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Full-Text Articles in International Public Health

Rights, Technology, And Services In Reproductive Health: A Report From A Meeting, Marion Carter, C. Elizabeth Mcgrory Jan 2000

Rights, Technology, And Services In Reproductive Health: A Report From A Meeting, Marion Carter, C. Elizabeth Mcgrory

Reproductive Health

The Population Council’s Robert H. Ebert Program on Critical Issues in Reproductive Health convened a two-day meeting to explore some of the compelling issues at the intersection of technology, services, and rights. Nearly 70 professionals from the research, policy, service delivery, human rights, and advocacy fields came together to grapple with some of the political aspects of reproductive technologies. Participants also discussed how these technologies can facilitate or constrain rights, depending on the interests involved and the particular social, political, and economic contexts in which they are used. This report on the meeting concludes that in order for program managers …


Enhancing The Use Of Emergency Contraception In A Refugee Setting: Findings From A Baseline Survey In Kakuma Refugee Camps, Kenya, Esther G. Muia, Joyce Olenja Jan 2000

Enhancing The Use Of Emergency Contraception In A Refugee Setting: Findings From A Baseline Survey In Kakuma Refugee Camps, Kenya, Esther G. Muia, Joyce Olenja

Reproductive Health

In August 1992, the International Rescue Committee (IRC) at the request of the United Nations, the United Nations High Commission for Refugees, and the Kenyan Government, initiated a primary health care program in the Kakuma Refugee Camp. Since then, the population of the camp has continued to grow, and activities have moved from a crisis to a maintenance phase. In January 1997, IRC assumed the additional responsibility of the camp hospital, bringing the entire health sector under their management. IRC's programs focus on maintaining and improving public health and promoting self-reliance, particularly of the most vulnerable communities. This project focuses …


Case Finding And Case Management Of Chlamydia And Gonorrhea Infections Among Women: What We Do And Do Not Know, Nicole Haberland, Beverly Winikoff, Nancy L. Sloan, Christiana Coggins, Christopher J. Elias Jan 1999

Case Finding And Case Management Of Chlamydia And Gonorrhea Infections Among Women: What We Do And Do Not Know, Nicole Haberland, Beverly Winikoff, Nancy L. Sloan, Christiana Coggins, Christopher J. Elias

Reproductive Health

As the world grapples with the HIV pandemic, the implementation of the agenda determined by the International Conference on Population and Development (1994) at Cairo, and the matter of providing health services of adequate quality in an ethical, gender-sensitive manner, new questions are arising about how to attend to reproductive tract infections, including sexually transmitted infections (STIs), among women. This paper reviews the results of validation studies of syndromic algorithms, other nonlaboratory clinically based tools, and risk scoring for finding women infected with chlamydia and gonorrhea, particularly among those attending family planning and antenatal clinics in developing countries. The results …


The Costs Of Integrating Reproductive Health Services: An Example Using Syndromic Management Of Stis In Family Planning Clinics In Zimbabwe, Baker Ndugga Maggwa, Ian Askew, Caroline S. Marangwanda, Barbara Janowitz, Laura Johnson, Andrew Thompson, Caroline West Jan 1999

The Costs Of Integrating Reproductive Health Services: An Example Using Syndromic Management Of Stis In Family Planning Clinics In Zimbabwe, Baker Ndugga Maggwa, Ian Askew, Caroline S. Marangwanda, Barbara Janowitz, Laura Johnson, Andrew Thompson, Caroline West

Reproductive Health

Estimates from the United Nations Population Fund indicate that the costs of family planning (FP) and other reproductive health (RH) services are increasing and that it will be difficult for donors and countries to meet these costs. Many institutions delivering RH services operate significantly below their physical capacity to see clients, and much of the equipment required for expanding RH services may already be available for use. The marginal costs of adding infrastructure could be low. Many institutions have staff that are not fully occupied, and thus the staff necessary to expand RH services may also be in place. In …


Expanding Men's Participation In Reproductive Health In Kenya, Bolaji M. Fapohunda, Naomi Rutenberg Jan 1999

Expanding Men's Participation In Reproductive Health In Kenya, Bolaji M. Fapohunda, Naomi Rutenberg

