Pathfinder International Research Articles

Electronic Procurement and Performance of Non-Governmental Organizations in Kenya. Empirical Evidence from Pathfinder International, Kenya

This study explored how electronic procurement and performance of organizations is related. Electronic Procurement is very vital in achievement of organizations objectives. Electronic procurement involves more than online transactions. E-procurement delivers a very manageable and orderly method to provide a clear path in communicating with vendors during transactions. Despite their crucial role in improving people’s lives and alleviating poverty, most non-governmental organizations have been recording poor performance. The general objective of the study was to establish the relationship of electronic procurement and performance of organizations in non-governmental organizations in Kenya. The specific objectives for the study were to establish how e-sourcing, e-ordering, e-invoicing and e-payment relates to performance of an organization. This study was guided by four theories namely, Disruptive Innovation Theory, Diffusion of Innovation Theory, Technology Acceptance Model Theory and Theory of Planned Behavior. The study adopted descriptive research design. The target population for the study was 135 participants. Census survey was employed whereby the entire population of 135 procurement staff were required to participate. Both open ended and close ended questionnaires were used to collect primary data. The study collected data through drop and pick method. Validity of the questionnaire were tested using content validity whereas reliability was tested using Cronbach’s Alpha. Quantitative data was analyzed using both descriptive and inferential statistics using SPSS Version 24 while qualitative data was analyzed using content analysis. Descriptive statistics was presented in frequency distributions tables and percentages. Inferential statistics such as correlation and regression were applied to assess the relationship between the independent and dependent variables. All ethical considerations were observed especially confidentiality, anonymity, consent and avoidance of biasness. The study revealed that there was a strong significant correlation between e-sourcing and performance, a medium significant correlation between e-ordering and performance, a strong significant correlation between e-invoicing and performance and a strong significant correlation between e-payment and performance. The study concluded that electronic procurement and performance of organizations was indeed related and it was recommended that all procurement systems be made mandatory and that the procurement teams be well trained on all systems used to ensure efficiency is achieved through use of e-procurement. The researcher suggested that further studies be conducted.

Improving wellbeing by integrating health and conservation: findings from cross-sectional surveys

BackgroundSince 2011, Pathfinder International, The Nature Conservancy, and local government authorities in western Tanzania have partnered on the Tuungane project to support communities facing multiple challenges not solved by a single sector, including poor access to health services such as maternal health and family planning, as well as a declining natural resource base. Tuungane uses a population, health, and environment approach that hypothesises that by integrating health and conservation activities, it can achieve greater overall benefits to both people and nature than single-sector projects. We investigated whether integrating health and conservation services and information leads to greater understanding of the links between people's health and the environment, resulting in more behaviours that improve health and increase sustainable natural resource management. MethodsUsing data from cross-sectional surveys done at the household level in western Tanzania, we assessed health and natural resource knowledge, attitudes, and practices, comparing baseline data collected in July, 2011, from 487 households (of 7700 households) with midterm data collected 5 years later in August, 2016, from 1010 households (of 9568 households). Data from a smaller assessment done in December, 2020, will be available later. FindingsBetween the baseline survey and the midterm survey, we found improvements in indicators for health and conservation knowledge, attitudes, and practices, and overall wellbeing. For example, most common illnesses, such as typhoid, decreased. Familiarity with family planning increased from 45% to 59%. Women who wished they could have postponed a pregnancy decreased from 43% to 34%. Fishermen reported an increase from 8% to 33% in fish catch in the main target species compared with 5 years ago. In 2016, a majority of people agreed that the village forest should be protected (88%). The ability of people to meet daily needs increased from 6% to 20%. People used fewer loans to buy food and had more assets. InterpretationThe results from the surveys suggest that not only the health and natural resource use of local people improved from 2011 to 2016, but also their overall wellbeing. FundingNone.

Influence of nursing interventions in improving midwives' knowledge of misoprostol use in the management of postpartum haemorrhage at selected hospitals in Ondo State, Nigeria.

