EVALUATING HIV/STD INTERVENTIONS IN
DEVELOPING COUNTRIES: DO CURRENT INDICATORS DO JUSTICE TO ADVANCES IN
INTERVENTION APPROACHES?
HIV continues to spread unabated in many
developing countries. Here we consider the interventions that are
currently in place and critically discuss the methods that are being
used to evaluate them as reported in the published literature. In
recent years there has been a move away from highly individual-oriented
interventions towards more participatory approaches that emphasise
techniques such as community-led peer education and group discussions.
However, this move towards more community orientated intervention
techniques has not been matched by the development of evaluation
methods with which to capture and explain the community and social
changes which are often necessary preconditions for health-enhancing
behaviour change. Evaluation research continues to rely on quantitative
methodologies that fail to elucidate the complex changes that the newer
interventions seek to promote within target communities. In addition,
these methods of evaluation tend to rely on the use of highly
individualistic and quantitative biomedical indicators such as HIV/STD
rates, or knowledge, attitude, perception and behaviour (KAPB) survey
questionnaires. We argue that such approaches are inadequate for the
task of tracking and measuring important determinants of programme
success such as psycho-social changes, features of the
community-intervention interface and the degree of trust and
identification with which members of target communities regard
particular interventions. Rigorously conducted qualitative process
evaluations taking account of the above factors could make a key
contribution to the development of more successful HIV-prevention
interventions.
* To whom correspondence should be addressed
Introduction
While the development of an effective vaccine
and cure for HIV remain elusive, interventions aimed at HIV-prevention
continue to be the best hope for limiting transmission of the virus and
the spread of infection. Approaches to prevention have evolved from an
early emphasis on information-based HIV-awareness campaigns and the
aggressive detection and treatment of sexually transmitted diseases
(operating at the behavioural and biomedical levels of analysis, and
focusing on individual levels of awareness and infection), towards more
community based approaches involving peer education, and using
participatory techniques such as peer-led role-plays and group
discussions.
in this paper we analyse in detail current
evaluation strategies for HIV-prevention interventions in developing
countries. Our analysis forms the basis for a critique of the
evaluation strategies that currently dominate the field of
HIV-prevention. We seek to show that despite the move towards more
social and community orientated approaches within HIV-prevention
interventions, project evaluators have tended to favour methodologies
that give precedence to the individual level of analysis, and in
particular methodologies that measure individual disease states (such
as STD results) and knowledge, attitudes and reported behaviours, also
measured as the properties of individuals.
In focusing on the individual level of
analysis, not only do these evaluations fail to capture the social and
community level processes that state-of-the-art HIV prevention
interventions seek to promote, they also squander a vital opportunity
to improve our understanding of factors that promote or hinder sexual
behaviour change in concrete social settings. Better understanding of
these processes could lead not only to the development of a more
refined battery of indicators of programme success -- but could also
contribute to the development of more effective interventions and
policies in the field of sexual health promotion.
We argue here that the task of developing
such indicators requires not only a shift away from individual towards
the social and community levels of analysis but it also involves paying
greater attention to the task of supplementing existing quantitative
measures of programme success or failure with qualitative contextual
material, and supplementing the current preference for outcome measures
with greater attention to the development of process measures.
Aggleton, Young, Moody, Kapila and Pye (1992) distinguish between
'outcome evaluation' and 'process evaluation'. Outcome evaluations are
usually quantitative in nature, and aim to measure whether and to what
extent the goals associated with a particular health intervention
programme have been met. Process evaluations are usually qualitative in
nature, and aim to examine how programme outcomes have been achieved.
Our belief that greater efforts should be devoted to qualitative
process evaluation strategies is not shared by all researchers, many of
whom regard the randomised controlled study as the gold standard needed
ensure the replicability and repeatability of HIV interventions (Choi
& Coates, 1994; Oakley, Fullerton & Holland, 1995; Peterman
& Aral, 1993). Randomised control trials (RCTs) are appropriate and
even essential in many situations and are held in high regard by
biomedical researchers who dominate the field of HIV-prevention. In
addition, they appeal to many programme funders in a competitive
funding climate, where money is often only available for short-term
projects, judged in terms of their potential to quickly produce
quantifiable outcomes, rather than to promote long-term community
development processes. Many social scientists would argue that the
latter are an essential precondition for ensuring that positive health
outcomes are sustainable and generalisable beyond the life of the
particular project and beyond the particular individual community
members exposed to the project (Beeker, Guenther-Grey & Raj, 1998;
Gillies, Tolley & Wolstenholme, 1996). They argue further that we
still lack adequate conceptual frameworks and indicators for
operationalising these community development processes which are
critical variables without which we cannot sensibly evaluate the
results of RCT trials. This point is developed further below.
We argue that while RCTs clearly provide a
valuable tool in a range of contexts, they are not necessarily relevant
or appropriate in all contexts. In particular we argue that RCTs are
not necessarily a feasible way of evaluating the often poorly funded,
small-scale HIV-prevention programmes in developing countries. The
first problem concerns ethics. RCTs usually involve withholding, or at
least not offering, treatment to control groups in order to show that a
more pronounced change in the intervention group can be directly
attributed to intervention. The ethics of withholding, or postponing,
treatment from control groups in the interests of scientific
investigation are now being debated. Furthermore, the literature
suggests that the use of placebo in HIV interventions will no longer be
acceptable (Abdool Karim, 1998; Lurie & Wolfe, 1997; Moodley,
1998). Some researchers try to deal with this ethical requirement by
introducing treatment to the control group later in the intervention.
However this issue remains controversial, with Angell (1997) arguing
that placebo trials are only justifiable where there is no known
effective treatment.
The second limitation is cost. Randomised
control trials demand high levels of expertise and expense in their
planning, design, execution and analysis and as such do not constitute
'appropriate technology' for often poorly funded research programmes in
developing countries.
Thirdly, and most relevant to the argument of
this paper, randomised control trials have a limited contribution to
make to the task of developing understandings of the complex
environments in which interventions directed at sexual behaviour take
place. Randomised control trials assume that we are already able to
define the factors that need to be taken into account in explaining the
success or failure of health promotion programmes. We argue that our
understanding of health promotion factors shaping sexuality is still in
its infancy, and that much more 'conceptual groundwork' needs to be
done before we can be confident that the discrete quantitative
indicators used in randomised control trials are indeed the best gauge
of processes shaping sexuality.
What then are the community and social level
processes which community based, participatory HIV-prevention
programmes seek to advance in pursuit of the outcomes of bringing about
health-promoting behaviour change and reduced STD/HIV levels?
Understanding of the processes underlying successful sexual behaviour
change interventions is still very under-developed. Here we refer to
three different areas in which researchers are currently seeking to
answer this question.
Psycho-social factors involved in sexual behaviour change
Campbell (1997) and Campbell and Williams
(1998) suggest that sexual behaviour is a complex and multi-determined
phenomenon, determined by intra-individual, inter-individual,
community, social and economic factors (see MacPhail, 1998). They argue
that we currently lack the conceptual tools needed to adequately
understand or measure the interacting effects of these factors, each
operating at a different level, on peoples' sexuality. They try to
unravel how some of these factors might operate through their attempts
to understand the factors underlying sexual behaviour change in the
context of HIV-prevention in the gold mining community of
Carletonville. They argue that HIV-prevention programmes will succeed
or fail in changing peoples' sexual behaviour to the extent that they:
(i) Increase levels of perceived
self-efficacy amongst target groupings. The greater control people have
over the important aspects of their lives, the greater likelihood there
is that they will adopt health-promoting behaviour (Syme, 1989).
Successful interventions will develop the individual's belief in
his/her potential to influence his or her life circumstances, including
his or her health status.
(ii) Provide the opportunity for target
audience members to renegotiate their sexual and social identities at
the collective level. Dube and Wilson (1996) argue that sexual
behaviour change is more likely to occur through the influence of peers
than through conscious rational choices made by individuals in
isolation. People are more likely to change their behaviour if they
perceive that liked and trusted peers are changing theirs.
(iii) Promote the development of community
contexts that enable and support the sexual behaviour changes that
HIV-prevention programmes seek to bring about. Campbell and Williams
(1999) argue that such changes in self-efficacy and social identity are
unlikely to occur unless attempts are made to simultaneously promote
the development of 'health-enabling communities'. Thus, for example,
there is no point in devoting efforts to encouraging condom use amongst
impoverished commercial sex workers, in a context where clients refuse
to use condoms, and where there is no consensus amongst women to
enforce condom use (Campbell, 1999). In this context, a
'health-enabling community' would be one where sex workers collectively
debated the way in which competition for clients was placing their
lives at risk, and then made a group-based decision to present a united
front to reluctant clients (see also Tawil, Verster & O'Reilly,
1995).
