Training in family planning for health personnel: report on a WHO meeting, Paris, 6–11 July 1981

C. . .2 World Health Organization • Regional Office for Europe lll Copenhagen Public Health in Europe 20 Training in family planning for health personnel /IQ :jb3 , C. E J'S- JS Tr c.z The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through this Organization, which was created in I 948, the health professions of some 160 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region has 33 active Member States,0 and is unique in that a large proportion of them are industrialized countries with highly advanced medical services. The European programme therefore differs from those of other regions in concentrating on the problems associated with industrial society. In its strategy for attaining the goal of "health for all by the year 2000" the Regional Office is arranging its activitie~ in three main areas: promotion oflifestyles conducive to health; reduction of preventable conditions; and provision of care that is ade- quate, accessible and acceptable to all. The Region is also characterized by the large number of languages sppken by its peoples, and the resulting difficulties in disseminating information to all who may need it. The Regional Office publishes in four languages - English, French, German and Russian - and applications for rights of translation into other languages are most welcome. u Albania . Au,1na. Belgium, Bulgaria, C,echo,lovakia , Denmark, Finland, France. German Dcmo- cratk Republic, Federal Republic of Germany. Greece. Hungary. Iceland, Ireland. Israel. Italy. Luxem- bourg. Malta . Monaco. Morocco. Netherland,. Norway. Poland. Portugal. Romania. San Manno. Spain. Sweden. Swu,erland. Turkey. USSR. United Kingdom and Yugo,lavia. Training in family planning for health personnel L:- ti t> ..Io,; ii:/ , . / /r") / 'l C , Wor!d Healt~ Organization -L ~ Reg10nal Office for Europe ~ • ~ Copenhagen ~ ~ Public Health in Europe 20 Training in family planning for health personnel Report on a WHO meeting Paris 6-11 July 1981 ICP,MCH 025 UNF PA / RMI /79/805 ISBN 92 890 1156 4 © World Health Organization 1985 Publications of the World Health Organization enjoy copyright protection in ac- cordance with the provisions of Protocol 2 of the Universal Copyright Convention. 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The views expressed in this publication are those of the participants in the meeting and do not necessarily represent the decisions or the stated policy of the World Health Organization. PRINTED I DEN MARK ISSN 0300-4880 CONTENTS Page Introduction I. Present positi o n with regard to the teaching 2. of fami ly planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The teaching of fam il y planning at medical . nursing and midwifery sc hools in various co untries of the Region - F. Puech and W. Haddad 5 Co mplementary study on the teaching of fami ly planning - M. Pechevis . . . 17 Summary of di sc uss ions 28 Introduction to aspects of family planning 29 Pro blems in the teaching of fam il y planning and sex ua lit y - M. Man ciaux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 S tra tegy for teaching human reproducti o n and fami ly planning - P. 0. Hubinon r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 I The soc ia l sta tus of women a nd family planning in developing cou ntri es - M. Ladjali and F. Oussedik 36 Ro le of the woman in fa mil y pla nning - D. Nardini-Maillard . . . . . . . . . . . 40 Commu nit y diagnos is - T. Amar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Psychosocial and educa tio na l aspects of fa mily planning - Ph. Lecorps . . . . 50 Eva lua tio n of fa mil y planning act ivities - £. Wol/asr 53 Pedagogica l support to fa mily planning programmes - M.A. C. Do wling 55 3. Activities of stud y groups: some reOections o n training in family planning - K. Edstrom . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Definition o f the functions of different profess ional groups in fa mily planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Pro posa ls fo r teaching fam il y planning to different categor ies of hea lth personnel on the basis of the defined functions . . . . . . . . . . . . . . . . 62 Strategies for a pplica tio n of the forego ing proposa ls to curri cula . . . . . . . . . 71 4. Presentation and di scussion of a draft educational handbook 77 Reasons for an educa tio na l handbook . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 V 5. The final content of the handbook The present state of the handbook Draft teaching package on psychosocial aspects: 78 78 the health professional/client relationship . . . . . . . . . . . . . . . . . . . . . . . . 78 Summary of discussions following circulation of the teaching package . . . . . 83 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Summary of plenary meetings grouped by topic Relations between health personnel and the community 87 87 Organization of new types of training . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 6. Recommendations and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Annex I. Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 VI Introduction Training in family planning for physicians, nurses, midwives and other health staff appears to be very unsatisfactory in most countries of the European Region at present. The WHO Regional Office for Europe and the International Children's Centre (ICC), which have together been holding courses in this field since 1973 with the financial assistance of the United Nations Fund for Popu- lation Activities (UNFPA), decided that an international conference should be convened to review the situation with regard to training in family plan- ning and to determine what such training should be based on if it is to meet the true needs and requirements of the populations concerned. The conference, arranged jointly by WHO and ICC, was held at the offices of the International Children's Centre in Paris and brought together participants from 21 countries (Algeria, Belgium, Bulgaria, Czechoslo- vakia, Egypt, France, the German Democratic Republic, Greece, Hungary, Italy, Madagascar, Morocco, Nigeria, the Netherlands, Poland, Portugal, Sweden , Tunisia, Turkey, the United Kingdom, and Yugoslavia), repre- sentatives of WHO headquarters and the WHO Regional Offices for Europe and the Eastern Mediterranean, the United Nations Fund for Population Activities, the United Nations Educational, Scientific and Cultural Organ- ization (UNESCO), the International Children's Centre and other inter- national bodies (the International Federation of Gynaecology and Ob- stetrics, the International Confederation of Midwives and the International Planned Parenthood Federation). Professor E. Aujaleu was elected Chairman and Mr P . Lecorps Rapporteur. Dr Nafis Sadik, Assistant Executive Director and Chief, Programme Division, United Nations Fund for Population Activities, stressed the im- portance attached by the Fund to the training of personnel. In practice, this appeared to be one of the most effective ways of strengthening the insti- tutional capacity of countries in the family planning sphere. Thus , out of the overall UNFPA budget devoted to family planning, one fifth had been allocated to training. The rise in the costs of programmes also required a new look at the concept of family planning and its public health com- ponents. Training programmes should therefore be reshaped in line with the new directions taken by family planning policies. The latter formed part of the maternal and child health programme and social strategies in general; bu't before introducing programmes it was essential to arrive at a better understanding of the organization and way oflife of different communities. Dr Sadik concluded by calling on participants to pool their experience in order to provide new solut ions. Dr A. Wojtczak, Director, Research, Planning and Human Resources at the WHO Regional Office for Europe conveyed to the participants the best wishes of Dr Leo A. Kaprio, WHO Regional Director for Europe. He recalled resolution WHA30.43 of May 1977 under which the Thirtieth World Health Assembly had defined WHO's goals for the twenty-first century . The Regional Office for Europe was playing a full part in the worldwide strategy to ach ieve "health for all by the year 2000". The "health for a ll" concept embodied a wide variety of concepts but presupposed the use of available resources to achieve a better life . Every society had to determine what was essent ia l as a function of its manpower and economic resources . It would therefore be a question of, at one and the same time, promoting the adoption of lifestyles conducive to health, of reducing the incidence of preventable diseases and of providing acceptable care that was accessible to all; and in each of these domains family planning had a part to play. One could not help feeling pleased at the convening of this meeting, crowning as it did the long cooperation between WHO and ICC as well as other ce ntres in Europe. The time had come to evaluate the programmes and to find new approaches and more effective means of action. After thanking Dr Sadik for the assistance from UNFPA, Dr Wojtczak expressed the hope that the discussions wou ld be both enriching and stimulating. Dr Angela Petros-Barvazian, Director, Division of Family Health at WHO headquarters, conveyed wishes of success to the conference from Dr Halfdan Mahler , Director-General of WHO. She expressed her recog- nition of the part played by the Regional Office for Europe and ICC in training in fami ly planning and thanked Dr Sadik for the UNFPA con- tribution in the areas of staff training and the development of family planning programmes. During the past 20 years relations between WHO and developing countries with regard to family planning had undergone considerable change. Initially it had been necessary to answer the question of "why" family planning was necessary. It was now essential to answer the question of "how" to improve services. What was important was to provide arguments on the va lue of spacing pregnancies, on the structure of family development and on the recognition of the rights of couples, in such a way that the countries would provide their populations with services that left room for choice. It was now important to find the best possible way of organizing services at every level to meet the needs of the community. The 1960s had been devoted to the study of what needed to be taught and the 1970s to the method of teaching; the 1980s should be used to deal with what was taught and how to teach it. It was imperative to find out how to prepare health workers without falling into the trap of overprofessionaliz- ation of simple problems, seeking a proper balance between training content 2 and training methods. She therefore called upon conference participants to display a spirit of innovation and suggest the direction that should be taken by training. Mrs M. T . Pierre, Deputy Director for Motherhood, Childhood and Specific Health Actions at the French Ministry of Health , speaking on behalf of the Minister, welcomed the participants and assured them of the great interest aroused by this conference . In a brief historical summary she noted that it was not until 1967 that a law provided free access to contra- ceptive methods in her country, where there was no problem of excessive births since, despite restrictive laws, there had been effective fertility control practices since the eighteenth century . The fact was that in the modern day, women had new demands in relation to sexuality. In an existence where everything was programmed, and there was a right moment for every event, an effort had to be made to control fertility. In granting this right to women the State had supported the financial implications; it had set up reception centres, 600 family planning and education centres and 2000 information posts. The situation was not satisfactory, however, and the discussions during the years 1975-1979 showed that abortion still had an important part to play in France. Major questions remained unanswered. There was no question today of dispensing with specific institutions or personnel such as marriage counsellors, but it was important to stress the training and role of all health personnel because they remained the best sources of information in this sphere. The move towards training was in line with the expectations of communities as well as the wishes of personnel who had a role to play that went beyond purely physical factors to concern itself with persona l matters. All health personnel should be prepared to li sten to those attending for consultations , to assist them both when they did not want to have children and when they did. She was convinced of the great interest represented by the conference; it should permit not on ly the knowledge and ski ll s of health personnel to be improved but also their attitudes. Professor M. Manciaux described the International Children's Centre, referring both to its history since being founded in I 949, and to its training, information, documentation and applied research activities. 3 1 Present position with regard to the teaching of family planning 0 The teaching of family planning at medical, nursing and mid- wifery schools in various countries of the Region F. Puech and W. Haddad A n intelligent view of pro blems co nnected with huma n reproduction, including the need fo r fa mil y pla nning, goes beyo nd the simple q ues ti o n of pa renta l res po nsibility; it is a lso a q ues tio n of res po nsib ilit y m med ica l practice. Hea lth pro fess io na ls shou ld acce pt g rea ter res po nsibility in ma tt ers co nnected with huma n re prod ucti o n, incl uding sex ua l behavio u r, sin ce it has to do with a n improve ment in the qu a lit y of li fe. Fo r the exerc ise of tha t respo nsibilit y, hea lth personne l mus t have bee n prepa red to inform , presc ribe, ad vise, superv ise, guide, refe r, in ter ru pt , a lter a nd pass judgements in res pect of the cont race ptive technique utili zed . As is sho wn in F ig. I, th ere a re ma ny o ther ca tegori es o f perso nnel co nce rned with pla nning, who sho uld a lso be give n suit a ble t ra ining: psych- o logists, psychi a tri sts, sexologists, fa mil y o r marri age counse llo rs, soc ia l workers, lawye rs, teachers at d ifferent leve ls, etc. With rega rd to the edu- ca tio n of hea lth perso nnel, howeve r, it is to be reg retted tha t a lth o ugh there is a high deg ree of exce ll ence so fa r as the tra ining of doctors, midwives a nd nurses in the hea lth ca re o f the indi vidua l is co nce rned , no t a ll the des ired importa nce has bee n a ttached to the questio n o f sex ua lit y a nd fa mil y pla nnin g. Thi s a t leas t is wh at ca n be es ta blished fr o m a study o f the present state of famil y pl anning educa ti on in medica l, nursing and mid wifery schools in seven co untri es in Europe (betwee n o ne a nd th ree uni ve rsities we re visited in each country, i.e . a to ta l o f 19 de pa rtments o f gy naeco logy a nd o bstetrics, a nd schools of midwifery a nd nursin g). The purpose o f the study was no t to pass judge ment o n whet her o r no t the rol e a nd prio rity a lloca ted to the three ca tegori es of perso nnel was well founded even if it is o bvious tha t a p ro per dist ributio n of labo ur is bo und a This chapter summarizes the resu lts of a study carr ied ou t in 1978 by the Regiona l Office fo r Europe a nd an addi tio na l study in 198 1 of co unt ries no t included in the ini ti a l su rvey. 5 Fig . 1. Ca tego ri es of personne l co nce rn ed with family p lanning to increase the effectiveness of se rvices provided to the community. It was rather to establish whether training, both theoretical and practical, was suited to the work assigned to the various types of personnel. The study related to: (a) theoretical training - number of teaching hours provided; - priority given to various aspects of family planning: medical and technical questions, marital psychology, sexology, socio logy; - distribution of this teaching in the various years of study; - teaching methods used: traditio nal (lecture sys tem) or active (discussion groups, case studies, etc .); - type of teaching (whether or not multidisciplinary). 6 (b) practical training - time a ll oca ted to prac ti ca l tra ining, a nd length of practice; - organization of places for practical work; - teaching staff, thei r tec hnica l knowledge of the psychology of education a nd sexology; - eva lua ti o n of the importance a ttached to suc h teaching by check- ing o n the knowledge acq uired; - continu o us ed ucat ion, whether o r not arranged by hea lth se r- vices, with the pa rticipati o n of profess io nal bodies, etc .; - ro le and place of genera l prac titione rs, midwi ves a nd nurses in family pla nning. It sho uld be stressed that it was a selective study in between o ne a nd three unive rsiti es in each of the countries visited a nd tha t the conclusions apply o nl y to those institutions seen, which may not necessari ly be representative of a ll universiti es and schools in the various countri es: F rance, Ital y, the Netherlands, Po la nd, Sweden, the United Kingdo m a nd Yugoslavia. Teaching at medical schools University teaching The length of university courses is more or less the same in a ll the countries visited, between five a nd six years . Fig. 2 shows the distribution of family pla nning teaching in various co urses o f medical training. The teaching of contraception is shown in black and that of psychology and soc iology in grey, while the dotted segments indica te where teaching is optional. It will be noted that the di st ribution of theoretical teaching during studies differs wide ly according to the co untries visited: o ut of the 13 univers ities visited in France, It a ly, Po land , Sweden, United Kingdo m a nd Yugoslavia, 9 provide family planning teach- ing mainly at the end of the course; the two uni versi ti es visited in the Netherlands (Leiden a nd Amster- dam) a nd two of the three universities visited in the United Kingdom (Edinburgh and Southampton) had tra ining in gynaecology, ob- stetrics and family planning firml y attached to their studies in general. It should be noted that in the three Italian universities visited, family pla nning matters come under a sepa rate certificate o r a re included in the human reproduction certificate, but are always optional. With regard to the number of hours allocated to the teaching of family planning, it should be noted that whereas the number of hours se t aside for purely medical problems (co ntraception, abortion, ste rility, etc.) is rela- tively clearly defined, a lbeit not the same everywhere, the lack of precision 7 C: 0 ·g ., E C: 0 Cf) u 0 I 0 _c u Cf) cu u "O QJ E -cu Ol C _c u cu QJ -Ol C C C cu o_ > E cu ..,_ ..,_ 0 C 0 :J _o ~ - Cf) 0 8 > 0 , 0 0 ·~ ,: 0 , 0 0 .c u > .r I ;-----~ ,---------------------1 ~ - - - - - '- - - - - - - - - - - - - - - - - - - - " " " , - - - - - • ,- - - - - - - - - - - - - - - - - - - ~ ~ - - - - - ·'- - - - - - - - - - - - - - - - - - - - ~ ,_ _ _ _ : ~ --:~ . . . . . - - - - - - - - - - - ~ N Southam pton Edinburgh London Am sterdam L eiden France R om e (Catholic University) R om e (State U niversity) Bologna N ovi Sad Belgrade W arsaw Sto ckholm increases when it comes to calculating the number of course hours on sexuality, marital psychology and sociological aspects of family planning. The results are shown in Table I. The second column gives the number of hours in medical teaching, which range between I and 15. The third column shows the wide variation in the number of teaching hours set aside for the teaching of sexuality, ranging from I 5 to nil (the term integrated teaching can be a synonym for imprecision). This is particularly true for the teaching of psychology and sociology, and the only place for which details have been obtained is the University of Leiden where two hours are set aside for family planning. Practical teaching and training is given at the end of studies in a ll of the universities visited except the University of Southampton, which provides practicals from the first year onwards. The last column gives the length of clinical work in gynaecology and obstetrics (GO) and family planning (FP). The family planning clinical stage is most often integrated with the gynaecology and obstetrics clinical phase. The use of crosses in this column is an attempt at qualitative appreciation of the importance given to family planning during the gynaecology and ob- stetrics clinicals. In most of the countries visited all students undergo a clinical phase in the gynaeco logy and obstetrics department, except in France where a certain percentage attend voluntarily and in Italy where the clinicals are not ob- ligatory ( except at the Catholic University of Rome where all students have access to hospital departments). Clinical practice in gynaecology and obstetrics departments is of varying length. It should also be noted that practical periods spent in obstetrics and gynaecology departments do not necessarily signify access to family plan- ning consultations. Although access to antenata l consultations is the rule, attendance at family planning consultations is not included in the syllabus for students in Bologna, or in Rome at the State University or the Catholic University, and it is a lmost non-existent at the University of Stockholm, where clinical practice in this sphere is set aside for student midwives. It should be noted that post-confinement units in the maternity depart- ments of the university hospital centres provide, where there is no access to family planning consultation centres, a particularly good opportunity for teaching contraception "around the post-partum bed", and one which does not a lways seem to be used as well as it might be. The integration of all teaching in the clinical period spent on the gynae- cology and obstetrics wards, as is the practice at University College Hospi- tal, London, and soon to be the case at University College Hospital, Edin- burgh, seems very promising but presupposes deep-rooted changes in the teaching of medicine. In most of the traditional universities visited the teaching methods remain by and large based on the lecture approach. A perceptible movement towards active methods can be felt at certain universities, for example 9 Table 1. Family planning teaching at medica l schools Medical Psychology Family planning Place Sexuality and teaching soc iology clinical work Stockho lm 8 hours 4 hours Integrated G0 8 approx . 4 weeks FPb 0 Warsaw 6 hours Integrated Integrated GO 1 7 weeks FP +++ Belgrade > 10 hours Integrated Integrated GO 1 14 hours FP +++ Novi Sad 1 2 hours Integrated Integrated GO FP 2 weeks Bologna 2 5 hours 3 hours GO 0 optional optional FP 0 Rome (State 1 -2 hours 0 Integrated GO 0 University) FP 0 Rome 2 5 hours GO 8 weeks (Catholic 0 University) optional FP 0 Tours 8 hours 1-3 hours Integrated GO approx . 12 weeks FP + Leiden 1 5 hours 1 5 hours 2 hours GO 10 weeks FP +++ Amsterdam 1 5 hours 5 hours Integrated GO 16 weeks FO +++ London 7 hours 8 hours Integrated GO 15 weeks FP +++ Edinburgh 10 hours Integrated Integrated GO 8 weeks FP + Southampton 7 hours 5 hours Integrated GO 10 weeks FP + a GO: gynaecology and obstetrics. b FP: family planning . mostly integrated with the gynaecology and obstetrics clinicals. The number of crosses is an attempt at a qualitative assessment of the importance attached to family planning during the gynaecology and obstetrics clinicals. 