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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 13, Num. 3, 2009, pp. 99-110

African Journal of Reproductive Health, Vol 13, No 3, September 2009, pp 99-110

ORIGINAL RESEARCH ARTICLE

Volunteerism Among Out-of-School Adolescent Reproductive Health Peer Educators: Is it a Sustainable Strategy in Resource Constrained Countries?

Le bénévolat chez les éducateurs de pairs qui ne fréquentent plus l’école et qui sont chargés de la santé de reproduction : Est-ce une stratégie durable dans les pays ayant des ressources limitées?

Daudi O. Simba1 and Deodatus C. Kakoko2

1Department of Community Health, Muhimbili University of Health and Allied Sciences (MUHAS];
2Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences (MUHAS].

For correspondence: Daudi O. Simba, School of Public Health and Social Sciences, MUHAS, Box 65015, Dar es Salaam. Tanzania. Email: dsimba@muhas.ac.tz Fax: 255222153114 / 255222151238. Tel: 255222150304/5.

ABSTRACT

Out-of-school peer educators [PE] are resourceful in transmitting reproductive health information but their retention remains a contentious issue. This study aimed to assess motivation and sustainability of out-of-school PEs in disseminating reproductive health information among adolescents. A structured questionnaire was used to interview 406 PEs in Mbeya region, Tanzania. Focus Group Discussions [FGDs] were also conducted with the PEs and other relevant stakeholders. Most PEs had hopes for future employment and allowances through continuous training. The fact that majority of PEs had primary level education [89%] and were either peasants or self employed [92%] posed a serious question as to whether voluntary work is for the less educated, peasants and self-employed. Sustenance of PEs needs to be a continuous activity aimed at increasing the number of trained adolescents from their own social and economic groups. Otherwise, provision of transport and compensation for time spent should be considered (Afr J Reprod Health 2009; 13[3]:99-110).

RĖSUMĖ

Les éducateurs de pairs qui ne fréquentent plus l’école (EPs) sont ingénieux en matière de la transmission de l’information concernant la santé de reproduction, mais le problème reste de savoir si l’on doit les retenir ou non. C’est-a-dire, il faut évaluer la motivation et la viabilité des EPs qui ne fréquentent plus l’école par rapport à la dissemination de l’information sur la santé de reproduction chez les adolescents. Nous avons interviewé 406 EPs dans la région de Mbeya en Tanzanie à l’aide d’un questionnaire structuré. Il y a eu aussi des discussions à groupe cible (DGC) avec les EPs et les autres intéressés appropriés. Le fait que la majorité des EPs avaient reçu l’éducation primaire (89%) et qu’ils étaient soit des paysans soit des auto-employés (92%) a soulevé une question importante de savoir si le bénévolat est destiné au gens moins scolarisés, aux paysans et aux auto-employés. Il faut que le maintien des besoins des EPs soit régulier pour les rendre une activité qui visent à l’augmentation de nombre des adolescents formés à partir de leurs groupes sociaux et économiques. Sinon, il faut tenir en compte l’assurance du transport et de la recompensation pour le temps qu’on a passé (Afr J Reprod Health 2009; 13[3]:99-110).

KEYWORDS: Peer education, Adolescent health, Tanzania

Introduction

Educating youth on matters relating to sexuality and reproductive health is of paramount importance given the high risk of HIV transmission at this age group. In areas where possession of radios and televisions is limited, peer education remains the most important strategy for effective communication of information. Studies have shown that contact with peer educator is associated with greater spontaneous knowledge of modern contraceptives, symptoms of sexually transmitted diseases [STDs] and greater use of condoms1. This is due to closeness of PEs to youths, and sharing common interest, sentiments and beliefs. Peer educators can pass on information to adolescents through formal and informal means. Accordingly, the Third Medium Term Plan for the prevention and control of HIV and AIDS in Tanzania identified peer education as one of the approaches for enhancing behavioral change.2

In Tanzania, Mbeya region introduced reproductive health counseling and services for adolescents in 2000/2001. The objective of the programme was to encourage young people aged 10 to 24 years to acquire positive behaviour towards prevention of STDs and HIV and to make use of reproductive health services provided by public health facilities in their respective areas. The ultimate goal of the programme was to reduce the number of adolescents infected with STDs including HIV. Accordingly, over 700 adolescents were trained throughout the region to provide peer education. Soon after training, PEs conducted education sessions to adolescents through meetings arranged by the village leaders in their respective villages. PEs were introduced by the district trainers to the nearby health facilities for support on supplies and patient referrals. Supervision of PEs was expected to be conducted by district health authorities, health workers from nearby health facilities and village leaders. Nonetheless, supervision reports made by the regional and district health management teams showed that three years after the training, only a few PEs were reported to continue with peer education.

