Article Original guiding principles for project implementation

Article Original guiding principles for project implementation
Article Original
Establishing support groups for HIV-infected women: Using experiences to develop
guiding principles for project implementation
Maretha J Visser, Jonathan P Mundell
HIV-infected women need support to deal with their diagnosis as well as with the stigma attached to HIV. As part of their practical
training, Master’s-level psychology students negotiated with the staff of four clinics in townships in Tshwane, South Africa, to
establish support groups for HIV+ women and offered to assist them in facilitating the groups. This study aimed to understand
why the implementation of groups was successful in one clinic and not other clinics. The student reports on their experiences and
interaction with clinic staff and clients were used as sources of data. Using qualitative data analysis, different dynamics and factors
that could affect project implementation were identified in each clinic. The socio-ecological and systems theories were used to
understand implementation processes and obstacles in implementation. The metaphor of building a bridge over a gorge was used to
describe the different phases in and obstacles to the implementation of the intervention. Valuable lessons were learnt, resulting in the
development of guiding principles for the implementation of support groups in community settings.
Keywords: Support groups, HIV+ women, project implementation strategies, change in systems, socio-ecological theory.
Les femmes séropositives ont besoin du soutien afin de faire face à leur diagnostique ainsi qu’avec la stigmatisation liée au VIH.
Faisant partie du programme pratique de formation, les étudiants de maîtrise en psychologie ont négocié avec le personnel de quatre
cliniques des townships (quartiers pour les Noirs) à Tshwane en Afrique du Sud. Le but fut d’établir des groupes de soutien pour des
femmes séropositives. Ces étudiants ont également offert leur aide en animant les groupes. Le but de cette étude est de comprendre
pourquoi l’exécution de groupes fut un succès dans une seule clinique et pas dans les autres. Les rapports des étudiants sur leurs
expériences et leurs interactions avec le personnel et les malades ont été utilisés comme sources de données. En utilisant l’analyse
qualitative des données, les dynamiques et les facteurs différents qui pourraient affecter l’exécution du projet furent identifiés dans
chacune des cliniques. Les théories de systèmes socio-écologiques ont été utilisées afin de comprendre le processus de l’exécution
ainsi que les obstacles à celle-ci. On a fait référence à la métaphore de bâtir un pont au dessus d’une gorge pour décrire les différentes
phases du processus d’exécution et les obstacles face à l’exécution de l’intervention. On a appris des leçons importantes qui ont, par la
suite, favorisé l’aménagement des principes directeurs des groupes de soutien dans un milieu communautaire.
Mots clés : Groupes de soutien, femmes séropositives, stratégies de l’exécution d’un projet, changement de systèmes, théorie
Maretha Visser is a counselling psychologist and associate professor in the Department of Psychology, University of Pretoria. She has a PhD in the field
of community psychology. She specialises in implementing interventions in community settings and has a longstanding interest in the prevention and
assistance for people living with HIV/AIDS.
Jonathan Mundell is a research fellow on the Serithi project at Kalafong Hospital. He completed his MA (Psychology) evaluating the impact of support
groups for HIV+ women at the University of Pretoria.
Correspondence to: [email protected]
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Original Article
It is estimated that between 5.7 and 6.2 million South Africans
are infected with HIV (Department of Health, 2006) – 12.8%
of women and 9.5% of men between the ages of 2 and 49 years
(Shisana & Simbayi, 2002). Due to stigmatising attitudes in the
community (Visser, De Villiers, Makin et al., 2005), people are
reluctant to test for HIV and those who test positive are scared
to disclose their status. This obviously has a negative effect
on care-seeking behaviour (Bond, Chase & Aggleton, 2002;
Gebrekristos, Abdool Karim & Lurie, 2003; Skinner & Mfecane,
Being diagnosed HIV positive constitutes a serious life crisis that
requires considerable coping resources. When receiving an HIV
diagnosis, a person has to deal not only with a life-threatening
disease and issues such as death and HIV-related symptoms,
but also with a change in life expectancy, change in body
image, decisions about disclosure, mistrust in relationships,
stigma and possible social isolation and rejection (Hudson, Lee,
Miramontes & Portillo, 2001; Skinner & Mfecane, 2004). The
emotional experiences of women with HIV are largely affected
by the stigma related to HIV/AIDS and the social support they
receive from significant others (Kalichman, DiMarco, Austin,
Luke & DiFonzo, 2003; Serovich, Kimberley, Mosack & Lewis,
2001; Silver, Bauman, Camacho & Hudis, 2003; Turner-Cobb,
Gore-Felton, Marouf et al., 2002). Various studies indicate
that people with HIV experience lower levels of social support
after the diagnosis than before, and less support than people
with other chronic diseases and those non-infected (Klein,
Armistead, Devine et al., 2000; Turner-Cobb et al., 2002). In
a study in Tshwane (South Africa) where 150 HIV-positive
women were interviewed, it was confirmed that women needed
support to deal with their diagnosis, to disclose their status to
significant others, and to deal with the stigma they perceive in
their communities (Visser & Makin, 2004).
