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Final Report for the
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Table of Contents I. Country Program Description B. Country Program Context: A Focus on Bangkok C. Accomplishments and Constraints (See Below) D. Implementation and Management Issues II. Lessons Learned and Recommendations I. Country Program Description C. Accomplishments and Constraints The design of the AIDSCAP/Thailand program was distinct from other large prevention programs being implemented in Asia by virtue of the comprehensive array of planned services and the network to link these together. As conceived, public and NGO health development agencies in Bangkok would join forces under the banner of "Bangkok Fights AIDS" and direct their services to the highly mobile lower-income 1.5 million young male and female laborers in the city. The Bangkok Metropolitan Administration (or city government) was the de facto focal point for coordination and official endorsement while a community mobilization subproject was created to prepare communities (worksite and residential) for the variety of technical packages that were soon to be implemented. The following sections explain how this structure was erected and the obstacles that prevented a full implementation of the plan. Community Mobilization Conceptual Background The term "community mobilization" in the context of health development first gained credence with the success of the Stanford 3-City Heart Disease Prevention Project in the 1970's. The evaluation of that project demonstrated that when mass communication is combined with interpersonal communication there can be a significant impact on health behavior (Farquar). A key ingredient of this success appeared to be the emergence of informal change agents who helped mobilize communities of peers to adopt new norms and behaviors (Wagner). This process builds on the propositions of diffusion theory as widely promoted by Rogers (Rogers). In the 1980's variations of community mobilization were applied in the areas of care for the elderly, child survival, cancer control, comprehensive rural health and AIDS prevention in the urban setting (Carlaw, Foster, Global AIDS News, Tweneboa, Wagner). Although these various projects are quite different in goal and scope, they share certain elements which characterize the community mobilization process. These elements were applied in the BFA Program by the Faculty of Public Health (FPH), Mahidol University through an AIDSCAP subproject. The subproject concentrated the first year of activities in six of Bangkok's 36 districts. These six districts are called the Phase I zone. The FPH identified four core components of a community mobilization effort as follows:
Local Coordinating Mechanism In community mobilization projects, community involvement is obtained by working through local groups of activity coordinators. In the urban setting, these may consist of block groups, volunteer networks, active members of appointed committees, etc. If they do not exist, they must be created. In the case of Bangkok, the Bangkok Metropolitan Administration (BMA) established district AIDS committees (DAC) for all 36 districts in mid-1992 to implement the now-famous 100% condom program of the MOPH which promotes 1005 condom use in commercial sex establishments. As envisioned by the Thailand Program Designers the role of these committees could be broadened to coordinate and promote AIDS prevention in a variety of at-risk populations, not just brothel patrons and CSWs. Members of the committees varied among the six DACs in the Phase I Zone but generally included representatives from the local government, NGOs, business community and labor force. The FPH identified the most active members of these committees to form working groups to coordinate AIDS prevention plans and activities in each district. Community Network Diagnosis After the local coordinating mechanism was established, the next step was to conduct an inventory and needs assessment among local "action groups". These action groups are loosely defined as collections of individuals who interact with each other on a regular basis in the course of work or social activity. Examples of these groups are a motel owners' association, factory assembly line shifts, a pharmacists club, taxi cooperatives, employees in a common office, motorcycle taxi queues, mechanics working in the same garage, etc. The individuals interact and communicate with each other within "networks". These networks were identified through interviews with key informants and focus group discussion. It was planned that the networks would provide the means of gaining access to the target population to provide information and other prevention services. Network Strengthening Community mobilization succeeds when the members of community networks adopt the program goals as their own. Thus, during the formative stage of the subproject, these networks needed to be identified or formed and then strengthened. One means of network strengthening is to arrange opportunities for network members to be together to discuss relationships within and among networks and the perceived needs of network members. Whenever appropriate, the subproject staff encouraged networks to focus on AIDS and STI or the social factors which aggravate the problem (e.g., partner-sharing norms, women's empowerment, drinking behavior). The networks were encouraged to propose their own solutions and which were considered in the context of the AIDSCAP prevention strategies and guidelines. In the Bangkok Program, the opportunities for network strengthening included World AIDS Day events, exhibitions, monthly meetings of associations or clubs, periodic training sessions, etc. The networks are the key to the mobilization process whereby modified social norms and new information are rapidly diffused through the community. The networks are also the key to sustainability and innovation after the outside seed funding and technical assistance shift to new sites. Previous projects in Thailand have shown that ample indigenous resources exist to fund AIDS prevention activities on a continuous basis (AIDSTECH/FHI 1990, 1991). Technical Packages In community mobilization projects, the network members need to have access to accurate information, appropriate behavioral models and services to aid in the adoption of new behaviors. AIDSCAP funded these technical packages separately from the Community Mobilization subproject but they were steered to specifically targeted audiences in the six districts of the Phase I Zone. Other AIDSCAP-funded interventions were planned which would strengthen mass and interpersonal communication which support condom use, STI control and reduced sexual networking. These are described in detail in subsequent sections of this report. The health service technical packages upgraded the existing diagnostic and treatment services for STI and improved the supply of condoms. The role of the Community Mobilization subproject was to help match the technical packages with the appropriate target audiences as identified in the community network diagnosis. In sum, the community mobilization process can be concisely described as follows:
Project Foundation-Laying The worldwide AIDSCAP Project was approved in August 1991 and most staff for Thailand and the Asia office were hired by December 1991. The AIDSCAP Asia team completed the Thailand country strategy in February 1992 and this document was approved by AIDSCAP headquarters two months later in April. The AIDSCAP Thailand Program Design Team had determined that community mobilization would be the core strategy to link all AIDSCAP components together in the Bangkok Program. It was believed that this approach would diffuse information, norms and services fast enough to overtake the spread of HIV in the large urban setting. Before the subproject could be fully developed, a database had to be created with key information about each of Bangkok's 36 districts. Although there is a large amount of data on the population and infrastructure of Bangkok, this information was scattered among many different agencies. After compiling and analyzing the database, six districts were selected for the first phase of activities. These districts represent inner, middle and outer Bangkok and comprise a range of community types at risk of HIV. This variety ensured that there would be a rigorous test of the community mobilization approach in different urban settings. The data for selected groups were also mapped using state-of-the-art computer graphics. The BMA Health Department was particularly interested in this subproject because of the focus on the DACs which the Department created in mid-1992 to help implement the 100% condom policy and the potential for overlap with existing BMA programs with the DACs. Through regular meetings and document sharing, AIDSCAP and the FPH kept the BMA informed of subproject progress. Implementation teams were formed consisting of three FPH faculty and each team was assigned to one of the six districts. The role of the teams was to (1) bring the DACs up-to-speed on HIV/AIDS and prevention strategies, (2) strengthen DAC planning and coordination, and (3) assist DACs in network strengthening through management of a DAC fund for conducting activities with social networks. These activities were intended to bring members of a common social or work network together. A manual of how to conduct network strengthening activities was developed. Games and exercises were used to increase familiarity among members and create an atmosphere of trust and openness. Some exercises were used to expose attitudes toward HIV/AIDS. The role of networks in Bangkok HIV prevention was explained. There were opportunities for open discussion. Results In this Phase I Zone pilot version of the Community Mobilization subproject, 117 members of the DACs were trained by the FPH faculty teams. The network strengthening exercises reached 7,273 men and women. In terms of basic outputs, the subproject clearly reached a substantial number of individuals in the six districts. The community diagnosis produced inventories and maps that are a testimony to the effort of the subproject teams -- and to the complexity of Bangkok social networks. This information provided a structure for the agencies implementing the educational outreach and STI service expansion to plan and build upon. However, the success or failure of the community mobilization component rested on the degree to which DACs could be strengthened to perform an active coordinating and planning function, and in the creation or identification of social networks through which prevention services could be channeled. An independent agency was commissioned to evaluate the Community Mobilization project in its pilot phase. The evaluation only looked at the issue of the functioning of the DACs and the degree of network creation. The following are excerpts from the evaluation report: The data from the observation and in-depth interviews in the Phase I districts concerning the ability of the subproject to identify and strengthen social networks exposed different degrees of success in the Community Mobilization project. DAC Meetings From the various sources of data it is possible to observe the following: While some districts convened meetings only rarely, all districts were able to fully implement the subproject through an active working group. The format and content of DAC meetings did not differ greatly among the districts and this forum was used to introduce to the DAC other agencies involved in the "Bangkok Fights AIDS" team and to facilitate their entry to worksites and communities. In addition, the agency conducting part of the evaluation of the BFA Program through a Behavioral Sentinel Surveillance tool routinely fed back data to the DAC after each round was complete. This is one example of how multiple subprojects of the BFA Program were linked through the DAC. Despite content similarities, the atmosphere of the DAC and working group meetings were distinctly different. For example in some DAC meetings, although the content was more technical than others, the atmosphere of group participation and enthusiasm was high. In other districts the atmosphere was rather casual yet suffered from the lack of greater participation from the private sector representatives on the DAC. Several districts stood out for the stressful atmosphere of their DAC meetings. Although no open conflicts were observed it was clear that many DAC members felt inhibited or unmotivated to contribute to the planning or deliberations in these districts. Working Group Members Viewpoint of the Subproject
The working groups were comprised of a subset of the DAC members and were intended to be the real driving force of the DACs. There was considerable variation however in the composition and operations of these working groups. Some met monthly, as scheduled, while others met only bimonthly. Some had equal participation from a range of multidisciplinary members while others were dominated by professional health staff. The external evaluation conducted in-depth interviews with some of the working group members to gain insight into the reason behind the greater or lesser success of the DACs in community mobilization. The following are excerpts from those interviews:
This second comment highlights one important shortcoming of the DACs: Many DAC members misunderstood their role to be AIDS educators. In fact, their principle duty was to strengthen networks. Indeed, the network strengthening activities did not have to address AIDS in particular but could center on any topic that was of interest to the group in general. The overemphasis on AIDS communication in this subproject may have impeded the network creation effort. Topics of more immediate and common interest should have been addressed first. Discussion of AIDS and risk behavior could have followed later and would be best delivered by the agencies contracted to do the BCC intervention of the BFA, not the DACs.
