During 2008, CHSR has continued working with Emerging Markets Group (EMG) on the 5-year USAID supported Primary Health Care Reform Project. CHSR mainly contributed to the project’s research, monitoring and evaluation components. Tsovinar Harutyunyan (Monitoring and Evaluation Director) and Anahit Demirchyan (Senior Research Director) have been the key local staff members involved FT in this project. Tsovinar Harutyunyan left the project for doctoral studies at the University of North Carolina at Charlotte, and Yelena Amirkhanyan replaced her in the position of the M&E Director. Within this project, CHSR assessed the ASTP achievements to develop recommendations for the current Primary Health Care Reform Project. The CHSR team has finished the baseline primary care facilities assessments and client satisfaction surveys in Lori, Shirak, Kotayk, Tavush, Gegharkunik, Aragatsotn, Artashat, and Armavir marzes targeted by the PHCR Project in the first, second and third years, and the nationwide health household survey. Overall, the CHSR/AUA team developed 14 reports during the first three years of the project (8 of them were developed in 2008). Currently, theses reports are being translated into Armenian and prepared for publication. The CHSR team has worked on the development of the MIS system and Performance Management Plan (PMP) for the entire project for the years 2006, 2007, 2008, and 2009, and provided consultancy to the project regarding the design and data analysis of small-scale research periodically conducted by different teams in the project.
Humanitarian Assistance Program for Nagorno Karabakh: Primary Health Care Trainings
The Center for Health services Research and Development (AUA/CHSR) organized the health-oriented training program as part of the United States Agency of International Development funded Humanitarian Assistance Program for Nagorno Karabagh that was led implemented by the Fund for Armenian Relief. It helped to ensure that the people of Nagorno Karabagh (NK) receive timely and effective primary care, emphasizing the most common conditions that threaten their well-being.
The comprehensive health training program addressed integrated management of childhood illnesses (IMCI); management of adult diseases (ADM); and health promotion/patient counseling skills (PCS). The IMCI training addressed the most common conditions affecting children: respiratory infections, diarrhea, nutritional problems, anemia, prophylaxis of intestinal worms, burns and traumas, skin diseases, and ear and throat infections. ADM training addressed diagnosis and treatment of the most common conditions affecting adults: respiratory infections, cardiac diseases, urinary tract infections, skin diseases, burns and traumas, and gastro-intestinal diseases. The patient counseling skills training enabled health professionals to effectively communicate with, educate, and motivate patients and community members in healthy habits and management of their illnesses.
In 2006, 265 nurses and 35 doctors throughout NK completed basic first aid and emergency skills training by the Armenian Red Cross Society. By 2007, 86 nurses/feldshers and 10 doctors had completed the clinical IMCI training. From May-November 2007, AUA/CHSR team trained nearly 150 providers on ADM, and over 250 providers in patient counseling and health communication skills.
In 2008, nearly 600 villagers from 32 villages were trained in community-IMCI to promote healthy lifestyles and to encourage caregivers to seek appropriate medical care when necessary.
The AUA/CHSR team was led by Drs. Michael Thompson and Alina Dorian. They were supported by experts such as Dr. Ara Tekian from the University of Illinois at Chicago, Dr. Sonia Arushanyan, Armenia’s IMCI expert, Dr. Aram Kaligian, a family physician from Boston, and a dedicated cadre of local trainers and professional staff.
These training programs, designed to meet international standards and conform to local needs and resources, help ensure that the people of Nagorno Karabagh receive timely and effective primary care, emphasizing the most common conditions that threaten their well-being.
Public Health Services Assessment and Restructuring
In collaboration with the MOH and WHO Country Office the CHSR started working on the Assessment of PH Services in Armenia (fall 2008). The objectives of this project include:
To map out and analyse the current public health services, to identify their strengths and weaknesses in order to design a detailed strategy and plan for the reform and modernization of the PH services and for further integration of disease prevention and health promotion services at the primary health care level.
