Community Health and Nutrition, Gender and Education Support (CHANGES) –2 Program Impact Evaluation of Students’ Alliance for Female Education (SAFE) Clubs and Peer Education Programs A Consultancy Report by Namposya Nampanya-Serpell, MSC., PHD. Deborah Ventimiglia, M.A., MPH. September 2006 Lusaka, Zambia Table of Contents Page Map of Zambia 2 Terms of Reference 3 Acronyms 4 Part 1: Introduction and background 5 Impact of HIV/AIDS on young people The magnitude of the OVC problem in Zambia Benefits of HIV/AIDS prevention Programs for young people Part 2: The SAFE Club/Peer Education Programs 7 Overview of the SAFE Clubs program Objectives of the SAFE Clubs Approach Guidelines for the Implementation of the SAFE Club Program Part 3: The Evaluation Research Methods 9 Evaluation Process Evaluation Design Framework for Measuring Impact Variable Definition Sample demographics Part 4: Main Findings of the Evaluation 13 Outcomes related to Knowledge Acquisition about HIV/AIDS Outcomes related to Attitudes and Behavior Change Outcomes related to the impact of peer Education Part 5: Recommendations 26 General Recommendations Evidence based recommendations References 41 Appendix A: Terms of Reference Appendix B: Assessment Instruments Appendix C: Core Elements of the SAFE Clubs program Appendix D: Schools with SAFE Clubs by Province and year of launch 2 TERMS OF REFERENCE FOR THE EVALUATION I: Objectives of the consultancy In July, 2006, CHANGES 2 contracted a two member team: Dr. Namposya Nampanya￾Serpell (Team Leader), assisted by Deborah Ventimiglia, M.A., MPH., to carryout an impact evaluation of SAFE Clubs and Peer Education activities in selected high schools where SAFE Clubs and activities exist. There were two major objectives for the consultancy: The first objective was to assess the impact of SAFE Clubs on: HIV/AIDS related attitudes and behavior of club members; changing the HIV/AIDS related attitudes and behavior of others at the school; and changing the HIV/AIDS related attitudes and behavior of community members. Specific attitudes and behaviors of interest were: Norms around adolescent sexuality; use of condoms and abstinence; decreasing stigma and discrimination against those infected and affected by HIV/AIDS and whether young people are either abstaining from sex or using condoms correctly and consistently. The second objective was to assess the impact of Peer Education including a review of the types of support Peer Educators receive; and what they learn at their initial training. Of particular interest was how participation in the PE activities changed their HIV/AIDS related attitudes and behavior, and how often Peer Educators talked to their peers about HIV/AIDS, ARH and gender. (Details of the terms of reference are at appendix A). II: Achievements All the tasks contained in the Terms of Reference above were achieved, with the exception of the section on the impact of SAFE Clubs on “Changing the HIV/AIDS related attitudes and behavior of community members” due to lack of time allocated to this aspect of the consultancy, no community based interviews were undertaken to learn from the communities themselves, if SAFE Club activities are benefiting community members or not. Questions related to the impact SAFE has made on the community were administered in focus group discussions, such that SAFE Club impacts at community level can only be seen through the lenses of SAFE Club members, and those stated impacts may not be representative of community leaders’ perception of the benefits of SAFE Club activities. III: Creation of an SPSS data base A data base was created for the information and data that was collected, for future reference. In the absence of baseline data to use for this particular impact evaluation, this data base could be regarded as baseline information for future evaluations. The same questionnaires could be administered to future and existing SAFE/non-SAFE Club members in order to assess how their attitudes, and behavior have changed compared to the cohort that was interviewed in this evaluation. The data could also be used for Provincial comparisons, and if relevant, future HIV/AIDS-focused youth programs could benefit from these provincial comparisons. 3 ACRONYMS AIDS Acquired Immunodeficiency Syndrome ART Adolescent Reproductive Health CHANGES2 Community Health and Nutrition, Gender and Education Support 2 CHEP Copperbelt Health Education Project CSO Central Statistical Office DEC District Executive Committee FAWEZA Forum for African Women Educationalists of Zambia FGD Focus Group Discussion NGO Non Governmental Organization OVC Orphans & other Vulnerable Children PE Peer Education PEC Provincial Executive Committee PLWHA People Living With HIV/AIDS SAFE Clubs Students’ Alliance for Female Education SPW Students Power Worldwide STIs Sexually Transmitted Diseases UNGASS United Nations General Assembly Special Session on HIV/AIDS VCT Voluntary Counseling and Testing 4 PART 1: INTRODUCTION AND BACKGROUND Impact of AIDS on the lives of young people According to a 2003 UNAIDS report, young people aged 15-24 account for half of all the new HIV infections around the world. An estimated 11.8 million young people were living with HIV/AIDS at the end of 2001-7.3million young women and 4.5 million young men. Furthermore, the AIDS pandemic in Africa, which has claimed over 18 million lives in the region, has hit women and girls harder than boys and men. In Zambia, statistics show that HIV prevalence among girls under the age of eighteen is four to seven times higher than among boys of the same age, which means a lower average age of death from AIDS, as well as more deaths overall, among women than men. In many parts of Zambia, tens of thousands of children have been orphaned and/or made vulnerable by the pandemic. These children are without parental care and guidance, their school drop￾out rates are high; and they are likely to suffer physical and sexual abuse. For these reasons, girls especially are at increased risk of contracting HIV. A study, (Zambia Sexual Behavior Survey) on knowledge and sexual behavior done in 2000, indicated that almost all adolescents in Zambia have heard of AIDS, however a large proportion of these young people did not think a person could do anything to avoid AIDS-over 30% and 32% of young women and men aged 15-19 thought that HIV could not be avoided. The study also found that adolescent knowledge regarding two specific ways to avoid HIV indicated that consistent use of condoms and having one faithful partner was higher among male than female: 64% of men cited consistent use of condoms, while 75% cited sticking to one faithful partner as ways of avoiding HIV. For the women, the figures were 57% and 73% respectively. The study also found that 30% of males and 24% females said HIV could be transmitted by witchcraft which indicates misconceptions regarding modes of HIV transmission. Orphans and Other Vulnerable Children (OVC) in Zambia The orphans’ crisis is growing in Zambia. A review by CSO showed that in 2002, over 15% of children under the age of 15 had lost one or both of their parents for an estimated total of 710, 000 orphaned children. This figure has grown steadily, such that by 2003, 19% of Zambian children under the age of 18 had been orphaned, totaling 1,100,000 children. Zambia has one of the highest proportions of AIDS orphans to the total number of orphans in sub-Saharan Africa. According to Children on the Brink 2004 report, AIDS orphans constitute 57% of the total number of orphans in the country. The CSO data also revealed that a higher number of children lose parents during middle childhood and early adolescence. Thus, even though prospects of physical survival maybe better, older orphans face emotional and social problems as a result of being orphaned, as well as the effects of deprivation, lack of schooling, sexual exploitation and poverty. Among young people, HIV spreads almost exclusively by unsafe sex between males and females, and between males. And yet, many young people do not know how to protect 5 themselves against HIV/AIDS. They often hear about sex, condoms and need for safer sex, yet there is a lot of confusion and misinformation surrounding these issues. In 2001, the UN held a special session on HIV- United Nations General Assembly Special Session on HIV/AIDS (UNGASS). One of their global targets was to reduce HIV-prevalence among young people by 25% by 2005. This goal was supposed to be achieved through the following interventions: • School based AIDS education • Peer education for out of school youth • Public sector condom promotion and distribution • Treatment of STIs and VCT. BENEFITS OF HIV/AIDS/STIS PREVENTION PROGRAMS FOR YOUTH School Based HIV/AIDS Interventions School based interventions have so far proved to be very effective in reducing young people’s vulnerability to the HIV/AIDS and to an increase in their ability to control their sexual lives. Research findings by Emerging Answers about Sex and HIV Education Program,1 in the USA, have demonstrated that several sex and HIV education programs have shown to delay the onset of sex, reduce the frequency of sex, reduce the number of sexual partners among teens and increase the use of condoms. An evaluation of several programs: Safer Choices; Becoming a Responsible Teen; making A Difference; A Safer Sex Approach to STD; Teen Pregnancy and HIV Prevention, were all found to delay the onset of intercourse among teenagers and to increase the use of contraceptives among groups of youth. These programs make a real difference in encouraging teens to remain abstinent or use contraceptives when they have sex. In particular larger, more vigorous sex and educational programs have found sustained positive effects on behavior for as long as three years after participation in such programs. SAFE Clubs as a Strategy for the Prevention of HIV/AIDS among Youth As discussed above, research has shown that young people exposed to appropriate information about sex tend to postpone sexual debut or use condoms. Ignorance on the other hand, increases their chances of acquiring HIV and other Sexually Transmitted Infections (STIs). Since some adolescents become sexually active at an early age, it is critical at the very least, that young people are informed about HIV/AIDS-how the virus is transmitted, what the effects are, when they are at risk of infection and how they can protect themselves against the epidemic. In addition, young people, especially girls need to know how to negotiate safe sex, cope with peer pressure and deal with threatening situations. SAFE Clubs are one of the vehicles that are well suited to reaching young people with appropriate messages that increases their knowledge about HIV/AIDS and can influence their sexual behavior and attitudes. 