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CULTURAL APPROACH TO HIV/AIDS PREVENTION AND CARE: EXPERIENCES

AND LESSONS LEARNT FROM THE KAWEMPE PROJECT UGANDA

By

Paul Bukuluki

(Medical Anthropologist)

Makerere University

Faculty of Social Sciences

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BackgroundThe cultural approach to HIV/AIDS Prevention and Care

project was designed bearing in mind a number of issues relating to culture and people’s behaviour.

We attach different significance and meaning to particular things because we are products of a socialisation process, which differs from one culture to another.

Culture embodies the knowledge, attitudes and practices that have meaning to a particular society. Culture, therefore, portends a set of guidelines internalised through a whole process of socialisation within the family, school, religious institution and the society at large (Alenja, 2000).

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BackgroundCulture has an inbuilt dynamism that ensures that change is possible over time

and under a given set of conditions, usually external to the community. It is during this period of uncertainty that problems come to light as people attempt to make adjustments to new and challenging social, economic or ecological situations. These challenges culminate into a complete set of problems that the community is ill prepared for. This is where we find ourselves in a dilemma in context of HIV/AIDS in Africa and Uganda in particular.

Therefore, culture determines the meaning that we attribute to every part of our existence (Oxfam, 1995).

Culture is central in defining health and disease in terms of aetiology, management and prevention. AIDS is one disease that demonstrates the complex interaction between a disease agent and human behaviour within varying cultural contexts. Therefore, in attempting to understand the various determinants of disease patterns, the inter-linkage between culture, gender and HIV/AIDS is particularly rewarding.

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Conceptual Framework

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CultureBeliefs, traditions, values, ways of life

mCultural Resources•Family life and education•Solidarity•Life skills•Coping abilities•Peer groups •Mutual education (young people associations)•Therapy management

Socio-economic Aggravating FactorsPoverty, Poor health, Family crises, Unemployment, Rural decline, Urban migration

Cultural References Potentially Risky

Cultural Customs•Forced marriages•Sexual experiments among the youth•Commercial sex•Sugar daddies/mummies

Cultural Traditions•Widow inheritance•Polygamy•Funeral Rites•Reproductive Value systems•circumcision/excision

HIV/AIDS Situation and Interventions•High rate of infection (especially among the young people

•Current intervention system: Prevention, care, treatment programs and activities

Major deficiencies:Disastrous economic and socio situations of many young peopleDisruption of their previous societal/cultural systemsQuantitative/Qualitative gaps for appropriate preventive education (IEC), absence of co-ordination between development efforts.

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Kawempe Project

A Cultural Approach to HIV/AIDS Prevention and Care for Sustainable Development recognized that there is an active interaction between culture/HIV/AIDS and Development.

It is against this recognition that the cultural approach to HIV/AID prevention and Care pilot project was designed to innovatively use the cultural resources and references to address the problem of HIV/AIDS.

Taking a cultural approach to HIV/AIDS Prevention and Care means that culture is considered the core of any economic and social transformation and that the people's ways of life, value system, traditions, and beliefs are considered key reference points for planned activities in mitigating HIV/AIDS epidemic.

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Problem Addressed by Kawempe ProjectThe complex nature of culture, manifested in the value system makes it

difficult to develop effective and well-focused strategies. There is a gap between what is known in terms of behaviour, and what has been done for behavioural modification. There was need to develop greater understanding of the impact of AIDS in the communities, with particular reference to the youths, women, persons with disabilities and the elderly. These groups are particularly vulnerable to exploitation and abuse. It was not known how these groups are coping, or how they are protected, or how their protection should be organized using the cultural approach to development.

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ObjectivesThe overall objective of this project was to promote HIV/AIDS

prevention and care based on the cultural approach to development perspective and more generally, the promotion of cultural, societal and economic revival, including self-esteem, coping mechanisms, not only for learners, but also, with special emphasis, for out of school youth. In carrying out the project, it was anticipated that its activities would contribute to:

a) Bring about sexual and relational behaviour changes in respect to HIV/AIDS prevention and dissemination risks taking into account the culture of the beneficiaries.

b) Develop more supportive attitude in human care to the infected and affected people ad their families to stop far and rejection and maintain solidarity among relatives and friends.

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Key Activities and OutputsCoping Mechanisms: The project developed appropriate tools for identification of

survival strategies. PLA tools were applied to learn how youth cope with their life in an environment which is not friendly. There are both positive and negative strategies and they vary according to gender. The female youth survive by engaging in petty trade; disguised unemployment such as sewing, food vending, house maids, bar maids, working in saloons, etc. Often they cohabit in “seeming marriages”, or commercial sex. The male youth survive by working as unskilled labourers in garages, wood works, transport services, car washing, and other disguised forms of unemployment. They also engage in many forms of substance abuse and crime.

