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Community participation and consensus in HIV/AIDS prevention

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Title:
Community participation and consensus in HIV/AIDS prevention an exploration of the suzgo, the issues of AIDS in Malawi
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Poehlman, Jon Aaron, 1971-
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cultural models
cultural consensus
anthropology
participatory research
sub-Saharan Africa
Dissertations, Academic -- Applied Anthropology -- Doctoral -- USF   ( lcsh )
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government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
theses   ( marcgt )
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ABSTRACT: After more than twenty years of increasing understanding of the human immunodeficiency virus known as HIV, the virus continues to spread throughout the world, manifesting itself lethally in the form of the Acquired Immune Deficiency Syndrome (AIDS). With no cure or affordable treatment presently available for the majority of the people of sub-Saharan Africa and the African nation of Malawi, work aimed at preventing the spread of the virus continues to be the best strategy for lessening its impact, both at a personal level and across populations. Most people and communities in this part of the world demonstrate some understanding of HIV and its impact, and strategies such as condom use and abstinence education are familiar program interventions. However, less is known about how social and cultural processes influence personal risk taking and decision making related to HIV/AIDS.In this research, participatory research activities involving planning and producing dramas provide a venue for exploration of how rural Malawian communities can investigate and confront HIV/AIDS social causality through analyzing, planning and acting, presenting, and critiquing research. This research studies the role that shared agreement or consensus plays in developing a community's AIDS-related knowledge and in creating community-specific priorities for AIDS prevention activities. This aspect of the research is significant for applications of participatory research in community AIDS work. The research was designed so that information was collected from individuals participating in the interventions both before and after the interventions. This was intended to facilitate a better understanding of how participatory research affected group knowledge.The analytical process of Cultural Domain Analysis was used in conjunction with the non-probabilistic analytical technique of consensus modeling to gauge whether changes in agreement or consensus occurred as a result of participatory activities among intervention groups.
Thesis:
Thesis (Ph.D.)--University of South Florida, 2004.
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Includes bibliographical references.
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by Jon Aaron Poehlman.
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Includes vita.
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Title from PDF of title page.
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Document formatted into pages; contains 275 pages.

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oclc - 57708815
notis - AJU6855
usfldc doi - E14-SFE0000477
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Community Participation and Consensus in HIV/AIDS Prevention: An Exploration of the Suzgo, the Issues of AIDS in Malawi by Jon Aaron Poehlman A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Anthropology College of Arts and Sciences University of South Florida Major Professor: Linda Whiteford, Ph.D. Michael V. Angrosino, Ph.D. Carol Bryant, Ph.D. Trevor Purcell, Ph.D. Nancy Romero-Daza, Ph.D. Date of Approval: September 17th, 2004 Keywords: Anthropology, cultural consensus, cultural models, participatory research, sub-Saharan Africa Copyright 2004, Jon Aaron Poehlman

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Acknowledgments I first want to thank the many wonderful people I lived among and worked with in Malawi. A few deserve special note: Mr. G. G. Jere for providing fatherly support as I moved into his community, Carolyn Phiri for her hard work and interest in this project, Suzgo Banda and Brenda Mahonie for their friendship and hard work as research assistants, Carolyn Randall for providing confidence and material support at just the right time to get this project going, and Jim and Jodi McGill for teaching us how to be insiders and outsiders at the same time. I want to thank Tikoleraneko AIDS Resource Center and its director, Blandina Tausi, for allowing this project to happen and letting me become part of its team. Thanks goes to UNICEF of Malawi and its prevention of mother-to-child transmission program for providing financial support. The Institute on Black Life at the University of South Florida provided initial funding to set up this research. Additionally, I am grateful to the Infocus Corporation for providing important audiovisual equipment, solely on the basis of a single appeal. A special thanks goes to Dr. Linda Whiteford, my advisor, for believing that I could do this work and helping me get through this tiring process. Thanks to Christin Poehlman, my sister, for her help in reading the dissertation. Dr. George S. Poehlman, my father, gave me courage to go far away on the simple premise that we should help others who are in need. Mary Bennett Poehlman, my fearless wife, although she may not always realize it, took this journey with me and helped me do my work in more ways than she can imagine. Most important, I want to acknowledge the ceaseless support and encouragement of my mother, Betty Stout Poehlman. She is the secret behind the success of all of us Poehlmans, and this research would not have gotten done without her. It is as much hers as mine.

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Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, its the only thing that ever has. Margaret Mead

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i Table of Contents Acknowledgments i List of Tables v List of Figures vii Chapter OneIntroduction 1 Background of the Problem 3 Statement of Problem 4 The Use of Participatory Research in the Pr evention of HIV/AIDS in the African Setting 5 Understanding the Role of Consensus in Participatory Research Activities 5 The Research Problem in Context 6 Research Objectives 9 Research Findings 9 Importance of the Study 10 Applied Praxis 11 Chapter TwoReview of Literature 13 Prevention Methods for HIV/AIDS in the African Setting 13 Engaging In Participatory Paradigm 21 Process Evaluations of Participatory and Development-Oriented Health Interventions 26 Conceptual Framework 28 Chapter ThreeResearch Setting 34 Contemporary Malawi 34 Research Community 36 Embangweni During the Period of Research 38 AIDS in Malawi 41 Factors Contributing to AIDS in Malawi 43 These different tiers of causality are addre ssed here as they relate to factors of HIV/AIDS transmission in sub-Saharan Africa and Malawi. 44 Proximate Causes of HIV/AIDS in Malawi 44 Causality on the Intermediate Tier 45 Production of Health on the Ultimate Tier 48 Chapter FourResearch Fram ework and Objectives 51 Structure of the Research 51

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ii Research Objectives 52 Chapter FiveResearch Design and Methods 54 Research Design 54 Organization of Research Tasks 54 Overview of the Program Implementation Task 55 Overview of the Process Evaluation Task 56 Research Timeline 58 Research Team 59 Informed Consent and Confidentiality 60 Program Implementation 60 Formative Research 61 Program Implementation Research 64 Selection of Communities 66 Recruitment of Participants 69 Participatory Research Workshops 72 Community Survey 80 Methods Used In Evaluating Consensus Among Intervention Participants 82 Direct Observation 87 Chapter SixResults of the Implementation Research 89 Participant Observation and Natural Group Discussions 89 Homes and Villages 90 Institutions and Their Response to HIV/AIDS 95 Public Presentations 103 National Representation 105 Community Intervention Activities 106 Workshop Participants 107 Reporting from Workshop Activities 108 Community Mapping 109 Diagramming 110 Role-plays 124 Dramas 125 Chapter SevenResults of the Process Evaluation 127 Community Survey 127 Information on Community Survey Participants 127 HIV/AIDS Experience, Knowledge, and Self-Efficacy Questions 134 Key Informant Interviews 137

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iii Characteristics of Interviewees 137 Overview of the Key Informant Interviews 140 Identification of the Domain of Social Causes 142 Measuring Consensus Among Participants 143 Direct Observation 147 Chapter EightDiscussion of the Research Results 148 Discussion of Program Implementation Findings 148 A1) Learn Significant Local Knowledge for Effective Program Development 148 A2) Conduct Research on HIV/AIDS While Enhancing Participating Communitys Ability to Conduct Research, Through the Use of Participatory Research Techniques. 149 A3) Develop an Understanding of the Current Application of Participatory Research so as to Refine and Benefit Future Application. 158 Discussion of Process Evaluation Findings 162 B1) Develop an Understanding of Potential Variations Among the Research Communities that Could Influence Program Activities. 163 B2) Identify the Cultural Domain of Locally Relevant Social Risks for HIV/AIDS in the community. 164 B3) Determine if the Intervention Process has an Effect on the Consensus of the Participants with regard to Co mmunity AIDS Knowledge Through Comparison of Levels of Consensus on Locally Relevant Social Risks for HIV/AIDS Before and After Participation in the Community Intervention. 166 B4) Document and Analyze the Inter action and Construction of Shared Community models as Evidenced in the Intervention Process. 169 Chapter NineConclusions, Limitations, and Suggestions for Future Research 171 Culture, Consensus, and Community Change 171 Engagement, Participation, and Drama 175 Summary 176 Tribute 177 References 180 Appendix A: Survey of Community Resources 195 Appendix B: Drama Dialogue Planning and Production for Community AIDS Prevention 203 Appendix C: Secondary Materials 240 Appendix D: Program Consensus and Program Consensus Survey 242

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iv Appendix E: List of Community Concerns for Ranking 249 Appendix F: Community AIDS Dramas 250 Appendix G: List of Community Concerns 257 Appendix H: Themes Among Social Causes Identified for HIV/AIDS 258 About the Author End

