Measuring the Impact of a Behaviour Change Intervention for Commercial Sex Workers and Their Potential Clients in Malawi

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This paper evaluates the impact of a peer-education HIV/AIDS prevention programme on bar-based sex workers and their potential clients (long-distance truck drivers) in Malawi. A mixed method approach was used, the tools being structured questionnaires and focus group discussions. The results showed that in the active districts, the presence of sex worker peer educators led to an increase in condom use with paying partners and increased condom distribution. Condom use with regular non-paying partners of sex workers had, however not increased since the baseline data. The truck driver peer educators were found to be generally inactive but companies where training had occured were more likely to encourage and distribute condoms. The qualitative data gave a more in-depth view of several areas for concern.
  HEALTH EDUCATION RESEARCH Vol.14 no.4 1999Theory & Practice Pages 545–554 Measuring the impact of a behaviour changeintervention for commercial sex workers and theirpotential clients in Malawi Vivien Margaret Walden, Kondwani Mwangulube 1 andPaul Makhumula-Nkhoma 1 Abstract A peer-education HIV/AIDS prevention pro-gramme for bar-based sex workers and theirpotential clients (long-distance truck drivers)in Malawi was evaluated for impact. A mixedmethod approach was used, the tools beingstructured questionnaires and focus groupdiscussions. The results showed that in theactive districts, the presence of sex workerpeer educators led to a increase in condomuse with paying partners (90.3 compared to66.7 and 76.3% in the two other groups—non-active and average) and increased condomdistribution. Condom use with regular non-paying partners of sex workers had, however,not increased since the baseline data. Thetruck driver peer educators were found to begenerally inactive but companies where train-ing had occurred were more likely to encourageand distribute condoms. The qualitative datagave a more in-depth view of several areasfor concern: the reasons for the non-use of condoms with non-paying partners; acceptanceof educators by their peers; and the sexworkers’ and truck drivers’ criteria for con-dom use based neither on knowledge nor ontheir own risk awareness. These issues needto be explored further. EC Technical Assistance and  1 National AIDS ControlProgramme/EC AIDS Project, Lilongwe, MalawiCorrespondence to: V. M. Walden, Flat 5, 23 Clyde Road,West Didsbury, Manchester M20 2NJ, UK © Oxford University Press 1999  545 Introduction The number of AIDS cases globally continues torise, with an estimated rate of new cases of 3million a year. Over 95% of these are in developingcountries (WHO, 1996). In sub-Saharan Africa,the majority of HIV-1 cases occur in east andcentral Africa (PHLS, 1996). The virus has tendedto follow the trade and population movementsdown through the continent, transmitted by thesexual habits of long-distance truck drivers andtraders, and the commercial sex workers alongthese routes (Orubuloye  et al ., 1993; Pozniak,1993; WHO, 1996; Mertens and Carael, 1997). Onthe east coast, the route has been from Kenya toTanzania, south to Zimbabwe, Malawi and SouthAfrica (Bassett and Mhloyi, 1991).Since the prospects of a vaccine being availablein the near future are remote, the only means of preventing transmission of the virus is by changinghigh-riskbehaviours(Bandura,1990;Catania etal .,1990). As 80% of all transmission in sub-SaharanAfrica is by heterosexual intercourse, most preven-tion programmes have concentrated their effortson increased condom use and a reduction of partners among high-risk groups. Health educationprogrammes targeting sex workers have been car-ried out in several countries, Cameroon (Monny-Lobe  et al ., 1989), Zimbabwe (Wilson  et al ., 1990),Tanzania (Mhalu  et al ., 1989) and Kenya (Plummer et al ., 1989) being examples. This paper evaluatesthe impact of such a programme for commercialsex workers and their potential clients (long-distance truck drivers) in Malawi.The evaluation methodology was designed toincorporate both qualitative and quantitative data—  V. M. Walden  et al .the mixed-method approach that is now consideredgood practice in evaluation (Greene  et al ., 1989;Lewin, 1994). The mixed-method approach Data collection has been traditionally divided intoquantitative (measurable and therefore deductiveand objective) and qualitative (descriptive, subject-ive and inductive) (Debus, 1986; Steckler  et al .,1992; Dootson, 1995). There has been a debateabout the terminology (triangulation or mixedmethod) when using more than one methodologyin the same study (Greene  et al ., 1989). Whereasthe term mixed method has been applied to amethodology using at least one qualitative and onequantitative method to ‘reveal different aspects’(Greene  et al ., 1989) (but not to seek convergenceor validation of results), triangulation has tradition-ally meant using two methods to ‘strengthen thevalidity of inquiry results’ (Greene  et al ., 1989).Denzin (Denzin, 1978) has identified four typesof triangulation:(1) Data triangulation—the use of a varietyof data sources in a study; (2) investigatortriangulation—the use of several differentresearchers or evaluators; (3) theory triangula-tion—the use of multiple perspectives to inter-pret a single set of data; and (4) methodologicaltriangulation—the use of multiple