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NIGER: Preliminary Results of the Survey of Providers’ Use of STI/HIV/AIDS Protocols
by Dr. Arziki Souley and M. Alio Sabo

Introduction

In 1998, Niger, like certain other countries of the sub-region, was instructed to develop documents for Reproductive Health (RH) Policies, Norms and Procedures (PNP). These documents were to be disseminated to various categories of healthcare institutions in the country.

Purpose of the Survey 

The purpose of this survey was to evaluate providers’ use of the protocols and to collect their opinions and suggestions on the content and format of the protocols.

Implementation of the Survey

This survey pertained only to physicians, midwives and nurses. Data collection took place between 16 July and 9 August 2002. A total of 21 health institutions from 4 regions in the country were involved in the study, producing a sample of 100 providers. The 21 sites surveyed were:

• Referral maternities (2)
• District hospital maternities (3)
• Type II integrated health centers (4)
• Type I integrated health centers (4)
• Community integrated health centers (4)
• Urban community maternal and child health centers in Niamey (4)

At the conclusion of the survey, we had been able to interview only 62 providers, in the following categories: 

• 10 physicians (4 men, 6 women)
• 26 midwives (26 women)
• 26 nurses (9 men, 17 women)

The reason for the smaller number is that some had not gone back to their posts, some were on vacation and others were attending seminars during the time we visited their institution.

Areas of specialization

There is no one exact area of specialization. Most of the providers surveyed (84%), offer the following services: 

• Family planning 
• Antenatal consultations 
• Newborn consultations
• Maternity (supervision of labor, delivery and postpartum care)
• Obstetrics and gynecology
• STIs
• HIV/AIDS
• Immunization

Professional experience

The providers surveyed had between 2 and 23 years of professional experience in RH, with the majority having between 5 and 10 years. Most of the providers interviewed, however, had between 10 months and 2 years of service in their present position. 

Types of family planning services offered 

All the providers offer all types of FP services but some, such as the maternal and child health center and referral maternity nurses, provide these services less frequently. Services offered are: 

• intrauterine devices (4,8%)
• injectables (8,2%)
• combined oral contraceptives (100%)
• progestin-only contraceptives (100%)
• male condoms (100%)
• female voluntary surgical contraception (6,5%)
• emergency contraception (25,8%)
• Lactational Amenorrhea Method—LAM (100%)

Types of STI/HIV/AIDS services offered to women

All the providers offer STI/HIV/AIDS services daily, to both women and men. Services offered are: group or individual education on STIs (100%), clinical examination for STI screening (100%), STI diagnosis and treatment (100%), voluntary counseling (88%), dual protection (100%).

Dissemination of the protocols

A total of 10 of 21 health institutions have a copy of the RH norms and procedures that were published in 1998. The institutions, however, use other publications for reference: syndromic management strategies (1994 and 1998 versions), FP protocols and technical data sheets (1993), flip chart on AIDS and the family (2001), standards for obstetrical and neonatal emergency care (Morocco 2000), emergency obstetrical care modules (Niger 2002), Essentials of Contraceptive Technology (2000).

These 10 institutions have data sheets following a dissemination (a reading of the document followed by explanations). Eighteen providers from these institutions were interviewed. Thirteen had been trained in the use of the protocols and 5 providers had been indoctrinated by their trained colleagues. All training courses (with dissemination) took place in 2002. All the trained providers had put the protocols into practice. Of those who did not have the protocols and who had not been trained (44 providers) only 7 had heard about the protocols. 

Use of the protocols

• 89% (16 of 18) know that there is information about STIs and HIV/AIDS in the RH norms and procedures document.
• In 50% of the institutions, there has been no formal discussion of the protocols with the other health workers. 
• 72% (13 of 18) have read the information about STIs and HIV/AIDS as often as once a week to at least once a month. 
• 83% (15 of 18) have used the protocols when providing services; frequency of use ranged from daily (33%), to at least once a week (46,5%), and at least once a month (20,5%).
• 100% of the providers believe that they benefit from use of the protocols.
• Other sources of information frequently used are: radio/television, particularly for HIV/AIDS and FP
• 100% consider the protocols appropriate
• The protocols most frequently used were:
  • Family planning 
  • STI/HIV/AIDS
  • Obstetrics and technical data sheets
  • Infection prevention

Format of the protocols

• 100% of those interviewed found the information understandable 
• 100% found the information on the following topics to be complete:
  • STIs/HIV/AIDS
  • Condoms
  • Syndromic management
  • Syphilis

Comments and suggestions

Almost all of the providers found the content appropriate but there are problems concerning a syndromic management strategies document that is used every day and on which all supervision, monitoring and cost recovery practices are based. This document also deals with STIs and obstetrical and gynecological complaints. As for format, the providers interviewed requested, above all, that the pages be laminated to make the document sturdier. 

Information Search 

• Search for STIs/HIV/AIDS information (how to protect oneself)
  • 65,5% found the correct answers when using the document 
  • 34,5% did not find the correct answers 
  • 55,5% found the correct answers easily 
  • 39% had difficulty finding the correct answers or did not find them in the document because they had not mastered use of the document or did not even know where to look for the information 
• Search for STI/HIV/AIDS information (advice to give someone to enable the person to protect himself/herself)
  • 65,5% found the correct answers 
  • 34,5% did not find the correct answers 
  • 44,5% easily found the correct answers in the document
  • 44,5% found the correct answers with difficulty or did not find them because they had not mastered the use of the document 

Recommendations and Comments

Changes to make in the format of the protocols

• Laminate the pages
• Use heavier paper

Comments and supplementary questions 

• Dissemination of the protocols was limited.
• At times only one provider in an institution receives training.
• There is only one copy of the document for all the staff. 
• The dissemination methodology is not appropriate and the training time is too short (3 to 5 days).
• The document concerning syndromic management strategies is an obstacle to the use of other reference documents such as the protocols.

Recommendations

• Disseminate the documents throughout the entire country.
• Train all providers working in the area of RH in healthcare institutions.
• Make two copies of the protocols available to Type II integrated health centers.
• Take the RH protocols into account when supervising and monitoring.
• Improve the dissemination methodology with case studies, information searches, etc. 
• Lengthen the training time.

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