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The development and
: S^'"“ implementation of programmes?5
theory, methodology and practice

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UNAIDS

UNAIDS Best Practice - Key Material

© UNESCO / UNAIDS June 2000
All rights reserved. This document, which is jointly produced by UNESCO and UNAIDS,
may be freely reviewed, quoted, reproduced or translated, in part or in full, provided the
source is acknowledged. The document may not be sold. Furthermore, it may not be
used in conjunction with commercial purposes without prior written approval from
UNESCO and UNAIDS.
The authors are responsible for the choice and presentation of the facts contained in this
book and for the opinions expressed therein, which arc not necessarily those of
UNESCO or UNAIDS and do not commit both organisations.

UNESCO and UNAIDS express their gratitude for the work done by Ronny A.
Shtarkshall and Varda Soskolne, The Hebrew University - Hadassah Braun School of
Public Health and Community Medicine, Israel.
The mention of specific companies or of certain manufacturers’ products does not
imply that they are endorsed or recommended by UNESCO or UNAIDS in preference to
others of a similar nature that are not mentioned. Errors and omissions excepted, the
names of proprietary products arc distinguished by initial capital letters.

Ronny Shtarkshall, PhD
Department of Social Medicine
The Hebrew University and Hadassah
Braun School of Public Health and Community
Medicine
P.O. Box 12272
Jerusalem, il-91120, Israel
Phone: +972-2-6777108
Fax: +972-2-6439730
e-mail: ronys@md2.huji.ac.il

Varda Soskolne, PhD
Department of Social Medicine
The Hebrew University and Hadassah
Braun School of Public Health and Community
Medicine
P.O. Box 12272
Jerusalem, il-91120, Israel
Phone: +972-2-6777879
Fax: +972-2-6439730
e-mail: varda@vms.huji.ac.il

UNESCO, Section for Preventive Education
7, Place de Fontenoy, 75007 Paris, France
www.unesco/org/education/educprog/pead/index.html
UNAIDS, Department of Policiy, Strategy and Research
20 avenue Appia, 1121 Geneva 27, Switzerland
unaids@unaids.org
www.unaids.org

MIGRANT
POPULATIONS
AND HIV/AIDS
The development and
implementation of programmes:
theory methodology and practice

UNESCO

UNAIDS
UNAIDS Best Practice - Key Material

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....

IDS and migration arc two of the crucial social issues facing
today's changing world. At the end of 1999, UNAIDS and the
World Health Organization estimated that almost 34 million
people were living with the human immunodeficiency virus (HIV). More
than ()5(/( of these infections have occurred in developing countries, where
poverty, poor health systems and limited resources for prevention and care
fuel the spread of the virus.
\t the same time, an estimated 125 million people live and often work
outside of their country of citizenship, while between two and four mil­
lion migrate permanently each year. At the end of 1997, the world counted
some 12 million refugees, with another six million people internally
displaced within their countries because of wars and ethnic tensions.

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Migrant populations have a greater risk for poor health in general and
HIV infection in particular. This is due to the impact of sociocultural pat­
terns of the migrant situation on health, their economic transitions,
reduced availability and accessibility of health services, and the difficulty
of the host country health care systems to cope with the traditions and
practices of the immigrants. The otherness of migrants creates often xeno­
phobia, isolation and hostility by the host community. In addition, as with
other people living with HIV/AIDS, migrants who are HIV-positive are
subject of stigmatisation and discrimination, and therefore, they hide their
HIV status as long as possible, thus making support services unavailable
for them.

Even if health and social services would be prepared to assist migrant
populations, they often encounter great difficulties to reach out to them.
More often than not, migrant populations live in a legal vacuum, having
no stay or work permit for the host country and live with the constant fear
of deportation. The contact with official government agencies increases
that fear and is, therefore, often accompanied by suspicion. The economic
situation of migrants gives them no choice for appropriate employment,
many of them are forced to accept jobs far below their qualification under
conditions which are in the grey area of illegality. Due to their powerless­
ness, they are frequently subject to all kinds of exploitation, including
sexual exploitation. To provide migrant populations with services to pre­
vent HIV infection and care for those living with HIV/AIDS requires
innovative and culturally sensitive approaches, some of which are descri­
bed in this monograph.
International challenges require international responses. In the mid1990s, it became clear that the relentless spread of HIV, and the
epidemic’s devastating impact on all aspects of human lives and on social

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Foreword

and economic development, were creating an emergency that would
require a greatly expanded United Nations cllort. No single United
Nations organization was in a position to provide the coordinated
assistance needed to address the many factors driving the HIV epidemic,

or help countries deal with the impact of H1V/AIDS on households, com­
munities and local economies.

Addressing these challenges head-on, the United Nations took an inno­
vative approach in 1996, drawing six organizations together in a joint and

cosponsored programme - the Joint United Nations Programme on
H1V/AIDS (UNAIDS). The six original Cosponsors of UNAIDS -

UNICEF, UNDP, UNFPA, UNESCO, WHO and the World Bank - were
joined in April 1999 by UNDCP. The goal of UNAIDS is to catalyse,
strengthen and orchestrate the unique expertise, resources, and networks
of influence that each of these organizations offers. Working together
through UNAIDS, the Cosponsors expand their outreach through stra­
tegic alliances with other United Nations agencies, national governments,
corporations, media, religious organizations, community-based groups,
regional and country networks of people living with HIV/AIDS, and other
non-governmental organizations.

UNESCO has been a Cosponsor of UNAIDS from the beginning.
UNESCO’s thematic and practical contributions to UNAIDS stem from

its multi-disciplinary approaches to education, scientific research, com­

munication, cultural and human rights. UNESCO mobilizes a vast net­
work of institutions with which it collaborates in advancing the responses
to AIDS. Given its comparative advantage in education, UNESCO plays
a leading role in assisting Member States in the development of effective
t

education strategies in preventive education.
Together, and with their range of partners and expertise, UNESCO and

UNAIDS are uniquely positioned to support the development of measures
to respond to the epidemic, and to disseminate experiences and lessons
learned. This joint publication is an example of cooperation between the
two partners, w

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i his publication is based on the experience of the authors and of
other researchers and programme developers with various migrant
populations in Israel in HIV/AIDS prevention and the related
fields of sexual health and sex education. Examples are drawn from the
work with two recent waves of immigration from Ethiopia and the former
USSR to Israel. Observations were made on similarities between the

migrant populations as well as on their unique characteristics in inter­
action with a host culture. This resulted in developing culturally sensitive
HIV/AIDS prevention programmes while responding to the general needs

of the migrant populations.
Although a large majority of the population in Israel are immigrants of

the last 50 years and their descendants, this publication is based on the
authors’ work with immigrant groups from Ethiopia and the former
USSR. The immigration from Ethiopia numbers about 50,000 people,
which came in two major waves in the mid-1980s and over one weekend
in May 1991. Most of these Jews came from remote rural areas and lived
in a traditional, extended family structure. Coming from a country with a
high HIV prevalence, the immigrants had a much higher values than those
known lor the genetai Isiacli population.

1

1 he latest wave of immigration from the former USSR, which started in
1989 and peaked in 1990/91, numbers more than 600,000 people (about
13% of the existing population). These immigrants, academics and
professionals, are mainly of urban origin from the European Republics of
the former USSR. Some groups of Jews from Georgia, Caucasus and the
Asian republics are also present among them.

It should be noted that the special interest in working with migrant popul­

ations stems from the perceived increase in vulnerability of immigrants
and their special needs, and not in viewing them as posing risk to the host
population.
1 his work is divided into three chapters. Chapter 1 summarizes the back­

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ground, theories, and principles underlying the development of
HIV/AIDS programmes for migrant populations. Three important
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components, which interact and partially overlap, define the special needs
of immigrant populations. These are the socioeconomic conditions caused
by uprooting from the old country and the hardships of resettling in the
new country; the sociocultural specificity of an immigrant population (a
phenomenon that needs to be dealt with also among non-immigrant
groups in multi-ethnic societies); and the sociocultural phenomenon of
immigration, characterized by transition, cross-cultural interactions, and
accelerated dynamics of change.

General introduction

(< hapter
hapter 22 Focuses
Focuses on the methods and steps to be taken in developing
programmes, projects, and interventions for migrant populations. A tight
integration of three elements is central to the model of development.
These are the close cooperation between cultural “insighters” and “outsighters”; the need to shorten the development period of programmes and
projects without giving up the principle of cultural adaptation to the
special conditions of the immigrants’ background; and the need for
continuous development according to the changing dynamics and the
identification of issues during fieldwork. Another element of this method­
ology is the interaction between methods, stages ol development, and
implementation, which supports and enhances the programme.
In Chapter 3, examples of programmes, projects, and interventions
demonstrate the methodology and its variations in specific conditions.
The resulting diversity, complexity, and specificity that can be achieved
through employing the principles described in ( hapter 1 and implement­
ing the model and methods detailed in C hapter 2 are lalmost endless. The
emphasis in Chapter 3 is on the systematic adaptation to specific circuinstances that resulted in diverse programmes and projects.

Some of the tools and instruments used in developing programmes and
projects, training courses, implementation ol activities, and monitoring
and evaluation are provided as examples in tables and text boxes.
Interested readers are encouraged to contact the authors directly for more
detailed information on those tools and instruments, w

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Foreword
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Chapter 1 Theoretical considerations and principles of interventions
Introduction

The characterization of migration and immigrants
Principles of cross-cultural cooperation
Cultural transitions and cross-cultural encounters
Iterative development cycles
Chapter 2 Programmes, projects, and interventions: A guide to development
Introduction
Terminology

Stages of development
Collecting and analysing data
Involving community leaders
The needs of immigrants with HIV/AIDS
Training programmes: data collection and developing interventions
Trial field implementation: iterative project development
Monitoring and evaluation: continuous parallel processes
Sensitizing the host country population
Chapter 3 Israeli programmes: Demonstrating principles of the method
Introduction...........................................................

An educational programme for immigrant youth ............................
Project for the general population of immigrants from Ethiopia . . .
Case managers: working with Ethiopian HIV-positive immigrants
Sensitizing health and welfare personnel

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References

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Table I
Table 2
Table 3
Table 4
Box 1:
Box 2:
Box 3:
Box 4:
Box 5:
Box 6:
Box 7:
Box 8:

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General introduction

Box 9:
Box 10:
Box 11 :
Box 12:
Box 13:
Box 14:
Box 15:

Lisi ol labks and ic\l hows
Use ol data collection methods al different stages of programme development
Use ol data collection methods al different stages of monitoring and evaluation
Steps and stages for programme development
Stages, steps and activities in the development of a project
The evolution of a steering committee and a professional team
Marital status
Methods of data collection
Sample semi-structured interview for trainees
Semi-structured interview for a migrant youth population
Responding to fear and shunning in a training session
Review of posters
Guidelines for observation of training sessions ..............................................................
Elements of a facilitators' training programme on sexual health for adolescents.............
Interventions, principles, and strategies .............................................................................
Means suggested by trainees to increase the acceptance of posters detailing condom use
Essential elements of a training programme
Questionnaire for monitoring trial implementation of interventions ...............................
Suggestions for dealing with the media
Educational units for HIV/AIDS prevention

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6
9
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. . . .15
. . . .15
. . . .15
. . 16
. . . .20

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. . . .32
. . . .33
. . . .36
. . . .39
. . . .39
. . . .39
. . . .46
. . . .55
. . . .62
. . . .65

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.12
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.16

.17
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21

. . . .23
. . . .24
. . . .25
. . . .26
. . . .27
. . . .27
. . . .31
...31
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. . 36
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Theoretical considerations and principles
of interventions
Introduction

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Migrant populations are at a higher risk than the overall population for poor health
m general and HIV infection in particular (Zwi & Cabral, 1991; Brindis et al., 1995).
I heie aie seveial reasons lor these phenomena, some of which are related directly to the
ellecls ol the sociocultural patterns of the migrant situation. Others are related to eco­
nomic transitions and changes in the availability and accessibility of health services, and
the difficulty of the host country health systems to cope with the traditions and practices
ol migianls. In teims ol these factors, H1V/AIDS is not dillcrent than other problems,
but it is lurther complicated by the stigma and sense of “otherness” attached to those
infected with the virus (Haour-Knipe, 1993).
Epidemiological data from many countries show that migrants could be at particu­
lar risk for HIV infection. However, it is important to treat these data with caution,
because dillerences exist between reporting systems of countries and the manner in
which data concerning migrants are presented. For example, some sources report the
incidence or prevalence ol HIV, others the incidence and prevalence only of AIDS. Some
countries (e.g., the United States) include data on immigrants together with those on
native-born ethnic minorities; making it difficult to calculate rates solely for immigrants.
In some European countries, the majority of foreign-born persons with HIV/AIDS are
horn other European countries or the United States and are not immigrants from
developing countries (Haour-Knipe, 1991). Moreover, in. many countries, release of data
concerning foreigners is limited to protect their privacy and to avoid stigmatization
through the misuse of epidemiological data.
AIDS case data for migrants in nine European countries indicate great variations
among the countries. For example, by 1990, 45 per cent of the people with AIDS in
Belgium, 20 per cent in the Netherlands, and 7 per cent in Norway were foreign resi­
dents. Where data on HIV were available, the proportion was 52 percent in Belgium, 20
percent in Sweden, and 10 percent in Norway. The proportion of immigrant populations
in these countries was significantly smaller than the percentage of the total of all those
being HIV-positive (Haour-Knipe, 1991). In Sweden, HIV prevalence among immi­
grants from sub-Saharan Africa residing in Stockholm was estimated to be 4 per cent in
1994 (Christenson & Stillstrom, 1995). In Amsterdam, only 0.12 per cent of pregnant
women in 1988-1991 were diagnosed with HIV, but 63 per cent of these were foreign
nationals (Bindies et al., 1994).
Outside Europe, too, data show that immigrants can be at greater risk for HIV/AIDS.
In Israel, the prevalence of HIV among immigrants from Ethiopia rose from 3 per cent
in 1991 to 7 per cent in 1996 (Kaplan, Kedem & Pollack 1998). Moreover, these immi­
grants constituted the predominant transmission group - 50 percent of all HIV sero-positive adults in Israel at the end on 1999 (Israeli Ministry of Health, 1999). Internal migra­
tion has also been found to be a major risk marker. In Uganda, HIV sero-prevalence was
5.5 per cent lor people who had not changed address during the surveillance period in a
rural region. It was two limes greater (11.5 per cent) among people who moved out of
the area and almost three times greater (16.3 per cent) for those who joined the study
area (Nunn et al., 1995).

The characterization of migration and immigrants
The definition of immigrants or migrant populations can be complicated and will
depend on whether one uses nationality or country of origin as a criterion. For the

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Chapter 1

TI inn | pl ir.ril po | V'i' I •'» pl iotir

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purpose of defining (he boundaries of immigrant populations, examining their epidem­
iological patterns, and evaluating programmes, these issues are highly important, but
they are less so to developers of programmes focusing on prevention within the migrant
populations. For them, other dimensions of characterizing migrant populations are of
greater significance, particularly those that affect the needs and specific situation of the
migrant population and the feasibility of and conditions for HIV/AIDS prevention in that
population (Haour-Knipe. 1994). Such dimensions include:

Choice: Did the immigrants leave their country of origin voluntarily or were they

forced to move?
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Cultural affinity: What is the degree of similarity or difference in language, reli­
gion, ethnicity, and other factors between the immigrant and the host culture? Additional

factors, such as ideology or nationalism, may affect the need for special programmes.
Intention: Do migrants intend to stay in (he host country? Their movement to the

new country could be temporary or short-term with the intention to return to (he country
of origin. Migrant populations may include transients who do not regard the current host
country as their final destination and intend to move on (but not back) or settlers who
intend, if allowed, to stay in the current host country.
Length of stay: 'Ibis factor is highly dynamic and changes continuously

throughout programmes. Length of stay is especially significant when the stay is short.
When the stay is long, there may be second- and third-generation immigrants who still
show distinct sociocultural differences from the host country, as well as from the home

country. Significant differences exist between short-term migration (like that of seasonal
workers), medium-term migration, and permanent migration. Each type requires a diffe­

rent approach because of the differences in commitment to (he “old country" culture.
Legal status: There arc at least three major categories within this dimension:

clandestine, semi-legal (or sufferance), and legal. Legal status affects the availability of

health and welfare services and the immigrants’ willingness to be in contact with
officials.

Needs of the host country: The needs of the host country could determine the

type and social status of migrants allowed into a country, the screening and entry proce­
dures, the amount of involvement of mainstream society with migrant populations, and
its investment in them.

These dimensions may interact with each other in influencing HIV/AIDS issues. For

example, refugees who were forced to leave their county and reside in refugee camps

may sec their situation as temporary and aspire to return to their country of origin. This
could affect their relationships with the host culture, such as their willingness to learn

the language. Seasonal migrant workers, who arc similar to the refugees in their int­
ention to return home and the degree of involvement with the host culture, are usually
able to realize their intention, while refugees could stay in exile for many years. The

needs of the host country could be related to legal status. This could produce a situation
in which the migrant population could be reluctant to approach health and welfare ser­

vices or any project that has any official association. It is therefore critically important

to examine the specific situation of migrants closely and characterize them on as many
dimensions as possible if meaningful programmes arc to be developed. It is also im­
portant to distinguish migrants from travellers and tourists, on the one hand, and ethnic
minorities on the other.
Certain types of travellers arc at higher risk for HIV infection while travelling than

in their home country, particularly those who (ravel to seek sexual experimentation.
I heir vulnerability is also related to the people with whom they associate in the host
countries. Travellers’ stay in a host country is too short and (heir degree of involvement

too small for programmes to target them directly. Instead, they arc best reached by gene­
ral information campaigns through various channels. Travellers are mainly considered as
a subgroup of the general population of the home country.

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Cliuplul I

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<iml principles of interventions

Migration involves both a partial loss of cultural environment of the “old country”
and an encounter with the environment, social constructs, and cultural atmosphere of the
new country. Migration is. therefore, related to a dynamic process of discontinuity and
liaiiMhoii, which is siiongly dependent on the tune elapsed since inignilion (Mirsky &
1 aiwei, 1992). 1 hat process is characterized by the move from a familiar and compre­
hensible existence to an unknown, confusing, distressing, but possibly exciting and
rewarding, life in a new country. Some of these elements are also experienced by the host
culture “receiving” the immigrants. Though not at so high a level of cultural transition
and loss, the host community does experience cross-cultural encounters and difficulties.
The hosts experience these pressures on different matters and from a position of greater
power than do the immigrants (Amir, Remcnnick & Elmelech 1997).
i
Immigration can precipitate many issues that stem from cultural transitions and
cross-cultural encounters:

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The distinction between immigrant groups and non-migrant cultural or ethnic mino­
rities is more difficult because most immigrant groups are also cultural or ethnic mino­
rities. The difference is mainly in the migrant conditions, which add to the difficulties
induced by minority status. The next sections discuss some of the unique factors asso­
ciated with immigration and relate them to specific cultural differences.

uih i j i iilious la
reduce llic risk <>/

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the breaking down of traditional norms and institutions with resulting confused,
unstable, and insecure behaviour;
difficulties in interpreting the new environment on the basis of pre-immigration
cultural patterns;
difficulties in accepting new environments, which could cause behavioural
discrepancies;
the widening of intergcncrational gaps;
feelings of estrangement and stigma.

These issues could change al a fast pace among immigrants and could interact with
other factors that could affect their health (Marmot, 1993/94). Such factors might
include the reasons for migrating; the effects of exposure to new environments,
including health status, culture, and lifestyle in the old country; the effects of the new
country; and the experience of being migrants undergoing social and cultural change.
The issues of HIV/AIDS prevention are unique because they involve intimacy and
sexual relations. In these areas, strong familial and social pressures exist for continuity
and conformity on both cultural sides, a situation that may create strong tensions not
only in the immigrant community but also in the host society (Amir, Remennick &
Elmelech 1997). Such tensions could occur at the mainstream and institutional levels,
but also among marginal and stigmatized groups within the host society.
The situation is further aggravated by the fact that, in many cultures, the issues of
intimate relations and sexual behaviour are shrouded in secrecy and taboo. Such cul­
tures, which are usually more traditional, have a tendency to avoid discussing sexual
issues in public. The public stance is denial of the possibility of either premarital or
youthiiul sexual behaviour. For example, the Ethiopian-Jewish tradition did not object to
sexual intercourse between young people as long as it was in the context of marriage.
Boys and girls were often married al puberty or even sooner. A similar tradition existed
among some Jewish immigrants from the former USSR, especially those coming from
the Caucasus and the central Asian republics. This was also the tradition in the Jewish
communities of eastern, central, and southern Europe at the beginning of the twentieth
century, and most of those of North Africa and the Middle East less than 50 years ago.
When they migrate from one society to another, immigrants may misunderstand new
situations on the basis of old conceptual frameworks. The example of Jewish immigrants
to Israel from Ethiopia and the former Soviet Union is typical. Immigrants from these
cultures may observe a high level of physical contact or intimate behaviour among

Chapter 1

Theoretical considerations and principles of interventions

Israeli young people in public places and interpret it according to the norms of their
country of origin. They assume that these young people are sexually active. Moreover,
since the physical contact is not always limited to one person, they assume that promis­
cuous sex is the norm. But according to secular Israeli norms, these arc misperceptions.
For Israeli young people, who are much more relaxed in their attitude to premarital sex,
public physical contact may be pre-intercourse or even non-sexual.
An additional factor is that immigrants from Ethiopia and the former USSR were
used to having sexual issues under strong social or institutional controls. Thus many of
them do not perceive and recognize the internalized personal controls among Israelis. As
a result, they view Israelis, especially Israeli young people, as having no norms or
controls or as having norms that are permissive or even promiscuous.
Such misperceptions can cause difficulties in various directions. First, immigrants
who view these misperceived behaviours as contrary to their internalized norms can feel
estranged from the host culture. Such feelings are hardly conducive to trust in profes­
sionals from the host culture who conduct prevention and care programmes. A second
route, which may be more risky in terms of HIV transmission, is the adoption by immi­
grants, especially immigrant youth, of the erroneously perceived promiscuous norms as
normative behaviour to be acted upon in the new country (Shtarkshall & Shimon, 1994).

