Health Promotion International, Vol. 19, No. 1, 69-76, March 2004
© Oxford University Press 2004. All rights reserved
A model HIV/AIDS risk reduction programme in the Philippines: a comprehensive community-based approach through participatory action research
1University of California, Los Angeles, CA, USA and 2University of the Philippines, Manila, the Philippines
Address for correspondence: Donald E. Morisky, UCLA School of Public Health Center for the Health Sciences, 26-070, 10833 Le Conte Avenue, Los Angeles, CA 90095-1772, USA, E-mail: dmorisky{at}ucla.edu
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SUMMARY |
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A 3-year, longitudinal, quasi-experimental study using participatory action research (PAR) was conducted to determine the feasibility and efficiency of an expanded sexually transmitted infection (STI) HIV/AIDS prevention program among diverse high-risk male heterosexual populations in the southern Philippines. A total of 3389 participants (
200 males from each of 18 study groups) were recruited, and 221 were trained as peer counselors to develop educational materials and reinforce safe sexual practices among their peers. Condom usage (36.10% to 38.70% to 46.31%), attitudes towards condoms (21.67% to 24.55% to 25.15%) and knowledge about HIV/STI transmission (41.87% to 42.19% to 33.31%) increased significantly from baseline to post-test and 6-month follow up, respectively (p < 0.01). Furthermore, the reported STI incidence decreased significantly (7.4% to 4.6% to 2.4%, respectively). Changes differed significantly between the intervention and control group at post-test and follow up (p < 0.01). These findings illustrate the appropriateness of using PAR methodology in promoting and sustaining positive behavior change. Key words: community-based intervention; condom use; HIV/AIDS; STI prevention
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INTRODUCTION |
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Of the estimated 40 million persons who are currently infected with HIV worldwide, 7.1 million live in South and South-East Asia. In 2001, the epidemic claimed the lives of 435 000 persons in this region (UNAIDS/WHO, 2001
). Low HIV prevalence in this area still results in high numbers of infections as this region includes highly populated countries such as China, India and Indonesia. It is therefore important to implement health promotion and disease prevention programs to avert epidemics in countries where HIV prevalence is still low. One such country is the Philippines.
In the Philippines, infection rates in general, even among the high-risk groups, have remained at low levels (<1%) (UNAIDS/WHO, 2000). The National HIV Sentinel Surveillance System (NHSSS) was implemented in two major cities, beginning in 1993 and expanded to 10 cities by 1996 throughout the entire archipelago (Department of Public Health, 2001). Behavioral sentinel surveillance was added to NHSSS in 1997 to monitor trends in knowledge and behaviors of vulnerable groups (injecting drug users, registered and freelance female sex workers, and men having sex with men).
A participatory research process
This paper reports the results of an innovative community-based participatory research program in the Philippines targeting the heterosexual male clients of commercial sex workers (CSW). Clients of CSW constitute a significant risk group that may benefit from educational and behavioral interventions to improve HIV knowledge, attitudes and practices concerning HIV and sexually transmitted infection (STI). Such efforts are crucial to avert an HIV epidemic in the Philippines. The present study sought to achieve those goals using a participatory action research (PAR) approach. PAR is defined as ‘systematic inquiry, with the collaboration of those affected by the issue, for the purposes of education or effecting social change’ (George et al., 1999). The PAR approach is characterized by six major criteria: (i) it is participatory; (ii) it is cooperative; (iii) it is a co-learning process; (iv) it involves systems development and local capacity building; (v) it is an empowering process for participants; and (vi) it achieves a balance between research and action (Israel et al., 1998). One of the main characteristics of PAR is that it eliminates the traditional distinction between the ‘researchers’ and the ‘researched’ (Gaventa, 1981). Both HIV/AIDS researchers and community-based organizations are partners and responsible for the conceptualization, needs analysis, development, implementation and evaluation of the program. As a result of this process, community participants are empowered with the realization of their own capabilities to be researchers and to induce desired changes within their communities (Hagey, 1997). This method seems particularly suitable when one is conducting research on controversial or sensitive issues such as HIV/AIDS.
