African Journal of AIDS Research
ISSN: 1608-5906 (Print) 1727-9445 (Online) Journal homepage: http://www.tandfonline.com/loi/raar20
The Simalelo Peer Education Programme for HIV prevention: a qualitative process evaluation of a project in Zambia Alexander Molassiotis , Irene Saralis-Avis , Wilson Nyirenda & Nina Atkins To cite this article: Alexander Molassiotis , Irene Saralis-Avis , Wilson Nyirenda & Nina Atkins (2004) The Simalelo Peer Education Programme for HIV prevention: a qualitative process evaluation of a project in Zambia, African Journal of AIDS Research, 3:2, 183-190, DOI: 10.2989/16085900409490333 To link to this article: http://dx.doi.org/10.2989/16085900409490333
Published online: 11 Nov 2009.
Submit your article to this journal
Article views: 58
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=raar20 Download by: [Texas A & M International University]
Date: 06 November 2015, At: 05:34
Copyright © NISC Pty Ltd
African Journal of AIDS Research 2004, 3(2): 183–190 Printed in South Africa — All rights reserved
AJAR EISSN 1727–9445
The Simalelo Peer Education Programme for HIV prevention: a qualitative process evaluation of a project in Zambia Alexander Molassiotis1*, Irene Saralis-Avis2, Wilson Nyirenda3 and Nina Atkins3 School of Nursing, Midwifery and Social Work, University of Manchester, Coupland III, Coupland Street, Manchester M13 9PL, United Kingdom 2 Peer Education Programme against AIDS (PEPAIDS), 19 Southey Street, Nottingham, NG7 4BG, United Kingdom 3 Simalelo Assistance Prevention Education Program (SAPEP), NAPSA, Room 9, New Building, PO Box 660197, Monze, Zambia * Corresponding author, e-mail: [email protected]
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
1
The aim of the project was to evaluate a peer education programme in Zambia run by local people in relation to changes in behaviours, the effects of the programme on the community and the dynamics of peer health promotion. A qualitative process evaluation using focus groups consisting of both participants in the peer education programme and educators was utilised. The peer education programme was aimed at setting up anti-AIDS clubs through recreational activities, empowering people in a variety of ways, and reaching people in some of the most remote parts of the country. Key findings indicate that the programme had an impact on participants’ attitudes to HIV/AIDS as well as on lifestyle and behaviour, both in relation to sexual practices and cultural norms. Knowledge about HIV prevention was substantial and clear. Most importantly, the findings suggest that success of the programme is related to the fact that it brought the community together to fight AIDS. Peer education programmes must be able to motivate people to work together with appropriate methods, empower local communities and consider issues of long-term sustainability. Keywords: AIDS, Africa, health promotion, youth
Introduction Health education has been traditionally provided through a passive model of the knowledgeable teacher who instructs learners in an attempt to elicit behaviour change. This method is often unsuccessful, since gains in knowledge do not necessarily translate into behaviour change. Peer education programmes in HIV prevention have proved a better method, especially in Africa, as they are communitybased programmes run by local people. Peer education seeks to empower lay people by providing health-related information (Campbell & Mzaidume, 2002), thus increasing the likelihood that people will feel they have some control over their health (Israel, Checkoway, Schultz & Zimmerman, 1994). A number of studies in Africa, all based on mobilising people in one way or another and empowering them through knowledge, have shown promising results. HIV prevention through peer education (in addition to condom promotion) among truck drivers and their sexual partners in Tanzania was shown to be effective in increasing knowledge and encouraging appropriate behaviour change (LaukammJosten, Mwizarubi, Outwater, Mwaijonga, Valadez, Nyamwaya, Swai, Saidel & Nyamuryekung’e, 2000). An adolescent peer education programme in Cameroon was also associated with greater knowledge of the symptoms of STDs and more frequent use of condoms (Speizer, Tambashe & Tegang, 2001). Similar benefits have been
reported as a result of peer education programmes in Botswana (Hope, 2003), Ghana (Wolf, Tawfik & Bond, 2000), Senegal (Leonard, Ndiaye, Kapadia, Eisen, Diop, Mboup & Kanki, 2000) and Zimbabwe (Bassett, 1998), all targetting a variety of people such as adolescents, prostitutes or factory workers. Although the effectiveness of peer education is evident through the literature, little is known about the process by which peer education enables people to change health behaviours. Little or no theoretical underpinning seems to be the norm in most peer education research, perhaps because the existing theories do not fully clarify the processes involved in delivering a successful peer education programme. Two theories that are prominent in the field of peer education are Social Learning and the Communication of Innovations. Social Learning Theory was developed by Bandura (1977) and postulates that the learning process takes place mainly through role modelling and credible role models. Reinforcement of information and the empowerment of peers through increased self-efficacy are also key concepts of this theory. Although such a theory has helped us to better understand the process of learning, its major limitation is that it requires observation of modelled behaviour, making it almost impossible to utilise in the context of sexual/HIV-related education. Communication of
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
184
Innovations Theory attempts to explain how innovations are adopted by communities and to identify the factors that may affect the rate of adoption (Rogers, 1983). Important factors for the adoption of innovations include the characteristics of the ‘change agents’ who influence key opinion leaders in the community, the characteristics of those adopting the innovation, the nature of the social system and the nature of the innovation. The application of this theory in peer education may have a wide scope, although its application in more formal models of peer education may be limiting. Campbell and MacPhail (2002) have recently provided a theoretical framework for explaining the process by which peer education can promote safe sexual behaviour in youths, based on their extensive work in an African context. They suggest that the interrelated concepts of social identity, empowerment and critical consciousness and social capital can provide a good basis for understanding how peer education works. The authors explain, for example, that the development of a critical consciousness around gender dynamics and relations plays a key role in changing at-risk sexual behaviours through re-negotiation of peer norms. However, the framework does not explain how social identity can be changed within a given cultural and value system with strong and deeply-rooted traditional beliefs, nor does it address the difficulties around the concept of social capital (which assists in empowering people to develop a ‘critical consciousness’) in the context of the political and economic constraints of many African communities and nations. Other theories partly explain why peer education may be effective, but their scope in relation to peer education is limited. These include Social Inoculation Theory (Duryea, 1991), whereby youths develop negotiating skills to minimise peer pressure; Role Theory (Sarbin & Allen, 1968), which focusses on social roles and role expectations; the Differential Association Theory (Sutherland & Cressy, 1960), based on peer education through friendships and other networks of association; and Subculture Theories (Cohen, 1955), based on the Differential Association Theory but with added concepts concerning culture and subculture (for an excellent review of the relevant theories, see Turner and Shepherd, 1999.) The shortcomings of some of the approaches used in delivering peer education in relation to HIV prevention have been highlighted in the literature. These include difficulties in working with hard-to-reach populations; the need to have a relatively stable population as opposed to mobile groups of people; the ineffectiveness of some authoritative and didactic school-based peer education programmes and the development of programmes based on Western science and policy that may be inappropriate for local conditions (Campbell & Mzaidume, 2002); the modes of delivery of the education (i.e. use of a biomedical model of teaching); the role of women in African societies; the low emphasis by some programmes on realistic information; lack of commitment at times; poverty (Gregson, Zhuwau, Anderson & Chandiwana, 1998); cultural norms; religious conflicts and confusing messages; and misconceptions or conflict between traditional and government health leaders (Tobias, 2001). Also, a number of peer educators promote abstinence, a strategy that few young people are likely to
Molassiotis, Saralis-Avis, Nyirenda and Atkins
take seriously (Campbell & MacPhail, 2002). Furthermore, it is often difficult to evaluate the effectiveness of a community peer education programme as results may be indirect and evident only after a long period of time. On the other hand, peer education has also been successful in reducing high risk sexual behaviours in the West (Kegeles, Hays, Pollack & Coates, 1999; Kocken, Voorham, Brandsma & Swart, 2001). However, some reports suggest that peer education programmes may be ineffective in changing behaviour (Elford, Sherr, Bolding, Serle & Maguire, 2002; Williamson, Hart, Flowers, Frankis & Der, 2001), although the actual reasons for this may not be related to the programme itself but rather to the lack of diffusion, the duration of the programme or the retention of peer educators (Elford et al., 2002). The aim of this study was to enhance our understanding of the dynamics and process of change through a peer education programme, in terms of: • knowledge gained and whether this knowledge has helped participants to change their behaviour and make informed decisions about their sexual health • impact of the programme on the community • the dynamics of peer health promotion Hence, the aim was not to evaluate the effectiveness of the programme but rather to shed light on the mechanisms by which the programme works (or does not work). Description of the programme The Peer Education Project is a new programme offered in the rural farming communities of southern Zambia, based on the experience gained from a 10-year programme for Teachers’ Education on AIDS operating in schools under the umbrella of the Monze Catholic Diocese and the Zambian Family Health Trust. The programme is now run by local people in the villages and towns of two districts under the auspices of a non-governmental organisation, the Simalelo AIDS Peer Education Programme (SAPEP), which does not have a direct religious affiliation. This programme started at the end of 2002 with two peer educators; currently there are 15 peer educators who each cover a specific area. In addition, there are two district co-ordinators who have the overall responsibility of running the programme together with the programme leader. Advisors and trustees (both local and UK-based) assist the programme in a number of ways. The peer educators are initially trained through workshops and gain experience from other peer educators. A team of experts and health professionals is available for further guidance and advice and ongoing workshops take place as required. The aim of the programme is to empower local young people with knowledge of HIV prevention. This is accomplished by mobilising the youth with recreational activities. Each area sets up anti-AIDS clubs with a focus on specific activities. Frequently-organised events provide an opportunity to educate people. Members of the clubs contribute by developing songs or plays around the theme of AIDS. Such activities are important, as many Zambians find it easier to relate to spoken rather than written words, and problems of illiteracy are circumvented (Hughes-d’Aeth,
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
African Journal of AIDS Research 2004, 3(2): 183–190
