Report No 81

USAID Ð²Ú²êî²ÜÆ êàòÆ²È²Î²Ü ´²ðºöàÊàôØÜºðÆ Ìð²¶Æð ARMENIA SOCIAL TRANSITION PROGRAM 14 êáõÝ¹ÏÛ³, ºñ¨ e -3175/69 g

REPORT NO 81

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPU- LATIONS IN ARMENIA

Prepared for Armenia Social Transition Program Prepared by The Center for Health Services Research and Development, American University of Armenia

July 29, 2002

PLANNING AND DEVELOPMENT COLLABORATIVE INTERNATIONAL Development Solutions for the 21st Century NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 2

PREFACE Under USAID Contract No. 111-C-00-00-00114-00, the Armenia Social Transition Program is providing assistance to the Government of Armenia to support the development of health promotion and education materials that can be used by primary care providers as a tool to improve the health status of vulnerable groups in Armenia. The development of these materials has been designed by the ASTP as a three-step process: Step 1: The conduct of a needs assessment to identify vulnerable groups in Armenia and their health problems/needs; Step 2: The design and modification of health education/health promotion materials; and, Step 3: The development of a curriculum for training health providers in the use of the health materials and the conduct a Training of Trainers course for Armenian Master Trainers in the use of the curriculum. This report represents Step 1 of this process. In this report, vulnerable population groups in Armenia are identified along with their major health problems and needs. The report concludes by presenting a list of recommended health topics that can be addressed through health education, followed by an exploration of channels for the delivery of these health education topics to vulnerable groups. This report has been prepared by the Center for Health Services Research and Development at the American University of Armenia.

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 3

TABLE OF CONTENTS

PREFACE ...... 2 TABLE OF CONTENTS...... 3 LIST OF ACRONYMS...... 5 EXECUTIVE SUMMARY...... 6 1. INTRODUCTION/BACKGROUND...... 9 1.1. ARMENIA SOCIAL TRANSITION PROGRAM (ASTP) ...... 9 1.2. ASTP PILOT SITES ...... 9 1.3. RESEARCH OBJECTIVES ...... 9 2. IDENTIFICATION OF VULNERABLE POPULATIONS IN ARMENIA...... 10 2.1. CHSR METHODOLOGY FOR IDENTIFICATION OF VULNERABLE GROUPS...... 10 2.2. REVIEW OF EXTANT AND PRIMARY DATA (BY METHODOLOGY)...... 11 2.2.1. The Paros System ...... 11 2.2.2. Family Poverty Benefit System...... 12 2.2.3. ASTP Poverty Assessment ...... 12 2.2.4. Assessment of Vulnerable Populations in the Region...... 14 2.2.5. Vulnerable Groups Identified by Government ...... 15 2.2.6. Vulnerable Groups Identified by NGO’s, Bi/Multi-Lateral Organizations...... 16 2.3. SYNTHESIS AND RECOMMENDATIONS ...... 17 3. HEALTH NEEDS OF VULNERABLE POPULATION GROUPS ...... 20 3.1. CHILDREN UNDER 5...... 20 3.1.1. General Health Problems...... 20 3.1.2. Health Problems of Socially Vulnerable Children...... 21 3.1.3. Health Education Programs – Caretakers of Children Under Five...... 22 3.1.4. Assessment of Health Problems/ Needs by Key Informants ...... 22 3.1.5. Recommended Topics for Health Education/ Promotion...... 23 3.2. PREGNANT/ LACTATING WOMEN...... 24 3.2.1. General Health Problems...... 24 3.2.2. Health Problems of Socially Vulnerable Pregnant Women ...... 26 3.2.3. Health Education Programs – Pregnant Women...... 26 3.2.4. Assessment of Health Problems / Needs by Key Informants ...... 27 3.2.5. Recommended Health Topics for Health Education/ Promotion ...... 27 3.3. ADOLESCENTS...... 28 3.3.1. General Health Problems...... 28 3.3.2. Health Problems of Socially Vulnerable Adolescents ...... 30 3.3.3. Health Education Programs - Adolescents ...... 30 3.3.4. Assessment of Health Problems/ Need by Key Informants...... 31 3.3.5. Recommended Topics for Health Education / Promotion...... 31 3.4. ELDERLY ...... 32 3.4.1. General Health Problems...... 32 3.4.2. Health Problems of Socially Vulnerable Elderly ...... 33 3.4.3. Health Education Programs - Elderly...... 34 3.4.4. Assessment of Health Problems/ Needs by Key Informants ...... 34 3.4.5. Recommended Topics for Health Education/ Promotion...... 35 3.5. SUMMARY OF RECOMMENDED TOPICS FOR HEALTH EDUCATION/PROMOTION MATERIALS FOR VULNERABLE GROUPS ...... 35

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 4

4. DELIVERY CHANNELS FOR HEALTH EDUCATION...... 36 4.1. HEALTH EDUCATION DELIVERY CHANNELS – CARETAKERS OF CHILDREN UNDER FIVE ...... 37 4.2. HEALTH EDUCATION DELIVERY CHANNELS – PREGNANT WOMEN...... 37 4.3. HEALTH EDUCATION DELIVERY CHANNELS – ADOLESCENTS ...... 37 4.4. HEALTH EDUCATION DELIVERY CHANNELS – ELDERLY ...... 37 4.5. HEALTH EDUCATION DELIVERY CHANNELS – SOCIALLY DISADVANTAGED GROUPS...... 38 4.6. SUMMARY OF HEALTH EDUCATION DELIVERY CHANNELS ...... 38 5. HEALTH EDUCATION/ PROMOTION MATERIALS AVAILABLE IN ARMENIA ...... 38 5.1. METHODS FOR COLLECTING AND CATALOGUING MATERIALS ...... 38 5.2. BRIEF SUMMARY OF MATERIALS COLLECTED ...... 39 6. CONCLUSIONS AND RECOMMENDATIONS ...... 39 6.1. GENERAL HEALTH EDUCATION/ PROMOTION NEEDS...... 40 6.2. DELIVERY CHANNELS FOR HEALTH EDUCATION/ PROMOTION...... 41 APPENDIX 1. DETAILED DESCRIPTIONS OF EACH METHODOLOGY...... 42 APPENDIX 2. IN-DEPTH INTERVIEW GUIDES...... 45 APPENDIX 3. QUESTIONNAIRE FOR THE COLLECTION OF INFORMATION ON EDUCATIONAL MATERIALS...... 55 APPENDIX 4. ORGANIZATION CONTACT INFORMATION SHEET ...... 60 APPENDIX 5. ORGANIZATIONS - HEALTH EDUCATION MATERIALS IN ARMENIA ...... 61 APPENDIX 6. SUMMARY OF HEALTH MATERIALS EXISTING IN ARMENIA ...... 68 Breastfeeding ...... 68 Cancer Prevention ...... 68 Cardiovascular Disease...... 68 Childcare ...... 68 Dental Care ...... 69 Diabetes ...... 69 Environmental Protection...... 69 First Aid...... 69 Health Policy ...... 70 Hygiene...... 70 Injury Prevention ...... 70 Malaria ...... 70 Mental Health ...... 70 Nutrition and Food Safety...... 71 People with Disabilities...... 71 Pharmaceuticals ...... 71 Physical Fitness ...... 71 Pregnancy...... 71 Reproductive Health ...... 72 Sexually Transmitted Infections including AIDS ...... 72 Tobacco and Other Substance Use...... 72 Tuberculosis...... 73 REFERENCES ...... 74

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 5

LIST OF ACRONYMS ADRA Adventist Development and Relief Agency AIDS Acquired Immunodeficiency Syndrome AIHA American International Health Alliance ARI Acute respiratory infection AWHHE Armenian Women for Health and Healthy Environment ASTP Armenia Social Transition Program BBP Basic Benefits Package CHSR Center for Health Services Research CPR Contraceptive Prevalence Rate CRS Catholic Relief Services DD Diarrheal Disease DHS Demographic and Health Survey E&E Europe and Eurasia FAP Feldsher Akusherski Punkt (Physician’s assistant/obstetrical health facility) FAR Fund for Armenia Relief of the Armenian Apostolic Church GOA Government of Armenia IDI In-depth interview IMCI Integrated Management of Childhood Illness IMR Infant mortality rate MSF Medecins Sans Frontieres MOH Ministry of Health MOSS Ministry of Social Security OXFAM Oxford Against Famine NGO Non-governmental Organization PFB Poverty Family Benefit RAP Rapid Assessment Procedures STI Sexually Transmitted Infection UMCOR United Methodist Committee on Relief UNDP United Nations Development Program UNICEF United Nations Children’s Fund USAID United States Agency for International Development WFP World Food Program

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 6

EXECUTIVE SUMMARY Adverse socio-economic conditions in Armenia over the past decade have impacted drastically on the health care system and the health status of the Armenian population. Negative changes in the health sector include decreased access to care; decreased utilization of health care services; an insufficient and unbalanced drug supply; and deterioration of the health communication and disease prevention systems. The Armenia Social Transition Program (ASTP), funded by the United States Agency for International De- velopment (USAID), provides support and technical assistance to the Government of Armenia for social and health sector reforms. One of the important components of the ASTP is to strengthen the role of Family Medicine in meeting the health needs of the population of Armenia – particularly the needs of vulnerable populations. A part of this strengthening is to develop materials that Family Practitioners can distribute to promote individual responsibility for health and the adoption of healthy behaviors to prevent future health problems. ASTP contracted the Center for Health Services Research and Development of the American University of Armenia (CHSR) to support the ASTP Health Promotion / Health Education component of its multi-year program. This report summarizes the first phase of this cooperative project: a comprehensive Needs Assess- ment that is based on four key steps: Step 1: The identification of vulnerable population groups in Armenia; Step 2: The identification of major health problems and needs of vulnerable population groups; Step 3: The development of a list of recommended health topics that can be addressed through health education; and, Step 4: The exploration of channels for the delivery of these health education topics to vulnerable groups. Step 3 – the development of a list of recommended health topics that can be addressed through health education – forms the key product of this report, and is the basis of the next step of the ASTP-CHSR collaboration: the development of health promotion materials targeted at the vulnerable populations of Armenia. During the Needs Assessment Phase, CHSR conducted a secondary analysis of existing literature and statistical information. The findings were complemented with additional information obtained from qualitative research conducted by CHSR – in-depth interviews with 1) health care professionals involved in ASTP pilot sites in Yerevan and Lori Marzes, and 2) professionals working with vulnerable population groups in Arme- nia. A summary of the results of the four steps is as follows: Step 1: Identification of Vulnerable Groups The results of the first step in the Needs Assessment Phase – identification of vulnerable groups -- identified the following four broad categories as vulnerable segments of the Armenian population: 1) children under 5; 2) pregnant/lactating women; 3) adolescents and 4) elderly. Within these broad categories, socially disadvantaged subgroups were emphasized for specific targeting by ASTP health promotion / health education activities. Step 2: Identification of major health problems and needs of vulnerable population groups Chapter 3 of this report presents a comprehensive analysis of the health problems and needs of the vulnerable groups identified in Step 1. Step 3: Identification of Recommended Health Topics The health problems identified in Step 2 were further analyzed to identify those problems that could be effectively targeted through health education/promotion materials. This Needs Assessment identified the following health topics to address through these materials: Children under 5 • Acute respiratory diseases • Diarrheal diseases • Accidents (injuries, poisoning)

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 7

• Nutrition (anemia, iodine deficiency) • Rickets • First aid Pregnant/lactating women • Nutritional needs during pregnancy (healthy diet, anemia/iron deficiency, and vitamin intake) • Breastfeeding • Reproductive health (danger of abortions, contraception use, sexually transmitted infections (STI) prevention/testing) • Dental health • Dangers of alcohol/passive smoking • Physical activity/exercising Adolescents • Reproductive health (danger of abortions, contraception use, STI prevention/ screening) • Substance abuse (smoking, alcohol/drug use) • Accidents (injuries) • Tuberculosis • Hygiene • First aid • Mental health (stress, depression) Elderly • Cardiovascular disease (hypertension, diet, exercise, frequent check-ups) • Cancer (breast cancer screening and self-screening for elder women, lung cancer prevention in men (anti-smoking education), prostate cancer in men (secondary prevention) • Diabetes: secondary prevention (hypertension, diet, exercise, frequent check-ups) • Respiratory illnesses (asthma/bronchitis/pneumonia) • Dental care/hygiene (paradontosis) • Nutrition • Tuberculosis • Mental health (depression) Step 4: Identification of Relevant Delivery Channels In Armenia, high access to television, near universal literacy rates, and a high level of trust in health providers open up multiple possibilities for delivery channels that may be used for the dissemination of health information. The most effective delivery channel for a particular health message will depend on the characteristics of the target audience. Several studies have shown that people, in general, prefer getting health information from physicians. Thus, the primary care facility (polyclinics, ambulatories, FAPs, Family Group Practices) was identified as an appropriate site for health education activities with mothers of children under 5, pregnant women, and elderly people. These groups tend to use primary care facilities for treatment or preventive care, and therefore have relatively better access to physicians. These target audiences could receive health messages through individual provider-to-client counseling sessions or through lectures /discussions held for groups of patients. Results from interviews with health care professionals substantiated this conclusion. Health professionals expressed the strong opinion that, for the majority of the vulnerable populations identified in this study, the best delivery channel for the dissemination of health information was the primary care facility, with physicians serving as the medium. Health care professionals stated their willingness to deliver health education in the primary care facilities.

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 8

For some vulnerable groups with low access to health facilities, other channels must be utilized for delivering health messages. Adolescents, who do not normally utilize services, may be reached most effectively through schools and mass media. The most socially disadvantaged populations, who have little to no access to health services, and are not extensively exposed to mass media messages, should be reached through direct contact in their localities. The recommended channels are non-governmental organizations complemented with visits with primary health care providers where applicable.

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 9

1. INTRODUCTION/BACKGROUND Like many of the Newly Independent States of the former Soviet Union, Armenia suffered major disruption to its economy following independence. Living standards decreased dramatically in the years following independence and poverty has become an increasingly urgent issue.1 Socio-economic difficulties have negatively impacted the health status of the population.2 Utilization of health services, particularly primary care services, has declined dramatically during this period.2 In an effort to reverse these negative trends, the Armenian Social Transition Program (ASTP), funded by the United States Agency for International Development (USAID), provides support and technical assistance to the Government of Armenia (GOA) in reforming social and health programs vital to the welfare of the Ar- menian population.3 1.1. ARMENIA SOCIAL TRANSITION PROGRAM (ASTP) The primary goal of the ASTP is “…to assist Armenia with the development of an integrated legal, regula- tory, and information framework that supports sustainable social insurance programs, provides needy people with adequate social assistance, and helps to improve primary health care for all Armenians”.3 The ASTP joins a number of international donor organizations in providing assistance to both the Ministry of Health (MOH) and the Ministry of Social Security (MOSS) in undertaking reforms.3 One of the important components of the ASTP is to strengthen the role of primary care relative to secondary care in meeting the health needs of the population. ASTP is assisting the Ministry of Health to expand the skills of family medicine practitioners to allow them to treat a wider range of health problems without refer- ring patients to the more expensive services of narrow specialists and hospitals. A more efficient and effective system of primary health care that can meet the needs of vulnerable population groups more effectively will include the development and distribution of health promotion / public education material intended to encourage the population to take steps to improve their own health and prevent future health problems by leading healthier lifestyles.3 1.2. ASTP PILOT SITES While overall reforms will be undertaken at a national level, piloted programs will be conducted at specific sites in Yerevan and Lori marzes. The pilot programs will be targeted towards specific communities, and focused on the improvement of the efficiency and the effectiveness of primary health care delivery in Arme- nia. 1.3. RESEARCH OBJECTIVES ASTP seeks to improve the health of Armenia’s population through a health promotion campaign that coincides with and complements its pilot activities in family medicine education and the creation of family group practices. The ASTP contracted the Center for Health Services Research and Development of the American University of Armenia (CHSR) to complete a series of inter-related tasks in support of the ASTP Health Educa- tion/Promotion component of its multi-year program. The CHSR project has four phases. Phase 1: CHSR will conduct a needs assessment to identify vulnerable groups in Armenia and their health problems/ needs; Phase 2: CHSR will modify/ design health education/health promotion materials to be used in ASTP pilot sites; Phase 3: CHSR will produce a curriculum for training health providers from ASTP pilot sites in the use of the health materials; CHSR will conduct a Training of Trainers course for Armenian Master Trainers (specific individuals selected by ASTP) in the use of the curriculum. Phase 4: CHSR will implement a baseline survey in ASTP pilot areas to assess the current knowledge, attitudes, and practices related to health education and health promotion objectives of ASTP. This report summarizes Phase 1 of this project, the Needs Assessment, which included the following tasks: 1. Identify Armenia’s vulnerable groups and their health needs amenable to health promotion activities;

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 10

2. Collect existing health education and health promotion materials from Armenia and the region and identify organizations involved in the design and delivery of health education material within Arme- nia; 3. Recommend specific vulnerable populations to be targeted; 4. Recommend specific contents/domains to be addressed through health education modules to be developed in Phase 2; 5. Recommend specific channels for disseminating materials and information.

2. IDENTIFICATION OF VULNERABLE POPULATIONS IN ARMENIA Most current governmental and non-governmental social assistance and health service programs in Armenia attempt to target vulnerable groups in the population. However, these groups are still disproportionately affected by the negative changes in the social service and health care systems that have taken place in the last decade. In an effort to improve the efficiency and effectiveness of primary health care for the most vulnerable, the ASTP places special emphasis on reaching these subgroups through health education programs and activities. For programs such as ASTP, with broadly defined objectives, the number of potential target groups is sizeable, and identification of the vulnerable populations that can most benefit from health education activities becomes crucial in light of limited resources and multiple competing health problems. This chapter of the report will 1) identify the vulnerable population subgroups in Armenia; and 2) recommend specific vulnerable groups for targeted health education activities conducted through the ASTP. The chapter is divided into three parts. Part 1 presents the methodology used by CHSR for the delineation of vulnerable population groups. Part 2 includes a review of extant data and the results of primary data collected by CHSR for the identification of vulnerable groups. Part 3 details the synthesis of all data and offers conclusions and recommendations for specific vulnerable groups to be targeted through ASTP health education programs. 2.1. CHSR METHODOLOGY FOR IDENTIFICATION OF VULNERABLE GROUPS Recognizing the limited time and resources allocated for this task, and the availability of a number of extant resources, CHSR elected to conduct a meta-analysis of existing health information on vulnerable populations -- worldwide, regionally and in Armenia -- to assess which population groups were most frequently identified as vulnerable to poor health. Included in the meta-analysis were primary data collected by CHSR to supplement the existing information. The specific population groups in Armenia that have been identified through the meta-analysis are recommended to the ASTP as the target of health promotion activities. The meta-analysis involved a multi-step process delineated below. Step 1: CHSR identified eight methodologies used worldwide to assess population groups vulnerable to poor health: 1) Burden of Disease Studies; 2) Health Surveillance System Data Analysis; 3) Population-Based Health Surveys; 4) Poverty Assessments; 5) Rapid Assessment Procedures; 6) Life Stage Analysis; 7) Socio- logical Analysis; 8) Post Factum Approach. Detailed descriptions of each methodology are included in Ap- pendix 1. Step 2: For each method, an extensive review was conducted of existing data -- worldwide, regionally and in Armenia -- on population groups vulnerable to poor health. CHSR also collected primary data to supplement the existing information. Two methods were used for the primary data collection: Rapid Assessment Proce- dures (in-depth interviews1) and Post Factum Approach (contact with organizations working with vulnerable groups). Detailed results by method are presented in Section 2.2. Step 3: CHSR selected five methods to include in the meta-analysis. Several factors were considered in this selection including: 1) the extent and quality of Armenia-specific data collected using the method; 2) the extent and quality of regional and worldwide data and its applicability for Armenia; and 3) the appropriateness of the method for assessing vulnerability in Armenia.

1 See Appendix 2 for In-Depth Interview Guides.

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 11

Step 4: Population subgroups, identified as vulnerable to poor health through each method, were listed. These included both broad and narrow subgroups. For ease of further analysis, narrow subgroups were grouped under broad categories that were determined through a study of the lists. A summary matrix was constructed that presents all of the vulnerable subgroups that were identified through each of the five methods. This matrix is presented in Section 2.3. Step 5: Vulnerable groups to recommend for ASTP health promotion activities were selected based on an analysis of the summary matrix. Specific criteria for selection were as follows: a) Broad vulnerable groups that were not common across all methods were identified and considered for elimination. b) Broad vulnerable groups that were inappropriate for targeting under the ASTP health promotion program were eliminated. c) The remaining broad vulnerable groups were analyzed for further divisions that allowed for delineation of narrow population subgroups. 2.2. REVIEW OF EXTANT AND PRIMARY DATA (BY METHODOLOGY) CHSR conducted an extensive review of extant and primary data to assess which population groups are most frequently identified as vulnerable to poor health. The data were collected using various methodologies. The results of this review are presented below by methodology. The following methods were included: a) Burden of Disease Studies; b) Health Surveillance System Data Analysis; c) Population-Based Health Surveys; d) Poverty Assessments; e) Rapid Assessment Procedures; f) Life Stage Analysis; g) Sociological Analysis; h) Post Factum Approach. a) Burden of Disease Studies There are currently no data available regarding the burden of disease in Armenia. Official statistics provided by the MOH were not sufficient to guide the selection of diseases / health conditions and risk groups vulnerable to these conditions. b) Health Surveillance System Data Analysis At present, the health surveillance system in Armenia is not well developed. As a result, there is a paucity of reliable health data stratified by different population groups. c) Population-Based Health Surveys Population-based health surveys are an objective and accurate means of assessing those worst-off and indi- cating their health needs. Numerous health surveys have been conducted in Armenia, including a Demo- graphic and Health Survey (DHS) in 2000. The data provided by the DHS and other surveys conducted by the government and various health organizations are not sufficient to form a basis for the identification of vulnerable populations in Armenia. However, they do provide an excellent source of information for the assessment of the health needs of specified vulnerable groups, and are extensively reviewed in this needs assessment study. d) Poverty Assessments Several poverty assessments have been conducted in Armenia, including assessments done by the Govern- ment of Armenia and the World Bank in 1997 and 1998. These assessments were used to improve the Paros (“beacon” in Armenian) system -- developed in 1994 to assess poverty status in Armenia -- and to form the Poverty Family Benefit (PFB) system in 1999. These two systems are described below. In addition, the results from a poverty assessment conducted by ASTP are presented. 2.2.1. The Paros System Government Offices of Social Services were operating in all regions and cities of Armenia from 1993 to 1999. Social assistance was distributed through these offices, which functioned under the Ministry of Social Welfare.4 Since August 1, 1994, the Paros system has been used to assess the financial status of families, their poverty ranking, and needs. The Paros system was funded by USAID through the Fund for Armenia Relief of the Armenian Apostolic Church (FAR). Initially the system was utilized to distribute humanitarian aid to the population. Household membership in certain social categories was taken into consideration when assigning a Paros score, with the highest score being assigned to the most vulnerable and needy families in Armenia (see Table 1). The condition and location of the household (earthquake zone, or border zone, or areas with scarce land/poor agricultural quality) were also considered when assigning the score.

