Coverage Evaluation 2000 - The INCLEN Trust

CENTRAL COORDINATING TEAM (CCT)Principal Investigator &Project CoordinatorDr. N. K. AroraAdditional ProfessorDepartment of PediatricsAll India Institute of Medical SciencesNew DelhiMembersDr. M. LakshmanConsultant Social ScientistDepartment of PediatricsAll India Institute of Medical SciencesNew DelhiDr. Kiran GoswamiAssociate ProfessorCentre for Community MedicineAll India Institute of Medical SciencesNew DelhiMs. Sneh RewalConsultant: Nutrition & HealthUnited Nations International Children’s FundLodhi EstateNew DelhiDr. R.M. PandeyAssociate ProfessorDepartment of BiostatisticsAll India Institute of Medical SciencesNew DelhiDr. K. AnandAssistant ProfessorComprehensive Rural Health ServicesProject, All India Institute of MedicalSciences, BallabgarhDr. K.K. GangulyAssistant ProfessorInstitute of Human Behavior & AlliedSciencesDelhiDr. Naveet WigAssistant ProfessorDepartment of MedicineAll India Institute of Medical SciencesNew DelhiMs. Leena SinhaResearch AssociateClinical Epidemiology UnitAll India Institute of Medical SciencesNew Delhi

EXTENDED CENTRAL COORDINATING TEAMDr. S. Vivek AdhishReaderDept. of Community Health AdminstrationNational Institute of Health & Family WelfareNew DelhiDr. N. ChaudhuriProfessorDepartment of PediatricsBurdwan Medical CollegeBurdwanDr. H.K. KumbnaniProfessorDepartment of AnthropologyNew DelhiDr. Thomas MathewAssistant ProfessorDepartment of Community MedicineMedical CollegeThiruvananthapuramDr. Sandip K. RayProfessorDepartment of Community MedicineMedical CollegeKolkataDr. S.L. ChadhaConsultant: Public HealthSita Ram Bhartia Institute of Scienceand ResearchNew DelhiDr. Rema DeviAssociate ProfessorDepartment of Community MedicineMedical CollegeThiruvananthapuramDr. K.C. MalhotraProfessor of AnthropologyIndian Statistical InstituteKolkataDr. R. SankarHead, Thyroid Research CentreInstitute of Nuclear Medicine & AlliedSciencesDelhiDr. Sunita ShanbhagAssociate ProfessorDepartment of Community MedicineLTM Medical CollegeMumbai

LIST OF ZONAL COORDINATORS AND INVESTIGATORSZone: 01 Chandigarh, Delhi, Haryana,Himachal Pradesh, PunjabZone: 03 Arunachal Pradesh, Assam,Meghalaya, SikkimCoordinator :Dr. S.K. KapoorCoordinator :Dr. Faruque AhmedC.R.H.S. Project (AIIMS), BallabgarhDr. Praveen KumarMr. M.K. TanejaDr. R.C. AgarwalPost Graduate Institute of Medical Sciences, RohtakDr. A.D. TiwariDr. B.K. NaglaDr. Mohinder SinghRegional Health & FW Training Centre, KangraDr. T.D. SharmaMrs. Swaran LataMr. G.L. JaryalMr. K.L. GhaiZone: 02 Uttar PradeshAssam Medical College, DibrugarhDr. Swapna D. KakotyMs. Mayashree KonwarDr. Bijit BhattacharyaDr. Mir Shahadat AliDr. Pranab Jyoti BhuyanNESPYM, GuwahatiDr. Chiranjeeb KakotyMr. Sajjad AhmedMrs. Alaka BhattacharyyaZone: 04 Manipur, Mizoram, Nagaland,TripuraCoordinator :Dr. R.C. AhujaCoordinator :Dr. E. Yaima SinghKing George’s Medical College, LucknowDr. Vikas ChandraDr. J.V. SinghDr. A.K. SrivastavaG.S.V.M. Medical College, KanpurDr. V.N. TripathiDr. Joginder SinghDr. R.P. SinghS.N. Medical College, AgraDr. Deoki NandanDr. S.K. MishraDr. S.P. AgnihotriAgartala, Tripura,Dr. Partha BhattacharjeaAizwal, MizoramDr. L. LalhrekimaKohima, NagalandDr. Tiasunup PongenerDr. UmatulaRegional Institute of Medical Sciences, ImphalDr. T.A. Achouba SinghDr. R.K. NarendraNote:Names of Research Associates who participated in the FHAC Coverage Evaluation - 2000 are listed in Annexure

Contd...Zone: 05 RajasthanZone: 07 OrissaCoordinator :Dr. S.L. SolankiCoordinator :Dr. B.C. DasDr. S.N. Medical College, JodhpurDr. Suman BhansaliDr. Afzal HakimDr. Y.R. JoshiMedical College, KotaDr. Raghuveer SinghDr. Gopal BunkarDr. Hans RajS.M.S. Medical College, JaipurDr. Anurag SarnaDr. Rajesh JainDr. Hemant JainM.K.C.G. Medical College, BerhampurDr. D.M. SatapathyMr. G.S. PatnaikDr. T. SahuS.C.B. Medical College, CuttackDr. S.C. JenaDr. S.K. SahuDr. K. MisraV.S.S. Medical College, Burla, SambhalpurDr. O.P. PanigarhiDr. H.P. AcharyaDr. S.C. PandaZone: 06 Madhya PradeshZone: 08 Goa, MaharashtraCoordinator :Dr. Sheela S. BhambalCoordinator :Dr. A.K. NiswadeGandhi Medical College, BhopalDr. A.K. UpadhyayaDr. R.K.S. KushwahaDr. U.K. DubeyGramin Sewa Sanstha, BilaspurMr. Vijay TiwariMr. D.N. MishraMr. Ajay GurudiwanMr. Ashok TiwariGwalior Medical College, GwaliorDr. A.G. ShingewekerDr. (Mrs.) A. ShingewekerL.T.M. Medical College, Sion, MumbaiDr. Alka JadhavDr. NagaonkarDr. Nitin DeshpandeDr. Shubhangi UpadhyeDr. Chitra NayakGovernment Medical College, NagpurDr. Sanjay ZodpeyDr. Sanjay DeshpandeDr. Suresh UghadeDr. Prashant Langewar

Contd...Zone: 11 Pondicherry, Tamil NaduZone: 09 Andhra PradeshCoordinator :Dr. S. Narasimha ReddyOsmania Medical College, HyderabadDr. B.V.N. Brahmeswar RaoDr. C. Bala KrishnaDr. J. Ravi KumarSiddhartha Medical College, VijayawadaDr. T.S.S. ManidharDr. A. Rama PrasadDr. C. Usha RaniS.V. Medical College, TirupatiDr. K. Raghava PrasadDr. N.A. ChettyDr. G. RaviprabhuZone: 10 KarnatakaCoordinator :Dr. B. MallikarjunBangalore Medical College, BangaloreDr. ShivanandaDr. GopalDr. PremalataM.R. Medical College, GulbargaDr. R.R. RampureDr. B.N. PatilMr. Shreeshail GhooliSt. John’s Medical College, BangaloreMr. A.S. MohammadMrs. Lalita BhattiMr. R.M. ChristopherCoordinator :C.M.C. Hospital, VelloreDr. Kurien ThomasDr. O.C. AbrahamDr. Mary KurienDr. R. SathianathanMadras Medical College, ChennaiMr. A. VengatesanMr. R.K. PadmanabanDr. S. KarthikeyanMadurai Medical College, MaduraiDr. C. KamarajDr. M. EswaranDr. T. RajagopalZone: 12 Kerala, LakshadweepCoordinator :Dr. M. NarendranathanAcademy of Medical Sciences, Pariyaram, KannurDr. Jeesha C. HaranDr. T.P. Mubarack SaniDr. M. JayakumaryMedical College, CalicutDr. M. Ramla BeegumDr. C.R. SajuDr. N.M. SebastienMedical College, ThiruvananthapuramDr. P.S. InduDr. J. PadmamohanMr. S.M. Nair

PREFACEThe primary function of program evaluation is to provide data on the extent to which programobjectives have been achieved. Evaluations can offer insight about program activities and process ofimplementation. When assistance is needed in clarifying objectives and / or establishing appropriateimplementation strategies for wider reach and acceptance of the program, the same methodologies ofprogram evaluation are effectively used.HIV pan-epidemic has struck almost every Indian state. Urgent public health measures are requiredto interrupt further transmission of the virus. National AIDS Control Organization (NACO), Ministryof Health, Government of India launched an innovative program “Family Health AwarenessCampaign” (FHAC) [initially named as “Family Health Awareness Week” (FHAW)], in April-May1999 to create awareness on reproductive tract infections (RTIs) and sexually transmitted diseases(STDs) among masses along with providing facilities to screen for and treat these infections.Appropriate management of RTIs / STDs are reported to reduce HIV transmission by 30-40 percent.Sensitive and personal issues regarding reproductive organs and sexual behavior were being discussedwith the community at their homes and in village camps through existing public health machinery.There were reservations about the appropriateness of strategies of program implementation, and socialmobilization as well as apprehensions regarding peoples’ response. IndiaCLEN had the opportunityto be associated as an external evaluation agency from the very first cycle of this program. Processevaluation of the pilot cycle of the program indicated acceptability of FHAC objectives and theimplementation strategy. Building on the experience gained from the first cycle of the program,IndiaCLEN team evaluated both coverage and process of implementing the FHAC cycle conductedduring summer of 2000.During last four years IndiaCLEN Program Evaluation Team has emerged as a highly professionalnetwork of academia. The network has expanded from twenty four medical colleges and two NGOsto forty two partners located in almost every Indian state. The team has also been involved with theprocess evaluation of four cycles of Pulse Polio Immunization (PPI) Program.The present program evaluation was considered a partnership exercise from the beginning and theevaluators collaborated with users of research as well as various categories of stakeholders who wouldbe directly or indirectly involved with implementation of the program. Qualitative methods were usedto obtain opinions and attitudes, behavior and motivations of both clients and providers within theircomplex rational matrix of personal as well as social realities. Quantitative methods using “probabilityproportionate to size (PPS)” cluster sampling technique were employed to estimate program coverage.Evaluation is useful to policy makers only if it is a scientific endeavor with results that can begeneralized. External evaluations are also characterized by their independence and minimal biases. It,therefore, bestows greater responsibilities on program evaluators to adopt research methods withutmost scientific rigor and in-built mechanisms for quality assurance. The current program evaluationis an effort in this direction.

REPORT WRITING TEAMCentral Coordinating Team MembersReport WritingDr. N.K. AroraEpidemiology &Program EvaluationDr. Kiran GoswamiEpidemiologyDr. K. AnandEpidemiologyDr. R.M. PandeyBiostatisticsDr. Naveet WigEpidemiologyDr. M. LakshmanHealth Social ScienceMs. Sneh RewalSocial ScienceDr. K.K. GangulySocial ScienceDr. S. Vivek AdhishEpidemiologyMs. Leena SinhaAnthropologyStatistical AnalysesDr. M. Lakshman Dr. N.K. Arora Dr. R.M. PandeyResearch AssociatesDr. Ashoo SewaniMs. Moumita BiswasMs. Maryann CharlesDr. Anita Patwari KaulResearch StaffMr. Sanjay SinghMr. Manish AeryMr. Pankaj BhandariMs. Pooja SinghalAdministrative AssistantMr. Rakesh SinghEditorial AssistanceMs. Jyoti Bahri

CONTENTSAcknowledgmentsAbbreviationsList of Tables and FiguresExecutive SummaryI. IntroductionII. ObjectivesIII. MethodologyStudy DesignSamplingNetwork Structure and DynamicsDevelopment of Interview SchedulesUnique Serial NumberTransmission of Data to CCOData ManagementData AnalysesLimitations and Potential BiasesTime-lineIV. Observations1. Background Information2. Results and Conclusions2.1. Reach of the ProgramProgram reachReasons of non utilization of program services2.2. RTI / STD / HIV-AIDS related awareness and behavior among the clientsKnowledge of clients about RTI/STD/HIV-AIDSPerception of clients about the problem of HIV-AIDS in their areaSafe sexPerceptions about benefits of Condom UsageUse of condoms during last intercourseInterpretation of differences in the knowledge and behavior related toRTI/STD/HIV-AIDS issues between various client categories2.3. Program ImplementationTraining of health providersSocial mobilizationField operations: Home visitsField operations: Camps

Treatment services for RTI/STDs and their utilization2.4. Provider’s Perspectives about Program Performance and Client BehaviorPerceptions about program reachPerceptions about clients behaviorPerceptions about problem of AIDS2.5. Adolescent ProfileReach of FHAC program among adolescentsAwareness of adolescents about RTI/STD/HIV-AIDSPrevalence of RTI/STD symptoms during two weeks prior to survey and safe sexrelated information2.6. Prevalence of RTI/STD Symptoms and Condom use during last IntercoursePrevalence of RTI/STD symptoms during two weeks period prior to surveyPrevalence of urethral discharge / painful micturitionPrevalence of genital ulcersPrevalence of RTI/STD symptoms according to HIV endemicityPrevalence of RTI/STD symptoms according to program utilization status of clientsCharacteristics of clients with presence of RTI/STD symptoms at the time of surveyUse of condoms during last intercourseCharacteristics of clients who had used condoms during last intercourseV. RecommendationsTables (6 to 66)AnnexuresBibliography

ACKNOWLEDGMENTSIndiaCLEN Family Health Awareness Campaign (Summer 2000) Program Evaluation had been apartnership exercise with every participating institution making equal contributions.We are greatly indebted to the support and encouragement extended by the following for successfulcompletion of the study.‚ National AIDS Control Organization (NACO), Ministry of Health and FamilyWelfare, Government of India, New Delhi‚ State Governments and District Administration of study sites‚ India Clinical Epidemiology Network (IndiaCLEN)‚ International Clinical Epidemiology Network (INCLEN), Philadelphia, USA‚ United States Agency for International Development (USAID), New Delhi‚ All India Institute of Medical Sciences (AIIMS), New Delhi‚ All stakeholders who agreed to share their perceptions and views about the program

ABBREVIATIONSAIDSAIIMSCCOCCTCEUDeffFHACFHAWHIVIBISIDIIIECINCLENIndiaCLENLMPNACONGOPHCPMCPPSRMPRTISTDTBWHOAcquired Immuno Deficiency SyndromeAll India Institute of Medical SciencesCentral Coordinating OfficeCentral Coordinating TeamClinical Epidemiology UnitDesign EffectFamily Health Awareness CampaignFamily Health Awareness WeekHuman Immunodeficiency VirusInvasive Bacterial Infections StudyInfectious Diseases Initiative of IndiaCLENInformation, Education and CommunicationInternational Clinical Epidemiology NetworkIndia Clinical Epidemiology NetworkLicentiate Medical PractitionerNational AIDS Control OrganizationNon Governmental OrganizationPrimary Health CentrePartner Medical CollegeProbability Proportionate to SizeRegistered Medical PractitionerReproductive Tract InfectionSexually Transmitted DiseaseTuberculosisWorld Health OrganizationKEY DEFINITIONSTarget Population / Clients : Both men and women between the age group of 15-49yearsContacted / Covered : Those clients who were either visited at their homes, attended the FHA campsor were exposed to both these activitiesNot Contacted / Covered : Clients who were either not aware of the FHAC program; or were awareabout the program through the publicity campaign but not exposed to the two main components of theprogram services, namely home visits or the attendance at campsProgram Reach : Was calculated as the percent of target population / clients visited at their homesand / or attended the FHA campsAdolescents : Boys and girls between the age group of 15-20 years were referred to as adolescents inthis evaluation report.

LIST OF TABLESTable 1Table 2Table 3Table 4Table 5Table 6.Table 7.Table 8.Table 9.Table 10.Table 11.Table 12.Table 13.Table 14.Table 15.Table 16.Table 17.Table 18.Zones for coverage evaluation of the Family Health Awareness Campaign-2000Coverage evaluation of family health campaign program : Zonal populations,clusters and cluster intervalsCoverage evaluation of family health awareness campaign program : Distribution ofhouseholds visited, refusals and clients recruited for the coverage survey by zoneand sexCoverage evaluation of family health awareness campaign program : Characteristicsof interviews rejected and analyzed by zone and place of residenceList of zones, partner medical colleges/NGOs, zonal coordinators and CCTmembers for coverage evaluationCharacteristics of clients according to reach of the program (Rural)Characteristics of clients according to reach of the program (Urban Slums)Reach of the family health awareness campaignProgram reach : proportion of clients who received services* during fhac programby zoneReach of the family health awareness campaign program by HIV- endemicityReasons for non-participation by the clients in FHAC campsReason for non - participation by clients : Lack of awareness about FHAC programReason for utilizing FHAC program services : Location of camp and attendanceClassification of client responses regarding RTI / STD / HIV-AIDSRTI/STD/HIV-AIDS related awareness (correct responses) among the clients - AllIndia DataRTI/STD/HIV-AIDS related awareness among rural areas menRTI/STD/HIV-AIDS related awareness among rural areas womenRTI/STD/HIV-AIDS related awareness among rural areas clients (Total)

Table 19.Table 20.Table 21.Table 22.Table 23.Table 24.Table 25.Table 26.Table 27.Table 28.Table 29.Table 30.Table 31.Table 32.Table 33.Table 34.Table 35.RTI/STD/HIV-AIDS related awareness among men from urban slumsRTI/STD/HIV-AIDS related awareness among women from urban slumsRTI/STD/HIV-AIDS related awareness among clients from urban slums (Total)Proportion of clients perceiving HIV-AIDS as a significant problem in their areaAwareness of clients about benefits of using condoms [CORRECTKNOWLEDGE*]Awareness of clients about benefits of using condoms [CORRECT KNOWLEDGE]Behavior of clients regarding safe sex - Use of condoms during last intercourseRTI/STD/HIV-AIDS related awareness among clients after controlling for maritalstatus - symptoms of RTI/STDs [CORRECT KNOWLEDGE]RTI/STD/HIV-AIDS related awareness among clients after controlling foreducation - symptoms of RTI/STDs [CORRECT KNOWLEDGE]RTI/STD/HIV-AIDS related awareness (Correct Responses): Distribution of ruralareas clients according to program contact status and presence of RTI/STDsymptoms during FHAC - 2000RTI/STD/HIV-AIDS related awareness (Correct Responses): Distribution of clientsfrom urban slums according to program contact status and presence of RTI/STDsymptoms during FHAC - 2000Training of health providers as part of FHAC program : Proportion trainedTraining of health providers as part of FHAC program : Process of trainingTraining of health providers as part of FHAC program : Topics discussed by thetrainersQuality of training of health providers : Perceptions of providers about FHACprogram objectivesQuality of training of health providers : RTI / STD / HIV-AIDS related awarenessamong doctors [CORRECT KNOWLEDGE]Quality of training of health providers (Doctors) : Treatment for men with urethraldischarge

Table 36.Table 37.Table 38.Table 39.Table 40.Table 41.Table 42.Table 43.Table 44.Table 45.Table 46.Table 47.Table 48.Table 49.Table 50.Table 51.Table 52.Table 53.Quality of training of health providers (Doctors) : Treatment for men with genitalulcersQuality of training of health providers (Doctors) : Treatment for women with foulsmelling vaginal dischargeQuality of training of health providers (Doctors) : Treatment for women with genitalulcersQuality of training of health providers (Health Workers) : RTI/STD/HIV-AIDSrelated awareness [CORRECT KNOWLEDGE]Social Mobilization : clients’ sources of information about FHAC programSocial Mobilization : knowledge about target population for FHAC programField Operations : personnel involved in house visits during the FHAC programField Operations : Location of FHAC camps [According to clients]Health workers perspective - Location of campsField operations : Personnel manning the camp*Field operations : Conduct of FHAC camps*Prevalence of RTI/STD symptoms in clients during the FHAC program according tocontact status of clientsTreatment seeking behavior of clients with RTI/STD symptoms during FHACprogramProviders perspective about program performance : Reach of the program duringFHAC programProvider perspective about program performance : Relative proportion of clientsattending the FHAC camps/ meetingsProviders’ perspective about client behavior : Clients’ reaction towards discussingissues of RTI/STDProviders’ perspective about client behavior : Treatment seeking behavior of clientsfor RTI/STDPerceptions of health providers regarding problem of RTI/STD/HIV-AIDS in their

areaTable 54.Table 55.Table 56.Table 57.Table 58.Table 59.Table 60.Table 61.Table 62.Reach of the family health awareness campaign to adolescents (< 20 years old)RTI / STD / HIV related awareness among adolescents (# 20 years old) [CORRECTKNOWLEDGE]Adolescent profile (# 20 years old) : Prevalence of RTI/STD symptoms during twoweeks prior to survey & safe sex related informationPrevalence of urethral discharge / painful micturition among the clients during thetwo weeks prior to the surveyPrevalence of genital ulcers during the two weeks prior to the surveyPrevalence of urethral discharge / painful micturition during two weeks prior tosurvey (According to HIV-endemicity zones)Prevalence of genital ulcers during two weeks prior to survey (According to HIVendemicity zones)Prevalence of urethral discharge / painful micturition during two weeks prior tosurvey (According to contact status of the clients)Prevalence of genital ulcers during two weeks prior to survey (According to contactstatus of the clients)Table 63. Characteristics of clients with presence of urethral discharge / painful micturition /genital ulcers during the surveyTable 64.Table 65.Table 66.Prevalence of condom usage during last intercoursePrevalence of Condom usage during last intercourse (Zonal data)Characteristics of clients who had used condoms during their last sexual intercourseLIST OF FIGURESFigure 1:Figure 2:Figure 3:Selection of Households for Coverage EvaluationNetwork StructureNetwork Monitoring

EXECUTIVE SUMMARY1. IntroductionThe world wide Acquired Immuno-Deficiency Syndrome (AIDS) epidemic is a human tragedy thatis reversing the gains in life expectancy of the last 30 years. The HIV-AIDS epidemic continues itsexpansion across the globe with approximately 16,000 new infections a day.Presence of sexually transmitted diseases (STDs) facilitate acquisition and transmission of HIVinfection tenfold and both are associated with the same risk behaviors. Measures that prevent STDsalso prevent sexual transmission of HIV infection. Early detection and effective treatment ofreproductive tract infections (RTIs) and STDs can significantly help to contain HIV transmission inpopulations.At present, the best hope to limit the spread of HIV infection and its human and economic impact isthrough behavior modification. Awareness is a powerful tool that has the potential to bring aboutattitudinal and behavioral change in individuals and the society such as reducing the number of sexualpartners, increasing condom use, seeking treatment for STDs and enabling safe injection practices.The HIV-AIDS scenario in India prompted the government to launch a mass awareness campaign.Family Health Awareness Campaign (FHAC) is a unique program that has not been attemptedanywhere in the world before. In this program, the task of disseminating awareness about the sensitiveissues related to RTI/STDs were taken up through the existing public health infrastructure.The program was conceived in early 1999 and the pilot phase of the FHAC [initially labeled as FamilyHealth Awareness Week (FHAW)] was carried out during 26 th April to 1 st May,1999 in 100 districtsall over the country. Encouraged by the response in phase I, Government of India launched thecampaign in 266 districts during 1 st - 15 th December,1999. The campaign was further expanded to coverall the districts of the country during the current round, i.e. summer of 2000. The strategy adopted forthis unique public health program was a ‘campaign mode’, where by target populations were sensitizedtowards the causes, symptoms and methods of preventing RTI/STD/HIV-AIDS, and all efforts weremade to encourage early detection and prompt treatment of RTI/STD by involving the community.IndiaCLEN has been associated as an external evaluation agency since the very first cycle of thisprogram. Building on the experience gained in the first cycle, IndiaCLEN team evaluated the FHACcycle conducted during the summer of 2000.Executive Summaryi

2. ObjectivesThe objective of the current evaluation was to assess the program coverage during summer 2000 cycleof FHAC.Primary ObjectivesTo determine1. The proportion of households visited by the health workers to create awareness about FHACand sensitize the community to RTI/STD/HIV-AIDS2. The proportion of target men and women (15 to 49 years age group) who were mobilized toattend the FHAC camps, during the summer 2000 cycle3. The awareness of clients regarding causes, symptoms, treatment and prevention ofRTI/STD/HIV-AIDSSecondary Objectives1. To determine the proportion of target population (men and women) who- received referral slips- sought care for RTI/STD at PHC and other health facilities (private practitioners)- received drugs from PHC during the last cycle of FHAC2. To estimate the proportion of target group (men and women) who had symptoms of RTI/STD(point prevalence) during 15 days prior to the survey (urethral discharge or genital ulcers)3. MethodologyQuantitative data was collected using the cluster sampling technique to get an estimate of coverage ofthe program and levels of awareness among clients about RTI/STD/HIV-AIDS across the country.Study DesignA population based cluster survey was conducted at household level. The sample communities wereselected using “probability proportionate to size” (PPS) technique. The entire country was divided intotwelve zones, each zone consisted of either one large state or a group (maximum four) of small states.The zones could later on be grouped according to HIV endemic regions (as illustrated in the followingTable). Census data of 1991 (Registrar General of India) was used as the sampling frame for selectingthe clusters. For urban areas, the clusters consisted of census wards and for rural areas, villages wereincluded.Executive Summaryii

