FHI - III. Improved STD Case Management

III. Subproject Highlights (continued)

4. Improved STD Case Management and Other Health Worker Training

Training Health Care Providers in STD Management

FCO 51475

AIDSCAP partner:	Moi University Department of Reproductive Health
Geographic focus:	Uashin Gishu District
Target population:	Private practitioners
Project dates:	July 1, 1995 - April 30, 1997

Background

It is generally acknowledged that most people in Kenya infected with STD consult private practitioners as the point of first treatment. This assumption was born out in the results of a needs assessment conducted by Moi University in the Uashin Gishu District (UGD), which showed that the majority of those infected with STD consulted private practitioners. However, it has been difficult to reach private practitioners with in-service education, since they have little time and are harder to access. In order to test the practicability of providing training to this professional group, Moi University carried out a pilot project funded by AIDSCAP.

The project included training, supervision and monitoring of individual private practitioners in the Uashin Gishu District (UGD) on syndromic STD case management using Kenyan national STD case management guidelines. Moi University, the agency implementing the project, is located in Eldoret, the main urban center in UGD. By April 1997, it had trained 95 health workers. Of these,

Accomplishments

Baseline Research

A self-administered questionnaire was completed by 97 private health care providers (PHCP) to determine their baseline practice and willingness to receive training in STD case management. Over half were nurses with the remainder being either doctors or clinical officers (COs). Sixty percent of nurses were female while the majority of clinical officers and doctors were male.

Nurses reported seeing the most patients (256) per month, of whom 9.0% were estimated to be for STD complaints. Clinical Officers reported 163 patients per month, 13.5% of whom were seen for STDs. Mean reported charges for STD treatment ranged from KSh 288 for nurses to 400 for COs, with doctors charging about KSh 300.

Diagnostic facilities were minimal among respondents with about a third of doctors and COs and less than one in five nurses having any laboratory facilities. STD management prior to training was varied and in most cases ineffective as assessed against Kenyan and international standards.

Training

The curriculum for the training was adapted from the University of Nairobi facilitator's guide. Training workshops lasted two days, and the participatory format included lectures, group discussions, demonstrations, role plays and case studies. The training schedule had to be adapted for doctors who were unwilling to attend training during the day when they would be seeing patients. Convenient hours for training seminars were found to be evenings and weekends involving minimal disruption to their practices.

Knowledge levels pre- and post training were assessed. Significantly higher scores were achieved after the training.

Monitoring and Supervision

The project included a post-training supervision component. Two clinical officers trained as STD field visitors visited trained health workers at their site of practice to monitor practice and reinforce STD management skills.

Individual patient encounter forms were introduced as a monitoring tool that also facilitated supervision by providing a record of the practitioner's case management that could be reviewed during the supervisory visit.

Results

Patient Encounter Forms and On-Site Observation

Sixty-six private practitioners (70% nurses, 30% clinical officers) completed patient encounter forms on 1758 index patients and 62 partners. The mean number of patient visits was 28 per practitioner (range 1-165). No data is available for doctors who were trained too late in the project to provide meaningful monitoring data. Of the patients reported, 769 were women, 1008 were men. The mean age for women was 26 and for men 29 years.

Presenting STD symptoms included genital (urethral and vaginal) discharges, genital ulcers, and lower abdominal pain in women. Urethral discharge was the most common symptom in men while lower abdominal pain accounted for the most women seeking care.

Appropriate syndromic diagnosis was applied in most cases (over 90%) of patients with presenting symptoms other than vaginal discharge. Since there are several syndromic diagnoses (vaginitis, cervicitis and PID) possible for women complaining of vaginal discharge, these were considered (VCP in chart below) in evaluating "appropriate" diagnosis.

Based on the diagnosis indicated by the health worker, the treatment that was prescribed was assessed using several criteria. The majority of patients were treated according to either the nationally recommended syndromic guidelines or with an effective alternative. Results were poorest for vaginal discharge where health workers were more likely to treat on clinical grounds, often giving single treatment for candidiasis.

Prevention advice was reported less consistently. Although over 80% reported having counseled patients, less than half said they gave a condom demonstration and about a third partner referral advice. Male patients were somewhat more likely to receive a condom demonstration and partner referral advice than females. Health workers reported giving condoms to 12% of women and 23% of men. Of those who were given partner referral coupons, only four women and five men took more than one. This is consistent with other experience in the region: when partners are referred for treatment, it is almost invariably one regular partner. Casual partners are rarely traced and referred.

Focus Group Discussions

During the refresher training sessions, focus group discussions were held with participants to evaluate the effectiveness of training and feasibility of applying syndromic approach. The format included structured discussions and case studies.

Syndromic management was discussed with the objective of determining the advantages and disadvantages perceived by the participants. The general consensus was that syndromic management permitted efficient and effective case management while minimizing the need for laboratory investigations. Most felt that the majority of patients responded well to syndromic management and were satisfied with the care they received. This was recognized as a positive point as patient satisfaction was a key concern.

Risk assessment was regarded by some as useful since it eliminated the need for speculum examination and lab tests. Others felt that risk assessment was confusing and conflicted with what they learned in their medical training.

The Kenya national STD treatment guidelines were found to be useful, though many health workers preferred to use alternative regimens for a number of reasons. Some felt that the recommended drugs were more expensive, and that they would be compelled to reduce their portion of the patient fee to cover the increase cost of drugs. Others were worried about the quality of generic drugs which they felt were of inferior quality. Gentamycin was a commonly mentioned drug used for the treatment of gonorrhea because of its low cost and perceived efficacy.

Partner treatment was generally regarded as difficult and many private practitioners expressed a fatalistic attitude about it, though some found the use of partner referral coupons useful. Condom promotion was also variable with some expressing interest in either providing free condoms or selling the socially marketed brand.

Lessons Learned and Constraints

The profit factor is an important consideration for private practitioners when they make decisions about case management and treatment options. Training should be offered after hours or weekends to minimize disruption to the practice. The choice of drugs is influenced by cost as many private practitioners include treatment in the cost of the consultation.

Changing practice is acceptable to private practitioners if the change is perceived to enhance their status. Such advantages of syndromic management as same day treatment, avoidance of laboratory testing with associated costs and high success rates were recognized as advantageous by private practitioners.

Conservative approaches to treatment exist and these approaches hamper change. Examples include the reliance on 'pet drugs', and preference for branded medications over generics.

Monitoring and supervision, though more difficult to carry out with private practitioners, is feasible. Care must be taken to provide monitoring and supervision discreetly, and to assure that such activities don't take time away from patients.

