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AIDS prevention interventions for specific risk situations in rural Northeast Thailand
Health & Place, Vol. 4, No. 3, pp. 265±272, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 1353-8292/98/$19.00 + 0.00
PII: S1353-8292(98)00021-5
Cattle markets and local festivals: Development of HIV/AIDS prevention interventions for speci®c risk situations in rural Northeast Thailand Lynn R. Dole,*$ David B. Elkins,*$ Kovit Boonjear,* Suwat Phiensrithom* and Eleanor Maticka-Tyndale% *Multi-sectoral AIDS Prevention Strategy (MAPS), Northeast Centre for AIDS Prevention and Care, Khon Kaen University, Khon Kaen, Thailand $Australian Centre for International and Tropical Health and Nutrition/Queensland Institute of Medical Research, 300 Herston Road, Herston, QLD 4006, Australia %Department of Sociology and Anthropology, University of Windsor, Winsor, Canada
In rural Northeast Thailand, risk of sexual transmission of HIV is popularly perceived to be site-speci®c. Risk of HIV transmission in local scenarios like cattle markets and village festivals has not been adequately addressed. This paper assesses the use of community consultation and formative research to overcome prevailing assumptions about HIV risk by involving community members in the process of identifying risks and developing HIV prevention strategies. This participatory approach can be used to develop prevention programs that are responsive to the speci®c context of risk behavior in rural environments. # 1998 Elsevier Science Ltd. All rights reserved Keywords: AIDS, HIV prevention, rural, Thailand
Introduction Extensive public health campaigns in Thailand have raised awareness of HIV transmission risks (Maticka-Tyndale et al., 1994; Sweat et al., 1995), and condom promotion targeting brothels has resulted in increased condom use in commercial sex encounters in brothels (Nelson et al., 1996). However, in rural Northeast Thailand exposure to these campaigns has contributed to the perception that risk of sexual transmission of HIV is site-speci®c. The use of Central Thai, the language of schools and government but not the dialect used in Northeastern villages, in most AIDS prevention campaigns has perpetuated local perceptions that HIV/AIDS is largely an urban problem, and not a relevant threat to rural communities in the Northeast (Lyttleton, 1994). The association between brothel-based commercial sex and HIV risk emphasized in many
interventions has resulted in the widespread view that unprotected sex with other partners is safe (Sweat et al., 1995). In research conducted with rural men in the Northeast, Maticka-Tyndale et al. (1997) found that the further a scenario diverged from brothel contact with a commercial sex worker (CSW), the less likely men were to recognize the potential risk of HIV transmission and the less likely they were to use a condom. This paper examines the use of a combination of formative research, community consultation, and the extension of existing services to develop targeted HIV/AIDS prevention interventions that meet rural needs. It focuses on two scenarios that are relevant to the daily lives of rural people in Northeast Thailand, cattle markets and village festivals, in order to assess how this integrated approach is responsive to a variety of factors in dierent locales. This paper looks at each scenario in turn, detailing the process used to identify 265
Cattle markets and local festivals: L. R. Dole et al.
risk sites, develop targeted interventions, implement, and evaluate these interventions. At the conclusion, this paper suggests how this approach could be modi®ed to other settings, emphasizing the importance of context in developing HIV/AIDS prevention programs. Context of sexual risk-taking in rural Northeast Thailand Commercial sex is available in a broad range of situations in rural Northeast Thailand (Ford and Koetsawang, 1991; Lyttleton, 1994; MatickaTyndale et al., 1997). In addition to brothels, restaurants and entertainment establishments, there are also a number of sites that are intrinsic to the rural environment, such as local festivals and cattle markets, where commercial or casual sex are widely available. Maticka-Tyndale et al. (1997) have produced an overview of the sexual risk scenarios and contexts for men in rural Northeast Thailand, and this paper details further work in the same project. Sentinel surveillance in 1995 found HIV prevalence rates in the Northeast of 12.1% among commercial sex workers, 7.5% among patients at sexually transmitted disease clinics, 0.7% among blood donors, and 1.5% among pregnant women (Ministry of Public Health, 1995). Despite signi®cant increases in condom use in brothels, condom use with other sex partners, such as wives, girlfriends (Nelson et al., 1996), and ``regular'' commercial sex partners (Morris et al., 1995), remains low. Some researchers have observed that as visits to brothels decline, the frequency of sex with other partners, such as girlfriends and casual partners, is increasing (Mastro and Limpakarnjanarat, 1995; Ford and Kittisuksathit, 1996). In interviews with 737 men in 32 Northeastern villages, Maticka-Tyndale et al. (1997) found that 48% had purchased sexual services. Fourteen percent (50) of those men had engaged sex workers at cattle markets. The vast majority (97%) of these 50 men were married, and half of them reported purchasing sex at cattle markets more than four times within the past year. A similar percentage (14%) of the sample reported having purchased sex at village festivals; 90% said they had done so within the past year (Maticka-Tyndale et al., 1997). Maticka-Tyndale et al. (1997) report that in focus group discussions men rarely associated sexual encounters with casual partners or female sex workers in their communities or other local settings with risk of HIV. For example, one focus group participant explained, ``There are small brothels and small risks in our village. Not like Bangkok. There the brothels are large and the risks are too''. Risk behavior persists because such sites are seen as familiar and therefore safe; 266
risk-reduction strategies that men might use in external settings are not triggered in these local situations. As one man explained in a focus group, ``It is in our village, no. We do not use condoms, it is safe'' (Maticka-Tyndale et al., 1997). In addition to peer in¯uence and alcohol use which are often associated with commercial sex in Thailand, Maticka-Tyndale et al. (1997) identi®ed other factors, including a sense of immediacy and spontaneity, which made it less likely that men would take precautions in sex encounters at cattle markets and local festivals. In these local settings, sexual activity takes place under the cover of darkness, on mats on the outskirts of the event. Queues form as men await their turn with the sex worker, and the men described a sense of urgency: ``It is an emergency situation. That means you have sex in the rice ®eld or the sugar ®eld. You do it in a hurry''. With few exceptions, the only source of condoms were those brought by the sex workers. There have been no sustained eorts to address risk in these scenarios. There had been sporadic government intervention in the cattle markets as evidenced by police involvement and occasional provision of condoms and media materials. The festivals, however, had never been recognized as a risk. Policymakers outside rural communities were unfamiliar with the extent of sexual risk under these circumstances. In both cases, basic qualitative research needed to be conducted that could help to explain the availability of commercial sex, the context of sexual risk-taking, and potential opportunities for intervention. Approach Through the MAPS community consultation process, men and women in over 450 villages in Northeast Thailand participated in identifying HIV transmission risks that aected their communities and families (Elkins et al., 1996). Cattle markets and local festivals were widely identi®ed with increased risk of sexual transmission of HIV. Of the 42 subdistricts participating in the community consultation process, all but four cited village festivals as a major public health concern. To assess the level and context of risk encountered at village festivals, ®ve focus group discussions were conducted with rural men in April 1995. Consultations with public health ocials, village health volunteers, and village leaders followed to develop a strategy for reducing risk at village festivals. Interventions, in the form of targeted media and condom distribution, were developed, piloted, revised, and implemented in late 1995 and early 1996. To construct a picture of HIV risk behavior at cattle markets, qualitative studies combining
Cattle markets and local festivals: L. R. Dole et al.
