3. Community knowledge, behaviors, and practices related to STD/AIDS.

Beliefs and Knowledge of STD/AIDS

Box 2 and Table 5 provide highlights of local beliefs surrounding the causes and symptoms of STD/AIDS. In general, the field research indicates that diseases which affect the genital area are believed to be transmitted via three routes:

Sexual intercourse 

It is thought that promiscuity spreads AIDS, and that this type of behavior is common among youths and men. It also is felt that certain types of women--namely, prostitutes or women who have been abroad and have sex with animals or western men--transmit these diseases. Lastly, sex for pleasure--as distinct from sex related to promiscuity or to procreation--is believed to cause STDs and AIDS.

Contact with urine

STDs are believed to be transmitted by stepping on or being in an area where someone with an STD urinates, "indiscriminate" urination, or using the same toilet as someone with an STD. The research is unable to identify why urination is thought to lead to disease. Many traditional healers conduct examinations of urine as part of their diagnostic procedure, which may suggest why urine plays a role in local health belief systems.

Box 2
Beliefs about STD and AIDS Causation

Making use of dirty toilets can cause disease that affects
sex organs, walking barefooted can also cause these
diseases and urinating at market places indiscriminately
can also cause these diseases.--Ante-natal clinic
patient, Langtang

AIDS. It is got through sex and through the bathroom
if an infected person passes urine before you. Also from
the toilet after an infected person passes stool in the
toilet.--Ante-natal clinic patient, Langtang

If a person dreams of having sex with a women and
discharges and it goes back to stomach it causes
gonorrhea.--Traditional healer, Jos North

It is got from zaki, sweet fruits and contaminated water;
excreting near a drinking pond can cause AIDS. Traditional
Healer

I don't know anything about AIDS but we believe that
whenever one has it will be washed out during
menstruation.--Commercial Sex Workers

[AIDS] was from abroad, those who go there for
business and some ladies abroad allow themselves to
have sex with animals such as monkey, dogs for money
and when they find that they have the disease they come
back and spread the disease with healthy people. Female
Secondary School student

AIDS is brought by hunger--that is only those who are
not well off are getting it ... caused by poor feeding,
malnutrition and poor environment.--Community Men,
Jos North

I heard AIDS could be spread like chicken lice on the
radio.--CHEW, Langtang

Sharing objects

There is widespread belief that STD, and AIDS in particular, could be transmitted through the sharing of personal items such as razors and clothes. Fingernail cutting, which would involve the sharing of scissors, is mentioned by all target groups as a behavior that increases the risk of contracting AIDS. Additional means of contracting STD/ AIDS are from the breath of someone with AIDS, eating with such a person, or wearing that person's clothes or underwear.

Among the target groups, students are most aware about the sexual transmission of All S and other STDs. While they are able to name all of the main STDs, they nevertheless express many commonly held misconceptions about STDs, including that AIDS is caused by mosquitoes, women who have been abroad, and fingernail cutting.

Knowledge levels among service providers is not uniformly high. Some believe that AIDS is caused by swallowing the saliva of an infected person, and they urge individuals to avoid kissing. One nurse observes that the disease is transmitted merely by coming into contact with an infected person; and a CHEW suggests that mosquitoes can spread the disease. Pharmacists and traditional healers have heard about AIDS but they are not all aware that the disease is sexually transmitted.

Symptoms

Men diagnose STDs in themselves when they see discharges of blood or pus, feel pain while urinating, or have difficulty walking. None of the men interviewed mention that STDs could be asymptomatic. To detect STDs in women, men look for vaginal discharges, "flecks" on the lips, changes in a woman's style of walking, or the loss of erections upon starting intercourse. Women identify six symptoms for self-diagnosis of STDs: pains in the lower abdomen, discharge from the vagina, yellow stains in the urine, itching in the vagina, swelling of the vagina/ groin region, and painful urination. Table 5 provides further detail on community beliefs surrounding STD symptoms and causes.