Zones for the Coverage Evaluation of the Family Health Awareness Campaign-2000Zone No.StatesA. High HIV Endemic Regions08 C Goa, Maharashtra09 C Andhra Pradesh10 C Karnataka11 C Pondicherry, Tamil NaduB. Medium HIV Endemic Regions03 C Arunachal Pradesh, Assam, Meghalaya, Sikkim04 C Manipur, Mizoram, Nagaland, TripuraC Gujarat*C West Bengal*C. Low HIV Endemic Regions01 C Chandigarh, Delhi, Haryana, Himachal Pradesh, Punjab02 C Uttar Pradesh05 C Rajasthan06 C Madhya Pradesh07 C Orissa12 C Kerala, LakshadweepC Bihar*C Jammu & Kashmir** Coverage evaluation was not done in these states due to non-implementation of FHAC program during summer 2000SamplingMethods of Drawing Clusters: Urban and rural populations in a zone were separately processed fordrawing clusters. The data consisted of names of the villages, towns and cities, the population of thecommunities and the cumulative population which was obtained by adding the population of all thecommunities preceding it on the list. The list was arranged in the same order given in the nationalcensus data. The sampling interval was obtained by dividing the total population of the zone by thenumber of clusters desired. A random number between one and the sampling interval was chosen asthe starting point and subsequently the sampling interval was added to the random number until thedesired number of clusters were obtained. The selected clusters were plotted on a map of the respectivezone, and a logical sequence (route map) for the field work was developed for each of the surveyteams.Sample Size: Sample sizes were calculated under the assumption that the program coverage was 50%,i.e. 50 percent of the target clients could be contacted at their homes and / or attended the camps.Executive Summaryiii

Rural : With an admissible error of ±10% at 95% confidence level, 289 men and 289 women wererequired in each zone for a design effect of 3. After rounding off, the sample size was decided as 300per strata. Therefore, for 30 clusters, a sample size of 10 men and 10 women per cluster was decided.Urban : Urban clusters were considered a more homogenous population and hence taking the samebasic assumptions as for rural clusters, with a design effect of 1.5, 150 men and 150 women wererequired from each zone. For operational reasons, the urban sample was collected from 15 clusters ineach zone.Thus, a total of 10800 clients (7200 rural and 3600 urban) with an equal number of men and womenwere to be interviewed from 12 zones.In addition, 1080 health workers (2 per cluster) and 540 doctors (1 per cluster) were also to beinterviewed for information about the program implementation.Network Structure and DynamicsZonal coordinators: The study was conducted in 12 zones. A coordinator was nominated for eachzone. The survey was carried out by the zonal coordinators along with investigators from the zone, andwith the assistance and guidance of the CCT members.Partner Medical Colleges / NGOs: There were three partner institutions in each zone, thus there were36 partner institutions and each partner contributed three survey teams.Survey Teams : Each survey team comprised of one senior investigator (leader), one male and onefemale research associate (medical students/ interns/anthropology or social science graduates).Eachteam surveyed five clusters, thereby nine teams covered forty five clusters (30 rural and 15 urban) inthe zone.Central Coordinating Office (CCO): The project was coordinated by the All India Institute of MedicalSciences-Clinical Epidemiology Unit (hence forth called Central Coordinating Office), New Delhi.Besides the Principal Investigator cum Project Coordinator, there were eight Principal Co-investigatorsfrom AIIMS CEU and other institutions in Delhi forming the Central Coordinating Team (CCT). Inaddition, ten investigators were coopted as extended central coordinating team members to supportquality assurance measures.Data AnalysesThe sampling unit was the zone. Program implementation strategy for rural areas and urban slums wasdifferent. Data collection was also stratified according to sex. Therefore data had six strata : rural men,women and total and same three strata for the urban slum population. Weighted estimates for thewhole country (urban and rural separately) were calculated with zonal rural and urban populationsrespectively as the weights. All point estimates were calculated with 95% confidence intervals(Estimate % ± 2 SE) and associated design effects. In addition, awareness about RTI/STD/HIV-AIDS,treatment seeking behavior and presence of symptoms of RTI/STDs was related to the programcontact status of the clients. Appropriate tests were applied to assess the statistical significance of theestimates. Survey analysis of the statistical package (“STATA” version 6) was used.Executive Summaryiv

Limitations and Potential BiasesThe sample size for every zone had been estimated assuming the program reach as 50% with anadmissible error of ± 10%. The design effect of 3 was considered appropriate. Both these parametersmight have varied significantly between zones depending upon the program performance andheterogeneity of population residing in each cluster. The estimates could be particularly unstable witha wide 95% CI if the program performance was at extremes i.e. < 10% or > 90%. Similarly, the designeffect might vary with individual estimates. It was, therefore, essential to look at the 95% CI inaddition to point estimates.As we were dealing with sensitive and personal issues related to sex and RTI/STDs, information soobtained was likely to have validity and reliability problems. These were minimized through rigoroustraining of the research teams who were well qualified. The instruments were administered in the locallanguage keeping in mind the cultural sensitivities of language and manner in which questions wereasked.4. ObservationsA. Background InformationFamily Health Awareness Campaign - 2000 was evaluated across the country with the exception ofthe states of Bihar, Gujarat, Jammu & Kashmir and West Bengal where the program was notconducted. The data was collected between September 9, 2000 and October 5, 2000. In all, 10811clients (5409 men and 5402 women), 1072 health workers and 538 doctors from 360 rural and 180urban clusters spread across 12 zones were interviewed for the study.Quality assurance measuresThe magnitude and span of field operations, and involvement of 324 researchers from 36 medicalcolleges / non-governmental organizations necessitated the need of strict adherence to qualityassurance measures right from the beginning.After the national protocol finalization and orientation workshop in August 2000, 12 zonal workshopswere conducted for the field teams. All these workshops were conducted by zonal coordinators alongwith a CCT member to develop a common understanding about the study objectives, study instrumentsand field operations. At zonal level, the zonal coordinators monitored the field operations very closelyon a daily basis.The team leaders ensured that the team reached the selected cluster, followed the protocol in selectingthe households and individuals for interviewing, and research associates adhered to the guidelineswhile interviewing the respondents. After completing the specified number of interviews in eachcluster, they also scrutinized all the questionnaires, rejected the incomplete / defective ones andorganized extra interviews to replace the rejected ones. Members of the CCT made surprise qualityassurance visits to a total of 45 (out of 540 clusters; 8.3%) clusters spread over 12 zones. During theirvisit to the cluster areas, data was cross checked with 2.4% (259/10811) clients in their houses and1.9% (209/10811) interviews were observed in the field.On arrival at CCO, AIIMS, New Delhi, the data were screened for appropriate coding of responses.Executive Summaryv

Thereafter, the data were entered twice into the computer and matched. Range checks and logical runswere incorporated in the data management software to minimize errors.Characteristics of interviewsClients : A total of 16432 households were visited (50.6 % more than the targeted number) by theresearch teams. Most of these (4652/10911= 42%) were necessitated by the fact that either the doorswere locked or there was no person of the specified sex in the eligible age group (15-49 years). Only869 (7.3% replacements) of the available / eligible respondents declined to be interviewed becausethey were either busy, embarrassed or shy. An additional 100 (0.9%) of the interviews were incomplete(non-cooperation, no privacy, unwilling after a while, poor quality) and hence rejected by either theteam leaders themselves or the CCO. Thus, a total of 10811 interviews were included for finalanalyses. Of these, 7212 were from rural areas (3611 men and 3601 women) while the rest (3599) werefrom urban slums (1798 men and 1801 women).Ninety percent of interviewed women (4852/5402) were married while 27.3% men, in both rural andurban settings, were unmarried. Maximum proportion of clients interviewed were in the age group of20-35 years (men: 3130/5409; 58%), (women: 3694/5402; 68%). A large proportion of interviewedwomen were illiterate in both rural [1566/3600; 43.5%] and urban slums [561/1801; 31.2%]. Asregards men, 66.9% ( 3586/5359) were educated up to high school and above, and only 17%(913/5359) were illiterate.Health Providers and Doctors: A total of 1084 health workers and 541 doctors were interviewed. Dueto incomplete and / or poor quality transcripts, interviews of 12 health workers (1.1%) and 3 doctors(0.9%) were rejected. Hence, data from 1072 health workers (714 - rural and 358 - urban) and 538doctors were analyzed and presented. Sample size of doctors and health workers interviewed from eachcluster and zone did not have sufficient power for analysis at zonal level. Hence for both thesecategories of stakeholders, all India estimates were calculated.B. Results and ConclusionsFHAC is a promising program. Creation of widespread awareness about RTI/STD/HIV-AIDS among15-49 year age group may prove to be the most effective means of bringing about changes in sexualbehavior. Safe sexual practices facilitate reduction in the transmission and in turn prevalence of thesediseases.Definitions of program reachFor the purpose of current program evaluation, program reach was defined as:Population contacted or covered: Those clients (aged15-49 years) who were either visited in theirhomes or those who attended the FHAC camps or were exposed to both these activities.Population not contacted or covered: This group included those clients (aged 15-49 years) who werenot aware of the FHAC program or those who were aware about it through the publicity campaign butwere not exposed to two main components of the program services, namely home visits and camps.Acceptability of the programFHAC has been a unique program; sensitive and personal issues of diseases of reproductive systemExecutive Summaryvi

and sexual behavior were discussed with the community through the public health system at theirhomes and in groups at the camps. Contrary to the apprehension of planners and providers,embarrassment and shyness were cited as reasons for not coming to camps by only 2-4% of clients whowere familiar about the existence of FHAC program. This was true in both urban slums and villagesindicating that the program objectives and its implementation strategies were acceptable to thecommunity at large.Reach of the programAs part of the program, 17% households in rural areas and 12% in urban slums were visited to contactthe target segment of the population at their homes. Barely 9% target clients from the rural areas, and4% in urban slums attended the camps. Overall, program services could cover only 19% rural and 13%of the eligible individuals residing in the urban slums and high risk areas either through house visitsand / or camps. More women than men could be covered in villages and in urban slums. Thus, theFigure A: Reach of Family Health Awareness Campaign ProgramRural Areas73%Not aware about FHAC7%82%2%11% 7%Urban SlumsAware but not attended campContacted at home aloneAttended camp onlyContacted at home & attended camp3% 1% 9% 5%program reach during summer 2000 was very limited. Program performance was consistently poorerin urban slums in almost all the states as compared to the villages (Figures A, B, C).Executive Summaryvii

Figure B: FHAC Program Coverage by Sex252016.921.819.317.2MenWomenTotalPercent15109.713.450Rural AreasUrban SlumsFigure C: FHAC Program Coverage by ZoneALL INDIAUrban SlumsRural AreasTamil NaduKarnatakaAndhra PradeshMaharashtra/GoaHigh HIV EndemicRegionManipur/Tripura/Mizoram/NagalandAssam/Arunchal Pradesh/Sikkim/MeghalayaMedium HIV EndemicRegionKeralaOrissaMadhya PradeshRajasthanUttar PradeshHaryana/Delhi/Punjab/HimachalPradesh/ChandigarhLow HIV EndemicRegion0 10 20 30 40PercentExecutive Summaryviii

Reasons for non-participation in the program activitiesAmongst the target population, 73% in rural areas and 82% in urban slums were unaware of theexistence of FHAC program (Figure A). Issues of client inconveniences (viz; inconvenient timings,loss of wages, location of camps, not present at home/village) were the other major factors for nonparticipationin the program and were mentioned by 50% of those who were aware about the programbut did not attend the camps. This was also endorsed by health care providers. The probability ofclients attending the camps was 74% higher if these were organized in or around the villages and urbanslums.Program implementationSocial mobilization: Creating awareness about FHAC program, camps and availability of treatmentfacilities at PHC was the key for success of this program. Information about FHAC in the communitywas disseminated primarily by the health workers and to some extent through friends, relatives andlocal influencers. Publicity channels like posters, banners, wall writings and occasionally mass mediawere mentioned by a mere 13% rural and 19% urban clients (Figure D). Usually, house visits (83%)and camps (90%) were conducted by health workers alone.Inadequacy of the social mobilization activities was the predominant factor for non-participation inthe program by the clients. The publicity campaign organized for the program was evidentlyineffective. Interpersonal communication is a persuasive and effective means of communication, butit is also more time consuming. To improve program coverage using interpersonal communication asa central strategy would need greater involvement of the non-health sector to contribute in a tangiblemanner to the program implementation.Screening and mobilization of RTI/STD patients during FHAC : During the campaign period, 10.2%of the contacted and 2.1% of the non-contacted clients had symptoms of RTI/STD. Data indicated thateither due to program strategy, self selection or both, the target population with symptoms of RTI/STDwere more likely to attend the camps. The program, particularly the camps, may be perceived to bemeant only for RTI/STD/HIV-AIDS patients and hence adversely influence the overall communityparticipation in future due to the associated stigma.Referral system for suspected RTI/STD patients : The referral system evolved as part of the FHACprogram appeared to be functioning reasonably well. However, there were no in-built mechanisms inthe program to follow up those who were screened, suspected and referred to higher level formanagement (Figure E).Training: Almost three-fourth of the doctors (72%) and health workers (76%) were trained (Figure F)near their place of work. These trained providers had high levels of correct knowledge about differentExecutive Summaryix

aspects of RTI/STD/HIV-AIDS. However, emphasis on the objectives and implementation of theprogram was insufficient during the training as only a few doctors (18%) and health workers (27%)mentioned discussing these topics. This inadequacy probably reflected on the program implementationand performance later. Doctors and health workers believed that 60-88% of the community memberssought care from private practitioners and other non-conventional health facilities for RTI/STD butprivate health care providers were largely left out of FHAC training (91%) and were not invited to bepartners in the program.Figure D: Clients’ Sources of Information about FHAC Program70 Health WorkerInterpersonalPublicity6050Percent403020100Men Women TotalMenWomenTotalRural AreasUrban SlumsFigure E: Referral System During FHAC, 2000ClientsContactedClientsNot Contacted100 Cohort of Suspected RTI/STD 10077 Aware about Referral Slips NA69 Took Referral Slips NA65 Went to PHC 2756 Received Medicines at PHC 17Executive Summaryx

Figure F: Proportion of Health Providers Trained for FHAC ProgramGovernment Doctors72%9%Private Doctors28%91%Health Workers76% TrainedUntrainedNo training3%21%Providers’ perceptions about program performance: Doctors and health workers grossly overestimated the performance of the program for almost all its components.RTI/STD/HIV-AIDS related awareness and behavior among the clientsCorrect knowledge about causes, ill effects, prevention and treatment of RTI/STD, and transmissionof HIV-AIDS was widely prevalent among the target population in both urban (52.3% to 84.6%) andrural (44.3% to 81.2%) areas. However, fewer clients were familiar with the symptoms of thesediseases (41%) and long term ill effects due the HIV infection (25.9% to 31.4%). Women in both ruralareas and urban slums were, in general, less knowledgeable than men about these diseases.The clients were stratified according to their contact status with the FHAC program implemented oneto three months prior to survey. The correct knowledge about different aspects of RTI/STD/HIV-AIDSand benefits of using condoms was significantly higher among target population from villages (55%to 91%) as well as urban slums (59% to 91%) who came in contact with the program services ascompared to those who were not contacted [rural-37% to 70%; urban slums-39% to 84%] (p

Familiarity with the ill effects of HIV-AIDS on the body was prevalent in 34% rural area and 37% ofurban slum clients who were covered under the program as compared to 24% and 30% of the noncontactedpersons in villages and urban slums, respectively (p=0.007).People residing in urban slums and those living in villages did not perceive HIV-AIDS as a significantproblem and this perception was irrespective of their program contact status (contacted 13%; notcontacted 8%). This was also in concordance with the providers’ perspective about the public healthsignificance of HIV-AIDS (doctors 28% ; health workers 26%).There were clients who had correct as well as incorrect perceptions about various aspects ofRTI/STD/HIV-AIDS. These reflect deep rooted socio-cultural beliefs about symptoms, causes andtreatment of RTI/STDs. Wrong perceptions were prevalent in clients from villages and citiesirrespective of their FHAC program contact status. It was surprising to observe that incorrectperceptions, particularly about symptoms of RTI/STD and ill effects of HIV-AIDS on the body werehigher among those who came in contact with the program than among those who did not (p=0.05 to0.001).The prevalence of condom use among rural clients who were covered under the FHAC program was12% (95% CI : 9-15) and 7% (95% CI : 6-9) among the non-contacted population of FHAC program(p=0.001). However such a difference was not observed in urban slums (11% in both category ofclients).The current study was a cross-sectional survey and differences between various client categories inthe knowledge and behavior parameters were likely to be due to several program and non programrelated inputs. RTI/STD symptoms were about 5 times higher among the participants of FHACprogram (10%) as compared to those who were not covered (2%). Marital status, education, agedistribution and occupation of subjects and their spouses were some of the other potential confoundersthat could influence the awareness level of the subjects. In view of the above, the observed differencesin the knowledge and behavior about RTI/STD/HIV-AIDS related issues between clients who had andhad not come in contact with the program services would have to be interpreted with caution andconsidered as hypothesis generating rather than causal in nature.Executive Summaryxii

Figure G: RTI/STD Related Correct Awareness Among ClientsPercent1009080706050403020100Contacted Not Contacted Contacted Not ContactedSymptomsIll effectsTreatmentRural AreasUrban SlumsFigure H: HIV-AIDS Related Correct Awareness Among Clients9080SpreadIll effectsPrevention7060Percent50403020100Contacted Not contacted Contacted Not contactedRural AreasUrban SlumsExecutive Summaryxiii

Adolescent profileThe target population for the program services was between 15-49 years. Those between the agegroup of 15-20 years were labeled as adolescents in this study.Reach of FHAC program to adolescents: Data indicated that during FHAC, 13% adolescents invillages and 14% in urban slums were covered under the program services. This was similar to theother age groups covered under the program.Awareness of adolescents about RTI/STD/HIV-AIDS: Both in villages and urban slums, theadolescents were correctly aware about several features of RTI/STD/HIV-AIDS in varyingproportions. The degree of appropriate knowledge of these disorders was higher among thoseadolescents who had come in contact with the program services as compared to those who had not.The proportion of adolescents who were sexually active could not be ascertained with the surveyinstrument used. However, condoms were used by 3.4% of rural and 6.3% urban slum adolescentsduring their last intercourse. The prevalence of condom usage was less as compared to subjects ofolder age group in both areas.Prevalence of RTI/STD symptoms and condom use during last intercourseClients were enquired about the presence of the symptoms of RTI/STD during the two week periodprior to the day of interview for coverage evaluation. These included urethral discharge or painfulmicturition and ulcers on / around genitalia. Period of enquiry was restricted to two weeks tominimize recall bias. The study subjects were also enquired about the use of condom during their lastsexual intercourse.Prevalence of urethral discharge / painful micturitionThe prevalence of RTI/STD symptoms was 2% among men residing in urban slums and 2.7% invillages. In 10% urban and 10.5% rural women, urethral discharge/painful micturition were present.Among men, prevalence varied between 0%-10%, while 5%-19% women complained about urethraldischarge/painful micturition in different study zones.Complaints of urethral discharge or painful micturition were almost five times higher among womenthan men. Vaginal discharge is one of the RTI/STD symptoms among women and was frequentlyreported. This symptom may have been confused with urethral discharge. Hence, higher prevalenceof urethral discharge reported by women might be biased due to co-existing vaginal discharge (FigureI).Prevalence of genital ulcersGenital ulcers were reported by 1.1% rural and 1.0% urban clients. There were no major differencesExecutive Summaryxiv

in their prevalence between the two sexes either in urban slums or villages (Figure I).Figure I: Prevalence of Urethral Discharge/Painful micturition and Genital ulcers121010.510MenWomenTotal866.664202.720.9 1.4 1.71.110.3Rural Areas Urban slums Rural Areas Urban slumsUrethral discharge/painful micturitionGenital ulcersUse of condoms during last intercourseIn villages, 8% of clients between the ages of 15-49 years had used condoms during their last sexualintercourse. In urban slums, the condoms were being used by 11.1% individuals. There were nodifferences in the prevalence reported by clients of either sex (Figure J).Figure J: Prevalence of Condom Usage During Last IntercourseALL INDIAKeralaTamil NaduKarnatakaUrban SlumsRural AreasAndhra PradeshMaharashtra/GoaOrissaMadhya PradeshRajasthanManipur/Tripura/Mizoram/NagalandAssam/Arunchal Pradesh/Sikkim/MeghalayaUttar PradeshHaryana/Delhi/Punjab/HimachalPradesh/Chandigarh0 5 10 15 20 25 30PercentExecutive Summaryxv

5. RecommendationsProgram AcceptabilityFHAC program was acceptable to the community in the villages as well as urban slums. It canbe continued with its current framework of objectives and implementation strategies.Program Reach2.1 The program coverage will have to be increased substantially to achieve the desiredchanges in the knowledge and behavior of the community.2.2 As originally envisaged, the program should target all community members betweenthe ages of 15-49 years. The current strategy of preferentially mobilizing theindividuals with suspected RTI/STD may have stigmatized the FHAC camps asRTI/STD camps thereby reducing attendance. Referral slips can be given both duringhouse visits and in the camps.Social Mobilization3.1 Major inputs are needed to improve social mobilization which appeared to be a weaklink in the program. Most of the community has to be made aware of the existence ofthe FHAC program. This requires using all channels of communication. The messagesabout RTI/STD/HIV-AIDS should be simple, consistent and culturally appropriate.Communication experts should be involved to mount publicity campaigns after pretestingthe messages for suitability and clarity.3.2 The community should also be debriefed about the prevalent misconceptionsregarding causes, symptoms, ill effects, treatment of RTI/STD/HIV-AIDS and safesexual practices.3.3 In view of the sensitive and personal nature of the issues related to various aspects ofRTI/STD/HIV-AIDS, inter-personal communication should continue to be a keystrategy in the field. This would mean involving non-health sectors, notablyNGOs/CBOs/local leadership and influencers, for home visits as well as organizationof the camps.3.4 Private health sector should be invited to participate in the program as an importantpartner because large segments of population seek treatment from them forRTI/STD/HIV-AIDS.Executive Summaryxvi

Program Implementation4.1 Client inconvenience: As the program coverage increases, this might emerge as animportant reason for non-utilization of the FHAC related services. Conveniences ofthe local community and partners should be taken into account before the time for theprogram is fixed. It was not necessary to organize the program in the whole countrysimultaneously. FHAC could be implemented more effectively with a wider coverageif it was organized in a staggered manner in different states. The house visits andcamps should be organized in a manner that are client friendly. Camps should beorganized exclusively within the villages / urban slums to facilitate maximumattendance.4.2 Extra efforts continue to be required to reach the male clients and adolescents.4.3 A mechanism for follow up of RTI/STD patients identified in the field needs to be putin place. This is essential for the sustainability of the referral system of FHACprogram.Training5.1 Remaining health providers need to be trained.5.2 Re-orientation of all health providers is necessary on a regular basis; these sessionsmay also be utilized to provide feed back to providers regarding program performance.5.3 With most of the health providers having already received training, the focus shouldnow shift to train the private practitioners, NGOs/CBOs and local leaders.5.4 Training should focus equally on the program objectives and strategies as on thesyndromic management of RTI/STD/HIV-AIDS.5.5 Training content requires suitable modifications to highlight the seriousness of theproblem of HIV-AIDS in the community, ill effects of HIV-AIDS, the symptoms ofRTI/STD and educating the community about the prevalent misconceptions aboutthese diseases.5.6 Special emphasis is required for imparting communication skills to deal withsensitive and personal issues like RTI/STD/HIV-AIDS.Future ChallengesThe public health system will have to be strengthened to meet the increasing demands forRTI/STD services as the program coverage is improved. Simultaneously, efforts will benecessary to improve the availability and accessibility of condoms to the sexually activesegment of the population.Executive Summaryxvii

