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Horizons Program PATH Tulane University University of Nairobi School as a Workplace in Kenya: Evaluation of the Teachers Matter HIV/AIDS Project School as a Workplace in Kenya: Evaluation of the Teachers Matter HIV Intervention Karusa Kiragu, Horizons/PATH Caroline Mackenzie, Horizons/Population Council Jennifer Weiss, Tulane University Murungaru Kimani, University of Nairobi Debbie Gachuh i, Independent Consultant Acknowledgments The authors would like to thank the following individuals and institutions for their invaluable contribution to the study: Isaac Thuita and Salome Maina of the Ministry of Education’s AIDS Cont rol Unit; Sarah Irungu and Oliver Munguti of the Teachers Service Commission’s AIDS Control Unit; the District Education Offices of Thika, Kiambu, Kwale, and Kilifi; the District Staffing Office at Kwale and Kilifi; and the Kenya Institute of Education’s A IDS Control Unit. We are also grateful for support from UNICEF, including Changu Mannathoko (formerly of UNICEF ESARO), as well as Roselyn Mutemi and Elias Noor (UNICEF - Kenya). We also thank the Project Advisory Committee members and especially the Kenya N ational Union of Teachers (KNUT), and the Center for British Teachers (CfBT) for their contributions in the early stages of the project. We make special mention of the We also recognize the Kenya AIDS and Drugs Alliance (KADA), for their work on the wellbeing of people living with HIV. We are grateful to Cornelius Mutangili for providing support supervision to the study, and George Odingo for data management. Gratitude i s extended to Ellen Weiss and Scott Kellerman for their useful comments during the preparation of this manuscript. We would also like to thank Sherry Hutchinson for the layout. We convey heartfelt thanks to all the interviewers, peer educators, and school managers for the crucial role they played in making this study a success. We appreciate the support of the head teachers in the participating schools. tive questions about their lives. Finally, the authors are grateful to UNICEF for funding the baseline study, and to USAID/PEPFAR for fund ing the intervention and follow - up phases of the study. This study and final report were made possible by the President’s Emergency Plan for AIDS Relief and the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Cooperative Agreement No. HRN - A - 00 - 97 - 00012 - 00. The contents are the respon sibility of the Horizons Program and do not necessarily reflect the views of USAID or the United States Government. Published in February 200 8 . The Population Council is an international, non - profit, nongovernmental institution that seeks to improve t he well - being and reproductive health of current and future generations around the world and to help achieve a humane, equitable, and sustainable balance between people and resources. The Council conducts biomedical, social science, and public health resea rch and helps build research capacities in developing countries. Established in 1952, the Council is governed by an international board of trustees. Its New York headquarters supports a global network of regional and country offices. Copyright © 2008 . The Population Council Inc. Suggested citation: Kiragu, Karusa, Caroline Mackenzie, Jennifer Weiss, Murungaru Kimani, and Debbie Gachuhi. 2008 . “School as a workplace in Kenya: Evaluation of the Teachers Matter HIV/AIDS project,” Horizons Final Report . Washi ngton, DC: Population Council. This document may be reproduced in whole or in part without permission of the Population Council provided full source citatio n is given and the reproduction is not for commercial purposes. Table of Contents Abbreviations Executive Summary 1 Background 7 Workplace programs for teachers 7 Education sector policies on HIV 9 Sample 10 Research questions 10 10 Study sample 11 Description of the Intervention 13 Theoretical framework 13 Progr am implementation 13 Results 20 Exposure to Teachers Matter 20 Effects of Teachers Matter intervention on selected outcome measures 2 3 Discussion and Recommendations 3 8 Successes 3 8 Challenges 3 9 Lessons learned 40 Appendices 4 3 References 4 5 Abbreviations AFT American Federation of Teachers AIDS Acquired Immune Deficiency Syndrome ART ARV BCC Behavior change communication CI Confidence interval FGD Focus group discussion HIV Human Immun odeficiency Virus KADA Kenya AIDS and Drugs Alliance KNUT Kenya National Union of Teachers MOE Ministry of Education KIE Kenya Institute of Education KENEPOTE NUD*IST Non - Numeric Unstructured Data * Indexing, Searchi ng and Theorizing NS Not significant OR Odds ratio PEP Post - exposure prophylaxis S TI Sexually transmitted infection TSC Teacher Service Commission VCT Voluntary testing and counseling Evaluation of Teachers Matter 1 Executive Summary Countless HIV interventions rely on teacher s to deliver vital prevention messages to their students but do infection. In 2004, the Horizons Program of Population Council embarked on an operations research initiative to test the feasibility of implementing a teacher - centered workplace program based in schools. The study was conducted in partnership with the Ministry of Education (MOE), the Kenya Institute of Education (KIE), the Teachers Service Co mmission (TSC), and UNICEF. Called “Teachers Matter,” the project’s main audience was primary and secondary school teachers. The purpose of the research was to assess whether such a program would improve teachers’ HIV - related knowledge, attitudes, and beha viors; increase the proportion of teachers seeking voluntary testing and counseling (VCT) ; and enhance their ability to cope with HIV - related issues in the workplace. Methods A quasi - experimental design was employed to assess the impact of Teachers Mat ter. Quantitative data were collected from 120 schools in two intervention sites (60 schools) and two comparison sites (60 schools) in Central and Coast provinces. The baseline survey was conducted in October 2004 and the follow up in March 2007. Data were gathered using an anonymous, pre - tested, self - administered questionnaire. The sample comprised 1,237 teachers at baseline and 1,307 teachers at follow up . Qualitative data were also collected through a total of 16 focus group discussions with teachers and peer educators. Description of the Intervention Teachers Matter is a peer - led education program, guided by a 10 - unit manual 1 . The manual drew on two theories of behavior change: The Transtheoretical Model (TM) (Peterson and DiClemente 2000), and the Th eory of Gender and Power (Connell 1987). Before the intervention, head teachers from each participating school were given a sensitization training to seek their input and support for the program. Subsequently, each school selected a teacher to be a peer ed ucator; these peer educators received a one - week training on how to use the manual. Throughout the 12 - month intervention, peer educators were supported by quarterly visits from the Teachers Matter study monitor, and received a refresher course midway throu gh the training. The manual had 30 units that were to be covered throughout the academic year (about 36 weeks). Peer educators were given freedom to schedule intervention activities based on the needs of their respective schools. Most meetings with teach ers were held once a week and lasted from 30 to 90 minutes. Peer educators were supplied with educational brochures, samples of condoms, and samples of antiretrovirals (ARVs) to show to teachers; specially - made calendars featuring teachers ; and other educa tional materials. that had been launched in 2004 . In addition to regular meetings, teachers also participated in community activities to increase AIDS awareness such as football tournaments and World AIDS Day events. The project sought 1 The manual was adapted from the Life Skills Manual for Guide Leaders developed by the Kenya Girl Guides Association. 2 opportuniti es to involve organizations for people living with HIV , and commissioned such a group to produce peer education bags and penis models. During peer educator training, a mobile V CT team provided services for free to the teachers. Of the 120 teachers a ttending the training, 40 ( 33 percent) got tested for HIV for the first time. Once the follow - up evaluation was conducted, Teachers Matter behavior change communication (BCC) materia ls were also provided to the 60 comparison schools. Collectively, the project reached over 2,700 teachers in both intervention and comparison schools. The intervention cost approximately $42,500 which covered preparation, printing and distribution of BCC m aterials, training of the peer educators (including materials, transport and accommodation), sensitization of headteachers, and offering mobile VCT services. This translates into roughly $16 per teacher reached. Challenges encountered included an abrupt c hange in the funding environment, leading to sharp financial cutbacks for operations research. This led to a17 - commencement of Teachers Matter. Data Analysis Both baseline and follow - up data were double - ent ered using EPIDATA. Data were analyzed with STATA measure of association was the chi - square and its p - value. For multivariate analysis, the statistical tech nique was logistic regression, and the measure of association was the odds ratio. Exposure to the intervention was classified into three groups: unexposed (teachers in the intervention schools who did not attend any meetings, and all those in the compariso n s chools ), moderately exposed (intervention school teachers who attended some of the meetings) and highly exposed (teachers in the intervention schools who attended all meetings) 2 . This allowed a dose - response analysis of the associations. Qualitative dat a were analyzed with NUD*IST. Key Findings Teachers were greatly interested in the intervention and found it beneficial. Almost all (92 percent) of the respondents in the intervention schools had heard of Teachers Matter at follow up , and 80 percent h ad p articipated in it. Thus the intervention was able to reach four out of five Participating teachers listed several kinds of information they obtained from the project, including basic information about HIV , HIV , male and female condoms, and how to live positively with HIV . Seventy - one percent of took further action related to HIV as a result of the project , such as remaining monogamous , talking with family members or friends ab . Nearly 75 percent of the teachers recommended that the program continue. 2 Attendance was measured by the answer to the following question: “How often did you attend Tea chers Matter since it started?” Answers were 1= Every meeting; 2 = Most meetings; 3 = About half the meetings; 4 = Rarely/never. Those attending most or some meetings were combined to form the “some” group. Evaluation of Teachers Matter 3 The intervention was well implemented and provided useful lessons for the future. In general, teachers were receptive to Teachers Matter and keen to di scuss how HIV was affecting their lives . Most attended enthusiastically and found the interactive nature of the sessions enjoyable and educational. Peer educators demonstrated innovation and resourcefulness in their ability to reach their fellow teachers. However, there were a few challenges at the beginning: a few teachers were skeptical that they would learn anything new, but this number gradually declined. Some teachers expected financial compensation for attending the me such incentives were available. Finding time in a busy school schedule was challenging. In addition, many teachers were still uncomfortable discussing sexual matters, especially topics like condoms . Also, due to the teachers, and this made discussions of some sensitive topics awkward. In some cases, teachers, and even peer educators, were relucta nt to participate actively, lest they draw undue attention to themselves and raise questions about their own HIV status. Supportive monitoring and support from head teachers often addressed these issues successfully. Endorsement from the district education offices greatly facilitated acceptance of the project. The mid - term peer educator training was a valued opportunity to share these experiences and find appropriate solutions. Awareness of the Education Sector Policy on HIV and AIDS increased among parti cipating teachers. Teachers Matter was effective in enhancing familiarity with the Education Sector Policy on HIV and AIDS . During the baseline survey, about 42 percent of teachers in the intervention site s had heard of the policy, and this had risen to 6 2 percent at follow up . However, in the comparison sites, 4 0 percent had heard of the policy at the baseline, but the percent remained unchanged (39 percent ) during follow up . The results were especially significant when examining readership of the booklet : t eachers who attended some of the Teachers Matter meetings were 2.0 times more likely to have read the policy compared to those who did not attend (CI 1.0 – 3 .9), while those who attended all the meetings were 5 .7 times more likely (CI: 2.8 – 11.2 ). Thus exposure to the intervention was associated with a greater utilization of the Participants perceived improvement in their s chool s ’ and fellow teachers’ abilit ies to cope with HIV issues. Respondents in schools where Teachers Matter was implemented reported significantly greater progress in how adept the teachers, and the school’s management, had become at coping with HIV issues compared to a year earlier. About 35 percent of teachers in the intervention schools reported “great improveme nt” in their being able to cope with HIV in the school setting, compared to 26 percent of their counterparts in the comparison sites. Regression analysis showed that compared to those who were not exposed to Teachers Matter, respondents who attended all th e meetings were 3.6 times more likely to report “great improvement” in teachers’ HIV coping abilities (CI: 1.9 - 6.7). Similar results were also obtained regarding management’s coping efficacy: 28 percent of teachers in intervention schools reported “great improvement” in management’s ability to cope with HIV compared to a year ago, while 19 percent of those in comparison schools reported so. Regression analysis showed 4 that compared to those who were not exposed to Teachers Matter, respondents who attended all the meetings were 1.7 times more likely to report “great improvement” (CI: 0.9 - 3.2). There was a decline in perceived risk of HIV . Baseline data showed that teachers feared being infected at work , such as being exposed to HIV when dealing with sch ool - related injuries during sports, or simply while separating scuffling classmates. In addition, the fact that primary school education is now free in Kenya means that many children whose parents could not afford school earlier , including some HIV - infecte d children, have now enrolled. In response, Teachers Matter educated teachers on HIV transmission, in an effort to allay their fears. After the project, the percent of teache r s who were “very concerned” about becoming infected with HIV while at work declin ed from 65 percent to 57 percent in the intervention schools (p .017), but there was no change in the comparison schools (61 percent both rounds, p = 0.726). However, it is worth noting that even after the intervention, 57 percent of teachers still cons ider their HIV risk at work high. One possible reason could be because less than 10 percent reported functional and fully - stocked first aid kits, as recommended by the Education Sector Policy on HIV and AIDS. There was an improvement in the awareness of post - exposure prophylaxis. Because post - exposure prophylaxis (PEP) is now available in Kenya, Teachers Matter provided an opportunity to explain the purpose of this medication and procedures for accessing it. Results show that after the intervention, ma ny teachers became better informed about PEP . At baseline, only 4 percent of teachers in the intervention group said they knew what PEP was; of those, 24 percent correctly explained what it was. At follow up , 25 percent of the same group reported knowing w hat it was and 50 percent of them were correct (p .0001). There were no significant gains made in knowledge of PEP in the comparison group (2 percent aware of it at baseline vs. 3 percent at follow up ). Multivariate analysis showed that teachers who atte nded some of the meetings were 2 . 