Please note: This archive was last updated in 2005.

RHO archives : Topics : Older Women

Program Examples

The programs described below illustrate some of the strategies developed to meet womens reproductive health needs throughout the life span, particularly as they grow older.

  • Ethiopia: Repairing obstetric fistulas at the Addis Ababa Fistula Hospital.
  • Malaysia: Launching special reproductive health services for women moving through menopause at FFPAM's Well Women's Clinics.
  • Newly Independent States and Eastern Europe: Creating a new model of health care delivery at the Women's Wellness Center.
  • Thailand: Helping older women care for adult children with HIV/AIDS and orphaned grandchildren.
  • Ukraine: Increasing the quality and utilization of breast cancer services.

Submit your own Program Example.

Ethiopia

Marriages at an early age, combined with inadequate medical care during pregnancy and childbirth, have led to high rates of obstructed labor and obstetric fistulas among women in Ethiopia. Doctors Reginald and Catherine Hamlin became pioneers in fistula surgery when they came to Ethiopia in 1959. They perfected surgical repair techniques and eventually built a special hospital to meet the need for fistula repair. Since the establishment of Addis Ababa Fistula Hospital in 1975, growing numbers of young women have sought treatment, often traveling for many days and weeks to do so. No one is turned away, and treatment is provided free.

When they arrive, the patients—primarily young women aged 14-22 although women of all ages have been treated—are fed, clothed, provided with basic medical care and, if necessary, extensive physiotherapy to restore the use of their legs. Equally important is the emotional and psychological support offered to these young women. The hospital also sponsors classes in basic hygiene, literacy, and marketable skills like sewing and knitting.

A team of five surgeons performs up to 30 operations each week. Operations typically take one to three hours and are generally conducted under a local spinal anaesthetic. The surgeons operate on four patients simultaneously, working at four operating tables placed within earshot of one other so that they can offer assistance when needed. Good nursing care is required after the operation since the women must spend about two weeks in bed with a catheter while they heal.

Women with uncomplicated cases are ready to return home after three weeks. Most are given new clothes and money to pay for the trip back. They also are warned to wait several months before remarrying or having sex with their husbands, and they are told that they must deliver any future children in a hospital. Some former patients have gone on to become nurses, hospital staff, and outreach workers to other fistula sufferers throughout Ethiopia.

Training medical staff and sharing fistula repair techniques is a top priority at the Fistula Hospital, since the surgery is technically difficult and requires special skills. About ten obstetrician/gynecologists from developing countries attend a one-month training program at the hospital each year to perfect their skills. When they return to their home countries, it is hoped they will train others in fistula repair. An equal number of post-graduate doctors from the Addis Ababa Medical Faculty receive two months of training each year. These young doctors will help prevent fistulas in the future by providing good obstetric care and will carry fistula repair skills to other parts of Ethiopia.

The Addis Ababa Fistula Hospital has become a model for fistula repair programs in other countries. Its accomplishments include:

  • The treatment of more than 1,000 women each year, with more than 20,000 women treated since the hospital opened;
  • A success rate of 92 percent for fistula repair; and
  • Lobbying the Ethiopian government to require every postgraduate student in gynecology in the country to complete a two-month training period in fistula surgery technique at the Fistula Hospital.

Financing the hospital's ongoing operations and its efforts to expand is a continuing challenge. While the Ministry of Health pays the salaries of the doctors and some nurses, the rest of the budget comes from donations. Hospital staff save money by sterilizing and reusing whatever supplies they can, but the cost of treating each patient remains about $350. Total running costs are $450,000 per year.

The overwhelming demand for fistula repair also presents a major challenge for the hospital. Beds are constantly full, and there is not enough room to house women waiting for operations. A newly built village outside Addis Ababa will help relieve the pressure on the hospital's facilities. It will house former patients whose fistulas are beyond repair. Because these women wear urostomy bags and require ongoing medical attention, they cannot return home. Many work as nursing assistants at the hospital, and others will be able to farm the land at the village of Desta Mender to support themselves. The village also will accommodate a rehabilitation unit for chronic patients, thus freeing up beds at the hospital for new patients.

