This Paper was presented by Chidi Ezegwu at the National Scientific Conference of Clinical Psychologists, Eastern Zone at Choice Hotels Awka, Anambra State, Nigeria.
Theme: PSYCHOLOGICAL HEALTH OF NIGERIAN YOUTHS AND SUSTAINABLE NATIONAL DEVELOPMENT
Date 15 – 17 November 2005
ABSTRACT
It is a message that cannot be repeated too often: “there is no known cure for AIDS”. A cheap, effective vaccine appears years away. The only way to stop the spread of HIV infection is through prevention. HIV is a fragile virus. The ways it is spread are well known, as are the ways to prevent transmission.
Numerous theories have been postulated on how to make people acknowledge and keep to these ways of prevention as well as impact mitigation. However, the translation of these theories into practice in many African societies appears to be eluding owing partly to socio-cultural and economic factors of these societies and also to the nature of the foreign theories that are unknown to local environmental settings.
The work adapts the UNESCO/UNAIDS joint project, “A Cultural Approach to HIV/AIDS Prevention” which was launched in 1998, for local replication to identify guidelines and methods for using cultural approaches and strategies to achieve more effective behavioural change towards HIV/AIDS issues. It elaborates on delivering culturally appropriate information/education/communication to effect behavioural changes.
The whole work portrays the assumption that greater efficiency and sustainability will be achieved when better understanding of the peoples’ motivation and reservations vis-à-vis changing their behaviours as regards to HIV/AIDS prevention and care are taking into considerations and appropriate intervention approached fine-tuned to address them.
INTRODUCTION
There are many different ways of contracting HIV.
There are just as many different ways of preventing HIV/AIDS.
There are many different groups of people exposed to HIV/AIDS.
There are many different ways of discriminating against people living with HIV/AIDS.
The WHYs, HOWs and WHOs change from CULTURE to CULTURE that is why we need: a culturally appropriate response to HIV/AIDS prevention and care (UNESCO, 2003)
Understanding of our culture, the nature of individual young people in the society, their psychology and their traditional backgrounds will go a long way to help educators, program managers and adult society working among young people or seeking to effect behavioural change among them to produce a work plan fine-tuned to suit their psycho-social nature so as to be more effective and their works to give better results.
Since the mid-eighties, the fight against HIV/AIDS has gradually mobilized governments, international agencies and non-governmental organizations (NGOs). However, it became evident that despite massive action to inform the public about the risks, behavioral changes were not occurring as expected. The infection continued to expand rapidly and serious questions began to emerge as to the efficiency of the efforts undertaken in combating the illness. Experience has demonstrated that the HIV/AIDS epidemic is a complex, multifaceted issue that requires close cooperation and therefore multidimensional strategies. The establishment of the Joint United Nations Program on HIV/AIDS (UNAIDS) in 1994 initiated a new approach to the prevention and care of this disease. Following a proposal made by UNESCO’s Culture Sector to the UNAIDS Program, on taking a cultural approach to HIV/AIDS prevention and treatment for sustainable development, a joint project “A Cultural Approach to HIV/AIDS: Prevention and Care” was launched in May 1998. The goals were to stimulate thinking and discussion and reconsider existing tools.
Taking a cultural approach means considering a population’s characteristics – including
lifestyles and beliefs- as essential references to the creation of action plans. This is indispensable if behavior patterns are to be changed on a long term basis, a vital condition for slowing down or for stopping the expansion of the epidemic.
The work benefits extensively from the Joint UNESCO/UNAIDS Project “A Cultural Approach to HIV/AIDS Prevention and Care” which was launched in mid-1998, in relation to the new approach to HIV/AIDS prevention and care inaugurated by UNAIDS. It also benefited from Advocates for Youth (1994) documents earlier publication on the issue under study. It however adapts and localizes the documents to Nigerian environment
Definitions of Youth
The word ‘youth’ invokes different feeling to different people and so with its definition. Many people and groups, including some international organisations have accorded different meaning to the concept. Webster’s Dictionary (1998) defines youth as the quality or state of being young; youthfulness; juvenility; the part of life that succeeds childhood; the period of existence preceding maturity or age; the whole early part of life, from childhood, or, sometimes, from infancy, to manhood. United Nations General Assembly and the U.S. Agency for International Development refer youths to ages of 15 to 24. However, the United Nations Convention on the Rights of the Child defines children as up to age 18, thus providing theoretically more protection and rights to those up to age 18; there is no similar United Nations Convention on the Rights of Youth. Thus in the global context, youth is generally defined as the cohort between ages 15 and 24, the generation straddling childhood and adulthood.
The operational definition and nuances of the term “youth”, however, often vary from country to country, depending on the socio-cultural, institutional, economic, and political factors. The Nigerian National Youth Policy, 2001, defines a youth as all young persons of ages 18 – 35, who are citizens of the Federal Republic of Nigeria. It notes that this category represents the most active, the most volatile, and the most vulnerable segment of the population socio-economically, emotionally and in other respects.
This work uses the terms youth, young people, young adults, and adolescents interchangeably – all referring to people 10 to 35 years of age, to include the Nigerian and UN definition of youths, unless otherwise specified. Definitions of youth are related to context, culture, programmatic goals, objectives, and other factors.
Defining Culture
Culture is an important element of the foundation of every society. Culture provides the framework for people's social behaviours, contributes to their feeling of community, and helps individuals form their identity. Culture may be described as the attitudes and behaviour that are characteristic of a particular social group or organization, and includes traditions that reflect norms of care and behaviour based on age, life stage, gender, and social class.
However, constraints arising from cultural traditions often limit young people's access to the information and services they need to make informed and responsible decisions about their sexual and reproductive lives. Because it is often used to justify social inequality and can be a roadblock to achieving the full spectrum of human rights, "culture" must be addressed vis-à-vis the rights of young people.
Starting from the premise that "rights are universal but cultures are different, it is important to understand the various cultural issues that are of great significance to young people worldwide, including such factors as information and communication technologies (ICTs) and media's influence on young people's choices.
