f /lj A c F- 2.. q cr )(N ~ r Or C( - STRENGTHENING THE MODEL OF INTEGRATED SERVICES FOR WOMEN AND CHILDREN I I MANAGUA,NICARAGUA I I I I I I

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1 f /lj A c F- 2.. q cr )(N ~ r Or C( - A STRENGTHENNG THE MODEL OF NTEGRATED SERVCES FOR WOMEN AND CHLDREN MANAGUA,NCARAGUA - - J

2 TTLE NSTTUTON AUTHORS PEROD Spamsh report S attached Date of Report August 1998 NOPALll EXECUTVE SUMMARY FNAL REPORT STRENGTHENNG THE MODEL OF NTEGRATED SERVCES FOR WOMEN AND CHLDREN ENGLSH SUMMARY NCARAGUAN MNSTRY OF HEALTH (MNSA) Carlos Brambla, Populaton Councl Emma Ottolengh, PopulatOn Councl Cecda Maurente, Consultant June 1997-August 1998

3 BACKGROUND n 1995, the Ncaraguan Mimstry of Health (MN SA) and ts 19 decentralzed dstncts (SLAS) mplemented a new, mtegrated model for provdmg servces to women and chldren The Objectves of the new model were to ncrease access and coverage to quahty servces and decrease mssed opportumtes The ntegraton of servces, whch had been planned smce 1990, foreshadowed the strateges promoted by the World Conferences m Cairo (1994) and BeJmg (1995) The servces mcluded n the new model were prenatal, birthmg and postpartum servces, servces to the newborn, well chld servces and mmuruzaton for chldren up to SX years old, famly plannmg, reproductve, obstetrc and neonatal nsk assessment, early cervcal and breast cancer detecton and STHV mformaton and servces The Users' Manual (AtencOn ntegral a la MUJer y la Nmez- Manual Operatvo, MNSA, 1995) developed by MNSA specfied that needed servces were to be provded n the least number of chmc VStS Servces not available at that Ste were to be obtaned by referral n 1996, the MNSA conducted a process evaluaton and concluded that, Wth vanatons, all vlslted SLAS were utilzmg the new Model and that provders, m general, had a postive atttude to changng the way they had tradtonally provded servces n 1997, the PopulatOn Councl, Wth MNSA, conducted an OR to determme, m 21 Health Centers m 4 SLAS, the degree acheved m servce mtegraton and completeness of servces provded n ths report we present an analyss of the data collected dunng July and August 1997 OBJECTVES The Objectves of ths OR are to analyze empmcally the degree ofmtegraton of servces provded m 21 Health Centers of the 4 SLAS selected by MNSA for ths study Boaco, Carazo, Granada and Matagalpa The questons posed were (1) Considenng the stage of each woman's reproductive (and her chldren's) StuatOn, how complete were the servces she was offered and WhCh dd she actually receved dunng the observed VSt? (2) What were the dentfied obstacles and problems preventmg full comphance With the Model and what are possble solutons to them? To answer these questons, the PopulatOn Councl and MNSA conducted nonpartcpatory servce observatons and mterviews With clmc clents to determne 1) the charactenstics of the clmc clent, 2) the servces she needed accordmg to these charactenstcs, 3) the servces she receved and 4) the degree of completeness of the mformaton and servces provded

