Turning Obstacles Into Opportunities: Haitian Workplace Project Breaks New Ground in HIV/AIDS Prevention

A workplace prevention project in Port-au-Prince overcomes logistical difficulties during Haiti's years of political chaos to develop an innovative method of teaching prevention communication skills.

It's early afternoon at Stewart Industries in the factory district of Port-au-Prince, and the temperature is rising on the shop floor. The workers stand back as sparks fly from the massive machines that bend hot iron into door frames. There's no complaint when the foreman stops work early and summons everyone into his air-conditioned office. Something different is scheduled today: a class on HIV prevention.

As the men find empty seats in the crowded room, HIV/AIDS educator Yvon Duvelson arranges his materials and looks around. Apart from their obvious pleasure at escaping the heat, it's difficult to read the expressions on the workers' faces: they're cordial and curious, yet reserved -- perhaps a bit embarrassed about the subject matter.

But Duvelson is a pro. A former factory worker himself, he knows how to break the ice.

"What a great place to work!" he quips in Creole. "You must be the only refrigerated ironworkers in Haiti!"

Laughter follows, the connection is made, and for the next hour -- an hour that could help these men save their own lives -- Duvelson has them hooked.

A Difficult Period

Duvelson's employer, the Groupe de Lutte Anti-Sida (Group in Struggle Against AIDS, known as GLAS), has since 1990 brought innovative HIV prevention education to dozens of workplaces in the Port-au-Prince area, home to more than a million people. From state-owned utility companies to Coca Cola bottling plants, dockside warehouses to small sewing workshops, GLAS carries the prevention message to a particularly important sector of the Haitian population: workers between 15 and 49 years old.

"This is the age group that holds up the country economically," said GLAS' dynamic director, Gessy Aubry. "And this is the generation of Haitians that's bringing the next generation into the world."

But for much of GLAS' existence, Haitians of all generations faced a particularly dangerous period in their country's struggle with HIV/AIDS. In September 1991, when GLAS was barely a year old, the Aristide government was overthrown, and Haiti was plunged into four years of often violent social and political upheaval. Like most other government institutions, the national health care system disintegrated during the crisis -- and Haiti became even more vulnerable to the deadly infection that has spread to as much as 10 percent of the urban population. Only a handful of nongovernmental organizations (NGOs) remained to provide critically important prevention services to the Haitian people.

"Haiti's NGOs were suddenly thrust into the leadership in AIDS prevention," said Aubry. "With no government health authority to control the epidemic, our work became more important than ever."

Despite an international embargo on trade and development assistance, humanitarian aid -- including health programs -- was still permitted, and the AIDS Control and Prevention (AIDSCAP) Project, with funding from the U.S. Agency for International Development, continued to provide technical assistance, financial management, and organizational and skills training to GLAS and a dozen other NGOs involved in HIV/AIDS prevention and care.

For GLAS, AIDSCAP support gave the small organization the means to think big -- and achieve big-scale success. From 1992 to 1996, GLAS used its new skills and the talents of a deeply committed staff to educate nearly 20,000 workers with a multitiered prevention education campaign, and many thousands more with its posters, brochures and other materials promoting behavior change. Through its education programs and a social marketing component, GLAS also distributed and sold more than half a million condoms throughout the Port-au-Prince area.

Flexibility and Creativity

Before it could realize such ambitious goals, GLAS had to overcome some formidable barriers to reaching its target audience. Most of the city's bigger factories -- where large numbers of workers could be educated at one time -- were closed either because of strikes or because of shortages of fuel and embargoed raw materials. And logistical difficulties were sometimes overwhelming. When gasoline became scarce, peaking at U.S.$10 per gallon, the city's transportation system shut down, making it virtually impossible for the eight staff educators to get to workplaces throughout the area.

But GLAS did not give up. When they discovered that smaller-scale workplaces using local supplies were still functioning, GLAS staff arranged educational sessions for these more modest venues. Aubry, her assistant and her secretary spent hours each day searching for gasoline for the office van so they could pick up educators at their homes and chauffeur them from workplace to workplace.

"We took creative advantage of those hours spent in gasoline lines to talk to other drivers about AIDS prevention," said Aubry. "We developed a portable presentation that could be delivered as we walked up and down the line, and even began to sell condoms to other gas customers."

Aubry believes that turning difficulty into opportunity soon became second nature for GLAS staff, helping the organization not only survive but thrive during those four years of chaos.

"We had to figure out how to move ahead as each new obstacle was thrown at us, and every time it happened we grew stronger," she said. "Without flexibility, we would have stopped growing."

Learning to adjust and retool as circumstances demanded also gave GLAS the ability to change course when its educational interventions were not achieving all the organization's goals. For example, GLAS at first offered only a single hour-long session, a general introduction to HIV and its prevention, followed by a question-and-answer period. But staff soon realized that their original class design was too limited.

"When the first year was over, we surveyed the workers we'd educated and found high levels of understanding about the virus and its transmission," said Aubry. "But while the survey also revealed a high level of interest in condoms for prevention, it showed that most participants still didn't know how to use them."