The need for support and the lack of professional services
have led to the idea of establishing support groups as a form
environment is created where each person receives and provides
support to deal with his/her specific situation. The emphasis
is on sharing personal experiences of the problem and taking
responsibility to help one another (Riessman, 1990).
Support groups in the HIV/AIDS context can be a valuable
tool to help individuals adjust to the consequences of living
with HIV in the absence of support from family and friends
(Brashers, Haas, Klingle & Neidig, 2000). Groups can provide
HIV-infected individuals with a non-stigmatising atmosphere
in which to gain information, share experiences and learn from
others. They can also offer sympathetic understanding and
establish social networks that can challenge loneliness, give a
sense of belonging, and supply mutual aid. Groups can help
individuals to renew their hope and confidence in the face of
devastating losses (Adamsen, 2002; Drower, 2005; Lyttleton,
2004; Summers, Robinson, Capps et al., 2000). Drower (2005)
advocates the empowerment of women in groups to disclose
their status and negotiate their relationships with their partners,
as this can contribute to social re-integration and a sense of
taking control over their lives.
Support groups for people living with HIV/AIDS can be
heterogeneous in both structure and format. Groups can have
a limited number of sessions or go on for an indefinite period
(Foster, Stevens & Hall, 1994), they can be open or closed to new
members (Coleman & Harris, 1989), and they can be facilitated
by professionals or by peers (Ribble, 1989). The success of a
support group often depends on the extent that the fears and
expectations of group members are taken into account and
the degree of adherence to group rules agreed upon to protect
members (Bor & Tilling, 1991). Confidentiality in HIV support
groups is extremely important to ensure that the members feel
free to express their feelings and experiences.
Research results show that HIV+ women who attended support
groups were less depressed (El-Sadr, 2001), as well as more
likely to disclose their HIV status and gain access to treatment
of intervention (Beckett & Rutan, 1990; Spirig, 1998). In
this community a few informally organised support groups
developed spontaneously, but there is no network of support
(Kalichman, Sikkema & Somlai, 1996). A high correlation was
found between the experience of social support and the slower
progression of HIV (Moskowitz, 2003; Summers et al., 2000).
groups to which newly diagnosed HIV-positive women can
An HIV support group is therefore a place where individuals
who spend much of their time preparing for death can work
be referred. This project intended to address this need by
establishing more and accessible support groups as part of
the public health infrastructure. Support groups are groups of
people with some pressing common concern coming together
on a regular basis, often face-to-face, to contribute personal
experiences and engage in the development of a cohesive,
supportive system (Schopler & Galinsky, 1993). Support groups
involve relationships on an equal level. A mutual supportive
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Journal of Social Aspects of HIV/AIDS
together in trying to learn how to live again (Beckett & Rutan,
Because of HIV+ women’s need for support, students at the
University of Pretoria attempted to establish support groups
for HIV+ women at primary health clinics in Tshwane as part
of their practical training. However, most of these attempts of
the students failed. In this paper, the students’ reports on their
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attempts to establish groups, presented in the form of four case
studies, are analysed in terms of existing theories to understand
to these theories. From these discussions guiding principles for
project implementation were developed that could be used in
why some of their efforts were successful and others failed.
This learning experience resulted in valuable lessons learned
future endeavours.
regarding project implementation that could pave the way for
implementing support groups in community settings in the
Eight Master’s-level psychology students (two black and six
white) explored ways of establishing and facilitating support
groups for HIV+ women at clinics in Tshwane as an assignment
for their practical training. Negotiations were conducted with
local government health services authorities to obtain the
necessary permission and support for the project. Four clinics
that provide voluntary counselling and testing (VCT) services
in townships in Tshwane agreed to participate in the project.
These clinics provide medical services to a mainly black urban
population in the very low to middle socio-economic class.