2002). People have opportunities to ask questions and discuss and clarify issues of importance to them. Materials for recreational activities (e.g. footballs and netballs) are provided as well as a bicycle per zone to help the peer educators reach the most remote villages. Events are organised on a regular basis when members from different villages come together for friendly competitions, where issues related to HIV can be further explored. Sports have proved to be the best vehicle to induce youth to form antiAIDS clubs in these rural communities. Distribution of condoms is also part of the programme. Some small-scale income-generating activities are carried out and formally encouraged by SAPEP. Currently, the programme includes more than 95 clubs (not all active) with 5–15 members per club. Although the programme was initially developed for youths, many adults wanted to participate, and hence the programme was eventually developed to be an inclusive one. Methods Design of the study A qualitative methodology employing focus groups was chosen for this study in order to systematically collect and synthesise the perspectives of anti-AIDS club members and peer educators about the programme. Focus groups were chosen because they encourage individuals to participate who might otherwise be reluctant to be interviewed or feel they have nothing to contribute; participants can interact with each other, rather than with the facilitator, emphasising their perspective (Macleod-Clark, Maben & Jones, 1996). A process evaluation was chosen for this study, as the programme is new and it may take years before some behaviour changes occur and outcome evaluations become possible. Also, at this stage of the development of the programme, we wanted to explore peer dynamics, the experiences of participants and the processes of change (if change occurred) before embarking on a more objective quantitative evaluation. This study could also give us indications of areas to assess in a quantitative outcome evaluation study. Setting and samples The study was carried out in two districts in the southern rural parts of Zambia (Monze and Mazabuka districts). Five focus group interviews were carried out with anti-AIDS club members, including participants from semi-urban and rural areas. Each mixed-age and mixed-sex focus group consisted of 5–14 participants. Interviews lasted between 45 and 75 minutes and involved a translator for the local Tonga dialect. Interviews were carried out in the participants’ villages in a predetermined open space. Three focus groups with the peer educators working in the programme were also set up; those interviews were held in English and lasted between 35 and 45 minutes. The evaluation was carried out during August and September 2003. Moderator’s guide A moderator’s guide was developed according to the key objectives of the project and following a review of the
185
relevant literature. After a standard introduction and an outline of the purpose and conduct of the focus group, standard probe questions were used to facilitate discussion of the following topics: • interest in participating in the programme • knowledge of HIV/AIDS • positive and negative aspects of the programme • reactions of peers and family to the participants’ involvement with the programme • whether new knowledge had helped participants to make lifestyle changes • the needs of HIV patients in their community. Questions were similarly presented to the different groups of anti-AIDS club members and peer educators so issues could be examined in parallel. Procedures A structured protocol (moderator’s guide) was used in each of the groups to stimulate discussion and to elicit ideas from participants, consisting of open-ended questions covering several domains. The guidelines allowed additional questions to be asked, and for participants to introduce their own questions. After hearing a brief presentation on the study and its purposes, participants were asked to introduce themselves. Demographic data was collected at this stage. All participants were reminded that there were no right or wrong answers and that all comments, both positive and negative, were welcomed. While the facilitators made sure that each participant had the opportunity to speak, participation in response to specific questions was completely voluntary; moreover, participants were advised that they did not have to answer any question if they felt uncomfortable with it. Probes were used, as necessary, to clarify answers and encourage participation. Two coinvestigators attended every focus group, both being nurses with experience in interview techniques and HIV/AIDS. They were also not otherwise known to the participants as part of the peer education programme. The investigators who collected the data also analysed it. Each session was loosely structured to allow for a permissive, non-threatening discussion that could be analysed inductively. With prior permission from the subjects, handwritten notes were used to transcribe the interviews. Analysis Systematic efforts were made to produce and collect data. During the focus group sessions, the investigators listened actively to the discussion and asked questions, as necessary, to enhance their understanding of language and content. Handwritten notes were reviewed for accuracy and used to capture first impressions as well as to identify major themes. All notes were also reviewed to make sure that they clearly differentiated between direct quotes and any paraphrased information. Review of the notes by the investigators after each session helped clarify ambiguities of meaning. After completion of all sessions, the notes from each focus group were independently reviewed for content and consistency of response by the two principal investigators. They also reviewed the major themes, key
186
Molassiotis, Saralis-Avis, Nyirenda and Atkins
terms and concepts, contrasts and notable quotes that evolved from the groups using thematic content analysis. This initially involved reading the entire transcript to generate a list of common themes. Themes were identified and synthesised first within groups, and then trends and patterns were examined across groups. Ambiguities or discrepancies were identified and resolved through review of the notes and discussion between the researchers.
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
Results and discussion Demographic data A total of 44 club members participated in the five focus groups. Their mean age was 29.5 years old (range 14–49), and the mean time involved with a club was 6.8 months (range 3–12). Furthermore, 10 peer educators were also involved in the focus groups. Their mean age was 23.9 years (range 20–32) and their mean time involved in the programme as peer educators was seven months (range 1–10 months). Other demographic data are given in Table 1. Participants’ motivation Five main reasons to be included in the programme were given by the club members: to learn and gain knowledge, to teach others, to fight AIDS, to protect those not infected, and to gain support from the group. These are reflected in the following comments: • to try to fight AIDS with every weapon we have as we all have lost brothers and sisters [to AIDS] • to learn more about HIV and to find ways to prevent it • to help me protect myself and help others to protect themselves • to teach other people about HIV. People don’t understand and fool around with sex; they have chosen it to be their way of life Participants also mentioned that they hoped to be able to lead a ‘better life’ with the newly-acquired knowledge. Furthermore, they all appreciated the importance of sporting activities, as it was a means to channel their energy. For many communities it was a way to forget their hunger, the
problem of AIDS and the associated deaths in their villages. They felt temporarily happy. The responses from peer educators were similar; they became involved in the programme to gain more knowledge themselves, to teach others by being role models and protect them from HIV/AIDS. Being involved with the community they were raised in was a fundamental factor in their commitment and involvement, as they had to make a number of personal sacrifices to sustain the programme on a longer-term basis. The personal benefits to those involved are often mentioned as a main characteristic of successful peer education initiatives (Turner & Shepherd, 1999). Personal development and growth have also been cited in other peer education programmes (Backett-Milburn & Wilson, 2000). Furthermore, peer educators who act as role models are a key element to success in peer education initiatives, as highlighted by Social Learning Theory. The participation of local community members is a key element in HIV prevention worldwide because trusting and co-operative relationships can develop (Campbell & Mzaidume, 2002). There is a sense of helping and supporting each other in AIDS-stricken African societies, and this occurs to the benefit of every peer education programme. However, the reasons that members participate in such programmes are important, and successful programmes need to address all these reasons and so base their education in the learners’ needs and expectations. Knowledge of HIV Club members were asked to identify two main ways of HIV transmission and the variety of diseases one can contract through unprotected sex, as well as [to raise] questions exploring discrimination against persons with AIDS. Most had a high and accurate level of knowledge except for a minority of members, the latter coming from recently-formed clubs. We observed that the longer people were involved in clubs, the more accurate their HIV-related knowledge and the more vocal the members were. Abstinence from sex among younger club members was also common. Even some deeply-rooted cultural beliefs and norms, such as
Table 1: Demographic data of participants Club members Gender Employment status
Religion
Martial status
Male Female Employed Unemployed Attending school Seventh Day Adventist Roman Catholic Salvation Army Zion Spirit Church New Apostolic Church Other Christian denomination Married Single Widowed
Peer educators
N
%
N
%
29 15 6 33 5 18 12 6 3 3 2 21 20 3
65.9 34.1 13.6 75.0 11.4 40.9 27.3 13.6 6.8 6.8 4.6 47.7 45.5 6.8
7 3 10
70 30 100
5 2
50 20
1 2 4 6
10 20 40 60
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
African Journal of AIDS Research 2004, 3(2): 183–190
‘sexual cleansing’ (a belief that once the husband has died the wife has to have sex with a relative so as to release the spirit of the dead and avoid mental illness) and the practices of traditional healers (i.e. scarification), were much-debated topics and many people believed that these contributed to the spread of AIDS. In some communities, such practices were already replaced by alternative safer ones. Modifications and changes in cultural norms and practices have been reported as outcomes of other peer education programmes in Zambia (Hughes-d’Aeth, 2002). Ongoing open debate and community discussion reflect empowerment and perhaps self-efficacy, as people believe they will not be infected with the virus if they follow certain practices they have learned from peer educators, and so modify some of their cultural norms (Social Learning Theory). For example, instead of allowing traditional healers to use unclean razors for scarification, they were now bringing along their own clean and unused razors. The pivotal role of the traditional chief in changing such practices was highlighted. Such involvement may be pivotal for the community in accepting new knowledge and changing health behaviours, as peer educators become more influential and are perceived as competent and credible. The latter characteristics are key aspects of a successful peer education initiative under both Social Learning Theory and the Communication of Innovations Theory. The only practice that people felt they should not follow (but for the wrong reasons) was dry sex, as they believed that the herbs used for dry sex can cause cancer. Very few mentioned AIDS in relation to dry sex and there was a tendency for males to still prefer to practise it. Improvements in knowledge have been seen in a range of other peer education programmes in Africa and beyond (Bassett, 1998; Wolf et al., 2000; Tobias, 2001; Hope, 2003; Perez & Dabis, 2003), but this does not necessarily translate to changes in lifestyles. Poverty, unemployment, hunger, low economic status, low female autonomy, male labour migration and alcohol consumption are all factors that have been identified as contributing to people not changing risky sexual behaviours (Gregson et al., 1998; Campbell & Mzaidume, 2002). Our own experience in Zambia suggests that these factors are too great to not influence sexual behaviour; for example, a number of businessmen from the cities come to the area to engage in sexual activities, sometimes paying K3 000 (US$0.63) for unprotected sex, but decreasing their offer to K400 (US$0.08) for protected sex. Prostitutes will take the risk and have unprotected sex even if they know about HIV, as the difference in pay terms is substantial for a poor and hungry family. However, the fact that certain rituals and cultural norms are changing, as suggested during the interviews, suggests that the peer education programme has caused people to consider risks to their own health and make informed decisions about risks taken. Hence, a new degree of empowerment and re-negotiation of norms (Campbell & MacPhail, 2002) was evident. Exploring issues as a community (rather than as individuals) brought about changes in people’s cultural belief system. Meanwhile, we stress consideration for the role of traditional chiefs in the villages, since programmes that do not include key players
