Building resilience to adverse childhood experiences

HEJ article

HEJ article - Building resilience to adverse childhood experiences An assessment of the effects of the Stepping Stones with Children training programme on Tanzanian children affected by HIV and their caregivers

In this article, published in the Health Education Journal, my colleagues and I presented the effects of the Stepping Stones with Children programme on children aged 5–14  years affected by HIV and their caregivers.  The findings are from the community workshops conducted by PASADA in four communities in Tanzania.

Although we intentionally excluded ‘disclosure’ of HIV sero-status to children as an indicator, the proportion who knew their sero-status increased from 27% to 93%. Assessment of clinical data before and after the workshops showed a statistically significant increase (p-value of <.01) in the CD4 count among the child participants living with HIV (n = 85, mean CD4 change + 317; from 530 to 847) compared with the control group (n = 91, mean CD4 change + 133; from 557 to 690). The mean weight gain was 3.51 kg for child participants and 1.33 kg for controls. Other benefits included improved relationships and reduced violence against the children, greater confidence, more willingness to use HIV services and better networks of support.  We concluded that the Stepping Stones with Children programme can achieve multiple outcomes, including disclosure and better adherence to treatment, to reduce the impact of the adverse childhood experience of being affected by HIV. The work also demonstrated that it is possible and acceptable to include children aged five and over in learning about HIV, sexual health and skills to improve their resilience.

Stepping Stones with Children

StStwC front cover

StStwC front cover A transformative training for children affected by HIV and their caregivers

Children living with HIV can live normal, healthy lives if they have love, care, and treatment when they need it. Yet they and their caregivers face many challenges, including stigma and self-stigma, discrimination, violence and abuse, and services that may not serve children well. While we would all prefer to experience relationships of love, appreciation, and compassion, challenges including grief, bereavement, stress, and poverty can get in the way. The result is that children suffer in many ways, and some die because they have not received treatment, and the care and support needed to take it, in time. Stepping Stones with Children is a response to this, enabling children and their caregivers to explore and change norms, learn and practise skills, and develop healthier and happier ways of living.

Please note, Gill Gordon is the author of Stepping Stones with Children; as manager of the project I played a role in shaping the materials by editing them and contributing some exercises, so am listed as a co-creator.  The manuals are available for purchase from Practical Action Publishing; if your organisation cannot afford to buy them please apply for free copies.

Stepping Stones with Children Counselling Guide

Stepping Stones Counselling

Stepping Stones with Children Counselling Guide

This guide accompanies the Stepping Stones with Children manuals.  I wrote it with Jovin Riziki, focussing on the additional knowledge and skills that HIV counsellors need to work with both children who are affected by or living with HIV and their caregivers. We explore the differences between counselling adults and children, and outline the key steps to follow in different counselling situations involving children and caregivers. You can download the guide for free here (scroll down the page); you may need to register with the Salamander Trust’s website to access the document. Also available in KiSwahili.

Extract

We’ve written this guide for people who already have the knowledge, skills and experience needed to counsel adults about HIV and related issues. We haven’t included basic information, such as what counselling is or key skills for counselling. Instead we’ve focused on the additional knowledge and skills that counsellors need to work both with children who are affected by or living with HIV, and with their caregivers. We also outline the key steps to follow in different counselling situations involving children and caregivers. This guide accompanies the Stepping Stones with Children manuals. Children and caregivers who attend Stepping Stones with Children workshops learn to appreciate their abilities, and to find ways of using these to improve their lives. For example: caregivers learn how to discipline children rather than hitting or otherwise punishing them, while children learn how to set boundaries regarding sexual intimacy, and how to protect themselves and others from sexual abuse. Basics of counselling children HIV counselling with children, as with adults, aims to help them cope with emotions and challenges relating to HIV and its effects, and to make informed choices that will improve their quality of life. Though the focus may be on HIV, counsellors need to see and work with the whole child: all the things that affect their life. Counselling children includes:

  • helping them tell their story;
  • listening carefully;
  • giving them correct and appropriate information;
  • helping them make informed decisions;
  • helping them recognize and build on their strengths;
  • helping them develop a positive attitude to life.

Counselling children does not include:

  • making decisions for them;
  • judging or blaming them;
  • interrogating or arguing with them;
  • making promises you cannot keep;
  • preaching to or lecturing them;
  • imposing your own beliefs on them.