Country Office Assessment

From the perspective of implementation, a striking feature of this subproject was the difference in carrying out the intervention at different levels of the private health care system. Whereas clinical officers and nurses welcomed the opportunity for further training in syndromic management, it was extremely difficult to involve doctors. Results (from the 66 clinical officers and nurses monitored) indicated that, except for vaginal discharge, over 90% of patients were treated with appropriate syndromic diagnosis. Prevention advice was, however, less consistent.

The project indicated the both the value and need for continued interventions directed at private health care workers, with particular need to develop a model to attract private doctors to training in syndromic STD case management. The challenge remains on how best to reach and convince the large number of private practitioners to adopt the national guidelines for syndromic management of STDs.

Process Indicator Summary

Process Indicator	Target	Actual	Percent
Providers trained	160	95	59%
Nos. at refresher training	120	42	35%
Nos. educated (dissemination workshop)	–	50	–

Training in STD Case Management for Family Planning Providers

FCO 51468

AIDSCAP partner:	Family Planning Private Sector (FPPS)/JSI
Geographic focus:	Country wide
Target population:	Service providers from private sector MCH/FP clinics
Project dates:	January 1, 1995 - May 31, 1997

Background

FPPS collaborates with a network of 204 private sector clinics operated by large agricultural and manufacturing industries, state corporations, NGOs and church groups, private health facilities and higher educational institutions.

The FPPS "Training in STD Case Management Project" included training, supervision and monitoring of service providers from private sector maternal child health and family planning (MCH/FP) clinics on syndromic STD case management using Kenyan national STD case management guidelines. Training by itself is often insufficient, however. Integral to this project is a cycle of training, supervision and monitoring with regular feedback to health workers.

Accomplishments

The project began in February 1995 and had, by April 1997, trained 402 staff drawn from 154 clinics. In addition, 64 clinic supervisors were sensitized after it was realized that they required orientation on syndromic STD management in order for them to effectively support their staff who were trained by the project.

The deliverables produced by the end of the project included a curriculum, participant hand-outs, and three quarterly newsletters. A poster on the project was presented at the XI International Conference on AIDS in Vancouver in July 1996.

Training Approach

The 3-day participatory training included sessions on the public health importance of STDs, the different approaches to STD care, syndromic management, counseling and prevention issues. Based on the curriculum developed by the University of Nairobi, topics covered included:

public health importance of STDs
rationale for the syndromic approach
STD case management using the syndromic approach
prevention advice
integration of STD management into MCH/FP services reporting.

Using case studies, health workers practiced managing STDs syndromically using Ministry of Health flow charts.

The training objectives of the project include increasing the participants' knowledge of STD management issues by 15%. At each training session, a pre-training knowledge assessment was done and this was compared with an assessment at the end of the training. All eleven trainings had a mean score increase of at least 20% with an overall increase of 32.4%.

Supervision, Monitoring and Feedback

Between trainings, project staff made supervisory field visits to the project sites where health workers had been trained. The purpose of the visits was to reinforce concepts learned in training and to identify and solve problems. Monitoring of STD case management took place at the supervisory visits as well as through review of STD case management forms completed by the health worker for each STD patient seen. Health workers also received regular feedback through supervisory visits and a quarterly newsletter.

The STD case management forms include information on presenting symptoms and signs, syndromes diagnosed, treatment given and prevention advice. They are forwarded to FPPS for analysis, and results are fed back through a quarterly newsletter to health workers and their supervisors. The newsletter also provides a medium for exchange of information and experiences among the health workers.

Results

Quality of STD Case Management

Between May 1995 and April 1997, 4551 STD case management forms were completed. One hundred seventy-eight health workers (44% of those trained) reported from 103 (67%) health facilities in 32 districts.

Clinic attendance for STD was almost equal for men (46.2%) and women (53.8%). Since MCH/FP was integrated into general medical services at most sites, women and men apparently felt equally comfortable seeking care for STDs. The age distribution of those seeking STD care is typical of STD epidemiology. Women predominate in the younger age groups while men constitute the majority of those over 35.

Evaluating the quality of STD case management can be broken down into several steps including correct (syndromic) diagnosis, appropriate treatment and provision of prevention advice including information about condom use and the importance of partner treatment. Over the course of the project, over 98% of patients with complaints or signs consistent with the common STD syndromes received an appropriate syndromic diagnosis.

While STDs drug use varied from site to site and over the course of the project, some trends were apparent. Supplies of medications are generally good in the private sector clinics, although access to MOH recommended drugs for STDs was inconsistent. Use of recommended drugs increased over the project period, probably as a result of trainings held for clinic supervisors. Most patients received either the first line recommended drugs for the diagnosed syndrome or an effective alternative treatment. A significant number received some other treatment (such as gentamycin for gonorrhoea) which, while not recommended, may be effective. Health workers often cited cost concerns as the reason for using these other treatments.

Overall, 32% of patients returned to the clinic for follow-up. Of these, 92.8% reported either cure or improvement. The proportion of returning patients reporting treatment failure decreased from 12% in 1995 to 5% in 1996 along with increased use of recommended drugs. Overall, clinical failure rates were lowest for cervicitis (4%) and highest for genital ulcer disease (15%).

Effective STD case management includes the provision of appropriate prevention advice to patients seen for STD. At minimum, patient education should cover the 4C's (counseling, compliance with treatment, contact treatment and condom promotion). All are taught during training; two of them, condom promotion and partner treatment, are monitored as indicators of complete case management.

Partner referral coupons were introduced during training as a method of facilitating patient-assisted partner referral. Some health facilities, however, refused to treat partners who were not employees or their dependents. The overall ratio of partners to index patients reported was 13%. Only 52.6% of index patients were reported to have been given partner referral coupons however. The ratio of partners treated to coupons handed out was 25%. Women (54.4%) were more likely to accept referral coupons than men (50.6%). Men who did accept referral coupons, however, were more likely to ask for more than one referral coupon, possibly a reflection of an increased number of sexual contacts.

Overall, 69% of STD patients received a demonstration of how to use a condom and 55% took home condom samples. Men were significantly more likely than women to receive the demonstration (75.2% to 62.4%) and to take the condoms samples (61.2% to 42.6%). Whether this is due to an unwillingness on the part of the health worker to bring up the subject of condoms with women, or to resistance from the women, is unclear.

Management of women presenting with vaginal discharge without reliable and affordable diagnostic tests is difficult. The training emphasizes use of the Kenya national flowcharts calling for treatment of all such women for vaginitis at the first visit. However, the WHO risk assessment criteria is also taught as a way of identifying women who might benefit from simultaneous treatment for cervicitis at the first visit.