Most educational efforts in the early phase of the HIV/AIDS pandemic have been concentrated on the high-risk groups, particularly CSW, men having sex with men, and intravenous drug users. In the same light, the first project launched jointly by the School of Public Health, University of California Los Angeles, and the College of Public Health, University of the Philippines, entitled ‘Behavioral Science in Support of HIV/AIDS Prevention’, also focused on CSW and managers/owners of the entertainment establishments utilizing an organizational change behavioral approach, including educational policy in the establishment (Tiglao et al., 1996; Morisky et al., 1998). Results of this programmatic effort indicated significant improvements in condom use behaviors and reduction of STI among female bar workers (Morisky et al., 2002a; Morisky et al., 2002b; Morisky et al., 2002c). However, in order to have a comprehensive program in the community, the customers of the CSW need to be included as well.
It is clear that men still dominate women's sexual behavior. It is recognized that men are generally more sexually active, have more sexual intercourse than the general female population, have more sexual partners, and generally take risks to maintain their machismo image to the extent that they refuse to practice safe sex. In short, they have a major role in the transmission of STI and HIV/AIDS. As a result of this, the second phase of the research was entitled ‘Comprehensive Community Based STI/HIV/AIDS Prevention Project’, which focused on the high-risk male client populations. Very few studies have assessed multiple intervention programs targeting a diverse male population using a variety of health education/promotion strategies and a PAR component.
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METHODS |
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Study population
The research was conducted in six study areas in the southern Philippines, namely: Lapu-Lapu and Mandaue City in Metropolitan Cebu; Legaspi and Daraga in the Bicol Region; and Cagayan de Oro City in Mindanao and Cavite City in the southern Tagalog Region. The six male population study groups were: (i) the military (air force); (ii) police and firemen; (iii) industrial workers; (iv) taxicab drivers; (v) pedicab drivers; and (vi) community (barangay) residents.
Design
A comprehensive community-based approach using a crossover study design was employed in the study. Baseline assessments were obtained with respect to HIV/AIDS knowledge, attitudes toward condoms, and condom use behavior in a 3-year longitudinal study. The six study groups were compared with post-intervention surveys (conducted 12 months following the training session) and follow-up surveys to evaluate the effectiveness of the intervention.
Table 1 displays the longitudinal crossover research design, with phase I and phase II of the intervention. All study groups were assessed at baseline (months 1–3), phase 1 interventions in study groups 1 and 3 (months 4–15), post-test assessment for all study groups (months 16–18), phase 2 interventions for study groups 2 and 4 (months 19–30), and finally follow-up assessment for all study groups (months 31–33). This design enabled all six study groups to participate in the intervention/training program, as well as allowing for the assessment of both short- and long-term impact of outcome indicators.
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Social preparation and the participatory process
Prior to the initiation of the intervention phase of the project, which in a way also served as a form of intervention, the collaboration of the City Health personnel, the Mayors and other city officials was sought in each of the six targeted sites. Executive officers, managers, military commanders and supervisors of each of the target populations were likewise oriented on the magnitude of the STI/HIV/AIDS problem and the importance of male involvement in the prevention of STI/HIV/AIDS. Each of these groups were invited to serve on local advisory committees
Sample size of target groups
The entire population of males in each targeted site was invited to participate in the study following informed consent procedures. Most of the time, this amounted to 200 individuals from each of the study populations. Study groups included one entire squadron of air force personnel, the packing and bottling division of industrial factory workers, the entire adult male population (18–45 years) from the community (barangay) located near the commercial sex establishment, and the total population of taxi and pedicab drivers from four sites. These study groups are representative of the entire population of males in each of the targeted sites. For the air force personnel, one squadron was randomly selected out of a total of four squadrons. Preliminary analysis revealed that this squadron is similar in demographic characteristics to the other remaining squadrons not selected in the study site, and presented no selection bias. Participation rate in each of the selected sites was high, ranging from 99% to 100%. A total of 3389 males participated in the 3-year longitudinal study.