Service providers are well informed of STD symptoms with the exception of AIDS. For example, some believe that AIDS causes hair loss and discharge from the penis. The levels of knowledge among CHEWs are much lower, with one stating that, with AIDS, the "eyes will blotch out, the hands and legs will thin, [there would be a] swollen abdomen [and a] big head."

Attitudes Towards Individuals with HIV/AIDS

Most health care providers interviewed, including those in Western and traditional practices, have treated STD patients. Very few, however, have seen or treated someone with AIDS. Approximately one-half of the service providers expressed fear of contracting AIDS while attending to an individual with the virus. This notwithstanding, many providers report that they would provide care and sympathy to such individuals. In none of the interviews does the distinction between having AIDS and being HIV-positive emerge, nor do observations that HIV-positive individuals could lead healthy, productive lives. Generally, service providers view HIV/AIDS as being synonymous with death.

The many negative perceptions about working with AIDS clients relate to beliefs that the disease could be transmitted through social contact or blood products and to misconceptions about the symptoms of the disease. Doctors and nurses are most concerned about AIDS transmission through infected needles and blood transfusions. Pharmacists and chemists, however, believe quarantine is needed. Indeed, one pharmacist stated, "I will not allow him [individual with AIDS] into my shop. Don't you know it has no cure and is a contagious disease? If he come here, I will wash the place he has stepped on." CHEWs as a group express the most negative attitudes towards working with individuals with AIDS. Many of them recommend quarantine, and a CHEW in Langtang observes: "I would feel like vomiting, as the AIDS patient will always be smelling."

At the community level, respondents consistently express fear and pity towards individuals with AIDS, and believe that those infected need to be quarantined. In Langtang, one community member suggests that the belongings of someone with AIDS should be burned when the person dies. Jos North communities observes that persons with AIDS should be treated in the hospital and reported to the police. Again, these reactions reflect underlying uncertainties and fears regarding the transmission and fatal impact of the disease.

Prevention

Common Methods

Service providers advocate abstinence and sticking to one partner as the main preventive measures for STD/AIDS, and infrequently promote condom use. In considering issues of prevention, providers place much emphasis on measures to reduce their own occupational risks associated with treating individuals with AIDS. Many providers mention the need to screen all blood and to use sterilized blades and instruments.

As explored in Box 3, CSWs report use of three preventive measures in addition to condom use. First, they conduct physical examinations of their clients, including squeezing a client's penis to see if pus or any other discharge emerge, and pressing their stomachs to see if this causes any pain. Similarly, the clients examine CSWs for signs of vaginal discharge by wiping white handkerchiefs on their vaginas. Second, CSWs, and particularly those in urban areas, go for regular medical examinations In some cases, these check-ups involve vaginal examinations and stool and urine tests. Third, auto-medication is also used for prevention. CSWs apply penicillin-based ointments to their vaginas after having sex to prevent infection. They also use these ointments as lubricants, and are familiar with the names of specific creams that they buy regularly. Self-medication is also reported as a preventive measure by many clients of CSWs, and they go to chemists and traditional healers for medicines prior to or between visits with CSWs. Of final note, CSWs link unclean toilets to STDs, and some report that they clean hotel toilets as another preventive measure.

Box 3
Approaches to Diagnosis of STDs
by Commercial Sex Workers

Some of the men before you check them will rush
and urinate the pus away but we insist that before
they go out to piss we press their prick to see if
discharges are coming out

I will touch his stomach and press it hard, if he feels
pains then I will know he has disease.

A woman who has this disease will not be able to
stand up and there will be stomach ache.

We check them by using a white handkerchief to
press his penis to see if he has a disease.

The men that come check us using white toilet paper
to see if we have disease.

Community members identify their main STD/ AIDS preventive measures as abstinence or monogamy and avoidance of areas where people urinate. As explored further below, condom use is infrequently mentioned and often associated with its contraceptive function. Among the individuals who believe that STDs, and AIDS in particular, are transmitted by the sharing of personal items, some report that they refuse to share razors and have bought their own pair of nail scissors.