informal interviews, observation, and focus groups were conducted at ®ve major cattle markets in the upper Northeast region in March 1995. The market owner(s), food vendors, and subdistrict public health ocials at each site were interviewed. Focus groups with 8±10 cattle traders were conducted at each market using a judgement sample, and informal interviews were conducted with at least three sex workers at each site. At two markets group discussions with 4±6 sex workers were conducted. Through this process, people directly associated with cattle markets recommended appropriate interventions for reducing the risk of HIV transmission. These suggestions were developed through research and ®eldtesting. The interventions were piloted at one site in August 1995 and modi®cations were made before implementing the program at principal markets throughout the northern Northeast region in November±December 1995. Evaluation was conducted in January±March 1996.
Kaen market indicated that she had been selling sex for 12 years, and during that time had worked at more than eight markets in three provinces; another woman reported that she had been selling sexual services at cattle markets for nine years, and regularly attended ®ve markets in three provinces. When asked if the CSWs knew each other, a 20 year-old sex worker at another market explained, ``Yes, I don't know what village they come from but we see each other at all of the markets''. CSWs typically meet their clients in small food stalls in the market, where men gather to eat and drink alcohol. Clients occasionally invited CSWs to hotels outside the market, but most of the sexual servicing took place after dark on mats on the outskirts of the market, or in rooms attached to or near the food stalls. In these low-walled bamboo structures, privacy is oered by darkness, as several couples may share the same open space.
Cattle markets Weekly cattle markets are held throughout the Northeast, where local farmers and traders buy and sell cattle and water bualo. Smaller markets are attended by 100±150 people, and larger ones can attract about 1,500 people. While farmers tend to go to the markets closest to their homes, cattle traders and buyers move throughout a circuit of major markets. For instance, at a large market in Khon Kaen province traders from more than fourteen provinces were recorded in one night. Cattle and bualo are brought to the market in the afternoon, and most of the trade occurs throughout the night, so that the market typically disperses by midday the following day. Farmers and traders watch their stock, engage in negotiation over sales, and drink throughout the night. Sexual networking at cattle markets links three populations: a large number of farmers who converge from neighboring communities, and two smaller but highly mobile populations that move throughout the region on a regular circuit, cattle traders from dierent provinces and female sex workers. Like the cattle traders, female commercial sex workers regularly attend a series of cattle markets throughout the region. Some are ``freelance'' workers who make arrangements with clients on an individual basis, while others work with a middleman who helps them secure clients in exchange for a portion of the money earned. The sex workers often reported that they travelled to cattle markets with a group of friends. While many described rice growing as their primary occupation, nearly all the women interviewed had sold sexual services at cattle markets for a period of several years. A 31 year-old woman at a Khon
Risk of HIV transmission at cattle markets In focus groups and interviews, people at the cattle markets identi®ed a number of factors which they felt contributed to HIV risk in this setting: heavy alcohol consumption, insucient risk awareness, lack of condoms, and the availability of sexual servicing. Qualitative research at several markets indicated that, although ranging in size, the cattle markets were similar in terms of availability of sex services, limited access to condoms, and current low levels of government involvement in AIDS education and condom distribution. Men who reported purchasing sex at cattle markets described the scenarios they associated with commercial sex. They explained that following a cattle sale there is the tradition of buying alcohol and cigarettes to show generosity to the buyers and the people who serve as witnesses. They indicated that in this context, purchasing sexual services is another way of expressing generosity and celebrating a sale. Due to heavy drinking, noise, and their responsibility for their cattle, some men reported being unable or unwilling to sleep so they purchased sex. Several men said that they purchased sex because they were away from their families for extended periods of time, asserting that this ``makes them wild'' and ``misbehave''. With the exception of one market where the owner maintained a small supply, the only condoms available at cattle markets were those which the CSWs brought with them. None of the men interviewed had brought condoms, and once they were at the cattle market they had no way to acquire condoms. In Northeast Thailand, condoms are sold in district centers or larger market towns, but in rural areas the only sources of con267
Cattle markets and local festivals: L. R. Dole et al.
