Leeds Health Education Database

Database entries with complete fields

1. Interventions to control AIDS and Sexually transmitted diseases

September 2003


 

1.1 Community-based programmes

1.2 Popular media including drama and music

1.3 Targeted interpersonal interventions directed at sex workers

1.4 Clinic-based education and counseling

1.5 Mass media programmes

1.6 Training programmes for persons involved in AIDS education

1.7 Schools-based and youth-targeted programmes

 

Note: Click on the links for:details of the database project, a listing of all database entries and details of publications on AIDS and STDs that were reviewed but excluded from the database (with reasons provided)


1.1 Community-based programmes

Babalola,S., Sakolsky,N., Vondrasek,C., Mounlom,D., Brown,J. and Tchupo,J.-P. (2001) The impact of a community mobilization project on health-related knowledge and practices in Cameroon. Journal of Community Health 26, 459-477. Ref ID 8984

Target Group/Country Urban and rural communities in Cameroon

Intervention Methodology Between 1997 and 1998 the project worked in a rural and an urban location. The theoretical basis for the intervention was Communications of Innovation Theory and activities involved selecting and training two prominent and influential members of each community as "relais" or middlemen. The "relais" then trained mobilizers from participating Njangis which were existing community-based self-help organizations. Community mobilizers provided relevant information and help to mobilize their fellow members in favour of the positive attitudes and practices concerning family planning, sexually transmitted diseases and general child health. promoted by the project.

Evaluation Method The project was evaluated through a structured questionnaire given to 803 men and women aged 15-49 at baseline and a follow-up at 20 months to a sample of 854. Attendance at family planning services was also monitored. There was no control.

Impact Achieved In the rural community there were significant increases in knowledge of at least one modern method of contraception (p<0.05), perception about vulnerability to AIDS (p<0.001), persons reporting to have ever used condoms (p<0.01) and use of health care services (p<0.01). Impact was greater for all of these variables among persons exposed to the programme than not exposed (p values not given). There were increases in new clients at the family planning clinic but the increase was not uniform and seemed to coincide with monitoring visits of the relais. There was no impact on urban location. This paper provides a very good discussion of the theoretical and practical basis of the community mobilization approach used and draws interesting conclusions about the value of working with existing indigenous organizations, the benefits of presenting baseline data to communities, the need for greater decentralization of management the challenge of finding incentives for community mobilizers. In the absence of controls it is disappointing that significance testing is not presented to accompany the finding of greater impact on community members exposed to the project. The great unanswered question is why an impact was achieved in the rural community and not the urban community. In the absence of any information on this it is difficult to generalise on the transferability of the method to other communities.

Bhuiya,A., Hanifi,S.M., Hossain,M. and Aziz,A. (2000)  Effects of an AIDS awareness campaign on knowledge about AIDS in a remote rural area of Bangladesh.  International Quarterly of Community Health Education  19, 51-63.Ref ID: 8786 (Borderline for inclusion in database)

Target Group/Country Community in a remote rural area of Bangladesh (3 Unions of Chakaria thana, population 65,000) in Cox's Bazar district in the south-East coast area of Bangladesh

Intervention Methodology An educational campaign as part of  "World AIDS Day, 1996" by the volunteers of the village-based traditional self-help organizations.  The activities included rallies at village level by school pupils, large community gatherings at schools and at thana headquarters.

Evaluation method Surveys were carried out of 300 males and 300 females from 30 out of the 50 villages were carried out using a before the campaign and one month afterwards. The questionnaire was in Bangla and consisted of open-ended questions. There was no control.

Impact achieved 39% of the respondents in the post-intervention survey reported having heard about AIDS compared to 19% in the pre-intervention survey. Authors claim that this increase is significant but no p value is provided. The programme did not succeed in creating an impact on the knowledge about transmission, prevention, and high-risk behavior. The improvement in knowledge was somewhat similar across all gender, age, and religious groups. The effect of the campaign was greater among illiterate respondents, having relatively smaller effect on the educated respondents. Lack of controls and supporting information on possible reasons for the low impact are limitations of this study.

Colon, H.M., Robles, R.R. Freeman, D. Matos, T. (1993) Effects of a HIV risk reduction education program among injection drug users in Puerto Rico. Puerto Rico Health Science Journal 12, 27-34..Ref ID : 8238

Target group/Country Injecting drug users in Puerto Rico

Intervention Methodology Three group educational sessions where detailed information on HIV risk and protective behaviours was conveyed, protective behaviours were shown and practiced, and a problem solving perspective guided discussion of serostatus results.

Evaluation Method Random allocation of 986 IDUs to the standard street outreach/referral programme and 880 to the enhanced programme with the three educational sessions. Interviewers administered on intake and 7 months after the educational programme the AIDS Initial Assessment Questionnaire (National Institute on Drug Abuse , US Dept of Health and Human Services at intake)

Impact Achieved Substantial risk reduction in behaviours including discontinuatin of injections, use of shooting galleries, borrowing of needles were prospectively measured by all participants. However, IDUs assigned on a random basis to the enhanced intervention, showed no significant differences in levels of risk reduction when compared to those assigned to the standard-only intervention. The authors suggest that there is a need for "interventions geared to maximize the utilization of health care services and enhance the supportive functions of familial and social networks of IDUs". Only a brief description is provided of the methodologies used in the three sessions and there is no descriptive/observational study of the quality of the educational input that might suggest any reason for the lack of educational impact.

Elkins, D., Maticka-Tyndale, E., Anusornteerakul S, Kuyyakanond, T., Kiewying, M., Chantapreeda, N., Haswell-Elkins, M., Choosathan, R., Sommapat, S. and Theerasobhon, P. (1996) Evaluation of HIV/AIDS education initiatives among women in northeastern Thai villages. Southeast Asian J. Trop. Med. Public Health 27, 430-442. Ref ID : 8213

Target Group/Country Women in villages in KhonKaen Province in North-eastern Thailand

Intervention Methodology The leaflet consisted of a single sheet folded into 3. Pictures with very few words were used to convey key messages on the nature of AIDS, transmission and the use of condoms. Every houseful received a leaflet.

Evaluation Method Pre-test KAP questionnaire was given to women in 6 villages before and after receiving the leaflet. A second group of six villages were given the leaflet and post-test one year later, a third group of 6 villages served as controls and were given a post-test but no leaflets. Nine hundred and fifty-four were sampled. The questionnaire measured knowledge, HIV/AIDS efficacy and condom readiness.

Impact Achieved Even among villages who had received leaflets, the major source of information identified by the participants were television or radio (89%) . There was no clearly demonstrable impact of the leaflet on most outcome measures. In villages receiving the leaflet there were more women blaming casual contacts as a source of risk of HIV (p=0.02). There were fewer women reporting condoms as a preventive method in villages receiving the leaflet and this was attributed to the negative impact of the use of cartoons and humour to show condoms. This study is of interest in that it points to the problems of  evaluating interventions in communities that are exposed to information from other sources (in this case mass media). The negative impact of the leaflet on condom use is also of interest and shows the importance of pre-testing to identify potential problems with visuals.

Elkins, D., Maticka-Tyndale, E., Kuyyakanond, T., Miller, P., and Haswell-Elkins, M. Towards reducing the spread of HIV in Northeastern Thai villages: evaluation of a village-based intervention. AIDS Education and Prevention 9(1):49-69, 1997. . Ref ID : 6027

Maticka-Tyndale,E., Haswell-Elkins,M., Kuyyakanond,T., Kiewying,M. and Elkins,D. (1994)  A research-based HIV intervention in northeast Thailand.  Health Transition Review  4 Suppl:349-67. 199, 349-367.Ref ID: 8278

Target Group/Country Women in northeastern Thai villages.

Intervention Methodology The intervention consisted of a 3 part village-based strategy:1) A meeting with village leaders to establish partnership and train volunteer leaders from the village to act as facilitators; 2)a broadcast of a 5-part (5 day) motivational audio-drama over village loudspeakers accompanied by 10 posters depicting each day's major issues. The plot revolved around married men engaging commercial sex workers, risk reduction within this context , and dialogues between women, between spouses and between men; 3) a village meeting to begin discussion of the drama and plan further village strategies.

Evaluation Method A longitudinal, naturalistic experimental design. A pre-test structured face-to-face interview using predominantly open-ended questions  was given to 6 intervention villages(  205 women, 185 men) randomly sampled from 1892 villages in the province. This was followed by a post-test interviews in the same villages (188 women, 151 men). 6 villages were selected randomly from a neighbouring province also to receive the post-test (207 women, 143 men). In addition, after the educational programme,  focus groups were carried out in the intervention villages (12 with women and 11 with men). The timescale between pre- and post intervention surveys is not given.

Impact Achieved Village meetings were widely attended and both men and women responded positively to the audio-drama. Men and women changed perceptions in directions consistent with eventual risk reduction. Project interventions increased the likelihood that women would recognize that they were personally at risk as a result of their husband engaging commercial sex workers (p=0.01). Following this evaluation, the strategy was adapted for larger scale intervention. There was no evidence that the men surveyed  changed their pattern of condom use. As of April 1995 the programme had been implemented in three provinces in Northeast Thailand (no evaluation published of the larger scale programme). The main methodological uncertainty in the evaluation is the lack of pre-test with the control villages

Ferreira Pinto, J.B. and Ramos, R. (1995) HIV/AIDS Prevention among Female Sexual Partners of Injection Drug Users in Ciudad Juarez, Mexico. AIDS Care 7, 477-488.. Ref ID : 5543

Target Group/Country Women who are sex partners of male injection drug users at the US-Mexico border town of Ciudad Juarez

Intervention Methodology Approach based on Paulo Freire and concientiization approach. Women participated in weekly discussion groups of 4-15 participants over an eight week period. As part of this they carried out homework exercises. Group discussions were promoted with three posters and 6 photo-novelas. Each discussion group evolved into a support group for the members.

Evaluation Method The 105 participants were given AIDS (acquired immune deficiency syndrome) Intake & Follow-up Assessment (AIA/AFA) questionnaires which contained a knowledge test, sexual behaviour variables, drug use and health history. This was applied at the beginning and end of intervention (exact time scale of pre- and post-test unclear from the report). 24 of the participants were randomly selected to be interviewed using an open-ended discussion protocol by an ethnographer - details of the methodology of qualitative analysis of the results of these interviews are not provided. There were no controls (authors argued that it was not possible to create meaningful controls).

Impact Achieved As measured by the questionnaire there was no change in sexual behaviour and, although there was a small but non-significant increase in condom use. The qualitative study indicated that the programme had had an impact on the women and enhanced their self-esteem, self-efficacy, & awareness of the social, economic, & political constraints of their lives. While providing an interesting and revealing extract from one of the interviews, it is disappointing that so little information is provided on the qualitative analysis of these interviews.

Grosskurth, H., Mosha, F., Todd, J., Mwijarubi, E., Klokke, A., Senkoro, K., Mayaud, P., Changalucha, J., Nicoll, A., and ka-Gina, G. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial [see comments].Lancet 346:530-536, 1995.  Ref ID : 4223

Target Group/Country The rural Mwanza region of Tanzania.

Intervention Methodology Intervention consisted of establishment of an STD reference clinic, staff training, regular supply of drugs, regular supervisory visits to health facilities, and health education about STDs.

Evaluation Method The impact of improved sexually transmitted disease (STD) case management at primary health care level on the incidence of HIV infection in HIV incidence was compared in six intervention communities and six pair-matched comparison communities. A random cohort of about 1000 adults aged 15-54 years from each community was surveyed at baseline and at follow-up 2 years later. A total of 12,537 individuals were recruited.

Impact Achieved Baseline HIV prevalences were 3.8% and 4.4% in the intervention and comparison communities, respectively. At follow-up, 8845 (71%) of the cohort were seen. Of those initially seronegative, the proportions seroconverting over 2 years were 48 of 4149 (1.2%) in the intervention communities and 82 of 4400 (1.9%) in the comparison communities. HIV incidence was consistently lower in the intervention communities in all six matched pairs. randomised design and the effects of confounding factors, the estimated risk ratio was 0.58 (95% CI 0.42-0.79, p = 0.007). The study found that improved STD treatment reduced HIV incidence by about 40% in this rural population. The classic study that demonstrated the impact of treatment of STDs on HIV transmission. The main weakness is that the impact of the educational input is not clearly separated from that of the treatment so it is not possible to separate out the relative contribution of each.

Hope, K. R. 2003, Promoting behaviour change in Botswana: An assessment of the peer education HIV/AIDS prevention programme at the workplace, Journal of Health Communication, 8 267-281. Ref ID: 9074. Borderline for inclusion in database.

Target Group/Country Workers in a range of private, government and parastatal businesses in Botswana

Intervention Methodology A peer education programme for prevention of HIV/AIDS. Limited information is provided in this report of the process of selection, training and functioning of the peer educators. The survey data from the evaluation indicated that 57% of the PEs are male, the majority are high school graduates. 80% pf the Peers were selected by the management and 20% volunteered.

Evaluation Method Questionnaires were administered to peer educators (n=73), managers (n=23) and peers (employees) n=439 in selected urban and rural locations covering all the countries districts. No information is provided of sampling. It is not clear how long the programme had been operating before the sample was taken. Very little information is provided on the actual carrying out of the data collection. There was no baseline study and no control.

Impact achieved 30% of the peer educators carried out some form of peer education activity every week, 11% of the monthly and 18% quarterly. It is disappointing that the evaluation provided no information of the extent and quality of the peer education activities. 78% of the peers indicated that the programme had improved their knowledge of HIV/AIDS. 76% of the peers indicated that the programme had led to a reduction in the number of their sexual partners. 67% of the female peers and 76% of the male peers stated that the peer education programme led to a positive change in their desire to use condoms during sexual intercourse. Some 89% of the peers stated that they now use condoms always or some the time due to their exposure to the peer education programme. Given the heavy reliance of the evaluation on self-reported behaviour change and the lack of controls or baseline data, it is disappointing that so little information is provided of the data collection processes and the quality control measure taken to ensure unbiased response.

.Kagimu, M., Marum, E., Nakyanjo, N., Walakira, Y., and Hogle, J. Evaluation of the effectiveness of AIDS health education interventions in the Muslim community in Uganda. AIDS Education and Prevention 10(3):215-228, 1998.. Ref ID : 7733

Target Group/Country Moslems in Mpigi and Iganga Districts, Uganda

Intervention Methodology Islamic Medical Association of Uganda designed an AIDS prevention project and conducted a baseline survey prior to community level activities. During 2 years of prevention activities in local Muslim communities, 23 trainers trained over 3,000 religious leaders and their assistants as ‘Family AIDS Workers’ who in turn educated their communities on AIDS during home visits and at religious gatherings.

Evaluation Method Baseline survey (n=1907) and follow-up survey two years later (n=1826). There were no controls although in one district the project was carried out in only half the district. The respondents were asked if they had been exposed to family AIDS workers and those who stated no, were also used as controls (566 compared with 1260 who had reported to be exposed) . Survey data was supplemented with data from project records,9  focus group studies and 25 key informant interviews.

Impact Achieved After 2 years, there was a significant increase in correct knowledge of HIV transmission, methods of preventing HIV infection and the risk associated with ablution of the dead and unsterile circumcision p < 0.001). There was a significant reduction in self-reported sexual partners among the young respondents less than 45 years. In addition there was a significant increase in self-reported condom use among males in urban areas (p < 0.001). This is a good example of an evaluation of a large-scale programme working through a religious institution.

Kipp,W., Kabagambe,G. and Konde-Lule,J. (2001) Low impact of a community-wide HIV testing and counseling program on sexual behavior in rural Uganda. AIDS Education and Prevention 13, 279-289. Ref ID: 8941

Target Group/Country Rural persons in Kigoyera Parish, western Uganda

Intervention Methodology 4 persons who already had some involvement in HIV counseling were provided with a 4 week training course in HIV counseling followed by an exam. Voluntary counseling and testing was offered to all adults in Kigoyera Parish. The counseling programme consisted of pre-and posttest counseling. A typical counseling session lasted 30 minutes. Condoms were made available and the posttest counseling session a personal risk reduction programme was negotiated for the based on their reported individual needs

Evaluation Method 2 stage sampling method was used to select 469 persons from 13 villages from the community (mean age 31 years). They were interviewed using a semistructured questionnaire with 42 closed and open-ended questions. The outcome variables for measuring sexual behaviour were condom use and mean number of casual sexual partners in the past 3 months.

Impact Achieved Out of total of 3,049 persons over the age of 15 years in the parish, 2,267 had participated in the HIV counseling and testing programme. 343 respondents (73.1%) had been tested for HIV and received counseling. Persons who were HIV tested and received counseling showed no difference in sexual behavior compared to those who were not tested (condom use 4.3% vs. 5.5% p=.334, mean number of sexual partner in the past three months 1.8 vs. 2.0 p=.538). The authors concluded that large scale counseling and testing is not cost-effective and should be discontinued if the HIV prevalence is low (an earlier survey had found a prevalence of 3.9% but the HIV prevalence among the persons tested as part of the counseling programme is not reported in the paper). A disappointing feature of this study was that they the quality of counseling provided was not measured. Some problems in the counseling provided might be inferred from the fact that 133 of the 334 persons tested (38.8%) did not some back for their test results and hence did not receive the post-test counseling with the personal risk reduction programme. Also, so many did not come back for reasons that included lack of knowledge when to come back (52 of 133) and fear of the result (1 person). Also the most reason given for attending counseling was that of wanting to participate in the study (247, 72.6%) and only a few (n=57, 16.6%) attended counseling because they were curious to know their HIV status. Note this is an example of mass screening and not strictly comparable to voluntary counseling and testing programmes where one would expect a higher proportion of persons attending who actually want to know their sero-status.

Laukamm-Josten,U., Mwizarubi,B.K., Outwater,A., Mwaijonga,C.L., Valadez,J.J., Nyamwaya,D., Swai,R., Saidel,T. and Nyamuryekunge'e,K. (2000)  Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania, 1990-1993.  AIDS Care  12, 27-40.. Ref ID: 8666

Target Group/Country Truck drivers and their sexual partners in Tanzania

Intervention Methodology Two health behaviour officers identified all bars, guest houses, pombe (local alcohol) shops, disco halls, truck stands, brothels and drew them on a mat. Peer educators at truck stops were female bar and guest house workers and male petrol station workers. At the trucking companies they were usually social welfare and transport officers. Peer educators received an initial orientation session zonal workshops and a central workshop. There were provided on-going training and support from their workplace. Verbal messages were reinforced with posters, stickers, pamphlets, booklets, flip charts, audio-cassettes, dramas and video shows. The project extended the government system of distribution of condoms into hotel bedrooms, bars and company bathrooms.

Evaluation Method KAP surveys were carried out of male  truck drivers and their assistants  and also females working at bars/commercial sex workers at baseline (1990, males n=425, females n=304), 18 months later (1991 males n=198, females n=121)after an intensive intervention and 24 months(1992, males n=305, females n=318) later after maintenance activities.  There were no controls.

Impact Achieved Trends for self-reported condom use were: increase among men (56 to 74%) during the first phase with a decrease (72%) during the maintenance phase (p<0.001). Respective figures for women were 51 %, 91% and 70% (p<0.001). Multivariate analyses revealed that men most likely to report using condoms were unmarried, had children, were more educated, had previously reported a genital ulcer, and perceived themselves at risk for HIV infection (OR= 1. 95-3.47). Women tending to use condoms were unmarried, aware of the limitations of condoms, not in denial as to the existence of HIV, harbored inaccurate information about HIV transmission and were afraid (OR= 1. 35-2.52). Both sets of results suggest that the most sexually experienced men and women who did not have a permanent stable relationship and who perceived themselves at risk, were most likely to use a condom.

Li, H., Chen, J., Liang, S., Zhang, K., Liang, F., Liu, W. and Li, R. (1999) Study on promoting safer behaviours among long-distance truck drivers. Chinese Medical Journal 112, 288 Ref ID : 8387  (Borderline for inclusion in database)

Target Group/Country Long distance truck drivers (LDTDs)in Nanning and Pingxiang cities in Guangxi Province between 1995 to 1997

Intervention Methodology Health education/promotion included items: lecture, watching video-tape, cassette tapes distributed, pamphlets distributed, discussion, in-depth interview/knowledge transferring, focus group discussion/knowledge transferring, peer education/information transferring, condom distribution and consulting services. The importance of "prevention of both root causes and pragmatic approaches was emphasized during intervention.

Evaluation Method Follow-up survey were carried out, with quantitative studies of(l) LDTDs completed by self-administered questionnaires; (2) 3-5 ml vein blood under informed consent was taken for detecting the infection of HIV (ELISA, PA, WB) and syphilis (RPR, TPHA); (3) 20-40 ml first stage urine was collected for detecting the infection of gonorrhoea (Gonorrhoea Rapid Diagnostic Test). Qualitative studies were carried out on (1) field observation; (2) in-depth interview and (3) focus group discussion . Totally 364 LDTDs were studied before intervention, with allocation of 184 in study and 180 in control group. 333 LDTDs were followed-up, with 108 in the study group, and 125 in the control.