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 12

Table 1. Points Assigned for Various Attributes (According to Social Category and Housing)5 Condition Points as- Housing Points assigned signed Social category

Category-less person 20 Domik (i.e., temporary shelter) 1.2 Unemployed person 22 None/Homeless 1.07 Student under age 23 (state benefit) 22 Temporary 1.06 Child of a divorced parent 26 Emergency (3-d, 4-d degree) 1.05 Child of a single mother 26 Dormitory 1.03 3rd degree disabled 28 Other 1.02 Pregnant woman (20 weeks and more) 30 Permanent 1.0 Child aged two to eighteen 33 Pensioner 34 Child under 2 35 Pensioner living alone 36 Twins (and more) under 5 36 2nd degree disabled 39 Pensioner age 75+ 39 Orphan, one-sided 43 Disabled child under 16 45 1st degree disabled 48 Orphan, two-sided 50 2.2.2. Family Poverty Benefit System The Family Poverty Benefit System (FPB) was introduced in Armenia on January 1, 1999. It has replaced nearly all of the previous forms of governmental social assistance allocated through the vulnerability category classification of the population. One of the most important features of the system is its principle of voluntary involvement (each family that considers itself poor and in need of social welfare may request assistance from the State). Family allowances are given to those families registered in the Paros system, whose degree of vulnerability exceeds 36.0 points. A family allowance depends on the size of a family and averages 7,500 Drams (USD 13/ month). Electricity compensations are paid to the families whose degree of vulnerability exceeds 33.70 points, irrespective of the number of family members. The points are revised on a monthly basis. The social categories of people identified through Paros/FPB system represent the socially disadvantaged subgroups in Armenia and may be considered as target groups for health education/ promotion program. 2.2.3. ASTP Poverty Assessment ASTP identified certain vulnerable groups in the Armenian population through a survey administered in De- cember 2000 covering 1,305 households in five marzes – Yerevan, Shirak, Lori, Gegharkunik, and Syunik. The survey provided information on the financial, health, and social situation of the population. Based on these data, vulnerable groups were identified either based on their financial situation or based on identifiable barriers facing them. Three broad indicators were used to construct a comprehensive measure of vulnerability: a financial indicator (household assessment of their financial situation), a health indicator (lack of access to health care), and a family benefit indicator (receiving Poverty Family Benefits). The results showed that a higher proportion of the most vulnerable families were headed by females, did not have any assets, did not have an employed family member, and were headed by elderly people, as compared to the non-vulnerable families. It was also shown that access to health care was directly related to the household’s financial situation – those who are most economically vulnerable had lower access to health care, with the single pensioners having the least access to health care in comparison to the general sample. The findings of the survey also

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 13 showed that the most vulnerable families, based on financial status, were applying for and receiving assistance through the PFB system. The analysis conducted by ASTP showed that the three indicators used for vulnerability of a family (financial, access to medical care, and receiving Poverty Family Benefit) are interre- lated and a good proxy for the identification of vulnerable individuals or subgroups. e) Rapid Assessment Procedures (RAP) CHSR collected qualitative data through in-depth interviews -- a key component of RAP methodology -- to identify vulnerable population groups. The interviews were conducted with health care professionals working in ASTP pilot sites. The majority of the respondents named broad categories of vulnerable groups, including children, adolescents, women and elderly. Children, especially those from low-income families, were considered as the most vulnerable population group. It was felt that these children were at high risk for health problems due to poor nutrition and inadequate childcare. Women were identified as especially vulnerable during pregnancy. Re- spondents stated that hard socioeconomic conditions are impacting on the nutritional status of pregnant women, making them more susceptible to anemia and infection. Adolescents were considered vulnerable because of their tendency towards high-risk behaviors, especially given their sensitivity to the hard socioeconomic conditions. This particular period of life was seen as the time when unhealthy behaviors are adopted which may impact health in adulthood. The elderly population (over 60) was considered vulnerable because they have numerous health conditions and should receive treatment, but they live in bad socioeconomic conditions and in many cases are deprived of adequate health care. Overall, people with low income and low education were considered to be vulnerable, since they are socially insecure, often have problems with malnutrition and lack access to health care. Other groups considered to be extremely vulnerable by respondents were disabled people, unemployed people, single mothers, families of war victims, and refugees. Many of the groups identified as vulnerable by key informants coincided with those identified for Armenia through other methodologies considered in this needs assessment study. f) Life Stage Analysis UNICEF, in their 1998 Situation Analysis of Women and Children in Armenia, employed this technique for analyzing specific health problems and risks for children, 0-17 years of age, beginning with birth and ending with entry into adulthood. However, this approach has not been used in Armenia for examination of health problems for all stages of life. Nevertheless, the underlying theory behind the life stage approach -- that all individuals can be vulnerable for different problems at different life stages -- can be useful for this Needs Assessment to ensure that all population groups are at least considered for targeted health promotion activities. g) Sociological Approach This method of identification of population groups at risk for poor health has not previously been used in Armenia, and there are limited data available to allow application of this approach. However, an example of the utilization of this approach from the USA may be useful in providing broad categories of vulnerable population groups for consideration in Armenia. Aday utilizes the sociological approach in her analysis of health and health care needs of vulnerable population groups in the USA. Table 2 presents a comparison of relative risks based on this analysis. Based on the availability of community and individual resources, broad groups are identified as being at higher or lower risk for poor health. Infants, children, adolescents and elderly are considered to be at higher risk and, therefore, more vulnerable than working-age adults. Females are more vulnerable than males. Although the groups mentioned are considered more or less prone to risk of poor health based on their age/gender (biological) characteristics, the nature of the increased risk is considered to be a social one. The status of ties between people also affects vulnerability, with single, separated, divorced, and widowed people being more vulnerable than married people, and households headed by either a female or a single parent being more vulnerable than households with extended families or two parents. Individuals with lower education and poor income are more at risk than educated, and middle/high income people. 6 Although these data are specific for the USA, the broad categories of vulnerable groups identified through this approach (infants, children, adolescents and elderly as well as females as a separate category) are similar to those categories identified for Armenia through poverty assessments.

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Table 2.Comparisons of relative risks for poor health among different categories in US according to L. A. Aday6 Community and Individual Resources Higher Risk Lower Risk The people: Social status Age Infants Working-age adults Children Adolescents Elderly

Gender Females Males

Race and ethnicity African Americans Whites Hispanics Native Americans Asian Americans

The ties between people: Social capital Family structure Living alone Extended families Female head Two-parent families

Marital status Single Married, mingles Separated Divorced Widowed

Voluntary organizations Nonmember Member

Social networks Weak Strong

The neighborhood: Human capital Schools Less than high school High school or beyond

Jobs Unemployed White collar Blue collar

Income Poor Middle income Low income High income

Housing Substandard Adequate or better h) Post Factum2 2.2.4. Assessment of Vulnerable Populations in the Region. Armenia is among the transition countries of the European and Eurasia region that are currently suffering from adverse social impacts. The whole region experienced a decline in social sector spending, which in turn lead to the breakdown of institutions of social welfare, education, health and public safety. The problems currently faced by Armenia are common to many other European & Eurasian countries.7 Concerning specific vulnerable groups common to the region, the USAID Bureau for Europe and Eurasia (E&E) indicates that

2 “After it’s done”, i.e., identification of vulnerable groups as defined and targeted by existing programs.

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 15 the particular risks of violence, exploitation, discrimination, poverty and neglect increased among children – particularly those living in institutions, pushed prematurely into the workforce, exposed to conflict, subjected to toxic or radioactive hazards, or identified early in life as mentally or physically handicapped. USAID also indicates that families with large numbers of children, especially single-parent households, are very vulnerable. There is increasing evidence that women are experiencing particularly unfavorable impacts from the transition process, including discrimination in layoffs and hiring, which has lead to increased poverty, especially in women-headed households with children. Women among the elderly are also suffering markedly from the loss of the value of their pensions. Elevated economic tension results in instances of domestic violence and exploitation of women in the sex industry. Adolescent boys and young men with limited job skills -- especially those in minority groups and outside urban centers -- may also need special assistance. Other vulnerable groups include ethnic and religious minorities, especially people affected by conflicts. USAID aims to incorporate vulnerable groups into its Social Transition Strategy to alleviate the root causes of the problems of vulnerable groups in the E&E region, and to better evaluate the impact of these problems. Concerning specific vulnerable groups common to the region, the USAID E&E Bureau identifies children, families with large numbers of children, single-parent households, women, adolescent boys and young men with limited job skills, and ethnic and religious minorities as the most vulnerable. Most USAID-funded organizations working in Armenia target populations either 1) defined as socially vulnerable under the present governmental definitions (Paros, PFB), or 2) particularly those population groups that are vulnerable to certain health conditions or diseases, such as women, children and elderly. The same refers to other NGOs working in Armenia. 2.2.5. Vulnerable Groups Identified by Government Several vulnerable groups are identified and targeted by Armenian Government for the provision of health benefits. The Government established a State Health Program in 1997 through which several services were to be provided free-of-charge to targeted segments of the population.8 A Basic Benefits Package (BBP) was developed through this program and was first implemented in 1998 with assistance from the World Bank. The BBP is a publicly-funded package of services provided to specific population groups. The BBP is periodi- cally reviewed and services or population groups may be added or removed. The BBP, revised in 2000, includes the following services: hygiene and anti-epidemic control, primary health care, medical care for children under 7, obstetrics–gynecology (including antenatal and perinatal care for pregnant women), medical care for socially vulnerable/exclusive groups, communicable disease control (tuberculosis, STIs, diarrheal diseases, etc.), non-communicable disease control (mental disorders, drug abuse, alcoholism, toxic substance abusers, oncology diseases), and emergency health care. Socially vulnerable/exclusive groups are defined under the BBP to include the following: • disabled persons (according to three degrees of disability) • war veterans • children under the age of 18 with one parent • orphans under the age of 18 • disabled children under the age of 16 • families with four or more children under the age of 18 • families of war victims • prisoners • children of disabled parents from Chernobyl disaster response activities • disaster response workers Under the current system of BBP, need is identified on the basis of multiple criteria, including age (e.g., am- bulatory care for children under 7, hospital care for children under 3), disability status (e.g., disabled adults of the three categories, disabled children under age 16, children under 18 in families with disabled family members), family size and composition (e.g., children from large families, i.e. with four or more children,

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 16 children of single mothers, orphans and children with one parent), income status (e.g., families that receive poverty allowances), institutional status (e.g., servicemen, conscripts, detained and convicted individuals), and merit (e.g., family members of servicemen who gave their lives for Armenia, victims of political repres- sion and persecution, participants of rescue efforts at Chernobyl, war veterans).9 The range of services and groups included in BBP shows the priority groups and health problems officially recognized by the MOH. 2.2.6. Vulnerable Groups Identified by NGO’s, Bi/Multi-Lateral Organizations There are several organizations currently conducting health-related programs and activities in Armenia, many with specific targeted populations and/or health problems. As most of these programs are planned and implemented based upon established needs, their target groups can also serve as good indicators of the vulnerable in Armenia. Most USAID-funded organizations target populations either 1) defined as socially vulnerable under the present governmental definitions (Paros, PFB), or 2) particularly vulnerable to certain health conditions or diseases, such as women, children and elderly. Examples of these programs include the following: • American International Health Alliance (AIHA) -- Focus on women, children and adolescents. Pro- grams include community education in diabetes, contraception, STIs, cardiovascular disease/stroke, respiratory diseases, breast and cervical cancer screening, and education. Narrow focus on adolescent women’s reproductive health, for which they develop school-based programs; • United Methodist Committee on Relief (UMCOR) -- Focus on socially vulnerable/economically deprived segments of Armenian population. Several of the programs (Pharmaceutical Distribution Pro- gram, Mobile Medical Teams Program) target people dwelling in remote, hard-to-reach poor villages with prevailing refugee and socially vulnerable populations, including children, pregnant women, pensioners and other groups indicated in Paros. They also target socially vulnerable children through their Health Nutrition program and conduct Health Education/Health Promotion activities focused on orphans and children from boarding schools; • Save the Children – Although not currently implementing any health-related programs, in the past Save The Children’s programs were focused on women’s health, including reproductive health/family planning and breast cancer screening; • Catholic Relief Services (CRS) has operated in Armenia since 1996. Currently their health programs are focused on children (Nutrition Program for schoolchildren (1-10 grades) in Yerevan, Shirak and Gegharkunik regions. Other international NGOs targeting vulnerable groups include Oxford Against Famine (OXFAM). Their main target groups are the socially vulnerable, with women and refugees receiving strong attention through their social and health programs. Currently, their largest health program -- access to primary health care/water sanitation on community level -- targets populations from rural/ mountainous/ distant villages and refugees, with specific emphasis on women. Recently, OXFAM implemented health education regarding infectious diseases and STIs for children, especially refugee and orphan children, as well as sanitation/hygiene education for mentally retarded orphans. Adventist Development and Relief Agency (ADRA) targets socially vulnerable groups including the poor, the deprived, and the disabled. Their programs emphasize the well-being of children and women. Currently ADRA/Armenia is focusing on family/reproductive health with no distinct target population identified. Médecins Sans Frontiéres - Belgium (MSF) is another large international organization working in Armenia since 1988. The main priority areas for their health programs are mental health (targeting adults, adolescents, and children with mental health disorders) and reproductive health/STI prevention (targeting women and schoolchildren in Tavush marz and adults and commercial sex workers in Bagratashen village). The target groups for United Nations Children’s Fund (UNICEF)/Armenia are children and women. They have been implementing several programs related to children’s health and development problems (including prevention and treatment of acute respiratory infections and diarrheal diseases), adolescents’ health (education regarding Acquired Immunodeficiency Syndrome (AIDS)), and nutrition problems (including the areas of iodine deficiency prevention and breastfeeding), as well as safe motherhood.

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 17

According to the World Bank, the most common broad categories targeted by social programs in Armenia are the elderly, children under five, pregnant and lactating women, and unemployed.10 The Human Rights and Development Report from the United Nations Development Program (UNDP) states that severe social problems in Armenia complicate the comprehensive realization of the citizens' right to health, and currently the most unprotected groups are women, children, pensioners, disabled, refugees, and the internally displaced persons. The alleviation of their problems and the implementation of their rights take on a particular urgency.11 2.3. SYNTHESIS AND RECOMMENDATIONS Although a large proportion of the Armenian population is considered to be vulnerable to poor social/health outcomes, limited time and resources prevent targeting the entire population. Thus, it is essential to limit the target population to selected vulnerable groups having specific health needs that can be addressed by the ASTP health promotion / health education component. However, it is also imperative to define target groups as broadly as possible in order to cover a greater proportion of the population. CHSR analyzed data collected using several approaches in order to combine a wide range of information and experiences for the selection of suitable target groups for ASTP health promotion activities. For each methodology reviewed above, a list of vulnerable groups was compiled based on available information and data and was summarized in tabular format. A review of these lists showed extensive overlap. For ease of analysis, vulnerable subgroups were sorted under the following broad categories: Children, Women, Youth, Adults, Elderly, Disabled, and Other. A summary of the vulnerable subgroups identified through the different methodologies is presented below in Table 3. Table 3. Summary of vulnerable groups identified through different methodologies used in NA study Broad Methodologies categories RAP Poverty assessment Life stage Sociological * Post Factum Children General Child of a divorced Neonatal period General General parent (till 28 days) Children from Child of a single Infants (28 days – 1 Infants Under 5 low-income mother year) families Child of a disabled Children aged 1-5 Living in institutions parent (Pre-school) Child aged 2-18 Children aged 5-10 Pushed prematurely years into the workforce Child under 2 Exposed to conflict Twins (and more) Subjected to toxic or under 5 radioactive hazards Orphan (1 & 2 sided) Socially vulnerable Refugee Children Orphans Child under 18 with one parent Children Children of disabled parents from Cherno- byl disaster School children grades 1-10 Women Single moth- Pregnant women (+ Pregnant/perinatal General Pregnant (+20 weeks) ers 20 weeks) period Pregnant General women Pregnant/ Lactating Commercial Sex Workers

NEEDS ASSESSMENT: PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS 18

Broad Methodologies categories RAP Poverty assessment Life stage Sociological * Post Factum Youth Adolescents Student under age 23 Youth (10-20) Adolescents Boys and Young Men Adolescents Adolescent Girls Adults - - Adults (general) - - Elderly Elderly (gen- Pensioner Elderly (general) Elderly (gen- Elderly (general) eral) eral) Pensioner living alone Elderly Women Pensioner age 75+ Disabled Disabled 1st, 2nd, 3rd, degree - - 1st, 2nd, 3rd degree dis- (general) disabled abled Disabled child under Disabled children un- 16 der 16 Other Low income Unemployed - People living UNEMPLOYED alone Low educa- Domik dwellers Female Living in Remote Vil- tion headed house- lages holds Unemployed Homeless Single/ sepa- Refugees rated/divorced/ widowed Families of Under temporary shel- People with Multiple-Child fami- war victims ter weak social lies networks Refugees Emergency houses Low educa- Multiple-Child / Sin- dwellers tion gle-parent households Dormitory dwellers Unemployed Female-Headed Households Female-headed house- Low income Ethnic/religious mi- hold norities Family with no assets Bad housing People affected by conflicts Other Family with no em- War Veterans ployed family member Elderly-headed house- Families with four or hold more children under 18 Families of war victims Prisoners

DISASTER RE- SPONSE WORKERS Socially vulnerable * - Only groups applicable to Armenia are listed

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 19

Identification of Vulnerable Groups for ASTP Health Promotion Activities Three methods were eliminated from consideration for inclusion in the meta-analysis: 1) Burden of Disease Study; 2) Health Surveillance System Data Analysis; and 3) Population-Based Health Survey. Elimination was based on three factors. Each of these methods required extensive time and resources to collect primary data; no secondary Armenia-specific health data (stratified by population subgroups) were available for analysis; and use of regional / worldwide data would not have been appropriate. Five of the eight reviewed methodologies were included in the summary matrix. The three methods that were considered the strongest in terms of identifying appropriate vulnerable groups for Armenia were RAP (collection of Armenia-specific primary data), Poverty Assessments (based on data collected from Armenia), and Post-Factum Approach (primarily based on experience of Armenia-based organizations). Also included in the table were Life Stage Approach and Sociological Approach. Although identification of vulnerable groups based on these two methods was not specific to Armenia, the groups identified are broad and can be considered for inclusion. The process used for narrowing the selection of vulnerable groups based on the summary table (Table 3) is described below. Step 1: Broad groups that were not common across all methods were identified and considered for elimination. This included three broad groups: Adults, Disabled and Other. Adult category was identified as vulnerable only through the Life Stage Approach, and this group was eliminated as a possible vulnerable group for specific targeting. Disabled category was identified as vulnerable through three of the five approaches: RAP, Poverty Assessment and Post Factum. However, these methods were considered to be the most important in terms of identifying Armenia-specific groups, so the category of disabled was not eliminated at this point. Other category was not included in just one method, Life Stage Approach, and was also not eliminated at this point. All other methods identified subgroups within each of the remaining broad categories – Children, Women, Youth, and Elderly. The final result of this step was the inclusion for further analysis of all subgroups within the categories of children, women, youth, elderly, disabled and others. Step 2: Vulnerable groups that are inappropriate for targeting through the ASTP health promotion project were eliminated. Based on this factor, the Disabled category was eliminated since individuals with disabilities will necessarily have health and information needs based on their specific disabilities. These may include a wide range of health problems considered to be outside of the scope of primary health care. The specific subgroups listed under the Other category were also considered to be very narrow and inappropriate as specific target groups for ASTP, given the limited resources and the vast number of groups. How- ever, many of these subgroups will be covered under other broad headings. For example, multiple child families are considered to be a vulnerable group. Although not specifically targeted, members of this group who visit polyclinics would still have access to and benefit from health education materials and activities offered through the ASTP. The final result from this step was the elimination of the categories Disabled and Other for specific targeting by ASTP. The remaining broad categories of Children, Women, Youth and Elderly were common to all of the methodologies. Further analysis of the summary table shows that within Children and Women there were further divisions that would allow for a more narrow focus. Under the category Children, very young children are emphasized. This is consistent with data throughout the world and in Armenia that emphasizes the ages of 0- 5 as a particularly vulnerable period for children.10, 12 Under Women, pregnant and lactating women are mentioned under every methodology. Based on the above meta-analysis, the broad groups suggested to be targeted under the ASTP health promotion component include children under 5, pregnant/lactating women, adolescents, and elderly. It should be noted that, with the exception of the Life Stage approach, all methods emphasize socially disadvantaged vulnerable population groups. The Life Stage approach, though not recognizing socially disadvantaged populations as a separate group, is widely used to assess risks to human life appearing at each particular stage with consideration of the poverty factor. Thus, all the approaches value the fact that people with a combination of biological and social determinants of poor health are extremely vulnerable and should receive special attention when planning and implementing health interventions. Taking this into account, available health information on socially disadvantaged subgroups within each broad category will be reported in the next section, and special consideration will be given to these groups in

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 20 the development and delivery of health education materials. Health education modules on certain topics may include some special materials developed for a particular subgroup. For example, although a Diabetes Health Education module might target the elderly population in general, some print materials may be prepared in large print specifically for elderly people over 70 years old.

