The origins of health promotion lie in the 19th century when epidemic disease eventually led to pressure for sanitary reform for the overcrowded industrial towns. Alongside the health movement emerged the idea of educating the public for the good of its health (Naidoo and Wills, 2000). In 1977 the World health Assembly at Alma Ata committed all member countries to the principles of Health for all 2000 (HFA 2000) that there ‘should be the attainment by all the people of the world by the tear 2000 of a level of health that will permit them to lead a socially and economically productive life’ Naidoo and Wills, 2000). The Ottawa charter held on the 21st of November 1986 was the first international conference on health promotion and provided the basis for the current practice of health promotion. It defined health promotion as “the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment” (WHO, 1986). Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being. It went ahead to identify strategies for health promotion namely; build healthy public policy, create supportive environment, strengthen community actions, develop personal skill and reorient health services (WHO, 1986).
HIV/AIDS BACKGROUND AND ZIMBABWE
The HIV virus is the cause of the Acquired immune deficiency syndrome (AIDS).
All countries of the world are now affected with about 39.5million people living with the disease globally. 2.1million of the global 2.9million deaths due to AIDS in 2006 occurred in Africa ( UNAIDS/WHO, 2007). The extent of the Human Immunodeficiency Virus (HIV) epidemic in Africa makes it qualitatively different from other regions. According to UNICEF (2005), the HIV/AIDS epidemic in sub-Saharan Africa has already orphaned a generation of children and it projected that by 2010, 18 million African children less than 18 years are likely to be orphaned by HIV. Africa has the world’s youngest population, with the youth constituting 33% of the total
population. Subâ€Sahara Africa is home to 70% of young people living with HIV/AIDS and
90% of the AIDS orphans in the world. Vulnerability to HIV/AIDS is compounded by gender
and age, making young people and women in particular more likely to contract the virus
than others. The age distribution of HIV infection in Africa is skewed towards younger
females, with infection rates among teenage girls five times higher than teenage boys in
some countries.Zimbabwe is not spared this burden. One in six African is a Zimbabwe which has a population of about estimate of 140 million people. The first case of the Acquired immune deficiency syndrome (AIDS) was identified in Zimbabwe in 1986. HIV prevalence then rose steadily from 1.8% in 1998 to 5.8% in 2001. However, in the 2003 survey, the National HIV prevalence had dropped to 5%. At a current level of 5.6%, HIV/AIDS prevalence is highest amongst young people less than 30 years (World Bank, 2006).
Several factors have been identified as the most important in driving the HIV epidemic in Zimbabwe. These include; early marriage of females and inadequate access to condoms and contraceptives particularly for young people. Young people’s lack of access to contraceptives is exacerbated by the age-structured society where children and young people have little or no control over their health, especially sexual health. There is also inadequate sexual education in schools as well as a restricted discussion of sexual health matters in public and even in families. Zimbabweans can have multiple wives as they think they can afford to take care of. This is very ambiguous and the result is that a lot of women are mistreated and left to take care of themselves without actually being empowered to do so. Other factors implicated are the presence of other sexually transmitted infections (STIs), stigmatization and the inadequacy of health care systems (APIN, 2006). In addition, various cultural practices and values influence the health practices and sexual behaviour of our focus group. This makes them particularly vulnerable. Vulnerability can be defined as the degree to which an individual or a population has control over their risk of acquiring HIV, or the degree to which those people who are infected an affected by HIV are able to access appropriate care and support.” (AIDS Vancouver, 2005)
Zimbabwe being a male-dominated society, women are viewed as inferior to men, in some areas in particular in rural areas and some townships.