I. INTRODUCTIONThe world wide Acquired Immuno Deficiency Syndrome (AIDS) epidemic is a human tragedy thatis reversing the gains in life expectancy of the last 30 years and exacerbating poverty in developingcountries. The HIV-AIDS epidemic continues its expansion across the globe with approximately16,000 new infections a day. According to the estimates by the joint United Nations program in HIV-AIDS (UNAIDS) and the World Health Organization (WHO), 32.4 million adults and 1.2 millionchildren were living with HIV by the end of 1999 and 16.3 million deaths have occurred since thestart of the epidemic. A staggering 95% of the infections occurred in developing countries. About4 million Indians, the largest number in any country, are currently infected with HIV. There is nostate in India that is free from the HIV/AIDS virus infection.About 80% of the HIV infections in India occur from sexual route (both heterosexual andhomosexual), about 8% through blood transfusion and about 8% through injecting drug use. Over90% of the reported cases occur in the sexually active and economically productive age group of15-49 years. One in every four cases reported is a woman.The main predisposing factors responsible for the spread of HIV infection are migration of thepopulation from one part of the country to another for jobs, particularly to metropolitan cities;poverty, illiteracy, urbanization and an increase in intercity transportation system in the backdropof ignorance and prevalent socio-cultural beliefs about RTI/STD and HIV infections.There is a probability that the gender disparity of sexually transmitted diseases (STDs) andreproductive tract infections (RTIs) in men and women may be a predisposing factor too. Thistogether with high prevalence of reproductive tract infections (RTIs) and sexually transmitteddiseases (STDs) could make the scenario of HIV infection even more grim.The growing evidence available from all over the world undoubtedly indicates that the incidence ofHIV infections is higher in the presence of sexually transmitted diseases. There is a close relationshipbetween STD and HIV infections. First, STD and HIV infections are associated with the same riskbehavior, that is unprotected sexual intercourse with multiple partners. Thus, the same measures thatprevent STDs also prevent sexual transmission of HIV infections.Secondly, the presence of STD has been found to facilitate the acquisition and transmission of HIVinfection by almost ten times. Thus early diagnosis and effective treatment of RTI/STD cansignificantly help to contain and reduce HIV transmission in populations. Widespread awareness canpotentially lead to attitudinal and behavioral change in the individual and the society towardsadopting safe sexual practices, thereby helping to limit the spread of HIV infection.To prevent the further progression of HIV infection, a two pronged strategy is necessary: to createawareness, and to provide care and support to those infected.The grim HIV-AIDS scenario in India prompted the government to launch a mass awarenesscampaign. Family Health Awareness Campaign (FHAC) is a unique program that has not beenattempted before, anywhere in the world. In this program, the task of disseminating awareness aboutIntroduction1

the sensitive issues related to reproductive tract infections and sexually transmitted diseases, wastaken up through the existing public health infrastructure in a developing world setting.The “Family Health Awareness Week” (FHAW) program was conceived in early 1999. The pilotphase of the program was carried out in 100 districts spread all over the country during 26 th Aprilto 1 st May,1999. Encouraged by the response of the phase I, the Government of India extended theprogram to 266 districts during 1 st - 15 th December,1999. The campaign was further expanded tocover all the districts of the country during the current round, i.e. summer of 2000. Family HealthAwareness Week was renamed “Family Health Awareness Campaign (FHAC)” in January, 2000.The name aptly conveyed the strategy adopted for this unique public health program. Using acampaign strategy, target populations were sensitized about the causes, symptoms and methods ofpreventing RTI/STD, and efforts were made to encourage early detection and prompt treatment ofRTI/STD by involving the community.IndiaCLEN has been associated as an external evaluation agency since the very first cycle of thisprogram. Building on the experience gained in the first cycle of the program, IndiaCLEN teamproposed to evaluate the current cycle of FHAC conducted during the summer of 2000.Evaluation of the Pilot Phase of Family Health Awareness Campaign by IndiaCLEN ProgramEvaluation Team (1999)It was a qualitative study conducted at 10 centers across India. The investigators were senior facultymembers from medical colleges. The objectives of the evaluation were: a) to evaluate the processinvolved in the planning and implementation of the program, b) to determine the factors thatinfluence the utilization of services by the clients, and c) to assess intermediate indicators of impactfor the program.Observations and Recommendations of FHAC Program Evaluation (Phase I - 1999)1. The Family Health Awareness Campaign (FHAC) program was acceptable to the communityand hence may be continued in order to cover all parts of India, maintaining essentially thesame objectives and broad strategies of implementation. At least 4-6 months of lead time isnecessary to do the ground work and planning for the subsequent cycles of FHAC.2. NGOs, local influential persons and panchayat leaders are likely to be particularly helpful inimplementing a sensitive and personal issue of RTI/STD through public health channels.3. Coordination committees at district and sub-district level were important institutions of intersectoralcoordination. They should continue to be headed by the District Magistrates and allpartners must attend the committee meetings.4. Microplanning should be considered a central and essential part of program implementationat district and block levels. All partners should participate in this process to convey theconcept of stakeholdership.Introduction2

5. Adolescent (15-20 years age group) boys and girls must be recognized as a priority targetgroup for the program and extra efforts made to mobilize them to attend the programactivities.6. All doctors and other providers who are to be involved in implementation should be orientedto the program objectives and trained for identification of RTI/STD patients from thecommunity, their referral to the health facilities and appropriate management. An equallyimportant issue is sensitizing the providers to the skills of communication, particularly whilehandling an issue like RTI/STD/HIV-AIDS at the homes, camps and PHCs.7. A well planned and coordinated campaign for social mobilization should be organized. Allchannels of communication should be used for this purpose. IEC material should be in thelocal language and appropriate to local customs and cultures.8. Interpersonal communication appeared to be the most appropriate channel of socialmobilization for this sensitive and personal issue. Door to door visits must be continued asan integral part of FHAC strategy.9. Camps should be organized within the villages at easily accessible locations. The campsshould have separate enclosures for men, women, adolescent girls and adolescent boys.Special care should be taken to ensure confidentiality if some clients want to discuss theirproblems on one to one basis.10. The system of referral for RTI/STD should be continued for the whole year.11. A system had to be evolved at PHCs to ensure availability of drugs for treatment of RTI/STDround the year.Need For External EvaluationNational AIDS Control Organization (NACO), conducted the Family Health Awareness Campaignfor the third time during the summer of 2000. In this cycle, the program was expanded to cover allthe districts in the country.This was a unique program with the objective of creating awareness about a sensitive and personalissue among masses. Therefore, there were apprehensions about the appropriateness of strategies ofprogram implementation, social mobilization and people’s response. In view of these sensitivities,the nodal implementation agency, NACO, built the process of evaluation within the program rightfrom the initiation of its activities. For independent appraisal NACO wanted a partnership with anexternal agency, which had experience and expertise in program evaluation.Why IndiaCLEN?Clinical Epidemiology Units (CEUs) are functioning in six medical colleges in India (New Delhi,Lucknow, Nagpur, Chennai, Vellore and Thiruvananthapuram). CEU faculty members were trainedIntroduction3

in clinical epidemiology, health social sciences, bio-statistics and health economics under the GlobalInternational Clinical Epidemiology Network (INCLEN) program.Members of the CEUs have formed a national body called IndiaCLEN with the objectives ofdisseminating the knowledge and skills of clinical epidemiology to other academic, non-academicand medical institutions in the country and for participating in policy relevant research activities.Members of the group have had the benefit of attending workshops on program evaluation andcontinuous quality assurance.IndiaCLEN as a group, has always encouraged development of collaborative study protocols.IndiaCLEN members have completed three cycles of evaluation of the Pulse Polio ImmunizationProgram [1997-98; 1998-99 and 1999-2000] at 24 centers across the country. Several keyrecommendations made on the basis of these reports were incorporated in the National Pulse PolioImmunization Program. IndiaCLEN was also involved in the evaluation of the first round of FamilyHealth Awareness Week-1999. The group was doing other networking studies viz. Invasive BacterialInfections Study (IBIS) and Survey of Abuse in Family Environment (IndiaSAFE). IndiaCLENmembers have also participated in the process and impact evaluation of the universal salt iodizationprogram of Government of Madhya Pradesh (India) in 1995. More recently, Infectious DiseasesInitiative of IndiaCLEN (IDII) had undertaken tuberculosis and related research projects at eightcenters in the country.Family Health Awareness Campaign (FHAC) - Summer, 2000The overall objective of the campaign was to contain the spread of reproductive tract infections(RTIs) including sexually transmitted diseases (STDs) and HIV-AIDS.The major focus of the program was:‘ To raise the awareness level of people about RTI/STDs and HIV-AIDS in rural areas andother vulnerable groups of the population, particularly urban slums‘ To encourage health seeking behavior for RTI/STDs in the general population‘ To make the people aware about the services available in the public health system for themanagement of RTI/STDs‘ To facilitate early detection and prompt treatment of RTI/STDs by mainstreaming theprogram with the infrastructure available under the primary health care system‘ To implement a focused IEC strategy for male populationAimThe overall aim of the present program evaluation exercise was to obtain estimates of targetpopulation covered under the FHAC program during summer 2000 and to document the reasons forclients not utilizing the program services. The findings from the study were to be shared withprogram managers to help them improve implementation and further refine program strategies.Study Hypotheses1. The program was utilized by at least 50% of the target population during summer 2000.2. The program was acceptable to the community.3. The awareness about RTI/STD/ HIV-AIDS among both providers and clients has improvedas a result of this program.Introduction4

II. OBJECTIVESCurrent evaluation assessed the program coverage during summer 2000 cycle of FHAC.Research QuestionsWhat was the coverage under the program for the following parameters:1. Reach of health workers to client’s house.2. Mobilization of clients (male and female) to the camps of FHAC.Primary ObjectivesTo determine:1. The proportion of households visited by the health workers to create awareness about FHACand sensitize the community to RTI/STD/HIV-AIDS.2. The proportion of target men and women (15 to 49 years age group) whowere mobilized toattend the FHAC camps during summer 2000 cycle.3. The awareness of clients regarding causes, symptoms, treatment and prevention ofRTI/STD/HIV-AIDS.Secondary Objectives1. To determine the proportion of target population (men and women) who- received referral slips- sought care for RTI/STD at PHC and other health facilities (private practitioners)- received drugs from PHC for their RTI/STD related symptoms during summer2000 cycle of FHAC.2. To estimate the proportion of target group (men and women) who had symptoms of RTI/STD(point prevalence) during 15 days prior to the survey (urethral discharge/painful micturitionor genital ulcers).Objectives 6

III. METHODOLOGYQuantitative data was collected using the 30 cluster sampling technique to get an estimate of thecoverage of the program and awareness of clients about RTI/STD/HIV-AIDS across the country.Study DesignA rapid population based cluster survey at the household level was performed for reasons of costsand logistics. The sample communities were selected using “probability proportionate to size” (PPS)technique. Under this method, the likelihood of a community being selected is in relation to theproportion of its population size i.e larger villages or cities (census wards) are more likely to beselected than the smaller ones. The entire country was divided into twelve zones, each zone consistedof either one large state or a group of small states (maximum four states). The zones could later begrouped according to HIV endemic regions (Table 1, Annexure II). Census data of 1991 (RegistrarGeneral of India) was used as the sampling frame for selecting the clusters.Table 1. Zones for the coverage evaluation - Family Health Awareness Campaign, 2000Zone No.StatesA. High HIV Endemic Regions08 C Goa, Maharashtra09 C Andhra Pradesh10 C Karnataka11 C Pondicherry, Tamil NaduB. Medium HIV Endemic Regions03 C Arunachal Pradesh, Assam, Meghalaya, Sikkim04 C Manipur, Mizoram, Nagaland, TripuraC Gujarat*C West Bengal*C. Low HIV Endemic Regions01 C Chandigarh, Delhi, Haryana, Himachal Pradesh, Punjab02 C Uttar Pradesh05 C Rajasthan06 C Madhya Pradesh07 C Orissa12 C Kerala, LakshadweepC Bihar*CJammu & Kashmir** Coverage evaluation was not done in these states due to non-implementation of FHAC program during summer 2000For urban slums, the clusters consisted of census wards and for rural areas, villages. This7Methodology

stratification was adopted for the following reasons:a) The major focus of the program was in rural areas. In cities it was focused in highrisk areas and slums only.b) Program implementation strategies were different in urban and rural areas.c) Differences exist in the socio-cultural and demographic features of the urban andrural populations.Hence the data for urban and rural areas were presented separately.Samplingi. Methods of Drawing ClustersUrban and rural populations in a zone were separately processed for drawing clusters (Table 2). Thesampling interval was obtained by dividing the total population of the zone by the number of clustersdesired. A random number between one and the sampling interval was chosen as the starting pointand subsequently the sampling interval was added to the random number until the desired numberof clusters were obtained. The villages / towns / cities whose cumulative population included thesenumbers were selected for the cluster survey. The selected clusters were plotted on a map of therespective zone, and a logical sequence (route map) for the field work was developed for each of thesurvey teams. A work plan was developed for all the zones and specific clusters were allotted to eachfield team (Annexure III).ii. Sample Size CalculationSince the extent of coverage was not known, it was assumed that the program coverage was 50%,i.e 50% of the target clients could be contacted at their homes and / or attended the camps. Thiswould give an estimate of the largest sample size required (for the given value of confidence limitsand precision).For the purpose of the current study, sample size was estimated for 95% confidence level with anadmissible error of ± 10%.The sample size required for the cluster survey was larger than that required for a random orstratified sample because of the phenomenon of design effect (Deff). If the proportion of a conditionis approximately the same in each sample cluster, Deff will be around the null value of one. Greaterthe clusters differ from one another, larger the Deff. As the Deff increases (which increases thevariance around the proportion estimate), the sample size must be increased to maintain a desiredlevel of precision.There was bound to be variation in the program performance in different parts of the same zone andhence Deff had to be more than one. After consulting with other public health persons, who hadconducted similar studies and adopting a conservative approach, the sample size was calculated withthe design effect of 3. Design effect gives an idea about the extent of variation in the implementationand performance of the program within the zone and across the zones.Methodology8

Table 2.Coverage evaluation of Family Health Awareness Campaign Program : Zonalpopulations, clusters and cluster intervalsZoneNo.States * Stratum Total Population TotalClustersCluster Interval1 Chandigarh, Delhi, Haryana,Himachal Pradesh, PunjabRural 32434534 30 1081151Urban 19544619 15 13029752 Uttar Pradesh Rural 111506372 30 3716879Urban 27605915 15 18403943 Assam, Arunachal Pradesh,Meghalaya, Sikkim,4 Manipur, Mizoram, Nagaland,TripuraRural 22494639 30 749821Urban 2965476 15 197698Rural 5040121 30 168004Urban 1453535 15 969025 Rajasthan Rural 33938877 30 1131296Urban 10067113 15 6711416 Madhya Pradesh Rural 50842333 30 1694744Urban 15338837 15 10225897 Orissa Rural 27424753 30 914158Urban 4234983 15 2823328 Goa, Maharashtra Rural 48395601 30 1613187Urban 30541586 15 20361069 Andhra Pradesh Rural 48620882 30 1620696Urban 17887126 15 119247510 Karnataka Rural 31069413 30 1035647Urban 13907788 15 92718611 Pondicherry, Tamil Nadu Rural 37072154 30 1235738Urban 19594577 15 130630512 Kerala, Lakshadweep Rural 21440817 30 714694Urban 7709408 15 513961* In other states the FHAC program was not conducted during summer 2000Based on the experience of the IndiaCLEN group during the first round of FHAC program andavailable coverage evaluation data from NACO, there were marked difference in the participationMethodology9

y men and women in the program activities. Reasons for participation by men and women in theprogram activities were likely to be different. Keeping this in mind, samples of both sexes weredrawn separately from each cluster. As already explained under ‘study design’, the first level ofstratification for drawing samples was rural and urban.iii. SampleClientsRural samples: With an admissible error of ±10% at 95% confidence level, 289 men and 289 womenwere required in each zone for a design effect of 3. After rounding off, the sample size was decidedas 300 per strata. Therefore for 30 clusters, sample size was 10 men and 10 women per cluster.Urban samples: Urban clusters were considered a more homogenous population and hence takingthe basic assumptions as for rural clusters, with a design effect of 1.5, we required 150 men and 150women from each zone. For operational reasons, the cluster numbers in urban areas were reducedto 15 per zone. Thus number of men and women respondents remained 10 each per cluster. This waslikely to increase the admissible error to around ±15% instead of ±10%. The point estimate wouldhowever remain stable.Thus it was envisaged that a total of 10800 clients (7200 rural and 3600 urban) would beinterviewed. This sample would include an equal number of men and women.ProvidersIn addition, 1080 health workers (2 per cluster) and 540 doctors (one per cluster) were also to beinterviewed for information about program implementation.iv. Selecting Houses and Respondents in Rural and Urban ClustersSelection of houses involved two steps: first, identifying the first house and second selection ofsubsequent houses. Men and women respondents were selected from different houses (Figure 1).STEP 1: < A landmark in the center of the village such as a temple, market place,mosque, church or chaupal (Panchayat Ghar) was located.< If no landmark could be identified, a central place for social activities of thecommunity was ascertained from the people.STEP 2: < A direction to select houses for interviewing male respondents was chosenrandomly by spinning a bottle on the ground. Whichever way the neck of thebottle pointed, the team went in that direction.< Similarly another direction was chosen for selecting houses to interviewwomen.STEP 3: < After deciding on the directions, the team walked towards the peripherycounting the number of houses in that segment of the village / locality.STEP 4: < A random number was selected [last two / three digits on a currency note].That was the number of the first house where the survey commenced. [eg. Ifthe total number of houses was 99 and below, then the last two digits on acurrency note were selected].STEP 5: < Another nine houses which were nearest to the first one were chosen forfurther interviews.Methodology10

An account of all the houses visited was kept by filling the log sheet forhouses surveyed for both women and men respondents separately.Figure 1: Selection of Households for Coverage EvaluationVillage / townSelect the landmarkSelect directionSelect the first houseEnter the cluster village/ locality andlook for-temple, market, mosque, churchor chaupal*Spin a bottle and move along thedirection it points to. Choose twodifferent direction for men/womenrespondents*Get an approximate estimate of thenumber of houses in the direction selectedSelect a currency note and see the last twoto three digits eg. 656505. No. 5 will bethe first house for male interviews. (repeatfor the women)1. For any reason, DO NOT change acluster which has been selected for thestudy2. If there are less than 10 houses inthe direction selected than go to thenext nearest lane and select theremaining houses consecutively till 10respondents are completedSelect the subsequenthouseSelect the house closest to the first houseand continue till 10 respondents havebeen interviewedv. Selection of Male and Female Respondents (Tables 3, 4)After reaching a house, all the eligible men or women (aged between 15-49 years) available at thattime were listed. All the households visited for selecting the respondent were listed and reasons fornot interviewing that household were specified (Annexure IV). If more than one was available in thespecified age group, one was randomly selected (the last digit of a currency note), the serial numberencircled and proceeded with the interview schedule.A total of 16432 households were visited (50.6 % more than the targeted number) by the researchteams. Most of these (4652/10911= 42%) were necessitated by the fact that either the doors werelocked or there was no person of the specified sex in the eligible age group (15-49 years). Only 869(7.3%) of the available / eligible respondents declined to be interviewed because they were eitherbusy, embarrassed or shy. An additional 100 (0.9%) of the interviews were incomplete (noncooperation,no privacy, unwilling after a while, poor quality) and hence rejected by either the teamleaders themselves or the Central Coordinating Office (CCO). Thus, a total of 10811 interviews wereincluded for final analyses. Of these, 7212 were from rural areas (3611 men and 3601 women) whilethe rest (3599) were from urban slums (1798 men and 1801 women).Methodology11

Table 3.Coverage evaluation of Family Health Awareness Campaign Program : Distribution ofhouseholds visited, refusals and clients recruited for the coverage survey by zone and sexZone No. States SexTargetapproachedNonavailabilityRefusals /Replacementsn %Recruited&Interviewed1 Chandigarh, Delhi, Haryana,Himachal Pradesh, PunjabMen 761 280 30 6.2 451Women 635 138 45 9.0 4522 Uttar Pradesh Men 558 92 11 2.3 455Women 511 42 12 2.5 4573 Assam, Arunachal Pradesh,Meghalaya, Sikkim,4 Manipur, Mizoram, Nagaland,TripuraMen 783 298 33 6.8 452Women 609 117 36 7.3 456Men 728 203 70 13.3 455Women 605 129 22 4.6 4545 Rajasthan Men 752 269 29 6.0 454Women 611 131 27 5.6 4536 Madhya Pradesh Men 728 257 16 3.4 455Women 624 163 10 2.2 4517 Orissa Men 559 71 25 5.1 463Women 562 85 23 4.8 4548 Goa, Maharashtra Men 629 140 36 7.3 453Women 647 165 26 5.4 4569 Andhra Pradesh Men 759 250 58 11.4 451Women 643 152 34 6.9 45710 Karnataka Men 911 356 104 18.7 451Women 705 200 53 10.5 45211 Pondicherry, Tamil Nadu Men 933 381 93 16.8 459Women 718 209 50 9.8 45912 Kerala, Lakshadweep Men 829 361 11 2.3 457Women 632 163 15 3.2 454Men 8930 2958 516 8.6 5456Total for 12 zonesWomen 7502 1694 353 6.0 5455Total 16432 4652 869 7.3 10911Methodology12

Table 4.ZoneNo.StratumCoverage evaluation of Family Health Awareness Campaign Program : Characteristics ofinterviews rejected and analyzed by zone and place of residenceInterviews RejectedMen Women HealthworkersInterviews AnalyzedDoctors Men Women HealthworkersDoctors1 Rural 0 2 1 1 301 300 58 29Urban 0 0 0 0 150 150 30 152 Rural 4 6 3 0 300 300 59 30Urban 1 1 0 0 150 150 30 153 Rural 0 3 0 0 301 301 60 31Urban 1 2 1 0 150 150 30 154 Rural 3 4 0 1 300 300 62 28Urban 2 0 0 0 150 150 30 155 Rural 4 4 1 0 300 299 60 30Urban 0 0 0 0 150 150 30 156 Rural 2 2 0 0 300 299 60 30Urban 2 0 0 0 151 150 29 157 Rural 4 2 0 0 306 300 60 30Urban 2 2 0 0 151 150 30 158 Rural 2 3 0 0 301 301 58 30Urban 4 2 1 0 146 150 29 159 Rural 1 4 2 0 300 301 58 30Urban 0 2 0 0 150 150 30 1510 Rural 1 0 0 0 300 300 60 30Urban 0 2 0 0 150 150 30 1511 Rural 6 7 2 2 302 300 59 30Urban 1 2 1 0 150 150 30 1512 Rural 4 3 0 1 300 300 60 30Urban 3 0 0 0 150 151 30 15AllIndiaRural 31 40 9 5 3611 3601 714 358Urban 16 13 3 0 1798 1801 358 180Total 47 53 12 5 5409 5402 1072 538Methodology13

Characteristics of Clients: Marital Status, Age and Education of the ClientsNinety percent of interviewed women, (4852/5402) in both rural and urban areas were married while27.3% men in both rural and urban settings were unmarried . Maximum proportion of clientsinterviewed were in the age group of 20-35 yrs (men: 3130/5409; 58%, women; 3694/5402; 68%).But in the age group of 35-49 years there were 10% more men [1739/5409; 32%], than women[1247/5402; 22%].A large proportion of interviewed women were illiterate in both rural [1566/3600; 43.5%], andurban slums [561/1801; 31.2%]. As regards men, 66.9% (3586/5359) were educated up to highschool and only 17% (913/5359) of men were illiterate.vi. Selection of Health WorkersTwo health workers were selected from the PHC / Sub center / Health post to which the selectedcluster village / locality belonged.vii. Selection of DoctorsThe medical officer of the PHC / Health post to which the selected cluster village / locality belongedwas interviewed where feasible. If unavailable, any doctor who was a private practitioner(Allopathy, RMP, LMP, Ayurveda, Unani) was chosen.A total of 1084 health workers and 541 doctors were interviewed at the rate of two health workersand one doctor per cluster. Due to incomplete and or poor quality transcripts, 12 interviews of healthworkers (1.1%) and 3 of doctors (0.9%) were rejected. Hence, data from 1072 health workers (714 -rural and 358 - urban) and 538 doctors were analyzed (Table 4).Network Structure and Dynamicsi. Investigatorsa. Zonal Coordinators: The study was conducted in 12 zones. A coordinator was nominated for eachzone. The zonal coordinators and investigators from the zone carried out the survey along withassistance and guidance from the CCT members (Table 5).b. Partner Medical Colleges (PMC) / NGOs: There were three partner institutions in each zone. Eachpartner contributed three survey teams.c. Survey Teams: Every survey team comprised of one senior investigator (leader), one male andone female research associate (medical students/ interns/anthropology or social science graduates).Each team surveyed five clusters, thereby nine teams covered forty five clusters (30 rural and 15urban) in the zone (Figure 2). It was estimated that each team would be able to cover one cluster perday and all five clusters in eight to twelve days time.Methodology14

Table 5.List of zones, partner medical colleges/NGOs, zonal coordinators and CCTmembers for coverage evaluationZone Medical Colleges /NGOsZonal CoordinatorCCT Member1 Chandigarh, Delhi,Haryana, HimachalPradesh, PunjabBallabhgarh, Kangra,RohtakDr. S.K Kapoor,BallabhgarhDr. S.L.Chaddha2 Uttar Pradesh Agra, Kanpur, Lucknow Dr. R.C.Ahuja,LucknowDr. K.C Malhotra &Ms. Leena Sinha3 Arunachal Pradesh,Assam, Meghalaya,Sikkim,Dibrugarh, GuwahatiDr. F.U Ahmed,DibrugarhDr. T. Mathews4 Manipur, Mizoram,Nagaland, TripuraAgartala, Aizwal,Imphal, KohimaDr. E. Yaima Singh,ImphalDr. Naveet Wig &Dr. Sandip Ray5 Rajasthan Jaipur, Jodhpur, Kota Dr. S.L.Solanki,JodhpurDr. S. Shanbhag6 Madhya Pradesh Bhopal, Bilaspur,Gwalior7 Orissa Berhampur, Cuttack,SambhalpurDr. S.S Bhambal,BhopalDr. B.C. Das,BerhampurDr. K. GoswamiDr. H. K. Kumbnani8 Goa, Maharashtra Nagpur, Mumbai Dr. A.K. Niswade,NagpurDr. N. Chaudhuri &Ms. Leena Sinha9 Andhra Pradesh Hyderabad, Tirupati,VijayawadaDr. S. NarasimhaReddy, VijayawadaMs. Sneh Rewal10 Karnataka Bangalore (2), Gulbarga Dr. B.Mallikarjun,GulbargaMs. Rema Devi11 Pondicherry, Tamil Nadu Chennai, Madurai,Vellore12 Kerala, Lakshadweep Calicut, Kannur,ThiruvananthapuramDr. R. Sathianathan,ChennaiDr. M. Narendranathan,ThiruvananthapuramDr. K. AnandDr. K. K Gangulyd. Central Coordinating Office (CCO): The project was coordinated by the AIIMS-CEU (hence forthcalled Central Coordinating Office), New Delhi. Besides the Principal Investigator cum ProjectCoordinator, there were eight Principal Co-investigators from AIIMS CEU and other institutions inDelhi forming the central coordinating team (CCT). In addition ten investigators were coopted asextended central coordinating team members to support quality assurance measures.Methodology15