Reproductive Health

To increase men’s participation in family planning (FP) and reproductive health (RH) both for their own well-being and as gatekeepers to women’s health, the African Population Policy Research Center and the Population Council’s OR/TA Project II launched a study designed to explore best practices for delivering services to men. The study examined men’s knowledge, perceptions, and concerns about RH issues, including FP, and the social context of their knowledge. In sub-Saharan Africa, FP and reproductive health-care research and interventions place a disproportionate emphasis on women and largely ignore the role of men. As a result, male participation in FP and …


Testing Strategies To Improve Access To Emergency Contraception Pills: Prescription Vs. Prophylactic Distribution, John P. Skibiak, Yusuf Ahmed, M. Ketata Jan 1999

Testing Strategies To Improve Access To Emergency Contraception Pills: Prescription Vs. Prophylactic Distribution, John P. Skibiak, Yusuf Ahmed, M. Ketata

Reproductive Health

This report is the second in a series of research summaries produced in connection with the operations research project “Enhancing Access to Family Planning Services through the Introduction of Emergency Contraception.” Launched in September 1997, the project explores the many issues surrounding the introduction and delivery of emergency contraception services in a developing country context. The study described in this report compares two different approaches to overcoming barriers that prevent women from accessing emergency contraception during the 72-hour period when the first dosage of emergency contraception pills (ECPs) must be taken. In one approach, new family planning (FP) acceptors were …


Integrating Sti And Mch/Fp Services, Population Council Jan 1999

Integrating Sti And Mch/Fp Services, Population Council

Reproductive Health

The integration of STI and HIV/AIDS information and services into existing MCH/FP programs has been strongly supported in recent years, following recommendations from the 1994 Cairo ICPD. Moreover, it is now widely accepted that early detection and management of STIs can reduce the incidence of HIV infection. Thus, there are powerful incentives to increase efforts to broaden the capacity of MCH/FP programs to provide STI prevention and management information and services for their clients, both as a comprehensive reproductive health service and as a preventive measure for reducing the transmission of HIV. As described in this brief, the Africa OR/TA …


Strengthening Reproductive Health Services In Africa Through Operations Research, Population Council Jan 1999

Strengthening Reproductive Health Services In Africa Through Operations Research, Population Council

Reproductive Health

The health status of women, men, and children in sub-Saharan Africa remains the poorest in the world. Moreover, virtually every country in the region is suffering mediocre economic growth or economic decline, thereby reducing the ability of their health care systems to respond adequately, and increasing dependence on external donor assistance. In terms of reproductive health (RH), the region is faced with high levels of unwanted fertility; high levels of maternal, child, and infant morbidity and mortality; and an almost exponential growth in HIV prevalence. Access to and quality of RH services remains poor in most countries, thereby maintaining unmet …


Reproductive Decisionmaking In The Context Of Hiv/Aids In Ndola, Zambia, Naomi Rutenberg, Ann E. Biddlecom, Frederick A.D. Kaona Jan 1999

Reproductive Decisionmaking In The Context Of Hiv/Aids In Ndola, Zambia, Naomi Rutenberg, Ann E. Biddlecom, Frederick A.D. Kaona

Reproductive Health

Family planning (FP) programs are increasingly being considered as a logical focal point for STD and HIV/AIDS prevention services because they serve large numbers of women at risk, address the sensitive issue of sexual behavior and fertility control, and the methods for preventing unwanted pregnancy and disease can be the same. FP programs, by providing contraceptive methods, are currently one of the few sources of assistance in the sub-Saharan African region for preventing perinatal transmission of HIV, while the promotion of barrier methods contributes to the prevention of heterosexual transmission. Given this potential, research is needed to understand how the …


Improving Quality Of Care In India's Family Welfare Programme: The Challenge Ahead, Michael A. Koenig, M.E. Khan Jan 1999

Improving Quality Of Care In India's Family Welfare Programme: The Challenge Ahead, Michael A. Koenig, M.E. Khan

Reproductive Health

This book on family planning in India includes detailed empirical data and analysis of the various dimensions of quality of care in different regions of the country. Focus areas include: women’s perceptions of the care they receive; observations of provider-client interactions; barriers to quality of service delivery; existing interregional variations; contraceptive choice and interpersonal relations; technical quality of care; and the effect of the target system on the work style of outreach staff. All elements of the quality-of-care framework elaborated by Judith Bruce are well documented and their relationships to broader program constraints are clearly identified. The overall impression one …