Impact Achieved The incidence of gonorrheae during the observation period was 4.4% and 7.14 in the study and control groups respectively with no significant differences between two rates. Before the intervention 47.3% in the study group know "condom can prevent STDs/HIV and the rate of self-reported condom use was 38% in the study group and 30.2% in the control. After the intervention 89.9% in the study group knew "condom can prevent STDs/HIV compared to 49% in the control group and the rate of self-reported condom use was 68.0% in the study group comparing to 30.6% in the control group (statistical tests not presented with data). The lack of detail on the educational methods, raw data and statistical analysis severely limits the value of this study.

Mercer, M.A., Gates, N., Holley, M., Malunga, L. and Arnold, R. (1996) Rapid KABP survey for evaluation of NGO HIV/AIDS prevention projects. AIDS Education and Prevention 8, 143-154..Ref ID : 8202  (Borderline for inclusion in database)

Target Group/Country Rural subsistence communities

Intervention Methodology An outreach approach was used by with an existing network of village community workers and farm health workers who provide home visits to project beneficiaries in the rural areas and commercial farms a on a NGO (Save the Children Fund) health project. A two day training to extend their educational activities to include HIV/AIDS education community representatives and government extension workers also attended the training session. The objective of the programme was that 80% of families would know the three ways of transmission and 3 behaviours for prevention of transmissions.

Evaluation Method A baseline study (n=1176) had earlier been carried out. This was  followed by final study (n-641) aged 18-45 years, selected by a modified 30-cluster sampling method, were interviewed in two of the three project areas (total community size 22532). There were no controls. However, for comparison purposes the sample were separated into two groups. The first group consisted of 429 persons who had named at least one source that had been used in the project and 212 persons who had not named any of the sources used in the project and had instead listed mass media as their source of information on AIDS. Comparison of the two groups showed similar characteristics.

Impact Achieved 85% of the respondents could state three modes for preventing transmission.  There was an increase from 31% (baseline) to 65% (post-test) in persons spontaneously mentioning the use of condoms as a means of preventing AIDS (no significance test provided). Among those reporting exposure to the project field staff there were significantly higher (p<0.01)   % of persons  reporting of knowledge of at least three ways of preventing HIV transmission  and reporting that they would was a family member with AIDS. Interpretation of this data is made difficult by the fact that minimal information is provided of the baseline study in which the interviewers had received less training and the questions were worded differently from the post-test. Also, self-reported exposure to project inputs is only an approximation to a true control. It is also important to note that the main purpose of this study was to validate a rapid appraisal methodology and its use for evaluation was incidental.

Nations, M.K. and de Souza, M.A. (1997) Umbanda healers as effective AIDS educators: case-control study in Brazilian urban slums (favelas). Trop. Doct. 27 Suppl 1:60-6. 60-66.. Ref ID : 6867

Target Group/Country Traditional healers in urban areas of Northeast Brazil.

Intervention Methodology During a 12-month period (November 1994 to October 1995), Afro-Brazilian Umbanda healers (Pais-de-Santo) taught 126 fellow healers from 51 Umbanda centers (terreiros), located in seven overcrowded slums (favelas) (population 104-343) in Brazil's northeast, the biomedical prevention of AIDS, including safe sex practices, avoidance of ritual blood behaviours, and sterilization of cutting instruments. A face-to-face educational intervention by healers, marginalized in society yet respected by devotees, which blended traditional healing--its language, codes, symbols, and images--and scientific medicine and addressed social injustices and discrimination was utilized in this project supported by the Brazilian Ministry of Health, National Program in STDs/AIDS

Evaluation Method Evaluation compared 126 trained healers with 100 untrained controls. A pre-test questionnaire was given before the training and three weeks of completion of training using a 187 item orally-administered questionnaire.

Impact Achieved Significant increases (P < 0.001) in AIDS awareness, knowledge about risky HIV behaviour, information about correct condom use, and acceptance of lower-risk alternative ritual blood practices and decreases (P < 0.001) in prejudicial attitudes related to HIV transmission were found. No data presented on impact of training on subsequent healing practices.

Pauw, J., Ferrie, J., Rivera Villegas, R., Medrano Martinez, J., Gorter, A., and Egger, M (1996) . A controlled HIV/AIDS-related health education programme in Managua, Nicaragua. AIDS 10(5):537-544.  Ref ID : 6101

Target Group/Country Households in two communities in Managua, Nicaragua.

Intervention Methodology A multi-disciplinary group of 10 individuals carried out a house-to-house campaign complemented by activities in schools and public meeting places. Each visit took between 15 and 30 minutes, depending on the questions asked. An informal presentation was made illustrated with drawing and the correct use of the condom was demonstrated. In addition leaflets on HIV and AIDS, and stickers, posters, calendars, T-shirts and free condoms were distributed in the neighbourhoods. Workshops and video presentations were held at secondary schools and information was given to the public via loudspeakers installed on the roof of a car.

Evaluation Method Four neighbourhoods were included, two received the intervention, and the other two served as controls. Randomly selected residents aged 15-45 years were interviewed at baseline (n = 2160) in Jan 1971 and follow-up (n = 2271) March/April 1992 using an identical questionnaire.

Impact Achieved In one community 904 houses were visited and in the other , 1000 visits were made. Condom use increased from 9 to 16% (p = 0.003) among intervention women, but only from 9 to 11% (p = 0.5) in control women (test for interaction, p = 0.08). Among men, increases were from 31 to 41% (p < 0.001) and from 30 to 37% (P = 0.06), respectively (test for interaction, P = 0.3). Levels of worries about HIV/AIDS decreased in all groups, but perception of individual risk increased only among intervention women (test for interaction, p = 0.02). The authors discuss the problems of carrying out a controlled trial when both the control and intervention group are also exposed to educational inputs from other sources. No information is provided of the cost of this intervention to enable a judgment of the feasibility of replicating this labour-intensive intervention in other communities.

Schoepf, B.G. (1993) AIDS action-research with women in Kinshasa, Zaire. [Review]. Social Science & Medicine 37, 1401-1413.. Ref ID : 1871  (Borderline for inclusion in database)

Target Group/Country Programme with sex workers and other women in suburban Kinshasha, Zaire

Intervention Methodology CONNAISSIDA, a trans-disciplinary medical anthropology research project, in which field researchers developed a series of 4 community-based empowerment workshops using role plays, case studies, picture codes and simulation exercises. They initially worked with a group of 15 sex workers and then with 60 members the mother's club of a local protestant church..

Evaluation Method An action research approach was used for the evaluation of this project based  on records of initial and subsequent encounters with the sex workers and local women. Additional meetings were held at 3 and 8 months to determine changes in the participants.

Impact Achieved At the end of the fourth week participants in both groups asked to be shown how they could carry out education with others. 20 additional women joined the subsequent meetings at the church. At the end of 3 months all but one of the sex workers reported using condoms regularly. At 8 months the use of condoms had declined from 'almost always' to 'sometimes'. One third of the 60 mother's club participants reported that their husbands utterly refused to consider using condoms, Another third said that they had managed to open a dialogue , but their husbands had persuaded them that the risks were negligible. This report provides a very detailed description of the activities and a valuable insights on the role of  economic and gender inequality. It is disappointing that the report is anecdotal and does not provide a more detailed and systematic account of analysis of ethnographic findings.

Schopper, D., Doussantousse, S., Ayiga, N., Ezatirale, G., Idro, W.J., and Homsy, J. Village-Based AIDS Prevention in a Rural District in Uganda. Health Policy and Planning (2):171-180, 1995.  Ref ID : 5604

Target Group/Country Ugandans ages 15-49 in the Moyo district

Intervention Methodology 30 community educators were recruited from every parish in the district and trained to conduct information sessions at the village level. Their educational work was supported by an illustrated AIDS information leaflet whose content was based on findings from a KAP study.,

Evaluation Method A baseline KAP study was carried out in Feb-March 1991 on a cluster sample of men (n=733) and women (n=753) aged 15-49yrs from the District.. After 18 months in Sept-October 1992 the impact of the program was measured through a second KAP survey of 1,744 individuals 9874 women, 870 men): There were no controls.

Impact Achieved During the first 5 months of the information campaign (Sept 1991 - January 1992) an estimated 50,000 people attended the village based information sessions and 45,000 pamphlets and 40,000 condoms were distribute. 60% had participated in an information session, & 42% had received the pamphlet. Knowledge about condoms increased from 26% to 63% in women & 57% to 91% in men (p<0.000001); & condom use in casual sex increased from 6% to 33% in women (p=0.12) & 27% to 48% in men (p=0.06). Authors claim that this is the first ever documented example of the impact of a village-based AIDS intervention in Africa. The main problem in interpreting the information is the lack of any control and the alternative explanation that the impact achieved was due to exposure of the community to other educational activities .

Simooya,O. and Sanjobon, N. (2001) "In But Free" - an HIV / AIDS intervention in an African prison. Culture Health and Sexuality 3, 241-251.Ref ID: 8987 (Borderline for inclusion in database)

Target Group/Country 1300 male and female inmates in a prison in Zambia

Intervention Methodology As part of an intervention entitled "In but free" Prisoners in each of 12 dormitories containing 80-100 inmates each were asked to nominate 5 inmates to receive a 3 day training as peer educators. Educational activities carried out by the peer educators included intensive person-to-person distribution, distribution of educational materials, the promotion of hygiene and plays and drama on HIV/AIDS. Meetings of 30-40 minutes were carried out on a weekly basis on Saturday afternoons when prisoners were free of other duties. Scissors were made available to reduce the potential risk from the widespread sharing of razor blades.

Evaluation Method An annual review is held drawing on peer educator diaries, monthly project meetings, in depth interviews with prison staff and focus group discussions held with prisoners other than peer educators. Plans to carry out a KABP study were dropped because of expense and the evaluation relied on qualitative methodology using group interviews carried out 3 years after the start of the programme. The project team had 33 meetings with peer educators and their coordinators, 11 focus group discussions and 3 prison conferences but information is not provided on the composition or methodology of these group interviews or how the qualitative data was analysed. There were no baseline data or controls.

Impact Achieved The need for the intervention was highlighted by the results of a voluntary testing programme in which 75% of 99 inmates tested were found to be HIV+. Three years after the commencement of thte project56 of the 119 inmates trained as peer educators were still in service (the rest having being released). Peer education activities are now a 'regular feature' of prison life (no data provided to support this) Both staff and inmates agree that despite some reduction in male-to-male sex unprotected intercourse still takes place. The sharing of shaving appliances like razor blades continues and of the 60 pairs of scissors distributed, only 2 were still available at the end of the project. There was a consensus that tattooing and injecting drugs bas been reduced but the authors are cautious of the validity of these findings. The authors make various suggestions which include distribution of condoms to prisoners, conjugal visits, repeal of current laws which prohibit male-to-male sex, alternatives to custodial sentences and increasing the age from 18 to 21 at which persons were committed to young offenders institutions rather than prisons. This report provides a valuable report and useful discussion on an intervention which targets an important target group. It is disappointing that the qualitative data used to generate its findings is inadequately described. However, given the overall negative nature of the findings this limitation is perhaps less important. However, a second limitation is the lack of any evaluation of the quality of the peer education. This weakens the main conclusion drawn from the report is that it is possible to carry out peer education in a prison environment but on its own this is insufficient to reduce risk of HIV transmission.

Stover, J. and Bravo, M. (1990) The impact of AIDS on knowledge and attitudes about condoms for family planning in urban Mexico. International Family Planning Perspectives 17, 61-64. Ref ID : 6806

Target Group/Country General population in Mexico

Intervention Methodology Phase one was a short media 'blitz' between many and June of 1987 . The 2nd phase involved a 30 second television spot directed at myths about AID which ran for 3 months (but because of objections by the government was rescheduled for showing after 11pm. The 3rd phase of the campaign beginning on December 1987 was a TV spot on methods of preventing AIDS. The spot was delayed until February 1988 because of objections to the use of the word condom and was shown only after 11pm for thee months.

Evaluation Method 6 surveys were conducted in urban areas in Mexico between February-October 1988 by the Mexican affiliate of Gallup, ECCO, which adds additional questions to its usual monthly demographic and economic survey. The weighted sample of 1300 males and 1300 females accurately represents Mexico. The 1st survey was carried out 2 months after the airing of TV AIDS programming with use of condoms, and before, during, and after the 2nd AIDS TV campaign.

Impact Achieved The proportion mentioning condoms as a way of preventing AIDS was 13-24% in the first two surveys and role to 32% in the third and subsequent surveys. The sharp increase between the 2nd and 3rd survey might have been due to the publicity surrounding the opposition to the government health education programme. Lack of controls makes it to difficult to attribute changes to programme inputs. However, the report is of interest in revealing the substantial difficulties faced launching AIDS education in a society where the use of condoms is criticised by the establishment.

Vaz, R.G., Gloyd, S. and Trinidade, R. (1996) The effects of peer education on STD and AIDS knowledge among prisoners in Mozambique. International Journal of STD and AIDS 7, 51-54.. Ref ID : 6840

Target Group/Country Prisoners in Mozambique

Intervention Methodology Primary school educated prisoner 'activists' were selected and provide 20h of training to lead educational sessions. Each prisoner attended 3 educational sessions on AIDS and STDs. Sessions were carried out in groups of 30 and lasted 30 minutes. Prisoners attended the performance of a theatre group comprised of prisoners trained by a semi-professional drama instructor. Prisoners diagnosed to have STDs at their medical examination were provided with counselling.

Evaluation Method A knowledge, attitudes and practices questionnaire regarding AIDS and STDs was administered to each 300 subject in 1883 as part of the intake medical examination and 6 months after the intervention. There was no baseline.

Impact Achieved There were significant increases in knowledge: that AIDS exists in prisons, (p<0.000001);  that HIV-infected persons without symptoms can transmit AIDS (0.01)that using condoms can protect against HIV/AIDS (p=0.004), that you cannot be infected by sharing a cell with a person with AIDS  (p<0.000001). Prisoners with less formal education had lower knowledge about AIDS but showed greater increases in overall knowledge scores than those of higher education  (41% increase vs. 24%, p<0.00001)

Wilson, D., Mparadzi, A., and Lavelle, S. An experimental comparison of two AIDS prevention interventions among young Zimbabweans. J.Soc.Psychol. 132(3):415-417, 1992.  Ref ID : 3667

Target Group/Country Students at teacher training college in Zimbabwe

Intervention Methodology An information-based interventions which consisted of a lecture on HIV prevention and opportunity for questions. A skills-based session lasted about 90 minutes and consisted of a condom-fitting demonstration followed by individual practice; large- and small group formulation of behavioural self-management strategies, demonstrations of social and assertiveness skills in negotiating condom use followed by dyad role plays and a video. Note the emphasis of this programme was the personal needs of the participants rather than developing their capacity as teachers.

Evaluation Method 50 male and 34 female student teachers completed a baseline questionnaire that measured the number of sexual partners and coital episodes without condoms in the previous year. They were then randomly allocated to two experimental groups of 41 persons each to receive the information-based and skills based intervention. 4 months after the intervention the questionnaire was re-administered. The questionnaire was anonymous but untraceable descriptors was used to link data.

Impact Achieved Compared with the information-based group, the skills-based group were more knowledgeable about condoms and their correct use (p<0.001), higher in self efficacy (p<0.05), perceived fewer barriers to action (p=4.8) reported fewer sexual partners in the previous month (p<0.05) and reported fewer coital acts without condom use in the previous month (p<0.05). A limitation of this short report is that information on the measurement tool is not provided and  raw data is not provide to show actual changes in response from baseline of the two groups.

Zimmerman, M.A., Ramirez-Valles, J., Suarez, E., de la Rosa, G., and Castro, M.A. An HIV/AIDS prevention project for Mexican homosexual men: an empowerment approach. Health Education and Behavior 24(2):177-190, 1997.Ref ID : 6772

Target group/Country Homosexual men in Mexico

Intervention Methodology The intervention was based on, empowerment theory. 15 community members were recruited and trained as community organizers. They carried out interview and focus group discussions in the community to provide information to design the intervention. 35 of the interview respondents joined the original 15 community members and formed weekly discussion groups were role play and problem-posing methods were used supported by videos and printed material. During the first 4 months these were guided by an external facilitator and then taken over by the group members. Group members were trained to carry out outreach education condom distribution and referral in community settings such as bars, streets and workplace.

Evaluation Method An initial interview questionnaire to determine knowledge and self-reported behaviour was carried out with 205 respondents. 37 persons who agreed to participate in the programme became the intervention group and the rest were treated as comparison control groups. 12 months afterwards follow-up interviews were carried out on the 37 intervention group members and 55 persons in the comparison group who could be traced. The 92 respondents had mean age 25yrs, 78% self identified as gay and 22% as bi-sexual.

Impact Achieved No differences were found in reported number of sexual partners. Participants reported higher levels compared to comparison groups (p<0.05) of HIV/AIDS knowledge and condom use Participants initiated a buddy system and fund-raising activities for persons with AIDS, organized drug- and alcohol-free weekly social groups. Some activities (not quantified) were still continuing a year after the funding for the project ended. Limitations of the Evaluation Method (also noted by the authors) are the non-random nature of the allocation between intervention and control and the reliance of self-reported data on condom use determined by interviews carried out by programme members. A disappointing feature of this study was that although empowerment theory was central to the intervention, there was no measure of achievement of empowerment among the participants.

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1.2 Popular media including drama and music

Bosompra, K. (1992) The potential of drama and songs as channels for AIDS education in Africa: a report on focus group findings from Ghana. International Quarterly of Community Health Education 12, 317-342.Ref ID : 2334

Target Group /Country Rural communities in Accra and the Ashanti and eastern regions of Ghana.

Intervention Methodology Health Education Division of the Ministry of Health established 3 drama troupes to carry out AIDS education on a pilot basis. Education was imparted through a play entitled The Bitter side of AIDS which was performed to communities, churches and factories in Accra and the Ashanti and eastern regions of the country. Songs with AIDS-related themes were incorporated in the dramas. The songs had also been broadcast on radio. Details of content of plays or songs are not provided.

Evaluation Method A total of 28 focus group discussions were held with groups of watchers and non-watchers immediately after the performances and one month later. The groups included the following categories: urban (males, females, out-of school youth, in-school youth) and rural (male, female and youth) Baseline studies before performances not carried out. Questions assessed awareness and knowledge of AIDS, impact of play and impact of songs. Details are not provided of analysis of qualitative data.

Impact Achieved Focus groups suggested (but no analysis of qualitative data presented) that self-reported knowledge and behaviour change increased and that even after one months key themes of the play were remembered. The play reinforced the misconception that you can tell if someone is infected with HIV. The songs were considered to have high entertainment value but limited educational value. Details are not provided of the total numbers of audiences reached or the separate responses of men, women, in- and out of-school youths. Useful insights are presented in this report on the audience's short-term and long-term reactions. However, the value of this study is limited by the lack of details of the actual performances and numbers reached, lack of baseline, lack of information on qualitative analysis.

Dole,L.R., Elkins,D.B., Boonjear,K., Phiensrithom,S. and Maticka-Tyndale,E. (1998)  Cattle markets and local festivals: development of HIV/AIDS prevention interventions for specific risk situations in rural northeast Thailand.  Health & Place  4, 265-272. Ref ID 8668

Target Group/Country Persons attending cattle markets and festivals in North East Thailand

Intervention Methodology Following local consultations interventions were developed for use at cattle markets and festivals for prevention of HIV transmission. At the cattle markets the cattle market owners and food vendors were involved in the programmes and condoms were made available free. The food shops were used as the focal point of the intervention. Messages were put on condom boxes, T-shirts for vendors, posters and mobiles for shops, stickers for trucks and motorcycles and key chains with pull-out drawers for condoms. At the festivals, the interventions worked through he village health workers. In addition to condoms boxes and posters a competition was held for songs and the winning songs were distributed on cassettes for broadcasts on village loudspeakers.

Evaluation Method A process model of evaluation was used which consisted of follow-up visits two months afterwards to the cattle markets, interviews with shop vendors, commercial sex workers, cattle traders and farmers. Details are not provided of the process evaluation of the festival interventions. Details of the samples or data-collection methods are not provided. There was no baseline or controls.

Impact Achieved Cattlemarkets: in interviews commercial sex workers stated that it was easier for them to negotiate safer sex after the intervention and that clients were more likely to have brought condoms themselves. Shopkeepers confirmed that both men and women accessed condoms. 3 months after 80 key chains had been distributed to cattle traders, throughout the region key chains were observed to be in use. Festivals: village health volunteers incorporated the AIDS prevention at village festivals. Exposure to the audiocassettes was reported to be high. Some villagers organized HIV/AIDS prevention training in festivals. A good description of the intervention is provided with illustrations of materials developed. It is disappointing that the process evaluation provided minimal information on the data collection method and there was no systematic presentation of data or analysis to support the conclusions.

McGill, D. and Joseph, W.D. (1997) An HIV/AIDS awareness prevention project in Sri Lanka: evaluation of drama and flyer distribution interventions. International Quarterly of Community Health Education 16, 237-255. Ref ID: 6890

Target/country Communities on West Coast of Sri Lanka.

Education methodology Dramas, performed primarily by volunteers, depicted the causes and consequences of HIV/AIDS. Performances were held in the evening and lasted about 2hrs. Flyers/leaflets illustrating specific facts about HIV/AIDS were given at the dramas and at specific sites, such as bus stations.

Evaluation Method Self-completed questionnaires were given out before (n=154 returns) and after (n=97 returns) two performances. The questionnaire consisted of a 10 item pre-test and 9 item post-test. This was supplemented with interviews with 21 key informants and observation of a performance. There were no controls.

