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Tropical Medicine and International Health Can a comprehensive voucher programme prompt changes indoctors’ knowledge, attitudes and practices related to sexualand reproductive health care for adolescents? A case study fromLatin America Liesbeth E. Meuwissen1,2, Anna C. Gorter2, Arnold D. M. Kester3 and J. A. Knottnerus1,4 1 Department of General Practice, University of Maastricht, The Netherlands2 Instituto CentroAmericano de la Salud, Managua, Nicaragua3 Department of Methodology and Statistics, University of Maastricht, The Netherlands4 Health Council of the Netherlands, The Hague, the Netherlands To evaluate whether participation in a competitive voucher programme designed to improve access to and quality of sexual and reproductive health care (SRH-care), prompted changes indoctors’ knowledge, attitudes and practices.
The voucher programme provided free access to SRH-care for adolescents. Doctors received training and guidelines on how to deal with adolescents, a treatment protocol, and financial incentivesfor each adolescent attended. To evaluate the impact of the intervention on doctors, nearly all partici-pating doctors (n ¼ 37) were interviewed before the intervention and 23 were interviewed after theintervention. Answers were grouped in subthemes and scores compared using nonparametric methods.
The initial interviews disclosed deficiencies in doctors’ knowledge, attitudes and practices relating to adolescent SRH-issues. Gender and age of the doctor were not associated with the initialscores. Comparing scores from before and after the intervention revealed significant increases in doctors’knowledge of contraceptives (P ¼ 0.003) and sexually transmittable infections (P < 0.001); barriers tocontraceptive use significantly diminished (P < 0.001 and P ¼ 0.003); and some attitudinal changeswere observed (0 ¼ 0.046 and P ¼ 0.11). Doctors became more aware of the need to improve theircommunication skills and were positive about the programme.
This study confirmed provider related barriers that adolescents in Nicaragua may face and reinforces the importance of focusing on the quality of care and strengthening doctors’ training.
Participation in the voucher programme resulted in increased knowledge, improved practices and, to alesser extent, in changed attitudes. A competitive voucher programme with technical support for theparticipating doctors can be a promising strategy to prompt change.
keywords adolescents, doctors’ knowledge attitudes practices, nicaragua, quality of care, reproductivehealth care, voucher programme sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). These risks are closely Nicaragua has one of the highest adolescent fertility rates connected with the low use of contraceptive methods of Latin America, with 119 births annually per 1000 young among sexually active adolescents: only 7% use a condom women aged 15–19. High fertility rates are associated with and 47% another modern method (INEC 2001).
low socio-economic status and low educational attainment Lack of access to information about sexual and repro- [Instituto Nacional de Estadı´stica y Censos and Ministerio ductive health, lack of access to sexual and reproductive de Salud (INEC) 2002]. In addition, adolescents experience health care (SRH-care) and a low quality of care are the high rates of unwanted pregnancy, illegal abortions, high principal reasons for the low use of contraceptive methods maternal mortality rates and are at high risk of contracting among adolescents. Whilst there is no need to further Tropical Medicine and International Health L. E. Meuwissen et al. Can voucher programmes influence doctors’ knowledge, attitudes and practices? assess the extent to which knowledge, attitudes, and attitudes and practices, doctors were interviewed before practices of medical doctors can be an obstacle to and after the intervention. This paper reports our findings.
appropriate care for adolescents, there is an urgent need tobetter understand how to motivate and support doctors tochange (Stanback et al. 1997; Eggleston et al. 1999; Pons 1999; Senderowitz 1999; Speizer et al. 2000; Shelton 2001; Stanback & Twum-Baah 2001; Lande 2002; Langer 2002;Rudy et al. 2003).
