Implementing community interventions for HIV prevention: Insights from project ethnography

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Social Science & Medicine 66 (2008) 467–478 www.elsevier.com/locate/socscimed

Implementing community interventions for HIV prevention: Insights from project ethnography Catrin Evansa,, Helen Lambertb a

University of Nottingham, School of Nursing, B floor, Queens Medical Centre, Nottingham NG7 2UH, UK b Department of Social Medicine, University of Bristol, UK Available online 24 October 2007

Abstract Global policy on HIV prevention among marginalised populations recommends a community-based approach with participation and mobilisation as central features. The overall aim is to empower individuals and groups to reduce their vulnerability to HIV. Community empowerment initiatives have had mixed results, however, in spite of utilising very similar peer-education based intervention strategies. This is particularly true of community-based interventions in sex work settings. Drawing upon an ethnographic study conducted in the early years of a well-known sex worker initiative—the Sonagachi STD/HIV Intervention Project (SHIP) in Kolkata, India—this paper argues that ethnographic research can illuminate the complex and inter-dependent dynamics of context, practice, agency and power that are specific to a project and shape the course of intervention implementation in ways that may be ‘hidden’ in conventional techniques of project reporting. Two detailed excerpts of what we refer to as ‘private contexts of practice’ are presented—focusing upon the complex processes underlying community mobilisation and peer education. We show that the gathering of ethnographic forms of evidence in conjunction with more conventional evaluation measures has two distinct benefits. First, an ethnographic approach is able to capture the play of power through observation of real-time events that involve multiple actors with widely different perspectives, as compared with retrospective accounts from carefully selected project representatives (the usual practice in project evaluations). Second, observation of actual intervention practices can reveal insights that may be hard for project staff to articulate or difficult to pinpoint, and can highlight important points of divergence and convergence from intervention theory or planning documents. r 2007 Elsevier Ltd. All rights reserved. Keywords: HIV; Sex work; Community interventions; Ethnography; Implementation research; India

Introduction Why do some community-based HIV prevention projects succeed whereas others falter? This paper explores this question with specific reference to sex Corresponding author. Tel.: +44 115 823 0894;

fax: +44 115 823 0999. E-mail addresses: [email protected] (C. Evans), [email protected] (H. Lambert). 0277-9536/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2007.08.030

work settings by drawing upon ethnographic research conducted in the early years of the Sonagachi STD/HIV Intervention Project (SHIP) in Kolkata, India. We argue that complex and inter-dependent dynamics of context, practice, agency and power specific to a project shape the course of intervention implementation in ways that may be ‘hidden’ in conventional techniques of project reporting. Hawe, Shiell, Riley, and Gold (2004, p. 788) have noted that evaluations of public health interventions

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rarely contain details on the ‘differential effect of intervention context’. They critique traditional process evaluations which tend to measure the type and nature of project inputs (content) and relate these rather deterministically (and usually retrospectively) to project outputs. Consequently, they have called for a shift from process evaluation to ‘context’ evaluation, defined as ‘naturally occurring events and influences in the setting and environment of the intervention that might act to contribute to or impede intervention success’ (p. 788). Roen, Arai, Roberts, and Popay (2006) have likewise called for the inclusion of evidence on implementation as a key part of research dissemination on community health programmes. In a recent systematic review of injury prevention initiatives, for example, they found that very few studies included data on implementation, and those that did tended to verge on ‘thin’ rather than ‘thick’ description, impeding their ability to draw conclusions on how local contextual factors may have contributed to intervention outcomes. The need to understand the role of contextual factors on intervention outcomes is also of great importance to HIV prevention initiatives in sex work settings, as these remain a key focus for public health interventions in most countries. Recent World Health Organisation (WHO, 2005, p. 7) guidelines recommend that, in addition to health service provision, condom promotion and individual behaviour change, interventions must also aim for: ‘increased sex worker involvement and control over working and social conditions’. Peer education, community mobilisation and ‘structural interventions’ are proposed as potential programme strategies to be adopted by community-based health projects in which sex workers’ participation is promoted as a central feature. The evidence for this approach comes largely from a rather small group of ‘successful’ projects (Evans, 1999), though this is complemented by evidence from a number of ‘failed’ projects that demonstrate that implementation of a community mobilisation agenda can be extremely challenging in spite of most projects having adopted very similar technical inputs (Asthana & Oostvogels, 1996; Busza, 2004; Campbell, 2003). To date, evaluation research on HIV community empowerment programmes has primarily taken the form of reviews (based on brief site visits and summarisation of secondary sources) of their implementation strategies, outcome evaluations that focus primarily on biomedical and behavioural