Figure 2: Network StructureCCO-AIIMS Zone (1 to 12) PMC/NGOs(3 per zone)CCO- Central Coordinating OfficePMC- Partner Medical CollegeT- TeamZONE9 Teams per zone45 Cluster per zoneRural(30 Clusters)Urban(15 Cluster)PMC 1 PMC 2 PMC 3T1 T2 T3 T1 T2 T3 T1 T2 T3Each Team Surveyed Five Clustersii. Network Monitoringa. Zonal Control Room and Data CollectionZonal coordinator in association with a CCT member set up a control room in every zone. The tasksof this duo were to:C Chart out route maps for every team to cover five clusters per teamC Hold a two day orientation to conduct the interviews to give hands on experience toall team members in the two clusters nearbyC Coordinate movements of all teams, solve problems and facilitate local arrangementsC Identify situations that trigger off problems and take pre-emptive actionsCCDisburse funds for field travelMonitor movements of teams in the field and facilitate quality assurance visits byCCT membersC Facilitate smooth data transmission (Refer figure 3)b. Monitoring Tasks of Investigators1. Senior investigator in each field team contacted their zonal coordinator to appraise them aboutC The number of interviews completed on that dayC Plan for the next day and problems faced, if any (Annexure V)2. Zonal coordinators were in constant touch with the CCO, Delhi. They contacted the CCOeveryday to give an update of the activities in the zone. They also faxed the details on everyMonday, Wednesday and Friday while the field operations lasted and the entire network wasmonitored by the CCO (Annexure VI).The information communicated to CCO included:C Number of clusters coveredC Number of interviews completedC Present location of the teamsMethodology16

C Problems faced, if anyC Proposed plans of the teams for the next day3. CCT members who were out in the field to ensure quality of data being collected contacted theCCO, Delhi every evening and reported the following (Annexure VII):C Details of clusters visitedC Problems in methodology, if anyC Corrective measures takenC Plans for the next dayiii. Quality Assurance MechanismThis was done at six stages :Level 1: Zonal coordinators and senior investigators assembled in Delhi during 27-29 August 2000to finalize the study protocol, methodology of data collection and interview schedules.Figure 3: Network MonitoringPhone daily: Progressof interviews, any problemsCCO-AIIMSFeed backabout zoneCCT MemberZonal workshop& quality checkZonal CoordinatorFax every Mon, Wed, Fri:No. of interviews completed;no. of schedules dispatchedPhone daily: Progress ofinterviews, schedules dispatched,travel plans, any problemsResearchAssistant(Male)Senior InvestigatorZonal workshop/route mapsdata transfer /funds/coordinationResearchAssistant(Female)Once a cluster is completed,Photocopy the filled schedules.Post the originals to CCO the nextday. The copies to be retained andsubmitted to zonal coordinator oncompleting all five clustersLevel 2: Two day orientation workshops were organized by zonal coordinators along with CCTmembers at zonal control rooms for all the survey team members from their respective zones. Theplan of interviews was finalized and a copy forwarded to CCO after the zonal workshop. Allparticipants had hands-on experience in conducting interviews under the close supervision of zonalcoordinators and the CCT member.Level 3: CCT members made at least four spot visits to clusters in every zone to assess twoparameters:(i) Authenticity of data that had actually been collected till then, and(ii) Quality of interviews being conducted by the researchers through direct observation.The schedule of quality assurance visits was not made known either to the zonal coordinators or thesurvey teams. Place and time of visits were synchronized with the route maps prepared inconsultation with the zonal coordinators.Methodology17

Level 4: After completing a cluster, the investigators along with their research associates scrutinizedthe schedules to check whether they were complete and appropriately marked. If satisfied, theinvestigator counter signed the schedules otherwise the research assistant was asked to do extrainterviews as replacement.Level 5: Interview schedules were designed to include verbatim responses (as open ended answers)and thereafter coded according to pre-determined close ended answers. All questionnaires receivedfrom the field were screened for the appropriateness of the codes put against the verbatim responses.Help of translators for various languages was taken for this purpose.Level 6: Double entry of data was taken up at CCO Delhi followed by range checks for plausible andnon-plausible values.Development of Interview SchedulesThe interview schedules were developed keeping in mind the objectives of the coverage evaluation.They included a mixture of structured close-ended and semi-structured open-ended questions. Listof responses for the former were printed below the respective questions to facilitate on the spotmarking by the research associates. For the open-ended questions, empty boxes were provided towrite down the respondent replies ‘verbatim’. These were later coded by the research associates inconsultation with their senior investigators (Team leaders). Domains identified for the correspondingquestions during the first cycle of process evaluation of FHAC program were utilized for thispurpose. Open ended questions obviously gave room to the respondents for multiple responses andhence the totals often exceeded 100 percent.The draft instruments developed by the CCT in close partnership with the program managersunderwent several revisions before they were pilot-tested at four study sites. These were finalizedduring the National Orientation Workshop at Delhi in the month of August, 2000.Unique Serial NumberEvery interview schedule was given a six digit unique serial number. The first two digits indicatedthe zone number (1-12), the next two digits the cluster number (1-30 for rural and 31-45 for urban)and the last two digits were serial numbers that indicated the category to which the respondentsbelonged (i.e 1-12 for men, 13-24 for women, 25-27 for health workers, 28, 29 for doctors). Thus,from the unique number, it was possible to identify the category to which a respondent belonged.Transmission of DataWithin 72 hours of data collection; the team made a photocopy of the completed instruments. Whilethe original set was despatched to the CCO, the other was retained by the survey team and submittedto the zonal coordinator at the end of the survey after completing all five clusters allocated to them.This was done to safeguard against accidental data loss during transmission to CCO, New Delhi.Data ManagementOne of the CCT members was a trained bio-statistician (Dr. R.M. Pandey) who supervised datacleaning process. In addition, two more CCT members (Dr. N.K. Arora, Dr. M. Lakshman) hadundergone formal training in bio-statistics. Data scrutiny and entry commenced immediately onarrival of completed schedules at CCO (Annexure VIII and IX).Methodology18

Data AnalysesProgram coverage of target population in rural and urban areas of the individual zones werecalculated. Program coverage / utilization was estimated separately for men and women as well byusing the statistical software package ‘STATA’. The ‘SURVEY ESTIMATES’ were computed usingthe population of the area as ‘pweight’, rural / urban locality as ‘strata’ and cluster number as the‘primary sampling unit (psu)’. These include : proportion estimate with standard error, 95%confidence limits of the estimate (Estimate % ± 2 SE) and design effect (deff). Where necessary,mean difference between two groups, standard error of the difference, 95% CI of the mean differencewere also worked out. The significance of the mean difference between the groups was tested bycalculating t-statistics and probability levels (p).Limitations and Potential BiasesSample size for every zone was estimated assuming the program reach as 50% with an admissibleerror of ± 10%. The design effect of 3 was considered appropriate. Both these parameters variedsignificantly between zones depending upon the program performance. The estimates wereparticularly unstable with a wide 95% CI if the program performance was at extremes i.e. < 10%or > 90%. Similarly, design effect also varied for different parameters.As we were dealing with sensitive and personal issues related to sexual practices and RTI/STDs,information obtained may have had validity and reliability problems. Attempts were made tominimize these through rigorous training of the qualified research teams. The instruments wereadministered in the local language with due attention paid to the cultural sensitivities and the mannerin which questions were asked.Time-line1. Preparatory phase June 15 - July 31, 20002. Interview schedule preparation and pilot testing August 1 - August 31, 20003. National protocol finalization workshop August 27 - August 29, 20004. Zonal orientation workshops September 1 - September 7, 20005. Data collection September 9 - October 5, 20006. Data processing, computer entry and analysis September 12 - December 31, 20007. Report writing January 1 - March 25, 20018. Submission of Report March 26, 2001Methodology19

IV. OBSERVATIONS1. Background InformationFamily Health Awareness Campaign - 2000 was evaluated across the country excepting the statesof Gujarat, Jammu & Kashmir, Bihar and West Bengal where the program was not conducted. Thecountry was divided into 12 zones which were later grouped according to reported HIV prevalence(Table 1).Totally 10811 clients (5409 men and 5402 women), 1072 health workers and 538 doctors from 540clusters were interviewed for the study using the probability proportionate to size (PPS) - 30 clustersurvey methodology.A strategy different from that in rural areas was adapted for implementation of FHAC program anda smaller design effect was considered for calculating sample size owing to the greater homogeneityof urban slum populations. Hence, the results were presented for rural and urban areas separately.Quality Assurance MeasuresThe magnitude and span of field operations, and involvement of 324 researchers (108 teams eachwith 2 research associates and one senior faculty member) from 36 medical colleges / nongovernmentalorganizations necessitated the need to adhere to quality assurance measures strictlyfrom the start of the evaluation program.As envisaged, after the national protocol finalization and orientation workshop in August 2000, 12zonal workshops were conducted for the field teams. All these workshops were conducted by zonalcoordinators along with a member of CCT. All the senior investigators and research associatesattended these workshops to develop an understanding of the objectives, study instruments and fieldoperations. At the zonal level, the zonal coordinators monitored the field operations very closely ona daily basis.The team leaders ensured that the team reached the selected cluster, followed the protocol inselecting the households and individuals for interviews, and research associates adhered to theguidelines while interviewing the respondents. After completing the specified number of interviewsin each cluster, they also scrutinized all the questionnaires, rejected the incomplete / defective onesand organized extra interviews to replace the rejected ones.Members of the Central Coordinating Team made surprise quality assurance visits to a total of 45(out of 540 clusters; 8.3%) clusters spread over 12 zones. During their visit to cluster areas, data wascross checked with 2.4% (259 / 10811) clients in their houses and 1.9% (209/10811) interviews wereobserved in the field.Observations19

On arrival at Central Coordinating Office, AIIMS, New Delhi, the data were screened for appropriatecoding of responses. Thereafter the data were entered twice into computer and matched. Rangechecks and logical runs were incorporated in the data management software to minimize errors.2. Results and Conclusions2.1 Reach of the ProgramDefinitions of Program ReachFHAC program had two main activities: home visits and organization of FHAC camps. Keepingthese in mind, for the purpose of current program evaluation, program reach was defined as:Population contacted or covered: Those clients (aged 15-49 years) who were either visited in theirhomes or those who attended the FHAC camps or were exposed to both these activities.Population not contacted or covered: These were clients (aged 15-49 years) who were either notaware of the FHAC program; or were aware about it through publicity campaign but were notexposed to two main components of the program services, namely home visits or the attendance atcamps.Characteristics of Clients According to Reach of the Program (Tables 6, 7 )RuralAge Groups: The proportion of adolescents (15 to 20 years old) was significantly less among thepopulation who were covered (6%) under the program services as compared to those who were notcovered (10%) (p

Program Reach (Tables 8-10)During the summer 2000 cycle of FHAC , 19.3% ( 95% CI; 16.8 - 21.9) of the target population inrural areas and 13.4% (95% CI; 10.9 - 15.9) of the individuals between 15-49 years of age residingin the urban slums and high risk areas came in contact with the program services. Over 17% clientsin villages and 12% in urban slums were visited at their houses mostly by health workers. The FHACcamps/meetings were attended by only 9% of target men and women in rural areas and 4%living inurban slums. Overall, 7% clients in villages and 3% in urban slums were exposed to both theprogram activities i.e. house visits and attendance at camps.Across the country, in both urban and rural areas, women consistently utilized the program servicesmore than men. But only the difference in urban slums (7.5%) was statistically significant (t=5.1p

existence of FHAC program. In villages, lack of awareness about the program varied between 91%in Uttar Pradesh to 66% in north east states of Manipur, Mizoram, Tripura and Nagaland. Similarly,in urban slums of Karnataka and Rajasthan over 90% clients were unaware about the program. Highprevalence of lack of awareness about the program, particularly in urban areas, probably reflectedpoor social mobilization efforts on part of program implementers.Both health workers and doctors believed embarrassment to be the reason in over 30% of the clientsfor their non participation in program activities. However, this was not cited as an important causeby either rural or urban clients. Among those who were aware of the program but did not attend thecamps, only 4% of rural and 2% of urban subjects gave embarrassment as the reason for their nonattendance at the camps.Issues of client inconveniences (viz; inconvenient timings, loss of wages, unacceptable camp sites,not present at home/village) were the other major factors for non-participation in the program andwere mentioned by 50% of the clients (who were aware about FHAC) in villages as well as urbanslums. This perception was also shared by health care providers.Place of Camp and Attendance (Table 13)The significance of client convenience in the program performance was further indicated by thehigher proportion of men or women attending the FHAC camp if these were conducted in and aroundthe village (40.3%; 95% CI 36.2-44.3) versus when the camps were held at the health facility likesub-center/PHC/dispensary (23.1%; 95% CI 17.9-28.2) [p

clients. Women in both rural areas and urban slums were in general, less knowledgeable than menabout these diseases (Table 15).The clients were stratified according to their contact status with the FHAC program implementedone to three months prior to survey. The correct knowledge about RTI/STD/HIV-AIDS wassignificantly higher among the target population from villages as well as urban slums who came incontact with the program services as compared to those who were not contacted (p0.05).Safe SexOne of the major objectives of FHAC program was to emphasize the fact that RTI/STDs/HIV canbe treated and prevented if people adopt safe sexual practices. One step in this direction wasadvocacy on the benefits of using condoms. It was hoped to lead to a behavioral change of higherusage of condoms in the long run.Observations23

Perceptions about Benefits of Condom Usage (Tables 23, 24)More than half of all clients in the community were aware about the benefits of using condomsduring sexual intercourse. It was irrespective of their place of residence and sex. Benefits of condomusage included prevention of pregnancy and RTI/STD/HIV-AIDS. Over 70% of the target men andwomen in villages and more than 80% clients in urban slums who were contacted during FHACprogram correctly enumerated the benefits of using condoms during sexual intercourse. This was 10-15% more than the clients of either sex who were not covered under the program in villages as wellas cities (p0.05). The prevalence of condom use among rural clients who were covered under theFHAC program was almost 5% higher than that among the non-contacted population of FHACprogram (p=0.001). Among urban clients, no significant differences were observed between twocategories.The observed differences between the rural clients who were covered and not covered under theprogram could also be due to the effect of their age, marital and educational status, and presence ofRTI/STD symptoms. On stratified analysis for educational status, condom usage in rural as well asurban clients were not significantly different (p>0.05) between clients contacted and non contactedthrough the program.Interpretation of Differences in the Knowledge and Behavior Related to RTI/STD/HIV-AIDS -Issues Between Various Client Categories (Tables 26-29)Overall it appeared that the correct knowledge about RTI/STD/HIV-AIDS was higher among menand women from rural as well as urban areas who came in contact with program services (either athomes or attended the camps) as compared to the rest of the community who could not be coveredfor these services. These differences persisted even after controlling for confounding factors likemarital status, education and age separately (Tables 26, 27). RTI/STD symptoms were about 5 timeshigher among the participants of FHAC program (10%) as compared to those who were not covered(2%). The data was stratified for presence and absence of RTI/STD symptoms and re-analyzed forObservations24

differences in their knowledge according to program contact status (Tables 28, 29). Correctknowledge about RTI/STD/HIV-AIDS among asymptomatic clients who came in contact with theprogram (34-91%) was significantly higher as compared to those asymptomatic clients who did notcome in contact with the program services (24-84%) in both villages and urban slums. Theknowledge level of clients with RTI/STD was similar in two categories essentially due to smallnumbers of subjects.Condom usage during last sexual intercourse was similar in various client categories in both ruraland urban areas when the data was adjusted for potential confounders like educational status andpresence of RTI/STD symptoms during FHAC program separately.The observed differences in the knowledge and behavior about RTI/STD/HIV-AIDS related issuesbetween clients who had and had not come in contact with the program services will have to beinterpreted with caution. The current study was a cross-sectional survey and hence differencesbetween various client categories in the knowledge parameters were likely to be due to severalprogram and non program related inputs.Therefore the observations made during the survey should be considered as hypothesis generatingrather than causal in nature.2.3 Program ImplementationAs part of the program implementation strategy, following three important activities wereundertaken:1. Training of government and private doctors in the district in syndromic management ofRTI/STD/ HIV-AIDS and about FHAC program implementation strategy. All health workerswere also imparted a similar training but with lesser emphasis on the treatment componentof RTI/STDs;2. Creating awareness about the program and RTI/STD/HIV-AIDS in the community throughhouse visits and organization of camps; and3. Referral of patients who were identified/suspected to have RTI/STD during the awarenesscampaign to PHC for treatmentAlthough the current study was not envisaged to be a process evaluation, a large number of healthproviders were interviewed [1072 health workers (2 per cluster) and 538 doctors (one per cluster)].This provided sufficient power to assess some of the program activities at an all India level ratherthan at the zonal level.The data interpretation and conclusions are to be drawn in this background.Observations25

Training of Health Providers (Table 30)Training of health providers was a major exercise of the program implementation strategy. It wasintended to serve dual purposes: immediately create an awareness in the community and mobilizepeople to seek treatment for their RTI/STD related problems as part of the FHAC; and the trainingwas also intended to serve as a capacity building exercise for the doctors in PHC.Among 538 doctors interviewed during the study 390 (72.5%) were with the state government and148 (27.5%) were in the private sector. Out of 148 private practitioners, 62.2% were practicingHomeopathy or Ayurveda, or were registered medical practitioners without any recognized medicaldegrees.A majority of doctors working at government health facilities like PHCs/health posts/dispensaries(72%; 95% CI 68-77) had attended the training sessions conducted at district level before the launchof the FHAC program. In contrast, only 9% (95% CI 4-13) doctors working in private sector couldbe sensitized in the syndromic management of RTI/STDs.Over 3/4 th of the health workers (76%; 95% CI 72-79) underwent training for the FHAC programeither at district or at the PHCs. A small proportion of health workers (3.4%) indicated that notraining was conducted in their area.Thus it appeared that most of the government health providers who were directly involved with theprogram implementation were trained as part of FHAC.Doctors as well as health workers believed that 60-88% of the community members sought care fromprivate practitioners or other non-conventional health facilities for RTI/STD. Yet private health careproviders who were recognized as important partners in the management of RTI/STD were largelyleft out of this program both in training and participation in program implementation.Training Sessions (Table 31)Most of the doctors (96%) and health workers (93%) who attended the training program mentionedthat training sessions for FHAC program lasted for one full day or more. Mostly doctors from districthead quarters (85%) served as trainers for the physicians, while PHC/dispensary doctors conductedthe training for the health workers in majority (68%) of the cases. In a few instances, experts fromoutside and medical colleges were drafted to train doctors as well as health workers.In the first cycle of FHAC program i.e. April 1999, training of the health workers was oftenconducted in English. This anomaly had been taken care of in the latest FHAC and almost all (99%)health workers received training in the local language.Organizers mostly used posters/flip charts/photographs (70%) and adopted the usual class roomapproach of lecturing with an occasional use of other audiovisual aids like overhead projectors (33%)Observations26

and film shows/video tapes (8.8%) for the training of health workers.Content of training (Table 32)The major emphasis in FHAC for both doctors and health workers was on the subject content ofRTI/STD (doctors- 52%; health workers-60%) and HIV-AIDS (doctors- 37%; health workers-49%).Issues like implementation of FHAC program, use of referral slips and availability of treatment atPHC were discussed less often (doctors-18%; health workers-27%).On the whole, 78% of the doctors were satisfied with the content and reported a change in theirpractice behavior after attending the training programs.Quality of trainingThe quality of training determines the overall program performance. The manner in which programis implemented, awareness created among clients and the impact on the community reflects to acertain extent the quality of training imparted to the program implementers. Quality of content of thetraining program was assessed by determining the knowledge of the doctors and health workersabout their understanding of FHAC program objectives as well as strategies and various aspects ofRTI/STD/HIV-AIDS.Perception of providers about FHAC program objectives (Table 33): The primary objective ofFHAC was to create an awareness in the community about RTI/STD/HIV-AIDS, their preventionand treatment. However, only 16% of the health workers and doctors remembered all the programobjectives; the others either mentioned the objectives partially (75%-76%) or perceived FHAC tobe a general health awareness campaign. An incomplete understanding of the objectives andimplementation strategies by health providers probably reflected on program performance.Knowledge of Doctors (Table 34): The awareness about symptoms, causes, ill effects and preventionof RTI/STD and HIV-AIDS was very high (90-99%) among the doctors irrespective of their trainingstatus. This was expected as all of them were in active practice. The doctors who had undergonetraining had better perceptions about various aspects of the disease than those who were not trained.Treatment practices for genital ulcers, urethral and vaginal discharge (Tables 35-38): Traineddoctors emphasized the role of antibiotics significantly more often in the treatment of these disordersas compared to their counterparts who had not received FHAC training (p

It was apparent that a large proportion of health workers in trained (24%) and untrained (42%)categories were not clear about the ill effects of HIV-AIDS on the body and hence gave incorrectanswers. This was also reflected in the knowledge of the clients, who despite their contact with theprogram services had low awareness about the ill effects of HIV-AIDS. Almost 23% of untrainedhealth workers were either ignorant about availability of treatment for RTI/STD or believed that thedisease does not require any treatment. The proportion of such health workers was 10% in the trainedgroup (p=0.003).Social MobilizationSpreading awareness about FHAC program, camps and availability of treatment facilities at PHCwas the key for success of this program. As already mentioned in section 2.1“Reach of the program”most of the community members (rural-73% and urban slums-82%) were unaware about theexistence of FHAC program in their area.Sources of information (Table 40)The program strategy was primarily dependent on interpersonal communication to create anawareness and demand for program services. Health workers were to visit every household in theirarea before the FHAC camp for this purpose. As envisaged in the program strategy, health workersused interpersonal communication as the major channel (75%) to create awareness about FHAC.According to health workers, volunteers, influencers and village elders were also involved for thispurpose. However other communication channels like posters, banners, printed handbills, wallwritings and occasionally radio and television were also used (69%) in the campaign.Among those who were aware about FHAC, over 50% in both rural and urban areas came to knowabout the program and its services mostly through the local health worker but volunteers, influencersand elderly family members also helped in disseminating the information (27-29 %). Other publicitychannels as a source of information about FHAC were mentioned only by 13% rural and 19% urbanclients. This clearly indicates the inadequacy as well as ineffectiveness of the publicity campaignorganized for the program.Target population (Table 41)It was clearly stated in the project operational manual and emphasized during the training programthat everybody in the age group of 15-49 years should be targeted for the program services.The health workers emphasized that adult men and women were the key target clients (91%) but only65% of them considered adolescents (

women in both villages and urban slums believed that the program was for adolescents as well.There were a few clients who expressed that the program was meant for those who frequentedprostitutes or for poor and marginalized sections of the community.It was important to note that about 7% health workers expressed ignorance about the intended targetgroup for the program. This was reflected in client perception as well; 15% of both rural and urbanclients who had come in contact with the program services did not know for whom the program wasmeant.Field Operations: Home Visits (Table 42)As already mentioned under Program Reach, 17% clients in villages and 12% in urban slums werevisited in their homes; 83% of these home visits were made by health workers alone.Over half (50%-59%) of the men and women in both rural and urban areas who were aware aboutthe FHAC program said that the health workers visited their homes during FHAC program andacquainted them about RTI/STD/HIV-AIDS and / or FHAC camps in their area. Although thepersonnel from other non-health departments, NGOs and local leadership were to be involved forvarious program activities only about 10% clients remembered any one from these categories whovisited them in connection with FHAC. The proportion of various personnel making house visits didnot differ markedly between rural and urban areas. Among those who were aware about the FHACprogram, 20-30% were not visited by any program functionary. They came to know about it throughtheir friends and elderly family members or the publicity campaign.Across the states, the pattern of house visits was similar; predominantly dependent on health workersand with little participation by non-health personnel or the NGOs.Field operations: CampsAs part of the program, the target population was to be mobilized to the awareness camps organizedin the villages or at health facilities (subcentre / PHC). In these camps and meetings, messages aboutRTI/STD/HIV-AIDS were to be reinforced through various communication channels.Location of the camps (Tables 43, 44)All states adopted a combined approach of conducting FHAC camps either as village based or healthfacility based. According to health workers, in 10% (95% CI: 7-13) rural areas and 19% (95% CI:12-25) urban slums, camps were not organized. In the remaining areas, village/slum based and healthfacility based camps were organized in almost equal proportions.Consistent with these observations, clients also mentioned that in rural areas 35% camps were heldat PHC or the sub-center and similarly in 27% urban locations, health facility based approach wasadopted. In the remaining areas, village or slum based camps were organized that were mostlyObservations29

located at the residential areas.Village / slum based camp organization was a predominate feature (>65%) in states like Nagaland,Tripura, Mizoram, Manipur, Madhya Pradesh, Orissa, Andhra Pradesh and Tamil Nadu. As alreadyreported, camp attendance was 74% more in village / slum based camps as compared to when thesewere organized at health facilities.Personnel manning the camp (Table 45)As was the case with house visits, health workers were the key personnel manning the FHAC camps(90-92%). Although, the health workers mentioned the participation of volunteers, local leaders andpersonnel from non-health departments (mostly teachers) in 74% of the camps, the clients couldremember their presence only in 5-9% of the camps. This inconsistency between the perceptions ofthe providers and the clients indicated the need for more tangible contributions from the non-healthpartners in the field operations.IEC material used in the camps (Table 46)Health workers largely (66.5%) used printed material for e.g. flip charts, posters and hand bills forhealth education. In 28% camps, interpersonal communication methods like narratives anddiscussions were also adopted. Audio-visual aids and traditional folk songs / plays were usedinfrequently.Issues discussed at the camps (Table 46)The objective of organizing the FHAC camps was to provide counseling and reinforce the messagesregarding RTI/STD/HIV-AIDS given during house visits. The health workers were also expectedto facilitate persons suspected to have RTI/STD to seek care at PHCs by giving them referral slips.As part of the program, no treatment facilities were to be provided at these camps. However, in someplaces, doctors were also present.Health workers mostly discussed the various aspects of RTI/STD/HIV-AIDS in the camps. This wasconfirmed by clients attending the camps. However, 13% health workers utilized the camps forscreening patients of RTI/STDs and hence no discussions and health counseling took place in theseareas.Availability of referral slips and treatment for RTI/STD patients at PHCs were discussed in only 11%of the camps.Treatment Services for RTI/STDs and their UtilizationThe summer 2000 cycle of FHAC program was evaluated almost 2 to 3 months after the camps wereheld. Hence the responses regarding the presence of RTI/STD symptoms during the program and thetype of care sought may have been affected by recall bias.Observations30

