Communications Materials Development & Support for BCC Strategy
(FCO# 53453)
| Implementing agency: |
Ministry of Health, Epidemiology Unit |
| Implementation dates: |
July 1994 to August 1996 |
| Primary target populations: |
Adolescents (13-18), young adults (19-30), persons with STIs |
| Secondary target populations: |
CSWs, MWM and persons with multiple partners |
| Geographical focus: |
National |
Background and Scope of the Intervention
This subproject was designed to support the Communications Team of the MOH/EPI Unit in the development and delivery of messages on HIV/AIDS prevention and control. This team is working with the mandate to implement the Communications Program of the NHCP and had been active in BCC since 1988. In the first stages of this program, four mass media campaigns were carried out with the messages: "AIDS Kills," "Get the Facts," contact the "AIDS Helpline" and "Keep on Keeping It On." When surveys indicated that these campaigns had raised awareness but not impacted risky behavior, the program determined its strategy should be to target risk groups, specifically persons with STIs, sexually active young adults and adolescents.
The new strategy included a situational analysis of these groups, elaboration of desired behaviors and interventions to bring about these behaviors. The objectives of the AIDSCAP subproject were to strengthen BCC activities conducted by the NAC member organizations, to develop or reprint and distribute high-quality educational materials consistent with the strategies for specific target groups and to coordinate public relations, mass and small media activities. The strategy integrated mass media, print materials and cultural vehicles as well as interpersonal contacts. All activities were closely linked to the public relations subagreement with Berl Francis and Company and with other subprojects within the MOH and the NGO/PVO sector.
Principal Accomplishments
During its two years, this subproject conducted 25 workshops with 48 NAC member organizations in BCC, reaching a total of over 75% of the members. In addition, the Communications team worked with the Red Cross, ACOSTRAD, three MOH subprojects and the YWCA to train their counselors, peer educators and other project staff who worked directly with the various target groups. With technical assistance from PATH, the team conducted a "low literate" material development workshop which focused on training in material development and pre-testing with focus groups.
As a result of the project, two posters - one on STIs and the other promoting the Helpline - were produced. A brochure promoting abstinence among adolescents was also developed. In addition to its own role in material production, this team coordinated material production for all of the NAC members, including all of AIDSCAP's subprojects.
In addition to print material, the team worked with the public relations firm and drama teachers to use local cultural media, including music and drama to reach adolescents. This resulted in two musical road shows which combined DJ music, drama, poetry and quiz competitions. Additionally, ten drama classes produced skits around HIV/AIDS themes which were videotaped and distributed to other schools.
As national level coordinators, the Communication team was active in special events around Safe Sex Week and World AIDS Day which reached some 15,000 people. The team participated in five exhibitions on BCC annually and coordinated over 140 talks for 30,000 people.
Important Constraints
The major constraints encountered by this project were related to activities that had to be canceled or reduced due to unanticipated budget cuts. Activities that were not implemented include the mass media campaign, musical performances, the TV serial drama, training for mass media and other BCC personnel and several video tape productions.
The subproject also found that the time consuming process of securing amendments to its subagreement was too rigid to allow for timely responses to the emerging needs of the program.
Additionally, the multitude of indicators in the subagreement led to a fragmented approach, causing the program to lose sight of its ultimate goal.
Lessons Learned and Recommendations
The subproject used a training of trainers methodology that it found was not as effective as it might have been. Some of the trainers were unable to conduct the level of training envisioned; some of the organizations were not committed to HIV/STI education and at times the selection of participants for training was not well thought out by the organizations.
It was recommended that training be done in smaller groups and be more field-based, with firm commitment from the organizations and participants involved. Additionally, more monitoring following training should be provided for, particularly in terms of sufficient staff to conduct follow-up.
In order to enlist the support of national leadership, both in the public and private sectors, a socioeconomic impact study of Jamaica should be carried out. Data from such a study would be useful in the policy arena as well as in garnering management's commitment to education and prevention efforts.
The mid-term evaluation found that behavior change was at a plateau and recommended that outside guidance be provided to reshape strategies for moving to the next strategic level. Additionally, the evaluators recommended that mechanisms be created to ensure that research findings are incorporated into project activities.