doms are the government Subdistrict Primary Health Care Stations (sathani anamai). The government provides these condoms free of charge, and CSWs at the cattle markets typically indicated these health stations as their source. The health stations are regularly open during ocial government work hours. Government public health workers also recognized the HIV risk at cattle markets, as attested by numerous eorts at intervention. However, none of these interventions had been sustained, except for the distribution of condoms to sex workers who requested them at health stations. In some areas, village health volunteers (Aw Saw Maw) had been given responsibility for maintaining condom supplies to cattle markets, but this practice was erratic at best. In general, the public health sector did not know how to go beyond what they were already doing: providing condoms when asked and making occasional forays to the cattle markets to hang posters and to encourage CSWs to have regular health checks. A basic constraint was that the health oces and the cattle markets operate on dierent schedules; when public health ocers visited the cattle market site during their daytime work hours, nothing was happening because most of the activity at the cattle markets takes place late at night. Developing an intervention strategy Development of appropriate HIV prevention interventions for cattle markets was a participatory process involving consultations and focus group discussions. Among the suggestions provided by participants were: education and training for the market owners, food vendors, CSWs, middlemen, and clients; condom distribution for middlemen, CSWs, and clients; and posters and tapes about AIDS to be used in the food shops. Both men and women emphasized that education for clients was essential because they often resisted using condoms and oered a higher price for sex without condoms. Based upon these recommendations, an HIV/ AIDS prevention strategy was developed which included establishing consistent condom distribution at cattle markets, designing targeted HIV prevention media with messages relevant to the context of risk at cattle markets, and establishing links between public health workers and the cattle markets. The cattle market owner and the food vendors were identi®ed as the principal contacts at each market because they were connected to the site on a regular and long-term basis. Recognizing their authority over the market domain, the cattle market owners were selected as the key contact at each site. Condoms were made openly accessible in condom boxes which indicated that they were available free of charge and provided information about correct condom 268
use. The cattle market owner and local health ocials worked together to maintain consistent supplies of condoms to the shop vendors who re®lled the boxes in their shops (Figure 1). The food shops where cattle traders gather to drink and where sex workers wait to meet customers were selected as the focal points of the intervention. Media exposure is highest here, and at night these are the best lit places in the market. Using images, language, and humor that were familiar to rural people in the Northeast, the media encouraged men to assess their personal risk, cultivated peer support for condom use, and provided constructive information about reducing risk behavior. These messages were reproduced in several forms: as condom boxes for open access to free condoms, as T-shirts for the participating vendors and the market owner, as posters and mobiles for the food shops, as stickers for trucks and motorcycles, and as key chains with a pull-out drawer for a condom that can be used and then replaced with a new one. Process evaluation Follow-up visits were made approximately two months after the interventions were launched at each cattle market. Evaluation was conducted via interviews with shop vendors and CSWs and focus group discussions with cattle traders and farmers to assess the impact of the intervention from several perspectives. Interviews with CSWs found that it was easier for them to negotiate condom use with clients for several reasons: the clients were more likely to have brought condoms themselves, the clients were more aware of the importance of condom use in preventing HIV transmission, and the clients were generally more conscious of issues of personal risk and HIV. CSWs reported that they also took condoms directly from the condom boxes. Shopkeepers con®rmed that both men and women accessed condoms from the condom boxes. Condoms were taken with greater frequency in shops where CSWs and clients typically meet than in shops that are not meeting places for the negotiation of commercial sex. Similarly, more condoms were taken at cattle markets with high levels of commercial sex activity than at cattle markets where police intervention had suppressed the sex trade. Cattle traders disseminated the messages as they moved through the circuit of cattle markets. Three months after 80 condom key chains were distributed to cattle traders at a pilot market in Mahasarakham province, key chains were observed being used by traders at cattle markets throughout the region. The media stimulated discussion about AIDS prevention, raising awareness of personal risk
Cattle markets and local festivals: L. R. Dole et al.
Figure 1. Targeted HIV prevention media for cattle markets. Condom key chains, condom box, stickers, and poster with HIV prevention messages speci®c to the context of risk behavior at cattle markets
and the need to modify behavior. In a focus group discussion, one 37 year-old cattle trader commented, ``When it comes right down to it, I don't like to use condoms. But if I think at all about AIDS prevention, I wear them''. This program brought ``thinking about AIDS prevention'' to an environment which had been associated with risk but had been underserved by conventional campaigns and the public health infrastructure.
Village festivals Northeast villagers celebrate a steady cycle of festivals according to agricultural and religious calendars. There are also events associated with some public holidays, and celebrations, particularly weddings and ordination ceremonies for young men entering the monkhood, which can be characterized as festivals. Family members who are working elsewhere often return home to attend these festivals, especially during Songkran, the traditional Thai New Year in April. Most festivals are celebrated with eating, drinking, and entertainment such as outdoor movies or performances of mawlam, a traditional lyrical drama genre in the Northeast.
HIV transmission risk at festivals During focus group discussions, a pattern of heavy alcohol consumption, a party atmosphere, celebration and reunion with old friends, and wide availability of negotiated sex emerged to characterize the risk context at village festivals. Men reported that women came into the communities at this time to sell sex, and some reported having sex with women who came from outside the village but whom they did not identify as commercial sex workers. Focus group participants described casual couplings which were possible in the context of festivals; ``if they like each other, they will go o together'', one man explained. In the focus groups, men expressed frequent disregard for the potential risks of unprotected sex in these situations. When asked if he thought about condoms, one focus group participant explained: ``There aren't any. When people go to festivals, none of them prepare (condoms) because once you have the opportunity, you don't have condoms. There aren't any. You have to have sex''. Another man, when asked if condoms were available at festivals, responded, ``There are absolutely no condoms at festivals''. Other men noted a sense of urgency brought on by fear of discovery by their wives or awareness 269
Cattle markets and local festivals: L. R. Dole et al.
that their friends were in a queue awaiting their turn. ``If I am in that situation, I just go for it and I don't use a condom'', one man explained. This notion was repeated in group after group; as one man said when asked if condoms were used, ``They can't ®nd them in time''. In this environment of celebration, alcohol, and availability of sex, there were no messages regarding HIV prevention. No public health campaigns had mentioned this risk scenario, which appears to have gone unrecognized by outsiders. One focus group participant summarized the situation: ``It is safer if I have sex at a brothel because I'll be more careful than at the festival''. Developing interventions for use at local festivals Focus group discussion and direct observation con®rmed that while commercial and casual sex were available at village festivals, condoms were not. Interventions were therefore developed to ®ll this crucial gap and raise awareness of risk behavior in local settings. Targeted messages were developed which emphasized community support for AIDS prevention awareness and risk reduction, including peer acceptance of condom use. Some of the media encouraged people to take condoms to give to their friends or for their own use. The messages were in the local dialect, and based on scenarios and expressions familiar to men and women in rural communities. The language and images were drawn directly from research data, including focus group discussions and observation (Figure 2). In addition to colorful posters and condom boxes intended for use during the festival, cassette tapes combining mawlam and targeted AIDS prevention messages were produced. In September 1995 a mawlam competition was held; local artists performed original lyrics based on themes identi®ed through focus groups and community consultations. These themes included reducing risk behavior at local festivals, recognizing the association of alcohol use and increased risk behavior, promoting the use of condoms and peer support for condom use, increasing awareness of personal risk, and encouraging sensitivity toward people living with HIV/AIDS. Several thousand people attended the competition which was held on a market day in the district center of PhuWiang District, Khon Kaen province. A team of local leaders and government ocials judged the entries on the clarity and appeal of the message. Winning performances were professionally recorded and mixed with targeted messages which reinforced the themes in a variety show format. The tapes were distributed to village leaders who broadcast them over the public address loudspeaker systems used in Northeast Thai communities. The mawlam tapes were an 270
Figure 2. Targeted HIV prevention media for local festivals. T-shirts, condom boxes, mobile, and mawlam cassette tapes with targeted HIV prevention messages speci®c to the context of risk behavior at local festivals
entertaining mix of music and dialogue which could be broadcast repeatedly; they were particularly appropriate for promoting upcoming community festivals, while also communicating relevant AIDS prevention messages. Village health volunteers were identi®ed as the most eective facilitators of this intervention. As the local representatives of the public health sector, they were already responsible for condom distribution in the community. However, before their participation in this program they typically kept the condom supplies in their homes, where they were rarely, if ever, accessed. In collaboration with public health ocials, the role of the village health volunteers was clari®ed, helping them identify concrete ways in which they could serve their communities' needs by providing open access to condoms during festivals. In addition to targeted HIV prevention training, village health volunteers received kits of materials to use during festivals, including condom boxes, supplies of condoms, posters, and other media promoting risk reduction. Many had participated in the initial community consultations and had seen ideas evolve through the participatory process into this concrete intervention to address local needs. This
Cattle markets and local festivals: L. R. Dole et al.