The intervention took place in Managua, the capital of Evidence of interventions that have succeeded in Nicaragua, one of the poorest countries of Latin Amer- improving the quality of SRH-care for adolescents in ica. Primary health services in Managua consist of public existing health centres in developing countries is scarce. A health centres run by the Ministry of Health, municipal competitive1 voucher programme for sex-workers in public health centres, private doctors, and clinics run by Managua, Nicaragua, proved to be a cost effective inter- non-governmental organizations (NGOs). Most clinics vention with potential to encourage quality care practices are staffed by two doctors, and, in general, in the larger (Borghi et al. 2005). Although indications existed that clinics two doctors were allocated to receive adolescents.
competitive voucher programmes in health have strong Over 15 months, 28 711 vouchers were distributed to potential to improve quality (Gorter et al. 2003), this had poor adolescents at markets, outside schools and door-to- never been the subject of explicit research. Therefore, when door in disadvantaged neighbourhoods. The vouchers gave the Central American Health Institute (ICAS) piloted, free access to SRH-care in any of the four public, five between 2000 and 2002, a voucher programme designed to private or 10 NGO clinics contracted by ICAS. The increase access to and quality of SRH-care for poor and selection of clinics was based on suitability and proximity underserved adolescents, various aspects of the quality of to the areas in which vouchers were distributed. Identified care provided were closely monitored and evaluated.
clinics invited to participate were required to sign a Methods used were interviews with adolescents, focus contract, while prices per consultation were negotiated group discussions, revision of medical files, simulated based on customary fees. The clinics received reimburse- patients and interviews with doctors.
ment for each adolescent consultation. The programme Evaluation of the impact of the intervention among started with four clinics and new clinics were added female adolescents showed that voucher receipt increased use of SRH care among all groups (adjusted odds ratio 3.1, Vouchers were valid for 3 months and 20% of the 95% confidence interval 2.5–3.9) and of contraceptives vouchers were redeemed by girls. This is a relatively high and condoms in specific groups (Meuwissen et al. 2006a).
redemption rate, considering the short life of the vouchers Furthermore, girls were more satisfied with the quality of (3 months) and that they were distributed without asking SRH-care delivered through the voucher programme, adolescents about their SRH-care needs. Among sexually compared to care delivered without voucher (Meuwissen active girls, 51% used their voucher, while among girls who were not yet sexually active use was only 14%.
The fact that vouchers offered SRH-care free-of-charge Adolescents could seek more than one service during their can explain part of the increase in satisfaction. However, consultation, so the sum of percentages exceeds 100%: the voucher programme was also seeking to induce 34% sought contraceptives, 30% sought treatment for an improvements in technical and communication skills in STI or reproductive tract infection (RTI), 28% counselling, relation to SRH-care in the participating health facilities.
27% antenatal care, 17% pregnancy testing and 15% gave This was to be achieved through specific training and support providers would receive as well as the experience Doctors completed standardized clinical forms that gained through participation in the programme. To guided them during each consultation. This protocol was evaluate whether the programme influenced knowledge, designed to ensure that every adolescent was asked abouttheir sexual activity, their need for information, their needfor contraceptives and was given a package with twocondoms plus health education material on adolescence 1 Competition refers to the fact that in the described programme and STIs. Doctors at participating clinics were obliged to there is competition between service providers, as opposed to attend an introductory meeting to learn about the pro- programmes were the voucher is redeemable at a single service gramme and its procedures. An information manual with provider. Competitive voucher schemes are one form of demandside financing where purchasing power is given to the consumer background information and guidelines was also provided.
and money follows the patient (Gorter et al. 2003).
Furthermore, all doctors were encouraged to attend a Tropical Medicine and International Health L. E. Meuwissen et al. Can voucher programmes influence doctors’ knowledge, attitudes and practices? training course, conducted over three mornings on ‘youth that cannot be scientifically justified (Bertrand et al.
friendly services’ (Senderowitz 1999), counselling, adoles- 1995). The focus was (i) on barriers because of errone- cence and sexuality, contraceptives and sexual abuse. The ous knowledge (e.g. When you prescribe MesigynaÒ2, course was organized by the Department of Sexual and when can it be started?); (ii) on barriers because of Reproductive Health at the University of Nicaragua.