Investigación Operativa En Planificación Familiar: Lecturas Selectas, James R. Foreit, Tomas Frejka Jan 1999

Investigación Operativa En Planificación Familiar: Lecturas Selectas, James R. Foreit, Tomas Frejka

Reproductive Health

Desde que existen los programas de planificación familiar existe la investigación sobre este tema. En el nivel teórico, los investigadores examinan el efecto de la fertilidad sobre la salud y el desarrollo socioeconómico y estudian los determinantes de la fecundidad para los individuos y la poblaciones. En el nivel de las políticas, los estudios exploran el papel que juegan los programas de planificación familiar en la modificación de la fecundidad y la salud. El desarrollo de nuevos anticonceptivos se acompaña de pruebas clínicas y pre-introductorias en el contexto de los programas. Se llevan a cabo encuestas para medir los cambios …


L'Approche De L'Analyse Situationnelle Pour L'Évaluation Des Services De Planification Familiale Et De Santé De La Reproduction: Manuel De Recherche, Robert A. Miller, Andrew A. Fisher, Kate Miller, Lewis Ndhlovu, Baker Ndugga Maggwa, Ian Askew, Diouratie Sanogo, Placide Tapsoba Jan 1999

L'Approche De L'Analyse Situationnelle Pour L'Évaluation Des Services De Planification Familiale Et De Santé De La Reproduction: Manuel De Recherche, Robert A. Miller, Andrew A. Fisher, Kate Miller, Lewis Ndhlovu, Baker Ndugga Maggwa, Ian Askew, Diouratie Sanogo, Placide Tapsoba

Reproductive Health

Une bonne prestation de services de planification familiale mettant l'accent à la fois sur l'accès et la qualité est la clé des objectifs interdépendants de satisfaction des besoins individuels et la réalisation du succès programmatique. L'analyse de situation (AS) fournit un lien nécessaire entre le responsable de programme et la cliente qu'il essaie de servir. Les données recueillies par l’AS offrent une image représentative du fonctionnement des composantes et permettent de «voir» l'expérience de la cliente. Les analyses situationnelles aident le responsable de programme à atteindre le plus grand but en termes de gestion—celui d’une administration efficace d'un service de …


Reproductive Health Indicators: Moving Forward, Kelly Blanchard, Batya Elul, Saumya Ramarao Jan 1999

Reproductive Health Indicators: Moving Forward, Kelly Blanchard, Batya Elul, Saumya Ramarao

Reproductive Health

This report is designed to help researchers, program managers, policymakers, and advocates sift through and evaluate which potential indicators might be useful in a particular programmatic context. It was initially prepared as a background manuscript for a Population Council meeting on reproductive health indicators held in Cairo in March 1998. The manuscript has since been modified to incorporate ideas and comments expressed at that meeting, as well as to include input from other Population Council colleagues.


Implementing A Reproductive Health Agenda In India: The Beginning, Saroj Pachauri Jan 1999

Implementing A Reproductive Health Agenda In India: The Beginning, Saroj Pachauri

Reproductive Health

At the International Conference on Population and Development (ICPD) in 1994, the nations of the world agreed to give special attention to girls’ education, women’s health, infant survival, and women’s empowerment, and to provide comprehensive reproductive health (RH) services to enable couples to achieve their reproductive goals. The government of India launched a reproductive and child health program in October 1997. This book begins a review of the processes underway to operationalize the program. It brings together several important initiatives at various stages of development and examines key policy and program issues based on empirical research and field experience. The …


Comparing Alternative Products In The Provision Of Emergency Contraception, John P. Skibiak, Yusuf Ahmed, M. Ketata Jan 1999

Comparing Alternative Products In The Provision Of Emergency Contraception, John P. Skibiak, Yusuf Ahmed, M. Ketata

Reproductive Health

This report is the third in a series of summaries produced in connection with the operations research project “Enhancing Access to Family Planning Services through the Introduction of Emergency Contraception.” Launched in September 1997, the project explores the many issues surrounding the introduction and delivery of emergency contraception services in a developing country context. The study compares the introduction of two different emergency contraception pills—the combined oral contraceptive PC-4, introduced in Zambia in 1997, and the progestin-only contraceptive Postinor-2, introduced by this study in the following year. Client histories showed only minor differences in the attitudes of emergency contraception users …


