The development and evaluation of a pilot school-based programme for prevention of HIV/AIDS among visually impaired and blind South African adolescents

Philander, J. H. (John Henry) (2007-03)

Dissertation (DPhil)--University of Stellenbosch, 2007.


ENGLISH ABSTRACT: The aim of this study was to develop a HIV intervention programme tailored for South African adolescents with visual impairments. A further aim was to pilot and evaluate this tailored programme. This investigation was deemed necessary in the light of the growing HIV pandemic in South Africa, which has proliferated over the last 10 years. Adolescents and young adults are among the most vulnerable to HIV infection, and this does not exclude adolescents with visual impairments. Despite the perceptions among sighted people of asexuality in adolescents with visual impairments, they are a vulnerable group for HIV infection. The motivation for this study is the fact that very little literature is available on HIV/AIDS and people with visual impairments, and that this vulnerable group is marginalized in HIV/AIDS campaigns internationally. As far as we could ascertain, there have been three HIV prevention initiatives for people with visual impairments in South Africa, none of which was fully researched and evaluated, and all of which used existing generic interventions but transcribed into Braille and large print format. The reality is, many adolescents with visual impairments, as is the case with sighted youths, are sexually active, and the absence of research on HIV prevalence and HIV prevention needs in this sector, is conspicuous. An urgent need exists to tailor HIV preventative programmes for this vulnerable sector. The dearth of research on HIV/AIDS and people with visual impairments motivated the choice of a key informant study to investigate the effects that HIV/AIDS and other concomitant issues have on persons with visual impairments, prior to the design of any intervention. A purposive sample of key informants who are working among people with visual impairments on a daily basis, most of whom had visual impairments themselves, was selected. Information gathered from the key informant study was combined with the lessons from a review of available literature on health promotion programmes and HIV prevention programmes in particular to develop an HIV/AIDS intervention programme to be piloted and evaluated for its effectiveness. The design of the programme took account, in addition, of broader contextual issues such as power and gender issues, and the marginalization and stigmatization of disabled people. The theoretical framework which forms the basis of the programme was informed by elements of a number of cognitive theories in the health promotion field, and especially the Informational-Motivational-Behavioural model (IMF). The programme was designed to empower participants and to create an environment of reallife experiences in which they could acquire important negotiation skills, decision-making skills, and practical skills to use condoms and HIV/AIDS knowledge to facilitate attitude and behaviour change. The next objective of this research was to implement the intervention programme of eight sessions designed for adolescents with visual impairments and to investigate the outcome on participants in this study. For this purpose an experimental design, one experimental group and three control groups (n= 56), not randomly assigned, was used to test the effect of the programme on participants in the intervention group compared to the control groups, who received a health promotion programme of four sessions. All participants were learners at the only two schools for learners with visual impairments in the Western Cape Province of South Africa, and they were allocated into treatment or control conditions on the basis of the school grades in which they were already placed. The empirical investigation utilized a questionnaire that was developed and transcribed into Braille as well as large print. Following a small pilot study, the questionnaire was finalized and administered to all four groups (pre-test, to determine baseline differences; post-test, to determine the immediate effect of the programme; and follow-up [3 months later] to determine longer term effectiveness). An analysis was done to assess the internal consistency of the measuring constructs of the questionnaire, and satisfactory internal consistency was found, with Cronbach’s alpha scores ranging between 0.72 and 0.92. Quantitative data were analyzing using multivariate techniques, beginning with a repeated measures MANOVA analysis and, once an overall significant F ratio between variables, time and groups (F=2.009, p<0.05); a significant F ratio between groups and variables (F=4.211, p<0.01), and significant F ratio between time and groups (F=2.611, p<0.01), had been found, we continued with more focused analyses. Baseline results revealed no statistical differences between the four groups. There were statistically significant improvements in knowledge of HIV/AIDS for both the experimental group and two of the control group, but these differences were not maintained at follow up. Significant differences in attitudes towards HIV/AIDS were found for the experimental group and for one of the control groups. Though there were significant changes in both knowledge and attitudes, therefore, it cannot be claimed that the intervention itself was responsible for knowledge and attitudinal change. There was some evidence for diffusion of innovation in terms of HIV knowledge from the experimental group and the control group situated at the same school. Changes in reported HIV risk behaviour were not recorded to a significant degree, a fact which may have been attributable in part to small sample size. Qualitative process information was used to get a sense of the experiences of participants and the concomitant issues they discussed during the intervention. The qualitative data revealed a host of contextual factors relevant to issues of HIV/AIDS and sexuality in this group, including experiences of stigmatization as people with visual impairment, negotiating masculinity in the context of visual impairment, gender oppression of women and resistance to this, and a general atmosphere of myths and silences around HIV/AIDS in particular and sexuality in general. Despite the limited impact of the programme, this pilot study revealed important issues for adolescents with visual impairments regarding HIV prevention which require further investigation. Participants in the experimental group indicated that they learned a lot from this programme and suggested that it be given to younger adolescents to enable them to acquire these vital skills prior to active sexual engagement and the involvement in any form of unprotected sex. A number or recommendations are made for further well-documented and evaluated research in this field.

