CENTRAL COORDINATING TEAM (CCT)

Principal Investigator & Project Coordinator

Dr. N. K. Arora Additional Professor Department of Pediatrics All India Institute of Medical Sciences New Delhi

Members

Dr. M. Lakshman Dr. K. Anand Consultant Social Scientist Assistant Professor Department of Pediatrics Comprehensive Rural Health Services All India Institute of Medical Sciences Project, All India Institute of Medical New Delhi Sciences, Ballabgarh

Dr. Kiran Goswami Dr. K.K. Ganguly Associate Professor Assistant Professor Centre for Community Medicine Institute of Human Behavior & Allied All India Institute of Medical Sciences Sciences New Delhi Delhi

Ms. Sneh Rewal Dr. Naveet Wig Consultant: Nutrition & Health Assistant Professor United Nations International Children’s Fund Department of Medicine Lodhi Estate All India Institute of Medical Sciences New Delhi New Delhi

Dr. R.M. Pandey Ms. Leena Sinha Associate Professor Research Associate Department of Biostatistics Clinical Epidemiology Unit All India Institute of Medical Sciences All India Institute of Medical Sciences New Delhi New Delhi EXTENDED CENTRAL COORDINATING TEAM

Dr. S. Vivek Adhish Dr. S.L. Chadha Reader Consultant: Public Health Dept. of Community Health Adminstration Sita Ram Bhartia Institute of Science National Institute of Health & Family Welfare and Research New Delhi New Delhi

Dr. N. Chaudhuri Dr. Rema Devi Professor Associate Professor Department of Pediatrics Department of Community Medicine Burdwan Medical College Medical College Burdwan Thiruvananthapuram

Dr. H.K. Kumbnani Dr. K.C. Malhotra Professor Professor of Anthropology Department of Anthropology Indian Statistical Institute New Delhi Kolkata

Dr. Thomas Mathew Dr. R. Sankar Assistant Professor Head, Thyroid Research Centre Department of Community Medicine Institute of Nuclear Medicine & Allied Medical College Sciences Thiruvananthapuram Delhi

Dr. Sandip K. Ray Dr. Sunita Shanbhag Professor Associate Professor Department of Community Medicine Department of Community Medicine Medical College LTM Medical College Kolkata Mumbai LIST OF ZONAL COORDINATORS AND INVESTIGATORS

Zone: 01 Chandigarh, Delhi, Haryana, Zone: 03 Arunachal Pradesh, Assam, Himachal Pradesh, Punjab Meghalaya, Sikkim

Coordinator : Dr. S.K. Kapoor Coordinator : Dr. Faruque Ahmed

C.R.H.S. Project (AIIMS), Ballabgarh Assam Medical College, Dibrugarh Dr. Praveen Kumar Dr. Swapna D. Kakoty Mr. M.K. Taneja Ms. Mayashree Konwar Dr. R.C. Agarwal Dr. Bijit Bhattacharya Dr. Mir Shahadat Ali Post Graduate Institute of Medical Sciences, Rohtak Dr. Pranab Jyoti Bhuyan Dr. A.D. Tiwari Dr. B.K. Nagla NESPYM, Guwahati Dr. Mohinder Singh Dr. Chiranjeeb Kakoty Mr. Sajjad Ahmed Regional Health & FW Training Centre, Kangra Mrs. Alaka Bhattacharyya Dr. T.D. Sharma Mrs. Swaran Lata Mr. G.L. Jaryal Mr. K.L. Ghai

Zone: 02 Uttar Pradesh Zone: 04 Manipur, Mizoram, Nagaland, Tripura

Coordinator : Dr. R.C. Ahuja Coordinator : Dr. E. Yaima Singh

King George’s Medical College, Lucknow Agartala, Tripura, Dr. Vikas Chandra Dr. Partha Bhattacharjea Dr. J.V. Singh Dr. A.K. Srivastava Aizwal, Mizoram Dr. L. Lalhrekima G.S.V.M. Medical College, Kanpur Dr. V.N. Tripathi Kohima, Nagaland Dr. Joginder Singh Dr. Tiasunup Pongener Dr. R.P. Singh Dr. Umatula

S.N. Medical College, Agra Regional Institute of Medical Sciences, Imphal Dr. Deoki Nandan Dr. T.A. Achouba Singh Dr. S.K. Mishra Dr. R.K. Narendra Dr. S.P. Agnihotri

Note: Names of Research Associates who participated in the FHAC Coverage Evaluation - 2000 are listed in Annexure Contd...

Zone: 05 Rajasthan Zone: 07 Orissa

Coordinator : Dr. S.L. Solanki Coordinator : Dr. B.C. Das

Dr. S.N. Medical College, Jodhpur M.K.C.G. Medical College, Berhampur Dr. Suman Bhansali Dr. D.M. Satapathy Dr. Afzal Hakim Mr. G.S. Patnaik Dr. Y.R. Joshi Dr. T. Sahu

Medical College, Kota S.C.B. Medical College, Cuttack Dr. Raghuveer Singh Dr. S.C. Jena Dr. Gopal Bunkar Dr. S.K. Sahu Dr. Hans Raj Dr. K. Misra

S.M.S. Medical College, Jaipur V.S.S. Medical College, Burla, Sambhalpur Dr. Anurag Sarna Dr. O.P. Panigarhi Dr. Rajesh Jain Dr. H.P. Acharya Dr. Hemant Jain Dr. S.C. Panda

Zone: 06 Madhya Pradesh Zone: 08 Goa, Maharashtra

Coordinator : Dr. Sheela S. Bhambal Coordinator : Dr. A.K. Niswade

Gandhi Medical College, Bhopal L.T.M. Medical College, Sion, Mumbai Dr. A.K. Upadhyaya Dr. Alka Jadhav Dr. R.K.S. Kushwaha Dr. Nagaonkar Dr. U.K. Dubey Dr. Nitin Deshpande Dr. Shubhangi Upadhye Gramin Sewa Sanstha, Bilaspur Dr. Chitra Nayak Mr. Vijay Tiwari Mr. D.N. Mishra Government Medical College, Nagpur Mr. Ajay Gurudiwan Dr. Sanjay Zodpey Mr. Ashok Tiwari Dr. Sanjay Deshpande Dr. Suresh Ughade Gwalior Medical College, Gwalior Dr. Prashant Langewar Dr. A.G. Shingeweker Dr. (Mrs.) A. Shingeweker Contd...

Zone: 11 Pondicherry, Tamil Nadu

Coordinator : Dr. R. Sathianathan Zone: 09 Andhra Pradesh C.M.C. Hospital, Vellore Coordinator : Dr. S. Narasimha Reddy Dr. Kurien Thomas Dr. O.C. Abraham Osmania Medical College, Hyderabad Dr. Mary Kurien Dr. B.V.N. Brahmeswar Rao Dr. C. Bala Krishna Madras Medical College, Chennai Dr. J. Ravi Kumar Mr. A. Vengatesan Mr. R.K. Padmanaban Siddhartha Medical College, Vijayawada Dr. S. Karthikeyan Dr. T.S.S. Manidhar Dr. A. Rama Prasad Madurai Medical College, Madurai Dr. C. Usha Rani Dr. C. Kamaraj Dr. M. Eswaran S.V. Medical College, Tirupati Dr. T. Rajagopal Dr. K. Raghava Prasad Dr. N.A. Chetty Dr. G. Raviprabhu Zone: 12 Kerala, Lakshadweep

Coordinator : Dr. M. Narendranathan Zone: 10 Karnataka Academy of Medical Sciences, Pariyaram, Kannur Coordinator : Dr. B. Mallikarjun Dr. Jeesha C. Haran Dr. T.P. Mubarack Sani Bangalore Medical College, Bangalore Dr. M. Jayakumary Dr. Shivananda Dr. Gopal Medical College, Calicut Dr. Premalata Dr. M. Ramla Beegum Dr. C.R. Saju M.R. Medical College, Gulbarga Dr. N.M. Sebastien Dr. R.R. Rampure Dr. B.N. Patil Medical College, Thiruvananthapuram Mr. Shreeshail Ghooli Dr. P.S. Indu Dr. J. Padmamohan St. John’s Medical College, Bangalore Mr. S.M. Nair Mr. A.S. Mohammad Mrs. Lalita Bhatti Mr. R.M. Christopher PREFACE

The primary function of program evaluation is to provide data on the extent to which program objectives have been achieved. Evaluations can offer insight about program activities and process of implementation. When assistance is needed in clarifying objectives and / or establishing appropriate implementation strategies for wider reach and acceptance of the program, the same methodologies of program evaluation are effectively used.

HIV pan-epidemic has struck almost every Indian state. Urgent public health measures are required to interrupt further transmission of the virus. National AIDS Control Organization (NACO), Ministry of Health, Government of India launched an innovative program “Family Health Awareness Campaign” (FHAC) [initially named as “Family Health Awareness Week” (FHAW)], in April-May 1999 to create awareness on reproductive tract infections (RTIs) and sexually transmitted diseases (STDs) among masses along with providing facilities to screen for and treat these infections. Appropriate management of RTIs / STDs are reported to reduce HIV transmission by 30-40 percent. Sensitive and personal issues regarding reproductive organs and sexual behavior were being discussed with the community at their homes and in village camps through existing public health machinery. There were reservations about the appropriateness of strategies of program implementation, and social mobilization as well as apprehensions regarding peoples’ response. IndiaCLEN had the opportunity to be associated as an external evaluation agency from the very first cycle of this program. Process evaluation of the pilot cycle of the program indicated acceptability of FHAC objectives and the implementation strategy. Building on the experience gained from the first cycle of the program, IndiaCLEN team evaluated both coverage and process of implementing the FHAC cycle conducted during summer of 2000.

During last four years IndiaCLEN Program Evaluation Team has emerged as a highly professional network of academia. The network has expanded from twenty four medical colleges and two NGOs to forty two partners located in almost every Indian state. The team has also been involved with the process evaluation of four cycles of Pulse Polio Immunization (PPI) Program.

The present program evaluation was considered a partnership exercise from the beginning and the evaluators collaborated with users of research as well as various categories of stakeholders who would be directly or indirectly involved with implementation of the program. Qualitative methods were used to obtain opinions and attitudes, behavior and motivations of both clients and providers within their complex rational matrix of personal as well as social realities. Quantitative methods using “probability proportionate to size (PPS)” cluster sampling technique were employed to estimate program coverage.

Evaluation is useful to policy makers only if it is a scientific endeavor with results that can be generalized. External evaluations are also characterized by their independence and minimal biases. It, therefore, bestows greater responsibilities on program evaluators to adopt research methods with utmost scientific rigor and in-built mechanisms for quality assurance. The current program evaluation is an effort in this direction. REPORT WRITING TEAM

Central Coordinating Team Members

Report Writing

Dr. N.K. Arora Dr. M. Lakshman Epidemiology & Health Social Science Program Evaluation

Dr. Kiran Goswami Ms. Sneh Rewal Epidemiology Social Science

Dr. K. Anand Dr. K.K. Ganguly Epidemiology Social Science

Dr. R.M. Pandey Dr. S. Vivek Adhish Biostatistics Epidemiology

Dr. Naveet Wig Ms. Leena Sinha Epidemiology Anthropology

Statistical Analyses

Dr. M. Lakshman Dr. N.K. Arora Dr. R.M. Pandey

Research Associates Research Staff

Dr. Ashoo Sewani Mr. Sanjay Singh Ms. Moumita Biswas Mr. Manish Aery Ms. Maryann Charles Mr. Pankaj Bhandari Dr. Anita Patwari Kaul Ms. Pooja Singhal

Administrative Assistant Editorial Assistance

Mr. Rakesh Singh Ms. Jyoti Bahri CONTENTS

Acknowledgments Abbreviations List of Tables and Figures

Executive Summary

I. Introduction

II. Objectives

III. Methodology Study Design Sampling Network Structure and Dynamics Development of Interview Schedules Unique Serial Number Transmission of Data to CCO Data Management Data Analyses Limitations and Potential Biases Time-line

IV. Observations 1. Background Information

2. Results and Conclusions 2.1. Reach of the Program Program reach Reasons of non utilization of program services

2.2. RTI / STD / HIV-AIDS related awareness and behavior among the clients Knowledge of clients about RTI/STD/HIV-AIDS Perception of clients about the problem of HIV-AIDS in their area Safe sex Perceptions about benefits of Condom Usage Use of condoms during last intercourse Interpretation of differences in the knowledge and behavior related to RTI/STD/HIV-AIDS issues between various client categories

2.3. Program Implementation Training of health providers Social mobilization Field operations: Home visits Field operations: Camps Treatment services for RTI/STDs and their utilization

2.4. Provider’s Perspectives about Program Performance and Client Behavior Perceptions about program reach Perceptions about clients behavior Perceptions about problem of AIDS

2.5. Adolescent Profile Reach of FHAC program among adolescents Awareness of adolescents about RTI/STD/HIV-AIDS Prevalence of RTI/STD symptoms during two weeks prior to survey and safe sex related information

2.6. Prevalence of RTI/STD Symptoms and Condom use during last Intercourse Prevalence of RTI/STD symptoms during two weeks period prior to survey Prevalence of urethral discharge / painful micturition Prevalence of genital ulcers Prevalence of RTI/STD symptoms according to HIV endemicity Prevalence of RTI/STD symptoms according to program utilization status of clients Characteristics of clients with presence of RTI/STD symptoms at the time of survey Use of condoms during last intercourse Characteristics of clients who had used condoms during last intercourse

V. Recommendations

Tables (6 to 66)

Annexures

Bibliography ACKNOWLEDGMENTS

IndiaCLEN Family Health Awareness Campaign (Summer 2000) Program Evaluation had been a partnership exercise with every participating institution making equal contributions.

We are greatly indebted to the support and encouragement extended by the following for successful completion of the study.

‚ National AIDS Control Organization (NACO), Ministry of Health and Family Welfare, Government of India, New Delhi

‚ State Governments and District Administration of study sites

‚ India Clinical Epidemiology Network (IndiaCLEN)

‚ International Clinical Epidemiology Network (INCLEN), Philadelphia, USA

‚ United States Agency for International Development (USAID), New Delhi

‚ All India Institute of Medical Sciences (AIIMS), New Delhi

‚ All stakeholders who agreed to share their perceptions and views about the program ABBREVIATIONS

AIDS Acquired Immuno Deficiency Syndrome AIIMS All India Institute of Medical Sciences CCO Central Coordinating Office CCT Central Coordinating Team CEU Clinical Epidemiology Unit Deff Design Effect FHAC Family Health Awareness Campaign FHAW Family Health Awareness Week HIV Human Immunodeficiency Virus IBIS Invasive Bacterial Infections Study IDII Infectious Diseases Initiative of IndiaCLEN IEC Information, Education and Communication INCLEN International Clinical Epidemiology Network IndiaCLEN India Clinical Epidemiology Network LMP Licentiate Medical Practitioner NACO National AIDS Control Organization NGO Non Governmental Organization PHC Primary Health Centre PMC Partner Medical College PPS Probability Proportionate to Size RMP Registered Medical Practitioner RTI Reproductive Tract Infection STD Sexually Transmitted Disease TB Tuberculosis WHO World Health Organization

KEY DEFINITIONS

Target Population / Clients : Both men and women between the age group of 15-49years

Contacted / Covered : Those clients who were either visited at their homes, attended the FHA camps or were exposed to both these activities

Not Contacted / Covered : Clients who were either not aware of the FHAC program; or were aware about the program through the publicity campaign but not exposed to the two main components of the program services, namely home visits or the attendance at camps

Program Reach : Was calculated as the percent of target population / clients visited at their homes and / or attended the FHA camps

Adolescents : Boys and girls between the age group of 15-20 years were referred to as adolescents in this evaluation report. LIST OF TABLES

Table 1 Zones for coverage evaluation of the Family Health Awareness Campaign-2000

Table 2 Coverage evaluation of family health campaign program : Zonal populations, clusters and cluster intervals

Table 3 Coverage evaluation of family health awareness campaign program : Distribution of households visited, refusals and clients recruited for the coverage survey by zone and sex

Table 4 Coverage evaluation of family health awareness campaign program : Characteristics of interviews rejected and analyzed by zone and place of residence

Table 5 List of zones, partner medical colleges/NGOs, zonal coordinators and CCT members for coverage evaluation

Table 6. Characteristics of clients according to reach of the program (Rural)

Table 7. Characteristics of clients according to reach of the program (Urban Slums)

Table 8. Reach of the family health awareness campaign

Table 9. Program reach : proportion of clients who received services* during fhac program by zone

Table 10. Reach of the family health awareness campaign program by HIV- endemicity

Table 11. Reasons for non-participation by the clients in FHAC camps

Table 12. Reason for non - participation by clients : Lack of awareness about FHAC program

Table 13. Reason for utilizing FHAC program services : Location of camp and attendance

Table 14. Classification of client responses regarding RTI / STD / HIV-AIDS

Table 15. RTI/STD/HIV-AIDS related awareness (correct responses) among the clients - All India Data

Table 16. RTI/STD/HIV-AIDS related awareness among rural areas men

Table 17. RTI/STD/HIV-AIDS related awareness among rural areas women

Table 18. RTI/STD/HIV-AIDS related awareness among rural areas clients (Total) Table 19. RTI/STD/HIV-AIDS related awareness among men from urban slums

Table 20. RTI/STD/HIV-AIDS related awareness among women from urban slums

Table 21. RTI/STD/HIV-AIDS related awareness among clients from urban slums (Total)

Table 22. Proportion of clients perceiving HIV-AIDS as a significant problem in their area

Table 23. Awareness of clients about benefits of using condoms [CORRECT KNOWLEDGE*]

Table 24. Awareness of clients about benefits of using condoms [CORRECT KNOWLEDGE]

Table 25. Behavior of clients regarding safe sex - Use of condoms during last intercourse

Table 26. RTI/STD/HIV-AIDS related awareness among clients after controlling for marital status - symptoms of RTI/STDs [CORRECT KNOWLEDGE]

Table 27. RTI/STD/HIV-AIDS related awareness among clients after controlling for education - symptoms of RTI/STDs [CORRECT KNOWLEDGE]

Table 28. RTI/STD/HIV-AIDS related awareness (Correct Responses): Distribution of rural areas clients according to program contact status and presence of RTI/STD symptoms during FHAC - 2000

Table 29. RTI/STD/HIV-AIDS related awareness (Correct Responses): Distribution of clients from urban slums according to program contact status and presence of RTI/STD symptoms during FHAC - 2000

Table 30. Training of health providers as part of FHAC program : Proportion trained

Table 31. Training of health providers as part of FHAC program : Process of training

Table 32. Training of health providers as part of FHAC program : Topics discussed by the trainers

Table 33. Quality of training of health providers : Perceptions of providers about FHAC program objectives

Table 34. Quality of training of health providers : RTI / STD / HIV-AIDS related awareness among doctors [CORRECT KNOWLEDGE]

Table 35. Quality of training of health providers (Doctors) : Treatment for men with urethral discharge Table 36. Quality of training of health providers (Doctors) : Treatment for men with genital ulcers

Table 37. Quality of training of health providers (Doctors) : Treatment for women with foul smelling vaginal discharge

Table 38. Quality of training of health providers (Doctors) : Treatment for women with genital ulcers

Table 39. Quality of training of health providers (Health Workers) : RTI/STD/HIV-AIDS related awareness [CORRECT KNOWLEDGE]

Table 40. Social Mobilization : clients’ sources of information about FHAC program

Table 41. Social Mobilization : knowledge about target population for FHAC program

Table 42. Field Operations : personnel involved in house visits during the FHAC program

Table 43. Field Operations : Location of FHAC camps [According to clients]

Table 44. Health workers perspective - Location of camps

Table 45. Field operations : Personnel manning the camp*

Table 46. Field operations : Conduct of FHAC camps*

Table 47. Prevalence of RTI/STD symptoms in clients during the FHAC program according to contact status of clients

Table 48. Treatment seeking behavior of clients with RTI/STD symptoms during FHAC program

Table 49. Providers perspective about program performance : Reach of the program during FHAC program

Table 50. Provider perspective about program performance : Relative proportion of clients attending the FHAC camps/ meetings

Table 51. Providers’ perspective about client behavior : Clients’ reaction towards discussing issues of RTI/STD

Table 52. Providers’ perspective about client behavior : Treatment seeking behavior of clients for RTI/STD

Table 53. Perceptions of health providers regarding problem of RTI/STD/HIV-AIDS in their area

Table 54. Reach of the family health awareness campaign to adolescents (< 20 years old)

Table 55. RTI / STD / HIV related awareness among adolescents (# 20 years old) [CORRECT KNOWLEDGE]

Table 56. Adolescent profile (# 20 years old) : Prevalence of RTI/STD symptoms during two weeks prior to survey & safe sex related information

Table 57. Prevalence of urethral discharge / painful micturition among the clients during the two weeks prior to the survey

Table 58. Prevalence of genital ulcers during the two weeks prior to the survey

Table 59. Prevalence of urethral discharge / painful micturition during two weeks prior to survey (According to HIV-endemicity zones)

Table 60. Prevalence of genital ulcers during two weeks prior to survey (According to HIV endemicity zones)

Table 61. Prevalence of urethral discharge / painful micturition during two weeks prior to survey (According to contact status of the clients)

Table 62. Prevalence of genital ulcers during two weeks prior to survey (According to contact status of the clients)

Table 63. Characteristics of clients with presence of urethral discharge / painful micturition / genital ulcers during the survey

Table 64. Prevalence of condom usage during last intercourse

Table 65. Prevalence of Condom usage during last intercourse (Zonal data)

Table 66. Characteristics of clients who had used condoms during their last sexual intercourse

LIST OF FIGURES

Figure 1: Selection of Households for Coverage Evaluation Figure 2: Network Structure Figure 3: Network Monitoring EXECUTIVE SUMMARY

1. Introduction The world wide Acquired Immuno-Deficiency Syndrome (AIDS) epidemic is a human tragedy that is reversing the gains in life expectancy of the last 30 years. The HIV-AIDS epidemic continues its expansion across the globe with approximately 16,000 new infections a day.

Presence of sexually transmitted diseases (STDs) facilitate acquisition and transmission of HIV infection tenfold and both are associated with the same risk behaviors. Measures that prevent STDs also prevent sexual transmission of HIV infection. Early detection and effective treatment of reproductive tract infections (RTIs) and STDs can significantly help to contain HIV transmission in populations.

At present, the best hope to limit the spread of HIV infection and its human and economic impact is through behavior modification. Awareness is a powerful tool that has the potential to bring about attitudinal and behavioral change in individuals and the society such as reducing the number of sexual partners, increasing condom use, seeking treatment for STDs and enabling safe injection practices.

The HIV-AIDS scenario in India prompted the government to launch a mass awareness campaign. Family Health Awareness Campaign (FHAC) is a unique program that has not been attempted anywhere in the world before. In this program, the task of disseminating awareness about the sensitive issues related to RTI/STDs were taken up through the existing public health infrastructure.

The program was conceived in early 1999 and the pilot phase of the FHAC [initially labeled as Family Health Awareness Week (FHAW)] was carried out during 26th April to 1st May,1999 in 100 districts all over the country. Encouraged by the response in phase I, Government of India launched the campaign in 266 districts during 1st- 15th December,1999. The campaign was further expanded to cover all the districts of the country during the current round, i.e. summer of 2000. The strategy adopted for this unique public health program was a ‘campaign mode’, where by target populations were sensitized towards the causes, symptoms and methods of preventing RTI/STD/HIV-AIDS, and all efforts were made to encourage early detection and prompt treatment of RTI/STD by involving the community.

IndiaCLEN has been associated as an external evaluation agency since the very first cycle of this program. Building on the experience gained in the first cycle, IndiaCLEN team evaluated the FHAC cycle conducted during the summer of 2000.

Executive Summary i 2. Objectives The objective of the current evaluation was to assess the program coverage during summer 2000 cycle of FHAC.

Primary Objectives To determine 1. The proportion of households visited by the health workers to create awareness about FHAC and sensitize the community to RTI/STD/HIV-AIDS 2. The proportion of target men and women (15 to 49 years age group) who were mobilized to attend the FHAC camps, during the summer 2000 cycle 3. The awareness of clients regarding causes, symptoms, treatment and prevention of RTI/STD/HIV-AIDS

Secondary Objectives 1. To determine the proportion of target population (men and women) who - received referral slips - sought care for RTI/STD at PHC and other health facilities (private practitioners) - received drugs from PHC during the last cycle of FHAC 2. To estimate the proportion of target group (men and women) who had symptoms of RTI/STD (point prevalence) during 15 days prior to the survey (urethral discharge or genital ulcers)

3. Methodology Quantitative data was collected using the cluster sampling technique to get an estimate of coverage of the program and levels of awareness among clients about RTI/STD/HIV-AIDS across the country.

Study Design A population based cluster survey was conducted at household level. The sample communities were selected using “probability proportionate to size” (PPS) technique. The entire country was divided into twelve zones, each zone consisted of either one large state or a group (maximum four) of small states. The zones could later on be grouped according to HIV endemic regions (as illustrated in the following Table). Census data of 1991 (Registrar General of India) was used as the sampling frame for selecting the clusters. For urban areas, the clusters consisted of census wards and for rural areas, villages were included.

Executive Summary ii Zones for the Coverage Evaluation of the Family Health Awareness Campaign-2000

Zone No. States A. High HIV Endemic Regions 08 C Goa, Maharashtra 09 C Andhra Pradesh 10 C Karnataka 11 C Pondicherry, Tamil Nadu B. Medium HIV Endemic Regions 03 C Arunachal Pradesh, Assam, Meghalaya, Sikkim 04 C Manipur, Mizoram, Nagaland, Tripura C Gujarat* C West Bengal* C. Low HIV Endemic Regions 01 C Chandigarh, Delhi, Haryana, Himachal Pradesh, Punjab 02 C Uttar Pradesh 05 C Rajasthan 06 C Madhya Pradesh 07 C Orissa 12 C Kerala, Lakshadweep C Bihar* C Jammu & Kashmir*

* Coverage evaluation was not done in these states due to non-implementation of FHAC program during summer 2000

Sampling Methods of Drawing Clusters: Urban and rural populations in a zone were separately processed for drawing clusters. The data consisted of names of the villages, towns and cities, the population of the communities and the cumulative population which was obtained by adding the population of all the communities preceding it on the list. The list was arranged in the same order given in the national census data. The sampling interval was obtained by dividing the total population of the zone by the number of clusters desired. A random number between one and the sampling interval was chosen as the starting point and subsequently the sampling interval was added to the random number until the desired number of clusters were obtained. The selected clusters were plotted on a map of the respective zone, and a logical sequence (route map) for the field work was developed for each of the survey teams.

Sample Size: Sample sizes were calculated under the assumption that the program coverage was 50%, i.e. 50 percent of the target clients could be contacted at their homes and / or attended the camps.

Executive Summary iii Rural : With an admissible error of ±10% at 95% confidence level, 289 men and 289 women were required in each zone for a design effect of 3. After rounding off, the sample size was decided as 300 per strata. Therefore, for 30 clusters, a sample size of 10 men and 10 women per cluster was decided.

Urban : Urban clusters were considered a more homogenous population and hence taking the same basic assumptions as for rural clusters, with a design effect of 1.5, 150 men and 150 women were required from each zone. For operational reasons, the urban sample was collected from 15 clusters in each zone.

Thus, a total of 10800 clients (7200 rural and 3600 urban) with an equal number of men and women were to be interviewed from 12 zones.

In addition, 1080 health workers (2 per cluster) and 540 doctors (1 per cluster) were also to be interviewed for information about the program implementation.