It is pertinent to note here that religion plays a significant role in culture, as do social and political institutions such as media and communications, systems of education, and modes of governance.
In this sense, “A Cultural Approach to HIV/AIDS Prevention and Care”, represents a new contribution towards finding solutions to this apparently insuperable challenge. Its major methodological output aims at tailoring the content and pace of action to people’s mentalities, beliefs, value systems, capacity to mobilize and, as a consequence to accordingly modify national and local strategies and policies, project design and field work.
What does culture have to do with HIV/AIDS?
On the basis of the Mexico Declaration of 1982, culture is broadly understood within UNESCO to include: ways of life, traditions and beliefs, representations of health and disease, perceptions of life and death, sexual norms and practices, power and gender relations, family structures, languages and means of communication; as well as arts and creativity. From this definition, it is clear that culture influences attitudes and behaviours related to the HIV/AIDS epidemic: in taking or not taking risk of contracting HIV, in accessing treatment and care, in shaping gender relations and roles that put young people at risk of infection, in being supportive towards or discriminating against people living with HIV/AIDS and their families, etc.
The difficulty in establishing effective HIV/AIDS programmes comes from a lack of openness, in many societies, regarding sexuality, male-female relationships, illness and death, taboo subjects deeply rooted in the cultures.
Understanding what motivates peoples’ behaviours, knowing how to address these motivations appropriately, and taking into consideration peoples’ cultures when developing programs addressing HIV/AIDS are essential to changing behaviours and attitudes towards HIV/AIDS.
Cultural Components
An individual's culture strongly influences his or her behavior, beliefs, attitudes and values. This is not a surprising statement; we all have an understanding that many of our present-day beliefs and behaviors have their roots in what we learned growing up in our own particular cultures. One useful definition of culture refers to it as a body of learned beliefs, traditions, principles and guides for behaviour that are commonly shared among members of a particular group. It serves a map for both perceiving and interacting with the world.
The journey towards maximizing cultural approaches to achieve behavioural changes among youths in the intervention, prevention and impact mitigation of the HIV/AIDS pandemic among youths begins with the understanding of the cultural components as well as making effort to change the harmful aspects of our cultures. Keep HIV/AIDS prevention in mind; many of the cultural components are directly related.
Language and Communication Style Language and communication style refers to a wide variety of verbal and nonverbal patterns and behaviors, including social customs about who speaks to whom—both how and when.
Health Beliefs Health beliefs cover a range of assumptions about the causes of disease as well as the proper remedies for illness. While the "germ theory" of disease holds that sickness is caused by microscopic organisms such as bacteria and viruses, it is not the only explanation people have come up with for disease. Divergent beliefs are growing, even among scientific circles, that the mind can affect the body's health in surprising ways. In addition, "supernatural" theories of disease, including the belief that a particular disease results from spiritually unhealthy activity, are very common in our societies. In this category, different kinds of healers are sought out in cases of illness, including spiritualists, herbalists, shamans and others—like acupuncturists or homeopaths—who practice what is labeled as "alternative health care."
Family Relationships The family is the primary unit of society. In it, children are socialized into human society and into a culture's particular beliefs, attitudes, values and behaviors. The topic of family relationships include family structure, roles, dynamics and expectations. Sexuality Sexuality involves more than genital activity. It includes five major areas: sensuality, sexual intimacy, sexual identity, reproduction/sexual heath and sexualisation. These areas are described below. Sensuality is what enables people to feel good about how their bodies look and feel. It allows them to enjoy the pleasure their bodies can give to them and others. The need to be touched by others in loving ways, the feeling of physical attraction for another person, body image and fantasy are all part of sensuality. Sexual intimacy is the ability and the need to be emotionally close with another and to have that closeness returned. While sensuality refers more to physical aspects of our relationships, sexual intimacy focuses on emotional needs. Sexual identity refers to people's understanding of who they are sexually, including
1. gender identity (their sense of being male or female),
2. their gender role (what men and what women are supposed to do) and
3. their sexual orientation (which gender they have primary affectional and sexual attraction to).
Reproduction and sexual health is the most familiar aspect of sexuality. It includes all the behaviors and attitudes having to do with having healthy sexual relationships and having the ability to bear children. Sexualization is using sex to influence, manipulate or control other people. Termed the "shadow" side of sexuality, sexualization spans behaviors that range from mutually enjoyable to harmlessly manipulative to violent and illegal. It includes such behaviors as flirting, seduction, withholding sex, sexual harassment, sexual abuse, incest and rape.
Gender Roles
Gender roles refer to what is considered appropriate and acceptable behavior for men and women. There has been tremendous change in the notion of gender roles in the last 20 years and doors have been opened to women in education and occupation. There are, however, still many deeply held beliefs about which behaviors are feminine and which are masculine.
Religion
Religion refers to a specific set of beliefs and practices regarding the spiritual realm beyond the visible world, including belief in the existence of a single being, or group of beings, who created and govern the world. Ritual, prayer and other spiritual exercises are commonly part of religious practice.
Religious beliefs often provide guidance for behavior and explanations for the human condition. Religious beliefs and communities are often sources of strength for cultural groups coping with the demands of the majority culture. Religion can provide a sense of community and a basis for cohesion and moral strength within a cultural group. Religious communities can also serve as centers of support, resistance and political action.
Many, if not all, religions establish sexual norms. Most organized religions condemn homosexuality and so it is often difficult for gay, lesbian and bisexual people to find full acceptance and spiritual peace within their families' house of worship or religious tradition.
Second, the belief that AIDS is punishment from God for immoral behavior is not uncommon. Messina (1994) notes that in a small study of African-American women from an urban area two-thirds believed that AIDS is a fulfillment of prophecy regarding plagues from the Book of Revelations. A study of people’s attitudes about HIV/AIDS revealed that their deeply held religious views lead to the belief that AIDS is God's punishment for young people’s corruption by modern western culture. This belief was found to be most common with the older generation.