In addition, efforts are underway to provide fistula repair services at other sites in Ethiopia. Currently, an outreach team from the Fistula Hospital makes one-week visits to regional hospitals, during which they operate on up to 20 fistula patients. As graduates of the hospital's training program take up posts in regional hospitals, fistula repair may become a permanent part of their services. In support of this effort, a new program has begun to train ward and theatre nurses throughout the country in the important nursing care of fistula patients. Five outreach centers of the Fistula Hospital also are being equipped to meet needs in rural Ethiopia.

The Fistula Hospital is also turning its attention to prevention programs. If pregnant women at high risk for obstructed labor can be referred to appropriate medical care, fistulas can be prevented. Raising awareness about the dangers of childhood marriages also is essential. Leaflets, flipcharts, videos, and plays are being planned for the community to raise awareness and develop patient advocates throughout Ethiopia.

For more information about the Addis Ababa Fistula Hospital, please contact:
Ruth C. Kennedy, Addis Ababa Fistula Hospital; P.O. Box 3609; Addis Ababa, Ethiopia.
Tele phone: 251-1-71-65-44; Fax: 251-1-71-28-66; Email [email protected]

Further information also is available online at www.fistulahospital.org.

References:
Addis Ababa Fistula Hospital 2001 Annual Report (www.fistulahospital.org/images/ar2001.pdf).
World Vision 2002 Project Summary: Addis Ababa Fistula Hospital (www.worldvision.org/worldvision/imagelib.nsf/main/Fistula.pdf/$file/Fistula.pdf).
Emekekwue, O. Addis Ababa Fistula Hospital: a success story in care of VVF patients. Populi 28(1) (April 2001).

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Malaysia

In 1991, the Federation of Family Planning Associations, Malaysia (FFPAM) launched menopause management services for older women as part of its life-span approach to reproductive health. FFPAM is committed to meeting the changing needs of its clients as they reach the end of their reproductive years and promotes the comprehensive management of menopause to enhance the quality of life and womens rights through the "golden" years. All 13 state affiliates offer special services to older women so that they can learn about the effects of menopause on their body, adapt to this change, and maintain a healthy life.

Because Malaysian women know little about the physiology of menopause, FFPAM has used a variety of information, education, and communication (IEC) strategies to raise their awareness of the health impacts of menopause. The organization has produced an educational booklet that describes menopause and its symptoms, explains the long-term health risks associated with menopause, and encourages menopausal women to actively manage their health. FFPAM also sponsors client forums where obstetrician/gynecologists educate women about menopause and hormone replacement therapy (HRT) and dispel their fears and misconceptions. By collaborating with other NGOs, such as the Malaysian Menopause Society, FFPAM has been able to take its message to broader audiences at public forums on menopause and HRT. State Family Planning Associations (FPAs) have used public seminars as an important channel not only to raise awareness, but also to publicize the range of reproductive health services available at FPA clinics, including menopause services.

State FPAs affiliated with FFPAM offer older women a variety of important services at their Well Women's Clinics, including:

  • Hormone replacement therapy.
  • Symptomatic treatment of menopausal symptoms.
  • Health screening, including breast examinations, Pap smears, and ultrasonography.
  • Education about menopause.
  • Counseling and advice.
  • Management of gynecological problems.

Physicians counsel women going through menopause about the benefits of HRT and also alert them to its potential risks. They advise HRT use to alleviate uncomfortable, short-term symptoms, such as mood swings and decreased libido, and to reduce the long-term risk of developing serious illnesses such as osteoporosis. Physicians update clients about findings from recent studies on HRT so that they can make fully informed decisions. After a thorough examination to rule out contraindications, physicians prescribe a suitable HRT drug to those women who want it. When HRT is inappropriate or unwanted, women receive symptomatic treatment for menopausal symptoms instead.

State FPAs also screen women for breast and cervical cancer in their clinics and in public outreach programs for underserved and marginalized groups. Family planning and reproductive health clients receive annual breast examinations and are taught to do monthly breast self-exams. A special effort is made to instruct young people in breast self-exams at camps, talks, and other gatherings. Current policy is to take a Pap smear every three years from women aged 20 to 65 unless their use of hormonal contraception or their sexual history puts them at special risk for cervical cancer, in which case Pap smears are taken annually. FFPAM operates a Cytology Laboratory to ensure reliable readings of Pap smears.