PIF Summary Table
(FCO# 53453)
| Process Indicator |
LOP Target |
LOP Actual |
LOP % Achieved |
| Materials Distributed |
726,281 |
414,746 |
57.1% |
Sentinel Surveillance
(FCO# 51449)
| Implementing agency: |
Ministry of Health, Epidemiology Research Training Unit |
| Implementation dates: |
July 1994 to August 1996 |
| Primary target audience: |
CSWs (male and female), STI clinic attendees, antenatal clinic attendees, informal commercial importers (higglers), food handlers, prisoners, MWM, drug abusers, hotel workers and marginalized community residents. |
| Geographical focus: |
Testing was done in six parishes, including one funded by GTZ |
Background and Scope of the Intervention
Current estimates indicate that between 5,000 and 10,000 Jamaicans are HIV+. Whereas hard data have been available on the number of AIDS cases over the fifteen years of the epidemic, these data do not reflect the number of individuals infected with HIV or among which population groups the virus is spreading most rapidly. This subproject was designed to answer those questions. There were three main objectives under this subproject. First, it was to conduct sentinel surveys in selected target groups. The project also aimed to improve the quality of laboratory testing for HIV/AIDS in public and private sector facilities and increase the number of NGOs accurately reporting HIV/AIDS to the MOH, Epi Unit.
As reflected in the list of target populations above, the subproject gathered data on ten subgroups resulting in comparative seroprevalence data in some cases and new baseline data in others. The accomplishments during this two-year project were numerous not only in so far as data collection and management but also in terms of developing strengthened surveillance protocols and creating awareness among policy makers and service providers.
Principal Accomplishments
HIV data are now available for six of 13 parishes, collection in five of these having been supported through AIDSCAP with additional funding through GTZ for the sixth. Protocols for sentinel surveillance and laboratory HIV surveillance have been produced. All major laboratories doing HIV testing now report to the MOH on a quarterly basis. Additionally, technical assistance through AIDSCAP/CDC collaboration to the EPI Unit resulted in strengthened data management capabilities and the establishing of a 50-user network allowing Internet access and simultaneous data entry.
Over 2,000 sentinel surveillance packages were distributed to private practitioners and more than 1,100 health care workers participated in training on HIV/AIDS counseling and case reporting. Over 11,000 blood samples were tested. The collection of samples relied on the active participation of several NGO implementing agencies, especially for recruitment in difficult to reach high risk target groups.
Data from the sentinel surveys have been shared with policy makers and service providers. As a result, the ministers of health and justice drafted a prison policy on HIV. Project implementers now have data available with which to make strategic planning decisions. The close coordination of the sentinel surveillance subproject with intervention programs has enhanced monitoring and evaluation of the latter.
Important Constraints
The major constraint faced by this project was a shortage of testing kits. In order to test 500 blood samples, for example, a total of 710 tests are needed to ensure accuracy. This was not planned for and budgetary shortfalls and an increase in the price of the kits resulted in over 300 untested samples and nearly 70 unconfirmed tests.
A shortage of technicians resulted in delays in processing specimens.
There is no legal requirement for private practitioners to report HIV+ clients to the government.
Lessons Learned and Recommendations
HIV seroprevalence among STI clinic attendees increased between 1993 and late 1994/early 1995 from 4.3% to 4.5% in the Kingston/St. Andrew (KSA) area and from 7.0% to 8.8% in St. James. The 1995 prevalence among this population in the parishes of St. Ann and St. Catherine was found to be 4.7% and 5.6% respectively. This target group remains a challenge, and the problem could be exacerbated by the fact that half of men with STIs do not seek proper treatment. Future programs should continue to try to reach this group to increase appropriate treatment to a higher proportion of people with STIs.
The sentinel surveillance of CSWs and MWM showed the following. CSW prevalence varied widely by parish. In KSA, where prevention interventions began in 1991, the percent has declined from 12.7% in 1989 to around 8% in 1996. In St. James, where interventions started in 1995, the percent is also decreasing. Estimates show that between 1993 and 1996, prevalence dropped from 25% to about 21%. It should be noted that the earlier samples included only female CSWs and the later samples include male and female. This high risk target group should continue to be a priority.
Surveys of antenatal clinic attendees in five parishes showed an increase in HIV prevalence from 0.4% in 1992 to 1.0% in 1995. However, in KSA, prevalence increased to 3.2% by 1995. Blood donor prevalence was stable at 0.4%.
It is recommended that surveillance be expanded to include all parishes. Additionally, surveys should be conducted annually in high prevalence areas, among high risk target groups and every three to five years among low risk populations. The data produced is extremely important for organizations implementing prevention and control interventions as well as policy makers. All possible efforts to link interventions with survey findings should be made.
Strengthening STD Services in the Public Sector
(FCO#s 31448 & 51448)
| Implementing agency: |
Ministry of Health, Epidemiology Unit |
| Implementation dates: |
July 1994 to August 1996 |
| Primary target populations: |
STI clinic attendees |
| Geographic focus: |
National |
Background and Scope of the Intervention
Studies conducted in 1986 and 1990 in Jamaica's main STI center showed that HIV prevalence among STI clinic attendees increased from 0.3% to 3.2% in Kingston. Another study in Montego Bay showed a 10% HIV prevalence rate among repeat STI clients. These findings have led the NHCP to prioritize improved STI case management as a major strategy for the prevention and control of HIV/AIDS. Effective management of STI clinic attendees has been found to be key in positively influencing future health-seeking and disease prevention behaviors.