3. HEALTH NEEDS OF VULNERABLE POPULATION GROUPS This section presents a detailed analysis of the health problems and needs of vulnerable population groups identified in this Needs Assessment. The information was obtained through secondary data analysis and in- depth interviews with professionals in the health and social sector. The information is presented by the broad categories identified as vulnerable to poor health: Children Under 5; Pregnant and Lactating Women; Adolescents; and Elderly. Under each category, the following topics are addressed: 1) general health problems of the group; 2) health problems and needs specific to the most vulnerable subgroups within each broad category; 3) assessment of current health education efforts in Armenia targeted towards each group; 4) assessment of health problems from the qualitative research; and 5) recommended topics for health promotion activities. The section concludes with a matrix presenting the overall assessment of the needs of each group and the cross-cutting health issues. 3.1. CHILDREN UNDER 5 3.1.1. General Health Problems According to official government statistics, the total number of children under 5 in Armenia at the beginning of 2001was 196,089, or 5.2% of the population: 45.9% female and 54.1% male.13 The results of a Demo- graphic Health Survey (DHS) conducted in 2000 differed regarding the proportion of females vs. males, with 43.2% females and 56.8% males. The DHS enumerated only children under 5 who were living at the time of the survey.14 After a steady decline for over a decade, the infant mortality rate (IMR) in Armenia slightly increased in 1999 and again in 2000. The IMR for 2000 was 15.6 per 1000 live births, compared to 14.7 in 1998. The IMR for girls was significantly lower than for boys (12.3 versus 18.6).13 According to MOH official statistics, the main causes of infant mortality in 2000 were diseases of the perinatal period (40.3%), congenital diseases (24.4%) and diseases of the respiratory system (18.7%) (Table 4). Intestinal infections constitute 5.2% of all causes.13 Table 4. Cause-specific infant mortality in Armenia, 1988-2000 (MOH of RA, official statistics) 1988 1990 1992 1993 1995 1996 1997 1998 1999 2000 Causes of infant mortality (per 1000 live births) Perinatal conditions 10.2 6.1 5.9 5.9 5.7 7.3 6.9 7.2 6.3 6.2 Respiratory diseases 6.0 4.8 4.8 4.8 3.2 3.3 2.6 2.5 3.3 2.9 Intestinal infections 2.6 2.2 2.5 2.5 1.7 1.2 1.3 1.1 1.1 0.8 Congenital pathologies 2.5 2.5 2.4 2.4 2.4 1.8 2.4 2.9 3.4 3.7 Causes of infant mortality (% distribution) Perinatal conditions 40.3 32.8 32.4 33.0 38.4 47.5 45.3 47.5 40.4 40.3 Respiratory diseases 24.1 25.7 25.9 26.4 21.8 21.6 16.9 17.1 21.0 18.7 Intestinal infections 10.3 11.9 13.5 12.2 11.6 7.4 8.2 7.5 7.0 5.2 Congenital pathologies 9.9 13.9 13.0 11.0 16.3 11.7 15.5 18.1 21.5 24.4 Other reasons 15.4 15.7 15.0 15.0 11.9 11.6 14.1 9.8 10.3 11.4 The main cause of morbidity in infants in 2000 was respiratory disease (866.2 per 1000 infants), in particular, infections of the upper respiratory tract, pneumonia, and influenza. The second most frequent cause of morbidity was intestinal infections (31.3 per 1,000).13

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 21

According to official vital statistics registries, there was a consistent gradual reduction of the under-5 mortality rate in Armenia over the last decade, with an upturn in the last two years.2, 13 For 2000 this rate was 19.2, with the rate being higher for boys (21.1) than girls (17.4).13 The main causes of under-five mortality in 1999 Armenia were: respiratory and infectious diseases; perinatal causes and congenital malformations; injuries and poisoning (Table 5).2,15 Table 5. Cause-specific under-5 mortality in Armenia (1990, 1995, 1999)2 % of under-5 deaths caused by given condition Cause of death 1990 1995 1999 Infectious diseases 17.5 13.7 11.5 Respiratory diseases 27.8 24.1 22.2 Injury, poison 10.5 12.3 4.8 Congenital malformations 11.8 13.9 19.9 Perinatal causes and other 32.4 36.0 41.6 These data do not allow for in-depth analysis of specific diseases/causes of mortality and morbidity among the major categories. In order to get a better picture of the mortality profile, specific data analysis was performed in 1994 by the MOH to investigate mortality causes for children from 1 to 5 years of age. The study found, that accidents were the most frequent cause of death among 1-5 year old children, specifically burns and trauma. Most of the accidents were occurring in rural areas, with the exception of deaths from burns in Yerevan.16 These findings could be explained by severe economic conditions (e.g., absence of electricity and usage of other heating devices) in the country at that time. However these data are old, and may not be applicable to the current situation in Armenia. According to more recent data from 1997,among the unintentional injury deaths of children ages 0-4 in Armenia, the highest percentage of deaths is due to choking, fire, and drowning. In 2000, the major causes of death in children 1-5 years old were accidents (40% of all deaths), diseases of respiratory system (23%) and diarrheal disease (13%).13 Infectious diseases in children under 5 are not considered a major problem for Armenia as there is an effective immunization program currently conducted with adequate coverage of the population. However, mumps and tuberculosis have been identified as potentially serious problems for Armenia’s children, as their incidence has increased in the past few years.15,16 Stunting is a significant concern in Armenia.2 A 1998 national nutrition survey was undertaken to provide baseline statistics on the nutritional status of women and children under-5. The survey results showed that less than 5% of children suffer from acute malnutrition.17 However, the prevalence rates of stunting were high, ranging from 9.1% in the urban areas to 15.5% in rural areas. Results from the 2000 DHS confirmed these rates, showing 14% stunting in children. Recent data show that low iodine consumption is a problem in Armenia. According to the 1998 nutrition survey, iodized salt was the main source of iodine for the population, but 30% of domestic salt was not iodized and 31.7% of children aged 6-59 months had low iodine consumption. However some improvement took place during the last few years due to rehabilitation of the salt iodination system in 1997. According to the 2000 DHS, domestic salt was sufficiently iodized in 84% of surveyed households.14 A notable difference existed between the consumption of iodized salt in different marzes (e.g. 95% of domestic salt iodized in Ararat and Armavir versus 59% in Tavush marz).14 According to the nutrition survey, 16% of children were anemic in 1998. The 2000 DHS showed similar results for urban children (16%), and much higher rates of anemia for rural children (33%).14 3.1.2. Health Problems of Socially Vulnerable Children There are no official statistics regarding the health status of the socially disadvantaged/vulnerable groups of children in Armenia identified in this Needs Assessment (children from low income families, refugee children, institutionalized children). MOH officials stated that these social groups tend to have more pronounced health problems than the general population, however this issue needs further investigation through targeted health surveys to clarify the different health needs in these population subgroups.18 Children from low-income families. There is strong association in studies outside of Armenia between childhood mortality and socioeconomic status due to differences in housing, nutrition, education, exposure to environmental risks and access to and use of health care services and facilities.19 A study of US children

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 22 from vulnerable families found that poor children die from cancer, heart diseases, and pneumonia/influenza, at a rate two to five times that of children who are not poor.19 Another US study showed that the highest rates of morbidity were in children from low-income, single-mother families.19 There have been no studies conducted in Armenia investigating the relationship between poverty and child health, however there is limited information on this topic obtained from health care workers and NGOs working with vulnerable population groups in Armenia. According to these sources, the problem most frequently seen in children from poor families is malnutrition. In 2001 the organization "Armenian Women for Health and Healthy Environment" (AWHHE) implemented a project, "Improvement of nutrition and health status of pregnant women and children".20 The AWHHE team investigated the health conditions of children 0-2 years old treated in the Department of Toxic Dystro- phies in the Yerevan Children’s Infectious Hospital. Severe conditions resulting from infections and insufficient nutrition were observed in these children, the majority of whom were from low-income, socially disadvantaged families. The malnutrition was attributed to the poor socio-economic condition of families and the lack of knowledge about a healthy diet. The lack of knowledge among parents regarding infant feeding may have lead to development of anemia and general weakening of the child. Faced with infection, these infants developed hypotrophy, toxicosis, and protein-free edemas.21 Refugee children. Approximately 350,000 refugees have entered Armenia since 1988, which is roughly equivalent to 10% of the entire population.16 As of 1998, the total number of refugee children residing in Armenia was 33,178 with 40% living in cities and 60% in villages. The nation-wide refugee survey conducted in July-August 1999 showed that overall, the health status of the refugee population was very poor, especially for refugees living in temporary shelter.22 It was also found that children aged 0-5 were more vulnerable to diseases than the rest of the refugee population due to lack of quality care for smaller children (hygienic conditions, pediatric counseling, healthy food, etc.).22 Institutionalized children. The number of children separated from their parents or deprived of a family environment is increasing at an alarming rate in Armenia. Many of these children are in institutionalized care, including boarding schools for children with special needs, orphanages, and sanatoriums.23 The rate of institutionalized children under 5 in Armenia in 1999 was 23.8 per 100,000 children less than five years of age (this rate has gradually increased over the past decade).23 There were no sound data found regarding the health problems of institutionalized children, except some information provided by the Director of one of the Yerevan orphanages, which is presented later in the report. 3.1.3. Health Education Programs – Caretakers of Children Under Five An official government program for the prevention of diarrheal disease in Armenia was established in 1993, and a program for the prevention of acute respiratory diseases was established in 1994. The main objectives of these programs were to decrease the cause-specific mortality rates for diarrheal disease (DD) and acute respiratory infection (ARI) by 30% and 50% respectively. The programs employed three main strategies: increase the knowledge of health professionals; improve practices in medical facilities through the provision of necessary medication; and increase the knowledge of caretakers through health education. The public health education component included provision of print materials to the public and health provider counseling for caretakers. The decreases in the cause-specific mortality rates for DD (4.6 to 2.95/1000 live births between 1993 and 2000) and ARI (1.8 to 0.8 between 1994 and 2000) was attributed to these activities; however an evaluation of the DD and ARI management practice in Armenia in 1999 showed that there are still some gaps to be addressed, particularly in the sphere of provider-to-caretaker health education.18 In 1999, MOH adopted the WHO/UNICEF Integrated Management of Childhood Illness (IMCI) strategy, a holistic approach to child health that focuses on the entire well-being of the child. IMCI includes the management of the most common conditions in children, such as otopharyngeal problems, fever, nutritional problems, and immunization. Training of health care professionals in IMCI was conducted in 3 pilot sites in 2001 (Martuni region of Gegharkunik marz, Ijevan region of Tavush marz, and Artik region of Shirak marz). The IMCI health education modules for caretakers that were delivered by UNICEF for use in this program were highly regarded by MOH specialists. 3.1.4. Assessment of Health Problems/ Needs by Key Informants Several of the respondents from ASTP pilot sites considered infants under 2 months to be especially vulnerable, since they are susceptible to several health conditions at this age such as respiratory infections includ-

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 23 ing acute pneumonia, and diarrheal disease. They reported that mothers often delay seeking treatment from a physician, despite the fact that an even one-hour delay at this age may lead to serious complications and in some cases death. Respondents reported that nutritional problems in children under 5 (especially children aged 0-1 year) are common (in particular, rickets and intestinal infections), especially if a child is not breastfed. They felt that nutritional problems were related to poverty, which is widespread in their catchment areas. Some of the respondents mentioned, however, that children under 5 were in a relatively good situation compared to the rest of the population, since their health problems received a lot of attention from the Armenian government and NGOs. Children were supposed to receive free medical care and immunizations. The Director of one of the Yerevan orphanages stated that the health status of children in orphanages can be considered optimal in comparison with other socially disadvantaged children (low-income families, children of lonely mothers, refugees, etc.), as they are under the constant control of physicians and receive timely care and attention. However, he stated that there were several problems typical for children from orphanages like intestinal disorders (result of absence of breastfeeding), digestion problems, allergies, rickets, and respiratory infections. They often have immune disturbances, and as a result are more susceptible to infections. DD peaks in orphanages during the summer period. Many of the respondents stressed the need for health education among mothers of children under 5 on breastfeeding and general childcare, as there were still significant knowledge gaps in these areas. For caretakers of socially disadvantaged children, respondents stressed the need for education on general childcare, DD, nutrition, rickets, and first aid. 3.1.5. Recommended Topics for Health Education/ Promotion The needs assessment identified multiple health problems affecting children under 5 in Armenia. However, taking into account the objectives of ASTP/health promotion component, several health problems are not recommended for targeting under the program, as being either 1) not amenable to health education / health promotion, 2) too broadly or narrowly defined, or 3) not prevalent. The problems that were excluded and the rationale for their exclusion are listed below (the same technique is used for recommending the health education topics for the rest of the vulnerable groups presented further in the report). Health Conditions Reason for elimination Congenital malformations Not amenable to health education/health promotion Perinatal causes Too broadly defined Intestinal disorders Too broadly defined Infectious diseases Not prevalent Allergies Not amenable to health education/health promotion Digestion problems Too broadly defined The rest of the topics are recommended for health education/ health promotion activities targeted towards parents/caretakers of children under five (no further selection or prioritizing of topics was performed, as it is projected that all the delineated topics can be covered by ASTP/health promotion component within the given resource/time constraints): 1. Acute respiratory diseases 2. Diarrheal diseases 3. Accidents (injuries, poisoning) 4. Nutrition (anemia, iodine deficiency, stunting) 5. Rickets 6. First aid Further discussions with ASTP staff will refine the final list of topics for which health promotion/ education modules will be developed.

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3.2. PREGNANT/ LACTATING WOMEN 3.2.1. General Health Problems Interest in the health of Armenian women has increased substantially due to several reports from the early- to-mid 1990s that stressed the need for more detailed data on the health of women as well as the necessity of implementing national strategies for improving women’s health. Since that time, a wealth of information has been collected in this sphere, and governmental and local agencies have shown a much stronger commitment towards women’s health issues. Family planning/abortion and STI prevention issues were the focus of many programs carried out by governmental and non-governmental organizations. Currently, perinatal care for women and newborn babies has taken center stage in Armenia.18 The main causes of mortality in women of reproductive age are complications related to pregnancy and childbirth. Maternal mortality fluctuates widely from year to year in Armenia due to the small number of births, and this indicator is usually assessed using three-year averages (Table 6). Table 6. Maternal mortality in Armenia (per 100, 000 live births), 1989-200015 Number of live Absolute number of Maternal mortality rate (per 100,000 live Years births deaths births) 1989-1991 233,475 98 41.9 1992-1994 179,181 59 32.9 1995-1997 140,059 45 32.1 1998-2000 112,180 46 41.0 The dynamics of this indicator shows the decrease in the maternal mortality by 23% from the period of 1989- 91 (41.9) till 1995-97 (32.1).15 However, the average rate increased in the period of 1998-2000 (41.0). There is an increasing concern that the deteriorating health care system (decreased access to care, decreased utilization of health care services, and deterioration of the health promotion and disease prevention systems) is leading to a renewed increase in maternal mortality.15 Hemorrhages, hypertension disorders, abortions, extra-genital diseases and post-delivery sepsis are the most common causes of maternal deaths in Armenia.2,15 It is estimated that the majority of the deaths can be pre- vented with appropriate prenatal care and obstetrical services.15 Induced abortion remains the major form of birth control among Armenian women, contributing to high rates of maternal mortality and preventable morbidity. This reliance on abortion can be explained by the lack of access to information concerning modern methods of contraception and widely held misinformation among women regarding family planning and reproductive health.24 The findings of the Reproductive Health survey conducted among Armenian women (married, age 18-35) by CHSR in 2000 showed that one in two pregnancies that occurred during the 5 years prior to the survey ended in abortion. Extrapolation of these data estimated a lifetime abortion rate of 4.3 per married woman. The data from the 2000 DHS supported these results.14 It was estimated that the average number of abortions an Armenian woman will have is more than 50% greater than the number of births she will have.14 Raising awareness of the population about modern contraceptives and advocating proper reproductive behavior is the best strategy to decrease the number of abortions and improve women’s reproductive health. Evaluation results from The USAID-funded Green Path Campaign, conducted in Armenia in 2000 to promote Family Planning Service Centers, showed an increase in awareness, knowledge, acceptance, and adoption of modern contraception through the increased utilization of counseling and related services provided at government Family Planning Cabinets.24 The contraceptive prevalence rate (CPR) increased from 23.8% to 28.4% following the campaign (Table 7).24 Table 7. Family planning practice prior to the “Green Path” campaign and at follow-up24 @Baseline @Follow-up n=1088 Current modern method use %* 23.8 28.4 Ever received FP care/counseling services % * 5.0¹ 7.7² * - the differences are statistically significant, p < 0.05

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¹ - in the last year ² - since June 1, 2000 It is possible that these changes in women’s attitude and practices will reverse as time passes, if there is no continuation or reinforcement of the advocacy of modern contraceptives. The 2000 DHS showed similar results; the CPR for modern methods of contraception was 22% among married women. 39.5% of married women were not using any method of contraception.14 Among the health problems of pregnant women in Armenia, diseases of the urogenital system, late toxicosis, and venous complications during pregnancy have been increasing in the last decade, with estimated rates of 17.3, 2.7 and 4.5 (% of all pregnant women) respectively for 1999.25 According to the available statistics, there was considerable improvement in breastfeeding rates during the second half of the 1990s in Armenia coinciding with the implementation of the National Breastfeeding Pro- motion program. There was a stable increase in the rate of exclusive breastfeeding at 4 months, from 30.6 in 1995 to 54.0 in 1999.2 However, some important indicators, such as exclusive breastfeeding rate, timely complementary feeding rate, and continued breastfeeding rate (> 12 months) are still low and should be targeted for improvement. Many women begin supplementing their milk early on with infant formula, which then leads to the early cessation of breastfeeding.18 Many lactating mothers still do not receive sufficient help and support with overcoming the difficulties faced during breastfeeding and lack the knowledge that their breast milk is sufficient nutrition for their infant.2,18 There were several problems related to Armenian women’s health behaviors during pregnancy that are associated with poor pregnancy outcomes. These include inadequate diet/vitamin and mineral supplementation during pregnancy, smoking/exposure to environmental smoke, alcohol intake, oral and dental health problems, and low awareness regarding STIs/AIDS.26 Lack of knowledge and socio-economic hardship have resulted in inadequate dietary intake during pregnancy for many Armenian women. In addition, use of vitamins during pregnancy is low and there are mis- conceptions that vitamin supplementation may harm the fetus.26 According to findings of the 1998 national nutrition survey, 16% of pregnant women had hemoglobin levels below 11g/dL (mild or moderate anemia).17 However, there were almost no cases of severe anemia identified (hemoglobin levels below 7 g/dL). The MOH official data were consistent with the survey results and indicated that the prevalence of anemia among pregnant women increased during the 1990s and was 15.6% in 2000 (Table 8).15 Anemia was more prevalent in urban areas and in refugee populations.2 The rates of anemia in pregnant women increased with the stage of pregnancy, an alarming fact given that late-stage anemia is one of the risk factors for hemorrhage during delivery and maternal deaths. Despite extensive prophylactic measures undertaken in the last decade, the level of anemia among pregnant women remains high.15 This may be due to poor nutrition of pregnant women and the insufficiency of proteins and microelements in their diet. Table 8. The dynamics of anemia in pregnant women (1980-2000)15 Years Early forms (%) Late forms (per 1000 deliveries) 1980 1.1 8.4 1990 1.3 9.5 1991 3.7 37.1 1992 6.7 45.6 1993 6.5 65.5 1994 7.3 73.1 1995 10.4 58.3 1996 10.8 44.7 1997 12.6 115.4 1998 14 110 1999 15.3 121 2000 15.6 130.6 There is a high prevalence of iodine deficiency disorders in Armenia, most likely due to the interruptions in salt iodization during the last decade.2 A nation-wide study conducted in 1995 found goiter in 50.4% of

