I 1 71 E N V I R O N M E N T D E P A R T M E N T *Ei PA P E RS Paper No. 050 TOWARD ENVIRONMENTALLY AND SOCIALLY SUSTAINABLE DEVELOPMENT PARTICIPATION SERIES Towards STD/AIDS Awareness and Prevention in Plateau State, Nigeria: Findings from a Participatory Rural Appraisal Ernest Massiah April 1997 Environmentally Sustainable Development The.World Bank ESD Environment Departmen apers Participa tion- Series, 001 ~~~~~Participation in EducaticrnNaJ.Clet -Gilhian'Perkins 002 artcptninWer & Sanitation Gabn'elle Watsoni N. Vija Jgannatban 00& Participation i-n Irrigation -Ruth Meinzent-DicJ Richard Reidinger 'Andrew Manzardo 004 ~~~~~Participation in Social Funds Mr cmd Alexandre Marc 006 ~~~~~Participation in Country EcoomcDan R. Aronso and Sector. Work Ellen Tyn-an 007 Designi'ng Community Based' Deepa Narayan Development 020 .Participation in Andrew Norton Poverty Assessments Thms Stephens -021 Participation and Ind-igenous Poplehlo H. Dai LarsT. ~Soeftestad '03 1 Participation Troug o Carroll.- 'In te'rmed ary NGsMary Schmidt Tony ebington 049 Participationi in Forest AtBanerjee Management and, Conserv'ation - Gabriel Campbell Maria Cpncepcionj J Crutz x Shelton H. Davis AuusaMolna Coipies are available from thie World Bank's:Environm.ent Departmont, Social Policy & Resettlement Di'vision. IIA Social Policy and Resettlement Division Towarids STD/AIDS Aware:ness and Prevention in Platieau State, Nigeria: Findings from a Participatory Rural Appraisal Ernest Massiah April 1997 Papers in this series are not formal publications of the World Bank. They are circulated to encourage thought and dis- cussion. The use and citation of this paper should take this into account. The views expressed are those of the authors and should not be attributed to the World Bank. Acronyms and Abbreviations AIDS Acquired Immunodeficiency Syndrome CBO Community Based Organization CHEW Community Health Extension Worker CSW Commercial Sex Worker HIV Human Immunodeficiency Virus LDTD Long-distance Truck Drivers LGA Local Government Authority NASCP National AIDS Surveillance and Control Programme NGO Non-governmental Organization PHC Primary Health Clinic PRA Participatory Rural Appraisal STD Sexually Transmitted Disease TB Tuberculosis TBA Traditional Birth Attendant VHW Village Health Worker Contents Executive Summary 1 1. The Participatory Research Framework 7 Project Rationale The Research and Field Teams Research and Action Agenda Methodology Beyond the Data: The PRA Process C onsidered 2. Community Priorities and Institutions 14 Priorty Development Concerns Priority Health Concerns Community Organizations 3. Community Knowledge, Behaviors, and Practices Related to STD/AIDS 18 Beliefs and Knowledge of STD/ AIDS; Symptoms Attitudes Towards Individuals with HIV/AIDS Prevention Frequency and Type of Sexual Behavior Determinants of Health Service Utilization The Role of Chemists, Patent Medicine Dealers, and Pharmacists Training and Supervision of Health 'iervice Providers 4. Community Health Information: Sources and Impacts 32 Inter-Personal Communication at Pu.blic Health Clinics Inter-Personal Communication at STD Clinics Effectiveness of Health Education/Community Outreach Community Interpretations of AIDS Poster Knowledge of the Proposed World Bank STD Project 5. Community Recommendations for STD/AIDS Interventions 38 Jos North LGA Community Meeting Mangu LGA Community Meeting Langtang LGA Community Meeting Report of Meeting of the Representatives of Langtang, Jos North, and Mangu LGAs Nigeria Plateau State STD/AIDS Participatory Rural Assessment Study Team The World Bank Local Government Authority (LGA) Ernest Massiah Study Teams Study Coordinator Langtang Foluso Okunmadewa Saul Salmak (AAM) World Bank Office, Lagos Folasade Oyeneye Emmanuel Ayanleye Sunday Maji Plateau State Ministry of Health Chalya Lar Jos North Janet Angbazo Boniface Abimiku (AAM) Naomi Adgidzi Jerry Afon Bala Rumtong David Badah Simon Cartier Glory Akpabio Stephen Aya University of Jos Mangu Oguh Alubo Julie Yabal (AAM) Susan Gyang Lucy Chindaba Pam Gyang ii Acknowledgmexnts This study was a collaborative undertak- the World Bank Resident Mission, Lagos, ing between the Plateau State Ministry of played a crucial role in supervising project Health, the Local Government Areas finances, assisting in the training of inter- (LGAs) of Langtang, Mangu and Jos viewers, and providing overall supervision North, and the World Bank. of activities; the study and this report reflects his invaluable inputs. The report I would like to thank members of the staff draws upon the summarized village of the Plateau State Ministry of Health, reports produced by the field teams super- staff of the River Blindness Project head- vised by Naomi Adgidzi, Simon Cartier quartered in Jos. and Bala Rumtong, all of the Plateau State Ministry of Health. Oguh Alubo, Univer- I am indebted to the AIDS Action Manag- sity of Jos, reviewed these reports and ers in each LGA, Boniface Abimiku, Julie analyzed the original data to produce a Yabal and Saul Salinak, for their consistent paper summarizing the findings. This support in all stages of the design of this report was edited by Ross Pfile and Tshiya study. In the World Bank, we wish t:o Subayi and formatted by Ross Pfile. acknowledge the counsel and advice of Maurizia Tovo, Wendy Roseberry, Paul Most of all, we are grateful to the residents Francis, David Peters, Larry Salmen, and of the three LGAs who participated in this Olusoji Adeyi. Foluso Okunmadewat at STD/AIDS Beneficiary Assessment. Executive SummaLry This is a report on the findings of a partici- trative level in Nigeria), a faculty member patory rural appraisal carried out in from the local university, and a represen- several communities of Nigeria's Plateau tative of the World Bank. The university State. It is the first phase of a World Bank- faculty member coordinated the research supported project to prevent sexually and prepared the draft report on the field transmitted diseases and Acquired Imrnmu- work. University students who spoke nodeficiency Syndrome (STD/AIDS) in English and the local languages served as that area. The Participatory Rural Ap- interviewers for the field work, which took praisal (PRA) findings provide valuable place in April 1995. information on local development and health priorities as well as on popular In the PRA approach, an interview team beliefs and understandings related to goes into a community and deploys re- STD/AIDS. While the community-level search methods designed to enable people analysis is expected to contribute to irn- to express and share information and to proved design of Plateau State's STD/ stimulate discussion and analysis. A total AIDS program, perhaps, more impor- of sixteen methods were used to engage a tantly, the process of undertaking the PRA dozen target groups in the research. The set in motion new partnerships among research methods used included card state and local health officials, community sorting, matrix ranking, social and institu- leaders and organizations, selected target tional mapping, and in-depth interviews. beneficiaries, and university faculty and Some team members expressed initial students. With follow-up, these evolving reservations over the qualitative nature of relationships can provide vital building the PRA methodology. As the team blocks for more effective state and locatl worked together to identify, experiment efforts to prevent the spread of STD/ with, and revise the methods, these con- AIDS. cems were overcome. The PRA Team, Methodology To present the initial research findings, and Process four local dissemination meetings were held with representatives from the target The research was planned by a core team groups and LGA and state health officials. of personnel from the State Ministry of The sessions provided an opportunity to Health, AIDS Action Managers in the report back and verify the conclusions in three participating Local Government the draft reports, and allowed the commu- Authorities (LGAs are the lowest admiLnis- nities to become more actively involved in Participation Series Towards STD/ AIDS Awareness & Prevention in Nigeria the dialogue on priorities for action and tently cited as the main problems facing their means of implementation. All of the the residents in the three LGAs. Although communities expressed a desire to be more somewhat less pressing, lack of adequate actively involved in STD/AIDS prevention health care is also a major concern for activities, and identified a series of initia- each of these communities. The principal tives that would be needed at the LGA health problems identified by women are and State levels to sustain their participa- childhood diseases: measles, dysentery/ tion. diarrhoea and hypertension; men rank their chief concerns as meningitis, typhoid The active involvement of local and state and hernia. Medical personnel identify government personnel in all stages of the the same priorities, with the addition of PRA has provided officials with a more abortion-related complications in women realistic understanding of he dynamics of under 20 years old. STDs, including sexual behaviours, communities' interpre- AIDS, are not considered priority health tation and acceptance of IEC messages, concerns. and the potential for community involve- ment in the supervision and evaluation of Local beliefs on STD/AIDS causation, interventions. This should prove useful as symptoms, and prevention shape commu- they now take steps to design a more nity behaviors effective and participatory program. The Causation. The three modes of STD/AIDS PRA initiative tapped into the research transmission most commonly observed by and evaluation capacity of the local uni- the target groups are: sexual intercourse, versity, thereby strengthening the links contact with urine, and sharing objects/ between academia, the government, and belongings of someone with a disease in community-level groups. While encour- the genital region. Sexual promiscuity is aged by the possibilities of greater partner- identified as a source of transmission and ship with the government, the communi- associated with prostitutes and women ties also expressed fatigue: many new who have traveled abroad. There is a initiatives have failed to be sustained strong belief that overseas women contract because they lack the necessary follow-up STD/AIDS through sexual intercourse and inputs. The PRA process may have with dogs and Westerners. Stepping over, identifiedm possible new partnerships and on, or by an area where someone has lines of accountability for more effective urinated, as well as "indiscriminate urina- STD/AIDS activities, but the next phases tion," are thought to transmit STDs. Shar- in the process, the design and implementa- ing of clothes, and, in particular, instru- tion of new programmes, will test the ments for shaving and nail cutting, also strength of these linkages. are associated with the spread of STD/ AIDS. While medical personnel have more Key Findings from the PRA accurate information about STD/AIDS, some of them believe that AIDS could be Health care in general, and STD/AIDS in transmitted by mosquitoes and via saliva particular, rank low amnong communities' (and therefore advise clients against development concems kissing). Lack of access to water, the storage of water, and low farm incomes are consis- 2 Environment Department Papers Executive Summary Symptoms. Most people associate STDUs condoms as contraceptives. They do not, with the presence of physical symptomns: however, associate condom use with STD/ discharges from the genitals, pain while AIDS prevention, except when they are urinating, and stomach cramps or swelling used with CSWs or non-regular partners. in the genital region. Men report looking Men also complain that condoms reduce for "flecks" on a woman's lips and sexual pleasure. Both men and women changes in her gait as signs of the presence are uncomfortable with the notion of using of an STD. Service providers did not condoms for disease protection, as this mention the existence of asymptomatic violates the trust in their relationships and STDs and the need for medical examina- could indicate infidelity. Women fear that tions and laboratory confirmations. AIDS by suggesting condom use they may be is frequently associated with an extremely physically attacked for their perceived emaciated physical state. According to infidelity and attempt to control the sexual one community health extension worker act. Men and women also express fears (CHEW), if one has AIDS the "eyes will that condoms may have negative side blotch out, the hands and legs will thin, effects, such as syphilis in men or may [there will be a ] swollen abdomen [and a] cause women to require surgery as big head." The difference between AIDS condoms can become lodged in the womb. and HIV is not commonly understood. Among CSWs, the cost of regular condom use is high for those who have few clients. Prevention. The main measures identified Condom use is not evenly promoted by the target groups for preventing STD/ among health care providers. Some AIDS are monogamy, examining the providers express reluctance to promote partner's genital area for signs of infection, condom use because doing so may provide avoiding areas where people urinate, and individuals with a false sense of protection refraining from sharing personal posses- (due to breakage), or may encourage sions. SeLf-medication is practiced widLely; promiscuity in youth. many commercial sex workers (CSWs) use penicillin-based creams as antibiotics (and Perceived risk of contracting AIDS is low, lubricants). Men report using medications but fear of people with AIDS is high or traditional medicines prior to and after As the disease is associated with promiscu- sexual intercourse with non-regular ity and overseas contact, most people do partners. Service providers advocate et not believe themselves to be at risk of reduction in the number of sexual partners contracting AIDS. Although men report but are ambivalent about promoting having many sexual partners, the only condom use. Most medical personnel are populations they perceive to be promiscu- concerned with the occupational risk ous are CSWs and youth. In Jos North, an associated with working with AIDS urban area, some residents feel that AIDS patients, and are concerned about the could increase, but feel they are protected need to screen blood and sterilize needles. because it is a Christian comnrmunity. The low levels of perceived risk also relate to Low levels of condom use the limited information available about All target groups report low levels of AIDS. According to one woman, "I hear condom use. Men generally accept say AIDS there I never see any body when Participation Series 3 Towards STD/AIDS Awareness & Prevention in Nigeria AIDS catch them. I never see any body when they provide diagnosis and treatment on AIDS kill them. All I hear the AIDS there, the spot; and, they are ashamed to use AIDS there." PHC facilities, believing them to cater exclusively to matemal and child health Tlhe primary commnunity responses toward needs. The lack of female doctors and the people with AIDS are fear, pity, and the relative lack of privacy deters some need for quarantine. People suggest that women from using government PHC the clothes and houses of people with facilities for the treatment of STDs. Com- AIDS should be burned, areas where they pared to clinics and hospitals, access to have been should be washed, and they traditional healers is easier and the length should be reported to the police and of time spent waiting to receive care and imnprisoned. Central to these reactions is medications significantly lower. There is the belief that AIDS is contagious and can no clear consensus on the impact of finan- be contracted via social contact. Health cial cost on service utilization; however, providers are primarily afraid of the many prefer the financing plan offered by occupational risks associated with work- traditional healers whose services can be ing with blood products and attending to paid for over time and in kind. someone with AIDS. While apprehensive, the majority express a desire to provide Third, providers' and clients' perceptions care and sympathy to individuals they of each other influence the use of health believe will soon die. services. Ethnic and gender stereotypes about patients are common among public Provider-switching is comnon sector service providers. They frequently Three factors contribute to extensive mention that their clients' illiteracy makes "switching" between traditional and them ignorant and unable to understand Western medical