SECTION II Literature Review
Chapter 7 Methodology
7.4. An overview of the programme: matching research typology with intervention
A brief r£sum6 of the entire process will be presented in this section (See Table 7.2), to enable the reader to gain insight into the multi-faceted nature of this intervention programme that called for careful matching of research typologies with the various steps in implementation and evaluation.
Table 7.2: A Brief resume of the procedural stages
Stage 1
2
3
4
5
6
7
8
9
10
Procedure Community selection Community
entry &
mobilisation Sensitisation programme
(SP) Community-
based initiatives Baseline data
collected Experimental
and Control Interventions.
Analysis of Data Intervention with control
groups On-going support of PSS activities
Dissemination of results
Main outcome measures
Identification of nine partnering communities: three rural, township and peri-urban areas. Informal settlements were excluded from this study.
Formation of collaborative partnerships between researcher, key stakeholders and community members to mobilise on the psychosocial needs of vulnerable children (Protocol in Appendix B).
20 - 30 adult community members participate in SP (identification of participants and logistics undertaken by community). Formative and summative evaluation.
Community identify vulnerable children and begin offering PSS.
Building and reinforcement of social networks within the community.
Support and encouragement offered by researcher.
Community members trained in basic research methods and then collect the pre- intervention data. Children randomly assigned to experimental or control conditions in 7 of the partnering communities.
Groups of 12 -18 children in two age groups (8-10 years and 10-12 years) participate in various experimental and control conditions.
Thematic analysis of evaluation data on the SP using post-workshop evaluation forms, focus groups and community initiatives.
4 way-factorial statistical analysis to evaluate die effectiveness of the SGTP.
Conduct SGTP with control groups. Opportunity for increasing the capacity of apprentice-facilitators to conduct die SGTP. Continue to involve all me vulnerable children in a variety of community-based initiatives.
On-going support and encouragement offered to the partnering communities to continue to offer vulnerable children a variety of PSS community-based initiatives.
Dissemination of die programme as a model for community-based intervention with vulnerable children in high HIV/AIDS communities.
Applying the principles of PAR, the programme began with community selection, entry and mobilisation. The process of selecting the partnering communities was a complex process that needed
to ensure that partner communities fulfilled certain criteria (See Section 7.5). Having identified potential partnering communities, the process of community entry and mobilisation proceeded. The intention was to facilitate a process through which the community would recognise, own and commit to addressing the psychosocial difficulties experienced by their vulnerable children. Attempts were made to ensure participation of all major stakeholders such as local traditional and political leadership, people who work with children in the partnering communities (educators, social workers, community mental health workers, home-based care volunteers), FBO, NGO and CBO representatives, youth, PLWA and affected families and children. A series of community mobilisation meetings (CMM's) were conducted in each community, with many community members participating in more than one CMM's (See Appendix B for the schedule of CMM's).
Having a pre-defined problem focus at the time of community entry may seem to be at odds with PAR. The principles of action research required that collaborative relationships be formed to explore if a problem existed and how the problem was to be framed and addressed (B liana. 2002; Collins,
1999). In practice, most communities (See Section 7.5.1. for discussion of the exceptions) readily recognised the pervasiveness and severity of risk and adversity that some children in their communities were experiencing. Employing the principles of action research led to each community having its own specific focus and the process of entry and mobilisation was unique to each community. The documentation of community entry and mobilisation is considered to be outside the focus of this dissertation, however, the researcher developed a community entry and mobilisation protocol that proved to useful in expediting this critical process (See Appendix B).
During the CMM's and subsequent dialogue, there was much debate on the concepts of vulnerability and psychosocial needs. Neither of these terms translate neatly into isiZulu (the home language of the participants) but the depth of understanding gained by both parties in terms of these key concepts was invaluable. In poverty-stricken communities in which basic survival needs are not guaranteed and in which there is no food security, some individuals regarded concern about psychosocial development as a luxury that they could not afford. The validity of this perspective is obvious and became a focus for independent initiatives undertaken by community members. These included establishing community food gardens, income generating projects, collective action to obtain documents for registering births and obtaining social grants, and so forth. Clearly these were valuable contributions towards meeting the needs of children.