Introduction:despite large investments in maternal health services in the world, postpartum hemorrhage (PPH) remains a major cause of maternal mortality. Misoprostol is the most available, accessible, and affordable uterotonic agent in the management of the third stage of labor and has been found to be effective in PPH prevention in low-income countries. This study, therefore, assessed the influence of nursing interventions improving midwives´ awareness of misoprostol use in the management of PPH at selected health facilities.Methods:we conducted a quasi-experimental study in two secondary health institutions in Ondo State. A total of 68 midwives, who consented to participate, were randomly distributed into experimental and control groups respectively. A questionnaire was administered for obtaining information about participants´ knowledge and use of misoprostol in the management of PPH. Midwives in the intervention group were trained using the adapted Pathfinder International Teaching Package on the use of misoprostol in the management of PPH. Data were analyzed using descriptive and inferential statistics.Results:in the pre-intervention phase, the mean knowledge score of the control group was 7.55 ± 2.57 while that of the experimental group was 8.89 ± 2.57. There was a significant increase in the number of participants knowing the correct dose of misoprostol for the management of PPH after intervention (27.0% vs 81.1% p=0.01). After intervention, there was a significant increase (p=0.01) in knowledge of misoprostol use in the intervention group compared to the control group (14.73 ± 2.57 vs 8.89 ± 2.57).Conclusion:misoprostol educational intervention was effective in improving knowledge and use of misoprostol. Hence, continuing educational units in hospitals should include periodic training of midwives on the use of misoprostol in PPH prevention.

Reducing Barriers to Postabortion Contraception: The Role of Expanding Coverage of Postabortion Care in Dar es Salaam, Tanzania.

In Tanzania, limited access to postabortion care (PAC) contributes to high rates of maternal mortality. To address the issue, Pathfinder International and the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) introduced and expanded coverage of PAC in 64 public health facilities in Dar es Salaam, Tanzania. During a 30-month period, we implemented a multifaceted approach to introduce and expand PAC, including clinical training and mentorship for health care providers; service reorganization, equipment provision, and an expanded method mix offering; standardization of PAC reporting tools; and community engagement and referral. We assessed outcomes using PAC service statistics from 64 public health facilities in 4 districts of Dar es Salaam and health care provider mentorship data from 385 observed PAC visits. From January 2016 to June 2018, voluntary postabortion contraceptive uptake increased steadily. A total of 6,636 PAC clients, including 2,731 young people (ages 10-24), adopted a method post-procedure. Average semesterly client volume per facility increased from 27 to 52.4 manual vacuum aspiration clients and 17.6 to 43.9 postabortion contraceptors between the first and last periods. Overall postabortion contraceptive uptake was 80.6% (6,636/8,230), with a method mix of 58.3% implant, 18.9% intrauterine device, 13.7% pills, 8.6% injectables, and 0.5% permanent methods. Adults and young people had comparable method mix. Mentored providers showed improvements in service quality indicators. During the last period, 92% counseled the client on contraception, 93% considered the client's sexual and reproductive health intentions, 94% provided correct method information and supply, and 96% documented services on the client's family planning card. Different provider types (mid- and senior-level) performed comparably. Expanding PAC coverage to primary- and secondary-level facilities led to high uptake of voluntary contraception among postabortion clients. Key interventions included PAC clinical training and mentorship; service reorganization, equipment provision, and an expanded method mix offering; use of standardized PAC registers; and community engagement for awareness building and linkage to PAC.

Addressing Family Planning Access Barriers Using an Integrated Population Health Environment Approach in Rural Uganda.

