AIDS action Issue 19 Page 1 2
Issue 19 December 1992
Training makes a big difference
People whose work relates to AIDS - teachers, community educators, counsellors, doctors, nurses or trainers themselves - need training. This will help them to deal with the ways in which HIV/AIDS can affect both their professional and their personal lives.
Training should include activities to increase people's knowledge about HIV and AIDS, to improve both their communication and technical skills, and to help them explore their feelings about sex, responsibility to others, compassion and death. It must also help to plan for their future work, and increase their confidence and their commitment to put into practice what they have learnt during the training.
It is important to find out what difficulties participants are experiencing in their work, and what their needs are. Training materials should be developed or adapted specifically for course participants and for the environment they are working in.
This issue of AIDS Action looks at four areas which need special consideration.
Dealing with fear and prejudice: Effectiveness and confidence can be hindered by fears of infection, and by prejudice towards people with HIV infection or AIDS, especially if they are members of marginalised groups such as drug users, men who have sex with men, sex workers and prisoners. These concerns and fears have to be resolved before workers can function effectively. On page 2 AIDS Action reports on training designed to help nurses to overcome their fears of infection, by explaining when and why they should use infection control procedures. And, just as important, it aims to address their prejudices.
Talking about sex: Lectures about sexuality and sexual practice rarely result in changes in behaviour or attitudes. Small group exercises help to start discussions about sensitive issues, and give trainees the skills and confidence to run their own 'talkshops'. Some of these methods are described in a special insert in this issue.
On page 4, health educators in Sierra Leone describe how they involved community leaders in AIDS education activities. Workshops with local religious leaders, for example, resulted in increasing their acceptance of condom use in sex outside marriage (although they did not necessarily approve of those relationships).
Managing with limited resources: The AIDS epidemic is putting great pressure on health services and staff. Access to treatment is often very restricted for many people who are ill and home care is becoming increasingly important. It relieves the burden on health services; can improve the quality of life for individuals with AIDS; and at the same time increases people's confidence in their capacity to cope with the epidemic. Providing training and back-up services for health workers, community volunteers and family members is a vital part of home care programmes, and is discussed on pages 5 and 6.
Coping with stress: Emotional stress and depression (sometimes called 'burn out') can be major problems for staff and volunteers. Working out a follow-up strategy with the trainees to provide support afterwards should always be part of a training course. This could mean setting up a support group and further training for the workers, or training them in how they can counsel each other about their experiences.
AIDS Action would like to hear from readers about their own experiences of training - what you feel works and does not work - for a future issue of the newsletter.
In this issue:
Increasing skills and confidence for health workers
Home care training guidelines
Special insert on teaching and training techniques
Training for health workers
Learning through experience
Janey Parris reports from Trinidad and Tobago on training health workers to feel confident about caring for people with AIDS, and preventing infection spread.
In Trinidad and Tobago, people with HIV/AIDS are cared for within the primary health care system. District health centre staff are responsible for making home visits, and ensuring that patients have access to hospital in-patient and out-patient facilities.
AIDS education for health workers was started soon after patients with AIDS related illnesses were first seen in 1983, in response to demands for more information about the new virus. Over the next five years all nurses in the country attended one or two days of lectures, given to large groups in a classroom setting.
Trouble with lectures
Participants felt that the information they received was useful, helping them most in infection control, which was their greatest concern. But, by 1989, health centre staff were still experiencing problems in caring for people with HIV/AIDS. Reports from patients stated that health workers tried to avoid treating or touching them, and would not visit them at home.
Although issues concerning sexuality, prejudices and religious beliefs had been covered by the lectures, nurses' attitudes had not really changed. They were afraid of being stigmatised through contact with people with AIDS and that they would be infected with the virus. They were more sympathetic towards HIV-positive children, and people infected through blood transfusion. Many still felt that AIDS was a punishment from God, and they were most prejudiced towards men who had sex with men, or who identified as being gay.
Jacqueline Wong, a district health visitor, comments: 'Even though I had the theory, I was very shocked when I first saw a patient with AIDS. I just froze. Now it's very different. What helped me most was facing the human reality of the situation, by meeting patients and taking part in the training.'
Coming to terms with reality
These factors influenced the design of a modified training programme, developed in 1990. The programme focuses not only on increasing knowledge but also on changing personal attitudes, reducing fears and increasing self-awareness.
Teaching methods reflect the fact that adults learn better when they experience the issues more personally. Exercises such as role play make situations seem more real to the trainees, and involve everyone in the group.
Small groups of 10 to 15 people attend the training course. The course is one day a week for eight weeks, and is held in an informal and relaxed environment.
