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African Journal of AIDS Research 2014, 13(3): 229–235 Printed in South Africa — All rights reserved
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ISSN 1608-5906 EISSN 1727-9445 http://dx.doi.org/10.2989/16085906.2014.952647
Tangible skill building and HIV youth prevention intervention in rural South Africa Jill Hanass-Hancock Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa Email: [email protected] There have been countless youth programmes throughout Africa resulting in increased knowledge of HIV, but all too often there is a discrepancy between knowledge and behaviour change. According to available literature, successful projects need to consider the context in which young people live, be consistent with community values, and be family inclusive and youth centred. This, however, requires active involvement of communities, families and youth, which in turn implies a more local response to the epidemic in small projects. This paper presents results from a survey in a rural community of South Africa which investigated the contextual factors associated with HIV knowledge, attitudes and practice in such a setting. The community was of particular interest as it had developed a local youth literacy and family support programme which included HIV-prevention messages. All school aged children of the two settlements were approached (N = 100), some of whom regularly participated in the literacy classes. The survey investigated the association between contextual factors such as caregivers, peers and exposure to the literacy classes in regards to HIV-knowledge, attitudes and practice. The results suggest that contextual factors have an impact on sexual behaviour and self-efficacy as well as on attitudes towards condom use. This indicates that peers and caregivers influence the perceived agency to practise safe sex and the likelihood that adolescents practise ‘deviant’ behaviour such as drinking, getting involved in drugs or becoming sexually active. However, the results suggest that exposure to community projects such as literacy classes have the potential to positively influence reading scores, attitudes towards condom use and delay of sexual debut while it has little effect on HIV knowledge. Keywords: Community, contextual factors, KAP survey, sexuality, literacy
Introduction Much has been written about youth HIV prevention in Southern Africa (Kamanga 1996, Peltzer and Promtussananon 2003, Peltzer and Pengpid 2006, Shamagonam et al. 2006, Kirby et al. 2007, Parker 2007, UNESCO 2007, Kirby et al. 2008). Generally, young people and families are especially affected by the epidemic (HSRC 2009, Richter et al. 2009). In addition, HIV transmission in this region is predominantly driven by unprotected sex. Countries in Africa have had countless youth programmes increasing knowledge of HIV (Kirby et al. 2007), but all too often there is a discrepancy between knowledge and behaviour change (Rwenge 2000, Lesch and Kruger 2004, James et al. 2006). The question is what elements influence change? Literature reviews on sexuality and HIV education (Kirby et al. 2007, UNESCO 2007) suggest what needs to be included in curricula, which teaching methods are useful and the optimum characteristics for good teachers (Kirby et al. 2007, UNESCO 2007). In addition, successful interventions need to be consistent with community values, be youth centred and family inclusive. The interventions require the active involvement of communities, families and the youth and therefore hold the power to address contextual factors that influence behaviour (Peltzer and Promtussananon 2005,
Brook et al. 2006, Peltzer and Pengpid 2006, Kirby et al. 2007, Campbell et al. 2009). In its 2004 report, the World Health Organization reflects that although ‘developing countries’ started to prioritise adolescent and reproductive health, few studies explored the associated ‘contextual factors’ in relation to communities, peer groups or families (WHO 2004). In this context Campbell (1997) criticises the knowledge, attitude and practice (KAP) approach and the use of the theory of planned behaviour. She argues that ‘sexuality consists of complex actions, emotions and relationships’ (p 273) often influenced by dominant concepts of sexuality and gender. These cannot be challenged by pure knowledge transfer, but need a much broader comprehensive approach that breaks with widely accepted taboos and social structures. Campbell et al. (2009) also argue that youth interventions need to go hand-in-hand with other social development programmes. They emphasise that, besides knowledge transfer, interventions need to provide social spaces for critical thinking, a sense of ownership by actively involving youth, developing confidence and self-efficacy and bridging relationships between generations and stakeholders. They argue further that Freire’s theory of critical consciousness provides a useful approach for this purpose. Critical consciousness (Freire 1993) is a process through which a person is enabled to reflect critically on the conditions shaping his
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or her life. To move from naïve to critical consciousness, Freire emphasises the need for an active educational programme (Freire 1993). In such a programme learners would be involved in the critical analysis of their living circumstances and the social norms of their communities (Freire 1993, Freire et al. 2000). It provides safe spaces for discussion and expression through facilitating approaches in which participants choose topics for discussion. While behaviour change has been difficult to establish, some studies using contextually appropriate interventions and a cognitive-behavioural health promotion approach show some promise for the future. For example, using this approach with South African school children Jemmott et al. (2011) were able to show that their intervention did not only change health promotion knowledge, attitude and intention but also increased fruit and vegetable consumption and the uptake of physical activity. Similarly, papers by Jewkes et al. (2006, 2010) on the Stepping Stones programme addressing gender issues reveal that the programme “empowered participants and engendered self-reflection, in a process circumscribed by social and cultural context” (p 1074). However, the study also revealed that gender and cultural factors provide greater difficulties for women to initiate change despite exposure to the programme. Jewkes et al. (2010: 1074)) write that while some of the women who participated in the intervention “showed greater assertiveness and some agency in HIV risk reduction, most challenged neither their male partners nor the existing cultural norms of conservative femininities”. As a result male participants benefited from the programme more than female participants did. The authors speculate that this may be associated with lack of power that women experience in their communities and that this provides difficulties for them to “embrace a greater feminist consciousness”. The authors therefore recommend that this intervention needs to be paired with other structural interventions. Using approaches enhancing critical consciousness could provide a tool to challenge structural barriers. Reflecting on a study in a school in rural KwaZulu-Natal, Campbell et al. (2009) emphasise that critical consciousness is difficult to achieve within the South African school context which is still characterised by an authoritarian leadership style. This is despite the national education programmes which try to encourage more facilitative teaching techniques. They argue that beyond the school context youth participation is further diminished through limited opportunities for communication, poor adult role models of sexual relationships, poor quality of the learners’ community and the macro-social environment (Campbell et al. 2009). Other authors argue further that inconsistent condom use and multiple partners are common among adolescents and youth in South Africa and that general aspects of parent– child relationships are crucial while developing safe sexual behaviour, a fact that is seldom examined in youth intervention evaluations (Brook et al. 2006). It is against this background that a small community in the KwaSani municipal area in KwaZulu-Natal was selected for a cross-sectional survey. The survey included a community project that used the methods of Paulo Freire to develop critical consciousness while developing other areas. The project was community driven and included youth and