Appropriate Life Skills: Using PLA tools and FGDs, it was established that the out-of-school youth had the potential to improve their living conditions if they are facilitated with the appropriate life and production skills. The gaps in life skills and productive skills were identified and these formed a basis for designing interventions to equip the youth with appropriate life skills with a key focus on production skills to enhance income generation and improve the welfare of the youth.

PLA tools were useful in operationalising the cultural approach to HIV/ADS prevention and care. Among others the study used Health mapping, Venn diagrams, children drawings, theatre for development, sporting activities and gender analysis tools. These tools were effective in identifying needs of young people, identification of community resources and references and stimulating participation.

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Key Activities and OutputsEnvironmental Factors: The project revealed that social and physical

environment in which the youth live offered less motivation for initiating and sustaining behavioural change in relation to HIV/AIDS. To help the youth make efforts towards behavioural change, the project looked at individuals in the context of their environment. Community dialogue tools were used to engage different actors in the community as change agents. Through this process the youth became aware of their potentials, began changing their attitudes and practices and improved their levels of esteem.

Net-working with NGOs and other actors: NGOs such as Uganda Youth Development Link (UYDEL), Uganda Association of Women Doctors (UAWD) and Plan International (Uganda) were actively involved in the entire process of project planning and implementation. Major project activities were contracted out to facilitate more specialised implementation of the project activities and to build capacity for sustainability.

The workshops with the government technical staff and staff from NGOs aimed at building the capacity to appreciate and apply the cultural approach in their respective HIV/AIDS activities.

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Key Activities and OutputsCommunication Channels: The Project established that communication and

willingness to dialogue is key to linking the youth to service centres. Many communication channels were revealed in the study and used to facilitate communication between the youth and service providers and leaders. These included among others: administrative structures, traditional leaders, youth councils, local councils, religious institutions, economic institutions, health service centres, transport service providers, counselling institutions, etc.

It should be noted that these offer an important communication network in the community which are constantly used to facilitate flow of information on matters affecting the community, including HIV/AIDS.

Community Mobilisation: Community mobilisation was used as a strategy as a culturally relevant method to stimulate interest and participation of the community. The project demonstrated that if the community is well mobilised, the people own the processes of change and the spirit of collective action is strengthened. Use cultural networks (such as markets, marriage ceremonies, cooperative ventures, drinking places, water wells, etc) proved to be effective for collective action.

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Key Activities and OutputsThe Institution of Paternal Auntie: The project established that the paternal

auntie is useful in assisting the young people (mostly female youth) to understand and cope with changes in their bodies as they grow up into adolescence. However, some youth find them unreliable in handling confidential matters (fears of being reported to parents).

They resort to mature women who act as ‘social aunties’. These too have limitations such as change of locations quite often and some parents and religious organisations accuse them of teaching immorality to their children.

IEC Strategy: The project found the IEC strategy wanting in many areas. Conceptually the IEC approach assumes the existence of a communication expert who identifies gaps in a program/activity. What is generally perceived as participation does not include decision making and control.

To address these gaps the project took the community dialogue strategy.

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Key Activities and OutputsCommunity Dialogue Strategy: Community dialogue is perceived and

practiced as continuous mutual exchange of views, ideas and opinions between people or groups of people. Its principle aim is to bring about mutual understanding and seeking of an issue to bring about a solution. It recognises existing knowledge, skills and capabilities of communities that can be used to improve or change their situation for the better by themselves.

It was assumed that the best way of achieving the objectives of the study was by using the community dialogue strategy that puts people/beneficiaries at the centre of bringing about behaviour change and prevention of HIV infection. The challenge therefore is to develop a model that allows the communities to dialogue about issues affecting their health and ultimately agree on what should be done and how it should be done, not by the experts, but by the people themselves. Community dialogue strategy facilitates more shared understanding of individual, group and community’s concerns and uses the community strength to enhance and sustain HIV/AIDS prevention and care activities. This illustrated paradigm shift from the traditional IEC perspective.

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Key Activities and OutputsFigure 1: The Community Dialogue Model

Ensuring Sustained Dialogue: Linking communities and services, supporting the channels to carry on themselves

Making Channels Action Plans: Based on the concerns and the current status, the community will make plans on how to achieve what they want to be in future

Making visible the unexpressed concerns: Helping the community identify the most important concerns and how to address them

Channel Identification and Mapping , Duty Bearers: Knowing which channels exist in the community, where they are, their roles

Setting the Stage – Making an entrance into the community, identifying community leadership and community structures

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Source: UNICEF, Uganda (2003), Community Dialogue Field Manual

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Key Activities and Outputs

The major tenet of CD: people are the experts in identifying development issues and taking collective actions.

Appreciative Inquiry (AI): This was used to enable the

community discover its strength, appreciate values which are important to them; dream/envision improved situations based on what is considered useful values and norms; they dialogue about what is, vis-à-vis, what ought to be.

The AI model was used to facilitate the process of discovering what the youth see to be their strength and opportunities and their dreams in their cultural settings. They would then engage in dialoguing about the issues that emerge, and design and deliver interventions.