Training content varies according to participants' needs. They fill in questionnaires before they start the course, and also discuss what they want during the workshop sessions. By the end of the training, participants have a better understanding of:
the feelings and needs of people with AIDS;
human sexuality in relation to themselves and others, and the diversity of sexual behaviour;
separating illness from sexual practices for the purposes of caring;
recognising the importance of each individual, regardless of illness or sexuality;
how to encourage families to accept the patient as a person and to give support to those who are ill, in spite of what the illness is or what caused it;
educating about preventing HIV and STD infection;
basic skills for effective communication with the patient and their family;
issues relating to HIV-positive gay and bisexual men (in view of the discrimination towards them in wider society).
HIV-positive people are invited to join in discussions, along with their family members and experienced nurses. Talking with women with AIDS helps the nurses (mostly women themselves) to understand what they have in common with their patients, and to identity more easily with people with AIDS, both men and women.
After this training, the nurses are encouraged to continue discussing the issues with their colleagues. Health centre co-ordinators are also able to contact AIDS programme staff with any problems. Support groups for the nurses themselves are being set up, where they can share experiences and advise on problems.
Janey Parris, AIDS Programme Co-ordinator, Eric Williams Medical Sciences Complex, Mt Hope, Trinidad and Tobago.
Training for health workers
Towards healthy working
The International Council of Nurses (ICN) has recently completed a two year HIV/AIDS education project, with eight of its member nurses' associations, including those in Côte d'Ivoire, Ghana, Malawi and Tanzania. In 1989 a questionnaire sent to over 100 associations revealed that less than half of them had carried out training related to HIV/AIDS, and that they all wanted up-to-date information and teaching resources.
Discussions were held with groups of nurses to assess knowledge levels and needs. 'Training the trainer' workshops on clinical management, prevention, counselling, home-based care and public education were then set up for about ten nurses from each association, in liaison with their national AIDS programmes.
These participants then organised workshops for other association members, using training materials adapted to their local situations. For some participants it was the first time that further education had been provided locally. Two nurses in rural northern Uganda walked 20 miles to get to a workshop!
In Uganda the National Association of Nurses and Midwives teamed up with The AIDS Support Organisation (TASO), and invited their counsellors to run training sessions. Nurses have also set up workshops for traditional birth attendants and family health and community nurses. In Zambia support groups for nurses are being established, providing 'care for the carers'.
Ghana goes forward
'Many health workers here used to be extremely reluctant to care for AIDS patients, and the training workshops helped greatly in reducing their anxieties and fears', comments Agnes Boahene, who co-ordinated the workshops in Ghana.
Participants included clinical nurses, nurse trainers, psychiatric workers, public health nurses, and government and private practice midwives. During the five day workshop, they visited hospitals to meet AIDS patients, and testing centres to see HIV antibody tests being carried out and analysed. In one workshop, participants visited a traditional herbalist to discuss caring for patients with AIDS related illnesses.
Nurses can now more easily recognise and treat infections that may be related to AIDS. They are more actively involved with health education for the general public, including lorry drivers, church groups, school children and market women. Some have organised a one or two day training for their fellow nurses.
In collaboration with the national programme, nurses have set up counselling services in hospitals. For example the unit at Koforidua Central Hospital caters for people who come to the hospital for voluntary HIV tests, and for medical care for illnesses associated with AIDS. More clients are being referred for pre- and post-test counselling by nurses.
Agnes Boahene, Regional Health Administration, Ministry of Health, PO Box 175, Koforidua, Ghana.
Source: Mobilizing nurses for AIDS prevention and care in eight African countries, ICN/WHO 1992.
The 'Guidelines for mobilizing National Nurses' Associations in HIV/AIDS prevention and care' are available from the ICN, 3 place Jean-Marteau, CH-1201 Geneva, Switzerland.
... and doctors
In Pakistan, where the reported incidence of HIV is still low, there is little public education about preventing sexual transmission. However, doctors are able to discuss sexuality, condom use and safer sex with their patients in the privacy of their consulting rooms. They have a vital role to play in raising awareness about HIV prevention.
The Physicians Forum for Family Planning (in the North West Frontier Province) has taken an essential first step through setting up training workshops for their member doctors. This new and exciting initiative has the valuable support of the Principal of the region's medical college, who is himself promoting HIV/AIDS issues in medical student training.
Source: Drs Tufail Mohammad, S Hakeem Shah, and Ihsanullah Khan, PFFP, Cantt. General Hospital, Peshawar, NWFP, Pakistan.
Training exercise: who will be treated?
This exercise will help health workers to confront prejudices and assumptions about patients' illnesses and lifestyles.
Before the training session write down on separate pieces of card short descriptions of an HIV-positive adult or child. For example:
a man with TB. He is married and has male sexual partners.
a woman with gonorrhea, who is a sex worker.
a woman who was infected with HIV through a contaminated blood transfusion. Her baby has severe respiratory problems.
Give one card to each participant, and ask them to imagine that the person is their patient. Write up each description on a chalk board or large piece of paper.
Then say that a cure for AIDS has been discovered, but that it is in very short supply. Tell them that their patient will be first to receive the new drug, but that they each have to decide who they would treat second, then third, and so on.