6 times more likely to know what PEP was (CI: 1 . 2 – 5.9 ), while those who attended all the meetings were 6.7 times more likely to know, compared to their counterparts who did not attend any meetings (CI: 3.0 – 15.2 ). There we re improvements in awareness and attitudes toward male and female condoms. After participating in the intervention, teachers demonstrated a statistically significant increase in positive attitudes toward male condoms from 49 to 64 percent (p .0001), com pared to no significant change in the comparison group (52 to 58 percent, p = 0.071). Teachers Matter also effectively conveyed information about female condoms, as there was a significant increase in those who had seen a female condom, from 42 to 77 perce nt in the intervention group (p .0001), compared to a smaller increase in the comparison group, from 47 to 55 percent (p .01). Multivariate analysis showed that teachers who attended all the Teachers Matter meetings were 1. 7 times more likely to have favorable attitudes toward male condoms (CI: 0.9 – 3.1 ) In addition, those who attended all meetings were 5.3 times more likely to have seen a female condom (CI: 2. 5 – 11.0 ) . Evaluation of Teachers Matter 5 There was an increase in HIV testing, but the majority of teachers still d id not know their HIV status or that of their partners. There was an increase in HIV testing , but the increment occurred in both intervention and comparison sites (24 percent to 39 percent in the intervention sites versus 25 percent to 41 percent in the compari son and HIV testing, suggesting that factors outside the intervention may have been more influential. The data show also that many teachers still fear ed being tested and that, although gains were made, only 43 percent of untested teachers in both the intervention and comparison groups wanted to be tested. The program did not impact on the li ke more specifically directed at partners and couples would be needed for this change to occur. Most teachers with multiple partners we re not protecting themselves from HIV. - taking among the study participa nts elicited a non - response rate of about 15 percent, available data showed that at follow up , 14 percent of respondents in the intervention schools had multiple partners in the 12 months preceding the research. In the comparison schools, about 17 percent did as well. However, 90 percent of such teachers in the intervention schools and 80 percent of their counterparts in the comparison schools said they did not use condoms “always” during these encounters. Because inconsistent condom use does not confer ade quate protection from HIV, programs are needed to help these teachers protect themselves effectively if they choose to have multiple sex partners. Multivariate analysis showed that there was no association between having multiple partners and exposure to t he intervention, suggesting that more concerted efforts would be needed for a behavioral effect to be achieved. testing among teachers with multiple partners , suggesting that further effo rts are needed to persuade such individuals to Nearly 40 percent of teachers have experienced an AI DS - related death in their families . Teachers continue to be strongly affected by HIV in their personal lives, as many of their relatives have been either infected with HIV or have died of AIDS. Indeed nearly 40 percent of teachers in the intervention and comparison schools at follow up were aware of an “immediate family member” who had died of AIDS. There was an increase in the percentage of tea chers reporting familial HIV in both intervention (30 percent to 41 percent ) and comparison (35 percent to 39 percent ) groups . The larger increment in the intervention site could be reflecting greater willingness to disclose this information . For example, Teachers Matter gave teachers information to help care for ailing relatives and many teachers to more PLHIV seeking them out for assistance . In addition, teachers may have become more informed about HIV HIV as a cause of death of a family member that might not have previously disclosed their status. Whatever the explanat ion, it is clear that many teachers have been directly affected by HIV. 6 The intervention was associated with improvements in HIV knowledge, but reduction of stigma occurred in both the intervention and comparison groups. Significant gains were made in general HIV knowledge, increasing in similar proportions in both intervention and comparison schools. However, regression analysis showed that those who attended all Teachers Matter sessions were 2.0 times more likely to have a high level of HIV knowledge, but those who only attended some sessions were no different than those who did not attend. There were also improvements in stigma, but this occurred in both the intervention and comparison groups. Regression analysis did not identify an association betwee n stigma and the intervention. Concerns remain ed about HIV - related confidentiality at work. Analysis shows that much ambiguity remain ed regarding job security if HIV positive and recourse for breaches of confidentiality. At follow up , over half of the teachers in both intervention and comparison schools reported not knowing what recourse there was if there was a breach of confidentiality, in part because the present policy is largely unclear on this issue. Conclusions The impact of HIV on the educat ion sector in Kenya has prompted key actors to explore appropriate responses. Already the Kenyan National Union of T eachers ( KNUT ) is implementing a peer education program in selected districts. Because many interventions may not have a strong evaluation c omponent, this report may offer a glimpse of possible outcomes, based on similar peer education strategies. The results suggest that a teacher - centered peer education program can be successful in increasing an overall level of openness and comfort surrou nding HIV issues in the school setting, familiarizing the population with previously unknown technologies such as PEP and female condoms, and HIV issues that may emerge. Teachers w ho participated fully in Teachers Matter had an advantage over their colleagues, and thus were more likely to have benefited from the intervention. Therefore programs seeking to implement a similar in a manner to maximize teacher participation, for example by incorporating it into the school time table, or recognizing participation with certificates or other incentives. The support of the school management was a significant determinant in how well T eachers Matter was implemented. The support of the Ministry of Education at the national and district level greatly facilitated the implementation of the intervention. B ecause four out of ten teachers have personally experienced a death fr om HIV in their i mmediate families , activities to help teachers cope in their individual lives may be as important as activities to help them educate their students. Evaluation of Teachers Matter 7 Background As the HIV epidemic continues to spread through sub - Saharan Africa, one of the most devast ating highest HIV infection rate and also make up the bulk of the workforce. AIDS strikes people in the prime of their lives and earning capacity, res ulting in devastating effects at the individual and societal levels. On a macro level, AIDS takes its toll on all aspects of the workforce, resulting in greater difficulties delivering services and products, reduced profits, strains on human resource manag ement, and weakened operations efficiency due to losses in employees from HIV – related illness and death ( UNAIDS 2006 ). The impact of HIV may be particularly pronounced in the education sector. Mortality due to AIDS among primary and secondary school teach ers results in decreased staffing and reduced ability to deliver educational outputs. Although reliable data regarding AIDS - related deaths among teachers in Kenya is with AIDS being the largest hypothesized contributor (Kelly 2000). A more recent analysis by the International Labor Organization (ILO) suggests that Kenya will be second only to South Africa in the sheer number of teachers dying from AIDS by 2010 (Cohen 2 002). The Kenya data is consistent with high teacher mortality and morbidity recorded in other African countries. In Zambia, for example, one study estimates that 840 teachers died from AIDS in 1999, equivalent to 46 percent of all teachers trained that ye ar . 2003). I n Botswana, 35 – 40 percent of teachers are thought to be infected with HIV (Clark 2001). In South Africa, the local teachers’ union documents a 43 percent increase in teacher deaths while in Malawi, reports say that 7,500 teachers die of AIDS annually (Comtex Newswire 2002). More positive news however is offered by Bennel (2006), who notes that even in high prevalence southern African countries, teacher mortality is falling or stabili zing in part due to behavior change and access to treatment. Teacher morbidity takes a heavy toll on schools; prolonged teacher absenteeism due to AIDS - related illness leads to a loss of learning time among students and an overall decrease in the quality of teaching. Morbidity and mortality among teachers is especially harmful in rural areas, where schools may only employ one or two teachers. Another impact of HIV on the education sector is economic: analysts suggest that in Africa, each death due to AIDS is preceded by about 18 months of disability ( Goliber 2000). Because it is unethical to dismiss sick teachers, such disability means that the education sector must support a large number of unproductive persons, resulting in severe economic loss. HIV als o contributes to a great deal of personal stress among teachers as their personal and professional lives are inevitably affected by the epidemic. Such stress in turn affects the quality of instruction in the classroom and may strain teacher - community relat ionships. The impact of HIV on teachers in Kenya is especially important to consider, as teachers represent Kenya’s single largest workforce, comprising 240,000 professionals (Kimani et al. 2005). Workplace Programs for Teachers The workplace provides central access to employees, making it an ideal venue for HIV education and teachers are limited in the literature, some work is now being undertaken in this are a . UNESCO and the 8 ILO have been spearheading policies to guide workplace activities in the education sector, highlighting that HI V - positive teachers can continue to be productive for many years to come (UNESCO and ILO 2006). The American Federation of Teac hers’ (AFT) Africa AIDS Campaign has been active in several countries since its program launch in 2001, partnering with national teachers’ unions to provide school - based peer education programs for teachers as well as counseling and treatment to those who are sick. In Zimbabwe, AFT partnered with the Zimbabwe Teachers Association (ZIMTA) to spread HIV awareness and prevention through a multi - strategies used in the campaign include the estab lishment of an AIDS hotline at ZIMTA offices throughout the country, the development of HIV educational materials focusing on lifestyle change for teachers and principals, and the revision and reinforcement of HIV management and workplace policies (kubatan a.net). In South Africa, AFT collaborated with four South African teachers’ unions to launch “Prevention, Care, and Treatment Access for South African Educators” in 2005. The program sought to train 7,500 peer educators in three South African provinces w ith the highest incidence of HIV among teachers. The goal of the trainings was to prevent HIV transmission, to increase access to couns eling, testing, and treatment, and to promote the development of workplace policies on HIV . The intervention also provide d ARV treatment to 2,300 teachers and their spouses (McElligot 2005). The AFT’s Africa AIDS Campaign has been active in Kenya as well. In 2005, the Kenyan National Union of Teachers (KNUT) and the AFT implemented a two - year project using peer education d esigned to reduce teachers’ vulnerability to HIV , to protect HIV - positive teachers from discrimination, and to provide sick leave benefits and healthcare to those teachers living with HIV . An informal assessment of the program found that teachers participa ting in the intervention felt more comfortable discussing HIV both in school and in the community as well as less fear and discrimination toward people living with HIV (AFT 2005). Several additional NGOs have also commenced HIV prevention programming targ In 2001, the World Health Organization, Education International, and Education Development Center, Inc. co - sponsored the extensive “Teacher Training Program to Prevent HIV Infection and Related Discrimination” in 17 countries primari ly in sub - Saharan Africa. Among the three goals of the intervention was to provide teachers with the knowledge and skills necessary to prevent HIV infection and to educate fellow teachers. Working