10 Stockholm, Warsaw, Novi Sad and Southampton. For its part, the Uni- versity of Leiden appears to have integrated active methods in its teaching of family planning particularly effectively. Audiovisual aids are used at all the universities, but the best equipped is the University of Leiden where courses are recorded on video-cassettes and are permanently accessible to students who can also check the progress of their knowledge using a multiple choice test paper, thereby obtaining im- mediate verification. Postgraduate education Specialist training in gynaecology and obstetrics ranges from four to seven years. Training in family planning varies: extensive provision for it is made in every country except France, Italy and Sweden . In Sweden, it is the result of deliberate disinvolvement , family planning being the province of midwives. Continuing education Continuing education is provided in all countries visited. Several different approaches are possible: courses outside working hours (evening courses, weekends); discussion evenings, seminars; short courses (several days) on gynaecology and obstetrics wards. Among the basic conditions for attendance at such continuing education courses (where they are not mandatory as in the Eastern European coun- tries) the following must be noted: reimbursement of costs; relevance of the subjects studied; teaching of high quality (in terms both of teaching methods used and of practical content). In the United Kingdom, two interesting approaches to continuing edu- cation in family planning are worth referring to: the first is training in family planning leading to the award of a diploma; the second is multidisciplinary weekend seminars on family planning. These courses are subsidized by the Department of Health and Social Security and the World Health Organization. They have been a great success and have now been extended to other centres in the country. These three-day multidisciplinary courses, held several times a year, are intended for general practitioners, physicians working as family planning instructors, and specialists, but are also attended by medical students, teachers, social workers, nurses, midwives, lawyers, etc. 11 The teaching of family planning at nursing schools Basic education Courses o f study leading to the award o f a nursing diplo ma va ry between two a nd four yea rs in the different countries visited. Theo reti ca l t ra ining in fa mily pla nning was parti cularl y poo r a t a ll the nursing schools visited . Purely technica l tra ining las ted "a few ho urs" , ra nging fro m simple in fo rm atio n sess io ns, as a t Bo logna, to seven ho urs o f special tra in ing, as a t the Natio nal Ass ista nce School of Nurses in Pa ris. Survey results a re given in T able 2. Tab le 2 . Teac hing of famil y pl annin g at nursin g sc hoo ls Place Length of Family Sexua lity Practica l tra, n,ng course p lan ning Stockholm 2½years a few hours GOa 4 weeks in teg rated FPb almost 0 Wa rsaw 2 yea rs a few hou rs GO 40 hours 5 yrs+ 2 FP almos t 0 Be lg rade 4 yrs+ 1 3-4 hou rs GO FP almos t 0 Nov, Sad Bo log na 3 yea rs 1nfo rma t1 on 0 GO 3 mo nths only FP 0 Rome (State sys tem) Rom e (Cat ho li c 3 yea rs 3 yea rs 0 0 system) Pari s 2½ yea rs 7 hours 0 GO 2 wee ks FP 1 - 2 c lasses Leid en 3½yea rs 4 hours 2 hours FP 0 Am sterd am 3½ years integ rated 6 hou rs GO 3 mon th s FP almos t 0 Lon don 3 yea rs 2 hours GO 1 2 weeks FP almos t 0 a GO (lynaeco logy and obs tetrics b FP family planning 12 Teaching o f sex ua lit y is prac ti ca ll y no n-ex istent in a ll co untri es apa rt fr o m the Netherl a nds (two ho urs a t Leiden a nd six ho urs a t the Amsterda m School o f Nursing). F ina ll y, no nursi ng school has a rra ngements fo r practi ca ls a t fa mil y pla nning centres; those give n in depa rtments o f gy naeco logy and obstetri cs va ry in length betwee n o ne week a nd three mo nths. Postbasic education and continuing training In addi t io n to bas ic ed uca t io n, add itio na l tra ining leading inter alia to the dipl o ma of public hea lth nurse , exis ts in courses las t ing an ex t ra 1-2 years. T ra in ing in fa mil y pla nning is na tura ll y give n more we ight th a n during bas ic educa tio n (fo ur ho urs of theoreti ca l teaching o n average) but is still no t eno ugh. Public hea lth nurses, howeve r, have a n impo rt an t ro le in fa mil y pl a n- ning, pa rti cul a rl y in rura l a reas , but their tra ining, it has to be admitted , then depends o n th eir persona l in teres t in the matter. It should be no ted tha t in the United Kingdom such "adva nced" tra ining, bo th fo r midwi ves a nd nurses, is rema rka bly we ll orga nized a nd incidenta ll y refl ects the under- sta nding tha t public hea lth nurses have d emo nst ra ted fo r ma ny decades in the ro le th ey have to play in fa mily pla nning. T heir ro le as adv ise r a nd ass is ta nt to the phys ician is incidenta ll y in the p rocess o f being extended to mo re impo rta nt responsibilities such as the prescripti o n o f contrace ptives a nd inse rti o n o f intra uterine devices, through experim ents tha t fo r the mo ment are o n a pilo t bas is (Lo ndo n). Teaching of family planning in schools of midwifery Results of this s tud y a re summari zed in Table 3. Basic education Studies ra nge in dura ti o n fr om two to fou r yea rs, with the nursing diplo ma being a prerequisite in most oft he count ries visited (except in Fra nce a nd the United Kingdo m). Th eoreti ca l t ra ining in fa mil y pl a nning va ri es widely a nd ge nera ll y co rres po nds to the leve l of respo nsibilit y in the matt er a lloca ted to the midwi ve. T he mos t comprehensive t ra ining is u ndoubted ly tha t prov ided in Swe- de n, with rega rd bo th to th eo reti ca l t rain in g a nd to p rac ti ca l fi eld tra ining a nd practi ca ls a t fa mil y pla nning ce ntres . Th is is to be expl a ined by the fact tha t it is the mid wifery p ro fess ion tha t is respo nsible fo r fa mil y pla nning pro blems as a whole. In the Netherl a nds a nd Pola nd th e programme, a ltho ugh less ex tensive parti cul a rl y in practica l terms, is nevertheless bett er t ha n the ave rage level of teaching in medica l schools. At the sa me time, teaching in hum an rela tions betwee n the two sexes rema ins inadequa te, in part icul a r in France, Ita ly a nd the United Kingdo m, and see mingly in Yugos lavia too . Access to fa mil y pl anning consult a tio ns is thoro ugh enough a nd effecti ve eno ugh to be o f use in most o f the countri es visited . 13 ..... Tabl e 3 . Tea ching of fa mi ly p lann ing at mi dwi fery schools ~ Psychology. Place Length of Medical Sexuality sociology. Family Cont1nu1ng education course education teaching planning methods Stockholm 2 ½ years integrated integrated 1 4 hours PWa 60 hours 4 weeks 2 years of > 10 hours> TCb 6 weeks obliga tory. every practicals 1 0 years Warsaw 2 '/, years B hours 5 hours 2 2 hours PW integrated 1 month 2 years of TC 2 weeks obligatory. every practicals 5 years Belgrade 4 years 4 hours 2 hours PW B hours 5 days per annum TC approx 2 weeks Bologna 2 years 4 hours 0 PW ;;:;o ;;:;o TC ;;:;o Rome !S tate 2 years approx. approx. TC 2 weeks system) 1 3 ho1Jrs B hours Rome !Catholic 2 years approx approx . PW approx 1 0 hours once every 4 years system) 5 hours 1 hour TC ;;:;o non-obligatory Pari s 3 years 6 hours ;;:;o > 2 hou rs PW 4 hours once a year TC approx 2 weeks 3 half days Leiden 3 years Integrated 5 hours 55 hours TC 6 weeks 1 0 hours Uni ted Kingdom 2 years 2 hours ;;:;o PW 40 hours government-TC 2 consultations organized lectures a PW practical work b TC mserv1ce training courses It sho uld be no ted that in co nt ras t to the medica l schools, acti ve teaching methods such as group di scuss io ns, sociod ra mas, etc. are widely used in most midwifery schools in the Netherl a nds, Pola nd and Sweden. Advanced training G enerall y spea king, whatever the country visited , the mid wi fe instructo rs in cha rge of tra ining have a n exce ll ent background in the psycho logy o f educatio n. Continuing education Two types o f t ra ining sho uld be contras ted , o ne being continuing educatio n pro perl y spea king a nd the othe r consisting o f simple additio nal bas ic tra in- in g to fill in the ga ps in t ra inin g progra mmes that a re too superfic ia l, a nd to help midwives acquire responsibil ities in the fa mily planning sphere. Facilities ex ist fo r refr es her tra ining in Po la nd , Sweden a nd Yugos lavia, where it is o bli ga to ry, with a n integral fa mil y pla nning compo nent. No n- ma ndato ry facilities also ex ist in France, Ita ly, the Netherl a nds a nd the United Kingdom. Provision o f add iti o na l t ra inin g in family planning giving eno ugh knowledge to permit respo nsibilities to be ass um ed is a majo r concern in the Netherla nds, Sweden a nd the United Kingdo m. In Sweden, acce lera ted t ra ining has been a rra nged , co nsisting o f a minimum of ten ho urs of lectu res fo llowed by p racti ca l work, fo r those midwives who gradu ated fro m midwifery school befo re 1973 (when the teaching o f famil y pla nning was strengthened) . In the United Kin gdo m the " 900 co urse" helps fill in the ga ps in uni- versity co urses th at a re timo rous where family planning is concerned . In the Netherl a nds additio nal training o f the sa me type gives midwives practising in hospita l centres the kno wledge needed to exercise responsi- bi lities for day-to-day interve ntio ns a t fa mily pla nning centres. Conclusions In co nclusio n, irrespective of the country's health policy the impo rt ance o f family plann ing is no wadays recognized by governments, medical schools and schools of nursing and midwifery. This is for a number o f reasons , inter alia: the wo rld popula tio n explos io n; the reali zatio n o f the need to ensure health and vita lity for women and chi ldren; the need for and impo rtance of reducing the number of abortio n requests . As all these "findings" have been understood and clearl y sta ted in most o f the countries visited we sho uld sum up by asking two questio ns: does the present distributio n of functio ns and responsibilities make for an o ptimum " yield" in se rvices designed for wo men , married couples a nd children? 15 is training in famil y pla nning in u01vers1t1es and a t nursing a nd midwifery schools in line with the rea l needs in the fi eld? With rega rd to the first questio n it is clear tha t , in o rder to a rrive at a bett er understa nding o f the p ro blem as a whole , the di stributio n o f tasks and respo nsibilities rela ting to famil y pl anning must be drawn up . This varies widely fro m o ne co untry to a nother. In Fran ce, fa mily pl a nning is beginning to be rea ll y ta ken over by the Sta te. G eneral practitio ners a nd specia lists a re in charge o f technica l aspects while the functi o ns o ft he midwife a re limited to the provision o f in fo rmatio n. For the mo ment the nurse has o nly a negligible role. In Italy, fa mily pl a nning is o nl y in the ex perim enta l phase but the infras tructure is being se t up ve ry fas t , in pa rti cul a r in no rthern Ita ly (B o logna) where public hea lth nurses a re to have a n impo rta nt rol e. In the Netherlands, 95% o f a ll fa mily pl anning, at least in its purely technica l as pects (cont raceptio n) , is provided by the general practi- ti o ners. Nurses/midwives wo rking in hospita ls have in recent times ta ken over respo nsibility fo r ora l contrace ptives a nd fo r IUD in- se rtio ns. In Poland, co nt racepti o n is in the ha nds of the gy naeco logist and o bstetri cia n while the mid wife acts as technica l ass ista nt ; the publi c hea lth nurse has a real ro le o nl y in rural a reas. In S weden, there is a n even d istributio n between the genera l prac- titi o ners a nd midwives, responsible fo r 56% o f co ntraceptive ac- ti vities; as in the Netherl ands a nd the United Kingdo m the gynae- co logist a nd o bstetricia n act as consult ant s. In the United Kingdom, genera l practitio ners, a nd in pa rti cular famil y planning phys icians , are very active but hea lth visito rs a re respo nsible to a la rge extent for se rvices in thi s fi eld ; fo r the mo ment they do not have the ri ght to prescribe. In Yugoslavia, it is the genera l medica l prac titi o ner who has the key ro le, while nurses a nd midwi ves both act as in fo rma nts at fa mily pla nning centres. To deal with the essential tas ks of fam ily planning (i .e. counse lling in contraceptio n, sex ua lity a nd co nj uga l pro blems), belier dis tribution of re- sponsibilities wo uld see m to be des ira ble in so me countri es a lo ng with belier training fo r the different ca tego ri es of personnel in charge of famil y pla nning. As has a lready been stressed , th e na rrow scope o f the stud y in ques tio n, limited as it was to medical , nursing a nd midwifery schools, sho uld no t lead 16 us to ignore the fact that family planning remains a team task, where psychologists, social workers, lawyers, etc. all have an essential part to play. With regard to the second question, i.e. whether training in family planning at uni versities and nursing and midwifery schools meets real field needs, there can be no single reply but rather a number of answers, each one resulting from the way family planning systems operate in the different coun tri es. . For example, although the teaching of family planning does not seem to be adequate in the Swedish universities , in practice this is a deliberate choice in line with the decision to give priority to student midwives in allocating field work places at family planning centres. In other countries, the same type of teaching appears to be clearly in short supply, given the responsi- bilities for it allocated to medical practitioners. Complementary study on the teaching of family planning M. Pechevis At the beginning of 1981, a study was undertaken to co llect information on the present teaching of family planning (basic education and refresher training) for different categories of health personnel in the countries repres- ented at the conference but not included in the study carried out in 1978 at the request of WH0. 0 Out of the I 3 countries contacted, ten replied to the questionnaire: Algeria, Belgium (midwives and nurses), Bulgaria, Egypt (training of mid- wives and nurses), Hungary, Portugal, Spain, Tunisia, Turkey a nd Yugo- slavia. The questionnaires were sent out to offices responsible for the training of personnel at ministry of education (in particular for physicians) and ministry of health levels . In addition, some teachers were contacted directly. Results of the study Role and responsibilities of different categories of personnel (Table 4) General practitioners act as informants o n family planning in almost all countries included in the study. Moreover, in most countries they are in charge of prescribing "medical" contraceptive methods , in particular the pill, and of monitoring and supervising contraception. In Turkey, one of their tasks is to supervise the midwives. Gynaecologists and obstetricians obviously have a more extensive role and appear everywhere to act as "technicians" in the family planning sphere. Their role in Turkey in supervising general practitioners and mid- wives is a lso noteworthy . a Unpublished WHO document ICP/ MCH-UNFPA/ RER 72/ P09. 17 -00 Tabl e 4 . Role and responsibilities of different categories of personnel Categories of personnel Medical personnel Role and respons1bil1t1es 1n family planning M1dw1ves Nurses Social Others General Gynaecologists workers medicine and Others obstetr1c1ans Information / counsel! 1ng +++ + paed1atr1c1ans +++ +++ +++ pharmacists (Tun1s1a) psychologists (Hungary) Record-keeping + + (Egypt) (Egypt) Prescr1pt1on of ··s1mp1e·· methods + (Tu n1s1a) Prescr1pt1on of the pill ++ +++ D1str1but1on of pills + + (Egypt) (Egypt. Turkey) Doc to(s assistant ++ \0 Table 4 (contd) Surveillance / mon1tori ng Referral to specialists IUD insertion " Surgical " methods Supervision Education of schoolchildren Counselling in the social and legal sphere Disturbances to the sex life +++ ++ + (Spain) + (Turkey) + (Hungary) all countries +++ +++ -- +++ + (Turkey) ++ some countr ies + (Turkey) + (Turkey) + one or two countries " spec ialized surgeries (Bulgaria) sexo logis ts (Spain) Among the other medical specialists, it is the paediatrician who is referred to most frequently, his role being basically at the information level. In most of the countries midwives act as informants and provide edu- cation in family planning matters, with only a few countries giving them an active part to play where they prescribe "simple" contraceptive methods or distribute pills. In Turkey they are beginning to be involved with IUD insertions. Nurses have more or less the same roles s midwives. It shou ld be noted that in Hungary midwives and nurses have no specific responsibilities in family planning. In Belgium only "graduate social nurses" have a major part to play in fami ly planning. Social workers are the category most frequently referred to as counsellors in everything related to fam ily health. In practice, as has been noted by some workers, in those countries with no precise family planning policy roles vary very wide ly and depend on the interest displayed by members of the health professions in family planning and o n their individual awareness of the problem. Basic medical education (Table 5) The amount of time devoted to the teaching of fami ly planning ranges between 4 and 20 hours depending on the country studied (theoretica l teaching). Practical training should a lso be added (clinical work whose duration and content is not given in precise detail). Teaching is by and large concerned with technical aspects (studies of different contraceptive methods) and steri lity. On the other hand, psycho- logical aspects, sexology and abortion are much less frequently specifica ll y attended to in teaching. Such teaching is generally integrated with other subjects and in most countries takes place during the fou rth or fifth year of medical studies. In Portugal, however, it is spread over fo ur years from the third to the sixth year of study. Training of specialists It was not possible to obtain precise information on the training of gynae- cologists and obstetr icians in family planning. There are wide variations from one country to another and the importance attached to training in this field depends on the interest displayed in it by teachers and students. It is a noteworthy fact that in Hungary teaching of different aspects of fami ly planning is combined together in a two-week course. Fut ure paediatricians receive some training in family planning in some coun tries (Bulgaria, Tunisia) . For other specialties (cardiology, psychiatry), fami ly planning remains an optional subject. Basic training of midwives and nurses The amount of time devoted to the training of midwives in fami ly planning ranges between 2 and 10 hours depending on the country and this training is given as part of training in other fields. In Algeria it remains a n option, as part of the six hours set aside for "organization of MCH" and therefore depends on the interest of instructors and teachers. Technical aspects are 20 Table 5. Training of medical students: teach ing of fam ily planning in medical schools Topics In or aspects of family plann ing Algeria Bu lgaria Hungary Portuga l Spain Tunis ia Turkey Yugoslavia Study of the various yes 4 hours 2 hours 3 hours 7 hours 6 hours 2 hours contraceptive techniques 4th year 4th yea r 4th year 5 th year 4th year 5th year 4th year 4th -5 th year Psychological aspects of family planning 1 hour 2 hours - 6 hours 4th year 5th year 1st year 4th-5th year Aborti on 4 hou rs 1 hou r Not stated 2 hours 2 hours 4th year 4th year - 4th-5th year Sterility yes 4 hours 1 hour 2 hours 4 hours 4 hours 4th year 5th year 4th year 5th year - 4th - 5th year Disorders of sexology (1nclud1ng sex life) 2 hours 3 hours 1 hour 5th year 6th year 4th -5th year Demographic aspects of family planning 2 hours 1 hour 1 hour 5th year 4th year 1st year 4th -5 th year L1sten1ng and conversational techniques Throughout Discussions 3 hours In fam ily planning the family during 4th - 5th year planning service course meetings 5th year Other aspects: con t raceptive pharmacology 3 hours 3rd year sexu ally transm1ss1ble diseases yes 4th year No of hours: theoreti ca l (4) 16 5 14 7 6 or 12 12 -20 N - practical (2) yes yes yes - 40 no yes yes dea lt with on a regul ar bas is but psychosocia l as pects, sex educatio n and t ra inin g in li stening a nd conve rsa t io n see m to be by a nd la rge absent fro m this type of tra ining in mos t of the co unt ries. At the sa me tim e it is often d ifficult to unde rsta nd the impo rt ance give n to a nd the exac t cont ent o f t ra ining in fa mily pla nning, as it is co mbined with tra ining in o ther wider di sciplines such as "obstetri cs, hyg iene a nd nursin g ca re" a nd " psycho logy a nd teac hing methods", as in Belgium , o r "gynae- cology a nd o bstetri cs" , " hea lth a nd hea lth educa ti o n" a nd "psychology", as in Yugos lav ia . Ge nera ll y, th e bas ic tra ining give n to nu rses in fa mily pla nning has the sa me characteri sti cs. Continuation and refresher training T hi s is the leve l where fa mil y pla nning teaching a ppea rs to be a t its mos t 'deve lo ped . In Algeria , mul tidisc iplina ry spec ia li zed co urses las ting o ne mo nth have been held regula rl y since 1974 by the Cent ra l Offi ce fo r Ma terna l a nd C hild Pro tectio n , in o rder to integra te birth spac ing ac ti vities with those o f ma- terna l a nd child hea lth. In p ractice it is the o nl y complete fa mil y planning tra ining scheme ex isting in the co untry. In Po rtuga l, there a re m ultidi sciplina ry refresher tra ining co urses (fo r ph ys icia ns a nd public hea lth nurses) a rra nged by the Direc to rate General o f Hea lth , las ting 1-2 wee ks a nd covering the chief aspec ts of fa mily pla nning. One-day se mina rs a re a lso held a t loca l level o n spec ific subj ec ts. Co ntinu- a ti o n tra ining is genera ll y provided by o ther age ncies such as the gynae- co logy depa rtment o f the Uni ve rsity Hos pita l o f Lisbo n, the Po rtuguese Gynaeco logy Society, the Po rtuguese Paed ia trics Society, the Psychia try Society a nd the Po rtuguese Medica l Associa tio n . Va rio us as pects o f fa mily pla nning a re dea lt with during o ther congresses o r meetings o n mo re ge nera l subjects such as ado lescence o r fa mil y hea lth (Table 6). In Tunisia , co urses ra ngi ng fro m o ne mo nth to six mo nths a re held by the Centre fo r Co ntinua ti o n T ra ining in Fa mily Pla nning, under the aus- pices o f the Na tio na l Office fo r Fa mil y Pla nn ing a nd Po pula tio n . They ei ther cove r a ll as pects o f fa mily pla nning o r single o ut specific individua l fea tures such as rece pti o n , di scuss io n techniques, supervisio n , adminis- tra ti ve ma tte rs, educa tio n , co ntrace ptive me thods o r coe lioscopy. So me o f the sess io ns a re multidisciplina ry, whi le o thers a re rese rved fo r a single ca tegory o f personnel (phys icia ns, midwi ves, educa tors, regio nal fa mily pla nning o fficers, etc.) , depending o n thei r respo nsibilities in the famil y pla nning sphere (Table 7) . In Turkey, the G enera l Directo ra te o f Po pulation Pla nning (GDPP) holds co urses va rying in length fro m two d ays to fo ur wee ks a nd dealing with diffe rent aspects of fa mily pla nning. These sess io ns a re genera ll y mo nodisc iplina ry a nd ma ndato ry fo r physicia ns dea ling with fa mily plan- ning in the public se rvices (Table 8). So me co untri es have not ye t a rranged re fresher o r specia li zed training courses fo r their fa mily pla nning personnel, a t least a t central level. Th is is the case fo r Spain . 22 N w Table 6 . Refresher and specialized training of health personnel: teaching of family planning in Portugal Sub1ect of course Responsible agen cy Length Part1c1pants Adolescence Contraception In the adolescent girl Gynaecology department. Lisbon 2 days Some 200 participants (physicians. Pregnancy and adolescence Un1vers1ty Hospital gynaecologists. psych1atr1sts. nurses. social workers) Es1abl1shed con1racep11ve 1echniques (Resul ts. poss1bil1t1es Portuguese Gynaecology Society 1 day Gynaecolog ists and gynaecology for changes) trainees Teaching of family planning (Round -table on occas ion of congress) Medical Association 1 half-day Open to all members of the Assoc1at1on Family heal1h (Including family planning) Psychiatry Society 5 days Open to all interested phys1c1ans Portuguese Paed1atr1cs Society N -"" Table 7. Refresher and specialized training of health personnel: teaching of family planning in Tunisia SubJect of course Respons ible Length Part1c1pants Comments agency Reception at family planning ON PF Pa 1 week Physicians, m1dw1ves, social For re ception. an effort Is cent res training cen tre workers. nurses. nursing assistants made to use staff from a single given health centre Admin1strat1on and manage - ONPFP 2 weeks Regional family planning officers. men t of family planning midwife superviso rs staff Educa ti on In family planning ONPFP 2 weeks Regional health educators, m1dw1fe superviso rs, social workers. male nurses Com munity approach to ONPFP 1 week Reg ional o ffi ce rs. phys1c1ans . family planning m1dw1ves. social wo rkers D1scuss1on techniques and ONPFP 4 days Educators. social workers traInIng me th ods for family 2 weeks Phys1c1ans. educa tors . trainers planning Supervision of family ONPFP 2 weeks Midwife supervisors. regional family planning services planning office rs Tra1n1ng In family planning ONPFP 6 weeks Pract1s1ng m1dw1ves 2 weeks' theory and sI mulated training centre practice 4 weeks' actual practice Introduction to family planning ONPFP 10 days M1dw1ves g raduat ing from schools Immedia tely after graduation traInIng cen tre N u, Table 7 (contd) Subiect of course Respons ible Length agency Coel1oscopy traInIng ONPFP 3 weeks Coel1oscopy traInIng ON PFP 2 weeks Training In family planning ONPFP 3 weeks (birth-spacing methods) Famrly planning , prevention ONPFP 1 week measures Integra t ion of famrly planning ONPFP 1 week at health schools a ONPFP: Nat ional Otf, c e fo r Family Plann ing and Popu lation . Part1c1pants Comments Gynaecologists International programme 1 week's theory 2 weeks' practice Operating-theatre nurses International programme 1 weeks' theory 1 weeks' pract ice General practitioners 1 weeks' theory 2 weeks' pract ice Nurse hyg1en1sts Pr1nc1pals and instructors at schools N 0\ Table 8. Refresher and spec1al1zed training of health personnel : teaching of family planning in Turkey Sub1ect of course Communication techniques In family planning Leadership techniques Family planning Maternal and child health Collection of data. record-keeping Family planning Maternal and child health Record-keeping Health and adm1n1s trat1 on Programme management Leadership techniques Data collection. record-keeping Integrated family planning/ma- ternal and child health departments Endoscopy Famil y planning Reproductive health Techniques In endoscopy Social and health aspects of family planning Responsible agency GDPP8 Provincial family planning adm1n- IstratIons (by nursing instructors) Provincial family planning adm1n- IstratIons (by nursing instructors) GDPP GDPP In collaboration with 5 teaching hospitals GDPP Length 5 days 5 days 2 weeks 2 days 5 days 3 weeks 2 weeks 1 week Participants Phys1c1ans Superv1s1ng nurses Rura l m1dw1ves Provincial directors of health Prov1nc1al directors of family planning Gynaecologists and obs tet ricians Operating -theatre nurses (instructors) Operating-theatre nurses (ins tructors) Comments Theoretical and practical course on the use and maintenance of audiovisual equipment Field work and theoretical course Field work and theoretical course Orientation course In family plan- ning / maternal and child health Orien tation course In family plan- ning / maternal and child health 1 week's theoretical course 3 weeks· clinical teaching lnserv1ce traInIng and theoret1cal teaching Guidance of public off1c 1als. religious !eaders. primary school teachers N --l Table 8 (co ntd) Subiec t of course IUD InsertIons Why family plann1ng7 Reproducti ve health Contraceptive techniques Record-keeping Ditto As for physicians. 