AIDS prevention through peer education, counselling, health care, training and urban refuges in Ghana

Evaluation and Program Planning 25 (2002) 409–420 www.elsevier.com/locate/evalprogplan

Evaluation of HIV/AIDS prevention through peer education, counselling, health care, training and urban refuges in Ghana UNICEF Ghana* UNICEF Ghana, P.O. Box 5051, Accra North, Ghana

Abstract Since 1996, Ireland Aid has supported UNICEF Ghana in the implementation of five activities that promote behaviour change to limit the spread of HIV/AIDS and STIs. The interventions are run by different local organisations, and have provided over 75,000 in and out-of-school youth and commercial sex workers with preventive education. People retained the information given, are knowledgeable about how HIV is transmitted, and can name key preventive methods. They pass on the information to their friends. Commercial sex workers were empowered to support one another in negotiating for safer sex. The programme was supported by community members, leading to demand for condoms and for education on HIV/AIDS/STIs. One project gave support to pregnant girls, including health care and vocational training. A drawback in the programme has been the occasional delays in the supply of the educational materials to the peer educators. q 2002 Elsevier Science Ltd. All rights reserved. Keywords: HIV/AIDS; Prevention; Youth; Ghana; Peer education; Commercial sex workers; Street children; Refuges; Vocational training; Health care; Counselling; Micro-credit

1. Introduction Epidemiological evidence indicates that HIV infection is spreading among all age groups and sexes in Ghana. From an initial adult sero prevalence result of 0.2% in 1991, the HIV prevalence rate rose to 3% by the end of 2000. At the end of 31st May 2001, the National AIDS Control Programme (NACP) reported a cumulative total of 47,444 AIDS cases. 64% were women and among them, 74% were between the ages of 20 and 39, with the peak ages for HIV infection being 15 – 25 years. Children under 5 years old represent 2.0%. The NACP has projected that the number of children orphaned by AIDS will rise to 252,000 in 2004 and to more than 603,000 by 2014. The social and economic consequence of maternal or double parental loss on children poses a potential threat to the gains achieved under the child survival and development programmes. The number of cases among 10 – 19 years, estimated at 2.2%, is rather low and justifies the focus of UNICEF’s prevention activities on young people as the ‘window of hope’. The Ghana AIDS Commission (GAC) was established in * Corresponding author: Ramesh Shrestha. Tel.: þ 21-770593. E-mail address: [email protected] (Ramesh Shrestha).

2000 to provide a multi-sectoral, national response to HIV/AIDS. A 5-year national HIV/AIDS strategic framework has been developed which focuses on five strategies: prevention of new HIV/AIDS infections, caring for people living with AIDS, creating an institutional and legal framework to enable a national response, a decentralised response, and a monitoring and evaluation framework. Promoting safer sex among the youth and other vulnerable groups have been highlighted, which is of particular importance to UNICEF.

2. Background to the programme Since 1996, Ireland Aid has supported UNICEF Ghana in the implementation of five activities that aim to promote behaviour change to limit the spread of HIV/AIDS and STIs. After an evaluation of these projects in 1997, Ireland Aid provided a second round of funding for the continuation of these activities in different areas of Ghana (Brugha, 1997).1 The interventions are projects run by different local 1 Ireland Aid’s support, though significant, has been a partial contribution to these projects, which have mixed funding and input arrangements.

0149-7189/02/$ - see front matter q 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 1 4 9 - 7 1 8 9 ( 0 2 ) 0 0 0 5 2 - 6

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agencies and organisations, which receive their Ireland Aid support through UNICEF Ghana in Accra. The five components are: 1. Youth to youth peer education in 12 districts in Upper Eastern and Northern Regions (Anarfi and Kannae, no date), 2. Peer education, condom distribution, STI services and micro-credit for commercial sex workers in Obuasi, Adansi West District, Ashanti Region, 3. Peer education, counselling, and skills training for in and out-of-school youth in Ga Mashie (part of UNICEF’s Urban Community Based Development Project), 4. Refuge, health care, education, counselling, skills training for female street youth in Maamobi, Accra (part of UNICEF’s Urban Community Based Development Project), and 5. Refuge, health care, education, and education sponsorship for male street youth in Jamestown (part of UNICEF’s Urban Community Based Development Project). A mid-term evaluation was performed in 1997 and numerous monitoring activities have been undertaken. A comprehensive baseline survey of the target populations’ knowledge, risk perception and behaviour with respect to HIV/AIDS and STIs, was carried out in 1998, though not published until April 2000. This study enabled the programme to incorporate improved indicators (Government of Ghana and UNICEF, 1998).

3. Description of programme components 3.1. The Peer Education Project in 12 districts in Upper East and Northern Regions This project is run by Ghana Red Cross Society for young people in and out-of-school (Ghana Red Cross Society and Action AIDS; UNICEF Ghana, 1996). Funds have been channelled through ActionAID, Ghana. UNICEF provides technical support to the project. The goal of the project is to reduce the incidence of HIV/AIDS amongst young people in 12 districts of the Upper East and Northern Regions. The main objectives are to promote HIV/AIDS awareness and knowledge and to promote safer sex practices among young people in the Upper East and Northern Regions of Ghana. Specifically the project aimed to: † educate 20,000 young people aged 15– 25 years on the knowledge, attitudes and skills needed to prevent HIV infection through peer to peer education, and † have peer educators and the participants at the education sessions pass on HIV information to at least 50,000 other persons, two thirds of who would be aged 15 –25 years.