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their caregivers (people looking after a child’s wellbeing). It aimed at improving literacy, addressing social issues and alleviating poverty among the underprivileged. HIV prevention was included in the broader project with the aim of developing knowledge and critical consciousness among the youth and among caregivers. The project had two main components, literacy and drama classes, which were held twice a week in the afternoons and specifically included HIV issues. These lessons were conducted continuously and were open to anybody as long as the learners wanted to participate. Classes were offered for children/youth and caregivers/adults separately. The lessons followed an approach similar to that described by the theory of critical consciousness. This means that both approaches based their lessons on the participants’ knowledge and issues, which they brought to the class and had no rigid lesson plan. In these lessons the participants were provided with a safe space to express themselves through writing and talking about social issues in their community, similar to a support group that used reading, writing and drama as a means to engage. The facilitators were trained in Freire’s theory of critical consciousness, his approach to literacy and in facilitating discussion around issues concerning the community including HIV and AIDS. The community was interested in seeing how the project performed in regard to improving literacy and HIV prevention for young people in the area. This paper presents quantitative results of a post-implementation cross-sectional survey. It focuses on the analysis of contextual factors in this community (caregiver, peers and the youth intervention) and its influence on literacy, HIV knowledge, attitude, practice and self-efficacy in the young population. Methodology Description of selected areas This study was undertaken from July to September 2008 in rural KwaZulu-Natal. It included 100 adolescents from two low-cost housing developments that were similar in structure (socio-economic) and exposed to the community project. Some of the residents participated in the reading and drama classes offered in the area. However, due to work migration or death of the primary caregiver some youngsters had moved between the two locations. The two small settlements were about 4 km apart, close to the small town. The survey approached all youngsters between the ages of 11 and 18 (see Table 1). Sample description Of the 100 adolescents 48 were male and 52 female with a mean age of 13.4 years (see Table 2). Some of the youngsters lived in an orphanage in one of the settlements. Youngsters from these communities who did not participate in the study either lived far away because of where their schools were located or were not present at the location on the days of the survey due to unknown reasons (only nine). As a result, the sample was quite young as some of the older children schooled further away at high-school level and were not resident in the community for the duration of the school term.
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Table 1: Overview of survey group (N = 100) Variable Sample size Age (mean in years) Gender (male) Socio-economic status (mean asset index)
Regularly in literacy classes 32 13.38 46.9% 11.34
As some of the participants in the two locations were exposed to the community project two groups were created by identifying those who had regularly attended the intervention over the last three years. A total of 56 participants indicated that they had visited the classes at least once, of whom 32 had attended regularly for the last 3 years (non-exposure group n = 68). The questionnaire included a series of questions that allowed for assessment of exposure to the classes as well as other socio-demographic factors. The analysis did not reveal any significant differences between the two groups in relation to household wealth, years of schooling, gender or age (see Table 1). Ethics Ethic approval for this study was given by the University of KwaZulu-Natal. Ethical issues included the procedure of gaining informed consent from the adolescents as well as their respective caregivers. The community organisation that ran the literacy and drama classes supported the informed consent process which was facilitated by the fieldworkers. The youngsters and caregivers (either parents or primary carer if parent was dead) both signed informed consent forms. In the case of the children from the orphanage the manager provided consent as the key caregiver. All names were removed from the data to ensure confidentiality. Information and results were disseminated to the community using a multi-media approach as requested by the community. Tools The study included a reading test containing English and isiZulu sections and a cross-sectional survey which was conducted with all youngsters. It also included five focus group discussions (FGD), some with the caregivers and some with the youngsters. FGD were analysed using conventional content analysis. The results of the FGD are not presented in this paper, but will be used to illustrate results from the survey. As no suitable standardised reading test was available to assess isiZulu and English, the test had to be developed and piloted by the research team. It included a section in English (widely spoken and taught at school) and a section in isiZulu (the local language). The survey questionnaire was divided into six sections. Besides demographic data it captured socio-economic data; knowledge, attitude and practice; exposure to HIV prevention interventions in schools; the community intervention; and exposure to media channels. For the socio-economic data an asset index scale similar to that of the Demographic Health Survey (DHS) was used. The survey assessed contextual factors measuring exposure to the intervention, ‘deviant’ peers (as used in Brook’s study) and the nature of caregiver–child
Not regularly in literacy classes 68 13.44 48.5% 11.65
relationships (see Table 2) using Brook (2006) scales. Furthermore, it included scales in relation to HIV knowledge and attitudes to condoms, abstinence and people living with HIV, as well as sexual behaviour and self-efficacy. The survey used validated scales that had been used previously in KwaZulu-Natal (see Table 2). Most scales used 5-point-Likert-scales which were transformed into dichotomous variables, as the sample size was relatively small. Both the reading test and the survey questionnaire were administered by trained fieldworkers (not from the area) who were fluent in isiZulu and English. The quantitative data (data from questionnaires and reading tests) were analysed using descriptive statistics, bivariate analysis and logistic regressions. Regression analysis was used to assess associations between contextual factors (exposure to literacy classes, ‘deviant’ peers and communication to caregivers) and outcome of the HIV knowledge, attitudes, practice and self-efficacy scales controlling for age, gender and socio-demographic co-factors. SPSS-15 supported the analysis. All significant differences were taken on a 95% significant level. Results The following sections present results in relation to the quantitative data of the survey. These data examined the influence of contextual factors such as exposure to literacy classes and ‘deviant’ peers and the caregiver–child relationship on HIV knowledge, attitudes, behaviour and self-efficacy. The community project Not surprisingly, the participation in the literacy and drama classes was positively associated with reading ability (p < 0.01). Children in this group achieved, on average, double the points of their peers. This applied to both the isiZulu and English sections (see combined results in Figure 1). There were no differences in socio-economic status of the two groups or the years they had attended school. A large percentage (53%) of the group, which did not participate in the extra classes, did not reach a basic level of reading in this test and 6% of this group was not able to read at all. In comparison only 19% of the children who regularly participated in the literacy and drama classes did not reach the basic level of reading in the test. None of them was illiterate. Participation in the classes was also associated with a positive attitude towards condom use. Analysing in a single model showed that belonging to the literacy classes had the strongest association (p < 0.05). While controlling for other variables this association became even stronger (p < 0.01, see Table 3). Children who participated in the classes were