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Key Activities and OutputsMetacognitive Strategy Instructions: The use of the cultural approach to

HIV/AIDS prevention requires that the issues, effect and impact be understood at personal level in order for the individual to avoid behaviours that can lead to infection. The IEC approach took this process for granted, that when the message had been designed and delivered the “early adopters” would take on the new behaviours almost automatically.

The project employed the metacognitive strategy to understand the process of reaching common understanding of an issue of concern to the community, such as HIV/AIDS. This strategy has added to the conceptual understanding of the process of how a community can reflect on an issue to reach common understanding of the implications as well as the required actions and resources to mitigate its negative impact in a given cultural setting.

The project found a wide range of metacognitive variables and behavioural indicators which are associated with how knowledge is shared and linked to personal attitudes, opinions, practices and the advocacy strategies adopted to modify personal traits, behaviours and the cultural environment.

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Key Activities and Outputs

The metacognitive Strategy Instructions (CSI) used in this project were replicated from those used by Mansoor Shavali and Kiumars Zarafshani (2002). However, there is need to replicate the approach in more cultures.

The integration and application of the metacognitive strategies within the cultural approach and policy allows people as individuals and collectives to develop common understanding of issues affecting their life and families and use this understanding to design more appropriate and realistic strategies for behaviour change.

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Lessons: Metacognitive StrategyThis approach provided a rich set of lessons including the following:a) It provides opportunities for participants to analyse an event. Participants

must not be hurriedb) It provides opportunity for participants to give critic by allowing them to

make comments, observations and asking questionsc) Allow original thinking and creative actiond) It encourages participants to identify problems within a given contexte) It facilitates learners to engage in dialoguingf) It encourage learners to use their passed experiencesg) It provides an opportunity for learners to understand the general objective

of a given taskh) It provides an opportunity for participants to recall what has been learnti) It provides an opportunity for participants to get involved in group workj) It facilitates participants to read or use maps, diagrams and figures that

describe their ecological and cultural context.

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Integrating the CA in the National HIV/AIDS Strategic Policy Framework

The cultural approach to HIV/AIDS cannot work independently and/or be effectively operationalised in isolation of other development initiatives. Its translation into action must be within the defined national policy framework and be integrated within the policy. The difficult we experienced was that neither policy nor culture is a permanent phenomenon. They are dynamic in nature and one is dealing with moving targets all the time.

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Lessons LearntBehavioural change in a given cultural context does not follow a linear

progression but follows an interactive process; moving back and fourth until the new culture/behaviour is adopted and sustained.

Behavioural change appears to follow a cyclic process where the cognitive and cultural niches that influence behaviour are closely intertwined. Both the process and outcome indicators are therefore slow to be identified since the social terrain in which they operate keeps on changing. For example, the institution of “Auntie” was culturally used as a biological institution, playing the ascribed role of counselling and guiding youth on sexual behaviours as may be required by the local culture.

Field evidence has shown that the youth are often uncomfortable with the biological Aunties. They fear to be reported to their parents. Instead of the biological auntie, a mature and knowledgeable lady can play that role as a social auntie. However, further enquiry shows that for some youth, social aunties are also problematic. They are usually agency-based and therefore there may be as many of them as the number of community-based agencies (usually NGOs) in the area. As the youth get used to a particular “Auntie” the agency stops its activities and another one sets in. There are issues of confidentiality and individual competencies involved as ‘Aunties’ keep on changing.

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Lessons LearntIndigenous knowledge as evidenced in the technology, language, idioms,

proverbs, songs, drama, etc., forms a rich source of culturally constructed information that can positively be used in behavioural change promotion and social marketing of pro-health practices and values.

To enhance the efficacy of the cultural approach, service providers from government and NGOs divorce themselves from playing the role of direct service providers and adopt the role of facilitators in the various target communities. Service providers should re-conceptualize their roles to focus more on brokers-linking communities to various service networks and assisting communities to benefit services.

Given the fact that behaviour is greatly influenced by the cultural environment and construct at the individual, family and community levels, there is need to understand the politics and power relations in the family and the community and how they relate to both change in behaviour and sustenance of the behaviour change.

Behavioural change models are useful in providing analytical frameworks for programs adopting the cultural approach to HIV/AIDS. They can facilitate delineation of metacognive, environmental and socio-cultural and time variables that affect behavioural change in a given target group.

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Lessons Learnt

The study shows that older youth tend to take their life a little more seriously compared to the younger youth. This experience was interpreted as a strength that can be used to build positive coping mechanisms.

In using the cultural approach to HIV/AIDS prevention, the researchers were faced with the problem of relativity in perceiving the power of culture in promoting and sustaining development.

The integration of SRH knowledge and skills with HIV/AIDS education for the youth out-of-school ha proved to be an exciting approach. There is however no systematic study that has been undertaken to identify the critical issues, opportunities and constraints relating to this concept. Most of the information about it is adhoc and anecdotal in nature.

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THANK YOU

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END