socio-cultural assumptions and values (e.g. In what type Seventy per cent of the doctors participated in at least one of cases do you propose the use of emergency contra- ceptives?) and facilitation of correct use (e.g. includedinstruction on what to do when a girl forgets to take thepill as essential information to be shared with an adolescent who starts using oral contraceptives) The full Thirty-seven of the 40 participating doctors were inter- questionnaire is available on request.
viewed before the programme started in their clinic. The The criteria for evaluation were based on programme three missed were doctors newly employed in the objectives, defined before the data were analysed and participating clinics after the programme had started and approved by the research team. Each aspect was divided in had already started seeing adolescents, using programme two subthemes as indicated above. By providing the correct protocols. Two doctors from the research team inter- responses to all four or five criteria of one subtheme, a viewed the participating doctors. They made appoint- maximum score of 10 points could be attained. For an ments and interviewed the doctors in the privacy of their overview of all criteria used see Tables 2–4. The internal consultation rooms. A structured questionnaire with 28 reliability of the multiple subscale scores is good (Cronb- open-ended questions was used. The interviewers were instructed to record answers and not to provide feed- All completed questionnaires were codified in a random back. One month after the intervention ended, doctors order (before and after mixed) by one doctor after were contacted for a second interview, with the same disconnection from the personal identifiers. Data were basic questionnaire, with additional questions on their entered twice using Epi Info 6.04 d (CDC, Atlanta, GA, experience. The study was approved by the ethical USA). Stata 7.0 software (State Corp, College Station, TX, The selection of questions was based on programme A general description of the participating doctors is objectives and literature review and was refined by a given, reflecting basic characteristics and experience. The team of medical doctors with experience of SRH-care in total number of positive answers for each criterion, and the Nicaragua. Measurement of knowledge was straightfor- mean score per subtheme, are calculated and tabulated for ward, focusing on (i) family planning and (ii) STIs. The all 37 doctors interviewed at the beginning of the doctors were asked for example: According to your programme. The relation between different characteristics criteria, what type of family planning is most suitable for of these 37 doctors (gender, age group and type of clinic) girls aged 12–14? What type for girls aged 15–17? And and their initial score was assessed. The Mann–Whitney for girls who have had a baby? Please explain your rank sum test was used to analyse the influence of gender understanding of the relationship between STIs and HIV/ and age group on the scores in each subtheme and the AIDS? Describe the syndromic treatment for STIs? Why Kruskal–Wallis test for the influence of the type of clinic is the syndromic treatment used in STI programmes? Attitudes were assessed through questions related to Of the 23 doctors interviewed twice, the numbers of barriers to SRH-care and to understanding how access to correct answers before and after the intervention are care can be facilitated. The focus was (i) on service delivery tabulated, and the total score per subtheme calculated. The and (ii) on family planning. Examples of questions include: scores before and after the intervention are compared using What do you think are the different reasons why adoles- the Wilcoxon signed rank test (paired design).
cents experience difficulties in consulting a doctor forsexual and reproductive health issues? If an adolescentaged 14 consults you and asks for oral contraceptives, do Mesigyna is a monthly injectable hormonal contraceptive Practices were assessed by evaluating the medical available in Latin America. This type of method has severaladvantages for adolescents: it does not require continuous appli- barriers mentioned when doctors described how they cation; it is coitus-independent; it is highly effective and reversible; dealt with contraception among adolescents. Medical and it does not require the user to keep supplies and therefore its barriers are practices that use a medical rationale but use can be concealed (Singh 1995). Mesigyna is very popular result in an impediment to or denial of contraceptive use among adolescents in Nicaragua but rather expensive.