187
in the change process are destined to fail. This has been highlighted by Campbell and Mzaidume (2002), who suggest that the success of peer education also depends on collaboration among diverse stakeholder groups at local, national and international levels. The current programme displays good collaboration and links to both local and international levels. Ways that new information on HIV can change or affect lifestyles The largest contribution of the programme was that of bringing the community together to fight the spread of AIDS. This connectedness seemed an important characteristic of the success of the programme, as collective negotiations were taking place. Such negotiations may challenge social identities and change power relations. Constructing identities within the group that challenge the ways in which traditional gender relations place one’s health at risk through sexual behaviour is discussed in detail elsewhere (see Campbell & Jovchelovich, 2000; Campbell & MacPhail, 2002). Certainly, our experience was that of vocal women disagreeing with men and explaining to them how they could be safe, taking the lead in suggesting changes and persuading men to follow their ways. Under the umbrella of that theme, a number of subthemes emerged, such as teaching and communication with children within the family unit, helping men and women stay with one partner and be faithful, abstaining from sex, leading an exemplary life, decreasing one’s prejudice against people with AIDS, understanding which practices of traditional healers can spread the disease and other infections and the benefit of using condoms. These themes are revealed in the following comments: • ‘The project managed to bring us together and increase our interactions with others in the community. We never did this before…. Also it increased our community spirit.’ • ‘It brought about courage to reach out to other communities and share.…’ • ‘… to abstain from sex and stay away from getting AIDS as I am single and living alone. I do not indulge in sexual activities’. • ‘After learning the information I decided to teach my children the ways AIDS is transmitted and tell them the facts about HIV prevention and also talk to friends and increase the communication at home with my children….’ • ‘Even if neighbours are around I help them to understand how to protect themselves, how to take care of AIDS patients… and how to provide compassion.…’ • ‘It taught me how to abstain from sex before marriage and stay with one partner after marriage’. • ‘I have selected abstinence from sex as the best way to protect myself’. Some comments highlighted the difficulties that religion has posed in carrying out appropriate sex education: ‘The church has barriers in talking about sex, so the anti-AIDS club helped me to talk about it….’. As many of the participants were religious and the subtheme of abstinence from sex was common, participants were asked whether this was the result of their religious
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
188
beliefs rather than the influence of the anti-AIDS club. The overwhelming answer was: • ‘The Church told us not to have sex, but the anti-AIDS clubs helped us to understand why we should not have sex before marriage. Using what I have learnt by the programme and having Christian values I teach my fellow Christians how I manage to abstain [from sex] and see the positive effects on me…’. Also, the adolescents in the groups were obviously scared of contracting AIDS and dying, as they have seen so many deaths. One said that of all his classmates of 10 years ago, he and a couple of others were the only ones living. The peer educators added that the programme caters for all people, young and old, and works in their own community. They reported that from their experience (some were involved in similar programmes in the past) other education projects in the schools had not been very successful. Many past initiatives, especially the ones started by international charities, were unsuccessful, as they communicated through leaflets and letters which never reached remote villages or the illiterate people in the villages. Also, some were formal (school) programmes and not sustained for long. It has been claimed that the informal passing of information by peers may be more successful than formal ways, as people identify with their peers (Turner & Shepherd, 1999). Also, whereas sustainability of peer education initiatives may depend on external funding being available, with peer education programmes we see that peer educators may still reach out to their community even when funding ceases (UNICEF/Ghana, 2002). The peer educators highlighted their aim to empower the community by giving the anti-AIDS club members ownership of the club and its activities. As one co-ordinator said: ‘Our offices are under the trees with the people; we are out there. Our coordinators know the communities, as they belong there…’. This connectedness might have been pivotal in the sustainability of the SAPEP programme, as one of the key elements of sustainability is community ownership (UNICEF/Ghana, 2002). Furthermore, peer educators were continuously mobile and able to reach many remote villages. Reaching those who are hard to reach through conventional teaching methods and those in isolated communities is another important characteristic for successful peer education initiatives (Differential Association Theory and Subculture Theory). Peer education programmes are about empowering the community. The dynamics of that empowerment are often complex; as seen in the interviews, empowerment can relate directly to HIV prevention behaviour, while it also indirectly improves family communication, cohesion and ties. One of the most successful elements of the programme was that information was directly provided to the community rather than to the individual, as the latter approach is often unsuccessful in terms of behaviour change (Ziersch, Gaffney & Tomlinson, 2000). The best way to empower people can differ; the means to empowerment needs to be adjusted to effectively mobilise people to develop a strong sense of community, and should be based on the specific needs and interests of that community. Often this takes imaginative and creative thinking, as in the case of a peer education
Molassiotis, Saralis-Avis, Nyirenda and Atkins
programme targetting African-American youths in the USA, where hip-hop music was used as the medium for delivering an HIV prevention message (Stephens, Braithwaite & Taylor, 1998). Peer education programmes must create unique and interesting ways of developing co-operative learning. It is interesting to see that a number of adolescents chose abstinence as the best way to protect themselves. This is in contrast to the literature that suggests that this strategy is not taken seriously by young people (Campbell & McPhail, 2002). Perhaps this message is more appropriate for adolescents who, in this way, delay the onset of sexual relationships as opposed to adolescents who are already sexually active. Nevertheless, the adolescents’ responses may have been dependent on the make-up of the focus groups and it is possible that the young people involved said what their families or other members of their community expected them to say. It is also possible that they were sexually active but did not want others in the group to know this. However, our informal individual discussions with these youths suggest that responding according to social norms may not have been the case. Change of attitudes towards AIDS patients Most participants agreed that patients with AIDS deserve compassion, and that their attitudes had changed since becoming involved in a club. For example: • ‘Before [the anti-AIDS club] I used to laugh at those infected and isolated them, but now I am trying to bring them closer to the community, fighting the stigma and discrimination…’ • ‘Before I got this knowledge, even touching an AIDS patient, I was afraid that the disease will pass on me. I used plastic bags on my hands, but now I don’t do that anymore…’ • ‘We know now that we should not isolate them [AIDS patients]. We are born one flesh, we are all brothers and sisters, and we should take care of each other…’ There were, however, occasional disagreements with such sentiments, as some participants (a handful) still believed that some people do deserve to get AIDS. Again, these were participants coming from recently-formed clubs. On the other hand, peer educators felt that they had to lead by example, so they were striving to lead an exemplary life. It was encouraging to see that change occurred in attitudes about HIV-infected people and to know that this may assist in the reduction of HIV transmission. Lamptey (2002) highlights that reduced stigma and discrimination is one of the main ways of reducing HIV infections in the long term. Community programmes should aim to change social norms and improve awareness, knowledge and attitudes, plus create a supportive social environment to sustain behavioural change (Lamptey, 2002). Positive effects on the family Both club members and peer educators reported that their families and friends liked their involvement in the anti-AIDS clubs. Eventually, although the clubs initially targetted youths, many adult family members wanted to participate, and did so frequently. Backett-Milburn and Wilson (2000) described a UK-based peer education programme where
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
African Journal of AIDS Research 2004, 3(2): 183–190
great interest was shown by the peer educators’ schoolmates, friends and families, and informal discussions and debate about what was learnt often took place. Our observation was that gaining new knowledge also had positive effects on the self-esteem of the youths: • ‘There is a lot of wisdom if you have knowledge; I look like a wise guy so the rest of the family envy me.…’ • ‘… in the late evenings all the family sits around the fire and we discuss these issues [about AIDS]…. We teach the family so as to have an HIV-free family’. • ‘My family found a lot of information through me…. Knowledge is power.…’ • ‘Besides my father being very old, after my involvement he also got involved in the club….’ We believe that these empowered youths may be less likely to engage in risky sexual behaviours which, in turn, can have an impact on their personal development. Their development as role models may also impact on their own families. Negative aspects Few negative aspects about the anti-AIDS clubs were reported. Some members mentioned a lack of sports equipment such as footballs, limited income-generating activities or insufficient support required to develop them, limited diversity of games/activities, a lack of mobility needed to work with other clubs and a lack of communication materials. Some peer educators thought they did not have adequate training in counselling skills; they felt this was a barrier to providing more effective education to their peers, especially when people asked difficult questions and had a great deal of problems. It is interesting to see that the negative aspects reported by the anti-AIDS club participants were all related to practical issues. This is perhaps a result of the participants’ motivation for joining an anti-AIDS club — which was not only to gain knowledge but also to gain things missing in their everyday life. Hence, we stress the important role of motivational factors in developing and sustaining longterm community education programmes. Peer educators suggested that the programme could be further improved by having larger functions and providing incentives to the club members. Workshops both for peer educators and for those assisting with club activities were necessary (with different content). People generally felt that income-generating activities were very important and should be better supported (especially in such deprived areas, where unemployment can exceed 80%). They all felt that the key to the continuing success of the programme was to keep people motivated. This highlights the importance of considering the longterm sustainability of peer education programmes. Thus, different health education mediums could be used on a regular basis so that people can continue to feel motivated and do not become ‘fatigued’ from talking about HIV prevention. Needs of AIDS patients AIDS patients identified a consistent set of needs among them. Lack of food was the largest issue. Insufficient clothing and bedding were also commonly reported.