1nclud1ng leadership techniques Health admin1strat1on Community health Maternal and child health Family planning Field work Family planning clinical practice Responsible agency GDPP training centre GDPP training centre GDPP training cen tre GDPP training cen tre GDPP In collaboration with the Gulve ren Family Health Centre and the Gevher Nes1be Institute of Health Educati on a GDPP General Directorate of Population Planning Length 2 1 days 3 days 4 weeks Participants General practItIoners Gynaecologis ts and obstetricians Nurse /midwives and m1dw1ves Head m1dw1ves at regional level Nurse instructors at provincial level Comments Clinical practice and theoret ical training Clinical practice and theoretical training Clinical practice and theoretical traInIng Superv1s1on of qual1f1ed midwives Conclusions Tra ining of different categories of personnel in family pl a nning a ppea rs to va ry widely fr o m o ne co untry to a no th er a nd , within a sin gle given country, from one faculty or school to a no ther. The importance a tt ac hed to such teaching frequently depends on official po licies in thi s area and o n it s ranking in pri o rity terms. A broad margin of fr eed o m is left to teac hers a nd the amount and qua lity of teaching then depends o n the interest they have in the subjec t. Scarcely a ny men ti o n was made in the replies to th e ques ti o nnaires of training o f hea lth a uxili a ri es. Th eir training in fa mil y pl a nnin g, as in o the r priority field s, is however crucia l because in ma ny cou ntries it is they who have much of th e responsibility a t the primary hea lth care leve l. Basic tra ining is ge nera ll y spea king very limited (as is shown by the pre Ii mi nary tests tha t pa rti cipants in refre sher or spec iali zed training courses have been asked to ta ke in various countries) . Continuing educa tio n a nd refreshe r training a re thus of vital importance in training hea lth perso nnel a nd make it poss ible to offse t at least so me of the shortcomings in basic tra ining. Refresher trainin g has o ther advantages. If courses are multidisc iplina ry, they form a n exce ll ent basis for tea mwo rk , which is o ne of the keys to success in family pla nning ac tiviti es. In addition, they are a fl ex ibl e approac h, a ll ow ing the needs of d iffere nt kinds of staff to be ca tered fo r , a nd a re o bvio usly irrepl acea ble as a mea ns of updating kn owledge. However, thi s does not mean tha t the need to develop teaching as pa rt of bas ic tra inin g ma y be igno red , as integra ted teaching is the bes t gro undwork for int egra ted ac ti vities. Summary of discussions The d a ta are no t very co mparable from one country to another. If they are to be a nal ysed , it is importa nt to bea r in mind : the way such questions a re ha ndled in the cou ntry: po litica l choices , reli gio us, cultural innuences, etc.; the goa ls of teaching and the rea lity of the teaching process: inte- gratio n in hospita l practice o r not, etc .; the types o f persona l motivation o f those respo nsible for teaching. The problem of division of la bo ur a ri ses in different ways in different co untries: in de ve loping countri es as many jobs as poss ible must be given to auxiliary perso nnel, a nd family planning must be integra ted with every o ther hea lth sec to r: M C H , hygiene, nutritio n, educa tion , etc.; in the industri a li zed countri es the ove rmed ica li za tio n of contracep- tion is often questioned. The prese nt trend is towa rds the integrat ion o f fami ly planning teaching with the bas ic tra ining in the various branches o f the hea lth professio ns: midwives, phys icia ns, etc. 28 2 Introduction to aspects of family planning Problems in the teaching of family planning and sexuality M. Manciaux Termino logy is no t a neut ra l ma tt er a nd the p ro posed titl e is sca rce ly likely to be the best. "Teaching" a tt ac hes too much pri o rity to the pass ive t ra nsfer o f kno wledge whereas it wo uld be bett er to stress acti ve t ra ining in the different areas o f educa ti o n: kn o wl edge, a ttitudes a nd aptitudes . "Fa mily pla nn ing" refers to a give n situa tio n o r fra mewo rk which, des pite the numerous socio logica l models tha t can be recognized in it , see ms presc riptive if not simpl y se ntent ious. Perhaps it wo uld be bett er to t rea t it si mpl y as tra ining in fertilit y co nt ro l. After a ll , it is a matte r of th e t ra ining to be give n to personnel " either du ring th ei r bas ic studi es o r afte r qua li fy ing", so they a re in a pos itio n to ca rry o ut their p rofess io na l res ponsibilities in thi s fi eld. It sho uld first o f a ll be noted tha t, as in ma ny o ther as pects of the t ra ining o f medi ca l and hea lth personnel, two wo rlds rub shou lders witho ut rea ll y meet ing: the wo rld o f acti o n progra mm es a nd se rvices a nd th a t o f training progra mmes fo r th ose who a re to be in cha rge o f implementing a nd o rga ni z- ing the former. When teac hing goa ls fo r fac ulti es a nd t ra in ing schools a re being d ra wn up , reference is hardl y eve r made to the hea lth po li cy of a country, its o pti o ns o r its hea lth code. With the except ion of the univers ity hospita l, insuffi cient use is made of the ex isting publ ic health infrast ructu re in the practical a nd clinica l tra ining p rogra mmes fo r future members of the hea lth profess io ns. The eva lu a tio n o f students rare ly a nswers the cru cia l ques ti o n as to wh eth er the t ra ined student is ca pa ble of taking hi s pl ace in hi s co untry's hea lth sys tem a nd wo rking effec tively in it in line with the coun- try's hea lth pla nning. There a re numerous exa mples of thi s lack of co mmunica ti on o r mee ting between the two needs, a nd a single gove rni ng autho rit y fo r educat io n a nd hea lth is not eno ugh to bridge the gap , a lth o ugh it can be of ass istance in ma int a ining co ntact. Here too, a cha nge of a tti tudes is needed which wo ul d ca ll in ques ti o n the goa ls themselves a nd the meth ods o f achievi ng th em in the t raining o f health pro fess iona ls. 29 In Fig. 3 consideration of t he insufficient intersection of the three circles "needs-demand-services" can be of great use provided it is based on a proper knowledge o f specific situations and it is first applied to analysing the needs-demand-services sequence in family planning, before being used in relation to training in this field. Worthwhile lessons may be drawn from a study of the areas of insufficient overlap between the different circles dis- playing dissatisfacti o n, frustration, underuse of services, activ ities to be undertaken to improve the degree o f interactio n (education for health, consc iousness raising, decentralization of activit ies, and the delegation of responsibilities are of capital importance here) and to achieve a regular eva luation of progress in se rvices and training. However , very few exa mples are known of an approach to the problem that is so rigorous . Fi g. 3. Needs. demand and provision of health se rvices Better understanding of the community, its living conditions~ and health status SERVICES i Development of basic health services and primary health care Education for health, / f~~:~~~~:=~~c~pation DEMAND Areas of overlap for needs. demand (expressed needs) and se rvices provided. with arrows 1nd 1- cat1ng the action to be undertaken In order to increase th e area The three areas of partial covera ge correspond to the following sItua tI ons : 1. Needs exIs tIng. demand exp ressed. ► disco nt ent no se rvices ava il ab le 2 . Needs ex isting. se rvices exIstIng . ► under use no demand expressed 3 . Demand expressed. services exis ting . ► 1neffect1veness no real need wastage Source: Manciaux . M.R.G. Maternal and chdd health · future problems and factors involved 1n the,r soluttons. Working paper IM CH/ WP. 7 5 .6) submitted to the WHO Expert Committee on New Trends and Approaches In th e Delivery o f Maternal and Child Care In Heal th Services. meeting In Geneva (Switzerland). 9-1 5 December 197 5. 30 There a re surely very few spheres of scie nce a nd huma n prac tice where such a n utt er lack of know ledge a nd such a wide cleavage betwee n ex isting knowledge, a ttitudes a nd p racti ces ca n be o bse rved . This may be because sex ua lity is a ma tter tha t goes deep into the innermos t pa rt o f o ur being, individua l a nd co llecti ve behav io ur a nd hum an re la ti o ns, a nd beca use it fo rms so profo und a pa rt of o ur subconscious. Here too clea r-minded a nalys is is ca lled fo r, both fro m the po int of view of the ex istin g situa tio n (KAP surveys, fo r exa mple) a nd of teaching methods (what knowlege is tra nsmitted a nd how it is tra nsmitted) . Other papers wi ll dea l with some as pects o f thi s, but let us say here tha t it will never be poss ible to reaso n over matters rela ted to tra ining in fe rtility cont ro l in the sa me way as is do ne fo r the teaching o f molecular bio logy o r the in fo rmatio n sciences. A philo- sophica l app roach a nd tho rough cons idera tio n of the subject may be o f use so lo ng as what is spec ifi c a nd wha t is th e fr uit of experie nce are no t th row n away and no attempt is made to bend the fac ts to fi t the de ma nds of doctrine. Both in the p rac ti ce a nd in teaching of fa mil y pl a nning we have a grea t need fo r spec ia li sts in communicatio n. But a re no t teaching methods themselves first a nd foremos t a matter o f co mmunica tio n, so long as they are p roperl y understood? Finally, a ny such deep co nsideratio n is o nl y worthwhile if it helps us to pass fro m pro blems to progra mmes. Even if a ll problems of co ncept have not been so lved , we must still undert ake prog rammes: fa mil y planning programmes fo r co mmunities tha t demand them of us and rightl y so; and educatio na l p rogra mmes to tra in hea lth personnel to orga nize actio n p ro- gra mmes. Beyo nd the few exa mples we have given in the present rev iew, the prepa ra tio n of t ra ining p rogra mmes is the very cru x o f the p rese nt con- ference in the sa me way as it is a t the heart of the concerns of the Inter- national Children's Centre. J o int re0 ectio n a nd exchange of ex perience should help us move forward together in this sphere. Strategy for teaching human reproduction and family planning P. 0. Hubinont Introduction The physician's pos iti on in society has varied widely over the centuries and the way medicine has been taught bears witness to the fac t. In other wo rds, medi cal educatio n has to ta ke account of the type o f physicia n expected by society a nd to fit in with such a dema nd , if it is to be a ble to perform its role properl y. The sa me thing is true fo r the o ther hea lth professions. Traditional medical educatio n based on the study o f natu ra l sciences, foll o wed by tra ining in basic medica l sciences a nd patho logy, a nd the observation of pati ents in hospita ls, has long since ceased to be enough , beca use it does not prepa re fo r the contingencies of general medical practice, the requirements o f preventive medica l ca re o r the integra tio n o f the phys- icia n in the community. The la tter therefo re does not rece ive a ll the services 31 it is entitl ed to ex pec t o f those it has in vested in a nd whose overheads it has mo re o r less directl y suppo rt ed th ro ugh a number o f yea r o f stud y. This is neither the pl ace no r the time to deve lo p these preliminary re marks, whi ch were neve rtheless wo rth ma king in o rder to provide th e fra mewo rk for what fo ll ows. If health is a sta te o f co mplete ph ys ica l, menta l a nd soc ia l wellbeing (and no t merely the a bse nce o f di sease o r infirmit y), then a mo ng the professions contributing to it th e medi ca l p rofess io n has the fun cti o n no t o nl y of co mba ting the ca uses of di sease a nd dea th but a lso o f preve nting them as far as poss ible a nd pro moting the wellbeing o f th ose it is respo nsibl e fo r. Even mo re, it sho uld be sa id as a co unse ll o r as much as a n intervening age nt (or bo th as co unse ll o r a nd interve ning age nt to the sa me degree), the hea lth wo rke r is the repos ito ry of sc ience as a se rvice a nd is no t entitled to use sc ience with the mo re o r less explicit des ign o f o ppress ing o r exe rting hi s power ove r o thers. In th e pa rt o f the wo rld wh ere I li ve, medica l edu ca ti o n leads to th e tra ining o f technicia ns wh o have extra o rdina ry techniques a nd kno wledge a t their di sposa l a nd wh ose practi ces a re la rgel y conce rned with solving problems while ge nera ll y spea king o mitting to invo lve the pa ti ent as a pa rticipant. While the emerge nce o f such a n a ttitude may be understood in the "gra nd" medica l di sc iplines such as resusc ita ti o n, ca nce r trea tment and emerge ncy surgery, where the pa ti ent' s ro le is oft en igno red beca use o f the intensive ca re to be p rov ided a nd th e gravit y of the case, it is no netheless inexcusa bl e. The great d octo r a re in a ny case those who have understood thi s a nd do eve rything to in vo lve the pa ti ent , sha ring th e respo nsibility fo r a rriving at in fo rm ed dec isio ns. This sharin g in no way diminishes deci sio n-making o r detracts from medica l res ponsibility but leads to a continuatio n o f di a logue between the ho lder o f kn owledge a nd the benefi cia ry. In a no ther sphe re, it may be as ked whether medica l educa tio n is d oing it s job when it leads to the esta blishment o f a caste tha t tends to try a nd prese rve its privil eges while iso la ting itse lf in a way tha t is ta nta mo unt to setting itse lf a pa rt fr o m socie ty a nd constituting a reacti o na ry pressure group . Cl earl y, th e sphere o f human rep roducti o n is o ne where the gap between medicine a nd the co mmunity ca n d o the most da mage. Afte r a ll , it was no t ve ry lo ng ago that prominent medi ca l a uthoriti es were kno wn to sta te tha t fa mil y pl a nning (a nd in pa rti cul a r volunta ry terminati o n o f pregna ncy) had no thing to d o with medicine, wh en we know tha t it is o ne o f the mos t signifi ca nt pa rameters fo r fa mil y health in particul a r a nd public health in ge nera l. If we co nsider the in fo rma tio n fo rming pa rt o f the teac hing o f human reproductio n in the contex t o f the p rogrammes of most medi ca l schools , we will see that it is to uched o n , but in most cases o nl y as pa rt o ft he teaching of natural sciences, bas ic medica l sciences o r pa tho logy, a nd in a ny case in a ge nera li zed fas hi o n , witho ut a ny a ppa rent link betwee n the vario us d isc iplines. 32 This was why ten yea rs ago the medical faculty I belong to was led to incorpora te in its progra mme of preclinical studi es 15 hours of teaching (one se mes ter) ofa n " Int roduction to huma n reproduction", cove ring co ncepts a lread y taught in co urses of a na to my, hi stology, ph ys io logy and biochem- istry with regard to the bio logica l mechanisms gove rning reproduction, a nd introducing ma tte rs re la ted to sexo logy, birth pla nning, and the psycho- logica l and socio logica l as pec ts of the problem , an d givi ng a prev iew of subjects to be dealt with during clinical teaching. This teaching is arra nged by a clinician who returns to th e sa me students during the fourth year to teach them gynaecologica l se mi ology a nd la ter gynaeco logica l pa tho logy a nd clinical as pects of gynaeco logy a nd obs tetri cs. Fi ve yea rs ago, the author introduced, o n a tri a l basis in the fifth year, courses in soc ial gynaecology during which students are brought into con- tac t with pregnant wo men , acco mpa ny social hea lth nurses o n ho me visi ts a nd ta ke pa rt in family pla nning consultations. This activity has no t so far been brought into genera l application but is of considerable interest for future physicians. In a world where human reproduction is creating ever-growing problems and where it is mo re a nd mo re widely accepted that the a im sho uld not be for the fertilit y o f a couple to lead to the procrea tio n of a ll th ose children th at co uld be bo rn as a res ult of sexua l ac tivit y, but rather to obta in control over fertility in such a way as to bring into the world the number of children (and with the bes t poss ibl e spaci ng) that the couple is ready to care for until the o nse t of ad ulthood , membe rs of the hea lth profess ions a nd in particular the medica l professio n must have a proper preparatio n for their ro le as guides, mentors a nd technicians in fa mil y hea lth . Va rio us studi es a na lys ing th e motivation of yo ung women a nd yo un g men ta king up the hea lth profess io ns have shown tha t first a nd foremos t they are strivin g to es ta blish fo r themselves a self-image where their conce rn to provide devotion, so lida rit y a nd respect for o thers may be give n free rein. It is to this goa l tha t medica l ed uca tion must contribute. Fin a ll y, if co nsidera tio n is give n to the fact tha t in the sphere we are discussing here, future doctors, midwives, nurses of bo th sexes and socia l workers will face problems th a t they were not in a pos iti o n to reso lve o n their o wn , teaching (whatever its direction and technique) must provide the necessa ry suppo rt. Pattern for integrated teaching of human reproduction and family planning In the specific exa mple o f the "Introduction to hum a n reproduction" de- scr ibed above, which consists of 15 hours of theore tica l teaching during preclinica l studies, a n a ttempt has been made to bring together bio logica l, sexological, socio logica l and preventive matters. The fo llowing subjects are ta ught in thi s course. Biological aspects formation of male and female go nads - genetic determination of sex 33 sperma togenes is neuro phys io logy of ejac ul atio n biochemist ry of seminal f1uid tra nsport o f ga metes in the fe male genita l tract menstrual cycle, growth of the fo llicle a nd ovul atio n the hypo thala mus-hypophys is-gonad axis fe rtili za ti o n a nd for mation of the bl as tocyte migratio n of the ovum and impla ntatio n fo rmatio n of the place nta deve lopment o f the embryo a nd of o rgans childbirth lacta tio n in relatio n to return o f ferti lit y Sexological aspects crit eria fo r sex determina tio n a no ma lies of deve lo pment : intersexuality child and ado lescent sex ua li ty independent stimula tio n gove rning erect io n and o rgasm sex ual stimula tion a nd res po nse sexual a ttitudes a nd behav iour sex ual mino riti es ge ri a t ric sexuality, menopause and cas tra tio n Sociological aspects fa mil y hea lth de mogra phy and hea lth psychosocia l o bstacles Preventive aspects invento ry o f birth spacing methods method of use, accepta bility, effectiveness, rela tio nship between cost and use sex educa tio n a nd hea lth educatio n prema rit a l a nd marita l ad vice a nd ma rri age counse lling prena ta l a nd pos tna ta l surve illance se rvice o rganizatio n models; role of the hea lth professio ns All thi s is preceded by teaching of psycho logy a nd t rai ni ng in medica l soc io logy, in ad d iti o n to co nvent ional teaching of the mo rpho logica l (ana t- omy, hi sto logy, embryo logy), phys io logica l and biochemica l sciences. 34 Aspects of training in the field The mos t frequent rep roach d irected a t schools of medicine, nursi ng and mid wife ry is that they are too co nse rva ti ve, promoting copio us scho lasti c educa tion but limiting practi ca l t ra ining to peri ods of hospi ta l practi ce a nd res tri cting the a pproach to hea lth p ro blems to cura ti ve aspects of med icine a nd nursing ca re. This ve ry widespread sho rt coming is a da maging o ne. On the o ne hand , it fa il s to ta ke into conside ra ti o n the consi dera ble interest gene ra ted by acti ve teachin g a nd pa rti cipa tio n of the stud ent in the acq ui siti o n of kn o wl ed ge a nd o n th e o th er , it fai ls to ta ke acco unt of the socio logica l a nd psycho logica l d imensio ns of hea lth p ro blems in the co mmunity as a who le. In the pas t o ne o r two decades, it is true tha t medica l educa tio n a nd care instituti o ns ha ve tended to beco me mo re o pen to the co mmunity, but the pheno meno n is fa r fr o m being ve ry widespread a nd the trend is ex tremely slow. In the case we a re conce rned with , the sho rtco ming is ca tast ro phic since it produces a situa tio n wh ere a ll tha t the co mmun ity has ava il a ble to it a re medica l p ractiti o ners, nurses a nd mid wi ves with onl y a rudi mentary ex- peri ence in p ro blems co ncern ing a ll of ado lescent a nd adult ma nkind, fro m the o nse t of fertil ity to its cessa tion. The measures to be ta ken a re genera l o nes and pres up pose a rev isio n o f educa tio na l p rogra mmes in teaching a nd trai ning institutio ns fo r hea lth profess io nals in such a way as to stress the balanced acq ui si ti o n of theo reti ca l in fo rma tio n a nd pract ica l skill s tha t may be a ppli ed stra ight away for the benefit of the community and the ind ivid uals it is com posed of. This presupposes a n effort a t integra ting fac ulti es and schools within the community, se lecting periods of tra ining " in the fie ld" ra ther tha n in closed institutio ns, ge tting rid of certa in superio rit y or infe rior ity com plexes ha m- pering co mmunica tio ns a mo ng the p rofessions a nd , in their place, crea ting a n a tm osphere of so lida rity a nd fellow-feeling where the team spirit may deve lo p and fl o urish . Conclusions and summary Va rio us fac to rs have to be ta ken acco unt o f in deve loping a stra tegy a imed a t providing the proper training in the fi eld of fa mil y pla nning. (a) Altho ugh sc ientifi c in fo rmatio n is necessa ry, there a re a se ries of psycho logica l a nd sociologica l ba rriers ha mpering access to it a nd prevent- ing receptio n o f it by the taught if not by the teachers . T hese barriers a re grounded in deep-rooted habits a nd convictio ns fo und in numerous cultures in different sha pes resulting in puri ta ni sm with rega rd to sexuality. (b) The hea lth pro blems ra ised by sex li fe a nd the re p roductive functio n involve individua ls deeply in the innerm os t pa rt of their being. This mea ns tha t those hea lth wo rkers whose fun ctio n it is to sugges t so luti o ns a nd assis t in their implementa tio n must no t o nl y have the pro per acade mic a nd practi ca l background but must a lso have had the opportunity to so lve their own problems in the best poss ible way. 35 (c) Sexua l a nd re p rodu cti ve ac ti vity for ms pa rt of life as a who le and there is no rea l reason fo r the rela ted preve ntive hea lth ca re to be dea lt wi th in iso la tio n fro m p reven ti ve materna l a nd child hea lth ca re. On the contrary, there a re ma ny argume nts fo r integrati o n in re lat io n both to teac hing a nd to the o rganizat ion of se rvices: with regard to teaching, it is eno ugh to proceed fro m the sim ple princ iple of trea ting contrace ption as the mir ro r image of fer til ity; wi th regard to the o rganiza tion of services , there has been a cl ea r demonstra tion of the potent ia l benefi t in terms of effecti ve ness re- sult ing fro m int egra ting co ntrace ptio n with materna l a nd chil d hea lth care se rvices. It is essenti a l not to lose sight of the fac t tha t the li fe of a co uple, and pa rti cul a rl y tha t o f the wo ma n, is a co ntinuing pheno meno n which it is impo rt ant to keep in perspecti ve. Reprodu cti ve potenti a l a nd , mo re a nd more, sex ua l activity beg in with the o nse t o f pubert y a nd ca rry on for severa l decades. This fac t sho uld not be los t sight of a nd there a re no grounds for giving sepa ra te trea tment to ado lescents, women witho ut children a nd those who have had a number, o r for sepa rati ng med ica l trea tment of wo men fro m tha t of children where fa mily hea lth p reventive measures are concerned. (d) Wh en we speak of integrat ion, we pres uppose a mul tid isc iplinary and a ll -round a pproac h. Teaching must therefo re a im a t tra ining the hea lth p rofess io ns fo r tea mwo rk , at leas t where it s field a pplica tio ns a re co n- ce rn ed. Tea mwo rk req uires no t o nl y good hum a n rela ti ons but a lso pre- supposes a commo n backgro und of doctrine and integra ted in fo rmatio n. T he la tt er co uld be based o n a commo n bo dy of knowledge for th e di ffe rent q uali fica tio ns. The social status of women and family planning in developing countries M. Ladjali and F. Oussedik T he a im of thi s pa per is to present some ideas a bo ut the soc ia l sta tus o f wo men a nd fa mily pla nning in developing countri es based o n a n exa mple fro m th e Mag hre b in No rth Africa. T he concepts underl ying these ideas sho uld first be defined . " Socia l status" mea ns a ll the functio ns of a person in a give n soc iety. Birth spac ing rela tes to women in their fun ctio n as re producers of hum an- kind. Fe rtil ity is therefo re just one as pect of thei r sta tus as a who le. In its conven tio na l definiti o n , fa mily plann ing brings two ma in co m- po nents int o play: o n the o ne ha nd, the medica l co mpo nent , consisting of those methods tha t enable undesi red p regna ncies to be avoided and the ot her, a more soc ia l di mensio n , which adds to a de libera te se lecti o n of the number of pregna ncies, va rio us acti vit ies ranging fro m trea tm en t of sterility 36 to sex education and to marriage a nd genetic counselling. In developing countries, a further economic component is added because the family in- come is inOuenced as a result. Family planning should therefore represent a deliberate act whereby a woman establishes a relationship between family size, family income and the sociocultura l circumstances she lives in. It is on ly by linking these three variables that family reproduction can be regarded as an index of a social future that has been brought under total control. In Algeria, what is the place of the woman in family planning? More precisely, what is her position in relation to fami ly size and to the economic resources of her fami ly? We intend to use the definition we have just given in order to establish the place of the woman in family planning. It will be a matter of asking ourse lves what her position is in relation to this definition of fami ly planning. Three points will be given particular attention: economica ll y, the place of the woman in the creation of the family income; medically, control over family size in relation to fertility and infant mortality; socioculturally, the conditions enabling a woman to link her place in the family income to control over her own fertility. This latter point will make it easier for the relationship of women to population policies to be grasped. The place of the woman in creating family income The problem of working women is still the subject of theoretical discussion which may be brieOy summarized in the fo llowing two statemen ts. The definition of the concept of housework based on a critica l ana lys is oft he concept of productive work. Women in the household are outside the system of so-called productive labour. Efforts are being made to consider housework as true productive la bour. This matter is still under study. Acknowledgement of the position of women in wage-earning em- ployment. This is the problem to be considered as it is the only one at present given social acknowledgement. For this reason , in the present paper only the place and structure of female labour in developing countries will be taken into consideration. In Algeria, for example, according to the 1977 census, out of a theor- etical population of working age ( 15-65 years) of some 8.5 million, only 2.5 million were in effect ive employment, including less than 200 000 women. This means a proportion of 8. 