Although the researcher hoped that one of the outcomes of the community entry and mobilisation
would be a request for adult community members to participate in training/sensitisation workshops on PSS, she waited until the request was made by community members. The rationale in this respect was for the community to recognise and use their own resources first. In all but two of the communities (both extremely under-resourced rural communities), the request for specific input on PSS took place several months after the community had begun their own initiatives. Once a request for a workshop was made, the 5-day SP was offered. Community members were asked to identify a group of 20-30 interested and committed people, find a suitable venue (community hall, church, school or tribal court) and make all of the logistical arrangements. The researcher took responsibility for providing catering and training materials.
Up to this stage, action research had been the research/intervention typology, since the purpose had been to generate immediate action to solve problems, in the belief that people can solve problems by themselves (Patton, 1990; Robson, 2002). The focus of the intervention was on the communities' strengths and problems, with no desire to achieve generalisability (Robson, 2002; Silverman, 2000) beyond establishing broad protocols. Once the SP was initiated, the work continued to be informed by a PAR ethic, but the research focus shifted to formative evaluation. The purpose in this regard was to focus on the 'here and now' needs of the participants and to identify the strengths and weaknesses of the SP. The assumption was that people can and will use information to improve what they are doing (Patton, 1990). However, using formative and action research means that the desired level of generalisability remained relatively limited (Silverman, 2000).
The first phase of the summative evaluation of the SP was undertaken on the final day of the SP.
Research participants were requested to develop plans of action through which they would offer (or strengthen since some communities had pre-existing activities) PSS to vulnerable children. These community initiatives generated one of the measures of the effectiveness of the SP. The SP participants were asked to complete post-workshop evaluation forms. In addition, at one of the follow-up support meetings, three people from each community were randomly selected to participate in a focus group discussion that was conducted by an independent researcher.
Follow-up support meetings were then arranged to support the SP participants in carrying out their plans of action. The communities took on the responsibility of organising activities that offered PSS to vulnerable children. At these meetings, participants reported on their volunteer work offering PSS to vulnerable children in their community. The researcher's role was to give support, guidance and input if necessary.
In all but two of the communities, the participants decided on the need to form a register of vulnerable children in their areas. In the other two communities where this was not a spontaneous suggestion, the researcher indicated that some of the other communities had found this to be useful and the decision was made to also collate registers in their areas. During the SP, working definitions of risk and vulnerability had been developed. The community members used these definitions to identify vulnerable children largely on the basis that some children were experiencing especially 'difficult lives'. Communities made no distinction between children rendered vulnerable through the HTV7AIDS pandemic and other risk factors. The process of establishing a register of vulnerable children was in itself a community awareness-raising exercise that enabled the reality of some children's life experiences to be clarified and explored. Training in ethical procedures was offered to ensure that this was done in a proper and responsible manner. The collating of registers of vulnerable children served as a major impetus towards people taking action on behalf of vulnerable children both in terms of advocacy and in more practical terms such as assistance to obtain social welfare, gain admission to school and so forth, as well as in offering PSS.
At this stage, the researcher offered to conduct the 15-session structured group therapy programme (SGTP) with children in the 8 -12 age range. The help and support of selected community members was solicited so that they would be exposed to a therapeutic, child-centered manner of relating to children and be apprenticed to facilitate SGTP. In each instance, the primary facilitator of the SGTP was a qualified psychologist who took ethical and legal responsibility for the well-being of the children.
UN AIDS (2001) endorsed the original form of the SGTP (Madorin, 2000) as a best practice model and pilot administrations of a modified version of this programme (Killian, 2002) had been promising. The modifications had been undertaken by the researcher to include (i) indigenous games, (ii) culturally matched stories, names, songs and activities, and (iii) greater focus on vulnerability as opposed to orphanhood. This modified version of the SGTP was evaluated for its effectiveness in the positivist tradition (Potter, 1999; Shaprio, 1999), using a quasi-experimental design (Haslam &
McGarty, 1998) with a number of experimental and control conditions as will be set out in Chapter 10. The shift to a focus on individual and group differences (Collins, 1999), coupled with the scientific and statistical rigour of a positivist methodology (Dawes & Donald, 1994) was considered to be necessary as the basis for making informed decisions about the relative effective of different intervention strategies. In turn, this would provide the empirical evidence on which a judgement could be made in terms of the possible up-scaling of the programme (Germann & Madorin, 2002).