Perceived Risk

The limited and ad hoc adoption of preventive measures is closely linked to the lack of a sense of perceived risk. As AIDS is associated with promiscuity, visitors, and women who have traveled abroad, most individuals do not consider themselves at risk. In Jos North, for example, women believe that their Christianity will protect them, while men in Laranto feel that the disease only affects the youth because they are promiscuous. The low levels of perceived risk may also be related to the limited availability of information about the disease and the communities' limited contact with people from the state who have AIDS. As one CSW said, "I hear say AIDS there I never see any body when AIDS catch them. I never see any body when AIDS kill them. All I hear the AIDS there, AIDS there."

Only one of five officials interviewed in Langtang perceives AIDS to be a serious problem, while another admitted that he has never heard of the disease. Local officials mention some problems with STDs more generally, but they associate the diseases with youth truancy and promiscuity. Similar perceptions can be found in Mangu, where the risk of AIDS spreading is thought to be slight. In Jos North, there is greater understanding of the potentially large impact of the disease because the city serves as an important transit point.

Awareness of and Attitudes Towards Condom Use

Condom use is low among all of the target groups, including among the high risk populations of CSWs, LDTDs, and clients of CSWs. In fact, very few people report that they have even seen a condom or know how to use them.1 Secondary students are most knowledgeable about how condoms work, but few of them (particularly female students) have ever seen one. In Langtang LGA, none of the STD clinic patients have ever seen a condom. While most CSWs know of condoms, many of them never use them and some have never seen one. Key obstacles to condom use include:

Cost. Condoms are too expensive for certain populations. For example, some CSWs report that they could not afford to use a condom with every client. CSWs working in rural areas average three-to-four customers on a good night, earning 20 to 30 naira per sex act; at 10 naira each, CSWs argue that condoms are too expensive. Other quotes on condom prices range from 2.5 naira for one to four for 20 naira.

Condom breakage. Many condom users complain that they break during sex. Condom breakage may be related to the unavailability of appropriate lubricants, the size of the condoms, and storage conditions.

Beliefs about negative health effects. One of the traditional beliefs about syphilis! is that it is caused by sperm re-entering a man's body through his penis. This leads some men to refuse to use condoms due to the belief that, by "trapping" the sperm, the device causes syphilis. Some women and female students believe that condoms can become dislodged during sex and enter the womb and other internal organs, which can cause bleeding or even death. In Mangu, women report that they know of condoms having to be surgically removed from the womb. Some service providers also express concern that condom use could lead to cancer.

Loss of sexual pleasure. Most men complain that condoms reduce sexual pleasure.

Rural-urban location. Knowledge, availability and use of condoms are lower in rural areas.

Skepticism among health service providers. Many providers believe that condoms, although useful in preventing disease, frequently break and provide a false sense of protection. Many providers in rural LGAs believe people are too uneducated to use condoms properly and therefore do not promote their use. Also, many providers do not support condom distribution to youth, as this would promote immorality and promiscuity.

In addition, the determinants of condom use are closely tied to behaviors surrounding sexuality and sexual relations. In all communities, the timing and duration of the sexual act is determined by men and a clear distinction exists between sex for procreation and sex for pleasure. Married women view sex as a means of satisfying their husband's desires and not their own, and as a means for procreation. They associate condoms with sex for pleasure in extra-marital affairs, and consider these immoral acts practiced by "loose" women or prostitutes.

Married women are therefore reluctant to purchase condoms or suggest their use to their mates, as this could be perceived as evidence of their own infidelity or immorality. In addition, women do not think they should purchase condoms because they do not "use" them or have control over the sexual act. Furthermore, men perceive the notion of women taking the initiative in determining the timing and nature of sexual interaction as an attempt to usurp the man's role and control their husbands. Such behavior is unacceptable to most men, and some indicate that they would respond violently (see Box 4). At a more basic level, many women are very uncomfortable presenting a condom to their partners because they do not know how to use it.