9% , i.e. scarce ly more than the proportion found in the 1966 census. It should also be clearly noted that the percentage is calcu lated in relation to the active population. As a whole, it amounts to 3.3% of women of working age. 37 With regard to the t ructu re of em ploy ment , since 1966 there has been a fa ll -off in sa laried fe male fa rm wo rkers and ho me wo rk ers and a stagna ti on in the number o f fe ma le tex til e wo rkers, wh ile the number o f wo men wo rking in o ther industri a l sec to rs a nd , in pa rti cula r, in the administratio n and community se rvices has been increas ing. Altho ugh 46% o f wo men o ut a t wo rk no w have schoo l-leaving qualifi- ca tio ns (as aga in st 15% o f men) , the a lmost to ta l absence o f women in senio r pos itio ns in the sys tem will be noted. Ano ther t raditi o nal feat ure is the fac t tha t o ne fi nds very few women in jobs requiring co nsta nt contac t with the public: office counters, the hotel t rade, res ta ura nts a nd ca tering, etc. T he di stributio n o f functions between men a nd wo men, without remain ing exactl y as it was in the o ld days, is still clea rl y sta mped by t radi tion . The number of wo rking wo men re ma ins low: 6 for every 100 men. Thus, men have the prio rit y in terms of jo bs as they a lo ne a re viewed as heads o f fa milies, a fac to r rein fo rcing socia l o ppre sio n: the wo man is subject to d o min a tio n by the ma le who ho lds the keys as breadwinner for mee ting the fa mily's needs. In conclusio n , it may be sa id tha t wo men have a n insignifi ca nt pos itio n in the crea tio n o f a fa mily inco me. Con trol over f amily size in relation to fertility and infant mortality In 1979, 60% of a ll births in Algeria st ill took place in the ho me. This expla ins th e high ra te of birth-rela ted mo rta lity a nd morbid it y. Study of such mo rta lity accordi ng to age shows tha t it is mo re seriou among women a t the two o ppos ite ex tremes of fe rtilit y: between 15 and 25 yea rs o f age a nd 35 a nd 40 yea rs o f age. In 1972, o ut o f 97800 births, perina ta l mo rt a lity reached 3.5 per tho usa nd wo men hos pita li zed in maternit y wa rds, i.e. 20-50 times hi gher tha n in well-off co untri es. Pregna ncy a nd deli ve ry cause majo r mate rna l mo rbidit y, a nd thi s is mo re frequent a mo ng mo thers of la rge fa milies . The ma in ca uses of hospita l mo rbid ity we re identi fied in 1972: o ut of I 00 000 hospita li za tio ns of wo men, a high perce ntage we re d ue to compli- ca tio ns during pregnancy or de li very, o r postpartum ; such co mpl ica tions affected o ne fi fth of a ll women below the age of 20, o ne third o f women between the age o f 20 and 44 and I 0% after the age o f 45. Infant mo rta lity is a lso high. Co nditio ns associa ted with the pregna ncy o f the mother a nd deli ve ry a re a ca use of 85% o f d ea ths a mo ng in fa nts aged less than o ne mo nth . Infant mo rt a lit y was still as high as 115 per tho usa nd in 1978, and now stands at I 05 per tho usand . Fac to rs in infant mo rta lit y in clude: 38 Low birth we ight a nd premature birth . These fac to rs involved in mo rt a lit y a nd future mo rbidit y are p red o mina nt a mo ng children o f mothers with la rge fa milies. Illite racy a mo ng the mo thers. It has been demo nstra ted tha t in fa nt mo rta lity fa lls as the leve l of educatio n o f the mo ther increases. Malnutrition, which is more frequently encountered amongst large families and is, in reality, the true cause of high mortality rates. When one child is born shortly after another, it has a bad sta rt in life because the mother is undernourished. Moreover, when he or she is displaced by a younger sibling, it often happens tha t there are not enough substitute foods. This se ts off malnutrition with its accom- panying train of interconnected or exacerbated illnesses: measles, whooping cough, dehydration, etc. Finally, the age of the mo ther. Infant mo rtality is higher among ch ildren of women aged under 20 years or over 35 years than in other age groups. Numerous studies have shown that the chances of surviva l (except for the first child) are higher when the interval between conceptions is wide. Infant mortality declines if births are more widely spaced. The overa ll rate of general fertility has been estimated at 203 per thousand in 1978, i.e. l000 women of procrea tive age produced an average of 203 children. This rate ri ses to 306 if the legitimate birth rates are considered, i.e. l000 married women of procreative age produced an average of 306 chi ldren. The average number of children per woman is seven. At the same time, the prime feature of the ma rriage rate is its leve l and the early age at which marriage takes place. The marriage rate is 98.2% in urban areas and 98.8% in rural areas. Moreover, in 1978, 35.5% of all women were married at less tha n age 19 and almost 96.6% at less than age 30. By the age of 20, one woman out of every two and one man out of every ten had a lready contracted a first marriage. The st ill quite low average age of marriage combined with early de- liveries means a very long fertile life during which reproductive activity is practically uninterrupted. All the foregoing means that the woman is hemmed in within her so-ca ll ed "natura l" functions while no account is taken of the way her body is being wasted. This results in an intensive explo itation of her natural functions, which strengthens the exclusion of women from other social activities. Women are thus potentially excluded from the productive sector and confined within that of reproduction ; and high maternity rates contribute to this process. It emerges from a 1980 national survey of the typical acceptor of co ntraceptive methods requesting family planning services for the first time that she is above all from an urban environment and has a lready had five children by the time she attends for consultation. Thus, birth spacing serv ices are not provided as part of family planning organized from the very onset of fertility but as one of a number of therapeutic actions initiated to assist ex hausted women . Medicine finds itself trapped in an inheritance of problems originating in the way society is organized, and the enclosure of women in the single dimension of motherhood. In reality, medicine puts up with a situ ation that is not of its own making. Moreover, some population 39 policies seek th ro ugh medica l acti o ns to reduce reprodu ctio n ra tes by con- t ro l ove r the fe male uterus a nd nega tio n of the persons they belo ng to. The true answers to the p ro blem of fa mil y planni ng will o nl y be provided by a change in the soc ia l sta tus of wo men. T heir fe rt ility is a n ex press io n of o nl y o ne o f their di ffe rent types of sta tus. Cert a in va lue systems have crys ta lli zed around wo ma n th e trad itio ns th a t have redu ced her to th e simple ro le of reprodu ce r with a la rge part of her life being devo ted to pregna ncies a nd the ra ising o f child re n. If a fa mil y pl a nning po li cy is to succeed, it is no t eno ugh to d ist ribute co ntrace ptives acco mpanied by instructio ns fo r use; it is essenti a l fo r wo men to fo ll o w them. Fo r wo men to co nscio usly pa rti cipa te in co nt ro lling fer- tilit y, a cha nge must ta ke pl ace in th e role traditi o na lly allo tt ed to them. If they a re relegated to the ro le o f chil d minders a nd to traditio na l ro les, they lose a ny poss ibilit y of fi nding wo rk o r engaging in po liti ca l acti vity. Th e di ffere nt pro blems ra ised in the fo regoing show the impo rt a nce of fa mil y pl annin g as defined in terms o f improv ing the qua lit y of life. For a fa mil y pl a nning po li cy to be rea li zed , wo men must be co nscio us supporters o f it. This pres upposes a ltering the ir soc ia l s ta tus th ro ugh recognitio n of o ther funct ions th a t they must o r wa nt to perfo rm , as di rec t produce rs a nd as citi zens. Role of the woman in family planning D. Nardini-Maillard The a im p ro posed he re is to co nsider the ro le o f the wo ma n first as an individua l a nd secondl y as a bein g with sex ua l prerogati ves of her o wn . This dis tinctio n ee ms of prime impo rt a nce beca use it conta ins the ro ugh o utline o f a reply to the ques tio ns th at will be as ked, i.e. tha t wo men canno t be re lega ted to th e reproducti ve fun ction alo ne no ma tt er how impo rt ant tha t may be, despite the fac t tha t it is a fun ctio n ph ys io logica ll y proper to them; they a re entitl ed to full y-fledged sta tus as indi vidua ls a nd therefore as socia l beings. T his is rea ll y th e o nl y way of a llowing a woma n to see so mething o ther th a n repea ted ly giving birth as the so le fo rm of ex istence, perso na l ri chness and socia l respectab ility. We mu st st ress, ho wever, tha t it is no t a ques tio n here o f providing a nswers to the co mplex p ro bl em under di scuss io n a t this confe rence but ra ther o f a ttempt ing to as k those ques ti o ns tha t might help to stimula te jo int thinking o n the ma tt er. If we spea k of women , it is beca use it is for them tha t the mos t wide- sp read cont race pti ve methods a re p rimaril y in te nded (the pill , IUD). It is first and fo remos t in their bo dies tha t they a re ca lled upo n to use birth cont ro l methods and it is up to them in their ove ra ll ind iv idua l being to acce pt them psycho logica ll y. It is th erefo re impo rta nt to understa nd the co ntex t in whi ch a woman lives, the cultu ra l laws she is subj ect to, a nd the 40 oth er traditi o ns a nd roles that gove rn her cho ices. In mos t cases, we a re fa ced with a soc iocultu ra l rea lit y do mina ted by a n a utho rit y th a t is to a ll intents a nd purposes a male o ne; in s uch soc ieti es, the o nl y in a li ena ble power wo men a re ac kn owledged as havi ng is tha t of giving birth to children. G irl s a re ra ised as a fun cti o n o f their future ro le as wives and mothers a nd the way wo men acquire ackn owledged soc ia l sta tus is in acco mplishing these fun ctio ns. As infa nts a re th eir o nl y wea lth , the number o f children they have beco mes the ca pit a l o f th e poor; in a coupl e, pregna ncy is a n in d ica tio n of the virilit y o f the husba nd a nd a co nt ro l ove r th e sex ua lit y o f the wi fe; repea ted pregna ncy co nfirms the power o f the man a nd ena bl es him to ensure hi s spouse' s fidelity. Wo men, ti ed do wn to this phys io logical rea lit y tha t carries with it soci a l s tanding, have bee n o bliged to co nfin e th emselves within thi s ro le and to derive fro m it the source o f their se lf-es tee m, their reaso n fo r ex istence in the wo rld a nd the ir va lue as individua ls. Thus it is tha t th ro ugh repea ted childbea ring the wife gains lo ve, respec t a nd soc ia l sta nding. This is where fa mil y planning co mes into play. When we see k to provide in fo rm atio n o n the poss ib ilit y o f co nt race pti o n a nd the mea ns fo r undert a king it , we enter int o the a bove-mentio ned situ a tio n, trying to int rodu ce a cha nge int o codi fied rul es and thereby upse tting the ba la nce o f ro les betwee n the pa rtners. By fr ee ing a wo ma n fro m undes ired childbea ring, by sho wing her the adva ntages of birth con- t ro l, we simulta neo usly remove fr o m her the so le pos itio n o f power th a t she prev io usly occupied ; wha t is given her in excha nge? One o f the o bstacles to successful co ntrace ptio n is, there is no do ubt , to be fo und a t thi s leve l; a wo ma n loses some o f her a uth o rit y and becomes an o bj ect o f mistrust fo r her husba nd a nd soc iety; she is a ll owed to discove r gratuito us sexua lity unsa nctioned by pregn a ncy a nd therefor e beco mes more free. Is she in a pos ition to ta ke up thi s liberty un a ided? Or will she be obliged to sa bo tage th e contraceptive method in o rder to enjoy the sa me considera ti o n as before? How can she agree to see herse lf depri ved o f the facult y tha t has hitherto reinfo rced her va lue as a spo use a nd in soc iety? It see ms impo rt a nt to avo id this stumbling block by propos ing in the first place to the wife and secondly to the couple something in return th a t wo uld support the decisio n to regulate births. At the leve l of the co uple , it may be tho ught th a t the idea o f rec iprocal sexua l pleasure fr ee fr o m the fea r of unwa nted p regna ncy, and therefore hav ing o nl y th e pl eas ure o f the pa rtners in mind , wo uld co nstitute a con- sidera ble step to wa rds freedo m a nd could take the place o f the dimension refe rred to beforeha nd (this wo uld pave the way fo r di scuss io ns tha t were more to do with sexology p roperl y speaking, a nd it wo uld be impo rt a nt to be ready to reply to new qu es tio ns a nd increased a nd differing d ema nds o n th e pa rt of the couple). But a new range o f p ro bl ems o pens up to us if th e immedia te goa ls a re reached . We have to as k o urse lves whether we a re capable o f pro viding thi s quid pro quo with impunity o r whether we run the risk o f prec ipitating the wo ma n into di strust o n the part of her husband a nd soc iety fro m the mo ment 41 her bod y no longer d isplays a ny sign tha t sexua l ta boos have bee n bro ken? How sho uld thi s pro bl em be tackled in order to preven t it fro m beco ming a n o bstacle insurm o untab le to the success of co ntrace ptio n, a success which, as was sa id ini ti a ll y, we co nsider to be of crucia l impo rt a nce in givi ng wo men the ir dimension as individ ua ls. If we ca nno t a nswer thi s questio n, which is o ne tha t wo uld be wo rth d iscuss ing a t grea ter length , a t least we ca n give o ur po int of view, a nd tha t o pens up a cha pter that is of equa l impo rta nce: the trai ning o f teachers of contrace ption. T o p rovide such teachin g, it is a t least esse nti a l to have adequa te train- ing, a nd a lso a nd in pa rti cula r to have asked ce rtain q ues tio ns a nd fo und the a nswers so as not to be ta ken by surpri se if some o f them a re a lso asked by contrace ptive users. This o penness o f mind presupposes no t tha t there is a n a bsence o f co nnicts but tha t they have been reso lved a nd a bo ve a ll tha t they are recogni zed as co nnicts and coped with . Wo men who use cont race ptives a nd wo men " teachers" (as we ll as men, incident a ll y) a re faced fro m the o utset with the sa me types of psychologica l res ista nce a nd th e sa me socia l const ra ints. It is essentia l for such res ista nce to have been de tected, co nfro nted , unde rstood a nd overcome if the use rs are to be ass isted by th e teachers to beco me aware of the impo rt a nce of fa mily pla nning a nd to use contrace ptive methods correc tl y. Let us t ry to rev iew the ma in types of res ista nce encountered in lea rning how to use contrace ptives and to p ract ise cont raceptio n successfull y. We sho uld firs t of a ll refe r to the menta l image of fa mi ly ma ke-up which each of us possesses. For persona l reaso ns bo und up with the hi sto ry of eve ry individua l, we a ll have a n image with in us o f o ur idea l fa mily size in whi ch the number a nd sex of the children va ry. If the idea of co nt raceptio n succeeds in a ltering, even in pa rt , thi s idea l image befo re it is rea li zed , it will be bo und to be co nsidered as a n o bstacle to that rea li za tio n a nd the risk of undermining o r rejecting it will be a ll the grea ter. The image a lso co mes into play a mo ng hea lth wo rkers made res po nsibl e fo r pla nning in that they will refer to their own idea l image when encouraging cont raceptio n o r not. The seco nd o bstacle is the o ne referred to ea rli er: the undermining of the woma n's ro le a t the soc ia l a nd marita l leve l, a nd the consequent need to es ta blish a new ba la nce. By free ing t he wo ma n fro m unwa nted childbea ring, co ntrace pti o n in so me respects opens up fo r he r other poss ibilities a nd other qua lities o f li fe, giving her roo m to express des ires, wh ich bo th stimula te the need a nd a t the same time make it feas ible. In add it ion, co nt race pti o n o pens up a way towa rds o ther types of sa ti sfactio n, whether the possibility of study, profess io nal success o r the simple di scovery o f other a reas of interes t. T his wo uld see m to be pa rt of the progress of wome n in achieving their sta tus as socia l bei ngs. It does not merely represe nt a wo ma n's right but a lso the enrichment of society; but how ma ny peo ple hold thi s o pinio n? And how ma ny, o n the o ther ha nd , will fear to interve ne in the delica te ba la nce o f the pos itio n of each woma n in rela tio n to motherh ood, not kno wing o r not being a ble to ta ke o n the task of esta blishing a new equilibrium tha t wo uld ce rtainly be richer a nd more respo nsible but ass uredl y give grounds fo r grea ter co nnict? 42 At the marriage level , other factors arise that stem more from the sphere of relationships and emotions and therefore belong to the private world of the individual. Contraception alters the balance of the marriage by making the sexual role of the woman more important, in a way that is not "justified" by her function as a mother. Many women will feel impoverished if this function is missing because, on the one hand, it deprives them of the essential prerogative of authority they have , and is intrinsically a loss, while on the other hand, it forces them to face sexuality as an "end in itself'. B~t to accept this "end in itself' means that the woman will have to comprehend sexuality as a function providing pleasure, and this is not necessarily some- thing that goes without question when the cultural and moral norms pro- hibiting it are borne in mind . Such norms can create a very heavy burden and even induce frigidity among women who were previously perfectly capable of enjoying satis- factory sexual relations. It is as if the woman was being offered access to sexual pleasure without being brought up to contemplate such a possibility; and this leads to anxiety at the prospect of a promised pleasure that she is not always equipped to face . In addition, this increased sexuality in the female role may be perceived by the husband, who is just as ill-prepared as his wife to take it on , with mixed feelings in which the possible relief due to the ability to regulate births is accompanied by a certain distrust stemming from the danger his feeling of possession is now subjected to. The couple then find themselves open to reactions of jealousy as a result of the woman's extra-marital freedom , which can certainly be real but are often imaginary. To this should be added fears of impotence arising from the elimination , however temporary, of the potential capacity to pro- create; this phenomenon is much more frequent among men who confuse or more or less consciously identify sexual power with reproductive power and who fear the absence of external signs of the frequency of their sexual relations. It is of particular importance to take account of this latter point , masculine resistance to contraception, as one of the most delicate and crucial issues in bringing effective contraception into being, because we cannot act as latter-day crusaders and combat the prejudices and obstacles faced by birth control and by free and responsible motherhood and father- hood. Rather, we must be conscious of the role we are called upon to play while respecting the consciences and freedoms of the individual and the couple. Our task is to free such men and women from their fetters rather than to convince them to use methods that would clash with their views of the world and of marriage. In order to do this, both individual effort and teamwork are essential on the part of the teachers, and that places them in a position to bring their own contradictions and prejudices out into the open and, thus enlightened in relation to themselves, makes them better able to listen to others without fear, prejudice or preconceived reactions. 43 Community diagnosis T. Amat Th e mo re we prog ress in a na lys ing the res ult s o f inte rve ntio ns by hea lth technicia ns, the mo re we pe rceive tha t the ro le mu st , if there is a des ire to a rrive at a reducti o n in high mo rtalit y a nd to improve the hea lth level o f th e co mmunity as a wh ole, go beyond the purely therapeutic a nd extend to preve ntio n. The sphere o f preve ntio n is a ve ry b road o ne, co mpri sing a ll th ose indi vidua l a nd co ll ec ti ve meas ures that ma ke it poss ible o n the o ne ha nd to improve th e a bilit y of th e o rga ni sm to p ro tec t itse lf fro m di sease a nd o n th e o th er to act o n the sur ro unding enviro nme nt so as to p rese rve those as pec ts o f it tha t fa vo ur hea lth a nd modify those tha t ca n da mage o r diminish the hea lth pote nti a l o f eac h person. Prima ry hea lth ca re, the new hea lth st ra tegy p ro posed by WHO a nd ado pted officia ll y by ma ny countri es since 1978, stresses the need to integra te different types o f preve nti ve acti vity a nd a rgues fo rcibl y fo r co mmunity pa rti cipa tio n in tac kling hea lth problems. In thi s new co ntex t , the hea lth tec hnicia n is bo und to be entrusted with thera peutic res po nsibilit ies, obvio usly, but will a lso have res po nsibilit ies in th e sph ere o f preve nti o n . He will o ft e n have to pl ay the ro le o f co mmunity o rga ni ze r. He will have to ass ume a tra ining ro le when wo rking with hea lth tea ms o r co mmunities. But the cha nge, o f course, is scarce ly a n easy o ne. Old habits di e ha rd , pa rti cularl y where they co nce rn the pres ti ge tha t a tt ac hes to trea tment a nd, let us recogni ze th e fac t , the low rega rd held fo r preventi ve a nd educa tio na l ac ti viti es, except perh a ps fo r vacc ina tio n progra mmes. Administrati ve infras tructures a re a lso res ista nt to cha nge: the co mpa rtme nta li za ti o n o f administratio ns, the excess ive ly "greedy" budge ts o f the hea lth ca re infra- structure, e tc. do no t make it easy to implement a different po li cy. F ina ll y, in the background a re to be fo und the hea lth perso nne l tra ining institutio ns tha t d o no t cha nge, o r d o no t cha nge eno ugh, in rela ti o n to the new responsibilities tha t hea lth technicia ns sho uld ta ke o n. Health wo rk ers a re continuing to be initi a ted int o a n unders ta nding o f di sease. C a use a nd effec t a re p ro perl y studied a lo ng with the mea ns ava il- a ble fo r treating s ick indi vidua ls. Medica l resea rch has made eno rmo us prog ress in thi s do ma in a nd it is the dut y o f hea lth personnel to be ca pa ble o f a llo wing pa ti ent s to benefit fro m the fac t. All thi s trainin g is imp rov ing day by d ay a nd it no w co nstitutes a precise a nd detail ed progra mme which is kn own to th e teache rs and in vo lves the use of a wide va ri ety o f teaching a pproac hes - ma nua ls, guidelines fo r practi ca l wo rk , dem o nstra ti o n ma teri a ls, etc . H ow sho uld cha nge be int roduced in thi s co ntex t a nd during the bas ic tra ining of hea lth personnel? Where ca n the time needed for acquiring the necessary knowledge a nd skill s be fo und to a rri ve a t a pro per a pp roac h a nd to ac t effecti ve ly in th e sphere o f preventio n, co mmunity pa rticipa ti o n a nd educa ti o·n fo r hea lth , etc.? How ca n the teachi ng corps be ex pa nded a nd a new a pproac h to tra ining, including perha ps a new di stribut ion o f academic 44 disc iplines, be envisaged? How ca n a sta rt be made witho ut hav ing ava il a ble a who le ra nge of teaching materi a ls to ease the tas k of the teacher? How ca n a cha nge in a ttitude a mo ng students be a rri ved a t and how can a preventi ve approac h be ado pt ed th at wo uld result in a las ting improve ment of th e hea lth o f each indi vidua l, when the sa me cha nge in a ttitude has no t a lways bee n a rri ved a t with in the teaching co rps and the hea lth perso nn el a lready in pos itio n? All o f these quest io ns, a lo ng with ma ny o thers, will be refe rred to parti cipa nts in the d iffe rent wo rking groups during the p rese nt confe rence. It is to be ho ped that o ne a nd a ll wi ll co nt ribu te to the se tting up o f tra inin g sys tems in lin e with the new needs. The ques tion we wo uld lik e to tackle now is p rec ise ly tha t of the a bility of the hea lth wo rker to unde rstand the people living in the a rea tha t he is ass igned to. Knowledge of the community The ecologica l, econo mic, soc ia l, cultu ra l a nd po litica l context determines the li ving conditi o ns o f each indi vidu a l within the community a nd the a ttitude o f tha t co mmunity vis-a-v is o ther human groups. In the co urse of time, eac h gro up develo ps a pa rti cula r type o f o rga ni z- ati o n a nd a spec ific know-ho w, ena bling it to profit mo re full y fro m the resources o f the enviro nment , to pro tect itse lf fr o m ha rmful fac to rs a nd to define the rela tio ns gove rning coexistence between individua ls. Each co mmunity mo re or less ex plicitl y lives th ro ugh a ce rta in pa ttern o f deve lo pment. This pa ttern possesses a logic wh ich sha pes the a ttitudes of indi vidua ls who have a sys tem for co mmunica ting the knowledge tha t is indispensa ble to a ll a nd sundry for ac hiev ing success in it and who a lways have a code a imed a t lubr ica ting the cogs in the mac hinery essenti a l fo r it s smooth fun ctio ning. The sa me com munity is bo und to have li ved th ro ugh eve nts (d ro ught , co lo niza tion , war, emigra tio n, etc.) that have th warted this pl an o f d eve lopment , obligi ng the grou p fo r a lo ng or sho rt pe riod o f time to seek readjustments in order to ensure its su rv iva l a nd to find ways to escape fro m " poor deve lo pment". Eve ry hea lth techn ic ian shou ld endeavou r to become fam ili a r with the phys ica l a nd huma n co ntex t of the co mmunity in which he has to wo rk as we ll as the mo re releva nt events in it s histo rica l background. Ano ther of hi s tas ks will be to define the pa ttern of deve lo pment tha t the group of huma ns in ques tio n is experi encing a t present a nd the degree of co nt ro l over th a t pa tt ern possessed by th e co mmunity. Are a ll members of the co mmunity ta king pa rt o r o nl y ce rt a in o nes? Is such pa rt ic ipa tio n a fun ctio n o f th eir age, their sex o r their econo mic power? Is the pa tt ern of deve lo pm ent a n in te rna l o ne, a nd part o f tha t co mmunity, or has it been imposed fro m o utside? To what ex tent d oes the prese nt pa ttern of deve lo p- ment , as experi enced by the co mmunity, meet the bas ic needs o f different members o f tha t co mmunity? Ho w d o the members of the community vo ice their unmet needs? 