AIDS in South Africa.

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Development and implementation of a peer-based mental health support programme for adolescents orphaned by HIV/AIDS in South Africa Gloria Thupayagale-Tshweneagae

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Department of Health Studies, Faculty of Human Sciences , University of South Africa , PO Box 392, UNISA 0003 Published online: 19 Dec 2011.

To cite this article: Gloria Thupayagale-Tshweneagae (2011) Development and implementation of a peer-based mental health support programme for adolescents orphaned by HIV/ AIDS in South Africa, Journal of Child & Adolescent Mental Health, 23:2, 129-141, DOI: 10.2989/17280583.2011.634554 To link to this article: http://dx.doi.org/10.2989/17280583.2011.634554

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Journal of Child and Adolescent Mental Health 2011, 23(2): 129–141 Printed in South Africa — All rights reserved

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JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1728–0583 EISSN 1728–0591 DOI: 10.2989/17280583.2011.634554

Research Paper


Development and implementation of a peer-based mental health support programme for adolescents orphaned by HIV/AIDS in South Africa Gloria Thupayagale-Tshweneagae Department of Health Studies, Faculty of Human Sciences, University of South Africa, PO Box 392, UNISA 0003 Email: [email protected] Aim: The article describes a framework and the process for the development of the peer-based mental health support programme and its implementation. The development of a peer-based mental health support programme is based on Erikson’s theory on the adolescent phase of development, the psycho-educational processes; the peer approach and the orphaned adolescents lived experiences as conceptual framework. Methods: A triangulation of five qualitative methods of photography, reflective diaries, focus groups, event history calendar and field notes were used to capture the lived experiences of adolescents orphaned to HIV and AIDS. Analysis of data followed Colaizzi’s method of data analysis. Results: The combination of psycho-education, Erikson’s stages of development and peer support assisted the participants to gain knowledge and skills to overcome adversity and to assist them to become to more resilient. Conclusion: The peer based mental health support programme if used would enhance the mental health of adolescent orphans.

Introduction Sub-Saharan Africa remains the region most heavily affected by HIV and AIDS than any other in the world. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), the region accounted for 72% of all new infections in 2008, and for 68% of the global number of people living with HIV in 2009 (UNAIDS 2010). UNAIDS further reports that during 2009 alone, an estimated 1.3 million adults and children died as a result of AIDS in sub-Saharan Africa and that more than 15 million have died since the beginning of the epidemic in the early 1980s (UNAIDS 2008, 2010). With this prevalence the AIDS epidemic in sub-Saharan Africa continues to devastate communities, rolling back decades of development progress. Among its major social ramifications is the increase in the number of orphans in the region. Although the levels of orphanhood have always been high in sub-Saharan Africa because of generally high levels of mortality, the AIDS epidemic has increased the phenomenon to unprecedented levels (UNECA 2004). For example, UNAIDS et al. (2004) projected that Africa’s estimated 43.4 million orphans in 2003 would increase to 50 million by 2010. The increase was attributed largely to AIDS, projecting that the estimated 12.3 million AIDS orphans at the end of 2003 would increase to 18.4 million in 2010 (UNAIDS et al. 2004). Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group