('haractcristics of
host (ind inimit’iuiH
populations

One factor that deals with specific situations but is still generalized is the degree of
accordance between the situations in the “old’'and “new” country.
Attitudes and norms towards sexuality and sexual behaviour influence HIV/AIDS
prevention in an indirect but important manner. Traditions of restricted public discussion
and strong normative controls over sex could lead to discordance between publicly
expressed norms and highly prevalent individual behaviour. z\ strong barrier to
HIV/AIDS prevention could exist where, for example, there is denial about the possi­
bility of pre-marital sexual behaviour among young people. Programme developers
should try to identify such discordance and must address it in their interventions.
Questions about the necessity for special HIV/AIDS education for migrants are
often raised based on the issue of their particular risk for HIV transmission. It has al­
ready been noted above that epidemiological evidence concerning HIV/AIDS pre­
valence rates in general and among migrants in particular should be used with caution
due to varying reporting systems and other methodological issues that weaken their
validity.
An examination of epidemiological and behavioural data suggests that part of the
greater apparent risk for HIV infection among migrant populations may stem from other
living condition variables and could be reduced by controlling or correcting these
variables. Sometimes such corrections show that the migrants’ risk is not greater than
that of the general population. For example, the argument that migrants usually have
more sexually transmitted diseases and therefore are at greater risk for HIV has been
shown to be true only for single men living under isolated conditions in the host culture.
When they live with families, the incidence is similar to that of the host population (de
Schryver & Meheus. 1990). On the other hand, single status may be related to a specific
immigrant group who want to improve their income, but who are employed in low-status
jobs;. They tend to have multiple partners and commercial sex because of their single

status, geographic mobility, and lower chances of creating stable relationships with
women in (he host culture. In this case, understanding the causes of increased risk can­
not change the situation, but it may add to the understanding of the factors that deter­
mine the risk and the directions of the interventions.
factors related to the greater risk ol HIV infection among migrant population in­
clude demographic and behavioural differences within the immigrant community, diffi­
culties in interactions with and integrating into the host society, less access to medical
services, and language and communication problems with health care personnel. Again,
a note ol caution in interpreting such data is necessary. Migrants may simply be more
known to health officials because they are more represented in public services than is the

Chapter 1

Theoretical considerations and principles of interventions

1

host population. They may not have the knowledge or the economic resources to use
other, more confidential private services. Many countries tend to screen immigrant
populations loi various infectious diseases but do not have similar screening of the gene­

ral population. From a public health perspective, this practice may be advisable, but in

many countries it has been found to violate human rights and to offend, stigmatize, and
alienate the immigrant population, thus creating barriers to preventive action. This was

the case in Norway in the late 1980s (Haour-Knipe, 1991) and has become the situation
in Israel with Ethiopian immigrants.
When a screening program is implemented and the country also accepts the position
that all sections ol the population have the right to equal access to information about
H1V/A1DS, then educational messages should be culturally adapted so they can be

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understood and perceived as pertinent. This necessitates the involvement of government
in health education. As the situation of immigration is by definition one of constant and

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rapid change both at the individual and the community levels, HIV education pro­

grammes have to be flexible enough to be changed and adapted to different situations.
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Another argument for the need for special programmes for immigrant groups is
based on observations that migrant groups tend to.have sexual partners and forip liaisons

mostly within their own group. This is determined by selection biases as well as by the
limited tendency of people from the host culture to choose sexual partners from
marginalized groups. Therefore the greater risk of transmission is internal. In other

situations where risk of transmission is external, such as commercial sex, the general

assumption is that here the responsibility to prevent transmission of HIV lies with the
client as much as with the commercial sex worker. Similar considerations apply for other

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avenues ol transmission. If the prevalence and incidence of HIV are either significantly
lower or significantly higher in the immigrant population than the host population, it is

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important to also include studies of the channels of transmission between the subgroups

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as part ol the basic data needed for prevention.
I he comparative prevalence and incidence of HIV/AIDS between the immigrant
population and the general host population are immaterial for setting the priority of spe­

cial immigrant programmes to lower the risk of transmission within this subgroup.

However, the fact that these rates are different and that the patterns of transmission may
be different are the important points for the design and implementation of such
programmes.

When the prevalence of HIV/AIDS among immigrants is higher than in the general
population, and this becomes a public issue, their marginality to the general host popul­
ation further increases their risk. The perception of them as a “risk group” may cause a

■

grave public health problem within both the immigrant community and the host
population.
Host population reactions that need to be dealt with are alarmism combined with
scapegoating and stigmatization. Irrational fears in the face of a threatening deadly
disease are natural and should be recognized as such. But an alarmist reaction is an
inadequate social-behavioural response, aggravating the distress of immigrants in gene­

ral and people with HIV/AIDS among them in particular. It may start with sensationalist

media reports that, even if isolated, can cause widespread damage. Such reports may be
characterized by inappropriate handling of epidemiological, medical, or behavioural data
that, even when correct, can be easily misinterpreted when not presented in the right

I

way. These reports may sometimes serve political or seemingly positive agendas such as
the distribution of HIV prevention programmes or drives for funding programmes, but

could be followed by shunning, discrimination, breaches of ethics, and even violent
reactions.
Stigmatization and shunning can increase the tendency of the immigrant community

to deny the issue and, in some cases, can alienate people with HIV/AIDS, make them
angry, and drive them into hiding. Thus the risk within the immigrant community can be
intensified by outside pressure. When the host population erroneously perceives that the
risk stems mainly from the immigrants, members of the host population may be at higher

risk because they do not feel the need to comply with protective measures with non-

5

Sy*

I
!

I
I

Theoretical considerations and principles of intervnntions

Chapter 1

immigrants. Therefore, while the needs of the immigrants must be dealt with in special
programmes and projects, it is also important - not only because of human rights consid­

erations but also because it is in the public interest - to address the general public in a
non-discriminatory manner through messages emphasizing appropriate behaviour. It is
only when highly specific routes of transmission are identified that there may be a need
for special projects for the host population.

Principles of cross-cultural cooperation
Two main options are available to the developers of national programmes con­
fronted with the need to deal with HIV/AIDS among immigrants: to adapt existing pro­

grammes that have been tried with other populations, or to use newly developed pro­
grammes that can be targeted and tailored to the needs of the specific immigrant popul­
ations. Existing programmes may originate from various sources. HIV/AIDS is a high­

ly entrepreneurial field. Many commercial and non-profit organizations market edu­
cational programmes that guarantee universality or adaptability to a wide range of cul­
tural conditions. Many of these focus mainly on knowledge or the technical aspects ol
condom use and claim the ability to train interveners in short periods of lime. Their gua­
rantee of universality is dubious, and the use of such programmes could he especially

problematic in dealing with immigrant populations.
As was demonstrated earlier, immigration is a unique cultural situation combining
cultural loss and transition with cross-cultural encounters. For these reasons, pro­
grammes from the “old country” are not recommended, unless they are just one of many

resources for developing a new programme. Although programmes from the old country

would cover cultural traditions, thus being an improvement on the so-called “universal”
programmes, they do not deal with the cultural loss, the new environment, and the cross-

cultural interactions, all of which can have strong bearings on coping with HIV/AIDS.
Their adaptation to these conditions may consume as much time and resources as devel­
oping a new programme that would take into account as many of these factors as pos­
sible. Programmes designed for the general population of the host country should be

rejected for similar reasons. This position is strongly reinforced in situations where the
patterns and modes of transmission within the immigrant population and the factors
affecting them are significantly different from those of the host population or the country

I

of origin.
The time frame for the development of newly designed, specific programmes for

immigrant communities may be the major obstacle to the adoption of such policy. The
more traditional, linear methods of development may seem inapplicable, especially
when urgency is perceived. T his may be one of the reasons why decision-makers opt for

other, less desirable alternatives. The iterative model for development of programmes

and projects that is presented in this document (sec page 11), among its other advantages,
saves a lot of time while making very few compromises in terms or adaptation to the
needs of the target populations. One of the contributing factors to the ability to develop

culturally appropriate programmes in a relatively short time is cross-cultural

cooperation.

77/r pit/ulls <>(
^priniilivc" or
"noble sovapc"

The basic principle of cross-cultural cooperation is mutual respect, which super­

sedes not only judgement and stigmatization but also glorification and idealization.
When the host and immigrant cultures are distant enough, especially when the host cul­
ture is urban, industrial, and literate, the images of the primitive and the noble savage
may be applied to the immigrant culture in varying degrees of intensity. It is important

to note that both the general population of the host country and the immigrant commu­
nity could fall into this trap. While the danger of the first is almost self-evident, the
second is more insidious and may be as pernicious. Both hinder the ability to understand

the factors that promote transmission of HIV and their behavioural, social, and cultural
determinants.

I
</11.1 ph; I I

1 licoii.tu.ul coiibidciutions und principles of interventions

I
I
>

Stigmatization has an additional damaging effect: it may promote denial and
avoidance, especially when it is directed towards a minority group. While stigmatization
must be dealt with deliberately at all levels through political, media, and community

i

action as well as education and counselling (Shtarkshall & Davidson, 1995; Shtarkshall,
Shimon

Bargai, 1997), idealization and glorification can be dealt with mainly by not

indulging in them or by refraining them when they are encountered. Experience shows

that most people, if treated with concern and respect, will accept straightforward
approaches to sensitive issues that might be prone to stigmatization.

r

I
i

“f uhural
iiisi^hl" anil
"luhurul

A unique factor in work with migrants, one inherent in the cross-cultural encounter,
is the need lor people from two cultures to work together. This occurs for two reasons.
First, the migrant culture is in a unique situation, in transition between two cultures and
developing some specific “old culture’ responses to host culture phenomena. Second,
people from the host culture who are in contact with migrants are affected by the cross-

cultural encounter. The cooperation between members of the two cultures can take many

I

forms and occur at many levels. In developing and implementing programmes and pro­
jects tor dealing with 111V/AIDS and the broader fields of sexual health and intimate and

i

sexual relations, a specific type of interaction is stressed for working on the cultural
components of projects in cross-cultural situations. Il is necessary that members of the
different cultures contribute their various perspectives if the aim of developing cultural­
ly appropriate programmes for (his unique situation is to be achieved. The terms “cultu­

ral insighters and cultural outsighters” have been coined to explain and emphasize the
different roles of the members of each culture who collaborate in developing and im­

plementing projects (Shtarkshall & Soskolne, 1994).

The culture of a society could be viewed as the collection of those attitudes, norms,
values, and practices that its members may not or will not ask questions about. One of

the roles of cultural outsighters is to raise questions about just these attitudes, norms,
values, and practices. Such questions may be quite disturbing, or they may seem of no
significance to insighters because they view their own attitudes and values as natural.

Sometimes only the outsighters recognize an important question, while people from
inside the culture are unaware of its significance. On the other hand, the people who are

best informed about cultural details and their internal interconnections, variations, and
explanations are those from inside (he culture - that is, the cultural insighters.
Some examples of cooperation between insighters and outsighters emerged through
an international training programme. One participant described a project that attempted

to lower the risk of HIV transmission to rural housewives whose husbands engaged in

commercial sex. Because such behaviour is described as highly prevalent, rural house­
wives are considered a priority at-risk group in the country.

Members of the inter­

national training group probed the participant for the reasons why husbands engaged in

commercial sex. Several of the questions raised by outsighters are questions that could
be examined almost exclusively by insighters. The resulting examination uncovered
phenomena highly relevant to project developers.

In (hat society, there is a dichotomy between sex for procreation and sex for
pleasure.

As a norm, “honourable” married women attempt to minimize intercourse by many
means and do not associate it with pleasure.
Discussion of the issue of whether this lack of pleasure is only the husbands’

inattention to the wives’ sexual needs (which is certainly part of it) revealed that
married women may feel offended if their husbands try sexual variations or
inventiveness in an attempt to increase the wives’ pleasure. A wife may think that

her husband is looking at her as a “pleasure woman” and may feel degraded.

A husband may feel very uncomfortable or even suspicious and resentful if his
wile requested or demanded pleasure from sex and would probably interpret it as

her acting in a “loose” manner.

!

i

Theoretical considerations and principles of interventions

Chapter 1

t

This example illustrates the link between insighters and outsiders. It also implies
that, at one time or another, most participants had experienced both roles - insighter on
their own projects, outsighter on those of others. Having been through this experience
repeatedly, they are aware of the importance of insighter-outsighter cooperation. They
can look for instances where programmes might benefit from these processes and may
be able to distance themselves from immediate emotional reactions. The answers to the
questions raised through such a process cannot come instantaneously but rather through
a series of questions and answers, mistakes and discoveries.
Another example of the process of insighting and outsighting was the analysis of the
custom that a widow has to have sexual intercourse with a close member of her late
husband’s family. In an international workshop, members were surprised to find that this
custom is prevalent in varying forms in many cultures. Some interesting questions,
which may have a strong impact on prevention of HIV/A1DS, were raised. What is the
purifying act, intromission or ejaculation? What happens when a condom is used in such
a ritual? Does it void it? All members from the cultures where this custom is practised
admitted that they had never thought of such questions.
This process is elaborated upon to contrast it with the alternatives: first, the con­
ventional development in which the immigrants participate mainly as subjects (Cornwall
& Jewkes, 1995), and, second, a process in which the full responsibility for development
of the programmes is delegated to the immigrants, in the tradition of ethnic minority
groups. Some argue that, if immigrants can be taught to view their culture from the out­
side or if individuals from the host culture can be trained as experts on the immigrant
population, then there is no need for cooperation. Either could take on the roles of both
insighters and outsighters. Yet this may take much more time than training them to
cooperate, and their proficiency in the reverse roles may be limited. In addition, an
important link between the two communities would be missing in which interactions
could be achieved. The interactions in themselves could add to the understanding of the
situation and address the reciprocal nature of the cross-cultural encounter, the fact that
people from the host culture are also affected by it. Training people from inside a culture
to view it from outside and outsiders to gain some insiders’ perspective can best be
achieved through extensive collaboration between members of both cultures who engage
in cross-cultural efforts.
Specifically in terms of HIV prevention projects, the study of cross-cultural
phenomena and coping with the problems they pose can be enhanced and accelerated if
people from inside and outside the cultures join forces in the attempt to reducing the
incidence of infection. People from each group may have dual roles, that of cultural
insighters for their own group and cultural outsighters to the complementary interacting
one.
In many instances, the objective of a project is to develop professionals capable of
mediating between members of the two cultures who cannot play the dual role of in­
sighters and outsighters because of lack of training and other professional duties. Such
is the case in direct interactions between people with HIV/AIDS and physicians or wel­
fare professionals. The need for cultural translation of concepts and the use of compre­
hensible communication goes far beyond language difficulties.
Programmes based on cross-cultural cooperation do not act only within the defined
area of their aims, on issues of sexual health or sexual relations. The participants,

whether they are interveners or the target population, could also apply them to other
cross-cultural issues. Cross-cultural cooperation in projects can also lead to better
cultural understanding and thus enhance the constructive interactions among members
of the two populations and facilitate integration of the immigrants into the new
environment.

I.(‘(ulcrship from the
migrant poimlution

HI 8

Sometimes community leaders believe that minimizing the extent ol the epidemic or
even denying its existence is in the best interest of their constituency, usually reflecting
the emotions of their community and the atmosphere within it. In order to address these

Gluiptur 1

J

1

I Ijl-uiuln,.il Gunbidciatioiib and principles of iiifervei.tions

responses, the reasons for them should be well understood.
First, in most cases, even in populations with high prevalence and incidence rates,
the majority of the group is not directly involved at the initial and often also at the later
stages ol the epidemic. Thus, if stigmatizing behaviour towards people with HIV/AIDS
is prevalent, it would affect a vastly larger proportion of the population than just those
with HIV/AIDS.
Second, the HIV/AIDS epidemic could remain “invisible” even when the prevalence
is already high. As the onset of symptoms may be years after initial infection, people
tend to locus on more visible and immediate issues such as discrimination, housing,
legal status, entrance into the labour market, providing for families, and other daily sur­
vival issues. All these issues could be adversely affected if the community were asso­
ciated with the epidemic, especially when members of the immigrant community are
easily recognizable by their physical appearance, language, dress, or behaviour.
Third, for many migrant populations, especially those arriving from rural, more
traditional countries, the biomedical concept of being HIV-positive is either alien or hard
to grasp. In such societies, disease is associated with symptoms that handicap people. In
many cases, people with HIV respond with suspicion and anger not only when informed
about the infection but also at later stages. A typical example of such a case is a person
who is already being treated because of a low CD4 count and who says: “I am not ill, I
felt OK and there was nothing wrong with me until the doctors started giving me these
medicines. It is your medicines that make me ill; they make me vomit, I have no appe­
tite and my whole body aches. When I stop taking the medicine, I feel much better.” The
suffering person must have some explanation in order to make sense of such seemingly
abusive treatment. If the treating staff does not provide the explanation, the patient will
do so. Physicians represent not only the health system, but the whole establishment, and
accusations are projected onto them. Several such explanations have been provided by
patients: “You test the immigrants therefore you find more among us than among the
old-timers”; “ This is a way to hold us down”; “You want to use us for experiments with
medicines.” Such explanations may seem perfectly logical to people who are in a pre­
carious social or legal position and are either being discriminated against or perceive
themselves to be facing discrimination. The leadership cannot be deaf to such voices. It
is, therefore, important to accompany treatment with culturally appropriate, compre­
hensible explanations, which will prepare the patient for changes in health status.
A fourth factor, which particularly affects traditional leaders, is the perception that
dealing with the epidemic could conflict with traditional values. Leaders may perceive
themselves as the guardians of traditional values and thus feel that their authority is chal­
lenged. The sexual nature of the transmission of HIV, whether homosexual or hetero­
sexual, likely goes against traditional norms. When incidence is intensified through
modes rooted in old country norms, such as de jure or de facto polygamy or casual sex,
it may be perceived as contrary to the host country values, and must therefore be kept
hidden.
Overcoming these barriers requires not only an understanding of specific arguments
and patients but also careful work in alleviating fears, familiarizing the migrant leader­
ship with the host country situation, and letting the needs of people with HIV/AIDS be
one of the factors around which new leadership could emerge.

Cultural transitions and cross-cultural encounters

■

■

In order to deal with HIV/AIDS among immigrants, suitable principles and
strategics, which address cultural transition and cross-cultural encounters, have to be
employed. These principles support culturally specific messages and modes of message
transmission, employing members of migrant populations and sensitization of host
country personnel.

Chapter 1

f linni ( tical coir, if 1^1 a I in!)' .iikI ptinciplnc of infnfvonfintis

( ullnrully spa i/ic
messages and modes
of message
transmission

Two ways of using culturally specific messages are available to developers and

implementers of projects and interventions. The first is finding concepts, stories, fables
and proverbs, situations, or visual presentations that may fit or approximate the desired
messages on HIV/AIDS. The task then is adapting them in such a way that they could

be associated with the HIV/AIDS interventions. An example is a message about termites

attacking a tree, a situation that would be familiar to immigrants from Ethiopia and that

can serve as an analogy to the hidden aspects of HIV infection. A more complex attempt

is to shift a traditional cultural concept to a new context, as in the case of the Ethiopian
concept of a gobez. This is a brave and clever man who is able to avert damage to his
fields and support his family through preventive actions and preparation. HIV is

compared to the natural enemies of the farmer, and the condom is equated with the

means that the gobez employs (Rosen, 1986. 1989; Chemtob and Rosen, 1992).
The second option is using a traditional mode of communicating cultural lore, but

introducing new content. Tables and proverbs arc traditional modes of communicating
wisdom and expressing opinions in the Ethiopian culture. Several parables have new
content to convey important messages in a comprehensible and acceptable manner.
Examples include “The parable of the two legs” and “Dangerous steps and levels of risk”
(Shtarkshall, Shimon & Bargain 1997).

I'mployin” members
of migrant
populations

Employing professionals from (he migrant population as interveners (educators,

group facilitators, cultural mediators, and case managers) and training (hem for working
in the field of HIV/AIDS serve more than one purpose. When trained, they could

enhance the transfer of messages from one culture to another. They are also the most

suitable people to act as cultural mediators in the framework of health, welfare, and edu­
cational systems, provided that professionals from the host culture learn to value their
contribution and cooperate with them.

Being well versed in the nuances of their own culture, they could inject cultural
insight into the development process and complement the needed cultural outsight of

experts from the host culture. They are thus assigned the roles of informants and co­
developers of the programmes. In this model, these roles are integrated into the devel­

opment, training, and implementation cycles.

I he sensiti~ation
of host country
personnel

Sensitization of host country personnel is a central concept for projects that target

people with HIV. It is also an important subject in every other training programme to

lower the cultural pressure on the immigrant population in their contact with caregivers.
Immigrant people with HIV find it more difficult (han the general population to
maintain continuous relationships with health centres. In addition to general alienation
and cultural difficulties, language and cross-cultural communication barriers affect the

relationship with the health system, especially when both health and sexual issues are

involved. Stigmatization and scapegoating, which are prevalent in relation to HIV, can
be augmented when immigrants are considered, especially (hose who are identifiable by

their physical appearance, behaviour, dress, or language. Cultural barriers may affect
health personnel, who, when working with people with HIV, must deal directly with

sexual issues. They may find immigrants’ relationship patterns or “esoteric” sexual
practices (e.g.. polygamy or early adolescent marriages) hard to deal with or even
repulsive.
The alienation of health personnel and the difficulties of their clients may be inten­
sified when the immigrants subcribe to non-biomedical models of health and disease or
mix traditional and biomedical models. The resulting frustrations and loss of confidence
can lead to reluctance to return for follow-up care and sometimes to loss of contact with

the health centres. Health personnel might interpret this behaviour as “resistance” and
add it to the bag of characteristics that make the immigrants “hopeless to work with.”
There arc many instances of very low tolerance of such “nonsense” within the health

r 10

Clkiptui 1

I liuui cticul considerations and principles of interventions

system. Mediation by trained people from the immigrant population could help health
personnel to establish a more understanding staff-patient relationship and has been
successful in increasing the rale of follow-up visits.

Iterative development cycles
Three important elements of the iterative model for programme development
converge in this section:
1. the close cooperation between cultural insighters and outsighters;
2. the need to shorten the development period without giving up the principles of
adaptation to the special conditions of the immigrant culture;
3. the need for continuous development according to the changing dynamics and the
identification of issues during fieldwork.
There are both conceptual and practical considerations for the application of this
methodology. First, when working with populations in cultural transition and crosscultural interaction, the situation is highly dynamic. Therefore it is imperative that
mechanisms for changing the programme according to changes within the population be
built into the development methods *.
Second, in most instances the situation within migrant groups is not only serious but
urgent. This is mainly because of the additional factors that increase the potential risk for
HIV transmission in immigrant populations. Urgency can push decision-makers into
using available programmes, on the assumption that doing something, even if it is not
culturally appropriate, is better than doing nothing. This is also on the side of political
caution or wisdom. Yet a continuous development process that is non-linear and iterative
saves lime at the critical period between the initiation of a project and the beginning of
field implementation, while making minimal compromises in terms of cultural needs. An
assumption of this method, which makes the iterative cycles essential, is that at the ini­
tial stages (moving into the training and experimental field implementation), a project
and its components are far from being fully developed. In combining the first and third
aspects of the iterative process as delineated above, this becomes an advantage rather
than a compromise for the sake of time saving.
Third, several components of the iterative cycle are designed for the purpose of
incorporating the perceptions, cultural insights, and ideas of people from within the
immigrant groups who are actively engaged in confronting HIV/AIDS issues.

i
!

biitu i^fllcction mid
analysis

Continuous data collection and its analysis and feedback into the system, at all the
stages of project development and implementation, are essential parts of the iterative
cycle. The principles behind it are that the professionals from both the immigrant and the
host culture who are being trained to carry out the interventions of the projects have
multiple roles, including that of partners in project development, and that training acti­
vities could be designed for the purposes of professional training as well as for inter­
vention and material development.

1
While evident in international migrations, we stress that such issues could arise also in internal
migrations such as rural-urban migrations in multi-ethnic societies. The cultural transition, crosscultural aspects, and dynamics of this internal migration are sometimes underplayed. Losing the
culturally homogeneous environment and the traditional social structures with their checks and
balances and being thrown together in close physical proximity with people from different, sometimes
hostile, ethnic groups can be as demanding as moving to another country. The often dire conditions
can only add to the difficulties of coping with these pressures and therefore pose additional chal­
lenges.

,11

I

Chapter 1

Theoretical considerations ami principles of interventions

Tables I and 2 detail the different methods used for data collection and the different

stages of the programme and projects within which they are used. Two points have to
be emphasized. First, every stage of the process, not only the initial one, includes data
collection and analysis components used for amending and refining the interventions.
Second, the data collected can be used in many ways, and further development is only
one way. The data can also be used as a professional development tool in training and
supervision of the interveners and for quality control and process evaluation.

The tables indicate that different methods must be employed at different stages and

that each stage needs more than one method of data collectioir to get a comprehensive

picture and to minimize mistakes. By structuring the time frame of the training
programme so that it coincides with experimental field implementation of the inter­

ventions, distinct iterative cycles of development could be enacted.

Table 1: Use of data collection methods at different stages of programme development

..........