Men who approve of family planning are more supportive of condom use, but, again, primarily for contraception and not to prevent STDs. Men who report having sex for pleasure or extra-marital relationships are also more supportive of condom use, and specifically for STD prevention. Women with spouses who use condoms view this as an indication of the desire of their husbands to space births; however, the same women also think condoms will protect them from disease. Male students see sex primarily as a rite of passage and form of enjoyment, and associate condoms with STDs and family planning. Most male students do not see themselves at risk of getting an STD or are worried about teenage pregnancies. Hence, they perceive no need to use condoms, which they feel reduces sexual pleasure. On the other hand, female students are very concerned about unwanted pregnancies and support condom use as a contraceptive device.

Box 4
Perceptions of and Attitudes
Towards Condom Use

If not nursing a baby and she say use a condom I
will beat hell out of her and sex her without condom.
--Long distance truck driver

It is not for our age but it is for children to use
during sexual intercourse because they are more
promiscuous.--Community women, Jos North

I don't allow my customer to use it on his bura
(penis) to have sex with me. I will allow him to go
with his money, because it can enter my stomach
during sex and disturb me.--Commercial Sex
Worker

It is risk some say because if it pass into the girl's
vagina it may lead to her death.--Secondary
School Student

People say it is not pleasurable and it is dirty.--Long
Distance Truck Driver

I will feel discouraged going to buy them because I
will be ashamed ... as people will know I will use
them with a harlot. I will feel shy if the person in
the chemist knows me.--Male secondary school
student

The say it is a dirty game--they believe is being
reused and it becomes clumsy.--Nurse

Frequency and Type of Sexual Behavior 

Jos North CSWs report having an average of five clients a day; in rural areas, the number of clients is about three a day. While the main type of sex reported is vaginal, CSWs in urban areas report that anal sex is increasingly in demand. The 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 majority of men claim to have sex two-to-three times a week. Among LDTDs, the average number of sexual interactions is once a week when they are traveling and three-to-four times a week when at home.

The average age for the initiation of sexual activity is sixteen years for girls and eighteen years for boys; in Jos North sexual activity as young as ten is reported.

Determinants of Health Service Utilization

There is evidence of extensive switching between Western and traditional medicine (see Box 5). Each of the communities interviewed contains two-to-four traditional healers compared with one PHC. Private clinics and hospitals are also available but are used less frequently due to higher costs. The sequencing of visits between Western and traditional health systems is determined by: 1) beliefs about the causation and appropriate treatment of the illness; 2) characteristics of the health delivery system; 3) cost and access to services; and, 4) the perceptions of providers and clients towards each other and of the quality of health services.

Beliefs about Illness Causation and its Appropriate Treatment

A clear distinction is made between treatment and cure of an illness. Treatment is associated with the abatement of symptoms, while the latter is linked to interventions that remove the cause of an illness.

A group of women in Jos North explain that hospitals are the first choice for the treatment of syphilis because the medicines given there will "kill the eggs of the tunjere [syphilis]," but then traditional medicine will be necessary to cure the disease.2 As one CSW succinctly explained: In some it will not show in urine but it will be eating up the groin. Even if take injection it will not die but will be dormant for some time before it starts again. Therefore, using traditional medicine is better. Using orthodox medicine will only make the sickness to lie dormant.

Box 5
Preferred Sequencing of Providers

Men, Kombun Community, Mangu LGA

Hiness      First Choke   Second Choice

Typhoid     Hospital      Traditional Healer
Gonorrhea   Chemist       Hospital
Syphilis    Chemist       Hospital
AIDS        Hospital      Traditional Healer
Hernia      Hospital      Death

Hiness      Third Choice          Fourth Choice

Typhoid     --                    --
Gonorrhea   Traditional Healer    Death
Syphilis    Traditional Healer    Death
AIDS        --                    --
Hernia      --                    --

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.