Impact The dramas were performed 58 times but total numbers in the audience are not presented. There was no significant change in overall knowledge after the intervention (the initial level of knowledge was already high). 50% of the persons claimed to have learned something new from the flyers. Participant's attitude changes as a result of the intervention, with increases in respondents agreeing to statements about their susceptibility to the disease (p<0.01), about the desirability of seeking out advice from the Buddhist clergy if diagnosed with HIV/AIDS (p<0.0.2) and the. Limitations of the study are the low % of women in the sample (18%), lack of controls and measurement of long-term impact. There is a very good discussion of the practical problems of collecting data on the sample and the implication of the findings.

Skinner, D., Metcalf, C.A., Seager, J.R., de-Swardt, J.S., and et al. An evaluation of an education programme on HIV infection using puppetry and street theatre. Special Section: AIDS--the first ten years. AIDS Care 3(3):317-329, 1991.  Ref ID : 3731

Target/country Urban population in public places in South Africa.

Education methodology Dramas performed by puppets 2 meters high. The story describes how Joe, who is infected with HIV, passes the infection to others through his sexual liaisons before eventually dying of AIDS. Little or no pre-publicity is given before the company arrive at the venue, usually a busy centre. The activity begins to attract a crowd, then music and drums and announcements over a public address system attract people - and finally the puppets appear to the waiting crowd.   

Evaluation Method The impact on the audience at 21 live shows was assessed before and after the shows through an interview and questionnaire survey in English, Xosa and Afrikaans of a convenience sample of about 6 persons per show aged between 15 and 45 years (n-208 52.7% female, 47.3% male) . Another group was interviewed only after the show (n=96) to control for the effect of the pre-test questionnaire

Impact Audiences for the 21 shows were 100-500. Many people did not see the whole show because of other commitments. 97% or respondents said they enjoyed the show. Correct knowledge increased in five of the seven knowledge questions) expressed concern about AIDS increased (p<0.001), knowledge of the healthy carrier state (p=0.003), knowledge of modes of transmission (p=0.0008), the fatality of AIDS (p=0.023) and knowledge of protective behaviour (p<0.001).  There was significant increase in knowledge after watching the show. Limitations of the study are lack of controls and the short-term nature of the evaluation. The need to control for the pre-test was brought out in the data-analysis. There is no information presented of the total numbers reached by the programme or the costs involved.

Valente, T.W. and Bharath, U. (1999) An evaluation of the use of drama to communicate HIV/AIDS information. AIDS Education and Prevention 11, 203-211. Ref ID 8528

Target/country Men , women and children in inner-city slums in Madras, India

Education methodology Three dramas created by the Nalamdana theatre group to disseminate HIV/AIDS information. An average of 1000 people attend each performance which lasts between 1-2 hours

Evaluation Method Pre-drama and post-drama interviews were conducted with a cohort of randomly selected audience members from ten separate performances in Tamil Nadu state, India (N=93).; an interview was also conducted with a post -drama comparison group (N=99) who had not received the pre-test questionnaire. There were no control interviews of people who had not been exposed to the drama. The questionnaire consisted of 12 true/false knowledge questions and an open-ended question about how they would treat a neighbour if they discovered he/she had AIDS.

Impact A total of 121,000 people attended the dramas - estimated 47% women, 37%men and 16% children. There was a significant increase (p<0.01)  in HIV/AIDS-related knowledge in the group after watching the drama. Before the drama, audiences had relatively high levels of accurate knowledge about HIV/AIDS but lower knowledge levels of common HIV/AIDS misconceptions. The drama reduced these misconceptions. The drama also slightly increased the levels of reported intentions to treat HIV positive individuals more kindly.  The % of persons who stated that hey would treat the person with AIDS the same as everybody else increased from 17% to 50% (no significance data provided). The usefulness of this study is limited by the lack of description of the dramas, the short-term nature of the evaluation and the lack of a control group not exposed to the drama.

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1.3 Targeted interpersonal interventions directed at sex workers

Asamoah-Adu, A., Weir, S., Pappoe, M., Kanlisi, N., Neequaye, A., and Lamptey, P. Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana. AIDS 8(2):239-246, 1994. . Ref ID : 6213

Target group/Country Prostitutes in Accra, Ghana

Intervention Methodology This was a six month pilot programme and then  a further group of sex workers were involved in follow-up activities. Sex workers were selected from communities (not through clinics). Local health workers trained and support selected sex workers prostitutes to be health educators and condom distributors to their peers. The educational aims included promotion of condom use and discouragement from prostitution. Project staff distributed condoms and  peer education was supplemented by group teaching sessions with sex workers in the community, bars and clinics where questions from sex workers were answered and further information presented. Very little information on the educational content/methods provided.

Evaluation Method Interviews were carried out to determine self reported condom use at baseline (June 1987 n=71, end of pilot intervention (Jan 1988 n=44) With the expanded group Jan 1988 n=176) and a long-term follow-up in 1991 (n=162). A comparison group was mentioned in the paper but not details are provided.

Impact Achieved Reported 'ever used condoms with clients'  in the initial pilot group increased from 68% to 96% and 'always used condoms'  increased from 6% to 71% during the first 6 months of the intervention. In 1991, after 3 years with no programme support, 107 (43%) of the 248 women who had enrolled in 1987 or 1988 were still in prostitution and located for interview. Sixty-four per cent of those followed-up reported always using condoms with clients in 1991. These ‘always users’ were more likely to have maintained informal contact with project staff, know that HIV can be transmitted by healthy clients, and report that clients frequently initiate condom use. The main weaknesses of this study are lower numbers reached in the follow-up study, lack of data on the comparison/control group and the reliance on self-reported use of condoms as an indication of behaviour change. The recruitment of a second group of sex workers to the study makes the evaluation method difficult to follow.

Bhave, G., Lindan, C.P., Hudes, E.S., Desai, S., Wagle, U., Tripathi, S.P. and 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, S21-30.. Ref ID : 4099

Target group/Country Sex workers and madams in the brothels of Bombay.

Intervention Methodology A clinic was set up in the target community in red-light areas of Bombay which acted as a point of contact and referral for sex workers. All subjects in the intervention group underwent a programme of 3-4 session which included larger groups of 25 to watch educational videos in Hindi, smaller groups of 10-15 for group discussions free condoms and a pictorial chart on the use of condoms were also distributed.  Pre-test counselling was given before blood was drawn for the HIV test. Madams attended 1-2 small group sessions. Social functions were organized for the madams and sex workers at the time of two Hindu festivals.

Evaluation Method A controlled intervention trial, with measurements before and 5-6 months after the intervention, 334 sex workers and 20 madams were recruited from an intervention site, and 207 and 17, respectively, from a similar control site, both in. All sex workers were tested for antibodies to HIV and syphilis, and for hepatitis B surface antigen. Information on sexual practices, condom use and knowledge of HIV was collected by interviewer-administered questionnaire given immediately after receiving the HIV test results. The blood tests and the questionnaire were re-administered to all subjects at both sites immediately after the intervention. Both groups were followed for approximately 1 year.

Impact Achieved The baseline level of knowledge about HIV and experience with condoms was extremely low among both sex workers and madams. The level of knowledge increased in the intervention group with little increase in controls (p<0.001). The baseline prevalence of HIV antibodies was 47% in the intervention group and 41% in the control group (P = 0.17). The incidence densities for HIV and sexually transmitted diseases were significantly less in the intervention group compared to control all p < 0.005): 0.05 and 0.16 per person-year of follow-up for HIV, 0.08 and 0.22 per person-year for antibodies to syphilis, and 0.04 and 0.12 per person-year for hepatitis B surface antigen in the intervention and control women, respectively. Following the intervention, women in the intervention group reported increased levels of condom use ('always use' 3% 28% p<0.001) with no change in controls , and some (0% 41%, p<0.001) said they were willing to refuse clients who wouldn’t use them. However, almost all the sex workers and the madams remained concerned about losing business if condom use was insisted upon. Note - lack of any impact on knowledge of controls does not reflect very well on the quality of the pre-test counselling given. This study is significant in demonstrating both an impact on self-reported condom use and HIV/STD status.

Egger,M., Pauw,J., Lopatatzidis,A., Medrano,D., Paccaud,F. and Smith,G.D. (2000)  Promotion of condom use in a high-risk setting in Nicaragua: a randomised controlled trial.  Lancet  355, 2101-2105. Ref ID 8741

Target group/Country Commercial sex and non-commercial sex users of motel rooms in Managua, Nicaragua

Intervention Methodology Three types of condom provision were tested: two condoms given on request; two condoms left on beds in motel rooms; and two condoms given to couples before they entered the room. The condoms were presented in glossy envelopes, each with a heart printed on the front and the Spanish text for "by courtesy of the management" printed on the back. Printed materials included a poster and a leaflet The posters measured 56x44 cm and showed a drawing of a naked couple. The leaflet was 7x11 cm and unfolded to four pages. The picture on the cover of the leaflet was the same as the poster and the leaflet contained six pictures showing correct use of condoms and comic-book style drawings explained the advantages of using a condom. Information on STDs and HIV infections in Nicaragua were given.

Evaluation Method In a randomised controlled trial, in 19 motels, condoms were given out on request, made available in rooms, or given directly to couples, with and without the presence of health-education material in the rooms. In a factorial design condom use was assessed directly by field staff dressed as cleaners searching the rooms after couples had left  Condom use was defined as retrieval of at least one condom containing semen. Clients of the rooms were not aware of the fact that a study was being carried out. The giving out of condoms on request was treated as the control). Condom use for 6463 couples was recorded on 456 motel days between July 31 and October 4th 1997.

Impact Achieved 11 motels were used mainly by sex workers and their clients and eight mainly for non-commercial sex. 6463 couples attended the motels in 24 days. On 3106 (48.0%) occasions, at least one used condom was retrieved. Condom use was more frequent for commercial sex than for non-commercial sex (60.5 vs 20.2%). The presence of health-education material lowered the frequency of condom use for commercial sex (odds ratio 0.89 [95% CI 0.84-0.94]) and had no effect on use for non-commercial sex (1.03 [0.97-1.08]). Condom use increased for commercial (1.31 [1.09-1.75]) and non commercial sex (1.81 (1.14-2.81) if condoms were available in rooms. Directly handing condoms to couples was similarly effective for commercial sex but less effective for non-commercial sex (1.32 [1.03-1.61] vs 1.52 [1-01-2.38]). Note only 19 of 36 motel owners chose to participate. The number of condoms retrieved from the more expensive rooms with en-suite facilities was less - this probably resulted in an under-reporting of condom use for non-commercial sex. This study is unique in not relying on self-reported behaviour change. The negative impact of health education material on condom use was a surprising result - if repeated would have implication for the use of these materials elsewhere in the country.

Ford, K., Wirawan, D.N., Fajans, P., Meliawan, P., MacDonald, K., and Thorpe, L. Behavioral interventions for reduction of sexually transmitted disease/HIV transmission among female commercial sex workers and clients in Bali, Indonesia. AIDS 10(2):213-222, 1996. . Ref ID : 6100

Target group/Country Low-price female commercial sex workers (CSW) in large brothel complexes, their pimps, and their male clients during 1994 in Bali, Indonesia

Intervention Methodology Trained outreach workers carried out a 3 session series of interactive lectures for commercial sex workers that covered knowledge or AIDS and STDs, condoms and negotiating skills. The education also sought to dispel the myth that AIDS is a disease of tourists only and that CSWs can become infected. This was supplemented by visits to the complexes where they worked six days per week to provide informal advice and distribute condoms.  Following an introductory session with pimps, a training session was carried with them. Condoms were supplied at a subsidized price to pimps who sold them to clients at a profit. Posters and pamphlets targeted at clients were made available at the CSWs places of work. Note that the high turnover of sex workers was stated as the reason for not using a peer education approach.  Theoretical perspectives guiding the intervention were the Health Belief Model and social cognitive theory.

Evaluation Method 200 CSWs and 200 clients from intervention areas and 100 CSWs and 100 clients from a control area were interviewed at baseline. After 6 months of programme activity The same numbers of interviewed . Approximately 50% of women in the baseline survey were also in the follow-up survey. The interview consisted of 14 questions on AIDS 13 questions on STDs and condom use in the last week and month. Self efficacy was measured through two questions: the first concerned their willingness to ask a client to use a condom and the second was their degree of certainty that the clients would use it. Interviews were conducted with the pimps before the training sessions and in the post-test interviews, CSWs were asked questions about their pimp's actions towards condom promotion.

Impact Achieved Both AIDS and sexually transmitted disease (STD) knowledge increased significantly over the intervention period (p<0.01). Condom use for vaginal sex with paid partners the day before the interview increased substantially in the two intervention areas: 1875% and 2962% (both at p<0.01). Condom use also increased in the control area, although the difference between baseline and evaluation measures was smaller. There were increases in self efficacy for both measures at p<0.01 level for the intervention groups. For the control group there was no increase in the first measures and an increase at only p<0.05 level for the second measure. There was some impact on the knowledge of clients on AIDS and STDs at p<0.01 and p<0.05 level but less impact on condom use (p<0.01 for one intervention community only, n.s for other intervention and control community). Data showed that older, married and less educated men were less likely to use condoms with CSWs. Data from the client interviews may be affected by the need to do them in daytime and that some interviews took place before their encounters with the CSWs. Multivariate analyses indicated that programmatic factors such as attendance at education sessions and reading the project brochure were related to condom use. Note, that this intervention is unique in its attempt to evaluate impact on clients, CSWs and pimps.

Ford,N. and Koetsawang,S. (1999)  A pragmatic intervention to promote condom use by female sex workers in Thailand.  Bull. World Health Organ  77, 888-894. Ref ID: 8664

Target group/Country Female commercial sex workers in Nakhon Pathon, Central Thailand

Intervention Methodology The project involved a succession of stages including pre- programme needs assessment, intervention design, implementation and evaluation. The intervention took place over a 6 month period and  key elements were: 1) training and briefing of health personnel in HIV counseling and education; 2) liaison with sex establishment management about promoting the 100% condom use policy; 3) an interactive series of sessions for sex workers using video and audio-cassettes aimed at helping sex workers to explore their personal and work-related dilemmas and concerns. A core objective was to enhance sex workers' self-esteem and perceived future with a view to strengthening their motivation to take preventive action against HIV infection;

Evaluation Method The intervention was evaluated using a combination of qualitative (process evaluation) and quantitative (outcome) methods. The outcome evaluation was undertaken using a pretest, post-test intervention and control group quasi-experimental design. The total number in the sample (not counting those who had dropped out from the post-test) 142 intervention group (80 high income/62 low income) and 80 in the controls (12 high income/68 controls). The data collected included: consistency of condom use, attitudes to condom use, knowledge of AIDS, self esteem, sexual  practices and interaction with their last three customers. A 15 item scale was used - this was based on a scale by R.Rubin, translated into Thai and adapted for use with sex workers.  (Data collection instruments and sampling method are not described)

Impact Achieved The condom use in high income intervention group rose from an already high level of 92% to 97% but small sample size caused by drop-out meant this was not significant. Condom use in low income intervention group rose from 66% to 86% which was significant at p<0.05% compared with a decline from 83% to 74% in the controls. There were significant increases in consistent condom use among the intervention groups but not among the controls. The self esteem in the low income sex workers showed a moderate improvement during the intervention but there was no change in self esteem among the low income control sex workers. Migh income sex workers was high at the outset and improved further. The participatory process used in the intervention is particularly well described in the study and the measurement of intervening variables such as self esteem is a welcome feature of the study.

Fox, L.J., Bailey, P.E., Clarke-Martinez, K.L., Coello, M. and et al. (1993) Condom use among high-risk women in Honduras: Evaluation of an AIDS prevention program. AIDS Education and Prevention 5, 1-10.. Ref ID : 3645

Target group/Country Registered commercial sex workers (CSWs) attending a STD control clinic in Tegucigalpa, Honduras.

Intervention Methodology The program consisted of weekly talks and free condom distribution to all CSWs who attended a clinic for sexually transmitted diseases during a 10-wk period. The talks were given by a physician-health educator team which conducted lectures and slide presentations on syphilis, gonorrhoea, genital ulcer disease, vaginal infections and the transmission, prevention and diagnosis of AIDS and high-risk behaviour. A graphic artist attended the series to involve the CSWs in the design of an AIDS poster tailored to this target group. During that period CSWs submitted weekly diaries of their client encounters on the basis of which they received free condoms. The project ws not able to continue the supply of free condoms after the programme.

Evaluation Method Pre- and post-intervention surveys of 134 CSWs were used to evaluate change in knowledge, attitudes, and sexual practices. Note that 292 CSWs completed the original questionnaire. Only 182 of these could be reached during the follow-up and  of these only 134 provided data on client and condom use and were used for the evaluation. Socio-demographic and work profiles of the 134 appeared similar to those who were lost to the study. The follow-up survey was carried out four months after the end of the programme at a time when free condoms were no longer being distributed. The diaries prepared by the sex workers during the 10 week programme were also consulted to provide data on client encounters during the programme. There was no control

Impact Achieved 84% of the sex workers attended at least 7 clinic presentations. The mean transmission knowledge scores increased significantly from 37% in the pre-test to 53% in the post-test (p<0.001). Attendance was associated with a significant increase in transmission knowledge scores  (p<0.01 for attending 7-9 lectures). Mean preventive knowledge scores decreased slightly from 71% to 68% and the change in knowledge of safer-sex practices were neither statistically significant nor did they increase with attendance. Increase in mean condom use from 64% to 70% of client contacts (p<0.05%) 4 mo after the intervention. The diaries showed an even greater increase in condom use during the intervention averaging 90% protected contacts which might be a reflection of the availability of free condoms. Greater knowledge did not appear to be associated with an increase in condom use. Note that the poor impact on knowledge of preventive measures might be due to the very biomedical approach in training. Lack of a control makes it difficult to attribute the increase in condom use to the programme.

van Griensven, G.J.P., Limanonda, B., Ngaokeow, S., Ayuthaya, S.I.N. and Poshyachinda, V. (1998) Evaluation of a targeted HIV prevention programme among female commercial sex workers in the south of Thailand. Sexually Transmitted Infections 74, 54-58.. Ref ID : 8189

Target group/Country Female commercial sex workers in the south of Thailand.

Intervention Methodology In Sungai Kolok sex workers were enrolled in the programme through a government run STD clinic. 100  "Walkman" and 600 cassette tapes with music and information messages were circulated among women and leaflets and comic books on HIV were handed out at the STD clinic. Videotapes were shown at the STD centre and provided for showing in sexual service establishments. Two peer leaders were selected ad given three on-day training sessions. Establishments were visited every two weeks by a nurse. Condoms were distributed free to sex establishments and via clinics.

Evaluation Method A pretest-post-test comparison group study was carried out in Sungai Kolok and Betong between June and December 1994. In June 408 CSWs were entered in Sungai Kolok (the intervention area) and 343 CSWs were enrolled in Betong (the comparison area  where women were recruited during six monthly visits by district hospital staff to sex establishments In December 1994, 416 women were enrolled in Sungai Kolok and 342 in Betong. Of these women 37% (n = 283) also participated in the June survey. Comparison was made on the total samples, not just on the ones who could be followed up. All women completed an oral interview with questions used to construct scales for knowledge, transmission and perceived vulnerability. Blood samples were collected for HIV serology.

Impact Achieved An increase in know of the prevention of transmission significantly  in intervention area (p<0.001) and in the control (p<0.02). The proportion of CSWs using condoms with the last three customers increased significantly (p<0.01)  in both intervention community (68%77%) and control (73%84%). Increase in knowledge and perceived vulnerability was more pronounced in the intervention area but did not translate into a greater increase in condom use. Refusal of customers unwilling to use a condom and manager support in doing so were the only factors independently related to positive changes in condom use. HIV prevalence (approximately 20%) and incidence (approximately 4.2 per 100 women years) were the same in both study locations. Women in the intervention area reported significantly fewer customers and income from sex work, possibly as a result of a coincidental police campaign to suppress (child) prostitution.  Given the high (but uncosted) programme inputs the lack of impact would seem surprising. However, the proportion of women at the outside using condoms was already high which might explain the small impact achieved during the programme. While the geographical separation between intervention and control communities reduced the likelihood of communication of programme activities across, both groups were exposed to substantial HIV education activities from other sources during the period of study.

Laga,M., Alary,M., Nzila,N., Manoka,A.T., Tuliza,M., Behets,F., Goeman,J., St Louis,M. and Piot,P. (1994)  Condom promotion, sexually transmitted diseases treatment, and declining incidence of HIV-1 infection in female Zairian sex workers.  Lancet  344, 246-248.Ref ID: 8177

Target group/Country Prostitutes in Kinshasha, Zaire.

Intervention Methodology A programme of monthly sexually transmitted disease screening, free treatment and condom promotion at a women's health center specially set up within easy reach of the women. Women received monthly individual health education and free condoms. In addition every three months a group session for condom promotion was held.

Evaluation Method Regular follow-up of a cohort of 531 HIV negative women participating in the programme. Condom use was assessed by monthly interviews covering the last working week. There were no controls.