Women’s traditional role is to have children and be responsible for the home. Their low status, lack of access to education, and certain social and cultural practices increase their vulnerability to HIV infection. Many marriage practices violate women’s human rights and contribute to increasing HIV rates among women and girls. Zimbabwe has legal minimum age for marriage, however in some areas early marriage is known to be allowed by parents, as they consider it a way to protect their young daughters from the outside world and maintain their chastity. Girls may get married between the ages of 14 and 15, and a large age gap usually exists between husbands and wives. Young married girls are at risk of contracting HIV from their husbands because it is considered acceptable for men to have sexual partners outside of marriage and even for some men to have more than one wife. Because of their age, lack of education, and low status, young married girls cannot negotiate condom use to protect themselves against HIV and other STIs. Practices such as female genital mutilation also contribute to the scourge (APIN, 2006).
From Appendix 1(behind), the tables show WHO statistics (2007) and compares different parameters from Zimbabwe, Brazil and South-Africa. It estimates Zimbabwe’s population, for 2005, at 131.5 million. This is compared to South Africa’s figure of 47.4 million and 186.4 million for Brazil. Zimbabwe and Brazil are classed as developing countries while South Africa is a middle-income African country. All these countries have achieved varying degrees of success in the fight against HIV/AIDS. Deaths due to HIV (per 100,000) are 8 for Brazil, 167 for Zimbawe and 675 for South Africa. Figures for HIV prevalence in adults aged 15 years and above show that the prevalence is reduced in Brazil (454 per 100,000 people), but Zimbabwe (3,547 per 100,000 population) and South Africa (16,579 per 100,000 population) still have very high numbers. This buttresses the fact that Africa still has major problems in the fight against HIV/AIDS.
HIV/AIDS POLICY IN ZIMBABWE
According to the Federal Government of Zimbabwe, the overall goal of the HIV/AIDS Policy is to control the spread of HIV, to provide equitable care and support for those infected by HIV and to mitigate its impact to the point where it is no longer of public health, social and economic concern, such that all Zimbabweans will be able to achieve socially and economically productive lives free of the disease and its effects. (Federal Government of Zimbabwe, National Policy on HIV/AIDS, 2003; pp. 13-14). The objectives of the policy include, among others to foster behaviour change as the main means of controlling the epidemic and to ensure that prevention programmes are developed and targeted at vulnerable groups such as women and children, adolescents and young adults, sex workers, long distance commercial vehicle drivers, prison inmates and migrant labour. The target is to improve the knowledge, attitude, behaviour and practices of high-risk populations, including youths and adolescents, to HIV/AIDS by 20 percent by the year 2005 and 40% by 2010. With the WHO statistics, there seem to be a lot of work to be done in achieving the above target.
YOUTH EMPOWERMENT MODEL THE INTERVENTION
The model was developed by a combination of two existing models of health promotion namely Caplan & Holland (1990) and Beattie (1991) (Naidoo and Wills, 2000). Beattie’s model uses criteria of mode of intervention (authoritative-negotiated) and focus of intervention (individual-collective) whereas Caplan and Holland use theories of knowledge and theories of society (Naidoo and Wills, 2000). From Caplan & Holland (1990) the following components were taken: radical humanistic perspective (empowerment approach) and humanistic perspective (educational approach). From Beattie (1991) were taken; health Persuasion (educational approach) and personal counselling (behavioural approach). This model thus comprises of the 4 components namely; Radical Humanist/Empowerment approach where individuals are encouraged to form social and organizational networks including self-help groups, Humanist/Health Education approach this involves peer education and awareness campaigns, including activities such as dramas, role plays and debates, Health Persuasion which is essentially behaviour modification and life skills, Personal counselling which is client led and focus on personal development. The health promoter is a facilitator rather than an expert. (Naidoo and Wills, 2000).
The components of this model made use of three main approaches to health promotion: behavioural, educational and empowerment approaches. The empowerment approach is based mainly on the formation of social and organisational networks including self-help groups, peer groups, abstinence clubs etc. The emphasis of this approach is to help people to identify their own concerns and gain the skill and confidence to act upon them Naidoo and Wills, (2000), and the behavioural approach aims at behaviour modification. It also uses personal counselling as a means of promoting healthy sexual behaviour, therefore aiming to impart life skills to the students, which would teach them to communicate, to learn to say no to casual sex, to wait till the right time and to make the right decisions.