4 METHODOLOGY Each of 4 Health Centers m 3 SLAS and 5 Centers m 1 were vlslted durmg 2 consecutve days The selecton of stes was MNSA' s considenng ther mdivdual servce demand and logstcs for the VSt All servces provded women of reproductve age attendmg durmg those 2 days were observed and the women were subsequently mterviewed Before these actvtes, each woman was mformed of the study and was asked for her consent to partcpate Provders, too gave ther consent to be observed An algonthm or senes of possble questons defined by the response to the prevous queston, were posed before she was seen by the provder to dentfy the segment or the partcular stuaton of each woman and the servces she mght need The questons asked were 1) 2) 3) 4) 5) 6) Are you currently mamed or m urnon (1 e sexually actve) Are you pregnant? Have you gven brth, had a Cesarean or had an aborton m the last 2 months (1 e postpartum or post aborton)? Do you have a chld under 2 years of age? Chldren under 6 years old? Would you hke to become pregnant m the next year? Are you usmg a famly planmng methodlf not, would you hke to use a method? ThS senes of questons permtted us to segment the chents mto 10 dstmct groups each wth dfferent servce needs Durmg the observaton, mformaton about servce avalabhty, servces provded and referral or return appomtments made was recorded After she exted her consultaton, the chent was mterviewed m depth to determme the degree of comprehenson of her consultaton Two mstruments (ObservatOn GUde and ntervew QuestOnnaire) were developed for ths purpose and are annexed to ths report The mstruments were based on JHU's CCP document "Tools to Assess Famly Plannmg Counselmg ObservatOn and ntervew" V RESULTS Chent Numbers and Characterstcs Durmg the months of August and September, 1998, 841 women were mterviewed and 854 consultatons were observed Of the total, 730 women were mamed or m umon, 177% of these women were under 20 years old, 50% were between the ages of20 and 29 and the remamder were between 30 and 45 years old Forty seven percent had one or two chldren, 11 3% had none, approxmately 25% had 3 or 4 chldren and 58 women (4%)

5 had 6 or more chldren SX hundred and seventy four women had chldren under 6 a total of 1101 chldren, of these, 462 were under 2 years old Clents were evenly dstnbuted by Health Dstnct or SLAS (table 1), breakdown by provder and first or follow-up VSt are found m Tables 2 and 3 respectvely SLAS Granada Carazo Matagalpa Boaeo Total * SLAS are Health districts SLAS Granada Carazo Matagalpa Boaeo Total SLAS Granada Carazo Matagalpa Boaeo Total Table 1 Number of observatons by SLAS* MNSA, Ncaragua July-August 1997 Centers ObservatOns ntervews Cases % Cases % Table 2 Number of consultatons observed by type of servce provider MNSA, Ncaragua July-August, 1997 Doctor Nurse Nurse Auxlary Total Cases % Cases % Cases % Cases Table 3 Number of first-tme and follow-up ViSitS by SLAS MNSA, Nicaragua July-August 1997 Frst-tme Follow-up Total Cases % Cases % Cases % n most cases (72%) women attend the Centers requestmg a smgle servce but m 25% of cases the clent requested 2 servces and fewer than 3% of clents requested 3 or %

6 more servces The most frequent reasons for requestmg a servce were Well Chld and mmuruzatlon (343% of clents), a sck chld (32 4%), famly planrung (18 3%) and prenatal care (16 8%) There S low demand for postpartum, cancer detecton and STHV mformaton and servces (Table 4) The above percentages add to more than 100 because, as mentoned above, 28% of clents requested more than one servce Table 4 Number of VStS observed each chent segment MNSA, Ncaragua July-August 1997 Type Segment Cases Per cent n union pregnant with children less than 2 years of age n union pregnant without children less than 2 years of age n Union, post-partum with children less than 2 years of age V n Union, post-partum without children less than 2 years of age 6 07 V n Union, not pregnant, not post-partum with children V n union not pregnant, not post-partum without children V Not n union pregnant, without children less than 2 years 3 04 V Not n union post-partum, with chldren less than 2 years 6 07 X Not n union not pregnant not post-partum, with children X Not n Union, not pregnant not post-partum, without children Total Cases not dentified 7 The algonthm allowed categonzaton of the clents mto 10 segments, the categones and number of women m each are to be found m Table 5 and Fgure 1 Table 5 Reason(s) for consultaton at Health Centers MNSA, Nicaragua July-August, 1997 BASE 846 CASES Cases Per cent Own Sickness Sickness of child Other Sickness Prenatal Postnatal Well Child Care and Development Vaccinations Family Planning Post-abortion 1 o 1 PAP smear Breast cancer detection 1 01 STDs 3 04 Percentage represents the number of persons requesting the service ThiS S a multiple response question Clients may request more than one services and thus, the sum of percentages exceeds 100%