intervention was part of an integrated condom promotion and distribution campaign in rural communities, so the messages about risk reduction at festivals were supported by other HIV prevention media and activities in the community. Process evaluation Village health volunteers incorporated AIDS prevention at village festivals into their ongoing health promotion activities in the community. The combination of increased exposure to messages about reducing the risk of HIV transmission at local festivals and access to condoms contributed to community awareness that HIV was a relevant concern to rural people and that risk of transmission could be reduced through correct and consistent condom use. Exposure to the mawlam tape was particularly high, and community members remembered the messages in the context of festivals. Because festivals are frequently held on the grounds of village temples, there was some discussion about whether condom promotion was appropriate in this setting. While some people, notably some government ocials, expressed reservations, local people tended to be more pragmatic in their approach. They felt that people were already having sex at the festivals, so the practical action was to make it safer. Reinforcing the message of community acceptance for condom use, some villages organized HIV/AIDS prevention trainings in temples. Conclusion These rural scenarios are particularly challenging because the locales for risk behavior are not ®xed in time and space. Both cattle markets and village festivals are periodic events, not institutionalized like brothels and entertainment businesses. Although cattle markets are generally held once a week at any particular site, the days are not ®xed and can change in response to other market activity within the trade circuit. Village festivals occur throughout the year following local calendars and traditions. The CSWs who work these venues move throughout the region. Unlike brothel or restaurant-based workers, they have no home base and are unlikely to receive consistent medical attention. Rural scenarios such as these are characterized by several factors which have not been adequately addressed by conventional prevention campaigns: (1) policies and programs which are designed in urban centers can overlook risk situations which are unique to rural areas. Because sex is not the raison d'etre of these events, outsiders may not recognize the risk of HIV transmission. (2) Yet the spontaneity, lack of preparedness, and unavailability of condoms
associated with sex in these settings contributes to the likelihood of unprotected sex. (3) For many rural people, risk is perceived as external and distant; these sites are close to home and familiar, so they seem ``safe''. This view is supported by messages developed outside the community which do not use language or situations that are familiar to rural people. (4) Even when recognized as sites requiring attention, scenarios like cattle markets and festivals are often not covered by existing health services because they occur outside of regular working hours and may be transient or irregular. These characteristics are not limited to cattle markets and village festivals in Northeast Thailand. The basic challenge is how to reach rural populations with relevant HIV/AIDS prevention interventions which are tailored to their experience and needs. All too often, public health campaigns originate from outside rural communities, and their messages stay outside because they have little meaning in local settings. In this project, collaboration with local government public health ocials was crucial to establishing appropriate interventions. Government health workers recognized that these activities coincided well with their eorts and they adopted them as their own. The public health sector provided ongoing access to condoms for distribution at these sites, and the Khon Kaen Provincial Public Health Oce plans to extend these interventions to all subdistricts in order to reach festivals and every cattle market throughout their jurisdiction. At the community level, the process of participating in identifying these risk situations and working with government and non-government agencies to develop interventions to reduce HIV risk inspired community members to consider other community concerns that should be addressed. This project provided concrete opportunities for public health workers and village health volunteers to be actively involved in reducing risks they had previously identi®ed. For both government ocials and community members, participation in this project was empowering; there is already work under way in rural communities and at cattle markets to build upon the linkages established in this project and extend services further. By involving rural people in the whole process of identifying and developing HIV risk reduction strategies, these interventions were based in the community and responded to local needs rather than the assumptions of policymakers in urban centers. There is also a role for ®eld-based researchers, who can facilitate the establishment of linkages within the community and support community-based research to clarify the situation. Formative research and community con271
Cattle markets and local festivals: L. R. Dole et al.
sultations are an essential foundation for developing HIV prevention interventions which adequately and appropriately address the needs of rural communities. These strategies can be applied to a wide range of community issues. Acknowledgements
Many thanks to the people of Northeast Thailand who participated in this project. Thanks to two anonymous reviewers for comments on an earlier draft. Research reported in this paper was funded through grants provided by PLAN International, the Australian Agency for International Development (AusAID), and the United Nations Development Programme (UNDP).