Monitoring data showed that risk assessment was used inconsistently in the management of vaginal discharge. Women with positive risk scores were more likely to receive combined treatment for cervicitis and vaginitis as recommended by WHO. Most women, however, were treated for either vaginitis or cervicitis, health workers being reluctant to treat simultaneously for both conditions. Furthermore, there was no significant difference in assessed risk between women treated for vaginitis and those treated for cervicitis.

Constraints

Among the problems identified early in the project was a lack of effective STD drugs, specifically those recommended by the Ministry of Health (MOH). Health workers complained that their supervisors did not see the reason to order the new medications which were often more costly than those in stock. In response, 3 training sessions were organized in late 1995 to orient supervisors to the STD program and to sensitize them to such issues as the importance of effective drugs and the need to treat sexual partners.

Following the supervisors' trainings, the use of first-line drugs increased from 38% before to 53% after (p<0.0001). Similarly, more patients received appropriate co-treatment for their syndrome (83% compared to 79% before training (p=0.04). With increased access to recommended STD drugs, reported treatment failure at follow-up visit fell from 12% to 5% (p<0.0001) over the same period.

Operations Research

In order to answer some questions about post-care perceptions and behavior that arose in monitoring of health workers, a simple operations research project was proposed and carried out in early 1997 at eight FPPS-supported health facilities. Ninety-seven patients were called back within 2 weeks of treatment and interviewed using a structured questionnaire about their perceived outcome following treatment, as well as about prevention behavior adopted.

Preliminary results indicate that over three quarters reported cure or improvement, though the proportion noting no change was significantly higher than that reported by patients returning to the health facility for follow-up. Sixty-seven percent said they received information about prevention from the health worker. Ninety-eight percent reported taking all medicine that was given. Forty-two percent said they discussed condom use with a partner.

Concerning partner referral, 56% said they referred at least one partner for treatment, 93% of whom admitted referring only 1 regular partner. Only one person admitted referring a casual partner. Reasons given for not referring a partner included the partner away (63%) and concern about possible violence (9%)

Lessons Learned

In the course of this project, FPPS gained considerable experience integrating STD case management into MCH/FP services provided at their supported clinics, many of which operate in large worksite settings. Among the lessons learned in implementing the project, the following stand out as most important:

Training increased health workers' knowledge about STDs and this knowledge led to improved case management of STDs.
Access to effective STD drugs is directly related to outcome of treatment.
Supportive policy is crucial for success, specifically in the areas of staff training, availability of drugs, reporting, correction of STD unfriendly policies and nurses' authority to prescribe. Some companies have negative policies that exclude treatment of STDs which are considered "self-inflicted wounds". Management and supervisors need orientation early to assure a supportive environment for those who receive training.
Service delivery issues needing more consideration include the time-consuming nature of prevention counseling. Health workers under pressure to see a large number of patients may neglect this aspect of STD case management. Condom promotion and demonstrations must be culturally sensitive. Since "old habits die hard", some form of post-training follow-up is necessary.
Supervision of health workers and monitoring of their practice is important to assure that training leads to a change in clinical practice. Such supervision should be carried out early after training. It can be difficult, however, to assure even one visit to each trained health worker. Other methods for updating health workers to maintain motivation and ensure standards include periodic refresher courses, and use of a newsletter or other form of regular feedback. Regular feedback to health workers helps to maintain motivation and to correct identified problems.
Training methods should be flexible and participatory. Case studies and role plays with clinical slides are useful when practicals are not feasible.
Risk assessment was used inconsistently to manage vaginal discharge syndrome in women.
Contact referral is a sensitive issue and requires a tactful approach on the part of the health worker. Some company policies prohibit the treatment of sexual partners unless they are employees or dependents. Referral coupons can be helpful.
There are often no referral mechanisms in place in the private sector making management of difficult cases problematic.

Country Office Assessment

The project results were encouraging, in that they showed that with adequate training, STD prevention and care could be integrated into family planning clinics. It is important to note, however, that clinics varied in their ability to implement and report consistently on the new procedures. On-site monitoring and supervision must be built into the training process in order to reinforce learning and assure standards. In addition, the STD newsletter was an innovative approach to motivating the clinic staff after their training, which could be replicated in future projects

Many of the clinics involved in this project were linked to worksites. Among the lessons learned were the need for supportive worksite policies, in particular to facilitate provision of drugs for STD treatment; the need for supervisor training to support nurses and clinical officers in introducing new procedures; and the need for cultural sensitivity when carrying out STD prevention. As with the Moi University training project for private practitioners, difficulties in partner referral are a major constraint to STD case management. Future operational research projects are needed to examine effective ways of addressing this issue.

Process Indicator Summary

Process Indicator	Target	Actual	Percent
Health workers trained	400	402	101%
Health workers at reinforcement training	100	78	78%
No. supervisors at orientation training	60	64	107%
Clinics included in training	110-150	154	103%
Clinics reporting STD case management forms	120	103	86%
Materials distributed	1500	3000	200%

Development of AIDS Curricula for Family Planning Providers

FCO 23478

AIDSCAP partner:	Family Planning Private Sector
Geographic focus:	Country wide
Target population:	FP service providers
Project dates:	March 1, 1993 - August 26, 1996

Background

USAID's strategy for HIV/AIDS prevention emphasized the collaboration and integration of activities at the service delivery level (AIDSCAP Strategic and Implementation Plan, September 1993). Within both the public and private sector, there was great potential for enhancing reproductive health services by offering both family planning and HIV/AIDS prevention simultaneously to enhance healthy sexuality and informed individual choice. The development and incorporation of a curriculum component on HIV/AIDS prevention within existing basic and refresher family planning training could facilitate and standardize this linkage between family planning and AIDS prevention in Kenya.

The Family Planning Private Sector (FPPS) Project had been assisting the private sector in Kenya to initiate, strengthen and sustain family planning services since 1984. FPPS provided technical assistance, particularly training, to a network of approximately 200 sites in the private sector, many based at industrial or plantation worksites. The catchment area of this network was estimated at 11% of the population (approximately 2.5 million people). FPPS's programs had also been proactive in popularizing the condom and in meeting the demand for it. Many FPPS sites had also provided services for the prevention and treatment of STDs.

FPPS was therefore selected to develop an AIDS component that could be incorporated into a national family planning curriculum, and to pilot test the modules and the completed curriculum within the FPPS network. The curriculum was to be competency-based, with a strong emphasis on practicing counseling skills with clients. A subagreement was therefore concluded, with activities to start on March 1, 1993.

Objective

The project goal was to incorporate AIDS prevention messages into the daily activities of FP service providers in FPPS family planning clinic sites. The purpose was to train selected FP service providers from FPPS FP sites in HIV/AIDS prevention counseling during scheduled training and retraining sessions. This would be achieved through:

Developing and incorporating an HIV/AIDS prevention component within the existing FP sites
Establishing a pilot training program for AIDS prevention at FPPS clinic sites.

