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The Knowledge Gap: Examining the Rhetoric and Implementation of Peer Education for HIV Prevention in Myanmar

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Title: The Knowledge Gap: Examining the Rhetoric and Implementation of Peer Education for HIV Prevention in Myanmar
Language: English
Authors: Fletcher, Gillian
Source: Sex Education: Sexuality, Society and Learning. 2015 15(4):378-391.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 14
Publication Date: 2015
Document Type: Journal Articles
Reports - Research
Descriptors: Foreign Countries, Peer Teaching, Acquired Immunodeficiency Syndrome (AIDS), Rhetoric, Program Implementation, Training, Knowledge Level, Teaching Methods, Skill Development, Qualitative Research, Interviews, Check Lists, Observation, Adults, Instructional Effectiveness, Emotional Response, Administrator Attitudes
Geographic Terms: Burma
DOI: 10.1080/14681811.2015.1028529
ISSN: 1468-1811
Abstract: In this paper, I report on an examination of the rhetoric and implementation of peer education in Myanmar. I demonstrate that while there was widespread consistency on interviewees' views of what peer education should involve, there was a significant gap between this rhetoric and the ways in which peer education was implemented, particularly in relation to the training of peer educators. It is my argument that this gap occurred because of failure to utilise, or even recognise, a particular form of knowledge: knowledge as "phronesis", which is most commonly translated as "practical wisdom" and incorporates factual, emotional and experiential knowledge. Instead, as I show, the pedagogic processes in use in peer education practice in Myanmar drew on an (unexpressed) understanding of knowledge as "episteme": a form of knowledge that is facts-based, technical and presumed objective.
Abstractor: As Provided
Number of References: 46
Entry Date: 2015
Accession Number: EJ1068303
Database: ERIC
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  Value: <anid>AN0108303430;bf401jul.15;2019Mar28.12:58;v2.2.500</anid> <title id="AN0108303430-1">The knowledge gap: examining the rhetoric and implementation of peer education for HIV prevention in Myanmar. </title> <p>In this paper, I report on an examination of the rhetoric and implementation of peer education in Myanmar. I demonstrate that while there was widespread consistency on interviewees' views of what peer education should involve, there was a significant gap between this rhetoric and the ways in which peer education was implemented, particularly in relation to the training of peer educators. It is my argument that this gap occurred because of failure to utilise, or even recognise, a particular form of knowledge: knowledge as phronesis, which is most commonly translated as 'practical wisdom' and incorporates factual, emotional and experiential knowledge. Instead, as I show, the pedagogic processes in use in peer education practice in Myanmar drew on an (unexpressed) understanding of knowledge as episteme: a form of knowledge that is facts-based, technical and presumed objective.</p> <p>Keywords: HIV; peer education; phronesis; Myanmar</p> <hd id="AN0108303430-2">Introduction</hd> <p>As of 13 August 2014, the UNAIDS website search function returned more than 600 entries for the term 'peer education'. Groups identified as being targeted with a peer education approach included bus drivers, families of people with AIDS-related illnesses, female sex workers, fishermen, footballers, homeless young people, members of the uniformed services, people living with HIV, prisoners, refugees, school pupils, young men and women based in universities, young men and women in the world of work, the list went on. Countries mentioned as sites for peer education included Afghanistan, Bangladesh, Chad, Costa Rica, Cyprus, Ethiopia, Jordan, Korea, Laos, Lebanon, Mozambique, Papua New Guinea, Romania, South Africa, Trinidad and Tobago, Uganda and Zambia.</p> <p>Questions have long been asked about the use of peer education. These have included questions as to its assumed effectiveness, the pedagogic approach used to train peer educators and the assumption that 'peers' can be easily identified by markers such as drug use, selling sex or age (Milburn [<reflink idref="bib29" id="ref1">29</reflink>]; Borgia, Marinacci, and Schifano [<reflink idref="bib5" id="ref2">5</reflink>]; Dowsett, Turney, and Woolcock [<reflink idref="bib9" id="ref3">9</reflink>]; Warwick and Aggleton [<reflink idref="bib43" id="ref4">43</reflink>]). Frankham ([<reflink idref="bib16" id="ref5">16</reflink>], 179) argued that the claims for peer education effectiveness among young people were 'overstated and in some cases disingenuous' and that peer educators struggled to negotiate between the domain of health education, in which they were required to pass on messages that had been largely decided by adults, and the domain of friendship or peer cultures. Dishion, McCord, and Poulin ([<reflink idref="bib8" id="ref6">8</reflink>]) argued that high-risk youth were vulnerable to having problem behaviour reinforced through peer groups. None of these questions have been decisively answered, yet peer education remains very much at the heart of HIV prevention efforts. Indeed, UNAIDS specifically identifies peer education as a key 'behavioural intervention strategy to promote individual [HIV] risk reduction' (UNAIDS [<reflink idref="bib40" id="ref7">40</reflink>], 23). Quite simply, peer education is recognised as the most widely practised approach to HIV prevention in the world today (Horizons [<reflink idref="bib18" id="ref8">18</reflink>]).</p> <p>This paper draws on a subset of data collected for a doctoral study, undertaken in Myanmar from 2006 to 2007. In this, I demonstrated that, while there was widespread consistency in the interviewees' views of what peer education should involve, there was a significant gap between this rhetoric and the ways in which implementation was described. It is my argument that this gap occurred because of failure to utilise, or even recognise, a particular form of knowledge: knowledge as <emph>phronesis</emph>, which is most commonly translated as 'practical wisdom' (Halverson [<reflink idref="bib17" id="ref9">17</reflink>]) and incorporates factual, emotional and experiential knowledge. Instead, as I show, the implementation of peer education practice in Myanmar drew on an (unexpressed) understanding of knowledge as <emph>episteme</emph>: a form of knowledge that is facts-based, technical and presumed objective (Flyvbjerg [<reflink idref="bib14" id="ref10">14</reflink>], 2).