Toward reducing the spread of HIV in northeastern Thai villages: evaluation of a village-based intervention.

This paper presents results of the evaluation of an intervention designed for northeastern Thai villages and particularly for village women. The intervention was based on established principles of behavior change, social learning theory, and community health promotion, and it was grounded in elicitation research. A total of 600 women and 479 men and 12 villages participated in the evaluation which used data collected from face-to-face knowledge, attitude, practices (KAP) surveys, focus groups, and village meetings in a quasi-experimental pre- and post-control group design. Eight of the nine outcome goals set for the intervention were achieved with significant increases in married women taking the initiative in reducing the risk posed to them by the sexual activities of their husbands.

PIP: This paper describes and evaluates a 1994 intervention designed to reduce HIV transmission among villagers in northeastern Thailand. The report opens with an introduction which describes the progression of HIV/AIDS in the country. The HIV prevention intervention is then described as consisting of 1) an agreement between intervention providers and village leaders to establish a partnership to introduce the intervention and train volunteers as facilitators, 2) broadcast of a 5-day motivational audio-drama over village loudspeakers, and 3) a village meeting to institute village discussions of AIDS and plan further village strategies. Outcome goals for women, for men, and for the village as a whole included 1) villager identification of the program as a major source of information, 2) increased risk awareness, 3) increased reporting of risk-reduction behavior, 4) increased communication about HIV/AIDS, 5) identification with characters in audio-drama, 6) identification of HIV/AIDS as a community concern, and 7) creation by the villagers of additional strategies. Description of the evaluation methodology includes data collection from KAP interviews and focus groups and a sample survey. Results are presented for each of the preliminary goals, and it is concluded that the project intervention was successful. Modifications were made based on the evaluation results, and the strategy was adapted for large-scale intervention. Using a strategic approach guided by established theories of behavior change and community development ensured that the program was sensitive to the sociocultural framework presented by the targeted village.

Contexts and patterns of men's commercial sexual partnerships in northeastern Thailand: implications for AIDS prevention.

Results of an exploratory research project elaborating the contexts, patterns and specific scenarios of the commercial sexual activity of northeastern Thai men are reported. Data were collected using face-to-face surveys, focus groups, key informant interviews and observations in 32 northeastern villages (n = 744 men), 18 migrant labour camps housing sugarcane workers (n = 219 men), and five cattlemarkets in northeast Thailand. Fifty percent of married men and 43% of single men had visited female sex workers (FSW). Female sex worker visits occurred primarily prior to marriage, though 13% of married men had purchased sexual services within the past year. Nonmarital sexual activity was set within the socio-cultural frameworks of poverty, circular migration, a large commercial sex sector, and a belief system about men's sexuality and men's and women's gender roles. Sexual services were typically purchased as part of friendship group partying (paiy tiaow) and generally included heavy alcohol consumption. The most common scenario for visiting FSWs involved brothels, though cattlemarkets, festivals, and migrant labour situations were also scenarios for FSW contact. These each had unique characteristics that affected the likelihood that condoms would be used. The further the specifics of a scenario (as evaluated by men) diverged from those of brothel contact with an FSW, the less likely men were to identify this as having the potential for HIV transmission and the less likely they were to use a condom. AIDS prevention campaigns must be developed that are sensitive to the socio-cultural framework, contexts and specific scenarios within which nonmarital sexual contacts occur.

Evaluation of HIV/AIDS education initiatives among women in northeastern Thai villages.

A longitudinal, naturalistic experimental design was used in an evaluation of the effects of an HIV/AIDS educational pamphlet controlling for secular trends (most specifically media coverage of HIV/AIDS) in Northeastern Thailand. Nine hundred and fifty-four women from 18 villages completed KAP interviews either in the autumn of 1991 or 1992 with HIV/AIDS education pamphlets distributed to every household in 12 of these villages in the spring of 1992. Pamphlets influenced women's perceptions of personal risk from casual sources and the degree to which they volunteered that condoms were a means of prevention of HIV transmission. Both results were related to the content and style of presentation of information about sources of risk and about condoms in the pamphlets. Secular trends and an increase in communication between villagers had a significant influence on knowledge, perceived efficacy of self protection, readiness to use condoms, and perception of levels and sources of personal risk.

Multisectoral strategy for AIDS prevention at community level.

In north-east Thailand a five-act drama is broadcast on the village sound system to catalyse involvement in planning and carrying out AIDS prevention activities. Each community's own suggestions for an effective strategy are presented to the relevant government and nongovernmental agencies for endorsement and support.