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v List of Tables Table 3-1. Malawi Social Statistics 34 Table 3-2. Population of the Embangweni Community 38 Table 3-3. Embangweni Social Statistics 1998 39 Table 5-1. Summaries of Research Tasks 54 Table 5-2. Formative Research Methods 61 Table 5-3. Categorization of Communities 66 Table 5-4. Community Participatory Research Methods 72 Table 5-5. Role-Play Questions 77 Table 5-6. Community Survey Question Formats 80 Table 5-7. Key Informant Interviews 83 Table 5-8. Pre-Program Questions Formats 86 Table 6-1. Mean Age for Workshop Participants by Villages 107 Table 6-2. Marital Status of Workshop Participants, by Percentage 108 Table 6-3. Kakoma Matrix DiagramQuestion One 112 Table 6-4. Kakoma Matrix DiagramAttributes 112 Table 6-5. Kakoma Matrix DiagramQuestion Two 113 Table 6-6. Kakoma Matrix DiagramQuestion TwoAttributes 114 Table 6-7. Foster Jere Matrix Diagram 114 Table 6-8. Foster Jere Matrix DiagramAttributes 115 Table 6-9. Takumanapo Matrix Diagram 115 Table 6-10. Takumanapo Matrix DiagramAttributes 116 Table 6-11. Kabira Matrix Diagram 116 Table 6-12. Kabira Matrix DiagramAttributes 117

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vi Table 6-13. Kakoma Matrix Diagram 117 Table 6-14. Foster Jere Matrix Diagram 118 Table 6-15. Takumanapo Matrix Diagram 118 Table 6-16. Kabira Matrix Diagram 118 Table 6-17. Social Factors that are Putting Peopl e in the Community at Risk for HIV/AIDS 120 Table 6-17. Social Factors that are Putting People in the Community at Risk for HIV/AIDS (continued) 121 Table 7-1. Mean Age for Survey Villages 128 Table 7-2. Distribution of Sex in all Villages 128 Table 7-3. Marital Status for the Complete Sample 128 Table 7-4. Highest Level Completed in School 129 Table 7.5. Difference in Years Lived in the Community by Gender 130 Table 7-6. Frequency of Heads of Household 132 Table 7-7. Mean Continuous Years in Village 132 Table 7-8. Mean Number of Children and Adults in a Household 133 Table 7-9. HIV/AIDS Knowledge Questions 135 Table 7-10. What a Person Can Do to Prevent AIDS 136 Table 7-11. Self-Effi cacy Questions 137 Table 7-12. Community Affiliations of Key Informants 138 Table 7-13. Years Identified for First Case of AIDS in the Community 140 Table 7-14. Five Most Frequently Listed Social Factors Contributing to AIDS 142 Table 7-15. Average Ranking Top and Bottom Items by Community Group 143 Table 7-16. Ratio of Eigenvalue in the Preand PostWorkshop Consensus Analysis 144 Table 7-17. Takumanapo Rankings 145 Table 7-18. Kabira Rankings 145 Table 7-19. P-Values on the Paired T-Test of Competency Scores 146 Table 7-20. Eigenvalue Ratios for Consensus by Genders in Workshop Groups 146 Table 8-1. List of Community AIDS Issues 165

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vii List of Figures Figure 3-1. Map of Malawi 37 Figure 3-2. Millards Model 44 Figure 4-1. Model for Research 52 Figure 5-1. Design of Research 58 Figure 6-1. Kakoma Flow Diagram of Community AIDS Risk Factors 122 Figure 6-2. Foster Jere Flow Diagram of Community AIDS Risk Factors 122 Figure 6-3. Takumanapo Flow Diagram of Community AIDS Risk Factors 123 Figure 6-4. Kabira Flow Diagram of Community AIDS Risk Factors 123 Figure 6.5 Force Field Diagram on Issues Concerning HIV/AIDS Testing 124 Figure 7-1. Religions or Religious Affiliations 131 Figure 7-2. Primary Cash Income Sources 134 Figure 8-1. Model of Consensus Interactions 168

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viii Community Participation and Con sensus in HIV/AIDS Prevention: An Exploration of the Suzgo, the Issues of AIDS in Malawi Jon Aaron Poehlman ABSTRACT After more than twenty years of increasing understanding of the human immunodeficiency virus known as HIV, the virus continues to spread throughout the world, manifesting itself lethally in the form of th e Acquired Immune Deficiency Syndrome (AIDS). With no cure or affordable treatment presently av ailable for the majority of the people of subSaharan Africa and the African nation of Malawi work aimed at preventing the spread of the virus continues to be the best strategy for lessening its impact, both at a personal level and across populations. Most people and communities in this part of the world demonstrate some understanding of HIV and its impact, and strategies such as condom use and abstinence education are familiar program interventions. However, less is known ab out how social and cultural processes influence personal risk taking and decision making related to HIV/AIDS. In this research, participatory research activities involving planning and produci ng dramas provide a venue for exploration of how rural Malawian communities can investigate and confront HIV/AIDS social causality through analyzing, planni ng and acting, presenting, and critiquing research. This research studies the role that shared agreemen t or consensus plays in developing a communitys AIDS-related knowledge and in creating community-specific pr iorities for AIDS prevention activities. This aspect of the research is significant for applicati ons of participatory research in community AIDS work. The research was designed so that information was collected from individuals participating in the interventions both before a nd after the interventions. This was intended to facilitate a better understanding of how particip atory research affected group knowledge. The analytical process of Cultural Domain Analysis was used in conjunction with the non-

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ix probabilistic analytical technique of consensus modeling to gauge whether changes in agreement or consensus occurred as a result of participatory activities among intervention groups.

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1 Chapter OneIntroduction Predicated on the understanding that drama can be a powerful means of shaping and sharing information on HIV/AIDS in commun ities, this dissertation research shows the application of drama as a tool in helping to prevent the spread of HIV/AIDS. Within the context of many African societies, drama is both a socially and technologically appropriate form of community intervention, and it is with this latte r dimension, its appropriateness in communities, that I would like to start my discussion. Particularly, drama is an integral part of Ngoni society, the ethnic group which lives in the region of Malawi where this research was c onducted. This I learned only later in my research, even after I had started to explore the use of drama as a tool in sharing ideas on HIV/AIDS prevention. I came to know its importance through participating, myself, in a local community drama put on to commemorate the one-hundredth anniversary of the Presbyterian Church and mission station located in th e community where I was living. Being one of the few muzungus or whites in the community, when it came time to cast the role of Donald Fraser, the Scottish missionary pivotal in founding the mission station, I was surprised to be contacted by one of the elder gen tlemen of the church about playing the role of Fraser in the upcoming anniversary celebration. Nonetheless, I took it as a great honor to be asked to play the role as there were Scottish missionaries living in Embangweni at that time who were skipped over in casting the part. Attributing my selection to my fieldwork and its efforts to work with members of the community, I had come to know many people in the community and had visited their villages and homes. Personally, I took their offer as a compliment in that Fraser was also known for his understanding of the people with whom he worked, going on to write several sympathetic and enlightened ethnographies of African people. As the anniversary celebration approached, I b ecome a little nervous about my role in the drama, particularly since the drama group saw no need to practice prior to the morning of the afternoon performance. This, itself, speaks to the engrained nature of drama in presentation as the conventions of dialogue and performance were all quite accepted and understood by the group, except me. Whereas I needed marks on the ground to tell me where to stand in enacting the symbolic migration of the Ngoni people to Northern Malawi, the other members of the cast

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2 were clear that three steps backward signaled a significant departure of hundreds of miles, whereas one step forward was not more than an actio n of greeting. Another issue, my inability to speak fluent Tumbuka, the language of the local group adopted by the Ngoni upon their conquest of the region, I was told not worry, that Donald Fraser did not know the language either when he arrived and that I could rely on a translator to say the important dialogue. Before the performance, I was presented with a pith helmet to wear. I was told it was just like that which Dr. Fraser wore. From examining the construction and label inside, I became convinced that it might have very well been his. The drama was performed in a field where makeshift bleachers, constructed out of rough wood, provided seating for senior dignitaries. Ot hers were seated on benches taken from the school and church, arranged in a circle around a patch of grass. In this arrangement, the action of the drama could be viewed from all sides by the couple of hundred people in the audience. Basically a two act play, the first act detailed the migration of the Ngoni people from South Africa as they left their Zulu ancestors in search of new land and less war. Drawn by a vision, they traveled north until they found a mountain believed to hold mystical powers. However, being the beer drinkers they were, the Ngoni decided ultimately to settle about thirty kilometers south of the mountain in an area th at had adequate millet for brewing beer. In the second act, I, Donald Fraser, come onto the scene. In search of a place to start a ministry, I wander into Ngoni land and settle near th e village of the Ngoni chiefs. Clear to me is the idea that the land that the Ngoni have settled on is not suitable, lacking adequate water supply. With permission from the Ngoni chief and he lp from a young chief Mzuka Zuka, Fraser undertakes several scouting parties to find a better place to settle and start his mission. Eventually, having found a more suitable location, he and the people of Mzuka Zuka, his new friend, travel together to the current site of Embangweni and establish a mission station, building a large brick church in the style of Scottish churches. Donald Fraser and his entourage of missionaries eventually settled on one side of th e Rukuru River, while Mzuka Zuka settled a few hundred meters on the other side. Mzuka Zuka and Fraser would develop a lasting and mutual respect that allowed the church to grow without conflict with the traditional authorities. In many ways the story told through the drama is the cosmological story of the birth of the Ngoni people, a group whose modern embodiment shares its arrival in the region with Christianity. More important than the interpretati on of the drama is the significance that drama is the devise that people use to tell their most important stories, in this case the tool by which they seek to understand or order their past and transm it it to future generations. In sum, it was a tremendous honor for me, having done fieldwork and participated in the community, to be asked