</p> <hd id="AN0108303430-3">Peer education principles</hd> <p>Sarafian ([<reflink idref="bib33" id="ref11">33</reflink>], 668) claims that 'the actual content of interactions with peer education recipients is never described'. While she is correct in that one cannot usually find clearly defined programme logic for peer education interventions (in other words: we want this outcome, we know this from theory and context, and we will do <emph>this</emph> in <emph>this</emph> way to achieve our desired outcome <emph>because</emph>...), the ubiquitous simile used for peer education is that of 'friend talking to friend', or a version thereof. This phrase, plus words or phrases such as participation, two-way communication or two-way discussion, experience, context (or contextual factors), mutual learning and informal learning pepper documents related to the 'how to' of peer education (AusAID [<reflink idref="bib3" id="ref12">3</reflink>]; Campbell and Mzaidume [<reflink idref="bib6" id="ref13">6</reflink>]; Horizons [<reflink idref="bib18" id="ref14">18</reflink>]; International HIV/AIDS Alliance in India [<reflink idref="bib23" id="ref15">23</reflink>]; International Planned Parenthood Federation [<reflink idref="bib24" id="ref16">24</reflink>]; UNAIDS [<reflink idref="bib36" id="ref17">36</reflink>]; UNFPA [<reflink idref="bib41" id="ref18">41</reflink>]; WHO [<reflink idref="bib46" id="ref19">46</reflink>]; Family Health International/Nigeria IMPACT Project [<reflink idref="bib11" id="ref20">11</reflink>]).</p> <p>These words and phrases, I argue, describe what can be called the underlying principles of peer education for HIV prevention: that peer education should be an iterative (not one-off) process, in which discussion is used as a tool to access and utilise participants' existing real-life knowledge (including knowledge of context, technical knowledge and emotional and experiential knowledge) in the prevention of transmission of HIV, supplemented by additional technical facts as required (AusAID [<reflink idref="bib4" id="ref21">4</reflink>]; Family Health International [<reflink idref="bib10" id="ref22">10</reflink>]; UNAIDS [<reflink idref="bib38" id="ref23">38</reflink>], [<reflink idref="bib39" id="ref24">39</reflink>]; Airhihenbuwa et al. [<reflink idref="bib1" id="ref25">1</reflink>]; International HIV/AIDS Alliance [<reflink idref="bib22" id="ref26">22</reflink>]).</p> <hd id="AN0108303430-4">Knowledge for HIV prevention: phronesis or episteme?</hd> <p>Wells ([<reflink idref="bib45" id="ref27">45</reflink>]) has noted that the meaning of the term 'knowledge' is 'very difficult to pin down'; it keeps escaping. In this paper, I reference two particular forms of knowledge originally defined and described by Greek philosophers (and Aristotle, in particular) as <emph>phronesis</emph> and <emph>episteme</emph>.</p> <p>While these terms originate from Greek philosophy, my understanding and intended meaning of these terms draw on the work of others who have used them (and other Greek terms for forms of knowledge) across a wide range of topics and disciplines in recent years. This includes anthropology and development economics (Apffel-Marglin and Marglin [<reflink idref="bib2" id="ref28">2</reflink>]); Aristotelian studies (Hursthouse [<reflink idref="bib21" id="ref29">21</reflink>]); development studies (Kassam [<reflink idref="bib25" id="ref30">25</reflink>]); education and social policy (Halverson [<reflink idref="bib17" id="ref31">17</reflink>]); emergency medicine (Wears [<reflink idref="bib44" id="ref32">44</reflink>]); policy and planning (Flyvbjerg [<reflink idref="bib14" id="ref33">14</reflink>]); and political science (Scott [<reflink idref="bib34" id="ref34">34</reflink>]).</p> <p>This is not to suggest that there is universal agreement on the delineation and meaning of forms of knowledge used within these different fields. For example, Halverson ([<reflink idref="bib17" id="ref35">17</reflink>]) has referenced five types of knowledge (including <emph>phronesis</emph> and <emph>episteme</emph>), while Flyvbjerg has referred to three types of knowledge: <emph>episteme</emph>, <emph>techne</emph> and <emph>phronesis.</emph> He defined these, respectively, as 'analytical, scientific knowledge', 'technical knowledge or know-how' and 'practical wisdom' (Flyvbjerg [<reflink idref="bib14" id="ref36">14</reflink>], 2). Scott also focused on three types of knowledge, but chose to focus on <emph>metis</emph>, <emph>techne</emph> and <emph>episteme.</emph> He argued that <emph>metis</emph> should be understood as, 'a wide array of practical skills and acquired intelligence in responding to a constantly changing natural and human environment' and that <emph>techne</emph> and <emph>episteme</emph> were synonymous, meaning 'logical deduction from self-evident first principles ... universal ... settled knowledge' (Scott [<reflink idref="bib34" id="ref37">34</reflink>], 213 and 313).</p> <p>My interest here lies not in 'pinning down the butterfly', but in the basic argument that runs through all of the variations of usage: there is knowledge that is factual, technical and perceived as objective and then there is knowledge that is embodied, which 'one knows with and through one's hands and eyes and heart as well as with one's head' (Marglin [<reflink idref="bib27" id="ref38">27</reflink>], 230).</p> <p>In this paper, I use the term <emph>episteme</emph> to refer to factual, technical, objective knowledge. Such knowledge may be applied – for example it would include the knowledge of how a piece of machinery operates, or the knowledge of the motor skills needed to put a condom on a penis – but it may also be abstract. An example of the abstract form of this knowledge would be the knowledge that AIDS is an acronym for the Acquired Immune Deficiency Syndrome. Whether applied or abstract, the form of knowledge referred to here by the term <emph>episteme</emph> is best understood as Scott's 'settled knowledge... [that is] organised analytically into small, explicit, logical steps and is both decomposable and verifiable' and Halverson's description of a type of knowledge that depends upon 'the control of regular contexts' (Scott [<reflink idref="bib34" id="ref39">34</reflink>], 320; Halverson [<reflink idref="bib17" id="ref40">17</reflink>], 41).</p> <p>In contrast, I use the term <emph>phronesis</emph> to describe 'practical wisdom' (Halverson [<reflink idref="bib17" id="ref41">17</reflink>], 31; Flyvbjerg [<reflink idref="bib14" id="ref42">14</reflink>], 2; Hursthouse [<reflink idref="bib21" id="ref43">21</reflink>], 285). Flyvbjerg ([<reflink idref="bib14" id="ref44">14</reflink>], 4) stated it was <emph>phronesis</emph> that resulted in the enactment of 'judgements and decisions made in the manner of a virtuoso social and political actor'. This type of knowledge is closely linked to the realm of context and lived experience. Phronesis can incorporate facts-based knowledge, but not as a stand-alone; rather, it incorporates facts-based knowledge as it is understood, applied and potentially extended within the realm of practice.