The interface between target community members and the intervention
Campbell and Williams (1998) consider the
broader psychosocial and community level processes that they believe
are most likely to maximise the chances of programme success. Kreuter
(1997,p. 8) focuses more narrowly on particular aspects of the
programme-target audience interface most likely to enhance the effects
of such health-promotion programmes, arguing that:
Health promotion interventions and tactics
will be effective to the extent that the target community has
organisational entities and systems that are supportive of the
enterprise, and that these entities and systems are activated. The
activation of relevant community entities and systems depends in part
on the extent to which community members are aware of, value and trust
the proposed intervention.
Kreuter argues for the need to develop
measurable indicators of notions such as 'activated organisational
entities' and 'community trust' in order to evaluate the extent to
which health promotional programmes set into motion processes most
likely to result in desired outcomes (in this case outcomes such as
condom use and lowered STD levels).
Multi-sectoral alliances: broader organisational context of the intervention
In her study of 'best practices' in health
promotion in a range of developed and developing countries, Gillies
(1998) emphasises the importance of alliances or partnership
initiatives between local health promotional efforts on the one hand,
and other health-related initiatives at the local, provincial and
national levels on the other. Thus, for example, grassroots women's
health projects should interface with similar projects in the
geographical vicinity, and as much as possible with representatives of
as broad a range of provincial and national health bodies as possible.
Such networking is most likely to result in sustainable health
promotion, through coordinating what might otherwise be piecemeal
attempts by different bodies to develop health-promoting interventions
and policies. Gillies also emphasises the importance of alliances
between workers in a range of other sectors that impact on health (e.g.
welfare, housing), as well as across lay and professional boundaries,
and between public, private and non-governmental organisations.
Methodology
In reviewing existing accounts of
HIV-prevention programme evaluations, a search was conducted on the
Current Contents and Medline databases to generate a list of published
articles discussing STD and HIV interventions in developing countries
with the specific aim of investigating the evaluation of these
projects. In Current Contents the keywords used were: human health
intervention: peer education; behaviour change; community outreach;
AIDS intervention; HIV intervention; STD intervention; sexual
behaviour; AIDS prevention and AIDS evaluation. For Medline the
keywords were similar but included condom use; evaluation; sexual;
education programme; AIDS; HIV intervention and condom promotion. In
addition, a manual bibliographic search was conducted using the
literature already generated by the electronic search. This manual
search pointed to the existence of a large body of unpublished or
'grey' literature about HIV prevention programmes in developing
countries.[ 1]
Once the 'grey' literature, and literature
regarding similar issues in developed countries had been eliminated, 41
articles remained. These were accessed and carefully read by the first
author, in order to develop an interpretative thematic analysis
focusing on the types of interventions described in these papers as
well as the methodologies used to evaluate them. In relation to the
characteristics of the interventions, information regarding the country
and target group was recorded, as were the various strategies utilised
during the period of intervention. In most cases, a variety of
intervention methods were employed within a single study. In relation
to evaluation, the methodology considered the nature of the evaluation
tools used ('method of evaluation'); the time frame in which the
intervention/evaluation took place; whether the study presented
quantitative and/or qualitative evaluation data: and the results
obtained during the process of evaluation.
Results
Table 1 presents the results of the analysis
of the 41 relevant articles. A descriptive summary of these results
follows after the table.
Country. Within the 41 studies reported on
here, 42 countries were used as intervention sites. The largest
percentage (57%) were in Africa (n = 24). Of these, four each were from
Zaire and Uganda: three each from Kenya, Zimbabwe and Tanzania; and a
single intervention each from Nigeria, Rwanda, Ghana, South Africa,
Malawi, Zambia and Mozambique. A further 18% of the interventions were
from Thailand and India (4 each), and the remainder from a mix of
countries including Honduras, Singapore (2 interventions), Peru, the
Philippines, Indonesia, Nicaragua, Brazil, Mexico and Nepal.
Subjects. The 41 interventions were directed
at a total of 51 different groups. 32% (16) of the subjects were sex
workers, 20% were directed at communities and 20% at young people (10
in each case). The interventions for young people included eight for
school students (only one of which was for primary school children),
one for student teachers and one for youth working in factories in
Thailand. Four interventions were aimed at the clients of commercial
sex workers and three at their madams, pimps or brothel owners. All of
these seven interventions were carried out in conjunction with
interventions aimed at sex workers. In addition, one intervention for
sex workers also had a general community component. Groups targeted
with a single intervention include non-commercial partners of sex
workers, female outpatients and their male partners, STD patients,
prisoners, trucking company workers, homosexual men and pharmacists.
Type of intervention. Only seven studies made
use of only a single intervention methodology but this may be because
they chose not to expand on their intervention methodologies. In one
case no details of the intervention were available (Rusaniko et al.,
1997). The majority of studies used a number of different intervention
methods (Mean = 3.7 per study), with a total of 152 intervention
methods being used across the 41 studies. Seventeen per cent of the
intervention methods related to health education within groups (20) or
directed at individuals (5). Other commonly used interventions included
condom promotion and/or distribution (11%), peer education (7%),
provision of or improvement of STD care (7%), educational videos/films
(7%), distribution of pamphlets (5%), condom demonstrations (5%),
lectures (5%), role plays (5%), educational posters (4%) and use of
mass media (3%). A few innovative interventions were recorded across
the different studies, but were especially concentrated in two
school-based interventions (Klepp et al., 1994; Kuhn, Steinberg &
Mathews, 1994). These include the use of cartoons (n = 2), poster
creation (n = 2), drama (n = 2), collective action (n = 2) and skills
development (n = 1).
Method of evaluation. Within the 41 studies
mentioned here, 42 evaluations were conducted with one study (Ngugi,
Wilson, Sebstad, Plummer & Moses, 1996) evaluating projects in both
Zimbabwe and Kenya. A total of 90 evaluation methods were used within
the studies (Mean = 2.2). The most common form of evaluation (38%)
relied on KAPB questionnaires or surveys (n = 34). The next most
commonly used evaluation method relied on STD test results from the
study populations (11%), and a further 4% used routinely collected
data. Collection of HIV test results, monitoring of unprotected sex
acts through some form of diary and evaluation of acceptability of the
intervention were frequently utilized and made up 10%, 7% and 7% of the
evaluation strategies, respectively. Qualitative evaluation methods
were less common but a small number of studies (7%) used in-depth
interviews and focus groups (n = 4 and n = 2 respectively). One study
used rapid formative assessment and another used participant
observation.
Study design. The evaluations (n = 42) were
almost completely divided between those that used control groups (43%)
and those that did not (53%). Post-testing was used in 83% of the
studies.
Time of post-testing. HIV interventions
frequently take time to implement and changes in behaviour are
therefore monitored over time. Thirty-four studies made use of a
baseline and posttesting design with the mean time lapse between the
two being 14 months. The shortest time lapse between baseline and
posttesting was two weeks while the longest was seven years. Shorter
time lapses between baseline and post-testing tend to be in
interventions directed towards school children due to the limited time
available during school hours.
Type of analysis. Of the 42 evaluations 81%
were entirely quantitative (n = 34). Researchers in only two of the
evaluations concentrated on qualitative evaluation alone while a
further five made use of a combination of both qualitative and
quantitative. In one study the details of the evaluation are unknown.
Discussion
Types of interventions
The interventions in the current review date
from between 1991 and 1998. The subjects of the interventions from
developing countries ranged across a number of target groups. In some
cases entire adult communities were targeted, but in most cases
commercial sex workers formed the target for intervention. A smaller
number of interventions of shorter duration were targeted at
school-going children at both primary and high school level.
The interventions investigated rarely focused
on a single intervention strategy but incorporated a number of
different methods which, in most cases, were utilised simultaneously.
In a few cases, however, the different intervention methods formed the
basis of comparison between multiple intervention groups (see
Nyamuryekung'e et al., 1997; Wilson, Mparadzi & Lavelle, 1992).
Interventions ranged from the purely
biomedical to those with a mix of biomedical and community
participatory approaches. The extent of community participation in
interventions varied, but on the whole the studies investigated
involved some form of participation. Participatory approaches varied
widely and a large range are represented in the highlighted studies.