1 The National Campaign to Prevent Teen Pregnancy; Frequently asked questions about “Emerging Answers: Research Findings on Programs to reduce teen pregnancy –by Douglas Kirby, PhD. 6 PART 2: THE SAFE CLUB/PEER EDUCATION PROGRAMS Overview of the SAFE Club/Peer Education Programs Students’ Alliance for Female Education (SAFE) Clubs major objective is to contribute to the promotion of female education in Zambia. They are voluntary student’s associations that are implemented in conjunction with the US government’s Scholarship Program funded through CHANGES2 and implemented by FAWEZA. Although the program was initially established for girls who were considered vulnerable and needed assistance to continue schooling, the program has been expanded to include non-bursary recipients both girls and boys. The goal of the clubs is to improve the learning experiences of girls and boys and young women and men in and outside the classroom, by creating an atmosphere that encourages students to stay in school until they complete their education cycle. The clubs assist young people to attain the necessary knowledge and life skills to enable them to face challenges such as the effect of the HIV/AIDS pandemic, poverty and other social ills. One of the major aims of the SAFE Clubs program is to cultivate positive gender relationships among young people in institutions of learning and training in order to create an environment for increasing girls’ access, retention, learning achievement and completion rates. Objectives of the SAFE Clubs2 • Redress gender imbalances in education through targeted interventions that directly benefit girls. • Train Peer mentors to help uplift, support and guide other young people who have low self-esteem. • Empower girls and young women to recognize and defend the right to their bodies. • Challenge the social-economic factors that constrain girls’ education, such as HIV/AIDS, early marriages and teenage pregnancy through community outreach and education. • Provide a forum for young people to talk about issues that affect them. • Educate girls and boys on their basic human rights such as the freedom from sexual exploitation, child labor, etc. as well as their social responsibilities in the family and wider community. • Provide communication channels between students and school administration. • Establish a network of SAFE Clubs to enable exchange of experiences, information and lessons on educational and personal development of students. 2 FAWEZA’s SAFE Clubs Profile and Guidelines. Full Details can be found at Appendix C. 7 Implementation Guidelines Details on the formation and operations of SAFE Clubs can be found at appendix C. The Clubs are open to both boys and girls, to scholarship recipients and also to non-recipients. However, membership in SAFE Clubs is mandatory for all scholarship recipients. The Head Teacher and a teacher chosen by FAWEZA as their “SAFE Club Overseer” The SAFE Club Overseer, monitors the functions of SAFE Clubs in each school. The Overseer helps the SAFE Club mobilize resources for it’s operations and activities; assists members plan, implement and monitor activities; manages and monitors the school’s ‘communication box’ and adheres to approved protocol for handling submissions; reviews reports and forwards them to District Executive Committee (DEC); monitors SAFE Club activities and submits reports to the PEC and FAWEZA secretariat. 8 PART 3: EVALUATION RESEARCH METHODS Evaluation Process Data collection instruments were developed by CHANGES2 and the consultants reviewed and discussed them with staff members. The instruments included structured interview questionnaires for students in participating schools; focus group discussions guides; SAFE Overseers and Heads/Deputy Heads interview guides. CHANGES2 Provincial Teams collected the data from selected schools in four target provinces: Copperbelt, Lusaka, Central and Southern. The consultants participated in the orientation of CHANGES2 Provincial staff, in the pilot testing of the instruments in Lusaka province, and in data collection in some of the schools in the Copperbelt, Southern and Central Provinces. Evaluation Design This was a retrospective impact assessment. Impact assessments are undertaken to estimate whether or not interventions are producing their intended effects. Secondly, evaluators assess the outcomes of programs by comparing information about participants and non-participants, or by repeated measurements on participants, most commonly before and after an intervention, or by other methods that attempt to achieve the equivalent of such comparisons. In this particular evaluation, since there was no pre-post baseline data collected for the students before and after they joined the SAFE Clubs, the evaluators assessed the SAFE Club program outcomes by comparing information from two groups: SAFE Club members as the participating group, and randomly selected students who are not members of SAFE Clubs as a comparison group. However, this comparison was only feasible for the general questions in the data collection instruments, but couldn’t be applied to the sections of the questionnaire that were specifically targeted to SAFE Club members only. Data Analysis The first part of the report, examines how student’s participation in SAFE Clubs has impacted their attitudes and behaviors vis-à-vis HIV/AIDS, from self reported responses to section two of the questionnaire, that targeted SAFE Club members only with questions such as: has being a member of the SAFE Club changed your thinking (attitude) about HIV/AIDS?, has being a member of the SAFE Club changed your behavior? In the second part of the report, comparisons between SAFE and Non-SAFE Club members are made for those questions that were directed at both SAFE/Non SAFE Club participants, more specifically questions in sections: 4-Sexual history and numbers of sexual partners; section 5- Sexual history for those who had sex in the last three months and whether they protected themselves or not during sexual activity; Section 6- Knowledge, opinions and attitudes of both SAFE and Non-SAFE respondents; Section7- 9 examines opinions of respondents about male sexual violence against women, and whether they would have the confidence to insist on condom use, and further, if they think they are at risk of contracting HIV in future. Framework for Measuring the Global Impact of SAFE Clubs on Students In order to evaluate the global impact of the SAFE Clubs on Knowledge, Attitudes and Practices/Behaviors of participating students, the following framework and indices for measuring the effects of the program were established for both the quantitative and qualitative data using the survey questionnaires as shown below. In this framework the following were identified as indices for the evaluation model’s three independent variables: a) Knowledge Acquisition • HIV/AIDS knowledge, including how the disease is transmitted • Protective knowledge - knowledge on risks that would expose them to infection by HIV, and how they can protect themselves by choosing abstinence, being faithful to one partner and by using condoms, including delaying their sexual debut). • Rejection of superstitious beliefs about HIV/AIDS b) Attitude change • Stigma reduction • Risk perception • Rejection of male sexual violence c) Behavior change • Condom use • Reduction in sexual partners • Abstinence The analysis utilizes this framework, both for ease of reference as well as clarity in the classification of the relevant independent and dependent variables in the model. 10 Figure 3-1 Framework for measuring the global impact of SAFE clubs GLOBAL IMPACTS Increased Condom Use Stigma Reduction Reduced Sexual Partners 3 Behavior 2 Attitudes Risk - Perception Self -Efficacy Increased Abstinence Rejection of Male Sexual Violence Knowledge About HIV/AIDS Protective Knowledge Rejection of Superstitious Beliefs 1 Knowledge Variable Definition/Classifications For the data analysis, the following variable categories were identified: Independent Variables (IVs) Dependent Variables (DVs) Index of Change Indices of: Male/Female Age (K) Knowledge Global Index SAFE/Non SAFE Club membership (A) Attitude of Positive Orphan-hood Status (B) Behavior Change Province ________________________________________________________________________ } Sample Demographics The following table shows the breakdown of the sample population who were interviewed, and forms the basis for making the calculations that are discussed in this report. Note that, in some cases there was either no response or don’t know, so the averages are not the same for each question, they only reflect the actual responses obtained for that particular question. 11 Table 3-1 Sample demographics Province Provincial Total SC NSC FGDS/SC FGD/NSC Overseers Total M F M F M F M F M F Lusaka 60 6 54 3 26 3 28 5 25 - 54 5 Southern 51 22 29 16 20 6 9 69 95 24 48 7 Copperbelt 56 27 29 15 17 12 12 40 48 22 19 5 Central 21 11 10 4 10 3 4 16 34 - 10 5 Total 188 66 122 38 73 24 53 130 202 46 131 22 Focus Group Discussions Forty sessions of Focus Group Discussions were held in the four provinces - 10 in each province, with two sessions per school, one which comprised of SAFE Club members and one other targeting Non-SAFE Club members. 