计划生育技术服务培训工作探索

<正> 我国从70年代末开始建立计划生育技术服务机构,全国约有4万个计划生育技术服务机构,15万计划生育技术服务人员,形成了遍布城乡的计划生育技术服务网络。培养造就一支合格的、深受育龄群众欢迎的计划生育技术服务队伍是做好人口与计划生育工作的重要保证。因此,加强科技人员的培训,提高知识水平和技能,是一项具有战略意义的任务。     

Training in Firearm Safety Counseling in Family Practice Residency Programs

The purpose of this study was to establish a national baseline regarding the prevalence of training of family practice residents regarding firearm safety counseling. A national survey of the residency directors at the 420 accredited family practice residency programs in the coterminous United States was used to assess the prevalance of training in firearm safety counseling, perceived effectiveness of such training, and perceived barriers to such counseling in residency programs. Program directors were sent a two-page questionnaire on firearm safety counseling activity in their programs and 71% responded. Few residencies (16%) had formal training in firearm safety counseling. The most common perceived barriers were no trained personnel (31%), too many other important issues (31%), not enough time (30%), and lack of educational resources (28%). Patient education materials (57%), video training programs (49%), and a curriculum guide (46%) were identified as resources, that would be most helpful in implementing a firearm safety counseling program. The results showed that formal training in firearm safety counseling is virtually absent from family practice residency training programs. This finding is not surprising given that less than 14% of the directors perceived firearm safety counseling would be effective in reducing firearm-related injuries or deaths and that research on effectiveness of such counseling is very limited.     

Reconsidering the doorstep-delivery system in the Bangladesh Family Planning Program

The government of Bangladesh is currently testing and implementing strategies to change its family planning program from a reliance on field-workers who conduct home visits to a conventional fixed-site delivery system. Researchers have made two suggestions: First, the program should encourage women to switch from nonclinical methods delivered by family planning workers to more cost-effective clinical methods such as sterilization, and second, field-workers should not be resupplying nonclinical methods, but should focus their attention on motivating nonusers to practice contraception. Longitudinal data from the Maternal and Child Health-Family Planning Extension Project of the International Centre for Diarrhoeal Disease Research, Bangladesh, are analyzed to show that a better strategy might be to target visits to women according to their educational level and area of residence. For uneducated women living far from clinics, access to contraceptives is likely to be a problem, and home visits for resupply might have a larger impact on the contraceptive prevalence rate than would field-workers' visits to motivate nonusers.     

医院流产后计划生育服务干预效果分析

目的:分析和评价对年轻人工流产妇女开展两种不同流产后计划生育服务干预的效果。方法:采用流行病学社区干预试验研究方法,随访调查在基线调查6个月后进行。结果:干预前组、基本干预组、全面干预组流产妇女调查人数分别为992、672、705,随访人数分别为590、476、519;干预前组、基本干预组、全面干预组流产妇女年龄分别为21.8±1.77、21.75±1.86、21.9±1.77岁;避孕知识得分分别为7.11±2.73、6.77±3.04、8.27±2.40分(F=58.96,P<0.001);流产后第一次性生活避孕措施使用率分别为76.3%、94.6%、90.1%(x2=76.08,P<0.01);流产后半年内有效避孕措施使用率分别为94.0%、83.2%、99.1%(x2=79.32,P<0.05);流产后性生活每次都使用避孕套的分别为22.7%、28.7%、36.1%(x2=73.37,P<0.01);流产后性生活正确使用避孕套的分别为20.3%、26.6%、53.2%(x2=331.35,P<0.01);流产后再次妊娠率分别为9.96%、10.3%、6.4%(x2=5.18,P<0.01);流产后非意愿妊娠率分别为18.8%、15.91%、0(x2=8.67,P<0.05)。结论:干预对改变流产后妇女避孕知识、态度和行为等方面都有一定的效果,全面干预效果更优。应在医院全面开展流产后计划生育服务。     

郑州市医院流产后计划生育服务现况的定性研究

目的:了解郑州市医院流产妇女流产原因及影响因素,医院开展流产后计划生育服务的需求以及服务现况。方法:采用个人访谈、关键信息人访谈和小组集中讨论的研究方法。结果:主要流产原因未婚妇女是不了解避孕方法而未采用避孕措施,已婚妇女多为避孕失败,少数是对优生考虑而流产。大多数流产妇女认为,医生的服务态度不好,只是简单介绍流产后注意事项,没有主动提供避孕知识的宣教和咨询,更没有提供免费的避孕药具。绝大多数流产妇女建议医院的流产后服务应该改善,医生应该主动向妇女介绍一些避孕方法,提供一些免费避孕药具等。大多数服务提供者认为流产前后对流产妇女进行避孕知识的宣传教育有必要,但存在一定的困难,主要是需要增加人员、加大经费投入等;一部分人认为若在流产后对妇女进行避孕知识的宣传和教育,可以增加避孕方法的使用,减少非意愿妊娠和重复流产。结论:流产原因多为未避孕和避孕失败,医院尚未开展流产后计划生育服务,应提供规范的流产后计划生育服务,以提高流产妇女的避孕知识和避孕方法的正确使用。     

