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Workplace peer educators and stress David Dickinson & Kabelo Duncan Kgatea Published online: 11 Nov 2009.

To cite this article: David Dickinson & Kabelo Duncan Kgatea (2008) Workplace peer educators and stress, African Journal of AIDS Research, 7:3, 293-303, DOI: 10.2989/AJAR.2008.7.3.6.653 To link to this article: http://dx.doi.org/10.2989/AJAR.2008.7.3.6.653

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African Journal of AIDS Research 2008, 7(3): 293–303 Printed in South Africa — All rights reserved

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ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2008.7.3.6.653

Workplace peer educators and stress David Dickinson1* and Kabelo Duncan Kgatea2 Wits Business School, University of the Witwatersrand, PO Box 98, Wits 2050, Johannesburg, South Africa Anglo Platinum, Rustenburg Section, PO Box 492, Tlhabane 0309, South Africa * Corresponding author, e-mail: [email protected]

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Peer educators form an important component of company responses to HIV and AIDS. Based on interviews with peer educators working in and around a mining company in South Africa’s North-West Province, the study examines the relationship between involvement in peer education and stress. The paper discusses how becoming a peer educator can be a response to the often personal stress brought about by the HIV epidemic. In addition, structural difficulties, skills deficiencies and other obstacles to effective communication with their peers can create stress. The stress that active peer education brings to individuals is discussed, particularly in regard to the embeddedness of peer educators within their communities. The need for confidentiality also magnifies stress in the case of individuals who disregard peer educators’ advice. Peer educators face many stresses in managing and supporting their own lives, thus their (voluntary) work as peer educators should not be taken out of context. Using this approach, we discuss how the role of peer educator should be conceptualised and how they can be organised and supported in order that their stress be minimised and effective engagement maximised. Keywords: case study, coping, health beliefs, health programmes, HIV/AIDS, mining industry, peer education, South Africa, support services

Introduction This paper is the joint work of an academic (D. Dickinson) and an active peer educator and peer-educator group coordinator (K.D. Kgatea) who is affiliated with a mining operation in South Africa. Workplace peer educators are rank-and-file employees who assume a role within company HIV/AIDS programmes and beyond. They are seen as particularly valuable in changing employees’ beliefs and behaviour, because, once trained, they are able to communicate more effectively with their peers than are external experts, given their physical, social and cultural proximity (UNAIDS, 1999). The research topic of peer educators and the stress that interaction with their peers entails was suggested in a personal communication from Kgatea to Dickinson (22 October 2007): “My worry is the stress that peer educators are going through. Employees at the workplace willingly disclose their [HIV-positive] status to peer educators, because they trust them…but once a peer educator sees this person with a beautiful girl in a few months time [and suspects they are having unprotected sex], the level of stress goes up. How much damage is caused by this?”

The issue of peer education being stressful resonated with a concern raised in previous research by Dickinson (2006a). In a survey of 600 workplace peer educators, just over 50% reported that they had had emotionally stressful discussions with co-workers. Additionally, almost 40% had had a co-worker disclose their HIV-positive status to them — a potentially stressful event. But the comment by Kgatea moves beyond such snapshot statistics: it points to how the embeddedness of peer educators within communities can prolong and increase the stressful consequences of a peer disclosing their HIV-positive status, an issue we explore in this paper. Our starting point, however, was less specific and simpler. We wanted to know what role stress might play in the attrition of peer-educator activity. If we had an answer to this, we could then suggest how company HIV/ AIDS managers, peer-educator coordinators and trainers, and peer educators themselves could respond. Our approach assumes, rather than critiques, the situation in which peer educators operate. The literature on peer education puts forward many suggestions but has failed to firmly establish the theoretical grounds concerning how peer educators might best change beliefs and bring about behavioural change (Turner & Shepherd, 1999). Workplace peer educators are formally positioned within vertically

Note on the peer-review process: Anonymous peer-review of this article was independently managed by the AJAR Managing Editor, since one of the authors was a guest editor of this issue.

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structured communication programmes run by HIV/AIDS managers, but the wide range of activities that they are expected to undertake are articulated with different degrees of clarity (Dickinson, 2006a). While these issues present challenges to peer education carried out in a range of settings, there have been suggestions that peer education is not an effective response within companies. Thus, Mametja (2005, p. 6) suggested that “peer education programmes [in the workplace may be] considered appropriate strategy, but [the] effect may be insignificant.” This assessment rests on relatively limited data (see Wolf & Bond, 2002; Setswe, 2005; Sloan & Myers, 2005). However, it is not clear how the suggested ‘gold standard’ test of controlled seroprevalence trials undertaken to assess the effectiveness of workplace peer education could be implemented. Such an approach would need to remove peer education from its context: but the context not only presents the challenges that peer educators are responding to, but also the provision of the support required for their response. Campbell (2004) points to the need for peer educators to operate within broader, multifaceted programmes that require, as a pre-requisite for success, the building of partnerships, to ensure that peer educators have the support and resources that they need. In short, despite ongoing research and practice, it is not yet fully clear what peer educators should be doing, how they should be doing it, whether they have the support they need, or what the outcomes might be. Based on the perceived advantages of peer education, workplace peer education is nevertheless included in many workplace HIV/AIDS guides (e.g.: International Labour Organisation [ILO], 2001; Rau, 2002; National Occupational Safety Association [NOSA], 2003; World Economic Forum, 2003). It is also recognised that such workplace programmes provide a relatively cheap response when compared to the use of professional personnel such as health and social workers (Hope, 2003). This latter consideration is valid, but raises the problem that peer education could be used inappropriately by companies to disguise an absence of commitment to more expensive elements of a comprehensive HIV/AIDS response (Sloan & Myers, 2005). While this may be the case, assuming that viewpoint alone would be to ignore the agency of peer educators and HIV/AIDS managers who are committed to effective responses (Dickinson, 2006b). These are all valid questions about peer education, encompassing various aspects likely to affect the stress that peer educators might experience. However, we felt it appropriate to work solely within the ‘social fact’ of workplace peer education, which is extensive and indeed expanding. We hope that working within a tangible (yet clearly far-fromperfect) context might begin a dialogue about the stress that peer educators face and possibly contribute to better understanding of HIV/AIDS peer education in general. As suggested by Kgatea’s initial comment, we uncovered something more complex than a simple formula along the lines that peer education equals stress, which, if greater than a certain threshold, results in disengagement. This paper explores key issues that expand on that basic, but still valid, equation. We begin with a brief discussion of what stress is, and then describe the particular context