Our key tasks during counselling sessions with children and caregivers include:

  • helping them understand their situation and how they are feeling by reflecting back what they have told us, both verbally and non-verbally;
  • helping them explore their regrets and feelings of blame and anger;
  • supporting them in seeing what they may be able to do to improve their situation, even though many factors are beyond their control;
  • supporting them in making informed decisions;
  • sharing useful information with them;
  • supporting them in developing the courage and confidence to come up with their own strategies and hopes and plans for their future.

What’s different about counselling children? There are four key differences when counselling children as opposed to adults.

  1. We must adjust what we say and do to suit the age and development stage of each child. There should be a big difference between the way we work with a five-year-old who may not yet be able to write, and a 15-year-old who may already be emotionally mature.
  2. We usually work not with a single client, but with a child and their caregiver(s). We must attend to their different hopes and needs, and support them in working together.
  3. We have to be willing and able to talk with children about sex and sexuality, and we may find this difficult.
  4. We need to be mindful of local rules and laws regarding children, for example, knowing at what age and under what circumstances a child can get an HIV test without a caregiver’s consent.

Planning and Support Tool for Empowering Approaches to SRHR Education with Young People

Planning and Support Tool for Empowering Approaches to SRHR Education with Young People

Stop Aids Now! Planning & Support Tool

Evidence and Rights-based Planning and Support Tool for Empowering Approaches to SRHR Education with Young People

STOP AIDS NOW! and Rutgers asked me to revise their Planning and Support Tool, which they had first published in 2009.

This involved a good deal of research, consultation and writing, to bring the document into line with the agencies’ changing approaches and to respond to users’ requests.

Download the 2016 PDF (2.2Mb).

Extract

This tool is designed to assist organisations that want to promote young people’s sexual and reproductive health and rights (SRHR) and to empower them to enjoy their (sexual) development, relationships, attain their rights and have a greater sense of wellbeing. It focuses mainly on the strategy of SRHR education, also known as (comprehensive) sexuality education.

To improve young people’s quality of life and (sexual) health we need effective programmes, but developing and implementing them is not easy. However, experience and evidence gained from work all over the world shows what contributes to effectiveness and what doesn’t. This tool summarises the most important evidence in a logical and easy to use way (much of it comes from research by Kirby and colleagues into HIV and sexuality education programmes around the world). It aims to help organisations to take well-informed decisions about the planning, development, implementation and evaluation of SRHR programmes, and to modify their work as needed. The outcome of using the tool should be more effective interventions which are empowering and rights- and evidence-based.

You can use the tool to analyse existing interventions, in order to identify what is already going well and what needs improvement. You can also use it to assist with designing new interventions.

Users have used the tool for various purposes:
• Analysing existing SRHR education programmes
• Designing of new SRHR education programmes
• As a framework to guide discussion with donor organisations
• Capacity building and improvement of their projects or programmes
• Documenting intervention planning afterwards
• Modifying an existing intervention to use in a different context
• Assessing project proposals
• For defining advocacy strategies
• Linking and learning between different organisations

However, this framework should not oblige you to implement programmes completely according to the tool; the particular context, implementation setting or mandate of your organisation may require choices that are not in line with the tool.

You can use the tool to analyse or plan a variety of SRHR interventions, for example: school based and out-of-school interventions; large and small projects; with different SRHR focuses; targeting children, younger or older people; for orphans and vulnerable children; or for young people who are at work.

DOWNLOAD the full 2016 PDF.

Making It Happen! Training young people to advocate for their sexual and reproductive health and rights

Making It Happen! Training young people to advocate for their sexual and reproductive health and rights

Making It Happen! Sexual and reproductive health and rightsMaking It Happen!  Training young people to advocate for their sexual and reproductive health and rights

I developed this advocacy training manual for dance4life, based on activities which they had developed. The manual is accompanied by handouts and a facilitators’ journal, and is also available in Spanish.

Download (6.7Mb)

Extract

Some changes just happen; the ground becomes wet because it is raining. But most changes come from someone; the idea to build a shelter to keep dry in the rain, then the work to build it. This training is about enabling young people to create change, to use their ideas and their voices effectively to influence others and to make things happen.

dance4life believes that advocacy is crucial if we are to achieve long term changes which benefit large numbers of young people and the wider community. The drive for those changes should come from young people themselves. They know best the issues they face and the changes that are needed. With support from relevant organisations young people are the best representatives of young people’s issues.

What is the purpose of this training manual?

It’s written to enable (advocacy) staff and facilitators of dance4life National Concept Owners (NCOs) to train young people in national lobby and advocacy. It’s a tool you can use to:

  • Strengthen the knowledge and capacity of young people through learning about advocacy.
  • Help young activists to figure out what they most want to change with regard to their sexual and reproductive health and rights (SRHR).
  • Give them meaningful involvement in refining, finalising and implementing your advocacy plans.