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Mastro, T. D. and Limpakarnjanarat, K. (1995) Condom use in Thailand: How much is it slowing the HIV/AIDS epidemic?. AIDS 9, 523±525. Maticka-Tyndale, E., Kiewying, M., Haswell-Elkins, M., Kuyyakanond, T., Anursornteerakul, S., Chatapreeda, N., Choosathan, R., Sornchai, S., Theerasobhon, P., Suporpun, A., Siriwattanametanont, J. and Elkins, D. (1994) Knowledge, attitudes and beliefs about HIV/AIDS among women in Northeastern Thailand. AIDS Education and Prevention 6(3), 205±218. Maticka-Tyndale, E., Elkins, D. B., Haswell-Elkins, M., Rujkorakarn, D., Kuyyakanond, T. and Stam, K. (1997) Contexts and patterns of men's commercial sexual partnerships in Northeastern Thailand: Implications for AIDS prevention. Social Science and Medicine 44(2), 199±213. Ministry of Public Health (1995) Results of the 13th HIV Sentinel Surveillance Survey (June 1995). Ministry of Public Health, Bangkok, Thailand. Morris, M., Pramualratana, A., Podhisita, C. and Wawer, M. J. (1995) The relational determinants of condom use with commercial sex partners in Thailand. AIDS 9, 507±515. Nelson, K. E., Celentano, D. D., Eiumtrakol, S., Hoover, D. R., Beyrer, C., Suprasert, S., Kuntolbutra, S. and Khamboonruang, C. (1996) Changes in sexual behavior and a decline in HIV infection among young men in Thailand. The New England Journal of Medicine 335(5), 297±303. Sweat, M. D., Nopkesorn, T., Mastro, T. D., Sangkharomya, S., MacQueen, K., Pokapanichwong, W., Sawaengdee, Y. and Weniger, B. G. (1995) AIDS awareness among a cohort of young Thai men: Exposure to information, level of knowledge, and perception of risk. AIDS Care 7(5), 573± 589.
PII: S1353-8292(98)00021-5
Cattle markets and local festivals: Development of HIV/AIDS prevention interventions for speci®c risk situations in rural Northeast Thailand Lynn R. Dole,*$ David B. Elkins,*$ Kovit Boonjear,* Suwat Phiensrithom* and Eleanor Maticka-Tyndale% *Multi-sectoral AIDS Prevention Strategy (MAPS), Northeast Centre for AIDS Prevention and Care, Khon Kaen University, Khon Kaen, Thailand $Australian Centre for International and Tropical Health and Nutrition/Queensland Institute of Medical Research, 300 Herston Road, Herston, QLD 4006, Australia %Department of Sociology and Anthropology, University of Windsor, Winsor, Canada
In rural Northeast Thailand, risk of sexual transmission of HIV is popularly perceived to be site-speci®c. Risk of HIV transmission in local scenarios like cattle markets and village festivals has not been adequately addressed. This paper assesses the use of community consultation and formative research to overcome prevailing assumptions about HIV risk by involving community members in the process of identifying risks and developing HIV prevention strategies. This participatory approach can be used to develop prevention programs that are responsive to the speci®c context of risk behavior in rural environments. # 1998 Elsevier Science Ltd. All rights reserved Keywords: AIDS, HIV prevention, rural, Thailand
Introduction Extensive public health campaigns in Thailand have raised awareness of HIV transmission risks (Maticka-Tyndale et al., 1994; Sweat et al., 1995), and condom promotion targeting brothels has resulted in increased condom use in commercial sex encounters in brothels (Nelson et al., 1996). However, in rural Northeast Thailand exposure to these campaigns has contributed to the perception that risk of sexual transmission of HIV is site-speci®c. The use of Central Thai, the language of schools and government but not the dialect used in Northeastern villages, in most AIDS prevention campaigns has perpetuated local perceptions that HIV/AIDS is largely an urban problem, and not a relevant threat to rural communities in the Northeast (Lyttleton, 1994). The association between brothel-based commercial sex and HIV risk emphasized in many
interventions has resulted in the widespread view that unprotected sex with other partners is safe (Sweat et al., 1995). In research conducted with rural men in the Northeast, Maticka-Tyndale et al. (1997) found that the further a scenario diverged from brothel contact with a commercial sex worker (CSW), the less likely men were to recognize the potential risk of HIV transmission and the less likely they were to use a condom. This paper examines the use of a combination of formative research, community consultation, and the extension of existing services to develop targeted HIV/AIDS prevention interventions that meet rural needs. It focuses on two scenarios that are relevant to the daily lives of rural people in Northeast Thailand, cattle markets and village festivals, in order to assess how this integrated approach is responsive to a variety of factors in dierent locales. This paper looks at each scenario in turn, detailing the process used to identify 265
Cattle markets and local festivals: L. R. Dole et al.
risk sites, develop targeted interventions, implement, and evaluate these interventions. At the conclusion, this paper suggests how this approach could be modi®ed to other settings, emphasizing the importance of context in developing HIV/AIDS prevention programs. Context of sexual risk-taking in rural Northeast Thailand Commercial sex is available in a broad range of situations in rural Northeast Thailand (Ford and Koetsawang, 1991; Lyttleton, 1994; MatickaTyndale et al., 1997). In addition to brothels, restaurants and entertainment establishments, there are also a number of sites that are intrinsic to the rural environment, such as local festivals and cattle markets, where commercial or casual sex are widely available. Maticka-Tyndale et al. (1997) have produced an overview of the sexual risk scenarios and contexts for men in rural Northeast Thailand, and this paper details further work in the same project. Sentinel surveillance in 1995 found HIV prevalence rates in the Northeast of 12.1% among commercial sex workers, 7.5% among patients at sexually transmitted disease clinics, 0.7% among blood donors, and 1.5% among pregnant women (Ministry of Public Health, 1995). Despite signi®cant increases in condom use in brothels, condom use with other sex partners, such as wives, girlfriends (Nelson et al., 1996), and ``regular'' commercial sex partners (Morris et al., 1995), remains low. Some researchers have observed that as visits to brothels decline, the frequency of sex with other partners, such as girlfriends and casual partners, is increasing (Mastro and Limpakarnjanarat, 1995; Ford and Kittisuksathit, 1996). In interviews with 737 men in 32 Northeastern villages, Maticka-Tyndale et al. (1997) found that 48% had purchased sexual services. Fourteen percent (50) of those men had engaged sex workers at cattle markets. The vast majority (97%) of these 50 men were married, and half of them reported purchasing sex at cattle markets more than four times within the past year. A similar percentage (14%) of the sample reported having purchased sex at village festivals; 90% said they had done so within the past year (Maticka-Tyndale et al., 1997). Maticka-Tyndale et al. (1997) report that in focus group discussions men rarely associated sexual encounters with casual partners or female sex workers in their communities or other local settings with risk of HIV. For example, one focus group participant explained, ``There are small brothels and small risks in our village. Not like Bangkok. There the brothels are large and the risks are too''. Risk behavior persists because such sites are seen as familiar and therefore safe; 266