The educational approach aims to provide knowledge and information with the hope that this information would enable the students to make the right and informed choices (Naidoo and Wills, 2000). This would be achieved by means of awareness campaigns, debates, lectures, dramas, role plays, posters and other information, education and communication (IEC) materials. A key part of the education of these students would be peer education. Over the years, there have been various studies and theories supporting the use of peer education as a successful health promotion strategy. Peer pressure can be quite enormous and influential particularly in the focus age group.
APPLYING THE COMPONENTS OF THE MODEL DISCUSSION
As earlier mentioned, there are four main components of this health promotion model: health education, health persuasion, empowerment and personal counselling.
Empowerment in the broadest sense is ‘â€¦.the process by which disadvantaged people work together to increase control over events that determine their lives'(Laverack, 2004). This entails raising consciousness of both the primary and secondary audiences; emphasis is on the exploration of personal responses to health issues. The students are encouraged to form social networks such as self-help groups and peer-educator-led groups. These social networks can lead to self-empowerment. The WHO’s definition of health promotion as ‘increasing people’s control over their health’ places it alongside the key concept of community empowerment (Laverack, 2004).
Community empowerment can be viewed as both a process (something used to accomplish a particular goal or objective) and an outcome (in which empowerment is the goal or objective itself). There is considerable overlap between community empowerment and other concepts such as community participation and community development. Community empowerment builds from the individual to the group to the broader community (Laverack, 2004). Health promoters have conventionally viewed community empowerment as a part of bottom-up approached. In this the outside agent act to support the community in the identification of issues which are important and relevant to their lives, and to enable them to develop strategies to resolve these issues. Community empowerment includes personal (psychological) empowerment, organizational empowerment and broader social and political changes.
Community empowerment has been viewed in health promotion literature as a five-point continuum model comprising the following elements; personal action, the development of small mutual groups, community organizations, partnership, social and political action.
Each point on the continuum can be viewed as an outcome in itself, as well as a progression onto the next point. If not achieved the outcome is stasis or even a move back to the preceding point on the continuum (Laverack, 2004). The latter goes on to say the dichotomy between top-down disease prevention and lifestyle change and bottom-up community empowerment approaches is not as fixed as it is sometimes portrayed. As applied in this youth empowerment model, both approaches were used.
Health promotion is rooted in the narrower, more established field of health education. Health education is communication activity aimed at enhancing positive health and preventing or diminishing ill-health in individuals and groups, through influencing the beliefs, attitudes, and behaviour of those with power and of the community at large (Downie et al, 2006). Use of education in health promotion has to do with communication aimed at enhancing well-being and preventing ill-health through influencing knowledge and attitudes. The purpose is to provide knowledge and information, and to develop the necessary skills so that a person can make informed choice about their health behaviour (Naidoo and Wills, 2005).
Health education interventions are valued because they empower people, enabling them to make desired changes and increase their control over their health. It involves working directly with them, enabling communication and feedback that in turn can be used to fine-tune the intervention, enhancing its effectiveness (Naidoo and Wills, 2009). This can be carried out in classrooms, and clubs aiming to empower the students. The peer educators will also be used at this stage as well as PLWHA. The contents for education in HIV prevention will include issues such as meaning and cause of HIV/AIDS, means of transmission & non-transmission, modes of prevention, available treatment and management for PLWHA.
Health persuasion in this initiative forms a part of the Prevention Education. These are intentions directed at individuals and involve mainly health professionals, trained counsellors and peer educators, all acting as facilitators. The aim of this is to influence the development of positive health behaviour in the students, so that as they grow older, they can have good sexual health. People Living with HIV/AIDS are also involved as they are some of the greatest champions of HIV prevention as earlier mentioned. The ultimate aim of health persuasion is encouraging people to adopt healthy and careful lifestyles. The emphasis is on abstinence, safer sex and faithful partnership. The avenues included: classrooms and School HIV/AIDS prevention clubs, distribution of fliers and Information, Education and Communication (IEC) materials and involvement of People Living with HIV/AIDS.