directly through national teachers’ unions, teachers were i dentified and trained to conduct skills - based, participatory learning exercises with their peers. An impact evaluation of the program found an increase in teachers’ knowledge of HIV prevention and increased confidence in ability to teach about HIV and AIDS among the more than 130,000 teachers trained from over 22,000 schools (Pevzner 2005). Another HIV Health, implemen ted by The Centre for British Teachers from 2005 – 2006. This program delivered training to teachers from nearly 5,000 schools and included knowledge about HIV for teachers as well as strategies for including the topic in their curriculum. A unique feature o f the intervention was the acknowledgment that teachers are not neutral carriers of HIV information and are influenced by their own beliefs and personal circumstances. Therefore, the program sought to complement its training by providing teachers with comm unity support and directly addressing their concerns about delivering HIV messages in the classroom. The evaluation found significant positive effects on pupils, although changes in teachers’ knowledge, attitudes, and behaviors were not measured (Brouillar d - Coyle et al. 2006). Evaluation of Teachers Matter 9 - positive teachers who wanted to shed light on the stigma and discrimination they faced from students’ parents and fellow colleagues. KENEPOTE h as since become a well - respected agent of change in the community as members bravely demonstrate that people living with HIV are no different than anyone - EFAIDS 2006). Education Sector Policies on HIV in Kenya In addition to programming, Kenya has been in the vanguard of developing and supporting various teacher training policies. In 2004, the government established the Education Sector Policy on HIV and AIDS (Republic of Kenya/Ministry of Education 2004), a comprehensive guideline of policies and procedures for HIV prevention, care, and support for teachers and pupils, which are in accordance with workplace policy recommendations set forth by the ILO and UNESCO. Further more, the Kenyan government has established an AIDS Control Unit within the Teacher Service Commission, the employer of teachers in Kenya, further demonstrating the commitment to combating AIDS in the education sector. In addit ion, the MOE has made HIV tes ting available to teachers at its headquarters. In 2005, MOE published the “Kenya Education Sector Support Program,” a five - year strategic framework for the national education sector. The report includes several goals and objectives relating to HIV among teachers, including in - service trainings on AIDS prevention, care, and support, as well as a commitment to implementing the Education Sector Policy on HIV and AIDS, and a strengthening of the Teachers Living with HIV Despite these efforts, a 200 6 survey by Education International, in coordination with the Kenyan National Union of Teachers (KNUT), found that among the 16,800 trainee teachers currently in teachers college, none had ever received any HIV training. Furthermore, in both primary and se condary schools, no teachers had received any HIV training from the state. Clearly, much work remains to be done. An analysis of the impact of HIV on the Zambia documents that the disease will have cost as much as $41.2 million b y 2010, to cover salaries paid to teachers absent because of AIDS - related illnesses (71 percent ), training of additional teachers (22 percent ), and funeral costs (7 percent ; Gra . 2003). These are funds that could solve other problems were infect ion rates among teachers lowered. Many HIV interventions rely on teachers to deliver vital prevention messages to their students, but few infection. The importance of an active response directed at teachers becomes more urgent when their influence as community leaders is considered. This report presents the findings of an evaluation of the Teachers Matter intervention, a school - based, workplace HIV pre primary and secondary schools in Kenya. 10 Methods and Study Sample Research Questions The purpose of this research was to test an HIV risk - reduction model for primary and secondary school teachers, to increase the p roportion that seek voluntary testing and counseling (VCT) , and to assist those living with HIV to identify resources that could help them. The intervention addressed various worksite and non - worksite issues that affect HIV among teachers. The research que stions tested were as follows: 1. Will a work - , and behaviors related to HIV? 2. Will the proposed inter vention reduce the level of HIV - related stigma among teachers? 3. Will the proposed intervent ion increase the proportion of teachers who seek VCT ? 4. Will schools that participate in the program be better able to develop internal coping mechanisms to deal with HIV in their teaching ranks? 5. What is the optimum manner of delivery of the intervention th at would be most effective in achieving the above outcomes? 6. How can the intervention be improved and how can it be sustained locally? Study Methods Study design In order to assess the impact of Teachers Matter, a quasi - experimental study design was e mployed. Quantitative and qualitative data were collected from schools in two intervention districts (Thika and Kwale) and schools in two comparison districts (Kiambu and Kilifi) in the Central and Coast provinces of Kenya. Data collection Quantitative surveys : Baseline survey data were collected in intervention and comparison schools prior to implementation of the intervention, and follow - up data were collected one year later. Both the baseline and follow - up surveys were administered in the same 120 sc hools. The study included urban and rural schools. The baselin e was conducted in October 2004 and the follow up in March 2007. Data were gathered using an anonymous, pre - tested, self - administered questionnaire in English. Most questions were multiple - cho ice. Interviewers received a two - day training and the same team that administered the baseline survey administered the follow - up survey. To minimize participant discomfort, school management was treated the same as other teachers during data collection, an d were asked to sit in the questionnaire like other teachers. Focus group discussions: Before commencement of the intervention, focus group discussions (FGDs) were conducted in both the intervention and comparison schools to in form the content of the study. During the baseline, four FGDs were conducted with teachers and two FGDs were conducted with head teachers in both intervention and comparison s chools . After the intervention, six FGDs were conducted Evaluation of Teachers Matter 11 with teachers in the inte rvention schools , and four with peer educators, in order to obtain their opinion s on how the intervention went. Data analysis Baseline and follow - up survey results were analyzed by intervention versus comparison s chool s. Bivariate analysis was employed outcomes of interest. Multivariate analysis was conducted to assess the associations between the intervention and the desired outcomes by applying logistic regression to the follow - up data in the intervention sites. Specifically, logistic regression analysis compared the outcomes among teachers who participated in the intervention versus those who did not. The measure of association was the odds ratio. Outcome variables were dichotomiz ed at the mean, or at appropriate quartiles. The analysis controlled for gender, age, level of teacher training, and location of the school (urban vs. rural) of the respondent. The results of the multivariate analysis are presented in Appendix I. Data were analyzed using STATA v.9.0 and SPSS v.15.0 key themes for coding and interpretation of study findings. The transcripts for all the FGDs were then anal yzed using the qualitative analysis software NUD*IST. Ethical considerations The study was reviewed and received approval from Horizons/Population Council’s ethical review process and Kenya’s National Council for Science and Technology. Approval was al so obtained from district gatekeepers and the head teachers in the participating schools. No school refused to participate in the intervention, although 17 participating teachers refused to take the follow - up survey. Study Sample After excluding 56 te achers who had been exposed to a similar intervention sponsored by AFT/KNUT, a total of 1,237 interviews at baseline and 1,307 interviews at follow up with teachers in four districts were lit between intervention and comparison s chools during both rounds. Data included for analysis are only from those questions that were answered; unanswered questions were omitted and classified as “missing values.” Such exclusions will only be footnoted if more than 5 percent of the responses were omitted from analysis. Table 1 provides details of the socioeconomic and demographic status of respondents in the intervention and comparison groups at baseline and follow up . Teachers from the intervention and c omparison groups at baseline and follow up did not differ significantly in terms of key demographic indicators. Overall, female teachers made up slightly more than half of the population. On average, teachers were 38 years old and about three - fourths were currently married. A third of the respondents in the intervention group taught in urban schools. Almost two - thirds of the total sample taught in primary schools. A fourth of the respondents had received graduate - level teacher training, about 18 percent had received their university 12 diploma, and over half of both comparison and intervention groups had been certified to teach at primary schools (level of teacher training P1 – P4). Analysis was done to compare intervention and comparison schools during the bas eline, and also during the follow up . There were no statistically significant differences between intervention and comparison groups during baseline with regards to the variables presented in Table 1. Neither were there any between intervention and compari son groups during follow up . Thus both intervention and comparison school teachers are largely comparable with regards to basic demographic characteristics. Table 1 S ocioeconomic and demographic characteristics of teachers at baseline and follow up ^5.5 percent missing values Intervention Comparison Baseline n = 572 % Follow up n = 622 % p Baseline n = 665 % Follow up n = 685 % p Sex (%) ns ns Male 51 48 48 48 Female 49 52 52 52 Age (%) ns ns Under 30 13 15 12 13 30 – 39 44 40 49 45 40 – 49 27 30 28 30 50+ 16 15 11 11 Marital status (%) ns ns Never married 14 17 16 16 Currently married 79 76 78 75 Other 6 7 6 8 School location (%) ns ns Urban 27 26 1 7 1 6 Rural 73 74 8 3 8 4 Highest level training (%) ns ns P1 – 4/other 58 56 56 58 S1/diploma 18 18 18 16 Graduate 25 26 26 26 School level taught (%) ns ns^ Primary 64 6 4 6 2 6 5 Secondary 36 3 6 38 3 5 Evaluation of Teachers Matter 13 Descripti on of the Intervention Theoretical Framework The intervention tested in this research was a peer education workplace program named Teachers Matter. It drew from two behavior change theories: The Transtheoretical Model for Individual Behavior Change and the Theory of Gender and Power. Developed by Prochaska et al (1992), the Transtheoretical Model is based on the belief that behavior change does not happen in one overt step, but may be a process that involves many small steps. Individuals can progress along the behavior change continuum systematically, step by step; or, they can programs that recognize these potential responses can intervene at the ap propriate stage. In addition, factors that may not have a direct impact on behavior change, per se, may have implications earlier in the change process. Teachers Matter used this theory to refine the intervention manual and to address the various steps to behavior change by encouraging teachers to take appropriate steps such as talking to others, assessing attitudes, seeking information, and adopting healthy behavior s . The Theory of Gender and Power posits that women have difficulties seeking self - protecti on from HIV because of gender - based power imbalances. Their efforts in engaging in safer sex are often influenced by their feelings about their partner s , socialization of women as sexually passive , regulation as to how women should express their sexuality, and econo - power factors. In a country like Kenya, where marriage and children are still important social achievements, women may strive to stay in a risky relationship to avoid the social costs of being unmarried and childless. Therefore the intervention included a strong gender component such as incorporating cultural values, gender dynamics, and attitudes that may leave one vulnerable to HIV as a result of such norms. Program Implementation Teachers Matter was implemented in 120 schools in Thika and Kwale districts. However, the evaluation was conducted in only 60 of these schools; the other 60 received the intervention but were not part of the evaluation. A total of 60 schools in Kiambu and Kilifi districts served as comparison schools, and partici pated in both the baseline and follow - up survey. Once the evaluation was over, they also received the full array of from these schools also participa ted in a one - day sensitization meeting so that they could explain the program to their employees. Thus collectively Teachers Matter reached 180 schools with some information about HIV , impacting about 2,700 teachers. The intervention cost approximately $42 ,500 which covered preparation, printing and distribution of behavior change communication ( BCC ) materials, training of the peer educators (including materials, transport and accommodation), sensitization of headteachers, and availing mobile VCT services. This translates into roughly $16 per teacher reached. 