This comment reflects a realism on the part of the working group of the difficulty of community mobilization for HIV prevention. However, working groups tried different approaches and often correctly analyzed the most important obstacles.
This last view reflects the stress some staff felt toward the demands of a community mobilization project which added to their workload and disrupted their personal lives. The evaluators of the Community Mobilization subproject also interviewed members from target population across a range of occupations such as motorcycle taxi driver, restaurant worker, housewife, garage mechanic and commercial sex worker. The box below summarizes responses to some questions about project activities which were intended to identify and/or strengthen social networks. Another measure of the impact of the activities is an estimate of the diffusion potential for information gained by participants. In some districts participants said they had spoken to an average of 13 network members while others spoke to an average of only seven. Potential impact of network strengthening: Voice of the participants
When assessing the different approaches of the Phase I districts, the methods used in some project districts created a closer relationship among participants and generated greater participation than in other districts. This may be attributed to better use of small group "breakout" sessions. Nevertheless, only conducting a single network strengthening activity per group seems not to have had a sustained effect as judged from the interviews with participants:
A more optimistic view was found in Pasicharoen District:
Having the free time is important as well:
In general, women more than men expressed a sense of civic responsibility to join the prevention effort:
A prevailing attitude among men however is that there is little time to discuss these things with peers:
Community Mobilization subproject districts lacked a clear explanation of the expected roles of the community network representatives and because of this it was unexplicit that they were expected to be a link between future outreach activities and their social/peer network. Although diffusion of some information beyond the sheer number of over 7,000 participants in the 64 activities (as high as 13 fold in the case of Phranakorn District), it was the conclusion of the evaluators that strengthening social networks was not adequately accomplished in this Phase I Zone pilot. The factors most likely to explain this shortcoming include:
The delayed launch of the technical packages by BFA caused confusion among DACs and the community mobilization subproject staff about their role. As a result, DACs assumed that they should be conducting outreach education for the target population. In a comprehensive program, the phasing and timing of the various components is critical to successful teamwork and needs greater attention in future efforts of this kind. In this case, the DAC could have devoted more time to social network creation while the technical agencies conducted the outreach education. Nevertheless, network creation was only part of the overall objective and SOW of this complex subproject. The subproject was clearly successful in conducting community mapping of the target population and these were used by other collaborating agencies in the BFA Program. The subproject reactivated defunct DACs and created effective working groups who learned to program and evaluate AIDS prevention activities. The subproject created a forum for linking the many agencies involved in the BMA-coordinate BFA so that they could coordinate, avoid duplication and take advantage of public and private resources. This subproject, more than any other in the AIDSCAP family of subprojects in Bangkok created a sense of partnership among collaborating agencies through seminars in which all BFA agencies and collaborators attended. These lessons learned and recommendations draw on the results of the evaluation presented above and on discussions with others who were closely involved with the subproject:
In the expansion phase to the remaining 32 districts of Bangkok, AIDSCAP applied some of the lessons from the Phase I Zone experience and focused on strengthening DAC performance, rather than creating social networks. Multidisciplinary teams visited each of the DACs to provide coaching sessions. The purpose of these coaching sessions was to help remind the DAC members what their role was (e.g., coordination not health education) to help define obstacles to more effective performance and work with DAC members to create solutions. The DACs are the appropriate and the only existing entity in Bangkok to provide a structure for community mobilization. However, the potential of the DACs has not yet been realized (at the end of AIDSCAP/Thailand) because of a number of obstacles:
The Technical Packages The Community Mobilization initiative was laying the foundation for what was to come in the Bangkok Fights AIDS Program that AIDSCAP was constructing with the BMA. Next, technical packages were put in place to strengthen the three pillars of the AIDSCAP/USAID prevention effort: prevention and control of STIs, behavior change communication (BCC) and condom use. The Thailand Country Program designers were keenly aware that interventions needed to be developed along two dimensions: (1) Interventions to help prevention transmission "today"; and (2) Interventions to help sustain prevention efforts "tomorrow" and beyond. Estimates and projections conducted by the Thailand Red Cross AIDS Program (funded by AIDSCAP) suggested that 50 persons living in Bangkok were becoming infected by HIV every day (see Table 1). Table 1: Estimated Number of HIV Infected in Each Region (mid 1992) *
New Infections Since the Previous Year: Whole Kingdom *
* Estimates of recent HIV infection levels in Thailand (pp. 19, 38). Research Report No. 9. Program on AIDS, Thai Red Cross Society. Tim Brown and Werasit Sittitrai Simultaneously, programs were developed to extend and strengthen the ability of Bangkok service providers to provide outreach BCC and to rapidly diagnose and treat STIs for the target population of lower income men and women age 15 to 29. The STI component placed an emphasis on the most vulnerable population in Thai society for acquiring an STI: female commercial sex workers. To complement this, the BCC component primarily targeted men who engage in commercial and noncommercial sex, and the female partners of these men. Earlier research near Bangkok had shown that marital status and economic level did not differentiate the sexual risk taking of Thai men and, that the most common pattern of sexual partner mixing (among those with multiple partners) was to combine commercial and noncommercial sex (Havanon). This form of "bridging" behavior between a relatively small group of very high risk partners (i.e., CSWs) with the large number of relatively lower risk partners (i.e., wives, girlfriends) is probably largely responsible for the extent of HIV in Thailand in the early 1990s. STI Strengthening in the Public, Private and Commercial Sectors This set of interventions spanned most of Years 2, 3 and 4 of the five-year AIDSCAP/Thailand Program. The goal was straightforward: to equip and enable medically authorized clinics to perform rapid diagnosis and treatment of STIs for both men and women. In addition, because research has shown that an important point of contact is the pharmacy for men seeking STI treatment, a model intervention for drug sellers was piloted and then replicated in Bangkok (see Figure 1 below). Figure 1: Average Number of STI Patients Per Week, Bangkok - 6 Pilot Districts
In all of AIDSCAP/Thailand subprojects which aimed to upgrade services, the first step was to conduct a needs assessment to determine that, indeed, upgrading was needed and what were the minimum essential inputs needed. At the time when AIDSCAP began, the BMA Health Department already had a network of 60 general community clinics. In nine of these clinics, a special STI clinic service was integrated. Generally, these nine sites were located in areas with a higher concentration of commercial sex establishments. AIDSCAP first worked with the BMA to assess and upgrade these clinics and conduct some piloted expansion of services. Prior to the subproject implementation, a needs assessment was conducted at these nine clinics to assess overall clinic operations, to determine training needs of nurses and laboratory technicians, and to determine the clinic and laboratory equipment needs. The assessment found that:
Based on results of the needs assessment, the following activities were then implemented:
Conclusion: BMA STI Clinic Intervention Evaluation of the efforts to upgrade and expand STI services was conducted in a variety of ways. Patient management practices in the clinics were evaluated by a post-test after the training workshop ended and by routine supervisory visits by BMA staff. Evaluation of the expanded clinics and extension hours was conducted by review of services statistics and key informant interviews. Highlights of the evaluation are as follows:
An analysis of BMA STI services was commissioned by the Policy Unit of AIDSCAP headquarters. The results are described in Policy Working Paper Series # 4 (January 1996). Two important findings of the analysis are that the evening clinics have a higher cost per patient treated than daytime clinics while the outreach activities were found to be highly cost-effective. Clearly upgrading and extending the hours of the small number of BMA STI clinics would not be enough to serve 1.5 million people through out the vast city. The designers of the AIDSCAP/Thailand Program were very cognizant of the large number private medical clinics and pharmacies which served as points of first (and only) contact for many STI patients in Bangkok. Thus, two additional subprojects attempted to bring these two sectors into the Bangkok Fights AIDS constellation of inter-linked programs. The subproject with private STI clinics was implemented by the Thai Medical Society for the Study of Sexually Transmitted Diseases (TMS-STD) with technical assistance from the Program for Appropriate Technology in Health (PATH). The PATH/Bangkok staff had had experience working with the private medical sector in Thailand and was the primary implementing agency in the previous AIDSTECH/FHI-funded subproject entitled "Upgrading Private STD Clinics." The long-term goal of this subproject, together with other government and private sector efforts, was to reduce the prevalence and incidence of STIs in Bangkok which, in turn, would help slow the spread of HIV infection in the city. As with the public sector subproject with the BMA, a needs assessment was conducted with a selection of private clinic physicians in Bangkok. Only clinics with 5 or more STI patients per week were included in the study and the intervention. Two hundred and three (203) out of 247 clinics identified in the Community Mobilization subproject (described above) were visited for the baseline assessment; the majority of the respondents (96%) were doctors, mostly general practitioners and worked in joint clinics (43%), solo clinics (33%) or polyclinics/hospitals (14%), Only 8% were STI specialists and men outnumbered women. Many of the respondents (56%) worked in both the public and private clinics. The remaining 44% worked only at their private clinics. A majority of the respondents provided services to one to nine STI cases per week. Nearly half (47%) stated their willingness to join the subproject's training, while 26% of the respondents were uncertain, and nearly 27% said that they were not ready to participate. A baseline survey was conducted to assess STI management in the STI clinics and to assess needs and appropriate timing for training. Nearly 74% of these clinics reported having microscopes available in their clinics and 78% provided VDRL diagnosis, 41% RPR, and 38% performed both RPR and VDRL; 54% offered wet mount service; 67% had gram-stain capability and 68% reported providing HIV screening. Over 90% of the respondents had ever provided condoms to their patients and on a selective basis. One-fifth of these clinics reported of ever having had condom stockouts in the previous year. The majority of practitioners provided 3-6 pieces of condoms for those patients receiving them. Two-thirds said they charged the patients for the condoms. [Only clinics with five or more STI patients were included in this assessment.] Of these, 64% reported having 5-19 STI cases per week. The range of STIs seen in these clinics include non-gonococcal infection (reported by 90%), gonococcal infection (74%), genital warts (56%), genital herpes (54%), chancroid (34%) and syphilis (31%). 90% of the interviewed practitioners performed history taking with all patients; 81% collected information on sexual contacts with every client. 70% of the respondents performed a genital exam with every STI client. The survey shows that practitioners used both syndromic and etiological diagnosis. One-third of respondents base treatment on both syndromic and laboratory results while only one-fifth base treatment on either laboratory or symptoms alone. The respondents were asked to describe the drug of choice for each STI as well as dose and duration of treatment. The results were evaluated as (1) correct recommended dose, (2) partially correct dose and (3) incorrect dose. The percent who could give correct answers on types of medicine and doses for treatment are as follows:
The average numbers of days for syphilis case follow-up is 17; 8 days for chancroid, 5 days for gonorrhea, and 8 days for non-gonococcal urethritis. Normally, private clinic physicians scheduled follow-up visits at one week intervals. Ninety-seven percent (97%) suggested that their clients bring their partners in for checkup; 95% recommended taking the complete dose of medicine, 92% recommended that sex partners take the same medicine as the clients and 85% recommended using condoms. The majority of the respondents (73.3%) stated their interest in participating in the training. In addition, most wanted to have the training held on Saturday or Sunday morning, and in Bangkok. To address remaining service gaps, the TMS-STD and PATH designed a subproject to achieve the following outputs: (1) The STI training course developed in this subproject for private practitioners in Bangkok would be institutionalized within the TMS-STD. The TMS-STD would offer this workshop in their annual schedule of courses to all private practitioners in Bangkok. (2) At least 50% of private physicians who practice in Phase I Zone districts and who see five or more STI patients during the average week would be trained through this subproject. (3) A reproduction and distribution system for patient educational material on STI/HIV would be established and operational. (4) A condom distribution system would be established. (5) A partner referral system would be established with a target of 50% of primary partners of index patients being referred and treated. (6) An HIV testing and counseling referral network would be established with a target of 70% of STI patients to be referred for HIV counseling. An independent agency was contracted to evaluate the performance of the subproject using mail-back rapid survey for all clinics, personal interviews with 80 private practitioners and two focus group sessions with five physicians each. The following is excerpted from the evaluation team report: The follow-up survey on STI diagnosis of the private practitioners was evaluated according to the standard flow chart endorsed by AIDSCAP. The question on history taking for both male and female clients was asked as an open question in order to elicit private physician practices in assessing clients' risk behavior for STI. For male clients presenting with genital discharge, 78% of the clinics with a laboratory would perform urethral gram stain to all patients. If IGND was found, two-thirds (66.7%) would treat both GC and NGU. In case of a positive IGND but WBC count of more than or equal to 5/oil field, 81.6% of the respondents claimed to treat only NGU. If the clinics did not have a laboratory, 87% would treat both GC and NGU when a male clients presented with a thick purulent urethral discharge. For female clients having a profuse watery vaginal discharge, the clinics with a laboratory would perform a vaginal wet mount and cervical gram stain for all clients, 79% and 71% respectively. If IGND was found, 82% of the respondents would treat both GC and NGU. In the case that IGND was not found but the patient's partner recently had a urethral discharge, they would treat only NGU (88%). For those clinics without a laboratory, when a female client complained of profuse watery vaginal discharge and had a risk history of STI, 87% of the respondents claimed that treatment for both GC and NGU is performed. In focus groups, the majority of the doctors agreed on the concept of blanket treatment for both GC and NGU, but this must be based on the clients' economic status as well. The results from the follow-up survey indicated that the percentage of correct answers increased significantly for gonorrhea and non-gonococcal urethritis but decreased primary syphilis. One-fifth listed incorrect treatment for herpes. Reasons for giving wrong answers on the drug of choice in the follow-up survey could be that there were differences in diagnosing severity of the diseases among respondents. For example, the treatment of herpes varies by stage of the disease. Also, some doctors did not accept all STI cases but would refer to other clinics, for example in the case of syphilis. Even though the doctors participating in this subproject felt the HIV/AIDS counseling was very useful, in practice, they could not provide this service. The study found that 19% of the respondents reported having no cases for whom the service could be provided. The main obstacle faced was time limitation of the doctors (44%). Results from the qualitative study suggests that time limitations discouraged private clinics from providing counseling. Sometimes the patients themselves were the constraint in that they would not want to spend the time to talk with the doctors. The private physicians also complain that providing the counseling service was tiring with no financial return. The response rate of the forms (STI tally sheet, partner notification form, and counseling referral card) distributed to the participating practitioners was low. Approximately 65% of the respondents reported not using them. Therefore, the reporting system as well as an attempt to follow-up the STI clients was not successful. Major reasons for not using these forms was lack of time and lack of cases. The practitioners found that the flow chart had very useful information, but in practice, most did not use it with their clients. The flow chart was more used in polyclinic settings where doctors work in shifts. Some doctors who did not attend the training could review an study the flow chart themselves. Major problems found during the subproject implementation can be summarized as follows:
C. Accomplishments and Constraints STI Strengthening in the Public, Private and Commercial Sectors (continued) Conclusion: Private Clinic Intervention In order to strengthen private STI clinic services in Bangkok, two training courses on STI case management and HIV/AIDS counseling were developed and delivered along with new reporting and referral systems. The half day refresher courses were well received and showed some impact in pre- and post-test scores. However, the attempt to add new activities to the clinic operations unrelated to income generation were not successful. Reported treatment practices were generally good but a planned mystery shopper assessment to confirm self-reports was rejected by the subproject technical advisory committee as being "unethical". Clinic materials (such as treatment guideline flip charts and flow charts) were well received by the participants but little used in practice. Materials for distribution such as His and Hers STI pamphlets and condoms were also distributed to STI patients. STI caseloads were lower than expected despite the fact that it is generally assumed that more STI patients seek medical treatment at private clinics rather than government outlets. In an atmosphere of declining STI caseloads, it is difficult to mobilize the private sector to become actively involved in STI case management and counseling. This subproject was not able to recruit the targeted number of STI clinics primarily because many clinics had closed (presumably due to the plummeting STI prevalence in the country) and because of the small numbers of caseloads in clinics which still treat STIs. Nevertheless, the subproject did engage a sizable number of clinic staff and met its service objectives in a reasonable manner. Concise, half-day