Peer Educator Online Toolkit for Blackboard by Cape Peninsula University of Technology

ACKNOWLEDGEMENTS

This manual has been made possible by the efforts and expertise of the following dedicated contributors, key stakeholders, and organisations that are committed to supporting HIGHER HEALTH’s programmes in the higher education sector: •

The HIGHER HEALTH Project Team (including Stephanie Joos-Vandewalle and Anuysha Naidu) led by the CEO, Dr Ramneek Ahluwalia.

•

Funders: The Department of Higher Education and Training (DHET) and the National Skills Fund.

•

Service Provider: The contracted service provider, Wildflower Projects, who developed this Manual.

•

Contributions: Our appreciation goes to the universities and TVET students and staff from various campuses who participated and gave input, as well as Ms Managa Pillay, the ex-Technical Advisor to HIGHER HEALTH.

Permission is granted to use the HIGHER HEALTH Training Resource Manual for educational and training purposes only and not for financial gain. HIGHER HEALTH: A Training Resource Manual

CONTENTS

Chapter 1: First Things First

Chapter 2: Sexual and Reproductive Health

Chapter 3: Sexual and Gender Diversity

Chapter 4: Gender-based Violence

Chapter 5: Mental Health

Chapter 6: Disability

111

Chapter 7: Alcohol and Drug Abuse Preventon

121

Chapter 8: Health and Human Rights

137

Chapter 9: Facilitation Guide and Peer Education Guidelines

153

APPENDIX: HIV/TB/STI and Sexual Reproductive Health Risk-screening Tool

176

APPENDIX: Mental Health and Gender-based Violence Risk-screening Tool

178

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

ACRONYMS

5Cs

Consent, Confidentiality, Counselling, Correct Results, and Connection

ADAP

Alcohol and Drug Abuse Prevention

AIDS

Acquired Immunodeficiency Syndrome

ANC

Antenatal Care

ART

Antiretroviral Treatment

ARV

Antiretroviral

BBBEE

Broad-Based Black Economic Empowerment

CCMA

Commission for Conciliation, Mediation and Arbitration

CD4

Cluster of Differentiation 4

CEDAW

Convention on the Elimination of all Forms of Discrimination Against Women

CICT

Client-initiated Counselling and Testing

DFID

Department for International Development

DHET

Department of Higher Education and Training

DNA

Deoxyribonucleic Acid

DOH

Department of Health

DOJCD

Department of Justice and Constitutional Development

DOTS

Directly Observed Treatment Short Course

DRTB

Drug-Resistant TB

DSD

Department of Social Development

DVA

Domestic Violence Act

EEA

Employment Equity Act

EFV

Efavirenz (ARV)

European Union

FDC

Fixed Dose Combination

FGM

Female Genital Mutilation

FTC

Emtricitabine (ARV)

FTF

First Things First

GAD

Generalised Anxiety Disorder

GBV

Gender-Based Violence

HCT

HIV Counselling and Testing

HEI

Higher Education Institution

HIGHER HEALTH

Higher Education Health, Wellness and Development Centre

HIV

Human Immunodeficiency Virus

HPV

Human Papillomavirus

HSV-2

Herpes Simplex Virus Type 2

HTS

HIV Testing Services

INDS

Integrated National Disability Strategy

IPV

Intimate Partner Violence

ISSSASA

Increasing Services for Survivors of Sexual Assault in South Africa

IUD

Intrauterine Device

LGBTQI+

Lesbian, Gay, Bisexual, Trans-gender, Queer, Intersex, plus Others

Life Orientation

LRA

Labour Relations Act

LTBI

Latent Tuberculosis Infection

MDR

Multi-Drug Resistant

MMC

Medical Male Circumcision

MRC

South African Medical Research Council

MTCT

Mother-to-Child Transmission

NCD

Non-Communicable Disease

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

NDOH

National Department of Health

NPA

National Prosecuting Authority

NPC

Non-Profit Company

NSP

National Strategic Plan

OCD

Obsessive Compulsive Disorder

Opportunistic Infection

PCR

Polymerase Chain Reaction

Peer Educator (this general term may refer to any person who is using this manual to conduct peer education activities or training)

PEP

Post-Exposure Prophylaxis

PEPUDA

Promotion of Equality and Prevention of Unfair Discrimination Amendment Act

PICT

Provider-Initiated HIV Counselling and Testing

PID

Pelvic Inflammatory Disease

PLWHA

People Living With HIV and AIDS

PMTCT

Prevention of Mother-to-Child Transmission

PrEP

Pre-Exposure Prophylaxis

PSET

Post-School Education and Training

PTSD

Post-Traumatic Stress Disorder

PWD

Person with a Disability

PWID

People Who Inject Drugs

PWUD

People Who Use Drugs

Q&A

Questions and Answers

Quality Assurance

RNA

Ribonucleic Acid

Reverse Transcriptase

South Africa

SACPO

South Africa College Principals Organisation

SANAC

South African National AIDS Council

SGBV

Sexual and Gender-Based Violence

SOCA

Sexual Offences and Communities Affairs

SRH

Sexual and Reproductive Health

SRHR

Sexual and Reproductive Health and Rights

STD

Sexually Transmitted Disease

STI

Sexually Transmitted Infection

TasP

Treatment as Prevention

Tuberculosis

TCC

Thuthuzela Care Centre

TDF

Tenofovir (ARV)

TOP

Termination of Pregnancy

TST

Tuberculin Skin Test (Mantoux Skin Test)

TVET

Technical and Vocational Education and Training

United Nations

UNAIDS

UN Programme on HIV/AIDS

UNESCO

UN Educational, Scientific and Cultural Organization

UNCRPD

UN Convention on the Rights of Persons with Disabilities

USAf

Universities South Africa

VMMC

Voluntary Medical Male Circumcision

WHO

World Health Organization

WPRPD

White Paper on the Rights of Persons with Disabilities

XDR

Extensively Drug Resistant HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

H I G H E R H E A LT H P R O G R A M M E INTRODUCTION The Higher Education and Training Health Wellness and Development Centre (HIGHER HEALTH, formerly known as HEAIDS) is an implementing agency of the Department of Higher Education and Training (DHET), working under the governance of Universities South Africa (USAf), the representative body of the 26 South African public higher education institutions (HEIs) and the South Africa College Principals Organisation (SACPO), the representative of the 50 South African public technical and vocational education and training (TVET) colleges. HIGHER HEALTH is a non-profit company (NPC) that supports HEIs and TVET colleges in responding to student health, wellness and development. Young South African students face many health and wellness challenges, which include HIV, TB, and STI infections, unplanned pregnancies, gender-based violence (GBV), mental ill-health, cancers, chronic conditions, such as diabetes and hypertension, gender identity and disability challenges, and substance abuse. HIGHER HEALTH is skilled in facilitating both first and second curriculum activities in the form of peer-to-peer education and inclassroom interventions through the integration of general health and wellness including HIV, TB, STIs, sexual and reproductive health (SRH), and other health and social challenges within the core function of the post-school education mandates. This is being done successfully across over 420 campuses countrywide. Students are capacitated each year through day-to-day campus activities and the HIGHER HEALTH second curriculum peer education programme, enabling them to engage at a peer-to-peer level. These engagements also serve as a tool for HIGHER HEALTH to undertake demand creation as well as for the recruitment of young people opting for a wide spectrum of services that includes: •

HIV testing services (HTS);

•

Medical male circumcision (MMC);

•

Contraception;

•

Pre-exposure prophylaxis (PrEP);

•

Non-communicable diseases (NCDs); and

•

Antiretroviral treatment (ART) for HIV positive young people, including the development of adherence clubs.

We have now also included GBV and mental health on-site psychosocial support services as part of the comprehensive package of services. The target population for HIGHER HEALTH is primarily young people between the ages of 15-35, which constitutes the largest proportion of the population within higher education. The HIGHER HEALTH focus is aligned to the White Paper of the DHET, the National Development Plan 2030, and the National Strategic Plan (NSP 2017-2022). HIGHER HEALTH’s mission is characterised by five main pillars, where these pillars are supported by a number of communication and awareness initiatives using conferences, workshops, campus and community radio stations, forms of social media, and printed media in a variety of forms. The five main pillars are: •

Engaging in wide-ranging resource mobilisation for its activities and operations

HIGHER HEALTH is committed to resource mobilisation from a diverse set of funders including government departments at national and provincial level, institutions in the post-school education and training (PSET) system, and international and national donor agencies. Such resource mobilisation covers monetary and “in-kind” resources, as well as services and service capacity, provided to HIGHER HEALTH. •

Monitoring and evaluating its impact in the field of student health, wellness, and development

HIGHER HEALTH recognises the importance of consistent monitoring and evaluation of its programmes and activities with a view to improvement and enhanced impact. To this end, HIGHER HEALTH has instituted improved systems and practices regarding the collection, analysis and interpretation of data at a number of decision-making levels. In fulfilling its mission, HIGHER HEALTH is committed to constant self- evaluation as well as evaluation by all its stakeholders and collaborative partners. HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

•

Developing and establishing capacity within PSET institutions in the field of student health, wellness and development

HIGHER HEALTH is committed to bringing its programmes and activities to students in the PSET system. This is pursued through strengthening existing campus-based structures, measures and programmes established by institutions to improve the overall and holistic health and wellness levels of students by, among others, building institutional capacities for the development and expansion of these measures and programmes, improving the levels of effectiveness and efficiency of these interventions, and ensuring their longer term sustainability.

•

Overseeing the implementation of relevant service delivery programmes

HIGHER HEALTH oversees the implementation of initiatives aimed at the cross-curricular inclusion of relevant health- and wellnessrelated knowledge in the formal education and training programmes of public sector PSET institutions. These initiatives, often referred to as first curriculum initiatives, aim to train and equip teaching and learning staff in the development, inclusion, and delivery of appropriate health and wellness information in their specific curricular knowledge areas. Second curriculum initiatives concern measures, programmes, and activities that fall outside the first curriculum of formal education and training programmes. These mainly involve training students to function as peers in appropriate mentorship roles for the benefit of their fellow students. In addition, facilitating the provision of nursing, social work, and psychosocial services on campuses where such services do not yet exist, and strengthening these services where they are not functioning optimally, form important aspects of HIGHER HEALTH’s second curriculum activities. •

Stimulating co-ordination of role-players and stakeholders

HIGHER HEALTH pursues its activities through stimulating co-ordination, impactful and wide-ranging partnerships and collaborative arrangements with national government departments, such as the DHET, Department of Health (DOH), Department of Social Welfare and Development, provincial DOHs, national and international funding agencies working within the broad field of human and social development, national and regional structures in the various sectors of our PSET system, institutions in the PSET system, and relevant structures on campuses.

HIGHER HEALTH IMPLEMENTATION MODEL

HIGHER HEALTH: A Training Resource Manual

M I S S I O N A N D V I S I O N S TAT E M E N T

MISSION

VISION

The mission of HIGHER HEALTH is to inspire

HIGHER HEALTH’s vision is to be a primary

success

among

instrument in our public post school education and

students across the post schooling education sector.

training system in improving student success rates

through

improving

wellbeing

and completion of studies through enhanced levels of overall and holistic health and psychosocial wellbeing.

HIGHER HEALTH: A Training Resource Manual

Peer-to-Peer Education •

Information Dissemination

•

Dialogues

•

Health & Wellness Campaigns

•

In-class Knowledge & Engagement Future Beats Campus & Community Radio Programme

Social Mobilisation •

Awareness & Skills Development

•

Demand Creation

•

Recruitment for Screening, Testing, Treatment, Care & Support

Health, Wellness and Development Services •

Testing & Screening: First Things First & Routine Services

•

Risk-screening and Assessment

•

Linkage to Treatment, Care & Support

•

Adherence Monitoring through Follow-up, Adherence Support Groups, Survivor Clubs & Safe Zones

HOW TO USE THIS MANUAL

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

IMPLEMENTATION MODEL Peer to Peer Education (Second Curriculum)

First Curriculum LO Lectures Integration with other disciplines

DEMAND

Campus & Community Radio Programming & Social Media

CREATION

EARLY RISK SCREENINGS & ASSESSMENTS AT CAMPUSES HIV/TB/STI

SRHR

GBV

MENTAL HEALTH

RECRUITMENT OF YOUNG PEOPLE-STUDENTS ARVs ON SITE; MMCs, CONTRACEPTION, PrEP, GBV & Mental Health Support Adherence Clubs on Positive living for HIV; young women on Contraceptives; PrEP; LGBTQI; Drugs & Alcohol; Gender Based Violence Survivor Clubs; Mental Health

On Site - Bi-Monthly - Appointment Student routine on-campus appointments for • NIMART and SRHR Services through Nurses • Social Worker, • Psychologist

First Things First Student Health & Wellness Activations – 3-5 Days/Campus Size – Monthly Free Health & Wellness Services Peer to Peer Testing/Screening/Counselling & Treatment/Care & Support services

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

The HIGHER HEALTH Second Curriculum Peer to Peer Training Resource Manual is divided into eight chapters. Each chapter contains a number of lessons which can be facilitated as standalone topics or focus areas. Chapter Nine is a facilitator’s guide to training and peer education . CHAPTER ONE: FIRST THINGS FIRST

CHAPTER FOUR: GENDER-BASED VIOLENCE

First Things First (FTF) is a HIGHER HEALTH programme that aims to increase knowledge and eliminate misinformation around communicable and non-communicable diseases. The primary goal of FTF is to encourage health-seeking behaviour and enhancement of quality of life in young people through regular testing and/or screening for major ailments, such as HIV, TB and sexually transmitted infections (STIs), cancer and cardiovascular risk factors, among others. The FTF chapter presents three lessons: 1. Overview of the FTF Programme 2. HIV and AIDS 3. TB

The key focus of this chapter is to clearly define what is meant by sexual and reproductive health and rights (SRHR) and responsibilities. It aims to encourage the use of SRH services and to empower young women in protecting themselves. The Gender-Based Violence (GBV) chapter has one lesson: 1. Gender-Based Violence Red Zones: 1. Domestic Violence 2. Gender-Based Violence

Red Zones: 1. HIV 2. Safer Sex 3. TB

CHAPTER FIVE: MENTAL HEALTH The key focus of this chapter is on creating awareness among students about risks and symptoms of mental illness, and when, how, and where to refer someone for treatment.

CHAPTER TWO: SEXUAL AND REPRODUCTIVE HEALTH The key focus of this chapter is to support young people to become personally and socially competent in managing their sexual and reproductive health and well-being.

The Mental Health chapter presents three lessons: 1. Self-Awareness 2. Identifying Red Zones: Mental Health 3. Creating Safety Networks Red Zones: 1. Mental Health 2. Stress

The Sexual and Reproductive Health (SRH) chapter presents two lessons: 1. Sexual Health 2. Reproductive Health

CHAPTER SIX: DISABILITY

Red Zones: 1. Sexually Transmitted Infections (STIs) 2. Unplanned Pregnancy

The key focus of this chapter is to equip trainees with accurate knowledge and information regarding people with disabilities (PWDs) so that they may educate peers and address discriminatory attitudes and ignorance in respect of disabilities.

CHAPTER THREE: SEXUAL AND GENDER DIVERSITY The key focus of this chapter is to provide information to enhance understanding of issues and challenges concerning the lesbian, gay, bisexual, transgender, queer, intersex, and other gender and sexuality forms not mentioned here (LGBTQI+) community and review accurate and relevant information about each of the key health risks pertaining to LGBTQI+ persons.

The Disability chapter presents one lesson: 1. Understanding Disability

The Sexual and Gender Diversity chapter presents four lessons: 1. Introduction to Sexuality 2. Coming Out 3. Attitudes and Self-Awareness 4. LGBTQI+ Health 10

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

CHAPTER SEVEN: ALCOHOL AND DRUG ABUSE PREVENTION The key focus of this chapter is to expose peers to information pertaining to alcohol and drug use/abuse that can lead to better health outcomes and ultimately influence students to reduce alcohol and drug use/abuse. The Alcohol and Drug Abuse Prevention (ADAP) chapter presents three lessons: 1. Overview of ADAP 2. Health Issues Related to ADAP 3. Alcohol and Drug Abuse – The Effects on Mind, Body, Soul. Red Zone: 1. Substance Abuse CHAPTER EIGHT: HEALTH AND HUMAN RIGHTS The key focus of this chapter is to identify the relationship between health and rights where students have control over and can decide freely and responsibly on matters related to their SRH free of coercion, discrimination, and violence. CHAPTER NINE: FACILITATION GUIDE AND PEER EDUCATION GUIDELINES The key focus of this chapter is to provide theories, principals, techniques and guidelines for effective activity facilitation and peer education training. MATERIALS NEEDED Materials required for activities in each of the chapters are set out separately for each activity. The list below suggests standard materials that will be required for all chapters: • Flipcharts • Coloured marker pens • Activity hand outs • Fact sheet hand outs • Cards of varying sizes • Pens • Notebooks

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Chapter 1|FIRST THINGS FIRST

Mental Health

Disability

Alcohol and Drug abuse

Chapter one has three lessons which focus on the areas shown in the diagram below.

FTF

• • • • •

Understand health and illness Know the stats Know the trends, patterns and risk factors Know the consequences of your behaviour Know what to do to manage your health

Education Family Relationships Career and job Income and future prospects

HIV and AIDS

• •

Know the facts

Know yourself

•

Know your goals

Know your challenges and obstacles

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

• •

Your unique identity What are your strengths, values and skills? What are your weaknesses and vulnerabilities? What are your needs?

What are the risks you face? What stands in your way?

AIM First Things First (FTF) is a HIGHER HEALTH programme that aims to increase knowledge and eliminate misinformation around communicable and non-communicable diseases. The primary goal of FTF is to encourage health-seeking behaviour

The FTF Programme specifically targets the issues cited in the following diagram.

and enhancement of quality of life in young people through regular testing and/or screening for major aliments such as HIV, TB, STIs, cancer and cardiovascular risk factors, among others. OVERALL OBJECTIVES By the end of this module, participants will: •

Be clear about the goals and objectives of the FTF programme.

•

Understand the importance of and need for testing and screening on a regular basis.

•

Have a clear definition of each of the three health risk areas outlined above.

•

Demonstrate an understanding of the facts around causes, symptoms, treatment and preventive measures for HIV, TB and STIs.

•

Be equipped with factual information on health risks to

LESSON ONE: OVERVIEW OF THE FTF PROGRAMME

encourage informed decision making and health-seeking behaviour. •

Be equipped to know how and where to get help or additional information on each of the areas.

Aim: To give participants a clear understanding of the FTF programme and to agree on their roles and responsibilities in FTF. Time:

INTRODUCTION: FIRST THINGS FIRST PROGRAMME HIGHER HEALTH advocates the FTF model. This model promotes that the first priority of every young South African is to look after their health. The vision of the programme is to build a culture where youths buy in to the concept that early detection saves lives. This would mean that they regularly: •

Screen and become educated in order to detect disease early.

•

Prioritise early detection through community or institution testing/care and support.

In this way, the programme contributes to the UN Programme on HIV/AIDS (UNAIDS) target of 90-90-90 with the key objective of reducing the rate of students becoming infected.

30 minutes

Lesson Objectives: On completion of this lesson, participants should demonstrate an enhanced understanding of: •

The purpose and goals of the FTF programme.

•

Why FTF is necessary and important.

•

The roles and responsibilities of peer educators and peers in FTF.

Procedure •

Introduce yourself and your role in the project.

•

Ask participants what they know about FTF.

•

Ask why FTF is necessary and fill in gaps after all group input has been given.

The goal of the 90-90-90 target is to ensure that 90% of all people living with HIV know their HIV status; 90% of those who are diagnosed with HIV receive antiretroviral (ARV) therapy; and as a result, 90% of those on treatment attain viral suppression. This would help to bring us closer to attaining zero new HIV infections by 2030.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

one per group) containing questions related to understanding HIV. 4.

Groups take turns to roll the dice.

The group with the sheet number corresponding to the number rolled will ask the group in play a question from the

LESSON TWO: HIV AIDS Aim: To increase, refresh and update participants’ knowledge regarding all aspects of HIV/AIDS transmission, prevention, treatment, and HIV counselling and testing (HCT) protocols. Time:

90 minutes (two activities)

Lesson Objectives: On completion of this lesson, participants should demonstrate increased understanding of: •

HIV the disease

•

Impact on the immune system

•

Life cycle of the virus

•

Stages and progression of the disease

•

Transmission of HIV

•

How HIV is transmitted

•

How HIV is NOT transmitted

•

HIV prevention

•

Lifestyle and behaviour

•

Pre-exposure prophylaxis (PrEP)

•

Post-exposure prophylaxis (PEP)

•

Prevention of mother-to-child transmission (PMTCT)

•

HIV testing services

•

Pre- and post-test counselling

•

TB screening

•

Human rights and HIV

•

Legislation

•

Stigma and discrimination

sheet they have (for example, if you roll number six, the group with sheet number six). 6.

same number of places as the number they rolled. 7.

To illustrate how quickly HIV can spread, and how correct, consistent condom use can stop its spread.

ROLL THE DICE Time: One hour

The team that has progressed furthest on the board when the time for the activity is up wins the game.

10. Allocate 35 minutes for this activity. 11. On completion of the activity, conclude by encouraging students to continue playing the game as a homework exercise to master all relevant information. 12. Task: Create your own dictionary or glossary of terms and concepts and exchange with one another to enrich your knowledge bank.

Discussion Questions •

Why is it important to know this information?

•

What does it mean for you right now?

KEY MESSAGES It is important to know your HIV status so that you can protect your own health and the health of your partner(s). •

HIV is preventable, through avoiding contact with other people’s body fluids such as blood and sexual fluids.

•

If a person is infected with HIV, there is a four- to 12-week period where they may not know that they have the virus (the window period), but the virus is very active and can easily pass to other people at this time.

•

It is important to know your HIV status so that you can protect your own health and the health of your partner(s).

•

HIV and AIDS can be managed and treated so that people with HIV can live happy, healthy and productive lives.

To show the importance of knowing your HIV status and empower participants to get tested.

All other aspects of the game “snakes and ladders” will apply as the teams move across the board.

To review baseline knowledge, create opportunities to clarify knowledge and skills regarding HIV and AIDS.

If they do not know the answer or answer incorrectly, they will remain in the same place on the board.

Purpose of activities myths and misconceptions, and empower participants with

If they answer correctly, they will be allowed to move the

The South African government has embarked on a deliberate effort to scale up HIV testing services (HTS) and strengthen its quality at all health facilities and non-health sites. With increasing availability of quality HTS and its uptake in all public health facilities in South Africa, the proportion of people

Divide the class into six small groups.

who have ever had an HIV test and are aware of their status

Distribute one dice and a “snakes and ladders” game board

increased from 50% in 2008 to 66.5% in 2014. In addition, the

per group.

2014 data showed that 92.3% South Africans are aware of HTS

Distribute sheets numbered one to six (randomly assigning

services, and 66.2% had actually utilised them in the previous

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

year. There is a global initiative to accelerate universal access to HIV prevention, treatment, care and support services for people living with HIV and AIDS (PLWHA). The main entry point for the HIV continuum of care is through HTS, which has become increasingly available. South Africa has more than 4 000 public health facilities offering provider-initiated counselling and testing (PICT) and client-initiated counselling and testing (CICT). In addition, HTS is also available through non-medical sites and the private sector.

https://www.ippf.org/sites/default/files/web_

young_people_as_advocates.pdf

when sero-conversion is taking place and antibodies have not yet formed. As a result, an HIV antibody test at this time will test negative (because it is looking for the antibodies), even though the person may, in fact, be infected. This period during which the formation of antibodies is taking place is called the

SRHR language: https://choiceforyouth.org/srhr/

•

https://catalogue.safaids.net/sites/default/files/publications/ Handbook.pd

therefore, indicates the level of infection. In other words, someone with a high viral load is likely to be showing symptoms CD4 count because it is when the CD4 count is low that OIs enter the body and increase the viral load. What is sero-conversion? Sero-conversion is the period of time during which HIV antibodies develop and become detectable. Sero-conversion

RESOURCES FOR THE ACTIVITY: ROLL THE DICE

generally takes place within a few weeks of initial infection. It is often, but not always, accompanied by flu-like symptoms, including fever, rash, muscle aches and swollen lymph nodes. Roll of #3

Roll of #1

HIV cannot be transmitted from one person to the

What is HIV? Human Immunodeficiency Virus (HIV) is a virus that targets CD4 cells in the human immune system. Without treatment, it would lead to severe immune deficiency (AIDS), high viral loads, and eventual death.

other if the infected person is showing no symptoms (asymptomatic) (T/F). False If both partners are HIV infected, it is not necessary to use a condom (T/F).

What is AIDS? Acquired Immunodeficiency Syndrome (AIDS) is a condition resulting from HIV infection (Acquired), the immune system is depleted of CD4 cells to the point of becoming deficient (Immunodeficiency), and unable to protect the body from infection and invasion by a myriad of infections at the same time (Syndrome). What is the difference between exposure and infection in relation to HIV? Exposure is where one has come into contact with the virus but has not been confirmed as being infected. At this point, infection can also be prevented (PEP). Infection is where the virus has entered the body and replicated to the point where prevention is no longer possible.

False If an HIV antibody test is used to diagnose an infant under 18 months, the baby’s HIV status can change if retested when he/she is older than 18 months (T/F). True: Babies carry their mother’s antibodies for the first 18 months. If they are born to an HIV-positive mother, they will inherit the HIV antibodies, which will show as HIV positive in an antibody test, EVEN IF THE BABY IS HIV-NEGATIVE. After 18 months, their own immune systems will kick in and, if tested again, an uninfected baby will test negative, even though they may have tested positive when they were under 18 months of age. People with disabilities (PWDs) are “safer” from HIV than able-bodied individuals because PWDs are “asexual”.

Name the three fluid types that can transmit HIV. Sexual fluids (semen and vaginal fluids), blood, and breast milk.

False: PWDs are far more vulnerable to sexual abuse than are their peers, especially those with developmental disabilities. They are therefore disempowered and at high risk for rape,

What is an opportunistic infection (OI)? An OI is an infection that is able to invade the body because it is immune-compromised (low CD4 cell count) and, therefore, unable to protect itself. In another words, OIs take the opportunity to enter the body when its defences are low.

A viral load quantifies the amount of virus in the body and,

(symptomatic) and very ill. They are also likely to have a low

•

Young4Real_Information_Services_Advocacy_Training_

The window period is the period after infection by the HI Virus

What is a viral load?

Advocacy for sexual and reproductive health and rights (SRHR):

What is the window period?

window period.

Further Resources •

Roll of #2

unsafe sex, and other forms of sexual abuse which also places them at high risk for HIV. They are also at risk because of the “virginity myth” that HIV can be cured by having sex with a virgin because it is often assumed that they are virgins because they are disabled.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Roll of #4

Sometimes the copies change a little bit, and the ARV drugs

What is a CD4 cell?

will not be as effective against them.

A cluster of differentiation 4 (CD4) cell is a white blood cell that

Your strain of HIV may become resistant to the ARVs, so even

plays a crucial role in the immune system.

if you decide to take them again at a later stage, they might

What is PEP?

not work. If HIV becomes drug-resistant, and you accidentally

PEP is Post (after) Exposure (having contact with the virus)

pass the virus on to another person, that person will find that

Prophylaxis (prevention). PEP is a type of anti-retroviral

the drugs do not work for them either.

(ARV). If it is a person’s first exposure to the virus and PEP

For these reasons, it is vital not only to take your medication

is administered within 72 hours of exposure, it may prevent

faithfully, but also to comply with the instructions exactly.

the virus from replicating sufficiently to infect the person. PEP

What is ARV adherence?

is a short-term ARV treatment that reduces the likelihood of

Adherence is the most effective way to ensure viral suppression

HIV infection after exposure to HIV-infected blood or sexual

(when the virus is undetectable). Adherence is about taking

contact with an HIV-positive person. The drug regimen for

the ARVs as directed by the health worker. It is defined as a

PEP consists of a combination of ARV medications that are

patient’s ability to follow a treatment plan, take medications

taken over a period of four weeks.

at prescribed times and frequencies, and follow restrictions

What is PrEP?

regarding food and other medications.

PrEP is Pre (before) Exposure (having contact with the virus)

Which partner is at a higher risk of contracting HIV during

Prophylaxis (prevention). It involves the use of anti-HIV

heterosexual intercourse and why?

medications to keep HIV-negative people from becoming

Women are two to four times more likely to get infected with

infected. PrEP has been shown to be safe and effective

HIV through unprotected vaginal sex than men, due to the

at preventing HIV infection. Truvada is currently the only

following reasons:

treatment approved for use as a PrEP. Truvada is a single pill

•

Women, as the recipients of semen, are exposed to

that is a combination of two anti-HIV drugs, tenofovir (TDF)

semen for a longer time (while semen remains in the body

and emtricitabine (FTC). PrEP is for HIV-negative adults and

of a woman for a few hours, a man is exposed to the body fluids of a woman for only a short time).

adolescents who are at very high risk for getting HIV from sex (such as sex workers) or injection drug use. The current

•

guidelines also recommend that PrEP be considered for people who are HIV-negative and in an on-going sexual relationship

The concentration of HIV in semen is much higher than the concentration of HIV in vaginal fluids.

•

Women possess a larger surface area of mucosa (the

with an HIV-positive partner. Research suggests that PrEP

thin lining of the vagina and cervix), which is exposed to

is highly efficacious in preventing the sexual transmission of

their partner’s secretions during sexual intercourse.

HIV, as long as the drugs are taken regularly and as directed.

•

However, PrEP does not prevent other sexually transmitted

STIs, erosions, open sores and infections that facilitate

infections (STIs) or pregnancy. It is recommended that PrEP be taken in conjunction with other methods of prevention.

Many women have cervical or vaginal conditions such as the transmission of HIV.

•

Many women practise “dry” sex, and they cause damage

Apart from PEP and PrEP, mention two other strategies

or infection to the vaginal walls. “Dry” sex is a cultural

for prevention that you are aware of.

practice where women use herbs or other substances –

ARVs taken by an HIV-positive woman during pregnancy and

such as liquid bleach (Jik) or washing powder – to dry out

childbirth for the prevention of mother-to-child transmission

their vaginas for the benefit of some men who believe that

(PMCT); ARVs taken by an HIV-positive person for treatment

a dry vagina is a sign of faithfulness, or to heighten their

as prevention (TasP); safer sex practices; or abstinence.

sexual pleasure. This practice is painful and extremely

Roll of #5 What is drug resistance?

dangerous because it increases the risk of HIV infection. •

Transmission of HIV is more likely to occur just before,

In simple terms, drug resistance refers to the ability of disease-

during or immediately after menstruation because of the

causing germs—such as bacteria and viruses—to continue

large, raw area of the inner uterine lining that is exposed.

multiplying despite the presence of drugs that usually kill them.

•

Younger women are especially vulnerable to HIV infection

With HIV, drug resistance is caused by changes (mutations) in

because their genital tracts are not yet fully mature, their

the virus’ genetic structure. Missing medication doses leads to

vaginal secretions are not as copious, and because they

an increased risk of resistance.

are more prone to lacerations or tears of the vaginal

If you miss medication doses, if the drugs are stopped, or not

lining. There is also evidence to suggest that women

taken at the right time each day, the HIV takes advantage of

once again become more vulnerable to HIV infection after

this and starts to make copies of itself again.

menopause.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

•

Women often practise anal sex to avoid pregnancy, to

Are you in the red?

maintain “virginity”, or because their male partners prefer

Zone Check: HIV

anal sex.

Are you having unprotected sex?

Disempowerment often makes women more vulnerable

Did you have unprotected sex in the last 24 hours?

Do you have only one sexual partner?

Do you have difficulty convincing your partner to use a condom?

Do you believe that you don’t need to use a condom because you (or your partner) are using contraception?

Do you know your HIV status?

Do you know your partner’s HIV status?

Do you think it is possible that you may have been exposed to HIV?

to HIV infection, especially in societies where the status of women is lower than men. Women in such situations have little or no control over their sex lives, and they are not in a position to negotiate safer sex practices because they fear violence and abandonment should they try to do so. Women from low socio-economic backgrounds are often driven to prostitution, and they are particularly vulnerable to rape. Roll of #6 Name four different groups of micro-organisms that cause STIs. Bacterial STIs may be found in one part of the body. If you go to the clinic, the health worker may give you medication that can treat and cure the STI. Examples of STIs that are caused by bacteria include diseases such as Gonorrhoea, Chlamydia, and Syphilis.

Yes

If any of your answers place you on a red square, you are in the RED ZONE. This means that you are at risk for HIV. Ask your HIGHER HEALTH Campus Coordinator for help with HIV Testing Services and support as soon as possible. It is important to know your HIV status so that you can protect yourself whether you are positive or negative

Viral STIs attack systems in the body. They often invade the whole body and its cells. They can be treated, but not cured. Some examples are Hepatitis B, HIV, Genital Herpes (HSV-2), and Genital Warts (HPV). Fungal STIs are caused by fungi, which are like plants, and they usually grow on or in the top layer of skin. They are not always passed on by having sex with someone, and they can be cured. Parasitic STIs are caused by parasites, which are creatures that live off another being’s body. Think of a parasite as a little bug that lives off a human, but cannot always be seen by the naked eye. These STIs that are caused by parasites are passed from person-to-person during sexual activity.

AN UNUSUAL STI: HUMAN IMMUNODEFICIENCY VIRUS (HIV) WHAT IS THE HI VIRUS AND HOW DOES IT INFECT THE BODY?

What types of STIs are incurable? Viral STIs. Name three ways to reduce the risk of mother-to-child transmission (MTCT). ARVs, C-Section delivery, and exclusive breastfeeding while the mother is on ARVs. Why is HIV antibody testing not recommended for infants under 18 months? Test results would reflect the mother’s HIV status because the test will detect the mother’s HIV antibodies until the baby develops its own immune system at 18 months. In order to

HIV is a virus that attacks the human immune system. Once infected, there is no cure, so you will have the virus in your body for the rest of your life, or until a cure is found. The virus targets the white blood cells in the immune system, specifically the CD4 cells. These cells play a very important role in protecting the body against disease and infection. If you don’t know you have the virus, it stays in your body, silently destroying your CD4 cells all the time, while you believe you are healthy and well because there are no symptoms for four to six years.

know the baby’s status, one would need to do a polymerase chain reaction (PCR) antigen test, which will test for the antigen (virus) and not the antibody.

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WHAT ARE THE STAGES AND SYMPTOMS OF THE DISEASE AND HOW DOES IT AFFECT THE IMMUNE SYSTEM? CLINICAL STAGES OF HIV-AIDS STAGE 1

STAGE 2

STAGE 3

STAGE 4

Asymptomatic (No symptoms of HIV disease)

Mild symptoms

Advanced symptoms

Severe symptoms (AIDS)

Short flu -like illness occurs 1-6 weeks after infection

Average: 10 yrs

Infected person can infect other people

Mild symptoms

The immune system deteriorates

Rapid decline in the number of CD4 T cells

HIV in blood drops to very low levels

Opportunistic infections (OI) start to appear

Opportunistic infections become severe and cancer my develop

Antibodies are detectable in the blood

HOW IS HIV PASSED ON FROM ONE PERSON TO ANOTHER?

For HIV to spread, there needs to be THREE factors present

ENTRY POINT A place for the virus to enter the uninfected person’s body. This could be a cut or break in the skin or an opening

EXIT POINT A place for the virus to leave the infected person This could be a cut or break in the skin or an opening

A BODY FLUID IN WHCH HIV VIRUS CAN LIVE A fluid to transport the virus and allow it to remain alive in the body

There are body fluids in which the virus can live and make copies of itself. These fluids must come into contact with an uninfected person’s body fluids through sexual contact, an entry point in the skin, infected needles, or from mother to child. HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

HOW HIV IS NOT TRANSMITTED

NEGOTIATING WITH YOUR PARTNER FOR SAFER SEX

Preventing the sexual transmission of HIV requires using condoms each and every time you have sex. Talking about safer sex with a partner is not always easy, as it often raises questions about trust, and may raise suspicion between a couple. It is important to introduce the topic at a relaxed time, not during a fight and not when the couple is aroused and already ready to have sex. A good idea is to have some strategies or pre-planned phrases to start the conversation. Some ideas on negotiating for safer sex are discussed below. NON-VERBAL NEGOTIATION Sometimes less direct approaches are as effective in promoting the use of safer sex practices as more direct, verbal suggestions. Non-verbal strategies include:

•

Strategically placing a condom on a pillow.

•

Placing a safer sex pamphlet in view to initiate discussion or to “drop a hint”.

•

Seduction (i.e., putting the condom on your partner).

•

Use flattery (“Ooo, we’ll need to use an extra-large condom!”).

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It’s also useful to start a conversation about the issue early on in the relationship, as explained in the table below. Technique

Why

Suggestion

Express your feelings using “I” statements

A “YOU” message, for example, “You need to use a condom because I don’t want you giving me some life threatening disease…” comes across as accusing and blaming. This is likely to trigger anger or resistance. “I messages” are about what you feel and think, and you avoid demanding, blaming, or finger pointing.

Instead, you could say: “I want to use a condom because I believe protecting our health and safety is a priority...”, or “I feel strongly about taking responsibility for my actions…”, and “My reasons are...”

Focus on interests, not positions

By exploring your partner’s interests, you will discover the real issue at hand. Avoid saying “So you’re refusing to use a condom…?” (Taking a position). That tone or style of question will start an argument that is not likely to end well.

Instead, say: “I would be really happy to talk more about why you don’t want to…” A person may not want to use condoms because he/she is concerned that their enjoyment (interest) will be affected. You can then address this concern with appropriate suggestions.

Listen to and acknowledge your partner’s concerns

In this way you let them know their needs are important to you too. Avoid saying: “So you don’t care about my feelings”, or “This relationship is all about you and your needs.”

Instead, say: “So you’re worried that it will spoil the moment and disrupt everything…? I understand what you’re saying, and I want us to enjoy our time together. Could we try... so we could avoid that situation, still have pleasure and be safe.”

Give your partner time Pushing or rushing creates pressures and leads to to think about what you resistance. Avoid stopping in the middle of a moment of passion and insisting on looking for a condom. It are saying; don’t rush will result in anger and frustration.

You don’t need to make a final decision during your first discussion

Safer sex is a big topic and a critical aspect of any relationship.

Instead, talk about it early on, just as the relationship starts to get physical, so that you are both clear about the terms of your sexual relationship. Have the discussion before you find yourself in the middle of the sexual act! Take your time, and if you need, decide together when you will continue the conversation.

REMEMBER: Anyone can get HIV, but you can take steps to protect yourself from HIV infection. The only way to know whether or not you have the virus is to test regularly for HIV. Are you in the red? Zone Check: Safer Sex I CANNOT talk to my partner about using condoms/I am not practising safer sex with my partner because: 1.

He/she will think I am cheating and will not trust me anymore

My partner will not enjoy sexual intercourse with me anymore

He/she will leave me to have sex with someone else

My partner makes those decisions and has control over when and how we have sex

My partner may beat me if I suggest such a thing

I am scared and/or embarrassed to bring up the topic of protection

I have only one partner so I’m not at risk in any way

I trust my partner

We can stop in time so there’s no risk or need for protection

Yes

If any of your answers place you on a red square, you are in the RED ZONE. This means you are at risk for HIV and STIs. Ask your HIGHER HEALTH Campus Coordinator for help with counselling, contraception and safer sex options and further support as soon as possible.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

WHAT YOU NEED TO KNOW ABOUT HIV TESTING SERVICES (HTS)

HIV counselling and testing (HCT) is now referred to as HIV testing services (HTS) to embrace the full range of services that should be provided together with HIV testing. These services are described below in more detail.

Counselling

Linkage to Care

Clinical and Support Services

Coordination with Laboratory Services

In the early years when there was no treatment for HIV, and widespread stigma and discrimination existed, it was difficult to see the benefits of testing as clearly as we see it now. But that was many years ago. HIV testing today is the crucial entry point for all HIV services, including both prevention and treatment. When someone tests and learns that they are HIV positive, there is an opportunity to get access to life-saving treatment, take care of their health and well-being and that of their loved ones. For those who test HIV negative, there is an opportunity to stop and think about their level of risk and make important life decisions about which HIV prevention options are the best fit for them. The South African government has made a determined effort to make HTS available as widely as possible. Strategies have been put in place to strengthen the quality of HTS at all health facilities and non-health sites. With HTS now available in all public health facilities in South Africa, the numbers of people who have ever had an HIV test and are aware of their status have increased significantly. There is a movement across the world to accelerate universal access to HIV prevention, treatment, care and support services for people living with HIV and AIDS (PLWHA). The main entry point for HIV treatment, care and support is through HTS, which is now also available on your campuses. South Africa has adopted the UNAIDS’ 90–90–90 strategy, which calls for 90% of all people living with HIV to be diagnosed; 90% of eligible people with diagnosed HIV to receive ART; and 90% of those on ART to have a suppressed viral load by 2020. THE 5Cs The 5Cs (Consent, Confidentiality, Counselling, Correct Results, Connection) are the foundation of effective HTS. 1. CONSENT People who receive testing must consent to be tested and counselled. Clients or patients must be informed of the process for HTS and of their right to decline testing. 2. CONFIDENTIALITY Discussions between the HTS provider and the client should not be disclosed to anyone without the express consent of the person being tested. Shared confidentiality with a partner or family members or trusted others must be encouraged. 3. COUNSELLING Pre-test information can be shared in a group setting, but a private setting must be provided for individuals who have questions that they do not wish to share with others. HIV testing must be followed by appropriate high-quality post-test counselling. 4. CORRECT RESULTS Quality assurance (QA) mechanisms are essential to ensure that people receive the correct diagnosis. 5. CONNECTION Linkage to prevention, treatment and care services and effective and appropriate follow-up should be provided. 24

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Higher education-based HTS will be offered continually to all

risk for getting HIV. This includes HIV-negative adults in on-

young people attending universities and TVET colleges, as well

going sexual relationships with HIV-positive partners, as

as to the staff at these institutions. As this is a high-risk group,

well as adolescents and young people who are at very high risk

HTS providers should ensure that as many young people as

for getting HIV. PrEP is currently being piloted for use in students

possible are voluntarily tested. These are aligned to the National

and this is likely to roll out to TVETs in the near future, as part

HTS Programme. Outreach services should also target HEIs

of a DOH prevention roll out strategy to students. Research

and all HIV testing conducted in these settings shall be reported

suggests that PrEP is highly effective in preventing the sexual

to the local health office. An HIV test can be done at any doctor,

transmission of HIV, as long as the drugs are taken regularly,

clinic or hospital, and is voluntary. Counselling before drawing

as directed. However, PrEP does not prevent other STIs or

blood (pre-test) and after giving the result (post-test) is standard

pregnancy. It is recommended that PrEP be used together with

practice and required by law in South Africa. Counselling

other methods of preventing HIV and STI transmission and

allows the patient to ask any questions, and to prepare for the

pregnancy.

possibility of a positive result. By law, the results of an HIV test are confidential, and may not be disclosed by the healthcare professional to anybody other than the patient. If a person tests positive for HIV, they will require additional counselling on living with HIV, options about disclosure, and possibly treatment adherence counselling.

Post-exposure prophylaxis (PEP) PEP is Post Exposure Prophylaxis. Post (meaning after), Exposure (meaning having had contact with the virus), and Prophylaxis (meaning prevention). PEP is where medication is used to prevent infection after someone has been exposed to

CAN medication be used to prevent HIV infection?

the virus, for example, through unprotected sex with an infected individual, rape where the perpetrator may be positive, a needle prick injury in a healthcare setting, etc. If it is the person’s first

Get tested and talk to your partner about HIV

exposure to the virus, and PEP (which consists of ARVs) is administered within 72 hours of exposure, it may prevent the virus from replicating sufficiently to infect the person. To be

Discuss HIV testing before you have sex

Oral sex is much less risky than anal or vaginal sex

If you’re sexually active, practice low-risk sexual behaviour

Use a condom correctly every time you have vaginal, anal, or oral sex

Get tested and treated for STIs and request that your partner(s) get tested and treated too

Avoid injectable drugs. But if you do, use only sterile equipment and water, and never share your equipment with anyone

Yes, HIV medicines are also used for pre- and post-exposure prophylaxis (PrEP and PEP, respectively) and to prevent motherto-child transmission (MTCT) of HIV. Pre-Exposure Prophylaxis (PrEP)

effective, PEP must be started within three days (72 hours) after possible exposure to HIV. PEP involves taking HIV medicines each day for 28 days. PEP is a short-term ART that reduces the likelihood of HIV infection after exposure to HIV-infected blood or sexual contact with an HIV-positive person or someone who may have HIV. The drug regimen for PEP consists of a combination of ARV mediations that are taken for a period of four weeks. Prevention of mother-to-child transmission of HIV (PMTCT) Pregnant HIV-infected women take HIV medicines during pregnancy and childbirth to reduce the risk of passing HIV to their babies. Their new-born babies also receive HIV medicine for six weeks after birth. The HIV medicine reduces the risk of infection from any HIV that may have entered a baby’s body during childbirth. PMTCT programmes provide ART to HIVpositive pregnant women to stop their infants from acquiring

PrEP is Pre-Exposure Prophylaxis. Pre (meaning before),

the virus. Without treatment, the likelihood of HIV passing from

Exposure (meaning contact with the virus), and Prophylaxis

mother-to-child is 15% to 45%. However, ART and other effective

(meaning prevention). It involves the use of ARVs to keep HIV-

PMTCT interventions can reduce this risk to below 5%.1

negative people negative. PrEP has been shown to be safe and effective at preventing HIV infection. Truvada is currently the only ARV approved for use as a PrEP. Truvada is administered as a single pill, but it in fact contains a combination of two ARV

drugs. PrEP is meant to be used by those who may be at high

vision 2010-2015: Preventing mother-to-child transmission of

World Health Organization (WHO). “PMTCT strategic

HIV.” WHO, Geneva, 2010. HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Mother to child transmission

HIV +

Pregnancy

Labour & Delivery

Breastfeeding

The Anatomy (physical structure) of the HIV virus

Steps in the HIV replication cycle

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What is a Fixed Dose Combination (FDC) ARV? •

FDC is a combination of two or more active drugs in a single pill.

•

The FDC ARV is a single tablet which contains a combination of tenofovir (TDF), emtricitabine (FTC), and efavirenz (EFV).

•

This means they are able to block the action of more than one HI virus at three different points at the same time. Antiretroviral (ARV) Drugs: How they Work

KEY MESSAGES THE IMMUNE SYSTEM RECOGNISES AND DESTROYS ANTIGENS (HARMFUL FOREIGN SUBSTANCES WHICH CAUSE ILLNESS AND DISEASE). A VIRUS IS AN EXAMPLE OF AN ANTIGEN. •

An immune response is when the immune system responds to the presence of “enemies” and makes antibodies to fight off diseases.

•

Antibodies are proteins in the blood that act as “weapons” to protect against future attacks from harmful substances (antigens).

•

The job of the antibody is to bind with antigens and immobilise them so that the T “killer” cells from the immune system can destroy and remove the foreign substances from the body.

•

With the HI Virus, it takes the body a long time to realise that they are in the body because of the integration of the viral DNA with the DNA of the CD4 cell.

•

This gives the virus enough time to replicate and produce millions of viruses before it is detected.

•

“Killer” T cells can only act if activated by the CD4 commander cell.

•

HIV is so powerful because it disables the CD4 cells so that they cannot give this command to the “killer” T cells to destroy the virus.

•

This allows invading antigens to remain in the body and weaken the immune system.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Myths about HIV transmission, prevention and treatment

Myth

Fact

Myth No. 1: I can get HIV by being around HIV-positive people

HIV is not spread through touching or hugging, sneezing, coughing or breathing the same air or being in the same room as an infected person.