14 Peer education training and preparation Teachers Matter was a peer - led education program, guided by a 10 - unit interactive and audience - driven manual. The manual provided factual information about ho w HIV is transmitted, risk reduction strategies, and HIV testing, as well as treatment, care, and support for people living with HIV . It also discussed home - based care and provided participants with HIV resources in their communities. In addition, the manu behavior even if they have the information. For example, topics such as sexuality, relationships, family values, and self - esteem were presented. Informed by the theories discussed above, the manual used experiential and adult - discussions and interactive exercises. Each section ended with a take - home message. Every unit was design ed with simple instructions so any peer educator could lead the discussion and convey the key messages. Head teachers from intervention school s received a two - day sensitization training about the Teachers Matter project, in order to seek their input and support . One teacher from each school was then selected by their colleagues, with consultation from the head teacher, to serve as the peer educator for that school. All schools approached for the intervention were cooperative and provided a peer educator for the training. At the end of the training, all peer educators received a certificate recognizing their participation. Before the intervention, the 120 peer educators received a one - week training on how to use the manual. During the training, they practiced thr ough group sessions, interactive activities, skits, and games. They received in - depth information about HIV , ranging from the origins of HIV to AIDS treatment. They opened condoms, stretched and twisted them, and filled them with water to test leakage. Man y saw both a male and female condom for the first time. They were also offered VCT by a mobile VCT team that availed services throughout the training. About 33 percent of the peer educators took an HIV test for the first time. A major component of the tra ining was the involvement of KENEPOTE. KENEPOTE members joined the training meetings and talked about the challenges of HIV - positive teachers. They gave concrete suggestions regarding how the school management could support HIV - positive colleagues, with an emphasis toward stigma reduction. Because of their enthusiasm, dedication, and openness, KENEPOTE members normally left most teachers feeling more comfortable dealing with HIV - positive colleagues. Prior to departure to their respective schools, peer educ ators developed a nine - month work plan and identified resources needed to execute the project in their school. Program implementation began immediately. Throughout the intervention, peer educators were supported by quarterly visits from the Teachers Matter study monitor, who assisted them with troubleshooting and also supplied them with recorded activities for each session and documented any issues that may h ave arisen. The Teachers Matter monitor reviewed the diaries during his visits. Peer educators also received refresher training midway through the intervention. Evaluation of Teachers Matter 15 Program activities Peer educators were given the freedom to schedule the intervention to m eet the needs of their respective schools. Most Teachers Matter meetings were held on a weekly basis, and lasted from 30 to 90 minutes. While some schools appointed a set time to meet each week, either after working hours or during lunch, others were more flexible and programmed as they went along. Most schools report ed having covered the majority of the manual by the conclusion of the nine - month program. During their training, peer educators were encouraged to identify a colleague in their school who coul d assist them as their co - peer educator. Many peers did so, and found the support to be invaluable, whether to fill in for the peer educator if there was a scheduling conflict, to provide expertise, or to lead a meeting that the main peer educator might no t have felt comfortable with. As one peer educator explained: I trained a [female teacher] given that our staff also has female teachers and there are some areas rstood properly. So this teacher was able to talk to female teachers on some areas that I found hard for me to discuss. Secondary school teacher, Kwale Several teachers echoed this sentiment and suggested that for future programs, two teachers from each s chool be selected and trained to lead the project, so they can share the work and complement one another. Head teachers and school management were also encouraged to be involved in the project. At some schools, management was very supportive of the progra m and allowed teachers time to meet and The program fared on well with the help of the head teacher. He treated it as a school program and everybody had to attend…. Secondary school teacher, Thika At others times, head teachers were not involved with the project, making the peer educators feel unsupported. As another peer educator commented: …I had to take the lead when most of the time the administrator is there…. Instead of him being a role model , I was the one who is supposed to go ahead and invite the other teachers to come, thus shouldering the responsibility. Secondary school teacher, Kwale Indeed, although it was important that the peer educators took ownership of the program, head teachers and school management involvement was invaluable in assuring program attendance and participation by other teachers. Peer educators had been trained to conduct the sessions in an interactive and adult - centered manner. Because of the friendly nature of t he manual, teachers took to it immediately. Discussions frequently erupted spontaneously addressing topics such as the availability of condoms in the staff room, HIV testing, stigma, sexual practices, domestic violence , and alcohol use. Some teachers asked 16 could bring their partners to participate in the discussions. Schools were given the leeway to respond to their issues as they arose. Support materials: All peer educators received an education kit that contained education brochures, a peni s model, samples of both male and female condoms, samples of ARVs, and other educational materials. Because Teachers Matter was commencing activities just as the MOE was starting distribution of its Education Sector Workplace Policy on HIV and AIDS, copies of the policy were included in the project as well. The project also adopted existing print materials and brochures to make them teacher - specific. A number of brochures were prepared: What Teachers Need to Know About Sexually Transmitted Diseases ( STDs ) Talking about Condoms What Teachers Need to Know About Condoms Talking about V oluntary Counseling and Testing (VCT) Talking about Antiretroviral Therapy ( ART ) Positive Living with HIV Care and Support for People Living with HIV : The Role of Teachers ARVs: What Teachers Need to Know Understanding Opportunistic Infections: What Teachers Need to Know ARVs : Managing Side Effects In addition, two 3 - leaf calendars for teachers were prepared. The 2006 calendar, distributed at the start of the intervention, addres sed three themes: HIV testing, stigma, and access to treatment. The 2007 calendar, distributed at the end of the intervention, portrayed photographs of teachers who had been tested for HIV as part of the project, stressing the importance of HIV testing and counseling for teachers and their partners. Many teachers were excited to see themselves in a calendar and some who had not been tested ould be in next year’s calendar. An important resource for the peer educator was the peer educators’ bag. A multi - compartment shoulder case, it was designed and produced by the Kenya AIDS and Drug Alliance (KADA), a group for people living with HIV . The bag was made of sturdy materials enabling use in inclement weathe r. It contained see - through pouches where the peer educator could easily access relevant supplies such as the penis model, brochure, and samples of ARVs. KADA was also contracted to supply penis models for the project. Throughout the intervention, the Te achers Matter study monitor cut out relevant newspaper clippings and provided any other materials that could assist teachers. He helped teachers in each school develop a resource corner in the staff room where materials could be displayed. The materials we re distributed strategically over the course of the intervention, to avoid inundating teachers , and to introduce materials as topics were being introduced. This information corner was very well - received. As one peer educator noted: The establishment of the information corner has been very helpful because even if the teachers miss a session, they come to the information corner and they are able to access some of the information that is very crucial. Secondary school teacher, Kwale Evaluation of Teachers Matter 17 Peer educators were espec ially enthusiastic about the BCC materials provided. Many found them to be useful teaching aids that often complemented the lessons taught: I think for my case the brochures were very useful. Sometimes when we couldn’t hold discussion sessions, teachers I would clarify what was not clear, and we would discuss any inquiries that they had on them. Secondary school teacher, Kwale Participating teachers also found the materials us eful: [The brochures] now serve as reference material, so that even later, we refer to it. If say now, I came across a question involving positive living … I will refer to this brochure on positive living; refer to it, get feedback, and pass it over. So i t is a reference material. Primary school teacher, Thika Teachers noted however that while a penis model was available for demonstrating the use of male condoms, there was no pelvic model for demonstrating the female condom. Many female teachers noted thi s issue and felt that one should have been provided. Additional activities: Teachers organized themselves to participate in other activities throughout the intervention. For example, during World AIDS Day, teachers in Kwale and Thika organized several lar ge - scale events to draw attention to the subject and involve the community. In Kwale, the day’s program included songs and dances by women’s groups and traditional dancers, poems read by members of the KENEPOTE, and speeches by peer educators. In additio n, teachers organized an inter - school football match entitled “The Teachers Matter Tournament.” The nine - team tournament culminated in the final round on World AIDS Day to convey the message that “AIDS is there, it has not gone.” Voluntary counseling and t esting services were made planted trees. At all schools, innovation was encouraged and teachers were free to adapt the intervention to their situation. Thika School for the Visually Impaired was one of the schools included in the intervention. Written materials provided to this school were converted into Braille, the first time any such information had been availed in this format. Teachers at this school were quite enthusiastic in their participation. Challenges Although the program was very well - received by the teachers, there were some challenges in program implementation. Participating teachers and peer educators alike complained of the meetings tak ing up valuable time during their busy days. Meetings were best attended when scheduled during lunch hour, instead of after school when many were in a rush to go home and attend to their families and other responsibilities. Peer educators especially felt t his constraint: 18 …Given the workload we had … the additional responsibility was quite an issue. I feel if my workload can be made easier, then the implementation of this program can be made more effective. Secondary school teacher, Kwale Another challe was quite large, it could be challenging for peer educators to teach lessons to a mixed age group. For example, some younger peer educators had a hard time deliverin g sensitive messages of condom use or safe sex to older teachers. As a p eer educator explained: In my school, I am the youngest. So when I introduced the Teachers Matter there, the teachers were negative about it. They were saying, “How can you tell us th ese things and you are our son?” But as we continued they became receptive of the program. Secondary school teacher, Kwale Attrition of both peer educators and teachers was another issue, as transfers between schools are frequent. At times, the program wa s preemptively terminated because the peer educator was moved to another school. As one peer educator recommended: Peer educators as teachers are faced with the inevitable transfers. And we might be taken to a school where there is already a peer educator , leaving the other school without any peer educator. So, I request that peer educators can be given a longer time in the current school…to make the program solid in those schools. Secondary school teacher, Kwale Some teachers requested incentives or fina ncial compensation to continue their participation, a common practice in Kenya called a “sitting allowance”: I feel the teacher should have received a motivation, given that we had to be here for the program. Because as much as the program is there for us, we need to be motivated in one way or the other, like giving us refreshments. If this component can be factored in the program then it will be more effective. If we can be issued with certificates of participation, that can be very nice. Primary school teacher, Kwale A nother peer educator confirmed: Teachers wanted a motivation, in form of an incentive for keeping them in the discussion for those hours. So, that component of complaints from the teachers is what I didn’t like, and the hard part of expla ining that there are no cash handouts or material incentives, but the knowledge they were Secondary school teacher, Kwale In some cases, teachers, including peer educators, were reluctant to participate fully in the intervention, lest it be construed that they had a “reason” to be so interested. Such peer educators would therefore conduct sessions nonchalantly, to distance themselves from the intervention. Some times disinterested teachers would sit on the side doing other work, while the Teachers Matter sessions were going on. Over time however, the majority of teachers joined in the group. As one of the peer educators later explained during a session on domestic violence, so me teachers sitting on the side lines had be en doing so because Evaluation of Teachers Matter 19 they were personally experiencing the problems being addressed, and the session had therefore been too painful. Another challenge was the difficulty in separating teachers from their roles as gatekeepers of information. Although it was stressed time and again that the information presented was for the teachers themselves, their instincts were to see it as a lesson to be passed on to their students or to the community. While teachers who are well educated about HIV issues are undoubtedly a benefit for the whole community, ensuring that lessons learned resonated in the teachers’ personal lives was a complex issue. The implementation of the project coincided with a turbulent change in the funding environment, leading to sharp financial cu tbacks for operations research. This primarily meant seeking funds afresh for the intervention, and the outcome was a 17 - intervention. In addition, because such a teacher - centered intervention was a relatively new undertaking in Kenya, there was also limited experience and personnel to draw from. 20 