Jamaica has 13 public sector STI clinics and several part-time facilities which see between 50,000 and 60,000 patients annually. Estimates show that some 64% of these patients are repeat attendees. The existing facilities experienced staffing shortages and a lack of supplies and equipment. A study conducted in 1991 revealed that only 40% of STI patients received counseling and only 74% of gonorrhea patients received appropriate treatment, largely due to a lack of drug supplies.
This subproject, within the MOH EPI Unit, was designed to strengthen services for case management and education of public STI clinic attendees; to strengthen laboratories for quicker, more effective patient diagnosis; to strengthen contact investigation service; and to conduct STI-related operational research.
Principal Accomplishments
As a result of this project, more than 500 public health care workers were trained. Sixteen laboratory technical assistants were given training to upgrade their skills in RPR testing. At present all public STI clinics and rural satellites conduct RPR testing on STI and antenatal clients. This testing has also been extended to the island's major maternity hospital in an attempt to control the high rate of syphilis reactors among antenatal patients attended at that institution. The subproject distributed over 2,000 manuals of guidelines for STI case management and counseling, now used in over 100 public clinics. Additionally, over 750,000 condoms were distributed.
The 1996 evaluation of the subproject showed encouraging signs of behavior change including condom use in high risk situations, partner reduction, universal knowledge of two prevention methods, fewer myths and a more positive attitude towards condom use. Appropriate drug treatment for gonorrhea increased from 74% to 100% between 1991 and 1996. Condom use in high risk encounters increased from 29% to 59%. STI clinic attendees endorsing appropriate practices only increased from 38% in 1994 to 69% in 1996. Additionally, the number of STI clients reporting two or more sexual partners in the previous year decreased from 83% to 60%. Counseling levels in clinics of 80% were not achieved, though this was attributable to the fact that in some facilities peer educators provided group counseling and condom demonstrations.
Important Constraints
In the implementation of this subproject, the project manager felt that the lack of close coordination between the financial management and program implementation caused difficulties. Additionally, the administrative support that was to be provided through CATC was not provided though it was much needed.
The monitoring of process indicators on a monthly basis was cumbersome and would have been better on a quarterly basis.
Finally, the cancellation of the condom social marketing program made it impossible for this subproject to make the linkages envisioned in the planning of the project.
Lessons Learned and Recommendations
The major finding of this project was that behavior change is not automatically a result of knowledge. The recommendation for future programs is to study the repeat STI clinic attendees and the reasons and attitudes behind their behavior, identifying methods to counter these behaviors.
The project also cited the need for improved monitoring and supervision systems to ensure the quality of the services and information provided in the clinics.
PIF Summary Table
(FCO#s 31448 & 51448)
| Process Indicator |
LOP Target |
LOP Actual |
LOP % Achieved |
| Persons trained |
524 |
775 |
147.9% |
| Materials distributed |
2,000 |
2,018 |
100.9% |
| Condoms distributed* |
not an indicator |
750,000 |
N/A |
*As condom distribution was not a project indicator, these data are not included in the PIF totals.
Face-to-Face Education and Outreach Activities
(FCO# 53451)
| Implementing agency: |
Ministry of Health, Epidemiology Unit |
| Implementation dates: |
July 1994 to August 1996 |
| Primary target population: |
Adolescents (13-18), adults with multiple partners and persons with STIs |
| Geographical focus: |
National |
Background and Scope of the Intervention
This BCC subproject was conceived to narrow the gap between awareness of HIV/AIDS and the minimal change in behavior in Jamaica. It focused on the development of communication interventions to promote sustained behavior change through selection and implementation of appropriate strategies for targeted audiences. Working at the community level, Face-to-face teams of five to eight members per parish used highly participatory and interactive methods to explore attitudes and myths surrounding sexuality and HIV/AIDS. The major objective was to reduce high risk behavior among three target groups in the island's thirteen parishes; adolescents, adults with multiple partners and persons with STIs. Programs aimed to encourage delay of sexual initiation, condom use, partner reduction and STI/HIV treatment seeking behavior.
Principal Accomplishments
The subproject trained more than 2,000 parish-based volunteer teams, teachers, community youth leaders and peer educators island-wide. These trained community members initiated both formal and informal interventions to reach large numbers of the target groups in a variety of settings including schools, workplaces and leisure organizations. Techniques were used such as competitions, games, puppetry and telephone chains were used. The major focus of these interventions was to promote condom use and to dispel the myths surrounding its use.
The formal strategies included the People Wave, which trained key people as community and peer educators within some 146 organizations. These people then acted as multipliers, creating a ripple effect in many of the organizations. Training included sessions on Facts on STIs, communication skills, human sexuality, strategies and myths. A total of 876 people were reached in their workplaces, with over 64% of these being women.