3.2. HIV/AIDS prevention through peer education with commercial sex workers in Obuasi, Ashanti Region Obuasi, in the Adansi West District, is a gold-mining area characterised by a high population density, high unemployment, high cost of living and predominantly male workforce. The town has attracted a large number of commercial sex workers. The goal of the project is to reduce the incidence of sexually transmitted infections, including HIV/AIDS, among commercial sex workers and young women in Obuasi (Anarfi and Kannae, 2000). The main objectives are: † to increase awareness on HIV/AIDS and to increase knowledge on modes of HIV/AIDS transmission amongst commercial sex workers in Obuasi, † to increase personal risk perception and safe sex practices among commercial sex workers in Obuasi, and † to promote appropriate health-seeking behaviour among commercial sex workers for the treatment of STDs. The project uses a peer education approach, combined with increasing access to condoms, improving access to quality STI services, and providing access to credit for commercial sex workers and single women. 3.3. The CENCOSAD project: peer education for in and outof-school youth in Ga Mashie CENCOSAD is a Ghanaian NGO with their own ‘Programme for HIV/AIDS Prevention and Awareness Creation’, funded by UNICEF (UNICEF Ghana, 2000b). The methods used are peer education, providing access to condoms and appropriate health services and counselling. The project is closely linked and synergistic with a Communities Reproductive Health Project funded by DFID through Save the Children Fund. UNICEF also supported CENCOSAD in other areas, such as skills and entrepreneurial training for young single mothers. A holistic approach to HIV/AIDS prevention is followed, meaning that the young mothers also received information on child caring practices, access to early childhood care and information on STI/ HIV/AIDS prevention. 3.4. The Street Girls Aid project: female street youth and refuge project in Maamobi, Accra A 1996 survey by Catholic Action for Street Girls (CAS) and Street Girls Aid (SGAID) counted at least 10,000 children living and working in the streets of Accra. The purpose of the collaboration between UNICEF and SGAID is to provide female street youth in difficult circumstances with access to adequate maternity services, other reproductive health services, and to help them to protect themselves

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against HIV/AIDS and STIs. UNICEF has supported SGAID in the running of a refuge centre, antenatal and post-natal care, delivery services, child care and nutrition education, counselling and vocational skills training and literacy training. Most activities are implemented in close collaboration with the Salvation Army and Catholic Action for Street Children. 3.5. Catholic Action for Street Children: a refuge project and Centre for Male Street Youth in James Town The purpose of the collaboration between UNICEF and Catholic Action for Street Children (CAS) (Catholic Action for Street Children and UNICEF, 1999) is to provide vulnerable male street youth with access to a non-resident refuge and to provide access to vocational skills training, literacy training, health services and health education. CAS offers street youth (mainly boys) a place of contact with people they are comfortable with and a place where they feel safe. In addition, CAS has a variety of activities aimed at ameliorating the youth’s living conditions, raising their self-esteem and, eventually getting them off the streets. CAS field workers now operate in more than four suburbs of Accra and provide street corner education on general health problems including HIV/AIDS. 3.6. Significant children’s and women’s rights addressed UNICEF and partners’ programmes comply with and advance human principles and goals of human rights. Particular focus is placed on the goals and principles of the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination against Women (UNICEF Ghana, 2000a). Regarding children’s rights, the child is the primary claim or right-holder. Parents, communities and ultimately states are all duty-bearers, but to meet their duties, they must have capacity and be able to claim their own rights. The HIV/AIDS programmes described in this evaluation often involve building up the capacities of right-holders to claim their rights and of duty-bearers to fulfil their obligations, as well as directly facilitating the realisation of rights. Specific rights addressed in the area of health and health education are summarised in Sidebar.

4. The evaluation Ireland Aid has supported UNICEF Ghana in HIV/AIDS prevention activities since 1996, but this evaluation focuses on the period between 1998 and 2000 when Ireland Aid provided a second round of funding for continued support of the five project components (UNICEF Ghana, 1998, 1999).

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Sidebar Significant children’s and women’s rights issues addressed The project addressed the following rights as specified in the Convention on the Rights of the Child (CRC): Right to education Right to an adequate standard of living Right to protection from sexual exploitation and sexual abuse Right to health and health facilities Right to dissemination of information of benefit to them And the following rights from the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW): Reduction of female student drop-out rates Access to specific educational information to help ensure the health and well being of families

The specific purposes of this evaluation were to: † identify the projects’ gains and achievements (intended and unintended), † describe the lessons learned and examples of best practices, † provide options for future developments, including improvements in programme implementation, sustainable expansion and replication, within the context of governmental policy and the UNICEF 2001 – 2005 Country Programme (UNICEF Ghana, 2001). The evaluation was to focus on the targeted beneficiaries and discuss with them any changes in their knowledge, perceptions and behaviour due to the project interventions. The evaluation was also expected to assess the organisation, structure and management of the programme and its component projects. In particular, an analysis would be made of the programme’s capacity and efficiency, its promotion of both intra-sectoral and inter-sectoral linkages and of the co-operation and involvement of relevant government ministries, such as Employment and Social Welfare, Education, Health and Sports.

5. Evaluation methodology The evaluation team comprised a public health physician, a sociologist, and a micro-credit specialist, who visited all the projects in May 2001. Several methods of data collection and analysis were used for the evaluation, including observations, in-depth interviews, focus group discussions, review of documentation and reports, and visits to pharmacies. Eleven different sites were visited and feedback workshops were held with peer educators, outreach staff and the management committee. Before finalisation of the evaluative report, the evaluation team had a debriefing meeting with the staff of UNICEF.