training on weekends is about the maximum that is feasible with cost-conscious private practitioners. Additional services which don't have an immediate impact on clinic revenue are unlikely to succeed however. Hence, referral cards, service statistics forms, and counseling were not well accepted by private practitioners in Bangkok. However, as approved therapies for HIV become more effective and affordable, it can be expected that there will be a resurgence of private clinic activity related to HIV and STI. At that time, integrated STI and HIV treatment networking and training should receive extensive interest among the private clinic practitioners in Bangkok. Perhaps the most important STI service site in any comprehensive prevention program is the pharmacy. For example, the results of caseload surveys of pharmacists, private clinics and BMA STD service outlets centers, the AIDSCAP Thailand office estimated that slightly over half of STI treatment encounters occur at drug stores. A semiformal association of pharmacists in Chiang Mai city (northern Thailand) had pioneered a subproject to improve over-the-counter contraceptive prescribing practices. This group was also contracted by AIDSCAP to develop communication materials, a newsletter and training package for drug sellers on STI and HIV/AIDS. The experience of the AIDSCAP-funded Chiang Mai version of this subproject is summarized below. However, it should be noted that the European Community funded the replication of this model for drugstores in Bangkok as one contribution to the Bangkok Fights AIDS effort of the BMA. The assessment of pharmacists and drug sellers in relation to STI drugs yielded the following results: There are 256 drugstores in the province of Chiang Mai which sell modern medicine. Of these, 149 drugstores are licensed to sell prescription medicines because they are owned by a registered pharmacist (78 stores), or have a pharmacist managing them (71 stores). The remaining 107 drugstores which sell modern medicines sell only over-the-counter (prepackaged) medication. Such stores are mostly managed by a nurse or by those who have passed a training conducted by the Thai Ministry of Public Health. Most of these drugstores open at about 8:00 a.m. and close around 10:00 p.m. The personnel in the drugstores owned by a pharmacist usually consists of the owner, the owner's immediate family members, and 1 to 4 additional employees. The drugstores which are not owned by a pharmacist usually hire a pharmacist to oversee the selling and dispensing and use pharmacy students as sales personnel. Services are aimed at facilitating a sale. For example, sellers ask customers for their preferred brand and show the product. Some drugstores ask for symptoms before selling any medicine, however, this was not a common practice. Based on standards set in the STI Medical Handbook (Dr. Anupong Chitvarakorn et al, 1993), the survey revealed:
Small group discussions were held for in-depth analysis of the different problems faced by sellers. The discussions also generated solutions which would be easily applicable. The results are summarized below:
PATH/Thailand provided key technical assistance to this subproject and also conducted a project evaluation. Excerpts from the evaluation report are as follows: The official and unofficial meetings and discussions of the subproject provided a framework in which the participants could offer their numerous ideas and views. These views could then be gathered as data and used in the summary of the various problems present. This then allowed for the solution of these problems as part of the improvement of the medication services of drugstore personnel. The activities of this subproject that were carried out by the participants provided a good working relationship between the members of the Chiang Mai Pharmacist Club and the Chiang Mai Drugstore Club. This relationship proved useful for the overall improvement of drugstore medication services and will be beneficial for future projects involving the members of these two groups. This subproject gave the participants of all professional levels the opportunity to get some practical experience with improving one's own potential throughout the length of the training process as well as for the future. The general role and the public relations capabilities of the pharmacists with the public were expanded as a result of this subproject. The inclusion of pharmacy students in the activities of this subproject allowed the students to get firsthand information about the current drugstore situation. It also provided the students with a base of knowledge upon which they can also strive for self-improvement when the time comes for them to become active pharmacists or drugstore personnel. Conclusion: Pharmacy Intervention This subproject addressed the importance of the drugstore sector in the overall health care system. Results show that given proper education, drugstore personnel develop responsible attitudes about their role. Drugstore personnel are very diverse, and consequently different methods are required in training them. These methods must be based on respect for their views and a belief in their capability to contribute to their own development. Inviting the pharmacy students to participate in this subproject gave them firsthand experience. This experience will be helpful to developing a future generation of responsible drugstores committed to provide appropriate and safe medications. The subproject design is replicable and could be used to cover other themes. For example, improving AIDS counseling services could be one such topic. Various aspects that would be covered are:
The subproject can be conducted in other settings. Appropriate baseline research must be conducted. To replicate it in a large city such as Bangkok would require consideration of the habits and types of drugstore customers, the characteristic levels of education, the pace of life, travel limitations and all other things which have some bearing on the drugstore situation. One approach would be to have a small scale subproject. Behavior Change Communication in the Worksite, Community and Home Behavior change communication (BCC) in the BFA Program encompassed interpersonal communication through outreach, mass communication and public relations. The vast majority of AIDSCAP BCC resources funded outreach. In retrospect it seemed like a daunting task to reach a critical mass of the Bangkok target population of 1.5 million men and women age 15 to 29 with enough interpersonal communication necessary to achieve sustained low risk behavior. Diffusion theory suggests that 15% to 20% across the range of a socially-linked community need be reached in order for messages and perceived norms to spread to all or most of a target audience (Kegeles et al.) That is equivalent to reaching between 200,000 and 300,000 persons with small group or individual communication -- much larger than the target populations of any published reports of prevention interventions through interpersonal communication in any single program. In late 1992, after the launch of the Community Mobilization Project, the designers of the AIDSCAP Thailand program were absorbed with the task of mounting an outreach offensive on the streets and in slum communities of Bangkok to begin the process of personalizing the risk for HIV. At this time, HIV was found in 3.3% of young men and 1.2% of young, married women in Bangkok. Given the enormous size of the target population the challenge was to identify enough technical agencies that could carry out the formidable task of recruiting, training and overseeing a small army of outreach workers. The solution was a consortium of NGO, university and BMA agencies -- each responsible for a different segment of the lower income Bangkok population, 15 to 49. To simplify the case somewhat, the target populations for outreach fell into four groups:
The following presents highlights of the implementation of each of these outreach subprojects. Outreach to Commercial Sex Workers Staff of the Health Department of the BMA had been conducting sporadic outreach education for Bangkok CSWs when AIDSCAP began. However, the BMA felt that this component needed to be revitalized, especially in view of the related STI strengthening subproject (described earlier). A strong BCC component was needed to encourage CSWs to visit the "new and improved" BMA network of STI clinics. Prior to the subproject implementation, the implementers reviewed existing formative research and conducted a limited number of focus group discussions with Bangkok CSWs. The purpose of the study was to give the CSWs an opportunity to express their view of obstacles to risk reduction, attitudes toward health care services and their preferences for new BCC materials. Key findings from the formative data collection are briefly noted as follows: Some CSWs do not use condoms with every customer especially when:
CSWs still have misconceptions about proper prevention, for example:
CSWs were bored with the repetitiveness of the AIDS communication materials used by health staff and tired of being lectured to and bled so often. The objective of this activity was to find ways to correct the above shortcomings and help CSWs protect themselves from HIV more completely. AIDSCAP encouraged the BMA to create a technical working group (TWG) with staff from the BMA, AIDSCAP and communication specialists. This working group would conduct the planning and provide technical oversight for all phases of the subproject and was seen by AIDSCAP as an essential ingredient for successful implementation. Staff from 60 health centers and health officers from 38 district offices were recruited for the outreach education teams. Each outreach team consisted of two nurse health educators, one health officer from the district, and a driver. Each team was responsible for conducting three rounds of outreach education sessions in at least eight establishments in their zone. Two meetings with CSE owners were held in order to obtain input, support and cooperation from the owners and managers of the establishments. The first meeting was held in January, 1994 with a group of CSE owner representatives. Senior BMA level officials joined in the sessions. Some of the issues that emerged from the participants in this meeting include the following:
A one-day training workshop for the outreach teams was conducted before each round of the outreach education. The curriculum included details on the latest information of STIs and AIDS, communication techniques and skills development. New BCC materials were developed for each round of outreach. These included an anatomy model (to help explain contraception and STI/HIV transmission); a 6-part video drama; and a flip chart. Posters with new themes and a photonovella were also produced as part of this subproject. Each outreach team was given specific training in the use of these materials. A total of 120 health educators from 60 health centers and 60 staff from the local district office from all 38 districts participated in the training. The three rounds of outreach education were carried out mostly during 1994 with two months in between each round. After the second round of outreach education, the outreach team recruited certain CSWs, touts and establishment managers, who were enthusiastic and appeared to be good educators, to become "peer educators". The peer educators were invited for a training on STIs and AIDS which emphasized misconceptions of CSWs about HIV/AIDS, and encouraged them to be key informants and helpers to their peers. Altogether 329 peer educators were recruited into this activity. To evaluate the outreach activity, the BCC TWG interviewed CSWs, CSE owners, and health educators, and observed outreach sessions. Figure 2 presents the PIF data over the subproject period compared with trends in risk behavior from the BSS. Narrative results of the evaluation are briefly summarized as follows: In general, the respondents agreed that this outreach education subproject was a beneficial activity which used new approaches that were appropriate for their needs. All education materials developed and produced for the subproject attracted considerable interest. The anatomy models and the dramatized video were the most popular media (and have been distributed to similar programs in other parts of Thailand and other countries in Asia). A majority of the health educators agreed that having training prior to the outreach activity helped them in exchanging ideas and preparing for the sessions. Each group of respondents agreed that conducting the outreach activity in the CSEs on a continuous basis is appropriate. One round every four to six months is optimal. Figure 2: Bangkok Fights AIDS -- CSW Outreach Activity and Condom Use Among Indirect CSWs Over Time
A "direct" CSW refers to a brothel worker; "indirect" refers to nightclub hostess or massage parlor workers who may negotiate sex for sale in addition to their non-sex services. Major constraints found during the implementation of the outreach activity can be summarized as follows: (1) inadequate understanding and support from supervisors of the outreach team members; (2) inadequate coordination between outreach team members (who came from different BMA offices); (3) too frequent changes in outreach team members during the subproject implementation which disrupted continuity and adequate understanding of the activities; (4) inadequate cooperation from some CSE owners; (5) high mobility of CSWs disrupted peer recruitment and opportunities for education reinforcement; (6) limited numbers of the anatomy models led to delays in implementing outreach; and (7) inadequate travel compensation for outreach team members who had to return home late in the evening. Conclusions: CSW/CSE Outreach Intervention Lessons from this outreach activity include the following:
Recommendations for future activities are as follows;
Outreach to Married Women and Adolescents in Low-Income Communities The outreach to Bangkok CSEs and CSWs described above is different from all other outreach subprojects in the Bangkok Fights AIDS Program in one important way. While the BMA relied on existing government staff to conduct outreach after routine government work hours, the other outreach subprojects employed full-time, salaried outreach workers. This difference has important implications for budget, sustainability and flexibility in reaching diverse and mobile populations. Two subprojects funded by AIDSCAP attempted to reach women and adolescents in low-income communities. The highlights of those subprojects are described next. The "Low Income Outreach Subproject" of the BFA targeted 100 of Bangkok's 1,000 low-income communities. The implementing agency was the Planned Parenthood Association of Thailand (PPAT). The subproject aimed to support the general BFA goal in three ways: (a) reduced risk behavior through interpersonal communication with trained outreach workers and through peer-based information dissemination; (b) increased condom use; and (c) increased accurate self-risk perception. Population surveys were conducted at the beginning and toward the end of the subproject period which describe the target population in terms of process and outcome indicators. The outreach workers (OWs) convened 374 group discussions in 85 communities with about 6,000 persons. Information from these sessions helped explore in greater depth why some people engage in risk behavior while others do not. The task of the OWs was to reach an estimated total of 16,000 male and female slum dwellers aged 15 to 29 through small group sessions and home visits. Another 9,000 persons were expected to be reached by peers and local agents recruited by the subproject. To help with these tasks, the OWs recruited approximately eight indigenous AIDS resource persons in each community. In addition, the subproject staff informed persons in the subproject area about the subproject by site/home visits. In all, subproject field workers made a total number of 564 visits in 100 communities reaching 5,550 persons with BCC interactions. OWs conducted interpersonal discussions on self-risk perception, how to reduce risk behavior, STI-related issues and sex-decision making. These activities were conducted in 90 communities with a total of 1,752 participants. To spark wider interest, innovative approaches were used to convey risk messages. A number of "AIDS Campaign in Low Income Communities" fairs were staged which included slogan competition, plays, and quizzes. A total of 58 campaigns were held in 58 communities reaching 3,392 persons. World Vision Relief and Development implemented a more intensive outreach subproject under the "Bangkok Fights AIDS" banner in 43 low-income communities over a period of three years. This subproject was funded under the PVO competitive grants program of AIDSCAP/HQ. The subproject targeted adolescents and young mothers (age 15 to 29) and used a similar, comprehensive approach that was being implementing under the BFA. This subproject reprinted materials used by other BCC subprojects of the BFA and worked more closely with the local District AIDS Committee than any other of the BFA subprojects. Figure 3 shows the combined output data for these two projects and results from pre-test, posttest behavioral surveys in some of the low-income communities. Figure 3: Bangkok Fights AIDS -- BCC outreach among low-income community residents and condom use over time
Conclusion: Outreach to Community-based Wives and Adolescents Some of the lessons from these two subprojects of the BFA Program are as follows:
Outreach to Wage Laborers in Large, Formal Worksites Over the past decade Thailand has become an increasingly popular site for international manufacturers. Hundreds of thousands of Thailand's relatively well-educated men and women work on assembly lines in and around Bangkok producing the full range of consumer or industrial products, from cars to computers and ships to shoes. Behavioral research conducted by ICRW has poignantly described the vulnerability of factory workers, especially young women, to casual relationships that carry with them the risk for HIV (see Cash in References annex). For prevention interventions, large factories offer the advantage of providing convenient access to a large number of the target population -- when they get off work. In the family of BFA interventions, the Factory Outreach subproject of the Asian Institute for Health Development (AIHD) was unique in that it mobilized the Thai version of the US Peace Corps, to recruit and train BA graduate volunteers to serve the development goals of the country by providing AIDS outreach to lower income Bangkok factory workers age 15 to 29. A total of 45 volunteers signed up for 18-month service and were given three weeks training in the principles of HIV/AIDS, BCC, group dynamics, planning and evaluation. The subproject managers selected the largest factories that could be easily accessed through cooperation with the DACs. The chief of the local BMA health center (also a DAC member) served as an intermediate gatekeeper for the outreach teams to gain access to the factory populations. Factories in Bangkok do not generally allow access to the work force because of potential disruption to productivity and concern about labor organizing activities (only 5% of the Thai labor force was unionized at the beginning of the BFA Program.) A target of 25,000 male and female factory workers was arrived at after identifying appropriate sites and gaining up-to-date data on the work force. The graduate volunteers were divided into coed teams of three to four individuals. Each team was deployed at a particular factory for a period of four months. Large group orientation of the work force was followed by small group sessions (10 to 20 persons) over a one-week period for each group. Time during lunch hour was used to conduct these sessions. From their closer interaction with factory workers, the graduate volunteers were able to identify candidates for more intensive training as peer educators. Once all peers were trained, the outreach team could move on to a new factory. Although the formal time with the target audience was limited to a brief period each day, the outreach teams had extensive informal contact before and after factory hours. Indeed, in some cases the graduate volunteers were so well-accepted by management that they were allowed to join the assembly line and, in this way, have more in-depth exchange with the target population. This approach to outreach was unique among the outreach subprojects of the BFA Program in that the OWs immersed themselves in the workers' lifestyle and work environment. They were able to establish a high level of trust an rapport with the target but had more limited reach of the total factory worker population in Bangkok. However, because of the large budget of the project, the AIDSCAP Thailand Country Program Office requested a cost-effectiveness analysis of this subproject. Accordingly, the AIDSCAP/HQ commissioned a study which concluded that the recurrent cost per worker reached was $12. In addition, if the outreach was 100% successful in preventing future infection then the benefit of investing in the outreach education is about 10 times greater than the cost over a ten-year period. The difficulty in interpreting this analysis however is that it is not possible to know how effective an outreach interaction is on average -- in most cases, the value is probably considerably less than 100%. To evaluate other aspects of the subproject, a variety of methods were used. In addition to the PIF data, baseline and follow-up surveys were conducted by the subproject staff. All 45 outreach workers kept personal diaries which describe their daily interactions with the target audience and the changes that occurred over the course of the subproject. Some of the key results of the pre- and post-surveys as conducted by AIHD are presented in Table 2 below. Table 2: Selected Results of Baseline and Follow-up Surveys, Factory Outreach Subproject