systems for the treatment information about diagnosis and treatment of STD/AIDS and other diseases. First, regimens. In almost every target group people perceive that the treatment and complaints were made about how they are cure of illnesses as distinct acts: hospitals treated at clinics. According to one are believed to remove the symptoms of an woman, "doctors and nurses don't care about STD, while traditional medicine is believed patients at all, they don't even ask you what to be effective in removing the cause of the your problems are. They just treat you very STD. If the medications given by one quickly." health system do not relieve symptoms, patients often seek treatment from the STD/AIDS education needs to be other medical system or another provider. strengthened AIDS, as a new and fatal disease, is be- Information on preventive measures, lieved to be best dealt with by hospitals. including on condom use, is given infre- quently by health care providers, and is Second, people look beyond the formal not always accurate. In exit interviews at health system due to its many inadequa- PHC clinics with ante-natal women, the cies, including the lack of drugs and main AIDS-related message recalled is that functioning equipment and long waiting AIDS could be contracted via blood should periods for service. For STD treatment, a transfusion be needed during delivery; men prefer going to pharmacists because few women recalled being told about the 4 Environment Department Papers Executive Sumnary sexual transmission of the HIV virus or people can read its English text; 3) the about condom use. Few of the patients at illustrations communicate messages that STD clinics are informed of their diagnosis are perceived to be about personal hygiene and none of those interviewed were told and not about STD/AIDS prevention; what medications they are being given or and, 4) the depiction of a person with how they worked. AIDS in an emaciated physical state furthers the belief that people with AIDS Posters are the main mass media chanmel can not lead productive lives, and that for AIDS education. Discussions witlh transmission of the virus can be prevented target groups on their understanding of if one learns to identify and then take the most widely distributed STD/AIlDS precautions with persons with certain poster reveal that: 1) most people, includ- physical symptoms. ing clinic staff, have never seen it; 2) few Participation Series 5 Towards STD/ AIDS Awareness & Prevention in Nigeria 6 Environment Department Papers 1. The Participatory Research Framework Project Rationale officials, community leaders and organiza- tions, and target beneficiaries. Over time, According to a 1993/94 Sentinel Survey, these new relationships can contribute the HIV and syphilis prevalence rates in significantly to more effective local devel- Nigeria are approximately 3.8 percent, a opment efforts. Thus, a second major significant increase over the prevalencie objective of the PRA is to begin to identify levels observed in the 1991/92 survey.' and develop capacity at the local level that With an estimated prevalence rate of 8 would be able to collect systematically, percent in 1994, Plateau State has amcng and in a participatory manner, informa- the highest HIV and syphilis levels in the tion for program planning, monitoring country. and redesign. T'his report presents the findings of a The research was supported by a grant of participatory rural appraisal (PRA) carried US$20,000 from the World Bank's System- out in three communities of Nigeria's atic Client Consultation Program of the Plateau State. It is part of the World Africa Region. Emest Massiah (Africa Bank's involvement in efforts to prevent Technical Human Resources III), the sexually transmitted diseases and AIDS project coordinator, developed the re- (STD/AIDS) in that area. Prior research search methods and conducted the train- on STD/AIDS in Plateau State primarily ing; Foluso Okunmadewa (World Bank focused on disease epidemiology, and did Resident Mission, Lagos) supervised the not fully involve State and local health field work and assisted in the training of officials or communities. This PRA ex.am- the research team. The Ford Foundation ines the social aspects of the diseases, amd provided a grant and technical input engages both state- and local-level officials during the later stages of the project. in research design, implementation, deata collection, and analysis. A main objective The Research and Field Teams of the research is to contribute to improved design of the health education component The core research team consisted of State of Plateau State's STD/AIDS program. Ministry of Health personnel, AIDS Action Managers in the three participating Local Perhaps, more importantly, however, IPRA Government Authorities (LGAs are the research processes help identify local lowest administrative level in Nigeria), a information and analysis, and often faculty member from the local university, catalyze new partnerships among local and a World Bank representative. The Participation Series 7 Towards STD/ AIDS Awareness & Prevention in Nigeria team organized the research and collabo- * Sexual behaviors practiced by the rated in planning all phases of the study.2 primary target groups, and the con- In addition, all members of the team texts in which these behaviors occur. participated in the field work, either in advising target communities, making * The reasons for and extent of medical logistical arrangements, or supervising pluralism-or provider shopping-as it interviewers. relates to the treatment of STD/AIDS. The State AIDS Coordinator and the * The willingness of and modalities for Research Coordinator provided overall traditional healers, chemists, and supervision for the field work. Five- pharmacists to become involved in member field teams were created for each project activities. of the LGAs, and included the respective LGA AIDS Action Manager, a State AIDS * Public and private sector service pro- Program official, and three University viders' knowledge and perceptions of students. The students, who spoke En- STD/AIDS prevention and treatment, glish, Hausa, and one of the local lan- and their perception of the needs in guages, were recruited and trained by the their target communities. research team to serve as interviewers. Appropriate communication channels Initially, the teams were skeptical about for the diffusion of STD/AIDS preven- using PRA methodology, which some tion and treatment messages. considered too simplistic relative to more quantitative approaches to field research. * The actions that communities believe As the team reviewed, experimented with, should be taken by: (a) individuals, (b) and revised the PRA research methods State and LGA officials, and (c) other over a six-month period in preparation for institutions. the field work, these concerns were over- come. The developmental, or process, objectives of the PRA were to: The Research and Action Agenda * Create a methodology and a set of The research was structured to elicit methods for obtaining information findings on the following eight issues: about STD/AIDS in conjunction with personnel working at the lowest ad- * Communities' perceptions of their ministrative level that could be used in priority health and non-health prob- their subsequent supervision/monitor- lems, and the role of STD/AIDS within ing exercises. these rankings. * Strengthen the capacity of the State * Knowledge and beliefs surrounding Ministry of Health to conduct similar STD/AIDS of the various target research in the future. groups. * Provide personnel at the Federal level in the National AIDS Surveillance and 8 Environment Department Papers Participatory Research Framework Control Programme (NASCP) wilh a information rapidly on condom use, methodological approach that could be knowledge of STD/AIDS, and quality of disseminated nationally. health care services. * Create new partnerships between the Mystery Client Interviews: Male and local university and LGA and State female interviewers, pretending to have an health officials by building acade]mic STD, seek treatment from pharmacists and capacity to conduct and assess PRAs, chemists. The information they are told is and to monitor and evaluate commu- recorded after the visit. nity-level STD/AIDS programs. Matrix Ranking: Groups are asked to list Methodology their main health and community prob- lems. Then, for each category of problem, This study utilized qualitative research groups are asked to rank them in order of methodologies common to PRA and Rapid priority. Rural Appraisal. A total of sixteen re- search methods were used in the field. Focus Group Interviews: Discussions are Some of the methods focus on the sarme conducted with students and CSWs. The issues in order to determine consistency of groups are comprised of five-to-eight responses and the perspectives of different people. target groups on the same issue. The principal data collection methods include: Card Sorting: In each community, single- sex groups of between six and nine men Social and Institutional Mapping: Groups and women are shown cards illustrating are asked to draw a map of their cornmu- specific health- and sex-related behaviors nity on a piece of paper or on the ground being performed by each sex. The group is and to indicate the main community asked to identify the behaviors which are institutions, including public and private easy or hard to perforzn and the reasons health facilities and hotels (brothels), and for their choice. their importance. They are also asked to draw a map of their desired arrangement Interview guides were developed for the and location of community institutions. semi-structured and focus group inter- views. Due to language and cultural Semi-Structured Interviews: Key commu- considerations interviewers were in- nity members-elders, teachers, local structed to be flexible in their interview policy makers, traditional healers, phar- approaches. macists, doctors, and nurses-are adminis- tered in-depth open ended interviews. Table 1 shows the relationship between the research methods and issues, and was Exit interviews: Short exit interviewvs are used to guide the development of the conducted with clients of Commercial Sex methods. Table 2 indicates the particular Workers (CSWs), ante-natal women, and methods used with each target group. STD patients. The interviews are he]Ld outside of the facilities and designed to get Participation Series 9 Towards STD/ AIDS Awareness & Prevention in Nigeria Table 1: Relationship Between Research Issues and Methods Issues Methods Perceptions of priority community and health Social Mapping problems Matrix Ranking - Community and Health Problems Perceptions of illness causation, treastment and Semi-structured interviews; Focus groups; prevention; local terminology for illnesses and Card Sort STD/AIDS Access to and usage of health services, by Semi-structured interviews; Ranking of services; gender and target group; perception of health providers; Card Sort; Exit Interviews; Mystery services and service providers Client Interviews Sexual behaviors - desires (actual and Semi-structured interviews; Focus groups; perceived, taboos Card Sort Perceptions of condoms; detrminants of Semi-strucutred interviews; Gender Analysis; condom usage and availability Focus Groups; Exit Interviews; Short Questionnaires with Clients of CSWs Relations between traditional healers, westem Semi-strucutred interviews. trained service providers and pharmacists Experience with and attitude towards community Social Mapping; Institutional Mapping; participation; role of community institutions; Semi-structured Interviews community dynamics Sources of information about health; exposure to Social Mapping; Semi-strucutred interviews and understanding of health information Knowledge, attitudes and needs of service Semi-structured interviews providers and teachers Table 2: Methods and Target Groups Target Population Methods Women (community) Matnx Ranking; Social Mapping; Description of STD; Card Sort; Men (community) Matrix Ranking of Service Providers; Semi-structured interviews Commercial Sex Workers (CSW) Focus Group Interviews; Semi-structured interviews Clients of CSW Exit Interviews Secondary School Students Focus Groups; Semi-structured Interviews Long-Distance Truck Drivers Semi-structured interviews Ante-natal Clinic Attendees Exit interviews STD Clinic Attendees Exit interviews Service Providers Semi-structured interviews Traditional Healers Semi-structured interviews LGA/State Health Personnel Semi-structured interviews Opinion/Traditional Leaders Semi-structured interviews 10 Environment Department Papers Participatory JResearch Framework Selection of Research Sites and has a strong Hausa and Muslim At the time of the research, Nigeria was presence. The third community, Apata, divided into thirty States, each of which has a large Ibo population and lacks a were further divided LGAs. The three commercial center. Plateau State LGAs selected for the PRA are target areas for a proposed World Mangu LGA: This semi-urban LGA resides Bank Nigeria STD Prevention Project. approximately 70 km Southeast of Jos. Within each of these LGAs, the selection of The research was conducted in Mangu specific communities was determined by: Town, the largest settlement in the LGA, the presence of PHC facilities; urban/rural and in the rural community of Kombun. characteristics cultural/ethnic characteris- The main ethnic groups in the LGA, the tics; and, ease of access for interviews. Mwaghaval, Pyem, Chakfem, and Jipal, are equally represented in the two sample An LGA is comprised of six-to-eight health sites. Kombun is situated in the largest districts, of which two or three were health district in the LGA and is accessible chosen from each of the three LGAs. The by paved road. district containing the LGA-level general hospital was included, as well as one or Langtang LGA: Langtang North LGA is two additional districts provided they located about 200 km southeast of Jos, and contained at least one private or public is primarily rural with a few large semi- health facility. urban settlements. Transportation is still problematic and for most communities The specific LGAs and communities only available on market days. The re- selected were: search was conducted in, Langtang Town, the LGA capital, and Zamko, a more rural Jos North LGA: This is one of two LGAs community. The main ethnic group in the that comprise the city of Jos, the Plateau LGA is the Taroh; there are also small State capital. The city developed in the Hausa communities. earlier part of the century as a tin mrninng settlement. As the state capital, the city Conduct of the Fieldwork has tertiary level educational and health Three field teams worked in each LGA for facilities and houses the state-level admin- twelve to fourteen days in April 1995. istrative and legislative offices. It has an Again, the five-member teams included estimated population of 500,000. Three three interviewers, the respective LGA's communities were interviewed. The first, AIDS Action Manager, and an official Laranto, is comprised mainly of people from the Plateau State AIDS program. from ethnic groups that are indigenous to The latter served as the Field Research the state. Laranto's large timber and grain Leader, and was responsible for organiz- markets attract people from all parts of the ing the schedule of interviews, checking state, and it is an important destination for the notes taken by the interviewers, and long-distance truck drivers (LDTD:s). The making modifications to the research plan, state-level Jos University Teaching Hospi- when necessary. The LGA AIDS Action tal has an STD clinic. The second commu- Managers made all of the logistical nity, Abba Na Shenu, is more traditional arrangements, informed communities and Participation Series 11 Towards STD/ AIDS Awareness & Prevention in Nigeria village elders of the purpose of the study, Beyond the Data: The PRA and introduced the field team to the Process Considered community. The AIDS Action Managers also conducted some of the interviews - An important obstacle to building produc- especially with potentially difficult popula- tive partnerships between local communi- tions such as commercial sex workers ties and public sector institutions is the (CSW) and village elders. Interviews were perception by many officials that conmmu- conducted the most frequently in Hausa, nity participation is synonymous with ihe prevalent language in the area. Other contributions of physical labor, and not language/ethnic groups used in the field- with local