The heart of the program in Cameroon was the use of the peer educator model to influence and change behavior. The philosophy behind the peer education model is that practical experience with peers and advice from peers will result in changed behavior. It was further assumed that peer education would be a cost-effective and sustainable way to deliver culturally sensitive messages within a community. The peer approaches ranged from class room-style, and neighborhood health education sessions, to informal, one-on-one counseling and chats.
The experiences from Cameroon indicate that a combination or variety of interpersonal peer approaches and educational techniques were effective in changing attitudes and behavior.
Informal educational "chats" about relevant sexual issues and personal experiences with HIV/AIDS were an effective way to support behavior change among CSWs. During structured interviews with project managers and field workers using survey instruments developed by the BCC unit of AIDSCAP, three managers of CSW projects placed their audiences at or near the end of the behavior change continuum (trial and success). The projects included a variety of interpersonal peer education and discussion techniques. According to the program managers, the most successful interventions involved "chats". "We decided to base our communication action on educative chats. The reason is that they enable us to have some feedback each time we have contact with the client. In so doing, we are able to determine each time whether our message went across." CSWs, with a higher overall HIV/AIDS prevalence than other population groups, also had death and illness as a motivation for sustained behavior change. Several project managers reported a direct relationship between personal experience and behavior change
Drama is a practical and accepted medium to reach people in bars and beer houses with educational messages. Because of its popularity among youth and older audiences, drama, skits and film were used effectively to reach large target audiences in Cameroon. However, its success was most visible when used in bars and beer houses. CSWs had a hard time conducting educational sessions in crowded and noisy places such as bars and beer houses. However, when the same messages were presented in a skit format with music, and at times supported by a DJ, people's attention naturally turned to the stage.
Fear-based messages can have their place in behavior change programs. In structured interviews with project staff, the use of graphic fear-based messages were reported to be the most influential and successful way to make an impact on behavior and attitude change in the Cameroon program. This contradicts conventional wisdom that postulates the use of fear can be a detrimental and inappropriate approach. The peer educators' educational materials included photo albums containing graphic depiction of people with AIDS and STIs. These albums, which were designed to arouse an emotional response from the various target audiences, used fear-inducing images to give rise to self-protective behaviors. After the albums were shared with the target audience (usually in small groups or one-on-one), the images were discussed with peers. During these discussions, emphasis was placed on behavior that resulted in the depicted infections, and ways that infection could be prevented. These albums were not designed to be distributed freely to the target audience, but rather for use in controlled situations only. Although no formal research was done to demonstrate the effectiveness of these materials in the AIDSCAP/Cameroon program, informal AIDSCAP-sponsored studies showed that fear-based messages, used in the proper context, in a safe environment, and with the ability to discuss the images after they are shown, can be successful.
Prevention efforts should include "regular" partners of sex workers. From quantitative and qualitative research among sex workers we learned that condom use was the highest when they provided services to "new" clients with consistent condom use gradually going down with clients they referred to as "old" clients, and that consist condom use with "regular" partners was often non existent. Although the sex workers were aware of their risks of acquiring STIs and HIV, they apparently did not perceive "regular" partners as a source of infection. Moreover, the better they knew the client the less likely they were to use condoms. This phenomena has also been observed in other interventions projects with sex workers (Mali).
Recommendation: Future interventions with CSWs will need to focus on the importance of using condoms consistently with "regular" partners as well as with clients. They (regular partners) may be a greater source of HIV and STIs and could account for a large part of repeat STIs in CSWs. Future projects would also benefit from research to determine who is and who is not considered a "regular" partner.
Peer Education projects should explore innovative ways to motivate their volunteers. Despite its effectiveness, the peer educator strategy based on voluntarism, may be difficult to sustain over the long-term without incentives or some degree of compensation in addition to recognition. Incentives was a recurrent theme among project managers and peer educators over the life of the project. During the CSW pilot phase, when there was a limited number of peer educators, CSW PHEs received free medical checkups as an incentive. When the project expanded it was not possible to extend this incentive to all PHEs. Projects will have to think of creative ways of compensating their "volunteers". Students (secondary and university), for example, could be offered credits for being peer educators. At the workplace, (military, university or private) benefits, in addition to time, could be offered to staff willing to volunteer their time. The Cameroon Military Projectrecommended that the Officer-Educator position be recognized as "regular" army duty that is officially sanctioned by the military authorities, including a job description, whereas the Student Projectrecommended self financing of the activities by the university or the Ministry of Education.
