   -   It appears that some health workers do not wash their hands before
       performing health services.
S Urgent behaviors in providing family planning services
   -   In providing family planning services, a lot of medical staff do not fully
       explain the services available and often recommend the IUD method to
       clients.
   -   Some medical staff imposes contraceptive methods on clients mainly
       because of their availability in order to achieve the target set by their
       superiors regardless of whether or not the recommended methods are
       compliant with the correct regulations.
   -   At many health centers, family planning services are performed in non-
       discreet environments with doors wide open or windows without blinds.
S Urgent behaviors in providing antenatal and postpartum services
Antenatal care:
Many medical staffs conduct the antenatal check arbitrarily, not in conformity
with the 9 steps required. Others skip the whole body checks including height
and weight measuring, pulse and blood pressure check, and urine test, etc.
Medical staffs do not counsel or discuss with pregnant women regarding their
status being either normal or abnormal after the antenatal check. Some of them


269
even exaggerate the status of pregnant women to avoid encountering problems
in the future.
Health officers forget to give advice to clients and their accompanying family
members on how to monitor dangerous health symptoms so that they can
acquire medical treatment in time.
Many medical staff do not respect the confidentiality of the information pregnant
women and disclose the information without clients' consent.
It has also been noted that some medical staff are disorganized in keeping
records of antenatal check, for instance, antenatal checks on one pregnant
woman are recorded on different books.
Postpartum care:
Medical staff skip the whole body checks (pulse, blood pressure, temperature,
height, weight, etc.), forget to inquire about the health history of pregnant women
and only focus on the obstetric examination.
It has also been found that many medical staffs do not record the pantograph
after the examination.
In their examinations, some staff do not explain to pregnant women, instead they
even yell at them causing more stress and anxiety.
When vein injections are required, medical staffs do not inform pregnant women
and their family members of the names of the medicines being injected and pos-
sible side effects.
It has also been noted that some staffs show a difficult, excessively serious and
gruesome attitude towards pregnant women and their family members.
Staffs do not counsel family members of pregnant women on a regular basis and
tend to keep their distance.
Newborn care:
Medical staffs do not perform examination on the whole body of newborns, thus
fail to diagnose possible birth defects. Furthermore, they do not advise mothers
how to take care of their newborn babies and now to breast-feed.




                                                                            270
Many staffs do not counsel mothers and their family members on unusual
symptoms, which may be exhibited by newborn babies.
     Urgent behaviors in the provision of examination and treatment
services of reproductive track infections and sexually transmitted
diseases inclusive of HIV/AIDS
    -   Some medical staff show contempt to patients/ clients and even
        discriminate against those suffering from sexually transmitted disease and
        HIV/AIDS.
    -   Concerning sexually transmitted disease, many medical staff counsel
        against examination of one's spouse or sex partner.
    -   Some medical staffs do not fully perform the whole counseling service,
        ask subject less questions.
    -   Some health centers conduct HIV tests without consulting clients or
        provide counseling to encourage them to take the test voluntarily.
    -   Some medical staffs do not keep confidential the test results, especially
        HIV tests, leading to discrimination in terms of treatment.
    -   Other staff display a distinct discriminatory attitude towards HIV/AIDS
        patients.
S       Urgent behaviors in abortion services.
    -   Some medical staff carry out the examination briskly and do not follow the
        correct procedures.
    -   Medical staff do not keep confidentiality of clients, especially adolescents
    -   Some staff are often angry, yell at clients or treat them as if they were
        guilty of some crime.
    -   Some staff keep asking about the partner of the clients even when it
        becomes clear that they do not want to touch on the subject.
    -   Many staff do not counsel clients on the consequences of abortion and fail
        to introduce the contraceptive methods to avoid unwanted pregnancy
        both before and after performing the abortion service.