"-r
2

■

Methods
Library research
Field observations
Non-structured
interviews

++

Semi-structured
interviews

+

+

+

Focus
groups

+++

Multi-purpose training
instruments
Observations of
project events

Self-reporting

+++

Self-response
questionnaires
Structured
interviews

#
+

Iterative cycles of project development
the greater the number of crosses, the more common the method

MB J.IVIU'WTI

+++

Chapter 1

5

Theoretical considerations and principles of interventions

Table 2: Use of data collection methods at different stages of monitoring and evaluation

' 311

i

____________

Methods
Library research
Semi-structured
interviews

++

(+ + +)

Focus
groups
Multi-purpose training
instruments

++

Observations of
project events
Self-reporting

+++

Self-response
questionnaires
Structured
interviews

I

(t+ +)

’Outcome evaluation of HIV prevention will depend on sero-prevalence. modelling, and epidemiological studies of markers like sexually transmit­
ted diseases. On the other hand, outcome evaluation of interim stages (like training of facilitators) could be measured bphaviourally, and the marking
of the methods refers to them.

$

-

“Policy studies, which could be highly important for the development of programmes and projects, should be external to the programmes and
projects. They are based mainly on studies of documents.

I

■

!
.

Developing
interventions and
educational tools

A central component of the iterative model is the combination of activities that are
integral to the training and monitoring procedures and those that contribute to the devel­

opmental elements of the programme. These activities start early in the training process
and continue throughout the programme. They are also integrated with trial implemen­
tation of the interventions, which are conducted in parallel with other activities.
Throughout training and monitoring, sensitive issues and hard-to-solve problems are
reframed as challenges. The training and development group has to cooperate in propo­
sing new ways to deal with the challenges or amending existing strategies. This group
dynamic approach is an important methodology in desensitizing and reorienting most of

the trainees to sensitive issues. Collective experiences from the field combined with
increased cross-cultural wisdom of the trainees through the span of the project elicit new
strategies in dealings with sensitive issues such as condom use. The trainees are able to

have face-to-face sessions about these issues without endangering their professional cre­
dibility or experiencing uneasiness in discussing the subjects. Often when trainees do not

agree with one approach, group activities help to build either a consensus or alternative
strategies from which each could find those most suitable to the specific audiences.
These solutions have a better chance of not being offensive to certain cultural groups and
of fitting to the specific population’s needs.

Employment of
The multiplicity of roles, discussed earlier, must be part of the iterative development
immigrant groups for cycles in order to train the interveners in multiple skills and to create opportunities for
the iterative
the trainees to practise these skills as part of the process. Both need to be deliberate
development cycles
activities that are integrated mainly in the training and trial implementation stages, h

Pi

..........................

_

Programmes, projects, and interventions:
A guide to development
Introduction
Immigrant populations are highly vulnerable to various social, economic, and health
problems. HIV/AIDS is one of these problems. Immigrant populations also have special
needs. Three main components define these special needs:
♦
socioeconomic conditions caused by uprooting from the old country and the hard
ships of resettling in the new country (a situation that may also characterize other
marginalized socioeconomic groups);

the sociocultural specificity of an immigrant population (a phenomenon that needs
to be dealt with also among non-immigrant groups in multi-ethnic societies);
♦
the sociocultural phenomenon of immigration, characterized by transition, crosscultural interactions, and accelerated dynamics of change.
When developing programmes, projects, or interventions for immigrants, a method­
ology is required that addresses both the increased vulnerability and the specific needs of
immigrants. Such a methodology should have a build-in data collection mechanism,
allow for on-going revision and amendments of interventions, and employ tools that can
bridge the gaps between host and immigrant communities.
Based on experiences with programmes and projects for immigrant populations in
Israel, this section provides programme planners with guidelines for project develop­
ment. These guidelines are not intended to replace standard planning tools. The intention
is to feature specific cross-cultural requirements, which need to be taken into account
when developing and delivering interventions for immigrants. Planners and implementers using these guidelines are reminded that it is essential to adapt the methodology
to the specific political, social, and cultural circumstances of the environment in which
they are working, taking into account both the host and the immigrant communities.

♦

Terminology
Three related terms are used in this section: programmes, projects, and interventions.
A programme is a series of interlinked projects. It is developed for the general pur­
pose ol lowciing the risk of HIV/AIDS and dealing with its issues in a specific immigrant
population. A programme is usually developed on a national or state level and must in­
clude policy and strategy components. It is composed of various levels of interventions
(e.g., communication, education, counselling), employs different channels (e.g., distri­
bution of pamphlets, use of print and/or electronic media), and may include non-behavioural components (e.g., regulations, procedures, and protocols, or changes in the
price and availability of condoms). A programme has more than one project. These may
run in a series, in parallel or partially overlapping, and may be modified with the
dynamics of time and sociocultural changes.
In contrast to a programme, a project has more limited aims and objectives, defined
by factors such as population, problem, context, or situation. Thus, within the program­
me for immigrants from Ethiopia to Israel, there are various projects:
The informational/educational project for the general population of immigrants
(1992-93), Your Life Is in Your Own Hands;
The training of veteran Israeli professionals working with the Ethiopians immigrant
community (1992-93 and 1994);
The sexual health-sexual responsibility educational project for young adults in
vocational training residential institutions (1993-94);
The project for case managers/cultural mediators working with people living with
HIV/AIDS (PLWHA) and their sexual partners (1995-present).

I

Chapter 2

Programmes, projects, and interventions: A guide to development

Interventions are discrete components of a project and have limited, specific
objectives. Each usually utilizes one methodology, one channel of communication, and
one level of interaction with the audience. Interventions are developed according to basic
cultural and educational premises and are interlinked and integrated within a programme
to achieve its aims and objectives. A specific intervention can be employed in more than
one project, and there are interventions that are specially designed to link projects.

T;

Stages of development
The initial stages of programmes and projects have some similarities and a few
distinct strategics. Early project development usually should start after the programme’s
broad goals and the specific objectives for each project are set. However, in many
instances, urgency dictates an almost simultaneous occurrence, and some activities in
these stages are similar, especially the initial collection of data from various sources,
including a search of the literature.
Tables 3 and 4 summarize the main stages in the development of a programme, of
projects within it, and their interventions. This chapter focuses on the description of the
methodology of developing programmes and projects, while Chapter 3 demonstrates
their application through description of the actual development of several projects.

Table 3:

Steps and stages for programme development

Stage

Steps and activities

Initial basic
formulation

Formation of a programme team
Literature review
Basic studies of pattern and routes of HIV
transmission of immigrant populations
Policy formulation
Development of strategies
Recruitment of community leadership to participate
in programme development
Initiation of multisectoral cooperation

Programme
development

Identification of subpopulations, critical issues,
and projects to address them
Defining goals and objectives for each project
Establishment of multiprofessional project teams
Defining relations and interactions between projects
Implementation of all the stages of the particular
projects

i

Monitoring and
continuing
development and
implementation

Setting up programme monitoring and evaluation
mechanisms
Regular meetings of programme steering committee
Follow-up and integration of the evaluations of each
project
Changes in policies and strategies

!

/

/'•
/'•

Chapter 2

fic
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an

Table 4:

Programmes, projects, and interventions: A guide to developmei

Steps and activities in the development of a project

______ Stag®

Steps and activities

Early project
development

w
fs

Development of goals and specific objectives
Formative studies
First cycle of the development of modes of intervention,
messages, and means of delivering them (including defining
the characteristics of the interveners
Planning of monitoring and evaluation according to the goals
and objectives of the whole project and its intermediate
stages (e.g., training)

Development of
basic training

Development of training concepts and team
Adapting training methods to the messages and modes of
delivery
Selection of interveners
Pre-training collection of data from selected interveners

Implementation of
basic training

Development of knowledge and attitudes and teaching
of basic skills
Data collection about responses to the messages and means,
barriers and missing links
Second cycle of developing modes, means, and messages.
Activities are structured into the training programme to utilize
the cultural insight of the trainees and engage them as
partners in further developing the project components
Process and outcome evaluation (initiating).

Continuing training
with experimental
implementation and
; monitoring as
;Integral components

Structuring the continuing training programme to include skill
development interlinked with feedback from the field
experience and its utilization in further refinement of the project
and its implementation
Data collection of the field experiences (focusing alternately
on the skills of the interveners and on responses of the
audience to the interventions)
Additional cycles of project refinement and re-implementation

’y
in

s,

1C

?s

A

I

:

■

■

Ongoing interventions
with monitoring and
process evaluation

Outcome evaluation
■

i

/ •

Delivery of the interventions
Data collection and analysis (focusing on monitoring and
evaluation)
Additional cycles of project amendments (for changes in
conditions and opening new channels)

■

Collection of^post-intervention and follow-up evaluation data
for analysis ’
Assessment of the impact on the target population at the
completion of the project in relation to its objectives
Recommendations for future action/inaction within the
framework of the programme

I

Teams to develop
and supervise
prgrammes and
projects

Central elements in the development of HIV/AIDS programmes for immigrants
include the development team and the steering committee. These two teams serve com­
plementary functions. While the development team usually represents professional
expertise, interest, and ethnic balance, the steering committee represents formal and
informal responsibilities, organizations and groups, vested interests, and the leadership
of the communities involved.
The teams usually evolve in an ad hoc manner, and concerned professionals may be
over-represented. But as the central role of both types of teams is the development of
policies and strategies, it is important to strive for recruitment from all concerned sectors
and segments of the populations targeted and to integrate them in the policy and strategy
development process.

Chapter 2

Programmes, projects, and intei ventions: A guide tn development

n The steering committee
The steering committee represents all aspects of the host and immigrant communities,
including their governmental and non-governmental organizations (see Box 1). The main
tasks of the committee include the development of the general objectives of a program­
me or project as well as broad guidelines for implementation, monitoring, and evaluation.
The committee also establishes the project development team. Usually the steering com­
mittee is not involved in the development of concrete project activities.

■

Bo\ 1:

I lie v\ oliifion of ;i sfecritt” cointnif tee and a professional team

The head of the Israeli National AIDS Steering Committee asked representatives of various
organizations and communities to form the interagency steering committee for an HIV edu­
cation project for Ethiopian immigrants to Israel. The Israeli National AIDS Steering
Committee decided to target the adult population among approximately 24,000 Ethiopian
immigrants residing in absorption centres and hotels at the end of 1991. An anthropologist,
who had studied the community and its concepts of health and disease, and a physician, who
had training in public health and medical anthropology and who had previously worked
within the community on hepatitis B virus and HIV infection, submitted an initial'proposal
to the head of the Israeli National AIDS Steering Committee. To reinforce their initiative,
they approached members of the Hebrew University—Hadassah School of Public Health.
Two staff members, who had experience in health education, including work with Ethiopian
young people and HIV prevention and in social-behavioural research and social work inter­
ventions with people of marginalized groups and people with HIV, agreed to join them. A
team of four was thus formed under the auspices of the school of public health. The diffe­
rent areas of experience of members of the team were highly relevant to the project. The
team proceeded to develop a full proposal lor the education project, with an initial concep­
tualization of the educational components and the methodology of the project, the structure
and content of the training, and ideas about implementation, monitoring, and evaluation.

t

1 he expanded proposal was submitted to the Israeli National AIDS Steering Committee. The
proposal was accepted and funded for the duration of February-August 1992. Early in the
project, the team recruited two coordinators, who were significant contributors to the project:
a cultural coordinator who was a veteran immigrant from Ethiopia with experience in
HIV/AIDS education, and a project education and field coordinator, who was a qualified
teacher and sex educator. During the work of the team, it became apparent that a wider inter­
agency steering committee would be beneficial, and it was therefore, widened. ®

“i I'lie development team
Il is important that the development team represents several areas of expertise and interest
as well as pertinent ethnic groups. The team can include professionals with experience in
medicine, public health, anthropology, sociology, social psychology, education, social
work, and communication, as well as research, evaluation, cultural and cross-cultural
issues, and development and implementation of interventions addressing human sexual­
ity, substance use. and HIV/AIDS. The balance of expertise can vary with the goals and
objectives of each project. Members of both the immigrant and the host communities
should be represented on the development team. It is especially beneficial to include
veteran immigrants - that is, immigrants who have lived for a long time in the host com­
munity. They can contribute valuable insights from both the host and the immigrant
communities.
In order for such a team to be manageable, the number of members should be limited
to include a representative selection of the needed professions and areas of interest and
expertise. Il is recommended that each member of the team have several of the required
characteristics. The optimal number of members for such a team is between four and
seven.

Chapter 2

es,
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■y

Programmes, projects, and interventions: A guide to developmen

A major aim of HIV programmes for immigrant populations is integrating a
comprehensive and appropriate migrant population policy within a national policy. This
can be quite a difficult and complicated task due to the barriers created by the special
situation of most migrant populations. These barriers include economic and social
marginalization, stigmatization (especially if they migrate from regions with a high pre­
valence ol HIV), and cultural difficulties such as language problems and alternative
models of health and disease, all of which demand greater effort, investment, and pers­
everance in risk reduction. These elements could easily be mistaken for non-compliance
or lack of interest in prevention, and they could lead policy-makers in the opposite direc­
tion. These difficulties may reduce the readiness of politicians to invest efforts and funds
in prevention, or may lead them to invest only when the HIV situation among the
migrants is perceived as a threat to the general host population. The use of culturally
inappropriate interventions could aggravate the situation. When such interventions fail
to have the desired impact, the result may be mistakenly interpreted as denial or lack of
interest.
Denial about HIV/AIDS is a common barrier in many situations and social groups.
It should be taken as a normal response; one that requires careful study before it can be
addressed. Denial may be intensified among migrant groups who are jmarginalized.
Sometimes data about HIV are used incautiously and in a manner that could aggravate
marginalization. Stigma perceived by the immigrant community could also be a pro­
jection of internal stigmatization of people with HIV within the immigrant community.
Recognizing these situations does not mean that denial has to be accepted, even in the
presence of stigmatization, if the denial persists and impedes risk reduction efforts in the
community. Groups need to explore other means to cope with stigmatization beside
denial and blaming, and interventions to deal with these barriers should be developed in
cooperation with the community.
The following recommendations for the development of national policies to deal
with migrant populations and HIV/AIDS are based on the view that migrant populations
have special needs and not that these populations constitute a threat. The recommend­
ations are directed primarily towards reducing the risk of HIV transmission within the
migrant populations and only secondarily at defending the general host population from
the migrant population.
❖ .* u i <n 11 ii iciii I .i I h m I; \dvdicakd polio slratcg) Irani

A special group should be responsible for formulating policies, at the national or regional
level, for the prevention of HIV transmission among immigrants. These policies should
be coordinated and integrated with other national HIV policy and strategies. It is
important that this group include representatives from the immigrant population, as well
as professionals who have knowledge of the community or who work in the field of
sociocultural transitions or migrations and HIV/AIDS. The group should include people
with direct links to executive authority and budget allocation and should have access to
all sources of epidemiological data about patterns of prevalence, incidence, and routes
of transmission of HIV/AIDS in the immigrant population. It should also have the
authority and means to gather sociocultural data about the factors determining the above
and about the specific difficulties and distribution of power within the immigrant group.
❖ Recommendation 2: Including actixists and coinnmnity leadership

Leaders of the community as well as community groups or organizations with special
interest in reducing the incidence of HIV transmission and caring for people with
HIV/AIDS should be involved in policy-making.

❖ Recommendation 3: Intergration of groups' ideas, plans, and agendas
Activist and interest groups within the migrant populations, for professionals, and
organized around HIV/AIDS issues should prepare their agendas and policy
recommendations from their unique perspectives. Such working documents could
enhance the development of policies and strategies by helping to identify special
concerns and issues.

Chapter 2

Programmes, projects, and interventions: A guide to development

♦ Recommendation 4: Transparency

All policies and strategies should be easily accessible to the community and all parties
involved.
♦ Recommendation 5: The formation of teams

Programme and project steering committees and professional project teams should be
formed to direct and oversee the execution of the programme and projects.

.dim

♦ Recommendation 6: Special programmes and adequate funding

The special needs and sociocultural conditions of migrant populations require specific
programmes and projects and adequate funding.
♦ Recommendation 7: Integration of universal with specific messages

I

Universal HIV prevention messages should be included, but appropriate messages
specific to the target population should be incorporated even when they seem to be alien
or controversial to the host culture. An example is the message to sterilize equipment
used for traditional medical practices, even if the general approach is that these practices
ought to be stopped.

.

♦ Recommendation 8: Destigmatization
Destigmatization and acceptance of both the general migrant population and people with
HIV among them are essential and have a strong bearing on prevention as well as on
appropriate care.

Jilj 1

♦ Recommendation 9: Sensiti/ino host population professionals

Programmes for immigrants should also include a training component for professionals
from the host culture to deal with the immigrant population in a culturally sensitive man­
ner and with cross-cultural competence.

Collecting and analysing data
An important feature of the methodology is the ongoing, deliberate, and structured
data collection and analysis with feedback into the development and implementation at
all stages of any project. Such collection, analysis, and feedback are essential parts of the
continuous iterative development of programmes and projects, and interventions within
them, of monitoring training processes and experimental interventions, and of eva­
luations. Ongoing data collection, analysis, and feedback serve two main purposes:
shortening the initial development period and allowing implementation to start at the ear­
liest time possible, even within three to four months: and offering the flexibility required
to adapt the programme in response to the dynamic changes that constantly occur in the
living conditions and sociocultural circumstances of migrant populations.
It is also important to collect and analyse data about the prevalence, incidence, pat­
terns, and routes of HIV transmission in the immigrant population. These can be dis­
tinctly different from those of the host population and reflect various aspects, or combi­
nations of aspects, of the sociocultural uniqueness of the immigrant situation. The contri­
butions of these distinct factors to the differences between the immigrant and host popul­
ations must be considered in the development of HIV/AIDS policies and strategies.
Cultural differences that influence transmission routes could include marriage or sexual
liaison patterns or sexual practices. Parenteral transmission routes could be rooted in
cultural traditions and rites, or in alternative medicine. Examples of the differences stem­
ming from the immigrant situation are diverse, and may include exploitation or partici­
pation of immigrants in the sex industry, low socioeconomic status, and less access to the
health system, which may influence patterns of transmission through alternative medici­
ne practices.

ft

I
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Chapter 2

Programmes, projects, and interventions: A guide to development

I

Population
characteristics

The following characteristics of the population should serve as the focus for the col­
lection of pertinent information to support the case for action, the initial formulation of
the programme, the selection of the target population, and the primary development of
projects, their interventions, and their messages.
Health status. This includes HIV/AIDS prevalence and incidence as well as
main modes of transmission. Other epidemiological and clinical facts, including
prevalence of other sexually transmitted diseases and tuberculosis, are also required.
Risk behaviour. Risk behaviours can include sexual behaviour, intravenous drug
use, and skin-piercing practices. Identifying the magnitude of risk behaviour and the
groups that it effects is crucial. In addition to the more recognized practices that are esta­
blished as risk factors for HIV, every culture may have additional practices that can
increase the risk of infection. These can include sexual practices such as heterosexual
anal intercourse as means of contraception or preservation of virginity, dry intercourse,
bloodletting by healers with the use of traditional tools, and uvulectomy.
❖
Attitudes, beliefs, and practices. What is the prevalent health model - tradit­
ional or modern, or a combination. What are the specific characteristics of such models
that may promote or hinder risk reduction efforts and caring for people with HIV/AIDS?
Legal status. The legal status of immigrants in the host country may^ influence
their vulnerability and their contacts with prevention and care projects. Immigrants
usually have less access than the general population to the health system. This may
increase their use of alternative medicine practices - which, in turn, increases the risk of
HIV transmission - and reduce the likelihood of medical follow-up of people with HIV
and symptomatic patients. Also, immigrants who reside in a country illegally or semilegally may avoid any contact with programmes or projects, as these may expose them.
Sometimes the legal status of temporary residents given to immigrants allows for depor­
tation of people with HIV, which may impose an additional barrier to prevention efforts.
Motives for migration and period of migration. A great difference exists bet­
ween immigrant communities, depending on whether people fled from their country
because of political, ethnic, or religious prosecution, or chose to migrate for economic
reasons. For example, if men migrate for better jobs, they sometimes do so without their
families, a fact that has implications for their social behaviour. Many of the immigrants
to Israel chose to migrate for ideological or religious reasons.
Demographic characteristics of the target population. Any information on the
demographic composition of the immigrant population could be essential for evaluating
their vulnerability to IIIV transmission. Age, gender, and marital status are the primary
variables to be considered. For example, if the proportion of children and young people
in the population is high, they should be targeted separately; if most of the migrants are
single men, the risk for HIV increases. The study of marital status may be problematic,
as the term may be culturally specific (see Box 2).

Box 2:

■

I

Marital status
‘

' "?v;' J

t; The recorded status “unmarried” can vividly illustrate the complications of cross-cultural
L communications. Many of the young men and women among Ethiopian immigrants to Israel, J
while legally unmarried, are “promised.” This was a highly binding status among the Jews in - J
Ethiopia and was usually consummated in marriage when the girl reached puberty. Tnie post-r , 1
ponement of marriage, in conditions of relatively low social control, exposed young men and
women to situations that many of them were not ready to handle.
j- Also, out of respect for the religious tradition of the community, most of the youth and young;>
l adults were sent to religious boarding schools for vocational training, language learning, and •
> cultural orientation. These were gender segregated and not geared to deal with married
: couples. Moreover, the schools together with the community decided not to separate families.
Therefore, one of the conditions of acceptance into the programme was that the candidate be
| unmarried. This tempted quite a few immigrants to declare themselves unmarried, especially
? when they did not arrive in Israel with their husband or wife, a

21

J

J

Chaplnr 2

Pioqtanunos, piojncts. anH ini

"'iiliorm A q'liHn P’ Hr-’rlnptnnnt

Similarly, the education level or literacy rate could determine immigrants’ previous ex­
posure to various channels of prevention messages and appropriate future methods for
development of the programme. The education level in the population is also connected
to the pace of mastering the language of the new country, and the readiness of the immi­
grants to communicate with members of the host country. For example, immigrants to
Israel from the former USSR who were well-educated professionals (intelligentsia)
found it especially difficult to communicate in a language that they did not master well.
Health professionals reported that these people rarely asked questions, made comments,
or volunteered information.
Other important demographic data should be collected, including information on religion
and religiosity, living conditions, geographic distribution, and housing arrangements. It
is important that the collection of statistic facts be supplemented by an understanding of
the meaning of these facts for the population. For instance, does being married mean that
no sex with another person is accepted, or is it common and culturally normative to have
sex outside marriage?
•>
Social position within the host society and social changes resulting from the
immigration. A review of (he status of migrant populations in the new country must be
carried out (c.g., their socioeconomic status, work opportunities, and degree of assim­
ilation, and the presence of stigmatization). Inappropriate job opportunities or employ­
ment in mainly low-income jobs because of cither low level of education or unfamiliar­
ity with the language could place immigrants at low socioeconomic levels. Even im­
migrants with high educational levels may experience a downward occupational drift
because of differences in professional knowledge and technology between the country of
origin and the new country, and licence limitations (as has been the case with immigrant
health professionals from eastern European countries in Western countries). This
situation is likely to cause stress, and can sometimes lead to risk-taking in order to
increase income and to belter social position (e.g., exploitation or participation of immi­
grants in the sex industry).
Immigration may also result in changes of authority within the immigrant community.
For example, elderly immigrants coming from traditional societies Find it most difficult
to adjust to the new country and so slowly lose their social power. A role reversal some­
times occurs when young children help their parents in their contacts with institutions
and then find it difficult to be submissive at home.

\h t/n)d\ for (lata
collection

r 22

At various stages of a project, similar data collection methods may serve different
purposes. Some methods are more appropriate al the initial development stages, while
others are more appropriate for later stages, monitoring, and evaluation.
Methods of data collection and analysis should be diverse. It is recommended that
developers and implemcnters of programmes for immigrants use at least four different
methods of data collection, preferably more. Data collection can be overlapping and
complementary; data collected using various methods may even be ambivalent or
seemingly contradictory. Sources of information may also be diverse: professional
literature, general knowledge, or governmental publications regarding legal, social, and
medical facts; professionals or volunteers from governmental or non-governmental orga­
nizations working with the population or in 111V transmission prevention; key members,
professionals, or “regular” persons from the target population.
Box 3 and Tables 1 and 2 (pages 12 and 13) list several data collection methods that
could be used at various stages of project development and implementation. These are
standard methods, which are described in many methodological textbooks. The following
subsection offers short descriptions that emphasize the specific demands of data collect­
ion for migrant populations.