Nurses in the clinics perform HIV testing, while volunteer HIV
counsellors offer pre- and post-test counselling. Two students
were assigned to each clinic for weekly sessions over a period of 6
months, with the aim of establishing and assisting in facilitating
support groups. The students negotiated the development
of groups with the clinic staff and HIV counsellors, who had
themselves observed the need for support, but did not have the
resources to start support groups. The HIV counsellors agreed to
participate in establishing support groups by referring recently
diagnosed HIV+ women, who consented to participate on a
voluntarily basis, to the groups and to co-facilitate the groups.
The goal of the groups was to assist HIV+ women to deal with
the psychological consequences of their diagnosis. Group
participation was to be voluntary with no cost involved for the
participants, except for their own travel costs to the clinic. The
two students working at each clinic kept a weekly diary of their
experiences, interactions with clinic staff and clients, as well as
progress made in the implementation of support groups.
This is therefore a descriptive study using qualitative research
methods to analyse the implementation strategies used
to establish support groups in clinics. The students were
the primary participants in this study and their reports of
experiences, interaction with clinic staff and clients, and progress
of implementation were the main sources of data used in the
analysis. As in all qualitative studies (Miles & Huberman, 1994)
the data obtained are of a subjective nature, being experiences
and perceptions of the process of implementation. The analysis
of the data is also a subjective process of making sense of the
observed data in relation to their understanding of existing
theories. The validity of the analysis was enhanced through
discussions of the interpretations.
The experiential learning of students reported on in this paper
was part of a larger project that was ethically approved by the
University of Pretoria Faculty of Humanities’ Ethics Committee.
Students gave consent that their reports and discussions be used
in this format.
The process of establishing support groups in
four clinics
Initially, the formation of support groups seemed a simple
answer to the needs of HIV+ women in underserved
communities. However, the experience gained in attempting to
establish groups has shown that this involves much more than
mere good intentions. The four case studies that follow represent
the students’ account of their attempts to establish support
groups. Each case study represents the experiences of the two
students assigned to a specific clinic. The interventions took
place independently, yet simultaneously. In each clinic different
obstacles were encountered, resulting in the termination of
efforts in two clinics and various degrees of success at the other
After being involved in the clinics for 3 months the students
met with their supervisor to report back on their practical
Clinic 1
work. The students discussed, interpreted and compared their
experiences. Using a qualitative data analysis paradigm (Miles
& Huberman, 1994), the students analysed their diaries in terms
In the first meeting between the students and the HIV counsellors
and nurses at the clinic, the students tried to establish a climate
of collaboration. The counsellors admitted the need for support
of the process of implementation, strategies that were successful,
and obstacles they experienced. Their accounts of their attempts
to establish groups are presented in the form of four case studies
groups. They undertook to inform newly diagnosed HIV+
women about the establishment of a support group and to
hand out pamphlets on the value of support groups and the
below. The socio-ecological and systems theory seemed to be
planned dates for meetings. The first meeting was scheduled 3
weeks in advance. No participants attended this first meeting.
appropriate to understand the processes taking place in the
clinics. Students then interpreted their experiences according
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The students then realised that the HIV counsellors had not
been handing out the pamphlets. When this was discussed
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with them, the counsellors contended that they felt that HIV+
women would not be interested in joining support groups. By
women referred to the support group, had joined that group
instead. The students then wondered if they should perhaps
attending such a group, an HIV+ woman would have to admit
her status to others and perhaps feel stigmatised if other people
assist that group in establishing itself, but the clinic staff insisted
that it would benefit the clinic to have its own support group.
They again undertook to refer women to the clinic group. After
knew she was HIV+. The counsellors also argued that the clinic,
which is part of a provincial hospital, was far from the township
where the women lived. Transport and lack of money would
therefore be further obstacles to the women’s attendance of a
support group. The students took note of their reservations, but
strongly re-emphasised the benefits of support groups. Thus the
counsellors agreed once more to refer the women diagnosed at
their clinic to start a group.
After another 3 weeks of no response, the students were
convinced of the unwillingness of the HIV counsellors to assist
them. They consulted with the social worker at the hospital,
who informed them that the clinic staff would actually act
unethically if they were to refer the HIV+ women to the groups,
because this would mean that they were indirectly disclosing
the patients’ status. The working relationship between the clinic
staff and the students was clearly not established well enough
to foster trust and collaboration. The students were seen as
outsiders and not as part of the professional team at the clinic.