Prevalence of RTI/STD symptoms during the FHAC program and their coverage during thecampaign (Table 47)During the campaign period 10.2% (95% CI 8.3-12.2) of the clients covered under the program and2.1% (95% CI 1.6-2.6) of the clients not covered recalled having symptoms of RTI/STDs. Womenin rural and urban slums reported presence of RTI/STD symptoms during FHAC more often thanmen in both client categories. The prevalence of RTI/STD symptoms was similar among the clients,who were unaware about the program; those who were aware about the program through thepublicity but did not utilize any of the program services; and those who were visited at their housesbut did not attend the camp (p>0.05). This was true in both urban and rural areas. Prevalence ofsymptoms among clients those who directly attended the camps without house visits was 14% inrural and 13% in urban slums. This was even higher (19% in villages and 30% in cities) among thosemen and women who had been visited at their houses and subsequently mobilized to the camps aswell.Notwithstanding the recall bias and differences in knowledge among different categories of clientsabout RTI/STD/HIV-AIDS, data did indicate that either due to program strategy or because of selfselection or both, those with RTI/STD symptoms were 5 (rural) to 12 (urban slums) times morelikely to attend the camps. One of the program strategies was to mobilize / encourage RTI/STDpatients to seek treatment. However if the community perceived the program, particularly the camps,to be meant for RTI/STD patients, then this strategy of selective mobilization may have adverseconsequences on the long term sustainability and acceptability of program by the people.According to 13% (95% CI; 10-15%) health workers, program was meant for screening RTI/STDpatients. This attitude among the health workers vindicated the above mentioned apprehensions.Referral slips and use of primary health center for management of RTI/STD (Table 48)Establishing a referral system from the field to PHC was an important component of the FHACprogram. Almost 10% of the clients who were contacted had symptoms of RTI/STD as comparedto 2% in the non-contacted clients. Among the contacted clients with symptoms, 77% were awareof the availability of referral slips with health workers and 69% actually took these. Almost 95% ofthe patients who obtained referral slips went to PHC. Overall, 56% of the symptomatic patients whowere covered under the program services received the drugs from PHC. In contrast, among thosewho were not covered under the program services, only 27% went to PHCs and 17% received thedrugs (ref : Figure E in Executive Summary).Private doctors and non-conventional health facilities were approached by 28% clients who weresymptomatic but not covered by the FHAC program. This was in sharp contrast to contactedRTI/STD patients (10%) (p

(32%) (p=0.002).The data evidently indicated to the existence of functioning referral system. This also underscoresthe potential future challenge of increased demand for RTI/STD services in the public sector as theprogram performance improves.2.4 Provider’s Perspectives about Program Performance and Client BehaviorThe provider’s perspectives about the key components of a public health program can provideinsights into its performance, potential challenges that need to be overcome and the need forrevisions in the of implementation strategy in future. For this purpose the perspectives of healthworkers and doctors were obtained and compared with client responses wherever possible.Perceptions about Program Reach (Tables 49, 50)House to house visits by health workers and attendance by the clients in FHA camps were two keyparameters of program performance. According to 73% of the health workers (95% CI; 69-77%),50% or more of the households were covered during the program. Only 21% health workers wererealistic in their perceptions that household visits covered less than 25% clients.For attendance at camps also, 43% health workers and 28% doctors were of the opinion that 50%or more clients attended the camps. According to 66% health workers, women attended the campsmore than men.Men and women suspected to have RTI/STD were identified during field operations and givenreferral slips for treatment at PHC / health post. Over 25% health workers were unaware about thefate of such patients while 18% of them thought that less than 25% of the referred patients utilizedthe PHC services.Overall, it appeared that health providers at the village and PHC levels grossly over estimated theperformance of the program for almost all its components. Furthermore, there were no in builtmechanisms in the program to follow up those who were suspected, screened and referred formanagement.Perceptions about Client Behavior (Tables 51, 52)Sensitive and personal issues of RTI/STD/HIV-AIDS were being discussed for the first time throughthe public health system in FHAC program. Many among the policy makers and planners hadapprehensions that given the conservative and traditional backgrounds of the people, difficulties maybe faced during field operations. Seemingly, this apprehension was passed on to the programimplementers. Over one fifth (22%) of the health workers believed that clients were embarrassed andfelt shy when various aspects of RTI/STD/HIV-AIDS were discussed with them either at home orin the camps. Consistent with this view, 30% health workers and 33% doctors maintained thatObservations32

embarrassment was the reason for non utilization of program services by the clients. This was insharp contrast to the client appreciations; only 4% of the rural and 2% of urban clients who wereaware of FHAC program but could not participate in its activities, cited embarrassment and shynessas the reason.Perceptions about treatment seeking behavior of clients: According to both health workers (88%)and doctors (60%), majority of RTI/STD patients went to either private practitioners or nonconventionalhealth facilities i.e. quacks/ ojhas. In addition, 25% health workers and 31% doctorssuspected that such patients may not be seeking any kind of medical help.Perceptions about problem of AIDS (Table 53)One of the primary objectives of the FHAC program was to create an awareness about HIV-AIDSand the potential of HIV infection assuming even bigger proportions in the community if measuresto contain it were not taken urgently. Unfortunately, only 28% doctors and 26% health workersacknowledged HIV-AIDS as a problem in their area. Compatible with this view of providers, only13% contacted clients in both urban and rural areas felt that HIV-AIDS was a problem that deservedattention. These perceptions of both providers and clients did undermine the significance that shouldhave been communicated about HIV infection both during the training and actual implementationof the program. There was a possibility that both providers and clients were talking about visiblepatients of HIV-AIDS in response to this question during survey.In conclusion, the perceptions of the health providers were often too different from actual groundrealities and brought in complacency about program performance among health functionaries. Thesefindings highlighted the need to give a regular feed back to the program implementers about actualperformance of programs and ground realities to help them reorient their functioning and approachto clients in the field.2.5 Adolescent ProfileTarget population for the program services was between 15-49 years. This included the critical agegroup of 15-20 years who were labeled as ‘adolescents’ for this study. Sexual activity and behaviorevolve in this age group. The adolescents were not the focus of the study. Nevertheless, sufficientnumber of adolescents were surveyed across different zones to obtain preliminary information abouttheir awareness about various aspects of RTI/STD/HIV-AIDS, prevalence of RTI/STD symptomsand sexual behavior. This chapter deals with these issues among adolescents.Reach of FHAC Program among Adolescents (Table 54)Among the surveyed population, adolescents (#20 years) comprised of 9.3% in rural areas and 8.7%in urban slums. During FHAC, 13% (95%CI: 10.1-16.6) adolescents in villages and 14% (95%CI:9.0-18.5 ) in urban slums were covered under the program services. This was similar to the other ageObservations33

groups covered under the program. Among the adolescents, 12% were contacted at their homes inboth rural areas and urban slums. In villages, 5.5% adolescents and 4.5% in urban slums attendedthe camps.Awareness of Adolescents about RTI/STD/HIV-AIDS (Table 55)Both in villages and urban slums, the adolescents were correctly aware about features of RTI/STD/HIV-AIDS in varying proportions. Background knowledge of adolescents about symptoms (rural-28%; urban-29%) and causes (rural-35%; urban-46%) of RTI/STD, and ill effects (rural-25%;urban-30%) of HIV-AIDS on body were less as compared to those pertaining to other aspects ofthese diseases. The degree of appropriate knowledge of these disorders was higher among thoseadolescents who had come in contact of the program services as compared to those who did not.Prevalence of RTI/STD/HIV-AIDS symptoms during two weeks prior to Survey & Informationrelated to Safe Sex (Table 56)Prevalence of urethral discharge/painful micturition was 3% among adolescents in urban slums and6% among rural adolescents. Only 0.2% adolescents in urban areas and 0.8% in rural areascomplained of genital ulcers. There were no urban rural differences. Estimations of prevalence inthe two sexes were not done because it was a sub-analysis and such estimates would be unstable withwide 95% CI.The proportion of adolescents who were sexually active could not be ascertained with the surveyinstrument used. However, condoms were used by 3.4% of rural and 6.3% urban slum adolescentsduring their last intercourse. The prevalence of condom usage was less as compared to clients ofolder age groups in both areas.Almost 75% individuals below 20 years residing in urban slums and 64% in villages correctlyenumerated the benefits of condom usage; this included prevention of pregnancy (41-53%) andprevention of RTI/STD/HIV-AIDS (32-41%).2.6 Prevalence of RTI/STD Symptoms and Condom use during last IntercourseClients were enquired about the presence of the symptoms of RTI/STD during the two week periodprior to the day of interview for coverage evaluation. These included presence of urethral dischargeor painful micturition and ulcers on or around genitalia. Period of enquiry was restricted to twoweeks to minimize recall bias. The study subjects were also enquired about the use of condomsduring their last sexual intercourse.Prevalence of RTI/STD symptoms during two weeks period prior to SurveyThe combined prevalence of urethral discharge / painful micturition and genital ulcers in ruralpopulation was 6.9% (95% CI: 5.7-8.0) and 6.3% (95% CI: 4.7-7.8) among urban slum dwellers.Observations34

Among rural men, it was 3.1% (95% CI: 2.3-3.8) and 10.8% (95% CI: 8.1-12.6) among women(p

Age Group: Over 7% individuals above the age of 20 years and 6.0% adolescents in villages hadRTI/STD symptoms at the time of survey (p>0.05). In urban slums, the prevalence of symptoms inthese two age categories was 7% and 3% respectively (p0.001).Educational Status: Probably due to their lack of awareness, RTI/STD symptoms were prevalent inhigher proportions among illiterate people in both villages and urban slums.Other Features: Among those men and women, who had RTI/STD symptoms during FHAC - 2000,52% (95% CI: 42.4-61.6) complained of presence of RTI/STD symptoms during the evaluationsurvey as well. In contrast, the prevalence was 5.1% (95% CI: 4.3-5.9) among those who wereasymptomatic during FHAC - 2000 (p

needs to be interpreted with this limitation in view.Educational Status: In villages as well as urban slums, literacy appeared to be associated withsignificantly higher use of condoms during sexual intercourse (p

V. RECOMMENDATIONSProgram AcceptabilityFHAC program was acceptable to the community in the villages as well as urban slums.It can be continued with its current framework of objectives and implementationstrategies.Program ReachCCThe program coverage will have to be increased substantially to achieve thedesired changes in the knowledge and behavior of the community.As originally envisaged, the program should target all community membersbetween the ages of 15-49 years. The current strategy of preferentially mobilizingthe individuals with suspected RTI/STD may have stigmatized the FHAC campsas RTI/STD camps, thereby reducing attendance. Referral slips can be given bothduring house visits and in the camps.Social MobilizationCCCCMajor inputs are needed to improve social mobilization which appeared to be aweak link in the program. Most of the community has to be made aware of theexistence of the FHAC program. This requires using all channels ofcommunication. The messages about RTI/STD/HIV-AIDS should be simple,consistent and culturally appropriate. Communication experts should be involvedto mount publicity campaigns after pre-testing the messages for suitability andclarity.The community should also be debriefed about the prevalent misconceptionsregarding causes, symptoms, ill effects, treatment of RTI/STD/HIV-AIDS andsafe sexual practices.In view of the sensitive and personal nature of the issues related to variousaspects of RTI/STD/HIV-AIDS, inter-personal communication should continueto be a key strategy in the field. This would mean involving non-health sectors,notably NGOs/CBOs/local leadership and influencers, for home visits as well asorganization of the camps.Private health sector should be invited to participate in the program as animportant partner because large segments of population seek treatment from themRecommendations 38

Program Implementationfor RTI/STD/HIV-AIDS.CCCClient inconvenience: As the program coverage increases, this might emerge asan important reason for non-utilization of the FHAC related services.Conveniences of the local community and partners should be taken into accountbefore the time for the program is fixed. It was not necessary to organize theprogram in the whole country simultaneously. FHAC could be implemented moreeffectively with a wider coverage if it was organized in a staggered manner indifferent states. The house visits and camps should be organized in a manner thatare client friendly. Camps should be organized exclusively within the villages /urban slums to facilitate maximum attendance.Extra efforts continue to be required to reach the male clients and adolescents.A mechanism for follow up of RTI/STD patients identified in the field needs tobe put in place. This is essential for the sustainability of the referral system ofFHAC program.TrainingCCCCCCRemaining health providers need to be trained.Re-orientation of all health providers is necessary on a regular basis; thesesessions may also be utilized to provide feed back to providers regarding programperformance.With most of the health providers having already received training, the focusshould now shift to train the private practitioners, NGOs/CBOs and local leaders.Training should focus equally on the program objectives and strategies as on thesyndromic management of RTI/STD/HIV-AIDS.Training content requires suitable modifications to highlight the seriousness ofthe problem of HIV-AIDS in the community, ill effects of HIV-AIDS, thesymptoms of RTI/STD and educating the community about the prevalentmisconceptions about these diseases.Special emphasis is required for imparting communication skills to deal withsensitive and personal issues like RTI/STD/HIV-AIDS.Future ChallengesThe public health system will have to be strengthened to meet the increasing demands forRTI/STD services as the program coverage is improved. Simultaneously, efforts will beRecommendations 39

necessary to improve the availability and accessibility of condoms to the sexually activesegment of the population.Recommendations 40

Table 6.Characteristics of clients according to reach of the program (Rural Areas)BackgroundvariableEstimate%Contacted - YESContacted - NOMen Women Total Men Women Total95 % CI Estimate%95 % CI Estimate%95 % CI Estimate%95 % CI Estimate%95 % CI Estimate%95 % CIAge group15 - 20 years 7.8 5.1- 10.4 5.0 3.3- 6.6 6.1 4.6- 7.7 10.5 9.0-11.9 10.1 8.6-11.6 10.3 9.3-11.321 - 35 years 56.6 51.8-61.5 71.8 68.7-74.9 65.2 62.2-68.2 59.6 57.4-61.8 68.2 65.9-70.5 63.8 62.2-65.3> 35 years 35.5 30.8-40.2 23.1 19.8-26.3 28.5 25.6-31.4 29.7 27.1-32.4 21.1 19.1-23.2 25.6 23.6-27.5Marital Status:Married 79.5 76.0-83.1 93.2 91.3-95.1 87.2 85.4-89.1 75.0 72.5-77.5 90.8 89.2-92.4 82.7 81.2-84.2Education:Literate 85.9 81.0-90.8 60.3 55.5-65.2 71.5 67.3-75.7 78.5 76.1-80.8 47.2 43.6-50.8 63.3 60.7-66.0RTI/STDduring FHAC:Present 3.2 1.4- 5.0 15.6 12.3-18.8 10.2 8.1-12.3 0.6 0.3-1.0 3.8 2.7-4.8 2.1 1.6-2.7

Table 7.Characteristics of clients according to reach of the program (Urban Slums)BackgroundvariableEstimate%Contacted - YESContacted - NOMen Women Total Men Women Total95 % CI Estimate%95 % CI Estimate%95 % CI Estimate%95 % CI Estimate%95 % CI Estimate%95 % CIAge group15 - 20 years 12.7 4.3-21.0 5.1 1.9-8.3 7.8 4.6-11.0 11.1 8.8-13.4 6.8 5.6-8.1 9.1 7.5-10.721 - 35 years 54.6 47.1-62.1 71.1 64.7-77.5 65.2 59.8-70.5 58.7 53.4-64.0 67.6 64.5-70.6 62.9 59.6-66.3>35 years 32.6 21.8-43.4 23.6 18.2-29.1 26.9 20.5-33.2 29.7 25.2-34.2 25.4 22.5-28.2 27.6 24.6-30.6Marital Status:Married 64.6 54.1-75.1 91.4 87.6-95.2 81.7 77.9-85.5 70.3 66.1-74.4 92.1 90.6-93.6 80.7 78.4-83.0Education:Literate 88.0 82.2-93.9 69.7 63.0-76.5 76.3 70.9-81.7 81.7 77.5-85.9 62.7 57.3-68.2 72.6 68.7-76.5RTI/STDduring FHAC:Present 3.4 0.7-6.1 14.3 8.0-20.6 10.4 6.1-14.7 0.6 -0.2-1.4 2.9 1.2-4.6 1.7 0.9-2.5

Table 8.Reach of the family health awareness campaignRural AreasUrban SlumsReach categoryMen Women Total Men Women TotalEstimate %95% CIDesign effectEstimate %95% CIDesign effectEstimate %95% CIDesign effectEstimate %95% CIDesign effectEstimate %95% CIDesign effectEstimate %95% CIDesign effectA. Clients who did not receive program services1. Not aware aboutFHAC program75.873.2-78.54.371.868.4-75.26.573.871.2-76.48.184.981.0-88.82.477.673.8-81.41.781.377.8-84.73.22. Aware aboutFHAC throughmedia but did notattend camp7.25.3-9.26.76.35.2-7.52.66.85.6-8.05.35.43.4-7.41.55.23.8-6.78.45.33.9-6.71.5B. Clients who received program services1. Contacted athome alone9.27.7-10.62.911.99.7-14.25.210.68.7-12.26.27.75.5-10.01.410.88.0-13.71.79.37.0-11.62.62. Attended campsonly1.91.2-2.52.41.81.2-2.42.11.81.4-2.32.71.10.3-1.81.10.70.3-1.20.40.90.5-1.30.63. Contacted athome + attendedcamp5.84.4-7.24.08.16.4-9.84.56.95.6-8.36.10.90.4-1.40.55.64.1-7.00.83.22.4-4.00.9

Table 9.Program reach : proportion of clients who received services* during fhac program by zoneRural AreasUrban SlumsStatesMen Women Total Men Women TotalEstimate %95% CIDesign effectEstimate %95% CIDesign effectEstimate %95% CIDesign effectEstimate %95% CIDesign effectEstimate %95% CIDesign effectEstimate %95% CIDesign effectChandigarh, Delhi,Haryana,Himachal Pradesh,Punjab (Zone 1)25.215.8-34.73.6644.331.0-57.75.5634.824.8-44.86.856.71.6-11.70.9726.712.2-41.12.4816.78.1-25.22.46Uttar Pradesh(Zone 2)10.03.4-16.612.76.01.4-13.526.38.02.5-13.522.17.31.4-16.03.6513.31.3-25.44.1610.31.0-19.76.22Assam, ArunachalPradesh,Meghalaya, Sikkim(Zone 3)4.71.3-8.01.3311.33.1-19.53.588.02.7-13.24.046.72.0-11.40.1214.01.7-26.20.4410.33.0-17.70.41Manipur,Mizoram,Nagaland, Tripura(Zone 4)20.011.9-28.10.4925.713.3-38.00.9622.814.1-31.61.0414.04.4-23.60.136.00.2-11.80.1010.04.2-15.80.13Rajasthan(Zone 5)10.72.0-19.46.4216.47.8-25.04.3413.56.4-20.66.978.00.8-15.20.8311.30.3-22.31.439.72.2-17.11.50Madhya Pradesh(Zone 6)13.04.2-21.88.2416.46.3-26.58.9814.76.2-23.213.97.30.9-15.51.8314.00.4-28.43.1710.60.3-21.54.58

Rural AreasUrban SlumsStatesMen Women Total Men Women TotalEstimate %(95% CI)Design effectEstimate %(95% CI)Design effectEstimate %(95% CI)Design effectEstimate %(95% CI)Design effectEstimate %(95% CI)Design effectEstimate %(95% CI)Design effectOrissa(Zone 7)21.611.0-32.14.3923.012.1-33.94.3622.313.0-31.56.5120.57.7-33.35.1129.312.6-46.10.6824.911.6-38.20.96Goa, Maharashtra(Zone 8)23.314.7-31.84.8234.223.6-44.85.8928.720.4-37.07.796.80.7-14.43.2517.36.6-28.02.9412.24.4-20.04.16Andhra Pradesh(Zone 9)28.717.9-39.46.5131.620.5-42.76.6530.120.5-39.710.1913.36.3-20.30.9118.75.0-32.42.6616.07.7-24.32.19Karnataka(Zone 10)25.015.2-34.83.8028.719.6-37.83.0126.818.8-34.94.914.00.7-8.70.9718.04.8-31.21.9711.02.8-19.22.30Pondicherry, TamilNadu(Zone 11)20.510.2-30.95.8739.027.0-51.05.3329.719.7-39.88.6223.36.9-39.73.5319.37.3-31.42.1721.39.2-33.54.11Kerala,Lakshwadeep(Zone 12)5.72.7-8.70.8710.02.8-17.22.927.83.6-12.02.515.30.6-10.10.515.91.2-10.73.655.61.4-9.96.29All India16.914.6-19.24.3621.818.5-25.17.1719.316.8-21.99.059.77.4-11.91.1717.213.7-20.61.6713.410.9-15.92.16* Definition of receiving program services : Contacted at home and/or attended camp

Table 10.Reach of the family health awareness campaign program by HIV- endemicityLow HIV Endemic States Medium HIV Endemic States High HIV Endemic StatesEstimate % (95% CI) Design effect Estimate % (95% CI) Design effect Estimate % (95% CI) Design effectRural AreasMen 13.2 10.6-15.9 3.6 7.4 4.4-10.5 2.7 24.6 19.8-29.3 4.4Women 15.6 11.7-19.6 6.7 13.9 7.1-20.7 8.0 33.5 27.1-39.9 6.5Total 14.4 12.0-16.9 5.7 10.7 6.3-15.1 8.3 29.0 23.8-34.2 9.4Urban SlumsMen 7.7 4.6-10.9 1.2 9.1 3.7-14.4 0.6 11.7 7.9-15.6 1.2Women 16.4 9.6-23.2 2.9 11.4 3.3-19.5 1.1 18.2 13.7-22.7 1.2Total 12.1 7.6-16.5 3.3 10.2 4.8-15.6 1.0 15.0 11.5-18.5 1.7

Table 11.Reasons for non-participation by the clients in FHAC campsReasonsNot aware aboutFHAC programRural AreasClients’ ResponsesUrbanHealth Workers’PerceptionDoctors’ PerceptionEstimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI81.1 78.7-83.3 84.8 81.5-88.2 - -Indifferent 2.5 1.9-3.2 3.3 2.3-4.3 14.7 11.6-17.8 21.4 17.8-24.9Embarrassed 0.8 0.5-1.2 0.3 0.0-0.5 30.4 26.5-34.2 32.9 28.9-36.8Not aware aboutcamp0.8 0.4-1.1 0.7 0.3-1.2 12.2 8.6-15.8 22.5 18.9-26.0Need - not felt 4.0 3.2-4.7 3.5 2.3-4.7 21.1 17.7-24.5 14.3 11.3-17.2InconvenienttimingsLoss of wages(affordability)Not in village(availability)2.2 1.6-2.9 2.3 1.0-3.5 15.4 11.6-19.2 11.7 8.9-14.47.0 5.8-8.1 3.9 2.9-4.9 52.8 49.9-55.8 34.0 29.9-38.01.7 1.2-2.1 1.0 0.3-1.7 3.8 2.2-5.4 1.3 0.3-2.2

Table 12.Reason for non - participation by clients : Lack of awareness about FHAC programZoneChandigarh, Delhi, Haryana,Himachal Pradesh, Punjab (Zone 1)Rural AreasUrban SlumsEstimate % 95% CI Estimate % 95% CI66.6 57.3-75.9 81.3 73.5-88.9Uttar Pradesh (Zone 2) 91.3 84.9-97.6 87.8 75.7-99.9Assam, Arunachal Pradesh,Meghalaya, Sikkim (Zone 3)Manipur, Mizoram, Nagaland,Tripura (Zone 4)81.2 75.9-90.5 84.5 77.2-91.866.2 53.3-79.2 84.9 77.1-92.8Rajasthan (Zone 5) 87.5 81.4-93.7 91.3 84.8-97.9Madhya Pradesh (Zone 6) 89.7 83.4-95.7 87.8 77.0-98.7Orissa (Zone 7) 75.0 66.7-83.4 82.2 71.3-93.0Goa, Maharashtra (Zone 8) 73.8 67.0-80.5 86.5 77.2-95.9Andhra Pradesh (Zone 9) 76.6 67.9-85.3 88.1 81.5-94.8Karnataka (Zone 10) 69.0 60.9-77.1 90.4 81.8-98.9Pondicherry, Tamil Nadu (Zone 11) 66.9 56.5-77.2 67.0 50.1-83.9Kerala, Lakshadweep (Zone12) 89.7 85.8-93.6 89.1 81.5-96.7All India 81.0 78.7-83.4 84.8 81.5-88.2

Table 13.Reason for utilizing FHAC program services : Location of camp and attendanceLocation of campProportion of clients attending the campsEstimate % 95% CI Design effectIn & around Village / Locality 40.3 36.2-44.3 2.44At Sub-centre / PHC /Dispensary 23.1 17.9-28.2 4.67Test ResultsDifference % 95% CI t p-value17.2 11.4-23.0 5.95 0.001