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in which we studied the nature of this stress (i.e. among peer educators based in or close to one company’s mining operations in South Africa). Our findings include basic information on the peer educators who formed the main set of respondents and an examination of several key themes, namely: being a peer educator may be a response to stress as well as a cause of stress; being a peer educator may be only one among many causes of stress; the location of peer educators within communities can increase their stress; peer-educator structures can both mitigate and increase an individual’s stress; and different individual or institution support mechanisms can be utilised by peer educators to deal with stress. The discussion of these themes needs to be contextualised within the developing situation at the company researched. The company is currently rolling out a massive, sophisticated, peer-educator programme to supersede existing, often already extensive, activity. Our research took place in an area of the mining company’s operations which had not yet been incorporated into the new processes. By and large, we believe that the environment we researched is typical of many corporate peer-educator programmes, particularly in regard to the provision of basic training, patchy follow-up or refresher training, weak monitoring and uneven levels of support. But, despite this, important work is being achieved due to the efforts of dedicated peer educators. We are not in a position to provide a comprehensive evaluation of the company’s new peer-educator programme (although clearly it will help support peer educators) but we draw on some of its features in our discussion. Stress Stress experienced by an individual is the result of a range of factors and it cannot be reduced to a single determinant. To determine how much stress an individual is under, a three-part model is typically used. Thus, drawing on McLean (1979) and Thompson, Murphy & Stradling (1994), our model incorporates: 1) the stressors or pressures that bear on an individual, 2) the individual’s ability to deal with these stresses (or their personal vulnerability), and 3) the environment (or context) and the ways that this does or does not provide support. In evaluating the stress that a peer educator is under, all three dimensions need to be evaluated. For example, an individual may be under constant pressures that we might expect to result in high levels of stress and corresponding behaviours, such as withdrawal, anxiety, depression or an inability to cope. However, if the individual has ways of dealing with the stresses, and/or the person is in an environment that is supportive, s/he may well be able to manage a level of pressure that would overwhelm others (Sulsky & Smith, 2005). Hence, we looked not only at what stressors the peer educators might encounter, but how well equipped they were to deal with these as individuals, and what social or programmatic environment they operated within. McLean (1979) points out that those who view only high levels of pressure as a problem will miss an important point. We must take into account not only the other two dimensions of the model (above) in assessing the impacts

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of a high level of pressure, but we must also recognise that a context of too little demand on an individual (such as unemployment) can also be a source of pressure. Thus, keeping stress within manageable levels involves a certain level of stressors and the matched ability of the individual — operating within a particular context — to constructively respond to the pressures. Individuals who perceive themselves as able to influence their situation or who have an internal locus of control are better able to cope with stress and can remain longer in a situation with stressors than others who have less belief in their own agency or have an external locus of control (Lefcourt, 1982). Not all stressors relate directly to the individual on which they bear; stress can be secondary if it is taken on as a result of either professional or lay involvement with the lives of others. The dangers that secondary stress presents is well recognised in the caring professions, such as among social workers and psychologists. Of course, secondary stress also affects peer educators, since they often take on, in a lay role, the stress emanating from their peers. Levels of stress are dynamic and likely to change over time (Ganster & Schaubroeck, 1991). For example, someone who is occupationally promoted is likely to face additional pressures as a result of their new position, while their personal ability to cope with new stresses is likely to decrease until they ‘learn the ropes.’ Whether or not the new context assists them depends on what collegial support they have and whether there is, for instance, an induction process to assist them with responding to new challenges. One possible response to an increased level of stress is for individuals to drop activities that cause them secondary stress (where this is an option, as with peer education), so as to be able to rebalance the level of pressures and their ability to cope. Henderson, Kelbey & Engebretson (1992) suggest that stress management workshops to openly deal with the topic of stress can increase people’s ability to deal with stressors. Thompson et al. (1994) point out that stress in one sphere of a person’s life can be offset in another sphere. Parts of a person’s life that are relatively free of pressures constitute ‘zones of stability’; these depend very much on individual circumstances. Thus, family life for some may be a zone of stability, while for others it is a sphere of pressures. Zones of stability can take many forms: friends, family, hobbies, church, sport, etc. In dealing with stressors, such zones of stability, and the individual’s ability to prevent pressure from entering these spaces, are important in enabling individuals to maintain control in regard to stress. Peer education and the company case study Workplace peer educators have become a standard component of company responses to HIV in South Africa. The South African Department of Labour (2003) recommends a ratio of one peer educator to every 50 workers. 1 Peer education is not confined to workplace HIV/AIDS programmes but has been used extensively in relation to a range of issues in order to educate and assist behavioural change (Horizons, UNAIDS, Jamaican Ministry of Health, AIDSMark/PSI, PATH, IMPACT/FHI & USAID,

