FHI - III. Targeted Interventions

1. Targeted Interventions

Peer Education at the Worksite

FCO 53676

AIDSCAP partner:	Family Planning Private Sector (FPPS)
Geographic focus:	Nairobi, Mombasa, Eldoret
Target population:	Male and Female workers
Project dates:	August 1, 1995 - May 31, 1997

Background

The peer education at the worksite project was started in 1993 and initially managed by AIDSCAP Kenya. In September 1995, implementation and coordination of the project was transferred to FPPS while AIDSCAP and USAID continued with program monitoring and funding. The Family Planning Private Sector Programme is a non-governmental organization established in 1984, whose major goal is to strengthen and expand the provision of reproductive health services in the private sector and other non-governmental organizations. FPPS already had an established network of clinics it was assisting in the three regions, that could support the peer education activities.

The implementation approach was based on the belief that the workplace plays a central role in influencing the social behavior of most adults. The project targeted a workforce population of about 24,000 men and women workers in 17 sites within three regions, Mombasa, Nairobi and Eldoret, mainly through peer education activities and working with management to gain their support.

Objectives

The ultimate goal of the project was to reduce high risk sexual behavior among men and women workers. The following objectives guided implementation:

Establish a workplace environment that would support prevention programs through mangers orientation workshops
Implement behavior change communication intervention to reduce high risk behavior in workplace population through peer education
Strengthen condom distribution by establishing accessible outlets within the workplace

Accomplishments

Management Support

The project design included initial introductory meetings and orientation for management, which was essential to create a supportive environment for peer education activities. AIDSCAP had held an introductory meeting with the Eldoret branch of the Kenya Association of Manufacturers, who had fostered the adoption of a jointly coordinated peer education program in nine workplaces in Eldoret town, and with two industries in Mombasa. FPPS continued these introductory meetings. Five one-day management orientation seminars were conducted for East African Industries (EAI), Bata , and Dagoretti Slaughter Houses in Nairobi; the Kenya Ports Authority (KPA) in Mombasa and the Eldoret sites.

In order to help participants understand the socio and economic impact of AIDS and the urgent need for instituting prevention intervention at the workplace, the Private Sector AIDS Policy (PSAP) and AIDS Impact Model (AIM) approaches were used extensively during the seminars. To create a sense of project ownership, facilitators involved managers in discussing strategies for instituting and sustaining the project within their worksites. The seminars provided a forum and an opportunity for managers to discuss risky sexual behaviors, prevention measures including condom demonstration and distribution. Further, managers were able to discuss how controversial issues related to their companies' policies.

The managers' orientation workshops contributed significantly to the cooperation and increasing support for peer education activities in the 17 sites participating in this project. In most of the sites, management support was demonstrated by allowing workers time release for peer education training and activities and through providing transport, refreshments, training venues and training material and equipment, such as video machines and cassettes.

This management support enabled the project to accomplish its expected outputs despite the short implementation period and has created a strong basis for future workplace interventions. However, this may not be enough to sustain the project without direct funding support.

Peer Educators/Coordinators Training

A total of 375 peer educators were trained in 15 three-day courses. The curriculum was designed to provide workers with the knowledge and skills required for effective communication and behavior change. It was later reviewed and revised to strengthen the gender responsive and advocacy components. A participatory multimedia adult learning approach was used in the training, which enabled participants to share their feelings, improve their knowledge on HIV/AIDS and strengthen the skills required for effective communication interactions.

The most challenging aspect of the peer education training was to assist adult men and women who had deep-rooted beliefs and no prior education on HIV/AIDS and sexuality to discuss and clarify their own values as they related to sexual behaviors and the spread of HIV/AIDS. FPPS observed that most participants discussed painful experiences regarding AIDS and therefore were either in fear or denial. Despite their experience, however, most admitted they were not taking steps to prevent themselves or their partners from HIV infection. Instead, they felt helpless, as they thought that only medically trained people could participate in prevention education. Peer education training changed this perception. The project managed to provoke a sense of active responsibility in the control of HIV/AIDS among men and women workers. Both collectively and at individual levels, workers are reaching each other with HIV/AIDS information.

Currently, there are 300 peer educators participating in the worksites project. Anecdotal accounts from peer educators indicate that 75% of those that drop out continue with informal peer education activities (some in their new places of work). The participating sites have a total of 36,000 workers, the majority of whom have been reached by project peer educators (more than the 24,000 target audience identified in the project document. Peer educators also reported reaching their partners and family members which indicates that the project also has a multiplier effect.

Training in Folk Media

In addition to peer education, folk media was used as a communication intervention to strengthen behavior change. The major advantage of folk media lies in its ability to reach a large audience in a language they best understand. A total of 62 troupe leaders were trained during 3 regional folk media courses. In mid 1996, all sites participated in regional folk media festivals. In each region, an audience of over 500 were reached with drama, poetry, folk dances and puppetry presentations. Some of the groups have now become well recognized locally. For instance, the KPA Mombasa and Rift Valley Bottlers folk media groups are being hired by other institutions to create HIV/AIDS awareness.