Table 6 lists what community members believe are the most appropriate treatments for STDs. Again, western medicine is used to treat the symptoms of most STDs, but there is always a traditional medicine that can be taken in conjunction or on its own. AIDS is the only disease that is referred exclusively to a Western provider because, as a new illness, there are no established traditional therapies. Moreover, most people, believing AIDS can not be treated or cured, view the hospital and not the clinic as the first treatment site.The practice of provider switching is also related to expectations about the course of treatment and the time within which medications should have an observable effect. Some patients report that hospital treatments take too long to relieve symptoms and therefore they turn to traditional medicines. Thus, if STD symptoms continue clients do not return to where they had last been treated but instead go to another type of provider. When there is no improvement after all types of providers have been consulted, most individuals resign themselves to their fate.

Characteristics of the Health Delivery System

Other factors relating to the health system itself greatly shape the way health services are used. These include:

Drug availability. Some men do not use clinics and hospitals because drugs are never available and they must then go to a chemist. They prefer to go to the chemist first where they can obtain both a diagnosis and the required drugs. Patients at STD clinics also complain about the lack of drugs and the length of time it takes to get test results. In addition, patients believe that drugs sold on the open market cost more than those at clinics and hospitals. There is also concern that drugs provided by chemists may be fake and not provide effective treatment.

Perceived Function of Treatment Site. Both men and women view PHC facilities as being exclusively for women and children, and men are unlikely to use them. "Clinic is meant for woman. The man only goes to hospital," as one group of men from Mangu bluntly explained. The name change from Maternal Child Health Clinics to PHCs has done little to alter these perceptions. Meanwhile, women are reluctant to visit traditional healers as this could be interpreted as an attempt to put a curse on their husbands. They also express reservations about purchasing drugs or condoms at chemist shops, as these visits could be seen as attempts to obtain medicines for inducing an abortion.

Gender of service provider. Women are unlikely to use faculties where examinations would be performed by male nurses or doctors. They believe that female providers would better understand their problems and feel less shame in exposing their bodies to someone of the same sex. Men are less adamant about the need to have a provider of the same sex; however, married men expressed concerns about their wives being given physical examinations by male doctors. Among adolescents of both sexes, there is a strong preference for a provider of the same sex.

Privacy of service. The lack of privacy between patients and providers at public sector hospitals and clinics is frequently cited as a reason why these facilities are not used for STD treatment. The lack of properly enclosed examination rooms and the approach to patient management made potential STD patients feel that the reason for their visit would be apparent to others in the facility. Privacy is not an issue at private f acuities; female students believe that visits to a private hospital would be confidential and expect to be better treated than by a chemist or traditional healer. On the other hand, male students say they would patronize both chemists and public hospitals.

Conditions of facilities. Patients are also concerned about, the appearance and cleanliness of the clinics, the limited range of services offered, and the lack of medical equipment. Ante-natal women find PHCs dirty, dark, and in need of renovation. Several women comment on the lack of toilet facilities, a particular inconvenience for pregnant women who must typically wait two hours or more to see a nurse or doctor. Similarly, patients at STD clinics also make observations on the need for repairs, the cramped conditions, and the lack of toilets.

During the interviews, three recommendations were made for improving health services. First, health education classes should be provided on disease causation and prevention. Second, many women want PHCs to expand beyond ante- and post-natal care in order to address a wider range of women's health concerns. Third, more--and/ or better functioning--equipment should be made available to PHCs and hospitals, particularly for the performance of simple procedures such as taking blood pressure. The lack of equipment in PHCs leads individuals to seek treatment in hospitals and private health facilities for health problems unrelated to pregnancy. Box 6 presents further suggestions from ante-natal women for improvements in clinic conditions.

Cost and Access to Services

Cost, in terms of both finance and time, are important determinants of service utilization. There is no clear consensus on whether going to a hospital or clinic is cheaper than being attended by a traditional healer (see Box 7). However, the financing plan adopted by traditional healers appears more convenient for patients: payments can be made over time and in kind.