Little is known regarding what motivates adolescents to volunteer in peer education activities and how these activities can be sustained. Therefore, this study explored the motive behind voluntarism among adolescent peer educators in Mbeya region, Tanzania with a view to making recommendation on strategies for sustaining peer education activities.

Methods

Study site

The study was conducted in 2004 in Mbeya region which is one of the 21 regions in Tanzania with a total of 2,070,046 people3, of whom 14% reside in urban areas, spreading over an area 63,622 km2. The region is divided into 7 districts and one Municipality. It has a total of 169 wards, 746 villages and 491,929 households. Regarding health facilities, the region has 283 dispensaries, 30 health centres and 16 hospitals including the Mbeya referral hospital.

Implementation of peer education programme in Mbeya

About 4-7 wards were selected on a convenience basis from each of the eight districts in the region making a total number of 38 wards involved. All villages in the selected wards were included in the programme. At least two adolescents, a male and a female, were selected from each village during a village assembly, making a total of 759 adolescents enrolled. This was followed by 3-week training in Mbeya Municipality. The main topics included; understanding of the body functions and changes during adolescence, communication skills, counseling on various issues related to sexuality and pregnancy, education on life skills and STDs including HIV and AIDS. A mixed methods approach was used in the training. Didactic approach was used when transmitting cognitive knowledge such as body awareness and changes during puberty while participatory method that included practical exercises and role play were applied for skill oriented tasks such as building and sustaining friendship.

At the end of the training, PEs were given instructions to provide reproductive health education to peer, on individual basis, and through meetings organized with the support from ward/village leaders. They were also instructed to offer counseling on reproductive health matters and to refer adolescents who will need more information or have STDs to the nearby primary health facility.

A one-day sensitization seminar was conducted for the village leaders to create awareness on the support needed by the PEs. A one-day sensitization seminar was also held for health workers with a view to acquaint them with knowledge on delivery of youth-friendly services and sensitizing them about the needs of young people in order to offer them high quality and non-judgmental care.

Study design

A cross-sectional study was conducted in March 2004 involving all adolescent PEs in 38 wards that implemented peer education programme in 2001/2002. Ward and village leaders were initially contacted and asked to invite all the trained PEs on a set date at the respective Ward Offices. Of the 759 PEs trained in 2000, 406 came. Using questionnaires with structured questions, all PEs who turned up were interviewed. PEs were asked questions pertaining to the type of activities they performed, what motivated them to join the PE program and constraints they faced and their opinion on sustaining activities through village governments’ support. Questionnaires were designed in English and translated into Kiswahili, a local language spoken by majority of the people in the country. The questionnaire was back-translated into English to achieve credibility of the translation.

Qualitative methods were also employed in this study in order to augment on the quantitative part and because this topic has not been well explored4. Focus group discussions [FGDs] were employed to extract information from PEs, adolescents, the expected beneficiaries of the services; village leaders who were the overseer of PEs’ day-to-day activities. The last 5 to 8 PEs to be interviewed in each ward were retained for FGDs. FGDs with PEs took about one hour and aimed at obtaining detailed information on the factors that motivated them to join the program, reasons for drop-outs and how could the village governments sustain peer education activities. FGDs were also held with adolescents who were the target for peer education and village leaders who were the overseer of peer education activities in their respective villages. This was aimed at triangulating information obtained from the PEs. Male and female adolescent groups of 5 to 12 were identified in their areas of domicility through the assistance of PEs. Village leaders were invited at the ward offices, along with the PEs, and FGDs were held by the Principal Investigator [PI]. FGDs with PEs were held in every second ward thus making a total of 19 FGDs. In these wards, FGDs were also conducted for village leaders [7 FGDs]), male adolescents [6 FGDs] and female adolescents [6 FGDs], in an alternating sequence.

Furthermore, in-depth interviews [IDI] were held with health workers who were responsible for receiving patients or clients referred to them by PEs. IDI were held by the PI in the respective health facilities. Each IDI took an average of 30 minutes with questions focusing on health workers perspective on the performance of PEs. Discussions during the FGDs and IDIs were recorded using audio tapes.

Data management and analysis

For a quantitative component, data entry and analysis of quantitative data was done using EPI-Info version 6 software. For qualitative data analysis, notes made during FGDs and the transcribed information from the tape-recorders were analysed by the Principal Investigator [PI] using qualitative content analysis approach. The qualitative information obtained through FGD was categorized into major themes in relation to the research objectives. A systematic comparison was done with the structured interviews in order to attain triangulation of the information.