Prior Family Planning Experiences of Obese Women Seeking Abortion Care

BackgroundThe prevalence of obesity among women of reproductive age calls for research focused on strategies that ensure obese women receive high-quality reproductive health care. This study adds to this literature on service delivery by exploring obese women's experiences receiving or avoiding family planning care.MethodsWe included 651 women seeking abortion care who completed iPad surveys about their previous family planning experiences.FindingsOne quarter were classified as obese, with almost 5% morbidly obese. Only 1% of obese women reported avoiding family planning care. More than 12% of morbidly obese women reported not having their family planning needs met (pap smears, sexually transmitted infection testing, or ultrasonography). This is compared with only 2% among overweight and obese women and 0% among normal and underweight women. Almost 10% of obese and morbidly obese women reported that at least one of the previous family planning clinics they had visited was not prepared to provide care for heavier women and around 25% of obese women reported at least one item in the clinic (such as blood pressure cuffs and examination gowns) was not adequate for their size.ResultsContrary to expectations, we did not find that obese women avoided family planning care. However, morbidly obese women reported not having all of their family planning needs met when they attended care. Family planning providers should ensure that their facilities have the capacity to meet the family planning needs of obese women and that they have adequate equipment to care for this population of women.     

Unintended Consequences: Abortion Training in the Years After Roe v Wade

The US Supreme Court’s 1973 Roe v Wade decision had clear implications for American women’s reproductive rights and physician ability to carry out patient choices. Its effect on physician abortion training was less apparent.In an effort to increase patient access to abortions after Roe, provision shifted from hospitals to nonhospital clinics. However, these procedures and patients were taken out of the medical education realm, and physicians became vulnerable to intimidation. The consequent provider shortage created an unexpected barrier to abortion access.Medical Students for Choice was founded in 1993 to increase abortion-training opportunities for medical students and residents. Its mission ensures that motivated medical students will learn and a growing number of physicians will commit to comprehensive abortion provision.THE 1973 US SUPREME COURT decision on Roe v Wade had far-reaching implications for the training and acceptability of abortion practice among physicians in the United States. Almost overnight, there was a shift in abortion provision from hospital centers to nonhospital clinics. Following Roe, the percentage of abortions performed in nonhospital clinics rose from 51% in early 1974 to 61% in 19761 and reached 95% in 2008.2 Although the shift of abortion provision out of hospitals increased the number of sites where women could access abortion and other critical family planning services, it unintentionally took the procedure, relevant reproductive health care topics, and the patients out of the realm of hospital-based medical education accessible to medical students and residents. Training in family planning became uncommon in residency programs, and by the early 1990s, only 12% of obstetrics and gynecology (OB/GYN) programs offered training in abortion care.3The exodus of abortion provision away from the safe haven of hospital medical centers and into specialized clinics also produced a shift in the focus of anti-abortion activists toward individual physicians and their clinics.4 Eventually, harassment previously reserved for clinic sidewalks moved to target the private homes of physician providers. Anti-abortion activists strove to intimidate and make pariahs of these health care professionals on a very personal level. In early 1993, thousands of medical students across the country were mailed a vulgar and menacing pamphlet of jokes by an anti-abortion group in Texas entitled, “Bottom Feeder: The Abortionists’ Jokebook.” One inclusion from the pamphlet read, “Q: What would you do if you found yourself in a room with Hitler, Mussolini and an abortionist, and you had a gun with only two bullets? A: Shoot the abortionist twice.”5^(p9) Later that same month, David Gunn, an abortion provider in Pensacola, Florida, was shot and killed in front of the clinic at which he worked. He was the first of many physicians, clinic staff, and volunteers to fall prey to the violent tactics of extreme anti-choice activists.The anti-abortion movement’s violence against physicians and attempts to influence medical students’ opinions on abortion met resistance from an unexpected, rising leader. Infuriated by anti-abortion tactics, Jody Steinauer, then a first-year medical student at the University of California, San Francisco, decided to take a year’s hiatus from school to counter these attacks on current and future physicians. Her attention became centered on the lack of abortion-related education and training within medical school curricula.6 Working as an intern at the National Abortion Federation, Steinauer began contacting like-minded medical students and quickly uncovered a burgeoning pro-choice medical student community yet to be organized. What started as a small gathering of medical students at the 1994 National Abortion Federation annual meeting quickly grew into a cohesive national community of pro-choice advocates. These students joined together to form a new organization named Medical Students for Choice (MSFC).In an environment that is often resistant to change and controversy, medical student activists of MSFC have worked steadily for almost two decades to reinstate abortion training in their medical education and to reverse the steady decline in the number of US abortion providers. Programming efforts have been at the heart of this work, including innovative medical-school curriculum reform strategies and clinical training opportunities including the Reproductive Health Externship, which provides financial and administrative support for medical students to gain exposure to abortion counseling and procedures. Although impressive inroads have been made, there remains a lack of comprehensive reproductive health education in medical school curricula nationwide.7 The loss of hospital-based abortion experiences for medical students and residents following the Roe decision has unfortunately made access to training more difficult for these students. Hence, it has potentially added to the lack of access to safe abortion care.Countless studies over the past decade have highlighted the necessity of comprehensive abortion training and reproductive health education for medical students. In a 2005 study, Espey et al. found that almost a quarter of medical schools provided no formal education on abortion in the third-year OB/GYN clerkship.8 A subsequent 2008 study showed that the majority of medical students view abortion education as an appropriate and valuable experience that they would recommend to others.9 Perhaps of most importance, increased exposure to abortion care has not only been shown to correlate with improved attitudes toward abortion among medical students,10 but also with more medical students considering abortion provision in their future careers.11The impact of the lack of abortion education and training on access has been profound. A recent study of practicing obstetricians and gynecologists in the United States shows that those who graduated from medical school between 1990 and 2000 have the lowest rate of abortion provision.12 In turn, these years correspond with the years of steepest decline in access. The most striking recent data show that 87% of US counties, home to one third of all women of reproductive age, have no abortion providers.13 Lack of abortion training is directly related to this provider shortage and causes a decreased access to options for patients.Since its inception, MSFC’s mission has been to increase medical student and resident exposure to and training in abortion procedures. This aim includes educating future obstetricians and gynecologists, family practitioners, emergency medicine physicians, pediatricians, and any other type of physician wishing to gain knowledge or skills in abortion provision. Ensuring adequate access for all women to safe and legal abortions requires a collaborative effort from physicians across the various specialties. In MSFC’s 2011 Alumni Survey, results showed that more than two thirds of OB/GYN alumni and one fourth of family medicine alumni provide abortions, and an array of physician alumni practicing pediatrics, internal medicine, and emergency medicine also provide abortion services to their patients (