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 26 pregnant women.2 According to the results of Nutritional Status survey conducted in 1998, 32% of pregnant women had goiter (similar to general population rate).17 Data regarding smoking rates for Armenian women are inadequate and limited, and mostly indicate low prevalence of smoking in comparison to Armenian men.27, 28, 29 Smoking during pregnancy is not culturally accepted in Armenia. However, as the prevalence rate of men who smoke was very high, the probability of exposure of pregnant women to secondary smoke was also high. Many women in Armenia were unaware of the potential health risks associated with passive smoke. In addition, even if women were aware of the risks, they often were not in control of their environment.26 Most women in Armenia were aware that drinking alcohol during pregnancy is harmful. However, many thought that drinking occasionally and drinking certain types of alcohol (like champagne, liqueurs, and beer) was not harmful, as long as it was consumed in low quantities.26 Oral and dental health was identified as a large problem in Armenia irrespective of pregnancy. Although current studies show that serious dental problems should be solved during pregnancy to avoid additional problems for the fetus and mother, women in Armenia delay their dental care until after delivery, as they fear that dental care will negatively affect the fetus.26 There was a lack of awareness among Armenian women regarding the dangers of undiagnosed and untreated sexually transmitted diseases. This has resulted in low levels of STI testing and timely treatment.15 Armenian women have very little access to information regarding exercise and physical activity during pregnancy. They were usually not counseled on this topic during prenatal care.26 3.2.2. Health Problems of Socially Vulnerable Pregnant Women Data regarding the health status and health needs of socially disadvantaged pregnant women in Armenia are extremely limited and no reliable statistics exist for this subgroup. Information regarding the health needs of socially vulnerable Armenian women is presented below, although this is not an ideal proxy for identifying specific health needs of pregnant women in this group. More specific information from key informant interviews regarding socially vulnerable pregnant women is reported in section 5.2.4. Single mothers/mothers with multiple children. According to a survey conducted by the Armenian Na- tional Fund for Motherhood in 1999, 85% of single mothers and mothers with multiple (4 or more) children surveyed do not have access to health care services.30 Of the women surveyed, 97% had at least one gynecological disease, 56% had problems with the central nervous system, 34% dental problems and 28% cardiovascular problems. The level of knowledge of health issues was low in this group. The majority of women surveyed lacked knowledge about sexually transmitted diseases (54%), modern methods of diagnosis and treatment (50%), and acute infectious diseases (62%). Use of modern contraceptives was very low. The most common method of contraception was withdrawal (65% of surveyed women).30 Refugee women. Refugee women are considered at high risk for health problems.30 A nationwide survey of 1000 refugee women conducted by UNHCR in collaboration with the Armenian Family Health Association (1998) showed an average of 6 abortions per woman (lifetime rate), a figure which exceeded the average number of abortions per Armenian woman.30 In addition, a high prevalence of sexually transmitted diseases was observed among refugee women in Communal Centers and those living in border regions. Low Income Women. As mentioned previously, AWHHE conducted a project in which socially disadvantaged pregnant women and children were given amaranth (a plant of high nutritional value) to improve their nutritional status. Among other activities, monitoring of the health status of participating pregnant women was carried out. The project included 193 pregnant women monitored in Yerevan Maternity Hospital #3. They were divided into three groups according to the economic status of their families. The first group was composed of 99 women from deprived families. The prevalence of anemia in this group was estimated at 13 percent. In the second group (women from families of middle income) and the third group (women from the high income families) the prevalence of anemia represented 4.5 and 3 percent, respectively.20 This notable difference in anemia rates between women with different incomes confirms the anecdotal evidence and literature findings that show a positive correlation between income and rate of anemia. 3.2.3. Health Education Programs – Pregnant Women There have been several health education programs targeting pregnant women in Armenia. Among these, two programs are described below. These programs were good examples of successful health promotion

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 27 educational programs for pregnant women, and can serve as valuable sources of information for future health education initiatives.26,31 In 1994, Wellstart International conducted a Breastfeeding Promotion campaign. The Breastfeeding campaign consisted of a press conference, a two-minute television spot, two radio spots, newspaper advertise- ments, production of 60,000 brochures for mothers and health care providers, and production of tee-shirts.31 The evaluation conducted one year after the campaign revealed that the print component of the program was the most effective. It was concluded that due to universal literacy in Armenia, print is a highly appropriate channel for health information delivery.31 The campaign had a long-term positive impact on the target population, as documented by the evaluation results and the increased breastfeeding rates in Armenia following the campaign. Jinishian Memorial Fund and CHSR conducted a Health Education Program for Pregnant Women from 1996 to 1998. The program included the dissemination of sixty-page booklets containing up-to-date information for pregnant women on several health topics, such as prenatal care, nutrition, breastfeeding, and family planning at prenatal consultations in Yerevan.26, 31The subsequent evaluation component revealed a significant increase in women’s knowledge due to reading the Health Pregnancy booklet. The booklet was favorably graded by women and lead to lifestyle changes for 75% of them.26, 31Again, it was concluded that the high- quality printed health education materials targeted for pregnant women served as an effective tool for modi- fying their behavior. 3.2.4. Assessment of Health Problems / Needs by Key Informants Information obtained from respondents working in ASTP pilot sites reinforced the findings of the literature review regarding the prevailing health needs of pregnant/lactating women. The problems of pregnant women mentioned most frequently by respondents were lack of proper nutrition and iron and vitamin deficiency, low awareness of the need for physical exercise during pregnancy, low personal hygiene, and lack of knowledge regarding breastfeeding techniques. One of the informants listed heart, kidney, and gynecological problems as frequent pathologies among pregnant women. However, there was also an opinion expressed that there has been significant progress made towards improved health status of pregnant women in Armenia, as many women are now more educated about healthy behaviors during pregnancy and are aware of potential health problems and ways of prevention. Specialists working with socially disadvantaged women in the field reported that the main problems seen in this subgroup of women are related to nutrition. According to several informants, malnutrition and anemia, as well as almost total absence of information regarding adequate diet during pregnancy were common in these women.21 3.2.5. Recommended Health Topics for Health Education/ Promotion Of all health problems in pregnant and lactating women, the following were eliminated as not appropriate for targeting under ASTP/health promotion component: Health Problems Reason for elimination Hemorrhages Not amenable to health education/health promotion Post-delivery sepsis Not amenable to health education/health promotion Diseases of urogenital system Not amenable to health education/health promotion Late toxicosis Not amenable to health education/health promotion Venous complications during pregnancy Not amenable to health education/health promotion Problems with central nervous system Too broadly defined Gynecological problems Too broadly defined Cardio-vascular diseases Too broadly defined Kidney problems Too broadly defined The following topics are recommended for health education/ health promotion activities targeted towards this group: 1. Nutritional needs during pregnancy • Healthy diet

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• Anemia/Iron deficiency • Vitamin intake 2. Breastfeeding 3. Reproductive health • Danger of abortions • Contraception use • STI/AIDS prevention/testing 4. Dental health 5. Dangers of alcohol/passive smoking 6. Physical activity/exercising Further discussions with ASTP staff will refine the final list of topics for which health promotion/ education modules will be developed. 3.3. ADOLESCENTS 3.3.1. General Health Problems Mortality among young people is generally low throughout the world, and severe chronic diseases are rare among persons in their teens and twenties. Health among young people should be considered in a wider sense; illnesses later in life may have their origins during the transition from childhood to adulthood.23 The second decade of life has special vulnerabilities, health concerns, and barriers to accessing health care.32 Numerous social and other factors have a great influence during adolescence and contribute to or interfere with the full-bodied development of a person. Armenian adolescents are passing through this difficult period in their lives during a time of great social and economic changes in the country.16 According to official government statistics, by the beginning of 2001 the total number of adolescents consti- tuted 9.8% (374089 people) of the general population (8.7% according to the results of DHS in 2000, where all the adolescents dwelling at surveyed households at the time of surveying were enumerated). Of them, 48.8% were males and 51.2% were females (57.2% males and 42.8% females according to DHS). Injury and violence have replaced illness as the leading causes of death for adolescents, and life conditions and risky behaviors are related to the major morbidities.32 Official figures show the accidents and injuries as the main cause of mortality in children ages 5-19 throughout the last decade. Among them, nearly half of the deaths each year occur in the male group aged 15-19 years due to accidents and injuries.16 These high rates of accidental deaths are at least partially attributable to risky behavior of many adolescents. Focus group research shows that Armenian adolescents do not perceive themselves at any risk as a result of their behaviors, but they are able to identify the high-risk behaviors practiced by their peers. Smoking, decreased physical activity, unhealthy diets, poor hygiene and stress-related violence were perceived by adolescents, parent and teachers as problems frequently occurring among Armenian adolescents.16 Adolescence is the period of sexual maturation, and therefore, reproductive health of adolescents is among the most important problems for this age group. Family and community usually tend to enforce strict rules about young people's sexual behavior in Armenia. However, urbanization, exposure to foreign cultures through migration, tourism and mass media, and changes in the standard of living, have contributed to a change in the attitudes of young people towards sexuality and reproductive rights.33 According to official MOH statistics, the rate of syphilis and gonorrhea among Armenian adolescents in 2000 was 3.2 and 13.0 respectively (per 100,000) (Table 9). The data show an overall decline in the rate of syphilis and gonorrhea over the last decade; however, the gonorrhea rate more than doubled between 1998 and 2000.13 Table 9. Sexually Transmitted Infection - Morbidity among Adolescents (15-17), 1990-200013 Disease 1990 1991 1995 1996 1997 1998 1999 2000 Syphilis (absolute numbers) 5 3 10 8 11 5 4 4 Syphilis (per 100, 000) 3.4 2.1 7.9 6.4 8.8 4.2 3.2 3.2 Gonorrhea (absolute numbers) 28 27 65 14 23 6 7 16 Gonorrhea (per 100,000) 19.2 18.8 51.5 11.2 18.3 5.0 5.7 13.0

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The official data may not reflect the real situation with regards to sexually transmitted infections (STIs) in the adolescent population and should be interpreted with caution and skepticism. Some patients are not registered in public and private health care facilities and therefore not included in the official statistics. In addition to this, people with STIs may not apply to health specialists, but instead seek the advice of friends and/or pharmacists. This practice may seriously worsen the health of adolescents leading to the recurrence of pathologies.18 The results of the 2000 DHS show that 24.4% of girls of 15-19 age group had pathologic secretion from their vagina and 3.5% had inflammation or ulcer of reproductive organs. Overall, 1.4% of the informants had an STI.14 Knowledge regarding STIs is extremely low; 75.7% of girls and 48% of boys had no knowledge about STIs.14 Among the respondents who knew about STIs, 17.5% of girls are not aware of any sign/symptom of STI in men, and 16.2% of symptoms in women, while 21.7% of boys were not able to mention any STI signs/symptoms in men, and 40.2% - in women.14 The 2000 DHS showed that although the majority of adolescent girls and boys has heard of HIV/AIDS (89.9% of girls and 92.3% of boys), only 46.2% of girls and 51.1% of boys believe that there is a way to avoid getting HIV/AIDS.14 Only 46.6% of girls and 38.2% of boys think that a healthy-looking person can be infected by HIV/AIDS. The results of the sexual and reproductive health epidemiological surveys that were conducted by the Family Planning Association of Armenia in 1996 and 1998 indicated that awareness and knowledge about contraceptive methods and sexually transmitted diseases and HIV prevention was very poor. Lack of knowledge and/ or the prohibitive expense of modern methods of contraception leads sexually active young people to use low-cost family planning methods that are free yet unreliable. As a result they were at high risk of unwanted pregnancy and STIs including HIV.33 The expectation that a woman should be a virgin until marriage increases the chance of early marriage among young girls, and the expectation to have a first child immediately after marriage leads to high teenage fertility rate.33 According to MOH data, the number of pregnancies among 15-19 years old girls has increased significantly over the last few years.15 Statistics on mental illness are collected through the MOH. Data from 2000 show that among 15-17 year olds, the rate of mental illness is 132/100 000 adolescents (Table 10).13 The rate has fluctuated over the last decade, however there is no consistent increase or decrease in the rate detected. Table 10. Mental disorders in adolescents (15-17), 1990-200013 1990 1991 1995 1996 1997 1998 1999 2000 Absolute number 213 121 101 107 162 197 163 163 Per 100,000 146.4 84.3 80.0 85.2 128.9 164.7 132.2 132.0 During the adolescent period, young people confront choices related to intoxicating and addictive substances like tobacco, alcohol and drugs.23 The 2000 DHS revealed that 20% of boys and 0.6% of girls in 15-19 age group were smokers and that 71.9% of men in 20-24 age group smoke.14 The large difference in rates may be attributed to under reporting in the 15-19 year age group, since societal and parental acceptance of smoking at that age is low.18 According to another quantitative study conducted among Yerevan school students of 7-9th grades, the percentage of boys smoking at least one cigarette per week was believed by participants of a survey to be an average 47%, while the percent of boys who self-reported using cigarettes at least once a week was 7%.29 Weekly use of tobacco by male participants’ closest friends was reported to fall between these two values. Again, as tobacco use is banned for students in schools, it is considered that informants preferred to underre- port their smoking habits rather than to be punished. Focus group participants from this age group confirmed this, stating that they were not convinced of the confidentiality of data, and that the actual rate of smoking should be higher.29 In recent years there has been an increase in tuberculosis in Eastern Europe and NIS countries. The rate of tuberculosis in Armenia more than doubled between 1993 and 2000, from 15.8 to 33.8/100,000.15 Although the disease is most common in adults, it is usually more serious in infants, children and adolescents. The highest incidence of tuberculosis in Armenia is registered in the 15-25 year old age group.15 The most fre-

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 30 quent type of tuberculosis seen in Armenia is the rapidly progressing pulmonary form. The current socio- economic conditions in the country are conducive to further spread of the disease. One conclusion that emerges from the data on adolescent health is that the majority of adolescent morbidity and mortality is caused by unhealthy behaviors. Substance use, unsafe sexual practices, and risky behavior leading to injuries begin during the adolescent years, but are also associated with adult morbidity and mortality. Intervening during adolescence gives the opportunity not only “to prevent the onset of health damaging behaviors, but also to intervene with health-compromising behaviors that may be less firmly established as part of the lifestyle”.32 3.3.2. Health Problems of Socially Vulnerable Adolescents There are no official statistics maintained by governmental agencies regarding the health status of socially vulnerable subgroups of adolescents (e.g., runaway adolescents, adolescents in institutions, adolescents from refugee families). However it is clear that "adolescents’ engagement in risky behaviors is embedded within a broader social context”.32 Socially disadvantaged adolescents often live in environments that are not conducive to healthy behaviors. For example, adolescents in the USA from lower income families are more likely to smoke cigarettes, be sedentary, or engage in episodic drinking than are adolescents from higher income families.32 Socially vulnerable adolescents are also prone to infectious diseases such as STIs and tuberculosis. It is indicated in the literature that the main risk factors that lead to the tuberculosis infection in adolescents are epidemiological factors (contact with person infected with tuberculosis); social factors (unfavorable social- economic conditions, incomplete families, being institutionalized - adolescents in orphanages, boarding schools, being migrants/refugees), biological factors (chronic conditions and co-morbidity) and non-quality tuberculosis vaccination.34 All problems faced by adolescents should be more pronounced in the socially vulnerable subgroups, and measures aimed to improve adolescents’ health in general should be specifically stressed for socially vulnerable adolescents. 3.3.3. Health Education Programs - Adolescents The results of the sexual and reproductive health epidemiological surveys that were conducted by the Family Planning Association of Armenia in 1996 and 1998 showed that there was very little sexual health education for children and that the information that was provided was often inadequate and misleading.33 According to MOH, the low knowledge and awareness about reproductive health issues indicate the need for sexual education in schools and establishment of health care facilities targeted especially towards adolescent health.18 Since 1996 the Family Planning Association (FPA) has made several efforts to educate adolescents in the sphere of reproductive health. A wide range of activities was undertaken by this organization, including seminars on reproductive health, development of the centers of sexual health, and the implementation of the school-based and community-based programs for adolescents regarding reproductive health issues. This ongoing program focuses on the issues of love, sexual maturity, relationships between men and women, family planning, STIs, AIDS, and sexual hygiene. The Life Skills Program is another example of a successful school-based educational program in Armenia. The program is currently running in 156 Armenian schools. It was introduced into the core curriculum by the Ministry of Education and Science in collaboration with UNICEF and the International Institute of Global Education of the University of Toronto, Canada. The Pilot " Life Skills Program was first launched in 16 schools throughout Armenia in 1998. The following main topics were included in the program: an individual and his/her relationships, making friends and having friends, human relationships, home and family, community and society, healthy lifestyle, environmental protection, conflict management, and sexual education. Classes are conducted by selected teachers who have received special training regarding the philosophy of the Life Skills Program, its goals, and methods of interactive teaching.. Evaluation showed that children were enthusiastic about the program. Due to overall success of the project, the Ministry of Education and Science of Armenia received requests to introduce Life Skills subjects in other schools throughout the country. People for Healthy Lifestyle, a local NGO, has conducted health education on the harmful effects of smoking. Through this project antismoking booklets were disseminated to children for family reading and educational classes were held for approximately 720 schoolchildren aged 10-14, and 5,000 children residing in summer camps in 1996-1997.

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The Substance Use Prevention Project for Armenian schools was implemented in 1999-2000 in four Yerevan schools. The goal of this program was to increase the motivation and skills of adolescents to adopt and maintain healthy behaviors.29 Evaluation of the project showed positive changes in decision-making skills and knowledge and attitudes about substance use in adolescents. Both teachers and students reported that they liked the program and found it to be very useful. The experience of the program and the lessons learned during its development and implementation could be very useful for the development of a national school health education program in this sphere. 3.3.4. Assessment of Health Problems/ Need by Key Informants Among the problems common in adolescents, informants reported that anemia and malnutrition were of concern, as well as the susceptibility of adolescents to mental disorders and depression. Early initiation of smoking and alcohol use was also reported as a problem. One of the informants mentioned that adolescents are unaware of ways of STI prevention and personal hygiene, and they need to be educated in these areas. Sev- eral informants noted that there are some adolescents applying to the clinic with eye problems and diabetes. Problems with posture, heart disease, and neurological disorders were also mentioned as frequently seen in their practice. One key informant -- a specialist concerned with problems of adolescents – discussed the problem of early marriages, unwanted pregnancies and complications of unwanted pregnancies. The informant mentioned the taboos in families on sexual education, lack of counseling services for adolescents on sexual education and limited information from mass media sources as the main causes for the increasing rate of STIs in adolescents. She also indicated that the current knowledge of adolescents regarding health issues in general is very limited and that the education of adolescents in school should include the dangers of smoking, drug abuse, injury prevention, and first aid along with reproductive health issues. Border/earthquake zone adolescents, adolescent refugees, and adolescents from single parent families were seen as among the most vulnerable. Children from boarding schools were mentioned as those who need special attention when planning and implementing health education programs. Often adolescents living in boarding schools have anemia and malnutrition. Runaway children are more prone to STIs and smoking habits, so the health education concerning these problems could be useful. Among other problems, drug abuse and prostitution were mentioned as problems more common in these subgroups (especially in runaway adolescents). It was also mentioned that socially vulnerable adolescents tend to suffer from the same problems as the general population, however their problems are more serious and complicated. Education regarding the harm of smoking and alcohol use would be appropriate to address the problem of smoking in adolescents. It was also suggested to include anti-alcohol/drug education component when developing the anti-smoking educational programs for adolescents in order to increase the level of knowledge among them and help them to prepare to cope with unhealthy behaviors in adulthood.18 3.3.5. Recommended Topics for Health Education / Promotion From the list of health problems in adolescents identified by needs assessment, the following problems were eliminated: Health Problems Reason for elimination Decreased physical activity Not prevalent Anemia Not prevalent Eye problems Too broadly defined Diabetes Not prevalent Problems with posture Not prevalent Heart disease Too broadly defined Malnutrition Not prevalent Neurological disorders Too broadly defined The following topics are suggested for targeting under the health education/promotion component of ASTP. 1. Reproductive health • Contraception use • Danger of abortions

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• STI/AIDS prevention/screening 2. Substance abuse • Smoking • Alcohol/drug use 3. Accidents (injuries) 4. Tuberculosis 5. Hygiene 6. First aid 7. Mental health (stress, depression) Further discussions with ASTP staff will refine the final list of topics for which health promotion/ education modules will be developed. 3.4. ELDERLY 3.4.1. General Health Problems Aging is a natural physiological process in which the body undergoes a series of changes. There is a wide range of variation in terms of how it impacts on individuals and their ability to lead an active and fulfilling life.35 Many older people remain active and fully independent until very close to the end of their lives. Older age, however, is very often accompanied by increased risk of certain diseases and disorders. Major threats to the health of older people include dementia, depression and suicide, cancer, cardiovascular diseases, osteopo- rosis, incontinence and injuries. According to the official statistics, at the beginning of the 2000, the elderly (greater than 65 years) consti- tuted 8.6% of the Armenian population, 58.3% women and 41.7% men.13 Cardiovascular disease (CVD) is the main cause of death in elderly (over 60 years) in Armenia, accounting for 47% of all deaths in women and 44% in men (in 2000). The mortality rate from CVD has been increasing since 1998, opposite to the trends seen now in Western Europe where CVD is on the decline. The increase in mortality rate from CVD may be attributed to the decline in the utilization of medical facilities and the increase in untreated cases.18 Other major causes of death in elderly Armenians are cancer (11.4% of deaths in women; 17% in men), diabetes (7.8% in women; 3.8% in men) and respiratory diseases (3.8% in women; 8.6% in men).13 Among cancers in males, the most frequent types are lung cancer (5.6% of all deaths in elderly men), stomach cancer (2.1%), cancer of organs of the intestinal tract (1.9%) and urogenital system (1.7%) In women the leading cause is breast cancer (2.3% of all deaths), followed by intestinal (1.4%) and stomach cancer (1.2%).13 Breast cancer deaths in women require special attention, as breast cancer is known to be one of the most cur- able cancers if detected and treated early. However the decrease in treatment-seeking rate in Armenia, as well as delay in timely screening has resulted in an increase in late-stage diagnosis when the treatment options are mostly palliative, and cannot save the lives of patients. This situation is typical for elderly women, who now constitute one of the most socially disadvantaged groups in the Armenian population. Official MOH data show a decrease in morbidity among the elderly in recent years.18 However, this should be interpreted with caution, as the mortality data show the opposite trend. The probable reason for this dis- crepancy is the decreased utilization of health care facilities, since these are the collection points for morbidity data. MOH officials claim that the mortality data more accurately reflect reality and are the most reliable indicator of the health status of elderly in the country.18 Delay in treatment has also leads to an increase in disability, one of the critical indicators of the health status of the population. The main cause of primary disability are the diseases of cardio-vascular system.18 In 1985, 694 people were classified as first category disabled as a result of heart ischemic disease. This rose to 1478 people in 1995 and 1733 people in 1998, representing a 2.4 fold increase from 1985.13, 36 The only survey concerned with health problems of elderly in Armenia was conducted in September 2000 by UNICEF, WFP (World Food Program) and UNHCR (Food Security and Nutritional Status survey).37 Over- all, 3, 900 households were surveyed, including 1955 elderly people (+60). 15% of elderly had a need for hospitalization, and only 21% felt themselves healthy with more elderly men considering themselves healthy