12 PART 4: MAIN FINDINGS OF THE IMPACT EVALUATION 4A. OUTCOMES RELATED TO SAFE CLUBS MEMBERS’ KNOWLEDGE ACQUISITION ABOUT HIV/AIDS Knowledge about HIV/AIDS SAFE members, both male and female identified four major areas in which they had acquired knowledge about HIV/AIDS by virtue of being members of SAFE Clubs: • HIV/AIDS transmission • Caring for PLWHA • Strategies on how to avoid peer pressure • How to protect oneself from HIV infection As figure 4.1 shows, the majority of SAFE Club members: 81.8 % of males and 67.2% females within their cohort, stated that they had acquired knowledge about HIV and its transmission through participation in SAFE Clubs; 88.2% of females and 11% of the males stated that they had learned how to care for PLWHA; while 65% females and 37% males had acquired knowledge regarding protection against HIV/STIs infection e.g., condom use, abstaining, and/or avoiding sexual relationships while at school. Twelve percent females and 5.3% males had learned how to avoid peer pressure to have sex. Two issues that have policy implications in order to improve future programmatic outcomes include the need to focus on increasing the girls’ knowledge base on HIV/AIDS and secondly, increasing the number of male students involved in the care of PLWHA. Figure 4-1 Acquired knowledge about HIV/AIDS among SC Members 0 10 20 30 40 50 60 70 80 90 % of Cohort 1 2 3 4 5 1=Knowledge about HIV/AIDS & its Transmission 2=How to care for PLWHA 3=How to protect oneself from HIV Infection 4=How to avoid peer pressure Knowledge Acquisition Male Female 13 Illustrative examples of acquired knowledge about HIV/AIDS from SAFE Club members “I know now that HIV/AIDS can affect anyone. It knows no age boundaries” (Female, Siavonga). “I used to think that AIDS could only happen to older people who were careless. Now I know it can happen to me” (Female, Central Province). “I used to think having a boyfriend was great. He provides. Now I know the dangers of STI/HIV/AIDS” (Female, Lusaka). Acquired Protective Knowledge among SAFE Club Members One of the objectives of SAFE Clubs is to teach members how to protect themselves against STI/HIV/AIDS infection and to avoid unwanted pregnancies among female students. As can be seen in figure 4-2, most female respondents (61.6%) and 34% of the male students chose abstinence as a way of protecting themselves against STIs/HIV infection. 13.2% of male respondents and 11% females chose condom use as the best method for self protection. And 6.9% and 5.3% of female and male students respectively, stated that getting more involved in games and other school activities would help them focus more on education and less on sex. More female respondents (26%) compared to 2.6% male students mentioned ‘not sharing sharp instruments’ as one way of protecting themselves against infection. This finding has implications regarding how messages are being imparted to the youth, i.e. need to focus on the most common mode of HIV transmission, which is “unprotected sexual intercourse.” This finding indicates that youth believe strongly that not sharing sharp instruments is more protective than e.g., condom use. A policy implication would be to increase HIV/AIDS prevention education that targets the individual’s understanding of personal risk. (Note that the respondents were allowed to choose more than one method of protection, therefore the percentages do not add-up to 100). 14 Figure 4-2 Percent of SAFE Club members who mentioned selected ways to avoid HIV infection 0 10 20 30 40 50 60 70 % of Cohort 1 23 4 1=Abstinence 2=Using condoms 3=Not sharing sharp instruments 4=Focusing on school and games/activities Protective Knowledge Male Female Other Important Areas of Knowledge Acquisition • Self esteem, confidence, and assertiveness • Ability to teach, encourage others and to communicate more effectively about HIV/AIDS and ARH • Girl Child Rights • Respect for others The theme of self esteem/confidence/assertiveness featured prominently especially among SAFE Club female respondents. As figure 4-3 shows, 52.1% of females and 5.3% of males stated that, belonging to SAFE Clubs had increased their self esteem; their self confidence; and their ability to be assertive in their conduct both in classroom situations and social relationships. More male students (31.6%) compared to 20.5% of females stated that they had gained the ability/skills that would enable them to teach, encourage others, and to communicate effectively with other students about HVI/AIDS/STIs and ARH. More female than male students stated the importance of girl child rights and respect for others. 15 Figure 4-3 other important areas of knowledge acquisition Other important areas of knowledge acquisition 0 10 20 30 40 50 60 1234 1=Self assertiveness/confidence 2=Ability to teach others 3=Girl Child Rights 4=Respect for others Female Male % of cohort Rejection of Superstitious Beliefs about HIV/AIDS (SAFE Club Members only) Respondents were asked a series of questions about their beliefs on HIV transmission: a) Do you think HIV is sometimes spread through witchcraft? b) Can a person get HIV through a mosquito bite? c) Can you tell by looking if a person is infected with HIV? The means of female and male SAFE Club members were compared using t-test for independent samples. The results showed a marked difference between the two groups with males (mean 13.61, n=33) rejecting superstitious beliefs more than female members (mean 7.13, n=91). (The higher the groups’ mean, the more rejection of superstitious beliefs). The results were statistically significant with P=.000. These results show that male SAFE Club students are less likely to be superstitious about the transmission mode of HIV than the females. More SAFE Club girls in their cohort believed that you could get HIV from mosquito bites or through witchcraft, than boys did. This finding has important implications for how information is disseminated about HIV transmission. More messages that emphasize the fact that HIV is mostly transmitted through sexual intercourse need to be targeted especially to girls who appear to have a knowledge gap in the area of false beliefs and myths about HIV transmission. An illustrative example of rejection of superstitious beliefs from a SAFE Club member “The notion that one can get cured of HIV/AIDS by having sex with a virgin or a minor is a myth and is wrong. It is destroying the lives of young people” Male student, Livingstone. 16 4B. OUTCOMES RELATED TO BEHAVIOR CHANGE AMONG SAFE CLUB PARTICIPANTS SAFE Club Members This section of the report examines the outcomes for Male and female SAFE Club members only who were asked open ended questions regarding how SAFE Clubs have changed their behavior in relation to HIV/AIDS. Respondents identified five primary ways in which they have changed their behavior since becoming members of SAFE: • Abstinence • Reduction of sexual partners • Avoiding peer pressure • Increased focus on school • General healthy behavior-reduced alcohol consumption, not going to nightclubs, and acting more “responsibly.” Figure 4-4 Ways in which safe club members have changed their behavior 0 5 10 15 20 25 30 35 40 45 % of cohort 1 2345 1=Abstinence 2=Reduction in sexual partners 3=Avoiding peer pressure 4=Focus on academics 5=General healthy behavior Behavior Change among SAFE Club members Male Female There were thirty six (19%) students who reported having had sex in the past out of the 188 interviewed. Thus, the data reported on abstinence and condom use in the past refers to responses made by sexually active students only and not the entire sample population. As figure 4-4 shows, 44.7% of male SAFE members and 15.1% of the females stated that they had begun abstaining from sex since they joined the SAFE Club. More females (25%), than males (15.8%) stated that they were now able to resist peer pressure to have sex. Both groups expressed the desire to reduce having sex in the future (7.9% and 6.8% males and females respectively, and concentrate on academics. The difficulty with interpreting this information is that, it is possible that respondents tend to state what they think the interviewer wants to hear, especially in matters regarding sexuality. 17 Illustrative examples from SAFE Club members on why one should avoid peer pressure “I stopped being influenced by friends; they would talk about having boyfriends and I intended to join them but now I am not. I’m focusing on school.” Female, Monze. “I used to agree to be proposed by anybody but now I know I can refuse and stand on my rights”, Female, Copperbelt. “You have to choose people who can support you in your vision, not friends who can influence you” I used to play with anyone, even those who went after men for money. “I was planning to have a boy friend and sex as a result of peer pressure, but being in the SAFE club helped me realize that life in not only sex“ Female, Copperbelt. COMPARISON BETWEEN SAFE CLUB AND NON-SAFE CLUB MEMBERS Plans to Abstain From Sexual Activity When both SAFE Club and non SAFE club members were asked what will you do to protect yourself against HIV infection in the future? 