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The purpose of this study was to investigate the effectiveness of an ongoing AIDS education intervention program (EMIMA) using peers in a sport context. A secondary purpose was to determine whether a mastery-based motivational strategy would enhance the effectiveness of the peer coaches. A quasi field experimental study was employed in which at-risk children in Dar es Salaam in Tanzania (N=764) were recruited (average age=13.6 years) and were randomly grouped into two treatment groups and two control groups. The treatment groups were peer coaches conducting the AIDS education to the children within sport, one with mastery coaching strategies and one without. The two control groups were in-school children, who received traditional AIDS education, and out-of-school children, who received no education at all. The intervention lasted for 8 weeks. The results indicated that the intervention using peers in sport was more effective in transmitting HIV prevention knowledge, cognitions and perceived behaviors than the control groups. The mastery-based motivational strategies were effective in influencing some of the variables. Contrary to expectation, the school-based HIV education was no more effective than the informal education obtained by the out-of-school children. The use of peer coaches within the EMIMA program was reliably the most effective means for HIV/AIDS education for these at-risk children.
In 2005, the number of people living with human immunodeficiency virus (HIV) worldwide was estimated to be 38.6 million with 28.5 million living in Sub-Saharan Africa, and there were 3.2 million new infections in 2005 (UNAIDS, 2006). Adolescents in Sub-Saharan Africa increasingly face the risk of contracting HIV infections, with women being far more likely than men (Glynn et al., 2001; Stover, 2004; UNAIDS, 2004). Tanzania has a national HIV prevalence estimate of 9% among youths aged 15–25 years who comprise 36% of the population, but account for approximately 60% of all the new HIV infections each year [National AIDS Control Programme (NACP) et al., 2004]. Unfortunately, as people do not get tested on a regular basis, many young Tanzanians are unaware that they are HIV-infected (Sangiwa et al., 2000). Among young people in Tanzania, the predominant mode of transmission is unprotected heterosexual intercourse (UNAIDS, 2005). Studies show that young people are sexually active at a young age and these early sexual experiences have been associated with the inadequate use of condoms and having multiple sexual partners (Klepp et al., 1997; UNAIDS & WHO, 2000; NACP et al., 2004). The consequences are quite profound. Not only is there a high rate of HIV infections among adolescents, but unwanted teenage pregnancies are also high (UNAIDS, 2005).
There is neither a vaccine nor a cure for AIDS; therefore, efforts to reduce the incidence of HIV/AIDS have been focused on at-risk behaviors. As a response to the growing infections among youths, following recommendations from the World Bank, the Tanzania government developed HIV/AIDS educational packages for schools and the school-based HIV/AIDS education program has been implemented since the early 1990s (World Bank, 1992; Ministry of Health, 1995; Mgalla et al., 1998). The focus on knowledge about HIV/AIDS is given priority on the assumption that it is ignorance that leads to risky sexual behaviors and the spread of AIDS, and that increased knowledge will elicit the expected preventive actions. In other words, individuals will reduce the risk of infection by personal application of the information (Choi & Coates, 1994; Lindegger & Wood, 1995; Bujra & Baylies, 2000). Formal settings such as churches, hospitals, schools, homes and political arenas (rallies) are being used to deliver the educational messages for prevention. Typically, the information is given by adults such as nurses, doctors, teachers and parents (NACP et al., 2004). Many campaigns are conducted through TV and the printed media outlets, including informational leaflets.
Although it is feasible to train local teachers and health workers to provide HIV/AIDS education to Tanzanian primary school children (Klepp et al., 1997; Mgalla et al., 1998), many adults in Sub-Saharan Africa believe AIDS education in schools is inappropriate and it is often not implemented (Ijsselmuiden et al., 1993). One study conducted among primary school pupils showed that schools were believed to be the least-rated source for AIDS information and school teachers were rated as significant others who pupils had talked to least about AIDS (Ndeki et al., 1994). Consistent with this, the National policy on AIDS refrained from emphasizing condom use for young people in primary school for moral reasons (MoH, 1995). In Tanzania, conventional adult institutions such as religious bodies, schools and families generally do not acknowledge that adolescents are sexually active and thus HIV/AIDS prevention strategies become controversial issues (e.g., recommending the use of condoms). For example, as late as 1998, it was admitted that a national AIDS curriculum for all primary schools in Tanzania had yet to be implemented (NACP, 1998).