risk-reduction strategies that men might use in external settings are not triggered in these local situations. As one man explained in a focus group, ``It is in our village, no. We do not use condoms, it is safe'' (Maticka-Tyndale et al., 1997). In addition to peer in¯uence and alcohol use which are often associated with commercial sex in Thailand, Maticka-Tyndale et al. (1997) identi®ed other factors, including a sense of immediacy and spontaneity, which made it less likely that men would take precautions in sex encounters at cattle markets and local festivals. In these local settings, sexual activity takes place under the cover of darkness, on mats on the outskirts of the event. Queues form as men await their turn with the sex worker, and the men described a sense of urgency: ``It is an emergency situation. That means you have sex in the rice ®eld or the sugar ®eld. You do it in a hurry''. With few exceptions, the only source of condoms were those brought by the sex workers. There have been no sustained eorts to address risk in these scenarios. There had been sporadic government intervention in the cattle markets as evidenced by police involvement and occasional provision of condoms and media materials. The festivals, however, had never been recognized as a risk. Policymakers outside rural communities were unfamiliar with the extent of sexual risk under these circumstances. In both cases, basic qualitative research needed to be conducted that could help to explain the availability of commercial sex, the context of sexual risk-taking, and potential opportunities for intervention. Approach Through the MAPS community consultation process, men and women in over 450 villages in Northeast Thailand participated in identifying HIV transmission risks that aected their communities and families (Elkins et al., 1996). Cattle markets and local festivals were widely identi®ed with increased risk of sexual transmission of HIV. Of the 42 subdistricts participating in the community consultation process, all but four cited village festivals as a major public health concern. To assess the level and context of risk encountered at village festivals, ®ve focus group discussions were conducted with rural men in April 1995. Consultations with public health ocials, village health volunteers, and village leaders followed to develop a strategy for reducing risk at village festivals. Interventions, in the form of targeted media and condom distribution, were developed, piloted, revised, and implemented in late 1995 and early 1996. To construct a picture of HIV risk behavior at cattle markets, qualitative studies combining
Cattle markets and local festivals: L. R. Dole et al.
informal interviews, observation, and focus groups were conducted at ®ve major cattle markets in the upper Northeast region in March 1995. The market owner(s), food vendors, and subdistrict public health ocials at each site were interviewed. Focus groups with 8±10 cattle traders were conducted at each market using a judgement sample, and informal interviews were conducted with at least three sex workers at each site. At two markets group discussions with 4±6 sex workers were conducted. Through this process, people directly associated with cattle markets recommended appropriate interventions for reducing the risk of HIV transmission. These suggestions were developed through research and ®eldtesting. The interventions were piloted at one site in August 1995 and modi®cations were made before implementing the program at principal markets throughout the northern Northeast region in November±December 1995. Evaluation was conducted in January±March 1996.
Kaen market indicated that she had been selling sex for 12 years, and during that time had worked at more than eight markets in three provinces; another woman reported that she had been selling sexual services at cattle markets for nine years, and regularly attended ®ve markets in three provinces. When asked if the CSWs knew each other, a 20 year-old sex worker at another market explained, ``Yes, I don't know what village they come from but we see each other at all of the markets''. CSWs typically meet their clients in small food stalls in the market, where men gather to eat and drink alcohol. Clients occasionally invited CSWs to hotels outside the market, but most of the sexual servicing took place after dark on mats on the outskirts of the market, or in rooms attached to or near the food stalls. In these low-walled bamboo structures, privacy is oered by darkness, as several couples may share the same open space.
Cattle markets Weekly cattle markets are held throughout the Northeast, where local farmers and traders buy and sell cattle and water bualo. Smaller markets are attended by 100±150 people, and larger ones can attract about 1,500 people. While farmers tend to go to the markets closest to their homes, cattle traders and buyers move throughout a circuit of major markets. For instance, at a large market in Khon Kaen province traders from more than fourteen provinces were recorded in one night. Cattle and bualo are brought to the market in the afternoon, and most of the trade occurs throughout the night, so that the market typically disperses by midday the following day. Farmers and traders watch their stock, engage in negotiation over sales, and drink throughout the night. Sexual networking at cattle markets links three populations: a large number of farmers who converge from neighboring communities, and two smaller but highly mobile populations that move throughout the region on a regular circuit, cattle traders from dierent provinces and female sex workers. Like the cattle traders, female commercial sex workers regularly attend a series of cattle markets throughout the region. Some are ``freelance'' workers who make arrangements with clients on an individual basis, while others work with a middleman who helps them secure clients in exchange for a portion of the money earned. The sex workers often reported that they travelled to cattle markets with a group of friends. While many described rice growing as their primary occupation, nearly all the women interviewed had sold sexual services at cattle markets for a period of several years. A 31 year-old woman at a Khon
Risk of HIV transmission at cattle markets In focus groups and interviews, people at the cattle markets identi®ed a number of factors which they felt contributed to HIV risk in this setting: heavy alcohol consumption, insucient risk awareness, lack of condoms, and the availability of sexual servicing. Qualitative research at several markets indicated that, although ranging in size, the cattle markets were similar in terms of availability of sex services, limited access to condoms, and current low levels of government involvement in AIDS education and condom distribution. Men who reported purchasing sex at cattle markets described the scenarios they associated with commercial sex. They explained that following a cattle sale there is the tradition of buying alcohol and cigarettes to show generosity to the buyers and the people who serve as witnesses. They indicated that in this context, purchasing sexual services is another way of expressing generosity and celebrating a sale. Due to heavy drinking, noise, and their responsibility for their cattle, some men reported being unable or unwilling to sleep so they purchased sex. Several men said that they purchased sex because they were away from their families for extended periods of time, asserting that this ``makes them wild'' and ``misbehave''. With the exception of one market where the owner maintained a small supply, the only condoms available at cattle markets were those which the CSWs brought with them. None of the men interviewed had brought condoms, and once they were at the cattle market they had no way to acquire condoms. In Northeast Thailand, condoms are sold in district centers or larger market towns, but in rural areas the only sources of con267
Cattle markets and local festivals: L. R. Dole et al.