A number of the studies under review improve
or supply STD treatment by doctors, nurses or other biomedically
trained personnel as part of their intervention strategy. In itself,
the provision of STD care does not encourage community participation
and a number of researchers attempt to remedy this by including
improved STD care in packages which embrace other more participatory
approaches. This supports the trend towards encouraging greater
participation of grassroots community members in the implementation of
sexual health promotion programmes. Thus, in the Cross River State of
Nigeria and in the truck stops of Tanzania the provision of STD care is
combined with peer education and the distribution of condoms
(Nyamuryekung'e et al., 1997; Williams, Lamson, Weir & Lamptey,
1992), while sex workers in Shurugwi, Zimbabwe are encouraged to take
part in a committee to decide on issues concerning HIV/STD transmission
to clients (Chipfakacha, 1993). The use of participatory methods in
combination with STD treatment is not, however, common to all
interventions and there are those which use other non-participatory
methods to enhance the provision of STD care. In these instances most
intervention teams incorporate health education and condom promotion
with STD clinic staff training, provision of a regular supply of drugs
and supervisory visits to clinics (Grosskurth et al., 1995; Jackson et
al., 1997; Laga et al., 1994; Moses, Plummer, Ngugi, Nagelkerke, Anzala
& Ndinya-Achola, 1991). STD care as a single intervention method
was only reported in two studies. One involved the training of Nepalese
pharmacists in syndromic management (Tuldhar, Mills, Acharya, Pradhan,
Pollock & Dallabetta, 1998) and the other initiated the periodic
presumptive treatment of a Ugandan community (Wawer at al., 1998). The
use of participatory methods was, however, more common among other
interventions.
A perusal of the remaining studies reveals
the extent to which HIV and STD interventions have moved towards
participatory methods. The most commonly used methods include group
education and discussion, peer education and the use of role plays.
While traditional didactic intervention methods remain common, it is
vital to recognise that in many cases videos, pamphlets, STD care and
lectures are being used in conjunction with active community
participation and as vehicles for peer education. Interventions aimed
at school children often attempt to completely submerge their subjects
in discussion and thought about HIV by adopting an HIV theme for all
school activities during a certain period of time (Kuhn et al., 1994).
A methodology such as this will usually include both didactic and
participatory methods.
While traditional intervention methods are
well known to intervention teams, participatory methods are still in
their infancy and therefore require innovative thought and formulation.
For this reason no single participatory intervention method was found
in all projects. Rather, a diverse range of methods are employed across
the studies highlighted here. Among students, prisoners and sex workers
attempts have been made to address HIV issues through drama, the
creation and exhibition of educational posters, games and dances
(Aplasca, et al., 1995; Asthana & Oostvogels, 1996; Klepp et al.,
1994; Kuhn et al., 1994; Schopper, Doussentousse, Ayiga, Ezatirale,
Idro & Homsy, 1995; Vaz, Gloyd & Trindade, 1996; Visrutaratna,
Lindan, Sirhorachai & Mandel, 1995; Williams et al., 1992).
Expansion of the audiences reached is also encouraged through the
involvement of sex worker clients, brothel owners, communities and
students' parents through meetings, committees and public events
(Chipfakacha, 1993; Klepp et al., 1994; Kuhn et al., 1994; Schoepf,
1993; Schopper et al., 1995). Participation of this sort encourages
sustainable and self-supporting change at the community level rather
than individual change in a hostile environment.
In recent work there has been recognition of
the importance of the community, social and economic determinants of
HIV. Asthana and Oostvogels (1996) highlight the role of community in
discussing their attempts to introduce community participation among
the economically marginalised and stigmatised sex workers of Madras,
India. Their experience indicates the difficulties, but also the
rewards, inherent in interventions aiming to increase community
participation where historically there has been no sense of
'community'. The eventual demise of the project, despite good condom
distribution, highlights the importance of political, economic and
community level co-operation.
Within Zaire similar work has been conducted
at the community level by making use of experiential training (Schoepf,
1993). This method '... concentrates on self-empowerment, [but] it can
also be used to initiate and sustain other, broader types of socially
transformative change' (Schoepf, 1993, p. 1404). Activities initiated
through role plays, picture 'codes' and ethnographic exercises
encourage women to share their experiences and to develop solutions to
problems communally. This method was particularly effective in allowing
commercial sex workers to gain personal experience of condom use. The
sex workers' knowledge and competence with condoms led to an increase
in their previously low social standing. In advocating participatory
methods as above, Schoepf (1993) stresses the fact that these
activities cannot take place among individuals without taking into
account society's discourses, such as racism, moralism, denial and male
chauvinism in Zaire, which impact on, and contribute to the spread of
HIV.
In short, the majority of interventions used
have sought in one way or another to encourage participation by target
audience members. Participatory methods take various forms ranging from
those in which target audience members simply participate in limited
programme activities (as in Asamoah-Adu, Weir, Pappoe, Kanlisi, Nequaye
& Lamprey, 1994) to more radical forms of participation, where
target audience members are actively involved ill programme planning or
implementation and drive the programme forward in the way best suited
to their community (as in Schoepf, 1993). Given the increasing
confidence that programme designers and funders are giving to the
process of participation, there is an urgent need for better
understanding of what constitutes health-enhancing participation. Not
only would this allow for improved intervention implementation, but
would encourage more rigorous participatory evaluation.
Methods of evaluation
As illustrated above, the progress that has
been made in the design of community-based interventions, and in
particular the trend towards greater participation by and
representation of grassroots target audience members in programme
planning and implementation, has not been matched in the development of
appropriate community-level indicators. Such indicators are needed for
evaluating the psycho-social and environmental processes which
community-level HIV prevention programmes seek to encourage so as to
promote health-enabling environments, that is, environments which
reduce the likelihood of people engaging in unsafe sexual behaviour.
Here we seek to highlight three crucial limitations of existing evaluation methods.
Over-reliance on quantitative methodologies
Existing evaluation strategies give too much
importance to quantitative analysis. Of the 42 different interventions
conducted in the studies under review, quantitative evaluations were
conducted in 34 cases. There were five attempts to conduct both
qualitative and quantitative evaluation within the same study and only
two studies made use of qualitative methods as their main evaluation
measurement.
A strong reliance on KAPB questionnaires is
present in most interventions with the evaluation being statistically
measured by administering questionnaires before and after the
intervention. From the results of these surveys researchers are able to
calculate the percentage increase in condom use (Ford, Wirawan, Fajans,
Meliawam, MacDonald & Thorpe, 1996; Fox, Bailey, Clarke-Martinez,
Coello, Ordonez & Barahona, 1993; Konde-Lule, Tumwesigye &
Lubanga, 1997; Ngugi et al., 1996; Visrutaratna et al., 1995; Williams
et al., 1992); increase in knowledge about HIV transmission; behaviour
change (Aplasca et al., 1995; Archibald, Chan, Wong, Goh & Goh,
1994; Asmoah-Adu, et al., 1994; Jackson et al., 1997; Klepp et al.,
1994; Munodawafa, Marty & Gwede, 1995; Schopper et al., 1995; Vaz
et al., 1996; Wilson et al., 1992; Wynendaele, Bomba, Manga, Bhart
& Fransen, 1995); and changes in perceptions of personal risk
(Pauw, Ferrie, Villegas, Martinez, Gorter & Egger, 1996).
Quantitative methodology is also used through pre-and post-intervention
STD tests with project success being measured by significant declines
in STD prevalence or incidence (Allen et al., 1992; Archibald et al.,
1994; Bhave et al., 1995; Chipfakacha, 1993; Jackson et al., 1997; Laga
et al., 1994; Nymauryekung'e et al., 1997). Evaluation through the
comparison of pre- and post-intervention HIV incidence or prevalence is
also employed (Allen et al., 1992: Grosskurth et al., 1995;
Nymauryekung'e et al., 1997). Modeling and estimations allow
researchers to estimate the number of potential HIV infections
interventions have prevented (Moses et al., 1991; Ngugi et al., 1996).
While quantitative measures are important in providing 'proof' that an
intervention has had the desired impact, they furnish limited or no
understanding of dynamics operating within the project. In addition,
the use of quantitative evaluation methods reinforce our third
limitation, still to be discussed, by focusing evaluation on the
individual rather than developing tools to evaluate the changes at the
community or social level.