The tabular data show improvements in risk reduction across a range of options including reduced sex networking and increased condom use among male factory workers. Data from the diaries of outreach workers also provide interesting insights into how female factory workers were changing in response to the outreach team efforts. Excerpts from these October 1993 personal accounts are presented below: Miss "M"
Mrs."K"
Miss "G"
Outreach to Wage Laborers in Small and Informal Worksites The largest subproject of all interventions in the BFA was the Service Workers Outreach subproject (SWOP). Although workers in large factories may outnumber those in smaller Bangkok worksites, wage laborers in small and informal worksites present a much greater outreach challenge. Motorcycle taxi driver, gas station attendant, restaurant waiter and waitress, bus conductor, construction site worker -- these occupations attract a constant stream of migrant Thai labor from throughout the country. Since these jobs require little formal training, turnover of the work force is high and the educational level is lower than for those in the large factories. Nor is there any real structure to provide services to this disparate group of itinerant young men and women. Street-based outreach at the site of employment was the only way feasible to engage these persons in some dialogue about HIV risk and safer sex options. For this task, a consortium of street-smart NGOs was formed from some of the most experience of Bangkok service organizations: ACCESS, UDF, CLIST, TAVS and TRRM. PATH/Thailand provided close BCC technical assistance to this and the Factory Outreach subproject described above since many elements of the training and communication strategies were the same. As with the Factory Outreach Subproject, SWOP recruited full-time outreach workers to canvass the worksites and train peer educators. SWOP was conducted in two phases: first in the six Phase I Zone districts and then expanded to cover most of Bangkok. The 54 full-time outreach workers reached an enormous number of highly mobile Bangkok wage-labor service workers. Over 2,700 men and women were trained as peers, and 80,000 workers were reached through interpersonal communication. Nearly one-half million educational materials were distributed and 350,000 condoms were distributed free. One of the more unique outputs of this project were the co-gender handbooks that were produced for the outreach workers ("The Male Formula for Love" and "Women DO Know How to Love"). In straight language, with colorful illustrations, these manuals explained sex decisions from the man's and woman's perspective, pointing out the different motivations each may have for intimacy and step-by-step instructions on how to skillfully negotiate sex (or abstinence) on one's own terms. These booklets epitomize the BCC approach to interpersonal communication used in the BFA Program: (1) comparable emphasis on men and women, (2) consideration of risk behavior from the perspective of the target audience, (3) exploration of a range of low-risk options, (4) skills building to help apply a self-selected option. . Country Program Description C. Accomplishments and Constraints STI Strengthening in the Public, Private and Commercial Sectors (continued) Conclusion: Private Clinic Intervention In order to strengthen private STI clinic services in Bangkok, two training courses on STI case management and HIV/AIDS counseling were developed and delivered along with new reporting and referral systems. The half day refresher courses were well received and showed some impact in pre- and post-test scores. However, the attempt to add new activities to the clinic operations unrelated to income generation were not successful. Reported treatment practices were generally good but a planned mystery shopper assessment to confirm self-reports was rejected by the subproject technical advisory committee as being "unethical". Clinic materials (such as treatment guideline flip charts and flow charts) were well received by the participants but little used in practice. Materials for distribution such as His and Hers STI pamphlets and condoms were also distributed to STI patients. STI caseloads were lower than expected despite the fact that it is generally assumed that more STI patients seek medical treatment at private clinics rather than government outlets. In an atmosphere of declining STI caseloads, it is difficult to mobilize the private sector to become actively involved in STI case management and counseling. This subproject was not able to recruit the targeted number of STI clinics primarily because many clinics had closed (presumably due to the plummeting STI prevalence in the country) and because of the small numbers of caseloads in clinics which still treat STIs. Nevertheless, the subproject did engage a sizable number of clinic staff and met its service objectives in a reasonable manner. Concise, half-day training on weekends is about the maximum that is feasible with cost-conscious private practitioners. Additional services which don't have an immediate impact on clinic revenue are unlikely to succeed however. Hence, referral cards, service statistics forms, and counseling were not well accepted by private practitioners in Bangkok. However, as approved therapies for HIV become more effective and affordable, it can be expected that there will be a resurgence of private clinic activity related to HIV and STI. At that time, integrated STI and HIV treatment networking and training should receive extensive interest among the private clinic practitioners in Bangkok. Perhaps the most important STI service site in any comprehensive prevention program is the pharmacy. For example, the results of caseload surveys of pharmacists, private clinics and BMA STD service outlets centers, the AIDSCAP Thailand office estimated that slightly over half of STI treatment encounters occur at drug stores. A semiformal association of pharmacists in Chiang Mai city (northern Thailand) had pioneered a subproject to improve over-the-counter contraceptive prescribing practices. This group was also contracted by AIDSCAP to develop communication materials, a newsletter and training package for drug sellers on STI and HIV/AIDS. The experience of the AIDSCAP-funded Chiang Mai version of this subproject is summarized below. However, it should be noted that the European Community funded the replication of this model for drugstores in Bangkok as one contribution to the Bangkok Fights AIDS effort of the BMA. The assessment of pharmacists and drug sellers in relation to STI drugs yielded the following results: There are 256 drugstores in the province of Chiang Mai which sell modern medicine. Of these, 149 drugstores are licensed to sell prescription medicines because they are owned by a registered pharmacist (78 stores), or have a pharmacist managing them (71 stores). The remaining 107 drugstores which sell modern medicines sell only over-the-counter (prepackaged) medication. Such stores are mostly managed by a nurse or by those who have passed a training conducted by the Thai Ministry of Public Health. Most of these drugstores open at about 8:00 a.m. and close around 10:00 p.m. The personnel in the drugstores owned by a pharmacist usually consists of the owner, the owner's immediate family members, and 1 to 4 additional employees. The drugstores which are not owned by a pharmacist usually hire a pharmacist to oversee the selling and dispensing and use pharmacy students as sales personnel. Services are aimed at facilitating a sale. For example, sellers ask customers for their preferred brand and show the product. Some drugstores ask for symptoms before selling any medicine, however, this was not a common practice. Based on standards set in the STI Medical Handbook (Dr. Anupong Chitvarakorn et al, 1993), the survey revealed:
Small group discussions were held for in-depth analysis of the different problems faced by sellers. The discussions also generated solutions which would be easily applicable. The results are summarized below:
PATH/Thailand provided key technical assistance to this subproject and also conducted a project evaluation. Excerpts from the evaluation report are as follows: The official and unofficial meetings and discussions of the subproject provided a framework in which the participants could offer their numerous ideas and views. These views could then be gathered as data and used in the summary of the various problems present. This then allowed for the solution of these problems as part of the improvement of the medication services of drugstore personnel. The activities of this subproject that were carried out by the participants provided a good working relationship between the members of the Chiang Mai Pharmacist Club and the Chiang Mai Drugstore Club. This relationship proved useful for the overall improvement of drugstore medication services and will be beneficial for future projects involving the members of these two groups. This subproject gave the participants of all professional levels the opportunity to get some practical experience with improving one's own potential throughout the length of the training process as well as for the future. The general role and the public relations capabilities of the pharmacists with the public were expanded as a result of this subproject. The inclusion of pharmacy students in the activities of this subproject allowed the students to get firsthand information about the current drugstore situation. It also provided the students with a base of knowledge upon which they can also strive for self-improvement when the time comes for them to become active pharmacists or drugstore personnel. Conclusion: Pharmacy Intervention This subproject addressed the importance of the drugstore sector in the overall health care system. Results show that given proper education, drugstore personnel develop responsible attitudes about their role. Drugstore personnel are very diverse, and consequently different methods are required in training them. These methods must be based on respect for their views and a belief in their capability to contribute to their own development. Inviting the pharmacy students to participate in this subproject gave them firsthand experience. This experience will be helpful to developing a future generation of responsible drugstores committed to provide appropriate and safe medications. The subproject design is replicable and could be used to cover other themes. For example, improving AIDS counseling services could be one such topic. Various aspects that would be covered are:
The subproject can be conducted in other settings. Appropriate baseline research must be conducted. To replicate it in a large city such as Bangkok would require consideration of the habits and types of drugstore customers, the characteristic levels of education, the pace of life, travel limitations and all other things which have some bearing on the drugstore situation. One approach would be to have a small scale subproject. Behavior Change Communication in the Worksite, Community and Home Behavior change communication (BCC) in the BFA Program encompassed interpersonal communication through outreach, mass communication and public relations. The vast majority of AIDSCAP BCC resources funded outreach. In retrospect it seemed like a daunting task to reach a critical mass of the Bangkok target population of 1.5 million men and women age 15 to 29 with enough interpersonal communication necessary to achieve sustained low risk behavior. Diffusion theory suggests that 15% to 20% across the range of a socially-linked community need be reached in order for messages and perceived norms to spread to all or most of a target audience (Kegeles et al.) That is equivalent to reaching between 200,000 and 300,000 persons with small group or individual communication -- much larger than the target populations of any published reports of prevention interventions through interpersonal communication in any single program. In late 1992, after the launch of the Community Mobilization Project, the designers of the AIDSCAP Thailand program were absorbed with the task of mounting an outreach offensive on the streets and in slum communities of Bangkok to begin the process of personalizing the risk for HIV. At this time, HIV was found in 3.3% of young men and 1.2% of young, married women in Bangkok. Given the enormous size of the target population the challenge was to identify enough technical agencies that could carry out the formidable task of recruiting, training and overseeing a small army of outreach workers. The solution was a consortium of NGO, university and BMA agencies -- each responsible for a different segment of the lower income Bangkok population, 15 to 49. To simplify the case somewhat, the target populations for outreach fell into four groups:
The following presents highlights of the implementation of each of these outreach subprojects. Outreach to Commercial Sex Workers Staff of the Health Department of the BMA had been conducting sporadic outreach education for Bangkok CSWs when AIDSCAP began. However, the BMA felt that this component needed to be revitalized, especially in view of the related STI strengthening subproject (described earlier). A strong BCC component was needed to encourage CSWs to visit the "new and improved" BMA network of STI clinics. Prior to the subproject implementation, the implementers reviewed existing formative research and conducted a limited number of focus group discussions with Bangkok CSWs. The purpose of the study was to give the CSWs an opportunity to express their view of obstacles to risk reduction, attitudes toward health care services and their preferences for new BCC materials. Key findings from the formative data collection are briefly noted as follows: Some CSWs do not use condoms with every customer especially when:
CSWs still have misconceptions about proper prevention, for example:
CSWs were bored with the repetitiveness of the AIDS communication materials used by health staff and tired of being lectured to and bled so often. The objective of this activity was to find ways to correct the above shortcomings and help CSWs protect themselves from HIV more completely. AIDSCAP encouraged the BMA to create a technical working group (TWG) with staff from the BMA, AIDSCAP and communication specialists. This working group would conduct the planning and provide technical oversight for all phases of the subproject and was seen by AIDSCAP as an essential ingredient for successful implementation. Staff from 60 health centers and health officers from 38 district offices were recruited for the outreach education teams. Each outreach team consisted of two nurse health educators, one health officer from the district, and a driver. Each team was responsible for conducting three rounds of outreach education sessions in at least eight establishments in their zone. Two meetings with CSE owners were held in order to obtain input, support and cooperation from the owners and managers of the establishments. The first meeting was held in January, 1994 with a group of CSE owner representatives. Senior BMA level officials joined in the sessions. Some of the issues that emerged from the participants in this meeting include the following:
A one-day training workshop for the outreach teams was conducted before each round of the outreach education. The curriculum included details on the latest information of STIs and AIDS, communication techniques and skills development. New BCC materials were developed for each round of outreach. These included an anatomy model (to help explain contraception and STI/HIV transmission); a 6-part video drama; and a flip chart. Posters with new themes and a photonovella were also produced as part of this subproject. Each outreach team was given specific training in the use of these materials. A total of 120 health educators from 60 health centers and 60 staff from the local district office from all 38 districts participated in the training. The three rounds of outreach education were carried out mostly during 1994 with two months in between each round. After the second round of outreach education, the outreach team recruited certain CSWs, touts and establishment managers, who were enthusiastic and appeared to be good educators, to become "peer educators". The peer educators were invited for a training on STIs and AIDS which emphasized misconceptions of CSWs about HIV/AIDS, and encouraged them to be key informants and helpers to their peers. Altogether 329 peer educators were recruited into this activity. To evaluate the outreach activity, the BCC TWG interviewed CSWs, CSE owners, and health educators, and observed outreach sessions. Figure 2 presents the PIF data over the subproject period compared with trends in risk behavior from the BSS. Narrative results of the evaluation are briefly summarized as follows: In general, the respondents agreed that this outreach education subproject was a beneficial activity which used new approaches that were appropriate for their needs. All education materials developed and produced for the subproject attracted considerable interest. The anatomy models and the dramatized video were the most popular media (and have been distributed to similar programs in other parts of Thailand and other countries in Asia). A majority of the health educators agreed that having training prior to the outreach activity helped them in exchanging ideas and preparing for the sessions. Each group of respondents agreed that conducting the outreach activity in the CSEs on a continuous basis is appropriate. One round every four to six months is optimal. Figure 2: Bangkok Fights AIDS -- CSW Outreach Activity and Condom Use Among Indirect CSWs Over Time
A "direct" CSW refers to a brothel worker; "indirect" refers to nightclub hostess or massage parlor workers who may negotiate sex for sale in addition to their non-sex services. Major constraints found during the implementation of the outreach activity can be summarized as follows: (1) inadequate understanding and support from supervisors of the outreach team members; (2) inadequate coordination between outreach team members (who came from different BMA offices); (3) too frequent changes in outreach team members during the subproject implementation which disrupted continuity and adequate understanding of the activities; (4) inadequate cooperation from some CSE owners; (5) high mobility of CSWs disrupted peer recruitment and opportunities for education reinforcement; (6) limited numbers of the anatomy models led to delays in implementing outreach; and (7) inadequate travel compensation for outreach team members who had to return home late in the evening. Conclusions: CSW/CSE Outreach Intervention Lessons from this outreach activity include the following:
Recommendations for future activities are as follows;