Materials Distribution

To complement both peer education and folk media activities over 2,000 copies of printed materials have been distributed to sites. They include books, training manuals, calendars, posters, charts and pamphlets. Apart from materials produced by FPPS, the rest were solicited from other collaborating organizations such as PATH, the Kenya AIDS NGOs Consortium, and NASCOP. While material sharing is cost effective, it is not always easy to access adequate and appropriate materials when they are needed. The other challenge is that workers reach a wide range of community groups in terms of age, literacy levels, culture and religious backgrounds. To access materials to cover such a wide range of target population would require extensive collaboration and adequate funds.

Condoms

To further support targeted behavior change among workers, the project aimed at improving the accessibility of condoms. One hundred condom dispensers were installed in companies participating in the project. In addition, peer educators were trained in condom use demonstration and negotiations. To date, men and women workers access condoms easily either through colleagues, clinics on site or from several dispensing outlets placed in offices, social halls, bars and toilets.

Follow-up visits and focus group discussions clearly indicate that the use of condoms has increased in all sites. Responding to a question on condom use, a worker from Bamburi stated that

"before the project, you almost had to use a password to secretly get a condom from the clinic. But now, we freely discuss about it. I am not even bothered by being referred to as a condom distributor". Workers at Bata, Nairobi also saw condom use as an indicator of efforts towards reducing risky sexual behavior among workers. A worker said that since the peer education training, there has been considerable behavior change. His evidence was that "condoms are now going like hot cakes".

Constraints and Challenges

Gaining Management Support

Getting initial entry to the sites was more difficult than originally anticipated. This was mainly because most managers were not well informed about HIV/AIDS and its possible social and economic impact. They also did not understand how the project would fit within their regulations, operational set-ups and financial limitations. Most of all, they were afraid the project would interfere with production or expose management to criticism about their regulations or lack of them on HIV/AIDS issues. Through follow-up meetings and managers' orientation seminars, however, managers came to appreciate and support the project.

Identification of New Sites

Although a total of 20 companies were initially recruited, three trucking industries dropped out mainly because of circumstances beyond the control of the project such as company closure and irregular operational schedules that were not conducive to the project's implementation system and schedules. In addition, many trucking companies are under the management of one person or family, which makes it difficult to pursue negotiation if the manager is biased against the concept of AIDS prevention. Such companies are also unlikely to support continuing prevention interventions without outside funding. An example was Kenya Bus Services, a major public transport industry with over 3,000 workers. The project failed to take off despite the eagerness of those identified as potential peer educators and coordinators to participate. Management refused all requests for both peer education and a management orientation seminar. Given the high risk of many transport workers, these drop-outs are unfortunate.

Other Constraints

The project period was too short to assess the impact of behavior change imparted by peer education activities.
The process of instituting prevention interventions at the worksites is longer and more complex than was initially anticipated. Winning management support, creating cohesive groups of peer educators/coordinators, and making follow-up visits to ensure that activities took off and to provide refresher training all had to be accomplished within one year. This marathon-like process of implementation can easily cause burn-out.
Because of the varied background of participants attending the peer education courses (in terms of literacy levels, age, sex, cultural and religious background), it was difficult to standardize training modules.
With the limitation of time and pressure of work, peer educators found it difficult to reach as many people as they would like to. This resulted in many peer educators conducting activities on their own time and at their own expense. This places a greater demand on the project for support, and could influence higher drop-outs rates.
It has been difficult to establish accurate reporting systems mainly because peer educators and coordinators have found it difficult to record all their activities most of which are informal interactions. Forwarding of reports on time has also been problematic.

Findings and Results

An end of project evaluation was conducted between February and March 1997. The main objective of this evaluation was to make a qualitative assessment of the influence of the project in reducing the risk of HIV infection among workers and of the process of project implementation. Nine sites were identified for this exercise (three in each region), and about 85-100 workers participated in focused group discussions. Sites identified ranged from large formal urban employers such as Kenya Ports Authority (KPA), to informal peri- urban employers such as Dagoretti Slaughter Houses. The evaluation targeted three categories of participants: peer educators/coordinators, members of the workforce (i.e. recipients of peer education activities) and management representatives. Focus group discussions were used to gather information from peer educators/coordinators and their contacts, while in-depth interviews were held with management representatives.

Although it may be difficult to assess behavior change within such a short project period, follow-up visits and the end of project evaluation provided some information that clearly indicated that the workforce population is engaging in activities that are likely to influence behavior change. For instance, peer educators and their contacts strongly agreed that the project has caused enormous awareness and has influenced the sexual behavior of men and women workers. At KPA, Mombasa we were informed that

"women are saying that their men have changed. We have also noted that reduced multiple sexual partners have caused a decline as the VDRL cases at our FP clinic continue to drop".

The main activities conducted were communication interventions and behavior support services through formal/informal education, referral services for counseling and management of HIV/AIDS/STD, and condom distribution. Peer educators have demonstrated great commitment in conducting activities and applying skills imparted to them during training. For instance, by applying the "No missed opportunity concept", they have reached colleagues and community target groups even in the midst of their busy working schedules. It was not uncommon to hold group discussions on HIV infection during a bus trip from work, at the cafeteria or even while working at the plantations. For instance, a worker from EATEC, Eldoret informed the evaluation team that:

"I learned about HIV/AIDS and condom use for the first time from a peer educator while we were stripping the wattle back trees at the forest".