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Perhaps the most important statistic for this paper is the fact that the majority of all orphans are adolescents aged 12 to 17 years (UNAIDS et al. 2004; Ruland, Finger and Williamson 2005). Although information is available on the exact proportion of adolescents among those orphaned by AIDS, the pattern is obvious that the prevalence of orphans increases with age (Ruland et al. 2005). Subbarao and Coury (2003) assert that AIDS often kills parents after infection, thus increasing the chance that a child will be an adolescent before being orphaned. Additionally, many orphaned children grow into adolescence. Despite these demographics, most programmes and organisations working with orphans do not focus on the particular needs of adolescents, but on the protection and care of orphans and vulnerable children. In consequence, the special emphasis and tailored programmes needed by the adolescent population are often neglected (Ruland et al. 2005, Osborn 2007). However, the needs of orphaned adolescents go beyond those that they share with younger orphans such as housing, food, social supports and education. Adolescents typically experience emotions of anger, resentment, hopelessness and depression. Losing one parent or both can aggravate these feelings, and also lead to a sense of alienation, desperation, risk-taking behaviour and withdrawal (UNAIDS et al. 2004, Ruland et al. 2005). To this end, adolescents orphaned by HIV and AIDS also represent a population vulnerable to mental health risks. Given the high HIV and AIDS prevalence in South Africa and the fact that 25% of the 1.9 million orphans in the country are adolescents (UNAIDS 2010), the establishment of a mental health support programme in South Africa is long overdue (Burnett 2000, Bray 2003). Such a programme would help uncover the needs of adolescent orphans in their struggle to deal with issues surrounding HIV and AIDS deaths, to cope with and adapt to the loss of a parent, and to grieve appropriately by learning how to express their feelings. This paper presents the results of a research project aimed at developing and implementing one such programme: a peer-based mental health support programme for orphaned adolescents in South Africa. Conceptual framework in the development of a peer-based mental health support programme for adolescents orphaned by HIV and AIDS The target population for the study was adolescents orphaned by HIV and AIDS. Erikson’s stages of adolescent development, the psycho-educational process, peer-based principles and the results of the situational analysis formed the basis of the programme development, based on the needs of the orphaned adolescents. The applications of the programme were based on the peer-based approach to bring about the desired outcomes of promoting the mental health of orphaned adolescents and preventing the occurrence of mental illness. Erikson’s adolescence stage According to Erikson (1980), adolescence is characterised as the period in the human life cycle during which the individual must achieve a sense of personal identity and avoid the dangers of role diffusion and identity confusion. Identity achievement requires that the individual appraise personal strengths and weaknesses and resolve how to deal with them (Boeree 2007). The adolescent must find an answer to identity questions, such as “Where do I come from?” “Who do I want to be?” and “What do I want to become?”. The term adolescence describes the transition from childhood to adulthood that is marked by distinct biological, cognitive and socio-cultural changes (Ajdukovic 1998). Adolescence is a period when individuals become increasingly aware of themselves as social beings. It involves the establishment of an adult identity which is a complex and demanding process. This means that adolescents will face key development issues which will be even more challenging for orphaned adolescents (Li et al. 2008). Adolescence is defined by Durkin (1995) as a dynamic period of change. These changes are not just within the young person, but also within his or her social structure. The fundamental feature in adolescents’ health and well-being is their ability to connect with their environment (GrieselRoux 2004). It is the researcher’s contention that adolescents’ ability to deal with such influences will depend on the conflict resolution that occurred in the preceding phases of child development. Erikson (1982) has stated that the identity established by the end of early adolescence includes identification with past significant figures (Ajdukovic 1998).