[<reflink idref="bib1" id="ref45">1</reflink>] Halverson's definition of <emph>phronesis</emph> is clear. Having stated that, according to the original texts, 'practical wisdom is supposed to carry with it possession of all the virtues', he described it as an acquired capacity that:</p> <p>Helps practitioners to ask penetrating questions, provide insight into the implications of actions and events, and to advise appropriate courses of action. <emph>Phronesis</emph> involves the ability to understand how complex and messy situations hang together, and to discern the affordances whereby appropriate actions might be founded. <emph>Phronesis</emph> is the ability to walk the talk. (Halverson [<reflink idref="bib17" id="ref46">17</reflink>], 32)</p> <p> <emph>Phronesis</emph> as used in this study also incorporates the meaning that Scott attributed to the term <emph>metis</emph>:</p> <p>A wide array of practical skills and acquired intelligence in responding to a constantly changing natural and human environment ... the environments in which it [<emph>metis</emph>] is exercised are so complex and nonrepeatable [<emph>sic</emph>] that formal procedures of rational decision making are impossible to apply. (Scott [<reflink idref="bib34" id="ref47">34</reflink>], 313 and 316)</p> <p>However, I have chosen not to use the term <emph>metis</emph>, because of the connotations of cunning that others have attached to it (e.g. Halverson [[<reflink idref="bib17" id="ref48">17</reflink>], 32 and 41] stated that <emph>metis</emph> could 'also look like manipulation of the rules, cheating, or treachery ... resourcefulness without purpose').</p> <p>The aforementioned principles of peer education all point towards generation and sharing of <emph>phronesis</emph>, not <emph>episteme</emph>. This is made explicit in the UNAIDS Peer Education Kit for Uniformed Services (developed in collaboration with Family Health International),which states that peer education should involve 'learning through experience' and that emotions need to be engaged if peer education is to help anyone to change their behaviour and reduce their risk of HIV infection. Indeed, the Kit warns expressly against taking the approach of knowledge as <emph>episteme</emph>:</p> <p>Hearing facts about HIV and AIDS does not usually result in people changing their risk-taking behaviour ... It is easy for peer beneficiaries to ignore the advice of peer educators who only talk about the facts of HIV and AIDS. (UNAIDS [<reflink idref="bib37" id="ref49">37</reflink>], 8 and 9)</p> <hd id="AN0108303430-5">HIV prevention in Myanmar</hd> <p>While there is debate regarding the level and effectiveness of the work carried out – and while accessing sufficient resources for development work has always been a challenge – there has been some form of national response to HIV in Myanmar for approximately 30 years. Certainly, there have been television, radio, print media and billboard campaigns for at least the past 25 years, with the coverage of these campaigns increasing over time from main urban centres to cover vast areas of the country.</p> <p>The English-language version of the Myanmar Medical Association newsletter reported on research into knowledge and behaviour among 'high risk people' carried out from the mid-1990s (if not before); this research showed that significant percentages of taxi drivers, trishawmen, female sex workers, truck drivers and highway workers (in cities) knew that HIV could be transmitted through sex (and needles) and that condoms could prevent the transmission of HIV (Asha Mehra, Htun, and Aye [<reflink idref="bib28" id="ref50">28</reflink>]; Myo Thet Htoon et al. [<reflink idref="bib20" id="ref51">20</reflink>]; Ne Win, Zaw, and Win [<reflink idref="bib31" id="ref52">31</reflink>]; Ni Ni Win, Oo, and Myint [<reflink idref="bib32" id="ref53">32</reflink>]; Mu, win, and Htoon [<reflink idref="bib30" id="ref54">30</reflink>]).</p> <p>Doe Kyaw, a medical doctor and HIV prevention programme senior manager in Myanmar and participant in the study on which this article is based, may have been exaggerating slightly but in 2007 his opinion on the level of HIV awareness in Myanmar was: 'you'd have to stay on another planet, not to know about HIV'.[<reflink idref="bib2" id="ref55">2</reflink>]</p> <p>'Peer-to-peer work' is specifically identified as a core modality for HIV prevention in the Myanmar National Strategic Plan on HIV and AIDS 2011–2015.</p> <hd id="AN0108303430-6">The research</hd> <p>This paper presents findings from the first phase of a two-phase qualitative research project that examined the rhetoric and implementation of HIV prevention in Myanmar. Data were gathered in Myanmar over a 12-month period from late 2005 to 2006, and ethics approval was provided by the La Trobe University Faculty of Health Sciences Human Ethics Committee.</p> <p>The first phase of the research was designed to (a) gain an overview of the ways in which principles of HIV prevention and peer education were spoken about in Myanmar; (b) begin to examine reports of peer education practice from those with a direct responsibility for managing HIV prevention projects or programmes, or managing staff working on HIV prevention; and (c) identify possible organisations to examine in more depth during research Phase Two.[<reflink idref="bib3" id="ref56">3</reflink>]</p> <p>Purposive sampling was used to identify staff members who were employed as mid- or senior-level managers, responsible for the management of staff involved in HIV prevention activities and/or responsible for the monitoring and evaluation of HIV prevention activities, and who held more than two years of experience in a managerial position.[<reflink idref="bib4" id="ref57">4</reflink>] A list was drawn up of international organisations that had a major focus on HIV prevention in Myanmar, and that had head offices in Yangon (for logistical reasons). Senior and middle-level HIV programme managers were identified through personal contacts, and through background conversations with members of the development community in Myanmar.[<reflink idref="bib5" id="ref58">5</reflink>] In total, 11 interviews were completed as part of Phase One. These interviews provided the data on which this paper is based.</p> <hd id="AN0108303430-7">Analysis</hd> <p>Interview transcripts, field notes, observation checklists, observation notes and notes from background conversations were all imported into NVivo and examined for trends using a version of content analysis that drew on Hsieh and Shannon ([<reflink idref="bib19" id="ref59">19</reflink>]) and Connolly ([<reflink idref="bib7" id="ref60">7</reflink>]). My analysis was subjective, critically reflexive, and took as its measure the qualitative research criteria of rigour, legitimacy and trustworthiness. Analysis began with a first-stage, inductive identification of themes. These themes were drawn both from the original interview questions and from repeated reading of interview transcripts, observation notes and checklists, and notes of background discussions.