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3 to play a pivotal part in the retelling of this stor y and to be a part in both this familiar, yet novel, production of their culture. Background of the Problem Although scientific understanding of the human immunodeficiency virus has been constantly improving for more than twenty years, HIV continues to spread throughout the world, manifesting lethally as AIDS. In 2003, it was estim ated that 40 million people in the world were infected with HIV, that three million people died from AIDS in 2003 alone, and that 21.8 million deaths have already occurred from AIDS (UNAIDS 2003, 2001a). As people in the sub-Saharan African nation of Malawi say about HIV/AIDS, the pandemic concerns both the infected and the aff ected: those whose health will be impaired by HIV infection as well as those who shoulder the increased burden that death and illness places on a society. The people of sub-Saharan Africa unde rstand these two levels of HIVs impact better than most because the virus h as affected this region disproportionally. Some 28.5 million people are infected with HIV in this region, almost tw o-thirds of all HIV-infected people in the world (UNAIDS 2003). In several African nations, the ra te of adult HIV infection is as high as 30 percent. In Malawi, the setting of this dissertation resear ch, the rate of infection in adults is 15 percent, although the rate reaches 30 percent in some distinct populations (UNAIDS 2002; Dallabetta 1993). There are an estimated 800,000 to 1 million people infected with HIV in this country of 11 million (UNAIDS 2002). Multiple partnering and transactional sexual exchanges are contributing to the continued spread of HIV/AIDS, particularly among 14-29 year olds (NACP 2000). In short, HIV/AIDS is denying the nation of Malawi its peopleand, in so doing, its hope of prosperity. With no cure or affordable treatment presently available for most people in sub-Saharan Africa, preventing the spread of the virus rema ins the best hope for lessening its impact. Because heterosexual intercourse is the principal mode of transmission in this region, prevention work has focused on modifying sexual behaviors to reduce individual risk of infection, with most interventions focusing on increasing individual knowledge concerning the disease and promoting personal methods of risk reduction, such as abstinence and condom use. Key to these strategies has been the learning theoretic that views knowledge, individuals attitudes, and the influence of social norms as central to decision making in sexual relationships.

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4 However, the continued spread of the virus suggests only moderate success in meeting the challenges of HIV/AIDS in the African setting. Statement of Problem This research, in considering HIV/AIDS in sub-Saharan Africa and Malawi, attempts to examine issues surrounding local responses to HI V/AIDS. This study does not disregard the larger context of the disease or the global imp lications of the pandemic. Rather, it focuses attention on critical community and individual factors that may be contributing to peoples risk for HIV/AIDS in sub-Saharan Africa and that frame local efforts to address the HIV/AIDS pandemic. To meet these challenges, there is a need for two kinds of research: ground-level research that extends the understanding of the disease with in communities, and research that improves and refines our understanding of HIV/AIDS risk and decision making (Campbell and Williams 1999; Van Campenhoudt 1997). Even modest changes in be haviors exist within a dynamic of social and cultural processes. Individuals actions are bot h shaped and limited by the political, economic, and social patterns within a community. At the same time, as members of a community, people are guided, encouraged, and restricted in their actions by the symbolic or interpretive frameworks shared among community members. In understanding those behaviors that put people at risk for contracting HIV/AIDS, we must understand the context within which decisions are made concerning sexual relationships and the cultural knowledge that people use in making those decisions (Bajos and Marquet 2000). Perhaps even more critical in the African se tting is the need to foster better community understanding and recognition of HIV/AIDS issu es in order to improve the ability of communities to address the HIV/AIDS epidemic. Almost fifteen years after the first case of AIDS was diagnosed in Malawi, AIDS remains a taboo subject in Malawian society, a topic avoided by church and state and only minimally addressed through medical services, despite an increasing number of deaths from AIDS. Progress in preventing the spread of AIDS has been hindered by this lack of community-level recognition or accepta nce of the AIDS epidemic. There is perhaps a lack of a shared symbolic vocabulary for mean ingfully discussing AIDS (Kesby 2000; Killewo et al. 1997; Lear 1995). A willingness to acknowledge the presence of AIDS within the community and to offer community-level support, without stigmatization, to the infected and affected remains critical to the development of commun ity and national capacity to confront AIDS.

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5 It is these issues of understanding the community context of HIV/AIDS and increasing community capacity for engagement in HIV/AI DS prevention that this dissertation seeks to address. The Use of Participatory Research in the Pr evention of HIV/AIDS in the African Setting Participatory research activities form a gr owing class of contextually directed interventions designed to address HIV/AIDS at the community level. Such interventions are thought to stimulate critical self-awareness a nd reflection within the community, potentially shaping future attitudes and behaviors related to HIV/AIDS. Community participatory research is incr easingly being used in HIV/AIDS-endemic settings as a tool to address the need for info rmation on HIV/AIDS in these communities. This kind of research engages community members in act ivities intended to help them understand and address conditions that contribute to the spread of HIV/AIDS. Further, participatory research is noted as being particularly effective in a ddressing the difficulties of conducting prevention research in resource-poor settings. In this research, participatory research activities, involving drama planning and production, provide a venue for exploring how rural Malawian communities can investigate and confront HIV/AIDS social causality by doing th eir own investigation th rough analyzing, planning and acting, presenting, and critiquing the research. Posited in this research is the potential utility of participatory research methods for engaging communities in AIDS prevention, to counteract a perceived lack of community recognition of and engagement with social factors contributing to the spread of AIDS. This research involved the development and piloting of a short community intervention utilizing a participatory research approach to addresses HIV/AIDS issues affecting rural Malawian communities. Following a proposed Dr ama Dialogue Planning and Production Model, intervention research was conducted in four v illages in a rural Malawian community. The intervention consisted of a series of workshops us ing participatory methods with ten to fifteen members selected from a community in order to research AIDS in the community and to share salient HIV/AIDS issues with the broader co mmunity by producing and performing dramas. Understanding the Role of Consensus in Participatory Research Activities While the role that shared agreement or consensus plays in developing knowledge of AIDS in communities and in creating community-specific priorities for AIDS planning and action is significant to the application of participat ory research, consensus is often neglected in theorizing on participatory research. In this research, understanding consensus is held to be

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6 crucial to developing a more critical understanding of the underlying cultural processes that drive the intervention. The study investigates the role consensus plays in the conduct of community participatory research and the potential implica tions for sustained changes that can benefit communities through AIDS reduction. The research was designed so that information was collected from individuals participating in the interventions both before a nd after the interventions. This was intended to facilitate a better understanding of how particip atory research affected group knowledge. To gauge whether changes in agreement or consensus occurred as a result of participatory activities, an analytical process of Cultural Domain Analysis was used. Cultural Domain Analysis offers a systematic process for eliciting data from member s of a group that can be analyzed quantitatively to demonstrate levels of agreement. In conducting Cultural Domain Analysis to determine whether the interventions encouraged agreement, three b asic steps were followed: 1) Elicitation where members from a community identify the content of a cultural domai n concerning issues key to the intervention; 2) Organization where the structure of the domain, consisting of different associations or relationships between domain items, is explicated through methods of systematic data collection as informants organize domain items (this organiza tion is also referred to as a cultural model for the domain), and 3) Visualization, where the researcher can make inferences about the organization of the domain th rough data-reduction methods. From data elicited in the organization step, levels of agreement on the content and structure of a domain can be interpreted through application of Consensus Analysis Consensus Analysis is a non-probabilistic mathematical procedure for measuring the level of agreement among a set of informants. As stated, a quasi-experimental design was used to test consensus both before and after the intervention process in conjunction with the community participatory workshops, measuring group consensus before and after the workshops to ascertain whether the levels of agreement among participants on key programmatic issues ch anged as a result of involvement in the intervention. To measure consensus, a domain of locally identified social risk factors for AIDS was elicited through qualitative research. Then, the informants performance on a ranking of task in regard to seriousness of the items within the do main was used to examine levels of agreement. The Research Problem in Context In 1999, this researcher learned of the ex istence of the town of Embangweni in the northern region of Malawi. As is the case in mu ch of Malawi, Embangwenis rural location had

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7 not been enough to insulate it from the spread of HIV/AIDS. Despite a lack of epidemiological surveillance, it was increasingly evident that AIDS was a problem in this community, as medical staff at the local community hospital reported that HIV/AIDS-related services accounted for the majority of all hospital care. 1 A visit to Embangweni in 2000 revealed a co mmunity that was taking its first steps to openly address the AIDS situation. A new community AIDS group was organizing in Embangweni, largely depending on the efforts of Malawian and foreign staff at a local mission hospital. This organization was named the Tikoleraneko (hand in hand in the local language) Community AIDS Resource Centre. Tikoleraneko was established as an independent organization to serve all members of the community, with no a ffiliation to any governmental, church, or nongovernmental organizations. Following a model suggested by the government for organizing AIDS groups, the organization, under the leadership of a former school headmistress, set out to develop a set of AIDS committees in neighboring villages. These co mmittees were intended to be the backbone of the organization, with the AIDS resource cen ter providing training to a network of village committees on topics such as prevention, home-based care, and orphan assistance. The formation of a new community AIDS organization in a rural community, where contacts and connection were in place, presente d this researcher with a possibility for collaboration and the potential to add needed know ledge and skills to a burgeoning organization. Contact was made with the Centre Director, and an agreement of mutual assistance was established. Building on the data collected in the preliminary community visit and on supporting evidence from the literature on the AIDS situation in Malawi, this researcher chose to pursue a research agenda that explored the developm ent of an innovative means for bringing AIDS prevention messages to communities and villages in and around the town of Embangweni. In developing AIDS prevention strategies, emphasis was placed on the indigenous practice of using drama as a tool for information dissemination. To improve the effectiveness of this use of drama and to encourage broader social change in r esponse to the dramas, community members involved in drama productions conducted participatory research on HIV/AIDS issues in their communities and incorporated their findings into the dramas infusing the dramas with greater saliency. 1 A widely published report from Malawi would later support these claims, estimating that 70 percent of all hospitalizations in Malawi were due to HIV/AIDS ( BBC 2004). At one time, a medical staff member at the hospital attributed all the cases in the male and female wards of the hospital to HIV/AIDS, with the exception of two individuals whose viral status had not been tested.