Network Structure and Dynamics Zonal coordinators: The study was conducted in 12 zones. A coordinator was nominated for each zone. The survey was carried out by the zonal coordinators along with investigators from the zone, and with the assistance and guidance of the CCT members.

Partner Medical Colleges / NGOs: There were three partner institutions in each zone, thus there were 36 partner institutions and each partner contributed three survey teams.

Survey Teams : Each survey team comprised of one senior investigator (leader), one male and one female research associate (medical students/ interns/anthropology or social science graduates).Each team surveyed five clusters, thereby nine teams covered forty five clusters (30 rural and 15 urban) in the zone.

Central Coordinating Office (CCO): The project was coordinated by the All India Institute of Medical Sciences-Clinical Epidemiology Unit (hence forth called Central Coordinating Office), New Delhi. Besides the Principal Investigator cum Project Coordinator, there were eight Principal Co-investigators from AIIMS CEU and other institutions in Delhi forming the Central Coordinating Team (CCT). In addition, ten investigators were coopted as extended central coordinating team members to support quality assurance measures.

Data Analyses The sampling unit was the zone. Program implementation strategy for rural areas and urban slums was different. Data collection was also stratified according to sex. Therefore data had six strata : rural men, women and total and same three strata for the urban slum population. Weighted estimates for the whole country (urban and rural separately) were calculated with zonal rural and urban populations respectively as the weights. All point estimates were calculated with 95% confidence intervals (Estimate % ± 2 SE) and associated design effects. In addition, awareness about RTI/STD/HIV-AIDS, treatment seeking behavior and presence of symptoms of RTI/STDs was related to the program contact status of the clients. Appropriate tests were applied to assess the statistical significance of the estimates. Survey analysis of the statistical package (“STATA” version 6) was used.

Executive Summary iv Limitations and Potential Biases The sample size for every zone had been estimated assuming the program reach as 50% with an admissible error of ± 10%. The design effect of 3 was considered appropriate. Both these parameters might have varied significantly between zones depending upon the program performance and heterogeneity of population residing in each cluster. The estimates could be particularly unstable with a wide 95% CI if the program performance was at extremes i.e. < 10% or > 90%. Similarly, the design effect might vary with individual estimates. It was, therefore, essential to look at the 95% CI in addition to point estimates.

As we were dealing with sensitive and personal issues related to sex and RTI/STDs, information so obtained was likely to have validity and reliability problems. These were minimized through rigorous training of the research teams who were well qualified. The instruments were administered in the local language keeping in mind the cultural sensitivities of language and manner in which questions were asked.

4. Observations

A. Background Information Family Health Awareness Campaign - 2000 was evaluated across the country with the exception of the states of Bihar, Gujarat, Jammu & Kashmir and West Bengal where the program was not conducted. The data was collected between September 9, 2000 and October 5, 2000. In all, 10811 clients (5409 men and 5402 women), 1072 health workers and 538 doctors from 360 rural and 180 urban clusters spread across 12 zones were interviewed for the study.

Quality assurance measures The magnitude and span of field operations, and involvement of 324 researchers from 36 medical colleges / non-governmental organizations necessitated the need of strict adherence to quality assurance measures right from the beginning.

After the national protocol finalization and orientation workshop in August 2000, 12 zonal workshops were conducted for the field teams. All these workshops were conducted by zonal coordinators along with a CCT member to develop a common understanding about the study objectives, study instruments and field operations. At zonal level, the zonal coordinators monitored the field operations very closely on a daily basis.

The team leaders ensured that the team reached the selected cluster, followed the protocol in selecting the households and individuals for interviewing, and research associates adhered to the guidelines while interviewing the respondents. After completing the specified number of interviews in each cluster, they also scrutinized all the questionnaires, rejected the incomplete / defective ones and organized extra interviews to replace the rejected ones. Members of the CCT made surprise quality assurance visits to a total of 45 (out of 540 clusters; 8.3%) clusters spread over 12 zones. During their visit to the cluster areas, data was cross checked with 2.4% (259/10811) clients in their houses and 1.9% (209/10811) interviews were observed in the field.

On arrival at CCO, AIIMS, New Delhi, the data were screened for appropriate coding of responses.

Executive Summary v Thereafter, the data were entered twice into the computer and matched. Range checks and logical runs were incorporated in the data management software to minimize errors. Characteristics of interviews Clients : A total of 16432 households were visited (50.6 % more than the targeted number) by the research teams. Most of these (4652/10911= 42%) were necessitated by the fact that either the doors were locked or there was no person of the specified sex in the eligible age group (15-49 years). Only 869 (7.3% replacements) of the available / eligible respondents declined to be interviewed because they were either busy, embarrassed or shy. An additional 100 (0.9%) of the interviews were incomplete (non-cooperation, no privacy, unwilling after a while, poor quality) and hence rejected by either the team leaders themselves or the CCO. Thus, a total of 10811 interviews were included for final analyses. Of these, 7212 were from rural areas (3611 men and 3601 women) while the rest (3599) were from urban slums (1798 men and 1801 women).

Ninety percent of interviewed women (4852/5402) were married while 27.3% men, in both rural and urban settings, were unmarried. Maximum proportion of clients interviewed were in the age group of 20-35 years (men: 3130/5409; 58%), (women: 3694/5402; 68%). A large proportion of interviewed women were illiterate in both rural [1566/3600; 43.5%] and urban slums [561/1801; 31.2%]. As regards men, 66.9% ( 3586/5359) were educated up to high school and above, and only 17% (913/5359) were illiterate.

Health Providers and Doctors: A total of 1084 health workers and 541 doctors were interviewed. Due to incomplete and / or poor quality transcripts, interviews of 12 health workers (1.1%) and 3 doctors (0.9%) were rejected. Hence, data from 1072 health workers (714 - rural and 358 - urban) and 538 doctors were analyzed and presented. Sample size of doctors and health workers interviewed from each cluster and zone did not have sufficient power for analysis at zonal level. Hence for both these categories of stakeholders, all India estimates were calculated.

B. Results and Conclusions FHAC is a promising program. Creation of widespread awareness about RTI/STD/HIV-AIDS among 15-49 year age group may prove to be the most effective means of bringing about changes in sexual behavior. Safe sexual practices facilitate reduction in the transmission and in turn prevalence of these diseases.

Definitions of program reach For the purpose of current program evaluation, program reach was defined as: Population contacted or covered: Those clients (aged15-49 years) who were either visited in their homes or those who attended the FHAC camps or were exposed to both these activities. Population not contacted or covered: This group included those clients (aged 15-49 years) who were not aware of the FHAC program or those who were aware about it through the publicity campaign but were not exposed to two main components of the program services, namely home visits and camps.

Acceptability of the program FHAC has been a unique program; sensitive and personal issues of diseases of reproductive system

Executive Summary vi and sexual behavior were discussed with the community through the public health system at their homes and in groups at the camps. Contrary to the apprehension of planners and providers, embarrassment and shyness were cited as reasons for not coming to camps by only 2-4% of clients who were familiar about the existence of FHAC program. This was true in both urban slums and villages indicating that the program objectives and its implementation strategies were acceptable to the community at large.

Reach of the program As part of the program, 17% households in rural areas and 12% in urban slums were visited to contact the target segment of the population at their homes. Barely 9% target clients from the rural areas, and 4% in urban slums attended the camps. Overall, program services could cover only 19% rural and 13% of the eligible individuals residing in the urban slums and high risk areas either through house visits and / or camps. More women than men could be covered in villages and in urban slums. Thus, the

Figure A: Reach of Family Health Awareness Campaign Program

Rural Areas

73%

Not aware about FHAC

7% Aware but not attended camp 2% 11% 7% Contacted at home alone Urban Slums Attended camp only 82% Contacted at home & attended camp

3% 1% 9% 5% program reach during summer 2000 was very limited. Program performance was consistently poorer in urban slums in almost all the states as compared to the villages (Figures A, B, C).

Executive Summary vii Figure B: FHAC Program Coverage by Sex

25 21.8 Men Women 19.3 20 Total 16.9 17.2

15 13.4

9.7 Percent 10

5

0 Rural Areas Urban Slums

Figure C: FHAC Program Coverage by Zone

ALL INDIA Urban Slums Rural Areas

Tamil Nadu

Karnataka

Andhra Pradesh High HIV Endemic Region Maharashtra/Goa

Manipur/Tripura/Mizoram/Nagaland Assam/Arunchal Pradesh/ Medium HIV Endemic Sikkim/Meghalaya Region

Kerala

Orissa

Madhya Pradesh Low HIV Endemic Rajasthan Region Uttar Pradesh Haryana/Delhi/Punjab/Himachal Pradesh/Chandigarh

0 10203040 Percent

Executive Summary viii Reasons for non-participation in the program activities Amongst the target population, 73% in rural areas and 82% in urban slums were unaware of the existence of FHAC program (Figure A). Issues of client inconveniences (viz; inconvenient timings, loss of wages, location of camps, not present at home/village) were the other major factors for non- participation in the program and were mentioned by 50% of those who were aware about the program but did not attend the camps. This was also endorsed by health care providers. The probability of clients attending the camps was 74% higher if these were organized in or around the villages and urban slums.

Program implementation Social mobilization: Creating awareness about FHAC program, camps and availability of treatment facilities at PHC was the key for success of this program. Information about FHAC in the community was disseminated primarily by the health workers and to some extent through friends, relatives and local influencers. Publicity channels like posters, banners, wall writings and occasionally mass media were mentioned by a mere 13% rural and 19% urban clients (Figure D). Usually, house visits (83%) and camps (90%) were conducted by health workers alone.

Inadequacy of the social mobilization activities was the predominant factor for non-participation in the program by the clients. The publicity campaign organized for the program was evidently ineffective. Interpersonal communication is a persuasive and effective means of communication, but it is also more time consuming. To improve program coverage using interpersonal communication as a central strategy would need greater involvement of the non-health sector to contribute in a tangible manner to the program implementation.

Screening and mobilization of RTI/STD patients during FHAC : During the campaign period, 10.2% of the contacted and 2.1% of the non-contacted clients had symptoms of RTI/STD. Data indicated that either due to program strategy, self selection or both, the target population with symptoms of RTI/STD were more likely to attend the camps. The program, particularly the camps, may be perceived to be meant only for RTI/STD/HIV-AIDS patients and hence adversely influence the overall community participation in future due to the associated stigma.

Referral system for suspected RTI/STD patients : The referral system evolved as part of the FHAC program appeared to be functioning reasonably well. However, there were no in-built mechanisms in the program to follow up those who were screened, suspected and referred to higher level for management (Figure E).

Training: Almost three-fourth of the doctors (72%) and health workers (76%) were trained (Figure F) near their place of work. These trained providers had high levels of correct knowledge about different Executive Summary ix aspects of RTI/STD/HIV-AIDS. However, emphasis on the objectives and implementation of the program was insufficient during the training as only a few doctors (18%) and health workers (27%) mentioned discussing these topics. This inadequacy probably reflected on the program implementation and performance later. Doctors and health workers believed that 60-88% of the community members sought care from private practitioners and other non-conventional health facilities for RTI/STD but private health care providers were largely left out of FHAC training (91%) and were not invited to be partners in the program.

Figure D: Clients’ Sources of Information about FHAC Program

70 Health Worker Interpersonal 60 Publicity 50 40

Percent 30 20 10 0 Men WomenTotal Men Women Total Rural Areas Urban Slums Figure E: Referral System During FHAC, 2000

Clients Clients Contacted Not Contacted

100 Cohort of Suspected RTI/STD 100

77 Aware about Referral Slips NA

69 Took Referral Slips NA

65 Went to PHC 27

56 Received Medicines at PHC 17

Executive Summary x Figure F: Proportion of Health Providers Trained for FHAC Program

Government Doctors Private Doctors

72% 9%

28% 91%

Health Workers 76% Trained

Untrained

No training

21% 3%

Providers’ perceptions about program performance: Doctors and health workers grossly over estimated the performance of the program for almost all its components.

RTI/STD/HIV-AIDS related awareness and behavior among the clients

Correct knowledge about causes, ill effects, prevention and treatment of RTI/STD, and transmission of HIV-AIDS was widely prevalent among the target population in both urban (52.3% to 84.6%) and rural (44.3% to 81.2%) areas. However, fewer clients were familiar with the symptoms of these diseases (41%) and long term ill effects due the HIV infection (25.9% to 31.4%). Women in both rural areas and urban slums were, in general, less knowledgeable than men about these diseases.

The clients were stratified according to their contact status with the FHAC program implemented one to three months prior to survey. The correct knowledge about different aspects of RTI/STD/HIV-AIDS and benefits of using condoms was significantly higher among target population from villages (55% to 91%) as well as urban slums (59% to 91%) who came in contact with the program services as compared to those who were not contacted [rural-37% to 70%; urban slums-39% to 84%] (p<0.01). Differences in the knowledge level between contacted and not contacted groups were similar for both sexes (Figures G, H).

Executive Summary xi Familiarity with the ill effects of HIV-AIDS on the body was prevalent in 34% rural area and 37% of urban slum clients who were covered under the program as compared to 24% and 30% of the non- contacted persons in villages and urban slums, respectively (p=0.007).

People residing in urban slums and those living in villages did not perceive HIV-AIDS as a significant problem and this perception was irrespective of their program contact status (contacted 13%; not contacted 8%). This was also in concordance with the providers’ perspective about the public health significance of HIV-AIDS (doctors 28% ; health workers 26%).

There were clients who had correct as well as incorrect perceptions about various aspects of RTI/STD/HIV-AIDS. These reflect deep rooted socio-cultural beliefs about symptoms, causes and treatment of RTI/STDs. Wrong perceptions were prevalent in clients from villages and cities irrespective of their FHAC program contact status. It was surprising to observe that incorrect perceptions, particularly about symptoms of RTI/STD and ill effects of HIV-AIDS on the body were higher among those who came in contact with the program than among those who did not (p=0.05 to 0.001).

The prevalence of condom use among rural clients who were covered under the FHAC program was 12% (95% CI : 9-15) and 7% (95% CI : 6-9) among the non-contacted population of FHAC program (p=0.001). However such a difference was not observed in urban slums (11% in both category of clients).

The current study was a cross-sectional survey and differences between various client categories in the knowledge and behavior parameters were likely to be due to several program and non program related inputs. RTI/STD symptoms were about 5 times higher among the participants of FHAC program (10%) as compared to those who were not covered (2%). Marital status, education, age distribution and occupation of subjects and their spouses were some of the other potential confounders that could influence the awareness level of the subjects. In view of the above, the observed differences in the knowledge and behavior about RTI/STD/HIV-AIDS related issues between clients who had and had not come in contact with the program services would have to be interpreted with caution and considered as hypothesis generating rather than causal in nature.

Executive Summary xii Figure G: RTI/STD Related Correct Awareness Among Clients

Symptoms Ill effects 100 Treatment 90 80 70 60

Percent 50 40 30 20 10 0 Contacted Not Contacted Contacted Not Contacted

Rural Areas Urban Slums

Figure H: HIV-AIDS Related Correct Awareness Among Clients

Spread 90 Ill effects Prevention 80

70

60

50

Percent 40

30

20

10

0 Contacted Not contacted Contacted Not contacted Rural Areas Urban Slums

Executive Summary xiii Adolescent profile The target population for the program services was between 15-49 years. Those between the age group of 15-20 years were labeled as adolescents in this study.

Reach of FHAC program to adolescents: Data indicated that during FHAC, 13% adolescents in villages and 14% in urban slums were covered under the program services. This was similar to the other age groups covered under the program.

Awareness of adolescents about RTI/STD/HIV-AIDS: Both in villages and urban slums, the adolescents were correctly aware about several features of RTI/STD/HIV-AIDS in varying proportions. The degree of appropriate knowledge of these disorders was higher among those adolescents who had come in contact with the program services as compared to those who had not. The proportion of adolescents who were sexually active could not be ascertained with the survey instrument used. However, condoms were used by 3.4% of rural and 6.3% urban slum adolescents during their last intercourse. The prevalence of condom usage was less as compared to subjects of older age group in both areas.

Prevalence of RTI/STD symptoms and condom use during last intercourse Clients were enquired about the presence of the symptoms of RTI/STD during the two week period prior to the day of interview for coverage evaluation. These included urethral discharge or painful micturition and ulcers on / around genitalia. Period of enquiry was restricted to two weeks to minimize recall bias. The study subjects were also enquired about the use of condom during their last sexual intercourse.

Prevalence of urethral discharge / painful micturition The prevalence of RTI/STD symptoms was 2% among men residing in urban slums and 2.7% in villages. In 10% urban and 10.5% rural women, urethral discharge/painful micturition were present. Among men, prevalence varied between 0%-10%, while 5%-19% women complained about urethral discharge/painful micturition in different study zones.

Complaints of urethral discharge or painful micturition were almost five times higher among women than men. Vaginal discharge is one of the RTI/STD symptoms among women and was frequently reported. This symptom may have been confused with urethral discharge. Hence, higher prevalence of urethral discharge reported by women might be biased due to co-existing vaginal discharge (Figure I).

Prevalence of genital ulcers Genital ulcers were reported by 1.1% rural and 1.0% urban clients. There were no major differences

Executive Summary xiv in their prevalence between the two sexes either in urban slums or villages (Figure I).

Figure I: Prevalence of Urethral Discharge/Painful micturition and Genital ulcers

12 Men 10.5 Women 10 10 Total

8 6.6 6 6

4 2.7 2 1.7 2 1.4 0.9 1.1 1 0.3 0 Rural Areas Urban slums Rural Areas Urban slums

Urethral discharge/painful micturition Genital ulcers

Use of condoms during last intercourse In villages, 8% of clients between the ages of 15-49 years had used condoms during their last sexual intercourse. In urban slums, the condoms were being used by 11.1% individuals. There were no differences in the prevalence reported by clients of either sex (Figure J).

Figure J: Prevalence of Condom Usage During Last Intercourse

ALL INDIA

Kerala

Tamil Nadu Urban Slums Rural Areas Karnataka

Andhra Pradesh

Maharashtra/Goa

Orissa

Madhya Pradesh

Rajasthan Manipur/Tripura/Mizoram/ Nagaland Assam/Arunchal Pradesh/ Sikkim/Meghalaya Uttar Pradesh Haryana/Delhi/Punjab/Himachal Pradesh/Chandigarh

0 5 10 15 20 25 30 Percent

Executive Summary xv 5. Recommendations

Program Acceptability FHAC program was acceptable to the community in the villages as well as urban slums. It can be continued with its current framework of objectives and implementation strategies.

Program Reach 2.1 The program coverage will have to be increased substantially to achieve the desired changes in the knowledge and behavior of the community. 2.2 As originally envisaged, the program should target all community members between the ages of 15-49 years. The current strategy of preferentially mobilizing the individuals with suspected RTI/STD may have stigmatized the FHAC camps as RTI/STD camps thereby reducing attendance. Referral slips can be given both during house visits and in the camps.

Social Mobilization 3.1 Major inputs are needed to improve social mobilization which appeared to be a weak link in the program. Most of the community has to be made aware of the existence of the FHAC program. This requires using all channels of communication. The messages about RTI/STD/HIV-AIDS should be simple, consistent and culturally appropriate. Communication experts should be involved to mount publicity campaigns after pre- testing the messages for suitability and clarity. 3.2 The community should also be debriefed about the prevalent misconceptions regarding causes, symptoms, ill effects, treatment of RTI/STD/HIV-AIDS and safe sexual practices. 3.3 In view of the sensitive and personal nature of the issues related to various aspects of RTI/STD/HIV-AIDS, inter-personal communication should continue to be a key strategy in the field. This would mean involving non-health sectors, notably NGOs/CBOs/local leadership and influencers, for home visits as well as organization of the camps. 3.4 Private health sector should be invited to participate in the program as an important partner because large segments of population seek treatment from them for RTI/STD/HIV-AIDS.

Executive Summary xvi Program Implementation 4.1 Client inconvenience: As the program coverage increases, this might emerge as an important reason for non-utilization of the FHAC related services. Conveniences of the local community and partners should be taken into account before the time for the program is fixed. It was not necessary to organize the program in the whole country simultaneously. FHAC could be implemented more effectively with a wider coverage if it was organized in a staggered manner in different states. The house visits and camps should be organized in a manner that are client friendly. Camps should be organized exclusively within the villages / urban slums to facilitate maximum attendance. 4.2 Extra efforts continue to be required to reach the male clients and adolescents. 4.3 A mechanism for follow up of RTI/STD patients identified in the field needs to be put in place. This is essential for the sustainability of the referral system of FHAC program.

Training 5.1 Remaining health providers need to be trained. 5.2 Re-orientation of all health providers is necessary on a regular basis; these sessions may also be utilized to provide feed back to providers regarding program performance. 5.3 With most of the health providers having already received training, the focus should now shift to train the private practitioners, NGOs/CBOs and local leaders. 5.4 Training should focus equally on the program objectives and strategies as on the syndromic management of RTI/STD/HIV-AIDS. 5.5 Training content requires suitable modifications to highlight the seriousness of the problem of HIV-AIDS in the community, ill effects of HIV-AIDS, the symptoms of RTI/STD and educating the community about the prevalent misconceptions about these diseases. 5.6 Special emphasis is required for imparting communication skills to deal with sensitive and personal issues like RTI/STD/HIV-AIDS.

Future Challenges The public health system will have to be strengthened to meet the increasing demands for RTI/STD services as the program coverage is improved. Simultaneously, efforts will be necessary to improve the availability and accessibility of condoms to the sexually active segment of the population.

Executive Summary xvii I. INTRODUCTION

The world wide Acquired Immuno Deficiency Syndrome (AIDS) epidemic is a human tragedy that is reversing the gains in life expectancy of the last 30 years and exacerbating poverty in developing countries. The HIV-AIDS epidemic continues its expansion across the globe with approximately 16,000 new infections a day. According to the estimates by the joint United Nations program in HIV- AIDS (UNAIDS) and the World Health Organization (WHO), 32.4 million adults and 1.2 million children were living with HIV by the end of 1999 and 16.3 million deaths have occurred since the start of the epidemic. A staggering 95% of the infections occurred in developing countries. About 4 million Indians, the largest number in any country, are currently infected with HIV. There is no state in India that is free from the HIV/AIDS virus infection.

About 80% of the HIV infections in India occur from sexual route (both heterosexual and homosexual), about 8% through blood transfusion and about 8% through injecting drug use. Over 90% of the reported cases occur in the sexually active and economically productive age group of 15-49 years. One in every four cases reported is a woman.

The main predisposing factors responsible for the spread of HIV infection are migration of the population from one part of the country to another for jobs, particularly to metropolitan cities; poverty, illiteracy, urbanization and an increase in intercity transportation system in the backdrop of ignorance and prevalent socio-cultural beliefs about RTI/STD and HIV infections.

There is a probability that the gender disparity of sexually transmitted diseases (STDs) and reproductive tract infections (RTIs) in men and women may be a predisposing factor too. This together with high prevalence of reproductive tract infections (RTIs) and sexually transmitted diseases (STDs) could make the scenario of HIV infection even more grim.

The growing evidence available from all over the world undoubtedly indicates that the incidence of HIV infections is higher in the presence of sexually transmitted diseases. There is a close relationship between STD and HIV infections. First, STD and HIV infections are associated with the same risk behavior, that is unprotected sexual intercourse with multiple partners. Thus, the same measures that prevent STDs also prevent sexual transmission of HIV infections.

Secondly, the presence of STD has been found to facilitate the acquisition and transmission of HIV infection by almost ten times. Thus early diagnosis and effective treatment of RTI/STD can significantly help to contain and reduce HIV transmission in populations. Widespread awareness can potentially lead to attitudinal and behavioral change in the individual and the society towards adopting safe sexual practices, thereby helping to limit the spread of HIV infection.

To prevent the further progression of HIV infection, a two pronged strategy is necessary: to create awareness, and to provide care and support to those infected.

The grim HIV-AIDS scenario in India prompted the government to launch a mass awareness campaign. Family Health Awareness Campaign (FHAC) is a unique program that has not been attempted before, anywhere in the world. In this program, the task of disseminating awareness about

Introduction 1 the sensitive issues related to reproductive tract infections and sexually transmitted diseases, was taken up through the existing public health infrastructure in a developing world setting.

The “Family Health Awareness Week” (FHAW) program was conceived in early 1999. The pilot phase of the program was carried out in 100 districts spread all over the country during 26th April to 1st May,1999. Encouraged by the response of the phase I, the Government of India extended the program to 266 districts during 1st- 15th December,1999. The campaign was further expanded to cover all the districts of the country during the current round, i.e. summer of 2000. Family Health Awareness Week was renamed “Family Health Awareness Campaign (FHAC)” in January, 2000. The name aptly conveyed the strategy adopted for this unique public health program. Using a campaign strategy, target populations were sensitized about the causes, symptoms and methods of preventing RTI/STD, and efforts were made to encourage early detection and prompt treatment of RTI/STD by involving the community.

IndiaCLEN has been associated as an external evaluation agency since the very first cycle of this program. Building on the experience gained in the first cycle of the program, IndiaCLEN team proposed to evaluate the current cycle of FHAC conducted during the summer of 2000.

Evaluation of the Pilot Phase of Family Health Awareness Campaign by IndiaCLEN Program Evaluation Team (1999)

It was a qualitative study conducted at 10 centers across India. The investigators were senior faculty members from medical colleges. The objectives of the evaluation were: a) to evaluate the process involved in the planning and implementation of the program, b) to determine the factors that influence the utilization of services by the clients, and c) to assess intermediate indicators of impact for the program.

Observations and Recommendations of FHAC Program Evaluation (Phase I - 1999)

1. The Family Health Awareness Campaign (FHAC) program was acceptable to the community and hence may be continued in order to cover all parts of India, maintaining essentially the same objectives and broad strategies of implementation. At least 4-6 months of lead time is necessary to do the ground work and planning for the subsequent cycles of FHAC.

2. NGOs, local influential persons and panchayat leaders are likely to be particularly helpful in implementing a sensitive and personal issue of RTI/STD through public health channels.

3. Coordination committees at district and sub-district level were important institutions of inter- sectoral coordination. They should continue to be headed by the District Magistrates and all partners must attend the committee meetings.

4. Microplanning should be considered a central and essential part of program implementation at district and block levels. All partners should participate in this process to convey the concept of stakeholdership.

Introduction 2 5. Adolescent (15-20 years age group) boys and girls must be recognized as a priority target group for the program and extra efforts made to mobilize them to attend the program activities.

6. All doctors and other providers who are to be involved in implementation should be oriented to the program objectives and trained for identification of RTI/STD patients from the community, their referral to the health facilities and appropriate management. An equally important issue is sensitizing the providers to the skills of communication, particularly while handling an issue like RTI/STD/HIV-AIDS at the homes, camps and PHCs.

7. A well planned and coordinated campaign for social mobilization should be organized. All channels of communication should be used for this purpose. IEC material should be in the local language and appropriate to local customs and cultures.

8. Interpersonal communication appeared to be the most appropriate channel of social mobilization for this sensitive and personal issue. Door to door visits must be continued as an integral part of FHAC strategy.

9. Camps should be organized within the villages at easily accessible locations. The camps should have separate enclosures for men, women, adolescent girls and adolescent boys. Special care should be taken to ensure confidentiality if some clients want to discuss their problems on one to one basis.

10. The system of referral for RTI/STD should be continued for the whole year.

11. A system had to be evolved at PHCs to ensure availability of drugs for treatment of RTI/STD round the year.

Need For External Evaluation

National AIDS Control Organization (NACO), conducted the Family Health Awareness Campaign for the third time during the summer of 2000. In this cycle, the program was expanded to cover all the districts in the country.