involvement in program re- work include Berom, Fulani, Mwaghavul, search, planning, monitoring and evalua- Nprom, Afirare, Anguta, and Taroh. tion. The active engagement of local and state govermment personnel in the design Sample Size and conduct of the PRA exercise increased Table 3 provides a matrix of the number of their understanding of the value of apply- people interviewed by target group and ing participatory principles more broadly. LGA. The two weeks of field work made the Table 3: Sample Size Target Group Jos North Mangu Langtang Service Providers Western - public facilities 3 doctors, 5 nurses 2 doctors, 10 nurses 3 doctors, 5 nurses CHEW 2 doctors, 4 nurses 10 3 Western - private facilities 3 doctors, 5 nurses 1 doctor, 2 nurses 2 doctors, 3 nurses Traditional Healers 8 3 3 Pharmacists 3 1 1 Chemists 3 1 Pa tent Medicine Dealers - 1 1 Community Members 3 groups female; 2 groups male; 1 group male; 3 groups male 2 groups female' 2 groups female Ante-Natal Women 17 21 13 CSW 2 Focus Groups (FG) I FG 1 FG Male Clients of CSW 10 4 3 Students 1 FG boys 1 FG boys 1 FG boys 1 FG girls 1 FG girls 1 FG girls Long Distance Truck Drivers 19 8 6 STD Patients 5 females, 5 males 3 males, 2 females 1 male, 1 female Mystery Clients interviews 2 male clients 2 male clients 2 male dients with Pharmacists/Chemists 2 female clients State and LGA Officials 5 8 5 12 Enviromnent Department Papers Participatory Research Framework officials more aware of their personal Frequently, the research and evaluation biases and assumptions, the issues of capacity in such institutions is unknown concern to the various target groups, and by technical government staff. Also specific opportunities for working with the problematic, university curricula do not communities. Prior to this experience, always reflect national or local needs. Out many of them assumed they knew more of the partnership established, increased than the "indigens" about local percep- interest is being expressed in the Univer- tions and knowledge of STD/AIDS, sity to examine PRA approaches further patterns of health service utilization, and and to carry out dissertation research on the effectiveness of public health edlucation community-level STD/AIDS issues. Also, programs. Evidence of a growing commit- the university will continue to work with ment to participatory principles can be the State AIDS program in monitoring and found in the Plateau research team's evaluation, and health officials plan to provision of technical assistance to groups work with the university to strengthen in Nigeria and the Benin Republic on how AIDS education courses and the public to organize STD/AIDS PRAs. health focus of other relevant courses. A key step in the PRA process was the These various "processes" proved to be local dissemination meetings attended by time-consuming, which can be an obstacle representatives from the target gro-ups and for development planners who are anxious the health officials. In reporting beack to to get tangible results in tne field within the communities that participated in the fixed fiscal or project cycles. The research field work, principles of transparency and was especially slowed by difficulties of accountability were upheld. The follow- communication between Plateau and up also provided an opportunity for the Lagos and the conflicting administrative communities to make recommendeations schedules of the agencies involved. The for action, and made government officials delays, however, may have helped to ease aware of the support and resources that the introduction and dissemination of the they could obtain from the communities. new PRA approaches in the participating Importantly, however, the commu:nities institutions. also expressed fatigue, and referred to the launching of many initiatives that are not sustained due to the lack of necessary The statistics are extrapolated from specific follow-up and inputs. While the F'RA populations (ante-natal patients, commercial sex process set in motion new partnerships workers, tuberculosis (TB) and sexually trans- and lines of accountability for moving the mitted diseases (STD) patients, and long distance effort forward, the next phases in the truck drivers. The syphilis prevalence rate is based on data from only 15 states. Plateau process wLll provide crucial tests. State's highest HIV prevalence rates are found in STD and TB patients, and ante-natal women. The recruitment of a facullty memnber from the local university as the research coordi- 2 The team agreed that no decisions would be nator helped to establish a link between taken unless all members of the team had been academia and local government, and consulted and had discussed the matter as a provided valuable input to the project. group. Participation Series 13 2. PRA Findings: Community Priorities and Institutions Priority Development Concerns authorities are aware of the issues that concern their constituents. Officials Men and women are asked in each of the research sites to identify the main institu- Box I tions in their community, the importance How to Read Institutional Maps of these institutions to them, and whether they perceive these institutions as belong- The circles and boxes in the map represent the ing to the community. They are then relative importance and accessibility of institutions asked to identify the institutions they to the group. The large circle represents the would like to see in the community. This community, and the smaller cirdes signify key institutions. The importance of an institution is exercise is done to gain a better under- depicted by its size- the larger the box or circle, standing of how people view their com- the more important the institution. Institutions munity, identify their priority problems, that are placed outside of the larger circle repre- ,the overall priori attached sents the perception that they do not "belong" to c athe community; and, in the case of the idealized to health concerns. maps, these are institutions that should be located outside of the community. In each LGA access to and storage of potable~~~~ wae isietfe.a h rmr A focus group of women in Zarnko community, potable water is idetifiedastheprimaLangtang drew the two maps below, and explain concern followed by the need to raise them as follows: agricultural production and improve Water. This is a basic necessity but the sources are access to markets. This relates closely to too distant. Lhe belief that poverty has increased, Hospital. The hospital is built but not equipped; it making it is necessary to improve agricul- should be on the outskirts of the community so tural yields and increase access to credit that people could not catch infectious diseases. and markets. While the lack of adequate Existing private facilities do not belong to the health care services and drugs is a concern community, as they could close at any time. in the LGAs, they are secondary to Market. It must be easily accessible, grinding in the LGAs, they are secondary to machines in the market must be close to its center broader poverty-related concerns. for ease of access. School. More government schools would be Policy nakers and public sector health cheaper than private education. service providers are also interviewed on Bank. It would provide loans for market women, the priority concerns of individuals in their protect money against theft, and allow them to LGA. The sizable overlap between the save. matrix rankintg of policy makers and that Church. It is located outside the community and matrix~~ rakn of po maer an tha controlled by missionaries. of community groups shows that poltical 14 Environment Department Papers PRA Findings: Community Priorities and Institutions MAP 1: Ideal Community Institutions (Illustrated by Women in Zamko. Lanctanc LGA) z M.Q. 0 w~~~~~~~~* .~~~~~~~~~~~~~P Primr,.&O i X W '' ~~~~~~~~~~~~~~Sodaych'0 .... ..c~ .-~o - -. .- .................... .- Gc X,., .. ,. ..~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. .......*. MAP 2: Ideal Community Institutions (Illustrated by Wormen in Zamko, Langtang LGA) ..~El X £ 70 ::7 [=FL]~~~~~L amln W Wate1p4;rbtWtr. _ _ .~~~~ ~ ~~~~~~~~. .. .. . . . ParSecondary School PatciaionuStratedsyWme nZ k.LactngLA Towards STD/AIDS Awareness & Prevention in Nigeria caution nonetheless that without financial established at govemmental request, such resources they are unable to address many as the Health and Village Development of their communities' needs. Committees, and organizations formed around local women's, civic or religious Priority Health Concerns concerns. In most of the communities studied government-sponsored organiza- To ascertain commuinities' perceived tions have either not met in a long time or health needs, respondents are also asked were never established. In the cases of to list and rank their main health con- groups that once functioned, such as the cerns. STDs and AIDS do not feature Village Development Conmmittees, the lack significantly in any of the rankings, with of sustained support is cited as a reason the exception of one group of women in for their failure. According to a group of Langtang Town (see Table 4). They rank women in Laranto, Jos North: The problem AIDS as their fourth health priority; and with the committees is that after meetings are they also rank gonorrhea as a problem. In held with us once or twice the organizers of general, women perceive childhood dis- such meetings don't come again and most of eases as priorities, and they rank them the time they don't supply the women with higher than men do. Among women, the enough materials to develop their skills, for main health concerns are measles, dysen- example in soap making, mat making. As a tery/diarrhea, and hypertension; men's result, we feel it is a waste of time and every- main health concerns are meningitis, one has to disperse. typhoid, and hernia. Malaria is mentioned more by men than by women. The exception to this pattern is the govern- ment-sponsored groups which conduct Doctors and nurses identify similar health fortnightly sanitation activities. In some priorities with some notable exceptions. In areas participation in sanitation days is the each LGA, for example, doctors at private only health activity that involves the entire and public hospitals indicate complica- community. However, government offi- tions arising from abortion as a priority cials generally perceive community partici- health problem, particularly among girls pation to be limited to contributions of under age 20. Relatedly, one of the health local labor. According to one LGA official, concerns secondary school girls express is "Community participation means acceptance the fear of pregnancy and having of our education to them and taking part abortions. which makes our work very easy." With respect to two high risk populations, Meanwhile, village-based organizations CSWs rank their reproductive health top have developed in all of the communities among their health concerns, and LDTDs to address common concerns. Indeed, give priority to piles, headaches, and local leaders and groups are willing to backache. become fully involved-financially, techni- cally and managerially-in developing Community Organizations and implementing strategies to address priorities and problems that they identify. Two types of community-based organiza- For example, Langtang church leaders tions have evolved in the LGAs: groups organize communal labor groups, or Gaya, 16 Environment Department Papers PRA Findings: Community Priorities and Institutions for building repair and agricultural work. at subsidized rates in PHC clinics. Never- Community groups also construct market theless, in the absence of sustained support stalls, schools and clinics; dig wells, work such as credit or technical assistance from on agricultural pests control; and maintain outside and within the community, even drainage systems. In Jos North, one many of these local initiatives have not community buys drugs and provides them been sustained. Table 4: 'Ranking of Health Problems Jos North LGA Laranto Apata Men Women Men Women Fever Meningitis Malaria Hypertension Meningitis Gastro-enteritis Tuberculosis Malnutrition Typhoid Typhoid Typhoid Diabetes Tuberculosis Measles Cough Anemia Hypertension Malaria Gastro-enteritis Measles Asthma Tuberculosis Piles Pneumonia Pneumonia Hypertens:ion Hypertension Whooping Cough Epilepsy - Meningitis Asthma Mangu LGA Kombun Mangu Town Men Women Men Women Typhoid Headache Hypertension/Typhoid Hypertension Ulcer Typhoid Meningitis Appendix Worms Hypertension Diarrhea Diabetes Meningitis Worms Measles Ulcer Bilharzia Measles Worms Diarrhea Dysentery Malaria Rheumatism Diarrhea Fever Measles Langtang LGA Zamko Langtang Men Womern Men Women Snakebite Eye Problsm Hypertension Meningitis Drug Abuse Diarrhea Typhoid Measles Diarrhea Cold/Chills Appendicitis Diarrhea Hernia Convulsion Hernia AIDS Meningitis Chest Pain Malaria Appendicitis Measles Liver Cirr'hosis Dysentery Diabetes Malaria Whooping Cough - Pneumonia Bilharzia Measles Gonorrhea Participation Series 17 3. Community Knowledge, Behaviors, and Practices Related to STD/AIDS Beliefs and Knowledge of STD/AIDS Box 2 Box 2 and Table 5 provide highlights of Beliefs about STD and AIDS Causation local beliefs surrounding the causes and symptoms of STD/AIDS. In general, the Making use of dirty toilets can cause disease that affects fieldtresearch STDAIc S. ta disease whi sex organs, walking barefooted can also cause these diseases and urinating at market places indiscriminately affect the genital area are believed to be can also cause these diseases. - Ante-natal clinic transmitted via three routes: patient, Langtang Sexual intercourse AIDS. It is got through sex and through the bathroom ifan infected person passes urine before you. Also from It is thought that promiscuity spreads the toilet after an infected person passes stool in the AIDS, and that this type of behavior is toilet. - Ante-natal clinic patient, Langtang common among youths and men. It also is felt that certain types of women-namely, Ifa person dreams of having sex with a women and felt hat ertai typs ofwho enb een , discharges and it goes back to stomach it causes prostitutes or women who have been gonorrhea. - Traditional healer, Jos North abroad and have sex with animals or western men -transmit these diseases. It is got from zaki, sweet fruits and contaminated water; Lastly, sex for pleasure -as distinct from excreting near a drinking pond can cause AIDS. - Traditional Healer sex related to promiscuity or to procre- ation -is believed to cause STDs and I don't know anything about AIDS but we believe that AIDS. when ever one has it will be washed out during menstruation. - Commercial Sex Workers Contact with urine ConTDact weithed urine transmitted by [AIDS] was from abroad, those who go there for STDs are believed to be transmitted by business and some ladies abroad allow themselves to stepping on or being in an area where have sex with animals such as monkey, dogs for money someone with an STD urinates, "indis- and when they find that they have the disease they come criminate" urination, or using the same back and spread the disease with healthy people. - toilet as someone with an STD. The Female Secondary School student research is unable to identify why urina- AIDS is brought by hunger - that is only those who are tion is thought to lead to disease. Many not well off are getting it ... caused by poor feeding, traditional healers conduct examinations malnutrition and poor environment. -Community Men, of urine as part of their diagnostic proce- Jos North dure, which may suggest why urine plays I heard AIDS could be spread like chicken lice Gn the a role in local health belief systems. radio. - CHEW, Langtang 18 Environment Department Papers Community Knowledge, Behaviors, and Practices Sharing objects as a behavior that increases the risk of There is widespread belief that STD, and contracting AIDS. Additional means of AIDS in particular, could be transmitted contracting STD/AIDS are from the through the sharing of personal items such breath of someone with AIDS, eating with as razors and clothes. Fingernail cu.tting, such a person, or wearing that person's which would involve the sharing of clothes or underwear. scissors, is mentioned by all target groups Table 5: STD Symptoms and Causes Disease Symptoms Causes Gonorrhea Dry lips, unclear eyes Sexual intercourse, promiscuity dull hair (Arwa Nungwan- Prolonged or painful Using same toilet as infected person, indiscri- Tarow) urination minate urination, blood transfusion (Ciwon-Sanyi - Swollen penis, white pus in Borrowing