Results Exposure to Teachers Matter The 622 respondents in the intervention s chools exposed (e.g., sought VCT), and whether they would recommend it be continued. The results , presented on Table 2 , are based on all 622 respondents, in order to as sess the aggregate levels of exposure to the intervention. The data show that 92 percent of all teachers in the intervention site had heard of Teachers Matter, 80 percent had participated, 71 percent had taken some type of action, and 75 percent would rec ommend that it continue. Exposure and interaction with Teachers Matter was the same among the various demographic groupings, but primary school teachers were more likely than secondary school teachers to have participate d in the intervention, to have taken action , and to say that they would recommend that the program continue. Similarly, older teachers were also more likely to have participated in the intervention than younger teachers, to have taken action as a result, and to recommend continuation. Of t he teachers who participated in Teachers Matter, 12 percent were peer educators . Table 2 Exposure to Teachers Matter in the intervention s chools at follow up , by selected respondent characteristics Heard of Teachers Matter n = 622 Participated in T eachers Matter n = 622 Took action n = 622 Recommend intervention continue n = 622 % p % p % p % p Gender ns ns ns ns Male 92 83 73 76 Female 91 78 70 75 Age ns 0.013 0.04 0.04 Mean or below 90 76 68 72 Above mean 93 85 75 79 School location ns ns ns 0.01 Urban 88 75 65 67 Rural 92 82 73 78 Level of school taught 0.02 .001 .001 .001 Primary 93 86 78 83 Secondary 88 72 60 64 Among all 92 80 71 75 Evaluation of Teachers Matter 21 Participating teachers (n = 500) listed several kinds of information that they obtained from the project, as illustrated in Figure 1. About 80 percent or more of those respondents reported acquiring basic facts about HIV , as well as information about mal positive living with HIV . Figure 1 Information obtained from Teachers Matter (n = 500) Teachers were also asked in what ways the program had benefited th em and the answers are presented in Figure 2. In addition to information obtained from the project previously listed, the majority of teachers also thought the intervention successfully encouraged behavior change, enabled more openness among teachers about HIV, improved the relationship between teachers and school management regarding HIV, and decreased the level of stigma among teachers. 22 Figure 2 Effect of Teachers Matter on lives of participating teachers (n = 500) Abo ut 90 percent of those teachers who participated in the Teachers Matter program took further action related to HIV as a result of what they learned from the project. Figure 3 shows the most popular examples of action taken. Evaluation of Teachers Matter 23 Figure 3 Actions taken relat ed to HIV by participating teachers (n = 442) Effects of Teachers Matter Intervention on Selected Outcome Measures 3 An assessment of the baseline and follow - up surveys of the intervention and comparison groups allows for a measurement of change in teachers’ knowledge, attitudes, and behaviors related to HIV . It is important to note, however, that the Teachers Matter project was not the only agent of change attempting to influence HIV knowledge, attitudes, and practices in K enya. For example, the country is in the middle of a vigorous campaign called “Total War Against AIDS,” which is being led by the country’s President himself. HIV is widely discussed in the media, public meetings, churches, and other venues. Politicians an d many famous personalities have publicly been tested for HIV, attracting large media coverage. And HIV is part of the education curriculum, with teachers expected to infuse HIV across all subjects in schools as they teach students. However, it was anticip ated that the teachers exposed to the intervention would exhibit greater changes in the outcomes assessed than their unexposed counterparts. 3 More detailed results of logistic regression are further found in Appendix I. 24 Work environment Coping with HIV at the Workplace: The defining feature of the Teachers Matter project was its design as a workplace intervention for teachers. As with most workplace interventions, a key objective was to create a supportive environment allowing teachers to effectively cope with HIV . Table 4 shows a significant difference in teachers’ opinions of h ow proficient school management and other teachers had become in coping with HIV issues. When the follow - up sample was asked how effective school management had become in coping with HIV issues at school in the last year, 28 percent of the intervention sch ool teachers said there had been a “great improvement,” compared to 19 percent of the comparison school teachers (p .0001). Similarly, 35 percent of the teachers in the intervention schools said their colleagues had shown “great improvement” in coping wi th HIV issues in school, with only 26 percent of teachers concurring in the comparison schools (p .0001). Thus there was greater improvement in collective self - efficacy and coping capacity demonstrated in the intervention s chools . Table 4 Perceived ef fectiveness of school management and colleagues to cope with HIV issues at the workplace, follow - up sample Intervention n = 622 % Comparison n = 695 % p Improvement of management’s effectiveness to cope with HIV/AIDS in school (compared to one year ag o) ^ .001 Great improvement 28 19 Some improvement 62 62 No improvement / worse 10 19 Improvement of teachers’ effectiveness to cope with HIV/AIDS in school (compared to one year ago) ^ .001 Great improvement 35 26 Some im provement 60 62 No improvement / worse 5 12 ^ 5 percent missing values Teachers and peer educators expressed enhanced ability to cope with colleagues infected with HIV or AIDS at the workplace. When asked how the teachers would treat an HIV - p ositive colleague, responses were very supportive: Previously, one would be stuck not knowing what to tell or how to treat the HIV - infected person. But after the introduction of Teachers Matter, you would not miss a word of encouragement and giving proper examples to such a person. Primary school teacher, Thika Personally, I can say there is a change in school environment. When you pass this knowledge to Evaluation of Teachers Matter 25 withi n our school who got sick and, in fact, everybody knew or suspected the disease and they tried to talk to him concerning the ARVs. Primary school teacher, Kwale After controlling for gender, age, level of teacher training, and urban - rural school location in multivariate analysis, attendance at Teachers Matter meetings was significantly associated with an increasingly positive belief that teachers were able to deal with HIV issues at the workplace. Those who attended some Teachers Matter meetings were 1. 7 t imes more likely to think that teachers could effectively cope with workplace HIV issues when compared to their unexposed counterparts (CI: 0.9 - 3.1), while those who attended all meetings were 3.6 times more likely to believe so (CI: 1. 9 – 6.7 ; see Appendix I). Regarding the perceived ability of management to cope with workplace HIV issues, th e effect was not as strong but all the same, th ose attending all meetings were 1. 7 times more likely to believe management could cope with such issues compared to their counterparts who did not attend any (CI: 0.9 - 3.2; see Appendix I). Job security and confidentiality : A vital part of any workplace HIV policy is confidentiality and non - discriminatory hiring and firing practices. However, even after the Teachers Matter in tervention, the consequences of breaching confidentiality and violating other policies remained largely unclear, in part because the current Education Sector Policy on HIV and AIDS does not provide definitive guidance on this issue. For example, teachers w ere asked, “As far as your school’s regulations are concerned, what recourse would an HIV - positive teacher have if a fellow teacher disclosed the HIV - positive teacher’s status without consent?” Over half of teachers in both comparison and intervention s cho ols said they did not know (see Table 5). Teachers also seemed uncertain that their school management could maintain confidentiality if a teacher were to disclose his or her HIV - positive status. When asked about this, the comparison and intervention popula tions were fairly evenly divided, with about a fourth thinking they could maintain confidentiality, another fourth saying they could somewhat maintain confidentiality, another fourth saying they could not maintain confidentiality, and a final fourth saying they did not know HIV confidentiality did not improve significantly over time. 26 Table 5 Perceptions of confidentiality and job security regarding HIV among teachers at basel ine and follow up Intervention Comparison Baseline n = 572 % Follow up n = 622 % p Baseline n = 665 % Follow up n = 685 % p Don’t know recourse for breach of confidentiality 56 59 ns 61 60 ns Administrator is able to maintain confidentiality 23 27 ns 22 23 ns What would happen if HIV - positive status disclosed to employer Would be fired 3 1 .001 2 2 .001 May not be fired but would be discriminated against 37 29 38 33 Nothing 35 48 32 45 Don’t know 25 21 27 21 There was an increase in perceptions of job security and HIV as evidenced by the proportion of teachers who thought “nothing” would happen to their jobs if their employers found out they were HIV - positive, which increased from a third of respond ents at baseline to nearly half at follow up . Similar findings were documented in the comparison group (see Table 5). Increases in perceived job security in both intervention and comparison groups may be attributed to widespread attention to the issue of j ob discrimination in the Kenyan media. Still many teachers remain apprehensive that all would not be well, and they would be discriminated against if they were HIV - positive even if they were not fired. In addition, nearly a fourth of respondents in both st udy sites said they did not know what would happen, - up survey, 51 percent of teachers in the intervention s chools and 56 percent of those in the comp arison s chools were doubtful that all would remain the same if the employer were to find out that they were HIV - positive. Workplace policy on HIV : An integral part of creating a HIV - supportive workplace environment is the development of a workplace polic y on HIV and ensuring the policies stated are known, understood, and adhered to by all employees. In this regard, the Kenya Ministry of Education published the “Education Sector Policy on HIV and AIDS” in 2004. Th is document w as distributed by the Ministry of Education to schools countrywide. and whether they had read it. Table 6 shows that there was a significant increase in the intervention groups’ know follow up . The percentage of those in the intervention group who had heard about the policy increased from 42 percent at baseline to 61 percent at follow up (p .0001). Of those, the percentage that had seen a copy of it also increased from 28 percent at baseline to 58 percent at follow up (p .0001). The percentage of teachers who had heard of and/or seen a copy of the policy in the comparison group did not change significantly over time. Evaluation of Teachers Matter 27 Table 6 Familiarity with Kenya MOE “Education Sector Policy on HIV and AIDS” among teachers at baseline and follow up Intervention Comparison Baseline Follow up Baseline Follow up n % n % p n % n % p Heard about policy^ 5 7 2 42 6 2 2 61 .001 6 65 40 6 8 5 3 9 ns Seen a copy of policy ∞ 220 28 3 62 58 .001 2 4 4 24 2 59 22 ns Read the policy^ – – 622 29 – – 685 6 ^Among the total sample; ∞ Among those who had heard about it At the follow - up survey, teachers were asked if they had read the policy. Table 6 shows that of the total sample, significantly more had done so in the intervention group compared to the comparison group (29 percent vs. 6 percent, p .001 ). These figures suggest that teachers are responsive to informing themselves of workplace policie s if they are given access to them. Multivariate analysis confirms these findings: after controlling for gender, age, level of teacher training, and urban - rural school location, teachers who attended Teachers Matter meetings were significantly more likely to read the Education Sector Policy on HIV and AIDS than their unexposed counterparts. Those who attended some meetings were 2.0 times more likely to have read it (CI: 1.0 – 3 .9); those who attended all meetings were 5.6 times more likely to have read the po licy (CI: 2 . 8 – 11.2 ; see Appendix I). Perceived risk of HIV infection : A final aspect of workplace HIV initiatives was to ease fears about HIV infection at the workplace. During the baseline, m transmission , for example while delivering first aid to children. They were concerned that the greater number of children now enrolled as a result of the free primary school program would include large numbers of poor HIV - positive children who had previously kept away . Therefore Teachers Matter worked to quell some of these apprehensions. After participating in the intervention , there was some improvement . For example, when asked how concerned they were about becoming infected with HIV at work, the percent that were “v ery concerned” decreased from 65 percent to 57 percent and follow up in the intervention group (p = 0 .017). There was no change in the comparison schools (61 percent during both rounds, p = 0.726; see Table 7). Multivariate analysis sugges ts that the changes were too small to observe after controlling for the confounders ( data not shown ). All the same, teachers were appreciative of the intervention and as one explained: Teachers Matter helped us to dispel the fear we used to have because i t is only a teacher who does not know how HIV is spread that has those fears. It has helped us to know that if I handled a child who has HIV but I do not touch his blood, I cannot contract this disease. So, those fears I can say, they are not really there anymore. Primary school teacher, Thika Still, it is noteworthy that 57 percent of teachers remain ed concerned about this problem despite the intervention . During the follow - up survey, the research team asked teachers whether their schools had a first - a id kit, as recommended by the Education Sector Policy on HIV and AIDS. Less than ten percent of sites had a fully stocked one (7 percent of intervention and 11 percent of comparison schools), while 28 about 40 percent of sites had a partially stocked one. The fears about HIV infection among teachers may be emanating from awareness that their schools are not adequately prepared in case of learner injury or other emergency. Table 7 Perceived r isk of HIV infection at work and overall among teachers at baseli ne and follow up Respondents were also asked to assess their overall risk of HIV at work and at home . It was anticipated that greater understanding about HIV , and increased self - efficacy and coping abilities would help teachers assess their risk in a more in formed manner. Table 7 shows that there was a significant increase in those believing they were at lower risk in the intervention s chools , from 39 percent at baseline to 47 percent at follow up in the intervention group (p = 0 .026). There was no change in perceived risk at work or at home in the comparison group (43 percent at baseline vs. 46 percent at follow up , p = 0.637). Post - exposure prophylaxis Post - exposure prophylaxis ( PEP ) is now widely available in Kenya, and Teachers Matter provided an oppor tunity to inform educators about it, for use both at work and at home. Figure 4 shows that at baseline, 4 percent of the teachers in the intervention schools said they knew what PEP was; at follow up , 25 percent of teachers said they did (p ≤ .0001). In th e comparison schools , 2 percent of teachers said they knew what PEP was at baseline, which remained about the same at follow up (3 percent). Greater exposure to Teachers Matter is significantly associated with higher knowledge of PEP, and each incrementa l exposure is associated with increased knowledge . After controlling for gender, age, level of teacher training, and urban - rural school location in multivariate analysis, those who attended some Teachers Matter meetings were 2. 