Journal of Child and Adolescent Mental Health 2011, 23(2): 129–141

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The concept of adolescence, though used in everyday language, is always difficult to define because of cultural and developmental variations. There is no physiological standard that fully correlates with age and no psychological state that is generally recognised as a gauge of adolescence (Durkin 1995). Adolescence starts between the ages of 11 and 13 years and ends between 18 and 21 years. The beginning of the adolescent phase is generally characterised by the child focusing on self, being moody, mostly interested in peers and lacking interest in parents. The end of adolescence is generally characterised by decreased conflict with parents and deeper capacity for caring (CDC 1992). The disparities in age definition are attributable to differences in cultural perceptions and ethnic customs (Fontaine and Fletcher 2004). For example, in some Tswana cultures, a 14-year-old boy has to undergo traditional circumcision. A boy who endures the pain and other environmental hardships that he is exposed to will be deemed to be a “man”; one who is unwilling to endure pain will be treated as a “boy”. Until he endures such pain he will be treated as a child (Mosinyi 2007). In other Tswana cultures boys are circumcised at the age of 18 years. It is in light of these age differences that researchers often describe adolescence by separating it into three different phases, namely: • early adolescence: between the ages of 11 and 14 years • middle adolescence: between 14 and 18 years • late adolescence: between 18 and 21 years. For the purpose of this research “adolescence” will refer to middle adolescence. During middle adolescence an adolescent strives to establish a clear sense of identity (Herbert 2003). Erikson (1982) views adolescence as a critical period for the formation of a sense of personal identity. He represents this stage as involving a conflict between the need to attain a sense of self-integration and the need to meet the diffuse external demands of society and determining one’s own place within it. It is through the resolution of this conflict that an individual becomes equipped for the next stage of human development, attaining the psychological intimacy of adult relationships (Durkin 1995). According to Ruland et al. (2005), adolescence involves moving toward social and economic independence. These authors also noted that the developmental challenges faced by middle adolescents, namely to establish identity as a sexual being, are more complex than in the other two phases of adolescence. Peer groups and adolescents Adolescence is a stage when peers play an increasingly important role in the lives of youth. Adolescents develop friendships that are more intimate, exclusive and more constant than in earlier years. These friendships provide safe contexts where adolescents can explore their identities, where they can feel accepted and where they can develop a sense of belongingness (Erikson 1985). Friendships also allow adolescents to practise and foster the social skills necessary for future success (Guzman 2008). As such, there have been many interventions for orphaned adolescents based on peer relationships (Norr et al. 2004). As pointed out by Wolfelt (2002), adolescents orphaned by HIV and AIDS are exposed to unpredictable and unfamiliar experiences which make them vulnerable to mental health problems. Goodman (2002) indicates that losing a parent during adolescence may adversely affect life-long mental health. This may be partly due to the fact that orphaned adolescents are forced to mature and take up responsibilities beyond their developmental phase (Erikson 1985). Research indicates that peer groups in structured mental health programmes may have positive effects (Morrison-Valfre 2003; Norr et al. 2004). Peer groups provide emotional support and a sense of belonging. According to Guzman (2008), peer groups help adolescents establish values and behavioural standards; they provide protection and safety, and allow adolescents to test and try out new behaviours. Peer groups promote behavioural changes in many ways, including social support, detailed information and the development of new norms and values. This may support effective coping styles, safer sex skills and situation adjustment (Norr et al. 2004). Unfortunately, peer groups may at times encourage self-destructive behaviour (Morrison, 2004). However, the successes of peer-based programmes far outweigh their failures (Norr et al. 2004). Peer groups act as a social environment that fosters growth in adolescents. Thorup, Kinkade and Velia (2003) assert that peer groups make adolescents feel less alone. When adolescents


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participate actively in peer-based programmes, it becomes easier for them to mobilise their peers to take action on a particular issue. Erhardt (1997) supports the idea of peer intervention, but cautions that it can only be effective if based on the culture of that specific group. The Canadian Mental Health Association has advocated for youth participation (McCall and Shannon 1999). It defines youth participation as the recognition of young people’s strengths, abilities and interests through the provision of real opportunities that help their growth and development. According to the literature reviewed by McCall and Shannon (1999), those who develop peer-based programmes for the youth must first seek the opinion of the young people and then apply it. It is the adolescents themselves who should determine what constitutes youth participation and empowerment. The adolescents must be involved in the design, implementation, evaluation and follow-up. Youth-led programmes help the youth develop confidence, skills and knowledge that serve to make them positive change makers and leaders in their societies (Thorup et al. 2003). Boyer et al. (2007) note that community level approaches using peer-based education have been successful in reducing sexual risk behaviour. Boyer et al. (2007) further evaluated the youth programmes and found that peer-led health outreach programmes are feasible and acceptable for implementing HIV prevention strategies. These principles can be applied in the development of a peer-based mental health support programme for adolescents orphaned by HIV and AIDS. Psycho-educational processes Psycho-education has its origin in mental health interventions (Griffiths 2006, McIntyre and Lallement 2008). The theory behind psycho-education is based on a holistic approach to understanding what it means to be human (Morse 2004). Psycho-education involves challenging maladaptive thinking processes and it suggests alternative adaptive patterns of thinking (Morse 2004). Colom and Lam (2005) define psycho-education as education offered to individuals who suffer from a psychological disturbance. Its main purpose is to reinforce and individual’s own strengths, resources and coping skills, which will promote health and wellness on a long-term basis. This definition is supported by Lukens and McFarlane (2004), who report that psycho-education involves teaching individuals about their problems, how to treat them, and how to recognise signs of relapse. They also emphasise education about coping strategies and problem-solving skills. The psycho-educational approach to behaviour assessment is broad in nature; it is known as the “ecological assessment”. It considers all aspects of the individual’s life that might have an impact on their behaviour (McIntyre and Lallement 2008). This psycho-educational perspective seeks to identify with the individual who is trapped in a failing effort to adequately handle life situations. Thus, it looks at both individual and social explanations for inappropriate, anti-social behaviour patterns (McFarlane 1994). As a result, psycho-education has been applied successfully in a wide arena of both social and emotional issues to redirect individuals’ thoughts and change their perceptions and behaviour (Griffiths 2006). There is increasing emphasis on psycho-education for those who are unable to cope with life stresses (Winkler 2006). Psycho-education does not focus on illness and its treatment only. Its major tenets are found in goal setting, skills acquisition, satisfaction with oneself, improving one’s coping abilities and achievement of the set goals (Authier 1997). This explanation is supported by Colom and Lam (2005) who hold that psycho-education focuses on compliance enhancement; importance of lifestyle regularity; exploration of the individual’s health beliefs; and on illness awareness. All these enable the individual to understand the complex relationship between personality factors and the interpersonal environment (Griffiths 2006). Method Research design Before the development of the peer-based mental health support programme, a phenomenological qualitative design was used to explore the lived experiences of adolescents orphaned by HIV and AIDS. The aim of phenomenological research is to examine the meaning of life through the interpretation of the individual’s lived experiences (Streubert-Speziale 2006). Lived experiences are defined by Manser (1984) as seeing or living through an event which gives one knowledge or skill.