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(25%) in comparison to women (17%). Malnutrition was found in 7.8% of elderly. Chronic disease was reported by 57% of all the surveyed elderly. Forty-two percent had heart problems with a higher proportion of elderly women (48%) suffering from heart problems compared to men (34%) (Table 11). About one in three elderly had paradontosis, which impede their ability to eat hard-to-chew food. Approximately 11% had high blood pressure. Table 11. Proportion of elderly men and women reporting selected health problems, 2000, Arme- nia37 Problems Men, % Women, % General, % Tuberculosis 3.6 2.9 3.2 Asthma/bronchitis 9.6 7.1 8.1 Diabetes 5.1 7.7 6.6 Paradontosis 31.4 32.7 32.2 Heart problems 33.5 47.7 42.1 Hypertension 10.5 11.7 10.9 Diseases of the cardio-vascular system were among the most frequently mentioned health problems. 3.4.2. Health Problems of Socially Vulnerable Elderly Older people living in poverty are more likely than their middle or upper-class peers to experience deteriorating health as they age. Moreover, low-income elders are at higher risk of experiencing difficulties perform- ing routine activities of daily living - bathing, preparing and eating meals, doing light housework or shopping for groceries. Low-income elders also suffer from more chronic diseases and are more likely to be function- ally impaired than higher income elderly individuals. Currently there are limited data available regarding the health status of socially vulnerable elderly. It is assumed that the same problems prevail in the groups of socially vulnerable elderly: however, they are more pronounced and aggravated by poor socio-economic conditions, which leads to the underutilization of health care, low awareness of and inability to maintain healthy behavior, and high rate of complications. The only information available in Armenia regarding health status of the elderly is comparison data between health status of elderly refugees and the general elderly population. These data are presented in the Food Se- curity and Nutritional Status Survey report.37 The results of the survey show that a higher proportion of elder refugees have chronic illness in comparison to the national sample elderly (71% versus 57%) (Table 12). Higher rates of asthma/bronchitis, heart problems, and paradontosis were reported in this group. However, surprisingly, elderly refugees had lower rates of TB and high blood pressure as opposed to the national sample. Table 12. Proportion of elderly refugees reporting selected health problems in comparison to local elderly population, 2000, Armenia37 Health problem Elderly refugees Local elderly, % Tuberculosis 0.9 3.2 Asthma/bronchitis 15.0 8.1 Diabetes 8.8 6.6 Paradontosis 46.0 32.2 Heart problems 49.6 42.1 Hypertension 4.4 10.5 Elderly women living alone deserve special attention when planning and implementing health interventions for elderly, as this group is considered to be even more vulnerable and prone to certain chronic conditions than the rest of the elderly population. Women live longer than men, but these extra years are frequently accompanied by chronic illness, disability and difficulties in functioning independently. The data show that the proportion of individuals over 67 who are physically inactive is larger among women than among men.38 The Denmark data of health and morbidity in 1994 showed that 26% of men and 42% of women in this age group are physically inactive, which is explained by their unfavorable health status and lifestyle.38 One of the possible causes for the gender-based difference in functional ability may be that, “as muscle mass become less, women fall below the ‘critical threshold’ earlier than men do”. In many countries it is also accompanied with

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 34 the extremely limited social life of this category of women and constant sedentary life style they follow in older ages. Another vulnerable subgroup among the elderly is the “oldest old” – people aged 80 and over who experience a considerable loss of capacity and who constitute a heterogeneous group with rather different needs for health promotion and prevention. Their health status and problems need further investigation. 3.4.3. Health Education Programs - Elderly Elderly people, just like the younger population, can benefit from prevention and heath promotion; age should therefore not be an argument for reducing efforts in this area.38 Currently there are few programs in Armenia devoted to health education for elderly. Mission Armenia, a local NGO, has collaborated with UMCOR to establish several charitable soup kitchens and social centers for elderly. These centers currently function in Yerevan, Gyumri and Sisian marzes. Semi- nars / consultations on a variety of topics are being carried out in these social centers. The topics include hygiene and oral health, CVDs, atherosclerosis, respiratory illnesses, pneumonia, diabetes and its complications, arthritis, gastro-intestinal disorders, hygiene for elderly, and hygiene for obese elderly. The lectures are being provided in a popular and understandable way. Specialists are invited for lecturing occasionally, but in most cases Mission Armenia medical teams, involving a physician, a gerontologist, a psychologist, and a neurologist conduct the lectures. After lectures, the audience participates in active discussions. According to program representatives, overall the program was successful. It was also mentioned that individual consultations or group sessions are more appropriate for elderly rather than distribution of educational materials. The Soup Kitchen for Elderly Program initiated by ADRA in 1994 in Yerevan is another ongoing program targeting the elderly. The main activity of the program is the provision of socially disadvantaged groups, including single pensioners, refugees, low-income families, and disabled (selected based on Armenian Gov- ernment definitions of vulnerability) with food. In 2001 a health education component was also incorporated in the program. Physical activity and nutrition were the main subtopics of this educational program. About 2000 people have been involved in the program since the beginning of its functioning. 3.4.4. Assessment of Health Problems/ Needs by Key Informants The majority of informants from ASTP pilot sites emphasized the poor health and social status of elderly. According to most informants , the condition of the elderly population in Armenia is disastrous, as they have numerous health problems but don’t have access to health care and are not able to afford even cheap medicine. CVD, cancers (especially breast and cervical cancer for women and lung cancer for men), diabetes, malnutrition, and gastrointestinal problems were among the conditions most frequently mentioned by the majority of key informants. Urogenital problems, neurological disorders and mental problems were also identified by some of the informants as conditions seen in their practice. A key informant working with socially vulnerable elderly mentioned that all the problems prevalent in the general elderly population are also present in the most vulnerable subgroups, although the presentation is often severe and often goes untreated for years. Lonely pensioners are the most vulnerable due to malnutrition, which is explained by the low socio-economic status and lack of care and support. Their problems are aggravated by their psychological condition, as typically, socially deprived elderly are more depressed and dissatisfied with their lives. Lonely elderly men in Armenia were also considered by several professionals as a very vulnerable category, as they are more helpless than elderly women, and are more prone to CVDs, in- farction and stroke. According to informants, the Armenian Government pays insufficient attention to the health needs of socially vulnerable elderly. In the absence of a state program focusing on the health of elderly, several NGOs (ADRA, Mission Armenia) are addressing the health needs of socially disadvantaged elderly through the establishment of charitable soup kitchens and social centers and the provision of medical examinations and treatment. Key informants expressed contradictory opinions regarding the health education for elderly. Some of them mentioned that elderly are very receptive to health education, while others stated that elderly people are in- different to their health, and it would be hard to involve them in health education activities. Some of the informants expressed the opinion that the elderly population “is too old for prevention” as they have already developed certain conditions; these informants felt that it is more reasonable to target the younger population with preventive/health education programs. The biased attitudes expressed by some health care professionals

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 35 could potentially affect the quality of health education given to elderly and should be taken into consideration when designing programs. Most informants mentioned CVD as an important health education topic for elderly. Some of the informants noticed that some elderly people practice self-treatment without even simple knowledge of their disease and that it usually results in complications. Diabetes, hygiene and care of mouth, respiratory illnesses, arthritis, gastro-intestinal disorders, and hygiene were also identified by many key informants as topics relevant for health education programs targeted towards the elderly. 3.4.5. Recommended Topics for Health Education/ Promotion Of the health needs in elderly, the following problems were eliminated as not appropriate for targeting by ASTP/health promotion component: Health Problems Reason for elimination Arthritis Not amenable to health education/health promotion Disability Not easily amenable to health education/health promotion Urogenital problems Not amenable to health education/health promotion Neurological disorders Too broadly defined Gastrointestinal problems Too broadly defined Hygiene Too broadly defined The following topics are suggested to be included in the health education/promotion materials: 1. Cardiovascular Disease • Hypertension • Diet • Exercise • Frequent check-ups 2. Cancer (primary and secondary prevention) • Breast cancer screening and self-screening for elder women • Lung cancer prevention in men (anti-smoking education) • Prostate cancer in men (secondary prevention) 3. Diabetes (secondary prevention) • Hypertension • Diet • Exercise • Frequent check-ups 4. Respiratory illnesses (asthma/bronchitis/pneumonia) 5. Dental care/hygiene (paradontosis) 6. Nutrition 7. Tuberculosis 8. Mental health (depression) Further discussions with ASTP staff will refine the final list of topics for which health promotion/ education modules will be developed. 3.5. SUMMARY OF RECOMMENDED TOPICS FOR HEALTH EDUCATION/PROMOTION MATERIALS FOR VULNERABLE GROUPS The assessment of health needs of vulnerable populations in Armenia revealed numerous problems that can be addressed by health education programs and suggests a variety of health education topics for each vulnerable group. Some of them are specific for a particular group, while others are common throughout the popu-

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 36 lations of interest. In Table 13, a summary of topics is presented according to the different vulnerable groups. Topics common to several groups include injuries, nutrition, first aid, reproductive health, dental health, substance abuse, tuberculosis and mental health. Each of the remaining topics was pertinent to one particular vulnerable group. The CHSR is able to develop health education/promotion materials for all of the conditions listed on Table 13 under its contract with ASTP. Table 13 therefore represents a comprehensive list of recommendations for health education / promotion materials that the CHSR proposes to develop. Table 13. Summary of Health Education Topics by Vulnerable Groups Groups Pregnant/ Topics Children Adoles- lactating Elderly under 5 cents women Acute respiratory diseases * Diarrheal diseases * Accidents (injuries) * * NUTRITION * * * Rickets * First aid * * Breastfeeding * Reproductive health * * Dental health * * Dangers of substance abuse (smoking/alcohol) * * Physical activity/exercising * Tuberculosis * * Hygiene * Mental health (stress, depression) * * CVD * Cancer (primary and secondary prevention) * Diabetes (secondary prevention) * Respiratory illnesses (asthma/ bronchitis/ pneumonia) *

4. DELIVERY CHANNELS FOR HEALTH EDUCATION A wealth of information was obtained regarding possible delivery channels for health education/ health promotion materials and messages for the vulnerable population groups in Armenia. Sources of information included literature, as well as the professional opinion of MOH consultants, specialists working with specific vulnerable groups, and health care professionals involved in ASTP pilot sites. Several studies have explored the question of optimal delivery channels for the dissemination of health- related information in Armenia.31, 39, 40 According to the Baseline Reproductive Health Survey results, the preferred sources of health information for women are doctors, followed by printed information (books, brochures, etc.).39 The Communications Situational Analysis study conducted in 1998 in Armenia showed that written materials (e.g., brochures) are effective tools for the dissemination of health-related information, especially when the materials are distributed to audiences at health care facilities.31 The same study showed that television is a good vehicle for reaching the general population, especially adolescents. However, the type and frequency of messages used should be carefully considered, taking into account the sensitivity of the population to certain health issues. Irrespective of the communication tool (print or broadcast information), the delivery of health-related messages should be done through health professionals.31

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The optimal delivery channels identified through in-depth interviews with health care professionals and specialists working with specific vulnerable populations varied depending on the target group. However, in the majority of cases, the preference was given to primary care facilities and physicians as a medium for delivering health information to the general population. 4.1. HEALTH EDUCATION DELIVERY CHANNELS – CARETAKERS OF CHILDREN UNDER FIVE Key informants felt that the most effective delivery channels for health information targeted towards caretakers of children under five were physician consultations and group lectures in the primary care facility. They stated that the lectures should be supported by visual aids. In addition, educational materials (booklets, newsletters) could be given to caretakers during these consultations/ lectures to take home for reference. Several informants felt that Armenian mothers would be very interested in health information, as they are usually concerned about the health of their children and visit the clinics often. Television and radio programs were mentioned as useful for reaching large numbers of the population; however the preference was still given to the delivery of educational materials through the primary care facilities. 4.2. HEALTH EDUCATION DELIVERY CHANNELS – PREGNANT WOMEN The primary care facility can also be used for the delivery of health information to pregnant women during prenatal care visits. It has been shown that Armenian pregnant women are receptive to printed health education materials and can modify their behavior according to the health messages received.31 4.3. HEALTH EDUCATION DELIVERY CHANNELS – ADOLESCENTS Informants felt that adolescents should be targeted for health education through schools, since they are not frequent visitors of primary care facilities. Schools have been identified as an obvious delivery point for channeling new information to adolescents, since many adolescents can be reached simultaneously.31 How- ever, officials from MOH stated that if sexual education for adolescents is to be provided in schools, specialists from different spheres (physicians, pedagogues, psychologists, etc.) must be involved in the preparatory phase in order to assess the mode and methods of teaching.18 The background and experience of the health educators are also important (e.g., teacher working at the school, outside lecturer, prepared professional, physician, etc). One option would be to use an outside specialist, though this may require additional expenses from schools. Informants felt that the presentation of health information to adolescents should be attractive and interesting, as adolescents are bored by the traditional modes of teaching.31 The positive experience of education in schools regarding substance abuse also suggests using the schools as a channel for information delivery.29 One informant who works in the field of adolescent health mentioned the Life Skills Program currently included in the school curriculum. She stated that it would be reasonable to incorporate several health topics into this program. According to MOH officials, adolescents are open to receiving information about reproductive health and other issues in schools.18 The results of the DHS showed that the majority of surveyed adolescents (about 90%) agreed with public discussions about HIV/AIDS in mass media.14 The positive opinion of parents regarding sexual education in schools is crucial for the success of the educational process. Overall, 44% of women surveyed, and 51% of men, thought that children 12-14 years old should be educated in schools about condom use.18 However, one third of adolescents thought that children ages12-14 should not be taught about condom use. Mass media (television and radio) was also mentioned as an appropriate tool for information delivery to Ar- menian adolescents. 4.4. HEALTH EDUCATION DELIVERY CHANNELS – ELDERLY For elderly, primary care facilities (physician consultations with the delivery of educational materials) and television/radio were mentioned as the most appropriate delivery channels for health education. Some of the key informants identified lectures and seminars in the health facility as appropriate ways to disseminate information to groups of elderly people. It was emphasized that lectures and active discussions on health education topics would be more useful for elderly than the delivery of health education materials alone, since many elderly people have vision problems and may have difficulties reading the literature. Respondents also felt that the elderly value direct communication with a specialist and with each other. One of the health care professionals felt that it would be a good idea to initiate a center for diabetics, where elderly people would

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 38 have an opportunity to receive and exchange information regarding diet, exercise, and other diabetes-related issues. According to MOH consultants, the optimal channels for CVD-related preventive health education for elderly were 1) mass-media; 2) special groups or clubs (organized in the primary health care facilities, where the CVD patients will have an opportunity to communicate and educate each other about the disease); and 3) counseling sessions (provided by physicians at primary health care clinics).18 4.5. HEALTH EDUCATION DELIVERY CHANNELS – SOCIALLY DISADVANTAGED GROUPS Several factors should be taken into account when choosing the optimal strategy for the delivery of health education to certain socially disadvantaged or “most vulnerable” subgroups,. Many key informants mentioned that socially disadvantaged groups are the most “hard-to reach” population, as they often do not apply to medical facilities, and sometimes do not have access to television. It was also mentioned that these groups might not be very receptive to written educational materials. Therefore, direct meetings with people from these subgroups at locations convenient to them might prove more effective. Others mentioned that nurses occasionally conduct outreach activities for socially disadvantaged people who are not able to visit the health facility. Another possible delivery channel mentioned were lectures in the canteens distributing free food. For example, WFP is organizing a “food for training” program under which they do training for the population and distribute free food, thus creating an incentive for the population to attend these trainings. It was mentioned that those people that never attend clinics (e.g., runaway adolescents) could be reached by NGOs working in the health sphere. The optimal delivery channel for the caretakers of institutionalized children/adolescents or institutionalized elderly are institution-based lectures and seminars with subsequent distribution of printed materials (books, brochures). Key informants stressed usage of video during lectures. Several informants emphasized that health education is not going to solve the health problems of socially disadvantaged people, as they are more in need of social / health programs that would directly deal with their poor socio-economic conditions (e.g., distribution of free medication, food, clothing, etc.). 4.6. SUMMARY OF HEALTH EDUCATION DELIVERY CHANNELS Based on information from literature and key informant interviews, the following health education delivery channels are recommended: • Caretakers of Children Under Five: Primary Health Care Facilities • Adolescents: Schools, Mass Media • Pregnant Women: Primary Health Care Facilities • Elderly: Primary Health Care Facilities • Socially Disadvantaged Populations: Institutions, Outreach, NGOs

5. HEALTH EDUCATION/ PROMOTION MATERIALS AVAILABLE IN AR- MENIA As part of this Needs Assessment, CHSR collected and catalogued health promotion/ health education materials developed or used in Armenia. This section presents a brief summary of the methodology used for collection and the types of materials collected. 5.1. METHODS FOR COLLECTING AND CATALOGUING MATERIALS A list was compiled of all international, local, and governmental organizations working in the sphere of health education and health promotion in Armenia. Using structured questionnaires (Appendices 3 and 4) information was collected from each organization regarding design, production, and utilization of health materials. The information was entered into a computer database that has been submitted separately to ASTP as part of this report.

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5.2. BRIEF SUMMARY OF MATERIALS COLLECTED Overall, 259 health education and health promotion materials were collected during the period from February to May 2002 from both governmental and non-governmental organizations involved in the design and delivery of health education materials within Armenia. The majority of the materials addressed several health topics simultaneously. Therefore, the summary of materials by health topics contains considerable overlaps. A summary of organizations and an inventory of health materials are included in Appendices 5 and 6. Individ- ual authors who are not affiliated with any organization developed some of the materials. To maintain con- sistency of reporting, these authors’ names are omitted in the summary of organizations. Table 14 presents a brief summary of the extent of coverage of health topics by existing materials in Arme- nia. Coverage was assessed for each health topic that was recommended for module development by this Needs Assessment. As shown in the table, there are particular topics for certain vulnerable groups for which no educational materials were found. Specifically, there was a paucity of materials for elderly, especially on respiratory illnesses, dental care, tuberculosis and nutrition. The materials regarding CVD, cancer and diabetes were extremely limited. No health materials were found which address the problems of rickets in children under 5. There were several topics covered only partially or insufficiently by the current array of materials. Table 14. The coverage of health topics3 by materials existing in Armenia Topics Children under Pregnant/ Lac- Adolescents Elderly 5 tating Women Accidents (injuries) Partially Covered Partially Covered Acute respiratory diseases Covered Breastfeeding Covered Cancer Partially Covered CVD Partially Covered Dental health Covered Not Covered Diabetes Partially Covered Diarrheal diseases Covered First aid Partially Covered Partially Covered Hygiene Partially Covered Mental health (stress, de- Partially Covered Partially Covered pression) Nutrition Covered Covered Not Covered Physical activity/exercising Covered Reproductive health Covered Covered Respiratory illnesses Not Covered Rickets Not Covered Substance abuse Covered Covered Tuberculosis Partially Covered Not Covered

6. CONCLUSIONS AND RECOMMENDATIONS The Needs Assessment identified several gaps in the current health policy regarding health care and prevention for vulnerable segments of the population in Armenia. Moreover, it revealed the pitfalls of the health surveillance system currently maintained in Armenia. Health statistics, one of the main sources of information used for monitoring the health situation, is not stratified for particular vulnerable population groups.

3 Extent of Coverage is given for topics identified as priority problems by this Needs Assessment. Shaded cells indicate that topic was not identified as priority for the particular subgroup.

