1. Have heard of HIV,
2. Know that AIDS is a serious problem in South Africa
3. Know that AI DS is a serious problem at the mines,
4. Know that you cannot catch AIDS by working alongside someone with AIDS,
5. Believe that one partner for life prevents AIDS,
6. Believe that condoms are not sufficient to prevent AIDS,
7. Believe that sexual faithfulness is important, and to
8. Have not had any sexual partners during the preceding month.

Introduction
Doctors For Life is a South African organisation consisting of almost 400 medical doctors who stand for the sanctity of human life from conception to natural death. In 1995, they were asked by the President Steyn Mine to develop an alternative to the present AIDS programs available. The program they developed,called,"Living Safely:the Family Friendly Alternative to AIDS", sprung from the conviction that in order to preserve life one has to address the issues which threaten life. Doctors For Life believe that it is not AIDS itself (which they consider the fire) that warrants special attention; but rather the breakdown in family values and careless lifestyles (which they consider the fuel for the fire). The Doctors For Life AIDS program is based on family values, especially the value of faithfulness to one's partner rather than relying on condoms or safe sex to prevent AIDS.

Early in 1995, Doctors for Life approached the Department of Family Medicine of Medunsa to evaluate their program. This , paper presents the results of a preliminary study completed in 1997 to test the effect of the Doctors For Life AIDS program on the knowledge, attitudes and sexual practices of mine workers concerning HIV/ AIDS at the President Steyn Mine.

The Freegold Mines, which include the I President Steyn Mine, had instituted an AIDS peer education system during 1993. Peer educators were trained and were provided with a handbook published by the World Health Organisation that provided a wealth of information about HIV/AIDS and a flip chart produced by the AIDS Education and Training CC, Johannesburg. However, by 1995, the health personnel at the mine desired additional input for their AIDS program, specifically one that included with values,and they asked Doctors for Life for help.

The program developed by Doctors for Life was to be conducted at the hostels by the previously trained peer educators and it consisted of posters, a flip chart and a video. The flip chart consisted of 12 pictures that told a story. The peer educators were expected to attract a small audience and then proceed to encourage the audience to describe the story depicted on the flip chart. The pictures showed a man leaving his home to go to work on the mines, contracting HIV virus from a casual sexual contact, infecting his wife, and finally, dying. His wife also dies from AIDS. leaving their children as orphans. The video was called "AIDS Against the Family" and it presented an informative and dramatic lecture about HIV/AIDS by Dr. Albu van Eeden, president of Doctors for Life. The video was to be shown whenever the peer educators chose to do so. The materials were available in English, Southern Sotho, Zulu and Xhosa.

Pilot studies were done first in July 1995. following the launch of the Doctors For Life Program at one of the mine shafts to test the content and process of the proposed interview format. and then again in March 1996 to test the revised interview forms and to learn what the peer educators had done with the materials. The video was being shown daily to those returning from leave and had been very well received, but the flip chart produced by Doctors For Life was not being used because the peer educators felt that their previous flip chart was more comprehensive. In addition, they thought that the flip chart produced by Doctors For Life gave the impression that AIDS was only a problem for migrant labourers suggesting that migrant labourers were more likely to be bad or misbehave than the other workers.This information was fed back to Doctors for Life who decided that they would produce a new flip chart in conjunction with the peer educators. However, the video was so popular that Doctors for Life were asked to launch it at several other mine shafts before they had time to complete a new flip chart. This study then, evaluates the impact of the posters and the video developed by Doctors for Life, but not the flip chart.

Methods
This was a before and after intervention study designed to measure the effect of implementing the Doctors For Life AIDS program at the President Stern Mine during 1997. The pre-implementation interviews were held during the week of April 7 to II. 1997. prior to the implementation of the program and again seven months later during the week of November 3 to 7, 1997. The interviews were conducted in the home languages of the participants, which were predominantly Southern Sotho and Xhosa. Our research team, consisting of an experienced field researcher from our department and 3 trained interviewers conducted semi-structured interviews at the hall and hostels of 5 shafts of the President Steyn Mine. An effort was made to ensure privacy for the interviews.