To review the international evidence and to build up a modern understanding of public health services (definition, scope, boundaries, domains, areas, operations, services, players, integrative approaches, etc.);
To learn about relevant experience and lessons learned from other European countries for improving the public health services of the health system;
To discuss and agree on thepolicyoptions for reforming, streamlining, modernizing and upgrading the individual and population-based public health services.
The project will be completed by the end of spring 2009.
TB Services Assessment in Armenia: Stakeholder Analysis
In May-November 2008, CHSR conducted analysis of the TB control system in Armenia in both the civilian and penitentiary sectors and made recommendations for improvement, as a consultancy on reviewing the Health System Strengthening component of the TB Control in Prisons Program in Armenia, a part of the “Hand Over Take Over (HOTO) Process Review” by ICRC. The report was based on international and local document review, stakeholder qualitative analysis, and review of legislative and regulatory approaches to TB Control in Armenia and Europe. Currently, the HOTO report is in the process of finalization. After ICRC gets approval from the Ministers of Health and Justice, the report will become publicly available.
Garo Meghrigian Institute for Preventive Ophthalmology
In June 2008, the Garo Meghrigian Institute for Preventive Ophthalmology finished the joint project with the Ararat Lions Club (ALC) {funded by Lions Club International Foundation} to establish the Lions Regional Ophthalmic Unit (ROU) in Sevan and a supporting screening and financing system. The core medical staff went through local and international training; the ROU building was renovated; all the necessary equipment was purchased and installed. In August 2005, the ROU started functioning at its minimal capacity. With great difficulties, in June 2007, the ROU was registered as an independent legal entity “Lions Regional Ophthalmic Unit.” It went through MOH licensing process and started surgeries in February 2008. Between February and June 2008, the Sevan ROU operated 228 patients of age 50 and over. For the duration of this project, 11,000 residents of Gegharkunik Marz received eye care services and screenings.
In August 2008, Meghrigian Institute screened 242 children of age 4-17 in 2 summer camps located in Vandazor (“Tsitsernak” camp) and in Dilijan (“Tiezerk” camp). These children were selected by World Vision Armenia as children from socially vulnerable families to spend 10 days in the summer camp. Face-to-face interviews, a basic eye exam, and simple anthropometric measurements were administered to all participants. Sixty three children (26.0%) were referred for more detailed examinations and/or treatment of suspected eye pathologies. Twenty five children (10.3%) received a pair of prescription glasses. The project staff educated children about how to wear and care for glasses as well as assisted them in selecting frames.
In October 2008, GMEIPO organized a 2-day ophthalmic training of 8 primary care nurses working in schools of Ghegharkunik marz (Vardenis and Martuni regions). The aim of these trainings was to strengthen eye care capacity of school health offices in Gegharkunik and raise public awareness of childhood blindness as an important health issue. This was a continuation of nurse trainings that started in 2007 (51 nurses were trained then).
In October 2008, the Garo Meghrigian Institute for Preventive Ophthalmology joined the celebration of World Sight Day. This year the Meghrigian Institute celebrated World Sight Day with the Yerevan Municipality Evening Boarding School for Blind and Visually Impaired Adults. On October 9 and 10 the Meghrigian Institute’s ophthalmic consultants provided detailed eye screening to 111 attendees (age range 16-60) of the boarding school. All visually impaired people in need (38 attendees) received prescribed eye glasses.
The Meghrigian Institute has also donated to the Boarding School a computer with a scanner, printer, headphones, and speakers; “Arev” software was installed on this computer. “Arev” software allows blind people to read books and use the internet in Armenian, Russian or English languages without assistance. Through the scanner the desired text is imported into the computer, letter images are converted into voice and the user can listen the text. With this software blind people can also compose music or play chess improving their quality of life. The Meghrigian Institute also supported the training of two representatives of the Boarding School in using “Arev” software.