Instrument
An interview schedule to measure knowledge, attitudes and practices related to STI/HIV/AIDS was used, including a 20-item, five-point scale which included questions on perceived level of knowledge, HIV/STI/AIDS transmission and risk of getting AIDS (
reliability = 0.81). Attitude towards condoms was measured by a seven-item, five-point scale ( reliability = 0.86). Participants were also asked a series of questions (yes/no) pertaining to condom use, STI incidence, discussion of AIDS with co-workers, attendance of AIDS prevention classes, and whether they received AIDS educational materials.
Gaining access to the community: presentation of baseline results
The coordinators of each of the six intervention sites arranged for presentation of baseline results to the entire group of participants. This included an overview of the problem of HIV/AIDS in Asia as well as the Philippines. Data were presented on cognitive indicators (knowledge, beliefs and attitudes) as well as behavioral determinants (condom use, multiple-sex partners and STI infection). Following this presentation of baseline information, speakers from the academe, the Department of Health and non-governmental organizations (NGOs) provided information on different types of STI with an emphasis on HIV/AIDS and its modes of transmission, and various methods of STI prevention, underscoring the importance of practicing safe sex (condom use), followed by demonstrations and role playing on the proper use of condoms. Slides and video presentations ensured lively discussion among participants.
Before the seminars ended, 10–20 peer counselors from each target group were recruited either by unanimous choice of the group, volunteering, or recommendation by their supervisors. Peer counselors attended a 1-day workshop, which included: a review of the technical aspects of STI/HIV/AIDS transmission and control; discussion of some of the myths about STI/HIV/AIDS and clarification of issues; skill-building teaching methods and strategies; counseling techniques; how to prepare Information, Education and Communication (IEC) materials; and how to use flip charts on HIV/AIDS. The flip chart was provided for each peer counselor during the training program. All peer counselors engaged in role plays simulating peer counseling activities. Resource speakers from the City Health Department Social Hygiene Clinic, NGOs, other government sectors (education and social welfare), and at times private clinician specialists on STIs were used as resource persons during the training.
Following this training session, peer counselors were expected: to educate at least 10 of their peers on STI/HIV/AIDS prevention; to meet with the site coordinator regularly to report the progress of their work; to conceptualize and develop IEC materials on STI/HIV/AIDS, including posters, stickers and photonovellas; and to distribute IEC materials on STI/HIV/AIDS to their co-workers. The photonovelas developed can be viewed online (Morisky, 2002c).
Peer counselors meet with the site coordinator every week for 1 h to go over the baseline data (at the aggregate level) specific to their own organization. Counselors review frequencies, request cross tabulations of different variables (such as how are attitudes towards condom use related to condom use behavior), and begin to construct a diagnostic assessment of the educational and counseling needs of their fellow co-workers. This process continued for 2 months, at which time educational responses to the identified needs were to be developed, including posters, fliers, brochures, stickers and photonovellas, or picture story presentations of common situations and events. One of the major activities of the peer educator was the conceptualization and development of the photonovella and posters and stickers. This proved a very productive process, evolving over several brain-storming sessions. Important diagnostic findings were conceptualized into story boards and scripts. As peer counselors clarified the facts and what went through the process, they unconsciously internalized the concept of STI/HIV/AIDS prevention. This was the most important component of the participatory research process in which the participants themselves developed and produced the educational responses to the diagnostic findings from the baseline needs assessment. Each study group produced their own photonovella, posed for pictures and translated the original English versions into the local dialect (Morisky, 2002c). The finished product was distributed to their peers. The posters were displayed in strategic places and the stickers placed in taxis and pedicabs.
Throughout the intervention, peer counselors and researchers identified and discussed specific problems arising at their sites. This strategy of identifying community needs and problems, highlighting the strategies used to engage in successfully influencing community development, has proven to be an effective modality in effecting change within the community (Wadsworth, 1998).