When they have each made a list, begin a group discussion about who they prioritised, and why, and how they made decisions about the order. Encourage them to discuss what thoughts they had, for example about having to treat their particular patient first. They may find this easier to do in pairs.
Finish with a group session, during which each person describes how the exercise made them feel, and what they learnt from it.
Working with community leaders
'AIDS is not a problem for us'
Educators in Sierra Leone found that targeting community leaders was an effective first step in tackling low public awareness about HIV risks.
Health educators working in Kenema town in eastern Sierra Leone were faced with the challenge of raising awareness about AIDS before it had become a visible problem. The educators decided to develop AIDS education activities through involving respected members of different groups, because they were already important sources of information and guidance for people.
One-day workshops were set up for about 12 people invited from each of these seven groups: health and social workers; clergy and church leaders in the Christian community; imams and mosque leaders in the Muslim community; leaders and chiefs from both women's and men's 'secret societies'; and young men and women.
These workshops aimed to give participants the knowledge and skills to act as teachers and resource persons for people they had regular contact with. The first workshop was followed up by a second, held three months later. Between the two workshops, participants were encouraged to keep in touch with the workshop facilitators and with each other.
Workshop I: introducing knowledge and skills
At the beginning of the day each participant was asked to say what they wanted from the workshop, and why they were there. This information was referred to at the end of the day, when the participants discussed whether their expectations had been met.
They were also asked to say something that they knew or had heard about AIDS. This helped the facilitators to make sure the sessions were adapted to the needs of the group. For example, some participants incorrectly thought that AIDS could be caught from mosquito bites or kissing. Others said they had heard that AIDS does not really exist, or that it meant 'American Intention to Discourage Sex'.
As well as discussing issues specific to HIV/AIDS, participants also explored health education strategies. For example, songs are a traditional method of communication in the women's societies, and this workshop group composed songs about AIDS for using with their members. Other examples included using drama, posters and leaflets, group and one-to-one discussions and setting up clubs.
They also practised, through role play, how to answer people's questions about AIDS, and basic communication skills. Depending on the group, other activities included learning how to sterilise needles and cutting instruments, and using condoms.
Workshop 2: problem solving
Almost all the participants returned for the second workshop. Activities they had carried out included setting up meetings for secret society members, with congregation members, and in schools, participating in World AIDS Day, and one-to-one discussions.
One of the most common difficulties they had confronted was the belief that AIDS does not exist, and people's reluctance to use condoms or to stick to one partner. Participants talked over these problems in smaller groups, trying to come up with ways of resolving them. Someone from each of these small groups reported back and invited comments from other participants.
The final session of the second workshop was called: 'Where do we go from here?'. The groups discussed how they could continue to do AIDS education and where they could find support. The youth groups were encouraged to set up their own AIDS prevention societies.
Participants themselves said that the workshops provided a valuable opportunity to discuss sensitive issues. Pre-and post-workshop questionnaires showed increased knowledge about HIV/AIDS.
The effect of the project in the wider community was measured through carrying out a survey of 1,000 people before and after the two workshops. Analysis showed that a significant change occurred in knowledge and attitudes about HIV and AIDS over the project's timespan. There had been no other significant education efforts during that time. The results of the evaluation were available to participants, and helped them and the facilitators to critically review the content of the workshops and to set up further activities. Ideally these workshops should be held at regular intervals over a longer period of time, along with setting up other services and activities, in order to sustain any change.
R Cracknell, P Kamara, J Kanu, A Levisay, c/o Lassa Fever Research Project, P O Box 66, Maxwell St, Kenema, Sierra Leone. Thanks also to B Hemore, Regional Health Educator, Eastern Province.
The project was made possible through the support of the US Embassy Self-Help Fund, the National AIDS Committee of Sierra Leone and the people of Kenema town.
Home care training guidelines
Courage, compassion and care
Looking after sick people at home is often best, but only if the carers have training and back-up support.
Home care means the things people can do to take care of themselves or the care given to them in their own homes by their family, friends, neighbours, volunteers or health worker. It means caring for people's emotional as well as their physical needs. Some programmes target people who are sick with other chronic illnesses in addition to AIDS, like TB or malaria, or are weakened because of old age or malnourishment.
The sick person and their carers work as a team, ideally with the support of a health worker or trained community volunteer. She or he must make sure that the patient is cared for as well as possible and that carers feel confident about their role. Carers must also know where and when to seek specialised medical care.
Home care is often preferable to hospital care because:
good basic care can be given successfully at home;
people who are very sick or perhaps dying would often rather stay at home, especially when they know that they cannot be cured in hospital;
they are comforted by being in their own homes with family and friends around them, and will often recover from specific illnesses faster at home than in hospital;
it can help the patient and their family come to terms with AIDS, playing a role in overcoming people's fears, anxieties and prejudices;
hospitals will be less crowded, so that people who really need to be in hospital can be cared for;
it can be difficult for family members to fulfill other responsibilities, if they have to stay at a hospital or visit the person often;
sometimes hospital care is simply not available.