Myth No. 2: HIV is no longer a problem because drugs and medication are easily available

ARVs are easily available and accessible in our country now. But this does not mean we should be careless or reckless or take unnecessary risks. Because there is no known cure, once you start, you have to be on treatment for the rest of your life. This can lead to your body becoming used to the drugs and the drugs not working anymore. What’s more, sometimes you get tired of taking medication every day, and you may miss doses. If you miss doses, you can become resistant and also create a new and stronger virus that cannot be treated by the same drugs. This creates a problem for everyone. Also, because of the urgency of having to provide treatment, there’s not enough time to conduct longterm research to know the long-term impact and possible side effects of the drugs. As it stands, many of these drugs have side-effects that impact on the quality of life.

Myth No. 3: Mosquitoes can carry and spread the HI virus from one person to another

HIV is a HUMAN virus and, therefore, requires human DNA to survive. Thus the virus would not survive long enough for the mosquito to carry it from one person to another. Mosquitos also do not inject blood into people. Finally, several studies show no evidence to support this – even in areas with lots of mosquitoes and cases of HIV.

Myth No. 4: HIV is a death sentence

There are people throughout the world living with HIV for more than 20 years. HIV is currently treatable, even though it’s not yet curable. Treatment, together with choosing to live a healthy and risk-free lifestyle, will ensure: The life expectancy of HIV-positive individuals increases to almost that of a healthy uninfected person. Infected people live much longer, normal, and productive lives.

Myth No. 5: HIV is a man-made virus being used by governments to decrease minority population groups

There is no proof or evidence to support this theory. On the contrary, governments throughout the world spend a significant portion of their budget on HIV care, support and treatment

Myth No. 6: Only gay men and users of injectable drugs are at risk of HIV infection. Straight men are safe

Evidence shows a higher rate of infection among heterosexual men compared to gay men. HIV is about lifestyle and risk, rather than about specific sectors of the population.

Myth No. 7: If you’re on treatment, you cannot transmit the virus or become re-infected

Even with treatment, the virus remains in the body. For as long as that is the case, you can transmit the virus, and you can become re-infected with the same strain or infected with a new strain of HIV.

Myth No. 8: If both partners in a relationship are HIV positive there’s no need to practice safer sex

Practising safer sex is important to prevent reinfection or infection with a different strain. Repeated exposure to the virus increases your viral load and may make treatment less effective.

Myth No. 9: If my partner is HIVpositive, I’m sure I’d know

The only way to know if someone is HIV is through testing.

Myth No. 10: You’re safe from HIV infection if you practice oral sex

Oral sex is safer than other types of sex, but it is still possible to transmit the virus if there are entry and exit points for infected body fluids.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

LESSON THREE: TUBERCULOSIS (TB)

ASK YOUR HEALTH WORKER Purpose of activity:

Aim:

•

To define and describe Tuberculosis (TB) and its relationship

To provide participants with the opportunity to demonstrate what they know about TB.

to HIV and AIDS.

•

Learning Outcomes

To assess the level of baseline knowledge of participants and fill in the gaps about TB.

Lesson Outcomes:

•

To provide a non-threatening way to learn.

By the end of this lesson, participants should:

•

To demonstrate interesting, informal and safe ways for

•

Know what TB is.

•

Know the signs, symptoms, risks and treatment of

discussion and debate on TB.

different types of TB.

Requirements: Leader’s Resource – TB Q&A

•

Understand what a latent TB infection.

Time: 45 minutes

•

Know the signs and symptoms of active TB disease.

Planning Notes:

•

Be familiar with how drug-resistant TB is created.

•

Know the relationship between TB and HIV.

lead this session with you and to provide an opportunity

•

Understand the importance of adherence to the treatment

for participants to become familiar with information about

regimen and the consequence of non-adherence.

the clinic. Knowing a friendly face at a local clinic may

Know the challenges related to diagnosis and the

make it easier for them to go there when they need health

relationship to HIV in this regard.

services.

•

Read Leader’s Resource: TB Q&A.

Introduce the lesson and explain that it is important for

•

Cut out the questions only.

participants to know the risks of being infected with TB,

•

Fold the strips and place them in a container.

how TB is transmitted, and what to do to if you have

Obtain pamphlets on TB from a local health department or a

symptoms of TB.

family planning clinic. Display the pamphlets and information

Procedure 1.

Acknowledge

that

participants

may

already

from the clinic in a prominent area of the room.

have

knowledge and access to information about TB. 3.

Explain that it is for this very reason that they will be given

DISCUSSION QUESTIONS

the opportunity to demonstrate what they know as well as 4. 5.

Invite a practitioner from a local TB or health clinic to co-

learn some new information about TB.

•

What is the difference between MDR and XDR TB?

Divide the group into two and have the first group carry

•

What is DOTS, and why do we use this strategy?

their chairs and sit in a circle.

•

What is the link between HIV and TB?

The second group should sit in a circle around the first group.

Place one chair in the middle of the inner circle.

The inner circle is the “health workers”, and the outer circle is the community members visiting the clinic.

Members of the outer circle will be given pieces of paper

KEY MESSAGES •

TB is a preventable and curable disease.

•

South Africa is estimated by the World Health Organization (WHO) to have the world’s third-largest TB burden and an

with questions or concerns relating to TB. 9.

exceptionally high rate of multi-drug resistant (MDR) and

Members of the outer circle will have turns to go into the centre and choose a “health worker” to address their concern about TB.

extensively drug-resistant (XDR) TB cases. •

and pose a greater risk of infection to people in close contact

10. If the chosen health worker cannot answer their concern,

with the infected person. These strains more often can lead

they can discuss with other health workers and provide an answer. 11. Conclude the activity using the Discussion Questions provided.

Drug-resistant strains are expensive and difficult to treat,

to treatment failure and death. •

TB cases have become almost five times more severe than they should be due to HIV and AIDS.

•

Antiretroviral drugs (ARVs) do not cure TB, and TB drugs don’t cure HIV.

•

This is why it is very important that people know their HIV status and get tested for TB and HIV regularly.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Resource for TB Activity: TB Q&A

WHAT ARE THE TESTS FOR TB? 1.

WHAT IS TB? Tuberculosis (TB) is a disease caused by germs that are spread

skin test, shows if a person has been infected. 2.

the air when a person with TB of

enough test for many people, and it is not used frequently. 3.

speaks,

sings.

People nearby may breathe in these

bacteria

and

become

infected. TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine. A person with TB can die if they do not get treatment. Other symptoms of TB depend on the parts of the body affected. With TB of the lungs, symptoms also can include coughing, chest pain, and coughing up blood

A chest x-ray is given if the TST shows that a person has been infected. The x-ray shows if any damage has been

the lungs or throat coughs, sneezes,

QuantiFERON is a blood test for diagnosing latent TB infections (LTBIs). However, it is not yet an accurate

from person to person through the air. The bacteria escape into

The tuberculin skin test (TST), also called the Mantoux

done to the lungs. 4.

A sputum test shows if there are TB germs in a person’s lungs. Sputum is phlegm from deep inside the lungs.

WHO SHOULD GET TESTED FOR TB? •

A person who has symptoms of active TB disease.

•

A person who has been exposed to someone (a family member, friend, or co-worker) who has active TB disease.

•

A person who has HIV infection or certain medical illnesses such as diabetes or chronic kidney failure.

•

A person who is taking steroid or other immunesuppressing drugs for chronic medical conditions.

WHAT CAUSES TB? TB is caused by the bacterium Mycobacterium tuberculosis. The bacterium can cause disease in any part of the body, but it normally enters the body through the lungs and resides there. HOW IS TB SPREAD?

•

A person who lives or works in a homeless shelter, prison, hospital, nursing home, or another similar group setting.

TB can be cured, even in people living with HIV. Directly Observed

Treatment

Short

Course

(DOTS)

the

internationally recommended strategy for TB control. This means that the person with TB should have a buddy (friend or family member) that observes them taking the medication. This is done to provide support and help them remember to take the treatment because, if they miss doses, it can make their TB virus stronger and more powerful so that it becomes resistant to the treatment. This is how drug-resistant TB strains are formed. DOTS treatment uses a variety of powerful antibiotics in different ways over a long period to attack bacteria and make sure that they are destroyed. Treatment has been shown to prolong the life of people living with HIV by at least two years. It

TB is spread through the air from one person to another. The bacteria come out into the air when a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected. When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to grow. From there, they can move through the blood to other parts of the body, such as the kidney, spine, and brain. TB in the lungs or throat can be infectious. This means that the bacteria can be spread to other people. TB in other parts of the body, such as the kidney or spine, is usually not infectious. People with active TB disease are most likely to spread it to people they spend time with every day. This includes family members, friends, and co-workers or schoolmates.

is important that people who have the disease are identified at the earliest possible stage so that they can receive treatment, contacts (people exposed to them while they were infectious) can be traced so that they too can be tested for TB, and measures can be taken to minimise the risk to others. However, some strains of bacteria have now become resistant to one or more of the antibiotics commonly used to treat them; these are known as drug-resistant strains. HOW IMPORTANT IS TREATMENT? If people with active TB disease do not take their medication, they can become seriously ill, they can develop germs that are resistant to the TB medications, and may even die. But people with active TB disease can be cured if they have proper medical treatment and take their medication as prescribed

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

SIGNS, SYMPTOMS, RISKS AND TREATMENT OF DIFFERENT TYPES OF TB There are many different types of TB that are commonly treated in South Africa. Some of these will be mentioned below. Latent (sleeping) TB infection When somebody who has TB of the lungs coughs or sneezes and the germs are released into the atmosphere, they may enter the bodies of people who are nearby. People who have many CD4 cells have strong immune systems, so they are able to fight the bacteria to stop them from growing. In such cases, the bacteria are not strong enough to make the person sick, but they stay in the body even though they are not active. This is called latent TB infection (LTBI). In other words, the germs are asleep but alive in the body. People with LTBI: •

Have no symptoms,

•

Don’t feel sick,

•

Can’t spread TB to others, but

•

Will test positive if they have a TB blood test.

In many people who have strong immune systems, this sleeping infection (latent TB) never awakens. In these people, the TB bacteria can remain inactive for a lifetime without making them sick. However, in other people, especially people who have weak immune systems, the bacteria wakes up and grows strong when there are not enough “soldiers” (healthy white blood cells and other immune system components) to protect the body. They multiply, cause TB disease, and then the person becomes sick and starts showing symptoms. What are signs and symptoms of active TB disease? TB bacteria become active if the immune system can’t stop them from growing. The active bacteria begin to multiply in the body and cause active TB disease. The germs attack the body and destroy important cells and body tissue. The person starts to feel sick and show symptoms. Symptoms of TB depend on where in the body the TB bacteria are growing. TB in the lungs may cause symptoms such as shown below. Other symptoms of active TB disease are:

TB can also affect other parts of your body, including your kidneys, spine or brain. When TB occurs outside your lungs, signs and symptoms vary according to the organs involved. For example, TB of the spine may give you back pain, and TB in your kidneys might cause blood in your urine.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

What is drug-resistant TB?

What is the relationship between TB and HIV?

If you have active TB and the TB drugs that the health worker

People with suppressed immunity are more likely to develop

or clinic gives you do not work, then we say the germs are

active TB than those with normal immunity. Between 50% and

resistant to the medication. In other words, they are stronger

60% of untreated HIV-positive people infected with a latent TB

than the medication and have found ways to fight the drugs.

infection will go on to develop the active disease. The annual risk of TB in an untreated HIV-positive person is 10% compared

This is another reason TB remains a major killer. Drug-resistant

to a lifetime risk of 10% in a healthy individual.

strains of TB come about when an antibiotic fails to kill all of the

Immunosuppressive conditions, such as silicosis, diabetes

germs it targets. Since the first antibiotics were used to fight TB

mellitus, and prolonged use of corticosteroids and other

more than 60 years ago, some TB germs have found ways to

immunosuppressive drugs, also increase the risk of progression

survive, they are able to duplicate themselves and, therefore,

to active TB. Since the 1980s, the number of cases of TB has

make more that are stronger and can beat the medication.

increased dramatically because of the spread of HIV, the virus

Drugs for treating TB have been used for many decades, and

that causes AIDS. Infection with HIV suppresses the immune

resistance to the medicines is growing.

system, making it difficult for the body to fight TB bacteria. As a result, people with HIV are many times more likely to get TB

The main cause of drug resistance is not taking the medication

and to progress from latent to active disease than people who

properly (missing doses). When people do this, we say that

aren’t HIV positive.

they are not adhering to treatment. It is becoming more common that people who get TB for the first time are getting

Adherence to the treatment regimen and the

infected with the drug-resistant strain of TB. This is very scary

consequence of non-adherence

because drug-resistant TB (DRTB) is much harder to treat.

Adherence means taking your pills the number of times you

A patient may have to take as many as 14 600 pills over a

are supposed to without missing doses. Earlier we said that

two-year period – as well as a painful daily injection for the

drug-resistant TB (DRTB) comes about when the antibiotic

first six months. The treatment also has many side effects,

does not succeed in killing off all the germs, and some of the

including nausea, vomiting, hallucinations (seeing things that

germs survive and become stronger because they can now

are not real or not really there), diarrhoea, suicidal feelings,

fight the antibiotic and win. This happens mainly when people

and even deafness. HIV and TB are a powerful “killer” team,

miss doses because then there is not enough of the antibiotic

each helping speed the other’s progress. Someone who is

to kill all the germs. The serious results of allowing your body

living with HIV and TB is much more likely to become sick with

to grow resistant germs have been explained already. It is

active TB.

important to realise that when this happens, it puts the infected person, their families and the entire community at risk. It also

Some TB bacteria have developed resistance to the most

makes health workers helpless because the medication does

commonly used treatments, such as isoniazid and rifampin.

not work anymore.

Some strains of TB have also developed resistance to drugs less commonly used in TB treatment. These medications are often used to treat infections that are resistant to the more commonly used drugs. How DOES ONE get drug-resistant TB? There are two ways that people get DRTB. Firstly, people get DRTB when their TB treatment is not right. This can be for a number of reasons, including that patients miss medication doses and don’t take their medication the way the healthcare worker explains to them, the wrong TB drugs are prescribed, or TB drugs that are used for the treatment are not strong enough for the strain of virus that is being treated. The Second means happens when DRTB is passed on from one person to another.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Are you in the RED? Zone Check: TB

Yes

References

Have you had a persistent cough with thick phlegm (mucus) for two weeks or more?

Avert. “HIV and AIDS in South Africa.” Avert, 2019. Available

Are you HIV positive and have been coughing as well?

saharan-africa/south-africa#sthash.orBk85Rd.dp

Have you experienced high temperatures/ fever for more than two weeks?

Centers for Disease Control and Prevention (CDC). “Tuberculosis.”

Have you experienced night sweats that leave you dripping wet?

Have you noticed that you’ve been losing weight without trying to (more than 1.5 kg in a month)?

Do you feel tired all the time?

Do you know/live with someone who is experiencing these symptoms?

If any of your answers place you on a red square, you are in the RED ZONE. This means that you are at risk for TB. Ask your HIGHER HEALTH Campus Coordinator for help with TB screening, testing, treatment and support as soon as possible.

at:

https://www.avert.org/professionals/hiv-around-world/sub-

CDC, 2018. Available at: http://www.cdc.gov/tb Dutta, SS. “History of Tuberculosis.” News Medical, 2019. Available

at:

http://www.news-medical.net/health/History-of-

Tuberculosis.aspx HEAIDS. “Students and staff at tertiary institutions at risk of TB.” HEAIDS, 2015. Available at: http://heaids.org.za/news/studentsand-staff-at-tertiary-institutions-at-risk-of-tb National Department of Health (NDOH). “South African National TB Management Guidelines 2014.” NDOH, 2014. Available at: http://www.tbonline.info/media/uploads/documents/ntcp_adult_ tb-guidelines-27.5.2014.pdf Mayo Clinic. “Tuberculosis.” Mayo Clinic, 2019. Available at: http://www.mayoclinic.org/diseases-conditions/tuberculosis/ symptoms-causes/dxc-20188557 SANAC. “National Strategic Plan on HIV, STIs and TB 20122016.” SANAC, 2011. Available at: www.health.gov.za/docs/ strategic/2012/NSPfull.pdf StatsSA. “Mortality and causes of death in South Africa, 2013: Findings from death notification.” StatsSA, December 2014. Available

at:

http://beta2.statssa.gov.za/publications/P03093/

P030932013.pdf WHO. “Tuberculosis Fact Sheet No. 104.” WHO, October 2014. Available at: http://www.who.int/mediacentre/factsheets/fs104/en

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Chapter 2|SEXUAL AND REPRODUCTIVE HEALTH

Mental Health

Disability

Alcohol and Drug abuse

Introduction and Overview

Aim

Prevention and treatment of sexual and reproductive health (SRH)

The key focus of the chapter is to support young people to

issues requires a thorough understanding of the psychological

become personally and socially competent in managing their

and social contexts in which they occur, as well as the biological

sexual and reproductive health and well-being

and diagnostic aspects of SRH and well-being. Introducing

What is Sexual and Reproductive Health?

reproductive health education at schools and post-schooling institutions can have many benefits. These programmes can help prevent early pregnancy, HIV/AIDS and STIs, as well as various cancers. Lecturers can also refer students to local health or counselling services when appropriate. By providing reproductive health education early, it is possible to encourage the formation of healthy sexual attitudes and practices. This is easier than changing well-established unhealthy habits later. Note to facilitators •

A peer educator’s own values should not interfere with teaching reproductive health, for example, if their religious beliefs prohibit termination of pregnancy (TOP) this should not preclude them from assuming a neutral stance when discussing the issue in a group or workshop setting.

•

Use respectful terms and avoid hurtful language, particularly in regard to sexually active young people, and those who do not conform to conventional gender and social norms.

•

Topics related to reproductive health — for example, TOP — may raise disturbing or intense feelings. Students should not feel pressured to disclose information about their own experiences.

•

Peer educators should be aware of their capacity to provide support to students. Should students choose to access such support, it is crucial to respect their confidentiality.

•

Be prepared to manage sensitive issues, and to challenge discriminatory attitudes. Here are some tips: --

Prepare yourself to discuss the issues without feeling uncomfortable.

Get as much information as possible on what potentially sensitive areas may be so that you can work out strategies to bring them out and handle them effectively.

Build an open atmosphere in which participants feel comfortable talking about these issues.

Encourage open and frank discussion and commend participants who display openness.

Observe the group’s body language to help you decide when to probe an issue further and when to back off. When people do not want to discuss something, they may avoid eye contact or fold their arms across their chest.

According

the

World

Health

Organization

(WHO), sexual and reproductive health (SRH) is a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction or infirmity (illness). Therefore, a positive approach to sexuality and reproduction should recognise the part played by pleasurable sexual relationships, trust and communication in promoting self-esteem and overall well-being. All individuals have a right to make decisions governing their bodies, sexuality and reproductive well-being, on condition that these decisions do not infringe on the rights of others. This includes the right to access education and information, services and healthcare on sexual and reproductive health and rights (SRHR). SRHR are basic human rights for everyone and are fundamental to the development conditions of any population. SRHR also seeks to ensure that users of the material, including peer educators and students, are informed of legislation and policy pertaining to SRHR. The training of peer educators will be designed to familiarise them with the methodology and provide them with opportunity to discuss how they can use and adapt the resources in the tool-kit for working with students. The facilitators will be able to share their own perspectives and experiences where it will help to modify the tool kit to meet their needs.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

THIS CHAPTER SEEKS TO:

Activities and tasks Discuss why this topic is important

Define relevant terminology

Identify SRH as an umbrella for issues that affect men, women and LGBTI individuals alike

Match that!

Support young people to manage their sexual and reproductive health

Quiz: Is that a fact? Instructions for the flow of the activities and tasks (sexual health) •

Introduce the module on SRH by asking the question: “What do we mean by the terms Sexual and Reproductive Health?”

LESSON ONE: SEXUAL HEALTH Aim To explore all aspects of sexual health and well-being, including a healthy lifestyle, sexual rights and responsibilities, as well as risks and consequences associated with lifestyle and sexual

•

Note all responses on the flip chart.

•

Ask “What is sexual health?” and note responses on the flipchart.

•

Instruct students on the procedure for the activity “match that”, as provided below. Explain that the activity will

behaviour.

explore other terms relevant to the core content of the

Lesson Objectives

entire module.

By the end of this lesson, peer educators will: •

Understand what is meant by sexual health and wellbeing and why this topic is important.

•

Understand relevant terms and concepts pertaining to Sexual and Reproductive Health (SRH).

•

Have explored several aspects of sexual behaviour, including consequences of high-risk practices:

Activity 1: Match that! a.

into two smaller groups (equal in number if possible). b.

STIs (risks, prevention, treatment, care and support),

•

Sexual consent,

•

Sexual decision-making,

•

Safer sex, and

•

Access to and availability of treatment, care and support.

•

Understand the concepts of adherence and resistance.

•

Know the different types of STIs and how they contribute

activity below). d.

monitoring. Be familiar with available resources and know-how to access health services. Planning Notes •

Prepare and review instructions for activities.

•

Ensure that preparation for the activities is completed

Sexual health, including sexual well-being.

•

Terminology and acronyms specific to SRH.

•

Four categories of STIs.

•

Education and prevention.

•

Treatment, care and support.

If it is a term, the person from the opposing team with a matching definition should put their hand up and read the definition aloud. The facilitator will confirm whether it is “a match”.

Continue until all terms and definitions have been matched.

Allocate 10-12 minutes for this activity.

Conclude the session by giving each student a handout containing all terms and definitions discussed.

On completion of this activity, conclude the lesson on terms, concepts and definitions by encouraging students

Lesson content •

Instruct students to read out aloud what is written on their card.

Be aware of the need for compliance and health

timeously.

Distribute cards with terms and concepts to one group and cards with definitions to the other group (see resources for

to increasing the risk of HIV infection.

•

Instruct each group to stand in a line side by side facing the other group.

•

Divide the class into groups of six, then divide each group

to master all relevant terms and definitions. j.

Task: Create your own dictionary or glossary of terms and concepts and exchange with each other to enrich your knowledge bank.

Time allocation 2 hours 30 minutes

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

RESOURCE FOR THE ACTIVITY: MATCH THAT!

There are human rights that recognise the basic right of all couples and individuals to:

REPRODUCTIVE RIGHTS

•

Decide freely and responsibly the number, spacing and timing of their children

•

have the information and means to do so,

•

attain the highest standard of sexual and reproductive health, and

•

make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents...”

GENDER IDENTITY

CONSENT

How a person perceives themselves - as a man, as a woman, or other. When someone clearly and voluntarily agrees to do something, fully understanding the consequences of their decision, and they do so without coercion, such as the use of force or threats to their safety and does so without being drunk, drugged or deceived.

GENDER ROLE

Norms of expected behaviour for men and women assigned primarily on basis of biological sex; a sociological construct, which varies from culture to culture. Violence against another person because of their gender. The violence can be physical,

G E N D E R - B A S E D sexual, psychological, economic or cultural. While this type of violence is largely experienced VIOLENCE

as violence against women, it can affect all people, including men, and gay, lesbian, transgender, queer and intersex (LGBTQI) persons. “These rights are usually understood as the right of all people, regardless of their nationality, age, sex, gender, health or HIV status, to make informed and free choices with regard to their

SRHR

own sexuality and reproductive well-being, on condition that these decisions do not infringe on the rights of others. This includes the right to access education and information, services and healthcare. They are considered to be a basic human rights for everyone and are fundamental to development conditions of any population”

SEXUAL RIGHTS

RAPE

The right of individuals to control their own bodies and their sexuality without discrimination, coercion, or violence. Non-consensual penetration, however slight, of the vagina, anus or mouth by a penis, any other body part or object. Unwanted or obscene remarks, including verbal and non-verbal conduct. Examples include

SEXUAL HARASSMENT

touching, unwelcome jokes, whistling, rude gestures, unwanted questions about sex life, requests for sex, staring at your body in an offensive way, or promising rewards in exchange for sexual favours, to name a few.

10. SEXUALITY 11. RAPE CULTURE

This term is about understanding one’s own sexual feelings and attractions one might feel towards others. It is not about whom we have sex with, but who we are sexually attracted to. The social or cultural practices and beliefs that allow for rape and sexual violence to be normalised, accepted and expected. The direction of one’s sexual interest toward members of certain sexes. Can involve fantasy,

12. SEXUAL ORIENTATION

behaviour, and self-identification; a person’s general makeup or alignment in terms of partner attraction. Includes (among others) a same-sex orientation, male-female orientation, a bisexual orientation, and a pansexual orientation.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

DISCUSSION QUESTIONS 1.

How did it feel to learn new and different terminology?

Why is it important to know this information?

What does language have to do with actual behaviour, practices and actions?

KEY MESSAGES •

Terms and concepts change and adapt in accordance with new strategies and information.

•

New terminology emerges regularly.

•

Keeping abreast with information is empowering because it ensures progressive thinking, standards and developments.

Allow a five-minute break 1.

Introduce the next lesson.

Explain that it is important for participants to know the risks of sexually transmitted infections (STIs), how they’re transmitted, and what to do to reduce that risk.

Acknowledge that participants may already have knowledge and access to information about STIs.

Explain that it is for this very reason that they will be given the opportunity, in the form of a quiz, to demonstrate what they know as well as learn some new information about STIs.

Activity 2: Is that a fact? Time: 45 mins •

Divide the group into four teams and have each team move to different corners of the room.

•

Tell participants that their team will play against the others in a game and the team with the most points wins.

•

Go over the instructions for the game.

•

Each team will draw a statement about STIs. The team must consider the statement and decide whether the statement is true or false.

•

If their answer is correct, the team scores two points. If the team can also explain why the answer is correct, they get an extra point.

•

If the team cannot correctly explain the answer, another team can try for the extra point.

•

Have someone from the first team draw a statement and confer with his/her team members to decide whether it is true or false. Ask the team member who drew the statement to declare whether the team has agreed that the statement is either true or false.

•

Ask the team to explain the statement and award an extra point if the explanation is correct. If not, allow any other team to try for the extra point.

•

As the game progresses, use the Fact Sheet (leader’s resource) and the content section in this lesson to provide additional information about the statements. Conclude the activity using the Discussion Questions provided for extra points.

•

Add up points and announce first, second, third, and fourth places.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

RESOURCE FOR THE ACTIVITY: IS THAT A FACT? #

STATEMENT 2 points

TRUE

FALSE

EXPLANATION 1 Point

A person can always tell if she/he has an STI.

People can and do have STIs without having any symptoms. Women often have STIs without symptoms because their reproductive organs are internal. However, men infected with some STIs, such as chlamydia, also may have no symptoms. People infected with HIV, the virus that causes AIDS, generally have no symptoms for some time, even years, after infection.

With appropriate medical treatment, all STIs, except HIV, can be cured.

Herpes and human papillomavirus (HPV) (genital warts) are STIs caused by viruses. Neither can be cured at the present time.

The organisms that cause STIs can only enter the body through a woman’s vagina or a man’s penis.

STI bacteria and STI viruses can enter the body through any mucous membranes, including the vagina, penis, anus, mouth, and, in some cases, the eyes. HIV can also enter the body when injected into the bloodstream from shared IV drug needles, or when an open wound comes into contact with infected blood.

Women who have regular Pap smears will also find out at that time if they have an STI.

The Pap smear is a test specifically for cancer and/or pre-cancerous conditions of the cervix. It may occasionally detect herpes infection, but it will not indicate the presence of other STIs. A woman who thinks she may have been exposed to an STI must be honest with her health practitioner and ask for STI tests.

Teens can receive testing and treatment for STIs without parents being notified.

STIs are a new medical problem that emerged with HIV.

STIs can cause major health problems, and some STIs may cause conditions that result in death.

Only people who have vaginal, anal, or oral intercourse can be infected with an STI.

Infants can contract some STIs, such as an HIV infection and herpes, during pregnancy and/or birth. Also, some STIs, as we have noted before, can be spread by close sexual contact that does not include vaginal, anal, or oral intercourse.

It does not hurt to delay STI testing and treatment after you think you have been infected.

Once an STI infects a person, it begins damaging his/her health. If someone waits weeks or months before getting tested and beginning treatment, his/ her health may be permanently damaged. Treatment may be unable to reverse this damage. In addition, the infected person can spread an STI to sexual partners.

In South Africa, teens can receive confidential testing and treatment at public health clinics. Confidential testing and treatment for STIs are available for youths as young as 12 years old. Confidential means that no one other than the teen and their healthcare provider may find out about the testing and treatment. Many community health clinics provide STI tests and treatment at no cost. X

STIs have existed since people began recording their history. There is evidence of medical damage caused by STIs in ancient writings, art, and skeletal remains. Writers of the Old Testament, Egyptian writers from the time of the pharaohs, and the famous Greek physician Hippocrates all mention symptoms of diseases and suffering caused by what we know today to have been STIs. Researchers and physicians began to find cures for most STIs during the 20th century. However, some STIs, such as herpes and genital warts, still cannot be cured. HIV infection, which can be spread through sexual contact, injures the immune system until Acquired Immunodeficiency Syndrome (AIDS) results. AIDS is fatal. Genital warts may be related to cervical cancer, which, if not treated, may become invasive and result in a woman’s death. Genital herpes can blind a person and otherwise injure babies born when infected women have open herpes lesions. Some STIs, such as gonorrhoea and chlamydia, can cause pelvic inflammatory disease (PID). If untreated, PID may cause sterility, heart disease, and/or death. Untreated syphilis can result in brain damage and death in infected people and, when infants are born to infected women, syphilis can cause severe retardation in infants.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

10.

Even if a woman is using oral contraceptives, she and her sexual partner should use latex condoms or dental dams to protect against infection with STIs, including HIV.

Oral contraceptives do not protect against STIs, so a condom or other barrier protection, such as a dental dam, is still necessary for protection against STIs, including HIV.

11.

Washing the genitals immediately after having sexual intercourse may help prevent some STIs.

However, personal cleanliness alone cannot prevent STIs. Washing will not prevent HIV from entering the body.

12.

It is possible to get some STIs from kissing.

It is rare, but it is possible to be infected with syphilis through kissing if the infected person has chancres (small sores) in or around the mouth. Herpes can also be spread by kissing if a person has herpes lesions around the mouth.

13.

Oral intercourse is a safe way to have sexual intercourse if you do not want to get a disease.

It is possible to be infected with HIV, gonorrhoea, syphilis, and herpes from oral intercourse.

14.

People usually know they have an STI within two to five days after being infected.

Many people never have symptoms, and others may not have symptoms for weeks or years after being infected. HIV infection may not show symptoms for years, but the infected person is capable of infecting others during that time.

15.

It is important to inform your sexual partner(s) if you suspect you have been infected with an STI.

The most important thing to do is to seek immediate testing and get treatment if the test results are positive (meaning you have an STI). Symptoms of an STI may never appear or may disappear after a short time, but the infection remains in the body. She/he can suffer serious physical damage and continue to infect others. Once treatment is begun, sexual partners should be informed. In the meantime, it is important to abstain from any sexual contact.

What is Sexual Health? The definition of Sexual Health is contained within the definition of SRH as “a state of physical, mental and social well-being in relation to sexuality”, which requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences free of coercion, discrimination and violence. This means that sexual health is not just about our bodies, it is about our mental and emotional state, as well as our sense of belonging in society. There isn’t a “one size fits all” definition of sexual health. Different cultures and societies have different ideas of what it means to be “sexually healthy”. It is important to understand that sexual health is more than avoiding disease. It is about sexual health, as defined above by the WHO. • Enjoyment of sexual relations without exploitation, oppression or abuse. • Safe, planned pregnancy and childbirth. • Absence and avoidance of STIs, including HIV.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Sexual behaviour and sexual health Our sexual health has a clear relationship with our sexual behaviour. If we take risks related to our sexual behaviour, for example, these risks have consequences. Examples of high-risk behaviours are shown in the diagram below.

Becoming sexually active under the age of 18

Having many sexual partners

Inconsistent or incorrect condom use

Having sex whilst under the influence of alcohol or drugs

Sexual violence

Having unprotected sex

Having unprotected sex with a stranger

Health Effects of Sexual Behaviour Risky sexual behaviours can lead to many negative health-related consequences, especially STIs and unplanned pregnancies. Poor sexual health can have many effects on an individual as well as a relationship. Unplanned and unintended pregnancies (will be discussed in more detail under reproductive health) Unplanned and unintended pregnancies can result in young mothers needing to sacrifice their education, which can create dependence on others to provide for the family economically. In such situations, women become vulnerable and have no power in their relationships. This can place them at great risk of being abused and exploited which, in turn, places them at risk in terms of their sexual health. STIs, including HIV Vulnerability, economic dependence, and lack of power in sexual relationships make it difficult for women to negotiate safer sex or have control over sexual decision-making. In such situations, women are at high risk for STIs, including HIV.

SEXUALLY TRANSMITTED INFECTIONS (STIS)

Key issues •

What are STIs?

•

Signs, symptoms and treatment options of different STIs.

•

Myths associated with STIs.

•

The relationship between STIs and HIV.

•

The importance of notifying relevant present and past partners when an STI is diagnosed.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

What are STIs? A Sexually Transmitted Infection, or STI, is an infection passed from one person to another person through sexual contact. STIs are spread from one person to another, mainly through unprotected sexual contact. If you have an STI and it is not treated, it can make you very sick. The worrying thing is that STIs sometimes don’t have symptoms, which means you or your partner may have an STI and not know it. STIs can be caused by a virus, bacteria, fungus or parasite. Having an STI can cause the body to lose some of the immune cells (soldiers) that keep the body strong and protect it from other dangerous infections. As a result, our immune system could become weak and allow other infections to enter the body at the same time. If an STI is not treated, it can result in serious long-term health problems, such as infertility, cancer, long-term pain, and even death. It can also be passed from a pregnant mother to her baby. There are FOUR possible STI families Bacterial STIs may be found in one part of the body. If you go to the clinic, the health worker may give you medication that can treat and cure the STI. Examples of STIs that are caused by bacteria include diseases such as Gonorrhoea, Chlamydia and Syphillis. Viral STIs attack systems in the body. They invade the whole body and its cells. They can be treated but not cured. Some examples are Hepatitis B, HIV Genital Herpes (HSV-2) and Genital Warts (HPV). Fungi are like plants and they usually grow on or in the top layer of the skin. They are not always passed on by having sex with someone, and they can be cured. A parasite is a creature that lives off another being’s body. Think of a parasite as a little bug that cannot always be seen by the naked eye. These STIs that are caused by parasites are passed from person-to-person during sexual activity.

General symptoms Some of these STIs and their symptoms can be permanent and can cause chronic pain, emotional distress, infertility, and even DEATH. Some STIs can show no symptoms.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

How can I prevent becoming infected with an STI? •

Abstaining from vaginal, oral, or anal sex is the best way to prevent an STI. However, if you are sexually active, you can protect yourself and lower your risk of getting an STI with the following steps: --

Use condoms. It is important to put the condom on before the penis touches the vagina, mouth, or anus. Other methods of birth control, like pills, injections, implants, or diaphragms, will not protect you from STIs.

Get vaccinated. There are vaccines to protect against HPV and Hepatitis B.

Get tested. Be sure you and your partner are tested for STIs. Talk to each other about the test before you have sex.

Be faithful. Having sex with just one partner can lower your risk for STIs. After being tested for STIs, be faithful to each other.

Limit your number of sex partners. Your risk of getting STIs goes up with the number of partners you have.

Do not douche. Douching is washing the inside of the vagina with water or other mixtures of fluids. Most douches are sold as pre-packaged mixes of water and vinegar, baking soda, or iodine. You squirt the douche upward into your vagina. The water mixture then comes back out through your vagina. Douching is different from washing the outside of your vagina during a bath or shower, which will not harm your vagina. But, douching can lead to many different health problems. It removes some of the normal bacteria in the vagina that protects you from infection. This may increase your risk of getting STIs.

Do not abuse alcohol or drugs. Drinking too much alcohol or using drugs increases risky behaviour, may put you at risk of sexual assault, and possible exposure to STIs.

Explore other forms of sexual pleasure.

Delay sexual activity.

DISCUSSION QUESTIONS RAPID FIRE... IN 30 SECS (First group to ring the bell can answer) What are the signs and symptoms of STIs? Redness or soreness of the genitals; pain when urinating (mostly among males); strong-smelling or cloudy urine; unusual discharge from the penis or vagina; sores or blisters on or around the genitals, mouth, or anus; a sexual partner with such symptoms. What are the most effective ways to avoid STIs? 1) Abstaining from vaginal, anal, and oral intercourse; and 2) using latex condoms every time you have any kind of sexual intercourse. What three things should you do if you are worried that you have been infected with an STI? 1) Seek medical testing and treatment right away; 2) inform your sexual partner(s); and 3) abstain from sexual contact at least until there is no evidence of infection and under the guidance of a healthcare worker. Men who have sex with men can use condoms to protect themselves and their partners from most STIs. What can women who have sex with women use? Barriers, such as squares of latex called dental dams, latex condoms which have been cut open, or plastic wrap to cover the vulva and form a barrier so body fluids cannot be exchanged.

KEY MESSAGES

•

STIs are infections that are spread from person to person through intimate sexual contact.

•

They can be dangerous and easily spread, and it is hard to tell just by looking if somebody has an STI.

•

There are four different types of STI: those caused by a virus, those caused by bacteria, those caused by a parasite, and those HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

caused by a fungus. •

If an STI is left untreated, it can result in serious long-term health problems, such as infertility, cancer, long-term pain, and death, and can be passed from a pregnant mother to her baby.

•

Viral STIs are systemic and invade the whole body and its cells. They are treatable, but not curable, and include Hepatitis B, HIV, Genital Herpes (HSV-2), and Genital Warts (HPV).

•

Bacterial STIs are localised to one part of the body, are curable by antibiotics, and include diseases such as Chlamydia, Gonorrhoea, and Syphilis.

•

Fungal infections commonly grow on or in the top layer of skin, are not always sexually transmitted, and are curable.

•

Other infections of the genital areas, which can be cured with antibiotics or topical creams, include Pubic Lice, Trichomoniasis, and Thrush (Candida), other inflammations of the vagina caused by organisms such as bacteria or yeast, and irritations from chemicals in creams, sprays, or clothing.

Testing and treatment for STIs •

If you have symptoms, you should go to your healthcare provider for a check-up.

•

Testing for STIs includes taking a urine sample, taking a swab of the vagina or penis for secretions, examining sores or bumps on the genitals, or doing a blood test. Managing an STI includes the following steps: --

Counselling for the individual, so they understand the STI and its spread and treatment;

Condom use for any future sexual encounters, to prevent the spread of the STI;

Compliance with treatment that is given to the patient at the clinic; and

Contacting previous sexual partners to advise them to get tested – it is their right to know as they have the responsibility to treat it and not spread it.

Are you in the Red? Zone Check: Sexually Transmitted Infections 1.

Are you using a condom if/when you’re having sex?

Do you have an unusual bad smell or coloured liquid coming from your vagina or penis?

Do you have any rash, bumps, sores or blisters around your genitals with or without pain?

Do you have genital warts?

Do you have an itchy penis, vagina or anus?

Do you experience a burning sensation when urinating?

Yes

If any of your answers place you on a red square, you are in the RED ZONE. This means that you are at risk for having a STI. Ask your HIGHER HEALTH Campus Coordinator for help with STI screening, testing, treatment and support as soon as possible.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Preparation for the lesson

LESSON TWO: REPRODUCTIVE HEALTH

To prepare, facilitators should: •

Aim •

To know what constitutes Reproductive Health and explore issues around family planning, particularly in relation to women, ways of preventing an unwanted pregnancy, and contraception.

the content. •

By the end of this lesson, peer educators will know:

•

What family planning is.

•

The benefits of family planning.

•

Methods of contraception.

•

The risks and consequences of unplanned pregnancies.

•

Interrogating termination of pregnancy (TOP), including

activity. •

Activities and tasks

•

The case for safer sex practices.

•

Why screening tests are important as part of reproductive health.

Planning Notes Read content and check for any updates in legislation and policy.

•

Crossword activity (in pairs)

•

Bag of dreams activity (in pairs)

Methods: •

Game

•

Reflection and introspection

•

Paired discussion and reflection

•

Simulation

Instructions for flow of the activities AND tasks 1.

Prepare and review instructions for activities.

•

Ensure that preparation for the activities is completed timeously.

What do we mean by “Reproductive Health”?

Why do we need to include this topic in the life orientation (LO) or life skills curriculum?

LESSON CONTENT brainstorm

Introduce the lesson on Reproductive Health by asking the following questions:

•

Plenary

Be aware that it is not possible to cover every detail in the be provided with handouts to supplement class activities.

legislation.

•

Familiarise themselves with how best to execute the

time allocated. At the end of the session, students should

•

Read through the lesson and familiarise themselves with

baseline

understanding

health, it is important to understand which body parts are

reproductive health. •

Reproductive system crossword puzzle.

•

Bag of dreams activity.

•

Group discussion and feedback. --

Family planning

Safer sex and contraception

Contraceptive methods

Unplanned pregnancy

Termination of pregnancy (TOP)

Screening for cancer

Time:

Explain that, to begin the discussion on reproductive involved in sexual and reproductive health.

Explain that the first activity, therefore, will focus on the biology of sexual and reproductive health.

Divide students into pairs using the “pick me” cards.

Hand out the “Reproductive System Crossword Puzzle” to each pair.

Teams have 10 minutes to complete the activity.

When the 10 minutes are up, instruct pairs to stay where they are for the plenary discussion.

Quickly go through the answers for the activity.

Instruct them as described below.

2 hours Material needed for the lesson:

•

Flip chart and markers

•

Pick me cards to divide into pairs

•

Reproductive Health crossword

•

Bag of dreams (zip lock bags with message)

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

RESOURCE FOR THE ACTIVITY REPRODUCTIVE SYSTEM CROSSWORD PUZZLE Time: 10 minutes Read each clue and fill in the correct answer. Your answer must fit into the correct number of boxes. Where a vertical answer crosses with a horizontal answer, they will share a box with the same letter. Across 5. The place where a baby develops. 7. Forceful release of semen from the penis. 8. Time in life when a woman’s menstruation ends. 9. Ducts connecting the ovaries to the uterus where fertilisation takes place (two words). Down 1. Passing of semen during sleep (two words). 2. Release of an egg from an ovary. 3. Place where sperm is produced. 4. A thick fluid that is discharged from the penis during ejaculation. 6. The process by which a child’s body develops toward becoming an adult body and being able to reproduce. 7. Hardening of the penis.

Answer key Across: 5. uterus; 7. ejaculation; 8. menopause; 9. Fallopian tubes. Down: 1. wet dream; 2. ovulation; 3. testicle; 4. semen; 6. puberty; 7. erection. Adapted from My Changing Body, courtesy of Institute for Reproductive Health. www.irh.org Upon completion of the exercise, leave the participants in the same pairs and instruct them as below for the next activity.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Group Three: Testicular Cancer

BAG OF DREAMS

Time: 30 minutes 1.

Discuss with your partner your dreams for your future (five minutes per person)

Where do you see yourself in the future? Do you have a skill, talent or resources that could make you well-known in your field?

Imagine there were no obstacles and, with your partner, make plans for yourself regarding your career, job, family, home, travel, etc.?

Hand out one “bag” to one person per pair.

Instruct student with the bag to a read message in the bag.

The message to females will read: “You receive a message that your pregnancy test came back positive…”

is pregnant…” What does this mean for you right now (practically and financially)? b.

How will this impact on the dreams and plans you have for yourself?

What will change?

Why are you in this situation?

What are your options going forward?

For the next activity, combine two pairs into a group.

Instruct groups to discuss the following:

do it? b.

Mention risk factors.

Danger signs (practice screening questions).

Treatment.

Group Four: Prostate Cancer a.

do it? b.

Mention risk factors.

Danger signs (practise screening questions).

Treatment.

Group Five: Breast Cancer a.

Mention risk factors.

Danger signs (practice screening questions).

Treatment.

10. In the plenary, facilitate a discussion based on feedback from all groups. 11. On completion of the activity, conclude by encouraging students to “Feel, THINK, and Act” as opposed to “Feel, ACT, and then Think”. 12. Task: Create your own dictionary or glossary of terms and concepts and exchange with one another to enrich your knowledge bank.

DISCUSSION QUESTIONS

What is family planning?

What are the benefits of family planning?

•

List the five main types or categories of contraception?

•

What is the legal age for termination of pregnancy (TOP), and when is it safe?

•

Reasons why young people may not use contraception.

Reasons young people have difficulty negotiating safer sex.

Group Two: Cervical Cancer

Mention risk factors.

Danger signs (practice screening questions).

Treatment.

Reproductive health is crucial to our overall health and Understanding sexuality and SRH is a pre-requisite to becoming sexually active.

•

Readiness for sex is crucial to understand.

•

Being sexually active involves sexual rights and responsibilities.

Why is this screening test important? How often should you do it?

What does it mean for you right now?

well-being.

Group One B:

Why is it important to know this information?

KEY MESSAGES

What is “dual protection”?

•

Why is this screening test important? How often should you

Group One A: a.

Why is this screening test important? How often should you

do it?

The message to males will read: “You receive a phone call from your girlfriend to say that she

Why is this screening test important? How often should you

•

Regular screening is important to prevent various cancers of the reproductive health system.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

What you need to know about reproductive health Background and motivation Prevention and treatment of sexual and reproductive health (SRH) issues requires a thorough understanding of the psychological and social contexts in which they occur as well as the biological and diagnostic aspects of SRH and wellbeing. Introducing reproductive health education at schools and post-schooling institutions can have added benefits. These programmes can help prevent early pregnancy, HIV/ AIDS and STIs, as well as various cancers. Lecturers can also refer students to local health or counselling services when appropriate. By providing reproductive health education early, it is possible to encourage the formation of healthy sexual attitudes and practices. This is easier than changing wellestablished unhealthy habits later.

Planning for pregnancy or contraception can be done by couples together, where women and men talk openly with their partners about their wish to have children, or their wish to delay or prevent having children. It can also be done individually, where a person makes a choice about contraception alone. It is important to think and talk about contraception before having sex to avoid unplanned pregnancy and to avoid HIV and other STIs. Why is Family Planning necessary AND important? Many unwanted pregnancies can be prevented if both partners agree not only to have safer sex but also to prevent unwanted pregnancy. There are many family planning methods providing sexually active men and women with different options to choose from. Family planning is the responsibility of both partners in a relationship.

What is family planning? Family Planning is about planning for pregnancy: •

How many children to have.

What are the benefits of

•

When to have these children.

family planning?

•

Who to have children with.

• It allows women to make

•

How to provide adequately for children.

decisions about when to

•

Prevention of pregnancy (contraception).

have children, who to have

•

Planning for pregnancy (conception).

them with, and how to provide adequately for children when they are born.

Unplanned pregnancies • • •

•

Unplanned pregnancies can have negative effects on the health of a woman, as well as having an impact on

girl.

the whole family. Unplanned pregnancies may result in

Cause financial stress including not being able to afford

parents not being able to afford the cost of having a child,

the cost of having a child.

as well as the other children in the family suffering from

Existing or new children in the family suffering from

hunger, neglect or abandonment.

hunger, neglect or abandonment. •

•

Can have negative effects on the health of a woman or

•

Impacts the whole family. Cause pregnant teenagers to be at high risk of:

Family planning allows couples to have planned families so that every child that they have is a wanted pregnancy.

•

It allows spacing between children so that the women

Premature labour and delivery,

have the opportunity to recover from one pregnancy

Anaemia,

before having another child. Too many pregnancies or

Pre-eclampsia, and

pregnancies that are closely spaced can cause major

Having a baby with a low birth weight.

health problems for women, including a shortage of essential nutrients such as iron and folate, stress, and

Too many pregnancies or pregnancies that are closely

complications with the uterus. There are also risks for

spaced can cause major health problems for women,

the baby, including low birth weight, premature birth, and

including: •

A shortage of essential nutrients such as iron and folate

developmental problems. •

In certain women where pregnancy would cause harm to

(Vitamin B),

her or the child’s well-being, it is a good method to prevent

•

Stress, and

pregnancy.