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2000). The advantage of peer education (which uses peers rather than status-holding professionals) stems from the “similarity between message source and recipient [which] is vital to the ultimate impact of the message” (Wolf & Bond, 2002, p. 362). Workplace peer educators within programmes run by HIV/AIDS managers are expected to give formal talks or training sessions to co-workers on assigned topics. Additionally, they are usually engaged in extensive, horizontal communication with peers both inside and outside the workplace — efforts that are often categorised as ‘informal activity’ (Dickinson, 2006a and 2007). Workplace peer educators in South Africa are essentially volunteers who conduct peer education alongside their normal work-related responsibilities. Initial training for peer educators is usually limited to 2–5 days. Typically these individuals are then left to their own devices. Increasingly, however, companies are organising refresher (or follow-up) training or workshops, and setting out expectations for the activities of peer educators and requiring feedback from them. This reflects continued interest in peer education by company HIV/AIDS managers despite the realisation that it may not be as cheap as initially thought. The expansion also represents ongoing attempts in South Africa to evaluate peer education and to establish what peer educators can do and how this can be done effectively. Study context The study took place at a mining operation in South Africa’s North West Province. The area has numerous mines and smelters based primarily on the platinum mining industry. Migrant workers are an important component of the workforce, and there are numerous single-sex hostels in the area to accommodate them. Although large government housing-development projects are underway, the extensive informal settlements and dirt tracks between workers’ hostels, mine heads, and the networks of industrial pipes and cables are most striking to the visitor. A slight distance away is the booming town of Rustenburg and a number of sprawling villages in the veldt of the previous Bophuthatswana homeland. As in all mining companies, the workers are given an annual health examination. This has provided a vehicle for voluntary counselling and testing (VCT) for HIV, which effectively operates on an opt-out basis (i.e. every employee enters a specific room for HIV testing during their check up, but can decline testing, which many do, for a variety of reasons). The company also runs an antiretroviral treatment (ART) programme for employees, but it does not include family members or the large number of contract workers. There is provision for handing over responsibility for ART — from the company programme to local clinics (often in far-flung parts of the county) — when employees leave the company. However, this is not always effective and, for many reasons, treatment can break down. Peer education at the company Peer educators at the company are organised into two structures, as workplace peer educators and community peer educators (with the latter paid a small monthly stipend).

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This arrangement is now coming to an end, with consolidation favouring workplace peer education. However, given the way in which peer educators operate, their activity typically stretches across both workplace and community environments. At this company, the workplace and community peer educators received basic training as early as 2000. In most cases, follow-up or refresher training has been sporadic at best. Given the workload of those charged with coordinating the peer educators, the peer educators in fact frequently operate on their own initiative. This system of peer education at the company is being rapidly overhauled, with a new, more intensive, peer educator programme being installed, which will see thousands of peer educators trained and supported as a key component of the company’s HIV/AIDS programme. This begins with potential volunteers been interviewed and then given a five-day training session. The peer educators are then organised into groups of 20; these groups hold monthly meetings for which the peer educators are released from their normal job duties, and the groups are run by an external facilitator whose role is to debrief members and build a range of skills. Each peer educator is provided with a printed monthly lesson and other support material. Counsellors are available at a toll-free phone number, and they also assist with collecting the monthly reports that each peer educator must provide. This new system, notwithstanding a range of local variations and inevitable start-up problems, will clearly provide a much greater level of contact and support than the older peer-educator structure at the company. Our research involved peer educators who were not part of the new system. Methods The research was conducted between January and May 2008, at three different mining operations (all in the North-West Province and belonging to the same large mining company), at three single-sex hostels and at three informal settlements. A total of 29 people were interviewed: 15 workplace peer educators (five of which had previously been community peer educators); 3 community peer educators; 3 group/ project coordinators of the peer educators; 3 VCT counsellors working in the company hospital; and 5 people involved in training and support for the company’s new peer-educator programme. The interview schedules were drawn up jointly by the two researchers. Informed and signed consent was obtained from each person interviewed. The interviews were conduced either by Kgatea alone or by both authors together. A maximum of three interviews were conduced in a single day, with an hour between them for the researcher(s) to analyse the interview and plan for the next. Kgatea did the majority of the peer-educator interviews, but six were conducted jointly. The interviews with coordinators, VCT counsellors, and those involved in peer-educator training and support were all conducted jointly. Both researchers took notes and made tape recordings of the interviews. Our work benefited greatly from previous research, conducted either together or separately, on workplace peer

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education, as well as from Kgatea’s own role as a peer educator at the company. Kgatea was released from his normal duties for one day per week in order to participate in the research. While the research covers what we believe is a widespread issue (i.e. peer educators and stress), we acknowledge that the research involved only one company’s programme within a particular industrial sector. Although care needs to be taken in relating the findings to other companies’ programmes, we believe that, on the whole, the findings are of value to those managing workplace peer-educator programmes. Results and discussion The peer educators We interviewed 15 workplace peer educators (men and women) and three community peer educators (all women). The workplace peer educators included five who had been community peer educators previously; one had also been a group coordinator and had recently left the company but remained active as a peer educator; 10 were males and 5 were females. Their average age was 41 (range 24 to 56 years old). Nine were married or had a long-term partner, four were single, and two were divorced. All had children (range 1 to 5 children; average 2.6 children). Five had up to Grade 10 education, three had Grade 11, four Grade 12, and three above Grade 12. On average they had been in the company for 9.7 years (range 3 months to 28 years), and their average monthly salary, after deductions, was R6 475 (range R1 186 to R15 000). Including periods as community peer educators their average length of experience in peer education was 7.4 years; excluding previous periods spent as a community peer educator, the average length of their experience dropped to 6 years. The home language of eight was Setswana, four Xhosa, one Zulu, one Sesotho, and one whose first language was not recorded. All were black Africans and all were Christians, many of them active in their churches. All three community peer educators were African women, and their ages were 25, 28 and 42 years old. Two were single and one was divorced, and they had an average of 2.3 children (range 1 to 4 children). Two had a Grade 9 education and one had completed Grade 11. Their income consisted of social grants plus a R300 stipend paid by the company for their peer-education activity. They had been peer educators for an average of five years (range 4 to 7 years). The home language of two was Sesotho and one spoke Xhosa. All were Christians. ‘Stressed if you don’t and stressed if you do’ At the beginning of the interviews with the peer educators we asked why they had taken up this role. Most accounts included a range of reasons, but almost inevitably included the impact that HIV/AIDS had had on them personally, and a desire, through becoming a peer educator, to equip themselves to handle or deal better with others who were HIV-positive. Here is a typical response to our opening question: ‘I became a peer educator because I wanted to help other people that I saw suffering with this, this