Manuel De Recherche Opérationnelle En Matière De Planification Familiale, Andrew A. Fisher, John E. Laing, John E. Stoeckel, John Townsend Jan 1998

Manuel De Recherche Opérationnelle En Matière De Planification Familiale, Andrew A. Fisher, John E. Laing, John E. Stoeckel, John Townsend

Reproductive Health

Le Manuel de recherche opérationnelle en matière de planification familiale, publié pour la première fois en anglais par le Population Council en 1984, se basait sur des projets de recherche en Asie. Cette seconde édition contient des sections révisées et développées. Le cas échéant, des exemples d'Amérique latine et d'Afrique ont été ajoutés. Le chapitre d'introduction comprend une exposé actualisé sur le processus de la recherche opérationnelle (RO) en matière de santé et planification familiale. De nouveaux chapitres concernent le choix du type d’intervention à tester dans une étude RO ainsi que les principaux éléments constituant un programme d'intervention. Le …


Reproductive Health Operations Research, 1995–1998, James R. Foreit, Federico R. Leon, Ricardo Vernon, Timothy D.N. King, Deborah L. Billings, A.B Friedman, Janie Benson Jan 1998

Reproductive Health Operations Research, 1995–1998, James R. Foreit, Federico R. Leon, Ricardo Vernon, Timothy D.N. King, Deborah L. Billings, A.B Friedman, Janie Benson

Reproductive Health

This book presents in-depth reports on promising new interventions that have been developed and important programmatic changes that have been achieved by operations research in Latin America between 1995 and 1998. The INOPAL III project has made advances in five areas including access and quality of services, integration of family planning and other reproductive health services, financial sustainability, post-abortion care, and emergency contraception. Each of these topics are represented by at least three studies conducted in two or more countries. The operations research projects discussed under each topic are not replications of a single study. They use different research designs …


Peru Logistics Chain Analysis, Jeanne Noble, James R. Foreit Jan 1998

Peru Logistics Chain Analysis, Jeanne Noble, James R. Foreit

Reproductive Health

The inventory module of situation analysis, developed by the Population Council, has been adapted to help generate indicators of logistics system functioning suggested by the Evaluation Project and to provide an analytical framework that permits more accurate estimations of the frequency, location, and patterns of logistics problems. In 1996, the module was implemented in southern Peru. In 1997, the same module was implemented in the province of Santa and two provinces of Huancavelica. Comparable information was obtained from 149 service delivery points (SDPs) in four departments. Data include inventories of contraceptive supplies and materials required for safe delivery of contraception; …


An Assessment Of The Zimbabwe Family Planning Programme: Results From The 1996 Situation Analysis Study, Lewis Ndhlovu, Hazel M.B. Dube, Caroline S. Marangwanda Jan 1998

An Assessment Of The Zimbabwe Family Planning Programme: Results From The 1996 Situation Analysis Study, Lewis Ndhlovu, Hazel M.B. Dube, Caroline S. Marangwanda

Reproductive Health

Within the past ten years, the Zimbabwe National Family Planning Council (ZNFPC) has conducted two major studies for assessing the availability and quality of reproductive health services. The two studies, generally referred to as Situation Analysis studies, were conducted in 1991 and 1996. The 1996 survey collected data from 192 health facilities spread throughout Zimbabwe. During this exercise, an inventory of physical facilities, equipment, and educational materials was taken. In addition, 758 provider–client interactions of new and revisit clients were observed. Exit interviews were conducted with service providers, and with family planning and maternal and child health clients. In this …


Needs And Risks Facing The Indonesian Youth Population, Desti Murdijana Jan 1998

Needs And Risks Facing The Indonesian Youth Population, Desti Murdijana

Reproductive Health

Youth are the leaders of tomorrow, but right now they face a formidable collection of problems that will determine the quality of their future lives and the lives of us all. Education, jobs, substance abuse, violence, sexuality, and marriage are examples of adolescent issues that demand special attention from researchers, youth activists and advocates, parents, and policymakers. In attempting to address these complex issues, we must be willing to confront ignorance, controversy, and cultural obstacles. Clear and focused policy and strategies must play a basic role in tackling these issues facing Indonesian adolescents. This paper provides a concise situation analysis …


