Review and Evaluation of the Steppingstones Participatory HIV Education Project in Zimbabwe

A REVIEW AND EVALUATION

OF THE

STEPPING STONES

PARTICIPATORY HIV EDUCATION PROJECT

RUN BY LOCAL NGO TSUNGIRIRAI,

IN

MHONDORO NORTH, ZIMBABWE

MARCH – JULY 2000

Mike Kesby, Caroline Maposhere, Irene Moyo,

Irene Tavengwa, Themba Mhlanga,

Unpublished report:

School of Geography, University of St Andrews, KY16 9AL, Fife, Scotland, UK

February 2002

LIST OF CONTENTS

1.  RESEARCH TEAM:

2.  INTRODUCTION:

2.1  Background to the study:

2.2 Research aims:

2.3 Background: the original Tsungirirai run Stepping Stones program:

2.3.1  Location:

2.3.2  Pre-intervention study:

2.3.3  Training of community facilitators: Implementation in the community:

2.3.4  Reported impacts:

3. RESEARCH DESIGN: of the independent evaluation August 2001

3.1  Sample:

3.1.1  Sample frame, selection and recruitment

3.1.1.1  Facilitators –

3.1.1.2  Participants –

3.1.1.3  Non-participants living in the same community –

3.1.1.4  Control group –

3.1.1.5  Elders –

3.1.1.6  Clinic staff

3.1.1.7  Commercial sex workers:

3.1.1.8  Tabulated Summary of Sample:

3.2  Techniques and methodology:

3.2.1  General approach:

Methodology/process through which research was conducted:

3.2.2  Techniques/tools:

4.  RESULTS:

4.1  Knowledge Attitudes and Practices (KAP questionnaire)

4.1.1 Younger women

4.1.2  Older women – a mixed group; both Stepping Stones participants and non-participants

4.1.3 Younger men

4.1.4 Older men

4.1.5 The control group: Men

4.1.6 The control group: Women

4.2 Results 2: Group diagramming/focus group interviews

4.2.1 Venn diagram – Information on HIV and AIDS

4.2.1.1 The control group

4.2.2 Venn diagram - Membership of community organisations and alternative delivery of Stepping Stones

4.2.2.1  The control group

4.2.3  Pie charts - Attendance and

Focus groups - Peer groups

4.2.4 Wheelbarrow diagram - Things that made Stepping Stones go well

4.2.5 Focus group - Likes and dislikes about Stepping stones

4.2.6 Flow diagram and focus groups - peer groups

4.2.7 Wheelbarrow diagram - Things that made the work of Stepping Stones continue

4.2.8 Flow diagram – contexts for sex

4.2.8.1  The control group

4.2.9 Tree diagram - Strategies to avoid risk

4.2.9.1  The control group

4.2.10 Focus group - Hoped for change and community requests

4.2.11 Flow diagram - positive changes due to Stepping Stones

4.2.12 Stepping Stones diagram – Future sexual health

4.2.13 Focus group - Final comments from focus group participants

4.3  Results 3: individual semi-structured interviews

4.3.1 Perceptions of Stepping Stones among participants

4.3.2 Knowledge of the Stepping Stones program among non-participants with non-participating relatives

4.3.3 Knowledge of the Stepping Stones program among non-participants with participating relatives

4.3.4  Reported changes in behaviour among Stepping Stones participants

4.3.5 Impacts of Stepping Stones reported by non-participants

4.3.6 Treatment of those with AIDS

4.3.7 Condoms - Lack of availability

4.3.8 Condom - use/lack of use

4.3.9 The situation among younger people

4.3.10 Activity in and around the bottle stores

4.3.11 Behaviour among Commercial sex workers

4.3.12 Reported instances of rape, sexual abuse, child abuse.

4.3.13  Logistical/organisational problems with the Stepping Stones program

5.  DISCUSSION AND CONCLUSIONS:

5.1  The success of the evaluation program

5.2 Strengths and weaknesses in program implementation

5.2.1 Acceptance and perceptions of the program:

5.2.2  The benefits and dis-benefits of the key role played by facilitators:

5.2.3 The problem of attendance:

5.2.4 The unfortunate consequences of split training venues:

5.2.5 The failure to sustain peer group activities beyond the lifetime of the program:

5.2.6 Failure to engage with the wider, non-participation community:

5.2.7  The failure to follow up the program:

5.3 Impacts of the Stepping Stones program

5.3.1 Positive impacts were observable:

5.3.2 Improvements in Knowledge:

5.3.3. Improvements in attitudes:

5.3.4 Improvements in practice;

5.3.4.1 Improvements in partner communication

5.3.4.2 Improvements in communication between parents and children:

5.3.4.3 A reduction in multiple partnering and the sale and purchase of sex

5.3.4.4.  Greatly improved treatment of those with AIDS

5.4 Areas where Stepping Stones has failed to have the desired impact

5.4.1 Continuation of potentially risky traditional practices:

5.4.2 Failure to adopt condom use:

5.4.2.1. Lack of access to condoms:

5.4.2.2. Knowledge and acceptance of condom in principal but not practice:

5.4.2.3. Failure to transfer all the messages of the program to the younger generation:

5.4.3  Summary:

6.  RECOMMENDATIONS

6.1  Participants and facilitators recommendations:

6.1  Evaluation team’s recommendations:

6.2.1  The need for a reliable supply of condoms:

6.2.2  HIV testing:

6.2.3  The need to engage peer croups in a single community:

6.2.4  Targeted recruitment.

6.2.5  Engagement with local leaders.

6.2.6  Engagement with the youth:

6.2.7  Joint peer group meetings:

6.2.8  Attendance:

6.2.9  The sustainability of peer group activities:

6.2.10  End of program community meeting and program sustainability:

6.2.11  The need for follow up projects and follow-on programs:

6.2.12  The need for a rolling rather discrete program:

6.2.13  Capacity building and facilitating sustainability:

7. ACKNOWLEDGEMENTS

8.  REFERENCE LIST

9.  APPENDXIES

Appendix 1 Techniques and Methodology

Appendix 2 Ballot style, Knowledge, Attitudes and Practices (KAP) questionnaire:

Appendix 3 The version of the ballot utilised by respondents

Appendix 4 Semi structure interview questions

Appendix 5 Interview schedule used when interviewing facilitators

1. RESEARCH TEAM:

1.1  Team leaders:

Dr Mike Kesby, School of Geography university of St Andrews, Fife, Scotland.

Caroline Maposhere, Independent consultant, Harare, Zimbabwe.

Irene Moyo, Independent consultant, Harare, Zimbabwe.

1.2 Research Assistants:

Irene Tavengwa, Harare Zimbabwe.

Themba Mhlanga, Harare Zimbabwe.

Elton Chidoni, Harare Zimbabwe.

2. INTRODUCTION:

2.2  Background to the study:

The study that took place in Mhondoro North between 20-31 August and on 9 October 2001 was part of a broader program to access the impacts and effectiveness of the “Stepping Stones” participatory HIV learning and action project. While the Stepping Stones approach has been utilised in a number of communities across the continent of Africa, Mhondoro North is one of only three sites in Zimbabwe[1] where the program has been run in its entirety. Impetus to undertake the review arose from several sources: (1) Dr Kesby is an independent academic researcher interested in the effectiveness of participatory approaches to HIV work in southern Africa. He invited Caroline Maposhere to work with him on the project. (2) Action Aid is the NGO responsible for developing Stepping Stones approach. Their Africa office in Harare was interested to undertake an evaluation of the program as practiced in Zimbabwe and they contracted, Irene Moyo to work with Kesby and Maposhere on a study of the three sites. (3) Tsungirirai entered a partnership with Action Aid in 2000 when they accepted a grant to undertake a Stepping Stones training program in one of their areas of operation. Subsequently they were interested to cooperate with the research team in an evaluation of the program in Mhondoro North. Funding for the Mhondoro North evaluation came primarily from a research grant awarded to Dr Kesby by The British Academy, but was supplemented by resources from Action Aid and by Tsungirirai’s provision of accommodation and access to a vehicle and driver.

2.2 Research aims:

2.2.1  Understand the conditions under which the program had been run

2.2.2  Ascertain the attitudes and experiences of the grassroots program facilitators

2.2.3  Ascertain the attitudes of community leaders towards the program

2.2.4  Evaluate the impacts of the program on the attitudes, knowledge and practices of participants

2.2.5  Evaluate the impacts of the program on non-participants in the same community

2.2.6  Compare the attitudes, knowledge and practices of those directly or indirectly exposed to the program, with those of people in a neighbouring but “unexposed” community

2.2.7  Identify the sustainability of the intervention beyond the limits of the formal program.

2.3 Background: the original, Tsungirirai run, Stepping Stones program:

The intervention, which the research team set out to evaluate, had taken place a full year previously. Below is a summary of the report on the intervention produced by Justin Mucheri (2001) who coordinated the project for Tsungirirai:

2.3.5  Location: The intervention, which was intended as a pilot, took place in Chivero area of Mhondoro North beginning in March 2000. This is the area of the communal land closest to Norton where Tsungirirai is based. The intervention had three phases; (i) a baseline survey, (ii) a program of training for those who would facilitate the program in the community and (iii) the grassroots intervention itself.