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Table 1 Youth to youth peer education project in Upper East and Northern Regions: number of young people reached through peer education sessions 1998– 2000 Target group

1998

1999

2000

Total

Northern Region Male Female Total

1904 1802 3706

5373 5231 10,604

11,008 10,765 21,773

18,285 17,798 36,083

Upper East Region Male Female Total

1598 1556 3154

6832 6514 13,346

8332 5293 13,625

16,762 13,363 30,125

6.1.2. Content of peer education sessions Twelve to fifteen participants meet on a weekly basis for a 2 h session over a 4-week period. The activities start with the target group going through games, role-playing, story telling, a quiz, and condom demonstrations. A pre-test and post-test exercise is carried out with the group to measure improvement in their knowledge after the four weekly sessions. Peer educators are highly motivated and enthusiastic and they have a good relationship with their peers, which enhances the peer education process. Peer educators handled the sessions with a high degree of self-confidence. Most of the key messages about HIV/AIDS and its prevention were clearly articulated and reinforced by the peer educators.

6. Main findings 6.1.3. Suggestions for improving sessions 6.1. Main findings: youth to youth peer education in Northern and Upper Eastern Regions This programme component had clear objectives and its educational activities were in line with the project document. The project centred on talks about sexual health, using active participatory methods—some game-based—to capture the interest and attention of young people. Fewer peer educators were trained than expected (514 vs. 750), but the number of youths reached greatly exceeded the number envisioned (62,208 vs. 20,000). Almost all the peer educators were retained. 20,000 more adults were reached indirectly with HIV/AIDS messages. See Table 1 for more details of male and female youths reached. The project formed a partnership with local health services for the referral of suspected STI cases. In some cases, the peer educators accompany the client to the clinic. Because of unclear financial agreements between the District Health Management Teams, the District Assemblies and the Ghana Red Cross Society, the proposed ‘Youth Friendly Centres’ were not completed for use before the end of 2000. 6.1.1. Selection, role and training of peer educators Clear criteria for the selection and role of peer educators exist and have been discussed and understood at all levels. They work in same-sex pairs to satisfy the concerns of a traditional and conservative community. The other reason for the same sex pairings is to ensure that target group members feel comfortable and participate effectively during the educational sessions. However, since 2000, some districts have experimented successfully with mixed pairing and mixed group meetings. A total of 222 peer educators were trained in the Northern Region and 292 in the Upper East Region. Each year starts with a review meeting and a Training of Trainers refresher workshop. New peer educators have two separate training sessions, a 5-day initial training and 3-day refresher training.

† Choose appropriate locations for out-of-school sessions, where there is minimal distraction. † Avoid conventional classroom seating, which is not conducive for teamwork or group discussion. † Increase listening and questioning skills among peer educators, to reduce misunderstanding of questions raised by group members. Train peer educators to avoid didactic teaching, and to build on the experience of the group through further discussions. † Improve peer educators’ understanding of the link between HIV infection and other sexually transmitted diseases. † Clarify among peer educators the relationship and difference between HIV and AIDS. † Improve peer educators’ understanding of mother to child transmission . 6.1.4. Impact on knowledge, attitudes and practices Many of the young people retained most of the information they had acquired through the sessions. Almost everyone could identify two modes of HIV transmission and invariably everyone mentioned abstinence, sticking to one partner and the use of condoms as prevention methods. Almost all the out-of-school youth could demonstrate the proper use of condoms. The interviews provided examples of individuals who have changed behaviour: Some of us here did not want to use condoms. It was like using a raincoat to shower. Since the peer educator taught us to fix and use a condom properly, I always use it. Since I attended the educational sessions, I have stopped having sex. Sometimes my friends laugh at me saying if you do not have sex the sperm would be stored in you and this would disturb you; but I do not mind them. Sometimes the girls put pressure on the boys to have sex with them and not use condoms. They say if you trust her

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why don’t you want to have sex without condoms. Then we tell them you may get an STI and if you have it you are likely to get HIV quickly. I am still at school but also work with my father. A group of us met last year, we were about 20 boys and all of us were footballers. The peer educators showed us how to use a condom. Sometimes they burst but now I know how to use a condom properly and I advise my friends.

6.1.5. Management, supervision and reporting Management and coverage are issues of concern. The project must be extended into other areas in order to benefit young people in the entire region, but if there is geographical expansion, transport issues will become more acute, and the structures for supervision will need to be revised. Many peer education sessions were not supervised. A more structured approach to supervision could help identify teaching problems at an early stage. At present, some of the more experienced peer educators are carrying out some supervisory duties and this could be formalised. The report forms were modified according to recommendations from earlier reviews and peer educators now find them easy to use. These reports have made it easy to collect and collate statistical information and to identify the problems. The peer educators receive feedback on their reports. 6.2. Main findings: HIV/AIDS prevention through peer education with commercial sex workers in Obuasi, Ashanti Region Peer education was the major activity of this project, along with increasing access to condoms, improving access to quality STI services, and providing access to credit for commercial sex workers and single women (UNAIDS, 2000b). There was an intention to reaching out to people with AIDS although this was not captured in the original logical framework for the project. 6.2.1. Selection and training of peer educators Peer educators were selected from commercial sex workers who were home-based, street-based, hotel-based and ‘invisible’. The last category consists of women who may have some other employment (e.g. hairdressers, seamstresses) but who are also involved in commercial sex activity. One group that was not identified by the project was brothel-based sex workers and a brothel system does operate in Obuasi. Overall the process of selection was excellent and the individuals chosen as peer educators had good access and were acceptable to members of the target group. Men were not selected as peer educators even though some had indicated a desire to be trained. In all, 110 peer educators were trained and 100 are still active. (In the project document it was planned to train 200