271
S Urgent behaviors in providing reproductive health services to
adolescents
  -   Medical staff simply do not pay attention to counseling adolescents on
      reproductive health.
  -   Some staff show a distinct discriminatory attitude to adolescents when
      they come to health centers to acquire reproductive health services,
      especially abortion service.
  -   Generally, medical staff do not consider it important to educate and
      provide reproductive health services to adolescents.
S Other emerging behaviors
  -   Some staffs do not wear the white uniform while at work
  -   Some staffs are not punctual and leave work while they are on duty.
  -   Some staffs show no commitment to their jobs and are always dying to go
      home to their private clinics.
  -   Many medical staffs consider providing medical treatment to others just
      like granting a favor.
  -   Staffs give prescriptions to patients arbitrarily and lure them to purchase
      medicines at the pharmacies that they have connections with to get kick-
      back or prescribe medicines available at the health center.
  -   Medical staffs do not have the habit of reading in order to improve their
      knowledge and professional skills, as a result they become heavily reliant
      on training courses.
  -   Some health officers are unwilling to share experiences or to help their
      colleagues.
  -   Generally, the handwriting of medical staffs in patients books is very
      difficult to read.
  -   In reality, the manager and the service providers often blame external
      conditions. Even at the health facilities where there are adequate working
      conditions, sufficient staffs with professional skills, compliance with
      professional regulations is still incomplete or difficult to achieve.




                                                                          272
3. The causes of the behaviors incompatible with the nation-
al standards

3.1. Subjective causes
S Habitual practices
In providing reproductive health services, the service providers usually trust their
own experience and tend to let work be guided by their habits many of which do
not meet the standards. They do not yet recognize the need to change their
behaviors and have not proactively worked to improre ther skills.
S Unaware of the consequences related to the health of clients
Regardless of the regulations of the medical profession, many service providers
are unaware of the consequences related to the health of clients and their
family members and the possibility of facing legal charges as a result of their
incorrect behaviors and habits.
S Disrespectful of the rights of clients
Equating medical services with distributing benefits is a mentality popular among
many service providers. Hence, they do not really care about the service
quality or are only interested in pursuing their own economic benefits and
neglect the need of clients to have access to quality services.
At some places, service providers do not pay attention to the services of the
health facilities where they are working; instead they pursue economic benefits
by investing time and working in private clinics.
S Lack of self-study to improve professional expertise
Many service providers do not proactively learn new knowledge, technology or
new treatment methods and standards in order to improve their professional
expertise.
For that reason, the behavioral change amongst medical staff depends to a large
extent on themselves, their service attitude, responsibilities and ethics.




 273
3.2 Objective causes
S Management
Changing the behavior of the service providers in reproductive health services
to meet the national standards depends significantly on the support of the man-
ager.
At many health facilities, the manager does not yet pay attention to creating a
favorable environment for the service provider to help change his behavior to
meet the national standards including providing partograph, antenatal check
record, organizing the counseling desk for clients, etc.
At many health facilities, work allocation done by the management is unclear
and unsuitable for the expertise of the service providers. Especially, service
providers at local level are responsible for implementing many health programs
and hence, are not in a good position to specialize in one area, which explains
why they do not pay much attention to acquiring new knowledge to improve their
professional expertise.
The support and encouragement for those individuals and teams that are well
behaved in providing services and show respect towards their clients have not
been provided on a timely basis. Similary, the behaviors which do not conform
to the code of conduct of the medical profession have not received criticism on
timely basis.
The manager does not pay attention to feedback from clients on the behaviors
of the service providers and the quality of the services. Neither is support
provided to help service providers to change.
S Lack of training and re-training
The lack of training for many years, outdated on current professional knowledge
and lack of resources for practice cause many reproductive health service
providers to fall short of technical procedures. Medical staff are unaware of
numerous technical procedures, new treatment methods and regulations that
have been introduced.