Third, the many Christian communities ban on any contraceptive use, even among married couples, makes it difficult to convince religious Christians and to use condoms. Fourth, fatalism is a significant barrier to HIV/AIDS prevention. Fatalism is the belief that life is pre-determined and that individuals are powerless to change what happens to them. Fatalism results from both the tremendous influence of religion and the reality of poverty and that it makes arguments for safer sex difficult.
To effect behaviour change among youths who may not find these religious doctrines and beliefs comfortable, it is necessary that strong advocacy and workshops to be organised for religious leaders and communities. While the belief augur well to practitioners of abstinence and strong believers of the faith, it is very difficult for many young people to understand and therefore constitutes an obstacle to behaviour change, since they cannot understand or appreciate the motive behind the belief or at least cannot endure the rigors of abstinence or change their sexual orientation.
The role of religious beliefs and the community in information and care
As seen in the various country reports, religious beliefs are closely related to representations of HIV/AIDS, its causes and effects. The spiritual and moral attitudes associated with these beliefs may be used to develop responsibility towards oneself and others with respect to the infection, and may also develop solidarity toward infected and sick people. Such solidarity is more specifically active among certain religious communities and spiritual leaders, for instance, Christian missionaries and Muslim
Imams.
Level of Acculturation
Acculturation is a process that occurs when two separate cultural groups come in contact with each other and change occurs in at least one of the two groups. While most changes are thought to occur only in immigrant groups in the urban areas, the dominant (mainstream) cultures in the all our societies have undergone changes as a result of contact with other cultures.
Individuals within racial or ethnic groups can be:
· acculturated—having given up most of the cultural traits of the culture of origin and assumed the traits of the dominant culture.
· bicultural—able to function effectively in the dominant culture while holding on to some traits of their own culture.
· traditional—holding on to a majority of the traits from the culture of origin while adopting only a few of the traits of the dominant culture.
· marginal—having little real contact with traits of either culture.
Individuals within any given cultural group can be anywhere along the continuum. For immigrants especially in our urban centers, it is common for variation to exist even within one family, with older generations holding onto traditional traits, and young people functioning more in a bicultural manner.
WHY YOUNG PEOPLE?
HIV/AIDS is increasingly a disease of the young and most vulnerable, particularly girls. More than a third of all people living with HIV/AIDS are under the age of 25, and almost two-thirds of them are women. Of the 5 million new infections in 2002, half were among young people. Preventing HIV among young people is at the core of UNICEF’s global response
Every minute of every day six young people between the age of 15 and 24 become HIV-positive. Yet young people remain alarmingly uninformed about the most basic facts about HIV and prevention. Sexual activity, the main route of transmission of HIV, begins in adolescence for the majority of people. Yet young people remain alarmingly uninformed about the most basic facts about HIV and prevention. In sub-Saharan Africa, where two girls are infected for every boy, half the teenage girls surveyed did not realize that a healthy looking person could be HIV-positive. In the Ukraine, 39 per cent of teenagers had never heard of AIDS or still believe HIV can be transferred through supernatural means.
Adolescence is also the time many young people are at risk of experimenting with drugs. Approximately 10 per cent of new infections worldwide – mostly among young people – result from the sharing of drug use paraphernalia. Young people often do not have the skills or the incentives to avoid starting doing drugs. Once they have started, many quickly progress from inhaling or snorting to injecting, which dramatically increases their risk of infection.
Establishing healthy behavioural patterns during adolescence is much easier than changing risky behaviour later on. Around the world, the evidence shows that wherever the spread of HIV is slowing or even declining, it is primarily because young men and women are being given the tools and the means to adopt safe behaviours. In fact, in every country where HIV transmission has been reduced, it has been among young people that the most spectacular reductions have occurred. But even when young people have the information they need, it is often not enough to make them act. They also need to develop ‘life skills’ – the attitudes and negotiating capacity to put what they know into practice and to make informed choices about sex, drugs and other issues
THE EFFECT OF CULTURE ON SEXUAL AND REPRODUCTIVE HEALTH POLICY AND PROGRAMMES FOR YOUTH
CULTURAL/SOCIETAL IMPACT OF HIV/AIDS
Many infected people remain unaware that they are HIV-positive, because testing systems are far from being available everywhere. When detected through HIV screening, the short- and long-term societal and cultural effects are generally disastrous for them and their families (or group). The professional and social rejection of the infected and sick frequently results in a serious crisis: destruction of personal and community ties, and deep moral, cultural and economic distress. For these reasons, infected people often tend not to inform their spouses or regular sexual/emotional partner. In other cases, people are not concerned with HIV/AIDS infection due to more pressing concerns associated with their “underprivileged” socio-economic situation. As for people in economically and socially superior positions (i.e. “sugar daddies”, people with authority in business, public, or educational sectors) they tend to regard themselves as “immune” from the disease because of their socio-economic standing. Many of those with professions that involve frequent mobility do not assume their responsibility towards occasional sexual partners. These professions include: truck drivers, peddlers, sailors, soldiers, mercenaries, itinerant merchants, officials, temporary workers in mining, industrial fishing, agriculture or construction. Thus the epidemic and prostitution are highly concentrated in activity zones related to these professions, especially along national borders. In the most extreme situations, the disease can result in an “AIDS rage”, where infected persons deliberately infect new sexual partners as a revenge or as a response to a supposed curse.
Attitude encountered among certain urban segregated groups of young people, is the deliberate participation in high-risk activities. Although they are conscious of the risk, they perceive it as a challenge, akin to a gambling-type behaviour. Finally, in areas where epidemiological risks are high and multiple (malaria, typhus, cholera, sleeping sickness, TB, STDs in general) and deadly dangers frequent (war zones, mined areas), people do not feel the same urge to crusade against a specific disease or deadly danger among others. The most serious obstacle to prevention, however, is the cultural shock experienced by the younger generations. They must at the same time face a world of materialistic interest, individualistic/selfish behaviour, harsh competition for employment, mass unemployment, poor housing or lack of accommodation, in other words daily “struggle for life”.