clothes from infected person Hausa) urine, fever, stomach pains Hair on the inside of the vagina Syphilis Swollen penis, wound on Sexual intercourse, at birth from infected penis mother, stepping on infected urine (Tunzere - Tarow) Penis in lower abdomen, boils Urination in same place as infected person (Tunjere - Hausa) Leprosy-like symptoms, Incomplete ejaculation while dreaming loss of body hair remains sediment in abdomen Water flowing from the Heat from pit toilets anus and vagina Sitting where an infected person sat AIDS Loss of weight, fever, body Sexual intercourse, unsterilized or infected swells, bad gums, vomiting needles/razor blades, fingernail cutting, consistent headache, big indiscriminate urination, a dirty environtnent, stomach, big head, water sex with dogs, blood transfusion, the breath coming out of a woman's of a victim, lying on victim's bed, sharing shoes, anus, sunken eyeballs, kissing an infected person, eating with someone yellow complexion with AIDS, women who had been abroad, eating uncooked monkey meat, from injections, sweat of someone with AIDS, contact with crabs on the lips of someone with AIDS. Mai-Pita Cut on penis Sexual intercourse, when a woman refuses to have sex when the man is ready Kabab ciki Clotted blood after birth, men sleeping in bad (infertility) position, not taking warm water after birth PubicLice Lice Dirt in genitals, lack of proper care Misham (Taroh) Mpah-Myar (Taroh) Cut on penis Forceful sex with woman who has a lot of Yankan Gashi (Hausa) genital hair, hair cuts penis Participation Series 19 Towards STD/ AIDS Awareness & Prevention in Nigeria Among the target groups, students are Service providers are well informed of STD most aware about the sexual transmission symptoms with the exception of AIDS. of AlI S and other STDs. While they are For example, some believe that AIDS able to name all of the main STDs, they causes hair loss and discharge from the nevertheless express many commonly held penis. The levels of knowledge among misconceptions about STDs, including that CHEWs are much lower, with one stating AIDS is caused by mosquitoes, women that, with AIDS, the "eyes will blotch out, who have been abroad, and fingernail the hands and legs will thin, [there would be cutting. a] swollen abdomen [and a] big head." Knowledge levels among service providers Attitudes Towards Individuals is not uniformly high. Some believe that with HIV/AIDS AIDS is caused by swallowing the saliva of an infected person, and they urge indi- Most health care providers interviewed, viduals to avoid kissing. One nurse ob- including those in Western and traditional serves that the disease is transmitted practices, have treated STD patients. Very merely by coming into contact with an few, however, have seen or treated some- infected person; and a CHEW suggests one with AIDS. Approximately one-half that mosquitoes can spread the disease. of the service providers expressed fear of Pharmacists and traditional healers have contracting AIDS while attending to an heard about AIDS but they are not all individual with the virus. This notwith- aware that the disease is sexually standing, many providers report that they transmitted. would provide care and sympathy to such individuals. In none of the interviews does Symptoms the distinction between having AIDS and being HIV-positive emerge, nor do obser- Men diagnose STDs in themselves when vations that HIV-positive individuals could they see discharges of blood or pus, feel lead healthy, productive lives. Generally, pain while urinating, or have difficulty service providers view FIIV/AIDS as being walking. None of the men interviewed synonymous with death. mention tnat STDs could be asymptom- atic. To detect STDs in women, men look The many negative perceptions about for vaginal discharges, "flecks" on the lips, working with AIDS clients relate to beliefs changes in a woman's style of walking, or that the disease could be transmitted the loss of erections upon starting inter- through social contact or blood products course. Women identify six symptoms for and to misconceptions about the symp- self-diagnosis of STDs: pains in the lower toms of the disease. Doctors and nurses abdomen, discharge from the vagina, are most concerned about AIDS transmis- yellow stains in the urine, itching in the sion through infected needles and blood vagina, swelling of the vagina/groin transfusions. Pharmacists and chemists, region, and painful urination. Table 5 however, believe quarantine is needed. provides further detail on community Indeed, one pharmacist stated, "I will not beliefs surrounding STD symptoms and allow him [individual with AIDS] into my causes. shop. Don't you know it has no cure and is a 20 Environment Department Papers Community Knowledge, Behaviors, and Practices contagious disease? If he come here, a will any other discharge emerge, and pressing wash the place he has stepped on." C'HEWs their stomachs to see if this causes any as a group express the most negative pain. Similarly, the clients examine CSWs attitudes towards working with individu- for signs of vaginal discharge by wiping als with AIDS. Many of them recommend white handkerchiefs on their vaginas. quarantine, and a CHEW in Langtang Second, CSWs, and particularly those in observes: "I wouldfeel like vomiting, as the urban areas, go for regular medical exami- AIDS patient will always be smelling." nations In some cases, these check-ups involve vaginal exaninations and stool At the community level, respondents and urine tests. Third, auto-medication is consistently express fear and pity towards also used for prevention. CSWs apply individuals with AIDS, and believe that penicillin-based oint'nents to their vaginas those infected need to be quarantined. In after having sex to prevent infection. They Langtang, one community member sug- also use these ointmnents as lubricants, and gests that the belongings of someone with are faniliar with the names of specific AIDS should be burned when the person creams that they buy regularly. Self- dies. Jos North communities observes that medication is also reported as a preventive persons with AIDS should be treated in measure by many clients of CSWs, and the hospital and reported to the pclice. they go to chemists and traditional healers Again, these reactions reflect unde:rlying for medicines prior to or between visits uncertainties and fears regarding the with CSWs. Of final note, CSWs link transmission and fatal impact of the unclean toilets to STDs, and some report disease. that they clean hotel toilets as another preventive measure. Prevention Common Methods Box 3 Approaches to Diagnosis of STDs Service providers advocate abstinence and by Commercial Sex Workers sticking to one partner as the main preven- tive measures for STD/AIDS, and infre- Some ofthe men before you check them will rush quently promote condom use. In consider- and urinate the pus away but we insist that before ing issues of prevention, providers place they go out to piss we press their prick to see if much emphasis on measures to reduce discharges are coming out. their own occupational risks associated with treating individuals with AIDS. I will touch his stomach and press it hard, if hefeels Many providers mention the need to pains then I will know he has disease. screen all blood and to use sterilized blades acreend instrumedant to use sterilized blades A woman who has this disease will not be able to stand up and there uwill be stomach ache. As explored in Box 3, CSWs report use of We check them by using a white handkerchiefto three preventive measures in addition to press his penis to see if he has a disease. condom use. First, they conduct p:hysical examinations of their clients, including 7he men that come check us using white toilet paper squeezing a client's penis to see if pus or to see ifwe have disease. Participation Series 21 Towards STD/ AIDS Awareness & Prevention in Nigeria Community members identify their main found in Mangu, where the risk of AIDS STD/ AIDS preventive measures as absti- spreading is thought to be slight. In Jos nence or monogamy and avoidance of North, there is greater understanding of areas where people urinate. As explored the potentially large impact of the disease further below, condom use is infrequently because the city serves as an important mentioned and often associated with its transit point. contraceptive function. Among the indi- viduals who believe that STDs, and AIDS Awareness of and Attitudes in particular, are transmitted by the Towards Condom Use sharing of personal items, some report that Condom use is low among all of the target they refuse to share razors and have groups, including among the high risk bought their own pair of nail scissors. populations of CSWs, LDTDs, and clients of CSWs. In fact, very few people report Perceived Risk that they have even seen a condom or The limited and ad hoc adoption of preven- know how to use them.' Secondary tive measures is closely linked to the lack students are most knowledgeable about of a sense of perceived risk. As AIDS is how condoms work, but few of them associated with promiscuity, visitors, and (particularly female students) have ever women who have traveled abroad, most seen one. In Langtang LGA, none of the individuals do not consider themselves at STD clinic patients have ever seen a risk. In Jos North, for example, women condom. While most CSWs know of believe that their Christianity will protect condoms, many of them never use them them, while men in Laranto feel that the and some have never seen one. Key disease only affects the youth because they obstacles to condom use include: are promiscuous. The low levels of per- ceived risk may also be related to the Cost. Condoms are too expensive for hmited availability of information about certain populations. For example, some the disease and the communities' limited CSWs report that they could not afford to contact with people from the state who use a condom with every client. CSWs have AIDS. As one CSW said, "I hear say working in rural areas average three-to- AIDS there I never see any body when AIDS four customers on a good night, earning catch them. I never see any body when AIDS 20 to 30 naira per sex act; at 10 naira each, kill them. All I hear the AIDS there, AIDS CSWs argue that condoms are too expen- there." sive. Other quotes on condom prices range from 2.5 naira for one to four for 20 Only one of five officials interviewed in naira. Langtang perceives AIDS to be a serious problem, while another admitted that he Condom breakage. Many condom users has never heard of the disease. Local complain that they break during sex. officials mention some problems with Condom breakage may be related to the STDs more generally, but they associate unavailability of appropriate lubricants, the diseases with youth truancy and the size of the condoms, and storage promiscuity. Similar perceptions can be conditions. 22 Environment Department Papers Community Knowledge, Behaviors, and Practices Beliefs about negative health effects. One of and as a means for procreation. They the traditional beliefs about syphilis is that associate condoms with sex for pleasure in it is caused by sperm re-entering a man's extra-marital affairs, and consider these body through his penis. This leads some inmmoral acts practiced by "loose" women men to refuse to use condoms due to the or prostitutes. belief that, by "trapping" the sperm, the device causes syphilis. Some women and Married women are therefore reluctant to female students believe that condoms can purchase condoms or suggest their use to become dislodged during sex and enter the their mates, as this could be perceived as womb and other internal organs, which evidence of their own infidelity or immo- can cause bleeding or even death. In rality. In addition, women do not think Mangu, women report that they know of they should purchase condoms because condoms having to be surgically reimoved they do not "use" them or have control from the womb. Some service providers over the sexual act. Furthermore, men also express concern that condom use perceive the notion of women taking the could lead to cancer. initiative in determining the timing and nature of sexual interaction as an attempt Loss of sexual pleasure. Most men complain to usurp the man's role and control their that condoms reduce sexual pleasure. husbands. Such behavior is unacceptable to most men, and some indicate that they Rural-urban location. Knowledge, availabil- would respond violently (see Box 4). At a ity and use of condoms are lower in rural more basic level, many women are very areas. uncomfortable presenting a condom to their partners because they do not know Skepticism among health service providers. how to use it. Many providers believe that condoms, although useful in preventing disease, Men who approve of family planning are frequently break and provide a false sense more supportive of condom use, but, of protection. Many providers in rural again, primarily for contraception and not LGAs believe people are too uneducated to to prevent STDs. Men who report having use condoms properly and therefore do sex for pleasure or extra-marital relation- not promote their use. Also, many provid- ships are also more supportive of condom ers do not support condom distribution to use, and specifically for STD prevention. youth, as this would promote immorality Women with spouses who use condoms and promiscuity. view this as an indication of the desire of their husbands to space births; however, In addition, the determinants of condom the same women also think condoms will use are closely tied to behaviors surround- protect them from disease. Male students ing sexuality and sexual relations. In all see sex primarily as a rite of passage and communities, the timing and duration of form of enjoyment, and associate condoms the sexual act is determined by men and a with STDs and family planning. Most clear distinction exists between sex for male students do not see themselves at risk procreation and sex for pleasure. Married of getting an STD or are worried about women view sex as a means of satisfying teenage pregnancies. Hence, they perceive their husband's desires and not their own, no need to use condoms, which they feel Participation Series 23 Towards STD/ AIDS Awareness & Prevention in Nigeria reduces sexual pleasure. On the other While the main type of sex reported is hand, female students are very concerned vaginal, CSWs in urban areas report that about unwanted pregnancies andsupport anal sex is increasingly in demand. The condom use as a contraceptive device. price for anal sex can be as high as 4,000 naira in urban areas, while vaginal sex costs between 50 and 200 naira. The Box 4 majority of men claim to have sex two-to- Perceptions of and Attitudes three times a week. Among LDTDs, the Towards Condom Use average number of sexual interactions is once a week when they are traveling and If not nursing a baby and she say use a condom I three-to-four times a week when at home. will beat hell out of her and sex her without condom. - Long distance truck driver The average age for the initiation of sexual It is not for our age but it isfor children to use activity is sixteen years for girls and eigh- during sexual intercourse because they are more teen years for boys; in Jos North sexual promiscuous .- Community women, Jos North activity as young as ten is reported. I don't allow my customer to use it on his bura Determinants of Health (penis) to have sex with me. I will allow him to go Service Utilization with his money, because it can enter my stomach during sex and disturb me. - Commercial Sex There is evidence of extensive switching Worker between Westem and traditional medicine It is risk some say because if it pass into the girl's (see Box 5). Each of the cormunities vagin it may lead to her death. - Secondary interviewed contains two-to-four tradi- vagina It may lead to her death. - Secondary onlhaescm rdwihneH. School Student honal healers compared with one PHC. Private clinics and hospitals are also People say it is not pleasurable and it is dirty .