CULTURAL APPROACH TO HIVAIDS PREVENTION AND CARE: EXPERIENCES AND LESSONS LEARNT FROM THE KAWEMPE PR

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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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Background

• The cultural approach to HIV/AIDS Prevention and
  Care project was designed bearing in mind a
  number of issues relating to culture and peoples
  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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Background

• Culture 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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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 Project

• The 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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Objectives

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

• Coping 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 Outputs

• Environmental 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 Outputs

• Communication 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 Outputs

• The 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 Outputs

• Community 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 communitys 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 Outputs

• Figure 1 The Community Dialogue Model

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 Outputs

• Metacognitive 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 Strategy

• This approach provided a rich set of lessons
  including the following
  
• It provides opportunities for participants to
  analyse an event. Participants must not be
  hurried
  
• It provides opportunity for participants to give
  critic by allowing them to make comments,
  observations and asking questions
  
• Allow original thinking and creative action
• It encourages participants to identify problems
  within a given context
  
• It facilitates learners to engage in dialoguing
• It encourage learners to use their passed
  experiences
  
• It provides an opportunity for learners to
  understand the general objective of a given task
  
• It provides an opportunity for participants to
  recall what has been learnt
  
• It provides an opportunity for participants to
  get involved in group work
  
• 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 Learnt

• Behavioural 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 Learnt

• Indigenous 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