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The Institute of Education and Health A Model of by orh20397

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									The Institute of Education and Health: A Model of Integrated
Reproductive Health Services for Adolescents in Peru1, Doug
Webb, HIV/AIDS Adviser, SC UK, 1999
       Sexual and Reproductive Health is a strategic theme for Save the Children in South
America, based on several years of experience of work on HIV/AIDS awareness and prevention
programmes with young people in Brazil, Peru and Colombia. The strategy focuses on young
people as the key agents of awareness raising and change amongst their peers and in the wider
community.

HIV/AIDS in Peru

        The exact picture of the epidemic in Peru is unclear due to the lack of consistent sentinel
HIV surveillance. UNAIDS estimates the HIV prevalence rate in those aged 15-49 to be 0.56%
at the end of 1998, which is relatively low for South America. This estimate may be based on the
0.6% prevalence rate found amongst pregnant women in a 1997 survey, and extrapolations from
the 9,155 reported AIDS cases as of August 1999.2 Overall there are an estimated 72,000 adults
and children living with HIV/AIDS, out of a national population of around 25 million. To date
80% of the reported AIDS cases in adolescents and adults have been in the capital city
Lima/Callao but the epidemic is now spreading to other major urban areas. At the same time,
there appears to be a variety of epidemic types within Peru; Lima and Chiclayo show a steady
pattern based on men who have sex with men, Iquito has a ‘rapidly growing, possibly generalising’
epidemic, while Cusco shows a small heterosexual epidemic.3 A sign of the spread of HIV within
Peru is the inland port of Iquito in Amazonia. Preliminary sentinel surveillance reports from the
national AIDS programme (PROCETSS) in 1998 indicate an HIV prevalence rate of 1.14% in
pregnant women, 5.2% in sex workers and 16% in men who have sex with men.4

        Following the first reported AIDS case in 1983, the impression is of a gradual shift from
generally homosexual transmission through to a predominance of heterosexual transmission.
The vast majority of cases are through sexual transmission, with 51% of cases being found
amongst heterosexuals. Some uncertainty exists as to the rate of this transition due to the
increasingly important role of the bisexual community in the epidemic, and the greater (stigma
related) tendency of homosexual or bisexual men to report themselves as heterosexual. The
AIDS case male/female ratio has declined consistently from 1990 onwards, from 14.5:1 in 1990
to 3.4:1 in 1998. It may be that the number of new AIDS cases is plateauing – it is uncertain to
what extent antiretroviral therapy is responsible for the continued decline in the number of new
cases. Vertical HIV transmission is reported but negligible.

   Up to 1998, 219 cases of AIDS were found in adolescents between the ages of 13 and 19
years, representing about 3.3% of cases. 40% of cases of AIDS are amongst the 20 to 29 age
bracket. Many of these people would probably have been infected during their adolescence
(CONTRASIDA, PROCETTS, 1998). Regarding the presence of others STDs, 1.3% of male
1 This case study is a combination of various documentation which is listed in the sources list. Added to this are

details and data from monitoring reports from IES and much of the analysis is based on field observations and
discussions with IES staff.
2 Information from the national AIDS programme (PROCETSS), August 1999.
3 Caceras et al. (1998) Is the AIDS epidemic expanding to inner cities in Latin American countries: a study of Peru, 12th World

AIDS Conference, Geneva 1998.
4 Calderon, R. (1999) Final Summary Project Report: Peru, Civil-Military Alliance to Combat HIV and AIDS Newsletter,

5, 1.
                                                               1
adolescents surveyed in the latest Demographic and Health Survey, reported genital ulcers and
1.6% urethral secretions. Unplanned pregnancies are also a major issue in Peru: taking into
consideration the percentage of adolescents between 15 and 19 years old that now are mothers
or are pregnant for the first time, there are about 175,000 teenage mothers as a whole in the
country (UNICEF/INEI, 1997). In 1996 nearly one third of 19 year old females were either a
mother or pregnant with their first child.5 More than 100,000 births by adolescent mothers in
Peru take place every year. In Peru 15% of maternal deaths correspond to pregnant adolescent
girls, from which 20% of the deaths are due to abortions (The situation of Childhood,
Adolescence and Women in Peru, UNICEF/INEI, 1996).6

         The high incidence of reported risk behaviours amongst young people in Peru is a great
cause of concern. According to a Lima study of adolescents and young adults (aged 19-30), only
11% of those heterosexually active used condoms consistently, and 22% reported an unplanned
pregnancy. Among self identified homosexual young men in Peru, two out of five reported having
unprotected anal intercourse in the past four months.7 In other words there are no reasons to
believe that HIV will not become a major public health issue in the future, through the emergence
of the ‘second wave’ of the epidemic. The lack of sentinel surveillance unfortunately does not allow
an accurate monitoring of the epidemic. Socio-cultural constraints impede prevention efforts;
notably lingering resistance from the Catholic Church, machista double standards regarding the
acceptance of male promiscuity and expectation of female monogamy, and a high prevalence of
bisexuality in men.