In many Nigerian societies, cultural taboos on sexuality have made it very difficult to create adequate policies and programme to deal with youth sexual and reproductive health and rights (SRHR). Sexuality itself is a difficult topic to broach in the public arena, and the idea of young people and sexuality introduces another level of difficulty. Even when laws and policies exist to protect youth's SRHR, cultural and religious climates may hinder their implementation.
For example, among Igbos, where there is widespread discomfort with sexuality, "accurate information on sexuality is scarce, and health care of any kind is hard to come by for young people in the area, who are seen as essentially healthy and not in need of service. Those who seek reproductive health services often are met by judgmental health providers, and are afforded little or no privacy in which to discuss their problems. In virtually all Nigerian societies, taboos on sexuality impede open communication and access to information about SRH. In some areas, low levels of literacy increase these problems.
Attention to the sexual and reproductive lives of young people in Nigeria arises from concern over national population momentum. Growing rates of HIV infection among young people also compels governments to look at SRHR education, less from concern for individuals than from concern about national goals and priorities.
Cultural and religious restrictions often mean that SRH is a part of a public health agenda, which is quite different from a rights-based approach to SRH. Public health policy usually looks at effects on entire populations and focuses less frequently on effects on individuals and their rights.
The constraints arising from cultural traditions often limit young people's access to the information and services they need to make informed and responsible decisions about their sexual and reproductive lives. Because it is often used to justify social inequality and can be a roadblock to achieving the full spectrum of human rights, "culture" must be addressed vis-à-vis the rights of young people.
Effect On Girls
Some cultural traditions and expectations place disproportionate constraints on girls and challenge the "physical and psychological health and integrity of individuals. This is most evident in the practices of marrying female children and very young women and female genital cutting (FGC).
Marrying girls at a young age is common in many cultures where girls are undervalued. They are an additional expense if dowry is to be paid; smaller dowries are one incentive for marrying girls earlier, as is the common belief that an early marriage ensures a long period of fertility. Early marriage may lead to early childbearing, with subsequent disruption of education as well as high rates of maternal morbidity and mortality.
FGC, which is till practiced in some part of Nigeria, is an important rite of passage that places female infants, children, and young women at risk of infection and infertility as well as of severe blood loss, shock, and even death. FGC is intended to curb female sexual desires or prevent sexual activity, and may be a cultural necessity for marriage. Young women often fear social rejection if they do not undergo the procedure. Cultural norms like this may place girls and young women at increased risk of HIV infection. Early marriage can lead to increased chance of infection, as young women tend to marry older men, who are at increased risk of being already infected. In these circumstances, most young married women cannot safely request their husband to use condoms.
THE ROLE OF INFORMATION AND COMMUNICATION
Besides media and education, live communication is the major channel for developing relevant dialogue, discussion and counselling concerning HIV/AIDS prevention, care and support. It needs openness to initiating and strengthening relations with local stakeholders, community leaders, population key informants and opinion leaders. If they respect the local culture and people’s life conditions, the arts, sports and creativity can provide opportunities in this respect.
Informing/sensitizing at the local level
Informing and sensitizing activities are at the core of culturally appropriate prevention projects and of the development of new attitudes toward people with AIDS. Non-school education associations and groups can work in this perspective, provided they adapt a tailored approach using the following methods of communication:
• Discussion sessions (group or personal) with local leaders, modern or traditional, political and social (trade unions) or spiritual, including traditional healers;
• Medical/sanitary training for people working in prevention and care projects and welfare centres;
• Encouraging peer educators (individuals or groups) to speak to their family, age group, work or leisure time partners, with emphasis on prevention and care;
• Mobilizing infected or sick people to speak about their experiences;
• Opportunities: workplace, public events, sports game, cultural festivals, religious celebrations, funerals, markets, school, and meetings;
• Informal opportunities: discussions in bars, hostels, discotheques, sports fields, other entertainment places.
Cultural communication for behaviour change
• Informing people:
- “Translating” the initial situation, bringing together local and external resources, explaining constraints linked to the institutional context, emphasizing the “invisible” aspects of the epidemic expansion;
- Ascertaining that the community grasps the problem, can identify the means to solve it and the expected improvement, and is ready to get fully involved to ensure the success of prevention and care activities already undertaken.
The global media culture can be an independent force in the lives of young people, influencing behavioural and value patterns that differ from those of their elders. Some argue that ICTs carry a "cultural package" of values associated with Western popular culture. Facilitated by ICTs, media culture can sometimes conflict with more traditional concepts of how youth should behave.
In urban centers, media culture and its predominant messages permeate almost all aspects of young people's lives. Increasingly, access to ICTs influences youth's education, personal relationships, employment opportunities, and more. The culture "industry", referring to the entirety of the media and ICTs, is a powerful tool through which young people can access information about SRH. With such information, they can exercise their sexual and reproductive rights and make better-informed decisions about their lives. Thus, ICTs should be available to all and should offer accurate information.
Information Communication Technology (IEC): Present Situation
In the UNFPA Evaluation Report (1999), the following observations were made
• IEC strategies focus too much on imparting knowledge (cognitive approach) and not on bringing about behaviour changes;
• They also miss target audiences because of lack of specification or by being too general IEC projects, underestimating and misunderstanding specific women’s, men’s and young people’s life issues and over-emphasizing individualistic rather than community models;
• Available research on sexual behaviours (major aspects and underlying value systems) is either absent or misused;
• Information based communication procedures are unidirectional and artificially didactic;
• Media programmes or articles are not related to available services and other IEC activities;
• Traditional media are not well identified and poorly used;
• There is some confusion between increasing knowledge and inducing change in behaviour; the latter would require encouragement and an emotional approach.
Thus, further effort is necessary in order to build culturally appropriate prototype educational material, and new information and communication channels using an inter-sector approach. This would require the cooperation of other local stakeholders, whether institutions or NGOs, at the international, national and local/cultural level, possibly along the lines of UNAIDS’ Communication Framework on HIV/AIDS.