6 times more likely to know w hat PEP was than their unexposed counterparts (CI: 1.2 – 5.9 ), while those who attended all Teachers Matter meetings were 6.7 times more likely to know what PEP was (CI: 3.0 – 15.2 ; see Appendix I). Intervention Comparison Baseline n = 572 % Follow up n = 622 % p Baseline n = 665 % Follow up n = 685 % p Highly concerned about HIV infection at work 65 57 0 .017 61 62 ns Low concern about HIV infection overall 39 47 0 .0 26 43 46 ns Evaluation of Teachers Matter 29 Figure 4 Percent who said they knew what PEP was, baseli ne and follow up Teachers were also able to translate what they learned about PEP into action: …On the issue of PEP, this program helped a lot. I remember sometime back when one of our students was injected by a person fea red to be HIV - positive, and then teachers who were around, employing the knowledge they had got about PEP took the necessary action of taking the child to the nearest VCT center, where the child was counseled, tested, and given the drug.” Primary school te acher, Thika Attitudes toward condoms Male condoms : Table 8 illustrates attitudes toward male condoms among the study population at baseline and follow up . To quantify attitudes, a nine - point question was posed in the survey asking respondents to agree or disagree with varying statements about the use and acceptability of condoms (see Appendix II). Based on the participants’ responses, a score was developed. Respondents were dichotomized as having favorable or unfavorable attitudes based on whether they scored above or below the mean of five favorable answers. A positive attitude toward condoms indicated more than five ( 5) supportive answers. A negative attitude indicated five or fewer ( ≤ 5) supportive answers. Bivariate analysis showed that there follow up , with the percent having supportive attitudes rising from 49 percent to 64 percent (p .0001). By compar ison, the increase in the comparison group was not significant (52 percent to 58 percent, p = 0. 071). 30 Table 8 Attitudes toward male condoms among teachers at baseline and follow up The bivariate results were marginally supported b y the m ultivariate analysis which showed that at the highest exposure to Teachers Matter , respondents were more likely to have positive attitudes toward condoms (OR 1.7, CI 0.9 - 3.1). Peer educators were provided with condoms, and study participants prefe rred accessing condoms from peer educators as opposed to doing so at kiosks and other public locations, which were considered …There was a remarkable observation of behavior change as far as co ndom use is concerned…. Like when I had a full box of male condoms when we came back from [the peer educator training]. Within no time they had disappeared…. It was obvious they were being used…. Secondary school teacher, Kwale I think behavior change is there, because you hear them when you are near them ask each other, “Do you have condoms? Do you have?” …They come to me to ask for the condoms. Like the ones I came with from [peer educator training], there was not even one left. They were telling me to a ssist them to get more …. Primary school teacher, Thika Female condoms: Female condoms are also a viable way to prevent HIV infection during sex. While there were significant increases in awareness of female condoms in both the intervention and comparison groups during the study period, the change was greater in the intervention group (see Table 9). About 79 percent of the baseline respondents in the intervention s chools had heard of female condoms prior to the intervention, and this had risen to 97 percen t at follow up ( p .001 ). In the comparison s chools , the percent who had heard of them rose from 87 percent to 93 percent ( p .001 ). Of those who had heard of it, there was an increase in the percent who had seen a female condom and the increase was grea ter in the intervention s chools (from 42 percent to 77 percent, p .001 ) compared to the comparison s chools (47 percent to 55 percent; p .001 ). When based on the total sample, the percent of intervention s chool teachers who had seen a female condom rose from 31 percent at baseline to 73 percent at follow up ( p .001 ), while the percent of those in the comparison s chools who had seen one rose from 39 percent to 51 percent ( p .001 ; data not shown). Thus at the end of Teachers Matter , three - fourths of th e intervention s chool respondents had seen a female condom compared to only half of those in the comparison schools . Intervention Comparison Baseline n = 572 % Follow up n = 622 % P Baseline n = 665 % Follow up n = 685 % p Condom attitude % .001 ns Positive 49 64 52 58 Negative 51 36 47 42 Mean score (out of 9) 5.1 6.1 .001 5.3 5.6 0.02 Evaluation of Teachers Matter 31 Improvements were also realized in respondents knowing where to procure a female condom, which significantly increased in the interventio n s chools from 40 percent to 53 percent ( p .001 ), and from 36 percent to 42 percent in the comparison group (p .05). Recalculated to include the total sample, this means that at baseline, 29 percent of the intervention school sample said they knew from where to obtain a female condom, but at follow up this had risen to 50 percent ( p .001 ). By comparison, 29 percent of the comparison school sample at follow up . Thus the gains we re greater in the intervention s chools . Multivariate analysis revealed that, after controlling for gender, age, level of teacher training, and urban - rural school location, attending Teachers Matter meetings significantly correlates with awareness of the female condom. Those who attended some Teachers Matter meetings were 3. 3 times more likely to have seen one (CI: 1 .7 – 6.3 ), while those who attended all meetings were 5. 3 times as likely to have seen one compared to those who did not attend any meetings (CI : 2.5 – 11.0 ). Table 9 Knowledge and attitudes toward female condom use among teachers at baseline and follow up ^Among those who have heard of the female condom HIV burden Teachers continue to be strongly aff ected by the HIV epidemic in their personal lives, as seen in Table 10. One teacher said : If one is not infected, one is affected. We have undergone the experience of our relatives suffering from this infection ; we have had to take care of them. Primary school teacher, Thika The data show that there was a significant increase in the percentage of teachers aware of an HIV - related death in their family in study s chools (from 30 percent at baseline to 41 percent at follow up in the intervention schools ; p .001 , compared to from 35 percent to 39 percent in the comparison schools ; p .05). There was also an increase in the proportion of teachers in both study sites reporting that an immediate family member was HIV - positive. Intervention Comparison Baseline Follow up Baseline Follow up n % n % p n % n % p Heard of female condom 572 79 622 97 .001 665 87 685 93 .001 Seen female condom^ 438 42 596 77 .001 562 47 627 55 0 .002 Knows where to acquire fe male condom^ 438 40 596 53 .001 562 36 627 42 0 .019 32 Teachers in intervention school s had been encouraged to talk with their family members and other individuals about HIV , and to share the information they were learning through Teachers Matter. The stigma - related sections of Teachers Matter had urged teachers to avail themselves as sourc es of support for people living with HIV , and to set a good example. As one teacher explained: After teaching about this program, some people who are HIV - infected from the community were referred to me. They were very sick. So, I advised them, organized for them to go to the hospital for ARVs. They are ok. Secondary school teacher, Kwale Table 10 Personal experience with HIV among teachers at baseline and follow up Intervention Comparison n % n % p n % n % p Immediate family member died of AIDS 56 3 30 604 41 .001 652 35 677 39 ns Immediate family member infected with HIV 572 18 622 29 .001 665 21 685 25 ns Currently taking care o f family or friend with HIV ^ 217 29 306 31 ns 297 25 297 32 ns ^Among those who have ever taken care of a family me mber with HIV The finding that teachers in the intervention s chools were more likely to report personal awareness of HIV in their family could be as a result of these factors. In addition, it is possible that family members may have learnt of a teacher’s involvement in Teachers Matter, and felt more confident in confiding to him/her. Some teachers may also have become more willing to disclose familial HIV during the follow - up survey compared to baseline. The findings could also be a result of epidemiologi c HIV trends in Kenya, with the epidemic now having reached the “death phase” — i.e., those who were infected during the peak incidence years are now dying of the disease (MOH/NASCOP 2005). Thus there are several factors that could explain the observed resul ts. At follow up , a third of all teachers in both groups were currently caring for somebody else who had AIDS. For this group, Teachers Matter provided much needed information on care and support: It taught us how to care for those people living with HIV and how to relate with them. Not the way we used to look down at them and despise them. After going through this program, we know how to relate to them. Primary school teacher, Thika Evaluation of Teachers Matter 33 HIV testing A key objective of the Teachers Matter project was to incr ease HIV testing among teachers. While almost action. Self - efficacy: An important aspect of encouraging HIV testing is self - efficacy: if individual s are not confident they are able to cope with a positive test result, they may be less likely to want to be tested and find out their status. The data suggest that teachers became more comfortable with the idea of being tested during the study period. The proportion of teachers who said they were not afraid of being tested increased from 47 percent to 54 percent in the intervention group (p .01), but a similar increase was documented in the comparison group (from 50 percent to 57 percent; p .05). Looki ng at the other side, the research found that an appreciable proportion of teachers were either “very” afraid or “somewhat” afraid of being tested. At the intervention sites, 53 percent of teachers reported this fear during the baseline, compared to 46 per cent during the follow up . At the comparison sites, the figures were 50 percent and 43 percent respectively. Thus this is an area in which teachers need considerable support. Although many teachers continue to fear being tested, Teachers Matter appears to have planted the seed and some admit ted giving it consideration: That decision … needs a lot of courage. And … I have to assess the repercussions … I’ll be there [go for testing]; I’ve thought of it so many times. Primary school teacher, Thika The clima te was to go and be tested. It scared some, but we struggled…. Primary school teacher, Kwale Table 11 describes testing behaviors of the intervention and comparison groups. There were significant increases in the percentage of teachers who had been tested for HIV, but this happened in both intervention and comparison s chools (intervention s chools : 24 percent to 39 percent [ p .001 ]; comparison s chools : 25 percent to 41 percent [ p .001 ]). Multivariate analysis also showed that the interve ntion was not significantly associated with HIV testing status, after controlling for the study confounders ( data not shown) . The fact that comparable increments were seen in both intervention and comparison s chools may reflect the possibility that HIV tes ting was influenced by factors impacting both intervention and comparison areas in a similar manner. HIV is a common topic of discussion nationwide and widely covered in the media, churches, and other places of public dialogue. Thus these factors may have exerted influences beyond the intervention. 