Training and support
Training is an essential part of a successful home care project. Health care workers and other trainers need to know how best to teach people the basic principles of caring for the sick. The carers (and patients themselves) need to know what to do, and how to give and seek emotional and practical support.
Support (for the carers) means setting up regular meetings, and ensuring that everyone has at least one other person with whom they can discuss problems, or who can take over for a while. Regular visits by trained volunteers can also help to relieve the pressure on family members.
Training should include discussion sessions, and demonstrations of the skills needed. Allowing time to practise these activities during the training is also important. Training for carers should include the following topics.
Facts about HIV and AIDS
Trainees need to know what HIV is, how it is transmitted, and how HIV infection causes AIDS. This section could include other illnesses too, if the project is targeting sick people in addition to those with AIDS.
Care for common symptoms
HIV infection damages the body's immune system. This means that resistance to organisms which cause other infections is lower. Many symptoms may be related to HIV/AIDS, including chronic and acute diarrhoea, and respiratory, skin and genital infections. All these symptoms may also be caused by other illnesses, or conditions like malnourishment.
how to recognise symptoms, their possible causes, and when carers should seek medical advice;
ways to manage pain and relieve symptoms using simple techniques and inexpensive remedies, such as gentian violet solution for mouth and skin infections; oral rehydration solution for replacing fluids lost through diarrhoea; and antipyretics such as aspirin or paracetamol for relieving fever. Local herbal remedies may also be valuable;
how to prevent symptoms developing. For example, keeping the skin clean and dry helps to prevent skin infections.
A patient with AIDS is about to go home from hospital. Their health worker talks with him and his wife about their anxieties. She finds out that they are most worried about what their neighbours and relatives will think. She listens to what they say carefully and discusses possible solutions. She suggests that they try not to hide the problems, but that they ask people for help, although they don't have to say what is causing the illness. She also shows them the necessary skills that they need to care for him at home, and watches while they practise. She also tells them what problems to watch out for. She helps them to think of other people who could give support, and asks them to come back after a month for a checkup.
Home care training guidelines
Carers need to feel confident that there is no risk of becoming infected with HIV through caring for someone, if skin contact with 'body fluids' is avoided (see page 7 for guidelines).
The risk of infections like diarrhoea and TB is reduced if everyone in the household maintains good hygiene. Training should include sessions on hand washing, food hygiene, safe handling and washing of bed clothes soiled with body fluids, and safely disposing of soiled dressings, and cloths or newspaper used for coughing into. The sick person should be as comfortable, and clean and dry as possible. Good ventilation is also important.
Preventing sexual transmission of HIV should also be discussed, together with practising how to use condoms.
Building strong and supportive relationships between carers and patient is very important. However, people are sometimes nervous about spending time with someone who is ill or dying, especially if they have AIDS.
Support does not mean giving advice or telling someone what to do or how they should feel. It often means just listening. The simple act of talking to a good listener can help make the issues seem clearer. Any questions asked should relate to what the person is saying, and help the person to explore their feelings, for example: 'What do you feel about...?' This approach helps the person come to terms with their situation, or make their own decision about how to solve a problem.
During training, practising listening skills through role plays is valuable. One of the best ways to help people overcome their fears or prejudices is for them to meet a person with HIV/AIDS, who is willing to discuss their experience. People also gain confidence through talking with other carers. It is also important to encourage family members to discuss the issues with each other and with the sick person themselves.
Information about someone's illnesses, whether the cause is known or not, should not be discussed with anyone unless the sick person has given their permission. However carers need to know how to deal with rumours in a positive way, by using them as an opportunity to talk about what AIDS is, and how to prevent infection spreading, as well as the need to support people who are ill.
A good diet is important for people who are sick. Discussion should cover reasons why sick people lose weight and commonly do not want to eat much; and preparing nourishing foods and ways to encourage a sick person to eat.
Further information is available in two new home care handbooks. Contact the Health Care Support Unit ( WHO, 1211 Geneva 27, Switzerland), and The Federation of Red Cross and Red Crescent Societies, P O Box 372, CH-1211 Geneva 19, Switzerland.
Building on tradition
Ajili is 29 years old, and lives in a village in the Rakai district in Uganda. Her husband died two years ago from AIDS, and now she is ill too.
Her neighbour, Gerald, visits her every second day and helps by doing some odd jobs and by bringing food and herbal remedies. More than this, he offers hope and emotional support, and practical suggestions about how to cope with her illness.
Gerald provides all these services free of charge. He is a member of a munno mukabi group. These are informal groups of villagers, mostly women, who traditionally support each other in times of need, by, for example cooking food at funerals or weddings. He is one of 142 representatives of munno mukabi groups, youth groups and football clubs in 17 villages, who have been trained to care for and support people with AIDS.