■

Chapter 2

Box 3:

n

... a
;

n

ip
q

Programmes, projects, and interventions: A guide to development

Methods of data collection

...
Literature review
On-site observations
Non-structured and semi-structured interviews
....
Focus groups
Training activities designed for review of project materials by immigrant
professionals in training and proposals for developing new materials/interventions
lUVlld
Structured observations of project activities
Reports on the implementation of activities
Questionnaires
Structured interviews, n

I

■

' Hi

■ I
i

The literature review is an important component of data collection in the formulation
stage. Several different types of literature need to be reviewed:
♦ Relevant epidemiological, social, cultural, and educational data from the country
of origin of the immigrants. For example, in our work we used such resources on
the immigrants from Ethiopia and the former USSR. This information should be
used with the understanding that the sociocultural situation of an immigrant
population in the host country is different than in the country of origin.
♦ Data from other host countries in which migrants from the target populations
reside. Because of the difference in situation, context, and culture, the use of such
data is limited to looking for similarities in the ways other cultures view this group,
gaining a different perspective on its uniqueness.
♦ General studies, guides, and manuals on HIV/AIDS prevention and care, which
may include recommendations and methods on cross-cultural aspects of
HIV/AIDS prevention.
♦ Studies on the immigrant populations in the host country. These are important
because they represent the issue of cultural transitions and cross-cultural inter
actions unique to the combination of both the host country and immigrants, and the
interactions between them. The previously collected materials could be of a basic
research nature in the Fields of anthropology, sociology, psychology, or health.
They need not be limited to the Field of HIV/AIDS. Related areas include
infectious diseases, sexuality, sexual and reproductive health, adolescence, and
immigration.
♦ Studies on the theory of cross-cultural relations and of their application in the
development of interventions to promote cross-cultural sensitivity and
competence.

|l

"i Literature review

Other areas that need to be covered include theories of health behaviour and health
education; the development of interventions to reduce the risk of HIV transmission,
especially those dealing with theory-based development; and sexual health and sex
education.

~i On-site observations
In this anthropological method, researchers introduce themselves to a community and
talk to its members about a wide range of subjects, which may include topics of specific
interest to the community. If the opportunity arises, the researchers could introduce the
issue of migration into the discussion and collect valuable information. This method
should be used during the initial development process to identify not only culturally
specific factors that may determine routes of transmission or barriers to prevention, but
also cultural themes that can be utilized for interventions. In some cases, the inclusion
of this method could be too time-consuming, and programmes should, if possible, use

23

II

I
I

Chapter 2

Programmes, projects, and interventions: A guide to development

existing data. For example, many of the initial data in the information and education pro­
ject for immigrants from Ethiopia were based on observations made in the course of
developing a programme for the prevention of hepatitis B transmission within this com­
munity (Chemtob et al. 1991). Because the modes of transmission are similar, the fin­
dings could be transferred to the HIV/AIDS field and the information could be used to
develop ideas about culturally appropriate methods for a programme for HIV transmis­
sion prevention.

n Non-structured and senii-stnictnred interviews
Interviews could be used at various stages of project development and implementation
for the identification of prevention themes, of strengths and weaknesses of interventions,
and of specific barriers to prevention, for the development of messages, and for process
evaluation. The difference between the two types of interviews is in the degree of direc­
tion that the interviewer provides. In a non-structured interview, the interviewee has
maximum control over the selection of topics of discussion and their depth and the juxta­
position of the subjects, within the general area of the interview as selected by the inter­
viewer. The interviewer's role is deliberately limited to introducing the area in a prefer­
ably neutral manner and asking probing questions. The non structured interview com­
plements mainly on-site observations and is applicable in the earliest stages of collecting
the basic data for the development of a programme or project.
Box 4:

Sample semi-sfruchired interview for trainees

Interviews about HIV/AIDS and sexual issues with Ethiopian immigrants to be trained as
educators/facilitators.
AIDS
What do people say about AIDS? fhe reasons or explanations they give for the way they
think. The feelings that people express about AIDS and the people who have it.
What do people think/say about how you get AIDS and about how it is passed on?
How can a person know if he or she has HIV/AIDS?

I

i

I

Sexually transmitted diseases
The explanations that people give about getting specific sexually transmitted diseases
(e.g., gonorrhoea).
The issues of sexual relations with people who have sexually transmitted diseases and
the way that these people have to behave.
Sexual relations
;.; : . ; . ;
The differences between Ethiopia and Israel in the relations between men and women
and in sexual relations.
What people feel and think about the differences.
The ways people cope with the differences (e.g., the difference in the age of marriage
and the arrangement of matches; the ways they manage without parents to arrange mar
riages).
Definitions of “manhood”, “man." The meaning of being a man in relation between a
man and a woman.
The definitions and descriptions of “woman,” “womanhood,” and a “good woman.”
Times, contexts, and arrangements in which people have sex. What is not permitted and
the way people transgress.
What happens to a woman who is 18-20 years old? How do people feel about what
happens?
Who can have sex? Who cannot have sex? With whom?
Widowhood and divorce in relations to sex and “arrangements.”
The ways men and women signal to each other about their wish to have sex or their
refusal to do so beside saj ing it explicitly.

When docs a women become pregnant? How many times do you have to have sex in
order to become pregnant (to make a woman pregnant)?
When do people have a new family? What happens to the old family? When does a man
have another wife? »

24

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Chapter 2 A guide to development
Programmes, projects, and interventions:

In a seini-siructured interview, the interviewer prepares a list of content areas in which
the development team is interested. This list is used as a general guide and a checklist
against which the interview is monitored. The example provided in Box 4 demonstrates
its use in the early stages of the development of a project, while Box 5 demonstrates its
use at a later stage, the second and third cycles of an iterative development, when the
intervievx ees have already been exposed lo an intervention programme or to parts
thereof. The interviewers may also prepare a set of questions, episodes, or other means
by which they can elicit information in the desired areas. The advantages of semi­
structured interviews for the development of intervention programmes are numerous.
First, they are open enough to elicit needed cultural information, but they still focus on
areas with higher probability of applicable information without being restricted by
assumptions. Second, the analysis of their results, while using predetermined categories,
has a built-in flexibility that allows the recognition of new categories and relationships.

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Box. 5: Sciiii-stiiiclurvd inlci xicw for a migrant \outh population
Content areas for interviewing migrant youth in a sexual health educational programme
It is suggested that the following domains be included in every interview:
Attitudes and opinions about sexuality; men, women, and the relationships between them
Responses to the intervention programme on Jsexual health ,(for the ipurpose of ongoing
1 -o development).
r

ii-

ig

'.V

This could be achieved without unnecessarily prolonging the interview (more than one and a half hours) by focus­
ing on only two or three of the areas of the first domain and building the questions about the educational pro­
gramme around these responses. The items need not relate to the same topics but rather can be used as entry points
to the subjects of the intervention programme. The choice of areas could be planned in advance or decided during
the interview. In planning a set of interviews, care must be taken to cover a variety of content areas, keeping some
overlap between different interviews.

■

i

■

|

Attitudes and opinions about sexuality; men, women, and the relationships between the genders
Couple formation and couple relations (intimacy in relationships).
Typology of men and women according to their sexuality and relations between the genders (good-bad,
desirable-undesirable, successful, respectable, etc.).
Currently important matters for young men and women (similarities and differences, priorities in relation
ships, life plans).
Sexual relations and their implications (including sexual intercourse within relationships and casual sex;
differences between reported and practised norms and behaviour).
Perceptions of Israeli reality in these areas and interpretations of this.
Birth control and contraceptives (including differences between contraception and preventive measures
against sexually transmitted diseases and HIV transmission; differences for men and women; motivations
and barriers to the use of contraception and to specific contraceptives, with an emphasis on condoms).
Pregnancy and its implications (including unplanned pregnancy, pregnancy in marriage, pregnancy
termination, etc.).
Sexual health; sexually transmitted diseases and HIV/AIDS: attitudes, risks, transmission, and prevention.
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sinceyour
your
immigration.
iiiiiingiauuii.How
nowdo
uothe
mechanges
cnangesaffect
ancciyou;
you;how
nowdo
uoyou
youfeel
teeiabout
aooutthem;
mem;how
nowdo
aoyou
youdeal
aeaiwith
wttnthem?
mem7
'd-- For women: your attitudes towards and feelings about men; the way you deal with men in different J
• circumstances and contexts; what women believe men think about women and want from them.
For men: what happened to Ethiopian women in Israel; how does this affect both genders, what are the
changes in women’s behaviour towards men here?
If
It new immigrants were to arrive from Ethiopia, and you were to meet them at the airport, or if they were
joining your vocational training or absorption centre, whai would be the most important thing for you to tell
them about life in Israel regarding men and women?

Responses to the sexual health education programme
How do you feel about this programme? What was good (beneficial, comfortable) about it? What wasn’t >;
good (disturbing, difficult, embarrassing) about it?
What was the most important thing in this programme? What was Ileast ....
x
„If....
z to
important?
it were necessary
shorten the programme because of time or budget constraints, what items would you choose to retain? What
parts would you advise the people responsible for running the programme to disper"
:‘u Would the
:nse —
with?
advice about retaining and dispensing with parts be the same if the programme were for groups of your own
_
____
gender or the opposite one?
...........
- were difficult to leam from the programme and could benefit from strengthening or changing
What subjects
methods?
.
.
Which subjects would you recommend not to teach/present to groups of your own gender (the opposite
gender)?
Which methods of presentation/mstruction/communication did you enjoy most? Least? (e.g., discussion,
fc'- ■ group activities, teaching with or without slides and overhead transparencies, movies).
In your opinion, is it advisable to conduct such a programme for men and women together or
separately? A
.

,.v

’... „

.

.

25

I

Chapter 2

Programmes, projects, and interventions: A guide to development

*

n Focus groups

In focus groups, information can be collected at both the initial development stages and
in response to interventions at the implementation stages. In such a group, members of
the target group are asked to discuss a specific subject relevant to the project or inter­
vention. The data collector takes notes on the responses. The data could include a range
of opinions, attitudes, and reactions expressed within a relatively homogeneous group in
response to an identical cue. The observation of the dynamic of interactions between the
participants of the group could provide additional valuable information.

|

"i Training activities for members of immigrant communities

During courses at which members of the immigrant population are trained to implement
activities, important information could be collected. Such information consists of the res­
ponse of the trainees to the activities or messages that are proposed for the project (see
Box 6). Training courses for members of the target group constitute a special form of
focus group that allows the trainees to respond to the proposed material from the view of
a future intervener and, by amending it, to adapt the course to their specific needs and
level of confidence. Their cultural insight and reactions provide them as well i
e
trainers with a much better understanding of the response of the target audience to the
proposed activities, messages, or educational instruments. Data gathering is done in
small working groups and in interaction with representatives of the project development
team, whose members act as facilitators.

III

Box 6:

t

Responding to fear and shunning in a training session

Taped situation
Friends discuss over coffee the fact that a next-door neighbour is ill with AIDS. A
woman states her fear, the fact that she would not go into this apartment, that she
does not allow her children to play with the children of that woman, and that she
wants her evicted from the building.
Process: The activity form and taped situation are introduced. The participants are
asked to write their responses individually, during the presentation of the tape and
immediately after it. After the participants record their responses on the form, they
are discussed in small groups with facilitators and the outcome reported to the whole
group. At the end of the intervention, the (anonymous) forms are collected for anal­
ysis.
Comments: The training objective and the data collection objectives are intertwi­
ned. We wanted to gain a better understanding of the factors affecting fear and pro­
moting shunning of people with H1V/AIDS within the community, a phenomenon
that was reported widely. Assuming that our trainees had very similar responses, we
aimed at allowing them to air and explore their own feelings and response. The next
objective was to look with them for ways of dealing with their emotions and of hel­
ping others to do so.
Activity form

I his tape holds an authentic conversation of friends meeting over a coffee, when the
talk turns to the topic of AIDS.
Listen to the tape and, while you listen, make notes of the thoughts, feelings,
and responses that the talk arouses in you.
Thoughts:
Feelings:
Other responses:
What would you say or do if you were the neighbour of the woman who was
infected with the AIDS virus?
As an educator delivering information on AIDS prevention, what would you
advise regarding behaviour towards the woman infected with HIV? ■

H 26

Chapter 2 A guide to development
Programmes, projects, and interventions:

n Structured observations of project activities

1
f

1

Structured observations of programme or project activities could provide valuable informa­
tion for development and training as well as for monitoring and evaluation purposes (see
Boxes 7 and 8). Data collection could be done by trained observers who do not participate in
the implementation of the activity but who are familiar with the basic premises of the pro­
gramme or project and its methodology.
Structured observations could result in identifying problems that need to be attended to and
difficulties facing interveners and in refining or amending interventions. One of the great
advantages of such observations is that as they are carried out by people who are familiar
with the project and who participated in planning and debriefing sessions. They can feed back
their information relatively quickly into the system. Such observations are especially useful
al the stages of (raining and experimental implementation of projects.
Bos 7;

Kc\ ii \s <d posk i s

Immigrant professionals being trained as educators were asked to review posters, using this
form. It may be used individually or in small groups.

Visual Aid Review Form

Poster no.:

- What subject would you use this poster for?
- What do you like about this poster?
- What do you dislike about this poster?
- What would you change?
- In what way would you like to change it?
- Are there things that need to be added?
- Are there things that need to be removed/erased? eb

The observers may be members of the immigrant population or of the host community, who
may not even understand the language. They look for the responses of the participants to the
processes and content of the interventions, whether they are training sessions or implementa­
tion of education or counselling sessions. It is not only the content of the responses that is
noted, although this may be very important, but also the emotional and attitudinal responses
and the interactions among the participants. Variations in responses and respondents are also
important - for example, whether men and women, young and old, respond differently to spe­
cific stimuli. Several important insights can be gained from observing the facial and body res­
ponses to the verbal and visual messages, the interactions between the facilitator and the
audience, and the level and tone of the verbal comments.
B<»\ S:

(.uidcliucs for obsri \ a lion of training sessions

Number of participants:
In Icctures/group interactions of all types

Describe the means and strategies used by the lecturers to involve the participants and the
degree of persistence and effectiveness of these means.
Describe the dynamics of interaction among participants, and between them and the ins
tructor (e.g., discussions taking place within the group; discussions among participants,
taking place apart from the group; persons expressing uneasiness by not joining, or by
their non-verbal communication, such as facial expressions, avoiding eye contact, and with
drawal from the group circle).
Identify, from the questions and answers, elements that are important for the participants’
understanding of, or their failure to understand, the content. Are there difficult elements that
are repeated? Also identify from the responses of the trainees successful strategies and inter
actions.
In interactive workshops
Describe the degree of interaction and cooperation in fulfilment of tasks within the small
groups (general involvement or individuals who lead the rest).
In demonstration work.shops.(iiiforination models)
Describe the degree of willingness by the participants regarding fulfilment of tasks, degree
of knowledge, fluency, and confidence shown by the demonstrator (give name). Describe the
responses of other participants to each demonstrator, u

27

Chapter 2

Programmes, projects, and interventions: A guide’ to development

n Reports on the implementation of activities

This method complements the observations of the trial implementation during the
training courses. It provides the subjective perspective of the intervener. Forms for selfreports should focus the attention of the implemcnters on two distinct areas: their own
issues in implementing activities, and the response of their audience. Further directions
focus their attention on strengths and barriers in working through the interventions.
1 Questionnaires
This method can be used at all stages for various purposes and with distinct formats and
lengths. Questionnaires can be given to the target population at the development stage to
evaluate baseline knowledge, attitudes, and behaviour in order to plan the intervention
and to compare these findings with those at the outcome evaluation stage. They can also
be used for process evaluation, especially in training. Their advantage is that in a group
situation they arc time saving and promise anonymity to the participants.
There are several constraints to their use. First they need adequate translation into the
native language of the immigrants and adaptation to their culture. Second, their use is
recommended only for populations with high literacy rates. Third, they are rccomir led
only in conditions where close monitoring is possible (i.e., in group situations) h> oid
response bias such as social desirability or fear of stigmatization. Fourth, many im­
migrant communities, especially those coming from less democratic societies, are wary
of questionnaires and distrust (he promise of anonymity.
"i Structured intersievs

Structured interviews are most useful for collection of baseline data from the target
population and for outcome evaluations. During structured interviews, the interviewer
uses formats similar to those of questionnaires. Due to the sensitive nature of subjects
related to HIV/AIDS in working with migrant populations, this method has a number of
advantages over questionnaires. Structured interviews provide opportunities to:

♦
♦
♦
♦
♦

build trust and alleviate suspicion during the interview
enhance valid and reliable answers
elicit more detailed explanations to difficult questions
respond to unforeseen reactions to the questions in the interview
provide HlV/AIDS-rekited information.

Some points of caution arc important:
♦ This method is more expensive than the use of questionnaires and, tlx
ne.
requires sufficient funding.
♦ It requires careful training of the interviewers to avoid the possibility of them
influencing the interviewees and to reduce response biases such as social
desirability to a minimum.
♦ In small immigrant populations with close social lies, the interviewers may find
that they have to interview their own acquaintances or relatives.
♦ In many traditional societies, only same-gender interviewers are acceptable. It may
also be difficult to interview couples without the presence of the other partner.
♦ The quality of data may sometimes suffer because it is not always possible to find
qualified people from the immigrant population to work as interviewers and they
themselves have difficulties working with structured formats.
♦ Often, the interveners may be the only available trained personnel who must also
carryout the data collection. The combination of the two roles may affect the
quality of data through reduced objectivity.

28

* 'WlTiilrr

Chapter 2

-

Programmes, projects, and interventions: A guide to development

Involving community leaders
I he importance ol involving the leadership and organizations of the immigrant com­
munity in the development oi policies and strategics cannot be stressed often enough.
Their involvement is in itself an intervention strategy that needs to be carefully planned
and, at a later stage, examined. The support of the formal and informal leadership of the
community during policy and strategy development as well as during development and
implementation of interventions is essential to the success of programmes and projects.
II is not recommended that the development and implementation of interventions be
delegated to the leadership or to teams composed only of the immigrant group. An
alliance and true cooperation between the migrant population and the host community
need to be created. The reasons for this include:

♦

i

♦

The immigrant population is in a cross-cultural situation, which requires the
inclusion of developers and implementers from the host culture as much as those
from within the immigrant group.
Preventive interventions for the migrant population have to deal with bridging gaps
and mediating between the migrant population and the host population and
segments within it (such as education and health professionals, who deal with the
migrants in close proximity).

Il is, therefore, important not only to identify leadership and interest groups within
the migrant population, but also to create links with professional and interest groups
within the host population. Representatives of the immigrant community leadership
should be included in steering committees for specific projects, and professionals from
the immigrant community should be included in the development and implementation
teams.
During the development of policies, it is important to consult and negotiate with
leaders of a wide range of groups, which represent the various opinions and interests
within the immigrant community. Those members of the group who are ready to take
responsibility for the implementation of activities or addressing the issue of the
development and implementation of the interventions in public should be linked with
each other.

The needs of immigrants with HIV/AIDS
Due io the additional burdens imposed by their life in the host society, immigrant
people with HIV are usually in a much worse situation than those in the host community.
Thus, health care for immigrant people with HIV might need to be more interdisciplinary
than usual, including psychosocial and cultural issues in the services. Such issues, if not
understood, can become obstacles to maintaining continuous relationships with health
centres, thus resulting in neglect and deterioration of health status. The issue of stigma­
tization becomes a greater issue than for the rest of the immigrant populations because
people with HIV/AIDS tend to be more isolated than others. This situation may be
aggravated when the stigma of AIDS is great within the immigrant population. The role
of mediators who are members of the community is very important for enhancing com­
munication between the health and other welfare systems and people with HIV, their
partners, and families. Many health centres recognize that they need the help of people
from within the community in their interactions with patients. But they often opt for the
most convenient solution, that of employing •‘someone" - and not always the same
person on a permanent basis - as a translator. There is an important distinction between
translators and mediators. The latter act not only in translating the language but in
bridging the cultural gap between the personnel of the host society and the immigrants
by explaining to each side the meaning of what is being said.
Thus, in projects tor people with HIV/AIDS, it is recommended that the following
points be considered:

♦

Recruitment and training of cultural mediators should be done as soon as HIV

29

Chapter 2

Programmes, projects, and interventions: A guide to dr’ rlopment

♦

♦

♦

♦

♦
I

infections within an immigrant population are discovered. Maintaining good
relationships from the outset is easier than reconnecting with frustrated and angry
people.
A project should be started only when there are skilled people from the immigrant
community who can be trained to work as mediators. Although professionals (e.g.,
registered or practical nurses, social workers, paramedics) are preferred, if they are
not available others may be employed after being sufficiently trained.
Even if people with HIV have been living in the new country for a while and have
a basic knowledge of the language, it is better to involve a mediator to overcome
cultural barriers. One should, however, be cautious of the possibility that
mmigrants may prefer to avoid any contact with people from their own
community for fear of stigmatization. The advantages of working with a mediator
should be explained to them, but patients should be given the option of not
involving a mediator, especially if contacts to the medical service centre have to be
maintained.
The main role of mediators is to establish communication between people of two
different cultures. Beyond their general cultural understanding, their ability
mediate will be enhanced if they know members of the community. Therefore, . .
recommend that the mediators be appointed to work also as case managers of
people living with HIV/AIDS and have a broad role in identifying problems and
referring them to the appropriate service.
Because of the relative isolation of people with HIV in the immigrant community,
and their reluctance to come for regular follow-up visits, mediators have to be
much more active in reaching out to people than is usually done in the host
community. Therefore, it is recommended that the mediators be placed at a
community health service and not at an HIV clinic. This would serve two purposes.
First, mediators may have better access than health service personnel to people
living with HIV/AIDS and could be more familiar with the various community
services. Second, mediators would not be identified as workers in the HIV clinic,
even if they accompanied a patient for medical visits. Thus, when they go on home
visits, the neighbours cannot guess the purpose of the visit, and therefore potential
stigmatization can be avoided.
Having case managers for the immigrants does not imply that the multidisciplina
ry care as provided by an HIV clinic to all other people living with HIV/AIDS from
the host country is transferred to the community. Rather, the case managers
become a means to enhance care and work as a liaison. They do not substitute
other professionals.

