The PRA Team, Methodology and Process
The research was planned by a core team of personnel from the State Ministry of Health, AIDS Action Managers in the three participating Local Government Authorities (LGAs are the lowest administrative level in Nigeria), a faculty member from the local university, and a representative of the World Bank. The university faculty member coordinated the research and prepared the draft report on the field work. University students who spoke English and the local languages served as interviewers for the field work, which took place in April 1995.
In the PRA approach, an interview team goes into a community and deploys research methods designed to enable people to express and share information and to stimulate discussion and analysis. A total of sixteen methods were used to engage a dozen target groups in the research. The research methods used included card sorting, matrix ranking, social and institutional mapping, and in-depth interviews. Some team members expressed initial reservations over the qualitative nature of the PRA methodology. As the team worked together to identify, experiment with, and revise the methods, these concerns were overcome.
To present the initial research findings, four local dissemination meetings were held with representatives from the target groups and LGA and state health officials. The sessions provided an opportunity to report back and verify the conclusions in the draft reports, and allowed the communities to become more actively involved in the dialogue on priorities for action and their means of implementation. All of the communities expressed a desire to be more actively involved in STD/ AIDS prevention activities, and identified a series of initiatives that would be needed at the LGA and State levels to sustain their participation.
The active involvement of local and state government personnel in all stages of the PRA has provided officials with a more realistic understanding of he dynamics of sexual behaviours, communities' interpretation and acceptance of IEC messages, and the potential for community involvement in the supervision and evaluation of interventions. This should prove useful as they now take steps to design a more effective and participatory program. The PRA initiative tapped into the research and evaluation capacity of the local university, thereby strengthening the links between academia, the government, and community-level groups. While encouraged by the possibilities of greater partnership with the government, the communities also expressed fatigue: many new initiatives have failed to be sustained because they lack the necessary follow-up and inputs. The PRA process may have identifiedm possible new partnerships and lines of accountability for more effective STD/AIDS activities, but the next phases in the process, the design and implementation of new programmes, will test the strength of these linkages.
Key Findings from the PRA
Health care in general, and STD/AIDS in particular, rank low among communities' development concerns
Lack of access to water, the storage of water, and low farm incomes are consistently cited as the main problems facing the residents in the three LGAs. Although somewhat less pressing, lack of adequate health care is also a major concern for each of these communities. The principal health problems identified by women are childhood diseases: measles, dysentery/ diarrhoea and hypertension; men rank their chief concerns as meningitis, typhoid and hernia. Medical personnel identify the same priorities, with the addition of abortion-related complications in women under 20 years old. STDs, including AIDS, are not considered priority health concerns.
Local beliefs on STD/AIDS causation, symptoms, and prevention shape community behaviors
Causation. The three modes of STD/AIDS transmission most commonly observed by the target groups are: sexual intercourse, contact with urine, and sharing objects/ belongings of someone with a disease in the genital region. Sexual promiscuity is identified as a source of transmission and associated with prostitutes and women who have traveled abroad. There is a strong belief that overseas women contract STD/ AIDS through sexual intercourse with dogs and Westerners. Stepping over, on, or by an area where someone has urinated, as well as "indiscriminate urination," are thought to transmit STDs. Sharing of clothes, and, in particular, instruments for shaving and nail cutting, also are associated with the spread of STD/ AIDS. While medical personnel have more accurate information about STD/ AIDS, some of them believe that AIDS could be transmitted by mosquitoes and via saliva (and therefore advise clients against kissing).
Symptoms. Most people associate STDs with the presence of physical symptoms: discharges from the genitals, pain while urinating, and stomach cramps or swelling in the genital region. Men report looking for "flecks" on a woman's lips and changes in her gait as signs of the presence of an STD. Service providers did not mention the existence of asymptomatic STDs and the need for medical examinations and laboratory confirmations. AIDS is frequently associated with an extremely emaciated physical state. According to one community health extension worker (CHEW), if one has AIDS the "eyes will blotch out, the hands and legs will thin, [there will be a] swollen abdomen [and a] big head." The difference between AIDS and HIV is not commonly understood.
Prevention. The main measures identified by the target groups for preventing STD/ AIDS are monogamy, examining the partner's genital area for signs of infection, avoiding areas where people urinate, find refraining from sharing personal possessions. Self-medication is practiced widely; many commercial sex workers (CSWs) use penicillin-based creams as antibiotics (and lubricants). Men report using medications or traditional medicines prior to and after sexual intercourse with non-regular partners. Service providers advocate a reduction in the number of sexual partners but are ambivalent about promoting condom use. Most medical personnel are concerned with the occupational risk associated with working with AIDS patients, and are concerned about the need to screen blood and sterilize needles.