Informed consent

This study was approved by the Ministry of Health in Tanzania and permission to conduct the study was obtained from the Mbeya Regional Medical Officer. Informed consent was obtained from interviewees prior to the interviews.

Results

Socio-demographic characteristics of study participants

A total of 406 adolescent peer educators were interviewed. This represented about

53.5 percent of PE who were trained in 2000/2001. The age range of study participants was between 12 and 42 years [see Table 1]. About 20.3 percent of them were aged 25 years and above.

More males [58.9%] turned up for the interviews compared to females [41.1%]. Since male to female recruitment ratio was 50:50, this shows that dropout was higher among female PEs than males. This was explained during FGDs to be due to girls getting married and shifting from their wards or not being allowed by husbands to continue with peer education activities. A male peer educator in Ulenje village was quoted saying that ‘a girl reaching the age of 20 and not married is seen to be abnormal’. This statement can be verified by the fact that female PEs who turned up for the interviews were younger compared to the males.

As Table 1 shows, majority of the PEs had primary level education [86.9%]. In addition, majority of the PEs were either peasants [65.8%] or self employed [25.9%]. Those who reported to be peasants were mostly from rural areas while the self employed, largely, came from urban areas.

What motivated adolescents to become PEs?

PEs were asked during FGDs the motive behind their decisions to serve as PEs and a number of themes emerged; expectation or hope for future employment; expectation or hope for allowance; benefit from training; obtaining certificates and opportunity to contribute to the problem of HIV and AIDS among youths.

Many of the PEs were of the opinion that being a PE exposes them to the possibility for future employment. As such, there were reports of some PEs being employed by Non-Governments [NGOs]. This might have been the reason behind volunteering. In relation to this, one of the PE was quoted saying,

I had expectation that later on we will be employed in the health sector or get some allowances for the work we do [male PE in Mabatini village].

Certificates that would be used as evidence for their training to be employed were considered as a motivating factor among PEs. Notably, these hopes or expectations for certificates were more pronounced in urban areas where most NGOs reside. In relation to this, one of the PE complained by saying,

We were promised a closing ceremony with certificates but did not get them [male PE in Isongole village].

Some of the PEs were motivated by the allowances provided during training as one PE was quoted saying,

I thought that training would be a continuous activity [female PE in Iwindi village].

Some PEs were moved by the pathetic situation of HIV and STDs affecting their fellow adolescents inspired them to seek for more knowledge that would give them an added advantage when discussing sexuality with other youths. For some of the PEs, this was an opportunity to gain personal knowledge on reproductive health issues, saying,

Training helped me to change my risky behaviors [male PE in Busale village]

Constraints that might have contributed to dropping out

PEs were asked about the nature of constraints they faced in their day to day work in order to explore factors that might have contributed to the high dropout rate. Major constraints reported by PEs included lack of supplies such as condoms and leaflets [23.1%] and lack of transport [22.0%], see Table 2.

Although the issue of remuneration did not surface as a constraint during structured interviews, it came out vividly during FGDs in all the wards. PEs complained about lack of incentives including allowances and bicycles. Apparently, when asked if these were promised prior to recruitment or during training, some of them admitted to have been promised neither financial nor material gains. There was, however, some evidence of expectation for financial and material gain as one of the PEs was quoted,

They told us there will be no pay, but one might be called for more seminars [female PE in Ubaruku village].

Similarly, another PE reported saying,

We were told that this is a project so we anticipated that one of these days we will get some returns.

This impression was justified from PEs past experience whereby projects operating in their areas provided volunteers with allowances and bicycles. In one of the wards a PE was quoted saying,

Look, other volunteers working in the same village have bicycles, why not us? We are seen like orphans abandoned by our donor [male PE in Itale village].

Some PEs reported being promised by district trainers

Your village governments will remunerate you accordingly [female PE in Ipinda ward].

Discussion with village leaders revealed that some villages paid PEs allowances when they called for youth meetings or when they conducted outreach visits. However, in some villages, leaders raised concerns on the number of health volunteers who needed to be supported by village governments. In one village [Malindo] leaders reported to have in their village six types of community owned resource persons [CORPS]; these were Community Based Distributors [CBDs], Peer educators [adolescents], peer educators for HIV and AIDS, Ward Training Teams [WTT], Onchocerciasis drug distributors and Village Heath Workers [VHWs]. Another member of village government did not see the rationale for paying allowances and providing bicycles to adolescent peer educators saying,

How can we give them when even village chairpersons do not get such amenities? [Village leader in Andete village]

Reasons for dropping out from the PE programme

PEs were asked if they were still active at the time of the interviews. Table 3 shows that, 81.3% [330] of the PEs reported to be continuing with peer education activities. It was reported during the FGDs held with PEs that many of those who could not turn up for the interviews had changed residence after marriage [for women] or left in search of income generating activities away from the ward. Some of the PEs were reported to have dropped out because of lack of support from village leaders; and lack of incentives such as allowance and transport facilities. Assuming that those who did not turn up for the interviews were drop-outs, only 43.5% [330/759] of the PEs were still active at the time of the interview. Drop-out was higher among female PEs compared to male PEs, 15.9% and 22.7% respectively.