Therefore, despite being in place for over a decade, the National policy on AIDS in Tanzania has not been successful in decreasing the rate of HIV infection in youths (Sangiwa et al., 2000; NACP et al., 2004; UNAIDS, 2005, 2006). Although awareness of the modes of HIV transmission is high in that over 90% of individuals aged 15–49 have heard of HIV/AIDS and know how HIV is transmitted (Tanzania Commission for AIDS [TACAIDS], 2005), HIV knowledge is still low (Schueller et al., 2003; NACP et al., 2004). Thus, HIV education and prevention strategies conducted through conventional adult-directed institutions such as schools, families and religious bodies have proven to be ineffective in reducing the rate of infection.
There is a further complicating factor. In Tanzania, the proportion of primary school-aged children attending school has steadily declined since 1991 (Family Health International [FHI], 2004; NACP et al., 2004). The reasons are varied, one is financial in that all pupils must pay fees, but a recent report indicated an increase in AIDS orphans, and that 50% of children (aged 10–14) who have lost both parents, and 30% who have lost one parent are not attending schools in Tanzania (UNICEF, 2004). As families break down, and many children become orphans (one in every seventh child in Tanzania is an orphan), and drop out of school, the efficacy of the AIDS education programe through conventional adult institutions decreases dramatically. Thus, new approaches are needed that are effective for young people (Schueller et al., 2003; NACP et al., 2004) and there is a need to target youths through avenues other than traditional institutions.
In many countries, the use of mass media might be one way to target at-risk youths. But in Tanzania this is not viable. Tanzanian people who are exposed to various media outlets are a small percentage of the population (newspapers: 11% women, 16% men: radio; 34% women, 44% men; TV: 14% women, 20% men). Exposure to the media has decreased among young people aged 15–24 years with the lowest levels of exposure among women (NACP et al., 2004). Coupled with the fact that children have an increased likelihood to be orphaned, and thus do not attend school, more and more children are at risk. Thus, there is an urgent need to re-think educational strategies aimed for at-risk youths (e.g., Klepp et al., 1997; Schueller et al., 2003; FHI, 2004; NACP et al., 2004; UNICEF, 2004). Recommendations for HIV/AIDS educational programs for Tanzania suggest that to be effective, any new approach must involve youths in the delivery of services, development of the learning materials and evaluation. In addition, programs should reach out to youths where they spend most of their time and use activities that youths are familiar with and value. Programs should recognize the role of peers and include employing peers as role models to serve as HIV/AIDS educators (e.g., Lugoe, 1996; Klepp et al., 1997; Downer et al., 2003; Schueller et al., 2003; NACP et al., 2004; UNICEF, 2004). In areas where young people have been so involved, the incidence of HIV cases has declined (UNICEF, 2004).
Therefore, the present study utilized the context of sport to conduct an experimental AIDS education project with at-risk youths. Sport is rapidly gaining recognition worldwide as an effective means of promoting education and health, which led the United Nations General Assembly to adopt resolution 58/5 and proclaimed 2005 the International Year of Sport and Physical Education (UNGAOR, 2003). In particular, the United Nations has named sport as an effective platform to increase HIV/AIDS knowledge and awareness (United Nations, 2003). Sport is meaningful for children, they experience the benefit of membership and affiliation and in general children enjoy playing sport and being on a sport team (Roberts, 1984; Siedentop, 1996).
Based on these contentions, the first author initiated an experimental community-based sport program called EMIMA1 designed for disadvantaged youth in Dar es Salaam, Tanzania, in 2001. The program utilizes peers as coaches for soccer skills and as a source of information, skills and attitudes related to HIV/AIDS education. Thus, the program used a popular youth activity to attract at-risk youths and used peer coaches as the instructors to deliver the educational information, knowledge and skills through the sport program (see http://www.emima.org). In 2004, we decided to conduct an evaluation of the effectiveness of the EMIMA program. Thus we initiated an experimental field study where we investigated the impact of the use of peer coaches to deliver HIV/AIDS education and the use of safe sex behaviors to at-risk youths.