Recommendation: Study the possibility of integrating the activities into the university curricula. Information should be shared among peer education projects on how each project found innovative ways to motivate their peer educators without straining their budgets.
A modified "Peer Educator" approach may be better suited for the military. As with many interventions, the early involvement of gatekeepers was the key to success for the intervention with the armed forces. Military authorities paved the way for the institutionalization of the STI/HIV prevention program. By signing an official decree, the Minister of Defense made HIV/STI training part of the official training program within the military, and gave credibility to the intervention program. However, the hierarchical approach of the military contradicts the basic premise of peer education. Therefore the military intervention, although theoretically based on the peer educator model, in practice implemented an education program that used "Officer-Educators" as the messengers of behavior change. The information was delivered in a classroom-style setting where participants were required to pass a test at the end of the class. Although the military program had a captive audience for AIDS prevention messages, comments made by some military program managers raised concerns about the impact of these messages on behavior change. This systematic education approach resulted in high knowledge levels among the target group, which in many cases turned into behavior change as demonstrated by the quantitative research, indicating that the intervention achieved positive behavior change.
Recommendation: Further research or/and assessments of military projects is recommended to determine which approach is most effective among this target group.
There was a lack of materials and messages for high risk groups with little or no schooling. Given widespread literacy in Cameroon, -- according to the 1987 census over three quarters of 15 year olds had attended school at sometime -- messages and materials were developed in French and English. Over the course of the interventions, however, it was noted that a high percentage of the targeted sex workers spoke little French, and that in Douala, the largest city in Cameroon, pidgin English was most often spoken among the targeted sex workers.
Recommendation: In future projects, priority should be given to the development of messages and skits in local languages to reach high risk groups with little or no schooling.
The involvement of political, traditional and religious leaders in decision-making is crucial in breaking cultural and religious barriers to AIDS prevention. A conscious decision was made by the national AIDS control program to involve political, traditional and religious leaders in the implementation of AIDS prevention activities. The decision was officially supported by the offices of the Minister of Health and the Prime Minister. Consensus building workshops were held with representatives from the ministries and traditional and religious leaders. Never before had Muslim, Catholic and Protestant leaders met together to address an issue. The consensus was that they would support AIDS prevention activities in their communities. When condom sales ran into problems in the predominantly Muslim north, the Minister of Public Health visited the Far North Province capital, Maroua, and met with religious leaders to explain the importance of condom use in AIDS prevention. He also paid a visit to PSI's principal distributor, a Muslim, and who's business is located in the center of the main market. Cultural barriers had affected retailers' and wholesalers' willingness to sell condoms. As a result of the visit by the Minister the number of wholesalers doubled within a week.
The project was able to include religious leaders in HIV/AIDS control interventions as long as the clergy was allowed to choose their preferred programs for endorsement. Although the implication of religious leaders in AIDS prevention campaigns was relatively easy, having the clergy also endorse condom use was much more difficult. Therefore with regard to condoms, the dialogue with religious leaders focused less on their endorsement of condom use and more on their tacit approval by not speaking out against it. This approach worked well in Cameroon and there was little adverse propaganda against condoms.
Recommendation: Future projects not only need to seek approval from government and religious leaders, but should maintain a continued dialogue with gatekeepers and leaders to find solutions to cultural and religious barriers to AIDS prevention.
By building the capacity and expertise of local consultants, cost-effective and culturally appropriate training curricula can be adapted in-country in a timely fashion. In the early stages of the Cameroon AIDS program, training was often conducted in a poorly-structured fashion, often resulting in less effective performances by peer educators. Under the AIDSCAP program Peer Educator Guides (manuals) were developed specifically adapted for each "peer" group. Local consultants , trained under AIDSTECH and AIDSCAP, were able to develop practical and easy to use manuals for each of the three target groups. The consultants spent considerable time with members of each group to develop themes that were culturally appropriate and understandable, while ensuring that the information was correct and factual. This resulted in three high-quality training manuals produced in-country by local consultants at a highly reduced cost. Subsequently, copies of these manuals on diskette were distributed to other AIDSCAP and non-AIDSCAP programs in Cameroon and the region for adaptation.