64% female SAFE Club members and 36% non-SAFE female members indicated that they would abstain from sexual activity while 56.5% and 43.5% SAFE and Non-SAFE males, respectively chose abstinence as a method of prevention. Abstinence is clearly one of the messages that SAFE Club members more than non-SAFE members are receiving as a way of protecting themselves against HIV infection. The lowest figure is that of non-SAFE club females, and that might be an issue worth looking into. It also demonstrates one of the benefits of belonging to SAFE Clubs for the young women. Another indicator that was examined was sexual history of respondents. Data shows females less likely to have had sex than males in the sample. Figure 4-5 below illustrates the trend towards abstinence among respondents. SAFE Club members in the sample, revealed a definite trend among the students, to delay sexual debut, especially among the girls. Eighty percent of the females interviewed had never had sex and expressed a strong desire to delay having sex until they got married, while twenty percent had sex in the past. Forty four percent of the boys had sex in the past, while fifty six had never had sex. Figure 4-5: Sexual History of the Respondents Sexual History of the Students 1 2 0 10 20 30 40 50 60 70 80 % of cohort 1=Female 2=Male Never had sex Has had sex 18 Illustrative examples of desire to abstain from sexual activity by SAFE Club members “I look at male folks as friends, brothers but previously they were husbands or people to have sex with” Female, Central Province. “I was fond of girlfriends, but now I’ve reduced.” Male, Livingstone. “Now I strongly feel that having sex with girls is not right, but have them as friends.” CONDOM USE AMONG SEXUALLY ACTIVE STUDENTS As indicated above, thirty six self reported sexually active respondents were asked a series of questions about condom use. Using cross-tabulations between male and female and SAFE/non-SAFE members, the outcomes consistently showed more condom use in the past and/or desire to use condoms in the future by SAFE Club members compared to non-SAFE Club members. Although, the sample size is too small to provide conclusive evidence, and the differences are not substantial, there is a consistent trend in the same direction once the three questions are analyzed separately as shown below: Actual reported behavior on condom use a) The last time you had sex with your girlfriend/boyfriend, did you use a condom? The outcomes were: 55.6 % of male SAFE Club members stated that they had used a condom last time they had sex, while 43.5% of their non-SAFE counterparts said they used a condom last time they had sex.3 b) In general how often did you and your girlfriend/boyfriend use a condom when you had sex during the last twelve months? Fifty eight percent of SAFE Club members stated that they had always used a condom whenever they had sex in the last twelve months, while 55.5% of the non-SAFE Club members within their cohort had always used a condom. Planned future condom use c) In future, how often will you use a condom? Do you think you will use one every time you have sex, when you have sex with a casual partner or never? Approximately 70% of SAFE Club members indicated that they would use condoms in future every time they had sex, while 63.6% of non-SAFE Club members stated that they would use condoms in the future. These finding have policy implications, i.e., the need for school-wide expansion in the dissemination of protective messages to increase coverage to non-SAFE members. 3 The responses from the females were discounted because some answers did not tally with an earlier question about whether they had never had sex. Some of those who had never had sex went ahead and still answered the condom use question as well which was contradictory. 19 Reduction in Sexual Partners Respondents were asked how many partners they think they will have in the future. More SAFE Club members stated none or one partner, whereas, more non-SAFE members stated that they would have several. The means of SAFE and Non-SAFE Club members were compared using t-test for independent samples. The results showed a significant difference between the two groups with SAFE Club members (mean 5.9, n=23) and non￾SAFE Club members (mean 18.5, n=11), stating a preference for one partner and (the higher the groups’ mean, the more sexual partners preferred). The results were statistically significant with P=.015. This finding shows that SAFE Club members have been sensitized to the concept of being faithful to one partner. The policy implication is that the program needs to be expanded to reach non-SAFE Club members with similar messages. The same data was analyzed using cross-tabulations instead of the t-test: 84.6% of the female SAFE Club members and 37.5% of the male SAFE club members, respectively, stated that they would only have one partner in future; while only 20% male and 28.6% female non-SAFE club members stated that they would be faithful to one partner. In addition, only non-SAFE Club members (12.5%) mentioned that they would have several sexual partners, but one at a time and14.3% would have several partners at the same time. None of the SAFE Club members listed those two alternatives in the questionnaire. (These were responses to statements in the questionnaire that asked whether they would have several sexual partners one at a time; or several sexual partners at the same time). These findings point to an urgent need to educate youth especially young men, regarding the increased risk of HIV/AIDS linked to having more than one partner. These findings point to an urgent need to educate the youth especially young men, regarding the increased risk of HIV/AIDS linked to having more than one partner. Rejection of Superstitious Beliefs about HIV/AIDS The means of SAFE Club and non-SAFE Club members were compared using t-test for independent samples. The results showed no significant differences in terms of superstitious beliefs between SAFE Club and Non-SAFE Club members, with SAFE Club members (mean 8.59 n=74) and non-SAFE Club members (mean 9.24, n=50) rejecting superstitious beliefs. (The lower the groups’ mean, the higher the rejection of superstitious beliefs). The results were statistically non-significant with P= .657. These results indicate that rejection of superstitious beliefs about HIV transmission is shared across the board, whether one is a member of a SAFE Club or not. These results also indicate that membership in SAFE Clubs is not changing the superstitious beliefs of youth and that future programming should place emphasis on this issue. However, as can be seen from the illustrative example above, at least one SAFE Club member was able to extend that rejection of superstitious beliefs to a very deadly belief that HIV positive men can be cured of the disease if they have sexual intercourse with a virgin or a young minor. This is a very important issue that should be addressed for both SAFE and non-SAFE Club members and wider society, i.e., the fact that sleeping with a virgin or a minor does not cure a man who is HIV positive. 20 C. OUTCOMES RELATED TO CHANGES IN ATTITUDES Rejection of male sexual violence One of the major findings of the survey was the change in attitudes towards male sex violence to women. Respondents were to agree or disagree with the following statement a) it is sometimes okay for a boy to pressure his girlfriend to have sex; b) It is sometimes okay for a man to force his wife to have sex; c) Sometimes men need to beat their wive when they refuse to have sex. The means of SAFE Club members and Non-SAFE Club members were th two groups with SAFE Club members (mean 32.38, n=61) and non-SAFE club membe (mean of 13.64, n=39), with SAFE Club members showing a much higher degree of intolerance of male sexual violence against women, compared to Non-SAFE Club members. The results were statistically significant at P=.000. (The higher the groups’ mean, the higher the rejection of male sexual violence). When cross-tabulations were performed, 83.3% of male SAFE Club members rejected the force his wife to have sex, while 81.3% non-SAFE Clu th Club members stated that they disag sex than male non-SAFE members, is important. This finding is very important because the ability of women and girls to negotiate and make decisions about engaging or not engaging in sexual activity without fear of male sexual violence is critical in cu sh the following example shows that, the girls themselves are sometimes, their own worst enemies when they feel inhibited to insist on safe sex, even when there is no violence indicated from the men they have sex with. A policy implication would be to emphasize the notion in future programming that women should not be forced to have sex and to increase safer sexual negotiating skills among women. Illustrative example of inability by girls to negotiate safer sex “My boyfriend would refuse a condom. He says “it’s like eating a sweet with a wrapper on.” Female, Southern province. “I wouldn’t be able to insist because I love him and fear to disappoint him.” Female, Southern province. C. OUTCOMES RELATED TO CHANGES IN ATTITUDES ual s: s, compared using e t-test for independent samples. The results showed a marked difference between the rs notion that a man should b males said they disagreed with e idea. Although the difference is small, nonetheless, the fact is that more male SAFE reed with the idea of men forcing their wives to have rbing the spread of HIV if the young generation, begin to ow intolerance of violent sexual behavior from men. In addition, it would appear as Reduction in Stigma against PLWHA among Students Respondents were asked a series of questions about their attitudes towards an infected class mate/teacher: a) if a student has HIV but is not sick, do you think he or she should be allowed to continue attending school? b) If a teacher has HIV but is not sick, do you think he or she should be allowed to continue teaching in school? c) If you know someone has HIV, would you share food with him or her? d) If you know someone has HIV, would you shake hands with him or her? 21 The data revealed that there was no significant difference between SAFE members, (mean 4.44, n=66), and Non-SAFE (mean 4.28, n=46), P=.194 and between males (mean 4.20, n=47) and females (mean 4.27, n=118), P=.926 respectively, in terms of reduction in stigma against PLWHA. (The