189
Although lack of medicines was often reported, food was mentioned above medicines. Concern for the number of AIDS orphans and a lack of homecare programmes were also talked about. The very same set of needs for persons with AIDS was referred to by peer educators. Supply of condoms An irregular supply of condoms to the area where the study took place appeared to be a major difficulty. Free condoms in Zambia are distributed through hospitals; however, the local hospital was run by Roman Catholic nuns who refused to distribute condoms through their hospital. Thus, peer educators often had to travel a long distance to another hospital in another district to obtain condoms for their community. The Catholic Church’s stance on not allowing condom use to prevent HIV transmission, in conflict with scientific evidence, is widely known and debated. Yet, providing information about HIV and AIDS and promoting condom use is unlikely to have an optimal impact on the spread of HIV/AIDS unless efforts are made at the same time to promote local condom availability (Campbell & Mzaidume, 2002). We feel that condom availability is a paramount factor impacting all HIV education programmes. Conclusion Several key characteristics of the current peer education initiative, SAPEP, have led to a successful programme. These include the provision of credible information, community empowerment, peer communication rather than professional teachers to disseminate information, peer educators as positive role models, peer education that benefits those providing it, learning reinforced through popular sports and drama activities, and outreach capabilities for hard-to-reach communities. Creative thinking, education and community mobilisation, coupled with sustainable programmes and supportive environments, all help to motivate the types of behaviour change that can reduce HIV incidence. References Backett-Milburn, K. & Wilson, S. (2000) Understanding peer education: insights from a process evaluation. Health Education Research 15, pp. 85–96. Bandura, A. (1977) Social Learning Theory. Englewood Cliffs, New Jersey, Prentice-Hall. Bassett, M. (1998) Impact of peer education on HIV infection in Zimbabwe. Sexual Health Exchange 4, pp. 14–15. Campbell, C. & Jovchelovich, S. (2000) Health, community and development: towards a social psychology of participation. Journal of Applied and Community Social Psychology 10, pp. 255–270. Campbell, C. & MacPhail, C. (2002) Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth. Social Science & Medicine 55, pp. 331–345. Campbell, C. & Mzaidume, Y. (2002) How can HIV be prevented in South Africa? A social perspective. British Medical Journal 324, pp. 229–232. Cohen, A.K. (1955) Delinquent Boys: the Culture of the Gang. New York, Free Press.
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
190
Duryea, E.J. (1991) Principles of non-verbal communication in efforts to reduce peer and social pressure. Journal of School Health 61, pp. 5–10. Elford, J., Sherr, L., Bolding, G., Serle, F. & Maguire, M. (2002) Peerled HIV prevention among gay men in London: process evaluation. AIDS Care 14, pp. 351–360. Gregson, S., Zhuwau, T., Anderson, R.M. & Chandiwana, S.K. (1998) Is there evidence for behaviour change in response to AIDS in rural Zimbabwe? Social Science & Medicine 46, pp. 321–330. Hope, R.H. (2003) Promoting behaviour change in Botswana: an assessment of the Peer Education HIV/AIDS Prevention Program at the workplace. Journal of Health Communication 8, pp. 267–281. Hughes-d’Aeth, A. (2002) Evaluation of HIV/AIDS peer education projects in Zambia. Evaluation and Program Planning 25, pp. 397–407. Israel, B., Checkoway, B., Schulz, A. & Zimmerman, M. (1994) Health education and community empowerment: conceptualising and measuring perceptions of individual, organisational and community control. Health Education Quarterly 21, pp. 49–70. Kegeles, S.M., Hays, R.B., Pollack, L.M. & Coates, T.J. (1999) Mobilizing young gay and bisexual men for HIV prevention: a twocommunity study. AIDS 13, pp. 1753–1762. Kocken, P., Voorham, T., Brandsma, J. & Swart, W. (2001) Effects of peer-led AIDS education aimed at Turkish and Moroccan male immigrants in The Netherlands. A randomised controlled evaluation study. European Journal of Public Health 11, pp. 153–159. Lamptey, P.R. (2002) Reducing heterosexual transmission of HIV in poor countries. British Medical Journal 324, pp. 207–211. Laukamm-Josten, U., Mwizarubi, B.K., Outwater, A., Mwaijonga, C.L., Valadez, J.J., Nyamwaya, D., Swai, R., Saidel, T. & Nyamuryekung’e, K. (2000) Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania, 1990–1993. AIDS Care 12, pp. 27–40. Leonard, L., Ndiaye, I., Kapadia, A., Eisen, G., Diop, O., Mboup, S. & Kanki, P. (2000) HIV prevention among male clients of female sex workers in Kaolack, Senegal: results of a peer education program. AIDS Education & Prevention 12, pp. 21–37. Macleod-Clark, J., Maben, J. & Jones, K. (1996) The use of focus group interviews in nursing research. NT Research 1(2), pp. 143–153.
Molassiotis, Saralis-Avis, Nyirenda and Atkins
Perez, F. & Dabis, F. (2003) HIV prevention in Latin America: reaching youth in Colombia. AIDS Care 15, pp. 77–87. Rogers, E.M. (1983) Diffusion of Innovations (3rd edn). New York, Free Press. Sarbin, T.R. & Allen, V.L. (1968) Role theory. In: Lindzey, G. & Aronson, E. eds. Handbook of Social Psychology, Vol. 1. Reading, UK, Addison-Wesley, pp. 488–567. Speizer, I.S., Tambashe, B.O. & Tegang, S.P. (2001) An evaluation of the ‘Entre Nous Jeunes’ peer-educator program for adolescents in Cameroon. Studies in Family Planning 32, pp. 339–351. Stephens, T., Braithwaite, R.L. & Taylor, S.E. (1998) Model for using hip-hop music for small group HIV/AIDS prevention counselling with African American adolescents and young adults. Patient Education & Counselling 35, pp. 127–137. Sutherland, E.H. & Cressy, D.R. (1960) Principles of Criminology. Philadelphia, Lippincott. Tobias, B.Q. (2001) A descriptive study of the cultural mores and beliefs toward HIV/AIDS in Swaziland, southern Africa. International Journal for the Advancement of Counselling 23, pp. 99–113. Turner, G. & Shepherd, J. (1999) A method in search of a theory: peer education and health promotion. Health Education Research 14, pp. 235–247. UNICEF (Ghana) (2002) Evaluation of HIV/AIDS prevention through peer education, counselling, healthcare, training and urban refuges in Ghana. Evaluation and Program Planning 25, pp. 409–420. Williamson, L.M., Hart, G.J., Flowers, P., Frankis, J.S. & Der, G.J. (2001) The gay men’s task force: the impact of peer education on the sexual health behaviour of homosexual men in Glasgow. Sexually Transmitted Diseases 77, pp. 427–432. Wolf, R.C., Tawfik, L.A. & Bond, K.C. (2000) Peer promotion programmes and social networks in Ghana: methods for monitoring and evaluating AIDS prevention and reproductive health programs among adolescents and young adults. Journal of Health Communication 5(suppl.), pp. 61–80. Ziersch, A., Gaffney, J. & Tomlinson, D.R. (2000) STI prevention and the male sex industry in London: evaluating a pilot peer education programme. Sexually Transmitted Infections 76, pp. 447–453.
