Abstract
This article describes the influence of a peer education programme on skills development among 22 women participating in HIV prevention trials. Interviews were used to collect data on peer educator experiences and their opinions of the trainings. The training enhanced their agency and confidence to engage their family and community on health promotion, including HIV prevention research procedures, thus improving their self-esteem and communication skills. Training and partnering with clinical trial participants as peer educators is an effective and sustainable community-based approach for HIV prevention.
Introduction
The social and economic burden of HIV/AIDS impacts women and increases their vulnerability to the acquisition of diseases, especially in South Africa (O’Hara Murdock et al., 2003). Therefore, it is imperative to educate women and community members about the causes, magnitude and effects of health disparities that affect them and to develop sustainable partnerships to improve health (Horowitz et al., 2004). These health promotion and education programmes must be context specific and tailored to suit the needs of the community.
One such programme is peer education, which is utilised worldwide, as a strategy for preventing HIV and sexually transmitted infections (STIs) (Lambert et al., 2013). This intervention targets individuals, with similar demographic characteristics or risk behaviours, and trains them to increase awareness, impart knowledge and encourage behaviour change among community members. Peer education can be delivered formally or informally during daily interactions (Shoemaker et al., 1998; Simoni et al., 2011), and activities includes advocacy, counselling, distributing materials, making referrals to services and providing support (UNAIDS, 1999).
A systematic review of peer education interventions for HIV prevention, highlighted recruitment, selection, training, supervision, compensation and retention of peer educators as key implementation processes that impact on effectiveness (Medley et al., 2009). A recent study reported that peer educators were empowered to manage their sexual and reproductive health, and that they were a sustainable resource in the community (Naidoo et al., 2013). However, there is limited data on the impact of peer education training programmes on the skills development of peer educators who are clinical trial participants.
The HIV Prevention Research Unit (HPRU) of the South African Medical Research Council (SAMRC) conducted several vaginal microbicide clinical trials in Durban (Ramjee et al., 2010). In 2005, the first group of trial participants were trained as peer educators within a HIV prevention diaphragm trial (Padian et al., 2007). They provided support and education to enrolled women and contributed to the recruitment and retention outcomes of the trial (Naidoo et al., 2013). The peer education programme was expanded at six research sites, and peer educators assisted with recruitment, retention and trial results messaging and dissemination (Ramjee et al., 2010). This study explored peer educators experiences and its effect on their skills development as community-based women living in a patriarchal community. Their empowerment and agency to promote HIV prevention awareness in the community is also highlighted.
Methodology
The study consent forms, in-depth interview (IDI) and round table discussion guides were approved by the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal (Ref.E053/05).
From 2005 to 2009, 53 trial participants from six semi-rural and urban clinical research sites volunteered to be trained as peer educators. They were participants in a vaginal diaphragm and microbicide trials (Ramjee et al., 2010), and they shared similar demographic characteristics (gender, age, ethnicity, language and education), living conditions and community setting.
As described elsewhere, the eligibility criteria for the recruitment and selection of peer educators included women who had a good understanding of HIV and the trial procedures, attended their scheduled study visits and were willing to share their trial experiences (Naidoo et al., 2013; Ramjee et al., 2010). Following discussions of the roles and responsibilities of peer educators, verbal consent was obtained and women were trained as peer educators. Their activities included health promotion, HIV prevention education, assisting with recruitment and retention and addressing research related rumours among trial participants and community members (Naidoo et al., 2013).
After the initial 5-day training workshop held in 2005, which focused on HIV/STI transmission, testing and condom use (Naidoo et al., 2013), they participated in annual and quarterly workshops. Information sessions were conducted on female condom use, modes of HIV transmission, referral for care, access to antiretroviral (ARV) and types of clinical trials. They were trained on co-enrolment processes (Harichund et al., 2013) which prevented women from screening and enrolling in more than one investigational drug trial at the same time.
Interviewers telephonically contacted 53 peer educators to participate in IDIs and the annual training workshops, where the round table discussions were held. A total of 25 women were disinterested or unavailable to continue to be peer educators as they were either inactive or seeking employment. In all, 28 peer educators attended the annual training workshops in 2009 (n = 12), 2010 (n = 15) and 2011 (n = 16), where the round table discussions were conducted. Some of the women participated in more than one round table discussion.
IDIs were conducted with 22 peer educators between June and December 2009. In all, 6 of the 22 peer educators did not take part in the round table discussions. Data were collected by two trained interviewers and the workshop trainers, who were not part of the clinical trial research team, thus minimising bias. All women consented to the IDIs being audio-recorded. The round table discussions were not audio-recorded due to logistical reasons.
The IDIs and round table discussions explored similar issues. Responses were categorised into four domains which included demographics, opinions of the training, and their experiences and skills development as peer educators. Data were independently analysed using thematic analysis.