Yet, another participant stated that the "handshake" game used by a peer educator during an AIDS education session greatly impressed on him the seriousness and urgency required to curb the spread of HIV. He stated that he was "shocked to see how the virus spread from one person to so many others". As more and more workers adopt safe sexual practices, the word being "converted" has gained the wider meaning of restraining from casual sex. The project also helped remove the sense of powerless most workers felt confronted with HIV/AIDS. For example, it was reported that "information on HIV/AIDS has reassured [workers] that there is no need to discriminate or fear an infected person". Peer educators' requests for more training on counseling and on home-based care is an indication of their positive attitude and willingness to continue with the program.

Besides influencing behavior change, the evaluation observed that the project had other merits which were not initially envisioned. For instance, the development of team spirit, concern for others, and the strengthened relationship between workers and management all add value to the workplace and the community environment. It is encouraging that peer educators in all sites have used their training to reach people outside the workplace, the first beneficiaries being workers' wives and children. One peer educator stated that "now my wife is a peer educator too".

Participation in the program has also given many peer educators an opportunity to share their strengths and talents with others. As noted, some sites such as Rift Valley Bottlers, Raymonds and KPA are taking their drama performances to the community. Individual workers have also used their talents as cartoonists, dancers, poets, counselors or effective educators to mobilize their fellow workers and this recognition of talent has been a positive incentive.

Lessons Learned

Workplace-based peer education programs require a flexible approach to project implementation to overcome the particular problems associated with an education program in this setting. Workplaces are characterized by a wide variety of operational set-ups and regulations. For example, some workplaces have a clinical services unit where HIV/AIDS counseling could be added while other sites required educators to investigate how workers could link to outside services to provide needed interventions. In workplaces where shifts are used or where outlying departments exist, FPPS had to design their peer education program to respond to the constraints created by these organizational set-ups.
FPPS trainers had to assess both managers' perceptions and the resources that each site offered that could be used to complement the program. For example, some sites had individual or shared training facilities that could be made available to the peer educators. Where obstacles or difficulties were encountered, FPPS staff had to change and adapt their steps in setting up the project, such as shortening sessions so that they could be completed within the time management made available.
Empowered peer educators are as good advocates as management for the development and adoption of HIV/AIDS policy in the workplace. Peer education advocacy has been successful in influencing management support and can work well in activating policy implementation at the workplace. Informing and educating workers and using a bottom up approach enabled peer educators to negotiate successfully with management and policy makers for a supportive environment to conduct HIV/AIDS interventions and prevention activities. In some companies a peer education program was introduced first, and then influenced management to request an orientation seminar.
Peer education activities at the workplace were spontaneously expanded to the educator's family and community settings. FPPS trained peer educators at the workplace with the intention of increasing worker's knowledge, skills, and attitudes in prevention of HIV/AIDS/STD. However, FPPS found an unexpected outcome that peer educators went "beyond" this and began very innovative activities in their own families and communities. One BATA peer educator was requested by area churches to educate parishioners on HIV/AIDS; one educator began working with youth in his community on drug issues; others have been invited to speak with Jua Kali workers.
Participation in peer education programs at the workplace gave an opportunity to increase people's self-esteem; utilize their hidden talents; and even to improve workforce skills. HIV/AIDS is perceived by most workers as a "health" problem. They think that HIV/AIDS prevention education has to be done by a medically trained person. This adds to the feeling of helplessness when people confront AIDS. However, when workers were trained as peer educators, they not only enjoyed what they were doing, but discovered that they were effective and that others looked at them as a change agent with something to offer. Through the workplace peer education program, workers also discovered talents as amateur poets, cartoonists, and puppet makers. FPPS educators were amazed at the talent which was shown when workers were allowed to creatively develop media materials related to the education program.
In addition, the values and skills that workers learned during the peer education training enhanced their everyday working relationships and skills. Some workers became more gender responsive, learned to work as a team through valuing different skills; learned how to plan and coordinate activities; were more respectful of each other. For example, some peer educators were excellent mobilizers while others were better at delivering the educational session once workers were assembled. This was also recognized by some managers who showed pride in what "my people" were able to do.
Peer education activities gave an added value to existing workplace services such as the personnel office and health facilities. The peer education activities stimulated workers to better demand the services offered by many workplace personnel offices and health facilities, such as STD services and condoms.
While peer education in HIV/AIDS prevention at the workplace is important, it is not adequate in many cases for effective behavior change. FPPS has realized that some of the older sites reached a saturation point where, after a high level of understanding had taken place, participant wondered "what next?" Some peer educators experience "burn-out" because of high demands placed on them by their community groups. Others wonder how to sustain activities and behavior change and how to reach the next generation of workers.
Although workers have increased their knowledge and "know the right answers" about HIV/AIDS prevention, many face serious challenges in applying the knowledge. To deal with this dilemma, FPPS had to challenge peer educators by appealing to their emotions and focusing educators on their children's future. However this was not adequate in all cases.
Changes in policy level changes relating to HIV/AIDS; changes in insurance policies; and increasing counseling services are just a few issues which have to be addressed in order to assist in sustainable behavior change.
Peer education needs some on-site guidance and coordination to be most effective. Although not originally planned, FPPS decided to hire on-site coordinators to supervise and motivate peer educators. Regular meetings and access to an FPPS staff person assisted peer educators to do their work more effectively.
Volunteer peer education can work if other forms of motivation are provided. Other than revenue, other forms of motivation can help volunteer peer education work. These forms include recognition and materials.