Responding to Client Needs

Aubry responded quickly by adding a second workplace session to give workers hands-on experience with condoms. Using a rubber penis model, GLAS educators demonstrate how to put condoms on, take them off safely and dispose of them, and they encourage the workers as each takes a turn. Both men and women participants -- about a half-dozen at a time -- practice again and again until they become competent at handling the condoms.

"Even workers who have some experience with condoms benefit from this session," Aubry said. "There are often complaints that condoms tear during sex, or that they stay inside the vagina after withdrawal, and we've been able to help class participants deal with such problems."

The ambience of these "condom fit" sessions and of all GLAS-sponsored educational events is comfortable, informal, interactive, even collegial. Because many workers in Haiti are embarrassed about their limited education or poor literacy skills, GLAS staff conscientiously establish an atmosphere of mutual respect, where each worker-participant is treated as an equal, someone with valuable experiences and perspectives to share. GLAS educators, themselves recruited from the industrial working class, understand the importance of overcoming such communication barriers. And all are trained in transactional analysis (TA), a therapeutic technique that raises awareness of the different roles people assume when they talk to each other, and how those roles can aid or impede true communication. Aubry, who has used TA for years as a trainer and communications consultant, praises its effectiveness in prevention education.

"By establishing an equality of communication, TA quickly enables all parties to listen and understand each other more fully," she said.

Because workers felt comfortable about voicing their concerns during the condom sessions, it soon became clear that GLAS staff had not addressed all of their questions about the epidemic. A third session was added soon after: an open-ended discussion hour in which workers who have participated in the first two sessions can ask questions, analyze rumors and superstitious beliefs about HIV/AIDS, and talk about such personal issues as introducing prevention methods into long-established sexual relationships.

GLAS' ongoing responsiveness to its clients' needs has led to a extremely effective multilayered approach to HIV prevention education. By following up each level of knowledge and skill building with more advanced classes, GLAS has been able to magnify and reinforce the awareness and commitment of the workers it teaches. And as the organization returns again and again to a workplace, management also develops a stronger sense of responsibility for helping employees avoid HIV infection.

"Prevention education is so important that we will devote production time for classes," said Harry Cadet, Stewart's plant director, who first asked for help from GLAS several years ago at another factory that lost two workers to AIDS. "Protecting our workers is definitely a worthwhile investment for us to make."

Breaking New Ground

In 1995, with more than four years of successful programming in the factories and workshops of Port-au-Prince behind them, GLAS staff once again challenged its own effectiveness by asking itself a tough question: After participating in a long-term, multilayered educational and skills-building program, are GLAS clients actually willing to translate knowledge and awareness into real behavior change?

"We were surprised to discover that even our most dedicated workers sometimes behave in ways that they themselves know are not safe," Aubry said. "I realized something was missing in our approach: what's known in developed countries as self-empowerment."

Aubry decided that helping GLAS' clients achieve the self-confidence needed to make major life changes required a more intensive form of psycho-social support. With AIDSCAP pilot project funding, she created unique support groups in which not only the facilitators but the participants use TA to more deeply understand why they continued to take risks, despite their high levels of knowledge after earlier training. Intensive therapeutic interventions of this kind are rare in developing country prevention programs.

"A lot of experts weren't sure it was possible to introduce something like transactional analysis to uneducated people," said Aubry. "But we translated the concept into their own language, using their own frame of reference, and it became our biggest success."

Examining roles in communication is by no means an abstract exercise for HIV/AIDS prevention. If, for example, traditional gender roles cause a man to attempt to control discussions with his female partner, honest dialogue about safe sex and fidelity is unlikely to take place. Or if a high school teacher speaks down to students during a class discussion about prevention, chances are slim that the young audience will absorb much information or -- even more important -- act on what they do learn.

"What's especially valuable about changing the way people communicate with each other is how motivating it can be," said Aubry. "When one is empowered by communication that shows respect for each other as adults, taking responsibility for one's actions is very often the result."

During the eight months of the pilot project, 20 groups -- two each in ten different workplaces -- met twice a month, facilitated by a TA-trained peer educator from the same workplace. Each group included both men and women, and welcomed the participation of spouses and companions. With personal behavior change to lower HIV risk as the central topic, the groups discussed a broad range of issues during their sessions: how to communicate better with one's partner, how to teach children about sexuality, how to treat the opposite sex with more understanding and respect, how to learn to respect oneself.

By the end of the project, both GLAS staff and many of the workers who participated felt that extraordinary progress had been made. One worker who can barely read told GLAS he felt he'd received the equivalent of a college education in communication skills -- and that during the sessions he also enjoyed being treated with the respect that college graduates receive from society at large. Even employers remarked at the positive changes in workers who participated in the sessions, citing greater cooperation, self-confidence and increased ability to work as team members. Although no formal evaluation of the pilot project has yet been conducted, Aubry feels that this experiment in adapting communication therapy to workplace prevention education has great potential.

"The workers who participated have learned how to solve problems, and are applying that knowledge to AIDS prevention with their partners," Aubry said. "To me, this deeper dimension to education is what we're really seeking -- otherwise you leave a person with the seed and then no water to make it grow."

-- Margaret J. Dadian

Although AIDSCAP's program in Haiti closed this July 1996 after five successful years, GLAS continues to fulfill its mission in the workplaces of Port-au-Prince and is seeking funding from new sources to expand its work into other provinces.