The sample was a convenience sample organised by the peer educators from the mineworkers available at the hostel between shifts.

The analysis was done using the EPI6 statistics programs. All of the associations shown were tested using the chi-square test.

Approval for the study was given both by the Steyn Mine Management and by the Research, Ethics and Publications Committee of the Medical University of Southern Africa.

Results
The pre-implementation sample consisted of 103 participants and the post-implementation sample of 138 participants for a total of 241 participants from 5 shafts. The demographic characteristics of the participants are shown in Table I (below). The only significant difference between the pre-and post- implementation participants was that the post-implementation participants were significantly more likely to be urban.

As shown in Figure I (below), the post-implementation participants were significantly more likely than the pre-implementation participants to:

1. Have heard of HIV,
2. Know that AIDS is a serious problem in South Africa,
3. Know that AIDS is a serious problem at the mines,
4. Know that you can not catch AIDS by working alongside someone with AIDS,
5. Believe that one partner for life prevents AIDS,
6. Believe that condoms are not sufficient to prevent AIDS,
7. Believe that sexual faithfulness is important. and to
8. Have not had any sexual partners during the preceding month.

These results were controlled for the potential confounding effect of there being a significantly greater percentage of post-implementation participants who were urban than pre-implementation participants. The results held in each instance but revealed the following interesting additional information.As shown in Figure 2 (below), there was a greater increase in the percentage of rural participants who had heard of HIV post-implementation compared to the urban participants and the urban participants were significantly more likely to become aware of the seriousness of AIDS in South Africa and to come to believe in sexual faithfulness.

The Doctors For Life AIDS program was described as very satisfactory by 86% of the participants.

Discussion
The President Steyn Mine was not virgin territory in which to study the impact of the Doctors for Life AIDS program. The media constantly exposes the public, including mine workers, to information about HIV/AIDS. In addition, there had been a previous AIDS program in place. Further, the Doctors For Life AIDS program had been implemented at one of the shafts a year and a half earlier and there may have been some spread of information from that shaft to the 5 shafts that provided the sample for this study. All of these factors would likely have worked to decrease the chance of showing an effect from the Doctors for Life program. In spite of these factors being present, some very encouraging and important results with respect to knowledge, attitudes and reported sexual practices were found.

Of interest is that a much higher percentage of participants, both pre- and post-implementation, thought that AIDS was a serious problem in South Africa than thought it was a serious problem at the mines, in spite of the AIDS programs run at the mine. Clearly the public media is having an impact.

A result of particular interest concerns the use of condoms. Many, if not most, AIDS programs push condoms as the major part of the answer to AIDS and it has usually been interpreted as a positive result if condom usage increases as the result of an AIDS program. For example; a survey done to assess the effectiveness of the peer education system in place in the Freegold Hostels from 1993 to 19952 found that mine workers who had been exposed to the peer educator training, were more than likely than those who had not, to choose condoms over one life long partner or abstinence as the most effective way of protecting oneself against HIV infection. In contrast. the present study showed that those who had experienced the Doctors For Life AIDS program were significantly less likely to put their faith in condoms.

Table I: Demographic Characteristics of the Participants Mine workers at the President Steyn Mine, 1997
	Total Sample N=241%	Before Sample N=IO3%	After Sample N=138%	p
Age
20-29 30-39 40-49 50+ TOTAL	7 55 29 9 100	5 55 27 13 100	9 55 30 6 100	0.19
Marital status
Single Married Divorced /Widowed TOTAL	5 93 2 100	3 93 4 100	6 94 0 100	0.03
Number of living children
None One Two Three Four Five + TOTAL	10 25 19 19 22 5 100	4 10 25 18 21 21 99	6 11 26 19 17 22 101	0.95
Distance of home from mine
< 1/2 day > 1/2 day TOTAL	35 65 100	30 70 100	39 61 100	0.19
Home
Rural Urban TOTAL	70 30 100	82 18 100	61 39 100	0.0007
Wife visits the mine
Yes	51	54	50	0.64
Home language
Xhosa S Sotho Other TOTAL	39 47 14 100	40 44 15 99	38 49 13 100	0.74
Level of education
None <Primary Primary <High School High School Further Ed TOTAL	8 39 17 20 12 4 100	10 45 18 16 10 0 99	6 35 16 22 13 7 99	0.056

The 1993 survey referred to above did not find a significant difference with respect to general knowledge about HIV/AIDS. nor did they find significant changes in attitudes. They did find that those who had been exposed to the previous peer education program were slightly more likely to answer questions about modes of transmission correctly. The present study found a number of significant differences not only with respect to knowledge and attitudes, but also with respect to reported sexual behaviour.The peer educators were the same; it would seem that the content of the program makes a difference.