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twice as likely to have a positive attitude towards condom use as those who did not. The creative reading and writing classes were also positively associated with delayed sexual debut (p < 0.05), as these children were three times less likely to indicate that they had sex than those who did not Table 2: Socio-demographic information and scales as used in the survey (N = 100) Background information General School enrolment of youngster At school Out of school Gender Male Female Age group Younger (11–14) Older (15–18) Household wealth (assit index1) Better off households Less well off households HIV Knowledge (Peltzer 20052; α = 0.65) Good knowledge Little knowledge Attitudes (Shamagonsm et al. 2006) Attitudes to abstinence (α 0.65) Good acceptance of abstinence Less acceptance of abstinence Attitudes to condoms (α 0.65) Good acceptance of condoms Less acceptance of condoms Attitudes to people living with HIV (α = 0.65) Good acceptance of PLHIV3 Less acceptance of PLHIV Behaviour (Brook et al. 2006) Sexual debut Had had sex Had never had sex Deviant behaviour (Brook 2006; α = 0.65) Some deviant behaviour No indicated deviant behaviour Self-efficacy (Shamagonam et al. 2006; α α = 0.65) Confidence to practise safer sex Good confidence to practise safer sex Less confidence to practise safer sex Contextual factors Community HIV and literacy classes Regular in the intervention Once or never in the intervention Parent-child relationship (Brook et al. 2006; α = 0.65) Supportive relationship Less supportive relationship Communication with caregiver (Shamagonam et al. 2006; α = 0.65) Good communication to caregiver Less open communication to caregiver Exposure to deviant peers (Brook et al. 2006; α = 0.65) More exposure Less exposure
N
97 3 52 48 56 44 44 56 53 47
45 55 66 34 45 55
18 82 72 28
57 43
32 68 69 31 50 50 73 27
Asset index as adapted from South African Demographic Health Survey 2 Brackets report original source of scales and their alphas 3 People living with HIV 1
participate in the classes. While controlling for other variables this association became weaker. Boys were more prone to report sexual activity than girls were. In the discussions, children indicated that the reading and drama classes kept them from ‘getting into trouble’, as they were busy with performing, rehearsing or writing instead of smoking, drinking or ‘playing the field’. Some reflected that through the youth project they ‘know how to practise safe sex and that it is not necessary to have unprotected sex’ (FGD boys). The survey did not show any direct association between participation in the project and increased knowledge of HIV, confidence to practise safe sex or the relationship to the primary caregiver. However, these outcomes were associated with other contextual factors, such as the influence of caregivers and peers. The primary caregiver The survey included a scale to assess knowledge about HIV and AIDS which comprised 18 questions (Johnson et al. 2003). In general, the youngsters scored very low with an average of only 6.9 out of 18 right answers (38%). The data showed no significant difference in knowledge between boys and girls. Furthermore, HIV knowledge was not associated with age, living arrangements or the literacy classes. It was, however, associated with the relationship to the primary caregiver. Surprisingly, the data revealed that youngsters who achieved higher HIV knowledge scores perceived their relationships with their primary caregivers as less supportive (p < 0.05). Similarly, a perceived less supportive relationship was also associated with a better attitude towards people living with HIV (p < 0.05). This only emerged in a single model and could indicate that adolescents with better HIV knowledge than their caregivers might challenge the views of their elders and thus influence the perception of their relationship. This relationship remained even after controlling for other variables. The data also revealed that adolescents who had caregivers with better life skills feared people living with HIV less than the comparison group (p < 0.05). The caregivers’ education, either formal or informal, seemed to influence the attitudes that children show towards people living with HIV. It is possible that the project’s activities in the community have influenced the caregivers’ and children’s behaviour and their interaction with each other. A positive association between the intervention and caregiver–child relationship was reflected in the FGD. Reflecting on the programme, caregivers, parents and youngsters all said that they had found new ways of communicating, thus increasing respect for each other. Participants said that the children learnt again to ‘look up to their elder’ or that they ‘learned to respect people with HIV’. Lastly the confidence to practise safe sex was positively associated with the perceived ability to communicate freely with the primary caregiver (p < 0.05). While controlling for other variables this association was still strong (see Table 4). This again reinforces the notion of how important caregivers are in influencing children’s development and self-efficacy. The peers As with caregivers, peers are thought to be influential in shaping knowledge, attitude and behaviour. Exposure to
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address the sexual and social realities that exist beyond the classroom” (UNESCO 2007: 19). Vulnerabilities in such a context can be driven by poor access to education, social context (e.g. gender norms) and financial constraints. The project described in this article addressed low levels of literacy, an aspect that influences all other learning outcomes at school and, therefore, the future prospects of the children. However, the literacy classes went beyond teaching reading and writing and also discussed social issues. Improved literacy could be expected to increase HIV knowledge providing the way to make informed decisions. The survey did not, however, reveal any direct relationship between the project and increased HIV knowledge. This is most likely due to the nature of the project. Lessons were not structured to address HIV knowledge systematically. Additionally, all participants of this survey attended the same local schools and had access to other HIV prevention interventions such as Love Life, which is one of South Africa’s largest national AIDS prevention, education and behaviour initiatives for young people (www.lovelife.org.za). HIV knowledge was passed on to everyone through those channels equally. The community project only provided an additional source of information, which did not appear
‘deviant’ peers1 was associated with an indication of deviant behaviour (p < 0.05). While controlling for other variables, this association still emerged strongly (see Table 4). In other words, children who indicated that their friends were already sexually active, used drugs or had been involved in fights were four times more likely to indicate that they would practise such behaviour. This had also a clear gender dynamic. Boys indicated such behaviour more than girls did. Exposure to ‘deviant’ peers was also negatively associated with the confidence to practise safe sex (p < 0.05). Children who indicated that their friends were already involved in sexual activities, took drugs or were involved in fights, were four times less confident of being able to practise safe sex than children who indicated less exposure to such peers. This again suggests that contextual factors are very important in changing behaviour and that the social context as well as the individual need to be addressed to initiate change. Discussion As a UNESCO report points out, “addressing vulnerability means going beyond the development of a curriculum to
