Disappointing results from two peer education projects in southern Africa

Two large HIV prevention programmes that recruited people to educate their friends and classmates have both failed to make an impact on sexual behaviour, researchers report in two separate articles published online ahead of print in AIDS and Behavior.

A peer education programme for 15 and 16 year old school students in South Africa did not have any effect on students’ age of sexual debut or their use of condoms. In Zimbabwe, a programme which trained male customers of beer halls to act as peer educators with their friends did not have an effect on how often men used condoms or how many sexual partners they had.

Whereas there are signs that there were problems with the implementation of the schools programme, the beer hall intervention appears to have been well-delivered. Nonetheless the programme seems to have been unable to make an impact in a context of deep-rooted social problems and tensions.

Peer education programmes recruit and train individuals who are asked to share information about HIV with people of a similar age, status or social group. Rather than relying on professionals who may have a different social background, peer education is based on the assumption that peers trust each other, learn from each other and influence each other (particularly in relation to the sensitive issue of sexual behaviour).

Peer education activities can be delivered through structured activities (for example, in the Zimbabwean beer halls, presentations to groups of customers) or informally during the course of everyday activities (the beer hall educators were also encouraged to watch out for their friends).

Some governments and donors may value peer education partly because it is perceived to be a relatively cheap way of delivering HIV prevention to large numbers of people.

Indeed, peer education is a widely used approach in HIV prevention initiatives, especially with young people in resource-limited settings. However very few programmes have been rigorously evaluated and when evaluation has been carried out, the results have been mixed. Some programmes have had a beneficial impact on knowledge and attitudes, but less often on sexual behaviour and rates of infection.

In South Africa, the government funded a number of non-governmental organisations and faith-based organisations to deliver a peer education programme to students in grade 10 (15-16 year olds).

The programme, known as ‘Rutanang’ (“learning from each other” in Sotho), provided considerable amounts of training to its peer educators, but this was not based on a clear theoretical framework. The peer educators conducted sessions during ‘life orientation’ classes (following a standard curriculum), had impromptu conversations with fellow students and referred students to other sources of support.

The primary aims of the programme were for students to delay the age at which they began having sex, and for those who had already started to have sex to increase their use of condoms.

It may be that social factors are so influential that an individualized health education program cannot hope to make changes.

In order to evaluate it, researchers from the University of Cape Town and the South African Medical Research Council compared 15 schools that received the intervention with 15 other schools that continued to receive standard life orientation classes. However the Education department had already decided which schools most needed the programme and so the allocation of schools to the intervention and comparison groups was not randomised. While efforts were made to identify comparison schools that were well matched, some differences remained: intervention schools had more students who were black, poor and not living with both parents.

Overall, there were slightly more girls than boys, just under half the pupils were black, half the students’ mothers had not completed high school and around a third did not have sufficient income for food and clothes.

Just under 4,000 students completed an anonymised self-completion questionnaire before the beginning of the intervention in 2007. Eighteen months later, the same students were asked to fill out another questionnaire. Unfortunately four in ten students were not able to do so as they had left school or were absent on the days the researchers visited. (Moreover, those who dropped out had higher rates of sexual risk at baseline than the average).

The survey results were disappointing, with no evidence of the programme having met its objectives. In all surveys, around seven in ten sexually active students had used a condom on the last occasion – the figures did not vary between intervention and comparison schools, or before and after the intervention. In each survey, the average age of first having sex was fifteen years or just under.

As the surveys were conducted 18 months apart around the time that many were losing their virginity, it’s not surprising that the proportion that had never had sex was lower after the intervention than it was before. But this was especially the case in the schools that had peer education, even after adjusting for known differences between the groups.

The programme had hoped to make an impact by affecting students’ attitudes and skills in relation to the future, goals and decision-making. But the evaluation found no evidence of any changes in relation to these.

The innovative project in Zimbabwe was an attempt to develop an intervention that would engage with heterosexual men as active agents in HIV prevention. Beer halls often play a key role in the social life of working class Zimbabwean men (few of the customers are female) and are seen as venues in which male bonding, alcohol consumption and sexual risk taking are intertwined.

Seeing beer halls as a key site for HIV prevention activities with men, the researchers designed the ‘Sahwira’ peer education programme. It centred on the Zimbabwean cultural concept of the sahwira, a particularly close and trusted friend. The intervention promoted the idea that men can and should take responsibility for their friends’ well-being by helping each other avoid high risk sexual encounters.

Beer halls are venues in which male bonding, alcohol consumption and sexual risk taking are intertwined.