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illness.… I was so hurt seeing my brothers and sisters dying like that. So I wanted to know and understand and help other people who are still alive to know exactly what HIV and AIDS is all about. Because if you don’t have any knowledge you’ll be dying. So, you want to talk to people and convince them how important it is to know yourself.’ This and similar accounts show that in the face of the HIV epidemic, having inadequate knowledge about HIV/AIDS and not being able to respond can be stressful. The implication was that nothing could be done in cases where a friend or a family or community member had died, but in an unfolding epidemic one could choose to either stand by (and watch more people die) or do something. Thus, the decision to become a peer educator is often an attempt by the individual to establish personal control within the local context of the epidemic. The issue was personal as well as public. Talking to people is a way in which peer educators (who often feel scared after the death of loved ones) can respond to stress. It was evident that the peer educators felt encouraged when people listened to them and when they were able to advise people about what to do to protect themselves from infection or how to deal with being HIV-positive. But not everybody wants to listen. Peer educators found it stressful to encounter people who were unwilling to engage with them, with their attempts to respond to the epidemic seemingly amounting to nothing. As a result, stress could arise for several reasons. One reason was because after taking the step to assist others by becoming a peer educator they found themselves blocked by supervisors and managers who refused to give them time to engage with co-workers, usually due to production pressures. One peer educator in that situation questioned the value of being a peer educator at all: ‘At work I cannot say I’m given the chance [to make presentations]. That I cannot say because you know when you are at work you are always under pressure to do the work, to finish the work, to go home…. [And] it’s hurting. It makes you to be lazy. It’s hurting. Because it makes you to feel like, if I’m not going to help the people whom I’m working with, [but] I’m a peer educator, then what’s the use of being a peer educator?’ A lack of opportunity to address co-workers during shift meetings does not mean that a peer educator cannot be active, but at the very least it will be disheartening. Most peer-educator training revolves around engaging in a regular formal education session with co-workers as their central activity. Such barriers to peer-educator work may be an initial obstacle. More problematic is that even when they have contact with their peers there is no guarantee that people will care to listen to them. Some of the experienced peer educators we spoke with shared how they advised other peer educators to reach people in ways that would get them to listen: ‘I taught myself [to avoid] being stressed [by people not listening]. People must ask you — What must be done? [i.e. not be told what to do]. Thereafter you’ll have an input in resolving a problem, and it

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[this approach] worked wonders for me. If [another peer educator] says — I met people in Sondela [an informal settlement] and I wanted to talk to them and they did not want to listen. [Then I] ask them what did they then do — Did you just sit and say it’s OK?’ …[I tell them, you need to] arrive and observe these people, get into the topic that they are discussing and as the topic goes on bring in a topic. And they will automatically enjoy it and join in [your] topic. [But] if I come in and say — Yes! Ho! [throws up his arms to demonstrate a messiah-like approach] I’m coming to talk about AIDS! — people will never listen to you.’ Successfully engaging people in conversations about HIV and AIDS was a clear source of satisfaction for many of the peer educators interviewed. Many pointed out that they genuinely liked talking to people, which meant that far from being a source of stress peer education was something that they enjoyed and which could enrich their lives. Part of our discussion covers stress generated when peers only selectively or partially listen to peer educators (section ‘Peer educators’ stress and their environment’). In addition to the problem of partial listening, the peer educators sometimes felt frustration when their own voice proved inadequate in the face of competing demands. Although people might understand what peer educators are saying, they may not be in a position to take the advice because of economic or other constraints. Here a peer educator outlines how women engaged in transactional sex in nearby informal settlements felt unable to insist on condom use: ‘In the communities here, these settlements, squatting areas, it’s really hard to convince people to use condoms. Really hard to convince people to be alert. Because some of the girls say — We are earning a living on this thing. Then how can someone give me money if I always say, ‘You must pump in this plastic?’’ In the face of enormous personal loss brought about by HIV-related illnesses, peer educators find that their own explanations of what is happening have to compete with other more easily understood explanations of the epidemic — such as involving witchcraft. One peer educator talked about eight aunts and uncles (all siblings) of whom two had died of AIDS and three were HIV–positive; with his grandparents asking him who would be left to bury them, he explained: ‘The belief that makes me bitter now is the belief that someone is bewitching the family. And it’s distracting them [family members] now from focusing on being aware of what’s happening to them. You find that this person is HIV-positive, but this thing of being HIV doesn’t get to his mind. It’s like — My neighbour is bewitching me to be like this. Someone is bewitching this family.’ Traditional healers can at times be active competitors in providing advice. On such occasions it is perhaps not incorrect to see traditional healers as a peer educator’s most powerful adversary, notwithstanding that many peer educators have some belief in traditional healing (Dickinson,