PIP: The multisectoral AIDS prevention strategy (MAPS) was implemented in four northeastern provinces of Thailand where a very developed infrastructure for health, education, and social welfare exists. (MAPS entails use of integrated government and nongovernmental AIDS-related services to conduct community-defined initiatives.) An audio-drama was used to introduce MAPS at the community level. It included risks, precautions, local beliefs, and modes of personal interaction pertaining to prevention of the spread of AIDS. The five-act audio-drama was entitled On the Brink and was broadcast over each of the 43 communities' public address systems. It revolved around the needs of married women in relation to AIDS prevention and addressed how men and rural people in general are involved. The stages of the MAPS program were a pre-drama subdistrict meeting, a week of drama in the communities, a post-drama community meeting to discuss a community AIDS strategy, a post-drama subdistrict meeting to present and consolidate the strategy, and implementation of the strategy. Three teams implemented MAPS. The post-drama community meetings began with games and a quiz on AIDS with small prizes to encourage participation in discussions. Identified local HIV risk situations included brothels, cattle auctions, certain festivals during which prostitution occurs, and intravenous drug use among young men. The first priority identified in all the subdistricts was open and free availability of condoms (e.g., available where alcohol is sold). Other suggested interventions were publicity about the danger of commercial sex work and training for women whose husbands travel in developing sexual negotiation skills. During the post-drama subdistrict meeting, an AIDS implementation committee was chosen to coordinate AIDS prevention activities conducted by both the government and nongovernmental organizations' staff in the subdistrict.

Epidemiological study on contamination of water and diarrheal diseases in a rural community in northeast Thailand.

An epidemiological and bacteriological study of diarrheal diseases as well as the relation between domestic-use water and passage of enteric pathogens with stools of the villagers was performed in the northeastern rural area of Thailand on 4 different occasions during the 3 years from 1992-1994. The questionnaire study indicated that 93% of the residents used rain water stored in containers for drinking and other domestic uses, and that 28% of them filtrated and/or boiled the water before drinking it. About 90% of drinking water samples collected from the same residents showed positive responses for the preliminary test ofEscherichia coli contamination. Furthermore, a precise bacteriological survey indicated that more than half of the drinking water samples collected from containers storing rain water were contaminated with various enteropathogenic bacteria, includingE. coli, Vibrio spp. andShigella spp. The new serotype ofV. cholerae O139, synonym 'Bengal cholerae,' which could be isolated from different specimens, is replacing the traditional species ofVibrio. Forty-one per cent of the villagers carried enteropathogenic bacteria in their stools. Most of them were asymptomatic carriers and only a few of them showed clinical features of diarrhea. A few concrete propositions were discussed to supply safe water in these areas where drinkable underground water is not available.

Knowledge, attitudes and beliefs about HIV/AIDS among women in northeastern Thailand.

Results of knowledge, attitudes, beliefs, and practices (KABP) interviews (N = 330) and focus groups (12 groups, 80 participants) addressing human immunodeficiency virus (HIV) and AIDS conducted with women living in rural villages in Khon Kaen province, Thailand, from November 1991 to January 1992 are reported. Women had obtained most of their information from television and radio. No AIDS health promotion programs had been targeted specifically to rural women. General knowledge regarding modes of transmission and prevention were good. The majority of women (85.5%) identified at least one known mode of transmission. Prostitution and contaminated needles were seen as the predominant sources of risk by these women. This knowledge, however, had not been applied to personal life circumstances in such a way that would facilitate avoidance of HIV infection. For example, few women considered themselves to be at risk for HIV infection even when they recognized that their husbands had engaged in risk-related behaviors (e.g., contracting for the services of commercial sex workers). Focus group discussions clarified the relationship between knowledge about HIV/AIDS, assessment of personal risk, use of condoms, and prevention strategies in general. Areas of misperception and confusion were identified, as well as potential vehicles for and content of AIDS health promotion initiatives. Results are currently being used to design health promotion interventions to reduce the spread of HIV.

A research-based HIV intervention in northeast Thailand.