•

Complications with the uterus.

•

Family planning can prevent unplanned pregnancies.

There are also risks for the baby, including:

Unplanned pregnancies among teenagers have a higher

•

Low birth weight,

risk of premature labour and delivery, anaemia, pre-

•

Premature birth, and

eclampsia, and having a baby with a low birth weight.

•

Developmental problems.

•

Family planning allows for partners to engage in sexual activity without conceiving a baby.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Are you in the Red? Zone Check: Unplanned Pregnancy You are NOT ON CONTRACEPTION because you

Yes

Are having unprotected sex but do not think you are at risk of pregnancy

Don’t have sex often enough to get pregnant

Want to have a baby so that your boyfriend will marry you

Are embarrassed to ask for information about contraception

You and your partner are ready/planning to have a baby

Don’t have access to contraception

Feel pressure from your partner or family to get pregnant

Are scared your partner will reject you if you talk about family planning

The FIVE main types or categories of contraception

Are scared of side effects of contraception (e.g. weight gain)

These include male and female condoms and diaphragms.

Barrier methods prevent sperm from getting inside the woman.

10. Fear that sex will feel different or less pleasurable

Hormonal methods are those that prevent eggs from being

If any of your answers place you on a red square, you are in the RED ZONE. This means you are at risk for unplanned pregnancy. Ask your HIGHER HEALTH Campus Coordinator for help with pregnancy testing, counselling, contraception and support as soon as possible.

released inside the woman’s uterus by altering hormone levels. These include pills, injectables, emergency contraception, and implants. Long-term methods have to be provided at a health clinic by a trained nurse or doctor. These include intrauterine devices (IUDs) and implants.

Contraception and Family Planning

Permanent methods like male and female sterilisation require

What is contraception? “Contra” means “against” and “ception” means “to conceive”. So

surgery. These methods are not usually recommended for

contraception involves the use of different devices, medicines,

young people who may change their minds about wanting to

sexual practices, or surgical procedures to prevent pregnancy.

have children in the future. Permanent methods are best for

There are many different contraceptive methods that are freely

adults who have already had children and know that they do

available at clinics around the country. Some methods are

not want to have any more.

more effective than others. Any person can use contraception, including those who are HIV positive. People who are on

Natural methods do not require any materials (i.e., the

antiretroviral therapy (ART) or any other medication should

withdrawal method, and the “rhythm method” which is when

consult a healthcare practitioner to discuss the best method

the woman learns to recognise when she is fertile and avoids

for them, as some medicines and contraceptive methods do

having sex during that time). In general, natural methods do not

not work well together.

work as well as the modern methods listed above. They require great self-control. The rhythm method only works well when a woman has very regular periods. In some places, people use traditional methods. These are mostly herbs that are given to prevent pregnancy. They are not reliable because the dosage is not controlled and they have not been scientifically proven to work.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

KEY MESSAGES •

Always use condoms consistently and correctly.

•

Condoms will prevent HIV, other STIs, AND pregnancy.

•

You may want to use a second method of contraception for additional protection from undesired pregnancy.

•

If a condom is not used correctly, consider emergency contraception as soon as possible.

•

Use a new condom for each sex act and check the expiry date.

•

After ejaculation, hold condom and remove the penis from the vagina.

•

Throw used condoms away properly.

•

Give condoms or explain where to buy or get them.

Emergency Contraception What is emergency contraception? Emergency contraception is a safe way to prevent pregnancy after unprotected sex. There are a few types of emergency contraception, and some work better than others. There are two ways to prevent pregnancy after you have unprotected sex: •

Option 1: An IUD can be inserted within 120 hours (five days) after having unprotected sex. This is the most effective type of emergency contraception.

•

Option 2: The emergency contraceptive pill (also known as the morning-after pill) can be taken within 120 hours (five days) after having unprotected sex.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

The morning-after pill

Reasons why young people may not use contraception

•

Ella is a type of “morning-after” pill that you can only get with a prescription.

HIV. They think: “It can’t happen to me” or “I don’t have

There are also Plan B, One Step, Take Action, My Way,

sex often enough to get pregnant or contract an STI or

AfterPill, and others. • •

HIV”.

You can buy these morning-after pills over the counter

•

health services, or are embarrassed to ask for information

These types of morning-after pills work best when you

or required services. •

sex, but you can take them up to five days afterwards. The sooner you take them, the better they work.

(television, radio, etc.). •

•

Contraceptive methods are not available or are too expensive.

pregnancy if:

•

They do not have access to accurate information at home, in school, in the community, or from media sources

You can use emergency contraception to prevent •

They do not have access to youth-friendly reproductive

without a prescription in most pharmacies. take them within 72 hours (three days) after unprotected •

They do not think they are at risk of pregnancy, STIs or

You didn’t use a condom or other birth control method

•

Denial: “My partner would never expose me to any risk”.

when you had vaginal sex.

•

They feel pressure from their boyfriend or family to get pregnant.

You messed up your regular birth control (forgot to take your birth control pills, change your patch or ring, or get

•

They are scared their partner will reject them.

your shot on time) and had vaginal sex.

•

They are scared of side effects (e.g., fear of hormonal side

Your condom broke or slipped off after ejaculation

effects associated with ‘the pill’, or fear that sex will feel

(coming).

different with a condom).

•

Your partner didn’t pull out in time.

•

They feel embarrassed.

•

You were forced to have unprotected vaginal sex.

•

A doctor or nurse at the clinic has a judgemental attitude.

•

They do not know how to negotiate condom use with their

Don’t use two different kinds of morning-after pill (like Plan B

partner.

and Ella) at the same time or within five days of each other, because they may counteract each other and not work at all.

•

They have inaccurate information, for example, thinking

And don’t take more than one dose of any type of morning-

that a girl cannot get pregnant if she is menstruating, or

after pill – it won’t give you extra protection from pregnancy,

that a girl cannot get pregnant when she has sex for the

but it can make you feel sick.

first time. Reasons young people have difficulty negotiating safer

KEY MESSAGES

sex •

Always use condoms •

•

intercourse. •

those decisions.

vagina. Condoms can be inserted up to eight hours ahead of time.

•

When finished, the woman must move away from her partner and take care not to spill semen on the vaginal

•

Young people may believe that if they suggest having safer sex, their partners will think they do not trust them.

•

Young people may be scared or embarrassed to bring up the topic of protection.

opening.

•

Young women may not have control over when and how they have sex because their male partners may make

Condoms should be inserted before the penis touches the

•

They may not have the right communication skills to talk about protection with their partners.

Couples should use a new condom for each act of

The condom should be thrown away properly, in a bin or

•

Young people may want to get pregnant. Young women

trash can as appropriate.

might believe that it is a way to stay in a relationship. For

Female condoms are more expensive than male condoms

young men, getting a girlfriend pregnant may be a way to prove their manhood.

and may be less widely available. •

Sometimes, young women who feel a lack of love in

For people living with HIV: Remember to apply the same

their lives think that having a baby assures them of

measures, even if you are on ART and you and your partner

unconditional love.

are both HIV positive

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

•

Young mothers are at a higher risk of complications during pregnancy because they are not fully developed, and their bodies may not be ready to handle pregnancy or to give birth.

•

Young mothers may face problems such as obstructed labour, long labour, anaemia, pre-eclampsia (a condition that pregnant women develop marked by high blood pressure which they never experienced before), a high

What is “dual protection”? Dual protection means preventing STIs, HIV and unwanted pregnancy at the same time. Dual protection includes: •

Using male or female condoms with another contraceptive method such as the oral contraceptive pill.

•

Using male or female condoms alone.

•

Abstinence (not having sex at all).

level of protein in their urine, and often swelling in the feet, legs, and hands. This may cause impaired kidney and liver function, blood clotting problems, pulmonary oedema (fluid on the lungs), seizures and, in severe forms or if untreated, maternal and infant death, or hypertension during pregnancy. •

Young mothers may also suffer the consequences of unsafe abortion, spontaneous abortion, stillbirth, and premature birth.

•

Adolescents younger than 17 often have not reached physical maturity, and their pelvises may be too narrow to

KEY MESSAGES •

well-being. •

Understanding sexuality and SRHR is a pre-requisite to becoming sexually active.

•

Readiness for sex is crucial to understand.

•

Being sexually active involves sexual rights and responsibilities.

•

accommodate a baby’s head. •

Reproductive health is crucial to our overall health and

Regular screening is important to prevent various cancers of the reproductive health system.

Pregnancy often means the end of formal education for girls, as they may have to drop out when they become pregnant.

•

Pregnancy changes a girl’s career options, her future opportunities, and may limit her marriage choices.

•

Unmarried mothers sometimes have to take low-paid and risky jobs, or become sex workers to support their children.

•

Sometimes the partner refuses to take responsibility for the pregnancy, which makes things much harder for the young mother and child.

•

Young parents are often not ready to raise a child which, in some cases, can lead to problems like child abuse or neglect.

•

Early marriages that happen because of an unplanned pregnancy are often unhappy and unstable.

•

What options are there for unplanned pregnancies, and what are the implications of each of these?

•

Termination of pregnancy (TOP): psychological issues of stress, anxiety, guilt, depression, and medical issues.

•

Having the baby:

•

Adoption: psychological issues of stress, anxiety, guilt, depression, and medical issues.

•

Foster care: psychological issues of stress, anxiety, guilt, depression, and medical issues.

•

Keeping the baby: financial, practical, education, support, and lifestyle change issues.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Chapter 3|SEXUAL AND GENDER DIVERSITY

Mental Health

Disability

Alcohol and Drug abuse

SEXUAL AND GENDER DIVERSITY

Introduction and Overview

Note to facilitators •

Remain neutral and avoid imposing your personal values on students.

•

Use respectful terms and avoid hurtful language, particularly with regard to same-sex attraction, sexually active youths, and young people who do not conform to conventional gender norms.

•

Topics related to LGBTQI+ health, for example, stigma and discrimination from healthcare workers, vulnerability for HIV, and access to appropriate services may raise disturbing or intense feelings. Students should not feel pressured to disclose information about their own experiences.

•

Peer educators should be aware of their capacity to provide support to students. Should students choose to access

Our institutions of learning have not really taught us much on the topic of gender and sexual diversity. What we know comes largely from our families and communities, and is influenced by

such support, it is crucial to respect their confidentiality. •

Be prepared to manage sensitive issues, and to challenge stigmatising attitudes. Here are some tips:

how we are socialised. From an early age, we learn that boys

and girls belong to two separate “worlds” and that these worlds

Prepare yourself to discuss the issues without feeling uncomfortable.

must never converge. For example, when buying gifts for our

friends and relatives’ newborn babies, it is difficult to resist the

Get as much information as possible on what potentially sensitive areas may be so that you can

temptation to buy pink clothes for girls and blue clothes for boys.

work out strategies to bring them out and handle them

Girls are taught to submit to men while boys are socialised to be

effectively.

dominant over women, and even made to believe that this might

feel natural. It is nothing but a consequence of being gendered

Build an open atmosphere in which participants feel comfortable talking about these issues. However, also

– a social construct.

remain vigilant about risks of stigma and discrimination from the target group itself towards those who may feel

From the moment we are born, we are inundated with messages,

encouraged to “come out” in these sessions.

spoken and unspoken, about different types of people. Often we

learn stereotypes and prejudices without even realising it. Some

Encourage open and frank discussion and commend participants who display openness.

of these messages may have been about ourselves and what

we are “supposed to” or “not supposed to” be. What were the

Observe the group’s body language to help you decide when to probe further on an issue and when to back

earliest messages you received about people who are lesbian,

off. When people do not want to discuss something,

gay, bisexual, transgender, queer, or intersex (plus other

they may avoid eye contact or fold their arms across

sexualities not listed here) (LGBTQI+), and where did they come

their chest.

from? Were they positive, negative or neutral? Understanding the messages we receive can help us identify our own beliefs

Overall aim

and biases that we can then challenge, helping to make us stronger allies. Even though it becomes difficult to discuss issues of gender and sexuality, this chapter aims to process these often difficult conversations by helping both peer educators and students to become gender and sexuality sensitised, so that we may start forging safer and friendlier environments for gender

To provide information to enhance understanding of issues and challenges concerning the LGBTQI+ community and review accurate and relevant information about each of the key health risks pertaining to LGBTQI+ persons.

and sexual minorities.

Overall objectives

“In too many countries, lesbian, gay, bisexual, transgender

This chapter seeks to:

and intersex people are among the poorest, most marginalized

•

and sexual diversity.

members of society... Studies show that gay and lesbian people suffer disproportionate discrimination and abuse” – Former UN

Provide peer educators with an understanding of gender

•

Secretary-General Ban Ki-Moon.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Enhance the understanding of the complexity of human sexuality.

•

Examine personal, cultural, and historical influences on human sexuality.

•

Sensitise peer educators to LGBTQI+ issues (coming out, coming to terms with sexual identity and sexual orientation).

•

Address myths and misconceptions to mitigate stigma and discrimination of gay and lesbian people and those belonging to other sexual and gender minority groups.

•

Promote understanding and insight into the health consequences of prejudice and discriminatory behaviour,

Activity One: Sexuality and Orientation: To review where LGBTQI+ issues fit within the broader context of human sexuality. Requirements Copies of the Sexual Activity handout for groups. Instructions for the flow of the activities

such as hate crimes. •

Foster awareness of general and specific issues pertaining

•

Introduce the lesson.

to health needs, challenges and risks faced by the LGBTQI+

•

Divide participants into pairs.

community.

•

Distribute a copy of the Sexuality and Orientation Activity handout to each pair.

•

Chapter content

sexual activity with a kind of sexual orientation that they

By the end of this module, peer educators will: •

Understand relevant terms and concepts pertaining to human sexuality.

•

feel best fits the sexual activity (10 mins). •

orientations.

sexual orientation, sexual identity, and sexual practices and behaviour. Have had opportunity to debate and discuss human sexuality with a focus on gender and sexual diversity. •

Be sensitised to the emotional and psychological aspects of “coming out”.

•

Be aware of stigma and discrimination within the context of gender and sexual diversity.

To review where LGBTQI+ issues fit within the broader context of human sexuality. Lesson objectives By the end of this lesson, peer educators will: Know the meaning of human sexuality.

•

Be familiar with terminology related to human sexuality.

•

Understand where LGBTQI+ sexuality fits within the context of human sexuality. Prepare and review instructions for activities.

•

Ensure that preparation for the activities is completed

Terminology and acronyms specific to SRH.

•

Four categories of STIs.

•

Education and prevention.

•

Treatment, care and support.

orientations, because we are not heterosexual or homosexual based on who we have sex with, or how we practice sex, but

Requirements •

A flipchart and pens.

•

Copies of the human sexuality handout for groups.

For the next activity, divide participants into groups.

Distribute copies of the handout on human sexuality to groups. Instruct them to complete the diagram in the handout by filling in the different categories of human sexuality (20

•

conclusion should be that sex is between two bodies, not sexual

Planning notes

Sexual health, including sexual well-being.

heterosexual or homosexual sex. From this activity, the

Instructions for the flow of the activities

•

The outcome of the activity should be that there is no

Activity Two: Human Sexuality Quadrant

Aim:

Lesson content

Note to facilitators:

on who we are attracted to.

LESSON ONE: SEXUALITY

timeously.

Once the time is up, ask pairs to give feedback on the various sexual activities and their matching sexual

Understand the differences between biological sex, gender,

•

Ask them to populate the handout by matching a particular

mins). d.

Go through the diagram in plenary inviting different groups to give input on aspects that are missing.

Process the activity using the discussion questions below.

On completion of the activity, conclude the lesson by encouraging students to master all relevant terms and definitions.

TIME ALLOCATION 50 minutes

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

RESOURCE FOR ACTIVITY ONE: SEXUAL ACTIVITY AND ORIENTATION

DISCUSSION QUESTIONS •

How did it feel to learn new and different terminology?

•

Why is it important to know this information?

•

Was anyone uncomfortable with the discussion?

•

Why were people uncomfortable?

Kissing

•

How does socialisation impact on sexuality?

Flirting

•

Did you learn anything new?

•

How do you feel about what you learnt?

Hugging

Sexual Activity

Heterosexual Gay Couple Couple

Lesbian Bisexual Couple Couple

Masturbation Vaginal sex

KEY MESSAGES

Anal sex

•

Oral sex

Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and in thoughts, fantasies, desires, beliefs, attitudes, values,

RESOURCE FOR ACTIVITY ONE: HUMAN SEXUALITY QUADRANT

behaviours, practices, roles and relationships.

Sex

Gender

Sexual Orientation

Sexual Behaviour

reproduction. Sexuality is experienced and expressed

•

Sexuality includes five interrelated, components: biological sex, gender (identity and expression), sexual orientation, sexual identity, and sexual practice or behaviour.

•

Biological sex refers to the scientific concept that categorises individuals as either male or female.

•

Biologically male: has a penis, testicles, XY chromosomes, and produces testosterone.

•

Biologically

female:

has

vagina,

ovaries,

chromosomes, and produces oestrogen. •

Intersex people are born with chromosomes, external genitalia, and/or internal reproductive systems that do not fit the “typical” definition of either male or female.

•

Sexual orientation is the way in which one expresses oneself sexually in relation to others. The three sexual orientations are: homosexual, bisexual, and heterosexual (straight). --

A person’s gender role is largely culturally and socially determined.

Gender identity is a person’s deeply felt individual experience of gender (man

ßà woman), which may

or may not correspond with the sex assigned at birth. --

Gender expression is the way in which a person’s sense of gender manifests itself, usually as an extension of the person’s gender identity.

Sexual identity is how one thinks of oneself in terms of who one is romantically or sexually attracted.

Sexual practice and behaviour are the manner in which humans experience and express their sexuality.

Understanding Human Sexuality Why is it important to understand human sexuality and sexual behaviour? Human behaviour, particularly sexual behaviour, is complex. Therefore, an introductory understanding of human sexuality will provide the necessary background required to understand sexual minorities better. By exploring human sexuality, individuals are often exposed to the vast spectrum of human behaviour that naturally exists among our societies and, in

Resource for Activity One: Sexual Activity and Orientation

so doing, offers a new lens through which to consider sexual minorities and their place in society.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

What is Human Sexuality

What is intersex? Intersex people are born with chromosomes, external genitalia,

According to the WHO, the working definition of sexuality

and/or internal reproductive organs that do not fit clearly into

is:

either sex category of male or female.

A central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual

Historically, intersex individuals are surgically altered soon

orientation, eroticism, pleasure, intimacy and reproduction.

after birth to appear more definitely male or female. These

Sexuality is experienced and expressed in thoughts, fantasies,

surgeries often have serious complications that can affect

desires, beliefs, attitudes, values, behaviours, practices,

individuals for the remainder of their lives. Specifically, these

roles and relationships. While sexuality can include all of

“corrective” surgeries remove any choice intersex individuals

these dimensions, not all of them are always experienced

have in deciding their sex, which can leave many mentally and

or expressed. Sexuality is influenced by the interaction of

emotionally traumatised. Intersexuality challenges the notion

biological, psychological, social, economic, political, cultural,

that human sex is binary (either male or female). Intersexuality

ethical, legal, historical and religious and spiritual factors.

shows that biological human sex is actually a spectrum with male on one end, female on the other end, and a variety of

Society has a tendency to put people into boxes which often

inter-sexualities in the middle. Caster Semenya is an example

don’t take into account the fact that we are all unique beings.

of such a case.

Just as we have a unique fingerprint, we also have a unique social and sexual identity. One can never know someone’s sexual identity based on their biological sex, gender identity, gender role, sexual orientation, or sexual behaviour. Furthermore, society looks at sex, sexual orientation and especially gender as binary concepts (either/or; one or the other), for example, male or female. However, male and female or man-ness and woman-ness are at different ends of a spectrum with many other possibilities in between. The more we learn, the more we realise that, when it comes to human sexuality, there are no basic rules or prescriptions that can apply to all. What follows is a description of each dimension.

What is gender? A person’s gender refers to attitudes, feelings, and behaviours that society associates with the biological sexes. Gender identity A person’s gender identity refers to how that individual feels and thinks about themselves as a man or a woman. It is common to confuse “sex” and “gender”, but they do not refer to the same thing. Sex is a biological concept, while gender is a social construct, that is, an idea, philosophy, or belief that is

Biological sex Biological sex categorises individuals based on certain

built or “constructed” by society rather than nature.

Gender Identity

characteristics like their chromosomes, internal and external genitalia, and their hormonal profile. A person’s sex is usually categorised as either male or female. Biologically male: has a penis, testicles, XY chromosomes, and produces testosterone. Biologically female: has a vagina, ovaries, XX chromosomes,

Woman

Genderqueer

Man

Cisgender (often abbreviated to cis) is a term for people whose gender identity matches the sex that they were assigned at birth.

and produces oestrogen. 62

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

sex.

What is transgender? Transgender is a broad term that refers to individuals whose gender, their self-identification as a man or woman, does not match their biological sex. Transgender people have a very intense experience of their gender being different from that assigned by birth. Transgender people sometimes seek medical treatment to bring their body and gender identity

Homosexual refers to an individual who has romantic, sexual, intellectual, and intimate feelings towards others of the same sex. There are two homosexual identities: gay and lesbian. Gay - A gay man is someone who has romantic, sexual, intellectual and intimate feelings for, or a love relationship with another man (or men), and identifies as gay.

closer into alignment.

Lesbian - A lesbian is a woman who has romantic, sexual,

Transitioning broadly refers to the act of changing genders

another woman (or women), and identifies as lesbian.

intellectual and intimate feelings for, or a love relationship with

to fit a person’s gender identity. For example, the baby girl described above would most likely “transition” to living life as a man. Transitioning can take many forms. For some

Bisexual refers to an individual who has romantic, sexual, intellectual, and intimate feelings towards others of the same sex as well as the opposite sex.

transgender individuals, it may include hormone treatment, surgery, or simply adjusting their clothing and role within their community. Gender expression Gender expression is how we show ourselves to the world through clothes, hair, and behaviour styles. Because gender is assigned many physical things, and even activities, it’s possible to express yourself through various preferences in a way that aligns with who you feel you really are. The most common gender association example is the colour pink for girls and the colour blue for boys.

Gender Expression Feminine

Androgynous

Masculine

What is sexual orientation?

What is sexual identity? Sexual identity is how one thinks of oneself in terms of to whom one is romantically or sexually attracted. Sexual identity may also refer to sexual orientation identity. What is sexual behaviour? Sexual behaviour is the way in which individuals experience their sexuality. All people, no matter their sexual orientation, use various body parts to experience sexual pleasure, on their own or with others. Sexual behaviour may be influenced by an individual’s biological sex, sexual orientation, sexual identity, or gender. LGBTQI In summary, sexuality and gender diverse persons are often

Sexual orientation is part of identity and includes sexual attraction as well as emotional, romantic, and intellectual attraction. Essentially, sexual orientation encompasses all of a person’s intimate psychological and physical feelings towards others. There are three main types of sexual orientation:

referred to with the acronym LGBTI. LGBTI is an umbrella term that refers to a diverse group of people who “are clustered together in one abbreviation due to similarities in experience of marginalisation, exclusion, discrimination, and victimisation in a heteronormative and heterosexist society.”

heterosexuality, homosexuality, and bisexuality. Heterosexual refers to an individual who has romantic, sexual, intellectual, and intimate feelings towards others of the opposite HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Lesson content

Lesbian

SEXUAL ORIENTATION Gay

Bisexual

Intersex

Understanding what is meant by “coming out”.

•

The six stages of coming out.

•

Guidelines for coming out.

TIME ALLOCATION

T Trans* Gender Identity and Expression Q Queer I

•

60 minutes

Biological Sex

Activity One: Secrets and Closets

Trans* people generally self-identify with a gender that does not correspond to the sex assigned to them at birth. The term trans* is used with an asterisk at the end to signify that “trans-” may be followed in a number of different terms (e.g., “transsexual,” “transgender,” and “transvestite”). The asterisk also acknowledges other gender identification categories and social gender roles, such as genderqueer and androgynous,

Requirements Flipchart and koki pens. Instructions for the flow of the activities 1.

Give each participant a small piece of paper.

Ask participants individually to think about a secret or something they have never told anyone and write it down

among others.

on the piece of paper provided. This must be something which if anyone found out about would cause discomfort,

LESSON TWO: COMING OUT

embarrassment or shame for the participant.

Coming out is a process of understanding, accepting, and valuing one’s sexual orientation and identity. It involves both exploring one’s identity and sharing this identity with others. Coming out can be a very difficult process. Our society strongly enforces codes of behaviour regarding sexual orientation and gender identity, and most people receive the message that they must be heterosexual and act according to society’s definition of their gender. This message is also communicated through cultural norms and values about sex, sexuality and gender. For LGBTQI persons, there may be a sense of being different or of not fitting into the roles expected of you by your family, friends, workplace or greater society. Coming out involves facing societal responses and attitudes toward LGBTQI people.

secret and write it down. Hint: the idea with the piece of paper is to make participants think you will share the secrets they write down with the rest of the group. This will, however, not be asked from them. Rather, the exercise is designed to make them reflect and interrogate themselves. There is a possibility that participants will refuse to write down a secret. If participants do not write down a secret, use this after the activity by including a question like: Why did you not want to write down your secret? 4.

To sensitise peer educators to the challenges faced by the

respond): a. b.

Note their responses on a flipchart, black board or white their feelings. Words that might be used are “scared”,

Lesson objectives

uncomfortable”, “guilty”, etc.

By the end of this lesson, peer educators will:

•

Know the meaning of “coming out”.

•

The stages of coming out.

•

The challenges related to facing the issues related to

What did you think I was going to ask you to do after thinking about your secret? (They will likely say they

sexual diversity. Some guidelines for students and others who are considering coming out.

expected the facilitator to write down and share their secrets.) d.

If I had asked you to write down and share your secrets, how would that have made you feel?

Planning notes

How did you feel doing the exercise? Why did you feel

board, focusing more on the words they use to describe

LGBTQI youth during their emerging sexuality.

Again, write their responses on a flipchart, focusing more on the words they use to describe their feelings. Words

•

Prepare and review instructions for activities.

•

Ensure that preparation for the activities is completed timeously.

Ask them the following questions (give them time to

that way?

Aim:

•

Give participants up to two minutes to think about their

that might be used are “worried”, “judged”, “stigmatised”, etc.

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Now relate the discussion to other people who might be facing some of the problems mentioned above, and ask

For most people, it takes time to know who they are. 2.

or how to come out.

the participants to put themselves in others’ shoes. Ask them: •

How do you think a person would feel if their secret came out and society discriminated against them?

•

What can we do better to make other people comfortable with “coming out”?

Remind the person: 3. 4.

the help needed from the resources available. At the end of this chapter, are some resources and contact details that

themselves) before they are even stigmatised by society.

may be helpful.

Focus the discussion on coming out, and emphasise ways, but it is not an easy thing to do because of societal

There are also people and institutions that can support or mentor those who need such support. It’s important to find

Highlight how vulnerable people with such secrets are,

that we all want to come out of our “closets” in different

That they are not alone. There are many others with the same questions and concerns that one may have.

and the level of internal stigma they face (stigmatising h.

It is okay to be confused or to be uncertain about whether

COMING OUT!

prejudice and discrimination. Move the discussion to focus on acceptable values by asking the participants to come up with a set of values they want to use and adhere to in the context of today’s session. This might include values such as “honesty”, “non-judgmental”, “respect”, etc. Write down these values on a flipchart and open a discussion around them. Ask the following questions: 1.

Why are these values important for you?

Can we use these values outside of this workshop? How so? Give examples.

How do we deal with a person who does not adhere to our values? Why do we treat them that way? Can we treat them any better? Can we accept a person who holds different values?

Note to facilitators Make participants aware that values clarification does not tell you what values you should live by, but provides you with a method that lets you discover what values you do live by. What gives our life its meaning and relevance are our values. When examined, we discover that they are the principles or standards upon which we base our decisions about how we want to live our lives now and in the future. Our choices, whether we are aware of it or not, reflect our values. Values are not transmitted or taught, but learnt directly from an individual’s life experiences. They develop, grow and change through interaction with the self, the environment, and other people. The process is dynamic, and throughout the course of life, values can change. Peer educators Remember: 1.

For gay, lesbian, bisexual, transgender and queer people, the coming out process can be both difficult and liberating.

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The Six Stages of Coming out

In 1979, Vivian Cass7 developed a model for coming out which is now known as the Cass Theory. It is a six-stage model that describes the developmental process individuals go through as they consider and then acquire a homosexual identity. This model includes lesbian, gay and bisexual identities. It is important to let your students know that they might find themselves in one of these stages. They just have to know that what they are experiencing is completely normal and that

Stage Three – Identity Tolerance

many, many others have had similar experiences.

Your acceptance of your homosexuality increases, and

http://patrickgarvin.com/blog/?p=312

distress concerning your sexual orientation decreases, you

you begin to tolerate this identity. Although confusion and may feel increased isolation and alienation, as your self-

Cass, V.C. (1979). Homosexuality identity formation: A

theoretical model. Journal of homosexuality, 4(3), 219-235.

concept becomes markedly different from broader society’s expectations of you. In this stage, you often begin to seek out positive relationships with other gays or lesbians, and begin to embrace your sexual orientation.

Stage Four – Identity Acceptance You have resolved most of the questions concerning your Stage One – Identifying Confusion

sexual identity, and have accepted yourself as homosexual.

At the beginning of a person’s coming out process is a period

You have increasing contact with the LGB community.

where that person begins to question their heterosexual identity. This typically happens when a person realises that they are attracted to members of the same sex. You begin to wonder whether you may be homosexual. Along with other thoughts and feelings, you may experience denial and confusion.

Stage Five – Identity Pride You begin to feel pride in being part of the LGB community and immerse yourself into LGB culture. In turn, you have less contact with the heterosexual community. Sometimes you may actually feel angry with or reject the heterosexual community.

Stage Two – Identity Comparison This is a dark and lonely stage marked by anxiety and depression. The mental struggle is about trying to figure out what it means to be gay or lesbian, etc. You accept the possibility that you may be gay and face the social isolation that can occur with this new identity.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

As peer educators, it is important to examine one’s personal attitudes and to become more self-aware so that if changes need to take place, one becomes aware and vigilant about one’s thoughts, actions and behaviour. Aim: To sensitise peer educators to their own attitudes and feelings regarding issues pertaining to sexual and gender diversity. Stage Six – Identity Synthesis You no longer see your sexual identity as being separate from other aspects of yourself. It becomes integrated so that it is just part of your whole identity. The anger you may have felt toward the heterosexual community or the intense pride you may have felt in being homosexual decreases, and you can be your whole self with others from both groups. You feel more congruence between your public self and your private self.

Lesson objectives By the end of this lesson, peer educators will: •

Have had the opportunity to introspect and become aware of their own attitudes regarding LGBTQI issues.

•

Have

Pick someone who you feel is very supportive to be the first person you come out to.

When you come out, think about what you want to say and choose the time and place carefully based on what will be safest and most supportive context.

Be prepared for an initially negative reaction from some people. Some individuals need more time than others to adjust to what they have heard from you.

Don’t give up hope if you do not initially get the reaction you wanted. Remember that you have the right to be who you are, and to be out and open about all important aspects of your identity, including your sexual orientation. In no case is another person’s rejection evidence of your lack of worth or value.

If you have already come out to others whom you trust,

debate

and

discuss

various

perspectives around sexuality. •

Address myths, misconceptions and stereotypes relating to the LGBTQI+ community.

•

Be able to understand how homophobia and transphobia affect everyone.

For students and others who are thinking about coming out, consider the following:

opportunities

Planning notes •

Prepare and review instructions for activities.

•

Ensure that preparation for the activities is completed timeously.

Notes for facilitator Positive and negative answers can come from this activity. Try not to be judgemental, but use the suggested discussion questions to make people reflect and aware of the effects of not clarifying myths, misconceptions and stereotypes (no safe space, no support…). This also relates to the topic of how peer educators can help, support and be allies. Lesson content •

Myths and misconceptions.

•

Challenging stigma and discrimination.

alert them that you are coming out, and make time to talk

Time allocation:

afterward about how things went. Find trusted allies who

30 minutes

can help you cope with your experiences. 6.

Get support and use the resources available to you.

LESSON THREE: ATTITUDES AND SELF-AWARENESS Despite the Constitution and other laws that protect the rights of LGBTQI+ communities, many face high levels of social stigma and homophobic violence as a result of traditional and conservative attitudes within the general population. LGBTQI+ individuals continue to experience many forms of discrimination,

Activity One: Sentence Completion Requirements Flipchart and koki pens. Sentences. Handout: Myth information. Instructions for the flow of the activities a.

sentences one-by-one, and that participants will be called

stigmatisation, and even violence and victimisation – including sexual abuse and rape, hate speech, domestic violence, and physical abuse or assault.

Explain to the participants that you will read incomplete upon to finish the sentences spontaneously.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Make sure to clarify whose turn it is before you read a sentence. 67

Mention that there is no right or wrong answer.

Read the provided sentences one-by-one.

Repeat until everyone has had their turn.

Facilitate a plenary discussion using discussion questions

•

Becoming knowledgeable, accepting, and comfortable with this topic before teaching it. If you cannot be, identify someone to teach in your place and carefully screen them.

•

provided.

Considering carefully how the institutional community (lecturers, students, religious leaders, and others) may feel about sexual orientation which is an extremely sensitive topic, and working with them to avoid negative

DISCUSSION QUESTIONS

reactions. •

Preparing this topic carefully, but not being overly hesitant

How did you feel during this activity?

Would anyone like to comment on what they just said?

about addressing it. If you meet a lot of resistance, work to

If there are no LGBTQI+ persons in the room that you are

educate other stakeholders before undertaking work with

aware of, ask: “How do you think LGBTQI+ individuals feel

the target group.

after hearing (some) of the answers?” OR, if persons are in the room who openly identify under the LGBTQI+ umbrella,

RESOURCE FOR ACTIVITY ONE: SENTENCES

ask them how the answers made them feel. 4.

If many of the answers reflect misconceptions or prejudice, ask: “What can we do to change this?”

à learn the facts to

debunk myths and misconceptions.

•

If I found out my colleague is bisexual, I would…

•

If a close friend of mine who I assumed was straight told me (s)he was gay/lesbian and was attracted to me, I would feel…

•

KEY MESSAGES

wearing clothing items meant for females and/or makeup,

For the peer education programme, destigmatising LGBTQI+ students means: Establishing a safe and supportive environment.

•

Objecting to and eliminating jokes and humour that put down or portray LGBTQI+ people in stereotypical ways.

•

Countering statements about sexual orientation or gender identity that are not relevant to decisions or evaluations being made regarding awards, selections, nominations or appointments.

•

Inviting “out” professionals to conduct seminars and provide guest lectures on LGBTQI+ topics and other topics of their expertise.

•

Not forcing LGBTQI+ people out of the closet or to “come out”. The process of coming out is one of enlarging a series of concentric circles and is very individual. Initially, the process should be in control of the individual until (and if) they consider it public knowledge.

•

I would… •

•

If a male friend of mine that I regularly go out with started

When I think of two people of the same sex making love to each other, I feel…

•

If I found out my child’s teacher was gay or lesbian, I would…

•

When I meet a trans* person, I feel or I would….

•

When I think about children who are being raised by lesbian or gay couples, I feel…

•

What I admire about gay people is…

•

What I don’t like about gay people is…

•

Lesbian or gay people make me uncomfortable when…

•

As a parent, if I learnt my child was lesbian or gay, I would…

•

In my culture or home town, lesbian, gay, bisexual or trans* individuals are…

•

If I found out my partner was intersex, I would…

•

If I found out I flirted with someone who is trans*, I would…

Not including sexual orientation or gender identity

LESSON FOUR: LGBTQI + HEALTH

information in letters of reference, or answering specific or implied questions without first clarifying how “out” the person chooses to be in the specific process in question.

Aim:

Because your environment may be safe, it does not mean

To review the issues related to LGBTQI+ health, including regular

all environments are safe.

screening, and the various health conditions that LGBTQI+

•

Recruiting and contracting LGBTQI+ peer educators.

persons are at risk for.

•

Viewing LGBTQI+ identity as a positive form of diversity that is desired in a multicultural setting.

Time: 35 minutes

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Lesson objectives On completion of this lesson, participants should: •

Know the health issues for LGBTQI+ persons, as identified by the WHO.

•

KEY MESSAGES •

individuals from accessing testing, prevention and

Be familiar with screening tests available for both

treatment services, and seeking support from friends and

communicable diseases (that can be passed from one person to another) and non-communicable diseases. •

Be familiar with the various health challenges that

family. •

appropriate care:

Purpose of activities To provide information on relevant issues pertaining to LGBTQI+ health. •

To provide opportunities for participants to demonstrate

as stigma and discrimination in terms of LGBTQI+ health. Activities Group: Discussion and brainstorming

Note all points on the flipchart.

Facilitate the popcorn exercise, i.e., people randomly “pop up” and say one thing they learnt from the lesson.

Summarise the lesson using the discussion questions provided.

Heightened concerns about confidentiality;

Fear of losing one’s job; and

Fear of talking about one’s sexual practices or These factors make LGBTQI+ individual more Higher rates of HIV and other sexually transmitted diseases (STDs);

Flipchart paper, markers

Requirements:

what’s different about LGBTQI+ health?”

Lack of access to culturally and orientation-

vulnerable to:

key issues related to LGBTQI+ health.

Introduce the subject of LGBTQI+ health, and ask: “So

Discrimination (unfairly treating a person or group of

To create opportunities for participants to become informed of

orientation.

Objective

Instructions for the flow of activities:

Stigma (negative and usually unfair beliefs);

appropriate medical and support services;

to understand the risks and consequences of issues such

20 minutes

Homophobia and transphobia;

To use methods that are interesting and enable participants

Time:

people differently);

existing knowledge. •

Factors that can negatively impact on LGBTQI+ individuals’ health, well-being and ability to receive

LGBTQI+ persons face. •

There are many reasons that prevent LGBTQI+

Tobacco, alcohol and drug use and abuse; and

Depression.

As elaborated on in previous chapters, multiple and overlapping forms of stigma and discrimination diminish the ability of LGBTQI+ individuals to realise their right to access healthcare. Failure to access appropriate healthcare services timeously to prevent or mitigate diseases and illnesses and receive treatment makes LGBTQI+ persons particularly vulnerable, especially in the context of HIV. Further, if health service providers are not sensitised or trained regarding the special health needs of LGBTQI+ individuals, the cycle of invisibility and discrimination is already in full swing. In South Africa, parts of the LGBTQI+ community are either identified as key or vulnerable populations for HIV and STIs

DISCUSSION QUESTIONS •

Ask participants if they have any further questions about LGBTQI+ Health.

•

Did they learn anything new?

•

Did new information change the way they think about LGBTQI+ health and the community?

•

How did the information impact them?

(National Strategic Plan (NSP) for HIV, TB and STIs: 20172022). Despite South Africa’s generalised HIV and TB epidemics and high STI rates, some groups are much more heavily affected than the general population and need special attention. Addressing the health needs of key and vulnerable populations is of utmost importance to tackle the generalised HIV epidemic. According to the South African National LGBTI HIV Framework, 2017-2022: Many factors contribute to the vulnerability of LGBTI people to HIV, TB and STIs. Stigma and discrimination based on sexual

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

orientation and gender identity and expression, as well as

•

Fear of talking about one’s sexual practices or orientation.

lack of knowledge about LGBTI health needs, prevents sexual minorities from accessing the necessary prevention, care and

These factors make LGBTQI+ individuals more vulnerable to:

sexual health services in the public system. Social stigma

•

Higher rates of HIV and other STDs.

is linked to poor mental health outcomes as well as sexual

•

Tobacco, alcohol and drug use and abuse.

and other violence perpetrated against LGBTI people, and

•

Depression.

diminished economic opportunities. Other contributing factors include misinformation about HIV and STI prevention among

The CDC recommends sexually active gay, bisexual, and other

LGBTI people, unavailability of HIV, STIs, and TB prevention

men who have sex with men test for:

commodities, high-risk sexual behaviours, and drug use and

•

HIV at least once a year.

alcohol abuse. Historical racial and socioeconomic inequalities

•

Syphilis.

exacerbate the vulnerability of many LGBTI people, particularly

•

Hepatitis B.

in areas where LGBTI-competent services are unavailable.

•

Chlamydia and gonorrhoea of the rectum, if you’ve had

While very little is known about TB among LGBTI groups in South Africa, it is likely that many of the above-mentioned factors

receptive or penetrative anal sex in the past year. •

also contribute to TB vulnerability.

Chlamydia and gonorrhoea of the penis (urethra), if you have had penetrative anal sex (been on the “top”), or received oral sex in the past year.

The new strategy aims to provide the basis for more inclusive

•

Gonorrhoea of the throat, if you’ve given oral sex (your

services so that LGBTQI+ communities have “the necessary

mouth on your partner’s penis, vagina, or anus) in the past

tools to realise their health and human rights goals.” More

year.

inclusive health services and health education will prevent new HIV infections among LGBTQI+ communities and will increase

Why are screening tests important?

the access and education of LGBTQI+ individuals who are living

Screening means prevention! It’s that simple. There are

with HIV because LGBTQI+ individuals do not have to fear that

different types of prevention, as described below.

they are being stigmatised or discriminated against by clinic staff and health workers.

PRIMARY PREVENTION means that checking on your health regularly can help to prevent you from getting serious life-

Fear is still prevalent, however, and it prevents LGBTQI+

threatening or less serious illnesses.

individuals from seeking needed health services, such as ART, thereby delaying access to life-saving prevention, care and

SECONDARY PREVENTION means that if you screen and

treatment services. LGBTQI+ youth are at increased risk for

find you’ve already been infected with some virus or have

being abandoned by their families and rejected, and barred from

developed a life-threatening condition, you can get treatment

accessing schools, all of which undermine their ability to learn

and manage your lifestyle to prevent it from becoming more

and develop the skills that are necessary for a productive life as

serious.

an adult. TERTIARY PREVENTION means that when you’ve caught In summary, factors that can negatively impact on LGBTQI+

it too late and it’s already serious, you can get treatment to

individuals’ health, well-being and ability to receive appropriate

manage pain and side-effects.

care are: •

Homophobia (negative attitudes and feelings toward homosexuality or people who are identified or perceived as being lesbian, gay or bisexual).

•

Transphobia (discrimination, prejudice and violence trans people face based on their gender identity).

•

Stigma (negative and usually unfair beliefs).

•

Discrimination (unfairly treating a person or group of people differently).

•

Lack of access to culturally and orientation-appropriate medical and support services.

•

Heightened concerns about confidentiality.

•

Fear of losing one’s job. HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

What services are available to LGBTQI+ individuals?

This includes but is not limited to:

Health service providers must be trained and sensitised

•

HIV counselling and testing (HCT),

regarding the special needs of LGBTQI+ individuals to

•

Sexually transmitted infection (STI) screenings and

be able to provide health services that are free of stigma

treatment,

and discrimination, and tailored to the needs of LGBTQI+

•

Tuberculosis (TB) screenings,

individuals. This means, for example, making Pre-Exposure

•

PrEP and Provision of post-exposure prophylaxis (PEP),

Prophylaxis (PrEP) available to all gay and bisexual men,

•

Anti-retroviral treatment (ART),

or considering issues of substance abuse or mental health

•

HIV management (CD4 and viral load),

issues during health tests and screenings, as these are

•

Pap smear,

coping mechanisms to deal with stigma and discrimination.

•

Basic wound care and clean needles and syringes,

LGBTQI+ individuals have the same rights as anyone else to

•

General medical, sexual health and safer sex consultations,

make use of health services.

•

Individual and couples’ counselling, and

•

Condoms and lubrication.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

References Brown, B., Duby, Z., & Van Dyk, D. “Health care provision for men who have sex with men, sex workers, and people who use drugs: An introductory manual for health care workers in South Africa.” Desmond Tutu HIV Foundation, 2013. Adapted from: Poteat, T. http://www.cdc.gov/lgbthealth Garofalo, R., et al., Sexual orientation and risk of suicide attempts among a representative sample of youth. Archives of Paediatrics and Adolescent Medicine, 1999, 153(5): 487. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “Healthy People 2010: Final Review.” DOH and Human Services Centers for Disease, 2012. Beyrer, C., et al., The expanding epidemics of HIV type 1 among men who have sex with men in low-and middle-income countries: Diversity and consistency. Epidemiologic Reviews, 2010, 32(1): 137-151. UNAIDS, “Meeting the HIV treatment and health needs of gay men and other men who have sex with men.” Meeting Report from UNAIDS Policy and Strategy Consultation, 2013, Geneva. Homosexuality and labour laws in SA: http://www.labour.gov.za/DOL/act/section_detail. jsp?legislationId=5954&actId=8191&sectionId=8327 Promotion of Equality and Prevention of Unfair Discrimination Act, 2000 (PEPUDA or the Equality Act, Act No. 4 of 2000). Same sex civil marriage. http://www.dha.gov.za/documents/act17.pdf OUT! Well-being, Train the trainer manual – Understanding Human Sexuality. https://www.out.org.za/index.php/library/manuals# The AIDS and Rights Alliance for Southern Africa (ARASA). “Sexual orientation, gender identity, HIV and human rights. An advocacy toolkit”, 2015. http://www.arasa.info/files/8414/3860/4501/ARASA_Toolkit_full_web.pdf DHET. “Policy framework for the realisation of social inclusion in post-school education and training institutions.” DHET, 2016. http:// www.dhet.gov.za/SiteAssets/Latest%20News/2017/january/Gazetted-Policy-Framework-for-the-Realisation-of-Social-Inclusion-inPSET-No40496-Notice-no-1560.pdf SANAC. “National Strategic Plan (NSP) for HIV, TB and STIs: 2017-2022.” http://sanac.org.za/wp-content/uploads/2017/05/NSP_ FullDocument_FINAL.pdf SANAC. “The South African National LGBTI HIV Framework, 2017-2022.” http://sanac.org.za/wp-content/uploads/2016/07/J6917_ LGBTI_Booklet_LR.pd http://itspronouncedmetrosexual.com Gender Dynamix, Advancing Transgender Human Rights. https://www.genderdynamix.org.za/resources

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Chapter 4|GENDER-BASED VIOLENCE Mental Health

Disability

Alcohol and Drug abuse

GENDER-BASED VIOLENCE

Introduction and Overview

and the Centre for Public Mental Health on IPV reveal that: •

Every eight hours (on average), a woman dies at the hands of an intimate partner in South Africa.

•

IPV is the most common form of violence experienced by South African women and is the leading cause of death among South African women.

•

More women are killed by their current or former intimate male partner in South Africa than in any other country in the world.

•

Victims remain hesitant to disclose their situation because of the stigma attached to IPV. Those who do report incidents often deal with public servants who fail to detect their problem or deny that it exists.

•

Of pregnant women, 36-40% experience physical IPV, and 15-19% experience sexual IPV. The violence increases the risk for the baby, which could be born pre-term and with a

Gender-based violence (GBV) is a global phenomenon and

low birth weight.

one of the most widespread violations of human rights, with a significant impact on physical, psychological, sexual and reproductive health. Evidence reveals that, although men and women (including individuals of varying sexual orientations) are affected by GBV, women and girls are disproportionately affected and bear the brunt of these severe human rights violations collectively at all stages of their lives. GBV is a mirror that reflects the gender stereotyping in society and the pattern of unequal social relations created by patriarchal cultures. Men and women do not experience the same forms of violence, nor do they experience violence to the same extent. In contrast to men, women have been more likely to be blamed for much of the violence inflicted upon them, which has also not historically been regarded as criminal, nor provided with effective legal remedies.

According to Professor Rachel Jewkes, the prevalence of GBV among young adults in HEIs in SA is alarming: •

Students comprised 1 in 10 rapes of adults reported to SAPS in 2012, i.e. 2600 reported cases.