7 c Q) to... Q) a Figure 1 Chent segmentation ntegral Attention to Women and Children MNSA, Nicaragua 1997 Ltl :> r--- /" ~ r--,,,p, - ~ 96 y-<, '>~ " <!' -R J -- k'"? ~ %, - J,.t '" 61 ~ " r-- ~ - ~ 07,> ~'" r--,...--., r-1 V v V V V X R.,l Servce ntegraton Chent segment (see names of segments n Table 5) To what extent dd servces provded satsfy chents' needs? We answer ths queston, analyzmg mfonnaton obtamed m chent mterviews 1) Servces receved by chldren under SX years old Before she entered the consultaton, women were asked f they had chldren under SX and m the postconsultaton mterview we asked what preventve servces had they been offered and lor had receved for each chld and f they had receved an appomtment for the next wellchld consultaton 674 women reported havmg 1101 chldren under SX years of age, 452 (707%) Said ther chld or chldren had had at least one well chld consultaton (Fgure 2) and 66% Said they had receved mfonnaton on the mportance ofmomtonng and keepmg growth records The remammg 29 3% had not been momtored even once On the postve Sde, 99% on the chldren had receved vaccmatons (the degree of completeness of the scheme was not detennmed) and there were no dfferences between SLAS 55% of the chldren had been scheduled for the next VSt x -- -,,- 1

8 ~ -r o r---- _,,~~' r--- r----, ~ Figure 2 Per cent children that have receved Well Child Care and Development consultatons Base 1101 chldren under 6 years of age MNSA, N,caragua ~ 934 :--- ~. 1>}:j. ~ r--- Y 817 ~ ~" ~ ~" :-- ~ ",,:"~f; - ~' ". ~ '" ~ '",,,"::':i&: ;;, ~ r 0 ';::~4.. - ff_ J ~.' ~: " "/ " ~ ~~/,, - / 4', "" :~:." :~~ / ~w,,fr'y, :z.-#- O1eck up Fbrto OPT l'v1easles BCG Service 705 r--.' r /-Q./ r;;~} r----, ~,' ~,-f/ 1'0/';;, Appolntrrent Dunng servce observaton of mothers Wth chldren under 6, m 411 cases (61 2%) the provder asked the mother f her chld had receved well chld servces and m 62% the provder venfied f the chld had had all hs or her mmunzatons Accordmg to MNSA, complete under-6 chldren's servces must mclude 5 pomts dentfymg the chld and venfymg f she or he has had well chld and mmumzaton servces, mothers' knowledge of alarm sgns and symptoms and gvmg a follow-up appomtment The average score for completeness was 2 6/5 With scores m dfferent SLAS varymg between 2 3 and 3 2) Servces to children under 2 years old 433 women had chldren under 2 years old Of them, only 52% had ever brought ther chld for neonatal care SXty one percent had breastfed ther chld (Fgure 3), only 62% of the mothers stated they had ever receved a breastfeedmg talk by a provder and 50% had receved mformaton on the LAM method A Smlar percentage receved mformaton on when to mtroduce supplementaton mto the mfant's det n addton, 85% of mothers stated they know how to prepare ORS and three out of four mothers Said they know symptoms of alarm when a chld S Wth darrhea or AR r----

9 - -Ī Figure 3 nformabon and Services provided children under 2 years of age MNSA Nicaragua 1997 Base 433 women With children under 2 years of age wi' p 853 / fi/ ~, ~ -,;.#.;C'.-.y',;-.- / 659,,,,,.: --;-fl- 758 '*':~-Y.1,-<- ~/;' /''' f' Exam. '" '", #J>y.' " :~ // yy,... %Jif ~,-,,~" f,,~ ~,- ~~,- ~/ ".' 7" Breat Sohdfood ExclusVe lactabon Oral serum Developrrent 4- /,f~ -'-;-r Alarm symptoms Assgnmg a score of 10 pomts for complete mformaton and servces provded to mothers and ther chldren under 2, 77% of the consultatons acheved a score of 5 or more and 42% had a score of8 or more, 8% had scores of2 or less of the requred 10 pomts (See Graph 3 for detail of servces provded) 3) Servces to pregnant women 161 pregnant women were mterviewed and servce observaton was completed m 160 of them Of these, 24 (17 9%) were m the first tnmester and 40 women were m the thrd tnmester On average, the women had had 2 8 prenatal VStS Wth those women m the eghth month of pregnancy havmg had 6 3 VStS Note that these numbers do not necessanly reflect the general populaton's level of