To reach adolescents, the Did You Know Sexuality Program was implemented in 240 schools, many of which had never before had human sexuality in their curricula. The project trained 368 teachers to provide correct information on HIV/AIDS/STI, human sexuality and myths while helping adolescents resist peer pressure and see abstinence as a viable alternative. As a result of this intervention, six of ten schools evaluated showed increased ability of adolescents to communicate with both teachers and parents and an increase in knowledge on HIV/STI. More students also said they were practicing abstinence after the intervention.
The Facts of Life Peer Education Program was designed to reach adolescents in youth groups, mainly church-based. Face-to-face teams worked with 27 groups, to train peer educators and focused on promoting condom use and counteracting the myths related to its use. In addition to these formal activities, the project reached young adults through informal one-on-one or small group sessions. Over the life of this project, these activities reached more than 300,000 adolescents and young adults. In addition, the project distributed 15,000 condoms.
Face-to-face encountered several constraints to the implementation of its project. Although frequently able to form linkages with other organizations working in isolated areas, at times project staff were unable to undertake night activities due to lack of transportation. Other logistical challenges included staff turnover, substantial time consumed completing monitoring forms, slow data and report submission from parish level.
Lessons Learned and Recommendations
Face-to-face found that its approach to reaching the target groups was important to its success. The project reached its target groups in their own environment, provided immediate feedback and conducted discussions using creative, stimulating methodologies. Furthermore they were able to explore the issues behind prevention messages and the target groups' resistance to the messages through interactive dialogue. In addition, the project promoted the NHCP Helpline, giving adolescents the option of a confidential, anonymous counseling service.
The project found pluses and minuses to working primarily with volunteers. First, volunteers were willing and able to do the work if given good guidance and supervision. On the other hand, relying on volunteers meant some communities were not adequately covered. The present program structure relies too heavily on volunteers and cannot support itself. The program determined it needed to strengthen its links to the public health system to ensure sustainability.
Behavior change happens slowly and despite the program's knowledge of cultural and other factors, barriers to change remain and cannot be ignored. Further work to identify and understand barriers will enable effective change to take place.
PIF Summary Table
(FCO# 53451)
| Process Indicator |
LOP Target |
LOP Actual |
LOP % Achieved |
| Persons trained |
106* |
2,342 |
2,209.4% |
| People educated |
100,000 |
342,074 |
342.1% |
| Materials distributed |
No objective in LogFrame |
146,320 |
N/A |
| Condoms distributed |
No objective in LogFrame |
15,000 |
N/A |
*No target was established for the training of adolescent and young adult peer educators
AIDS in the Workplace
(FCO #33459)
| Implementing agency: |
Ministry of Health, Epidemiology Unit |
| Implementation dates: |
October 1994 to August 1996 |
| Primary target population: |
Employees in their workplaces |
| Geographical focus: |
Nationwide |
Background and Scope of the Intervention
The AIDS in the Workplace subproject began in October 1994 with the objective of initiating programs in Jamaican businesses that would educate their staffs about HIV/AIDS. The aim was to develop a cadre of peer educators within the companies who would then sustain the education program. Additionally, the subproject strove to assist companies in the development and promotion of nondiscriminatory policies and practices with respect to HIV-infected employees and prospective employees. In collaboration with other AIDSCAP-funded activities, this project built on and complemented the awareness being created and took information to the workplace where the worker spends a third of each work day.
Worldwide, and in Jamaica as well, the AIDS epidemic is striking most dramatically the 20 to 39 year old age group. Nearly 60% of the AIDS cases occur in people approaching or in the prime of their most productive, working years. Therefore, it was reasoned, a workplace-based program was an opportunity for Jamaican employers to encourage and promote healthy lifestyles and behavior change to lower their employees' risk of contracting HIV. The project targeted twenty companies with 1,000 or more employees.
Principal Accomplishments
When the project began, employers were demonstrating increasing willingness to address this issue where previously they had resisted. By the end of the project, employers were allowing staff half an hour out of the work day to attend or present sessions. Additionally, employers began to see the need for policy guidelines to protect infected and affected staff members. The subproject also achieved a change in attitudes among employees, including an increased awareness of the need to use condoms as well as the fact that HIV is not transmitted through casual contact.
Important Constraints
While the project succeeded in reaching nearly 4,000 workers, managers and employers tended to see the intervention as appropriate for the more junior, lower level employees. There seemed to be the perception that management was not at risk. Some CEOs did not wish to be associated with the intervention and did not take a leadership role in the efforts. To counter this, the project arranged a high-level meeting with the Governor General who endorsed the project activities and called for the CEOs' cooperation. Unfortunately, apathy persisted.
Another constraint was that the volunteer peer educators conducted educational sessions in addition to their full-time duties, which meant that at times they delayed or failed to implement the voluntary duties. In other cases, these educators were perceived as being sympathetic to homosexual behavior and were ostracized by homophobic coworkers.