It was expected that 500 FP service providers would be trained in HIV/AIDS prevention counseling during the basic and refresher course. In addition 80% of trained FP service providers would be able to provide appropriate HIV/AIDS prevention counseling.

Accomplishments

A 16-hour information and counseling course was developed and pre-tested in initial training sessions. A draft of the document was then presented to a one-day review workshop attended by NGOs, government officials, USAID, and university staff. The workshop deliberated on the training content, process, teaching methodology and evaluation procedures for the course. They recommended extending it to 20 hours, and including additional topics. The curriculum was then further pre-tested in 8 workshops for CBDs and nurses. This review process enhanced the quality and appropriateness of the messages in the course.

The final curriculum was incorporated into the basic and refresher courses held by FPPS to train and upgrade health providers. The 11- module course includes sessions on self-assessment, values clarification, HIV transmission, diagnosis and management, risk assessment, condom use, and counseling. A brief counseling practicum is part of the course. This curriculum was subsequently printed as Facing HIV/AIDS: Curriculum and Facilitator's Guide (for Nurses and Clinical Officers).

35 courses were held from 1994-96, with the majority (28) in the first two years. A total of 711 participants were trained, comprised of 508 nurses and clinical officers, 157 CBDs, and 46 trainer of trainers.

66 of those trained were managers and supervisors. This category was significant because their support was need to ensure that counseling would be offered at the sites.

Findings

A formal on-site evaluation exercise to assess the effectiveness of the training was carried out in September 1995. Thirty-four participants (23 nurses/clinical officers and 11 CBDs) were interviewed in 24 sites, where health providers had been implementing their training for not less than six months.

The effectiveness of the training was indicated both by this on-site evaluation and training assessments. Participants at the sessions rated training as very useful, with an average score of 98%. Information gathered during monitoring site visits showed that all sites visited had implemented condom distribution and HIV/AIDS prevention education and counseling. 19 of 24 sites visited (79.1%) were implementing HIV/AIDS counseling.

The condom demonstration and distribution component was found by the evaluation to be well established. All sites reported access to condom distribution centers, and had set up their own distribution points at the workplace. There were, however, as noted below, some constraints in ensuring distribution at the field level.

Constraints

Insufficient time was allocated for the course content. It became apparent that 16 hours was too short to cover the material adequately. The implementing agency recommended that future courses should be increased to 20 hours.

Scheduling of the training was very intensive, given the number of staff assigned to the project and the geographical areas covered. As a result it was difficult to review and revise the course content in response to experience.

Lack of integrated services in most FPPS sites at the start of the project limited the utilization of the skills learned in training. 90% of the trained health providers work exclusively in family planning clinics and thus miss opportunities to reach other clients at risk for HIV (for example, men and youth). The project pointed to the need to promote ways to reach a wider range of clients with integrated service provision in FP clinics in order to use staff training in HIV more effectively. Application of the skills learned by the CBDs in outreach activities was also limited. Only 4 of 24 sites visited reported their CBDs carried out field work; in other sites, CBDs only worked in the clinic.

Although most sites provided counseling services, responses from the 1995 site evaluation indicated that these were limited to clients who had STD or signs and symptoms of AIDS. The implication is that clients at risk or asymptomatic were not identified for counseling. From evidence from the evaluation carried out in connection with the FPPS STD case management training, this situation appears to have improved somewhat later. That evaluation found that the risk assessment form included in the HIV/AIDS prevention module was in use, though it is not clear for what proportion of clients. The shortage of trained staff at the time of the study (1995) most likely contributed to the limits on client counseling at that time. The 22 sites visited had an average of 2 trained staff, with a ratio of trained staff to client of between 1:20 and 1:38 and counseling time ranging from 9 to 20 minutes per client.

Lessons Learned

Supervisor support was important in ensuring effective implementation of the HIV/AIDS prevention counseling element of the course. In sites where supervisors had been trained, it was found that the training was implemented in a more organized manner. This included allowing staff enough time to give prevention messages and providing adequate space to ensure the confidentiality of clients.

The factors that contribute to successful FP outcomes (trained staff, non-judgmental staff attitudes, client-centered and client-specific advice) were similar to those that contribute to effective HIV/AIDS prevention and counseling outcomes. Offering the two services simultaneously was prudent since one reinforces the other.

Country Office Assessment

The impetus for this project came from FPPS's realization in 1993 that staff in FPPS clinics were unprepared to deal with the gradually increasing number of AIDS-related situations presented by clients. Staff lacked knowledge about HIV/AIDS and how to counsel clients on prevention and were often hampered by their own prejudices and fear about the disease. The project was successful in training a large number of family planning providers who are now confident in counseling their clients, many in rural or peri-urban areas, on HIV. It has thus contributed to the integration of HIV/AIDS prevention into a wider reproductive health context, to reaching women at risk, and to expanding HIV prevention to the regional and district level. The FPPS HIV/AIDS curriculum project was therefore well-timed to provide services in line with the changing face of the epidemic. It indicates the value of planning interventions that look ahead to that changing situation, in addition to meeting current needs.

The review process was useful in refining the curriculum and training methodology. From observations by the Country Office, the training was highly interactive and focused successfully on health provider attitudes and on effective client counseling skills for behavior change. Condom demonstration and facts about condoms were also well addressed. However, there was a conflict between the skills needed to deliver this training and those needed to document it in a printed curriculum. As a result, though the training was highly successful, production of the printed curriculum was delayed. Future projects should ensure that staff will be assigned to focus exclusively on writing and editing, without conflicting with training needs.

The delay in finalizing the printed curriculum weakened its potential input into the design of national curricula. When the project began, no such curricula existed. However, by summer 1996, the situation had changed, with both the GOK and other USAID implementing agencies involved in redesigning training curricula to include HIV/AIDS prevention. FPPS's work was therefore valuable as training for health providers in its wide network of private sector clinics, rather than at the national level.

Process Indicator Summary

Process Indicator	Target	Actual	Percent
Health providers trained	500	711	142%
Training sessions held	17	35	205%
Persons educated (regional meetings, managers)	–	700
Appropriate counseling provided	80% trained providers	79.1%	99%

HIV Counseling and Testing Efficacy Study

FCO 44066

AIDSCAP partner:	Kenya Association of Professional Counsellors
Geographic focus:	Country wide
Target population:	General population
Project dates:	December 16, 1994 - September 1997

Background

HIV counseling and testing is currently a major component of HIV prevention in most developed countries. As the HIV epidemic continue to spread in many developing countries, particularly in Sub-Saharan Africa, HIV counseling and testing is being advocated as both a care and prevention tool in these countries. However, questions continue to be asked about the efficacy of counseling and testing in promoting behavior change, and its cost-effectiveness.

