Global Health Communication
- • Promoting Digital Health Communication in Kenya
- • China CDC-Guangzhou Province Visits US CDC (Nov 08)
- • Lao PDR-Thailand Border – HIV/STI Prevention & Care (Aug 08)
- • Archive
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Spotlight: A Comprehensive Approach to HIV and STI Prevention and Care in a Cross Border Setting
The Lao People’s Democratic Republic (Lao PDR) is a low HIV prevalence country with high rates of sexually transmitted infection (STI), and it is surrounded by higher HIV prevalence countries. Thailand and Lao PDR share similar languages, histories and culture, and it has been shown that a history of work in Thailand is an HIV risk factor for people from Lao PDR. Although CDC’s Global AIDS Program (GAP) does not have a country office in Lao PDR, GAP’s Asia Regional Program (ARP), based in Bangkok, Thailand, began to explore ways to work in border areas to help mitigate the effects of HIV in both countries.
On a visit to northeastern Thailand to assess programming options in 2005, the GAP Thailand network coordinator in Ubon Ratchathani province, Ms. Pimontipa Malahom (better known locally as Khun Nit) said, “If you want to do cross-border work, you have to come to Chong Mek.”
The border community clinic in Chong Mek, Thailand.
The next day, we visited this rural border area linking Chong Mek, Thailand and Vong Tao, Lao PDR where between 2,000 and 5,000 people cross every day. A large number of service women (a direct translation from the Lao phrase phuxao bolikan, commonly used to refer to women selling sex) and men with income to spend on entertainment, such as truck drivers, porters moving goods across the border, and uniformed personnel, work in the border area. Khun Nit took us to several bars where we talked to young Lao service women about their lives. One 19-year-old woman told us she had heard about condoms, but she had never seen one. While sexual risk behavior appeared to be common at this border, no HIV and STI prevention and treatment services were readily accessible.
Working together with Khun Nit and her staff in the Ubon Ratchathani Provincial Chief Medical Office (PCMO), we discussed ways to address the issues of sexual risk behavior, poor access to services, inaccurate risk perception, lack of knowledge about HIV transmission and prevention, and high levels of stigma and discrimination. We collaborated with multiple partners to maximize our reach and leverage existing resources and developed a comprehensive approach to address the complex issues in this setting. GAP Thailand staff members, Usanee Kritsanavarin, Orapin Suksripanich and Liesbeth Bollen and the community-based organization, Yellow Rose, led by Thassika Champasri, all helped make this project idea a reality.
Basic primary health care was provided by staff from Srinthorn District Hospital, near the border crossing.
The 3 main components that seemed to best address the needs of people in the border area were: 1) clinical services targeting female sex workers, 2) an annual, one-day health fair targeting men with sexual risk behavior, and 3) an innovative behavior change communications intervention targeting a range of mobile people including sex workers and their clients.
Clinic Services
The clinic is housed in a simple, 2-story building with the exam room upstairs and common space downstairs. The building is located in the “free zone,” a half kilometer radius around the immigration office in which people can move freely without a passport or border pass during the day. Clinic services are available twice each month and are provided by staff of the nearest hospital in Thailand, the Srinthorn District Hospital. The leader of Yellow Rose, Thassika Champasri, lives next door to the clinic and is available daily for counseling, education, and condom distribution. The downstairs space in the clinic has become a Community Learning Center, where Lao service women are taught skills such as cooking, hair styling, Thai massage, English and Thai language, and artificial flower making. The Center is also used for regular health education sessions, and as a place to conduct focus group discussions and interviews with the project’s target populations.
Health Fairs
HIV-related games helped raise awareness during the health
fair.
Our annual health fairs combine entertainment, community participation, education and voluntary counseling and testing (VCT) for HIV as well as STI testing. All members of the community are encouraged to join the health fair activities, and basic primary health care is available to everyone for free from Srinthorn District Hospital staff, the same hospital providing regular clinic services. During the health fairs, VCT and STI testing services are specifically targeted at men with high-risk sexual behavior. Taking HIV and STI services to places where men work and congregate increases the opportunities for men to get tested. Women interested in these services are directed to the clinic where they can receive a complete pelvic exam.