Impact Achieved Among 531 initially HIV-1 negative female sex workers in Kinshasa, Zaire, 70 became infected with HIV-1 (incidence of 8.0 per 100 women-years [wy]). A decline of HIV-1 incidence was observed over time, from 11.7/100 wy during the first 6 months, to 4.4/100 wy over the last 6 months, 3 years later (p = 0.003). Simultaneously, regular use of condoms with clients went up from 11% to 52% and 68%, after 6 and 36 months of intervention, respectively. Risk factors for HIV-1 seroconversion after multivariate analysis included irregular condom use (RR 1.6 [95% Cl 1.1-2.8]), gonorrhoea (RR 2.5 [1.1-6.4]), trichomoniasis (RR 1.7 [1.1-2.8]), and genital ulcer disease (RR 2.5 [1.1-6.4]), during the probable period of acquisition of HIV-1. In women who attended more than 90% of their clinic appointments, the HIV-1 incidence was 2.7/100 was compared to 7.1, 20.3, and 44.1 per 100 wy among women who attended 76-90%, 50-75%, and less than 50% of the monthly appointments, respectively (p < 0.0001). These trends remained after controlling for reported condom use and number of clients. While pointing the value of the clinic-based intervention consisting of STD care and condom promotion, lack of information on the educational component makes it difficult to attribute the relative contribution of educational and clinical programme components.

Moses, S., Plummer, F.A., Ngugi, E.N., Nagelkerke, N.J., Anzala, A.O. and Ndinya-Achola, J. (1991) Controlling HIV in Africa: Effectiveness and cost of an intervention in a high-frequency STD transmitter core group. AIDS 5, 407-411. Ref ID : 3757

Ngugi, E.N., Plummer, F.A., Simonsen, J.N., Cameron, D.W., Bosire, M., Waiyaki, P., Ronald, A.R. and Ndinya-Achola, J.O. (1988) Prevention of transmission of human immunodeficiency virus in Africa: effectiveness of condom promotion and health education among prostitutes. Lancet 2, 887-890.. Ref ID : 3289

Ngugi, E. and Plummer, F. (1991) Prostitutes teaching prostitutes in Nairobi. In: Anonymous AIDS prevention through health promotion: facing sensitive issues, pp. 51-55. Geneva, Amsterdam: World Health Organization [WHO], Royal Tropical Institute]. Ref ID : 2425

Target group/Country Prostitutes in Nairobi, Kenya

Intervention Methodology Health education was provided at barazas (general community meetings including lectures, skits, role playing, and discussion) and individual counselling sessions. Prostitutes were located from the roster of clients treated for sexually transmitted diseases (STDs) of the Skin and Special Treatment Clinic. Team members made brief visits to the women in their homes and introduced themselves as health personnel interested in reducing the prevalence of STDs. 300 prostitutes attended the first public meeting or baraza. The team explained the transmission, effects and prevention of AIDS. Invitations were made to visit the new clinic. A leader and committee were formed by the women. Committee members from the 3 villages were trained in community mobilization and basic communication skills in order to effectively promote condom use. The health team met with the village health committee every 2 months, during which time some women were identified as carrying the HIV virus. They were advised to give up prostitution or to insist on condom use. Questionnaires and other interactive activities such as role playing were initiated.

Evaluation Method A cohort study had followed 595 prostitutes since January 1985 with data-collection on all prostitutes carried out in January, May and November 1986. For purposes of analysis the cohort members were retrospectively divided into three groups for purpose of analysis. 1) those who received their health education through both barazas and individual sessions at which the results of serological tests for HIV infection were discussed (n=91; 2) those who attended barazas only (n=67) ; and 3) the ones who had received neither intervention n=205). Condoms were distributed free of charge to all prostitutes who requested them. Condom use was measured by reported number clients in the preceding week using condoms and a semi-quantitative estimation of condom use (never, occasional, often, always).

Impact Achieved At the start of the study, 61% of these prostitutes were infected with HIV and only 10%, 7%, and 7% of prostitutes in Groups 1, 2, and 3, respectively, reported some use of condoms. After 6 months in the program, this statistic had increased to 80%, 70%, and 58%, respectively. The mean frequency of condom use was 38.7%, 34.6%, and 25.6% of sexual encounters in Group 1, 2, and 3 women. Any condom use resulted in a 3-fold reduction in risk of seroconversion. 20 of 28 women who were not condom users seroconverted compared with 23 of 50 condom users. Stepwise logistic regression confirmed that group discussion was the factor most significantly associated with condom use. Note the authors stated that their reason for using this rather complex model was that they felt that a randomised clinical trial would have been unethical. It is difficult to establish from the paper whether the group 3 were part of the original cohort of 506 followed up since Jan 1985 or an additional group of women outside this group. It is assumed that they were part of the original group. Note this is the classic study that first showed that health education could have an impact on seroconversion. An economic analysis of the programme suggests that the cost of the programme is $8-12 per case of HIV transmission prevented which is remarkably low.

Pickering, H., Quigley, M., Pepin, J., Todd, J. and Wilkins, A. (1993) The effects of post-test counselling on condom use among prostitutes in The Gambia. AIDS 7, 271-273. Ref ID : 7235

Target group/Country Counselling of prostitutes in the Gambia

Intervention Methodology Post-test HIV counselling given in local language by trained field workers to sex workers who had taken part in a sero-survey. During the counselling the meaning of the test result was explained, advice on safer sex given, free condoms distributed and they were told that they could come to the clinic for treatment and condoms whenever they wished.

Evaluation Method Cohort study of thirty-one (12 HIV-positive and 19 HIV- negative) prostitutes. Data collection before and 2-5 months after counselling representing 4949 sexual contacts. Note- the reason for the small sample was the high turnover and difficulty of tracing the sex workers. There were no controls.

Impact Achieved Overall, counselling did not increase reported condom use. The authors use this to conclude that scarce resources should be directed towards providing condoms in bars rather than counselling. However, it should be noted that detailed information on the counselling process and quality are not provided and that the small size of the cohort makes statistical analysis very difficult.

Swaddiwudhipong, W., Nguntra, P., Chaovakiratipong, C., Koonchote, S., Lerdlukanavonge, P., and Chandoun, C. Effect of health education and condom promotion on behavioral change among low socioeconomic prostitutes in Mae Sot, Tak, Thailand. Southeast Asian J.Trop.Med.Public Health 21(3):453-457, 1990.  Ref ID : 2568

Target group/Country Female prostitutes in Mae Sot, Tak Province, Thailand. Intervention carried out by STD clinic in hospital serving a semi-rural district.

Intervention Methodology The educational intervention consisted of education given during routine monthly visits to brothels, use of mass media and during visits by prostitutes to clinics. This was supported by free condom distribution.

Evaluation Method 248 prostitutes were interviewed in January 1989 and at the end of the intervention in December 1989, 373 were interviewed.. No controls. It is not stated whether the same prostitutes were followed up or the sample was merely those who attended the clinic.

Impact Achieved The proportion of prostitutes’ sexual partners using condoms increased from 13.5% in January 1989 to 50.4% by December 1989. The proportion of prostitutes who said that they would refuse to have sex with a man who refused to use condoms increased from 2.4% to 17.2% There was a decline in the incidence rate of gonorrhoea among the prostitutes during the same period. Anal intercourse decreased from 9.7% in January to 1.8% in December 1989. None of the 248 prostitutes tested in January 1989 were HIV-1 seropositive. 10 of 405 (2.5%) initially-seronegative prostitutes who were subsequently tested at 3-month intervals became seropositive. Raw data or significance tests not provided.. Lack of clarity on the identity of the women followed up and lack of use of controls limits the value of this study.

Visrutaratna, S., Lindan, C.P., Sirhorachai, A., and Mandel, J.S. 'Superstar' and 'model brothel': developing and evaluating a condom promotion program for sex establishments in Chiang Mai, Thailand. AIDS 9 Suppl 1:S69-75, 1995. . Ref ID : 6211

Target group/Country Sex workers, brothel owners and clients in the city of Chiang Mai, Northern Thailand

Intervention Methodology A year-long intervention targeted 500 women from 43 sex establishments. . 15 teams of 3-4 public health workers conducted 2-h training sessions with small groups (5-10 sex workers) every 3 months for 1 year. Each team was assigned to 6-8 sex establishments. The sessions were carried out at the women's place of work and aids used included a flip chart, models of penises, and special card game and role play games. 1-3 experienced women (‘superstars’) were trained as peer educators for each establishment. Influential brothel owners were selected to develop ‘model brothel’ to influence others in the locality. A free condom supply for sex establishments was established. Note -the educational methodology used is particularly well described in this paper.

Evaluation Method 20 trained volunteers posing as clients tested a sub sample of one in five sex workers per establishment to see whether they insisted on condom use. A convenience sample of 24 women from 11 brothels was tested before the intervention, a larger sample of 78 women were evaluated one year later in 1991 and a further sample of 86 in 1992.Initially the "client" would note whether the sex worker asked him to use a condom; second, he would insist on not using a condom and observe whether the sex worker refused; third, he would offer the sex worker three times her customary fee if she would have sex without a condom. (note that If she insisted on using a condom he left, if she agreed to have sex without a condom, an excuse was made for him leaving). There were no controls.

Impact Achieved The intervention was well received by sex workers and obtained strong support and cooperation from brothel owners. Before the intervention, only 42% (10/24) of women surveyed by volunteers posing as clients refused to have sex without a condom, even when the client insisted and offered to pay three times the usual fee. Following the program, 92% (72/78) refused; 1 year later, 78% (69/86) refused during the same. The three factors identified for success of the programme were: securing endorsement of brothel owners to a policy of refusing clients not using condoms, participation of the sex workers through appealing to the long term benefits for future family life of staying healthy and the use of peer educators. A strength of this project is the use of simulated clients and the detailed description of educational methods. A weakness is the lack of controls.

Walden, V.M., Mwangulube, K. and Makhumula-Nkhoma, P. (1999) Measuring the impact of a behaviour change intervention for commercial sex workers and their potential clients in Malawi. Health Education Research: Theory and Practice 14, 545-554..Ref ID : 8561

Target group/Country Commercial sex workers and their clients in Malawi

Intervention Methodology A peer-education HIV/AIDS prevention programme for bar-based sex workers and their potential clients long-distance truck drivers in Malawi. The programme had been running since 1991 and had  trained 1183 sex workers from all 24 districts by 1992.  the high turnover of bar girls meant that the peer education programme had to be continued but on a smaller scale.

Evaluation Method All bar-based sex workers were interviewed in two districts from three categories: active - where peer education training had taken place within the last year (n=147); non-active where no training had taken place since the initial programme in 1991 (n=154) and average - districts were training had taken place but there was little observed activity (n=123).  6 focus group discussions were held.

Impact Achieved 70% of whole sample said that they had used a condom in their last sexual encounter. This was only a slight increase (non-significant) over 67.5% reported in the 1991 study. Levels of condom use were The results showed that in the active districts, the presence of sex worker peer educators was associated with  increased condom use with paying partners (90.3 compared to 66.7 and 76.3% in the two other groups-non-active and  average p<0.01) and increased condom distribution. Condom use with regular non-paying partners of sex workers was not higher with bar girls in the active districts. Even in the active districts, only 40.1% of bar girls reported having heard of AIDS from a peer educator (compared to 27.5% and 23.6% from non-active and average group p<0.001) raising questions about the credibility and acceptability of peer educators. The qualitative data provides useful insights into issues concerning use of condoms with non-paying sexual partners and the acceptance of educators by their peers.

Williams, E., Lamson, N., Efem, S., Weir, S., and Lamptey, P. Implementation of an AIDS prevention program among prostitutes in the Cross River State of Nigeria [letter]. AIDS 6(2):229-230, 1992.  Ref ID : 2526

Esu-Williams, E. (1998) Sexually transmitted diseases and condom interventions among prostitutes and their clients in Cross River State Nigeria. Health Transition Review 5, 223-228.Ref ID : 8009

Target group/Country Prostitutes and male clients in hotels and housing settings, both in the Cross River Esu-

Intervention Methodology The program consisted of  three components: (1) Health education involving educational sessions in hotels at compounds for sex workers and clients, group discussions, film shows and distribution of materials in hotels and night clubs for part time sex workers and outreach activities by male and female peer educators; (2) Condom promotion based on initial free distribution then a cost recovery programme which allowed condom vendors to make a small profit; (3) STD services through setting up of a special clinic.

Evaluation Method Number of condoms distributed and attendances at STD clinics were monitored. Baseline survey carried out of 139  sex workers and follow-up survey one year later of 102 sex workers. Sampling information not provided. There was no baseline.

Impact Achieved Between September 1989-September 1990, the program reached >1000 clients and partners and 450 prostitutes in Calabar and 700 full time prostitutes and >1500 clients and partners in Ikom. The monthly distribution of condoms from all sites varied between 4000-58, 000. Patients at the STD clinic rose consistently from 16-13,510. There was an increase in sex workers reporting to always use condoms from 12.2% to 24.2%. Only 34.8% of prostitutes at the beginning of the study knew that sexual intercourse transmits HIV but all knew it by the end of the study. By the end of the study, >96% knew the 3 other modes of transmission: mother to child, healthy carrier, and blood. Moreover, at the end of the study, 82.9% believed condoms to be effective in preventing AIDS compared to only 17.4% prior to the study. Lack of information on sampling, control or significance data severely limits the value of this study.

Wong, M.L., Chan, R., Lee, J., Koh, D. and Wong, C. (1996) Controlled evaluation of a behavioural intervention programme on condom use and gonorrhoea incidence among sex workers in Singapore. Health Education Research: Theory and Practice 11, 423-432. Ref ID : 5830

Wong, M.L., Chan, K.W. and Koh, D. (1998) A sustainable behavioral intervention to increase condom use and reduce gonorrhea among sex workers in Singapore: 2-year follow-up. Preventive Medicine 27, 891-900.  Ref ID : 8398

Target group/Country Female brothel-based sex workers in Singapore

Intervention Methodology The intervention programme concentrated on developing sex workers’ condom negotiation skills, and on gathering support from peers, brothel keepers and heath staff in promoting condom use. The intervention was based on Green's Precede framework, social learning theory and the Theory of Reasoned Action. The intervention consisted of two 2hr small group sessions  with 16 participants on condom negotiation skills using role play and peer led discussion in the public STD clinic. 3months later a booster session was held with peer leaders to get feedback on problems and discuss possible solutions. Individual counselling was provided to non condom using sex workers brought to the attention of the programme by peer leaders. The content and theoretical basis of the educational sessions are well described but the specific details of the use of peer leaders including supervision, training and monitoring are not provided.

Evaluation Method A pre-test/post-test design with one intervention site (n = 124) and another comparable control site (n = 122) was maintained for 5 months followed by a time series design to follow up the intervention group for 2 years. The three outcome measures are self-reported success in persuading clients to use condoms, refusal of sex without a condom, and cumulative gonorrhoea incidence as measured by the percentage of sex workers with a new occurrence of a positive culture in the 5 month period before and after the intervention.

Impact Achieved At 5 months, the intervention group improved significantly in negotiation skills and at 72% were almost twice as likely as controls to always refuse unprotected sex (adjusted rate ratio 1.90, 95% CI 1.22-2.94). Gonorrheae incidence declined considerably by 77.1% in the intervention group compared with 37.6% in the controls. Consistent refusals of unprotected sex in the intervention group increased from 44.4% at baseline to 65.2% at 5 months, 73.6% at 1 year, and 90.5% at 2 years with a corresponding decline in gonorrheae. Success in the promotion of sustained, consistent condom use was attributed by the authors to maintained contact with the sex workers, continual appraisal of their problems and appropriate solutions and on going support from health staff, peers and brothel keepers.

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1.4 Clinic-based education and counselling

Asuzu, M.C., Rotowa, N.A. and Ajayi, I.O. (1990) The use of mail reminders in STD contact tracing in Ibadan, Nigeria. East. Afr. Med. J. 67, 75-78. Ref ID : 8393

Target group/Country STD patients and their contacts at an STD clinic in Ibadan, Nigeria

Intervention Methodology A two year trial of contact tracing.. Every patient is initially seen by the health sister/contact tracer who gives the patient an audio-visual aided health education on STD and obtains information on contacts. The patients are then seen by the doctor who provides treatment, reinforces the counselling and gives the patients notes for their contacts asking them to come for treatment. If the patient does not come back for follow-up or the contact does not come a reminder sticker is sent to them.

Evaluation Method Follow up of 2444 STD patients using attendances from clinic records. There were no controls

Impact Achieved 141 letters were sent to defaulting patients, 27% were returned by postal services as untraceable, only 7 of the patients responded to the reminder and came for follow-up. None of the 39 contacts to whom letters were sent responded and came to the clinic. The project managed to trace 7 of the original 103 patients  - 6 of whom had not returned for treatment because their symptoms had disappeared and they considered themselves cured. This is a very simple and unsophisticated but it does emphasise the difficulty of carrying out contact tracing and points to a lack of effectiveness of reminder letters.

Faxelid,E., Tembo,G., Ndulo,J. and Krantz,I. (1996) Individual counseling of patients with sexually transmitted diseases. A way to improve partner notification in a Zambian setting? Sexually Transmitted Diseases 23, 289-292.Ref ID: 8969

Target Group/Country Sexually transmitted disease patients at an urban health center in Lusaka, Zambia

Intervention Methodology All patients received information and routine STD care. The intervention was a one-to-one counseling session in which a female nurse talked with women patients and a male clinical officer talked to males. Approximately 10-20 minutes were spent with each patient in the intervention group proving information about STDs (transmission, treatment, complications and prevention), the need to complete treatment, not having sex during treatment period and why and how they should inform their sexual partners from the previous 3 months. Names and addresses of the sex partners were registered and patients received contact slips to give to all their sex partners. The contact slips began with the sentence "To love is to care and explained the importance of seeing health care even in the case of no symptoms. No details are provided of the routine STD provided and the information that the control group would have been exposed to.

Evaluation Method A randomized trial comprised of 94 female and 302 male patients diagnosed with a clinical or laboratory diagnosed STD (patients with only one STD) who were asked to come back for a follow-up and second interview two weeks after the intervention. Clinic data monitored persons coming to clinic for referral cards which could be traced to original index patient through a reference number. 20 men (6%) did not want to participate in the study and were excluded before randomization. 8 patients from the intervention group and 11 from their control group did not show for the second interview.

Impact Achieved In the intervention group using self-reported data from index patients, 1.8 partners per man was treated compared to 1.2 in the control group (P < 0.001). There was no difference between the two groups of women. Judged by the number of contact slips recorded 1.6 partners per man and only 0.4 partners per women in the intervention group. Among the stated reasons for not telling partners was that they could not afford to buy medicines, their partners were unknown or out of town and that the patients did not realize that they needed to refer more than one partner (the latter explanation only provided by persons in the control group). Of interest are the gender issues raised by the apparent lack of communication by female patients with their partners and ethical issues raised by the authors in their findings that breaking the news to partners caused more quarrels with sex partners in the male intervention group than male control group and the possible problems of providing written contact information to persons who are illiterate. The authors draw the conclusion that individual counseling of men with STD improved partner notification. The main limitation of this study is the comparison data with controls is based on self-reported referrals which may be subject to bias and it is not clear what health education was provided to the control group as part of routine care. Also, it is not possible to separate out the effects of the counseling and referral slips. Also the policy at this health service was not to treat an index patient unless they bring a partner which may affect the generalisability of the study to other settings (it is also not clear whether an accompanying partner at the initial interview counted towards the successful contacts treated).

Hira, S.K., Bhat, G.J., Chikamata, D.M., Nkowane, B., Tembo, G., Perine, P.L. and Meheus, A. (1990) Syphilis intervention in pregnancy: Zambian demonstration project. Genitourin. Med. 66, 159-164. Ref ID : 6449

Target group/Country Pregnant women in Lusaka, Zambia.

Intervention Methodology The health education targeted at: a) sexually active women attending prenatal, family planning and underfives clinics, b) sexually active men and women attending the outpatient departments c) elderly men and women attending outpatients (important as  community motivators of behavioural change). Two 5 day workshops to train the study centres health staff in health education, clinical evaluation, serological testing for syphilis and assessment of pregnancy outcomes.  "Active syphilis intervention":  Control clinics continued with original antenatal health education and syphilis screening / treatment programme.  Health education intervention at study centres consisted of: a) New health education messages: A list of 20 topics were developed with help of local leaders. These included sessions on "syphilis", "congenital syphilis" and "STDs (general)" p.161. Other topics included prenatal care, immunisation, anaemia in pregnancy etc. messages "kept simple, clear and repetitive" with local words, picture and stories being used (messages modified at 6 and 9 months to make more simple and understandable). Methods: lectures, question and answer sessions, handouts, brainstorming, group discussion, audio messages, and individual counselling. Sessions had 12-15 people attending. Topics repeated "several times" during the year.

Evaluation Method Three control centres and three study centres (n=5007). Centres all comparable in size and  socio-economic status . During pre-intervention phase, approximately 150 consecutive pregnant women from each of the three study and the three control centres were recruited when they presented in labour at the University Teaching Hospital.  Pre (early intervention) and post (late intervention) questionnaires were given to 150 differing prenatal attenders at each study centre to determine a)pattern and frequency of prenatal attendance b) reasons for attending late in pregnancy. During  Feb - June 1987: "evaluative pregnancy outcomes "were determined in  post intervention study. Study centre (n=806), control centres (n= 1274).