</p> <p>The theoretical perspectives with which I began the research influenced both the analysis and the data collection and, at the same time, the analysis and data collection influenced my theoretical perspectives, affecting the areas of theory I examined and the ways in which I understood that theory. For example, it was reading and puzzling over participants' reference to 'knowledge' that led me to consider different forms of knowledge.</p> <hd id="AN0108303430-8">Participants</hd> <p>Eleven Phase One interviewees had worked for INGOs, international organisations, UN agencies and one local non-governmental organisation over the span of their HIV prevention careers. The use of peer education was endemic within the organisations for which interviewees had worked.</p> <p>All of these interviewees were expected to operate in both English and Burmese on a daily basis, and all had learnt about HIV prevention principles in English. For these reasons, all interviews were conducted in English.</p> <p>The age of Phase-One interviewees ranged from 29 to 62. Seven were male and four were female; eight had trained as doctors, three had not. Among them, interviewees reported between two and a half and 15 years of experience in INGO work related to HIV prevention and/or broader public health. While there was a difference in seniority, each had staff members reporting to him or her.</p> <p>Another point of similarity among the interviewees was possession of high levels of social responsibility and commitment to their work. Each of the interviewees spoke either directly or indirectly of wanting to make a positive difference to people's lives, and all worked extremely hard towards that end. For instance, I interviewed Soe Kyaw at his office on a Sunday, while he was trying to catch up with his never-ending workload. Ma Maw Htin told me of finishing a day in the office then spending her nights driving around the streets of Yangon looking for sex workers to talk to. U Win Maung, 62, travelled around the country enduring tough conditions and, often, serious gut infections caused by dirty water. Htwe Oo told how he spent his nights reading anything he could find to improve his understanding of his work. Other interviewees regularly worked six- or seven-day weeks.</p> <hd id="AN0108303430-9">Findings and discussion</hd> <p>Overall, interviewees knew the rhetoric of peer education and were well aware of the problems of using a facts-based approach (alone) to HIV prevention. Yet when it came to describing the training peer educators received within their organisations, the interviewees described facts-based processes that paid no attention to emotions and experience. As I show, <emph>episteme</emph> took over.</p> <hd id="AN0108303430-10">Talking the talk</hd> <p>Despite management-level interviewee diversity in terms of age, sex, years of experience, education and positions held, all 11 Phase-One participants presented peer education as the best method of promoting behaviour change for HIV prevention, and repeatedly described it as being like 'friend talking to friend', a (non-didactic) process in which two-way communication and mutual learning occurred, based on the reality of people's lives and the context in which they live.</p> <p>The difference between peer education and didactic teaching of facts was widely emphasised by these interviewees. For example, Ko Kyaw Naing, the only management-level interviewee to report personal experience of undertaking HIV prevention work as a peer educator, was clear that one important principle was 'the way of talking – no, I won't say teaching'. He explained 'the way of talking' as 'the discussion style ... by, y'know ... two-way discussion'. Ko Kyaw Naing added that his organisation deliberately avoided referring to its HIV peer education work as 'teaching', because 'when you say [we are] teachers you are like, above other people. And we don't want that situation ... so we never use the teaching word.' This distinction between 'friend talking to friend' and 'teaching' was repeated by other management-level interviewees.</p> <hd id="AN0108303430-11">Recognition of the role of emotion and experience in peer education and HIV</hd> <p>There was frequent emphasis among interviewees on the importance of emotional and experiential knowledge in HIV prevention in general, and in peer education relationships in particular. For example, Sanda Lwin was clear that effective peer education requires an understanding of what she called 'the needs of the community' and their 'real practice', as well as understanding of 'the contextual factor'. U Win Maung expressed the belief that peer education work that seeks behaviour change will only be effective when it takes into account the realities of people's lives and circumstances, and added 'there are many, so many factors'.</p> <p>Emotional knowledge identified by management-level interviewees as central to HIV prevention work included knowledge of the role of the emotions of shame and fear. Aye Aye and several other interviewees said that condoms were frequently considered outside the bounds of cultural acceptance, despite their role at the centre of HIV prevention efforts. According to Aye Aye, 'people say that using condom is not for married woman ... if you have affairs, then, then you use it.' Sanda Lwin had carried out research with young men and women in Yangon in which, she reported, the young women were 'scared to talk about condom' because 'they say condom is really concerned with sex workers. Not with ordinary girls.'</p> <p>Htwe Oo said, 'With the peer educators, when we do follow-up meetings with them we find that many of them are reluctant to ... discuss HIV/AIDS and sexuality in public.' For these peer educators, being required to speak that which is considered culturally unacceptable while providing HIV prevention education gave rise to the emotions of shame, and to the experience of being judged outside the bounds of cultural norms. Emotional and experiential knowledge also affected community members who were the expected 'beneficiaries' of the training sessions run by Htwe Oo's organisation. He said:</p> <p>Many people, many people, expect that we will talk something about sex and we will talk about something that we do not usually discuss in public and so, some female participants even do not want to join our sessions because of that expectation ... 'oh they are going to talk dirty things today', before we even start something.