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8 Following a proposed Drama Planning/Production Model, a set of community interventions were designed, consisting of workshops that use participatory methods with ten to fifteen members selected from a community. Within these workshops, individuals conducted research on AIDS in the community and produced a drama or dramas that shared their findings with the community at large. In this desi gn, the process of drama planning and production functions as the venue for exploration of what rural African communities in Malawi can do to help investigate and confront HIV/AIDS social causality. Upon arriving at the research setting in December 2001, and after an initial period of observation in the community, assumptions made about the community and its needs concerning HIV/AIDS were borne out. The proposed interven tion was both viable and potentially beneficial. However, one difference that significantly affected the course of the research was the lack of progress in program development at Tikoleran eko since the organizations inception. Tikoleraneko had initial success in launchi ng a network of community committees, completing the remarkable task of setting up AIDS committees in over 90 villages in the Embangweni area. But little had been done afte r establishing the committees. The organization, now employing two additional staff members, was unsure of how to proceed in bringing services and training to the community committees. The lack of activity at the village/community level reinforced the need to develop programming in the communities. This situation suggested a shift in priorities in the proposed Drama Dialogue Planning and Production. Prior to entry into the field, one of th e main interests of the research was to develop information for program planning at the AI DS resource center and explore the role that drama can play in changing communities social norms regarding HIV/AIDS. Upon discovering a network of unused community structures in place to address HIV/AIDS, the creation of an affordable and replicable intervention that c ould be conducted using the network of committees became a new emphasis. It was thought that th e intervention might offer a model for more sustainable practices in community AIDS prevention and other public-health efforts. In this sense, the research would serve to increase the comm unities capacity for further research on and engagement in AIDS issues. As a result, explicit steps in a planning pr ocess were used with community members in developing and presenting the community drama. Ef fort was made in using these planning steps to draw parallels with other health and social concerns, with the suggestion that the methods could be used to guide other community activities. In this reformulation, the drama was no longer the end, but instead became the means to mobili ze a cadre of individuals in villages who could bring about change. In spite of these differences in community needs, the original objectives for

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9 the community intervention remain ed intact, with some shifting in emphasis toward developing and delineating steps for community planning to bett er meet the real human needs motivating this research. Research Objectives This research addresses the need for comm unity-level research and programming for AIDS prevention in African communities. It does so by exploring a novel application of participatory research activities in one set of co mmunities in rural Malawi. Additionally, through evaluation of the conduct of the participatory research, our understanding of the role that consensus plays in the participatory research pr ocess is increased, a dimension of participatory research that has not been previous ly investigated in empirical research. This research offers the potential to contribute to both applied and theoretical concerns in the field of anthropology as it explores the conduct of participatory research activities carried out in the form of AIDS drama planning and production, with specific emphasi s on examining how such activities influence consensus on community AIDS issues among participants. This research has the following objectives: 1) To develop and pilot the use of a Drama Dialogue Planning and Production model as a tool for building community capacity for dealing with HIV/AIDS in rural Malawian communities. 2) To develop an understanding of the u nderlying cultural process that drives the intervention in terms of creating shared values on HIV/AIDS social causality, with specific interest in determining whether levels of consensus are influenced among program participants. Research Findings The findings of this research suggest, first, that an established mode of public discourse, the community drama, can effect a short-term in crease in community capacity to think about and address AIDS, and that a mix of drama activities and participatory research activities is a viable strategy for engaging local communities in AIDS prevention activities. Furthermore, the addition of participatory research activities has helped to move the content of such drama from more proscriptive themes to themes that promote c ontemplation and reflection among the audience, two activities associated with effective co mmunity participation and empowerment. Second, the tool of cultural consensus, when applied to the drama planning and production groups, yielded provocative results in te rms of the relationship between participatory research and shared agreement. The participatory research activities used in the community

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10 drama workshops suggested signi ficant increases in consensus am ong participants based on the intervention activities in two of the four interv ention communities. Another of the communities, however, demonstrated contradictory results that suggest the importance of understanding intercultural variation in such group activities. In particular, gender of participants was found to be an important factor in achievi ng group consensus in communities. Beyond the direct findings of the current application, cultural consensus modeling was also found to be a workable tool for understandi ng levels of group agreement in the context of small workshop groups. With further research that helps us understand the role of consensus in community success in addressing social issues, this research demonstrates that an understanding of group agreement or consensus has the potential to serve as an important intermediate indicator and objective in measuring program success. Importance of the Study This research is primarily concerned with AIDS prevention in a part of the world heavily affected by HIV/AIDS. It addresses AIDS preven tion through the development and piloting of a community intervention to address HIV/AIDS issues affecting rural Malawian communities. This task stems from the real human need for communities to identify and respond to growing social problems resulting from high rates of HIV/AIDS infe ction in Malawi and is part of the ongoing efforts of anthropologists to use anthropological methods and theories to inform social policy and action. Beyond the overt applied goal of this r esearch is the responsibility to produce new knowledge through a process of scientific inquiry that will advance our ability to understand and address future human problems. This knowledge must be based on good empirical observation and framed by theoretical insights, offering opportunities for further discovery. In developing a participatory intervention fo r communities as part of the research, there is the potential to add to the deve loping knowledge base on these interventions in order to improve future applications. In using drama as tool in conducting such community and participatory prevention activities, we may better understand the utility of drama in such applications. Likewise, the use of formal consensus testing is part of a growing field of cultural anthropology interested in relationships between cognition and behavior. To date, consensus analysis has been used most frequently to test assumptions con cerning the distribution of cultural knowledge. This research suggests future directions for the u se of consensus analysis in addressing dynamic cultural processes and can assist us in better understanding and evaluati ng interventions to improve community health.

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11 Having identified these goals for the research, it is suggested that it is somewhere between these tensionsthe desire to do something that will be judged useful, particularly in the eyes of those we work with, and the need to expand the body of knowledge called anthropology and the social sciences in generalthat th is dissertation seeks to make itself relevant. Applied Praxis This research was conceived as a project of an thropology and is offered, here, as a work of applied anthropology. As such, it meets two conditions: 1) It has been conducted in accordance with theories concerning culture, know ledge, and cognition and using methods such as participant observation, in-depth interviews, a nd structured interviews, all from the discipline of anthropology; 2) It offers utility for info rming practice and policy regarding a real human problem. Foremost, this research shows a commitment to the anthropological concept of culture. If we are to understand practices or patterns that c ontribute to HIV/AIDS infections in African communities, we must consider the ways in which people conceive of such practices, particularly in terms of shared understanding or meaning. To those with a cognitive orientation (Dressler and Bindon 2000; Mathews 2000; Strauss and Quinn 1 997; DAndrade 1995), these shared meanings or patterns of thinking and cognition, shaped conjointly by human experience and group ethos in terms of goals, values, and orienta tions, are labeled as culture. This research seeks to build on this understanding of the concept of culture as it em pirically investigates its bounds in community AIDS prevention activities. This research adheres to many of the traditional methods and practices of anthropological research. In this respect, it bears some resemb lance to the classic fieldwork experience enshrined in the literature of anthropology where fieldworke r has traveled to some distant location and, by virtue of isolation, must integrate into a foreign society. More importantly, it was conducted through intense fieldwork in a community using methods such as participant observation and interviews. This was done to establish an et hnographic understanding of the research setting where peoples beliefs and the meanings they bring to their world contribute to the overall interpretation of social phenomena. Concerning the research being applied, Erve Chambers (1985) has made the following suggestion: Applied research is subject, for example, not only to the scientific criteria of validity and reliability, but also to various criteria of utilitysuch as relevance, significance and credibility (17). The conduct of this research is intended to contribute meaningfully to the lives

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12 of people living in a time of epidemic. While changes in social environment via intervention in political or economic realms are useful in mitiga ting the problem of HIV/AIDS in Africa, this research suggests that change must involve individuals and communities in preventing HIV/AIDS in the sub-Saharan African settings as they ask, What is the suzgo (problem)? What are the issues of HIV/AIDS? The potential of this kind of research makes it both highly relevant and significant in a world of ever-increasing HIV/AIDS infections. This research follows a tradition of appl ied research concerned with including and empowering communities through the research pr ocess (Tax 1975; Schensul 1999). By engaging communities in the research process, the credibilit y of the research findings is thought to be enhanced as they reflect findings that not only belong to the researcher but also to those participating in the research process.