Lessons Learned and Recommendations
Several lessons were learned that should be considered by any future workplace-based projects. First, employers need to be shown how the program will benefit the company, not just the employees. Integration of HIV/AIDS/STI information into a general wellness program is one option. Second, in order to ensure a sustainable intervention, greater up front commitment on the part of the companies is necessary in terms of in-kind and financial contribution as well as key personnel designated to manage the activities. The project found that to succeed, three to four staff had to be involved in monitoring and maintaining the activities within the workplaces.
PIF Summary Table
(FCO#s 33459 & 53459)
| Process Indicator |
LOP Target |
LOP Actual |
LOP % Achieved |
| Persons trained |
20 |
118 |
590% |
| People educated |
20,000 |
3,943 |
19.7% |
| Materials distributed |
1,000 |
97 |
9.7% |
Targeted Community Intervention
(FCO# 33457)
| Implementing agency: |
Ministry of Health, Epidemiology Unit |
| Implementation dates: |
September 1994 to August 1996 |
| Primary target populations: |
Four marginalized urban communities and one mental hospital |
| Geographic focus: |
Kingston Metropolitan Area |
Background and Scope of the Intervention
The Targeted Community Intervention (TCI) subproject was designed to reach the residents of six marginalized Kingston communities and the Bellevue Mental Hospital with an estimated total population of approximately 21,500. The goal of the project was to reduce high risk sexual behavior and increase appropriate treatment seeking behavior in these communities. The objectives of this project were to develop an expanded, targeted BCC intervention for the target group, develop a condom distribution system and develop sustainable linkages with other programs for peer education, STI referrals, telephone Helpline, counseling and testing and social services for people with HIV/AIDS.
Principal Accomplishments
TCI aimed to increase levels of appropriate risk awareness, reduce incidences of high risk behavior and STIs, increase condom availability and use, increase health and treatment seeking behavior and medical compliance and reduce the stigma of HIV/AIDS. The project began by entering the communities through first gaining acceptance among community gatekeepers. This was done in order to develop partnerships and to develop and implement culturally appropriate interventions, which would be acceptable to residents, while still employing strategies that would enable and encourage persons practicing high risk sexual behavior to contemplate change.
The project used innovative techniques to reach the residents of the targeted low-income communities. These included interpersonal street corner "reasoning", drama workshops, comedy performances by popular Jamaican comedians and music by well-known local DJs. In addition, the subproject set up a total of 34 condom access points in the targeted communities and the hospital, and collaborated with community-based organizations to ensure continued prevention and behavior change efforts. The project also initiated peer education through the Face-to-face program in community meetings.
Important Constraints
Safety in the targeted communities was a significant constraint to the subproject at times in spite of the effective relationships the project staff established with the communities.
The low level of community infrastructure, specifically electricity and running water impacted on the project's ability to conduct sessions.
The time frame of this project was too short given the extensive amount of effort needed to gain entrance into these marginalized areas that are suspicious of outside interventions. Even though the project tapped resources within the community, significant lead time was needed prior to initiating activities.
Lessons Learned and Recommendations
This approach used insiders to promote behavior change through the use of drama written and performed by the community members themselves, rather than bringing in outsiders. This gave the communities an important sense of ownership. Gaining the approval and participation of gatekeepers (community leaders) was also essential to the success of the project, as it allowed access to the target population and added credibility to the project's activities.
PIF Summary Table
(FCO#s 33457 & 53457)
| Process Indicator |
LOP Target |
LOP Actual |
LOP % Achieved |
| People educated |
20,000 |
12,551 |
62.8% |
| Materials distributed |
20,000 |
8,322 |
41.6% |
| Condom outlets established |
30 |
34 |
113.3% |
Counseling and Social Welfare
(FCO# 53454)
| Implementing agency: |
Ministry of Health, Epidemiology Unit Counseling and Community Outreach Program |
| Implementation dates: |
August 1994 to August 1996 |
| Primary target population: |
NGOs, HIV+ people, health care providers, caregivers, volunteers |
| Geographical focus: |
National |
Background and Scope of the Intervention
To reduce the rate of sexual transmission of HIV, it is important to target people who are already HIV positive in order to try to contain the spread of the disease. The goal of the Counseling and Community Outreach program (CCO) of the Epidemiology Unit of the Ministry of Health in Jamaica was to influence the behavior of people infected with and affected by HIV in order to promote safer behavior and prevent further transmission of HIV/STIs. This subproject represents the first concerted effort in Jamaica to develop a network of counselors, to provide care and community outreach for people affected by HIV/AIDS. The CCO program initiated activities aimed at identifying and sensitizing key individuals and organizations who were most likely to be in contact with people living with HIV/AIDS.