</p> <p>Some audiences were actively 'hostile', he said, 'because they think that we are stigmatising them with the HIV. So they are quite resistant.'</p> <p>For seven of the interviewees, this awareness of the importance of emotional and experiential knowledge existed alongside an awareness of the limitations of taking an approach to HIV prevention that focused on <emph>episteme</emph>, or technical facts.</p> <hd id="AN0108303430-12">Awareness of the limitations of a facts-based approach</hd> <p>As mentioned earlier, a majority of the management-level interviewees explicitly identified and critiqued what they saw as a reliance on fact-giving within HIV prevention in Myanmar. Some of the critiques were less coherent and wide-ranging than others, but nevertheless critiques were expressed.</p> <p>One of the most outspoken of the critics was Sanda Lwin. She had undertaken a Masters research into sexual health knowledge and behaviour among young men and women in Yangon and discovered that the boys 'have enough knowledge about HIV and AIDS' but made decisions on condom use with sex workers based on a division of sex workers as 'clean or dirty. If the sex worker is very beautiful and fair-skinned, they thought she is clean ... not infectious.'</p> <p>Htwe Oo had not undertaken Masters-level study, but commented:</p> <p>[Participants in training or workshops] will get some information, many details many many details about HIV and AIDS, but ... many of the facts are not applicable ... in their practical life. Like the CD4 count, or something. They might be grateful that they learn, ok, today we learnt about CD4 count, we learnt something we've never heard ... but after that it's very hard for them to practise in real life.</p> <p>U Win Maung reflected on his years of experience (and possibly his own Masters-level education) to admit that, in the beginning, he had thought HIV prevention was simply a matter of education but that his thinking had changed over time:</p> <p>I'm, thinking of the Western countries. In the world set-up they have, er, more educated, their education level is in general higher than our countries, and they have more knowledge and they can get condom everywhere, but in spite of that the infection has been transmitted among the people. Why? There may be some factors beyond that.</p> <p>Win Maung was of the opinion that 'in Myanmar [today], usually people are saying that people are ignorant about that [HIV], people have no knowledge about that'. But, he said, 'Even in Myanmar, there are many organisations that are working for many years, for the prevention education ... the knowledge level has been increased [yet] some people change but the majority do not change.'</p> <p>'We have more than enough of the knowledge of how you can get it and how you can protect yourself,' said Kyaw Thu. Ma Maw Htin said that the sex workers with whom her organisation worked 'got only [the] message about ... for example, where the disease comes [into the body]. Oh, they know all these place. But change behaviour? I don't think [so].'</p> <p>When I asked Sanda Lwin how many people in Myanmar she thought had not heard about HIV, she said that 'most of the people they know HIV because it's mass media and everything'. The 'everything' she was referring to here included the hundreds of thousands, if not millions, of HIV prevention sessions run in communities across the country over the years. The Three Diseases Fund reported that 'around 380,000' people were reached by HIV prevention services in 2011 alone (Three Diseases Fund [<reflink idref="bib35" id="ref61">35</reflink>], 6).</p> <p>Moet Moet Lin characterised the practice of most HIV prevention organisations in Myanmar as 'talk talk talk, it's just, <emph>knowledge</emph>. We are providing knowledge and not exploring their background attitude.' By knowledge, she was referring simply to facts; to <emph>episteme</emph>. Kyaw Thu also characterised such sessions as 'very didactic ... people tend to stop at [the] imparting knowledge and information level'. This state of affairs continued, said Kyaw Thu, despite the reality that in his opinion, 'most [field workers] <emph>know</emph> what are the weaknesses of education'. 'As long as they have been doing it, on and on and on, as long as they have any glimpse of what happened, after, I think they realise,' he added. 'That it's not enough and that it's not working.' Htwe Oo was somewhat bitterly (and amusingly) critical of his and his organisation's own practice, which relies heavily on use of <emph>PowerPoint</emph>:</p> <p>Many people just listen to our presentation, they say 'wow, beautiful colours [both laughing], oh very good animation, funny, very good jokes' ... like we are entertaining them.</p> <p>When I asked Htwe Oo whether he thought his organisation's peer education work changed behaviours or not, he simply replied 'to be short, I don't think so'.</p> <p>Htwe Oo also acknowledged 'the people's attitude towards the educators' as: 'Okay, these people come again [laughs], they just come again to repeat the HIV/AIDS education. We have heard it from someone else.'</p> <hd id="AN0108303430-13">The dominance of episteme in peer educator training and peer education practice</hd> <p>Despite all of these points, when management-level interviewees talked about the training given to their field workers or about prevention sessions run in communities they did so in terms of one-way transfer of 'the knowledge', 'the basic knowledge', or 'the basic facts' of HIV and AIDS. 'Knowledge' became an objective object of external origin, to be passed on whole if it was to retain its talismanic quality. In other words, they spoke of knowledge as <emph>episteme</emph>. The research project as a whole included identification of several complex and interlinked reasons for this, which included: Myanmar educational norms in which rote learning dominates, community member expectations of 'educators' as being holders of knowledge, field worker desire to be seen as knowledgeable (and to be helpful), deeply embedded assumptions of community-level ignorance and community-level adoption of a position of ignorance. These issues have been discussed in greater detail elsewhere (Fletcher [<reflink idref="bib12" id="ref62">12</reflink>], [<reflink idref="bib13" id="ref63">13</reflink>]).</p> <p>Several interviewees referred to the need to give 'proper', 'complete', 'correct' or 'the whole knowledge' both when training peer educators, and when peer educators work with community members. For instance, Aye Aye was clear that she wanted all field workers to give the same factual knowledge to every community group with which they worked.