higher the groups’ mean, the less discrimination against PLWHA). As can be seen, the results are not statistically significant, meaning that respondents from all the groups stated that they did not discriminate against PLWHA. In focus group discussions with SAFE members, SAFE females indicted that they had stopped stigmatizing PLWHA through community work in hospices. Non-SAFE students did not mention decreased stigmatization nor had they been exposed to community work. However, SAFE members and non-SAFE members defined stigmatization in completely different ways. For SAFE club members, it was defined as not discriminating against PLWHA, for non-SAFE members it was defined as not discriminating against girls returning to school after pregnancy and child birth, and not discriminating against students with HIV+ parents. In other words, SAFE Club members’ definition fits the general public definition of stigma, while that of non-SAFE members was more selective. Policy implications for future programming are that since SAFE members’ change in attitude towards PLWHA was due to some exposure to hospice care, it should be considered an important component of activities of SAFE Clubs in the future. The following are two illustrative examples of students attitude change towards PLWHA from SAFE members “I thought that HIV positive people were careless people and so I was negligent towards them but now I know about it and I think differently about it (HIV/AIDS) and HIV positive people” Female, Chongwe. ‘I have learned how to care for the infected and have stopped discriminating.’ Female, Chibombo, Central Province. Risk Perception among SAFE and non-SAFE members Respondents were asked about what factors in their lives may make them at risk of getting HIV. As figure 4-6 shows, female non-SAFE members felt they were at higher risk for HIV/AIDS than female SAFE members in two ways: not using condoms and the feeling that HIV is everywhere and cannot be avoided. Eight percent of female non￾SAFE members indicated they are at higher risk because AIDS is everywhere, while 3.5% of female SAFE club members felt the same. This may be attributed to their less informed, more fatalistic attitude about their ability to protect themselves against HIV/AIDS. As for condom use, 5% and 8.5% of female SAFE/non-SAFE club members respectively, regarded not using condoms as a risk factor. This risk perception may be linked to non-SAFE girls feeling less able to convince their partners to use condoms. Sixty percent of this cohort expressed the fear that they would not be able to convince their sexual partners to use condoms in future for many reasons that included: their fear of losing their partners if they insisted on using a condom during sexual activity; and that it shows lack of trust for the partner if one insists on condoms. 22 As for males ( figure 4-6), a higher percentage (29.2%) of male non-SAFE club and 23.7% male SAFE members feared not knowing the partners’ HIV status as the highest risk factor, whereas fewer females (13.7%) and 9.4% from SAFE/non-SAFE, respectively shared that fear. This could be an indicator of more HIV/AIDS knowledge on the part of the male cohort and this might be another area for intensified program focus. Both female (13.8%) and 15.8% male SAFE club members felt they were at increased risk than non-SAFE males due to issues surrounding their partners’ status and fidelity, i.e., they couldn’t trust their partners, which also may be attributed to their increased awareness and information regarding modes of HIV/AIDS transmission and prevention. Only females 9.6% of SAFE club females and 5.7% of non-SAFE club members, respectively, mentioned rape and sexual abuse as risk factors that concerned them. Figure 4-6 Perception of risk by SAFE/Non-SAFE Club members Risk Perception 0 5 10 15 20 25 30 35 1 2 3456 1=Not using a condom 2= Do not trust partner 3=Do not know partner status 4= Partner not faithful 5= AIDS cannot be avoided 6=Rape/sexual abuse % of Cohort Male SC Female SC Male NSC Female NSC Sources of HIV/AIDS information for Non-SAFE Club members As can be seen in figure 4-7 Non-SAFE members receive most of their HIV/AIDS information from family members/friends/ church, followed by IEC materials such as books, magazines, pamphlets and posters. “Other clubs” were mentioned as the third primary source of HIV/AIDS information and included drama club, youth alive, scripture union, Jets, debate club and SPW. Teachers were the fourth primary resource for HIV/AIDS information, particularly the school guidance teacher. The media (radio, television, music and drama) were mentioned as the fifth resource for non-members, followed by the Anti-AIDS Club. None of the non-SAFE club respondents mentioned 23 peer educators as a source of HIV/AIDS information. This is an area where the visibility of peer educators in participating schools is very important. During focus group discussions with Non-SAFE members, students were asked if they had ever heard of the SAFE Club. Overall, a few in each group had heard about SAFE and, when prompted, the other students remembered hearing of the club, too. When asked what type of SAFE activities they had either observed or heard about, students responded first with outreach “helping OVC, making donations to orphanages, going to hospitals.” The second activity they had noticed was sensitization during assemblies. Figure 4-7 Sources of Information for Non-SAFE Club members Non-SAFE Members sources of information 4 6 8 10 12 14 Cases Non-SAFE 0 2 12 345 6 1=Family/friends 2=IEC materials 3=Other Clubs 4=Teachers 5=Media 6=Anti-AIDS 24 D. MENTORSHIP OF STUDENTS It would appear from the survey responses that the word “Mentor” is not clearly understood by the students, peer educators or overseers. When the concept was explained, approximately 37% of SAFE Club members and 30.2% female non-SAFE club members went to their family members for advice. Table 4-1 Person students go to for advice Category SAFE Club Members Non-SAFE Club Members Family member 40 17 SAFE Overseer 28 2 Guidance Teacher 2 2 Teacher 5 2 Pupil 3 Friend 18 7 Church friend 9 2 Friend/ SAFE Club 4 3 Out of the 109 SAFE Club members who responded to this question, approximately 26% went to Overseers for advice, while the number of non-SAFE members who went to the Overseer for advice is negligible as can be seen in table 4-1. Neither group mentioned Peer Educators as sources of advice. This finding indicates that the mentoring services that are supposed to be offered to non-SAFE club members by both Overseers and peer educators in the schools are not sufficiently visible to non-SAFE members. They seem to regard the availability of services by peer educators and overseers as a service that is restricted to SAFE Club members only. The following figure is a breakdown of category of people whom SAFE/non-SAFE; male and female members go to consult when they need advice: Figure 4-8 Mentors selected by SAFE/non-SAFE Club members Type of mentors who SC/NSC members chose 40 50 6 anc Counselor 4=Frie end in SAFE Club % of Male SC 30 Cohort Female SC Male NSC Female 0 10 20 1 2345 1=family member 2=SAFE Overseer 3=Teacher/Guid nd 5= Church friend 6=fri e 25 II: CHANGES SAFE CLUBS HAVE MADE AT SCHOOL LEVEL Focus group discussions among SAFE Club members revealed their perception that the SAFE activities they conduct at the school level have led to significant changes in attitudes and behavior of both their peers and the general school community. SAFE members stated that they have observed an increase in the number of girls returning to school after pregnancy. This was confirmed by the Safe Overseer in Central Province. Other observed impacts attributed to SAFE Club activities are listed below. Note that although these are self-reported results and reflect only SAFE members’ perceptions, they are interesting and deserve mention. Decrease in the number of pregnancies among school girls The SAFE Club Overseer at Kasenshi High School on the Copperbelt mentioned that the number of unintended pregnancies has reduced to two pregnancies from five in one year since SAFE activities began in the school. Decrease number of sexual relationships at school SAFE members also had observed less sexual relationships among school youth. However, only anecdotal evidence of this exists. Focus group Discussions suggested that there were “less condoms found around campus.” Increased awareness of the dangers of HIV/AIDS/STI and use of alcohol/ drugs SAFE members perceive they have created an increased awareness of HIV/AIDS/STI, stigmatization and that drug and alcohol use has been curbed. Figure 4-9 Changes in the School that are Attributed to Activities Carried out by SAFE Clubs Changes at school due to SAFE 1 3 4 5 6 2 All Students 0 1 2 3 4 5 1 Increased no of girls returning after preg, 2 Less pregnancies, 3 increased abstinence, 4 increased awareness of HIV, 5 Decrease in drug and alcohol use 26 III: CHANGES THAT THE SAFE CLUB PROGRAM HAS MADE AT COMMUNITY LEVEL Information about outreach activities of SAFE Clubs was provided by SAFE Club members themselves. The survey did not include interviews in surrounding communities. Therefore, this section describes the impact of SAFE Clubs on the community through the lenses of members. Impact of SAFE Clubs at community level Although more than half the schools visited said they had received no money this year to conduct outreach into the community, focus group discussions held among SAFE members expressed their perception that those SAFE Clubs that did conduct outreach have led to important attitudinal changes including: • Increased awareness among parents of the dangers of HIV/AIDS. Students expressed that parents in the community have approached them to speak to their children about prevention. • Decreased stigmatization of PLWHA • Increased amount of information available on HIV/AIDS