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2007). Traditional healers are equally embedded in communities as are peer educators, and they therefore have the same socio-cultural access. In cases where an individual struggles between choosing traditional health practices or using Western medicine, the advice of a traditional healer can overtake the best efforts of a peer educator. Here a peer educator explains: Peer educator: The problem is this: believing in traditional medicine. [A peer may say] — ‘I’ve got a traditional doctor. Why do you say I must go for ART? Why go for testing?’ Researcher: That’s frustrating for you? Peer educator: Really! Because we want to help these [people], but now it’s the other way round. Two years back I dealt with somebody [like this]. The person passed away. Researcher: If it was to happen again, what would you do this time around? Peer educator: This time around [pause], I’ll have to talk to him or her and thereafter I have to refer to the relevant people in the hospitals…I’d try, but it’s going to frustrate me. But, as a peer education you have to see to it, you have to [try to] help him or her…. In summary, becoming a peer educator is often a response to the stress that the epidemic places on individuals; a way to turn the tables on the disease. Not surprisingly then, anything that prevents the peer educator from getting others to protect their health is frustrating. Viewed from this perspective, a number of apparently different problems for peer educators can be seen as very similar in their impact. Taken sequentially, there is the problem of being given access to co-workers, then the problem of learning how to engage effectively with people, and, finally, the factors that limit even the best communicator in getting people to change their behaviour. Of course, while there is a logical sequential ordering of these problems, many peer educators face them simultaneously. Most of the peer educators we interviewed were continuing their work despite facing these problems. They used a range of techniques to cope with the stress of being a peer educator (see section ‘What supports peer educators?’). The participants revealed that a peer educator is often driven harder by the stress brought on by the HIV epidemic than slowed down by the frustrations that active peer education entails. While attention should be given to how to overcome these frustrations, peer educators notably often set high standards for themselves. They hope that people will not only listen to them, but that they will then change deep-seated, significant and often pleasurable behaviours as a result. Of course, behavioural change must remain the ultimate objective, but it may be useful to reassure peer educators that getting people to listen is, in itself, a major feat. Effecting behaviour change is likely to be a longer, more complex process to which they can contribute but not control. Peer education as one stress among many Taking into account the three-part model of stress (stressors, ability to cope, and environment), we sought

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to gain a broader picture of stress in the lives of the workplace peer educators that we interviewed. We asked the interviewees to rank, on a five-point scale, the extent to which they felt 16 different issues caused them stress or gave them support. Table 1 summarises their responses. The minimum score was ‘1’ for ‘not at all stressful’/‘gives me no support’ and the maximum score was ‘5’ for ‘extremely stressful’/‘gives me a huge amount of support.’ Thus, each item could be assessed in terms of how stressful it was perceived, how much support it was perceived to provide, and by the overall, net balance of stress and support. If we regard peer education as a source of both stress and support for workplace peer educators, we see that it ranked the fifth most stressful of the sixteen items, but it also ranked the fourth most supportive. Overall, it ranked midway in terms of net support/stress. That peer education provides a relatively high level of support, as well as stress, links to the point that involvement in peer education is a way to cope with the stress of the HIV epidemic as well as generating its own stress. Overall, the most supportive aspects (net support) in the lives of the workplace peer educators were church, their own health, and their workmates/colleagues. Our interviews indicated that religion played a major role in their lives, they highly appreciated their own health as a result of being in close contact with sick people, and had a great love for other people. Two sources represented a net level of stress for the peer educators: neighbours, marginally so (net score of –0.1), and money, decidedly so (net score of –1.8). As one of the least supportive and by far the most stressful aspect, the latter is worth examining — especially so since the question of payment for peer educators’ work is a long-running and unresolved issue within workplace programmes (Dickinson, 2006a). One position is to argue that involvement in peer education is a labour of love and so people should not be paid for being empowered to help each other. Alternately, it is contended that since companies ask people to become peer educators as part of their HIV/AIDS programmes they should be paid for the extra work that signifies. Money as a source of stress and support in the life of a peer educator cannot be regarded in isolation. The interviews made it apparent that, as breadwinners, the ability to bring home sufficient earnings to meet needs and expectations impacted on family relationships. For example, some peer educators reported that they made promises to family members on the basis of expected bonuses. Sometimes goods were bought on credit in anticipation of such bonuses. But when the payments did not materialise, stressful arguments ensued. In this context, it was easy for family members to disapprove of peer educators for doing voluntary work, seen as being on behalf of the company, when they could not provide adequately for their family. Thus, they would be criticised for doing peer education, rather than putting in overtime. In such situations the peer educators clearly felt uncomfortable and even stupid. One peer educator, who had previously coordinated a group, concisely linked this problem to the difficulty of getting people to listen: ‘They [peers] don’t want to listen. You [management] don’t want to pay.’

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Table 1: Scores for workplace peer educators’ ranking of sources of stress or support (n = 14, unless otherwise indicated) Source of stress: Your job Workmates/colleagues Church/church groups Male friends Female friends Wife or husband/partner Children Other family members Neighbours Social sports and other groups Trade union Peer education Money (what you earn, what you pay) Your health Your free time Government Net total Average

Average score for stress 2.2 1.6 1.6 2.3 2.1 2.8 2.6 2.1 2.7 1.8 (13) 2.2 2.6 4.4 1.9 1.6 2.7 (13)