</p> <p>Underneath all senior manager comments regarding 'the knowledge' or 'the basic knowledge' lay an assumption that the interviewee and I shared an understanding of what was meant by 'knowledge'. It was presented as a static object, to be passed from holder to receiver, and known by us all without the need for definition. When I asked interviewees to spell out what the terms 'basic knowledge' or 'the knowledge' included for them, everyone mentioned: what is HIV; what is AIDS (frequently with an explanation of the full terms, human immunodeficiency virus and acquired immune deficiency syndrome, despite the strangeness of explaining the abbreviation and acronym in a language other than English); how is HIV transmitted; and how is transmission prevented. Some interviewees mentioned extra topics, such as where HIV and AIDS 'comes from' (Ko Kyaw Naing), the difference between a virus and a microbe (Ye Hlin), and how to support people living with HIV (Sanda Lwin). But overall, 'knowledge' was used to refer to facts, the transmission of which could prevent HIV transmission.</p> <p>Ma Maw Htin, whose programme worked with female sex workers and men who have sex with men, said that her organisation trained its field staff on 'what is STI'. I then asked 'signs and symptoms?' and she replied:</p> <p>Yeah. About STI and HIV, relationship between STI and HIV, and PLHA [people living with HIV and AIDS].</p> <p>Q: What do they teach them about HIV?</p> <p>It generally is what is the virus look like, and then how it comes, and what is transmission, mode of transmission, and what's the relationship between STI and HIV.</p> <p>Q: What do you mean about how did it come?</p> <p>Ah, history of HIV [laughing]. Actually that's, yeah, the training curriculum.</p> <p>When I asked Htwe Oo the main focus of his organisation's HIV and STI training, he was clear: 'That's knowledge on HIV. What is HIV.' He added that a 'normal education session' covered 'the HIV basic facts, healthy living, mode of transmission and condom demonstration, condom usage skills'. 'The immune system and working of the white cells in the blood' was also included, he said, because:</p> <p>Later in the session we want to teach them how to maintain your health. We just want to say HIV is destroying your health through the destruction of the white cells, so we mention the white cells in our training.</p> <p>The examples used so far are related to the training that was provided by organisations at the time of interviews. U Win Maung also told me about the work he had been involved in more than a decade previously, in which 'as far as I remember, it include about the basic facts about HIV and AIDS and means of transmission, and means of prevention, yeah. These are the three major topics.'</p> <p>This repeated focus on transmission of <emph>episteme</emph> (which was presented as a one-way transfer, with knowledge going from the knowledge holders within INGOs to non-knowledge holders, who were either new field workers or community members) can be read as evidence of an unstated assumption that the knowledge recipients were previously ignorant of the <emph>episteme</emph> being passed on to them. Management-level interviewees again and again presented both new field workers, and community members, as blank slates that needed to be inscribed with facts. This occurred both implicitly and explicitly.</p> <p>Htwe Oo acknowledged the existence of prior (but not 'complete') HIV-related knowledge among field workers newly employed by his organisation, but only after repeated questioning. He had told me that his organisation gave all new peer educators a pre-training questionnaire to assess their knowledge of 'the mode of transmission and the attitude of people towards ... people with HIV/AIDS and the mode [of transmission], and the non-transmissible situations'. Participants were 'most of the time right' in these pre-tests, he added, but then rationalised this evidence of pre-existing knowledge away. 'Many people do not have correct HIV/AIDS knowledge but for the educators because they come to the organisation to work as an educator they have prepared themselves for that I think', he said.</p> <p>Whether the knowledge so clearly displayed in these pre-tests had resulted from cramming in order to get a position, from previous training received, from watching the television, reading books, taking part in school-based HIV programmes or from any other medium, was irrelevant. The educators demonstrated possession of factual knowledge, but despite this were still required to undertake 'basic HIV' training. The <emph>episteme</emph> had to be transmitted.</p> <p>Field workers from Ko Tin Aung's organisation taught sex workers 'how to treat their clients', as well as teaching them about HIV transmission, condom use, condom use negotiation or about safer sex:</p> <p>We are going to ... transmit the HIV knowledge, and then the condom usage, right condom usage, and then, safer sex, condom negotiation skill for the sex workers, and ... we will explain the sexual behaviour.</p> <p>One of the things that Ko Tin Aung's organisation taught 'mostly ... uneducated' sex workers – as part of 'HIV knowledge' – was the long form of the abbreviation HIV. At first, the sex workers 'don't understand, they cannot accept words', he said. Now, he added, 'mostly they know. Because we are going to them many times ... repeat, repeat and repeat. And then follow up.'</p> <p>During his interview, Ko Tin Aung demonstrated an awareness of the possibility that the community members with whom his organisation worked could have some pre-existing knowledge related to HIV and AIDS. Yet even as he recognised this possibility, he downplayed it. Having begun by stating that sex workers 'don't know [about HIV]' before meeting his organisation's field staff, Ko Tin Aung checked himself and added the caveat that they knew 'a little' knowledge. Then he reasserted the women's ignorance by saying that 'now we [are] going to teach them they will more understand'. The women's own emotional and experiential knowledge (let alone their pre-existing factual knowledge) was ignored.</p> <p>With respect to the men who have sex with men with whom Ko Tin Aung's organisation worked, Ko Tin Aung was clear about the importance of the experiential and the emotional when he stated: 'MSM don't like ... condom ... because there is no pleasure.' Yet his response to this was, 'we will explain that next time ... you should use the condom. Condom is very nice pleasures ... we will teach oral sex with the condom.' The real-life barrier to condom use of lack of physical sensation on penetration was met by an explanation that condoms should be used, plus a 'how to' teaching on using oral sex to put a condom on a penis. Implicit in his response to the challenge of pleasure were assumptions that, somehow, men who said they did not like condoms because of lack of pleasure did not know that condoms prevented HIV; they simply did not know the technical skill of putting a condom on orally; and that the possible pleasure of oral sex with a condom (anecdotally, a pleasure experienced predominantly for the receiver of the oral sex, despite the development of flavoured condoms) would negate the reduction of pleasure during intercourse. A further assumption is inherent here; that once the men who have sex with men knew these things they would change their behaviour.