Table 14.Classification of client responses regarding RTI / STD / HIV-AIDSCorrect Responses1. Symptoms of RTI/STDsC Urethral discharge (including pus, blood)C Ulcers on genitals / warts / papillomas / infectionC Pain or swelling in and around penis or groin or vagina orvulva / vaginitis / pain during intercourseC Pain lower back or abdomenC Swollen glands / ulcers in inguinal region / inguinal buboC Any vaginal dischargeC Foul smelling discharge / pus from vaginaC Menstrual disturbancesC Painful micturition / difficult micturition / urethritis2. Causes of RTI/STDsC Multiple partners / sexual promiscuity / extra maritalrelationship / prostitutionC Spouse having multiple partnersC Infected spouse / partner / caused by germsC Transfusion of infected blood / blood productsC Unsafe needles or syringes or instruments / sharing shavingblades or razorsC Drug abuseC Unprotected sex / non-use of condomsC Lack of personal hygiene / unhygienic conditions / habitsduring menstruationC Mother to childIncorrect ResponsesC Non-specific systemic symptoms (e.g. weakness / pallor / feeling sick / no bloodformation / loss of appetite / weight loss/ giddiness / lack of concentration /darkening of complexion / looking old / fatigue / pimples / decaying limbs / tremors /sleeplessness / memory loss / fever/ heat / lymph node enlargement)C Socio cultural beliefs (e.g. any swelling in scrotal or inguinal area i.e hernia /hydrocoele / change in gait / masturbation)C Itching on / around genitalsC Infertility / uterine prolapse/ abortions / uterus gets spoiltC Unrelated / Irrelevant (e.g. TB / cancer / stones / cough / difficulty in breathing /diabetes / vomiting / depression / liver disease / diarrhoea / anemia / skininfection/frequent micturitionC Nightfall / premature ejaculation / dhat / passage of thick urineC Lack of awarenessC Socio-cultural beliefs: (e.g. bathing in dirty water / wearing or using other person’sclothes or towel / eating sweets, hot or fried things / body heat / diet related /urinating in a bad place / eating betel nut / masturbation / mosquito bite / hereditary /malnutrition / alcoholism / witchcraft / contagious / watching pictures)C Homosexuality / wrong type of intercourseC Non specific causes: pregnancy / large number of children / weakness / diabetes /poor appetite / fungus / anaemia / allergy / post tubectomy / using copper-T/ woundin uterus / increased sexual intercourse / abortions / early marriage / lack ofhormones

Table 14. Contd...Correct Responses3. Ill Effects of RTI/STDs(what will happen if not treated)C Affects new born / children, will affect generationsC Spreads to spouseC Spreads to others in communityC Leads to infertility / uterus gets spoilt / impotency resultsC Disease worsen / won’t heal / damage to bodyC Leads to development of AIDSC Leads to deathIncorrect ResponsesC Nothing will happen / heals by itselfC Others: various symptoms / community looks down on them /weakness / cancer4. Prevention of RTI/STDsC Avoid multiple sex partners / high moral and ethical code ofconduct / modify sexual behaviorC Safe sexual practices / use of condomsC Use of sterile needles or syringes or instruments or gloves /avoid drugsC Use of tested blood / blood productsC Screening / identification of patients /sex education / createawarenessC Use clean or new razors and blades for shavingC Treat RTI or STD / consult doctorsC Maintain hygiene / take care of bodyC Prevention possible (but details not known)CCNot possible to preventOthers (specify): avoid sexual intercourse / keep distance from wife orhusband / avoid sex during menstruation or during pregnancy / don’tmix with infected person / don’t masturbate / remove uterus or haveoperation / avoid urinating in dirty places / avoid smoking or drinking/ take oral pills / avoid getting children / oil massage / take traditionalmedicine / do exercise / take nutritious food / avoid hot things / don’tdrink too much tea

Table 14. Contd...Correct Responses5. Treatment of RTI/STDsC Consult doctor / PHC / dispensary / private practitioner / allopathyC Consult indigenous practitioners / ayurvedic/ homeopathic / unanimedicine / traditional medicineCCCCIncorrect ResponsesNo treatment available (only prevention)No need to treat / goes away on its own / hides the diseaseNon-conventional health facility (including quack, black magic, Ojhas, temple,priest)Self treatment / self medications / maintain hygieneBoth husband and wifeshould be treated6. Treatment if husband is affected with RTI/STDsC Both husband and wife should be treated C No need of treatmentC Treat husband onlyC Treat wife only7. Treatment if wife is affected with RTI/STDsC Both husband and wife should be treated C No need of treatmentC Treat husband onlyC Treat wife only8. Spread of HIV/AIDSC Lack of awarenessC Multiple partners / sexual promiscuity / extra marital relationship /prostitutionC Spouse having multiple partnersC Infected spouse / partner / by germsC Transfusion of Infected blood or blood products / contact withinfected blood through wounds cutsC Unsafe needles or syringes or instruments / sharing shaving bladesor razors / piercing ears or noseC Drug abuseC Unprotected sex / non-use of condomsC Mother to childC Same as RTI/STD or due to RTI/STDC Lack of personal hygiene / unhygienic conditions / habits during menstruationC Socio-cultural beliefs (e.g. bathing in dirty water / wearing or using otherperson’s clothes or towel / eating sweets, hot or fried things / body heat /urinating in a bad place / chewing betel nut / masturbation / mosquito bite /hereditary / cough / alcoholism / contagious)C Homosexuality / wrong type of intercourseC Non specific causes : kissing / touching the patient / excessive use of condom /sharing infected person’s things / using same thermometer

Table 14. Contd...Correct Responses9. Ill effects of HIV-AIDS on the bodyC Repeated infections of many kinds (diarrhoea / respiratory or anyother organ infection / skin diseaseC Weak immune system / will get sickC DeathIncorrect ResponsesC Unrelated (e.g. TB / cancer / anemia )C Non-specific body or systemic effects (e.g. fever, weakness, weight loss, loss ofappetite, fatigue, looking old, lack of concentration, darkening of complexion /loss of hair / heat / irritation / change in gait / worsens / uneasiness / life getsaffected)C Urethral discharge / vaginal dischargeC Genital ulcers / ulcersC Other manifestations related to genital organs / itching / infertility / uterus getsspoilt / hydrocoele10. Prevention of HIV-AIDSC Avoid multiple sex partners / high moral and ethical code ofconduct / fear of god / modify sexual behaviorC Avoid having children (vertical transmission)C Safe sexual practices / use of condomsC Use of sterile needles or syringes or instruments or gloves / avoiddrug addiction (intra-venous)C Use of tested blood / blood productsC Screening / identification of patients /sex education / createawarenessC Clean or new razors and bladesC Treat RTI or STD / consult doctorsC Prevention possible (but details not known)CCCMaintain hygiene / take care of bodyNot possible to preventOthers (specify): don’t mix with them / don’t eat or drink with them / eatvegetarian food or good food / do exercise / avoid intercourse during pregnancyor during menstruation / don’t use others’ things / make a law/ avoid alcohol orsmoking

Table 15. RTI/STD/HIV-AIDS related awareness (correct responses) among the clients - All India DataAwareness TopicsRural AreasUrban SlumsMen Women Total Men Women TotalReproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)Symptoms Estimate %95% CI33.229.4-36.950.247.2-53.341.739.0-44.333.727.9-39.548.943.2-54.741.336.4-46.3Causes Estimate %95% CI54.551.3-57.834.031.0-37.044.342.2-46.464.960.8-68.939.736.1-43.352.349.4-55.2Ill Effects Estimate %95% CI77.675.3-79.964.961.5-68.371.368.9-73.577.572.5-82.469.456.2-72.573.470.4-76.5Prevention Estimate %95% CI67.965.4-70.651.246.8-55.659.657.2-61.973.167.8-74.458.955.2-62.866.061.9-70.1Treatment Estimate %95% CI84.381.7-86.978.174.9-81.381.278.7-83.782.577.6-87.486.784.1-89.384.682.1-87.1Who should Estimate %be treated? @ 95% CI50.447.1-53.838.034.3-41.844.241.3-47.249.544.8-54.244.540.4-48.546.943.4-50.6Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)Spread Estimate %95% CI66.963.9-70.146.543.9-49.056.854.6-58.980.276.3-84.164.560.8-68.372.369.5-75.2Ill effects Estimate %on body 95% CI30.026.3-33.821.718.7-24.825.923.2-28.634.128.4-39.728.724.2-33.231.427.3-35.4Prevention Estimate %95% CI67.864.2-71.344.641.9-47.356.253.9-58.477.373.4-81.361.356.8-65.869.366.1-72.4@If one of the spouses were having RTI/STD symptoms (correct response - treat both)

Table 16.RTI/STD/HIV-AIDS related awareness among rural areas menAwareness status Correct responses Incorrect responses IgnorantProgram Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NOReproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)SymptomsEstimate%95% CI56.349.2-63.328.4 $24.8-31.938.932.9-44.927.6 $25.0-30.230.025.3-34.656.6 $53.6-59.5Causes Estimate %95% CI73.565.7-81.250.6 $47.2-53.913.28.9-17.512.210.1-14.323.415.5-31.244.8 $41.5-48.1Ill Effects Estimate %95% CI86.482.5-90.375.7 $73.1-78.414.69.5-19.610.48.6-12.17.14.2-10.120.3 $17.5-23.1Prevention Estimate %95% CI87.484.4-90.463.8 $60.9-66.86.54.4- 8.67.86.2- 9.510.27.4-13.132.7 $29.8-35.7Treatment Estimate %95% CI92.089.3-94.682.8 $79.7-85.810.77.2-14.29.67.9-11.45.22.8- 7.513.1 $10.4-15.9Who should Estimate %be treated? @ 95% CI65.559.5-71.447.4 $43.5-51.231.925.4-38.343.4 #39.6-47.32.70.7- 4.69.1 $7.1-11.2Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)Spread Estimate %95% CI87.583.6-91.362.7 $59.3-66.113.38.9-17.810.28.7-11.711.17.3-15.034.9 $31.7-38.1Ill effects Estimate %on body 95% CI37.531.1-44.028.4 $24.5-32.366.260.3-72.042.3 $38.0-46.521.715.9-27.443.5 $39.8-47.1Prevention Estimate %95% CI87.584.1-90.963.7 $59.8-67.67.75.2-10.27.56.1- 8.911.37.8-14.8Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients wasstatistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001@ If one of the spouses were having RTI/STD symptoms (correct response - treat both)33.7 $30.1-37.3

Table 17.RTI/STD/HIV-AIDS related awareness among rural areas womenAwareness status Correct responses Incorrect responses IgnorantProgram Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NOReproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)Symptoms Estimate %95% CI65.257.7-72.646.0 $42.3-49.528.924.5-33.321.9 #19.8-23.930.222.8-37.549.5 $45.6-53.4Causes Estimate %95% CI49.945.0-54.629.5 $26.3-32.822.316.8-27.815.7 *13.2-18.138.833.9-43.760.2 $57.0-63.3Ill Effects Estimate %95% CI75.770.9-80.561.8 $58.0-65.522.217.7-26.711.8 $10.1-13.614.19.2-19.032.3 $27.4-36.6Prevention Estimate %95% CI68.762.8-74.646.2 $41.8-50.610.47.5-13.37.1 *5.8-8.426.220.5-32.049.2 $44.9-53.5Treatment Estimate %95% CI90.387.7-92.974.7 $71.1-78.39.66.6-12.510.88.0-13.66.94.5-9.319.2 $15.3-23.0Who should Estimate %be treated? @ 95% CI47.841.3-54.335.3 #31.0-39.648.341.8-54.947.342.6-52.03.82.2-5.417.3 $13.6-20.9Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)Spread Estimate %95% CI68.964.6-73.140.1 $37.6-42.79.06.4-11.67.46.0-8.828.424.1-32.857.1 $54.6-59.7Ill effects Estimate %on body 95% CI30.423.5-37.419.2 #16.2-22.351.346.0-56.627.3 $25.0-29.736.432.4-40.362.7 $60.2-65.3Prevention Estimate %95% CI66.662.2-71.138.4 $35.6-41.29.06.7-11.26.2 #5.0-7.530.225.8-34.5Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients wasstatistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001@ If one of the spouses were having RTI/STD symptoms (correct response - treat both)59.6 $56.9-62.2

Table 18.RTI/STD/HIV-AIDS related awareness among rural areas clients (Total)Awareness status Correct responses Incorrect responses IgnorantProgram Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NOReproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)Symptoms Estimate %95% CI61.355.5-67.236.9 $34.3-39.633.329.8-36.824.9 $23.2-26.530.124.9-35.453.2 $50.6-55.8Causes Estimate %95% CI60.255.7-64.740.4 $38.2-42.618.314.3-22.313.9 *12.3-15.532.127.4-36.852.3 $50.2-54.3Ill Effects Estimate %95% CI80.477.3-83.569.0 $66.3-71.618.915.9-21.911.1 $9.8-12.411.17.9-14.226.1 $23.2-29.1Prevention Estimate %95% CI76.973.1-80.855.3 $53.1-57.68.76.8-10.67.56.4-8.619.315.6-23.040.8 $38.3-43.2Treatment Estimate %95% CI91.088.9-93.178.8 $76.0-81.610.17.7-12.510.28.6-11.86.14.1-8.116.0 $13.1-18.9Who should Estimate %be treated? @ 95% CI55.550.8-60.241.5 $38.1-44.841.236.3-46.045.341.8-48.83.32.2-4.313.0 $10.7-15.4Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)Spread Estimate %95% CI77.173.8-80.351.8 $49.8-53.810.98.5-13.48.87.8-9.920.917.8-24.145.7 $43.6-47.9Ill effects Estimate %on body 95% CI33.627.7-39.524.0 #21.3-26.757.853.4-62.235.0 $32.3-37.730.026.3-33.752.9 $50.8-54.9Prevention Estimate %95% CI75.872.4-79.251.5 $49.1-53.88.46.9-9.96.9 *5.8-7.922.018.8-25.2Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients wasstatistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001@ If one of the spouses were having RTI/STD symptoms (correct response - treat both)46.3 $44.1-48.5

Table 19.RTI/STD/HIV-AIDS related awareness among men from urban slumsAwareness status Correct responses Incorrect responses IgnorantProgram Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NOReproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)Symptoms Estimate %95% CI44.131.7-56.432.626.6-38.546.331.2-61.327.6 *23.3-31.931.515.5-47.552.6 #46.5-58.6Causes Estimate %95% CI76.568.9-84.163.5 #59.0-68.118.48.5-28.214.211.2-17.220.412.0-28.833.0 *27.9-38.1Ill Effects Estimate %95% CI89.782.6-96.976.1 $71.1-81.112.45.3-19.514.510.9-18.09.32.2-16.319.9 #14.9-24.9Prevention Estimate %95% CI84.377.4-91.271.8 #66.2-77.56.00.8-11.27.85.7-9.811.54.8-18.126.1 $20.3-31.9Treatment Estimate %95% CI87.481.2-93.682.076.9-87.08.82.8-14.99.16.0-12.27.61.0-14.213.98.9-18.8Who should Estimate %be treated? @ 95% CI63.351.8-74.848.0 *43.1-52.932.822.7-43.041.437.5-45.43.80.2-7.910.3 *5.8-14.7Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)Spread Estimate %95% CI93.288.8-97.678.7 $74.7-82.711.94.6-19.212.49.8-15.06.52.4-10.719.5 $15.6-23.4Ill effects Estimate %on body 95% CI39.726.6-52.733.427.0-39.868.256.2-80.251.3 #47.1-55.613.96.2-21.532.0 $25.4-38.6Prevention Estimate %95% CI94.189.4-98.775.5 $71.5-9.49.93.8-16.08.26.0-10.35.00.4-9.6Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients wasstatistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001@ If one of the spouses were having RTI/STD symptoms (correct response - treat both)22.3 $18.0-26.6

Table 20.RTI/STD/HIV-AIDS related awareness among women from urban slumsAwareness status Correct responses Incorrect responses IgnorantProgram Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NOReproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)Symptoms Estimate %95% CI68.458.8-77.944.8 $39.2-50.439.128.3-49.923.6 #20.2-27.027.918.4-37.449.1 $43.3-54.9Causes Estimate %95% CI49.841.5-58.037.6 #33.6-41.623.414.8-31.919.115.7-22.434.824.4-45.350.7 #48.1-53.4Ill Effects Estimate %95% CI82.175.7-88.666.7 $63.0-70.318.313.1-23.415.512.8-18.111.36.2-16.425.9 $21.8-29.9Prevention Estimate %95% CI75.566.0-85.055.5 $51.9-59.012.56.6-18.48.55.9-11.122.513.2-31.840.0 $36.0-44.0Treatment Estimate %95% CI93.289.7-96.885.4 $82.7-88.06.53.2-9.85.73.7-7.74.31.0-7.712.2 $9.3-15.2Who should Estimate %be treated? @ 95% CI57.248.8-65.741.8 $37.9-45.840.631.8-49.348.043.9-52.12.2-1.2-5.710.0 $6.7-13.4Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)Spread Estimate %95% CI74.968.1-81.662.4 $58.3-66.49.95.6-14.18.66.8-10.423.817.2-30.535.4 #31.5-39.4Ill effects Estimate %on body 95% CI35.324.2-46.327.322.0-32.551.240.0-62.439.4 *35.4-43.436.226.9-45.547.0 *42.2-51.8Prevention Estimate %95% CI72.264.1-80.358.9 #53.9-64.07.34.2-10.47.85.8-9.727.218.6-35.5Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients wasstatistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001@ If one of the spouses were having RTI/STD symptoms (correct response - treat both)38.9 *34.2-43.1

Table 21.RTI/STD/HIV-AIDS related awareness among clients from urban slums (Total)Awareness status Correct responses Incorrect responses IgnorantProgram Contact status Contact - YES Contact - NO Contact - YES Contact - NO Contact - YES Contact - NOReproductive Tract Infections / Sexually Transmitted Diseases (RTI/STD)Symptoms Estimate %95% CI59.753.8-65.638.5 $33.6-43.441.734.6-48.825.7 $22.5-28.929.323.4-35.050.9 $46.0-55.9Causes Estimate %95% CI59.653.2-66.051.2 *47.8-54.621.615.2-28.016.614.9-18.229.722.3-37.141.5 #38.2-44.9Ill Effects Estimate %95% CI84.980.3-89.571.6 $68.4-74.916.212.6-19.815.012.4-17.610.67.1-14.222.8 $19.2-26.3Prevention Estimate %95% CI78.771.6-85.864.0 $59.8-68.210.26.6-13.88.16.2-10.118.612.3-24.832.8 $28.4-37.2Treatment Estimate %95% CI91.188.1-94.283.5 $80.9-86.27.45.1-9.67.55.3-9.75.52.8-8.213.0 $10.4-15.7Who should Estimate %be treated? @ 95% CI59.452.9-65.845.0 $41.1-48.937.831.6-44.044.6 *41.1-48.12.80.1-5.810.1 $7.1-13.1Human Immunodeficiency Virus Infection / Acquired Immunodeficiency Syndrome (HIV-AIDS)Spread Estimate %95% CI81.577.8-85.270.9 $67.7-74.110.66.6-14.610.68.9-12.317.614.0-21.327.2 $24.1-30.3Ill effects Estimate %on body 95% CI36.926.9-46.930.125.8-35.257.349.8-64.945.6 #42.6-48.528.222.3-34.139.2 $35.2-43.2Prevention Estimate %95% CI80.174.6-85.767.6 $64.0-71.28.25.1-11.37.96.3-9.719.213.5-24.9Note: Where indicated the difference between Contact-YES and Contact-NO categories of clients wasstatistically significant at probability levels * p < 0.05 # p < 0.01 $ p < 0.001@ If one of the spouses were having RTI/STD symptoms (correct response - treat both)30.2 #26.7-33.8

Table 22.Proportion of clients perceiving HIV-AIDS as a significant problem in their areaClientsProgram Contact - Yes Program Contact - No Test ResultsEstimate%95% CI Estimate%95% CI Difference % 95% CI t p-valueRural AreasMen 12.9 8.0-17.9 9.7 7.4-11.9 3.3 1.9-8.5 1.3 NSWomen 12.8 5.4-20.2 7.1 5.1-9.0 5.7 2.1-13.6 1.5 NSTotal 12.9 7.9-17.8 8.4 6.5-10.2 4.5 0.5-9.4 1.8 NSUrban SlumsMen 12.7 5.8-19.5 9.4 6.0-12.8 3.3 4.2-10.7 0.9 NSWomen 13.3 4.5-22.1 7.3 4.5-10.0 6.0 1.6-13.7 1.6 NSTotal 13.1 6.7-19.5 8.4 6.1-10.6 4.7 1.6-10.9 1.5 NS

Table 23.Awareness of clients about benefits of using condoms [CORRECT KNOWLEDGE*]ClientsEstimate%Program Contact - Yes Program Contact - No Test Results95% CI DesignEffectEstimate%95% CI DesignEffectDifference%95% CI t p-valueRural AreasMen 82.8 78.4-87.1 2.5 69.5 66.3-72.6 4.5 13.3 7.2-19.4 4.4 0.001Women 66.2 61.3-71.1 2.63 54.1 50.7-57.4 3.9 12.1 5.8-18.4 3.9 0.001Total 73.4 69.3-77.5 3.8 62.0 59.4-64.6 5.4 11.4 6.0-16.9 4.2 0.001Urban SlumsMen 88.4 83.4-93.1 0.42 78.4 73.3-83.4 2.77 10.0 4.8-15.2 3.9 0.001Women 82.0 73.5-90.5 1.72 67.0 62.8-71.3 1.38 14.9 6.8-23.1 3.7 0.001Total 84.3 78.6-90.0 1.4 73.0 69.0-76.9 2.8 11.3 6.0-16.7 4.3 0.001* Prevents pregnancy and / or diseases like RTI/STD/HIV-AIDS

Table 24.Awareness of clients about benefits of using condoms [CORRECT KNOWLEDGE]Program Contact - YesProgram Contact - NoClientsPrevents PregnancyPrevents RTI/STD/HIV-AIDSPrevents PregnancyPrevents RTI/STD/HIV-AIDSEstimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % 95% CIRural AreasMen 65.2 59.2-71.1 66.4 60.6-72 57.7 54.2-61.2 40.2 26.9-43.5Women 57.3 53.1-61.5 34.5 29.2-39.7 51.9 48.4-55.5 14.5 12.4-16.7Total 60.7 57.1-64.4 48.4 43.5-53.3 54.9 52.1-57.7 27.8 25.8-29.7Urban SlumsMen 65.1 56.1-74.2 73.3 64.1-82.6 62.8 58.6-67.1 54.1 49.0-59.2Women 74.3 65.8-82.8 38.4 28.2-48.7 63.1 58.7-67.5 22.7 18.9-26.6Total 71.0 64.9-77.1 51.0 43.8-58.1 63.0 59.2-66.7 39.1 35.1-43.1

Table 25.Behavior of clients regarding safe sex - Use of condoms during last intercourseProgram Contact - Yes Program Contact - No Test ResultsEstimate % 95% CI Estimate % 95% CI Difference % 95% CI t p-valueRural AreasMen 15.2 11.5-19.0 8.2 6.6-9.7 7.0 3.9-10.4 4.4 0.001Women 9.6 6.6-12.7 5.7 4.5-6.9 3.9 0.7-7.1 2.5 0.001Total 12.1 9.4-14.9 7.0 6.2-7.8 5.1 2.4-7.8 3.9 0.001Urban SlumsMen 8.6 4.4-12.7 10.7 7.8-13.5 2.1 1.9-6.1 1.1 NSWomen 12.0 7.6-16.3 11.6 9.0-14.1 0.4 0.0-0.8 0.2 NSTotal 10.8 6.9-14.7 11.1 9.0-13.2 0.3 -4.7-4.0 0.2 NS

Table 26.RTI/STD/HIV-AIDS related awareness among clients after controlling for marital status - symptoms of RTI/STDs[CORRECT KNOWLEDGE]Program Contact - YesProgram Contact - NoClientsRural AreasEstimate(%)Single Married Single Married95 % CI Estimate(%)95 % CI Estimate(%)95 % CI Estimate(%)95 % CIMen 43.8 32.0-55.7 59.3 51.9-66.8 25.7 21.1-30.3 29.4 25.4-33.4Women 33.0 21.3-44.8 67.0 59.4-74.6 35.3 24.9-45.6 47.0 43.1-51.0Total 40.8 31.4-50.3 63.9 57.7-70.1 28.0 22.9-33 38.8 35.9-41.6Urban SlumsMen 41.7 26.2-57.1 45.5 32.7-58.3 30.0 22.1-37.9 33.5 27.6-39.4Women 57.5 37.9-77.2 68.9 59.0-78.8 31.1 23.2-39.1 46.1 40.4-51.8Total 46.0 33.5-58.5 62.2 55.3-69.2 30.2 23.7-36.7 40.4 35.6-45.1

Table 27.RTI/STD/HIV-AIDS related awareness among clients after controlling for education - symptoms of RTI/STDs[CORRECT KNOWLEDGE]Program Contact YesProgram Contact NoClientsEstimate(%)Uneducated Educated Uneducated Educated95 % CI Estimate(%)95 % CI Estimate(%)95 % CI Estimate(%)95 % CIRural AreasMen 49.6 38.2-61.0 59.0 50.7-67.2 23.8 19.0-28.7 31.1 27.1-35.2Women 62.5 52.9-72.1 69.1 61.7-76.4 45.8 41.2-50.4 46.4 41.5-51.3Total 58.9 50.3-67.6 63.3 57.6-68.9 37.5 33.8-41.3 36.3 32.8-39.8Urban SlumsMen 28.4 7.7-49.2 50.0 37.7-64.3 26.2 19.4-32.9 35.6 28.3-42.9Women 65.7 51.5-80.0 70.8 61.3-80.3 41.0 36.3-45.7 49.5 41.2-57.9Total 56.6 46.1-67.1 61.7 54.9-68.4 35.3 31.5-39.1 40.9 34.0-47.8