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peer educators.) Peer educators also underwent refresher training and some were also taken on an exposure visit to a CARE project. Recently, the trainers have used tests before and after the training to assess its effectiveness (UNICEF Ghana, 1996). 6.2.2. Outreach The target group for the project was defined as commercial sex workers and young women. The peer educators also reach out to young men and much of the condom distribution is to men, although men were not identified as a target group in the project logical framework. A survey carried out for the 1997 evaluation showed that the peer educators each reached an average of 15 – 20 commercial sex workers on a regular basis. If this average still holds, the 100 active peer educators could be reaching as many as 2000 commercial sex workers. Unfortunately, it is difficult to draw firm conclusions about the level of outreach activity from the reporting system that is in place. The project was very successful in breaking down barriers and reaching home-based commercial sex workers. The hotel-based commercial sex workers were difficult to reach on a sustained basis, as they are a very transient group. The project developed several tactics for reaching out to this group including the training of security staff at the hotels, but the numbers reached remained small. 6.2.3. Nature of outreach activity The peer educators used focus group discussions and individual meetings with commercial sex workers and other community members (Apt, 1999). The messages they conveyed aimed to create awareness about HIV/AIDS and the need to reduce risk through behavioural change. Their advocacy focused on promoting safer sexual behaviour, providing access to condoms, and promoting early diagnosis and adequate treatment of STIs. 6.2.4. Impact on knowledge and behaviour change Since the survey on knowledge and behaviour was carried out during the project activities, it cannot be used to measure final project impact. There is a high level of knowledge about HIV/AIDS, but a lower level of knowledge about STIs. All of the interviewed peer educators believed that condom usage had increased. Many women spoke about how they now negotiate for safe sex, and how they support one another to do this. Information on reduction of sexual partners was not obtained, but some of the peer educators have left the commercial sex work profession. 6.2.5. Access to condoms Purchase of condoms was done through non-UNICEF funding sources. Project-supplied condoms are not always available, but some peer educators buy them from local stores. At first condoms were distributed free of charge, but since early 2001 peer educators purchase condoms and then

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re-sell them at a small profit or at cost. According to the 1998 survey, peer educators are not a major source of supply, but they may be an important source for youth that are too shy to purchase condoms at drug stores. 6.2.6. Strengthening STI services As part of the programme to provide quality STI management, a comprehensive assessment of STI clinical services available in Obuasi was undertaken. Doctors, pharmacists, medical assistants, nurses and midwives were trained in treatment and counselling of STI patients. In order to increase the use of properly trained health care workers, chemical sellers were also trained in STI symptom recognition, health education with counselling and partner notification. They were also briefed on referral of clients and given forms to enable them to do this more effectively. Laboratory technicians also received training and a laboratory was provided with basic equipment to conduct HIV antibody testing. 6.2.7. Micro-credit scheme US $34,000 was made available for small-scale loans to enable commercial sex workers to develop alternative sources of income. The scheme was poorly managed from the start and has not been a success. Nevertheless, the scheme is very much in demand with the peer educators and with proper management it could succeed. 6.2.8. Outreach to people living with HIV/AIDS (PLWHA) There are very negative attitudes towards people living with HIV/AIDS, even among peer educators. Over 75% believed that PLWHA should be kept in isolation, kept in hospital or killed. Only one support group was formed, and support from the project was a one-time only contribution. PLWHA were not integrated into the main project as peer educators. The District Assembly has identified CARE as a partner that could take the lead on this activity. 6.2.9. Management, supervision and monitoring Twelve supervisors were trained, of which six are still active. There have been management and funding problems, including non-payment of allowances, erratic supply of condoms and delays in implementing the micro-credit scheme. Problems with the management of loans prevented the programme from providing commercial sex workers with alternative incomes. Progress reports indicated that all the stakeholders clearly understood the collection, documentation and dissemination of relevant information for checking the progress of the project. During the evaluation it was clear that there were still problems with the reporting system. It is difficult to confirm the total number of people reached by the peer educators. There was no evidence of analysis as the reporting moved up the line and the information did not seem to be used by management at district level.

6.2.10. UNICEF phase-out During its planning for the new Country Programme (2001 –2005), UNICEF decided to phase out its interventions in Obuasi, Adansi West (UNICEF Ghana, 1995). Agreements were reached with various NGOs (such as CARE International, Save the Children) and the District Assembly to take over the various activities. 6.3. Main findings: the CENCOSAD project: peer education for in and out-of-school youth in Ga Mashie This project was part of UNICEF’s Urban Community Based Development Project. The NGO CENCOSAD (Centre for Community Studies Action and Development) was responsible for a peer education programme for in and out-of-school youth in the Ga Mashie area of Accra. There was also an element of skills training for single mothers. 6.3.1. Selection and training of peer educators CENCOSAD used clear criteria in the selection of peer educators, supervisors and counsellors. The project involved teachers and communities in the selection process. The out-of-school youth were usually selected from among members of community-based organisations, such as environmental groups. Opinion leaders launched the programme in communities, to help ensure continuing support. The programme achieved its expected output by training 252 peer educators, 50 counsellors and 50 supervisors. They provided HIV/AIDS education to more than 12,000 young people. There was an initial 5-day training, followed 6 months later by refresher training. Peer educators grasped the basic messages in relation to HIV/AIDS and its prevention, but there were misconceptions about STIs. All the peer educators are volunteers, and the programme successful retained most of them. The leadership skills they obtained and the heightening of their self-esteem were major factors for their continuation in the programme. The programme has both peer educators and counsellors.2 One of the counsellors explained his role thus: The role of the counsellor is a bit different to that of a peer educator as we do a lot of one-to-one counselling. If a person has a problem they are taken away from the main group to talk to a counsellor. One of the issues I deal with is teenage pregnancy. I work closely with the peer educators and sometimes if I find that a girl would prefer to talk to another girl, I refer them to a female counsellor but I find that many girls are happy to talk to me and they don’t feel shy. 2 For another approach using counselling, see the loveLife evaluation in this journal.