IES and integrated service development

        Save the Children has worked with the Instituto de Educacion y Salud (IES) since 1992.
The IES has been validating, since its foundation in June 1991, intervention strategies in schools
promoting health and development for male and female adolescents with an emphasis on sexual
and reproductive health, focusing on health through education and from a gender perspective.
One of its strategies is a peer education intervention, which has been developed in 16 schools in
Lima and six in Chimbote, obtaining as a result the formation of a group of young health
promoters who provide basic information and orientation to their peers on themes associated
with self care in sexual and reproductive health, referring those who need assistance to the local
health centres.

        This intervention has been complemented by an articulated strategy between pilot
schools and health centres, establishing within the school area a reference system of cases to be
derived to the nearest health centre. The identification of other support networks existing in the
community, to enclose the care circle for the development and health of adolescents, has been a
constant concern in the development of these strategies. These actions have been developed in
co-ordination with the Ministry of Health (MINSA) in accordance with the objectives and aims
of its Adolescent and Student Health Programme. IES has an agreement with the Health
Executives in Lima and the East section of Lima to carry out common actions, implement
intervention strategies, provide technical assistance and share data obtained in research studies.



5 Demographic and Health Survey, 1996.
6 Extracted from the document; Department for International Development, Innovation grant application,
SCF/IES, October 1999.
7 UNAIDS, Listen, Learn, Live!: 1999 World AIDS Campaign with children and Young People, Challenges for Latin America

and the Caribbean.
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        As well as these contacts with the Ministry of Health, IES is also part of the group of
Executive Organisations for the Ministry of Education (MOE), helping to develop training
courses on family and sexual education within the framework of the Ministry’s National
Programme for Sexual Education and the Programmes of Integrated Prevention. On the local
level an agreement has been signed with the Board of Education in Lima to develop joint actions
in the educational field. IES’s interventions complement those actions of the MOE and provide
a response to the orientation and counselling needs generated amongst students as a result of the
insertion of a National Programme on Sex Education in the school curriculum. This intervention
has been evaluated, resulting in a Guide that indicates how to implement a peer education
programme on sexual and reproductive health in state schools. It covers the training of teachers,
health workers and adolescents on counselling, education and the implementation of
communication activities to improve the health and well-being of the adolescent population.

         In 1996, a Care Service in Sexual and Reproductive Health programme, with an emphasis
on HIV/AIDS, was implemented for young people in a working class area of Lima. A care
model in sexual and reproductive health was put into practice in this project, using individuals,
groups and community strategies in order to respond to adolescent needs in this field. As a result
of this intervention, the IES has been recognised both by the public and private health sectors as
an institution with technical capacity to assess the training and educational needs of health
professionals in sexual and reproductive health and adolescent counselling, as well as the quality
of service providers. To put this into effect, IES developed a validated Training Guide, and
instruments for the monitoring and follow up of health services with an emphasis on the quality
of care.

          IES has also completed a research study: The Social Construction of Adolescent Sexuality:
Gender and Sexual Health, which shows how both male and female adolescents from marginal
urban neighbourhoods experience their sexuality, taking into account the cultural mores
prevalent in Peruvian society which make it difficult to adopt healthy attitudes and practices.
Currently, the IES research team is conducting a research project on: Relationships between sexual
and reproductive health itineraries of adolescents and young adults and the types of care in two socio-economic
sectors in Lima. This study is based on the application of quantitative and qualitative techniques
and will collect information concerning the totality of experiences and behaviours among young
people and how they confront different situations connected with sexual and reproductive
health. The study starts from the hypothesis that the sexual and reproductive health behaviour
profile is formed by the social representations of health, sickness and sexuality, as well as by the
structures of social networks, gender, socio-economic sector and age. The hypothesis is that the
school constitutes the most competent ‘socialisation space’ to respond to adolescent needs for
information, education and orientation on sexual and reproductive health and integrated
development. The school’s potential role is under-developed at the present time.