Each health fair event has been larger than the last, with more community participation and increasing involvement of Lao officials. Over the three-year period, we observed low rates of STI and HIV in persons getting tested at the health fairs, consistent with Lao national surveillance. However, questionnaires completed by men participating in the health fairs show that unprotected commercial sex in this cross border area remains common. A paper is planned to show that health fairs may be a helpful tool to describe the local situation and target prevention efforts.
Behavior Change Communication
The third component of the project is an innovative behavior change intervention developed in partnership with an Atlanta-based consultancy group specializing in behavior change in public health called Global Health Communication (GHC). The intervention, Reflection and Action within Most at-risk Populations (RAMP), has 2 key components. Those are: 1) a behavior change narrative (in this case, in the form of a comic book) that does not tell people how to change, but shows people what change looks like in an authentic situation, and 2) a series of “Action Phases” that move people from reflection to action. This second aspect of the activity requires that outreach workers from local communities are trained in facilitation skills and then work with the target populations to motivate real change.
A page from Somchai’s Story, a role model story that helps men with high risk behavior prioritize their own issues and develop their own solutions.
The first comic book is entitled, “Somchai’s Story” and follows the life of a Thai soldier stationed at the border. He has a relationship with Joy, a young Lao service woman, who becomes the main character in the second story. The third and fourth comic books focus on porters and truck drivers, respectively, and the stories all continue to be related but independent. Each of these comic books deals with situations, issues, and problems relevant to the target populations. Stories are developed in Thai by a local creative team; the team is first trained in conducting qualitative research with the target population to elicit relevant information and then in crafting behavior change stories. Each story has been translated into the Lao language and into English.
In addition, local musical talent has created Maw Lum songs related to the characters in the comic books. Maw Lum is a form of traditional music that incorporates detailed character development and description of place. It is particularly popular in northeastern Thailand and the Lao PDR.
But creating compelling stories and popular songs is not enough to change peoples’ behavior. The ideas and issues addressed in these stories must be interpreted, discussed, and applied to real peoples’ lives. In order to do this, outreach workers, health care professionals, counselors and community groups must understand how to work with small groups of the target populations to prioritize their own problems, encourage them to reflect on the situation in their own communities and ultimately, to apply these ideas and actionable steps to their own lives. This is accomplished through the Action Phases, which we coordinate with local non-governmental organizations (NGOs) and government health staff.
Staff from the Ubon Ratchathani PCMO and Yellow Rose meet with men in border military camps, Lao service women, porters and truck drivers to read the stories, identify and prioritize similar issues in their own communities, and brainstorm ideas for addressing these concerns. In addition, we have conducted several facilitator trainings for members of NGOs working in the border area. This increases the likelihood that the at-risk populations will encounter multiple outreach workers in different locations using the same tools, thereby reinforcing the steps required to change behavior. Working within existing structures also improves sustainability of the project, as well as making interesting, useful tools available to people already in regular contact with the target population.
This comprehensive, cross border project would not have been possible without strong partnerships on many levels. We were able to build on existing positive relationships between provincial level health officials in Ubon Ratchathani province (Thailand) and Champasak province (Lao PDR). Strong collaboration also came from Srinthorn District Hospital and Yellow Rose, as well as NGOs working in the border areas. In addition, we worked closely with Population Services International (PSI), Family Health International (FHI), the United Nations Population Fund (UNFPA) and the Rockefeller Foundation to leverage resources and combine efforts. Without Khun Nit and her entire team at the Ubon Ratchthani PCMO leading the way, this project could not have achieved the level of collaboration that we have seen.
The Ubon Ratchathani PCMO, Srinthorn District Hospital, and Yellow Rose are committed to continuing to provide these services in the long term. They are developing plans now to combine local and external resources to support ongoing activities in Chong Mek as well as expanding to other border districts. Knowing the levels of dedication, determination, energy and skill of all those participating in this effort, I feel confident that this comprehensive cross-border work will continue and thrive in the future.
By Martha Scherzer
After contracting as Deputy Chief of the GAP Asia Regional Program for five years, Martha Scherzer is now a McKing contractor to the National Center for Health Marketing on the Global Health Communication team.
This article first appeared in CCID Spectrum, an internal newsletter of CDC’s Coordinating Center for Infectious Diseases.
Date last reviewed: August 15, 2007
Date last updated: August 15, 2007
Content source: National Center for Health Marketing
Content owner: National Center for Health Marketing