prevention • Increased adolescent health: Two focus group discussions expressed that attitudes were beginning to change regarding early marriage and teenage pregnancy. • Increased awareness of girl child rights in terms of communities being more aware of sexual abuse, sugar daddies, not pushing their children to have sex for money. Figure 4-10 below indicates the number of members who mentioned the type of change that they feel is occurring in the communities that could be attributed to outreach activities by SAFE Clubs. Figure 4-10 Changes at community level attributed to SAFE Clubs Changes in community due to SAFE club activities 6 5 Cases 4 3 2 1 0 1234 5 1=Increased awareness among parents 2=Reduced y of HIV info. 5=Increased Changes stigma 3=Increased availabilit 4=Increased adolescent health girl/child rights awareness 27 NORMS AROUND ADOLESCENT SEXUALITY to ic on norms around issues of adolescent sexuality was discussed in focus gro ions with SAFE Club members in all four provinces. Thus, the responses in this cannot be generalized to the ud d non-SAFE Club members. Of the 38 ng eople have sex? Fifty five percent of the respondents stated that girls be ween 12-15 years old, while 44.7% stated that boys start having sex between the o 14-16. so s why school-aged young people have sex lub members were asked during mixed (male/female) focus groups discussions below in order of emphasis-rank ordered in absolute numbers of responses for each response to reasons why young people have sex, and reflected in Figure 4 -11 below: Peer Pressure Overwhelmingly, peer pressure is mentioned by SAFE members as a primary factor for why school-aged youth have sex. Both girls and boys mention they are pressured by their peers to ‘practice sex’ because practice makes perfect and that by the time they get married, they’ll be able to handle their spouses. Older siblings are targeted as a source of pressure for both girls and boys. They discussed how their siblings encourage them to have sex to prove their manhood, prove their love to a boyfriend and become part of “an exclusive group.” Thus, both sexes feel pressure from both their female and male peers to engage in pre-marital sex. Poverty/desire for material things and money The second primary reason mentioned for school-aged sexual debut was their desire for things and money. “Things” ranged from essentials such as food, school fees, spending money and clothing to sweets, nice things, and favors from teachers. Girls mentioned that some of their friends get money for ‘fun sex’ ranging from K5, 000-50,000 for touching, fondling, touching thighs, breasts. Fun sex and the general topic of sugar daddies was repeated throughout focus group discussions. They noted that it is sometimes difficult to control the situation during ‘fun sex’ and it oftentimes turns into sexual intercourse. This concept is tightly woven together with the idea of peer pressure as many girls felt concerned that their friends could pressure them into having sex for money. Il “My situation of not having electricity and food may force me to have sex for money to survive though FAWEZA pays for me.” “If my parents cannot give me what I wan will have to get it myself,” Female, Copperbelt. NORMS AROUND ADOLESCENT SEXUALITY The p up discuss section whole sample population in focus groups that incl e responses to the question: at what age do you p start having sex t ages f Rea n SAFE C why school-aged people engage in sexual activity. The eight primary reasons are listed lustrative examples of poverty driven sexual activity among SAFE Club students t, I 28 Watching movies Both males and females expressed that watching movies with sexual themes caused adolescents to want to experiment and imitate them. Curiosity and experimentation A general feeling was expressed among SAFE members during focus group discussions that adolescents are simply curious about their bodies and sexuality, and want to experiment. This experiment then leads to becoming more and more comfortable with the idea of having intercourse and “once you’ve started, you can’t stop.” No parental guidance Lack of proper parental control and/or guidance, was cited as a risk factor that leads young people to have sex at an early age. Myths surrounding sexuality A number of myths were mentioned during focus group discussions as a reason why school-aged youth become sexually active. They included the belief that a man will be impotent if he doesn’t practice sex early—that he must prove he can make sperms. For females, many said it was believed that they will have bigger breasts and hips if they are sexually active before marriage. Other factors for early sexual debut among school-aged youth included: General lack of self control; Ignorance of HIV/AIDS; Rape Figure 4-11 Reasons why SC members engage in sexual activity Reasons for sexual debut among SC members 15 20 1 2 3 4 5 6789 25 30 35 0 5 10 1=Peer pressure 2=Poverty 3=Movies 4=Curiosity 5=No parental guidance 6=Myths 7=No self control 8=Ignorance 9=Rape Reasons for sex Cases 29 F. PEER EDUCATION Approximately 51.5% (35 out of 68), SAFE Club peer educators interviewed were trained by FAWEZA. The additional forty eight percent of students who stated that they were also trained as peer educators received their training primarily from other NGOs (including Kara Counseling) and faith-based organizations as well as from hospitals, Anti-AIDS Clubs and SPW (Central Province). The following analysis concerns the perceptions, behavior and attitudes of peer educators trained by FAWEZA. Role of Peer Educators Fifty one percent of the peer educators perceived their primary responsibility to be: educating, sensitizing others on HIV/AIDS, life skills, and reducing stigmatization. Thirty three percent stated that they perceived their responsibility as counseling others, while 18% felt that one of their responsibilities was to be a role model for their peers. Frequency with which Peer Educators talk to others about HIV/AIDS Peer Educators were asked the following: a) in the past month, how often did you talk to other students about HIV/AIDS? b) in a normal week, how many individual young people do you talk to as a Peer Educator about HIV/AIDS? The responses to these questions are tabulated in tables 4-2/3 below: Table 4-3 Number of young people whom Peer educators talked to in a normal week No. of young people No. of Peer Educators stating that number 1-10 53 11-20 4 31-40 2 41-50 2 Table 4-2 Number of times Peer educators talked to young people about HIV/AIDS Frequency No. of Peer Educators stating that frequency Once per day 12 Twice per week 22 Once per week 11 Twice per month 8 Twice per month 12 As can be seen in table 4-3: 83% of the peer educators interviewed stated that they talk to at least ten young people about HIV/AIDS in a normal week. 30 Relevance of Training Twenty eight percent of the peer educators responded that they learned how to approach other students and facilitate a discussion. Twenty three percent stated that the training helped them to assist others in identifying their problems and in providing appropriate counseling to them. Eighteen percent of the respondents felt that the training increased their understanding of HIV/AIDS and life skills, while 8 % stated that it helped them understand the importance of acting as role models. Generally, peer educators felt their training was sufficient but during focus group discussion, most asked when or if they could receive follow-up (refresher courses) training. Behavior change among peer educators When peer educators were asked how their behavior has changed through their service as peer educators, 20% responded that they are now ensuring that others receive correct information on HIV/AIDS in order to protect themselves; and 5 % indicated that they now abstain from sex as a result of being peer educators. Attitude change among peer educators Eighteen percent of peer educators stated that they now feel more responsible and assertive; Fifteen percent felt motivated to prevent the spread of HIV/AIDS among their schoolmates; Another 15% expressed the view that they have changed the way they feel about PLWHA; and 13% had developed a sense of support to others and actively sought out situations where they could help. Support received by peer educators When peer educators were asked what type of support they receive 26% responded that they do not receive any support; 13 % stated that their clubs had received grants and/or training from FAWEZA; while 3% stated that they received some material support. The evaluation team’s general impression is that peer educators are not monitored or adequately coordinated in their outreach activities. 