        A core theme of the work is integration. This project aims to integrate the following:

n   Health Sector - Educational Sector
n   Reproductive and Sexual Health - An integral development
n   Promotion and Prevention - Health Assistance
n   Technical capacity - Quality of assistance
n   Youth participation - Community networks
n   Sexual and Reproductive health - Gender Equity


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This project identifies the following current problems:

à   There are no concrete and political actions within the schools that allow the adolescents to
    improve their power to take decisions in a responsible and free way about their sexuality.
à   Absence of actions to promote safe behaviour, to educate in health issues, to detect and
    modify behaviour risk and ensure immediate referral/treatment of cases detected among the
    adolescent population in schools.
à   The sexual and reproductive health services are insufficient and there is a lack of confidence
    of adolescents to address their needs, because of the cultural and family barriers that limit
    their access to such services.
à   Insufficient and inadequate information on education and communication on the part of the
    sexual and reproductive health services in the community, thus perpetuating a negative image
    of the quality and characteristics of the services, which reduces the adolescents’ demand for
    them.
à   Deficiency in the type of assistance provided, as expressed by the users, incomplete
    information, little capacity to diagnose and a deficient follow-up of the users and therefore
    the absence of preventive measures in the risky cases.
à   The orientation of the services for adolescents emphasises reproductive health to the
    detriment of the psychosocial health, growth and development, i.e. a more integrated
    approach.
à   The Health School Program, as well as the Program for the Adolescent of the Ministry of
    Public Health and the Prevention Programs of the Ministry of Public Education do not have
    an efficient systematised Health Promotion System for the school population.
à   The Ministry of Public Health – in spite of its efforts - does not include a mainstream
    prevention component in its programmes.
à   Few technical professionals in health and education are fully capable to offer counselling and
    orientation on sexuality, sexual and reproductive health and an integral development of the
    adolescent, taking in account gender considerations in their intervention.
à   Finally, there is limited action among sectors to favour the adolescents’ health as an
    important component of well being and integral development of this target group.

How do we know that the project is responding to the needs of the adolescents? – How
are the needs assessment conducted and how is the information used? Are we
addressing the priority concerns of the adolescents?

·   A diagnosis is made of general problems by participants (youths and teachers) of workshops
    at the start of the project by. Peer educators chose sexual and reproductive health as the key
    area.
§   The main need identified is decision-making skills; communication skills – self esteem
    building.
§   At the mid project stage, the educators chose their own topics of discussion.
§   Focus group discussions are conducted with project workers and peer educators after the
    project phase during the evaluation exercises (internal and external) to assess project
    relevance.
§   Through continual participation throughout the project cycle.


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How do the adolescents view their situation?

        Three separate meetings were held with peer educators between the ages of 13-20. In the
discussions, various topics were addressed: general problems experienced by adolescents in the
area, the experiences of being an educator, the changes happening as a result of their activities,
and their suggestions for changes to the project in the future. Peer educators reach peers both in
school and those who have already left school, attend another school or those that have dropped
out early (aged 13-15). The educators claim to have 2-5 new contacts per month, which are
specific cases. Informal conversations occur everyday with a variety of contacts. They themselves
volunteered to be educators and were elected by peers. They give out IEC materials and conduct
games which are very popular with friends.

The main problems amongst girls were listed by the educators:

·   Unwanted pregnancy – girls fear sex because of it
·   Boyfriends pressurising girls into having sex
·   Drug abuse; crack, hash, cocaine and glue. This is linked to family problems.
·   Family problems – physical and mental abuse – often the situation is bad enough that the
    adolescents want to run away from home.

The boys:

·   Drugs – particularly cocaine. Boys often start taking it around the ages of 16-17. It is more
    common amongst out of schoolboys, and there are recognised times and places where it
    occurs (‘every Saturday after football’). Some steal to get money to buy drugs – or parents
    give pocket money that is spent on drugs. Drug use is integrally linked to gang membership.
·   Girls come to boy educators to ask advice about boyfriends (and vice versa).
·   Gangs – who encourage members to drink, smoke and take drugs.

        Common to both males and females are the issues within sexuality and the need for
information. One boy who got his girlfriend parent blamed his own parents for not giving him
enough advice and information. The educators encourage condom use which youths can get
from pharmacies. Boys generally say that they don’t use them as they ‘can’t feel anything’. The
educators on the whole feel that condom use rates have not increased significantly amongst their
friends. The adolescents fear HIV, but don’t fear STDs as they can be cured – there is little
understanding of the link between HIV and STDs.

         An important issue for the girls is unwanted pregnancy and abortion. Some girls abort
but only a minority. They go to back-street doctors and the operation costs between 200-400
soles (c. US$60-120). The price varies according to the stage of the pregnancy.

         Homosexuality and bisexuality is common according to the educators. Boys often have a
girlfriend but have sex with older men for money. Girls also sleep with older men, as well as
older women with younger boys (‘boys get more money when the women fall in love’). These
relationships are not stigmatised and are considered to be quite common. The average age of
sexual debut was put at about 14-15, but deemed to be younger in the gangs. In the gangs one of
the initiations is that a boy must have sex with a girl. Gang members also engage in commercial

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sex – it is considered an easy way to make money. The physical and verbal abuse of girlfriends is
seen to be common – girls are forced to give money to male gang members. This is most
common in adolescents not attending school. In Victoria, helping others is seen to be a sign of
weakness – to give good advice is not ‘cool’. As one educator put it – it is ‘bad to be good’.