When clients have a suspicious lump in their breast or an abnormal Pap smear, they are referred to a government, university, or private hospital for further investigation and treatment. FFPAM staff members follow up these women to ensure the quality of their care.

Physicians at FPA clinics also treat older women for a wide variety of gynecological problems, including reproductive and urinary tract infections, vaginal dryness, incontinence, and dyspareunia. If the FPA cannot offer effective treatment for a client's problem, the client is referred to an outside hospital. When older women complain of bone ache, back ache, or joint pains, they are treated symptomatically and offered HRT.

FFPAM's services for older women have faced many challenges, including:

  • Lack of expertise: Health care workers at state FPAs initially were not familiar with the medical issues surrounding menopause and its treatment;
  • Staff shortage: Staff turnover exacerbates the shortage of female obstetrician/ gynecologists who can provide menopause services;
  • Client motivation: Some clients are reluctant to accept HRT, especially for long-term use, and many drop out after their symptoms improve;
  • Affordability: Poor clients cannot afford HRT and other drugs.

To overcome these obstacles, FFPAM and its state affiliates have trained staff members on menopause management, raised extra funds to upgrade clinics, worked to raise public awareness of the benefits of HRT, and established strong referral links with government, university, and private medical facilities to provide specialized services. FFPAM also has standardized services by reviewing guidelines on how to set up a menopause clinic and how to manage women who are going through menopause. In 2002, FFPAM revised its guidelines on menopause to further improve services.

FFPAM also has worked to expand reproductive health services for older women, which are available at clinics with specially trained gynecologists or general practitioners. For example, all state affiliates now provide ultrasonography services. More recently, FFPAM used funding from the Embassy of Japan to develop new leaflets and posters on coping with menopause and its signs and symptoms in four languages and to purchase a Bone Mineral Densitometer to identify women at risk for osteoporosis. The densitometer is loaned to State FPAs for use during Well Womens Clinics, which offer women counseling on diet, exercise, and HRT to prevent osteoporosis. In 2001, a total of 1,380 women were screened for bone mineral density.

IEC activities highlighting the health impacts of menopause and the increasing range of services, including screening for bone mineral density, have attracted growing numbers of menopausal women to FPA clinics for services. For example, the number of HRT clients rose from 1,032 in 1996 to 2,445 in 1998 and 3,921 in 2001, with the number expected to continue growing in 2002. In addition to the 123,000 family planning clients served in 2001, FFPAM affiliates helped over 25,000 women with menopausal, gynecological, and STI services.

Lessons learned by FFPAM include:

  • To attract older women to new health care services and sustain their interest, FPAs must continue to develop IEC materials and activities that raise their awareness of the health problems associated with menopause and aging.
  • Providers should encourage the continuity of care by informing women about the long-term benefits of HRT for reducing the risk of serious diseases associated with aging.
  • HRT drugs must be made affordable to all segments of the population

In the future, FFPAM plans to extend its services to the "old old," that is, women over the age of 65, in order to provide care throughout the entire life span. Currently, their programs are designed for women age 45 to 65. Separate clinic sessions will be held and specialized health services designed for the oldest cohort of women. FFPAM is also moving to address the reproductive health of men with the objective of improving the sexuality of women and men.

For more information about FFPAM's reproductive health services for older women, please contact:
Dr. Ang Eng Suan, Executive Director, Federation of Family Planning Associations, Malaysia (FFPAM), 81B, Jalan SS15/5A, Subang Jaya, 47500 Petaling Jaya, Selangor Darul Ehsan, Malaysia
Telephone: 603-56337514/7516/7528; Fax: 603-56346638; Email: [email protected]

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Newly Independent States and Eastern Europe

Women’s health status and life expectancy suffered after the collapse of the Soviet Union, due to gaps in health care coverage, financial instability, and rising rates of smoking, alcohol and drug use, unsafe sexual practices, and intimate partner violence. In 1997 a Women’s Health Task Force, operating under the auspices of the American International Health Alliance (AIHA), created a new model of health care delivery to combat these problems: the Women’s Wellness Center.