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6.3.2. Peer education sessions The educational materials used were appropriate for all young people, and acceptable to school authorities, parents and community groups. The educators usually work as a mixed-sex pair. They use group discussions, home and church visits, sporting events, sanitation exercises, film shows, drama activities, debates and games. There are also four Stop AIDS clubs in schools. Educational materials were limited to a training manual and some leaflets from the Ministry of Health. Target groups for the peer educators are classmates for the school-based educators, and for out-of-school youth, friends, acquaintances, clubs, sport associations and groups of apprentices. The project does not reach certain groups such as disabled youth and youth from northern Ghana who speak a different language. As a general point, the issue of transportation for peer educators as the project expands to hard-to-reach communities will have to be addressed. Peer education is a very important part of peer educators’ lives and they use all types of opportunities to pass on messages. Below are quotes from a school-based and community based peer educator. School based peer educator: I am thirteen years of age. My teachers selected me and I was really happy, I spoke to my parents and they agreed that I could be trained as a peer educator. When I came back to the school I started a Stop AIDS club with 10 boys and five girls. I like having a mixed group but sometimes the boys can be disruptive when there is no teacher present. I can handle the situation and even the boys who are disruptive are really interested in learning about HIV/AIDS and they will ask me questions afterwards. Each week I choose a topic for the club on some aspect of reproductive health or HIV/AIDS and I prepare it in advance. I also talk to my classmates during free periods and because people know that I am a peer educator they come to me with their questions. If I am asked a question and I don’t know the answer, I discuss it with one of the teachers who is a supervisor. Also sometimes if I find a student who has a problem I can bring that student to a teacher counsellor. Some of the students I talk to are sexually active and they raise the issue of condom availability. I give them information but I am not allowed to promote condoms at school. My main advice is abstinence. Community-based peer educator: I am twenty years of age and unemployed; sometimes I get casual work loading and unloading. I completed secondary school, but as my father is dead I didn’t have any support to continue my education. I am the eldest of three boys and I live with my aunt. I was involved with an environmental group, the Society for Educational and Environmental Development (SEED) and they selected

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me to be a peer educator. I was trained over a year ago and I enjoy being a peer educator, it gives me something to do every day and prevents me from getting bored. I have a regular group of young women apprentices but I also talk to a lot of individuals. People in the area know that I am a peer educator and they come to me, especially for condoms. I get some condoms from the project and I buy some myself. Condoms are easily available locally though some people are shy to buy them. I meet regularly with other peer educators, counsellors and supervisors and then we have a quarterly meeting with CENCOSAD. The meetings help keep us motivated, but we don’t get any other incentives.

6.3.3. Supervision, monitoring and reporting The supervision system is an important element in maintaining programme quality. In the case of in-school youth, teachers supply the immediate supervision and in the case of out-of-school youth, it is provided by other youth who have been trained as supervisors. In some cases, peer educators have been promoted to the supervisory level. There was a very positive, supportive relationship between the peer educators and their supervisors. A strong link was also made between the supervisors and the project management structure in CENCOSAD. A simple reporting format is in place for peer educators, counsellors, and supervisors and additional information is captured through informal discussions and meetings. The report format captures the main activities that the peer educator has carried out during the month. The form serves its purpose well, but it doesn’t differentiate between new clients and repeats and so calculating the total number of people reached by the project is problematic. Peer educators write reports for their supervisors, but much of the reporting is verbal. During monthly monitoring visits, CENCOSAD collects the reports and later compiles quarterly, mid-year and end of year reports. 6.3.4. Impact on knowledge, attitudes and practices Peer educators referred to increased demand for condoms and increased condom usage among their peers. They also indicated that female condoms are now being purchased. A 1998 baseline survey was unfortunately not finalised until April 2000. The survey indicated that friends were an important source of information on HIV/AIDS and STIs; a peer education approach therefore is a good response to this finding. The survey also found a high level of awareness about HIV/AIDS, but less awareness about STIs. The CENCOSAD project has not yet systematically captured information that could be compared with the baseline or used to evaluate impact in any other way. 6.3.5. Skills training The skills training component achieved its objective of equipping 100 unskilled, unemployed, young single

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mothers with skills, entrepreneurial training, counselling and guidance in dressmaking, catering, hairdressing or tie and dye and batik. These trainees were also educated on STIs and HIV/AIDS prevention. CENCOSAD contracted out the skills training, but provided direct support in entrepreneurial training and counselling. Some trainees were confused over financial arrangements for the training. 6.4. Main findings: the Street Girls Aid project: female street youth and refuge project in Maamobi, Accra 6.4.1. Residential care at a refuge The SGAID refuge centre offers residential care for 40– 45 pregnant girls in the last month of pregnancy until 3 months after the delivery. All girls working and living on the streets can attend the shelter during the day and are offered vocational skills training, literacy training and health education. There are eight field workers who support the activities of the centre. Social workers visit the girls’ family homes to ascertain the social circumstances and try to reunite the girls with their families, but of the 125 – 130 girls staying in the SGAID refuge each year, only about 30 go back to their families. It is very difficult to trace the families of the children. Many have run away because of divorce, abuse or parental neglect and are unwilling to return home. Others are unwilling to disclose the whereabouts of their parents. 6.4.2. Antenatal care Pregnant girls receive antenatal care and some can deliver their babies at the nearby Urban Aid Clinic run by the Salvation Army. Those with complications are referred to higher level care. The babies receive health care for minor ailments, and the childhood immunisation regime. In total, 400 girls were provided with antenatal care at Urban Aid Clinic between 1998 and 2000. 6.4.3. Outreach Social workers of both CAS and SGAID move to the areas where the girls live and work, to counsel them, befriend them and provide them with health information, including STI/HIV/AIDS. These social workers reach about 300 girls daily. 6.4.4. Health education Health education is part of the counselling at the refuge and in the streets. Social workers provide the education and try to reach street girls whilst they are working, while girls at the refuge take classes from qualified health staff of the Salvation Army. Through this dual approach, a total of 870 street girls are reached each year with HIV/AIDS education. 6.4.5. Training The refuge has a training centre where girls learn cookery, sewing, hair dressing, batik and tie and dye. In the year 2000, 25 girls completed apprenticeships. The training