Recent studies recommend FP initiatives in rural sub-Saharan Africa operate in more context-specific ways to reduce inequities. In 2011 such a project, HoPE-LVB, was implemented by Pathfinder International and local partners among Ugandan Lake Victoria fishing communities using a Population, Health and Environment approach. Among other objectives, the project aimed to increase support for FP and women's involvement in decision-making by linking FP benefits to community needs including income generation from nature-based livelihoods. Improved FP access was measured by the project using qualitative methods and the project's indicator database in terms of five barriers: service quality, community knowledge, physical access, finances, and social acceptability. Through coordinated interventions representing multiple sectors, the project helped communities move more towards a -tipping point‖ whereby FP use has now become more an acceptable and accepted social norm. Central to this has been improving service quality and physical access as well as facilitating women's involvement in income-generation, thereby increasing their agency and contribution to decision-making including pregnancy timing.

An evaluation of a family planning mobile job aid for community health workers in Tanzania

ObjectivesThe global rapid growth in mobile technology provides unique opportunities to support community health workers (CHWs) in providing family planning (FP) services. FHI 360, Pathfinder International and D-tree International developed an evidence-based mobile job aid to support CHW counseling, screening, service provision and referrals, with mobile forms for client and service data, and text-message reporting and reminders. The purpose of this study is to evaluate the acceptability and potential benefits to service quality from the perspective of CHWs and their clients. Study designThe mobile job aid was piloted in Dar es Salaam, Tanzania. Data collection tools included a demographic survey of all 25 CHWs trained to use the mobile job aid, in-depth interviews with 20 of the CHWs after 3 months and a survey of 176 clients who received FP services from a CHW using the mobile job aid after 6 months. ResultsBoth CHWs and their clients reported that the mobile job aid was a highly acceptable FP support tool. CHWs perceived benefits to service quality, including timelier and more convenient care; better quality of information; increased method choice; and improved privacy, confidentiality and trust with clients. Most clients discussed multiple FP methods with CHWs; only 1 in 10 clients reported discussion of all 9 methods. ConclusionsThis research suggests that mobile phones can be effective tools to support CHWs with FP counseling, screening and referrals, data collection and reporting, and communication. Challenges remain to support informed contraceptive choice. Future research should focus on implementation, including scale-up and sustainability. ImplicationsMobile job aids can uniquely enhance FP service provision at the community level through adherence to standard protocols, real-time feedback and technical assistance, and provision of confidential care. This study can inform future efforts to support and expand the role of CHWs in increasing FP access and informed contraceptive choice.

Expanding Access to the Intrauterine Device in Public Health Facilities in Ethiopia: A Mixed-Methods Study.

In Ethiopia, modern contraceptive prevalence among currently married women nearly tripled over the last decade, but the method mix remains skewed toward short-acting methods. Since 2011, the Integrated Family Health Program (IFHP+), jointly implemented by Pathfinder International and John Snow Inc., has supported the Federal Ministry of Health to introduce intrauterine devices (IUDs) in more than 800 health centers across 4 regions to improve access to a wider range of methods. Between March and August 2014, Pathfinder conducted a mixed-methods study in 40 purposively selected health centers to assess shifts in the contraceptive method mix following introduction of IUDs using data from family planning registers; determine the characteristics of IUD users through a cross-sectional survey of 2,943 family planning clients who accepted the IUD; explore reasons for method discontinuation among 165 clients seeking IUD removal services; and identify facilitators and barriers to IUD use through focus group discussions (N = 115 clients) and key informant interviews (N = 36 providers, facility heads, and health office heads). Introduction of IUDs into the 40 health centers participating in the study was correlated with a statistically significant increase in the contribution of all long-acting reversible contraceptives (LARCs)-both IUDs and implants-to the method mix, from 6.9% in 2011 to 20.5% in 2014 (P<.001). Our study found that latent demand for the IUD was more prevalent than anticipated and that the method was acceptable to a broad cross-section of women. Of the 2,943 women who sought IUDs during the 6-month study period, 18.0% were new contraceptive users (i.e., those using a contraceptive method for the first time ever), 44.7% reported no educational attainment, 62.5% were from rural areas, and 59.3% were younger than 30 years old, with almost 3 in 10 (27.7%) under the age of 25. The most commonly cited reason for seeking IUD removal services was a desire to become pregnant (43% of women). Qualitative data indicated that while acceptability of the method is growing, limited community awareness, myths and misconceptions about the IUD, and infrastructure deficits at health centers must be addressed to further expand access to a broad range of contraceptive methods.