45 This knowledge o f the group , a na lys is o f the factors that ha ve influenced the life o f it s members, a nd awa reness o f the degre-e to which the bas ic needs o f each a re met , go to make up wha t may be termed community diagnosis. If the a im is the improve ment of the hea lth sta tus o f fa milies in the co mmunity, it will be esse nti al to undert a ke a n a nalys is o f those fac to rs tha t influence the hea lth o f the individua l a nd the group and which go to make up the structural causes o f the hea lth level of each individual. This ve ry wide ra nge o f fac to rs - phys ical , eco no mic, demogra phic, soc ia l, cultural and po liti ca l - may exercise a benign o r ha rmful effec t o n the hea lth of ind ividua ls a nd the group. The rela tio nship between such ri sk fac tors (o r facto rs tha t ha rm hea lth ) and the means of eliminating o r reducing them (benign facto rs) gove rns the sta te o f hea lth of each individua l. The ba la nce between the facto rs o ft en va ries according to the age and sex o f individu a ls in th e co mmunity as well as according to professio n, eco n- o mic level, educa tio na l background, etc. Ana lysis o f the factors must take account o f two para meters. On the o ne ha nd , the most o bjective identifica ti o n possible must be made o f risk facto rs fo r health and individual a nd co ll ective techniques available for combating them. But it is a lso essential to consider the subjective express io n o f these factors vo iced by members o f the co mmunity. Fo r the mos t pa rt , the relatio nship between the objective acts a nd the way in which subjective fa cts are vo iced is a wide one, in which case it wo uld be easy to accept prio riti es . But if the a rea in co mm o n is na rrow, a particular effo rt o f communi- ca tio n, discuss io n, and excha nge o f in fo rmatio n within the co mmunity will be required befo re it is poss ibl e to select a priority activit y. In cases where there is no area in comm o n, this is an indicati o n that there has been a n incorrect a nalys is o r interpreta tio n of data co ll ected o r tha t the views expressed by the members o f the community have been mistakenly put. After examining the circumstances which have led to such a situa tio n, some wo rk will need to be redo ne. Ho wever, kno wledge o f the co mmunity is no t solely the business o f age nts o uts ide the community who wo rk for the develo pment oft he area . If o ne accepts the principle that the develo pment of a community sho uld be the fruit o f an interna l d yna mism, the essent ia l element then beco mes the a nalys is o f the situa tio n made by the co mmunity itself. Th e int erve ntio n of o uts ide persons ca n o nl y be a seco nda ry element a nd a technica l suppo rt fo r the a na lys is, dec isio ns a nd actio ns that the group will have to ca rry o ut. After a n internal a nalys is (appraisa l = diagnos is), the co mmunity (o r individua l) will be a ble to identify and express a number o f un sa ti sfi ed needs in rela ti o n to the idea o f ha ppin ess o f thi s pa rticular group. The selectio n o f prio riti es a nd the search for the most appropriate ways of meeting needs o r reso lving a problem will also be the result of joint wo rk involving the community . Thus, for the outside technica l wo rker it is not a matter of making "his own diagn osis" o r of determining, in his ca pacity as an expert , the needs 46 which seem to him to be "rea li sti c" fo r the "obvio us" priorities, o r the "logical" ways o f a rri ving a t a so lutio n o f the p roblems ide ntified . On the cont ra ry, it is a ques ti o n o f lis tenin g to thi s group a nd of ass istin g it to a nalyse a given situa tio n o r to ca rry o ut a n acti vity a imed a t reso lving a specific problem. There a re a few occas io ns when the o utside age nt will himse lf have to induce this ana lys is within the co mmunity. But in mos t cases, it has a lready been do ne a nd it is a simple matter o f identifying it . In brief, to succeed in initia ting rea l co mmunity deve lo pment , the notion o f "do ing so mething fo r" the com munity shou ld be repl aced by tha t of " doing so mething with it" . This does no t mea n th at studies made by tec hnicia ns to a rri ve a t a bett er identifi catio n o f pro bl ems are not of inte res t , but th is is true o nl y prov ided tha t they kn ow how to pass o n the res ult s of their o bserva ti o ns in such a ma nner that the co mmunity ca n diges t the data a nd use them fo r bette r appra isa l o f the situa tio n, better se lectio n of prio riti es a nd bett er implemen- ta ti o n o f acti vities des igned to achi eve a so luti o n. This line o f approach, by a nd la rge kno wn as the participa to ry in ves ti- ga tio n technique, requires neve rtheless tha t th e deve lo pment agent be con- vin ced th a t members o f the co mmunity have so mething to teach him a nd that the group possesses the reso urces a nd capacity fo r re newa l. Training of health workers in "community diagnosis" In the past few yea rs, "community di agnos is" has fo rmed a tra ining module in the WHO/ ICC internationa l courses o n fa mily health and fa mily planning. Implementa tio n o f a suita ble fa mily pla nning progra mme must be based o n the mos t ex tensive poss ible kno wled ge of the fac tors influencing the hea lth o f individu al famili es. For these reasons, it has bee n dec ided to devote part of the tra ining period to thi s aspect of the matter. The period o f tim e se t as ide fo r the module is too sho rt to be able to a ttempt to train participa nts in the techniques tha t fac ilita te knowledge of the co mmunity. The fo ur days are however eno ugh to fa mili a ri ze them with ce rta in meth ods such as co nsulta tio n of registers, a nalys is of documents, interviews with co mmunit y leaders a nd members, o bse rva ti o n o f the en- viro nment , ma nagement a nd a na lys is of a ques tionnaire, no te-ta king, etc. But the mos t interes ting result of the mo dule is moti va tio n of pa rti cipants to a pproach the problem and to exchange ideas with the communit y. So far as the compos itio n of the module is concerned , we have ad opted the foll o wing p rogra mme. First day "Co mmunity di agnos is" . What is it? Why? H ow? Introductio n o f the subject by th e modera to r, group work a nd jo int development o f coding shee ts for analytical purposes. Second and third days Visits to different urban a nd ru ra l co mmunities in groups o f five o r six participants. 47 The progra mming o f ac tiviti es during co mmunity practi ce is left to the initia tive of eac h group , to a grea ter o r lesse r ex tent under the guida nce o f local hea lth personnel. Alm os t a ll o f the gro ups visit a hea lth centre a nd ta lk to the staff. They a lso have discuss io ns with the a utho riti es a nd certa in famili es, vi sit places o f wo rk a nd go to schools where they have di scuss io ns with teachers and pupils, pa rti cipa te in meetings, etc. Fourth day Co lla ti o n o f the in fo rm atio n o bta ined a nd a na lys is o f surveys. This oper- atio n ma kes it poss ible to: summa ri ze the ma in facto rs hav ing a pos iti ve o r nega tive effect o n the hea lth of the fa mil y o r community in the place under stud y; identify o ne o r o th er o f the ri sk fac tors with a grea t degree of precisio n; relate needs and prio rit y goa ls to th e needs a nd prio riti es vo iced by different members o f the co mmunity; understa nd those elements useful fo r p rogra mming a nd fo r ca rrying out fa mily pl a nning acti vities . Subsequentl y, each group submits its findin gs to the parti cipa nts in the course as a wh ole. The las t po rtio n is devo ted to meth odo logica l o bse rva tio ns. The sma ll a mo unt o f time ava ilable an d the co mplex ity o f practi ca l o rgani zatio n have prevented part of thi s t ra ining module fro m being imple- mented. In sofa r as reference is ma de to send ing back da ta to each co m- munity that has received the groups, thi s is in the cl ea r kno wl edge th a t it is a matter o f an initi a l impress io n whi ch will be deve lo ped with the input fro m each person conce rned . From the develo pm ent sta ndpo int , the technicia n must know how to co nvey th e res ult s o f o bse rvatio ns he ma kes in th e fi eld back to the com- munity clea rl y, simply and in a suita ble fas hio n. It is impo rt ant to give considera tio n to the way in which in fo rm atio n is provided back to the co mmunity a nd to the usua l in fo rmatio n transmiss io n methods within the la tter. In groups in which ora l t ra nsmiss io n o f in fo r- mati o n is o f prime impo rta nce a nd a la rge pro po rtio n o f individu a ls is una ble to read o r write, there is no point in trying to interes t the group o r make it understand a method which uses " sc ientifi c" ta bles a nd summary cha rts. In each case , it is essenti a l to stud y the mos t suita bl e methods fo r transmitting inform atio n co ll ected so as to a ll o w the co mmunity to under- sta nd and to a rouse di scuss io n a nd exchange of views o n the subjects rai sed. Some comments on the above teaching module Hea lth perso nn el ca n be familiari zed with the co mmunity quite quickly so lo ng as the teaching is based on practice, i.e. o n a rea l introductio n to a community a nd the identificatio n of prio rity hea lth problems. 48 The role o f the teacher will be to motivate and guide the wo rking groups and to p rovide eno ugh theore ti ca l a nd p racti ca l tools to ma ke it poss ible for each indi vidua l to ma ke a "community diagnos is". Prelimina ry co ntact must be made with the rece iving community. It is essentia l for the la tter to be in fo rmed of the usefuln ess o f the wo rk to be done by students a nd the meth odo logy se lected so that they ca n a pprecia te the interes t that th e practi ca l work o f the students may have both fo r the latter a nd fo r the co mmunity itse lf. It is essentia l for the co mmunity to be in a pos itio n to fr ee ly accept o r reject the p ractica l fi eld wo rk and to -g ive its agree ment to the group spending tim e there. It must be in a pos itio n to eva luate the interes t o f a given acti vity a nd to ass ist in improving the methods proposed by the teachers. It is no t a good idea to keep the sa me practi ca l fi eld work a reas yea r after yea r beca use it will no t be lo ng before the co mmunity is tired o f being so close ly examined and questio ned o n the sa me subjects, while nothing is done to reso lve their problems. The attitude o f teachers a nd students greatl y influences th e qua lity o f exchanges betwee n them a nd the co mmunity. The la tter will be ve ry quick to divine the underlying intentio ns o f those who wish to " kno w". Are they striving for a bett er a nalys is o f the p ro blems in co njunctio n with them? Or simply to extract in fo rm at io n? Are they se tt ing in motio n a dyna mic a na lyti- ca l effo rt a nd stri ving to so lve questi o ns in co mm o n? Or is a ll tha t they are interes ted in a hasty judgement a nd the d istributio n of a few pieces o f on-the- spot advice? Are they trying to understand in o rder to provide mo re va luabl e support to the community? Or to be in a better position to manipula te it? The wo rk invo lved in a rri ving a t an understa nd ing and knowledge o f the co mmunity dema nds the suppo rt of other technicia ns tha n hea lth wo rkers. Analyses made by technicia ns with local respo nsibilities in agriculture, education, vocational and ma nual training, hydraulics, etc . will prove to be o f grea t use for the hea lth wo rker. But it is important fo r him also to beco me famili a r with the sta tements made by o ther technicians. A knowledge o f the co mmunity is not a o nce a nd fo rever thing, acquired as soon as the hea lth wo rker is in post. The co mmunity is a living tissue which acts and reacts to a number of different fa cto rs, no w advancing a nd now retrea ting in o rder to prepa re the ground fo r a new advance. A kno wledge of the enviro nment must be a n o ngoi ng thing if such changes are to be recorded a nd understood . The reason o ne speaks o f int roducing " indicators" is to give prominence to these changes. Conventio nal indica tors should be backed by indicators that can be used for different actio ns underway and defin ed jo intly with the community, whi ch is the first to be interested in understa nding the im- po rtance of the change. Kno wledge o f the co mmunity a nd fo ll ow-up of trends in indica to rs a re essentia l a t local level in guiding the pl a nning and actio n o f the co mmunity a nd in determining the suppo rt provided by the local hea lth worker. But at the sa me time, this knowledge is a ve ry useful source of in fo rm atio n fo r regio na l and even natio na l o rganize rs a nd planners, who oft en ma ke very poor use of it. The reli a bility o f information requires, however, that the 49 worker be motivated and have a desire to understand the community properly, that he be capable of collecting and reco·rding information cor- rectly and that he be encouraged in his work by his hierarchical superiors. The understanding of the community obtained by harnessing the latter's dynamics should be extended by taking decisions and arranging priority activities designed to improve health. Needs (sub1ec t1ve Analysis of factors or o therwise) that affect Understanding Select ion the heal th of o f present of the family and s1tua t1on pri ori t ies comm uni ty Reso urces (whether used or not) Sea rc h fo r so lut ions Unde rt ak ing Prog ramm in g the ac t1v1ty the a;;t:v1 ty This approach causes no problems for health personnel a lready in post who are there in any case to help improve the health of each individual. But so far as students are concerned, familiarization with the community should take place with the support and advice of health personnel already in position in such a way as to make possible a continuing exchange between the comm unity and the health workers. C onclusion To become thoroughly familiar with the community must be a goal in the basic training of all health workers if it is desired that they should be of real use and help in improving the health status of each individual. This is not done very frequently , but in some institutions it is the practice. It would be interesting for such training practices to be more widely known so as to encourage others to set up models suitable for acquiring the knowledge and skill necessary to understand community problems and to develop jointly with the community the strategies that might improve the situat ion. Psychosocial and educational aspects of family planning Ph. Lecorps The psychosocial aspects of family planning may be defined as being all those disciplines a nd languages that view man both as an individual replete 50 with des ires a nd contradictio ns a nd as a social being livi ng in a society a nd culture that sha pe him a nd give a fra mework to his li fe . One ca n go o n to defin e the educative as pects of such pl anning as being a ll those co mmunica tio n a nd informatio n techn iques and socia l stra tegies that have to be put into effect if ma n, as pa rt of his commun ity, is to acq uire the ava il able info rma tio n and techniq ues a nd thereby to develo p hi s o wn plans. The psychosocial aspects But why speak o f psychosocial aspects in the fa mily pla nning sphere? The p racti ces that make up fa mily planning must a llow individua ls and couples to a tta in ce rta in personal goa ls: to pro mote des ired bi rths, to have a n influence o n the interva ls between births, to avo id un wanted bi rt hs, to determine the number of child ren des ired to ma ke up a fa mily. Each of these a ims is lin ked wi th ind ivid ua l, cultu ra l a nd po litica l problem a reas. At the individua l leve l, the questio n is to know how the partners view the child to be bo rn , pla nned a nd des ired , ho w the woman in parti cul a r ex- peri ences the des ire fo r o r the postpo nement of pregnancy, how she will be a ble to develo p her love re la tionship in iso la tio n fro m the risk of p roc rea ti on a nd how th e ma n when faced with this new, to so me ex tent " free" wo man, will be able to continue to keep his co nfidence. Th ese fee lin gs ex peri enced by men a nd women over fa mil y pl a nnin g for m pa rt o f a ra nge o f mea nin gs, va lu es a nd models la id d own a nd strength ened by the cultu ra l backgro und . It is the enviro nment which , a t a given period o f time, in a given locality a nd fo r a given socia l ca tego ry, decides what is constituted by " good sexua l behav iour", the respecti ve ro les o f men a nd wo men, the ru les gove rning the way they meet o ne a nother a nd fa mily size. The views of society concerning children to be bro ught into the wor ld or avo ided a re ta ken up in each co untry by the natio nal a uth o rit ies which, using econo mic, demogra phic or hea lth situat ion ana lyses, lay down nata li st poli cies to co mbat the aging o f popula tio ns or birth spaci ng po licies to improve the health sta tus of mot hers a nd children o r even policies des igned to act as a bra ke o n po pula tion p ressu re. In the cho ice a nd effecti ve use of medica l o r social techniques to pro mote birth , delayed birth , adopt ion o r a bort ion, a ll those fa mily, societal, a nd religio us norms a nd the po litica l opt ions of a coun try play a pa rt , which always has to be identified fo r the ind ividua l concerned . One o f the purposes of the t ra ining will be des igned to permit hea lth personnel to co mprehend the diffe rent leve ls of argument o n sex uality a nd birth with rega rd to thei r own lives, so as to improve the way they receive and listen to a person a tt end ing fo r consult a tio n, and to ma tch the technical so lutio ns pro posed to the needs of the co mmunity in q ues tio n. 51 Educative aspects It is interesting to no te th a t training in pl a nning is often designed only to provide practitio ners a nd the public with in forma tion a nd techniques, as if th ese could be trea ted in iso la tio n from the cu lture that has made poss ible their emergence a nd dissemination. Howeve r , what is new in the hi story of man kind is not th e effo rt by ma n to master fertility, a n effort th at has succeeded in ma ny co untri es and has been tri ed everywhere else, but the appeara nce in the las t 30 o r so yea rs ofan entire range of contracepti ve tools th a t a re to a grea ter or lesser ex tent effec tive, harml ess, ag reeable to use, a nd acceptab le to couples. What is also new is the ex is tence and development of a co ll ec ti ve discussion o n man , woman and the way the two meet, on sex li fe and ero ti cism , and o n sex life and procrea tion. The foregoing is worth recalling here to show clea rl y tha t no thing tha t affec ts family pla nning ca n be treated in iso la tio n fro m the soc ia l organiz- a tio n producin g the too ls a nd a rgume nts th a t faci lit a te it o r prohibit its use. Let us no te th en tha t the effecti ve use of fami ly pl anning techniques is obse rved above a ll in the urbani zed areas of indust ri a l co untries, i.e. in areas where a t the same time cha nges in hous ing, working conditio ns, educa tio n, entry into a syste m gove rn ed by mo neta ry rela tio ns a nd , mo re deeply still , a maj o r change in co nsumptio n models, have been o bserved . The financial cost of the a rri va l o f a child ass umes it s place as o ne of the constituents of a family deve lo pm ent plan, co mpeting with the purch ase of a ho use, the financing of a car, and va rio us types o f investment related to children already born o r family comfort. In normal urban middle-class co nversa ti o n, a new concept has devel- o ped , that of t he "wanted child", a phrase tha t has graduall y come, through a process of lin gui stic slippage and reduction of mea ning, to have a mea ning close to that o f a "planned child" rationally des ired and directly dependent o n what th e family econo my pe rmit s, o n the hea lth of the mother a nd on the harmo ny ex isting in the life of the couple. The educational messages are developed from thi s standpoint of the "wanted child", the child that is bo rn as a result of conscious choice, and res po nsibl e fatherhood. We a rgue tha t such approaches a re already suitable fo r reac hing th e middle classes in towns in industri a li zed countries a nd a t a ny time now those in no n-industri a li zed co untri es. But we kn ow tha t mos t men a nd women now a live a nd most of those to be born in the next few yea rs will have their roots in rural surroundings and mo re particul a rl y in the rura l world of non-i ndustri a li zed na tio ns. In that environment , the o rga ni za tio n o f labour, beliefs a nd myths relating to the rela ti o nships between men a nd women, and the risks of infant morta lit y, demand tha t the woman co nsta ntl y demonstrate her fertility: the child is the essential proof of the woman's affect io n a nd of ma le power. The large number of children is what guarantees the surviva l of the family farm. Social techniques tha t a ll ow the number of children to be ma tched to the needs of fa mil y se lf-reliance, such as the prohibition of sexual relationships a t certain tim es o r the g iving away of excess children to members of t he family who a re better off nowadays functions o nl y with partial success. Traditional 52 birth spacing techniques such as potions and amulets nowadays seem to be very ineffective. At the same time, modern medical techniques do not appear very cred- ible. For these groups, with the different thought patterns that govern their lives, it seems unthinkable that the paraphenalia oft he family planning team can contro l a woman's fertility. They also consider it strange that in order to have chi ldren they should not have them and what is more , that they must pay for the privilege. Fina ll y, the techniques are often taught, disseminated, and provided by personnel (doctors, midwives, teachers and health educators) who differ so much in terms of their socioeconomic status, lifestyle and aspirations, that it seems difficult for the most poorly-off population groups to be able to appreciate the teaching as a life-giving message. Does it not seem more likely to be heavy pressure from the dominant class trying to indoctrinate the poor with methods of not reproducing? Educational messages relating to family planning therefore make sense to and can be directly taken up by the middle class who compile and disseminate them . However, they must be radically changed if they are to penetrate the countryside and produce the beneficial effects that are to be expected from a reduction in population pressure on economic develop- ment, and from improvement in health of mothers and children already born by extending the interval between births . The change will have to be made by health and development workers taking into account all value systems that relate to the family, pregnancy, delivery , the number of children and rural health in general. It should also not be forgotten that in graphics or visual aids, frontal or side-on cross-sections oft he male and female genitalia mean something only for those individuals trained to understand such abstractions; for most rural populations that have little familiarity with such graphics, the represent- ations are meaningless. A major effort will therefore have to be made to bring practitioners to an understanding of what family planning means personally to those attending for consu ltation. The practitioner will then have to be able to explain, using his or her clients' own words and suitable imagery, how the male and female bodies function and how the different available methods of contraception operate. With such training, health personnel will make it possible for the com- munity in which they work to focus attention on itself, to define its own needs and to manage family planning side by side with maternal and child pro- tection and development, in the realization of its own community projects. Evaluation of family planning activities E. Wollast Any provision of knowledge and techniques aimed at making health person- ne l responsible for a given activity must always be backed by an introduction 53 to evaluation methods designed to check and improve a given activity. All health workers have a concern in the evaluation of their activities, irrespec- tive of the level of the health system where they operate. Thus, in the basic training of physicians, midwives, nurses, etc., the progra mme should include simple evaluation procedures designed to meet the needs of their operational activities. In addition, family planning activities by their very nature require more control and supervision than most health serv ices. There are a number of reasons for this: (a) they are services of the preventive type which go beyond supposed, albeit poorly expressed, needs of the population; thus it is a matter of ensuring that expectations are properly met ; (b) family planning often forms part of major programmes which make use of considerable financial resources and staff, and it is therefore of major importance to calculate the impact of the activity; (c) the effectiveness of contraceptive methods is closely bound up with their continuity, and that presupposes specific evaluation methods. Finally , and more generally, it is useful to recall that evaluation must always be conducted from the standpoint of change, with a view to improving services. To some extent, it ensures that the activities of health workers are tailored to meet the needs of the population. Teaching that is limited to the imparting of theoretical knowledge or familiarization with given tasks, without evaluation procedures , trains people to provide static services that rapidly lose their value. The teaching of evaluation methods must make it possible for users to arrive at judgements as to their own work ( or as to a point of departure) and to make changes to it with a view to improvement. A number of different types of evaluation must be tackled if future workers are to be able to respond to the various problems they will be faced with: problems related to their pattern of organization and performance, to the quality of care and to the efficiency and effectiveness of their programme. All these different types of evaluation must stem from the initiative of the workers themselves and be carried out by them. For that purpose, training must deal with the three phases essential to any evaluation process: selection and definition of subjects to be evaluated; evaluation procedures and tools suited for different subjects; organization of steps and procedures to ensure the success of evaluation. More specifically, teaching of evaluation concepts in a family planning training course should cover the following points. I . Clear and coherent definition of the various goals of family planning: demography, family health, risks to mothers, etc. 54 2. Demo nstrat io n o f the relat ive impo rt a nce of the various types of evaluation a pplica bl e to fa mil y pla nning acti vities; releva nce of the pro- gra mm e, perfo rma nce o r qua lity of se rvice, co ntinuity, impac t o n the po pu- la tio n, etc. Fo r such teaching, it is mos t importa nt of a ll to ensure the acq uisit ion of the too ls needed to carry o ut "i nternal eva lua tio ns" in a se rvice (checking of pe rfor ma nce a nd the qua lity of se rvice), which by a nd la rge rela te to opera tio na l ac tivi ti es. 3. Acquisiti o n of simple evaluation methods. Initia ll y, thi s mea ns the co mputa tio n a nd utili za tio n of class ifie rs, a nd the se lecti o n of de mographi c a nd fa mily hea lth indica tors, a nd of crite ria related to wha t it is intended to measure. The ma king of simple meas ure ments (rela tio nships, ra tes, per- centages, etc. ) a nd the use o f no rms making it poss ible to interpret the results a re additio nal elements in acquiring such knowledge. 