Notwithstanding this emphasis on quantitative
methods in the HIV-intervention programmes, a small number of
qualitative evaluation strategies appear in the literature. Unlike more
quantitative methods there is great variety in their formulation and
execution. Those studies that do report qualitative findings are
hampered by their failure to provide a systematic account of the
methods by which their data were collected and analysed. Too often, the
reporting of qualitative data takes the form of anecdotal observations,
or informal thumbnail sketches of authors' personal impressions of
psycho-social or community level factors which they believe had an
impact on the intervention. There is a considerable social scientific
literature on qualitative research methodology, and this needs to be
drawn on more rigorously by intervention evaluators, thereby
encouraging the scientific community to take their findings seriously.
As Asthana and Oostvogels (1996) comment,
there is still a widely held view within the scientific community that
qualitative evaluations lack the rigour of their quantitative
counterparts. Our views on this criticism of qualitative researchers
depend on what criteria one is using for 'rigour'. If one interprets
rigour as the use of systematic methods of data collection and
analysis, we would agree with this criticism but insist that
qualitative research can, and should be done rigorously. However, the
biomedical community who dominate the field of HIV-prevention, often
imply that the only kind of research that is rigorous is research using
quantifiable indicators, analysed by statistical, preferably
parametric, methods. It is our belief that it is premature and possibly
inappropriate to use this criterion of 'scientific rigour' as the gold
standard for judging evaluation strategies in the field of HIV
prevention. A great deal more theoretical and empirical research
remains to be done before our understanding of the determinants of
sexual behaviour and sexual behaviour change can be operationalised in
terms of a few quantitatively measurable, discrete survey variables of
the type which would be amenable to 'rigorous' analysis under this
definition (MacPhail, 1998).
As we argue above, a great deal more
qualitative research remains to be done in the interests of developing
quantifiable indicators of intervention success which move beyond the
theoretically limited variables that are measured in KAPB surveys, for
example. We believe such criteria of rigour might also be inappropriate
because sexuality and sexual behaviour change are such complex,
multi-level (individual, group, community, social) and
context-dependent phenomena that it seems unlikely that they will ever
be adequately accounted for in discrete, generalisable variables of the
kind traditionally privileged by biomedical scientists.
Returning to the literature review,
qualitative evaluation is rarely used alone but rather as a means of
enhancing and interpreting information collected through KAPB
questionnaires. The five studies using this approach generated richer
evaluative information than those that focused on quantitative methods
alone. Among young adults in Sao Paulo, Brazil KAPB questionnaires
established that there was almost no change in high risk behaviour
post-intervention. Workshops held after the intervention ascertained
that societal uncertainties such as unemployment, housing problems and
harsh economic environments were far more pressing concerns for this
group than STDs and HIV. In addition, the group indicated their
inability to afford condoms and the inaccessibility of condom supplies
(Antunes et al., 1997). Similar information was forthcoming from focus
groups held in Ugandan Muslim communities. While informants
acknowledged the need to adopt condoms within sexual relationships,
discussion centered on the fact that low condom use could be blamed on
the suspicion that requesting condom use induced in marriage partners
(Kagimu, Marum, Wabire-Mangen & Hogle, 1998). Comparable problems
articulated in workshops with Zairian married women were solved through
participatory workshops and role plays that allowed women to develop
effective strategies to broach this topic in a manner acceptable to
their husbands (Schoepf, 1993). Among school children qualitative
evaluation, in the form of focus groups and workshops, was used as a
means of establishing the acceptability of methods used, thus leading
to the development of more refined interventions (Caceres, Rosasco,
Mandel & Hearst, 1994; Kuhn et al., 1994).
Qualitative evaluation through participatory
observation allowed Lyttleton (1994) to formulate ideas about the
behavioural and psychological responses of a rural Thai village to a
government AIDS media campaign. While levels of knowledge (indicated
through KAPB survey) were high, translation into behaviour change was
minimal. Lyttleton's observational evaluation highlights arguments for
location specific interventions by indicating factors such as villagers
inability to view 'local injection doctors' as doctors who should
sterilize needles between uses. Perhaps the most successful qualitative
evaluation, and one which uses qualitative evaluation alone, was
undertaken in Zaire among sex workers. Schoepf (1993) conducted
user-focused evaluations in which project staff observed sex workers
teaching methods and material to new groups of subjects. This allowed
the intervention team not only to evaluate uptake of information but
also to establish that participatory methods were firmly entrenched
within the functioning of the project.
The studies highlighted above indicate the
continued focus of intervention evaluations on quantitative methods
despite the rich data that could be unearthed through qualitative
methodologies. While quantitative research methods are important within
the unavoidable reality of a funding culture where programmes are
expected to 'prove' to funders that they have achieved quantifiable
short-term results, we argue that they have less value in relation to
the broader task of understanding the processes by which programmes
have these quantifiable effects (enabling us to learn something about
sexuality and behaviour change in general, rather than simply about the
results of one particular programme), and the extent to which programme
results are likely to be sustainable over time. It is only through
in-depth qualitative studies that we are likely to develop our
understandings of such processes. Qualitative approaches are usually an
essential component of process evaluation strategies, the topic of the
next section. Relative neglect of 'process evaluation' strategies
In developing their account of what should be
the appropriate focus of process analyses, Aggleton et al. (1992)
indicate that communication between the project staff and target
communities should be the major form of assessment of the processes
underlying why a project did or did not succeed. Campbell and Williams
(1998), however, disagree arguing that this definition is too narrow
and requires further expansion. Such expansion might include attention
to, for example, the extent to which target audiences identify with the
project; the organisational context of the project; the relationships
between the project and other organisations; the national policy
context in which the project operates; the extent to which the project
engenders the transformation of sexual norms and identities on a
societal level; and the extent to which adequate resources are
available for meeting project goals within their definition of process
evaluation.
The interventions described in our literature
of interest show a clear bias in favour of outcome evaluation
strategies. The use of pre- and post-test methodologies enable
researchers to quantify the uptake of knowledge and changes in STD
prevalence through comparisons between test scores at the start of
programmes and the final scores once programmes have been completed.
From this type of evaluation one is able to deduce that changes in
target communities have been achieved; explanations for the reasons
behind these changes are seldom given. Exceptions here include the
efforts that have been made to obtain a clearer understanding of the
processes leading to the observed outcomes in studies of interventions
involving school children (Caceres et al., 1994; Kuhn et al., 1994;
Munodawafa et al., 1995). In these evaluations students engaged in the
intervention as well as teachers or facilitators were asked to evaluate
the actual intervention. Comments received in this way were then
utilised in planning further interventions and refining techniques. The
same approach has also been adopted among sex workers in Ghana
(Asamoah-Adu et al., 1994).
While the four studies mentioned above have
attempted to incorporate some form of process evaluation in their
design, the most sophisticated forms of process evaluation can be seen
in the work of Schoepf (1993) and Asthana and Oostvogels (1996). The
work of Schoepf among the women of Zaire has been mentioned previously
as an example of an intervention making use of both participatory
intervention methods and qualitative evaluation. In terms of process
evaluation, Schoepf offers important explanations for the reasons
behind changes in the use of condoms. During much of the study there
was a reported increase in the number of protected sex acts. Schoepf
begins to explore some of the psycho-social issues highlighted by
Campbell and Williams (1998) when she attributes this to two major
factors. In the first instance the project enabled married women to
learn means of encouraging their husbands to use condoms as
contraceptives rather than prophylaxis through discussion about the
high costs of education and the need to limit family size. in the
second case, increased condom use could not be fully attributed to the
programme but rather to the deaths from AIDS of two sex workers within
the network. Sex workers within the project were appreciative that they
had learned the value of condoms before the sudden increase in condom
use that followed these deaths. At eight months post-intervention sex
workers engaged in the project reported a decline in the number of
protected sex acts. An interview with Jonathan Kolodney in Paris-Match
had been erroneously interpreted by students in Kinshasa as indicating
the uselessness of condoms for combating HIV infection. Viewed as an
educated elite and valued client-base the students were one of the few
sources of AIDS information the sex workers had. Differences in social
standing and economic dependence therefore encouraged the sex workers
to believe what the students had told them.
The intervention aimed at empowering sex
workers in Madras provides one of the richest sources of process
evaluation despite the authors themselves stating that evaluation fell
by the wayside in favour of intervention (Asthana & Oostvogels,
1996). The eventual demise of the intervention was due to a number of
seemingly minor issues which combined to overwhelm the efforts of the
project staff and sex worker community. The initial part of the
intervention had been planned and implemented through an external WHO
consultant; once control was handed to a local NGO, their lack of
political leverage and practical experience in running interventions
caused many of the project objectives to flounder. Continued harassment
from police in Madras finally culminated in a crackdown forcing all
brothels in the intervention area to either close or relocate.