This focused on personal development and students (one-on-one or in groups) are helped by a facilitator to identify their health needs to increase their confidence and life skills.
This is the teaching or sharing of information, values and behaviours between individuals with shared characteristics such as behaviour, experience, status or social and cultural backgrounds (Macdowall et al, 2006). It is a prevention strategy for reaching youth either in school settings or for marginalized out of school youth, mainly through community based out reach programmes. Approaches to recruiting peer educators have included; providing information about a project and then asking for volunteers (Macdowall et al, 2006) identifying and approaching popular ‘opinion leaders’ from among target groups; and asking members of the target groups to nominate peers.
HEALTH PROMOTION RATIONALE
Zimbabwe for obvious reasons stated above has a problem in tackling the scourge of HIV/AIDS and this required a multi-pronged approach in order to make an impact. Thus, developing a health promotion model targeted at the youth is in place. According to WHO, it is imperative to focus on young people because they have a high risk of contracting HIV since once they become sexually active, they often have several, usually consecutive, short-term sexual relationships and do not consistently use condoms. Likewise, IV drug use spreads at an alarming rate in this age group. Furthermore, young people often have insufficient information and understanding about HIV/AIDS; they may not be aware of their vulnerability to it or how best to prevent it. They also often lack access to the means of protecting themselves (WHO, 2004). The National HIV/AIDS policy specifically focuses on adolescents and youths, with a view to changing their sexual behaviour and practices, particularly before they become sexually active. School based programmes are logical avenues to provide most youth with preventive health education which should include helping the youth to identify their personal values and to promote positive self -esteem to enable them to resist pressure to engage in risky sexual behaviour.
Zimbabwe practices a 7-2-3 system of education. Here individuals are expected to spend 7 years in the primary school, 2 years in sixth form 3-4 years in the University. The secondary school age in Zimbabwe is between 12-18 years. The focus for the model is in high school students aged 12 to 18. There were several reasons why the school is a key arena for health promotion. First, in accordance with a ‘prevention is better than cure’ philosophy, it is better to encourage young people to adopt healthful lifestyles than to try to change unhealthful behaviour patterns in adulthood. Secondly, there is evidence that risk factors for disease in adulthood often originate early in life. Thirdly, schools provides a unique opportunity to augment other influences on health-related behaviour with properly planned programmes of health education (Downie et al, 2006). As early as 1982, it was reported that the age of first sexual intercourse had continued to drop in Zimbabwe and was then such that 50% of 16 year kids were already sexually active (Nwokocha and Nwakoby, 2002). Thus, the age range for the study is appropriate to equip them before they become sexually active.
Mzikazi High School Bulawayo, Zimbabwe was the chosen high school.
Mzilikazi is in Matebelaland, second capital city of Zimbabwe with an estimated population of 1.2 million residents. The city has a rich tourism culture and hospitality. Current research estimates the prevalence of HIV in Bulawayo at 6.19% , making it the second highest of all the states in Zimbabwe (The Herald News, 2006).
It’s easy access to Victoria Falls makes it a centre for visitors from different parts of the world. All these aid the sex trade in a country so rich yet poverty is the order of the day.
People who do possess some knowledge about HIV often do not protect themselves because they lack the skills, support or incentives to adopt safe behaviours. High levels of awareness among the youth, a population group particularly vulnerable and significant as regards the spread of HIV/Aids, have not led, in many cases, to sufficient behavioural change. Young people may lack the skills to negotiate abstinence or condom use, or be fearful or embarrassed to talk with their partner about sex. Lack of open discussion and guidance about sexuality is often lacking in the home, and many young people pick up misinformation from their peers instead.