Prevalence and Risk Factors of Primary Postpartum Hemorrhage after Vaginal Deliveries in the Bonassama District Hospital, Cameroon

Background: Approximately 800 women die from pregnancy-related conditions daily with 99% of these maternal deaths occurring in low resource countries. Primary postpartum haemorrhage accounts for 25.7% of maternal deaths in Africa. In Cameroon, primary postpartum hemorrhage remains the leading cause of maternal death. Objective: The aim of this study was to determine the prevalence, risk factors, and the maternal and fetal outcomes of primary postpartum hemorrhage in the Bonassama District Hospital, Douala, Cameroon. Methods: This study was a cross-sectional study. Of the 556 women interviewed regarding their willingness to participate in the study, 550 consented. Quantification of blood loss was done over the 24 hours using a 700cc measuring cylinder, an electronic weighing balance and the Pathfinder International wall chart for visual estimation of blood loss. The well-being of the neonates was evaluated by a pediatrician. Data was collected using a structured questionnaire and analyzed using EPI-INFOTM version 7.1.4.0. A P-value <0.05 used to determine association between variables was considered statistically significant. Results: The prevalence of primary postpartum hemorrhage was 23.6%. The risk factors of primary postpartum hemorrhage were: previous postpartum hemorrhage (aO.R=6.50; 95% C.I=4.60-9.20), multiparity (aO.R=7.02; 95% C.I=5.27-8.02), prolonged labor (aO.R= 1.1; 95% C.I=1.01-6.61) and macrosomia (aO.R=8.18; 95% C.I= 5.53-8.51). The main causes of PPH were uterine atony and obstetrical lacerations (P-value<0.01). Two (1.5%) maternal and 2 (0.4%) perinatal deaths were recorded. Conclusion: The prevalence of postpartum hemorrhage was high. The main cause of primary post-partum hemorrhage was uterine atony. Primary PPH was associated with uterine hypotonia, placenta retention and genital lacerations. The maternal and perinatal mortality were high. These findings highlight the pressing need for good quality emergency obstetric care and the availability of more accurate techniques of postpartum blood loss measurement. Secondly, hospitals need blood banks to manage patients with severe hemorrhage.

Assessing the Influence of a 360-degree Marketing Communications Campaign With 360-degree Feedback

Marketers realize the importance of 360-degree communication (reaching audience members in consistent but multiple ways) to improve brand salience, increase the effectiveness of behavior change strategies, and achieve organizational objectives. While several social marketing organizations have embraced the 360-degree approach, their effectiveness has not been adequately captured by research approaches such as 360-degree feedback. Our study addresses this gap by reporting the influence of Project Raksha (“protection” in Hindi), launched in November 2007 in the rural areas of four Indian states by Pathfinder International in support of government of India’s efforts to reduce maternal mortality and morbidity by promoting institutionalized delivery. The project designed specific interventions at the household, community, local government, and clinical levels to address four types of delays in response to obstetric complications. Westat India carried out postintervention-only evaluation by conducting self-report surveys and interviews with women and their influencers, community health workers, health service providers, and local government members. Findings revealed that most interventions proved effective in addressing the four types of delay that were key contributors to maternal mortality in the project areas. The 360-degree feedback mechanism allowed the social marketing organization to obtain a comprehensive grasp of its persuasion efforts. Achievements and failures were better captured and lessons better learned for future behavior change attempts.