Significant relationships on which much of the intervention was based
were consequently lost. However, the nature and organisation of sex
work within the various communities had the most consequential impact
on the intervention. Initial enthusiasm among the sex worker peer
educators could not be maintained once the initial 'scare' factor of
AIDS had worn off. Many found it increasingly hard to maintain their
enthusiasm for peer education when they lost clients (and money) due to
the time the intervention took and the fact that the message they
spread was a threat to the perceived self-interests of their clients.
Power structures within Madras society were also perceived to have a
negative impact on the project in a number of ways. Firstly, educated
clients were often not prepared to listen to brokers' safe sex messages
as they felt themselves to be socially superior. Secondly, the
development of community organization was difficult among sex workers
who lived in isolated communities and maintained their subservient
relationships with their brothel-owners and brokers in the face of
vulnerability to police and clients.
In keeping with their commitment to
explaining some of the processes underlying the outcomes of
interventions, Asthana and Oostvogels (1996) make a number of useful
comments about the organisational context of the Madras project thus
highlighting issues raised by Gillies (1998) and Campbell and Williams
(1998) referred to in the introductory section;
-- National policy as a favourable context in
which to conduct local health work. The authors evaluate their
intervention in the light of the changing attitudes to HIV/AIDS being
felt within the Indian government. The National AIDS Prevention and
Control Programme (NAPCP) has moved from a focus on surveillance of
'high-risk groups' towards educational and support-based AIDS messages.
A part of this changed attitude has been the encouragement of alliances
with non-governmental organisations (NGO) and grassroots mobilisation.
The NAPCP realisation that too little was known about sex workers in
India led to the development of relationships with the World Health
Organisation.
-- Communication between programme and target
audience. The intervention team was aware of the problems facing them
in attempting to create a sense of community in a diverse and disparate
group of sex workers. To this end an open office policy with
interaction between project staff and sex workers was promoted. Through
communication and the provision of a meeting place the project fostered
some sense of community among the different groups.
-- Relationships between the project and
other organisations. This aspect of process evaluation has already been
touched on in examining the role that the local Madras police played in
the intervention. Despite changes in the official government attitude
towards HIV risk groups such as sex workers, police continue to
penalize sex workers under the Suppression of Immoral Traffic Act. The
strained relationship between sex workers and police was evaluated as
one of the factors involved in the loss of important alliances. --
Organisational context of project. Evaluation of the changing role of
the project highlights the change in organisation which took place
during 1993 when responsibility was handed over to a local NGO without
the necessary experience and political affiliations to adequately
promote the project.
From the examples provided above by Schoepf
(1993) and Asthana and Oostvogels (1996) the benefits of process
evaluation become clear. Through outcome evaluation the intervention in
India would have been termed a failure and the data would have
suggested that few of the intervention objectives had been met. Process
evaluation, however, highlights the particular circumstances of the
intervention and makes it possible to develop an understanding of the
factors acting for and against the intervention objectives. This is
done in a way that can be generalised to an understanding of other
programmes in other contexts. It is only through a detailed account of
obstacles facing the interventions of this sort that lessons can be
learned for future projects.
Over-reliance on the individual level of analysis
The conceptual tools that are used are often
ones that favour the individual level of analysis. HIV/STD
interventions have adopted methods which seek to impact not only on the
individual but also on the community which acts on and influences the
individual. From the analysis of the evaluation content of these
interventions it is clear that researchers have yet to find a way which
effectively evaluates the contribution of interventions to community
and social processes. Evaluations are all concentrated at the
individual level of analysis and while they do provide indications of
the extent to which interventions have succeeded in achieving their
stated aims, they fail to explain the deeper processes promoted within
the intervention community.
In most studies (34 studies) evaluation is
achieved by exploring knowledge, beliefs, attitudes and practices
through administering individual questionnaires to selected groups.
Other evaluative methods include individual STD and HIV tests and
recording of numbers of unprotected sex acts (25 studies). As we have
already stated, in the few studies that do try and incorporate
attention to broader social factors beyond the biomedical and
behavioural levels of analysis, such qualitative material is often
presented in the form of anecdotes or of fairly unsystematic personal
observations by authors of papers, rather than in a rigorous way, using
well-defined concepts and indicators. Indeed, Antunes et al. (1997)
bemoan the fact that there are no evaluative measures of the community
processes promoted by intervention programmes. In their Brazilian
intervention they indicate that the sexual decision-making of
adolescents cannot be separated from their reproductive choices and
socially determined sexual roles they engage with. Changes in these
aspects have been felt but their measurement or evaluation remain
problematic.
Conclusion
In this paper we have reviewed the published
literature which deals with the evaluation of HIV-prevention programmes
in developing countries. Our review suggests that such programmes often
seek to encourage community-level processes such as participation,
representation and empowerment. However, this 'paradigm drift' (Beeker
et al., 1998) away from purely biomedical and behavioural approaches
towards attempts to create health-enabling community contexts, is often
not reflected in evaluation methodologies.
In the literature we reviewed evaluation
methodologies were mostly quantitative, outcomes orientated and
concerned with the individual level of analysis. Few of the studies
examined here made rigorous use of qualitative evaluation, indicating
the problems facing researchers in their efforts to firstly, collect
such information and secondly, to present it in an acceptable way to
the scientific community. Evaluation concentrated primarily on the
individual level of analysis through the use of largely biomedical
outcomes measures such as HIV or STD rates and the changes observed in
KAPB questionnaires. While some of the interventions attempted to
encourage change at the community and social level, the representation
of these changes through evaluation remains problematic.
One reason for this very narrow approach to
evaluation is a funding culture which pressurises programme organisers
to provide evidence of 'quick fix' changes, measured in discrete
quantifiable terms that will appeal to the biomedical fraternity who
often dominate the field of HIV-prevention. Another reason for this is
that we currently lack adequate conceptual understandings of the
mechanisms or pathways whereby community development processes (such as
participation, representation or 'community partnerships for health')
serve to mediate between intervention activities and health outcomes
(Campbell & Mzaidume, 1999).
in the introductory section we highlighted
three areas of research in which hypotheses regarding psycho-social and
community-level factors which might serve to promote programme success
have been sought. Campbell and Williams (1998) argue that programmes
are likely to succeed to the extent that they promote psycho-social
changes, including increased self-efficacy among target audience
members, as well as providing opportunities for the collective
re-negotiation of social and sexual identities. Kreuter (1998) states
that the intervention-community interface is an important determinant
of programme success, suggesting that a key determinant of success is
the extent to which communities have a range of formal and informal
networks and resources that are broadly supportive of what the
programme is trying to achieve. They also emphasise that community
members should trust and identify with the programme. Gillies (1998)
highlights the importance of the intervention being linked into a
network of similar interventions, as well as the importance of
alliances between grassroots interventions and representatives of
broader provincial and national programmes and policies in the public,
private and voluntary spheres. None of these hypotheses are currently
adequately operationalisable in concrete quantifiable indicators, which
could be used to evaluate programme success or failure, in a way that
moves beyond the narrow biomedical and behavioural outcome measures
which currently dominate programme evaluation.
We argue that rigorously conducted and
systematically documented qualitative process evaluations of concrete
interventions could make a key contribution to our understanding of
these psycho-social, organisational and community level processes --
and as such could make a key contribution to not only the development
of the science/art of programme evaluation, but also to the development
of more successful HIV-prevention interventions.
Acknowledgements
Thanks to Brian Williams of the CSIR,
coordinator of the evaluation of the Mothusimpilo HIV-prevention
Project, for his comments on the manuscript, as well as for his more
general input into the authors' early discussions of the paper.
Note
1.
Campbell and Williams (1996) call for the development of a resource
centre to house the unpublished literature on HIV prevention in South
Africa. Such a centre is currently being established by the AIDS
Consortium in Johannesburg. Aidscons@global.co.za
Table 1 Analysis of the published literature on HIV/AIDS intervention programmes in developing countries
Legend for Chart:
A - Date
B - Country
C - Subjects
D - Type of intervention
E - Method of evaluation
F - Time of post testing
G - Analysis
H - Results
A B
C
D
E
F
G
H
1991[2] Kenya
Sex workers
Free primary health care (mainly STD); individual
and group health education; encourage clients to
use condoms; condom distribution.
Questionnaire completed frequently; estimates of
impact on HIV through modeling; numbers of
condoms handed out; numbers of STDs compared to
another area.
No post-testing but questionnaire every 6 months
Quantitative
Decreased rates of gonorrhoea not matched in
other area; estimated 50% condom use.
