Jane you reported the following challenges # 1. Opposition to the change by the conservative traditionalists. # 2. Education to be graded according to the enlightenment levels of the different classes of the community. # 3. Appropriate language for communication well understood by the people. # 4. The material and human resources to establish new health facilities or to strengthen the existing ones. # 5. Negative attitude of some health care providers towards the patients. # 6. To take into consideration the culturally free days for health meetings and gatherings such as the – market days - farming period - periods of hibernation for women - access to the homes of the muslim communities My response to #1 Change is always hard for conservative traditionalists because they want to hold on to traditions no matter how backwards. Coercing them will only maked them more resistant to change. These traditionalists are found among the illiterate as well as the educated community. The easiest way to incorporate them in activities is to emphasize commonalities and bonds shared and to express deep appreciation. Traditionalist love us to teach them how to improve their livelyhood and productivity and farm yields. They love ideas how to better take care of their herds of cattle, goat, camels and sheep. Since these workshops offer economic incentives the community as a whole should be invited to help them to soften up and to establish strong bonds of friendship. When they get to trust and open up to us we bring up topics of tolerance and mutual cooperation that will unify and enhance the community. We stress community togetherness to eradicate disease, poverty, ignorance etc and ask them to give us their committment to be more tolerant as they are learning to accept "those that may be different." We must first genuinely praise tradionalist for their efforts to keep the community together and use this as a starting point for dialogue to achieve positive community transformation without resorting to forms of bribery. My response to # 2 & 3 To achieve positive community transformation and for our community to understand and participate in our surveys, data collection, research and even to understand issues of cause and effect which are not part of the traditional language vehicle we must make our communities functionally literate. For education to be "graded" according to the enlightenment levels of different classes of the community may be theoretically sound but principles of cause and effect are only well understood when an intermediate level of functional literacy is achieved. The principle of using condoms to protect us from STD's is actually a cause and effect conceptualization. This explains why condom use in certain communities is not widely accepted. Its not just a problem of culture but a lack of functional literacy issue # 4 Material and Human Resources...we need to dig deep and be creative in transforming local materials into usable materials...it will not get any better unless we write proposals for donor funding. This is a must for organizations to survive # 5 Negative attitude of healthworkers towards patients is a deeper issue relating to the worldview. Workers should not represent our organization to the public unless their worldview is transformed. This is critical because they will be an eyesore and stumbling block to our organization's goals and objectives. Our workers represent our image to the world. If they are ugly to the clients that is the impression our clients will leave with and will never want to come back. # 6 I believe these aren't that complex with the exception of access to the homes of Muslim communities...this needs to be done by a respected female Muslim member of the community especially if the home has lots of females. I'm not a Muslim woman but dress in the attire and find myself anywhere in the North. I change my traditional attire according to the area I'm working in including my headgear. Thanks for enlightening me on issues. Fenna E. Bacchus

Jane, You are sharp like a razor. I hope the GF is taking serious notes. You are quite experienced in this areas and we can all learn from you. I take your responses very seriously and have to study them in the broader global context. This is actually very comprehensive because you discuss the interventions and also the challenges. let us take this debate couple notches higher and I will be providing a detailed response to your challenges how to effectively address them. You know one of my blood line traces back to the Akan Jews from the Gold Coast, who I found out have the same market days as the Igbo. The Lugbarra people from Northern Uganda are actually Igbo's. I shall be coming to Nigeria late this year. You know that is also my home. It was brought to my attention 6 years ago that among our female Igbo's and many of the Nuns we have many same sex relationships. I'm wondering if we have STD's/STIs in these communities and what the prevalence is and how Nigeria reaches out to this community that have kept this in utter secrecy. How are you reaching out? How is Sharia Law dealing with all this in the North? I know how they behave because I lived and worked in Nigeria and also been in Igbo land, Yoruba land and the North Fenna E. Bacchus

Which Interventions are proven to be effective in improving sexual minorities’ access to health services? What are the challenges for programs for sexual minorities? In certain culture and generally speaking the females are disadvantaged in accessing health services.

Abdulahi I support you

Ashish, Its so delightful to read from all of you and the wonderful contributions you are making. Its comprehensive and practical and I support you to translate this into a policy strategy.