Teachers’ perspectives on the situation of the adolescents

        Teachers are integral to the programme in that they act as guides and a support to the
educators themselves. A group discussion was held with six such teachers in one school involved
in the project in Victoria.

What are the problems of the children?

-     drugs
-     gangs
-     stealing
-     low self esteem
-     no aspirations
-     not enough values – not taught them at home
-     no honesty or loyalty – children insult each other
-     many children from problem homes
-     aggression – physical abuse of each other

What are the strengths of the children?

-     Creative
-     Artistic
-     Sporty
-     Observant
-     Quick

        The teachers believed that the problem is that these strengths are used in a negative
sense, and that there is a lot of anger amongst the children.

Goal and Objectives of the project

     The end goal of the project is to have schools become an effective place for the promotion of
adolescent sexual and reproductive health and development of life skills. The project is designed to
have a participatory approach where each of the schools will form a committee of promotion and
prevention, chaired by its director. This committee will lead a series of activities, which will also
include community participation. Two main areas will be developed:

1.   Information and Education on Sexual and Reproductive Health Issues.
2.   A School - Health Centre Link.

   The sexual and reproductive health education participation includes the implementation of education and
counselling activities in each school. A selection of trained students and teachers offer information,
advice and orientation to the adolescent population. Peer education interventions are included to
help create an environment within the schools in which young people can participate actively.

                                                    6
Information and educational materials have been designed, produced and disseminated in the
project schools. Health centres located in the same district area of the selected schools participate in
the project. The objective is to improve the quality of care on issues related to adolescent health.
For this, health staff are trained on specific issues: counselling, family planning, gender, pregnancy in
adolescents, STD/HIV/AIDS, amongst others. Specific considerations are accessibility and
procedures including confidentiality. The school-health centre link enables the promotion of the
health centres amongst the students, thus encouraging the use of these reproductive health services.
Itinerant ‘health care visits’ to the schools by health care workers forge the institutional links. Care
providers are encouraged to develop partnerships between schools and health centres, so that both
goals of high quality and cost reduction can be achieved.

   The overall purpose of the project is to reduce the incidence of unwanted pregnancies,
HIV/AIDS and other STDs and sexual abuse in the adolescent population by strengthening the
preventive strategies and skill building within the school.

The specific objectives of the project are:

à To strengthen the capacity of the state schools for the execution and development of
  educational projects which will favour sexual and reproductive health and an integrated
  development of students.

à To promote attitudes and self-care practices in sexual and reproductive health within the
  school, using the resources and skills of principals, teachers, parents and students.

à To promote a link between schools and health services through the referral of cases and the
  development of joint actions between the education and health sectors.

What behaviours are IES trying to (a) encourage (b) prevent? How can we measure
changes in these particular behaviours?

This question was raised during a group meeting with IES staff.

(a) Behaviours to encourage:

1. Ability to say yes or no in risk situations. This is the most important behaviour, but is not itself
useful as an indicator – we need proxy measures of this skill, which then introduces a degree of
subjectivity.
2. Consistent condom use. This can be assessed in self-reported knowledge, attitude and practice
(KAP) surveys, qualitatively in focus group discussions (FGDs), along with interviews with peers
and health care workers. Other indicators options regarding condom use are; use at first
intercourse, use at most recent intercourse, ever used (reported in DHS for women only) and
self selected frequency estimation (i.e. always, most of the time, about half of the time, rarely,
never) and intention to use at first/next intercourse. It needs to be ascertained where condoms
are available and whether adolescents know this.
3. Ability to seek professional help when it is needed. This relates to health (e.g. early treatment of STDs,
early ANC attendance), welfare (drug rehabilitation) and counselling professionals. All data
sources can be used here, including referral rates from educators and attendance rates at the
professional services. A problem here could be that adolescents do not utilise the geographically
closest services, especially clinics, due to worries about confidentiality.

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4. Advocate sexual rights to others. This is more of an intermediate indicator but is useful to look at
message comprehension, retention and communication patterns with others. A key question is
who the advocacy targets are; peers, partners, parents?
5. Delay first sexual act (until act is voluntary). This is an important indicator as age of first intercourse
is used by the national AIDS programme (PROCETSS) and is reported in the DHS
(respondents aged 20-24). Data sources here would be the KAP survey and FGDs. Language
used in research methods by PROCETSS should be checked to ensure comparability. The aspect
of rejection of sexual harassment should be looked at in more qualitative methods.
6. Talk with girlfriend/boyfriend about sexual issues. The issue to monitor here is the ability to say what
you want to say, and to ensure equity in ease of communication between the sexes.