Impact Achieved The % of women who had their first prenatal visit under 16 wks gestation improved from 9.4 to 42.5%. The main reason for not attending before 16 weeks was that it  not thought necessary (55.1%, 145/263 respondents). There was no difference between the study and control groups in the sero prevalence of syphilis.  Adverse pregnancy outcomes of syphilitic pregnancies at study centres reduced from 56.1% to 28.3% (P<0.001) ( abortions, stillbirth, preterm/premature, LBW and congenital syphilis). In the control centres there was a slight but not significant increase. The cost of each prenatal screening is US$0.60 and of averting each adverse outcome $12.

Hiramani, A.B., Srivastava, U., and Misra, R.S. Health education for STD patients in a New Delhi hospital. Hygie 4(3):26-31, 1985.  Ref ID : 443

Target Group/Country Patients who presented for treatment of syphillis, gonorrhea, chancroid, or gonorrhea and chancroid at the STD clinic of a hospital in New Delhi, India. Hiramani, A.B., Srivastava,

Intervention Methodology Following a pilot study of 31 patients and educational programme was developed for patients reinforcede by a set of educational materials, including folders, photographs, flip-charts, and posters.  Some of the educational materials were used during the education sessions and the patients were instructed to read the remaining materials on their own

Evaluation Method 107 patients who presented at the clinic for treatment were interviewed in order to obtain baseline information on their STD knowledge levels. Individual education sessions were held with 80 of the 107 patients.  Approximately 18 days following the education sessions, 56 of the 80 patients were retested on their knowledge of STDs. The remaining patients were lost to follow-up. There were no controls

Impact Achieved The results of the retests following the educational sessions indicated that the patients with syphilis or gonorrhoea tripled their knowledge level of the 3 STDs and that patients with chancroid more than doubled their STD knowledge level. 2/3 of the 56 patients said that the program increased their understanding of STDs. The increases were significant to the p<0.01 level. The educational method preferred by the largest proportion of respondents (64%) was the individual educational sessions. The folders and photographs were ranked as 2nd and 3rd in preference. Many of the patients had delayed seeking treatment for their condition. The major reason for the delay was that the patient did not understand the seriousness of the disease. Lack of controls and the small sample size  limit the value of this study.

Jackson, D.J., Rakwar, J.P., Richardson, B.A., Mandliya, K., Chohan, B.H., Bwayo, J.J., Ndinya-Achola, J.O., Martin, H.L., Moses, S. and Kreiss, J.K. (1997) Decreased incidence of sexually transmitted diseases among trucking company workers in Kenya: results of a behavioural risk-reduction programme. AIDS 11, 903-909.. Ref ID : 7275

Target group/Country Male employees of trucking companies in Mombasa, Kenya

Intervention Methodology A behavioural intervention programme was implemented at rotating on-site clinics held weekly in the depots of each of six of the largest trucking companies in Mombasa. The educational intervention was carried out by health workers and a health educator included initial informal group discussions, pre- and post-HIV test counselling and condom promotion. This pre-test counselling took place at the point of enrolment and at each 3 month follow-up visit. Post-test counselling took place one week later when the test results were available.

Evaluation Method A prospective cohort study was conducted among 556 male HIV-seronegative employees. At each 3 month follow-up visit a questionnaire on recent sexual behaviour and medical history was complete, physical examination performed and a 10 ml blood sample was drawn for HIV testing.

Impact Achieved Using time-trend modelling, significant declines in self-reported high-risk sexual behaviour were demonstrated during a 1-year follow-up. The percentage of men reporting any extramarital sex during the 3-month period prior to a follow-up visit decreased from 49% during the first quarter of follow-up to 36% during the last quarter (P <0.001). The decline in reported female sex worker contact was from 12% to 6% (P = 0.001). Approximately 30% of men reported consistent condom use during extramarital sex and this percentage remained unchanged during the study period. The incidence of STD declined from 34 per 100 person years (PY) during the first quarter to 10 per 100 PY during the last quarter (P = 0.001). Significant reductions in gonorrhoea (15 to 5 cases per 100 PY, P = 0.04), non-gonococcal urethritis (10 to 2 cases per 100 PY, P = 0.05), and genital ulcer disease (9 to 2 cases per 100 PY, P = 0.02) were observed. The intervention concluded that among truck company workers who participated in a cohort study in Mombasa, Kenya, there was a significant decrease in sex with high-risk partners, but no change in condom use. The change in heterosexual risk behaviour was accompanied by a significant decrease in incidence of gonorrhoea, non-gonococcal urethritis, and genital ulcer disease. Note the fact that the number of sexual contacts was reduced but there was no change in condom use is an interesting observation.

Kaleeba, N., Kalibala, S., Kaseje, M., Ssebbanja, P., Anderson, S., Praag, E.v., Tembo, G., and Katabira, E. Participatory evaluation of counselling, medical and social services of The AIDS Support Organization (TASO) in Uganda. AIDS Care 9(1):13-26, 1997. . Ref ID : 6029

Target group/Country People living with HIV/AIDS in Uganda

Intervention Methodology The AIDS Support Organization (TASO) is an indigenous non-governmental organization (NGO) of HIV-infected and affected people in Uganda. TASO provides counselling, social support, medical and nursing care for opportunistic infections at 7 centres affiliated to district hospitals in Uganda.

Evaluation Method Over three months beginning August 1993 the services provided by TASO were evaluated through a participatory  approach in which staff and clients carried out interviews with 324 clients currently attending  7 TASO clinics, 322 clients who were visited at home, 74 client drop-outs who no longer used TASO services and 232 family care-givers of clients. This was supplemented with 24 key informant interviews and observation of 49 counselling sessions. There were no controls.

Impact Achieved TASO counselling services helped clients and their families to cope with HIV and AIDS, with 90.4% of clients revealing their serostatus, and 57.2% reporting consistent use of condoms in the past 3 months (higher than surveys of the general population in Uganda reported in other recent studies). TASO was also the main source of medical care for clients with opportunistic infections in the last 6 months (63. 8%). As a result of counselling, over half of the clients (56. 9%) made plans for the future and 51.3% wished to make wills. There was a high level of acceptance of people living with HIV/AIDS (PWAs) by families (79%) and the community (76%). Of clients sampled at home 49.4% were on medication and 57% of these appeared to be taking medicines correctly. 50.&% of family care givers know how to make up sugar-salt oral rehydration while 78.6% knew how to use ready-made sachets of ORS. Of the 49 counselling sessions observed, 39 (79.6%) addressed safer sex practices. Note this is a useful process evaluation of a well known programme. Interpretation of impact is limited by lack of controls and the fact that raw data and details of analysis of qualitative and observational data are not always provided.

Matthews,C., Ellison,G., Guttmacher,S., Reisch,N. and Goldstein,S. (1999)  Can audiovisual presentations be used to provide health education at primary care facilities in South Africa?  Health Education Journal  58, 146-156. Ref ID8740

Target group/Country Patients at waiting rooms four primary health care clinics serving large, poor peri-urban townships in South Africa

Educational Methodology A 24-minute episode of South Africa's popular soap opera, Soul City was played continuously during three consecutive days in the clinic waiting areas. The storyline of the episode chosen was intended to convey key health messages regarding the prevention and treatment of STDs..

Evaluation Method Observations of patient behaviour were made, and a random selection of about  25 male and 25 female patients were interviewed from each of the four clinics (total n=187 patients) patients were interviewed on exit. A focus-group discussion was held with all of the clinic staff at each clinic site, to assess staff attitudes towards the use of such audiovisual presentations as part of their future routine duties.

Impact Achieved The mean proportion of patients who were observed watching the video at any one time varied from 34 to 64 per cent at all four clinics. Based on "it interviews, the presentation was seen by 88.2 per cent of patients attending all four clinics, and its STD content was recognised by 91.5 per cent of those who had seen it. Over 90 per cent of patients found the presentation helpful and interesting. Clinic staff described the use of video-mediated education as a solution to the problem of inadequate health education, and there was unanimous support for it.

Ogunbanjo, B.O., Azulu, M.C., Edet, E. and Osoba, A.O. (1986) Reinforcement of health education and counselling by doctors in treatment and control of sexually transmitted disease. Genitourin. Med. 62, 53-55.. Ref ID : 6842

Target group/Country STD patients in a clinic in Nigeria.

Intervention Methodology Male patients treated for acute gonococcal urethritis received standard STD counselling by a social worker, treatment by a doctor and contact tracing. Without the knowledge of the social worker, half the patients were given 5-7 minutes extra counselling and STD health education by a doctor covering transmission of STD, importance for follow-up and the need to bring sexual contacts for treatment.

Evaluation Method A randomised controlled trial. 64  patients were randomised into two groups of 32. Both groups received the counselling but the experimental group received reinforcement from the doctor. Each group attended three follow-up examinations

Impact Achieved There were 20 defaults from attending follow-up interviews in the control group (8, 4 and 8 defaults from each round of follow-up visits) of whom 4 became reinfected. For the group receiving counselling, none defaulted from attending the first follow-up visit, one from the second and 3 from the third (p<0.01) and ther were no cases of reinfection (p<0.061). This simple study shows that even a small additional educational input can have an influence on patient compliance. Details of the health education provided by the social worker and doctor are not provided so it is not clear whether the  impact from the additional educational input was achieved because of the increased educational activity, an improved quality of delivery of education or greater credibility of education delivered by a doctor

Temmerman, M., Kiragu, D., Fusallah, S., Piot, P. and Wamola, I.A. (1990) Impact of single session post-partum counselling of HIV infected women on their subsequent reproductive behaviour. AIDS Care 2, 247-252.. Ref ID : 3772

Target group/Country Mothers at a large maternity hospital in Nairobi, Kenya Temmerman, M., Kiragu, D., Fusallah, S.,

Intervention Methodology Asymptomatic HIV-positive women who had recently delivered were informed of their HIV sero-status and counselled by a trained nurse regarding contraception and reproductive behaviour in a single session.

Evaluation Method 94 infected women and 94 uninfected women matched for pregnancy outcome were followed up after 1 yr.

Impact Achieved Contraceptive use, condom use, and pregnancy rates were similar in both groups. Only 37.5% of infected subjects  had informed their partners of their sero-status, and the single session of counselling did not influence decisions on subsequent condom use or reproductive behaviour. Results suggest that more intensive counseling of HIV-positive individuals should be developed and evaluated.

Wilkins, H.A., Alonso, P., Baldeh, S., Cham, M.K., Corrah, T., Hughes, A., Jaiteh, K.O., Oelman, B., and Pickering, H. Knowledge of AIDS, use of condoms and results of counselling subjects with asymptomatic HIV2 infection in The Gambia. AIDS Care 1(3):247-256, 1989. Ref ID : 2669

Target group/Country Rural and urban populations in The Gambia

Intervention Methodology A counsellor met with 31 asymptomatic, HIV-positive subjects in their homes on 2 occasions during the survey.

Evaluation Method Follow-up of 31 persons 1-2 months after receiving initial counselling. There were no controls. (Programme incidental to a large scale survey).

Impact Achieved By the 2nd interview, only 3 subjects had discussed AIDS and HIV infection with their partner and only one. Only 8 of the 14 subjects who had taken condoms at the first visit had used any by the time of the second visit. 21 of the persons appeared very worried by their serostatus at the second visit. Condoms were offered again on the second visit but only 5 subjects wanted a supply. Limited information is provided of the counselling sessions which is disappointing as some were tape-recorded. The data bear out the authors' conclusions on the need for a more sustained and intensive counselling process.

Wynendaele, B., Bomba, W., M'Manga, W., Bhart, S., and Fransen, L. Impact of counselling on safer sex and STD occurrence among STD patients in Malawi. International Journal of STD and AIDS 6(2):105-109, 1995. l. Ref ID : 7321

Target group/Country STD patients in hospital clinics in Malawi

Intervention Methodology Counselling as part of STD treatment.. Trained counsellors discussed modes of transmission and prevention of STD/AIDS including a condom demonstration; symptoms and treatment of STDs; partner notification; risk taking and reasons for doing so; and motivations for behaviour change

Evaluation Method Increases in safer sex practices are used as indicators of prevention behaviour. A pre-test (n=155 intervention and n=154 control)  post-test (n=75 intervention and n=70 control)  group design over a 4-month interval was conducted in 1991 in 2 comparable hospitals approximately 100 km apart. STD was diagnosed symptomatically and Knowledge Attitude Practice and Behaviour (KAPB) data collected using a structured questionnaire..

Impact Achieved ( half the test and control sample dropped out over the four months).The group receiving counselling were more likely to have used a condom (11%73% compared with 1126% in controls p<0.05%), more likely to have reported fewer partners in the previous month (1.31.1 compared with 1.32.1in controls P<0.05) and less likely to have an STD on their follow-up visit (100%12% compared with 100%77% p.05). Note very little information is provided on the counselling process used also there was a very high drop-out from the original sample.

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1.5 Mass media

Bessinger, R., Katende, C., & Gupta, N. (2004) Multi-media campaign exposure effects on knowledge and use of condoms for STI and HIV/AIDS prevention in Uganda., Evaluation and Program Planning, 27(4) 397-407. Ref ID: 9206

Target Group/Country General Public in Uganda
Intervention Methodology Several mass media campaigns were conducted during the project's first phase (1995-1999). The 'Stop, Treat, and Destroy' campaign sought to educate women and men about the prevention of STIs through condom use, and about the signs of infection and need for treatment. Among the specific HIV prevention activities was the youth-oriented 'Safer Sex or AIDS' campaign that encouraged adolescents who were not abstaining from sex to use condoms. DISH assisted the Ministry of Health to distribute the national 'Rainbow over the Yellow Flower' logo to identify health facilities offering integrated reproductive health services, and conducted publicity encouraging couples to visit facilities displaying the logos for information and services. Campaigns were multi-lingual and usually include a mix of radio, television, and print messages as well as community education activities. A weekly reproductive health radio program was produced, 'Capitol Doctor', aiming to educate men and women about STI/HIV prevention and to promote condom use. In addition there was a social marketing programme with advertisements and feature in the Capital Doctor progrramme.
Evaluation Method Data for this analysis have been drawn from two household surveys conducted in the DISH project districts of Uganda. The 1997 DISH Evaluation Survey (DES) collected data from a representative sample of 1697 women aged 15-49 and 900 men aged 15-54 in the project districts. The 1999 DES gathered information from 1766 women and 1057 men of the same age groups, respectively. Both surveys used a two-stage sampling procedure, based on a random sample of enumeration clusters in proportion to district population sizes and sub-sample of households. The use of similar sampling frames and questionnaires ensured general comparability between survey rounds. BCC exposure was measured by creating a variable to capture the number of media through which an individual reported having been exposed in the last six months to messages about diseases that can be transmitted through sex. This included the following: (i) on the radio; (ii) on the television; (iii) on a poster; and (iv) in a print material (including newspapers, magazines, brochures or leaflets). The total number of media through which the respondent was exposed to BCC messages was summed, to a maximum of four media types. An individual who had heard messages through two or more different channels was considered to have a high intensity of exposure.
Impact Achieved In 1997, 70% of women reported BCC exposure through one or more types of media, a figure that rose to 77% in 1999 (Fig. 2). The radio was by far the most common source, followed by posters. Exposure via television remained low across surveys. Exposure to mass media BCC messages was higher among men than among women, reflecting a pattern of higher proportions of men listening to the radio or watching television overall (Katende et al., 2000). Eighty-one percent of men reported exposure to STI messages via one or more media channel in 1997, rising to 88% in 1999. As was the case for women, radio was the most popular individual source of BCC exposure among men. With respect to specific programmatic radio messages promoted in the DISH districts, 22% of women reported having heard advertisements for Protector condoms in 1999, while 30% had listened to Capitol Doctor. Following the same general exposure trend, more men than women reported having heard these radio messages: 36% for Protector advertisements and 42% for Capitol.
BCC exposure was strongly associated with higher condom knowledge: women and men who reported being exposed to messages in the mass media were at least twice as likely as those with no exposure to know of condoms as a mean to avoid HIV/AIDS (p<0.001). A dose-response effect was observed with a greater effect reported by those who had been exposed to multiple messages. While women who were exposed reported higher levels of "used a condom at last sex" (p<0.5 for one exposure, p<0.01 for multiple exposure_ no effect was recorded by men suggesting a gender effect. This evaluation provides good evidence of the changes in understanding of condoms that has taken place in Uganda. As an evaluation of the BCC programme it suffers from the same problem as all such studies in that an alternative interpretation of data is possible that those who were motivated to take an interest in the topic were the ones wo selectively sought out and noted the campaigns.

Evian, C.R., De-Beer, M., Crewe, M., Padayachee, G.N., and Hurwitz, H.S. Evaluation of an AIDS awareness campaign using city buses in Johannesburg. S.Afr.Med.J.80(7):343-346, 1991.  Ref ID : 2548  (Borderline for inclusion in database)

Target Group/Country General Public in Johannesburg, South Africa

Intervention Methodology The use of city buses as “vehicles” for an AIDS The 6-month campaign run by the city council began August 24, 1989 with ads on the back of 30 buses stating: “Learn about AIDS and keep yourself safe. Phone 339-2345. JHB City Health Dept. “ This message was selected from a list of 10 possibilities by telephoning 52 random adults. The programme on the buses was part of a larger mass media campaign on HIV/AIDS.

Evaluation Method The evaluation consisted of telephoning 280 and 145 people selected at random from the Johannesburg telephone directory 2.5 and 6 months after the campaign. The evaluation assessed the acceptability, effectiveness, impact and cost-effectiveness of using buses, and determined what people could recall of the message. 255 (91%) of the person telephone in the first survey and 127 (87%) of the persons contacted in the second survey agreed to answer the questions. There was no baseline or control.

Impact Achieved 30.2 and 31.5% of the subjects in the 1st and 2nd survey recalled seeing the message. 72 and 67% recalled only seeing an AIDS message. 8.5% remembered the message accurately. 12.8% remembered that the message urged people to learn about AIDS. Only 1 person could remember a phone number and the City Health Department.  Of those who reported seeing the message, 35.1% and 55% of the 1st and 2nd series respectively reported taking some action which included visiting a doctor, telling others or wanted to learn about AIDS.  90.5% considered buses suitable for AIDS health awareness messages. This study showed that buses could be used as sites for posters to promote AIDS awareness.. It was estimated that a minimum of 57,970 persons saw the messages, at a cost of 7627 Rand for 6 months. However, only 229 persons telephoned the Health Department on the number provided which was disappointing. provided The main limitation with this study is the possible bias in sampling from using a telephone interview and lack of baseline. However, for the limited objective of establishing feasibility and acceptability of using buses for education, the methodology would seem appropriate.

Karlyn,A.S. (2001) The impact of a targeted radio campaign to prevent STIs and HIV/AIDS in Mozambique. AIDS Education and Prevention 13, 438-451. Reference ID: 9106

Target Group/Country Youth - in- and out-of-school, and adults associated with risk behaviours e.g. users of commercial sex in urban and peri-urban areas of Mozambique

Intervention Methodology There is a very good description of the "education-entertainment" radio campaign with a detailed listing of the messages for each target group.The targeted radio campaign followed up earlier mass media social marketing condom promotion radio activities. On World AIDS Day 1996 Population Services International launched the "So a Vida Oferece Flores" (only life offers flowers) national radio campaign using nine spots in Portuguese. The spots were designed to reinforce key messages from the PSI play of the same name using the same personalities, music and themes. Local language versions of the spots were broadcast 11 months later and were broadcasted 10,000 times over a two year period. and there was an attempt to segment the target with distinct messages The spots were targeted to youths aged 13-20 and adults 21-49.

Evaluation Method A cross-sectional study using a two-stage random sample of "at-risk" individuals; 754 individuals between the ages of 13 and 49 were interviewed.

Impact Achieved Over half (52.4%) heard the campaign and 45.5% recalled one or more radio messages. However, recall of specific messages in specific risk groups was low. A multivariate model demonstrates that among those exposed to the radio campaign, 97.2% reported intent to change their sexual behavior compared with 62.8% of those not exposed to the campaign (p < .001). Among those who recalled campaign messages, 86.1% attempted to change their behavior compared with 58% of those who had no message recall (p <.001). Success in changing behaviour was significantly higher among those with message recall (83.8%) than those without (56.8%, p < .001). Despite the limitations in using radio to target, exposure to the radio campaign has contributed to individual intent to change sexual behavior. The author comments that the this study illustrates the difficulties in using radio to target a specific group with a corresponding behavior change message. Although general recall of campaign messages was high per target group, the author concluded that campaign did not succeed in ensuring exposure to the intended target group. The strategy of airing all of the spots simultaneously with different but similar messages resulted in one spot "stepping on" another.
See also the study by the same athors of another aspect of the social marketing programe in Mozambique: Agha,S., Karlyn,A. and Meekers,D. (2001) The promotion of condom use in non-regular sexual partnerships in urban Mozambique. Health Policy and Planning 16, 144-151. Ref ID 9105 Ref ID: 9105

Middlestadt, S., Fishbein, M., Albarracin, D., Francis, C., Eustace, M.A., Helquist, M. and Schneider, A. (1995) Evaluating the impact of a national AIDS prevention radio campaign in St Vincent and the Grenadines. Journal of Applied Social Psychology 25, 21-34.Ref ID : 8477

Target/Country Youth in St Lucia, St.Vincent and the Grenadines and Grenada,  Eastern Caribbean

Intervention Methodology Based on extensive formative research in the three Eastern Caribbean countries of a three-nation mass media radio campaign to promote condom use by teenagers was developed drawing upon Fishbein's Theory of Reasoned Action. A radio campaign lasting two months was targeted primarily to parents o teenage children, The central message was "When you can't protect them any more …..condoms can". Parents were urged to talk to their teenagers about sexual responsibility and safer sex.