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13 Chapter TwoReview of Literature This chapter presents information on interv entions presently employed in HIV/AIDS prevention in the African setting, followed by a discussion of participatory research methods and a review of the research literature that investigates participation and group dynamics in applications of participatory research effort s. A final section discusses cultural cognition and consensus, which form this researchs central conceptual framework. Prevention Methods for HIV/AIDS in the African Setting Strategies for preventing AIDS in the African setting have been limited, particularly in regard to medical interventions. While antiretrovira l drugs are the standard for treatment of AIDS in the West, their cost remains prohibitive for the majority of Africans (Waldo and Coates 2000). The use of male condoms, used to interrupt the flow of bodily fluids during sexual penetration, continues to be the primary strategy for preventi ng the spread of AIDS. When used correctly, the condom reduces transmission of HIV almost to zero. However, condom use in sub-Saharan Africa remains relatively low (Clela nd and Ferry 1995; Webb 1997). While the inaccessibility of condoms is an i ssue, negative perceptions of condoms and their efficacy is an even greater barrier to th eir use (Killewo et al. 1997). Arguments offered by males against condom use include the complain t that the condom feels unnatural or is inappropriate for use with regular partners. In addition, in some societies semen is believed to provide a necessary component for continued feta l growth, which makes regular unprotected sex required during pregnancy (Schoe pf 1992). For similar reasons, condoms are less favored in family planning programs, contributing to a lack of familiarity with their use among African populations (Ankomah 1998). At a societal level, or ganized Christian religions in Africa are slow to condone the use of condoms a nd have challenged the promotion of condoms, in the belief that condom use will promote promiscuity (Webb 1997). Female condoms are not widely available a nd are subject to the same criticisms as the male counterparts. Female spermicidal barriers that help block HIV would offer women more control in protecting themselves from HIV; however such products are only in the development phase.

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14 Treatment of sexually transmitted diseases (STDs) is another strategy for preventing the spread of HIV. However, STD treatment is costly, requiring regular monitoring and relying on the availability of medical services (Campbell 2000). Antiretroviral drugs have been used to decrease mother-to-child transmission of HIV through childbirth and breast feeding (Coutsoudis et al. 1999). Recent pilot programs conducted in Malawi show that the affordable drug nevi rapine can greatly reduce the chance of mother-tochild transmission. Nevirapines maker is currently offering the drug at no cost to the nations in sub-Saharan Africa (Motti 1999). In trials in Ug anda, a two-dose regimen of nevirapine, with a dose each given before and after childbirth, redu ced mother-to-child transmission of HIV by 50% compared to AZT (Guay et al. 1999). Before medical or preventive intervention can be possible, significant groundwork must be laid in terms of sustainable resources and the terrain surveyed in terms of social, cultural, economic, and ethical issues. Health care systems, in particular, are inadequate for the widespread introduction of biomedical interventions su ch as antiretroviral therapies (Webb 1997:106). To date, most efforts to change behaviors around HIV/AIDS have been individually oriented and directed toward providing inform ation for making personal health decisions (Moatti et al. 2000). Starting in the sixties and seventies, survey research on Knowledge, Attitude, and Practices (KAP) was conducted in Africa with the objective of providing information for family planning efforts and education, while also pr oviding baseline behavioral measures for program evaluation purposes (Schopper et al. 1993). KAP research highlighted questions designed to gauge differences in biomedical knowledge, establish attitudinal markers, and quantify health behaviors among respondents. With the onset of AIDS in African communiti es and its link to sexual behavior, the data gathered through KAP surveys became the reasonable starting point for developing AIDS programming. Implicit in the use of such surv ey information in prevention research was the learning theoretic that views individuals knowledge and attitudes as central to decision making around sexual relationships. In this light, re-educating groups with proper knowledge and attitudes regarding AIDS became a goal for much health education in Africa and the developing world. In communities, these same health edu cation programs are frequently coordinated with socially marketed strategies for condom distribution (Harrison et al. 2000). An important modification to the educational a pproach has been the use of peer educators in providing AIDS information. Wingood and Di Clemente (1996) note that peers may be seen as providing more credible information, may comm unicate more effectivel y using local language, and can serve as positive role models to others. In Zimbabwe, those involved in peer education

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15 among factory workers showed 38 percent less HIV infection than those involved in traditional health education (Katzenstein et al. 1998). As Harrison et al. (2000) suggest, peer education can add a measure of empowerment to the learner in the education process. The effectiveness of education interventions has not always been clear. While awareness of HIV/AIDS is undoubtedly an important component in bringing about directed behavior change, recent research on behavior change theo ry suggests the relationship between knowledge and behavior is not so straightforward. Valente et al. (1998), based on a meta-analysis of behavior change interventions in health communications, cited instances when changes in behavior occur and precede any actual changes in beliefs. As Kille wo et al. state in their study of community AIDS understanding in Tanzania, . many studi es have shown that while general knowledge or awareness about health problems may increase, there is often little change in behavior towards solutions if the problem is due to lack of motiv ation for internalizing such knowledge to achieve the desired goal (1997:325). This sentiment is echoed by Campbell and Williams (1996). Nonetheless, the assumptions formed through KAP-dir ected surveys continue to be the basis for many educational interventions that promote a greater understanding of the disease for the purpose of increasing individual desire to adopt safer sexual behaviors. AIDS educational interventions in commun ities are not universal, with much of the efforts toward prevention designed to meet the n eeds of specific groups within societies. Based mostly on epidemiological evidence, prevention research targets health education programs and AIDS testing for groups who are thought to be at higher risk, such as sex workers, migrant workers, and women (Harrison et al. 2000). Target ed prevention efforts are efficient and offer the possibility of limiting the spread of AIDS in a comm unity in its early stages. In contending with AIDS among sex workers, the most common strategy has been to provide education and counseling to encourage safer sex practices, incl uding consistent and pr oper condom use (Ngugi et al. 2001). In other cases, prevention research has ranged from focusing on regular testing for HIV and STDs to programs that encourage econo mic empowerment in women who must engage in sex work. Criticisms have been leveled at targeted e fforts at prevention, both for being limited in scope and for failing to have broad public hea lth impact, as evidenced by increasing infection rates in South Africa (Harrison et al. 2000). The discourse on risk groups, often surrounded by moral valences, is thought to distance people from the disease, limiting perceptions of individual risk (Glick Schiller et al. 1994; Craddock 200 0). As Romero-Daza says about a reliance on epidemiological data, such an approach may defl ect interest away . . from the wider social, economic, and political context in wh ich disease is embedded (1994:194).

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16 Beyond the transfer of knowledge is the perhaps more complex problem of how to motivate changes in an individuals sexual behavi or when it is believed that he or she has adequate knowledge. This concern has been the th rust of recent research in North America and Europe, where HIV/AIDS prevention has focused on the individual psychological attributes that are believed to influence ones choice of behavi or. The Health Beliefs Model (Janz and Becker 1984), the Theory of Reasoned Action (Ajzen and Fishbein 1975), and Social Cognitive Learning Theory (Bandura 1986) are three of the main theories from the field of social psychology that have attempted to link individual beliefs and attitudes to the likeli hood of particular behaviors. While formal theories of behavior change ar e less commonly included in the design of AIDS interventions in the African context, particul arly where gaps between biomedical and local knowledge are more common and often take priority in program design, psychological theories for changing behavior are part of strategies in in ternational health and aid organizations that deal with HIV/AIDS behavior change in bot h developed and developing nations. While advocating for the development of th eory-driven intervention in the African setting, Stanton et al. (1999) recognize certain factors inhibiting the use of social-cognitive interventions. First, communication patterns va ry by culture, with ethnic background throwing into question the use of questionnaires and scales developed in Western settings. Second, while social-cognitive theories have had success in the West, such theori es may not be appropriate in other settings (Ankrah 1991). Third, in specifica lly addressing Western youth, risk behaviors are found to co-vary significantly, suggesting certain strategies for intervention. Whether such covariation exists in Africa is another question to be answered. Stanton et al. (1999), in adapting the social-cognitive theory of Protection Motivation, used formative ethnographic methods to adapt instruments designed for youth in the United States to address AIDS risk among Namibian youth. From their result, they conclude that these fact ors can be overcome in AIDS prevention research in cross-cultural settings. Building on some of the insights of social-c ognitive theories, Campbell (2000) offers a hybrid approach based on three factors in AI DS prevention in African communities: 1) the negotiation of social and sexual identities for persons in high-risk settings, 2) increased levels of perceived control over health, and 3) the promotion of community contexts that enable and support the desired behavior change. In interventi ons with South African sex workers in a mining community, work was conducted across these factors by providing condoms and promoting peerled health education, while also working to establish women-only support groups, revolving credit groups, and burial societies. Campbell and Williams (1999) advocate for more multi-