34 Table 11 HIV testing among teachers at baseline and follow up Overall, the total number of times respondents that had significantly in the intervention group (p .05). The percentage of teachers who had been tested twice increased from 21 percent to 31 percent, while the percentage that had tested three or more times incre ased from 16 percent to 23 percent, making it apparent that the intervention was successful at encouraging those who had already been tested to continue doing so to be sure of their HIV status. There was no significant change in number of times teachers ha d been tested in the comparison schools. During the peer educator training, about a third of trainees got tested for HIV for the first time, and others got tested once they started implementing the intervention. As they said: I had to be a role model so that when I urge the other teachers to go for the testing, I talk from experience. Primary school teacher, Thika tested. Primary school teacher, Kwale Although much of the emphasis of Teachers Matter was on the individual teacher, they were encouraged to discuss HIV testing with partners and to in the proportion of teachers who reported that their partners had been tested, this increase was across both intervention and comparison s chools (from 25 percent to 41 percent in the intervention schools [ p .001 ], compared to 26 percent to 41 percent in the comparison schools [ p .001 ]). Multivari ate testing (data not shown) . Untested teachers: Among those who had never been tested for HIV, there was no significant change over time in their r easoning for avoiding the test. About a third of all un - tested teachers said they did not have a particular reason why they had never been tested, and an additional third said it was because they did not feel at risk. One teacher explained why he, and othe rs like him, ha s avoided the test: I’ve considered [testing] many times but backed off because of the fear of knowing your status, guilt, stigma, and immediately what will start happening to you when you are told you are positive. Intervention Comparison Baseline Follow up p Baseline Follow up p n % n % n % n % Have ever been tested 572 24 622 39 .001 665 25 685 41 .001 Number of times ever tested^ 132 225 0 .02 166 266 ns One 61 43 53 48 Two 21 31 26 28 Three or more 16 23 17 21 ^Among those who have ever been tested Evaluation of Teachers Matter 35 You see now, for people like us with families, you start feeling guilty…it is the fear of what might come after…. Secondary school teacher, Thika Table 12. There was a signifi cant increase in the percent of untested respondents in the intervention schools who would consider testing (from 35 percent to 42 percent; p = 0.004), and a significant decrease in those who said they did not want to be tested (from 39 percent to 27 perce nt). The changes in the comparison s chools were less significant, with the percent wishing to be tested rising from 37 percent to 43 percent, and the proportion saying they did not want to be tested remaining constant at 33 percent (p = 0.08). However, aft er controlling for gender, age, level of teacher training, and urban - rural school the intervention (data not shown) . Table 12 Percent of untested teachers who want to be tested for HIV at baseline and follow up Sexual risk taking During both rounds of data collection, about 81 percent of respondents in the intervention s chools reported that they were sexually active, and the percent reporting multiple partners remained the same (4 percent at baseline, 6 percent at follow up ; p = 0.21). In the comparison s chools , the proportion reporting that they were currently sexually active rose slightly from 78 percent at baseline to 83 percent at follow up (p = 0.02). The percent of these reporting multiple partners there remained the same though, 8 percent at baseline and 10 percent at follow up (p = 0.32). In order to assess risk - taking among teachers, sexually active respondents were asked how many different individuals they had had sex with in the 12 months preceding the survey. However, this question elicited large non - responses, an average of 14 percent in both intervention and comparison s chools analysis showed that the percent of sexually active respondents who reported multiple partners remained constant at the intervention schools (from 12 percent to 14 percent, p = 0.40), but inched up in the comparison school s (from 12 percent to 17 percent; p = 0.09). Multivariate analysis did not find an association betwee n multiple partnerships and exposure to the intervention ( data not shown) . Thus exposure to Teachers Matter did not increase or decrease m ultiple partnerships in the preceding 12 months. Intervention Comparison Baseline n = 425 % Follow up n = 364 % p Baseline n = 487 % Follow up n= 400 % p Want to be tested for HIV .004 ns Yes 3 5 4 2 37 43 No 39 27 33 32 Not sure 27 31 31 25 36 Respondents reporting multiple partners were asked how often they ha d used condoms with these individuals, with possible responses ranging from “all the time,” “almost every time,” “sometimes,” “hardly ever,” and “not at all.” It also included an option for “don’t know/not sure.” Those who said “all the time” were classifi ed against the other categories. The percent of multi - partnered respondents who reported using condoms always in the 12 months preceding the survey remained the same at the intervention schools , at 9 percent during both rounds (p = 0.93). The proportions a lso remained statistically unchanged in the comparison s chools (14 percent to 20 percent, p = 0.41). Th us the overwhelming majority of teachers reporting multi ple sex partner s , 91 percent of those in the intervention s chools and 80 percent of those in the comparison s chools at follow up , said they were not protecting themselves always and could therefore be at risk for HIV . The sample size was too small for meaningful multivariate analysis. d ever been tested for HIV. Bivariate results showed that individuals with multiple partners were no more likely to report having been tested for HIV compared to their monogamous counterparts at baseline in both intervention and comparison s chools (see Tab le 13). The sample size was too small for meaningful multivariate analysis. Table 13 Percent of tested teachers by number of partners in the past one year, baseline and follow up General HIV knowledge One of the objectives of Teachers Matter was to improve the level of participants’ knowledge ab out HIV, and to reduce stigma. During the baseline survey , knowledge was measured by a series of seven true/false questions covering basic information about the HIV epidemic, transmission, and treatment (see Appendix II). Each correct answer was awarded a point, and the percent correct was calculated. The same process was used for the follow - up survey. However, three additional questions were included in the follow - up survey, in order to incorporate emerging HIV information (on discordance, male circumcisio n, and HIV transmission through saliva). The mean HIV knowledge rose in the intervention s chools from 67 percent to 71 percent ( p .001 ), but rose too in the comparison s chools , also from 67 percent to 72 percent ( p .001 ). Respondents were dichotomized at the mean, with those scoring below the average considered having low knowledge, and those at or above the average considered having high knowledge. Logistic regression analysis was conducted in these groupings and the results show that those who attend ed all sessions of Teachers Matter were 2.0 times more likely to score above the mean compared to the other groupings (CI: 1.1 - 3.6) . Partial participation was not associated with incremental gains (see Appendix I). Baseline Follow up Multiple partners One partner Multiple partners One partner n % n % p N % n % p Intervention 45 29 300 24 ns 65 37 373 42 ns Comparison 50 18 3 66 25 ns 85 31 417 43 .001 Evaluation of Teachers Matter 37 Stigma Another outcome measure Teacher s Matter sought to influence was the level of stigma teachers harbored toward people living with HIV . Stigma was measured by a series of six survey questions about attitudes toward people living with HIV and how those people deserve to be treated (see Appe ndix II). Respondents whose answers did not include any stigmatizing attitudes were classified at “no stigma,” those with one or two answers portraying stigmatizing feelings were scored as “some stigma,” and those with more than three stigmatizing answers were classified as “high stigma.” Significant reductions in stigma among teachers occurred in both intervention and comparison groups, although the changes were greater in the intervention group. Those with no stigmatizing attitudes increased from 36 perce nt to 62 percent and those with high stigma decreased from 22 percent to 8 percent in the intervention group ( p .001 ; see Table 14), compared to an increase in those with no stigma from 38 percent to 60 percent and a decrease in those with high stigma fr om 21 percent to 11 percent ( p .001 0) in the comparison group. However, multivariate analysis found that after controlling for gender, age, level of teacher training, and urban - rural school location, there was no significant relationship between level of HIV stigma and exposure to the intervention, suggesting that other factors were influencing the observed changes (data not shown) . Table 14 Changes in HIV knowledge and stigma level among teachers at baseline and follow up Intervention Comparison Baseline n = 572 Follow up n = 622 p Baseline n = 665 Follow up n = 685 p Mean % knowledge score 67 71 .001 67 72 .001 Stigma level (%) .001 .001 None 36 62 38 60 Some 42 30 41 30 High 22 8 21 11 Mean stigma score (out of 6, 0 = no stigma) 1.40 0.66 1.33 0.76 38 Discussion and Recommendations Teachers Matter is one of the first well - documented HIV workplace programs in sub - Saharan Africa pportunity not only to assess the needs of teachers as adults who too are infected and affected by HIV , but also to explore the effectiveness of a teacher - centered workplace HIV intervention can improve knowledge, attitudes, and HIV prevention practices among this cohort, and also - based workplace program is able to improve the work environment through confidentiality and job security, the development of coping skills among managem ent and staff, and the dissemination of workplace policies surrounding HIV . Bec ause many workplace programs for teachers in Kenya are likely to use a peer education strategy (e.g. , KNUT), it also provides useful lessons for scaling up such interventions. Successes Teachers Matter allowed an enhanced discussion of HIV prevention and treatment technologies, and was particularly successful in dealing with topics teachers were unfamiliar with. For example, it was particularly successful in disseminating the new Education Sector Policy on HIV and AIDS , updating teachers in less common technologies such as female condoms , and introducing them to innovations in HIV management such as post - exposure prophylaxis . Teachers who participated in the intervention were nearly six times more likely to have read (not merely to have heard about) the Education Sector Policy on HIV and AIDS than their colleagues who did not participate, and greater participation was associated with greater likelihood of having read it. Exposu re to such workplace policies empowers teachers to know their rights and to ensure that the administration is performing in an ethical and appropriate way. This empowerment in turn translates into teachers becoming more comfortable with discussing HIV issu es and supporting those who are infected. T eachers who participated in the intervention were five times more likely to have seen (not merely heard of) a female condom, and there was a clear dose - response effect. While only 31 percent of teachers at the in tervention sites reported having seen a female condom during the baseline survey, this had risen to 73 percent after Teachers Matter. And while the rates at the comparison sites also rose (from 39 percent to 51 percent), clearly Teachers Matter was associa ted with greater gains in this regard. Likewise, there were sharper gains in awareness of PEP. Teachers exposed to the intervention were nearly 7 times more likely to report being aware of PEP, also with a strong dose response. At baseline , less than four percent of teachers said they had been aware of PEP but after the intervention, a quarter of those in the intervention sites said they were aware of it, compared to only three percent in the intervention sites. There were also other achievements. For exa mple, a lthough most teachers were aware of male condoms, for many it was the first time they had seen or touched one. Many peer educators cringed when condoms were distributed during training, and several observed their colleagues first before eventually t ouching one. Trainers spent many hours helping teachers address conflicts such as perceived links between condoms and promiscuity and infidelity. Once teachers were able to become more familiar with male condoms, the intervention proved successful in impro ving attitudes toward them. Teachers participating in the intervention were 1.7 times more likely to have positive attitudes towards male condoms. Evaluation of Teachers Matter 39 The intervention was also associated with improvements in knowledge, with those who had attended all session s more than twice as likely to have high knowledge scores compared to those who had not attended any sessions. With increased knowledge and comfort level gained in discussing HIV issues, teachers may have been more willing to disclose their own HIV burden; the percent reporting HIV infection or AIDS - related death among close family members rose from around a third at baseline to about 40 percent at follow up members. Many said that relatives and friends had approached them to confide in them about their HIV status. Teachers responded in turn, by providing much - needed information on VCT and ARVs, and often ommunity, participating teachers were also called upon by the community to speak to parents and in churches about HIV . This may also partly explain why there was an association between the intervention and teachers’ awareness of HIV in their personal setti ngs. Teachers Matter was highly effective in improving the work environment with regards to HIV . Teachers who participated in the intervention were significantly more likely to say that both the school equipped to cope with HIV at school than they were the year before. In follow - up focus group discussions in the intervention group, many teachers reported increased empathy and support for HIV - positive colleagues, where previously they had been shunned and excluded. The intervention also provid ed an enabling environment for numerous informal discussions – many reported dialogues surrounding HIV testing, stigma, personal relationships with partners, sexual conduct, alcohol use , domestic violence , and other se nsitive issues that could now be debated in the staff room. Expressing one’s opinions on a topic is often an effective way of solidifying behavior change, and such dialogue served to refine teacher’s attitudes toward such issues. The intervention reached about 2700 teachers at a cost of US $42,500. This included the costs of preparing and printing the BCC materials, full costs of training the peer educators including transport and accommodation, full costs of sensitizations for head teachers, and mobile VC T services. This translates into roughly $16 per teacher reached. Challenges In some areas, changes occurred in both intervention and comparison s chools . For example, reductions in stigma occurred in both s chools , making it difficult to attribute such gains to Teachers Matter. We attribute this to concomitant programs HIV information campaigns being conducted in Kenya. Regardless of the cause, it