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Study population and setting The study took place at a day care centre run by a non-governmental organisation in an urban area just outside the capital city of South Africa, Pretoria. The centre serves as a hospice for feeding and providing social support for vulnerable populations including orphans, most of whom are orphaned by AIDS. The target population for the study was adolescents who met the following criteria: • aged 14 to 18 years • had been orphaned by HIV and AIDS • had been orphaned for more than one year • attended the centre regularly once a week • were willing to participate in the study. The participants did not know their own HIV status as none of them had been tested. Sampling procedure Purposive sampling was used to recruit the participants using the criteria discussed above. Purposive sampling is a technique in which the investigators choose the participants on a judgment of the extent to which the potential participants meet the selection criteria and illustrate some feature or process in which the investigators are interested (Silverman 2000, Welman and Kruger 2000). The sampling yielded a total of 15 adolescents. Data collection Five qualitative methods of photography and photo-elicitation, reflective diaries, field notes, event history calendar and focus group discussions were used to elicit lived experiences from the participating orphaned adolescents. Photography and photo-elicitation Photographs facilitate a vivid and accurate recollection of events. A photograph captures an event as it occurs (Emme 1988). In this study, photography was used to capture and communicate the non-verbal aspects of a lived experience. Participants were given disposable cameras and asked to take photographs that depicted their loss and grief, and experiences that related to being orphaned by HIV and AIDS. They were also asked to take photographs of things that would help them cope with their loss and those things that represent their intention in life. Since 10 of the 15 participants had never used a camera before, the researcher began by explaining how a camera works and demonstrating how to take a picture. The participants were given an album of their photos so that they could keep them for further probes and clarification. Reflective diaries Diaries are a useful tool for studying any phenomenon in qualitative research, as they reflect the research participants’ subjective knowledge of the experiences, emotions and meanings associated with the phenomenon under study (Rosenblatt 1995, Deacon 2000). To this end, the research participants were given small notebooks to serve as diaries. They were then asked to record their experiences of being orphaned by HIV and AIDS in the diaries. Participants were also asked to record their thoughts, feelings and experiences during the weekly meetings at the centre. Recordings in diaries lasted for six months. However, only eight participants actually wrote in their diaries; the other seven handed in empty diaries. The latter group reported that they did not have anything to record. Field notes The researcher recorded field notes of any observed phenomenon during data collection. The researcher also kept a self-reflective diary of her own emotions, feelings and thoughts that she experienced during the process of data collection. Event history calendar An event calendar approach is an interviewing method in which the more memorable events serve as cues to help the participant remember other life events (Martyn and Belli 2002). It is designed to