In Kenya, where it is believed that about 10% of the population is already infected with HIV, there is a felt need for counseling and testing to provide care and support to those already infected and their families and to assist people in changing their sexual behavior to prevent HIV transmission. Despite this, HIV counseling and testing is not readily available. Addressing questions about HIV counseling and testing efficacy and cost-effectiveness represents a very important public health policy contribution, and will provide the Government of Kenya and donor agencies working in Kenya with valuable information to negotiate resource allocation for HIV counseling and testing activities.

It was in response to this need that AIDSCAP selected Kenya as one of the sites for an international randomized controlled study of the efficacy of HIV counseling and testing. The study was a collaborative research activity by the World Health Organization's Global Programme on AIDS, the Center for AIDS Prevention Studies of the University of California San Francisco, and AIDSCAP. The Kenya Association of Professional Counselors was commissioned to conduct this study in Kenya. This project was supported from USAID/Washington's AIDSCAP funds, and supervised by the AIDSCAP Behavioral Research Unit.

Objectives

Determine the impact of HIV counseling and testing on behavior change among people voluntarily seeking such services
Describe the social and psychological consequences of HIV counseling and testing
Evaluate the cost-effectiveness of HIV counseling and testing

Methodology

This was a randomized study in which subjects were assigned to either HIV counseling and testing (C&T) or HIV standard health information (HI). Subjects in the C&T arm received pre-test counseling, had blood taken for HIV antibody testing, were provided with condoms, and asked to return two weeks later for HIV serostatus notification and post-test counseling. Those in the HI arm were shown an informational videotape containing culturally appropriate information on the prevention of HIV and other STDs, and provided with a stock of condoms.

All subjects were invited to come back to the center at 6 and 12 months. At 6 months they were administered a follow-up questionnaire and underwent physical examination and laboratory testing for sexually transmitted diseases (and received treatment if positive for any STD). People in the HI arm were offered HIV counseling and testing at this point. At 12 months a final questionnaire was administered to all returning study participants.

Findings

Outcome data from this study are not available yet as the research team is still in the process of data entry, cleaning and analysis. It is expected that final results will be available in April 1998. However, the following few preliminary observations are interesting:

A total of 1514 people were recruited for the study. 87% of them returned for the six-month follow-up visit and 75% returned for the 12 month follow-up visit.
Asked about their reason for enrolling in the study, more than 85% of the participants said that they "just wanted to know their HIV status".
Of the 708 assigned to the C&T arm at baseline, 149 (21%) were found to be HIV positive. Twenty seven percent of women were infected compared to 15% of men.
There is a high demand for HIV counseling and testing. Even after the end of recruitment for the study, 4-10 people presented themselves at the site every day seeking the service.
Returning for HIV test results has always been a problem in many HIV counseling and testing programs. However, in this study, more than 85% of those participants assigned to the counseling and testing arm of the study returned for their results without any tracing.
Counselors reported that although couple counseling was extremely challenging at the beginning of the study, they found it to be more rewarding as it offers a very good opportunity for them to assist the couple in negotiating behavior change.
More than 50% of the study participants reported that they would be willing to pay up to the equivalent of about US$2 if asked to pay for the service. This has an implication with regard to cost recovery or sharing in the implementation of C&T services.

As shown in the table below, some participants reported they had initiated behavior change before coming to the C&T site. This may support the idea that people do initiate some behavior change before seeking HIV counseling and testing as has been suggested in the literature.

Table 1. Risk Reduction Strategies

Strategy	Past Two Months		Next Two Months
Strategy	Females (n=756)	Males (n=756)	Females (n=756)	Males (n=756)
Abstain from sex	17%	20%	19%	21%
Always use condoms	11%	8%	32%	23%
Use condom 1st time	3%	3%	17%	13%
Reduce # of sex partners	17%	20%	22%	35%
Have sex with only one partner	66%	53%	76%	71%

Constraints

People's movement between Nairobi and their rural areas presented a real challenge to the tracing activities for the six and twelve month follow-up visits as the research team had sometimes to wait several weeks before being able to establish contact with some study participants

Frequent electricity shortage in the Kariobangi area significantly slowed down the process of computer data entry and cleaning.

Lessons Learned

There is a high demand for HIV counseling and testing.

Although for most clients counseling is an unexpected product discovered in the process of seeking HIV testing, clients highly value counseling provided as part of the C&T process.

Protecting confidentiality is vital in maintaining the clients' trust in the C&T services.

Country Office Assessment

The acceptance of this service by the local community and the few services available for low-income clients in Kenya indicate that the C&T site at Kariobangi must be supported (funded) to continue providing this much-requested service. However, efforts should be made to assess how best to introduce cost-sharing by clients. The study also indicated areas where additional operational research should be carried out, namely into:

What level of service do individuals request (i.e. how many pre- and post-test counseling sessions?)
What additional services to C&T do clients request?
What is the best way to provide couple counseling?
What level (or what mechanism) of cost-sharing can be achieved without turning people away from C&T
Would it be possible to use rapid tests to maximize the number of clients receiving their test results and cut the cost of service provision?
How can STD and family planning services be added efficiently and at low cost?
How can training be integrated efficiently into the ongoing services?

Investigation of Strategies for Renegotiating Sexual Relationships

FCO 54071

AIDSCAP partner:	Kenya Association of Professional Counsellors
Geographic focus:	Nairobi
Target population:	Sexually active adult population
Project dates:	January 15, 1995 - May 31, 1996

Background

As in the rest of Sub-Saharan Africa, in Kenya HIV is predominantly transmitted through heterosexual activities. This reality highlights the importance of prevention interventions aimed at promoting condom use, fidelity (monogamy), and reduction in the number of sex partners. For these behavior changes to happen, frank and equal negotiation must occur between already existing sexual partners or those considering entering new relationships. However, in the African cultural context, sexual negotiation between males and females is know to be minimal to non-existent. To investigate strategies for negotiating sexual behaviors among stable heterosexual relationships in Kenya, AIDSCAP contracted the KAPC to conduct the present study.

Objectives

The main objectives of the study were to:

Identify general beliefs, attitudes, and practices regarding HIV risk in a cross-section of sexually active Kenyans
Identify strategies for changing sexual behavior within different socio-economic groups
Assess the acceptability of different strategies for changing sexual behavior in the population
Identify barriers to change regarding the strategies identified
Explore the determinants that affect gender differentiation and how this affects the negotiation of sexual behavior
Identify mechanisms which facilitate public debate and private behavior change.