Training programmes: data collection and developing
interventions
The goals and general objectives of the training programme can be summarized as
follows: teaching essential and relevant knowledge, developing appropriate altitudes and
professional skills according to the goals and objectives of the specific projects, and
continuously supervising, monitoring, and developing the performance of the trainees. In
working with immigrant populations, trainees must have skills in cultural sensitivity and
cross-cultural competence as well as extensive knowledge of HIV/AIDS. Additional
goals and objectives do not supplant those of professional development, but are inte­
grated with them. They constitute mainly the continuing gathering of relevant inform­
ation and the testing of messages, their channels4>f delivery, and modes of interventions.
The trainees also have an active collaborative role in the future iterative cycles of amen­
ding and developing project activities.
To achieve these goals, several principles and methods of training were integrated
with specific modes of data collection and analysis as delineated earlier in this section.
As many these modes as possible should be used, especially multipurpose instruments

Chapter 2

Programmes, projects, and interventions: A guide to development

)O(J

that are designed for the purpose of training as well as of eliciting data. The training

gry

period should be designed to include field experience and trial implementation of inter­
ventions, combined with supervision. In some cases, there is the need for continuous

ant

training and development throughout the whole period of the project.
Basic information about sexuality and sexual development (including HIV/AIDS

g-,
are

:tve
me
hat
wn

and contraceptives) and immigration is included within the initial steps of the training
course, and is presented in an interactive format. The next stage usually includes ad­
ditional information on topics more specific to the project, such as sexuality, adoles­

cence, stages of behavioural change, basic teaching skills, and health and welfare

I

services. These are usually taught by the same methods that the trainees have to develop,

thus exposing them to teaching methods and skills. The trainees start to practise their
teaching skills with their colleagues in simulation activities and then move on to super­

tor

not

vised fieldwork, concomitant with continuing training. At this stage, the training

be

sessions focus on supporting trainees in overcoming difficulties and building confidence

wo

competence is achieved through their participation in the development and testing of

to

channels for message transmission, educational interventions, and materials. Detailed

is

descriptions of the components of a training programme and its structure are summarized

of

in Boxes 9 and 10.

in their teaching skills. Additional development in cross-cultural understanding and

nd

Box

ty.
be
3St

a

Topics in adolescence, sexuality, and sexual behaviour, from a multidimensional
perspective (psychosocial, personal, interpersonal, peer group, and societal).
Topics in immigration, adolescents’ family interactions and how these are affected by
immigration, and the culture of the immigrants from Ethiopia and the former USSR.
Encountering the sexuality of youth and the interaction among them on sexual
contents (including the wide range of variations within and between groups).
Re-experiencing and refraining cultural transition and cross-cultural interactions (for
both immigrant and veteran facilitators).

■

2S.

ile
ity
ic,

s

ne

ial

fin

irs
or

Principles of sex education and their implementation.

J
&

g

I Icmcnts of a facilitators* training programme on sexual health for adolescents

Principles, methodology, and implementation of cross-cultural educational work
aimed at gaining insight into difficulties and coping with them, bridging cultural gaps,
and facilitating cross-cultural communications.
Experiencing educational interventions adapted to the aims of the programme:
working on sexual health and responsibility, learning to cope with the effects of
cultural transition and cross-cultural encounters, and bridging the cultural gaps.
Collecting and analysing data about the response of the facilitators in training and of
the youth to the types of interventions and their content.
Amending existing interventions and designing and implementing new ones in
collaboration with the facilitators in training. &

as
id
id
In
id
al
e-

Box 10: Intersvntions, principle's, aiid strategics

Use experiential and participatory interventions oriented towards the common issues of
immigration that have an impact on HIV/AIDS while eliciting the specific cultural content
that is typical of the immigrant culture; deal directly with the cultural transition and crosscultural encounters.

s.
n-

Use interventions that allow the participants, educators, and facilitators to elicit and include
the culturally specific content of each immigrant community. Such interventions are also
adaptable to groups of different demographic characteristics or different levels of
homogeneity.

id

Employ professionals from the immigrant population as implementers.

n.

Assign to immigrant professionals the roles of implementer, informant, and collaborator in

ts

developing the projects and interventions and their strategies, s

n-

Employ culturally specific messages and traditional modes of message transmission.

Chapter 2

Programmes, projects, and interventions: A guide to development

Trial field implementation: iterative project development
In addition to shortening the development period, initiating trial field implement­
ation at an early stage of a project as an integral part of the training ol interveners (as
early as a quarter but usually a third to half ol the way through the training programme)
serves several cyclical purposes. First, it gives the interveners a chance to experience and

try out their acquired knowledge, skills, and intervention strategies while still being able
to further develop them under supervision, thus adding to their sense of security and
competence. Second, it allows the developers to test the proposed interventions in
“real-life” conditions and discover the strengths, weaknesses, and constraints imposed by

the methodology. It takes the development one step further than the approximate
conditions of collecting the responses of the educators after exposing them to the inter­
ventions in training. Adding data collection and feeding it back into developmental

cycles at this formative stage provide another dimension to the training of the inter­
veners, refraining their task definition and further augmenting their sell-image and com­
mitment. Third, it enables the development team, now strengthened by the interveners in
training, an examination of the wider picture of the project beyond the separate inter­

ventions. They may notice missing parts and have a chance Io review main messages,

channels of communications, and methodology at an early stage, when amendments arc
possible and feasible. Fourth, it adds the target population as a dillerent group ol
reviewers, who have different perspectives and interests. Both the interveners and the
audience arc the desired participants of participatory research (Cornwall & Jewkes,
1995) and the end criterion in formative research (Mathews et al.. 1995). Involving them
at this early stage also, in a sense, adds quality control at the start.
Sometimes only going through field trial in parallel with the training and as part of

the development cycles will combine all of the above to give the desired results. Such
was the case in developing strategies to introduce posters detailing condom use to an
audience of Ethiopian immigrants under the project Your Life Is in Your Own Hands (see

Box 7). In the development of these posters, there were three cycles of amendments: first

with the project development team and then with the educators in training (see Box 12,
which shows a sample questionnaire to determine participants reactions to the posters).
But only observations of field trials and self-reports of the educators who presented them

revealed continuing difficulties with the two posters detailing the use of condoms. One

more cycle was conducted, composed of two separate activities during the continuing
I

training and supervision component, which ran parallel to the field trial implementation.
These cycles were not dedicated to amending the posters, which were central to risk­
reduction strategies in the community. Rather, they were dedicated to developing
strategics that would make it possible for the educators to present the posters and to

reduce (he level of embarrassment of the audience viewing them. The difficulties were

analysed until the group of professionals from the host and immigrant cultures (this time

including the educators in training) could come up with detailed descriptions and a
typology of the difficulties.
The immigrant educators expressed strong concerns about the uneasiness that the

posters elicited in their audience. While these could have been projections of (heir own

embarrassment, observations confirmed that the educators are highly attuned to the
emotions expressed by the audience. They were a very good resource not only for under­
standing the difficulties but also for finding alternative ways to cope with them. These

strategies were explored in a later activity, the results of which are given in Box 11. When

new waves of immigrants arrived between 1996 and 1998. new posters were developed

in order to avoid uneasiness and embarrassment among the audience. The drawings on

the new posters were not so realistic anil diil not depict women.

EBMfnSli

Chapter 2

Programmes, projects, and interventions: A guide to development

Box If: Means suggoted 1)\ iraimts to increase the acceptance of posters detailing
condom use
ni­
las
ie)
nd
de
nd
in
by
ale
ertal
ernin

The educator apologizes for the crudeness of the drawings and admits their impropriety but
justifies their use by citing the grave danger the audience is already aware of.
Combine I with the educator asking the permission of the audience to use the posters
(especially the permission of the elders, who could be people above 40-45). A variation of z
this method is that people who feel embarrassed are given permission not to look or to leave
the room (if the condom presentation is at the end of the activity).
The educator shows a later poster in the series, the one detailing a couple speaking to a
physician, prior to presenting the posters on condom use and then bases showing these
drawings on the advice of the physician.
The educator orally explains condom use without demonstrating it. If this elicits confusion
from the audience, the educator admits to the availability of the posters but expresses
reluctance to use them unless the audience requests it and feels that they can cope with the
embarrassing visual presentation, a
.

. ....

.

..

'L

—------------------- -—,h.,i

• •

Box 12: i .sscntial ckincnts of a training programme
3S,

ire
of
he
is,
in

of
:h
tn
?e
st

2,
.)•
in
ie

ig
n.

‘g
lo
re
ie
a
ie
'n
ie
r;e
tn
td
>n

fc

Structure a training programme to integrate the professional development objectives with
the data gathering and project development objectives.
Recognize the central elements of the training process: professional development,
experiential-participatory methods, utilization of field experience, and the learning group
as a supportive environment.
Design and implement multipurpose training activities that, in conjunction with the profes­
sional training, are also aimed at gathering relevant data for the further development and
evaluation of the programme.
Design and implement activities and interventions that are structured to recruit the trainees
as partners in the further development and amendment of the programme.
Constantly monitor and evaluate the training process and its outcome. Use the gathered
information for further training and for supervision sessions. The evaluation should
include changes in HIV-related knowledge and attitudes as well as in educational skills and
efficacy. Several methods of monitoring and evaluation should be employed. ■
.

’

■

....

Monitoring and evaluation: continuous parallel processes
This section does not aim to repeat general guidelines for monitoring and evaluation
of HIV/AIDS prevention programmes, which have been published elsewhere (e.g.,
Ration, I9K7; WHO, I9K9; Paccaud, Vader & Gutzwiller, 1992; Cole et al., 1995), but to
highlight their features for HIV education for immigrant populations and their inte­
gration with iterative development cycles. It is, however, important to clarify the
terminology. Monitoring and process evaluation examine the operation and quality of
activities and usually take place during the course of the project. Outcome (also termed
effectiveness) evaluation examines the effect of the programme in relation to its ob­
jectives and usually takes place at the completion of the programme (Cole et al., 1995).
Monitoring and evaluation are sequential steps only in principle: in reality they are paral­
lel. In programmes for immigrant populations it is recommended that they be designed
as parallel steps with ongoing feedback in the iterative process.
There are several obstacles to evaluative methods for projects with immigrant
populations:
♦ It is difficult to find evaluation methods that will accurately measure changes in
behaviour in every culture, and especially in traditional societies that refrain from
talking about sexual practices. The evaluations may thus tend to concentrate more
on process evaluation such as the assessment of dissemination of information, or
outcome evaluation of knowledge and beliefs, and to a lesser degree on behavioural
change.
♦ Other factors, external to the programme, influence trends in behaviour and are very
difficult to study. The pace of changes in immigrants’ lives is sometimes so rapid

’ 1

Chapter 2

Programmes, projects, and interventions: A qui 1

t

*lopment

!

that they can adjust to no further modifications. Many frequently move from one
place to another in search of employment or housing. The result might be
difficulties maintaining steady relationships. Those who are HIV-positive may have
difficulty keeping medical follow-up appointments or may avoid transfer to another

clinic for fear of exposure to more people. Media coverage linking the immigrant
community with HIV/AIDS may aggravate feelings of stigmatization or
discrimination and may initiate or aggravate defensive responses such as denial or

■

projection. One may encounter statements like “They [the health care system or the
host society at large] invent this story in order to discriminate against us.’’ People

living with HIV/AIDS may lose their trust in health care personnel and refuse to

come for check-ups, or may even deny that they are seropositive or that they have to
use condoms. Such situations may be aggravated by statements such as “Your blood

tests are OK,” which may mean totally different things to health personnel and

people with HIV. The latter may be unfamiliar with both the language and the
biomedical model used by health professionals.
It is difficult to maintain collection ol data at regular time pciiods because the

♦

immigrants are mobile and cannot always be located, especially il they ai<

clandestine migrants fearing deportation. I hey may also refuse to cooperate alter t
first interview if they perceive the topics to be loo intimate. I he establishment ol an

appropriate follow-up period sufficient to observe changes as a result of a
programme is always difficult, but more so with immigrants because of other
influences and changes.
An extensive evaluation of the effectiveness of a programme requires expert

♦

personnel and considerable amounts of time and funds. Process evaluation may be
less expensive, simpler, and possible to achieve, yet modest outcome evaluations can

be carefully selected.
Sometimes external factors, like the allocation of funds or the timing when funds are

♦

made available, can determine the mode of evaluation.
Following are some examples of the ways in which various data collection methods
detailed in previous sections could be used for monitoring and evaluation purposes. It is

recommended that several methods be used in order to receive information from diverse
sources and from different perspectives. One of the reasons is the difficulty in eliciting
information from some immigrant populations.
Monitoring the training, the responses to materials, and the implementation should
I

provide information about how and to what extent the activities ol the project arc being

carried out and identify causes of success or failure. Methods include.
♦

observations of the training sessions and interventions

♦

self-report by the trainees of trial field implementation

♦

monitoring reports by the project coordinator

♦

interviews.

Monitoring the training should provide information on:

♦
♦

how many people were recruited
how many successfully completed the training

♦
♦

what the main problems were in their approach to HIV
how they responded to the materials and interventions presented to them and to their
trial implementation
how many of those trained were actually assigned to the project.

Monitoring interventions should provide information on the structural elements ol
the implementation of the project and the target audience as well as additional informa­
tion on the training and the trainees. For the project implementation, monitoring should

provide information on:
♦
access and exposure to the programme
♦
the number of people attending the education sessions
♦
the number of lectures given and materials distributed during a period ol time
♦

the number of home visits made to people with HIV

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Chapter 2 A guide to development
Piogranmius, projects, and interventions:

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the composition of the groups in terms of gender or age.

For monitoring population response, information includes:
the reactions of and differences among various groups
which materials worked better with which audience
the reactions of people from outside the population to the implementation of the
project.
In terms of the training and trainees, monitoring should identify:
difficulties in implementing specific interventions or presenting some of the
materials
differences among presenters (age, gender, professional experience) and the
interaction of these with the composition and circumstances of the target audience
(age and gender composition in relation to the presenter’s age and gender).

Evaluation of the outcomes of the training is aimed at assessing knowledge and
attitude changes, by interviews or self-report questionnaires before and after the course,
and assessing the building of education skills by observation and self-evaluation (see
Box 13). Evaluation of the effect of the interventions on the target population may be
carried out by self-report questionnaires and interviews to evaluate knowledge, attitudes,
and intended or actual (if possible) behaviour changes.

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Bo\ 13: (Juislioiiiiuii c h»r inonihiriiig trial implementation of interventions

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Please complete this form for every presentation that you deliver.
Name of instructor:
Date of lecture:
Place of lecture:
Data on participants in your lectures:
■ -o.kr,
Number of participants at lecture:
‘
:?fe
'
(a)
men
(b) women
Approx, number over the age of 14:
Breakdown of participants by age (mark relevant age groups with a circle):
14-18
(a)
(b) young adults (15-40)
(c)
older adults (over 40)
(d) mixed
For this group, this meeting was (circle your answer):
first meeting on AIDS
(a)
(b) second meeting on AIDS
(c)
third meeting on AIDS
During your lecture, did you use the posters we prepared?
(a)
yes
(b) no
■S-H
J
If yes, did you use all the posters?
(a)
yes
(b) no (stale which posters you didn’t use and why)
What form of responses did the group show? (circle the nearest answer)
they only listened and did not ask questions or make comments
(a)
(b)
they listened and asked a few questions
they listened, asked questions, and joined a discussion on the subject of the lecture
(c)
If the group was mixed men and women (or women only) what was the degree of active
participation of the women?
(a)
they were silent
(b) only very few spoke or asked questions
(c) some of them spoke and asked questions
(d) many of them spoke and asked questions
What were the main questions asked (what did they not know, and what was of interest to
them)?
What did they say about the relationship one should have towards people with HIV, or people
ill with AIDS, and the necessity of disclosing who is infected?
Include exceptional responses during the course of the lecture, or afterwards (such as matters
they did not wish to have mentioned, expressions of anger at a particular subject, positive
responses to an idea, a particular example, or any other responses), a
■

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35

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Chapter 2

ProgrammeS, p.biect,.

same questionnaire
used, both closed and open
accustomed to surveys. An open
questionnaires can be developed for popudaltons no
..
irus?” may elicit one answer. Then
question like “What are: thefew times, until the respondent says that

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mission that the person knows about as well as mispercephons.

Sensitizing the host country population
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in low tones when faced with severe cases of inflammatory publicity.

Box

14: Suggestions for dealing pith the media

Keep information about HIV/AIDS programmes and projects for immigrants low key

(although not to the extent of making them secretive).
Whenever called to issue statements, emphasize the relilevant data and caution against
misinterpreting epidemiological information.
Recognize reactions of fear (even when they arc irrational) emphasizing controlled
behaviour and the risk to public health from uncontrolled behaviour.
Stay with rational arguments and use a low tone when responding to incorrect or

emotional communications and accusations.
When justifying the need for special programmes for immigrants, focus on the
Zuar mts- s" cine cultural needs and the prevention of HIV transmission among the
immigrants’ subgroup, not among the general population of the host culture.
Identify members of press and inform them of key messages and information on the
project regularly (even before being approached for queshons or interviews).

36

W/

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I'i'hji.iiiiiiii.:., pHip-t.t ,, and mlcivt.-nlioi

A guide Io development

!

Despite the diliiculties, these are the only possible means to contain damage from

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adverse publicity, hi many instances, they could be carried out with the help of allies
wtthm the media and the general public. It has to be pointed out that neither the media

i

nor the general public should be viewed as opposition. On the contrary, only with the

i

cooperation of caring and responsible members of both groups can correct and relevant
data be distributed and an accepting atmosphere for prevention efforts be achieved.

i

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Dealing with the attitudes and behaviour of professionals working with immigrant
populations poses an interesting conundrum. On the one hand, they are members of the
host population and may share the.ir attitudes towards HIV/AIDS, but, on the other hand,
their personal and professional responsibilities are directly related to the specific
immigrant population and to dilficullies in understanding their culture.

f..'

It is recommended that training opportunities be set up for professionals working as
■

caregivers to the immigrant population and for those who work with people living with
IV/AIDS. These should focus on cultural sensitivity, competence in cross-cultural

1

E

communication, and elements of the immigrants’ culture that are relevant for HIV/AIDS
transmission and prevention and for care for people living with HIV/AIDS.

ft

These training programmes, although essential for conducting daily interactions

I

those professionals working with people with HIV/AIDS. Other means of responding to

I

may be insufficient to answer all the needs for cross-cultural competence, especially for

such needs should be considered and enacted as part of the immigrants’ programme.

I-.

These may take the form- of cross-cultural teams in addition to employment of cross-

I

cultural mediators. In designing such programmes, it is not enough to train immigrant

II
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II

professionals It is important to sensitize host country professionals to the need for such

teams or interveners and their potential functions and contributions. They should also be
made aware of modes of constructive cooperation with these teams in order to
effectively implement interventions.

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Israeli programmes: Demonstrating
principles of the method

I

Introduction
This chapter describes the variations, diversity, and complexity in practice of the
principles and methodology discussed in the first two chapters. Variations are dictated by
the differences in needs and conditions, and also by constraints imposed by reality. It is
exactly these features of flexibility and adaptability that may make this model useful in
different contexts.
Tilie general approach is that HIV/AIDS risk reduction should be introduced through
a wide range of interventions (not necessarily limited to HIV/AIDS) and integrated into
as many other relevant programmes as possible. This approach was applied to the
immigrant situation. Some of the instruments and interventions that were developed for
these projects are included here to demonstrate principles and methods. Ap example is
the data collection and activities that led to the development of the Language of Sex
intervention. Although that project is currently part of the Gesher la’Kesher programme,
the data that led to its development were collected and analysed mainly in the immigrant
Russian professionals (raining programmes and a study of immigrants from the former
USSR.
This chapter looks at four specific programmes on for youth, immigrants from
Ethiopia, case managers, and sensitizing health and welfare personnel.

An educational programme for immigrant youth
In many countries, young people in general are considered to be a priority population
for HIV/AIDS interventions, even if epidemiological data do not warrant this. Major
social and cultural factors are involved in this appraisal. Youth are perceived as re­
presenting continuity as well as the future of collective identities. Immigrant adolescents
can have a higher vulnerability to HIV/AIDS than host country youth, because of
additional challenges in the relationships field resulting from their immigrant status.
Presented here is an educational programme for immigrant youth, called Gesher
la’Kesher The programme addressed HIV/AIDS risk reduction by integrating specific
interventions into a comprehensive sex education programme. It focuses on issues com­
mon to immigration - cultural transitions, cultural loss, and cross-cultural encounters while eliciting the specific cultural content unique to each immigrant group. The pro­
gramme is also flexible enough to allow for work with different compositions of groups,
homogeneous or heterogeneous. The rationale for developing such a programme and for
dealing with HIV/AIDS through a comprehensive sex education programme, rather than
through AIDS education only, is part of the presentation.
The educational project presented here is part of a programme for immigrant youth
from various countries. It incorporates the experience and results of three earlier projects
and represents the evolution of an educational approach that started in 1987 with an ex­
periment in developing a programme entitled the Sexual Health Programme for Male
Immigrants from Ethiopia in Residential Vocational Training Centres.
At that time, only the rudiments of methods to develop such a programme were
available, and the understanding of the complexities and difficulties of immigrant youth
was limited. The main concerns were cultural differences and the need for cultural
sensitivity. After experience with three projects - which separately addressed immigrant
youth from Ethiopia and the former USSR - a method for developing culturally sensitive.

2

Literally in Hebrew “A Bridge to Relationship”

Israeli programmes: Demonstrating principles of the method

Chapter 3

participatory sex education programmes is available, consisting ol training facilitators
and implementing integrated sex education programmes that also address HIV/AIDS.

Background

I

Alarming reports from varying sources on sexual behaviour raised concerns about
potential threats to the health and welfare of immigrant youth. It was reported that
immigrant youth engaged in sexual practices with little protection, increasing their risk
of HIV infection.
These reports described a variety of phenomena related to sexual behaviour and
sexual health. Health, education, and welfare caregivers also mentioned alarming num­
ber of requests for pregnancy terminations among immigrant youth. Some research
findings (Sabatello, 1992) indicated that the rate of requests for abortions among the
recent wave of immigrants from the former USSR was twice the rate of the general
population. As abortions in Israel are not funded by the health services except for cases
of undcraged girls, rape, or health risks, there were concerns about immigrant women
resorting to illegal abortions. Other findings indicated the low use of contraceptives
among immigrants from the former USSR, among both youth and married couples. It
was also observed that the health and educational system had difficulties relating to the
needs of the immigrants. I'urthermore, there were strong indications of immigrants’ mis­
perceptions of the behaviour of Israeli youth and misunderstandings of norms,
boundaries, and communications.
Theoretical considerations led to the development of the concepts that immigrants
were a unique group whose needs extended beyond simple aids for cultural adaptation,
that immigrant adolescents and young adults were a unique group who were more
vulnerable than other adolescents or immigrants, and that the issues of sexuality brought
additional specificity and complexities to the development of programmes.
In summary, these considerations, were:
♦ Adolescence and young adulthood are stages of development in which intimate and
sexual relations develop. Among a significant proportion of adolescents this
development process is characterized by sexual experimentation, serial monogamy
or multiple partnerships, and low protective behaviour (Hein, 1988).
♦ In adolescence, much energy is invested in various developmental tasks (which can
be highly rewarding and enriching). In some societies, adults impose a special
burden on adolescents through expectations and coni lifting messages (Muuss, 1982;
Hurrelmann, 1989; Bronfenbrenner. 1989).
♦ During adolescence, peer group norms gain relative power, at least temporarily, over
personal and familial norms. In many such instances, peer groups are organized
around defying adult norms and authority, and engaging in risky behaviour.
♦ People who leave their familiar environment could undergo a crisis similar to that of
adolescence. When a crisis resulting from migration is superimposed on adolescent
developmental tasks, young persons experience additional stress.
♦ In addition to the cultural transitions resulting from migration and the crisis of
adolescence. HIV/AIDS prevention targeting sexual relations could add further
stress to the life of youth, because this area is sensitive and a taboo in many cultures.
♦ The stress resulting from adolescence, migration, and sexual relations is aggravated
for immigrant adolescents who come from cultures where sexual behaviour is
governed by strong social controls. Migration tends to lower these controls and
disrupt traditional authority, and thus create the task of developing new controls over

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sexual behaviour.

H hy can't
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Previous experience in the field of reproductive health with adolescents and young
adults in general led to the conclusion that, even in situations of immediate risk, the
longer and more comprehensive road of sex education is much more appropriate for
dealing with issues of HIV/AIDS than are stop-gap AIDS education programmes
(Shtarkshall & Bargai. 1987. 1989; Shtarkshall. 1994). The main arguments follow.

n.
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Chapter 3

♦

In many countries, including those absorbing migrant populations, the issues of
immediate relevance, importance, and concern to the majority of adolescents and
young adults do not necessarily focus on HIV/AIDS. Rather, they focus on the
development of intimate and sexual relations and on the risks of pregnancy and
sexually transmitted diseases, which are of much higher incidence than HIV/AIDS.