What Can Be Done To Foster Multisectoral Population Policies? Summary Report Of A Seminar, Population Council, Overseas Development Council Jan 1998

What Can Be Done To Foster Multisectoral Population Policies? Summary Report Of A Seminar, Population Council, Overseas Development Council

Poverty, Gender, and Youth

The 1994 International Conference on Population and Development in Cairo was a watershed moment in the definition of population policies. The meeting put an end to the unproductive debate on which is more instrumental in achieving voluntary fertility decline: providing family planning (FP) services or improving social and economic development. The answer was that both are essential. The Cairo meeting also defined the most desirable services and the kind of development that was most empowering, particularly with respect to achieving reproductive choice. Despite this strong dual message from Cairo, only the call for a move away from a narrow vision …


Continuing The Strengthening Of Situation Analysis Methodology: An Africa-Focused Approach, Robert A. Miller Jan 1998

Continuing The Strengthening Of Situation Analysis Methodology: An Africa-Focused Approach, Robert A. Miller

Reproductive Health

In 1995, the Population Council’s Africa OR/TA Project II proposed a three-year subproject to organize and strengthen the Situation Analysis methodology that had been developed by the first Africa OR/TA Project in 1989. This subproject proposed to concentrate on three areas of continuing importance in the African context: wider use of the established database to explore program issues in reproductive health (RH); synthesis of the knowledge that has been collected about African family planning (FP) programs into a monograph analyzing program issues, patterns of services, and their implications; and continued assistance in training and data processing on field studies. These …


On The Quantum And Tempo Of Fertility, John Bongaarts, Griffith Feeney Jan 1998

On The Quantum And Tempo Of Fertility, John Bongaarts, Griffith Feeney

Poverty, Gender, and Youth

Demographers have known since the 1940s that standard measures of period fertility, such as the widely used total fertility rate, are distorted by changes in the timing of childbearing. Period fertility rates are depressed during years in which women delay childbearing and inflated in years when childbearing is accelerated. This problem is usually ignored because there has been no generally accepted method for solving it. This study proposes a method for removing the tempo distortions from the total fertility rate. The key assumption of the method is that period effects, rather than cohorts effects, are the primary force in fertility …


Clinic-Based Family Planning And Reproductive Health Services In Africa: Findings From Situation Analysis Studies, Kate Miller, Robert A. Miller, Ian Askew, Marjorie C. Horn, Lewis Ndhlovu Jan 1998

Clinic-Based Family Planning And Reproductive Health Services In Africa: Findings From Situation Analysis Studies, Kate Miller, Robert A. Miller, Ian Askew, Marjorie C. Horn, Lewis Ndhlovu

Reproductive Health

The United States Agency for International Development (USAID) supported publication of “Clinic-Based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies.” The book reflects USAID's commitment to improving quality of reproductive health (RH) care and expanding access for underserved groups. Nowhere are these efforts more important than in Africa, where use of family planning (FP) and other measures of RH status are lowest among the world’s regions. Providing high-quality health services that meet couples' reproductive needs is a socially just and humane goal in itself. Moreover, higher-quality services can be expected to result in better outcomes …


Assessing The Quality Of Reproductive Health Services, Raeda Al Qutob, Salah Mawajdeh, Laila Nawar, Salama Saidi, Firas Raad Jan 1998

Assessing The Quality Of Reproductive Health Services, Raeda Al Qutob, Salah Mawajdeh, Laila Nawar, Salama Saidi, Firas Raad

Reproductive Health

This paper offers a broad definition of quality of care and presents a comprehensive conceptual framework for the assessment of quality of reproductive health services and methodological approaches for its measurement. It presents three studies that were conducted between 1990 and 1991 by members of the regional Reproductive Health Working Group from Egypt, Jordan, and Tunisia. The studies provide examples of applications of the framework and its measurement using multiple data sources. Selected findings are presented to illustrate comparative results between countries. Based on the lessons learned from the studies, examples of reproductive health interventions that may improve the quality …


Comparing Quality Of Reproductive Health Services Before And After Clinic-Strengthening Activities: A Case Study In Rural Burkina Faso, Direction De La Santé Et De La Famille (Dsf), University Of Ouagadougou Demographic Research Unit (Uerd), Mwangaza, Population Council Jan 1998