Principal Accomplishments
The CCO program aimed to increase the effectiveness and utilization of support and referral services provided by governmental and non-governmental agencies through the establishment of a National Support and Referral system for PWAs. CCO activities ensured that all individuals who sought HIV/AIDS testing were provided with appropriate counseling, including referrals to needed services. Gatekeepers, the first to identify persons with HIV/AIDS, are the link between the network of support agencies and persons with HIV/AIDS. Thus, the gatekeepers play a vital role within the referral network.
The referral network was established and included a confidential telephone counseling and referral system, the Helpline, which facilitated the effective use of support agencies in Jamaica. The Helpline, a 12-hour per day, five day a week service, was enhanced through this project and received between 400 and 500 calls per month. Budget cuts precluded additional funding for the Helpline; nonetheless, a cadre of counselors was maintained as planned, with one full-time counselor and several part-time counselors.
Training sessions were held to educate and sensitize caregivers, counselors, medical personnel, social workers and community mental health officers on issues surrounding HIV/AIDS. Some 350 women and 168 men participated in these workshops in which topics such as epidemiology, and the services and needs of PWA were discussed. Behavior change among caregivers follows a process similar to that of the general public -- information can lead to knowledge and awareness but not necessarily to behavior change. Interventions must be ongoing if attitudes are also to be changed. Sixty community-based counselors were recruited and maintained island-wide with the majority of counselors in parishes with the highest prevalence.
Through collaboration with the Communications Team of the Epi Unit, educational materials, such as posters and brochures, were developed for people living with HIV/AIDS and for those involved in their care and support, including service providers, professional care givers and key care givers such as friends and family. Enhancing the resources of this population is very important and should be continued. A Referral Resource Manual was also developed to provide information on accessing services in Jamaica. This manual is a service directory listing of care, counseling and social welfare service providers, such as those working in hospitals, hospices, counseling and social welfare organizations. These providers make up a network of care givers in communities across the island. Over 100 providers received an early version of this manual and an updated version is being produced. Additionally, a newsletter to service providers was initiated.
All individuals and agencies within the network were sensitized to the importance of condoms as a means of protection and were provided with information on how to access condoms. CCO collaborated with the PR consultant and other agencies in the development of condom distribution strategies.
Important Constraints
Several setbacks in project implementation occurred as a result of staffing and funding issues. At the project's onset, it was anticipated that there would be an additional counselor and/or social worker on the team throughout the project, and that the Helpline staff would be able to provide additional logistical support. For a number of reasons this was not the case. Similarly, the extended absence of the CCO specialist further inhibited the full and successful implementation of this project. In addition, lack of funds severely limited certain activities, such as promotion of the Helpline.
As the training programs began, it became apparent that participants had a wide range of knowledge, experience and education on HIV/AIDS. In many of the sessions the curriculum had to be modified to provide basic information on HIV/AIDS to participants and to dispel negative attitudes, even where preliminary sensitization had occurred. This was, in part, due to attrition of staff and some strongly held attitudes particularly among those who felt they did not have adequate supplies to implement Universal precautions. These factors sometimes meant that more sessions were needed to move people to the desired point, but time and other resources were not always available. Additionally, participation in follow-up sessions was not as high as in the initial sessions. In future projects, training sessions should start with very basic HIV/AIDS information and then build to more complex topics.
A set back in materials production occurred when the review and testing took more time than anticipated. While these phases of material development were completed, the materials were not printed or distributed as originally planned.
Lessons Learned and Recommendations
Qualitative studies show that more than 75% of the care givers sampled had participated in training in the past two years. Of the total sample, 82% were aware of and affiliated with the Care Counseling and Support Committee of the National AIDS Committee (CCS/NAC). The research revealed that the majority of caregivers interviewed had assisted PWAs. Caregivers felt that they were able to offer counseling and emotional support to both PWAs and their families. More than 16 agencies had been used as referral resources, with JAS and the Helpline being the most frequently used.
It is strongly recommended that efforts be made to institutionalize some of these initiatives and to maintain public education in support of this work. Due to the present relatively low HIV prevalence in Jamaica, it is going to be important to ensure that gatekeepers are provided with the skills to support and influence PWAs in order to prevent increased transmission of the virus. The participation of PWAs, their friends and families will play a major role in changing the social response to the epidemic. In addition, the National Program must continue to play an active role in the process even as other organizations are encouraged to support and assume certain roles.