In October-November 2008, Meghrigian Institute in collaboration with the Lions Regional Ophthalmic Unit (ROU) in Sevan organized two outreach visits in remote and poor villages of Tavush marz (Haghartsin and Gandzaqar). The village population was invited for eye screenings to identify eye pathologies, prescribe glasses, and provide frames as needed. In case of having other than refraction error eye pathologies the Meghrigian Institute ophthalmologist referred the residents of these villages for detailed diagnosis and/or treatment to the ROU in Sevan. Overall, 50 people from Haghartsin and 34 from Gandzaqar participated in the eye screenings; 49 had different types and degrees of refraction errors and were prescribed glasses. In addition to prescription for glasses, they received frames which would help them to order glasses in the optics.
CHSR Tobacco Control Projects:
I. Tobacco control policy monitoring and evaluation project.
Timeframe: February 1, 2008 - November 31, 2008.
Funding agency: Open Society Institute Assistance Foundation Armenia
The Project’s main accomplishments in 2008 included preparing and publishing “Analytical Review of Tobacco Control Policy in Armenia 2005-2007,” monitoring of tobacco control policy implementation in four cities of Armenia and support of the Coalition for Tobacco Free Armenia activities, including the Coalition’s 3rd National meeting. During the 3rd National meeting of the Coalition for Tobacco Free Armenia CHSR presented the findings and policy recommendations based on the “Analysis of Tobacco Control Policy in Armenia 2005-2007” and organized two discussion sessions: 1) Future Strategies for Tobacco Control and 2) Evaluation of Targeted Health Programs in Armenia.
The following activities were accomplished within this project:
Legal analysis of the national anti-tobacco law (“On Limitations of Tobacco Sale, Consumption and Use”) and its enforcement mechanisms;
Review of the official documents to identify strengths and weaknesses of the national tobacco control strategy;
A series of in-depth interviews and qualitative data analysis;
Discussion of the preliminary findings and recommendations with state officials and civil society organizations;
Publication of the evaluation report on the tobacco control policy in Armenia 2005-2007 with policy recommendations;
Organization of the monitoring training and implementation of tobacco control policy monitoring activities in Yerevan, Gyumri, Vanadzor and Goris;
Organization and hosting of the 3rd Annual National Meeting of the Coalition for Tobacco Free Armenia
II. Developing guidelines for health professionals to treat tobacco use and dependence in Armenia.
Timeframe: May 1, 2008 - November 1, 2008.
Funding agency: WHO Country Office.
The CHSR has provided consultancy on elaborating the guidelines on tobacco dependence treatment for Armenian health professionals.
III. FCTC “Building NGOs monitoring capacities to support FCTC implementation in Armenia”
Timeframe: June 1, 2008 – May 31, 2010
Funding agency: American Cancer Society, Cancer Research UK, and the Framework Convention Alliance.
The goal of the project is to build monitoring capacities of non-governmental organizations involved in tobacco control in Armenia through an interactive training seminar and field work.
It is a two-year project; the activities in 2008 were mostly preparatory.
IV. Epidemiology and intervention research for Tobacco Control in Armenia
In 2008, CHSR has collaborated with Johns Hopkins Institute for Global Tobacco Control (JH IGTC) on a three-year research grant project, aimed at reducing the SHS exposure in Armenia.
The first phase of the project includes a demonstration project in selected worksites in Yerevan (Year1) and a clinical trial to reduce SHS exposure in homes (Year 2). The Center for Excellence for Tobacco Control Research and Advocacy will be established in the second phase of the project (Years 2&3) in collaboration with the JH IGTC to train collaborators in neighboring countries on the protocols developed in the demonstration project and the clinical trial. Activities in 2008 included review of research instruments and research design and preparing an IRB application via e-communication and conference calls.