</p> <p>Ma Maw Htin worked in the same organisation as Ko Tin Aung, but was a higher-level manager. Again, there was a clear assumption of ignorance when Ma Maw Htin spoke about interactions between 'new' women – sex workers who had not been in contact with her organisation before – and field workers. These women may well have been involved with other organisations (a common occurrence among the sex workers and men who have sex with men interviewed for this study) but they were still considered 'new' to the field workers in Ma Maw Htin and Ko Tin Aung's organisation. With these 'new' women, said Ma Maw Htin, the field workers 'try to give whole session ... trying to cover <emph>all ...</emph> because they're new'. She added, '[Field workers] assume that [the women] haven't had the information.' Then she added:</p> <p>[Field workers] ask OK have you met people [from other INGOs] before, and they ask them some question. And ... even they said that 'OK, I have met [an INGO]', we cannot totally trust what they said. Maybe [laughing], they are lying because [they] don't want to listen.</p> <p>Here, Ma Maw Htin reaffirms an assumption of ignorance, acknowledges that repeated transmission of facts might actually not be welcomed by sex workers, then overwrites this reality by implying that the sex workers are potentially liars who simply don't want to listen to information that is for their own good. They are not to be trusted. The organisation's responsibility to equip its field workers with the skills to engage participants as willing partners in an HIV prevention intervention is set aside, along with the HIV prevention pedagogic principle of two-way communication between equal partners, actively engaged in experiential learning.</p> <p>The most striking disavowals of the importance of experiential and emotional knowledge came from Ko Kyaw Naing and Htwe Oo. Ko Kyaw Naing reported that when he was a peer educator and involved in running training sessions in communities, he would ask community members: 'What do you think about [HIV] in your township, what do you say in your township and ... how are the people's reaction to that?' In response, he said, 'They did talk "OK, yeah ... one boy die with that and there is rumour and people doesn't want to go to his funeral" and things like that, so, he talk, he or she talk, about their own experience.'</p> <p>The response of Ko Kyaw Naing and his peer educator colleagues was to 'start with like a small survey, "OK what is HIV. HIV is like micro only, you cannot see [it]", something like that ... so I have to explain like that'.</p> <p>Previously, I reported that Htwe Oo was well aware of the emotional difficulties his peer educators faced, having to talk about HIV and AIDS in the community. In his own, diligent way, Htwe Oo wanted to respond to this challenge. Yet instead of examining the content or processes of the training provided to the field workers, Htwe Oo was considering changing the training format and running mixed-sex training sessions instead of the single-sex sessions run previously. The reason he gave was:</p> <p>Separating the gender [<emph>sic</emph>] for classes enhance and encourage their embarrassment, and their feeling that sex is not a good thing to discuss. So ... I want them to think that sex is not an embarrassing thing to discuss in public.</p> <p>I questioned the reality of this desire, by suggesting that discussing sex in public is indeed embarrassing, and he responded with disarming honesty: 'Yeah actually it is for me too. I have to make it, I have to fake it.' That Htwe Oo had decided to run mixed-sex sessions flew in the face of this personal awareness.</p> <hd id="AN0108303430-14">Conclusion</hd> <p>Management-level participants interviewed for this study cared deeply about the work they did. Each was also well aware of, and expressed a commitment to, the same principles of peer education: that it should be an iterative (not one-off) process, in which discussion is used as a tool to access and utilise participants' existing real-life knowledge (including knowledge of context, technical knowledge and emotional and experiential knowledge) in the prevention of transmission of HIV, supplemented by additional technical facts as required.</p> <p>As the majority of interviewees agreed, facts alone will not change behaviour (nor will facts plus technical skills). The knowledge needed to prevent transmission of HIV is <emph>phronesis</emph>. Indeed, Halverson's description of <emph>phronesis</emph> is strikingly similar to what is required if one is to be able to prevent HIV transmission: 'the ability to understand how complex and messy situations hang together, and to discern the affordances whereby appropriate actions might be founded ... the ability to walk the talk' (Halverson [<reflink idref="bib17" id="ref64">17</reflink>], 32). As Wells ([<reflink idref="bib45" id="ref65">45</reflink>], 58) argued, 'knowledge only has significance and value in the context of joint action and interaction'.</p> <p>Yet these same interviewees – and the programmes for which they worked – subjugated the complications of emotional and experiential knowledge in relation to HIV prevention. They 'disqualified [it] as non-conceptual knowledges' (Foucault [[<reflink idref="bib15" id="ref66">15</reflink>]] 2003, 7) in favour of <emph>episteme</emph>.</p> <p>As noted, the factors contributing to this outcome are both complex and interlinked. However, I argue that international organisations would do well to pay attention to the forms of knowledge that they prioritise within their HIV prevention programmes, and specifically to pay attention to whether or not their peer education training programmes equip peer educators to share (and generate) <emph>phronesis</emph>, or simply to pass on the parcel of facts represented by <emph>episteme</emph>.</p> <hd id="AN0108303430-15">Acknowledgements</hd> <p>The author expresses her thanks to the Harold Mitchell Foundation, and The Institute of Development Studies (IDS), University of Sussex, Brighton. This paper is based on a presentation given by the author while a Visiting Fellow at IDS in April 2013.</p> <hd id="AN0108303430-16">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author.</p> <ref id="AN0108303430-17"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref25" type="bt">1</bibl> <bibtext> <sups>1.