Creating a positive learning context

Remember how boring it can be, being taught? How the teacher’s voice goes on, and your mind wanders? Feeling frustrated there’s no chance to speak? Or feeling worried that you’ll get something ‘wrong’? This training should be NOTHING like that! It will be fun and creative and involve everyone, without fear and anxiety.

Your role is not to be the teacher or the expert! Instead you are a facilitator: someone who eases a process of learning and discovery. The methods in the training sessions help this to happen; they enable participants to figure out things for themselves, rather than being told. Your task is to create a positive context for their learning in the following ways:

  • Lead by example, with a positive approach, willingness to listen, and respectful behavior.
  • Give the sessions structure by following the training plan, explaining what to do, and keeping time.
  • Support groups to stick to the task they are doing, rather than go off the topic.
  • Be open to unexpected but important discussions and be flexible in adapting the plan, explaining changes as needed.
  • Manage how people interact, if necessary, so everyone has the opportunity to add their voice, and no one dominates.
  • Respond to any problems that arise, perhaps by asking the group what to do.
  • Provide everyone with a chance to give feedback about the training and to improve the process.
  • Praise participants for their efforts, and the virtues and leadership they have shown.
  • Use humour and a diplomatic approach to deal with conflicts within the group.

DOWNLOAD full PDF. (6.7Mb)

Know Much More About HIV: Staying positive and healthy in the workplace

Know Much More About HIV

Know Much More About HIVKnow Much More About HIV: Staying positive and healthy in the workplace

SAfAIDS asked me to write a booklet for employees, as part of a toolkit to support workplace responses to HIV. I wanted to give readers more options and more detail than the usual HIV prevention messages, and so set out 26 ways in which individuals can reduce their risk of acquiring HIV.

The booklet also outlines the steps which individuals can take to create a supportive and healthier workplace, and is available in Portuguese.

Download

Extract

What has HIV got to do with your workplace?

There are many different things which affect how well you and your colleagues work, and how productive your organisation is. Among those many factors, the impact of the HIV epidemic is likely to be significant. The effects of HIV in the workplace include:

  • If employees become infected with HIV and do not access treatment, then HIV will, in time, badly affect their health and productivity, leading to severe illness and their eventual death;
  • Increased staff absenteeism and higher staff turnover cause problems. These include stalled projects, missed targets, colleagues becoming overworked, managers spending too much time sorting out problems related to health issues, and lower morale in the workforce;
  • Staff costs tend to rise. This is due to higher medical costs, more funeral expenses and death benefits, and increased recruitment and training costs;
  • Efficiency is also undermined when staff are indirectly affected by HIV. For example, caring for sick relatives, or taking on responsibility for relatives’ children, takes time and causes stress.

However, we are not powerless against HIV. We can manage HIV in the workplace in three ways:

  1. Support staff and their family members to protect themselves from HIV infection
  2. Support staff (and sometimes their family members) who are HIV infected to maintain their health and their ability to work.
  3. By advocating for and creating a supportive working environment that implements its HIV policy and operates a wellness programme, with peer educators, educational awareness campaigns and programmes for staff.

What’s in this booklet?

Section 2 covers basic information on HIV transmission, progression to AIDS, and treatments for HIV and the opportunistic infections that arise from it. It may be a useful reminder for you, even though you already know a lot. You can use the information there to work out for yourself if a certain situation has potential for HIV transmission.

Section 3 deals with ways of preventing HIV transmission. This means both protecting yourself from getting infected, and stopping transmission of HIV to others.

Section 3.1 goes beyond the usual ABC of HIV prevention, and gives you 14 different options for reducing the chance of HIV transmission through sex! You may find new options there that you can use.

Section 3.2 concentrates on reducing HIV transmission from mother to child. It includes options for couples who want to get pregnant where one or both of them are infected with HIV.

Section 3.3 looks at ways of maintaining health and preventing opportunistic infections

Section 3.4 looks at ways of reducing HIV transmission through medical, cutting and injecting procedures. This section should also give you food for thought.

In Section 4 we move on to the more general topic of valuing our health. HIV is not the only threat we face, and there is a lot we can do to increase our chances of enjoying good health and productive lives.

Lastly, in Section 5 we set out the key ways in which we can create a supportive workplace for the benefit of all staff.