•

Under-reporting of rape to the police is estimated to be in the region of 23 400.

•

65 000 per annum is the true number of rapes among students.

•

A third of women experience physical partner violence.

While these inferences can be made to underscore the problem in higher education, it is also important to acknowledge that there are gaps in data and further research is necessary to understand the true extent of the problem at universities and colleges.

GBV also perpetuates vulnerability while compromising the

GBV in HEIs in South Africa

health, safety, and autonomy of survivors, keeping them trapped

While some data is lacking for GBV in higher education, the

in a cycle of violence and abuse. GBV is a complex issue and, to address the situation effectively, it is crucial to ensure that efficient and functional support systems are available to provide survivors with immediate care and safety. Such support must include quality mental, physical, and sexual and reproductive health (SRH) services; protection and shelter; and social and justice services. WHO statistics reflect that 35% of women worldwide experienced either physical or sexual intimate partner violence (IPV), or nonpartner sexual violence, and we know that in South Africa the problem is even more severe, with high levels of violence being

sector is a microcosm of the broader society that it draws its students and staff from. GBV has plagued the PSET system for quite some time and, in recent years, more cases of rape and murder of women students have been reported. Most of these crimes against women are perpetrated by men who are well known to the victims as partners, former partners, or fellow students. Sexual harassment, “sex for marks”, as well as violations against gender minority groups have taken a prominent place in discussion and dialogues on the issue.

a prominent historical feature. Statistics from studies by the Medical Research Council (MRC)

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

GBV has also been linked to various other issues such as drug and alcohol abuse, abuse of people with disabilities (PWDs), abuse of gender diverse people, safety of students and staff on campuses and in student residences, and mental health problems, such as depression and trauma on the part of

institutions are therefore a critical entry point for identifying GBV, and empowering young women with skills and techniques to reclaim their power base and find ways to prevent and/or stand up against GBV.

victims and their families.

Particularly

post-schooling

institutions,

where

adult

As such, students and student activists have called for

service, namely, promoting and teaching protective behaviours

relationships are generally forged, it is crucial to offer a twofold

deliberate action through protest action against unsafe environments, demanding gender transformation in institutions and deliberate response strategies and prevention work in relation to GBV.

and prevention strategies as well as offering services where survivors of violence may access treatment, support and care. In recognising the complexities and sensitivities in responding to GBV, the Framework emphasises the principles and objectives

The Higher Education GBV Policy And Strategy Framework The Higher Education Health Wellness and Development Centre (HIGHER HEALTH, formerly known as HEAIDS), on behalf of the DHET, has developed a GBV Policy and Strategy Framework to respond to GBV as it impacts on staff and students at its university and college campuses. The Framework will guide a response strategy that will give direction to managing

described below against which GBV programming and responses may be framed. Principles Rights-based: The values and rights contained in the Constitution

must

underpin

all

policy

processes

and

procedures. At a minimum, these must actively seek to give

and responding to GBV critically.

concrete expression to the rights to equality, dignity, freedom

The policy recognises that GBV manifests in the following ways

integrity.

and security of the person, and bodily and psychological

in institutions and is thus framed to address these issues: i.

Grading or rating of appearance by verbal comments, wolfwhistling, or other noises. Stalking and repeated unwanted requests for dates.

iii.

Derogatory comments, including in relation to people’s gender non-conformity. The use of work (either academic or administrative) as an excuse for inappropriate, private meetings.

Rape.

vi.

Sexual assault.

aspect or manifestation of the problem alone. Even though be responded to. Furthermore, interventions to address GBV must be multi-faceted, comprising complaints’ processes and procedures; support to complainants; and (where possible) assistance to the perpetrator in changing their behaviour. Comprehensive and multi-faceted approaches to GBV prevention: PSET institutions’ responses to GBV must include

vii. Physical assaults by intimate partners, or against individuals perceived as gender nonconforming. viii. Requests or demands for sex in exchange for improved marks, accommodation in residences, or other needs and benefits. ix.

PSET institutions’ responses to GBV cannot focus on one the nature of the response may differ, all forms of GBV must

ii.

iv.

Comprehensive and multi-faceted approaches to GBV:

Spying, or intruding upon women in residences while bathing or dressing.

comprehensive prevention, education and information about GBV policies; and programmes, including social mobilisation activities and campaigns, intended to promote safety on campus and prevent GBV. Specialisation: Responding to GBV requires specialised knowledge and skills. All staff and students involved in addressing GBV in any way must be skilled and gendersensitive, receive ongoing training, and conduct their work in

Streaking and flashing.

xi.

In the case of abusive relationships, preventing or interfering with a partner’s studies, including by withholding fees.

accordance with clear guidelines, protocols and codes of ethics. Programmes and other responses must reject ideologies that

xii. Murder by an intimate partner.

excuse or justify men’s violence or blame complainants.

These various abuses can occur between students, between

confidentiality and privacy of the complainant whose safety

Confidentiality: All responses to GBV must maintain the

staff and students, as well as between staff. They may also be

and physical and psychological needs must be prioritised.

perpetrated by third parties such as visitors to campus, or on-site contractors. As a primary and/or secondary prevention strategy, educational 76

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Complainant-centred: Assistance to the complainant must

•

Capacity development of institutional staff at every

support and encourage their sense of personal control, which

campus, including all staff involved in direct and indirect

includes respecting the complainant’s informed decision at

support to victims.

every stage of the process. Reporting, investigative or support

•

staff must offer comprehensive information about all processes

Capacity development of peer-to-peer mobilisers to advance the programming and uptake of the same.

and options in a manner which is non-judgmental, appropriate,

•

clear and sensitive to the complainant in terms of language,

Technical support in setting up disciplinary tribunals and capacity development of members at every campus level.

culture, disability, gender and sexuality.

•

Zero tolerance: Policies must contain a clear statement by the

Linkage to care and support – psycho-social support for the victim across every campus.

university or college rejecting all forms of GBV. This message

•

must not be diluted or made ambiguous by the policy referring

Development of call centre and other technology-based applications.

to false complaints, or procedures for dealing with allegedly

•

false complaints. Should investigations yield evidence of

Safer Campus Programme – campus safety audits, campus infrastructure, Red zones, and access control (to

false complaints, these can be dealt with in the same way

draw from the UN Women – Safer Cities tool kit).

misconduct is ordinarily dealt with.

•

Accountability: Implementation of the policy must be

Life Orientation (LO) in the classroom through the formal curriculum, and capacity development of teaching staff.

routinely monitored and evaluated, and senior managers held accountable for its effective implementation. This includes

The efficient delivery of this Framework and GBV prevention

maintaining documentation and records in accordance

programming will be supported by leadership and extensive

with health, police and legal requirements and the need for

resource mobilisation as an enabling pillar for this work.

confidentiality, security and choice. Best practice in violence prevention in higher education: Objectives

At TVET or university level, there is a need to:

The Framework outlines four objectives that speaks to the

•

• •

Establishing just, specialised procedures for the reporting,

•

Assess GBV threats on campus and respond proactively.

investigation and resolution of complaints.

•

Support victims and respond timeously and appropriately to GBV.

Providing comprehensive, specialised support and other assistance to complainants of GBV.

•

Create an environment of zero tolerance to gender discrimination and violence.

effective management, response and prevention of GBV.

•

becoming victims, and seek assistance when GBV occurs.

Promoting the safety of all students and staff by putting in place comprehensive prevention programmes intended to

Empower women to protect and prevent themselves

•

Empower men to embrace equitable and respectful gender relations and recognise that violence is not an option.

raise awareness of policies and services addressing GBV, as well as other measures aimed at preventing incidents of •

•

GBV in the PSET sector.

What works for prevention?

Ensuring the effective implementation of policy and

A strong university and TVET policy framework for prevention

programmes through attention to budgeting; monitoring and

and response.

evaluation; and the creation of a system of accountability.

•

Assess the threat: What policies, practices, and systems

Establishing national structures and mechanisms intended

create GBV risks? Do we know when it is occurring? Where,

to enable PSET institutions’ implementation of their

when, and impacting whom?

institutions’ policies.

•

New directions for protecting women from sexual assault. For example, combining gender empowerment and selfdefence.

Programme Elements Programme implementation will be comprehensive, harnessing

•

Interventions with men. Workshop-based interventions do

the strengths and capabilities of existing health, wellness

work. For example, Stepping Stones implemented with

and development initiatives being led through the HIGHER

youths in a school in the Eastern Cape reduced perpetration

HEALTH Centre.

by men for up to two years after the programme (Jewkes et

•

al., 2008).

A national PSET GBV Education, Awareness and Prevention Campaign.

•

Strengthening the capacity of peer educators to identify and

Institutional-level policy development and implementation

support survivors of violence is crucial to the prevention of

strategies.

and response to GBV.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Note to Peer Educators:

LESSON PLAN: GENDER-BASED VIOLENCE

Be prepared for the sensitive nature of the topic. •

Aim To clearly define what is meant by Sexual and Reproductive Health rights and responsibilities

Ensure that the approach to facilitating is neutral and nonjudgemental.

•

Anticipate that there may be awkwardness or discomfort with the subject matter.

•

Pay attention to your use of language: ensure that it is

Learning Outcomes

simple, accessible, easy to understand, and relevant to the

By the end of this lesson participants should be able to:

context of the students.

•

Explain what gender-based violence (GBV) is.

•

Describe who is most at risk for GBV.

•

List the forms and nature of GBV.

•

Identify risk factors for GBV.

•

Explain causes of GBV.

•

Describe the link between GBV and HIV.

•

Identify and counter myths surrounding GBV.

•

Describe health outcomes of GBV.

•

Outline prevention strategies in the SA context.

Background/ Motivation South African law protects people’s SRHR. It is therefore important for students to know that sexual and reproductive rights exist, and that people have control over and can decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health free of coercion, discrimination and violence. These rights are embedded in the South African Constitution and in South Africa’s commitment to implement international human rights

Lesson Content •

What is GBV?

•

Who is most at risk for GBV?

•

Forms and nature of GBV.

•

Risk factors for GBV.

•

Causes of GBV.

•

GBV and HIV.

•

Myths surrounding GBV.

•

Health outcomes of GBV.

•

Prevention strategies in the SA context.

treaties. The relationship between health and rights is important for students to know because they are primarily young people at their peak of sexuality, and their approach to sexual health requires a positive and respectful outlook. To be sexually healthy, people need to be able to have pleasurable and safe sexual experiences free of coercion, discrimination and violence. They need access to sexual health information and services. For people to have and keep their sexual health, their sexual rights must be respected, protected and fulfilled. The expected outcome of the session is to impart accurate

Time:

knowledge as a vehicle to opening debate and discussion on

150 minutes

this subject as well as to assess students’ baseline knowledge of rights, responsibilities and resources (services, support

Material needed for the lesson:

structures and legislation).

Flip chart and markers

One’s sexual rights are often violated when GBV occurs, and

Copies of case study

thus it is important to understand one’s rights.

Preparation for the lesson: In this session, the Peer Educator will use interactive methods

Activities and tasks •

Case study: Introducing the subject with a case study

to access the baseline knowledge of the students as well as

presents an excellent point of entry for teaching students

tap into the attitudes and behaviour patterns of students in

about sexual and reproductive rights.

respect of SRHR. To prepare, peer educators should:

•

Group exercises

•

Games

Read and understand the reference notes to get a thorough grasp of the subject content.

•

Familiarise themselves with the suggested format and instruction guidelines for the activities.

•

Read and familiarise themselves with the prepared material.

•

Anticipate questions that may arise.

•

Print any handouts that may be required.

Methods: •

Brainstorming

•

Questioning

•

Group exercises: --

Small group discussion of prepared questions

Case Study

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Instructions for flow of the activities/tasks 1.

Introduce lesson on GBV

Ask “What do we understand by the term gender-based violence?”

Note responses on the flip chart and encourage discussion

Divide group into smaller discussion groups:

What is GBV?

Who is most at risk for GBV?

Where does GBV happen?

How many types of GBV do you know?

Allow 15 minutes for completion of the exercise, and then discuss the responses to the questions in the plenary using the notes provided below as a guide.

KEY MESSAGES •

services, including sexual and reproductive healthcare for everyone. •

rights (SRHR) laws, policies and guidelines, which are described below. •

signed and ratified, including the: --

Introduce the activity as per the instructions outlined

---

the scenario. c.

Which of Tessa’s sexual and reproductive health rights have

What are Tessa’s rights as a survivor of sexual violence?

What options are available to Tessa’s mum?

What are the challenges that may prevent Tessa’s mum

on Population (September 1994). •

•

Hand out copies of the red zone on GBV

•

Allow the class to complete the screening individually and anonymously then and hand it back. For this exercise, they are only required to state whether they are male or female.

•

Facilitate a plenary discussion on GBV.

Touching,

Jokes and innuendos of a sexual nature,

Persistent probing about personal and intimate information related to one’s sex life,

Allow 30 minutes for completion of the exercise, and then reconvene as a class

Sexual harassment is any kind of sexual behaviour that makes you feel uncomfortable, including:

from exercising her options? •

International consensus agreements, including the Programme of Action of the International Conference

been violated? d.

UN Convention on the Rights of Persons with Disabilities (UNCRPD, 2006), and

the following questions Identify and name three types of sexual violence evident in

Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW, 1979),

Read the case study to the class and instruct them to answer

UN Convention on the Rights of the Child (UNCRC, 1989),

Begin by dividing the class into three groups:

What is happening in the scenario?

A human rights approach to sexuality and reproduction is reflected in the international treaties that South Africa has

Explain that the next activity may be sensitive and emotive

International law also supports a human rights approach to sexuality and reproduction.

•

below 8.

These fundamental, constitutional rights are reflected in South Africa’s many sexual and reproductive health and

but is important to discuss 7.

The Constitution guarantees the right to healthcare

Rude and inappropriate comments or gestures,

Unwelcome advances of a sexual nature, and

Leering or staring at your body in an offensive way.

•

Sexual harassment can happen anywhere.

•

Sometimes sexual violence is implicit (difficult to see) so we need to trust our instincts.

•

How we see and accept, or challenge violence affects others around us.

•

It is up to each person individually to make changes in their own environment if they would like to see a world

DISCUSSION QUESTIONS •

What surprised you in this lesson?

•

What made an impact on you?

•

Do you think these situations are real?

with less violence. •

There are steps you can take if your rights or those of somebody you know have been violated.

RESOURCE FOR GROUP ACTIVITY: TOUCH ME NOT (CASE STUDY) Time Required: 15 minutes

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Part One:

Part two

It’s the start of the new semester and Tessa is first in class

Tessa feels troubled as she walks home the following day.

eagerly waiting for the IT lecture to begin. Mr Vee is an

There’s a pit of anxiety in her tummy as she contemplates her

excellent lecturer and for the first time she actually “gets it”.

options. Deep in thought, she reaches home and suddenly

This semester she is certain she could top the class again!

becomes aware of muffled screams and sounds of breaking glass. She feels the familiar sense of panic “Oh no… he must

Tessa greets Mr Vee enthusiastically, he smiles and tells her

be drinking again. She rushes in and bumps into her step-

she’s looking really good. She thanks him shyly and smiles

father…he looks enraged. He shoves her out of the way and

back. Later, Mr Vee walks past Tessa and drops his pen on

leaves slamming the door shut behind him. Tessa rushes to

her desk. His hands lightly brush across her breasts as he

her mother’s bedroom to find her bleeding on the floor sobbing.

leans across to pick up his pen. She recoils in shock, and he

“Mum, mum…what happened?” “He said I was flirting with the

apologises but winks and smiles.

taxi driver”, her mum answers in a feeble whisper struggling to breathe, her face contorted in pain…. Distraught, Tessa

Later that week, Tessa bumps into Mr Vee in the corridor, and

rushes next door to ask her neighbour for help.

he asks if she’s free to assist him with some administrative work. Tessa is flattered and agrees to help. When she arrives at his office, he invites her to sit and then sits beside her to “show her what needed to be done”. She feels a twinge of discomfort at his closeness, but brushes it away thinking she’s being silly.

The following day, Tessa gets off the bus to walk a few hundred meters to college. The rain is falling heavily and an icy wind is blowing. A car pulls up silently next to her. It’s Mr Vee. “C’mon, get in young lady, I’ll give you a ride. She gets

As they work, she suddenly feels his hand sliding under her skirt. She jumps up in shock and says she has to leave, or she’ll be late for her next lecture. Tessa feels tense and decidedly awkward at the thought of Mr Vee’s lecture the following day. She is quiet and distant in class the next day and can feel Mr Vee’s eyes on her.

in quickly thinking “it’s okay- the college is just around the corner. She feels a twinge of alarm as Mr Vee drives past the college smiling and chatting all the while. “Mr Vee, I have a first lecture- where are you going? Please drop me off…He laughs and continues to the end of the road towards the deserted park. “It’s okay Tessa, you don’t have to pretend…I know what you want. I want it too.. “Oh my God, no, please no…

As she gets up to leave, she is nervous and anxious because Mr Vee is standing at the door chatting with students. As she passes him, he grabs her arm and leans into her, looking directly down her cleavage. “What’s up young lady? You were very quiet today,” He says. Tessa hurriedly answers that she is ok and breaks free, rushing out so that she is not left alone. Two weeks later, Tessa receives a call from Mr Vee. He explains that he would like her to assist him with administrative tasks on two afternoons per week. In return, he says he is sure she will receive the IT yearend award because of the commitment she demonstrates. She explains that she has too much work and would be unable to assist. He says it is a real pity, especially as there are three students competing for the prize.

let me out.” He laughs and pulls into a dark shaded area of the park. Frantically she tries to open the locked car door. He pushes her gently back into the seat, smiling and whispering endearments all the while. Her body trapped beneath him, she continues to struggle. What is happening in the scenario? Answer: Various forms of sexual violence Identify and name three types of sexual violence evident in the scenario Answer: Sexual Harassment; Intimate partner violence/domestic violence; rape Which of Tessa’s sexual and reproductive health rights have been violated? Answer: The right to be treated with dignity and respect, the right to freedom and security; the right to control over her own body; the right to say “no”, the right to safer sex, the right to life (HIV/

“What do you mean?” she asks, confused. He laughs and says, “Work it out young lady, you’re intelligent…”

Part three

STIs); the right to choose (unplanned pregnancy) What are Tessa’s rights as a “survivor” of sexual violence? PEP, HTS, TOP (if necessary); legal recourse. What options are available to Tessa’s mum? Report to police and charge with assault; interdict, legal action. What are the challenges that may prevent Tessa’s mum from

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exercising her options?

Gender-Based Violence: “Gender-based violence is an

Disempowerment; economic dependence; fear for her life

umbrella term for any harm that is perpetrated against a person’s

Important definitions

gender roles. Around the world, gender-based violence almost

The definitions below are provided in an effort to standardise

always has a greater negative impact on women and girls.

the way in which GBV is understood within humanitarian

For this reason the term gender-based violence is often used

settings in order to promote more useful data collection,

interchangeably with the term “violence against women.” One

dialogue, and action.

reason the term “gender-based violence” is often considered

will, and that results from power inequities that are based on

preferable to other terms that describe violence against women Gender: Refers to the social differences between men and

is that it highlights the relationship between women’s subordinate

women that are learnt, and though deeply rooted in every

status in society and their increased vulnerability to violence.

culture, are changeable over time, and have wide variations

However, it is important to remember that in some cases

both within and between cultures.

men and boys may also be victims of gender-based violence. Violence may be physical, sexual, psychological, economic, or

Violent Episode: An act or series of acts of violence or

socio-cultural. Categories of perpetrators may include family

abuse by one perpetrator or group of perpetrators. May

members, community members, and/or those acting on behalf

involve multiple types of violence (physical, sexual, emotional,

of cultural, religious, or state institutions” (RHRC Consortium,

economic, socio-cultural); and may involve repetition of

2004, page 11).

violence over a period of minutes, hours, or days. Survivor: Person who has experienced violence or other abuse. Secondary Survivor: Person impacted by the experience of GBV inflicted upon the survivor. May include family members or others close to the survivor. Perpetrator: Person, group, or institution that directly inflicts or otherwise supports violence or other abuse inflicted on another against her/his will. Intimate Partner: Includes current or former spouses (legal and common law), non-marital partners (boyfriend, girlfriend, same-sex partner, dating partner). Intimate partners may or may not be cohabitating and the relationship need not involve sexual activities. Minor: Person under the age of 18, according to the UN Convention on the Rights of the Child (UNCRC).

VIOLENCE AGAINST WOMEN IS GENDER-BASED: IT DOES NOT OCCUR T O W O M E N R A N D O M LY.

(Gender-based Violence Tools Manual. Compiled by the Reproductive Health Response in Conflict (RHRC) Consortium. UNHCR, UNFPA, the Center for Health and Gender Equity, and WHO. February 2004)

What is Gender-Based Violence? “Gender-based violence (GBV) is the general term used to capture violence that occurs as a result of the normative role expectations associated with each gender, along with the unequal power relationships between the two genders, within the context of a specific society.” (Bloom 2008, p. 14).

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From these international definitions, we may understand the term

Who is most at risk for GBV?

GBV as follows: GBV is •

a structural problem that is deeply embedded in unequal power relationships between men and women

•

perpetuated by harmful social and cultural expectations about gender roles

•

associated with being a woman or being a man, a girl or a boy

•

a mechanism for enforcing and sustaining gender inequality

•

a means to send a message to women and girls that they are worth less than others and that they do not have control over their own lives and bodies

This has direct consequences on: •

health

•

employment

•

Where does GBV happen?

participation in social and political life (Kelly 2005) GBV is most often directed at women and girls as the obvious bearers of the female and feminine. LGBTQI+ individuals may also experience GBV, including based on being gender nonconforming and/or not practising heterosexuality. Violence may also be used to feminise men, or undermine their masculinity, ensuring that they are not exempt from some forms of GBV either. The use of violence to institute and maintain forms of gender relations is also influenced in complex ways by perpetrators’ ideas about their victim’s race, disability, social class and citizenship status, among other factors. These factors similarly influence how others respond to instances of GBV, as well as individuals’ access to helpful resources. GENDER-BASED VIOLENCE POLICY AND STRATEGY FRAMEWORK FOR THE POST-SCHOOL EDUCATION AND TRAINING SECTOR, April 2019.

Gender-based violence in South Africa According to the Alberton Record, an online news website, “South Africa has one of the world’s highest gender based violence rates in the world, some experts say it is comparable to countries that are at war.” September 6, 2019 (https:// albertonrecord.co.za/) The article goes on to say that “a report by Statistics SA shows that femicide (the murder of women on the basis of their gender) is 5 times higher than the global average. This means that in South Africa, women are 5 times more likely to be killed due to gender-based violence committed by men. Up to 40% of South African women have experienced sexual and/or physical interpersonal violence in their lifetime (http://www.saferspaces.org.za/) Gender-based violence in South Africa has various drivers, including, for example, rigid notions of masculinity that condone violent behaviour towards women and children, the socio-economic situation of many women that makes them dependent on their male partners or a patriarchal, conservative understanding of gender roles.

Form and Nature The primary inequality that gives rise to GBV is the power inequality between women and men. The majority of perpetrators of GBV are men. However, despite the fact that no society is free from it, male violence against women varies in degree and intensity according to the specific circumstances. Many men choose to reject dominant stereotypes of violent, controlling masculinity.

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Types of GBV include:

Economic Violence •

Used to deny and control a woman’s access to resources, including time, money, transportation, food or clothing. Acts of economic violence include:

•

prohibiting an individual from working

•

excluding them from financial decision making in the family

•

withholding money or financial information

•

refusing to pay bills or maintenance for her or the children; and

•

destroying jointly owned assets

Sources: adapted from Warshaw/Ganley 1996, WHO 2003, WHO 2013 Risk Factors for GBV (Ecological Framework) It is widely understood that GBV - be it in the form of isolated acts or systematic patterns of violence - is not caused by any single factor. Rather, it is a combination of several factors that increase the risk of a man committing violence and the risk of a woman experiencing violence.

Physical Violence Physical force that results in bodily injury, pain, or impairment. The severity of injury ranges from minimal tissue damage,

Individual level

broken bones to permanent injury and death.

Perpetration by men

Victimization by women

Demographics: • Low income • Low education

Demographics: • Young age • Low education • Separated/ divorced marital status

Child maltreatment • Sexual abuse • Inter-parental violence

Child maltreatment • Inter-parental violence

Mental disorder • Anti-social personality disorders

Mental disorder • Depression

Substance abuse: • Harmful use of alcohol • Illicit drug use

Acceptance of violence

Sexual Violence According to WHO 2002, cited in WHO 2013, sexual violence refers to any sexual act or attempt to obtain a sexual act using force, unwanted sexual comments or advances trafficking, or otherwise directed against a person’s sexuality, using force in any setting, including, home and work. Examples of include: •

rape, other forms of sexual assault

•

sexual harassment

•

trafficking for the purpose of sexual exploitation

•

forced exposure to pornography

•

forced pregnancy, forced sterilisation, forced abortion

•

forced marriage, early/child marriage

•

female genital mutilation (FGM)

•

virginity testing

•

incest

Psychological Violence Acts of psychological violence include: •

threats of violence through words or actions (e.g. through

Relationship level

Multiple partners /infidelity • Low resistance to peer pressure

Community level

• Weak community sanctions • Poverty

Societal level

• Traditional gender and social norms supportive of violence

Domestic Violence is an umbrella term that encompasses both Intimate Partner Violence (IPV) and Family Violence. •

to maintain power and control over another partner in an

stalking or displaying weapons) •

humiliating and insulting comments

•

isolation (e.g. through locking her up in the house, forcing

intimate relationship. This includes people with any current or former romantic involvement, for example dating, previously dating, on again/off again, married, divorced,

her to quit her job or prohibiting her from seeing a doctor) •

living together or apart. IPV can occur between people of

use of children to control or hurt (e.g. through attacking

any gender identity or sexual orientation, and can include

a child, forcing children to watch attacks against their

manipulation, threats, or the actual use of physical, sexual,

mother, threatening to take children away, or kidnapping the child). These acts constitute both, violence against children as well as violence against women

IPV is a pattern of abusive behaviours used by one partner

emotional, verbal, psychological, or financial abuse. •

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Family Violence is any abusive behaviour that occurs between members of a family or household who are not 83

involved in a romantic relationship. This includes chosen

harm (threats, insults, being humiliated or talked down to), by

family as well as people related by blood, marriage, foster

members of their own family, acquaintances, and/or strangers

care, adoption or any other familial relationships. Family

in the home, community, TVET college. The purpose of these

violence can include threats or the actual use of physical,

questions is to assess your experiences of gender based

sexual, emotional, verbal, psychological, or financial abuse.

violence. Your responses can help us identify with you the most appropriate health and protection services.

Are you in the red? Zone Check: Domestic Violence 1.

Are you in a relationship with a jealous and/ or possessive partner or family member?

Do you feel dominated and controlled by someone you live with?

Do you feel anxious and afraid when your partner/a family member is in your presence?

Are you always trying to please your partner/ family member to keep the peace?

Does your partner/family member isolate you by keeping you away from family and friends/ your support network?

Do you feel put down/criticised and/ or humiliated in public by someone you live with?

Does your partner /a family member force sexual acts upon you that you’re not comfortable with?

Do you feel bullied, harassed, physically harmed or pushed around and abused by someone in your home?

Does your partner/a family member control all decisions about money, relationships/ friendships, and personal life decisions (job/ studies)?

Yes No

Are you in the red? Zone Check: Gender-based Violence (GBV)

10. Are you anxious or depressed, have lost confidence, or become unusually quiet due to being in a relationship you’re afraid to leave? 11. Are you reluctant to leave the children alone with your partner or a family member?

In the past 12 months, have you been threatened with physical or sexual violence by someone in your home or outside of your home?

Have you ever been hit, punched, kicked, slapped, choked, hurt with a weapon, or otherwise physically hurt by someone in your house or outside of your house?

Have you been forced to have sex against your will?

Were you ever forced to have sex in exchange for a “reward” [such as food,, a job, a place at the college, good test and exam marks, money to support your family]

Were you ever forced to have sex because you or someone in your family would be in physical danger if you refused?

Were you ever physically forced or made to feel that you had to become pregnant or get married against your will?

Has anyone ever forced you to lose a pregnancy (i.e. forced you take medication, go to a clinic, or physically hurt you to lose your pregnancy)?

Are you always trying to please someone to keep him/her calm and prevent them from harming you some way?

At any point were you forced into a marriage or relationship with someone?

12. Have you ever been threatened with harm or death by someone you live with?

10. Does someone in your home or outside of your home isolate you by keeping you away from your family and friends/support network

If any of your answers place you on a red square, you are in the RED ZONE. This means you are at risk for domestic violence and abuse. Ask your HIGHER HEALTH Campus Coordinator for help with counselling, care and support as soon as possible.

12. Are you being harassed/stalked, bullied, or victimised by someone in your home or outside of your home?

Yes No

11. Are you being put down/criticised, or humiliated in public?

GBV is a traumatic experience for both men and women. This RED ZONE is asking about different types of GBV that women/ girls/LGBTQI may experience. This could include physical violence (hitting, punching, being kicked, slapped, choked,

If any of your answers place you on a red square, you are in the RED ZONE. This means you are at risk for gender-based violence and abuse. Ask your HIGHER HEALTH Campus Coordinator for help with counselling, care and support as soon as possible.

hurt with a weapon, or otherwise physically hurt), sexual violence (rape, sexual slavery, human trafficking) psychological 84

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Myths surrounding GBV Myths and stereotypical attitudes about GBV shape the way in which society perceives and responds to violence perpetrated against women. Such myths and attitudes are harmful as they tend to blame the survivors for the violence, rather than holding perpetrators responsible for their behaviour Myth 1: Individuals allow intimate partner intimate violence to happen to them and if they really want to, they can leave their abusive partners. Facts: In no case does anyone deserve to be abused. As explained in several theories on the dynamics of violent relationships, such as the Stockholm Syndrome or the Power and Control Wheel, perpetrators use a combination of tactics of control and abuse that make it very difficult for victims to escape the violence. It is also important to understand that people who experience violence from an intimate partner and seek to leave the relationship in order to ensure their own and their children’s safety paradoxically face an increased risk of escalating violence. Intimate partners are also prevented from leaving violent relationships due to feelings of shame and guilt, lack of safe spaces, fear of others getting involved or hurt, or the belief that home is the best place for children. It is particularly difficult for male victims to leave abusive relationships for fear of being ridiculed and stigmatised for “allowing” the abuse (adapted from Hagemeister et al., 2003). Myth 2: Conflicts and Discord are a normal part of any relationship Facts: “Everybody can lose control,” is a commonly used excuse to justify intimate partner violence (IPV). However, violence is not about “losing” control – rather, it is about “gaining” control through the use of threats, intimidation, and violence, as demonstrated by the Power and Control Wheel. Violence in a relationship is not normal - it is a manifestation of unequal power relations within a relationship. Myth 3: Men and women are equally violent to each other. Facts: The majority of those affected by GBV, in particular IPV, are women and girls. Worldwide, almost half (47%) of all female victims of homicide in 2012 were killed by their intimate partners or family members, compared to less than 6% of male homicide victims. According to EU-wide data, 67% of physical violence and 97% of sexual violence perpetrated against women is committed by men. This fact is also confirmed by research from a study from Moldova which shows that the perpetrators of violence against women are often family members, the overwhelming majority being husbands or former husbands (73.4%), followed by fathers or stepfathers (13.7%) Myth 4: Domestic violence happens only to a certain type of person. Facts: GBV is a global problem of pandemic proportions. 35% of all women worldwide have experienced either physical and/ or sexual violence from an intimate partner or sexual violence from a non-partner (WHO et al., 2013). While a number of factors may increase the risk of women experiencing GBV, domestic violence can affect anyone –man or woman-, irrespective of socioeconomic status, educational achievements, ethnic origin, religion or sexual orientation Myth 5: GBV only includes physical abuse (hitting, punching, biting, slapping, pushing, etc.). Facts: Physical abuse is just one form of violence. GBV also includes sexual, mental, psychological, emotional and economic abuse. Some studies show that psychological abuse and humiliation is often considered more devastating than physical assault (Casey 1988, cited in Heise et al., 1994). Myth 6: GBV is caused by substance abuse such as alcohol and/or drugs. Facts: While substance abuse is present in many domestic violence cases and may lower inhibitions, it is a contributing factor, not the cause of violence, neither should alcohol or drug abuse be used to justify violence. Not all perpetrators of violence use drugs or alcohol, and not all those who use drugs or alcohol are violent Myth 7: Violence should be tolerated to keep the family together. Facts: Every individual has the right to safety, dignity and a life free of violence. Every survivor of GBV has the right of selfdetermination- they can decide to stay with the abusive partner or to leave and either way they are entitled to support and protection from the state. The argument that victims should stay in an abusive relationship is often justified for the well-being of the children. However, it is well established that the safety and health of children are negatively affected when children experience or witness violence Myth 8: Domestic violence is a private family matter, in which the state has no right to intervene. Facts: Violence is a human rights violation, no matter whether it occurs in the family or in the public sphere. Under international human rights law such as the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) or the Istanbul Convention, governments are not only expected to eliminate all forms of violence, they are obligated to do so.

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Myth 9: Sex workers cannot experience rape. Facts: International definitions of rape and other forms of sexual assault (WHO 2013) focus on the type of violent acts committed, without consideration of who is the perpetrator or the survivor. Accordingly, anyone who forces another into a sexual act against their will and without their consent, is committing rape, regardless of what the victim’s occupation is Myth 10: a man cannot rape his wife. Facts: As mentioned earlier, rape is defined by an action and not by the identity of the perpetrator or the survivor. Accordingly, any forced sexual intercourse is rape, irrespective of whether the woman survivor is married to the perpetrator or not. What can be done to prevent GBV? • EMPOWER the disempowered! If they feel physically stronger they feel mentally and psychologically stronger. • Offer onsite sexual and gender-based violence (SGBV) services: Psychosocial support. • Access to counselling and tangible assistance.• • Self-defence: being able to defend oneself makes one feel psychologically and mentally stronger and more empowered. GBV happens to those without power – prevention is about giving back and taking back one’s power. Victor Lyalko, a reputed martial arts master, described the most effective methods of selfdefence to help women if they are attacked.

Below are some of the easiest and most effective moves for different situations. Anyone can do these no matter how big or heavy the attacker is. 1. For starters, memorise the most vulnerable places

2. The simplest and most effective moves

It doesn’t matter how big or heavy your

attacker

because

you

can

anyone

beat you

know where the most vulnerable spots are. The main ones are the eyes, nose, throat,

chest,

knees, and groin.

One of the best moves that will make any giant whimper or drop to their knees is grabbing the wrist. Grab the little finger and ring finger with one hand, and the middle and index finger with the

You can attack in any way you want, but to be on the safe side, you need to remember that the most effective moves are aimed at these areas.

other and bend the wrist forward. If you can’t grab your opponent’s hand, hit them with a fist or with a finger between the collarbones or, if it is a man, into his Adam’s apple. This will allow you to disorient your opponent enough that it will take him a long time to come back to his senses.

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3. If you were grabbed from the front:

If you were grabbed from the front and you can’t lift your hands, The most obvious area for an attack on a male attacker is the groin. All self-defence courses advise aiming for this area.

do the following: move your hands forward and make a fist in front of your pelvis. This will create enough room between you

and the attacker. Hitting this area will literally paralyse the attacker and you will After that, hit the attacker’s nose with your forehead. This will have just enough time to escape. make the attacker move away from you. Now hit him in the groin with your knee. 4. How to free your hands:

If there is still some room between you and the attacker, there is a way you can protect yourself using your palm. Straighten your left arm and hit the attacker on the chin and nose with your right arm. Then again, in the case of a male, hit him in the groin. In the case of a female, hit her on the breasts and in the vagina. This way the attacker will be disoriented for a long time and they won’t be able to move.

You can easily escape a stronghold if you remember the “rule of thumb”: rotate your arm to the side of the attacker’s thumb. If they’re holding your arm tightly, rotate your wrist toward the thumb. When your arm is under the attacker’s, pull your arm as strongly as you can.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

5. If you were grabbed from behind:

6. If you approached and grabbed from the side:

Attackers often come from the back because this is the easiest An elbow hit is one of the most dangerous hits in all kinds of martial arts. This is exactly the hit you need if you are approached way to hold the victim’s arms so that they can’t move them. To set yourself free, quickly bend back and try to hit the attacker from the side. with the back of your head. It’s OK if you can’t do it: the point is Hit the attacker’s temple, jaw, or nose with an arched move. After to make the attacker put one of his legs forward.

this, the attacker will take a few steps back. Now hit them in the

Now quickly bend down, grab his/her leg and get up pulling it belly or chest. Elbow hits are so strong that they will disorient with you. Now the attacker will lose balance and you will be able any opponent. to drop even the biggest opponent. 7. If you were pushed against a wall: It happens very often that attackers try to corner their victims or push them against a wall. In this situation, it’s necessary to remember the most vulnerable places and hit one of them depending on your position. •

If both of the attacker’s arms are up, then straighten your palm and hit him/her in the armpit.

•

If one of your arms is down, there is a chance you can hit the opponent in the chest, neck, or jaw.

•

But one of the most effective and powerful hits is a hit with your head. Squat a little to be lower than the opponent. Then quickly jump up and hit them in the jaw with your forehead. This move will instantly disorient the attacker and give you a chance to escape.

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There are three categories of prevention intervention that can be adopted, namely:

• • • • • •

Address GBV before it occurs to prevent it happening Targeted action must be aimed at behavioural issues and reducing risk Teach protective behaviours Build confidence and selfesteem from an early age/ stage Teach assertiveness skills Encourage self-reliance and economic independence by: -- Encouraging particularly young women to stay in school -- Discouraging early sexual debut -- Counselling and education on unplanned pregnancy prevention and options -- Teaching entrepeurnarial skills

•

• • • •

Primary prevention

Deal with the short-term consequences, e.g., treatment, counselling on options, self-preservation, protective behaviours, and restoring the sense of self immediately after the violence has occurred to prevent further incidents Rebuild the emotional and psychological infrastructure of the person Identify sources of help and support for those who feel at risk or are in danger Help them identify ways to decrease dependence on the perpetrator Attempt to identify and address the root causes of their vulnerability that places them at risk

•

Tertiary prevention focuses on long-term interventions after the violence has occurred in order to address lasting consequences, including perpetrator counselling interventions

Secondary prevention

Tertiary prevention

Across South Africa there are many organisations working towards preventing the root causes of GBV. The “What Works to Prevent Violence” programme is a global initiative, which is funded by the British Department for International Development (DFID) and coordinated by the MRC, currently supports research on a number of South African interventions in this regard. The programme aims to provide evidence on what makes these interventions successful and how they can be replicated, adapted and scaled up. The primary objectives of preventive programme’s objectives were as follows:

Reflect on social norms that impact on GBV

Address risk factors for violence

Encourage positive relationships

Address contributing factors such as unemployment and substance abuse

Confront harmful aspects of masculinity

Promote non-violent ways of conflict resolution

Improve stress management

Strengthen relationship skills

Improve psychological well-being of young people

Teach value-based decision making

Promotion sexual health

Develop livelihoods strategies

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School and post-school based programmes target young people at a primary preventative level to:

What can Peer Educators do to help? Peer educators can do an Institutional Mapping Assessment Are there individuals in the institution / host community that are known to be a threat to vulnerable groups? Are there aervices available to address gender-based violence or sexual assault / rape? Where are they? Who do students trust to help them deal with gender-based violence or sexual assault / rape? Where are the health / psycho-social support services located? Are there any support groups or resource centers in the college or host community? Ehere should students go to address security concerns or issues? Are there places in the community that are regarded as safe places for students to go if they’re at risk / in danger?

Peer educators can offer:

Validation

nonjudgemental support

listening without pressuring the survivor to talk

non-intrusive response to concerns

practical care and support

information about resources

increased access to safety options

Confidentiality

mobilisation of social support

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Do’s

Don’ts

Take the initiative to ask about violence – do not wait for the person Don’t ask about violence in the presence of a partner, family member or friend. Remember that the patient’s safety is to bring it up. This shows that you take personal responsibility for paramount. the situation, and it helps to build trust Emphasise that violence is not their fault and that the perpetrator is Don’t blame the woman. Avoid questions such as “Why responsible for their behaviour. do you stay with him?” “Did you have an argument before violence happened?” “What were you doing out alone?” “What were you wearing?” Instead, reinforce that GBV cannot be tolerated. Explain that the information will remain confidential and inform them about any limitations to confidentiality.

Disclose to other health care workers without her consent

Use eye contact and focus all attention on the survivor

Avoid passive listening and non-commenting. This may make her think that you do not believe her and that she is wrong, and the perpetrator is right Avoid doing paper work at the same time.

Be aware of your body language. How you stand and hold your arms and head, the nature of your expression and tone of voice all convey a clear message about how you perceive the situation.

Avoid body language conveying the message of irritation, disbelief, dislike, or anger toward the survivor.

Show a non-judgemental and supportive attitude and validate what he/she is saying. Use supportive statements, such as “I am sorry that this happened to you” or “You really have been through a lot” which may encourage them to disclose more information.

Do not judge a survivor’s behaviour based on culture or religion.

Use a kind, calm and gentle voice to reassure the survivor. Emphasise options and resources available. Try to find adequate services together with the survivor. Leave “the door” open for him/ her to come back to you.

Avoid giving the impression that you’re uncomfortable dealing with the issue

Carefully listen to their experience and assure them that their feelings are justified

Ask too many questions or she will feel like she’s being interrogated

Show that you believe their story.

Do not cross question and expect proof/evidence to corroborate her story If doubtful, document your doubts and evidence they are based on.

Be patient with woman and girl survivors of GBV, keeping in mind that they are in a state of crisis and may have contradictory feelings.

Don’t pressure her to disclose. If she does not disclose, tell her it’s okay but that she can call at any time. Explain to her that she can come back for further assistance.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Chapter 5|MENTAL HEALTH Mental Health

Disability

Alcohol and Drug abuse

M E N T A L H E A LT H Note to facilitators

Introduction and Overview

Peer educators should be aware of their capacity to provide limited support to students in respect of mental health issues. Should students choose to access such support, it is crucial to respect their confidentiality. Be aware of your own issues and mental state. If you are currently experiencing problems yourself, refer the case to someone else. Be prepared to manage sensitive issues. Here are some tips: •

Know that your limited training only enables you to provide crisis intervention and refer students for more help.

•

Prepare students for the need for a referral to a professional.

•

Prepare yourself to discuss the issues without feeling uncomfortable about managing emotions.

•

Prepare yourself for the need to listen mostly, and offer

Young people in a post-schooling setting are at a stage where they are faced with many choices, challenges and stressful

unconditional support and acceptance. •

Build an open atmosphere in which students feel comfortable

situations, all of which impact on their mental and physical wellbeing. At this life stage, peer influence is exceptionally strong.

talking about these issues. •

Encourage open and frank discussion so you will be able to

Hence peer counselling can help create positive peer pressure to normalise healthy behaviour.

refer them appropriately. •

Observe body language to help you decide when to probe further on an issue and when to back off.

This

chapter

provides

interesting

sessions

review

•

When people do not want to discuss something, they may

communication skills and acquire basic helping techniques. It

avoid eye contact or fold their arms across their chest.

describes the basic principles and process of counselling and how this has a major impact on young people.

Aim: To create awareness among students about risks and

Among the student population, studies show that one in four

symptoms of mental illness and when, how and where to refer

students have a diagnosable mental illness, of which 40% do not seek help. The five most common mental health problems that

them.

students face are depression, anxiety, suicide, eating disorders,

Overall objectives of the chapter:

and substance abuse. This module will talk about the important symptoms to be aware of and when and how to seek help. It is important to remember that, if left untreated, many of these issues can become unbearable to the point that daily living becomes a challenge. So whether you or a friend you are concerned about are experiencing these issues, you should take action as soon as possible. Getting help will ultimately lead to a happier and healthier life.

By the end of this module, participants will: •

Have more information about depression, anxiety, stress and eating disorders.

•

Understand the importance of and need for self-awareness regarding their own mental health.

•

Have a clear definition of each of the mental health risk areas outlined above.

•

Demonstrate an understanding of the facts around causes, symptoms, treatment and preventive measures for specific mental health challenges.

•

Be equipped with factual information on mental health risks to encourage informed decision-making and health-seeking behaviour.

•

Have an opportunity to practice basic counselling skills.

•

Be equipped to know how and where to refer peers for help or additional information on each of the areas.

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Activity One: Silent Questionnaire

Purpose of activities: •

To provide an opportunity for students to be involved in a

Instructions for the flow of activities

self-awareness exercise to get a sense of their own mental

wellbeing. •

enable participants to tap into their own mental and

To provide opportunity for students to conduct basic self-

emotional states.

assessments regarding various mental conditions. •

To equip participants with basic counselling skills. Mental health content:

areas:

•

Anxiety

Stress

Eating disorders

Play soft music in the background.

Ask questions (see resource sheet) for participants to

Observe their reactions to the questions.

When the exercise is done, ask them to open their eyes.

DISCUSSION QUESTIONS

Self-awareness exercises

•

Self-assessment tests

•

Basic counselling skills

•

Referrals

Aim: To create awareness among students about their own mental illness and when, how and where to find help and support.

•

Why is it important to know this information?

•

What does it mean for you right now?

KEY MESSAGES •

Optimal mental health is crucial to optimal functioning.

•

Mental illness can be invisible to others as well as

•

20 minutes

•

Know how to get in touch with their own mental and

•

Understand how mental state impacts work, relationships and functionality.:

RESOURCE FOR ACTIVITY ONE: SILENT QUESTIONNAIRE 1.

Planning notes

Our mental state affects our work and relationships, be it positive or negative.

emotional state.

Think of three people in your life who are closest to you. When was the last time you told them you loved them?

•

Prepare and review instructions for activities.

•

Ensure preparation for the activities is completed timeously.

When was the last time anyone said they loved you?

Have you experienced the death of a loved one in the last year?

Are you in a relationship right now? • If yes, rate your relationship on a scale of 1 to 10.

20 minutes

Our mental state affects our psychological well-being, our emotions, and our behaviour.

On completion of this lesson, participants should:

Lesson content: Self-awareness exercise

Often we’re not aware that our mental state is compromised.

Lesson objectives

Time:

Ask how they experienced the exercise and what insights

ourselves.

Time:

•

Ask which question made the biggest impact. did they gain.

LESSON ONE: SELF-AWARENESS

•

silently answer in their heads.

Mental illnesses: Depression

Their eyes should remain closed for the duration of the exercise.

The module has three lessons, which focus on the following

Inform participants that they should make themselves comfortable and close their eyes.

•

Explain that you will be doing an opening exercise to

• If no, rate your sense of self-worth on a scale of 1 to 10. 5.

Rate your physical health on a scale of 1 to 10.

Rate your mental health on a scale of 1 to 10.

Rate your emotional health on a scale of 1 to 10.

Rate your spiritual health on a scale of 1 to 10.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Activity One: Individual Self-Assessments

Rate your energy levels on a scale of 1 to 10.

10. Rate your ability to sleep well on a scale of 1 to 10. Think of your three greatest strengths… How are you using

Instructions for the flow of activities

them?

Explain to participants that you will be handing out selfassessment forms.

11. Think of your three greatest weaknesses… What are you 2.

doing about them?

Instruct participants to complete the forms individually and as honestly as possible.

12. If you had to get sick today, who will care for you? 3.

13. Think of someone you confide in and share your secrets

Explain that the exercise is for them alone and they won’t have to share their scores with the class unless they wish

with. What would you do if you lost them?

to.

14. Imagine you visited the doctor and were told that all your 4.

blood tests came back and you have a rare, untreatable

Read through the instructions on the form to ensure that everything is clear.

form of cancer. You have two months at the most. What 5.

aspects of your life would you change?

Give participants 10 minutes to complete the first form and 5 minutes to score.

LESSON TWO: IDENTIFYING RED ZONES

Once they’ve completed the first form, hand out the second form.