ISSN: 1608-5906 (Print) 1727-9445 (Online) Journal homepage: http://www.tandfonline.com/loi/raar20
The Simalelo Peer Education Programme for HIV prevention: a qualitative process evaluation of a project in Zambia Alexander Molassiotis , Irene Saralis-Avis , Wilson Nyirenda & Nina Atkins To cite this article: Alexander Molassiotis , Irene Saralis-Avis , Wilson Nyirenda & Nina Atkins (2004) The Simalelo Peer Education Programme for HIV prevention: a qualitative process evaluation of a project in Zambia, African Journal of AIDS Research, 3:2, 183-190, DOI: 10.2989/16085900409490333 To link to this article: http://dx.doi.org/10.2989/16085900409490333
Published online: 11 Nov 2009.
Submit your article to this journal
Article views: 58
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=raar20 Download by: [Texas A & M International University]
Date: 06 November 2015, At: 05:34
Copyright © NISC Pty Ltd
African Journal of AIDS Research 2004, 3(2): 183–190 Printed in South Africa — All rights reserved
AJAR EISSN 1727–9445
The Simalelo Peer Education Programme for HIV prevention: a qualitative process evaluation of a project in Zambia Alexander Molassiotis1*, Irene Saralis-Avis2, Wilson Nyirenda3 and Nina Atkins3 School of Nursing, Midwifery and Social Work, University of Manchester, Coupland III, Coupland Street, Manchester M13 9PL, United Kingdom 2 Peer Education Programme against AIDS (PEPAIDS), 19 Southey Street, Nottingham, NG7 4BG, United Kingdom 3 Simalelo Assistance Prevention Education Program (SAPEP), NAPSA, Room 9, New Building, PO Box 660197, Monze, Zambia * Corresponding author, e-mail: [email protected]
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
1
The aim of the project was to evaluate a peer education programme in Zambia run by local people in relation to changes in behaviours, the effects of the programme on the community and the dynamics of peer health promotion. A qualitative process evaluation using focus groups consisting of both participants in the peer education programme and educators was utilised. The peer education programme was aimed at setting up anti-AIDS clubs through recreational activities, empowering people in a variety of ways, and reaching people in some of the most remote parts of the country. Key findings indicate that the programme had an impact on participants’ attitudes to HIV/AIDS as well as on lifestyle and behaviour, both in relation to sexual practices and cultural norms. Knowledge about HIV prevention was substantial and clear. Most importantly, the findings suggest that success of the programme is related to the fact that it brought the community together to fight AIDS. Peer education programmes must be able to motivate people to work together with appropriate methods, empower local communities and consider issues of long-term sustainability. Keywords: AIDS, Africa, health promotion, youth
Introduction Health education has been traditionally provided through a passive model of the knowledgeable teacher who instructs learners in an attempt to elicit behaviour change. This method is often unsuccessful, since gains in knowledge do not necessarily translate into behaviour change. Peer education programmes in HIV prevention have proved a better method, especially in Africa, as they are communitybased programmes run by local people. Peer education seeks to empower lay people by providing health-related information (Campbell & Mzaidume, 2002), thus increasing the likelihood that people will feel they have some control over their health (Israel, Checkoway, Schultz & Zimmerman, 1994). A number of studies in Africa, all based on mobilising people in one way or another and empowering them through knowledge, have shown promising results. HIV prevention through peer education (in addition to condom promotion) among truck drivers and their sexual partners in Tanzania was shown to be effective in increasing knowledge and encouraging appropriate behaviour change (LaukammJosten, Mwizarubi, Outwater, Mwaijonga, Valadez, Nyamwaya, Swai, Saidel & Nyamuryekung’e, 2000). An adolescent peer education programme in Cameroon was also associated with greater knowledge of the symptoms of STDs and more frequent use of condoms (Speizer, Tambashe & Tegang, 2001). Similar benefits have been
reported as a result of peer education programmes in Botswana (Hope, 2003), Ghana (Wolf, Tawfik & Bond, 2000), Senegal (Leonard, Ndiaye, Kapadia, Eisen, Diop, Mboup & Kanki, 2000) and Zimbabwe (Bassett, 1998), all targetting a variety of people such as adolescents, prostitutes or factory workers. Although the effectiveness of peer education is evident through the literature, little is known about the process by which peer education enables people to change health behaviours. Little or no theoretical underpinning seems to be the norm in most peer education research, perhaps because the existing theories do not fully clarify the processes involved in delivering a successful peer education programme. Two theories that are prominent in the field of peer education are Social Learning and the Communication of Innovations. Social Learning Theory was developed by Bandura (1977) and postulates that the learning process takes place mainly through role modelling and credible role models. Reinforcement of information and the empowerment of peers through increased self-efficacy are also key concepts of this theory. Although such a theory has helped us to better understand the process of learning, its major limitation is that it requires observation of modelled behaviour, making it almost impossible to utilise in the context of sexual/HIV-related education. Communication of
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
184
Innovations Theory attempts to explain how innovations are adopted by communities and to identify the factors that may affect the rate of adoption (Rogers, 1983). Important factors for the adoption of innovations include the characteristics of the ‘change agents’ who influence key opinion leaders in the community, the characteristics of those adopting the innovation, the nature of the social system and the nature of the innovation. The application of this theory in peer education may have a wide scope, although its application in more formal models of peer education may be limiting. Campbell and MacPhail (2002) have recently provided a theoretical framework for explaining the process by which peer education can promote safe sexual behaviour in youths, based on their extensive work in an African context. They suggest that the interrelated concepts of social identity, empowerment and critical consciousness and social capital can provide a good basis for understanding how peer education works. The authors explain, for example, that the development of a critical consciousness around gender dynamics and relations plays a key role in changing at-risk sexual behaviours through re-negotiation of peer norms. However, the framework does not explain how social identity can be changed within a given cultural and value system with strong and deeply-rooted traditional beliefs, nor does it address the difficulties around the concept of social capital (which assists in empowering people to develop a ‘critical consciousness’) in the context of the political and economic constraints of many African communities and nations. Other theories partly explain why peer education may be effective, but their scope in relation to peer education is limited. These include Social Inoculation Theory (Duryea, 1991), whereby youths develop negotiating skills to minimise peer pressure; Role Theory (Sarbin & Allen, 1968), which focusses on social roles and role expectations; the Differential Association Theory (Sutherland & Cressy, 1960), based on peer education through friendships and other networks of association; and Subculture Theories (Cohen, 1955), based on the Differential Association Theory but with added concepts concerning culture and subculture (for an excellent review of the relevant theories, see Turner and Shepherd, 1999.) The shortcomings of some of the approaches used in delivering peer education in relation to HIV prevention have been highlighted in the literature. These include difficulties in working with hard-to-reach populations; the need to have a relatively stable population as opposed to mobile groups of people; the ineffectiveness of some authoritative and didactic school-based peer education programmes and the development of programmes based on Western science and policy that may be inappropriate for local conditions (Campbell & Mzaidume, 2002); the modes of delivery of the education (i.e. use of a biomedical model of teaching); the role of women in African societies; the low emphasis by some programmes on realistic information; lack of commitment at times; poverty (Gregson, Zhuwau, Anderson & Chandiwana, 1998); cultural norms; religious conflicts and confusing messages; and misconceptions or conflict between traditional and government health leaders (Tobias, 2001). Also, a number of peer educators promote abstinence, a strategy that few young people are likely to
Molassiotis, Saralis-Avis, Nyirenda and Atkins
take seriously (Campbell & MacPhail, 2002). Furthermore, it is often difficult to evaluate the effectiveness of a community peer education programme as results may be indirect and evident only after a long period of time. On the other hand, peer education has also been successful in reducing high risk sexual behaviours in the West (Kegeles, Hays, Pollack & Coates, 1999; Kocken, Voorham, Brandsma & Swart, 2001). However, some reports suggest that peer education programmes may be ineffective in changing behaviour (Elford, Sherr, Bolding, Serle & Maguire, 2002; Williamson, Hart, Flowers, Frankis & Der, 2001), although the actual reasons for this may not be related to the programme itself but rather to the lack of diffusion, the duration of the programme or the retention of peer educators (Elford et al., 2002). The aim of this study was to enhance our understanding of the dynamics and process of change through a peer education programme, in terms of: • knowledge gained and whether this knowledge has helped participants to change their behaviour and make informed decisions about their sexual health • impact of the programme on the community • the dynamics of peer health promotion Hence, the aim was not to evaluate the effectiveness of the programme but rather to shed light on the mechanisms by which the programme works (or does not work). Description of the programme The Peer Education Project is a new programme offered in the rural farming communities of southern Zambia, based on the experience gained from a 10-year programme for Teachers’ Education on AIDS operating in schools under the umbrella of the Monze Catholic Diocese and the Zambian Family Health Trust. The programme is now run by local people in the villages and towns of two districts under the auspices of a non-governmental organisation, the Simalelo AIDS Peer Education Programme (SAPEP), which does not have a direct religious affiliation. This programme started at the end of 2002 with two peer educators; currently there are 15 peer educators who each cover a specific area. In addition, there are two district co-ordinators who have the overall responsibility of running the programme together with the programme leader. Advisors and trustees (both local and UK-based) assist the programme in a number of ways. The peer educators are initially trained through workshops and gain experience from other peer educators. A team of experts and health professionals is available for further guidance and advice and ongoing workshops take place as required. The aim of the programme is to empower local young people with knowledge of HIV prevention. This is accomplished by mobilising the youth with recreational activities. Each area sets up anti-AIDS clubs with a focus on specific activities. Frequently-organised events provide an opportunity to educate people. Members of the clubs contribute by developing songs or plays around the theme of AIDS. Such activities are important, as many Zambians find it easier to relate to spoken rather than written words, and problems of illiteracy are circumvented (Hughes-d’Aeth,
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
African Journal of AIDS Research 2004, 3(2): 183–190