Behaviours 1,2 and 3 were deemed to be the most important to the project.

(b) Behaviours to prevent

1. Coerced sex (see above)
2. Unsafe sex (see above)
3. Unwanted pregnancy. This is very difficult to measure accurately due to the lack of data, the
difficulty in validating that a teenage pregnancy is unwanted as opposed to planned or
unplanned, and the lack of information on the prevalence of abortion. There is a need for
qualitative assessment to back up more formal reports of teachers. The DHS reports on the
percentage of teenagers (age 15-19) who are mothers or are pregnant with their first child.
4. Abortions. This is a very difficult issue to address due to the illegal nature of abortions.
Education messages should emphasise unsafe nature of back street or self-induced abortions in
an effort to discourage unwanted pregnancy.
5. Informal STD treatment (self-treatment, visiting unqualified ‘doctors’). This can be addressed by
examining the intention to utilise various service providers and attendance at formal health care
settings (see below).
6. High number of sexual partners. This indicator is also used by PROCETSS, and can be analysed in
both KAP and FGDs.

The monitoring and evaluation system
IES focus on three indicator areas:

·   Performance – functional indicators – in terms of access, quality and image of services
    (related to training, management and image).
·   Service outputs – adequacy of the provision of services.
·   Service utilisation – profile of who is using the services.

IES have a sophisticated process monitoring system (Table 1), with peer educators, teachers,
health care workers and IES staff contributing to the data collection process.

Functional outputs

·   Number of guidance sessions given by individuals to friends
·   Number and type of activities designed and implemented
·   Number of IEC leaflets designed
·   Number of IEC leaflets distributed
                                                      8
·   Number of trained peer educators
·   Performance of the educators (…)
·   Number of health professionals trained
·   Number of teachers trained
·   Performance of health professionals (…)
·   Performance of teachers (…)
·   Number of schools that have contact with other service institutions
·   Type and number of the activities implemented by service institutions in the schools
·   % of schools which have a visiting health worker
·   % of schools which have a procedure which facilitates access of adolescents to services

Service utilisation

·   Number/% of adolescents who have received advice from (1) peer educators (2) teachers
    (3) health professionals (4) service institutions
·   Number/% of adolescents who have received group help regarding (1) training (2)
    information
·   Number and type of activities given by the health workers

Table 1. Currently used process monitoring tools

Tool                                          Purpose
Peer educator, post project assessment        Ascertain immediate benefits of project to
form                                          themselves and to others
Activity recording form (educators)           Record details of events and activities held,
                                              such as the fairs (ferias)
Activity recording form (teachers)            Record details of events and activities held,
                                              such as the fairs (ferias) – look at levels of
                                              involvement, reception and participation
Case reporting form (educators)               Record number of cases in contact with
                                              educators, age and sex of the contact, the
                                              nature of the problems. One form for each
                                              case
Case reporting form (teachers)                Record number of cases in contact with
                                              teachers, age and sex of the contact, the nature
                                              of the problems. One form for each case
Monthly reporting form (educators)            Monthly summaries
Monthly reporting form (teachers)             Monthly summaries
Monthly reporting form (health centres)       Monthly summaries on types and nature of
                                              attendance at the participating health centre
Profile of CBOs                               Educators are asked to keep an up to date
                                              record of service providers within the
                                              community
Monthly refresher course form                 Assessment of the education session held by
                                              the teachers by the teachers themselves
Monthly refresher course form                 Assessment of the education session held by
                                              the teachers by IES staff
Impact of fairs (ferias)                      KAP questionnaire to examine basic
                                                9
                                             knowledge and misconceptions amongst
                                             participants

Impact assessment

        In addressing project impact assessment, the categories of intermediate impacts and
longer term (behavioural) impacts are used;

Intermediate impacts

· Number/% of adolescents who know about the (1) health centre (2) peer educators
· One means of preventing HIV/AIDS
· Number/% of adolescents considering themselves at risk of HIV/AIDS
· Number/% not using health centres for psycho-social reasons
· Number/% intending to use a condom <when?>
· Number/% communicating about sexuality with <…>
· Number/% adolescents exposed to messages who (1) retain the message (2) agree with the
message (3) discuss the message with others

IES staff themselves identified the most important intermediate impact indicators:

§   Communication between partners
§   Intention to use condoms
§   Knowledge of HIV transmission routes and HIV prevention methods
§   Recognition of self vulnerability to infection
§   Intention to use health services in case of STD
§   Intention to ask for appropriate help when needed
§   Ability to recall messages
§   Proportion agreeing with and advocating messages
§   Proportion of respondents able to name a professional source of help for a specified
    problem
§   % of respondents who asked for help
§   % of respondents who reported seeking help

Longer Term Impact Indicators

·   Reduction in the number of teenage pregnancies
·   Detection and treatment of STDs
·   Reduction in number of infections of HIV/AIDS

         To assess the changes in the intermediate impacts, a pre-post KAP questionnaire has
been developed. The sample size has been around 500, with 40 respondents per school, aged 14-
18. All the respondents answered the same questionnaire.