The major purpose of this research was to investigate the relative effectiveness of the peer coach intervention through sport within the EMIMA program. We predicted that relative to a control group of at-risk youths who did not experience the EMIMA program, and who were not within the school system in Dar es Salaam, the participants in the EMIMA group would increase their HIV-related knowledge, risk perceptions and behavioral intentions while reducing HIV-risk-related behavioral practices. We added a second control group. In order to determine whether the EMIMA program was more effective than the normal practice of giving HIV/AIDS education in the school system, we recruited a group of youths who were educated about HIV/AIDS and safe sex practices within the normal school system. These youths were typical of the youths in Tanzania who are educated about HIV/AIDS through the normal educational practice in schools. We predicted that the participants in the EMIMA group would have greater HIV-related knowledge, risk perceptions, and behavioral intentions than the participants in the regular school environment.
We decided to add a second intervention group. In order to make the intervention more effective, we utilized some motivational enhancement strategies. As suggested by previous research (e.g., Carey & Lewis, 1999), motivational enhancement approaches improve behavioral skill-based interventions and have been successful in behavior change and risk reduction in several contexts (Miller, 1985, 1989; Miller & Rollnick, 1991; Miller et al., 2005; Lemyre et al., 2006). Therefore, we gave additional training in motivational strategies to some of the peer coaches to facilitate the HIV/AIDS intervention. Thus, a second purpose of the investigation was to determine whether the EMIMA program could be enhanced were we to introduce motivation strategies to the intervention.
The motivation strategies we decided to implement emanated from the social cognitive approach that has dominated research on motivation in sport over the past 30 years. The specific theory that informed our research in sport was achievement goal theory (e.g., Roberts, 2001; Roberts et al., 2007). In particular, we used the research that has investigated the impact of the motivational climate on cognition, affect and behavior (e.g., Ames, 1992). Thus, we had an additional EMIMA group of peer coaches who underwent additional training on how to implement mastery-oriented strategies in the peer coaching environment. With youth in HIV/AIDS crisis who often lack motivation to do many youth activities, and are pressed with many life events and stressors, introduction of motivational procedures in an AIDS intervention program in EMIMA may augment the regular skill-based interventions through sport (see Carey & Lewis, 1999; Beatty et al., 2004) and enhance risk reduction among youths (see Miller & Rollnick, 1991).
Therefore, the current study had two purposes: first, we wished to determine the efficacy of the EMIMA program with peer coach intervention through sport to deliver HIV/AIDS education and knowledge about the use of safe sex behaviors to at-risk youths. Second, we wished to determine whether a mastery-based motivational strategy would enhance the effectiveness of the peer coaches to deliver HIV/AIDS education and knowledge.
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In the present study, we report on the first experimental HIV/AIDS prevention program using peers in a sport context that targeted children in a developing country in Sub-Saharan Africa who are at-risk for infection. We investigated the efficacy of the EMIMA Kicking AIDS out program that has been in existence since 2001 in Dar es Salaam in Tanzania. The study focused on knowledge about HIV/AIDS, attitudes and implementation of safe sex knowledge and behaviors.
The important findings of the present study show that the use of peer coaches within the soccer coaching environment of the EMIMA program was effective in transmitting knowledge about HIV/AIDS and safe sex practices. Indeed, the EMIMA intervention soccer program was reliably more effective than the traditional HIV/AIDS education through the normal school system for all knowledge, attitudinal and behavioral variables investigated in this study. Relative to the in-school children and the out-of-school children in the second control group, children in the EMIMA intervention groups reported significantly greater beliefs and perceived control in condom use, abstinence, and in using exclusive sexual relationships to prevent HIV infection. In addition, children in the EMIMA intervention sport programs were significantly more likely than children in school who received AIDS education through the traditional approach to report reliably higher levels of HIV and condom use knowledge, more positive normative beliefs and perceived control in prevention of HIV infection. Clearly, the results demonstrate that HIV/AIDS education using peer coaches in sport can effectively reduce the risk of at-risk children from infection with HIV.
The current findings suggest that EMIMA-type interventions using peers in sport may serve as an approach for AIDS risk reduction interventions in Africa for at-risk youths who are similar to the youths in the present study: youths who are currently sexually inactive, many of them orphans, many not in school, in areas with limited resources, cultural taboos and a high prevalence of AIDS and HIV infection. Given the widely recognized potential risk of sexually transmitted HIV among disadvantaged youth (NACP et al., 2004; UNICEF, 2004), the findings of the present study suggest an alternative avenue to transmit the important messages behind HIV/AIDS education programs. The EMIMA program takes advantage of the fact that playing soccer is the most popular sport for youths in general in Africa, and disadvantaged youths in particular. By incorporating the HIV/AIDS messages into the practice sessions, we have demonstrated that this is an effective way of transmitting information, positive attitudes and behavioral intentions to at-risk youths.