The Big Picture: A guide for implementing HIV prevention that empowers women and girls

The Big Picture - Implementing HIV prevention

The Big Picture - A guide for Implementing HIV prevention that empowers women and girlsThe Big Picture: A guide for implementing HIV prevention that empowers women and girls

From 2006 to 2010 STOP AIDS NOW! supported an innovative project in Kenya and Indonesia which gave equal weight to HIV prevention, gender equity and human rights. At the end of the project they asked me to set out the theory and practice of their partners’ efforts in a ‘how to’ guide. This is the result, which I co-authored with the project’s manager, Jennifer Bushee.

This guide will be particularly interesting for people working at community level who want to address the structural factors behind the vulnerability of women and girls to HIV.

Download

Extract

This guide provides ‘how-to’ information for developing a ‘transformative approach’ to HIV prevention for women and girls. Such an approach addresses key root causes of vulnerability to HIV and seeks to reshape the beliefs, attitudes and behaviours of individuals and communities in favour of women and girls and gender equality. It also aims to empower women and girls to protect themselves from HIV infection and from the negative impact of living with HIV.

It sets out the rationale for working on HIV prevention using a transformative approach. It also shares experiences and promising practices from the Gender Development Project. It then provides 5 steps based on these for developing HIV prevention work aimed at reducing the HIV risk of women and girl through promotion of gender equality and women’s rights.

This guide will be particularly interesting for people working at community level who want to address the structural factors behind the vulnerability of women and girls to HIV.

We note that the advice in this guide is not fixed and definite; please read it as providing suggestions based on the experiences of the partners in the Gender Development Project. The advice should be adapted to fit local needs and the relevant social, political and cultural context.

We also note that this guide is not comprehensive and is not written to support the development of a whole project cycle. It gives guidance about how to think from a ‘gender transformative’ perspective, but it does not, for example, give step-by-step instructions for doing a needs assessment.

Finally, we note that this guide encourages readers to think differently about how to respond to HIV, using a holistic perspective, the so-called ‘big picture’. This approach gives you wider scope for doing HIV prevention work. It allows you to integrate HIV prevention in other work on gender and rights. It also allows you to respond more closely to the felt needs of girls and women. Crucially, the ‘big picture’ approach, over time, allows you to work in a ‘transformative’ way. This means it helps supports people to transform or change gender relations in ways that are beneficial to all, including—but by no means limited to—by reducing vulnerability to HIV transmission.

A Different Way: Young women, their sexual orientations and their sexual rights

Sexual Orientation and sexual rights

A different way - International Programme on SexualityA Different Way: Young women, their sexual orientations and their sexual rights

Rutgers WPF asked gay and straight young people from around the world about what information would help girls and young women who have questions about their sexual orientation.  I used their ideas and queries to write A Different Way, which was also translated into French as Vivre Sa Difference.

Download

Extract

All around the world, people’s ideas of sex, love and marriage focus on men and women. But this is not the whole story! There are different ways to be, including relationships between women, and relationships between men. But there is not much information available to help young women find their way.

We have written this booklet for young women who:

  • may be feeling different;
  • want to know more;
  • have questions about their sexuality;
  • and want to do what is best for themselves.

We want to give young women information about different sexual orientations. We hope it will help them to understand the issues better, and to make good choices, particularly if they are feeling unsure. This booklet should also be useful for people who work with young women, such as teachers and health workers.

Our values

We believe in human rights. They are things which everyone should have. Among them are sexual rights. Everyone should be able to choose their sexual partner, to decide whether or not to have sex, and be free to try and have a satisfying and safe sexual life.

Too often these sexual rights are abused. For example, young women are forced or pressurised into having sex, or required to marry a certain man. The situation is usually worse for women who are attracted to other women.

Sometimes information can help. In many cultures young people get a confusing mix of messages from films, magazines, friends, family members, and religious leaders. Some of this information is incorrect. Some of it is used to try and control them. Many adults think telling young people information about sex will lead to them having sex. This is not true! Many studies have shown that getting information about sex and healthy relationships helps young people to make better decisions.

What’s in this booklet

Chapter 2 is about sex and healthy relationships. It should be useful to all young women.

Chapter 3 explains what gender identity is, and outlines the different kinds of attraction or sexual orientation that are normal for humans.

Chapter 4 has a lot of questions and answers about women who are attracted to other women. They should be interesting to young people in general, and particularly to young women who are trying to figure out their sexual orientation.

Managing HIV in the Workplace: A Guide for CSOs

Managing HIV in the Workplace

Managing HIV in the WorkplaceManaging HIV in the Workplace: A Guide for CSOs

STOP AIDS NOW! commissioned me to research and write this handbook (which they translated into French) to help organisations reduce the effects of HIV on their staff and their work. Other terms for this include ‘internal mainstreaming’ or ‘mainstreaming HIV at the organisational level’ or ‘addressing HIV in the workplace’.