Outreach to Married Women and Adolescents in Low-Income Communities The outreach to Bangkok CSEs and CSWs described above is different from all other outreach subprojects in the Bangkok Fights AIDS Program in one important way. While the BMA relied on existing government staff to conduct outreach after routine government work hours, the other outreach subprojects employed full-time, salaried outreach workers. This difference has important implications for budget, sustainability and flexibility in reaching diverse and mobile populations. Two subprojects funded by AIDSCAP attempted to reach women and adolescents in low-income communities. The highlights of those subprojects are described next. The "Low Income Outreach Subproject" of the BFA targeted 100 of Bangkok's 1,000 low-income communities. The implementing agency was the Planned Parenthood Association of Thailand (PPAT). The subproject aimed to support the general BFA goal in three ways: (a) reduced risk behavior through interpersonal communication with trained outreach workers and through peer-based information dissemination; (b) increased condom use; and (c) increased accurate self-risk perception. Population surveys were conducted at the beginning and toward the end of the subproject period which describe the target population in terms of process and outcome indicators. The outreach workers (OWs) convened 374 group discussions in 85 communities with about 6,000 persons. Information from these sessions helped explore in greater depth why some people engage in risk behavior while others do not. The task of the OWs was to reach an estimated total of 16,000 male and female slum dwellers aged 15 to 29 through small group sessions and home visits. Another 9,000 persons were expected to be reached by peers and local agents recruited by the subproject. To help with these tasks, the OWs recruited approximately eight indigenous AIDS resource persons in each community. In addition, the subproject staff informed persons in the subproject area about the subproject by site/home visits. In all, subproject field workers made a total number of 564 visits in 100 communities reaching 5,550 persons with BCC interactions. OWs conducted interpersonal discussions on self-risk perception, how to reduce risk behavior, STI-related issues and sex-decision making. These activities were conducted in 90 communities with a total of 1,752 participants. To spark wider interest, innovative approaches were used to convey risk messages. A number of "AIDS Campaign in Low Income Communities" fairs were staged which included slogan competition, plays, and quizzes. A total of 58 campaigns were held in 58 communities reaching 3,392 persons. World Vision Relief and Development implemented a more intensive outreach subproject under the "Bangkok Fights AIDS" banner in 43 low-income communities over a period of three years. This subproject was funded under the PVO competitive grants program of AIDSCAP/HQ. The subproject targeted adolescents and young mothers (age 15 to 29) and used a similar, comprehensive approach that was being implementing under the BFA. This subproject reprinted materials used by other BCC subprojects of the BFA and worked more closely with the local District AIDS Committee than any other of the BFA subprojects. Figure 3 shows the combined output data for these two projects and results from pre-test, posttest behavioral surveys in some of the low-income communities. Figure 3: Bangkok Fights AIDS -- BCC outreach among low-income community residents and condom use over time
Conclusion: Outreach to Community-based Wives and Adolescents Some of the lessons from these two subprojects of the BFA Program are as follows:
Outreach to Wage Laborers in Large, Formal Worksites Over the past decade Thailand has become an increasingly popular site for international manufacturers. Hundreds of thousands of Thailand's relatively well-educated men and women work on assembly lines in and around Bangkok producing the full range of consumer or industrial products, from cars to computers and ships to shoes. Behavioral research conducted by ICRW has poignantly described the vulnerability of factory workers, especially young women, to casual relationships that carry with them the risk for HIV (see Cash in References annex). For prevention interventions, large factories offer the advantage of providing convenient access to a large number of the target population -- when they get off work. In the family of BFA interventions, the Factory Outreach subproject of the Asian Institute for Health Development (AIHD) was unique in that it mobilized the Thai version of the US Peace Corps, to recruit and train BA graduate volunteers to serve the development goals of the country by providing AIDS outreach to lower income Bangkok factory workers age 15 to 29. A total of 45 volunteers signed up for 18-month service and were given three weeks training in the principles of HIV/AIDS, BCC, group dynamics, planning and evaluation. The subproject managers selected the largest factories that could be easily accessed through cooperation with the DACs. The chief of the local BMA health center (also a DAC member) served as an intermediate gatekeeper for the outreach teams to gain access to the factory populations. Factories in Bangkok do not generally allow access to the work force because of potential disruption to productivity and concern about labor organizing activities (only 5% of the Thai labor force was unionized at the beginning of the BFA Program.) A target of 25,000 male and female factory workers was arrived at after identifying appropriate sites and gaining up-to-date data on the work force. The graduate volunteers were divided into coed teams of three to four individuals. Each team was deployed at a particular factory for a period of four months. Large group orientation of the work force was followed by small group sessions (10 to 20 persons) over a one-week period for each group. Time during lunch hour was used to conduct these sessions. From their closer interaction with factory workers, the graduate volunteers were able to identify candidates for more intensive training as peer educators. Once all peers were trained, the outreach team could move on to a new factory. Although the formal time with the target audience was limited to a brief period each day, the outreach teams had extensive informal contact before and after factory hours. Indeed, in some cases the graduate volunteers were so well-accepted by management that they were allowed to join the assembly line and, in this way, have more in-depth exchange with the target population. This approach to outreach was unique among the outreach subprojects of the BFA Program in that the OWs immersed themselves in the workers' lifestyle and work environment. They were able to establish a high level of trust an rapport with the target but had more limited reach of the total factory worker population in Bangkok. However, because of the large budget of the project, the AIDSCAP Thailand Country Program Office requested a cost-effectiveness analysis of this subproject. Accordingly, the AIDSCAP/HQ commissioned a study which concluded that the recurrent cost per worker reached was $12. In addition, if the outreach was 100% successful in preventing future infection then the benefit of investing in the outreach education is about 10 times greater than the cost over a ten-year period. The difficulty in interpreting this analysis however is that it is not possible to know how effective an outreach interaction is on average -- in most cases, the value is probably considerably less than 100%. To evaluate other aspects of the subproject, a variety of methods were used. In addition to the PIF data, baseline and follow-up surveys were conducted by the subproject staff. All 45 outreach workers kept personal diaries which describe their daily interactions with the target audience and the changes that occurred over the course of the subproject. Some of the key results of the pre- and post-surveys as conducted by AIHD are presented in Table 2 below. Table 2: Selected Results of Baseline and Follow-up Surveys, Factory Outreach Subproject
The tabular data show improvements in risk reduction across a range of options including reduced sex networking and increased condom use among male factory workers. Data from the diaries of outreach workers also provide interesting insights into how female factory workers were changing in response to the outreach team efforts. Excerpts from these October 1993 personal accounts are presented below: Miss "M"
Mrs."K"
Miss "G"
Outreach to Wage Laborers in Small and Informal Worksites The largest subproject of all interventions in the BFA was the Service Workers Outreach subproject (SWOP). Although workers in large factories may outnumber those in smaller Bangkok worksites, wage laborers in small and informal worksites present a much greater outreach challenge. Motorcycle taxi driver, gas station attendant, restaurant waiter and waitress, bus conductor, construction site worker -- these occupations attract a constant stream of migrant Thai labor from throughout the country. Since these jobs require little formal training, turnover of the work force is high and the educational level is lower than for those in the large factories. Nor is there any real structure to provide services to this disparate group of itinerant young men and women. Street-based outreach at the site of employment was the only way feasible to engage these persons in some dialogue about HIV risk and safer sex options. For this task, a consortium of street-smart NGOs was formed from some of the most experience of Bangkok service organizations: ACCESS, UDF, CLIST, TAVS and TRRM. PATH/Thailand provided close BCC technical assistance to this and the Factory Outreach subproject described above since many elements of the training and communication strategies were the same. As with the Factory Outreach Subproject, SWOP recruited full-time outreach workers to canvass the worksites and train peer educators. SWOP was conducted in two phases: first in the six Phase I Zone districts and then expanded to cover most of Bangkok. The 54 full-time outreach workers reached an enormous number of highly mobile Bangkok wage-labor service workers. Over 2,700 men and women were trained as peers, and 80,000 workers were reached through interpersonal communication. Nearly one-half million educational materials were distributed and 350,000 condoms were distributed free. One of the more unique outputs of this project were the co-gender handbooks that were produced for the outreach workers ("The Male Formula for Love" and "Women DO Know How to Love"). In straight language, with colorful illustrations, these manuals explained sex decisions from the man's and woman's perspective, pointing out the different motivations each may have for intimacy and step-by-step instructions on how to skillfully negotiate sex (or abstinence) on one's own terms. These booklets epitomize the BCC approach to interpersonal communication used in the BFA Program: (1) comparable emphasis on men and women, (2) consideration of risk behavior from the perspective of the target audience, (3) exploration of a range of low-risk options, (4) skills building to help apply a self-selected option. |
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