PARTNERS IN THIS HEALTH PROMOTION
The key partners in this initiative were the primary the students, and the secondary parents, teachers, school nurse and other members of the school community including staff. Other partners included professionals such as all clinical health practitioners such as doctors, nurses, and others health professionals who will act as facilitators, the local School Authorities, and donor agencies that are focused on HIV/AIDS issues they play a very crucial roles in community HIV prevention programmes. Donor agencies were involved in the provision of funds that were used in executing the project. PLWHA (People living with HIV/AIDS) have very important impact as people see for themselves living testimonies of the HIV scourge. It must be stated that stigmatization and discrimination against PLWHA are common in Zimbabwe. Nevertheless, some progress has been made more recently because of increased national campaigns and more visible and vocal societies and support groups for people infected with or affected by HIV. Their efforts have helped educate the public about HIV/AIDS, dispelling myths and giving the disease a human face (APIN, 2006). A potential reason for failure of school health promotion is that of ‘culture clash’ between the school and the home and elsewhere (Downie et al, 2006) hence the inclusion of the parents in the secondary audience. However while the concepts of outcome succees were addressed to some degree in the study, there was nevertheless, a lack of firm and consistent evidence that positive outcomes had been achieved by the partnership concerned.
Partnership working is seen as providing benefits that are achievable, improve health of whole population through working in partnerships with groups and individual to systematically address health needs within a community, (Coles and Porter, 2009). The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society, (Achenson, 1998). Wilson and Charlton (2004), claim that culture clashes in partnership working can often expected between people from different social background. In this study the barrier between the partners was the cultural background for the children , parents and the leaders. In this instance the NGOs were the leaders of the health promotion. The break down in communication and understanding of the intended education started when the educators told the students it is advisable to use condoms whenever you have sex. In Zimbabwe there is a deep-seated unwillingness to talk openly about sex, partly due to rules of respect that lie at the heart of family and kinship structures, which limit communication across generation and sexual divides. Certain prevalent cultural norms and practices related to sexuality contribute to the risk of HIV infection. Negative attitudes towards condoms, as well as difficulties negotiating and following through with their use. Men in southern Africa regularly do not want to use condoms, because of beliefs such that “flesh to flesh” sex is equated with masculinity and is necessary for male health. Condoms also have strong associations of unfaithfulness, lack of trust and love, and disease.
Certain sexual practices, such as dry sex (where the vagina is expected to be small and dry), and unprotected anal sex, carry a high risk of HIV because they cause abrasions to the lining of the vagina or anus. In cultures where virginity is a condition for marriage, girls may protect their virginity by engaging in unprotected anal sex.
The importance of fertility in African communities may hinder the practice of safer sex. Young women under pressure to prove their fertility prior to marriage may try to fall pregnant, and therefore do not use condoms or abstain from sex. Fathering many children is also seen as a sign of virile masculinity.
Polygamy is practised in some parts of southern Africa. Even where traditional polygamy is no longer the norm, men tend to have more sexual partners and to use the services of sex workers. This is condoned by the widespread belief that males are biologically programmed to need sex with more than one woman, ( ).
Urbanisation and migrant labour expose people to a variety of new cultural influences, with the result that traditional and modern values often co-exist. Certain traditional values that could serve to protect people from HIV infection, such as abstinence from sex before marriage, are being eroded by cultural modernisation. ( ).
However the NGOs wanted to continue with this education even the other secondary partners could tell it is affecting the whole process, with advice to first stop teaching the children, educate the parents first so when the children are taught it does not cause conflict. This dilemma here appears largely about power – who has it, who needs it, and how much? Successful partnership requires leaders to redefine the boundaries of power in the organisation, and this can prove challenging, ( ). Careful design of the organisation’s decision-making processes and the setting of clear boundaries can help you tackle the leadership dilemma. Therefore with partnership, effective communication enables us to discuss each other’s concerns, acknowledge our different points of view and strive to understand those views. Good communication is especially important when there are strong views or feelings about an issue. The key thing to remember is that communication goes in all directions. Effective communication isn’t just about telling people things. It’s mostly about listening to each other. Consequently good communication is crucial to partnership. Lack of communication often creates an information vacuum. This vacuum is sometimes filled with rumour and speculation.
