Bringing health education to rural Kenya

The Global Initiative for Village Empowerment (GIVE) was created in 2006 by a group of UBC students with the goal of bringing HIV/AIDS education to the community of Kanyawegi, Kenya. The community borders Lake Victoria and is located near Kisumu, the second-largest city in Kenya, in the Nyanza province. There is an estimated 15% HIV prevalence in Nyanza province, which is much higher than the reported rate of 7.4% for Kenya as a whole.[1] We suspect this is due to a variety of factors including the transient fishing population, cultural practices around sex, barriers to practising safe sex, lack of education, and significant stigma around HIV/AIDS.

GIVE is run by volunteers from Canada and Kenya—as well as by paid Kenyan employees—is governed by an elected executive, and fundraises for all project costs.

In addition to the original HIV/AIDS education project, GIVE has expanded to include health, food security and nutrition, and economic development teams. The HIV/AIDS education project is the focus of this article.

The education project is a collaboration between GIVE volunteers and the zonal officer, head teachers, and teachers of the Ojola school zone. The Ojola school zone consists of 18 primary schools. The education project has involved developing and integrating an HIV/AIDS curriculum into the Ojola school zone, zonal paper-exam funding, a zonal education day, and facilitating an extracurricular girls’ club in many schools. From May to August between 2006 and 2012, volunteers traveled from Canada to facilitate this project; however, we recognized early on that this is not a sustainable model. Our goal has been for the project to run independently without help from GIVE’s stakeholders in Canada. In 2013 GIVE did not send any Canadian volunteers to support the project, signaling our much-anticipated transition out of project management. By continuing to hand over responsibility and ownership to the community in stages, we hope to be hands-off (and wallets-off) in 2016.

This article is our first step in making our project an open-source guide to establishing, conducting, and transitioning a community-initiated, sustainable global health education project. The article provides an overview of our goals and how we executed them, outlines challenges we faced and how we adapted the project to meet local needs, and describes where we are going next.

Project goals
We intended to create a sustainable model of supporting education in low-income countries that can be adapted to any educational topic and hopefully any setting with the proper research and implementation strategy. To achieve this ultimate result, this project started with three main goals:
•    To increase knowledge of HIV/AIDS in the community by educating and engaging young people.
•    To decrease risky sexual behavior in the community’s at-risk youth.
•    To increase the number of students proceeding to secondary education.

How we approached our goals
To increase knowledge of HIV/AIDS in the community we organized workshops in primary and secondary schools, held parent meetings, established an annual HIV/AIDS awareness soccer tournament and, most successfully, introduced HIV/AIDS as an examinable subject in the curriculum. Creating this new subject area involved conducting extensive research, writing new teachers’ guides (a collaborative effort between Canadian volunteers and teachers in the school district), training and recertifying trained teachers on HIV/AIDS material, creating and invigilating annual exams, and awarding achievement through an annual education day.

To decrease risky sexual behavior, our educational tools focus on the scientific basis of how HIV transmission occurs as well as lifesaving skills such as condom use, condom negotiation, volunteer counseling and testing, self-esteem building, and empowering women. Anecdotally, heterosexual sexual intercourse is the most common mode of transmission in this region.

The third goal—increasing the number of students proceeding to secondary education—is multifaceted. This goal demonstrates our commitment to the overall academic success and continued education of students and has operated as an incentive to teachers, head teachers, the zonal officer, and other stakeholders to allow this project to continue. To increase the number of students going to secondary school we funded annual paper exams for standards 6 to 8 (the equivalent to our grades 6 to 8) for all subjects (i.e., math, religion/social studies, English, Kiswahili, science, and HIV/AIDS).

Primary education is free in Kenya but mandatory components such as uniforms, school supplies, and exams are not. This poses a significant barrier to students’ success as there is tremendous poverty in the area. Many students cannot afford to write the exams and, therefore, reach the end of standard 8 and their national exams (which determine whether they will be admitted to secondary school) without having practised writing a paper test. 

By supporting the setting, vetting, typesetting, proofreading, printing, marking, and analysis of these exams financially and logistically, we have given thousands of students the opportunity to practise writing at a subsidized rate of 10 Kenyan shillings (approximately 15 cents). The minimal cost to the student was retained to preserve some ownership within the community without being so high as to prevent any child from participating.

What we achieved
Over the past 7 years we have achieved each of our goals, at least in part. The project’s major weakness is a lack of measurable outcomes from which to analyze our success. Unlike in research, aid and development projects tend to be initiated without measurable outcomes in place. Additionally, many aid and development projects are initiated with the intention of doing good while neglecting to be aware that it is possible to do harm no matter how positive the intentions. For example, an organization running a project must ensure that resources reach the intended recipients rather than being diverted to unintended recipients for profit.