improved the image of the girls among their family members. The NGO Catholic Action for Street Children provided sponsorship to 40 of the SGAID girls for various forms of long term vocational skills training. 6.5. Catholic Action for Street Children: a refuge project and Centre for Male Street Youth in James Town 6.5.1. Refuge, mini-refuges and kiosks Originally CAS operated a house of refuge in James Town, where many urban poor children can be found. Since 1999, a new Refuge House has been acquired in Laterbiokorshie, which is a more organised residential set up than in James Town, but is more difficult to reach for the target group. Therefore, CAS has established mini-refuge centres and kiosks, where field workers meet the children for both counselling and medical care for minor problems. Forty to fifty street children visit the mini refuges daily, while about 200 children visit the health kiosks daily and receive education on health, including HIV/AIDS, as well as treatments for wounds, rashes etc. In the streets, social workers also meet children on a daily basis and health education is usually one of the topics of discussion. However, monitoring the content of the sessions has been weak. 6.5.2. Salvation Army outreach clinics UNICEF also supported the Salvation Army with its outreach immunisation and health education. The outreach clinic schedules about 20 outings per month. A mobile van moves into various areas where many street children reside. The team immunises during the day, and provides health information on various issues such as family planning, breast-feeding, malaria, personal hygiene STIs and HIV/AIDS in the evening. The nurse provides health care when needed and refers complicated cases to the hospitals. Through these outreach activities, many thousands of mothers and children are reached every year. 6.5.3. Education and training CAS has a sponsorship scheme to increase access to education for street children. Children visit the refuge centres regularly to participate in literacy and vocational skill demonstration classes. Some of these children are sponsored to follow a long term training of about 3 years in a new skill, or to return to the formal education system. This initiative also provides them with shelter, pocket money, and basic vocational equipment. There is intensive followup by the CAS social workers, who visit the children at least once a month at their home or educational environment. 85% of these sponsored children complete the training and use it for their livelihood. In 1999, CAS sponsored 250 children, all less than 18 years of age. There is an approximately equal number of sponsored girls and boys.

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Table 2 Lessons learned from the youth to youth peer education project in Northern and Upper East Regions, and applications to improve programmes Lessons learned

Applications to improve programmes

Careful selection and training of peer educators is critical to the success of the peer to peer approach

Involvement of the schoolteachers and parents in the case of in-school youth and the community leaders in the case of out-of-school youth ensured that very few of the selected candidates were found unsuitable after the training, or required replacement Weekly meetings with supervisors to review each week’s activities allow additional training for the peer educators and their existing knowledge is reinforced. The less assertive gain confidence over time, and misconceptions are clarified Involve adults and opinion leaders in peer educator selection, review of approaches and selected activities Well-trained peer educators, even though they may be young people, can provide HIV/AIDS education to their peers and to unintended target groups such as adults This can be obtained through the adoption of appropriate and easy to understand tools Effective project management requires a critical mass of local staff working full-time on the project

The initial training of the peer educators over a 5-day period is short given the volume of information to be absorbed

Adults and opinion leaders are supportive of peer education activities and participate in activities in which they are involved There is a high demand for HIV/AIDS education in the communities

Effective project monitoring requires intensive on site support

The dependence of management on volunteers is likely to create undue delays in programme implementation, which in turn may de-motivate peer educators New methods for improving the delivery of the information by peer educators Peer educators’ training should include aspects of listening and negotiating skills to improve their efficiency in communication. Peer education have to be explored. This is vital to overcome the tendency to resort to didactic teachings sessions could be organised in a horseshoe shape and include small group work to encourage shy participants The standard of peer educators is an issue: it needs to be raised. While Project managers must endeavour to select new peer educators from those important, interest and motivation are not enough most likely to meet the challenges as peer educators There must be a timely and adequate supply of educational materials. At Project management should include attention to supply logistics and to the time of review, the new peer educators had not received their supply periodic review of supply systems to remove bottlenecks There is ignorance and misconceptions about fertility management, There is a need for education and information on reproductive health preparation for menarche, sexual hygiene, etc issues not directly related to HIV/AIDS

7. Conclusions To a large extent the UNICEF activities supported by Ireland Aid have been very successful. The five activities have provided over 75,000 young people with preventive education on HIV/AIDS/STI. These young people have retained the information given; they are knowledgeable about how HIV is transmitted and can name the key prevention methods—abstinence and the use of condoms. They also pass on the information to their friends. Outreach activities have ensured that thousands of street children are immunised, counselled, receive first aid and information about their health. Hundreds avail themselves of the urban refuges every year. The commercial sex workers project educated and informed high-risk women in ways that have empowered them to negotiate for safer sex, and that resulted in increased use of condoms. The SGAID Project supported pregnant girls and their newborns during difficult periods of their life. The skills training component provided a new way of life for the young girls. Several challenges associated with the design and implementation of HIV/AIDS education, such as the selection, training supervision and motivation of the peer educators, have been well addressed. The programme has been well received by the target group and by community

members. This has led to high demand for education on HIV/AIDS/STIs in the project areas. A major drawback has been the occasional delays in the supply of the educational materials to the peer educators. Arrangements relating to purchasing and supply have been largely responsible for these delays. The continuation of these projects would greatly boost HIV/AIDS prevention and control activities among young people.