This training and support programme (organised by CONCERN) aims to build on an existing community spirit, enabling the villagers to care for anyone in the community who is ill or in need of assistance. This means that group members are not labelled as AIDS workers, and villagers are more willing to see them because their visit does not imply that the sick person has AIDS.
Organising the work
Participants for the training course are selected by the munno mukabi group members. Well respected individuals are chosen on the basis of their ability to keep information about others to themselves, and to care for people.
The chair of the village committee also attends the course. It is important to have the support of the village leaders, because they can help solve any conflicts. After the training, the trainees organise a meeting to explain their work to other villagers. In consultation with the village leaders, each trained visitor takes responsibility for about 20 households.
The home visitors usually meet together once a month to discuss their work, and to make sure it is fairly distributed. They often share two sets of households, and sometimes visit together. This means that they can give each other support, and if one home visitor falls sick, or fails to build a relationship with the sick person, the other can continue the work and train another visitor if necessary.
The most important part of the home visitor's job is to build up a trusting relationship, through regular visits once a week, with the people in the household. Some find it easier to do things for the sick person, rather than sitting and talking with them. In the local language, the words used for talking with the sick person mean comforting, caring for, and in sympathy with. Although the trained visitors are responsible for most of the work, other munno mukabi group members do some visiting, and are often responsible for practical tasks.
Eamonn Brehony and Margaret Ssemukasa, CONCERN, P O Box 1644, Masaka, Uganda.
Infection prevention for carers
The risks of HIV transmission in the health care setting are very low, especially if carers minimise skin contact with blood and body fluids.
Health workers and carers need training in the principles of good hygiene and in 'universal precautions'. The universal precautions protect against hepatitis B and other infections in addition to HIV, and the guidelines should be followed with every patient, whether or not they are known to be HIV-positive. They include how to:
avoid skin and eye contact with patients' blood and other body fluids;
dispose of waste safely;
follow appropriate cleaning, disinfection and sterilisation procedures; and
prevent needle stick and other injuries.
Clean, intact skin is an excellent barrier to HIV. There is an extremely low risk of infection from HIV or hepatitis B if blood comes into contact with unbroken skin.
However, it is possible that the virus could enter the bloodstream where the skin is damaged. This is most likely if there are open cuts and abrasions or if the blood remains in contact for a long time. However, few, if any, cases of such transmissions have occurred.
In order to minimise the risks the following precautions are advisable:
Latex gloves should be used if, and only if, contact with blood or body fluids is likely. If gloves are in short supply, keep them for when they are needed most, such as when the worker's skin is damaged and when extensive and prolonged blood contact is expected.
Health workers should examine the skin of their hands and forearms for cuts, abrasions, insect bites, blisters or other damage before starting work. Any open wounds should be covered with a waterproof dressing. If this is not possible gloves should be worn, or direct contact with blood should be avoided.
Whether or not gloves are to be used, the hands and forearms should be washed thoroughly with soap and water before and after caring for a patient, avoiding damage to the skin and particularly to any areas that are healing up. Take care when using scrubbing brushes because these may damage the skin if they are used too harshly
Any blood and body fluids should be carefully washed off with soap and water from the skin (or other areas such as the eyes) as soon as possible. Take care not to damage the area when doing this.
If gloves are not available, minimise skin contact with body fluids, and wash hands after contact. If clothing or sheets are soiled with body fluids, try to handle them without touching the soiled areas. Or, use a piece of paper, plastic or cloth, or even a big leaf to pick up the item using the paper as a barrier. Small plastic bags can be used instead of gloves, tied around the wrist at the top.
Wash soiled items separately from other laundry, wearing gloves while doing so or trying not to touch stained parts. Rinse off any blood or diarrhoea with water. Wash in warm soapy water, and dry as normal, in sunlight if possible. Bleach solution or boiling water can be used, but are not necessary. Normal washing and drying kill the virus.
Needles, syringes and blades should always be considered as possible sources of infection, and handled with great care to avoid accidents. They should either be disposed of safely, or cleaned and sterilised before reuse.
Latex gloves can be safely used again, if they can be thoroughly washed and sterilised or disinfected after use with each patient. Better quality latex gloves (the more expensive they are, in general), will withstand re-use much better than poor quality gloves. If possible, gloves should be worn while cleaning the used ones, to avoid contaminating the hands.
After use the gloves should be inspected. Damaged ones should be disposed of safely. Intact gloves should be washed clean of any blood or body fluids using water (but not soap). Soap can make the latex sticky.
Then sterilise or disinfect the gloves by:
immersing them in boiling water for 20 minutes; OR
soaking them overnight in 1 per cent sodium hypochlorite, OR
Choice of method will vary with the make of glove used. Each method should be tried out on a different batch of used gloves, to find out which is most convenient, and causes no deterioration (stickiness or tiny breaks). Good quality latex gloves should withstand boiling or bleach immersion many times, but autoclaving weakens them after a few times'.