This was a unique program with the objective of creating awareness about a sensitive and personal issue among masses. Therefore, there were apprehensions about the appropriateness of strategies of program implementation, social mobilization and people’s response. In view of these sensitivities, the nodal implementation agency, NACO, built the process of evaluation within the program right from the initiation of its activities. For independent appraisal NACO wanted a partnership with an external agency, which had experience and expertise in program evaluation.

Why IndiaCLEN?

Clinical Epidemiology Units (CEUs) are functioning in six medical colleges in India (New Delhi, Lucknow, Nagpur, Chennai, Vellore and Thiruvananthapuram). CEU faculty members were trained

Introduction 3 in clinical epidemiology, health social sciences, bio-statistics and health economics under the Global International Clinical Epidemiology Network (INCLEN) program.

Members of the CEUs have formed a national body called IndiaCLEN with the objectives of disseminating the knowledge and skills of clinical epidemiology to other academic, non-academic and medical institutions in the country and for participating in policy relevant research activities. Members of the group have had the benefit of attending workshops on program evaluation and continuous quality assurance.

IndiaCLEN as a group, has always encouraged development of collaborative study protocols. IndiaCLEN members have completed three cycles of evaluation of the Pulse Polio Immunization Program [1997-98; 1998-99 and 1999-2000] at 24 centers across the country. Several key recommendations made on the basis of these reports were incorporated in the National Pulse Polio Immunization Program. IndiaCLEN was also involved in the evaluation of the first round of Family Health Awareness Week-1999. The group was doing other networking studies viz. Invasive Bacterial Infections Study (IBIS) and Survey of Abuse in Family Environment (IndiaSAFE). IndiaCLEN members have also participated in the process and impact evaluation of the universal salt iodization program of Government of Madhya Pradesh (India) in 1995. More recently, Infectious Diseases Initiative of IndiaCLEN (IDII) had undertaken tuberculosis and related research projects at eight centers in the country.

Family Health Awareness Campaign (FHAC) - Summer, 2000 The overall objective of the campaign was to contain the spread of reproductive tract infections (RTIs) including sexually transmitted diseases (STDs) and HIV-AIDS. The major focus of the program was: ‘ To raise the awareness level of people about RTI/STDs and HIV-AIDS in rural areas and other vulnerable groups of the population, particularly urban slums ‘ To encourage health seeking behavior for RTI/STDs in the general population ‘ To make the people aware about the services available in the public health system for the management of RTI/STDs ‘ To facilitate early detection and prompt treatment of RTI/STDs by mainstreaming the program with the infrastructure available under the primary health care system ‘ To implement a focused IEC strategy for male population

Aim The overall aim of the present program evaluation exercise was to obtain estimates of target population covered under the FHAC program during summer 2000 and to document the reasons for clients not utilizing the program services. The findings from the study were to be shared with program managers to help them improve implementation and further refine program strategies.

Study Hypotheses 1. The program was utilized by at least 50% of the target population during summer 2000. 2. The program was acceptable to the community. 3. The awareness about RTI/STD/ HIV-AIDS among both providers and clients has improved as a result of this program.

Introduction 4 II. OBJECTIVES

Current evaluation assessed the program coverage during summer 2000 cycle of FHAC.

Research Questions What was the coverage under the program for the following parameters: 1. Reach of health workers to client’s house. 2. Mobilization of clients (male and female) to the camps of FHAC.

Primary Objectives To determine: 1. The proportion of households visited by the health workers to create awareness about FHAC and sensitize the community to RTI/STD/HIV-AIDS. 2. The proportion of target men and women (15 to 49 years age group) whowere mobilized to attend the FHAC camps during summer 2000 cycle. 3. The awareness of clients regarding causes, symptoms, treatment and prevention of RTI/STD/HIV-AIDS.

Secondary Objectives 1. To determine the proportion of target population (men and women) who - received referral slips - sought care for RTI/STD at PHC and other health facilities (private practitioners) - received drugs from PHC for their RTI/STD related symptoms during summer 2000 cycle of FHAC. 2. To estimate the proportion of target group (men and women) who had symptoms of RTI/STD (point prevalence) during 15 days prior to the survey (urethral discharge/painful micturition or genital ulcers).

Objectives 6 III. METHODOLOGY

Quantitative data was collected using the 30 cluster sampling technique to get an estimate of the coverage of the program and awareness of clients about RTI/STD/HIV-AIDS across the country.

Study Design A rapid population based cluster survey at the household level was performed for reasons of costs and logistics. The sample communities were selected using “probability proportionate to size” (PPS) technique. Under this method, the likelihood of a community being selected is in relation to the proportion of its population size i.e larger villages or cities (census wards) are more likely to be selected than the smaller ones. The entire country was divided into twelve zones, each zone consisted of either one large state or a group of small states (maximum four states). The zones could later be grouped according to HIV endemic regions (Table 1, Annexure II). Census data of 1991 (Registrar General of India) was used as the sampling frame for selecting the clusters.

Table 1. Zones for the coverage evaluation - Family Health Awareness Campaign, 2000

Zone No. States A. High HIV Endemic Regions 08 C Goa, Maharashtra 09 C Andhra Pradesh 10 C Karnataka 11 C Pondicherry, Tamil Nadu B. Medium HIV Endemic Regions 03 C Arunachal Pradesh, Assam, Meghalaya, Sikkim 04 C Manipur, Mizoram, Nagaland, Tripura C Gujarat* C West Bengal* C. Low HIV Endemic Regions 01 C Chandigarh, Delhi, Haryana, Himachal Pradesh, Punjab 02 C Uttar Pradesh 05 C Rajasthan 06 C Madhya Pradesh 07 C Orissa 12 C Kerala, Lakshadweep C Bihar* C Jammu & Kashmir* * Coverage evaluation was not done in these states due to non-implementation of FHAC program during summer 2000

For urban slums, the clusters consisted of census wards and for rural areas, villages. This Methodology 7 stratification was adopted for the following reasons: a) The major focus of the program was in rural areas. In cities it was focused in high risk areas and slums only. b) Program implementation strategies were different in urban and rural areas. c) Differences exist in the socio-cultural and demographic features of the urban and rural populations. Hence the data for urban and rural areas were presented separately.

Sampling i. Methods of Drawing Clusters Urban and rural populations in a zone were separately processed for drawing clusters (Table 2). The sampling interval was obtained by dividing the total population of the zone by the number of clusters desired. A random number between one and the sampling interval was chosen as the starting point and subsequently the sampling interval was added to the random number until the desired number of clusters were obtained. The villages / towns / cities whose cumulative population included these numbers were selected for the cluster survey. The selected clusters were plotted on a map of the respective zone, and a logical sequence (route map) for the field work was developed for each of the survey teams. A work plan was developed for all the zones and specific clusters were allotted to each field team (Annexure III).

ii. Sample Size Calculation Since the extent of coverage was not known, it was assumed that the program coverage was 50%, i.e 50% of the target clients could be contacted at their homes and / or attended the camps. This would give an estimate of the largest sample size required (for the given value of confidence limits and precision).

For the purpose of the current study, sample size was estimated for 95% confidence level with an admissible error of ± 10%.

The sample size required for the cluster survey was larger than that required for a random or stratified sample because of the phenomenon of design effect (Deff). If the proportion of a condition is approximately the same in each sample cluster, Deff will be around the null value of one. Greater the clusters differ from one another, larger the Deff. As the Deff increases (which increases the variance around the proportion estimate), the sample size must be increased to maintain a desired level of precision.

There was bound to be variation in the program performance in different parts of the same zone and hence Deff had to be more than one. After consulting with other public health persons, who had conducted similar studies and adopting a conservative approach, the sample size was calculated with the design effect of 3. Design effect gives an idea about the extent of variation in the implementation and performance of the program within the zone and across the zones.

Methodology 8 Table 2. Coverage evaluation of Family Health Awareness Campaign Program : Zonal populations, clusters and cluster intervals

Zone States * Stratum Total Population Total Cluster Interval No. Clusters

1 Chandigarh, Delhi, Haryana, Rural 32434534 30 1081151 Himachal Pradesh, Punjab Urban 19544619 15 1302975

2 Uttar Pradesh Rural 111506372 30 3716879

Urban 27605915 15 1840394

3 Assam, Arunachal Pradesh, Rural 22494639 30 749821 Meghalaya, Sikkim, Urban 2965476 15 197698

4 Manipur, Mizoram, Nagaland, Rural 5040121 30 168004 Tripura Urban 1453535 15 96902

5 Rajasthan Rural 33938877 30 1131296

Urban 10067113 15 671141

6 Madhya Pradesh Rural 50842333 30 1694744

Urban 15338837 15 1022589

7 Orissa Rural 27424753 30 914158

Urban 4234983 15 282332

8 Goa, Maharashtra Rural 48395601 30 1613187

Urban 30541586 15 2036106

9 Andhra Pradesh Rural 48620882 30 1620696

Urban 17887126 15 1192475

10 Karnataka Rural 31069413 30 1035647

Urban 13907788 15 927186

11 Pondicherry, Tamil Nadu Rural 37072154 30 1235738

Urban 19594577 15 1306305

12 Kerala, Lakshadweep Rural 21440817 30 714694

Urban 7709408 15 513961

* In other states the FHAC program was not conducted during summer 2000

Based on the experience of the IndiaCLEN group during the first round of FHAC program and available coverage evaluation data from NACO, there were marked difference in the participation

Methodology 9 by men and women in the program activities. Reasons for participation by men and women in the program activities were likely to be different. Keeping this in mind, samples of both sexes were drawn separately from each cluster. As already explained under ‘study design’, the first level of stratification for drawing samples was rural and urban. iii. Sample Clients Rural samples: With an admissible error of ±10% at 95% confidence level, 289 men and 289 women were required in each zone for a design effect of 3. After rounding off, the sample size was decided as 300 per strata. Therefore for 30 clusters, sample size was 10 men and 10 women per cluster.

Urban samples: Urban clusters were considered a more homogenous population and hence taking the basic assumptions as for rural clusters, with a design effect of 1.5, we required 150 men and 150 women from each zone. For operational reasons, the cluster numbers in urban areas were reduced to 15 per zone. Thus number of men and women respondents remained 10 each per cluster. This was likely to increase the admissible error to around ±15% instead of ±10%. The point estimate would however remain stable.

Thus it was envisaged that a total of 10800 clients (7200 rural and 3600 urban) would be interviewed. This sample would include an equal number of men and women.

Providers In addition, 1080 health workers (2 per cluster) and 540 doctors (one per cluster) were also to be interviewed for information about program implementation. iv. Selecting Houses and Respondents in Rural and Urban Clusters Selection of houses involved two steps: first, identifying the first house and second selection of subsequent houses. Men and women respondents were selected from different houses (Figure 1). STEP 1: < A landmark in the center of the village such as a temple, market place, mosque, church or chaupal (Panchayat Ghar) was located. < If no landmark could be identified, a central place for social activities of the community was ascertained from the people. STEP 2: < A direction to select houses for interviewing male respondents was chosen randomly by spinning a bottle on the ground. Whichever way the neck of the bottle pointed, the team went in that direction. < Similarly another direction was chosen for selecting houses to interview women. STEP 3: < After deciding on the directions, the team walked towards the periphery counting the number of houses in that segment of the village / locality. STEP 4: < A random number was selected [last two / three digits on a currency note]. That was the number of the first house where the survey commenced. [eg. If the total number of houses was 99 and below, then the last two digits on a currency note were selected]. STEP 5: < Another nine houses which were nearest to the first one were chosen for further interviews.

Methodology 10 < An account of all the houses visited was kept by filling the log sheet for houses surveyed for both women and men respondents separately.

Figure 1: Selection of Households for Coverage Evaluation

Village / town

Enter the cluster village/ locality and look for-temple, market, mosque, church Select the landmark or chaupal 1. For any reason, DO NOT change a cluster which has been selected for the *Spin a bottle and move along the study Select direction direction it points to. Choose two different direction for men/women 2. If there are less than 10 houses in respondents the direction selected than go to the *Get an approximate estimate of the next nearest lane and select the number of houses in the direction selected remaining houses consecutively till 10 respondents are completed Select a currency note and see the last two Select the first house to three digits eg. 656505. No. 5 will be the first house for male interviews. (repeat for the women)

Select the house closest to the first house Select the subsequent and continue till 10 respondents have house been interviewed

v. Selection of Male and Female Respondents (Tables 3, 4) After reaching a house, all the eligible men or women (aged between 15-49 years) available at that time were listed. All the households visited for selecting the respondent were listed and reasons for not interviewing that household were specified (Annexure IV). If more than one was available in the specified age group, one was randomly selected (the last digit of a currency note), the serial number encircled and proceeded with the interview schedule.

A total of 16432 households were visited (50.6 % more than the targeted number) by the research teams. Most of these (4652/10911= 42%) were necessitated by the fact that either the doors were locked or there was no person of the specified sex in the eligible age group (15-49 years). Only 869 (7.3%) of the available / eligible respondents declined to be interviewed because they were either busy, embarrassed or shy. An additional 100 (0.9%) of the interviews were incomplete (non- cooperation, no privacy, unwilling after a while, poor quality) and hence rejected by either the team leaders themselves or the Central Coordinating Office (CCO). Thus, a total of 10811 interviews were included for final analyses. Of these, 7212 were from rural areas (3611 men and 3601 women) while the rest (3599) were from urban slums (1798 men and 1801 women).

Methodology 11 Table 3. Coverage evaluation of Family Health Awareness Campaign Program : Distribution of households visited, refusals and clients recruited for the coverage survey by zone and sex

Target Non- Refusals / Recruited Zone No. States Sex approached availability Replacements & n % Interviewed

1 Chandigarh, Delhi, Haryana, Men 761 280 30 6.2 451 Himachal Pradesh, Punjab Women 635 138 45 9.0 452

2 Uttar Pradesh Men 558 92 11 2.3 455

Women 511 42 12 2.5 457

3 Assam, Arunachal Pradesh, Men 783 298 33 6.8 452 Meghalaya, Sikkim, Women 609 117 36 7.3 456

4 Manipur, Mizoram, Nagaland, Men 728 203 70 13.3 455 Tripura Women 605 129 22 4.6 454

5 Rajasthan Men 752 269 29 6.0 454

Women 611 131 27 5.6 453

6 Madhya Pradesh Men 728 257 16 3.4 455

Women 624 163 10 2.2 451

7 Orissa Men 559 71 25 5.1 463

Women 562 85 23 4.8 454

8 Goa, Maharashtra Men 629 140 36 7.3 453

Women 647 165 26 5.4 456

9 Andhra Pradesh Men 759 250 58 11.4 451

Women 643 152 34 6.9 457

10 Karnataka Men 911 356 104 18.7 451

Women 705 200 53 10.5 452

11 Pondicherry, Tamil Nadu Men 933 381 93 16.8 459

Women 718 209 50 9.8 459

12 Kerala, Lakshadweep Men 829 361 11 2.3 457

Women 632 163 15 3.2 454

Men 8930 2958 516 8.6 5456

Total for 12 zones Women 7502 1694 353 6.0 5455

Total 16432 4652 869 7.3 10911

Methodology 12 Table 4. Coverage evaluation of Family Health Awareness Campaign Program : Characteristics of interviews rejected and analyzed by zone and place of residence Interviews Rejected Interviews Analyzed Zone Stratum No. Men Women Health Doctors Men Women Health Doctors workers workers

1 Rural 0 2 1 1 301 300 58 29

Urban 0 0 0 0 150 150 30 15

2 Rural 4 6 3 0 300 300 59 30

Urban 1 1 0 0 150 150 30 15

3 Rural 0 3 0 0 301 301 60 31

Urban 1 2 1 0 150 150 30 15

4 Rural 3 4 0 1 300 300 62 28

Urban 2 0 0 0 150 150 30 15

5 Rural 4 4 1 0 300 299 60 30

Urban 0 0 0 0 150 150 30 15

6 Rural 2 2 0 0 300 299 60 30

Urban 2 0 0 0 151 150 29 15

7 Rural 4 2 0 0 306 300 60 30

Urban 2 2 0 0 151 150 30 15

8 Rural 2 3 0 0 301 301 58 30

Urban 4 2 1 0 146 150 29 15

9 Rural 1 4 2 0 300 301 58 30

Urban 0 2 0 0 150 150 30 15

10 Rural 1 0 0 0 300 300 60 30

Urban 0 2 0 0 150 150 30 15

11 Rural 6 7 2 2 302 300 59 30

Urban 1 2 1 0 150 150 30 15

12 Rural 4 3 0 1 300 300 60 30

Urban 3 0 0 0 150 151 30 15

All Rural 31 40 9 5 3611 3601 714 358 India Urban 16 13 3 0 1798 1801 358 180

Total 47 53 12 5 5409 5402 1072 538

Methodology 13 Characteristics of Clients: Marital Status, Age and Education of the Clients Ninety percent of interviewed women, (4852/5402) in both rural and urban areas were married while 27.3% men in both rural and urban settings were unmarried . Maximum proportion of clients interviewed were in the age group of 20-35 yrs (men: 3130/5409; 58%, women; 3694/5402; 68%). But in the age group of 35-49 years there were 10% more men [1739/5409; 32%], than women [1247/5402; 22%].

A large proportion of interviewed women were illiterate in both rural [1566/3600; 43.5%], and urban slums [561/1801; 31.2%]. As regards men, 66.9% (3586/5359) were educated up to high school and only 17% (913/5359) of men were illiterate. vi. Selection of Health Workers Two health workers were selected from the PHC / Sub center / Health post to which the selected cluster village / locality belonged.

vii. Selection of Doctors The medical officer of the PHC / Health post to which the selected cluster village / locality belonged was interviewed where feasible. If unavailable, any doctor who was a private practitioner (Allopathy, RMP, LMP, Ayurveda, Unani) was chosen.

A total of 1084 health workers and 541 doctors were interviewed at the rate of two health workers and one doctor per cluster. Due to incomplete and or poor quality transcripts, 12 interviews of health workers (1.1%) and 3 of doctors (0.9%) were rejected. Hence, data from 1072 health workers (714 - rural and 358 - urban) and 538 doctors were analyzed (Table 4).

Network Structure and Dynamics i. Investigators a. Zonal Coordinators: The study was conducted in 12 zones. A coordinator was nominated for each zone. The zonal coordinators and investigators from the zone carried out the survey along with assistance and guidance from the CCT members (Table 5).

b. Partner Medical Colleges (PMC) / NGOs: There were three partner institutions in each zone. Each partner contributed three survey teams.

c. Survey Teams: Every survey team comprised of one senior investigator (leader), one male and one female research associate (medical students/ interns/anthropology or social science graduates). Each team surveyed five clusters, thereby nine teams covered forty five clusters (30 rural and 15 urban) in the zone (Figure 2). It was estimated that each team would be able to cover one cluster per day and all five clusters in eight to twelve days time.

Methodology 14 Table 5. List of zones, partner medical colleges/NGOs, zonal coordinators and CCT members for coverage evaluation

Zone Medical Colleges / Zonal Coordinator CCT Member NGOs 1 Chandigarh, Delhi, Ballabhgarh, Kangra, Dr. S.K Kapoor, Dr. S.L.Chaddha Haryana, Himachal Rohtak Ballabhgarh Pradesh, Punjab 2 Uttar Pradesh Agra, Kanpur, Lucknow Dr. R.C.Ahuja, Dr. K.C Malhotra & Lucknow Ms. Leena Sinha

3 Arunachal Pradesh, Dibrugarh, Guwahati Dr. F.U Ahmed, Dr. T. Mathews Assam, Meghalaya, Dibrugarh Sikkim, 4 Manipur, Mizoram, Agartala, Aizwal, Dr. E. Yaima Singh, Dr. Naveet Wig & Nagaland, Tripura Imphal, Kohima Imphal Dr. Sandip Ray 5 Rajasthan Jaipur, Jodhpur, Kota Dr. S.L.Solanki, Dr. S. Shanbhag Jodhpur 6 Madhya Pradesh Bhopal, Bilaspur, Dr. S.S Bhambal, Dr. K. Goswami Gwalior Bhopal 7 Orissa Berhampur, Cuttack, Dr. B.C. Das, Dr. H. K. Kumbnani Sambhalpur Berhampur

8 Goa, Maharashtra Nagpur, Mumbai Dr. A.K. Niswade, Dr. N. Chaudhuri & Nagpur Ms. Leena Sinha 9 Andhra Pradesh Hyderabad, Tirupati, Dr. S. Narasimha Ms. Sneh Rewal Vijayawada Reddy, Vijayawada 10 Karnataka Bangalore (2), Gulbarga Dr. B.Mallikarjun, Ms. Rema Devi Gulbarga

11 Pondicherry, Tamil Nadu Chennai, Madurai, Dr. R. Sathianathan, Dr. K. Anand Vellore Chennai

12 Kerala, Lakshadweep Calicut, Kannur, Dr. M. Narendranathan, Dr. K. K Ganguly Thiruvananthapuram Thiruvananthapuram d. Central Coordinating Office (CCO): The project was coordinated by the AIIMS-CEU (hence forth called Central Coordinating Office), New Delhi. Besides the Principal Investigator cum Project Coordinator, there were eight Principal Co-investigators from AIIMS CEU and other institutions in Delhi forming the central coordinating team (CCT). In addition ten investigators were coopted as extended central coordinating team members to support quality assurance measures.

Methodology 15 Figure 2: Network Structure

CCO-AIIMS Zone (1 to 12) PMC/NGOs 9 Teams per zone (3 per zone) CCO- Central Coordinating Office 45 Cluster per zone PMC- Partner Medical College T- Team Rural Urban ZONE (30 Clusters) (15 Cluster)

PMC 1 PMC 2 PMC 3

T1 T2T3 T1 T2 T3 T1 T2 T3

Each Team Surveyed Five Clusters

ii. Network Monitoring a. Zonal Control Room and Data Collection Zonal coordinator in association with a CCT member set up a control room in every zone. The tasks of this duo were to: C Chart out route maps for every team to cover five clusters per team C Hold a two day orientation to conduct the interviews to give hands on experience to all team members in the two clusters nearby C Coordinate movements of all teams, solve problems and facilitate local arrangements C Identify situations that trigger off problems and take pre-emptive actions C Disburse funds for field travel C Monitor movements of teams in the field and facilitate quality assurance visits by CCT members C Facilitate smooth data transmission (Refer figure 3) b. Monitoring Tasks of Investigators 1. Senior investigator in each field team contacted their zonal coordinator to appraise them about C The number of interviews completed on that day C Plan for the next day and problems faced, if any (Annexure V)

2. Zonal coordinators were in constant touch with the CCO, Delhi. They contacted the CCO everyday to give an update of the activities in the zone. They also faxed the details on every Monday, Wednesday and Friday while the field operations lasted and the entire network was monitored by the CCO (Annexure VI). The information communicated to CCO included: C Number of clusters covered C Number of interviews completed C Present location of the teams

Methodology 16 C Problems faced, if any C Proposed plans of the teams for the next day 3. CCT members who were out in the field to ensure quality of data being collected contacted the CCO, Delhi every evening and reported the following (Annexure VII): C Details of clusters visited C Problems in methodology, if any C Corrective measures taken C Plans for the next day

iii. Quality Assurance Mechanism This was done at six stages :

Level 1: Zonal coordinators and senior investigators assembled in Delhi during 27-29 August 2000 to finalize the study protocol, methodology of data collection and interview schedules.

Figure 3: Network Monitoring

CCO-AIIMS Feed back about zone Phone daily: Progress Fax every Mon, Wed, Fri: of interviews, any problems CCT Member No. of interviews completed; Zonal workshop no. of schedules dispatched & quality check Zonal Coordinator

Phone daily: Progress of Zonal workshop/route maps interviews, schedules dispatched, data transfer /funds/coordination travel plans, any problems Senior Investigator Once a cluster is completed, Research Research Photocopy the filled schedules. Post the originals to CCO the next Assistant Assistant day. The copies to be retained and (Male) (Female) submitted to zonal coordinator on completing all five clusters

Level 2: Two day orientation workshops were organized by zonal coordinators along with CCT members at zonal control rooms for all the survey team members from their respective zones. The plan of interviews was finalized and a copy forwarded to CCO after the zonal workshop. All participants had hands-on experience in conducting interviews under the close supervision of zonal coordinators and the CCT member.

Level 3: CCT members made at least four spot visits to clusters in every zone to assess two parameters: (i) Authenticity of data that had actually been collected till then, and (ii) Quality of interviews being conducted by the researchers through direct observation. The schedule of quality assurance visits was not made known either to the zonal coordinators or the survey teams. Place and time of visits were synchronized with the route maps prepared in consultation with the zonal coordinators.

Methodology 17 Level 4: After completing a cluster, the investigators along with their research associates scrutinized the schedules to check whether they were complete and appropriately marked. If satisfied, the investigator counter signed the schedules otherwise the research assistant was asked to do extra interviews as replacement.

Level 5: Interview schedules were designed to include verbatim responses (as open ended answers) and thereafter coded according to pre-determined close ended answers. All questionnaires received from the field were screened for the appropriateness of the codes put against the verbatim responses. Help of translators for various languages was taken for this purpose.

Level 6: Double entry of data was taken up at CCO Delhi followed by range checks for plausible and non-plausible values.

Development of Interview Schedules The interview schedules were developed keeping in mind the objectives of the coverage evaluation. They included a mixture of structured close-ended and semi-structured open-ended questions. List of responses for the former were printed below the respective questions to facilitate on the spot marking by the research associates. For the open-ended questions, empty boxes were provided to write down the respondent replies ‘verbatim’. These were later coded by the research associates in consultation with their senior investigators (Team leaders). Domains identified for the corresponding questions during the first cycle of process evaluation of FHAC program were utilized for this purpose. Open ended questions obviously gave room to the respondents for multiple responses and hence the totals often exceeded 100 percent.

The draft instruments developed by the CCT in close partnership with the program managers underwent several revisions before they were pilot-tested at four study sites. These were finalized during the National Orientation Workshop at Delhi in the month of August, 2000.

Unique Serial Number Every interview schedule was given a six digit unique serial number. The first two digits indicated the zone number (1-12), the next two digits the cluster number (1-30 for rural and 31-45 for urban) and the last two digits were serial numbers that indicated the category to which the respondents belonged (i.e 1-12 for men, 13-24 for women, 25-27 for health workers, 28, 29 for doctors). Thus, from the unique number, it was possible to identify the category to which a respondent belonged.

Transmission of Data Within 72 hours of data collection; the team made a photocopy of the completed instruments. While the original set was despatched to the CCO, the other was retained by the survey team and submitted to the zonal coordinator at the end of the survey after completing all five clusters allocated to them. This was done to safeguard against accidental data loss during transmission to CCO, New Delhi.

Data Management One of the CCT members was a trained bio-statistician (Dr. R.M. Pandey) who supervised data cleaning process. In addition, two more CCT members (Dr. N.K. Arora, Dr. M. Lakshman) had undergone formal training in bio-statistics. Data scrutiny and entry commenced immediately on arrival of completed schedules at CCO (Annexure VIII and IX).

Methodology 18 Data Analyses Program coverage of target population in rural and urban areas of the individual zones were calculated. Program coverage / utilization was estimated separately for men and women as well by using the statistical software package ‘STATA’. The ‘SURVEY ESTIMATES’ were computed using the population of the area as ‘pweight’, rural / urban locality as ‘strata’ and cluster number as the ‘primary sampling unit (psu)’. These include : proportion estimate with standard error, 95% confidence limits of the estimate (Estimate % ± 2 SE) and design effect (deff). Where necessary, mean difference between two groups, standard error of the difference, 95% CI of the mean difference were also worked out. The significance of the mean difference between the groups was tested by calculating t-statistics and probability levels (p).