♦

In countries with moderate and low prevalence of HIV, it is questionable whether
young people can be defined as being al risk because of the prevalence of risk
behaviours among them. They are, however a unique subgroup at risk in the future.
Because it is questionable whether one can work with youth on issues of future
relevance, it is necessary to encourage within this group the development of
protective behaviour and reduce the rate of high-risk behaviour on the basis of
current relevant issues (Coleman, 1989).

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The development
team

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♦

The skills needed to cope with developmental issues in adolescence are similar to the
ones needed for the prevention of HIV transmission. The barriers to such coping
behaviour are also the same as those that impede the development of low-risk
behaviour. Therefore with low additional educational investment, efforts developing
general coping skills will have an impact on risk behaviour related to HIV
transmission.

♦

Expci ience with immigrants and the theoretical considerations about the uniqueness
of immigrant adolescents and their needs in the area of intimate and sexual relations,
delineated above, only reinforce the conclusion: educational programmes dealing
with the wider perspectives of intimate and sexual behaviour, with a focus on sexual
health care, are the preferred choice for immigrant youth. Such programmes must
also be culturally adapted and designed to cope with the unique issues of cultural
transitions and cross-cultural interactions.

The programme was (developed
’
by a team that comprised people with various protessional and ethnic background:
♦ a behavioural scientist with experience in sex education
♦ a sex educator, who also served as programme coordinator
♦ an educational counsellor specializing in sex education through group dynamics
♦ two immigiants from Ethiopia - a male nurse and a female social worker
♦ a consultant from the former USSR, who has worked on a study of immigrants from
the former USSR.

Other parties important to the development process were the training facilitators:
these consisted of a group of Israelis and immigrants from both Ethiopia and the former
USSR who worked with immigrant youth, and another more general group of Israelis and
Ethiopian immigrants. They all participated in the development of the project and added
their unique perspectives to its structure and interventions.

1

1J

Israeli programmes: Demonstrating principles of the method

(iouls

Although the goals and objectives of the programme were much wider, the focus here
is on those directly related to sexual health and particularly to the prevention of HIV
transmission. The goals and objectives concerning the generalized issues of intimate and
sexual relations in the cultural transition and cross-cultural encounter are expounded in
the Gesher La’Kesher facilitators! manual (Shtarkshall, Shimon & Bargai, 1997). The
general goal concerning sexual health was to lower the barriers to safe behaviour,
focusing on those barriers resulting from immigration and developing the skills needed
for preserving health in intimate and sexual relations. The objectives were:
♦ to enable the participants to identify and confront their personal difficulties in
adopting strategies to preserve their health, including condom use, and to make them
aware of possible difficulties for their partners;
♦ to develop interpersonal skills needed for using or requesting the use of preventive
measures;

&
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l
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Chapter 3

Israeli programmes: Demonstrating principles of the method

to familiarize the participants with the appropriate help agencies and lower the

♦

barriers to seeking help;
. .
.
.
,
to cope with the stigma associated with HIV/AIDS and ethnic origin and to develop
strategies other than avoidance and denial to deal with them.
All these objectives can have specific cultural and cross-cultural aspects that need to
be dealt with together with the more generalized issues that are common to the popul­
ation as a whole. For example, some of the barriers may be specific to the country of
origin like the difficulty immigrants from Ethiopia have with “skin-coloured or
yellowish white condoms, or the experience of immigrants from the former USSR with
the thickness and low quality of condoms (a nickname for condoms there was galoshes
- rubber boots). Cross-cultural issues may arise if partners are of mixed origins. Another
difficulty (hat may be specific to immigrants is the heightened distrust of authorities,
even helping authorities, stemming from traditions of the country of origin and the diffi­
culties in negotiating with authorities in the new environment. In their country of origin,
many immigrants from the former USSR had encountered instances of non-confidentiality within and among institutions where confidentiality is often assumed. The goals
and objectives of special programmes for immigrants must address these difficulties. In
addition, they must augment the goals of programmes for the general population, and not

'B-

♦

IS

I

supplant them.

Cross-cultural
sex education

R

The two methodologies that converged in the developing and implementing ot the
educational programme Gesher la'Kcsher were (hat of interactive sex education and
cross-cultural approaches. The first methodology, a developmental-humanistic approach
using experiential and interactive group methods, has been the core of sex^ducat’on in
the national general school system in Israel (e.g.. Raz & Wieseltir -Raziel, 1 )80; Pazi,
1987; Shtarkshall & Bargai, 1987. 1989; Smilansky, 1989; Boneh, Shtrum & Bargai,
1992) It has also been tried in unique cross-cultural situations (Shtarkshall, 198 ,
Appelbaum & Erez. 1990; Aliyat Hanoar. 1992). The second methodology is that of
dealing with cultural transitions and cross-cultural encounters not only in unique
situations but also in a generalized manner.
The integration of these two methodologies resulted in the adaptation and application
of the developmental-humanistic approach in sex education to the immigrant situation in
a planned manner. The focus is on the special situation and needs of immigrant popul­
ations and on cross-cultural encounters. Rather than considering the cultural issues of a
specific group or of a specific encounter, the educational programmes are based on
educational instruments that can elicit and illuminate the cultural content and variability
from each unique situation. The advantage of this approach is that a given programme
can be used not only with immigrant groups but also with homogeneous group from the
host population, mixed groups of immigrants from various countries, or groups including
both Israelis and immigrants. Focusing on group processes allows the group to be viewed
as a microcosm in which cross-cultural encounters arc enacted in a protected
environment.
As the principles of experiential interactive and integrative group processes are
deliberately applied to the immigrant and cross-cultural situations, the preference is not
to focus on teaching “optimal" or “socially desirable” solutions, an option that many of
the immigrants understandably seek. Instead, the aim is to create situations in which
participants can explore their own attitudes, feelings, and behaviours, perceive their own
impact on other people, and experience their response. This method enables group
members to examine the interactions among the components of specific situations, and
then choose to reintegrate different options into their own lifestyles. Such methods
require complementarity between the educational messages and the means by which the
messages are expressed. Tor example, if a programme deals with issues of internal locus
of control and responsibility for one's action and independence, it should not be taught
in an authoritative manner with the participants remaining passive and not participating
in the decision-making process.

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Chapter 3

Israeli programmes: Demonstrating principles of the method

As in any group work, balances between process and content, private and public, old
and new, must be maintained by expert facilitation. Group processes occurring in public
arc visible to all the participants. However, participation of individuals will differ wide­
ly and is strongly dependent on personal characteristics as well as on cultural traditions
and the intervention of the facilitator. If group members arc to share their feelings and
problems and further process these feelings and problems, they must feel comfortable
and trust both the facilitator and the group. It is critical that even those who do not share
their thoughts and experiences verbally can still deal with many of these issues internal­
ly as pait of the group dynamics. Structured in this way, the programme can be used with
socioculturally heterogeneous groups with varying traditions of trust and sharing. This
is an important point among immigrants from both Ethiopia and the former USSR, and
additionally among refugees and illegal immigrants.
In cross-cultural work, it is most important to recognize that each group is unique.
In order to deal with this uniqueness, group diagnostic components and flexibility are
structured into the educational interventions. In addition, the facilitators are trained and
encouraged to “rethink the intervention,” and to constantly adapt it to the needs and
characteristics of each group.
The next stage is the development of the educational means through which these
principles and other derived issues are applied. There are 32 educational units or instr­
uments from which facilitators can build the skeleton of their programme for a specific
group (see Box 15). The design of the programme for a specific group - the choice of
units, their order, and the process through which these choices are reached — is an
important facilitators’ skill and is included in their training. It can also become an
integral part of the intervention itself.

<

I

Box 15: Kducutional units for HIX/AIDS prc\cntion
Coping with resettlement, departing from the old culture (2 units).
Comparing issues of intimate and sexual relations in the old country and the new
country; making choices and examining costs and benefits (5 units).
Interpreting the new environment within its own frame of reference - the cross-cultural
encounter; seeking help (3 units).
Learning about sexuality, sexual health, and methods of contraception in a group setting
(5 units).
■
.. ; • xg
Discussing intimate and sexual relations: context, choice, control, and coping; making
choices and negotiating methods of contraception (6 units).
Discussing pregnancy and sexually transmitted diseases; planning the future and making
difficult choices (2 units).
Discussing sexual behaviour and learning about sexual health - HIV/AIDS and sexually
transmitted diseases (5 units).
Coping with stigma (4 units).
There are 32 units in total within these 8 domains. Those that appear in domains 4, 5, 6, 7, and
8 are directly relevant to reducing the risk of HIV transmission. B

Based on past experiences, the number of meetings of each group ranges from 4 to
14. Thus, it is not possible or even desirable for each group to be guided through all of
the educational encounters. For example, although there are three units dealing with
stigma, it is recommended that each group use the one most suitable to its needs. It is also
recommended that no more than two units be used from the section on comparing
realities. Thus, the facilitators must choose the units most suitable for each group,
designing and introducing original units as they see fit. It may also be necessary to rear­
range the order of units. Every planned action should be considered as only initial and
tentative tor two reasons: first, the facilitators do not know the specific group and may
base their choice of educational units on past experiences (stereotyping); second, the
dynamics of group work may change the initial wishes of the group itself.
In the training and the programme manual, a structure for the selection, development,
and modification of a programme is introduced as part of the intervention itself

1

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Chapter 3

Israeli programmes: Demonstrating principles of the method

(Shtarkshall, Shimon & Bargai. 1997). Facilitator trainees have pointed out that these
components of the training deal with issues very similar to those that occur in the pro­
gramme itself: learning to plan for an unknown future, examining perceptions of reality
and amending these perceptions when necessary, identifying and correcting stereotypes,
or negotiating and balancing power.

Sexual health
and IHV/AIDS:
a comprehensive
programme

Even if general aspects of intimate and sexual behaviour arc dealt with in some units
- like those devoted to initiation of intercourse, pregnancy and contraception, and gender
issues - those issues directly connected to sexual health and HIV/AIDS can be covered
in more detail in other units. For example, although negotiating methods of contraception
and the use of condoms were part of other units, they can be repeated in a unit on pre­
vention of HIV/AIDS. This unit can go into detail on all possible options, like nonpenetrative intercourse, disclosure of previous risk behaviour and HIV status, conjoint
testing, and abstinence. A unit on condoms can deal with how to correctly use condoms
(technical aspects) as well as issues of culturally specific and other barriers to their use.
Incorporation of HIV/AIDS issues should take into account as an important component
the adaptation of universal messages to specific cultural situations and the development
of messages tailored for specific cultural groups.

The training process

The principles and methodologies of the training process have been described in
Chapters One and Two. They were applied to this project in the form of the combined
training-development-trial implementation process. While the structuring of the training
programme in parallel with the development and the trial implementation allowed the
development team and the facilitators in training to experience all three processes, the
inclusion of interventions at appropriate points in time allowed these to be integrated into
a unified experience.
Training workshops conducted before the development of the Gesher la’Kesher pro­
gramme were dedicated mostly to methods and skills. Subsequent training sessions,
although continuing to develop methods, focused on the implementation and use of these
methods and skills in the further development of the programme. The earlier training
workshops dealt mainly with: (a) sensitizing the facilitators to the cultural transitions and
cross-cultural issues in the areas of intimate and sexual relations, and (b) training facili­
tators on group dynamics and group facilitation skills, while familiarizing the facilitators
with the contents of the educational programme and introducing them to the concept and
methods of continuous development. Elements such as feedback from field experience
appeared in most of the sessions and were used for both facilitating skills and for
amending the programme. An additional component is supervision, which was carried
out either on-site, after an observation of a session, or in regional meetings. The col­
lection of data throughout the training process and trial implementation allowed the move
from isolated projects to comprehensive programmes addressing HIV/A1DS among
immigrants.

t

Evaluation

44

Due to budgetary constraints, no overall evaluation of this programme was made.
Instead, several smaller evaluation exercises were conducted on specific projects. An
evaluation of the training programme and trial implementation of a project for female
immigrants from Ethiopia has been conducted. An external evaluation of another facili­
tator-training programme and a process evaluation of field implementation by the trained
facilitators of a project for immigrant youth from the former USSR arc being conducted.
In the evaluation of the training programme for facilitators, the following
instruments were used:
♦ pre- and post-workshop questionnaires
♦ observation of events and activities in the training programme
♦ observation of trial implementation, focusing on the facilitator
♦ self-evaluation reports.

I

Chapter 3

Israeli programmes: Demonstrating principles of the method

In the evaluation of the training programme and trial implementation of a project for
female immigrants from Ethiopia, the following instruments were used:
♦ semi-structured interviews
♦ non-structured interviews in which the participants were asked to respond to
intimate or sexual scenarios, emphasizing the ways they look for solutions and the
considerations they employ, rather than the results themselves
♦ questionnaires before and after the training and trial implementation
♦ observations of educational sessions, focusing on participants
♦ self-evaluation reports of the facilitators.

I he results ol these evaluation exercises are forthcoming. As large parts of the trial
implementation were conducted in parallel with the training of facilitators, direct and
indirect feedback was received on both the training and implementation. Some anecdotal
information was important for the evaluation. For example, one of the major aims of the
ti.lining was to empower the facilitators to use the educational programme in a flexible
way, adapting it to the needs of specific groups, and to design activities according to the
educational principles and methodology. The fact that several facilitators in the training,
without being so directed, developed new interventions and even whole new .units and
shared the experience with their colleagues was viewed as highly indicative of the suc­
cess of the training.

Diffusion and
implementation

A strategy for the diffusion and continuation of a programme is required if a large
population is targeted. This educational programme had a potential target population of
more than 150,000 youth, ranging from young adolescents to young adults, in various
educational settings (absorption centres, hostels, boarding schools, day schools, and spe­
cial programmes for youth in distress). The first part of the strategy involved handing
over programme diffusion and continuation to an organization that had vested interests
in, and the structure and mechanisms to carry out, the promotion of educational pro­
grammes. The organization selected was the Israeli Family Planning Association. The
second part of the strategy was to ensure collaboration between the developing team and
the selected organization. The developing team should not be completely dissociated
from the continuing implementation of the programme, but should remain involved with
the training, supervision, and further development of the programme.
The third part of the strategy was to work in two parallel tracks. These were to offer
implementation of the programme by trained facilitators employed by the Israeli Family
Planning Association in formal and informal educational organizations, and to have
leading trainers offer training on the programme to the staff of such educational organi­
zations. It is the second track, the introduction of the programme into the structure of
existing educational organizations, that has been most successful. In 1997, the education
sector decided to adopt the programme into different country-wide educational projects.
These included the Unit for the Promotion of Youth of the Ministry of Education, which
deals with adolescents at risk in out-of-school settings; First Home, a six-month pro­
gramme of the Jewish Agency in which young adults who immigrate without families
are housed, taught Hebrew, and acclimatized to the country in kibbutzim (communal
settlements); and the Female Adolescents in Distress programme of the Ministry of
Welfare. Currently, the Israeli Family Planning Association is negotiating the intro­
duction of the programme into two other educational settings.
There is an unexpected but very important spin-off from these training programmes.
Many organizations found it difficult to introduce the notion of volunteer organizations
and volunteer work to the immigrant groups. This is highly understandable if one
remembers that volunteer activities in the former USSR were mostly a euphemism for
coerced participation in political activities. However, many of the immigrants trained as
facilitators in this programme are now also volunteers in other activities of the Israeli
Family Planning Association dedicated to reproductive and sexual health of the
immigrant communities.

45

*•MlI
i

■i:

Chapter 3

Israeli programmes: Demonstrating principles of the method

Project for the general population of immigrants from
Ethiopia 3
Introduction

In the early 1990s, several factors converged to create a very serious situation in
relation to HIV infection among immigrants from Ethiopia. After a large wave of immi­
gration in the mid-1980s, a second large wave of about 20,000 arrived in 1991, most of
them in an airlift organized by the Israeli government at the end of the civil war in
Ethiopia. Between these two waves of immigrations, HIV had spread rapidly in Ethiopia,
mainly in the urban centres (Ethiopian Ministry of Health, 1990). Despite the knowledge
that infectious diseases were prevalent in the population, all immigrants had been first
brought to Israel and then examined for various health conditions including hepatitis B,
tuberculosis, malaria, and HIV. These examinations indicated that over 200 of the 13,000
people tested were HIV-positive. The Ministry of Health decided to refer all HIV­
positive people to HIV centres for follow-up and to provide them with medical care. No
prevention programme for this immigrant population was initiated at that time, but there
was deep concern about the possibility of further transmission. In a meeting of represen­
tatives of various governmental groups (mainly the Ministries of Health and Absorption)
and other organizations working with immigrants, it was agreed that this condition
required the immediate development and implementation of a culturally appropriate
education programme to reduce the risk of HIV transmission in this population. It was
proposed to target the general population of immigrants as a first priority.

■ I
■

1

The head of the Israeli National AIDS Steering Committee asked representatives of
The steering
committee and
various organizations and the leadership of the migrant community to become the inter­
project development
agency steering committee of the project. That committee decided to target the adult
team
population among approximately 24,000 Ethiopian immigrants residing in absorption
centres and hotels at that time. A proposal was submitted to the Israeli National AIDS
Steering Committee by a public health physician and an anthropologist, and, to reinforce
the initiative, members of the Hebrew University-Hadassah School of Public Health were
approached. Two staff members with experience in health and sex education, HIV pre­
vention, social-behavioural research, and social work interventions agreed to join the
project. A team of four, all with previous experience in interventions with Ethiopian
immigrants or with marginalized groups, was formed under the auspices of the Hebrew
t
University-Hadassah School of Public Health. An expanded proposal was submitted to
the steering committee National AIDS Steering Committee.
Early in the project, the team recruited two coordinators: a cultural coordinator, who
was a veteran immigrant from Ethiopia with previous experience in HIV/AIDS educ­
ation, and a project education and field coordinator, who was a teacher and sex educator.
Initial background data were limited, as the urgency of the situation did not leave time
for a lengthy process of data collection to obtain data specifically on HIV. The infor­
mation was collected mainly during the project, an example of an iterative process.

The overall
perspective

<♦ Timetable. The project lasted eight months. The preparatory stage was completed
within two months; the training and implementation of activities were conducted for six
months. The experimental lectures for the target population started within two weeks of
the initial training workshop and continued until the end of the project. During the fol­
lowing year, many requests for additional lectures, mainly for new immigrants, were sub­
mitted to the project coordinator, but only sporadic lectures were given, by four or five
educators who were still available.

3
This Section was prepared by RA Shtarkshall. V Soskolne. D Chemtob, and H Rosen. Parts of
this section were published earlier in Chemtob el al., 1993; Chemtob et al. 1995; and, Soskolne et al.
1995.

USE

I

Chapter 3

Israeli programmes: Demonstrating principles of the me

cl

■> Budget. The total budget of the project. US$50,000, was contributed by a non-govern­
mental organization as part of its activities and programmes for new immigrants. The
total budget was initially earmarked to cover the salaries of the educators, the two coor­
dinators ot the project, and their expenses, but it was used mainly for the development
and production of the educational materials, including posters, booklets, pamphlets, and
audio cassettes. Some of the educators were employed by one of the collaborating orga­
nizations and included project activities as part of their job commitment on a one-dayper-week basis. The four senior professionals of lhe development team were not salaried
by the project. Their participation was considered part of their duties in their respective
organizations.
Responsibility. The personal dedication of many individuals and the willingness of
some organizations to devote the time of their employees made the implementation of the
project possible. However, the project could not have continued under such circum­
stances. The Israel Ministry of Health had to become fully responsible for continuing
these activities to make the project sustainable. Unfortunately, this did not occur, and for
more than four years, until 1997, no educational activities were carried out by the
Ministry.
v Ollier constraints. The main problem was lhe need to start the project immediately,
which left very little time for planning and preparation of the logistics, the training
course, and specific interventions. For example, lhe first educational sessions were
conducted as lectures because the posters were still being designed. They were
completed with the cooperation of the trainees four to five weeks after the start of
educational sessions, and only then was the visual channel of communication added. The
budget did not allow the development team to plan for all components of the project in
the desired form. No funding was allocated for outcome evaluation. Only after repeated
requests by the development team was additional funding granted, and that only towards
the final stages of lhe project. Consequently, no “before-after” comparisons were pos­
sible. Exposure of individuals to lhe project was used as a proxy variable in lieu of base­
line data. However, the iterative design process made it possible to start a project under
such conditions.

I

I

Methods and stages
of development

♦
♦

■

♦

• .^b .v.-

♦
♦

The methods used in this programme can be divided into the following components:
structuring the programme and interorganizational negotiations, including the
selection of trainees;
collecting data essential for the formulation of the training courses and educational
strategies;
organizing the training process and delivering the messages to the community of
immigrants at large;
preparing and adapting culturally appropriate training materials (e.g., posters that
had been prepared in Ethiopia and had to be changed extensively);
monitoring and evaluation.

n Collection of background data

;

. h.:;j .•;
■

.

!

.

.

i
... .
/mjiii fl...

liyiCtfi.?, i
■’o
'^f { ii.

■ tod Io;j

.

As background data for the development of the educational programme, the information
summarized below was obtained through the following sources:
♦ epidemiological data from the Israel Ministry of Health
♦ general and professional knowledge about the state of immigrants and of the
attitudes and beliefs of the Ethiopian immigrants
♦ in-depth interviews.

A format for semi-structured interviews was developed covering the following content
areas:
♦ the general perception of HIV/AIDS as a disease with a hidden component, and of
the people who are HIV-positive
♦ the reactions to proposed behavioural practices
♦ the readiness of people to discuss sexual issues.

Chapter 3

I

Israeli programmes: Demonstrating principles of the method

Using the same format, all development team members interviewed both participants in
the training programme and people from the target community. The focus of the inter­
views was on sexual networks, number of sex partners, and frequency of change of
sexual partners. Some of the interviews were conducted prior to the commencement of
the workshop and others during the period of the training. The interviews were trans­
cribed and analysed for material relevant to the training programme and to the trainees’
work with the target population.
■

“1 Legal stains and motives for migration

-

All Jews who immigrate to Israel receive citizenship rights immediately, irrespective of
their health status. The motives for immigration from Ethiopia are religious and national
- that is. identification with the Jewish state. However, the last wave of immigration in
1991 was accelerated by the political situation in Ethiopia at the end of the civil war and
the fall of the Menegistu regime. People arrived with only a few belongings, almost as
refugees. Upon arrival, all immigrants arc entitled to health care and social, occup­
ational, and economic support services through government-subsidized programmes.
General health education programmes arc provided by the medical insurance companies
or by the Ministry of Health, but HIV/AIDS education is not routinely provided to the
immigrants.

Il

“1 HIV/AIDS and other special health needs

‘1

According to data from the Ministry' of Health, the male-to-female ratio of HIV-positive
persons was slightly greater than 1. indicating that heterosexual intercourse is the main
mode of HIV transmission. It was difficult to establish how much of the infection occur­
red as a result of the use of non-stcrile tools either for blood-letting in traditional medical
practices or in medical settings in Ethiopia. Some of the persons with HIV were children,
babies, or pregnant women. Most of those found to be infected with HIV were still
asymptomatic, indicating infection in recent years. Tuberculosis rates were high, and
some of the patients already had AIDS. These data suggest that the prevention of
heterosexual and vertical HIV transmission had to be the main target.

ll
■

I Health beliefs and practices

I

Traditional health attitudes and beliefs and extensive use of traditional healers are
generally prevalent among this population. The modern biomedical model of health and
disease is less prevalent. For example, the concept of infectiousness during the asymp­
tomatic stage of HIV infection is incomprehensible. In the tradition of the immigrants
from Ethiopia, only someone who presents symptoms is viewed as being a risk to others.
Usually, such a person is isolated in order to prevent transmission to others. To make the
project acceptable to the immigrant population, it was essential to integrate the
traditional model familiar to immigrants with the modern biomedical model prevalent in
Israel.