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There is insufficient information for informed prioritization and development of targeted health promotion and prevention programs. There are several approaches/ methodologies outlined in this Needs Assessment study that can be used for the identification of vulnerable populations in a country. However, no one methodology alone can be employed to identify population groups that would be appropriate for the ASTP health education program. The final approach employed in this study combined results obtained from several methodologies; vulnerable groups were identified based on the appropriateness of these methodologies for use in this study and an analysis of where the results they generated converged and diverged. This provided the information necessary for selecting suitable target groups, which included broad vulnerable groups (Children Under 5; Preg- nant/ Lactating Women; Adolescents; and Elderly) and extremely vulnerable subpopulations within these groups. Health education materials produced for the large groups can also be used for health education with extremely vulnerable subpopulations. It is also recommended to develop specific health materials for subpopulations of interest when appropriate. Assessment of the major health needs and health promotion needs of vulnerable groups was done based on available data provided by MOH and several non-governmental organizations or gathered through an extensive literature review. This information was complemented with expert opinions obtained from in-depth interviews with health care professionals and specialists working with certain population strata. There is a wealth of existing health educational materials in Armenia on a variety of topics. However, there are topic areas that are not sufficiently addressed by the current array of educational materials. Inju- ries/accidents, poisoning, dental health, and respiratory illnesses among elderly are among the topics for which no educational materials are found. Existing materials covering tuberculosis, CVD, mental health, and diabetes do not provide sufficient breadth and depth appropriate to these topics. These gaps are to be filled by the development/adaptation of materials available in other countries. 6.1. GENERAL HEALTH EDUCATION/ PROMOTION NEEDS Based on the analysis presented in the previous sections, the following health topics are recommended for inclusion in the health education/health promotion materials to be delivered to vulnerable population group under the ASTP health promotion component. Children under 5 • Acute respiratory diseases • Diarrheal diseases • Accidents (injuries, poisoning) • Nutrition (anemia, iodine deficiency) • Rickets • First aid Pregnant/lactating women • Nutritional needs during pregnancy (healthy diet, anemia/iron deficiency, and vitamin intake) • Breastfeeding • Reproductive health (danger of abortions, contraception use, STI prevention/testing) • Dental health • Dangers of alcohol/passive smoking • Physical activity/exercising Adolescents • Reproductive health (danger of abortions, contraception use, STI prevention/screening) • Substance abuse (smoking, alcohol/drug use) • Accidents (injuries) • Tuberculosis • Hygiene

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• First aid • Mental health (stress, depression) Elderly • Cardiovascular disease (hypertension, diet, exercise, frequent check-ups) • Cancer (breast cancer screening and self-screening for elder women, lung cancer prevention in men (anti-smoking education), prostate cancer in men (secondary prevention) • Diabetes: secondary prevention (hypertension, diet, exercise, frequent check-ups) • Respiratory illnesses (asthma/bronchitis/pneumonia) • Dental care/hygiene (paradontosis) • Nutrition • Tuberculosis • Mental health (depression) 6.2. DELIVERY CHANNELS FOR HEALTH EDUCATION/ PROMOTION Despite the low utilization of primary care health facilities by the public, these facilities may still be the most optimal channel for delivering health education to mothers of children under 5, pregnant women and elderly people. These groups can receive consultations and educational materials during their visits to polyclinics. In addition, lectures and seminars can be organized in the polyclinics for groups of patients (especially for elderly and mothers of under 5 children) utilizing video aids. Lectures can be reinforced by discussions and printed materials. For adolescents and other socially disadvantaged population groups who rarely attend primary health care facilities, other mechanisms must be developed to reach them. The recommended channels for the delivery of health education for adolescents are school and mass media. The positive experience of similar educational programs conducted in the schools in the past is promising; however, school programs should be developed with caution and thorough consideration of the curriculum and teachers to be involved. The other possible way of reaching the adolescents would be the provision of information through mass media. According to several sources, adolescents are ready to accept information through mass media on all topics, even sensitive issues. However, taking into account the cultural and societal constraints in the Armenian society regarding open discussions of reproductive health issues, it is suggested not to develop extensive mass media campaigns for adolescents on these specific topics. Polyclinics and mass media are not considered to be effective channels for information delivery to socially disadvantaged subgroups since, according to professionals working with these groups, access to these channels by socially deprived populations is low. The most appropriate strategy to reach these groups is outreach to families/individuals at sites convenient to them and personal or group consulting on pressing health problems. This task is more likely to be properly addressed by NGOs, some of which have already established mechanisms for accessing these groups. The most effective channel for health information delivery to socially disadvantaged subgroups (e.g., low- income families, single pensioners, “oldest of the old ” (+80)) would include home visits by physicians. Al- though community outreach is not currently included in the daily routine of polyclinic physicians, the Family Medicine Practice could be an ideal medium for the incorporation of outreach home visits and provision of health consultation and educational materials to the socially disadvantaged groups of the population.

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APPENDIX 1. DETAILED DESCRIPTIONS OF EACH METHODOLOGY a) Burden of Disease Studies Assessment of the burden of disease in a given country – identification of the health problems placing the biggest burden on the society – can be useful for identifying groups at high risk for specific diseases/ health problems. The methodology requires extensive time and resources, and a separate Burden of Disease study if the local health information system is not adequately developed. b) Health Surveillance System Data Analysis Vulnerable population groups can be identified based on statistical data collected through health surveillance systems. Highly developed surveillance systems provide a wealth of information on population subgroups, allowing for comparisons and identification of groups most vulnerable to specific health problems. Public health communities largely rely on surveillance data to set research and health prevention priorities. Accu- rate, timely, and relevant information about the health status of a population makes possible the identification of health problems, the discovery of specific vulnerable groups in the population with particular problems, and the design and targeting of private and public sector programs to address these problems, provided there is an appropriate infrastructure to achieve this. c) Population-Based Health Surveys In the absence of a well-developed official surveillance system, quantitative surveys of a representative sample of the population may be used to collect data on the health status of the general population. However, population surveys require extensive time and resources. d) Poverty Assessments Poverty assessment is one of the most utilized approaches for assessing the population subgroups most at risk for poor health outcomes. This approach is based on the fact that poverty - whether defined by income, socio-economic status, living conditions, or educational level - is the largest single determinant of poor health.41 “Inequities in health occur across a wide range of disease types and causes, with the vulnerability and exposure to these diseases as well as their negative consequences inevitably clustering among those at the lower end of the socio-economic spectrum.”42 Several risk factors and diseases are disproportionately concentrated in poorer populations. Living in poverty is associated with higher rates of communicable diseases, accidents, injuries, substance use (tobacco, alcohol, drugs), depression, suicide, antisocial behavior and violence, and nutrition problems. e) Rapid Assessment Procedures Rapid assessment procedures (RAP) are widely used as a means of identifying risk groups in the population (either disease-specific vulnerable groups or groups vulnerable in the broader context). RAP employ a combination of different research methods from various disciplines.43 Principal among these are qualitative research methods from the fields of sociology and anthropology; applied survey research from public health epidemiology; and action research for community development and emergency response.43 The focus of this approach is intervention development, and information is used to assist decision-makers regarding the need, feasibility, and relevance of interventions. Qualitative data on individual perceptions, beliefs, and values are central to RAP and are mainly obtained through the following research techniques: • Formal interviews • Informal interviews • Conversations with well informed individuals or groups • Observations • Participant observations • Focus group discussions (FGD) The RAP approach requires relatively less time and resources for implementation. However, the results are largely based on subjective opinions / assessments. f) Life Stage Analysis

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 43

This approach assumes that each stage of life is characterized by specific risk factors and conditions, which may lead to poor health. All individuals can be at risk for specific health problems at each life stage when particular life events occur. For example, childbearing and menopause are life events experienced by women of reproductive age, which are characterized by specific health problems and which may affect the health of a woman. Infancy and aging are also crucial transition periods making people more vulnerable to poor health. The targeting of vulnerable populations based on specific risk factors present during each life stage is common throughout the world.44 This approach is widely applied in risk assessment for social protection projects.45 For example, social risk management using a lifecycle approach has been carried out in several Latin American countries for identification of vulnerable age groups and development of specific interventions that ensure social protection for each age group.45 Figure 1. The Main Stages in the Life Cycle45

Perinatal period

Pregnancy Neonatal period

Birth 7 days Early Infancy neonatal 28 days Death period

Aging 1 year

Adulthood "Pre -school” years 20 years 5 years Reproductive period 10 years Childhood

Adolescence "SScchool-age" Figure 1 shows the lifecycle beginning with conception, birth and progressing through childhood, adulthood and old age up to death. Childhood is subdivided into several periods including infancy, preschool and school age period, and adolescence. The reproductive period is included within adolescence and adulthood.45 This approach recognizes the complex interactions between life events, biological risks, and health determinants, and also allows intervention and supportive action to reach almost all the vulnerable groups in the population, instead of focusing the efforts on narrow population groups at the possible expense of others that may be at equal or greater risk for poor health. However, this approach does not necessarily identify narrow vulnerable subpopulations. Rather, it is based on the inclusion of the whole population, with separate analysis of needs specific to each life stage and the design of health interventions specific to each group. g) Sociological Analysis This approach for identification of vulnerable population groups is based on the assertion that “…differential risks exist for different groups as a function of the availability of opportunities and resources present in that society/community for maximizing the health of these groups.” The resources, “frequently distributed un- evenly across society, include money, power, prestige, and various kinds of interpersonal relationships”. Re- searchers consider that social conditions defined by socioeconomic position, race/ethnicity, and gender, influence the access of individuals to the resources and are social determinants of health status. To a large extent, differences in health among different social subgroups of people are determined by the differences in life style and behavior (e.g. tobacco use, alcohol use, nutrition and exercise). Unhealthy life-styles are more often present in socially deprived populations. This approach is rather complex and requires country-specific data and information stratified by social categories (the various ways of classifying the different combinations of age, gender, race/ethnicity, and income

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 44 groups). According to this approach, individuals falling into multiple risk categories (e.g. poor elderly women) are considered to be in the most vulnerable position. h) “Post-factum” approach This approach makes use of the extensive experiences of government, international, and local organizations already working in the country. A thorough review is conducted of health programs and the various population groups whom they target. A list is compiled of all target groups currently receiving attention / assistance. These target groups are considered to be vulnerable. The underlying assumption behind this approach is that the organizations working in Armenia have previously identified those most vulnerable and, working within the confines of their own goals, will target their programs towards these groups. There are limits to this approach in the context of this needs assessment. This method does not provide solid justification of why any particular group is chosen. Many organizations may just be responding to donor requests, although it can be assumed that donors are also interested in targeting the most vulnerable. In addition, in many cases the targeted groups may not be appropriate for health promotion programs through the ASTP project.

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APPENDIX 2. IN-DEPTH INTERVIEW GUIDES ASTP/CHSR/Health Promotion Needs Assessment phase

GUIDE FOR INDEPTH INTERVIEWS WITH HEALTH PROFESSIONALS IN ASTP CATCH- MENT AREA

Date______

Location______

Interviewer______

INTRODUCTION (Please read the following introduction verbatim) Hello, I am ….., from the Center for Health Services Research and Development (CHSR) of AUA. We are conducting interviews with health providers involved in ASTP pilot sites about the population’s health needs amenable to health promotion activities. ASTP proposes to promote the health of Armenia’s population with a health promotion campaign that coincides with its pilot activities in family medicine education. CHSR is completing a series of inter-related tasks in support of the ASTP Health Education/Promotion component including research on needs assessment for the identification of vulnerable groups in Armenia and their health promotion/education needs to collect/design appropriate health education/health promotion materials for Armenian population. So we would like to better understand the health situation in the catchment area of your policlinic and what people need in terms of health education. May I ask you a few questions about these issues? Everything you tell me will be kept confidential and your name will not be attached to any written information/report. In addition, you do not have to respond to any question you do not wish to answer. May I continue? A. Current state of health promotion in the catchment area I would like to ask you about the current/ past health promotion activities that took/take part in the catchment area of your policlinic. 1. Who (what organization) has conducted/conducts health promotion/education in this area? When did this activity take place? Were you involved in that in some way? How? 2. What were the topics of this health promotion/education (make a list for each organization)? 3. What types of materials were used during these activities (books, brochures, lectures, consultations, or else)? 4. What were the delivery channels for the health education/health promotion in your region? Was it done through the policlinics, or schools, or through some NGOs/governmental organizations? Were training materials targeted for the physicians or for the general population? 5. What segments of population were involved in this (was it for general population or for some specific age/gender/social groups)? 6. How many of population were involved approximately (how many people participated/were exposed to the delivery)? 7. Are there any materials used in your clinic currently (are there any materials used/distributed to people occasionally/at consultations/as an ongoing activity)? What topics are they covering? Who is the target audience? B. Vulnerable population 8. What population groups are the most vulnerable in your opinion (based on your experience)? 9. Why do you consider them to be more vulnerable than others?

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10. What do you think of children under 5, adolescents, pregnant/lactating women, and elderly? Are they vulnerable? (ask for each group). What makes them vulnerable? Who are the most vulnerable in these vulnerable groups (ask about social subgroups, for instance, refugee women, or lonely pensioners, or orphans) • Children under 5 • Adolescents • Pregnant/lactating women • Elderly • Else (identified under question 8) 11. Do you deal with these groups in your practice? 12. Do you think that there are groups that need special attention when planning/implementing health education/promotion? Which groups? C. Health needs/Health promotion needs in the pilot sites 13. What are the most important/prevailing health needs of the target population in the catchment area? (make a list for each target group) • Children under 5 • Adolescents • Pregnant/lactating women • Elderly • Other group identified under the question 8 14. What are the most important/prevailing health needs of the most vulnerable social subgroups in each group? (For instance, orphans, runaway adolescents, refugee, lonely pensioners, etc.) 15. What are the health education/health promotion needs in these groups (make a list for each target)? Are there gaps in the current knowledge of the population regarding the most important health problems? • Children under 5 • Adolescents • Pregnant/lactating women • Elderly • Other group identified under the question 8 16. Could you tell us about health promotion/education needs in certain social subgroups within the groups identified above (institutionalised children, runaway adolescents, single mothers, refugees, lonely elderly women, etc.). Do they have some specific needs? Do they differ in this respect from the “normal” people in the same age/gender group? 17. Do these social groups need special (separate) health education? How this could be done in your opinion? 18. As I told at the beginning of the interview, we are going to develop health education materials for the target groups identified. We suppose to have 15 modules devoted to different health topics. Based on your knowledge and experience, what topics you would suggest to include? (Make a list). D. Delivery channels for health promotion 19. In your opinion, what would be the best delivery channels for the health education/promotion information in your area? What channels would you recommend for each of the vulnerable groups we were talking about? Why? Is there a way that would be appropriate for all the groups? • Children under 5 • Adolescents • Pregnant/lactating women

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• Elderly • Other group identified under the question 8 20. What do you think, what types of materials would be best to use under this health education/promotion activities in general? (Brochures, books, lectures, consultations, or else). What would work better for the specific target groups? (record for each group) • Children under 5 • Adolescents • Pregnant/lactating women • Elderly • Other group identified under the question 8 21. In your opinion, what could the best delivery channel for health education/health promotion materials for the most disadvantaged/vulnerable subgroups? 22. Who are the most “hard-to-reach” population in your practice? How do you deal with them? 23. How it would be possible to access hard-to reach-population within the target groups (for instance, runaway adolescents, or institutionalised children, or refugees, or pensioners, or the most poor)? What methods would be appropriate/would work? Your recommendations?

THANK YOU FOR YOUR PARTICIPATION

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 48

ASTP/CHSR/Health Promotion Needs Assessment phase

GUIDE FOR KEY INFROMANT INTERVIEW WITH HEALTH PROFESSIONAL (FAMILY PLANNING CENTER) ADOLESCENTS HEALTH

Date______

Location______

Interviewer______

INTRODUCTION (Please read the following introduction verbatim) Hello, I am…., from the Center for Health Services Research and Development (CHSR) of AUA. We are conducting key informant interviews with professionals in the area of adolescents health. Armenia Social Transition Program proposes to promote the health of Armenia’s population with a health promotion campaign that coincides with its pilot activities in family medicine education. CHSR is completing a series of inter-related tasks in support of the ASTP Health Education/Promotion component including research on needs assessment for the identification of vulnerable groups in Armenia and their health promotion/education needs in order to collect/design appropriate health education/health promotion materials for the population. Adolescents are one of the target groups for the above-mentioned activities, so we would like to better understand the situation with adolescent health in the country and health education needs of adolescents. May I ask you a few questions about these issues? First I would like to talk about health needs of Armenian adolescents in general (will focus specifically on reproductive health later in our interview). A. Health needs of adolescents 1. In your opinion, what are the most important/prevailing health needs of the adolescents in Armenia? (make a list of problems). What are the reasons for these problems to occur? 2. Could you tell us, what are the important/prevailing health needs of the most vulnerable social subgroups among adolescents? (for instance runaway adolescents, refugee adolescents, institutionalised)? Are there specific problems/problems that are more prevalent in these categories (for instance tuberculosis, unprotected sexual behaviour, substance use, mental health problems, etc.)? Do you have any data/statistical information regarding this? 3. Are health problems of adolescents in Armenia properly addressed by Government and NGOs? Are there areas that need closer attention currently? Which areas? Are health problems of socially vulnerable adolescents being properly addressed (runaway adolescents, refugee adolescents, institutionalised)? Do you know what programs are currently in place targeted specifically for adolescents/socially vulnerable adolescents (make a list of programs)? 4. What are the health education/health promotion needs of adolescents? What are the gaps in the current knowledge regarding the most important health problems (make a list)? Which of the current problems can be addressed by health education/promotion activities the best? (Do not focus on reproductive health – we’ll talk about it later) 5. (Check Q3). What health promotion/education programs were/are conducted in the sphere of adolescents’ health? When? By whom (make a list, including the name of the organization, the time, who was involved)? 6. What were the topics of this health promotion/education (make a list for each organization)? 7. What types of materials were used during these activities (books, brochures, lectures, consultations, TV/radio messages, or else)? 8. What were the delivery channels for the health education/health promotion programs you mentioned? Was it done through the policlinics, or schools, or through some NGOs/governmental or-

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 49

ganizations, or delivered to the public, generally? Were training materials targeted for the physicians or for the general population? 9. What segments of population were involved in this (was it for adolescents in general, or for some specific gender/social group among adolescents, or was it for the parents)? 10. What topics you would suggest to use under health education/promotion program for adolescents? What delivery channels you would suggest using? What type of health education materials would work the best, in your opinion? 11. What about socially vulnerable adolescents: how health education/promotion campaign can reach this group? What would be the best approach to accomplish this? 12. Now let’s focus on the reproductive health of Armenian adolescents B. Reproductive health of adolescents 13. Could you talk about reproductive health status of Armenian adolescents? What are the main problems in this area (make a detailed list)? What are the reasons for these problems to occur? Do you have any statistical information/data regarding the prevalence of reproductive health problems in adolescents? Are they available? 14. Is there a gender difference in the problems experienced by adolescents (problems more apparent in girls or in boys). Do you have any data regarding this? 15. What about the socially vulnerable adolescents: is there any data/evidence about their reproductive health status? Do you have any data available? 16. Are the reproductive health problems of adolescents currently addressed by Government of Armenia and NGOs? Could you list the programs conducted in this sphere in the recent past/currently (make a list). Are there any gaps in these programs? 17. What are the health education/health promotion needs of adolescents? What are the gaps in the current knowledge regarding the reproductive health problems (make a list)? Which of the current reproductive health problems can be addressed by health education/promotion activities the best? 18. (Check Q14). What health promotion/education programs were conducted in the sphere of adolescents’ reproductive health? When? By whom? Include the activities performed by your organization/NGO/agency/center (make a list, including the name of the organization, the time, who was involved). 19. What were the topics of this health promotion/education (make a list for each organization)? 20. What types of materials were used during these activities (books, brochures, lectures, consultations, TV/radio messages, or else)? 21. What were the delivery channels for the health education/health promotion programs you mentioned? Was it done through the policlinics, or schools, or through some NGOs/governmental organizations, or delivered to the public, generally? Were training materials targeted for the physicians or for the general population? 22. What segments of population were involved in this (was it for adolescents in general, or for some specific gender/social group among adolescents, or was it for the parents)? 23. What about socially vulnerable adolescents: how reproductive health education/promotion campaign can reach this group? What would be the best approach to accomplish this? 24. Do these social groups need special (separate) health education? How this could be done in your opinion? C. Delivery channels for reproductive health promotion/education for adolescents 25. In your opinion, based on your experience, what would be the best delivery channels for the health education/promotion information for adolescents in the area of reproductive health? What channels would you recommend. Why? 26. What do you think, what types of materials would be best to use under this health education/promotion activities? (Brochures, books, lectures, consultations, or else). What would work better?

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 50

27. In your opinion, what could be the best delivery channel and types of materials for health education/health promotion for the most disadvantaged/vulnerable subgroups among adolescents? Your recommendations?

(Could you identify is there an agency/specialist in Armenia concerned with health problems of runaway, and/or institutionalised adolescents)

THANK YOU FOR YOUR PARTICIPATION

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 51

ASTP/CHSR/Health Promotion Needs Assessment phase

GUIDE FOR KEY INFROMANT INTERVIEW WITH HEALTH PROFESSIONAL (ORPHANAGE DIRECTOR) HEALTH OF VULNERABLE CHILDREN

Date______

Location______

Interviewer______

INTRODUCTION (Please read the following introduction verbatim) Hello, I am…., from the Center for Health Services Research and Development (CHSR) of AUA. We are conducting key informant interviews with professionals in the area of children health. Armenia Social Tran- sition Program proposes to promote the health of Armenia’s population with a health promotion campaign that coincides with its pilot activities in family medicine education. CHSR is completing a series of inter- related tasks in support of the ASTP Health Education/Promotion component including research on needs assessment for the identification of vulnerable groups in Armenia and their health promotion/education needs in order to collect/design appropriate health education/health promotion materials for the population. Chil- dren (specifically children under 5) are one of the target groups for the above-mentioned activities, so we would like to better understand the situation with children health in the country and health education needs of children. We also would like to clarify the situation with socially vulnerable children: what their health needs are and what health promotion programs should be developed to improve their health situation. May I ask you a few questions about these issues? First I would like to talk about health needs of Armenian children in general (will focus specifically on socially vulnerable children/children from infant homes later in our interview). A. Health needs of children 1. In your opinion, what are the most important/prevailing health needs of the children in Armenia? (for instance respiratory diseases, diarrhoea, nutritional problems, etc.) (make a list of problems). What are the reasons for these problems to occur? What about the children under 5? Let’s focus on their problems (make a list). 2. Are health problems of children in Armenia properly addressed by Government and NGOs? Are there areas that need closer attention currently? Which areas? Do you know what programs are currently in place targeted specifically for children? 3. What are the health education/health promotion needs of children? Which of the current problems can be addressed by health education/promotion activities the best? What are the gaps in the current knowledge of the population/caretakers regarding the most important health problems in children under 5 (make a list)? 4. (Check Q2). What health promotion/education programs were/are conducted in the sphere of children’s health? (children under 5) When? By whom (make a list, including the name of the organization, the time, who was involved)? 5. What were the topics of this health promotion/education programs (make a list for each organization)? 6. What types of materials were used during these activities (books, brochures, lectures, consultations, TV/radio messages, or else)? 7. What were the delivery channels for the health education/health promotion programs you mentioned? Was it done through the policlinics, or through some NGOs/governmental organizations, or delivered to the public, generally? Were training materials targeted for the physicians or for the general population?

