| AIDS prevention through health promotion: Facing sensitive issues |
|PART 3 Increasing the credibility of the message: peers and patients as health promoters|
Elizabeth Ngugi and Francis Plummer
Prostitutes are usually hard to reach. In Kenya, our multidisciplinary health team walked through mud, rain, and hot sun in an effort to meet these women where they live and work and to establish a rapport with them based on mutual trust and confidence.
Before the team started working with the prostitutes towards better health, it was important for the members to go through a "self-awareness" exercise. This enabled them to shed their biases and myths and close the gap between themselves and the prostitutes. Members of the health team asked such questions as:
• How do you manage to work with prostitutes?
• What do you say to them?
• Do you actually sit in the same room with them?
• Aren't you afraid of them?
This calls for an analysis of feelings and attitudes towards prostitutes and prostitution, in order to see the situation without imposing value judgements. Only then can the health worker enter into a useful relationship with the prostitutes that helps them to learn.
The initial contact
How did we find the prostitutes? It is not easy to know who is a prostitute where prostitution is illegal, so we looked at the register of the Skin and Special Treatment Clinic, to which the majority of persons suffering from sexually transmitted diseases are referred. It showed that most of the women and their contacts with such diseases resided in Pumwani. Accordingly we made that area the operational target, following the principle of taking services to where the people concerned live and work. We made brief visits to the homes of the women, introducing ourselves as health personnel interested in working with them to reduce the prevalence of sexually transmitted diseases. We approached them as we would any other group of women. We did not call them prostitutes. They told us what they were.
We believe that it was because they understood that we were going to work with them, and help them learn how best to reduce the sickness due to sexually transmitted diseases, and that they were going to be active in the process rather than being told what to do or how to behave, that as many as 300 came to the first baraza (public meeting). Once we had got to know each other they brought us a wealth of practical knowledge. The fact that they had been accepted as human beings needing support was a tremendous source of motivation for them.
The evolving programme
During the baraza, the prostitutes told us what their needs were in relation to the control and prevention of sexually transmitted diseases. There had been no reported cases of AIDS in Kenya at that time. We explained to them how HIV infection is transmitted and what its effects are. We told them how infection could be prevented and invited them to register at a new clinic established specifically to serve them, to distribute condoms, and to provide counselling, diagnosis, and treatment as well as follow up.
The women showed enthusiasm for protecting their own health, and elected a leader and a committee to represent the three villages in which they lived. We trained the committee members in community mobilization and basic communication skills in order to promote condom use. They acted as informal health educators for the rest. We told them that HIV detection and surveillance activities were to commence and invited all the women to take part. The leader was given condoms to distribute to those whose stock ran out between clinic sessions.
The village health committee met the health team every two months, and barazas took place every six months. At one of them, attended by about 300 women, we told them that our studies showed that some of them were infected with HIV or with other sexually transmitted diseases. We explained that those who were infected were likely to transmit the infection to their clients, and that those not infected were at risk of becoming infected. The best thing they could do, we told them, was to give up prostitution; the next best was to insist that their clients used condoms.
We used several educational methods. One was a questionnaire testing the women's knowledge of AIDS, of their ability to prevent it, and of how they could teach others to avoid becoming infected. About 250 women completed this questionnaire. The ten giving the best answers were invited to address the other women at the next baraza (see Box). They shared with them their knowledge and impressed upon them the nature and consequences of infection with HIV.
Another approach was to use sketches and role-plays reinforcing earlier messages, performed by members of the village committee. A song was also sung by members of the village health committee at a baraza.
In addition, group and individual counselling enabled the women to discuss with us their problems and how best to solve them. It emerged during counselling that most of the women wished to change their life-style and give up prostitution. They asked for a rehabilitation programme to train them for other suitable work, as a starting-point for a new life.
The result of these joint efforts was a dramatic increase in condom use. At the beginning, 8% of the women occasionally insisted that their clients use condoms. After a year, more than 50% were making their clients use condoms all the time and a further 40% did so occasionally, with a mean of 72% by mid-July 1988. A small number of women also informed us that they had given up prostitution. These changes, occurring after only a modest educational input, are remarkable since condoms are not readily accepted as a method of contraception in Africa. The outcome of all this was a threefold lower rate of HIV seroconversion among the women insisting on condom use, than among those not insisting on such use.
The ten best replies to the question "How would you teach others to prevent the spread of AIDS?" were as follows:
1. I would teach a group of men and women:
(a) that they should see a doctor every two months to be examined for sexually transmitted disease;
(b) that men should use a condom during casual sexual intercourse;
(c) that all should maintain good personal hygiene by washing with warm water and soap after every sexual encounter;
(d) that all should wash any towels used to clean their genitalia after intercourse.
2. In order to prevent sexually transmitted diseases:
(a) women should clean the vulva with warm water after sexual intercourse;
(b) they should attend a clinic/doctor regularly;
(c) men must always wear condoms in casual sexual encounters.
3. Sexually transmitted diseases can be prevented by:
(a) the use of condoms;
(b) washing with warm water after sexual intercourse;
(c) taking medication prescribed by the doctor when infected.
4. To prevent sexually transmitted diseases, it is necessary:
(a) to see a doctor;
(b) to follow the advice given by the doctor;
(c) for men to use condoms before engaging in casual sex.
5. It is necessary:
(a) that men should use condoms;
(b) that women should go to the doctor/clinic from time to time;
(c) that they should take medicine as prescribed.
6. It is necessary:
(a) to teach men to use condoms;
(b) to see a doctor from time to time;
(c) to take medicine as prescribed.
7. It is necessary:
(a) to go to a doctor/clinic immediately when you have a problem;
(b) to take your sexual contact to the doctor for treatment. If you do not do this, treatment of just one person is useless.
8. It is necessary to require men to use a condom.
9. It is necessary:
(a) to advise men to use condoms;
(b) to take preventive medicine.
10. If you know that you are suffering from any sexually transmitted disease, go to the hospital immediately, so that you do not infect other sex partners.
We believe that the main factor that made this programme so successful was the fact that the women themselves were responsible for the programme. This was reinforced by the methods we used: taking services to the people and mobilizing the community. The community responded with a high level of participation, and the prostitutes themselves became the educators of their peers.
Making condoms easily available was another important factor. This depended greatly on the support of the health education services. A third factor was that we succeeded in reaching the clients indirectly through the women, who thus proved to be agents of change for the men.
It is gratifying that even women who were already infected with HIV insisted on the use of condoms. They had been educated to such a level that they appreciated the need to protect their clients.
Because of the encouraging results of this programme there are now plans to train multidisciplinary health teams in four other sites as a preliminary step towards implementing the programme on a national scale.