Table 3: Influence of the literacy and drama classes on selected outcomes
Sexual experience (had already had sex) (N = 100) Age group (15–18 years) Gender (male) Socio-economics (wealthier) No intervention (not regular in reading or drama classes) HIV knowledge (more knowledge) Log likelihood Positive attitudes towards condoms (N = 100) Age group (15–18 years) Gender (male) Socio-economics (wealthier) Intervention (regular in reading classes) HIV knowledge (more knowledge) Log likelihood
N
Log odds
95% CI
44 52 44 32 53
0.000 6.390* 4.309 2.963* 0.113 33.051
44 52 44 32 53
0.738 0.728 0.370* 2.066*** 5.108*** 110.822
0.294–1.853 0.293–1.807 0.137–1.002 1.218–3.503 1.830–14.258
N
Log odds
95% CI
44 52 44 73 50
1.893 0.604 0.594 0.380* 2.464** 124.304
0.801–4.474 0.529–2.992 0.250–1.412 0.135–1.070 1.042–5.824
44 52 44 73
1.470 2.852** 1.580 4.035**
0.997–40.955 0.626–29.683 0.916–9.585 0.113–4.160
*p < 0.1; **p < 0.05; ***p < 0.01 Table 4: Influence of peers and communication with caregiver on selected outcomes
Confidence to practise safer sex (N = 100) Age (15–18 years) Gender (males) Socio-economics (wealthier) Exposure to deviant peers (more exposure) Communication to caregiver (better communication) Log likelihood Deviant behaviour (N = 100) Age (14–18 years) Gender (males) Socio-economics (wealthier) Exposure to deviant peers (more exposure) Communication to caregiver (better communication) Log Likelihood *p < 0.1; **p < 0.05; ***p < 0.01
50
1.650 105.052
0.572–3.778 1.069–7.608 0.615–4.058 1.050–15.506 0.635–4.297
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statistically significant during the analysis. However the low results of HIV knowledge in both groups are an issue of concern and it is advisable that the community project takes a more structured approach towards conveying HIV knowledge. This can possibly happen in conjunction with local schools. The literacy and drama classes aimed at providing safe spaces to discuss social issues in which behaviour and attitudes could evolve. As the general public has tired of HIV messages, approaches such as the described reading and writing classes are innovative ideas that can serve the immediate needs of the community (e.g. learning to read) while at the same time addressing the underlying factors of HIV. The data suggest that instead of increasing HIV knowledge the creative writing and drama classes functioned as a catalyst for change particularly in relation to attitudes to condoms and sexual behaviour. Because of the sample size and the post-intervention study design these results can only be seen as suggestive at this stage. The self-selecting character in determining exposure to the project is a further limitation. Using the Campbell et al. (2009) analysis it could be argued that a community project approach and engagement with caregivers and peers are the key to these findings. Through providing safe spaces, the classes, caregivers and peers who did not practise ‘deviant’ behaviour might have supported the development of critical thinking around norms, values and behaviour. We suspected that this enabled the youngsters to be more amenable to condom use, in turn enabling them to challenge traditional denial. Critical thinking might also lead to a change in sexual behaviour because coercion might be less likely to be successful with a conscious individual. In addition, the classes might have facilitated an improved caregiver–child relationship, empowering caregivers to help with school work. Chandan and Richter (2009: 8) write that the family is “the single most important locus of care and protection for children”. In the case of adolescents it also means that it is an important source of information and transfer of values. Through strengthening the ability of caregivers and families to look after and also to guide their youngsters, the community project might have also indirectly influenced the attitudes to people living with HIV and the confidence to practise safe sex. Communication with the primary caregiver emerged as an important indicator in relation to the confidence to practise safe sex, even stronger than the exposure to ‘deviant’ peers. In talking to their caregivers, children developed responsibility about their sexual behaviour. This, however, required open communication about sexuality rather than abstinence doctrines. On the contrary, the exposure to ‘deviant’ peers was associated with lower perceived responsibility to practise safe sex. Communication here had a negative influence. It appeared that exposure to peers who boasted about their sexual or violent experiences (which might or might not be true) decreased perceived agency over sexual behaviour. This again indicated that contextual factors are very important in changing sexual behaviour and that the social network as well as the individual need to be addressed in order to initiate change.
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The results suggest that peers, caregivers and community interventions have the potential to provide spaces for discussion of sensitive topics that can be a medium to be used in HIV prevention interventions. However, the sample used in this survey was very small and this limited the way in which results can be generalised. The results are, however, interesting and further research should shed more light on the interrelationship between contextual factors and HIV knowledge, attitudes, practise and self-efficacy. Particular evaluation research with community outreach activities using methods of critical consciousness which tries to influence contextual factors could be conducted to investigate more thoroughly how safe sexual behaviour can be developed. Conclusions The survey suggests that approaches such as creative writing classes and improved caregiver–child communication can improve educational outcomes, for example literacy, while providing a platform for HIV intervention. These approaches offer safe spaces for discussion of such sensitive topics as social issues, sexuality and HIV. It could also be argued that the classes hold the potential to address contextual factors related to sexual behaviour and HIV and AIDS, but that they need a more structured approach in order to achieve changes in knowledge as well as in attitude and behaviour scales. Addressing HIV and AIDS through literacy intervention might provide an entrée in a context where people have more immediate needs (food and education) than information on HIV and AIDS. Literacy and drama classes can also provide safe spaces to discuss sexuality, relationships and HIV not only with the young but also with the older generation. This, in turn, can influence communication between youngsters and caregivers. The data suggest that open channels of communication between the youngsters and caregivers can improve the perceived agency to practise safe sex and perception of people living with HIV. This type of interaction needs to be strengthened as it seems to address the field of HIV prevention (attitudes and practise) that appear to be difficult to change. Therefore more innovative approaches and evaluation to access changes in attitudes, behaviour and child–caregiver relationships are needed. In the face of the character of the epidemic of HIV in Southern Africa, interventions which target young people as well as their contextual factors (caregivers and peers, poverty and lack of education) are desperately needed because this epidemic needs the involvement of everyone. Community projects can fulfil the requirement of being community driven, youth orientated and family inclusivity. Small community projects might, however, be faced with financial constraints and lack structured approaches particularly in a time of recession. More thought is needed on how to support such small-scale projects. Note 1
Defined in Brook’s sense as children who are already involved in sexual activities, take drugs or get involved in fights.
African Journal of AIDS Research 2014, 13(3): 229–235
The author — Jill Hanass-Hancock, PhD, works at HEARD at the University of KwaZulu-Natal. She leads the disability, health and livelihood programme at HEARD.
