title: Can a comprehensive voucher programme prompt changes in doctors' knowledge, attitudes and practices related to sexual and reproductive health care for adolescents? A case study from Latin America.
abstract: OBJECTIVE
  To evaluate whether participation in a competitive voucher programme designed to improve access to and quality of sexual and reproductive health care (SRH-care), prompted changes in doctors' knowledge, attitudes and practices.
  
  
  METHODS
  The voucher programme provided free access to SRH-care for adolescents. Doctors received training and guidelines on how to deal with adolescents, a treatment protocol, and financial incentives for each adolescent attended. To evaluate the impact of the intervention on doctors, nearly all participating doctors (n = 37) were interviewed before the intervention and 23 were interviewed after the intervention. Answers were grouped in subthemes and scores compared using nonparametric methods.
  
  
  RESULTS
  The initial interviews disclosed deficiencies in doctors' knowledge, attitudes and practices relating to adolescent SRH-issues. Gender and age of the doctor were not associated with the initial scores. Comparing scores from before and after the intervention revealed significant increases in doctors' knowledge of contraceptives (P = 0.003) and sexually transmittable infections (P < 0.001); barriers to contraceptive use significantly diminished (P < 0.001 and P = 0.003); and some attitudinal changes were observed (0 = 0.046 and P = 0.11). Doctors became more aware of the need to improve their communication skills and were positive about the programme.
  
  
  CONCLUSIONS
  This study confirmed provider related barriers that adolescents in Nicaragua may face and reinforces the importance of focusing on the quality of care and strengthening doctors' training. Participation in the voucher programme resulted in increased knowledge, improved practices and, to a lesser extent, in changed attitudes. A competitive voucher programme with technical support for the participating doctors can be a promising strategy to prompt change.
authors.affiliation: Department of General Practice, University of Maastricht, The Netherlands. liesbethmeuwissen@yahoo.com
authors.forename: Liesbeth E
authors.initials: LE
authors.lastname: Meuwissen
authors.forename: Anna C
authors.initials: AC
authors.lastname: Gorter
authors.forename: Arnold D M
authors.initials: AD
authors.lastname: Kester
authors.forename: J A
authors.initials: JA
authors.lastname: Knottnerus
mesh_terms: D000293:Adolescent; D016497:Adolescent Health Services; D000328:Adult; D001291:Attitude of Health Personnel; D002983:Clinical Competence / Q000592:standards*; D019111:Single-Use Internal Condom; D003270:Contraceptive Agents / Q000627:therapeutic use; D003695:Delivery of Health Care / Q000379:methods; D005260:Female; D006293:Health Promotion / Q000379:methods; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D009527:Nicaragua; D015397:Program Evaluation; D011787:Quality of Health Care; D034121:Reproductive Health Services; D012736:Sex Education; D012749:Sexually Transmitted Diseases / Q000517:prevention & control
chemical_list: D003270:Contraceptive Agents