Some thoughts on disrespect and abuse in childbirth in response to FIGO’s Mother–Baby Friendly Birthing Facilities Initiative

Women everywhere deserve respectful, affordable, quality maternal care. The guidelines for mother–baby friendly birthing facilities recently developed by the International Federation of Gynecology and Obstetrics (FIGO) Safe Motherhood and Newborn Health Committee [1], which propose certification of health facilities that meet 10 essential criteria, are an important contribution to that end. Like FIGO, Pathfinder International has observed that facility delivery/skilled birth attendance does not guarantee qualityofcareorareductioninmaternalmorbidityandmortality. Quality of care can still be absent in facilities, thus countering the usual health benefits of skilled birth attendance over home birth. Pathfinder salutes FIGO’ sM other–Baby Friendly Birthing Facilities Initiative as an important step toward eliminating disrespectful treatment within maternity care, as well as improving quality of care during pregnancy, birth, and the postpartum period more generally, which is so sorely needed given the greater-than-expected and unacceptable remaining burden of maternal and newborn mortality in the post-Millennium Development Goals context. The guidelines also prompted renewed discussion among Pathfinder staff about respectful care, specifically with regard to government accountability, community engagement, and a rights-based approach. The guidelines are both appropriate and comprehensive. But what will it take for them to be embraced and implemented universally? It will first require, of course, a combination of persuasion and improved conditions—for the mothers and babies, but also for the providers and staff charged with caring for and safeguarding them. Several measures will be necessary—e.g. provider education and staff training that infuses a rights-based approach to maternity care; high-quality mentoring that continually promotes the same; integrated supervision whereby providers are trained and motivated to ensure continuous quality improvement themselves through collective responsibility and true provider-client partnership; and communities that are capacitated to continually intervene around quality and rights, particularly respectful care (e.g. community-facility co-management committees). FIGO’s guidance spells out enabling measures, but how can we guarantee that the necessary changes are made and sustained within countries? Currently, there are no consequencesfor noncompliance to ensure accountability by governments—either national or local—that are ultimately responsible for providing the necessary resources and other support to make the needed changes by allocating more of their budgets to maternity care and health in general. FIGO’s suggested solution lies largely in the hands of the professional associations within countries and entities like the White Ribbon Alliance, International Pediatricians Association, and WHO to push governments to comply. There must be real consequences for governments who do not vigorously and successfully address this current unacceptable abuse of fundamental human rights and the resulting loss of life and health. As implementers, we must also determine how we will help health workers and health systems respond to the needs of communities and clients, which will require more than adoption of static clinical policies. Dynamic feedback mechanisms that allow individual clients to report cases of abuse or poor treatment (and positive experiences too) are an important part of identifying problems and holding providers accountable. To be effective, feedback mechanisms must be accompanied by education for clients on their rights so that they know that demeaning care is not acceptable, and by an administrative system capable of acting on the reports of bad (and good) service experiences to provide censure, recognition, or support in response to client feedback. Furthermore, broader community feedback on the quality of maternal and newborn health services should occur through co-management structures (e.g. health committees) and requires both that communities become aware of their right to respectful care and an administrative commitment by the health system to respect community preferences, including traditional birthing practices, when they do not put the mother or baby at risk. Finally, theguidelinesframedisrespectandabuse asarightsissue—a position Pathfinder agrees with wholeheartedly. Unfortunately, in debates and literature on disrespect and abuse in childbirth, the bulk of the responsibility for demanding and ensuring that these rights are fulfilled is often placed on individual women themselves. What is really needed is for communities to rally in support of women and hold the system accountable. Since so many of the causes of disrespect and abuse—such as prejudices related to gender, class, education, ethnic origin, and age—are socially rooted, it is absolutely essential that the community be fully engaged in preventing disrespect and abuse and demanding respectful care. A rights-based approach to respectful care has to be about meaningful community mobilization and social change. Pathfinder would like to reiterate its appreciation for FIGO’ sc ontribution to this critical issue and looks forward to continued discussion and collaboration on ways forward.

Comorbidities and lack of blood transfusion may negatively affect maternal outcomes of women with obstetric hemorrhage treated with NASG.