Tropical Medicine and International Health L. E. Meuwissen et al. Can voucher programmes influence doctors’ knowledge, attitudes and practices? clinics. More female than male doctors participated, similar to the gender profile among general practitioners in Twenty-three of the 37 medical doctors were interviewed twice (62%). Reasons for failure to follow-up were that the Answers from the 37 initial interviews are shown in the doctor had stopped working in the participating clinics second column of Tables 2–4. In summary, the main (five doctors); exclusion of the clinic from the programme findings were: not all doctors knew of current contracep- because of administrative reasons (four); absence during tives appropriate for adolescents and knowledge of STIs interview period (two); refusal because of moral rejection and syndromic treatment was limited (Table 2). Few of the programme (two); removal from the programme doctors appreciated that provider related obstacles con- because of complaints from adolescents (one). The sample tribute to non-use of health care services by adolescents of 23 doctors (that is, those who participated in the follow- and many were reluctant to prescribe contraceptives to up) did not differ significantly in terms of their main younger adolescents (Table 3). Many doctors imposed characteristics from the 14 doctors lost to follow-up medical barriers to the use of modern contraceptives and most doctors clearly had a favourite contraceptive that As a result of the stepwise introduction of the pro- they prescribed for specific age groups (Table 4). For gramme, the period over which ‘the 23 doctors’ had example, a condom is their favourite method for girls aged participated before the second interview varied between 12–15, while only two of 37 (5%) include condoms as the 4.5 months and 15.2 months: 44% had participated more recommended method for girls who have already had a than 9 months. ‘The 23 doctors’ were aged between 28 and baby. Ten of the 37 doctors (27%) gave information on the 53. Most were younger than 40, and worked in NGO negative aspects of condom use to teenagers who wanted to Table 1 Baseline characteristics and experience of the doctors Experience with prescribing the morning after pill Reported experience in this year with girls suffering from sexual abuse à * Doctors with complete follow-up.
  Doctors lost to follow-up.
à This question was not asked for in the first nine interviews.
Tropical Medicine and International Health L. E. Meuwissen et al. Can voucher programmes influence doctors’ knowledge, attitudes and practices? Table 2 The knowledge of the medical doctors before and after the intervention I On contraceptives and their use1.1 Did not mention natural methods as 1.2 Prescribes OvretteÒ only to lactating mothers 1.3 Knows girls can start MesigynaÒ on day 1–5 of 1.4 Can mention at least one method for emergency 1.5 Can mention the dose of at least one method or emergency II On STIs, their prevention and treatment2.1 Mentions risk assessment, as a crucial part of STI treatment 2.2 Knows what syndromic treatment is and can give 2.3 Mentions that STIs increase the transmission-rates of HIV 2.4 Knows the correct treatment for urethral * Number of doctors and percentage of total that responded correctly to the criteria.
  These columns reflect the absolute number of doctors who gave the correct answers in the interviews before and after the intervention.
à The P-value calculated from the Wilcoxon Signed Rank Test comparing the scores before and after the intervention for every subtheme.
§ Scores are the mean scores per subtheme and can range between 0 and 10 points.
start using them: for example ‘not the best method to Knowledge of STIs also increased significantly prevent STIs’; ‘can give irritations’; ‘can give allergic (P < 0.001; Table 2). Higher proportions, but far from all, reactions’; ‘psychological disadvantages’; ‘condoms break understood what syndromic treatment is and why it is used easily’; ‘can have disadvantages’; ‘90% effective’; ‘not good and/or could mention that STIs facilitate the transmission When comparing the initial scores of male and female A significant improvement was observed in attitudes doctors and doctors under 35 with older doctors, no towards accessibility of SRH-care, more doctors recog- statistically significant differences were found in any nized obstacles faced by adolescents to accessing SRH- subtheme. However, the initial scores of doctors working care (P ¼ 0.046; Table 3). Many more mentioned in public clinics were statistically significantly lower in accessibility to health services and contraceptives as attitudes towards accessibility (subtheme 3) and medical crucial elements of SRH programmes, while in the first barriers because of erroneous knowledge (subtheme 5) (not interview, their focus had been more on health shown). The group followed up was too small to permit analysis of whether different groups of doctors responded Attitudes by doctors towards contraceptive use by adolescents did not change significantly (P ¼ 0.11; Table The scores of the initial interviews with ‘the 23 doctors’ 3). Many doctors remained reluctant to prescribe hormo- are comparable to the scores of the complete group of 37 nal contraceptives in the hypothesized case where reques- (Tables 2–4, column ‘All Initial’ and column ‘Initial’).
