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close this bookSexually Transmitted Diseases (STD) Prevention: New Challenges, New Approaches (AIDSCAP/FHI - USAID, 1996, 47 p.)
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Listening to Patients: Targeted Intervention Research to Improve STD Programs

by Mary Lyn Field

In South Africa, men drink an herbal beverage before having sex because they believe it protects them from any attack of evil, including sexually transmitted disease.

In Malawi, different stages of the same STD, such as genital ulcers and ruptured buboes, are often considered separate illnesses with different names and treatments.

In Senegal, when people experience the symptoms of siti (the local name for the symptoms of several STDs), they go directly to the pharmacist. “At the health center there's a long line and no confidentiality” one person explained.

Patients' beliefs about the causes of illness and their perceptions of the services available to treat them exert a powerful influence over where and when-or even whether-they seek care. Differences between standard medical terms for symptoms and patients' own terminology can cause serious misunderstandings. And in many countries, self-treatment is common because it is inexpensive and convenient or because people feel uncomfortable going to the local clinic, particularly when the illness is an STD.

Since prompt, effective treatment of an infection is the best way to prevent further transmission, studying local perceptions, terminology, practices and beliefs about illnesses is no academic exercise. But designing ethnographic studies so the results can be used to improve health programs is a difficult challenge.

A rapid ethnographic methodology called targeted intervention research (TIR) bridges the gap between research and practice. Developed by the AIDS Control and Prevention (AIDSCAP) Project in collaboration with researchers from Johns Hopkins University and the University of Washington, the TIR is designed to identify perceptions and beliefs that serve as barriers to STD treatment and prevention.

AIDSCAP has sponsored TIR studies to improve STD services in six countries (two in collaboration with UNICEF) and plans a seventh study with UNICEF. In Zambia, TIR results are being used to develop a communication plan to encourage early antenatal clinic attendance. In Swaziland the TIR will target adolescents and explore broader reproductive health issues, including family planning.

What Is TIR?

Modeled after the World Health Organization's Acute Respiratory Illness Focused Ethnographic Survey, the TIR is designed so that STD program managers can conduct their own studies with the help of a multidisciplinary technical advisory group of local experts in STD services, communication and social science research. A manual produced by AIDSCAP gives STD managers step-by-step guidelines to organizing a TIR study.

The TIR manual covers a range of programmatic issues, from patient-provider communication to perceptions about the quality of service delivery (see Questions Addressed by the TIR). The first part of the manual explains how to conduct a TIR and how to analyze and apply study results. The second part of the manual consists of 10 research guides with instructions and questions for interviewers.

A typical TIR study involves interviews with people living in communities served by an STD program and with STD patients at least one clinic. The semi-structured inter- view guides in the manual ensure that each informant is asked the same questions, but also encourage interviewers to probe for more information and to ask respondents to elaborate on other topics that arise during interviews.

Four of the interview guides help researchers use a technique called free listing to learn more about community perceptions about diseases. Interviewers begin by asking people to list the most common illnesses that affect adults in their community, then ask them to list the symptoms of each illness mentioned. The guides become increasingly specific as the interviews progress, asking for lists of illnesses that affect the “nether area” between the waist and thighs, then asking about illnesses transmitted through sexual intercourse, and finally asking informants to associate illnesses with specific symptoms. Researchers can use details such as the order in which illnesses are mentioned to learn about their significance and the experience of community members with the illnesses.

Analysis of TIR data begins during fieldwork so that the illnesses most frequently mentioned during the first interviews can be investigated in greater detail in subsequent interviews with community members. During the first interviews, interviewers also identify people who would be willing to discuss their personal experiences with an STD in greater detail.

Because the TIR is designed to answer specific programmatic questions, it can be done more efficiently than a more traditional ethnographic inquiry. Researchers can design, conduct and analyze a TIR study in three to six months.


In Senegal, 253 interviews were conducted in four regions (16 sites). Causes of STDs cited included God, eating certain kinds of fish, and an intense desire for or lack of satisfaction with sexual contact.

Informants in Senegal reported that they respond to STD symptoms by treating themselves with drugs they have at home or buy from street vendors, followed by a visit to a pharmacy or traditional healer. People often seek treatment from retired health workers or from health workers at their homes after clinic hours because they believe it is impossible to have a private conversation with a provider at the clinic.

AIDSCAP's manual on targeted intervention research gives STD managers step-by-step guidelines to organizing a TIR study.

Perceptions about lack of confidentiality also influence where people seek care when they choose to attend a clinic. In many places, finding a provider who does not have some connection with relatives or friends is difficult. Fearing that information about their infection might be disclosed, many bypass the local clinic and seek treatment far from home.