1992[3] Nigeria
Sex workers, clients and non-commercial partners
Peer education; condom promotion; STD clinic;
educational videos; leaflet distribution.
Baseline survey and follow up KAPB; record of
condoms distributed and individuals reached.
1 year
Quantitative
Increased STD clinic use; increased use and
belief in protection methods.
1992[4] Rwanda
Female outpatients and male partners
Videos; HIV testing and counseling; free condoms
and spermicides; focus group discussions.
Baseline and follow up KAPB; HIV and gonorrhoea
testing; diaries of sex acts to determine
protection used.
1 year
Quantitative
Increased condom use; most effective in couples
where male also tested and counseled; decrease in
gonorrhoea among HIV infected women; decrease in
seroconversion of women with counseled partners.
1992[5] Zimbabwe
Student teachers
Lecture; question session; condom demonstration;
role plays; psychodrama; video about well known
PWA.
Pre- and post-test with two different
intervention groups; KAPB; number of partners;
measurement of sex without condoms
4 months
Quantitative
Skills trained students had increased knowledge
about condoms; higher self efficacy; fewer
barriers to action, sexual partners and sexual
acts without condoms.
1993[6] Zimbabwe
Sex workers
Committee formed; cards issued to healthy sex
workers; sex workers with HIV or STDs prevented
from working; monthly examinations for STDs; STD
lectures.
Looked at STD rates at a local clinic.
No post-testing but evaluation continued for
6 months.
Quantitative
Decreased number of STD patients at mine
hospitals; vaginal discharges decreased.
1993[7] Zaire
Community
Small group dynamics; role plays; case studies;
condom demonstrations; adjusted AIDS message for
individuals; work shops.
User-focused evaluation; meeting held to see
what changes were being maintained.
No post-testing but user-focused evaluation at
3, 8 and approximately 36 months.
Qualitative
Sex workers easily influenced by those they
perceive to have more knowledge.
1993[8] Honduras
Sex workers
Weekly talks on STDs and HIV; free condom
distribution.
Pre- and post-intervention KAP survey; condom
diaries.
4 months
Quantitative
Increased knowledge about HIV transmission;
little increase in safe sex; increased condom
use among some.
1994[9] Singapore
Brothel based sex workers
3 hour intervention session with educational
lectures; video presentations; role playing.
Pre- and post-test case-control study; KAPB and
gonorrhoea rates.
3 months
Quantitative
Misconceptions about HIV transmission declined;
negotiated condom use barely changed but there
was already high condom use.
1994[10] Thailand
Sex workers and clients
Free condom distribution; identification of
brothels without 100% condom use; mass
advertising.
Ongoing STD monitoring; evaluation of numbers
of clients; numbers using condoms; statistics
on number of sex establishments.
No post-testing but evaluation continued for
4 years.
Quantitative
Increased condom use in commercial sex acts;
steep decline in reported STDs among men; large
decline in 5 most common STDs; new cases of STDs
declined by half.
1994[11] Ghana
Sex workers
Peer education; role plays; condom distribution.
Pre- and post-test KAPB and measurement of impact
of contact with project staff.
Final evaluation at 51 months but also at 4 and
7 months.
Quantitative
Increased condom use even after 3 years;
maintained contact with project staff despite
project stopping.
1994[12] Peru
Secondary school students
Educational sessions within school hours by
trained teachers.
Pre- and post-test case-control study; KAPB;
intervention evaluated with questionnaire.
7 weeks
Quantitative and qualitative
Machismo and discrimination against PWA
decreased; increased knowledge about and
acceptance of condoms.
1994[13] Tanzania
Primary school students
Factual information; poster creation; performing
songs and poetry; peer leaders; group
discussions; role plays; panel discussions with
community and meetings with parents.
Pre- and post-test case-control; KAPB.
6 months
Quantitative
Increased frequency of exposure to AIDS
Information and more AIDS related discussions;
increased knowledge; positive attitudes to PWA;
restricted attitudes towards engaging in sex.
1994[14] Thailand
Rural community
Mass media intervention by central government.
Questionnaires on changes in sexual behaviour and
places where people get AIDS information.
Participant observation.
No post-testing but questionnaires administered
at 3 months. Entire study over 7 months.
Quantitative and qualitative
Uncertainty about modes of transmission; most
common modes of transmission understood;
knowldege from medical profession, TV and
headman; some reluctance to use sex workers; no
or little condom use.
1994[15] South Africa
Students
Structured information sessions; open
discussions; role-plays; games; group work;
language exercises with AIDS theme; videos;
poster creation and exhibition; slogan
competition; graffiti wall; stickers; condom
distribution; leaflets.
Pre- and post-test case-control; KAPB; student
evaluation of intervention.
2 weeks
Quantitative and qualitative
Increased knowledge and improved attitudes
towards PWA; insignificant move towards changing
personal behaviour; low belief in self risk;
positive attitudes about intervention.
1994[16] Zaire
Sex workers
Monthly interviews and STD diagnosis; 3 monthly
HIV screening; free STD treatment among HIV
negative women; individual health education; free
condoms.
Condom use and numbers of clients evaluated in
monthly interviews; intervention exposure
estimated from attendance at appointments; STD
and HIV tests performed.
Women followed for an average of 23 months with
testing every 3 months.
No post testing.
Quantitative
Increased condom use; decrease in STDs except
chlamydia; decline in HIV conversion rates;
increased STD clinic use if having unprotected
sex.
1994[17] India
Sex workers
Group discussions; counseling of madams, pimps,
sex workers and nochis; posters; pamphlets and
Hindi video; peer education.
Pre- and post-intervention KAPB surveys with HIV
testing.
2 years after baseline.
Quantitative
Increased awareness of HIV; increased condom use.
1995[18] India
Sex workers and madams
Group discussions; educational videos; condom
demonstrations.
Pre- and post-test case-control with HIV, Hep B
and syphilis testing; questionnaire on
demographics, clients, STDs and KAPB.
1 year.
Quantitative
More condoms used; sex workers more likely to
refuse clients without condoms; greater
understanding of STDs and HIV, especially
transmission.
1995[19] Malawi
STD patients
Trained counselors discussed the seriousness of
STDs; condom demonstrations.
Pre- and post-test case-control study; risk
behaviour; STD occurrence and behaviour.
4 months.
Quantitative
Greater knowledge of STDs; increased condom use;
reduction in number of partners.
1995[20] Uganda
Adult rural community
Condom distribution; AIDS pamphlets; meetings at
village level.
Pre-and post-intervention KAPB questionnaire;
investigated how well intervention had reached
community.
18 months
Quantitative
Improved knowledge; decrease in men's casual
partners; increased condom use in casual sex;
decreased STDs; increased condom use and less
discrimination.
1995[21] Thailand
Sex workers, clients and brothel owners.
Peer educators; educational lectures; condom
demonstrations; games and small group training
sessions.
Volunteer clients requested sex without condoms
and offered to pay 3 times the usual price at
baseline and 2 follow ups.
2 months and 1 year.
Quantitative
93% refusal of sex without a condom; maintained
at 76% a year after the intervention.
1995[22] Philippines
High school students
Role playing; condom promotion; games; didactic
lectures; group discussions; exercises; focus
groups.
Pre- and post-test case-control KAPB. Actual
intervention also evaluated by external review
committee.
2 weeks and 8 weeks.
Quantitative
Increased knowledge; positive attitudes to PWA;
thought sex should wait until adulthood; no
changes in actual or intended behaviour.
1995[23] Tanzania
Community
STD syndromic management; staff training;
supervisory visits; regular supply of drugs;
group health education.
Pre- and post-test case-control questionnaire on
sexual practices; testing for HIV, syphilis,
gonorrhoea and chlamydia.
2 years
Quantitative
HIV incidence and STD prevalence lower in
intervention villages; no changes in sexual
behaviour; acceptance and use of condoms remained
low.
1995[24] Zimbabwe
Students
No information given except that education was
provided by student nurses in a structured
manner. 14 classes. Presume group education.
Pre- and post-test case-control knowledge
questionnaire on AIDS, STDs and alcohol and drug
abuse. Also questionnaire on performance of
student nurses.
7 weeks
Quantitative
Increase in knowledge about AIDS, STDs and drugs
and alcohol. Ratings by teachers and pupils
showed the acceptability of student nurses as
health educators.
1996[25] Indonesia
Sex workers, clients and pimps
Interactive lectures; informal advice and condom
distribution; formal training sessions; client
media in brothels (posters and pamphlets).