Box 6
Suggestions for Improving
PHC Clinics

Sweep it, remove cobwebs, clean tables, and wash the
toilets so that the place would look nice to see. PHC
Clinic, Mangu

I would like the structure to be renovated. And there
should be electric supply regularly.--PHC Clinic
Langtang

Give the nurses some incentives.--Plateau
Hospital

The nurses should be sincere in the way they treat
people. They are sometimes harsh to us when we
want to ask some questions they shout us down
sometime or they may not answer us very well. Plateau
Hospital

Educate us more about illness and their causes. PHC
Clinic, Langtang

If I had the chance I will buy air fresheners and put
some in every room in this hospital and also help
buy some tins of paint and re-paint the walls. The
walls are dirty.--Plateau Hospital

All facilities related to child delivery should be
made more available.--PHC Clinic Langtang

I will make equipment for working available. What
they measure for blood pressure has gone bad, there
are no hand gloves and mucus extractors.--Plateau
Hospital

Things like seats.--Plateau Hospital

I would like spirited individuals to assist the clinic
with more drugs, as there is always no drugs. They
do give us prescriptions to go and buy outside. PHC
Clinic, Langtang

In rural LGAs ante-natal visits at PHC clinics are estimated to cost between 20 and 25 naira; and some women who arrive after 9:00 am are charged a late fee of two naira. Visits to the Plateau Hospital, at an average cost of 100 naira, are more expensive but include fees for laboratory tests and drugs when available. In the urban areas where taxis are more available, women spend an additional 20 to 30 naira traveling to and from clinics and hospitals. Many traditional healers and pharmacists are open on a 24-hour basis. By contrast, PHC clinics have more restricted hours that are often inconvenient to women with agricultural and household obligations. In Langtang and Mangu, most women arrive at PHCs before 8:30 a.m. and spend on average two hours in the clinic, though visits lasting over three hours are not uncommon. At the Plateau Hospital in Jos North the average visit lasts two and one-half hours. The majority of this time is spent waiting to see the nurse or doctor. In rural areas, most women walk to the clinic, requiring an average of fifteen to thirty minutes (but can be as much as 2 hours). In urban areas, the average walking time to a clinic is twenty minutes.

Box 7
Choice of Provider for
Treatment of STD/AIDS

We go to the hospital first for drugs, when it is not
treated then Traditional Healer who helps sometimes,
and if they fail too, then we resort to the
prayer house for spiritual care and attention and
finally we stay at home waiting for death--Women
in Langtang on treatment choices for gonorrhea

Traditional healers charge costly than hospital and
clinic. They will ask someone to buy cow, goat, fowl
and the same time collect money again on only one
sickness--Community women, Jos North

For privacy they hardly go to the hospital. They
prefer going to the chemists and pharmacists for
there is absolute privacy there--Policy maker,
Langtang LGA

Perceptions and Attitudes of Various Target Groupsabout Each Other

Providers. The cultural, linguistic and gender differences between public health providers and their clients influences providers' perceptions of their patients, and vice versa. As seen in Box 8, doctors and nurses have many stereotypes about patients based on gender, age, educational level and ethnicity. Overall, they view men as being more difficult because they ask questions and do not follow treatment guidelines. Providers perceive youth to be arrogant. In addition, there is widespread rejection of the behavior and belief s of those who are thought to be "ignorant," "arrogant," or "illiterate"--labels that are frequently applied to villagers or individuals with little formal schooling. Ethnic stereotypes are also common; according to one provider, the Fulani are ignorant and difficult because they don't listen to instructions, they come to see patients outside of visiting hours, and they litter the hospitals and pester those on duty. In some cases, patients are belittled if 1hey do not speak Hausa, the most widely-spoken language among public sector service providers. Providers also express gender-biases, including that women use health services more than men because they can not cope with pain and are more biologically predisposed to have illnesses. One doctor suggested that women, because they live in purdah, need the "fresh air" afforded by a clinic visit.

Many doctors and nurses are willing to work with traditional healers, but they express widespread skepticism of the healers' diagnostic ability. Few Western-trained providers believe that they have anything to learn from traditional healers, with the exception of much interest in learning about the techniques used by healers to set broken bones.