10 prenatal care, they only reflect that of women who attend health servces n ths study we dd not attempt to dentfy the fraction of the total populaton of pregnant women who do not demand prenatal servces Fgure 4 shows the followng elements of prenatal care observed durng the study Of the 160 pregnant women, 87 2% receved self care nformaton and 82 7% receved nformation on when and where to seek emergency care However, only 60% receved nformaton on breastfeedng, only 53 2% receved nformaton on the mportance of brth spacng and the use of postpartum famly plannng and 55 % receved nformaton on care of the neonate Figure 4 nformation and services provided pregnant women MNSA Nicaragua 1997 Base 160 pregnantwomen 100,- -, OO+-- ~~~6 ~~'~'? ,-- ~7 ~ BO r 50 - ' < r--.2, 40 - r ~~ 30 - r 20 ; f f-- - j - 0 Exam+appolntment -~r t~~ ~ ~J- i... ' _ ' r ~r~ ~ - - Emergency cases, - i,.r----jf Breast feed - Care of newbom y y --- Attend control Attention 4) Famly plannng users and non-users n the study, 680 women who said they were not pregnant were ntervewed Of these, 445 (65 4%) stated they were USng a famly plannng method and the remanng 235 were not Of the latter 235 women, 89 stated they dd not Wsh to use a method and 146 (62 1%) wanted to adopt a method Of ths group of women who were not pregnant, dd not Wish a pregnancy but were not USng a method, only 16 (109%) left the Health Center With a method and another 44 (30 1 %) receved an appontment to come back for famly plannng (However, durng the observaton of servces, only 25% of women who were not pregnant were asked by the

11 provder fthey wshed to become pregnant) deally all these women should have left the Center wth a method, even a temporary one f they needed to return A large number of mssed opportumtes are evdent m ths servce (Fgure 5) Pregnant 19% Pregnant and non pregnant women Base 84L WOMEN NTERVEWED 2) Non pregnant ~ 810/ Received method appointment or neither Recell.ed method Base 680 no pregnant Use or not use methods Use methdos Want use methods 62% G1ii 35%.Doesnot want to use methdos 38% the women mtervewed, both users and non-users, most stated they knew about famly plannmg methods but 92 8% stated they would lke to have addtonal mformaton Among the reasons gven by women who do not Wish to use a method, are she S not sexually actve (587%), m much smaller numbers, the reasons mcluded a desre to get pregnant, fear of Sde effects, relgous reasons or non-approval from the spouse Servces to famly plannmg users Of the 445 famly planmng method users, 391% use oral contraceptves, 15% mjectables, 13% UDs, 74% condoms and 07%,

12 rhythm 18 4% of the women had undergone a stenlzaton procedure and only one case of vasectomy was recorded Of the women usmg reversble methods, 83 9% stated they had receved brth control nformaton from the Health Center provders Of the users, only 41 % were asked f they were havmg any problems With ther method, 45 7% were gven mformaton on correct use and 40 2% were gven the opton ofswtchmg method Dunng the mtervew, 121 users (33,5%) stated they would prefer usmg a dfferent method, prmcipally mjectable, stenlzaton or UD Over one half of the clents receved a follow-up appomtment (Fgure 6) User or not user of contraceptive methods... n vv Methods used n 'V ~, "~' " '''' =LH?t-n 1 0 R LJ nformation provded during consultation Non users 65% Users 35% 90 tu !,;:l tv", r r-- r-- r--r-c-- f ~ r--j r-- r-- ":' -- /f r.f r-- r-- _ r-- -- ;f-, 0 Base 80 no pregnant oomen Frst tme famly plannmg VStS 148 women were first tme famly planmng chents, of these, 101 (682%) receved nformaton on methods avalable, and the same number stated they chose the method they wanted to use 28 4% of the women who came for famly plannng was not able to obtan ther first choce method 71% of the chents were gven mformaton on possble Sde effects, and 82% receved detaled mformaton on how to use the chosen method These results are shown n Fgure 7