Evaluation method A follow-up survey was conducted in St Vincent and the Grenadines. A multi-stage sampling plan was resulted in interviews carried out with 297 respondents (109 teenagers, 102 parents of teens and 86 other adults). 71.6% (213) of the sample not only reported hearing an AIDS-related ad on the radio but were able to correctly describe its content. Those were classified as 'exposed' to the campaign and the remaining 28.4% were classified as 'non-exposed'.

Impact Achieved The age breakdown of those exposed to the campaign was 15-19 yrs 39.6%; 20-29 yrs 24.4%, 30-44yrs 26.2% and 45-54 yrs 8.8%. Those exposed to the message were significantly more likely: (1) to believe that it is possible to protect oneself from AIDS than those not exposed (p<0.01); (2) to believe that parents and teens should discuss sexual responsibility(p<0.01); (3) to believe that their potential sex partners thought that they should use condoms(p<0.01); (4) to believe that their friends used condoms (p<0.01) and  5) to be aware of the existence of the AIDS hotline (p<0.01). There was little difference between the two groups in reported condom use 

Tambashe, B. O., Speizer, I. S., Amouzou, A., & Djangone, A. M. 2003. Evaluation of the PSAMAO "Roulez Protege mass media campaign in Burkina Faso. AIDS Education and Prevention, 15(1) 33-48. Ref ID: 9068

Target Group/Country Truck drivers and seasonal workers and female sex workers along transport routesin Burkino Faso, West Africa

Intervention Methodology This study assesses the impact of the Prevention du SIDA sur les Axes Migratoires de l'Afrique de l'Ouest . The campaign is based around a 30 minute film drama entitled Roulez Protg which was shown on television and through mobile video units. Volunteer peer educators were recruited among truck drivers and their assistants and were responsible for conducting large scale meetings of 100-300 in public places, discussion groups of 30 or less participants and condom distribution/demonstration. Other materials produced included audiocassettes and a flip chart. There were also billboards, radio and TV spots (detailed information not provided)

Evaluation Method A total of 764 and 1,032 truckers and helpers were interviewed in 1997 and 2000 along the Ouagadougou-Niangoloko trucking route. The data was analyzed to determine three outcome variables: whether they had spoken to a colleague about AIDS, whether they reported an intention to use condoms next time and whether they used a condom the last time they had sex. There were no controls.

Impact achieved Virtually all truckers (95.8%) had seen the Roulez Protg message on a billboard, 45.1% had seen the spot on the television and 38% had heard the spot on radio. There was an overall increase in knowledge about HIV/AIDS however the authors point out that during this period there had been many other educational activities in the region. Logistic regression analyses suggest that the campaign did not have direct behavioral impacts. Exposure to radio spots and participation in group discussions were found to be significantly associated with truckers discussing AIDS with peers or reporting intentions to use a condom in the future. Exposure to Roulez Protege messages through television or billboards was not found to be significantly associated with interpersonal discussion or condom use intentions. Specific information is not provided on the number of meetings, group discussion sessions, bill boards. This evaluation is significant in that it shows that a two year intensive programme did not achieve behaviour change. Some information is reported from focus group discussions (no details of methodology provided) which suggested that the truck drivers did not consider television to be appropriate to their life style. Unfortunately there is nothing reported on the quality of the public meetings and group discussions and the performance of the peer educators.

Vaughan,P., Rogers,E.M., Singhal,A. and Swalehe,R.M. (2000)  Entertainment-education and HIV/AIDS prevention: a field experiement in Tanzania.  Journal of Health Communication  5, 81-100. Ref ID 8751

Mohammed,S. (2001) Personal communication networks and the effects of an entertainment-education radio soap opera in Tanzania. Journal of Health Communication 6, 137-154. Ref ID: 8927

Target group/country General public in Tanzania

Intervention Methodology A radio soap opera Twende na Wakati (Let's go with the times) was broadcast in Swahili twice per week for 30 minutes from July 1993 through to the end of 1999. Four key HIV/AIDS prevention themes were covered: 1) that STDs should be treated; 2) that condoms can prevent HIV infection; 3) that AIDS is an incurable disease that is spread by sexual contact; and 4) that the various rumours about AIDS are false. The characters in the soap operas were designed to provide negative, transitional and positive role models for HIV prevention behaviours.

Evaluation Method The soap opera was not broadcast in one region (Dodoma) from 1993-1995 to create a comparison area so that an experimental design could be used. From 1995 to 1997 all regions received the broadcasts and Dodoma received the earlier episodes. Five surveys based on personal interviews were carried out from just priori to broadcast in imd 1993and at one year intervals. The questionnaire measured respondent's (1) personal characteristics, (2) exposure to and perceptions of the soap opera (3) knowledge of HIV/AIDS (4) relevant attitudes and (5) the practice of HIV/AIDS preventive behaviours. Respondents included females aged 15-49 and males aged 15-60 (ages ranges chosen to be inline with another national survey to allow comparison. 5 districts were chosen at random in the comparison area and 9 districts in the treatment area - each district with average sample size of 214.

Impact Achieved 47% of respondents in the treatment area reported listening to the soap opera which increased to 58% by 1997. Respondents reporting having heard the soap operas in the comparison area (e.g. through travel to other areas) was about 2%. 73% of listeners reported learning about AIDS from the soap opera in the treatment area in 1994 and 46% reported talking to someone about the programme content. In response to an unprompted question the numbers reporting adopting an HIV/AIDS prevention behaviour as a result of the programme was 16% in 1996 and 12% in 1997. Most listeners who reported adopting an HIV/AIDS prevention method, reported reducing their number of sexual partners (77% in 1995) rather than adopting condom use (15% in 1995). Between 1993 and 1993 there was a greater decrease in reported number of sexual partners in the intervention area (men 2.31.6; women 1.91.2) than comparison area (men 2.21.9, women 1.81.3) both for men and women (p<0.01). This evaluation is significant as one of the few evaluations of mass media in developing countries to use a comparison group.

Vaughan,P.W., Regis,A. and St Catherine,E. (2000)  Effects of an entertainment-education radio soap opera on family planning and HIV prevention in St Lucia.  International Family Planning Perspectives  26, 148-157. Ref ID: 8813

Target Group/Country General public in St Lucia

Intervention Methodology The entertainment-education radio soap opera Apwe Plezi was designed to address 37 educational issues identified in formative research. These included knowledge, attitudes and behaviour related to family planning, HIV prevention, gender equity, relationship fidelity and domestic violence. During the first phase between Feb 1996 to May 1997, 260 episodes were broadcast. Fir the second phase from July 1997 to September 1998 105 episodes were broadcast, The characters served as positive, negative and transitional behavioural role models and their fates provide learning experiences to demonstrate the consequences of alternative behaviours. Accompanying activities to promote and reinforce the radio dramas included a street theatre version performed 21 times, story updates in the local press posters, bumper stickers and billboards. The soap opera launched a new name for condoms - 'catapult'.

Evaluation Method A January 1995 survey of 753 men and women aged 15-54 yrs provided baseline data. Post-test surveys were conducted in June 1997 (n=741) and September 1998 (n=497) which were combined for the purpose of analysis. There were no controls. Respondents were considered regular listeners if they reported listening to the radio soap opera once a week or more and this was used to infer causal effects. A personal interview questionnaire was used which asked prompted (open-ended) questions first and then prompted questions. In addition 44 focus group interviews were conducted at intervals throughout the broadcast period to monitor listeners' responses. A hot line for telephone consultations was established and content analyses were undertaken on the recorded messages.

Impact Achieved According to the 1977 survey Apwe Plezi was the second most popular programme on Radio ST Lucia that Year and the 4th most popular on any radio programme. 65% did not listen, 23% reported to be casual listeners and 12% regular listeners. In response to an unprompted question on what they had learned from the programme 52-60% of regular listeners reported HIV, AIDS teenage pregnancy or drug abuse. The proportion of survey respondents who were aware of contraceptive pills increased from 77% to 83%between the pre-test and post-test (p<0.01).

Yoder, P.S., Hornik, R., and Chirwa, B.C. Evaluating the program effects of a radio drama about AIDS in Zambia. Stud.Fam.Plann. 27(4):188-203, 1996.  Ref ID : 4749

Target Group/Country Bemba speakers in northern Zambia.

Intervention Methodology The Nshilakamona radio drama portrayed two families in Lusaka and their friends as they responded to problems of raising teen-age children, friendships, making ends meet, sex relations, and AIDS. Messages were that everyone is at risk for AIDS, you can prevent HIV transmission, people should talk to their spouse and children about AIDS, condoms protect against HIV transmission, and it is safer to have only one sex partner. Broadcasts began August 1991 and ran for nine months.

Evaluation Method A baseline survey conducted shortly before the broadcasts began (n=1,613) and a follow-up survey (n=1,682) directly after the broadcasts ended. Both surveys were conducted in Copperbelt and Northern provinces. 1613 men and women in randomly selected households of ages 15-45 years were interviewed in each survey examining knowledge about the transmission and prevention of AIDS, reported condom use and attitudes towards condoms, and reported behaviour related to reducing the risk of HIV transmission. There were no controls. 665 of the 1992 sample were owned a radio and listened (to any programme) to the radio one or more times a week and was classifieds as the high access group and used a form of intervention group to compare with the remainder who where classified as 'low access'.

Impact Achieved Only about 40% of the 'high access' group claimed regular exposure to the radio drama. Knowledge of AIDS and the importance of taking measures to prevent infection increased in the overall sample between 1991 and 1992 (p<0.001), although no changes were reported in the proportions of men and women who stated they had sexual partners outside marriage, and the proportions using a condom to prevent HIV transmission. The surveys also found an increase in the percentage of respondents who had ever used a condom. However most of these increases were found in both individuals with high exposure to the program as well as low exposure. There were only 4 areas where 'high exposure' sub-sample showed a trend towards more change: knowledge of the extended period of infection, willingness to talk to spouses or children about AIDS, and, among women, reports that they had reduced their number of partners and believed that they were more vulnerable to AIDS. Otherwise they were no different in knowledge, attitude, or behaviour from those who had no or low exposure so it is likely that the changes observed were due to educational activities other than the radio programme. This is a very good example of how mass media might be evaluated in the absence of controls. It does seem unclear why the intervention group was defined as the group who had high exposure to radio and not the sub-set who reported high listening. Positive impact on the 'high exposure group' might also be attributed to the higher socio-economic status of that group.

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1.6 Training programmes for persons involved in health promotion

Santana, R.T., Monzon, O.T., Mandel, J., Hall, T.L., and Hearst, N. AIDS education for hospital workers in Manila: effects on knowledge, attitudes, and infection control practices. AIDS 6(11):1359-1363, 1992. . Ref ID : 2399

Target Group/Country Intervention for health workers in Metro Manila hospitals, The Philippines

Intervention Methodology A training programme consisting of lectures, role-plays, posters, and pamphlets was delivered to physicians, nurses, laboratory technologists, and orderlies

Evaluation Method 18 hospitals in metro manila were selected at random - 6 each from the three categories: 1) hospitals that provide care for AIDS patients 2) hospitals that do not admit AIDS patients but have residency training programmes and 3) hospitals that have neither AIDS patients or training programmes. Knowledge, attitudes, and infection control practices were measured using a self-completed questionnaire before, immediately after, and 2 months following the intervention over the period March and December 1990.

Impact Achieved Baseline survey among 641 hospital workers revealed poor knowledge, negative attitudes toward AIDS patients, and inappropriate infection control practices. Immediately after the intervention, there was significant improvement in (1) knowledge scores (8.7-11.2 in the intervention group vs. 8.5-9.5 in the control group; range, 0-14%; (2) attitude scores (54.4-60.6 vs. 54.6-57.8; range 22-88); and (3) intention to perform needle-recapping (14-43% vs. 39- 43%) (all p values <0.001). After 2 months, attitude scores in the experimental group fell to the same level as those of the control group, while improvements in knowledge and needle recapping were largely maintained. More impact was obtained in hospitals not specifically involved with AIDS patients. It is disappointing that the study did not investigate impact on actual infection control practices including needle re-capping.

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1.7 School-based and youth-targeted programmes

Agha, S. & Van Rossem, R. (2004), Impact of a school-based peer sexual health intervention on normative beliefs, risk perceptions, and sexual behavior of Zambian adolescents, Journal of Adolescent Health, 34(5) 441-452. Ref ID: 9197

Target Group/Country Male and female adolescents in grades 10 and 11 aged 14-23 in Lusaka, Central and Copperbelt sites Secondary Schools, Zambia

Intervention Methodology A single session school-based peer sexual health intervention lasting 1hr 45 mins to promote abstinence and condom use among male and female school children.. No information is provided on the selection or training of the peer educators. Per educators provided information through explanations, discussion, demonstration of condoms, drama and giving out a leaflet.

Evaluation Method A quasi-experimental, longitudinal panel design was. Three boarding schools were randomly assigned to the intervention condition and two to the control condition. Three rounds of data from male and female adolescents in grades 10 and 11 were collected at baseline in July 2000, at first follow-up in the second half of September 2000, and at second follow-up in early April 2001. A total of 416 respondents aged 14-23 (at baseline) were interviewed/reinterviewed in all three survey rounds (Control n=162; intervention n=254) . A mixed-effects logistic regression growth curve analysis was used to calculate adjusted odds ratios to compare intervention and control groups on the outcome variables.

Impact Achieved At first follow-up, students in the intervention group were more likely than students in the control group to have received about condoms from peer educators (p=0.21)and to approve of individuals using condoms (p=0.22) and to intend to use condoms with a regular partner (p=0.03). These positive outcomes could not be sustained during the 6 months that followed the intervention Compared with the control groups, students in the intervention group showed positive changes in normative beliefs about abstinence immediately after the intervention (p=0.047), and these improvements were largely sustained until 6 months after the intervention (p=0.017). Students reported significant (p=0.40) reductions in multiple regular partnerships at the second follow-up but not the first which the authors interpret as suggesting that change takes a longer time to develop (but, given the differences between the control and intervention community and the 6 month time scale and the high p value care is needed in drawing conclusions about this. The authors note that the schools chosen were boarding schools to minimise the confounding effects of mass media communication. Children from these schools tend to come from more affluent families. Differences were shown between control and intervention schools. Note that this kind of peer education involving a peer delivering a single teaching session in a classroom setting is very different from the alternative use of the term to describe the involvement of peers to deliver informal education in community settings. Given the very modest nature of the input of a single 1hr 45 min session, the changes achieved would appear quite reasonable. The design did not allow any conclusion about the value of peer education vs. a teacher led approach. The measurement of short-term and longer term impact is a welcome feature of this evaluation.

Aplasca, M.R., Siegel, D., Mandel, J.S., Santana-Arciaga, R.T., Paul, J., Hudes, E.S., Monzon, O.T. and Hearst, N. (1995) Results of a model AIDS prevention program for high school students in the Philippines. AIDS 9 Suppl 1, S7-13. Ref ID : 4093

Target Group /Country High school students  aged 13-16 yrs in a semi-urban district of Metro Manila, the Philippines

Intervention Methodology 30 teachers attended a two day workshop on AIDS education and a core group of participating teachers were involved in the design of a school-based educational curriculum. The curriculum covered five areas: human sexuality and STDs, AIDS, the immune system, development of self esteem, decision-making skills  and refusal skills. The educational programme consisted of 12 lessons taught as two 40 minute lessons per week over six weeks. As well as traditional lectures, sessions included role playing, games, dialogues, group discussions and exercises. Support materials included a teacher's manual, flip charts and audiotapes.

Evaluation Method Pre-test post-test in two intervention schools (n=420) and two control schools (n=384). The intervention and control schools were randomly assigned from a pool of 10 schools. One class in each year in both schools were randomly selected for the measurement. Pupils were given self-administered questionnaires to assess knowledge, attitudes, beliefs and behaviour patterns. Details of timing of pre- and post-tests are not provided.

Impact Achieved Intervention group had higher levels of HIV-related knowledge (p<0.01), were and scored higher positive attitudes (less likely to avoid people with AIDS (p<0.01) and more likely to show compassion to persons with AIDS (p<0001). The slight increase in students stated intentions to adopt safer sexual behaviour was not significant although there was a significant increase in the proportion of students who agreed that students should delay sex until they became adults (p<0.0001 data not shown).  Possible reasons identified for lack of impact on attitudes include: the need to provide more training to teachers beyond the initial 2 day programme, the need to allow more time for exploring peer pressure and practicing resistance and refusal skills and the need to incorporate more intensive student participation.

Awasthi,S., Nichter,M. and Pande,V.K. (2000)  Developing an interactive STD-prevention programme for youth; lessons from a North Indian slum.  Studies in Family Planning  31, 138-150. Ref ID 8753

Target group/country Young men in urban slums in Lucknow, India

Intervention Methodology The intervention consisted of three educational sessions at two-week intervals. The educational programme was designed to provide basic information to young men about: (a) reproductive anatomy and physiology, fertility and conception; b) how STDs are transmitted, types of STDs, the signs and symptoms of STDs and asymptomatic infection; (c) the link between STDs and HIV infection; d) the HIV test and when one should take them; and e) methods of STD prevention and harm reduction that are and are not effective. The session facilitator was supported by three male assistants who made themselves available for individual consultations afterwards. Each session lasted approximately an hour. During the last 15 minutes, a taped set of educational messages about sexual health was played that repeated key points made in the live sessions. A voluntary urine test to detect bacterial infections was provided at the second educational to generate information to feed back to the young people at the third session.

Evaluation Method 28 of 261 slums were selected randomly. A sample of young men was drawn - 377 (mean age 18.3 yrs 33.4% still at school) in the intervention group and 343 (mean age 18.2 yrs 25.7% still at school) in the control group. Data was collected each boy's sexual history and knowledge of STDs and the same survey was administered to the boys 6 - 8 weeks after the intervention. Loss to follow-up in the intervention group was 4% (14 boys) in the intervention group and none in the control. The leukocyte esterase test was administered as a proxy measure of bacterial infection .

Impact Achieved There was a significant increase in awareness that STDs could be caught from women other than prostitutes in the intervention group from 46.9% to 76% (p<0.001). There were significant increases in knowledge about symptoms of STDs in the intervention group (p<0.001). The intervention failed to increase young men's awareness of the long time it can take for symptoms of STDs to emerge and also failed to dispel the myth that washing the private parts with disinfectants can prevent STDs. The evaluation reviewed valuable insights into the sexual practices of young men. One notable finding was that young men who engage in high risk sex with prostitutes were also more likely to engage in sex with men and that information was required on forms of coitus other than vaginal sex. The urine test was found to be an unreliable predictor of infection with and STD in a population with low levels of sexual intercourse.

Brieger,W.R., Delano,G.E., Lane,C.G., Oladepo,O. and Oyediran,K.A. (2001) West African Youth Initiative: outcome of a reproductive health education program. Journal of Adolescent Health 29, 436-446. Ref ID: 8972.

Target Group/Country Young people aged12-24 in and out of school in Ghana and Nigeria

Intervention Methodology The West African Youth Initiative (WAYI) worked through 8 youth service organizations which each selected its own target population of youth, either secondary school post secondary school or out of school settings. They trained adolescent peer educators to reach target populations through one-on-one and group activities, distribution of printed materials and drama; to create awareness of available services and to make appropriate referrals for the services that the peer educators could not provide such as prescriptive contraceptive, STI diagnosis and treatment or in-depth counseling.

Evaluation Method Random sampling was employed in each project site to obtain interview from 100 youth in the intervention and 100 youth in the control sites and samples were equally divided between males and females. The survey was self-administered at schools. 3585 interviews were analyzed including 911 respondents at baseline and 908 at 2yr follow-up in the intervention sites and 873 at baseline and 893 at follow-up in control communities. 6 outcome variables were studied; reproductive health knowledge was scored on a 20-point scale based on questions concerning types of STIs, HIV/AIDS prevention, pregnancy prevention methods and reproductive anatomy and function. An opinion scale on contraceptive use, reported use of contraceptive methods by sexually active youths, self efficacy in undertaking safer sex practices and willingness to purchase condoms and foaming scales; an 8 point scale to measure respondent's feelings of confidence and competence in acquiring, negotiating and using contraceptives; 3 pt scale of young people's degree of willingness to porches contraceptives.

Impact Achieved The final mean knowledge score (8.7points) was significantly greater than that of youth in the control areas (7.9) There was no significant change in reported sexual activity between baseline and follow-up surveys in either group. The proportion of youth in the intervention group who reported use of a modern contraceptive method increased significantly from 47.2% of 309 at baseline to 55.6% of 315 at follow-up (p=0.045) while in the control areas there was a slight decrease. Higher scores were achieved by the intervention youth for perceived self-efficacy in contraceptives use (p=0.000013), willingness to buy condoms (p=0.000005) and foaming tablets (p=0.000007). Most of the programme impact was found in the in-school group and there were no significant differences between out-of-school intervention and control youth at follow-up for any of the six variables. The data from this study point to significant impact of peer education within the school setting but do not support the impact of peer education in out of school-setting. Reasons for this suggested by the authors include the widespread exposure of youth to educational messages from mass media, the greater amount of effort required for peer educators making contact with youths in out-of-school settings and also the increased economic power and sexual maturity of the out of school youth. However, further interpretation of this apparent difference is difficult in the absence of detailed information on the implementation of the peer education process.

