Health Education Research Vol.20 no.2, © Oxford University Press 2005; All rights reserved
Letting Them Die: Why HIV/AIDS Prevention Programmes Fail
Catherine CampbellJames Currey, Oxford, 2003
214 pp, ISBN 0-85255-868-6
Catherine Campbell's book explores the processes by which a multi-faceted and theoretically informed HIV prevention programme in Summertown, South African appeared not to work. The programme aimed to involve local youth, mineworkers and sex workers in peer education in order that people from these groups could modify their behaviour and enhance their sexual health. It also aimed to bring together representatives of these groups with more powerful stakeholders in order to develop a local community that would support such behaviour change.
The programme was informed by a number of theories drawn from social psychology, sociology and political science. Peer education was theorized as developing ‘bonding’ social capital whereby people with common interests might come together, support each other, and develop critical consciousness about how their circumstances shape their identities and predispose them to behave in ways that may damage their health. Stakeholder meetings were theorized as developing ‘bridging’ social capital so that socially excluded communities could engage with more powerful groups in order that aspects of the social environment that impede individuals' abilities to engage in health-enhancing behaviours are reduced.
The programme encountered much greater problems in developing peer education amongst socially excluded groups than it expected. The evaluation found that groups such as sex workers, assumed to be communities of individuals with common interests, were in fact highly diverse, and contained different and sometimes conflicting interests. Programme implementers also found it difficult to develop effective stakeholder meetings, these being dominated by more powerful groups who were unwilling to compromise their own interests in order to develop a health-enhancing local community.
The publication of the book is timely given the recent upsurge in recognition that evaluations of the effectiveness of HIV prevention interventions must be accompanied by integral evaluations of the processes involved in intervention planning and delivery. Evaluations must go beyond merely reporting whether an intervention is effective or not, to describing the intervention and analysing why. Evaluators should consider how the intervention's feasibility, accessibility and acceptability are promoted or impeded by contextual factors. This will inform decisions either about how to modify an effective intervention when it is implemented elsewhere or how an ineffective intervention might be re-developed and re-piloted.
The book explores these questions in fascinating if depressing detail, drawing out how wider structural factors such as the economic incentives for migrant work and the alienation of sex workers impeded HIV prevention efforts. The analysis of process is greatly facilitated by the use of theory. The concepts of bonding and bridging forms of social capital, as well as ideas about critical consciousness, identity and power provide a framework for describing why processes did not unfold as they were intended to, and for examining the reasons for this relating to the local community and the wider society.
The main shortcoming of the book is that it is based on an exemplary process evaluation, but a less exemplary evaluation of effectiveness. Outcomes relating to sexually transmitted infection rates as well as behavioural and social factors were surveyed at baseline and then annually thereafter in the intervention site. No improvements were noted and some measures indicated increases in risk. However, without being able to compare what happened in the intervention site to a comparison site, it is impossible to rule out the possibility that the intervention was in fact effective and that without it the situation would have been worse still. Because of this, it is possible—if perhaps not probable—that the analysis of processes presented in the book is biased towards negative assessments of the programme.
This limitation aside, the book is a major achievement, setting the standard for rigorous evaluation of planning and delivering HIV prevention. It should be required reading not only for those with an interest in HIV prevention in southern Africa, but for all interested in developing or evaluating social interventions to promote health.
Assistant Director, Social Science Research Unit, Institute of Education, University of London, UK
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