4. Determina tio n of procedures requiring evaluation. Here, tra ining must teach the student to spec ify clea rl y wha t is being in vestiga ted (what dec isio ns the eva lua ti o n is designed to back up) a nd to a rra nge da ta co l- lectio n (establi shment of a "fa mily pla nning" heading in a fi le, fo r exa mple). It is a lso usefu l to determine the mos t effecti ve procedure fo r o bta ining importa nt results such as co ntinuity, e .g. th ro ugh continuo us eva lua tio n o r periodic survey. Fina ll y, it wo uld be necessa ry to provide students with a n abilit y to define intermediate indicators ena bling them to a pprecia te the impact o f their ac tivity in the sho rt term and its mo re direc t o r less direct rela tio nship with their programme. Intermediate indica to rs lie between the end goa ls a nd the means underta ken. In fa mily pla nning programmes, a good intermediate indica to r could , for insta nce, be the gap between births, which is much more sensitive to fa mily pla nning acti vities than the birth ra te. Pedagogical support to family planning programmes M.A. C. Dowling Specific teaching a nd lea rning methods and materia ls need to be deve lo ped to mee t the needs of the different ca tego ri es of indi vidua l in vo lved in famil y pla nning acti vities . Each type of lea rning o r user requires di ffe rent materia ls and different a pproac hes. The ca tegori es a re as fo llows. I. Practising physicians. This group requires recent , frequentl y up- da ted materi a ls. The use of microfi ches, wa ll cha rt s o r illustra ted brochures . wi th acco mpa nying tex ts a nd/o r cassette ta pes, could be considered fo r thi s purpose. One exa mple we might qu ote is the continuing educa tion pro- gramme of the American Co llege of Phys icia ns. 55 2. Medical students. For this ca tegory, teaching ma teria l a nd methods need to be deve lo ped which ca n eas il y be fitted into a n a lread y hea vil y loaded program me o f wo rk. Teaching a nd lea rn ing meth ods will be backed by suita ble techniq ues such as case stud ies and se lf-instructio na l unit s. The teac hers wo uld require slides, films a nd /o r video cassettes, which illustra te espec ia ll y the demogra phic a nd psychosocia l as pec ts o f fa mil y pla nning. Medica l sc hoo ls co uld ta ke the initi a ti ve by deve lo ping materi a ls fo r use in teaching a t a ll leve ls. Mos t schools have ve ry ac ti ve depa rtments o f medica l illustra ti o n which co uld unde rt a ke the tas k of prepa ring se ts o f slides o r ot her a udi ovisua l materi a ls. This p rocedure wo uld have th e ad va ntage th a t, unlik e mos t co mm ercia ll y ava il a bl e products, ma te ria ls wo uld be direc tl y relevant to loca l situa tions. 3. Train ers of f amily planning workers. Ma teri a ls simila r to those menti o ned in paragra ph 2 above may be used , a ltho ugh the curri cula will , of co urse, be different. Ro le-pl ay ing is a n exce ll ent method o f lea rning. Case studies a re a lso ve ry impo rta nt as a bas is fo r d iscuss io n groups. They should be based o n spec ific factua l in fo rm ation, p refera bly releva nt to the loca l situa ti o n. This dema nds a n effo rt , o n the pa rt of tra iners a nd supervisors, to co ll ect da ta o n typica l p ro blems fac ing fa mil y pla nning sta ff in the fi eld . Such probl ems, pro perl y illustra ted , will fo rm a n exce llent source o f teach- ing material whi ch ca n be used in ma ny different ways by teachers a t a ll levels. 4 . Family planning workers. This category o f staff will require refer- ence guides o n different co ntraceptive methods, checkli sts for use in consul- ta tio ns o r discuss io ns with "clients", a va ri ety o f simple a udi ovisua l ma- teri a l for demo nstra tio ns (flip cha rts, fl as h ca rds, posters a nd models). Practi ce in the use o f materi a ls in simula ted situa ti o ns sho uld be built into the training so tha t th e students beco me fa milia r with them. Th e case studies referred to a bove (pa ragraph 3) ca n be ada pted fo r these simula ti o ns. A problem co mmo n to a ll sta ff in the fi eld is tha t of updating and refres her t ra ining so as to ma inta in a nd co nsta ntl y improve the qua lity o f their performance. Co nsiderable experi ence has bee n ga ined in the use o f "dis- ta nce educa ti o n" in deve lo ping countries ove r the pas t fe w yea rs, making use o f radio a nd co rrespo ndence. The potenti a l provided by thi s meth od co uld be bo rne in mind fo r the continuing educa tio n o f fi eld staff. 5. " Clients" and the general public, including schoolchildren. Here, we sho uld se lect exa mples fr o m the wide va ri ety of ava il a ble ma terials, bro- chures, film s, no n-verba l materi a ls, sho rt radi o a nd televisio n p rogra mmes, etc. It ca nno t be too stro ngly emphas ized that a ll such materi a l must be fi eld tes ted with ta rget a udiences befo re release a nd di sse mina tio n. Additio na l metho ds of co mmunica tio n such as the "photo novell a " (in Mexico), puppet sho ws, songs a nd sto ri es sho uld a lso be used , pa rticularl y in develo ping countri es. 56 The following works may also be consulted. Abbat, F.R. Teaching for better learning: a guide for teachers of primary health care staff Geneva, World Health Organization, 1980. Guilbert, J.J. Educational handbook for health personnel (revised edition). Geneva, World Health Organization, 1981 (WHO Offset Publication No. 35). Holmberg, B. Status and trends of distance education. London, Kogan Page, 1981. Young, M. et al. Distance teaching/or the Third World. London, Routledge & Kegan Paul, 1980. 57 3 Activities of study groups: some reflections on training in family planning K. Edstrom T ra ining in fa mil y pla nning has rece ntl y undergone a radica l cha nge. Now- adays there is grea ter rea li za tio n that tra ining programmes must be directed to wa rds co mm unit y needs. The specifi c tas ks o f hea lth personnel in tra ining matters must therefo re be defin ed in rela tio n to these funda mental needs. It is intended to se t fo rth here ce rta in basic princip les that can be applied in the training o f both medica l personnel and the traditio na l birth attendant. I. A start must be made by definin g community and individu al needs and transla ting these into hea lth ca re activ iti es and tasks. 2. Care must be ta ken to ensure tha t train ing of o ne category of hea lth personnel is no t made in iso la tio n fro m training programmes for o ther profess io na ls. Decisio ns o n respo nsibilities within the tea m must be taken on a jo int basis . Mo reover, in the primary hea lth ca re approach the team co nsists o f seve ra l perso ns, including workers fro m o ther secto rs. Mo reover the key person in th e tea m is the " client", i.e. the individua l o r coup le requmng informatio n o n the pros pects open to them in pla nning their fam il y. 3. Fin ally, tra ining must be fo unded o n a deta il ed knowledge o f what the students will have to do, o n wha t their reso urces a re, a nd in wha t co nd iti ons the tasks must be carr ied o ut. The bas ics fo r drawing up a training programme consist in : a definiti o n of educa ti o nal goals, the de- velopment o f a course structure (curri culum), the selectio n of methods a nd teaching materials, a nd a n evaluat io n o f the p rogramme res ults. In recent years the Fa mi ly Health Di vision a t WHO has been p ro mo ting task ana lys is studies to o btain better results fro m maternal and child hea lth and famil y training programmes. The repo rt 0 o n a co nsulta tio n held in G eneva fro m 13 to 16 August I 979 o n systemati c a pproac hes to task a na lysis in materna l and child hea lth ca re, a Unpublished WH O documen t, MC H/ HMD/79.1 , 1979. 59 li sts the s teps to be foll o wed if programmes fo r training o r planning o f se rvices a re to be releva nt to the needs o f a po pulatio n. This a pproach a pplies equ a ll y to the tra ining o f hea lth wo rkers, to the programming of maternal and child hea lth / famil y pla nning se rvices and to the deve lo pment o f a prima ry hea lth ca re tea m. In an a lys ing wha t a hea lth wo rker has to d o it is no t sufficient just to fo cus o n th e tec hnica l ma tt ers (fo r exa mple, the use o f a given contra- cepti ve ); o ne a lso has to co nsider the perso n herse lf, her probl ems, her in fo rmati on needs in rela ti o n to ava il able meth ods a nd hea lth se rvices , etc. As a n a na lys is thi s is no t so mething tha t is se lf-ev ident. It is even esse ntial if a n effec ti ve t ra ining progra mme is to be prepa red. The curriculum must be based o n a n a na lys is o f probl ems ex peri enced by individua ls a nd groups. Beca use o f the tas ks of the hea lth wo rk er emphas is is placed o n practica l tra ining meth ods. This does no t mea n, ho weve r, that o ther form s o f training (semin a rs, fo r exa mple) do no t have a pl ace o f their o wn . But a co nference o n rep rodu cti ve phys io logy is perh aps no t the bes t method for use in a fa mil y pl a nning tra ining co urse; th e mos t impo rt a nt thing is to present specific cases o r simula ti o ns. This wo uld ma ke it poss ible to a lign the tra inin g process with the wo rk to be do ne by the students a ft erwa rds. Have th e teaching spec ia li sts bee n adeq ua tely in fo rmed a bo ut eva lu- a tio n meth ods? This ma y be do ubted as generall y spea king evaluation is limited to o ra l exa min a tio ns, th e use o f a multiple-cho ice questi o nnaire and the se tting o f theoreti ca l pro bl ems. It is no t eno ugh fo r the student to be a ble to d escribe a procedure (e.g. inserti o n o f a n IUD). It must be ascerta in ed wh ether she is capable o f applying her kn owledge in practi ce. C lea rl y, simple and precise measure- ment tools a re required to eva lu a te a student 's performa nce by means o f o bse rva tio n . Definition of functions of different professional groups in family planning The pa rti cipa nt s were ass igned to fi ve stud y gro ups whi ch then a lloca ted, respo nsibilit y fo r the va ri o us fun ctio ns, as li sted in T a bl e 9, to se lected: profess io na l gro ups such as: medica l spec ia lis ts, genera l practitio ners, mid- wives, nurses, medica l wo rk ers, soc ia l wo rkers, teach ers, etc . The a im o f this exe rcise was fo r the stud y groups to ex periment with the p rocess o f drawin g up curri culum d es ign, the first phase o f whi ch consists in definin g fun cti o ns and a lloca ting th em a mong the members o f the different profess io ns conce rn ed . Th e wo rk o f th e stud y gro ups was ve ry wo rthwhile. The ma in problem lay in the fac t th a t a single table of fun ct io ns was pro posed to all the pa rticipants, whereas eac h member of the groups had ex perience o f ve ry d ifferent situ a tio ns in the ho me co untry. At the sa me time, the proposed model was sla nted to wa rds the medica l p ro fess io ns a nd did no t mentio n ce rt a in ve ry impo rt a nt fun cti o ns such as the need to identify the soc ia l co ntext ·of those requirin g se rvi ces, the va lu es they were expressing, their cho ices, des ires, etc. As a result , in the exerci se the tas ks were in mos t cases 60 Action Activities designed to promote family planning Counselling services Identification of famili es exposed to risks ln1ttal prov1s1on of a cont raceptive method (on con ta ct. for family planning services) (determination of lactati on. breast- feeding) M onito red d istribution o f con tracep tive methods Treatment of compl1ca t1 ons Treatment of 1nferttl1ty Table 9. Family plann ing Tasks M otivation of community leaders. etc. lnd1v1dual tracing Group 1nformat1on Information. including possible side effects of the methods proposed C ho1 ce of method Sex education Tracing . opening of files Oral con tra ce ptives lniect1ble contrace ptives IUD Vasectomy Uterine tube l1gat1on Oth er inert methods (male contraceptives. periodic abstin ence. etc .) Oral co ntraceptives lnJ ect1ble contracepti ves Other inert methods Treatment of minor side effects Adm1n1strat1on of iron supplements IUD withdrawal M easures 1n even t of failure of method Tracing Search for previous instances. co unselling Clinical exam1nat1on Treatment Category of personnel 61 a ll oca ted to hea lth perso nnel, spec ia li st ph ys icia ns, genera l pract1t1 o ners, nu rses a nd midwives. T he di scuss io ns showed t-ha t there was roo m fo r expa nding the ro le of auxiliaries, socia l workers a nd teache rs in the very wide fi eld o f the no t specifica ll y medi ca l aspects of fa mil y pla nni ng . Proposals for teaching family planning to different categories of health personnel on the basis of the defined functions T he a im o f th e exe rcise was no t to g ive an ex ha usti ve descri ptio n of a p rog ra mme tha t could be a pplied in a ll co untr ies a nd to each ca tegory of staff, but ra th er to assis t edu ca ti o na l pl a nners to deve lo p or to revise curri cul a . Each study gro up th erefore endeavoured: to o utlin e the genera l o bjecti ves fo r the teaching of fa mil y pla nning to the profess io na l ca tego ry un de r consideratio n; to ma ke reco mm enda ti o ns in respec t of the necessa ry aptitudes, knowledge, a ttitudes, teachin g/lea rning methods, eva lua tio n tech- niques an d mea ns of integra ti ng the teac hing in p rogra mmes; to indi ca te ways of eva lu a tin g t ra in ing p rogra mm es in fa mil y pl a nn ing. Basic and refresher training for midwives and nurses Fa mil y pla nnin g must be integra ted within the prima ry hea lth ca re system. A t this leve l nurses a nd midwives have impo rt a nt fun ctio ns a nd sho uld therefo re rece ive spec ific training in fa mil y pla nning. (a) Basic training General goals Upo n co mpletio n o f their tra ining, the nurses must be a ble to : 62 crea te a n awa reness in the co mmunity of the adva ntages o f famil y planning; identify fa mili es o r individua ls tha t a re in pa rticula r need o f family pla nning and persuade them to practi se it ; ta ke into acco unt th e psyc hosocia l as pects of the va rio us famil y pla nning acti vities; advise o n a cont raceptive method ; identify a nd guide co upl es with a n infertility p ro blem, identify th e main ca uses of in fe rtilit y, a nd know how to prevent them ; moti va te co mmunity leaders and enco urage them to take pa rt in th e acti vities; sup·ervise traditio na l mid wives a nd ot her community hea lth wo rkers in countri es where such practi tio ners ex ist. Knowledge General stru c tur e and function o f a communi ty: main health o r related problems What 1s family planning? Factors inf I uenc Ing family and ind1v1dual health: birth spacing. socioeconomic and biological fa ctors. etc . Risk factors showing ind1v1duals and families at risk How to encounter and establish contact w ith cl ients . groups and the commu nity Human relation s and sexual behaviour Contraceptive methods. side effects and complica t ions Usual causes o f infertility and methods of preventing it Legis lative aspects of family p lan ning . including aborti on Ap(l(udes Communicat ion with 1nd1v1duals or groups and with community leaders Superv1s1on of trad1t1onal m1dw1ves and other A11,1udes Tolerant and / or pos1t1ve attitu de to family plannin g Understanding and tolerance of cultural and community health workers trad1t1onal patterns 1n the society Harmonious balance between personal c hoi ce and authority 1n relations with families and 1nd1v1duals An understanding attitude towards different patterns of sexual behaviour Teaching/ learning methods Communication techniques: role-playing, conversational techniques, lec- tures, use of audiovisual aids 63 Training in relationships: group discussions, role-playing, video recording and other audiovisual methods Technical knowledge : case studies, problem-solving, lectures, handbooks and manuals, seminars (b) Refresher/further training Goals In addition to the goals already mentioned in relation to basic training, general nurses should also be capable of: selecting methods that are tailored to meet the needs of their clients; assisting clients to make a choice and providing them with the most suitable method or referring them to a higher level; understanding and accepting the role and function of each team member with regard to family planning; collecting, processing and making use of the necessary data for a family planning programme; supervising family planning activities in the community; educating and guiding other health workers . Knowledge Indica tions and contraindications for th e different methods avai lable Factors involved 1n the acceptan ce of methods at communi ty and individual level Legal. psychosocial and medical aspects of abo rt ion Organization of monitoring of con tra ceptive users Approaches to infertili ty problems Role. function . rights and duties of different members of the team 64 Aplltudes Clinical examinati on of clien ts Description and prov1s1on of suitable contraceptive methods Diagnosis and treatment of com pli cations Collection. processing and evaluation of basic data Awrudes Ability to work in a team Basic training of medical students, further training of general practitioners and specialists At the pre-unive rsity o r seconda ry leve l, in structi ons shou ld be give n o n: bio logy, po pula tio n ma tte rs, human reproductio n, huma n rela ti o ns, a wa reness of co mmunit y needs . (a) Basic training of medical students Human reproduction and human relations T he students sho uld acq uire a bas ic knowledge of hum a n reprod uct io n a nd huma n rela tio ns geared to co mmu nity needs a nd integra ted with instructi o n on: a na to my, physio logy, soc io logy and psychology; huma n sex ua lit y; bas ic principles of famil y pla nning. Family planning Knowledge As pa rt of the soc ia l a nd com munity medicine co urse: popula tio n size age pyra mid civil registra ti o n sta tisti cs fertility behav io u r family hea lth influence of enviro nmenta l fac to rs o n hea lth impo rta nce of fa mil y pla nning po pula tio n dy na mics Kno wledge As pa rt of the gynaeco logy co urse: review of knowledge o f huma n reproductio n contraceptive a nd pregna ncy termina tio n methods sterilizatio n methods genetic counse lling diagnosis, trea tment a nd approac hes to infertilit y pro blems human sexuality a t different ages sexual mino riti es sex ual dysfun ctio n genita l infectio ns and their consequences 65 Aptitudes Instructio n in techniques of: clinical hi sto ry and prese ntatio n o f cases general exa mina tio ns including breast examinations vaginal smears vaginal touch insertion o f speculum As far as poss ible, practical training in : different contraceptive methods prescriptio n of ora l co ntraceptives measurements for se lecti o n of diaphragms IUD insertions pregnancy terminations individual surveillance Attitudes Empathy: to be able to li sten to respect the client's situation to be aware of her own values to give enough time for the client to feel at ease Respect for human rights and the dignity of the client in the process of decision-making with regard to family planning Other common subjects 66 In psychiatry: problems in human relatio ns problems in the sexual sphere abnormal human behaviour mother-child relations family relations In paediatrics: intra-family relations parental bonds relationships of the couple The other medical di sc iplines shou ld give attention to as pec ts of human sex ua lity, human relationships and family planning in relatio n to various medical proble ms such as: th e effects of drugs, neurologi ca l conditi o ns (paraplegia, etc.), surgical conditions and cardiac disorders. (b) Training of general practitioners Updating of knowledge on technical progress and the use of resources A llitudes As under (a) Aptitudes Strengthening of basic aptitudes: case history gynaecological examination technica l competence: IUD insertion and surveillance, interruption of pregancy If necessa ry: tuba l sterilization by minilaparotomy vasectomy Approaches to infertility problems: case history and genital examination case study advice and techniques of coitus, etc. ( c) Training of specialists in gynaecology and obstetrics Knowledge All aspects of fertility regulation (updating and extension of knowledge of infertility, contraception, abortion, reversibility of sterilization, tubal surgery, etc.) Psychosexual problems Elements of demography Principles of genetic counselling Guidance before conception Health services concerned in family planning 67 Teaching meth ods Inclusio n o f different as pects o f family pla nning in th e stud y o f gynae- cologica l conditio ns a nd the orga niza tio n of ca re: antenatal, intrapa r- tum , pos tna ta l Aptitudes Cont race ptive techniques, including ste rili za ti o n and terminati o n of pregna ncy Spec ific tra ining in a ll the different methods Advice o n pro blems of fe rtilit y regu la tio n Advice o n psychosexua l problems Advice befo re contrace ptio n Orga ni za tio n o f hea lth se rvi ces for the development o f family planning ac tiviti es as rela ted to Other clinica l needs (d) Training of other specialists Paediatrician Mother-a nd-child relationship Sexual deve lo pment Sex ua lity of the ado lescent a nd pro blems of fertility Psychiatrist Advice o n problems of rela tio nships and sex ua lity Geneticist Genetic counse lling Training of community health workers With rega rd to the training of traditio nal birth a ttendants a nd ho me visitors, the quest io n a ri ses of whether the use o f such personnel is for want of a better a lterna tive o r ra ther , o n the contrary, is in accordance with the approach reco mmended by the Inte rna tio na l Conference o n Primary Health Care (Alma-Ata, 1978), a nd represents a n impo rta nt mea ns of making hea lth less " techno logica l" a nd placing respo nsi bility for hea lth pro blems wit h the co mmunity itse lf. Functions Ana lys is of the functions o f thi s ca tegory o f staff leads to the questio n of how far one ca n go in delegating respo nsibility. 