indicators (rather than changes in the wider social environment) and relatively atheoretical descriptions drawing on internal project documentation (AIDSCAP, 1997; AIDSTECH, 1992; Synergy, 2002; UNAIDS, 1999, 2000, 2002; WHO, 2005). These activities produce ‘best practice’ guidelines and training manuals intended for use by project planners that doubtless provide useful guidance on which strategies an intervention could include, but shed little light on why these strategies may work in some situations but not in others. There is a tendency to transfer models for intervention developed in one setting to other contexts (often between countries and regions), with little attention to whether they are necessarily appropriate for such disparate circumstances (cf. Parker & Erhardt, 2001, p. 111). Research from sex work community projects that have faltered indicates that project outcomes were shaped as much by particular community, organisational, social and policy contexts, as by the technical or conceptual adequacy of particular strategies. Thus, Campbell’s (2003) case study highlights how the institutional context of an intervention in South Africa hampered the development of effective partnerships, due to a lack political will and common vision among stakeholders and problems with programme management. Other authors identify the hidden, stratified, highly controlled and mobile nature of local sex trades as a barrier to community building activities (Asthana & Oostvogels, 1996; Busza, 2004). In cases where projects have experienced difficulties with peer education, the cultural context has been cited as a possible cause (Asthana & Oostvogels, 1996; Campbell & Mzaidume, 2001)—for example, due to local preference for didactic education and sex workers’ unfamiliarity with bureaucratic requirements of participation (such as the need for punctuality). Policy and legislative issues have also affected project implementation, as for example when police raids have undone months of community building work (Asthana & Oostvogels, 1996; Busza, 2004) or, in Cambodia, when a US policy shift on HIV and trafficking meant the withdrawal of political and financial support from the intervention (Busza, 2006). The focus of this paper is the Sonagachi STD/ HIV Prevention Project (SHIP) in Kolkata, India, which, in contrast to the above, has achieved quite dramatic changes in safer sex behaviour, reductions in STI prevalence, and low rates of HIV, whilst

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simultaneously catalysing a dramatic process of collectivisation and participation among sex workers.1 Remarkably, it has been sustained for 15 years. It began in 1992 as a conventional targeted HV intervention focusing upon behaviour change and STI treatment. Notably, community empowerment was not an explicit aim at this point. Red-light areas covering approximately 18,000 sex workers were sub-divided into ‘fields’. Local sex workers were recruited to be peer educators (PEs), trained and allocated to specific fields in groups, overseen by social workers (supervisors). Their job was to distribute free condoms, undertake health education about AIDS (using a pictorial flip chart) and accompany women to free clinics that were run from local clubs. PEs were paid a daily wage roughly equivalent to that of an unskilled worker in the informal sector. This represented a valuable source of extra income, especially since many of the PEs were older, experienced women whose sex work business was on the decline. Supervisors and PEs wore different coloured coats to denote their status as project workers. Depending on the size of the field, SHIP workers made contact with most sex workers on a daily or at least weekly basis. The SHIP was originally managed by the All India Institute of Hygiene and Public Health (supported by WHO, DFID and other agencies) but is now run by a complex conglomerate of sex worker-led organisations. These organisations continue their sexual health work but also pursue a range of social development activities (e.g., micro-finance and adult and children’s education). The sex workers’ main organisational body, the Durbar Mahila Samanwaya Committee (DMSC) is heavily involved in political lobbying and advocacy for sex workers’ rights, and has branches in every sex work locality that act to solve local problems and enforce safe working conditions. Various research papers, internal project reports and best practice synopses have been published on the SHIP that have greatly aided understanding of its achievements, philosophy and strategies but have been largely descriptive in nature (Jana & Singh, 1995; Jana, Basu, Rotheram-Borus, & Newman, 2004; UNAIDS, 2000). As with all other sex worker 1 For example, monitoring surveys in 2004 have found that consistent condom use is 85% and HIV prevalence is 4%. This is in marked contrast to figures from comparable Indian cities such as Mumbai, where HIV prevalence amongst sex workers has been over 50% since 2000 (UNAIDS, 2005, p. 34).