This resulted in the students withdrawing from the clinic.
Clinic 2
At this clinic, negotiations with HIV counsellors resulted in the
latter being eager to assist in establishing a support group, since
they were well aware of the women’s need for more support. The
counsellors recommended that support groups be conducted
in the nearby community centre, since the venue was available
during the day and there were no vacant rooms in the clinic.
At each weekly visit of the students, the counsellors reported
how many women they had referred to the support group.
However, for 4 weeks the students waited in an empty room
for the women to attend the group. The students then started
questioning the appropriateness of the venue, since it was
in a public place where many people gathered. In this highly
stigmatising community, they guessed that the women were
afraid to come to the meetings for fear of being identified by
others. The clinic staff subsequently suggested that a room in
the clinic, which was a less public venue, be used for the group.
Again, however, the room stayed empty at the times scheduled
for the support group.
another 6 weeks of no response the students eventually decided
to terminate their efforts.
Clinic 3
At this clinic the nurses and HIV counsellors were eager to
support the students in establishing a support group. They
provided a private venue and referred women diagnosed with
HIV. After 3 weeks there were 8 women in the group, 4 of whom
were committed members who attended regularly. In assessing
the needs of the HIV+ women, the students identified the most
important to be information on HIV and healthy living, as well
as support to cope with their diagnosis. In the first few sessions
information about HIV was discussed. After 6 sessions the
students started enquiring why the group was not growing and
why all the women did not attend the sessions regularly. The
women all came from a very poor socio-economic background
and had no sources of income. Although not identified in the
needs assessment, the students realised that the women’s main
concern was their need for financial resources to support their
health, to afford medication and provide a future for their
children. In trying to address the women’s lack of basic resources
for survival, a vegetable garden was started at the clinic with
the permission of the clinic staff. The aim of the garden was
to provide nutritious food and possibly a small income. On a
therapeutic level the garden could also function as a metaphor for
healing and growing together. The group worked in the garden
for 3 weeks and shared fears, loneliness and disappointments
in an informal way. However, membership started to dwindle,
despite the fact that the garden was the group’s own idea and
they enjoyed participating in the endeavour. Not understanding
what was happening, the students called a meeting with the
clinic staff. It was established that one of the counsellors had
referred some of the women to a nearby community-based
organisation for financial support. The students realised that
the immediate needs of the women were not talking about their
fears, hopes and dreams, but to find a place to stay, to be able
to feed their children and to pay school fees. The garden could
provide means, but it would take too long for desperate people
to benefit.
After many discussions with the clinic staff and other
community members, the students learnt that a number of
Clinic 4
HIV-infected individuals had taken the initiative of starting a
support group close by and that some of the recently diagnosed
In the fourth clinic the counsellors referred HIV+ women to
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Journal of Social Aspects of HIV/AIDS
the support group. At first only a few women attended, but they
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were scared of sharing their HIV status, and needed assurance
that the discussions would be confidential and in a private
interrelated and keep a system in balance. Interventions are
challenges to alter the current context, which generally resists
venue. They mistrusted one another until they agreed on ground
rules in the group, inter alia to commit to the confidentiality
change. The way in which an intervention is introduced into
a particular context will play a crucial role in its acceptance
and implementation. The change agent therefore needs to
of discussions. After 4 weeks there were 12 women who
regularly attended the group sessions. For the next 12 weeks the
students facilitated weekly group discussions on themes such
as emotional reactions after the diagnosis, a healthy lifestyle,
nutritious food, stress management and disclosure of status.
The group afterwards continued to meet at the clinic and the
HIV counsellors facilitated sessions. This proceeded for at least
another 3 months of which we are aware. They also started an
exercise group separate from the support group to stay healthy.
Three group members who had to travel far to attend the
sessions (some travelled 40 km) eventually dropped out of the
group because of the high transport costs, but they started a new
group closer to their homes.
The students reported that the group interaction assisted HIVinfected women to build positive relationships, to share their
experiences and to build confidence. This empowered them to
feel stronger in their interaction with others, despite existing
stigmatising attitudes in their community.