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Extract

The costs and benefits of managing HIV

Of course, managing HIV in the workplace is not free of cost.

One cost is the staff time your CSO will use to come up with plans, and to put them into action. You may also need extra money, for example, if your CSO hires trainers to help you run workshops, or helps with the insurance or medical costs for staff.

The actual costs in time and money vary a lot between CSOs in different countries. But whatever they are, you might think that ignoring HIV has to be cheaper, because that doesn’t cost anything. Yet in the case study on page 7, when the CSO ignored HIV the consequences included: staff away from work; a failing project; the death of a valued member of staff; misuse of resources; management stress; a sacked member of staff; loss of a donor; underperforming staff; and bad feelings among staff. The costs of the consequences of doing nothing can be substantial.

We don’t have much information on the costs and benefits of managing HIV in the CSO sector. Many CSOs don’t record sick leave, and CSOs’ outputs are often hard to measure. But recent research among companies in Zambia showed that, on average, the benefits of managing HIV were three times the costs. So for every kwacha (or dollar) spent, they saved three.

It is no coincidence that businesses were the first organisations to manage HIV. They are very sensitive to higher costs and reductions in productivity because they mean lower profits. Many businesses have recognised that it is cheaper to manage HIV than to ignore it. This is also the experience of many of the CSOs supported by STOP AIDS NOW!’s projects in Uganda, Ethiopia and India. They have found that investing some time and money now allows them to get benefits now, and to avoid higher costs in the future.

So, managing HIV within organisations is cost-effective. It is also necessary, particularly in places with high HIV prevalence, if your organisation is to protect its ability to deliver its outputs.

CSOs that have chosen to manage HIV report various benefits. These include:

  • Staff are better informed, and more able to talk about HIV and sexuality issues;
  • There is less stigma and discrimination in the workplace;
  • Staff feel more confident that they can keep their job if they are HIV-positive, and are more willing to disclose their status;
  • More staff and their family members get tested for HIV (in STOP AIDS NOW!’s Uganda project, 65% of CSO staff had tested, compared to 13% of the population);
  • Staff report safer sexual behaviour, so are less likely to get infected with HIV;
  • More HIV-positive staff link to positive living networks, prevent opportunistic infections and use ART, so have better health and longer lives;
  • Staff become more gender sensitive leading to less discrimination against women and transgendered members of staff;
  • Staff feel more valued and, through participatory approaches, have a greater sense of togetherness;
  • Staff capacity is enhanced, and the organisation is stimulated to improve its work by adapting its programmes to take account of HIV, or by doing AIDS work;
  • The positive effects spill over to family members and the wider community.

Break Another Silence: Understanding Sexual Minorities and Taking Action for Sexual Rights in Africa

understanding sexual minorities in Africa

Sexual Minorities and rights in AfricaBreak Another Silence: Understanding Sexual Minorities and Taking Action for Sexual Rights in Africa

This booklet is about marginalised sexualities and human rights and is also available in French.

In a context of widespread homophobia and misinformation, it aims to give Oxfam’s and other NGOs’ staff both facts and food for thought about alternative sexualities.  It’s written for people working in civil society and government organisations, with a focus on Africa, particularly the Horn, East, and Central Africa.

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Extract

The idea for this booklet came from an HIV and AIDS forum, held in the Horn, East & Central Africa region, for Civil Society Organisation (CSO) staff working on HIV. The forum focussed on learning about linkages between gender, HIV & AIDS, and sexual rights. Two East African activists from a sexual minorities network spoke about how badly sexual minorities are treated, the violence and discrimination they experience, and the difficulties they face in accessing HIV and AIDS prevention, treatment & care services. Their testimonials stirred the participants’ interest. Some felt that they needed to know more. Many were surprised; they were working on HIV, and yet had not given much thought to sexual minorities. Some, perhaps, felt negative towards the two activists, a common reaction in African cultural settings. Others wondered how they and their organisations might support sexual minorities to claim their rights.

This booklet is to encourage staff in civil society and government organisations to: understand sexual rights as human rights; to become aware of the ongoing abuses of sexual minorities’ human rights including lack of access to essential services; and to take action to protect rights for all, including minority groups.

Chapter 1 focuses on basic information and key debates. Chapter 2 looks at reactions to sexual minorities and their sexual rights. The linkage between sexual minorities, human rights and HIV programming is explored in Chapter 3, while Chapter 4 deals with why most NGOs have been silent on the issue. The concluding chapter suggests ways to break that silence.