Follow the same procedure.

Mental health Aim:

DISCUSSION QUESTIONS

To create awareness among students about their own mental illness and when, how and where to find help and support.

•

Ask how they experienced the exercise and what insights

Time: 45 minutes (two activities)

did they gain. •

Why is it important to know this information?

•

What does it mean for you right now?

Lesson objectives On completion of this lesson, participants should: •

Get in touch with their own mental and emotional state.

•

Understand how mental state impacts work, relationships and functionality.

Planning notes •

Prepare and review instructions for activities.

•

Ensure that preparation for the activities is completed timeously. Lesson content

KEY MESSAGES •

Optimal mental health is crucial to optimal functioning.

•

Mental illness is invisible to others as well as ourselves.

•

Often we’re not aware that our mental state is compromised.

•

emotions, and our behaviour. •

45 minute

Our mental state affects our work and relationships, be it positive or negative.

Self-assessment exercise Time:

Our mental state affects our psychological well-being, our

RESOURCE FOR ACTIVITY ONE: DEPRESSION SELF-ASSESSMENT Periodic blue moods, grief from loss, or mild sadness are normal occurrences for nearly everyone. When these feelings become more intense and last longer, it could be a sign of more serious depression. Difficult life events, family history and genetics, severe stress, trauma, major loss, and excess alcohol or drug use can all lead to a higher risk of depression which doesn’t lift and may require counselling and/or medication. Depression can be treated successfully. Here is a simple quiz that will help you to make some initial decisions about next steps. You may want to speak to a professional about your symptoms.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Note that this self-assessment quiz is not a diagnostic tool. It is simply one way to help you to begin thinking about your current mood and symptoms. We urge you to share your responses with a licensed professional. The questionnaire is provided by E4 Health Inc.© www.e4healthinc.com 1.

I have seen a steady change in my appetite and eating patterns, such as a loss of appetite or eating much more Yes

than normal. 2.

I have lost interest in activities that I typically enjoy.

Yes

Sometimes I just feel like crying.

Yes

I am having difficulty sleeping, e.g., sleeping too much, waking very early in the morning, and/or having difficulty Yes

falling and staying asleep. 5.

I have had more thoughts about dying and suicide. Sometimes I feel as if people would be better off without me Yes

in their lives. 6.

I feel as if I have very little energy.

Yes

I am having more difficulty concentrating on things.

Yes

I have little interest in sexual intimacy.

Yes

I get much more irritable or angry lately.

Yes

10. The future seems bleak to me.

Now count up the number of “Yes” answers. If you have answered “Yes” to three or more of these questions, there is a good chance that you may be experiencing some type of depression. However, even one “Yes” answer could signal serious depression that requires professional help. We suggest that you discuss your answers with a licensed counsellor by calling E4 Health. Remember, there are different types of depression and different levels of severity. Obtaining an accurate diagnosis from a professional is a necessary first step in order to match an appropriate treatment. Are you in the Red? Zone Check: Mental Health

Yes

Have you lost interest and motivation in activities you used to enjoy?

Are you struggling to cope with daily activities (feel listless and without energy)?

Do you avoid people, have difficulty making conversation and dread social events (family functions/gatherings with friends)?

Do you think about and plan different ways to kill yourself?

Have your sleeping patterns changed where you’re either sleeping too much or not being able to sleep at all?

Are you hearing, feeling, or seeing things that other people cannot?

Are you feeling anxious all the time (knot in your tummy, dry mouth, clammy hands) and have no idea why you feel that way?

Do you sometimes have panic attacks (feel like you can’t breathe, need air, experience feelings of terror) without knowing why?

Do you have flashbacks (vivid memories and visions; reliving the event) of something bad that happened to you?

10. Are you feeling tired and without energy or unnaturally excited with too much energy? 11. Do you experience changing eating habits from having a loss of appetite to binge eating (eating huge amounts of food in one sitting)? 12. Do you constantly feel and think that other people are trying to control you, are talking about you or trying to kill you? If any of your answers place you on a red square, you are in the RED ZONE. This means you may be at risk for mental illness. Ask your HIGHER HEALTH Campus Coordinator for help with counselling, care, treatment and support as soon as possible.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

RESOURCE FOR ACTIVITY ONE: ANXIETY SELF-ASSESSMENT This following questionnaire is called the GAD-7 screening tool. It can help you find out if you might have an anxiety disorder that needs treatment. It calculates how many common symptoms you have and, based on your answers, suggests where you might be on a scale from mild to severe anxiety. GAD stands for “Generalised Anxiety Disorder”, and there are seven questions in the tool. Choose one answer for each of the seven questions below. Several days

Nearly More every than half the day days

Over the last two weeks, how often have you been bothered by the following problems?

Not at all

1. Feeling nervous, anxious or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

Here are some questions to ask yourself: Are you experiencing anxious or worrisome thoughts on a daily basis? Are you plagued by fears others perceive as unfounded or irrational? Do you avoid everyday social activities because they cause you anxiety? Do you experience sudden heart-pounding panic attacks? Is your anxiety interfering with your schoolwork, social life and family? Are you in the Red? Zone Check: Stress 1.

Do you have frequent headaches?

Do you have difficulty sleeping for more than 3 nights in a row?

Do you have chronic back or neck pain and muscle tension?

Have you been feeling light headed, faint or dizzy?

Do you have sweaty palms, dry mouth and rapid heart rate?

Do you feel uninterested and have low energy?

5. Being so restless that it’s hard to sit still

Are you feeling irritable and snappy?

6. Becoming easily annoyed or irritable

Are you feeling overwhelmed?

Are you forgetful?

7. Feeling afraid, as if something awful might happen

Add up your results for each column Total score (add column totals together) What your total score means

Yes

10. Do you have difficulty concentrating? 11. Do you have chronic constipation or diarrhoea? 12. Do you find yourself getting sick all the time? If any of your answers place you on a red square, you are in the RED ZONE. This means you are at risk of being too stressed. Ask your HIGHER HEALTH Campus Coordinator for help with counselling, care and support as soon as possible.

Your total score is a guide to how severe an anxiety disorder may be: •

0 to 4 = mild anxiety

•

5 to 9 = moderate anxiety

•

10 to 14 = moderately severe anxiety

•

15 to 21 = severe anxiety

If your score is 10 or higher, or if you feel that anxiety is affecting your daily life, call your doctor. The GAD-7 was developed by Robert, L. et al., 1995-2018,

DEPRESSION VERSUS ANXIETY What is depression Depression is a common but serious illness and, if left untreated, can lead to suicide. It can make you feel helpless and hopeless, making it difficult to work, study, sleep, eat and complete basic everyday tasks. Depression is caused by a combination of factors which lead to a chemical imbalance in our brains. Because of this, the symptoms may not be the same for each person.

Healthwise Incorporated© This information does not replace the advice of a doctor. Healthwise Incorporated disclaims any warranty or liability for your use of this information.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

What causes depression? To understand depression, it is important to understand what causes this disorder in the first place. The WHO states that depression is a complicated combination of various psychological, environmental (connected to social and family environment), and biological factors.

How can you tell if you or someone else is depressed? For a diagnosis of major depressive disorder, a person needs to have experienced five or more of these symptoms for at least two weeks. Sadness

Self-critic

Chronic fatigue

Withdraw from others

Anger

Impaired Memory

Lack of energy

Neglect health/ studies

Emotions

Thoughts

Physical

Guilt

Confusion

Anxiety

Thoughts of Death

Mood swings

Weight gain/ loss

Behaviour

Demotivated

Substance abuse

Neglect self

Sleeping too much or too litttle

What are the complications of depression? If left untreated, depression can get worse and can result in complications which will affect every area of your life, including the emotional, mental, behavioural, and physical aspects. The complications can include substance addiction, panic attacks, anxiety, and suicide.: How to manage depression Get enough sleep

100

Exercise regularly

Talk to someone you trust

Take time to relax

Change your diet

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

What is anxiety?

Everyone feels anxious at some point in their life, whether it’s writing an exam, going on a date for the first time, speaking in front of people, or doing something that has risk associated with it. Anxiety starts out as stress, and it is useful to have some stress because it keeps us stay alert, quickens our reflexes, and keeps us energised and focused. In a normal situation, it usually settles once the stressful situation has passed. When it does not settle and you remain in a state of heightened stress, it turns into anxiety. Anxiety, therefore, is when those feelings of stress don’t go away, and you can’t seem to control them. People who experience constant anxiety find it difficult to cope with normal daily life. Characteristics of anxiety: •

Can be very intense and hard to control.

•

Can last for weeks, months or over many years.

•

Negatively affect your thoughts, behaviour and general health.

•

Leave you feeling distressed and not enjoying life.

Anxiety can cause physical symptoms like pain, a pounding heart, or stomach cramps. For some people, these physical symptoms are their main concern. Anxiety can also affect other areas of your life – like your ability to cope, or perform at work), and can affect your relationships with friends, peers, or loved ones. What are the signs and symptoms to look out for?

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

101

Most common types of anxiety Generalised Anxiety Disorder (GAD) is when people worry all the time about different things. The anxiety is not just one specific issue and any one situation that triggers the anxiety can cause an avalanche of anxiety that can be hard to control and it can impact all parts of one’s daily life. Recognising the signs: One of the most important things to remember about anxiety disorders is that brief and occasional flashes of anxious feelings or behaviour do not automatically indicate a mental illness. •

Are you experiencing anxious thoughts on a daily basis?

•

Are you overcome by fears others cannot identify with?

•

Do you avoid everyday social activities because they cause you anxiety?

•

Do you experience sudden heart-pounding panic attacks?

•

Is your anxiety interfering with your schoolwork, social life and family?

If the anxious feelings persist, or if they begin to manifest in obsessive behaviour or an overwhelming sense of fear or phobias, it is time to seek help for yourself or your peer. Obsessive Compulsive Disorder (OCD) is when a person has unwanted, ongoing thoughts, feelings, and ideas which cause anxiety. So they then carry out actions to reduce the anxiety or get rid of those thoughts. For example, one might have an excessive and abnormal fear of germs. The person may try to relieve the anxiety through repeated hand washing or avoiding touching things like money or escalator rails. They may know these thoughts are unreasonable but be unable to stop them. When OCD is severe and left untreated, it can be very distressing, and get in the way of work, college and normal life at home. Post-Traumatic Stress Disorder (PTSD) is a reaction to a highly stressful event when a person feels very unsafe or threatened. These are unusual experiences, such as a violent attack (verbal, physical or sexual), accidents, or a natural disaster. The symptoms usually include irritability, anxiety, severe panic attacks, flashbacks, repeated nightmares, and avoiding situations that might bring back memories of the event. Panic Disorder is when a person has panic attacks. These are intense feelings of anxiety along with the kind of physical symptoms and overwhelming sensations you would have if you were in great danger, like a pounding heart, feeling faint, sweating, shaky limbs, nausea, chest pains, breathing discomfort, and feelings of losing control. The symptoms rise and peak rapidly. The effects can be so severe that people experiencing panic attacks can believe they are dying. However, despite being frightening and “very real”, they are not life-threatening. Phobias are intense uncontrollable fears that are not always based on logic or facts. The fear can be so great that the person goes to great lengths to avoid something, even if it’s harmless. For example, social phobia is fear of being judged or embarrassed in public or even noticed. Another common type is claustrophobia, which is a fear of small closed spaces. It can be extremely disabling and frightening to the extent that people may fear using lifts or bathrooms, going into caves, or even medical procedures that involve dark closed spaces.

ANXIETY versus

102

DEPRESSION

A person suffering from anxiety will feel apprehensive about one’s future and will have troubled thoughts

A person suffering from depression will feel hopeless about the future and will imagine worst case scenarios

Anxiety can lead to depression

Depression can lead a person to suicide

Bodily symptoms will occur only after an intense attack

A huge trigger may not be needed to develop characteristic physical changes

Patients will often display a flight or fight response; their bodies will often look tense and rigid

Patients will appear hopeless, drained and energy-less; will experience changes in sleeping pattern, appetite and social interactions

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

RESOURCE FOR ACTIVITY ONE: EATING DISORDER SELF-ASSESSMENT RATING

I have eating habits that are different from those of my family and friends

Often

Sometimes

Rarely

Never

I cannot go through the day without worrying about what I will / will not eat

Almost Sometimes Always

Rarely

Never

I prefer to eat alone or when I am sure that no one will see me

Often

Sometimes

Rarely

Never

I make excuses (e.g. “I already ate”, “I am not feeling well”, etc.) so that I will not have to eat with friends and family

Often

Sometimes

Rarely

Never

I have uncontrollable eating binges during which I consume large amounts of food and afterwards I make myself vomit

Never

Less than 1-6 x a once a week week

Once or more a day

I cut my food into tiny pieces, I hide it so people will think I ate it, I chew and spitt it out without swallowing it

Often

Sometimes

Rarely

Never

I’ll keep hidden stashes of food in my room

Often

Sometimes

Rarely

Never

I become angry when others show interest in what I eat and pressure me to eat more

Often

Sometimes

Rarely

Never

I am afraid that no one would understand my fears about food and eating, so I keep these things to myself

Often

Sometimes

Rarely

Never

10. I go through long periods of time without eating (fasting) or eating very little as means of weight control

Often

Sometimes

Rarely

Never

11. My friends tell me I am thin, but I do not believe them because I feel fat

Often

Sometimes

Rarely

Never

12. I would panic if I got on the scale and found that I had gained weight

Almost Sometimes Always

Rarely

Never

13. I use laxatives or diuretics as a means of weight control.

Never

Rarely

Sometimes On a regular basis

14. I have an overwhelming fear of gaining weight

True

False

15. I exercise excessively to try to lose weight and become anxious if I miss a workout

True

False

16. It is very important that I am thinner than all of my friends

Almost Sometimes Always

17. I am unable to maintain a weight that is considered healthy and consistent with my build, age and height

True

False

18. (Females only) My menstrual period has stopped or become irregular due to no known medical reasons

True

False

19. I can spend hours reading books or magazines about dieting, exercising, fitness, or calorie counting

Often

Sometimes

20. I have felt depressed and irritable lately, and spend most of my time alone

True

False

21. I tend to be a perfectionist, I am not satisfied unless things are perfect

Often

Sometimes

Rarely

Never

Rarely

Never

Rarely

Never

Total Score

COLUMN TOTALS How are the results scored? 38 or less – Strong tendencies toward anorexia nervosa 39 to 50 – Strong tendencies toward bulimia nervosa 50 to 60 – Weight conscious. May or may not have tendencies toward an eating disorder. Not likely to have anorexia or bulimia nervosa. May have tendencies toward compulsive overeating, obesity, or binge-eating disorder. Over 60 – Extremely unlikely to have anorexia nervosa or bulimia nervosa, however, scoring over 60 does not rule out tendencies toward compulsive eating, binge-eating disorder, or obesity. HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

103

If you scored below 50, it would be wise for you to seek more information about anorexia nervosa and bulimia nervosa and contact a counsellor, peer educator, lecturer, or doctor in order to find out if you have an eating disorder and, if you do, talk about what kind of assistance would be best for you. If you scored between 50 and 60, it would be a good idea for you to talk to a counsellor, pastor, teacher, or physician in order to find out if you have an eating disorder and, if you do, how to get some help. If you scored over 60, but have questions and concerns about the way you eat and/or your weight, it would be a good idea for you to talk to a counsellor, pastor, teacher, or physician in order to determine if you have an eating disorder and, if you do, how to get some help. https://casapalmera.com/assessments/eatingdisorder-self-assessment? Many young people develop eating disorders but do

Eating disorders Eating disorders commonly affect both men and women between the ages of 12 and 25 years of age. Many develop eating disorders during their college or university years and do not seek help or do not realise how bad the disorder is. Eating disorders lead to extreme behaviours, thoughts and attitudes to do with food and can lead to death if left untreated.

not understand just how dangerous they are and do not seek help or treatment for them. There are many other serious complications of eating disorders, including brain damage, bone loss, and death. Some of the signs to look out for if you or a friend are suffering from an eating disorder are:

The main types of eating disorders

Brain & Nerves (Can’t think right, fear of gaining weight, sad, moody, irritable, bad memory, fainting, changes in brain chemistry)

EATING DISORDERS

Hair (Hair thins and gets brittle)

Anorexia Nervosa

Bulimia Nervosa

Dangerously underweight

May be of normal weight or

Obsessed with being thin Distorted body image Intense fear of weight gain

Heart (Low blood pressure, slow heart rate, fluttering of the heart (palpitations), heart failure)

slightly overweight

Blood (Anemia and other blood problems)

Repeated episodes of binging and purging to

Skin (Bruise easily, dry skin, growth of fine hair all over body, get cold easily, yellow skin, nails get brittle)

prevent weight gain Worried about weight and feels lackof control over such episodes

Binge eating/ purging type Regularly engages in binge eating and purges through self-induced vomiting; laxatives or other medication 104

Restriciting type Limit their intake of food to consume because they see themselves as overweight, even when they are underweight Focus on calorie intake The goal is always rapid weight loss

Kidneys (Kidney stones, kidney failure) Muscles and Joints (Weak muscles, swollen joints, fractures, osteoporosis)

Purges through self- induced vomiting; laxatives or other medication

Tries to lose weight through fasting or excessive exercising

Intestines (Constipation, bloating) Hormones (Periods stop, bone loss, problems growing, trouble getting pregnant, if pregnant - higher risk for miscarriage, having a C-section, baby with low birthweight, and post partum depression) Body Fluids (Low potassium, magnesium and sodium)

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

If you believe you or a friend may be developing an eating disorder, it is vital that you seek help as soon as possible. Eating disorders and body image are sensitive issues, so it is important to remain non-judgemental when approaching your friend if you suspect they may have a problem. There are, however, many treatments and programmes available that can help people suffering from eating disorders, so seeking professional help will lead to a healthier and happier life. Suicide Students are particularly at risk for suicide as college can be a stressful time for young people, and it is a phase of life where many things are happening at the same time. It is the time of awakening in terms of sexuality, relationships and selfawareness. It is also the time when new relationships start and most breakups happen. Because of raging hormones at this stage and age, all feelings and emotions (good and bad) are intensified and magnified. Body image is also a key issue in this phase of life. In addition, the workload is high, making friends and fitting in is stressful, and the pressure to succeed can become too much to cope with for many people. If the right steps are not taken to deal with the stress of studying, feelings of guilt, depression and hopelessness can take over your life. Depression, anxiety and suicide are closely linked, so it is important to know when to reach out for help and to know that there is always another way out and that suicide is not the only or the right option. If you are worried about a friend or peer being suicidal, you should seek help immediately. The best people to handle these kinds of situations are trained professionals, so contact your campus support or healthcare provider as soon as possible. Some of the warning signs to look out for in friends and peers that could help you save a life are:

Suicide is completely preventable, and the underlying conditions that may be causing it are treatable. There is always another way out, and it is important to remember that there will always be someone who can help you. What can peer educators do? If you believe someone may have an anxiety disorder, be an active listener when they are feeling stressed or anxious and help them research next steps. Avoid criticising or belittling the severity of their anxious symptoms and encourage coping strategies that avoid the issues or cause further anxiety. Encourage your friend to visit your campus healthcare centre and seek help from a professional. If your friend is reluctant to seek treatment, you can consult a mental healthcare provider for suggestions moving forward. Look out for these common suicidal warning signs in your peers: •

Depression, negative change in mood, and a sense of hopelessness.

•

Talk of suicide, wanting to die, or dropping hints about suicidal thoughts.

•

Abrupt change in personality and behaviour.

•

Extreme physical and emotional pain.

•

Drop in academic performance.

•

Avoiding friends or social activities.

•

Sudden calmness after a long period of depression.

Severe depression •

Anxiety and devastation from a broken relationship or lost loved one.

•

Family mental health history.

•

Feelings of failure and hopelessness.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

105

Level of Risk

Risk factors

Action plan for peer educators 1.

Low Risk

------

Occasional suicidal thoughts Minimal external risk factors No previous suicide attempts No specific plan / intention or means Support and other protective factors are in place

2. 3.

1. 2.

Moderate Risk

-------

Suicidal thoughts Some risk factors Suicidal plan with some detail Means are available (access to weapon / medication etc) Vague intention to act Some protective factors are in place

3. 4. 5. 6. 7.

High Risk

---------

106

Suicidal thoughts Previous suicide attempt Numerous risk factors Clear and detailed suicidal plan Immediate intent to act Means are available and lethal (access to weapon/ medication etc) Social isolation Limited support in place

1. 2. 3. 4. 5.

Observe and remain vigilant for changes in mood or circumstances Take note of deterioration in mental state/ changes in behaviour Agree beforehand on what to do if the student feels a crisis coming on (crisis plan and support / emergency numbers) Consult with Peers and Peer Mentor Refer to doctor for further assessment Remain vigilant and provide telephonic support Schedule follow up appointment within a week Monitor mood and risk until student is stable Agree on written safety management plan Get permission to inform significant others (best friend/ partner / family) Consult Peer Mentor immediately Refer for urgent psychiatric assessment / intervention Remain vigilant and provide telephonic support Agree on written safety management plan Get permission to inform significant others (best friend / partner / family)

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

LESSON THREE: CREATING SAFETY NETWORKS

to reflect on the following issues: --

Aim:

students in crisis. 45 minutes (two activities)

relationships.

initiate

helping

What was that like for the counsellors and the peers?

Identify all the strategies of initiating helping

Helping skills for peer educators

Learn basic skills to assist peers with problems.

Skilled peer counsellors need to have and use the following basic principles and code of ethics:

Planning Notes

•

Prepare and review instructions for activities.

•

Ensure that preparation for the activities is completed timeously.

Peer educators need to be able to develop skills to connect with, listen to and communicate with peers in the best interests of the person being helped.

•

Peer educators are in a position of influence with respect to the people they are helping.

Lesson content

•

Role play

•

Application of skills

They need to be careful not to exploit the trust and vulnerability of their peers who come for help.

•

Peer educators need to respect the confidentiality and privacy of the people they are helping. They need to inform

Time:

those they are helping about any situations when they are

45 minutes

required to break confidentiality and privacy. •

Activity One: Helping Skills

Peer educators should not disclose information except where they are given information that involves risk to the safety of self, or other/s, self-harm, abuse, violence, or

Instructions for the flow of activities

criminal behaviour.

Explain to participants that they will be put into pairs for

•

Peer educators must recognise their personal limitations

this next activity. the

group

and refer students for appropriate assistance for students in in

half.

Identify

one

half

“COUNSELLORS” and the remaining half as “PEERS”. 3.

counsellor

conversation, use of questions, etc

Become familiar with principles and ethics of helping

Divide

the

introducing themselves, “joining” comments, general

On completion of this lesson, participants should:

did

conversations together with the participants, such as

Lesson Objectives

How

conversation?

Time:

•

What did you do? How did you feel when the counsellor approached you?

To equip peer educators with skills to intervene and assist

•

After they complete this part of the exercise, ask the peer

crisis or with professional therapeutic needs. •

Peer educators should not help or advise about problems

Ask the peers to imagine they have heard some

outside their recognised area of knowledge and training.

distressing news or had a distressing experience (break up of relationship, failed exam, or moving away to another province). It may even be something real if they feel comfortable talking about it. 4.

Ask both the counsellors and the peers to wander around the room in any direction.

When a counsellor passes a peer, the counsellor stops to join the peer and tries to find out if there is a problem, and if they want to talk about it.

Ask the counsellor to end the conversation as soon as the

Basic counselling skills for peer counsellors •

foundation for counselling is to: •

Show that you understand and care.

•

Build trust.

•

Give useful, correct information, and help in understanding what this information means.

•

Help make choices based on clear information, the nature of the situation, and the needs and feelings of the student

peer has told them about the problem. and the counsellor should not explore the problem more fully at this stage.

Everyone can learn good counselling skills. The

or client. •

Help them remember what to do.

Although counselling is a skill that can be learnt and improved with practice, it is important to realise when a problem or situation is beyond your experience and ability. Be familiar with HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

107

other services and refer peers as needed.

Self-disclosure Sometimes they will tell you something which is similar

How to start a conversation and find out if there is a problem

to an experience of yours, and you may wish to disclose

Joining •

Mention what you noticed about the person. For example: “You look worried”, or “I get the sense that you’re feeling quite anxious.”

•

Ask a question showing interest and beginning with: “Can you tell me more about what seems to be troubling you?”

•

Acknowledge that you have heard their answer by sharing your own feelings or concerns about the situation. For example: “I am sorry to hear that”, “I feel a bit like that too”, or “Breaking up with your boyfriend must feel like your world is falling apart.”

•

Invite the other person to talk or to choose not to. For example: “Would it help to talk over it or not?”, or “Are you okay to talk more about this issue?”

Find out what the other person wants from you. For

Ask about the problem. For example: “What can you tell me about the problem?”, “What can you tell me about the thing that has upset you?”, or “What can you tell me about the fight with your mother?”

• •

Ask open questions and listen carefully to the answers to find out more. Maybe ask further questions. If things get tense or there are awkward long pauses, change the subject for a little while and then come back to the discussion. Let the other person change the subject if they want to and then come back to the discussion.

or felt then sharing that experience can be useful. However, be careful not to overshare, as this may compromise your boundaries and objectivity. You must always remain aware that you’re in a “helping relationship” not a “friendship”. Supportive statements Supportive statements can indicate your agreement with the other person’s situation. They provide an opportunity for you to affirm and reassure the other person.

“It seems you’ve had a really hard time.” “It is possible for something like that to happen to anyone.” Unhelpful supporting comments Supporting comments can sometimes be helpful. However, in some instances, supporting comments can be unhelpful and make things worse. Playing down or making light of the other person’s worry. For example: “Never mind…”, “Everything will be different by next

Telling a person who is obviously upset, “Don’t be upset, it’s just a small thing. Everything is all right” won’t be helpful. Some statements are not useful when the other person is so upset that they aren’t ready or able to hear anything positive,

Suggestions for actively participating in the conversation When exploring the problem, you can decide when to use open or closed questions in a conversation. For a conversation to run smoothly and comfortably, you will also need to respond by actively participating in the conversation rather than just using questions.

or when your expression of support is inappropriate, such as the example below. “Hey… Heard your abusive ex-boyfriend is working at your brother’s school. That would make it convenient if he’s changed and you wanted to get back together…” Basic Counselling Process

SHORT RESPONSES (minimal encouragers) Let the person talking know you are interested and are listening by saying things like: “…uh, uh”, “…yes”, “…wow”, “…true”, “…really”, etc.

a minute and connecting with what you would have thought

week; you’ll get over it.”

• •

be helpful. Putting yourself in the other person’s shoes for

“Yeah, I can imagine how tough that must have been.”

example: “How can I help you?” •

similar information to what the other person has revealed can

Examples:

Finding out about the problem •

something about yourself that may be helpful. Giving back

The counselling process has elements that are implemented in step-by-step approaches. The six (6) elements of the counselling process can be remembered with the letters in the word GATHER. Not everyone will need to be counselled in this order, and not everyone will need all six GATHER steps. Some may need a step repeated. Counselling can change to fit individual

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needs.

What the Peer Counsellor does

How the other person responds

Intitiates the conversation

Person begins to tell their story

Listens using short responses

Person knows the Peer counsellor is listening

Uses self disclosure where appropriate

Person feels equal in the helping relationship

Uses open questions to get a better picture

Person feels able to talk more about their troubles

Checks out that they have got the story right

Person knows the Peer counsellor understands

Identifies the main problem

Problem comes into focus

Continue by inviting the person to explore options and choices

Feels able to take some action

In conclusion It is important to take your mental health seriously and to seek G – GREET them and give your full attention immediately; be polite, friendly, and respectful; tell them that you will not tell others what they say. A – ASK QUESTIONS about their reasons for coming to you. Help them identify the decisions they face; keep questions open, simple, and brief; look at them; ask them what they want to do; show your interest and understanding at all times; and avoid judgments and opinions. T – TALK to them about their choices. Assist them to explore the options they have and the pros and cons of each option. To make informed choices and good decisions, people need clear,

help if you think you or a friend is at risk. If someone you’re related to has suffered from a mental illness, know that your genetics could be a factor in your development of a mental condition. Research your mental health treatment options on campus, and get involved with support groups, or consult your student health centre to learn more about student wellness. Take charge of your life on campus, and take the first step towards a healthy college career.

accurate and specific information about their options that relates

Emergency lines

Contact number

to their own lives.

Dr Reddy’s Help Line

0800 21 22 23

H – HELP them choose based on the pros and cons of each

Cipla 24-hour Mental Health Helpline

0800 456 789

Pharmadynamics Police and Trauma Line

0800 20 50 26

option. Explain that the choice is theirs; offer suggestions, but do not make decisions for them; encourage them to think about their future plans; help them think about the results of their options. Finally, ask, “What have you decided to do?” Then help them work out how they can do what they have decided. What would be the immediate next step? E – EXPLAIN what to do next. After they made their decision, explain what additional support services that are available to

Adcock Ingram Depression and Anxiety 0800 70 80 90 Helpline Destiny Helpline for Youth and Students

0800 41 42 43

Attention Deficit Hyperactivity Disorder 0800 55 44 33 (ADHD) Helpline Department of Social Development (DSD) 0800 12 13 14

them, and let them know they can come back anytime.

Substance Abuse Line 24-hour helpline

SMS 32312

R – RETURN, encourage them to return for a follow-up and

Suicide Crisis Line

0800 567 567

agree on a time. Ask if they have any questions or anything else

South African Depression and Anxiety 011 234 4837

to discuss.

Group (SADAG) Mental Health Line Akeso Psychiatric Response Unit, 24 0861 435 787 Hours

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SADAG has an office in Durban with the support of Psychiatrist Dr Suvira Ramlall and Clinical Psychologist Suntosh Pillay. The offices are based in Life St Joseph’s Hospital in Durban and are managed by Lynn Norton. The Kwazulu-Natal (KZN) Branch is deeply committed to: •

Launching new support groups.

•

Workshops on aspects of mental health.

•

School talks on suicide prevention.

•

Corporate wellness for KZN companies.

Support Groups To find a Support Group in your area, please phone SADAG on 0800 21 22 23.

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Chapter 6|DISABILITY Disability

Alcohol and Drug abuse

DISABILITY

Introduction and Overview

Different models are used to explain disability. The early understanding of disability focused on impairment and equated disability with a deficiency in the individual. This limiting medical definition influenced measures that resulted in policies and practices that excluded persons with disabilities (PWDs) from mainstream society for decades (medical model). The social model focuses on the abilities of PWDs rather than on their inabilities. It assesses the impact that the environment has on the full participation, inclusion and acceptance of persons with disabilities as part of mainstream society. It shows us how disability is a result of the interaction between social and environmental barriers and people with impairments. What we should be doing is adapting our environments, attitudes and

Understanding Disability

organisations to enable or accommodate people with certain impairments. Instead, a lot of the time we expect PWDs to

There are many different definitions and interpretations of the

adapt to our environments in order to fit in. This limits their

term “disability”. One way to understand it is to look at the

ability to function properly and participate equally in society.

word as an “umbrella” term for multiple concepts. Most of the

This definition describes the relationship between an individual

definitions and explanations of the term have the following

and their environmental factors. Below is a visual model to help

aspects in common:

understand this concept.

•

They describe the presence of an impairment.

•

They mention certain limitations which prevent someone from being able to participate equally in society.

•

Indicate that the focus should be on the abilities of a person rather than their disabilities.

•

There is mention of a lack of access to opportunities due to environmental factors as well as discrimination in society.

•

Disability can be permanent or temporary.

Models of disability

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Types of disabilities

It is important to remember that there are different types of disabilities and that people can have more than one disability at the same time. Some disabilities can’t be seen, and some are more obvious. Either way, all disabilities can impact on a person’s ability to study or work. Just like everyone else, each person with a disability is an individual and will have their own specific needs and their own experience of what it is like to live with a disability.

Aim The key focus of the chapter is to equip peer educators with accurate knowledge and information regarding PWDs so that they may educate peers and address discriminatory attitudes and ignorance in respect of disability.

LESSON ONE: UNDERSTANDING DISABILITY Aim To create awareness of how disability is experienced by PWDs and the impact of ignorance and discrimination. Lesson objectives By the end of this lesson, peer educators will: •

Access experiential understanding of how disability is experienced.

•

Develop self-awareness regarding their own attitudes towards disability and PWDs.

•

Have knowledge of challenges experienced with different types of disabilities.

Planning Notes •

Prepare and review instructions for activities.

•

Ensure that preparation for the activities is completed timeously. Lesson Content •

Activities on visual impairment, hearing impairment, and autism.

Time Allocation 2 hours 30 minutes Material needed for the lesson

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•

Hand-outs

•

Flip chart and koki pens

•

Card or piece of paper

•

Book or any piece of writing HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

problems. Instructions for the flow of the lesson •

Introduce the lesson by saying: “There are many different

DISCUSSION QUESTIONS

types of disability. Some are obvious, and others are not so

How did it feel to have so much going on?

obvious. Some people may have more than one disability.

How did you wish to react?

Different disabilities will impact a person’s involvement

Were you able to concentrate on the paragraph being read?

in study or work in different ways. People who have the

What might have helped?

same type of disability will not experience their disability in the same way. It is important to remember that every person with a disability is an individual who will have their own specific experiences and disability-related needs as they interact with the environment.” •

Start the session with Activity One.

•

Divide the class into groups of five. Explain that each person in the group will be assigned a task. Explain the task as outlined below and instruct them to start when you give the signal.

Activity One •

•

• •

Activity Two Note to facilitators Hearing impairments include everything from not being able to hear certain sounds to being totally deaf. In most cases, hearing loss doesn’t simply mean that sounds are not loud enough. It usually means that sounds are garbled or unclear. A hearing aid may make speech louder, but usually it will not make speech clearer. Materials needed •

Lists with words and sentences

•

Pen and paper

Person #1 – You will play the part of a person with autism. Your job is to try and listen to what Person #5 is reading

Instructions

to you so you can be tested on the material. Try to ignore

•

Put people into pairs.

everyone else.

•

Provide one person (Person A) in each pair with a page

Person #2 – Stand behind the student playing the part of

with the following instructions:

the person with autism. Rub the edge of an index card (or

piece of cardboard) against the back of their neck. You

Read the list of words as follows: move your mouth

do not need to rub hard, but keep doing it over and over.

but make NO sounds and do not move your hands.

Person #3 – Grab a book (any book will do), lean close to

Say each word only once. After each word, give

Person #1, and read in a loud voice the entire time.

your partner time to write down the word. --

Person #4 – Pat Person #1 on the head and shoulder the Person #5 – Using a normal voice, read the paragraph

•

Next, the partner/s (Person B) will be provided with a page with the following instructions:

(provided by the facilitator) to Person #1. Then ask them

•

Wordlist: ship, Jim, chimp, punk, mud, bun, jeer, cheer, jib, chip.

entire time. •

Don’t let your partner (Person B) see this page!

questions about what you read. Do NOT try to drown out

Read the sentences below to your partner (Person A). Move

the other noises.

your mouth, but make NO sounds and don’t move your hands.

Have all the students in the group take a turn being

Say each sentence only once. Give your partner time to write

Person #1 before you discuss it.

each one down.

Discuss disabilities, their impacts, and adjustments with

Sentences

the participants (of some selected disabilities). Note to facilitators Activity One can demonstrate how the brain of a person with a learning disability or a disability like autism may work, and what kind of challenges this can pose to learning in a nonaccommodating learning environment. This activity is designed to show how people with autism are bothered by things most

•

Would you like tea or coffee?

•

Do you take sugar?

•

Here’s the milk for your cereal.

•

Would you like more toast?

Allow 15 minutes for the exercise in pairs, then have everyone return to the main group. •

people don’t notice. People with autism often are extra sensitive to noise, movement and even things like background noises most of us don’t notice. Remember, however, that not everyone with autism has these specific problems, they may have different

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Second round: This time tell your partner (really talking) that you will read sentences about breakfast. Now silently (moving your mouth but making NO sounds) read the same sentences as before. This time you can use your hands if you want. Give your partner time to write down what you said. Check how many were right this time. 115

Behaviour and attitude regarding disability

DISCUSSION QUESTIONS

It is important to remember that PWDs are people, so you should

How did you experience the activities?

What did you observe and learn?

What was different in the second round of the second

treat them as such. There are certain behaviours and actions that

exercise? 4.

How would this influence your future actions and behaviour?

are inappropriate or disrespectful, and we need to avoid these when interacting with PWDs. The following are some examples of common inappropriate behaviour.

Activity Three: Learning disabilities Note to facilitators There are many kinds of learning disabilities, and they can range from mild to severe problems. This activity gives a general idea of what it is like to struggle against what your brain may be telling you. Materials needed •

Colour printout of the paper.

Instructions They must read the COLOUR the word is written in, not the word itself. Afterward, discuss how your brain wants to read the actual word. Even when you can make yourself do it correctly, you have to read much slower than normal.

Terms to avoid retarded handicapped able-bodies physically challenged differently abled This is an example of how difficult it is for students with learning disabilities to get through the day. Their brain understands what needs to be done, but they have to struggle to make it come out right. Not being able to do this activity correctly does not mean you are not smart. It just means that your brain wants to do something different.

So what would be the appropriate way to behave? •

Treat all people as equals.

•

Speak directly to the person and not to their friend or peer.

•

Respect people and do not pity them.

•

Speak normally (same pitch and volume), but speak a little slower if someone has a hearing impairment.

DISCUSSION QUESTIONS

•

Do not stare.

•

Make eye contact and be friendly.

How did you experience the activities?

•

Ask how you can help before making assumptions.

What were the problems? What would have helped?

•

Allow enough time for communication.

What did you observe and learn?

•

Do not tease or make fun of people – treat others as you would like to be treated.

•

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Use appropriate language and do not stereotype.

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Discrimination

Sexual health and the disabled

What is Discrimination? Our world has a lot of diversity. There are religious people, nonreligious people, tall and short people, people with long hair, others with short hair, women, men, young girls, young boys, elderly people, babies in strollers, people with dogs, people wearing hoods, short skirts, tight dresses or suits, people with different skin colours, speaking different languages, and so on. Some people have some disability, and others do not have any disability. We are all very different. Discrimination is when a person or group of people are treated differently and unfairly based on certain characteristics they may have, e.g., race, gender, or disability. Discrimination against people who belong to a certain group is against the

Women and disability

law. All people should be provided with equal opportunity and

PWDs are often discriminated against when it comes to

have the right not to be discriminated against.

accessing sexual and reproductive health (SRH) services. It has been said that to be a woman with a disability is to be

Disability discrimination means treating someone unfairly

doubly marginalised. Among obstacles faced particularly by

because of their disability. There are increasing numbers of

women are the following:

people with disabilities (PWDs) in our society and changing

•

Maternal morbidity and mortality: Women with disabilities

negative attitudes in communities is essential in order to get rid

are less likely to receive general information on SRH, and

of discrimination. Understanding disability and how to accept

are less likely to have access to family planning services.

people with different needs is also important. The Bill of Rights

Furthermore, should they become pregnant, they are also

in our Constitution protects the rights of PWDs and condemns

less likely than their non-disabled peers to have access

unfair discrimination against people on the basis of disability.

to prenatal, labour and delivery, and post-natal services. •

Physical, attitudinal and information barriers frequently exist. Often community-level midwifery staff will not see women with disabilities, arguing that the birthing process needs the help of a specialist, or will need a Caesarean section, which is not necessarily the case. Of equal concern is the fact that in many places women with disabilities are routinely turned away from such services should they seek help, often being told that they should not be pregnant, or scolded because they have decided to have a child.

•

Furthermore, in a number of societies, if a child is born with a disability, it is assumed that the mother has been unfaithful or has otherwise sinned or is bewitched. She suffers significantly as a result of this assumption.

•

Even without such stigma, the physical, mental and financial stresses, coupled with social isolation, result in rates of divorce and desertion twice as high among mothers of children with disabilities compared to their peers who do not have children with disabilities. There are a number of ramifications of this – most striking, a cycle of increasing poverty.

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Five actions towards full inclusion of the sexual and

Men and disability

reproductive health of persons with a disability

Men with disabilities also face gender-related issues: •

SRH education: In many societies, while women receive instruction about SRH either at home or in school, young

1. Establish partnerships

men are left to pick up information “on the streets”, or casually, through other men’s comments, jokes and 5. Promote research

innuendoes. Young men with disabilities are often shielded from even this information, unreliable and incomplete

2. Raise awareness

as it may be. Young men with mental and intellectual

Full inclusion of persons with disabilities

impairments are particularly likely to be deprived of SRH information. •

Sexual exploitation: It is widely believed that men are not sexually abused. This is not true, however. In particular,

4. Policy, laws, budgets

men with disabilities are susceptible to sexual abuse, from both male and female perpetrators. Accessible abuse

3. Reach and serve

reporting channels and effective intervention programmes are as important for men with disabilities as they are for women with disabilities.

Contraception considerations for the disabled Contraception options should be discussed with all women with

Lifecycle approach Like everyone else, persons with disabilities have SRH needs throughout their lives, and these needs change over one’s lifetime. Different age groups face different challenges. For example, adolescents go through puberty and require information about the changes in their bodies and emotions, and about the choices they face concerning SRH-related behaviour. Adolescents with disabilities need to know all this information, but they also may need special preparation concerning sexual abuse and violence and the right to protection from it. It is important to assure that SRH services are friendly to youths with disabilities. On reaching the age for having a family, women and couples with disabilities, like everyone else, have the right to decide whether and when to have children and a right to sound, unbiased information on which to base these decisions. Healthcare providers owe all clients, whether they have disabilities or not, encouragement, support, and appropriate services over the years – both when they want to have children and when they want to avoid pregnancy.

disabilities. Considerations involve: •

The physical and pharmacological interaction of the contraception method.

•

The actual or potential conditions of the woman.

•

The amount of assistance available to and required by the woman.

•

Her lifestyle and self-care needs.

•

Her goals for pregnancy.

When making recommendations and prescribing contraception, it is important to determine if the method can be administered when needed by the woman or coordinated with home or partner assistance. •

Consider side-effects of the contraception method.

•

Consider effects on menstruation.

•

Consider need for protection from STIs.

•

Consider costs.

•

Consider need for legal consent.

Progestin-only pills Advantages

Mental health and psychological needs within SRH care Mental health is related to many aspects of SRH. These include,

oestrogen-containing contraception.

among others, perinatal depression and suicide, mental health and psychological consequences of GBV or HIV/AIDS, feelings of loss and guilt after miscarriage, stillbirth, or unsafe abortion. For PWDs, social barriers may increase the chances of mental health difficulties in these circumstances. It is crucial to pay close attention to the mental health or psychological wellbeing

An alternative for those who have contraindications to

Disadvantages --

Irregular bleeding.

Must be taken at the same time daily or efficacy is affected.

Some anticonvulsants decrease effectiveness (Beck, 1990).

of PWDs, their families, and other care providers.

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The intrauterine device or IUD •

•

the Post-school Education and Training System. http://

IUDs provide excellent long-term, reversible contraception,

www.dhet.gov.za/SiteAssets/Gazettes/Approved%20

and can be a good choice for many women with disabilities. •

There are two main types of IUDs currently being used:

•

The Copper T IUD is a non-hormonal contraceptive that can remain in place for 10 years. There is some risk of increased

Strategic%20Disability%20Policy%20Framework%20 Layout220518.pdf •

disability. Discrimination against PWDs continues since

The progestin-containing IUD has the benefit of decreased

there are no consequences for failing to implement the

menstrual flow to amenorrhea after the first few months of

legislation and policies, with the result that mainstreaming

use. It may be an ideal method of contraception as well

of disability in all areas of life is lagging behind (DSD,

as menstrual regulation for women with menstrual flow

2015).

management problems. •

The

IUD

may

used

women

risk

for

thromboembolism, who have other barriers to oestrogencontaining contraception, and for those who have difficulty in remembering or administering daily contraception. •

Patient positioning for IUD insertion may be difficult for some women with contractures or spasms, or for those women who cannot cooperate with a pelvic exam. In some

The South African Constitution (Act 108 of 1996) outlaws all forms of discrimination, including those based on

cramping and heavy menses. •

DHET. Strategic Policy Framework on Disability for

International Documents •

UN Convention on the Rights of Persons with Disabilities (UNCRPD). 2006. http://www.un.org/disability

•

UN 2015 Sustainable Development Goals. http://www. un.org/sustainabledevelopment

•

Link between the Sustainable Development Goals and the UNCRPD. https://www.globaldisabilityrightsnow.org/

instances, difficult insertions may require anaesthesia.

infographics/link-between-sustainable-developmentgoals-and-crpd

Summary

•

and Health (ICF) is a classification of health and health-

What you need to know about disability awareness

related domains. As the functioning and disability of an

Globally, PWDs are marginalised and excluded from full

individual occur in a context, the ICF also includes a list

participation in society. In South Africa, PWDs face multiple

of environmental factors. The ICF is the WHO framework

forms of discrimination in various social spheres, including in

for measuring health and disability at both individual and

respect of access to healthcare services, employment and education.

population levels. http://www.who.int/classifications/icf/en •

years and older were classified as disabled in 2015. A larger

Eastern Cape (6.8%) presented the highest prevalence of

“International

Classiﬁcation

Functioning,

2001. •

WHO. “World report on disability.” Geneva, Switzerland: WHO, 2011.

percentage of women (5.5%) than men (4.7%) were classified as disabled. North West (7.4%), Northern Cape (7.1%) and

WHO.

Disability and Health: ICF.” Geneva, Switzerland: WHO,

StatsSA’s General Household Survey 2015 (2016) sets out relevant demographics: “5.1% of South Africans aged 5

The International Classification of Functioning, Disability

Useful webpages

disability in the country.”

•

StatsSA. 2011. “Stats in brief: August 2011.” Pretoria: StatsSA.

•

Higher

and

Further

Education

Disability

Services

Association, https://www.hedsa.org.za Disability Info South Africa, http://disabilityinfosa.co.za

South African Legislation and Policy Documents

Videos

•

Department of Labour. 1998. Employment Equity Act (Act

Things not to say to someone who uses a wheelchair (BBC

55 of 1998) (EEA). https://www.acts.co.za/employment-

video short) https://www.youtube.com/watch?v=1RLTtk9Mc14

equity-act-1998/index.html

Things not to say to a blind person (BBC video short) https://

Department of Labour. 2003. Technical Assistance

www.youtube.com/watch?v=SarMSwv_aHI

Guidelines on the Employment of People with Disabilities.

Things not to say to a blind person (BBC video short) https://

Pretoria: Government Publishers.

www.youtube.com/watch?v=ykW4tYbRgo8

Department of Labour. 1998. Employment Equity Act (Act

Things not to say to a person with cerebral palsy (BBC video

55 of 1998) (EEA). https://www.acts.co.za/employment-

short) https://www.youtube.com/watch?v=kohcRR3VXyY

equity-act-1998/index.html

Things not to say to an autistic person (BBC video short) https://

•

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www.youtube.com/watch?v=d69tTXOvRq4 Things not to say to someone with depression (BBC video short) https://www.youtube.com/watch?v=d69tTXOvRq4 After facilitating a class or lesson on disability and inclusion (or a class where disability and inclusion was part of) as well as discrimination and stereotyping of PWDs, facilitators can show one of the videos to close the lesson or the topic. It is a fun way to close the lesson and reflect on the content that students learnt, as well as their own attitude towards the topic. Plan 10 minutes for the viewing of the short video and the debriefing of students. Ask students the following about the BBC videos: •

Were any of the statements surprising after learning more about disability?

•

Before today’s class, would you have asked similar questions (that are prejudiced)?

•

Would you refrain from asking a person with a disability certain (prejudicial) questions after today’s class?

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Chapter 7|ALCOHOL AND DRUG ABUSE PREVENTION

Alcohol and Drug abuse

ALCOHOL AND DRUG ABUSE PREVENTION

LESSON ONE: OVERVIEW OF ADAP Aim To provide an overview of issues related to ADAP. Time 30 minutes Lesson Objectives •

To provide information on the rationale, goals and key definitions pertaining to alcohol and drugs.