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projects, the SHIP was implemented in a difficult environment. Thus, key questions remain as to how and why this particular project managed to overcome a range of significant obstacles when other very similarly designed projects did not. In this paper, we begin to shed light on these questions as a means to demonstrate the urgent need for research to examine the gap between the de-contextualised science of programme design and the much messier art of real world, programme-incontext implementation. Using the SHIP as an example, we make a start at conceptualising this ‘gap’ by presenting two excerpts derived from ethnographic research that illustrate the SHIP’s approach to two key strategies in community sex work projects: peer education and participation. The material presented here limits itself to the SHIP’s early phase of development (1993–1997), because this is a key phase for those concerned with project replication. This intervention phase included the introduction of the project (health clinics and condom promotion) in sex work sites, the development of the peer education programme and the formation of the first sex workers’ collective organisation, the DMSC. Our analysis does not claim to provide a fully comprehensive picture of project implementation but rather aims to illustrate the complexities of project implementation that conventional evaluation methodologies may miss. Methodology: researching an intervention Methodologically and conceptually, the area of ‘implementation research’ is an embryonic field. Some anthropologists argue that ethnography based upon an in-depth understanding of the local sociocultural context can offer valuable insights (Long & Long, 1992; Mosse, Farrington, & Rew, 1998; Parker & Erhardt, 2001). They suggest a conceptual approach that recognises interventions as social arenas made up of different social actors and intersecting ideologies, relationships, interests and resources. The interactions between different actors (including the project and its staff) and the changes that occur over time as a result of these interactions form the focus for understanding intervention processes. Project ethnographies thus have the potential to reveal how interventions enter into existing life worlds and both shape and are shaped by them. Lewis et al. (2003) have proposed a tentative organising framework for ethnographic intervention research. First, they propose a focus on

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‘context’ defined both as the context of the wider society as well as the micro-level project context and the relationships between the two. Second, they suggest that ‘practice’ and ‘agency’ must be central to any analysis. This recognises that projects are implemented through a range of every day formal and informal practices that are imbued with cultural meanings and values. It also recognises that projects are implemented with and through ‘agents’ who are embedded within broader social relationships (of which a project is just one). Finally, they stress that ethnographies must engage with the concept of ‘power’, paying attention to whose voices, interests and ideas come to dominate within projects at different times and why. Our findings are based upon two periods of ethnographic research that took place between 1992 and 1998 (Evans, 2000; Evans & Lambert, 1997). Since this time, the first author has stayed in touch and up-to-date with SHIP developments, reviewing all project documentation, and visiting the project on numerous subsequent occasions (most recently in 2005). The focus of the research initially was women’s sexual health and vulnerability to HIV. However, the impact of the SHIP was so marked and sometimes unexpected, that the project itself came to be an integral focus of the inquiry. Micro-level context and practice were investigated by the first author becoming actively involved in SHIP life and observing everyday project work (e.g., attending formal/informal meetings, attending training sessions and accompanying PEs during their field work). To gain a representative picture of the sex trade, the first author and a research assistant spent time with project staff in three different red-light areas, including the largest, Sonagachi, which housed 5000 women. However, she began her research and spent extended periods in one particular locality—Girishbagan (a pseudonym—see excerpt one, below)—to develop a deeper understanding of community dynamics and the micro-level context of women’s lives and work. This was achieved through attachment to a local sex workers’ organisation whose club-room was a focal meeting point in the area. Sixty in-depth interviews were conducted with sex workers from the different red-light areas to explore their lives, sexual and work practices in more detail. Contact was made with sex workers through PEs in which the first author was introduced as a researcher. Twelve group discussions were held with PEs themselves to explore processes of project implementation.

Interviews were also conducted with professional project staff. The wider context of sex work-related HIV prevention in India was explored through visiting a number of other sex work projects, reading policy documents and popular press, and working as a research consultant on various other HIV projects. The study was given ethical clearance by the London School of Hygiene and Tropical Medicine and by the SHIP management. The consent of key community opinion leaders was obtained and individual verbal consent was obtained prior to any interview activity. Interviews and group discussions were tape recorded and transcribed and were supplemented by field notes that were written up daily. Findings Excerpt one: sex workers’ initial participation in the SHIP This excerpt is derived primarily from Girishbagan, a small sex work locality that is a few minutes walk away from Kolkata’s largest and busiest sex work site, Sonagachi. At the time of fieldwork, business in Girishbagan was poor and most sex workers were older women who were struggling to manage financially. Most worked independently, renting their rooms from landlords (in contrast to Sonagachi where sex workers are younger and often work under madams with whom they share half their earnings). Sex work sites are organised through a range of different actors (landlords, madams, pimps, gangs, clubs of local men, clients, boyfriends and local branches of political parties) who maintain their power through a complex web of patronage relationships and financial exploitation. Sex workers protect their interests through forging relationships with actors within this hierarchy of power rather than with each other. Prior to the SHIP, therefore, sex work sites tended to be characterised by high levels of mobility and a sense of competition and mistrust amongst women who rarely mixed together. When the SHIP started in 1992, Girishbagan was home to the only sex workers’ collective in Kolkata, called the Mahila Sangha (MS). The MS had been formed by a former sex worker called Durga (who had become a landlady) her husband and other landlords in order to combat extreme gang violence. Following a remarkable campaign to evict the gang