doms are the government Subdistrict Primary Health Care Stations (sathani anamai). The government provides these condoms free of charge, and CSWs at the cattle markets typically indicated these health stations as their source. The health stations are regularly open during ocial government work hours. Government public health workers also recognized the HIV risk at cattle markets, as attested by numerous eorts at intervention. However, none of these interventions had been sustained, except for the distribution of condoms to sex workers who requested them at health stations. In some areas, village health volunteers (Aw Saw Maw) had been given responsibility for maintaining condom supplies to cattle markets, but this practice was erratic at best. In general, the public health sector did not know how to go beyond what they were already doing: providing condoms when asked and making occasional forays to the cattle markets to hang posters and to encourage CSWs to have regular health checks. A basic constraint was that the health oces and the cattle markets operate on dierent schedules; when public health ocers visited the cattle market site during their daytime work hours, nothing was happening because most of the activity at the cattle markets takes place late at night. Developing an intervention strategy Development of appropriate HIV prevention interventions for cattle markets was a participatory process involving consultations and focus group discussions. Among the suggestions provided by participants were: education and training for the market owners, food vendors, CSWs, middlemen, and clients; condom distribution for middlemen, CSWs, and clients; and posters and tapes about AIDS to be used in the food shops. Both men and women emphasized that education for clients was essential because they often resisted using condoms and oered a higher price for sex without condoms. Based upon these recommendations, an HIV/ AIDS prevention strategy was developed which included establishing consistent condom distribution at cattle markets, designing targeted HIV prevention media with messages relevant to the context of risk at cattle markets, and establishing links between public health workers and the cattle markets. The cattle market owner and the food vendors were identi®ed as the principal contacts at each market because they were connected to the site on a regular and long-term basis. Recognizing their authority over the market domain, the cattle market owners were selected as the key contact at each site. Condoms were made openly accessible in condom boxes which indicated that they were available free of charge and provided information about correct condom 268
use. The cattle market owner and local health ocials worked together to maintain consistent supplies of condoms to the shop vendors who re®lled the boxes in their shops (Figure 1). The food shops where cattle traders gather to drink and where sex workers wait to meet customers were selected as the focal points of the intervention. Media exposure is highest here, and at night these are the best lit places in the market. Using images, language, and humor that were familiar to rural people in the Northeast, the media encouraged men to assess their personal risk, cultivated peer support for condom use, and provided constructive information about reducing risk behavior. These messages were reproduced in several forms: as condom boxes for open access to free condoms, as T-shirts for the participating vendors and the market owner, as posters and mobiles for the food shops, as stickers for trucks and motorcycles, and as key chains with a pull-out drawer for a condom that can be used and then replaced with a new one. Process evaluation Follow-up visits were made approximately two months after the interventions were launched at each cattle market. Evaluation was conducted via interviews with shop vendors and CSWs and focus group discussions with cattle traders and farmers to assess the impact of the intervention from several perspectives. Interviews with CSWs found that it was easier for them to negotiate condom use with clients for several reasons: the clients were more likely to have brought condoms themselves, the clients were more aware of the importance of condom use in preventing HIV transmission, and the clients were generally more conscious of issues of personal risk and HIV. CSWs reported that they also took condoms directly from the condom boxes. Shopkeepers con®rmed that both men and women accessed condoms from the condom boxes. Condoms were taken with greater frequency in shops where CSWs and clients typically meet than in shops that are not meeting places for the negotiation of commercial sex. Similarly, more condoms were taken at cattle markets with high levels of commercial sex activity than at cattle markets where police intervention had suppressed the sex trade. Cattle traders disseminated the messages as they moved through the circuit of cattle markets. Three months after 80 condom key chains were distributed to cattle traders at a pilot market in Mahasarakham province, key chains were observed being used by traders at cattle markets throughout the region. The media stimulated discussion about AIDS prevention, raising awareness of personal risk
Cattle markets and local festivals: L. R. Dole et al.
Figure 1. Targeted HIV prevention media for cattle markets. Condom key chains, condom box, stickers, and poster with HIV prevention messages speci®c to the context of risk behavior at cattle markets
and the need to modify behavior. In a focus group discussion, one 37 year-old cattle trader commented, ``When it comes right down to it, I don't like to use condoms. But if I think at all about AIDS prevention, I wear them''. This program brought ``thinking about AIDS prevention'' to an environment which had been associated with risk but had been underserved by conventional campaigns and the public health infrastructure.
Village festivals Northeast villagers celebrate a steady cycle of festivals according to agricultural and religious calendars. There are also events associated with some public holidays, and celebrations, particularly weddings and ordination ceremonies for young men entering the monkhood, which can be characterized as festivals. Family members who are working elsewhere often return home to attend these festivals, especially during Songkran, the traditional Thai New Year in April. Most festivals are celebrated with eating, drinking, and entertainment such as outdoor movies or performances of mawlam, a traditional lyrical drama genre in the Northeast.
HIV transmission risk at festivals During focus group discussions, a pattern of heavy alcohol consumption, a party atmosphere, celebration and reunion with old friends, and wide availability of negotiated sex emerged to characterize the risk context at village festivals. Men reported that women came into the communities at this time to sell sex, and some reported having sex with women who came from outside the village but whom they did not identify as commercial sex workers. Focus group participants described casual couplings which were possible in the context of festivals; ``if they like each other, they will go o together'', one man explained. In the focus groups, men expressed frequent disregard for the potential risks of unprotected sex in these situations. When asked if he thought about condoms, one focus group participant explained: ``There aren't any. When people go to festivals, none of them prepare (condoms) because once you have the opportunity, you don't have condoms. There aren't any. You have to have sex''. Another man, when asked if condoms were available at festivals, responded, ``There are absolutely no condoms at festivals''. Other men noted a sense of urgency brought on by fear of discovery by their wives or awareness 269
Cattle markets and local festivals: L. R. Dole et al.
