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Complex factors hinder condom promotion.

Despite high HIV rates in Kenya, recent studies indicate that people who provide services to clients with sexually transmitted infections (STIs) in western Kenya are not actively promoting condoms to such clients. As a result, few clients are using condoms to prevent transmitting STIs/HIV to others or to prevent reinfection. (1) In recent research using both quantitative and qualitative methods, FHI investigators sought to identify and explain factors interfering with condom promotion at two locations in Nyanza province, western Kenya, with the goal of helping the Kenyan Ministry of Health lower the prevalence of STIs/HIV in the region by developing ways to improve condom counseling and distribution. (2)

In Kisumu and Siaya, in western Kenya, data were collected over 10 months at 12 sites in the formal health care sector (such as public and private licensed clinics, hospitals, and dispensaries) and in the informal health care system that includes traditional healers, herbalists, unlicensed health workers and drug sellers, and untrained pharmacy clerks. Field workers conducted 135 in-depth and semistructured interviews with clinicians, STI patients, local experts, pharmacy clerks, and drug sellers. They also conducted focus group discussions with people at risk for STI/HIV, including bicycle taxi drivers, sex workers, fish sellers, and youth. Other research methods used in the study included participant observation; structured observations (during which field workers observed STI counseling sessions and recorded, on a checklist, what the provider said and did with respect to condom promotion) and site mapping to identify locations where services are provided.

Data analysis is nearing completion, with a final report expected in early 2003. Preliminary findings confirmed that, both in the formal and informal health settings, condom promotion to STI clients was low. Condom counseling at public clinics and hospitals was often short and rudimentary, consisting of providers briefly mentioning condoms as a good way to prevent STI transmission. "The structured observation data indicate that few providers demonstrated condom use or even offered condoms to clients," says Dr. Lorie Broomhall, an FHI senior associate who served as study coinvestigator with the project director, Jennifer Liku of FHI's Kenya office. "Notably, many providers believed they were promoting condoms more than they were observed doing."

Interviews with hospital directors and clinical supervisors revealed that staff under their supervision had not been trained in the previous three years in STI counseling and condom promotion. This problem was blamed, in part, on high staff turnover. Other organizational factors that may have impeded condom promotion included an overburdened health care system characterized by low morale, labor disputes, large client loads, and staff shortages. Nurses who were interviewed said they were too busy to provide general counseling about STIs or specific counseling about condoms. "Staff shortages may also explain the presence of untrained employees serving as medical staff," Dr. Broomhall says. "Field notes recorded instances in which 'cleaners' and other maintenance personnel were diagnosing and treating patients at both public and private clinics."

Interviews with medical directors and community health advocates indicated that STI medications, once provided free at public clinics and hospitals, had become unavailable. The lack of free STI medications encouraged some people with STIs to bypass the clinics and hospitals and, instead, buy those drugs from pharmacies and unlicensed and untrained drug sellers. "Such informal providers had little knowledge about STIs, and thus were unlikely to make proper diagnoses," says Dr. Broomhall. "Furthermore, STI counseling and condom promotion in the informal health sector were practically nonexistent. In structured observations, no informal provider mentioned condoms to clients. Also, participant observation and interviews revealed that STI patients often self-medicated by purchasing the least expensive STI drugs, often at inadequate dosages, at shops and pharmacies and in the marketplace."

On the basis of these preliminary findings, FHI researchers have recommended:

* Increasing public awareness of STIs through media campaigns that stress the importance of professional treatment of STIs, the dangers of self-diagnosis and treatment, and that behaviors that put one at risk for HIV also put one at risk for STIs.

* Extending condom-promotion training to providers in the informal health care sector.

* Increasing the frequency of STI counseling and condom-promotion training at clinics and hospitals to offset the problem of high staff turnover.

* Improving overall STI services by standardizing and supervising staff to ensure patients receive adequate condom counseling.

* Addressing shortages or lack of STI drugs.


(1.) Miller K, Miller R, Askew I, et al. Clinic-Based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies. New York, NY: Population Council, 1998; Joint United Nations Programme on HIV/AIDS. Differences in HIV Spread in Four Sub-Saharan African Cities. Geneva: World Health Organization, 2001; Macro International Inc. Kenya Service Provision Assessment Survey. Nairobi, Kenya: Ministry of Health, 1999.

(2.) Broomhall L, Liku J, Okowa R, et al. Factors hindering the promotion of condoms by STI service providers in Kenya [poster session]. The XIV International Conference on HIV/AIDS, Barcelona, Spain, July 7-12, 2002.
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Author:Best, Kim
Geographic Code:6KENY
Date:Dec 22, 2002
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