7.5. The process of community selection:
The selection of community sites was based on non-probability purposive sampling. The strength and logic of this sampling method enabled the researcher to gather an "information rich" (Patton, 1990, p. 169) sample to evaluate the effectiveness of the programme. The selection criteria were:
(1) Geographic region: On the basis of their geographic setting, eleven communities were identified as potential sites for the intervention programmes. There were two informal settlements and three each of urban townships, peri-urban and rural communities. Problems were encountered with the informal settlements (See Section 7.5.1) and they were subsequently dropped from this study.
Communities categorised themselves according to type of region, however more rigourous specifications were explored in the community profiles.
(2) Increase in recent mortality rates: The researcher wished to work in communities that had high HIV/AIDS prevalence, defined for the purpose of this study as an increase in deaths, especially of young people. The degree of stigma associated with HIV/AIDS precluded accessing communities by introducing the topic of HIV/AIDS until such time as a trusting relationship had been developed. It had been discovered, during early community contact, that introducing the topic of HIV/AIDS created resistance. Therefore, a conservative approach was adopted in which HIV/AIDS discussion was deferred until sufficient trust had been established between the researcher and community members.
Carefully considered strategies were required to see if the criteria for communities had high HTV7AIDS prevalence rates.
Identifying communities likely to meet the first criterion involved systematic consideration and networking within NPO and CBO groups. The researcher enjoyed pre-established, long-term relationships with certain community members in most of the partnering communities. Productive discussion and debate about vulnerable children took place while these relationships were rekindled and entry into the communities was secured. Each community that was approached was found to be suitable for inclusion.
The recent increase in mortality as a criterion for selecting partnering communities required an initial data gathering procedure. Once potential communities were identified on the basis of the first criterion, an informal survey was conducted using two respondent sub-groups to assess mortality rates within a community: (i) Five key stakeholders in each community were identified using snowball sampling (Patton, 1990) on the basis of their presumed special insight into community
demographics (Robson, 2002). This group of respondents included the Amakhozi and Indunas (the traditional leadership), the political leaders (representing local, provincial and national government structures), the leaders of FBO's (the church ministers, the Pentecostal leaders and Zionist pastors) as well as chairpersons or executive members of community development forums, (ii) A convenience sample of twenty people from each of the potential communities was identified. People who were attending meetings, waiting for public transport, or sitting at clinics were approached and asked if they would be willing to respond to a few questions. The only criterion for inclusion in this survey was that they were resident in the community. There was a large degree of homogeneity within each partnering communities, so this initial informal survey was simply a preliminary data gathering exercise. Nevertheless, care was taken to include people of both genders and from different age groups.
The survey consisted of the following five questions. The exact wording differed according to the respondent and the need to establish rapport.
/. Increased number of deaths: Do you feel that there are more people dying in your community now than ever before? Are there more deaths now than this time last year? An affirmative response from 89% of the respondents (87.2% of informal respondents and 88.88% of key stakeholders) was obtained across the nine partnering communities (this excludes the informal settlements).
2. Attendance at funerals over the immediately preceding two months. How many funerals, for people from this community, have you personally attended over the last two months? The
respondents were encouraged to give the first name of the deceased and were then asked to approximate his or her age at the time of death. Although there is no suggestion that all of these deaths were AIDS-related, it is reasonable to presume that a proportion, especially of the younger people who had died, could be attributed to AIDS-related conditions. It was interesting to note that criminal violence, motor vehicle accidents and suicide were also considered to be major causes of death. Across the nine communities, respondents reported having attended an average of 19 funerals over the preceding two months, with a mean of 16.8 from the three township areas, 18.5 from the three peri-urban areas and 22 from the three rural areas. The average age at death was 25.3 years: the estimated average age for township regions was 26.2 years, 23.5 years in peri-urban areas and 26.1 years in the rural areas (see Table 7.3). The relatively young age of the deceased was consistent with the pattern associated with AIDS-related deaths (Shisana & Simbayi, 2002). This connection was not made explicit by the researcher, but some respondents (15%) spontaneously raised the matter
themselves, usually with reference to the stigma associated with HIV/AIDS. The responses obtained from people in the informal settlements were not regarded as reliable community statistics as they varied greatly between respondents and appeared to reflect deaths from communities other than their own.