The EMIMA program focuses on changing the social, cultural and peer norms associated with sexual activity and facilitates cognitive and behavioral skill acquisition through the regular practice of life skills through games in a fun, enjoyable and non-scary environment. At-risk youths with limited opportunities within the African cultural context need these programs for sustained behavior change for HIV prevention. Participation in sporting activities that also provide competencies in HIV prevention and enforce peer norms to facilitate sustained behavioural change, and provide motivation to continue participation is a promising avenue for HIV/AIDS prevention (see Rotheram-Borus et al., 1991; Jemmott et al., 1992; Downer et al., 2003).
Similar to the rest of Sub-Saharan Africa, to a greater or lesser extent, the number of orphans in Tanzania is rapidly increasing (NACP et al., 2004) and the number of children who cannot afford to go to school is increasing (Ministry of Education and culture & Ministry of Science Technology and Higher Education, 1993; UNICEF, 2004). The need for an effective approach that targets children outside the school system is urgently required. Using sport, or at least soccer, as part of that approach may be effective on two counts. First, as demonstrated by this study, using peers within the sport context to disseminate information about appropriate prevention behaviors, and involving children in learning the skills in a non-scary environment by anchoring education within sport may help to reduce the normative and cultural barriers about sexual behavior within these at-risk groups. Second, by using sport in a systematic manner within this at-risk population, some of the concomitant learning that may come with participation in sport may ensue. We know that being an orphan in Africa, in particular an AIDS orphan, has a major negative psychological effect on the child (Sengendo & Nambi, 1997). We also know that participating in team sports has a positive psychological benefit for most of the participants (Siedentop, 1996). Therefore, participation in EMIMA-type intervention programs may have psychosocial benefits that are important for at-risk children living in areas highly affected by AIDS. At-risk children are able to belong to a group, make friends, enjoy being on a team, have fun and also get an opportunity to practice soccer skills and benefit from the HIV/AIDS messages within the practice environment The sport context in itself may have been a major reason for the facilitation of individual change. The context and the training of the peer coaches facilitated the learning of life skills through providing an accepting context to discuss the risk behaviors, and importantly, had peers reinforcing each participant's efforts at risk reduction.
We were not surprised with the major finding that peer coaching in sport was the most effective strategy of HIV/AIDS education. However, we were surprised with some of the other findings. Based on the current approach of HIV education to youths being school based in Tanzania (MoH, 1995; Klepp et al., 1997; NACP et al., 2004), we expected the youths in schools to have higher knowledge, more positive attitudes and beliefs, and have lower at-risk behaviors than the youths we designated as being out-of-school children. This was not the case! We found that school-based HIV/AIDS education was not more effective than the informal education obtained by the out-of-school children. This was not expected given the fact that children in schools are exposed to systematic information about HIV/AIDS through the school curriculum. We can only speculate on this finding. It may well be that the HIV preventive education in schools is implemented by adults in teacher-pupil relationships typical for academic subjects. Thus, the HIV preventive education in schools tends to be didactic by nature and taught in science lessons without actively engaging the pupils. Also, the strong message given in school is sexual abstinence (just say no!). Even though the school-based children did show greater knowledge than the out-of-school children, the knowledge about safe sex practices, especially condom use, was greater for the out-of-school children. The out-of-school children also had a more positive attitude than the in-school group toward condom use. However, when asked, neither the out-of-school children nor the school children were likely to use a condom in the next/first sexual intercourse.
The AIDS policy in Tanzania from the early 1990s refrained from emphasizing the use of condoms in the school curriculum for religious and moral reasons (MoH, 1995). Although the policy has recently been reviewed, these findings are a clear indication of the consequences of such a policy. Some studies have argued that HIV/AIDS education in schools is a controversial issue as many adults in Sub-Saharan Africa do not acknowledge that youths engage in sexual activity (e.g., Ijsselmuiden et al., 1993). The findings that indicate that the differences between the out-of-school children and the in-school children are more toward the fact that the in-school children are more at risk for contracting HIV/AIDS is a clear call for more effective approaches for educating youths about safe sex practices. As this study illustrates, regardless of other programs that may be implemented, one effective approach that should be further investigated is an EMIMA- type program.