The Non-Pneumatic Anti-Shock Garment (NASG) is a first-aid device to reduce mortality from severe obstetric hemorrhage, the leading cause of maternal mortality globally. We sought to evaluate patient characteristics associated with mortality among a cohort of women treated with the NASG in Nigeria. Data on 1,149 women were collected from 50 facilities participating in the Pathfinder International Continuum of Care: Addressing Postpartum Hemorrhage project in Nigeria from 2007–2012. Characteristics were compared using the appropriate distributional tests, and we estimated multivariable logistic regression models to control for treatment received. There were 201 deaths (17.5%). Women who died were significantly more likely to have any co-morbidity (AOR 3.63, 95% CI: 2.41–5.48), ruptured uterus (AOR 2.79, 95% CI: 1.48–5.28), macerated stillbirth (AOR 2.96, 95% CI 1.60–5.48) and to have had 6 or more previous births, (AOR 1.53, 95% CI 1.11–2.12), after adjusting for treatment received. These results suggest certain maternal conditions, particularly the presence of another life-threatening co-morbidity or macerated stillbirth, conferred a higher risk of mortality from PPH. This underscores the need for multi-system assessment and a comprehensive approach to the treatment of women with pregnancy complications.

“Well Beyond” Permissible: How Severing the Leadership Act's Policy Requirement Affirms Our Commitment to First Amendment Values

Imagine an American physician working with Pathfinder International's Mukta Project to combat the prevalence and spread of Sexually Transmitted Infections (STIs) and HIV in Maharashtra, India. The physician provides HIV/AIDS prevention and treatment services at a health clinic as well as coordinates educational programs about STIs for local residents. A young woman approaches the physician's clinic. The woman tentatively informs the physician that she has recently entered the local sex trade and may have contracted HIV. The physician wishes she could speak freely about the realities of prostitution in India. The physician wishes she could empower her new patient to adopt behaviors that would reduce her vulnerability to HIV/AIDS. In spite of any professional or personal opinions the physician might hold on the subject of prostitution, however, she must choose her words carefully. In order to receive program funding from the United States government, Pathfinder International has reluctantly endorsed a strict anti-prostitution policy, and the physician is prohibited from engaging in any activities that are inconsistent with that policy.

The Standard Days Method®: an addition to the arsenal of family planning method choice in Ethiopia

Background and methodologyThe Standard Days Method® (SDM) is a fertility awareness-based method of family planning that helps users to identify the fertile days of the reproductive cycle (Days 8–19). To...

Determinants of young people’s sexual behaviour concerning HIV and AIDS in the practice population of a university health centre in Lagos, Nigeria

BackgroundAIDS has been a scourge of universities in Africa for a long time. This study was launched at ground-level to fight the dreaded disease by concentrating on young people and to counter the ignorance that surrounds the disease even in numerous African universities. This study of the student community was carried out by family doctors at the University Health Department to determine the prevalence of the determinants of young people's reproductive health behaviour.ObjectivesThis study is aimed at determining young people's sexual behaviour concerning HIV and AIDS in the practice population of a university in Lagos, Nigeria.MethodSelf-administered 63-item questionnaires were distributed amongst 2000 randomly selected students of the University of Lagos, Lagos, Nigeria in September 2005, using a semi-structured form of the Comprehensive Youth Survey questionnaire, developed by FOCUS (led by Pathfinder International, Futures Group International and Tulane University School of Public Health).ResultsThe age distribution of the respondents was designated in the age groups of 15–19 years (15.8%), 20–24 years (60.1%), 25–29 years (19.6%), 30–34 years (2.8%). Demographics of note were that 88.3% of the fathers of the respondents were literate and that 94.5% of the fathers earned more than one US $ per day. The majority of the respondents (99.1%) indicated adherence to one religious faith or the other and 58.8% believed definitely that religion shaped their attitudes about sexual intercourse and sexuality. More than half (64.0%) denied having had sex at all in the three months preceding the study. Furthermore, 68.8% affirmed that it was common amongst friends of their age to use condoms. A significant number of respondents (65.5%) thought that their friends have drunken alcohol. Almost all of the respondents (94.3%) had a positive perception of their family.ConclusionThe Programming for HIV and AIDS Reduction on university campuses in Africa should be conducted comprehensively rather than monothematically and should, take into consideration the five thematic areas of behaviour change communication amongst young people concerning their reproductive health.