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RESULTS |
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Demographics
The socio-demographic characteristics of the participants and their peer counselors obtained at baseline were not significantly different. The mean age of the participants was 34.7 years. Sixty-seven percent were married, and had worked in their jobs for an average of 10 years. The mean educational level of the participants was 10.7 years of schooling.
Knowledge, attitudes and beliefs surrounding HIV/AIDS
Knowledge about HIV/STI transmission increased significantly from baseline to post-test and 6-month follow up in the intervention group (see Table 2). The control group's knowledge about HIV/STI was not significantly different from the intervention group at baseline and remained constant at post-test and follow up.
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Similarly, there was no significant difference in attitude towards condoms at baseline between the intervention and control group; however, at post-test and follow up there were significant differences in condom use attitude between the intervention and the control group, with scores significantly increasing for the intervention group.
Reported STIs and condom use
The number of respondents who had ‘ever used condoms’ increased significantly among participants in the intervention group (38.7% to 46.3%) but not in the control group (33.79% to 38.72%) during the post-test and the follow-up period (see Table 3). Furthermore, there was a significant difference in the responses between peer counselors and regular participants at post-test (t = 2.5, p < 0.01) and follow up (t = 2.6, p < 0.009). Among respondents in the intervention group who had sex with CSW, the condom usage ‘during the last time’ they had sex also increased significantly from post-test to follow up for peer counselors (13.36% to 18.65%), but condom usage remained unchanged for the control group (11.08% to 11.81%). Peer counselors reported a significantly higher condom usage ‘during the last time’ they had sex compared with regular participants in the study in the post-test (t = 2.2, p < 0.02) and follow-up period (t = 2.60, p < 0.009).
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After the intervention, there was a decrease in the number of participants who reported having an STI episode. Self-reported STI incidence decreased among participants from 4.6% to 2.4% versus 6.9% to 5.8% for the control group. There was a significant difference in the reported STI incidence between regular participants and peer counselors at post-test (t = 2.59, p < 0.009) and follow up (t = 2.71, p < 0.008).
A more detailed analysis of condom use behavior revealed that in the high-risk population (barangay residents), condom usage with CSW was not significant at post-test, but increased significantly at follow up (from 29% to 55%). Additionally, we found that among those who declared that they did not have sexual intercourse, condom use with CSW increased significantly for the industrial factory workers (18% to 30%) and for the taxi drivers (17% to 21%) from post-test to follow-up. Among tricycle drivers and military personnel, however, condom use increased at post-test, but the level of condom use at follow up was below that observed at baseline. And in the police/fireman group, condom usage decreased at both post-test and follow up (Table 4).
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Monitoring community participation, peer influence and policy change
In order to monitor community participation, individuals were asked whether they had ever discussed HIV/STI prevention with their co-workers, and whether they had ever attended an AIDS prevention workshop or seminar. Participants were also asked whether they ever received educational materials on AIDS/STI prevention from their employers.
The number of respondents who had ‘ever discussed HIV/AIDS with their co-workers’ increased significantly in the intervention group (51.9% to 54.9%), but not in the control group during the post-test and the follow-up period (Table 3). Furthermore, there was a significant difference in the responses between peer counselors and regular participants during the post-test (t = 3.52, p < 0.001) and follow-up periods (t = 4.81, p < 0.001). The participation in HIV/STI prevention workshops increased significantly from post-test to follow up among participants in the intervention group (22.0% to 32.0%), but not in the control group (6.2% to 5.8%). Peer counselors reported a significantly higher participation in HIV/STI prevention workshops compared with the other participants in the study during the post-test (t = 2.8, p < 0.003) and the follow-up periods (t = 2.7, p < 0.008).
The number of respondents who received educational materials on HIV/STI prevention from their employers increased significantly from post-test to follow up in the intervention group (88.0% to 90.4%), but not in the control group (70.2% to 72.4%). There was a significant difference between regular participants and peer counselors who received the educational materials during the post-test (t = 2.6, p < 0.007) and the follow-up period (t = 2.9, p < 0.001).