Peer educators’ stress and their environment Two important features of the environment that peer educators typically operate in are their closeness to peers and the ease with which they are able to effectively hand over, or refer, peers to other more professionalised elements of HIV/AIDS programmes. A decisive advantage of peer educators is their closeness to their audience. At the same time this can have direct implications for the stress that peer education involves. The need to maintain confidentiality was well understood by the peer educators, but given the blurring of boundaries between their personal lives and their peer education efforts, this ‘keeping of secrets’ can become a significant burden. Family members, workmates, or close friends may entrust them with secrets, while certain structures available to them, such as their workplace or a community peer educator network, are often uncomfortably close to those whose confidentiality they share. As a result, there is often reluctance to talk about the information they are privy to for fear that someone will guess who they are talking about specifically. This burden is sometimes intensified when they find their advice is ignored after being taken into a peer’s confidence. Several peer educators related how people close to them had shared their HIV-positive status, but then continued to ‘sleep around’ and/or had not disclosed their status to their spouse. In one case, the peer educator had supported his friend (with whom he shared accommodation as a migrant worker) in taking an HIV test; hearing the news that he was HIV-positive had been difficult and emotional for them both. His friend asked him not to tell anyone else about his status and he also asked for advice about how to disclose to his wife. Despite suggestions from the peer educator,2 when we interviewed him six months later, the friend’s wife still knew nothing. The peer educator found it most difficult to see his friend everyday, knowing that he continued to have sex with other women. He constantly wanted to raise the issue of HIV, but said when he did so, ‘My friend agrees with words,

Average score for support 3.6 3.7 4.1 3.4 3.7 4.3 3.1 3.4 2.6 (13) 3.2 (13) 2.9 3.9 2.6 (13) 4.2 3.2 2.8

Net support (+) or stress (–) +1.4 +2.1 +2.5 +1.1 +1.6 +1.5 +0.5 +1.3 –0.1 +1.4 +0.7 +1.3 –1.8 +2.3 +1.6 +0.1 17.5 1.1

but not with his eyes.’ The peer educator felt unable to change this situation, in part because ‘with a sick person [especially a friend] you’re supposed to try and distract them from their illness.’ At the time of our interview he had stopped raising the issue with his friend, but it remained a daily burden. His story was not unique; it demonstrates how people’s ‘zones of stability’ to offset stressful environments elsewhere, can be encroached upon, since the people that peer educators work with are also the people they live with. Some of these problems can be emphasised through comparisons with the work of VCT counsellors. The VCT counsellors we interviewed saw approximately 60 to 80 people per day as part of the company’s annual health check-up for all workers (employees and contractors). The majority of the employees chose not to test for HIV, but typically about 20 did test each day, and usually two or three were HIV-positive. Based on this, such a job would seem to be enormously stressful, and at times it clearly is: one VCT counsellor described how she hated the moment when she had to look away from the form on which she was noting ‘reactive’ (to the test) and face the client. Yet, the three VCT counsellors that we interviewed gave their work a lower stress rating than the peer educators gave for their peer education.3 It became clear that this was in large part because they were not familiar with the people they were testing. On the relatively few occasions that someone they knew entered the testing room the usual procedure was to ask if they would like to test with another VCT counsellor (which they almost always did). Moreover, for the VCT counsellors, dealing with someone who had tested positive was a short (typically 15-minute) process of providing advice, after which they would then refer them to further assistance (and which generally ended their contact with the employee). The only times that contact between the VCT counsellors and clients was extended were occasional SMSs and phone calls offering thanks, or instances of contract workers returning for more advice, often because they had been

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frustrated by trying to enrol at the state clinic or hospital to which they had been referred.4 Such return visits were a source of frustration to VCT counsellors. However, they said they responded by sharing information among themselves, and it helped that they possessed a list of the area’s best clinics and hospitals to refer contract workers to. By contrast, peer educators not only remain in constant contact with the peers who share their HIV status with them, but they tend to have less resources and knowledge with which to ensure that appropriate support and treatment is accessed. The more empowered peer educators had good knowledge of available health facilities and sometimes used their own transport, and even money, to ensure that these were accessed. However, this arrangement was entirely informal. Unlike the VCT counsellors, the peer educators had no standard referral letter for referring someone to a clinic. Peer educators struggled with the inefficiencies of their company’s antiretroviral drug programmes. The aggravating nature of such situations occupied their minds and it also strengthened rival approaches to illness, which they saw themselves as competing against. Peer educators: selfless ‘angels’ or a social movement? Most peer educators are attached to a peer educator group, at least notionally. Such groups provide a first line of collective or structural support. However, as well as providing support, peer educator groups were also sources of tension. Many peer educators disapproved of other peer educators who came to meetings only when things (such as T-shirts or caps) were offered. Such ‘fair-weather’ peer educators were an irritation to those who persisted irrespective of material rewards. Yet, the same peer educators were themselves frustrated at the lack of resources available to them (including the things that they criticised other peer educators of coveting). Plans made by peer educator groups which did not come to fruition for lack of resources or capacity were another demoralising aspect. Some suggested that other companies provided better for their peer educators while their own company ignored them. This may not be as contradictory as it first appears. There is a tendency to promote peer educators as ‘angels,’ selflessly working with more fallible peers. As such, thinking about material rewards is considered offensive, and believing that personal will can triumph over any adversity is expected. Many of the peer educators we interviewed had been active for years, despite adversity and isolation. Although it seemed that many will continue their involvement ‘no matter what,’ others needed motivating. This is understandable. Similar to a social movement, there is room for committed activists at the core, as well as for supporters and sympathisers making lesser, still important contributions. Thus, to focus on the core participants only would be misguided. Skilled social activists understand the need to find ways to motivate everyone to contribute even if it is at different levels of intensity. Social movements do not reimburse people to participate, they devise a range of motivators, which includes, but is not limited to, altruism. Hence, comradeship, education, self-improvement, a sense of purpose, successfully completed campaigns, acknowledgement, and social

