Theatre-Based Peer Education for Youth: A Powerful Medium for HIV Prevention, Sexuality Education and Social Change by Josephine Margaret MacIntosh B.A., University of Victoria, 1997 A Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY in the Faculty of Graduate Studies (Social Sciences) Interdisciplinary Studies © Josephine MacIntosh, 2006 University of Victoria All rights reserved. This thesis may not be reproduced in whole or in part, by photocopy or other means, without the permission of the author. ii Supervisory Page Theatre-Based Peer Education for Youth: A Powerful Medium for HIV Prevention, Sexuality Education and Social Change by Josephine Margaret MacIntosh B.A., University of Victoria, 1997 Supervisory Committee Dr. Aaron H. Devor (Department of Sociology) _______________________________________________________________________ Supervisor Dr. Bonnie Leadbeater (Department of Psychology) _______________________________________________________________________ Member Dr. Bram Goldwater (Department of Psychology) _______________________________________________________________________ Member Dr. Peter Stephenson (Department of Anthropology) _______________________________________________________________________ Member Dr. Cydelle Berlin (St. Luke's-Roosevelt Hospital Center, NY) _______________________________________________________________________ External Examiner iii Supervisory Committee Dr. Aaron H. Devor (Department of Sociology) _______________________________________________________________________ Supervisor Dr. Bonnie Leadbeater (Department of Psychology) _______________________________________________________________________ Member Dr. Bram Goldwater (Department of Psychology) _______________________________________________________________________ Member Dr. Peter Stephenson (Department of Anthropology) _______________________________________________________________________ Member Dr. Cydelle Berlin (St. Luke's-Roosevelt Hospital Center, NY) _______________________________________________________________________ External Examiner Abstract HIV/AIDS continues to challenge prevention, care and treatment efforts and presents an increasingly urgent and potentially catastrophic threat to population health. In the context of prevention, this fatal sexually transmitted infection (STI) underscores the importance of providing youth (the fastest growing risk group) with adequate information, motivation, behavioural skills, and access to resources that support the achievement and maintenance of sexual health across the lifespan. However, youth have proven to be a difficult audience to reach, particularly with educational programs that approach adolescent sexuality from an adult frame of reference, one that often stresses the negative aspects of human sexuality. Yet many of the tasks associated with a successful transition into adulthood and social integration depend upon the ability to initiate and maintain long-term, intimate sexual relationships. Using a case study methodology, this research—which was conducted in British Columbia, Canada— investigated the potential effects of an innovative theatre-based, peer-led HIV prevention/sexuality education program on four groups of high school students and the peer leaders. iv The potential of theatre-in-education was examined to determine if this format would engage youth audiences—and keep them engaged—and if it would have a positive impact on self-reported confidence in performing risk-reduction behaviours. The results from the four case studies strongly suggest that peer-led theatre presented in conjunction with peer-led discussion has the potential to not only engage youth between 12 and 17, but to also increase self-reported confidence in their ability reduce risk. In two of the cases, engagement was high and constant; while the two other cases demonstrated that the format has a strong potential for drawing more reluctant audiences into discussions over time. In all cases, confidence reportedly increased. Further to this, audiences reported gains in knowledge, improvements in behavioural and communication skills, and increased motivation to use condoms and to access sexual health care. In addition, and perhaps most importantly, there were reports of increased communication about sexual health issues, the development of greater compassion and tolerance, along with the desire to avoid stigmatizing HIV-positive individuals and sexual minorities. The peer leaders reported comparable effects. Given that stigma has been identified as the most persistent barrier to HIV/AIDS prevention, care and treatment, embedding peer-led theatre programs—focused on sexuality and HIV prevention—into currently existing theatre arts curricula within the public school system offers a powerful and cost-effective means of providing comprehensive sexual health education. It would be shrewd (from both a social and economic perspective) for education ministries and school districts to capitalize on the positive aspects of adolescent peer networks and youths’ natural tendency to learn from one another. This research, while based on informed judgment, adequacy and plausibility rather than on the gold standard of a randomized control trial, arguably provides initial evidence that the theatre-in-education format is worthy of implementation on a wider scale. Investing in the set-up, maintenance and rigorous evaluation of peer-led theatre-in- education programs which focus on sexuality has the potential to normalize safer sexual practices and improve population health, for this generation and generations to come. Keywords: HIV prevention, peer education, youth sexuality, theatre education, case study, stigma, social norms, population health v Table of Contents Supervisory Page ................................................................................................................ ii Abstract..............................................................................................................................iii Table of Contents................................................................................................................ v List of Tables .................................................................................................................... vii List of Figures..................................................................................................................viii Acknowledgments.............................................................................................................. ix Dedication........................................................................................................................... x Chapter 1: Introduction....................................................................................................... 1 1.1 Research Purpose...................................................................................................... 8 1.2 Definitions of Key Concepts................................................................................... 10 1.3 Organization of the Dissertation ............................................................................. 10 Chapter 2: HIV/AIDS - A Primer ..................................................................................... 12 2.1 The Discovery of HIV/AIDS.................................................................................. 12 HIV ............................................................................................................................... 14 2.11 The Causal Debate: Does HIV cause AIDS?.................................................... 15 2.12 Where Did the Virus Come From? ................................................................... 19 2.2 The Epidemiological Findings................................................................................ 21 2.21 Virus Types....................................................................................................... 21 2.22 Infectivity and Incubation Periods.................................................................... 22 2.23 Stages of Infection ............................................................................................ 23 2.24 Transmission Networks .................................................................................... 25 2.25 Patterns of HIV Transmission........................................................................... 26 2.26 Risk Groups and Risk Behaviours .................................................................... 26 2.27 HIV & Women.................................................................................................. 32 2.3 An Epidemic of Stigma........................................................................................... 36 2.31 The Nature of Stigma........................................................................................ 39 2.32 The Nature of Epidemics .................................................................................. 50 2.33 How Stigma Influences Epidemics................................................................... 55 2.34 Reducing Stigma, Improving Public Health ..................................................... 58 Chapter 3: A Review of HIV Prevention/Sexuality Education Literature........................ 63 3.1 The Developmental Perspective ............................................................................. 64 3.2 A Focus on Youth ..................................................................................................