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17 sectoral approaches to prevention efforts, in whic h health education and structural change are coordinated across a range of comm unity and government activities. Feldman et al. (1997), in conducting epidem iological and ethnographic research, found adolescents in Zambia at high risk for HIV infection. Recognizing that traditional health education methods had little impact on this population, Feldmans group developed a peer education program based on theories developed in the field of social psychology (ARRM and Stages of Change). Traditional prevention research was enhanced through the incorporation of ethnographic methods, including consensus and networks analysis. The resulting research strategy, called the Values Utilization/Norms Ch ange Model, incorporates community core values, identified through ethnographic research, in to the behavioral principles of social-cognitive theory. Worldwide, AIDS infection rates are thought to be rising more quickly among adolescents than among adults. However, Feldma ns (1997) work suggests that few data are available on AIDS rates among adolescents in sub-Saharan Africa. Moreover, ethnographic research among this group, which is required fo r the development of any future programming addressing risk in this population, is lacking. As with other groups with limited access to resources, . the social, and often economic (in the case of females) pressure for adolescents to become sexually active at an early age and to ha ve multiple partners places adolescents in one of the highest risk groups (Feldman 1997:457). School-based programming using health and peer education designs is the primary strategy for addressing HIV/AIDS prevention among adolescents (Campbell and MacPhail 2002; Green 2003). Abstinence education is also advocated as another method of risk reduction for this group (USAID 2000). A more theory-driven approach has been developed in schools in Uganda. Based on precepts of Social Cognitive Learning Theo ry and using Life Skill Initiatives, a fictional character models positive skills and behaviors that promote risk reduction (Buczkiewicz and Carnegie 2001). Outside the school setting, there is little eviden ce of AIDS research or targeted prevention for youth. Under-addressed in AIDS literature on Malawi are household patterns of communication about AIDS. It is suggested that generational differences and intra-family networks for learning gender and sexual roles d eserve more attention (Burja 2000). Burja, from her work among youth in Tanzania, recognized the need to build bridges between generations in dealing with AIDS. In response, she helped establish a community Girls Group, directed by elder community women, to deal with issues of female sexual development in adolescent girls.

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18 Individualistic, psychologically oriented approaches to behavior change have been criticized for relying on a utilitarian or maximi zing model of individual human thought (Kippax and Crawford 1993; Moatti et al. 1997; Singer 1998; Van Campenhoudt 2000). 2 The core of these challenges is the contention that behavior is a socially constructed phenomenon. Research that has adopted a constructed or relations-based view of sexual behaviors has focused on networks of social relations and how members of those networks construct the knowledge that shapes individual practices (Bajos and Marquet 2000). As Kippax and Crawford stated in discussing sexual behavior, Action is cons tituted with reference to shared meanings (1993:255). At a base level, this requires thinking about the interacti on of partners engaged in sexual acts and how the actions and understandings of each influence the other. However, this also extends to understanding the individuals larger network of social relations, including family, peer groups, co-workers, and membership organizations. Nonetheless, while the move to a more constructed understandi ng of sexuality and HIV/AIDS may be a needed corrective to overly reductionist models of individual behavior change, this move does not in itself suggest cl ear strategies for advancing our understanding of theoretically informed change. Social-cognitive theories, developed in the field of social psychology, have formed an almost paradigmatic tradition in health behavior research; yet the more constructed, social relations approach (s ometimes referred to a holistic approach) is disorganized. While the works of Campbell (1999) and Feldman (Feldman et al. 1997) represent tacit attempts to broaden social-cognitive approach es, the majority of works that demonstrate a social relations approach have ranged widely in design and theoretical grounding. It is suggested that as AIDS prevention moves into its third decad e of work, what is required in community-level interventions are more nuanced investigations into situated behaviors that offer broader possibilities for change in response to HIV/AIDS (Van Campenhoudt 2000). Approaches to HIV/AIDS prevention that have incorporated elements of a constructivist perspective include research involving social networks (Valente 1997), participatory and collaborative community work (Kesby 2000), eco logical theories (Turshen 1998; Waldo and Coates 2000), and critical medical perspectives (Schoepf 1991). A notable criticism of these constructivist or holistic approaches, however, is that they do not offer needed in-depth research into the . practical mechanisms through wh ich environments, norms, networks, and dynamic processes (such as learning and reflection) infl uence individual behaviors (Moatti et al. 2000:1527). 2 For a more detailed argument, see Byron Goods Medicine, Rationality, and Experience 1994.

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19 One strategy used in AIDS prevention research emphasizes social relations by focusing on social networks. Valente et al. (1997), recognizi ng that individuals do not function in isolation, studied contraceptive use among women in Cameroon by looking at social interactions and networks as a way to understand the spread of ideas. Findings from the research suggest that women are more likely to express a positive attitude towards contraceptive use if the closest members of ones social network are supportive of that method of contraception. Social networks can be useful in AIDS prevention work by pr oviding a serviceable tool for the diffusion of information on methods of personal protection, especially in environments lacking other forms of media. Gender is believed to play a powerful role in shaping behaviors around human sexuality. The importance of male identity, as defined by peer and community expectations, can be critical to how behavioral knowledge is applied in sexual situations. Likewise, gender roles are thought to influence a womans ability to ne gotiate matters of risk reduction in sexual relationships. Ankomah (1998), in her research on condom use among women in Ghana, recognizes the economic relations embedded in sexua l relations. She cites exchange as an often important component in relati ons and concludes that improvi ng womens economic condition is necessary if women are to have power in negotiating condom use. Issues of economic and social power underlie gender and ones ability to negotiate sex safely. After Schoepfs initial efforts at behavioral change in Zaire, it became clear to her that . information and a desire to avoid infections are not sufficient to reduce situations of risk (1992:228). Schoepf advocates the empowerment of women as necessary for adoption of basic behavioral strategies for AIDS prevention, such as the use of condoms. Particularly useful in addressing gendered expectations is the use of participatory research methods (Schoepf 1992; Kesby 2000). In researching gendered communi cation around HIV/AIDS in communities in Zimbabwe, Kesbys (2000) methods of research required community participation. While eliciting local understanding of AIDS causation, th e participatory methods also created dialogue around HIV/AIDS issues and fostered an environment where change is possible. A local response to HIV/AIDS prevention is the call for the return of traditional culture. For instance, some groups in Malawi ar e re-emphasizing the importance of premarital virginity (Kamwendo and Kamowa 1999). Likewise, th e role of religion and faith in marriage has been reinforced as a way of discouraging ma le promiscuity. Recent reporting on community responses to AIDS in Tanzania found one comm unity passing new laws aimed at discouraging people from frequenting places where illicit sexual encounters take place (Phillips 2001).

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20 The collaboration of traditional healers with community AIDS prevention programs is another way to incorporate traditional African healing systems into the task of AIDS prevention. Traditional healers, seen as culturally appropriate change agents, have the potential to introduce new ideas about AIDS prevention by incorporating these ideas into traditional cosmologies (Schoepf 1992). In her work in Zaire, Schoepf collaborated with traditional healers in promoting condom use by addressing local beliefs about th e requirement for semen intromission during pregnancy to ensure proper fetal development. As part of a general strategy for reducing the transmission of AIDS, Green (1999) enlisted the aid of indigenous healers, who used shared understandings and locally meaningful concepts to increase patient referrals for treatment of STDs. Working with traditional healers may also require contending with non-constructive views of AIDS etiology and treatment and dea ling with healers who make accusations as a means of enhancing individual power (S choepf 1992). Ingstand (1990), in studying traditional medical systems in Botswana, suggests that it is important whether AIDS is classified in the community as a Western disease (thus requiring biomedical treatment) or as a traditional disease (one for local healers to cure). She, t oo, advocates working with healers to develop referral systems. Another AIDS prevention strategy that relies on indigenous knowledge is the use of narratives in exploring community AIDS understa nding. Mogensen (1997) suggests that simply understanding disease categories is insufficient; one must also understand how disease is comprehended and portrayed in lived experience, incorporating social and cultural relations. Drama is suggested as a tool that allows for an opening of dialogue about AIDS-related issues, which then allows for the formation of alternative narratives that include messages of prevention. The use of drama in addressing social issues in Africa has a long history and has been advocated as a means of community participatory r esearch. In a recent study by Trykker (reported in Gausset 2001:515-16), it was noted that in co mmunities where dramas were used as an AIDS prevention tool, there was better knowledge about AIDS and indications of increased condom use (a 5 percent increase in reported use) as compar ed to communities where only community health workers were involved. Although Malawi is one of the nations hardest hit by HIV/AIDS, the literature specific to Malawi and efforts at prevention in the nation is sparse. It can be assumed that some of the findings related to AIDS prevention interventions in other parts of southern Africa have been paralleled in Malawi. Nevertheless, every effort must be made to recognize the ways in which responses to AIDS have been uniquely shaped by the Malawian setting. Indeed, there is a need for additional research on approaches consistent with local culture and on Western-imported