Information (mass media)
The mass media have a significant role in creating and sustaining public opinion and the political will to deal with the HIV/AIDS epidemic. The media can expose certain trends and phenomena in the community or society that facilitate the spread of HIV/AIDS and inform the public about them. They can also play a central role in educating the public about the importance of preventive measures and serve to point out threats. They can help create public awareness and mobilize public opinion against trends, phenomena and practices, which favour the spread of the epidemic. Active involvement of media organizations and communication practitioners in the effort to deal with HIV/AIDS is critical, if knowledge and awareness are to be increased and risk behaviour reduced among different population segments in African countries.
Important groups like young people are not reached by media prevention messages due to multiple factors, such as political barriers and the fear of a possible repressive attitude from authorities. Communities in remote areas and/or speaking minority languages are also difficult to reach by the established media channels.
Moreover, in many cases, the message is inefficient in its form and content, because it is not adapted to the specific cultural context.
The major factors, which contribute to the inefficiency of the mass media, are:
1) The ignorance and relative indifference of the “gatekeepers” in the media to HIV/AIDS issues. Editors and managers in media institutions decide which stories are to be published/broadcast or not. News selection depends on their choice;
2) The inability of media practitioners to conduct investigative reporting on HIV/AIDS.
3.) More often than not the language and content of the message does not suit the target group it intends to change their behaviour.
Beyond these limited achievements, more complex shortcomings have been encountered in IEC projects. The lack of understanding with respect to the medical or informative content of the message, as well as the subsequent behaviour involved. For instance, in in our communities, media messages broadcast to the rural, urban, uneducated or poor populations have not been understood. Instead they have conveyed or reinforced irrational fears and provoked rejection from possibly infected or sick people, resulting in a fatalist attitude concerning prevention and self-protection. Many tribal populations are so scared by images broadcast on television and showing the physical degradation of people with AIDS, that they refused to hear any more about the disease. Thus, information on prevention and care action is being made much more complicated and, in some cases, impossible.
Preventive education
School education achievements
From UNESCO’s experience, education, and more specifically at school and university, is a key instrument in prevention. Specific information courses are being developed in many countries, as an integral part of the school curriculum on topics such as: life skills, the mutual respect and understanding of women and men and peer education. Practical information about body physiology, sexual education and the importance of protection (i.e. condoms) is also taught. This effort needs to be reinforced and adapted in our communities as well as widened and made accessible to all school-age children within the context of basic learning, using well adapted methods and contents, in other words, culturally-appropriate education for all.
1. Education principles; A continuing life-skills and HIV/AIDS education programme must be implemented at all schools and institutions for all learners, students, educators
and other staff members. Measures must also be implemented at hostels.
2. Age-appropriate education on HIV/AIDS; It must form a part of the curriculum for all learners and students, and should be integrated in the life-skills education programme for pre-primary, primary and secondary school learners. This should include the following:
a.) Providing information on HIV/AIDS and developing the life skills necessary for prevention;
b.) Inculcating basic first-aid principles from an early age, including how to deal with the necessary safety precautions when bleeding;
c.) Emphasizing the role of drugs, sexual abuse and violence, and sexually transmitted diseases (STDs) in the transmission of HIV and empowering learners to deal with these situations;
d.) Encouraging learners and students to make use of health care, counseling and support services (including services related to reproductive health care and the prevention and treatment of sexually transmitted diseases) offered by community service organizations and other institutions;
e.) Teaching learners and students how to behave towards persons with HIV/AIDS, raising awareness on prejudice and stereotypes surrounding HIV/AIDS;
f.) Cultivating an enabling environment and a culture of non-discrimination towards persons with HIV/AIDS, and
g.) Providing information on appropriate prevention and avoidance measures, including abstinence from sexual intercourse and immorality, the use of condoms, faithfulness to one's partner, obtaining prompt medical treatment for sexually transmitted diseases and tuberculosis, avoiding traumatic contact with blood, and the application of universal precautions.
3. Education and information; Education and information regarding HIV/AIDS must be given in an accurate and scientific manner using comprehensible language and terminology.
4. School, education and parents; Parents of learners and students must be informed about all life-skills and HIV/AIDS education offered at schools and institutions, the learning content and methodology to be used, as well as values that will be imparted. They should be invited to participate in parental guidance sessions and should be made aware of their role as sexuality educators and importers of values at home.
5. Educators, pupils and students; Educators may not have sexual relations with learners or students and, should this happen; the matter has to be handled with all manner seriousness
6. Infection and teaching activity; If learners, students or educators are infected with HIV, they should be informed
7. Duties and responsibilities; All learners, students and educators should respect the rights of other learners, students and educators. The Code of Conduct adopted for learners at a school or for students at an institution should include provisions regarding the unacceptability of behaviour that may create the risk of HIV transmission. The ultimate responsibility for a learner's or a student's behaviour rests with his or her parents. Parents of all learners and students:
- Are expected to require learners or students to observe all rules aimed at preventing behaviour which may create a risk of HIV transmission;
- Are encouraged to take an active interest in acquiring any information or knowledge on HIV/AIDS supplied by the school or institution, and to attend meetings convened for them by the governing body or council.
It is recommended that a learner, student or educator with HIV/AIDS (and his or her parent, in the case of learners or students) should consult medical opinion to assess whether the learner, student or educator, owing to his or her condition or conduct, poses a medically recognized, significant health risk to others. If such a risk is established, the principal of the school or institution should be informed. The principal of the school or institution must take the necessary steps to ensure the health and safety of the other learners, students, educators and other staff members. Educators have a particular duty to ensure that the rights and dignity of all learners, students and educators are respected and protected.