Another important component of the present study is that it integrated HIV/AIDS skills training with a motivational enhancement strategy to determine whether we could enhance the effectiveness of the HIV/AIDS intervention in sport (Carey et al., 1997a, b). Supplementing HIV/AIDS life skills with a motivational enhancement approach within the sport context has not occurred in prior applications. Thus, in the present study, we compared the group that had mastery enhancement strategies as part of the intervention with the normal EMIMA approach as practiced in the project. We wished to determine whether a mastery motivational strategy would enhance the effectiveness of the peer coaches to deliver HIV/AIDS education. The findings indicated that a mastery-based motivational strategy is effective in AIDS education, most of the time. We found no differences in knowledge, but the motivational enhancement groups were more effective in communicating and influencing attitudes and norms about condom use and abstinence, the intention to use condoms and increased perceived behavioral control in engaging in safe sex practices. These attitudinal and behavioral intention variables are proximal determinants of youth sexual behaviors and may mediate other determinants such as social norms. However, the important point is that the motivational enhancement approach is effective in changing the intentions to use safe sex practices (DiClemente et al., 1990; Norris & Ford, 1991; Braithwaite & Thomas, 2001).
The mastery motivation strategies were introduced to emphasize task involvement (see Ames, 1992). We trained the peer coaches to focus on encouraging effort, to enhance self-efficacy and autonomy. We deliberately refrained from emphasizing normative competence and superiority (e.g., see Treasure & Roberts, 2001). The mastery strategies were given in a 2-week extra-educational module to the peer coaches who were randomly selected into the mastery groups. This rather basic motivational strategy was sufficient to change the behavioral intentions of the participants. Even though this will have to be the focus of future research, we may argue that the motivational strategy enhanced the perception of the participants that they could carry out the intentions to use safe sex practices. In other words, we increased the efficacy of the participants to utilize the safe sex strategies we investigated in this study.
Even though we managed to make some changes in a positive direction, the findings of this study indicate that HIV knowledge among young people in Tanzania is generally low. The majority of youth in Tanzania have a limited understanding of how the HIV virus is transmitted and how it can be prevented, as well as knowledge of the virus itself. This is frightening as the participants in this study all reported relatively low HIV knowledge and experience about condom use. Unfortunately, the children who were educated in schools have the most unfavorable attitudes toward condom use. Clearly, there is a need for community programs such as EMIMA to target both the in-school and out-of-school youths as they are both equally at risk for HIV infection.
An important limitation of conducting research with disadvantaged participants who are traumatized and stigmatized by the AIDS epidemic is the question of accessibility. The out-of-school children were the most difficult individuals to recruit. They were recruited from orphan institutions in the same communities, as well as being recruited from garbage collection areas. Orphans and street children do not stay in one area or institution for a long time. Soccer played an important role in motivating the street children to take part in the study that involved the EMIMA group. Furthermore, conducting field-based research on high-risk sexual behaviors of youths in an environment where many cultural taboos about sex poses a big challenge that must be recognized. We approached the vulnerable children through sport activities they are familiar with, and implemented a culturally sensitive peer-friendly recruitment approach. Using peer coaches provided fun and enjoyment throughout the sport team activities, and they conducted all intervention sessions in their local community facilities. The use of sport activities to attract adolescents was a useful intervention strategy to encourage involvement of the at-risk children in this study. This approach facilitated the smooth and easy atmosphere for the participants to disclose honestly sensitive information regarding their sex life.
The present study investigated behavior outcome measures including abstinence and condom use that are consistent with recommendations for effective interventions (Jemmott & Jemmott, 2000). Given that both in- and out-of-school children are equally at risk, effective HIV prevention interventions for young people should target the total population, not just the out-of-school children. Sexual activity among adolescents is very common in many Sub-Saharan African countries (Meekers, 1994). The present study indicated that 95%, 89% and 86.5% of youths from out-of-school, in-school and in EMIMA, respectively, were not sexually active during the study. The intervention aimed at sexually inexperienced youths is effective because they are good candidates for HIV prevention and previous research has shown that it is more difficult to achieve behavior change in teens who have already initiated sex (Kirby et al., 1991).
Furthermore, because there is evidence of the role attitudes and norms play in the adolescent's decision to engage in safe sex practices (Gallois & McCamish, 1989; Leviton et al., 1990; Kelly et al., 1991), the intervention program of the present study specifically targeted young peoples' beliefs about condom use and created a supportive environment by using peers as the method of delivery of the information. Clearly, using peer coaches is a procedure to be further investigated.