Two different views of evaluation pervade the literature on health promotion. From the first view point, evaluation involves assessing an activity in terms of the aims or specific objectives of that activity. William (1987) has written as follows: .the purpose of evaluation is that it should demonstrate whether an activity has been successful or to what degree it has failed to achievee some stated aims.
Before we can evaluate, then, we need to be clear about the aims of the activity in relation to the degree of attainment of these aims. From the second view point, evaluation is a broader process. It involves assessing an activity by measuring it against a standard which is not necessarily related to the specific objectives or purpose of the activity. This approach has been advocated by Green et al. (1980). From the second view point, evaluation is a broader process (Downie et al, 1996).
Evaluation can be defined as the critical assessment of the value of an activity (Macdowall et al, 2006).
Evaluation is needed to ensure that health promotion activities are having the intended effects. Evaluating activities helps inform future plans and contributes to the building up of a knowledge base for health promotion. It also helps prevent the reinvention of the wheel, by informing other health promoters of the effectiveness of different methods and strategies (Naidoo and Wills, 2000).
Downie et al (1996) identifies reasons for evaluating health promotion activities. These are to assess the extent to which projects are achieving their stated objectives, to inform the development of materials and methods, to ensure ethical practice, to optimize use of resources and to assess the place of health promotion within overall efforts to achieve health gain.
Evaluation includes assessments of different kinds of events at varying time periods. A distinction is often made between process, impact and outcome evaluation.
Process evaluation: this involves assessing the process programme implementation. It addresses participants’ perceptions and reactions to health promotion interventions. It is therefore a useful means to assess acceptability and may assess the appropriateness and equity of a health promotion intervention (Naidoo and Wills, 2000). In doing this in our health promotion study, inputs (time, IEC materials, money); self-evaluation (self-reflection); feedback from primary and secondary audience (using questionnaires, question and answer sessions, individual discussions) will be used.
Impact and Outcome evaluation:
Evaluation of health promotion programmes is usually concerned to identify their effects. The effects of an intervention may be evaluated according to its impact ( the immediate effects such as increased knowledge or shifts in attitude) and outcome ( the longer-term effects such as changes in lifestyle).
Impact evaluation tends to be more popular because it is easier to do. Outcome evaluation more difficult because it involves an assessment of long-term effects (Naidoo and Wills, 2000).
Evaluation of the impact could be planned or unplanned.
Planned impact can be assessed using pre-session and post-session questionnaires or a review session with the target audience. Some of the planned impact/outcomes would include increasing attendance to activities, increase in the number of people taking part in voluntary counselling and testing (VCT), increase in age of first sexual encounter and reduction in HIV prevalence rate.
Unplanned impact/outcome will include counselling for other issues such as drugs and alcohol use, provision of support for PLWHA within the school community by referrals to NGOs and other support groups that can provide treatment and help them cope with other effects of living with HIV/AIDS.
There are limitations to the implementation of this health promotion model. There is an ethical dilemma with regards what will be too much sexual information for the teenagers considering the cultural background. Many parents will object to some information given to their children.
Issues pertaining to funds for running and sustaining the programme need to be considered. There could also be some logistics problems in terms of accessing rural areas: power, security, mobility and communication facilities all have to be provided and these are all functions of funds.
Acceptability of the programme by the primary audience may be in question. The students may view the activities as being prescriptive rather than participatory, also, they may view the health professionals and facilitators as being ‘old school’ in terms of age or social background or socioeconomic status and this could be a barrier which might face the programme. This is where the peer educators come in and may go a long way in overcoming this problem. If the students are able to see the project/activities as theirs, it would help to sustain the efforts after the health professionals may have left. Such continuity could be anchored on peer educator groups, abstinence clubs and other social networks.
Long-term assessment of empowerment and change in behaviour is difficult. Is there any behaviour change? If so, is the behaviour change due to this Health Promotion activity alone?. These are pertinent questions which will need to be addressed at the long run.
The model focuses mainly on empowerment without addressing other socio-economic determinants of sexual hea
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