Box 8
Providers Perception of Patients
and Their Target Communities

Youth are rude ... very difficult to work with they are
arrogant. They don't have regard for us here. They
want everything to be done to them at once.--Nurse,
Langtang Hospital

They pretend just like the Yorubas, they praise you
in your presence and when you turn your back they
abuse you.--Doctor, Mangu

Hausas are very difficult to deal with. They are
illiterate, jobless in purdah therefore solely dependent
on their husbands. They misinterpret their
religion. They seek medical advice late and they
interfere with medical intervention. They don t
give a free hand to the decision of the doctors due to
their religious bias.--Doctor, Plateau Hospital,
Jos

Men are difficult to work with.... men tend to be
stubborn, some are not willing to tell you their
problems. -Hausa speaking doctor, Langtang
General Hospital

Ibo patients tend to know too much. The pagans are
not patient ... they prefer traditional medicine. The
patients that are easy to work with are the
Moslems.... they are cooperative and are willing to
listen to instructions concerning their health. Nurse,
Langtang General Hospital

I find it difficult to work with the Tar ok people
those who are illiterate and come from the villages.
They don't speak Hausa. ...A lot of times they are not
given all the information they need on health issues
because I can't communicate with them.--Staff
nurse, PHC Clinic

Patients. Most target groups complain about the attitudes of clinic and hospital staff. CSWs report that unless they show they can pay for services they are not treated properly at hospitals. They mention having to bribe staff to be admitted to hospitals and feel they are sometimes overcharged. According to one CSW, "Some doctors and nurses don't care about patients at all, they don't even ask you what your problems are. They just treat you very quickly."

In interviews, many individuals express concerns about the manner in which providers speak to them and the lack of information they are given about their illnesses. For example, exit interviews with patients at PHC and STD clinics reveal that most of them are unable to recall their diagnosis, if they have been given one. Nor can they recall the medications prescribed and the treatment regimen they are expected to follow.

Traditional Healers. Most traditional healers believe that hospital and clinic staff have inappropriate interpersonal skills. According to a traditional healer in Langtang, "There is delay in the hospital; when it comes to attending to a patient, when you don't have money one is treated like a dog." Most of the traditional healers express a willingness to work collaboratively with Western-trained staff and help doctors improve their communication skills. The majority of traditional healers in the interviews have lived and practiced in their communities for at least 10 years; and, unlike PHC or hospital staff, most of them speak Hausa and at least one of the other local languages.

LGA and State Officials. In contrast to the behaviors and practices reported by the communities, officials believe that most people go to PHC clinics and hospitals for health care services, and particularly for STDs, and do not regularly seek treatment from traditional healers. Officials maintain that public health facilities are widely preferred because they are better staffed and equipped, easily accessible, cheap, and provide genuine drugs. Few officials acknowledge the need to address the qualitative dimension of service delivery--e.g. the need for improvements in interpersonal communication between patients and providers or in clinic management and supervision.

The Role of Chemists, Patent Medicine Dealers, and Pharmacists

Face-to-face interviews with chemists, patent medicine dealers, and pharmacists show them to be knowledgeable about STD causation, keen on collaborating with clinic and hospital staff, and committed to selling STD drugs only to patients with a prescription. This was not found to be the case with the "mystery client" interviews (in which male and female members of the research team approach these providers and pretend to be suffering from an STD).

As explored in Box 9, the mystery clients' diagnoses are often based on the relative ability to pay for treatment. The majority of patients are sold a combination of pills and, in some cases, told that they need injections. The mystery clients are not informed of what medications they are being given, and merely receive simple instructions on what color pills to take and in what order. A female mystery patient who asks how a prescribed cream should be used is told to read the instructions on the tube. Few of the mystery clients are told about the cause of their illness, STD prevention, condom use, or the need to return for a follow-up visit.

Box 9
Treatment Given by Chemists
to Mystery Clients

In Langtang, a male (mystery) patient approached
a pharmacist and a chemist and
informed them that he had a pain in his
genitals and "a whitish discharge" from his
penis. Both providers asked when the symptoms
started. The pharmacist informed him
that he had a "woman disease". Both wrote
prescriptions for the illness, the pharmacist,
gave a prescription for six medicines. These
medications cost 135 naira. The pharmacist
also wanted to administer an injection, but said
that he could not do so because the sun was
hot and asked the 'patient' to return later in the
day. The chemist prescribed three medicines,
supposedly, amplixlox, tetracycline and
nitrofurantoin, and charged 65 naira. He
suggested that they be taken before the end of
the day and said that they would cure the
illness.