2002). People have opportunities to ask questions and discuss and clarify issues of importance to them. Materials for recreational activities (e.g. footballs and netballs) are provided as well as a bicycle per zone to help the peer educators reach the most remote villages. Events are organised on a regular basis when members from different villages come together for friendly competitions, where issues related to HIV can be further explored. Sports have proved to be the best vehicle to induce youth to form antiAIDS clubs in these rural communities. Distribution of condoms is also part of the programme. Some small-scale income-generating activities are carried out and formally encouraged by SAPEP. Currently, the programme includes more than 95 clubs (not all active) with 5–15 members per club. Although the programme was initially developed for youths, many adults wanted to participate, and hence the programme was eventually developed to be an inclusive one. Methods Design of the study A qualitative methodology employing focus groups was chosen for this study in order to systematically collect and synthesise the perspectives of anti-AIDS club members and peer educators about the programme. Focus groups were chosen because they encourage individuals to participate who might otherwise be reluctant to be interviewed or feel they have nothing to contribute; participants can interact with each other, rather than with the facilitator, emphasising their perspective (Macleod-Clark, Maben & Jones, 1996). A process evaluation was chosen for this study, as the programme is new and it may take years before some behaviour changes occur and outcome evaluations become possible. Also, at this stage of the development of the programme, we wanted to explore peer dynamics, the experiences of participants and the processes of change (if change occurred) before embarking on a more objective quantitative evaluation. This study could also give us indications of areas to assess in a quantitative outcome evaluation study. Setting and samples The study was carried out in two districts in the southern rural parts of Zambia (Monze and Mazabuka districts). Five focus group interviews were carried out with anti-AIDS club members, including participants from semi-urban and rural areas. Each mixed-age and mixed-sex focus group consisted of 5–14 participants. Interviews lasted between 45 and 75 minutes and involved a translator for the local Tonga dialect. Interviews were carried out in the participants’ villages in a predetermined open space. Three focus groups with the peer educators working in the programme were also set up; those interviews were held in English and lasted between 35 and 45 minutes. The evaluation was carried out during August and September 2003. Moderator’s guide A moderator’s guide was developed according to the key objectives of the project and following a review of the
185
relevant literature. After a standard introduction and an outline of the purpose and conduct of the focus group, standard probe questions were used to facilitate discussion of the following topics: • interest in participating in the programme • knowledge of HIV/AIDS • positive and negative aspects of the programme • reactions of peers and family to the participants’ involvement with the programme • whether new knowledge had helped participants to make lifestyle changes • the needs of HIV patients in their community. Questions were similarly presented to the different groups of anti-AIDS club members and peer educators so issues could be examined in parallel. Procedures A structured protocol (moderator’s guide) was used in each of the groups to stimulate discussion and to elicit ideas from participants, consisting of open-ended questions covering several domains. The guidelines allowed additional questions to be asked, and for participants to introduce their own questions. After hearing a brief presentation on the study and its purposes, participants were asked to introduce themselves. Demographic data was collected at this stage. All participants were reminded that there were no right or wrong answers and that all comments, both positive and negative, were welcomed. While the facilitators made sure that each participant had the opportunity to speak, participation in response to specific questions was completely voluntary; moreover, participants were advised that they did not have to answer any question if they felt uncomfortable with it. Probes were used, as necessary, to clarify answers and encourage participation. Two coinvestigators attended every focus group, both being nurses with experience in interview techniques and HIV/AIDS. They were also not otherwise known to the participants as part of the peer education programme. The investigators who collected the data also analysed it. Each session was loosely structured to allow for a permissive, non-threatening discussion that could be analysed inductively. With prior permission from the subjects, handwritten notes were used to transcribe the interviews. Analysis Systematic efforts were made to produce and collect data. During the focus group sessions, the investigators listened actively to the discussion and asked questions, as necessary, to enhance their understanding of language and content. Handwritten notes were reviewed for accuracy and used to capture first impressions as well as to identify major themes. All notes were also reviewed to make sure that they clearly differentiated between direct quotes and any paraphrased information. Review of the notes by the investigators after each session helped clarify ambiguities of meaning. After completion of all sessions, the notes from each focus group were independently reviewed for content and consistency of response by the two principal investigators. They also reviewed the major themes, key
186
Molassiotis, Saralis-Avis, Nyirenda and Atkins
terms and concepts, contrasts and notable quotes that evolved from the groups using thematic content analysis. This initially involved reading the entire transcript to generate a list of common themes. Themes were identified and synthesised first within groups, and then trends and patterns were examined across groups. Ambiguities or discrepancies were identified and resolved through review of the notes and discussion between the researchers.
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
Results and discussion Demographic data A total of 44 club members participated in the five focus groups. Their mean age was 29.5 years old (range 14–49), and the mean time involved with a club was 6.8 months (range 3–12). Furthermore, 10 peer educators were also involved in the focus groups. Their mean age was 23.9 years (range 20–32) and their mean time involved in the programme as peer educators was seven months (range 1–10 months). Other demographic data are given in Table 1. Participants’ motivation Five main reasons to be included in the programme were given by the club members: to learn and gain knowledge, to teach others, to fight AIDS, to protect those not infected, and to gain support from the group. These are reflected in the following comments: • to try to fight AIDS with every weapon we have as we all have lost brothers and sisters [to AIDS] • to learn more about HIV and to find ways to prevent it • to help me protect myself and help others to protect themselves • to teach other people about HIV. People don’t understand and fool around with sex; they have chosen it to be their way of life Participants also mentioned that they hoped to be able to lead a ‘better life’ with the newly-acquired knowledge. Furthermore, they all appreciated the importance of sporting activities, as it was a means to channel their energy. For many communities it was a way to forget their hunger, the
problem of AIDS and the associated deaths in their villages. They felt temporarily happy. The responses from peer educators were similar; they became involved in the programme to gain more knowledge themselves, to teach others by being role models and protect them from HIV/AIDS. Being involved with the community they were raised in was a fundamental factor in their commitment and involvement, as they had to make a number of personal sacrifices to sustain the programme on a longer-term basis. The personal benefits to those involved are often mentioned as a main characteristic of successful peer education initiatives (Turner & Shepherd, 1999). Personal development and growth have also been cited in other peer education programmes (Backett-Milburn & Wilson, 2000). Furthermore, peer educators who act as role models are a key element to success in peer education initiatives, as highlighted by Social Learning Theory. The participation of local community members is a key element in HIV prevention worldwide because trusting and co-operative relationships can develop (Campbell & Mzaidume, 2002). There is a sense of helping and supporting each other in AIDS-stricken African societies, and this occurs to the benefit of every peer education programme. However, the reasons that members participate in such programmes are important, and successful programmes need to address all these reasons and so base their education in the learners’ needs and expectations. Knowledge of HIV Club members were asked to identify two main ways of HIV transmission and the variety of diseases one can contract through unprotected sex, as well as [to raise] questions exploring discrimination against persons with AIDS. Most had a high and accurate level of knowledge except for a minority of members, the latter coming from recently-formed clubs. We observed that the longer people were involved in clubs, the more accurate their HIV-related knowledge and the more vocal the members were. Abstinence from sex among younger club members was also common. Even some deeply-rooted cultural beliefs and norms, such as
Table 1: Demographic data of participants Club members Gender Employment status
Religion
Martial status
Male Female Employed Unemployed Attending school Seventh Day Adventist Roman Catholic Salvation Army Zion Spirit Church New Apostolic Church Other Christian denomination Married Single Widowed
Peer educators
N
%
N
%
29 15 6 33 5 18 12 6 3 3 2 21 20 3
65.9 34.1 13.6 75.0 11.4 40.9 27.3 13.6 6.8 6.8 4.6 47.7 45.5 6.8
7 3 10
70 30 100
5 2
50 20
1 2 4 6
10 20 40 60
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
African Journal of AIDS Research 2004, 3(2): 183–190
‘sexual cleansing’ (a belief that once the husband has died the wife has to have sex with a relative so as to release the spirit of the dead and avoid mental illness) and the practices of traditional healers (i.e. scarification), were much-debated topics and many people believed that these contributed to the spread of AIDS. In some communities, such practices were already replaced by alternative safer ones. Modifications and changes in cultural norms and practices have been reported as outcomes of other peer education programmes in Zambia (Hughes-d’Aeth, 2002). Ongoing open debate and community discussion reflect empowerment and perhaps self-efficacy, as people believe they will not be infected with the virus if they follow certain practices they have learned from peer educators, and so modify some of their cultural norms (Social Learning Theory). For example, instead of allowing traditional healers to use unclean razors for scarification, they were now bringing along their own clean and unused razors. The pivotal role of the traditional chief in changing such practices was highlighted. Such involvement may be pivotal for the community in accepting new knowledge and changing health behaviours, as peer educators become more influential and are perceived as competent and credible. The latter characteristics are key aspects of a successful peer education initiative under both Social Learning Theory and the Communication of Innovations Theory. The only practice that people felt they should not follow (but for the wrong reasons) was dry sex, as they believed that the herbs used for dry sex can cause cancer. Very few mentioned AIDS in relation to dry sex and there was a tendency for males to still prefer to practise it. Improvements in knowledge have been seen in a range of other peer education programmes in Africa and beyond (Bassett, 1998; Wolf et al., 2000; Tobias, 2001; Hope, 2003; Perez & Dabis, 2003), but this does not necessarily translate to changes in lifestyles. Poverty, unemployment, hunger, low economic status, low female autonomy, male labour migration and alcohol consumption are all factors that have been identified as contributing to people not changing risky sexual behaviours (Gregson et al., 1998; Campbell & Mzaidume, 2002). Our own experience in Zambia suggests that these factors are too great to not influence sexual behaviour; for example, a number of businessmen from the cities come to the area to engage in sexual activities, sometimes paying K3 000 (US$0.63) for unprotected sex, but decreasing their offer to K400 (US$0.08) for protected sex. Prostitutes will take the risk and have unprotected sex even if they know about HIV, as the difference in pay terms is substantial for a poor and hungry family. However, the fact that certain rituals and cultural norms are changing, as suggested during the interviews, suggests that the peer education programme has caused people to consider risks to their own health and make informed decisions about risks taken. Hence, a new degree of empowerment and re-negotiation of norms (Campbell & MacPhail, 2002) was evident. Exploring issues as a community (rather than as individuals) brought about changes in people’s cultural belief system. Meanwhile, we stress consideration for the role of traditional chiefs in the villages, since programmes that do not include key players