is gratifying to note that stigma levels declined over the course of the intervention. Teachers Matter asp that they could be infected by interacting with children. While the intervention reduced the level of concern for some , still nearly 60 percent of teachers said they feared that they could be infected at work. Further discussions revealed that this was in part because many did not have infection control equipment such as first aid kits, gloves , or disinfectant . Th us this remains an area of concern. Although participan ts in Teachers Matter had increased levels of HIV testing, there remained a sizable proportion of participants who continue to fear this procedure. Comments from the qualitative study suggest that the “fear” to test is not simple fear, but is a rather comp lex sentiment wrapping actual fear of 40 HIV results of t he test were positive, they would be inviting the stigma and discrimination they have witnessed others face upon them, their families, and friends. The fact that teachers are so highly regarded in their communities may result in even harsher self - assessmen t, feeling they have failed as role models. Teachers are also particularly vulnerable because if they seek VCT, they may discover that some of the counselors are their former students. This complicates HIV testing behavior in a way that may be unique to te achers, and may discourag e many from seeking testing. The study encouraged teachers to learn the HIV status of their partners, but the follow - up survey data show that nearly 60 percent of those with partners do not know this person’s status. Therefore c ouple counseling and testing initiatives are needed for this population. Teachers seemed particularly interested in mobile VCT, and this could be a possible strategy. A mobile VCT counselor can un - intrusively visit schools and test willing teachers. Such a service could potentially extend to homes for teachers who request this service, especially to enable couple counseling and testing. - response rate of about 1 5 percent, available data showed that 14 percent of follow - up respondents in the intervention s chools had multiple partners in the 12 months preceding the research. In the comparison s chools , about 17 percent did as well. However, 90 percent of these teach ers in the intervention s chools and 80 percent of their counterparts in the comparison s chools said they did not use condoms “always” during these encounters. Because inconsistent condom use does not confer adequate protection from HIV, programs are needed to help these teachers to protect themselves effectively if they choose to have partners or using condoms always, this suggests that more intensive int erventions would be needed to elicit the desired behavioral response. Teachers Matter was also not able to increase perceptions of job security. At the end of the intervention, uncertainty continued over what would happen if their employer discovered they were HIV - positive or what would happen if there was a breach of confidentiality. Much of this confusion is justified: although teachers are now familiar with workplace policies and procedures in theory, there is still ambiguity even among head teachers an d school management about the actual steps that must be carried out to comply with these policies. Thus further discussions to help teachers accurately interpret the Education Sector Policy on HIV and AIDS are needed. Other sensitive issues such as breach of confidentiality remained unclear. Future programs can work with teachers to develop school - specific policies, even as more comprehensive national ones are developed. Lessons Learned Teachers Matter was based on the tried and true peer education strat egy and used a simple, teacher - friendly, and adult - oriented manual. The intervention and activities were well received by the teachers, as well as by the education sector management at the school, district, and national level. Several lessons were learnt h owever, that can make future initiatives like these more successful: Evaluation of Teachers Matter 41 Preparatory activities 1. The support of the national, district, and school level management was essential. Teacher - centered interventions will be more successful if they work closely wit h these structures. 2. Careful formative research enabled Teachers Matter to build on empirical evidence, and to address the issues teachers had raised. However, the 17 - month time - and follow - up survey likely diluted the measurabl e results of some topics. Therefore time further out would still be useful, to measure the sustainability of change. Training of peer educators 1. It is prudent to train two or more peer educators per school. This can enable an appropriate gender and age balance, and provide important social support when the program experiences challenges. It can also minimize interruptions in case of teacher absenteeism, transfers , a nd related attrition . 2. It is valuable to build in a mid - share experiences and solve mutual problems. Recognizing peer educators with non - awards such as certificates was an effectiv e way of keeping them motivated. 3. During training, it was helpful to develop school - specific workplans to guide the intervention. This enabled the peer educators to remain focused and provided a measure of accountability to the management. It was also impo rtant for each peer educator to develop a list of HIV resources in the community, so that s/he could immediately start referring teachers as soon as the program commenced. Programs adapting a similar strategy would find these aspects particularly effective . Implementing the intervention 1. Even though programs need to be flexible, setting aside a specific time for Teachers Matter during the school week was valuable and allowed predictability. It was especially effective when the head teacher endorsed the ti me allocation, and also participated. The time identified is important: t eachers preferred the sessions be conducted during lunch time instead of evenings when they are rushing to go home. 2. t them and not the students is important. During Teachers Matter, there was a tendency for teachers to revert into their roles as teachers and not adults who are also at risk for HIV . Activities at the beginning of each meeting to allow teachers to reflect on their personal lives may assist teachers to remove their “teacher” hat and consider how the topic of the day is relevant to their private live and behaviors. 3. Providing mobile VCT services to teachers may be a useful approach, as it would reduce the s ocial distance they have to cover to learn their HIV status. 42 4. Providing educational informatio n. By staggering the BCC materials over the life of the project rather than giving them out all at once, Teachers Matter was able to offer materials that corresponded with the topic under discussion. 5. Schools are diverse and teacher - centered interventions should plan for an appropriate response. For example, one of the schools in the study was for the visually disabled students, and had visually impaired teachers. Teachers Matter was able to convert some of the materials into Braille. As part of comprehensi ve risk reduction, initiatives for teachers with disabilities such as the hearing impaired would also be needed. 6. It is helpful to involve g roups of people living with HIV : Teachers Matter worked with many people living with HIV , both as resource persons a nd as vendors for the materials prepared for the project. People living with HIV were employed as speakers where possible to talk with attendees. These speakers were exceptionally powerful and often left the teachers challenged but impressed. 7. Supportive m onitoring was key to the success of the project. Quarterly visits kept the peer educators motivated and goal - oriented. The peer educators’ diaries provided essential snap - shots about activities within a specific school. 8. Anticipate requests for compensati on: In the early stages, there were numerous requests from teachers for “sitting allowances”, a Kenyan practice associated with payment for attending meetings. Teachers believed that peer educators were receiving financial compensation, and agitated for a part of it. Teachers Matter did not pay peer educators; rather the project recognized them in non - , and providing supportive supervision during the intervention. Peer educators also received certificates of recognition after the training. Because the program involved the head teachers from the start, implementing a similar activity therefore need to se lect committed peer educators and work closely with the school management to minimize some of the challenging requests. 9. Partial participation will only achieve limited results: The evaluation data show that the greatest impact was achieved among teachers who attended all the sessions of Teachers Matter. For the most part, those attending only some of the sessions did not register substantial enough gains, suggesting that partial participation may be ineffectual. Therefore future interventions should be str uctured in a manner to enable full participation among teachers. This could be done by integrating the program into the school curriculum, or dedicating other appropriate time to it. Teachers could also be recognized for completing the course, for example by being awarded a certificate of participation or similar honor. Evaluation of Teachers Matter 43 Appendix I Adjusted Odds Ratio of Specific Outcome by Exposure to Teachers Matter Outcome variable A OR ^ 95% CI Believe fellow teacher can cope with HIV in the workplace (n = 514) Did not attend TM meetings 1.0 Attended some TM meetings 1.7* 0.9 3.1 Attended all TM meetings 3.6* 1.9 6.7 Believe school managem ent can cope with HIV in workplace (n = 515) Did not attend TM meetings 1.0 Attend ed some TM meetings 1.0 0.6 1.8 Attended all TM meetings 1.7* 0.9 3.2 Read Education Sector Policy on HIV and AIDS (n = 536) Did not attend TM meetings 1.0 Attended some TM meetings 2.0* 1.0 3.9 Attended all TM meeting s 5.7* 2.8 11.2 Aware of PEP (n = 509) Did not attend TM meetings 1.0 Attended some TM meetings 2.6* 1.2 5.9 Attended all TM meetings 6.7* 3.0 15.2 Positive attitude toward male condoms (n = 536) Did not attend T M meetings 1.0 Attended some TM meetings 1.0 0.6 1.7 Attended all TM meetings 1.7 0.9 3.1 Have seen a female condom (n = 483) Did not attend TM meetings 1.0 Attended some TM meetings 3.3* 1.7 6.3 Attended all TM meetings 5.3* 2.5 11.0 High level of HIV/AIDS knowledge (n = 536) Did not attend TM meetings 1.0 Attended some TM meetings 1.4 0.8 2.3 Attended all TM meetings 2.0* 1.1 3.6 ^ Controlling for sex, age, urb an - rural locati on of school and level of teacher training ; *Association between outcome and exposure to Teachers Matter s ignificant ( p ≤ 0.05 ) 44 Appendix II Measures Used Knowledge and attitudes toward condoms 1. I believe male condoms decrease a man’s sexual pleasure (disagree) 2. I believe male condoms are quite convenient to use (agree) 3. I believe male condoms can be reused (disagree) 4. I b elieve male condoms are effective in preventing HIV if used properly (agree) 5. I fear I would lose respect if I suggested to a woman we use a condom (disagree) 6. I would NOT be embarrassed to buy condoms (agree) 7. I feel that using a condom shows you care for y our partner (agree) 8. I think it is alright for a married woman to ask her husband to use a condom (agree) 9. I think it is acceptable for a married man to offer to use condoms with his wife (agree) Knowledge 1. More women are infected with HIV in Kenya than men (true) 2. HIV and AIDS are the same thing (false) 3. Someone can be infected with different types of HIV at the same time (true) 4. If you go for voluntary counseling and testing (VCT), you must take the HIV test (false) 5. There is now a cure for AIDS (false) 6. Sexua lly transmitted diseases increase the risk of HIV (true) 7. If an HIV - positive woman becomes pregnant, the chances of infecting her unborn baby are 100 percent (false) 8. It is possible for a sexually active couple to be discordant (true; question in follow up o nly) 9. Circumcision makes a man immune to HIV (false; question in follow up only) 10. follow up only) Stigma 1. If a student at your school has HIV but is not sick, should he or she be allowed to continue attendin g school? (Yes) 2. If food was prepared for you by someone you knew or suspected has HIV, would you eat it? (Yes) 3. If you knew a shopkeeper or food seller had HIV, would you buy food from him/her? (Yes) 4. How afraid would you are of people living with AIDS? Woul d you say you feel very afraid, afraid, a little afraid, not at all afraid (not at all afraid) 5. People with HIV should be made public so that others can avoid them (disagree) 6. People who are infected with HIV through sex have got what they deserve (disagree) Evaluation of Teachers Matter 45 References American Federation of Teachers (AFT) . 2005. “Kenyan teachers lead the fight against AIDS” retrieved from http://www.aft.org/topics/international/solidarity/Africa - AIDS - Kenyareport.htm Bennel, P. 2006. Anti - n teacher mortality in sub - Saharan Africa. Brighton, UK. Unpublished report, Skills for Development. Brouillard - Coyle, C. et al. 2006. “Teachers as conduits for a school - based HIV intervention in Kenya,” Journal of Sex Research 43(1). Clark, A. 2001. “AI DS decimates African teachers,” 79(10): 999. Cohen, D. 2002. “Human capital and the HIV epidemic in sub - Saharan Africa,” Working Paper 2 . Geneva: ILO Program on AIDS and the World Bank. Comtex Newswire Service. 2002. “HIV/AIDS kills 7500 Malawian teachers annually,” Comtex Newswire Service , African Eye news Service/All Africa Global Media , Feb 04. Connell, R . W. 1987. Gender and Power. 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Nairobi: NASCOP/Ministry of Health. Handbook of HIV Prevention. New York: Kluwer Academic/Pl enum Publishers. Pevzner, E. 2005. “Teachers confronting the HIV epidemic: Skills for teaching and survival.” Chapel Hill: University of North Carolina. 46 Prochaska, J.O., C. C. DiClemente, and J.C. Norcoss. 1992. “In search of how people change: Application to addictive behaviors,” American Psychologist 47: 1102 – 1114. Republic of Kenya/Ministry of Education . 2004. “ Education s ector p olicy on HIV and AIDS .” Nairobi: UNESCO. UNAIDS . 2006. “ 2006 r eport on the g lobal AIDS e pidemic. ” Geneva : UNAIDS. UNESCO and ILO . 2006. “ An HIV and AIDS w orkplace p olicy for the e ducation s ector in s outhern Africa. ” Paris : UNESCO. ——— . 2006. “ Supporting HIV - positive teachers in e ast and s outhern Africa ,” Technica l Consultation Report . Nairobi : UNESCO. International Center for Research on