•

To provide information on key approaches and strategies to reduce alcohol and drug use and abuse.

Aim The aim of the module is to expose peers to information pertaining to alcohol and drug use and abuse that can lead to better health outcomes and ultimately influence students to reduce alcohol and drug use and abuse.

Purpose of Activities •

use and abuse. •

To empower participants with knowledge and skills to educate their peers on ADAP.

By the end of the lesson, participants will: •

To provide updated and relevant information on substance

Activity: Plenary Discussion

Have knowledge about drug terms, classification and

Objective:

the social, psychological, and physiological impact of

To ensure that participants know essential facts about ADAP.

substance use and abuse. • • •

Have information about key health issues relating to

Materials:

alcohol and drug use and abuse.

A flipchart and pens.

Be able to identify risks and dangers surrounding alcohol and drug use and abuse.

Time:

Have information on key concepts pertaining to ADAP,

45 minutes

such as addiction, overdose, craving, withdrawal and •

relapse.

Planning Notes

Understand the link between ADAP and communicable

•

diseases such as HIV, TB and STIs. •

Know the association between mental illness and ADAP.

•

Be aware of key behavioural interventions pertaining to

•

pertaining to ADAP. •

Consider ways to make the session interactive.

harm minimisation and risk reduction.

Procedure

Have reinforced existing knowledge, positive attitudes

•

and values and pro-social, healthy skills and behaviour. •

Familiarise yourself with all the necessary issues

as well as harm minimisation, and the rationale and key

Be educated on how to prevent or reduce myths and

issues pertaining to alcohol and drug use and abuse.

misinformation, negative attitudes and risky behaviours.

•

Invite comments, questions, etc.

•

Facilitate a plenary discussion using the discussion questions provided.

Module Content The module has three lessons which focus on the following targeted areas: •

Overview of ADAP (rationale, goals and key definitions).

•

Health issues related to ADAP.

•

Alcohol and drug abuse- The effects on mind, body and soul

Facilitate a buzz session on what ADAP education is,

DISCUSSION QUESTIONS •

Discuss whether any new information was covered.

•

Discuss general attitudes and responses to individuals who use and abuse alcohol and/or drugs.

•

What would be the impact of discriminating against these individuals?

•

What do you understand by the phrase: “Alcohol is a disease”?

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Harm minimisation offers three major strategies

What is alcohol and drug education?

Demand reduction – education not to use or use less.

Supply reduction – laws, including school policies, to limit availability.

Harm reduction – use safely, use safer substances.

Understanding substance use and abuse •

A drug is any substance, other than food, which is taken to change the way your body or mind functions.

•

Alcohol and tobacco are the most commonly abused drugs.

•

Drugs can be legal, or illegal.

•

They can be helpful, or harmful.

•

Drugs may come from doctors or pharmacies.

•

Some drugs can only be obtained with a written prescription from a doctor.

•

your garden. (For example, digitalis, a powerful drug

Alcohol and drug education is defined as: “educational

given to persons who have heart disease, comes from the

programmes, policies, guidelines and procedures that contribute to the achievement of broader public health goals of preventing and reducing alcohol and drug use and substance related harm to individuals and society” (Ballard and Robertson, 1999).

foxglove, a common garden flower.) •

A drug is called harmful if it is used incorrectly (abused) to the extent that it interferes with your normal life.

•

You develop drug tolerance when your body becomes used to the drug you are taking to the point that you must

Among young adults, there is a definite predisposition to risk

take more of the drug to get the effect from it that you

related to the following characteristics:

want.

•

Young, feeling of being invincible.

•

Prone to experimentation.

•

No longer considered to be minors – legal access.

•

The desire to have fun, be free, take risks, and shed

•

Legal drugs that are often abused are nicotine, caffeine, and alcohol.

inhibitions is high. •

Some drugs can be obtained from plants that grow in

Why do people use alcohol and drugs? A person may begin to use substances such as alcohol or

Post-school institutions are high-stress environments.

drugs because of the intense and very appealing feelings they produce. These feelings, such as wellbeing, elation, happiness,

Goals of Alcohol and drug education

ecstasy, excitement, and joy, can help some individuals

•

Reduce the level of use.

overcome the negative circumstances they experience. They

•

Delay the uptake of alcohol and particular drugs.

can also give them courage and confidence to do things that

•

Reduce the harmful use of alcohol and drugs.

normally create anxiety, or enhance their performance, e.g.,

•

Minimise the harm associated with the use of alcohol and

in sport.

drugs. For others, alcohol and drug use may form a significant part of What does harm minimisation mean? Harm

minimisation

has

the

important

their social lives and, therefore, they may use in order to fit in role

keeping

and be accepted. In some cases, it may not be a choice. For

communication about substance use open to those who may be

example, a young and disempowered partner may be forced

currently using. The goal of minimising harm respects human

to use. Others may get involved because they deal or sell on

rights, equity and discrimination issues that influence acceptance

behalf of dealers to earn money, and still others may have been

of people living with AIDS and the treatment of drug users.

lured in to “try it for fun” and then developed a dependency.

Harm minimisation accepts that, despite our best efforts, some will choose to use alcohol and drugs, even some illicit drugs. It does not mean that alcohol or drug use is encouraged or promoted. 124

What is alcohol? Alcohol is a drug. It is classified as a depressant, meaning that it slows down vital functions, resulting in slurred speech, unsteady movement, disturbed perceptions, and an inability

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

to react quickly. It is a drug that reduces a person’s ability to

order to get to a previous level of intoxication. Alcoholism

think rationally and distorts their judgment. It can also trigger

is a progression, a long road of deterioration during

depressive episodes in individuals experiencing some type of life

which the cumulative impact gets progressively worse.

challenge or problem (breakup of a relationship, divorce, death of a loved one, unemployment, etc.) The amount of alcohol one drinks determines the type of effect. Most people drink for the relaxation effect, such as a beer or glass of wine taken to “loosen up”. But if a person consumes more than the body can handle, they then experience alcohol’s depressant effect, and start to lose coordination and control. Alcohol is absorbed into the bloodstream through small blood vessels in the walls of the stomach and small intestine. Within minutes of drinking alcohol, it travels from the stomach to the brain, where it quickly produces its effects, slowing the action of nerve cells. Approximately 20% of alcohol is absorbed through the stomach. Most of the remaining 80% is absorbed through the small intestine. Alcohol is also carried by the bloodstream to the liver, which eliminates the alcohol from the blood through the process of metabolism, where it is converted to a nontoxic substance. The liver can only metabolise a certain amount of alcohol at a time, leaving the excess circulating throughout the body. Thus the intensity of the effect on the body is directly related to the amount consumed. When the amount of alcohol in the blood

How does alcohol affect the body? Binge drinking and continued alcohol use in large amounts are associated with many health problems, including: •

Unintentional injuries such as car crashes, falls, burns, drowning, and firearm injuries.

•

Sexual assault and domestic violence

•

Increased on-the-job injuries and loss of productivity.

•

Increased family problems, and broken relationships.

•

Alcohol poisoning,

•

Increased risk for HIV, as well as HIV transmission to others.

•

High blood pressure, stroke, and other heart-related diseases.

•

Liver disease.

•

Nerve damage,

•

Sexual problems.

•

Permanent damage to the brain.

•

Vitamin B1 deficiency, which can lead to a disorder characterised by amnesia, apathy, and disorientation.

•

Ulcers.

•

Gastritis (inflammation of stomach walls).

•

Cancer of the mouth and throat.

exceeds a certain level, the respiratory (breathing) system slows down markedly, and can cause a coma or death because oxygen no longer reaches the brain. Binge drinking is the practice of consuming large quantities of alcohol in a single session, usually defined as five or more drinks at one time for a man, or four or more drinks at one time for a woman. Binge drinking is a common practice by youth under the age of 21. Alcohol

dependence

(alcoholism)

consists

four

symptoms: •

Craving: a strong need, or compulsion, to drink.

•

Loss of control: the inability to limit one’s drinking on any given occasion.

•

Physical dependence: withdrawal symptoms, such as nausea, sweating, shakiness and anxiety occur when alcohol use is stopped after a period of heavy drinking. Serious dependence can lead to life-threatening withdrawal symptoms, including convulsions, starting eight to twelve hours after the last drink. The delirium tremens (DTs) begins three to four days later, where the person becomes extremely agitated, shakes, hallucinates and loses touch with reality.

•

Tolerance: the need to drink greater amounts of alcohol in

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125

Alcohol and drugs in SA STIMULANTS/UPPERS Stimulants, such as cocaine, speed up the central nervous system. People using stimulants may feel happy and excited and have more energy, better concentration or motivation. However, once the drug is out of the system, it creates restlessness and a sense of agitation and irritation. Stimulants make it difficult to sleep. Users feel the urge to take it again to settle the restlessness and to “feel good” again. Repeated use leads to addiction and overdose, which can cause heart attacks, exhaustion, seizures, and severe disorientation. DEPRESSANTS/DOWNERS Depressants are drugs like opiates (e.g., heroin) and sedatives (e.g., Valium and alcohol) which slow down the central nervous system. People using depressants may feel happy and content, as well as sleepy and relaxed. Depressants often slow down bodily functions, such as breathing and heart rate and may make it hard to speak (slurred speech) or move properly in large enough doses, in which case they may be harmful. A person who overdoses on a depressant will experience breathing that can become life-threateningly slow or stop altogether, leading to heart failure. HALLUCINOGENS Hallucinogens change the way people see, hear, feel or think. There are three main groups of hallucinogens: psychedelics, dissociatives and deliriants. Each group has different effects. They may cause hallucinations, when a person imagines something that is not really

ILLEGAL

there. Drug/Substance

Type

Street names

Method of use

Cannabis

Downer, Relaxant, Depressant

Marijuana, Dagga, Weed, Zol, Ganja, Spliu

Smoke, eat

Heroin

Opiate, Downer, Relaxant, Depressant

Gear, Smack, H, Horse, Brown

Inject, smoke

Cannabis and heroin and/or other substance mixtures

Downer, Relaxant

Nyaope, Whoonga

Usually smoked

Methaqualone (Mandrax)

Downer, Barbiturate

Buttons, White pipe

Smoke, ingest, inject

Cocaine or Crack cocaine

Upper, Stimulant, Amphetamine

Coke, Charlie

Snort, inject

E, Pills

Tablet (ingest), snort, inject

Ecstasy / MDMA Methamphetamine

Crystal Meth, Crystal, Tik, Ice Ingest, inject, smoke, snort

Methcathinone

Cat, Khat

Smoke, ingest, snort

Acid

Ingest

Mushrooms

Magic Mushrooms, Shrooms

Ingest

Ketamine

K, Special K

Snort, ingest

LEGAL

LSD

126

Psychotropic, Hallucinogen

Caffeine

Upper, Stimulant

Coffee, tea, energy drinks

Nicotine

Relaxant

Cigarettes, nicotine patches, e-cigarette, pens, vape

Alcohol

Downer, Relaxant

Booze, Drink, Dop, Liquor

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Alcohol & Drug Use Q&A Guide Q1: What are alcohol and drug dependence? Answer: Alcohol and drug dependence is a complex and often chronic brain disease. It occurs when the use of a substance dominates a person’s life and becomes a compulsive behaviour that is hard to control. When a person who uses substances is experiencing dependence, they have extreme difficulty in resisting the urge to use despite the negative consequences and harmful effects. Q2: What are cravings? Answer: Cravings are strong memories that are linked to the effect of alcohol or drugs on the brain and can cause strong physiological effects. Q3: Why do some PWID share needles? Answer: According to recent South African research, injecting alone or in pairs is more common than group injecting. For those PWID who do share needles and syringes or use non-sterile equipment, their reasons for sharing vary. In most cases, poverty is cited by PWID as a key reason for sharing needles and syringes. Q4: What is an overdose? Answer: People who use drugs (PWUD) are also vulnerable to overdose, which occurs when they take too much of a drug in a single episode of injecting or using. This can happen if a PWUD increases the quantity of the drug they are using, but also if they use the same quantity of a stronger drug. Q5: What are the consequences of overdosing? Answer: Overdosing can have significant consequences, including death. For PWUD, accessing care to manage an overdose can be challenging because of fear of being arrested or otherwise becoming involved in the criminal justice system after disclosing their drug use to a healthcare worker. There is also very little information available for PWUD on what to do if an overdose occurs, and often the healthcare system is not capacitated to manage such a situation. Q6: What are the signs of an overdose? Answer: One of the clearest signs that someone is overdosing is that their face or lips will turn blue. They may also look very pale; be very limp; be able to breathe and look at you, but not be able to talk; be breathing, but very slowly and shallowly; or stop breathing altogether. They may have a slow pulse (heartbeat) or no pulse at all; foam at the mouth; vomit; shake or have a seizure; complain of chest pain, pressure, tightness, or shortness of breath; or suddenly collapse and become unconscious. You have about four minutes from the time your lips turn blue to coma. If a person stops breathing, it can take only a few minutes for them to die. Just waiting for them to “get over it” is the worst thing you can do if someone is overdosing. Immediate action must be taken to help them survive. Q7: What is withdrawal? Answer: Withdrawal occurs when an alcoholic or PWUD suddenly stops using the substance upon which he or she has become dependent. This usually results in a number of physical and mental withdrawal symptoms, including abdominal cramps, muscle spasms, vomiting, chills, high fever, restlessness, irritability or depression. PWUD commonly call withdrawal “getting sick”. The symptoms of withdrawal are very intense, leading users to do whatever is needed to remove these symptoms. Shaking and tremors are common during severe withdrawal. Q8: What is a relapse? Answer: A relapse occurs when a PWUD or alcoholic begins using again after having successfully stopped using for a period of time. Relapse is common and is a normal part of recovery. Alcohol and drug use is highly addictive, and it can often take a number of attempts before a user can stop.

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to present on the various topics allocated on the previous

LESSON TWO: HEALTH ISSUES RELATED TO ADAP

day (five minutes to present).

Aim

•

Invite comments, questions etc.

•

Facilitate a plenary discussion using the discussion

To provide an overview of alcohol and drug abuse prevention

questions provided.

(ADAP) issues and show their link to health. Time

DISCUSSION QUESTIONS

30 minutes Lesson Objectives •

To provide information on various health conditions and demonstrate the impact of substance use/abuse.

•

To highlight risks and responsibilities relating to alcohol and drug use/abuse.

• •

Discuss the issue of ADAP and behaviour change.

Alcohol and drug use and abuse can:

•

Impact on existing health conditions.

•

Create new health conditions.

•

Be aggravated by health conditions.

Young people are at high risk:

•

Due to peer pressure.

•

In high-stress environments where there is pressure to

To empower participants with the required knowledge to

To provide opportunities for participants to do self-study.

•

To give participants a chance to demonstrate their understanding of the link between alcohol and drug use and health.

achieve or perform. 3.

There is a high correlation between risk for transmission of HIV and other STIs and alcohol and drug use/abuse.

Activity One: Self-study

Objectives: To ensure that participants know essential facts about ADAP. To assess the ability of participants to transfer knowledge clearly and accurately.

Behaviour change is difficult and cannot happen overnight. There are various stages in the model for behaviour change.

The health issues related to ADAP Tuberculosis

Requirements: A flipchart and pens

The use/abuse of injected drugs is associated with increased

Time:

drug users/abusers are likely due to other risk factors for TB

rates of TB infection. Increased TB disease rates among disease, such as being in prison, homelessness, and poverty.

60 minutes

TB is a leading cause of death among people who inject drugs (PWID) living with HIV.

Planning Notes Familiarise yourself with all the necessary issues pertaining to ADAP. Group 1: Relationship between mental illness and drug use. --

Group 2: Risks and responsibilities regarding injecting drug use.

Mental Illness & Drug Use Not all people who use/abuse drugs and alcohol are mentally

Allocate topics to groups to prepare: --

Group 3: Other common infections related to alcohol and drug use including HIV and Hepatitis C.

ill, although mental illness does have a strong association with alcohol and drug use/abuse. In some cases, mental illness may already be present before an individual becomes a user/abuser. In this situation, mental illness may be one of the factors that lead individuals to drug use as a method of coping. In other cases, mental illness may result from drug use/abuse since some drugs manipulate the brain. Also, for some, alcohol or drug use stressors, such as homelessness or

Procedure

128

session. •

KEY MESSAGES

•

Ask how participants felt about what they learnt in the

and abuse and their impact on health.

Purpose of Activities

•

Discuss whether any new information was covered.

•

To provide comprehensive information on substance use

enable them to educate their peers on ADAP.

•

Allow groups to prepare for fifteen minutes and invite groups

unemployment, can lead to mental illness.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Depression and Anxiety Depression can prevent substance users/abusers from taking their medication as the doctor instructed them to (e.g., missing doses, taking too few or too many), or even prevent them from going to a healthcare facility. Anxiety can lead to unwillingness to interact with others, which may include healthcare service providers. Also, a user/abuser may show signs of a behavioural disorder, act out in a clinic setting, and become challenging to treat. Individuals who are experiencing a mental illness may, therefore, be more difficult to treat for HIV and other issues. Anxiety is a normal emotion in everyday life and is closely related to fear. Anxiety can become a mental illness when it is prolonged, feels never-ending, or when the anxiety becomes out of control and affects an individual’s daily functioning. Signs and symptoms of anxiety may include excessive worry, fear, feelings of uneasiness, tightness in the chest, difficulty breathing, heart palpitations, dizziness, light-headedness, nausea, diarrhoea, and excessive sweating. At the extreme, anxiety can often lead to panic (or a panic attack) where a person experiences intense stress and a sense of not being in control. A special type of anxiety disorder that may be related to alcohol and drug use is social anxiety disorder. When someone suffers from social anxiety, they experience intense fear, panic or stress while engaging in everyday social situations. It can create feelings of humiliation, embarrassment and judgement. Social anxiety may include symptoms such as sweating, blushing, trembling, nausea, and stammering. An individual who is experiencing social anxiety may be more likely to use drugs or alcohol to help them cope, and less likely to seek healthcare services because of fear of being judged by healthcare staff. Anxiety can also be caused by drug use/abuse, particularly the use/abuse of stimulants such as cocaine. What about the use of non-sterile injecting equipment? Non-sterile injecting equipment refers to the re-use of previously used injecting equipment to inject a drug. The association between using non-sterile injecting equipment or sharing needles and HIV infection is a strong one. There are a few methods for sharing injection drugs and equipment, all of which can lead to contamination of the injection equipment by HIV and other infections. What are the side-effects of injecting drug use? Because the drugs go directly into the bloodstream when injected, the effects are more intense and addictive – and so are the risks for overdosing. There are also many social, physical and mental consequences of using injection drugs. For example, injecting HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

129

drug use is much more addictive than other forms of drug use,

PHLEBITIS

creating physical dependence, and often leading to more severe

Phlebitis results in the development of track marks along the

withdrawal symptoms than when non-injection users stop taking

veins where the drug is injected. Track marks are actually

the drug.

damaged or infected veins that can lead to the formation of blood clots.

In addition to the high risk for overdosing, injecting drug use can result in damage to the arteries and scarring of the veins.

HIV, Hepatitis C and other infections

Bacteria can also cause infections at injection sites. A common

PWID can easily get bacterial infections that travel through the

effect is skin irritation or itching that is relieved by scratching.

blood because they may use unsterilised injection equipment

Some injectable drugs, such as heroin, make you throw up.

or share needles when they inject drugs. In these situations,

Users sometimes judge the strength of the dose by the force of

they may become infected if they use a needle, syringe, or

their nausea or urge to throw up.

other equipment that is contaminated with bacteria, viruses and/or other foreign material.

DEPRESSANT DRUGS, like opiates (e.g., heroin) and sedatives (e.g. Valium and alcohol), slow down the body’s functions. A

These infections can lead to a variety of illnesses and can cause

person who

death of drug users, their sexual partners, and their children

overdoses on a depressant will experience breathing that can

through mother-to-child transmission. Drug use can increase

become life-threateningly slow or stop altogether, leading to

sexual risk because it can affect judgment and decision-

heart failure.

making as well as lower inhibitions during sexual activity. For example, cocaine use can sustain an enhanced period of

STIMULANT DRUGS, such as cocaine and speed, can cause a

sexual activity but also dries out the mucous membranes, and

person who has overdosed to have a heart attack or experience

the long duration of sex might cause bleeding due to bruising

cardiac arrest, collapse from exhaustion, have a seizure, or

and small cuts.

become so disoriented that they accidentally hurt themselves.

Discrimination and stigma surrounding alcohol and drug

Other common infections

use/abuse have been reported as barriers to accessing HIV

PWID may also experience the following common infections.

testing services (HTS) and other medical services in South Africa, which adds to the overall vulnerability of people who

ABSCESSES AND ULCERS

use alcohol and drugs. Fear often prevents these individuals

PWID may be affected by abscesses or ulcers around the

from seeking help, not only because of the legal aspects,

areas of their bodies where they inject, usually the arms or legs.

but also because of a lack of easy access to treatment and

Abscesses may be difficult to heal. Ulcers are generally not deep

medication.

and can heal with good wound care and antibiotics. Women who inject drugs: Risks and vulnerabilities

SEPTICAEMIA Septicaemia is a life-threatening infection of the blood resulting from the presence of certain bacteria. Symptoms of septicaemia include high fever, shivers, headache, and possibly convulsions.

Studies from around the world show that: •

The average HIV prevalence among women who inject is 50% higher than among men who inject.

•

Many women begin injecting drugs in the context of sexual relationships, and they often borrow or share injecting

ENDOCARDITIS Endocarditis is an inflammation of the heart due to infection from foreign matter that may enter the bloodstream of injecting drug

equipment from their male partners. •

and being injected by another person or being helped to

users through injection. Endocarditis symptoms include irregular heartbeats and chest pain.

Women are more likely to be injected by their male partner inject is a predictor of HIV infection.

•

Women are more likely to be the last person to use shared injecting equipment.

CELLULITIS Cellulitis is a common bacterial skin infection that can affect

•

Women who inject drugs are often dependent on their sexual partners to obtain drugs, which compromises their

PWID. Cellulitis shows up as an inflammation of the skin.

ability to negotiate safer sex or safe injecting practices. •

Women who inject drugs have lower access to services than men who inject drugs.

130

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Lesson Objectives

Sexually transmitted infections

•

There is a lot of education and information about the importance

To educate through participative peer-led action learning, as well as to develop skills amongst peer educators

of protecting against HIV and human papillomavirus

•

(HPV) infection (the world’s most common STI). But it is

To provide an opportunity for participants to express personal opinions about alcohol and drug use/abuse.

also important to do a better job of preventing and treating

•

diseases like gonorrhoea, chlamydia and syphilis. These are all STIs. There are more than 200,000 stillbirths and babies

To empower participants to consider ways of avoiding risk

Activity One: Getting the “dope” on alcohol and drugs

dying in the womb every year, as well as deaths of over 90

Objectives:

000 newborns because of not treating syphilis.

To expose participants to information on how the use of alcohol and drugs can cause physical, psychological, legal

STIs are common among people who use drugs and alcohol,

and financial harm.

especially infections such as herpes simplex virus type 2 (HSV-2, HPV, gonorrhoea, chlamydia, and syphilis. Large

Requirements:

numbers of sexual partners and frequent unprotected sex are

Fact sheets: handouts

common among this group, which increases their risk for STIs. Untreated STIs also increase the HIV risk and contributes to

Time:

their transmission within communities.

45 minutes Planning Notes Study the drug facts sheets. Procedure Facilitate a plennery discussion using the discussion questions provided.

DISCUSSION QUESTIONS •

What did you learn about risks and dangers?

•

What did you learn about health?

•

How did the activity impact on you?

•

Did the information have the power to influence choices that the people make?

LESSON THREE: ALCOHOL AND DRUG ABUSE - THE EFFECTS ON MIND, BODY AND SOUL Aim

KEY MESSAGES 1.

or mentally requires the drug to function normally 2.

can be done to help. Time 45 minutes

Drug dependence is a chronic relapsing mental illness, not simply a behaviour that can be changed through

To provide participants with information regarding the social, mental and psychological impact of alcholo and drugs and what

Drug dependence occurs when a person physically and/

councilling alone. 3.

When an individual is dependent on a drug and the drug is stopped abruptly, they may experience withdrawl symptoms

Drug dependence can also be identified when an indivdual experiences disturbance in their psychological functioning such as difficulty in concentrating, anxiety, depression, irritability, insomnia, headaches and muscle cramps.

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131

RESOURES FOR ACTIVITY ONE Common signs and symptoms of alcohol and/or drug abuse Physical symptoms and signs

Behavioural symptoms and signs

Psychological symptoms and signs

• Red eyes or dilated or pinpoint pupils

• Drop in attendance and lack of interest

• Unexplained change in personality,

• Changes in appetite

in work or school

• Changes in sleep patterns

attitude and behaviour

• Unexplained need for money that leads

• Sudden weight loss or gain

to borrowing and stealing

• Deterioration of physical appearance • Skin manifestations such as abscesses or ulcers

• Engaging in secretive or suspicious behaviour

skin from injecting

outbursts or unexplained excitement • Periods of unusual hyperactivity, agitation or giddiness

• Sudden changes in friends, favourite

• Needle marks or puncture wounds on

• Mood swings, irritability, angry

hang outs, and hobbies • Frequently getting into trouble (fights, accidents, illegal activities)

• Lack of motivation and ambition • Appears lethargic or spaced out • Appears fearful, anxious or paranoid with no reason

• Possession of drug gear or paraphernalia Behavioural risk for alcohol and/or drug abuse

132

Individual Risks

Societal Risks

Environmental Risks

Structural Risks

• • • • • • • • • •

• • • • • • •

• • • • • •

• Lack of access to justice / police support • Lack of access to health care • Difficult to get employment • Illegality of behaviours • Punitive legislation • Lack of access to commodities: lubricant; clean injecting equipment

Unprotected sex Substance use Substance use while having sex Sharing injecting needles Multiple partners Low self-esteem Disinhibition Depression Internal stigma Lack of information

Stigma Discrimination Prejudice Social Norms Family expectations Homophobia Heteronormativity • Penile-vaginal normativity • Cultural/ Religious beliefs

Dangerous places Invisibility Badly lit High levels of crime Having to hide Having to buy drugs from dangerous place/ person • Having to sell sex in dangerous place • High level of violence • Unhygienic conditions

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

Are you in the red?

commitment to change.

Zone Check: Substance Abuse

Yes

Are you concerned about your use of drugs and alcohol at times?

Stage #3: Preparation

Have you tried to stop using or cut down the amount of substances you use on your own but you have not been successful?

behaviour. They weigh options and select techniques for

Are your family members and loved ones concerned about your use of alcohol and drugs ?

confidence and commitment to change; and having the intention

At this stage, people accept responsibility to change their behavioural change. Characteristics of this stage include: developing a plan to make the needed changes; building to change within one month. We might describe this person as willing to change and anticipating

Do you have legal, financial and relationship issues which are directly and indirectly related to your usage of alcohol and drugs?

of the benefits of

change. Stage #4: Action

Are you unable to function normally without taking alcohol or drugs or feel extremely down when you don’t take them?

At this stage, people begin behavioural change efforts. Although

Has your usage of drugs and alcohol affected your work performance negatively?

of this stage include: consciously choosing new behaviour;

these change efforts are self-directed, outside help may be sought. This might include rehab or therapy. Characteristics learning to overcome tendencies toward unwanted behaviour;

If any of your answers place you in a red square, you in the RED ZONE. This might mean you are at risk for substance abuse and addiction. Ask your HIGHER HEALTH Campus Coordinator for help with counselling, care and support as soon as possible.

and engaging in change actions for less than six months. We

Behavioural and psychological interventions for ADAP

People in the maintenance stage have mastered the ability to

might describe this person as embracing change and gaining momentum. Stage #5: Maintenance sustain new behaviour with minimal effort. They have established

Motivation for change: the stages of change model

new behavioural patterns and self-control. Characteristics of this

In Changing for Good (1994), Prochaska and DiClemente describe the six stages of change: Stage

#1:

Pre-contemplation

stage include: remaining alert to high-risk situations; maintaining a focus on relapse prevention; and behavioural change that has been sustained for six months. We might describe this person

(before

the

impact

understood) People at this stage may not see the consequences of addiction as important enough compared to the benefits. As a result, at this stage, they demonstrate a lack of interest in wanting or needing to change, and having no plan or intention to change.

as persevering and consolidating their change efforts. They are integrating change into the way they live their life. Stage #6: Termination At the termination stage, people have adopted a new self-image consistent with desired behaviour and lifestyle. They do not

We might describe this person as unaware.

react to temptation in any situation. Characteristics of this stage

Stage #2: Contemplation (thinking about the impact)

a healthier and happier life. The relapse prevention plan has

People in the contemplation stage are starting to see or realise the impact of substance use on their actions or behaviour. However, they are still conflicted about whether it is necessary or worthwhile to change. The individual in this stage is thinking about and wanting to change, but not sure if they can change or will be able to commit to change. They lack the confidence and commitment to change behaviour, but have the intention to change at some point. We might describe this person as aware and open to change.

include confidence; enjoying self-control; and appreciation of evolved into the pursuit of a meaningful and healthy lifestyle. As such, relapse into the former way of life becomes almost unthinkable. Note: Relapse to a prior stage can occur anywhere during this process. For example, someone in the action stage may move back to the contemplation or pre-contemplation stage (Horvath, A. et al., http://www.amhc.org/1408-addictions/article/48541types-of-evidenced-based- effective-treatments-for-addiction).

Between stage 2 and 3: A decision is made. People realise that the negative consequences of their behaviour outweigh the positives. They choose to change their behaviour. They make a HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

133

Promoting HIV/TB/STI Testing and Screening Treatment •

Each engagement with people who use drugs and alcohol

cookers, spoons or filters with other drug users, or use

offers an opportunity to educate and increase their

new injecting equipment every time. If you use new

awareness of HIV risks and the prevention tools available

injection equipment every time, you cannot catch viral

to them. Peer educators should take this opportunity to provide facts and support to these individuals. •

Peer educators should educate by dispelling common

infections such as HIV through needle sharing. 4.

injection equipment every time, you cannot catch viral

example, it is a common misconception that HIV-positive

infections such as HIV, unless someone else has used

individuals do not face any risk if they are re-exposed as HIV reinfection and, unfortunately, it can significantly reduce future treatment options as well as increase a client’s viral load. •

People who use drugs and alcohol should be aware and educated about the dangers of infecting other people in their community.

•

If an individual is HIV-positive, they risk infecting their sexual partners and anyone with whom they may be

If you need to re-use any equipment, use your own injecting equipment every time. If you re-use your own

misconceptions or myths associated with HIV. For

to HIV after they have become infected. This is known

If you cannot stop injecting drugs, do not share needles,

your equipment without your knowledge. 5.

If you need to re-use any equipment and you believe you need to use someone else’s equipment, then clean needles by an approved method. There is some risk for HIV transmission after needle cleaning, but cleaning in an approved manner will reduce the likelihood of transmission.

What peer educators can do

sharing injection equipment. Harm Reduction Strategies •

Help reduce risks that individuals may face when using drugs or alcohol, and not necessarily promote abstinence from using.

•

Aim to make it safer for those who continue to use alcohol and drugs to reduce the risk of becoming infected with or transmitting HIV.

•

Can be effective methods for reducing the spread of HIV among PWID.

•

Not only support PWID in improving their health, but also provide services that can support the broader community.

•

Support the development of trusting relationships between users and peer educators as these interventions are nonstigmatising.

•

Take a neutral stance on drug use. In this way, healthcare workers are able to actively address the health risks that people who use drugs and alcohol face, particularly HIV infection, and support them in accessing care without stigmatising or isolating them. Hierarchy for injecting drug use Understanding the following levels of risk can be a useful tool when supporting PWID in reducing their risk: 1.

You will not get infections from sharing needles if you stop or never start injecting drugs.

If you cannot stop using drugs, use them in any way except injecting. If you do not inject drugs, you cannot catch infections through needle sharing.

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Principles of good practice in ADAP Education ADAP Education must involve trained facilitator / Peer Educator •

Peer educators must have specific knowledge of the students and the learning context.

•

Peer educators are best placed to identify and respond to the needs of students and to coordinate drug education with other activities.

•

Selected external resources are recommended for use where appropriate. ADAP programmes should have sequence, progression and continuity Health messages must be regular, timely and come from a credible source.

Education messages should be consistent and coherent, and based on student needs Programmes must be linked to the overall goal of prevention and harm reduction through behaviour change. •

They must be in line with broader policies and practices that reinforce programme objectives to maximise the potential for success.

•

They must provide information about the harmful long-term effects of drug use as well as demonstrate an understanding of the perceived benefits for users in order to demonstrate empathy and understanding of the challenges for users. Effective ADAP education programmes

•

Include a balance of knowledge, attitudes and skills.

•

Are participant-centred.

•

Contribute to long-term positive outcomes in the health curriculum.

•

Should reflect an understanding of characteristics of the individual, the social context, the drug, and the interrelationship of these factors.

•

Involve students at both the planning and implementation stages.

•

Respond to developmental, gender, cultural, language, socio-economic and lifestyle differences relevant to the levels of student drug use.

•

Address the motivations for drug use derived from influences such as culture and gender.

•

Involve a collaborative approach to reinforce desired behaviours.

•

Provide a supportive environment for programmes.

The emphasis of education should be on substance use likely to occur in the target group and use that causes the most harm to the individual and society. Tips for Risk Reduction Counselling •

Do what is possible first: Emphasis on short-term pragmatic goals (for example, preventing HIV transmission in a specific circumstance) over long-term idealistic goals (for example, overall reduction in harm/risk from drug use).

•

Small changes are easier than big changes. Establishment of a scale of means to achieving specific goals, for example, a hierarchy of risks.

•

Say the same thing many times in many ways. Use multiple strategies to achieve goals.

•

Give clients the tools they need and provision of the means to accomplish risk reduction, for example, condoms and sterile needles and syringes.

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Knowledge, attitudes, values and skills for peer educators involved in ADAP programs Knowledge General: knowledge about alcohol and drugs (composition, legality, effects) Social, emotional, physical and financial impact Current issues, policies, protocols and laws Current trends in use and abuse (local and global)

Attitudes

Values analysis and clarification skills

Skills Empathy Active Listening Giving and receiving feedback

Warmth, empathy, genuineness

Skills for identifying important influences on values and attitudes, and aligning values, attitudes and behaviour

Respect

Non-judgmental

Conviction regarding the legitimacy of the issues

Non-discriminatory

Care and compassion

Unconditional acceptance

Available resources Knowledge of addiction

Coping skills Self-control skills Coping with (peer) pressure

Decision-making skills Time management skills Assertion and refusal skills

Dealing with emotions: grief, anxiety

Belief in the potential to change

Critical and creative thinking skills

Dealing with difficult situations: conflict, loss, abuse trauma

Understanding of social disadvantage

Problem-solving skills

Help-seeking skills

No stereotyping

Skills for assessing risks Skills for informationgathering and generating alternatives Group management skills Facilitation skills

References •

Brown, B., Duby, Z., and Van Dyk, D. “Health Care Provision for Men who have Sex with Men, Sex Workers, and People who use Drugs: An Introductory Manual for Health Care Workers in South Africa.” The Desmond Tutu HIV Foundation 2013. Adapted from Poteat, T. Revised May 2012.

•

Ballard, R. and Robertson, T. “Review of Drug Education in Schools, Education Queensland, Brisbane,” 1999, Drug info sheets: http://www.drugfreeworld.org/drugfacts

•

Harm Reduction Coalition. “Getting off right: A safety manual for injection drug users,” New York, http://harmreduction.org/drugsand-drug-users/drugtools/getting-off-right

•

Anderson, L. “The acute effects of cannabis intoxication National Drug Strategy,” Monograph Series No. 25. US Drug Enforcement Administration Cannabis Information. The Substance Abuse and Mental Health Services Administration. National Institute on Drug Abuse.

•

International HIV/AIDS Alliance, “HIV and drug use: Community responses to injecting drug use and HIV – Good Practice Guide,” 2010.

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Chapter 8|HEALTH AND HUMAN RIGHTS

CHAPTER 8: HEALTH AND HUMAN RIGHTS The relationship between health and rights Sexual and reproductive rights exist when all people have control over and can decide freely and responsibly on matters related to their sexuality, including their sexual and reproductive health (SRH), free of coercion, discrimination and violence. These rights are embedded in the South African Constitution and in South Africa’s commitment to implement international human rights treaties. Sexual health requires a positive and respectful approach to a person’s sexuality and sexual relationships. To be sexually healthy, people need to be able to have pleasurable and safe sexual experiences, free of coercion, discrimination and violence. They need to have access to sexual health information and services. For people to have and keep their sexual health, their sexual rights must be respected, protected and fulfilled. Reproductive health requires that a person can reproduce and has the freedom to decide if, when and how often to do so. This implies that all people have the right to be informed about reproduction. They have the right to access contraception that is safe, effective, affordable, acceptable, and of their choosing, and to safe termination of pregnancy (TOP). All people have the right to healthcare services that will enable women to go safely through pregnancy and childbirth and will give couples the best chance of having a healthy baby. South African law protects people’s sexual and reproductive health and rights (SRHR).

South Africa’s Constitution refers to sexual and reproductive rights in three places •

The equality clause (s.9.3), which forbids discrimination on the grounds of sex, gender and sexual orientation;

•

Section 27. 1. A, which states that “Everyone has the right to have access to health care services, including reproductive health care”; and

•

Section 12 dealing with “freedom and security of the person”.

These rights in relation to SRH include the rights to access information (frequently manifest in health professionals’ obtaining informed consent for medical procedures following adequate counselling), education, dignity, and for our bodily integrity to be respected. Everyone in South Africa has the right to choose to engage in pleasurable, safer sexual experiences free from violence, and to choose whether they would like to reproduce and, if so, the number of offspring they would like to have.

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The Constitution also guarantees the rights to healthcare

Sexual harassment is any kind of sexual behaviour that makes

services, including sexual and reproductive healthcare for

you feel uncomfortable, including:

everyone. These fundamental, constitutional rights are reflected

•

Touching,

in South Africa’s many SRHR laws, policies and guidelines,

•

Jokes and innuendos of a sexual nature,

which are described below.

•

Persistent probing about personal and intimate information related to one’s sex life,

International law also supports a human rights approach

•

Rude and inappropriate comments or gestures,

to sexuality and reproduction

•

Unwelcome advances of a sexual nature, and

A human rights approach to sexuality and reproduction is

•

Leering or staring at your body in an offensive way.

also reflected in the international treaties that South Africa has signed and ratified, including the UN Convention on

Sexual harassment can happen anywhere, but is often happens

the Rights of the Child (UNCRC, 1989), Convention of the

in the workplace. In South Africa, the Labour Relations Act

Elimination of all Forms of Discrimination Against Women

(LRA) is the main act that deals with sexual harassment in the

(CEDAW, 1979), and Convention on the Rights of Persons

workplace. It has a Code of Good Practice on Sexual Harassment

with Disabilities (UNCRPD, 2006), as well as international

that sets out the best ways to deal with complaints about sexual

consensus agreements, including the Programme of Action of

harassment.

the International Conference on Population. Labour Rights

Guiding Principles

According to the LRA, sexual harassment is an unfair labour

•

Strong and visible ownership

•

Integrated services at the district level

•

A human rights approach

•

Meeting diverse needs

•

Care for the caregivers

•

Intersectoral collaboration

practice and, if it happens to you, you can ask your employer to deal with it. You have the right to:

Barriers to achieving SRHR in South Africa Poverty

•

Violence: defining violence and its impact

•

Stigma and discrimination

•

Service delivery in the public sector

•

Lack of information for planning, monitoring and decision-

To report sexual harassment without fear of victimisation Have your complaint treated seriously and confidentially

What to do if you are Sexually Harassed? You can deal with sexual harassment in an informal or formal way.

of a sexual nature”. This may happen in the following contexts: In exchange for an individual’s employment, education,

Informal Ways of taking informal action include: •

The acceptance or refusal of such advances is used as a factor in decisions affecting an individual’s employment, creates

environment

an for

intimidating, the

hostile

individual.

studentsexualmisconductpolicy.umich.edu)

Requesting assistance from a third party that you trust (friend or colleague) to accompany you when you talk to the perpetrator.

•

Writing to the person about the behaviour and specifying the actions or words that cause discomfort and requesting that

education, living environment, etc. behaviour

Talking to the person to address the behaviour and actions that make you feel uncomfortable.

•

living environment, or participation in a community.

offensive

Be treated equally, and not to be discriminated against

•

requests for sexual favours, and other verbal or physical conduct

The

•

(ill-treatment).

Sexual harassment is defined as “unwelcome sexual advances,

•

Be treated with dignity and respect at work.

•

Sexual Harassment

•

A workplace that is free from sexual harassment.

•

because of race, gender or HIV status.

•

making

•

it stops. In this instance, it is important to send the letter by

registered mail and keep a copy of the letter so that you can

(http://

prove that you sent it. •

Requesting assistance from a third party to speak to the abuser, for example, the shop steward or a work colleague.

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Formal

•

The Domestic Violence Act (Act No. 116, 1998) (DVA).

Where a formal procedure has been chosen by the aggrieved, a

•

The Criminal Law Sexual Offences and Related Matters

formal procedure for resolving the grievance should be available

Amendment Act (Act No. 32, 2007).

and should:

•

Firearms Control Act (Act No. 60, 2000).

•

Specify to whom the employee should lodge the grievance.

•

The Children’s Act (Act No. 38, 2005).

•

Make reference to timeframes which allow the grievance to

•

National Policy Guidelines on Victim Empowerment.

be dealt with expeditiously.

•

National Instructions on Domestic Violence.

Provide that if the case is not resolved satisfactorily, the

•

National Policy Framework on the Management of Sexual

•

issue can be dealt with in terms of the dispute procedures

Offences.

contained in item 7(7) of the Code of Good Practice on

•

National Instructions on Sexual Offences.

Sexual Harassment.

•

National Directives and Instruction on Conducting a Forensic Examination on Survivors of Sexual Offences in terms of the Criminal Law Sexual Offences and Related

Investigation and disciplinary action •

•

Matters Amendment Act (Act No. 32, 2007).

Care should be taken to ensure that the person reporting sexual harassment is not stigmatised, ostracised or

•

The Victims Charter (2004).

disadvantaged during the investigation. Care should

•

National Management Guidelines for Sexual Assault (2003).

also be taken and that the position of other parties is not

•

Court System and Case Flow Management.

prejudiced if the grievance is found to be unwarranted.

•

Family Violence Child Protection and Sexual Offences (FCS) investigation units at the SAPS.

The Code of Good Practice provides that an employee may be dismissed for serious misconduct or repeated

•

offences. Serious incidents of sexual harassment or

It is worth noting that while there might be various laws,

continued harassment after warnings are dismissible

policies and frameworks in place, enforcement of these is often

offences (Schedule 8 of this Act).

inadequate (WHO, 2014).

In cases of persistent harassment or single incidents of serious misconduct, employers ought to follow the

The prevalence of GBV in South Africa

procedures set out in the Code of Practice contained in

When interpreting statistics on the prevalence of GBV, it is

Schedule 8 of this Act.

important to be aware that under-reporting is likely for a number

The range of disciplinary sanctions to which employees

of reasons that include:

will be liable should be clearly stated, and it should also

•

ostracism

be made clear that it will be a disciplinary offence to victimise or retaliate against an employee who, in good

•

The perpetrator is known (family member, powerful figure, religious leader)

faith, lodges a grievance of sexual harassment. •

Shame, embarrassment and fear of humiliation and

A victim of sexual assault has the right to press

•

Self-blame

separate criminal and/or civil charges against an alleged

•

Inappropriate societal norms that blame the victim, etc.

perpetrator, and the legal rights of the victim are in no way

(Kim and Motsei, 2002; Parliamentary Research Unit, 2013;

limited by this code.

NACOSA, 2015; SAHRC, 2015).

Should a complaint of alleged sexual harassment not be satisfactorily resolved by the internal procedures

Research on gender-based and sexual violence indicates that

set out above, either party may within 30 days of the

victims and survivors may be subjected to GBV repeatedly

dispute having arisen, refer the matter to the Commission

throughout their lives. (Weideman, 2008). Surveys conducted

for Conciliation, Mediation and Arbitration (CCMA) for

in four South African provinces in 2008 and 2010 showed the

conciliation in accordance with the provisions of section

following:

135 of this Act. Should the dispute remain unresolved,

•

More than 80% of respondents believed that “women should

either party may refer the dispute to the Labour Court

obey their husbands”, or that “women need their husbands’

within 30 days of receipt of the certificate issued by the

permission” to do things they need to do.

commissioner in terms of section 135(5).

•

50% believed that “men should share the work around the house with women”.

Gender-based violence

•

choice about whether or not to have sexual intercourse with

South Africa has a number of responses addressing GBV. This

their partners.

is a comprehensive list of legislative and policy frameworks to address and combat the prevalence of GBV in South Africa.

The majority of female respondents did not think they had a

•

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It was disturbing that as many as 40% thought “beating was 141

•

a sign of love”.

survivors of violence in a variety of ways (for instance, medical

Unequal power relations that arise from a male-dominated

help, psychosocial support, and shelter). Prevention initiatives

society and a bias towards heterosexuality also have

look at how GBV can be prevented from happening. Response

implications for the prevalence, type and responses to

services can, in turn, contribute towards preventing violence

violence. (Jewkes, n.d.; NACOSA, 2015)

from occurring or reoccurring.

Even though laws, policies and various codes and charters

Dealing With Stigma And Discrimination

are in place, they are not sufficiently enforced (WHO, 2014).

Definitions

The Increasing Services for Survivors of Sexual Assault in

Stigma: “When we have a negative attitude toward people

South Africa (ISSSASA) Programme funded by USAID is a

who we think are different, or not ‘normal’ or ‘right’. For

coming together of leading South African organisations –

example, stigma can mean not valuing people living with HIV

Foundation for Professional Development, Soul City Institute,

(PLHIV) or people associated with PLHIV, or people we think

Sonke Gender Justice Network, and the South African Medical

are homosexual” (https://www.avert.org).

Research Council (MRC). The primary intention is to improve

To stigmatise someone: Labelling a person and seeing them

service provision and community awareness of services for

as inferior (less than or below others) because of something

survivors of sexual assault in South Africa, which has one of

about them, or something you assume about them (e.g.,

the highest rates of GBV in the world.

because of their job, because they are poor, because they

The South African Government relies on the Sexual Offences

have a disease, etc.). Often people stigmatise others because

and Community Affairs (SOCA) unit of the National Prosecuting

they do not have accurate information and knowledge, and

Authority (NPA) to lead the fight against sexual violence.

this leads to fear.

USAID has worked with the NPA and SOCA for almost a

Discrimination: Treating someone unfairly or differently from

decade to establish the Thuthuzela Care Centre (TCC) model.

others because they are different in some way (for example,

TCCs provide a wide range of services to survivors of GBV,

because a person has HIV). Discrimination is the action that

including emergency medical care, psychosocial counselling,

often follows stigma.

post-exposure prophylaxis (PEP), HIV testing and counselling, and assistance with case reporting and court preparation in an

Key points about stigma and discrimination

integrated and victim-friendly manner. The TCC model seeks to

All over the world, stigma and discrimination are some of the

streamline the care process for GBV survivors by establishing

biggest challenges affecting all sorts of people, including PLHIV,

effective linkages between various service providers and

people living with a disability, and homosexuals. Stigma and

government stakeholders, and to improve legal services by

discrimination make it hard for people to feel accepted within

reducing time-to-court and increasing the conviction rate.

society, to access services such as SRHR, STI and HIV services, and communicate about the challenges they face. Stigma and

What do we do?

discrimination can also prevent young people from accessing

South Africa is a signatory to a number of international treaties

community-based services, such as food support. We have all

on GBV, and has a strong legislative framework, for example, the

felt rejected or isolated at some point in our lives. We have also

DVA (1998), Sexual Offences Act (2007), and the Prevention and

all probably rejected or isolated another person, or group of

Combatting of Trafficking in Human Persons (2013) Act.

people, because we thought of them as different.