- available but are used less frequently due Long Distance Truck Driver to higher costs. The sequencing of visits between Western and traditional health I willfeel discouraged going to buy them because I systems is determined by: 1) beliefs about will be ashamed ... as people will know I will use the causation and appropriate treatment them with a harlot. I will feel shy if the person in of the llness 2) characteristics of the the chemist knows me. - Male secondary school f athe illnerss c teristi of hes student health delivery system; 3) cost and access to services; and, 4) the perceptions of The say it is a dirty game- they believe is being providers and clients towards each other reused and it becomes clumsy. - Nurse and of the quality of health services. Beliefs about Illness Causation and Frequency and Type of its Appropriate Treatment Sexual Behavior A clear distinction is made between treat- ment and cure of an illness. Treatment is Jos North CSWs report having an average associated with the abatement of symp- of five clients a day; in rural areas, the toms, while the latter is linked to interven- number of clients is about three a day. tions that remove the cause of an illness. 24 Environment Department Papers Community Knowledge, Behaviors, and Practices A group of women in Jos North explain plained: In some it will not show in urine but that hospitals are the first choice for the it will be eating up the groin. Even if take treatment of syphilis because the medi- injection it will not die but will be dormantfor cines given there will "kill the eggs cf the some time before it starts again. Therefore, tunjere [syphilis]," but then traditional using traditional medicine is better. Using medicine will be necessary to cure the orthodox medicine will only make the sickness disease.2 As one CSW succinctly ex- to lie dormant. Box 5 Preferred Sequencing of Providers Men, Kombun Community, Mangu LGA Illness First Choice Second Choice Third Choice Fourth Choice Typhoid Hospital Traditional Healer - Gonorrhea Chemist Hospital Traditional Healer Death Syphilis Chemist Hospital Traditional Healer Death AIDS Hospital Traditional Healer Hernia Hospital Death Reasons for choice: Gonorrhea and Syphilis: Go to chemist first because of shame, the chemist would provide privately and be discreet, if the chemist does not work one has no choice but to go to the hospital because they have drugs, the hospital drugs might not heal completely but traditional drugs heal completely. Women, Laranto Community, Jos North LGA Illness First Choice Second Choice Third Choice Meningitis Hospital Clinic Traditional Healer Diarrhea Clinic Hospital Traditional Healer Typhoid Hospital Clinic AIDS Hospital Traditional Healer Gonorrhea Clinic Hospital Traditional Healer Syphilis Hospital Traditional Healer Reasons for choice: Meningitis: Serious problem only doctors know how to treat it; if hospitals cannot cure it we go to the clinics; when we have tried all ways without working then we have to go to the traditional healer. Diarrhea: Clinic is the nearest place; if the sickness persists we go to the hospital; if the two treatments do not work we go to the traditional healer. Typhoid: Hospital cure this very fast; if it persists the next place to go is clinic. AIDS: One has to be serious with AIDS treatment because it can kill .... we go to hospital; when the sickness cannot be solved the next place is the traditional healer. Gonorrhea: Clinic first but if the clinic cannot cure the victim the second place to go is the hospital; the traditional healer for the next treatment since everybody like traditional medicine. Syphilis: The hospital first in order to treat and kill the eggs of the tunjere; but if the medicine from the hospital cannot cure it we have to go to the traditional healer. Participation Series 25 Towards STD/ AIDS Awareness & Prevention in Nigeria Table 6 lists what community members Characteristics of the Health believe are the most appropriate treat- Delivery System ments for STDs. Again, western medicine Other factors relating to the health system is used to treat the symptoms of most itself greatly shape the way health services STDs, but there is always a traditional are used. These include: medicine that car, be taken in conjunction or on its own. AIDS is the only disease Drug availability. Some men do not use that is referred exclusively to a Western clinics and hospitals because drugs are provider because, as a new illness, there never available and they must then go to a are no established traditional therapies. chemist. They prefer to go to the chemist Moreover, most people, believing AIDS first where they can obtain both a diagno- can not be treated or cured, view the sis and the required drugs. Patients at hospital and not the clinic as the first STD clinics also complain about the lack of treatment site.The practice of provider drugs and the length of time it takes to get switching is also related to expectations test results. In addition, patients believe about the course of treatment and the time that drugs sold on the open market cost within which medications should have an more than those at clinics and hospitals. observable effect. Some patients report There is also concern that drugs provided that hospital treatments take too long to by chemists may be fake and not provide relieve symptoms and therefore they turn effective treatment. to traditional medicines. Thus, if STD symptoms continue clients do not return to Perceived Function of Treatment Site. Both where they had last been treated but men and women view PHC facilities as instead go to another type of provider. being exclusively for women and children, When there is no improvement after all and men are unlikely to use them. "Clinic types of providers have been consulted, is meant for woman. The man only goes to most individuals resign themselves to their hospital," as one group of men from fate. Table 6: Appropriate Treatments for STD/AIDS Name of STD Appropriate Treatment AIDS No cure; injection to prevent person passing it on to others; go to the hospital Ciwin Sanyi Roots of bini mixed with guinea corn powder; mix lemon (Gonorrhea) juice with cow's milk; go to hospital Tunjere Roots of bini mixed with guinea corn powder; go to hospital; (Syphilis) traditional medicine applied to the anus Pubic Lice Powder from ash, mix with kashi makera and drink Yankan-Gashi Cigarette ash on wounds Kaba Mangul and whisky 26 Environment Department Papers Community Knowledge, Behaviors, and Practices Mangu bluntly explained. The name Conditions offacilities. Patients are also change from Maternal Child Healthl concerned about, the appearance and Clinics to PHCs has done little to a:Lter cleanliness of the clinics, the limited range these perceptions. Meanwhile, women are of services offered, and the lack of medical reluctant to visit traditional healers as this equipment. Ante-natal women find PHCs could be interpreted as an attempt to put a dirty, dark, and in need of renovation. curse on their husbands. They also ex- Several women comment on the lack of press reservations about purchasing drugs toilet facilities, a particular inconvenience or condoms at chemist shops, as these for pregnant women who must typically visits could be seen as attempts to obtain wait two hours or more to see a nurse or medicines for inducing an abortion. doctor. Similarly, patients at STD clinics also make observations on the need for Gender of service provider. Women are repairs, the cramped conditions, and the unlikely to use facilities where examnina- lack of toilets. tions would be performed by male nurses or doctors. They believe that female During the interviews, three recommenda- providers would better understancl their tions were made for improving health problems and feel less shame in exposing services. First, health education classes their bodies to someone of the same sex. should be provided on disease causation Men are less adamant about the need to and prevention. Second, many women have a provider of the same sex; however, want PHCs to expand beyond ante- and married men expressed concerns about post-natal care in order to address a wider their wives being given physical examina- range of women's health concerns. Third, tions by male doctors. Among adolescents more-and/or better functioning-equip- of both sexes, ft iere is a strong preference ment should be made available to PHCs for a provider of the same sex. 'T and hospitals, particularly for the perfor- mance of simple procedures such as taking Privacy of service. The lack of priivacy blood pressure. The lack of equipment in between patients and providers at public PHCs leads individuals to seek treatment sector hospitals and clinics is frequently in hospitals and private health facilities for cited as a reason why these facilities are health problems unrelated to pregnancy. not used for STD treatment. The lack of Box 6 presents further suggestions from properly enclosed examination rooms and ante-natal women for improvements in the approach to patient management clinic conditions. made potential STD patients feel that the reason for their visit would be apparent to Cost and Access to Services others in the facility. Privacy is not an Cost, in terms of both finance and time, issue at private facilities; female students are important determinants of service believe that visits to a private hospital utilization. There is no clear consensus on would be confidential and expect to be whether going to a hospital or clinic is better treated than by a chemist o:r tradi- cheaper than being attended by a tradi- tional healer. On the other hand, male tional healer (see Box 7). However, the students say they would patronize both financing plan adopted by traditional chemists and public hospitals. healers appears more convenient for Participation Series 27 Towards STD/ AIDS Awareness & Prevention in Nigeria patients: payments can be made over time In rural LGAs ante-natal visits at PHC and in kind. clinics are estimated to cost between 20 and 25 naira; and some women who arrive after 9:00 am are charged a late fee Box 6 of two naira. Visits to the Plateau Hospi- Suggestions for Improving tal, at an average cost of 100 naira, are PHC Clinics more expensive but include fees for labora- tory tests and drugs when available. In Sweep it, remove cobwebs, clean tables, and wash the the urban areas where taxis are more toilets so that the place would look nice to see. - available, women spend an additional 20 PHC Chnic, Mangu to 30 naira traveling to and from clinics I would like the structure to be renovated. And there and hospitals. Many traditional healers should be electric supply regularly. - PHC Clinic and pharmacists are open on a 24-hour Langtang basis. By contrast, PHC clinics have more restricted hours that are often inconve- Give the nurses some incentives. - Plateau nient to women with agricultural and Hospital household obligations. In Langtang and Mangu, most women arrive at PHCs The nurses should be sincere in the way they treat before 8:30 a.m. and spend on average people. They aresometimes harsh to us when we teo hours in the clinic, though visits want to ask some questions they shout us down sometime or they may not answer us very well. - lasting over three hours are not uncom- Plateau Hospital mon. At the Plateau Hospital in Jos North the average visit lasts two and one-half Educate us more about illness and their causes. - hours. The majority of this time is spent PHC Clinic, Langtang waiting to see the nurse or doctor. In rural If I had the chance I will buy airfresheners and put Box 7 some in every room in this hospital and also help Choice of Provider for buysome tins of paint and re-paint the walls. The Treatment of STD/AIDS walls are dirty. -Plateau Hospital Allfacilities related to child delivery should be Wego to the hospitalfirstfor drugs, when it is not made more available. - PHC Clinic Langtang treated then Traditional Healer who helps some- times, and if theyfail too, then we resort to the I will make equipmentfor working available. What prayer housefor spiritual care and attention and they measurefor blood pressure has gone bad, there finally we stay at home waitingfor death - Women are no hand gloves and mucus extractors. - Plateau in Langtang on treatment choices for gonorrhea Hospital Traditional healers charge costly than hospital and Things like seats. - Plateau Hospital clinic. They will ask someone to buy cow, goat, fowl and the same time collect money again on only one I would like spirited individuals to assist the clinic sickness - Community women, Jos North with more drugs, as there is always no drugs. They do give us prescriptions to go and buy outside. - For privacy they hardly go to the hospital. They PHC Clinic, Langtang prefer going to the chemists and pharmnacists for there is absolute privacy there - Policy maker, Langtang LGA 28 Enviromnent Department Papers Community Knowledge, Behaviors, and Practices areas, most women walk to the clinic, express widespread skepticism of the requiring an average of fifteen to thirty healers' diagnostic ability. Few Western- minutes (but can be as much as 2 hours). trained providers believe that they have In urban areas, the average walking time anything to learn from traditional healers, to a clinic is twenty minutes. with the exception of much interest in learning about the techniques used by Perceptions and Attitudes of Various healers to set broken bones. Target Groupsabout Each Other Providers. The cultural, linguistic and gender differences between public health Box 8 providers and their clients influencEs Providers Perception of Patients providers' perceptions of their patients, and Their Target Communities and vice versa. As seen in Box 8, doctors and nurses have many stereotypes iabout Youth are rude ... very difficult to work with they are patients based on gender, age, educational arrogant. They don't have regardfor us here. They level and ethnicity. Overall, they view want everything to be done to them at once. - men as being more difficult because they Nurse, Langtang Hospital ask questions and do not follow treatment They pretendjust like the Yorubas, they praise you guidelines. Providers perceive youth to be in your presence and when you turn your back they arrogant. In addition, there is widespread abuse you. - Doctor, Mangu rejection of the behavior and beliefs of Hausas are very difficult to deal with. They are those who are thought to be "ignorant," illiterate, jobless in purdah therefore solely depen- "arrogant," or "illiterate"- labels that are dent on their husbands. They misinterpret their frequently applied to villagers or individu- religion. Theyseek medical advice late and they als with little formal schooling. Ethnic interfere with medical intervention. They don't stereotypes are also common; according to give afree hand to the decision of the doctors due to one provider, the Fulani are ignorant and their religious bias. - Doctor, Plateau Hospital, difficult because they don't listen to in- Jos structions, they come to see patients Men are difficult to work with ..... men tend to be outside of visiting hours, and they litter the stubborn, some are not willing to tell you their hospitals and pester those on duty. In problems. -Hausa speaking doctor, Langtang some cases, patients are belittled if they do General Hospital not speak Hausa, the most widely-spoken Ibo patients tend to know too much. The pagans are language among public sector service not patient ... they prefer traditional medicine. The providers. Providers also express gender- patients that are easy to work with are the biases, including that women use health Moslems.... they are cooperative and are willing to services more than men because they can listen to instructions concerning their health. - not cope with pain and are more biologi- Nurse, Langtang General Hospital cally predisposed to have illnesses. One Ifind it difficult to work with the Tarok people doctor suggested that women, because those who are illiterate and comefrom the villages. they live in purdah, need the "fresh air" They don't speak Hausa .. A lot oftimes they are not afforded by a clinic visit. given all the information they need on health issues because I can't communicate with them. - Staff Many doctors and nurses are willing to nurse, PHC Clinic work with traditional healers, but they Participation Series 29 Towards STD/ AIDS Awareness & Prevention in Nigeria Patients. Most target groups complain communities, officials believe that most about the attitudes of clinic and hospital people go to PHC clinics and hospitals for staff. CSWs report that unless they show health care services, and particularly for they can pay for services they are not STDs, and do not regularly seek treatment treated properly at hospitals. They men- from traditional healers. Officials main- tion having to bribe staff to be admitted to tain that public health facilities are widely hospitals and feel they are sometimes preferred because they are better staffed overcharged. According to one CSW, and equipped, easily accessible, cheap, "Some doctors and nurses don't care about and