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African Journal of AIDS Research 2014, 13(3): 229–235 Printed in South Africa — All rights reserved
AJAR
ISSN 1608-5906 EISSN 1727-9445 http://dx.doi.org/10.2989/16085906.2014.952647
Tangible skill building and HIV youth prevention intervention in rural South Africa Jill Hanass-Hancock Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa Email: [email protected] There have been countless youth programmes throughout Africa resulting in increased knowledge of HIV, but all too often there is a discrepancy between knowledge and behaviour change. According to available literature, successful projects need to consider the context in which young people live, be consistent with community values, and be family inclusive and youth centred. This, however, requires active involvement of communities, families and youth, which in turn implies a more local response to the epidemic in small projects. This paper presents results from a survey in a rural community of South Africa which investigated the contextual factors associated with HIV knowledge, attitudes and practice in such a setting. The community was of particular interest as it had developed a local youth literacy and family support programme which included HIV-prevention messages. All school aged children of the two settlements were approached (N = 100), some of whom regularly participated in the literacy classes. The survey investigated the association between contextual factors such as caregivers, peers and exposure to the literacy classes in regards to HIV-knowledge, attitudes and practice. The results suggest that contextual factors have an impact on sexual behaviour and self-efficacy as well as on attitudes towards condom use. This indicates that peers and caregivers influence the perceived agency to practise safe sex and the likelihood that adolescents practise ‘deviant’ behaviour such as drinking, getting involved in drugs or becoming sexually active. However, the results suggest that exposure to community projects such as literacy classes have the potential to positively influence reading scores, attitudes towards condom use and delay of sexual debut while it has little effect on HIV knowledge. Keywords: Community, contextual factors, KAP survey, sexuality, literacy
Introduction Much has been written about youth HIV prevention in Southern Africa (Kamanga 1996, Peltzer and Promtussananon 2003, Peltzer and Pengpid 2006, Shamagonam et al. 2006, Kirby et al. 2007, Parker 2007, UNESCO 2007, Kirby et al. 2008). Generally, young people and families are especially affected by the epidemic (HSRC 2009, Richter et al. 2009). In addition, HIV transmission in this region is predominantly driven by unprotected sex. Countries in Africa have had countless youth programmes increasing knowledge of HIV (Kirby et al. 2007), but all too often there is a discrepancy between knowledge and behaviour change (Rwenge 2000, Lesch and Kruger 2004, James et al. 2006). The question is what elements influence change? Literature reviews on sexuality and HIV education (Kirby et al. 2007, UNESCO 2007) suggest what needs to be included in curricula, which teaching methods are useful and the optimum characteristics for good teachers (Kirby et al. 2007, UNESCO 2007). In addition, successful interventions need to be consistent with community values, be youth centred and family inclusive. The interventions require the active involvement of communities, families and the youth and therefore hold the power to address contextual factors that influence behaviour (Peltzer and Promtussananon 2005,
Brook et al. 2006, Peltzer and Pengpid 2006, Kirby et al. 2007, Campbell et al. 2009). In its 2004 report, the World Health Organization reflects that although ‘developing countries’ started to prioritise adolescent and reproductive health, few studies explored the associated ‘contextual factors’ in relation to communities, peer groups or families (WHO 2004). In this context Campbell (1997) criticises the knowledge, attitude and practice (KAP) approach and the use of the theory of planned behaviour. She argues that ‘sexuality consists of complex actions, emotions and relationships’ (p 273) often influenced by dominant concepts of sexuality and gender. These cannot be challenged by pure knowledge transfer, but need a much broader comprehensive approach that breaks with widely accepted taboos and social structures. Campbell et al. (2009) also argue that youth interventions need to go hand-in-hand with other social development programmes. They emphasise that, besides knowledge transfer, interventions need to provide social spaces for critical thinking, a sense of ownership by actively involving youth, developing confidence and self-efficacy and bridging relationships between generations and stakeholders. They argue further that Freire’s theory of critical consciousness provides a useful approach for this purpose. Critical consciousness (Freire 1993) is a process through which a person is enabled to reflect critically on the conditions shaping his
African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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or her life. To move from naïve to critical consciousness, Freire emphasises the need for an active educational programme (Freire 1993). In such a programme learners would be involved in the critical analysis of their living circumstances and the social norms of their communities (Freire 1993, Freire et al. 2000). It provides safe spaces for discussion and expression through facilitating approaches in which participants choose topics for discussion. While behaviour change has been difficult to establish, some studies using contextually appropriate interventions and a cognitive-behavioural health promotion approach show some promise for the future. For example, using this approach with South African school children Jemmott et al. (2011) were able to show that their intervention did not only change health promotion knowledge, attitude and intention but also increased fruit and vegetable consumption and the uptake of physical activity. Similarly, papers by Jewkes et al. (2006, 2010) on the Stepping Stones programme addressing gender issues reveal that the programme “empowered participants and engendered self-reflection, in a process circumscribed by social and cultural context” (p 1074). However, the study also revealed that gender and cultural factors provide greater difficulties for women to initiate change despite exposure to the programme. Jewkes et al. (2010: 1074)) write that while some of the women who participated in the intervention “showed greater assertiveness and some agency in HIV risk reduction, most challenged neither their male partners nor the existing cultural norms of conservative femininities”. As a result male participants benefited from the programme more than female participants did. The authors speculate that this may be associated with lack of power that women experience in their communities and that this provides difficulties for them to “embrace a greater feminist consciousness”. The authors therefore recommend that this intervention needs to be paired with other structural interventions. Using approaches enhancing critical consciousness could provide a tool to challenge structural barriers. Reflecting on a study in a school in rural KwaZulu-Natal, Campbell et al. (2009) emphasise that critical consciousness is difficult to achieve within the South African school context which is still characterised by an authoritarian leadership style. This is despite the national education programmes which try to encourage more facilitative teaching techniques. They argue that beyond the school context youth participation is further diminished through limited opportunities for communication, poor adult role models of sexual relationships, poor quality of the learners’ community and the macro-social environment (Campbell et al. 2009). Other authors argue further that inconsistent condom use and multiple partners are common among adolescents and youth in South Africa and that general aspects of parent– child relationships are crucial while developing safe sexual behaviour, a fact that is seldom examined in youth intervention evaluations (Brook et al. 2006). It is against this background that a small community in the KwaSani municipal area in KwaZulu-Natal was selected for a cross-sectional survey. The survey included a community project that used the methods of Paulo Freire to develop critical consciousness while developing other areas. The project was community driven and included youth and