PIF Summary Table
(FCO# 53454)
| Process Indicator |
LOP Target |
LOP Actual |
LOP % Achieved |
| People trained |
375 |
1,072 |
285.9% |
| Materials distributed |
15,000 |
6,525 |
43.5% |
Establishing a Resource Center for the MOH
(FCO# 20445)
| Implementing agency: |
Health Information Unit (HIU), Ministry of Health |
| Implementation dates: |
October 1, 1993 to June 30, 1994 |
| Primary target population: |
HIV/AIDS prevention organizations and advocates |
| Geographical focus: |
National |
Background and Scope of the Intervention
The HIU of the Ministry of Health was contracted by FHI to provide assistance in establishing a Resource Center to serve as a national central repository for all HIV/AIDS information that would better organize resources of the MOH, and expedite information retrieval and dissemination. Specifically, the Center would facilitate the ease of services for the Communications Unit of the MOH. As the HIV/STI Control Program is the only local agency totally dedicated to the dissemination of information on HIV/AIDS and other STIs, this resource center was expected to play an invaluable role in the National Information System as the national locus for collection and dissemination of HIV/AIDS/STI materials.
To achieve these objectives, the HIU planned to focus on three areas of activity: 1) preparation of the physical facilities of the center; 2) organization of outreach materials; and 3) the establishment of the resource center as a focal point for HIV/STI information. The Resource Center was to be located in the building currently occupied by the HIU and the main library of the MOH. The facilities were to be painted and furnished, and a system was to have been established to facilitate the collection of, and organization of the materials. A system following three specialized collections of materials was to have been established for the use of the NHCP staff during outreach activities: 1) a collection of printed material was to have been compiled and organized for easy reference; 2) a permanent but moving exhibit was to have been created and displayed at various locations island-wide; and 3) workshop kits containing existing items were to have been compiled for easy reference.
In addition, the Resource Center was planned as the central location for HIV/STI information. The Resource Center was scheduled to apply to NACOLAIS for recognition and membership of the Scientific and Technical Information Network (STIN) and establish membership with the National Referral Service at the National Library of Jamaica. A program was developed to sustained distribution of locally produced materials which would allow for the acquisition of overseas publications including regional and international technical journals in the field, research papers and conference proceeding. A periodic accessions list was to have been published and a toll free number was publicized across the island.
Principal Accomplishments
The activities listed above were not accomplished in nine months. Due to administrative issues at the country office and implementing agency levels, the project was not amended in a timely manner. Rather than amend the project it was decided to incorporate the funding for this project into the communications project "Communications Team: Materials Development and Support for BCC Strategy" (FCO#53453).
The Reassessment of STD Case Management through Health Facility Survey
(FCO# 40015)
| Implementing agency: |
MOH, Epi Unit |
| Implementation dates: |
March 1996 to August 1996 |
| Primary target population: |
STI clinics |
| Geographical focus: |
National |
Background and Scope of the Intervention
In 1991 the Epidemiology Unit of the Ministry of Health was contracted to support a reassessment of STI case management. From September through October 1991, a formal, baseline assessment of the quality of STI case management in the Jamaican public sector took place. Thirteen health facilities were evaluated: two specialty STI clinics; six primary clinics with an STI contact investigator (CI) on staff; and five district primary clinics without a contact investigator. The assessment included an inventory of equipment and drugs, interviews with clinic staff about the function of the clinic and the standard of care, and observations of provider/STI patient encounters. The researchers evaluated health care providers in two main areas: 1) appropriate medical management of STIs, including in-depth history taking and physical examination, use of available laboratory tests and prescription of treatment for specific diagnosis; and 2) appropriate counseling, including information about the course of treatment, partner notification and the distribution of condoms.
Problems with STI case management noted in 1991 included inadequate history taking, incomplete management syphilis and insufficient counseling and distribution of condoms to STI patients. Since 1991 several activities and programmatic changes have been implemented by the Jamaican National HIV/STI Control Program in order to address some of the problem areas noted in the 1991 assessment of STI case management. These include the development of national STI management guidelines based on syndromic diagnosis, the expansion of the contact investigation program, extensive training of clinic staff in STI case management, and the decentralization of the syphilis serology program to facilitate local testing.
Principal Accomplishments
The assessment of STI case management was repeated in 1996 to evaluate the impact of the improvement efforts. Methodology was the same as in 1991 with the inclusion of additional indicators from the current edition of WHO's prevention indicators (PI) numbers six and seven. PI 6 measures the proportion of clients presenting for STI diagnosis and treatment who are treated according to national guidelines. PI 7 measures the proportion of clients presenting for STI diagnosis and treatment who receive basic counseling on condoms and partner notification. The same number (115) of provider/patient encounter observations were conducted. The clinic sample was selected in the same fashion as in 1991. Study participants were selected at random from the total number of clinic types in the country.
Important Constraints
The main constraints which inhibited full facility comparison between the 1991 and 1996 data related to data collection. In 1991 data were not collected on waiting time, i.e., the delay between initial consultation or blood collection and the provision of treatment. These delays may constitute a significant issue for public clinics in Jamaica. Another measurement related to the number of total number of patients in general and STI patients in particular turned away in the past month. Unfortunately the comparison could not be calculated because of indecipherable coding in the 1991 dataset. In addition, the location where patients obtained prescribed drugs could not be compared because this question was not asked in 1991. These constraints are typical of this type of assessment. Researchers learn from the first assessment, so the second assessment is often more complete than the first.