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from the locality, Durga was able to wield considerable local influence and developed the MS into a community welfare organisation that had its own club room and offered sewing classes and children’s tuition provided through a small NonGovernmental Organisation (NGO). Durga was smart, dynamic and highly articulate. When government officials began to investigate the HIV problem in Kolkata in the early 1990s, Durga quickly positioned herself as a key sex workers’ leader. She and other MS leaders were among the first to become SHIP PEs and their participation proved pivotal in enabling the SHIP to access other sex workers and sex trade gate keepers. Prior to the SHIP, the influence of the MS locally had actually waned considerably and the SHIP provided an opportunity for MS leaders to use their new jobs to reinforce their power base in Girishbagan. Situating themselves as key brokers between local women and SHIP staff, they told local women that many new jobs and new ‘projects’ would be coming to their area. In response, there was a surge of renewed enthusiasm for the MS—its small club room was packed everyday with aspirants hoping to curry favour with the leaders. Upon Durga’s recommendation, 16 Girishbagan women were in fact appointed as SHIP PEs. At this time, SHIP PEs were also lobbying the SHIP Director to expand the Project to cover all the city’s red-light areas and indeed, the SHIP eventually obtained approval for this development. In anticipation, Durga obtained help from some relatives and established literacy classes and ‘flip chart learning’ classes in the MS club room, in the hope that this would provide women from Girishbagan with a competitive advantage in the next round of PE job allocations. Many struggling sex workers in Girishbagan began to pin their hopes on getting jobs with the SHIP and some spent almost 2 years coming daily to the club room. Durga also sent a number of women to work in other red-light areas so that they could claim to be ‘local’ when the SHIP started recruiting there. At this time, the SHIP began to encourage sex workers to undertake collective action (e.g., street rallies, large meetings, debates) to protest exploitation. Girishbagan women invariably made up a major part of the participants. When asked about their motives, many said that they were doing so to show their support for Durga (thus hoping to gain her favour in the next round of job allocations), or—at Durga’s instigation—so that she could show the SHIP project director that the MS was

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committed to the SHIP’s work (in the hope that it would be rewarded for their support). Discussions with women as they journeyed to political rallies, for example, showed that many seemed to have no idea of what they were actually about. In fact, the use of individual patronage ties to mobilise crowd support in this manner is a commonplace strategy among political parties in South Asia: Durga said lots of ‘projects’ are coming y I am not interested in all this politics y It doesn’t make a difference to me y. (Girishbagan sex worker). As part of shrewd public relations and advocacy strategies, the media, NGOs, politicians and other city opinion leaders were always invited to attend SHIP events and they were invariably greatly impressed with the strength of ‘community spirit’ and ‘community participation’ that they witnessed. The SHIP also encouraged visitors to come to the red-light areas and to interact directly with sex workers. In the early years, Girishbagan was a common location to which such visitors would be taken. Upon Durga’s instigation, local women were called to gather together at large community meetings where they were ‘coached’ to give appropriate replies to the visitors’ questions. They were also taken to the MS club room where the scene of poor women using precious time to improve themselves was always commented upon as highly impressive— an example of empowerment and community initiative. By late 1994 however, it was apparent to everybody in Girishbagan that the SHIP had no more jobs to give. Many women became disillusioned by Durga’s inability to deliver on her promises and stopped attending classes. Only a faithful few still hung around in the afternoons, hoping to hear of some opportunities on the horizon. The Girishbagan women already employed as SHIP PEs, by contrast, no longer seemed interested in local affairs. They were now heavily involved in SHIP work and had begun to see the SHIP Director as a key patron and gatekeeper to further opportunities. As a result, Durga found her own power base shrinking and began to view the Director as her rival. Their relationship deteriorated rapidly and tension was exacerbated when the SHIP Director began to bring PEs from other red-light areas into prominent leadership positions both within the SHIP and within the emerging sex workers’ collective, the DMSC.

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Durga attempted to keep the MS functioning by seeking support from other agencies and NGOs, some of which were ideologically opposed to the SHIP’s promotion of sex workers’ rights (as opposed to the more traditional ‘rescue and rehabilitation’ model). Others were frustrated by the SHIP’s seeming monopoly on funding for HIV activities in the red-light areas.2 Several NGOs exploited the rift between SHIP and MS in order to press their case with donor agencies, or to try and establish some influence in the red-light areas. With Durga’s help, one even set up another clinic in a neighbouring locality and recruited a rival cadre of PEs, although the area was already well served with SHIP clinics. Durga once again arrived in the MS club room to announce that she had brought another ‘project’ and more jobs to the neighbourhood. She invited officials of other NGOs to visit Girishbagan, thereby creating the impression locally that more projects, and hence more jobs, were imminent. The MS club room became full yet again with local sex workers hoping for a lucky break. Durga eventually managed to persuade the other MS leaders (by now senior SHIP PEs) to resign from the SHIP and throw their allegiance behind the new clinic and NGO. Other SHIP staff perceived this move as a direct threat to the growing solidarity amongst the wider body of PEs whom the Project was supporting to establish the DMSC. They engineered a series of covert political manoeuvres to outflank Durga. The defecting MS leaders agreed to be reinstated by the SHIP; Durga was then accused of embezzling MS funds and forced to resign from the MS, and the SHIP arranged for an NGO-ally to begin working in Girishbagan and proposed a number of new ‘projects’. Moreover, a new SHIP field site and clinic was formally established in Girishbagan— even though the Sonagachi clinic was just 5 min walk away—and another large batch of PEs from Girishbagan was employed.3 This move rewarded Girishbagan women for their loyalty to the SHIP and gave it a concrete presence in the neighbourhood to forestall any renewal of opposition. What does this excerpt tell us about implementing a ‘participatory approach’? First, it illustrates the 2