13 ' Fgure 7 nformaton provded to first tome family planning clients ~ 90~ ~----~ 00 " # 82.. / 80~ _J----1_----~ N /?'" #F?~~4$ 71 70r---~6~8~2~------~=!68~2~------_r--~J_---- l ':fff,w/ "::-/r 1- ;:;~ ". y / -, ~F 40 - r---- / ''it 30 - V 10 _r~f # ~ y.'~, f ~ (',"" ;.~..;~.<-#<-;;~ " ",..." /f/,~ : p..? / '.. j nform about methods Chose method nform symptoms How to use Understood Opportumtes used, Opportumtes mssed..j ~{"'-h- r r---- To estmate the proporton of opporturntes used and those mssed, we based our calculatons on the MNSA' s norms of whch servces are requred to be offered to women m dfferent hfe stages and ther chldren under 2 and under 6 years of age We consder an Opportunty used when the chent was ether offered and provded addtonal servces or was gven an return appomtment for other servces For example m the case of a woman who S not pregnant and not postpartum wth a chld under 2 years of age, mformaton and servces to be offered accordmg to the Norms are well chld care and mmumzatons, famly planrung, cervcal and breast cancer screenmg and mformaton (servces f needed) on STslHV Durmg the study, 242 women m ths segment were dentfied Tables 6 and 7 represent the servce or servces requested by these women and the addtonal servces offered or provded her

14 Table 6 Services requested by women m uulon, not pregnant with chldren younger than 2 years of age MNSA, Nicaragua July-August 1997 Requested service Did not request service Cases Per cent Cases Per cent Own sickness Sickness of child Other adult sickness Prenatal Well Child care and Development Vaccinations Family Planning PAP smears Breast cancer STDs a a a a Table 7 Additional services provided to women m UUlon, not pregnant With chldren younger than 2 years of age MNSA, Nicaragua July-August, 1997 Cases Total Per cent a a a a a a a a a a Opportlmty used Missed opportumty Old not request service KEY Attention Cases Per cent Cases Per cent Cases Per cent CH Well Child care and Development VAC Vaccinations FP Family Planning PAP PAP smears BRE Breast cancer STD STDs * We consider that an opportunity S used when the provider (1) verifies f woman has chldren under two years of age and f so nforms or provdes Well Child Care and Development consultation and applies needed vaccinatons (2) nforms or provides PAP smears (3) breast cancer detecton and (4) STD information return appointment and/or services for famly planning consultation n Table 7 and Fgure 8 we note that for those women m ths group who dd not come requestmg famly planmng, 79% were offered ths servce

15 ... c rf. Figure 8 Used and missed opportumtles. Women n umon, not pregnant, with children under 2 years of age MNSA, Nicaragua ~ ~ ~~~~--~~==~~--~===_ ,---,--_ CHLD VAG FP PAP BREAST SD Service Used Missed However, of the 78 women m ths segment who do not wsh to become pregnant but were not usmg a method only 1 out of 4 receved mformaton and/or famly planmng servce dunng that VSt (Table 8) Almost 75% of these women were offered well chld servces The same Table and Fgure above demonstrate that STHV mformaton was only offered to 3 (l 2%) users m ths segment and a large number of them dd not receve mformaton or screemng for cervcal (70%) and breast (90%) cancer Tables 8 to 11 and Fgures 8 and 9 descnbe servces requested and addtonal servces provded women m other segments n general, we can state that certam servces are offered wth frequency even when not requested by the chent (well chld care and mmumzatons, famly planmng and prenatal care) Other servces are offered With lower frequency, among these postpartum care was offered sporadcally to pregnant women cancer screenmg and STHV mformaton and servces were only offered to a small mmonty of chents