                                                                        274
S Lack of information
Access to new information on new methods and technical regulations are still
limited. There is also a shortage of documents related to medical regulations.
S Lack of investment in the local health system
At some health centers, the minimum conditions to enable the service providers
to practice according to the national standards are not ensured.
At many health centers, the equipment is incompatible with existing
infrastructural conditions such as facilities, electricity, and water supply, etc. The
lack of enabling conditions to organize the services properly causes special
medical equipment to be wasted and difficult to put into use.
S The life of medical professionals remains difficult
General speaking, the salary of most medical professionals remains low and
inadequate to cover the basis expenses of themselves and their families. It is
precisely for this reason that many medical professionals pay attention only to
quantity instead of quality.

4. The consequences of the failure to provide reproductive
health services in accordance with the national standards.

4.1. Health-related consequences
If the service provider does not perform services in accordance with the
national standards, he/she may bring about serious consequences to clients,
their families and the community.
The least serious consequence is the wasted time and money of clients due to
multiple travel and long waiting time.
A mistaken diagnosis or an incorrect treatment scheme may cause patient's
illness to prolong, become more serious and complications to develop. Worse,
should a patient's illness not be monitored closely during emergencies, his/ her
life may be threatened. It should be noted that the majority of obstetric accidents
could be avoided should the service provider use appropriate antenatal,
intrapartum and postpartum monitoring and provide proper treatment.




 275
When clients are not counseled fully, the rate of dropouts, non-compliances with
the treatment plan and disease re-occurrences increase accordingly. For
instance, when clients are not properly counseled on contraceptive methods, the
chance of unwanted pregnancies increase, leading to multiple abortions.
The above behaviors may lead to severe consequences to the individual patient,
his/her family and the society.

4.2. Consequences related to reputation of medical facilities and
service providers
If behaviors are not changed, especially when they lead to mistakes causing
dangerous complications to clients or the attitude of the service provider is
inappropriate, clients will lose faith in the facility and the service provider,
consequently they may not come to the facility the next time they need medical
services.
This will spread rumors within the community causing serious negative affects
on the reputation of the medical center.

4.3. Possible legal consequences
If the complications causing life threatening consequences to the client are con-
sidered to be due to the incompetence of the service providers and incompati-
bility with the national standards or the irresponsibility of the service providers,
he/ she may be prosecuted.

5. Main reasons for the must to change the behaviors of
reproductive health service provider
Changing the behaviors of reproductive health service providers must be based
on the following basis:
      + The State and Health Ministry regulations on health care and repro
        ductive health.
      + The law on the protection of people's health states that health care and
        provision of reproductive health services are the functions and
        responsibilities of the health sector.
      + The policy on the promotion of poor people' s access to health care



                                                                             276
         services has step by step achieved more equality in terms of poor
         people' s access to health care services.
      + Changing the behaviors in providing quality health services at
        grass-root level and in accordance with the National Standards is
        essentially aimed at enabling poor people to enjoy equal access to
        public health services. This is entirely in line with the Government's
        guidelines on providing health care to poor people.
      + The national strategy for reproductive health during the period 2001-
         2010. This strategy also lists out the priority areas in reproductive
         health care in our country today and outlines the measures to achieve
         the set objectives.
      + The code of ethics of the medical profession has been promulgated by
         the Ministry of Health. This code of ethics specifies the behaviors in the
         relationship between doctors and patients and between service
         providers and clients.
      + Decision 385 of the Ministry of Health stipulates the technical functions
         of each level of the health care system related to reproductive health
         services. This decision shows the responsibilities of each medical
         facility through which the service provider can determine the
         necessary behaviors to achieve the targets set for his/ her work level.
      + The national standards on reproductive health services: The Ministry of
         Health has issued the guidelines for the implementation of the
         national standards on reproductive health services. The national
         standards clearly describe the technical procedures and the steps
         involved in the reproductive health counseling process. Based upon
         the national standards, medical professionals have to maintain and
         develop the reproductive health services that health centers have
         provides in accordance with the national standards as well as
         determine those inappropriate behaviors that need to be charged.
      + Other regulations of the Ministry of Health such as those for the
        hospital system, instructions on how to handle special health cases
        and policy documents regarding organization and administration, etc.,
        provide a sound basis for determining correct and necessary
        behaviors for the service providers.