THE CULTURAL APPROACH TO BEHAVIOUR CHANGE INTERVENTION TECHNIQUE
Focusing on Economic and Sexuality Issues
Research indicates that the sexual behaviors that put young people at risk for HIV/AIDS and unwanted pregnancy are often tied to what teens see in their future. Those visions are often linked to economic realities in their lives. Therefore, society and people working to effect behavioural change among youths should pay particular attention to topics related to economics and sexuality that include:
· the young people's and the family's level of acculturation;
· economic status and opportunities for their families;
· whether teenage sexual activity and parenthood is common and what your young people think about these issues;
· the availability of low- or no-cost contraception, including condoms;
· the availability of community resources for medical, housing and other assistance for people with HIV infection and AIDS
Advocacy for Youth (2004) notes that as the HIV/AIDS epidemic moves into its second decade, it is hitting particularly hard on young people in poor communities. Young African experience higher rates of unemployment, poor housing, poor health, early death and inadequate medical insurance than others. Many would argue that the greatest problems facing many African youth and are economic. In order to fight the AIDS epidemic, we have to fight the evils of poverty.
Culturally, the best way to deal with poverty is going back to the communal/extended family system. This appears to be the major option in the face of worsening global economy. Depending on the government to provide all including employment for its ever-growing population may be disappointing. It is rooted in our culture for the rich members of the extended family to care and assist the poor ones especially the young ones. Unfortunately the modern trend urbanization and globalization appears to have eroded this practice. Selfishness has overtaken the brotherly care and support for the week members of the family.
One of the major roles of the family is psychological and economic backup. In the time past, enlarge family membership was of economic advantage owing to the system of farming and trading. Contemporarily, it is advisable for the old practice of bearing many children to be changed vis-à-vis the unfavorable global economic situation that affect the poor the more. People should bear less number of children as they would be able to train to the optimum levels where the would be beneficial to the family and society at large rather than becoming burden to them.
Traditional Family Values And HIV/AIDS
Family education, in general, exerts an indispensable influence on youth behaviour. However, HIV/AIDS is very rarely discussed between parents and children, in so far as sex issues are considered “taboo”. Generally, this subject is tackled with friends, school acquaintances or partners. According to some authors, parents avoid this issue, because they believe it encourages the early practice of sex. As regards family patterns, the idea of the family in Nigeria is very complex, due to the diversity of patterns of family organization. The idea of family brought from European countries does not fit with the local reality, since it is narrowly related to the socio-cultural context of each group, community or society. “The traditional idea of family encompasses criteria of blood, marriage links and sometimes housing. Family is the space where children get along with their siblings, where community norms and values are transmitted and social control is exercised”. (Locoh, 1988). Therefore, the family may exert control over sexuality. Likewise, kinship systems may influence sexual behaviour. For example, in a matrilineal system, male sexual dominance is weaker because of women’s control over domestic production. Thus, this system contributes to the autonomy and even independence of women. Concerning the structure of the household, the control over sexuality would be more severe in the extended families in which, unlike nuclear families, several generations live together.
The loss of traditional values regarding sexuality is another critical factor in HIV/AIDS prevention and care. Many traditional societies have suffered severe changes as part of the “modernization” process. These transformations have led to the loss of some traditional cultural norms and values that once influenced individual sexual behaviours. Urbanization and formal education moved individuals away from their groups. Then decisions regarding sex became an individual issue rather than a family or community subject.
SENSITIZATION/MOBILIZATION
Mobilizing people is an indispensable condition for the success of culturally-appropriate preventive action. It has to be closely linked to people’s cultures, value systems, and ways of thinking. This is why views on gender, health and disease, sexuality, life and death, beliefs, needs and expectations should be duly understood, assessed and reflected upon in the design of strategies and policies. These will have to be articulated so as to allow for response building at the local levels accordingly.
The most important issue in bringing about change in behaviour is the identification and mobilization of the motivations of a given group. According to observations by high-level medical and IEC specialists, the actual content of messages is not appropriately disseminated and applied. These messages are devised to give people a clear understanding of the origins and manifestations of infection. Unfortunately, though these messages may be learned and “memorized ” from an intellectual standpoint, they are neither appropriated by the given target group, nor integrated into their everyday habits and behaviour. Therefore, understanding the message does not entail an inward conviction, which would make people modify their sexual and non-sexual practices regarding HIV/AIDS. Therefore, cultural references and resources play a more important role in the development of perceptions and attitudes for communities, groups and individuals, than the medical, educational, or institutional approach.
IEC APPROPRIATENESS
IEC will have to be tailored to people’s knowledge, value systems and cultural acceptance.
Efficient IEC will only be secured as a two-way information system, which integrates local values and knowledge with modern medical data and explanation system. These must be phrased and conveyed using the appropriate language (national and local) and semantics of the group in question and not the purely medical, epidemiological and sexological terminology:
a) In matters of mobilization, the role of religious communities, social movements (women, young people, sports associations, etc.), labour, trade and business unions will be essential. They convey their own value systems, and will evaluate HIV/AIDS prevention and care activities according to their own spiritual, ethical and practical mandates and duties;
b) Traditional cultural leaders, more specifically traditional healers may also be consulted to establish links with the modern-type medical and educational system. It is indispensable to consider their role in prevention and care, because many people consult them when afraid of being infected or effectively HIV-positive, not only as medical experts, but also as social and psychological advisers. They play a recognized role in South Africa and Zimbabwe, Western Africa as well as in other types of societies;
c) Individuals: advocating abstinence, monogamy and condom use raises complex practical and moral issues. These will only be accepted if people’s principles, sexual culture and real life conditions fit with such practices. The same difficulty arises in the transmission of the infection and disease to a sexual partner (or partners). Notification in this case means breaking taboos, models and losing “prestige”. Moreover, traditional family rules can impose silence on the subject, especially with respect to women and girls;
d) Risk groups, or culturally and socially endangered groups, are susceptible to socio-economic, educational and cultural factors, which interact dramatically with medical and health issues. These groups are endangered by various types of difficulties at the same time, all of them with seriously destabilizing and segregating effects: massive unemployment, poor or absent housing, economic distress, lack of education;
e) In this context, unsafe practices, refusal of the condom use, drug abuse and smuggling, alcoholism, sexual and all forms of violence, prostitution and procuring are all aspects of the emerging sub-cultures, which are linked to mere survival concerns in a world of brutal power and materialistic interest. They may create serious obstacles to HIV/AIDS prevention and care, and subsequently, must also be addressed in order to reach significant results in fighting the epidemic.