Results
Demographics of peer educators
The 22 peer educators were between 28 and 50 years old, and majority (72%) of them were unemployed. Over 70 per cent of the women were unmarried, with long-term partners. Most (n = 16) were from semi-rural areas, with a few (n = 6) residing in urban areas. Since joining the peer programme, several peer educators (20%) had taken on voluntary work as community health care workers within the public health clinics and day-care centres. Two peer educators received a financial stipend as independent volunteers. The training and skills development sessions contributed to their retention in the peer programme, even after their trial participation ended. Over 60 per cent of the women have been peer educators for over 4 years even though most of them were unemployed and had limited access to resources.
Impact of training on peer educators activities
The benefits from the training programme enabled peer educators to conduct education, outreach and information sessions within the community and with other trial participants.
Of the 22 peer educators, 18 (81%) had shared HIV and health promotion information with their peers, 15 (68%) provided education, 18 (81%) conducted outreach sessions independent of the researchers, 16 (73%) responded to community needs and 15 (68%) promoted safe sex practices.
They used the written material provided by the researchers as a reference tool during these education sessions on condom use, benefits of HIV testing, access to ARVs and procedures in clinical trials. A few peer educators conducted outreach sessions with commuters while travelling in the train, while others focused their education sessions among their friends and community members. This highlights their willingness and confidence to increase awareness of HIV prevention and treatment in their community:
As a peer educator, researchers helped in being able to connect us with the community and be able to work for the community. They gave us help, they trained us in such a way - we were good but their education made it possible for us to face the community. We were also able to address questions to the public without having to refer to a member of the MRC. They gave us gifts (fact sheets, written material) to read through at home so if someone asks you what HIV is, you’re able to explain it if you see the material. (Peer educator for 7 years, Botha’s Hill, semi-rural site)
Peer educators’ participated in the messaging of trial results and they explained the negative outcomes of the HIV prevention microbicide trials. They became agents of HIV prevention and the research projects being conducted within their communities.
Some of the peer educators (20%) counselled their peers on adherence to medication, use of HIV prevention methods and provided information about nutrition to people living with HIV/AIDS:
In my time I just love helping people, it’s what I’ve always done. I love it. I have courses that I do but it helped me in that I am able to help sick people. Not only sick people, but also if a woman has a problem and she doesn’t want me to counsel her on how we were taught in training, then I just advise her. So I’ve learnt to handle matters accordingly and not be hard headed and I have reduced my anger. (Peer educator for 6 years, Verulam, semi-rural site)
They shared their own experiences of HIV testing within the trial and volunteered to accompany people to HIV testing centres:
It played a role because most people didn’t know what their status was. Even myself, I didn’t have the courage to check myself but during my time as trial participant I would check my HIV. As a peer educator if someone is too scared to check HIV status, I am able to say I’ll come along with them. I now know the importance of checking for HIV. (Peer educator for 6 years, Verulam, semi-rural site)
Personal growth and skills development of peer educators
The acquisition of new knowledge improved their confidence and self-esteem as they were able to effectively communicate about condom use, reproductive health, research and HIV with their partners, family and friends even though this was not the norm in the community:
It [experience of being a peer] helped me with my family to be able to face and talk to my family even my boyfriend, the father of my kids [giggles] to be able to talk to him tell him we should use condoms at all times. They [MRC] encouraged us and gave us good condoms so mine [boyfriend] wasn’t educated about condoms but because MRC taught me how to put on a condom and even that some people don’t like condoms but if you as a woman are pleasured by it then he’s able to enjoy it (sex) too. There’s a lot it [training] helped me with. (Peer educator for 7 years, Bothas Hill, semi-rural site)
Peer educators improved their public speaking skills. They were speakers at community engagement activities and networked with the stakeholders. This contributed to their acceptance within the community. As educators, they felt empowered to make informed decisions regarding their own trial participation, and communicating about sexual and health related issues within their communities. A few peer educators (n = 9) joined the research based community working groups (CWGs) where they openly discussed their trial participation experiences and they were able to sustain links with the community and the researchers.
The peer programme contributed to their personal achievements, such as being eligible for employment and being recognised by the community leaders. A few (n = 4) peer educators were successful in securing employment as receptionists, general assistants and as care givers in the public health clinics. One peer educator received an award for her contribution to increasing HIV awareness in the community and she was recognised as ‘woman of the year’ by a local community-based organisation – ‘I’ve also been Woman of the Year and they say I’ve done my work well’. Another peer educator acquired funding for a community-based soup kitchen, as she had been providing soup to patients accessing their ARVs at the clinic. One peer educator had her first experience to travel in an aeroplane when she attended a national workshop with community members from all the provinces and she said, ‘I didn’t expect to fly to Pretoria … I felt like I have wings’:
I’m happy with it because I help the community. I am very happy, I love being a peer educator because you’re able to educate and not fear the community. Even if person in charge of the clinic walk in, we see the nurses but Nunu (fictitious name) and I are able to face him/her and say what we need to say. Even when one day Nunu’s child was bitten by a dog and we got to the clinic and we found they didn’t have the injection for dog bites, so the nurses said they had ordered it. Nunu said wait let me try call the manager. Nurse said just now please, I will get the injection, because she knew us and she brought the injection quickly by car you see, we are able to help the community. (Peer educator for 4 years, Bothas Hill, semi-rural site)
Sustaining and supporting peer educators
The challenges peer educators faced in the community included their lack of acceptance among community members, and difficulty in addressing rumours about the research, including negative media reports of the vaginal gel during post-trial results dissemination events. They were also accused of promoting sex in the community and perceived as being HIV infected. Peer educators were supported by the researchers to educate the community and to dispel myths about the research. Researchers held stakeholder engagement events to explain the role of peer educators in the community.