provide genuine drugs. Few officials patients at all, they don't even ask you what acknowledge the need to address the your problems are. They just treat you very qualitative dimension of service delivery- quickly." e.g. the need for improvements in interper- sonal communication between patients In interviews, many individuals express and providers or in clinic management concerns about the manner in which and supervision. providers speak to them and the lack of information they are given about their The Role of Chemists, Patent illnesses. For example, exit interviews Medicine Dealers, and Pharmacists with patients at PHC and STD clinics reveal that most of them are unable to Face-to-face interviews with chemists, recall their diagnosis, if they have been patent medicine dealers, and pharmacists given one. Nor can they recall the medica- show them to be knowledgeable about tions prescribed and the treatment regi- STD causation, keen on collaborating with men they are expected to follow. clinic and hospital staff, and committed to selling STD drugs only to patients with a Traditional Healers. Most traditional prescription. This was not found to be the healers believe that hospital and clinic staff case with the "mystery client' interviews have inappropriate interpersonal skills. (in which male and female members of the According to a traditional healer in research team approach these providers Langtang, "There is delay in the hospital; and pretend to be suffering from an STD). when it comes to attending to a patient, when you don't have money one is treated like a As explored in Box 9, the mystery clients' dog." Most of the traditional healers diagnoses are often based on the relative express a willingness to work collabora- ability to pay for treatment. The majority tively with Western-trained staff and help of patients are sold a combination of pills doctors improve their commnunication and, in some cases, told that they need skills. The majority of traditional healers injections. The mystery clients are not in the interviews have lived and practiced informed of what medications they are in their communities for at least 10 years; being given, and merely receive simple and, unlike PHC or hospital staff, most of instructions on what color pills to take and them speak Hausa and at least one of the in what order. A female mystery patient other local languages. who asks how a prescribed cream should be used is told to read the instructions on LGA and State Officials. In contrast to the the tube. Few of the mystery clients are behaviors and practices reported by the told about the cause of their illness, STD 3 0 Environment Department Papers Community Knowledge, Behaviors, and Practices Box 9 lack of training is most evident among Box . CHEWs. Existing in-service training to Mystery Clients generally focuses on famnily planning or ymidwifery, and the providers indicate that In Langtang, a male (mystery) patient ap- no training has been offered on the pre- proached a pharmacist and a chemist and vention, treatment, and care of STDs or informed them that he had a pain in his other diseases that are prevalent in their genitals and "a whitish discharge" from his communities. In contrast, the majority of penis. Both providers asked when the symp- providers in private hospitals and clinics toms started. The pharmacist informed him have received in-service training within that he had a "woman disease". Both wrote the last two years. prescriptions for the iDlness, the pharm.acist, gave a prescription for six medicines. T'hese Supervision of staff performance is ad hoc medications cost 135 naira. The pharmLacist or non-existent, particularly for doctors. also wanted to administer an injection, but said According to one doctor, "nobody comes that he could not do so because the surL was hot and asked the 'patient' to return later in the here to supervise my work, because I am the day. The chemist prescribed three meclicines, Medical Superintendent here. But this should supposedly, amplixlox, tetracycline and not be so, due to the poor administrative nitrofurantoin, and charged 65 naira. He system this... .has been overlooked so I do what suggested that they be taken before the end of I can." Supervision of nursing staff is done the day and said that they would cure ithe more regularly, but with somewhat less illness. efficiency in rural areas. Senior nursing staff are generally not supervised and do In Jos North, a male (mystery) patient was nt e te theln performance offered three treatment options: Full Treatment evaluted. for 320 naira; Not Full Treatment, which evaluated. involved medicines that would not work so fast, for 120 naira, Half Not Full Treatmkent for 60 naira. The last treatment consisted of two red pills, two white pills and 32 purple pills. ' Condoms are known as condom mba, condom, The 'patient' was told to take them at home and rain coat, and Durex (a brand name). In addition, a that his urine would turn dark yellow. series of names in Hausa and the local languages are used, such as: Hulan maza kuta, Fulan maza kuta, prevention, condom use, or the need to Sock nababa (Hausa), and Atangia-achei (Taroh). In return for a follow-up visit. Jos North, condoms are also called evidence, protector, screw driver, and cap. Training and Supervision of Health Service Providers 2 The dichotomy between treatment and cure is also observed for non-sexually transmitted diseases. Mostof the public sector staff have-a not For example, men in Langtang state that they would Mostived any training in the last three to first go to the hospital for hypertension treatment, as received any training in the last three to the tests done there would "detect" the disease; but four years, which is often the length of a complete cure would only occur when they have time they have been in their posts. The taken traditional medicine. Participation Series 31 4. Community Health Information: Sources and ImpaCts In rural LGAs interpersonal communica- Communities have mixed perceptions of tion provides the main vehicle for all forms the quality of information provided by of information dissemination due to health outreach workers. In Langtang limited access to mass media.' Credible and Jos North, CHEWs are viewed as sources of information for these popula- credible, trustworthy and skilled sources of tions include religious leaders, traditional health information. This contrasts with elders, village chiefs (particularly the perceptions of traditional birth attendants, Ponzhi Taroh, the highest traditional ruler), who are considered only skilled in matters the district head (Magajin Garin), and the concerning pregnancy and not as knowl- town crier-who goes out on the instruc- edgeable as CHEWs. Some of the Mangu tions of the village head. Access to mass communities refer to information officers media is greater in Jos North, where radio attached to the Federal Ministry of Infor- is popular among students and women. mation as reliable and credible sources of Many women, however, report that they health information can not understand the programs broad- cast in English. Printed reading materials Inter-Personal Communication are available in all areas but reach a small at Public Health Clinics segment of the population due to low literacy levels. Exit interviews with anti-natal women reveal that they have limited recall of In their identification of health opinion information provided by the clinics on leaders, communities make references to immunization, family planning, AIDS, residents who provide treatment on credit and children's diseases. For example, or who settle land disputes, and they also women's understanding of ante-natal mention wealthy individuals engaged in examinations is limited. The recall of the community development. In addition, visit by a woman in Langtang is typical of doctors and nurses are widely identified as other responses in the interviews: The credible sources for health information. nurse told me to lie down so that she could Female secondary school students cite check my pregnancy, then I lied down and she doctors, pharmacists/chemists, and their checked my pregnancy and after checking the parents as credible sources of information. pregnancy she gave me tablets red in color Boys report that they would avoid talking and the red syrup which I don't know their to their parents and would obtain health names. Then, the nurse told me to come next information by consulting peers who have Friday for check up. suffered from the disease in question. 32 Environment Department Papers Community Health Information: Sources and Impacts In fact, the most frequently recallecd aspect blood in the body. Most women inter- of the ante-natal visit is the list of things to viewed report that the sexual transmission bring to the hospital for the delivery: of STDs and AIDS is either not discussed sweaters, baby clothes, olive oil, toilet or the information given can not be re- soap, razors, Dettol, and 500 naira. called. Most of the Jos North women report being Inter-Personal CommuLnication told about immunizations, while only at STD Clinics about half of the women in Langtang and Mangu recall receiving such information. Exit interviews with STD patients reveal The main messages that they retain are the similar patterns of limited communication need for women to be immunized, the and recall. Of the five patients interviewed scheduling of immunization appoint- in Mangu, only two are informed that they ments, and the importance of not rnissing have contracted their infection through appointmnents. The reason for being either sex or a toilet seat and only one immunized is not clear to all of the women patient is informed of his specific diagnosis interviewed, and some can not recall what (syphilis). Most patients only receive a immunizations they have received. urine test, with the exception of one culture test for syphilis. In Langtang, a In general, family planning is discussed woman who received a diagnosis of pelvic less frequently than is immunization, but inflammatory disease reported that the the main messages that women can recall provider did not give her a physical exami- are that: 1) a variety of contraceptive methods are available; 2) women should stop having children after the fourth birth; Box 10 and, 3) contraceptives should be used for Women's Recall of Discussions on two-to-three years to space births. The STD/AIDS in Health Facilities first message is the most frequently men- tioned. Comments by women on health The nurse only told us that anybody that does not education sessions suggest that infDrma- have his blood examined, the pregnant woman will tion is provided on methods that are not be sent away during labor. The nurse did not tell us available to them, and that the talks are why, she only said that it is important to have our not well understood. For example, a blood tested so that we will know the type of sickness Plateau Hospital women mentions being one has and to know whether one has enough blood. told about "something that is put in the - Plateau Hospital armpits" (Norplant). Protect against mosquito bite. This will enable us to have enough blood in their body so that on the day AIDS is discussed with anti-natal patients of delivery they will not be short ofblood and result primarily in the context of taking measures to blood transfusion because they are too many to avoid the need for blood transfuLsions sickness nowadays like AIDS. - Plateau Hospital during delivery (See Box 10). Accordingly, They told us to eat goodfood that will avoid many women report that they are told toThytlusoeagodfdtatwlavi "ulu ,extraboda" Dons o anything that will cause blood transfusion because nbuildupextritionoalsoDfo cussononed to eAIDS is very rampant. They did not tell us much nutrition also focus on the need to eat about AIDS. -PLateau Hospital foods that will increase the amount of Participation Series 33 Towards STD/ AIDS Awareness & Prevention in Nigeria nation but did take her temperature and complain about this and recommend that blood pressure. STD patients are given a the target groups for outreach programs combination of tablets and injections, but be expanded (see Box 11). none of them are told how the medications work and few know what specific drugs Some LGA officials observe that health have been prescribed. education efforts are having an impact. Others, however, express serious concerns The majority of patients are not told about the program's lack of focus, appro- anything about STD or AIDS prevention, priately trained staff, and coherent imple- including the patient with a diagnosed mentation. Supporting these latter views case of syphilis. A Langtang STD patient is evidence that consistent strategies and is advised, however, "not to eat kola nuts, plans for selecting health education pepper or alcohol." The few patients who themes and approaches are largely absent can recall having been told about AIDS and administrative processes for staff report being informed that it is incurable, supervision and program evaluation are new, dangerous, transmitted through sex, generally poor or non-existent. Many and that one needs to use condoms and CHEWs, for example, evaluate their work clean needles. Again, however, most by the number of people who attend talks patients are not told about condoms, and or come to clinics. none receive free condoms or demonstra- tions on their correct use. Also significant, Box 11 clients rarely are asked about previous Perceptions of Sources of sexual partners; although one patient with Health Information a suspected fungal infection is told to have her husband come in to be examined The health talks are not enough, not to speak of (which she refuses to do out of fear that he enlightenment. The onlypeople who have the will suspect she is unfaithful and beat her). opportunity of getting these talks are those women All patients are asked to return for a who attend the MCH. In the village such talks are follow-up visit. not done - Men, Langtang Effectiveness of Health VHW, TBA (traditional birth attendant), or CHEW Education,/Community Outreach are completely absentfrom here. It has been a long time since we talked to a CHEW. We don't have health talks, we never had any - Men, Jos North The effectiveness of health outreach efforts is hampered by the infrequency of visits by There has been some campaign going on. The outreach staff, poor targeting of audiences, campaign has not deterred anybody - Pohcy and weaknesses in program administra- Maker, Langtang tion and supervision. Infrequent visits by health education workers is identified as a We have never talked to any VHW, TBA, or CHEW problem by every community. No visita- because we don't even know them and we are not problarem byrevter cmommunity Noavdst- familiar with such people - Women, Jos North tions are reported among the hard-to-, reach CSW and LDTD groups. In fact, There is an AIDS Action Manager, but less has been CHEWs- a primary agent for outreach- done about enlightenment - Policy Maker, report that women are their main target Langtang audience. In some communities, men 34 Environment Department Papers Community Health Information: Sources and Impacts Community Interpretations Box 12 of AIDS Poster Interpretation of AIDS Poster CHEWs find posters to be an effective Keeping neat is a task that mustbedone, so thatyou means of outreach and use them exten*- cannot contact any type ofdisease; with cleanliness sively. They assert that the public health sickness will not be difficult to cure. - Long messages conveyed by this tool are easily distance truck driver. understood by their target audiences. At the State level, resources are available f or Does it mean if all the instructions under the keep the reproucio of existcng psers, ard clean picture are not kept one will catch AIDS. - the reproduction of existing posters, and Nurse at PHC clinic most requests for program funds include a budget for the production of new posters. Well, I will just agree because I can't read and also cannot get the message. - Ante-natal clinic In the course of the interviews, all of the attendee target audiences in the study are askecl to comment on poster in Figure 1. It is We should protect ourselves from diseases by chosen because it had been printed in washing our hands. - Secondary school students large quantities, distributed throughout De man in de poster get headache and de woman the State (including to health clinics), and touch the head and .... look on. - Commercial sex clearly shows the word "AIDS." Signifi- workre cantly, the poster requires both writtenw and pictorial interpretation about