Caceres,C.F., Rosasco,A.M., Mandel,J.S. and Hearst,N. (1994)  Evaluating a school-based intervention for STD/AIDS prevention in Peru.  Journal of Adolescent Health  15, 582-591. Ref, ID 8720

Target Group /Country Secondary school pupils in Lima, Peru

Intervention Methodology The programme was designed to take into account Social Learning Theory, the Freireian model of education and the constructs of machismo and erotophilia- erotophobia (openess towards sexuality). It consisted of seven weekly two-hour sessions which included discussions, verbal exercises, role playing, familiarization with condoms/contraceptives, and lectures. Homework promoted interaction with family, friends and local health institutions. Trained teachers facilitated the program. Contents were organize in seven units: 1)adult sexuality, puberty including puberty and adolescence; 2)reproductive anatomy and physiology; 3)conception, prenatal care, delivery, breastfeeding and unplanned pregnancy; 4) planned parenthood, contraception and abortion; 5) STDs, HIV/AIDS and safer sex; 6)sexuality as a social/cultural construct, sexual roles and orientation; 7) decision-making and communication skills. Teachers from the schools with experience as school counselors were given 3 day training course to act as facilitators.

Evaluation Method A quasi-experimental study. 14 schools were randomly assigned as intervention and controls. A pre-test was given the intervention (n=604) and control (n=609). Post-tests were given 3 months later to intervention (n=406) and controls (n=402). The pre-test and post-test consisted of a self-completed questionnaire with likert -type scales to measure erotophila, machismo, attitude towards contraception, attitude towards condoms and attitude toward persons with HIV/AIDS. The questionnaire used a Guttman-type scale to measure self-efficacy and behavioural intentions. Separate questionnaires were developed for male and female students.

Impact Achieved Significant changes in knowledge on sexuality and AIDS (p<0.0001), erotophilia (p=0.004), acceptance of contraception (p=0.002), machismo (p<0.0001), and discrimination against persons with HIV/AIDS (p<0.0001)were found in the intervention group, as compared to the control group. Self-efficacy (p<0.0001) and prevention-oriented behavioral intentions  (p<0.0001) were significantly better in the intervention group. Multivariate analysis found that machismo decreased more in boys than girls but knowledge of AIDS and self-efficacy outcomes were more positive among girls. Cost exclusive of research expenses was $3 per student reached.

Dalrymple, L. and du-Toit, M.K. (1993) The evaluation of a drama approach to AIDS education. Educational Psychology 13(2):147-154, 1993. Ref ID : 3634 

Dalrymple (1992) Drama approach to AIDS education: a report on an AIDS and lifestyle education project undertaken in a rural school in Zululand, Unpublished Report Kwa Dlangezwa 3886, South Africa:  Department of Drama, University of Zululand. Ref ID 1792

Target Group /Country Zulu-speaking high school pupils in South Africa.

Intervention Methodology A play about AIDS was presented to students who were then given the opportunity to attend drama workshops to design their own plays, songs and poetry. These were presented at an open day

Evaluation Method A self-completed questionnaire in simple English with 47 items including a likert-type attitude scale and knowledge test was developed, tested and given to 72 Zulu-speaking high school pupils 'randomly selected' from each participating class before and after drama intervention. Details of sampling method or age/sex composition of the sample not provided. There were no controls.

Impact Achieved Mean knowledge scores increased from 4.19 to 7.15 p<0.01).At baseline student already had a positive attitude to AIDS which did not change during the intervention. There was a decrease in the number of pupils who agreed with the statement "I would like to have more than one sexual partner" (p<0.01). The authors considered that their data on attitude scales was affected by the level of English of the pupils. Note: raw data not provided in published evaluation.

Fawole, I.O., Asuzu, M.C., Oduntan, S.O. and Brieger, W.R. (1999) A school-based AIDS education programme for secondary school students in Nigeria: a review of effectiveness. Health Education Research: Theory and Practice 14, 675-683.Ref ID : 8593

Target Group /Country/Reference Secondary school pupils in two schools in Ibadan South East Local government Area of SouthWest Nigeria

Intervention Methodology A community physician and two trained teachers gave six weekly sessions of 2-6 hrs including lectures, film, role plays, stories, songs and debates about HIV and AIDS prevention. (very little detail of the content of the sessions provided)

Evaluation Method A self-administered questionnaire was given to 233 students randomly selected from senior classes of two schools before receiving the health education intervention and compared with 217 controls. The questionnaire was modified and re-administered 6 months after the intervention. Questions determined knowledge of transmission and  prevention of AIDS, attitudes (Likert scale) and self-reported behaviours.

Impact Achieved At post-test, intervention students exhibited greater knowledge about HIV/AIDS transmission and prevention (P < 0.05). Intervention students were less likely to feel AIDS is a white man's disease and were more likely to be tolerant of people living with the disease (P < 0.05). After the intervention, the mean number of reported sexual partners among the experimental students significantly decreased from 1.51 to 1.06, while it increased from 1.3 to 1.39 among the controls (p<0.05). Among the intervention students there was also an increase in consistent use of the condom and the use of the condom at last sexual Intercourse but this was not statistically significant. Sustainability of intervention limited by use of external persons to do AIDS education.

Fitzgerald,A.M., Stanton,B.F., Terreri,N., Shipena,H., Li,X., Kahihuata,J., Ricardo,I.B., Galbraith,J.S. and De Jaeger,A.M. (1999)  Use of Western-based HIV risk-reduction interventions targeting adolescents in an - African setting.  Journal of Adolescent Health  25, 52-61.Reference ID: 8586

Target Group /Country/Reference Adolescents attending 10 secondary schools in two districts  in Namibia

Intervention Methodology The intervention was adapted from one previous used in USA and adapted to Namibia. Following piloting, the programme consisted of 14 two-hour sessions over 7 weeks which focused on basic facts about reproduction and risk behaviours such as alcohol, drug abuse and violence. The sessions were derived from 'Protective Motivation Theory' emphasized communication and decision-making skills. The sessions were facilitated during after-school hours by a volunteer teacher and an out-of-school youth (either a student teacher or a youth who had completed Grade 12 in a classroom to groups of 15-20 mixed gender students

Evaluation Method Pupils were asked to volunteer for study. 80% agreed. 515 youth (median age 17 years; median grade 11)were given a baseline self-completed questionnaire and randomly assigned to the control or intervention group. A follow-up questionnaire was given immediately after the intervention. The questionnaire measured knowledge, attitudes, intentions, and HIV risk behaviors. Following the post-intervention questionnaire controls were given the intervention.

Impact Achieved Knowledge increased significantly among intervention compared to control youth (88% vs. 82%; correct responses, p < .0001). At post-intervention follow-up, more intervention than control youth believed that they could be intimate without having sex (p<0.05%), could have a girlfriend or boyfriend for a long time without having sex (p<0.01), could explain the process of impregnation (p<0.05), knew how to use a condom (p<0.0001) and could ask for condoms in a clinic (p<0.05). Fewer intervention than control youth believed that if a girl refused to have sex with her boyfriend it was permissible for him to strike her (p<0.01), and that condoms took away a boy's pleasure. More intervention than control youth anticipated using a condom when they did have sex (p<0.05) , and fewer expected to drink alcohol (p<0.05). Finally, after intervention, there was a trend for increased condom use (but not significant). There were significant gender-related differences at baseline, although the intervention method had similar impact on both sexes.

Harvey,B., Stuart,J. and Swan,T. (2000)  Evaluation of a drama-in-education programme to increase AIDS awareness in South African high schools: a randomized community intervention trial.  Int. J. STD AIDS  11, 105-111. Ref ID 8726

Dalrymple, L. and du-Toit, M.K. (1993) The evaluation of a drama approach to AIDS education. Educational Psychology 13(2):147-154, 1993. Ref ID : 3634 

Target group/country 800,00 pupils in 800 secondary schools in KwaZulu, South Africa

Intervention Methodology The programme was carried out in 1993/4. During the first phase, teams composed qualified teachers/actors and nurses presented a play incorporating issues surrounding HIV and AIDS to each school. The second stage involved team members running drama workshops in the schools with teachers and students using participatory techniques such as role play. The programme ended with a 'school open day' focusing on HIV and AIDS through drama, song, dance, poetry and posters all prepared and presented by the students..

Evaluation method Two schools separated by more than 10 km in each of five districts (4 rural and 1 urban) were selected were selected to be intervention (receiving the drama programme) and control schools (receiving a 10 page booklet on AIDS). A self-completed questionnaire was given to the same standard 8 class pupils before (n= 1080) and 6 months later after the intervention (n=699 ) - mean age 18.3 in range 13-25 years. The questionnaire included sections on knowledge about HIV/AIDS, attitudes relating to personal susceptibility, immediacy of threat and perceived severity, attitudes towards people with AIDS, self-efficacy and reported behaviour including, whether have had sex, condom use, number of partners)

Impact Achieved There was a greater increase (p<0.0002) in mean percentage score on attitudes relating to HIV/AIDS increased from 38.1 (n=491) to 50.5 (n=305) in intervention schools compared with  the control schools (50.0, n=585 to 51.8, n=394).  There was also a greater increase (p<0.0000) in mean percentage score on attitudes with the intervention schools 38.1, n=491 before and 50.5, n=305 afterwards) compared with the control schools (40.5, n-586 and 40.3, n=392). There slightly higher behaviour change among the sexually active students in the intervention group but the increase was only significant for increased condom use (p<0.01). There was no evidence of an increase in sexual activity as a result of the educational programme. The main limitations in this study which the authors noted was lack of linking of pre and post-test (because the questionnaires were anonymous), the use of outcomes based on self-reporting and the loss of pupils from the original pre-test sample. However, it is important to not that the achievements measured had been sustained over the six month period between pre-and post-test showing that the intervention had achieved more than merely short-term improvements.

Kinsman,J., Nakiyingi,J.K.A., Carpenter,L.Q.M.P.R. and Whitworth,J. (2001)  Evaluation of a comprehensive school-based AIDS education programme in rural Masaka, Uganda.  Health Education Research: Theory and Practice  16, 85-100.Ref ID: 8810

Target group/Country Schoolchildren in primary and secondary schools in Masaka District, Southwest Uganda

Intervention Methodology The programme was an an adapted version of WHO/UNESCO (1994) School health Education to prevent AIDS and STD - A resource Package for Curriculum Planners. Two teachers from each participating school attended a series of three training and evaluation workshops of total length 5 days over 12 months. The teachers were expected to introduce the programme in classroom and out-of-school activities over the 12 month period.  The programme and subsequent evaluation was influenced by the behavioural Change for Interventions (BCI) Model which is closely related to the Theory of Reasoned Action and identifies the following 5 elements and important for behaviour change: knowledge acquisition, skills development, attitude development and motivational support.

Evaluation Method 1274 students from 20 intervention schools and 803 students from 11 control schools completed questionnaires in English at baseline and their classes were followed up. The self-completed questionnaires measured the four elements of the BCI model. Students in the intervention schools completed questionnaire directly before the programme began (round 1), immediately after it ended (round 2, 10-12 months later) and again 6 months after that (round 3). Students in the top 2 years of the primary schools and the lower 2 years of the secondary schools were asked to complete questionnaires at baseline and these classes were then followed up in subsequent rounds. Logistical problems prevented the children in control schools from completing the questionnaire at round 1 and they completed rounds 2&3.  In addition 93 students from 5 of the intervention schools participated in 12 focus group discussions.

Impact Achieved Analysis of the questionnaires suggest that the programmes overall effect was minimal and not statistically significant. Data from the focus group suggested that the programme was incompletely implemented and that key activities such as condoms and the role play exercises were covered only very superficially. The main reasons for this were a shortage of classroom time as well as teachers' fear of controversy and the unfamiliar. The findings highlighted the problems of locating AIDS education within a science curriculum and suggest that AIDS needs to be more fully incorporated into the national curriculum and located within the life skills curriculum with teachers receiving more training in participatory methods.

Klepp,K.I., Ndeki,S.S., Seha,A.M., Hannan,P.Lyimo,B.A., Msuya,M.H., Irema,M.N. and Schreiner, A. AIDS education for primary school children in Tanzania: an evaluation study. AIDS :1157-1162, 1994. Ref ID : 258

Target Group /Country/Reference Public primary schools in Arusha and Kilimanjaro regions, Tanzania.

Intervention Methodology Local teachers and health workers attended a 1-week training workshop before implementing the program over a 2-3-month period (averaging 20 school hours per class).Theory of Reasoned Action and Social Learning Theory was used to guide development of the educational programme which consisted of: (1) Teacher supported by health workers providing factual teaching; (2)pupils making posters showing HIV risk factors; (3) pupils writing songs about the danger of AIDS and how children can protect themselves; (4) pupils in small groups discussing what they can do to reduce their risk; (5) pupils writing and performing role plays practicing refusal skills (6) performing plays, songs, poetry to younger pupils. Te programme was called 'Ngao' -meaning shield in Swahili - children were given t-shirts with the ngao symbol.

Evaluation Method A quasi-experimental, nested cross-sectional design including baseline and 6-month follow-up surveys. Schools, stratified according to location, were randomly assigned to intervention (n = 6) or comparison conditions (n = 12). A total of 2026 sixth and seventh grade pupils (average age, 14.0 years) participated at baseline (85%) and 1785 at follow-up 6 months later.

Impact Achieved Following this program, intervention pupils reported significantly higher scores for the following outcome measures than pupils attending the comparison schools: AIDS information (13.1 versus 10.5; P = 0.0001), AIDS communication (10.9 versus 7.8; P = 0.0001) AIDS knowledge (14.5 versus 11.5; P = 0.0001), attitudes towards people with AIDS (9.0 versus 6.7; P = 0.0008), subjective norms (45.5 versus 43.9; P = 0.011), and intention (1.3 versus 1.4; P = 0.020). No program effect was seen for attitudes towards sexual intercourse (47.0 versus 46.3, P = 0.44).

Kuhn, L., Steinberg, M., and Mathews, C. Participation of the school community in AIDS education: an evaluation of a high school programme in South Africa. AIDS Care 6(2):161-171, 1994. Ref ID : 15

Target Group /Country A high school in a socio-economically disadvantaged, urban, African area in South Africa.

Intervention Methodology School nurses addressed a meeting of parents who gave their consent. Teachers and pupil representatives then planned the activity which was an intensive school-wide programme over two weeks. The programme implemented by the teachers included structured classroom sessions on AIDS, open discussions, integration into language teaching of the theme, showing of videos in breaks, a grafitti wall, stickers and condom distribution through a designated teacher.

Evaluation Method Students’ knowledge of and attitudes towards AIDS prevention were measured using a self-completed questionnaire in Xosa language before and after the AIDS programme, and compared to a neighbouring school, in which no AIDS education was conducted. 231 children in the intervention group and 336 in the control group at baseline and 206 in the intervention group and 276 in the control group at post-test. Teachers' knowledge was also evaluated before and after the programme.

Impact Achieved Following the intervention, students' knowledge about HIV transmission, prevention and the role of condoms, and the course of the disease was greater in the intervention school (p<0.001). Reported willingness to accept someone with AIDS increased (p<0.001) but was still at a low level (41.2%). There was a significant increase in numbers of pupils who claimed to have discussed AIDS with parents, nurses, teachers, friends and sexual partners (p<0.1). There was a small but statistically insignificant increase in student's intention to use condoms. Teachers' knowledge of AIDS improved but some misconceptions still remained as well as a hesitance to accept a person with AIDS. An unfortunate consequence of the programme was that a rumour circulated that the reason that they had had the AIDS education programme was because students and teachers had AIDS. This caused distress to the pupils.

MacLachlan, M., Chimombo, M. and Mpemba, N. (1997) AIDS education for youth through active learning: a school-based approach from Malawi. International Journal Of Educational Development 17, 41-50. Ref ID : 6866

Target Group /Country Secondary school pupils in one school in Malawi.

Intervention Methodology In this 3-year project, run by lecturers in the University of Malawi, a questionnaire survey of 756 secondary school children had showed that pupils gave more than 70% correct answers to knowledge questions on AIDS. This was followed by development, trial use, and evaluation of an educational board game. In this pupils had to give and explain and justify their response to a set of questions in order to advance in the game..

Evaluation Method 72 pupils aged 13-20 were selected from one school. These students were given a questionnaire and then played the game weekly for four weeks. Their game scores were recorded. One month from the last game session the questionnaire was re-administered. There were no controls.The questionnaire consisted of 40 true/false items were developed over a 2.5-year period and were drawn from separate and complementary sources including pupil observation, teachers, medical doctors, and government representatives.

Impact Achieved The test score increased each time the game was played. Although scores dropped between the final session on one month follow-up there was still an overall increase in scores between baseline and follow-up (73.5) and follow-up (88.2 p<0.001) The knowledge of pupils at the experimental school who did not play the game also improved, showing a “trickle down” effect. these results led to further development and distribution of the board game, dubbed “The AIDS Challenge.”.

Meekers,D. (1998)  The effectiveness of targeted social marketing to promote adolescent reproductive health: the case of Soweto, South Africa. PSI Research Division Working Paper No 16,  Washington:  Population Services International. Ref ID8755

Target group/country Young people in Soweto, South Africa

Intervention Methodology The Soweto Adolescent Reproductive Health Programme was implemented from June 1994 through April 1997 as part of a wider social marketing programme. During the intervention 70 adolescents were trained in participatory media development, peer education and condom distribution. Using participatory media development Soweto youths developed materials that were distributed through radio, television, print media, educational materials and interpersonal communications. To ensure adequate condom distribution, over 3000 condom distribution outlets were opened. Communications materials including radio advertisements, posters, T-shirts, buttons, slogans and a 44 page adolescent sexuality booklet. Soweto Community Radio and Voice of Soweto broadcast weekly 2 hour talk shows which included live call-in questions and discussions. . A six part documentary on condoms and safer sex was produced for South African TV and for showing as videos.

Evaluation Method Both men and women aged 17-20 were sampled but only the data from men could be used because of technical problems in data collection. A quasi-experimental control group design with a pre-intervention survey in in Soweto 1996 (n=118) and control area Umlazi (n=108) and a post-intervention survey in 1997 in Soweto (n=101) and Umlazi (n=103). Choice of questions was designed using a behavioural model combining the Health Belief Model and Self Efficacy.

Impact Achieved The % of young women who received instruction about pregnancy, contraceptives, STDs and HIV/AIDS increased rapidly in the intervention location but did not change in the control location (p<0.1).The results also suggested that the Soweto intervention influence health beliefs (p<0.1) including increased awareness of risk of becoming pregnant, that condoms can prevent HIV/AIDS, that young people do not have problems in preventing pregnancy, STDs  and HIV/AIDS. There was an increase in the % of women reporting to have talked about contraception with someone  (but not about STD/HIV prevention). In Soweto there was an increase in proportion of women who ever used condoms and the proportion of women who used condoms in last sex increased significantly in both areas. There was no change in other sexual behaviours (either a reduction or increase in sexual activity) The findings suggested that the intervention was more effective in changing beliefs related to pregnancy prevention than those related to STD/HIV. Thus may be a consequence of the fact that the young people in Soweto were more concerned about pregnancy prevention and this influence the content of the participatory. Note that the control community had a higher level of STD/AIDS and the young people were also exposed to education on HIV/AIDS from other sources. The sample sizes were small which may be a reason for the low p values

Meekers,D., Stallworth,G. and Harris,J. (1977)  Changing adolescent's beliefs about protective sexual behavior: the Botswana Tsa Banana program. PSI Research Division Working Paper No. 3,  Washington:  Population Services International. Ref ID 8754

Target group/country Young people in Botswana

Intervention Methodology The Tsa Banana programme was designed to help persuade young people that reproductive health services exist not only for other people but for adolescents and they should use them. The project was implemented in Lobatse from March 1995 to March 1996 and included: 1) a communications campaigns with radio messages, printed media, information campaigns directed towards parents, teachers and youth community leaders; 2)youth-oriented social marketing of condoms including teen-oriented inserts into magazines; 3) community outreach through peer sales educators; and 4) the development to of adolescent friendly outlets - retail outlets and health clinics were trained to participate in the service and given a special sign . In addition the programme promoted less risky behaviour A.B.C. "Abstain, Be faithful and Condomize". Peer educators taught negotiation skills such as and refusal skills or requesting the use of condoms. Peer education was provided in primary and secondary schools. In secondary schools all students were targeted and messages included safer sexual behaviours and condom use. In primary school children aged 13 and over were targeted and messages provided mainly information on puberty and encouraged abstinence. The Health Belief Model was used as a framework for educational activities and subsequent evaluation.

Evaluation Method A quasi-experimental control group research design was used with a pre-intervention and post-intervention survey conducted on a sample of male and female adolescents aged 13-18 years in both the intervention location and a comparison location. The first round of surveys were conducted in 1994 in the intervention (n=507) and comparison area Francistown (n=495). The second round was carried out in 8 months after implementation of the project  (n=1230 and n=1196 for intervention and comparison areas). Both questionnaires contained questions on reproductive health  and AIDs-related topics and the second one contained further questions relating to exposure to the programme activities.