ted by a 14-year-old girl. With regard to instructions given When comparing the results of the initial interview with to adolescents wanting to start using condoms, only a few the interview after the intervention, a significant increase in doctors stressed the advantage of condoms for dual knowledge of contraceptives was noted (P ¼ 0.003; protection against pregnancy and STIs.
Table 2). A higher percentage knew that MesigynaÒ2 can Significantly fewer medical barriers because of erro- be started from day 1 up to day 5 of the menstrual cycle neous knowledge were observed (P < 0.001; Table 4).
and more were able to mention at least one emergency However, most doctors remained very reluctant to prescribe intra-uterine device (IUD) to adolescents who Tropical Medicine and International Health L. E. Meuwissen et al. Can voucher programmes influence doctors’ knowledge, attitudes and practices? Table 3 The attitudes of the medical doctors before and after the intervention III Towards accessibility SRH-care for adolescents3.1 Mentions at least one clinic related obstacle as reason for no-use of SRH-care 3.2 Does not mention negative factors attributed to adolescents such as they do not care/do not have time/ignorance as reason for non-use of SRH carethey do not care/do not have time/ignorance as reason for no-use of SRH care 3.3 Mentions the importance of health care services in SRH programmes 3.4 Mentions the importance of contraceptives in SRH programmes IV Towards contraceptive use by adolescents4.1 Includes a modern contraceptive that can be controlled by girls amongst methods suitable for girls of 12–14 years 4.2 Suggests more then one modern method for girls of 15–17 years 4.3 Prescribes oral contraceptives if an adolescent of 14 years ask for that 4.4 Indicates what a girl should do when forgetting to take the pill, as essential information when prescribing oral contraceptives.
4.5 Explains that the condom has double usage, preventing STIs and pregnancy * Number of doctors and percentage of total that responded correctly to the criteria.
  These columns reflect the absolute number of doctors who gave the correct answers in the interviews before and after the intervention.
à The P-value calculated from the Wilcoxon Signed Rank Test comparing the scores before and after the intervention for every subtheme.
§ Scores are the mean scores per subtheme and can range between 0 and 10 points.
had not yet given birth. The promotion of condoms for explained that it was difficult to gain their confidence; that protection against STIs increased, but remained low.
it was hard to identify their real reason for consulting; that Also significantly less medical barriers because of the some were very timid; and that adolescents lack a lot of doctors’ socio-cultural assumptions and values were recorded (P ¼ 0.003; Table 4). More doctors suggested toyounger girls contraceptive methods which girls could themselves control; indicated unprotected intercourse asreason to prescribe emergency contraception and not only The responses of the doctors clearly illustrate the obstacles in cases of rape; and less frequently provided negative that adolescents may face when they consult a doctor for sexual or reproductive health care. Erroneous knowledge, All doctors were asked on which topics they would like outdated practices and non-supportive attitudes appeared to be better informed. In the initial interview 13 of 23 rather common. Significant improvements were observed asked for information on contraception, 14 of 23 on STIs among the participating doctors, especially with regard to and two of 23 on topics related to communication (on sexuality, counselling, or dealing with violence). When There was nearly full participation of available doctors.
