Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth

https://doi.org/10.1016/S0277-9536(01)00289-1Get rights and content

Abstract

Despite the growing popularity of participatory peer education as an HIV-prevention strategy worldwide, our understandings of the processes underlying its impact on sexual norms are still in their infancy. Starting from the assumption that gender inequalities play a key role in driving the epidemic amongst young people, we outline a framework for conceptualizing the processes underlying successful peer education. We draw on the inter-locking concepts of social identity, empowerment (with particular emphasis on Freire's account of critical consciousness) and social capital. Thereafter we provide a critical case study of a school-based peer education programme in a South African township school, drawing on a longitudinal case study of the programme, and interviews and focus groups with young people in the township. Our research highlights a number of features of the programme itself, as well as the broader context within which it was implemented, which are likely to undermine the development of the critical thinking and empowerment which we argue are key preconditions for programme success. In relation to the programme itself, these include peer educators’ preference for didactic methods and biomedical frameworks, unequal gender dynamics amongst the peer educators, the highly regulated and teacher-driven nature of the school environment and negative learner attitudes to the programme. In relation to the broader context of the programme, we point to factors such as limited opportunities for communication about sex outside of the peer educational setting, poor adult role models of sexual relationships, poverty and unemployment, low levels of social capital and poor community facilities. We discuss the implications of our findings for the design of peer educational activities, and point to a number of broader social and community development initiatives that would maximize the likelihood of programme success.

Introduction

Drawing on Paulo Freire's notion of critical consciousness, this paper presents a critical discussion of a school-based participatory peer education programme aimed at reducing HIV transmission amongst young people in a South African township. In South Africa there are particularly high levels of HIV amongst young people, despite sound levels of knowledge about sexual health risks. In Summertown1, our region of interest near Johannesburg, a recent community survey found that HIV prevalence was 0.2% and 8% for men and women aged 15, 11% and 47% for men and women aged 20, and 39% and 58% for men and women aged 25, respectively (Williams, MacPhail, & Campbell, 2000a). Levels of perceived vulnerability amongst this group are low, and unprotected sex is common (MacPhail & Campbell, 2000). In focus group research we found, unsurprisingly, that gender identity played a key role in high-risk sexual behaviour. Young peoples’ sexual encounters were negotiated within a context where dominant social norms of masculinity portrayed young men as conquering heroes and macho risk-takers in the sexual arena, and where the social construction of femininity predisposed women to use the responses of passivity or fruitless resistance in the face of male advances (MacPhail & Campbell, 2001). Within such a context, sex often took place under conditions of at best, emotional pressure, and at worst, physical coercion of young women. Our findings were consistent with a large literature that suggests that the empowerment of young women is an important precondition for safer sex amongst young people.

It is in the context of our interest in the possibility of changing gender norms as an HIV prevention strategy that this paper provides a critical case study of a participatory programme seeking to empower young people. Our programme of interest uses the method of peer education, one of the most commonly used strategies of HIV prevention worldwide (Horizons, 1999). Peer education involves the dissemination of health-related information and condoms by members of target groups to their peers. Such programmes have been shown to increase condom use and reduce levels of HIV and other sexually transmitted infections (STIs) in some countries and contexts in central and southern Africa (Vaz, Gloyd, & Trindade, 1996; Laukamm-Josten et al., 2000; Wolf, Tawfik, & Bond, 2000). Others have had more limited success (Leonard et al., 2000). The approach has also been effective in sexual health promotion amongst young people in certain contexts in the United States (Janz et al., 1996).

However, while peer educational approaches have increased in both popularity and practice amongst sexual health promoters, our understandings of the processes and mechanisms underlying their successes or failures are still in their infancy. As a result, our ability to learn lessons from successful and unsuccessful programmes is limited. Peer education has been described as “a method in search of a theory” (Turner & Shepherd, 1999) and it has also been argued that peer education “suffers from an inadequately specified theoretical base” (Milburn, 1995). This dearth of theory is reflected in existing research into peer education, which tends to take the form of quantitative outcome evaluations of interventions (MacPhail & Campbell, 1999). Such studies usually describe the extent to which programmes result in changes in target individuals’ HIV-related knowledge, attitudes and reported behaviours, with little systematic discussion of the processes whereby peer education has its allegedly beneficial effects on health.