2.3.6  Pre-intervention study: A brief survey was conducted to gauge attitudes and perceptions among the target population that would provide something of a baseline survey against which the intervention might later be judged. Fifteen semi-structured interviews and four focus group discussions were conducted between 7 and 11 March 2000. Informants included the Chief and kraal heads, school heads, teachers, nurses, village health workers, traditional healers, business people, political leaders, the police as well as village youth, women and men. No formal set of study results exist but the general findings are presented below;

Issues articulated /

Perceived causes

Increasing illness and death / People are succumbing to HIV infection.
Collapse in the customary system of sex education but parents uncomfortable talking to their own children / Tetes and Sekurus no longer performing traditional roles of educating and counselling youth on sexual and reproductive health issues.
(L.A.M.A)
Legal Age of Majority Act / Perceived by the elders as the main cause of traditional system collapse.
Increasing crime including rape / Youth unemployment.
High drop out rates from school. Grandparents cannot afford high school fees / An increase in the number of orphans
Sugar Daddies.
Teenage pregnancies / Poverty is forcing some young girls to exchange sex for money with older males.
Unemployment / No self-help projects especially for youth
Parents not being role models / Parents are no-longer leading by example in the way they live (no dialogue on moral issues).
No spouse communication / Cultural beliefs prevent communication about sexual issues.
Poverty, especially among households headed by the elderly or orphans
Condoms / Perceived by most elders as the main cause of promiscuity (attitudes).

Respondents did not report Gender/domestic violence but members of the research team suspected it existed. Participatory diagramming methods were also used with the focus groups. They identified; (i) Men primarily control household decision-making, (ii) women have longer working days than men and undertake more tasks, (iii) men tend to take leadership roles in HIV/AIDS initiatives (such as home based care) but women undertake most of the work. Finally, the survey revealed that while people in the area had already been exposed to a number of HIV initiatives, the impacts of these initiatives were not immediately obvious. Nevertheless, respondents to the survey displayed a realisation that the problem of HIV must be addressed and a willingness to support and be involved in the Stepping Stones program as a means to achieve this. In conducting their pre-intervention study, the survey team experienced delays and problems due to other work commitments, rains and poor roads, parliamentary elections, fuel shortages, poor communications and too short notice being given to respondents (many of these were to affect the intervention itself and the final two also proved problematic our independent evaluation team).

2.3.7  Training of community facilitators: A weeklong program was conducted in Norton in March 2000 and trained seventeen men and women (roughly a 50:50 division) to be facilitators. Eight were from the Chivero area and were to work on the initial intervention (the others worked for HIV/AIDS groups in Norton). They had previously been elected to fulfil this role at a community meeting in the area. Two younger women, two younger men, two older women and two older men were trained with the intension that they would facilitate peer groups divided along similar age/sex lines. Those taking part were trained in both single sex groups and whole group sessions using similar techniques to those they would themselves use in the field as community facilitators. They were instructed in the Stepping Stones method, communication skills and the qualities of good facilitation. Because the training venue had power the facilitators-in-training were able to use the video supplied with the Stepping Stones training package, and they found it very useful and stimulating. It is worth commenting that participants felt that abstinence and faithfulness to one partner were preferable to the use of condoms. Through drama presentations, the women highlighted the problem of ‘sugar daddies’: older men who seduce economically disadvantaged girls and young women, while men depicted traditional healers sexually exploiting female patients. Participants also identified ‘Chiramu’ (a man having sex with his wife’s sister) as a traditional practice that would increase HIV risk. Furthermore, they suggested that young people were engaging in alcohol use and sex activity at an early age. Finally it should be noted that the facilitators-in-training engaged in several full group workshop sessions at which debate was extremely animated and engaged in a final session in which “special requests to the community” were made. Significantly female participants requested that women should be treated as equals and not as under men. Participants requested and were given certification of their training. The program of training was somewhat curtailed to fit the 5 day residential format. Those training to be facilitators were enthusiastic and hardworking and gave evaluations of the training program that were extremely positive. However, it is again worth noting that only two of the facilitators-in-training were able to attend the entire workshop. Nevertheless, further training to strengthen the community facilitators’ skills followed the Norton workshop and took place in the Chivero Community Hall.

2.3.8  Implementation in the community: A community meeting was held to notify people about the project, seek their approval and identify those willing to volunteer to participate in the extensive Stepping Stones program. Two venues for training were established. The younger peer groups met at the community hall (next to Chivero Clinic near the Mauto Business Centre), while the older peer group met under tree near Mupfumira Business Centre (these sites were some four kilometres apart). Each peer group planned to meet twice a week in an attempt to (i) reduce the total length of the program (ii) facilitate the attendance of women who feared husbands would object to too extended a commitment (iii) and maintain the motivation of the trained but unpaid facilitators. Approximately eighty people in total attended all or part of the program however average attendance for each peer group were as follows: (i) Older men; sixteen, (ii) older women; seventeen, (iii) younger men; eleven, (iv) younger women; eight. Attendance at each peer group session fluctuated markedly and the progress of the program was frequently interrupted by participants’ need to attend funerals (particularly women and older men). The youth peer groups had to delay their training in order to allow the older peer groups to catch up before full workshops could commence. While facilitators were not able to use the video, due to lack of a power source, they followed the Stepping Stones manual closely. The report on the implementation seems to suggest that sixteen training sessions and two full community sessions were undertaken.