AIDS peer education projects in Zambia

Evaluation and Program Planning 25 (2002) 397–407 www.elsevier.com/locate/evalprogplan

Evaluation of HIV/AIDS peer education projects in Zambia Armand Hughes-d’Aeth Hughes-d’Aeth Associates

Abstract This 1998 evaluation assessed the peer education programmes of HIV/AIDS projects run by four non-governmental organisations. A minicase study approach was used and analysis was based on cross-case itemistic variables. The projects were assessed only in terms of immediate developmental outcomes to target groups rather than on long-term impact. The study concluded the following: (1) The projects had raised community awareness of HIV/AIDS; (2) Basic knowledge of HIV/AIDS was for the most part accurate; (3) There was anecdotal evidence of behavioural changes in terms of partner-reduction as reported by the projects, though the evidence was sometimes conflicting; and (4) There was evidence that certain traditional practices, which contributed to the spread of the virus (e.g. sexual cleansing and scarification), were becoming modified over time. The programmes were also instrumental in protecting human rights and enabling people living with HIV/AIDS to maintain human dignity. q 2002 Published by Elsevier Science Ltd. Keywords: HIV/AIDS; Zambia; Peer education; Non-governmental organisations; Community awareness; Behaviour change

1. Introduction An evaluation of four non-governmental organisations (NGOs) in Zambia was conducted to assess their peer education programmes. These were the family health trust (FHT), Kanyama Compound Project, Kara Counselling, and the Copperbelt Health Education Project (CHEP). The wider aspects of their programmes (e.g. HIV testing services, home-based care, etc.) were not included in the assessment. The evaluation was undertaken in 1998 over a period of 2 weeks. Operational areas such as cost-efficiency, financing, and NGO – UNICEF linkage and further support were included in the original study (Hughes-d’Aeth, 2000) but are not included in this paper.

2. Background to the study 2.1. HIV/AIDS situation in Zambia The situation in Zambia concerning patterns of spread of the HIV virus is consonant with that found in sub-Sahara Africa in general. The epidemiological pattern tends to be one where transmission is mostly through heterosexual men and women and with an even male to female ratio of infection (Whiteside & Loewenson, 1998), though this may rise higher (Fleming, 1993) as a consequence of social factors and the biologically greater efficiency of male-toE-mail address: [email protected] (A. Hughes-d’Aeth). 0149-7189/02/$ - see front matter q 2002 Published by Elsevier Science Ltd. PII: S 0 1 4 9 - 7 1 8 9 ( 0 2 ) 0 0 0 5 1 - 4

female transmission. Transmission via infected blood is also noteworthy given the prevalence of certain cultural practices (e.g. akalimi, inembo—scarification) and recourse to traditional healers and traditional birthing attendants (TBAs) (Hughes-d’Aeth, Chitalima, Cooper, & Mugala, 1997). National prevalence of HIV infection of the 15 – 49 years age group is high and paediatric AIDS is common. The long period of asymptomatic infectiousness makes HIV a ‘long-wave disaster’. Governmental coping responses are often inadequate to confront an epidemic that is already well established in a population. The costs of dealing with the epidemic are already high by the time it is recognised, these costs being compounded by increasing incidences of tuberculosis, malaria, meningitis, etc. which at one time seemed to be coming under reasonable control. There were an estimated 853,000 adults (17% of the population) infected with HIV in Zambia in 1995 (UNDP, 1997), with some 500 new infections per day in 1998. However, these figures are unreliable because of underreporting, and the figures are likely to be higher (Government of Zambia, 1998). AIDS/ARC was the second most common cause of death in hospitals in 1998. Webb (1997a) indicates that HIV prevalence and HIVrelated disease in Zambia is seen most frequently in 20– 30 year old women and 30– 40 year old men. Amongst younger cohorts (15 –19 years age group), the rate is highest among females—seven times higher than same-age males and indicative of a high incidence of inter-age cohort sexual mixing. The dynamics of transmission of heterosexual HIV/ AIDS are dependent on the high rates of sexual partner

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change amongst younger groups and male preference for sexual contact with younger women. Reports indicate that school children on average put the age of their first sexual encounter at between 15 –16 years old. Girls from poor background frequently begin sexual activity at the age of 12 years old whereas boys engage in sexual activities at a later age. Normative values towards condom use are much higher in the younger age groups. Although girls may suggest the use of condoms, boys are the decision-makers and the ones who have to obtain condoms. Youths report that their main sources of condoms are from clinics, chemists, communitybased distributors and bars. Levels of HIV infection are generally lower in rural areas than in towns and cities (O’Keeffe, 1996). Traditional attitudes still influence sexual behaviour even though there have been changes in life styles as a result of urbanisation. The growing incidence of HIV/AIDS has served to accelerate the emergence of child-led households and to the breakdown of traditional value systems leading to a loss of the extended family and security system. This is perceived to be a contributory factor to the loss of interpersonal relationships and violent criminal behaviour (UNDP, 1997). The likely impact of HIV-AIDS infection on Zambia will be great in terms of direct costs in caring for HIV-related illnesses, which is closely linked to the country’s wealth and which has consequent implications for government resource allocation. Moreover, major sections of trained and skilled manpower groups are being affected. Impact is also great at the household level in terms of financial and emotional effects. “Behaviour modification is the only effective defence against AIDS which we possess” (Cross, 1993, p. 318). Education programmes may be successful in disseminating information, but these have been far less successful in bringing about behavioural change (O’Keeffe, 1996; Southall, 1993). “The challenge for the 1990s is to translate knowledge about the dangers and risks into changes in behaviour and maintenance of those changes” (FitzSimons, 1993, p. 27).