Impact Achieved 41% of female and 33% of male adolescents were directly involved in programme activities (including low-level involvement such as wearing a T-shirt.68% of female and 71% of males had heard of the programme. A significant positive change among both males and females in the intervention location was an increased belief that people use condoms to avoid sexual risks (p<0.01), a reduction in belief among males that it is hard to convince a partner to use condoms (p<0.01 ) and a reduced belief among females that sex is good because it leads to marriage  and increases among females in the belief that AIDS cannot be cured and that people may abstain from sexual risk. The evaluation also indicated that the programme had brought about some undesirable changes. Females in both comparison and intervention locations were more likely to feel shy about purchasing condoms in public, to believe that women lose respect if they initiate condom use and to believe that few of their friends use condoms (p<0.01). This is used by the authors to suggest that that AIDS prevention programmes need to recognize possible conflicts between encouraging awareness of individual risks from unsafe sexual practices on the one hand and de-stigmatizing condom use on the other. (Though the presence of the same trend in the control does suggest that factors other than the intervention may be operating). The programme had different effects on males and females suggesting that in future these need to be targeted separately with different approaches and messages.

Migliori, G.B., Spanevello, A., Manfrin, V., Abongomera, A., Pedretti, R.F., Ballardini, L., Neri, M., and Borghesi, A. AIDS and tuberculosis control programmes: an integrated approach at educational level. Monaldi.Arch.Chest Dis. 51(2):102-107, 1996. Ref ID : 7251

Target Group /Country Secondary schools in Arua District Uganda

Intervention Methodology A 1.5 hour standardized HE session (covering the key- points of AIDS and TB control including treatment and need for case-finding and compliance with tuberculosis treatment.

Evaluation Method  The impact  was evaluated by comparing answers to 1,478.pre- and post-test questionnaires (multiple choice) before and three months after the intervention and evaluating TB case-finding performances from clinic records in the period preceding and following the survey. A control was not used.

Impact Achieved The overall impact of the health education on the knowledge scores was significant at p<00001 level. .However, a notable exception was a lack of significant impact on the knowledge of males on the preventive role of condoms In the period preceding the study 188 new cases of TB were diagnosed versus 241 in the following period. 19% of them were sent by one of the students or their families. (p<0.001). 12 defaulters started treatment in the period before the health education and 21 in the period following.

Monteiro, S.S., Rebello, S.M., and Schall, V.T. Zigzaids—an educational game about AIDS for children. Hygie 10(4):32-35, 1991.  Ref ID : 490  (Borderline for inclusion in database)

Schall,V., Monteiro,S., Rebello,S.M. and Torres,M. (1999)  Evaluation of the ZIG-ZAIDS game: an entertaining AIDS tool for HIV/AIDS prevention.  Cadernos de Saude Publica  15, 107-119.Ref ID: 8806  (Borderline for inclusion in database)

Target Group/Country Young people aged 10-14 years in Brazil.

Intervention Methodology Zigzaids is a board game with 23 spaces that contain instructions for moving forwards or backwards. Players roll the dice to move along but must answer questions about AIDS contained in cards. Additionally, the game also includes “surprise topics” that deal with such issues as haemophilia, blood transfusion, and drug action. A player wins by arriving to first to the end, and his or her prize is a condom. called Zigzaids. The educational theories of Paulo Freire were incorporated into the design of the game. The game also contained a leaflet for parents and teachers. In its original form the game was intended to be marketed through commercial outlets but the sexual language in the dictionary provided, the nature of the topic and the inclusion of a condom as a prize led to disappointing sales. The game was re-issued without the condom prize and sold mainly to government and NGO projects rather than through commercial channels.

Evaluation Method An evaluation sample was selected of 34 children aged 9-14 yrs attending two public and two private schools in Rio de Janeiro State. Some had volunteered and some were randomly selected. The game was evaluated by observing children as they played and then asking them to complete an oral questionnaire before and after they played. The children were also asked to write comments on their enjoyment of the game. There were no controls. The methodology for the observational study is not described. In addition a feedback questionnaire was sent to people ordering the game and questionnaires were sent to

Impact Achieved The game was widely distributed (100,000 copies alone were purchased and distributed by the National AIDS Control Programme). The feedback from schools and other institutions were very positive. The game was used in a variety of settings including classrooms, parents' meetings, vocational courses, day-care centres, company education programmes, supervision sessions for health workers etc. Following the playing of the game, the observational study found changes in the children’s ideas and attitudes concerning the disease. The children no longer considered embracing, eating, or playing with an individual with AIDS to be risky behaviour. Asked whether they had learned any new knowledge, all but 1 of the children said yes. And again, of the 11children that responded to the question of whether they would play the game again, only 1 child said no. Raw data is not presented and there were no significance tests. It is disappointing that given the innovative nature of this programme, so little data is presented on impact.

Nastasi, B., Schensul, J.J., Amarasiri de Silfa, M.W., Varjas, K., Silva, K.T., Ratnayake, P. and Schensul, S. (1998) Community-based sexual risk prevention programme for Sri Lankan youth: influencing sexual-risk decision making. International Quarterly of Community Health Education 18, 139-155.Ref ID : 8037

Target Group /Country Urban youth aged 17-27 years in Sri Lanka

Intervention Methodology Following two years ethnographic research a peer education programme for young persons aged 17-27 years was developed based on theory-driven risk-reduction mode (social construction theory that takes into account : 1) social competencies; 2) personal resources; 3)cultural norms; 4) socialization practices: and 5)cultural agents).Peer educators were selected and provided 30 hour training programme. These peer educators ran a training programme consisting of 12x90 minute sessions over four weeks.

Evaluation Method The training was evaluated by documentation of the programme and pre- and post-test measures of sexual knowledge, attitudes, perception of risk and decision-making through self-report questionnaires of 66 persons who had attended at least 6 of the sessions. There were no controls.

Impact Achieved There was a significant interest in knowledge of women on condoms (p<0.01) and sex terms (p<0.001) but no increase for men. There was no significant impact on attitudes towards sex or perception of future risk. There was no impact in the confidence of women and a decline in confidence of men (p<0.05). Some impact of the programme is claimed on perception of risks as measured by responses to open-ended scenarios - but no analysis of qualitative findings is presented. The significance of this evaluation is limited by its short-term nature and by the fact that impact is studied of the training on the peer educators and not the subsequent peer education activities among young people in the community.

Sankaranarayan, S., Naik, E., Reddy, P.S., Gurunani, G., Ganesh, K., Gandewar, K., Singh, K.P., and Vermund, S.H. Impact of school-based HIV and AIDS education for adolescents in Bombay, India. Southeast.Asian.J.Trop.Med.Public Health 27(4):692-695, 1996. Ref ID : 7792

Target Group /Country Pupils aged 12-15 in 10 schools in F North District of Bombay (Mumbai), India

Intervention Methodology An education program was instituted for one half school day at ten secondary schools selected out of a total of 45 schools in the district. The content consisted of a presentation on AIDS (causes, distribution, transmission, treatment and prevention) followed by a video and street play. (details are not provided, but it is likely that the presentation was to the whole school and not individual classes)

Evaluation Method A pre-test-post-test evaluation of a school-based HIV/AIDS educational program. The pre-test self-administered questionnaire in English and Marathi modes of transmission and prevention of HIV/AID was administered to a convenience sample of all pupils from 8,9 and 10th grade attending that day from 10 schools  - total sample 2,919 students, the post-test was administered to 2,400 students one month after the presentation

Impact Achieved There were increases (p<0.001) in the following areas of knowledge: that HIV/AIDS is transmitted sexually (43.995.6%), that there is no treatment (3492.4%); that HIV is not transmitted by mosquitoes (2476%); condoms can prevent AIDS (31.786.1); Vaccines are not available (24.786.4%) and voluntary blood donors are better than professional donors 30.186.5%). Principles of two schools refused to allow the AIDS education. Some class teachers did not attend the sessions because they were embarrassed.

Speizer,I.S., Tambashe,B.O. and Tegang,S.P. (2001) An evaluation of the "Entre Nous Jeunes" peer-educator program for adolescents in Cameroon. Studies in Family Planning 32, 339-351. Ref ID: 8965

Target Group/Country Youths aged 12-25 yrs in Nkongsamba (a town 102,000 population 120 km from the capital Douala), Cameroon

Intervention Methodology The Entre Nous Jeunes peer-educator program carried out over an 18-month intervention period from June 1997 - December 1998. 42 peer educators were recruited from schools and youth associations (selection included an oral and written test) An initial one week training programme provide information techniques for group discussion, reproductive anatomy, contraceptive methods, advantages and disadvantages of contraceptive methods and condom negotiation skills. Peer educators worked as volunteers receiving travel expenses and carried out discussion groups, one-on-one meetings and sessions at health and sports associations. Promotional materials included calendars, comic strips, posters, t-shirts, baseball caps and bags.

Evaluation Method Quasi-experimental Method. Baseline study of equal proportions of male and female randomly selected adolescents aged 10-25 were selected in the intervention area (n=402) and comparison community (a twon of similar size 40km from the major economic city of Yaound (n=400). A follow-up study was carried out 17 months later in the intervention community (n=405) and comparison (n=413) of young people aged 12-25 (the older sample was because parent's resistance to interviewing young children about sexual activity).

Impact Achieved During the intervention period peer educators organized 353 discussion groups with 12,000 young people and distributed materials to 5,000 adolescents. At follow-up 54% of the intervention sample said that they knew about the ENJ program and 39% reported having had contact with a peer educator. Peer-educator exposure is associated with greater knowledge among adolescents (p<0.55). Pre-intervention adolescents from the intervention sample were significantly less likely (p<0.01) to know female STI symptoms than the comparison group and at follow-up this situation reverses with peer-educator contact significantly associated with knowledge of female STI symptoms (p<0.001). At baseline no significant differences are found between current modern-method use by location or recent exposure to reproductive health information. At follow-up young people from the intervention areas are significantly more likely to use modern contraceptives than those from the comparison group (p<0.05). At follow-up adolescents who had an encounter with an ENJ peer educator are significantly more likely to be current condom users than are adolescents who did not have one (p<0.001). Notwithstanding the impact of the programme the authors draw attention to the short term nature of the evaluation, whether this type of peer-based strategy can be replicated on a larger scale and whether the impacts observed were specifically the result of using peers to educate young people or whether other aspects of the programme produced the impacts. In discussing the findings authors comment on the possible confounding factor of a slightly older sample in the follow-up studies and the proximity of the comparison city to Yaound whose larger and more bustling nature means that they young people had a wider access to non-programme information on reproductive health.

Rossem,R.V. and Meekers,D. (1999)  An evaluation of the effectiveness of targeted social marketing to promote adolescent reproductive health in Guinea. PSI Research Division Working Paper No. 23,  Washington:  Population Services International. Ref ID8756

Target group/country Young people aged 12-19 years in Conakry and Karkan cities in Guinea

Intervention Methodology The objectives of the adolescent reproductive health programme included to increase youth's knowledge of STDs and AIDS, to increase knowledge and use of condoms an other modern contraceptives, to increase delayed sexual initiation and sexual abstinence and to increase access to affordable condoms. The intervention was integrated into a larger nationwide contraceptive social marketing programme. The programme recruited and provided a two week training for 36 peer educators in Conakry and 22 in Kankan. Peer educators were equally selected from males and females who were active members of youth programmes or were volunteers. Training focused on topics related to family, STD/HIV and on communication techniques. The adolescents developed the project logo Mon avenir d'abord ("my future first") used to identify youth-friendly retail outlets . Peer educators handed out youth-oriented materials including posters, flyers, T-shirts, stickers, badges and caps. Billboards with information on STDs/AIDS were also installed. The peer educators also organized monthly discussion groups, educational theatre and dances and soccer tournaments.

Evaluation Method A pre- (Jan/Feb 1997) and post-intervention ( 8 months later in March 1998) survey design in two regions - each containing both experimental sites where the intervention took place and geographically distant control sites with no intervention. The 1997 baseline survey included 2508 adolescents divided equally between intervention and control communities and the 1988 follow-up study included 1009 intervention and 796 control. The questions were based on a modified Health Belief Model.

Impact Achieved 38.9% of the men but only 14.5% of the women in the intervention sites reported to have participated in programme activities. Soccer was the most popular of programme activities. 15% reported attending soccer games, 14% discussion groups, 9% attended theatre and 9% dances. Men participated more in all of these activities. There was no evidence of an effect of the programme on young people's perception of the risk of AIDS, awareness of sexual risk, perception of the benefits of prevention. The intervention did not affect the proportion of youths who reported sexual experience. 24% of the young people in the sample from the intervention area reported to have changed their sexual behaviour in response to the programme (use of condoms 13%, faithfulness 11% and abstinence 10%).There was a significant increase (a=5%) in condom use among sexually active men from an already high level of 53% to 65% (no effect on women) in the intervention area and a slight decrease in the control area. The authors attribute the lack of impact of the programme to the low educational potential of the most popular activity soccer, the short 8 month duration of the campaign and the fact that the need to have distinct control communities in the study design meant that there was no mass media support for the interpersonal activities.

Shuey, D.A., Babishangire, B.B., Omiat, S. and Bagarukayo, H. (1999) Increased sexual abstinence among in-school adolescents as a result of school health education in Soroti district, Uganda. Health Education Research: Theory and Practice 14, 411-419.Ref ID : 8437

Target Group /Country Primary schools aimed in Soroti district of Uganda

Intervention Methodology Activities included sensitization of local leaders and head teachers in a one-day workshop and an initial survey of school children. Teachers were trained on implementation of the school health curriculum, AIDS prevention and the use of child-to-child techniques. Activities in the schools consisted of formation and meetings of school health clubs, application of child-to-child health education  techniques, and competitions in plays, essays, poems and songs on health-related issues.

Evaluation Method A cross-sectional sample of 10 students (5 boys/5 girls) average age 14 years, in their final year of primary school was drawn from 38 randomly selected schools. They were given a self-completed questionnaire in English (but questions were explained in local language). The questionnaire was given to a similar sample of children in that same year after 2 years of interventions.

Impact Achieved The percentage of students who stated they had been sexually active fell from 42.9% (123 of 287) to 11.1% (31 of 280) in the intervention group (p<0.001%), while no significant change was recorded in a control group. The changes remained significant when segregated by gender or rural and urban location. Students in the intervention group tended to speak to peers and teachers more often about sexual matters (p=0.34). Increases in reasons given by students for abstaining from sex over the study period occurred in those reasons associated with a rational decision-making model rather than fear of punishment. The project had aimed to achieve sustainability through working through the existing structures and only employed one additional full-time. Details of the total number of children reached are not provided,

Van Rossem,R. and Meekers,D. (2000) An evaluation of the effectiveness of targeted social marketing to promote adolescent and young adult reproductive health in Cameroon. AIDS Education and Prevention 12, 383-404. Reference ID: 9103

Target Group/Country Young people in Cameroon

Intervention Methodology The Horizon Jeune program included youth -targeted behaviour change communication and promotion and youth-targeted distribution of prudence condoms and Novelle oral contraceptives. The programme targeted adolescents through peer education, youth clubs, mass media promotion, and behavior change communications. Youths from the target population were involved in the development and production of all campaign messages which were disseminated through youth-oriented promotional events, peer education, and counseling, radio talk shows, brochures and other media.28 peer educators were recruited from the target population and were trained in social marketing and interpersonal behaviour change communication. Peer educators help to set up a network of youth clubs in six schools. Radio spots and talk shows were broadcast . The project t also targeted parents, teachers and community leaders and held events such as video broadcast, condom demonstrations at night-clubs during "Prudence Night", presentations at local soccer games and drama productions on reproductive health issues. The programme was based on the Health Belief Model and the concept of self-efficacy from Social Learning Theory.

Evaluation Method .Program effectiveness was examined using a quasi-experimental research design with a pre-intervention (n=1,606 - 805 intervention and 801 comparison) and post-intervention survey (n=1633 (811intervention, 822 comparison) in an intervention and comparison site. The intervention site was a cosmopolitan city located 40 miles outside Douala with population 86,000. The comparison site Bafia was 80 miles north of Yaounde with a population of 73,000 and sufficiently far away from the intervention site to prevent contamination.

Impact Achieved After about 13 months of intervention, knowledge of the program was nearly universal, and the majority of youths had direct contact with the program. The intervention had a significant effect on several determinants of preventive behavior, including awareness of sexual risks, knowledge of birth control methods, and discussion of sexuality and contraceptives. Among the female youths in the intervention site the proportion who became sexually active prior to age 15 yrs decline from 10% to 4% whereas the level in the girls in the comparison group increased from 9% to 13% (p= .000) - there was a similar decline with boys but it was not significant. The proportion of female youths who reported to have ever used a condom rose from 58% in 1996 to 76% in 1997 (p=0.001) with no change in the comparison site.. However, condom use was not yet consistent. Although the proportion of young men who reported using condoms for birth control also increased, this change could not be attributed to the intervention. Although this short intervention successfully increased the reported use of various birth control methods, including condoms, there is no evidence that the intervention increased use of condoms for STD prevention of sexually transmitted diseases.. This study is of interest for its application of the Health Belief Model. The authors point to the need for future programmes to place more emphasis on the need to use condoms with regular partners.

Visser,M. (1996)  Evaluation of the First AIDS Kit, the AIDS and lifestyle education programme for teenagers.  South African Journal of Psychology/Suid-Afrikaanse Tydskrif vir Sielkunde  26, 103-113.Ref ID 8680

Target Group /Country Teenagers at 11 schools from different language groups in South Africa

Intervention Methodology The First AIDS Kit is an AIDS and lifestyle education program for teenagers developed by the Department of National Health and Population Development. The programme was based around the Theory of Reasoned Action, The Health Belief Model and the self-efficacy approach. The kit consists of 5 modules covering: 1) adolescence; 2) AIDS and STDs; 3) relationships; 4) life skills; and 5) safe sex skills. The kit included a video, quiz to teach facts and exercises in assertiveness, decision-making, negotiation skills, choosing low risk behaviours. Teachers were encouraged to select parts of the kit that they considered appropriate to the students' needs.

Evaluation Method The program was evaluated using a self-completed questionnaire before and one week after the program by187 pupils in standards 6-9 in 11 schools , as well as by focus group discussions with students and interviews with the teachers. The questionnaire was adapted from one issued by WHO and consisted of questions to measure knowledge, attitudes towards people with AIDS, behavioural intention to engage in high-risk behaviour and perception of condom use. The intention had been to select schools from all the language groups but the sample had to be reduced by two schools initiating their programme before receiving the pretest with result that the sample include the following language groups Afrikaans (53, 28%), English (78, 42%) and African (29, 16%) and not completed (27, 14%).  A control was not used because of the cost involved.

Impact Achieved There was improvement (p<0.005) on all the knowledge scales except susceptibility and the attititude towards people with AIDS (p<0.005). No significant improvements were found in the behavioural intention and perceptions of condom use.. Students gave favorable evaluations of the program and offered suggestions on how to improve it with regard to the content, presenter, educational techniques, the role of parents, and how to address moral issues. AIDS education should form part of long-term life skills and sex education, with a focus upon behavioral change. No significant difference between the pre-test and post-test results of students with an African home language - probably due to their small numbers in the sample.

Wolf,R.C., Tawfik,L.A. and Bond,K.C. (2000)  Peer promotion programs and social networks in Ghana: methods for monitoring and evaluating AIDS prevention and reproductive health programs among adolescents and young adults.  Journal of Health Communication  5, 61-80. Ref ID 8752 (Borderline for inclusion in database)

Target Group/Country Young people aged between 11 and 26 years in three urban locations in Ghana

Intervention Methodology Peer education programmes in different cities in Ghana carried out inside and out-of-school. No information is provided of the educational content of the training and the instructions provided to the peer educators on how to conduct their peer education. Five one-day training sessions were conducted with groups of up to 40 peer promoters. Each of the 106 peer educators was trained (no information provided on content).

Evaluation Method Multiple semi-structured interviews with 106 peer promoters (41% male,59% female; 64% currently attending school) ) and 526 contacts (46% male/54% female; 64% attending school) from three sites in Ghana (Accra, Kumasi and Aflao). The peer educators were paired up and each of the pair administered the questionnaire to the other in the pair. Each was then given questionnaires to give to five peer contacts - people they normally talk to and counsel about reported health and HIV/AIDS. They were instructed to return the completed questionnaires after a two week  period. The questionnaire included four components: demographic characteristics, behavioural indicators and message exposure, network and peer influence data and a summary of the peer education encounter including the main issues and messages delivered and services provided by the peer educator during their one-on-one peer encounter.

Impact Achieved 28% of contacts report having heard of AIDS within the past 30 days from a peer educators. Peer educators report that their contacts are mainly their friends (46%). More than half (53%) see the people from the peer encounter every day. Another 29% see them once a week. Peer educators who attend school tend to mainly reach others who attend school - even if the peer education programme is not school-based. Only 9% of peer educators and 58% of their contacts said they had done anything to protect themselves from AIDS and no information is provided to explain this. The value of this study is severely limited by the lack of information on the peer education programmes from which the sample of peer educators and contacts are drawn.


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