Orphanhood: Do you know children in this community who are orphans, or who are likely to become orphans in the near future? Canyou name them and give their approximate ages?
The naming process was included to obtain an estimate of the breadth of the problem. It was possible that there were a few well-known orphans with whom many people were familiar.
No validity checks on the lists were made. Certain children were repeatedly mentioned by respondents. The question of why some children have high social visibility, whilst others were identified only during door-to-door surveys was an issue that needed to be considered by both the researcher and the community during later stages of the intervention. An average of 48 orphans were identified from the three township regions, with the average across the three peri-urban and three rural areas being 52 and 65.6 respectively (see Table 7.3). Across all nine partnering communities, the average number of identified orphans was 55.2. It would appear, from this informal survey, that the rural communities are bearing the brunt of orphan care.
Willingness to commit to action: Do you think that there are people in your community who would be willing to work together to help children who are experiencing especially 'difficult lives'? Can you name them? Are you willing to be involved? Responses to this question generated lists of people to be invited to community mobilisation meetings and potential participants in the SP.
Difficulties experienced by children in the community: What do you think are the major difficulties experienced by children in this community? The responses to this questions were not used for selection purposes. They merely provided the researcher with some indication of the communities' perceptions of the problems facing children. The three most frequently identified difficulties were poverty-related circumstances (including responses of'no money', 'no food', 'parents are unemployed', 'no school fees', 'no health care'), orphans, and child abuse and neglect (Table 7.3). The communities seemed to distinguish between sexual abuse, which was frequently linked to rape and other forms of child abuse such as physical beatings and neglect. The category of parental alcoholism covered drunkenness and substance abuse.
Alcoholic beverages and traditional beers were frequently mentioned as the substances most likely to be abused.
Table 7.3. Community selection:
Community Region
NPO/CBO
% confirming rapid increase in
deaths N. funerals in
last 2 mths.
Mean age of deceased N. orphans identified by
name Problems experienced by
children
A Township
NPO KS: 90%
CM: 95%
K S = 1 7 CM = 1 4
26,3
53
Poverty Abuse Alcohol-
ism
B Township
CBO KS: 80%
CM: 75%
KS=18 CM = 16
27,7
45
Poverty Rape Physical
abuse
C Township
CBO KS: 85%
CM: 75%
KS = 19 CM =17
25,3
46
Orphans Sexual
abuse Neglect
D Peri-urban
CBO KS: 90%
CM: 90%
KS=19 CM =14
25,6
54
Poverty Orphans Sexual
abuse
E Peri-urban
CBO KS: 80%
CM: 85%
KS = 22 CM = 22
24,3
48
Orphans Alcohol-
ism Sexual
abuse
F Peri-urban
NPO KS: 90%
CM: 90%
KS = 18 CM =16
20,7
54
Poverty Orphans Sexual
abuse
G Rural
NPO KS:100%
CM: 100%
KS = 21 CM = 19
25,8
58
Poverty Orphans
Neglect
H Rural
NPO KS: 90%
CM: 85%
KS = 23 CM = 24
28,0
65
Orphans Poverty Alcoholism
I Rural
CBO KS: 95%
CM: 90%
KS = 22 CM = 23 24,6
74
Poverty Alcoholis
m Orphans
MEAN NA
NA KS: 88%
CM: 87,2%
KS=19,8 CM =18,3
25,3
55.2
J Informal settlement
CBO KS: 90%
CM: 85%
KS=10 CM = 22 Not reliable
Not reliable
Poverty No water
No electricity
K Informal settlement
NPO KS: 90%
CM: 80%
KS = 13 CM = 28
Not reliable
Not reliable
Poverty Unempl- oyment Neglect
Key: KS = Key stakeholders, CM = Community members.
* See Section 3 for more details about how these decisions were reached in this regard. Experimental Group 3 was not drawn from any of the above mentioned communities Selection criteria for this group are presented in Section 3 of this dissertation.