APPROPRIATE MESSAGES AND PROCESSES
Major lines of culturally appropriate IEC messages and processes (including the use of local languages and modes of expression) have to be defined and qualified in order to design and implement the following strategies:
• Initiate mass mobilization in institutions, the society, families and individuals;
• Raise public awareness towards behaviour change;
• Develop proximity relations between the prevention and care system and populations;
• Cooperate with the civil society, religious communities and traditional healers;
• Build community-based prevention and care projects;
• Elaborate or adapt training systems for planners, civil servants, the media, school- and non-school educators, social workers and medical staff;
• Support new creativity linked to HIV/AIDS (preventive/informative creative material, literary and artistic initiatives) improve its correlation with sports;
• Give special attention to endangered groups;
• More in depth investigation of the “grew zones”.
Mass Mobilization: From Duty To Consensus
First, a fundamental distinction has to be clearly established between institutional action/reaction and society’s response:
• Through their professional culture, institutional networks and agents play a certain role in interpreting decision-makers’ instructions. To this extent, institutional echelons and their staff are used to implement instructions from above, which they understand and integrate through their training, experience and institutional culture. This includes HIV/AIDS Prevention and Care policies and projects. Thus, a fundamental “rethinking” effort is necessary in order to shift from carrying out plans and instructions in a top-down process to adapting working methods to people’s cultures and life habits. Innovative training/sensitizing methods and curricula have to be developed for professionals working in cultural setting.
•Civil society has recourse to its own cultural references and resources, before modeling its response to the challenge and the institutional pressure to change behaviour. Thus, the response will be built on the basis of group and personal consensus, acceptance, conviction and motivations. More precisely, its cultural references and resources (i.e. knowledge and perceptions, traditions, beliefs, and behaviour norms) will be the foundation of new cultural practices, which will respond to the constrains and evolution of the socio-economic environment.
Therefore, community-based project clusters will have to be built on a fully participatory basis, with local key leaders, informants and families, including the HIV-positive and even sick persons. People will mobilize themselves only if they are reached where they are and on an equal footing.
Cultural motivations and concrete interests
One of the major issues concerning HIV/AIDS prevention and care is frequently people’s lack of motivation to become involved in the battle against HIV/AIDS, which for many is a low priority among what they consider to be their most pressing issues and needs. Their life patterns, spiritual and ethical beliefs, relationship to their past and value systems are more likely to be oriented towards preserving their identity, developing daily survival strategies in extreme poverty and facing all kinds of deadly threats, including diseases they and their close family or community are permanently exposed to. This is why they do not see their day-to-day interest in giving HIV/AIDS prevention and care a high priority. Thus any rethinking process and subsequent attitudes towards behaviour change should emphasize concrete reasons for this shift in their priority systems, in order to preserve or regain their identity, improve their daily life conditions and encourage the respect of human life and basic human rights.
Generally speaking, in daily life experience, a culture’s constituent features remain tacit, or unsaid even in extremely extravert cultures. Thus, certain references or resources become apparent only in certain specific circumstances, such as the challenges brought about by HIV/AIDS.
Ultimately, cultural references and resources may be taken into account in identifying prevention and care choices at the local level by three different approaches:
• Identifying cultural values, translated into questions about relevance or interest, based on the community’s reactions to HIV/AIDS;
• Identifying the societal or cultural relevance of possible alternatives (thus substituting the reductionist cost/benefit approach);
• Implementing a process of negotiation between external intervention and local community.
BUILDING COMMUNITY-BASED RESPONSE
Involving people in the battle against the epidemic is of prime importance. In other words, building an appropriate and sustainable response to HIV/AIDS means that people have to be involved personally: at home, in their neighborhood and at their work place. In order to change their behaviour, people need a supportive environment. Developing partnerships at a local level can improve the effectiveness of their response. Thus, a well-supported mobilization process should result in numerous local initiatives. Sustained behavioural change comes as a result of a shared social reaction and a clear understanding that disease and death are the direct consequences of HIV/AIDS for ones self and one’s family.
Beliefs/Attitudes
To deal with the belief system that obstruct the positive behaviour change, or encourages negative and risk behaviours, communities and people working to effect behaviour change among young people should;
· Be conscious and sensitive to cultural heritage and respects and values different heritages while harmonizing them with the conventional beliefs and discoveries. The negative beliefs that effect people’s reproductive health should be changed, i.e. denial of sexual education to young persons on the belief that it will corrupt them. There is need for a high level advocacy to be paid to traditional and opinion leaders who are very resourceful to influencing the beliefs and practices of the communities. While the cultural heritages are preserved, it is however pertinent harmonize the beliefs and practices with healthy conventional beliefs and practices.
· Be aware of the inherent cultural values and biases and how they may affect perception of conventional beliefs; This is very important to identifying the harmful cultural practices as well as working out modalities to effect changes, bearing in mind they are the primary factors of negative practices and risk behaviours and effort should be made to work out behaviour change.
· Be sensitive to circumstances (personal biases, ethnic identity, political influence, etc.) that may require seeking assistance from a member of the culture when interacting with member of that culture in order to identify the vantage point for dealing with such circumstances.
Highlighting cultural references and resources for behaviour change
Existing culture is not a fossilized code, it responds to new challenges. It changes according to material, environmental and external circumstances as well as evolves according to its own internal logic. In terms of HIV/AIDS, this response will have to question ways of life, traditions and beliefs, value systems, basic human rights. In other words, these various cultural references and resources will have to be reconsidered: encouraged, modified, reinvented or dropped. This choice belongs to the community, not to the development worker. It should take place as a process of self-evaluation. Under no circumstances should field workers attempt to change the culture of a community by depriving it of its greatest asset – its sense of autonomy. Field workers can, however, enhance invention, creativity and criticism from certain groups within a culture, who can help their community in seeing its weaknesses and its potential, so as to be able to build a genuinely local response.