In Ethiopia, where TIR data were collected from four research sites, most people interviewed were able to name three or four STDs and some associated symptoms. The majority of respondents reported waiting ten days to one month before seeking treatment for their STD symptoms at a clinic. By the time most went to a clinic, they had already consulted a traditional healer or pharmacist.

Reasons for not seeking care at STD clinics include fear of stigma, especially in clinics with an “STD room” or in freestanding STD clinics; cost (even though treatment is provided free of charge at clinics); lack of privacy; and shortages of medicine. The most frequently cited barrier to use of clinic services is health providers' attitudes toward patients. Community members complain that health providers are often condescending and judgmental. “Health providers should not scold,” one informant said.


The TIR is being used in Zambia to develop a communication strategy for increasing early attendance (before 16 weeks gestation) at antenatal clinics by pregnant women in Lusaka as part of a maternal syphilis prevention project. Early detection of syphilis in pregnant women is essential because untreated maternal syphilis can lead to spontaneous abortion, stillbirth, prematurity and congenital syphilis.

A total of 85 people were interviewed, and 54 participated in six focus group discussions. Potential motivating factors for clinic attendance were high knowledge and awareness of STDs, particularly syphilis and HIV. The women's responses suggest that they have a great deal of experience with STDs. This finding is supported by the fact that between April 1994 and March 1995, 17.5 percent of 42,366 new antenatal clients screened for syphilis tested positive.

The research also identified taboos that interfere with early antenatal clinic attendance. One informant said that pregnant women should go to the antenatal clinic “when the pregnancy is showing, because if you go early, the pregnancy is only a ball of blood.” Because of taboos, she explained, women think that their pregnancies may be stolen from them if they seek care earlier.

The Philippines

A TIR study in metropolitan Manila and Cebu involved interviews with 858 people, including registered and unregistered female sex workers and their managers, owners and managers of establishments where sex is sold, and health care workers. The study found that the STDs of most concern are gonorrhea and HIV/AIDS. Sex workers, for whom gonorrhea seems to be a catchall term for a number of sexually transmitted infections, named it as the cause of seven of eight symptoms mentioned by interviewers.

Many respondents reported prophylactic use of antibiotics to prevent STDs. A few of the women also reported drinking cold water and avoiding salty, fishy and sour foods.

Most of the sex workers seek STD care at a public health clinic. Inadequate waiting rooms and lack of privacy and confidentiality were frequently reported obstacles to clinic use. Some respondents reported treating their own STD symptoms, usually discontinuing medication after the symptoms disappeared.

Improving Programs

The next challenge will be ensuring that the TIR results are used to improve STD services and educational campaigns. STD case management training can include discussions about local terminology for illnesses to help patients and providers understand each other better. Program managers can use findings about patients' perceptions of STD services to restructure the way services are provided, train staff to address patients' concerns, and improve educational materials and outreach messages.

Many of the studies found that a real or perceived lack of confidentiality discouraged people from seeking STD treatment at clinics. If lack of privacy is the source of this problem, a clinic manager can resolve it by relocating the place where providers interview patients or, if no other space is available, by adding a screen or curtain. If the breach of confidentiality is due to providers' lack of awareness or professionalism, these problems can be addressed in training and clinic rules and as part of employee evaluations.

Understanding community members' perceptions about STDs and STD services helps program managers design more effective programs. (E. Hooper/WHO)

Misinformation about the causes of STDs and the taboos that discourage people from seeking care will be more difficult to overcome and may require further research. The Zambian women who think that early antenatal clinic attendance can be harmful need reassurance about what actually happens during a clinic visit. To counter deeply ingrained cultural beliefs, however, outreach workers and those who design communication campaigns to encourage clinic attendance may need more information about such beliefs.

In Ethiopia (see Using TIR Result in Ethiopia) and Zambia, TIR results are already being used to improve communication between patients and providers. For example, an STD project implemented by the Morehouse School of Medicine in Zambia is teaching health care workers to use descriptions of symptoms rather than the names of diseases when they talk to community members and community outreach workers.

As the results of other TIR studies become available, AIDSCAP staff will work with STD program managers to encourage them to apply the findings in the design of services and communication programs. Because program managers helped identify the questions they wanted the studies to answer, the prospects for direct application of the findings are good. If the results foster improved communication between client and service provider and more culturally appropriate clinic services, STD program managers will have gained an important new tool in fighting the spread of STDs.