The SHIP’s city-wide scaling up strategy had involved a bitter process of negotiation between stakeholders as many other NGOs had wanted to participate (by dividing up the red-light areas with different NGOs responsible for different localities). 3 By 1995, 44 out of the 230 sex workers in Sett Bagan were formally employed as PEs.

socio-political culture of patron–client relations through which a project such as the SHIP had to manoeuvre. Second, it highlights sex workers’ agency and exceptional resourcefulness in their negotiations with the SHIP and with others to try and maximise all possible benefits from a new resource. Third, it demonstrates the strategic value of using locally familiar and acceptable tactics (such as crowd recruitment through local patrons) to achieve social and political acceptance and support for a project. Fourth, it demonstrates that participation in the early stages of a project is not always democratic or transparent and is not always altruistic—indeed Mosse (2005) notes that an initial preference for the extension of patronage relations to a new project is consistent with tried and tested survival strategies of socially excluded groups in India. Sex workers’ negotiations were, initially at least (and quite understandably), rather self-serving. To outsiders however, Girishbagan provided a remarkable example of ‘community participation’ and ‘solidarity’. A key research question therefore is how participation changes in content and meaning over time. Finally, the excerpt highlights that a key task for a project is to create a positive representation of itself that will enable it to enrol the support of powerful groups. In this case, what Mosse (2005, p. 160) refers to as the ‘ambiguity of the powerful master metaphor of participation’ enabled a particular public story to be presented. This representation was used strategically by the SHIP to harness essential political and financial support for the intervention and to reduce the influence of opposing individuals and NGOs whose presence could have been divisive. Excerpt two: peer education: content or context? Our second excerpt examines the nature of peer education within the SHIP, contrasting models of this pedagogical approach with practice in this setting and highlighting the mechanisms, many of them informal, that contributed to the development of trust, political consciousness, and a change in safer sex norms among sex workers. As described previously, peer education was a core component of the SHIP as initially formulated. In most templates for community-based HIV intervention, peer education is recommended as the most appropriate means of delivering health education, particularly where groups are ‘hard to reach’. In community empowerment programmes,

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peer education is additionally viewed as a key emancipatory tool. In theory, peer education is a dialogical process that recognises local knowledge and experience and slowly builds towards a wider understanding and collective renegotiation of social identity and norms, including those around safer sex (Backett-Milburn & Wilson, 2000; Campbell & Mzaidume, 2001; Turner & Shepherd, 1999). Observation of peer education in the early years of the SHIP, however, found that it was in fact highly didactic rather than dialogical (in keeping with standard pedagogical approaches across India generally). PEs were trained in sessions conducted by project supervisors that entailed the trainees learning by rote a particular narrative that accompanied a series of flip chart pictures. PEs went to great efforts to learn this narrative accurately, correcting each other if any words were missed out or improvised. Thus, formal PE training sessions involved (often illiterate) PEs struggling to remember new and unfamiliar English words (such as human immunodeficiency virus). The emphasis was on ‘correct’ biomedical knowledge and there was little if any attempt to facilitate or incorporate women’s own lay understandings. In turn, the PEs educated fellow sex workers in a similarly didactic style, where ‘new’ knowledge was presented to them by teams of PEs in a wholly decontextualised manner. Day after day PEs visited individual brothels and ‘recited’ the flip chart to their sex worker peers, distributed condoms and gave demonstrations on their correct use, with very little additional discussion or debate. In view of the apparent inappropriateness of such a top-down approach to health education in this context, it is important to examine the reasons for its evident success in helping to shift group norms around safer sex and build solidarity. A crucial dimension appeared to be the engagement of the PEs themselves in the process. PEs stated that they greatly valued their new jobs, both for the income but also for the status and prestige that it lent them. Conversing in the respected idiom of biomedicine, combined with wearing a health workers’ uniform that denoted their salaried employment and distinguished them from other sex workers, gave them tremendous pride and helped them to build up a more positive self-image: This work lends a sort of respectability to us. We are getting an opportunity to do social work, to