At clinic 4 a number of factors contributed to the successful
establishment of the group. The HIV counsellors and nurses
had good relationships with the HIV+ women whom they
referred to the group. The counsellors attended every session,
co-facilitated discussions and provided the group members with
information and support. The presence of the HIV counsellors as
co-facilitators allowed for the group to converse in their mother
tongue, as most of the members were Tswana- and Sothospeaking while the students spoke English. The counsellors
translated highlights of the discussions, allowing the students
to facilitate but not to take control of the group process. The
advantage was that the responsibility for running the group was
shared by all its members. Group sessions were conducted in an
unstructured and informal way. Group members could suggest
topics for and participated in open discussion. This allowed
understand the dynamics of the context (such as relationships,
climate and ability to influence the current structure) to be able
to establish a fit between the context and the intervention, and to
mobilise people in the context to bring about change (Edwards,
Jumper-Thurman, Plested, Oetting & Swanson, 2000; Goodman
et al., 1998). Sarason (1996, p.11) wrote in this regard: ‘The more
sensitive you become to this complicated embeddedness, the more
you realise how many different systems have to change if the change
you seek … can be successfully introduced and maintained.’
Systems theory provides us with concepts to understand
change. Change can take place when the balance in a system
is disrupted, which activates self-regulatory mechanisms to
restore balance or to reach another balance (Capra, 1997). The
balance in a system can be disrupted by changing components
of the system, changing feedback patterns, or creating awareness
that the current situation is different from the ideal. Imbalance
in a social system may mobilise people to activate change by
extending the system’s capacity or by restructuring the resources
within the system (Ford & Lerner, 1992; Levine, Van Sell &
Rubin, 1992). Because of unique internal processes, each system
reacts in a unique way to interventions; therefore the impact
of an intervention cannot be predicted beforehand (Hanson,
1995). Another key concept in systems theory is that change can
only take place from within a system (Capra, 1997). External
change agents therefore need to mobilise people who are inside
the system to activate change (Scheirer, 1990).
In terms of the theoretical framework, the goal of the
intervention was to link students, as external change agents, to
township clinics to create an awareness of HIV+ women’s need
for support and to provide the skills and capacity required for
establishing and facilitating support groups in the clinics. The
strategy was to mobilise HIV counsellors and nurses in the
members to interact with each other in an almost natural social
milieu. It encouraged the development of personal relationships
between members and fostered the sustainability of the group.
clinics (as gate keepers and possible internal change agents)
Discussion of implementation processes
from a theoretical perspective
in dealing with HIV+ women. Although the same strategy
was followed in all four clinics, the students reported different
dynamics and factors that could affect the implementation of
In the discussion of students’ experiences in implementing the
intervention, the socio-ecological theory (Goodman, Speers,
Mc Leroy et al., 1998; Goodman, 2000; Sarason, 1996) and the
systems theory (Capra, 1997; Hanson, 1995) were especially
relevant. According to these theories, all parts of a system are
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to refer and motivate recently diagnosed HIV+ women to join
the support groups for psychological assistance. This could
mobilise resources from within the clinic to support change
the intervention.
In clinic 1 the students (as external change agents) did not
succeed in joining with the clinic team and establishing a
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relationship that would enable them to initiate change. They
could not mobilise the clinic staff (as gate keepers and internal
In clinic 4, the enthusiasm and commitment of the HIV
counsellors (internal change agents) clearly mobilised change
change agents) to motivate women to attend the groups. This may
be attributed to the fact that the students did not understand the
from within the system (Capra, 1997). The relationship between
the counsellors and the HIV+ women was used as a link into
dynamics of the context in the clinic (such as the relationships
and the procedures) and therefore could not establish a fit
between the context and the planned intervention (Edwards et
the support group. In the group, women took the lead to
initiate discussion themes and to support each other. The group
leaders also initiated new ways of relating to one another, such
al., 2000; Goodman et al., 1998). Another problem could have
been that the HIV counsellors (as internal change agents) who
as forming an exercise group to stay healthy. The role of the
students (as external change agents) was to mobilise the HIV
were supposed to recruit the women did not hold influential
positions in the clinics that allowed them to change the existing
patterns of dealing with HIV+ women. The concept of support
counsellors to recruit women, and to lay the foundation for
group interaction and confidentiality. Their acceptance of the
groups had also not been introduced to the counsellors in such a
way that they were convinced of its value. It was their perception
that HIV-infected women would not like to be identified or to
meet with other HIV+ women, which may be indicative of their
own perception of HIV rather than of the infected women’s
needs. The relationships within the clinic and with the students
(as external change agents) did not promote mobilisation of the
counsellors towards the establishment of support groups.