31 G: SAFE CLUB OVERSEERS A total of twenty two SAFE Club Overseers were interviewed -5 from each province, except Southern province, where there were seven. These interviews were conducted in order to obtain information regarding their perceived responsibilities as overseers; their impressions of attitudinal change and behavior change of SAFE members; and the type of training they desired in the future that would enhance their present skills. Fifteen (68.2%) of the 22 Overseers stated that they were trained by FAWEZA. Two by Ministry of Education, one by a mission hospital and the remaining four did not state where they got their training from. Role of SAFE Club Overseers Thirty-eight percent of the overseers cited their primary role as a counselor or guide to students in SAFE. Twenty nine percent of the cohort stated that their role was to give SAFE Club members information on HIV/AIDS and Life Skills; Nineteen percent identified their role as conducting meetings and helping design activities; Fourteen percent stated that one of their roles was monitoring SAFE money and activities; while 14% stated their role was to identify recipients and interview them for the bursary program. Attitude and Behavior Change among SAFE Overseers Data obtained from discussions with overseers suggest they have noticed both attitudinal and behavioral changes among students belonging to SAFE Clubs regarding HIV/AIDS. Overseers believe that through increased knowledge of HIV/AIDS, SAFE members have dispelled myths and rumors related to its transmission; have increased assertiveness, increased self respect, an increased desire to abstain from sex and an increased willingness to communicate HIV/AIDS prevention messages. This data supports similar findings among SAFE members interviewed about their own attitudinal and behavioral changes discussed above. Other training SAFE Overseers would like to have: When asked what other training they would like to have, a majority-63% (12 out of 19) who responded to this question, wanted further training in psychosocial counseling. Other topics included: • Research on social issues • Monitoring and evaluation • Project management • HIV/AIDS particularly as it relates to ARVs • More in depth understating of HIV/AIDS • Guidance • FAWEZA accounting systems • Peer education. • Training about sexuality • Topics concerning Girl Child Rights in general/child counseling 32 • Diseases and their prevention especially as related to HIV/AIDS and reproductive health. Most of the topics listed were mentioned at least by one person. Some were mentioned by more than one respondent, because the question allowed them to list more than one topic. Funding of SAFE Club activities at school level In addition to responses to structured questions above, SAFE Overseers from each province except Lusaka mentioned the need for money to run SAFE club activities at school level and to also for community outreach. One of the constraints cited by Overseers, was the need for guidelines on funding/budget for SAFE activities, frequency and amounts that they should expect per semester and/or per year so that they could plan their activities accordingly. Involvement of Overseers in selection of scholarship recipients Overseers’ general feeling was that they were overwhelmed with the growing number of students needing bursaries and that they sometimes feel left out of the loop when it came to selection of bursary recipients and/or the whole bursary process. Other important comments included the need for feedback from FAWEZA and the need for Overseers to receive compensation for their work. The evaluation teams’ general impression regarding SAFE Overseers is that their activities range from extremely involved and active in SAFE Clubs to little or no involvement. Furthermore, although SAFE Clubs are scheduled to meet each week, focus group discussions revealed that the SAFE Club Overseers are sometimes not present due to other obligations. These impressions/ findings further indicate that increased communication, support and monitoring from the implementing organization on a consistent basis would have a positive impact on Overseers’ participation in the program. 33 PART V: RECOMMENDATIONS PART 5-A: GENERAL PROGRAM RECOMMENDATIONS Overview Evidence from the impact evaluation found that the SAFE Club program implemented by FAWEZA is making a positive and measurable impact on the knowledge, behavior and attitudes of SAFE Club participating members at an individual level, as can be seen from Part IV above that summarizes all the outcomes for male/female SAFE and non-SAFE club members. However, the program has limitations in terms of coverage and/or impact on HIV/AIDS related attitudes and behavior of non-participants in the schools where the program is operational, nor has the program extended coverage sufficiently beyond the school to the community level, except in isolated cases in each province. This might be due to FAWEZA’s mandate that targets first and foremost scholarship recipients for membership in SAFE Clubs, and/or the organization does not have the capacity or the funding base for an expanded HIV/AIDS component of their program. Two recommendations are provided in this report based on the evaluation findings, that affirm the critical role that SAFE Clubs are playing in influencing behavior and attitudes of both male and female members in relation to HIV/AIDS prevention; girls education and life skills, on one hand, and the limited coverage of the current program to the whole school and surrounding community, on the other. If CHANGES-2 wishes to increase/expand coverage of the HIV/AIDS prevention component of the SAFE Clubs, they could consider: A. Establishing and supporting a partnership between FAWEZA and other NGO(s) that specializes in HIV/AIDS and youth prevention programming B. Funding a large scale HIV/AIDS youth prevention program in selected high schools Note that these two recommendations are not mutually exclusive they could be implemented simultaneously in different high schools and districts/provinces. A. Establishing and supporting a partnership between FAWEZA and another NGO Given that FAWEZA’s mandate emphasizes the delivery of a multi-sectoral training package that includes a range of topics including ARH, gender relations, girl’s education, life skills and other issues… of which HIV/AIDS is just one, the establishment and funding of a partnership between FAWEZA and another local NGO whose orientation is distinctly HIV/AIDS programming and implementation, would allow for a much more expanded HIV/AIDS youth prevention program in participating secondary schools as well as expanded outreach services to surrounding communities. 34 The following is a possible scenario for establishing a partnership between FAWEZA and HIV/AIDS NGO(s) that would focus on reducing the transmission of HIV among young high school boys and girls 15-25 years. Potential NGO partners in Zambia could include the Zambian Red Cross, FHT, YWCA, ZINGO, SPW, CHEPS and others that CHANGES-2 is working with in Zambia and/or internationally. Program Goals/ Objectives: 1. To scale up youth HIV/AIDS prevention components of the SAFE Clubs program in participating provinces 2. Enhance the capacities of FAWEZA and partner HIV/AIDS NGO (s) to scale up and engage in joint activities to achieve economies of scale 3. Expand the program to school wide and community levels in participating districts 4. Build the leadership skills of Zambian youth in HIV/AIDS prevention and strengthen the capacity of Peer Educators to be fully engaged in all the participating high schools. Recommended Program Activities: 1. Sponsor a learning workshop in Lusaka between FAWEZA and one or two NGO partners with the goal of exchanging knowledge, tools and materials on effective HIV/AIDS prevention strategies for high school youth 2. Develop a common manual/curriculum of “promising practices” 3. Launch a joint Peer Education Training Program CHANGES-2/FAWEZA could implement program activities in stages as follows: 1st stage: Organize a Round Table Meeting that would provide a forum for participating partners and institutions to get to know each other and plan activities and programs to be undertaken by all cooperating partners. Possible agenda for the Round table meeting: • Identify common concerns of NGOs working with HIV/AIDS youth prevention programs • Identify “gaps” in current information flow and messages for the youth-could discuss some of the findings of this evaluation. • Exchange experiences and strengths each partner will bring to the table in terms of managing youth HIV/AIDS prevention programs in general and in high schools in particular. 35 • Identify available training and learning materials as well as promising practices that would be shared and/or accessed from the NGO-NGO partnership. 2nd Stage: During the round table meeting, form a committee that will coordinate activities where partner NGOs meet to plan, design and organize the national learning workshop. 3rd Stage: Post-workshop plan that describes how participating organizations will form and enhance national and provincial training teams to facilitate future training programs for Peer Educators. 4th Stage: Decide on who will coordinate the joint program and create a shared program secretariat. Funding: CHANGES-2 could float a small grant for access by each participating partner organization, to support firstly the workshops and secondly, the integration of peer education promising practices into jointly implemented youth HIV/AIDS prevention programs, as well as strengthening the skills of peer educators in participating high schools. 2. FUNDING A LARGE SCALE HIV/AIDS YOUTH PREVENTION PROGRAM IN SELECTED HIGH SCHOOLS CHANGES-2 could fund a large scale HIV/AIDS youth prevention program that would cover high schools in the four selected provinces, where large gaps exist in terms of HIV/AIDS youth programs targeting secondary schools. In this scenario, CHANGES-2 would select a separate NGO with the capacity to conduct an expanded school-based HIV/AIDS prevention and Peer Education program. This NGO would select two secondary school graduates with Peer education experience from each school, train them as HIV/AIDS Peer educators and develop a classroom-based peer education program. In this respect CHANGES2 is encouraged to take a closer look at the SPW model in Central Province especially as it relates to identifying school graduates, the peer education curriculum used, and their coordination with school administrators to conduct classroom- based HIV/AIDS prevention lessons. The trained peer educators would also be available for after school club-based activities which would primarily support already existing HIV/AIDS – related activities in clubs including (but not limited to) SAFE and Anti-AIDS clubs. The peer educators together with the implementing organization would develop a plan of action at school level that would outline club-based after school activities they intend to support and enhance. 