Women’s health—what’s new worldwide

Women’s health—what’s new worldwide

Sexual behavior, fertility desires and unmet need for family planning among home-based care clients and caregivers in Kenya

As antiretroviral treatment becomes more available, community home-based care (CHBC) clients may begin to resume normal daily activities including the resumption of sexual relationships. This study examines sexual behavior, contraceptive use, unmet need for family planning and attitudes toward pregnancy in the context of HIV among CHBC participants (clients and caregivers), many of whom are HIV-positive or at risk for HIV, of the COPHIA project in Kenya. The COPHIA project was implemented by Pathfinder International with support from USAID/Kenya. We interviewed 171 CHBC clients and 183 CHBC caregivers and conducted four focus groups with caregivers. Data were collected from randomly selected COPHIA-affiliated CHBC programs in Western Province and in Nairobi between September and November 2004. Forty-four percent of clients and 55% of caregivers had been sexually active in the past six months. The reproductive health needs of this population are complex; a significant percentage of study participants have an unmet need for family planning and some desire more children. A small proportion of study participants were pregnant during the time of the interview. The majority of those who use contraception reported relying solely on the male condom to prevent pregnancy. While vital for HIV prevention and easily distributed by CHBC programs, the male condom is not as effective as other methods in preventing pregnancy. Community home-based care program participants need counseling related to contraception, fertility desires and pregnancy. The promotion of dual method use is crucial to this population. Besides referring participants to family planning services, CHBC programs need to consider how and if they can meet the family planning and other reproductive health needs of their participants.

The US anti-prostitution pledge: First Amendment challenges and public health priorities.

In January 2003, United States President George W. Bush announced the President's Emergency Plan for AIDS Relief (PEPFAR), the appropriation of $15 billion dollars for programs to combat the global HIV/AIDS epidemic, in his State of the Union address. Congress responded with the legislative authorization for the plan, the United States Leadership Against Global HIV/AIDS, Tuberculosis, and Malaria Act of 2003, and assigned seven primary implementing agencies, including the United States Agency for International Development (USAID) and the United States Department of Health and Human Services (HHS) [1]. Although the Act will expire in fiscal year 2008, the President has called on Congress once again to extend the plan for another five years and double the funding to $30 billion [2]. Within the detailed plan, Congress expressed concern about the social, cultural, and behavioral causes of HIV, specifically naming prostitution and sex trafficking as among the behavioral forces behind the spread of the virus. This legislation advanced a new policy goal for the US: the global eradication of prostitution [1]. Requirements for grantees were based on this explicit link between HIV prevention and the eradication of prostitution. In order to receive AIDS funds from the US, all grantees must have (1) a policy explicitly opposing prostitution and sex trafficking and (2) certification of compliance with the “Prohibition on the Promotion and Advocacy of the Legalization or Practice of Prostitution or Sex Trafficking,” which applies to all organization activities, including those with funding from private grants [1,3]. “The Prostitution Pledge,” as this requirement is often called, has evoked strong and mixed reactions. It has led some grantees, most prominently the government of Brazil, to reject US AIDS dollars altogether [4]. But it is the breadth of the requirement and its application to privately funded activities that has led to legal challenge of its constitutionality. One ongoing lawsuit involves the Alliance for Open Society International (AOSI), the Open Society Institute, and Pathfinder International versus USAID, HHS, and the Centers for Disease Control and Prevention's Global AIDS Program. AOSI and the Open Society Institute filed a complaint against the US government on September 23, 2005 and moved for a preliminary injunction arguing that the pledge policy requirement cannot restrict activities supported by private funds [5]. Both cases were preceded by a similar case from DKT International, a nonprofit organization that provides family planning and HIV/AIDS prevention programs internationally [6]. The Brennan Center for Justice at NYU School of Law, the legal counsel representing AOSI, asked our Center for Public Health and Human Rights at Johns Hopkins to review the existing scientific evidence on strategies that effectively reduce rates of HIV among sex workers and to present our findings in a Declaration for the court (the full text of the Declaration is available at [7]). In this article, we present a brief summary of our findings and the main arguments used in AOSI's First Amendment case, followed by a discussion of how these data have created an ethical dilemma in policy decisions. Our methods are shown in Box 1. Box 1. Methods Our methods included a literature search using the electronic database PubMed, and a search for published, freely available reports on Web sites of HIV prevention organizations. All studies found on PubMed and used in the Declaration were published in peerreviewed journals. The following subject heading terms were used: “HIV/AIDS,” “HIV prevention,” “sexually transmitted diseases prevention,” “sex workers (male, female, and not gender speci. c),” “sex work,” “prostitutes,” “prostitution,” and “effective HIV strategies.” Bibliographies of articles were also reviewed, and only one unique report from the Joint United Nations Programme on HIV/AIDS was retrieved by this method. Next, we reviewed published “Best Practices” reports from key global health organizations including the World Health Organization, the Joint United Nations Programme on HIV/AIDS, and the World Bank's HIV programs. In all the reports used, evidence-based studies shaped the guidelines and suggestions for future projects. Lastly, we used a case studies approach to investigate HIV prevention policies and practices in those developing countries where there was evidence of control of HIV spread and relatively low and stable HIV prevalence among sex workers at national levels.