Recommendations

Future projects should consider the issue of sustainability from the start, by working with companies to establish in-house sustainability mechanisms, ensure continuous motivation of peer educators, and institutionalize the project. To do so, project design should include such aspects as incorporating peer education training and messages into other existing skills training at the workplace, through a TOT system. Since sustainability is a sensitive issue, management in different sites would have to advise on the sustainability strategies pertinent to their regulations and operational policies.
Future projects should collaborate with other institutions (for example, employers' association) that could enhance the discussion on policy issues and foster policy change. In addition, the peer education curriculum needs to be expanded to include counseling and home-based care components.

Process Indicator Summary

Process Indicator	Target	Actual	Percent
Companies reached	22	17	77%
Peer educators trained	364	375	103%
Coordinators trained	44	58	132%
PE refresher training	150	27	18%
Folk media troupe leaders trained	30	62	207%
Managers trained	–	82	–
Workers educated	24,000	24,000	100%
General public reached	–	1,500	–
Materials distributed	30,000	2,000	7%
Condom dispensers installed	100	100	100%
Condoms distributed	350,000	550,000	157%

Meeting the STD and HIV/AIDS Information Needs of Security Guard Personnel

FCO 53689

AIDSCAP partner:	PATH/Kenya
Geographic focus:	Nairobi
Target population:	Security guard personnel
Project dates:	May 15, 1996 - April 30, 1997

Background

Security guards make up a discrete group of the workforce in Nairobi. They are employed to guard offices and houses by several companies, estimated to have a workforce of about 40,000 men. They are most often less educated men who have left their families behind in the rural village when they moved to the urban centers to seek employment, as unskilled laborers in the construction industry, or as security guards. This single gender migration is still a very common phenomenon in Kenya. In Nairobi today, the ratio of men to women aged 20 to 39 years is 1.5 to 1. Once established in the city, the husband may return to his village very irregularly because of insufficient funds and the inability to take time off work. The long periods of time spent away from home are likely to result in a number of extramarital relationships or frequent visits to commercial sex workers. When the men return to their village wives, they complete the circuit of transmission which results in the increasing rates of STDs and HIV transmission in the rural areas.

Poor information levels, coupled with negative attitudes toward the use of protective techniques such as the condom, have increased the risk of STDs and HIV infection among security guard personnel. PATH/Kenya was therefore contracted to target five security firms in Nairobi: Bob Morgan, Securicor Kenya Limited, Ultimate Security, Factory Guards, and EARS, employing a total of 10,000 guards.

Objectives

To increase the awareness among Nairobi security guard personnel of HIV and STD modes of transmissions and means of prevention;
To increase the availability of condoms for use by security guard personnel by providing easy access (including knowledge on correct use) at their place of employment.
To establish a cadre of trained peer counselors among security guard forces.

Accomplishments

Selection of Security Firms

After intensive discussions with the management of various companies, PATH selected five security firms to participate in the project. Criteria for selection were a minimum of 1,500 employees and the willingness of the management to take part. Security firms are strictly profit oriented: guards work under strict shift schedules and must be at their stations at all times. Many companies were therefore apprehensive as they felt the project would disrupt their operations. PATH's task was convincing management of the dividends of investing in the health of their workers.

Baseline Survey Results

PATH contracted an external consultant to conduct a qualitative and quantitative baseline study, which formed the foundation for the IEC intervention. The study's objectives were to: identify the knowledge, attitudes, behavior, and practices of security guards in relation to STDs and AIDS; identify their information needs; and determine appropriate communication channels for reaching guards with this information. In-depth interviews were carried out with a sample of 335 guards complemented by 11 focus group discussions. Findings from the KABP baseline study highlighted four key issues that needed to be addressed in the STDs and HIV/AIDS educational program for the guards:

Sex partners: The majority of the guards had multiple sexual partners, and were heavily engaging in casual sex.
Perception of risk: Though they have multiple sex partners, most of the guards do not perceive themselves as at risk of contracting STDs and HIV. Most said they feel safe because they "trust" their partners.
Condom use: Most do not use, and do not like condoms. For those who use condoms, none had been shown how to use them correctly.
Misinformation/negative attitudes: Many guards believe that condoms burst during sex; reduce sexual enjoyment for both partners; cannot be used with regular partners; and are laced with the HIV virus.

Development of IEC Materials

Based on the information needs identified in the baseline study and reaffirmed during the group discussions, PATH developed an assortment of five materials comprising a leaflet and booklets on various STDs and HIV/AIDS, produced in both English and Kiswahili, the languages preferred by the target audience. The titles of the materials are:

Look Out! What to Do if You have a Strange Discharge from your Penis, a leaflet on gonorrhea and chlamydia.
Look Out! What to Do if you have Sores on your Genitals, a booklet on syphilis, chancroid, and genital herpes.
Living and Loving: What my Partner and I need to know about STDs, a booklet about STDs that affect women.
The Condom: Get It! Use It! Protect Yourself! a booklet about condoms.
Could I Have HIV? a booklet about HIV/AIDS

The materials are a source of further information and were also meant to help the guards discuss STDs and HIV/AIDS issues with their colleagues and sexual partners.