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stand by the girls in their hour of need y for me, this is a source of great joy (peer educator). Importantly, it also lent their message about a disease—AIDS-authority and credibility, in a deeply suspicious context: We don’t know if all this AIDS talk is really true. How can we know? but after the didis (PEs) kept coming y and I saw all these pictures and writing about it, then I believed it (Sonagachi sex worker). As the PEs established relationships with other sex workers, we observed that they began to be asked for a range of medical advice. On these occasions, PEs would draw upon their own knowledge and experiences and engage in long dialogues over possible causes and courses of action. They were quick to point out that this was not daktari biggaen (scientific medical knowledge) however—‘we don’t usually tell the girls all this—only if they ask’. Likewise, discussions on safer sex rarely involved discursive deliberations in which women were encouraged to articulate their own understanding of constraints and possible actions. Sex workers (and madams) were simply told what to do—use condoms. The fact that PEs went about their work in large groups and visited sex workers on an almost daily basis, meant that considerable group pressure could be exerted on non-compliant sex workers and madams. In addition, PEs were required to keep track of how many condoms they distributed in the ‘field’. They did this by filling in notebooks as they made their visits. This created an impression that sex workers were being individually monitored. In many ways then, it seemed that the early years of peer education took on the structure of formal teaching, surveillance and control rather than dialogue. These observations indicate that the formal content and structure of the SHIP’s initial PE strategy did not appear to encompass the dialogical and emancipatory elements that, according to community development theory (Turner & Shepherd, 1999), would lead to social mobilisation on the scale subsequently seen in Kolkata. So how was social mobilisation facilitated? Further research indicates that it may in fact have been the informal context of peer education rather than its formal structure or technical content that played the most significant role. Two elements of this informal context seem most significant here: the

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SHIP’s overall organisational culture and political philosophy and the wider socio-political context of West Bengal. By 1995, the SHIP had established clinics and employed PEs from all the major sex work sites in Kolkata. Hence, whereas sex workers had been very isolated from each other both within their own neighbourhoods and especially across neighbourhoods, the SHIP provided an unprecedented opportunity for women to meet and mix in the neutral context of a health project. Their mobility within and across red-light areas meant that PEs (and, through them, the SHIP) were hearing about a range of exploitative situations. Whereas in previous times (as in Girishbagan), sex workers only had their own local resources to turn to in times of trouble, PEs now had access to the SHIP professional staff. Afternoons after work came to be characterised by long informal debates and interactions in the SHIP office and it was these (rather than the ‘formal’ pedagogical activities), that formed the critical foundation for re-thinking the ideological discourse on sex work, deciding to undertake collective action to create supportive community contexts for safer sex, and forming a sex workers’ political organisation, the DMSC: We get together and talk about things. We never did this before. Each existed in her own world. Before, we were in darkness, unable to speak about our work. y Now, we realise that our profession is like any other y Now our eyes are opening y like this, we thought of having our own committee y We have made our DMSC so that we can all go and stand next to a girl in trouble y We have learnt that we have rights (peer educator). During our research, SHIP staff identified three organisational features of the SHIP that they believe influenced its ability to mobilise the PEs. First, it encouraged a highly flexible approach, going beyond the blueprints of project design, and placing great importance on building trust and responding to expressed needs and new situations as they emerged (thus, for example, upon request from local women, many activities were organised for sex workers’ children). The SHIP director lobbied hard to ensure that this flexibility was built into the project budget. It was also able to utilise the considerable social connections of professional project staff to bring in additional resources for the sex work community.

Second, in keeping with common organisational traditions in India, although the SHIP ostensibly had a democratic management structure, in reality power was concentrated very much in the hands of the Director (cf. Burghart, 1993). PEs and staff alike represented him as a revered ‘benevolent patron’ and would not take any decisions, however small, without his knowledge and consent: Sir is like a God to us. (a peer educator). In many situations, this dynamic would be a severe impediment to community ownership. However, the SHIP Director used his position to create a relatively egalitarian organisational culture within the project. All levels of staff (including PEs) were encouraged to participate in debates on major issues through frequent formal and informal meetings in which all voices were valued. The Director subsequently formalised PEs’ involvement in the project by lobbying donor agencies to agree to an organisational structure in which sex workers’ organisations could take on ever-increasing roles. Thirdly, professional staff working for the SHIP were encouraged to adopt a non-judgmental and open-minded approach to sex, sex work and their own professional role, nurturing sex workers’ own abilities and agency, and eventually handing over power and control to the DMSC: It is true that everything has come through ‘Sir’—right from the start we were guided to accept that we knew nothing about sex work and that we had to learn from the sex workers and respond to their needs y. (Supervisor). PEs were increasingly encouraged by project staff to go beyond their health education role—to befriend other sex workers, to respond to nonhealth related needs, to share the insights that they were developing on the nature of sex workers’ oppression, and to mobilise women on the basis of a newly constructed identity as ‘workers’. In the course of these interactions, PEs began to request, and were provided with, a range of capacity building activities to equip them with new skills and knowledge to fulfil an expanded role. The peer (and health) education component of the SHIP has now moved on a great deal from these early years. The key point, however, is that social change did not emerge from an a priori expertly designed dialogical methodology, but emerged from the SHIP’s overall organisational culture and values. This respected sex workers’ opinions and