16 Table 8 Famly planning services provided to women m uolon, not pregnant, With chldren under 2 MNSA, Nicaragua July-August 1997 Received service Not received service Total Cases Per cent Cases Per cent Cases Per cent Wants children soon Uses method Doesn't want preg/doesn't use method Total Table 11 Famly plannmg services provided to women m UOlon, not pregnant, not post With chldren under 2 years of age MNSA, Nicaragua July-August, 1997 Received service Did not receive servlc Total Cases Per cent Cases Per cent Cases Per cent Wants children soon Uses methods Does not want and does not use Total c: Q1.. (J Q1 L Figure 9 Used and missed opportunities Women n Union not pregnant not post partum without children under 2 years of age MNSA Nicaragua r- -, 100~ ~~~~~ O~--,- FP PAP BREA.ST SD Service CJ Used 1111 Msse,=-

17 v DSCUSSON ObJectmg to the findmgs presented one mght argue that provders perform best when observed, such as m ths study However, the findmgs, even f they represent better than average provder performance, dentfy elements m the mplementaton of the mtegrated strategy that need strengthemng A second possble ObjectOn to our analyss S that we assgned equal weghts or value to each pomt mcluded m what the MNSA consders S a complete servce This does not allow for makng dstnctons between omtted essental pomts and less mportant omssons ThS queston can be taken up m further studes, but, for the present study, t enables the observer to assure completeness of the servce offered Fmally, ths sample S not a random sample of MN SA's Health Centers Fmdngs cannot be generalzed to the rest of the SLAS or Centers across the country t S probable however, that many of the problems dentfied can be found m other regons V CONCLUSONS ThS report proposes a methodology for measurmg complance With MNSA's norms for delvery of ntegrated Servces for Women and Children The study dentfied both strenghths and weaknesses m the mplementaton of the ntegrated model to date ThS new model mples a sgmficant change n provders' behavor Fndngs show that provders m the observed Centers have adopted the mtegrated servce model and that Opportuntes for offenng prenatal, well child care and famly planrung are beng utlzed wth acceptable frequency n the case of famly planrung servces, however, 33% of the women who do not wsh to become pregnant and don't use brth control, were not offered a method ThS may be due to a deficency n the dentficaton of needs based on a woman's lfe stage n addton, only 26% of unmarred women receved any nformaton on famly plannng and avalable servces, despte the fact that they are vulnerable to unwanted pregnancy There are other elements that have not been ncorporated mto the provder's performance yet and have not receved the same attenton, these nclude postpartum care, cervcal and breast cancer detecton (mcludmg Pap smear and self-breast exam mstructon) and STHV nformaton and servces Of the 82 women who had had a brth m the prevous 2 months and had not had a postpartum exam, for example, only 60% receved ths servce durmg the observed VSt and an addtonal 11 % were gven an appomtment for a return VSt, contravenmg the MNSA's norms for the provson of all needed and available servces m one VSt and nskmg that the woman Wll not return for her appomtment And, of the 160 pregnant women seen durmg the observaton penod, only 49 receved mformaton on the mportance of the postpartum check n the preventon of maternal and chld morbdty This suggests a need to ncrease demand by mformaton and promoton of the servce n the cornmumty Via EC strateges and to strengthen provders' servce offenng to clmc clents