Coverage and Impacts of the Project
1. Coverage


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·   In an average year between 250-300 youth leaders, selected by classmates and teachers, are
    trained. They are aged 15-18 and are there have been more girls than boys. In one year the
    educators were 65% girls and 35% boys. There are around 30 educators per school, and
    these educators have 2,500 classroom colleagues and contact with a further 3,700 adolescents
    as direct beneficiaries.
·   80 teachers have received support in the project and 184 health workers in workshops about
    working with adolescents.
·   IES has also worked with 400 parents through discussion groups.
·   Between April 1996 and March 1997 – 350 peer leaders were trained in four schools. These
    educators received about 1500 requests for advice from friends.
·   Between March 1997 and March 1998, 744 adolescents were recorded as having received
    support from peer educators. The real figure is ‘probably three times higher because many
    cases are not registered’.
·   Nearly 7,000 adolescents have received information from the leaders.
·   Health centres have attended to 160 cases during school visits and have received 73 referrals.

·   Over 1700 registered visits to HCWs at schools and clinics by the children
·   Two HIV cases identified in schools and three by the health centres.
·   Teachers attended to 157 cases, with a ‘non registered rate of 2-1 approximately’.
·   1997-1998: Five mass distributions of pamphlets were carried out to all 6,993 beneficiaries of
    the programme and nine fairs.
·   Support was given to the school for parents in the school where the programme was being
    carried out – 400 parents were helped.

2. Impacts

    Initial work by IES underwent internal evaluation which showed the increase in self esteem
of those involved and revealed attitude shifts between the beneficiary group and control group.
Important lessons have been learned in advocacy – little progress in influencing was achieved
when IES solely had a local focus. Once IES participated in national events, its work gained
attention.

    The KAP survey addressed the issues of changes in communication between children and
service providers. 520 children, aged 14-17, took part.

At follow up:

·   100% of respondents knew of a peer educator.
·   boys were more likely to speak to teachers about everything except STDs.
·   Both sexes were more likely to intend to go to health centres when they have an STD.
·   Reported discussion between partners has increased regarding sexual issues.
·   Inter-partner communication about condoms has increased – especially amongst girls, but
    not significantly amongst boys.

Do the peer educators see any changes taking place in their friends?

       During the discussion sessions held by DW, the educators noted some changes that they
had seen taking place;
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·   Some are more aware about contraception– use of the pill and injections especially.
·   Some now have one sexual partner.
·   Some delay having sex (in a stable relationship).

How have the peer educators benefited from the project?

· help friends handle problems – themselves and peers – helps build solidarity – help
others ‘go ahead’ and gain control
· like giving advice
· self learning
· get information
· self esteem has gone up
· friendly atmosphere – enjoy being part of the team
· one male educator used to be part of a gang before becoming an educator. Since then
   communication with his family has improved and taken on responsibility - he now tries to
   help friends with problems.

What changes have the teachers seen in the children?

·   There is less vandalism at the school.
·   There is more discipline generally amongst the students.
·   The peer educators are more self-confident – this self-esteem is crucial – ‘they can do
    anything after that’. The academic performance of the educators has improved for example.
·   The children want to participate and are enthusiastic. The educators now are proud to have
    badges – they want to be identified, as they feel valued. The educators have produced their
    own posters advertising their services. More children want to become educators.

Future Development of the Monitoring and Evaluation System
          Much of the discussion with IES was based on this issue, and several key questions were
raised;

How useful have the identified indicators been in relation to (a) project management
and (b) advocacy?

        The indicators used have been mainly intermediate (interaction between project and
immediate beneficiaries) with a lack of examination of longer term, more impact orientated
indicators. Little information generated to date has therefore been useful for advocacy.
Behavioural outcomes of the project are not being assessed. The institutional profile, encompassing the
project, is therefore based on research findings rather than impacts of the project.

Are there any indicators already being used by other institutions that IES could also use?

These are important to be aware of for comparison and ultimately advocacy purposes. Using the
same indicators as other organisations allows you to speak in ‘their language’ and therefore have
more say in policy debates by using commonly accepted indicators.