Should the Recommended Number of IUD Revisits be Reduced?

This study uses data from clinical trials of intrauterine devices to examine the effect of reducing the recommended number of IUD follow-up visits. Over 11,000 follow-up forms were analyzed to estimate the number of health problems that would have escaped detection if women with no or mild symptoms had not made recommended revisits. Less than one percent of woman-visits with no or only mild symptoms had an underlying health risk that could have gone undetected if the follow-up visits that were made in the clinic trial setting had not been made. The results from this analysis suggest that a reduction in the number of recommended follow-up visits is safe, when measured according to selected conditions. Additional research is necessary to determine whether any revisits should be recommended in the absence of signs or symptoms.

High blood pressure control program in a high-risk inner city population: Lee R. Bone, Johns Hopkins Health Services Research and Development Center, 624 North Broadway, Baltimore, Maryland 21205; Elizabeth Ward; William B. Ward; Donald E. Morisky; Ruth McKinney; David M. Levine; Mike Horan; Wilhelm Baermann; Diadema Simone; Sidney Kreider; Ramona Johnson; Jeanne Fralich

The global rapid growth in mobile technology provides unique opportunities to support community health workers (CHWs) in providing family planning (FP) services. FHI 360, Pathfinder International and D-tree International developed an evidence-based mobile job aid to support CHW counseling, screening, service provision and referrals, with mobile forms for client and service data, and text-message reporting and reminders. The purpose of this study is to evaluate the acceptability and potential benefits to service quality from the perspective of CHWs and their clients.The mobile job aid was piloted in Dar es Salaam, Tanzania. Data collection tools included a demographic survey of all 25 CHWs trained to use the mobile job aid, in-depth interviews with 20 of the CHWs after 3 months and a survey of 176 clients who received FP services from a CHW using the mobile job aid after 6 months.Both CHWs and their clients reported that the mobile job aid was a highly acceptable FP support tool. CHWs perceived benefits to service quality, including timelier and more convenient care; better quality of information; increased method choice; and improved privacy, confidentiality and trust with clients. Most clients discussed multiple FP methods with CHWs; only 1 in 10 clients reported discussion of all 9 methods.This research suggests that mobile phones can be effective tools to support CHWs with FP counseling, screening and referrals, data collection and reporting, and communication. Challenges remain to support informed contraceptive choice. Future research should focus on implementation, including scale-up and sustainability.Mobile job aids can uniquely enhance FP service provision at the community level through adherence to standard protocols, real-time feedback and technical assistance, and provision of confidential care. This study can inform future efforts to support and expand the role of CHWs in increasing FP access and informed contraceptive choice.