The National Area Health Education Center Program and Primary Care Residency Training

The Area Health Education Center (AHEC) program was established in 1972 to improve the supply, distribution, retention and quality of primary care and other health practitioners in medically underserved areas. Through academic/community partnerships, regional AHECs offer a broad array of educational programs for students, residents and practicing health professionals. With primary care medical education a core part of AHEC programs, AHECs have been involved in decentralized residency training from the outset, with particular attention to family medicine. This paper provides an overview of the national AHEC program, its core components and its support for primary care residency training. Although AHECs have achieved considerable success in training primary care physicians for their respective states, continued refinements of programs are needed to address the needs of the most rural and underserved communities.     

针对流动人口开展流产后计划生育服务的必要性研究

目的了解北京市寻求人工流产的年轻流动妇女避孕、流产相关情况以及流产后获得计划生育服务的现状,探讨对流动人口开展流产后计划生育服务的必要性。方法采用自行设计的调查问卷,对1008名25岁以下的人工流产妇女进行横断面调查。对其中624名流动人口的数据进行对比分析。结果流动人口中77.1%为未婚,≤19岁占11.1%,初中以下文化程度占22.9%,工作不稳定占23.2%,月收入≤1000元占46.5%,16.5%的人经历过高危流产;本次流产原因是未避孕及不知道避孕方法的比例分别为64.1%和11.8%,与户籍妇女相比均有统计学意义(P<0.05)。流产后没有接受任何避孕宣教服务的占35.1%,没有接受计划生育咨询服务的占84.1%,5.47%的人表示医生向其提供了避孕药具,10.42%的人表示医生向其建议转诊(获得药具或宣教)。结论与户籍妇女相比,流动人口中人工流产妇女的年龄相对较小,文化程度较低,工作不稳定、收入低,避孕知识欠缺,避孕方法使用率低,高危流产比例高,而现有流产后计划生育服务提供的数量和内容有限,应针对其特点加强流产后计划生育服务。     

The oral pill in the Indonesian Population/Family Planning Program

The oral pill is the most extensively used contraceptive in Indonesia. Of new users, 64% use the pill, 20% IUDs, 8% injectables, 6% condoms and 2% voluntary sterilization. Since the continuation rate of pill use is low as compared to the other non-permanent methods, i.e. the IUD and the injectables, special steps must be taken in order to reach the goal of the program, i.e. the reduction of the crude birth rate (CBR) to 22/1000 by the year 1990. These special steps involve selecting the best pill for Indonesian women, and determining the best contraceptive combination for each region and for new pill acceptors. The role of the oral pill in the program is also discussed.