Activeness of PEs was also posed as a question during in-depth discussions with health workers and FGDs with village leaders and adolescents. Health workers from the nearby health facilities where PEs were supposed to refer youth reported that when active, PEs were referring adolescents to the health facility and also educating adolescents on the use of condoms. They, however, reported to no longer receive any referrals from PEs. Discussions with village leaders, who were supposed to facilitate PEs meetings with adolescents, revealed that PEs had stopped doing so, saying,

Initially, they were working hard when they came back from training but later ceased … Many of them complained of lack of transport and remunerations [Village leader in Chitete village].

Attitude towards sustainability of PE activities

PEs were also asked to express their opinion on whether PE activities are likely to continue without resources from outside the village. Two-third of PEs thought it was not possible [see Table 4]. Reasons given to justify this argument were mainly lack of transport and supplies that cannot be provided by the village government [31.7%] and that village governments do not have funds [26.3%] as shown in Table 5.

It was established during FGDs with village leaders that peer education activities can be sustained through mobilization of local support. They reported of social groups such as burial ceremony groups and football teams that were formed by PEs with support from village leaders and influential people in the village. When village leaders were asked to depict some of the possible sources of funding for supporting PEs many of them mentioned donor support and the District Council. One village leader from one of the villages was quoted saying,

We used to depend on levy that has now been stopped. We have currently no source of fund, everything goes to the Council. Nowadays, if we ask people to contribute they complain saying that this is another form of taxation, hence refuse to contribute [Ward leader in Kyela ward].

Discussion

This study contributes to an understanding of what motivates out-of school PEs to work as volunteers in providing sexual and reproductive health education. We categorized motivating factors into two main categories; those that lead to personal benefits of the PEs and those that are supposed to be for the benefit of the adolescents as recipient of health education. In addition, personal benefits were further divided into direct benefits, such as, monthly allowances, transport reimbursement, bicycles and Tshirts; and indirect benefits, such as, certificates after training and hopes for future employment by the projects. Thomas et al [2007] categorized motivational factors into personal satisfaction, personal gains and social mindedness5. We conceptualized our categorization on the basis of possible interventions from which we envisage program managers tailoring motivational strategies accordingly.

As regard the direct benefits we found that most PEs were motivated to join the programme with expectation of mainly financial and material gains. Financial and material gains have been reported to be major constrains attributing to high drop out rates even among village health workers6,7 . By definition, volunteering is an activity carried out by choice5. Since PEs work is voluntary, something that was clearly communicated during training, it was expected that PEs would not demand for direct financial and material gain. It was therefore not surprising to find that demands for remuneration were not presented directly during questionnaire interviews. During FGDs, many PEs admitted that they were given no promises for be remuneration when conducting PE activities. Similar findings had been reported in South Africa where the need for financial incentive came out strongly during the qualitative interviews8. This raises a pertinent question as to why there were many PEs harboring expectations for direct benefits? PEs reported of projects that offered financial and material support to ‘their volunteers’. This might have created a precedence that it is possible to get paid while doing voluntary work.

Majority of the PEs in our study reported to be either self employed (for those found in urban areas) or peasants (if found in the rural areas). In Mbeya region, these groups, to a large extent, tend to accommodate people with no source of income or the unemployed; thus, the need for an income to support themselves in their day to day life is imperative. Studies have shown that volunteer projects in developing countries are successful where there is large available workforce not fully employed9. It can be argued that, unemployed or self-employed youths were more likely to be recruited into the adolescent peer education program because they had ample time for such work. However, this raises a serious question as to why voluntary work such as peer education should attract mainly the less educated, peasants and selfemployed. Majority of the PEs in this study had primary level education and under normal circumstances they have less chance to secure employment in formal institutions, especially, in the presence of an increasing number of unemployed secondary school leavers. It could be argued that perhaps PEs are volunteering with the anticipation for material gain or hope for future employment in formal sector. Otherwise, why wouldn’t the better educated [secondary school leavers] and those employed in the formal sector not be attracted to the work. After all, they have high potential for disseminating health education to peer in out-of-school context.