Limitations and Potential Biases Sample size for every zone was estimated assuming the program reach as 50% with an admissible error of ± 10%. The design effect of 3 was considered appropriate. Both these parameters varied significantly between zones depending upon the program performance. The estimates were particularly unstable with a wide 95% CI if the program performance was at extremes i.e. < 10% or > 90%. Similarly, design effect also varied for different parameters.

As we were dealing with sensitive and personal issues related to sexual practices and RTI/STDs, information obtained may have had validity and reliability problems. Attempts were made to minimize these through rigorous training of the qualified research teams. The instruments were administered in the local language with due attention paid to the cultural sensitivities and the manner in which questions were asked.

Time-line 1. Preparatory phase June 15 - July 31, 2000 2. Interview schedule preparation and pilot testing August 1 - August 31, 2000 3. National protocol finalization workshop August 27 - August 29, 2000 4. Zonal orientation workshops September 1 - September 7, 2000 5. Data collection September 9 - October 5, 2000 6. Data processing, computer entry and analysis September 12 - December 31, 2000 7. Report writing January 1 - March 25, 2001 8. Submission of Report March 26, 2001

Methodology 19 IV. OBSERVATIONS

1. Background Information

Family Health Awareness Campaign - 2000 was evaluated across the country excepting the states of Gujarat, Jammu & Kashmir, Bihar and West Bengal where the program was not conducted. The country was divided into 12 zones which were later grouped according to reported HIV prevalence (Table 1).

Totally 10811 clients (5409 men and 5402 women), 1072 health workers and 538 doctors from 540 clusters were interviewed for the study using the probability proportionate to size (PPS) - 30 cluster survey methodology.

A strategy different from that in rural areas was adapted for implementation of FHAC program and a smaller design effect was considered for calculating sample size owing to the greater homogeneity of urban slum populations. Hence, the results were presented for rural and urban areas separately.

Quality Assurance Measures

The magnitude and span of field operations, and involvement of 324 researchers (108 teams each with 2 research associates and one senior faculty member) from 36 medical colleges / non- governmental organizations necessitated the need to adhere to quality assurance measures strictly from the start of the evaluation program.

As envisaged, after the national protocol finalization and orientation workshop in August 2000, 12 zonal workshops were conducted for the field teams. All these workshops were conducted by zonal coordinators along with a member of CCT. All the senior investigators and research associates attended these workshops to develop an understanding of the objectives, study instruments and field operations. At the zonal level, the zonal coordinators monitored the field operations very closely on a daily basis.

The team leaders ensured that the team reached the selected cluster, followed the protocol in selecting the households and individuals for interviews, and research associates adhered to the guidelines while interviewing the respondents. After completing the specified number of interviews in each cluster, they also scrutinized all the questionnaires, rejected the incomplete / defective ones and organized extra interviews to replace the rejected ones.

Members of the Central Coordinating Team made surprise quality assurance visits to a total of 45 (out of 540 clusters; 8.3%) clusters spread over 12 zones. During their visit to cluster areas, data was cross checked with 2.4% (259 / 10811) clients in their houses and 1.9% (209/10811) interviews were observed in the field.

Observations 19 On arrival at Central Coordinating Office, AIIMS, New Delhi, the data were screened for appropriate coding of responses. Thereafter the data were entered twice into computer and matched. Range checks and logical runs were incorporated in the data management software to minimize errors.

2. Results and Conclusions 2.1 Reach of the Program Definitions of Program Reach FHAC program had two main activities: home visits and organization of FHAC camps. Keeping these in mind, for the purpose of current program evaluation, program reach was defined as:

Population contacted or covered: Those clients (aged 15-49 years) who were either visited in their homes or those who attended the FHAC camps or were exposed to both these activities.

Population not contacted or covered: These were clients (aged 15-49 years) who were either not aware of the FHAC program; or were aware about it through publicity campaign but were not exposed to two main components of the program services, namely home visits or the attendance at camps.

Characteristics of Clients According to Reach of the Program (Tables 6, 7 )

Rural

Age Groups: The proportion of adolescents (15 to 20 years old) was significantly less among the population who were covered (6%) under the program services as compared to those who were not covered (10%) (p<0.001). Within the category of adolescents, covered by the program, more boys were contacted (8%) as compared to girls (5%).

Marital Status: In villages, 87% of individuals covered by the program were married as compared to 83% individuals who were left out (p<0.01).

Education Status: Higher proportion of contacted individuals (72%) were literate as compared to those who could not be contacted (63%) (p<0.001). The difference of literacy level between covered (60%) and non covered women (47%) was even higher.

Presence of RTI/STD symptoms during FHAC: Both men and women with these symptoms were preferentially covered under the program services.

Urban Slums In urban slums, there were no major differences in the age distribution, marital status and literacy level between contacted and non contacted individuals. However, similar to villages, the prevalence of RTI/STD symptoms among the covered individuals (10.4%) was much higher than those who were not covered (1.7%).

Observations 20 Program Reach (Tables 8-10)

During the summer 2000 cycle of FHAC , 19.3% ( 95% CI; 16.8 - 21.9) of the target population in rural areas and 13.4% (95% CI; 10.9 - 15.9) of the individuals between 15-49 years of age residing in the urban slums and high risk areas came in contact with the program services. Over 17% clients in villages and 12% in urban slums were visited at their houses mostly by health workers. The FHAC camps/meetings were attended by only 9% of target men and women in rural areas and 4%living in urban slums. Overall, 7% clients in villages and 3% in urban slums were exposed to both the program activities i.e. house visits and attendance at camps.

Across the country, in both urban and rural areas, women consistently utilized the program services more than men. But only the difference in urban slums (7.5%) was statistically significant (t=5.1 p<0.001). Among the clients who were contacted during the campaign, 6.1% in rural and 7.6% in urban areas were adolescents (i.e. <20 years).

The performance of the program was highly variable across the states. In rural areas, coverage was between 8% (in UP, Assam, Arunachal Pradesh, Meghalaya, Sikkim) to about 30% (in Andhra Pradesh, Tamil Nadu and north western states including Haryana, Delhi, Punjab, Himachal Pradesh and Chandigarh)

The program was implemented in restricted areas of urban India with the exception of Orissa, performance was uniformly poor in urban areas of all the states as compared to that in villages; the coverage varied between 5.6% to 25% in different regions of the country.

The study areas could be divided into three HIV endemic regions; namely high, intermediate and low. The high endemic states were Maharashtra, Goa, Andhra Pradesh, Karnataka, Tamil Nadu & Pondicherry. Assam, Meghalaya, Arunachal Pradesh, Nagaland, Tripura, Mizoram and Manipur were intermediate HIV endemic areas and the remaining states i.e. Haryana, Delhi, Punjab, Himachal Pradesh, Chandigarh, Uttar Pradesh, Rajasthan, Madhya Pradesh, Orissa and Kerala were categorized as the low endemic region.

The program coverage in high endemic rural areas was highest (29%; 95% CI 23.8-34.2) and significantly more (p<0.001) than the other two endemic zones (intermediate zone- coverage 10.7%, 95% CI 6.3-15.1; low endemic zone - coverage 14.4%; 95% CI 12.0-16.9). In urban slums, the performance of the program was similar in all three endemic zones (10%-15%).

There was no definite pattern of program coverage that could explain the variability in performance except as already stated, the slightly better coverage in rural high HIV endemic areas.

Reasons of Non-utilization of Program Services (Tables 11,12)

Among the target population, 73% in rural areas and 82% in urban slums, were unaware about the

Observations 21 existence of FHAC program. In villages, lack of awareness about the program varied between 91% in Uttar Pradesh to 66% in north east states of Manipur, Mizoram, Tripura and Nagaland. Similarly, in urban slums of Karnataka and Rajasthan over 90% clients were unaware about the program. High prevalence of lack of awareness about the program, particularly in urban areas, probably reflected poor social mobilization efforts on part of program implementers.

Both health workers and doctors believed embarrassment to be the reason in over 30% of the clients for their non participation in program activities. However, this was not cited as an important cause by either rural or urban clients. Among those who were aware of the program but did not attend the camps, only 4% of rural and 2% of urban subjects gave embarrassment as the reason for their non attendance at the camps.

Issues of client inconveniences (viz; inconvenient timings, loss of wages, unacceptable camp sites, not present at home/village) were the other major factors for non-participation in the program and were mentioned by 50% of the clients (who were aware about FHAC) in villages as well as urban slums. This perception was also shared by health care providers.

Place of Camp and Attendance (Table 13)

The significance of client convenience in the program performance was further indicated by the higher proportion of men or women attending the FHAC camp if these were conducted in and around the village (40.3%; 95% CI 36.2-44.3) versus when the camps were held at the health facility like sub-center/PHC/dispensary (23.1%; 95% CI 17.9-28.2) [p<0.001]. This clearly demonstrates that there was 74% more likelihood of an individual attending the campaign activities when these were near their homes.

2.2 RTI/STD/HIV-AIDS Related Awareness and Behavior Among the Clients (Table 14)

The overall aim of FHAC program was to reduce the prevalence and transmission of RTI/STD/HIV- AIDS. However, the program impact could only assessed in the short run for intermediate impact indicators. The dynamics of RTI/STD/HIV-AIDS in the community is linked to individual behavior, prevailing knowledge and treatment seeking issues associated with these diseases. Knowledge among men and women about causes, symptoms, ill effects, prevention and treatment of these diseases determine the overall awareness in the community. The study assessed this knowledge of clients under three broad headings of ‘correct knowledge’, ‘incorrect knowledge’ and ‘ignorance’.

Knowledge of Clients about RTI/STD/HIV-AIDS (Tables 15-21)

Correct knowledge about causes, ill effects, prevention and treatment of RTI/STD, and the way HIV- AIDS spreads was widely prevalent in the target population in both urban (52.3% to 84.6%) and rural (44.3% to 81.2%) areas. However, knowledge about the symptoms of these diseases (41%) and long term ill effects due the HIV (25.9% to 31.4%) infection were known in lower proportion of

Observations 22 clients. Women in both rural areas and urban slums were in general, less knowledgeable than men about these diseases (Table 15).

The clients were stratified according to their contact status with the FHAC program implemented one to three months prior to survey. The correct knowledge about RTI/STD/HIV-AIDS was significantly higher among the target population from villages as well as urban slums who came in contact with the program services as compared to those who were not contacted (p<0.01). The observed difference between the two groups was generally higher in rural (10 to 25%) than in urban subjects (6 to 21%). Differences in the knowledge level between contacted and not contacted groups was similar for both sexes.

Familiarity with ill effects of HIV-AIDS on the body was prevalent in 34% rural and 37% of urban slum clients who were covered under the program as compared to 24% and 30% of the non contacted persons in villages and urban slums respectively (p = 0.007).

A large number of clients from both sexes interviewed either in villages or urban slums were oblivious to various aspects of RTI/STD/HIV-AIDS. This ignorance was mainly about symptoms of RTI/STDs and ill effects of HIV-AIDS on the body. Women (39-60%) appeared to be more ignorant about the causes of these diseases than men (23-45%). However, the proportion of clients unaware about the various aspects of RTI/STD/HIV-AIDS in both rural and urban areas was less among those covered under the FHAC program as compared to those who were not.

The study instruments allowed multiple answers to a particular query. Hence there were clients who had correct as well as wrong perceptions about various aspects of RTI/STD/HIV-AIDS. These answers reflected deep rooted socio-cultural beliefs about symptoms, causes, and treatment of RTI/STDs. Almost 30% to 66% of the clients had erroneous notions about the ill effects of this infection on the body. Wrong perceptions were prevalent in clients from villages and cities irrespective of their FHAC program contact status. Nevertheless, it was surprising to observe that incorrect perceptions particularly about symptoms of RTI/STD and ill effects of HIV-AIDS on the body were higher among those who came in contact with the program than among those who did not.

Perception of Clients about the Problem of HIV-AIDS in their Area (Table 22) The perception of people residing either in urban or rural areas about the magnitude of HIV-AIDS in their area was similar irrespective of their program contact status. Approximately 13% utilizer clients in both urban and rural areas considered HIV-AIDS as a problem in the area as compared to 8% non-contacted clients (p>0.05). Safe Sex

One of the major objectives of FHAC program was to emphasize the fact that RTI/STDs/HIV can be treated and prevented if people adopt safe sexual practices. One step in this direction was advocacy on the benefits of using condoms. It was hoped to lead to a behavioral change of higher usage of condoms in the long run.

Observations 23 Perceptions about Benefits of Condom Usage (Tables 23, 24)

More than half of all clients in the community were aware about the benefits of using condoms during sexual intercourse. It was irrespective of their place of residence and sex. Benefits of condom usage included prevention of pregnancy and RTI/STD/HIV-AIDS. Over 70% of the target men and women in villages and more than 80% clients in urban slums who were contacted during FHAC program correctly enumerated the benefits of using condoms during sexual intercourse. This was 10- 15% more than the clients of either sex who were not covered under the program in villages as well as cities (p<0.001).

Most clients emphasized the benefit as prevention of pregnancy (61-71%) but prevention of RTI/STD was also cited as a benefit by almost half of the contacted persons (48-51%). Only 28% rural and 39% urban non-contacted clients cited prevention of RTI/STD/HIV-AIDS as a significant benefit of using condoms.

Use of Condom During Last Intercourse (Table 25)

During the present evaluation survey clients were enquired about the use of condom during last intercourse. Condoms were used by 12% (95% CI ; 9 -15) rural and 11% (95% CI ; 7 - 15) urban clients who came in contact with program services. The reported use was similar among clients of either sex (p>0.05). The prevalence of condom use among rural clients who were covered under the FHAC program was almost 5% higher than that among the non-contacted population of FHAC program (p=0.001). Among urban clients, no significant differences were observed between two categories.

The observed differences between the rural clients who were covered and not covered under the program could also be due to the effect of their age, marital and educational status, and presence of RTI/STD symptoms. On stratified analysis for educational status, condom usage in rural as well as urban clients were not significantly different (p>0.05) between clients contacted and non contacted through the program.

Interpretation of Differences in the Knowledge and Behavior Related to RTI/STD/HIV-AIDS - Issues Between Various Client Categories (Tables 26-29)

Overall it appeared that the correct knowledge about RTI/STD/HIV-AIDS was higher among men and women from rural as well as urban areas who came in contact with program services (either at homes or attended the camps) as compared to the rest of the community who could not be covered for these services. These differences persisted even after controlling for confounding factors like marital status, education and age separately (Tables 26, 27). RTI/STD symptoms were about 5 times higher among the participants of FHAC program (10%) as compared to those who were not covered (2%). The data was stratified for presence and absence of RTI/STD symptoms and re-analyzed for

Observations 24 differences in their knowledge according to program contact status (Tables 28, 29). Correct knowledge about RTI/STD/HIV-AIDS among asymptomatic clients who came in contact with the program (34-91%) was significantly higher as compared to those asymptomatic clients who did not come in contact with the program services (24-84%) in both villages and urban slums. The knowledge level of clients with RTI/STD was similar in two categories essentially due to small numbers of subjects.

Condom usage during last sexual intercourse was similar in various client categories in both rural and urban areas when the data was adjusted for potential confounders like educational status and presence of RTI/STD symptoms during FHAC program separately.

The observed differences in the knowledge and behavior about RTI/STD/HIV-AIDS related issues between clients who had and had not come in contact with the program services will have to be interpreted with caution. The current study was a cross-sectional survey and hence differences between various client categories in the knowledge parameters were likely to be due to several program and non program related inputs.

Therefore the observations made during the survey should be considered as hypothesis generating rather than causal in nature.

2.3 Program Implementation

As part of the program implementation strategy, following three important activities were undertaken:

1. Training of government and private doctors in the district in syndromic management of RTI/STD/ HIV-AIDS and about FHAC program implementation strategy. All health workers were also imparted a similar training but with lesser emphasis on the treatment component of RTI/STDs;

2. Creating awareness about the program and RTI/STD/HIV-AIDS in the community through house visits and organization of camps; and

3. Referral of patients who were identified/suspected to have RTI/STD during the awareness campaign to PHC for treatment

Although the current study was not envisaged to be a process evaluation, a large number of health providers were interviewed [1072 health workers (2 per cluster) and 538 doctors (one per cluster)]. This provided sufficient power to assess some of the program activities at an all India level rather than at the zonal level.

The data interpretation and conclusions are to be drawn in this background.

Observations 25 Training of Health Providers (Table 30)

Training of health providers was a major exercise of the program implementation strategy. It was intended to serve dual purposes: immediately create an awareness in the community and mobilize people to seek treatment for their RTI/STD related problems as part of the FHAC; and the training was also intended to serve as a capacity building exercise for the doctors in PHC.

Among 538 doctors interviewed during the study 390 (72.5%) were with the state government and 148 (27.5%) were in the private sector. Out of 148 private practitioners, 62.2% were practicing Homeopathy or Ayurveda, or were registered medical practitioners without any recognized medical degrees.

A majority of doctors working at government health facilities like PHCs/health posts/dispensaries (72%; 95% CI 68-77) had attended the training sessions conducted at district level before the launch of the FHAC program. In contrast, only 9% (95% CI 4-13) doctors working in private sector could be sensitized in the syndromic management of RTI/STDs.

Over 3/4th of the health workers (76%; 95% CI 72-79) underwent training for the FHAC program either at district or at the PHCs. A small proportion of health workers (3.4%) indicated that no training was conducted in their area.

Thus it appeared that most of the government health providers who were directly involved with the program implementation were trained as part of FHAC.

Doctors as well as health workers believed that 60-88% of the community members sought care from private practitioners or other non-conventional health facilities for RTI/STD. Yet private health care providers who were recognized as important partners in the management of RTI/STD were largely left out of this program both in training and participation in program implementation.

Training Sessions (Table 31)

Most of the doctors (96%) and health workers (93%) who attended the training program mentioned that training sessions for FHAC program lasted for one full day or more. Mostly doctors from district head quarters (85%) served as trainers for the physicians, while PHC/dispensary doctors conducted the training for the health workers in majority (68%) of the cases. In a few instances, experts from outside and medical colleges were drafted to train doctors as well as health workers.

In the first cycle of FHAC program i.e. April 1999, training of the health workers was often conducted in English. This anomaly had been taken care of in the latest FHAC and almost all (99%) health workers received training in the local language.

Organizers mostly used posters/flip charts/photographs (70%) and adopted the usual class room approach of lecturing with an occasional use of other audiovisual aids like overhead projectors (33%)

Observations 26 and film shows/video tapes (8.8%) for the training of health workers.

Content of training (Table 32)

The major emphasis in FHAC for both doctors and health workers was on the subject content of RTI/STD (doctors- 52%; health workers-60%) and HIV-AIDS (doctors- 37%; health workers-49%). Issues like implementation of FHAC program, use of referral slips and availability of treatment at PHC were discussed less often (doctors-18%; health workers-27%).

On the whole, 78% of the doctors were satisfied with the content and reported a change in their practice behavior after attending the training programs.

Quality of training

The quality of training determines the overall program performance. The manner in which program is implemented, awareness created among clients and the impact on the community reflects to a certain extent the quality of training imparted to the program implementers. Quality of content of the training program was assessed by determining the knowledge of the doctors and health workers about their understanding of FHAC program objectives as well as strategies and various aspects of RTI/STD/HIV-AIDS.

Perception of providers about FHAC program objectives (Table 33): The primary objective of FHAC was to create an awareness in the community about RTI/STD/HIV-AIDS, their prevention and treatment. However, only 16% of the health workers and doctors remembered all the program objectives; the others either mentioned the objectives partially (75%-76%) or perceived FHAC to be a general health awareness campaign. An incomplete understanding of the objectives and implementation strategies by health providers probably reflected on program performance.

Knowledge of Doctors (Table 34): The awareness about symptoms, causes, ill effects and prevention of RTI/STD and HIV-AIDS was very high (90-99%) among the doctors irrespective of their training status. This was expected as all of them were in active practice. The doctors who had undergone training had better perceptions about various aspects of the disease than those who were not trained.

Treatment practices for genital ulcers, urethral and vaginal discharge (Tables 35-38): Trained doctors emphasized the role of antibiotics significantly more often in the treatment of these disorders as compared to their counterparts who had not received FHAC training (p<0.001). Comparatively, a higher proportion (34%-52%) of untrained doctors resorted to symptomatic treatment, prescribing antiseptic lotions, ointments and creams.

Knowledge of Health workers (Table 39): It was gratifying to note that a majority of the health workers were aware about various aspects of RTI/STD and HIV-AIDS. However, the correct responses were consistently higher (3% - 13% more) among the trained health workers than those who did not attend the training program.

Observations 27 It was apparent that a large proportion of health workers in trained (24%) and untrained (42%) categories were not clear about the ill effects of HIV-AIDS on the body and hence gave incorrect answers. This was also reflected in the knowledge of the clients, who despite their contact with the program services had low awareness about the ill effects of HIV-AIDS. Almost 23% of untrained health workers were either ignorant about availability of treatment for RTI/STD or believed that the disease does not require any treatment. The proportion of such health workers was 10% in the trained group (p=0.003).

Social Mobilization

Spreading awareness about FHAC program, camps and availability of treatment facilities at PHC was the key for success of this program. As already mentioned in section 2.1“Reach of the program” most of the community members (rural-73% and urban slums-82%) were unaware about the existence of FHAC program in their area.

Sources of information (Table 40)

The program strategy was primarily dependent on interpersonal communication to create an awareness and demand for program services. Health workers were to visit every household in their area before the FHAC camp for this purpose. As envisaged in the program strategy, health workers used interpersonal communication as the major channel (75%) to create awareness about FHAC. According to health workers, volunteers, influencers and village elders were also involved for this purpose. However other communication channels like posters, banners, printed handbills, wall writings and occasionally radio and television were also used (69%) in the campaign.

Among those who were aware about FHAC, over 50% in both rural and urban areas came to know about the program and its services mostly through the local health worker but volunteers, influencers and elderly family members also helped in disseminating the information (27-29 %). Other publicity channels as a source of information about FHAC were mentioned only by 13% rural and 19% urban clients. This clearly indicates the inadequacy as well as ineffectiveness of the publicity campaign organized for the program.

Target population (Table 41)

It was clearly stated in the project operational manual and emphasized during the training program that everybody in the age group of 15-49 years should be targeted for the program services.

The health workers emphasized that adult men and women were the key target clients (91%) but only 65% of them considered adolescents (<20 years old) also as their target population. This perception of health workers had percolated down into the community and was reflected in the responses of clients. Most of the clients (rural-77% and urban-76%) who were aware about the program in their area opined that FHAC was meant for adults. Interestingly, nearly 50% of the men and one third

Observations 28 women in both villages and urban slums believed that the program was for adolescents as well. There were a few clients who expressed that the program was meant for those who frequented prostitutes or for poor and marginalized sections of the community.

It was important to note that about 7% health workers expressed ignorance about the intended target group for the program. This was reflected in client perception as well; 15% of both rural and urban clients who had come in contact with the program services did not know for whom the program was meant.

Field Operations: Home Visits (Table 42)

As already mentioned under Program Reach, 17% clients in villages and 12% in urban slums were visited in their homes; 83% of these home visits were made by health workers alone.

Over half (50%-59%) of the men and women in both rural and urban areas who were aware about the FHAC program said that the health workers visited their homes during FHAC program and acquainted them about RTI/STD/HIV-AIDS and / or FHAC camps in their area. Although the personnel from other non-health departments, NGOs and local leadership were to be involved for various program activities only about 10% clients remembered any one from these categories who visited them in connection with FHAC. The proportion of various personnel making house visits did not differ markedly between rural and urban areas. Among those who were aware about the FHAC program, 20-30% were not visited by any program functionary. They came to know about it through their friends and elderly family members or the publicity campaign.

Across the states, the pattern of house visits was similar; predominantly dependent on health workers and with little participation by non-health personnel or the NGOs.

Field operations: Camps

As part of the program, the target population was to be mobilized to the awareness camps organized in the villages or at health facilities (subcentre / PHC). In these camps and meetings, messages about RTI/STD/HIV-AIDS were to be reinforced through various communication channels.

Location of the camps (Tables 43, 44)

All states adopted a combined approach of conducting FHAC camps either as village based or health facility based. According to health workers, in 10% (95% CI: 7-13) rural areas and 19% (95% CI: 12-25) urban slums, camps were not organized. In the remaining areas, village/slum based and health facility based camps were organized in almost equal proportions.

Consistent with these observations, clients also mentioned that in rural areas 35% camps were held at PHC or the sub-center and similarly in 27% urban locations, health facility based approach was adopted. In the remaining areas, village or slum based camps were organized that were mostly

Observations 29 located at the residential areas.

Village / slum based camp organization was a predominate feature (>65%) in states like Nagaland, Tripura, Mizoram, Manipur, Madhya Pradesh, Orissa, Andhra Pradesh and Tamil Nadu. As already reported, camp attendance was 74% more in village / slum based camps as compared to when these were organized at health facilities.

Personnel manning the camp (Table 45)

As was the case with house visits, health workers were the key personnel manning the FHAC camps (90-92%). Although, the health workers mentioned the participation of volunteers, local leaders and personnel from non-health departments (mostly teachers) in 74% of the camps, the clients could remember their presence only in 5-9% of the camps. This inconsistency between the perceptions of the providers and the clients indicated the need for more tangible contributions from the non-health partners in the field operations.

IEC material used in the camps (Table 46)

Health workers largely (66.5%) used printed material for e.g. flip charts, posters and hand bills for health education. In 28% camps, interpersonal communication methods like narratives and discussions were also adopted. Audio-visual aids and traditional folk songs / plays were used infrequently.

Issues discussed at the camps (Table 46)

The objective of organizing the FHAC camps was to provide counseling and reinforce the messages regarding RTI/STD/HIV-AIDS given during house visits. The health workers were also expected to facilitate persons suspected to have RTI/STD to seek care at PHCs by giving them referral slips. As part of the program, no treatment facilities were to be provided at these camps. However, in some places, doctors were also present.

Health workers mostly discussed the various aspects of RTI/STD/HIV-AIDS in the camps. This was confirmed by clients attending the camps. However, 13% health workers utilized the camps for screening patients of RTI/STDs and hence no discussions and health counseling took place in these areas.

Availability of referral slips and treatment for RTI/STD patients at PHCs were discussed in only 11% of the camps.

Treatment Services for RTI/STDs and their Utilization

The summer 2000 cycle of FHAC program was evaluated almost 2 to 3 months after the camps were held. Hence the responses regarding the presence of RTI/STD symptoms during the program and the type of care sought may have been affected by recall bias.

Observations 30 Prevalence of RTI/STD symptoms during the FHAC program and their coverage during the campaign (Table 47)

During the campaign period 10.2% (95% CI 8.3-12.2) of the clients covered under the program and 2.1% (95% CI 1.6-2.6) of the clients not covered recalled having symptoms of RTI/STDs. Women in rural and urban slums reported presence of RTI/STD symptoms during FHAC more often than men in both client categories. The prevalence of RTI/STD symptoms was similar among the clients, who were unaware about the program; those who were aware about the program through the publicity but did not utilize any of the program services; and those who were visited at their houses but did not attend the camp (p>0.05). This was true in both urban and rural areas. Prevalence of symptoms among clients those who directly attended the camps without house visits was 14% in rural and 13% in urban slums. This was even higher (19% in villages and 30% in cities) among those men and women who had been visited at their houses and subsequently mobilized to the camps as well.

Notwithstanding the recall bias and differences in knowledge among different categories of clients about RTI/STD/HIV-AIDS, data did indicate that either due to program strategy or because of self selection or both, those with RTI/STD symptoms were 5 (rural) to 12 (urban slums) times more likely to attend the camps. One of the program strategies was to mobilize / encourage RTI/STD patients to seek treatment. However if the community perceived the program, particularly the camps, to be meant for RTI/STD patients, then this strategy of selective mobilization may have adverse consequences on the long term sustainability and acceptability of program by the people.