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Resumen La pastilla es el anticonceptivo más extonsamente usado en Indonesia. De los usuarios nuevos, 64% prefieren la pastilla, 20% los dispositivos intrauterinos, 8% los inyectables, 6% el condon y 2% la esterilizacion voluntaria. Puesto que la continuidad de los que usan la pastilla es baja si se la compara con la de los otros métodos no permanentes, por ejemplo los DIU y los inyectables, se deberán tomar medidas especiales con el objeto de cumplir con el propósito del programa, es decir, la disminución de la tasa bruta de nacimientos a 22/1000 para el año 1990. Estas medidas especiales implican seleccionar la mejor pastilla para la mujer indonesa y determinar la mejor combinación de anticonceptivos para cada región y para las nuevas aceptantes. También se discute el papel de la pastilla en el programa.

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Resumé Les contraceptifs oraux constituent la principale méthode contraceptive utilisée en Indonésie. Parmi les femmes qui adoptent pour la première fois une méthode contraceptive, 64% utilisent la pilule, 20% le stérilet, 8% les produits injectables, 6% les préservatifs et 2% recourent à la stérilisation volontaire. Etant donné que le taux d'abandon de la pilule est plus élevé que celui des autres méthodes non définitives, est-à-dire le stérilet et les produits injectables, il faut adopter des mesures spécifiques si l'on veut atteindre l'objectif poursuivi, qui est de réduire le taux brut de natalité à 22/1000 en 1990. Ces mesures comportent notamment le choix de la pilule la mieux adaptée aux femmes Indonésiennes et la détermination de la combinaison contraceptive la mieux adaptée à chaque région et aux femmes n'ayant éncore jamais pris la pilule. On discute également la place des contraceptifs oraux dans ce programme.

     

External Practicum-Year Residency Training in Occupational and Environmental Medicine: the University of Pennsylvania Medical Center Program

We describe a competency-based training program that allows physicians employed full-time in occupational and environmental medicine to satisfy the supervised practicum year of training required by the American Board of Preventive Medicine (ABPM). The program is designed for trainees with greater clinical experience than the 1 clinical year required by the ABPM. To date, 25 physicians from clinic-based, academic, corporate, and government employment across most geographic regions of the United States have been admitted into the program. Most completed a master's in public health (MPH) in a distance-learning, on-job, on-campus, or executive program. The practicum-year training has been highly successful, as evidenced by improvements in resident self-assessment of competency, resident satisfaction with the training, faculty evaluation of resident performance, and success rate in the ABPM examination. The program has opened a new pathway for physicians making a mid-career shift to occupational and environmental medicine to obtain high-quality, in-depth education and board certification.     

The Montana Model: Integrated Primary Care and Behavioral Health in a Family Practice Residency Program

To address the local health care needs of both patients and primary care providers in Montana, an integrated primary care and behavioral health family practice clinic was developed. In this paper we describe our experience with integrating mental health and substance abuse services into a primary care setting (a community health center) while simultaneously teaching family practice physicians to take the lead in providing these services. The Deering Community Health Center in Billings, Montana, is a Federally Qualified Health Center serving a largely low-income patient population. The medical care at the clinic is provided primarily by the faculty and residents of the Montana Family Medicine Residency. The teaching model was founded on the belief that improved care will result when physicians have increased comfort with, and are able to enjoy the challenges of, patients with mental illnesses. The enhanced longitudinal curriculum incorporates mental health across the 3 years of the family practice residency. Unique characteristics of this model include staffing and the concurrent delivery of a high volume mental health service while teaching family practice resident physicians and the faculty to integrate this competency into their primary care practices.     

人工流产后计划生育服务干预实施效果的问卷调查

目的 探讨人工流产后计划生育服务干预实施的效果.方法 选择1 200名行人工流产妇女在流产术前行避孕相关知识问卷调查,将其随机分为两组,干预组实施流产后计划生育服务干预措施,对照组行常规处理,1年后再次对所有研究对象进行避孕相关知识等问卷调查.结果 随访1年后,收回有效问卷1 042份,其中干预组524份,对照组518份.干预组避孕相关知识得分与对照组比较差异有统计学意义(P＜0.01),干预组未采取避孕措施比例与对照组比较有差异有统计学意义(P＜0.01),干预组非意愿妊娠率与对照组比较差异有统计学意义(P＜0.01).结论 人工流产后实施计划生育服务干预措施有利于提高避孕相关知识水平,提高避孕措施使用比率,降低非意愿妊娠率.