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1. The Demographic and Health Survey (DHS) has three relevant indicators:

·   % of respondents who have ever used a condom (women only, age groups 15-19, 20-24).
    Note: this is actually not that useful as an indicator as the proportion of those sexually active
    who have ever used a condom is not reported.
·   Median age at first sexual experience.
·   % of teenagers (age 15-19) who are mothers or are pregnant with their first child.

2. National AIDS Programme (PROCETSS). The three objectives of the programme in
   relation to their pilot programme with young people are;

·   Postpone sexual debut
·   Reduce number of sexual partners
·   Increase in condom use

3. PAHO (?)

4. National Population Plan (?)

5. Ministry of Education secondary school programme. This has technical support from UNFPA
and Tulane University. There are three KAP questionnaires being used in the evaluation process
– for primary, secondary and high schools.

How do we assess sustainability of the project – what does sustainability mean to IES?

As far as IES is concerned, sustainability relates to the following criteria:

·   School teams manage the projects: i.e. the day to day responsibility is handed over to the
    school team.
·   Capacities are built in the school team – teachers, principal, peer educators, HCWs, to allow
    for this handover to occur.
·   Resources to fund the project are found from outside of IES… but from where – public
    sector?
·   Project included in the school plan – mainstream, in the curriculum, and within school hours
    (this implies the school has a plan).
·   Health centres initiate links with other schools.
·   Joint planning between school and health centres.
·   Schools link up with other institutions.

Sustainability from a donor perspective either means that the project is self-funded through its
own income generation (often at community level), or the project is funded by the public sector.
Sustainability is a difficult concept as it is determined by the perspective of the stakeholder.

The Future of the Project
        In the group discussions with the peer educators and the teachers, this issue was raised:

How can the project be improved (peer educators)

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 -   more training – refresher courses
 -   the educators want more regular contact with IES personnel
 -   communication with teachers still difficult
 -   want friends to be trained/taught
 -   more training for the teachers and nurses
 -   Allow training to reach all the children
 -   Training in how to communicate, social skills, decision making
 -   Want to make their own projects
 -   Have their own newsletter
-    Need more materials

How can the project be improved? (teachers’ perspective)

·    A key challenge for the teachers is increasing the participation of the parents. There has been
     a low turnout in previous events.
·    The project needs materials to harness creativity of the children – video, loudspeaker –
     microphone etc.
·    The children like contests and sports – the project needs materials for these events – the
     ministry has no money.
·    Need to involve the other teachers – the other teachers need sensitising (one teacher
     allegedly makes the children kneel down in front of him if they have not done their
     homework). This is seen to be the main constraint on the success of the project. There is a
     need for monthly teachers’ meeting to discuss the progress of the children.

Conclusions and Recommendations
1. Defining the future role of IES

This is an important issue which needs tackling. Peer education is now a widely used and
advocated strategy – this is arguably a direct result of the valuable work which IES has been
involved in during recent years. Does the project want to refocus on more marginal groups such
as out of school youth or youth in rural areas? Project staff suggested that the main goal of the
project is to demonstrate to the government that the intervention model developed is replicable
and effective. In order to do this:

·    The issue of sustainability needs to be incorporated into the monitoring and evaluation
     system. The indicators identified in relation to sustainability need to be simplified and
     prioritised, with appropriate means of verification outlined. Progress towards ‘handover’ can
     then be monitored, with important lessons learned along the way. A vital issue for many
     projects of this type is the question of what needs to be in place in order that responsibility is
     handed over successfully? This is an important aspect of good practice development.
·    The project needs to refocus to identify behavioural outcomes. An overemphasis has been placed
     on process monitoring to date with too little attention paid to the outcomes of the project.
     Intermediate indicators are utilised which is valuable but not the next stages of resulting
     behaviours. Many indicators have been suggested along with means of verification. The
     project in the next phase could attempt to address some of these indicators and reflect on
     these experiences (see below).

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·   The unique elements of the model need to be spelled out. What is different about the IES
    model and why is it more effective? How is it more effective? Impact assessment structures
    need to focus on these three questions.

2. Defining training requirements. IES need to address two important questions in the
   coming planning period:

§   What are the training demands of the people in the project? How can we prioritise and
    respond to these demands?
§   What are our own training needs as project managers – where can we get assistance?

        The demand on the project from the educators and the teachers is considerable. In
response to such demands, IES needs to be clear about what it can and cannot respond to, to
ensure that expectations do not become too great.