munication. Furthermore, the government aims to integrate HIV/STD prevention education into schools, as well as to develop IEC programmes targeted at out-of-school youths. Formal government institutional capacity to respond to the epidemic is already extended to its limits. Thus, “only through community voluntarism can projects of sufficient number, scope, coverage and value for resources and effort be achieved” (Kanyama, 1998). The UNICEF country program in Zambia provides financial and technical assistance to support peer education projects to limit the transmission of HIV/AIDS, to help communities cope with those infected, and to maintain human dignity and human rights.

3. Study design and methodology 3.1. Design The evaluation describes and assesses the HIV/AIDS projects of the four NGOs using an approach consisting of a series of ‘mini-case-studies’. The two main operational limitations of the evaluation were time and geographical spread. These affected issues such as cost-effectiveness, informant trust and confidentiality, checking on reliability of information obtained, adequate time for observations of peer activities, situating activities within the context of alternative NGO outreach work and, most importantly, collection of information on behaviour change. However, some primary data was collected from key targets within communities where the projects operated. Triangulation of the data through an alternative research approach (e.g. KAP survey) would have increased validity. The brief descriptions of peer strategies used by the four NGOs provided the basis for a case-oriented and cross-case analysis of how the projects and activities were operationalised on a variable-by-variable basis (e.g. Strategy, Targets, Capacity-Building, Empowerment, etc.). This enabled identification of recurrent value variables common between, or distinctive to, the projects.

2.2. Zambia’s strategy to fight HIV/AIDS The Government of Zambia’s response is set out in its ‘Strategic Plan 1994– 1998’ (ZNSP, 1998, pp. 9 –14). This elaborated a set of intervention strategies to ensure the reduction of HIV and STD transmission. Its main targets were children and ‘out-of-school youths’; women who are disempowered through low levels of literacy and/or social and economic dependence, which renders them vulnerable; and other high-risk groups (armed forces, prisoners, etc.). Key government HIV prevention strategies include the promotion of safer sexual behaviour through mutual faithfulness, abstinence, ‘zero grazing’ (meaning no sex outside of a regular partnership), and increased condom use. The main governmental anti-HIV/AIDS information campaigns have been through multi-media channels of com-

A case-oriented approach considers the case as a whole entity, looking at configurations, associations, causes, and effects within the case—and only then turns to comparative analysis. …A variable-oriented analysis is good for finding probabilistic relationships among variables. (Miles & Huberman, 1994, p. 174).

3.2. Methods The main activities during this evaluation were: † document reviews; † interviews with key informants (semi-and non-structured); † on-site visits to observe peer activities.

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Assessment of IEC activities was on the basis of: † † † †

appropriateness of message and channels of communication; message clarity; focus on targets; levels of outreach.

This was followed by an impressionistic assessment of possible impact since attributable, causal links between project activities and behaviour change could not be proven given the time constraints (if, indeed, they ever can be). Any assessment of actual or possible behaviour change and/or modification is limited by three considerations. Firstly, no project or strategy can ensure actual behaviour change. Secondly, behaviour change or modification takes place against prevailing norms of personal and cultural practices within that community, which may either promote or hinder behaviour change. Thirdly, because individuals are often unwilling to be completely frank on sexual issues, there is under-reporting of AIDS cases. Analysis of impact aimed to assess the effectiveness of peer activities using the following criteria: † awareness of AIDS and its nature; † accuracy of information provided to ensure realistic individual perceptions of risks; † appropriateness of peer strategies to promote behaviour changes or modification; † and, unanticipated outcomes. External validation was assessed through personal experience (posting in Zambia 1990– 1994: Hughes-d’Aeth et al., 1997); through outside validating sources, such as reports as well as through discussions with colleagues; and validation through informants. The reliability of these sources was gauged in terms of plausibility, coherence, and correspondence.