36 5-B: SPECIFIC EVIDENCE BASED RECOMMENDATIONS The following section highlights programmatic improvements to the current program based on findings from this evaluation. These would include strategies that FAWEZA could take to enhance the program and to have a greater impact on SAFE students as well as more expanded coverage to non-SAFE students and community level, and what CHANGES-2 could do to enhance the existing program. CHANGES2 could consider: 1. Regionally-based training options for future peer Educators’ training, particularly follow-up/refresher courses. 2. Expanding and improving the existing program by streamlining SAFE Club activities and financial support in all the participating schools/districts/provinces. Under this scenario SAFE Club activities would continue to be run by FAWEZA, under the supervision of the school SAFE Overseer, however, funding would be augmented so that the program is expanded to include non-SAFE club members, school-wide HIV/AIDS activities and community outreach. Consider enhancing the current SAFE program by: • Directing peer educator and SAFE Overseer training to focus on HIV/AIDS prevention • Recruiting a salaried focal point person/HIV/AIDS coordinator at district level and development of a payment scheme. • Making SAFE Club membership free of charge in order to encourage participation by non-scholarship recipients and by providing/funding for after school club activities and community outreach activities. FAWEZA could undertake the following aimed at improving current operations of SAFE clubs and its impact on participants and non-participants: • Increase male (SAFE/non- SAFE club) involvement in outreach activities including hospice care that would impact their attitudes and behavior towards PLWHA especially reduction of stigma. • Enhance skills building that targets males to enable them to avoid peer pressure to have sex. • Training should seek to clarify concerns among SAFE and non-SAFE Club Members, regarding HIV/AIDS transmission attributed to sharing sharp instruments and concentrate on the most common mode of transmission, which is sexual intercourse. • Provide more games and extra curricular activities in the schools that help the students to focus on their academic studies and less on sexual activity. • SAFE training and activities should continue to emphasize skills/topics including self-esteem, confidence, assertiveness, and ability to communicate SAFE messages among club members as well as reaching non-club, as this seems to have had a positive impact on SAFE club members’ attitudes and behavior. 37 • SAFE Overseers should be visible as sources of HIV/AIDS prevention information and counseling for both SAFE and non-SAFE members. • Increase activities that target non-SAFE club members at the school level and Outreach programs and activities for the surrounding communities, with protection messages such as abstinence, condom use, and reduction in sexual partners. • Dispel fatalistic attitudes/risk perceptions about HIV/AIDS and encourage PLWHA to live positively. • Provide appropriate skills especially to female SAFE/non-SAFE club members that would enable them negotiate safer sex. • Provide an appropriate definition of ‘mentoring’ and guidelines for peer educators The following section considers the differences in impact of SAFE clubs on attitudes, and behavior (by gender and membership), and makes specific recommendations based on the findings: 1. Salient Gender Differences/Similarities among SAFE Club Members observations/comments a) Category – Knowledge Base Female Male Observations/Recommendations 1. Knowledge about HIV/AIDS 67.2% 81.8% Need to focus on girls knowledge base 2. Learned how to care for PLWHA 88.2% 11% More male involvement in care of PLWHA 3. Knowledge on protection against 65% 37% Focus on male knowledge base about self protection HIV 4. Learned how to avoid peer pressure to have sex 12% 5.3% Since peer pressure to have sex tends to be intense esp. among boys-this is an area that needs more attention 5. protective knowledge - Abstinence 61.6% 34% More messages on abstinence as an option for boys - Condom use for self protection 11% 13.2% An area that needs serious attention - Not sharing sharp instruments 26% 2.6% Concentrate on real HIV transmission route-sexual intercourse for protective messages to the students - Involvement in games/school 6.9% 5.3% An area that needs attention-as this has been shown to activities reduce sexual activity if students are busy with e.g., sports/after school extra curricular activities 6. Rejection of superstitious beliefs 7.13 gm 13.61gm - Boys rejected superstitious beliefs about HIV/AIDS more than girls-more education required for both, esp. girls on mode of HIV transmission. - Enhance peer educator and SAFE Overseer training that focuses on dispelling superstitious beliefs/myths in relation to HIV/AIDS transmission, specifically among females and non-SAFE members who haven’t yet internalized messages on modes of HIV transmission, which mainly through sexual intercourse 38 7. Positive self esteem/Assertiveness 52.1% 5.3% Need to target boys more in this area 8. Skills to teach/counsel others 20.5% 31.6% Motivating/providing girls teaching skills 9. Respecting girl/child rights 12% 2% More work to be done esp. educating boys on GCRs 10. Respect for others 10% 0% Target boys with messages about respect for others b) Category – Behavior change 1. Reduction in sexual partners 6.8% 7.9% This is out of a total of 21 who were sexually active 2. Avoiding peer pressure to have sex 25% 15.8% Important topic to focus on 3. Focusing on academics 7.5% 8% Encouraging this desire in all students 4. General healthy behavior 12% 7% Avoiding alcohol 2. Salient Differences/Similarities among SAFE and Non-SAFE Club Members and Recommendations for Action Category SAFE Club NON SAFE Observations/comments a) Attitude Change 1. rejection of male sexual 32.38 13.64 The higher # of rejections, the higher the group means-more violence group Gm SAFE club members reject male sexual violence against means P=.000 women while less non-SAFE club members do so. 2. Condom use: a) last time sexual act 55.6% 43.5% More SAFE members consistently cite condom use as a way b) last 12 months 58% 55.5% of protecting themselves against infection-and this is attributed c) use in the future 70% 63.6% to lessons/awareness messages in SAFE clubs-they are benefiting by being members-policy implications-expanding the program school wide to increase coverage. 3. Reduction in Sexual 5.9gm 18.5gm The higher the group means, the higher the number of desired partners P=.015 sexual partners in future. SAFE Club members stated that they would like only one partner more times than Non-SAFE who expressed desire for more partners. SAFE members have been more sensitized on being faithful. b) Risk perception 1. Not knowing partner status F 13.7% M 23.7 F 9.4 % M 29.2 Both male cohorts seem to be worried about partner status/more knowledgeable about that as a risk factor 2. Partner not faithful 13.8% 15.8 1% 8% This shows less knowledge about mode of transmission among non-SAFE Club members, esp. females. 3. Rape/sexual abuse 9.6% 5.7 % Only the females mentioned this risk factor-more awareness needed for the males about sexual abuse/rape of women as a risk factor for both the victims and the perpetrators. 39 c) Superstitious Beliefs about mode of transmission of HIV There was no significant difference between SAFE/Non-SAFE club members in terms of rejection of superstitious beliefs such as being infected by a mosquito bite or through witchcraft. Both groups dismissed those myths as untrue. d) Stigma reduction This was another area which was shared across the board i.e. reduction of stigma against PLWHA. The only problem was the difference in definition of stigma between SAFE/Non-SAFE club members. Stigma needs to be defined and explained to students so that they all share the same meaning (public) understanding of the term. e) Norms around sexuality Since the students rank ordered the following reasons why young girls have sex, it might be a good idea to take these into account when developing curriculum for the SAFE Clubs. These were listed in order of most frequently cited reason. 1) Peer Pressure 2) Poverty/desire for material things and money 3) Watching movies 4) Curiosity and experimentation 5) No parental guidance 6) Myths surrounding sexuality 7) General lack of self control 8) Ignorance of HIV/AIDS 9) Rape f) Safe Overseers SAFE Club overseers listed the following topics that they would like to be trained in the future. These should be taken into account when organizing refresher courses/further training for Overseers: a) Psychosocial counseling b) Research on social issues c) Monitoring and evaluation d) Project management e) HIV/AIDS particularly as it relates to ARVs f) More in depth understating of HIV/AIDS g) Guidance h) FAWEZA accounting systems i) Peer education. j) Training about sexuality k) Topics concerning Girl Child Rights in general/child counseling l) Diseases and their prevention especially as related to HIV/AIDS and ARH g) Peer Education: Peer Educator Training for an expanded HIV/AIDS program should increase its focus on HIV/AIDS information and skills building. 40 References 1. CHANGES2 (May-June, 2006). Scholarships and SAFE Monitoring Report in Central, Copperbelt, Eastern, Lusaka, and Southern Provinces. Lusaka, Zambia 2. CSO/MEASURE/Ministry of Health (2000): Zambia Sexual Behavior Survey. Lusaka, Zambia. 3. Kirby Douglas (2005) The National Campaign to Prevent Teen Pregnancy: Research findings on the program to reduce teen pregnancy. Washington D.C., USA. 4. Norusis Marija J. (1990): The SPSS Guide to Data Analysis-For Release 4: SPSS Incorporated: Chicago, SA. 5. Rossi Peter H. & Howard E. Freeman (1993). Evaluation: A Systematic Approach 5. Sage Publications: Newbury Park, California, USA. 6. UNAIDS (2003): HIV/AIDS and young people: Hope for tomorrow. Geneva, Switzerland. 41