In clinic 2 the students succeeded in involving clinic staff in the
effort to establish groups. As outsiders, the students were not
familiar with the infrastructure and resources in this community
and relied on the clinic staff for referrals and advice. As they
gained more knowledge about the community, they questioned
the appropriateness of the venue and learnt about the existence
of another group. It was easier for women to join a support group
of familiar people within their community, where perhaps there
were existing relationships of trust, than to join a group led by
outsiders with whom they had no relationship. However, the
positive impact that the students had in this clinic was to raise
awareness of the possibility of joining a group to access support.
This assisted HIV+ women in general, but did not contribute
to the goal of the project to establish a support group in this
Experiences in clinic 3 showed that although students succeeded
in establishing a group of women who met regularly, the group
interaction was not sustainable because the primary needs of
the women were not addressed. Their needs were on a concrete
and survival level, confirming Maslow’s (1970) theory that basic
needs should be satisfied in order for higher needs to be fulfilled.
Therefore, when given the option, the women chose to turn to
women could have contributed to the accepting climate in the
group. Although the students as facilitators brought information
about HIV, nutrition and coping styles, the group members took
the responsibility for the functioning of the group. Being part of
the support group as co-facilitators gave the HIV counsellors
the opportunity to develop facilitation skills that enabled them
to continue running the groups after the student facilitators
were not available any more. In this group, change was initiated
in such a way that new behaviour patterns developed, which
contributed to sustainability of the group.
Developing guiding principles
In the discussion of the case studies the students suggested that
the process of implementing support groups could be compared
with building a bridge over a gorge. A bridge is defined as a
structure spanning and providing passage over the gorge. The
process of building a bridge can be complicated and multifaceted,
as it involves planning, collaboration among project team
members, organising building material and resources, securing
a foundation, constructing the bridge from both sides to meet
somewhere towards the middle, and finally crossing over the
bridge. All of these processes require cooperation among various
stakeholders. In the case studies referred to, the bridge needed
to connect students who were not HIV-infected and women
who were infected to travel together towards better wellbeing.
Other differences that had to be overcome in connecting the
two groups were differences in socio-economic status, level
of education, cultural background and language, as well as
different perceptions of HIV-related stigma.
In each clinic a different stage of building this metaphorical
bridge was accomplished and different obstacles were
an organisation where they could get food for their families, and
in so doing, address their immediate needs. The support group
encountered. In the first clinic discussed, the builders could
not round up a committed construction team that could work
together towards a common goal. The students remained
sessions that the women attended could have given them the
support and courage to attempt to address their most pressing
outsiders and did not succeed in mobilising the HIV counsellors
to address the need for support. Other issues such as the HIV
counsellors’ own perception of stigmatising attitudes (internal
processes) inhibited them from taking action. The balance in
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the system was therefore not disrupted and the procedures in
the system remained as they were.
In the second clinic attempts were made at laying a foundation
for the bridge by recruiting women for the groups, although
it was found that the bridge was planned on the wrong
construction site – HIV+ women started to build their own
bridge on another more appropriate site. In this case resources
were available, but research to identify an appropriate
construction site was limited. Without knowledge of the
community structures and relationships it was not possible to fit
an intervention into existing structures. This was the only clinic
where the background of the students could have played a role
in the unsuccessful implementation, since the women obviously
wanted to join a group, but rather joined a group led by people
from within their own community.
In the third clinic the construction of the bridge was initiated as
a connection between the two sides of the gorge. Yet, after initial
connection, the bridge broke down because building blocks
were slowly falling away – this bridge did not connect women
with resources to meet their most pressing needs. Change was
therefore not sustainable.
In the last clinic the metaphorical building site was prepared
through good relationships between the students, HIV
counsellors and HIV-infected women attending the clinic.
The counsellors from within the clinic anchored the bridge,
rendering support and information, and cultivating a positive
relationship with the HIV+ women whom they had referred
to the group. Together the bridge could be secured from both
sides of the divide, enabling the construction of a crossing.
• Thorough knowledge of the construction site is essential
to decide on an appropriate site for laying the foundation
– understanding the functioning and interaction within
the context is needed for the intervention to fit into existing
patterns (Goodman et al., 1998; Goodman, 2000).
• Building of the bridge needs to take place from both sides of
the gorge – change needs to take place from within the system
and cannot be brought about by outsiders (Capra, 1997).
• If building blocks are not secured and they start falling
apart, reconstruction of parts may be necessary to secure the
bridge – feedback processes in a system should be used to
understand what change actually took place and to overcome
barriers by initiating new strategies to accomplish the goal
(Capra, 1997; Levine et al., 1992).
