CREATING RESPONSIVE SERVICES
How can RTI services be made more available, more hospitable? Most women who need RTI diagnosis or treatment are reluctant to attend conventional STD clinics because of the stigma attached to such centers, or even to visit a doctor who knows them, preferring instead to ignore their symptoms or seek alliterative therapies. Yet primary health care centers and family planning services are in a key position to offer RTI diagnosis and treatment as a routine service. Humane and realistic services treat patients with respect, and in so doing, help remove the stigma that the community, individuals, and health providers widely attach to infection.HOSPITABLE ENVIRONMENTS
Special programs for young people need to address their needs for information and services and to build toward the profound changes that are required.Involving health and family planning clients and women's groups in decisions about planning, managing, and evaluating RTI, health, and family planning services will ensure that programs are sensitive to gender issues, build confidence, and treat clients with privacy and dignity. RTI services, along with contraception and safe abortion, need a strong dose of humanity. We need to avoid the conveyor-belt approach and avoid over-medicalizing services at the expense of the individual human being and her particular strengths and vulnerabilities. "The inner person is a neglected person, and needs to feel powerful. To feel powerful inside, the woman must hear an echo on the outside" (Nalini Singh, India). Having service personnel spend more time with each client in open, two-way communication must be part of program policy.
Services need to be sensitive to the special needs of all women-not only sexually active women and mothers, but also prepubertal girls; adolescents; menopausal women; and women who are unmarried, celibate, or childless. Special programs for young people need to be developed to address their needs for information and services and to build toward the profound changes that are required. Viewing service provision through a "women's lens" suggests a self-help approach -- empowerment through self-awareness -- that includes teaching women how to distinguish between normal vaginal discharge and abnormal discharge, discomfort, or pain. Women need to know that pain and discomfort during intercourse or at other times are not a woman's lot in life, but conditions that can be corrected.
Ideally, RTI services would be readily available and integrated with existing family planning and maternal and child health (MCH) facilities. Counseling is a key factor, as is follow-up care to ensure that women clients and their partners receive full treatment and know how to prevent further infection. Quality medical care is also essential to prevent iatrogenic infection and ensure accurate diagnosis and treatment of STDs. Where possible all clinic services should be provided in one place so that clients' needs are considered holistically rather than separated by function or "body part." RTI diagnosis and treatment are natural components of other reproductive health services, such as contraceptive counseling, safe and early termination of unwanted pregnancies, prenatal care and safe delivery of wanted pregnancies, infertility diagnosis and treatment, and infant and child health care.
Available services need to be advertised: warning messages that do not state clearly where people can go for information and services are insufficient. Participants pointed out that the gender and age segregation of many existing services must be modified if all people are to be adequately served. In particular, they noted that boys and men have rarely been considered "clients" of family planning programs. Little is accomplished by treating women's infections if their partners' infections remain untreated and their sexual behavior unchanged. How, and where, can adolescent boys and men best receive sexual and reproductive health care? In many cases, it may be feasible to offer combined services; in others, separate hours or separate facilities may be needed. Conventional STD clinics are probably not enough. Although conference participants focused primarily on women's needs, they recognized that the failure to address men's needs results in cycles of misinformation, inadequate treatment, and repeated infection.
"Structural adjustment" programs and other economic forces resulting in cutbacks in the funding of social services, including health services, have wreaked havoc with community health and family planning programs in many countries. Such cuts have also encouraged territoriality among agencies and had a chilling effect on adding new programs. It is clear that outside donors and private organizations, as well as national governments, will need to reassess priorities. Participants urged that donors broaden their mission to encompass a wider range of reproductive health elements, not just "family planning" as conventionally defined. Such an approach serves people best and is also likely to be more efficient. Donors will also need to pay particular attention to population subgroups who cannot pay for services or for whom previous services are no longer available or accessible.
Little is accomplished by treating women's infections if their partners' infections remain untreated and their sexual behavior unchanged.
TECHNOLOGY AND TRAINING NEEDS
Community health and family planning programs have been reluctant to take on the diagnosis and treatment of RTIs, in part because of the perceived expense and technical expertise required, and in part, perhaps, because of the stigmatized nature of most RTIs. There is an urgent need for cheaper, simpler, and more accessible diagnostic technologies. There is a need for research on alternative or traditional therapies for RTIs, including single-dose antibiotics. And there is a need for further work on woman-controlled barrier methods that can be used without the cooperation or knowledge of their partners to protect against STDs and HIV infection (with and without protection against pregnancy). Vaginal microbicides need to be developed that, ideally, would permit a woman to get pregnant if she wishes (in other words, that do not act as spermicides) while protecting her from sexually transmitted viral and bacterial infections. Most important, providers need to be motivated and enabled to offer services instead of just closing their eyes to what they see; for example, commenting on the frequency of observed discharges in family planning clients without offering routine diagnosis and treatment.In this connection, participatory research into how particular contraceptive methods may prevent, inhibit, or facilitate the spread of STDs needs higher priority, with the full collaboration of clients women's health activists to ensure that ethical standards are maintained. Links between research and service urgently need to be strengthened. Counseling clients on the connections between RTIs and contraceptive use (as well as sexual behavior) should be a routine component of family planning service provision. Each individual needs to weigh the likely contraceptive effectiveness of barrier methods against their effectiveness in inhibiting disease transmission, for example, and clients need to understand that hormonal or surgical contraceptive methods do not offer protection against infection. To protect themselves against STDs, women who use means of protection other than condoms need to be counseled and supported to require their partners to use condoms; need to give higher priority to condom provision than they have in the past. Men who have had a vasectomy and who have multiple partners need to be encouraged to use condoms.
As is the case for RTI educators, health-care providers at all levels should be trained to see RTIs in the context of gender power, sexuality, and violence. Medical and health training should emphasize the social, cultural, and economic contexts of health and sexual behavior, and should address gender bias in textbooks and other educational materials. The curricula of pre-service and in-service training of family planning workers, community health workers, and medical students should include materials on RTIs. Health and family planning education needs to emphasize the human qualities of mutual caring and respect, not simply the scientific and medical aspects of service delivery.
There is an urgent need for cheaper, simpler, and more accessible diagnostic technologies and for research on alternative or traditional therapies for RTIs.
Providers at all levels need to be trained to respect women's perceptions of their own problems, to appreciate women's knowledge, and to understand the socioeconomic context of women's lives. Provider training should include sessions that would expose and challenge personal biases and internalized prejudices toward sexual issues; gender relations; and particular subpopulations that may be marginalized or stigmatized, such as sexually active teenagers, welfare mothers, illiterate clients, racial or ethnic minorities, or other individuals or groups that providers may think of as "unworthy." Too little is known of the effect of providers' attitudes on quality of care, especially in the personally sensitive realms of sexuality, contraception, and STDs.
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