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21 approaches using biomedical and behavioral know ledge that may not be useful in African settings. To create local and meaningful responses to AIDS, approaches that blend the best of Western knowledge with indige nous wisdom are needed. Engaging In Participatory Paradigm Significant to work in anthropology, and perhap s unique to the social sciences, is the use of collaborative research and participatory research as modes of inquiry. Stull et al. (1987) connect anthropologys current interest in collabor ative and participatory research with concerns that emerged in the sixties and seventies regard ing the need to better represent anthropological research to its subjects. A growing resistance to anthropological research by groups who traditionally had been subjects created the need for anthropologists to rethink and reformulate their relationships with the subjects and the projected impact of their studies. Of particular importance were Sol Taxs (1975) work and th e emergence of Action anthropology as a response to the growing critique of anthropology and its historical relation to its subject. Similar movements were occurring in the fields of sociology and development. Participatory Action Research, building on the insights of Paolo Freire and his work on education for liberation, proffered another mode l of research that privileged community voices in efforts to empower people through reflection and action (Fals-Borda and Rahamn 1991; de Koning and Martian 1996; Wolf 2001). Rapid or Pa rticipatory Rural Appraisal (PRA), another variant of Action research, emerged in the late seventies. Influenced by Farming Systems Research, PRA incorporated the use of community researchers in investigating local agricultural practices (Chambers 1992). More recent calls for community involvement and oversight in gove rnment and nonprofit service agencies and the establishment of colla borative methods in community-based social planning (Ervin 1996), as well as the rise of interdisciplinary research and improvements in communication systems (Schensul et al. 1999), ha ve maintained and promoted a concern for participation in the research process. There has al so been a steady proliferation of participatory and collaborative research in other fields, as disci plines like geography, gender studies, education, and the health sciences have incorporated collaborative designs and participatory techniques into their programs of research (Maguire 1996; Tolle y and Bentley 1996; Meul enberg-Buskens 1996; Kesby 2000). The terms collaborative and participatory are often used interchangeably in describing research that involves members of a community. Collaborative research tends to be associated with a more front-loaded sharing of power in the research process, in which the objectives of

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22 research are themselves open to revision and ne gotiation. Participator y research, on the other hand, is used more often to describe the inco rporation of subjects in the actual methods of research. Biggs (1989) offers a more definitiv e typology for modes of research relations, comprising Contractual, Consultative, Collabora tive, and Collegial. Cornwall and Jewkes (1995) note that researchers may, and often do, move back and forth along this continuum in the course of a project. With a range of research activities falling under the labels of collaborative and participatory research, establishing the bounds of such activities is not an easy task. However, certain core principles of participatory research can be identified: 1) Research that is collaborative or partic ipatory in nature is concerned about power within the research process and calls for gr eater involvement of the subjects in the research. Important changes occur as a resu lt of undertaking the reflexive activities of identifying power and authority over oneself and then seizing ones own authority or voice (Hagey 1997). 2) Collaborative and participatory research requires people not formally trained in research to become involved in conduc ting inductive research on themselves. In contrast to positivistic research, where the goal is knowledge for understanding, collaborative or participatory research i nvolves the development of knowledge for action (Cornwall and Jewkes 1995:1667). 3) Research that is collaborative or particip atory is usually tied to programs for which change in the group or community is one of the goals. Identified benefits of collaborative and participatory research include: helping communities identify their problems, issues, and strengths (Hagey 1997), providing rapid feedback of information from the research to the community (Kesby 2000), building community research capacity (S. Schensul 1987; Singer 1994), and increasing the likelihood that the results of the research will be used in the communiti es where the research was conducted (S. Schensul 1987). Another benefit is the ethics of the research become part of the research processes, with community input ensuring that the tenets of ethical and informed research are obeyed. Difficulties in conducting research of this type include informants who are not always interested in the issue being researched or who lack the time and ability to participate (Cornwall and Jewkes 1995). Informants also may experience discomfort with the outside researcher, necessitating the expenditure of researcher time and effort to overcome interpersonal tension in the research process (Ervin 1996:331).

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23 Broenlee-Greaves (2001) also offers the general reminder that participation in a project is not sufficient to ensure project success. Project participation can have unintended consequences; for instance, the selection of those who particip ate in research can sometimes disrupt traditional authority and power structures (Paul and Demarest 1984). Also, newly empowered communities may effect changes not anticipated by the researcher (Cornwall and Jewkes 1995). There is also a concern regarding abuse of the participatory research methods. Kelly and Vlaenderen (1995) warn of the potential in developing settings for some to present a facade emphasizing the democratic aspects of participatory research while concealing behind-the-scenes domination. The fear is that participatory resear ch may be used to garner approval for certain measures without adequately informing or engagi ng community members in the decision process. Both collaborative and participatory resear ch have been criticized for a lack of objectivity. Collaborative research can lead to a recursive process of forming and reforming community problems, thus complicating scientific means of evaluating the results of the research (Bennett 1996). Another consideration is that the form of collaborative research may vary based on whether it takes place in developed nations or developing nations. One finds in the literature a greater emphasis on partnering and power in collaborative research in Western settings. Alternatively, in a developing nation, there is more emphasis on the development of community capacity. These aspects are not mutually exclus ive; in fact, both aspects would have to be exhibited to some extent for the research to be considered participatory. However, lack of resources, functional differentiation in pa rticipants, and smaller groupsthe common characteristics of collaborative research applications in developing nationsm ay lead to a greater emphasis on the intervention or action aspects of the research as opposed to the development of information for program planning. This may have led to further semantic distinction between Participatory Action Research and Participatory Research. In terms of related methods, all methodologies shared in the course of research have the potential to be used in a collaborative or pa rticipatory manner. Interviews, focus groups, community surveys, and the battery of techniques that form Rapid Assessment Procedures are just a few of the methods that have been ad apted to collaborative and participatory research. Some specialized methods that have emerged are social mapping, visual diagramming, and listening surveys. In particular, visual exercises have proven to be powerful tools for communicating ideas in communities (Butcher a nd Kievelitz 1997). Body mapping, community mapping, social mapping, and risk diagrams are methods used in visual research.

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24 Kesby suggests that in dealing with AIDS in sub-Saharan Africa, there is a need for more action-oriented research (2000:1725). In his stud y, participatory methodology was used to good effect in the form of visual diagramming to research gender roles and their effect on couple relations around HIV/AIDS in a rural Zimbabwe community. In a mixed-group setting, participatory methods were used to help co mmunity members confront gendered communication problems that contribute to an environment that promotes the rapid transmission of HIV in a community. The use of drama as a tool in the participat ory researchers tool kit first started in Botswana in the sixties at Theatre for Developm ent (TfD). Ahmadu Bello University in Nigeria pioneered the use of dramas as a tool for m obilizing communities for social change in the seventies (Byam 1999). The publishing of Augusto Boals Theater of the Oppressed in 1974 started a similar critical theater movement in Latin America. Activists and community members in these movements created dramas around community issues, and the dramas were used to facilitate discussion among community members on key social issues. Later theater designs incorporated audience members in performances, al lowing the narrative structure to be broken in order to elicit feedback from the community and to allow for alternative scenarios to be offered in response to the problems posited in the play (Har ding 1987). Plays that work this way necessitate an extension of analysis from the play itself to include elements of its production. Specific drama designs used by TfD include Im agine Theatre, in which particular social situations are presented to the audience through act ors frozen in a scene. The theater also used a design called Forum Theatre, in which a play is performed once, and then a facilitator guides audience members through the process of changing problematic features of the play so it can be performed again differently (Scott-Danter 1999). Extended analysis designs have also been incorporated into the use of dramas. For inst ance, TfD in Tanzania operates in a workshop context that lasts about three weeks. The workshops use seven stages of research: familiarization, research, data and problem analysis, theatre creation, performance, post-performance discussion, and follow-up (Walter 2001). As Cornwall and Jewkes (1995) have said about the use of drama, . the process of drama building often draws more on stimulating crea tive conflict, in order to stimulate reflection by those who have power as well as to empower t hose who lack it. In dealing with matters of sexuality, there often is difficulty in discussing su ch personal and socially sensitive areas. The drama, as a tool for both research and intervention, is well suited for handling of such issues in a non-intrusive manner (Scott-Danter 1999). Unlike other communication media, drama is adaptable to specific communities and allows for community participation (Walter 2001).

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25 Drama has been used in West Africa to challenge gender consciousness within communities (Morrison 1995). In Mozambique, it has helped to address refugee and migration issues (Scott-Danter 1999). In Tanzania, drama is used to discuss AIDS and voter education (Walter 1997). In South Africa, DramaAide is a strategy for addressing AIDS risk in schoolchildren (Whyte and Dalrymple 1996). Beyond its uses as a participatory technique, drama has been found useful in community educational outreach. In a large sample evaluati on of HIV/AIDS informational dramas in South Africa, students who viewed informational dramas showed significant improvements in terms of knowledge and attitude toward AIDS and reported condom u se (Harvey and Tony 2000). Valente and Bharath (1999) found drama to be an effective way to disseminate information about AIDS in a developing nation. A ccording to their research, some of the benefits of using drama as a means of disseminating inform ation were: 1) it is culturally appropriate and sensitive, 2) it is a non-intrusive means of sharing information, 3) it can be recorded for broader usage, 4) it is cost-effective, 5) it retains much of the intimacy of interpersonal communication, and 6) it can be reinforced with other forms of me dia. They conclude that drama has an advantage in addressing difficult community subjects, such as matters of sexuality, because dramas can be used to . . embed health and other issues in their social context which assists audiences in their discussion of the issues (204). The U.S. Centers for Disease Control has al so shown interest in the use of narrativeoriented prevention designs. In a 1997 report (Brinson and Brown) issued on the use of risk narratives in preventing HIV/AIDS, the effectiven ess of a series of public service announcements based on Fishers Narrative Theory was noted. Bu ilding on narrative theories of communication, Fisher (1989) proposed that the persuasiveness of an argument depends on its good reasons, which are tied to peoples own histories and expe riences as captured in the narrative structure. To build a good argument, your narrative must contain Probability and Fidelity or coherence and truthfulness. The drama as a tool of research is seen both as an indigenous model for social change and an extension of the oral tradition, an important idiom in the African setting. As Walter notes, The African roots of community theatre are the traveling theatre and various traditional theatrical forms such as storytelling, mimes, ritu als, songs, and dance riddles. In the past, those performances satirized lazy farmers, accused despo tic rulers and even very private issues could be the subject of a lively dance or a song (Walter 2001). The traditional uses of drama allow it to function as both a form of entertainment and an important means of sharing socially and culturally relevant messages.