According to 13% (95% CI; 10-15%) health workers, program was meant for screening RTI/STD patients. This attitude among the health workers vindicated the above mentioned apprehensions.

Referral slips and use of primary health center for management of RTI/STD (Table 48)

Establishing a referral system from the field to PHC was an important component of the FHAC program. Almost 10% of the clients who were contacted had symptoms of RTI/STD as compared to 2% in the non-contacted clients. Among the contacted clients with symptoms, 77% were aware of the availability of referral slips with health workers and 69% actually took these. Almost 95% of the patients who obtained referral slips went to PHC. Overall, 56% of the symptomatic patients who were covered under the program services received the drugs from PHC. In contrast, among those who were not covered under the program services, only 27% went to PHCs and 17% received the drugs (ref : Figure E in Executive Summary).

Private doctors and non-conventional health facilities were approached by 28% clients who were symptomatic but not covered by the FHAC program. This was in sharp contrast to contacted RTI/STD patients (10%) (p<0.001). A significantly lesser proportion of clients who were contacted (13%) had not sought any form of treatment as compared to those among the not contacted category

Observations 31 (32%) (p=0.002).

The data evidently indicated to the existence of functioning referral system. This also underscores the potential future challenge of increased demand for RTI/STD services in the public sector as the program performance improves.

2.4 Provider’s Perspectives about Program Performance and Client Behavior

The provider’s perspectives about the key components of a public health program can provide insights into its performance, potential challenges that need to be overcome and the need for revisions in the of implementation strategy in future. For this purpose the perspectives of health workers and doctors were obtained and compared with client responses wherever possible.

Perceptions about Program Reach (Tables 49, 50)

House to house visits by health workers and attendance by the clients in FHA camps were two key parameters of program performance. According to 73% of the health workers (95% CI; 69-77%), 50% or more of the households were covered during the program. Only 21% health workers were realistic in their perceptions that household visits covered less than 25% clients.

For attendance at camps also, 43% health workers and 28% doctors were of the opinion that 50% or more clients attended the camps. According to 66% health workers, women attended the camps more than men.

Men and women suspected to have RTI/STD were identified during field operations and given referral slips for treatment at PHC / health post. Over 25% health workers were unaware about the fate of such patients while 18% of them thought that less than 25% of the referred patients utilized the PHC services.

Overall, it appeared that health providers at the village and PHC levels grossly over estimated the performance of the program for almost all its components. Furthermore, there were no in built mechanisms in the program to follow up those who were suspected, screened and referred for management.

Perceptions about Client Behavior (Tables 51, 52)

Sensitive and personal issues of RTI/STD/HIV-AIDS were being discussed for the first time through the public health system in FHAC program. Many among the policy makers and planners had apprehensions that given the conservative and traditional backgrounds of the people, difficulties may be faced during field operations. Seemingly, this apprehension was passed on to the program implementers. Over one fifth (22%) of the health workers believed that clients were embarrassed and felt shy when various aspects of RTI/STD/HIV-AIDS were discussed with them either at home or in the camps. Consistent with this view, 30% health workers and 33% doctors maintained that

Observations 32 embarrassment was the reason for non utilization of program services by the clients. This was in sharp contrast to the client appreciations; only 4% of the rural and 2% of urban clients who were aware of FHAC program but could not participate in its activities, cited embarrassment and shyness as the reason.

Perceptions about treatment seeking behavior of clients: According to both health workers (88%) and doctors (60%), majority of RTI/STD patients went to either private practitioners or non- conventional health facilities i.e. quacks/ ojhas. In addition, 25% health workers and 31% doctors suspected that such patients may not be seeking any kind of medical help.

Perceptions about problem of AIDS (Table 53)

One of the primary objectives of the FHAC program was to create an awareness about HIV-AIDS and the potential of HIV infection assuming even bigger proportions in the community if measures to contain it were not taken urgently. Unfortunately, only 28% doctors and 26% health workers acknowledged HIV-AIDS as a problem in their area. Compatible with this view of providers, only 13% contacted clients in both urban and rural areas felt that HIV-AIDS was a problem that deserved attention. These perceptions of both providers and clients did undermine the significance that should have been communicated about HIV infection both during the training and actual implementation of the program. There was a possibility that both providers and clients were talking about visible patients of HIV-AIDS in response to this question during survey.

In conclusion, the perceptions of the health providers were often too different from actual ground realities and brought in complacency about program performance among health functionaries. These findings highlighted the need to give a regular feed back to the program implementers about actual performance of programs and ground realities to help them reorient their functioning and approach to clients in the field.

2.5 Adolescent Profile

Target population for the program services was between 15-49 years. This included the critical age group of 15-20 years who were labeled as ‘adolescents’ for this study. Sexual activity and behavior evolve in this age group. The adolescents were not the focus of the study. Nevertheless, sufficient number of adolescents were surveyed across different zones to obtain preliminary information about their awareness about various aspects of RTI/STD/HIV-AIDS, prevalence of RTI/STD symptoms and sexual behavior. This chapter deals with these issues among adolescents.

Reach of FHAC Program among Adolescents (Table 54)

Among the surveyed population, adolescents (#20 years) comprised of 9.3% in rural areas and 8.7% in urban slums. During FHAC, 13% (95%CI: 10.1-16.6) adolescents in villages and 14% (95%CI: 9.0-18.5 ) in urban slums were covered under the program services. This was similar to the other age

Observations 33 groups covered under the program. Among the adolescents, 12% were contacted at their homes in both rural areas and urban slums. In villages, 5.5% adolescents and 4.5% in urban slums attended the camps.

Awareness of Adolescents about RTI/STD/HIV-AIDS (Table 55)

Both in villages and urban slums, the adolescents were correctly aware about features of RTI/STD/ HIV-AIDS in varying proportions. Background knowledge of adolescents about symptoms (rural- 28%; urban-29%) and causes (rural-35%; urban-46%) of RTI/STD, and ill effects (rural-25%; urban-30%) of HIV-AIDS on body were less as compared to those pertaining to other aspects of these diseases. The degree of appropriate knowledge of these disorders was higher among those adolescents who had come in contact of the program services as compared to those who did not.

Prevalence of RTI/STD/HIV-AIDS symptoms during two weeks prior to Survey & Information related to Safe Sex (Table 56)

Prevalence of urethral discharge/painful micturition was 3% among adolescents in urban slums and 6% among rural adolescents. Only 0.2% adolescents in urban areas and 0.8% in rural areas complained of genital ulcers. There were no urban rural differences. Estimations of prevalence in the two sexes were not done because it was a sub-analysis and such estimates would be unstable with wide 95% CI.

The proportion of adolescents who were sexually active could not be ascertained with the survey instrument used. However, condoms were used by 3.4% of rural and 6.3% urban slum adolescents during their last intercourse. The prevalence of condom usage was less as compared to clients of older age groups in both areas.

Almost 75% individuals below 20 years residing in urban slums and 64% in villages correctly enumerated the benefits of condom usage; this included prevention of pregnancy (41-53%) and prevention of RTI/STD/HIV-AIDS (32-41%).

2.6 Prevalence of RTI/STD Symptoms and Condom use during last Intercourse

Clients were enquired about the presence of the symptoms of RTI/STD during the two week period prior to the day of interview for coverage evaluation. These included presence of urethral discharge or painful micturition and ulcers on or around genitalia. Period of enquiry was restricted to two weeks to minimize recall bias. The study subjects were also enquired about the use of condoms during their last sexual intercourse.

Prevalence of RTI/STD symptoms during two weeks period prior to Survey

The combined prevalence of urethral discharge / painful micturition and genital ulcers in rural population was 6.9% (95% CI: 5.7-8.0) and 6.3% (95% CI: 4.7-7.8) among urban slum dwellers.

Observations 34 Among rural men, it was 3.1% (95% CI: 2.3-3.8) and 10.8% (95% CI: 8.1-12.6) among women (p<0.000). In urban slums, 2.3% (95%CI: 1.6-3.0) men and 10.2% (95% CI: 7.1-13.4) women (p<0.000) complained of presence of these symptoms during the two week period prior to the current survey.

Prevalence of Urethral Discharge / Painful Micturition (Table 57)

The prevalence of urethral discharge / painful micturition was 2% (95% CI: 1.3-2.7) among men residing in urban slums and 2.7% (95% CI: 2.0-3.4) in villages. Ten percent (95% CI: 6.8-13.2) urban and 10.5% (95% CI: 8.7-12.3) rural women complained of urethral discharge/painful micturition. Among men, it varied between 0%-10%, while 5%-19% women reported having urethral discharge/painful micturition in different study zones.

These symptoms were reported almost five times more by women (10%-10.5%) as compared to men (2%-2.7%). Vaginal discharge is one of the common symptoms of RTI/STD among women. These symptoms could have been confused with urethral discharge. Hence, higher prevalence of urethral discharge reported by women might be biased due to the inclusion of vaginal discharge as well.

Prevalence of Genital Ulcers (Table 58)

Genital ulcers were reported by 1.1% rural (95% CI 0.8-1.5) and 1.0% urban (95% CI 0.6-1.4) clients. There were no major differences in their prevalence between the two sexes either in urban or rural areas.

Prevalence of RTI/STD symptoms according to HIV Endemicity (Tables 59, 60)

Prevalence of urethral discharge/painful micturition in medium HIV endemic states was 13% and 11% respectively in rural areas and urban slums. This was higher than that reported for low as well as high endemic regions.

Prevalence of genital ulcers similarly showed a trend towards higher prevalence in medium endemic states although differences were not statistically significant as compared to the other two endemic regions.

From the available data, it was not possible to postulate factors for differences observed between the three endemic regions.

Prevalence of RTI/STD symptoms according to Program Utilization Status of Clients

The prevalence of either urethral discharge/painful micturition or genital ulcers did not vary significantly according to program contact status of the clients in both rural and urban slum populations (Tables 61, 62).

Characteristics of Clients with presence of RTI/STD symptoms at the time of Survey (Table 63)

Observations 35 Age Group: Over 7% individuals above the age of 20 years and 6.0% adolescents in villages had RTI/STD symptoms at the time of survey (p>0.05). In urban slums, the prevalence of symptoms in these two age categories was 7% and 3% respectively (p<0.01). This difference in prevalence among the two age categories in urban slums may be related to marital status rather than the age of the clients.

Marital Status: In villages and urban slums, the prevalence of RTI/STD symptoms was almost two times higher among married individuals as compared to unmarried ones (p>0.001).

Educational Status: Probably due to their lack of awareness, RTI/STD symptoms were prevalent in higher proportions among illiterate people in both villages and urban slums.

Other Features: Among those men and women, who had RTI/STD symptoms during FHAC - 2000, 52% (95% CI: 42.4-61.6) complained of presence of RTI/STD symptoms during the evaluation survey as well. In contrast, the prevalence was 5.1% (95% CI: 4.3-5.9) among those who were asymptomatic during FHAC - 2000 (p<0.001).

Use of Condoms during last Intercourse (Tables 64, 65)

In villages, 8% (95% CI: 7.0-8.9) of clients between the age of 15-49 years had used condoms during their last sexual intercourse before the survey. In urban slums, the condoms were being used by 11.1% (95% CI: 9.2-13.0) individuals. There were no differences in the prevalence reported by clients of either sex in villages and city slums.

The prevalence of condom use varied across the country from a low of 4% in states like Andhra Pradesh, Karnataka and Tamil Nadu to a high of 15% in rural and 26% in urban slum population of north western states like Himachal Pradesh, Punjab, Chandigarh, Haryana and Delhi.

Condom use was reported by 10% (95% CI: 8.5-11.4) rural and 12.4% (95% CI: 9.9-14.9) urban slum dwellers who were literate. In contrast, these were significantly less used by illiterate subjects in both villages (4.3%; 95% CI: 2.9-5.7) and urban slums (7.5%; 95% CI: 5.2-9.8) [p < 0.001]. The other variables that confounded condom usage were marital status (p< 0.001). Presence of symptoms suggestive of RTI/STD were not associated with its use (p = ns).

Characteristics of Clients who had used Condoms during last Intercourse (Table 66)

Age Group: The prevalence of condom use among individuals older than 20 years was almost twice as compared to that in younger people in both villages and urban slums (p<0.001).

Marital Status: Almost 9% married individuals in rural areas and 13% in urban slums had used condoms during their last sexual intercourse. In contrast 3.2% unmarried persons in both areas were using condoms (p<0.001). However the study design did not permit estimates of the proportion of unmarried persons who were sexually active. Hence, condom usage in this segment of population

Observations 36 needs to be interpreted with this limitation in view.

Educational Status: In villages as well as urban slums, literacy appeared to be associated with significantly higher use of condoms during sexual intercourse (p<0.001).

Other Features: Condom usage was significantly high among those who had RTI/STD symptoms during the survey (11.8%) as compared to those who did not have (8.2%) (p<0.001). Thus it appeared that condom usage was influenced by the place of residence (rural vs. urban slums), marital status, educational level and presence of RTI/STD symptoms.

Observations 37 V. RECOMMENDATIONS

Program Acceptability

FHAC program was acceptable to the community in the villages as well as urban slums. It can be continued with its current framework of objectives and implementation strategies.

Program Reach

C The program coverage will have to be increased substantially to achieve the desired changes in the knowledge and behavior of the community.

C As originally envisaged, the program should target all community members between the ages of 15-49 years. The current strategy of preferentially mobilizing the individuals with suspected RTI/STD may have stigmatized the FHAC camps as RTI/STD camps, thereby reducing attendance. Referral slips can be given both during house visits and in the camps.

Social Mobilization

C Major inputs are needed to improve social mobilization which appeared to be a weak link in the program. Most of the community has to be made aware of the existence of the FHAC program. This requires using all channels of communication. The messages about RTI/STD/HIV-AIDS should be simple, consistent and culturally appropriate. Communication experts should be involved to mount publicity campaigns after pre-testing the messages for suitability and clarity.

C The community should also be debriefed about the prevalent misconceptions regarding causes, symptoms, ill effects, treatment of RTI/STD/HIV-AIDS and safe sexual practices.

C In view of the sensitive and personal nature of the issues related to various aspects of RTI/STD/HIV-AIDS, inter-personal communication should continue to be a key strategy in the field. This would mean involving non-health sectors, notably NGOs/CBOs/local leadership and influencers, for home visits as well as organization of the camps.

C Private health sector should be invited to participate in the program as an important partner because large segments of population seek treatment from them

Recommendations 38 for RTI/STD/HIV-AIDS.

Program Implementation

C Client inconvenience: As the program coverage increases, this might emerge as an important reason for non-utilization of the FHAC related services. Conveniences of the local community and partners should be taken into account before the time for the program is fixed. It was not necessary to organize the program in the whole country simultaneously. FHAC could be implemented more effectively with a wider coverage if it was organized in a staggered manner in different states. The house visits and camps should be organized in a manner that are client friendly. Camps should be organized exclusively within the villages / urban slums to facilitate maximum attendance.

C Extra efforts continue to be required to reach the male clients and adolescents.

C A mechanism for follow up of RTI/STD patients identified in the field needs to be put in place. This is essential for the sustainability of the referral system of FHAC program.

Training

C Remaining health providers need to be trained.

C Re-orientation of all health providers is necessary on a regular basis; these sessions may also be utilized to provide feed back to providers regarding program performance.

C With most of the health providers having already received training, the focus should now shift to train the private practitioners, NGOs/CBOs and local leaders.

C Training should focus equally on the program objectives and strategies as on the syndromic management of RTI/STD/HIV-AIDS.

C Training content requires suitable modifications to highlight the seriousness of the problem of HIV-AIDS in the community, ill effects of HIV-AIDS, the symptoms of RTI/STD and educating the community about the prevalent misconceptions about these diseases.

C Special emphasis is required for imparting communication skills to deal with sensitive and personal issues like RTI/STD/HIV-AIDS.

Future Challenges

The public health system will have to be strengthened to meet the increasing demands for RTI/STD services as the program coverage is improved. Simultaneously, efforts will be

Recommendations 39 necessary to improve the availability and accessibility of condoms to the sexually active segment of the population.

Recommendations 40 Table 6. Characteristics of clients according to reach of the program (Rural Areas)

Contacted - YES Contacted - NO Background variable Men Women Total Men Women Total Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI % % % % % % Age group 15 - 20 years 7.8 5.1- 10.4 5.0 3.3- 6.6 6.1 4.6- 7.7 10.5 9.0-11.9 10.1 8.6-11.6 10.3 9.3-11.3 21 - 35 years 56.6 51.8-61.5 71.8 68.7-74.9 65.2 62.2-68.2 59.6 57.4-61.8 68.2 65.9-70.5 63.8 62.2-65.3 > 35 years 35.5 30.8-40.2 23.1 19.8-26.3 28.5 25.6-31.4 29.7 27.1-32.4 21.1 19.1-23.2 25.6 23.6-27.5 Marital Status: Married 79.5 76.0-83.1 93.2 91.3-95.1 87.2 85.4-89.1 75.0 72.5-77.5 90.8 89.2-92.4 82.7 81.2-84.2 Education: Literate 85.9 81.0-90.8 60.3 55.5-65.2 71.5 67.3-75.7 78.5 76.1-80.8 47.2 43.6-50.8 63.3 60.7-66.0 RTI/STD during FHAC: Present 3.2 1.4- 5.0 15.6 12.3-18.8 10.2 8.1-12.3 0.6 0.3-1.0 3.8 2.7-4.8 2.1 1.6-2.7 Table 7. Characteristics of clients according to reach of the program (Urban Slums)

Contacted - YES Contacted - NO Background variable Men Women Total Men Women Total Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI % % % % % % Age group 15 - 20 years 12.7 4.3-21.0 5.1 1.9-8.3 7.8 4.6-11.0 11.1 8.8-13.4 6.8 5.6-8.1 9.1 7.5-10.7 21 - 35 years 54.6 47.1-62.1 71.1 64.7-77.5 65.2 59.8-70.5 58.7 53.4-64.0 67.6 64.5-70.6 62.9 59.6-66.3 >35 years 32.6 21.8-43.4 23.6 18.2-29.1 26.9 20.5-33.2 29.7 25.2-34.2 25.4 22.5-28.2 27.6 24.6-30.6 Marital Status: Married 64.6 54.1-75.1 91.4 87.6-95.2 81.7 77.9-85.5 70.3 66.1-74.4 92.1 90.6-93.6 80.7 78.4-83.0 Education: Literate 88.0 82.2-93.9 69.7 63.0-76.5 76.3 70.9-81.7 81.7 77.5-85.9 62.7 57.3-68.2 72.6 68.7-76.5 RTI/STD during FHAC: Present 3.4 0.7-6.1 14.3 8.0-20.6 10.4 6.1-14.7 0.6 -0.2-1.4 2.9 1.2-4.6 1.7 0.9-2.5 Table 8. Reach of the family health awareness campaign

Rural Areas Urban Slums

Reach category Men Women Total Men Women Total

Estimate % Estimate % Estimate % Estimate % Estimate % Estimate % 95% CI 95% CI 95% CI 95% CI 95% CI 95% CI Design effect Design effect Design effect Design effect Design effect Design effect A. Clients who did not receive program services 1. Not aware about 75.8 71.8 73.8 84.9 77.6 81.3 FHAC program 73.2-78.5 68.4-75.2 71.2-76.4 81.0-88.8 73.8-81.4 77.8-84.7 4.3 6.5 8.1 2.4 1.7 3.2 2. Aware about 7.2 6.3 6.8 5.4 5.2 5.3 FHAC through 5.3-9.2 5.2-7.5 5.6-8.0 3.4-7.4 3.8-6.7 3.9-6.7 media but did not attend camp 6.7 2.6 5.3 1.5 8.4 1.5 B. Clients who received program services 1. Contacted at 9.2 11.9 10.6 7.7 10.8 9.3 home alone 7.7-10.6 9.7-14.2 8.7-12.2 5.5-10.0 8.0-13.7 7.0-11.6 2.9 5.2 6.2 1.4 1.7 2.6 2. Attended camps 1.9 1.8 1.8 1.1 0.7 0.9 only 1.2-2.5 1.2-2.4 1.4-2.3 0.3-1.8 0.3-1.2 0.5-1.3 2.4 2.1 2.7 1.1 0.4 0.6 3. Contacted at 5.8 8.1 6.9 0.9 5.6 3.2 home + attended 4.4-7.2 6.4-9.8 5.6-8.3 0.4-1.4 4.1-7.0 2.4-4.0 camp 4.0 4.5 6.1 0.5 0.8 0.9

Table 9. Program reach : proportion of clients who received services* during fhac program by zone

Rural Areas Urban Slums

States Men Women Total Men Women Total

Estimate % Estimate % Estimate % Estimate % Estimate % Estimate % 95% CI 95% CI 95% CI 95% CI 95% CI 95% CI Design effect Design effect Design effect Design effect Design effect Design effect

Chandigarh, Delhi, 25.2 44.3 34.8 6.7 26.7 16.7 Haryana, 15.8-34.7 31.0-57.7 24.8-44.8 1.6-11.7 12.2-41.1 8.1-25.2 Himachal Pradesh, 3.66 5.56 6.85 0.97 2.48 2.46 Punjab (Zone 1)

Uttar Pradesh 10.0 6.0 8.0 7.3 13.3 10.3 (Zone 2) 3.4-16.6 1.4-13.5 2.5-13.5 1.4-16.0 1.3-25.4 1.0-19.7 12.7 26.3 22.1 3.65 4.16 6.22

Assam, Arunachal 4.7 11.3 8.0 6.7 14.0 10.3 Pradesh, 1.3-8.0 3.1-19.5 2.7-13.2 2.0-11.4 1.7-26.2 3.0-17.7 Meghalaya, Sikkim 1.33 3.58 4.04 0.12 0.44 0.41 (Zone 3)

Manipur, 20.0 25.7 22.8 14.0 6.0 10.0 Mizoram, 11.9-28.1 13.3-38.0 14.1-31.6 4.4-23.6 0.2-11.8 4.2-15.8 Nagaland, Tripura 0.49 0.96 1.04 0.13 0.10 0.13 (Zone 4)

Rajasthan 10.7 16.4 13.5 8.0 11.3 9.7 (Zone 5) 2.0-19.4 7.8-25.0 6.4-20.6 0.8-15.2 0.3-22.3 2.2-17.1 6.42 4.34 6.97 0.83 1.43 1.50

Madhya Pradesh 13.0 16.4 14.7 7.3 14.0 10.6 (Zone 6) 4.2-21.8 6.3-26.5 6.2-23.2 0.9-15.5 0.4-28.4 0.3-21.5 8.24 8.98 13.9 1.83 3.17 4.58 Rural Areas Urban Slums

States Men Women Total Men Women Total

Estimate % Estimate % Estimate % Estimate % Estimate % Estimate % (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Design effect Design effect Design effect Design effect Design effect Design effect

Orissa 21.6 23.0 22.3 20.5 29.3 24.9 (Zone 7) 11.0-32.1 12.1-33.9 13.0-31.5 7.7-33.3 12.6-46.1 11.6-38.2 4.39 4.36 6.51 5.11 0.68 0.96

Goa, Maharashtra 23.3 34.2 28.7 6.8 17.3 12.2 (Zone 8) 14.7-31.8 23.6-44.8 20.4-37.0 0.7-14.4 6.6-28.0 4.4-20.0 4.82 5.89 7.79 3.25 2.94 4.16

Andhra Pradesh 28.7 31.6 30.1 13.3 18.7 16.0 (Zone 9) 17.9-39.4 20.5-42.7 20.5-39.7 6.3-20.3 5.0-32.4 7.7-24.3 6.51 6.65 10.19 0.91 2.66 2.19

Karnataka 25.0 28.7 26.8 4.0 18.0 11.0 (Zone 10) 15.2-34.8 19.6-37.8 18.8-34.9 0.7-8.7 4.8-31.2 2.8-19.2 3.80 3.01 4.91 0.97 1.97 2.30

Pondicherry, Tamil 20.5 39.0 29.7 23.3 19.3 21.3 Nadu 10.2-30.9 27.0-51.0 19.7-39.8 6.9-39.7 7.3-31.4 9.2-33.5 (Zone 11) 5.87 5.33 8.62 3.53 2.17 4.11

Kerala, 5.7 10.0 7.8 5.3 5.9 5.6 Lakshwadeep 2.7-8.7 2.8-17.2 3.6-12.0 0.6-10.1 1.2-10.7 1.4-9.9 (Zone 12) 0.87 2.92 2.51 0.51 3.65 6.29 16.9 21.8 19.3 9.7 17.2 13.4 All India 14.6-19.2 18.5-25.1 16.8-21.9 7.4-11.9 13.7-20.6 10.9-15.9 4.36 7.17 9.05 1.17 1.67 2.16 * Definition of receiving program services : Contacted at home and/or attended camp Table 10. Reach of the family health awareness campaign program by HIV- endemicity

Low HIV Endemic States Medium HIV Endemic States High HIV Endemic States

Estimate % (95% CI) Design effect Estimate % (95% CI) Design effect Estimate % (95% CI) Design effect Rural Areas Men 13.2 10.6-15.9 3.6 7.4 4.4-10.5 2.7 24.6 19.8-29.3 4.4 Women 15.6 11.7-19.6 6.7 13.9 7.1-20.7 8.0 33.5 27.1-39.9 6.5 Total 14.4 12.0-16.9 5.7 10.7 6.3-15.1 8.3 29.0 23.8-34.2 9.4 Urban Slums Men 7.7 4.6-10.9 1.2 9.1 3.7-14.4 0.6 11.7 7.9-15.6 1.2 Women 16.4 9.6-23.2 2.9 11.4 3.3-19.5 1.1 18.2 13.7-22.7 1.2 Total 12.1 7.6-16.5 3.3 10.2 4.8-15.6 1.0 15.0 11.5-18.5 1.7 Table 11. Reasons for non-participation by the clients in FHAC camps

Clients’ Responses Health Workers’ Doctors’ Perception Perception Rural Areas Urban

Reasons Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI

Not aware about 81.1 78.7-83.3 84.8 81.5-88.2 - - FHAC program Indifferent 2.5 1.9-3.2 3.3 2.3-4.3 14.7 11.6-17.8 21.4 17.8-24.9

Embarrassed 0.8 0.5-1.2 0.3 0.0-0.5 30.4 26.5-34.2 32.9 28.9-36.8

Not aware about 0.8 0.4-1.1 0.7 0.3-1.2 12.2 8.6-15.8 22.5 18.9-26.0 camp Need - not felt 4.0 3.2-4.7 3.5 2.3-4.7 21.1 17.7-24.5 14.3 11.3-17.2

Inconvenient 2.2 1.6-2.9 2.3 1.0-3.5 15.4 11.6-19.2 11.7 8.9-14.4 timings Loss of wages 7.0 5.8-8.1 3.9 2.9-4.9 52.8 49.9-55.8 34.0 29.9-38.0 (affordability) Not in village 1.7 1.2-2.1 1.0 0.3-1.7 3.8 2.2-5.4 1.3 0.3-2.2 (availability) Table 12. Reason for non - participation by clients : Lack of awareness about FHAC program

Rural Areas Urban Slums Zone Estimate % 95% CI Estimate % 95% CI Chandigarh, Delhi, Haryana, 66.6 57.3-75.9 81.3 73.5-88.9 Himachal Pradesh, Punjab (Zone 1) Uttar Pradesh (Zone 2) 91.3 84.9-97.6 87.8 75.7-99.9 Assam, Arunachal Pradesh, 81.2 75.9-90.5 84.5 77.2-91.8 Meghalaya, Sikkim (Zone 3) Manipur, Mizoram, Nagaland, 66.2 53.3-79.2 84.9 77.1-92.8 Tripura (Zone 4) Rajasthan (Zone 5) 87.5 81.4-93.7 91.3 84.8-97.9 Madhya Pradesh (Zone 6) 89.7 83.4-95.7 87.8 77.0-98.7 Orissa (Zone 7) 75.0 66.7-83.4 82.2 71.3-93.0 Goa, Maharashtra (Zone 8) 73.8 67.0-80.5 86.5 77.2-95.9 Andhra Pradesh (Zone 9) 76.6 67.9-85.3 88.1 81.5-94.8 Karnataka (Zone 10) 69.0 60.9-77.1 90.4 81.8-98.9 Pondicherry, Tamil Nadu (Zone 11) 66.9 56.5-77.2 67.0 50.1-83.9 Kerala, Lakshadweep (Zone12) 89.7 85.8-93.6 89.1 81.5-96.7 All India 81.0 78.7-83.4 84.8 81.5-88.2 Table 13. Reason for utilizing FHAC program services : Location of camp and attendance

Proportion of clients attending the camps Location of camp Estimate % 95% CI Design effect In & around Village / Locality 40.3 36.2-44.3 2.44 At Sub-centre / PHC /Dispensary 23.1 17.9-28.2 4.67

Test Results Difference % 95% CI t p-value 17.2 11.4-23.0 5.95 0.001 Table 14. Classification of client responses regarding RTI / STD / HIV-AIDS

Correct Responses Incorrect Responses

1. Symptoms of RTI/STDs C Urethral discharge (including pus, blood) C Non-specific systemic symptoms (e.g. weakness / pallor / feeling sick / no blood C Ulcers on genitals / warts / papillomas / infection formation / loss of appetite / weight loss/ giddiness / lack of concentration / C Pain or swelling in and around penis or groin or vagina or darkening of complexion / looking old / fatigue / pimples / decaying limbs / tremors / vulva / vaginitis / pain during intercourse sleeplessness / memory loss / fever/ heat / lymph node enlargement) C Pain lower back or abdomen C Socio cultural beliefs (e.g. any swelling in scrotal or inguinal area i.e hernia / C Swollen glands / ulcers in inguinal region / inguinal bubo hydrocoele / change in gait / masturbation) C Any vaginal discharge C Itching on / around genitals C Foul smelling discharge / pus from vagina C Infertility / uterine prolapse/ abortions / uterus gets spoilt C Menstrual disturbances C Unrelated / Irrelevant (e.g. TB / cancer / stones / cough / difficulty in breathing / C Painful micturition / difficult micturition / urethritis diabetes / vomiting / depression / liver disease / diarrhoea / anemia / skin infection/frequent micturition C Nightfall / premature ejaculation / dhat / passage of thick urine

2. Causes of RTI/STDs C Multiple partners / sexual promiscuity / extra marital C Lack of awareness relationship / prostitution C Socio-cultural beliefs: (e.g. bathing in dirty water / wearing or using other person’s C Spouse having multiple partners clothes or towel / eating sweets, hot or fried things / body heat / diet related / C Infected spouse / partner / caused by germs urinating in a bad place / eating betel nut / masturbation / mosquito bite / hereditary / C Transfusion of infected blood / blood products malnutrition / alcoholism / witchcraft / contagious / watching pictures) C Unsafe needles or syringes or instruments / sharing shaving C Homosexuality / wrong type of intercourse blades or razors C Non specific causes: pregnancy / large number of children / weakness / diabetes / C Drug abuse poor appetite / fungus / anaemia / allergy / post tubectomy / using copper-T/ wound C Unprotected sex / non-use of condoms in uterus / increased sexual intercourse / abortions / early marriage / lack of C Lack of personal hygiene / unhygienic conditions / habits hormones during menstruation C Mother to child Table 14. Contd...