After sterilisation the gloves must be re-examined for damage by either gently blowing them full of air, twisting the cuff closed and holding them under clean water or by filling them with clean water, twisting the cuff closed and squeezing them to see if they leak. Any damaged gloves must be discarded.
The gloves should be dried, out of direct sunlight, and their insides dusted with talcum powder (if available) before re-use.
Mike Bailey, Technical Adviser on AIDS, UNDP.
Note: WHO is currently researching into the pros and cons of latex re-use (gloves and condoms.)
News and resources / Readers' survey
'Good but could do even better!''
Thanks to everyone who returned the questionnaire sent with issue 15 of AIDS Action. Your comments are helping us to plan the future look and content of the newsletter, and to make sure that it provides you with the information you need.
Readers use AIDS Action in lots of different ways. Copies are shared with up to 30 other people, including family members, friends and colleagues at work.
The newsletter is also a source for teaching and training activities with, for example, nurses, school children, prison inmates, students, traditional birth attendants, voluntary health workers and other community based workers. And, altogether, AIDS Action has been translated into 94 languages!
In answer to the question: 'Do you think the content and look of AIDS Action could be improved?', three-quarters of you replied, 'Yes.' We're aiming to do just that by developing a new and more exciting design which will be launched in 1993.
In response to your requests, there will also be more information on diagnosis and clinical management of AIDS related illnesses in children and adults, on counselling, and more on different approaches to health education. But, despite these shortcomings, nearly 90 per cent gave AIDS Action a generous grade of seven or more out of ten.
Please continue to write to us with your comments, suggestions and questions. We're also very interested in hearing about your work and any problems you are facing - so that we can share your experiences with other readers.
Resources for trainers
Working with Uncertainty: a handbook for those involved in training on HIV and AIDS. Hilary Dixon and Peter Gordon, 2nd edition, 1991. Available in English for £12.99 (plus £2.00 for postage) from the Family Planning Association, 27-35 Mortimer St, London W1N 7RJ, UK.
Let's teach about AIDS. Sue Laver and AHRTAG, 1991. A series of six booklets with practical exercises for group work. Available from AHRTAG.
Training of trainers in AIDS education. Save the Children, 1991. A compilation of learning exercises and information, this manual covers a broad range of topics and is available in English, French or Spanish for $12 from Save the Children, 54 Wilton Road, Westport, CT 06880, USA.
What is AIDS? A manual for health workers. World Council of Churches/Christian Medical Commission, 1989. Available in English, French, Spanish, Portuguese and Kiswahili from WCC/CMC, 150 route de Ferney, 1211 Geneva 2, Switzerland.
Action for youth: AIDS training manual. Federation of Red Cross and Red Crescent Societies, 1990. Available for Sw.fr.20 in English, Spanish, French and Arabic from the Federation, PO Box 372, CH-1211 Geneva 19, Switzerland.
Practical tips for running AIDS education and training sessions
Steps to success in teaching and training
In this special insert, AIDS Action provides some practical tips for running AIDS education and training sessions.
AIDS education and training activities share an important goal. Both aim to increase knowledge and confidence, and to encourage change in attitudes and behaviour, whether in people's personal or working lives.
Many teaching and training activities focus on simply giving information to people through posters or lectures (see diagram). While it is true that people need to know the facts about HIV/AIDS, information alone does not usually change people's attitudes or behaviours.
Too often education and training activities consist of 'talking at' people, telling them what to do and what not to do, or what they already know.
Traditional teaching techniques often do not take into account people's own experiences and their understanding of disease, which influence their attitudes to life, death and risk taking.
These techniques do not give people the opportunity to find ways to solve problems at work, in their communities or personal lives, or to assess change in attitudes or behaviour.
Educators and trainers often say that they find it easier to do most of the talking because they feel they do not have the skills and confidence to try other methods.
Education and training sessions should start with what people already know and think about AIDS, and should address the issues they are concerned about. This is best achieved using methods that encourage people to communicate with each other. Communication is a two way process and means sharing information, ideas, feelings and knowledge. It means that people themselves do the talking, as well as listening to others. The methods described in this insert help to promote effective communication and are part of what is called the 'participatory learning' approach.
If you are new to AIDS education or training, or even if you have been teaching for a long time, it is a good idea to take time to think about your:
own feelings about HIV infection and AIDS;
fears and ideas about illness and death;
attitudes to sex;
past experiences - the way that you were taught, how you teach now, and whether you need to make any changes in the way that you teach.
In your role as a trainer or facilitator, avoid being judgemental and forcing your opinions on others - listen, and only give advice when asked. Choose your words carefully. Think about:
being direct and clear, while not offending people;
using words that are locally acceptable to describe sexual practices and male and female genitals;
your ability to talk freely about sex;
using words which do not offend people who have HIV/AIDS, or their families;
using expressions that do not stigmatise or blame people; for example, say person with HIV or AIDS, not victim; and sex worker, not prostitute.