Much of our effort in South Africa has been focused on response. However, our response efforts need to be supported

Different kinds of stigma

and complemented by prevention programming and policy

Stigma toward others: Rejecting or isolating other people

development. By addressing the underlying, interlinked causes

because they are different or because they are seen as different

of GBV, we can work towards preventing it from happening in

(e.g. being isolated by peers at school or being abandoned by

the first place.

friends).

Addressing GBV is complicated and needs a multilevel response

Self-stigma: When a person adopts the cruel and hurtful views

from all stakeholders, including government, civil society and

that others may have of them. In other words, when a person

other citizens. There is growing recognition in South Africa of the

begins to see themselves in a negative way because of the way

magnitude and impact of GBV and of the need to strengthen the

others see them, or because of the way they perceive others

response across sectors.

to think. Self-stigma can lead people to isolate themselves from their families and communities (e.g., someone is HIV-positive

142

Approaches to addressing GBV can be divided into response

and is afraid of “giving the disease” to their family, so they keep

and prevention. Response services aim to support and help

to themselves, eat meals alone, and use separate cups and

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

plates). Secondary stigma: When people are stigmatised by their association with someone else, for example, the family member of an HIV-positive individual may also be stigmatised by the community. Secondary stigma may affect doctors and nurses at HIV clinics, family members or caregivers of PLHIV, and even SRHR champions. There are different forms of discrimination, including: •

Facing violence at home or in the community.

•

Not being able to attend school or social functions.

•

Being expelled from school.

•

Not being able to get a job.

•

Being isolated or shunned by the family or community.

•

Not having access to quality healthcare or other services.

•

Being rejected from a church, mosque, or temple.

•

Police harassment.

•

Verbal discrimination: gossiping, taunting, scolding.

•

Physical discrimination: insisting that a person uses separate eating utensils or sleeps in a separate living space.

Stigma and discrimination prevent good access to SRH services and to STI and HIV prevention, care, and treatment services for many people. Stigma and discrimination around HIV, people living with a disability, young people’s SRH, and people with different sexualities impact on everyone. Stigma and discrimination can: •

Prevent people from getting an HIV test and from accessing ART.

•

Stop people from openly acknowledging their sexuality.

•

Make it hard for people to tell their partner(s) their HIV or STI test results.

•

Make it hard for people to suggest safer sex practices to their partner(s).

•

Cause anxiety, stress, and depression.

•

Make it hard for parents to disclose their HIV status to their

Adolescents and Youths Adolescents and youths face several reproductive health challenges. These include early pregnancies, which are mostly unwanted, complications of unsafe abortions, and complications of pregnancy and childbirth. Adolescents lack easy access to quality and friendly healthcare, including STI services, safe abortion services, antenatal care (ANC), and skilled attendance during delivery, which result in higher rates of maternal and perinatal mortality. Other specific reproductive health problems experienced by adolescents are being subjected to harmful cultural practices including female genital mutilation (FGM), early forced marriage, and sexual violence and abuse, including coerced sex, incest, defilement and rape, which increase their risk of STIs, including HIV. Generally, adolescents and youths lack relevant, accurate information on sex, sexuality and reproductive health. In some instances, they are subjected to sex tourism. Unsafe abortions This was said to be rampant among adolescents and youths, especially in universities and other technical colleges. Sometimes, arising from abortions, foetuses are collected from dustbins in universities. Most girls do not seek safe abortion services, including post-abortion care, as they fear gossip, ostracism, stigma and discrimination, and breach of confidentiality. What is the legal age for TOP and when is it safe? Termination of pregnancy (TOP), commonly referred to as an abortion, is legal in South Africa from the age of 12 years old without parental consent. This law was passed because many young and underage girls who were sexually active became pregnant and were seeking unsafe back-street abortions. Currently, the practice is done at some clinics. If a woman requests it, and it is not done at the community clinic, she must be referred to a centre that offers TOP.

Up to 12 weeks

One request of a pregnant woman (the woman must ask for a TOP)

Informed consent from the pregnant woman

13 to 20 weeks

• If having the baby could harm the woman’s body or affect her mental state • If she cannot afford to have the baby because she does not have enough money, or if having the baby would affect her relationships with her family and community • iIf the baby is not growing normally • If the pregnancy is a result of rape or incest

Informed consent from the pregnant woman

Prevent young people from discussing their SRH needs Make people afraid of knowing their HIV status, meaning access to ART is delayed.

•

Make young people afraid to ask for advice on contraceptives, resulting in unintended pregnancy, or HIV or STI infection.

•

Who can give informed consent?

exclusively or for pregnant women to access PMTCT

with parents or from visiting the local clinic. •

When does she qualify for a TOP?

Make it hard for breastfeeding mothers to breastfeed services.

•

vulnerable and marginalised groups

How far pregnant is she?

children. •

Sexual and Reproductive Health Rights (SRHR) of

Result in low-quality services at clinics and hospitals, making it less likely that people will access the care they need.

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143

How far pregnant is she? After 20weeks

When does she qualify for a TOP? If the pregnancy would: • be dangerous to the woman’s life • affect the normal growth of the baby • cause a risk of the baby being hurt

Who can give informed consent?

•

The right to respect for private and family life.

•

The right to benefit from scientific progress.

•

The right to freedom of expression.

Informed consent from the pregnant woman

The Rights Of Disabled People To Sexual And Reproductive Health Advocating for equal access to mainstream SRH services and a positive, healthy understanding of sexuality requires a multi-faceted approach that goes beyond the social model of disability. It requires a perspective that acknowledges the intersections between disability, gender, race, sexual orientation, age, socio-economic status and other factors, but does not privilege one over another. A human rights-based approach can accommodate all the above-mentioned factors because it is premised on the inherent dignity and equality of all persons. International human rights documents, treaties, conventions and standards provide the platform from which disabled people’s rights to SRH can be realised. Harmful myths and stereotypes regarding sexuality and disability Various conflicting myths with respect to sexuality and disability prevail in society which perpetuate and reinforce the marginalisation and discrimination of people with disabilities (PWDs). Examples of some myths include: •

All PWDs have the same needs.

•

All PWDs are heterosexual.

•

All PWDs are asexual or hypersexual.

•

Information and education about sex will encourage “inappropriate” sexual behaviour.

•

Intellectually disabled people are incapable of understanding sexuality.

•

Physically disabled people are unable to have sex.

•

PWDs cannot or should not be parents.

•

PWDs should be “grateful” for any type of sexual relationship.

Sexual and reproductive health rights (SRHR) for people with a disability In order to understand the SRHR of PWDs, we must start with the acknowledgement that all people have a right to their own sexuality. The right to sexuality and SRH for every person can be found in the following human rights principles: •

The right to equality and non-discrimination.

•

The right to marry and found a family.

•

The right to reproductive health, including family planning and maternal health services, information and education.

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These rights are recognised in international treaties and

blind, deaf or have intellectual or cognitive impairments.

conventions such as the European Convention on Human Rights; Universal Declaration on Human Rights; International Covenant

For instance, health information displayed on the boards of

on Civil and Political Rights; Convention on the Elimination of All

health facilities cannot be read by those who are blind, yet,

Forms of Discrimination Against Women (CEDAW); International

the government and/or the health providers do not provide

Covenant on Economic, Social and Cultural Rights; Beijing

health information in Braille formats. Similarly, health facilities

Platform for Action; and International Conference on Population

have not invested in sign language interpreters – this makes

and Development.

communication between health providers and the deaf a challenge.

Lack of informed consent PWDs have complained that healthcare providers performed

It appears that there are no specific SRH programmes targeting

medical procedures on them without obtaining their consent.

PWDs, despite these people having special SRH needs.

For instance, a woman with a disability narrated how she

Generally, PWDs are denied basic facts and information about

underwent a hysterectomy without her consent. When she

themselves and how to protect themselves from STIs and HIV/

inquired from the surgeon why this irreversible procedure was

AIDS. There are no well-coordinated efforts to reach PWDs with

carried out without her consent, the surgeon stated that PWDs

contraceptives or STI and HIV/AIDS prevention and care.

should not have children because they have no potential to adequately bring up the children. Some disabled women

Disability Rights

said they were subjected to forced abortions by caregivers

Background:

or relatives who were responsible for the pregnancy to avoid

Protecting and promoting the human rights of PWDs is an

embarrassment at home.

underlying principle in all the articles of the Convention on

At community, family or health facilities levels, PWDs are

the Rights of Persons with Disabilities (UNCRPD). Article 4

excluded from decision-making processes, and are always

commits State parties to ensure and promote the full realisation

required to follow instructions without questioning. Family and

of all human rights and the fundamental freedom for all PWDs

community members justify this act by arguing that PWDs are

without discrimination of any kind on the basis of disability,

vulnerable, delicate and helpless, and need sympathy. The

and to protect all persons against the violation of their human

legal system has been unable to offer PWDs redress since

rights.

some of them are highly dependent on third parties to access legal services or relevant information on their behalf.

An erroneous perception exists among some HEIs that current legislation does not create enforceable rights for students with

Difficulties in accessing health facilities due to physical

disabilities. Very few SA institutions have started to understand

infrastructure

and/or put measures in place to ensure integrated learning

People with physical disabilities often find it difficult to access

and education methodologies and processes. Disability Units

healthcare facilities owing to the lack of suitable ramps (metallic

or Disability Rights Units (DUs or DRUs) must move beyond

ramps are too slippery, dangerous and difficult to use when one is

the built environment, technology and assistive devices to

using a wheelchair or crutches). The distances between service

interrogate the learning and teaching methodologies at their

areas within health facilities are also prohibitive, especially in the

institutions. Any future service delivery model developed by

absence of paved paths. Inside clinics, the height of examination

role players for DUs/DRUs needs to be built on the premise

couches and delivery beds can make it difficult to get onto them.

of human rights, universal access design and consumerism approaches. This section will focus on discrimination in the

Abuse and mistreatment

context of disability and how legislation supports students with

Women with disabilities often experience abuse and mistreatment by health workers because of not following instructions (which they could not hear or respond quickly enough to).

disabilities. A quick chronological overview: •

white paper set out a variety of government policy positions

Difficulties in accessing information The blind and deaf face serious challenges when it comes to access to information. Yet, healthcare providers and facilities

on disability. •

not in friendly formats that can be accessed by those who are

South Africa is a party to the UNCRPD, as well as the Optional Protocol to the Convention, signed on 30 March

have not designed methods to facilitate communication with them. The modes of communication in most health facilities are

The 1997 Integrated National Disability Strategy (INDS)

2007, and ratified on 30 November 2007. •

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From 2009 to 2014, a Ministry and Department of Women, 145

Children and Persons with Disabilities existed. When the

needs of such persons.

Ministry and Department were closed in 2014, responsibility

•

for matters relating to disability passed to the Department of

Following a review of the PEPUDA, numerous suggestions were

Social Development (DSD).

made for its improvement. The PEPUDA Amendment Bill is, at

The DSD’s 2015 White Paper on the Rights of Persons with

the time of writing, being drafted by the Department of Justice

Disabilities (WPRPD) updated and supplemented the 1997

and Constitutional Development (DOJCD).

INDS by integrating the provisions of the UNCRPD and its Optional Protocol.

Another important act is the Employment Equity Act (EEA). The EEA was passed in order to promote equal opportunity and

South African Legal and Policy Framework

fair treatment in employment through the elimination of unfair

Section 9 of the Constitution prohibits unfair discrimination on the

discrimination. The EEA promotes substantive equality through

basis of disability. Discrimination on these grounds is presumed

the implementation of affirmative action to ensure redress and

to be unfair unless it has been shown to be otherwise. Section

equitable representation in the workforce.

9 of the Constitution further allows for positive measures to be taken to promote the achievement of equality for categories

The Broad-Based Black Economic Empowerment (BBBEE) Act,

of persons previously disadvantaged by unfair discrimination,

53 of 2003, and the BBBEE Amendment Act, 55 of 2013, are

which includes PWDs.

reflections of the EEA and provide practical legislative definitions and policies to realise substantive equality.

Chapter 2 of the South African Constitution, Bill of Rights, Section 9, Equality

In terms of the applicable policy framework, the DSD circulated

(3) The state may not unfairly discriminate directly or indirectly

the WPRPD in 2016. It provides clarity on various issues,

against anyone on one or more grounds, including race,

including the development of standard operating procedures for

gender, sex, pregnancy, marital status, ethnic or social origin,

mainstreaming disability; it sets out the norms and standards in

colour, sexual orientation, age, disability, religion, conscience,

terms of which discriminatory barriers should be removed; and it

belief, culture, language and birth.

broadly outlines stakeholder responsibilities.

(4) No person may unfairly discriminate directly or indirectly against anyone on one or more grounds in terms of subsection

Strategic Policy Framework on Disability for the Post-

(3). National legislation must be enacted to prevent or prohibit

School Education and Training System

unfair discrimination.

In the first half of 2018, the DHET finalised the Strategic Policy

Various statutes aim to give effect to the constitutional right

Framework on Disability for the Post-School Education and

to equality, the most prominent of which are the Promotion of

Training (PSET) System.

Equality and Prevention of Unfair Discrimination Amendment Act

The South African Government saw the need to develop the

(PEPUDA), and the Employment Equity Act, 55 of 1998 (EEA).

policy framework to make institutions of higher education and training inclusive. The policy framework “is necessary to guide

The PEPUDA is the national legislation mandated by section 9(4)

the improvement of access to and success at PSET institutions

of the Constitution, and thus enjoys special constitutional status.

and programmes [including in private institutions] for people

Significantly, the Act recognises the need to address systemic

with disabilities”. The strategic policy framework aims to create

discrimination, and specifically aims at the “eradication of social

“an enabling and empowering environment across the PSET

and economic inequalities.”

system. This includes, but is not limited to setting norms and standards for the inclusion of students and staff with disabilities

Section 9 of the PEPUDA prohibits unfair discrimination on the

in all aspects of university, college and skills development

grounds of disability, including:

life, including academic studies, culture, social life, sport and

accommodation.”

Denying or removing from any person who has a disability, any supporting or enabling facility necessary for their

146

functioning in society.

The National Strategic Plan on HIV, TB and STIs: 2017-2022

Contravening the code of practice or regulations of the South

The National Strategic Plan (NSP): 2017-2022 is the country’s

African Bureau of Standards that govern environmental

fourth master plan that outlines how the country will respond to

accessibility.

the prevention and treatment of HIV/AIDS, TB and STIs over the

Failing to eliminate obstacles that unfairly limit or restrict

next five years. It seeks to improve on the achievements of the

persons with disabilities from enjoying equal opportunities

last plan (NSP 2012-2016), which massively scaled up South

or failing to take steps to reasonably accommodate the

Africa’s anti-retroviral treatment (ART) programme and reduced

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the MTCT rate to just 1.5%. As a peer educator, you need to be aware of this strategic plan. It is important to note that in the original NSP, PWDs were to a large extent excluded from the proposed action plan. This has been corrected to some extent by disability sector representatives to the Civil Society Forum of the South African National AIDS Council (SANAC). PWDs were identified as a vulnerable population for HIV and STIs. Vulnerable populations are much more affected than the general population and need special attention. Furthermore, they are often highly marginalised, which diminishes their access to health information and deters them from seeking services. This violates the SRH rights of PWDs. HIV-positive PWDs often face the double stigma of disability and HIV. International and Regional Legal Frameworks South Africa ratified the UNCRPD and its Optional Protocol without any reservations in 2007, and it subsequently entered into force on 3 May 2008. The UNCRPD sets out a broad range of rights – ranging from civil and political rights to social, economic and cultural rights – of PWDs in an effort to enhance the lives of this group. Although the African Charter on Human and Peoples’ Rights does not exclusively deal with disability, it addresses the rights of PWDs in article 18(4), which provides that the aged and the disabled have the right to “special measures of protection” in keeping with their physical or moral needs. In February 2016, the African Commission on Human and Peoples’ Rights adopted the Draft African Protocol on the Rights of Persons with Disabilities, which aims to address continued exclusion, harmful practices, and discrimination affecting those with disabilities, especially women, children, and the elderly. Closely related to affirmative action, and especially significant in relation to disability, is the concept of reasonable accommodation. The UNCRPD defines reasonable accommodation as “necessary and appropriate modification and adjustments not imposing a disproportionate or undue burden, where needed in a particular case, to ensure to persons with disabilities the enjoyment or exercise on an equal basis with others of all human rights and fundamental freedoms.” In terms of the PEPUDA and the UNCRPD, failure to reasonably accommodate vulnerable groups amounts to unfair discrimination on the grounds of disability. Reasonable accommodation is further defined in the EEA as “any modification or adjustment to a job or to the working environment that will enable a person from a designated group to have access to or participate or advance in employment.” As explained by former Chief Justice Langa, “At its core is the notion that sometimes the community, whether it is the State, an employer or a school, must take positive measures and possibly incur additional hardship or expense in order to allow all people HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

147

to participate and enjoy all their rights equally. It ensures that we

The decision to add a universal human rights instrument specific

do not relegate people to the margins of society because they do

to PWDs was borne of the fact that, despite being theoretically

not or cannot conform to certain social norms.”1

entitled to all human rights, PWDs are still, in practice, denied those basic rights and fundamental freedoms that most people

Disability Discrimination

take for granted (UN, 2007).

Disability discrimination is the unfair treatment of people because of their disability.

The UN General Assembly adopted the UNCRPD in 2006.

Changing community attitudes is vital in eliminating discrimination.

The UNCRPD is a particularly useful advocacy tool because

The rising number of PWDs and the transition of PWDs into

Articles 23 and 25 provide explicit rights to sexuality and sexual

the community has helped to increase the understanding and

health services for PWDs. Article 23 – Respect for home and the

acceptance of people with different needs.

family states:

This is reflected in legislation that helps to protect the rights

•

Parties shall take effective and appropriate measures to

of all PWDs to participate in all aspects of community life. The

eliminate discrimination against persons with disabilities

National Constitution’s chapter two, “Bill of Rights” explicitly

in all matters relating to marriage, family, parenthood and

prohibits unfair discrimination against people on the basis of

relationships, on an equal basis with others so as to ensure

disability or health status.

that: a.

The right of all persons with disabilities who are of

Types of Discrimination

marriageable age to marry and to found a family on the

Discrimination can be direct or indirect.

basis of free and full consent of the intending spouses is

Direct discrimination occurs when someone is treated unfairly

recognised.

and is disadvantaged because of a personal characteristic or

The rights of persons with disabilities to decide freely and

behaviour that is protected under South African law. Direct

responsibly on the number and spacing of their children and

discrimination occurs when a person or group is harassed

to have access to age-appropriate information, reproductive

or excluded because of a personal characteristic, or treated

and family planning education are recognised, and the

less favourably than another person in the same or similar

means necessary to enable them to exercise these rights

circumstances.

are provided. c.

Indirect discrimination occurs when treating everyone the

Persons with disabilities, including children, retain their fertility on an equal basis with others.

same way disadvantages someone because of a personal characteristic. It occurs where a rule, work practice or decision

Impact Of Stigma And Discrimination On The Health Of

is made that applies to all people equally and appears to be

The Lgbtqi+ Population

non-discriminatory, but which in practice substantially reduces

•

the chances of a particular person or group of people from complying with it.

LGBTQI+ persons report fear of and may avoid accessing healthcare services for various reasons.

•

They fear unfair and discriminatory treatment at the hands of health service providers with limited understanding

Indirect discrimination appears to be equal treatment, but is unfair

of sexual orientation, gender identity, and transgender

on certain people because of a particular personal characteristic.

issues.

This is sometimes called systemic discrimination.

•

This leads to prejudice, mistrust, discriminatory treatment, denial of healthcare, and even abuse.

For indirect discrimination to be unlawful, it must also be

•

unreasonable. Examples of indirect discrimination: A recruitment

regarding their HIV status, sexual orientation, or gender

or promotion based on seniority or length of service may indirectly discriminate against women applicants because women are

They express fears relating to disclosure of information identity.

•

A Human Rights Watch (HRW) report documented denial

more likely to have taken career breaks to accommodate family

of healthcare, verbal abuse, harassment and violations

responsibilities. Selection criteria requiring a specific number of

of confidentiality of men who have sex with men, gay

years of previous experience may also constitute indirect age

men, transgender men, and intersex persons in Tanzania.

discrimination.

As a result, LGBTQI+ persons may not seek out health

UNCRPD

services that they need.

MEC for Education: Kwazulu-Natal and Others v Pillay

2008 (1) SA 474 (CC) para 73. 148

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•

As a result of criminal laws, stigma and discrimination and the general “invisibility” of LGBTQI+ populations in some countries, health information and services are not designed to meet specific healthcare needs relating to LGBTQI+ person’s sexual orientation and gender identity.

•

Many health facilities and service providers fail to understand and have outdated approaches to gender identity and expression.

•

to provide access to education and information about HIV, or treatment, and care and support services further fuels the HIV/ AIDS epidemic. These elements are essential components of an effective response to HIV/AIDS, which is hampered if these rights are not respected. •

What is a human rights approach to HIV and AIDS?

•

The right to education, free association, information and, most importantly, non-discrimination are recognised and

Healthcare services fail to provide appropriate SRH services for LGBTQI+ populations, such as appropriate barrier methods for lesbian, gay, bisexual, transgender or intersex persons (e.g., condoms with lubricants for men who have sex with men), hormone replacement therapy,

upheld. •

infected with HIV. •

HIV and AIDS: Health And Human Rights

The infected and affected are protected from discrimination, treated with dignity, and provided with access to treatment,

or gender-affirming surgery. This further discourages access to healthcare.

An open and supportive environment exists for those

care and support. •

HIV and AIDS are de-stigmatised.

In these circumstances, individuals are more likely to seek testing

There is a clear link between human rights and the spread and

in order to know their status. In turn, those people who are HIV-

impact of HIV on individuals and communities around the world.

positive may deal with their status more effectively by seeking

The disregard for human rights contributes to the spread of the

and receiving treatment and psychosocial support, and by taking

disease. This can be seen in the differences in incidence and

measures to prevent transmission to others, thus reducing the

spread of HIV among certain groups, which include women

impact of HIV on themselves and on others in society.

and children, those who are poverty-stricken, the lesbian, gay, bisexual, transgender and intersex (LGBTI) community, injecting

HIV testing and human rights

drug users, sex workers, and other stigmatised or disempowered

A human rights-based approach to HTS ensures that the essential

groups.

elements of the programme are aimed towards the realisation of rights and that those rights are used as standards. HTS must be

The relationship between HIV/AIDS and human rights is

offered in a way that is consistent with the rights described in the

highlighted in three areas

Constitution of South Africa and in the Children’s Act. It must be

Increased vulnerability: Groups who are unable to realise their

ethical and be conducted within a supportive environment.

social, cultural, economic and political rights are more vulnerable to contracting HIV. For example, individuals who are denied the

Some important human rights are described below

right to freedom of association and access to information may

•

not be able to freely discuss issues related to HIV, disclose their

All personal information concerning a client, their health status,

status, get treatment, join support groups, or take preventive

treatment, or stay in a health establishment must be kept

measures to protect themselves from HIV infection.

confidential, unless ordered by a court of law or done so for the

Right to privacy and confidentiality

advancement of the client’s care and treatment after following Discrimination and stigma: Stigma and discrimination may

the necessary procedure.

obstruct access to treatment and may prevent individuals from

•

seeking treatment, care and support which, in turn, contributes

Clients have the right to refuse HIV testing, without compromising

to the vulnerability of others to infection. The result is that those

their access to standard healthcare. There shall be no mandatory

most needing information, education and counselling will not

HIV testing, and all testing shall remain voluntary with informed

benefit even where such services are available.

consent, even when the services are initiated by the service

Right to refuse HIV testing

provider. Prevents an effective response: Strategies to address the

•

epidemic are hampered in an environment where human

Informed consent refers to a person being given relevant and

rights are not respected. For example, discrimination and

appropriate information about an HIV test, and based on that

stigmatisation drive the affected groups underground. This

information, given an opportunity to either accept or refuse to

means that prevention efforts do not reach these groups, and

do the HIV test. Informed consent should always be in written

thus increases their vulnerability to HIV. Likewise, the failure

form and signed by the client and the healthcare provider only to

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Informed consent

149

avoid unintended disclosure of results. •

Appendix 1:

Requirements of informed consent

The information that clients and patients require in order to give their informed consent may vary based on the service delivery approach and setting, but should generally include information about: •

Benefits and implications of knowing one’s status and reasons for recommending HTS.

•

Client’s right to withdraw consent at any stage of the process.

•

Availability of follow-up treatment, care and support, and prevention services.

•

Importance of disclosure, partner/family testing, and availability of couple’s HTS.

•

HTS process and procedures.

South Africa’s Constitution says that women and men must be treated equally and fairly. It also says that no one has the right to control or dominate another person. Both women and men are sexual beings with equal rights in their relationships. However, many people are not able to enjoy these rights. We know this because South Africa has very high levels of: •

Rape, including date rape, marital rape and incest

•

Domestic violence

•

HIV and AIDS

•

Teenage pregnancy

If we follow the sexual rights and responsibilities in this Charter, our country will be less violent, safer and happier for all. The

HIV-Related Stigma In some communities, people who are HIV-positive or have AIDS are made to feel ashamed. No one in the community will associate with them, and they think the family of someone who has HIV/AIDS has disgraced the community. Thousands of HIV-positive people hide their status. They are frightened of rejection by friends, family, and neighbours, even though HIV/AIDS is not passed from one person to another through casual contact.

right to enjoy sex in sexual relationships, you have the right to: •

Enjoy sex just for the pleasure of it

•

Enjoy sex right up into old age

•

Be treated as an equal sexual partner

•

Be treated with dignity and respect

•

Express your desires, needs and concerns and be listened to

•

Be the one to initiate sex

•

Choose your sexual partner, whether they are the same or the opposite sex

Many people with AIDS and their families do not ask for help from their communities because of the shame and disgrace they are made to feel. This can make it very difficult for someone with AIDS to get the help and treatment they need, even though there are medicines available that allow people with AIDS to live longer, healthier lives.

South Africa’s Sexual Rights Charter

You too have the responsibility to respect the rights of your sexual partner. The right to safer sex Safer sex is a way of having sex that protects you from sexually transmitted infections (STIs), including HIV/AIDS, and from unwanted pregnancy. It is therefore your right to: •

Have a clinic or healthcare centre nearby that can offer you safe and reliable ways to protect yourself from unwanted pregnancy.

•

Be given the correct information about safer sex, so that you can choose how you want to have sex.

•

Have access to affordable healthcare.

•

Be treated by healthcare workers in a respectful, caring and sensitive way.

•

Use male or female condoms to protect yourself from STIs, including HIV.

• You have the responsibility to protect yourself and your partner. The right to say “NO” You have the right to: ♦ Say “no” and “stop” if you do not want to go ahead with sex. ♦ Be listened to and respected.

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Other sexual rights

Appendix 2: organisations involved in advocating for the rights of

We also have the right to:

marginalised groups

•

Laws, policies and practices that do not discriminate against anyone, especially not against women, gays, lesbians, young people, people with disabilities, and people living with HIV/AIDS.

•

More job opportunities so that people are not forced into commercial sex work.

•

Specially

trained,

professional

and

caring services. How will the goals of this Charter be achieved? To achieve this Charter’s goals, you need to: •

Understand and practise your sexual rights

and

responsibilities

your

relationships. •

Acknowledge the rights of others, especially women.

•

See that government, business, civil society organisations, communities, and households promote and uphold the rights in this Charter. The South African Government signed an international agreement from the Fourth World Conference on Women held in Beijing in 1995. The agreement supports all the rights in this Charter. The government is therefore committed to promoting these rights.

How can you make sure that everyone in your home, community and workplace is able to enjoy the rights and accept the responsibilities in this Charter? https://www.google.com/ www.wits.ac.za%2FmediaFsexrightscharter. pdf

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Chapter 9|FACILITATION GUIDE AND PEER EDUCATION GUIDELINES

FACILITATION GUIDE AND PEER EDUCATION GUIDELINES

Theoretical Framework

In the Context of the Higher Education Sector

THEORIES OF RELEVANCE

A programme that does not have a comprehensive approach, including all four IMBR concepts, probably lacks the essential

Behaviour change theories attempt to address the debates

components for reducing risk behaviour and promoting

that surround the nature of behaviour change. At the heart of

healthier lifestyles. A programme might, for example, explain

these debates are questions about how the individual functions

to young people the need for contraception and describe

in society, and how that society inﬂuences the individual’s

contraceptive methods, but it might fail to demonstrate their

behaviour.

proper use. Participants would then be informed about what to do, but not how to do it. Other programmes might inform

Behaviour change theories can be divided into two broad

participants of the “what” and the “how” of certain healthy

categories that address these debates. These categories can

behaviours, but not give them strong emotional or intellectual

be summarised as those that focus on individual psychological

reasons as to why they would want to practice such behaviours.

processes, and those that focus on community or societal

As an example, even if a young person knows that safer sex

changes.

may prevent the spread of HIV, he or she might still need to be motivated to practice safer sex.

Theories of Individual Behaviour Change Individual

behaviour

change

theories

suggest

that

the

components necessary for an individual to change behaviour include an ability to explore personal attitudes, beliefs and intentions; an understanding of personal risk; and the knowledge and opportunity to practice skills that will reduce the possibility of risk and the practice of risk-taking behaviours.

THE IMBR MODEL: INFORMATION, MOTIVATION, BEHAVIOURAL SKILLS AND RESOURCES The Information, Motivation, Behavioural Skills and Resources (IMBR) model addresses health-related behaviour in a way that is comprehensive and clear, and that can be applied to and across different cultures. Peer education in the context of the

Although resources can be considered part of “information”, it is important to provide young people with information about where to access appropriate resources or services beyond the scope of peer education sessions. Such resources might include, for example, youth-friendly clinics, counselling services, HIV/STI and pregnancy testing, care programmes, and commodities (such as condoms and contraceptives).

THEORY OF REASONED ACTION The theory of reasoned action states that the intention or desire to adopt a new behaviour is inﬂuenced both by the individuals’ beliefs (i.e., family norms) and the community standards to which the individual is exposed.

IMBR model focuses on:

Therefore, the intention of a person to adopt a recommended

•

about the consequences of the behaviour. For example, a young

Information (the “what”) relating to knowledge and facts relevant to the focus of the project, for example, HIV or wellness management.

•

Motivation (the “why”) relating to the risks and beneﬁts pertaining to lifestyle choices and behaviour.

•

Behavioural skills (the “how”) that involve transferring skills that empower peers to make healthy, responsible choices that reduce risk.

behaviour is determined by the person’s attitudes and beliefs woman who thinks that using contraception will have positive results for her will have a positive attitude towards contraceptive use. The person’s subjective or personal viewpoint about an issue is also inﬂuenced by signiﬁcant others and by the norms or standards in their community or culture. This is based on what others think one should do, and whether important individuals approve or disapprove of the behaviour.

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Theories of individual behaviour change have come under

In the Context of the Higher Education Sector

criticism when applied in non-western contexts. Social conditions

For students, the relevance lies in the following:

in these contexts often determine that individuals do not have

•

Subjective beliefs and norms are shaped by the education

the personal power or efﬁcacy to carry out decisions that they

input and especially by the methods employed to deliver

might have made on an individual level.

crucial messages. • •

Young people’s attitudes are highly influenced by their

An additional problem is that non-consensual sex is prevalent in

perceptions of what their peers do and think.

South Africa. Where rape is common, an individual has no power

Young people are highly motivated by the expectations of

to protect him or herself from HIV infection. Cultural patterns

respected individuals.

and behaviours may also render these theories inappropriate. In many non-western contexts, notions of health are more closely

Clearly, for behaviour change to occur, information, skills,

tied to the health of the community, rather than that of the

motivation, and resources need to be in place, but factors such

individual. Examples include practices such as virginity testing

as cultural heritage and socio-economic status undermine the

and ritual circumcision in which a strong traditional heritage

outcomes of even the best intervention efforts.

overrides rationality.

HEALTH BELIEF MODEL

SOCIAL BEHAVIOUR CHANGE THEORIES

The health belief model was developed in the early 1950s by

Social behaviour change theories address some of the concerns

social psychologists Godfrey Hochbaum, Stephen Kegels, and

raised by the inadequacies of the individual models, and they

Irwin Rosenstock. It was used to explain and predict health

place more emphasis on “the interactive relationship of behaviour

behaviour, mainly through perceived susceptibility, perceived

in its social, cultural, and economic dimension” (UNAIDS, 1999:

barriers, and perceived beneﬁts. That is, if a person desires a

8). These theories recognise the important role that societal

particular health outcome, he or she will take actions to help

norms play in determining an individual’s behaviour, and they

bring about that outcome. Hence, the health belief model feeds

view the individual in the context of a particular community.

into the peer education strategy by inﬂuencing perceptions through persuasive messaging. This model suggests that if a

These theories argue that to change the behaviour of the

person has a desire to avoid illness or to get well (value), and

individual, the behaviour of the entire community needs to

the belief that a speciﬁc health action would prevent illness

change to ensure group support for individuals who wish

(expectancy), then a positive behavioural action would be taken

to adopt new behaviours.

towards that behaviour. Unfortunately, this model of behaviour change does not sufﬁciently take into account factors like habits, attitudes, and emotions. Although the health belief model is useful, the effects of a number of factors on behaviour (culture, social inﬂuence, socio-economic status, personal experiences, etc.) need to be considered if the model is to be integrated into peer education work.

SOCIAL LEARNING THEORY Social learning theory, as outlined by the American psychologist Albert Bandura, suggests that people learn through direct experiences, i.e., watching the actions of others. Bandura’s theory also suggests that learning occurs through the observation of role models, as well as through training that develops self-

In the Context of the Higher Education Sector

efﬁcacy, for example, through practising responses to simulated

The health belief model’s most relevant concept is that of

situations. The theory takes into account the social nature of

perceived barriers, or a person’s opinion of the tangible and psychological costs of the advised action. In this regard, a

individual behaviour change. Viewing the actions of others can allow insight into the consequences of one’s own actions.

facilitator could reduce perceived barriers through reassurance, correction of misinformation, incentives, and assistance. For example, if a young person does not seek healthcare at the

THE SOCIAL NETWORK THEORY

local clinic because they feel that their conﬁdentiality will not

Wolf, Tawﬁk, and Bond, proponents of the social network theory,

be respected, the facilitator may provide information about a

suggest that the persuasiveness of one’s social network plays a

youth-friendly service, thus helping to overcome this barrier to

vital role in behaviour modiﬁcation or change.

accessing proper healthcare.

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In the Context of the Higher Education Sector

The inclusion of interactive experimental learning activities

The relevance of this theory is obvious. Many

is extremely important, and facilitators can be important role

advocates of peer education claim that the (horizontal) process

models in this regard. The implication for the classroom is that

of peers talking among themselves and determining a course

training be made as interactive and experiential as possible.

of action is key to the successful behavior change.

A further implication is that facilitators are visible,

The theory suggests that this will enable participants to come

and their actions and attitudes are emulated by their peers.

up with the ideas and solutions, which they will then own. This

This theory implies that the choice of facilitator is critical, and

increases the likelihood that cognitive restrucutring will take

it is also important to check whether or not selected facilitators

place and, more significantly, that behaviour change will take

are comfortable being viewed as role models.

place.

DIFFUSION OF INNOVATIONS THEORY

TRANSLATING THEORY INTO PRACTICE

The diffusion of innovation theory (Ryan and Gross, 1943, in

Whether you are providing training of trainers (ToT), training

Rogers, 1983) proposes that gatekeepers and opinion leaders

of peer educators, or peer education sessions with the target

in a particular community may have the power to inﬂuence

population, there are some basic methodological considerations

the behaviour of others. This implies that an innovation (a

for translating the theory into practice.

new behaviour) can be ﬁltered down through leaders. Like the social network theory, this theory emphasises that leaders

Most important are learning based on experience and observation

and respected individuals inﬂuence norms by disseminating

(experiential learning), and the use of interactive methodologies

information through one-to-one contact and in group discussions.

and drama.

THEORY OF PARTICIPATORY EDUCATION

EXPERIENTIAL LEARNING There is an ancient proverb that says:

Adult educator Paulo Freire proposes that the full participation

Tell me… I forget, show me… I remember, involve me… I

and empowerment of the people affected by a problem is

understand.

essential in order to enact change. Hence, peer educators are themselves a part of the target group, and the primary strategy employed is to enable cognitive restructuring to take place so

“Involving” the participants in a training workshop in an active

that people may be empowered to take charge of their lives.

way that incorporates their own experience is essential. Such

Participatory education concepts are based on Paulo Freire’s

developing their skills with immediate feedback. It also gives

critique of education in Brazil in the 1970s. Freire suggested that the “banking” concept of learning, where learners are empty vessels to be ﬁlled with knowledge, was both inappropriate and ineffective, particularly with adult learners. He proposed

experiential learning gives the trainees an opportunity to begin them the opportunity to participate in many of the training exercises and techniques ﬁrst-hand, before they engage other students in such exercises.

that education be viewed as a participative facilitated process,

USE OF ROLE PLAY

whereby learners build on their own prior knowledge and

Facilitation uses a range of interactive techniques, including

experience to develop a conscious and critical view of the world.

brainstorming, small-group discussions, case studies, quizzes, etc. Another commonly used and highly interactive technique is

The process of Freire’s methodology is action-reﬂection praxis,

role play. Effective and believable role play is a technique that

where participants are encouraged to take a step back from

can help achieve several major objectives of a health education

their lives and their practices and examine them objectively to

programme. Role play can do the following:

develop a critical consciousness of what they see. This reﬂection offers the perspective and strength to re-engage in action and

•

continue the cycle.

Provide information. Role play is an attractive way to deliver information through humour and real-life drama. It permits educators to dramatise the myths that people spread and show how to break them down. In role play, people can explore problems that they might feel uncomfortable

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discussing in real life. •

Create motivation. Role play can effectively dramatise life’s external situational pressures (life stressors) and difﬁcult psychosocial situations, which are sometimes the consequences of poor decision-making and risky behaviour. It can bring to life the realities of, for example, getting an unwanted positive pregnancy test result, testing positive for STIs or HIV, etc. They can demonstrate the difﬁculties of having to disclose sensitive and painful information to a loved one. Strong role play engages the hearts and minds of the audience, and can motivate them to change their attitudes on certain issues.

•

Build skills. When done well, role play has the potential to shape behaviour. It can demonstrate various skills, such as negotiation, refusal, decision-making, and practical expertise (for example, how to use a condom correctly).

•

Create links to resources. Role play can provide an opportunity to inform the audience about the services that exist in the community, or to discuss their characteristics, for example, whether they are accessible to young people, whether they respect their right to conﬁdentiality, etc.

The ToT proposed in this manual is based on an experiential learning model that uses highly interactive techniques. The model includes four elements: direct experience (an activity in which learners create an experience), reﬂection on the experience, generalisation (lessons learned), and application of lessons learned. It can be summarised in a diagram as shown below.

DIRECT EXPERIENCE: TRAINER INTRODUCES THE ACTIVITY OR EXERCISE AND EXPLAINS HOW IT IS DONE PARTICIPATION Trainees participate in: • Brainstorming • Role play and story-telling • Small group discussion • Case studies • Games and drawing pictures

APPLICATION Next steps, trainer gives suggestions and trainees discuss: • How the new knowledge and skills can be useful in their lives • How to overcome difﬁculties in using the knowledge and skills • Plan follow-up to use the knowledge and skills

REFLECTIONS Thoughts and feelings, trainer guides discussion: • Answer questions • Share reactions to activity • Identify key results

GENERALISATION Lessons learnt, trainer gives information, draws out similarities and differences, and summarises. Trainees participate in: • Presenting their results • Drawing general conclusions

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ADULT LEARNING PRINCIPLES PRINCIPLES OF ADULT LEARNING Adult learners are unique. They are people with years of experience; they have established values, beliefs, and opinions; and they have a deep need to be self-directing. This component explains adult learning principles and styles. A comprehensive understanding of adult learning principles is critical to developing

content will be useful to them. 4. ADULTS ARE GOAL-ORIENTED Adults primarily participate in learning programmes to achieve a particular goal. Therefore, they appreciate an educational programme that is organised and has clearly deﬁned learning objectives. These need to be communicated early on in the course.

successful education programmes that result in participant engagement and the facilitation of learning. Adults have special needs and requirements as learners. 1. ADULTS ARE AUTONOMOUS AND SELF-DIRECTED Adults need to be free to direct their own learning. If the learning engagement is classroom-based, the facilitator must actively involve adult participants in the learning process. Speciﬁcally, they have to be sure to act as facilitators, guiding participants to their own knowledge rather than supplying them with all of the answers. They should allow participants to assume responsibility for their learning and engage them in discussions, presentations, and group-based tasks. If the learning engagement is an

5. ADULTS ARE PROBLEM-ORIENTED AND WANT TO APPLY WHAT THEY LEARN Adult learners want to be able to apply their learning to their work or personal life immediately. Using examples to help them see the connection between classroom theories and practical application, utilising problem-solving activities as part of the learning experience, and creating action plans together with learners are important concepts that enable real-life application. 6. ADULTS ARE MOTIVATED BY INTRINSIC AND EXTRINSIC FACTORS

e-Learning course, it should be designed to allow participants to

Learning is driven by participant motivation. The more motivated

explore topics in greater detail and choose from multiple learning

someone is to participate in training, the more likely they are

activities.

to learn and retain information. Adults are motivated by both

2. ADULTS BRING KNOWLEDGE AND EXPERIENCE TO EACH LEARNING ACTIVITY

internal and external factors. During the ﬁrst few weeks on the job, adults are highly motivated to learn. Similarly, motivation is high when they are faced with learning a new work process or

Adults have accumulated a wealth of life experience and

approach to a problem. However, as they become more familiar

knowledge. This may include family memories, work-related

with the content, motivation to learn may decrease until a speciﬁc

experiences, and previous education. Linking new material in a

need arises.

course to learners’ existing knowledge and experience creates a powerful and relevant learning experience. Relating theories and concepts to the participants and recognising the value of experience in learning are two important factors to keep in mind.

7. ADULTS ARE PRESSED FOR TIME In today’s fast-paced world, adults have to juggle demanding jobs, family responsibilities, and community commitments. Even if they are highly motivated to learn, the pressures of life often

3. ADULTS NEED LEARNING TO BE RELEVANT AND PRACTICAL

limit the time many adults can invest in learning. Therefore, in many cases, learning must be available when it is convenient for the learner and delivered in manageable sections or chunks.

Every day, the human brain takes in an endless number of

These may come in the form of modularised e-Learning

sensory inputs. As the brain processes these inputs, it identifies

programs, podcasts, webcasts, or may be strategically delivered

information it deems relevant. Relevancy increases the likelihood

through informal training initiatives.

of information being retained. Adults must see a reason for learning something, and the learning must be applicable to their work or other responsibilities for it to be valuable to them.

8. ADULTS HAVE DIFFERENT LEARNING STYLES A learning style refers to how a person learns, categorises,

Therefore, learning engagements must identify objectives for

and processes new content. Each person may have multiple

adult participants before the course begins. By nature, most

preferred learning styles. In training, each of these styles should

adults are practical about their learning.

be considered when delivering content.

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SUMMARY

VISUAL LEARNERS

A principle, philosophers say, is the beginning of action. In order

Visual learners like to learn through written language, such as

to facilitate actions that result in learning among adults, it is

reading and writing tasks. They may remember what has been

critical to have a fundamental knowledge of all of the principles,

written down, even if they do not read it more than once. They

as well as an understanding of how to implement them, in the

like to write down directions and pay better attention to lectures

design of learning and training initiatives. Learners use all three

if they watch them. Learners who are visual-spatial usually do

modalities to receive and learn new information and experiences.

better with charts, demonstrations, videos, and other visual

However, according to the visual, auditory, and kinaesthetic

materials. They easily visualise faces and places by using their

(VAK) or modality theory, one or two of these receiving styles

imagination and seldom get lost in new surroundings. To integrate

are normally dominant. This dominant style deﬁnes the best way

this style into the learning environment, try the following:

for a person to learn new information by ﬁltering out what is to

•

Use graphs, charts, illustrations, slides, or other visual aids.

be learned. This style may not always to be the same for some

•

Include outlines, concept maps, agendas, handouts, etc. for

tasks. The learner may prefer one style of learning for one task,

reading and taking notes.

and a combination of others for a different task.

•

Classically, our learning style is forced upon us through life in the

•

Leave blank space in handouts for note-taking.

following manner:

•

Invite questions to help them stay alert in auditory

Include plenty of content in handouts to reread after the learning session.

•

From pre-school to Grade 3, new information is presented to us kinaesthetically.

environments. •

•

In Grade 4 to 8, information is visually presented.

•

From Grade 9 to tertiary level and on into the business

Post ﬂip charts to show what will come and what has been presented.

•

environment, information is presented to us mostly through auditory means, such as lectures.

Emphasise key points to indicate to learners when to take notes.

•

Eliminate potential distractions.

•

Supplement textual information with illustrations whenever

According to the VAK theorists, we need to present information

possible.

using all three styles. This allows all learners the opportunity to become involved, no matter what their preferred style may be.

KINAESTHETIC LEARNERS Kinaesthetic learners do best while touching and moving. This learning style happens through two sub-channels: kinaesthetic

RECOGNISING AND IMPLEMENTING THE THREE STYLES

(movement) and tactile (touch). These learners tend to lose concentration if there is little or no external stimulation or movement. When listening to lectures, they may want to take

AUDITORY LEARNERS Auditory learners often perform better by talking about, discussing and hearing what was said. To integrate this style into the learning environment, you can do the following: •

Begin new material with a brief explanation of what is Conclude with a summary of what has been covered. This is the old adage of “tell them what they are going to learn, teach them, and tell them what they have learnt.”

•

Use the Socratic method of questioning learners to draw as much information from them as possible and then ﬁll in the gaps with your own expertise.

•

like to scan the material ﬁrst (to get the big picture), and then focus in on the details. They typically use coloured highlighters and take notes by drawing pictures, diagrams, or doodling. To

coming. •

notes for the sake of moving their hands. When reading, they

Include auditory activities, such as brainstorming, buzz groups, or the game Jeopardy. Leave plenty of time to

integrate this style into the learning environment, use activities that get the learners up and moving, such as the following: •

Use role play and drama.

•

Set tasks for the learners.

•

Play music, when appropriate, during activities.

•

Use coloured markers to emphasise key points on ﬂip charts or white boards.

•

Give frequent stretch breaks (brain breaks).

•

Guide learners through a visualisation of complex tasks.

debrief activities. This allows learners to make connections between what they learnt and how it applies to their situation.

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•

Have the learners verbalise the questions.

•

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sensitive to the needs and circumstances of the group. For

THE ENERGY CYCLE UNDERSTANDING YOUR PERSONAL ENERGY CYCLE

example, some games may exclude people with disabilities. •

Ensure the safety of the group, particularly with games that involve running. For example, make sure that there is

An important aspect of productivity concerns what time of day you select to work on which activities. Everyone has a natural

enough space and that the ﬂoor is clear. •

Try not to use only competitive games, but also include ones

time during the day when they are “UP” (prime time), and a natural time when they are “DOWN” (down time). During prime

that encourage team-building. •

Avoid energisers that are too long. Keep them short and

time, your brain is “on”, your batteries are charged, and you are

move on to the next planned activity when everyone has

able to focus. During down time, your brain feels “slow”, and it is

had a chance to move about and wake up.

difﬁcult to get through your work. First, let’s chart your personal energy levels. Get out a piece of paper and draw a big “L” for a graph with a vertical and a horizontal axis. Mark the vertical axis “0” to “100” in increments of 10 to represent your energy level as a percentage. Mark the horizontal axis with your work hours in one-hour increments. When you arrive at training in the morning, draw a dot where energy intersects with time to indicate how you feel in terms of your energy level. As the day progresses, draw a series of dots horizontally to show how your energy ebbs and ﬂows. Then connect the dots and analyse your line chart. Draw a horizontal dotted line across your line drawing at about the 75% energy level mark. The section above this line represents your peak productivity zone. Write the exact time ranges when you are in the peak productivity zone to the side of your graph. These are your “expensive” hours, compared to other times during the day, because your brain is capable of doing higher-

FACILITATION Facilitation is a way of working with people. It enables and empowers people to learn skills, think critically and creatively, and ultimately realise their own potential. In the role of facilitator, one does not perform the task, provide solutions or teach. Facilitators use a particular set of skills in a process which allows the individual or group to reach their decision, set their goal, or

level activities in that range.

learn a skill.