Correct Responses Incorrect Responses 3. Ill Effects of RTI/STDs (what will happen if not treated) C Affects new born / children, will affect generations C Nothing will happen / heals by itself C Spreads to spouse C Others: various symptoms / community looks down on them / C Spreads to others in community weakness / cancer C Leads to infertility / uterus gets spoilt / impotency results C Disease worsen / won’t heal / damage to body C Leads to development of AIDS C Leads to death 4. Prevention of RTI/STDs C Avoid multiple sex partners / high moral and ethical code of C Not possible to prevent conduct / modify sexual behavior C Others (specify): avoid sexual intercourse / keep distance from wife or C Safe sexual practices / use of condoms husband / avoid sex during menstruation or during pregnancy / don’t C Use of sterile needles or syringes or instruments or gloves / mix with infected person / don’t masturbate / remove uterus or have avoid drugs operation / avoid urinating in dirty places / avoid smoking or drinking C Use of tested blood / blood products / take oral pills / avoid getting children / oil massage / take traditional C Screening / identification of patients /sex education / create medicine / do exercise / take nutritious food / avoid hot things / don’t awareness drink too much tea C Use clean or new razors and blades for shaving C Treat RTI or STD / consult doctors C Maintain hygiene / take care of body C Prevention possible (but details not known) Table 14. Contd...

Correct Responses Incorrect Responses

5. Treatment of RTI/STDs C Consult doctor / PHC / dispensary / private practitioner / allopathy C No treatment available (only prevention) C Consult indigenous practitioners / ayurvedic/ homeopathic / unani C No need to treat / goes away on its own / hides the disease medicine / traditional medicine C Non-conventional health facility (including quack, black magic, Ojhas, temple, priest) C Self treatment / self medications / maintain hygieneBoth husband and wife should be treated

6. Treatment if husband is affected with RTI/STDs C Both husband and wife should be treated C No need of treatment C Treat husband only C Treat wife only

7. Treatment if wife is affected with RTI/STDs C Both husband and wife should be treated C No need of treatment C Treat husband only C Treat wife only

8. Spread of HIV/AIDS C Lack of awareness C Lack of personal hygiene / unhygienic conditions / habits during menstruation C Multiple partners / sexual promiscuity / extra marital relationship / C Socio-cultural beliefs (e.g. bathing in dirty water / wearing or using other prostitution person’s clothes or towel / eating sweets, hot or fried things / body heat / C Spouse having multiple partners urinating in a bad place / chewing betel nut / masturbation / mosquito bite / C Infected spouse / partner / by germs hereditary / cough / alcoholism / contagious) C Transfusion of Infected blood or blood products / contact with C Homosexuality / wrong type of intercourse infected blood through wounds cuts C Non specific causes : kissing / touching the patient / excessive use of condom / C Unsafe needles or syringes or instruments / sharing shaving blades sharing infected person’s things / using same thermometer or razors / piercing ears or nose C Drug abuse C Unprotected sex / non-use of condoms C Mother to child C Same as RTI/STD or due to RTI/STD Table 14. Contd...

Correct Responses Incorrect Responses

9. Ill effects of HIV-AIDS on the body C Repeated infections of many kinds (diarrhoea / respiratory or any C Unrelated (e.g. TB / cancer / anemia ) other organ infection / skin disease C Non-specific body or systemic effects (e.g. fever, weakness, weight loss, loss of C Weak immune system / will get sick appetite, fatigue, looking old, lack of concentration, darkening of complexion / C Death loss of hair / heat / irritation / change in gait / worsens / uneasiness / life gets affected) C Urethral discharge / vaginal discharge C Genital ulcers / ulcers C Other manifestations related to genital organs / itching / infertility / uterus gets spoilt / hydrocoele

10. Prevention of HIV-AIDS C Avoid multiple sex partners / high moral and ethical code of C Maintain hygiene / take care of body conduct / fear of god / modify sexual behavior C Not possible to prevent C Avoid having children (vertical transmission) C Others (specify): don’t mix with them / don’t eat or drink with them / eat C Safe sexual practices / use of condoms vegetarian food or good food / do exercise / avoid intercourse during pregnancy C Use of sterile needles or syringes or instruments or gloves / avoid or during menstruation / don’t use others’ things / make a law/ avoid alcohol or drug addiction (intra-venous) smoking C Use of tested blood / blood products C Screening / identification of patients /sex education / create awareness C Clean or new razors and blades C Treat RTI or STD / consult doctors C Prevention possible (but details not known) Table 15. RTI/STD/HIV-AIDS related awareness (correct responses) among the clients - All India Data

Rural Areas Urban Slums Awareness Topics Men Women Total Men Women Total

Reproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)

Symptoms Estimate % 33.2 50.2 41.7 33.7 48.9 41.3 95% CI 29.4-36.9 47.2-53.3 39.0-44.3 27.9-39.5 43.2-54.7 36.4-46.3

Causes Estimate % 54.5 34.0 44.3 64.9 39.7 52.3 95% CI 51.3-57.8 31.0-37.0 42.2-46.4 60.8-68.9 36.1-43.3 49.4-55.2

Ill Effects Estimate % 77.6 64.9 71.3 77.5 69.4 73.4 95% CI 75.3-79.9 61.5-68.3 68.9-73.5 72.5-82.4 56.2-72.5 70.4-76.5

Prevention Estimate % 67.9 51.2 59.6 73.1 58.9 66.0 95% CI 65.4-70.6 46.8-55.6 57.2-61.9 67.8-74.4 55.2-62.8 61.9-70.1

Treatment Estimate % 84.3 78.1 81.2 82.5 86.7 84.6 95% CI 81.7-86.9 74.9-81.3 78.7-83.7 77.6-87.4 84.1-89.3 82.1-87.1

Who should Estimate % 50.4 38.0 44.2 49.5 44.5 46.9 be treated? @ 95% CI 47.1-53.8 34.3-41.8 41.3-47.2 44.8-54.2 40.4-48.5 43.4-50.6

Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)

Spread Estimate % 66.9 46.5 56.8 80.2 64.5 72.3 95% CI 63.9-70.1 43.9-49.0 54.6-58.9 76.3-84.1 60.8-68.3 69.5-75.2

Ill effects Estimate % 30.0 21.7 25.9 34.1 28.7 31.4 on body 95% CI 26.3-33.8 18.7-24.8 23.2-28.6 28.4-39.7 24.2-33.2 27.3-35.4

Prevention Estimate % 67.8 44.6 56.2 77.3 61.3 69.3 95% CI 64.2-71.3 41.9-47.3 53.9-58.4 73.4-81.3 56.8-65.8 66.1-72.4

@ If one of the spouses were having RTI/STD symptoms (correct response - treat both) Table 16. RTI/STD/HIV-AIDS related awareness among rural areas men

Awareness status Correct responses Incorrect responses Ignorant

Program Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NO

Reproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)

Symptoms Estimate% 56.3 28.4 $ 38.9 27.6 $ 30.0 56.6 $ 95% CI 49.2-63.3 24.8-31.9 32.9-44.9 25.0-30.2 25.3-34.6 53.6-59.5

Causes Estimate % 73.5 50.6 $ 13.2 12.2 23.4 44.8 $ 95% CI 65.7-81.2 47.2-53.9 8.9-17.5 10.1-14.3 15.5-31.2 41.5-48.1

Ill Effects Estimate % 86.4 75.7 $ 14.6 10.4 7.1 20.3 $ 95% CI 82.5-90.3 73.1-78.4 9.5-19.6 8.6-12.1 4.2-10.1 17.5-23.1

Prevention Estimate % 87.4 63.8 $ 6.5 7.8 10.2 32.7 $ 95% CI 84.4-90.4 60.9-66.8 4.4- 8.6 6.2- 9.5 7.4-13.1 29.8-35.7

Treatment Estimate % 92.0 82.8 $ 10.7 9.6 5.2 13.1 $ 95% CI 89.3-94.6 79.7-85.8 7.2-14.2 7.9-11.4 2.8- 7.5 10.4-15.9

Who should Estimate % 65.5 47.4 $ 31.9 43.4 # 2.7 9.1 $ be treated? @ 95% CI 59.5-71.4 43.5-51.2 25.4-38.3 39.6-47.3 0.7- 4.6 7.1-11.2

Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)

Spread Estimate % 87.5 62.7 $ 13.3 10.2 11.1 34.9 $ 95% CI 83.6-91.3 59.3-66.1 8.9-17.8 8.7-11.7 7.3-15.0 31.7-38.1

Ill effects Estimate % 37.5 28.4 $ 66.2 42.3 $ 21.7 43.5 $ on body 95% CI 31.1-44.0 24.5-32.3 60.3-72.0 38.0-46.5 15.9-27.4 39.8-47.1

Prevention Estimate % 87.5 63.7 $ 7.7 7.5 11.3 33.7 $ 95% CI 84.1-90.9 59.8-67.6 5.2-10.2 6.1- 8.9 7.8-14.8 30.1-37.3 Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients was statistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001 @ If one of the spouses were having RTI/STD symptoms (correct response - treat both) Table 17. RTI/STD/HIV-AIDS related awareness among rural areas women

Awareness status Correct responses Incorrect responses Ignorant

Program Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NO

Reproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)

Symptoms Estimate % 65.2 46.0 $ 28.9 21.9 # 30.2 49.5 $ 95% CI 57.7-72.6 42.3-49.5 24.5-33.3 19.8-23.9 22.8-37.5 45.6-53.4

Causes Estimate % 49.9 29.5 $ 22.3 15.7 * 38.8 60.2 $ 95% CI 45.0-54.6 26.3-32.8 16.8-27.8 13.2-18.1 33.9-43.7 57.0-63.3

Ill Effects Estimate % 75.7 61.8 $ 22.2 11.8 $ 14.1 32.3 $ 95% CI 70.9-80.5 58.0-65.5 17.7-26.7 10.1-13.6 9.2-19.0 27.4-36.6

Prevention Estimate % 68.7 46.2 $ 10.4 7.1 * 26.2 49.2 $ 95% CI 62.8-74.6 41.8-50.6 7.5-13.3 5.8-8.4 20.5-32.0 44.9-53.5

Treatment Estimate % 90.3 74.7 $ 9.6 10.8 6.9 19.2 $ 95% CI 87.7-92.9 71.1-78.3 6.6-12.5 8.0-13.6 4.5-9.3 15.3-23.0

Who should Estimate % 47.8 35.3 # 48.3 47.3 3.8 17.3 $ be treated? @ 95% CI 41.3-54.3 31.0-39.6 41.8-54.9 42.6-52.0 2.2-5.4 13.6-20.9

Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)

Spread Estimate % 68.9 40.1 $ 9.0 7.4 28.4 57.1 $ 95% CI 64.6-73.1 37.6-42.7 6.4-11.6 6.0-8.8 24.1-32.8 54.6-59.7

Ill effects Estimate % 30.4 19.2 # 51.3 27.3 $ 36.4 62.7 $ on body 95% CI 23.5-37.4 16.2-22.3 46.0-56.6 25.0-29.7 32.4-40.3 60.2-65.3

Prevention Estimate % 66.6 38.4 $ 9.0 6.2 # 30.2 59.6 $ 95% CI 62.2-71.1 35.6-41.2 6.7-11.2 5.0-7.5 25.8-34.5 56.9-62.2 Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients was statistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001 @ If one of the spouses were having RTI/STD symptoms (correct response - treat both) Table 18. RTI/STD/HIV-AIDS related awareness among rural areas clients (Total)

Awareness status Correct responses Incorrect responses Ignorant

Program Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NO

Reproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)

Symptoms Estimate % 61.3 36.9 $ 33.3 24.9 $ 30.1 53.2 $ 95% CI 55.5-67.2 34.3-39.6 29.8-36.8 23.2-26.5 24.9-35.4 50.6-55.8

Causes Estimate % 60.2 40.4 $ 18.3 13.9 * 32.1 52.3 $ 95% CI 55.7-64.7 38.2-42.6 14.3-22.3 12.3-15.5 27.4-36.8 50.2-54.3

Ill Effects Estimate % 80.4 69.0 $ 18.9 11.1 $ 11.1 26.1 $ 95% CI 77.3-83.5 66.3-71.6 15.9-21.9 9.8-12.4 7.9-14.2 23.2-29.1

Prevention Estimate % 76.9 55.3 $ 8.7 7.5 19.3 40.8 $ 95% CI 73.1-80.8 53.1-57.6 6.8-10.6 6.4-8.6 15.6-23.0 38.3-43.2

Treatment Estimate % 91.0 78.8 $ 10.1 10.2 6.1 16.0 $ 95% CI 88.9-93.1 76.0-81.6 7.7-12.5 8.6-11.8 4.1-8.1 13.1-18.9

Who should Estimate % 55.5 41.5 $ 41.2 45.3 3.3 13.0 $ be treated? @ 95% CI 50.8-60.2 38.1-44.8 36.3-46.0 41.8-48.8 2.2-4.3 10.7-15.4

Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)

Spread Estimate % 77.1 51.8 $ 10.9 8.8 20.9 45.7 $ 95% CI 73.8-80.3 49.8-53.8 8.5-13.4 7.8-9.9 17.8-24.1 43.6-47.9

Ill effects Estimate % 33.6 24.0 # 57.8 35.0 $ 30.0 52.9 $ on body 95% CI 27.7-39.5 21.3-26.7 53.4-62.2 32.3-37.7 26.3-33.7 50.8-54.9

Prevention Estimate % 75.8 51.5 $ 8.4 6.9 * 22.0 46.3 $ 95% CI 72.4-79.2 49.1-53.8 6.9-9.9 5.8-7.9 18.8-25.2 44.1-48.5 Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients was statistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001 @ If one of the spouses were having RTI/STD symptoms (correct response - treat both) Table 19. RTI/STD/HIV-AIDS related awareness among men from urban slums

Awareness status Correct responses Incorrect responses Ignorant

Program Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NO

Reproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)

Symptoms Estimate % 44.1 32.6 46.3 27.6 * 31.5 52.6 # 95% CI 31.7-56.4 26.6-38.5 31.2-61.3 23.3-31.9 15.5-47.5 46.5-58.6

Causes Estimate % 76.5 63.5 # 18.4 14.2 20.4 33.0 * 95% CI 68.9-84.1 59.0-68.1 8.5-28.2 11.2-17.2 12.0-28.8 27.9-38.1

Ill Effects Estimate % 89.7 76.1 $ 12.4 14.5 9.3 19.9 # 95% CI 82.6-96.9 71.1-81.1 5.3-19.5 10.9-18.0 2.2-16.3 14.9-24.9

Prevention Estimate % 84.3 71.8 # 6.0 7.8 11.5 26.1 $ 95% CI 77.4-91.2 66.2-77.5 0.8-11.2 5.7-9.8 4.8-18.1 20.3-31.9

Treatment Estimate % 87.4 82.0 8.8 9.1 7.6 13.9 95% CI 81.2-93.6 76.9-87.0 2.8-14.9 6.0-12.2 1.0-14.2 8.9-18.8

Who should Estimate % 63.3 48.0 * 32.8 41.4 3.8 10.3 * be treated? @ 95% CI 51.8-74.8 43.1-52.9 22.7-43.0 37.5-45.4 0.2-7.9 5.8-14.7

Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)

Spread Estimate % 93.2 78.7 $ 11.9 12.4 6.5 19.5 $ 95% CI 88.8-97.6 74.7-82.7 4.6-19.2 9.8-15.0 2.4-10.7 15.6-23.4

Ill effects Estimate % 39.7 33.4 68.2 51.3 # 13.9 32.0 $ on body 95% CI 26.6-52.7 27.0-39.8 56.2-80.2 47.1-55.6 6.2-21.5 25.4-38.6

Prevention Estimate % 94.1 75.5 $ 9.9 8.2 5.0 22.3 $ 95% CI 89.4-98.7 71.5-9.4 3.8-16.0 6.0-10.3 0.4-9.6 18.0-26.6 Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients was statistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001 @ If one of the spouses were having RTI/STD symptoms (correct response - treat both) Table 20. RTI/STD/HIV-AIDS related awareness among women from urban slums

Awareness status Correct responses Incorrect responses Ignorant

Program Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NO

Reproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)

Symptoms Estimate % 68.4 44.8 $ 39.1 23.6 # 27.9 49.1 $ 95% CI 58.8-77.9 39.2-50.4 28.3-49.9 20.2-27.0 18.4-37.4 43.3-54.9

Causes Estimate % 49.8 37.6 # 23.4 19.1 34.8 50.7 # 95% CI 41.5-58.0 33.6-41.6 14.8-31.9 15.7-22.4 24.4-45.3 48.1-53.4

Ill Effects Estimate % 82.1 66.7 $ 18.3 15.5 11.3 25.9 $ 95% CI 75.7-88.6 63.0-70.3 13.1-23.4 12.8-18.1 6.2-16.4 21.8-29.9

Prevention Estimate % 75.5 55.5 $ 12.5 8.5 22.5 40.0 $ 95% CI 66.0-85.0 51.9-59.0 6.6-18.4 5.9-11.1 13.2-31.8 36.0-44.0

Treatment Estimate % 93.2 85.4 $ 6.5 5.7 4.3 12.2 $ 95% CI 89.7-96.8 82.7-88.0 3.2-9.8 3.7-7.7 1.0-7.7 9.3-15.2

Who should Estimate % 57.2 41.8 $ 40.6 48.0 2.2 10.0 $ be treated? @ 95% CI 48.8-65.7 37.9-45.8 31.8-49.3 43.9-52.1 -1.2-5.7 6.7-13.4

Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)

Spread Estimate % 74.9 62.4 $ 9.9 8.6 23.8 35.4 # 95% CI 68.1-81.6 58.3-66.4 5.6-14.1 6.8-10.4 17.2-30.5 31.5-39.4

Ill effects Estimate % 35.3 27.3 51.2 39.4 * 36.2 47.0 * on body 95% CI 24.2-46.3 22.0-32.5 40.0-62.4 35.4-43.4 26.9-45.5 42.2-51.8

Prevention Estimate % 72.2 58.9 # 7.3 7.8 27.2 38.9 * 95% CI 64.1-80.3 53.9-64.0 4.2-10.4 5.8-9.7 18.6-35.5 34.2-43.1 Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients was statistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001 @ If one of the spouses were having RTI/STD symptoms (correct response - treat both) Table 21. RTI/STD/HIV-AIDS related awareness among clients from urban slums (Total)

Awareness status Correct responses Incorrect responses Ignorant

Program Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NO

Reproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)

Symptoms Estimate % 59.7 38.5 $ 41.7 25.7 $ 29.3 50.9 $ 95% CI 53.8-65.6 33.6-43.4 34.6-48.8 22.5-28.9 23.4-35.0 46.0-55.9

Causes Estimate % 59.6 51.2 * 21.6 16.6 29.7 41.5 # 95% CI 53.2-66.0 47.8-54.6 15.2-28.0 14.9-18.2 22.3-37.1 38.2-44.9

Ill Effects Estimate % 84.9 71.6 $ 16.2 15.0 10.6 22.8 $ 95% CI 80.3-89.5 68.4-74.9 12.6-19.8 12.4-17.6 7.1-14.2 19.2-26.3

Prevention Estimate % 78.7 64.0 $ 10.2 8.1 18.6 32.8 $ 95% CI 71.6-85.8 59.8-68.2 6.6-13.8 6.2-10.1 12.3-24.8 28.4-37.2

Treatment Estimate % 91.1 83.5 $ 7.4 7.5 5.5 13.0 $ 95% CI 88.1-94.2 80.9-86.2 5.1-9.6 5.3-9.7 2.8-8.2 10.4-15.7

Who should Estimate % 59.4 45.0 $ 37.8 44.6 * 2.8 10.1 $ be treated? @ 95% CI 52.9-65.8 41.1-48.9 31.6-44.0 41.1-48.1 0.1-5.8 7.1-13.1

Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)

Spread Estimate % 81.5 70.9 $ 10.6 10.6 17.6 27.2 $ 95% CI 77.8-85.2 67.7-74.1 6.6-14.6 8.9-12.3 14.0-21.3 24.1-30.3

Ill effects Estimate % 36.9 30.1 57.3 45.6 # 28.2 39.2 $ on body 95% CI 26.9-46.9 25.8-35.2 49.8-64.9 42.6-48.5 22.3-34.1 35.2-43.2

Prevention Estimate % 80.1 67.6 $ 8.2 7.9 19.2 30.2 # 95% CI 74.6-85.7 64.0-71.2 5.1-11.3 6.3-9.7 13.5-24.9 26.7-33.8 Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients was statistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001 @ If one of the spouses were having RTI/STD symptoms (correct response - treat both) Table 22. Proportion of clients perceiving HIV-AIDS as a significant problem in their area

Program Contact - Yes Program Contact - No Test Results Clients Estimate 95% CI Estimate 95% CI Difference % 95% CI t p-value % % Rural Areas Men 12.9 8.0-17.9 9.7 7.4-11.9 3.3 1.9-8.5 1.3 NS

Women 12.8 5.4-20.2 7.1 5.1-9.0 5.7 2.1-13.6 1.5 NS

Total 12.9 7.9-17.8 8.4 6.5-10.2 4.5 0.5-9.4 1.8 NS

Urban Slums Men 12.7 5.8-19.5 9.4 6.0-12.8 3.3 4.2-10.7 0.9 NS

Women 13.3 4.5-22.1 7.3 4.5-10.0 6.0 1.6-13.7 1.6 NS

Total 13.1 6.7-19.5 8.4 6.1-10.6 4.7 1.6-10.9 1.5 NS Table 23. Awareness of clients about benefits of using condoms [CORRECT KNOWLEDGE*]

Program Contact - Yes Program Contact - No Test Results Clients Estimate 95% CI Design Estimate 95% CI Design Difference 95% CI t p-value % Effect % Effect % Rural Areas

Men 82.8 78.4-87.1 2.5 69.5 66.3-72.6 4.5 13.3 7.2-19.4 4.4 0.001

Women 66.2 61.3-71.1 2.63 54.1 50.7-57.4 3.9 12.1 5.8-18.4 3.9 0.001

Total 73.4 69.3-77.5 3.8 62.0 59.4-64.6 5.4 11.4 6.0-16.9 4.2 0.001

Urban Slums

Men 88.4 83.4-93.1 0.42 78.4 73.3-83.4 2.77 10.0 4.8-15.2 3.9 0.001

Women 82.0 73.5-90.5 1.72 67.0 62.8-71.3 1.38 14.9 6.8-23.1 3.7 0.001

Total 84.3 78.6-90.0 1.4 73.0 69.0-76.9 2.8 11.3 6.0-16.7 4.3 0.001

* Prevents pregnancy and / or diseases like RTI/STD/HIV-AIDS Table 24. Awareness of clients about benefits of using condoms [CORRECT KNOWLEDGE]

Program Contact - Yes Program Contact - No

Clients Prevents Pregnancy Prevents RTI/STD/HIV- Prevents Pregnancy Prevents RTI/STD/HIV- AIDS AIDS

Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Rural Areas

Men 65.2 59.2-71.1 66.4 60.6-72 57.7 54.2-61.2 40.2 26.9-43.5

Women 57.3 53.1-61.5 34.5 29.2-39.7 51.9 48.4-55.5 14.5 12.4-16.7

Total 60.7 57.1-64.4 48.4 43.5-53.3 54.9 52.1-57.7 27.8 25.8-29.7 Urban Slums

Men 65.1 56.1-74.2 73.3 64.1-82.6 62.8 58.6-67.1 54.1 49.0-59.2

Women 74.3 65.8-82.8 38.4 28.2-48.7 63.1 58.7-67.5 22.7 18.9-26.6

Total 71.0 64.9-77.1 51.0 43.8-58.1 63.0 59.2-66.7 39.1 35.1-43.1 Table 25. Behavior of clients regarding safe sex - Use of condoms during last intercourse