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retrospectively collect life course reports (Arbor 2006). Event history calendars are used to collect data about events and life transitions over short and long periods of time. In the calendar methodology, separate timelines for each of the areas of interest to the study were used. For instance, participants were asked to trace certain behaviours, such as feelings of isolation, anxiety and depression over a period of two years, and were then aligned with the time of parents’ illness to the time of death and after death. Focus group discussions Four focus group discussions were conducted with the adolescents to explore their grieving processes. The focus group discussions were structured around the following themes: grieving, coping support, experience with loss and expectations about the future. The discussions were held in Setswana (the vernacular for all participants) and later translated into English. Data analysis Colaizzi’s model of data analysis was applied to analyse the themes that emerged from the various types of subjective data provided by the research participants (Sanders2003). This included data from the photo-elicitation interviews, focus group discussions, event history calendars, reflective diaries and field notes. This data analysis method consists of seven steps. Step 1: Transcripts. The researcher read and re-read word-for-word the participants’ interviews to make sense of them and acquire a feel for each description. It was through this step that the researcher aimed to internalise the lived experiences of adolescents orphaned by HIV and AIDS, in particular how orphaned adolescents grieve for their parents and cope with the loss. Step 2: Extracting significant statements. The researcher extracted from the descriptions all the significant statements which pertained directly to the study theme. Each statement extracted by the researcher in this study related to the way the participants grieved for their parents and coped with the loss. Examples of significant statements are: • “I felt like the world had ended.” • “I sit alone, I do not share my grief with anyone, they would not understand.” • “I would have liked to say goodbye, choose a coffin and say a eulogy.” • “People contribute money, that’s not what I want. What I want is for them to tell me my mother will be back.” Step 3: Formulating meanings. According to Colaizzi (1978), formulation of meaning is the most difficult step because the formulated meanings need to reflect what the participant said without distortion. In this study, the researcher formulated meanings after analysing each significant statement. The researcher then re-read the original transcripts to ensure that the original description was truthfully portrayed in the extracted significant statement meanings. Examples of formulated meanings are the following: Significant statement: “I sit alone and do not share my thoughts.” Interpretation: Isolation, a way of grieving. Significant statement: “Whenever my uncle abuses me about my mother I go into my room and write a poem for my mother.” Interpretation: Uses poems to cope. Step 4: Theme clusters. The researcher organised the formulated meanings into clusters which allowed themes to emerge. The researcher also referred to the original transcripts for validation, being cognisant of repetitive themes and discrepancies. Step 5: Exhaustive description. The researcher integrated the themes into an exhaustive description. The exhaustive descriptions in this study lent themselves to the discovery of the lived experiences of adolescents orphaned by HIV and AIDS. Step 6: Statement of identification. The researcher made concise statements of the exhaustive description and provided a fundamental statement of identification. The statement of identification reflected the essential structure of the phenomenon under study. Step 7: Participant verification. The researcher presented a concise statement of the exhaustive description to the original participants of the study to verify the statement. Colaizzi


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(1978) suggests that the researcher validate the information by asking the participants what aspects of their experience have been omitted in the concise statement. Some of the comments made by the participants in this study were: “That is what I said.” “I agree with what you wrote.” Lived experiences of adolescents orphaned by AIDS An understanding of the lived experiences of the adolescent orphans provided unique insights into their expressed emotions and needs. The adolescents reported that they experienced pain and rebuke from caregivers, both at school and at home. At times, the participants had to suppress their emotions for fear of being rebuked and blamed for not appreciating the care being given them. After the death of their parents, uncertainty surrounded the lives of the adolescents. Anger, isolation and fear of the unknown and the future were the strong emotions that came from the participants. Participants could not cope with the death of their parent(s) and at times experienced suicidal ideation. The stigma of HIV and AIDS led the participants to isolate themselves from those who could have helped, such as friends and teachers. There was a great deal of uncertainty about the future. Participants needed to feel accepted by caregivers and to be supported throughout their journey of grief. These experiences formed the basis for the development of a peer-based mental health support programme. It was deduced from the situational analysis that orphaned adolescents grieve inappropriately and have a passive way of coping with the loss of parents. The grieving process for an adolescent orphaned by AIDS may be prolonged because of lack of social support, especially if it is the mother who died and the surviving next of kin is also grieving the loss of a spouse or child (Geballe and Gruendel 1998). In African communities this situation is compounded by the fact that children are socially conditioned to hide their feelings. In addition, more attention is often given to the grieving adult than to the children (Tsheko 2006). Lack of support and poor communication patterns may later result in adjustment disorders in adolescents (Van Dyk 2003). Coping strategies for adolescents orphaned to HIV and AIDS were numerous. Behaviours associated with grieving included crying, fighting, isolation and silence. Participants’ descriptions of behaviours associated with coping included developing a carefree attitude; seeking professional counselling; expressing feelings of loss to caregivers and friends; reading a book on death and dying; poetry; singing; and pretending it did not matter. HIV and AIDS is an unremitting stressor in the lives of many South African adolescents. They have to cope with the loss of their parent(s), engage in adult responsibilities that they are ill-prepared for and in many cases leave school to become economic earners for their households (Foster and Williamson 2002, Ruland et al. 2005). They are hampered by grief and are prone to developing mental health problems, including post-traumatic stress syndrome, depression and anxiety. These conditions may be kept hidden from health care workers and other caregivers responsible for their care (Foster 2002). Early identification of such psychosocial effects will assist the adolescents to better cope with the many losses that the deaths of their parent(s) have brought upon them. At the end of the situational analysis results showed that some of the participants needed to be motivated to stay positive about their lives. Thus, they were shown the three-hour film — War Dance (Fine and Fine 1998) — which presents the story of adolescents who lived through the war in Uganda in the 1980s. The adolescents in the film had seen their parents being killed and then lived with relatives who verbally and physically abused them and were emotionally distant from them. The adolescents in the film overcame adversity through music and hard work at school. They eventually held down good jobs. The film served as a motivator for the programme participants. The programme participants initially expressed emotions such as anger towards the people who had abused the adolescents in the film. They later expressed hope for the future. Development and implementation of the programme The adolescents’ lived experiences were used to form the basis of the peer-based mental health support programme for orphaned adolescents. The programme was developed over a series of 16