3. Defining cost efficiency. The pressure on projects to demonstrate this aspect of intervention
effectiveness is growing. The importance of rigorous process monitoring is emphasised here, and
the impacts of the work of educators on their friends, as well as themselves. In one school
visited, there were 32 peer educators in a school population of around 700-800. We need to
ascertain the impact of the educators on the lives of the other school going children, as well as
the benefit of the training on their own knowledge and self-esteem. In the proposed next phase
of the project, the cost of the intervention is approximately £9.30 per school child in the project
schools. This cost represents an opportunity cost in relation to other interventions (i.e. can the
project justify that this money is not better spent elsewhere?).

4. Speaking the same language as other institutions. Effort should be spent on clarifying the
indicators used in other similar programmes, particularly those supported by government
institutions (PROCETSS, MOE, MOH). Government are certainly keen that IES focus on
similar indicators and IES work is then integrated further into the national response.

5. Attempt to include clinic-based data in monitoring system. Having an objective impact
indicator is important. Medical records should back up KAP survey data. Indicators to consider
are:
(a) proportion (%) of out-patients whom are adolescent (define ages)
(b) proportion of STD cases which are adolescent
(c) proportion of adolescent presentations which are STD.

        Health care workers are confident that monitoring forms can be an integral part of the
information system and expressed interest that such forms are co-designed with the IES team.
These forms may focus on specific issues such as STD or pregnancy or cases of domestic
violence. As mentioned before, a problem here could be that adolescents do not utilise the
geographically closest services (to the intervention school), especially clinics, due to worries
about confidentiality. Mobility mapping of services with adolescents should be conducted in
needs assessment or formative research to closely examine health-seeking behaviour. This could
be incorporated into the World AIDS Foundation sponsored research.

6. Attempt to address improvements in clinical services. Improving clinical services
    (specifically related to STD diagnosis, treatment and partner notification) is a key component
    of the project but it is absent from the present monitoring structure. The project should look
    at incorporating this aspect into the impact assessment system.
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Annex 1. Information sources

SCF South America (1997) DFID Joint Funding Scheme Project Report Summary
1996/97, Colombia.

SCF Peru (1998) Project Report on Programa de articulation de servicios de salud sexual
y reproductiva dirigidos a adolescents con los programas preventivos en las escualas,
Lima.

SCF Briefing note; From grass roots to national policy – HIV and AIDS work in Lima,
Peru, October 1997.

SCF Peru; Country Profile on HIV/AIDS, November 1997.

IES presentation made to SCF Workshop on HIV/AIDS and children, November-
December 1997, London.

SCFUK Peru/IES (1999) Department for International Development, Health and
Population Division, Innovation Grant Application, for project ‘Schools as Promoters of
Adolescent Health’.

Annex 2. Perspectives of the health care workers

        Five health care workers involved in the project in Victoria were met and a
discussion was held in relation to the project. These health workers regularly visit the
school at their own expense and have group and individual sessions with the children. A
‘corner’ has been set up in the library where such consultations can take place in relative
privacy. In addition the health workers installed a phone in the school for the use of
students to contact helplines and outside support services. This has proved very popular
with the children.

         Regarding sexual health, STDs are seen to be the main problem in young people:
balinitis, gonorrhoea, chancroid, some syphilis, candidiasis, trichomoniasis, and especially
chlamydia. It is mainly girls who attend with STDs – there is a move at the present time
to develop partner notification and treatment capacity. There has been a recent increase
in tuberculosis. One or two new cases are seen per month at the clinic. HIV testing is
available for those presenting with tuberculosis, and DOTS (directly observed treatment
short course) treatment is available. Four or five incomplete abortions are presented per
month at the clinic, but most in the area go straight to the hospital.

        There is no antenatal clinic at the health centre. The clinic provides free condoms
and oral contraceptives. The demand for condoms going up, due to the counselling,
according to the health workers. All services to adolescents are free, as are all STD
treatments. The health workers believe that this is not known by everyone and that
perceived costs of treatment deter some potential patients. One drawback is that if an
adolescent (under 18) wants family planning services they must have parents or guardians
consent. Voluntary testing and counselling is provided free at the clinic and the staff are
receiving counselling training.

        Regarding the monitoring of the project, medical records can be used, as they
give the routine information of age, sex and diagnosis. The health workers considered


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they could be accessed for monitoring purposes. The health workers deemed having a
parallel monitoring system for the specific purposes of the project acceptable and the
accumulation of case studies was considered to be worthwhile. It is important that
monitoring forms or case history structures are designed in conjunction with the health
workers.

         Current challenges faced by the health workers are the lack of printed materials
for distribution and the lack of incentives, such as the costs of travelling to the school (if
sustainability is the issue these costs should be covered by the Ministry of Health). They
also see a potential problem in that children, if encouraged to go to the clinic, will find it
too far to travel or actually go to a different clinic. The consultation sessions held at the
school have so far been invaluable.




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