Methodology

The study was conducted in three successive phases. The first phase was a quantitative assessment of 500 people through a standardized questionnaire. Following the first phase, a sample from the 500 people interviewed was selected to participate in a series of focused group discussions focusing on main topics raised by the analysis of the phase one questionnaire and propose strategies for sexual re-negotiation. Phase three selected another sample from the original 500 people to discuss the acceptability of the strategies for sexual re-negotiation generated in phase 2.

Findings

Sexual negotiation strategies were found to be non-verbal among stable partners, regardless of gender or age. Examples of strategies used are: touching the partner in sensitive areas of the body, use of suggestive looks, dressing to expose the chest, reading materials that would stimulate both partners (e.g. pornographic magazines).

Study participants recognized that sexual negotiation strategies and communication between sex partners were very limited in Kenya and they suggested the need for an education program on sexuality and sexual behavior focusing on dialogue, gender equality, condoms, and knowledge. These four areas of focus became known by the acronym DECK. Findings related to each area covered the following:

Dialogue

Verbalization about sex is culturally taboo in Kenya, but participants felt there was a need for better communication. They said that dialogue between partners was important, and would encourage understanding, openness and respect. Dialogue would permit discussion of sexual preferences, sexual gratification and the avoidance of risky behavior.

Equality

Participants felt that gender equality was not accepted in Kenya. Men who recognized the need for gender equality were viewed as feminine, and consequently, pressured by their peers, relatives and neighbors. Men wanted their wives to work but also expected them to perform all the domestic duties. Equality strategies were needed to change this situation.

Condoms

There was a lack of trust regarding the use of condoms. A strong belief existed that condoms encouraged people to have sex. Condoms used between spouses was very unpopular as it was suggestive of infidelity. Also it was very difficult for wives to introduce condoms into the relationship because of the suspicion of promiscuity. There was a need to develop strategies that would allow condoms to be introduced where necessary.

Knowledge

There was a lack of knowledge about different sex behavior. Accordingly, men and women used only one sex style throughout marriage. (no variety, no change from first encounter). Better knowledge is needed if partners are to achieve sexual satisfaction and remain monogamous. It was decided that both men and women needed more knowledge about their partners sexual organs and how they functioned.

Constraints

It was initially planned to recruit the study sample from family planning clinics, STD clinics, sports clubs, community centers, and universities to ensure a wide selection of the population. However, due to lack of cooperation by the authorities of these institutions, the sample ended up being drawn from Nairobi city center and its satellite estates.

The fact that study participants were recruited on the streets (not from institutions to which they were attached) made it difficult to trace those who were randomly selected to participate in the subsequent focus group discussions.

Country Office Assessment

The research raised important questions for the development of interventions to encourage a reduction of risk among persons in steady partnerships. The DECK model identified by the research specifically points to some of the important components that must be addressed by such interventions. It also raises a few questions to be addressed by future research. For example, future research should:

Establish the frequency of HIV risk among persons in stable partnerships at the population level using rigorous sampling techniques
Clearly define what a "stable partnership" means to various persons at risk for HIV infection, and how the conceptualization of stable partnerships affects their risk behavior
Examine the efficacy of the use of the DECK model in specific interventions, with examination of the discrete components to identify which are most effective
Further examine the acceptability of the DECK approach to ensure that it is culturally appropriate
Examine how counseling modalities might specifically incorporate DECK components
Identify the quantitative distribution of demographic and personal characteristics of persons in stable relationships, and
Examine how the DECK component might be used in behavior change media campaigns.

The Female Condom as a Woman-Controlled Protective Method Research Study

FCO 54366

AIDSCAP partner:	Collaborative Centre on Gender and Development
Geographic focus:	Nairobi
Target population:	Urban women
Project dates:	October 15, 1995 to October 31, 1996

Background

The female condom has been recognized as a method that provides women with some control in their efforts to protect themselves from HIV/AIDS and other STDs. The exact degree of protection offered by the device against HIV transmission is yet to be determined through clinical trials (Farr 1993). It is clear, though, that its potential as a female-controlled method of protection is great.

Results from studies on the acceptability of the female condom show that more women have a positive attitude than a negative one to the device (Ruminjo et al 1991-4, Daly et al 1993, Sakondhavat et al 1993, Monny Lobe 199, Daly et al 1991). Less is known about how the device assists or hinders women's negotiation of protection against STDs. Yet studies show that women sometimes face severe difficulties in negotiating use of the male condom with their partners (Ulin 1992, Renard 1993). In Kenya, the female condom is virtually unavailable and therefore not widely known. Male condoms were little used until recently and were associated with casual sex or use with prostitutes, but not use within steady partnerships.

There is clearly a need for alternative barrier methods that allow women to protect themselves when males reject male condom use. In addition, the impact of the female condom on sexual relationships, and the social, cultural and economic factors that may promote or hinder its use have not been addressed in research studies. The AIDSCAP Women's Initiative therefore developed a protocol to study these issues in two countries: Brazil and Kenya. In Kenya, the study was carried out by Dr. Wanjiku Kabira and Dr. Joseph Ruminjo, Principal Investigators, through the Collaborative Centre for Gender and Development.

Objectives

The objectives of the study were to:

Identify factors affecting use and non-use of the female condom
Determine ways in which introduction of the female condom affects women's ability to negotiate protection against HIV/AIDS and other STDs
Explore and assess the role of peer and women's groups in sustaining the use of the female condom.

These objectives would be achieved through:

Assessing the range and type of women's protective strategies
Assessing women's perceptions of the female condom as a protective device
Exploring the impact of the female condom on sexual and peer relationships
Assessing the strategies and practices that facilitate women's ability to negotiate its use and to act on their sexual choices.

Methodology

The study in Kenya introduced the female condom to urban women, recruited through women's organizations, who perceived they might be at risk of HIV/STD infection and who showed interest in using the method. It was designed to use a combination of quantitative and qualitative data over an eight-month period, in order to provide a holistic picture of the issues of power and negotiation within sexual partnerships. Data was collected through interviews, coital calendars, focus group discussions and intervening peer support group discussions with women, and focus group discussions with male partners.

132 women participated in the initial in-depth interviews, of which 106 were recruited for the study and 100 completed the final interview. Participants were divided into four categories, by age (24 and under, and 25-40) and socio-economic status, and met in nine groups. In addition, six focus groups were conducted for 46 male partners.

The study process was: study recruitment, initial in-depth interview, initial focus group discussion, first and second peer support group discussions, final focus group, and exit interview. Coital calendars were introduced at the first peer support group discussion. The process for each group lasted for about three months, with two weeks between each stage. Focus group discussions were also held with male partners.

An essential feature of the study was the approach to recruiting participants. In recognition of the fact that women operate through their own structures, the research was introduced to over 20 national women's organizations and groups, who helped to recruit participants through facilitating meetings with women's groups at the community level.