Approaches to education and training
Information giving approach
Information sharing approach
'Top-down', talking at people
Professional knows best
Depends on lectures
Uses many methods
Teacher makes decisions
Promotes decision making
Practical tips for running AIDS education and training sessions
Steps to participatory learning
The five steps described in this insert are all part of successful communication. They can be used to help with planning, organising and evaluating training and education sessions. The exercises provide examples of what you can do for each step, and they can also be used for the other steps too.
1: Assess what people know already
It is easy to waste time telling people what they know already and talking about things in a way that is not relevant to them. It is very important to find out:
about people's concerns, fear and anxieties;
what they know about HIV and AIDS and what misunderstandings exist;
what they think can and cannot be changed through education;
the factors that influence people's behaviour.
One way to find out what people think and know about AIDS is to carry out a 'listening survey',
What is a listening survey?
To carry out a listening survey, the trainer or educator needs to spend time in public places, such as buses or market places, listening to what people are saying. Sometimes the topic of AIDS is not raised at all, because people are thinking about other issues such a drought or the rise in the cost of living. Then it may be necessary to prompt discussion by saying something about AIDS which causes people to react and start talking.
'... be there, be aware, but try to remain in the background'
A listening survey is different to a formal kind of survey where certain questions are asked and the responses are immediately recorded by a researcher. In a listening survey, the listener must listen, remember what is said, and write it down afterwards.
Another way to find out what people think or know about AIDS is by doing the beliefs activity described below.
Exercise: Beliefs activity
Take a large piece of paper, or prepare a clean surface on a chalkboard.
Ask people to name ways in which they think the virus is and is not transmitted. Write down the suggestions.
Then ask people to place a tick or a cross in columns next to the suggestions marked 'true' or 'false' depending on what they believe.
Use this information as the basis for a discussion on AIDS or to clear up misunderstandings, and to provide information to fill the gaps in people's understanding.
You could use this exercise in other ways, such as asking people to name signs and symptoms of HIV infection and AIDS. This could help to resolve misunderstandings about the differences between HIV infection and AIDS.
When you have found out what people know or do not
know about AIDS, and what misinformation exists, you
can begin to fill the gaps and teach the facts.
Tips for teaching the facts
Although people need to know the facts, this does not mean that the trainer or educator should do all the talking! It is better to create an atmosphere which enables people to take part as much as possible. Here are some important hints.
Plan the session carefully:
get your information together and be sure of your facts;
make sure that the group is not too large and encourage people to form a circle with you as part of it;
try to break up the session with exercises;
leave time for a summary and questions.
And, during the session:
use the KISS rule: Keep It Short and Simple, avoiding complicated language;
talk honestly about behaviour change options - if people are reluctant to talk about sex, start off with other forms of behaviour change they may feel more comfortable with, such as drinking or smoking less;
avoid making people more fearful, and emphasise the benefits of change;
repeat the information without boring people by asking them to summarise what you have said;
use visual aids, and make sure they can be seen;
break the group into smaller groups to discuss issues, and ask members to summarise their discussions in the main group.
Practical tips for running AIDS education and training sessions
3: Check people's understanding
It is important to check that what you have said has been understood. But tests are not necessary! Different participatory activities can be used to check people's understanding.
For example, try the beliefs activity described in Step 1. Another is called 'check the rumours'.
Exercise: Check the rumours
There are many rumours about AIDS. This exercise allows people to talk about these issues, and explore their own fears and prejudices. It also helps the trainer to find out if misunderstandings still exist after a 'teach the facts' session.
Before the exercise, write down statements on cards that reflect what you know to be misunderstandings or local rumours about AIDS. Examples include: AIDS is a problem caused by foreigners; HIV infection means a person has AIDS; AIDS is a punishment from God and only people who are guilty need to worry about getting it.
Each person in the group will need at least one card.
Pass the cards around to each group member, and ask everyone to discuss the statements in pairs.
Ask each person to read out the statement, and comment on whether it is true or false.
Invite other people's opinions and discuss the conclusions reached.
You can also ask people to make their own statements and use these as a basis for discussion.
Exercises like group discussions also help to reveal misunderstandings.
Exercise: Small group discussion
In this exercise, six to ten people discuss issues around a specific subject. Allow half an hour to an hour: any longer and people will get tired! Your role is outlined below.
Stress that everyone's opinion is valuable, and make clear that the only rules are that one person speaks at a time, that people stick to the topic, and that no one is obliged to talk;
Start the discussion with a few questions like the ones below. The questions will depend on what people already know, and the purpose of the workshop.
Does AIDS exist? Is it a problem in your community? How does a person become infected? How can we prevent AIDS? Are people changing their behaviour? What stops people changing their behaviour? What can be done about the problem?
Listen to, and note down what people say. Don't become involved in the discussion, except to guide it by reminding people of the questions, for example. Ensure that everyone has a chance to speak. Encourage people who are quiet, but avoid putting pressure on them.