It’s important to know when you are in prime time, because

Facilitation is a developmental educational method which

you can get so much more done.

encourages people to share ideas, resources, opinions, and

During this time, the key is to focus on:

ways of satisfying those needs. Through facilitation, group

Important tasks

Critical decisions

Problem solving

Complex thought

Things to consider when using energising activities: •

Use energisers frequently during a training session, whenever people look sleepy or tired, or to create a natural break between activities.

•

Choose games that are appropriate for the local context. Think carefully, for example, about games that involve touch, particularly of different body parts.

•

Select games in which everybody can participate, and be

to think critically in order to identify needs and ﬁnd effective members come to value and develop their own expertise and skills. Facilitation involves many facets of interaction between individuals, such

as clariﬁcation, conﬂict management, and

planning. It can be learnt and developed through practice and supervision. An openness to constant learning and development is necessary for anyone seeking to improve their facilitation skills. A facilitator helps people decide what they want to accomplish, reminds them of their responsibility in achieving it, and encourages and helps them to complete an agreed task or activity. The facilitator ensures that the needs of individuals within the group are recognised, acknowledged, and responded to; this is seen as an integral part of the task at hand and not superﬂuous to it.

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In some settings, the facilitator plays an objective role by

value in relation to behaviour, for example: “That seems to have

asking questions, encouraging responses, and enabling group

worked well for you is…”

members to discuss, respond and reach a conclusion. In other situations, they may stimulate group members to create solutions

Sharing

to problems they have identiﬁed by offering suggestions or

Encouraging the sharing of past and present feelings and those

creating simulations which the group can practise. In facilitation,

about future events with a question such as: “Does anyone else

there is an equal emphasis on achieving the task and on the

feel this way?”

process involved in that achievement. Directive Facilitators use a wide range of styles with groups, depending

Guiding members as they explore their feelings and begin to

on the task, activity, people involved, time available and needs of

express them, for example: “Let’s take a few moments to gather

the group members. The various styles enable particular matters

our thoughts and think about how this event has affected the

to be addressed most effectively, and facilitators should be able

group.”

to modify their style to meet the group’s needs. For the task at hand, a facilitator’s approach and role may be one or a combination of the following:

FACILITATION TECHNIQUES The facilitator guiding a discussion Facilitators have the unique role of needing to portray leadership, while allowing participants to take charge and stamp

Directive Giving people information or instructing them how to do something, for example: “This is how to develop a work plan.”

their ownership on the process. In other words, the facilitator strives to demonstrate the paradox of leading by following. So, in guiding discussions, one needs to resist the impulse to provide all the answers and inputs. Instead, facilitators are required

Exploratory Asking questions, encouraging people to speak about their experiences and ideas, for example: “What did you ﬁnd useful in the last peer education session you were part of?”

to lead the discussion by non-directive positioning and the asking of strategic questions designed to foster critical thinking. Facilitators thus provide a catalyst for cognitive restructuring.

ASKING PROBING QUESTIONS

Delegating Assigning tasks, roles, or functions to individuals. For example, in planning a facilitation training session with a group, some organisational tasks may need to be shared.

Questioning is a technique that facilitators must use with caution. One needs to be careful not to come across as interrogating. Questions must be subtle and thought-provoking, and hold the inherent potential to stimulate debate, discussion, and personal

Participative Taking part in discussion, sharing personal experiences and

growth.

encouraging others to do the same, for example: “The ﬁrst time I

CREATING A LEARNER-CENTRED ETHOS

ever did a skills-sharing workshop like this was…” During the learning process, a facilitator’s approach or role may involve a combination of facilitation styles

Facilitators need to be committed to making the course learnercentred. This provides an opportunity to model skills that enable participants to own the process and take charge of discussions, while still maintaining control without being controlling or

Interpretive Assisting participants to verbalise a contribution or helping

authoritative. This would demonstrate to peer educators

someone to ﬁnd the words to express what they mean.

appropriate techniques to listen patiently and respond to the concerns of their peers, while resisting the impulse to tell them what to do or not to do.

Cathartic Encouraging and modelling the expressions of feelings and emotions as they emerge by asking a question such as: “And was that a very painful time?”

ENCOURAGING INTERACTION •

Evaluative Assessing what someone says, or providing a statement of 162

Techniques to foster such a context include:

During training, interact at least once with every participant individually.

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•

Motivate, manage, and encourage participants to interact

Trainers are advised to adhere to the prescribed methodology

with you by being approachable and attentive, and reaching

to ensure attainment of training goals, objectives, and envisaged

out particularly to those who appear disengaged, difﬁdent,

outcomes. As a trainer, you are required to facilitate, not teach.

or introverted. This will help them overcome shyness, gain

You are required to:

conﬁdence, feel valued and accepted, and increase the

•

likelihood of them engaging and becoming invested in the

•

Control the process in a non-directive way.

goals and objectives of the course.

•

Make learning happen.

Make an effort to learn participants’ names early on in the

•

Set the stage and provide the props to create the conditions

course, and use their names whenever it is appropriate. Use

for “ah-ha” moments to occur.

their names when you invite participants to speak or answer

•

Make participants feel “in charge” of the process.

questions, and when you refer to their comments or thank

•

Provide the triggers that allow participants to make the

them. This will make them feel valued and respected. •

necessary connections.

Be available, approachable, and accessible to participants

•

Act as a catalyst for participants to grow in conﬁdence.

during training. Remain in the room, and encourage them

•

Allow participants to take ownership of ideas and “solutions”.

to come to you with their concerns or if they need clarity on anything.

LIMITATIONS OF FACILITATION Facilitation has its limitations. Facilitated groups are not therapy

REINFORCING PARTICIPANTS’ EFFORTS •

Take care not to seem authoritative or threatening.

•

Be careful not to use facial expressions or comments that could make participants feel ridiculed, embarrassed, or humiliated.

•

Be patient and accommodating when asking or answering questions.

•

Be attentive and show interest in what participants say.

•

For example, encourage focus by making non-threatening

groups. Personal development groups may be led by facilitators who are also trained in the use of other, more speciﬁc skills such as organisational development or community development. Gaining consensus on the purpose of each group is important, so that appropriate and relevant boundaries can be developed and maintained.

GROUP MANAGEMENT KNOW-IT-ALLS, TALKERS, AND BULLIES: MANAGING HECKLERS

eye contact, use minimal encouragers, ask for clarity or •

•

more information, or afﬁrm their contribution.

It is sometimes said that “there is one in every group”. A difﬁcult

Praise or thank participants who make an effort, including,

person makes the trainer’s job a challenge at best. Learning how

for example, when they try hard, ask for an explanation or

to manage those participants who don’t want to be in training

clarity regarding an unclear or confusing point, participate

is an essential skill for trainers. This section explores handling

in a group discussion, or provide assistance and support to

difﬁcult people and how to turn them into active participants in

fellow participants.

the learning process.

Model appropriate communication skills (open questions, tuning into non-verbal cues, showing empathy, and using

Groups are dynamic. It is fascinating how individuals in a group

good listening skills).

interact and form a pattern of interaction. A group can sometimes take on a singular identity. The study of these interaction patterns is called

YOUR ROLE AS A TRAINER

“group dynamics”

DELIVERING THE TRAINING A useful way to begin preparing is to review the material. Such a review might consist of a walkthrough of each lesson including preparation, gathering and organising the material, tools, and equipment (assessment tools, handouts, slides, ﬂipchart and pens, and projector) needed for the workshop, as well as reviewing all relevant policies, protocols and guidelines. This will provide you with a clear mental image of how each lesson’s methods and materials support the speciﬁed objectives. Having

An examination of both content and process within a group can speak volumes about the work, impact, and effectiveness of a facilitator. An examination of content would, for example, be the teaching of the peer educator content and skills. An examination of process is done by exploring what is happening in the group, both for the facilitator and individual members. In other words, is there conﬂict, dominance, bullying, or a clique formation?

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From the facilitator’s point of view, by exploring the work of

NON-VERBAL INTERACTION EXAMPLES

groups at these levels, they acquire a more complete picture

•

Facial expressions and posture.

of the group and its dynamic. An understanding of this two-

•

Assumptions based on gender.

tier analysis can assist the facilitator when they are planning

•

Assumptions about a person’s social class.

sessions and designing exercises and effective interventions.

•

Perceptions of a person’s racial or ethnic background.

•

How and when a person chooses to sit, move, or hold

TO BE EFFECTIVE, A FACILITATOR MUST:

themselves.

•

Recognise both individual and group needs.

•

Be able to identify and recognise the needs, roles and

How the facilitator interacts with group members strongly

resistance of group members.

inﬂuences the group process. It is not only what the facilitator

Distinguish between what is happening because of the

says, but how they behave that is important. People take in

facilitator and what is happening because of the group’s

messages (verbal and non-verbal) from one another all the time.

make-up.

The non-verbal can either enhance or contradict a point being

Have a clearer view of how certain conﬂicts or difﬁculties

communicated. Saying you are not angry, while clearly giving

may be resolved.

off the body language of a stiff back and hurt expression are

•

Be aware that self-awareness is critical.

contradictory signals.

•

Be clear about where their involvement and commitment to

•

a group begins and ends. In this way, the facilitator takes

Remember:

care of her/himself. • •

You have got to be on the balcony and in the dance

Be mindful that it is important not to fulﬁl unreasonable expectations which the group may have.

One needs to be constantly self-aware and reﬂecting on one’s

Challenge and work with negative projections within the

own feelings, emotions, and attitude. Facilitators are human

group.

beings who have been socialised within a particular context. It can be difﬁcult to eliminate ideas, assumptions, beliefs of, and

COMMUNICATING WITH THE GROUP

perhaps prejudices against, other people. However, observing

When interacting with the group, the facilitator must remember

responses, behaviours and attitudes from group members in

that a two-way process of transmitting and receiving information

relation to oneself is a valuable barometer to gauge one’s own

is in operation. Both sender and receiver interpret messages

attitude, behaviour, and responses.

in different ways, depending on a number of factors such as class, ethnic background, gender, sexual orientation, and age.

It is the facilitator’s job to recognise how these assumptions

A facilitator’s interaction with group members is both verbal

operate, negatively and positively, within the group. It is also the

and non-verbal. The verbal interactions are stated openly using

facilitator’s role to work at challenging and diluting the negative

speech. The non-verbal aspects are not stated in speech, but

impacts of any prejudice within a group. The facilitator’s ability

are transmitted in other ways, such as in body language. Both

and readiness to challenge negative effects of social prejudice is

have a powerful effect on the group, and a facilitator needs to

an important indicator to group members, i.e., that this behaviour

be aware of the impact he or she can have as a result of the

is not to be tolerated. The facilitator can encourage the group

position they hold within a group.

members to create a group contract which excludes prejudices, stereotyping, or discrimination by agreeing that these are all

VERBAL INTERACTION EXAMPLES

to be challenged. This creates a safe space outside of which

•

members agree to leave their negative beliefs and values.

Comments to people: “You are very brave to say that” (I wouldn’t have said that).

• • •

Expressions of values and attitudes: “I really like strong

Overcoming the fear of speaking before a group:

women” (If you are not strong, I don’t like you).

•

Know your material well.

Volume and tone of voice (loud-aggressive, intimidating;

•

Practice your material.

soft-passive, weak, lacking in conﬁdence).

•

Use participatory techniques.

Revealing political agenda by excluding or including certain

•

Learn participants’ names and use them.

beliefs: “The unemployed have only themselves to blame”;

•

Establish your credibility early.

“I believe that while it is hard, we need to work towards

•

Use eye contact to establish rapport.

including and accepting homosexuals” (discriminatory).

•

Exhibit your preparation in advance (via handouts, etc.).

•

Anticipate potential problems and prepare reasonable responses.

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•

Check the facilities and equipment in advance.

•

Feelings of insecurity may arise for facilitators.

•

Obtain information about the group in advance.

•

One co-facilitator may dominate.

•

Convince yourself to relax (breathe deeply, meditate, talk

•

Rivalry between co-facilitators may develop.

to yourself).

•

Vague deﬁnitions and unclear delineation of responsibilities

•

Prepare an outline and follow it.

•

Manage

your

appearance

may cause problems between co-facilitators. (dress

comfortably

and

appropriately).

Remember:

•

Rest so that you are physically and psychologically alert.

•

Use your own style (don’t imitate someone else).

•

Use your own words.

•

Plan your work together.

•

Put yourself in your trainees’ shoes (they’re asking, “What’s

•

Decide how sections of the session will be shared.

in it for me?”).

•

Discuss how the session will be divided between both of

Choose to work with someone whose values are similar to your own.

•

Assume they’re on your side (not antagonistic or hostile).

•

Provide an overview of the workshop.

•

Decide who will take which section.

•

Accept some fears as being good (energising stress vs.

•

Consider how to behave when the other person is facilitating.

destructive).

•

Decide whether to leave the room, participate, or remain

•

Identify your fears, categorise them as controllable or uncontrollable, and confront them.

•

you.

silent. •

Give special emphasis to the ﬁrst ﬁve minutes (super preparation).

•

Imagine yourself as a good speaker (self-fulﬁlling prophecy).

•

Practice responses to tough questions or situations.

•

Create an informal setting.

Plan to let the group know the session or programme will be jointly facilitated.

•

Decide what to do when one person wants to interrupt the other.

•

Allow some ﬂexibility so that non-threatening, nonchallenging contributions may be welcomed by the other partner (for instance, if one facilitator has forgotten

CO-FACILITATION: WORKING WITH A PARTNER

something, or if one facilitator has a different experience

The technique of working with a partner can be rewarding for a group and its facilitators, but it is a practice which requires

that could be usefully shared). •

Support each other during the session – offer appropriate

planning and periodic evaluation with the co-worker if it is to

feedback and provide a second voice to the facilitator if you

yield results. Co-facilitation has advantages and disadvantages.

detect resistance or dissidence from the group.

Not everyone wants to or is ready to co-facilitate. If a facilitator

•

Agree never to side with the group against your co-facilitator.

chooses to co-facilitate, it is crucial to plan how the two will share

•

After the session, evaluate both performances jointly.

the work, how they can best support each other, and that they

•

Give positive and critical feedback on how the two facilitators

learn to communicate effectively. It must never be forgotten that the focus of co-facilitation remains the needs of the group.

might improve their work together. •

Plan the next session on the basis of the previous one.

Co-facilitation may be used as a training mechanism for one individual in the co-facilitating pair. While this works well, care must be taken that the group does not lose out by time or energy being directed towards the co-facilitator. ADVANTAGES OF CO-FACILITATION: •

Eases the pressure of full responsibility.

•

Allows for joint planning, evaluation, and feedback.

•

Brings different experiences and attributes to the group.

•

Means a greater sharing of skills, resources, and energy.

•

Enables less experienced facilitators to develop skills.

DISADVANTAGES OF CO-FACILITATION: •

Joint planning, evaluation, and feedback are timeconsuming.

•

Co-facilitators can be “played off against each other”.

•

One co-facilitator may get on better with the group.

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FACILITATOR COMPETENCY MODEL Desired Competency

Demonstrated Proﬁciency (in another area of life or work, or as a facilitator if currently a trainer)

Application as a Facilitator

Technically Current, Capable and Open to Learning

Engaged in life-long learning. Picks up on the need to change personal and interpersonal behaviour quickly. Seeks feedback. Picks up on verbal and non-verbal cues regarding their impact on others, and adjusts.

Shares personal successes and failures to enhance participant learning. Applies experience as a peer mentor to facilitate excellent learning and experience for participants. Remains current in and shows ability to apply knowledge to the learning experience.

Capable of Creating an Environment for Learning

Creates a positive and safe atmosphere for participants to experiment and enhance personal learning. Expresses thoughts, feelings, and ideas in a clear, concise, and compelling manner. Adjusts style to engage participants. Assesses learning needs and adjusts as necessary.

Demonstrates an approach that values different learning styles (visual, experiential, auditory) as well as backgrounds and experience (industry vs. academia). Brings personal background and experience as a peer mentor, onsite experiences, etc., that contribute to participant understanding. Makes appropriate judgements that demonstrate competence in delivering experiential learning.

Additional for lead facilitators: Manages the front of the room – has an engaging presentation style and platform skills. Promotes a successful experience in training and facilitating experiential adult learning. Promotes a successful experience in leading other trainers.

Additional for lead facilitators: Demonstrates an ability to lead support facilitators. Treats facilitators as valued members of the training team. Intervenes as necessary to ensure facilitators are fully contributing members of the training team, enhancing the learning of participants.

Builds trust. Listens and places input into context. Maintains an open mind and avoids personal bias. Finds common ground and gets cooperation easily. Diffuses tense situations. Displays cultural sensitivity. Communicates well.

Provides constructive feedback to assist in learning. Deals tactfully with participants who don’t complete training requirements. Makes an objective evaluation of a participant’s potential peer educator. Effectively communicates concerns to individuals and/ or appropriate parties.

Interpersonally Skilled

RECOMMENDED AND SUGGESTED GROUND RULES 1. Respect

Give undivided attention to the person who has the floor. Inappropriate laughter or comments are not acceptable.

2. Confidentiality

What we share in this group will remain in this group.

3. Openness

We will be as open and honest as possible, but we won’t disclose or discuss others’ (family, neighbours’, friends’) personal or private issues or lives. It is okay to discuss situations as general examples, but we won’t use names or other identification. For example, we won’t say, “My older sister did…”

4. Non-judgmental Approach

We can disagree with another person’s point of view or behaviour without judging or putting them down.

5. Sensitivity to Diversity

We will remember that members in the group may differ in many ways, including cultural background and/or sexual orientation. We will be careful about making insensitive or careless remarks.

6. Right to Pass

It is always okay to pass, i.e., to say, “I’d rather not do this activity”, or “I don’t want to answer that question”.

7. Anonymity

It is okay to ask a question anonymously (using the suggestion or comment box), and the coordinator will respond to all questions.

8. Unconditional Acceptance

We must accept every member of the group unconditionally and without bias, judgement or unfair expectations.

9. Have a Good Time The FTF programme is also about coming together as a community and enjoying working with each other. 10. Rule of Two Feet 166

If your two feet take you out of the room while the facilitation is in session, you forfeit the right to have information repeated. You must take the responsibility to catch up so you don’t disrupt the group process. HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

PRINCIPLES AND VALUES OF FACILITATION: Bearing in mind that the ToT facilitation stage is an opportunity for facilitators to model all desired facilitation behaviours, it is imperative that they demonstrate, verbally and non-verbally, their commitment to the following principles: •

Listening: Facilitation entails listening to what people are saying and noticing what they are not saying verbally. This includes being aware of verbal and non-verbal means of communication.

•

Confidentiality: In order to participate fully, participants must be confident that everything of relevance can be discussed freely without inappropriate disclosure by the facilitator/s outside the group. Groups normally set the parameters of confidentiality at the outset.

•

Respect: A facilitator must acknowledge and respect every participant. It is crucial to be assertive when required to prevent dominant and/or aggressive participants from undermining the basic respect that should be accorded to each individual in the group.

•

Equality: Every participant has an equal right to contribute, inﬂuence, and determine the direction of the group. Facilitators have the responsibility to encourage participation and gate-keep dominant participants with this in mind.

•

The value of personal experience: Participation and sharing of personal experience should be afﬁrmed. Every participant’s contribution to a discussion or skill-sharing activity from this perspective is equally valid and valuable.

•

Agreed goals: Participants must be encouraged to agree on a common vision and goal for the programme to mark their ownership of the process. Facilitators need to manage group consensus to this end.

•

Group process: Facilitation requires giving attention to how the group operates. This includes attempting to resolve conﬂict or challenges that might arise in the group relating to individual members that may impact the group dynamic.

•

Trust and safety: Participants should not fear ostracism, discrimination, or judgement related to their personal views or lifestyle. Facilitators must model qualities such as warmth, empathy and genuineness, a non-judgemental attitude, and the skill of neutrality. They are therefore compelled to

•

Participation: Consultation with group members on direction, pace, content and method, with an openness to change, is vital. Facilitation succeeds when there is a consistent consultative ethos, combined with a genuine belief in the value of encouraging trainees to own the process through participation, interaction, and feedback.

IMPORTANT TEACHING AND LEARNING PRINCIPLES IMMEDIACY Enable participants to identify how they can use their knowledge, skills, and attitudes in the real and immediate context. EXPERIENCE Kinaesthetic learning (learning by doing) is known as the most effective way to learn a skill. Hence, facilitators need to create opportunities to engage participants in an appropriate activity, and then enable them to make the necessary connections for the purpose of application.

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APPROACHES AND METHODOLOGIES FOR TRAINING ADULTS

Buzz Session

Buzz sessions are highly interactive sessions that involve small-group discussions. These sessions are designed to stimulate thinking, and draw on the collective experirnce of the audience.

• Introductory presentation introduce an issue or task to the audience • Audience divides into small groups to discuss • Groups report back on key ideas or findings from their discussion

Simulation

A mode of instruction that relies on imitating or estimating how an event, process, skill or behaviour might occur in a real situation. This format is best used when content can be conveyed through a single example, which can be replicated on-site.

• Introductory presentation introduce an issue or task to the audience • Audience divides into small groups to discuss • Groups report back on key ideas or findings from their discussion

An intense analysis of a situation providing participants with realistic, complex, and contextually rich situations. This format is best used when content can be through a dilemma, conflict, or problem that must be negotiated.

• Real-lie scenario is presented • Audience is asked to consider a scenario either individually or in small groups • Debrief is conducted and key learnings discussed

Controversy Panel

Two or more views on a controversial issues are presented and debated. A moderator may challenge panelists and sharpen the focus of discussion. This format is best used when a few varied perspectives can be included in a session.

• Panelists are chosen preconference and given the topic for discussion • On site, panelists are asked questions by a moderator and the audience • Audience feedback is encouraged

Flipped Classroom

Participants are provided with access to new content before the conference in order to participate in more active learning and discussion of the content during their session. This format allows participants to receive more coaching from faculty.

• Pre-work is sent to participants prior to the start of the session • Pre-work is discussed during the session. Learning is evaluated through group discussion and exercises • Presenters encourage feedback and coaching

Case Study

Lecture

168

Highly didactic session with minimal attendee participation. This format is best used when a large amount of content can be conveyed with minimal interaction.

• Use a break technique to engage and involve listeners (i.e. self-test, talk to your neighbour) • Ensure that 10 to 15 minutes are allocated for Q&A at the end of the session

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

APPROACHES AND METHODOLOGIES FOR TRAINING ADULTS

Rapid Fire

Storyboard Walkaround

Rapid fire sessions consist of multiple, fast-paced presentations on the same topic. These sessions are designed to keep the information ﬂowing and the audience fully engaged.

• Consists of one moderator and four presenters • Each presentation is exactly 10 minutes with no more than 10 slides • Each presentation is followed by ﬁve minutes of Q&A facilitated by the moderator

An interactive session that allows attendees to learn on their feet. Presenters will guide a group of participants through a set of improvement projects on a common topic, and provide an opportunity for discussion.

• Consists of one moderator and four presenters • Improvement projects are presented through storyboards (no AV) • Moderator facilitates Q&A to generate discussion and feedback on projects

RECRUITMENT OF PEER EDUCATORS The peer educator recruitment process should follow the steps described below.

STEP 1: IDENTIFY SOURCES AND CHANNELS FOR RECRUITING PEER EDUCATORS Where will you get them from? How will you ﬁnd them? It is important to develop a plan to identify recruitment sources (staff recommendations, student leaders, peer nominations) and •

Observe the target group to ﬁnd the natural leaders.

•

Conduct awareness and education programmes and identify those who demonstrate interest.

•

Call for volunteers to assist at FTF activations and observe candidates who show passion and promise.

•

Talk to the members of the target group about who they feel most comfortable talking to about HIV and STIs.

STEP 2: ADVERTISE THE SCOPE OF ACTIVITIES PEER EDUCATORS WOULD BE REQUIRED TO DO •

Conduct informal, small-group discussions about health and wellness, including sexual and reproductive health.

•

Organise and conduct formal group discussions with peers about lifestyle and behaviour change.

•

Hold regular meetings.

•

Distribute educational materials.

•

Display posters and other educational materials.

•

Present video/DVD screenings.

•

Design and develop educational materials.

•

Perform in dramas.

•

Participate in special events, for example, World AIDS Day, sporting carnivals.

•

Be engaged in activities to motivate and support behaviour change and build skills.

•

Talk to peers one-to-one.

•

Teach peers how to do a personal risk assessment.

•

Teach peers how to negotiate safe sex (including condom use).

•

Recommend or refer peers for HIV and STI testing.

•

Provide referrals to specialist services for clients requiring more substantial information or support.

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project team should not expect members of the target group to

RECRUITMENT STRATEGIES

share all the same characteristics, attitudes, beliefs, values, and

•

Built-in incentives.

practices. In composing the selection criteria, you could choose

•

Make the advertisements easy to understand.

from the elements listed below.

•

Allow sufﬁcient time for interested people to consider the

•

advertisement and apply.

Successful candidates must:

Provide contact details, such as a phone number, so that

•

Be members of the intended target group.

interested people can obtain further information if they need

•

Be understanding of and relate to the target group.

it.

•

Be acceptable to and respected by the “host community”, in

STEP1: INVITE INTERESTED INDIVIDUALS TO APPLY

this instance, the institution. •

Design a simple form for completion by interested applicants.

Be motivated to work on reducing the impact of HIV and STIs.

The effort to obtain, complete, and submit the form already

•

Be non-judgemental and compassionate.

indicates enthusiasm and commitment. The form should ask

•

Be able to communicate effectively, and educate and

why applicants are interested, what characteristics and qualities

persuade others.

they possess that might make them effective peer educators,

•

Be honest and able to maintain conﬁdentiality.

year of study, availability for training, availability to execute peer

•

Be a strong role model for the behaviour they seek to

educator duties (how many hours per week), desire to commit,

promote in others, and have self-conﬁdence and leadership

period available to be appointed, etc.

qualities. •

STEP 2: COMPILE A SHORTLIST

Have strong interpersonal communication skills, be able to engage with their peers and establish rapport, and be able

Based on responses, compile a shortlist of suitable candidates. Selecting and keeping peer educators are two factors that are

to listen and reﬂect. •

crucial to the success of a peer education project. One study of

Be comfortable talking about sexual, personal and taboo topics, or be able to develop that quality during training.

peer education projects found that a key challenge was selecting

•

Be able to work in a team.

peer educators who are acceptable to both project staff and to

•

Possess, or be able to develop, public speaking skills.

community members (Horizons 2000, p. 16). In this context, the

•

Be able to control and facilitate a group

implication would be ﬁnding students who are popular among

•

Be reliable and able to commit to the work programme,

the staff and student community. The study also highlighted

which may include after-hours work.

the following key characteristics to look for when selecting peer educators: •

Conﬁdence

•

Technical competency

•

Communication skills

•

Compassion

STEP 2: IDENTIFY THE NUMBER OF EDUCATORS THAT THE PROJECT NEEDS

PEER

Select the required number from the candidates shortlisted during recruitment.

STEP 3: COMPOSE AN INTERVIEW PANEL Set up a panel consisting of programme managers and members of the target group. The selection of peer educators needs to

SELECTION OF PEER EDUCATORS STEP 1: DECIDE ON CRITERIA FOR PEER EDUCATOR SELECTION Programme managers must ﬁrst construct a consensus-driven criteria list for selecting peer educators. In a post-school context, criteria must include availability, gender, desire and motivation, popularity, reputation among staff and students, acceptability by target audience, previous experience, personal traits (behaviour, team player, volunteer spirit, potential for leadership, etc.), and other characteristics deemed relevant for a particular programme. In selection, one must consider the diversity of the target group and ﬁnd peer educators who are representative of the range. A

170

be an inclusive process. When arranging the selection process, it is important to remember the principles of involving both stakeholders and members of the target group in key stages of the project’s activities – which include the stage of selecting peer educators. Ensure gender balance on the panel. The next few steps discussed in this section are necessary to arrange the selection process.

STEP 4: MEET BEFOREHAND TO PREPARE FOR THE INTERVIEWS Arrange selection criteria, compose questions, and prepare sheets for recording comments and scores on each criterion for each interviewee.

HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

STEP 5: ORGANISE LOGISTICS •

Arrange a room for interviews.

2. STRUCTURE AGENDA AND TIME TO MEET TRAINING NEEDS

•

Contact short-listed applicants and schedule interview

The training must be carried out so that modules are given

times, allowing enough time for each interview.

appropriate time, according to relevance and trainees’ levels of

Inform candidates if they need to prepare a short talk or

knowledge and skills. Avoid overloading trainees. Include time

presentation.

for evaluation, summary, and planning future tasks.

•

STEP 6: CONDUCT INTERVIEWS

Tips:

Ensure that the process is informal and not intimidating.

•

Plan for adequate time, especially for participatory activities. If the schedule cannot be followed as planned, make

STEP 7: SELECT CANDIDATES

adjustments as soon as possible, prioritising activities to

The basis of the selection criteria for peer educators is an analysis

ensure there is time for the most important of them.

of the target group, and the skills and personal features needed

•

to create a relationship to work with them. Seek a balanced team

Maintain balance between unanticipated discussions and the need to keep on schedule to accomplish the critical

of peer educators representing the important criteria across the

objectives of the training.

group. Individual educators do not have to meet all criteria.

•

Select some charismatic facilitators, some organised and low-

•

Vary the type and pace of activities, paying attention to the tempo of the day.

key observers, and some sensitive communicators.

Peer educators need a minimum level of knowledge and skills, so that they can transmit accurate information on the topics for which they are being trained.

STEP 8: INFORM SELECTED CANDIDATES Contact and inform selected candidates.

3. PROVIDE RELEVANT MATERIALS AND HANDOUTS Participants must be provided with materials in advance and

STEP 9: CONVENE A MEETING OF SELECTED CANDIDATES

during the sessions, as appropriate, including practical handouts

Convene a meeting of selected candidates at the earliest

materials should be provided at the conclusion of the training.

and materials for exercises. Copies of reference and review

available opportunity. Tips:

STEP 10: SCHEDULE TRAINING OF SELECTED CANDIDATES

•

Set a date for training as soon as possible.

•

Be a model of good planning and provide useful, professional materials in a timely and orderly way. Use notebook binders, colour-coding, and other means to keep materials organised and easy to access.

TRAINING 1. ARRANGE FOR APPROPRIATELY SIZED GROUPS Keeping the size of the trainee group between 15 and 20, as appropriate for the trainer, allows for effective participation, offers opportunities for leadership and skills practice, and allows for full interaction among peers and trainers. Tips: •

Even when the training group is a manageable size, it can often be helpful to divide into smaller sub-groups during

4. USE INTERACTIVE, PARTICIPATORY, AND SKILLS DEVELOPMENT APPROACHES The training should model approaches that maximise trainee participation, such as interactive exercises, opportunities to practise new (or important existing) skills, and role play situations peer educators may encounter. Tips: •

skills during the training.

exercises to allow trainees to practise new skills. •

Training in “waves” (new groups start the training programme every few months) can solve the problem of group size, and also capture new recruits in a timely way.

Ensure that peer educators are given ample time to practise

5. IMPLEMENT TOOLS AND METHODS TO EVALUATE TRAINING AND TRAINING PARTICIPANTS Mechanisms for assessing trainees’ knowledge and skills development must be in place at the onset of training (as a baseline), and they should be used at the conclusion of the training (post-training evaluation). Tools should be available for trainees to evaluate the training.

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Tips: •

Seek expert assistance in developing tools to assess trainees’ progress and the training itself, including facilitator performance. Use these results to redesign training as necessary.

•

Place a reasonable focus on M&E of the training itself, and look towards future M&E efforts to address ongoing assessment of peer educators’ skill acquisition and performance.

•

In addition to using pre- and post-tests to determine whether peer educators have acquired the necessary knowledge and skills, it is useful to have trainees complete an evaluation at the end of the training. In this way, they can help identify strengths and weaknesses of the training, as well as topics about which they would like refresher courses and updates.

6. DISCUSS ETHICAL ISSUES Ethical issues that are likely to arise in connection with peer educators’ activities – such as conﬁdentiality, power balance, and gender equity – must be discussed as part of the training. Tips: •

Ensure that topics are considered in light of the most pressing, relevant concerns.

•

Talk about ethical issues among the programme planners before training commences.

•

Consider working with a team of staff and peer educators to develop a code of ethics for the programme.

PLANNING CYCLE

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expectations of stakeholders as well as the target population

SUPERVISION 1. SUPERVISORS MUST HAVE BEEN TRAINED IN SUPERVISION SKILLS, PROGRAMME EXPECTATIONS, AND PEER EDUCATION CONTENT AND APPROACHES Tips: • •

(peers). •

Support mechanisms are needed to address motivation, stress, and burnout among peer educators.

4. MANAGE THE GROUP DYNAMIC AND ENCOURAGE TEAM-BUILDING

Supervisors of peer educators must be aware of the

Supervisors must manage the group dynamic, encourage

importance of team-building.

team-building, promote a safe environment, and stay aware of

Supervisors need to be sensitive to group dynamics, aware

personal relationships.

of their own values and attitudes, and perceptive about psychological issues faced by peer educators. •

Supervisors must periodically review programme plans

Tips: •

and objectives to make sure their oversight complies with

Supervisors must monitor individual behaviour, personal interactions, and the group dynamic overall, intervening

programme goals.

early if problems surface.

2. ENSURE THAT PEER EDUCATORS ARE WELL PREPARED

•

Training and group supervision meetings should retain a climate of safety, fun, and teamwork. Icebreakers and other activities, some of them physical, are important teambuilding tools and should not be discarded for lack of time.

Supervisors must ensure that peer educators have received

•

It is necessary, not unprofessional, for peer educators and

adequate preparation, through training and skills acquisition and

supervisors to use group sessions to address upsetting

practice, before they begin their work. Updates in knowledge

issues, with appropriate concern for emotional safety.

and skills must be provided as needed.

•

amount and nature of gossip. They might specify conditions

Tips: •

•

under which supervisors must be told immediately about the

After the initial training, supervisors should track performance

conduct of a peer educator, and other conditions in which the

and requests for assistance, and schedule timely refresher

proper procedure is to talk directly with the offending person,

courses or other ways to meet identiﬁed needs.

rather than involve supervisors, unless the behaviour is not

Some supervisory activities should take place in the ﬁeld, once the peer educators have begun their work.

•

Programme managers are wise to develop rules that limit the

remedied. •

Supervisors must share supervisory responsibilities with

Weekly meetings should be held, in which peer educators

peer educators, and involve them as active participants in

lead activities in front of the programme staff on various

the supervision process, with feedback regularly invited.

reproductive health issues that they choose, organise, and develop. This will provide opportunities for improving their facilitation and communication skills, updating their

Tips: •

knowledge on reproductive health issues, and formulating their attitudes and ethics as peer educators.

what the supervisee wants and needs to learn. •

3. CONTINUALLY REINFORCE MOTIVATION AND ETHICAL BEHAVIOUR limitations

(personal

professional),

Supervisors and peer educators should look at programme outcomes when considering how supervision or supervisory activities can be changed to improve programme results.

•

Supervisors must continually reinforce peer educator motivation, monitor

Supervisors and supervisees should explicitly agree on

Ideally, peer educators should be active participants in their own supervision.

reinforce

compliance with the code of ethics, and monitor sensitivity to gender and cultural concerns. Supervisors must promote opportunities for personal development. Tips: •

Motivating peer educators and reinforcing compliance with ethical standards requires a balance between realistically accepting young people’s behaviour and managing external

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LEARN SKILLS TO GIVE CONSTRUCTIVE CRITICISM

ASK – TELL – ASK

WHY IS GIVING FEEDBACK AN INTEGRAL PART OF SUPERVISION SKILLS? he role of the peer mentor as a supervisor is to guide peer educators to perform their tasks and roles effectively

WHAT HAPPENS WITHOUT PROPER FEEDBACK? •

Mistakes

•

Failure to meet goals and targets

•

Disrepute about the programme and programme personnel

•

Internal and/or external ﬁghting

•

End users suffer impact

•

Funding may be withdrawn

WHAT ARE THE KEYS TO EFFECTIVE FEEDBACK? •

Don’t make assumptions

•

Ask question to clarify issues

•

Keep your focus in the conversation

•

Focus on behaviour, not the person

Feedback is an important cog in communication skills, in both personal and professional contexts. Effective feedback helps us in negotiation, meetings, interviewing, building consensus, etc.

TRAINERS’ COUCH

Below are the two recommended feedback techniques

ANSWERS TO THE TOUGHEST QUESTIONS

SANDWICH FEEDBACK to help managers who are ill at ease with providing corrective

WHAT DO YOU DO WHEN YOU DON’T KNOW THE ANSWER?

feedback. The sandwich feedback method consists of praise,

People may come up with some excellent questions and

followed by corrective feedback, followed by more praise. In

comments or ask for an opinion for which you may have no

other words, the sandwich feedback method involves corrective

easy answer. Sometimes you just don’t know. Sometimes, it is

feedback “sandwiched” between two “layers” of praise.

possible to ﬁnd the answer if you have the time to do research.

The sandwich feedback technique is a three-step procedure

At other times, the answer is complex and might depend on the situation. •

Don’t try to provide an answer if you don’t know it. It’s ﬁne not to know. It’s NOT ﬁne to try to fake your way through it, because they WILL know, and you will damage your credibility.

•

Rather say: “I’m not sure”, or “I haven’t really thought about that, but it’s a good question”, and then throw it back to the group: “What do others think?”

HOW DO YOU KEEP TRAINING FRESH AND INTERESTING TO THE TRAINEE? Remember that if you, the trainer, are bored with your training, YOU will bore your trainees. In most instances, one cannot 174

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alter the core content, but what you can do is experiment with

some groups, here are some tips:

different approaches, methods, techniques and strategies, use energisers and games, update the information, etc.

•

For questions and comments that are relevant, but probably not of interest to other group members, suggest the person

WHAT IF YOUR PARTICIPANTS JUST AREN’T RESPONDING?

talk to you at break or right after the workshop. •

For questions and comments that are not constructive, lead

Try different innovative techniques to get people to participate,

the discussion astray or, as sometimes happens, show a

such as ﬁsh bowl, post-its, small groups, individual written work,

hidden agenda, it is useful to recognise that the person

etc.

is passionate about the comment, but that you can’t do anything about the situation they might be describing. For

DEALING WITH A RESISTANT PARTICIPANT

example, they may bring up institutional management that

This is a common issue in training. Here are some possible

is unsupportive, or a gripe about somebody. In this situation,

responses, using examples that might occur in a session, and

indicate that the group needs to focus on things that they

techniques for dealing with difﬁcult participants:

have some control over, which is their own behaviour and

•

“You probably know your context better than I do, so you can

actions, so the group should get back to that. In this way,

pick and choose what seems to work for you. The only thing

you can return to the agenda.

I’d suggest is that you give it a try. Or, if it’s uncomfortable for you for whatever reason, don’t use it. You don’t need to use all the techniques to succeed.” •

•

“That’s ﬁne. Is there any way to change the technique

REFERENCES

in such a way so that you’d be more conﬁdent about it

United Nations Population Fund (UNFPA) and Family Health

working?” This is a technique that involves throwing back

International (FHI). Training of Trainers Peer Education and

the comment, and getting the commenter to think a little

HIV/AIDS: Concepts, uses and challenges. Report of a

more deeply.

consultation cosponsored by UNAIDS Geneva, Switzerland,

A similar response is: “Do you have some ideas about what

1999.

will work for your particular situation?” •

Or, invite the rest of the group to comment. “Let’s see

Peer

whether others in the group feel the same or differently

challenges. Report of a consultation cosponsored by UNAIDS

about this. Do you think this might work?” (to the group).

Geneva, Switzerland, 1999.

Sometimes you’ll get one person who is particularly sceptical

Education

and

HIV/AIDS:

Concepts,

uses

and

Shoemaker et al., 1998; Flanagan et al., 1996.

regarding the content. Typical comments include: “Well, that won’t work for me”, or “If someone said that to me, I’d hate it.”

Adamchak S. Youth peer education in reproductive health and HIV/AIDS. Youth issues paper 7.

The general rule to follow here is to take the path of least resistance:

United Nations Population Fund and Youth Peer Education

•

Give participants the “freedom” to disagree.

Network (Y-PEER). 220 East 42nd Street, 18th Floor, New

•

Never pressure or try to convince participants to use a

York, NY 10017, USA

particular technique, but suggest that it’s up to them and that they might be surprised if they try it out. •

Open up the discussion to the group by asking: “It’s OK if you’re uncomfortable using this, but I’m wondering what others think. Can you see this working?”

HOW CAN A TRAINER REFOCUS A TRAINING SESSION ONCE IT’S GONE OFF TRACK? REFOCUSING BACK TO THE AGENDA Sometimes it’s necessary to cut short discussions due to time constraints, or because the comment or question is somewhat off-topic. If you feel the need to do that, and it’s likely you will for HIGHER HEALTH: Second Curriculum Peer to Peer Training Resource Manual

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APPENDIX

HIV/TB/STI AND SEXUAL REPRODUCTIVE HEALTH RISK-SCREENING TOOL Name & Surname (optional) Cell Number (optional) Gender Date of Birth Institution Campus Date I declare and understand that completing this questionnaire is voluntary and that my answers to the below questions will be kept confidential. I also give consent for the person receiving my completed risk-assessment tool to follow up with me if I may require further services, should I want them to. I also understand that this is a self risk assessment and is not a diagnostic tool and is not for research purposes but rather for creating insights into one’s own vulnerability. The aim of HIGHER HEALTH is to determine the risk at early stages and to link to relevant services for further treatment, care and support. Early prevention saves lives. Signature…………………………………………………………. Are you in the red? HIV 1.

Are you having unprotected sex?

Did you have unprotected sex in the last 24 hours?

Do you have only one sexual partner?

Do you have difficulty convincing your partner to use a condom?

Do you believe you NOT use a condom because you are on contraception?

Do you know your HIV status?

Do you know your partner’s HIV status?

Do you think it is possible that you may have been exposed to HIV?

TB 9.

Yes

Do you have a persistent cough with thick phlegm (mucus) for two weeks or more?

10. Are you HIV positive and have been coughing? 11. Have you experienced high temperatures/fever for more than two weeks? 12. Have you experienced night sweats that leave you dripping wet? 13. Have you noticed that you’ve been losing weight without trying to (more than 1.5 kg in a month? 14. Do you feel tired all the time? 15. Do you know/live with someone who is experiencing these symptoms? STI 16. Do you have an unusual bad smell or coloured liquid coming from your vagina or penis? 17. Do you have any rash, bumps, sores or blisters with or without pain? 18. Do you have genital warts? 19. Do you have an itchy penis, vagina or anus? 20. Do you experience a burning sensation when urinating? 21. Do you have lower stomach pain? 176

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CONTRACEPTION

Yes

22. Do you have access to contraception? 23. Are you having unprotected sex but do not think you are at risk of pregnancy? 24. Do you think you don’t have sex often enough to get pregnant? 25. Do you want to have a baby so that your boyfriend will marry you? 26. Are you embarrassed to ask for information about contraception? 27. Are you embarrassed to ask for information about contraception? 28. Do you feel pressure from your partner or family to get pregnant? 29. Are you scared your partner will reject you if you talk about family planning 30. Are you scared of side effects of contraception (e.g. weight gain)? 31. Do you fear that sex will feel different or less pleasurable if you are on contraception? If your answer to any of these questions is in a red square you are in the Red Zone. You may be at risk or vulnerable to mental illness and/or domestic and gender-based violence and should seek help and support from someone. The following person can be contacted for help and support: (contact person name) at (contact person number) at the (campus name) campus. Remember, you are not alone!

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APPENDIX

MENTAL HEALTH AND GENDER-BASED VIOLENCE RISK-SCREENING TOOL Name & Surname (optional) Cell Number (optional) Gender Date of Birth Institution Campus Date I declare and understand that completing this questionnaire is voluntary and that my answers to the below questions will be kept confidential. I also give consent for the person receiving my completed risk-assessment tool to follow up with me if I may require further services, should I want them to. I also understand that this is a self risk assessment and is not a diagnostic tool and is not for research purposes but rather for creating insights into one’s own vulnerability. The aim of HIGHER HEALTH is to determine the risk at early stages and to link to relevant services for further treatment, care and support. Early prevention saves lives. Signature…………………………………………………………. Are you in the red? Mental Health 1.

Have you lost interest and motivation in activities you used to enjoy?

Are you struggling to cope with daily activities because you are feeling tired and without energy or unnaturally excited with too much energy?

Do you avoid people, have difficulty making conversation and dread social events (family functions/gatherings with friends)??

Do you think about and plan different ways to kill yourself?

Have your sleeping patterns changed where you’re either sleeping too much or not being able to sleep at all?

Are you hearing, feeling, or seeing things that other people cannot?

Do you experience changing eating habits from having a loss of appetite to binge eating (eating huge amounts of food in one sitting)?

Do you constantly feel and think that other people are trying to control you, are talking about you or trying to kill you?

Gender-Based (GBV) and Domestic Violence 9.

Yes

In the past 12 months, have you been threatened with physical or sexual violence by someone in your home or outside of your home?

10. Have you ever been hit, punched, kicked, slapped, choked, hurt with a weapon, or otherwise physically hurt by someone in your house or outside of your house? 11. Are you in a relationship with a jealous, controlling and/or possessive partner or family member? 12. Do you feel anxious and afraid when your partner/a family member is in your presence? 13. Have you been forced to have sex against your will? 14. Were you ever forced to have sex in exchange for a “reward” [such as food, a job, a place at the college, good test and exam marks, money to support your family]? 15. Were you ever physically forced or made to feel that you had to become pregnant against your will? 16. Has anyone ever forced you to lose a pregnancy? (i.e. forced you to take medication, go to a clinic, or physically hurt you to end your pregnancy) 17. Does your partner/family member isolate you by keeping you away from family and friends/your support network 178

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18. Is there someone in your home that makes you afraid/uncomfortable to talk to people when they are present? 19. Do you feel put down/criticised and/or humiliated in public by someone you live with? 20. Are you afraid of your partner’s/family member’s anger? 21. Are you anxious or depressed, have lost confidence, or become unusually quiet due to being in a relationship you’re afraid to leave? 22. Are you reluctant to leave the children alone with your partner or a family member? If your answer to any of these questions is in a red square you are in the Red Zone. You may be at risk or vulnerable to mental illness and/or domestic and gender-based violence and should seek help and support from someone. The following person can be contacted for help and support: (contact person name) at (contact person number) at the (campus name) campus. Remember, you are not alone!

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Dialogue Attendance Register Province:

Topics HIV: SRH: GBV: Mental Health: Other (specify):

Name of Institution: Name of Campus: Name of Facilitator: Facilitator Signature:

YES / NO YES / NO YES / NO YES / NO _______________________________________

Dialogue Date:

Name of Student

ID Number

Cell Number

Age

Gender

Male Condoms Received?

Female Condoms Received?

HIV/SRH Pamphlet Received?

GBV/MH Pamphlet Received?

HIV/SRH RiskAssessment Done?

GBV/MH RiskAssessment Done?

Signature