asked in the second interview, the results on contraception Only one doctor refused to participate in the second and STIs were the same, but the number of doctors asking interview. The most important reason for doctors being not for training in relation to communication had increased to available was frequent doctors’ rotation, not only in the public but also in the private and non-governmental sector, When asked about their experience with the programme, complicating the intervention as well as the survey. The all but one were positive: 17 of 23 reported to have interviews were taken in a relaxed and non-judgmental improved their knowledge, 15 of 23 reported to have way and the doctors appeared to put effort in answering improved their communication skills and 15 of 23 to have the questions. While a potential bias of this type of survey gained experience. None complained about the increased is that study participants report what they think the workload. Most had enjoyed this new experience, although interviewer wants to hear, rather than what they actually 12 of 23 found it difficult to work with adolescents. Some do (Hardee et al. 2001), the strength of the design was that Tropical Medicine and International Health L. E. Meuwissen et al. Can voucher programmes influence doctors’ knowledge, attitudes and practices? Table 4 The medical barriers before and after the intervention V Because of erroneous knowledge5.1 Knows the current contraceptive methods for adolescents 5.2 Does not mention out-dated contra-indications for IUD use 5.3 Knows girls can start MesigynaÒ on day 1–5 of their menstrual cycle 5.4 Knows that emergency contraception can be prescribed 5.5 Explains that condoms protect against STIs.
VI Because of socio-cultural assumptions and values6.1 Includes a modern contraceptive that can be controlled by girls amongst methods suitable for girls of 12–14 years 6.2 Includes condoms in the methods preference in girls who already have a baby 6.3 Prescribes oral contraceptives if an adolescent of 14 years ask for that.
6.4 Considers unprotected intercourse an indication for emergency contraception 6.5 Does not give exclusive practical and negative attributions * Number of doctors and percentage of total who responded correctly to the criteria.
  These columns reflect the absolute number of doctors who gave the correct answers in the interviews before and after the intervention.
à The P-value calculated from the Wilcoxon Signed Rank Test comparing the scores before and after the intervention for every subtheme.
§ Scores are the mean scores per subtheme and can range between 0 and 10 points.
no feedback was given to the doctors. Their answers give of a competitive voucher programme in other populations the impression that they were not seeking to provide of adolescents and doctors; to evaluate whether specific answers consistent with the objectives of the intervention.
groups of doctors are more responsive to this kind of The degree of correspondence between their answers and intervention; which elements of the programme are espe- their daily practice cannot be assessed by interviews alone, cially effective; and how the length of the implementation but it is unlikely that they perform better than their self- assessment (Hardee et al. 1995, 1998).
Although no control group was available, the observed changes are likely to be attributed to the voucherprogramme as no other interventions on SRH-care took The study illustrates the many opportunities that are place in these clinics in the same timeframe. Furthermore, missed by health care providers to reach out to adoles- all but one doctor confirmed the contribution the inter- cents who want to protect themselves against the risks of vention had made in improving their knowledge of sexual intercourse. Provider attitudes persist as a major SRH-care and their experience and communication with obstacle towards good quality SRH-care. In Nicaragua, doctors know that sexual activity among young teenagers The main objective of this survey was to evaluate is a reality, with 8% of 15-year-old girls and 45% of whether participation in a voucher programme could 19-year-old girls pregnant or already mothers (INEC improve doctors’ knowledge, attitudes and practices. As a 2002), and they are familiar with the high levels of result, the representativeness of the sample for all Nicara- unwanted pregnancies and forced sexual activity (Olsson guan doctors was for this exploratory study of less et al. 2000; INEC 2002). The reluctance to prescribe the importance. However, the fact that only few differences contraceptive pill to a 14-year-old girl, despite the risks were observed between different groups of doctors (male- of a pregnancy and the lack of alternative contraception, female, younger-older and public-private-NGO), suggests is more typically characteristic of a parent than a that similar results might be found among other doctors in medical doctor. Also, the negative attitudes towards Nicaragua. More research is needed to assess the potential condom use that some doctors exhibit do not reflect Tropical Medicine and International Health L. E. Meuwissen et al. Can voucher programmes influence doctors’ knowledge, attitudes and practices? current public health insights that promote the use of with regard to the quality of SRH-care provided to condoms among sexually active teenagers for their dual adolescents; that doctors were willing to improve; that a protection (prevention of STIs and prevention of competitive voucher programme with technical support for the participating doctors can be a promising strategy to It should be noted that these phenomena are not unique prompt change among practicing doctors; and that the to Nicaragua (Pons 1999; Hardee et al. 2001; Langer voucher programme can be developed further to increase 2002). The results underscore the need to develop and its’ impact. The success of the intervention could be evaluate effective approaches to improve the quality of the explained by the combination of training, support and care delivered by the doctors. Strengthening the demand experience with adolescents, as well as financial incentives.