In Jos North, a male (mystery) patient was
offered three treatment options: Full Treatment
for 320 naira; Not Full Treatment, which
involved medicines that would not work so
fast, for 120 naira, Half Not Full Treatment for
60 naira. The last treatment consisted of two
red pills, two white pills and 32 purple pills.
The 'patient' was told to take them at home and
that his urine would turn dark yellow.

Training and Supervision of Health Service Providers

Most of the public sector staff have not received any training in the last three to four years, which is often the length of time they have been in their posts. The lack of training is most evident among CHEWs. Existing in-service training generally focuses on family planning or midwifery, and the providers indicate that no training has been offered on the prevention, treatment, and care of STDs or other diseases that are prevalent in their communities. In contrast, the majority of providers in private hospitals and clinics have received in-service training within the last two years.

Supervision of staff performance is ad hoc or non-existent, particularly for doctors. According to one doctor, "nobody comes here to supervise my work, because I am the Medical Superintendent here. But this should not be so, due to the poor administrative system this ... has been overlooked so I do what I can." Supervision of nursing staff is done more regularly, but with somewhat less efficiency in rural areas. Senior nursing staff are generally not supervised and do not expect to have their performance evaluated.

(1) Condoms are known as condom ruba, condom, rain coat, and Durex (a brand name). In addition, a series of names in Hausa and the local languages are used, such as: Hulan maza kuta, Fulan maza kuta, Sock nababa (Hausa), and Atangia-achei (Taroh). In Jos North, condoms are also called evidence, protector, screwdriver, and cap.

(2) The dichotomy between treatment and cure is also observed for non-sexually transmitted diseases. For example, men in Langtang state that they would first go to the hospital for hypertension treatment, as the tests done there would "detect" the disease; but a complete cure would only occur when they have taken traditional medicine.

Table 5: STD Symptoms and Causes

Disease              Symptoms                  Causes

Gonorrhea            Dry lips, unclear eyes    Sexual intercourse,
                     dull hair                 promiscuity

(Arwa Nungwan--      Prolonged or painful      Using same toilet as
Tarow)               urination                 infected person,
                                               indiscriminate
                                               urination, blood
                                               transfusion

(Ciwon-Sanyi--       Swollen penis, white      Borrowing clothes from
Hausa)               pus in urine, fever,      infected person Hair
                     stomach pains             on the inside of the
                                               vagina

Syphilis             Swollen penis, wound      Sexual intercourse, at
                     on penis                  birth from infected
                                               mother, stepping on
                                               infected urine

(Tunzere--Tarow)     Penis in lower            Urination in same
(Tunjere--Hausa)     abdomen, boils            place as infected
                     Leprosy-like symptoms,    person Incomplete
                     loss of body hair         ejaculation while
                                               dreaming 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,    Sexual intercourse,
                     body swells, bad gums,    unsterilized or
                     vomiting consistent       infected needles/razor
                     headache, big stomach,    blades, fingernail
                     big head, water coming    cutting, indiscriminate
                     out of a woman's anus,    urination, a dirty
                     sunken eyeballs,          environment, sex with
                     yellow complexion         dogs, blood
                                               transfusion, the breath
                                               of a victim, lying on
                                               victim's bed, sharing
                                               shoes, kissing an
                                               infected person, eating
                                               with someone 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
(infertility)                                  birth, men sleeping in
                                               bad position, not
                                               taking warm water after
                                               birth

Pubic Lice           Lice                      Dirt in genitals, lack
Misham (Taroh)                                 of proper care

Mpah-Myar (Taroh)    Cut on penis              Forceful sex with woman
Yankan Gashi                                   who has a lot of
(Hausa)                                        genital hair, hair cuts
                                               penis

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
(Syphilis)     hospital; 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