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events all help to strengthen the activities and impacts of social movements. Where this is not achieved because resources and/or organisational skills are lacking, social movements collapse into cliques of diehard activists. We suggest that it would be valuable to reconceptualise peer educators — from angel-like to activists — and to provide them with the skills and resources to draw in others, at different levels of intensity. To clarify this, we suggest an analogy with church choirs. In African communities, church choirs are important social networks with members that join voluntarily because they enjoy not only singing but also the companionship of fellow members and the activities of the group. Such groups depend on a minimal level of resources necessary to put together events, costumes, travel, and so on. Such an analogy brings us down to earth: people may well choose between spending time as a peer educator or being a member of a choir. If so, then a peer educator group needs to be able to attract such people who are weighing up how to spend their time. Thus, it may be helpful to envision peer education as a form of social movement, which must be able to sustain itself over decades, with participation by many people, not all of whom are or should be thought of as ‘angels.’5 What supports peer educators? The peer educators had a range of ways to support themselves and maintain their activity. Many of these were individualistic and reflected personal strengths and strategies rather than organised support. This helps explain how they had often kept going for long, difficult years. Friends, colleagues and family were all significant sources of support, but also sources of stress. Church was decidedly a source of support: it ranked the third most supportive aspect of their lives and the lowest in terms of stress (along with colleagues and their free time). Support from religious belief and activity took two forms. First, church services and associated groups, such as choirs, formed ‘zones of stability’ in which the peer educators felt able to safely relax and enjoy themselves. In this sense church membership was similar to sports activities, socialising and watching TV, and other ways to relax that they (less commonly) reported. Second, was the way in which several of the peer educators used religious belief to limit or contain stress. When confronted with a problem they said they would pray and locate the matter in the hands of God; this form of referral allowed them to pass over a problem that they would otherwise continue to worry about (e.g. a peer not taking their advice on HIV testing or treatment). A small number of peer educators appeared to use ongoing learning about HIV and AIDS as a way to deal with stress. This connected to personal motivation for becoming a peer educator. The more they empowered themselves with information about HIV and AIDS the better equipped they felt to confront the disease. However, the number of peer educators with the skills and resources (such as Internet access) to pursue this was limited (see also Dickinson, 2007). One structural (rather than individual) support mechanism for peer educators is contact with other peer educators. The peer educators reported they valued meetings where

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they could exchange ideas and concerns. Even in cases where the individuals did not attend meetings it emerged that they generally maintained some contact with other peer educators; thus, keeping in touch also allowed them to discuss problems. This was especially apparent with community peer educators (and ex-community now-workplace peer educators), who were often in daily contact with each other. Despite regular interaction, it appeared that individuals were often not comfortable using such contact to talk about particularly difficult or stressful encounters, since other peer educators might be able to guess who they were referring to. This belief may have been well-founded, yet the approach seemed overcautious and may have reflected uncertainty about how the problems that preoccupied them could be aired without compromising confidentiality. One peer educator explained that she had dealt with a difficult and disturbing situation involving disclosure a few days before; she was still struggling to come to terms with the incident and wanted to meet with a fellow peer educator/ friend with whom she could talk. However, it was evident that she intended to relate the episode in a heavily disguised form, beginning with ‘If you met somebody on the road and they told you this story, what would you do?’ By contrast, a group facilitator who supported several peer educator groups in the newly rolled out programme structure (see above section ‘Peer education and the company case study’) explained that debriefing was an important part of meetings.6 Thus, while peer educator groups may provide a means to share emotional stress, this may not happen automatically. One problem may be the heavy-handed and over-simplified way in which confidentiality issues are instilled in peer educators. The presence of an outside facilitator may ‘allow’ peer educators to unburden. Although they could do this without outside facilitation, they may feel the need for external permission to break the (over-interpreted) rule that they must tell nobody what has been told to them. When asked what they thought would help peer educators in regard to stress the most common responses were suggestions about making the peer education system more effective: the need for more time to conduct their work, support from supervisors and management to allow them to talk to co-workers, and refresher training. These points were largely in line with agreed policy, although not always implemented; other ideas were couched in the form of suggestions to bypass operational difficulties. Overall, their input points to a commitment to respond to the epidemic, rather than focus on the stress that being a peer educator brings. In regard to the latter problem, the most typical suggestion involved a desire to be trained as an HIV/AIDS counsellor, which they felt would empower them to respond to stress. Given the constraints they face and their embeddedness within their community context, the desire for training as a counsellor came across as putting a great deal of faith in a suggestion that was not fully grasped. Indeed, it is possible that being trained as an HIV/ AIDS counsellor may increase rather than decrease stress. The most striking need is for mechanisms to help peer educators to unburden themselves without compromising