18 Cervcal cancer S relatvely frequent n Ncaragua, affectng approxmately 2% of women over 40 PreventOn of morbdty and mortahty depends on detecton of premahgnant lesons through the use of the Pap smear, ths test, whch S Sad to be avalable n the SLAS, needs to be promoted to women most at nsk of the dsease and all women need nformaton Breast self exam, whch S the only affordable technology for early cancer detecton n developng countres, S a technque that needs to be taught women Fnally, HV and STls are becomng more prevalent and are affectng younger populatons All women n reproductve age (and men) must be offered nformaton on these dseases and need to know how to obtan condoms and access servces f needed V RECOMMENDATONS Gven the relatvely recent ntroducton of the Model for ntegrated Servces whch mples a sgmficant change n provder atttudes and performance, first level provders need contnued assstance and support for ts mplementaton Several recommendatons are lsted below, they are not mutually exclusve 1) ProVders need tramng on the Model and the elements ncluded n t Some provders have been traned but others have not, on-the-job re-tranng can be benefical to both these groups The tranng should emphasze the provlslon of the maxmum number of needed servces m a Sngle VSt ThS wll dlmlmsh mssed opportumtles SupervSors need to be tramed m how to provde SUpportve pedagogc supervson and performance based tranng MNSA would find t useful to modfy and strengthen exstng supervsory nstruments (whle at the same tme decreasng ther number) so that they better reflect the ntegrated servce model New nstruments may mclude checklsts and supervson gudes 2) PrOVders too need tools that assst them n the dentficaton of mdlvldual women's reproductve health needs as well as ther chldren's and n the provson of more complete servces, based on MNSA's norms There are several model mstruments developed n Latn Amenca whch have demonstrated ther utlty for the mtegraton of servces, these tools nclude Smple algonthms that permt the segmentaton of users based on a short senes of questons There S also a need for Smplfied gudes Wth checklsts whch can be used both for trammg and practce purposes 3) To boost demand of mtegrated servces, actual and potental chents need to be nformed through EC both n the chmcs and n the commumty ThS nformaton should nclude the servces that are avalable m the Health Centers, the hours of servces and nformaton that a chent can demand and receve multple servces for her and her

19 chldren m one VSt The mformaton should mclude the mportance to health and preventve character of many of the servces 4) There needs to be regular, yearly or sem-annual momtonng of the mplementaton of the mtegrated servce model The methodology used m ths study could be adapted and smphfied for ths purpose n ths manner, weak servce Stes and elements needmg strengthemng can be dentfied and more attenton can be devoted to them References, Ncaragua, Mmlstry of Health Manual Operativo de AtenclOn ntegral a la MUjer, Nznez y Adolescencla, Apnl 1994 Ncaragua, Mmstry of Health EvaluaclOn del Proceso de mplementaclon del Modelo de AtenclOn ntegral a la MUjer, Nznez y Adolescencza, November 1996 PopulatOn CouncVGuatemala-NOPAL, Algorztmo y Guza para la Oferta Sstematca de SerVClOS de Salud Reproductlva, 1996

20 Yf\J,- AcF-~<=>(Y- q. NOPAL. REPORTE FNAL f o t -::. o "2- TTULO FORTALECMENTO DEL MODELO DE ATENCÓN NTEGRAL A LA MUJER, LA NÑEZ Y LA ADOLESCENCA NSTTUCON MNSTERO DE SALUD DE NCARAGUA MNSA NVESTGADORES MmlsterlO de Salud Dr Dlom Fuentes Dra Blanca Bernard PopulatlOn Councd Dr Carlos Brambda Dra Emma Ottolenghl Dra Ceclha Maurente PERODO JUOlO Agosto, 1998 FECHA DEL REPORTE Juho, 1998