Low levels of condom use
All target groups report low levels of condom use. Men generally accept condoms as contraceptives. They do not, however, associate condom use with STD/ AIDS prevention, except when they are used with CSWs or non-regular partners. Men also complain that condoms reduce sexual pleasure. Both men and women are uncomfortable with the notion of using condoms for disease protection, as this violates the trust in their relationships and could indicate infidelity. Women fear that by suggesting condom use they may be physically attacked for their perceived infidelity and attempt to control the sexual act. Men and women also express fears that condoms may have negative side effects, such as syphilis in men or may cause women to require surgery as condoms can become lodged in the womb. Among CSWs, the cost of regular condom use is high for those who have few clients. Condom use is not evenly promoted among health care providers. Some providers express reluctance to promote condom use because doing so may provide individuals with a false sense of protection (due to breakage), or may encourage promiscuity in youth.
Perceived risk of contracting AIDS is low, but fear of people with AIDS is high
As the disease is associated with promiscuity and overseas contact, most people do not believe themselves to be at risk of contracting AIDS. Although men report having many sexual partners, the only populations they perceive to be promiscuous are CSWs and youth. In Jos North, an urban area, some residents feel that AIDS could increase, but feel they are protected because it is a Christian community. The low levels of perceived risk also relate to the limited information available about AIDS. According to one woman, "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."
The primary community responses toward people with AIDS are fear, pity, and the need for quarantine. People suggest that the clothes and houses of people with AIDS should be burned, areas where they have been should be washed, and they should be reported to the police and imprisoned. Central to these reactions is the belief that AIDS is contagious and can be contracted via social contact. Health providers are primarily afraid of the occupational risks associated with working with blood products and attending to someone with AIDS. While apprehensive, the majority express a desire to provide care and sympathy to individuals they believe will soon die.
Provider-switching is common
Three factors contribute to extensive "switching" between traditional and Western medical systems for the treatment of STD/ AIDS and other diseases. First, people perceive that the treatment and cure of illnesses as distinct acts: hospitals are believed to remove the symptoms of an STD, while traditional medicine is believed to be effective in removing the cause of the STD. If the medications given by one health system do not relieve symptoms, patients often seek treatment from the other medical system or another provider. AIDS, as a new and fatal disease, is believed to be best dealt with by hospitals.
Second, people look beyond the formal health system due to its many inadequacies, including the lack of drugs and functioning equipment and long waiting periods for service. For STD treatment, men prefer going to pharmacists because they provide diagnosis and treatment on the spot; and, they are ashamed to use PHC facilities, believing them to cater exclusively to maternal and child health needs. The lack of female doctors and the relative lack of privacy deters some women from using government PHC facilities for the treatment of STDs. Compared to clinics and hospitals, access to traditional healers is easier and the length of time spent waiting to receive care and medications significantly lower. There is no clear consensus on the impact of financial cost on service utilization; however, many prefer the financing plan offered by traditional healers whose services can be paid for over time and in kind.
Third, providers' and clients' perceptions of each other influence the use of health services. Ethnic and gender stereotypes about patients are common among public sector service providers. They frequently mention that their clients' illiteracy makes them ignorant and unable to understand information about diagnosis and treatment regimens. In almost every target group complaints were made about how they are treated at clinics. According to one woman, "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."
STD/AIDS education needs to be strengthened
Information on preventive measures, including on condom use, is given infrequently by health care providers, and is not always accurate. In exit interviews at PHC clinics with ante-natal women, the main AIDS-related message recalled is that AIDS could be contracted via blood should a transfusion be needed during delivery; few women recalled being told about the sexual transmission of the HIV virus or about condom use. Few of the patients at STD clinics are informed of their diagnosis and none of those interviewed were told what medications they are being given or how they worked.
Posters are the main mass media channel for AIDS education. Discussions with target groups on their understanding of the most widely distributed STD/ AIDS poster reveal that: 1) most people, including clinic staff, have never seen it; 2) few people can read its English text; 3) the illustrations communicate messages that are perceived to be about personal hygiene and not about STD/AIDS prevention; and, 4) the depiction of a person with AIDS in an emaciated physical state furthers the belief that people with AIDS can not lead productive lives, and that transmission of the virus can be prevented if one learns to identify and then take precautions with persons with certain physical symptoms.
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|Title Annotation:||Towards STD/AIDS Awareness and Prevention in Plateau State, Nigeria: Findings from a Participatory Rural Appraisal|
|Publication:||Towards STD/AIDS Awareness and Prevention In Plateau State, Nigeria: Findings From A Paricipatory Ru|
|Date:||Apr 1, 1997|
|Next Article:||1. The participatory research framework.|