Table 28.RTI/STD/HIV-AIDS related awareness (Correct Responses): Distribution of rural areas clients according to programcontact status and presence of RTI/STD symptoms during FHAC - 2000ProgramContactContact - YESContact - NOSymptomsduringFHACSymptoms -YES Symptoms - NO Symptoms -YES Symptoms - NOAwarenessregardingEstimate%95 % CI Estimate%95 % CI Estimate%95 % CI Estimate%95 % CIRTI/STDSymptoms 82.2 75.8-88.6 59.0 52.9-65.1 71.8 62.7-80.9 36.1 23.4-38.8Treatment 95.3 91.1-99.6 90.5 88.3-92.8 89.0 84.1-93.9 78.5 75.7-81.4Prevention 67.0 57.6-76.5 78.1 74.2-82.0 65.7 55.8-75.7 55.1 52.9-57.4HIV/AIDSSpread 72.5 66.7-78.5 77.5 73.9-81.1 38.3 26.4-50.2 52.1 50.1-54.1Ill effects 32.5 21.9-42.9 33.7 27.8-39.6 17.1 7.6-26.5 24.2 21.5-26.9

Table 29.RTI/STD/HIV-AIDS related awareness (Correct Responses): Distribution of clients from urban slums according toprogram contact status and presence of RTI/STD symptoms during FHAC - 2000ProgramContactContact - YESContact - NOSymptomsduringFHACSymptoms -YES Symptoms - NO Symptoms -YES Symptoms - NOAwarenessregardingEstimate%95 % CI Estimate%95 % CI Estimate%95 % CI Estimate%95 % CIRTI/STDSymptoms 62.2 40.1-84.2 59.3 53.3-65.4 54.6 37.6-71.7 38.4 33.4-43.3Treatment 90.1 79.9-100 91.2 88.4-94.2 95.3 88.9-100 83.5 80.7-86.3Prevention 62.9 42.7-83.3 80.5 72.6-88.5 82.6 71.4-93.8 63.8 59.4-68.2HIV/AIDSSpread 67.7 51.0-84.3 83.1 79.0-87.2 75.8 64.6-86.9 70.8 67.6-74.0Ill effects 30.5 8.5-52.5 37.7 27.8-47.5 41.4 21.9-60.8 30.2 25.5-34.9

Table 30.Training of health providers as part of FHAC program : Proportion trainedTraining StatusGovernment (n=390)DoctorsPrivate (n=148)Health Workers(n=1072)Estimate 95% CI(%)Estimate 95% CI(%)Estimate 95% CI(%)Trained 72.3 67.8-76.8 8.8 4.2-13.4 75.5 71.8-79.2Not trained 27.7 23.2-32.1 91.2 86.6-95.8 21.2 17.6-24.8No training held - - 3.4 2.1 -4.5

Table 31.Training of health providers as part of FHAC program : Process of trainingParameter Doctors’ Training Heath Workers’ TrainingEstimate (%) 95% CI Estimate (%) 95% CIDurationLess than one dayOne day or more3.796.21.5-5.994.0-98.47.492.54.2-10.689.3-95.7Who were the trainers?Do not know 0.3 -0.3-1.0 1.5 0.2-2.7Experts from outside 20.0 15.4-24.5 9.9 7.2-12.6Medical College experts 16.9 12.6-21.2 45.2 39.7-50.6Doctors from District Headquarters/ PHC85.4 81.3-89.4 68.2 63.7-72.6Language used for trainingLocal language - - 98.9 97.9-99.8Audio-visual aids usedDo not remember - - 2.8 0.8-4.7Posters / Flip Charts / Photos - - 69.9 65.1-74.7Film / Media - - 8.8 6.3-11.4Others - - 32.9 28.4-37.4Nothing was used (Lectures only) - - 15.4 12.2-18.7

Table 32.Training of health providers as part of FHAC program : Topics discussed by the trainersTopicsRTI/STD (causes / treatment /prevention)HIV-AIDS (causes / treatment /prevention)Doctors’ TrainingHealth Workers’ TrainingEstimate % (95% CI) Estimate % (95% CI)52.0 47.8-56.2 60.3 55.6-65.136.8 32.7-40.9 49.2 44.0-54.4Disease / good health 5.5 3.6-7.5 12.6 10.1-15.0Referral slips for treatment 2.6 1.2-3.9 7.8 5.9-9.6Availability of treatment at PHCs 4.0 2.4-5.7 5.0 3.4-6.6Conduct of FHAC program 11.5 8.8-14.2 14.8 11.7-17.8Nothing discussed 0 0 0.2 -0.0-0.5

Table 33.Quality of training of health providers : Perceptions of providers about FHAC program objectivesProgram Objectives Doctors Health WorkersEstimate % (95% CI)Estimate % (95% CI)Do not know 2.8 1.7-4.4 0.8 0.2-1.4Awareness, Treatment & Prevention ofRTI/STD/HIV-AIDS (Correct)Awareness / Treatment / Prevention ofRTI/STD/HIV-AIDS (Partially Correct)Others(to improve the image of govt servicesprovided at PHCs / Dispensaries, to trainpersonnel, and to create awareness aboutdiseases in general)15.9 12.3-19.5 16.7 13.7-19.775.1 70.9-79.4 76.1 72.5-79.821.6 17.6-25.7 17.4 14.1-20.6

Table 34.Quality of training of health providers : RTI / STD / HIV-AIDS related awareness among doctors[CORRECT KNOWLEDGE]TopicsTrained doctors Untrained doctors Test ResultsEstimate (%) 95% CI Estimate (%) 95% CI Difference t p-valueRTI/STDSymptoms in Men 98.9 97.8-100 93.4 90.2-96.5 5.5 3.28 0.001Symptoms in Women 99.6 98.9-100 96.7 94.4-99.5 2.9 2.47 0.014Causes 84.5 80.1-88.9 90.4 86.4-94.4 5.9 1.95 0.051Ill effects of RTI/STD onnew-born99.3 98.4-100 90.1 86.4-93.9 9.2 4.7 0.001Prevention 100 100-100 97.5 95.5-99.4 2.4 2.47 0.014HIV-AIDSPrevention 99.6 98.9-100 97.9 96.1-99.7 1.7 1.76 0.078

Table 35.Quality of training of health providers (Doctors) : Treatment for men with urethral dischargePrescriptionTrained doctors Untrained doctors Test ResultsEstimate (%) 95% CI Estimate (%) 95% CI Difference t p-valueDo not know 0 0 1.6 0.04-3.2 1.6 2.01 0.04No need for treatment0.3 -0.3-1.0 0.4 -0.4-1.2 0.1 0.13 NSAntibiotics 97.6 95.8-99.3 81.8 77.0-86.7 15.7 5.99 0.001Metronidazole 24.0 19.1-28.9 21.3 16.2-26.5 2.7 0.73 NSOthers (Symptomatictreatment, antisepticlotions, ointments,lotions, creams)21.6 16.9-26.4 34.5 28.5-40.5 12.8 3.31 0.001

Table 36.Quality of training of health providers (Doctors) : Treatment for men with genital ulcersPrescription Trained doctors Untrained doctors Test ResultsEstimate (%) 95% CI Estimate (%) 95% CI Difference t p-valueDo not know 0.3 -0.4-1.2 2.9 0.7-5.0 2.6 2.25 0.02No need fortreatment0.3 -0.3-1.0 0.4 -0.4-1.2 0.1 0.13 NSAntibiotics 94.9 92.4-97.4 78.1 72.9-83.3 16.8 5.68 0.001Metronidazole 11.8 8.1-15.5 12.3 8.1-16.5 0.5 0.17 NSOthers(Symptomatictreatment,antiseptic lotions,ointments, lotions,creams)27.8 22.6-33.2 37.4 31.3-43.5 9.6 2.37 0.02

Table 37.Quality of training of health providers (Doctors) : Treatment for women with foul smelling vaginal dischargePrescriptionTrained doctors Untrained doctors Test ResultsEstimate (%) 95% CI Estimate (%) 95% CI Difference t p-valueDo not know 0.3 -0.3-1.0 2.0 0.2-3.8 1.7 1.77 NSNo need fortreatment0.3 -0.3-1.0 0 0 0.3 1.00 NSAntibiotics 92.8 1.5-95.8 74.4 68.9-79.9 18.4 5.79 0.001Metronidazole 67.8 62.4-73.1 43.6 37.3-49.8 24.2 5.77 0.001Others(Symptomatictreatment, antisepticlotions, ointments,lotions, creams)42.7 37.1-48.3 52.6 46.3-59.7 9.9 2.31 0.02

Table 38.Quality of training of health providers (Doctors) : Treatment for women with genital ulcersPrescriptionsTrained doctors Untrained doctors Test ResultsEstimate (%) 95% CI Estimate (%) 95% CI Difference t p-valueDo not know 0.6 -0.3-1.6 2.4 0.5-4.4 1.8 1.62 NSNo need fortreatment1.0 -0.1-2.1 0 0 1.0 1.73 NSAntibiotics 92.5 89.5-95.5 76.5 71.2-81.9 16.0 5.12 0.001Metronidazole 26.1 21.1-31.1 17.2 12.5-22.0 8.9 2.50 0.01Others(Symptomatictreatment, antisepticlotions, ointments,lotions, creams)33.9 28.4-39.3 41.9 35.7-48.2 8.0 1.92 0.06

Table 39.Quality of training of health providers (Health Workers) : RTI/STD/HIV-AIDS related awareness[CORRECT KNOWLEDGE]Awareness regardingTrained Health Workers Untrained Health Workers Test ResultsEstimate (%) 95% CI Estimate (%) 95% CI Difference t p-valueRTI/STDSymptoms in Men 93.6 90.9-96.3 80.5 74.2-86.7 13.1 4.12 0.001Symptoms in Women 97.9 96.4-99.3 88.1 82.4-93.8 9.8 3.29 0.002Causes 86.2 82.2-90.2 83.5 77.1-89.9 2.7 0.67 NSPrevention 99.6 99.1-100 92.9 89.0-96.9 6.7 3.41 0.001Ill effects of RTI/STD onnew-born88.0 84.3-91.7 82.7 76.2-89.2 5.3 1.57 NSTreatment for RTI/STDsReferred to Doctor 89.6 86.3-92.9 75.6 66.5-84.8 13.9 3.16 0.003HIV-AIDSIll effects on body 76.4 72.1-80.7 58.2 49.8-66.5 18.2 4.03 0.001Prevention 99.2 98.2-100 92.1 87.7-96.6 7.1 3.07 0.004

Table 40.Social Mobilization : clients’ sources of information about FHAC programRespondentCategoryClients’ Sources of informationHealth workers Interpersonal - other sources** PublicityEstimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI)Rural Areas*Urban Slums*Men 49.6 43.3-55.9 30.9 26.4-35.3 19.0 13.3-24.7Women 61.5 55.9-67.1 27.6 23.7-31.4 8.5 5.6-11.5Total 56.0 51.4-60.7 29.1 26.4-31.8 13.3 9.8-16.9Men 43.2 37.7-48.7 27.7 22.5-32.8 28.8 22.2-35.4Women 59.6 50.6-68.7 26.7 19.2-34.2 12.2 4.0-20.5Total 53.1 47.5-58.7 27.1 21.7-32.5 18.8 12.4-25.2Health Workers 74.9 @ 70.4-79.3 68.9 65.2-72.5* Denominator was the total number of clients who were aware about the FHAC program** Include : Volunteers, influencers, elderly members etc.@ Include : Health workers and other sources of interpersonal communication

Table 41. Social Mobilization : knowledge about target population for FHAC programRespondentCategoryClients *Rural AreasUrban SlumsMen Women Total Men Women TotalHealthWorkersPerceivedTarget GroupEstimate %95% CIEstimate %95% CIEstimate %95% CIEstimate %95% CIEstimate %95% CIEstimate %95% CIEstimate %95% CIDo not know 12.39.4-15.218.615.5-21.715.713.7-17.712.98.6-17.316.09.7-22.414.811.7-17.96.64.4-8.8Adults 78.474.4-82.574.971.2-78.676.574.0-79.075.363.8-86.875.870.6-81.075.670.1-81.191.289.0-93.4Adolescents 48.140.8-55.231.026.2-35.838.834.1-43.750.340.0-60.627.819.3-36.236.830.1-43.564.961.2-68.7Who go toprostitutes &others8.55.4-11.66.94.7-9.17.65.9-9.312.93.7-22.19.55.4-13.610.96.1-15.7-* Denominator was the total number of clients who were aware about the FHAC program

Table 42.Field Operations : personnel involved in house visits during the FHAC programHouse visits by Health workers Workers of nonhealthdepartmentsVolunteers /influencersNo one visitedDo not rememberRespondents Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % (95% CI) Estimate % 95% CIRural AreasMen 54.4 47.2-61.6 3.5 1.6-5.3 5.3 2.7-7.9 29.8 22.9-36.6 7.1 4.4-9.8Women 58.0 52.0-63.9 7.9 5.0-10.8 5.3 2.3-8.3 23.4 19.0-27.8 5.4 3.5-7.2Total 56.3 50.7-62.0 5.9 3.8-7.9 5.3 3.4-7.2 26.3 21.6-31.7 6.2 4.4-7.9Urban SlumsMen 50.2 39.8-60.6 4.8 0.6-10.1 2.2 0.0-4.7 29.5 20.8-38.2 13.4 6.7-20.1Women 58.5 51.6-65.5 9.9 4.6-15.2 4.8 1.2-8.3 19.5 13.1-25.8 7.3 2.9-11.7Total 55.2 49.0-61.4 7.8 3.1-12.6 3.7 1.6-5.8 23.5 18.6-28.4 9.8 5.8-13.8

Table 43.Field Operations : Location of FHAC camps [According to clients]Rural AreasUrban SlumsZoneCamps in and aroundthe villageCamps at Sub-center /PHCCamps in and aroundthe localityCamps at Health Post /DispensaryEstimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI1. Chandigarh, Delhi,Haryana, Himachal Pradesh,Punjab36.7 17.1-56.3 52.0 34.5-71.5 31.4 10.9-51.9 35.7 16.6-54.82. Uttar Pradesh 51.2 20.3-82.2 37.1 7.0-67.3 34.1 -4.3-72.6 48.8 19.1-78.43. Assam, Arunachal Pradesh,Meghalaya, Sikkim4. Manipur, Mizoram,Nagaland, Tripura36.1 14.6-57.6 21.3 6.5-36.0 18.3 -2.4-39.2 28.5 -0.7-57.883.1 70.1-96.1 11.9 0.2-23.6 68.4 44.2-92.6 17.5 -2.0-37.15. Rajasthan 50.8 27.3-74.4 38.6 17.2-60.0 52.7 27.3-78.2 22.2 5.0-39.46. Madhya Pradesh 64.4 40.9-87.8 30.7 5.9-55.6 77.5 51.9-100 17.5 -8.3-43.37. Orissa 64.9 48.5-81.2 11.7 2.4-21.0 70.2 49.0-91.4 14.2 -3.2-31.78. Goa, Maharashtra 28.8 13.4-44.4 66.6 50.8-82.5 52.9 20.6-85.2 21.5 -0.9-44.19. Andhra Pradesh 84.5 68.6-100 11.2 -5.0-27.4 80.0 62.4-97.5 7.2 -4.7-19.310. Karnataka 29.9 13.0-46.7 46.7 29.7-63.7 29.7 9.2-50.2 37.8 9.7-65.911. Pondicherry, Tamil Nadu 76.2 62.6-89.8 17.5 5.9-29.1 68.4 44.3-92.6 23.4 1.1-45.712. Kerala, Lakshadweep 29.4 7.2-51.7 46.1 27.1-65.1 7.7 -2.4-17.8 58.9 29.9-88.0All India 53.7 46.1-61.3 34.9 27.5-22.3 53.1 42.1-64.0 27.3 16.4-38.2

Table 44.Health workers perspective - Location of campsLocation of FHAC campsRural AreasUrban SlumsEstimate % 95% CI Estimate % 95% CICamps not organized 10.1 7.0-13.1 18.8 12.2-25.4Camps in & around the village / locality 44.2 37.4-50.9 42.5 35.5-49.5Camps at PHC / Health Post / Dispensary 45.7 39.3-52.2 37.7 28.6-46.9

Table 45.Field operations : Personnel manning the camp*Personnel atCampsHealth workersWorkers of non-healthdepartmentsVolunteers / influencersDo not rememberRespondentCategory*Estimate % 95% CI Estimate % 95% CI Estimate % 95% CI Estimate % 95% CIRural AreasMen 89.6 82.3-96.8 1.5 0.0-3.6 7.7 2.0-13.5 1.2 0.0-2.5Women 90.2 84.7-95.7 2.7 0.3-5.1 5.7 1.8-9.7 1.3 0.0-2.9Total 89.9 84.2-96.6 2.2 0.2-4.1 6.6 2.7-10.5 1.3 0.0-2.5Urban SlumsMen 92.3 84.0-100 0 3.6 -3.1-10.2 4.1 -1.1-9.4Women 89.3 82.8-95.7 2.1 0.0-4.9 3.8 -1.4-8.9 4.8 0.0-9.7Total 90.0 83.8-97.1 1.6 0.0-3.8 3.7 -0.4-7.9 4.7 0.8-8.5* Denominator was the number of clients who attended the FHAC camps

Table 46.Field operations : Conduct of FHAC camps*Estimate % (95% CI) Design effectPersonnel Manning the CampsHealth Worker Alone 23.9 19.6-28.1 2.64Non-Health Departments / Volunteers / Influencers &Health Workers 73.8 69.3-78.2 2.71IEC Methods UsedPrint material 66.5 62.6-70.3 1.53Audio-visual 4.8 2.9-6.6 1.82Folk / songs / plays 4.0 2.4-5.6 1.60Interpersonal / Lectures / Discussions 27.9 23.8-32.0 2.0Topics Discussed in CampsRTI/STD (causes / treatment / prevention) 63.4 59.4-67.3 1.77HIV-AIDS (causes / treatment / prevention) 46.2 41.6-50.9 2.26Disease / good health 1.7 0.5-2.9 2.29Referral slips for treatment 4.2 2.7-5.7 1.50Availability of treatment at PHCs 6.6 4.9-8.3 1.21Conduct of FHAC program 0.06 -0.07-0.2 0.73Nothing discussed** 12.6 10.0-15.2 1.64* Based on responses from Health Workers; ** As camps were meant for screening and treating RTI/STD patients

Table 47.Prevalence of RTI/STD symptoms in clients during the FHAC program according to contact status of clientsClients’ ContactstatusRural AreasUrban SlumsMen Women Total Men Women TotalEstimate%(95% CI)Estimate%(95% CI)Estimate%(95% CI)Estimate%(95% CI)Estimate%(95% CI)Estimate%(95% CI)A. Clients who did not receive program services1. Not awareabout FHACprogram0.7(0.3-1.1)3.7(2.7-4.8)2.1(1.6-2.7)0.4(0.0-0.7)2.7(1.2-4.3)1.5(0.8-2.2)2.Aware aboutFHAC throughmedia but did notattend camp0.6(-0.2-1.5)4.8(1.8-7.8)2.6(0.8-4.4)4.5(-4.6-13.6)6.3(-0.7-13.4)5.4(0.1-10.7)B. Clients who received program services1. Contacted athome alone0.6(-0.2-1.5)5.9(3.0-8.8)3.6(2.0-5.2)0.7(-0.7-2.1)5.6(3.1-8.1)3.5(1.8-5.2)2. Attendedcamps only6.2(1.2-11.2)21.2(8.7-33.8)13.6(7.2-19.9)7.1(-7.1-21.4)20.1(-15.9-56.0)12.5(-5.9-30.9)3. Contacted athome + attendedcamps6.5(1.7-11.3)28.7(22.0-35.4)19.4(14.4-24.3)23.4(-4.9-51.7)30.6(12.5-48.8)29.6(13.3-46.0)

Table 48.Treatment seeking behavior of clients with RTI/STD symptoms during FHAC programPlace of treatmentProgram Contact - Yes Program Contact - No Test resultsEstimate%95% CI Estimate%95% CI Difference%95% CI t pvalueNo Treatment 12.9 7.8-18.0 32.4 21.8-43.1 19.6 7.9-31.2 3.4 0.002Home / Self 1.8 -0.2-3.9 2.2 0.1-4.4 0.4 -2.9-3.6 0.2 NSPrivate Doctor 9.9 5.2-14.6 25.1 16.5-33.7 15.1 4.7-25.5 2.9 0.005GovernmentHospital / PHC65.3 56.6-73.9 27.2 18.6-35.8 38.1 27.6-48.6 7.3 0.001Non-conventional 0.5 -0.5-1.6 2.7 0.4-5.0 2.2 0.2-4.1 2.2 0.03Not aware 9.6 5.0-15.2 10.4 4.5-17.1 0.8 -2.0-3.6 0.3 NS* Denominator was the number of clients with symptoms of RTI/STD during FHAC Program

Table 49.Providers perspective about program performance : Reach of the program during FHAC programHome Visits Camp attendance Clients using referral slipsPerception ofHealth WorkersHealth Workers’PerspectiveHealth Workers’PerspectiveDoctors’ PerspectiveHealth Workers’PerspectiveEstimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI)Do not know 6.0 3.8-8.2 9.1 6.3-11.8 31.2 27.1-35.2 25.4 21.6-29.3Less than 25% 21.0 17.0-25.1 47.5 43.1-51.8 40.3 36.0-44.6 17.8 14.1-21.6About 50% 39.5 35.4-43.5 37.2 33.1-41.2 25.9 22.0-29.7 25.9 21.6-30.3More then 75% 33.3 29.1-37.6 6.1 3.9-8.4 2.5 1.2-3.9 18.9 14.1-23.7Table 50.Provider perspective about program performance : Relative proportion of clients attending the FHAC camps/ meetingsPerception ofHealth WorkersEstimate % (95% CI) Design effectNot sure 9.4 6.5-12.4 2.39Men were more 9.9 7.4-12.5 1.71Women were more 65.5 60.2-70.7 2.90Men & Women equal 13.6 10.0-17.3 2.73Adolescents were more 0.9 -0.06-2.0 2.72Others 0.3 -0.05-0.7 1.15

Table 51.Providers’ perspective about client behavior : Clients’ reaction towards discussing issues of RTI/STDHealth Worker Perspective Estimate (%) 95% CI Design EffectNot sure / do not know 7.1 4.9-9.1 1.70Appreciated 62.5 58.6-66.4 1.62Indifferent 5.7 3.9-7.5 1.53Felt shy / embarrassed 22.0 18.8-25.1 1.47Abused / rebuked 2.6 1.2-3.9 1.93Table 52.Providers’ perspective about client behavior : Treatment seeking behavior of clients for RTI/STDPlace of Treatment Health Workers’ Perspective Doctors’ PerspectiveEstimate% 95% CI Estimate% 95% CIDo not know 1.5 0.4-2.5 1.9 0.7-3.0No treatment 24.7 21.0-28.3 31.2 27.3-35.2Government facilities 59.0 55.0-63.1 45.0 40.8-49.2Private Doctor 81.8 79.0-84.5 23.2 19.7-26.8Quack / Ojha 6.7 5.0-8.5 36.6 32.5-40.7

Table 53.Perceptions of health providers regarding problem of RTI/STD/HIV-AIDS in their areaHIV-AIDSEstimate(%)Doctors’ Perspective95% CI Estimate(%)Health Workers’ Perspective95% CIProblem (Yes) 28.3 24.4-32.1 25.9 22.8-29.1Problem (No) 60.3 56.2-64.4 74.0 70.8-77.1Unsure 11.35 8.7-14.0 - -

Table 54.Reach of the family health awareness campaign to adolescents (< 20 years old)ReachRural AreasEstimate% 95% CI DesigneffectUrban SlumsEstimate% 95% CI DesigneffectA. Clients who did not receive program services1. Not aware about FHAC program 80.1 76.2-84.0 3.2 81.4 75.6-87.1 1.22. Aware about FHAC through media but did notattend camp6.5 4.7-8.3 1.8 4.8 2.5-7.1 0.6B. Clients who received program services1. Contacted at home alone 7.9 5.3-10.5 3.0 9.3 5.2-13.4 1.12. Attended camps only 1.0 0.4- 1.5 1.0 1.8 -0.9-4.5 2.43. Contacted at home + attended camp 4.5 2.9- 6.0 1.9 2.7 1.0-4.3 0.6

Table 55.AwarenessRegardingRTI / STD / HIV related awareness among adolescents (# 20 years old) [CORRECT KNOWLEDGE]Rural AreasUrban SlumsProgram contact-Yes Program contact-No Program contact-Yes Program contact-NoEstimate % 95% CI Estimate% 95% CI Estimate% 95% CI Estimate% 95% CIRTI/STDSymptoms 43.6 32.1-55.0 28.3 23.2-33.3 54.6 39.4-69.8 29.3 24.2-34.4Causes 54.0 44.1-63.8 34.7 29.3-40.0 68.9 58.3-79.6 46.3 41.0-51.6Ill effects 73.9 64.2-83.6 62.7 57.0-68.4 83.1 68.4-97.7 64.7 56.0-73.3Treatment 86.9 78.7-95.0 74.9 69.4-80.4 89.5 81.2-97.8 78.7 73.7-83.7Prevention 67.7 57.9-77.5 48.3 43.0-53.7 75.9 62.2-89.7 60.4 52.7-68.1HIV-AIDSSymptoms 78.1 70.3-85.8 52.4 47.4-57.5 78.7 66.0-91.5 69.0 64.4-73.7Ill effects 34.3 22.7-45.9 24.9 21.4-28.5 38.5 19.3-57.7 30.2 24.6-35.7Prevention 79.4 71.2-87.7 52.0 47.0-57.0 80.1 67.5-92.8 64.0 57.4-70.5