277
      + The State has invested in upgrading the infrastructure, equipment and
         further training for managers and service providers to create favorable
         conditions for the provision of services.
      + The supervision of local authorities, social organizations, community
         leaders and the people has also helped improve the quality of health
         services.
      + Internal improvement is also seen within the medical system with the
         increased supervision of the upper level on the lower level regarding
         the quality of services.

6. The role and responsibilities of the service providers in
dealing with the emerging behaviors in reproductive health
services
The service provider himself is held accountable for both appropriate and
inappropriate behaviors in providing reproductive health services. Thus, whether
or not those behaviors can be changed depends on themselves. Changing the
behaviors of reproductive health service providers requires that each and every
one them recognize the behaviors that need to be changed, accept the change
and adopt a positive attitude towards changing those behaviors. They need to
train themselves and maintain their correct behaviors.
In addition, each service provider should be proactive in reminding and
supporting his/her colleagues to change their behaviors to meet the national
Standards.
The service provider is always considered an active participant in the behavioral
change process through group work organized by the manager.
At present, there are many service providers who comply with the professional
regulations of the health system and show respect towards their clients. However,
in view of the current prevalence of incorrect behaviors in health services, in order
to change his/ her behavior, the service providers has to be aware of his/ her
responsibilities for those problems and understand that changing the behaviors in
health services is a process in which each individual or group determine the
behaviors that need changing and work together to find solutions to change. The
service provider takes part in the behavior change process at his or her own health
center.


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TOOL T12
UPSU MONITORING CHECKLISTS

These checklists have been developed by UPSU to monitor the RHIYA project.
However, you may also find them useful to monitor activities in your own Health
Station and ensure that the quality of service provision is good.


                    Checklist for Material Development

               (Used by EAs, IAs, TAs and UPSU to monitor a process
                              of material development)


                           Activities                          Yes   No   Comments
     Identify intervention group and appropriate consult-
1
     ants (external/internal)

2    Identify needs of intervention groups

3    Review relevant existing materials

     Identify prioritized issues and messages/contents for
4
     the materials relevant to intervention target group
     Pre-test and post-test with intervention group (one or
5
     more times)
     Piloting design (drafting process of material/produce
6
     sample before mass production)

7    Revision and finalization of materials

8    Printing and distribution of materials

9    Re-produce after using (if budget available)

     Participation of intervention group in all steps of the
10
     process



281
                                Peer Selection Criteria

             Selection criteria               Yes          No   Comments

     Is person of similar age/background to
1
     youth target population?
     Is person voluntary and willing to do
2
     the work

3    Is person committed to RH

4    Is person respected by peers?

5    Is person trustworthy?

6    Does person have time to participate?

     Is person able to interact with both
7
     peers and adults?
     Is person understandable when
8
     speaking in public?
     Does person speak the language of
9
     youth target population?

10   Is person able to hold confidences?

     Is person able to hold public's
11
     interests?

12   Is person caring?

* Person will be selected if they meet at least from 1-8




                                                                     282
                 Checklist of Peer Education Activities

                             Activities                       Yes   No   Comments

1     Introduction
      Does person introduce herself (himself) and the
1.1
      purpose of peer education?
2     Environment

2.1   Is the location suitable (convenient, privacy)?

2.2   Is time suitable?

3     Information provided

3.1   Language used is understandable?

3.2   Information provided is sufficient and accurate?
      Does the peer educator introduce appropriate referral
3.3
      services ?
4     Attitude

4.1   Is person friendly/open to the peer(s)?

4.2   Is person empathy to the peer(s)?

4.3   Is person able to hold confidentiality?

5     Skills demonstrated

5.1   Is person confident?
      Does person provide guidance and demonstration if
5.2
      possible?
6     Material provided

6.1   Is the material appropriate for targets and subjects?
      Does person provide safe/necessary supplies to
6.2
      peer(s)