In addition, PATH produced and distributed an audio tape of a 30-minute drama, Maisha na Mapenzi (Life and Love), which was adapted from a script developed during the materials development training carried out by PATH for members of the NGO Consortium (see subproject description below). The audio tape story dramatizes the messages on protection against HIV through the lives of three couples. A narrator summarizes the key lessons at the end of the tape and leaves the listener with challenging questions for self-evaluation. The tape offers a good entry point for initiating group discussions.

Institutionalizing and Integrating HIV/AIDS Education Within Guard Training Programs

The original project design sought to train a cadre of peer educators among guards. However, due to operational constraints, the design was changed to integrating this education within the regular guard training program. Despite the short time for implementation, PATH was able to work with the training managers and instructors of the various guard training schools to start the process of institutionalizing and integrating this project. By the end of the project, three out of the five companies had allocated a permanent time slot for this program in their training schedule.

Establishing a regular supply of condoms within the worksites

To ensure that condoms and condom information reached the guards, PATH worked with PSI (Population Services International). Through PSI, two major accomplishments were realized. First, two companies agreed to distribute a TRUST condom promotional leaflet (containing sample condoms with instructions on how to use them) with the guards' monthly pay checks. Second, PATH conducted condom demonstration sessions during group education sessions for the guards.

Constraints

The project was originally proposed as a two-year activity, but AIDSCAP funding was only available for one year. Most project activities have therefore not been developed to their full potential, for example in providing follow-up support to the training schools. Because of the short implementation period, there is also no end-of-project comparative data to assess the impact of this intervention.

Second, the constraints within the different security firms required change in the original project design. Because of the unique nature of operations in security firms -- where guards work long shifts, are not allowed to congregate during work hours, and where outsiders are not allowed into the companies when guards congregate for their advance and monthly pay -- a peer education strategy would not work. PATH therefore started working with the management to promote the integration of this education in their regular guard training programs.

Third, the companies are all structured differently. Some do not have a formal training school or program for their newly recruited guards or those attending refresher training. Working with such companies to identify forums for meeting with the guards was not an easy task.

Lessons Learned

The KABP study of this project highlighted four important issues for the IEC intervention on HIV/AIDS to be implemented for security guards:

multiple sex partners;
perception of personal risk of STDs and HIV;
condom use; and
misinformation/negative attitudes towards protection against infection.

The security guards' peculiar constraints and work situation altered the peer education strategy initially chosen for this intervention. Security guards work very long hours which leave very little time for them to meet with other guards. Traditional peer education models could not work with this group given their isolation and company policies that they are not allowed to leave individual job sites.

There is a dearth of educational materials, particularly on STI and for target audiences with low literacy levels. It was necessary to develop specific STI educational materials for this group to address information needs identified in the KABP study. New materials had to respond to the low literacy levels indicated by the KABP, and the information needed to be in a format that security guards could both read and share with colleagues. Additionally, during the pre-testing the guards requested educational materials that they could share with their partners.

Language issues are complex and in developing education materials, several stages of pre-testing, reviews, and revisions are required. In choosing the language for materials, care should be taken to strike a balance between the ability to read easily versus the ability to understand better. For example, the guards appeared to read the English-language materials more easily than the Kiswahili, but further testing showed that the did not understand the concepts in the English materials as well. Extensive probing during pre-testing can help overcome this problem.

Country Office Assessment

The project achieved a remarkable degree of success in reaching this vulnerable group, particularly given the short implementation period. It is likely to have a notable impact on a population that has often been ignored. In addition, the STI materials produced under the project answered a need for STI information, which should have wider value for use with similar target audiences in Kenya. The integration of the STDs/HIV/AIDS by three security firms into their training programs is a significant step towards sustainability. It is important that some mechanism be found for PATH to continue activities with the other companies that have been unable to integrate the program into their training. Development of a Trainers' Guide for the various companies would be particularly useful, given the highly mobile nature of their workforce. In addition, some modules on counseling could be added to the Trainers' Guide in order to meet a fast-growing need within most populations. The project showed the importance of flexibility and willingness to review the project design in response to a situation analysis

Process Indicator Summary

Process Indicator	Target	Actual	Percent
Individuals educated	–	2,650	–
Individuals trained	–	19	–
Materials distributed	–	25,000	–
Condoms distributed	–	2,000	–

HIV/AIDS Materials for Worksite Employees

FCO 43465

AIDSCAP partner:	Program for Appropriate Technology in Health (PATH)
Geographic focus:	Mombasa, Nairobi, Eldoret
Target population:	General populations
Project dates:	December 15, 1996 - April 30, 1997

Background

In a qualitative assessment of the FPPS worksite peer education project in June 1996, which involved focus group discussions (FGDs) with peer educators and coordinators, the Country Office learned that these worksite volunteers felt a strong need for materials to use for reference and to share with colleagues. Some of their worksite colleagues expressed the need for materials to share with their families, and those with pre- and adolescent children needed help to communicate about sexual and reproductive health issues with this vulnerable age group.

Information, education and communication materials are an important component of a peer education program. FPPS produced some materials which were distributed to all the companies. However, funds were inadequate to reprint them once the initial copies were out of stock. Consequently, most of the sites were faced with the problem of lack of IEC materials to give away to their peers after a counseling or discussion session. Many of the sites expressed the need for materials by writing or calling FPPS directly. This project was therefore designed as a supplementary input to strengthen the existing peer education program. The challenge to PATH was to select, reprint, and distribute appropriate materials to the worksites in a short period of time.

