More widespread promotion of STD services and more public information about STDs are desperately needed. In both developed and developing countries, many people know little about STDs—how they are transmitted, their symptoms, how they threaten health, how they should be treated, and how to prevent them—and many are misinformed (3, 7, 42, 208, 209, 216, 310). In Nigeria, for example, some men believe that their semen will cure their partners (3). In the US many people say that they do not fear getting AIDS because they are not in any of the groups with a high prevalence of AIDS (7).

As a result of ignorance or misinformation, some people engage in risky sexual behavior or delay seeking treatment from a health care clinic. In studies in Nigeria and Uganda, for example, men with symptoms of urethritis waited an average of about 21/2 years before seeking treatment at a clinic (138, 278). Women who delay treatment risk life-threatening complications and infertility.

Also, people may be afraid to seek care. Some people stay away from public clinics because they do not want to answer questions about their sexual partners, as has been reported in Uganda (322). Callers to a US STD telephone hotline who were infected or who had been exposed to infection said that they did not seek care because they worried about confidentiality, the procedures for diagnosis and treatment, being humiliated by clinic staff, and the long-term consequences of infection (141).

To overcome barriers, programs have used various approaches:

• Videotapes in STD clinics. In a US program, for example, patients at an STD clinic in Baltimore saw a 10-minute videotape urging them to bring sexual partners to the clinic and to return themselves to make sure that they had been cured. Some 54% of the patients who saw the videotape returned for a test of cure, while 43% of those who did not see the videotape returned (279).
• Counseling of STD patients. A study in Nigeria tested the effect of reinforcing a social worker's counseling with a doctor's counseling. All patients who received expanded counseling returned for their first follow-up visit, while only three-quarters of those who did not receive the extra counseling returned (211).
• Counseling of pregnant women and influential family members. For example, in Zambia a prenatal syphilis screening program told pregnant women about STDs when they came to antenatal clinics. Young women often talk to their mothers first if they have symptoms. Therefore the program also informed elderly women about STDs when they came to a clinic for treatment of diabetes or hypertension. The program helped to increase the percentage of women attending the screening clinics in their first trimester of pregnancy from 12% in the mid-1980s to 42% in 1990-91 (114).
• Brochures. In Zambia the Copperbelt Health Education Project has published an illustrated brochure entitled What Everyone Should Know About STD, which describes symptoms, the ways STDs are spread, and ways that they are not spread. It urges people to seek treatment at a clinic and to avoid unqualified practitioners (59).
• Education of community leaders. For example, in Kenya the Nairobi STD program conducts workshops for school heads and leaders of parent-teacher associations (199, 255).
• Radio drama. For example, in The Gambia an episode of a popular weekly radio drama series broadcast in 1991 encouraged people to go to a doctor or health center for STD services rather than treat themselves (92).
• Education and clinics especially for young people. A world survey of AIDS prevention programs found that 19 of 23 developing countries had AIDS education programs in schools (177). Other in-school activities have included health clinics (4, 326) and peer education (4, 94, 192).

Mass-media promotion can have a large impact, as coverage of AIDS has shown. Such coverage is especially effective when it is entertaining. In the Philippines, for example, a popular television soap opera broadcast an episode that portrayed a businessman who had become infected with HIV from a prostitute. In the week following the broadcast, visits to STD clinics in Manila doubled (66). Also, a celebrity with an STD attracts media coverage that can bring people to clinics. US basketball player "Magic" Johnson's announcement that he was infected with HIV was probably the main reason that requests to US public clinics for HIV tests increased by 10%, from 400,000 to 440,000, in the last three months of 1991 (95).