Comparing Quality Of Reproductive Health Services Before And After Clinic-Strengthening Activities: A Case Study In Rural Burkina Faso, Direction De La Santé Et De La Famille (Dsf), University Of Ouagadougou Demographic Research Unit (Uerd), Mwangaza, Population Council

Reproductive Health

Much literature has been written about improving the quality of reproductive health (RH) care at service delivery points (SDPs) because women deserve quality services, and as a means of increasing use of family planning (FP) and other RH services. There are six fundamental dimensions of quality of care: choice of methods, information given to clients, technical competence, interpersonal relations, mechanisms to encourage continuity, and an appropriate constellation of services. Improving these elements is thought to increase client satisfaction, resulting in an increase in contraceptive use and eventually fertility decline. Existing research has not convincingly demonstrated this link between quality of …


Strengthening The Utilization Of Family Planning Operations Research: Findings From Case Studies In Africa, Julie Solo, Annamaria Cerulli, Robert A. Miller, Ian Askew, Elizabeth Pearlman Jan 1998

Strengthening The Utilization Of Family Planning Operations Research: Findings From Case Studies In Africa, Julie Solo, Annamaria Cerulli, Robert A. Miller, Ian Askew, Elizabeth Pearlman

Reproductive Health

The goal of undertaking operations research (OR) on family planning (FP) and reproductive health (RH) services is to strengthen the ability of programs and policies to maximize access to and quality of these services. This report addresses the need for a greater understanding of how information from OR studies is utilized. The Africa OR/TA Project II undertook a study to assess the extent to which information from OR studies conducted under the Africa OR/TA Project I (1988–1993) was utilized. The study also examined the factors influencing how study results were utilized. Case studies of several OR projects were undertaken to …


Seminar On Male Involvement In Reproductive Health In Egypt: Summary Of Research Findings And Future Directions, Nahla G. Abdel-Tawab Jan 1998

Seminar On Male Involvement In Reproductive Health In Egypt: Summary Of Research Findings And Future Directions, Nahla G. Abdel-Tawab

Reproductive Health

As more work in the area of male involvement in reproductive health (RH) is expected in Egypt, it is important that researchers and donor agencies become aware of existing studies, topics covered, and main research findings so duplication can be avoided. It is also important that policymakers and program managers learn about the results of existing studies so they can use those results in designing more effective policies to increase male involvement in Egypt. To address this need, the Population Council’s ANE OR/TA Project organized a seminar on “Disseminating Results of Research on Male Involvement in Reproductive Health in Egypt” …


Analysis Of Price Change On The Perceptions And Use Of Dmpa Among Clients Using Reproductive Health Services In Uttar Pradesh, India, Leila Caleb-Varkey, John Townsend, Sneh Vishwanath, Sudha Tiwari Jan 1998

Analysis Of Price Change On The Perceptions And Use Of Dmpa Among Clients Using Reproductive Health Services In Uttar Pradesh, India, Leila Caleb-Varkey, John Townsend, Sneh Vishwanath, Sudha Tiwari

Reproductive Health

Depo-medroxy Progesterone Acetate (DMPA) is a progesterone-only injectable contraceptive that has been approved by the Government of India for provision in the commercial sector, where it is marketed under the brand name Depo-Provera. In 1996, it was available at rates between Rs. 140 to Rs. 180 per injection. At this price it is often beyond the reach of many women wanting a safe and effective contraceptive. In January 1996, DMPA was provided to women in three cities of Uttar Pradesh through Parivar Seva Sanstha’s (PSS) clinics at Rs. 150. In July 1996, as part of operations research (OR), the price …


Workshop On Youth Across Asia, John Townsend, Ann P. Mccauley, Kokila Agarwal Jan 1998

Workshop On Youth Across Asia, John Townsend, Ann P. Mccauley, Kokila Agarwal

Reproductive Health

The issues facing youth across Asia are as diverse as the cultures they represent. Issues involving schooling, employment, sexuality, and marriage take on increased significance for young people aged 10–24 in every country. Decisions made by youth and their families will dramatically affect their individual welfare. Few programs outside of public education systems exist at a sufficiently large scale to assist youth. Decisions to stay in school, opportunities to learn skills and manage resources, the exercise of sexual responsibility, and the process of family formation all impact both personal welfare and community development. Gender-equality issues compound many of the problems. …