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sessions of 90 minutes each. A session was defined as a day’s activities in which participants and the researcher interacted to achieve a set goal. The sessions took place in an assigned meeting room at the day care centre that allowed for privacy. The chairs and tables were arranged in a circle to allow for easy interaction with one another. Since trust and rapport had already been established during the situational analysis, each session started with the group leader introducing the topic of the day and reminding the participants about the set rules. Sessions were organised around three cyclical steps: orientation; knowledge and skill acquisition; and evaluation. Orientation Phase (sessions 1 and 2) The orientation phase consisted of seven components: revisiting the lived experiences of orphaned adolescents; reassessing adaptive coping strategies; choosing a name for the programme; choosing peer group leaders; training group leaders; reading assignment; and deciding on the indicators for the success of the programme. Revisiting the lived experiences It was important to revisit the lived experiences deduced from the situational analysis to confirm that the adolescents did indeed consider them as their own. After discussing the experiences again, the group agreed that any intervention should be able to assist adolescents to adapt to the changes brought about by their parents’ death. Reassessing adaptive coping strategies The coping strategies identified in the situation analysis were reassessed to ensure that the programme participants agreed on the adaptive coping strategies. To read a simple book on death and dying written in the local language was suggested by some of the participants as an effective starting point for the group. The main emphasis of the book was that each person has his or her time to die. The group chose the book because they agreed that the group member who had actually used it as a coping strategy seems to be doing well. It was agreed that she would bring the book to the next session. Other adaptive strategies were reported to be common and it was agreed that each individual could practise them separately. Poetry was also regarded as an adaptive coping strategy, however, the participants felt that it should be left to the participant who was already practising it. Choosing a name for the programme The researcher explained to the participants that the programme material would be compiled into a manual so that it could be used with other groups after completing the study. Thus, the group was requested to select a name for the intervention programme. Two abbreviated names were suggested, namely PUSH (Pray Until Something Happens) and BAR (Better Accept Reality). Some participants felt that prayer had not helped them sufficiently with their pain: they had been praying without experiencing real healing. As a result, this name was not adopted. Participants accepted the name BAR for the programme. Choosing peer leaders The researcher explained that participants had to choose leaders from among the group. Choosing peer group leaders prepared the group for the process of knowledge and skill acquisition. The selected peer leaders would be trained in the content to be taught during the facilitation of the various discussions. Group members identified specific individuals because of their various successes and positive attitudes. For example, one leader was nominated because she was known to be supportive. However, every member of the group was given the chance to act as co-leader or leader in at least one session. Training group leaders The researcher trained group leaders in the content of the programme which included death and dying; assertiveness and communication within families; and problem solving. Peer group leaders


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were trained in how to conduct groups and to have the group comply with group rules. They were also trained in how to become active listeners in a group setting. The researcher trained the participants in two sessions before the actual knowledge and skill acquisition phase began. The peer leaders’ roles were to facilitate discussions on the content and scenarios for role plays.