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their caregivers (people looking after a child’s wellbeing). It aimed at improving literacy, addressing social issues and alleviating poverty among the underprivileged. HIV prevention was included in the broader project with the aim of developing knowledge and critical consciousness among the youth and among caregivers. The project had two main components, literacy and drama classes, which were held twice a week in the afternoons and specifically included HIV issues. These lessons were conducted continuously and were open to anybody as long as the learners wanted to participate. Classes were offered for children/youth and caregivers/adults separately. The lessons followed an approach similar to that described by the theory of critical consciousness. This means that both approaches based their lessons on the participants’ knowledge and issues, which they brought to the class and had no rigid lesson plan. In these lessons the participants were provided with a safe space to express themselves through writing and talking about social issues in their community, similar to a support group that used reading, writing and drama as a means to engage. The facilitators were trained in Freire’s theory of critical consciousness, his approach to literacy and in facilitating discussion around issues concerning the community including HIV and AIDS. The community was interested in seeing how the project performed in regard to improving literacy and HIV prevention for young people in the area. This paper presents quantitative results of a post-implementation cross-sectional survey. It focuses on the analysis of contextual factors in this community (caregiver, peers and the youth intervention) and its influence on literacy, HIV knowledge, attitude, practice and self-efficacy in the young population. Methodology Description of selected areas This study was undertaken from July to September 2008 in rural KwaZulu-Natal. It included 100 adolescents from two low-cost housing developments that were similar in structure (socio-economic) and exposed to the community project. Some of the residents participated in the reading and drama classes offered in the area. However, due to work migration or death of the primary caregiver some youngsters had moved between the two locations. The two small settlements were about 4 km apart, close to the small town. The survey approached all youngsters between the ages of 11 and 18 (see Table 1). Sample description Of the 100 adolescents 48 were male and 52 female with a mean age of 13.4 years (see Table 2). Some of the youngsters lived in an orphanage in one of the settlements. Youngsters from these communities who did not participate in the study either lived far away because of where their schools were located or were not present at the location on the days of the survey due to unknown reasons (only nine). As a result, the sample was quite young as some of the older children schooled further away at high-school level and were not resident in the community for the duration of the school term.
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Table 1: Overview of survey group (N = 100) Variable Sample size Age (mean in years) Gender (male) Socio-economic status (mean asset index)
Regularly in literacy classes 32 13.38 46.9% 11.34
As some of the participants in the two locations were exposed to the community project two groups were created by identifying those who had regularly attended the intervention over the last three years. A total of 56 participants indicated that they had visited the classes at least once, of whom 32 had attended regularly for the last 3 years (non-exposure group n = 68). The questionnaire included a series of questions that allowed for assessment of exposure to the classes as well as other socio-demographic factors. The analysis did not reveal any significant differences between the two groups in relation to household wealth, years of schooling, gender or age (see Table 1). Ethics Ethic approval for this study was given by the University of KwaZulu-Natal. Ethical issues included the procedure of gaining informed consent from the adolescents as well as their respective caregivers. The community organisation that ran the literacy and drama classes supported the informed consent process which was facilitated by the fieldworkers. The youngsters and caregivers (either parents or primary carer if parent was dead) both signed informed consent forms. In the case of the children from the orphanage the manager provided consent as the key caregiver. All names were removed from the data to ensure confidentiality. Information and results were disseminated to the community using a multi-media approach as requested by the community. Tools The study included a reading test containing English and isiZulu sections and a cross-sectional survey which was conducted with all youngsters. It also included five focus group discussions (FGD), some with the caregivers and some with the youngsters. FGD were analysed using conventional content analysis. The results of the FGD are not presented in this paper, but will be used to illustrate results from the survey. As no suitable standardised reading test was available to assess isiZulu and English, the test had to be developed and piloted by the research team. It included a section in English (widely spoken and taught at school) and a section in isiZulu (the local language). The survey questionnaire was divided into six sections. Besides demographic data it captured socio-economic data; knowledge, attitude and practice; exposure to HIV prevention interventions in schools; the community intervention; and exposure to media channels. For the socio-economic data an asset index scale similar to that of the Demographic Health Survey (DHS) was used. The survey assessed contextual factors measuring exposure to the intervention, ‘deviant’ peers (as used in Brook’s study) and the nature of caregiver–child
Not regularly in literacy classes 68 13.44 48.5% 11.65
relationships (see Table 2) using Brook (2006) scales. Furthermore, it included scales in relation to HIV knowledge and attitudes to condoms, abstinence and people living with HIV, as well as sexual behaviour and self-efficacy. The survey used validated scales that had been used previously in KwaZulu-Natal (see Table 2). Most scales used 5-point-Likert-scales which were transformed into dichotomous variables, as the sample size was relatively small. Both the reading test and the survey questionnaire were administered by trained fieldworkers (not from the area) who were fluent in isiZulu and English. The quantitative data (data from questionnaires and reading tests) were analysed using descriptive statistics, bivariate analysis and logistic regressions. Regression analysis was used to assess associations between contextual factors (exposure to literacy classes, ‘deviant’ peers and communication to caregivers) and outcome of the HIV knowledge, attitudes, practice and self-efficacy scales controlling for age, gender and socio-demographic co-factors. SPSS-15 supported the analysis. All significant differences were taken on a 95% significant level. Results The following sections present results in relation to the quantitative data of the survey. These data examined the influence of contextual factors such as exposure to literacy classes and ‘deviant’ peers and the caregiver–child relationship on HIV knowledge, attitudes, behaviour and self-efficacy. The community project Not surprisingly, the participation in the literacy and drama classes was positively associated with reading ability (p < 0.01). Children in this group achieved, on average, double the points of their peers. This applied to both the isiZulu and English sections (see combined results in Figure 1). There were no differences in socio-economic status of the two groups or the years they had attended school. A large percentage (53%) of the group, which did not participate in the extra classes, did not reach a basic level of reading in this test and 6% of this group was not able to read at all. In comparison only 19% of the children who regularly participated in the literacy and drama classes did not reach the basic level of reading in the test. None of them was illiterate. Participation in the classes was also associated with a positive attitude towards condom use. Analysing in a single model showed that belonging to the literacy classes had the strongest association (p < 0.05). While controlling for other variables this association became even stronger (p < 0.01, see Table 3). Children who participated in the classes were