Program Contact - Yes Program Contact - No Test Results

Estimate % 95% CI Estimate % 95% CI Difference % 95% CI t p-value

Rural Areas Men 15.2 11.5-19.0 8.2 6.6-9.7 7.0 3.9-10.4 4.4 0.001

Women 9.6 6.6-12.7 5.7 4.5-6.9 3.9 0.7-7.1 2.5 0.001

Total 12.1 9.4-14.9 7.0 6.2-7.8 5.1 2.4-7.8 3.9 0.001

Urban Slums Men 8.6 4.4-12.7 10.7 7.8-13.5 2.1 1.9-6.1 1.1 NS

Women 12.0 7.6-16.3 11.6 9.0-14.1 0.4 0.0-0.8 0.2 NS

Total 10.8 6.9-14.7 11.1 9.0-13.2 0.3 -4.7-4.0 0.2 NS Table 26. RTI/STD/HIV-AIDS related awareness among clients after controlling for marital status - symptoms of RTI/STDs [CORRECT KNOWLEDGE]

Program Contact - Yes Program Contact - No

Clients Single Married Single Married Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI (%) (%) (%) (%) Rural Areas Men 43.8 32.0-55.7 59.3 51.9-66.8 25.7 21.1-30.3 29.4 25.4-33.4

Women 33.0 21.3-44.8 67.0 59.4-74.6 35.3 24.9-45.6 47.0 43.1-51.0

Total 40.8 31.4-50.3 63.9 57.7-70.1 28.0 22.9-33 38.8 35.9-41.6

Urban Slums Men 41.7 26.2-57.1 45.5 32.7-58.3 30.0 22.1-37.9 33.5 27.6-39.4

Women 57.5 37.9-77.2 68.9 59.0-78.8 31.1 23.2-39.1 46.1 40.4-51.8

Total 46.0 33.5-58.5 62.2 55.3-69.2 30.2 23.7-36.7 40.4 35.6-45.1 Table 27. RTI/STD/HIV-AIDS related awareness among clients after controlling for education - symptoms of RTI/STDs [CORRECT KNOWLEDGE]

Program Contact Yes Program Contact No

Clients Uneducated Educated Uneducated Educated Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI (%) (%) (%) (%) Rural Areas Men 49.6 38.2-61.0 59.0 50.7-67.2 23.8 19.0-28.7 31.1 27.1-35.2

Women 62.5 52.9-72.1 69.1 61.7-76.4 45.8 41.2-50.4 46.4 41.5-51.3

Total 58.9 50.3-67.6 63.3 57.6-68.9 37.5 33.8-41.3 36.3 32.8-39.8

Urban Slums Men 28.4 7.7-49.2 50.0 37.7-64.3 26.2 19.4-32.9 35.6 28.3-42.9

Women 65.7 51.5-80.0 70.8 61.3-80.3 41.0 36.3-45.7 49.5 41.2-57.9

Total 56.6 46.1-67.1 61.7 54.9-68.4 35.3 31.5-39.1 40.9 34.0-47.8 Table 28. RTI/STD/HIV-AIDS related awareness (Correct Responses): Distribution of rural areas clients according to program contact status and presence of RTI/STD symptoms during FHAC - 2000

Program Contact - YES Contact - NO Contact Symptoms during Symptoms -YES Symptoms - NO Symptoms -YES Symptoms - NO FHAC Awareness Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI regarding % % % % RTI/STD Symptoms 82.2 75.8-88.6 59.0 52.9-65.1 71.8 62.7-80.9 36.1 23.4-38.8 Treatment 95.3 91.1-99.6 90.5 88.3-92.8 89.0 84.1-93.9 78.5 75.7-81.4 Prevention 67.0 57.6-76.5 78.1 74.2-82.0 65.7 55.8-75.7 55.1 52.9-57.4 HIV/AIDS Spread 72.5 66.7-78.5 77.5 73.9-81.1 38.3 26.4-50.2 52.1 50.1-54.1 Ill effects 32.5 21.9-42.9 33.7 27.8-39.6 17.1 7.6-26.5 24.2 21.5-26.9 Table 29. RTI/STD/HIV-AIDS related awareness (Correct Responses): Distribution of clients from urban slums according to program contact status and presence of RTI/STD symptoms during FHAC - 2000

Program Contact - YES Contact - NO Contact Symptoms during Symptoms -YES Symptoms - NO Symptoms -YES Symptoms - NO FHAC Awareness Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI Estimate 95 % CI regarding % % % % RTI/STD Symptoms 62.2 40.1-84.2 59.3 53.3-65.4 54.6 37.6-71.7 38.4 33.4-43.3 Treatment 90.1 79.9-100 91.2 88.4-94.2 95.3 88.9-100 83.5 80.7-86.3 Prevention 62.9 42.7-83.3 80.5 72.6-88.5 82.6 71.4-93.8 63.8 59.4-68.2 HIV/AIDS Spread 67.7 51.0-84.3 83.1 79.0-87.2 75.8 64.6-86.9 70.8 67.6-74.0 Ill effects 30.5 8.5-52.5 37.7 27.8-47.5 41.4 21.9-60.8 30.2 25.5-34.9 Table 30. Training of health providers as part of FHAC program : Proportion trained

Doctors Health Workers Training Status (n=1072) Government (n=390) Private (n=148) Estimate 95% CI Estimate 95% CI Estimate 95% CI (%) (%) (%)

Trained 72.3 67.8-76.8 8.8 4.2-13.4 75.5 71.8-79.2 Not trained 27.7 23.2-32.1 91.2 86.6-95.8 21.2 17.6-24.8 No training held - - 3.4 2.1 -4.5 Table 31. Training of health providers as part of FHAC program : Process of training

Parameter Doctors’ Training Heath Workers’ Training Estimate (%) 95% CI Estimate (%) 95% CI Duration Less than one day 3.7 1.5-5.9 7.4 4.2-10.6 One day or more 96.2 94.0-98.4 92.5 89.3-95.7 Who were the trainers? Do not know 0.3 -0.3-1.0 1.5 0.2-2.7 Experts from outside 20.0 15.4-24.5 9.9 7.2-12.6 Medical College experts 16.9 12.6-21.2 45.2 39.7-50.6 Doctors from District Headquarters 85.4 81.3-89.4 68.2 63.7-72.6 / PHC Language used for training Local language - - 98.9 97.9-99.8 Audio-visual aids used Do not remember - - 2.8 0.8-4.7 Posters / Flip Charts / Photos - - 69.9 65.1-74.7 Film / Media - - 8.8 6.3-11.4 Others - - 32.9 28.4-37.4 Nothing was used (Lectures only) - - 15.4 12.2-18.7 Table 32. Training of health providers as part of FHAC program : Topics discussed by the trainers

Doctors’ Training Health Workers’ Training Topics Estimate % (95% CI) Estimate % (95% CI) RTI/STD (causes / treatment / 52.0 47.8-56.2 60.3 55.6-65.1 prevention) HIV-AIDS (causes / treatment / 36.8 32.7-40.9 49.2 44.0-54.4 prevention) Disease / good health 5.5 3.6-7.5 12.6 10.1-15.0 Referral slips for treatment 2.6 1.2-3.9 7.8 5.9-9.6 Availability of treatment at PHCs 4.0 2.4-5.7 5.0 3.4-6.6 Conduct of FHAC program 11.5 8.8-14.2 14.8 11.7-17.8 Nothing discussed 0 0 0.2 -0.0-0.5 Table 33. Quality of training of health providers : Perceptions of providers about FHAC program objectives

Program Objectives Doctors Health Workers Estimate % (95% CI) Estimate % (95% CI) Do not know 2.8 1.7-4.4 0.8 0.2-1.4 Awareness, Treatment & Prevention of 15.9 12.3-19.5 16.7 13.7-19.7 RTI/STD/HIV-AIDS (Correct) Awareness / Treatment / Prevention of 75.1 70.9-79.4 76.1 72.5-79.8 RTI/STD/HIV-AIDS (Partially Correct) Others (to improve the image of govt services 21.6 17.6-25.7 17.4 14.1-20.6 provided at PHCs / Dispensaries, to train personnel, and to create awareness about diseases in general) Table 34. Quality of training of health providers : RTI / STD / HIV-AIDS related awareness among doctors [CORRECT KNOWLEDGE]

Trained doctors Untrained doctors Test Results Topics Estimate (%) 95% CI Estimate (%) 95% CI Difference t p-value RTI/STD Symptoms in Men 98.9 97.8-100 93.4 90.2-96.5 5.5 3.28 0.001 Symptoms in Women 99.6 98.9-100 96.7 94.4-99.5 2.9 2.47 0.014 Causes 84.5 80.1-88.9 90.4 86.4-94.4 5.9 1.95 0.051 Ill effects of RTI/STD on 99.3 98.4-100 90.1 86.4-93.9 9.2 4.7 0.001 new-born Prevention 100 100-100 97.5 95.5-99.4 2.4 2.47 0.014 HIV-AIDS Prevention 99.6 98.9-100 97.9 96.1-99.7 1.7 1.76 0.078 Table 35. Quality of training of health providers (Doctors) : Treatment for men with urethral discharge

Trained doctors Untrained doctors Test Results Prescription Estimate (%) 95% CI Estimate (%) 95% CI Difference t p-value Do not know 0 0 1.6 0.04-3.2 1.6 2.01 0.04 No need for treatment 0.3 -0.3-1.0 0.4 -0.4-1.2 0.1 0.13 NS Antibiotics 97.6 95.8-99.3 81.8 77.0-86.7 15.7 5.99 0.001 Metronidazole 24.0 19.1-28.9 21.3 16.2-26.5 2.7 0.73 NS Others (Symptomatic treatment, antiseptic 21.6 16.9-26.4 34.5 28.5-40.5 12.8 3.31 0.001 lotions, ointments, lotions, creams) Table 36. Quality of training of health providers (Doctors) : Treatment for men with genital ulcers

Prescription Trained doctors Untrained doctors Test Results

Estimate (%) 95% CI Estimate (%) 95% CI Difference t p-value Do not know 0.3 -0.4-1.2 2.9 0.7-5.0 2.6 2.25 0.02 No need for 0.3 -0.3-1.0 0.4 -0.4-1.2 0.1 0.13 NS treatment Antibiotics 94.9 92.4-97.4 78.1 72.9-83.3 16.8 5.68 0.001 Metronidazole 11.8 8.1-15.5 12.3 8.1-16.5 0.5 0.17 NS Others (Symptomatic 27.8 22.6-33.2 37.4 31.3-43.5 9.6 2.37 0.02 treatment, antiseptic lotions, ointments, lotions, creams) Table 37. Quality of training of health providers (Doctors) : Treatment for women with foul smelling vaginal discharge

Trained doctors Untrained doctors Test Results Prescription Estimate (%) 95% CI Estimate (%) 95% CI Difference t p-value Do not know 0.3 -0.3-1.0 2.0 0.2-3.8 1.7 1.77 NS No need for 0.3 -0.3-1.0 0 0 0.3 1.00 NS treatment Antibiotics 92.8 1.5-95.8 74.4 68.9-79.9 18.4 5.79 0.001 Metronidazole 67.8 62.4-73.1 43.6 37.3-49.8 24.2 5.77 0.001 Others (Symptomatic treatment, antiseptic 42.7 37.1-48.3 52.6 46.3-59.7 9.9 2.31 0.02 lotions, ointments, lotions, creams) Table 38. Quality of training of health providers (Doctors) : Treatment for women with genital ulcers

Trained doctors Untrained doctors Test Results Prescriptions Estimate (%) 95% CI Estimate (%) 95% CI Difference t p-value Do not know 0.6 -0.3-1.6 2.4 0.5-4.4 1.8 1.62 NS No need for 1.0 -0.1-2.1 0 0 1.0 1.73 NS treatment Antibiotics 92.5 89.5-95.5 76.5 71.2-81.9 16.0 5.12 0.001 Metronidazole 26.1 21.1-31.1 17.2 12.5-22.0 8.9 2.50 0.01 Others (Symptomatic treatment, antiseptic 33.9 28.4-39.3 41.9 35.7-48.2 8.0 1.92 0.06 lotions, ointments, lotions, creams) Table 39. Quality of training of health providers (Health Workers) : RTI/STD/HIV-AIDS related awareness [CORRECT KNOWLEDGE]

Trained Health Workers Untrained Health Workers Test Results Awareness regarding Estimate (%) 95% CI Estimate (%) 95% CI Difference t p-value RTI/STD Symptoms in Men 93.6 90.9-96.3 80.5 74.2-86.7 13.1 4.12 0.001 Symptoms in Women 97.9 96.4-99.3 88.1 82.4-93.8 9.8 3.29 0.002 Causes 86.2 82.2-90.2 83.5 77.1-89.9 2.7 0.67 NS Prevention 99.6 99.1-100 92.9 89.0-96.9 6.7 3.41 0.001 Ill effects of RTI/STD on 88.0 84.3-91.7 82.7 76.2-89.2 5.3 1.57 NS new-born Treatment for RTI/STDs Referred to Doctor 89.6 86.3-92.9 75.6 66.5-84.8 13.9 3.16 0.003 HIV-AIDS Ill effects on body 76.4 72.1-80.7 58.2 49.8-66.5 18.2 4.03 0.001 Prevention 99.2 98.2-100 92.1 87.7-96.6 7.1 3.07 0.004 Table 40. Social Mobilization : clients’ sources of information about FHAC program

Clients’ Sources of information Respondent Category Health workers Interpersonal - other sources** Publicity Estimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI) Rural Areas* Men 49.6 43.3-55.9 30.9 26.4-35.3 19.0 13.3-24.7 Women 61.5 55.9-67.1 27.6 23.7-31.4 8.5 5.6-11.5 Total 56.0 51.4-60.7 29.1 26.4-31.8 13.3 9.8-16.9 Urban Slums* Men 43.2 37.7-48.7 27.7 22.5-32.8 28.8 22.2-35.4 Women 59.6 50.6-68.7 26.7 19.2-34.2 12.2 4.0-20.5 Total 53.1 47.5-58.7 27.1 21.7-32.5 18.8 12.4-25.2 Health Workers 74.9 @ 70.4-79.3 68.9 65.2-72.5

* Denominator was the total number of clients who were aware about the FHAC program ** Include : Volunteers, influencers, elderly members etc. @ Include : Health workers and other sources of interpersonal communication Table 41. Social Mobilization : knowledge about target population for FHAC program

Clients * Respondent Health Category Rural Areas Urban Slums Workers Men Women Total Men Women Total Perceived Estimate % Estimate % Estimate % Estimate % Estimate % Estimate % Estimate % Target Group 95% CI 95% CI 95% CI 95% CI 95% CI 95% CI 95% CI Do not know 12.3 18.6 15.7 12.9 16.0 14.8 6.6 9.4-15.2 15.5-21.7 13.7-17.7 8.6-17.3 9.7-22.4 11.7-17.9 4.4-8.8 Adults 78.4 74.9 76.5 75.3 75.8 75.6 91.2 74.4-82.5 71.2-78.6 74.0-79.0 63.8-86.8 70.6-81.0 70.1-81.1 89.0-93.4 Adolescents 48.1 31.0 38.8 50.3 27.8 36.8 64.9 40.8-55.2 26.2-35.8 34.1-43.7 40.0-60.6 19.3-36.2 30.1-43.5 61.2-68.7 Who go to 8.5 6.9 7.6 12.9 9.5 10.9 - prostitutes & 5.4-11.6 4.7-9.1 5.9-9.3 3.7-22.1 5.4-13.6 6.1-15.7 others

* Denominator was the total number of clients who were aware about the FHAC program Table 42. Field Operations : personnel involved in house visits during the FHAC program

House visits by Health workers Workers of non- Volunteers / No one visited Do not remember health departments influencers

Respondents Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % (95% CI) Estimate % 95% CI Rural Areas Men 54.4 47.2-61.6 3.5 1.6-5.3 5.3 2.7-7.9 29.8 22.9-36.6 7.1 4.4-9.8 Women 58.0 52.0-63.9 7.9 5.0-10.8 5.3 2.3-8.3 23.4 19.0-27.8 5.4 3.5-7.2 Total 56.3 50.7-62.0 5.9 3.8-7.9 5.3 3.4-7.2 26.3 21.6-31.7 6.2 4.4-7.9 Urban Slums Men 50.2 39.8-60.6 4.8 0.6-10.1 2.2 0.0-4.7 29.5 20.8-38.2 13.4 6.7-20.1 Women 58.5 51.6-65.5 9.9 4.6-15.2 4.8 1.2-8.3 19.5 13.1-25.8 7.3 2.9-11.7 Total 55.2 49.0-61.4 7.8 3.1-12.6 3.7 1.6-5.8 23.5 18.6-28.4 9.8 5.8-13.8 Table 43. Field Operations : Location of FHAC camps [According to clients]

Rural Areas Urban Slums

Zone Camps in and around Camps at Sub-center / Camps in and around Camps at Health Post / the village PHC the locality Dispensary

Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI

1. Chandigarh, Delhi, 36.7 17.1-56.3 52.0 34.5-71.5 31.4 10.9-51.9 35.7 16.6-54.8 Haryana, Himachal Pradesh, Punjab 2. Uttar Pradesh 51.2 20.3-82.2 37.1 7.0-67.3 34.1 -4.3-72.6 48.8 19.1-78.4 3. Assam, Arunachal Pradesh, 36.1 14.6-57.6 21.3 6.5-36.0 18.3 -2.4-39.2 28.5 -0.7-57.8 Meghalaya, Sikkim

4. Manipur, Mizoram, 83.1 70.1-96.1 11.9 0.2-23.6 68.4 44.2-92.6 17.5 -2.0-37.1 Nagaland, Tripura 5. Rajasthan 50.8 27.3-74.4 38.6 17.2-60.0 52.7 27.3-78.2 22.2 5.0-39.4 6. Madhya Pradesh 64.4 40.9-87.8 30.7 5.9-55.6 77.5 51.9-100 17.5 -8.3-43.3 7. Orissa 64.9 48.5-81.2 11.7 2.4-21.0 70.2 49.0-91.4 14.2 -3.2-31.7 8. Goa, Maharashtra 28.8 13.4-44.4 66.6 50.8-82.5 52.9 20.6-85.2 21.5 -0.9-44.1 9. Andhra Pradesh 84.5 68.6-100 11.2 -5.0-27.4 80.0 62.4-97.5 7.2 -4.7-19.3 10. Karnataka 29.9 13.0-46.7 46.7 29.7-63.7 29.7 9.2-50.2 37.8 9.7-65.9 11. Pondicherry, Tamil Nadu 76.2 62.6-89.8 17.5 5.9-29.1 68.4 44.3-92.6 23.4 1.1-45.7 12. Kerala, Lakshadweep 29.4 7.2-51.7 46.1 27.1-65.1 7.7 -2.4-17.8 58.9 29.9-88.0 All India 53.7 46.1-61.3 34.9 27.5-22.3 53.1 42.1-64.0 27.3 16.4-38.2 Table 44. Health workers perspective - Location of camps

Rural Areas Urban Slums Location of FHAC camps Estimate % 95% CI Estimate % 95% CI Camps not organized 10.1 7.0-13.1 18.8 12.2-25.4 Camps in & around the village / locality 44.2 37.4-50.9 42.5 35.5-49.5 Camps at PHC / Health Post / Dispensary 45.7 39.3-52.2 37.7 28.6-46.9 Table 45. Field operations : Personnel manning the camp*

Personnel at Health workers Workers of non-health Volunteers / influencers Do not remember Camps departments Respondent Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Category* Rural Areas Men 89.6 82.3-96.8 1.5 0.0-3.6 7.7 2.0-13.5 1.2 0.0-2.5 Women 90.2 84.7-95.7 2.7 0.3-5.1 5.7 1.8-9.7 1.3 0.0-2.9 Total 89.9 84.2-96.6 2.2 0.2-4.1 6.6 2.7-10.5 1.3 0.0-2.5 Urban Slums Men 92.3 84.0-100 0 3.6 -3.1-10.2 4.1 -1.1-9.4 Women 89.3 82.8-95.7 2.1 0.0-4.9 3.8 -1.4-8.9 4.8 0.0-9.7 Total 90.0 83.8-97.1 1.6 0.0-3.8 3.7 -0.4-7.9 4.7 0.8-8.5

* Denominator was the number of clients who attended the FHAC camps Table 46. Field operations : Conduct of FHAC camps*

Estimate % (95% CI) Design effect Personnel Manning the Camps Health Worker Alone 23.9 19.6-28.1 2.64 Non-Health Departments / Volunteers / Influencers & Health Workers 73.8 69.3-78.2 2.71 IEC Methods Used Print material 66.5 62.6-70.3 1.53 Audio-visual 4.8 2.9-6.6 1.82 Folk / songs / plays 4.0 2.4-5.6 1.60 Interpersonal / Lectures / Discussions 27.9 23.8-32.0 2.0 Topics Discussed in Camps RTI/STD (causes / treatment / prevention) 63.4 59.4-67.3 1.77 HIV-AIDS (causes / treatment / prevention) 46.2 41.6-50.9 2.26 Disease / good health 1.7 0.5-2.9 2.29 Referral slips for treatment 4.2 2.7-5.7 1.50 Availability of treatment at PHCs 6.6 4.9-8.3 1.21 Conduct of FHAC program 0.06 -0.07-0.2 0.73 Nothing discussed** 12.6 10.0-15.2 1.64 * Based on responses from Health Workers; ** As camps were meant for screening and treating RTI/STD patients Table 47. Prevalence of RTI/STD symptoms in clients during the FHAC program according to contact status of clients

Rural Areas Urban Slums Clients’ Contact status Men Women Total Men Women Total Estimate% Estimate% Estimate% Estimate% Estimate% Estimate% (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) A. Clients who did not receive program services 1. Not aware 0.7 3.7 2.1 0.4 2.7 1.5 about FHAC (0.3-1.1) (2.7-4.8) (1.6-2.7) (0.0-0.7) (1.2-4.3) (0.8-2.2) program 2.Aware about 0.6 4.8 2.6 4.5 6.3 5.4 FHAC through (-0.2-1.5) (1.8-7.8) (0.8-4.4) (-4.6-13.6) (-0.7-13.4) (0.1-10.7) media but did not attend camp B. Clients who received program services 1. Contacted at 0.6 5.9 3.6 0.7 5.6 3.5 home alone (-0.2-1.5) (3.0-8.8) (2.0-5.2) (-0.7-2.1) (3.1-8.1) (1.8-5.2) 2. Attended 6.2 21.2 13.6 7.1 20.1 12.5 camps only (1.2-11.2) (8.7-33.8) (7.2-19.9) (-7.1-21.4) (-15.9-56.0) (-5.9-30.9) 3. Contacted at 6.5 28.7 19.4 23.4 30.6 29.6 home + attended (1.7-11.3) (22.0-35.4) (14.4-24.3) (-4.9-51.7) (12.5-48.8) (13.3-46.0) camps Table 48. Treatment seeking behavior of clients with RTI/STD symptoms during FHAC program

Program Contact - Yes Program Contact - No Test results Place of treatment Estimate 95% CI Estimate 95% CI Difference 95% CI t p % % % value No Treatment 12.9 7.8-18.0 32.4 21.8-43.1 19.6 7.9-31.2 3.4 0.002 Home / Self 1.8 -0.2-3.9 2.2 0.1-4.4 0.4 -2.9-3.6 0.2 NS Private Doctor 9.9 5.2-14.6 25.1 16.5-33.7 15.1 4.7-25.5 2.9 0.005 Government 65.3 56.6-73.9 27.2 18.6-35.8 38.1 27.6-48.6 7.3 0.001 Hospital / PHC Non-conventional 0.5 -0.5-1.6 2.7 0.4-5.0 2.2 0.2-4.1 2.2 0.03 Not aware 9.6 5.0-15.2 10.4 4.5-17.1 0.8 -2.0-3.6 0.3 NS

* Denominator was the number of clients with symptoms of RTI/STD during FHAC Program Table 49. Providers perspective about program performance : Reach of the program during FHAC program

Home Visits Camp attendance Clients using referral slips

Perception of Health Workers’ Health Workers’ Doctors’ Perspective Health Workers’ Health Workers Perspective Perspective Perspective Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI)

Do not know 6.0 3.8-8.2 9.1 6.3-11.8 31.2 27.1-35.2 25.4 21.6-29.3 Less than 25% 21.0 17.0-25.1 47.5 43.1-51.8 40.3 36.0-44.6 17.8 14.1-21.6 About 50% 39.5 35.4-43.5 37.2 33.1-41.2 25.9 22.0-29.7 25.9 21.6-30.3 More then 75% 33.3 29.1-37.6 6.1 3.9-8.4 2.5 1.2-3.9 18.9 14.1-23.7

Table 50. Provider perspective about program performance : Relative proportion of clients attending the FHAC camps/ meetings

Perception of Estimate % (95% CI) Design effect Health Workers Not sure 9.4 6.5-12.4 2.39 Men were more 9.9 7.4-12.5 1.71 Women were more 65.5 60.2-70.7 2.90 Men & Women equal 13.6 10.0-17.3 2.73 Adolescents were more 0.9 -0.06-2.0 2.72 Others 0.3 -0.05-0.7 1.15 Table 51. Providers’ perspective about client behavior : Clients’ reaction towards discussing issues of RTI/STD

Health Worker Perspective Estimate (%) 95% CI Design Effect Not sure / do not know 7.1 4.9-9.1 1.70 Appreciated 62.5 58.6-66.4 1.62 Indifferent 5.7 3.9-7.5 1.53 Felt shy / embarrassed 22.0 18.8-25.1 1.47 Abused / rebuked 2.6 1.2-3.9 1.93

Table 52. Providers’ perspective about client behavior : Treatment seeking behavior of clients for RTI/STD

Place of Treatment Health Workers’ Perspective Doctors’ Perspective

Estimate% 95% CI Estimate% 95% CI Do not know 1.5 0.4-2.5 1.9 0.7-3.0 No treatment 24.7 21.0-28.3 31.2 27.3-35.2 Government facilities 59.0 55.0-63.1 45.0 40.8-49.2 Private Doctor 81.8 79.0-84.5 23.2 19.7-26.8 Quack / Ojha 6.7 5.0-8.5 36.6 32.5-40.7 Table 53. Perceptions of health providers regarding problem of RTI/STD/HIV-AIDS in their area

Doctors’ Perspective Health Workers’ Perspective HIV-AIDS Estimate 95% CI Estimate 95% CI (%) (%) Problem (Yes) 28.3 24.4-32.1 25.9 22.8-29.1 Problem (No) 60.3 56.2-64.4 74.0 70.8-77.1 Unsure 11.35 8.7-14.0 - - Table 54. Reach of the family health awareness campaign to adolescents (< 20 years old)

Rural Areas Urban Slums Reach Estimate% 95% CI Design Estimate% 95% CI Design effect effect A. Clients who did not receive program services 1. Not aware about FHAC program 80.1 76.2-84.0 3.2 81.4 75.6-87.1 1.2 2. Aware about FHAC through media but did not 6.5 4.7-8.3 1.8 4.8 2.5-7.1 0.6 attend camp B. Clients who received program services 1. Contacted at home alone 7.9 5.3-10.5 3.0 9.3 5.2-13.4 1.1 2. Attended camps only 1.0 0.4- 1.5 1.0 1.8 -0.9-4.5 2.4 3. Contacted at home + attended camp 4.5 2.9- 6.0 1.9 2.7 1.0-4.3 0.6 Table 55. RTI / STD / HIV related awareness among adolescents (# 20 years old) [CORRECT KNOWLEDGE]