Dr. Muhabello, Can you explain the first sentence? Are you from the North?

Yes Martha, This is what I found out about Zimbabwe a long time ago; but we need regime change in Zimbabwe to get things done. What policies are in place are not followed since people's beliefs are already entrenched in the community's worldview. The leaders themselves are power hungry even if it is by the gun they will do it.

This is excellent and well thought off and a implementable and workable strategy that needs not to be ignored

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Please find below the contribution from Rajan.M .Karakkattil from India.

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It is quite interesting to analyze the latest trends of sexual abuse towards sexual minorities. I think it is because of psychological aberaltion of the adult who take the groups into the trap . Therefore the parental health care services should be widened to address the programs.

 

 

Please find below the contribution from C. Ravichandran from India.

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The following interventions are effective use to sexual minorities’ access to health services:

a.          Awareness Generation

Posters and wall writings

One to one

Mass awareness

Street theater

Exhibition

Audio/Visual shows

Insist ABC methodology

b.          Behaviour change communications

Condom demonstration

Condom distribution

c.          Counseling

Counseling to all cases

Keeping confident on counseling

Referral to clinics

Referral to ICTC

d.          Advocacy

e.          Selection and Train the peer educator among the risk behaviour groups.

f.           Care and support

Home based treatment

Hospital based treatment

Supply of medicines & nutrients periodically

Economic income generation activities to the family members of the infected person.

g.          Improve the service providers quality regarding home based treatment.

-          Peer educators themselves do not like to use condoms with their regular partner.

-          PEs not able to convince their peer groups about the importance of reducing the number of sexual partner.

-          Peers do not like to practice non penetrative sex.

-          PEs who keep IEC materials with them to train peers find it difficult. This is because of lack of private space and to keep their families away from their life style.

-          Peers do not accept advice given by the peer educators. Peers think that PEs do not have more knowledge as they were also like them till recently.

-          Peers do not inform their PEs about their STI symptoms.

-          Peers do not like to take treatment from Health care providers trained in syndromic case management.

-          Some health care providers do not cooperate with the peer educators whey they refer their peers.

-          Peers want the PEs to accompany them for treatment.

-          Peers are not confident that the doctors will maintain confidentiality about their symptoms.

-          PEs find difficulties to motivate their peers to go for periodic check ups, especially if they are asymptomatic.

-          Peers believe that symptoms of STIs are not serious and therefore do not require treatment.

-          PEs not able to motivate their peers for partner treatment.

-          PEs hesitate to keep penis model and condom at home because of fear of being reprimanded or being identified as having multi partner sex.

-          Lack of privacy in the field for condom demonstration especially for street based sex workers.

-          Some PEs do not talk to their peers seriously because they themselves do not use condoms consistly.

-          It take a long time to motivate peers to go for counseling. A large number of PEs therefore get burnt out and do not continue to motivate them.

-          Peers often refuse to go to the ICTC because of distance.

-          Peers are afraid that their high risk behaviours will be known to others and so refuse counseling.

-          Family members of PEs do not allow them to interact with their peers. This is especially true for adolescents in the urban slum.

-          PEs are not able to maintain confidentiality. Some times they quote other peers as an example to motivate resistant peers.

-          High dropout rate of peer educators and the resultant inadequacy in number of trained PEs in proportion to target groups.

-          Pes may limit their interaction with the peer groups to mere transfer of information but not for supporting behaviour change.

my belief is that from our experience here in Nigeria, interventions for the sexuabeenl minorities access to health has well laid. young girls have access to drug teatment at all levels of medicare due to the free democratic nature of families. and except in few cases where parents are wont to intervene as watchdogs, sexual minorities have adequate medical attention.the challenges for the programme is the unavailability of forums for sex eeducation, A THORNY issue here because of sensitive reigiuos values

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Please find below the contribution from Racma Nguda-Sulaiman from The Philippines

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 Interventions:

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Please find below the contribution from AFTAB ALAM from India.

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Major challanges for services of identification of community is big issues in my areas. Open discussion on the issues is not good environment and also sensitization issues of stakeholders are very poor.

AFTAB ALAM