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twice as likely to have a positive attitude towards condom use as those who did not. The creative reading and writing classes were also positively associated with delayed sexual debut (p < 0.05), as these children were three times less likely to indicate that they had sex than those who did not Table 2: Socio-demographic information and scales as used in the survey (N = 100) Background information General School enrolment of youngster At school Out of school Gender Male Female Age group Younger (11–14) Older (15–18) Household wealth (assit index1) Better off households Less well off households HIV Knowledge (Peltzer 20052; α = 0.65) Good knowledge Little knowledge Attitudes (Shamagonsm et al. 2006) Attitudes to abstinence (α 0.65) Good acceptance of abstinence Less acceptance of abstinence Attitudes to condoms (α 0.65) Good acceptance of condoms Less acceptance of condoms Attitudes to people living with HIV (α = 0.65) Good acceptance of PLHIV3 Less acceptance of PLHIV Behaviour (Brook et al. 2006) Sexual debut Had had sex Had never had sex Deviant behaviour (Brook 2006; α = 0.65) Some deviant behaviour No indicated deviant behaviour Self-efficacy (Shamagonam et al. 2006; α α = 0.65) Confidence to practise safer sex Good confidence to practise safer sex Less confidence to practise safer sex Contextual factors Community HIV and literacy classes Regular in the intervention Once or never in the intervention Parent-child relationship (Brook et al. 2006; α = 0.65) Supportive relationship Less supportive relationship Communication with caregiver (Shamagonam et al. 2006; α = 0.65) Good communication to caregiver Less open communication to caregiver Exposure to deviant peers (Brook et al. 2006; α = 0.65) More exposure Less exposure
N
97 3 52 48 56 44 44 56 53 47
45 55 66 34 45 55
18 82 72 28
57 43
32 68 69 31 50 50 73 27
Asset index as adapted from South African Demographic Health Survey 2 Brackets report original source of scales and their alphas 3 People living with HIV 1
participate in the classes. While controlling for other variables this association became weaker. Boys were more prone to report sexual activity than girls were. In the discussions, children indicated that the reading and drama classes kept them from ‘getting into trouble’, as they were busy with performing, rehearsing or writing instead of smoking, drinking or ‘playing the field’. Some reflected that through the youth project they ‘know how to practise safe sex and that it is not necessary to have unprotected sex’ (FGD boys). The survey did not show any direct association between participation in the project and increased knowledge of HIV, confidence to practise safe sex or the relationship to the primary caregiver. However, these outcomes were associated with other contextual factors, such as the influence of caregivers and peers. The primary caregiver The survey included a scale to assess knowledge about HIV and AIDS which comprised 18 questions (Johnson et al. 2003). In general, the youngsters scored very low with an average of only 6.9 out of 18 right answers (38%). The data showed no significant difference in knowledge between boys and girls. Furthermore, HIV knowledge was not associated with age, living arrangements or the literacy classes. It was, however, associated with the relationship to the primary caregiver. Surprisingly, the data revealed that youngsters who achieved higher HIV knowledge scores perceived their relationships with their primary caregivers as less supportive (p < 0.05). Similarly, a perceived less supportive relationship was also associated with a better attitude towards people living with HIV (p < 0.05). This only emerged in a single model and could indicate that adolescents with better HIV knowledge than their caregivers might challenge the views of their elders and thus influence the perception of their relationship. This relationship remained even after controlling for other variables. The data also revealed that adolescents who had caregivers with better life skills feared people living with HIV less than the comparison group (p < 0.05). The caregivers’ education, either formal or informal, seemed to influence the attitudes that children show towards people living with HIV. It is possible that the project’s activities in the community have influenced the caregivers’ and children’s behaviour and their interaction with each other. A positive association between the intervention and caregiver–child relationship was reflected in the FGD. Reflecting on the programme, caregivers, parents and youngsters all said that they had found new ways of communicating, thus increasing respect for each other. Participants said that the children learnt again to ‘look up to their elder’ or that they ‘learned to respect people with HIV’. Lastly the confidence to practise safe sex was positively associated with the perceived ability to communicate freely with the primary caregiver (p < 0.05). While controlling for other variables this association was still strong (see Table 4). This again reinforces the notion of how important caregivers are in influencing children’s development and self-efficacy. The peers As with caregivers, peers are thought to be influential in shaping knowledge, attitude and behaviour. Exposure to
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address the sexual and social realities that exist beyond the classroom” (UNESCO 2007: 19). Vulnerabilities in such a context can be driven by poor access to education, social context (e.g. gender norms) and financial constraints. The project described in this article addressed low levels of literacy, an aspect that influences all other learning outcomes at school and, therefore, the future prospects of the children. However, the literacy classes went beyond teaching reading and writing and also discussed social issues. Improved literacy could be expected to increase HIV knowledge providing the way to make informed decisions. The survey did not, however, reveal any direct relationship between the project and increased HIV knowledge. This is most likely due to the nature of the project. Lessons were not structured to address HIV knowledge systematically. Additionally, all participants of this survey attended the same local schools and had access to other HIV prevention interventions such as Love Life, which is one of South Africa’s largest national AIDS prevention, education and behaviour initiatives for young people (www.lovelife.org.za). HIV knowledge was passed on to everyone through those channels equally. The community project only provided an additional source of information, which did not appear
‘deviant’ peers1 was associated with an indication of deviant behaviour (p < 0.05). While controlling for other variables, this association still emerged strongly (see Table 4). In other words, children who indicated that their friends were already sexually active, used drugs or had been involved in fights were four times more likely to indicate that they would practise such behaviour. This had also a clear gender dynamic. Boys indicated such behaviour more than girls did. Exposure to ‘deviant’ peers was also negatively associated with the confidence to practise safe sex (p < 0.05). Children who indicated that their friends were already involved in sexual activities, took drugs or were involved in fights, were four times less confident of being able to practise safe sex than children who indicated less exposure to such peers. This again suggests that contextual factors are very important in changing behaviour and that the social context as well as the individual need to be addressed to initiate change. Discussion As a UNESCO report points out, “addressing vulnerability means going beyond the development of a curriculum to