4. Description of the NGO projects evaluated The Family Health Trust (FHT) works extensively in Lusaka and in Eastern Province; the Kanyama Compound Project targets three poorer areas in Lusaka—Kanyama, Matero and George; Kara Counselling, which acts mostly as a service provider, is based in Lusaka; and the Copperbelt Health Education Project (CHEP) is located in Zambia’s mining province. A number of other NGOs with HIV/AIDS Information, Education and Communication (IEC) activities are also working in Zambia, but these were not a focus for evaluation. The evaluation report provided single case study descriptions of each NGO. 4.1. NGOs’ aims The four NGOs were similar in that they had shared aims

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and similar intervention activities, though with differing degrees of emphasis. All sought to increase awareness of the virus; to provide accurate information on HIV/AIDS and STDs to target groups; to promote safer lifestyles and behaviour through education and thereby to slow down the rate of transmission; and to build institutional and community capacity to respond and to cope with HIV/AIDS. Common cross-cutting aspects included the establishment of services available to youths and women; condom distribution and life-skills training; the integration of gender awareness within HIV/AIDS and STD prevention control; sensitisation to stigmatisation and need for human dignity; improved quality of life for people with AIDS (PWAs); and the need to network with the government, other organisations and the community. 4.2. Target groups Youth was variously and broadly described by the NGOs, but were generally considered to be young persons of both sexes between the ages of 14– 25 years old. In practice, NGOs targeted a wide-ranging group at either end of the spectrum, and included people with HIV/AIDS and their families, persons with STD, persons using drugs, as well as a general public living in an environment where HIV/AIDS is not common. Typical of this was CHEP, which had activities aimed at school children, out-of-school youths, traditional healers, health workers, religious and other community leaders, and women’s groups. In general, there was a focus on three groups within this broad-based approach: Youths, especially in the teenage range at a time of sexual awakening, were targeted since they form a substantial high-risk grouping within society. In many countries over two thirds of adolescents aged 15 –19 years, male and female, have had sexual intercourse. Adolescents and young adults (20 –24 years of age) account for a disproportionate share of the increase in reported cases of syphilis and gonorrhoea worldwide… In addition, at least one fifth of all people with AIDS are in their twenties, and most are likely to become infected with HIV as adolescents. (WHO, 1992: Series No. 10, p. 1.1992). Youths are vulnerable through peer pressure to conform, and they often lack coping skills in the face of fear and trauma (O’Keeffe, 1996). Youths out-of-school are particularly vulnerable as they have little access to information and are often isolated. The younger elements of youths having the lowest incidence of HIV form a ‘window of hope’, and it is vital to reach them at an early stage. In addition, the numbers of households that are dependent on an older sibling to lead and provide for the household are increasing. Schools (in 1998) provided little in the way of information, life-skills or hope. CHEP is also involved in an active

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Child-to-Child programme (grades 1 – 7), an outreach strategy which they consider to be a more inclusive way of targeting children of different age groups. Women are frequently disempowered through lack of information and access to education. They are often the first to drop out of schools due to opportunity costs of sending girls to schools and early marriage. Their submissive roles in social interactions and traditional cultural practices (e.g. ubupyani—sexual cleansing of a husband’s spirit after death through inter-course) and their economic vulnerability often means that they are unable to refuse sexual approaches, are unable to adequately negotiate on the use of condoms, and are sometimes dependent on granting sexual favours for their survival. Older men—‘sugar daddies’—often target young women. Finally, women with AIDS tend to be more stigmatised than men. The Kanyama Compound Project specifically targeted vulnerable women and commercial sex workers (CSWs), who may be described as ‘high frequency transmitter core groups’ having rapidly changing male partners. It is to be noted that prostitution was not legalised and therefore CSWs constitute a particularly vulnerable group with little or no defence against violence and abuse. Gatekeepers such as teachers, peer educators, TBAs, traditional healers, nurses, trade unions etcetera were targeted, especially by CHEP and Kara, as being important sources of information to communities and influential for behaviour formation/modification. Their positions often give them direct and indirect contact with ‘primary vulnerable groups’. 4.3. Peer education activities Peer education activities were multi-various and included drama and music activities (one-minute roleplays; ten-minute mini-plays on various topics); games and sport’s groups, and assistance to peer associations (women’s groups, youth clubs, etc.). Drama, game and music activities are important given the fact that many Zambians find it easier to relate to the spoken rather than to the written word, and problems of illiteracy are circumvented. Secondly, ‘shared’ activities have greater impact in allocentric cultures. Finally, it is easier to be more explicit about sensitive issues such as sex and relationships within a drama performance that enables the audience to discover the relevance of a message without threat or accusation. Such activities place information within a context, people are involved in a personal way, and understanding and empathy is enabled.1 The FHT and CHEP peer education approach was mainly participatory and elicitation-focused. FHT emphasised inter-club anti-AIDS meetings, the production of anti1 Editor’s note: See the article on Popular Theatre in Tanzania in this publication.