68 The following functions were decided on: promotion of family planning: information, motivation and edu- cation; information of other health workers with regard to commun ity needs and hence identification of such needs; individual case detection; provision of family planning services, prescription of simple and traditional methods; preparation of and participation in care; fo llow-up and "re-motivation" of cases; management of contraceptive stocks; participation in the co ll ection of basic health and demographic data; guidance in cases of infertility. Training Principles. There is a need for a universally applicable training pro- gramme, but one suited to the local context; training within the integrated framework of family health; field training in the same conditions as those of professional practice; and short courses in the form of on-the-spot seminars. Problems. Account should be taken of the fact that the training may have to be given to illiterates and elderly persons - hence the importance of su itable teaching methods. Conclusion. Emphasis was placed on the important role of this cat- egory of worker, which should be seen as an entity. They are "intermediate personnel" responsible for care of minor cases and guidance of more serious cases . Their training should be brief as far as technical knowledge is con- cerned but more developed in terms of information. Training of auxiliary health personnel This term should be taken as referring to "rural birth attendants" with schooling up to the age of about 14 years. Choice of candidates The youth of the candidates makes their selection difficult. A number of cri- teria were proposed whereby preference would be given to candidates who: are open-minded; show adaptabi lity; have a certain degree of independence in relation to their cultural and religious surroundings; 69 come from and a re members of the community but are also capable of standing to so me extent o utside that community. Training Such training should last a year and develop both attitudes and skills . With regard to af!itudes, the training must ensure that the staff: consider women as a whole, give prominence to the personal views of the woman in relation to family planning and on ly then take into account the commun ity and social aspects; as part of an approach th at tak es the psychosocial dimension into account, attach importance to listening to clients (in terms of what they express both explicitly and implicitly) , and to their outward attitudes (happiness, sadness, etc.); develop empathy vis-a-vis the client (make her relax, smile, give encouragement); identify the resources and assistance available in the community, as we ll as the prevailing beliefs, cultural values and taboos ; and ana lyse their own values and maintain a certain detachment from their own views; as part of health education for family planning, know how to listen to clients through dialogue that produces replies to problems raised; and develop an aptitude for teamwork. With regard to skills, two examples may be given . One relates to the use of the IUD and the other to ways of enlisting the support of local community leaders. IUD. Staff must be familiar with indications and contraindications; selection of a suitable type of IUD; identification of psychological sources of opposition (foreign body, discharges, embarrassment, etc.) or religious obstacles (sin , etc.); performance of speculum ex- aminations, follow-up of side effects, diagnosis and treatment of complications, insertion and withdrawal; and referral of the patient to a specialist if necessary. Motivation of local community leaders. In order to motivate com- munity leaders it is essential to be able to identify them and find ways of convincing them, to be able to listen to problems, to put forward health arguments that will be accepted by the community, and to find and use the necessary means of support. Training of social workers Functions Social workers have roles which are complementary to those of other health personnel. They seek to modify the situation by: 70 contacts with community leaders, activities in the family (home visits), in fo rma ti o n sess io ns fo r pa rent s, co ntac ts with empl oye rs, co ntacts with neighbo urhood co mmittees, contacts with pri va te age ncies (fo r the ha ndica pped, migra nt s, etc.). Their goa l is to a ppra ise, in fo rm , mo ti va te, guide a nd reass ure, a nd to ass ure the repleni shment o f suppli es of co ntrace pt ives a nd mo nito r their use. Training Ce rta in as pec ts o f fa mil y pla nning co uld be int roduced into ex isting cur- ri cul a, na mely: li stening a nd conve rsa tio n techniques in famil y pla nnin g, socia l, econo mic and medica l consequences of fa mil y pla nning, pro blems o f communica tio n, la ws, progra mmes a nd serv ices re lat ing to fa mil y pl a nnin g, kn o wledge o f a na to my, th e phys io logy o f hu ma n reproductio n, con- trace pti ve meth ods, side effects, co mplica ti o ns, in psycho logy, the stud y of circumsta nces in wh ich there is acce pta nce o r rejectio n o f fa mil y pla nn ing a nd psychoso matic sy mptoms, a n understa nding o f the behav io ur o f min o riti es. On co mpletio n of their tra ining, soc ia l wo rkers must be ca pa ble of eva lua ting the fa mil y pla nning needs o f a n indi vid ua l, a gro up or a co m- munity, ass isting cli ents to se lec t a co ntrace pti ve method by li s tening to them a nd g iving them adequa te in fo rm atio n, refu ting rum o urs tha t a re da maging to famil y pla nning, a nd ensuring sho rt- a nd lo ng- term fo llo w-up in cooperatio n with the health services . The method s used a re those of theo reti ca l a nd prac ti ca l tra ining (in - se rvice in fa mil y pla nning ce ntres), with pro minence being give n to acti ve in vo lvement of students (role-play ing, psyc hod ra ma, Ba lint gro ups, case studies). Kno wledge sho uld be eva lua ted by exa mina tio n, as for o ther subjects. C ha nges in behaviour a mo ng social wo rke rs ca n be eva lua ted by rev iewing thei r repo rts o n their p racti ca l tra ining, which sho uld g ive a tt entio n to fa mil y pla nning pro blems. Strategies for application of the foregoing proposals to curricula Beca use the co nfe rence pa rti cipa nts ca me from ma ny countri es, it was no t poss ible fo r the va rio us subco mmittees to ma ke::: deta iled exa mina tio n o f na tio na l co nstraints a nd thus to propose spec ific stra tegies fo r pa rticula r co untry situatio ns. On the o the r ha nd , thi s fo rum p rov ided a n o ppo rtunit y to g ive broad considera tio n to the co nst rai nts a nd o bstacles tha t a rise in redesigning 71 curri cul a fo r different types of profess io n a nd to p ro pose stra tegies fo r ove rco min g them . Wh a t the subcom mittees did was first of a ll to tak e no te of the ge nera l o bstacles assoc ia ted with a ll fa mil y pl a nning pro blems, in- cludin g those relating to cur ri culum cha nges. This broad a pproac h a p- peared to be necessary in view of the fac t tha t the direction ta ken by the tra ining is by a nd la rge innue nced by po liti ca l a nd cultural res traints, patterns of medical ad ministratio n, the a ttitude of the medica l professions, the ava il abi lit y of suit ab le teaching methods, and prob lems of teaching o n sex ua l ma tt ers. Obstacles to changes in curricula Obstacles associated ll'ith policies Nati o na l po li cies that limit o r p ro hibit fa mily planning In adequa te political will in rela ti o n to fa mil y planning p rogra mmes and training needs In adequa te budgets for family planning Inadeq ua te resources for tra ining: too littl e time and too few teachers for a la rge number of student s Ge nera l lack of econo mic a nd teac hing resources Obstacles associated with culture Images projected by the va rio us religio ns a nd , more broadly spea king, cultures co nce rning the fa mil y and values a tt ac hed to reproduction and fertility th a t may be very traditio na l a nd conse rva tive a nd fo rm se rious o bstacl es to the design a nd impl eme nt a tio n of fa mil y pla nning programmes The ro le of parents' assoc ia ti o ns that o ft en ado pt traditional values a nd prevent the development of sex educa tio n curri cul a th a t wou ld be suit a ble for schools Obstacles associated with medical administration The prevalence of conse rva ti ve a ttitudes amo ng med ica l fac ulti es with regard to the a tt ention to be pa id to comm u nit y needs The fac t tha t facu lti es a re mai nl y co ncerned with clini ca l practice, a nd primary hea lth care is no t cons idered as real priority Medica l teaching tha t is centred o n pa tho logy and p rovides no prepa ration fo r unde rsta nding the psychosocia l aspects of sex ua l behav io ur a nd the life of couples Preve ntive activiti es tha t are not immedi a tely rewarding for hea lth workers since the res ult s a re no t direct , as in the case of trea tm ent ac tiviti es 72 Th e fact that family planning is considered as being a subo rdina te bran ch of medicine, to which little time is devo ted T eaching that foc uses o n the acqui sitio n of kn o wledge ra ther tha n skill s o r attitudes Obstacles associated ll'ith the altitude of teachers The ina ppro pri a te a ttitude of medica l a nd pa ra medi ca l perso nnel in cha rge o f supervisio n a nd the lack o f p ro fess io na l presti ge fo r fa mil y planning Pa rtly as a res ult o f ignorance a nd pa rtl y for psychosocia l a nd psych o- cultural reasons , th e o ften nega ti ve a ttitude of teach ers, which mea ns tha t they a re no t ready to identify with the ro le tha t th ey sho uld be play ing Lack of the necessa ry prepara tio n fo r teac hing fa mily pla nning a nd true a wareness o f co mmunity needs in thi s a rea o n the pa rt o f teachers Inadequate kn o wledge of teachers concerning the most suit a ble methods fo r teaching famil y planning Obstacles associated with teaching Lac k o f tea che rs with a n adequa te bac kgro und fo r imple menting pro- gra mmes Lac k o f rea l coo rdina tio n betwee n theo reti ca l teachin g a nd fi eld p racti ce T eaching ma teri a ls tha t are o ft en ill -ad a pted to instructi o n o n fa mil y pl a n- ning teaching Inadequacy o f co ntinuing educa tio n for teachers C urricula fo r bas ic training th a t a re recognized as no t being suit a ble, but a re a lready overl oa ded a nd diffi cult to a lt er Exa minatio ns tha t a llo w the eva lua ti o n o f students' kn o wledge but no t their a bility to understa nd o r solve pro blems re la ting to the co mmunity Obstacles associated wirh teaching on sexual life Difficult y o f teac hers in es tab lis hin g tru e co mmuni ca ti o n with yo un g s tudents with rega rd to sexua l ma tt ers a nd fa mil y pla nning, i.e. no t kn ow- ing how to es tabli sh it or no t wa nting to, which has so mething to do with their own situatio n and their perso na l problems Rela tive inability o f hea lth personnel to dea l with ma tt ers rela ting to th e intimate li ves o f their client s, to des ires a nd to pleasure Where sex is co nce rned , the fac t tha t teac hers a re face d with co mplex huma n fa cto rs a nd no t merely with techni ca l co nsideratio ns 73 Strategies that cou ld be used to change curricula Srraregies associared wirh policies Th ro ugh interna tio na l coopera ti o n , a na lyse tra 111111g a nd o rganiza tio na l ex peri ence in equi va lent depa rtments in o ther co untri es I mp rove the understa ndin g of econo mi c, psychologica l a nd soc ia l as pec ts o f popula ti o n pro blems Improve rela tio ns with po liti ca l leaders to bring laws into line with soc ia l practi ces Ass ist in g ivin g effect to fa mil y po licies tha t include fa mil y pl anning Identify "friends" a mo ng gy naeco logists a nd paedia t ricia ns a t na tiona l leve l who are in a pos itio n to d iscuss ma tters with na ti o na l hea lth decisio n- ma kers Co nduct pilo t ac ti o ns with a view to eva lua ting constra ints and reso urces a nd to expa nding the scope o f ac tiviti es T a ke pa rt in direct ac tio n with the co mmunity a nd loca l leaders Srraregies associared 111irh culrure Prov ide re ligio us leaders with co mplete and regula r in fo rma tio n a nd obta in their understa nding Initia te di scuss io ns o n the a ttitudes of religio ns to fa mil y pla nning S rraregies associared wirh communiry info rmarion Pro mote the d isse min ati o n o f in fo rma tio n to bo th the ma le a nd the fema le popula tio n Dissemina te the fa mil y pla nning message by eve ry poss ib le cha nnel Undert a ke infor ma tio n ac ti vities a imed a t public o pinio n, pressure groups, dec isio n- ma kers a nd t ra ining institutio ns, a t bo th loca l a nd na tio na l leve l, so as to p ro mote awareness of community needs in fa mil y pla nning and the advantages o f fa mil y pla nning Disse min a te the in fo rmatio n th ro ugh the mass media, o ther audiovisua l techniques, se mina rs, wo rksho ps, etc . Srrategies directly associated wirh rraining of health personnel (a) Teacher rraining Es ta blish continua tio n p rogra mmes, including interd isciplina ry refresher courses, fo r future teachers 74 Asse mble a multidi sc iplina ry team o f trainers co nsisting of hea lth wo rkers in the fi eld Arra nge fo r teac he rs, during their period of training, to ge t to know the co mmunit y a nd its needs th ro ugh practi ca l fi eld wo rk , thereby deve lo pi ng their co mmunity wo rk skill s Ensure tha t the teac hin g o f fa mil y pl a nning is free fr o m spec ia li za ti o n, i.e. tha t it is prese nted as pa rt of t rai ning in bas ic hea lth ca re in tegra ted with co mmunity medicine as a who le Ensure tha t teac hers lea rn to go beyo nd ma tt ers rela ting to techniq ues a nd to tra in personnel in recepti o n, li stening a nd res po nsive behavio ur Make teachers a wa re o f the need to understa nd spec ific pro blems a nd facto rs rela ted to ado lescent s a nd their sex ua lit y, so as to improve di a logue wi th them T ra in teac hers in p ro blem-o ri ented a nd pro blem-so lving teaching meth od s, a nd emphas ize teac hing-lea rning methods ma kin g it poss ibl e to acqui re practi ca l a ptitudes (b) Organization of teaching Dra w up curr ic ulum co ntent co nce rned with fa mily pl a nn ing in such a fas hio n tha t the student ca n identify a nd meet co mmunit y needs while ta king account of sociocultu ra l a nd eco no mic facto rs Integ ra te the teachi ng o f fa mil y pla nnin g a nd fa mil y hea lth wi th various disc iplin es, o ne o f which must be made res po nsible fo r it s coordin a tio n in every as pect Se t aside sufficie nt time a nd provide the ri ght logisti c suppo rt to ma ke it poss ible for s tude nt s, during the t ra inin g peri od , to co me into co ntact with the community a nd identify it s needs, as well as pa rti cipa ting in hea lth activiti es in the fi eld Ensure th a t the number o f students fo r each teacher is Ii mited so as to ma ke it poss ible to prov ide qua lity educa tio n centred o n a cha nge in behav io ur Ensure tha t the eva lua tio n of educa tio n is prim a ril y co nce rned with assess- ing the a bility of s tude nt s to perfo rm tas ks spec ifica ll y rela ted to hea lth a nd fa mil y pla nning 75 4 Presentation and discussion of a draft educational handbook An editoria l committee 0 met on a number of occasions to outline the general concept of an educational handbook a nd draft the sec tion concerned with training in the hea lth professio nal / client re lationship. The committee informed the conference of the reasons for drafting the handbook, its expectations with regard to the final content and the stage of preparat ion it had reached. Reasons for an educational handbook The teaching of fami ly planning presents teachers with problems re lating to : the non-availability or the lack of updated information ; the difficulty of defining educational objectives in behavioural terms; the difficulty of introducing teaching methods in line with the goals that are aimed at. What is being proposed, therefore, is an ed ucatio nal handbook pro- viding a wea lth of documentatio n that may be updated and adapted to d iffere nt cu ltures and leve ls of personnel. The idea is to set out certain educa tiona l goals and a selection of teaching methods. This means that the teacher will have avai lable a variety of raw materia ls which he can use in order to deve lop his own programme in line with his own goa ls and the group to be trained. a This commi tt ee consisted of Miss W. Haddad. Regi o na l Officer for Famil y Planning. WHO Regional Office for Europe; Miss M. Ladjali, Mate rnal and Child Health Cen t ral Office, Natio na l Institute of Public Health, Algiers; Professo r P. Lecorps. Department of Health Educat io n and Family Planning, Nati o nal Sch oo l of Pu b li c Health, Renn es; Dr M. Pechevis , Department of Training, Internat iona l Children's Centre; and Mrs E. Wo llast, Schoo l o f Public Hea lth . Free Universi ty of Brusse ls. The draft educationa l handbook was circulated to conference participants as document ICP/ MCH 025/15 . This doc ument ma y be obtained o n request from the WHO Regio nal Office for Europe. 77 The final content of the handbook Fa mil y pla nning dea ls with numero us as pec ts of hum an life a nd presupposes coope ra ti o n by a va ri ety of technicians a nd th e a pplica ti o n o f a wide range of reso urces in o rder to sa ti sfy de ma nd expressed by indi vid ua ls a nd co upl es. Th e va ri o us ques tio ns in vo lved in fa mil y pla nning training may be grouped under fo ur headings: psychosocial aspects: i.e. a ll di sc ipli nes which co nsider the hum a n being as a n indi vidua l, with h is des ires a nd connict s, a nd the huma n being as a pa rt o f a group within the community a nd culture tha t have mo ulded him ; organiza tional aspects: i. e . ma tt ers rela ting to the ma nage ment o f institut io ns a nd sta ff prov iding fo r the ex press io n a nd trea tment o f c li ent de ma nd ; biophysical aspects: i.e. eve rythin g rela ting to th e bi o logica l a nd ph ys ica l mec ha ni s ms bo und up w ith hum a n rep rodu cti o n a nd sex ua lit y; technical aspects: i. e. the va ri o us method s a nd mea ns ava il a ble to help clients succeed in their family co mpos itio n pla ns, as well as the va ri o us clinica l interventio ns a nd o bse rva tio ns whi ch will help in a rri ving a t an eva lua ti o n , a nd in s ugges ting prescripti o ns tha t ta ke the hea lth of clients into co nsideratio n . The present state of the handbook The ha ndboo k , as it was prese nted to th e confe rence, conta ined the ob- jec ti ves, exa mples o f meth ods to ac hieve them , a nd documenta tio n fo r o ne of th e to pics o f th e teaching pac kage o n psychosocia l as pec ts. The to p ic is the hea lth profess io na l/ clie nt rela ti o nship in famil y plan- ning. It was dec ided to dra ft this to pic firs t beca use it is o ft en neglected in fa mil y pla nning tra ining, whil e success in fa mil y planning tra ining p ro- gra mmes de pends o n a constructi ve rela ti o nship between health pe rsonnel a nd family planning clients. It was considered as a wo rking doc ument , circulated as such for di s- cuss io n a nd des igned to be rewo rked a nd expa nded in the li ght o f co mments made a t the co nference. Draft teaching package on psychosocial aspects: the health professional/ client relationship Objectives A t the end o f the tra ining sess io n the student must be able to: - es ta blish suita ble co nditio ns fo r an interview; 78 identify th e client's implicit o r ex plicit request ; mee t the client's demand; ass ist in individual and co mmunity hea lth educa tio n; eva lua te th e cli ent 's sa ti sfact io n . Subobjectives Establish suitable conditions fo r an intervieu· I. C rea te th e physica l and psycho logica l ambience tha t will fac ilita te the client's first contact with hea lth personnel. 2. Create the ph ys ica l a nd psychol ogical ambience tha t wi ll g ive initia l impetus to the interview. Identify the client's implicit or explicit request 3. Express his/her own sys tem o f values as to socia l mode ls, famil y o rga n- iza tio n , sex ua lit y, co ntracepti on, abo rti o n. 4 . Identify th e cli ent's system of values as revea led by the inte rview. 5. Identify th e client's request a nd re-s ta te it. Meet the client's demand 6. Define his/her own a ttitude to the client' s request. 7. Prese nt in la nguage eas il y understood by the client a n a nswer tha t ta kes due accoun t o f the client' s req ues t. Assist in individual and community health education 8. Determine the cli ent' s level of knowledge. 9. Provide informa tion, based on the client's o r group's request, o n the difficulti es connected with sex uality a nd huma n reproducti o n. 10 . Check the leve l o f understanding o f the informatio n given. 11 . Sta te the a dva ntages of family planning for better hea lth a nd ada pt them to the soc ial groups concerned. 12. Select teaching methods suita ble for the gro up. 13. Select useful teaching a ids. Evaluate the client's satisfaction 14. Draw up indica to rs for: the qua lity of the first contact with hea lth personnel; the rel eva nce of the response to the client's req uest ; the deg ree of understanding of informatio n rece ived . 79 15. Use the in d icators to assess client sat isfac tio n. Th e psychosocia l as pects o f medica l exa mina tio ns a nd presc ribing will be di scussed in the teaching package o n technica l as pects. Examples of methods and means in relation to goals Obiec t,ves Topics l and 2 3 4 and 5 80 Cond1t1ons for first con tac t and effec t ive 1r11t1al 1n terv1ew 111g ln1 erv1ewers· recogn It1 on of their own system of va lu es Recognize th e c l ien t' s system of va lues and rdentify th e demand M ethod s and resources Lecrure (f o llowed by d1scuss10ns) 1 teacher o r Ro/e .play,ng - 1 organizer for a max imum o f 1 2 people or Video recording + group discussion - 1 organ izer - 1 techn1c1an - camera - video -tape recorder - tape s or Duration Remarks 1 - 2 hours 11h hours Organize an 1111t1al con ta ct 1n terv1 ew Experiment wi th ways o f in111atmg heal th personnel / clien t dialogue 1 ½ hours V1deo-record1ng of some con ta ct scenes and the opemng o f the interview Climcal observauon 10 be + report and discussion es tab lished - 1 organize r - cl 1n1 cs and centres Semmar - 1 organizer for a group of 1 5 people Role ·playmg - 1 organizer for a group of 1 5 people or Case study wllh video -tape recorder - 1 organiz er for a g roup of 30 people - camera - video-tape recorder - tapes later 1 ½ hours 1 ½ hours Top ic d iscussed spec d1cal ly. while form ing part o f overa ll training package Simulate a given con ta c t si tu ati on (spontaneous or prepared 1nterv1ew) Taped sequence of portion o f an interview showing on ly the che nt" s request. to be formulated by the group Ob1ect1ves Topics Methods and resources Duration Remarks 6 Interviewers· atti tude Role -playing to the client's request - 1 organizer for a and group of 1 5 people or 7 Response to the Case study with request wdeo -tape recorder - 1 organizer for a group of 30 people - camera - video -tape recorder - tapes 8 Ass essment of 1nformat1on given to an ind1v1dual Role-playing 1 ½ hours Establish what the client and (1nterv1ew) knows and how he/she - 1 organizer for a uses 1t group of 1 5 people a group Role-playing 1 ½ hours Establish a knowledge - 1 organ izer for a threshold appl icable to group of 30 people the whole group 9 Provide 1nforma t1 on on Role-playing The student must sexua lity and human (as In 0biect1 ve 8) prepare and use and reproducti on teachi ng methods with an ind1v1dual or a group 10 Check understanding Role-playing 1 ½ hou rs Th e studen t must ask the of the information (as In 0biec11ve 8) 1nd1v1dual or group g iven questions to ver ify understanding 1 1 State the advantages Semmar 1 ½ hours Students must use of family planning 1n a - 1 organizer for a arguments suitable for fashi on appropriate to the sociocultural the audience group of 30 people background of clients 1 2 Choose sui tabl e Lecture 1 ½ hours Introduce criteria by methods + d1scuss1on which choices may be - 1 teacher made according to· - ob1ect1ves - group charac terist ics - available resources 13 Choose suitable Demonstration and 11/2 hours Justify the choice of teaching aids analysis teaching aids ma given - 1 teacher situation + available material 14 and 1 5 Evaluation through Introductory statement 1 ½ hours Allow the students to sa tisfaction indicators or se lected reading discover s1 mple + Seminar with indicators (1.e. case histories. quest1onna1res) exercises and tea ch them to use them for self-evaluation 81 Examples of role-playing Consu/1atio11 Role of the "client". Yo ur nam e is Mrs Lucie Demanet. Yo u are 32 years o ld and yo u married a t the age o f 22. Yo u have two children, Elise 8 years o ld a nd J ea n 6 years o ld . Yo ur husband is a po li ce ma n . Yo u ha ve completed th e first few yea rs ofa seco nda ry sc hool. Yo u don' t work o utside the ho me. Yo u are sa ti s fi ed with yo ur marr ied life. Yo u have a lways tended to be ove r- we ight. T a kin g ora l co ntrace pti ves has no t ca used yo u to gai n weight undul y, but you wo nde r ifit does n' t in crease th e tendency. Yo u tri ed to lose weight, but yo u lac k th e di sc iplin e to forego the pl easure of a good mea l. Yo u a re quit e to uchy o n the s ubject , a nd yo u don't like it being referred to in pa rti cul a r beca use yo u o nce co nsult ed a doc to r a bo ut it , but yo u felt that he exagge ra ted the pro bl em a nd made yo u feel gu ilt y, a nd yo u neve r went back . Anyway , yo u do no t int end to bring up thi s ma tt er yourse lf, but if th e d oc to r' s a ttitude were helpful a nd since re, yo u would be ready to li sten to what he/she has to say. Yo u ex press yo urse lf without difficulty; howeve r, yo u are a little prudish when spea kin g of sex ua l ma tt e rs. For 11/ 2 years yo u have regularl y gone to th e fam il y plannin g clinic and Dr Durant has presc ribed Lyndio l as yo ur o ra l co ntrace ptive. Yo u have bee n ta kin g it regularly and a re relative ly sa ti sfi ed . Yo ur probl em today : you ha ve come for a new oral co ntraceptive presc riptio n with the underl ying belief that taking the pill is incompatible with yo ur tendency to o bes it y. This is yo ur first visit in s ix mo nths. Wh en yo u enter the consulting roo m, yo u rea li ze tha t you will no t see Dr Durant, but a "young d oc to r" instead ... R ole of th e "doctor". Yo u are a medica l student interested in birth co ntrol. As pa rt of yo ur prac ti ca l t ra ining, yo u a re working in the family planning clinic a t St Peter' s Hos pita l. Yo u a re replac ing Dr Durant who s upervi ses eac h o f yo ur co nsult a ti o ns. The in fo rm a ti o n yo u require is in the clinical file a tt ac hed. Check-list fo r observers. Wha t information did the consultant gather during th e 15 minutes? 82 Spec ifica ll y: is it clear tha t the consultant understands the client 's probl em? Rega rdin g th e client's a ttitude to the problem: what kind of atmos- phere has the co nsulta nt crea ted? H ow did he act (verbal a nd no n- ve rbal a ttitudes)? Is he concerned about prese rving hi s relationsh ip with th e cli ent? Is he considering together with the client so lutions that are com- patible with her way of life? Role-play ing fo r evaluc11io11: individual illl erviell' Situation I. Yo u a rc a ge nera l prac titi o ner. A you ng woma n co mes to yo ur co nsulting room. She see ms nervo us a nd te ll s you ri gh t away th a t she think s s he is pregnant. She will be 20 yea rs o ld in a few mo nth s. The tes t proves to be pos itive. By now yo ur cli e nt is sea ted in fr o nt o f yo u. What will you say to her? What will be the o utcome of the intervi ew? S ituation 2. Yo u a re a ge nera l p rac titi o ner. A second client co mes to yo ur co nsulting room. She see ms to be of It a li a n o ri gi n. She believes s he is pregnant aga in . Th e tes t proves to be nega ti ve. She seems relieved, because s he says " I do n't kn ow wha t I'd have done if I were pregnant agai n". How do yo u ca rry o n with th e int erview? What will be it s ou tco me? Summary of discussions following circulation of the teaching package The following criti cis ms were made: it is difficult to elimin a te the lec ture system ; the metho ds proposed in th e pac kage require a grea t deal of time a nd a large number of qualified staff; it is dangero us to u c teaching methods go in g beyo nd the technical level (for exa mple, ro le-playing requires qualified orga ni zers). Refe rence s hould be made to s imilar wo rk , such as the guide developed by Abba t fo r a WHO p rojec t a nd published in 1980 under th e title Teaching for better learning, which demonstrates how: courses can be made rel eva nt ; the best possible teaching can be provided ; performance ma y be eva ula ted ; a nd eva lua tion tests may be developed. Th e following pos iti ve fac tors were a lso given we ight : recognitio n of t he c rucia l nature of such matte rs as the initial co ntact between client s a nd hea lth perso nnel, hitherto neg lec ted; the fact tha t the teac hing methods proposed are stimula ting and should encourage deve lo pm ent of a team spirit ; a nd the possibi lity o f making the programmes Oex ible and adjusting them to loca l conditions in te rms of time ava il a ble, perso nnel, re- sources, etc. Conclusions An eva lua tion questio nna ire was distributed to a ll confere nce parti cipants and ma ny o f them agreed to test the teaching method a nd sugges t amend- ments to the editorial tea m which wo uld continue to develop it. 83 Bibliography Balint, M. Techniques psychorherapeuriques en medecin e. Pa ri s, Payo t, 1970. Bizouard, C. De /'accueil au dialogue. Lyo n, Chronique soc ia le de France, 1976. Bland, C.J. Faculry developmenr rhrough u·orkshops. Springfie ld , IL , C ha rl es C. Thomas, 1980. Bligh, D.A. Whar's rh e use of /ecrures? H a rm o ndswo rth, Penguin Books, 1972. Boszormenyi-Nagy, I. & Framo, J.L. lnrensive family rherapy- rh eorerical and pracrical aspecrs. New York, Ha rper & Row, 1965 . British Life Assurance Trust Centre for Health and Medical Education. Facili- raring reaching-learning 11·irh modules: an approach fo r nurse mid1Fife reachers. 