In this paper we have two goals. Firstly, we outline what we believe are the key elements for a conceptual framework for understanding peer education, in the light of the gap in understandings identified above. Central amongst these elements is Paulo Freire's account of the development of critical consciousness. Secondly, we use this conceptual framework as the basis of a discussion of a number of factors that enable and constrain the potential success of peer education programmes in the South African township context. In conclusion, we discuss the implications of our critique for the design of future peer education programmes.

Section snippets

Theoretical framework

In this section we will highlight the ways in which the inter-locking concepts of social identity, empowerment and critical consciousness, and social capital provide a useful starting point for theorizing the processes whereby peer education might serve as a mechanism for promoting safe sexual behaviour by youth.

Methodology

Summertown, our area of interest, is a township not far from Johannesburg. It has a population of 150 000 black African people, living in a range of housing types, with about 65% of residents living in small formal houses and 35% in informal shacks made of corrugated iron and wooden poles. The township has benefited from some changes since the post-apartheid government, particularly an increase in the availability of formal housing. Other changes have been slower in coming. Township residents

The peer education programme

The social construction of gender undermines the likelihood of safe sex amongst young people in our township of interest. As argued above, the development of critical consciousness of the impact of gender relations on sexual health has the potential to contribute to two key processes underlying the impact of peer education. The first of these is the collective and critical renegotiation of sexual and social identities in ways which are less damaging to young peoples’ sexual health. The second

The context of the programme

Above we have cited the claim by Tawil et al. (1995) that the successes of HIV prevention initiatives are most likely to be maximized when they are located within broader community and social contexts that are enabling and supportive of health-enhancing behaviour change. In this section we focus on three aspects of learners’ beyond-school environments that we argue have the potential to undermine programme success. These include: limited opportunities for communication about sex; poor adult

Conclusion

In this paper we have sought to highlight factors which might impact on our peer education programme's achievement of increased condom use by young people. We have done so through focusing on the programme itself, as well as relevant contextual dimensions of young peoples’ lives. The paper rests on the starting assumption that gender relations constitute a key obstacle to condom use by young township people. We locate our discussion within a conceptual framework that emphasizes the role of the

Acknowledgements

The intervention project in which this research is located was initiated and developed by Brian Williams. Our thanks to him for support throughout the research process, and for commenting on the work that appears in this paper. Thanks also to Zodwa Mzaidume for discussion of various points. The research in this paper was funded through the UK Department for International Development, and UN AIDS. Our thanks for their financial assistance. The views expressed in this paper are those of the

References (44)

  • C Campbell et al.

    Health, community and developmentTowards a social psychology of participation

    Journal of Applied and Community Social Psychology

    (2000)
  • C Campbell et al.

    Social capital and health

    (1999)
  • P Christie et al.

    Bantu educationApartheid ideology or labour reproduction

    Comparative Education

    (1985)
  • M Cross

    Youths, culture and politics in South African educationThe past, present, and future

    Youth and Society

    (1993)
  • N Dube et al.

    Peer education programs among HIV-vulnerable communities in Southern Africa

  • P Freire

    The pedagogy of the oppressed

    (1993)
  • P Freire

    Education for critical consciousness

    (1993)
  • P Gillies

    Effectiveness of alliances and partnerships for health promotion

    Health Promotion International

    (1998)
  • J Holland et al.

    The male in the headheterosexuality and power

    (1998)
  • Horizons. (1999). Peer Education and HIV/AIDS: Past Experience, Future Directions. Kingston: Discussion document...
  • N.K Janz et al.

    Evaluation of 37 AIDS prevention projectsSuccessful approaches and barriers to program effectiveness

    Health Education Quarterly

    (1996)
  • U Laukamm-Josten et al.

    Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania

    AIDS Care

    (2000)
  • Cited by (348)

    View all citing articles on Scopus
    View full text