This paper presents a case study of the development, implementation and evaluation of an HIV prevention strategy for rural, married women in the northeastern, Isan region of Thailand. The strategy is based on established principles of behaviour change, social learning, and community health promotion; grounded in baseline research, that identifies relevant contextual factors; community-based; evaluated; and applicable elsewhere. The methodology of the project includes four phases: data collection, strategy design, implementation, and evaluation. Baseline data were collected from an age-stratified sample of married women from 24 randomly chosen villages in Khon Kaen province in two waves. A total of 654 women participated in structured face-to-face interviews and 150 also participated in focus groups. Using the baseline data, a health promotion strategy including three components was designed: meetings with and training of village leaders and health workers; a five-part week long audio-drama, together with posters and other publicity conducted in villages; and village meetings to discuss the potential impact of HIV/AIDS on the village and to establish a village strategy to address this. This paper reports the results of the baseline data collection, how the data were used to produce an HIV prevention initiative for rural villages, results of the process evaluation and future development in HIV/AIDS prevention initiatives in this region.

The mechanism of action of chlorhexidine.

Chlorhexidine did not inhibit ATPase in intact cells of Escherichia coli K12 W1317i-, even at bactericidal concentrations, and ATP hydrolysis was greatest at the highest concentration (40 mg/l), even though no net uptake of substrate occurred. Like dinitrophenol and tribrominated salicylanilide, polymyxin and chlorhexidine collapsed the membrane potential at inhibitory concentrations. Membrane disruption, and not ATPase inactivation, is considered the lethal event in chlorhexidine action.

Vibrio cholerae serogroup O1 in northeast Thailand.

Strains of Vibrio cholerae serogroup O1 biotype El Tor that are susceptible to Mukerjee cholera bacteriophage group IV (S. Mukerjee, Bull. W.H.O. 28:333-336, 1963) were found. Cholera vibrios isolated from epidemics in northeast Thailand were characterized, and 57 of 60 strains isolated in 1986 were susceptible to cholera phage IV. However, all 113 strains isolated in 1988 were not susceptible to the phage. All isolates in both epidemics revealed behaviors typical of El Tor vibrios, except phage IV susceptibility in the 57 strains. Although the plaques of phage IV were generally translucent, plaques on some isolates looked transparent, just like those on classical vibrios. The organisms grown in the plaques were lysogenized. If this kind of strain is frequently isolated, the biotype of V. cholerae O1 should be reconsidered.

Red rubber bulb, cheap and effective vacuum drainage.

Red rubber bulbs have been used for vacuum drainage in head, neck, breast and several other operations by the authors since 1975 quite effectively without any major problems. The vacuum pressure of the red rubber bulbs was found to be higher than the expensive commercially available vacuum wound drainage device. The question of remaining old blood and infective microorganisms inside the reservoir for the reused ones were tested by the manual cleaning process and the standard sterile technique using steam under increased pressure (autoclave). The result is quite satisfactory. We encourage the use of this cheap and effective (made in Thailand) vacuum wound drainage in Thai hospitals and Thai medical schools.

Hemolytic Vibrio cholerae O1 that is sensitive to Mukerjee's cholera phage IV and the phage produced by the hemolytic vibrio lysogenized with the infection of Mukerjee's cholera phage IV.

Strains of hemolytic Vibrio cholerae O1 (El Tor vibrio) which are sensitive to Mukerjee's cholera phage group IV were isolated from cholera patients in North-East Thailand in 1986. Plaques of the phage on these hemolytic V. cholerae O1 were usually translucent but almost transparent on some strains, just like the plaques on non-hemolytic V. cholerae O1 (classical vibrio). These hemolytic V. cholerae O1 were lysogenized with the infection of cholera phage IV, and the lysogenized strains produced phage different from cholera phage IV. These hemolytic strains were classified into Cured type in prophage typing of V. cholerae O1, El Tor, because they were also lysogenized with Kappa phage and were hemolytic. When Cured-type V. cholerae O1, El Tor previously isolated in various countries were examined for the sensitivity to cholera phage IV, some of the isolates were sensitive.

Large production of cholera toxin by Vibrio cholerae O1 in yeast extract peptone water.

A large amount of cholera toxin (CT) was produced by Vibrio cholerae O1 cultured in yeast extract-peptone water. The organisms were cultured initially in a stationary test tube (small surface-to-volume ratio) until the end of the exponential phase and subsequently cultured in a shaking flask for 15 to 20 h. By this method (previously reported as the AKI-SW method), most cholera vibrios produced an abundance of CT (up to 64 micrograms/ml), regardless of their biotype and serotype. A substantial amount of CT was produced even in basic peptone water (2% peptone, 0.5% NaCl). Use of sodium bicarbonate, which markedly stimulated CT production in the stationary test tube culture, was undesirable for CT production by the culture method used here. CT production was greatly influenced by culture conditions but was not significantly affected by the composition of the medium.