Awareness Rural Areas Urban Slums Regarding Program contact-Yes Program contact-No Program contact-Yes Program contact-No Estimate % 95% CI Estimate% 95% CI Estimate% 95% CI Estimate% 95% CI RTI/STD Symptoms 43.6 32.1-55.0 28.3 23.2-33.3 54.6 39.4-69.8 29.3 24.2-34.4 Causes 54.0 44.1-63.8 34.7 29.3-40.0 68.9 58.3-79.6 46.3 41.0-51.6 Ill effects 73.9 64.2-83.6 62.7 57.0-68.4 83.1 68.4-97.7 64.7 56.0-73.3 Treatment 86.9 78.7-95.0 74.9 69.4-80.4 89.5 81.2-97.8 78.7 73.7-83.7 Prevention 67.7 57.9-77.5 48.3 43.0-53.7 75.9 62.2-89.7 60.4 52.7-68.1 HIV-AIDS Symptoms 78.1 70.3-85.8 52.4 47.4-57.5 78.7 66.0-91.5 69.0 64.4-73.7 Ill effects 34.3 22.7-45.9 24.9 21.4-28.5 38.5 19.3-57.7 30.2 24.6-35.7 Prevention 79.4 71.2-87.7 52.0 47.0-57.0 80.1 67.5-92.8 64.0 57.4-70.5 Table 56. Adolescent profile (# 20 years old) : Prevalence of RTI/STD symptoms during two weeks prior to survey & safe sex related information

Parameter Rural Areas Urban Slums

Estimate% 95% CI Estimate% 95% CI Prevalence Data Urethral Discharge 5.8 3.5-8.1 3.1 1.0-5.3 Genital Ulcers 0.8 0.1-1.5 0.2 -0.2-0.6

Condom Use 3.4 2.1-4.6 6.3 3.2-9.4 Benefits of condom use [CORRECT KNOWLEDGE] Prevents Pregnancy 41.3 37.2-45.3 53.0 48.3-57.7 Prevents 32.0 28.1-35.9 40.5 35.6-45.4 RTI/STD/HIV-AIDS Correct Responses (Prevents pregnancy 64.2 62.1-66.3 74.5 70.6-78.4 and / or diseases like RTI/STD/HIV-AIDS) Table 57. Prevalence of urethral discharge / painful micturition among the clients during the two weeks prior to the survey

Rural Areas Urban Slums

Zone Men Women Total Men Women Total Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Zone 1 2.6 0.5-4.7 10 4.2-15.7 6.3 2.6-9.9 0.6 -0.6-2.0 8.0 2.7-13.2 4.3 1.4-7.2 Zone 2 3.0 0.4-5.6 8.3 4.3-12.3 5.6 3.2-8.1 2.6 0.2-5.1 10.8 2.5-19.1 6.7 2.6-10.8 Zone 3 8.3 5.0-11.5 19.0 11.3-26.6 13.6 9.0-18.2 10.0 2.3-17.7 19.3 6.3-32.3 14.7 6.7-22.6 Zone 4 2.6 0.5-4.8 17.0 8.7-25.3 9.8 5.3-14.3 2.0 -0.1-4.1 5.3 0.9-9.6 3.6 1.1-6.1 Zone 5 2.0 0.5-3.4 28.5 17.1-39.9 15.2 9.1-21.2 2.0 0.1-4.1 22.8 10.3-35.2 12.3 5.6-19.1 Zone 6 8.0 3.8-12.1 10.0 5.8-14.3 9.0 5.7-12.3 6.6 1.1-12.0 5.4 -0.2-11.0 6.0 2.0-10.0 Zone 7 0.3 -0.3-0.9 2.6 0.7-4.5 1.4 0.4-25.7 0 6.0 0.1-11.8 2.9 0.07-5.9 Zone 8 1.0 -0.1-2.1 8.6 4.1-12.8 4.8 2.6-7.0 1.3 -0.5-3.2 10 2.6-17.3 5.7 2.0-9.4 Zone 9 1.3 -0.2-2.9 7.6 3.5-11.7 4.5 1.9-7.0 2.6 0.2-5.0 10 3.1-16.8 6.3 3.0-9.6

Zone 10 1.3 -0.2-2.9 10.6 4.7-16.5 6.0 2.8-9.1 1.3 -1.3-4.0 12.0 1.5-22.4 6.6 1.3-12.0 Zone 11 0.6 -02-1.5 13.3 8.5-18.2 6.9 4.3-9.6 0 10.6 5.6-15.6 5.3 2.8-7.8 Zone 12 0.3 -0.3-1.0 1.6 0.2-3.1 1.0 0.2-1.7 0 0 0

All India 2.7 2.0-3.4 10.5 8.7-12.3 6.6 5.6-7.7 2.0 1.3-2.7 10.0 6.8-13.2 6.0 4.5-7.6 Table 58. Prevalence of genital ulcers during the two weeks prior to the survey

Rural Areas Urban Slums

Zone Men Women Total Men Women Total Estimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI) Zone 1 0.6 -0.2-1.5 0 0.3 -0.1-0.8 0 2.0 -0.9-4.9 1.0 -0.4-2.4 Zone 2 1.3 -0.2-2.9 0.3 -0.3-1.0 0.8 -0.2-1.9 0.6 -0.6-2.0 0.6 -0.6-2.0 0.6 -0.2-1.6 Zone 3 2.9 0.4-5.5 2.3 0.7-3.9 2.6 1.2-4.0 3.3 -0.9-7.6 3.3 -0.4-7.1 3.3 0.7-5.9 Zone 4 1.3 -0.2-2.9 5.0 1.1-8.8 3.1 1.1-5.2 1.3 -0.5-3.1 0 0.6 -0.2-1.5 Zone 5 0.6 -0.2-1.6 5.7 0.2-11.2 3.2 0.4-5.9 0.6 -.06-2.0 3.3 0.08-6.6 2.0 0.3-3.6 Zone 6 2.0 0.2-3.8 3.3 0.9-4.3 2.6 1.0-4.3 0.6 -0.6-2.0 3.3 -2.2-8.9 2.0 -0.7-4.7

Zone 7 0 1.0 -0.1-2.1 0.4 -0.06-1.0 0 0 0 Zone 8 0.6 -0.2-1.6 0.6 -0.2-1.6 0.6 0.03-1.3 0 2.0 -0.1-4.1 1.0 -0.07-2.1 Zone 9 0.3 -0.3-1.0 0 0.1 -0.2-0.5 0 1.3 -0.5-3.1 0.6 -0.2-1.5 Zone 10 0.6 -0.2-1.6 1.6 -0.03-3.3 1.17 0.2-2.1 0 2.0 -2.0-6.0 1.0 -1.0-3.0 Zone 11 0 2.0 -0.2-4.2 1.0 -0.1-2.1 0.6 -0.7-2.0 1.3 -0.5-3.1 1.0 -0.07-2.0 Zone 12 0 0.3 -0.3-1.0 0.1 -0.2-0.5 0 0 0 All India 0.9 0.5-1.3 1.4 0.9-1.9 1.1 0.8-1.5 0.3 0.07-0.6 1.7 0.9-2.4 1.0 0.6-1.4 Table 59. Prevalence of urethral discharge / painful micturition during two weeks prior to survey (According to HIV-endemicity zones)

HIV Endemicity Low Medium High Client Category Estimate 95% CI Design Estimate 95% CI Design Estimate 95% CI Design % effect % effect % effect Rural Areas Men 3.3 2.1-4.4 2.7 7.2 4.6-9.9 0.7 1.0 0.3-1.8 2.1 Women 10.2 7.4-13.0 5.7 18.6 12.4-24.8 1.6 9.7 7.1-12.4 3.1 Total 6.7 5.1-8.3 5.4 12.9 9.2-16.6 1.5 5.4 3.9-6.9 3.6 Urban Slums Men 2.4 1.2-3.7 0.7 7.4 2.2-12.5 0.2 1.3 0.3-2.3 0.7 Women 9.3 5.3-13.4 1.9 14.7 5.9-23.4 0.3 10.4 5.5-15.4 2.5 Total 5.9 3.7-8.0 1.6 11.0 5.7-16.3 0.3 5.9 3.4-8.4 2.1 Table 60. Prevalence of genital ulcers during two weeks prior to survey (According to HIV endemicity zones)

HIV Endemicity Low Medium High Client Category Estimate % 95% CI Design Estimate % 95% CI Design Estimate % 95% CI Design effect effect effect Rural Areas Men 1.1 0.3-1.7 3.0 2.6 0.5-4.8 1.2 0.4 0.05-0.8 1.2 Women 1.5 1.7-2.3 2.6 2.8 1.5-4.1 0.4 0.9 0.3-1.5 1.6 Total 1.3 0.7-1.9 3.7 2.7 1.6-3.9 0.6 0.7 0.3-1.1 1.8 Urban Slums Men 0.4 0.07-0.9 0.6 2.7 0.3-5.7 0.2 0.1 0.2-0.5 0.6 Women 1.7 0.2-3.1 1.3 2.2 0.3-4.7 0.1 1.7 0.7-2.6 0.5 Total 1.0 0.3-1.7 0.9 2.4 0.6-4.2 0.1 0.9 0.5-1.4 0.4 Table 61. Prevalence of urethral discharge / painful micturition during two weeks prior to survey (According to contact status of the clients)

Clients’ Contact Status Rural Areas Urban Slums

Estimate% 95% CI Design effect Estimate% 95% CI Design effect A. Clients who did not receive program services 1. Not Aware about FHAC 6.6 5.4-7.8 3.9 5.2 3.9-6.6 1.1 2. Aware about FHAC through publicity 4.0 2.2-5.9 1.4 7.7 2.6-12.8 0.8 but did not attend camps B. Clients who received program services 1. Contacted at home only 6.4 3.8-8.9 2.6 9.0 3.7-14.4 1.3 2. Attended camps only 9.9 5.0-14.7 1.1 8.0 -2.2-18.1 0.5 3. Contacted at home & attended camps 9.6 5.8-13.3 2.5 15.3 7.0-23.5 0.7 Table 62. Prevalence of genital ulcers during two weeks prior to survey (According to contact status of the clients)

Clients’ Contact Status Rural Areas Urban Slums

Estimate% 95% CI Design effect Estimate% 95% CI Design effect A. Clients who did not receive program services 1. Not Aware about FHAC 1.2 0.8-1.7 2.8 0.9 0.5-1.3 0.6 2. Aware about FHAC through publicity 0.6 0.0-1.3 1.1 0.1 -0.1-0.3 0.1 but did not attend camps B. Clients who received program services 1. Contacted at home only 1.0 0.2-1.8 1.4 1.4 -1.2-4.1 1.9 2. Attended camps only 0.7 -0.4-1.9 0.7 4.2 -4.2-12.6 0.7 3. Contacted at home & attended camps 1.5 0.2-2.8 1.8 4.5 -1.9-10.9 1.2 Table 63. Characteristics of clients with presence of urethral discharge / painful micturition / genital ulcers during the survey

Current Prevalence of RTI/STD symptoms

Rural Areas Urban Slums Estimate% 95 % CI Estimate% 95 % CI Age Group Adults (>20 yrs) 7.1 6.1-8.1 6.8 * 5.3-8.3 Adolescents (15-20 yrs) 6.0 3.8-8.3 3.1 1.0-5.3 Marital Status Married 7.6* 6.4-8.7 7.2 * 5.4-8.9 Unmarried 3.4 1.9-4.9 2.5 1.1-3.9 Education Literate 5.5 4.5-6.5 5.5 4.2-6.9 Illiterate 9.5 * 7.7-11.4 8.3 5.1-11.5

* The difference between the categories was significant at p<0.001 Table 64. Prevalence of condom usage during last intercourse

Clients Category Estimate% 95% CI Design effect Rural Areas Men 9.4 7.7-11.0 3.6 Women 6.6 5.4-7.8 2.7 Total 8.0 7.0-8.9 2.8 Urban Slums Men 10.5 7.8-13.3 1.6 Women 11.7 9.6-13.8 0.9 Total 11.1 9.2-13.0 1.5 Table 65. Prevalence of Condom usage during last intercourse (Zonal data)

Rural Areas Urban Slums Zone Estimate % (95% CI) Estimate % (95% CI) 1. Chandigarh, Delhi, Haryana, 15.3 9.9-20.7 25.7 17.7-33.6 Himachal Pradesh, Punjab 2. Uttar Pradesh 9.5 6.7-12.3 13.0 6.3-19.7 3. Arunachal Pradesh, Assam, 10.6 4.8-16.5 9.0 3.1-14.9 Meghalaya, Sikkim 4. Manipur, Mizoram, Nagaland, 9.3 5.7-12.8 8.7 4.7-12.7 Tripura 5. Rajasthan 12.2 9.1-15.2 16.0 10.4-21.6 6. Madhya Pradesh 4.8 2.3-7.3 8.6 4.2-13.1 7. Orissa 6.6 1.6-11.6 10.6 4.5-17.4 8. Goa, Maharashtra 10.5 7.0-13.9 11.1 5.0-17.3 9. Andhra Pradesh 3.7 1.3-6.0 3.7 0.0-8.0 10. Karnataka 3.5 1.2-5.8 5.7 3.3-8.1 11. Pondicherry, Tamil Nadu 3.8 1.3-6.3 5.3 2.6-8.0 12. Kerala, Lakshadweep 6.7 3.9-9.4 8.6 3.3-13.9 All India 8.0 7.0-8.9 11.1 9.2-13.0 Table 66. Characteristics of clients who had used condoms during their last sexual intercourse

Current Condom Use

Rural Areas Urban Slums Estimate% 95 % CI Estimate% 95 % CI Age Group Adults (>20 yrs) 8.8 * 7.7-9.8 11.9 * 9.8-14.0 Adolescents (15-20 yrs) 3.4 2.1-4.6 6.3 3.2-9.4 Marital Status Married 8.9 * 7.8-9.9 12.9 * 10.7-15.2 Unmarried 3.2 2.1-4.2 3.2 1.5-5.0 Education Literate 10.0 * 8.5-11.4 12.4 * 9.9-14.9 Illiterate 4.3 2.9-5.7 7.5 5.2-9.7

* The difference between the categories was significant at p<0.001 Annexure I

List of Research Associates Participated in FHAC Coverage Evaluation -2000

Zone : 01 Chandigarh, Delhi, Haryana, Himachal Pradesh, Punjab

All India Institute of Medical Sciences, C.R.H.S. Project Ballabgarh Mr. Desh Raj Ms. Shikha Mr. Suresh Kumar Mrs. Neelam Sinha Mr. Gaj Raj Mrs. Krishna Purohit

Regional Health & Family Welfare Training Centre, Kangra Mr. Darshan Kumar Ms. Deep Mala Mr. Rajiv Bhardwaj Ms. Neelam Rana Mr. Bishan Dutt Ms. Sarita Bala

Post Graduate Institute of Medical Sciences, Rohtak Dr. Gurvinder Singh Dr. Renu Mr. Devendra Kumar Ms. Sunila Mr. Darshan Singh Ms. Renu Rani

Zone : 02 Uttar Pradesh

S.N. Medical College, Agra Dr. Anurag Srivastava Ms. Meera Gautam Dr. Manish Jain Dr. Neeta Sharma Dr. O.P. Sharma Dr. Khurshid Parveen

G.S.V.M. Medical College, Kanpur Dr. D.N. Tripathi Dr. Pushpa Tripathi Dr. Ghanshyam Chaudhary Dr. Dimple Singh Dr. Faizur Rahman Ms. Parul Tripathi

King George’s Medical College, Lucknow Dr. Sanjeev Miglani Ms. Vidhatri Singh Dr. Anil Kantura Ms. Seema Saxena Dr. Deepak Pandey Ms. Vimala Devi

Zone : 03 Arunachal Pradesh, Assam, Meghalaya, Sikkim

Assam Medical College, Dibrugarh Dr. Barun Kakoty Dr. Malabika Devi Dr. Pranab Kalita Dr. Kaveri Borah Dr. Ajanta Deuri Dr. Rupiyoti Borthakur Dr. Rinku Bori Dr. Baphira Wankhar Dr. Maxilline Mark Dr. Edmond Khong Thaw Dr. Mukrang Terang Dr. Shamim Ahmed Mr. S.R. Nath Ms. Jubin Parveez

North East Society for the Promotion of Youth & Masses, Guwahati Mr. Paragmoni Dutta Ms. Nivedita Deka Mr. Jyotish Borah Ms. Ritumoni Das Mr. Swarup Bhatta Ms. Madhulekha Hazarika Zone : 04 Manipur, Mizoram, Nagaland, Tripura

Aizwal, Mizoram Mr. B. Hmingthantsuala Ms. Malsawmtuangi

Agartala, Tripura Mr. Arijit Ganguly Ms. Bharati Chakraborty Mr. Mahendra Tanti Ms. Soma Poddar Mr. Sumit Ghosh Ms. Suman Barik Mr. Mriganka Silchar Ms. Kakali Sen Ms. Uttam Saha Kohima, Nagaland Mr. Bendangmoa Ms. Moatula Mr. Limakumzuk Ms. Noleivile

Regional Institute of Medical Sciences, Imphal Dr. Shangam Rungsung Dr. Vijaya Elangbam Mr. P. Babu Singh Dr. H. Sanayaina Devi

Zone : 05 Rajasthan

Dr. S.N. Medical College, Jodhpur Dr. Ashok Chaturvedi Dr. Usha Vyas Dr. Narendra Chauhan Mrs. Anita Vyas Dr. Piyush Mathur Mrs. Neelu Joshi

Medical College, Kota Dr. Rajeev Lochan Ms. Ridhubala Dr. Mukesh Suwalka Mrs. Raj Kumari Dr. Veerbhan Mrs. Anju Meena

S.M.S Medical College, Jaipur Dr. Mukesh Goyal Dr. Manju Jain Dr. Gopal Dhakar Dr. Shailee Jain Mr. Shyam Singh Ms. Shalini

Zone : 06 Madhya Pradesh

Gandhi Medical College, Bhopal Dr. Rameshwar Patel Ms. Asha Jain Dr. Y.P. Singh Mrs. S. Kushawaha Mr. Ramakant Patel Ms. Apra Vijayvargiya

Gwalior Medical College, Gwalior Dr. S.R. Sharma Dr. Purnima Dr. N. Arya Dr. Anoop Pradhan

Gramin Sewa Sanstha, Bilaspur Dr. Narendra Sahu Ms. Smriti Tiwari Mr. Om Praskash Ms. Rajkumari Mr. Rakesh Singh Ms. Rekha Jhadhe Mr. Ram Kumar Ms. Sharda Sharma Zone : 07 Orissa

S.C.B. Medical College, Cuttack Dr. I.C. Behera Dr. Arachana Patnaik Dr. P. Sukala Dr. M. Mohanty Dr. Satyakam Jena Dr. Sunita Nayak

V.S.S. Medical College, Burla, Sambhalpur Dr. B.K. Behra Dr. (Mrs.) S.Sarkar Dr. S.S. Mohanty Mrs. Trupti Singh Dr. L.P. Nayak Mrs. N. Das

M.K.C.G. Medical College, Berhampur Dr. S.K. Pradhan Dr. (Mrs.) S. Mallin Dr. R.M. Panda Dr. (Mrs.) S. Das Mr. S.K. Patnaik Ms. C. Das

Zone : 08 Goa, Maharashtra

LTM Medical College, Sion, Mumbai Dr. Pankaj Shah Dr. Subeeta Dopas Dr. Himansh Gupte Dr. Geeta Bhate Dr. Hemant Kulkarni Dr. Madhavi Sawant Dr. Santosh Bhalke Dr. Kavita Prabhakar Mrs. Preetali Hakandkar

Government Medical College, Nagpur Mr. Abhishek Ms. Megha Mr. Nikhil Ms. Rupali Mr. Sagar Ms. Poonam Mr. Abhishek

Zone : 09 Andhra Pradesh

Siddhartha Medical College, Vijayawada Ch. S. Nageswar Rao Dr. N. Sridevi Mr. D. Ramudu Dr. M. Suneetha Mr. V. Visweswarayya Mrs. Sowri Rani

Osmania Medical College, Hyderabad Dr. G. Sukhadas Dr. C. Mary Kumari Dr. A. Shravan Kumar Dr. A.S.N. Lalitha Rao Mr. P. Chandraiah Ms. B. Akkamma

S.V. Medical College, Tirupati Dr. Artaf Hussain Dr. Y. Sumathi Dr. P. Ganesh Dr. N. Swarna Latha Dr. A. Narasimhulu ` Dr. S. Vijaya Laxmi Zone : 10 Karnataka

M.R. Medical College, Gulbarga Dr. Girish Kumar Ms. Poonam R. Patne Dr. B. Rohit Ms. Renuka Hosamani Dr. Preetam Hooli Ms. Mallamma Hiremath

St. John’s Medical College, Bangalore Dr. S.R. Srikrishna Dr. Priya Maladan Dr. Anton Isaacs Dr. C.T. Anita Mr. B. Vekatesh Mrs. Ratna Kumari

Bangalore Medical College, Bangalore Dr. Veerendra Dr. Vasu Agarwal Dr. Pappu Dr. Usha Dr. Shamsundar Mrs. Suprada

Zone : 11 Pondicherry, Tamil Nadu

Madras Medical College, Chennai Mr. M.D. Tilak Raj Ms. Devika Mr. M. Sahabudeen Ms. Mary Glory Mr. P.S. Mohan Kumar Ms. N. Krithiga

Christian Medical College & Hospital, Vellore Mr. Anand Ms. A. Ruby Mr. Umakanth Mrs. Joyce Rajan Mr. John Mrs. Margaret Silas

Madurai Medical College, Madurai Dr. P. Muthu Kumar Dr. R. Maha Lakshmi Dr. P. Muthu Kumar Dr. R. Poppy Rejoice Dr. S. Jaya Dr. K. Usha

Zone : 12 Kerala, Lakshadweep

Medical College, Thiruvananthapuram Dr. Biju M. Dr. Geetha Rai Dr. Pradeep Ravindran Ms. Sandhya Cherian Dr. Biju B. Nair Ms. Asha P.R.

Medical College, Calicut Dr. Mathew Nampeli Dr. Somy Saju Dr. V.V. Suraj Ms. Sushli Dr. Shibulal Ms. Sandhya

Academy of Medical Sciences, Pariyaram, Kannur Dr. V.K. Shameer Dr. Vandana Menon Dr. Vimal Varkey Dr. S. Sindhu Dr. Shameer Chand Dr. L.R Vandana

Annexure III Work Plan for Interviews (Composition of Field Teams)

Zone Name: ...... Zonal Coordinator:...... CCT Member:......

PMC’s Investigators Team PMC: Team PMC: Team PMC: No. No. No.

Team Investigator’s name 1* 4* 7*

Research Assistant’s name

Research Assistant’s name

Team Investigator’s name 2* 5* 8*

Research Assistant’s name

Research Assistant’s name

Team Investigator’s name 3* 6* 9*

Research Assistant’s name

Research Assistant’s name Annexure III (contd.) Work Plan for Interviews

Zone Name: ...... Zonal Coordinator:...... CCT Member:......

PMC: PMC: PMC:

Cluster Name Team* Date Cluster Name Team* Date Cluster Name Team* Date No. No. Planned No. No. Planned No. No. Planned

Annexure IV

Log Sheet for Households Surveyed for Male/Female Respondents in Each Cluster

Please note 1. To be maintained by research assistants 2. Give details of the households visited for selecting respondents 3. To be submitted along with the original interview schedules to CCO, New Delhi

Zone No: ------Cluster No. and Details ------

S. No. Name - Head of family Remarks*

1 Sh. Ram Kumar Door locked

2 Sh. Mahesh Eligible individuals not at home

3 Sh. Ramesh Eligible individuals busy, come back after 2 hours

4 Sh. Rajan Kumar Refused to be interviewed

5 Sh. Roop Kumar Interviewed

* Should include comments like: Interviewed; door locked; no one in the eligible age group available at home; individuals available but busy with (household) work; refused to be interviewed; no privacy; etc.

Signature of Research Assistant------

Date------Annexure V

Interview Schedule log sheet for Team Leaders

Please Note: (i) Format to be filled by the senior investigator of each team after completing each cluster. (ii) Original of this format to be sent to CCO, New Delhi, along with original copy of the completed schedules at the end of each cluster. (iii) Copy of this format to be submitted along with the xerox copy of the schedules to the zonal coordinator towards the end of the study. (iv) Return the rejected / unused schedules also to the CCO, New Delhi.

Zone Name:...... Date:......

Cluster Address: ......

Investigator: ...... Research Assts.: ...... 1. Number of interviews completed

Male: 10 Yes / No

Female: 10 Yes / No

GHW: 2 Yes / No

Doctor: 1 Yes / No

2. Blank / rejected schedules sent to CCO (enter unique number of the schedule)

Male:...... Female:...... GHW:...... Doctor:......

3. Date of Dispatch to CCO, New Delhi: ......

4. Problems encountered, if any:

5. House visit log sheet - Men & Women

Signature of the investigator:...... Date: ...... Annexure VII

Report of Quality Assurance Field Visits by CCT Member

Zone No and Name :...... Date:......

Cluster No and Name :......

A. Mode of selection of households / samples / any related problems (describe):

B. Cross Check of interviews already done: i) Number of households/ interviewees contacted- ...... ii) Authenticated Yes/No

C. Interviewing technique: i) Number of interviews observed:...... ii) Quality of interviews: Acceptable Unacceptable • Cooperation of interviewee • Probing techniques • Prompting • Questions skipped / left out? • Completeness of schedules

D. Summary of deficiencies noticed and remedial actions taken:

CCT Member’s Signature: ------Annexure VI Network Progress at a Glance ZONE:...... Fax: 011 6862663 / 6865934 / 6853125

Please Note: Update this monitoring sheet everyday, but fax it on every Monday, Wednesday, Friday to CCO, AIIMS, New Delhi.

Date PMC: PMC: PMC:

Cluster Date Date done Date of Cluster Date Date done Date of Cluster Date Date done Date of (No. & Planned Dispatch (No. & Planned dispatch (No. & planned dispatch Name) Name) Name) Annexure VIII Cluster Schedule Monitoring Sheet

Zone: Cluster Date Total Recd Rejected/ CE - CE- Cluster Date Total Recd Rejected/ CE - CE- Cluster Date Total Recd Rejected/ CE- CE- No. done unused 1* 2* No. done unused 1* 2* No. done unused 1* 2*

01 16 31

02 17 32

03 18 33

04 19 34

05 20 35

06 21 36

07 22 37

08 23 38

09 24 39

10 25 40

11 26 41

12 27 42

13 28 43

14 29 44

15 30 45

* CE : Computer entry (first & second) Unique numbers of rejected / unused schedules: Annexure IX Interview Schedule Monitoring Sheet

Zone: ...... Uniq Recd Rejected CE-1* CE-2* Uniq Recd Rejected CE-1* CE-2* Uniq Recd Rejected CE-1* CE-2* Uniq Recd Rejected CE-1* CE - 2* No. /unused No. /unused No. /unused No. /unused

0101 0109 0125 0141

0102 0110 0126 0142

0103 0111 0127 0143

0104 0112 0128 0151

0105 0121 0129 0152

0106 0122 0130

0107 0123 0131

0108 0124 0132

* CE : Computer entry (first & second) Bibliography 1. AIDS Awareness in North East Thailand (1995). Monograph 1. INCLEN Monograph Series on Critical International Health Issues. INCLEN Publications, Philadelphia, USA.

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15. NACO (2000). National AIDS Control Program : Family Health Awareness Campaign [1st -15th June, 2000] Operational Guide, Ministry of Health & Family Welfare, Government of India, New Delhi. 16. World Bank (2000). Accelerating an AIDS Vaccine for Developing Countries: Recommendations for the World Bank. Washington D.C., USA.