AIDS club newsletters, youth magazines and materials (leaflets, calendars, booklets for secondary school students). CHEP used a range of outreach activities, and its programmes were wide-ranging—income generation activities for ‘out-of-school’ youths, child-to-child education, community and peer education, women’s programs (including those for CSWs and alternative income generation), and training in pastoral skills as well as research and surveys. HIV/AIDS messages were delivered via community radio broadcasts, peer group meetings and training activities for peer educators, health workers, business groups and police personnel. To facilitate this, publication and distribution of IEC materials and extensive networking also took place. The project also contacted village communities that are inaccessible by road and reached refugee groups from the Democratic Republic of Congo. Condom distribution was undertaken by the NGOs and they all used various channels including women’s clubs, anti-AIDS clubs, and bars. Condom distribution at the sites where high-risk activity is being carried out is a vital element of the information campaign since this is a practical means of translating advice on safe sex behaviour into actual practical change, but the concomitant is that condoms must be available and safe. It is to be noted that female condoms were not made available at the time. Interestingly, none of the projects at the time seemed to have focused on alternative traditional means of safer sex (e.g. thigh sex). Formal training and informal capacity-building. The Kara Counselling Trust uses a ‘trainer-of-trainers’ approach to access wider communities and peer groups through a ‘centre-periphery cascade’ strategy. It develops specialised courses on demand for specific groups—for example, teachers, peer educators, banks, and the ‘Youth Friendly Services’. The training component offered a number of courses in basic human development, self-awareness, sexuality and reproductive health, managing stress, and basic counselling skills of varying duration. FHT, CHEP and Kanyama concentrated mainly on the training of facilitators and ‘patrons’ so that information could be distributed accurately, and to assist target groups to obtain counselling and referrals. Empowerment. The Kanyama Compound Project on AIDS targeted several key areas of HIV/AIDS prevention by empowering women. One of the most important was to give CSWs the assertiveness and negotiating skills necessary to persuade clients to use condoms given their reluctance. Another key area was to give women the confidence and the means to seek clinical help in view of their high-risk from STDs. Economic empowerment was also provided through access to revolving credit funds and bereavement funds. Accessing this community is usually difficult and such marginalised groups are best reached by peer educators and proxies. CHEP, FHT and Kara dealt with empowerment issues targeted at youths by fostering life-skills. FHT produced a book on life-skills (Happy, Healthy and Safe) using Anti-

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AIDS youths in its development. CHEP also dealt with lifeskills issues—love and relationships, peer pressure, and adolescent pregnancy.

5. Discussion of the findings 5.1. Appropriateness of peer education strategies Peer education is an appropriate and effective strategy if used within a complex of mutually supportive activities (counselling, referrals, testing, orphan care, etc.). An effective strategy is one that reconciles the differences between integrated programmes (e.g. credit provision and income generation) and vertical single issues (e.g. condom use), as well as reconciling the tension between long-term strategy (e.g. institutional and behavioural change) and short-term needs (e.g. immediate coping requirements of individuals and communities) (AIDS Consortium Report, 1996). The NGOs were aware of these considerations (to a greater or lesser extent) and their peer education programmes were but a single strand of their overall outreach work. Furthermore, NGOs need to take into account the wider cross-sector context of their work given that their operations impact on such issues. Effective anti-HIV/AIDS responses are linked to development issues such as urbanisation, poverty which increases people’s vulnerability, sanitation and health provision, and gender roles (AIDS Consortium Report, 1996). The wider context influences both the types of activities NGOs organise and their response to the effects of HIV/AIDS. CHEP and Kanyama were particularly aware of these considerations and their responses were deemed appropriate. Peer education is viewed as reaching out through social networks on the basis of like-to-like, for example gender-togender or youth-to-youth groupings. In this review, the peer education strategies of NGOs were focused on three main target groups, though there was considerable overlapping between each: age groups, gender groups and socioeconomic groups. Individuals, rather than the community were also a focus through counselling services, but this fell outside the scope of the evaluation. The rationale given by NGOs for using a peer education approach was broadly similar. Persons-at-risk could be reached by peers in a personal and sensitive manner as they are best able to understand their contextual situation. Peer educators engender trust, they are seen as a credible source of information, they gain access to communities through knowing the local language and use of existing networks, and they are suasive role models for change. Hence, they are likely to promote behaviour change and community values, and to foster local commitment. Peer educators are concerned with the processes of change and they provide a continuing mutually supportive framework to help make prevention choices workable. This