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knowledge but did not place it on a pedestal of ‘local knowledge’. Instead, it challenged PEs to develop new analyses of their situation and to come up with collective solutions. In additional to organisational culture, we suggest that aspects of the wider regional political context were significant to the SHIP’s social mobilisation activities. West Bengal’s long standing Left Front Communist Government has pursued workers’ rights as a key political strategy for over two decades. Even the most marginalised citizens are familiar with the associated political rhetoric and protest strategies. Addressing sex workers’ concerns from a perspective of workers’ rights resonated strongly amongst sex workers and external observers alike (although it also invited considerable opposition). It is plausible that in other settings, such a rhetoric might have alienated rather than emboldened some participants, whereas other models of solidarity (for example kinship- or gender-based discourses of solidarity invoking ‘family’ or ‘sisterhood’, respectively) might have greater success. In fact, the support that the SHIP has received from individual members of the ruling Party has been variable, but the project has been helped at critical junctures by direct intervention from senior government ministers who profess solidarity with the sex workers’ cause. Discussion: public accounts and private contexts of practice The excerpts presented above have a number of implications for the way in which ‘best practice’ for health promotion is researched and represented. Here, we first highlight particular features specific to the SHIP that are obscured by the usual means for documenting projects and identifying best practice. We then consider more generally the implications of our material for implementation research. Internal SHIP documentation is highly reflective and provides considerable detail on its intervention strategies and overall approach. Numerous project publications attempt to distil its lessons for success, and suggest that its participatory approach and organisational philosophy (as noted in excerpt two) have had a major impact on project outcomes. This philosophy is defined as ‘reliance’ (on sex workers’ understanding and capability), ‘respect’ (of sex workers and their profession) and ‘recognition’ (of sex work as a profession and sex workers’ rights) (Jana et al., 2004). SHIP documentation also notes

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that its implementation journey (as shown in excerpt one) has been far from straightforward. For example, the SHIP notes how project stakeholders: y had to be pacified and brought under the folds of the project y it was and still continues to be more of a power game where adjustments and reorientations had to be made to keep all feathers unruffled (Jana & Singh, 1995). Whilst such analyses are illuminating, those interested in project replication desire more concrete guidance. In 1996 for example, an international donor-funded evaluation team called the SHIP an example of global best practice, and suggested it to be used as a ‘working model’ for similar endeavours worldwide. It identified a need to provide more detailed direction on implementation, and included recommendations for the development of manuals for peer education selection and training, guidelines on staff recruitment, revision of health education materials to incorporate women’s expressed needs, development of clear roles and responsibilities for project staff and partners and clear mechanisms for collaboration. The project’s internal documentation and donor agencies’ insistence on ordering and systematising practice by creating models, manuals and guidelines represent two aspects of what we call ‘public accounts of practice’. The SHIP wants to disseminate its unique story, but because it needs to maintain working relationships with diverse constituencies, it cannot fully reveal its hand, resorting to ambiguities that are open to multiple interpretations. Additionally, such ‘insider accounts’ are inevitably produced from a particular subject position and struggle to capture versions and processes not immediately visible to those who produce them. By contrast, models and manuals (often based upon external consultants’ selective retrospective assessments) aim to provide transferable generalities rather than focusing upon the specifics of particular implementation strategies. In both types of account, the messy real world of implementation or what Trickett (1998, p. 329) calls the ‘private context of practice’ is hidden along with an understanding of the key elements that may lead a project to succeed or fail. Conclusion: the implications of ethnographic insights for project replication and implementation research By contrast with these ‘public accounts’, our ethnographic excerpts were concerned with the