methods tostudy a single problem or program.The reason for these methods was the validationof findings (Patton, 1990; Flick, 1992). However,Denzin has since modified his definition and nowstates that ‘the goal of multiple triangulation is afully grounded interpretive research approach’ andthat ‘in-depth understanding’ and not validity isthe reason for mixing methods (Denzin, 1989;Flick, 1992). He has also stated that mixed methodis a part of triangulation: the fourth type of hisclassification.In-depth understanding is especially importantin sexual behaviour research. Sensitive issues suchas condom use and the reasons for not using themcan often be better explored in the more congenial 546 environment of a focus group than by answeringa questionnaire. A programme for sex workers inCalifornia has found that ‘neither quantitative norqualitative data alone were sufficient for under-standing AIDS risk for sex workers’ (Dorfman et al ., 1992). Background The republic of Malawi is situated in CentralAfrica, between Tanzania, Mozambique andZambia. It is a small landlocked country with apopulation of 10.8 million and almost one-fifth of the 118 480 km 2 land mass covered by the watersof Lake Malawi. The country rates among theworld’s 10 least developed countries with a GNPper capita of US$200 with 85% of the ruralpopulation and 25% of urban below the absolutepoverty line (UNICEF, 1995). The under-5 mortal-ity rate is currently 221 per 1000. After 30 yearsof a repressive one party state under PresidentKamuzu Banda, the country held the first demo-cratic elections in 1994.AIDS was first diagnosed in Malawi in 1985and by 1994 there were 36 236 reported cases. In1993, it was estimated that one in five adults wasaffected and that 80% of commercial sex workerswere found to be HIV-positive (UN and GOM,1993). At the present time, it is estimated that onein three of urban adults and one in five of ruraladults are infected.In 1988, in response to the AIDS epidemic, theMalawi government prepared a Medium TermPlan to cover the years 1988–1993. Information,education and communication were considered tobe important components and were, for the first 2years, directed at the public in general. Studies in1986 and 1987 had shown an increase in HIV ratesamong sex workers from 42 to 80% and, in1989, a study among STD patients showed 62.4%positivity (UN and GOM, 1993). In view of thesefindings, the National AIDS Control Programmelaunched a project entitled ‘Prevention of SexualTransmission of HIV through Information, Educa-tion and Communication’ in 1990, with fundingand technical assistance from the European Com-  Behaviour change intervention for commercial sex workersmission of the European Union. The project pro-posed to train peer educators, an approach that hasbeen used both with adolescents (Arnold andBarnes, 1989), prison inmates (Lyons  et al ., 1989),prostitutes (Monny-Lobe  et al ., 1989) and youngpeople in summer resorts (Weise  et al ., 1989). The pilot phase and base-line survey The education programme began with two high-risk groups, i.e. sex workers and long-distancetruck drivers, the potential clients of the sexworkers. Prostitution is illegal in Malawi, as it isin many African countries and therefore bar-basedsex workers are defined as being women whowork in a registered bar as cleaners, barmaids orresthouse attendants, occupying quarters behindthe bar. In 1990, there could be up to 20 girls ateach bar with an appointed head sex worker incharge. In exchange for accommodation, thewomen were expected to work in the bar and toencourage customers to buy drinks. If the womenso wished to engage in prostitution, the customerswere taken to the quarters behind the bar. Womenoften had to share rooms and had to wait their turnto entertain a customer. Pimping is a little-knownphenomenon in Malawi and therefore the barowners or managers received no part of the fee.The specific objectives of the project were topromoterisk-reducingbehaviourandmaintainlow-risk behaviour among the two target groups. Peereducators would be trained in each bar and in eachof the trucking companies.The peer education intervention began with apilot project among sex workers in three districttowns, Dedza, Mponela and Mchinji. The threetowns are in districts adjacent to the capital city,Lilongwe, and are on main trucking routes fromTanzania and Zambia. Ethnically and linguisticallythe three areas are similar.A pre-intervention base-line Knowledge, Atti-tudes, Practice and Behaviour (KAPB) study wascarriedouton242sexworkersusingquestionnairesonly. The respondents were selected randomlyfrom a list of registered bars supplied by the localhealth authorities. Awareness of the nature of the 547 AIDS epidemic was high: 97.5% (236 of 242) hadheard of AIDS; 64.8% (153 of 236) of respondentsknew AIDS was sexually transmitted while 73.2%(99 of 176) knew that there was no cure. Onmethods of prevention, 56.3% (99 of 176) men-tioned avoiding sex with multiple partners while50.6% (89 of 176) mentioned condoms. Condomuse—on at least one occasion—was reported by66.5% (161 of 242) of sex workers. Among sexworkers, 63.6% (154 of 242) had sex with non-paying partners (boyfriends) and of those 67.5%(104 of 154) used a condom with these men(Wynendaele  et al ., 1991).During the following 4 months, peer educationtraining was given in Dedza; a low-effort interven-tion (health talks) took place in Mponela whileMchinji served as the control town. The peereducators were