</sups> In July 2009, I carried out a research feedback and validation session with a group of four senior management INGO colleagues in Yangon (three of whom had been involved in the research). When I spoke about <emph>episteme</emph> and <emph>phronesis</emph>, my colleagues interjected: 'It's the same in Buddhism'. According to the Vipassana Research Institute, the highest form of wisdom is <emph>bhavana-maya</emph>, or 'experiential wisdom' (Vipassana Research Institute [42]).</bibtext> </blist> <blist> <bibl id="bib2" idref="ref28" type="bt">2</bibl> <bibtext> <sups>2.</sups> All the names used are pseudonyms.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref12" type="bt">3</bibl> <bibtext> <sups>3.</sups> Phase Two consisted of individual interviews with fieldworkers, and community members, connected to two HIV prevention programmes (identified as a result of Phase One). This phase included use of an innovative data collection method in which metaphors for HIV prevention work were elicited and expanded upon by participants during interview. Findings from this phase have been published elsewhere (Fletcher [12], [13]).</bibtext> </blist> <blist> <bibl id="bib4" idref="ref21" type="bt">4</bibl> <bibtext> <sups>4.</sups> It should be noted that none of these managers were linked to projects or programmes that worked with injecting drug users (IDUs). This was the result of access and logistics, rather than of a conscious policy of exclusion. People who are IDUs in Myanmar have been particularly hard hit by the HIV epidemic. The findings of this study are potentially applicable to IDU prevention programmes; as Kermode et al. 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  Label: Title
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  Data: The Knowledge Gap: Examining the Rhetoric and Implementation of Peer Education for HIV Prevention in Myanmar
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  Data: English
– Name: Author
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  Data: <searchLink fieldCode="AR" term="%22Fletcher%2C+Gillian%22">Fletcher, Gillian</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Sex+Education%3A+Sexuality%2C+Society+and+Learning%22"><i>Sex Education: Sexuality, Society and Learning</i></searchLink>. 2015 15(4):378-391.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
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  Data: Y
– Name: Pages
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  Data: 14
– Name: DatePubCY
  Label: Publication Date
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  Data: 2015
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  Data: Journal Articles<br />Reports - Research
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Peer+Teaching%22">Peer Teaching</searchLink><br /><searchLink fieldCode="DE" term="%22Acquired+Immunodeficiency+Syndrome+%28AIDS%29%22">Acquired Immunodeficiency Syndrome (AIDS)</searchLink><br /><searchLink fieldCode="DE" term="%22Rhetoric%22">Rhetoric</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Implementation%22">Program Implementation</searchLink><br /><searchLink fieldCode="DE" term="%22Training%22">Training</searchLink><br /><searchLink fieldCode="DE" term="%22Knowledge+Level%22">Knowledge Level</searchLink><br /><searchLink fieldCode="DE" term="%22Teaching+Methods%22">Teaching Methods</searchLink><br /><searchLink fieldCode="DE" term="%22Skill+Development%22">Skill Development</searchLink><br /><searchLink fieldCode="DE" term="%22Qualitative+Research%22">Qualitative Research</searchLink><br /><searchLink fieldCode="DE" term="%22Interviews%22">Interviews</searchLink><br /><searchLink fieldCode="DE" term="%22Check+Lists%22">Check Lists</searchLink><br /><searchLink fieldCode="DE" term="%22Observation%22">Observation</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Effectiveness%22">Instructional Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Emotional+Response%22">Emotional Response</searchLink><br /><searchLink fieldCode="DE" term="%22Administrator+Attitudes%22">Administrator Attitudes</searchLink>
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  Label: Geographic Terms
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  Data: <searchLink fieldCode="DE" term="%22Burma%22">Burma</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/14681811.2015.1028529
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1468-1811
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: In this paper, I report on an examination of the rhetoric and implementation of peer education in Myanmar. I demonstrate that while there was widespread consistency on interviewees' views of what peer education should involve, there was a significant gap between this rhetoric and the ways in which peer education was implemented, particularly in relation to the training of peer educators. It is my argument that this gap occurred because of failure to utilise, or even recognise, a particular form of knowledge: knowledge as "phronesis", which is most commonly translated as "practical wisdom" and incorporates factual, emotional and experiential knowledge. Instead, as I show, the pedagogic processes in use in peer education practice in Myanmar drew on an (unexpressed) understanding of knowledge as "episteme": a form of knowledge that is facts-based, technical and presumed objective.
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  Data: As Provided
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  Data: 46
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  Data: 2015
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  Label: Accession Number
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  Data: EJ1068303
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        Value: 10.1080/14681811.2015.1028529
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      – Text: English
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        PageCount: 14
        StartPage: 378
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      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Peer Teaching
        Type: general
      – SubjectFull: Acquired Immunodeficiency Syndrome (AIDS)
        Type: general
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      – SubjectFull: Qualitative Research
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      – SubjectFull: Burma
        Type: general
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      – TitleFull: The Knowledge Gap: Examining the Rhetoric and Implementation of Peer Education for HIV Prevention in Myanmar
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            – TitleFull: Sex Education: Sexuality, Society and Learning
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