187
in the change process are destined to fail. This has been highlighted by Campbell and Mzaidume (2002), who suggest that the success of peer education also depends on collaboration among diverse stakeholder groups at local, national and international levels. The current programme displays good collaboration and links to both local and international levels. Ways that new information on HIV can change or affect lifestyles The largest contribution of the programme was that of bringing the community together to fight the spread of AIDS. This connectedness seemed an important characteristic of the success of the programme, as collective negotiations were taking place. Such negotiations may challenge social identities and change power relations. Constructing identities within the group that challenge the ways in which traditional gender relations place one’s health at risk through sexual behaviour is discussed in detail elsewhere (see Campbell & Jovchelovich, 2000; Campbell & MacPhail, 2002). Certainly, our experience was that of vocal women disagreeing with men and explaining to them how they could be safe, taking the lead in suggesting changes and persuading men to follow their ways. Under the umbrella of that theme, a number of subthemes emerged, such as teaching and communication with children within the family unit, helping men and women stay with one partner and be faithful, abstaining from sex, leading an exemplary life, decreasing one’s prejudice against people with AIDS, understanding which practices of traditional healers can spread the disease and other infections and the benefit of using condoms. These themes are revealed in the following comments: • ‘The project managed to bring us together and increase our interactions with others in the community. We never did this before…. Also it increased our community spirit.’ • ‘It brought about courage to reach out to other communities and share.…’ • ‘… to abstain from sex and stay away from getting AIDS as I am single and living alone. I do not indulge in sexual activities’. • ‘After learning the information I decided to teach my children the ways AIDS is transmitted and tell them the facts about HIV prevention and also talk to friends and increase the communication at home with my children….’ • ‘Even if neighbours are around I help them to understand how to protect themselves, how to take care of AIDS patients… and how to provide compassion.…’ • ‘It taught me how to abstain from sex before marriage and stay with one partner after marriage’. • ‘I have selected abstinence from sex as the best way to protect myself’. Some comments highlighted the difficulties that religion has posed in carrying out appropriate sex education: ‘The church has barriers in talking about sex, so the anti-AIDS club helped me to talk about it….’. As many of the participants were religious and the subtheme of abstinence from sex was common, participants were asked whether this was the result of their religious
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
188
beliefs rather than the influence of the anti-AIDS club. The overwhelming answer was: • ‘The Church told us not to have sex, but the anti-AIDS clubs helped us to understand why we should not have sex before marriage. Using what I have learnt by the programme and having Christian values I teach my fellow Christians how I manage to abstain [from sex] and see the positive effects on me…’. Also, the adolescents in the groups were obviously scared of contracting AIDS and dying, as they have seen so many deaths. One said that of all his classmates of 10 years ago, he and a couple of others were the only ones living. The peer educators added that the programme caters for all people, young and old, and works in their own community. They reported that from their experience (some were involved in similar programmes in the past) other education projects in the schools had not been very successful. Many past initiatives, especially the ones started by international charities, were unsuccessful, as they communicated through leaflets and letters which never reached remote villages or the illiterate people in the villages. Also, some were formal (school) programmes and not sustained for long. It has been claimed that the informal passing of information by peers may be more successful than formal ways, as people identify with their peers (Turner & Shepherd, 1999). Also, whereas sustainability of peer education initiatives may depend on external funding being available, with peer education programmes we see that peer educators may still reach out to their community even when funding ceases (UNICEF/Ghana, 2002). The peer educators highlighted their aim to empower the community by giving the anti-AIDS club members ownership of the club and its activities. As one co-ordinator said: ‘Our offices are under the trees with the people; we are out there. Our coordinators know the communities, as they belong there…’. This connectedness might have been pivotal in the sustainability of the SAPEP programme, as one of the key elements of sustainability is community ownership (UNICEF/Ghana, 2002). Furthermore, peer educators were continuously mobile and able to reach many remote villages. Reaching those who are hard to reach through conventional teaching methods and those in isolated communities is another important characteristic for successful peer education initiatives (Differential Association Theory and Subculture Theory). Peer education programmes are about empowering the community. The dynamics of that empowerment are often complex; as seen in the interviews, empowerment can relate directly to HIV prevention behaviour, while it also indirectly improves family communication, cohesion and ties. One of the most successful elements of the programme was that information was directly provided to the community rather than to the individual, as the latter approach is often unsuccessful in terms of behaviour change (Ziersch, Gaffney & Tomlinson, 2000). The best way to empower people can differ; the means to empowerment needs to be adjusted to effectively mobilise people to develop a strong sense of community, and should be based on the specific needs and interests of that community. Often this takes imaginative and creative thinking, as in the case of a peer education
Molassiotis, Saralis-Avis, Nyirenda and Atkins
programme targetting African-American youths in the USA, where hip-hop music was used as the medium for delivering an HIV prevention message (Stephens, Braithwaite & Taylor, 1998). Peer education programmes must create unique and interesting ways of developing co-operative learning. It is interesting to see that a number of adolescents chose abstinence as the best way to protect themselves. This is in contrast to the literature that suggests that this strategy is not taken seriously by young people (Campbell & McPhail, 2002). Perhaps this message is more appropriate for adolescents who, in this way, delay the onset of sexual relationships as opposed to adolescents who are already sexually active. Nevertheless, the adolescents’ responses may have been dependent on the make-up of the focus groups and it is possible that the young people involved said what their families or other members of their community expected them to say. It is also possible that they were sexually active but did not want others in the group to know this. However, our informal individual discussions with these youths suggest that responding according to social norms may not have been the case. Change of attitudes towards AIDS patients Most participants agreed that patients with AIDS deserve compassion, and that their attitudes had changed since becoming involved in a club. For example: • ‘Before [the anti-AIDS club] I used to laugh at those infected and isolated them, but now I am trying to bring them closer to the community, fighting the stigma and discrimination…’ • ‘Before I got this knowledge, even touching an AIDS patient, I was afraid that the disease will pass on me. I used plastic bags on my hands, but now I don’t do that anymore…’ • ‘We know now that we should not isolate them [AIDS patients]. We are born one flesh, we are all brothers and sisters, and we should take care of each other…’ There were, however, occasional disagreements with such sentiments, as some participants (a handful) still believed that some people do deserve to get AIDS. Again, these were participants coming from recently-formed clubs. On the other hand, peer educators felt that they had to lead by example, so they were striving to lead an exemplary life. It was encouraging to see that change occurred in attitudes about HIV-infected people and to know that this may assist in the reduction of HIV transmission. Lamptey (2002) highlights that reduced stigma and discrimination is one of the main ways of reducing HIV infections in the long term. Community programmes should aim to change social norms and improve awareness, knowledge and attitudes, plus create a supportive social environment to sustain behavioural change (Lamptey, 2002). Positive effects on the family Both club members and peer educators reported that their families and friends liked their involvement in the anti-AIDS clubs. Eventually, although the clubs initially targetted youths, many adult family members wanted to participate, and did so frequently. Backett-Milburn and Wilson (2000) described a UK-based peer education programme where
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
African Journal of AIDS Research 2004, 3(2): 183–190
great interest was shown by the peer educators’ schoolmates, friends and families, and informal discussions and debate about what was learnt often took place. Our observation was that gaining new knowledge also had positive effects on the self-esteem of the youths: • ‘There is a lot of wisdom if you have knowledge; I look like a wise guy so the rest of the family envy me.…’ • ‘… in the late evenings all the family sits around the fire and we discuss these issues [about AIDS]…. We teach the family so as to have an HIV-free family’. • ‘My family found a lot of information through me…. Knowledge is power.…’ • ‘Besides my father being very old, after my involvement he also got involved in the club….’ We believe that these empowered youths may be less likely to engage in risky sexual behaviours which, in turn, can have an impact on their personal development. Their development as role models may also impact on their own families. Negative aspects Few negative aspects about the anti-AIDS clubs were reported. Some members mentioned a lack of sports equipment such as footballs, limited income-generating activities or insufficient support required to develop them, limited diversity of games/activities, a lack of mobility needed to work with other clubs and a lack of communication materials. Some peer educators thought they did not have adequate training in counselling skills; they felt this was a barrier to providing more effective education to their peers, especially when people asked difficult questions and had a great deal of problems. It is interesting to see that the negative aspects reported by the anti-AIDS club participants were all related to practical issues. This is perhaps a result of the participants’ motivation for joining an anti-AIDS club — which was not only to gain knowledge but also to gain things missing in their everyday life. Hence, we stress the important role of motivational factors in developing and sustaining longterm community education programmes. Peer educators suggested that the programme could be further improved by having larger functions and providing incentives to the club members. Workshops both for peer educators and for those assisting with club activities were necessary (with different content). People generally felt that income-generating activities were very important and should be better supported (especially in such deprived areas, where unemployment can exceed 80%). They all felt that the key to the continuing success of the programme was to keep people motivated. This highlights the importance of considering the longterm sustainability of peer education programmes. Thus, different health education mediums could be used on a regular basis so that people can continue to feel motivated and do not become ‘fatigued’ from talking about HIV prevention. Needs of AIDS patients AIDS patients identified a consistent set of needs among them. Lack of food was the largest issue. Insufficient clothing and bedding were also commonly reported.