283
                     POST TRAINING ASSESSMENT

Question 1: Please let us know something about yourself?
Gender:              c Male                    c Female
Year of birth:       19cc
Question 2: In which health facilities are you currently working? (Please mark
X on only one appropriate square)
1-c Provincial/City Health Service    4-c District health center
2-c Provincial/City hospital          5-c Inter-commune poli-clinic
3-c Provincial/City MCH center        6-c Commune health center
                                      7-c Other (Specify:............................)
Question 3: Since the year of 2004, what training course have you attended?
1-c Yes ' On which month cc year 200c
2-c No
Question 4: Were the contents of the training course suitable to your work?
(Please mark X on only one appropriate square)
1-c Very suitable;                2-c Suitable;                3-c Normal;
4-c Unsuitable;                   5-c Very unsuitable
Question 5: At present, which material(s) provided during the course are you
still keeping? (You can mark X on one or more appropriate squares)
1-c The course agenda                 3-c Other materials (Specify:.................)
2-c Material(s) provided during       4-c Do not keep any material
    the course                        5-c I did not receive any material
Question 6: Was the material provided during the course suitable to your work?
(Please mark X on only one appropriate square)
1-c Very suitable;                2-c Suitable;                3-c Normal;
4-c Unsuitable;                   5-c Very unsuitable



                                                                                  284
Question 7: Since the training course, have you exchanged what you have
learned from it with other people? (Please mark X on only one appropriate
square)
1-0 Yes                 2-0 No
If yes, with whom have you exchanged? (You can mark X on one or more
appropriate squares)
1-0 Managers of the facility                               2-0 Colleagues
3-0 Others (Specify…………………………….)
If no, please indicate why you have not yet exchanged with others? (You
can mark X on one or more appropriate squares)
1-0 I do not have time
2-0 I think it is not necessary
3-0 I have not yet have chance to meet them
4-0 I feel that I did not firmly capture what was taught in the course
5-0 Others (Specify:.................................)
Question 8: Since the course, what knowledge and skills have you applied
most?
Specify
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................




285
Question 9: In addition, please provide some more opinions on the
training course you attended
On training materials:
...............................................................
...............................................................
...............................................................
...............................................................
 ..............................................................
...............................................................


On teaching methods:
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................




                                                            286
      CHECKLISTS FOR "YOUTH-FRIENDLY" SERVICES

Service providers (counselor) and staff                                     Yes    No

Service providers are trained on ARH service provision

Staff are friendly and responsive to youth clients

Staff are respectful to and ensures privacy of youth clients

Staff ensures confidentiality of youth clients
Staff are understanding of and knowledgeable about youth corner and
needs
Service providers spend adequate time with youth clients

Service providers use language that is understandable to youth

Service providers are nonjudmental and approachable

Information provided during counseling is clear and helpful
Information on need for and timing of follow-up visit(s) is provided and
clear
Service providers offer choices, including abstinence, contraception and
withdrawal
Youth friendly mobile activities

Policies and procedures                                                    Yes    No

Youth drop-ins are welcome and accommodated

Services are offered to both male and female youth clients
Facility provides informational and/or audiovisual materials on ARH
services and concerns youth clients
Facility provides contraceptive methods that are most popular among
youth clients
Youth corners are introduced in the community




287
Policies and procedures                                            Yes   No

Facility offers wide range of services

Services are linked to other youth service and program networks



Cost of ARH services is affordable

Environment and facilities                                         Yes   No
ARH services are provided at convenient (and separate) hours
for youth clients
Decor and surrounding are inviting to youth clients
(i.e. non-medical)
Counseling rooms ensure privacy for youth clients

Examination rooms ensure privacy or youth clients

Separate space is used for youth clients

Facilities are conveniently located for youth

Education materials are displayed and available to youth clients

Youth clients report overall satisfactions with ARH services


General comments
...............................................................
...............................................................
...............................................................
...............................................................
Recommendations
...............................................................
...............................................................
...............................................................
...............................................................


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