Supporting the behaviour change process
It is also important to rethink which role field workers will play once the community accepts the idea of behaviour change. In this process, more than leaders of the debate, field workers are resource persons whom the community members can draw upon when identifying cultural and societal conditions for change in behaviour. As a general rule, field workers’ support should never interfere with the community’s prerogative in the behaviour change process, including the solidarity movement to be launched or reactivated.
In this perspective, three areas can be distinguished in which field workers and groups working to effect behaviour change can usefully intervene:
• Stimulating debate;
• Mediating conflicts;
• Defining activities.
These should be implemented through various methods.
Time and energy expected from community members
There are very few examples of spontaneous mobilization against HIV/AIDS and they depend heavily on the participation of unpaid volunteers who have many other priorities, and who have to be recruited, trained and motivated. These volunteers are often peasants or labourers who must balance the time they spend volunteering with the time they need to spend in working in order to feed themselves and their families. Sometimes volunteers are unemployed persons whose first priority is to find a job. Paid facilitators sometimes do not understand the priorities and needs of their volunteers. This often leads to unrealistic expectations about what volunteers will do with no other incentive than their awareness of the problem.
Motivation cannot be taken for granted, even with a serious threat like the AIDS pandemic. Most community initiatives, at some time or another, are forced to find new ways of keeping volunteers’ enthusiasm high and helping them continue to identify the problem. But HIV/AIDS initiatives have an additional vulnerability: it is especially hard to maintain motivation when highly valued colleagues who are infected with the virus eventually succumb to it.
Traditional healers: opportunities and limits
• Traditional healers often outnumber doctors by 100 to 1 or more in most African
countries. They provide a large accessible, available, and affordable trained human
resource pool.
• Traditional healers possess many effective treatment methods.
• Traditional healers provide client-centered, personalized health care, which is culturally
appropriate, holistic, and tailored to meet the needs and expectations of the patient.
Traditional healers are culturally close to clients, which facilitates communication about
disease and related social issues. This is especially important in the case of STDs.
• Traditional healers often see their patients in the presence of the other family
members, this gives insight on the traditional healers’ role in promoting social stability
and family counseling.
• When traditional healers engage in harmful practices, there is a public health responsibility to try to change these practices, which is only possible with dialogue and cooperation. Research has shown that traditional healers abstain from dangerous practices when educated about the risk.
• Traditional healers are generally respected health care providers and opinion leaders
in their communities, and thus treat large numbers of people through dialogue and cooperation. Healers have greater credibility than village health workers (who are often their counterparts in village settings), especially with respect to social and spiritual matters.
• Since traditional healers occupy a crucial role in African societies, they are not likely
to disappear soon. They survived even strict colonial legislation forbidding their practice. Even with the rapid socio-cultural changes occurring in many African societies, traditional healers continue to play a crucial role in addressing a variety of psychosocial problems that arise from conflicting expectations of a changing society.
• Numerous studies document traditional healers’ enthusiasm for collaborating with
biomedical health providers and show that their activities are sustainable as they generate their own source of income.
• Since the 1980s, healers have been organizing themselves into traditional healers’ associations, which make it easier to establish collaborative programmes.
• Collaboration seems to improve health delivery in number of ways: increased
knowledge and skills of traditional healers, increased confidence in their practice,
increased openness towards the community within their work, earlier referral to
hospital or health center.
However, points against, or weaknesses of collaboration include:
• The training and licensing of healers is not institutionalized, which makes it difficult to reach and train them regularly in a standardized manner.
• Quality control of healers is difficult in the absence of officially recognized licensing procedures.
• There is no general monitoring of healers’ activities or claims.
• Traditional healers lack detailed anatomical and physiological knowledge.
• Traditional healers may engage in some harmful practice or cause delays in referral to biomedical facilities.
• Promotion and improvement of traditional methods may undermine efforts to increase access to biomedicine.
• Official recognition of traditional medicine gives legitimacy to traditional healers though their treatments and methods are still largely untested.
• Collaboration with traditional healers raises their expectations of greater recognition from government, which they may not be able to give
Expected changes
It is important to recognize that the expected results of the action undertaken cannot be identified as
quickly and precisely as institutions would hope for, except, to some extent. It may be counter-productive to try to predict the results of the action for three major reasons:
• The apparent “disorder” (when compared with administrative models of “order”) of the behaviour
change process (i.e. condom use, stable relations and sexual abstinence) which has been fully
integrated into the culture of community, does not mean that the action has been totally
unsuccessful;
• “Invisible” changes (in mentalities and behaviour underlying rationality) may be more valuable to
the community than the more visible results repeatedly advocated by institutions (infection
decrease, statistical data in general, etc.);
• It should be kept in mind that, especially when considering the HIV/AIDS issue, the process of
change may require much more time than could be initially predicted (the time needed for the
cultural integration of prevention and care action is essentially unquantifiable: interactive
consensus, collective will and responsibility, etc.).
At the same time, it may be necessary to explain to the community the possible unforeseen effects of the action undertaken, so that they may assess it in their own terms
CONCLUSIONS
a) Though there is worldwide awareness of the danger, it is not enough to motivate people to adopt significant changes in their sexual and non-sexual behaviour with respect to prevention and care. This is due to non-medical or health-related factors, which must be better understood and integrated into new strategies. Moreover, information methods are often unsuited to the understanding capacity of a given population.
b) HIV/AIDS is in permanent interaction with people’s cultures and overall socio-economic development.
c) These interactions, as any two-way process, develop situations and obstacles, which prevent medical and informative action from being fully effective. These can be summarized as follows:
• economic and social development issues heavily influence the spread of the epidemic, in so far as they seriously affect people’s life conditions;
• socio-economic evolution also seriously impacts on societal/cultural previous value systems and life models, especially in developing countries, mainly through population movements, migrations, miserable housing and living conditions, thus aggravating infection risks;
• HIV/AIDS in turn develops important economic, social/societal and cultural effects.
d) Thus, reliable prevention and care IEC has to consider the relationship between cultural references and resources, and socio-economic development issues.
SUMMARY
The ways and means for bui