Peer educators requested for additional material and trainings on caring for orphans and people living with cancer and chronic diseases. They also requested training on communication skills and addressing conflict. As the trials ended, the peer educators were concerned about their sustainability in the peer programme and access to funds to continue with their activities:
Peers need money to reach the community. (Peer educator for 5 years, Verulam site) I need money for transport to visit the community. (Peer educator for 3 years, Umkomaas, semi-rural site)
Discussion
Peer education programmes have been recognised as an effective educational strategy that has been used among a number of populations including youth, commercial sex workers and injection drug users (Medley et al., 2009). Studies in South Africa have highlighted the effectiveness of the peer education programmes to promote sexual and reproductive health among women and adolescents (Mason-Jones et al., 2011; Naidoo et al., 2013). However, to our knowledge, this is the only study that describes the experiences and opinions of peer educators who were participants in a HIV prevention clinical trial in South Africa, with a focus on the impact of the programme on their skills development. This article highlights that the knowledge and experiences that peer educators gained from the peer education programme contributed to their personal growth and skills development.
These women made a choice to not only join the HIV prevention trial but also to volunteer as peer educators and create HIV awareness in their communities. The training coupled with their experience enhanced their knowledge on HIV/AIDS and their understanding of the research studies, thus improving their outcomes as peer educators. They contributed to the recruitment and retention efforts in the diaphragm trial (Naidoo et al., 2013; Padian et al., 2007), which was also a reflection of their agency and confidence to promote HIV prevention messages and research awareness among their peers and communities.
Although the benefits of training peer educators was reported among university students who gained new knowledge on reproductive health (Visser, 2007), this group of student educators were not confident to educate their peers. They believed that their peers would not believe or listen to their education messages on reproductive health. The peer educators in our study, who did not have tertiary level education, were able to confidently address the misperceptions of the community about HIV prevention trials and reproductive health. This confirms previous findings of the role of training peer educators on research outcomes (Naidoo et al., 2013).
In addition to gaining knowledge, peer educators changed their own behaviour as they increased self-worth which contributed to their well-being. Due to the constant and reciprocal nature of interaction and communication between researchers and peer educators, they were able to develop a positive attitude to HIV prevention and treatment messages. The reporting of sustained good health by the peer educators, confirms that this responsibility served as an important psychological function in the development of their sense of self, which was also reported in a previous study (Visser, 2007) where peer educators gained insights into their own limits and adopted a non-judgemental approach to HIV counselling and testing (HCT) and sexual issues.
The tokens of appreciation recognising the peer educators for the peer related activities may have contributed to their retention and sustainability in the programme. Several other peer education programmes (Dilek et al., 2012) have provided tokens of appreciation which included financial compensation in resource limited settings, to help peer educators conduct their activities and meet basic expenses. Thus, we recommend that programmes make every effort to compensate peer educators for their voluntary work.
Several peer educators used the knowledge they gained in the training to seek employment and improve their future job opportunities in the formal economic sector. A previous research study showed that peer education programmes aid in developing skills and confidence of trained peer educators and their communities, which assists in overcoming barriers of talking openly about sensitive and sexually explicit topics. As promoters of public health, peer educators become a source of pride and social recognition who are well received by communities and consequently improve health awareness by positively changing attitudes and risk behaviours (Van Rompay et al., 2008).
A few peer educators sourced support from the research staff and the community leaders when they faced challenges with acceptance in their communities. However, their choice to remain in the peer programme to increase HIV awareness in their community reflects their agency to promote HIV prevention options.
This study showed that training trial participants as peer educators was effective in developing their skills and knowledge and that the on-going training and supervision may have contributed to the retention of the peer educators in the programme. A limitation of this study is that the data were only collected from the active peer educators who were available at the time of data collection and does not reflect experiences from those who were inactive.
Conclusion
This peer education programme contributed to the skills development of the peer educators as women and trial participants. The training information enabled them to exercise agency, engage their communities and be part of HIV prevention education efforts. The peer educators developed confidence to conduct outreach and education sessions to increase HIV awareness among family and community members. Thus, partnering with clinical trial participants and training them as peer educators is an effective way to develop skills and capacity of women within communities, and to increase and sustain HIV/AIDS awareness in the community.
Footnotes
Acknowledgements
The authors thank the trial participants of the peer education programme, research team members and the HIV Prevention Research Unit of the South African Medical Research Council. N.S.M. was the lead author and is the principal investigator of the study. S.N. was the principal investigator from 2005–2006 and contributed to the manuscript. G.R. initiated the concept of the peer programme in 2005 and is the Director of the HIV Prevention Research Unit. G.R. reviewed and edited the draft manuscript. A.G. contributed to the data management and to the draft manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the SAMRC and the trials were funded by global sponsors.