Findings

Acceptance of the Female Condom

Some participants had initial difficulties with inserting and removing the device. However, by the end of the study, results showed a very high acceptance of the female condom. Those who reported liking the female condom "very much" increased significantly between the first and last interviews from 80% to 100% among young women of low socio-economic status, 70% to 94% among older women of low SES, and 32% to 71% among young women of high SES. 93 of 100 participants stated they were always satisfied with the device and 81 stated they would continue to use it if it were available.

Awareness of Personal Risk

Before the introduction of the female condom very few women were aware of their own risk of HIV infection. Their range of protective devices against HIV/STDs was also limited. Use of the male condom was minimal, particularly among married couples. The intervention strategy, the peer support group discussions, had an impact on awareness of risk of HIV/AIDS infection and on participants' perceived need for self-protection during coitus. This went up in all categories of women, as shown below:

Participants' Perceived Need for Self Protection against STD/HIV/AIDS (N=100)

	Initial In-depth	Final In-depth	CHI-Square	Percentile
Older High SES
Very much	1 (4%)	10 (100%)	32.4	0.00
Moderate	0 (0%)	0 (0%)
No need	27 (93%)	0 (0%)
No response	1 (4%)	0 (0%)
Young High SES
Very much	21 (84%)	24 (100%)	4.18	0.1
Moderate	0 (0%)	0 (0%)
No need	4 (16%)	0 (0%)
No response	0 (0%)	0 (0%)
Young Low SES
Very much	0 (0%)	34 (97%)		<0.00
Moderate	0 (0%)	0 (0%)
No need	43 (96%)	0 (0%)
No response	2 (4%)	1 (3%)
Older Low SES
Very much	0 (0%)	27 (87%)	51.06	<0.00
Moderate	0 (0%)	1 (3%)
No need	31 (94%)	3 (10%)
No response	2 (6%)	0 (0%)

Factors that Facilitated High Acceptance of the Device

Fear of HIV infection among both men and women
Women's ability to negotiate use without appearing to challenge accepted cultural norms of power within relationships
The nature of the device, which both men and women feel is more reliable than the male condom. Women felt the female condom was supple, compared to the male condom which, according to their partners, was also "tight." Women considered the female condom reliable because they could check it when they disposed of it, and there was no evidence of its rupturing. In addition, the female condom appealed to men because it removed the burden of protection from them.
The feeling among women of control and ownership in using the female condom. This result was strengthened by the use of women peer support groups as a channel to introduce the device, since the support provided in the process of negotiating for sex using the condom helped in empowering women in general. It is interesting to note, however, that the group of educated professional women appeared less empowered in negotiating use.
Women also felt that the female condom enhanced their sexual satisfaction, owing to its reliability and comfort. They felt more relaxed when using it and in particular could enjoy post-coital relaxation with their partner.

Factors Negatively Affecting Women's Ability to Use the Female Condom

Cultural rules and norms that do not allow women to negotiate for sex are the major factors that inhibit women's ability to use protective methods. Such traditions and cultures socialize women to be passive recipients of sex. Conversely, these same cultures and traditions make it a taboo for women to express their sexual desires or initiate sexual activity.
The cultural association of condoms with prostitution is the other factor that makes married women more vulnerable to HIV/AIDS infection. Married women will therefore object to the use of the male condom, even when it is introduced by the husband, for fear of appearing indecent.
Although all the study participants, both unmarried and married, succeeded in negotiating the use of the female condom within the course of the study, it appears from FGDs and peer support group discussions that unmarried women have more power in negotiating the use of protection methods. This is because both their relationships and communication within them are freer.
According to the participants, women's inability to negotiate for protection is directly related to their socioeconomic status. Their economic dependence on men weakens their negotiating power.
Cooperation from the male sexual partner is crucial. This often depended on the woman's ability to negotiate the use of protection without appearing to challenge his faithfulness or dominance within the relationship.

Strategies Used by the Women to Ensure Use of the Female Condom

Given the socio-cultural environment, the initial introduction of the female condom was difficult. However, as the study progressed, women adopted various strategies to overcome these cultural barriers, including:

Indirect strategies, which included using pregnancy prevention as an entry point, rather than telling partners that they needed to use the device against HIV/AIDS. They told partners that doctors had recommended use of the female condom because the pill has negative side effects. This strategy was the one most used by married women and those with permanent sexual partners. In addition, some women used the condom secretly when their partners were drunk. This worked if they inserted the condom early enough to pick up body heat.
Gentle negotiating strategies, such as asking partners to experiment and then make a joint decision.
Education strategies, such as giving men the opportunity to read brochures, and putting condoms where partners could see them and ask about them.
Cooperative strategies, such as using friends' partners to introduce the topic of using the female condom to a male partner.

The Role of Women's Groups and Peer Groups in Sustaining Use of the Female Condom

Women's organizations and groups proved to be highly effective structures for promoting and sustaining the use of the female condom. These structures provided support systems, learning opportunities to share ideas, encouragement and discussion of any problems that arose from using the device.

Exchange of ideas with other women was an important element in the development of negotiation strategies. Women in the peer groups advised each other on how to deal with non-compliant male partners. The groups also fostered the women's ability to learn to make decisions and stick with them.

Constraints

The popularity of the female condom among the women's groups presented challenges to the research project. First, members of the groups, including those not officially study subjects, requested condoms to try. Given the cooperative ethic of the groups, women could not refuse these requests, which resulted in the need to supplement the study's condom supply. In addition, the women had to be gradually weaned off their use of the device. The project encouraged them to substitute use of the male condom. It is, however, not clear how successful this was, nor what strategies the women used to return to use of the contraceptive pill, if that was still their preferred contraceptive method.

Country Office Assessment

The high acceptance rate of the female condom by both the women and their male partners indicate that it would be a very important barrier method with a valuable role in HIV/STD prevention in Kenya. The device was acceptable for use in steady relationships and indeed facilitated discussions on sexuality between the partners. The findings of this study should therefore be widely publicized in order to advocate for support for the introduction of the female condom in Kenya at an affordable price. Research into an acceptable price and appropriate distribution and promotion systems for a socially marketed product should be carried out as soon as possible.

Given the current cost of the female condom, the extent to which it can be safely reused is an important issue; research is currently being done by FHI on this issue, and the findings should be distributed to influential organizations in Kenya.

In the introduction of the female condom, women's structures remain the most appropriate vehicle to ensure continued use of condoms. In addressing such issues, the study provided insights into how women's behavior is affected by their feelings and perceptions on their status in society. Such issues must continue to be recognized if we wish to introduce female-controlled methods successfully.