Pre- and post-test case-control with sex workers
and clients; KAPB.
6 months
Quantitative
Increased knowledge in al areas but particularly
intervention areas; decreased misinformation
about transmission of HIV; increased condom use.
1996[26] Nicaragua
Adult community
Informal presentation; condom demonstration;
stickers; posters; free condoms; HIV leaflets.
Pre- and post-test case-control KAPB.
14 months
Quantitative
Less fear of AIDS but no increased idea of
personal risk.
1996[27] India
Sex workers and general community
Peer educators; condom and information
distribution; co-operation with people connected
to the industry; posters; pamphlets; meetings;
dances and films.
Attempt to make full and effective use of
community participation; used simulated clients;
some qualitative interviews.
No post-testing and very little formal
evaluation.
Qualitative
Project became more concerned with implementation
rather than evaluation; peer recruitment not
maintained and decline in community
participation.
1996[28] Zambia
Community
Radio drama broadcast in local language.
Pre- and post-intervention KAPB survey with
case-control. Control group selected from area
unlikely to have heard drama.
14 months
Quantitative
No proof that small increases in HIV knowledge
ware due to drama. Did increase parent-child
discussion of HIV.
1996[29] Kenya and Zimbabwe
Sex workers
Peer education and improved STD management in
Kenya.
Pre- and post-intervention surveys with
consideration of STD rates in Kenya. Rapid
formative assessment initially and then
in-depth interviews in Zimbabwe. Also questioned
on programme exposure.
Kenya was 1 year and Zimbabwe 2 years.
Quantitative
Kenya had increased condom use, price per sex act
and reduction in number of partners. Zimbabwe had
increased condom use and a decline in STDs among
the general population.
1996[30] Mozambique
Prisoners
Pamphlets and cartoons about HIV and STDs; peer
education; theatre group.
Pre- and post-intervention KAPB surveys
6 months
Quantitative
Improved knowledge about true transmission of HIV
although false transmission methods still
believed.
1996[31] India
Students
School-based education programme.
Pre- and post-test with questionnaire on
transmission and prevention of HIV/AIDS.
1 month
Quantitative
Increase in correct knowledge about transmission
of HIV, potential cure for HIV and that HIV is
transmitted sexually.
1997[32] Kenya
Trucking company workers
HIV serological testing; individual counseling;
condom promotion; STD diagnosis and management.
Baseline with regular follow-up interviews and
STD and HIV testing.
Every 3 months for a year.
Quantitative
Significant decline in extramarital sex and sex
with a CSW; no change in condom use; decrease in
ulcerative and non-ulcerative STDs.
1997[33] Tanzania
Women at truck stops (sex workers)
Already had peer education and condom
distribution in place, now provided improved
STD treatment. Comparison of 4 different methods.
Pre- and post-intervention questionnaire on
demographics and acceptance of STD services. 3 case
groups and one control group.
12 months
Quantitative
There was acceptability of all methods of STD
treatment. No information on changes in STD or HIV
rates.
1997[34] Uganda
Community
Government intervention - posters; condom
distribution; availability of information
through a number of mass media sources.
Baseline survey with a number of follow-up
surveys using KAPB. HIV testing at one early
survey.
7 years
Quantitative
Increased support for condoms but still little
use; decrease in number of sexual partners;
decreased STD incidence.
1997[35] Brazil
Students
Group discussions; training for teachers; peer
support; public events; condom demonstrations;
role plays.
Baseline surveys using KAPB at case and control
schools. Follow-up questionnaires at end of
intervention.
Follow-up at 6 months and 1 year. Results from 6
months due to loss to follow-up.
Quantitative and qualitative
Positive perception of the programme; Only women
had significant changes in increased
communication about sex/AIDS after the
intervention.
1997[36] Mexico
Homosexual men
Intervention designed by participants to empower
community by enhancing collective action, skills
development and resource creation.
KAPB survey. No control group and not known if
pre- and post-testing completed.
Unknown
Quantitative and qualitative
Improvement in HIV-related behaviour and
knowledge.
1997[37] Zimbabwe
Students
Unknown (presumed to be group education)
Pre- and post-test case-control KAPB
questionnaires.
9 months but with testing also at 5 months
Quantitative
Increased knowledge on menstruation, family
planning, contraception, STDs and HIV.
1998[38] Uganda
Muslim community
Education provided by imams and family AIDS
workers to increase HIV knowledge and condom
use; to encourage support from the community
towards those infected.
Pre- and post-intervention questionnaires as well
as focus groups and in-depth interviews.
2 years
Quantitative and qualitative
Increase in correct knowledge of HIV
transmission, methods of preventing HIV infection
and the risks involved in circumcision and
ablution of the dead; reduction in sexual
partners and increased condom use.
1998[39] Thailand
Youth in factories
Education through videos, cartoons and other
unknown methods.
Pre- and post-test case-control study with KAPB
questionnaire, in-depth interviews and focus groups
Unknown
Unknown
Higher levels of knowledge among the workers
receiving the intervention
1998[40] Nepal
Pharmacists
Syndromic management training
Pre- and post-intervention interviews using
simulated patients
2 groups: 1 evaluated immediately, the
other 7-9 months after training.
Quantitative
Decline in pharmacists suggesting rejections;
increase in correct drug prescriptions; increase
in partner notification and suggested condom
use but not sale of condom or HIV testing.
1998[41] Singapore
Sex workers
Development of negotiation skills, educating
clients and mobilizing support from peers and
health staff for condom use
Pre- and post-test case-control study using KAPB
and gonorrhoea testing.
At 5 months, 1 year and 2 years.
Quantitative
Increase in refusals of unprotected sex and a
decline in gonorrhea incidence.
1998[42] Uganda
Community
Single oral dose of STD treatment; HIV prevention
education and counseling; condoms and free health
care.
Randomized controlled trail with baseline and
post-testing using KAPB, HIV and STD testing.
Testing and interviewing every 10 months but
unknown date of final evaluation.
Quantitative
Decrease in syphilis, chlamydia, gonorrhoea and
BV in intervention group. No difference in HIV
incidence rates.
- 2 Moses, S., Plummer, F.A., Ngugi, E.N.,
Nagelkerke, N.J.D., Anzala, A.O. & Ndinya-Achola, J.O. (1991)
Controlling HIV in Africa: effectiveness and cost of an intervention in
a high-frequency STD transmitter core group. AIDS, 5, 407-411.
- 3 Williams, E., Lamson, N., Weir, S. & Lamptey,
P. (1992) Implementation of an AIDS prevention program among
prostitutes in the Cross River State of Nigeria. AIDS, 6, 229-242.
- 4 Allen, S., Serufilira, A., Bogaerts, J., Van de
Perre, P., Nsengumuremyi, F., Lindan, C., Carael, M., Wolf, W., Coates,
T. & Hulley, S. (1992) Confidential HIV testing and condom
promotion in Africa. Journal of the American Medical Association, 268,
3338-3343.
- 5 Wilson, D., Mparadzi, A. & Lavelle, S. (1992)
An experimental comparison of two AIDS prevention interventions among
young Zimbabweans. The Journal of Social Psychology, 132, 415-417.
- 6 Chipfakacha, V. (1993) Prevention of sexually
transmitted diseases: the Shurugwi sex-workers project. South African
Medical Journal, 83, 40-41.
- 7 Shoepf, B.G. (1993) AIDS action-research with women in Kinshasa, Zaire. Social Science and Medicine, 37,1401-1413.
- 8 Fox, L., Bailey, P.E., Clarke-Martinez, K.L.,
Coello, M., Ordonez, F.N. & Barahona, F. (1993) Condom use among
high-risk women in Honduras: evaluation of an AIDS prevention program.
AIDS Education and Intervention, 5, 1-10.
- 9 Archibald, CP. Chan, RKW. Wong, ML. Goh, A. and
Goh, CL. (1994) Evaluation of a safe-sex intervention programme among
sex workers in Singapore. International Journal of STDs and AIDS, 5,
268-272.
- 10 Hanenberg, R.S., Rojanapithayakorn, W., Kunasol,
P. & Sokal, D.C (1994) Impact of Thailand's HIV-control programme
as indicated by the decline of sexually transmitted diseases. The
Lancet, 344, 243-245.
- 11 Asamoah-Adu, A., Weir, S., Pappoe, M., Kanlisi,
N., Nequaye, A. & Lamptey, P. (1994) Evaluation of a targeted AIDS
prevention intervention to increase condom use among prostitutes in
Ghana. AIDS, 8, 239-246.