8. Lessons learned and applications to improve programmes Specific lessons learned from the five programme components, and applications to improve programmes, are shown in Tables 2– 6. A more general discussion of lessons learned follows. 8.1. Building ownership ‘Building community ownership’ of intervention activities has been a strong element in all the projects. By identifying NGO partners with strong links to the community it has been possible to get strong community support from the outset. Potential areas of difficulty, such as sex education in schools and girls acting as peer educators, have

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Table 3 Lessons learned from the project on peer education with commercial sex workers in Obuasi, Ashanti Region, and applications to improve programmes Lessons learned

Application to improve programmes

There was a missed opportunity to deal with child prostitution and with the health and development of children of commercial sex workers

Projects focused on commercial sex workers should exploit opportunities to discourage child prostitution and to promote the rights of children of commercial sex workers, who are a very vulnerable group Advocacy for ownership should occur from the beginning of a project. There is also a need for a clear strategy for working with the private sector Projects need a committed, responsible focal person who will oversee prompt and complete monitoring and reporting of accounts and of achievements

Sustainability remains doubtful, partly because involvement in the project by partners and potential partners was minimal Lack of time given to project management can weaken the entire project

been overcome by building community ownership of the intervention. Of particular significance is ownership by target groups, whether in-school youth, out-of-school youth, or commercial sex workers. Ownership at government level is also important and major attempts have been made to ensure that the Obuasi project is ‘owned’ by the District Assembly. Building ownership at local government and national government level will be important in terms of the scaling up and the long-term sustainability of the interventions. 8.2. Peer education and other interventions with young people The projects are sensitive to gender issues and this has been taken into account in developing materials and in the way peer education and social worker outreach are organised. The projects are also conscious of the need to develop different approaches to in-school and out-of-school youth, but this may need to be developed even further. Outof-school youth are not a homogenous group and it is important to develop a variety of strategies to reach the various sub-groups. Existing projects have been particularly successful in reaching vocational groups such as apprentices. Projects dealing with in-school youth can be institutionalised and scaled up through educational authorities (Ireland Aid, 2000a,b). UNICEF aims to influence HIV prevention while

focusing on the needs of children. To do this, it needs to intervene at a number of levels including national policy level. It also needs to play an advocacy role for AIDS orphans, young people living with HIV/AIDS and children involved in prostitution. The numbers in these groups may be relatively small in Ghana compared to some other countries, but their rights are very likely to be violated (Commission on Macroeconomics and Health, 2001). 8.3. Interventions with commercial sex workers The project in Obuasi has strong ownership by peer educators and commercial sex workers and has the support of key staff at District level. The project has been particularly successful in diminishing moralistic and judgmental attitudes among staff. It has broken down the barriers and suspicion between local government staff and commercial sex workers. The project recognises that commitment and active involvement of the sex workers is dependent on treating the sex worker with dignity, encouraging her to recognise and express her needs and treating her in a fully ethical manner. Unfortunately, the credit support component of the project was not well handled and this tended to undermine the commitment of the sex workers. Supporting health care was an example of treating the commercial sex worker as a whole person. But other opportunities for reaffirming this, such as understanding the commercial sex worker as a

Table 4 Lessons learned from the CENCOSAD project on peer education for in and out-of-school youth in Ga Mashie, and applications to improve programmes Lessons learned

Application to improve programmes

Individual behaviour change cannot be sustained unless the social environment encourages healthy behaviour. Parents and community members who have participated in the planning of the youth programme are willing to defend the programme and deal with the other adults who want the programme to stop Working through existing community-based organizations allows individuals with common social networks to be reached with HIV/AIDS prevention messages. However, some vulnerable groups may not be reached because they do not belong to any social network and are not easily identifiable Community-based groups with little or no previous HIV/AIDS experience can be mobilised to support HIV/AIDS prevention in their communities if the process is kept simple

Advocacy and involvement with the entire community is particularly important

Baseline studies should identify all groups that need to be reached. Strategies for including hard-to-reach groups should be developed

Project design must ensure that goals and activities are not too complicated

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Table 5 Lessons learned from the Street Girls Aid project in Maamobi, Accra, and applications to improve programmes Lessons learned

Application to improve programme

Efforts to re-unite girls with their families achieved minimal success. Unless there is a general improvement in the economy, many of the young girls will continue to move from rural areas to the urban areas to face the difficulties of street life Despite the HIV/AIDS education, some of the street girls supplement their income by engaging in commercial sex

Programmes need to be realistic in their expectations regarding family re-unification and support for girls. Sponsorship programmes should be expanded, which promote education and vocational training for girls

mother and family person, were not explored by the project. Nor is there much evidence of self-organisation in any formal way. This may be partly because of the reluctance of many to define themselves as commercial sex workers. The work with commercial sex workers could be given a stronger child rights perspective if UNICEF used its existing project network to explore the area of child prostitution, and the rights of children of commercial sex workers. 8.4. STI management The interventions had some success in increasing understanding of health-seeking behaviours and increasing use of STI services. The services became more sensitive to the particular needs of both commercial sex workers and youth. It has been much more difficult to ensure that the other elements of successful STI management are addressed in a coherent manner. If UNICEF is to influence the overall issue of STI management, it will need to negotiate with many stakeholders, at national and district level, on an ongoing basis. 8.5. Monitoring and evaluation Many of the projects had difficulties with monitoring and evaluation. Some NGOs involved in the project have strengths in developing monitoring systems but need ongoing support for effective use. Data collection in government systems was not always consistent and there is very little evidence of analysis of data. UNICEF needs to pay particular attention to monitoring systems so that pilot projects can be properly assessed. Less sophisticated monitoring systems suffice for proven approaches.