Table 3: Influence of the literacy and drama classes on selected outcomes
Sexual experience (had already had sex) (N = 100) Age group (15–18 years) Gender (male) Socio-economics (wealthier) No intervention (not regular in reading or drama classes) HIV knowledge (more knowledge) Log likelihood Positive attitudes towards condoms (N = 100) Age group (15–18 years) Gender (male) Socio-economics (wealthier) Intervention (regular in reading classes) HIV knowledge (more knowledge) Log likelihood
N
Log odds
95% CI
44 52 44 32 53
0.000 6.390* 4.309 2.963* 0.113 33.051
44 52 44 32 53
0.738 0.728 0.370* 2.066*** 5.108*** 110.822
0.294–1.853 0.293–1.807 0.137–1.002 1.218–3.503 1.830–14.258
N
Log odds
95% CI
44 52 44 73 50
1.893 0.604 0.594 0.380* 2.464** 124.304
0.801–4.474 0.529–2.992 0.250–1.412 0.135–1.070 1.042–5.824
44 52 44 73
1.470 2.852** 1.580 4.035**
0.997–40.955 0.626–29.683 0.916–9.585 0.113–4.160
*p < 0.1; **p < 0.05; ***p < 0.01 Table 4: Influence of peers and communication with caregiver on selected outcomes
Confidence to practise safer sex (N = 100) Age (15–18 years) Gender (males) Socio-economics (wealthier) Exposure to deviant peers (more exposure) Communication to caregiver (better communication) Log likelihood Deviant behaviour (N = 100) Age (14–18 years) Gender (males) Socio-economics (wealthier) Exposure to deviant peers (more exposure) Communication to caregiver (better communication) Log Likelihood *p < 0.1; **p < 0.05; ***p < 0.01
50
1.650 105.052
0.572–3.778 1.069–7.608 0.615–4.058 1.050–15.506 0.635–4.297
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statistically significant during the analysis. However the low results of HIV knowledge in both groups are an issue of concern and it is advisable that the community project takes a more structured approach towards conveying HIV knowledge. This can possibly happen in conjunction with local schools. The literacy and drama classes aimed at providing safe spaces to discuss social issues in which behaviour and attitudes could evolve. As the general public has tired of HIV messages, approaches such as the described reading and writing classes are innovative ideas that can serve the immediate needs of the community (e.g. learning to read) while at the same time addressing the underlying factors of HIV. The data suggest that instead of increasing HIV knowledge the creative writing and drama classes functioned as a catalyst for change particularly in relation to attitudes to condoms and sexual behaviour. Because of the sample size and the post-intervention study design these results can only be seen as suggestive at this stage. The self-selecting character in determining exposure to the project is a further limitation. Using the Campbell et al. (2009) analysis it could be argued that a community project approach and engagement with caregivers and peers are the key to these findings. Through providing safe spaces, the classes, caregivers and peers who did not practise ‘deviant’ behaviour might have supported the development of critical thinking around norms, values and behaviour. We suspected that this enabled the youngsters to be more amenable to condom use, in turn enabling them to challenge traditional denial. Critical thinking might also lead to a change in sexual behaviour because coercion might be less likely to be successful with a conscious individual. In addition, the classes might have facilitated an improved caregiver–child relationship, empowering caregivers to help with school work. Chandan and Richter (2009: 8) write that the family is “the single most important locus of care and protection for children”. In the case of adolescents it also means that it is an important source of information and transfer of values. Through strengthening the ability of caregivers and families to look after and also to guide their youngsters, the community project might have also indirectly influenced the attitudes to people living with HIV and the confidence to practise safe sex. Communication with the primary caregiver emerged as an important indicator in relation to the confidence to practise safe sex, even stronger than the exposure to ‘deviant’ peers. In talking to their caregivers, children developed responsibility about their sexual behaviour. This, however, required open communication about sexuality rather than abstinence doctrines. On the contrary, the exposure to ‘deviant’ peers was associated with lower perceived responsibility to practise safe sex. Communication here had a negative influence. It appeared that exposure to peers who boasted about their sexual or violent experiences (which might or might not be true) decreased perceived agency over sexual behaviour. This again indicated that contextual factors are very important in changing sexual behaviour and that the social network as well as the individual need to be addressed in order to initiate change.
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The results suggest that peers, caregivers and community interventions have the potential to provide spaces for discussion of sensitive topics that can be a medium to be used in HIV prevention interventions. However, the sample used in this survey was very small and this limited the way in which results can be generalised. The results are, however, interesting and further research should shed more light on the interrelationship between contextual factors and HIV knowledge, attitudes, practise and self-efficacy. Particular evaluation research with community outreach activities using methods of critical consciousness which tries to influence contextual factors could be conducted to investigate more thoroughly how safe sexual behaviour can be developed. Conclusions The survey suggests that approaches such as creative writing classes and improved caregiver–child communication can improve educational outcomes, for example literacy, while providing a platform for HIV intervention. These approaches offer safe spaces for discussion of such sensitive topics as social issues, sexuality and HIV. It could also be argued that the classes hold the potential to address contextual factors related to sexual behaviour and HIV and AIDS, but that they need a more structured approach in order to achieve changes in knowledge as well as in attitude and behaviour scales. Addressing HIV and AIDS through literacy intervention might provide an entrée in a context where people have more immediate needs (food and education) than information on HIV and AIDS. Literacy and drama classes can also provide safe spaces to discuss sexuality, relationships and HIV not only with the young but also with the older generation. This, in turn, can influence communication between youngsters and caregivers. The data suggest that open channels of communication between the youngsters and caregivers can improve the perceived agency to practise safe sex and perception of people living with HIV. This type of interaction needs to be strengthened as it seems to address the field of HIV prevention (attitudes and practise) that appear to be difficult to change. Therefore more innovative approaches and evaluation to access changes in attitudes, behaviour and child–caregiver relationships are needed. In the face of the character of the epidemic of HIV in Southern Africa, interventions which target young people as well as their contextual factors (caregivers and peers, poverty and lack of education) are desperately needed because this epidemic needs the involvement of everyone. Community projects can fulfil the requirement of being community driven, youth orientated and family inclusivity. Small community projects might, however, be faced with financial constraints and lack structured approaches particularly in a time of recession. More thought is needed on how to support such small-scale projects. Note 1
Defined in Brook’s sense as children who are already involved in sexual activities, take drugs or get involved in fights.
African Journal of AIDS Research 2014, 13(3): 229–235
The author — Jill Hanass-Hancock, PhD, works at HEARD at the University of KwaZulu-Natal. She leads the disability, health and livelihood programme at HEARD.
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