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involves raising awareness, providing accurate information, challenging the barriers to behaviour modification and reinforcing values required to effect positive change behaviour. For example, FHT challenged the use of sexual stimulants within communities in Eastern Province. CHEP specifically targeted pre-teen groups with emphasis on behaviour formation (as opposed to modification) by encouraging the kinds of values that establish norms conducive to safe sex practice in later years. These are demanding tasks requiring high levels of commitment and skill. The peer educators for the most part, many of them unemployed young persons, did their very best to respond to the challenge. 5.2. Information and education ‘messages’ The way an NGO defines infection risks influences the ways it attempts to modify that risk, thus targeting of groups and clarification of risks is part of the process of developing effective anti-HIV/AIDS messages. There is no single risk reduction message relevant to all. The IEC programmes included a range of prevention choices to meet the various contexts and circumstances of people. However, the information must be unambiguous and enable recipients to personally identify with those messages. The initial strategy of NGOs was to raise awareness through accurate and timely information to the community. The development of IEC messages by the NGOs reflects the stages through which Zambia has passed since the onset of HIV/AIDS. Initially, the messages were designed to ‘electrify the people’s minds’, but this later changed to a focus on reassurance and hope. The next stage of the process was one of filling in the gaps, clarifying aspects of the message, and dealing with the fears and misconceptions of target audiences. There was a shift in focus, appropriateness, and information level in response to the increasing levels of community awareness of HIV/AIDS and knowledge base. Messages were targeted to particular groups and to address areas of specific needs in order to localise and personalise the information. The need for clarity of messages concerning modes of transmission is important and obvious, but it is not so simple to ensure. Evidence worldwide and in Zambia indicates that rumours, misconceptions and fears abound, and hinder the force and effectiveness of AIDS messages (Baggaley, 1996a, and see also Bond et al. in this journal issue). Consonant with this process are messages that are designed to be enabling and to provide individuals with a choice. In effect, people were informed that it is in their power to prevent acquisition/transmission of HIV, and advice on safe-sex practice was provided in a nonjudgmental manner. Prevention of transmission through persuading persons not to engage in high-risk sexual behaviour and the abandonment of high-risk traditional practices is the major goal of intervention groups. The evaluation findings indicated there was definite

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awareness of HIV/AIDS, even in areas remote from urban centres. Secondly, generalised knowledge of the virus and its symptoms was for the most part accurate amongst those interviewed. There was awareness of different modes of transmission, the dangers of multiple partners, the problem of sugar daddies, STD and HIV acquisition, infection through body fluids, etc. but some of the more detailed aspects of transmission (e.g. mother-to-child transmission) were not always clear. No reliable evidence was obtained with regard to increased awareness of PWAs’ legal rights, nor of impact on government policy changes. Denial of HIV/AIDS status was also apparent and informants mentioned that a sizeable proportion within communities believed that AIDS was ‘something that happened to others and not to them’. A similar evaluation in Northern Province, Zambia (Hughes-d’Aeth et al., 1997) revealed that denial was often linked to witchcraft as a rebuttal to charges of promiscuity and to lessen stigmatisation. 5.3. Information and education ‘activities’ The dramas and other activities were acted out with great gusto and there was a lively sense of fun, and the following comments do not detract from this aspect of the presentation. It is to be noted that observations of such activities were limited and these comments can only be considered indicative. Drama and other such activities need to be developmental with a clear purpose and a structured sequence of presentation. Observation of plays presented indicated little difference in terms of focus and levelling, and impact would have been greater through better sequencing. For example, two plays were observed, one intended for youths and the other for children but both were diffuse in their focus and designed to appeal to as wide an audience as possible. Youth audiences require youth interpretations in terms of topics, messages, presentations, etc.; activities for children need to actively involve children rather than being directed at children and, as such, need to enter into the magical world and absurdities of children. Secondly, each presentation requires a specific message or focus—a message that is clearly articulated and designed to elicit a response from the audience. For example ‘Name games’ to explore meaning of words; ‘Trust games’ to build up and explore ideas of trust in partnerships; ‘Choice games’ linking themes of power, status, assertiveness, gender roles, and means of resisting peer pressures, etc. (Lynch & Gordon, 1991). Thirdly, the types of activities observed or which were mentioned during interviews seemed to be restrictive. For example, there was no mention made of story-telling activities with audience participation as a means of sharing personal experiences, nor of different techniques being used—e.g. repetition and dance; chain and group stories with each person adding a bit or ending to a story; mimes

showing dramatic situations that allow audience members to interpret the story—each according to their own predisposition and experience. Engagement and interpretation are important features of any activity (Lynch & Gordon, 1991). Finally, activities observed needed to be ‘milked’—that is explored and talked through with the audience afterwards and for subsequent non on-site actions. The point is raised simply as a reminder since some on-site follow-up was done, but it was of a limited nature—probably because of time constraints. The relevance of health promotion activities centres on the opportunities these provide to explore the forces that influence behaviour—personal and social changes leading to prevention and safer sexual life, whether people have the power and resources to institute such changes, etc. Such activities provide a framework within the local situation to enable an exploration of health and prevention practices. The impression given during observation was that these were one-off activities rather than part of an overall programme, which included a service. For example, the personalisation of a message within a drama leads to discussion opportunities. Or, the simple giving of information to people about where they can get further information, systems of referrals and how to seek medical help. The impact of such activities were difficult to follow through given the time constraints, but the peer educators did assert that in their opinion there had been improved selfreliance of communities in coping with HIV/AIDS. No reliable evidence was obtained on whether such activities had truly reduced stigmatisation, but the raising of such issues is the first step in doing so. 5.4. Condom distribution activities Condom distribution was one of a number of activities to support the message of behavioural change, but condom supply must be regular, rather than intermittent and insufficient, as was found to be the case in some areas, and the quality of the condoms needed to be assured to give confidence to users. Otherwise, the message cannot be realised in a practical way. Some areas experienced insufficient and intermittent supply from the Ministry of Health, though the Kanyama Project expediently circumvented this problem by hiring transport to collect condoms from a central depot. Once again, condom distribution forms part of a process rather than being a one-off activity. For example, how to obtain or buy condoms (distribution systems/price/availability); dealing with community acceptance and ‘smart girls’ carrying condoms; how to introduce the idea of condom use with partners and means of overcoming partner embarrassment; means of disposal; and ensuring that all the above aspects are repeated every time with every sexual partner. The Kanyama project commendably included