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‘private contexts’ or ‘hidden stories’ of project practice. Access to such contexts was facilitated through the positioning of the first author as participant-observer. Though focusing on relatively minor events early in the SHIP’s history, the excerpts nonetheless provide important insights with regard to project implementation and replication. First, the manoeuvring for power and the sometimes uncomfortable tactics adopted to counter resistance constitute the subject of many hidden stories of practice in the SHIP’s history. Excerpt one was just one of many potential examples that could have been used. As Cornish and Ghosh (2007) point out, this should not surprise us. In difficult sex work environments, compromises have to be made and politics played. The realities of these practice contexts may not sit comfortably within consensual models of health promotion that emphasise collaboration and partnership working. So, rather than engaging in open debate on how to theorise and manage social power relations, bitter political struggles for representation and power become glossed over, hidden behind the ‘warmly persuasive’ rhetoric of ‘participation’ (cf. Nelson & Wright, 1995). Excerpt two provides another example of how project implementation can be obscured. SHIP documentation represents the formation of the DMSC merely as a positive outcome of ‘participatory’ community development approaches based on humanistic principles. This downplays the reality that the mobilisation of sex workers in Kolkata was a deliberate political movement, facilitated through peer education and predicated upon a new ideological construction of a ‘community of workers’ within a social environment that recognised the validity of political mobilisation for workers’ rights. Thus, the potentially crucial role of political ideology in project implementation is concealed. Second, both the above examples highlight the SHIP’s own agency and commitment to fostering community mobilisation. Though rarely an explicit focus of analysis, they make clear that a key actor for community-based HIV prevention is the organisation that is charged with its implementation. To state the obvious, unless project management and key stakeholders are committed to a community mobilisation approach and are able to convince key stakeholders of its value, it cannot happen. Our excerpts support Hawe et al.’s (2004) assertion that intervention research needs to explore the ‘indigenous theory’ of the intervention—i.e., the ‘causal assumptions and principles that govern decision

making in the intervention, which may or may not match the rhetoric of the theory claimed to inform the intervention design’ (p. 789). Thus, for example, although the initial peer education components were highly didactic and concerned with one-way knowledge transfer, the SHIP’s informal rightsbased philosophy ensured that PEs nonetheless became agents of change. The significance of this for implementation research is that without an indepth ethnographic understanding of intervention processes, it would be easy to misunderstand and misrepresent the key factors that led to intervention outcomes (in this case, by focusing upon the mechanism and content of the peer education approach, as opposed to the organisational context in which it developed). The characteristics of ‘empowering’ organisations, and the ways in which they and the key individuals within them pursue an empowerment agenda successfully are issues that require further empirical investigation through longitudinal process-oriented research (Lewis et al., 2003). Another related insight concerns the key role that the SHIP Director himself appeared to play in shaping the path of project implementation. In terms of lessons for project replication, it may not be very satisfying to learn that project outcomes can depend very heavily upon key individuals and the organisational culture that they are able to create. However, although it may not be possible to replicate individuals, it is possible to identify the core values, principles and resources that they have brought to their work and to look for similar characteristics when recruiting staff for new projects. Third, our material points to the value of studying the specific micro-social contexts in which an intervention is initiated. The fact that the project began by recruiting PEs in an environment like Girishbagan, where most of the sex workers were effectively self-employed (operating independently of brothels) and, as a population, were relatively old and therefore were experiencing economic hardship due to difficulties in attracting clients, undoubtedly meant that they were more receptive to alternative employment within the SHIP and freer to undertake it than younger, brothel-based sex workers might have been. Had the SHIP started by attempting to recruit PEs from among the latter type of population it might have encountered even greater difficulty in gaining momentum and representation among sex workers. Thus, representing project

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activities as working with an undifferentiated mass of sex workers risks glossing over particular features that may appear insignificant but may actually be critical to project success. In summary, we have argued that the likelihood of replicating successful interventions would be enhanced by more detailed ethnographic evidence and analysis of the micro-level social and political negotiations that led to these successes in addition to documenting the overall principles that guided them. With the growing advocacy of ‘evidencebased’ approaches in health promotion, the need to be able to demonstrate effectiveness for projects is an increasing preoccupation. The gathering of ethnographic forms of evidence in conjunction with more conventional evaluation measures has two distinct benefits. First, an ethnographic approach is able to capture the play of power through observation of real-time events that involve multiple actors with widely different perspectives, as compared with retrospective accounts from carefully selected project representatives (the usual practice in project evaluations). Second, observation of actual intervention practices can reveal insights that may be hard for project staff to articulate or difficult to pinpoint (e.g., didactic vs. dialogical peer education practice), and can highlight important points of divergence and convergence from intervention theory or planning documents. The explanatory and methodological contribution of ethnography in implementation research has much potential and deserves increased attention to develop it further. Acknowledgements We are very grateful to the Songachi STD/HIV Intervention Project (SHIP), the Durbar Mahila Samanwaya Committee and the Mahila Sangha, and to the British Department for International Development and the Economic & Social Science Research Council for supporting this research. We thank our anonymous reviewers for some very helpful comments.

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