AFRIKAANSE OPSOMMING: Die doel van die studie was om ’n MIV-intervensieprogram te ontwikkel wat op Suid- Afrikaanse adolessente met gesigsgestremdhede gemik is. ’n Verdere doel was om ’n proeflopie van die pasgemaakte program te doen en dit te evalueer. Hierdie ondersoek is nodig geag in die lig van die groeiende MIV-pandemie in Suid-Afrika, wat oor die afgelope tien jaar vinnig versprei het. Adolessente en jong volwassenes tel onder die kwesbaarstes vir MIV-infeksie, en dit sluit nie adolessente met gesigsgestremdhede uit nie. Ongeag die persepsies omtrent aseksualiteit in adolessente met gesigsgestremdhede onder diegene wat nie gesigsgestremd is nie, is eersgenoemde ’n kwesbare groep vir MIV-infeksie. Die motivering vir hierdie studie is die feit dat baie min literatuur vir mense met gesigsgestremdhede beskikbaar is, en dat hierdie kwesbare groep wêreldwyd in MIV/VIGSveldtogte gemarginaliseerd is. Sover ons kon vasstel, was daar drie MIV-voorkomingsinisiatiewe vir mense met gesigsgestremdhede in Suid-Afrika, waarvan nie een ten volle nagevors en geëvalueer is nie, en wat almal bestaande generiese intervensies gebruik het wat in Braille en grootdruk-formaat omgesit is. Die werklikheid is dat baie adolessente met gesigsgestremdhede – nes die geval is met jeugdiges sonder gesigsgestremdhede – seksueel aktief is en dat die afwesigheid van navorsing oor MIV-voorkoms en MIVvoorkomingsbehoeftes in hierdie sektor opvallend is. Daar is ’n dringende behoefte aan pasgemaakte MIV-voorkomende programme vir hierdie kwesbare sektor. Die gebrek aan navorsing oor MIV/vigs en mense met gesigsgestremdhede het die keuse van ’n sleutelinformantstudie gemotiveer om die invloed wat MIV/vigs en ander gepaardgaande kwessies op mense met gesigsgestremdhede het, voor die ontwikkeling van enige intervensie te ondersoek. ’n Doelgerigte steekproef van sleutelinformante wat op ’n daaglikse grondslag onder mense met gesigsgestremdhede werk, waarvan die meeste self gesigsgestremd is, is gekies. Inligting wat van die sleutelinformantstudie verkry is, is gekombineer met die lesse uit ’n oorsig van die bestaande literatuur oor gesondheidsbevorderingsprogramme – in die besonder MIV-voorkomingsprogramme – om ’n MIV/vigs-intervensieprogram te ontwikkel wat as loodsprojek kon dien en wat vir doeltreffendheid geëvalueer kon word. Die ontwerp van die projek het, daarbenewens, ag geslaan op breër kontekstuele kwessies soos mags- en genderkwessies en die marginalisering en stigmatisering van mense met getremdhede. Die teoretiese raamwerk wat die grondslag vir die program vorm, is op elemente van ’n aantal kognitiewe teorieë op die gebied van gesondheidsbevordering, en spesifiek die inligtingmotivering- gedragsmodel geskoei. Die program is ontwerp om deelnemers te bemagtig en om ’n omgewing van lewenservaringe te skep waarbinne hulle belangrike onderhandelings-, besluitnemings- en praktiese vaardighede kon ontwikkel om kondoomgebruik te bevorder, asook kennis omtrent MIV/vigs om houdings- en gedragsverandering te fasiliteer. Die volgende doelwit van hierdie navorsing was om die intervensieprogram van agt sessies wat vir adolessente met gesigsgestremdhede ontwerp is, te implementeer en om die resultate ten opsigte van die deelnemers aan die studie te ondersoek. Met hierdie doel voor oë is ’n eksperimentele ontwerp – een eksperimentele groep en drie kontrolegroepe (n=56), wat nie ewekansig toegewys is nie – gebruik om die invloed van die program op deelnemers in die intervensiegroep te toets teenoor dié op die kontrolegroepe, wat aan ’n gesondheidsbevorderings-program