We have had a few encouraging developments over the years. First, the number of girls in primary schools who become pregnant has dropped. In 2007 there were seven pregnancies at Oyiengo Primary, one of the schools in the Ojola zone. In 2010 we saw pregnant girls in many of the schools we visited while teaching workshops. By 2012 the zonal officer reported that there were no pregnancies at that time. There are, of course, many explanations for this change besides the additional sexual education in the curriculum, but recognition from a key stakeholder that our programs were helping in this positive indicator is encouraging. Additionally, scores on the HIV/AIDS exam are consistently the highest of any tested subject. Again, confounding factors could be that we rigorously vet these exams to ensure questions are clear, teachers are retrained every year on the material, and we focus the exam questions on important facts for prevention. We have also qualitatively observed a massive positive shift in the community’s approach and openness toward contraceptives such as condoms. When we first arrived, teaching how to use condoms correctly and permitting youth access to condoms was opposed by many community stakeholders—a significant challenge. In recent years all schools began teaching how to use condoms, condoms are available at every annual HIV/AIDS awareness soccer tournament, and there have been community-initiated discussions seeking to improve access to condoms for primary school students.

What we did not achieve and why
We tried to initiate a procedure to track school attendance in an effort to measure dropout rates and pregnancies, but without adequate incentives—or perhaps due to incomplete communication—the record booklets circulated to all schools were not completed in a way that allowed us to track this information. We also did not have the resources to track how many students progressed to secondary school. We had planned to compare the national exam graduating marks of the first three classes going through the program, each successive class having an extra year of exam practice. However, the district’s zonal officer changed partway through the tracking process and we were not able to obtain these marks from the replacement office to compare successive years. 

Problems that emerged and our solutions
In 2010 the education team members were asked for sanitary napkins by girls at every school at which they taught workshops. When they spoke to the teachers and head teachers about this, they discovered that many girls were staying home from school because they did not have any sanitary products to use while they were menstruating. The same summer we tested a self-esteem building workshop and noticed that students had a difficult time performing tasks that we took for granted, such as listing their positive attributes. Combining these two issues, and engaging many teachers, head teachers, and community members in discussion, led us to create girls’ clubs comparable to the Girl Guides of Canada. The clubs were led by volunteer female teachers from the community with the purpose of empowering young girls and to serve as a way to distribute sanitary napkins to participating girls in a controlled and sustainable manner. Unfortunately we did not have the resources to fund the sanitary napkin distribution at the time, but we moved forward with the educational component of this idea with great success.

We based our training materials on an existing life skills course, which many teachers had been trained to teach during university, to ensure that the content was culturally appropriate and in keeping with Kenyan policymakers’ goals for the children. As a small incentive for participation, we gave each school a package of arts and crafts materials, made from donated goods, for use in their sessions. The majority of the 18 schools in the zone now have trained female teachers who lead this program on their own time, demonstrating yet again how committed this community is to improving the quality of life and education for their children and that significant positive changes can be made without a lot of material input from GIVE. We provided the idea and some initial support, and what resulted was an important step toward addressing critical issues faced by the community’s girls.

Where we are now
We completed our first summer without volunteers from Canada managing the education project on the ground in Kenya. Volunteers from another GIVE team conducted the refresher training for our teachers; otherwise, the community and our Kenyan GIVE employees were responsible for the program’s day-to-day operations. Thus far, this first transitional stage toward making the education project truly sustainable has been a success. 

We hope to be completely hands-off in 2016. Next year we will decrease funding for undertakings such as exam printing (the bulk of our annual budget—approximately $2500) and transition some of the funding responsibility to the community’s stakeholders. We are also assembling a group of teachers trained on the HIV curriculum to take responsibility for ongoing teacher training and motivation and for the girls’ clubs.

As we complete this transition we plan to compile the resources we have created into an open-source package that can be used by other organizations to implement education projects in a global context.

Recommendations
The benefits of a project like GIVE are that it uses existing infrastructure, engages influential members of the local community, and requires little monetary support for the amount of development that occurs. We encourage anyone planning global health projects to build strong partnerships with their stakeholders, incorporate local priorities and initiatives as fundamental aspects of any program, and encourage a sense of community ownership from the planning stages to maximize opportunities for success and easily transition to a sustainable model. Additionally, conducting research to objectively identify the project’s strengths and limitations, and ultimately demonstrate that the project is making a difference, is of paramount importance.

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This article has been peer reviewed.

References

1.    National AIDS and STI Control Programme. Ministry of Health, Kenya. Kenya AIDS indicator survey 2007: Preliminary report. Accessed 28 January 2014. www.wofak.or.ke/Publications/kais_preliminary_report_july_29.pdf.

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Rebecca Gordon is a medical student at the University of British Columbia. She became a member of GIVE in 2009 and has been leading the education team since 2010. Katie de Champlain holds a master of science in audiology and works as a registered audiologist for Alberta Health Services in Calgary. She has been volunteering with GIVE since 2007. Jennifer Sibley is a medical student at the University of British Columbia. She became a member of GIVE more than 7 years ago. Jennifer has led education and health teams in Kanyawegi, Kenya, on three occasions and has been an executive with the organization for 6 years.