Volunteers talk in reference to money was indirect since most of the proposed non-monetary options would in the long run be utilized to obtain monetary benefits8. As reported by other authors we also found that some PEs were keen to be engaged in training and retraining as part of motivation scheme9. However, offering continuous training is a major problem in sustaining voluntary activities in low income countries, mainly due to insufficient funds and dependence on donor funding that most often is not predictable9. In addition, training has been reported to be a source of income that ensures a steady income to participants10 . One wonders if training demanded by PEs was based on the need for knowledge per se or for the financial benefits attached. Further research is needed to determine if PEs would still be motivated if training will be conducted locally and no allowances are given. The demand for certificates after peer education training could be translated as a need for something useful in future when they look for employment 8.

PEs mentioned about the pathetic situation of HIV and AIDS and expressed their wish to contribute towards alleviating the problem through educating others. Unlike in other studies where volunteers were reported to be motivated by altruistic motives and the need to fill in their spare time9 very few PEs in our study expressed the need to contribute to HIV/AIDS pandemic HIV/AIDS as their main motive for being peer educators. Variations in the nature of the study groups might serve to explain this difference. For example, whereas almost 90% of our study subjects were either peasants or selfemployed youths in the study done in Nepal about half of the subjects were students.

Methodological considerations

Only 53.5% of the PEs invited for the interview came. The rest were reported, by their colleagues, to have shifted to other places after getting married [girls] or in search of jobs. No follow up was done to determine if PEs who did not turn up were characteristically similar to those who turned up for the interview. However, we had no reason to think that there was any significant difference between the two groups because information obtained from the PEs who turned up was confirmed by village leaders, adolescents and health workers through triangulation.

Conclusion

This study has shown that peer educators were motivated by material gain, direct or indirect. This calls for a need to change strategies to cope with the changing spirit of volunteerism in order to sustain peer education activities. PEs training need to be a continuous activity aimed at increasing the number of trained adolescents in the community; drawn from their own social and economic groups. Where this approach is not feasible, compensation for time spent and transport where necessary should be considered.

Acknowledgements

The authors wish to acknowledge the Tanzania Germany Programme Support to Health [TGPSH] of the GTZ for financial support towards the study that led to this paper. The authors also wish to thank Ms Cordula Schuemer, Ms Lucy Ikamba, Ms Isabella Nyalusi for their contribution in the preparation and logistic support towards the conduct of the study that led to production of this paper.

References

  1. Speizer IT, O. and Tegang, S. An evaluation of the "Entre NOus Jeunes" Peer-educator programme for adolescents in Cameroon. Studies in Family Planning. 2001; 32(4):339-51.
  2. NACP. MoH TM. Strategic Framework for the third medium term plan for prevention and control of HIV/AIDS/STD 1998-2002. 1998. p. 21-4.

  3. Central-Census-Office. 2002 National Census Population and Housing Census. General Report. Government Printers. Dar es Salaam. In: National-Bureau-of-Statistics, editor.; 2003. p. 107.

  4. Kironde S, Klaasen S. What motivates lay volunteers in high burden but resourcelimited tuberculosis control programmes? Perceptions from the Northern Cape province, South Africa. International Journal of Tuberculosis and Lung Diseases. 2002 6(2):104-10.

  5. Thomas C NJ, Baral S and Byannjankar L. The contribution of volunteers to a successful community-oriented tuberculosis treatment centre in an urban setting in Nepal. Journal

    of Health Organisation and Management. 2007;23(6):554-72.
  6. ENABLE. Using Peer Educators to Improve Adolescent Reproductive Health in Ghana. CEDPA. 1400 16th Street, NW, Suite 100. Washington, DC 20036 USA. 1998 [cited [Accessed 30 March 2008]; Available from: . www.cedpa.org/publications/pdf/ghana_peer ed.pdf

  7. Heggenhouggen KV, P. Muhondwa, E. Rutabanzibwa-Ngaiza, J. Community health Workers. The Tanzanian Experience: Oxford University Press; 1987.

  8. Kironde S, Klaasen S. What motivates lay volunteers in high burden but resourcelimited tuberculosis control programmes? Perceptions from the Northern Cape province, South Africa. . Int J Tuberc Lung Dis 2002;6(2):104-10.

  9. Lysack C LK. Community-based rehabilitation cadres: their motivation for volunteerism. International Journal of Rehabilitation Research. 1993;16:133-41.

  10. Rozenbaum W. The Human Resources Crisis in Southern Countries: A Major Obstacle to the Fight Against HIV A report by Conseil national du sida’s International Commission 14 June 2005; 2005.


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