At the end of the discussion:
ask each person for their final comments;
summarise what people have said, without giving your own opinion, unless you are asked for it;
talk about any prejudices or misunderstandings, without saying who said what;
ask people what their ideas are for developing any suggestions that came out of the discussion.
4: Problem solving and decision making
Teaching the facts about AIDS provides only the background for attitude and behaviour change. Training and education should go beyond giving information; they should encourage people to talk about problems and work out solutions. Activities can include role playing, telling an open ended story or using visual aids such as picture codes.
Here is an activity that helps people to think about and actively participate in solving a problem.
Exercise: Tell an open-ended story
The facilitator or a member of the group tells a short story which describes a problem, based on a real life situation. It includes people's emotions, beliefs and attitudes. The story stops at a point of decision, and then people discuss possible solutions to the problem.
Here is an example of an open-ended story about a woman called Mary which could be adapted to your own situation:
We live in town, and my husband runs a small business selling vegetables. He has many friends and I suspect that he likes to spend time with girlfriends too. As the bread winner of the family I suppose that he feels free to do what he likes. I think that he has an STD too, although I cannot be sure and of course I cannot ask. He is sometimes violent if I ask too many questions. There are many things on my mind this year: shortages, the drought, rising prices and the fear of getting an STD, this problem of AIDS...and now I'm pregnant again.
AIDS action Issue 19 11 Page 12
Practical tips for running AIDS education and training sessions
Now ask these questions:
What is happening at home?
How does Mary feel?
What advice can we offer Mary?
What do you think her husband should do?
Encourage the group to discuss the problem and suggest practical solutions; and to tell stories based on their own experience.
Many training and education programmes stop short of
evaluating and assessing change. Sometimes evaluation
is left until the project is nearly finished, or is
avoided because change is felt to be too difficult to
measure. But evaluation is a very important part of any
project, and should start at the planning stages.
The techniques and exercises described in this insert are a useful way to involve participants in the process of evaluation. They help to:
find out what problems need to be addressed;
see what people want;
assess changes in attitudes;
plan ahead for other activities.
Exercise: Structured discussion
You will need about two hours for this activity.
Divide the main group into small groups of six to eight people. Give each group a large piece of paper on which to record information.
Before the session, and depending on the objectives of the evaluation, prepare a few questions for each group to answer. If you are evaluating a community education project, questions might include: What misunderstandings about AIDS still exist in the community? What are the main problems that have been experienced during the project? What changes in behaviour have been observed in the community since the project started? How should the project develop?
Each group selects a recorder to list the responses suggested by the participants.
The recorder will then ask the group to order the responses so that the most important are first on the list, and the least important are last. Make sure that everyone agrees the order.
Ask everyone to go back into the main group, and display all the response sheets.
Discuss the responses again in the large group, reach agreement about the order of importance and make a final list.
Evaluation also helps the trainer or
educator to find out:
So always make time at the end for people to give feedback on the session. Here are some ideas for finding out what people thought.
Go round the group asking each person to say one thing they have found useful or one thing that they would like to know more about. They could also say one thing they have changed their mind about, or something they didn't like about the session.
Spend time discussing people's future plans. If they themselves are trainers or educators, encourage them to spend time in small groups working out strategies for changing their approach.
Spend time developing any ideas or plans that arose out of earlier group discussions.
Ask people if they would like a follow-up session, and what they would like to learn about or do.
Written by Sue Laver, Lecturer, Department of Community Medicine, University of Zimbabwe.
Illustrations and design copyright Action Magazine, Harare, Zimbabwe.
All these activities, and more, are described in detail in booklets 1 to 6 in the 'Let's teach about AIDS' series. These can be obtained by writing to Healthlink Worldwide, or to Sue Laver, Department of Community Medicine, Box A 178, Avondale, Harare, Zimbabwe.
Editorial advisory group: Calle Almedal (Norway), Nina Castillo (Philippines), Professor E M Essien (Nigeria), Dr Sam Kalibala (Uganda), Ashok Row Kavi (India), Dr Ute Küpper (Germany), Professor Keith McAdam (UK), Dr Tuti Parwati Merati (Indonesia), Dr Claudia Garcia Moreno (UK), Dr Chandra Mouli (Zambia), Dr Anthony Pinching (UK), Dr Peter Poore (UK), Barbara Wallace (UK), Dr Michael Wolff (Tanzania).
With support from HIVOS (Netherlands), ICCO, Memisa Medicus Mundi, Misereor, Norwegian Red Cross, Oak Foundation, ODA, Oxfam, Save the Children Fund, SIDA and WHO/GPA.
AIDS Action is produced in five language editions. Publishing partners: ABIA (Brazil), Colectivo Sol (Mexico), ENDA (Senegal), Univ E Mondlane (Mozambique). English edition produced and distributed by Healthlink Worldwide.
Printed in England by Bourne Offset Ltd.
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