side by supporting adolescents to claim their rights is very These results are of special interest in view of the key role that doctors can play in decreasing the vulnerability of Individual doctors cannot be blamed. During their youth to HIV infection through correct treatment of STIs, training in medical school, SRH-care is scarcely addressed, and in reducing the risks of unwanted teenage pregnancies communication training is not given, neither are medical by providing ready access to reliable contraceptives.
ethics and attitudes discussed. Most doctors participatedenthusiastically in the voucher programme and training sessions and attempted to provide this new group of clientswith high quality care. The fact that payment was linked to We thank all doctors for their enthusiastic participation in the number of adolescents a doctor succeeded in attracting the intervention and the evaluation. Special words of to her/his clinic may have been an important incentive. An thanks go to Patricia Gonzalez, Amelia Tijerino, Roger interesting result of the programme was that doctors Torrentes, Alejandro Dormes, Zoyla Seguro, Joel Medina, discovered their own deficiencies in communicating with and Toma´s Donaire. We are very grateful to Julienne adolescents. Improving client-provider interactions shows McKay for her encouraging and continued support during great promise in increasing positive outcomes in terms of the preparation of this report. Last but not least, without clients’ satisfaction, increased knowledge, and more the financial support of DFID this programme would never effective and longer use of contraceptives (RamaRao & Mohanam 2003). Consulting with adolescents in relationto SRH is not easy, as has been concluded in many places in the world (MacFarlane & McPherson 1995; Hassan &Creatsas 2000). More substantial changes in how the Bertrand JG, Hardee K, Magnani RJ & Angle MA (1995) Ac- participants deal with adolescents might be achieved by cess, quality of care, and medical barriers in family planning intensification of the training in communication and programs. International Family Planning Perspectives 21, 64– extension of the intervention period.
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International Journal for Quality in Health Care 6, 115–132.
Corresponding Author Liesbeth Meuwissen, Krozengaarde 11, 3992 JP Houten, The Netherlands. E-mail: Tropical Medicine and International Health L. E. Meuwissen et al. Can voucher programmes influence doctors’ knowledge, attitudes and practices? L’application d’un programmme d’aide complet par distribution de bons peut-elle favoriser le changement des connaissances, attitudes et pratiquesme´dicales dans les soins de sante´ de reproduction chez les adolescents? Etude de cas en Amerique Latine Evaluer si la participation a` un programme de bons d’aide concu pour ame´liorer l’acce´s aux et la qualite´ des soins de sante´ de reproduction pour les adolescents favorisait le changement des connaissance, attitudes et pratiques des me´decins.
Le programme d’aide a procure´ l’acce`s gratuit aux soins de sante´ de reproduction pour les adolescents, un protocol de traitement et un support financier pour chaque adolescent servido. Pour l’e´valuation de l’impacte chez les me´decins, presque tous les me´decins (n ¼ 37) ont e´te´interviewe´s avant l’intervention et 23 d’entre eux ont e´te´ interviewe´s apre`s l’intervention. Les re´ponses obtenues ont e´te´ groupe´es en sous-the`mes et lesscores ont e´te´ compare´s en utilisant des me´thodes parame´triques.
