Recommendations for policy in the Western Cape Province regarding the prevention of Major Infectious Diseases including hiv/AI

Peer Educators in Schools:

A key element of the response of the Western Cape Health and Education Departments to the HIV/AIDS epidemic has been the school-based HIV/AIDS peer education programmes. Although the Western Cape has had a curriculum-based awareness and lifeskills programme operational in schools, it is likely that HIV prevalence among 15 – 19 year olds continues to rise. With a view to scaling up prevention activities for school-going youth, the Departments of Health and Education have contracted 15 locally based NGOs with experience in the field to implement a standardised peer education programme in schools. The programme had been rolled out to 135 high schools in the province by 2006, and approximately 5300 peer educators had been selected and trained and were in these schools in 2006. The programme’s aim is to delay sexual debut, decrease partners, increase condom use and encourage abstinence and to encourage early sexual health seeking behaviour (as appropriate). The programme is funded from the Global Fund Grant awarded to the Western Cape Department of Health.
Reviews of school-based AIDS prevention programmes in sub-Saharan African concluded that the quality of the evaluations is generally low, which makes it difficult to draw confident conclusions about the efficacy of the programmes. Notwithstanding this, there is some evidence that the better-designed evaluations demonstrated programme effects. Specifically, the interventions revealed the expected effects on knowledge, attitudes and communication about sexuality. Some programmes also had an effect on behaviour. The evidence from the developed world is derived from intervention methodologies of higher quality. There is consensus that school-based interventions can be effective in reducing the extent of unsafe sexual behaviours as manifest by condom use, sexual frequency outcomes, communication with sexual partners, and objectively measured condom use and negotiation skills.

A large amount of research reveals the strong and consistent influence of social norms on adolescent sexual behaviour. Douglas Kirby, an expert in the adolescent health in the U.S., proposed that a simple conceptual framework concerning social norms and connectedness to those expressing the norms can be used to explain some of effects of the disparate adolescent sexual risk reduction interventions. Specifically, if a group has clear norms for (or against) sex or contraceptive use, then adolescents associated with this group will be more (or less) likely to have sex and use contraceptives. Kirby recommends giving greater consideration to norms, connectedness and their interaction in research and in the development of programmes to reduce adolescent sexual risk-taking. This can be done by mobilizing friends and “opinion leaders” to take a positive public stance on sexual risk-taking. Opinion leaders are visible, popular and well-liked members of selected (pro- and anti-) social networks, strategically selected for popularity, community respect and influence. They influence social norms among their peers through informal social contacts. Opinion leader interventions are based on the diffusion of innovations theoretical model.

A “popular opinion leader” intervention has been shown to be effective at reducing sexual risk behaviour among adults in the US. A seminal series of studies was conducted by Kelly and colleagues, culminating in a randomized controlled trial among adult gay bar patrons in eight small American cities demonstrating that reliably-selected popular opinion leaders, trained to promote risk-reduction to their peers, were effective in achieving community-wide reductions in self-reported sexual risk behaviourI (Kelly et al. 2005)ⁱ. In summary, the research base provides grounds to believe that the peer education intervention has been rolled out in Western Cape schools might be effective. Furthermore, it may be more likely to be effective if an opinion leader approach is followed, as opposed to more a traditional peer education approach.

The process evaluation of the Western Cape school-based peer education programme, conducted by the Adolescent Health Research Institute in 2005 identified that the school environment of the peer education intervention was crucial in either facilitating or frustrating peer education. An important consideration for South Africa is the extent to which peer education programmes will be embedded in broader school development programmes to improve school functioning and school climate, as opposed to functioning as a discrete programme.

The Western Cape schools based PEP will run alongside related initiatives (curriculum based lifeskills, adolescent friendly clinic initiative and numerous local NGO youth projects). The appearance of notions of building “social and human capital” in the provincial government lexicon pinpoints the important advance in the thinking within government when tackling complex social ills such as the spread of HIV infection. Simply put, strengthening the fabric of the school environment constitutes an essential prerequisite for reducing adolescent sexual risk taking in a context of multiple exposures feeding the spread of HIV, including substance and alcohol abuse, gender inequality, gansterism, teenage pregnancy and sexual abuse. It would be a considerable achievement for the Departments of Health and Education to contribute to the understanding and implementation of effective peer educational interventions in complex settings.

It is essential that the Western Cape peer education programme is subject to process and outcome evaluations. The evaluation should be comprehensive, and address at least the following three aspects:

1. 
   input (the total resources required for the intervention);
   
2. 
   process (the quality of the implementation of the intervention); and
   
3. 
   outcome (the effectiveness of the intervention). In assessing the outcome, it is important to answer the question of why the intervention was effective as this will inform the ongoing development and refinement of the proposed peer education intervention, and also of course inform new interventions. In answering this question, it is crucial to include the social and cultural context of the schools, for example school climate. The Departments of Health and Education have demonstrated their commitment to evaluation by commissioning the Adolescent Health Research Institute to conduct such evaluation.
   

Implementation strategy:

1. 
   Expand existing peer education programmes to more secondary schools;
   
2. 
   Formally evaluate the peer education programmes in 2008
   

4.