caring There should be health education like teaching us for people with AIDS and preventing more about the poster. - Nurse at PHC clinic transmission of the virus. I don't know how someone can get AIDSfrom the The majority of the sample report having use ofa brush. - Nurse at PHC clinic never seen the poster, but a few do recall it at Jos University Teaching Hospital. Less than half of the ante-natal women Among health providers who are sup- interviewed are literate, and must inter- posed to be using the poster in their educa- pret the poster solely from the illustrations. tion efforts, most PHC staff are not famil- None of these women are able to associate iar with the poster but some hospital staff the pictures with AIDS prevention, and recall seeing it at work. some unintended interpretations arise. Many women believe that the man in bed Upon studying the poster, many audiences is sick with either headache or fever, and, do not understand its messages and sug- consequently, understand the poster to be gest improvements (see Box 12). The about the need to take care of the sick. density of the written text and the wide Some women interpret the poster based on range of information presented lead most only one or two of the drawings, and people to rely heavily on the drawings for believe it to be about food preparation or understanding the poster. Many think it first aid. In the few cases where AIDS is to be concerned with hygiene and cleanli- mentioned, the women think the poster is ness, and few can make the connection to about taking care of someone with AIDS, AIDS. According to one student, "I don't and do not relate the actions shown to see how keeping clean relates to AIDS." AIDS prevention. Participation Series 35 Figure 1 Care For People with AIDS PROTECT Your Patient from Infections PROTECT Yourself and others from AIDS r~~~: r e WASH HANDS COVER WOUNDS KEEP CLEAN DON'TSHARE SHARP Wash hands often Cover wounds especially Keep all bedclothes, THINGS especially after using on hands or places likely towels, the patient's body Don't share razors, latrines or toilets, to touch the patient. Use and clothing clean. toothbrushing sticks, changing soiled bedding clean cloth or plasters to Especially clean away toothbrushes or any other and clothing and before cover wounds. faeces, blood, vomit and things which can possibly handling your own or the sweat. Use bleach (JIK) draw blood or touch sore. patient's food. on bedclothes or dry them in the sun and iron them. Adapted from the Uganda School Health Kit on AIDS Control (Item 10) BY: Ministry of Health (AIDS Control Progranwne), Plateau State Reproduced by: Covenant Press Limited, Jos. 36 Environment Departnent Papers Community Health Information: Sources and Impacts Moreover, many people express confusion such a manner may serve to reinforce over the presence of the brush, spoon, cup, beliefs that: 1) transmission can be pre- tray, toothbrush, and pencil in the poster. vented if one learns to identify (and take They are uncertain whether the messaige precautions) with persons with certain indicates that AIDS can be transmitted physical symptoms; and, 2) infected through the use of these items if someone individuals can not lead productive lives with AIDS has used them. In each target and represent a threat to society. group, comments are made about the exclusive use of English text for the large To improve outreach initiatives, much populations that can not speak the lan- potential exists for engaging communities guage nor can read. Many suggest that directly in the design, production, and the poster be translated into Hausa and dissemination of their own educational the other local languages. materials. Such an approach would tap the creative potential at the LGA level, Most PHC staff and students who are able facilitate the production of more relevant to read the English text observe correctly materials, and increase local ownership in that the poster is about AIDS. Generally, the development of AIDS prevention PHC staff believe that the poster is self- activities. explanatory and can be understood By their patients. This is true even as many Knowledge of the proposed nurses perceive that the poster conveys World Bank STD Project messages about cleanliness, general hy- giene, and other illnesses in addition to The Bank is increasingly taking steps to AIDS. Expressing a commonly held view, promote the active involvement of all a nurse comments that the poster "makes relevant partners -and particularly com- them aware of the dangers of communicable munity members and local officials - in diseases like AIDS, tetanus, and tuberculo- the development of its projects. In inter- sis." Many others believe it provides views with local LGA officials, however, information on how to treat an AIDS none recall being informed of the proposed patient: "washing hands after attending to World Bank STD Prevention Project even an AIDS patient, covering open wounds though a series of meetings were held in before attending to an AIDS patient, and each of the LGAs on design of the PRA. keeping the surroundings of an AIDS patient The information gap raises questions about clean. the participatory nature of the 18-month PRA planning process involving LGA and All of the target groups comment on the State officials and Bank staff. It is a sober- physical appearance of the man, with ing reminder of the filtering of information some suggesting that he should have been that occurs and of rapid personnel turn- drawn even thinner to portray AIDS more over at the State and LGA levels. accurately. Others report that his depic- tion as weak and bed-ridden is what leads them to conclude that the poster is con- Viewing centers exist in most of the communities cemed with AIDS. Unfortunately, how- studied, but the majority of their television sets are ever, the poster's depiction of AIDS in not functioning and require repair Participation Series 37 5. Community Recommendations for STD/AIDS Interventions Four dissemination meetings were con- as well as the interventions recommended vened following preparation of draft field in the course of the meetings. reports by the research coordinator. These included three community-level meetings Table 7 summarizes the recommendations convened in each of the LGAs, and one for action which evolved from the commu- session which brought together representa- nities in the dissemination meetings. A tives from all three LGAs. The fora repre- record of the discussions and recommen- sented the first time that members from all dations from the individual meetings of the target groups, with the exception of follow. These reports were prepared by CSW clients, participated in such discus- the research team and have been edited sions. onlyfor typographical errors. The meetings provided an opportunity to Jos North LGA Community Meeting report back and verify the conclusions of the draft reports, and allowed the commu- The purpose of the meeting was to provide nities to become more actively involved in LGA officials and representatives of the deciding priorities for action and how they communities the opportunity to share in, should be implemented. Most important, as well as discuss the research findings. In all of the communities expressed a desire this way respondents could suggest modi- to be more actively involved in STD/AIDS fications to the findings and also make prevention activities, and identified spe- recommendations for intervention. cific initiatives that would be needed at the LGA and State levels to sustain their The meeting was preceded by mobilization involvement. by the AAM in the LGA among commu- nity members and LGA representatives. It is significant that some of the more Through the mobilization process the contentious issues surrounding STD/AIDS community was further sensitized about were raised in the discussions, such as the the study and the need to share the re- distribution of condoms to adolescents and search findings. sexual behaviors in the community. In fact, such dialogue was welcomed and Participation/Attendance encouraged by the LGA and State officials. Through the mobilization process, partici- The PRA research experience no doubt pants to the meeting were selected. This gave the officials a much better context for selection was entirely by the community understanding the issues which surfaced members and the various target groups. 38 Environment Department Papers Cormunuity Recommendations for STD/AIDS Interventions Table 7: Commurity Perceptions and Analysis Summary of Recornmendations for Action Level Recommendations Individual Be disciplined, faithful and stick to one sexual partner. Individuals who cannot maintain one sexual partner should use condoms. Each individual should give health education; each one, reach one, teach one. parents should give children health education. Community, - Opinions leader should be informed about AIDS and carry out AIDS awareness including campaigns. NGO, CBO - Organize AIDS lectures andl talks in mosques and churches and clinics - Make condoms available and delegate a specific individual to distribute same Local - Provide reactivate, TV/ Information center and furnish films on STD/ AIDS. Government - Finance seminars on health education and AIDS awareness - Provide funds for training health personnel - Provide logistics and posters - Should monitor incidence of AIDS - Send AIDS patients to traditional healers State - Provide funds to the LGA to help STD/ AIDS program Government - Initiate, monitor, and supervise HIV screening in all LGA - Make health education compulsory in schools - Provide mobile cinemas in LGA, buy air time on radio and TV to enhance AIDS awareness - Take AIDS patients to traditionatl healers for treatment - Foster collaboration between traditional and western healers Federal - Should take World AIDS Day, December 1, more seriously Goverunent - Train AIDS personnel and give them more incentives - Advertise condoms, especially their use in STD/AIDS prevention - Ensure adequate budgetary allocation to STD/ AIDS control - Should deduct State and LGA funds at source - Provide transportation and other logistics - Foster more collaboration between traditional and western medical practitioners Donor Agencies - Provide scientific equipment but without conditionalities - Train personnel at State and LGA levels - Provide STD/AIDS campaign materials. Run workshops and seminars at State and LGA levels There were conscious efforts to ensure a * One representative each of Students, gender balance to enable respondents feel LDTD, Traditional healers free to discuss. . Two CSW The fo.owing were thepThe State AIDS Coordinator, the The followmng were the participants: Director of the Research, AIDS Action * Representatives of Each of Laranto, Direr, the Research ads Apata and Abba Na Shehu Commu- Manager, Field Research Leaders nity * Representatives of the World Bank Participation Series 39 Towards STD/ AIDS Awareness & Prevention in Nigeria Format of the Meeting Sexual Behavior The meeting took the form of [a] participa- Participants accepted that sexual relations tory workshop. The Research Coordinator are normal; however, sex before or outside summarized the research findings and marriage is normatively prohibited, virgin- distributed these to participants. After ity at marriage is priced. Further, boys they had read through, the summaries and girls initiate sex at different ages, boys were itemized and written out on a flip between 17-20, and girls 14-18. Most chart. Each item was then presented in sexual intercourse involves heterosexual English and Hausa after which partici- penis-vaginal sex. pants discussed, modified and suggested recommendations. Discussions and in- Participants acknowledged that in prac- deed the entire business of the meeting tice there is a lot of sexual relations outside were in both English and Hausa. marriage and that there is so much por- nography. They also said that there is oral Community Problems sex, this is however a minority view. To the problems of road, water supply and Finally, there is also enormous peer pres- schools, participants added - refuse dis- sure on adolescent boys and girls to en- posal and general sanitation, and the high gage in sex. In addition, housing problems level of illiteracy. which compel some parents to live in single rooms exposes children to the sexual Health Problems acts of parents. Such exposure could lead In addition to malaria, aches, hyperten- to the children to experiment with sex. sion, meningitis, participants included worm infestations 'and insisted on the term Perception of STD/AIDS water borne diseases. This term includes There was general consensus that STD/ cholera which they said, frequently breaks AIDS are caused by sexual intercourse, out in their communities. stepping over the urine of an infected person and blood transfusion. Partici- Gender and Sex Roles pants also agreed that treatment for STD is Participants agreed completely with the sought in both Western and traditional research findings that cultural and reli- medical sources. Determinants of which gious norms prescribe different roles for source is first contacted include the pa- women and a different set for men. Roles tients sense of shame or shyness (for STD) that conform with these expectations are and therefore the need for privacy, belief regarded as proper and easy, roles which in efficacy (for example of herbs over do not are regarded as difficult and im- tables for malaria or pile) and consider- proper. A female doctor conducting a ation for costs. pelvic examination on a female patient is proper, but the same is not true when the As revealed during the LGA meetings, doctor is male. In the latter case, the while the three consideration are impor- situation is perceived as hard, stressful and tant, the general consensus is that cost of embarrassing. Also regarded as improper treatment is the most crucial. In term of is a woman buying or giving condoms to a ranking therefore, cost comes first fol- man. lowed by the need for privacy and per- 40 Environrment Departmnent Papers Community Recommendations for STD/AIDS Interventions ceived efficacy in descending order. ber of pictures. Proper places for posters The major forms of prevention are absti- were identified as churches, mosques, road nence, use of condoms and screening of junctions and markets. CSW client. Perception of Condoms Specific Recommendations Condoms were recognized by the majority Participants made specific recommenda- of the participants which are known tions thus: variously as raincoat, Hulan maza and Saban Baba. * This research should be used as a basis for "Each One, Reach One, Teach Participants suggested that women who One" about AIDS. buy condoms should not be regarded as * Cost of living should be brought down. promiscuous. They specifically recom- - Relgious leaders need be involved in mended condoms to men who have many STD/AIDS campaign. sex partners. Some participants said Islam does not allow the use of condoms. This * Two members from each community view which a majority felt originated fiom should be appointed to educate com- wrong interpretation, is attributed to munity members. inadequate enlightenment. The consensus * Intervention to include both urban and is that disease prevention rather than rural areas. pregnancy prevention aspects of condom * Efforts should be made to foster col- usage should be emphasized. laboration between traditional and Health Workers and AIDS western medical care providers. Participants agreed with the research Government should sponsor a national findings that health workers indicate documentary to enable a lot more people willingness to work with AIDS patient. to become more aware of AIDS. Collaboration between traditional Mangu LGA Community Meeting and Western Healers Participants agreed that there is little The Mangu LGA/Community Meetings collaboration between the two at the were held on June 5, 1995. The purpose of moment. They suggested more collabora- the meeting was to take the research tion. findings back to the community and to enable them discuss and modify these. Health Informnation Participants agreed that health informa- The meeting was preceded by mobilization tion are received through informal chan- by the AAM among community members, nels such as opinion leaders, churches and LGA officials and target groups. mosques and from formal sources - radio, television and posters. Only a few under- Attendance/Participation stood the AIDS poster which they felt Participants were drawn from the same could be improved by reducing the num- group who were respondents in the