Les premiers interviews ont revele´ des de´ficiences dans les connnaissances, attitudes et pratiques des me´decins pour ce qui est des soins de sante´ de reproduction chez les adolescents. Le sexe et l’aˆge des medecins n’e´taient pas associe´s avec les scores initiaux. La comparaison des scores avantet apres l’intervention a revele` une augmentation significative de la connaissance des me´decins sur la contraception (P ¼ 0,003) et les infectionssexuellement transmissibles (P < 0,001), les barrie`res a` la contraception ont significativement diminue´ (P < 0,001 et P < 0,003), des changementsd’attitude ont e´te´ observe´s (P ¼ 0,0046 et P ¼ 0,11). Les me´decins se sont rendu compte de la ne´cessite´ d’ameliorer leur abilite´s de communication ete´taient positifs vis a` vis du programme en ge´ne´ral.
Cette e´tude confirme l’existence de barrie`res lie´es aux praticiens, auxquelles les adolescents du Nicaragua peuvent eˆtre confronte´s et rappelle l’importance de la focalisation sur la qualite´ des soins et le renforcement de la formation des me´decins. La participation dans le programme debons d’aide a mene´ a` une augmentation de la connaissance, une ame´lioration des pratiques et dans une moindre mesure, un changement des attitudes.
Un programme de bons d’aide incluant un support technique pour les me´decins participant peut eˆtre une strate´gie prometteuse pour favoriser lechangement mots cle´s adolescents, Nicaragua, qualite´ des soins, soins de sante de reproduction, connaissance, attitudes et pratiques me´dicales, programme d’aidepar distribution de bons Puede un programa de bonas competitivo inducir cambios enel conocimiento; actitudes y pra´cticas de los doctors relacianados a los servicios deSalud Sexual y Reproductiva para Adolescentes? Un estudio de casos en Ame´rica Latina Evaluar si la participacio´n en un programa competitivo de bonus (voucher program) disen˜ado para mejorar el acceso y la calidad del acceso de adolescentes a la salud sexual y reproductiva (SSR), inducjo cambios en los conocimientos, actitudes y pra´cticas de los me´dicos.
El programa de bonus provee acceso gratuito a los adolescentes a la SSR. Los me´dicos recibieron entrenamiento y formacio´n sobre co´mo tratar con adolescentes, un protocolo de tratamiento e incentivos financieros por cada adolescente atendido. Con el fin de evaluar el impacto de laintervencio´n sobre los me´dicos, pra´cticamente todos los participantes (N ¼ 37) fueron entrevistados antes de la intervencio´n mientras que 23 de ellosfueron entrevistados tras ella. Las respuestas fueron agrupadas bajo sub-temas, y las puntuaciones comparadas utilizando me´todos no parame´tricos.
Las entrevistas iniciales mostraron deficiencias en los conocimientos de los me´dicos, en actitudes y pra´cticas relacionadas con la SSR de los adolescentes. Ni la edad ni el ge´nero de los me´dicos estaban asociados con el puntaje inicial. La comparacio´n de los puntajes previos y posteriores ala intervencio´n revelo´ un aumento significativo en los conocimientos de los me´dicos acerca de me´todos anticonceptivos (P ¼ 0.003) e infecciones detransmisio´n sexual (P < 0.001); los obsta´culos frente al uso de anticonceptivos disminuyeron(P < 0.001 & P ¼ 0.003); y se observaron algunos cambiosde actitud(0 ¼ 0.046 & P ¼ 0.11). Los me´dicos se tornaron ma´s conscientes sobre la necesidad de mejorar sus habilidades de comunicacio´n y semostraban optimistas con el programa.
Este estudio confirmo´ la presencia de obsta´culos que a nivel de proveedores pueden encontrar los adolescentes en Nicaragua, y apoya la importancia de enfocarse en la calidad del servicio y el fortalecimiento del entrenamiento del me´dico. La participacio´n en el programa de bonus resulto´en un aumento del conocimiento, unas pra´cticas mejoradas y en menor medida, cambios en la actitud. Un programa de bonus competitivo, con el apoyote´cnico para los me´dicos participantes, puede ser una estrategia prometedora para inducir cambio.
palabras clave adolescentes, Nicaragua, calidad del servicio, salud reproductiva, conocimiento actitudes y pra´cticas de los me´dicos, programa de cupo´n


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