Because the study only measured counseling by physicians at the time of physical examination it often underestimated the education and counseling actually provided to patients. Pre-examination counseling by auxiliary staff, such as nurses or contact investigators, often provides valuable information to patients. Because non-physician counseling was not recorded, actual improvements in counseling probably exceeded the recorded improvements in counseling.
Many of the indicators of STI case management from 1991 were quite strong, which means that the 1996 assessment could by definition show only small improvements in these areas.
Lessons Learned and Recommendations
Several points of the study show evidence of improved management of STIs between 1991 and 1996. Both history-taking and syphilis treatment have improved.
In-depth history taking and physical examination -- In all the facilities there has been significant improvement in history taking. The percentage of encounters which featured adequate history taking increased from 50.0% to 59.0% in the mid-level clinics without CIs, from 26.9% to 63.0% in the mid-level clinics with CIs and from 34.3% to 86.0% in the comprehensive clinics.
The proportion of patients receiving adequate examinations increased from 74% to 81% in the mid-level clinics without CIs and from 73% to 89% in the comprehensive clinics. However, the proportion of patients receiving adequate exams at the mid-level clinics with CIs decreased from 59% to 48%. While the reason for this decrease is not entirely clear it may be that in some cases the CI is the clinician doing the exam, and that CIs are more likely to treat syndromically. Researchers noted that the main role of the CIs is to do contact investigation in the field; exams are to be performed by nurses and physicians in the clinic. Overall the percentage of females given speculum examinations increased by 12% between 1991 and 1996. This is especially promising given the relative difficulty of speculum examinations compared with male examinations.
Use of Available Lab tests -- A major improvement from 1991 to 1996 has been the presence of decentralized syphilis testing in most clinics. Tests are now often done by the lab technician before the patient sees the clinician. At least 60% of STI clientele are likely to get an on-the-spot RPR trust test for syphilis. The ability to obtain test results on the same day of the clinic visit represents a great improvement since rapid test results facilitate early treatment.
Rates of testing for HIV increased from 2.6% in 1991 to 9.4% in 1996. This may reflect both increased attention to HIV by providers and CIs as well as the increasing HIV epidemic in Jamaica, which has led to increased demand for contact tracing of HIV cases.
Fewer gram stains and gonorrhea cultures were ordered in 1996 than in 1991. This is due to the fact that the new guidelines for STI management encourage syndromic management of STIs, i.e., providing infected patients with treatment for all possible causes of infection. Syndromic (rather than etiological) management of STIs is necessary in the Jamaican context because of the long turnaround time for lab results and the likelihood that patients will not return to the clinic for follow-up care. In 1996 100% of gonorrhea and syphilis cases were treated according to national guidelines. This is important because the 1991 assessment highlighted treatment as an area of special concern.
Counseling of STI patients has also improved over the past five years.
Provision of education and counseling -- In 1996 a larger proportion of patients presented for follow-up or as referrals from other health facilities than in 1991. This suggests that the training of clinic staff has improved quality of care. Also of significance is the fact that a larger proportion of STI patients in 1996 were referred by their sexual partners. Data indicate a 4% increase in physician discussion of partner referral, which suggests that providers are become more adept at addressing this important issue. Furthermore, these data suggest that more work is being done to manage contact tracing.
The distribution of condoms -- Overall, the primary providers in 1996 did a better job of asking about problems with condoms than in 1991 (14%, 1991 vs. 17% in 1996). The number of clients offered condoms almost doubled during this time, from 18% to 34%.
It is interesting to note that fewer people aged 20 years and younger sought treatment in 1996 (18% of the sample) than in 1991 (30.7%). There are two possible explanations for this scenario. It is entirely possible that behavior change messages have led to increased condom use and/or reduced risk behaviors in this age group, resulting in a decreased incidence of STIs. The other explanation, supported by anecdotal evidence from other settings, suggests that adolescents do not access care at family planning and STI clinics for fear of encountering judgmental providers and a generally nonsupportive environment. In this case infected adolescents may be self-treating or may lack treatment altogether. Further research could determine whether the decrease in adolescent patients is being driven by decreased incidence of STIs or by fear of utilizing reproductive health services.
It is also interesting to note that relatively more women sought STI treatment in 1996. This is interesting given that a large percentage of sexually transmitted infection in females is asymptomatic. Since most patients presented at the clinic with symptoms of infection, the women who did seek treatment probably represent merely a fraction of the infected female population. Because untreated STIs can have life-threatening sequellae for women (Pelvic Inflammatory Disease, ectopic pregnancy), STI health seeking behavior in women is a variable that needs to be tracked by the National Program.