Objective

The objective of this project was to provide worksite peer educators in Eldoret, Nairobi and Mombasa with a packet of materials on STDs/AIDS/HIV that they could share and distribute as appropriate to those with whom they interact with during work or after work.

Accomplishments

A needs assessment/baseline survey was conducted among peer educators in eight companies in Nairobi and Eldoret on their IEC needs. Information was mostly collected through focus groups. In some cases personal interviews were also held with coordinators and medical officers in charge of company clinics.

A sample of the proposed resource kit for worksite peer educators was pre-tested. In response to peer educator requests, it was decided to package the materials in a strong, easily portable and weatherproof bag, marked with the words "Peer Educator." This would protect the materials, be a small incentive for the peer educators, and help them to be easily identified by their colleagues.

A materials kit was finalized, which included 15 different IEC materials, packaged in a peer educator bag. The materials included a folder, sample leaflets, booklets and posters, as follows:

Discharges (Leaflet) 8 panels, English
Genital Sores (Booklet) 12 pages + cover, English/Kiswahili
The Condom ... (Booklet) 12 pages + cover, English/Kiswahili.
Could I have HIV/AIDS? (Booklet) 24 pages + cover, English/Kiswahili.
Living and Loving (Booklet) 16 pages + cover, English/Kiswahili
Living with AIDS, English
Life, Love, and AIDS (Drama), English
Life, Love, and AIDS (comic booklet), English.
Ukweli juu ya UKIMWI, Kiswahili/English
Peter and Anne Discuss AIDS with Auntie Mary, English
Modern methods of family planning, English
Three posters:
AIDS is not witchcraft
Using condoms means you really care
Your wife and children need you.

The kit also included an annotated bibliography of video and HIV/AIDS materials that peer educators can access, and three leaflets on special topics, developed by PATH to address issues raised by peer educators in the needs assessment.

PATH distributed 320 materials kits to peer educators at 18 companies in Mombasa, Nairobi, and Eldoret. It is planned to carry out a rapid follow-up assessment at the worksites in about six months' time to assess how the materials are actually being used.

Findings of the Needs Assessment

The needs assessment carried out a detailed review of the materials currently used by peer educators. These included booklets and leaflets, posters, and video cassettes. Of all the print materials peer educators had ever used in this project, "Living with AIDS" was the most popular. Most peer educators recommended that more copies of this material be made since most of their colleagues asked for it. They also indicated that there was a high level of awareness about HIV/AIDS, but there was little or no information available on community/ home-based care for people living with the disease.

The survey confirmed that peer educators needed IEC materials to give to their colleagues after an education or counseling session. However, it was noted that all the materials provided either by FPPS or other sources, were out of stock. Most peer educators reported having received only a few copies of some of the materials and therefore were reluctant to give these away to their colleagues. Some companies, for example, Rift Valley Bottlers, encouraged peer educators to develop their own IEC materials as a solution to the shortage they experience. Most peer educators felt that information presented in IEC materials was more reinforcing than information received through verbal messages alone. This continuing need for materials should be borne in mind when designing future peer education projects and efforts should be made to identify sources of supply and/or to convince management to fund materials to support the project

None of the eight companies visited had a resource center. They relied on the company clinic and/or training halls to store materials they received and to conduct project activities. The clinics and training centers visited had very few materials on display, but there were none for people to take away, if they desired to do so. They, however, had large quantities of condoms and some family planning leaflets.

Only three -- Rivatex, Ken Knit, and Rift Valley Bottlers -- out of the eight companies had a video facility which the peer educators had access to, and a collection of videos which could be used to educate other employees. Peer educators in the other companies relied on well-wishers from the management to assist them whenever they needed to show videos. This created difficulties because they could not borrow the facilities as often as they required. In addition, all the companies in Eldoret reported that they had problems obtaining videos to show the workers. The same videos were often shown repeatedly resulting in a decline in attendance.

The survey also revealed that most peer educators were committed to their work and thought they had been very successful. It was, however, difficult for them to estimate the number of people reached as they did not keep a detailed record of their personal interactions with their colleagues. Only one of the companies (Rivatex), had kept such a record, which indicated that peer educators had reached 2077 workers between September 1995 and June 1996.

Peer educators reported that their workmates have responded to the project by seeking further information and/or asking questions over a wide range of issues. These include: whether there is a cure for AIDS, care for people suffering from AIDS, problems/myths associated with condoms and how to use them properly. Some peer educators had also come across people who needed counseling. However, they felt handicapped by their lack of counseling skills and asked whether the project could provide training in counseling.

Despite their sense of achievement, peer educators felt that some incentive was required to encourage them to continue educating their colleagues. In some companies, peer educators were so highly motivated they were reaching out to communities in their neighborhood. This finding was the basis for PATH's decision to provide peer educators with bags to carry their IEC materials as they conducted their outreach and peer education activities.

Constraints

Some companies did not have conducive meeting facilities or resource centers, but were using the training centers or rooms allocated by the management. These facilities were used by other groups as well. Thus the security of IEC materials was not guaranteed and they may be a future problem with storage of bulk materials when they are delivered. If this project will be replicated in other areas, the implementers should ensure that appropriate arrangements are made with the management to provide meeting rooms or resource centers where peer educators can keep their IEC materials, and where they can hold meetings.