Several characteristics set Women’s Wellness Centers apart from conventional health services in the region. They offer integrated care and address women’s health needs throughout the life span, from adolescence to menopause and beyond. They focus on health promotion and patient education as well as diagnostic screening and clinical services. They take a client-centered approach and empower women to become active participants in their own health care.

Initially, all of the Women’s Wellness Centers (WWCs) were established as part of an AIHA partnership, which pairs hospitals or other health organizations in the NIS and Central and Eastern Europe with a counterpart in the United States. The partners collaborate on a needs assessment, site selection, work plan, staff training and development, clinical practice guidelines, quality assurance, and patient education.

While all Women’s Wellness Centers follow a common set of guidelines, each one adapts the model to serve the special needs of its own community. In Moldova, for example, one center has focused its efforts on widespread domestic violence, while a center in Ukraine has launched outreach campaigns to address high rates of STIs. Programs for post-menopausal women are a focus area at centers in Moscow and St. Petersburg, Russia, and Mozyr, Belarus, where there are large elderly populations. The Women’s Wellness Center in Moscow, for example, sponsored a seminar on older women’s health in 1998 to educate its staff on breast disease, cardiovascular disease during menopause, osteoporosis, and HRT. About 15 percent of all women served at the center are over age 49.

Among the wide array of services offered by WWCs, the following are especially important for older women:

  • Education and screening for cervical, breast, and uterine cancers (some centers have breast health programs that teach breast self-examination, perform clinical breast exams, and offer mammography screening).
  • Education and services related to menopause, including hormone replacement therapy.
  • Prevention and treatment of problems associated with menopause and the post-menopausal period, such as osteoporosis.
  • Screening and treatment for chronic diseases such as diabetes and hypertension.
  • Promotion of a healthy lifestyle, including education on diet and exercise.

An assessment of 10 WWCs in 2001 found, however, that services for older women, especially health promotion activities, were not as well developed or utilized as services for younger women. Some centers find it difficult to attract older clients. In the 10 centers assessed, the percentage of clients who were over age 49 ranged from 0.3 percent to 10.6 percent. Providers at many of the centers also needed additional training to increase capabilities for serving women past their reproductive years.

Achievements of the Women’s Wellness Center initiative include:

  • Since 1997, more than 30 centers have opened in 11 countries.
  • The centers have created a model that can be easily reproduced and adapted to local needs. Several countries, including Belarus, Moldova, and Uzbekistan, have replicated the original Women’s Wellness Center at satellite sites.
  • The centers have raised standards and influenced the delivery of health care for women in surrounding areas.

As some of the countries served by AIHA begin to experience declining birth rates and a "graying" of their populations, it is expected that increasing emphasis will be placed on those services provided to women beyond their reproductive years. Thus, it is the goal of AIHA to provide educational programs to the providers associated with its network of WWCs, and to otherwise encourage centers to improve the quality of care provided to women, no matter what their age.

For more information, please contact:
Fran Jaeger, DrPH, Program Officer, American International Health Alliance, 1212 New York Avenue NW, Suite 750, Washington, DC 20005
Telephone: 1-202-789-1136; Fax: 202-789-1277; Email: [email protected]

This program example is based on:
American International Health Alliance (AIHA). Making Women’s Health Matter: An Integrated Approach. Washington, DC: AIHA; 2002-2003. Available at: www.aiha.com/index.jsp?sid=1&id=4054&pid=4048&revid=0.
Jaeger F. Women’s Wellness Centers-Assessment Report. Chicago: University of Illinois at Chicago, Department of Obstetrics and Gynecology; 2001. Available at: www.aiha.com/index.jsp?sid=1&id=4808&pid=1284.

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Thailand

In 1992, a group of academics and health professionals in Chiang Mai, Thailand, responded to the growing HIV/AIDS epidemic by launching the Sanpatong Home Based Care Project. The project sought to improve care for people living with HIV/AIDS and to reduce the burden on overstretched hospitals by enabling their families to care for them at home. From the start, the project took a holistic "bio-psycho-social" approach, aiming not just to treat physical symptoms but also to help people cope psychologically and to encourage community acceptance.