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confidentiality. Being trained as a counsellor may not provide such a mechanism and, indeed, is likely to increase the burden of confidentiality. There is a clear need for this issue to be openly discussed by peer educators, with emphasis on understanding their role and how the stresses it brings can be mitigated. Conclusions and recommendations Many of the peer educators that we interviewed had great powers of endurance, with an average of 7+ years’ experience among them. Maintaining peer-educator activity, despite the stress it brings, was achieved through high levels of personal commitment, individual coping mechanisms, and networking with other peer educators. Besides these stalwarts in the workplace and community, many others contribute to processes of peer education, albeit at lower levels of activity. Indeed, our initial intention to interview ex-peer-educators, to see if stress had played a role in them dropping out, proved complicated because the ex-peer-educators we did interview were far from inactive. While they had ceased attending peer-educator meetings — hence their inclusion in the planned subsample of ex-peer-educators — it was clear that they remained active both at work and in their community.7 Some of the peer educators had the slogan, ‘Once a peer educator, always a peer educator.’ This meant that they had no intention of giving up on what they were doing.8 However, the slogan can be applied beyond these determined individuals. As we have outlined, becoming a peer educator is, for many, an attempt to respond to the HIV epidemic. And, not to do so is stressful. Given this, while those trained as peer educators may not be able to continue high-profile activity, it seems unlikely that they will remain quiet or inactive as HIV continues to overwhelm communities. Nevertheless, in seeking to mount effective responses to the HIV epidemic we need to move beyond the untiring efforts of a relatively small number of core peer educators. Recognising that peer education involvement reflects a desire to respond to the HIV epidemic means that we need to address the frustrations that peer educators regularly face, especially the likelihood that they are not given the time or opportunity to reach others or that they lack the skills to successfully engage their peers. Even when these obstacles are overcome, the closeness of peer educators to other members of the community that they seek to influence can ratchet up their sense of responsibility. When peer educators are successful in providing information and guidance the rewards are high, but when peers struggle to implement advice or to influence behaviour change they may carry onerous burdens in silence. Peer educators should be allowed to feel pride for getting their peers to listen, without insisting that behaviour change must occur before they rightfully feel they have made progress. Such an approach would be facilitated by explicit discussions among peer educators about their role, while taking cognisance of their embeddedness within communities. This latter fact of peer education raises the important issue of locating mechanisms that can allow peer educators to debrief and unburden while still maintaining confidentiality.

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Taking responsibility for the attitudes and behaviour choices of others is but one stress that peer educators face. Like all people, they manage complex lives and responsibilities. Not least of these is to provide for their families. Given this, their voluntary contribution to peer education can place them in awkward positions which challenge their personal commitment to helping others. Some bear up despite these problems, and we gratefully laud them. But this may also set the bar too high. We need to rethink and expand who we want as peer educators. Possibly, we must convert our peer educators into activists — that is, individuals at the centre of a wider, more heterogeneous social movement. Such a movement needs sufficient resourcing in order for its activities to succeed and compete among those whose commitment is less total. We also need to solve how we can enlist more peer educators, how we can raise their level of activity, and how we can maintain peer education activity over decades. The company that we researched is still in the early stages of rolling out a peer educator programme that attempts to achieve all this. We note with approval several features that address points we have raised and that other companies should consider. In particular, we propose regular monthly meeting of groups of peer educators. Outside facilitation of these meetings (while not something that can or should be maintained indefinitely) can be of immense value. Not only are facilitated regular meetings a vehicle for much-needed skills development, they can also provide peer educators with guidance and support, such as how they are not expected to take on everything by themselves and ways they can unburden themselves without compromising confidentiality. The availability of dedicated counsellors at the end of a toll-free phone line is another important way that peer educators can be supported. Easy access to answers that they can provide to peers, whether about content or processes, specific to their location, is also critical to minimise peer educators’ frustrations in the face of the epidemic as well as the inadequacies of the national response. We would add, given the issues we have explored in this paper, that skills-building needs to take into account the vision of building a social movement of peer educators. Those at its centre need to be taught the organisational skills that will maintain activity by peer educators who are operating at different, probably fluctuating, levels of activity. This calls for skills of engagement and encouragement within the ranks of peer educators if activity is to be maintained or increased. And, if people are to listen, it is vital to teach peer educators how to engage with others, not only through a formal session or presentation, but in everyday moments, where perhaps the most can be ultimately accomplished. Notes 1 2

3

For a discussion of this ratio see Dickinson, 2006a. Such as that they both test for HIV together without revealing that he already knows his status. Net support score of +1.7 (3.7–2) for VCT counsellors, versus +1.3 (3.9–2.6) for workplace peer educators.

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4

5

6

7

8

This appeared not to be a problem with company employees who tested positive. Typically, the VCT counsellors would escort an HIV-positive employee to the HIV management programme premises in the same hospital building. We acknowledge the reviewers’ comment that the idea of peer educators as a social movement needs further elaboration. In particular, we accept the point that an emphasis on peer education as a movement may detract from the need for efficient and effective systems. Peer educators frequently point to the glaring shortcomings in their company’s peer-educator systems. Such systems need to be addressed systematically and comprehensively. Nevertheless, conceptualising peer education as a social movement has its merits. Hopefully, in the future, we will be able to further outline and analyse the potential for it. The facilitator made it clear that she directed the group to support each other in these situations, rather than use her for emotional support. It is possible that their level of activity was ‘talked up’ for the researchers’ benefit, but the level of detail they provided about ongoing activity indicated that it was genuine. See Dickinson, 2006c, for a discussion of peer educators’ independence and dedication.

Acknowledgements — We extend thanks to all the participants in this research. The project would not have been possible without the company’s Group HIV and AIDS Manager agreeing to free Kabelo Kgatea to work on the project one day per week. Krish Sigamoney at Wits Business School provided administrative support. Project expenses were funded by David Dickinson’s Wits (Faculty of Commerce Law and Management) research-incentive account. We are grateful to the insightful comments of two referees, as these improved the paper and challenged us to think further about how peer education needs to be taken forward in response to the HIV epidemic. The authors — David Dickinson is an associate professor of HIV/ AIDS in the Workplace at the Wits Business School. He was co-chair of the 2nd Wits HIV/AIDS in the Workplace Research Symposium. His research focuses on the mobilisation of social agencies in response to the HIV epidemic. Kabelo Duncan Kgatea has worked for Anglo Platinum for 29 years, 20 of these doing jobs underground. He became a peer educator in 1999 and was a peer-educator group coordinator for four years. He is currently working as a communications officer. He is a prize-winning author of four books in Setswana for young people and has had numerous plays and poems performed on radio.

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