Pilot HIV-Risk Reduction Behavioral Intervention for Commercial Sex Workers in Yerevan, Armenia
The project’s purpose was to pilot-test a theory-based culturally appropriate HIV-risk reduction behavioral intervention with a cohort of Armenian female commercial sex workers (FCSW). The goal of the intervention was to favorably change in Armenian FCSWs HIV-risk and protective behaviors (with condom use as a primary focus) through provision of appropriate information and development of their motivation and capacity to maintain or adopt low-risk/protective behaviors. Evaluation of the results utilized a randomized control trial (RCT) design to assess the outcomes of the project at baseline, as well as after three and six months following the intervention.
Between October 2006-July 2007 the collaborative US-Armenian staff prepared the study materials, hired and trained the staff, and rented and equipped the project site. The field work took place from August 2007 to July 2008. Of 168 self-identified street FCSWs screened by outreach workers, 120 met eligibility criteria, provided informed consent, completed baseline assessments and were randomized to study groups (54-intervention, 66-control). At baseline, the intervention and control groups were comparable in terms of sociodemographic characteristics, psychosocial mediators linked to HIV-preventive behaviors and sexual behaviors. Of the 54 participants assigned to the HIV intervention group, 49 completed the 3-month assessment and 48 completed the 6-month assessment. Of the 66 participants allocated to the waitlist control group, 58 completed the 3-month assessment and 50 the 6-month assessment. At each assessment, trained surveyor administered face-to-face interviews with the participants in a private room. The interviews lasted approximately 30-40 minutes.
An Armenian Health Educator who was trained by professional health educator from Emory University conducted the two-hour intervention based on multiple models of behavior change. Women randomized to the control group (n=66) were offered the same intervention after the 6-month follow-up assessment was complete.
It was one of the first randomized, controlled trials performed with commercial sex workers, a difficult to reach population. The Armenian research team gained valuable experience in rigorous and ethical evaluation methods and cutting-edge HIV-prevention theory. The results suggest that theory of behavior change developed in industrialized societies can help guide interventions internationally, if targeted appropriately. This study demonstrated that behavioral interventions can be effective even among disempowered, HIV high-risk populations. The project resulted in lower HIV-risk for Armenian FCSWs. Findings suggest that a similar program should be incorporated into national HIV prevention strategies. Similar interventions could be recommended for other Caucasian nations where commercial sex workers operate within similar social and political structures.
Health Awareness in Armenia: a Qualitative Study (Academy for Educational Development)
In June 2008, the AED contracted the CHSR to conduct a series of eight focus group discussions (FGD) as a part of the review being conducted by USAID in three countries: Kyrgyzstan, Albania, and Armenia. The purpose of this review was to determine ways in which USAID can help the governments of different countries to promote better awareness about health care, prevention and the health services available.
The semi-structured FGD guide was provided by the AED. The CHSR team translated it into Armenian and pre-tested with two focus groups: women aged 20-40 and over 40 years old. After the pre-test, minor modifications were made and two questions were added regarding participants’ awareness about most recent public education campaigns and about the best information channels to reach large group of population. The FGD participants were selected in accordance with the AED requirements:
People who have used the health care system in the last year
Public users vs. private users
Urban/rural
Sex and age variables
1 male groups - urban - age 20-40
1 male groups - urban – age 40+
1 female group - urban - age 20-40
1 female group - urban - age 40+
1 male groups - rural - age 20-40
1 male groups - rural – age 40+
1 female group - rural - age 20-40
1 female group - rural - age 40
Healthy Food and Lifestyle book translation/publication
CHSR translated and published Arpi A. Simonian’s book on Healthy Food and Lifestyle. Besides translation from English, the CHSR adapted the book content to the Armenian situation; later the AUA Digital Library editorial staff proofread the text. The project started in February 2008 and 1000 copies of the book were printed in Armenian. CHSR is responsible for disseminating the book among Armenian female population, particularly from the regions.
On-line Courses
Currently, the CHS has 5 on-line courses developed within different CHSR projects: Basics of Health Planning, Malaria, Health Systems in Transition, Human Participant Protections, and Basic Epidemiology.