Table 56.Adolescent profile (# 20 years old) : Prevalence of RTI/STD symptoms during two weeksprior to survey & safe sex related informationParameter Rural Areas Urban SlumsEstimate% 95% CIEstimate% 95% CIPrevalence DataUrethral Discharge 5.8 3.5-8.1 3.1 1.0-5.3Genital Ulcers 0.8 0.1-1.5 0.2 -0.2-0.6Condom Use 3.4 2.1-4.6 6.3 3.2-9.4Benefits of condom use [CORRECT KNOWLEDGE]Prevents Pregnancy 41.3 37.2-45.3 53.0 48.3-57.7PreventsRTI/STD/HIV-AIDSCorrect Responses(Prevents pregnancyand / or diseases likeRTI/STD/HIV-AIDS)32.0 28.1-35.9 40.5 35.6-45.464.2 62.1-66.3 74.5 70.6-78.4

Table 57.Prevalence of urethral discharge / painful micturition among the clients during the two weeks prior to the surveyRural AreasUrban SlumsZoneMen Women Total Men Women TotalEstimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI) Estimate% (95% CI)Zone 1 2.6 0.5-4.7 10 4.2-15.7 6.3 2.6-9.9 0.6 -0.6-2.0 8.0 2.7-13.2 4.3 1.4-7.2Zone 2 3.0 0.4-5.6 8.3 4.3-12.3 5.6 3.2-8.1 2.6 0.2-5.1 10.8 2.5-19.1 6.7 2.6-10.8Zone 3 8.3 5.0-11.5 19.0 11.3-26.6 13.6 9.0-18.2 10.0 2.3-17.7 19.3 6.3-32.3 14.7 6.7-22.6Zone 4 2.6 0.5-4.8 17.0 8.7-25.3 9.8 5.3-14.3 2.0 -0.1-4.1 5.3 0.9-9.6 3.6 1.1-6.1Zone 5 2.0 0.5-3.4 28.5 17.1-39.9 15.2 9.1-21.2 2.0 0.1-4.1 22.8 10.3-35.2 12.3 5.6-19.1Zone 6 8.0 3.8-12.1 10.0 5.8-14.3 9.0 5.7-12.3 6.6 1.1-12.0 5.4 -0.2-11.0 6.0 2.0-10.0Zone 7 0.3 -0.3-0.9 2.6 0.7-4.5 1.4 0.4-25.7 0 6.0 0.1-11.8 2.9 0.07-5.9Zone 8 1.0 -0.1-2.1 8.6 4.1-12.8 4.8 2.6-7.0 1.3 -0.5-3.2 10 2.6-17.3 5.7 2.0-9.4Zone 9 1.3 -0.2-2.9 7.6 3.5-11.7 4.5 1.9-7.0 2.6 0.2-5.0 10 3.1-16.8 6.3 3.0-9.6Zone 10 1.3 -0.2-2.9 10.6 4.7-16.5 6.0 2.8-9.1 1.3 -1.3-4.0 12.0 1.5-22.4 6.6 1.3-12.0Zone 11 0.6 -02-1.5 13.3 8.5-18.2 6.9 4.3-9.6 0 10.6 5.6-15.6 5.3 2.8-7.8Zone 12 0.3 -0.3-1.0 1.6 0.2-3.1 1.0 0.2-1.7 0 0 0All India 2.7 2.0-3.4 10.5 8.7-12.3 6.6 5.6-7.7 2.0 1.3-2.7 10.0 6.8-13.2 6.0 4.5-7.6

Table 58.Prevalence of genital ulcers during the two weeks prior to the surveyRural AreasUrban SlumsZoneMen Women Total Men Women TotalEstimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI) Estimate % (95% CI)Zone 1 0.6 -0.2-1.5 0 0.3 -0.1-0.8 0 2.0 -0.9-4.9 1.0 -0.4-2.4Zone 2 1.3 -0.2-2.9 0.3 -0.3-1.0 0.8 -0.2-1.9 0.6 -0.6-2.0 0.6 -0.6-2.0 0.6 -0.2-1.6Zone 3 2.9 0.4-5.5 2.3 0.7-3.9 2.6 1.2-4.0 3.3 -0.9-7.6 3.3 -0.4-7.1 3.3 0.7-5.9Zone 4 1.3 -0.2-2.9 5.0 1.1-8.8 3.1 1.1-5.2 1.3 -0.5-3.1 0 0.6 -0.2-1.5Zone 5 0.6 -0.2-1.6 5.7 0.2-11.2 3.2 0.4-5.9 0.6 -.06-2.0 3.3 0.08-6.6 2.0 0.3-3.6Zone 6 2.0 0.2-3.8 3.3 0.9-4.3 2.6 1.0-4.3 0.6 -0.6-2.0 3.3 -2.2-8.9 2.0 -0.7-4.7Zone 7 0 1.0 -0.1-2.1 0.4 -0.06-1.0 0 0 0Zone 8 0.6 -0.2-1.6 0.6 -0.2-1.6 0.6 0.03-1.3 0 2.0 -0.1-4.1 1.0 -0.07-2.1Zone 9 0.3 -0.3-1.0 0 0.1 -0.2-0.5 0 1.3 -0.5-3.1 0.6 -0.2-1.5Zone 10 0.6 -0.2-1.6 1.6 -0.03-3.3 1.17 0.2-2.1 0 2.0 -2.0-6.0 1.0 -1.0-3.0Zone 11 0 2.0 -0.2-4.2 1.0 -0.1-2.1 0.6 -0.7-2.0 1.3 -0.5-3.1 1.0 -0.07-2.0Zone 12 0 0.3 -0.3-1.0 0.1 -0.2-0.5 0 0 0All India 0.9 0.5-1.3 1.4 0.9-1.9 1.1 0.8-1.5 0.3 0.07-0.6 1.7 0.9-2.4 1.0 0.6-1.4

Table 59.Prevalence of urethral discharge / painful micturition during two weeks prior to survey(According to HIV-endemicity zones)HIV Endemicity Low Medium HighClient CategoryEstimate 95% CI Design% effectEstimate 95% CI Design% effectEstimate 95% CI Design% effectRural AreasMen 3.3 2.1-4.4 2.7 7.2 4.6-9.9 0.7 1.0 0.3-1.8 2.1Women 10.2 7.4-13.0 5.7 18.6 12.4-24.8 1.6 9.7 7.1-12.4 3.1Total 6.7 5.1-8.3 5.4 12.9 9.2-16.6 1.5 5.4 3.9-6.9 3.6Urban SlumsMen 2.4 1.2-3.7 0.7 7.4 2.2-12.5 0.2 1.3 0.3-2.3 0.7Women 9.3 5.3-13.4 1.9 14.7 5.9-23.4 0.3 10.4 5.5-15.4 2.5Total 5.9 3.7-8.0 1.6 11.0 5.7-16.3 0.3 5.9 3.4-8.4 2.1

Table 60.Prevalence of genital ulcers during two weeks prior to survey (According to HIV endemicity zones)HIV Endemicity Low Medium HighClient CategoryEstimate % 95% CI DesigneffectEstimate % 95% CI DesigneffectEstimate % 95% CI DesigneffectRural AreasMen 1.1 0.3-1.7 3.0 2.6 0.5-4.8 1.2 0.4 0.05-0.8 1.2Women 1.5 1.7-2.3 2.6 2.8 1.5-4.1 0.4 0.9 0.3-1.5 1.6Total 1.3 0.7-1.9 3.7 2.7 1.6-3.9 0.6 0.7 0.3-1.1 1.8Urban SlumsMen 0.4 0.07-0.9 0.6 2.7 0.3-5.7 0.2 0.1 0.2-0.5 0.6Women 1.7 0.2-3.1 1.3 2.2 0.3-4.7 0.1 1.7 0.7-2.6 0.5Total 1.0 0.3-1.7 0.9 2.4 0.6-4.2 0.1 0.9 0.5-1.4 0.4

Table 61.Prevalence of urethral discharge / painful micturition during two weeks prior to survey(According to contact status of the clients)Clients’ Contact Status Rural Areas Urban SlumsEstimate% 95% CI Design effectEstimate% 95% CI Design effectA. Clients who did not receive program services1. Not Aware about FHAC 6.6 5.4-7.8 3.9 5.2 3.9-6.6 1.12. Aware about FHAC through publicitybut did not attend camps4.0 2.2-5.9 1.4 7.7 2.6-12.8 0.8B. Clients who received program services1. Contacted at home only 6.4 3.8-8.9 2.6 9.0 3.7-14.4 1.32. Attended camps only 9.9 5.0-14.7 1.1 8.0 -2.2-18.1 0.53. Contacted at home & attended camps 9.6 5.8-13.3 2.5 15.3 7.0-23.5 0.7

Table 62.Prevalence of genital ulcers during two weeks prior to survey (According to contact status of the clients)Clients’ Contact Status Rural Areas Urban SlumsEstimate% 95% CI Design effectEstimate% 95% CI Design effectA. Clients who did not receive program services1. Not Aware about FHAC 1.2 0.8-1.7 2.8 0.9 0.5-1.3 0.62. Aware about FHAC through publicitybut did not attend camps0.6 0.0-1.3 1.1 0.1 -0.1-0.3 0.1B. Clients who received program services1. Contacted at home only 1.0 0.2-1.8 1.4 1.4 -1.2-4.1 1.92. Attended camps only 0.7 -0.4-1.9 0.7 4.2 -4.2-12.6 0.73. Contacted at home & attended camps 1.5 0.2-2.8 1.8 4.5 -1.9-10.9 1.2

Table 63.Characteristics of clients with presence of urethral discharge / painful micturition / genital ulcers during the surveyCurrent Prevalence of RTI/STD symptomsRural AreasUrban SlumsEstimate% 95 % CI Estimate% 95 % CIAge GroupAdults (>20 yrs) 7.1 6.1-8.1 6.8 * 5.3-8.3Adolescents (15-20 yrs) 6.0 3.8-8.3 3.1 1.0-5.3Marital StatusMarried 7.6* 6.4-8.7 7.2 * 5.4-8.9Unmarried 3.4 1.9-4.9 2.5 1.1-3.9EducationLiterate 5.5 4.5-6.5 5.5 4.2-6.9Illiterate 9.5 * 7.7-11.4 8.3 5.1-11.5* The difference between the categories was significant at p

Table 64.Prevalence of condom usage during last intercourseClients Category Estimate% 95% CI Design effectRural AreasMen 9.4 7.7-11.0 3.6Women 6.6 5.4-7.8 2.7Total 8.0 7.0-8.9 2.8Urban SlumsMen 10.5 7.8-13.3 1.6Women 11.7 9.6-13.8 0.9Total 11.1 9.2-13.0 1.5

Table 65.Prevalence of Condom usage during last intercourse (Zonal data)Zone1. Chandigarh, Delhi, Haryana,Himachal Pradesh, PunjabRural AreasUrban SlumsEstimate % (95% CI) Estimate % (95% CI)15.3 9.9-20.7 25.7 17.7-33.62. Uttar Pradesh 9.5 6.7-12.3 13.0 6.3-19.73. Arunachal Pradesh, Assam,Meghalaya, Sikkim4. Manipur, Mizoram, Nagaland,Tripura10.6 4.8-16.5 9.0 3.1-14.99.3 5.7-12.8 8.7 4.7-12.75. Rajasthan 12.2 9.1-15.2 16.0 10.4-21.66. Madhya Pradesh 4.8 2.3-7.3 8.6 4.2-13.17. Orissa 6.6 1.6-11.6 10.6 4.5-17.48. Goa, Maharashtra 10.5 7.0-13.9 11.1 5.0-17.39. Andhra Pradesh 3.7 1.3-6.0 3.7 0.0-8.010. Karnataka 3.5 1.2-5.8 5.7 3.3-8.111. Pondicherry, Tamil Nadu 3.8 1.3-6.3 5.3 2.6-8.012. Kerala, Lakshadweep 6.7 3.9-9.4 8.6 3.3-13.9All India 8.0 7.0-8.9 11.1 9.2-13.0

Table 66.Characteristics of clients who had used condoms during their last sexual intercourseCurrent Condom UseRural AreasUrban SlumsEstimate% 95 % CI Estimate% 95 % CIAge GroupAdults (>20 yrs) 8.8 * 7.7-9.8 11.9 * 9.8-14.0Adolescents (15-20 yrs) 3.4 2.1-4.6 6.3 3.2-9.4Marital StatusMarried 8.9 * 7.8-9.9 12.9 * 10.7-15.2Unmarried 3.2 2.1-4.2 3.2 1.5-5.0EducationLiterate 10.0 * 8.5-11.4 12.4 * 9.9-14.9Illiterate 4.3 2.9-5.7 7.5 5.2-9.7* The difference between the categories was significant at p

Annexure IList of Research Associates Participated in FHAC Coverage Evaluation -2000Zone : 01 Chandigarh, Delhi, Haryana, Himachal Pradesh, PunjabAll India Institute of Medical Sciences, C.R.H.S. Project BallabgarhMr. Desh RajMs. ShikhaMr. Suresh KumarMrs. Neelam SinhaMr. Gaj RajMrs. Krishna PurohitRegional Health & Family Welfare Training Centre, KangraMr. Darshan KumarMs. Deep MalaMr. Rajiv BhardwajMs. Neelam RanaMr. Bishan DuttMs. Sarita BalaPost Graduate Institute of Medical Sciences, RohtakDr. Gurvinder SinghMr. Devendra KumarMr. Darshan SinghDr. RenuMs. SunilaMs. Renu RaniZone : 02 Uttar PradeshS.N. Medical College, AgraDr. Anurag SrivastavaDr. Manish JainDr. O.P. SharmaG.S.V.M. Medical College, KanpurDr. D.N. TripathiDr. Ghanshyam ChaudharyDr. Faizur RahmanKing George’s Medical College, LucknowDr. Sanjeev MiglaniDr. Anil KanturaDr. Deepak PandeyMs. Meera GautamDr. Neeta SharmaDr. Khurshid ParveenDr. Pushpa TripathiDr. Dimple SinghMs. Parul TripathiMs. Vidhatri SinghMs. Seema SaxenaMs. Vimala DeviZone : 03 Arunachal Pradesh, Assam, Meghalaya, SikkimAssam Medical College, DibrugarhDr. Barun KakotyDr. Pranab KalitaDr. Ajanta DeuriDr. Rinku BoriDr. Maxilline MarkDr. Mukrang TerangMr. S.R. NathDr. Malabika DeviDr. Kaveri BorahDr. Rupiyoti BorthakurDr. Baphira WankharDr. Edmond Khong ThawDr. Shamim AhmedMs. Jubin ParveezNorth East Society for the Promotion of Youth & Masses, GuwahatiMr. Paragmoni DuttaMs. Nivedita DekaMr. Jyotish BorahMs. Ritumoni DasMr. Swarup Bhatta Ms. Madhulekha Hazarika

Zone : 04 Manipur, Mizoram, Nagaland, TripuraAizwal, MizoramMr. B. HmingthantsualaAgartala, TripuraMr. Arijit GangulyMr. Mahendra TantiMr. Sumit GhoshMr. Mriganka SilcharKohima, NagalandMr. BendangmoaMr. LimakumzukRegional Institute of Medical Sciences, ImphalDr. Shangam RungsungMr. P. Babu SinghMs. MalsawmtuangiMs. Bharati ChakrabortyMs. Soma PoddarMs. Suman BarikMs. Kakali SenMs. Uttam SahaMs. MoatulaMs. NoleivileDr. Vijaya ElangbamDr. H. Sanayaina DeviZone : 05 RajasthanDr. S.N. Medical College, JodhpurDr. Ashok ChaturvediDr. Narendra ChauhanDr. Piyush MathurMedical College, KotaDr. Rajeev LochanDr. Mukesh SuwalkaDr. VeerbhanS.M.S Medical College, JaipurDr. Mukesh GoyalDr. Gopal DhakarMr. Shyam SinghDr. Usha VyasMrs. Anita VyasMrs. Neelu JoshiMs. RidhubalaMrs. Raj KumariMrs. Anju MeenaDr. Manju JainDr. Shailee JainMs. ShaliniZone : 06 Madhya PradeshGandhi Medical College, BhopalDr. Rameshwar PatelDr. Y.P. SinghMr. Ramakant PatelGwalior Medical College, GwaliorDr. S.R. SharmaDr. N. AryaGramin Sewa Sanstha, BilaspurDr. Narendra SahuMr. Om PraskashMr. Rakesh SinghMr. Ram KumarMs. Asha JainMrs. S. KushawahaMs. Apra VijayvargiyaDr. PurnimaDr. Anoop PradhanMs. Smriti TiwariMs. RajkumariMs. Rekha JhadheMs. Sharda Sharma

Zone : 07 OrissaS.C.B. Medical College, CuttackDr. I.C. BeheraDr. P. SukalaDr. Satyakam JenaV.S.S. Medical College, Burla, SambhalpurDr. B.K. BehraDr. S.S. MohantyDr. L.P. NayakM.K.C.G. Medical College, BerhampurDr. S.K. PradhanDr. R.M. PandaMr. S.K. PatnaikDr. Arachana PatnaikDr. M. MohantyDr. Sunita NayakDr. (Mrs.) S.SarkarMrs. Trupti SinghMrs. N. DasDr. (Mrs.) S. MallinDr. (Mrs.) S. DasMs. C. DasZone : 08 Goa, MaharashtraLTM Medical College, Sion, MumbaiDr. Pankaj ShahDr. Himansh GupteDr. Hemant KulkarniDr. Santosh BhalkeGovernment Medical College, NagpurMr. AbhishekMr. NikhilMr. SagarMr. AbhishekDr. Subeeta DopasDr. Geeta BhateDr. Madhavi SawantDr. Kavita PrabhakarMrs. Preetali HakandkarMs. MeghaMs. RupaliMs. PoonamZone : 09Siddhartha Medical College, VijayawadaCh. S. Nageswar RaoMr. D. RamuduMr. V. VisweswarayyaOsmania Medical College, HyderabadDr. G. SukhadasDr. A. Shravan KumarMr. P. ChandraiahAndhra PradeshDr. N. SrideviDr. M. SuneethaMrs. Sowri RaniDr. C. Mary KumariDr. A.S.N. Lalitha RaoMs. B. AkkammaS.V. Medical College, TirupatiDr. Artaf HussainDr. Y. SumathiDr. P. GaneshDr. N. Swarna LathaDr. A. Narasimhulu ` Dr. S. Vijaya Laxmi

Zone : 10 KarnatakaM.R. Medical College, GulbargaDr. Girish KumarDr. B. RohitDr. Preetam HooliSt. John’s Medical College, BangaloreDr. S.R. SrikrishnaDr. Anton IsaacsMr. B. VekateshBangalore Medical College, BangaloreDr. VeerendraDr. PappuDr. ShamsundarMs. Poonam R. PatneMs. Renuka HosamaniMs. Mallamma HiremathDr. Priya MaladanDr. C.T. AnitaMrs. Ratna KumariDr. Vasu AgarwalDr. UshaMrs. SupradaZone : 11 Pondicherry, Tamil NaduMadras Medical College, ChennaiMr. M.D. Tilak RajMr. M. SahabudeenMr. P.S. Mohan KumarChristian Medical College & Hospital, VelloreMr. AnandMr. UmakanthMr. JohnMadurai Medical College, MaduraiDr. P. Muthu KumarDr. P. Muthu KumarDr. S. JayaMs. DevikaMs. Mary GloryMs. N. KrithigaMs. A. RubyMrs. Joyce RajanMrs. Margaret SilasDr. R. Maha LakshmiDr. R. Poppy RejoiceDr. K. UshaZone : 12 Kerala, LakshadweepMedical College, ThiruvananthapuramDr. Biju M.Dr. Pradeep RavindranDr. Biju B. NairMedical College, CalicutDr. Mathew NampeliDr. V.V. SurajDr. ShibulalAcademy of Medical Sciences, Pariyaram, KannurDr. V.K. ShameerDr. Vimal VarkeyDr. Shameer ChandDr. Geetha RaiMs. Sandhya CherianMs. Asha P.R.Dr. Somy SajuMs. SushliMs. SandhyaDr. Vandana MenonDr. S. SindhuDr. L.R Vandana

Work Plan for Interviews(Composition of Field Teams)Annexure IIIZone Name: .................................................... Zonal Coordinator:................................ CCT Member:.................................................PMC’s InvestigatorsTeamNo.PMC:TeamNo.PMC:TeamNo.PMC:Team Investigator’s name 1* 4* 7*Research Assistant’s nameResearch Assistant’s nameTeam Investigator’s name 2* 5* 8*Research Assistant’s nameResearch Assistant’s nameTeam Investigator’s name 3* 6* 9*Research Assistant’s nameResearch Assistant’s name

Work Plan for InterviewsAnnexure III (contd.)Zone Name: .................................................... Zonal Coordinator:................................ CCT Member:.................................................PMC: PMC: PMC:ClusterNo.NameTeam*No.DatePlannedClusterNo.NameTeam*No.DatePlannedClusterNo.NameTeam*No.DatePlanned

Log Sheet for Households Surveyed for Male/Female Respondents in Each ClusterAnnexure IVPlease note1. To be maintained by research assistants2. Give details of the households visited for selecting respondents3. To be submitted along with the original interview schedules to CCO, New DelhiZone No: ------------------- Cluster No. and Details --------------------------------------------------------------------------S. No. Name - Head of family Remarks*1 Sh. Ram Kumar Door locked2 Sh. Mahesh Eligible individuals not at home3 Sh. Ramesh Eligible individuals busy, come back after 2 hours4 Sh. Rajan Kumar Refused to be interviewed5 Sh. Roop Kumar Interviewed* Should include comments like: Interviewed; door locked; no one in the eligible age group available athome; individuals available but busy with (household) work; refused to be interviewed; no privacy; etc.Signature of Research Assistant--------------------------------Date--------------------------------

Annexure VInterview Schedule log sheet for Team LeadersPlease Note: (i) Format to be filled by the senior investigator of each team after completing eachcluster.(ii) Original of this format to be sent to CCO, New Delhi, along with original copy of thecompleted schedules at the end of each cluster.(iii) Copy of this format to be submitted along with the xerox copy of the schedules to thezonal coordinator towards the end of the study.(iv) Return the rejected / unused schedules also to the CCO, New Delhi.Zone Name:......................................Date:.....................Cluster Address: .................................Investigator: .................................... Research Assts.: ......................................................................................1. Number of interviews completedMale: 10 Yes / NoFemale: 10GHW: 2Doctor: 1Yes / NoYes / NoYes / No2. Blank / rejected schedules sent to CCO (enter unique number of the schedule)Male:....................................Female:................................GHW:..................................Doctor:.................................3. Date of Dispatch to CCO, New Delhi: ..........................4. Problems encountered, if any:5. House visit log sheet - Men & WomenSignature of the investigator:............................ Date: ....................

Annexure VIIReport of Quality Assurance Field Visits by CCT MemberZone No and Name :..............................Date:...................Cluster No and Name :............................A. Mode of selection of households / samples / any related problems (describe):B. Cross Check of interviews already done:i) Number of households/ interviewees contacted- .......................................ii) AuthenticatedYes/NoC. Interviewing technique:i) Number of interviews observed:.....................................................ii) Quality of interviews: Acceptable Unacceptable• Cooperation of interviewee• Probing techniques• Prompting• Questions skipped / left out?• Completeness of schedulesD. Summary of deficiencies noticed and remedial actions taken:CCT Member’s Signature: --------------------------

Network Progress at a GlanceZONE:..................................................... Fax: 011 6862663 / 6865934 / 6853125Please Note: Update this monitoring sheet everyday, but fax it on every Monday, Wednesday, Friday to CCO, AIIMS, New Delhi.Annexure VIDate PMC: PMC: PMC:Cluster(No. &Name)DatePlannedDate doneDate ofDispatchCluster(No. &Name)DatePlannedDate doneDate ofdispatchCluster(No. &Name)DateplannedDate doneDate ofdispatch

Cluster Schedule Monitoring SheetAnnexure VIIIZone:ClusterNo.DateTotaldoneRecdRejected/unusedCE -1*CE-2*ClusterNo.DateTotaldoneRecdRejected/unusedCE -1*CE-2*ClusterNo.DateTotaldoneRecdRejected/unusedCE-1*CE-2*01 16 3102 17 3203 18 3304 19 3405 20 3506 21 3607 22 3708 23 3809 24 3910 25 4011 26 4112 27 4213 28 4314 29 4415 30 45Unique numbers of rejected / unused schedules:* CE : Computer entry (first & second)

Interview Schedule Monitoring SheetAnnexure IXZone: ..............................................UniqNo.RecdRejected/unusedCE-1* CE-2* UniqNo.RecdRejected/unusedCE-1* CE-2* UniqNo.RecdRejected/unusedCE-1* CE-2* UniqNo.RecdRejected/unusedCE-1* CE - 2*0101 0109 0125 01410102 0110 0126 01420103 0111 0127 01430104 0112 0128 01510105 0121 0129 01520106 0122 01300107 0123 01310108 0124 0132* CE : Computer entry (first & second)

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