Mary Lyn Field, MSN, FNP, is AIDSCAP's senior program officer for the Sexually Transmitted Diseases Unit and UNICEF technical support.

Questions Addressed by the TIR

General Information:

community names for illnesses, community understanding of transmission and prevention, sources of health care for STDs

Illness Management:

recognition of disease, determinants of health-seeking behavior

Service Delivery:

perception of health services, recommendations for improvement of services


perceptions about differences between men and women in terms of diseases, clinic access, stigma

Partner Notification:

perceptions of vulnerability of partners and referring partners for treatment


issues of abstinence, prescription use, condom use, sexual behavior change


sources of trusted STD information, skills necessary to improve patient-provider communication

Prevention Program:

community's current activities to prevent STDs, attitudes about and use of condoms

AIDSCAP-Sponsored TIR Research


Target Groups


numerous groups, including those targeted by AIDS campaigns


community members


sex workers

South Africa

miners and sex workers

In collaboration with UNICEF:


young adults and other community members, military personnel and religious authorities




pregnant women and providers

The information in this article is based on reports and personal communications with Cheikh Ibrahima Niang of the University of Dakar, Senegal; Annette Ghee, an AIDSCAP consultant formerly with the University of Washington, Seattle; Ayalew Gabre and Woldeab Teshome of the Ethiopian Ministry of Health; Mark Lurie, AIDSCAP consultant; and Deborah Helitzer-Allen and Hubert A. Alien, Jr., co-authors of The Manual for Targeted Intervention Research on Sexually Transmitted Illnesses with Community Members.

Using TIR Results in Ethiopia

Targeted intervention research bridges the gap between research and practice

When 21 health care professionals from four regions of Ethiopia gathered in Addis Ababa for a six-day workshop on materials development, they were ready to get right down to business. Divided into regional teams, they were expected to create STD prevention materials suitable for the language and culture of each region.

Team members were dismayed to learn that they would not immediately deal with the nuts and bolts of developing brochures and posters. They were eager to put pen to paper, learn about formatting and printing, and get on with the job. When queried about what messages they would use, many looked a bit exasperated. They patiently explained to the facilitator that they would tell people about the dangers of STDs, describe the symptoms, and urge people to seek professional medical care. Yes, they admitted, these messages have been used before-but the people are not yet listening, so we should tell them again.

At this point, message decisions were put on hold for what seemed to be a diversion. Researchers Ayalew Gabre and Woldeab Teshome had been invited to present and discuss their preliminary findings from the targeted intervention research (TIR) conducted in the four regions represented at the workshop. They spoke about people's perceptions of inadequate diagnostic facilities and rude health workers at government facilities; they mentioned that women disliked the lack of privacy in examination rooms; they noted that people often do not return for follow up. The participants nodded in recognition.

The researchers described findings on self-medication (asking a pharmacist for a medication based on the recommendations of a friend), stigma (STDs are a “women's illness”) and ideas of causality (urinating where a chicken has urinated causes STD). They mentioned the beliefs that STDs could be avoided by washing genitals after sexual intercourse or by taking ampicillin before. They told of sex workers who disliked using a condom because it “takes a man longer to ejaculate.”

The participants nodded and discussed their own experience with patients who had similar opinions. Yes, they agreed, what the researchers say is true.

As smiles began to appear around the room, the health care professionals took an enormous step toward becoming professional materials designers. Based on the information they had heard, they listed 33 topics that needed to be addressed in the STD prevention materials. These topics included the following:

· STDs do NOT cure themselves.
· Government clinics are now efficient, private and free.
· Don't sell half of your drugs. Take the entire treatment.
· Discussing sexual matters with your partner is difficult - BUT it may save your life.

STD dangers and symptoms did not make the list. Instead, the topics addressed the reasons why patients do not use health services. After hearing what their prospective patients thought about STDs and STD services, the participants had changed their minds about what their materials should say.

A brochure developed during the workshop featured a “cool” guy from the city advising his country bumpkin friend. He convinces his friend that you cannot get an STD by sitting on a hot rock-one of the beliefs revealed in the research-and urges him to seek treatment at the local clinic, where he could get a correct diagnosis and free, effective treatment.

Because of time and financial constraints, the materials developed in the workshop and pre-tested and adapted in the regions reflect only a small portion of the 33 messages the participants recognized as important. Nevertheless, future educational materials and patient contacts by these professionals are likely to reflect the wider and more targeted issues that came to their attention through the TIR.

- Donna Flanagan

Donna Flanagan, MA, MSW, is associate director of AIDSCAP's Behavior Change Communication Unit.