'I

n Social situation

Most of the immigrants came from a rural region in northern Ethiopia and spoke only
Amharic. A modern way of life was generally alien to most of them. Their culture is
characterized by a predominantly oral transfer of knowledge and values, using proverbs
and fables. Literacy rates are low.
The immigrants of the target population had just started to learn Hebrew in special
classes in their residential locations. Children over five attended compulsory kinder­
gartens and schools. Usually, they mastered the Hebrew language quickly and often
served as translators for their parents in contact with Israeli services, a fact that some­
times threatened traditional parent-child roles.
Some adults had started to work as unskilled labourers in low-paid jobs. Although many
were receiving social security benefits, they were barely sufficient to meet even minimal
needs. Religious leaders used to have inlluence in the community, but a group of
political leaders, who were more familiar with Israeli society, had started to gain more
influence among community members. Most of the recent immigrants were isolated

48

(

I

Chapter 3

Israeli programmes: Demonstrating principles of the method

from the rest of the Israeli society because of the large gap between (he two cultures.
Ilvcij though they were not openly discriminated against, they were the only ethnic group
in Israel with black skin. The health care and welfare workers were usually Israelis
completely foreign to the immigrants. In order to improve communication, many
services had started to employ veteran immigrants as translators. Unfortunately, these
people were given no special (raining.
n N'ulnerabilitv and risk factors
Risk factors related to HIV transmission was investigated through structured and semi­
structured interviews with key members of the immigrant community. Every member of
the development team interviewed two to ten persons.
The interviews indicated that open discussion of sex is not common in the target popul­
ation. Even married couples do not usually talk about sex, or the use of contraceptives,
including condoms. Male dominance in the initiation of sex and during the sexual act is
very clear. Men may have several female partners, and it is not uncommon for a married
man to have a sexual relationship with another woman, usually one who is divorced or
widowed. Divorcees and widows submit to these relationships because they need econ­
omic support. Married women do not have extramarital relationships. Single women are
often virgins until they marry or have had a few serially monogamous relationships.
lost of the sexual networks occur within the community, including mixing between
veteran and new immigrants. A generally negative attitude towards condom use is based
on religious and cultural beliefs in the value of fertility. Among veteran immigrants, some
changes may occur, mainly among young adults who started their sexual experiences in
Israel.
Less information was obtained about other HIV-related risk behaviours. However, the
impression was that intravenous drug use or homosexuality were uncommon and highly
stigmatized.
In summary, the mainly endogamous sexual networks within a relatively small commu­
nity of about 50,(XX) people and the prevalent negative attitudes towards condom use
increased the development team’s fears about the possibility of further HIV transmission
in (he target population.

I
I
I

ii

Purpose uml
objectives

The purpose of the project was to decrease the risk of HIV transmission among
immigrants from Ethiopia in Israel. The general goals were:
♦

to provide the immigrant community with accurate information on HIV/AIDS in a
culhnally acceptable form;

♦
♦

♦
♦
♦

Project
approaches

♦

♦

to encourage tolerance and support of persons with HIV and their families;
to promote adoption of risk reduction behaviour to prevent the transmission of HIV,
including condom use and sterilization of traditional medical instruments.

The specific objectives were:
to improve the level of accurate knowledge about the modes of transmission of HIV
and the prevention of transmission and to decrease misconceptions about HIV/AIDS;
to promote positive attitudes towards condoms and to encourage condom use;
to promote positive attitudes towards people with HIV/AIDS.

The main approaches planned for the educational intervention were as follows.
The prevention of the transmission of HIV had to be embedded in a framework
juxtaposing biomedical Israeli with traditional Ethiopian health concepts. Adaptation
of proverbs and traditional beliefs was required to integrate the traditional health
models with the biomedical model and with the situation in Israel. Familiar
Ethiopian concepts and beliefs were to be used to transmit prevention messages.
The most popular modes of communication in the population, oral and visual, were
to be used as the main channels of intervention. Lectures in small groups with the

49

Chapter 3

Israeli programmes: Demonshalinq pnnciplos of the method

jl

♦

I

♦

aid of posters were planed first; other audio and written materials were developed
later.
Messages of HIV prevention were to be introduced into educational materials (e.g.,
the concept of infectiousness during the incubation period, the main routes of
transmission and prevention, the proper use of condoms).
Specific strategies to encourage discussion of sexual practices were to be developed,
as were empowering and participatory methods for intervening in this population.

1
rr(iinini>

Training started with a three-day workshop with 34 trainees and continued over
three months in three weekly and four biweekly meetings running parallel with the inter­
ventions. Trainees asked to meet longer than planned because they felt the need to dis­
cuss upcoming issues, participate in the completion of additional educational materials,
and get the support of the professional team and their other colleagues. Twenty-nine
trainees completed the whole training course.
The trainees were nurses, social workers, and other professionals. Some of them had
been employed as translators or facilitators in the absorption centres. They were all
veteran immigrants from Ethiopia fluent in both Amharic and Hebrew. Because they
were to be trained as health educators and cultural mediators, their careful selection was
important. Some of them were also recruited to collect data needed lor the training and
the planning of interventions.
The training consisted of group activities and a scries of lectures given by profes­
sionals. The sessions included the following subjects:
♦ information on HIV/AIDS and hepatitis B, their modes of transmission, and
prevention strategies
♦ understanding and accepting attitudes and beliefs of different cultures; changing
attitudes
I
♦ techniques for educational interaction
♦ cultural mediation and bridging skills
♦ management of conflicts and emotions that may arise during the educational work.

Ih vchi^incnt of
(•(liicalioiial
incs taxes

It was important to develop acceptable messages that could relate directly to issues
and concerns of the target population. During the training process, previous experiences
with prevention messages were combined with new concepts and new ways to transmit
messages. Only a few central messages were developed and refined throughout the
project. These included:
♦ “HIV/AIDS is a serious but a controllable problem. It is up to each and every one to
protect himself or herself against being infected.” This was embodied in the idea that
“Your life is in your own hands.” which was also the name of a poster series, as well
as in the message to “Be gobcz” - that is, to be victorious over one’s enemies,
including HIV (Chemtob and Rosen, 1992).
♦ “It is better to do things when you can prevent them than to cry when you are
already suffering and nothing can be done anymore,” which is taken from a wellknown Amharic proverb (Rosen. 19X9).
“Each member of the community can protect himself/herself, his/her family, the
Ethiopian Jewish community and all the people of Israel.“This message was
planned to tap the solidarity of the group and their wish to be an integral part of
Israeli society.
<> “There is hope.” People who are infected with HIV should not despair and perceive
immediate death as the only consequence. It is possible to postpone the development
of the disease and to raise the quality of life for infected people through early
detection and proper, continuous care.
♦ “There is no need to know which person is infected." Protection lies in behaving as
if everybody could be infected. This is a message to the population of immigrants as

1

Chapter 3

Israeli programmes: Demonstrating principles of the method

well as the general public. An exception is the case of sexual partners of people with
HIV. While the latter situation should be dealt with in individual counselling, this
exception to the rule may also be an important educational message.
“There is no need to shun people with HIV/AIDS. One can do the right and
honourable thing. Befriend them and help them in a dire situation, while taking the
necessary precautions.’ 1 his can be an extremely important message for groups
emigrating from areas of endemic infectious diseases and less developed health
systems. In such cultures, the tradition of shunning people and even families with
infectious diseases is an important health measure.

Experimental
implementation

After the second training session, the trainees started to deliver, under supervision,
teaching sessions about HIV/AIDS to the immigrant community. This activity, combined
with the monitoring and the continuing training sessions, can be considered as teaching
under supervision. The training sessions became much more interactive, combined with
work in small groups, and only a few lectures. For example, trainees had to demonstrate
how they lectured about a subject of their choice, participate in role-playing, listen to
tapes ol demonstration lectures and discussions, write down their reactions and then
discuss them in the group. The feedback regarding their field experiences was a central
component. Trainees had to report about each teaching session using the self-monitoring
sheet. In each meeting, many of the educators brought up issues about which they wanted
to consult the other educators and professional team or that they wanted to share with
them. A gieat part of the meetings was also devoted to the development and amendment
of the educational materials.

Development and
amendment of
educational
materials

The trainees were regarded by the development team as cultural experts and were
asked to assist in the development process by reviewing and amending educational
materials and messages from the preliminary plans and drafts. They were consulted about
the appropriateness of materials and messages, using a structured format for responding
and suggesting alterations or new ideas. The review and amendment process was often
iterative. This is an example of cooperation between people internal and external to the
culture of the target population.
The first of the educational materials was a set of 16 posters, designed as visual aids
for educational presentations. These posters were developed by incorporating some
features of posters from Ethiopia and of the World Health Organization. They were later
reconceptualized to fit the situation and the environment in Israel through the reviews
and amendment suggestions from the trainees. The relevant messages and information
were printed on the back of each poster in Amharic and simple Hebrew.
The posters were later published in booklet form for use in face-to-face counselling.
They were distributed to the educators as well as to Israeli health personnel in HIV
clinics or in primary-care community clinics who participated in training workshops
about the appropriate use of the booklets.
As the project proceeded, the educators suggested widening the channels of com­
munication and adding other teaching materials. These had become more essential as the
mandate for the educational lectures was coming to an end and it was necessary to
employ other modes of information dissemination to the target population. The additional
methods included audio cassettes, radio programmes, pamphlets, and newspaper articles.

Training
methods

Diverse methods were used to build the teaching skills of the trainees, including
traditional lectures, the use of proverbs and fables, learning through action, participatory
methods, group dynamics, and supervision.
Trainers stressed the importance of relating to the cultural traditions of the target
population as well as the use of methods to induce change. For example, in order to over­
come passivity in learning situations and reluctance to discuss controversial or

I

Chapter 3

Israeli programmes: Demonstrating principles of the method

embarrassing issues, the trainees were engaged in active discourse through methods

that were previously developed for working with Ethiopian men on their sexual health.

Participatory methods were central in working with the trainees. These methods
assume that the content of the messages and the process by which they are delivered
should be complementary. The design of several units for the initial workshop and the

continuing training sessions introduced the principle that, during the training course,
the same methods arc used that the trainees have to use in their work. For example, at

ft

i

the first sessions the trainees were encouraged to raise whatever questions they had

about HIV/A1DS and to which they hoped to get answers during the training pro­

*

gramme. These were classified into knowledge, attitudes, behaviours, and medical or
social issues. During the subsequent presentations, many of these questions were
answered in a respectful, non-judgemental way. This demonstrated how the trainees
could respond to their audience with empathy. The fact that several trainees raised

i

further potentially embarrassing questions indicated the success of this strategy.

The trainees were asked to share their anxieties prior to delivering a lecture. After
sharing their difficulties and looking into their meaning, the members of the group were

asked to suggest methods of overcoming them. Many brought up ideas that could be
adopted by other participants. In addition to lowering anxieties, this exercise was also

a learning process, which increased teaching options, and helped trainees perceive
themselves as independent generators of information.
Other training methods included mutual interviewing, simulation games, or role­

playing. These enhanced the traineesi self-confidence as lecturers and facilitators of
group discussions and as individual counsellors.
Adapting a traditional Ethiopian teaching mode, trainers made use of proverbs,
fables, and stories to integrate traditional concepts and means of transferring know­

ledge into the educational messages at the training level, in the development of mate­
rials, and at the level of transmission to the community. People who had previous expe­

rience in this mode demonstrated to the trainees how they could use proverbs in

delivering educational messages. Familiar Ethiopian messages were integrated into the

posters and audio cassettes. For example, to deal w ith the fact that the notion of viruses
or germs did not exist as part of the traditional cultural vocabulary, it was suggested to

the trainees to compare the viruses to “little worms.” “small living creatures,” or

“mouldy bread.”
In Ethiopian culture, the unique concept of gobez refers to an individual who is
clever, brave, hardworking, and manly. Il reflects a goal that most young men strive to
achieve. The trainees were encouraged in their presentations to connect being gobez to

health awareness, caring for one's partner, using a condom, and ultimately, being

responsible for one's overall sexual behaviour. Another method was the invention of

new fables to emphasize some important points. One such point was the difficulty in
reframing the concept of risk, which was usually perceived in a dichotomous way
(dangerous/not dangerous), into gradual terms. This was illustrated through the use of

an interactive story about “steps of danger.” w here trying to jump off one stair is shown
to be much less risky than jumping from a height of 20 stairs.
Il was also important to work on the attitudes and emotions of the trainees to
enhance their teaching skills and to lower anxiety about their role as educators. Several

experiential workshops were dedicated not only to airing attitudinal and emotional
issues, but also to relating them to the trainees' task and to neutralizing their negative
impact.
Mediation skills and expected difficulties in mediation were dealt with by
practising two-directional mediation between the veteran health professionals and the

lay clients - that is, the immigrants. Emphasis was given to assertiveness, sensitivity,
listening, and tact. Different w ays to explain what each side means beyond their verbal
expression were explored and jointly discussed w ith the participants.

52

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Chapter 3

rhe interventions

I

Israeli programmes: Demonstrating principles of the method

I he main mode of intervention was lectures with the aid of the posters in small
groups ol 20-25 persons from the target community. The project coordinator mapped the
residential areas in each region in the country and gave each educator a list of locations
in which he/she had to work. At the lime of the project, most of the immigrants were
living in hotels or absorption centres (compounds of small apartments). Each centre was
run by staff who took care of the immigrants’ needs and who could assemble the res­
idents in a central hall for meetings. The district director notified the centres that an edu­
cator would contact them, and the centre managers were asked to cooperate by informing
the residents and encouraging them to attend the lectures. Sometimes, the centre

manager requested that big groups attend the lecture to get “maximum exposure in mini­
mum time,’’ but generally the lectures were presented to small groups. Each educator
deli vered between two and six lectures per week, depending on the importance of his/her
position and the geographical distribution of immigrant centres in his/her region.
Depending on the audience and the educators, many of these lectures became more
inteiactive and turned into group discussions. Towards the end of the project, when the
audio cassettes were prepared, the attendees were given the cassettes so that they could
listen to further information and discussions.
As the interventions continued, it became apparent which educators were skilled in
providing additional interventions, like small group discussion, mediation in HIV, or
community clinics. These interventions were conducted at the request of the clinics or
the management of the absorption centres, and were not part of the overall project
strategy.
When the audio cassettes were produced, an initial trial distribution was conducted
in a sample of absorption centres. The cultural coordinator, who had also conducted
many of the interventions, went to each household in the sample, explained the purpose
of the cassettes and asked for permission to leave a copy for the use of the people in the
household. He returned a week later and asked for their response. This monitoring re­
vealed positive responses in general to the cassette, and usually the tape initiated many
questions. These visits turned into family or group educational sessions or individual
counselling. After this, more than 5,000 audio cassettes were distributed to the manage­
ment offices of all centres in the country, with a request to distribute them to all house­
holds at the site. Additional cassettes were sent to HIV or community clinics for
distribution.
Written information was prepared in the form of two pamphlets. One gave general
information about HIV/AIDS. the other specific instructions and illustrations about the
correct use of condoms. Sensitivity and the desire to avoid offending the community
stood behind the decision to separate the pamphlets. Whoever was not interested in or
was embarrassed by the second pamphlet could at least get basic information on
HIV/AIDS. The illustrations of condom use were drawn on the opposite edges of two
pages, which were then partially folded over so that the drawings were not immediately
exposed when one opened they pamphlet.
In collaboration with Israeli radio, programmes in Amharic were prepared and
broadcasted. Each broadcast, which had been planned to last about 10-15 minutes,
started with a professional giving a short presentation in Hebrew on a different topic.
This was immediately translated into Amharic by one of the educators from the project.
Then the listeners were invited to phone the studio and present questions to the Israeli
and Ethiopian professionals. After the first broadcast, so many phone calls came in that
the broadcasts were extended to 30 minutes. The impression at the time was that the res­
ponse was very positive and proved how powerful this medium is for the community.
People said that they called from public telephone booths because they did not yet have
phones in their temporary housing.

I

I
■

I

i
i

I

I

Monitoring
and evaluation

n Monitoring of the training sessions
Process and outcome evaluation of the trainees was conducted using qualitative and
quantitative, structured and semi-structured approaches, reports, and direct observations.

53

Israeli programmes: Demonstrating principles of the method

Chapter 3

Even the selection of the individuals for the training was an integral part of the monit­
oring and evaluation process. It included an evaluation of their ability to associate them­

selves with the subject, despite its stigmatizing potential, and their ability to deliver the
sensitive messages in public.
The monitoring and the educators’ evaluation were done by:
♦
Direct observation of the educational activities by trained observers (people who

spoke Amharic or the teaching staff). In addition, a structured report was submitted
by the observer and some of the lectures were recorded.
A self-monitoring form completed by the trainees, which included data on the

♦

number of persons attending, the composition of the group by gender and age,

difficulties encountered, reactions during and after the lecture, and other important
issues.
Outcome evaluation using structured self-report questionnaires in Hebrew to assess

♦

changes in HIV-related knowledge and altitudes at three stages: the beginning of a

three-day training workshop, the end of the workshop, and the completion of the
whole training programme four months later.
The attitudes and feelings of the trainees about teaching these subjects and their per­

ceptions of their teaching skills were measured only after the training workshop and at
the end of the training programme. The results showed that most of the trainees’ signif­

icant improvement in HIV-related knowledge and the changes to more positive attitudes

occurred during the workshop; only minor additional changes occurred after the whole

course. A large proportion of the trainees felt they had acquired much knowledge and had
developed teaching skills.
“I Monitoring the intervention
Monitoring of the educational sessions was conducted as part of the monitoring of the

training as described above. In addition to the formal monitoring and evaluation records,
many informal reports by the trainees themselves indicated that breakthroughs in under­

standing often seemed to follow the presentation of new ideas in familiar terms. The
project coordinator had been constantly monitoring implementation by making sure that

educational materials reached the population - the presentation of the lecture sessions and
later the distribution of the audio cassettes to all residential locations (100 per cent
coverage of locations) and the distribution of pamphlets to health and welfare services.

In total, about 250 lectures were presented by the educators, and 5,000 audio cassettes

t

and about 15,000 pamphlets were distributed.

“i Outcome evaluation
The main results of the project, even before the impact evaluation was carried out,

included:
♦
The training of a group of health educators who could deliver HIV/AIDS
educational sessions to the general population of immigrants from Ethiopia. A core

of this group have since continued to participate at different levels in additional
♦

activities.
The development of culturally appropriate educational messages and methods and

alternative ways to deliver them. These educational materials have since been used
for other population groups of these immigrants.
One surprising outcome was the initiative of the educators to establish a telephone hot­

line on HIV/AIDS in Amharic. The professional staff aided them in finding the appro­

priate organization to host and supervise them (the Israel Family Planning Association).
Since that time, the hotline has run once a week, each session lasting three hours.
i Impact e\aluation

As it was not possible to collect pre-intervention data from the population, the evaluation
was conducted by interviews with two random samples, each consisting of 315 adults,
comparing attendees with non-attendecs three months and one year after the intervention
began. At the time of the first round of interviews, no educational method but the lecture

sessions had been implemented. The second round ofcvaluation was conducted after the

I
I

Chapter 3

Israeli programmes: Demonstrating principles of the methou

distribution of the pamphlets to all services, shortly after the distribution of the audio
cassettes, but just before the first radio broadcast.
A semi-structured questionnaire was developed for the interview. Data collection had to
be conducted as part of a more casual encounter, in which the interviewer spent some
time “socializing,’ drinking coffee offered in the traditional Ethiopian way, and becoming
belter acquainted with the person before the questions could be asked. In most cases,
same-gender interviewers were arranged. Most of the questions were open, and the inter­
viewers were instructed to probe to elicit the maximum possible information but without
pressure and in a non-judgemental fashion. Thus, qualitative analyses of the responses
preceded the quantitative analysis.
The results showed that 60 per cent of the first sample and 32 per cent of the second
sample attended the lectures. This difference could be explained by the fact that some of
the interviewees in the second sample arrived in the country after the lecture sessions
were terminated and some actually forgot they had attended the lecture. The main out­
comes were that, in both samples, those who attended the education sessions had signif­
icantly better knowledge of correct modes of HIV transmission and prevention, more
positive attitudes towards people with HIV, and more positive attitudes towards condom
use compared to non-attendees. However, no differences were found in misperceptions or
in willingness to use condoms. Logistic regression analysis showed that more positive
altitudes towards condom use were found among people who had attended the lectures,
had better HIV-related knowledge, were younger than 45 years, were literate, and were in
the first wave of evaluation, and among men.
These results indicate that the education programme achieved most of its aims. It suc­
ceeded in improving the level of correct knowledge about modes of HIV transmission and
prevention, although it did not decrease misperceptions. It enhanced positive attitudes
towards condom use and positive attitudes towards people with HIV/AIDS, but the more
positive attitudes towards condom use were not sufficient to increase willingness to use
condoms. The analysis showed that women and the less educated should be targeted for
further education to enhance positive altitudes towards condom use. Beyond that, there
was a decay of knowledge and of positive altitudes over lime. This is expected because
the intervention did not continue. The results proved that a one-time lecture, even if
complemented by other modes of education, is not sufficient and that ongoing inter­
ventions of various modes are required.

i
I

I

I

I

I

Case managers: working with Ethiopian HIV-positive
immigrants
Two fundamental ideas underlay the project of mediation and case management of
people with HIV, their families, and sexual partners. First, proper care of people with HIV
is related to the prevention of transmission of HIV. Second, because of the pattern of
sexual partners among immigrants, the greatest risk for transmission of HIV within the
immigrant population is through immigrants who are HIV-positive. There is a much smal­
ler risk for transfer into the general host country population. Therefore, a comprehensive
prevention programme to lower the risk of HIV transmission within an immigrant popul­
ation must include a component of working with immigrants who are already infected.

noil

Background
Jih’ J;;:*: ..

As a result of HIV screening after immigration, most of the HIV-positive persons
among the Ethiopian immigrants to Israel are known to the health authorities. This creates
a unique opportunity in which public health interventions could be targeted specifically
to these persons to prevent further transmission. It is the responsibility of public health
services not only to prevent HIV transmission, but to provide counselling and care once
people are screened.
In Israel, follow-up of HIV-infected persons is provided by HIV/AIDS clinics in
public hospitals. Although all medical services for HIV-infected persons arc covered by

55

I

Chapter 3

Israeli programmes: Demonstrating principles of the method

insurance, psychosocial services and behavioural intervention for the HIV-positive
population are minimal. Because of cultural differences and communication problems
between immigrants and the medical and paramedical staff, the absence of such services
and interventions creates a serious problem.
In response to that situation, a subcommittee of the Israel National AIDS Steering
Committee recommended to the Ministry of Health that a case managers project directed
at immigrants who are HIV-positive should be established as part of a comprehensive
programme for the immigrant population. By this time, the funding for the information
and education project for the general population of Ethiopian immigrants had been used
up and the project discontinued. Thus, new immigrants were not exposed to any educ­
ation programme, and the veteran immigrants had not received any ongoing education.
The recommendations of the subcommittee included re-establishment of education pro­
grammes for the general population and for specific sectors within it according to their
specific needs and a special project targeting people with HIV. An initial project, limited
to a few public health districts, was supported by the Ministry of Health.

Stcci incommittee
ami project team

A steering committee was established with representatives of the Ministries of
Health, Absorption. Labour, and Welfare, the American Jewish Joint Distribution
Commitee, Inc., and the Braun School of Public Health. The committee agreed on the
structure of the project, and appointed a project team, which included the Director of
Public Health Services and the Director of Public Health Nursing at the Ministry of
Health and two social scientists from the Braun School of Public Health.
In order to avoid stigmatization of its workers and those being treated by them, the
project was named Prevention of Infectious Diseases among Ethiopian Immigrants. The
steering committee met regularly at three-month intervals to monitor the project and
recommend changes. It was agreed that the committee would have the authority to
recommend the closing of the project, if necessary.