The support to street girls needs to explore economic opportunities for them, to reduce the need for them to continue to engage in high-risk practices for survival

8.6. Scaling up The issue of scaling up was not adequately addressed in the projects. A key issue in scaling up is the selection of effective partners. The NGO partners that UNICEF works with have clear limits in terms of capacity, but some of them are in a position to assist in the capacity building of other NGOs. Scaling up would also require a deepening of the relationship with key ministries and a coherent strategy for support at district level with the possibility of replication in other districts. 8.7. Sustainability Most of the HIV prevention initiatives are heavily dependent on external support. Sustainability is closely linked to community ownership and to institutional arrangements. Evidence indicates that peer educators will continue to reach out to their community, even if external support is not available. Mainstreaming interventions into NGO and governmental systems can be achieved by ensuring that HIV prevention is included at all stages of planning and budgeting. Ensuring a co-ordinated donor response is also important for sustainability. Individual interventions must be seen as part of a coherent approach and not solely identified with a particular external support agent. As an international organisation, UNICEF’s great strength is its ability to influence policy at national level, while having a more direct influence on programme implementation at the lower levels. Future interventions should link the experience gained at district level to policy development at national level and also link to the wider UN

Table 6 Lessons learned from the Catholic Action for Street Children project in James Town, and applications to improve programmes Lessons learned

Application to improve programme

Health kiosks, can reach large numbers of street children with health education and treatment of minor ailments

Focal meeting points, located where large numbers of street children are found, and where children know they can find help, are a powerful outreach approach

Mini-refuges can attract children who find it difficult to reach one, main refuge Mobile vans can provide not only immunisations and referrals to hospitals, but also health education

Extend the hours of mobile vans so that immunisations are provided in the day and health education in the evening

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family to ensure that all programme developments are informed by international best practices (UNAIDS, 2000a).

evaluation of various project activities together. UNICEF ESARO helped formulate this article.

9. Evaluation follow up

References

The evaluation was disseminated to all partners involved in the implementation of the projects for review and comments. After finalisation of the evaluation, two workshops were organised. First, an internal strategic workshop was organised comprising the UNICEF multi-sectoral HIV/AIDS team. The evaluation results and recommendations were disseminated and used to work towards a new strategic framework, taking into account the national HIV/AIDS strategic plan. The regional advisor of UNICEF West and Central Africa also attended this internal workshop. A second workshop was organised with current partners, possible future partners and Ireland Aid to further develop the new strategies and intervention areas. The new strategic plan takes into account the recommendations and lessons learned from this evaluation as well as the national policy framework in Ghana on HIV/AIDS, comprising issues such as care for vulnerable children and MTCT. At the same time, the new strategic framework serves as a fundraising document.

Anarfi, J. K., & Kannae, L. A. (2000). STD/AIDS related knowledge, attitude and behaviour among commercial sex workers in Obuasi. Accra: UNICEF Ghana. Anarfi, J. K. & Kannae, L. A. (no date). Results from a baseline survey on STD/AIDS for in and out of school youth in the Northern and Upper East Regions. Accra: UNICEF Ghana. Apt, N. (1999). Participatory assessments: Focus group discussion with commercial sex workers, peer educators and street children. UNICEF Ghana. Brugha, R. (1997). Evaluation report. Catholic Action for Street Children and UNICEF (1999). The exodus: The growing migration of children from Ghana’s rural areas to the urban centres. Commission on Macroeconomics and Health (2001). Working Paper WG5:2, The evidence base for interventions to prevent HIV infection in low and middle-income countries, August. Ghana Red Cross Society and Action AIDS. Ghana, Youth and AIDS Peer Education Project. Session Manual. Government of Ghana and UNICEF (1998). Task Forces’ Report. Mid Term Review September. Ireland Aid (2000a). Health sector strategy and guidelines. Ireland Aid (2000b). An HIV/AIDS strategy for the Ireland Aid Programme. UNAIDS (2000a). Summary Booklet of Best Practices Issue 2 September. UNAIDS (2000b). Female sex worker HIV prevention projects. UNAIDS Case Study, November. UNICEF Ghana (1995). Factors contributing to teenage pregnancy and school drop out among adolescents in Adansi West District, Ghana. UNICEF Ghana (1996). Ghana Red Cross Society Youth and AIDS Peer Education Project. Project Evaluation, December. UNICEF Ghana (1998). Logframes for UNICEF Ghana HIV/AIDS and STI Programme 1998–2000. UNICEF Ghana (1999). Donor Report by Social Mobilization on utilisation of funds from Irish Aid. December 1998–December 1999. UNICEF Ghana (2000a). Situation analysis of children and women in Ghana 2000. UNICEF Ghana (2000b). HIV/AIDS Prevention Project Fifth Progress/ Utilization Report December. UNICEF Ghana (2001). Master Plan of Operations and Programme Plans of Operation 2001–2005, UNICEF.

Acknowledgements This work could not have been completed without the participation, co-operation and goodwill of all the project staff interviewed in the Northern and Upper East Region, Adansi West District and the Urban Project in Accra. We also recognise the input of the staff of UNICEF, Red Cross Society and Action Aid and extend our thanks. Several editors have contributed to this evaluation. Dr Phyllis Antwi, Public Health Physician and Finbar O’Brien, Sociologist with Ireland Aid, evaluated the activities in Northern and Upper East Region, Obuasi and CENCOSAD. Nana Osafo Ansong, microcredit expert of the Dutch Development Organisation SNV in Accra evaluated the micro-credit component in Obuasi. Andrew Osei, Programme Officer HIV/AIDS and Monique Kamphuis, Programme Officer Monitoring and Evaluation of UNICEF Ghana were responsible for the final editing and putting the

Further Reading UNICEF Ghana (1997). Project Document Support to UNICEF HIV/AIDS activities. 28 November.