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negotiating skills and assertiveness training to CSWs to overcome obstacles of clients not wishing to use condoms. 5.5. Training activities Training through a ‘centre-periphery cascade’ model of dissemination and skills provision can be a very costeffective means of reaching out to dispersed communities where communication is poor and access difficult. This is especially so when locally based and credible channels are used to confront sensitive issues such as sexual behaviour and the stigma of AIDS. Cascade model effectiveness prerequires: 1. targeting groups and individuals (gatekeepers) that are most influential within a community; 2. good initial training to participants; 3. credible change agents; 4. short links within the cascade chain to assure the availability of necessary resources and psychological support to on-site peer educators; 5. an extensive programme of consolidation and refresher courses to limit message diffusiveness and misconceptions; and, 6. a reliable monitoring system to pre-empt problem areas and ascertain effectiveness. The projects achieved this with differing levels of efficiency and in diverse ways by making use of existing networks to target and focus on high-risk groups: (youths to) unemployed young persons, (teachers to) pupils, (trade union members to) workers, etc. The projects used credible and already existing channels by working through Women’s Clubs, and school-based Anti-AIDS clubs. Links within the cascade chain were kept short, but feedback was sometimes inadequate. A constraint in training identified by Kanyama concerned the medium of training/instruction. English is the language generally used, whereas a number of peer educators have low levels of formal education. They have very sensibly decided to train project co-ordinators using English, and these coordinators then train their own peer groups using the local vernacular. There are overlaps between community and institutional capacity-building, and peer-training strategies and networking can assist institutions to deliver an appropriate and responsive service at all levels. Thus, for example, there was need for staff in District Health Centres (DHCs) in Eastern Province to focus on adolescents. Health workers require to be sensitised to the problems of young people who should be encouraged to use the clinics. Young people were reported to be hesitant to make use of DHCs as they feared that some nurses would not respect their confidentiality, that they would be stigmatised for trying to obtain information on HIV/AIDS and STD given their youth, and that they might even be sent away. Targeted messages need to emphasise client confidentiality, the importance of early STD treat-

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ment and of early antenatal screening, and safe condom use. As Webb asserts (1997a), fear of district health clinic services is a major factor why young people seek help from traditional healers. This kind of work could effectively be undertaken by nurses, who are specifically trained to deal with HIV/AIDS issues, running workshops for local nurses in DHCs. This is already happening in other regions (e.g. NHEP work in Kasama; CHEP in Copperbelt). Counselling work and increased outreach activities should also be given to health workers to enable them to recognise the potential of peer educators as a force for change, and the potential of working with traditional healers “who probably represent the single largest service provider of care for young people today in relation to sexual health” (Webb, 1997a). One important area of training undertaken by Kara Counselling concentrated on training teachers to deal with HIV/AIDS in schools (e.g. pupil reluctance to share problems with teachers, poor class performance, family problems, and trauma). The course also helped teachers to cope with personal anxieties, and they were thus better able to cope with personal family problems. Teachers who attended the course reported that they were now using their skills to deal with the behavioural problems of pupils by no longer relying on disciplinary measures, and that they had become more patient and were more ready to listen to pupil anxieties (Baggaley, 1996b). 5.6. Informal capacity-building activities Capacity building is a strategic issue and an important means of ensuring sustainability. The staff and peer educators in the four projects received training relevant to their respective activities. All the NGOs provided training for peer-educators and training materials were up-dated regularly. In addition, and very importantly, it was noted that CHEP trained everyone in the office with basic counselling skills so that even the secretary was able to respond appropriately to emergency situations. FHT made commendable efforts to develop a core group of peereducators and to consolidate its field support and supervisory system. However, staff retention was reported to be a major challenge to their capacity-building efforts with turnover rates of between 35 and 50%. The consolation, however, is that trained peer educators are not necessarily lost to the health care system as they tend to work within the same or similar domain. There was a crosscutting need for office skills (especially computer skills) and basic project management training (project planning, proposal writing, financial budgeting). Development of such skills enables co-ordinators to become more self-reliant and facilitates decentralised management thereby adding to sustainability and ownership. Increased networking is important as it leads to complementarity with government, other NGO and church programmes; it enables skills-sharing and access to wider