Reading assignment The participants agreed to read the book on death and dying that was used by one participant to cope with the death of her mother. The book written in Setswana was photocopied and given to participants. Deciding on the indicators of success for the programme Qualitative and quantitative indicators were agreed upon by participants as indicators for success or lack of it. Qualitative indicators are indicators of people’s judgements or perceptions about a subject (Patto 1996). In other words, achievement of qualitative indicators would refer to changes in opinion, beliefs or way of thinking. The participants agreed on the following criteria as qualitative indicators of intervention success: improved relationships with caregivers; increased ability to express needs; increased ability to mentor one another; the formation of enduring relationships with other group participants; and increased knowledge on death and dying. The achievement of these indicators would be regarded as indicative of the adolescents’ increased ability to accept and cope with their many losses. Also, it would give them foundational skills upon which to build future mental health. Participants agreed on the following quantitative indicators of intervention success: improvement of average school grades by at least 10% within one year. The achievement of this goal would be regarded as indicative of a success pattern that could be readily recognised and which would be an encouragement for future academic success. Knowledge and skill acquisition phase The primary aims of this phase were to confront the orphaned adolescents with two major challenges: to accept the reality of the situation, and to improve the quality of their lives. The purpose was to help adolescents to depend on their personal resources to meet their needs. During each session, the participants had to write down their own needs in their diaries and the strategies to meet them. Participants were also asked to share their entries with other group members and to have their entries discussed at the end of each session or at the beginning of the following session. The sessions were in modular form as outlined in Table 1. The two primary modes of transmitting information to the programme participants under a peer-group leader’s facilitation were role playing and group discussions. These two modes were Table 1: Module outline Module title Death and dying

Topics Defining death and dying Attitudes towards death Experienced emotions: despair, grief, bitterness, rage, numbness and isolation Acceptance of death Assertiveness and communication Defining assertiveness Skills acquisition Accepting change Learning to forgive Communicating effectively Problem-solving skills Identify the problem Know the origin of the problem Seek possible solutions Implement solutions Evaluate the solutions Revise the solutions if needed

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chosen for their effectiveness among adolescents and to allow for ownership of the proceedings by all. The researcher was present at all the sessions to provide ongoing support and encouragement and to be available to answer any questions that might arise during the sessions. Understanding the concept of death and dying The module on death and dying was led by the peer-group leader who had read the book on death and dying. Before the session, participants had to read the 15-page book written in the local language (Setswana). It was provided to the participants before the session. The book provided the participants with the opportunity to better understand the concept of death and dying and to make it easier for them to accept that death is inevitable, and that it comes at different times and in different ways for different people. The four elements in the book, namely forgiveness, love, gratitude and hope, were discussed during the session. This module included discussions around various aspects of death and dying. The topic allowed participants to reflect on their experiences, as it covered some of their stated needs. The module also informed the participants on the concept of death and dying, emotions attached to death and how to accept the death of a loved one. This information enabled the participants to make decisions on how to resolve their perceived problems related to their parents’ deaths. Assertiveness and communication skills acquisition The assertiveness and communication skills acquisition module was led by the peer- group leader who used poetry as a coping strategy. The peer group leader of module 1 acted as the co-leader. Both the peer-group leader and co-leader were selected by programme participants. The module focused on defining assertiveness and how to communicate clearly. Learning how to become assertive and knowing how to communicate would help participants accept change and learn how to forgive. The programme participants had to understand assertiveness, how they could become assertive and yet remain respectful to caregivers, teachers and peers. Participants had to accept that change was inevitable as a result of their parents’ death. Their parents would no longer be there to meet any of their needs. The use of role play during this module taught participants how to forgive their parents for dying, their caregivers for not being their parents, and themselves for blaming God for their parents’ death. Role playing is a methodology derived from socio-drama that may be used to help students understand the more subtle aspects of literature or social studies (Blatner 1995). Role playing is the best way to develop skills of initiative, communication, problem-solving and working cooperatively with others. It helps people deal with challenges that may occur (Blatner 1995). The module taught participants to always express what they felt in the group sessions without censoring it. The module was designed to help participants reflect on past behaviour and move on to acceptance. Problem-solving skills Group leaders for this module role-played their personal experiences at home, including their difficult relationship(s) with their grandmother(s). Their school experiences were also enacted, including being scolded by a teacher. This session covered problem definition and finding solutions to the problem. In the second session of the module, group leaders facilitated some role plays with other participants and they also acted out their experienced problems, including being verbally abused by relatives. The use of appropriate assertiveness techniques that had been previously learned was demonstrated in these role plays. The emphasis of the overall module was to assist the programme participants to understand that they were in control of their own destiny and that they had choices in their own lives. Evaluation The evaluation of the support programme was an outcome-based evaluation that used both qualitative and quantitative methods. The qualitative and quantitative methods followed the indicators agreed upon by participants at the beginning of the programme development. The indicators were evaluated through focus group discussions and individual interviews.