Peer educators were recruited as pairs of good friends who regularly attended the beer hall together and who wished to take part. Although the training to be a peer educator was time-consuming (three days initial training plus refresher courses) and there was no financial compensation, there was strong interest in becoming a peer educator, with some men having to be turned away.

The programme was based on the information-motivation-behavioural skills model. Moreover, the researchers used the diffusion of innovation theory to calculate the number of peer educators required (just over 400) in order to spread information to clientele of the twelve beer halls that received the intervention.

To evaluate the programme, 24 beer halls were randomised to receive either the peer education intervention or just condom supplies and advertisements. There were no significant differences between the customers of intervention and comparison beer halls.

In order to avoid the risk that customers of the comparison beer halls had also participated in intervention activities at another beer hall, the venues selected were all in residential neighbourhoods, away from large markets and transport hubs, with a mostly local clientele.

Surveys of beer hall customers were conducted before and after the fifteen month intervention. In contrast to the South African study, the men responding to the second survey were not necessarily the same individuals who had completed the first.

Customers’ average age was 30, around two-thirds were educated to O-level or higher (an exam typically taken at age 16) and over half were married.

In the second survey, customers at the intervention beer halls were aware of the project activities: 60% knew that others had been trained as a peer educator, 38% had seen a condom demonstration, 28% had seen an HIV prevention video, 27% had seen an educational presentation, 13% had attended a quiz show. Very few customers of comparison beer halls had come across these activities.

But the activities only seemed to have a minimal impact on the customers’ personal interactions around HIV and sexual risk. Whereas 77% of customers at the intervention beer halls said they had helped a friend avoid HIV risk, 72% of comparison group customers had done so. The difference is statistically significant, but remains slight. On some other measures, such as having a one-to-one discussion about risk behaviour, there was no difference between the two groups.

Moreover there was no effect on actual sexual behaviour. The primary outcome the researchers were looking for was a reduction in the number of times men had recently had unprotected sex with someone apart from their wife – but the average was five occasions in both groups. Similarly, there was no difference in the number of sexual partners, whether men had had sex when drunk, whether men had been faithful to their wives or in HIV testing rates.

While there was some evidence of a reduction in risk behaviour between the two surveys, this was the case in both the intervention and comparison beer halls.

The researchers evaluating the South African schools programme note that there were problems with the implementation of the programme. Whereas the effectiveness of peer education is probably dependent on the quality of recruitment methods, training and supervision, as well as the involvement and co-operation of teachers, parents, community and other stakeholders, the authors suggest that this is often difficult to achieve in resource-limited settings.

Specifically in the Western Cape, the non-governmental organisations training the peer educators were poorly coordinated and had different approaches based on their own belief systems. Some faith-based organisations were uncomfortable with open discussion of sex and condoms, preferring to concentrate on abstinence.

The careful examination of unsuccessful interventions is an important part of the process to improve HIV prevention.

On the other hand, the negative results from the Zimbabwean beer halls seem less likely to be due to poor implementation. The programme was based on health promotion theory and was delivered as planned, with beer hall customers both being receptive to the programme and remembering its activities.

Nonetheless, given the social and economic upheaval of Zimbabwe during the study period (2005-6), the researchers question “whether the intervention ever created sufficient intensity to produce measurable effects”. This was a period of hyperinflation, food shortages and a government “clean-up campaign” which involved the demolition of informal housing, shops and markets in the Harare neighbourhoods under study.

Similarly the researchers in South Africa comment: “It may be that social factors are so influential that an individualized health education program cannot hope to make changes”. They suggest that more effective programmes may need to involve the wider community and tackle wider social issues, such as poverty and gendered power relations.

The evaluators of the Zimbabwe programme comment that the careful examination of unsuccessful interventions is an important, but difficult part of the process to improve HIV prevention.

“Our negative findings do not mean that such peer interventions cannot work but that we have not yet found the means of harnessing male bonding in ways that significantly reduce HIV-related risk behaviors,” they say. “In our view, it remains an imperative to productively engage men in AIDS prevention broadly and, more specifically, to intervene in those processes where male bonding, alcohol consumption, and sexual risk behavior are intertwined.”

The South African researchers also believe that community-wide interventions which include schools are needed.

Mason-Jones AJ et al. Can Peer Education Make a Difference? Evaluation of a South African Adolescent Peer Education Program to Promote Sexual and Reproductive Health. AIDS & Behavior, published online ahead of print, 2011. Click here for the free abstract.

Fritz K et al. Evaluation of a Peer Network-Based Sexual Risk Reduction Intervention for Men in Beer Halls in Zimbabwe: Results from a Randomized Controlled Trial. AIDS & Behavior, published online ahead of print, 2011. Click here for the free full text article.