• To be a functional bridge, the bridge should assist travellers
to get to their destination – the needs of the participants must
be addressed to ensure the value and sustainability of change
(Akerlund, 2000; Pentz, 2000).
• The bridge needs to be strong to assure a sustainable
crossing – responsibility needs to be shared by all members
and structural changes are needed in the setting to ensure
sustainability (Akerlund, 2000; Ford & Lerner, 1992).
Stigmatising attitudes played a dominant role in the establishment of HIV support groups. Such attitudes in the community
were the underlying reason for the need for support groups, since
women did not get support from family and friends. Stigmatising
attitudes also posed obstacles to HIV+ women’s decision to join
the groups, because these women actually disclosed their status
The strength of this bridge eventually lay in the sharing of
by joining the groups. Once group rules of confidentiality were
experiences between group members. The gorge was spanned
successfully, as the whole team worked together to construct a
established and women could build trusting relationships, they
gained confidence to face stigmatising attitudes outside of the
strong bridge. Cultural and educational differences between the
support group.
team members did not play a role, since they were overcome
through collaboration and sharing of a vision and responsibility
in the group.
In bridging the gap between non-infected students and HIV+
women, it seemed that differences in background regarding
socio-economic status, level of education, cultural background
Experiences of failure to implement the interventions
highlighted a few valuable principles in project implementation.
and language did not play a decisive role. The two groups
that were established successfully were facilitated by students
To mobilise change in an existing context, the metaphor of the
who came from different racial groups than the participants.
Differences in personal characteristics can therefore be overcome
bridge can be used again:
• A construction team is necessary to work towards a common
goal – joining needs to take place between stakeholders, and
a shared vision is needed to mobilise resources (Levine et al.,
1992; Scheirer, 1990).
VOL. 5 NO. 2 JUILLET 2008
pg. 65-73.indd 71
if appropriate implementation strategies are followed.
Another valuable lesson learnt was that women with HIV do
experience obstacles because of their diagnosis, especially on an
emotional and social level, but that their lives are not reduced to
Journal des Aspects Sociaux du VIH/SIDA
6/23/08 11:06:49 AM
Original Article
dealing with HIV. Women in HIV support groups have a wide
spectrum of needs that need to be taken into account in planning
and HIV counsellors at the different clinics, as well as the HIV+
women who participated in the groups.
interventions. When women overcome the emotional and social
barriers, they can be empowered to live constructively and
contribute to the wellbeing of their families and communities.
In this study, students’ reports on their experiences and
interpretations of processes in primary health clinics that can
affect attempts to establish support groups for HIV+ women,
were analysed in terms of the ecological and system theory to
derive principles to be considered in project implementation.
It needs to be kept in mind that the subjective experiences
and interpretations of 8 students doing practical work were
used in the qualitative analysis. The perceptions of the other
roleplayers such as the health care staff, counsellors and clients
were not incorporated in this analysis. This is therefore one
of many other possible interpretations of processes that could
have played a role in the implementation of change in these
clinics. The perspective of the students as both insider and
outsider could also have played a role in their perceptions of
the implementation process. Interesting though, is how well
the experiences of the implementation process fitted into the
theoretical framework that was used.
Although the establishment of support groups seemed to be the
obvious intervention to provide psychological support for HIV+
women, students found that it involved much more than simply
good intentions to establish sustainable groups in the clinics of
Tshwane. The establishment of groups involved relationships
with stakeholders, a shared vision, the mobilisation of resources
and a grounded knowledge of relationships, culture and
procedures in clinics, as well as community processes, to be able
to fit an intervention into the current functioning of a clinic. A
relationship of trust is needed to mobilise HIV+ women to take
the step of joining a support group that will help them to deal
with issues that result from an HIV+ diagnosis. The value and
sustainability of groups are related, inter alia, to relationships
within the group, the needs that are addressed and ownership of
the group. Because of the complexity involved, the establishment
of support groups in community settings can only be successful
if clear theoretical guidelines are adhered to.
We acknowledge the contribution of Thembi Barnabas, Karen
Bradford, Elizabeth Faria, Angelique Grigoratos, Ingrid Jonker,
Tanya Meyburgh, David Thompson and Xandie van Dyk
(Master’s students in Counselling Psychology at UP), the staff
pg. 65-73.indd 72
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