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The theoretical benefits of using a participatory peer education approach are well discussed in the literature. However, little information on the application and efficacy of community-based participation research methods in actual projects has been reported (Higgins and Metzler, 2001
). This study reports the results of a PAR intervention program. It stresses the impact of the intervention on risk reduction and includes a comparison of the incremental difference the intervention had for peer counselors compared with the regular participants. The theoretical concept behind peer education is relative simple. People with the same cultural background, experience and lifestyles are more effective teachers within that group compared with outsiders. Since peer counselors are selected within the group, they share the same concerns and have similar values and norms to the rest of the community that they work within. Peer counselors also have more access to influence the group, provide a more credible and trusted source of information, and can constantly reinforce safe sexual practices in a culturally sensitive manner, thereby enhancing the educational learning process. The reported condom usage increased significantly after the intervention, and along with this, the reported STI incidence also decreased significantly. The key factors for the success of the intervention included the fact that the peer counselors were able to understand important issues within the target group and develop educational materials that were culturally sensitive and easily understood by other participants in the study. The intervention overcame barriers of discussing sensitive issues like HIV, STI and condoms because the peer counselors were carefully selected, and were considered influential leaders among the different groups. The peer counselors were instrumental in developing culturally appropriate photonovellas that depict HIV/STI prevention in the form of a pictorial narrative illustrating different scenarios that can be easily understood, assimilated and accepted by the other participants in the group.
A more detailed analysis was also made of condom use behavior with CSW for the different types of client-centered populations (i.e. high-risk barangay residents, factory workers, taxi drivers, tricycle drivers, police/firemen and military). The results indicate that the intervention effect is not always apparent at post-test, but becomes meaningfully significant at follow up. For example, for the high-risk population (barangay residents), condom usage with CSW was not significant at post-test, but increased significantly at follow up (from 29% to 55% condom usage, respectively). This result suggests a delay in the impact of the educational strategy that was not observed at post-test, but as other factors intervened over time (peer support, social influence, organizational policy) the behavior change became evident (Green, 1977). However, since the findings also indicate that the intervention did not have the desired effect on condom use in some target groups, the results of the intervention may be considered somewhat mixed.
In order to be effective, peer education needs to be maintained over a long period of time. Other studies on peer education have reported that without continuing motivation and maintenance, momentum is diminished (Hayman et al., 1996). When support for the program decreased, knowledge and reported condom use declined but still remained at the pre-intervention levels. Follow-up evaluation for at least 6 months beyond the post-test has to be conducted to correctly assess the maintenance of the behavioral changes as a result of the intervention. In this study, if condom use had been assessed only at post-test, only minor changes would have been identified.
Monitoring participation and peer influence during the course of the intervention is important. In this research, discussion about HIV/AIDS among co-workers was assessed at baseline, post-test and follow up, and the effect was found to be significant from post-test to follow up, indicating maintenance of change. Participants also attended more HIV/AIDS-prevention workshops after the intervention, and received more educational materials on HIV/STI prevention from their employers. These measured effects, which reflect the degree of participation from the individuals (i.e. attendance, discussion, etc.) and the employers (distribution of education materials to employees), are important factors that help promote the success of this intervention.
PAR involves a process of cooperation and active participation among community members. In this research, the different communities were found to be cooperative and willing to participate in the program. The use of peer counselors was found to be an effective tool for increasing knowledge, improving attitudes towards more favorable condom use, and encouraging and sustaining appropriate behavior change.
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ACKNOWLEDGEMENTS |
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We extend appreciation to the City Health Officers who provided access to the study sites, CEOs and managers of study sites, participants who enrolled in the program, peer counselors who provided educational counseling and site coordinators who provided ongoing training and management of the program. This research was supported by grant R01-AI33845 from the National Institutes of Allergy and Infectious Diseases to D. E. M.
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