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 52

8. What topics you would suggest to use under health education/promotion program for children? What delivery channels you would suggest using? What type of health education materials would work the best, in your opinion? 9. Now let’s focus on health needs of and health promotion for the most vulnerable children B. Vulnerable children 10. In your opinion what are the most vulnerable subgroups among the children in Armenia? Why they are vulnerable? Do you think that they need special attention from the Government/NGOs when planning and implementing programs aimed to improve children’s health? 11. What are the most important/prevailing health needs of the most vulnerable subgroups in children? (For instance runaway adolescents, institutionalised children, children from socially disadvantaged families, refugees, etc.). Do they have some specific needs? (Make a list of problems for each category). Do they differ in this respect from the “normal” children in the same age/gender group? Are there problems that are more prevalent/dominant in these groups? Do you have any info/statistical data on this? • Institutionalised • Runaway children/adolescents • Children from refugee families • Other group mentioned at Q9 12. Please talk in details about the health needs of children in your orphanage and other orphanages in Armenia. 13. Are health problems of vulnerable children in Armenia properly addressed by Government and NGOs? Are there areas that need closer attention currently? Which areas? 14. What are the health education/health promotion needs of vulnerable children (their caretakers)? Which of the current problems can be addressed by health education/promotion activities the best? 15. (Check Q2). What health promotion/education programs were/are conducted in the sphere of vulnerable children’s health? (ask separately for children under 5) When? By whom (make a list, including the name of the organization, the time, who was involved)? What programs were carried out in your orphanage/infant home? 16. What were the topics of these programs (make a list for each organization)? 17. What types of materials were used during these activities (books, brochures, lectures, consultations, TV/radio messages, or else)? 18. What topics you would suggest to use under health education/promotion program for children (caretakers)? As you know we are going to develop health education materials for children health, specifically children under 5. If there were 5 most important topics for children to be targeted under the health education program, what would you suggest to include? (Make a list). What about your orphanage/other orphanages in Armenia? What’s most needed? 19. What delivery channels you would suggest using? What type of health education materials would work the best, in your opinion? What type of health education materials would work the best for the physicians/caretakers from your orphanage? 20. Do these social groups need special/separate health education? (Do you think the caretakers need to receive special education?) How this could be done in your opinion? How it is possible to better address the needs of runaway, institutionalised, poor children, children from refugee families? Specifi- cally, children from your orphanage?

THANK YOU FOR YOUR PARTICIPATION

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 53

ASTP/CHSR/Health Promotion Needs Assessment phase

GUIDE FOR KEY INFROMANT INTERVIEW WITH HEALTH PROFESSIONAL (Mission Arme- nia) HEALTH OF VULNERABLE ELDERLY

Date______

Location______

Interviewer______

INTRODUCTION (Please read the following introduction verbatim) Hello, I am…., from the Center for Health Services Research and Development (CHSR) of AUA. We are conducting key informant interviews with professionals in the area of elderly people health. Armenia Social Transition Program proposes to promote the health of Armenia’s population with a health promotion campaign that coincides with its pilot activities in family medicine education. CHSR is completing a series of inter-related tasks in support of the ASTP Health Education/Promotion component including research on needs assessment for the identification of vulnerable groups in Armenia and their health promotion/education needs in order to collect/design appropriate health education/health promotion materials for the population. Elderly (specifically, socially vulnerable elderly) are one of the target groups for the above-mentioned activities, so we would like to better understand the situation with health of elderly in the country and their health education needs. We also would like to clarify the situation with socially vulnerable elderly: what their health needs are and what health promotion programs should be developed to improve their health situation. May I ask you a few questions about these issues? First I would like to talk about health needs of Armenian elderly in general (will focus specifically on socially vulnerable elderly later in our interview). A. Health needs of elderly 1. In your opinion, what are the most important/prevailing health needs of the elderly in Armenia? (for instance cardiovascular diseases, cancer, diabetes, etc.) (make a list of problems). What are the reasons for these problems to occur? 2. Are health problems of elderly in Armenia properly addressed by Government and NGOs? Are there areas that need closer attention currently? Which areas? Do you know what programs are currently in place targeted specifically for elderly? 3. What are the health education/health promotion needs of elderly population? Which of the current problems can be addressed by health education/promotion activities the best? What are the gaps in the current knowledge of the population regarding the most important health problems in elderly (make a list)? 4. (Check Q2). What health promotion/education programs were/are conducted in the sphere of elderly’s health? When? By whom (make a list, including the name of the organization, the time, who was involved)? 5. What were the topics of this health promotion/education programs (make a list for each organization)? 6. What types of materials were used during these activities (books, brochures, lectures, consultations, TV/radio messages, or else)? 7. What were the delivery channels for the health education/health promotion programs you mentioned? Was it done through the policlinics, or through some NGOs/governmental organizations, or delivered to the public, generally? Were training materials targeted for the physicians or for the general population?

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 54

8. What topics you would suggest to use under health education/promotion program for elderly? What delivery channels you would suggest using? What type of health education materials would work the best, in your opinion? 9. Now let’s focus on health needs of and health promotion for the most vulnerable elderly B. Socially vulnerable elderly 10. In your opinion what are the most vulnerable subgroups among the elderly population in Armenia? Why they are vulnerable? Do you think that they need special attention from the Government/NGOs when planning and implementing programs aimed to improve elderly’s health? 11. What are the most important/prevailing health needs of the most vulnerable subgroups in elderly? (For instance lonely pensioners, lonely elderly women as a group, institutionalised elderly, etc.). Do they have some specific needs? (Make a list of problems for each category). Do they differ in this respect from the “normal” elderly? Are there problems that are more prevalent/dominant in these groups? Do you have any info/statistical data on this? • Lonely pensioners • Institutionalised • Lonely elderly women • Other group mentioned at Q9 12. Please talk in details about the health needs of elderly targeted by your programs. What have you discovered while working with elderly population regarding their health problems? 13. Are health problems of socially vulnerable elderly in Armenia properly addressed by Government and NGOs? Are there areas that need closer attention currently? Which areas? 14. What are the health education/health promotion needs of vulnerable elderly? Which of the current problems can be addressed by health education/promotion activities the best? 15. (Check Q2). What health promotion/education programs were/are conducted in the sphere of socially vulnerable elderly. When? By whom (make a list, including the name of the organization, the time, who was involved)? What programs were carried by your organization in the sphere of health education? 16. What were the topics of these programs (make a list for each organization)? What were the topics of your programs? 17. What types of materials were used during these activities (books, brochures, lectures, consultations, TV/radio messages, or else)? 18. What topics you would suggest to use under health education/promotion program for elderly? As you know we are going to develop health education materials for elderly. If there were 5 most important health topics for elderly to be targeted under the health education program, what would you suggest to include? (Make a list). What’s most needed? 19. What delivery channels you would suggest using (through the policlinics, or through some NGOs/governmental organizations, or delivered to the public, generally)? What type of health education materials would work the best, in your opinion? 20. Do these social groups need special/separate health education? How this could be done in your opinion? Specifically, institutionalised elderly?

THANK YOU FOR YOUR PARTICIPATION

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 55

APPENDIX 3. QUESTIONNAIRE FOR THE COLLECTION OF INFORMATION ON EDUCATIONAL MATERIALS Information to be collected on each material 1. ID (a 6-digit sequential number) ______2. English title of the material ______3. Title of the material (in original language) ______4. Languages the material was developed in (check all that apply): Armenian Russian English Other (specify) ______5. Type of the material being collected (check one from the codes listed bellow) AT (audiotape) KT (kit) BK (book) LF (leaflet) BKL (booklet) PO (poster) BR (brochure) RP (report) CD (compact disk) SL (slide set) CL (calendar) TR (training material) FL (film) VT (video tape) FC (flipchart) 6. Physical description of the material (number of pages, cover, pictures etc) ______7. Genre (use only for audiotapes and videotapes to describe the style of production) (check only one) Animation Radio program Clinic video Radio spot Comedy Soap opera Documentary Television Program Drama Television spot Music Training material News/Talk Other (specify) ______8. Number of copies of the material provided ______

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 56

9. Check if the original or the photocopy of the material was provided Original Photocopy 10. Electronic version of the material/item Available Not available (go to question 12) 11. If electronic version of the material is available, will it be given to CHSR? Yes No 12. English version of the material, if original is not in English Available Not available (go to question 14) 13. If English version of the material is available, will it be given to CHSR? Yes No 14. Organization (or individual) responsible for the development of the material (add organization's code) ______15. Contact person, address, phone, fax, e-mail in the organization responsible for the development of the material ______16. Project/program under the terms of which health education/health promotion materials were developed/produced ______17. Year when the project was implemented ______18. Individual author(s) of the work ______19. Date of publication ______20. Edition ______21. Publisher (if different from organization responsible for the production) (contact person, address, phone, fax, e-mail) ______22. Donor organization who funded development of the materials (if different from organization responsible for the production & publisher) (contact person, address, phone, fax, e-mail) ______

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 57

23. Number of copies of the material published/produced ______24. Cost of the material per item, if known ______25. Category/Topic (check all that apply from the codes listed bellow) ADOL for adolescents ENV environmental health AIDS for AIDS /STD HYG for hygiene BRST for breastfeeding and safe motherhood HYP for hypertension CANC for cancer prevention INJ for injury control CHILD for child care NUTR for nutrition & food safety CVD for cardiovascular diseases PREG for pregnancy DIABT for diabetes RH for reproductive health DRUG for drugs & alcohol TOBC for tobacco Other (specify) ______26. Audience for which the material/item was developed (choose all that apply from the list bellow) Adolescents Health personnel Adults Hispanics African Americans Low literates Asian Americans Men Children Military personnel Community workers Mothers Couples Native Americans Drug users Parents Fathers Policy makers Gays/Lesbians Trainers (including Teachers) General (if no audience is indicated) Women Other ______27. The region for which the material was produced (check one from the codes listed bellow) Africa Near East Asia North America Europe New Independent States (specify) ______ Latin America Armenia (specify the region within Armenia) ______28. Country or countries in which the material was intended to be used ______29. Distribution plan of the material/item 29a. Distributor information, if different than organization/publisher/donor (contact person, address, phone, fax, e-mail) ______

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 58

______29b. Which channel of distribution was used? (Check all that apply from the list bellow) community schools health care providers (specify) ______ health care facilities (specify) ______ drug stores other (specify) ______29c. Number of copies distributed ______29d. Duration of distribution (Check all that apply from the list bellow) single distribution time to time distribution continuous distribution other (specify) ______30. Any notes about the material/item ______31. Was consultant/expert opinion solicited for the content of the materials developed/produced? Yes (specify the name______) No 32. Pretest of health education/health promotion materials 32a. Were the materials pre-tested with target group before final production and distribution? Yes No (go to question 33) 32b. If pre-tested what key changes were incorporated, if any? ______33. Was the effectiveness of the material evaluated? Yes (specify the evaluator ______) No (go to question 35) 33a. Was qualitative evaluation conducted? Yes No 33b. Was quantitative evaluation conducted? Yes No 34. If evaluated, what was the effectiveness of the materials (key findings)? ______

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 59

35. If not evaluated, what is anticipated effectiveness of the materials? ______36. Permission for reproduction/copy right issues Yes No Specific comments: ______37. Contact information on international partners/headquarters etc in NIS/worldwide who might be involved in development/production of health education/health promotion materials elsewhere ______

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APPENDIX 4. ORGANIZATION CONTACT INFORMATION SHEET 1. Name of the organization: ______2. Address of the organization (including street, building, city, country, zip code): ______3. Person contacted in the organization (name, position, phone #, e-mail address) ______

Date of a visit (month, dd, yyyy): ______/____/____ Comments:

Follow-up visit, if necessary: (date and purpose)

Date of the next visit (month, dd, yyyy): ______/____/____ Comments:

Follow-up visit, if necessary: (date and purpose)

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 61

APPENDIX 5. ORGANIZATIONS - HEALTH EDUCATION MATERIALS IN ARMENIA

Acronyms for Health Topics Used in Table ADOL Adolescent Health BC BreastCare BRST Breastfeeding CAN Cancer Prevention CHILD Childcare CVD Cardiovascular Disease DENT Dental Care DIAB Diabetes DISB Disabilities DRUG Drug / Alcohol Use EAR Hearing Problems ENV Environmental Health FA First Aid HERB Herbs HEP Hepatitis B HP Health Policy HYG Hygiene HYP Hypertension INF Infection Prevention INJ Injury Control MAL Malaria MH Mental Health NUT Nutrition and Food Safety PHAR Pharmaceutical PREG Pregnancy and Safe Motherhood RH Reproductive Health STD Sexually Transmitted Diseases including AIDS STR Stress TOB Tobacco Use TB Tuberculosis

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Organizations in Armenia -- Experience with Health Materials # of Organizational Involvement4 Type of Ma- N Name of Organization Mate- Health Topic Develop- Distribu- terial Funding rials ment tion 1 “Anna” National Association 10 ENV, HP, NUT, 6 brochures of Consumers STD, STR 4 magazine *** ** *** articles 2 ADRA -Adventist Develop- 8 1 booklet ment and Relief Agency In- 7 newsletters ** ternational 3 ACFPD - Armenian Charity 4 AIDS, BRST, 1 book Fund for Population Devel- CHILD, DRUG, 1 booklet * * opment PREG, RH, TOB, 2 calendars STD, STR 4 ADMTA - Armenian Drug 4 PHAR 3 brochures and Medical Technology 1 set of leaf- * * * Agency lets 5 ADRA -Adventist Develop- 7 CHILD, HYG, ment and Relief Agency In- NUT, PREG, RH, 7 newsletters ** ** ternational, Family Health STD Center 6 African Medical and Research 1 BRST 1 book * Foundation 7 AIHA - American Interna- 4 DENT, DRUG, 4 training * tional Health Alliance TOB, manuals 8 Altman Foundation 1 ENV 1 brochure * 9 American Red Cross 5 FA 1 book ** 4 booklets 10 AmeriCares 1 CHILD 1 book * 11 APEC - AIDS Prevention, 3 STD 1 leaflet * * Education and Care NGO 2 calendars 12 ARC -Armenian Red Cross, 1 BRST 1 booklet * Central Executive Board 13 ARC -Armenian Red Cross 1 HYG, NUT 1 leaflet * Society 14 ARC -Armenian Red Cross 5 FA 1 book Society, First Aid Training 4 booklets ** * Methodological Center 15 ARC -Armenian Red Cross 9 CHILD, HYG, 2 books, Society, Health Department MAL, NUT, RH, 1 booklet STD, TB 3 brochures ** ** 1 leaflet 1 VT 1 calendar 16 Armenian Association for 1 DIAB 1 book * * Diabetic Children 17 Armenian Foundation for 2 DIAB 1 booklet * * * Diabetes 1 leaflet

4 Levels of involvement * low (1-4 materials) ** moderate (5-9 materials) *** high (> 10 materials)

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 63

# of Organizational Involvement4 Type of Ma- N Name of Organization Mate- Health Topic Develop- Distribu- terial Funding rials ment tion 18 Armenian-American Wellness 2 CAN, RH 2 brochures * * * Center 19 Armenian Medical Society 1 DIAB 1 book * 20 Armenian Missionary Asso- 2 DRUG, RH, TOB 1 book * ciation of Armenia 1 booklet 21 Armenian Pediatrics Associa- 1 CHILD 1 book * tion 22 ARPA – Analysis, Research 2 DRUG, RH, TOB 1 book and Planning for Armenia, 1 booklet * * NGO 23 ARPEN Center 1 BRST, CHILD 1 booklet * 24 Association for Children with 1 EAR 1 booklet * Hearing Impairments 25 Association of Gynecologists- 1 RH 1 brochure Endocrinologists *

26 Authors from different organi- 1 BRST, CHILD 1 book * zations 27 AUA, CHSR -American Uni- 6 ADOL, BRST, 5 booklets versity of Armenia, Center for CHILD, CVD, 2 training ** * * Health Services Research and DRUG, ENV, manuals Development PREG, TOB 28 AUA, ECRC -American Uni- 2 ENV 1 poster versity of Armenia, Environ- 1 research * * mental Conversation and Re- paper search Center 29 AWHHE-Armenian Women 4 ENV, NUT, 4 brochures for Health and Healthy Envi- PREG * * ronment 30 “Bridge of Hope” NGO 5 CHILD 4 booklets ** 1 VT 31 “Behind the closed doors”, 1 ADOL, BRST, 1 newspaper LTD CHILD, PREG, * RH, STD 32 Boston’s women Health Book 1 BRST, CHILD, 1 book Collective DRUG, PREG, * RH, STD, STR, TOB 33 Civilian Research Develop- 2 ENV 1poster ment Fund 1 research * paper 34 Coca-Cola 1 FA 1 booklet * 35 Corporation for Peace and 1 FA 1 training Harmonious Development of manual * * Society 36 DNSG -Diabetes Nutrition 1 DIAB 1 booklet * Study Group 37 EASD - Eastern European 1 DIAB 1 booklet Association for * the Study of Diabetes (EASD)

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# of Organizational Involvement4 Type of Ma- N Name of Organization Mate- Health Topic Develop- Distribu- terial Funding rials ment tion 38 ECHO - European 2 PREG, RH, STD 2 brochures Community * Humanitarian Office 39 Edem 1 RH 1 brochure *

40 “For Family and Health” 30 ADOL, BRST, 1 book, Association CHILD, HYG, 1 booklet, NUT, PREG, RH, 3 brochures, STD *** *** 23 leaflets 1 calendar 1 newspaper 41 “Full Life” Handicaps’ Union 1 INJ 1 leaflet * * * 42 Future Generation Union 3 HYG, RH, STD 2 booklets * * 1 brochure 43 German Red Cross 1 FA 1 booklet * 44 Greek Red Cross 2 TB 1 brochure * 1 VT 45 GTZ IFSPSA- German Tech- 11 BRST, CHILD, 2 brochures nical Corporation, Interna- CVD, DIAB, FA, 5 booklets tional Food Security Program HERB, HYG, 3 VT *** *** for South Armenia NUT, PREG, RH, 1 leaflet STD 46 “Havat” Union EAR 1 booklet * 47 HAI - Health Activities Inter- 1 PHAR Set of leaflets * * national 48 Holland, Private Foundations 1 NUT. PREG 1 brochure * 49 Hope and Help NGO 4 STD 4 booklets * * 50 HPI - Heifer Program Interna- 1 ADOL, DRUG, 1 booklet tional HYG, RH *

51 IBFAN - International Baby 2 BRST 1 magazine * Food Action Network 1 booklet 52 International Federation of 3 CHILD, HYG, 1 booklet Red Cross and Red Crescent NUT 1 brochure * * Societies 1 leaflet

53 IPPF - International Planned 24 BRST, CHILD, 1 brochure Parenthood Federation HYG, NUT, 23 leaflets *** PREG, RH, STD 54 IOM - International Organiza- 3 STD 3 booklets * tion of Migration 55 IPEN - International POP’s 1 ENV 1 brochure * Elimination Network 56 IREX – International Research 1 NUT 1 booklet * and Exchange Board 57 JHU- Johns Hopkins Univer- 5 RH 4 brochures sity, Population Communica- 1 poster ** ** tion Services, Armenia Field Office

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 65

# of Organizational Involvement4 Type of Ma- N Name of Organization Mate- Health Topic Develop- Distribu- terial Funding rials ment tion 58 JHU -Johns Hopkins Univer- 1 RH 1 book sity, School of Hygiene and * Public Health 59 JMF - Jinishian Memorial 7 CHILD, DENT, 6 books Foundation EAR, PREG, RH, 1 booklet ** ** ** STD 60 “Maternal Fund of Armenia” 1 BRST 1 leaflet Charitable Public Organiza- * tion 61 Medical Scientific Center of 4 RH, STD 1 book Dermatology and STI 3 booklets *

62 Medical Union of Endocrinol- 1 DIAB 1 brochure * ogy Help 63 Mental Health Foundation 2 MH 1 brochure * * * 1 newsletter 64 MOH -Ministry of Health of 23 BRST, CAN, 2 books Republic of Armenia CHILD, DIABT, 7 brochures 6 HERB, HYG, booklets MAL, NUT, 4 leaflets *** *** PREG, RH, STD 1 poster 1 training manual 65 Mother and Child Health Pro- 4 BRST, CHILD, 3 booklets tection Association “Confi- NUT 1 magazine * * dence” 66 MSF -Medecins Sans Fron- 6 HYG, NUT, 5 brochure ** * ** tiers Belgium PREG, RH, STD 1 booklet 67 MSF -Medecins Sans Fron- 7 TB 3 booklet tiers France 2 brochure ** ** ** 1 leaflet 1 pamphlet 68 MSF - Medecins Sans Fron- 1 RH, STD 1 brochure * tiers German 69 Nairi Benevolent Union 2 CHILD 2 booklets * 70 Nagorno-Karabakh Republic, 8 BRST, CHILD, 4 brochure Ministry of Health TB 2 booklet ** * 1 leaflet 1 pamphlet 71 Nagorno-Karabakh Republic, 1 HYG, NUT 1 booklet Sanitary Epidemiological De- * partment 72 National Center for AIDS 5 HEP, RH, STD 5 brochure ** Prevention, Armenia 73 NIHA - National Institute of 5 BRST, CHILD, 2 brochures Health, Armenia DIABT, HERB, 2 booklets ** NUT, STD, 1 TR 74 NIHA - National Institute of 1 CHILD 1 book Health, Armenia, Department * of Pediatrics