- 12 Caceres, C.F., Rosasco, A.M., Mandel, J.S. &
Hearst, N. (1994) Evaluating a school-based intervention for STD/AIDS
prevention in Peru. Journal of Adolescent Health, 15,582-591.
- 13 Klepp, K., Ndeki, S.S., Seha, A.M., Hannan, P.,
Lyimo, B.A., Msuya, M.H., Irema, M.N. & Schreiner, A. (1994) AIDS
education for primary school children in Tanzania: an evaluation study.
AIDS, 8, 1157-1162.
- 14 Lyttleton, C. (1994) Knowledge and meaning: the
AIDS education campaign in rural northeast Thailand. Social Science and
Medicine, 38( 1), 135-146.
- 15 Kuhn, L., Steinberg, M. & Mathews, C. (1994)
Participation of the school community in AIDS education: an evaluation
of a high school programme in South Africa. AIDS Care, 6, 161-171
- 16 Laga, M., Alary, M., Nzila, N., Manoka, A.T.,
Tuliza, M., Behets, F., Goeman, J., St Louis, M. & Piot, P. (1994)
Condom promotion, sexually transmitted diseases treatment, and
declining incidence of HIV-1 infection in female Zairian sex workers.
The Lancet, 344, 246-248.
- 17 Singh, Y.N. & Malaviya, A.N. (1994)
Experience of HIV prevention interventions among female sex workers in
Delhi, India. International Journal of STDs and AIDS, 5, 56-57.
- 18 Bhave, G., Lindan, C.P., Hudes, E.S., Desai, S.,
Wagle, U., Tripathi, S.P. & Mandel, J.S. (1995) Impact of an
intervention on HIV, sexually transmitted diseases, and condom use
among sex workers in Bombay, India. AIDS, 9 (suppl 1), s21-s30.
- 19 Wynendaele, B., Bomba, W., Manga, W.M., Bhart,
S. & Fransen, L. (1995) Impact of counselling on safer sex and STD
occurrence among STD patients in Malawi, International Journal of STDs
and AIDS 6: 105-109.
- 20 Schopper, D., Doussentousse, S., Ayiga, N.,
Ezatirale, G., Idro, W.J. & Homsy, J. (1995) Village-based AIDS
prevention in a rural district in Uganda. Health Policy and Planning,
10, 171-180.
- 21 Visrutaratna, S., Lindan, C.P., Sirhorachai, A.
& Mandel, JS. 1995. 'Superstar' and 'model brothel': developing and
evaluating a condom promotion program for sex establishments in Chiang
Mai, Thailand. AIDS, 9 (supp 1), s69-s75.
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Santana-Arciaga, R.T., Paul, J., Hudes, E.S., Monzon, O.T. &
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ka-Gina, G., Newell, J., Mugeye, K., Mabey, D. & Hayes, R. (1995)
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- 24 Munodawafa, D., Marty, P.J. & Gwede, C.
(1995) Effectiveness of health instruction provided by student nurses
in rural secondary schools of Zimbabwe: a feasibility study.
International Journal of Nursing Studies, 32, 27-38.
- 25 Ford, K., Wirawan, D.N., Fajans, P., Meliawan,
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- 27 Asthana, S. & Oostvogels, R. (1996)
Community participation in HIV prevention: problems and prospects for
community-based strategies among female sex workers in Madras. Social
Science and Medicine, 43, 133-148.
- 28 Yoder, P.S., Hornik, R. & Chirwa, B.C.
(1996) Evaluating the program effects of a radio drama about AIDS in
Zambia. Studies in Family Planning, 27, 188-203.
- 29 Ngugi, E.N., Wilson, D., Sebstad, J., Plummer,
F.A. & Moses, S. (1996) Focused peer-mediated educational program
among female sex workers to reduce sexually transmitted disease and
Human Immunodeficiency Virus transmission in Kenya and Zimbabwe. The
Journal of Infectious Diseases, 174 (suppl 2), s240-s247.
- 30 Vaz, R.G., Gloyd, S. & Trindade, R. (1996)
The effects of peer education on STD and AIDS knowledge among prisoners
in Mozambique. International Journal of STDs and AIDS, 7, 51-54.
- 31 Sankaranarayan, S., Naik, E., Reddy, P.S.,
Gurunani, G., Ganesh, K., Gandewar, K., Singh, K.P. & Vermund, S.H.
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Bombay, India. Southeast Asian Journal of Tropical Medicine and Public
Health, 27(4), 692-695.
- 32 Jackson, D.J., Rakwar, J.P., Richardson, B.A.,
Mandaliya, K., Chohan, B.H., Bwayo, J.J., Ndinya-Achola, J.O., Martin,
H.L., Moses, S. & Kreiss, J.K. (1997) Decreased incidence of
sexually transmitted diseases among trucking company workers in Kenya:
results of a beahvioural risk-reduction programme. AIDS, 11, 903-909.
- 33 Nyamuryekung'e, K., Laukamm-Josten, U.,
Vuylsteke, B., Mbuya, C., Hamelmann, C., Outwater, A., Steen, R.,
Ocheng, D., Msauka, A. & Datlebetta, G. (1997) STD services for
women at truck stops in Tanzania: evaluation of acceptable approaches.
East African Medical Journal, 74(6), 343-347.
- 34 Konde-Lule, J.K., Tumwesigye, M.N. &
Lubanga, R.G.N. (1997) Trends in attitudes and behaviour relevant to
AIDS in Ugandan community. East African Medical Journal, 74(7),
406-410.
- 35 Antunes, M.C., Stall, R.D., Paiva, V., Peres,
C.A., Paul, J., Hudes, M & Hearst, N. (1997) Evaluating an AIDS
sexual risk reduction program for young adults in public night schools
in Sao Paulo, Brazil. AIDS 11 (suppl 1): s121-s127.
- 36 Zimmerman, M.A., Ramirez-Valles, J., Suarez, E.,
de la Rosa, G. & Castro, M.A. (1997) An HIV/AIDS prevention project
for Mexican homosexual men: an empowerment approach. Health Education
and Behaviour, 24(2), 177-190.
- 37 Rusaniko, S., Mbizvo, M.T., Kasule, J., Gupta,
V., Kinoti, S.N., Mpanju-Shumbushu, W., Sebina-Zziwa, J., Mwateba, R.
& Padayachy, J. (1997) Trends in reproductive health knowledge
following a health education intervention among adolescents in
Zimbabwe. Central African Journal of Medicine, 43( 1), 1-6.
- 36 Kagimu, M., Marum, E., Wabire-Mangen, F.,
Nakyanjo, N. & Hogle, J. (1998) Evaluation of the effectiveness of
AIDS health education interventions in the Muslim community in Uganda.
AIDS Education and Prevention, 10(3), 215-228.
- 39 Sakondhavat, C., Sittitrai, W., Soontharapa, S.,
Werawatanakul, Y. & Pinitsoontorn, P. (1998) AIDS education and
intervention trials among youths in factories: a pilot project. Journal
of the Medical Association of Thailand, 81 (11), 872-878.
- 40 Tuladhar, S.M., Mills, S., Acharya, S., Pradhan,
M., Pollock, J. & Dallabetta, G. (1998) The role of pharmacists in
HIV/STD prevention: evaluation of an STD syndromic management
intervention in Nepal. AIDS, 12(suppl 2), s81-s87.
- 41 Wong, M.L., Chan, K.W. & Koh, D. (1998) A
sustainable behavioural intervention to increase condom use and reduce
gonorrhea among sex workers in Singapore: 2-year follow-up.
Preventative Medicine, 27(6), 891-900.
- 42 Wawer, M.J., Gray, R.H., Sewankambo, N.K.,
Serwadda, D., Paxton, L., Berkley, S., McNairn, D., Wabwire-Mangen, F.,
Li, C., Nalugods, F., Kiwanuka, N., Lutalo, T., Brookmeyer, R., Kelly,
R. & Quinn, T.C. (1998) A randomized, community trial of intensive
sexually transmitted disease control for AIDS prevention, Rakai,
Uganda. AIDS, 12(10), 1211-1225.
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~~~~~~~~ By Catherine MacPhail, CSIR
Mining Technology, P.O. Box 91230, Auckland Park 2006, South Africa
(E-mail: cmacphai@csir.co.za) and Catherine Campbell, Department of
Social Psychology, London School of Economics, Houghton Street, London
WC2A 2AE, Britain (E-mail: c.campbell@lse.ac.uk)
|