189
Although lack of medicines was often reported, food was mentioned above medicines. Concern for the number of AIDS orphans and a lack of homecare programmes were also talked about. The very same set of needs for persons with AIDS was referred to by peer educators. Supply of condoms An irregular supply of condoms to the area where the study took place appeared to be a major difficulty. Free condoms in Zambia are distributed through hospitals; however, the local hospital was run by Roman Catholic nuns who refused to distribute condoms through their hospital. Thus, peer educators often had to travel a long distance to another hospital in another district to obtain condoms for their community. The Catholic Church’s stance on not allowing condom use to prevent HIV transmission, in conflict with scientific evidence, is widely known and debated. Yet, providing information about HIV and AIDS and promoting condom use is unlikely to have an optimal impact on the spread of HIV/AIDS unless efforts are made at the same time to promote local condom availability (Campbell & Mzaidume, 2002). We feel that condom availability is a paramount factor impacting all HIV education programmes. Conclusion Several key characteristics of the current peer education initiative, SAPEP, have led to a successful programme. These include the provision of credible information, community empowerment, peer communication rather than professional teachers to disseminate information, peer educators as positive role models, peer education that benefits those providing it, learning reinforced through popular sports and drama activities, and outreach capabilities for hard-to-reach communities. Creative thinking, education and community mobilisation, coupled with sustainable programmes and supportive environments, all help to motivate the types of behaviour change that can reduce HIV incidence. References Backett-Milburn, K. & Wilson, S. (2000) Understanding peer education: insights from a process evaluation. Health Education Research 15, pp. 85–96. Bandura, A. (1977) Social Learning Theory. Englewood Cliffs, New Jersey, Prentice-Hall. Bassett, M. (1998) Impact of peer education on HIV infection in Zimbabwe. Sexual Health Exchange 4, pp. 14–15. Campbell, C. & Jovchelovich, S. (2000) Health, community and development: towards a social psychology of participation. Journal of Applied and Community Social Psychology 10, pp. 255–270. Campbell, C. & MacPhail, C. (2002) Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth. Social Science & Medicine 55, pp. 331–345. Campbell, C. & Mzaidume, Y. (2002) How can HIV be prevented in South Africa? A social perspective. British Medical Journal 324, pp. 229–232. Cohen, A.K. (1955) Delinquent Boys: the Culture of the Gang. New York, Free Press.
Downloaded by [Texas A & M International University] at 05:34 06 November 2015
190
Duryea, E.J. (1991) Principles of non-verbal communication in efforts to reduce peer and social pressure. Journal of School Health 61, pp. 5–10. Elford, J., Sherr, L., Bolding, G., Serle, F. & Maguire, M. (2002) Peerled HIV prevention among gay men in London: process evaluation. AIDS Care 14, pp. 351–360. Gregson, S., Zhuwau, T., Anderson, R.M. & Chandiwana, S.K. (1998) Is there evidence for behaviour change in response to AIDS in rural Zimbabwe? Social Science & Medicine 46, pp. 321–330. Hope, R.H. (2003) Promoting behaviour change in Botswana: an assessment of the Peer Education HIV/AIDS Prevention Program at the workplace. Journal of Health Communication 8, pp. 267–281. Hughes-d’Aeth, A. (2002) Evaluation of HIV/AIDS peer education projects in Zambia. Evaluation and Program Planning 25, pp. 397–407. Israel, B., Checkoway, B., Schulz, A. & Zimmerman, M. (1994) Health education and community empowerment: conceptualising and measuring perceptions of individual, organisational and community control. Health Education Quarterly 21, pp. 49–70. Kegeles, S.M., Hays, R.B., Pollack, L.M. & Coates, T.J. (1999) Mobilizing young gay and bisexual men for HIV prevention: a twocommunity study. AIDS 13, pp. 1753–1762. Kocken, P., Voorham, T., Brandsma, J. & Swart, W. (2001) Effects of peer-led AIDS education aimed at Turkish and Moroccan male immigrants in The Netherlands. A randomised controlled evaluation study. European Journal of Public Health 11, pp. 153–159. Lamptey, P.R. (2002) Reducing heterosexual transmission of HIV in poor countries. British Medical Journal 324, pp. 207–211. Laukamm-Josten, U., Mwizarubi, B.K., Outwater, A., Mwaijonga, C.L., Valadez, J.J., Nyamwaya, D., Swai, R., Saidel, T. & Nyamuryekung’e, K. (2000) Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania, 1990–1993. AIDS Care 12, pp. 27–40. Leonard, L., Ndiaye, I., Kapadia, A., Eisen, G., Diop, O., Mboup, S. & Kanki, P. (2000) HIV prevention among male clients of female sex workers in Kaolack, Senegal: results of a peer education program. AIDS Education & Prevention 12, pp. 21–37. Macleod-Clark, J., Maben, J. & Jones, K. (1996) The use of focus group interviews in nursing research. NT Research 1(2), pp. 143–153.
Molassiotis, Saralis-Avis, Nyirenda and Atkins
Perez, F. & Dabis, F. (2003) HIV prevention in Latin America: reaching youth in Colombia. AIDS Care 15, pp. 77–87. Rogers, E.M. (1983) Diffusion of Innovations (3rd edn). New York, Free Press. Sarbin, T.R. & Allen, V.L. (1968) Role theory. In: Lindzey, G. & Aronson, E. eds. Handbook of Social Psychology, Vol. 1. Reading, UK, Addison-Wesley, pp. 488–567. Speizer, I.S., Tambashe, B.O. & Tegang, S.P. (2001) An evaluation of the ‘Entre Nous Jeunes’ peer-educator program for adolescents in Cameroon. Studies in Family Planning 32, pp. 339–351. Stephens, T., Braithwaite, R.L. & Taylor, S.E. (1998) Model for using hip-hop music for small group HIV/AIDS prevention counselling with African American adolescents and young adults. Patient Education & Counselling 35, pp. 127–137. Sutherland, E.H. & Cressy, D.R. (1960) Principles of Criminology. Philadelphia, Lippincott. Tobias, B.Q. (2001) A descriptive study of the cultural mores and beliefs toward HIV/AIDS in Swaziland, southern Africa. International Journal for the Advancement of Counselling 23, pp. 99–113. Turner, G. & Shepherd, J. (1999) A method in search of a theory: peer education and health promotion. Health Education Research 14, pp. 235–247. UNICEF (Ghana) (2002) Evaluation of HIV/AIDS prevention through peer education, counselling, healthcare, training and urban refuges in Ghana. Evaluation and Program Planning 25, pp. 409–420. Williamson, L.M., Hart, G.J., Flowers, P., Frankis, J.S. & Der, G.J. (2001) The gay men’s task force: the impact of peer education on the sexual health behaviour of homosexual men in Glasgow. Sexually Transmitted Diseases 77, pp. 427–432. Wolf, R.C., Tawfik, L.A. & Bond, K.C. (2000) Peer promotion programmes and social networks in Ghana: methods for monitoring and evaluating AIDS prevention and reproductive health programs among adolescents and young adults. Journal of Health Communication 5(suppl.), pp. 61–80. Ziersch, A., Gaffney, J. & Tomlinson, D.R. (2000) STI prevention and the male sex industry in London: evaluating a pilot peer education programme. Sexually Transmitted Infections 76, pp. 447–453.