Initially the project directed its efforts to HIV-positive individuals, who are invited to attend monthly lunch gatherings and support groups and to take a training course in home care before they develop full-blown AIDS. The project also offers meditation, yoga, and spiritual instruction according to Buddhist traditions. Later, activities were broadened to include the entire family and the community. In 1999, under the leadership of the Zonta International Chiangmai Club (ZICC), Sanpatong launched a special project for grandmothers because they so frequently assumed the role of primary caregiver for their adult children with HIV/AIDS and for grandchildren orphaned by AIDS.

In Thailand, grandmothers have always played a special role in caring for children and running the household, but the AIDS epidemic has brought new and heavy burdens for them. These older women, who may be frail and in poor health themselves, have to deal with the physical effort, emotional stress, and social stigma associated with caring for people with HIV/AIDS. Putting the burden of AIDS care on aging grandmothers, as local tradition dictates, raises some ethical concerns. However, these women willingly assume the role of caregiver, and the "Grandma Cares" project tries to make their jobs easier by giving them the skills and support they need to handle the role of caregiver and by training other family members to help.

A key component of the project is a one-day training session on home-care skills. This course discusses important topics, such as universal precautions and nutrition, and demonstrates practical nursing skills, such as giving medicines, changing sheets, using bedpans, giving bed baths, and taking temperatures. It also gives participants an opportunity to exchange stories, express their feelings, and ask questions. The goal is to make participants feel confident in their ability to provide home care. Regular, ongoing support continues after training. Trained health care volunteers and nursing staff make home visits to monitor patients, supervise caretakers, and provide medicines for common ailments, such as diarrhea, fever, cough, and skin diseases. Groups of 30 grandparents also meet monthly to discuss their needs and concerns and to receive additional information on caring for themselves and their grandchildren as well as HIV-infected family members.

Grandmothers also benefit from Sanpatongs community mobilization component, which encourages entire villages to accept and participate in the care of people with HIV/AIDS and their families. The project involves village leaders and holds monthly meetings in local houses, village halls, and health centers to encourage neighbors to support one another. Community involvement relieves some of the burden borne by family members, both by providing them with additional help and by reducing the stigma associated with HIV/AIDS. Communities are encouraged to continue helping affected families, including orphans, even after the patient dies.

Caring for AIDS patients and orphans makes tremendous financial demands on families. Therefore, the project also tries to offer financial assistance. For example, the project has established a store at the district hospital to sell handicrafts made by people infected with HIV. The project also uses donated money and goods to provide families with blankets, clothing, and food and to pay school fees for AIDS orphans.

Lessons learned include:

  • Trained family members, including grandmothers, are capable of assuming the day-to-day care of large numbers of people with HIV/AIDS at low monetary and administrative costs.
  • It is more efficient to train people with HIV/AIDS and their families in the basics of home care in the early stages of the illness, before symptoms appear and while they are still functioning normally.
  • Involving the formal health system, that is, the Thai Red Cross, Chiang Mai public health staff, and the Faculty of Medicine at Chiang Mai University, safeguards the quality of home care services.

For further information about the Sanpatang Home Based Care Project and "Grandma Cares," please contact:
Mrs. Somboon Suprasert, Charter President of the Zonta International Chiangmai Club, 464 Moo 3, Chiangmai Lamphun Rd, Tambon Nonghoi, Chiangmai Thailand 50000
Telephone: 0-5380-1232, 01-951-0888; Fax: 0-5332-1969; Email: [email protected]

This profile is based in part on: UNAIDS. Comfort and Hope: Six Case Studies on Mobilizing Family and Community Care for and by People with HIV/AIDS. Geneva: UNAIDS (1999). Available in English, French, and Spanish at: www.unaids.org/en/other/functionalities/ViewAllLanguages.asp?href=http%3a%2f%2fgva-doc-owl%2fWEBcontent%2fDocuments%2fpub%2fPublications%2fIRC-pub01%2fJC099-Comfort_Hope_en%26%2346%3bpdf&Type=pdf.

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Ukraine

Breast cancer is the leading cause of cancer death among women in Ukraine. In 1998 there were 14,615 new cases of breast cancer and more than 8,000 deaths nationally—which reflects a six percent increase in incidence since 1992. Late detection of the disease contributes to high mortality rates. Only 12 percent of new breast cancer cases in Ukraine are detected in the first stage, when treatment is most successful and least traumatic; about one-third are not identified until after the cancer has spread outside the breast.