21 FORTALECMENTO DEL MODEW DE ATENCÓN NTEGRAL A LA MUJER, LA NÑEZ Y LA ADOLESCENCA. MNSA, NCARAGUA! NOPAL m, POPULATON COUNCL. ESTUDO SOBRE EL AVANCE DEL MODELO DE A TENCON NTEGRAL EN CUATRO SLAS. MNSA, NCARAGUA TABLA DE CONTENDO RESUMEN 1 L NTRODUCCON 2 n. OBJETVOS" m CONCEPTOS Y DEFNCONES 2 3 V METODOLOGA PARA LA MEDCON DE LA ATENCON NTEGRAL. V 1 PROCEDMENTO DE RECOLECCON DE DATOS 2 CuEsTONARO y GUA DE OBSERVACON 3 PRocEDMENTO PARA \ledr LA ATE... CO.., "EGRAL 4 SEGME'T ACON DE LAS LSl o\ras DEL SER \ lco TAMAÑO Y DESCRPCON DE LA MUESTRA 1 NUMERO DE OBSERVACONES 'r ENTREVST -\S A USUARAS DEL SER VCO 6 2 CARACTERSllCAS DE LAS USlAR-\S E "'RE\lSTADAS 6 3 SEGMENT AcrON DE USUARAS 7 VL RESULTADOS " 7 1 MOTVO DE LAS CONSULTAS 7 2 (,QUE SERVJCOS HAN RECBDO LAS llslfar-\s DELSER\lCO DE ATENCON NTEGRAL A LA MUJER 'r LA N~u? 8 :! AtenclOn recibida por niños menores de 6 años 8 :!:! AtenclOn o/ (/a) menor de dos años de edad 8 :!.; -t/enclon a madres de mño't(q'i) menore" de 6 año<; de edad 9 J' MUjeres embarazadas 10 :! 5 ServiCO de me/odos anticonceptivos 10 3 OPORTFNroADES APROVECHADAS OPORn" r DAD ES PERDDAS 12 VL DSCUSON 13 VR CONCLUSONES 14 oc RECOMENDACONES 15 X. BBLlOGRAFA " 6

22 FORTALECMENTO DEL MODELO DE ATENCÓN NTEGRAL A LA MUJER, LA NÑEZ Y la ADOLESCENCA. MNSA, NCARAGUA! NOPAL m, PO PULA TON COUNCL ESTUDO SOBRE EL AVANCE DEL MODELO DE A TENCON NTEGRAL EN CUATRO SLAS MNSA, NCARAGUA RESUMEN En que medida las usuanas de los sej"vcos del Mmlsteno de Salud de Nicaragua (MNSA) reciben la atenclon que requieren, considerando su sltuaclon personal?, cuales son los problemas y obstaculos para bnndar una aten clan mtegral a mujeres y ruños? Estas son las preguntas que este estudio busca responder Para responder fas antenores preguntas se reahzo un estudio de campo en 17 Centros de Salud, en el que se observaron 854 eonsultas de atenclon mtegral a la mujer y se entrev:tstaron a 841 usuanas del selv100 El estudio se realzo en los SLAS de Boaeo, Carazo, Granada y Matagalpa El estudio buscaba detennmar (1) las caractenstlcas de la mujer que sohclta una consulta (2) las atencones que requiere tanto Ja mujer, como sus hijos, (3) las atencjones que efectivamente recibe durante la consulta y (4) que tan completo es el mterrogatono y la mformaclon proporconada a las chentes El objetvo pnnclpal del estudio fue deterrnmar en que grado se ofrecen consultas mtegrales en Centros de Salud seleccjonados y analzar el ruvel de avance del Modelo de Atenclon ntegral a la MUjer Los resultados muestran un panorama positivo en cuanto a los semclos adcionales que se ofrecen a las usuanas y al mismo tiempo muestran un largo cammo por recorrer Se aprovechan entre 60 y 70 por ciento de las oportumdades para bnndar CUdado prenatal VgilanCia y vacunas a los mños y plamficaclon famlbar Sm embargo se observa poca atenclon a la atenclon post-parto al cancer cemco-utenno y mamano y la valoraclon de enfennedades de transmlslon sexual El estudio dentdico 680 mujeres no embarazadas Entre estas 445 mujeres usaban metodos anticonceptivos en el momento del estudio ( por ciento) y las restantes 235 (345 por cento) no los usan Entre estas mujeres, 89 casos djeron no desear metados antconceptivos (37 87 por ciento) y 146 casos (62 13 por ciento) desean un melodo Se perdlo la oportumdad de bnndar el semelo a 86 mujeres lo que slgmfica un 58 9 por cento de oportunidades perdidas para bnndar metodos antconceptivos a quienes lo necesitan y desean A partir de los resultados del estudio se recomienda reforzar la capacltaclon sobre el Modelo de AtencJOn ntegral y supefvsar utilizando hstas de chequeo y guias dldactlcas Tamblen se recomienda desarrollar o adaptar Dstrumentos de apoyo a los y las proveedores para faclluar su labor y hacer la Atenclon ntegral una realidad

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