Most peer educators did not keep good records of their activities. This made it difficult to estimate the quantity of materials required, since information regarding the number of workers reached was unavailable. Materials are very costly and should be used carefully to avoid wastage. Thus future projects of this kind should ensure that peer educators are properly trained on record- keeping and how to use IEC materials available to them.

Lessons Learned

A needs assessment or baseline survey is an essential component of any program. Through the baseline survey PATH identified the felt needs of the peer educators to guide the re-printing and production of new materials. Peer educators felt, for instance, that materials on certain subjects had been widely distributed and there was no need to reproduce them. Most peer educators felt there was already a high level of awareness about HIV/AIDS, but that there was very little information on home based care for people with AIDS.

Cooperation from the company management is essential. Management allowed the peer educators time off to attend focus group discussions and gave permission for PATH to visit the sites. Most of these companies are very strict about use of employee time, since an hour's break for 20 employees is a loss to the company. But the management understood that by sparing one hour they were saving the lives of many employees.

Involving the target audience in the production of materials ensures the relevance and accuracy of the materials. PATH worked with the target audience to select and develop all the materials. Some of the materials were pre-tested in the development stage with a similar audience, the security guards. However, all sample materials were reviewed with the peer educators and their comments considered before the final versions were produced. As a result the final product was well accepted, with several peer educators identifying their input in the final kit.

Adapting existing materials is a cost effective and faster way of providing IEC materials to interested groups. PATH was able to complete this project in less than five months because most materials were adapted from PATH's existing IEC materials. Future projects should take advantage of what already exists before venturing into full production of new IEC materials. However, it is important to note that each adapted material should be adequately pre-tested with the target group.

Peer educators have faith in the value of IEC materials to reinforce information passed through verbal communication. PATH learned that most peer educators felt they were not being very effective because they had no IEC materials to give away to their colleagues after verbal discussions. Most peer educators argued that their colleagues could not remember everything they were told during the discussion sessions. Thus they felt that IEC materials would remind workers of the verbal messages and facilitate the process of behavior change.

In order to ensure effective use of the IEC materials produced the next step should be to train the peer educators on how to use them and how to keep records of their work. Such training should be included in any follow-up activities to this project.

Country Office Assessment

The project demonstrated that there can be a fast response to peer educator demands - in this case for relevant materials on HIV/AIDS prevention. Providing these materials in an attractive "Peer Educator" bag was mentioned by peer educators as a strong motivating factor to increase their self-esteem and involvement in the program. This project will be followed up in the coming year to assess the extent to which the materials have actually been used by peer educators over time.

Process Indicator Summary

Process Indicator	Target	Actual	Percent
Materials distributed	93,000	86,000	93%

HIV/AIDS/STD Education in Institutions of Higher Learning

FCO 33567/53567

AIDSCAP partner:	Family Planning Private Sector
Geographic focus:	Nairobi, Eldoret, Mombasa
Target population:	University students
Project dates:	January 1, 1995 - May 31, 1997

Background

Between 80,000 and 100,000 students are enrolled in institutions of higher learning in Kenya. An operations research study, The Universities Analysis Study, carried out by FPPS in 1993 in three of these institutions (the University of Nairobi, Moi University and Maseno University College) to review various aspects of knowledge, attitudes, practices and health seeking behavior found that a significant number of students in these institutions are sexually active and that the use contraceptive is relatively low. Furthermore, many young women in these institutions are at high risk of contracting STDs due to their involvement with "sugar daddies" and male students, who, the report shows, have multiple partners. Between January 1995 and May 1997, FPPS was funded by AIDSCAP to carry out a project of HIV/AIDS prevention education in nine institutions of higher education in Kenya.

Objective

The goal of the project was to expand and strengthen students' knowledge on reproductive health and increase their capacity to make positive decisions about safer sexual behavior. It was envisaged that during the project period, peer education activities by students would intensify and expand HIV/AIDS awareness among students and in the process minimize the incidence and prevalence of STDs and HIV within the campuses. In particular the project would:

Disseminate information to youth on sexuality, HIV/AIDS, STDs and family planning
Enlighten students about the physiological and emotional changes that occur during adolescence
Train students leaders as peer counselors/educators
Create awareness of the interrelationship between sex, among other factors, and the spread of AIDS and other STDs
Correct the false picture of sex as created by rumors, the mass media and other channels.
Help students learn how to communicate with others and make informed choices about relationships.
Contribute positively to HIV/AIDS prevention in higher institutions of learning by strengthening contraceptive accessibility for the youth.

The following nine institutions of higher learning were included in the project: University of Nairobi, Chepkoilel Campus, Moi University, Maseno University College, Jomo Kenyatta University of Agriculture & Technology, Kenya Utalii College, Kenya College of Communications Technology, and Mombasa Polytechnic. All these institutions except Mombasa Polytechnic had been previously assisted by FPPS in the provision of family planning services.