Recommendation: Programs should take the time and effort to build local expertise to develop curricula in country.
Continued subsidizing of condoms is critical to achieve sustainable behavior change. The subsidizing of condoms is critical and will remain so until there is significant improvement in the social-economic well-being of Cameroonians. Because of poor buying power of the average Cameroonian, sales revenues cannot fully support the supply of condoms and the necessary advertising and promotion. Social marketing is an extremely effective tool in promoting behavior change and condom use. Even if most Cameroonians areattracted by the low price of PRUDENCE PLUS condoms, 10 - 20 US cents, attractive packaging and promotion are also contributing to high sales.
Recommendation: Since IEC and promotion campaigns remain the key to success in achieving behavior change and condom use, every effort should be made by international donors to continue support for subsidized condoms.
Serious consideration should be given to subsidizing STI drugs as well. Increased sales of condoms was seen as the most reliable indicator of behavior change by subproject staff. This is encouraging because it is well documented that correct condom use prevents transmission of STI and HIV. Condom use is getting more widespread partly because they are subsidized, therefore it might be worth investigating the feasibility of subsidizing STI drugs. Recently, a number of studies on the interrelationships between HIV and STIs have confirmed that better treatment of STIs will reduce HIV transmission.
Recommendation: Donors and governments should look into the feasibility of subsidizing effective drugs for the treatment of curable STIs.
Subsidized marketing of prepackaged STI treatment remains valid. The MSTOP project encountered many difficulties including a change in the Ministry of Health leadership, resistance from physicians and pharmacy associations, and the country's drug registration law, which precluded use of the cheapest and most effective drug. Although the Cameroon project did not achieve the anticipated level of success in marketing a prepackaged STI treatment, the potential for socially marketed STI treatment and prevention delivery system remains good if the following conditions apply (1) the kit is introduced in a country with a tradition of health care provision, including prescribing drugs, by non-physicians, (2) health care workers are familiar with the syndromic approach; (3) national treatment guidelines and standard drug regimens have been approved and implemented, (4) gatekeepers feel an ownership of the project, and (5) the kit is sold at an affordable price.
Necessity to evaluate STI drugs periodically. From the results of the antibiotic sensitivity study, we learned that it is important to evaluate drugs periodically to ensure that N. Gonorrhoeae has not developed a drug resistance. This is especially important for drugs recommended in national treatment guidelines to ensure that (1) recommended drugs are still effective, (2) treatment guidelines are updated and, (3) effective drugs are added to the essential drug list.
Recommendation: Governments and donors should include periodic evaluation of recommended drugs used in national treatment guidelines in their STI prevention and control programs.
NGOs and Government implementing agencies often lack the proper skills and time to conduct quality quantitative and qualitative research. This resulted often in poor quality research and data.
Recommendation: Impact evaluations should be limited to a few well-designed studies. Furthermore, a local research organization should be identified early in the program, and provided with the necessary technical assistance to design and implement evaluation and other research activities.
Behavior change is a long and continued process -- awareness raising, education and counseling need to be continuously reinforced in order to change behavior and cultural norms, -- and this often goes beyond the lifespan of a particular project. In addition educational interventions will need to focus more on behavior change. Knowledge of HIV is generally high in target groups, but actual behavior change has not yet changed significantly.
Recommendation: Donors and governments should make commitments to long-term projects and their integration into existing services to ensure continuity and sustainability.
Young peer educators working among their peers in schools and other settings need the support of adults to give them credibility among their peers. Using the Peer Educator approach worked much better with the adult target population than youth. Military, truckers and CSWs participated in sessions organized by their trained peers. Students, on the other hand, challenged the knowledge of their peers despite the training received by the latter. This problem was corrected by teaming up student peer educators with adult "animators". The lesson learned by Save the Children in the North Province, as well as in the East Province under the CARE project, was that in order for the peer educator strategy to succeed, trained youth peer educators must work under the supervision of a senior person, be it a teacher, parent or adult outsider. This gives credibility to the young peer educator.
Recommendation: Other projects should not underestimate challenges young peer educators encounter and ensure that they have the necessary credibility to effectively perform their duties.
