Sexually transmitted diseases in Morocco: gender influences on prevention and health care seeking behavior.

Increased awareness of the medical and social costs of sexually transmitted diseases (STD) has resulted in greater attention to the control of these illnesses. STDs are responsible for a significant amount of morbidity in Morocco and have become a key target of the HIV control program. In 1996, the Ministry of Health conducted a qualitative study in order to enhance information, education and communication strategies in the national STD/HIV program. Data on the conceptualization and knowledge of STD, information sources and health-care-seeking behavior were gathered through 70 semidirected, in-depth interviews conducted with men and women in the general population and health care providers (HCPs). Two commonly applied health behavior theories in STD/HIV prevention, the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) served as a framework for data analysis. The most common name for STD is berd, which means "the cold" in Moroccan Arabic. Berd is caused either by cold striking the genital area or sexual intercourse and most often designates a syndrome of genital discharge. However, the term was also often used to indicate STD in general. The dual causality of berd maintains social stability by providing an honorable excuse for individuals who become infected, while warning against unsanctioned sexual behavior. Clear gender differences in understanding STDs and health-care-seeking behavior emerged through these interviews. STDs in Morocco are viewed as women's illnesses and men with STD often reported feeling victimized by women. Men appear to have more extensive informal information sources for STD than women. Consequences of STD, both physical and psychosocial, were viewed as more severe for women than men, and men had greater access to treatment, for both social and economic reasons.

Targeted intervention research studies on sexually transmitted diseases (STD): methodology, selected findings and implications for STD service delivery and communications.

OBJECTIVE: To report the findings of qualitative studies designed for use in improving sexually transmitted disease (STD) programs. The studies explore illness conceptions and treatment behaviors for STD in five African countries. These targeted intervention research (TIR) studies were performed on clinic-based and community-based samples in representative communities and utilized a variety of qualitative research methods (e.g. in-depth and key informant interviews, focus group discussions). FINDINGS: Study findings revealed that community members' explanations of symptoms, classification of illnesses, and perceptions of whether symptoms are pathological or serious influence individual health-care-seeking behaviors. Data also showed that local terms for STD are often disparaging and do not fit into biomedical designations. STD patient care-seeking frequently reflects an ordered, albeit loosely constructed, process of elimination in pursuit of symptom relief, wherein alternative treatments are tried and proven effective or abandoned. CONCLUSIONS: The TIR studies highlight the importance of community-specific strategies aimed at increasing prompt care seeking at qualified biomedical facilities. Information from study data should lead programs to sensitize health professionals to community understanding about STD and to design services and communication programs that are meaningful and appropriate to local contexts.

PIP: Targeted intervention research (TIR) studies were performed in five African countries (Senegal, Ethiopia, Benin, Morocco, and Swaziland) to improve the utilization of a community perspective in sexually transmitted disease (STD) programs. TIR, conducted by program managers with the aid of a multidisciplinary technical advisory group, examines factors at five levels of analysis (individual, social network, organization, community, and policy) through a variety of qualitative methods. The TIR studies indicated that patients' conceptions of normal versus abnormal health are fundamental to the process of interpreting symptoms and subsequently seeking care. The interpretation of STD symptoms varied across settings (e.g., vaginal lesions and discharge were considered signs of healing in Morocco and Benin), but increasing pain and discomfort were key triggers to seeking treatment. The concept of sexual transmission was blended with other causes such as violation of religious or moral codes, consumption of certain foods, and supernatural forces. Care-seeking tended to reflect an ordered yet loosely constructed process of elimination in pursuit of symptom relief, beginning with alternative regimens. Barriers to biomedical STD care included the need for husband's permission, costs, confidentiality concerns, long waits in public clinics, and fear of judgmental health provider attitudes. Overall, the findings highlight the importance of location-specific strategies aimed at increasing prompt care-seeking at qualified biomedical facilities.