1977. De Cecco, J.P. Th e psychology of learning and insrrucrion. educariona/ psy- chology. London , Prentice-Hall , 1974. Flament, C. Reseaux de communicarion er srrucrure de groupe. Pa ri s, Du nod, 1965 . The author introduces ex periments leading to a stud y o f co mmunication networks and the structure o f gro ups. Guilbert, J.-J. Guide pedagogique pour /es personnels de sanre. Geneva, Wo rld H ea lth Orga niza tio n, 198 1 (WHO Offset Publica tio n No. 35) (revised editio n). Haddad, W. Training in fa mily planning for nurses in fami ly planning. In: Family healrh and family planning: a col/ecrion of papers published under rh e sponsorship of rhe WHO R egional Office for Europe and rh e lnrer- narional Children's Cenrre. Paris, ICC, 1979. Haddad, W. The ro le of midwives a nd nurses in family pla nning. In: Family healrh and family planning: a col/ecrion of papers published under rhe sponsorship of rh e WHO Regional Office for Europe and rhe lnrernarional Children's Cenrre. Paris, ICC, 1979. Jacobson, V. Enrreriens er dialogue. T o ulo use , Priva t , 1967. Lapassade, G. Croupes, organisarions er insrirurions. Recherches insrirurion- nelles, I. Paris, G a uthier-Villars, 1974. Lobrot, M. L'animarion non direcrive des groupes. Paris, Payo t, 1974. Maccio, C. Animarion de groupes. Lyon, Collection L'essentiel, C hronique soc ia le de France, 1973. This book co nsists of a se ri es o f brief or comprehensive answers o n a ll questions, whether practica l o r theoretical , that may be asked by a person starting o ut as a group o rganizer. Mace, D.R. et al. The reaching of human sexualiry in schools fo r healrh professions. Geneva, Wo rld Health Orga ni za tio n, 1974 (Public Health Pa pers, No. 57) . 84 Mager, R.F. & Beach, K.M. Preparing instructional objectives. Belm o nt , Fearo n Publica tio ns, 1967. Maisonneuve, J. La dy namique des groups. Pa ri s, Coll ec ti o n Que sa is-je? Presses unive rsita ires de F ra nce, 1968. This work a pproac hes the chief resea rch to pics in gro up dynamics: cohesion, res is tance to cha nge, interaction, leadership , a nd emotio na l response, and rev iews a pplica ti o ns in training fo r group dynamics . Maisonneuve, J. La psychologie sociale. Pa ri s, Collection Que sa is-je ? Presses universita ires de France, 197 1. This work describes so me of the pheno mena usua ll y s tudied as pa rt of soc ia l psyc ho logy: communi ca tio n a nd it s soc ial perso nn el, gro up inter- action, a nd group dyna mics. Miller, G.E. et al. Teaching and learning in medical school. Cam bridge, MA , Harvard University Press, 1962. Moreno, J.L. Psychotherapie de groupes et psychodram e. Pa ri s, Presses uni- versitaires de France, 1965. This boo k, written by th e invento r o f the psyc hodra ma, int roduces thi s group activity , group tra inin g a nd gro up psychotherapy, ro le-play ing, simulation and gro up acti vity, based o n ac tua l situations. Mucchielli, R. L'intervieu· de groupe. Pa ri s, Entreprise mode rne d'Edition , Ed iti o ns soc ia les franyai ses, 1979. Mucchielli, R. La methode des cas. Pa ri s, Entreprise moderne d'Edition , Ed itio ns soc ia les franyai ses, 1979. Mucchielli, R. La conduite des reunions. Pa ri s, Ent reprise moderne d'Edition , Editio ns soc iales franyaises, 1980 . Mucchielli, R. L' entretien de face i.r face, clans la relation d' aide. Pa ri s, Editions soc iales fra nya ises, 1980 . Mucchielli' s books co nsist of two pa rt s: a theo reti ca l sec tio n consisting of a se ries o f no tes a nd a practica l pa rt consisting, in ge nera l, of gro up exerc ises, which may a lso be p racti sed by o ne student wo rking o n hi s own. They fo rm a kind of fra mewo rk fo r what the o rgani ze r o r wo rker in the field sho uld say a nd do. Nahoum, Ch. L'entretien psychologique. Pa ri s, Presses uni vers itaires de France, 1971. Pages, M. L' orientation non directive en psychotherapie et psychologie sociale. Pa ri s, Dun od, 1970. Robert, M.A. Psychologie du groupe. Manuel theorique et pratique de /' ani- mateur. Brusse ls, Co llectio n Humanisme d 'a uj o urd'hui , Vie o uvriere, 1969. Rocheblave-Spenle, A.-M. La notion de role en psychologie sociale. Pa ri s, Presses universita ires de France , 1969. Rogers, C. & Kinget, M. Psychotherapie et relations humaines. Vo l. II. La pratique. Louva in, Publica tio ns uni ve rsita ires, 1971 . 85 Turnbull, L. & Pizurki, H. Family Planning in the education of nurses and midwives. Geneva, World Health Organization, 1973 (Public Health Papers, No. 53). WHO Technical Report Series, No . 572, 1975 (Educa tion and treatment in human sexuality: the training of health professionals: report of a WHO Meeting). WHO Technical Report Series, No. 608, I 977 ( Criteria for the evaluation of learning objectives in the education of health personnel: report of a WHO Study Group). For further information, we refer the reader to the bibliographic bulletins on family health and fami ly planning, published under the sponsorship of the WHO Regional Office for Europe and the International Children's Centre. 86 5 Summary of plenary meetings grouped by topic Relations between health personnel and the community Health personnel and political choices Po litica l choices play a n impo rta nt pa rt in the int rod ucti o n a nd es tablish- ment o f fa mily pla nning progra mmes. Na ti o ns which a re awa re of their fa mily pla nning needs orga nize them- selves a nd ac t th ro ugh assoc ia tio ns, movements a nd p ressure groups. In respo nse to public pressure, po liti ca l a utho riti es sooner o r la ter mee t the needs o f the co mmunity by p rov iding it with the necessa ry administrati ve a nd o ther mea ns a nd se rvices . In countri es where a mo re or less considera ble po rti o n o f the populatio n feels no need for fa mily pla nning, the po liti ca l authorities who a re aware of such a need are po werl ess a nd ca nnot deal with the o ppos itio n o f the publi c without incurring major ri sks. Health profess io nals must ass ist the political a utho riti es to put forward introducto ry family planning programmes in terms tha t a re accepta ble to the po pul a tio n. Health personnel and culture In the tra ining o f hea lth perso nnel, matters rela ted to fertility a nd it s cont ro l ca n o nl y be dea lt with in the contex t of the li fe of the fa mily as a who le, the culture o f the country a nd the life of the communit y. Hea lth perso nnel must a lso ta ke acco unt of religious fac to rs. In some co untries, religio n plays a co nsiderable pa rt in a ttitudes to sex ua l matters a nd the ad o ptio n o r rej ectio n o f fa mily pla nning. Role of health personnel in relation to community organization, its needs and demands The term " co mmunity" is too extensive since there are subcultures which fol- low their o wn laws: the wo rld o f the countrys ide or the town, ado lescents, etc. In the relations between hea lth workers a nd the community: the idea l is for the co mmunity itse lf to diagnose its own behaviour, with personnel only acting as technicians for the formulation and solution of problems; 87 a di s to rti o n of the relationship wi th the co mmunit y ca n occur ifit is used as a test bed, for exa mple for th e benefit of hea lth personnel under training. Needs expressed by the community of it s own accord are not necessa ril y it s priority needs. It is esse ntial to prepare students fo r a n ep idemio logica l approach, e nab ling th em to pick o ut a t-ri sk groups and nego ti a te wit h the com munity a sca le of pri o riti es which would take acco unt of a ll the needs observed. Needs increase with the provision of se rvi ces. If hea lth personnel provide fami ly p lanning serv ices, members of the com munit y wi ll fee l the need for them . Very frequent ly, there is a co rrelation between suppl y a nd demand. H ealth personnel in relation to trends in the role of women and couples The impo rt a nce of the woman's ro le in fami ly pla nning progra mmes has been stressed by a ll ; unless women ag ree with it , no programme ca n succeed. Fami ly planning practices e ma ncipa te women; in ma ny cu ltures thi s crea tes new problems of identification a nd relationships with men. The changing ro les of men and women ma ke the pro bl ems of childbirth , the ed uca ti o n of children a nd family life in ge nera l take o n a new light, and they ca ll for new so lutions. Prepara tion for a nd discussion of these new ro les sho uld begin in child- hood. Some experime nts in doing so have been cond ucted: sex ed uca tio n programmes at primary schools in Sweden, ed uca ti o n for fam il y life in kindergartens in the Federal Republic of Germany, etc. Staff of family plann ing cen tres sho uld be tra ined through continuous tea mwork to rece ive both men and women, li sten to them a nd help them find individua l a nswe rs to their quest io ns. Organization of new types of training A new programme It is ve ry difficult for a new training programme to be produced within an already ex is ting framework. It presupposes sha rp negotia tion bet ween differ- en t spec ialists, eac h of them defe nding the teaching time a ll oca ted to them. If they are to be effecti ve, psychosocial as pec ts sho uld be in corpora ted in fami ly pla nning programmes. Hea lth profess iona ls sho uld be trained in dialogue with th ose cons ulting them and in developing good relations with the latter tha t wou ld ass ist in co nvey ing what they have to say . The tra ining of hea lth personnel sho uld include mat ters relating to the ma nageme nt of services a nd programmes (e.g. transpo rt , eq uipment and su ppli es, staffing, etc.). A new distribution of tasks among personnel With a view to reo rgan izing hea lth se rvices a t the prima ry , seco nda ry a nd terti a ry level, the tas ks of members of the various profess io ns should be redi stributed a nd tea mwork int roduced: Who does what? And with whom? 88 The ph ys icia n may have a very thoroug h understanding of the different aspec ts of family pl a nning with ou t, however, being completely a t ho me in such spheres as ma nagemen t , in for ma ti o n, mar ita l co unse llin g, e tc. Given th e prese nt sta te of medical train in g a nd medical practice, some pa rti cipa nt s wondered whether it wa s poss ible to bring physicia ns into community work, ask ing whether it mi ght not be preferable to ca ll upon members of profess ions more in tune with th e dynamics of co mmuniti es. This o pini o n , based o n the ac tua l s itua ti on observed in many co untri es, sho ws how urgen t it is to reo rient the tra ining of the medical professions so tha t a community perspective develops . Paed iatricia ns a t the co nference s tressed the importance of the ir ro le in fami ly pla nnin g. After a ll , it is th ey who initi a te ea rl y con tac ts wit h the family, who supervise the growth a nd harmonious development of children, who adv ise mothers o n ways of avo iding difficult pregnancies a nd major co nge nita l diseases a nd who inform fam ili es of how to behave towards ha ndica pped c hildre n. They shou ld therefore have tim e devo ted to famil y pla nning during their tra ining. The need for evaluation Eva lua ti o n mu st be a co ntinu ous process and involve staff participation at a ll leve ls. Eva lua tion must not be an act ivit y designed and carried ou t by an o ut s ide age ncy; at every step it must involve the persons affected by the programmes . T o mee t th e concern of some participants ove r the time necessary for eva lua ti o n , it was stressed that a lth ough it is true tha t th e development a nd int rod ucti o n of p ro tocols is bound to take a long time, the ir app li ca ti o n is s imple a nd does no t tak e lo ng. A detailed ana lys is of tas ks wo uld make for ra ti o na li za ti o n of work a nd for bett er use of the time avai lab le. Evaluation sho uld relate so le ly to th ose factor s that can promote dec is io n-m a kin g. Eva lua ti on sho uld go beyond the co ll ec ti on of sta ti sti ca l data and take into acco unt qualitative factors such as the sociocultural or relational as pec ts o f a programme. It is essenti a l for eva lua tion methods to be sta ndardized so that com- para ble results betwee n different se rvices a nd regions in a give n cou ntry may be obtained. The a im o f eva lu a ti o n is no t o nl y to measu re resu lt s of a programme a t the glo bal level but also to ma ke it poss ible to improve se rvi ces loca ll y. 89 Recommendations General 6 Recommendations and conclusions The training of hea lth personnel in family pl anni ng must take in to cons ider- at io n the fam il y planning po li cies of cou ntries, the needs expressed by the co mmunity, the ro les a nd tasks of the personnel meeti ng those needs, and the conditions under which the personnel must work . The educati o n of hea lth person nel sho uld be related to loca l co mmunity needs and sho uld be flexible . Motivational activities Motivatio na l ac ti vi ti es should be a imed a t public opinion, pressure groups, dec ision-ma kers a nd t ra ining institutions, a t national a nd loca l leve ls, in order to increase awa reness of co mmunity needs rega rding family hea lth a nd the benefits of family plann ing, and a lso in o rder to guide the training of hea lth personnel. This may be do ne through the mass media, specia ll y programmed a udi ovisual ma teri a l, sem ina rs a nd workshops for the a bove gro ups , etc. In addition, trainers (teachers) must establish perso na l co ntact with dec ision-makers in o rder to inform and establish dia logue with them. Training of trainers Interdisciplinary co ntinuo us training programmes (including refresher co urses) sho uld be organized fo r teachers, in order to update their knowl- edge a nd prom ote understanding a nd implementatio n of team work . Training of trainers must be carried out at success ive levels, providing both regional and local facilities for the purpose. During their training teachers should learn a bout the community and its needs through practica l fi eld activities in and with the local community. They shou ld learn how to work with the community a nd its leaders. Teachers sho uld be trained in the use of problem-oriented and problem- solving teaching methodology. Emphasis should also be given to teaching/ lea rning methods enabling students to acquire practical skills and develo p 91 a ttitudes o f in sig ht a nd unde rsta ndin g res pec tful o f huma n ri g ht s. In o rd er to ac hieve thi s, a pp ro pria te educa ti o na l reso urce-s must be made ava il a ble. T eachers sho uld be g ive n a n und ers ta nding of th e p ro ble ms a nd spec ifi c p ro ble ms o f ad o lesce nt s a nd their sex ua lit y, so th a t th ey may ac hieve bette r co mmunica ti o n with th em . Organization of training The curric ulum co ntent in fa mil y pla nnin g sho uld be des ig ned to ena ble th e stude nt s to ide nt ify th e needs of the co mmunit y a nd to mee t th em , ta kin g into account th e soc ioc ultura l a nd eco nom ic as pec ts o f fa mil y pla nning. Fo r thi s purpose, s tress sho uld be la id es pec ia ll y o n co mmuni ca ti o n with th e po pul a ti o n , prepa ra ti o n fo r ca rry ing o ut progra mm es a nd th eir eva lua ti o n. Tra ining in fa mil y pla nning sho uld be integra ted with va ri o us di sc iplines, but o ne o f these sho uld p rov ide overa ll coo rd ina ti o n of th e tra ining to ensu re full cove rage o f the subject. Suffi cient time a nd logisti c suppo rt sho uld be ava il a bl e to ex pose th e student s to th e co mmunit y a nd e na ble the m to ide ntify it s needs a nd pa rti c ipa te in prac ti ca l hea lth ca re ac ti viti es during their tra ining. Eva lua ti o n of tra ining sho uld be d irected no t o nl y to checkin g the student s' kn owledge but , a bove a ll , to assess ing th eir a bilit y to perfo rm tas ks releva nt to fa mil y pla nning. The tra inin g of hea lth pe rso nne l sho uld s tress the mos t effec ti ve a nd eco no mica l use o f loca l reso urces . International cooperation Contac ts bet wee n co unt ries sho uld be enco uraged , fac ilit a ted a nd coo rd i- na ted in o rd er to p rov ide a n o ppo rtunit y fo r them to excha nge ex peri ence a nd poss ibl y to coopera te in des ig ning p rogra mmes a nd in testin g teaching methods a nd ma teri a ls. Conclusions The pa rti cipa nt s recogni zed th a t the teachin g of fa mil y pla nning to ph ys- icia ns, nurses, midwi ves a nd o ther hea lth perso nnel is a t prese nt fa r fr o m sa ti sfa cto ry in mos t of the co untries represe nted . In bas ic tra ining p rogrammes, it usua ll y co nsists o f brief theo reti ca l lesso ns o n the clinica l as pects o f contrace ptio n, sterilit y o r a bo rti o n. It was no ted tha t th ere a re wea kn esses in p racti ca l tra ining a nd no pre pa ra ti o n fo r th e rela ti o nship betwee n hea lth perso nnel a nd th ose who co me to seek advi ce a nd ca re. H o weve r, a number o f experime nt s in multidi sc iplina ry re fres her train- ing we re repo rt ed , whi ch p rov ide exce ll ent prepa ra ti o n fo r tea m wo rk a nd cl a rifi ca ti o n o f th e ro les o f the di ffe re nt members o f th e hea lth tea m: rece pti o n , in fo rma ti o n, clinica l exa min a ti o n , presc ripti o n , fo llow- up o f cli e nt s, etc. Co nference pa rti c ipa nts recogni zed th e impo rta nce o f see kin g to recon- cil e in a ny g ive n co mmunity the felt needs, th e ex pressed de m a nds a nd the se rvi ces o ffered . 92 With rega rd to tra ining, it is thus impo rtant to ensure that hea lth perso nnel no t o nl y rece ive clinica l training but a lso lea rn to understand the environment in which they wo rk , to mee t the influenti a l people in th e co mmunit y and, a bove a ll , to li sten to women o n whose full cooperation the success o f any birth spac ing po li cy is based. Parti ci pa nts in the co nfe rence co nsidered it des ira ble tha t training pro- grammes sho uld be developed in coopera ti o n with prima ry hea lth ca re tea ms a nd tha t they sho uld focus o n the dema nds of th e clients. It was co nsidered esse nti a l to stress tha t eva lua ti o n sho uld be uhder- ta ken toge ther with basic hea lth workers, and that it sho uld be carried o ut by them in stages, with the help of suit a ble tools a nd proced ures. In se tting o ut proposa ls fo r training in family planning fo r different categories o f hea lth personnel , a numbe r of o bstacl es of va rio us types a ri se: po litica l p rob lems with their effec t o n the ex istence a nd development of se rvices in a country; p ro blems of culture a nd re ligion, adult s' a nd pa rents' va lues; indi vidua l probl ems o f hea lth profess io na ls who a re no t acc usto med to discussing sex ua lit y, pleasure, the desire to have childre n, e tc . There are o ther problem s o f an educa tio nal na ture, due to the large number of students, the lac k o f fac iliti es a nd the littl e time ava il a ble because of the ri gidity o f traditi o na l curri cul a. To ove rcom e these o bstacles, the most impo rtant thing is to deal with th e socia l a nd eco no mic co nditio ns in which communities live: to bring infor- mation to bea r o n public o pinio n; to educate teachers to identify community needs and to provide training in which the stude nts will participate; a nd to teac h students to develo p no t o nl y kn o wledge and skills but also adequate att itudes so that they ma y serve the community. 93 Annex 1 Participants Belgium Dr M .G . Vekemans, Gynaeco logy Department, Saint Pierre Uni vers ity Hospita l, Brusse ls £gyp! Dr F . E l Marsafawi, Ge nera l Direc to r, Family Pla nning D epa rtment , Ministry of Hea lth , Ca iro France Dr N. Lora ux, Technical Adviser, D epartment o f Profess io na l a nd Institutio na l Affairs, Directorate-General o f Hea lth a nd Hospita ls, Ministry o f Hea lth, Paris Dr J. Pa turea u, Subdirectorate of Ma terna l a nd C hild Hea lth , D epart- ment of Profess io nal and Instituti o na l Affairs, Directo ra te-Ge nera l of Hea lth a nd H ospita ls, Ministry o f Hea lth , Pa ri s flaly Dr I. C hiesa, Profess io nal School of Nursing of the Ita li a n Red Cross, Ro me Madagascar Dr L. Ra mialison, Mate rnit y Unit , General Hospita l, Anta na na ri vo Morocco Dr 0 . Akalay, Prov incia l Medica l Officer , Agadir 95 Nigeria Dr O .A. Oj o, Fac ult y o f Medicine, Uni ve rsity o f Ibadan Netherlands Mrs M. Dersja nt Roorda , Head , Fa mil y Pla nning Department , D epa rt- ment o f Obstetr ics a nd G ynaeco logy, Uni ve rsity H ospita l, Leiden S weden Mrs L. Frostensso n, Nursing Office r a nd Midwi fe Tuto r, Natio na l Board of Hea lth a nd Welfa re, Stockh olm Turkey Mrs H . G i.i ze l, Directo r, Educa tio n Sec ti o n a nd Bio medica l Depa rt- ment , Genera l Direc to ra te of Po pula tio n Pla nning, Ministry o f Hea lth a nd Socia l Welfa re, Sihhiye-Ankara United Kingdom Professo r M . Elstein , Depa rtment o f Obstetri cs a nd G ynaeco logy, Uni- versity Hospita l o f So uth Ma nchester, Ma nchester Yugoslavia Dr M. G o lubov ic, Vice Pres ide nt a nd H ead , Depa rtment o f Fa mily Planning, Co mmittee fo r Hea lth , La bo ur a nd Socia l Po licy of the C it y of Belgrade Representatives of other Organizations 96 International Confede ration of Midwives Mrs R. Fo res ti er, Pres ident , Na tio na l Orga ni za ti o n of Mid wifery As- socia tio ns, Pa ris, Fra nce International Federation of Gynaecology Dr C. Surea u, C hi ef, Depa rtment o f Obstetri ca l G ynaeco logy, Ba ude- locque Uni vers ity C linic, Pa ri s, F ra nce Professo r M . Tournaire, Department of Obstetrical Gynaecology, Saint Vincent de Paul Hospital, Paris, France International Planned Parenthood Federation Mrs J. Skjreraasen, Associate Professo r, Department of Obstetrics and Gynaecology, University C linic, State Hospita l, Oslo, Norway Un ited Na tions Educational. Scientific and Cultural Organization Mrs Abrahamsson, Progra mme Specialist, Po pulation Division , Paris, France United Nations Fund for Population Activities Dr D . Piero tti , Coo rdinato r for Indian Ocean Isla nds Dr N . Sadik, Assistant Exec uti ve Director a nd Chief, Progra mme Div- ision , New York, USA Temporary advisers Dr T. Amat, Head , Ta sk Force on Human Resources, CI NAM , Mont- pellier, France Professo r E. Aujaleu, Executive Boa rd , International Children's Centre, Paris, France ( Chairman) Dr M . Botelho, Santa Ma ri a Hospital, University of Lisbo n, Portuga l Professo r K . Bozkowa, Director, Na tio na l Mother and Child Resea rch Institute, Wa rsaw, Po la nd Mrs S. C hater , Director-General, Na tiona l Office of Family Planning and Po pulatio n, Tunis, Tunisia Dr M . Purifi cac;:ao Costa Araujo, Consultant in Obstetrics for Mater- na l Hea lth a nd Family Plan nin g, Direc torate-Genera l of Health , Lisbo n, Po rtuga l Dr R. Dali, Chief, Medica l Division, National Office of Family Pla nning a nd Po pulation, Tunis, Tunisia Dr J. Dunoysky, Chair of Paediatrics, Institute of Postgraduate Medical Education, Prag ue, Czechoslovakia 97 Professor P.O. Hubinont, Head, Department of Gynaecology and Ob- stetrics , Saint Pierre Hospital , Free University of Brussels, Belgium Dr A. Jouahri , Senior Medical Officer, Population Division , Ministry of Public Health, Rabat , Morocco Dr G. Kin tis , Secretary-General, Family Planning Association of Greece, Athens, Greece Professor M . Ladjali , Senior Medical Officer, Maternal and Child Health Section , National Institute of Public Health , El Madania, Algiers , Algeria Mr Ph. Lecorps, Head of Section, Health Education - Family Planning, National School of Public Health, Rennes, France (Rapporteur) Dr D. Maillard Nardini , Consultant Physician, University Unit of Youth Psychiatry, University of Geneva, Switzerland Professor K.H. Mehlan , Director, Institute of Hygiene, University of Rostock, German Democratic Republic Dr A. Popivanova, Institute of Obstetrics and Gynaecology, Sofia, Bulgaria Professor E.A. Sand , School of Public Health, Free University of Brussels, Belgium Mr T. Tokgoz, General Director of Population Planning, Ministry of Health and Social Welfare , Sihhiye-Ankara, Turkey Professor E. Wollast, School of Public Health , Free University of Brussels, Belgium International Children's Centre Professor J . Guignard , Director, Department of Education and Training Professor M. Manciaux, Director-General Dr M. Pechevis, Department of Education and Training ( Co-Secretary) World Health Organization Regional Office for the Eastern Mediterranean Dr S.A. Zafir, Regional Adviser for Family Health 98 Regional Office for Europe Miss W. Haddad, Regional Officer for Family Planning (Co-Secretary) Dr A. Wojtczak , Director, Research , Planning and Human Resources Headquarters Dr M.A.C. Dowling, Educationa l Communication Systems Dr K. Edstrom, Medical Officer, Maternal and Child Health Dr A. Petros-Bavazian, Directo r, Division of Family Health 99 WHO publlcatlona may be obtained, direct or through bookullers, from: 41.GDIA:Eiia.priol...,..dooLi..,.(ENAL).)bdin.Yooaf. MALAWI: MaMwi llcloll Scrva. P.O. Boa :IOOU. Cllidlili. ALOIIIS 111.ANTYltE J AaGafflNA:ClrloaHindlSALl'larm16'.0elerllloa....Elcri- MALAWIA: TIie WHO Prapammc Coonl-. a- HIIM. IOIII IDrio 45J/46', IUINCJI AIUS Floor. 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C/1/85 In the last 20 years, the most important aspect of family planning has been to present arguments on the benefits to be derived from birth spacing, on the structure of families and on the recognition of conjugal rights so that countries will provide their populations with services where there is some element of choice. It is essential now to improve the organization of services at every level in order to meet needs. It is also important to give prominence to the training and role of health personnel so that they meet the expectations of communities and help fulfil the desire of members of the professions involved to go beyond pure treatment and tackle the problem at the personal level. The natural demands of women with regard to sexuality call for this new approach if lifestyles favourable to health are to be adopted, preventable conditions are to be reduced and acceptable and accessible levels of care are to be provided for all. This book tries to provide some of the information needed in such an effort. Various aspects of family planning are reviewed; a number of different • training units designed to develop and improve the teaching of different categories of health personnel were discussed in study 1roups. The relationship between health personnel and the community as well as the organization of new types of training are thus studied in detail. Conclusions and recommendations are included on activities involved in motivating and educating those involved in training, or1anizing teaching and international collaboration.