Project (levclopnicul

"i Target population
All 1 HV-positivc Ethiopian immigrants who had been identified when screened after
immigration or otherwise found to be HIV-positive were targeted. As the number of case
managers was limited and none were employed full-time, the HIV/AIDS centres and the
relevant health district authorities created priority lists of people who had lost contact
with medical or care centres and their personnel. Existing data indicated that these people
needed the most support and should be targeted with prevention interventions.
“I Collection of background data
The main sources for background data were health care workers of Ethiopian and non­
Ethiopian origin who had been working with this population in HIV/AIDS clinics. They
provided details on the major problems, which resulted mainly from cultural barriers from misperceptions and misunderstanding by both the immigrant patients and the Israeli
health care providers. Some of the health care workers presented their experience with
trying alternative ways to address problems. Other pertinent information on Ethiopian
immigrants in Israel and their health beliefs, attitudes, and behaviour was known from
the collection of data prior to the information project for the general immigrant popul­
ation and its outcome evaluation.
At that time, no data were found in the literature about the use of bicultural mediators or
case managers with immigrants in other countries. Downing (1992) has stated that the
use of cultural mediators as a means to provide culturally sensitive health care is recom­
mended but is often dealt with only al the level of individual institutions or individual
practitioners and not at the national level.

n Goal and objectives
'Hie main goal of the project was to prevent further HIV transmission in the immigrant
community and to minimize the harmful effects of HIV infection on patients, their

Chapter 3

Israeli programmes: Demonstrating principles of the method

families, and partners. The project aimed to provide culturally sensitive behaviour
modification ami counselling. I he specific objectives were to:
«

decrease cultural barriers through case managers and mediators;

♦

reach out to people with HIV;

v
♦

promote and reinforce reduction in HIV-related risk behaviour;
increase partner notification;

♦

provide emotional and social support to persons with HIV and their families;

♦

decrease the rate of HIV transmission to sexual partners or infants.

i Planning the interventions
Fhe job description of the case managers included:
♦

Reaching out to HIV-positive persons registered in their region.

Periodic follow-up of HIV-positive persons through home visits or in any other
location as decided with the patient.
♦

Mediation between all agencies that should be involved in the care of the patient and
family, included receiving their instructions and conveying them to the patient and

explaining to staff members of concerned agencies the problems raised by the

patient. The case manager had to refer patients to the appropriate services once a
problem was identified, instruct them about the necessary procedures, and ensure
that they completed the process. Only on special occasions would the case manager
accompany the patient.
Regular counselling of HIV-positive persons, their families, and partners. The idea

was to use culturally specific behavioural modification interventions by integrating
all educational tools developed by the HIV/AIDS information programme for the
Ethiopian immigrants together with intensive individual or couple counselling. The

counselling included information on HIV infection and how it can be lived with and
managed, the means by which to maximize the chances of remaining healthy, the
responsibilities that HIV-positive people have for themselves and their sexual

contacts, and effective strategies to avoid transmission. Partner notification was
discussed at the initial contact and at follow-up, and assistance in disclosure of
diagnosis to partners or family members was offered.

1 Structure, staffing, and selection of case managers
The project was administered by the Department of Public Health Nursing at the Ministry
of Health, fhe case managers were placed al district health departments, under the
administrative supervision of public health nurses. The decision about whom to contact

was made jointly by the public health nurse and the regional HIV clinic staff. Fhe case
managers were Io be present at the clinic once a week. The project was innovative in its
collaboration between community public health services and hospital clinics. The idea
behind this decision was that the case managers would be identified as community

workers in a health promotion programme - the prevention of infectious diseases - and

not as workers in hospital HIV/AIDS clinics. This was an important way of maintaining
confidentiality, because the case managers were to contact the patients at their homes.
All case managers were professionals, mainly nurses. Each was employed half-time. This

was partly to avoid burnout but also to help conceal public identification with HIV/AIDS
by employing people working in other jobs. Most of the case managers had been working
in other health education projects in the community or as hospital nurses.
The two social scientists from the school of public health developed the training and the
interventions, provided ongoing training and supervision, and monitored and evaluated

the programme in collaboration with the public health services of the Ministry of Health.
A coordinator was employed on a part-time basis. Her duties included coordinating acti­
vities throughout the country, preparing each case manager individually for the job,

monitoring and following up on case managers’ work, reviewing their reports and
providing them with feedback, transferring the forms for evaluation, and taking care of
the administration of the project.

Chapter 3

Israeli programmes: Demonslrating principles of

method

"i Planning of monitoring and evaluation methods
The case managers were instructed to report their activities routinely to the supervising

district nurse with copies to the project coordinator.
The forms for the data collection served for monitoring and evaluation and as a tool for
supervision. They were divided into three parts. The first section was to be filled in after

the initial contact, leaving space for possible changes during the follow-up period. It

included data on personal characteristics (gender, age, year of immigration, marital
status and number of children, work, type of residence, fluency and literacy in Hebrew

or Amharic) and medical status (date of diagnosis, stage of the disease, whether
medication had already been recommended and, if so, whether it was taken). No medical

data were taken from the patient’s clinic files.
The second section, which provided data on behavioural and psychosocial problems dis­
cussed during each meeting with the patient, was to be completed for each contact. It was

designed as an open-ended form to facilitate the work of the case managers. The case
managers were instructed to report all problems raised during the visit. They were also

instructed to detail after the first visit the number and type (regular and casual) of sexual

partners during the last month, the use of condoms, and the disclosure of diagnosis to
partners and family, and to probe for this information on every visit. Other problems
(c.g., work, housing, marital conflict) were to be written down only if raised by the

client. Any changes in HIV status of partner(s) or pregnancy of a female patient or part­

1

ner of a male patient were reported as well. This section was used mainly for monitoring

the intervention, supervision, and outcome evaluation.
The third section was to sum up the monthly activities with community services in
relation to each patient, the total number of patients treated at the medical service centres
during this month, and the total number of contacts with case managers.
The second and third sections were to be used for the outcome evaluation. This eval­
uation, to be conducted after a year, would assess changes in sexual behaviour,

!

pregnancy rates, and the rate of partner notification by the patients, and would measure

such variables as the number of patients served by each case manager in each region, the
number of contacts with each patient per month, and the duration of follow-up. The last

and most important objective - the decrease in HIV infection rate - was to be evaluated
at the end of the project.

liainhit; and
Mipervi^ion

’Hie planned supervision of the case managers was carried out by the district health
nurses, the project coordinator, and the professional team. The nurses were to supervise

the case managers on a weekly basis, mainly on administrative matters and ways to
approach patients. They were less familiar with HIV issues and with the specific cultural

problems of this community. The professional supervision and training on HIV/A1DS

and the interventions with the patients were delegated to the professional team. Group

supervision and (raining took place every month. The project coordinator supervised the
case managers on individual cases.
After an initial two-day training seminar, the case managers started working. The
follow-up training sessions were used for the development of changes in interventions

in an iterative process. As in other projects in this community, the case managers have
acted as aids to the professional team in the development of interventions. They are the
“insighters” who have suggested alternative modes of intervention to the professional

team and to each other.
Each training session was usually divided into two parts. The first, more academic
part included presentations on specific subjects (e.g.. HIV transmission and prevention,
clinical treatment of HIV-positive persons and AIDS patients, psychological stress of
persons with HIV, models of behaviour change and how they could be applied to this
population, approaches to discussion of the use of condoms, family issues, and social
security benefits). The second part was usually more interactive, either role-playing to

demonstrate encounters with patients, or group supervision of cases presented by the
case managers.

Chapter 3

Experimental
implementation

Il was decided (hat the case managers would mainly do outreach in the community,
but would also work once a week at the regional HIV/AIDS centres in the hospitals and
receive referrals there from the staff. People who were known to have HIV and who had
not yet been seen by the medical staff of the HIV clinic in the region or who had not
attended the clinic for follow-up visits were targeted as the first priority for outreach. Any
other referral by the HIV clinic or community services was to be accepted by the case
managers, as were patients identified by the case workers themselves.
The case managers were advised to present themselves as professionals of the district
health office who wanted to assist the family with health problems. If the patient dis­
closed his or her HIV status to the case managers, they could proceed to talk about HIVrelated issues. However, in most cases, people were reluctant to talk about problems, and
the first visits were "social calls.” The case managers were encouraged to keep visiting
the patient and, when it was suitable, to mention "A while ago you received a letter from
the hospital to ask you to come for a visit. This is important for your health and I suggest
that I make an appointment for you.” Under no circumstance were they to disclose or
mention the possibility of HIV to lhe patient. When the patient came to the clinic to
repeat the ELISA test, the case managers were asked by the physician to assist in medi­
ation when the result was revealed to the patient. They later accompanied the patient as
instructed by lhe clinic medical staff and lhe social worker. Patients who had already
visited lhe HIV clinic and were notified of their HIV status were reminded by lhe case
managers that they had been al the clinic and asked to come for a follow-up visit. When
they agreed, lhe date and time were set up for them. Once it was clear that the reason for
the contact was HIV, the case managers were free to continue working with lhe patient
and lhe family members. Follow-up visits or meetings al other places were set up as
needed.
There is great respect in lhe immigrant community for medical professionals. The
case managers were advised to create an atmosphere of acceptance for the patients and
to establish contacts. The main messages that lhe case managers were to convey included
the following:

♦

♦
♦

♦

Ongoing
interventions,
training, ami
monitoring

Israeli programmes: Demonstrating principles of the method

"We are here to listen to you and to help you. Your situation is difficult and we, as
people from your community, understand you and can mediate between you and the
medical services. You are not alone, we are here with you and we will keep your HIV
status confidential.”
"The staff at lhe HIV clinic can help persons with HIV. There are drugs to delay the
onset of AIDS and to make those with symptoms feel better.”
‘‘To be HIV-positive is a serious but a controllable problem. You can control it by
going to lhe doctor and by having safe sex. It is your responsibility to yourself and
to others.” Some of lhe specific messages embodied here had cultural meaning
specific to this community and were similar to those used in the information project
.to lhe general community. These included "It is better to do things when you can
prevent problems than to cry when you are suffering,” “Be gobez - a wise person
who protects his family,” and "Your life is in your own hands.”
“The problem of HIV exists in many communities and in many countries.
Everywhere in the world people with HIV have difficulties in maintaining the use of
condoms but many have found ways to overcome barriers.”

During the first year of the implementation of the project, the iterative process led to
some major changes as the project stabilized and lessons learned from mistakes and
successes could be included. The ongoing monitoring and supervision sessions revealed
two major types of problems: the personal barriers of the patients, and administrative
problems and system barriers.
“I Personal barriers
Denial of HIV status. Denial is the strongest argument of asymptomatic patients. The
community perception is that, without symptoms, there is no infection, and therefore no

Chapter 3

Israeli programmes: Demonstrating principles of the method

risk of transmission to others. Denial was quite common and was often the reason for
resistance to continuing contact, to attending the HIV clinic, or to disclosing HIV status

to partners and family. The main approach was not to argue with the patient but to try to
explain HIV by calling it “the hidden disease” and comparing it to situations from
agricultural life (e.g., termites) or even social conflicts, which are at first hidden and be­

come visible only when they are more serious. The case manager explained that
physicians have a way to test the blood to see if the disease is hiding there and how much

it has progressed, and can give medicine to slow down the progression.
Fear of stigma. The level of stigmatization of HIV/AIDS in the community presents a

very high barrier to treatment. Patients resisted contact with the case manager for fear of

being “found out” by others in the community. They also resisted disclosing diagnosis

to family members or partners and changing their sexual behaviour. Fear of stigma by

family members or regular partners could be overcome by offering help in disclosure,
but it was still a great barrier for unmarried young adults. In a few cases, the partner
broke off the relationship after the patient revealed his or her HIV status.
This project could not have an impact on changing the attitudes of the whole commun­

ity without a parallel education for the total community. Thus, the case managers could
only assure a patient that they were professionals who had to keep information confi­
dential. 'Hiey suggested meeting places other than the home or clinic, like coffee houses

or parks. In many case, this has become the best way to establish and maintain the

contact.
Lack of basic knowledge on HIV/AIDS and on the proper use of condoms. Lack of
knowledge about HIV/AIDS or the use of condoms was relatively easy to solve by
repeated education and demonstration of the use of condoms.

Resistance to condom use. Reactions to condoms often depended on the marital status

of the HIV-positive person or the type of relationship that this person had. There were
several reasons for resistance to using condoms.

♦

Most of the people in the community are religious, and the Jewish faith favours large

families and opposes prevention of pregnancy. There was little that could be said to
married couples who wanted to have unprotected sex because they wanted more
children, especially if these couples believed that it was healthy to have many

children. Arguments that pregnancy can cause deterioration in the health of an HIV­
positive woman, or that unprotected sex with an HIV-negative woman poses a risk

for her. are usually not accepted by men or, in a few cases, by women either. Thus,

there were quite a few cases of pregnancies. In some cases, there was more than one
pregnancy in the same family within the first 15-month period of the project.

♦

Many HIV-positive men regarded impregnation of their wives as a sign of their

virility and health. In these cases, the case managers tried to discuss the concept of
virility as being responsible for one's family, wife, and children, and thus protecting

one's wife.

Some patients did not believe in the ability of condoms to prevent infection.

❖

Some patients indicated their belief that condoms decrease sexual pleasure. In this
case, the case managers explained that condom are made from a special material that

is extremely thin and does not inhibit sexual pleasure. If the patient consented, the
♦

case manager then proceeded to demonstrate a condom.
Some patients feared that if they suggested or used a condom, it would indicate to
their partners that they were HIV-positive. The most common approach to overcome

this obstacle was to tell patients to suggest to their partners that until they were
completely confident about the relationship they should both agree to use condoms
to avoid pregnancy. Another approach was to say that there was talk about HIV in
the community and that it might be better to gel tested before having a relationship.

♦

Very few adopted this approach.
Patients who denied their HIV status reliised to use condoms. One case manager

suggested overcoming this obstacle by reversing the situation. She told a patient that

Chapter 3

Israeli programmes: Demonstrating principles of the method

although he believed he was HIV-negative, he could not know the status of his
partner. As she might be HIV-positive, he should wear a condom to protect himself
from getting infected.
Fatalistic beliefs. This barrier included the belief that the disease is ordained or is a

stroke of fate. There is nothing a person can do to change the situation. Most patients

saw it as an act of God or of a bad spirit, as a punishment or curse. The only way to over­
come this barrier was to persuade patients by quoting the Bible: “God makes all things

happen but man has a potential to change the situation by making a choice.” Case

managers tried to persuade patients that they needed to change their behaviour and show
that they were responsible for others; then God would make things better for them.
Lack of empowerment of women in sexual matters. Many wives of infected men said

that they could not refuse sex because of their dependency on their partner. The need to
empower women was widespread and had to be accomplished in very sensitive ways.
Many case managers met with the partners separately and with both of them together.
The best argument was the importance of preserving the health of one’s wife, so that she
should lake care of the children and also support the husband when needed. In some
cases, the fear of being abandoned by their spouse encouraged men to practise safe sex.

1 Administrative problems, system barriers

System barriers were not related to the difficulties of the people with HIV but were '

imposed on them and on the case managers by the system.

Reporting. Many of the case managers found the forms too demanding, and some
changes were initiated to make them more manageable. However, during the first

months a high proportion of forms were missing information. Persistence by the coordi­

nator and the professional team, as well as restructuring of the forms (some closed-ended
items in addition to the freestyle reporting of each contact) improved the reporting.
Coordination between the district health nurse and the HIV clinic. Sometimes the

case managers received contradictory demands from the district health nurse and the
HIV clinic staff. Alternatively, there were problems with the level of cooperation between community services and hospital staff, and with the case managers. The coordi­

nator organized meetings of both services to solve problems, and such meetings became
a routine in many regions.
Mobility. Due to moves from temporary Io permanent housing, the target population is
characterized by high mobility. For this reason, the case managers encountered great dif­
ficulties in locating patients. Sometimes it took 5-12 visits until they managed to locate
and contact the person.

Isolated efforts. No parallel education campaign for the general population existed to
continue what the information project had started in 1992-93. No ongoing educational
efforts attempted to change misperceptions and decrease stigmatization of or prejudice

and discrimination towards HIV-positive people. Yet, without the norms in the environ­
ment of these patients being modified, the difficulties to persuade them to change their
behaviour are greater.
■ :li' >h.

Attrition and shortage of suitable case managers. A great turnover resulted from some

case managers being replaced w hen found unsuitable for such sensitive work. However,
of the first five case managers three were still employed as of January 1997 and have
contributed tremendously to the project.
Disbelief. Some personnel, usually concentrated in an agency, district, or clinic, even

among those participating in the project, did not believe that behavioural interventions
of the Ethiopian case managers could change the situation. These people sometimes

employ the criteria of all-or-nothing when discussing the issue in order to prove their
point. Such disbelief tends to be self-fulfilling, as these people are less cooperative with
the case managers, sometimes unintentionally undermining their efforts.

Chapter 3

Isiaeli pioqrainrnes: Demolish.'itiriq pmiciplns of tlio oirllv- !

Interim outcome
evaluation

Al the end of the rust year, ongoing monitoring and several discussions with the
district health offices and the regional HIV clinics showed that the project was expected
to continue. The public health nurses and the hospital staff valued the work of the case
managers. They saw it more realistically and understood the tremendous barriers to
behaviour change in the immigrant community. The problems of cooperation had disap­
peared, and the case managers were viewed more positively and as professionals who
make important contributions. Moreover, there was a demand to expand the project to
other regions. By the end of the first year, funding of the project was extended for
another year and the project was implemented in four additional districts, employing
eleven additional case managers.
Initial data analysis showed that about 13 per cent of the persons with HIV had not
been located. Only 5 per cent refused any contact with the case managers after several
trials. Most of the patients were seen once or twice a month.
Great improvement in the rate of regular clinic follow-up was seen during the year.
The first priority was to reach out to people who were not coming to the clinic, but al the
end of the year 48 per cent were attending the clinic regularly and 24 per cent were at- *
tending sporadically. Twenty-one per cent were not allcnding the clinic and data were
missing tor 7 per cent. These results indicate that efforts have lo be focused on under­
standing the reasons for refusal to attend the clinic.
Disclosure of diagnosis to sexual partners was still problematic. About 33 per cent
of the patients said that they did not have sexual partners al all, 47 per cent disclosed the
diagnosis to partners or other family members, and 20 per cent did not disclose.
Condom use was the item with the most reporting problems by the case managers,
with 47 per cent missing data. Towards the end of the first year, the forms were changed,
and reporting has improved. Because of the inadequate data, analysis could be carried
out, but the case managers say there is still a lot of reluctance to use condoms.
At the end of the first year, the subjects that case managers raised with their super­
visors have changed from issues of how to approach patients and how to overcome
resistance to contact, to issues of initiation of behaviour change (condom use) and
maintenance of changes.

Sensitizing health and welfare personnel
Hm ki*iomul
mul i i{liiiihiIc

I he policy ol concentrated care for immigrants to Israel - and especially for those
from Ethiopia, who were considered in special need for support - had important impli­
cations because it brought a large group of caregivers in absorption centres into close
contact with the immigrants. 4 he level of education of these caregivers varied from aca­
demic training of physicians, nurses, social workers, and some of the teachers, to almost
no education among house helpers and administrative and maintenance staff. With
regard to the high prevalence of HIV infection among the immigrants, the reactions and
attitudes of caregivers also varied. Yet, surprisingly, these were not correlated to the
educational background of the staff members.
Calls for sensitizing and training staff came from the AIDS centres even prior to the
introduction of mediators and case managers 4. At that time, the centres used lay
translators and experienced great difficulties in communicating with their clients. The
centres requested guidance in working with immigrant people with HIV and AIDS.
The need for interventions, focusing not only on some AIDS centres, but also on dis­
trict nurses, was also expressed by immigrant professionals working with people living
with HIV. Those professionals indicated that part of the failure to maintain contact bet­
ween AIDS centres and immigrants in some AIDS centres the dropout rales were over
60 per cent - was due to cross-cultural problems. Details of such cases were described

4
There are eight HIV/AIDS treatment/care centres in large medical centres around the country.
Although the centres are distributed regionally, people with HIV/AIDS can choose the centre they
want to be associated with and change centres at will. These centres are also responsible for testing,
which in Israel is confidential but not anonymous.

1
Ciidptui 3

I

I .i.icli pi m>ji uiniiK, i>; DuiiionL.li tiling principles of tho method

repeatedly in training and supervision sessions for case managers of people with HIV and
their partners. As described earlier, case managers were professionals from the immigrant
community, working in cooperation with district nurses, AIDS centres, and with a central
team of developers and trainers.
One of the monthly training and supervision sessions for case managers was used to
develop stiategies to overcome such difficulties and problems, and to increase the
retention rate oi the AIDS centres. One way to do that, proposed by a case manager, was
to inform the health personnel directly about instances in which their behaviour was res­
ponsible for the loss of contact with specific clients. Several case managers felt un­
comfortable with this strategy, although it was viewed as highly effective. Cultural norms
and respect for professional status inhibited them from approaching physicians, nurses,
or social workers with critical and judgmental remarks.
Instead, it was decided to design joint training and sensitization sessions with the
AIDS centre personnel and regional community nurses, and, al the annual meetings, with
all stall members of the centres. Tor these sessions, fictitious cases based on the reports
of the case managers, were prepared and discussed. These case descriptions, in which a
specific AIDS centre or a region could not be identified, were used as non-threatening
examples to practise cross-cultural problem-solving skills and increase capacity to work
in a multicultural context.

Design of the
sensiti~ati(Hi
progrmnuie

Two sets of sensitization regional seminars were organized by the team that had
worked on the project for the general population for Ethiopian immigrants (see Section
“Project for the general population of immigrants from Ethiopia”): one for a mixed
audience of caregivers in residential centres and HIV centres, and another for social
workers working in municipalities into which immigrants were moving. The structure
and content of these seminars were essentially the same, although in the set for social
workers the emphasis was more on psychosocial issues.
About 300 people participated in the first scries of six regional seminars, and about
250 in the second series of three seminars for social workers for which there was no
enrolment or fee.
A one-day seminar included the following:

♦
♦

♦

Learning about HIV/AIDS (a lecture and discussion that allowed the participants to
improve their knowledge and express their concerns and fears).
Learning basic elements of the culture of the immigrants to increase the caregivers’
understanding of factors that have an impact on HIV/AIDS, including their medical
and health model and their views on sexual health and intimate behaviour. This
session sometimes included presentation of the posters that were used to explain
HIV/AIDS to the immigrants.
Group sessions on coping with practical issues in which the concerns of the
participants were involved.

Although there was no formal evaluation, an informal feedback session raised
persisting concerns of the participants and discussed whether they gained some insights
into coping with those concerns. The majority reported an increase in their understanding
of HIV/AIDS, improvement in coping with issues of HIV/AIDS among immigrants, and
improvement in working with their own fears. Some reported an increase in their know­
ledge but no change in their concerns and fears, and a very small minority reported an
increase in fear.

Introducing a
counselling aid t(f
the staff of the
AIDS centres

In the effort to ameliorate the situation at the AIDS centres, and until a better solution
could be introduced, the set of posters explaining HIV/AIDS was printed in a booklet
form, suitable for individual counselling. Guidelines explaining the changes in tone and
approach needed to transform the posters from an educational to a counselling instrument
were also printed. In a two-hour orientation session, conducted by one of the developers,

Chapter 3

Israeli programmes: Demonstrating principles of the method

I
the staff of each centre was introduced to the use of these counselling aids, its central
messages, and cultural background.
As the intervention was very short and informal, and the number of participants in

each orientation session small, no evaluation was attempted. Some information could be
collected about the use of the booklets and the satisfaction of the staff with them from
numerous anecdotal reports, b

1

.64

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