study. Participation Series 41 Towards STD/AIDS Awareness & Prevention in Nigeria Accordingly, participants were selected by inability to purchase fertilizer which has their own communities and target groups implications for income as well as for food from Mangu and Kombun; while the production. Furthermore, participants target groups were CSW, LDTD, Students, pointed out that growing level of poverty Traditional healers. The LGA officials has tended to encourage promiscuity include the Chairman, the supervisory among women who "sell themselves" to councilor for health and the PHC director. obtain money. Poverty also compromise The SAC, RC, AAM, FRL and two note the capacity to pay for treatment. takers were also participants. Gender and Sex Roles Fornat of the Meeting Participants said there are cultural norms The meeting took a participatory seminar which define men's roles as distinct from format in which the research findings women's roles. The man is the bread were summarized and distributed to winner while the woman complements the participants. After the participants had husband's roles in adcldition to being a read the summaries, these were iternized wife/mother. Roles which reflect and and written out on flip charts. Each item conform with these expectations are was then presented after which partici- regarded as appropriate and easy. pants discussed, debated and modified the findings. Suggestions and recommenda- These cultural expectations, participants tions were also made. noted, are changing as a result of westem education and the diffusion of western All presentations and discussions were in culture through films and the media. both English and the Hausa languages for These changes were said to be faster in the the benefit of those who spoke only one of towns than in the villages. the languages. Sexual Behavior Community Problems Sexual relations are not allowed before The participants accepted that the general and outside marriage. This cultural norm problems in the communities were water, is however frequently violated in contem- roads, electricity and unemployment. porary society because of the following reasons:- Health Problems * Increased financial burden especially According to participants, most of the for hose maintenance schooling leads community health problems relate to many school girls into sexual activities water and mosquitoes. There is thus often with older men of "sugar dad- typhoid, cholera, malaria, in addition dies". The second situation leads there are childhood diseases such as many married women to extra marital measles, diarrhoea and fever. sexual activities, some times with the consent of the husbands who care It was emphasized at the meetings that about the proceeds . poverty was a major health problem. Inadequate housing has forced parents According to participants, poverty is to share the same room with their related to several factors such as the 42 Environment Department Papers Community Recommendations for STD/AIDS Interventions children. In this process, the children Collaboration Between Traditional and often watch their parents have sex. Western Practitioners Peer pressure forces many youth into The participants said collaboration be- sex. These youths claim that until you tween traditional and westem health have sex with a girl friend, she would providers would be beneficial to society. not take you seriously. This collaboration is however hampered by the perceived unwillingness of tradi- STD/AIDS tional healers to share their knowledge. According to participants, STD/AIDS are The cloak of secrecy enshrouding tradi- caused mainly by sexual intercourse ancd tional medical practice is thus a stumbling incomplete ejaculation. STD other than block to the successful collaboration. AIDS are said to be common. Participants said STD were not listed as health prob- Health Infonnation lems because the secrecy with which Health messages in Mangu and Konbum victims seek care does not allow for any communities are received through the information of its prevalence. STD are LGA Information and Health depart- treated in Western and Traditional ments, traditional rulers and health work- sources. ers. The radio, TV and newspapers are also important media for health messages. Perception of Condoms Posters are also frequently used to dissemi- Most of the participants know about nate health messages. The general consen- condoms although only a few had used sus is that the AIDS poster used for the them. Participants said condoms help study was difficult to understand. prevent unwanted pregnancy as well as the transmission of STD. Recommendations and Suggestions Participants said condoms should only be Participants made specific recommenda- sold to adults. Furthermore, participants tions on who can and should be done to also recognized good and bad condoms. resolve particular issues. The bad ones were said to slip into the woman's womb. Should this happen, Community Problems surgery would be needed or the woman might end up with cancer. Participants recommend that these be resolved through Health Workers and AIDS Participants said health workers would be * More govermnent funding and con- willing to treat AIDS patients. They said struction of pipe bore water the possibility of health workers contract- * Government should crack down on ing AIDS from patients was remote. corruption and looters of public funds However extra precautions were recomi- * The state government should repair mended for health workers treating AIDS and build roads patients. Partidpation Series 43 Towards STD/ AIDS Awareness & Prevention in Nigeria State and federal governments should care providers. Also at the Langtang meet provide more electricity were the SAC, RC, FRC, AAM and two note takers. Health Problems The state government should provide Format of the Meeting drugs in hospitals and clinics. The meeting was conducted in a participa- tory seminar format. The research find- STD/AIDS ings were summarized and distributed. Health workers should help sensitize and The summaries were also itemized and enlighten the people about the causes, written out on a flip chart. each item was prevention and treatment of STD/AIDS presented in English and Hausa languages for the benefit of those who did not speak Collaboration Between Traditional and one of the languages. Western Medical Practitioners There should be more mutual referral of Commiunity Problems patients from one source to the other. Participants added the need for feeder roads to list the community problems; the Health Information other were snake bite and safe water. In The state and local govetment should their opinion feeder roads will facilitate make posters to enlo ghten the people. easier transportation of food from the rural areas to the urban. It would also facilitate the movement of people. For Langtang LGA Community Meeting participants, while the incidence of snake bite has decreased, the cost of anti-snake The Langtang LGA Community Meeting venom are prohibitive and should be was held on June 16 1995. Some of the remedied. participants for the meeting confused it for another meeting (Launching of Vitamin A Health Problems Supplement Campaign) which preceded Participants said their communities were the community meeting. afflicted by diarrhea, measles, malaria and typhoid. It was however argued that the The meeting was made possible because of prevalence of typhoid might have been mobilization by the LGA AAM. exaggerated due to unreliable tests which were said to almost always read positive. Attendance/Participation The meeting drew participants from both Gender and Sex Roles Langtang town and from Zamko, the two The participants agreed that the tradi- communities where the research was tional separation between women and conducted. Participants who were se- men's roles were gradually changing. lected by their own communities and These changes were attributed to adverse target groups included the LGA chairman, economic conditions which now compel PHC director, Supervisory councillor for men, most of who can no longer afford health, representatives of students, LDTD, house helps, to carry out household CSW, traditional healers, western medical chores. 44 Enviroranent Department Papers Community Recommendations for STD/AIDS Interventions Women were also said to be freer now to tured in different sizes. The last sugges- go out, work and pursue careers. This tion was thought to guide against break- increased freedom, in the participants age which might result from the use of view, should include the liberty to buy under size condoms by "big men ". condoms for their husbands. Health Workers and AIDS Sexual Behavior According to participants health workers According to participants, cultural norms should treat AIDS patients and show them forbid sex before and outside marriage. great sympathy in the process. This cultural norm is however frequently violated because of economic hardship Collaboration Between Traditional which compel many to engage in piece and Western Health Providers meal "sex for sale". Participants agreed that more collabora- tion between the two modes of care will be Participants said most of the burden of to the benefit of the community. running the household (food, school fees, health needs etc.) was borne by women. Health Infornation This burden has led many to premarital Health messages are received from clinics, and extramarital sexual relationship. hospitals, health workers and the radio. The participants said specific posters be Perceptions of STDiAIDS designed for specific communities. According to participants, STD/AIDS are caused by sexual intercourse, blood trans- Suggestions and Recommendations fusion and stepping over the urine of a victim. Participants were however divided Community Problems on this last cause of STD. Some insistec[ Government should force down the cost of that not only can stepping over the urine Lving. of victims cause STD, even the smell can also do this. Health problems Some participants said goverment is Drugs and equipment should be made contributing to the spread of STD/AIDJS more available in government hospitals through the formation of Association of and clinics. Widows. The idea is that the bringing STD/AIDS together young women by government might encourage sexual activities and with An HIV screening Center should be estab- these the spread of STD. lished in the LGA. Perceptions About Condoms * All blood should be screened before It was the general opinion of participants transfusion. that condoms prevent unwanted pregnan- * All AIDS Patients should be incarcer- cies as well as the spread of STD/AIDS. It ated to prevent the spread of the was then suggested that condoms be made disease. more widely available and be manufac- Participation Series 45 Towards STD/ AIDS Awareness & Prevention in Nigeria Government should screen all incom- SAC in the State capital and the RC who ing people before allowing them into liaised with and coordinated these various Nigeria. mobilization activities. Sexual Behavior Participation/Attendance Every person should be encouraged to Participants were selected by their various have and keep only one sex partner. communities and target groups in the three LGA and included representatives Collaboration between Western of: and Traditional Practitioners Western practitioners should be encour- * All communities in the study aged to be more cooperative with tradi- * Al target groups tional healers. 0 LGA officials (Chairman, PHC Direc- Health Information tor, Supervisory councillor for Health) More public enlightenment through films * Western and Traditional Health Ser- and drama is recommended to sensitize vice Providers people to STD/AIDS. * The Research Team (SAC, RC, AAM, Report of Meeting of Representatives FRL, and two note takers) from Langtang, Jos North, and * Representative of the World Bank Mangu LGA Through the mobilization efforts, these various communities and target groups The meeting of representatives of the three vaderstoodundtensured argoo gender understood and ensured a good gender LGA in the STD/AIDS Qualitative study balance in the representation. This was to was held in Jos the State capital on July 4, ensure tha neotegender catego 1995. The purpose of the meeting was to felthelmed or int eridated. * g ~~~~~~~~~felt overwhelrned or inhimidated . bring together representatives from the three LGA in which the research was Format of the Meeting conducted, share the findings with them The summaries of the research report were and provide the opportunity to debate, andiscuss anovidem the fiundin to dathe distributed to participants. These summa- discuss and modify the findings. On the riswealotn-zdndrtenutn basis of these discussions and debates, ries were also itemized and writen out on participants offered sugges.ions and a flip chart and were subsequently pre- recmmnts on whaticn and sented in English and Hausa. Each item recommendations on what can and should wadetdandicsd.Tenir be done. ~~~~~~~was debated and discussed. The entire business of the meeting was conducted in The joint three LGA Meeting was pre- English and Hausa to ensure full participa- The~~~~~~ join tion of every one. ceded by intense mobilization by the AAMs in the local government areas, the 46 Environment Department Papers Community Recommendations for STD/AIDS Interventions Community Problems agreed that there was a lot of porno- Participants added refuse disposal and graphic film in the communities particu- high level of illiteracy to the list of commu- larly in the urban areas. nity problems( lack of water and electric- ity, inadequate medical facilities and Perceptions of STD/AIDS schools). Participants agreed that STD are common but lack visibility because of the of the Health Problems secrecy with which people respond to Participants agreed that the summary them. The most common mode of trans- accurately reflected their major healtht mission was identified as sexual inter- problems; namely typhoid, worms and course for gonorrhea and syphilis. water borne diseases in general, malaria, meningitis, hypertension, aches and snake It was the general consensus that Westem bite. The last problem is particularly acute and traditional sources are consulted for in Langtang. The sale of expired drugs the treatment of STD. A new name for was also added to the list of community AIDS was given in Hausa as Kanjiki, health problems. Tsenke-tsenke and Gobe de nisa. Gender and Sex Roles Perceptions and Usage of Condoms It was agreed that male and female roles Condoms were said to be gaining ground which were traditionally distinct were but should be used only by adults. It was now merging. This change which was agreed that women should be at liberty to said to be more pronounced in urban than buy condoms. The CSW in the meeting in rural areas was attributed to foreign asked for and received condoms from the influence and economic adversity. The research team. Over 300 packets of latter compels the men unable to pay for condoms (of 4 teats) were distributed to domestic servants to carry out house hold participants who asked for them. chores. After a protracted debate on Islam and the Sexual Behavior use of Condoms, it was agreed that Islam Participants agreed with the research did not prohibit the use of condoms. More summary that sex before or outside mar- public enlightenment was suggested to riage was prohibited and that boys start clear doubts in people's minds. sexual activities 4-7 years later than girls, and that traditional values about sex were changing. Participants agree that while most people engage in heterosexual (penis- vaginal intercourse, some anal and oral sex also goes on in the society. It was also Partidpation Series 47 Towards STD/ AIDS Awareness & Prevention in Nigeria Health Workers and AIDS Health Information There was a general consensus that not Health information is received mostly from only should health workers treat AIDS informal sources such as mosques, patients, they should also be kind to such churches as well as from health workers in patients. hospitals. The major channels of health information are radio, TV and posters. Collaboration Between Traditional Posters were said to be a particularly and Western Healers useful medium for health messages. It was the consensus of participants that collaboration between traditional and western healers would benefit society. it was however pointed out that the secre- tive nature of traditional medicine was an inhibiting factor. 48 Environment Department Papers Environment Department The World Bank. 1818 H Street, N.W. 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