Figure 1: The Effectiveness of the Living Safely AIDS Program. Implemented by Doctors for Life at the President Steyn Mine, 1997			P
Heard of HIV		75%	0.024
		87%
AIDS is serious in South Africa		73%	0.022
		86%
AIDS is serious at the mines		51%	0.005
		65%
Can't catch AIDS by  working alongside		64%	0.003
		83%
One partner for life prevents AIDS		54%	0.02
		70%
Condoms not suf- ficient to prevent AIDS		3%	0.005
		16%
Sexual Faithfulness is important		83%	0.04
		90%
No sexual partners during past month		42%	0.04
		56%
Before  After

An example of another program that has shown positive results is the AIDS education package developed as part of the National AIDS Program by the Medical Research Council of South Africa. It consists of a video, a photo-novella and a series of lecture/discussion sessions. A randomised controlled trial of its use in a rural high school in South Africa showed a dramatic increase in awareness of AIDS as a problem in the community, in the knowledge that AIDS is preventable and incurable, and most importantly, a significant decrease in reported high risk behaviour including a decrease in reported sexual intercourse with more than partner and a decrease in casual sex.

Figure 2: Selected Outcomes according to Urban/Rural Habitat Doctors For Life AIDS Program at the President Steyn Mine, 1997				P
Heard of HIV	Urban		94%	0.73
			96%
	Rural		71%	0.17
			81%
AIDS is serious in S.A.	Urban		50%	0.002
			87%
	Rural		79%	0.50
			84%
Sexual faithfulness is important	Urban		56%	0.003
			89%
	Rural		89%	0.22
			93%
Before  After

Two of the results obtained by controlling for the habitat of the participants were predictable; the third was a surprise. Understandably a higher percentage of the urban participants had already heard of HIV, prior to the program. but what surprised us was that the rural participants were more aware that AIDS is a serious problem in South Africa. Quite strikingly. and encouragingly, the urban participants were significantly more likely to come to believe in sexual faithfulness after the program; the rural participants already did.

Conclusion
This preliminary evaluation found that "Living Safely: The Family Friendly Alternative to AIDS" program not only significantly increased mine workers' awareness of and knowledge and understanding about HIV/AIDS, but also changed values and self-reported sexual behaviour in a way that would prevent HIV infection. These are encouraging and important results. Hopefully follow-up studies will confirm these findings and also demonstrate a decrease in AIDS at the mine.

Further information about the program and materials can be obtained from Doctors for Life (PO Box 61897. Bishopsgate 4008. Telephone and fax: (03 I) 306- 0972).

References

1. World Health Organisation. AIDS Home Care Handbook, Global program on AIDS, 1993.


2. Erasmus S, van der Linda J, Maritz C. Freegold Health Service: Interim Report on AIDS/HIV Program. Psycho-Social Services, June 1995.


3. Ogunbanjo GA, Henbest RJ. Can AIDS education change sexual behaviour? A randomised controlled trial of an AIDS education package, developed by the Medical Research Counsel, on high school students in KwaNdebele, South Africa. S Afr Pract 1998;19:71 1-4

Henbest, RJ
BSc, MD, CCFP, MCISc
Malete, NHM RN, RM, RCH
Department of Family Medicine Medical University of Southern Africa (Medunsa)

Address for Correspondence:
Dr. RJ Henbest, c/o RW Large Memorial Hospital
Waglisla, BC, Canada VOT I ZO Tel: 250-957-2332 Fax: 250-957-2360
E-Mail: henbest@capescott.net

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