The study area, Sekhukhuneland, is located in Limpopo Province, South Africa, and consists of densely settled rural villages. With few local employment opportunities, most households rely on remittances from family members who have migrated to urban areas, occasional manual or commercial labor, and state pension and childcare grants. A minority of households have access to piped water or electricity and quality of housing is poor. As in much of South Africa, sustained poverty has been accompanied by a deepening HIV epidemic. Statistics for the province showed an HIV prevalence rate among adults aged 15-49 years of 11.0 % in 2005 (Shisana et al., 2005
The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) is a community randomized controlled trial of a program integrating microfinance with participatory education addressing HIV and gender awareness. Women from the poorest half of households were eligible to participate in the intervention, which was administered in partnership with a South African microfinance initiative, the Small Enterprise Foundation. Women who joined the program were organized into “loan centers” comprising 40 participants. Within these centers, smaller “solidarity groups” of five women guaranteed one anothers’ loans, which were used to establish income generating projects. Mandatory fortnightly center meetings provided an opportunity for women to report back on their investments, request additional loan cycles, and make deposits into savings funds.
At these meetings, trained facilitators conducted interactive education and empowerment activities known as Sisters for Life (SfL). These included 10 structured sessions designed to stimulate awareness and discussion on issues related to gender inequalities, intimate partner violence, sexual health, and the role of culture in shaping behavioral norms (); these were followed by an open-ended phase of community mobilisation in which participant women worked together to identify local priority issues and develop appropriate responses.
Sisters for Life Training Sessions
Details of the intervention and evaluation study have been published elsewhere (Pronyk et al., 2006
; RADAR, 2002a
), and in this article, we focus on the specific components of the program that encouraged participants to challenge barriers to engaging with young people about sex and sexual health. Whereas the overall intervention was based on the premise that both economic and psycho-social resources and skills are required to address the gender-based inequities behind South Africa’s HIV epidemic, the participatory activities aimed to influence specific behavioral norms at the individual, household, and community levels, including challenging cultural taboos surrounding talking openly about sex and sexuality. As this was such an explicit message within the SfL sessions, for the purposes of this evaluation we assume the SfL curriculum, rather than women’s participation in the microfinance scheme, would have been the primary driving force behind any increase in parent-child communication.
Throughout SfL sessions, trainers emphasised the importance of sharing key messages from the program with families, extended households, and the wider community. Diffusion of new knowledge and attitudes beyond the enrolled participants was an explicit objective of the intervention. The curriculum offered concrete skills in addition to engendering a supportive environment within the group. In particular, Session 9, “Empowering Change,” included opportunities to share communication strategies and previous experience, as well as practice different approaches to talking to young people about sex through a role-play exercise.
To assess the effects of this component of the program, we monitored four centers (120 women) throughout the SfL sessions. We observed all fortnightly meetings to elicit participants’ responses to the health education themes and activities. Data were collected using flip charts, standardized forms to record the process and content of group discussions, and additional notes taken by the observer. Focus groups were also conducted with eight loan groups at two points in time: immediately after the 10 SfL sessions and 1 year later, upon completion of the community mobilization phase. These asked respondents to reflect on the acceptability of the participatory activities and group dynamics. Finally, to gain the perspectives of young people, 24 interactive workshops and 6 follow-up interviews examined young people’s perceptions of the intervention and potential effects in their households and community. Transcripts and interviews were entered into the software package qSR N6 for data management, coding, and comparative thematic analysis.
These qualitative methods were nested within a cluster randomized trial collecting quantitative data at baseline and 2 years later in four intervention and four control villages. We successfully interviewed 387 women from intervention villages at 2-year follow-up (90% of those who joined the program), and 363 age and village type matched controls (84%) who would have been eligible to join the program if available in their village. In addition, we collected data from 443 young people aged 14-35 years (56% of those eligible) resident in the households of loan recipients and 427 (54%) young people from matched households.
Questionnaires asked about frequency of sexual communication in the household over the past 12 months, whether respondents felt “free/open” in discussing topics related to sex, and what topics were covered. Unlike in studies conducted in Western settings, we did not ask respondents to differentiate between conversations held with their own children or parents from those with other adults or young people residing in the household, as South African families often display an “extended” rather than nuclear structure that can include long-term fostering of nieces, nephews, and grandchildren. The qualitative data, however, suggests that seeking and/or providing sex-related information and advice occurred between young people and their mothers.