trained for 4 days to give informa-tion about HIV/AIDS, to promote and distributecondoms, and to teach safe sex negotiation skillsto their fellow sex workers. The low-impact healthtalks were given by health staff to groups of sex workers.At the end of the 4 months, the same question-naire was administered to measure the impact of the intervention. Unfortunately there was a highdropout rate and only 116 of the srcinal 242 girlswere interviewed in the follow-up. Results fromthe remaining respondents showed, however, thatcorrect condom use increased from 18.9% (40 of 212) to 68% (59 of 116) and the proportionreporting having ever using condoms increasedfrom 66.5% (161 of 242) to 100% (116 of 116)(Wynendaele  et al ., 1991).As the sex workers appeared to be a group thatwas easily reached (through already establishedcommunitieswithanappointedleader),peereduca-tion was considered an appropriate approach. Thisassumption, plus the encouraging results from thepilot sites, led to a nationwide expansion of theinterventions. Long-distance truck drivers werealso targeted as potential sex worker clients. Thesewere reached through trucking companies in thetwo main towns of Malawi. By the end of 1992,1183 sex workers and 458 truck drivers had been  V. M. Walden  et al .trained as peer educators, in most of the 24 districtsnationwide.In 1994, monitoring data showed that few of the trained peer educators had remained in placeand that activity in several districts had ceased(Kajawo, 1994).District healthmanagement teams,struggling with limited resources and an ever-increasing demand on their time, have had toprioritize which projects should be supported andwhich donors should be accommodated; usuallydepending on the going allowance rate. As theresponsibility for the implementation of the projectat district level lies with the district AIDS co-ordinator (a part-time position), it was decided toconcentrate on three districts where there was acommitted worker and potential for a successfulintervention. An impact evaluation for this newphase was planned and carried out in 1996. Evaluation methodology Since 1991, more and more bar-based commercialsexworkers aremovingawayfrom barsandjoiningthe ever-increasing number of so-called ‘free-lancers’ (women who are not employed by a bar,but are free to solicit where they wish and whoutilize either hotel rooms or a rented room forclients). Although this phenomenon was known tothe project staff, it was only during the impactevaluation that the real situation became apparent.The planned methodology for random selection of respondents had therefore to be modified, as therewere considerably fewer bar-based sex workersthan had been envisaged: all bar-based sex workersin the selected six districts were therefore inter-viewed. As the project had srcinally targeted bar-based workers, it was felt inappropriate to extendthe evaluation to the free-lancers.The district towns in which data was collectedwere chosen from two of the three regions. Thedecision not to include the northern region wasdue to logistical and financial constraints, and thefact that only 11% of the population live in thenorth. The chosen towns were taken from active(districts where peer education training had takenplace within the last year), non-active (no training 548 had taken place since the initial one in 1991) andaverage (districts where training had taken placebut there was little observed activity). Two districtswere chosen from each group, the criteria beingdetermined by process evaluation reports from theDistrict AIDS Co-ordinators and the project staff field visits reports. All bars in the district werevisited and all sex workers currently employedthere were interviewed. The list of bars was sup-plied by the District AIDS Co-ordinators. A bar-based sex worker was defined as being employedby the bar and occupying accommodation on site.In total 424 women in all were interviewed, fallingshort of the planned 600.The truck drivers were also interviewed at alltrucking companies in the main city of Blantyre,where most of the companies have their headquar-ters. The companies were listed (by the CityCouncil Health Department), ranked according tosize and, using company pay-rolls, 600 driverswere chosen—this being the calculated sample sizecomputed by the statistical package EPI-INFO6.Three groupings were planned, i.e. active (activetrained peer educator present), non-active (notrained peer educator) and average (where therewas no trained peer educator but city health person-nel made frequent visits).Although the data collection period wasextended, the research assistants faced problemsin reaching the target figure (600 in total). Drivers,although on the pay roll, were often seconded tocompanies in other towns or were on sick leave.Due to these logistical problems and to economicconstraints, convenience sampling was used. Atotal of 347 drivers was eventually reached.Standard questionnaires, one for each group,were translated into Chichewa, the local languageand were back-translated for accuracy (Brislin et al ., 1973). Having been pre-tested, they wereadministered to all respondents by the trainedenumerators. Focus group discussions were heldwitharandomsampleofthequestionnairerespond-ents. Six groups were held for sex workers whileonly one was held for the truck drivers. Here aproblem arose when drivers who were asked toparticipate, refused, due to a fear that they had
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