that their friends were in a queue awaiting their turn. ``If I am in that situation, I just go for it and I don't use a condom'', one man explained. This notion was repeated in group after group; as one man said when asked if condoms were used, ``They can't ®nd them in time''. In this environment of celebration, alcohol, and availability of sex, there were no messages regarding HIV prevention. No public health campaigns had mentioned this risk scenario, which appears to have gone unrecognized by outsiders. One focus group participant summarized the situation: ``It is safer if I have sex at a brothel because I'll be more careful than at the festival''. Developing interventions for use at local festivals Focus group discussion and direct observation con®rmed that while commercial and casual sex were available at village festivals, condoms were not. Interventions were therefore developed to ®ll this crucial gap and raise awareness of risk behavior in local settings. Targeted messages were developed which emphasized community support for AIDS prevention awareness and risk reduction, including peer acceptance of condom use. Some of the media encouraged people to take condoms to give to their friends or for their own use. The messages were in the local dialect, and based on scenarios and expressions familiar to men and women in rural communities. The language and images were drawn directly from research data, including focus group discussions and observation (Figure 2). In addition to colorful posters and condom boxes intended for use during the festival, cassette tapes combining mawlam and targeted AIDS prevention messages were produced. In September 1995 a mawlam competition was held; local artists performed original lyrics based on themes identi®ed through focus groups and community consultations. These themes included reducing risk behavior at local festivals, recognizing the association of alcohol use and increased risk behavior, promoting the use of condoms and peer support for condom use, increasing awareness of personal risk, and encouraging sensitivity toward people living with HIV/AIDS. Several thousand people attended the competition which was held on a market day in the district center of PhuWiang District, Khon Kaen province. A team of local leaders and government ocials judged the entries on the clarity and appeal of the message. Winning performances were professionally recorded and mixed with targeted messages which reinforced the themes in a variety show format. The tapes were distributed to village leaders who broadcast them over the public address loudspeaker systems used in Northeast Thai communities. The mawlam tapes were an 270
Figure 2. Targeted HIV prevention media for local festivals. T-shirts, condom boxes, mobile, and mawlam cassette tapes with targeted HIV prevention messages speci®c to the context of risk behavior at local festivals
entertaining mix of music and dialogue which could be broadcast repeatedly; they were particularly appropriate for promoting upcoming community festivals, while also communicating relevant AIDS prevention messages. Village health volunteers were identi®ed as the most eective facilitators of this intervention. As the local representatives of the public health sector, they were already responsible for condom distribution in the community. However, before their participation in this program they typically kept the condom supplies in their homes, where they were rarely, if ever, accessed. In collaboration with public health ocials, the role of the village health volunteers was clari®ed, helping them identify concrete ways in which they could serve their communities' needs by providing open access to condoms during festivals. In addition to targeted HIV prevention training, village health volunteers received kits of materials to use during festivals, including condom boxes, supplies of condoms, posters, and other media promoting risk reduction. Many had participated in the initial community consultations and had seen ideas evolve through the participatory process into this concrete intervention to address local needs. This
Cattle markets and local festivals: L. R. Dole et al.
intervention was part of an integrated condom promotion and distribution campaign in rural communities, so the messages about risk reduction at festivals were supported by other HIV prevention media and activities in the community. Process evaluation Village health volunteers incorporated AIDS prevention at village festivals into their ongoing health promotion activities in the community. The combination of increased exposure to messages about reducing the risk of HIV transmission at local festivals and access to condoms contributed to community awareness that HIV was a relevant concern to rural people and that risk of transmission could be reduced through correct and consistent condom use. Exposure to the mawlam tape was particularly high, and community members remembered the messages in the context of festivals. Because festivals are frequently held on the grounds of village temples, there was some discussion about whether condom promotion was appropriate in this setting. While some people, notably some government ocials, expressed reservations, local people tended to be more pragmatic in their approach. They felt that people were already having sex at the festivals, so the practical action was to make it safer. Reinforcing the message of community acceptance for condom use, some villages organized HIV/AIDS prevention trainings in temples. Conclusion These rural scenarios are particularly challenging because the locales for risk behavior are not ®xed in time and space. Both cattle markets and village festivals are periodic events, not institutionalized like brothels and entertainment businesses. Although cattle markets are generally held once a week at any particular site, the days are not ®xed and can change in response to other market activity within the trade circuit. Village festivals occur throughout the year following local calendars and traditions. The CSWs who work these venues move throughout the region. Unlike brothel or restaurant-based workers, they have no home base and are unlikely to receive consistent medical attention. Rural scenarios such as these are characterized by several factors which have not been adequately addressed by conventional prevention campaigns: (1) policies and programs which are designed in urban centers can overlook risk situations which are unique to rural areas. Because sex is not the raison d'etre of these events, outsiders may not recognize the risk of HIV transmission. (2) Yet the spontaneity, lack of preparedness, and unavailability of condoms
associated with sex in these settings contributes to the likelihood of unprotected sex. (3) For many rural people, risk is perceived as external and distant; these sites are close to home and familiar, so they seem ``safe''. This view is supported by messages developed outside the community which do not use language or situations that are familiar to rural people. (4) Even when recognized as sites requiring attention, scenarios like cattle markets and festivals are often not covered by existing health services because they occur outside of regular working hours and may be transient or irregular. These characteristics are not limited to cattle markets and village festivals in Northeast Thailand. The basic challenge is how to reach rural populations with relevant HIV/AIDS prevention interventions which are tailored to their experience and needs. All too often, public health campaigns originate from outside rural communities, and their messages stay outside because they have little meaning in local settings. In this project, collaboration with local government public health ocials was crucial to establishing appropriate interventions. Government health workers recognized that these activities coincided well with their eorts and they adopted them as their own. The public health sector provided ongoing access to condoms for distribution at these sites, and the Khon Kaen Provincial Public Health Oce plans to extend these interventions to all subdistricts in order to reach festivals and every cattle market throughout their jurisdiction. At the community level, the process of participating in identifying these risk situations and working with government and non-government agencies to develop interventions to reduce HIV risk inspired community members to consider other community concerns that should be addressed. This project provided concrete opportunities for public health workers and village health volunteers to be actively involved in reducing risks they had previously identi®ed. For both government ocials and community members, participation in this project was empowering; there is already work under way in rural communities and at cattle markets to build upon the linkages established in this project and extend services further. By involving rural people in the whole process of identifying and developing HIV risk reduction strategies, these interventions were based in the community and responded to local needs rather than the assumptions of policymakers in urban centers. There is also a role for ®eld-based researchers, who can facilitate the establishment of linkages within the community and support community-based research to clarify the situation. Formative research and community con271
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sultations are an essential foundation for developing HIV prevention interventions which adequately and appropriately address the needs of rural communities. These strategies can be applied to a wide range of community issues. Acknowledgements
Many thanks to the people of Northeast Thailand who participated in this project. Thanks to two anonymous reviewers for comments on an earlier draft. Research reported in this paper was funded through grants provided by PLAN International, the Australian Agency for International Development (AusAID), and the United Nations Development Programme (UNDP).
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