van vier sessies deelgeneem het. Alle deelnemers was leerders by die enigste twee skole vir leerders met gesigsgestremdhede in die Wes-Kaap, Suid-Afrika. Hulle is op grond van die skoolgraad waarin hulle reeds geplaas is, aan behandelings- of kontroletoestande toegewys. Die empiriese ondersoek het ’n ontwikkelde vraelys gebruik wat sowel in Braille getranskribeer is as in grootdruk gedruk is. Ná afloop van ’n klein loodsstudie is die vraelys gefinaliseer en aan al vier groepe toegedien (voortoets, om die basisverskille vas te stel; na-toets, om die onmiddellike invloed van die program vas te stel; en opvolg [3 maande later] om doeltreffendheid op langer termyn vas te stel). ’n Ontleding is gedoen om die interne konsekwentheid van die meetkonstrukte van die vraelys te assesseer: voldoende interne konsekwentheid is gevind, met Cronbach se alfapunte wat tussen 0.72 en 0.92 gewissel het. Kwantitatiewe data is met behulp van meervariaattegnieke ontleed. Eers is ’n herhaaldemeting- MANOVA-ontleding gedoen en daarna – nadat ’n algeheel beduidende F verhouding tussen veranderlikes, tyd en groepe (F=2.009, p<0.05); ’n beduidende Fverhouding tussen groepe en veranderlikes (F=4.211, p<0.01) en ’n beduidende F-verhouding tussen tyd en groepe (F=2.611, p<0.01) gevind is – is dit deur meer gefokusde ontledings gevolg. Basislynuitslae het geen statistiese verskille tussen die vier groepe getoon nie. Daar was statisties beduidende verbeteringe in kennis oor MIV/vigs in sowel die eksperimentele groep as die twee kontrolegroepe, maar hierdie verskille is nie met die opvolgtoets volgehou nie. Beduidende verskille in houding jeens MIV/vigs is by die eksperimentele groep en een van die kontrolegroepe gevind. Hoewel daar beduidende veranderinge in sowel kennis as houdings gevind is, kan daar nie beweer word dat die intervensie self vir die kennis- en houdingsveranderinge verantwoordelik was nie. Daar was ’n mate van bewys vir diffusie van innovering wat betref kennis oor MIV van die eksperimentele groep en die kontrolegroep by dieselfde skool. Veranderinge in aangemelde MIV-risikogedrag is nie in ’n beduidende mate aangeteken nie, ’n feit wat gedeeltelik aan die beperkte grootte van die steekproef te wyte kan wees. Inligting uit ’n kwalitatiewe proses is gebruik om ’n indruk te skep van die ervaringe van deelnemers en gepaardgaande kwessies wat hulle tydens die intervensie bespreek het. Die kwalitatiewe data het ’n reeks kontekstuele faktore blootgelê wat vir kwessies van MIV/vigs en seksualiteit in hierdie groep tersaaklik is, met inbegrip van ervaringe van stigmatisering as mense met gesigsgestremdhede, die hantering van manlikheid binne die konteks van gesigsgestremdheid, genderonderdrukking van vroue en weerstand hierteen, asook ’n algemene atmosfeer van mites en stilswye oor MIV/vigs in die besonder en seksualiteit in die algemeen. Ten spyte van die beperkte impak van die program het hierdie loodsstudie belangrike kwessies vir adolessente met gesigsgestremdhede betreffende MIV-voorkoming blootgelê wat verdere ondersoek noodsaak. Deelnemers in die eksperimentele groep het aangedui dat hulle baie uit hierdie program geleer het en het voorgestel dat dit aan jonger adolessente aangebied word om hulle in staat te stel om hierdie noodsaaklike vaardighede te ontwikkel voordat aktiewe seksuele betrokkenheid en betrokkenheid by enige vorm van onbeskermde seks plaasvind. ’n Aantal aanbevelings vir verdere goed gedokumenteerde en geëvalueerde navorsing op hierdie gebied word gemaak.

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