Accomplishments

26 representatives of students leaders and deans of students from 9 institutions were brought together to discuss the reproductive health needs of students and discuss the peer educators training curriculum outline.
Student leaders initiated reproductive health AIDS awareness clubs in the nine participating institutions. Once set up, these clubs became the primary coordinating bodies for reproductive health activities on campus. Their membership included both female and male students.
Ten peer education training workshops were organized and 251 peer educators trained. Once trained the peer educators organized a variety of activities to promote responsible sexual behavior among their peers. These activities include condom distribution and demonstrations. FPPS estimated that approximately 19,000 students were reached through peer education and other awareness activities.
FPPS provided appropriate IEC materials in form of posters, pamphlets, booklets and videos to facilitate peer education activities. Efforts were made to produce gender sensitive materials aimed specifically to empower the female student.
Four issues of the peer educators' newsletter, Crossroads, were published. It included articles on reproductive health and HIV/AIDS and covered activities organized by the peer educators clubs.
39 peer educators made up of both students and members of staff were trained as trainers of trainers (TOT) to enable them to support future training activities of their clubs.
A number of reproductive health clubs initiated fund raising activities for club sustainability in the form of income generating activities. These ranged from setting up a canteen at the college to holding balls, walks and other special events.

Constraints

Peer education activities at the institutional level were hampered by lack of basic equipment like VCR and television monitors, which had to be hired wherever the groups wanted to show videos.
Training of peer educators and other peer education activities were disrupted by unscheduled and prolonged closures of the public universities.

Findings

Between March and April 1997, an evaluation was carried out at five of the institutions to evaluate the effectiveness and impact of the youth reproductive health initiative. The study mainly focused on the role of peer educators in the provision of reproductive health information to other students. Focus group discussions were held with a total of 37 peer educators to gather information on training, impact, experiences, and strategies used to implement the project. Focus group discussions were also held with 43 members of the target group of students. In-depth interviews were also held with 7 project coordinators and 5 club leaders (mainly deans of students and student counselors) to solicit information pertaining to the administration's involvement with and support for the project.

Analysis of the focus group discussions and the in-depth interviews strongly suggest the project has succeeded in increasing young people's access to reproductive health information and services in the participating institutions. Although it is difficult to assess behavior change especially with transitional groups like students, focus group discussions suggest students are modifying their sexual behavior as a result of peer education activities. They are reducing the number of sexual partners, abstaining, discussing HIV/AIDS more freely and using condoms. Reproductive health clubs have achieved greater visibility as a result of their work and are being sought out by other clubs and students for help. Many of the clubs are also undertaking activities to enhance their sustainability.

The findings of the evaluation strongly suggest that the HIV/AIDS/STD Education in Institutions of Higher Education Project has achieved its main objectives and was able to do so in the short two-year period of the project.

Lessons Learned

Given the necessary skills and knowledge peer educators can effectively bring about changes in health practices among their peers. It was reported during the focus group discussions (FGDs) with both peer educators and target groups that students have overcome social and traditional barriers and are discussing sexuality and HIV/AIDS freely and there is more freedom in seeking for STD treatment on campus and asking for condoms.

Peer education activities thrive best where they are supported by both the administration and the target groups. Peer education has done well where there has been involvement of the administration whether through providing financial or in kind contributions, or through giving support to carrying out project activities on campus.

Peer education is a practical easy to use strategy for HIV/AIDS prevention which can successfully reach a large number of students with minimal financial support. Peer education is a cost effective strategy as peers are trained on site as opposed to traditional workshops which are held in hotels and involve transportation, accommodation and meals for trainees and facilitators. The target groups are also easily reached with reproductive health messages as they are already residents in the institution.

The organization of reproductive health clubs was an essential complementary activity to peer education. Although HIV/AIDS education was a major component of the project the clubs that evolved look at the total health of the individual student and hence addressed diverse educational activities, which included family planning, drug abuse, life skills, and gender empowerment.

Prospects for long term sustainability of reproductive health clubs are enhanced if specific sustainability elements are included during the project design. Assumptions were made that reproductive health clubs would automatically be fully supported by the administration. But given the nature and structure of the higher institutions of learning this is not always possible. To address this issue, reproductive health clubs are encouraged to initiate fund raising activities in form of income-generating projects to meet their administrative costs and other contingencies.

Country Office Assessment

The qualitative evaluation findings suggest that this subproject achieved its major objectives. In view of the lessons learned and the fact that peer education is relatively low cost, efforts should be made to sustain the peer education concept and expand it to other institutions.

Efforts should therefore be made to mobilize resources to support the current reproductive health clubs to sustain and expand their activities, and assist them in advocating within their institutions for club support. Strategies should also be developed to increase the collaboration of the clubs with other NGOs involved in reproductive health for young people.

This project raises similar issues to the project with security guards about the need for the continuing input of an external organization to project in order to sustain motivation, particularly when the project has been operational for a relatively short time. While the university AIDS clubs will most likely continue to operate without external input, their long-term sustainability would be strengthened by: providing follow-up training in leadership and management skills for club leaders to enable them run the clubs more effectively, continued regular monitoring visits to the project sites to encourage and motivate peer educators, expanding the current reproductive health training curriculum to cover other issues of concern to young people such as drug abuse, abortion and relationships. Holding or enabling peer educators to attend national dissemination workshops to enable peer educators share experiences and ideas on youth reproductive health would also be a valuable way to strengthen their sense of identity and commitment.

Process Indicator Summary

Process Indicator	Target	Actual	Percent
Peer educators trained	200	251	126%
PE Training of Trainers	–	36	–
Gender empowerment training	–	200	–
Patrons/coordinators sensitized	–	76	–
Students educated	–	19,000	–
Materials distributed	–	11,800	–
Condoms distributed	–	300,000	–

Final Report for the AIDSCAP Program in Kenya: Subproject Highlights