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information sources; it facilitates referrals between NGOs and the health systems; and it provides a more comprehensive system within which HIV/AIDS work can be undertaken. 5.7. Behaviour change People have the information about the AIDS but the biggest problem is the penis! (Village headmen in Eastern Province, Zambia) There was anecdotal evidence of some change of behaviour although this was conflicting, and there was contradictory evidence concerning whether there had been partner-reduction or ‘zero grazing’. Some of the NGO workers (FHT, Kanyama) cited increasing levels of condom sales, a lowering of STD trends and the RPR figures from the ante-natal clinics, as well as anecdotal evidence of less frequent casual sex and of fewer numbers of women in bars as evidence of changing sexual patterns of behaviour. The consultant’s own evening observations in Matero (a bar area in Lusaka) led him to treat the latter assertion with caution. Few persons mentioned abstinence to be a realistic means of prevention—though some youths felt it was appropriate for old people whereas some of the older people pointed out that this was a traditionally recommended practice for unmarried youths. But there was evidence from another project evaluation in Northern Province, Zambia (Hughes-d’Aeth et al., 1997) of changing cultural practices in non-sexual modes of transmission, and where projects can and do contribute positively as catalysts for change. Two examples are given: TBAs now sometimes wear plastic bags over their hands given their lack of surgical gloves; some traditional healers in rural areas said they had reverted to using disposal sharpened slivers of wood instead of re-used (nonsterilised) razors for practices which involve skin-piercing. The FHT regional coordinator for Minga (Eastern Province) indicated that the use of sexual stimulants (mutoto and vbubwe) was lessening, though this could not be confirmed. However, this assertion appears congruent with the modification of certain cultural practices in other areas of Zambia. 5.8. Monitoring and evaluation The four NGOs made various definite efforts to ensure some form of monitoring of their activities and performance. One of the weaknesses observed was the absence of any baseline study on community needs, or detailed baseline information about sexual behaviour. A baseline study provides an assessment of the health status of the community and indicates priorities for intervention, which could then be matched to the resources and expertise of the projects.

Secondly, there was a need for increased inclusion of qualitative aspects of monitoring and follow-up procedures for a more rigorous tracking of actual behaviour change (Webb, 1997b; Webb, Kathuria, & Mwangala, 1996). Whilst NGO operations may achieve internal efficiency, it is much more difficult for them to be effective on local and/ or national events and to show impact. Project documents reviewed provided limited indication of criteria for evaluation, and measures of success were usually quantitative with little mention of what these meant with regard to quality or levels of behaviour change/modification. Intangible, non-material considerations (e.g. changing ways of thinking, shifting values and attitudes, creating opportunities for development and personal growth) were not covered. As the training co-ordinator at Kara Counselling reports, they are “struggling to arrive at a qualitative evaluation system of client effect in community. We need practical experience and exposure to monitoring to touch the people down there—but are we really touching them?”

6. Rights issues Rights issues were addressed at all levels in that human rights were an intrinsic part of the HIV/AIDS peer education programmes assessed. These recognised that dignity is a right of all persons irrespective of their status. At its most fundamental level, the NGOs sought to provide individuals with an environment of respect consonant with United Nations guidelines. An environment in which human rights are respected ensures that vulnerability to HIV/AIDS is reduced, those infected with and affected by HIV/AIDS live a life of dignity without discrimination, and the personal and societal impact of HIV infection is alleviated. (UNAIDS, 1998, p. 5). The rights of PWAs and their dependents were supported through reduction of stigmatisation, and through IEC messages and activities to promote a better, more even understanding of the needs of PWAs and their rights to privacy, their rights to friendships, and their rights to a livelihood. The rights of women were promoted through empowerment strategies and the right to access information and services specific to their circumstances and their needs, and through activities to reduce gender inequalities such as access to credit. These rights are recognised as fundamental to the general well-being of societies and consonant with the International Development Goals adopted by the OECD in 1996 and The Convention on the Elimination of Discrimination against Women, which are endorsed by many international agencies and national governments.

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Table 1 Lessons learned and applications to improve programmes Lesson learned

Application to improve programmes

Extending target groups

Targeting youths, women, gatekeepers has been appropriate but targeting to be more fine-tuned to pre-youth groups, pupils (especially girls) below grade 5, other high-risk women (e.g. low status women—‘amaules’) Information, education and communication work has been good but knowledge gaps to be filled in Range of communication channels could be extended through use of alternative media (e.g. radio) Development of life-skills programmes and materials for younger age groups Extending range of audience participation activities—drama, games, plays, etc. Negotiation skills and assertiveness training on condom use by all NGOs Activities need to be structured, sequenced and developmental, and appropriately focused to target audience Condom supply to be improved and quality to be assured All NGO members of staff to be appropriately trained and responsive to situations Sensitisation of all persons dealing with clients seeking help—e.g. health workers Greater focus on teacher coping skills by all NGOs Improved management skills Improved networking and planning with the Ministry of Education, Ministry of Health, District Health Management Teams, etc. Feeding in ‘best practice’ ideas Training in monitoring skills and techniques for central offices and coordinators Qualitative indicator setting, collection and analysis. Emphasis on linking quantitative and qualitative data Listing and standardisation of indicators Inclusion of baselines for planning and tracking purposes