Mother/Daughter Communication: An Empowerment Tool for Women

FCO 54469

AIDSCAP partner:	Centre for the Study of Adolescence
Geographic focus:	Nairobi
Target population:	Mothers and daughters
Project dates:	November 1, 1996 - March 31, 1997

Background

In their journey towards adulthood, young girls are faced with a myriad of physical, personality, emotional, social and other demands associated with growing up. Studies in Kenya indicate that girls have inadequate and inappropriate information and skills to prepare them for adulthood. Researchers and other concerned persons have decried the diminishing role of the traditional socialization agents without seriously questioning the role played by cultural traditional beliefs and practices in perpetuating negative gender stereotypes from one generation to another.

The role of mother to daughter communication in providing information and skills has been underplayed despite the acknowledged weakening traditional cultural systems. An information and skills vacuum among young girls, especially in the face of AIDS, raises a number of problematic issues that need to be addressed.

This study attempted to address this need and was designed as a three-phased project. Phase one was a needs assessment, phase two was to be the intervention stage, and phase three was to focus on evaluation. The findings of the needs assessment would be crucial in the design of interventions aimed at improving and strengthening the communication patterns. Only phase one of the study was covered, owing to time constraints.

Objective

The major objective of this study was to strengthen communication patterns between mothers and their daughters in order to enhance the acquisition of skills for the prevention of HIV/AIDS and STDs.

The study aimed at seeking ways of empowering mothers to provide appropriate role models to their children in order to enhance development skills, so that they could develop responsible and healthy relationships in matters related to sexuality, and HIV/AIDS.

Methodology

A total of 40 participants were recruited into the study, namely: 20 mothers (10 Christians and 10 Muslims) and 20 teenage daughters (also Christian and Muslim) aged between 10 and 19 years. Half of the participating mothers had primary schooling and below, while the other half had secondary to university education.

Data collected was qualitative in nature and involved 40 in-depth interviews with mothers and daughters, and eight focus group discussions for mothers and daughters separately. Simple statistics showing frequency distributions were used to analyze data from the in-depth interviews. The focus group discussion data was analyzed thematically after transcription.

Information on sons and fathers was sought indirectly from the mothers and daughters.

Findings

It was evident from the study that the relationships between mother and daughter were poor, particularly with mothers of higher educational levels who reported poorer relationships with their daughters than those with lower education levels. While the mothers viewed their daughters as rude, disobedient, hostile, moody and manipulative, the daughters felt that their mothers were harsh, domineering, suspicious and unnecessarily violent. Feelings bordered on hatred towards their mothers. Both mothers and daughters expressed hopelessness and helplessness in achieving positive relationships with each other. The older the teenagers became, (around 17) the more difficult their mothers found them to be.

The girls have learned most of what they know on HIV/AIDS and STDs from their friends, peers, schools, both mass and electronic media. Sometimes the information is misleading, incorrect or distorted. They claim to know the consequences of indulging in sex which they listed as pregnancy, STD, HIV/AIDS infections. However, they have a false sense of their ability to manage their sexuality and HIV/AIDS prevention. Even those who were sexually active claimed they had information about sex and could walk away from, scream or say no to boys and men who demanded sex. None of those who were sexually active reported use of condoms. Mothers communicated to the daughters on HIV/AIDS matters, but on obvious issues which the daughters claim they already knew: that AIDS is fatal and has no cure. Mothers did not provide practical guidance on issues of pregnancy and how to avoid it, relationships with boys, etc. They were uncomfortable about contraceptives as they thought this was tantamount to promoting promiscuity. Mothers themselves did not believe in the effectiveness of condoms, hence did not view this as an option. The mothers admitted their inadequacy and lack of skills in talking to their daughters on certain issues like sex and sexuality. Both parties wished for clearer definition of expectations in order to reduce the conflict that existed.

Most of the mothers believed that women must be submissive to their husbands and must endure problems and mistreatment from husbands. For them, the qualities of a good woman were obedience and respect for the man. While most mothers had positive aspirations for their daughters (to finish school, get good jobs, get good husbands) they communicated the importance of the same qualities (obedience, respect and submission towards man) to their daughters.

Generally, the fathers' role in communicating on sexuality and HIV/AIDS related issues was almost non-existent.

Some mothers who became realistic about their daughters' sexual activities and their risks of contracting HIV/AIDS were more willing to explore ways in which their daughters can be provided with information on preventive services. Where emergency intervention was conducted by the principal investigator, improved communication was reported.

Constraints

The study required more time especially since under some circumstances remedial measures to rectify relationships amongst mothers and their daughters were necessary. The time available for the study was very tight, especially given the fact that participants could only be met during the weekends. Additionally, the effects of the Christmas season and Idd festivities affected the study activities. The most ideal time to work with this target group would be during school holidays that have few festivities, such as the April and August holidays.

Lessons Learned

A clear need was identified to develop interventions that would strengthen mother/daughter communication by: (1) lowering levels of hostility and mistrust among mothers and daughters; (ii) addressing some of the constraints emerging from the study, e.g. fear and embarrassment; and (iii) encouraging mothers to establish links with daughters before they become teenagers. Interventions are necessary to empower mothers in their negotiation for protected sexual relationships with their partners so that they have accurate information on the condom and other HIV/AIDS prevention methods and as a way of improving communication patterns between mothers, their daughters and sons so that they can acquire information and skills that will help them in HIV/AIDS prevention.

Mothers and daughters need training on assertive skills through various methodologies such as role plays and participatory education theater. Mothers and daughters need empowerment to negotiate for protected sexual relationships with their partners.

The study design should have some forms of intervention in-built to take place concurrently. Both mothers and daughters did not approve of the idea of people coming to do research, get the information they need, and then leave them with the problems. It was important to have some kind of "damage control" that would assist both mothers and daughters to solve pressing issues.

Since some daughters found it easier to communicate with their fathers, ways should be explored to include fathers in such projects. Fathers have a role to play in socializing their children. Boys in particular learn about patterns of behavior and expectations from their fathers. Sons seem, however, to be completely neglected in mother/son communication and there was no evidence from the mothers that fathers communicated with their sons either.

Country Office Assessment

The research process was very well conducted and the report captured key issues surrounding mother/daughter communication. It is unfortunate that project had to start late, as the principal investigator had other commitments, and so could not complete the second, intervention stage. The study deserves large-scale replication, considering the vulnerability of women world-wide and particularly in the developing countries where harsh economic realities mitigate against the empowerment of women and the girl-child.

Final Report for theAIDSCAP Program in Kenya September 1992 to December 1997: Subproject Highlights

Final Report for the
AIDSCAP Program in Kenya September 1992 to December 1997: Subproject Highlights