To strengthen breast cancer services in Ukraine, PATH organized a team of U.S. specialists to work with breast cancer diagnosis and treatment centers in several Ukrainian cities and with the Pathology and Oncology Departments of Lviv State Medical University. The Ukraine Breast Cancer Assistance Project began in 1997 with a two-week assessment visit by the U.S. team, a systematic information-gathering exercise, and several baseline surveys. Based on the assessment findings, project partners agreed on the following three goals:

  • Improving the quality of breast cancer services for screening, diagnosis, treatment, and rehabilitation;
  • Increasing the utilization of services by women at risk, especially those exposed to radiation from the Chornobyl accident; and
  • Enhancing the cost-effectiveness of breast cancer services at existing facilities and within current resource constraints.

To improve the quality of services, training activities for health workers were conducted both within Ukraine and abroad. They included a U.S. study tour, visits to Poland, fellowships, skills workshops, medical symposia, conferences, and medical literature dissemination. To enable health workers to apply their newly learned skills, service sites were furnished with basic equipment and supplies for mammography, ultrasound, pathology, surgery, and chemotherapy.

To increase patient understanding and public awareness of breast cancer, the project developed informational materials, facilitated public awareness campaigns, and supported efforts to address the psychosocial needs of patients and families. These efforts eventually gave rise to innovative and successful community- and facility-based survivor support and outreach programs. Project staff found that breast cancer patients wanted to know their diagnosis and talk openly with health care professionals about their disease, which was a major break with accepted medical practice in Ukraine. To promote psychosocial support for breast cancer survivors, the project facilitated the womens efforts to organize and link survivors with established international groups.

To strengthen the health infrastructure, the project provided the National Cancer Registry with a computer and fax-modem, technical assistance, and support for central registry staff to work with staff at the oblast level. A pilot program for the early detection of breast cancer in Chernihiv also modified the local health information system to collect data on the outcome of clinical breast exams.

To influence national and local policies and practice guidelines, project activities demonstrated effective approaches to combating breast cancer. For example, a pilot program deployed an early detection strategy using both clinical breast exams and mammography, while a clinical trial tested an international standard-dose chemotherapy regimen. Other activities demonstrated the value of immunocytochemistry (ICC) methods for better diagnosis as well as the feasibility of survivor outreach and advocacy initiatives.

During the course of the project, Ukrainian participants developed growing connections with colleagues and volunteer partners in Poland, the Czech Republic, Russia, and Belarus. Regional activities proved strategically effective because of the history, problems, and organizational structures shared by these nations.

Lessons learned from the Ukraine Breast Cancer Assistance Project include:

  • Medical approaches from other areas should not be adopted without careful analysis of their appropriateness to the local situation.
  • A team approach to clinical care is feasible and cost-effective. Effective clinical care depends upon the coordination of services including reliable pathology, appropriate surgical care, chemotherapy, and radiotherapy.
  • Most breast cancer patients want to be told their diagnosis and to communicate openly with health care professionals about their disease.
  • Links with neighboring countries can provide useful and relevant experience and knowledge.

When the Ukrainian Breast Cancer Assistance Project closed in September 2000, many needs were not yet fully addressed but its achievements will endure. Health workers, patients, and the general public were exposed to new ideas that will influence their perceptions and attitudes for years to come. Similarly, training activities and tools—including curricula, learning aids, print and audiovisual materials, and medical equipment—have made a lasting impact on provider skills. New and strengthened institutional structures, such as breast cancer survivor groups, the early detection working group, and cancer registries, will carry on the work begun by the project.

For further information, please contact:
Amie Bishop, Senior Program Officer and Ukraine Country Manager, PATH,1455 NW Leary Way, Seattle, WA 98107-5136, USA
Telephone: 206-285-3500; Fax: 206-285-6619; Email: [email protected]

Dr. Kateryna Gamazina, PATH Ukraine, 18/2, Kruglouniversytetska St., Apt. 2, 01024 Kyiv, Ukraine
Telephone: 380-44-293-2409; Fax: 253-9028/56/68; Email: [email protected]

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