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The study demonstrated that the peer-based mental health support programme is effective in meeting the mental health needs of adolescents orphaned by HIV and AIDS. The participants were able to express their needs and improve relationships with caregivers — a clear sign of adapting to their loss.


Conclusion This article focused on the process undertaken to develop and implement the peer-based mental health support programme for adolescents orphaned by HIV and AIDS. The use of a conceptual framework in the development of the programme was explained and the strategies used for the implementation were discussed. The peer-based mental health support programme was based on psycho-educational principles and Erikson’s adolescent stage of development. It afforded the researcher the opportunity to assist the participants with appropriate grieving patterns and adaptive coping strategies. In turn, this would promote their mental health and prevent mental illness in future. The combination of psychoeducation, Erikson’s stages of development, and peer support assisted the participants to gain knowledge and skills to overcome adversity and to assist them in becoming more resilient. The study’s unique contribution to current literature is that the adolescents presented very powerful messages regarding being involved in their parents’ illness, funeral arrangements and choosing where and with whom they had to stay after their parents’ death. This notion has not been identified in literature. It also places mental health practitioners in a unique position to educate communities in adolescent involvement and to caution on cultural practices in situations where a parent’s illness is not discussed with adolescents. The other unique contribution of the study is the development and implementation of the peer-based mental health support programme. No other similar programmes for orphaned adolescents are reported in the literature; thus this adds a unique new programme to enhance the mental health of adolescent orphans. References Ajdukovic M. 1998. Displaced adolescents in Croatia: sources of stress and Posttraumatic stress reaction. Journal of the Association of Nurses in AIDS Care 33: 209–217. Authier J. 1997. The psychoeducation model: definition, contemporary roots and content. Canadian Counsellor 12: 15–20. Arbor A. 2006. Using calendar diary methodologies in life events research: Proceedings of the Panel Study of Income Dynamics Proceedings of the Event History Calendar Conference, held in Michigan on 15–17 June, 2006. Ann Arbor, Michigan. Blanter A. 1995. Drama in education as mental hygiene: A Child Psychiatrist Perspective. Youth Theatre Journal 9: 92–96. Boeree G. 2007. Personality theories: Erik Erikson, 1902–1994. Available from: http://webspace.ship.edu/ cgboer/erikson.html [accessed: 4 December 2007]. Boyer CB., Sieverding J, Siller J, Gallaread A, Chang JY. 2007. Youth united through health education: Community-level, peer-led outreach to increase awareness and improve non-invasive sexually transmitted infection screening in urban African American youth. Journal of Adolescent Health 40: 499–505. Bray R. 2003. Predicting the social consequences of orphanhood in South Africa. African Journal of AIDS Research 2: 39–55. Burnett A. 2000. Gateway to care. The Big Issue. 40: 20–21. Cape Town. CDC (Centers for Disease Control and Prevention). 1992. Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents. Washington DC: CDC. Colaizzi P. 1978. Psychological research as the phenomenologist views it. In: Valle R, King M (eds), Existentialphenomenological alternatives for psychology. New York: Oxford University Press: pp 48–79. Colom F, Lam D. 2005. Psychoeducation: improving outcomes in bipolar disorder. European Psychiatry 20: 359–364. Deacon SA . 2000. Creativity within qualitative research on families: new ideas for old methods. Qualitative Report 4: 2–10. Durkin K. 1995. Developmental social psychology — from infancy to old age. Cambridge: Blackwell Publishers Inc.


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