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 66

# of Organizational Involvement4 Type of Ma- N Name of Organization Mate- Health Topic Develop- Distribu- terial Funding rials ment tion 75 NIHA - National Institute of 1 FA 1 booklet Health, Armenia, First Aid * Department 76 NIHA - National Institute of 1 TOB 1 leaflet Health, Armenia, Aleksandr * Bazarchyan 77 Netherlands Ministry for De- 3 BRST, CHILD, 3 booklets * velopment Corporation NUT 78 Netherlands Red Cross 1 CHILD, HYG 1 booklet * 79 NMMC - Nork Marash Medi- 7 CVD 7 training ** ** ** cal Center manuals 80 NMMC - Nork Marash Medi- 1 CVD 1 training cal Center, Pediatric Cardiac manual * * Center 81 Norway Red Cross 3 HYG, MAL, 1 book NUT, STD 1 brochure * 1 leaflet 82 NOVIB - Netherlands Organi- 1 RH, STD 1 booklet zation for International Devel- * opment 83 OSI – Open Society Institute 1 DIAB 1 brochure * 84 OXFAM – Oxford Committee 9 ADOL, BRST, 1 book for Famine Relief CHILD, HYG, 4 brochure ** NUT, PREG, RH, 1 booklet STD 3 leaflet 85 People for Healthy Lifestyle 1 TOB 1 booklet * *

86 PHARE/TACIS LIEN Pro- 1 MH 1 newsletter * gram of European Union 87 Plastic Uro-Gynecology and 1 CHILD, RH, STD 1 brochure Proctology “Veracnund” Cen- * ter 88 Psychological Center “Mek- 1 RH 1 booklet * nutyun” 89 SAMSA - Scientific Associa- 9 ADOL, RH, STD 5 brochures tion of Medical Students of 3 posters ** ** Armenia 1 flipchart 90 Save the Children 3 BC, CAN, ENV, 2 booklets, * * * HYG, INF, RH 1 brochure 91 SERVIER 1 DIAB 1 booklet * * * 92 Sevan Policlinic 4 DRUG, TOB, 4 training * * DENT manuals 93 Syunik Region, Goris Hospital 1 FA 1 booklet * 94 Syunik Region, Mass Media 1 DIAB, HERB 1 booklet * Department 95 Syunik Region, Sanitation 6 BRST, CHILD, 2 brochures Hygiene Center and local doc- DIAB, HYG, 1 booklet ** tors NUT, PREG, RH, 3 VT STD

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 67

# of Organizational Involvement4 Type of Ma- N Name of Organization Mate- Health Topic Develop- Distribu- terial Funding rials ment tion 96 The Judy and Michael 1 DISB 1 book Cheteian Educational/ Chari- * table Foundation 97 Tides Foundation 1 ENV 1 brochure * 98 UK, Hamlet Trust 1 MH 1 book * * 99 UMCOR - United Methodist 6 ADOL, BRST, 1 book Committee on Relief CHILD, DRUG, 4 booklets ** * ENV, TOB 1 training manuals 100 UNAIDS- United Nations 2 STD 2 brochures * Anti-AIDS Program 101 UNDP – United Nations Devel- 1 RH, STD 1 brochure opment Program

102 UNFPA- United Nations Fund 20 ADOL, BRST, 2 book for Population Development CHILD, HYG, 3 booklets PREG, RH, STD 8 brochures 2 calendars 1 *** * 1 poster 2 leaflets 1 flipchart 1 newspaper 103 UNHCR – United Nations High 9 ADOL, BRST, 1 book Commission for Refugees CHILD, HYG, NUT, 3 brochures ** PREG, RH, STD 3 leaflets 2 calendars 104 UNICEF – United Nations Chil- 25 BRST, CAN, 5 books dren’s Fund CHILD, CVD, 9 booklets HYG, NUT, PREG, 5 brochures RH, STD 2 posters *** *** *** 2 leaflets 1 training manual 1 VT

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 68

APPENDIX 6. SUMMARY OF HEALTH MATERIALS EXISTING IN ARMENIA This summary presents information on collected materials by topic area including 1) number and type of materials collected; 2) original language and available translations; 3) organizations involved in the development of materials; 4) project(s) under which the materials were developed; 5) target audiences; and 6) distribution information. Breastfeeding Six materials were collected on breastfeeding and related topics such as pregnancy, reproductive health, and childcare. Four of them were originally developed in Armenian, one is available only in Russian, and one was originally developed in English and then translated into Armenian. The 6 materials include two books, one brochure, one newspaper, one Reproductive Health folder with several brochures, and one videotape. The National Institute of Health (NIH), local physicians of Syunik region of Armenia, the local NGO “For Family and Health”, and the Boston’s Women Health Book Collective were involved in the development of these materials. The materials were developed during 1999-2002 under the projects related to Reproductive and Adolescent Sexual Health and Mother and Child Health Care. The materials target women, mothers, fathers, men, couples, and the general population. The materials are intended for nation-wide distribution, with one specifically targeting Syunik marz. Community outreach and health care providers were the most widely used distribution channels. The newspaper and the Reproductive Health Folder were distributed through schools, drug stores, and streets. In addition, the brochure developed by NIH was distributed to lactating women in Syunik region of Armenia. Most of the health promotion/health education materials on breastfeeding are currently available at health care facilities. Cancer Prevention Three materials (two brochures and one booklet) were collected on cancer prevention. In addition to cancer prevention, the brochures also address reproductive health issues, and the booklet provides information on acute respiratory infections. All three are available in Armenian, and one of the brochures is also available in Russian. The Armenian-American Wellness Center and the Ministry of Health of RA are responsible for the production of these materials. The materials target women and mothers. The brochures and the booklet were developed under the projects aimed at the prevention of breast and cervical cancer in women and acute respiratory infections among children in 1997, 1999, and 2001. One of the brochures, “For All Women – How to Prevent Cervical Cancer” was specifically developed in 2001 by the Armenian-American Wellness Center for distribution to clients attending the Center. All three materials were developed for the Armenian population, with the brochure about cervical cancer intended specifically for Yerevan and Gegharkunik regions. The materials were distributed through health care facilities by health care providers. The brochure about breast cancer prevention is currently available in the Armenian-American Wellness Center and is distributed to all visitors of the Center and to women attending the seminars organized for them. Cardiovascular Disease There is only one booklet on cardio vascular diseases, which also includes information on cardio-pulmonary resuscitation (CPR). The booklet was produced by the Department of Anesthesiology and Intensive Therapy of the Medical State University in 2001 to facilitate training and education of physicians. It is available in Armenian only. This booklet, intended for health care providers and medical students, was distributed to health care facilities all over Armenia. Childcare Sixteen health education materials addressing childcare issues were collected. The materials reflect different aspects of childcare including reproductive health, pregnancy, breastfeeding, nutrition, immunization, acute respiratory infections, diarrhea, and prevention of gastrointestinal infections. All materials are available in Armenian. The materials include 2 newsletters developed by Family Health Center (ADRA); 2 videotapes developed by local physicians of Syunik region; 5 booklets developed by a number of different organizations; 3 brochures produced by the Yerevan Residents World Club, Medicines Sans Frontiers-Belgium, and Ministry of Health; 2 books, 1 reproductive health folder, and 1 newspaper developed by the local NGO “For Family and Health” and Boston’s Women Health Book Collective.

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 69

The majority of the materials were developed recently (1999-2002) under the terms of the different projects, which target mothers and women. Several materials were developed for both parents and adolescents, and one covering acute respiratory infections was intended for use by health personnel. Another brochure addressing diarrhea was developed for the general population of Nagorno Karabakh Republic. All remaining materials were mainly intended for distribution throughout Armenia, with five of them designed specifically for Syunik marz. Health care facilities including hospitals, polyclinics, and drug stores are the predominant channels of distribution for these materials. In addition, several materials have been distributed via schools and communities, and one booklet developed by the Armenian Red Cross Society and International Federa- tion of Red Cross and Crescent Societies under the terms of Lice Prevention Project has also been made available in kindergartens. Another booklet addressing healthy life style issues is being currently distributed in schools. Dental Care There is one book and one training material addressing children’s dental care. The book was developed by the Center for Health Services Research and Development in 1997 under the “Health Education Program”, the implementation of which continues since then. The book is available in Armenian and is intended to be used nation-wide. It targets children and is continuously distributed in schools and kindergartens by different NGOs and organizations. The training material was developed by physicians from Sevan polyclinic, Gegharkunik marz under auspices of the AIHA. It targets adolescents and school children and was distributed in schools of Gegharkunik marz. Diabetes There are 2 materials on this topic including one booklet and one brochure. Both of them are available in Armenian and are intended for patients with diabetes and the general population. The booklet was developed in 2001 by Mass Media Department of Syunik region of Armenia with the support of the MOH (Ministry of Health) and the NIH (National Institute of Health of RA). It was produced monthly during 6-month period in 2001. However, only last edition of the booklet was provided for the database. The booklet was specifically developed for Syunik marz and was distributed via health care providers. Currently it is available in libraries of health care facilities in Syunik. The brochure was developed in 2000 by the Medical Union of Endocrinology Help for use in Yerevan and Lori marzes. The brochure was distributed by the local NGO Center to patients with diabetes. Environmental Protection There is one booklet that touches upon environmental issues, mainly addressing hygiene and prevention of water-born infections. The booklet is developed by the international NGO “Save the Children” under the Community Development Program, which was implemented nation-wide from 1995 to 2000. The booklet, targeting the general population, was distributed to community members following the training on prevention of water-born infections. First Aid A total of 8 materials are available regarding safety and first aid issues. Among them, 7 booklets are available in Armenian, and only 1 training manual is in Russian. Half of the materials were prepared by the Ar- menian Red Cross Society during the period from 1998 to 2002 as a result of projects on fundamentals of first aid and teaching safe behaviors. Two other booklets discussing tracheal intubations and cardio- pulmonary resuscitation were prepared by the Department of Anesthesiology and Intensive Therapy, State Medical University in 2001 to use for the training and education of physicians. The National Institute of Health and the Cooperation for Peace and Harmonious Development of Society were also involved in the development of first aid-related materials in 2001-2002. The majority of the provided materials are intended for the participants of special training programs and workshops on first aid. Among the others, the target audience included: policemen, rescuers, disaster workers, firemen, teachers, and health care providers. Some of the materials are also aimed at general population, medical students, and mothers and women. Most of the materials were produced to be used all over Armenia, and some of them were designed for use in Yerevan and Syunik marzes. The materials were mainly distributed to the participants of training programs and workshops, as well as to teachers in schools, health care providers, and students.

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Health Policy There are seven materials addressing different aspects of health policy in Armenia. There are six brochures that explain a range of laws, decrees, and regulations enacted by the Government of the Republic of Armenia regarding various facets of provision of medical care and services to the population. These brochures were produced in Armenian by the “Anna” National Association of Consumers and intended for the general population. They all were continuously distributed to communities in Yerevan, Armavir, and Syunik marzes and in Nagorno-Karabakh Republic via marzpetarans (regional governors offices). There is also one booklet produced in 1999 by the Charitable Public Association, “Maternal Fund of Arme- nia,” under the “Propaganda on Changes in Social Policy in Public Health” project. It was developed in Ar- menian and intended for nation–wide distribution to single mothers and mothers with many children. The distribution was conducted through community outreach programs and during trainings organized by the As- sociation. Hygiene A total of 8 health education materials regarding personal hygiene were collected from local and international NGOs including “For Family and Health”, “Future Generation Union”, “Save the Children”, Arme- nian Red Cross Society, International Federation of Red Cross and Red Crescent Societies, and Medicines Sans Frontiers-Belgium. In addition, the Ministry of Health, the Regional Sanitary-Hygienic Center of Syunik region of Armenia, and the Sanitary-Epidemiological Department of the Nagorno Karabakh Republic were also involved in the development of these materials. All materials are available in Armenian, with 3 of them also available in Russian and 1 in English. Materials include 4 booklets, 2 brochures, 1 videotape, and 1 leaflet. The organizations listed above have been involved in the development of hygiene-related education materials under different projects starting from 1995 and continuing up to 2003. Projects range from short-term (hygiene, water and sanitation, prevention of intestinal parasites) to long-term projects (community development program, preventive health care and sanitary-hygienic education). The majority of the hygiene materials target the general population, with some of them intended particularly for children and adolescents. More than half of these materials were produced for use throughout Armenia. Some of the materials were developed for specific regions such as Armavir, Aragatsotn, Syunik, Ararat, and Shirak marzes and Nagorno-Karabakh Republic. Half of the materials were distributed through several channels including community, schools, health care facilities, drug stores, and streets. Other materials were mostly distributed via one channel - through health care providers, in schools or kindergartens. Injury Prevention There is only one booklet addressing injury prevention among pre-school and elementary school children. It was developed by the Armenian Red Cross Society in 2000 with the purpose of teaching safe behavior to children and developing necessary life skills. It is available in Armenian and is produced for use all over Armenia. The booklet was distributed to the participants of the “Safe Behavior” seminar conducted in 2000, and is planned to be distributed in kindergartens and schools. Malaria There is one brochure developed by the Armenian Red Cross Society during the implementation of the Na- tional Project Against Malaria. The brochure targets the general population and is available in Armenian and Russian. It was continuously distributed during 1999 to the malaria-affected communities in Armavir, Vay- ots Dzor, and Ararat marzes of Armenia. Mental Health There are four materials including a book, a booklet, a newsletter, and an article in a magazine that address mental health issues. The book was developed by the “Hamlet Trust” British organization in 2001 under the Community Mental Health project. The booklet and the newsletter were produced by the Mental Health Foundation under the “NGOs in Mental Health: Developing and Networking” project, which was implemented from the beginning of 1999 till the end of 2001. The article describing how to cope with stress was published by the “Anna” National Association of Consumers in the magazine, “Consumer”, in 1999. All of the materials are available in Armenian. The book was intended for self-support groups organized by mentally ill patients attending Mental Health Foundation Center, and the remaining three materials targeted the general population. The newsletter was also addressed to mentally ill patients. All materials except the

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 71 magazine were distributed via health care providers working in the sphere of mental health. The booklet and the newsletter were also distributed via community outreach, and the newsletter was also disseminated in universities and to local authorities. The magazine with the article about stress was continuously distributed to communities in Yerevan, Ararat, and Kotayk marzes via mass media and regional governors offices. Nutrition and Food Safety Overall, there are 7 materials regarding this health topic. In addition to nutrition and food safety, some of them address other related issues such as breastfeeding, pregnancy, reproductive health, gastrointestinal infections, and anemia. There are 2 videotapes developed by local physicians of Syunik region and Regional Sanitary-Hygienic Center of Syunik region, 1 training material and 1 leaflet developed by the World Food Program (WFP), and 3 newsletters produced by the Family Health Center of ADRA. All materials are available in Armenian, and some of them are available in Russian and English also. All of these materials have been developed recently (during 2000-2001) under a variety of projects regarding mother and child health care, food for teaching, improving health information and knowledge, and nutrition program at schools. The majority of these materials are intended for mothers, and some are aimed at the general population, school cafeteria staff or farmers. A leaflet targeting farmers was produced to be distributed throughout Armenia, while the remaining materials were predominantly produced for distribution in mostly Syunik region, as well as in Tavush, Shirak, and Gegharkunik regions of Armenia. The majority of the materials were distributed via health care facilities and health care providers. WFP organized seminars for community members and in schools to distribute the leaflet for farmers and the training manual for school cafeteria staff. People with Disabilities There were two materials addressing health problems of people with disabilities. The first was a book about self-care of patients with disabilities, which was translated from English into Armenian by a group of public health specialists. This book was intended for parents and patients with disabilities and was distributed nation-wide to parents of children with disabilities. The second was a booklet developed by the Association of Children with Hearing Impairments under the Health Education Program implemented during 1998-1999. The booklet was in Armenian and targeted parents and the general population. It was continuously distributed nation-wide via pediatric hospitals. Pharmaceuticals There are four materials related to use of pharmaceutical products. They all are available in Russian, and three of them are also available in Armenian. There are three brochures and a set of leaflets. The brochures were developed by the Drug and Medical Technology Agency in 2000 under the WHO project, “False Drug - Global Problem”. The set of leaflets, describing criteria for correct prescription of various medicines, was developed in 1999 by the Health Activity International (HAI). All materials target the general population and health care providers, and were continuously distributed during training sessions held with the staff of the National Institute of Health in Armenia. The brochures also target mentally ill patients. Three of these materials were designed for use in Yerevan, with only one brochure intended for nation-wide use. Physical Fitness There is one booklet, which touches upon physical activity, but primarily addresses nutrition and drug abuse issues. The booklet was translated into Armenian from English by the World Health Organization as a component of “Healthy Nutrition” activities conducted in 2000 nation-wide. It was intended for the general population and was continuously distributed by health care providers through health care facilities throughout Armenia. Pregnancy Altogether, there are 10 materials discussing pregnancy and related issues. Only one of these materials was provided in English. All others are available in Armenian, and one is available in both Russian and English as well. Among these materials there are brochures, books, newsletters, and a videotape. The following organizations were involved in the development of these materials: Medicines Sans Frontiers-Belgium, the Ministry of Health of the Republic of Armenia, the NGO “For Family and Health”, the Family Health Center (ADRA), local physicians of Syunik region of Armenia, and the Boston’s Women Health Book Collective.

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Most of the materials were developed under projects related to reproductive health and family planning, which started in 1999 and are currently ongoing. Target audience varies from men and women of reproductive age to mothers, couples, and the general population. Out of 10 materials, only 4 were developed for use nation-wide. Six materials were produced for particular regions of Armenia. For example, the newsletters and the videotape were intended for Syunik region of Ar- menia, and brochures were specifically developed for Tavush region. While materials intended for use in regions were distributed through hospitals, polyclinics, and FAPs with the help of health care providers (predominantly gynecologists), the materials produced for the whole country were mainly distributed in schools, communities, and on streets. Reproductive Health There are 23 materials on reproductive health and related issues. The majority of them are available in Ar- menian, with some available also in Russian and English. One material is available in English only. There are 4 books, 2 booklets, 10 brochures, 3 newsletters, 2 calendars, 1 videotape, and 1 reproductive health folder. A wide range of organizations were involved in the development of these materials including governmental and non-governmental, local and international organizations. Among them there are the Ministry of Health, the Medical Scientific Center of Dermatology and Sexually Transmitted Infections, SAMSA, the local NGO “For Family and Health”, “Future Generation Union”, Armenian Charity Fund for Public Devel- opment, Armenian-American Wellness Center, the Family Health Center of ADRA, Medicines Sans Fron- tiers-Belgium, Johns Hopkins University, and the Boston’s Women Health Book Collective. Most of the materials were produced starting from 1999 and have an on-going distribution status. The materials are targeting the general population, couples, parents, mothers, men and women of reproductive age, and health personnel. The materials are intended to be used both all over Armenia and in specific regions such as Aragatsotn, Gegharkunik, and Syunik. Numerous channels of distribution are utilized including community distribution, schools, health care facilities, drug stores, and streets. Sexually Transmitted Infections including AIDS Many organizations in Armenia were involved in the development, funding or distribution of materials addressing STIs/AIDS issues including governmental organizations (Ministry of Health of RA, the National Institute of Health, the National Center for AIDS Prevention, the Medical Scientific Center of Dermatology and Sexually Transmitted Infections), international organizations (UNFPA, Family Health Center of ADRA, Boston’s Women Health Book Collective), and local NGOs (“For Family and Health”, “Future Generation”, Armenian Red Cross Society, “Hope and Help” NGO, Association of Gynecologists- Endocrinologists, Sci- entific Association of Medical Students of Armenia (SAMSA), and Yerevan Residents World Club). A total of thirty-one materials were collected. All of the materials were available in Armenian, and some were also available in Russian and English. The majority of materials are brochures and booklets, although posters, books, newsletters, and flipcharts are also available. The materials target many audiences including the general population, children, adolescents, parents, couples, men, and women. Materials were developed under projects related to HIV/AIDS, Reproductive and Adolescent Sexual Health, and Preventive Health Care and Hygiene Education. Most of these projects are ongoing, with either nation-wide or region-specific implementation (Yerevan, Lori, Syunik, and Tavush). Many different channels of distribution were used for the dissemination of STI/AIDS-preventive information and materials, including community outreach, schools and universities, health care providers (physicians, nurses, and midwifes), and health care-related facilities (polyclinics, hospitals, and drugstores). In addition, specific outreach programs have been initiated to reach young people on streets and in public places. Tobacco and Other Substance Use Two materials were collected that address issues of tobacco and substance use. The first was a booklet developed in 1997 by the local NGO “People for Healthy Lifestyle” under the “Anti Smoking Propaganda in Schools” project. This booklet targeting adolescents and school-age children was presented and distributed in schools of Yerevan, Armenia. The booklet is available in Armenian, Russian and English. The second material was a book, “Our Bodies, Ourselves”, developed by Boston’s Women Health Book Col- lective. The book addresses not only tobacco and drug use, but also a number of other health topics. The book, originally produced in English was translated into Armenian in 2001 under the “Reproductive Health”

PRIMARY HEALTH PROBLEMS AND HEALTH EDUCATION NEEDS OF VULNERABLE POPULATIONS IN ARMENIA 73 project. The book was distributed via community outreach channel to women and mothers in all regions of Armenia. Tuberculosis There are nine materials addressing treatment and prevention of tuberculosis (TB). Seven of them including 3 booklets, 2 brochures, and 2 leaflets were prepared collaboratively by MSF-France and the Ministry of Health of Nagorno Karabakh Republic (NKR). They were specifically developed for use in NKR during the implementation of an anti-tuberculosis program in 2001. All of them but one are available in both Armenian and Russian, and one brochure is available in Russian only. Almost all of these materials target the general population or family members of patients with TB, and one brochure is addressed to patients with TB. These materials were distributed to the communities and polyclinics in NKR. The remaining 2 materials including 1 brochure and 1 videotape were developed by Armenian Red Cross Society while implementing TB treatment and prevention programs since 1996. They were both produced for nation-wide use and are aimed at the general population. The brochure is available in both Armenian and Russian and was distributed via communities, schools, hospitals, polyclinics, and universities. The videotape was broadcasted on TV in Armenian.

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