Need for increased IEC

Complementing and extending range of activities/message

Improved activity structures Access to condoms Staff and peer-educator training/capacity-building is important

Cross-sectoral linkages and networking is necessary

Improved monitoring skills

The rights of youths were promoted through access to accurate information and activities that raised their awareness to reduce infection, and through provision of life-skills which dealt with issues faced by them. Rights of pupils were also addressed though sensitising teachers to their needs, and such rights are within the framework of the ‘World Conference Education For All’ conference report and subsequent conference held in Senegal in 2000. The rights of individuals were promoted in general through peer activities designed to safeguard all within a community from becoming HIV/AIDS victims and the subsequent poverty trap that awaits many in developing countries. These rights are underscored in the poverty reduction strategies of the Government of Zambia and its partner development agencies. UNICEF’s support to the NGOs is a direct and supportive contribution to the dignity and rights of all.

7. Conclusions and lessons learnt The projects were instrumental in raising awareness, in providing accurate information on the nature and spread of HIV/AIDS, and in providing psychological support to ‘highrisk’ groups. Moreover, they provided target groups with

information on safe sex practice, with life-skills to cope with high-risk situations, and with a practical way to support behavioural change through condom distribution and information on use. The efficiency of the NGOs programmes could be improved and their effectiveness in terms of impact on sexual behaviour change was sometimes uncertain. However, the NGO projects are important given the seriousness and urgency of the nature of the spread of HIV/AIDS, and there is need for the continued role and input of NGOs given the Government’s over-stretched resources. Importantly, the NGO staff and peer educators enabled people living with AIDS, their dependents, and the community at large to retain a measure of dignity in the face of the most appalling uncertainties and fear. The value of a cross-case evaluation analysis is that identified areas of ‘best practice’ from one NGO can be recommended for implementation to other NGOs. This is the basis for the formulation of the table of ‘Lessons Learnt’ shown in Table 1.

8. Follow-up by UNICEF UNICEF responses to the recommendations in this

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evaluation were in four main areas, as summarised below. 1. Support to the four NGOs to expand HIV/AIDS prevention programmes for all children under 18 years old with special efforts on: * development and production of IEC materials for all children under 18 years old; * adaptation/development life skills materials for children aged 9 – 14 years who are not in school, so that this risk group does not miss out on the education provided in school and through ‘child – child peer education’; * training in-school and out-of school children and peer educators on the utilisation of life skills and IEC materials; * organising participatory games for children of 5 – 8 years old, while youth are attracted by activities such as Teen-Time discos, fashion parades, question-and-answer sessions, quizzes and songs such ‘We are the Cure’, by the Sakala Brothers. 2. Support to strengthening partnerships/networks between Government Ministries and NGOs/CBOs: * support the linkage NGOs with DHMTs and health centres, especially establishing the referral channel between peer education activities and professional counselling in health centres; * support the linkage NGOs with MoE through mutual participation in the annual planning process and annual review meetings. 3. Support NGOs to improve the quality of drama and other peer education activities through structured sequence of presentation of messages: * peer educators are using support to 2 – 3 min drama sketches as stimulants to discussions related to HIV/AIDS, sexually transmitted infections (STIs), voluntary testing and counselling (VTC) and other health issues for specific target groups; * support EDU-sport (Infotainment) and games for life festivals, using sport as a metaphor in HIV/AIDS and life skills education, is being encouraged for young people; * support NGOs for community awareness by peer education volunteers to promote rights based approaches, HIV/AIDS prevention, VTC and life skills interventions in targeted provinces. 4. Support to improve monitoring and evaluation: * monitoring and evaluation have been improved through the introduction of five levels of monitoring forms, and of field supervision. Project Officers visit all the zone areas at least once a month; * a volunteer from VSO now serves as an M&E advisor to the program. 5. The CHEP serves a knowledge centre, and: * it provides training activities, and guides researchers;

UNICEF provided support to build the capacity of CHEP in the area of Research, Monitoring and Evaluation. This support helps not only to better run their organisation, but also to help other partner NGOs and CBOs to improve services through strengthening organisational monitoring and evaluation systems.

*

Acknowledgements Earnest Kasuta, Lecturer at the University of Zambia, used the original author’s research report to write a later paper, which the author consulted for this article. Siping Wang and Harriet Miyato of UNICEF Zambia facilitated the paper’s production and contributed the section on Follow-up by UNICEF.

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