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26 Tembo (1995), in evaluating recent grass-root s health education strategies in Malawi, suggests there is a place for both creative role-playing and community health committees in addressing infectious diseases in rural Malawian co mmunities. With limited outlets in Malawi for HIV/AIDS information and media, drama has th e potential to meet an important need by delivering informationtailored to the particular needs of a communityto the people who need it. Process Evaluations of Participatory and De velopment-Oriented Health Interventions Additional crucial considerations in unde rstanding participatory research are group process and change behavior. To aid in understanding these factors, literature on research efforts directed at evaluating group dynamics in partic ipatory research programs is reviewed below. While there may be an abundance of literatur e on participatory research and its goals and objectives, there has been only limited empirical investigation into the processes that constitute participatory research activities. Schulz, Israel, and Lantz (2003) suggest that funding agencies are increasingly interested in assessing group partnerships and their effectiveness in addressing public health problems (249). From their perspective, however, there has been a lack of comprehensive evaluations addressing how partnerships achieve program objec tives. These researchers say that the question of Whether and how multiple perspectives are engaged in the analysis and development of solutions is critical to understanding outcom es in the participatory process and developing potential intermediary goals or objectives, which can be used in understanding overall program outcomes. Lasker et al. have noted that of the few studi es conducted that offer an empirical basis for evaluating participatory research activities, . . th e basic premise of their work is that achieving health and health systems goalssuch as reduci ng tobacco use, increasing immunization rates, improving access to care, and strengthening the influence of underrepresented community groupsdepends on how well partne rships function (2001:181). Schulz, Israel, and Lantz (2003) follow this lin e of inquiry in developing their instrument for evaluating group dynamics in participatory research. The characteristics of an effective group, including leadership, participation, and communication, were established based on a review of group process literature. These characteristics then were matched with questions from existing surveys on group process in order to create an eval uation strategy. To pilot their instrument, they evaluated the formative stage of three participat ory health research projects in which there was considerable collaboration between community members and health care professionals. This

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27 process evaluation was done in the early stages of the projects so findings could be used to improve group interactions in the later stages of the project. Scaled data were collected from participants in relation to the hypothesized characteristics of effective group process and then aggregated to create an overall team measure of satisfaction. Individuals assessments of the process were not tracked. The final overall results were reported back to the group in order to improve future group interactions. It is important to recognize that Schulz, Israel, and Lantz operated with two central assumptions: 1) diverse partners contribute to diffe rent perspectives, expertise, and resources in identifying and understanding co mmunity health concerns, and, 2) these multiple perspectives and resources can effectively enga ge to develop solutions to those community health concerns (2003:250). Their interest, therefore, was in determining whether equitable engagement occurred and whether all partners felt supported an d valued in the research process. A lack of such support is thought to potentially decrease th e effectiveness of the research partnership. Naylor et al. (2002) offer another evaluation method for considering group process, used in the British Columbia Heart Health Project. In this multiple-site community-based intervention, community members, researchers, and provincial project coordinators were brought together to conduct a participatory evaluation of the project. In further evaluating the process used in the participatory evaluation, researchers hypothesized six salient features of successful participation and developed rating scales for these six features. In focus groups used as part of the evaluation of the project, participants rated engagement in terms of the six features. Ratings were then averaged across the three project groups and plotted against each other. The researchers found variations in ratings among the constituent groups. Their methodology did not permit them to set a definitive level of participation for the en tire group. They were, however, able to better understand differences among groups with regard to percei ved participation. Underlying this methodology was a concern for the supportive inte raction of the constituent groups across the research process. Kelly and Vlaenderen (1995) offer another varian t on partnership evaluation. First, they suggest that the term participation has varied from application to application, which suggests the need to better operationalize the concept of pa rticipation used in community research. In response, their research has considered two aspects of participation: partnership and dialogue Partnership refers to the relationship of the various constituents in the participatory research process as measured in terms of the levels of inclus ion and equality in partne rships. Alternatively, dialogue is a condition in which a communicative contex t exists that permits participation. These concepts were used as a conceptual framework in conducting qualitative evaluations of

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28 participants involved in primary health care pl anning in South Africa. Using grounded theory, the researcher analyzed post-intervention interviews of participants to identif y program participants concerns regarding participation and communica tion. Voyle and Simmons (1999) use a similar approach in evaluating health partnership in indigenous communities in New Zealand. In other research, Wandersman, Goodman, and Butterfoss (1997) have studied similar attributes of partnering, examining these attributes across different project stages. In studying the quality of partnerships, Lasker et al. (2001) suggest that research has failed to adequately address the mechanisms by which collaboration achieves greater success than individual efforts. They call for a sharper focus on how collaboration enhances the ability of groups to achieve health goals, and they suggest synergy as a mediating mechanism between partnerships and effective out comessynergy being a construc tivist rendering of practical knowledge or knowledge for application through the mutual exchange of information. In operationalizing synergy Lasker et al. have identified it as the ability of partners to identify and focus on problems in a community, to communicate how actions will deal with a problem, and to obtain community support in order to sustain long-term intervention effects (2001:188). In further operationalizing this concept, they have developed a framework for evaluation that combines more traditional internal measures of partnership (trust, respect, conflict, power) with other measures that can be externally validated, su ch as group homogeneity and resource sharing. Another strategy utilizing external markers for partnership is network analysis. Provan and Milward (2001) used network analysis to analyze collaboration among groups in projects. Other research considers the framing of group tasks as relevant to performance outcomes on related collaborative community tasks. Davis et al. (1997), in conducting mock school-board tasks concerning AIDS education in a school system, found that when groups were given explicit instructions in terms of whether groups were to consider outcomes or process, their task outcomes differed considerably from those of groups given no instructions. Conceptual Framework In developing this research, much of the conceptual base used in examining participatory research is drawn from the field of cognitive anthro pology. This body of knowledge is thought to provide insights that are useful for both conceptualizing and evaluating the community interventions conducted as part of this research. The study of consensus within cultural an thropology concerns understanding 1) how knowledge, beliefs, and ideas come to be shared among members of a society, and 2) to what extent such knowledge is shared. This interest forms part of the field of cognitive anthropology,

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29 the branch of anthropology concerned with how humans think and organize their world (DAndrade 1995). In the field of cognitive anthropology, curre nt theory emphasizes the role of cultural models or schema in how cultural knowledge is processed, organized, and generated. There remains, however, a more general interest in identifying the common or shared pool of cultural knowledge held by groups. Boster (1997) likens the difference in selection of these research interests as the choice between studying wave or particle theory in physics; both are valid for understanding phenomena, but each provides di fferent information based on particular operational assumptions. On the wave side are those studies that view cultural knowledge as sets of generative principles or guiding concepts that are shared by members of a group. The particle side treats cultural knowledge in terms of discrete packets of in formation that can be compared between informants. The concept of consensus is likewise employ ed in two ways in this research, based on different operational assumptions about culture. Firs t, consensus is hypoth esized as an element in a process of change, or something to be achieved through the research activities. In this regard, the study of consensus is an attempt to tap into the shared models used and created in response to the relatively recent phenomenon of AIDS in th e African setting. Second, the research must concern itself with gauging whether change occu rs in response to the intervention process in terms of peoples cognitive domains. Consensus Analysis as a formal model for measuring agreement among research participan ts on elements of cultural knowledge, is offered as a tool for understanding the outcome of the intervention process. Consensus Analysis is based on the idea of a shared pool of knowledge with regard to AIDS that can be changed and measured in the intervention activities. In the following sections, th ese two uses of consensus are further detailed. Drawing on work in cognitive science and connectionist models of neural functioning, interest in the cognitive side of culture has more recently focused on the role of cultural models or schemata in shaping social behavior. Schemata, and the related concept of cultural models, refer to learned or innate mental structures that help arrange knowledge and process information (Strauss and Quinn 1997:48). Or as Bloch (1997) describes them, schemata and models are nonverbalized and often a kind of taken for granted knowledge of the world. In their simplest form, schemata and models are skeletal representations of a cultural domain or a set of associated concepts that are flexible enough for applica tion across experiences and that are enlisted and supplied with detail within specific contexts. Likewise, schemata are durable concepts with qualities that last beyond an experience. They come to be shared by members of a group through

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30 common experiences in terms of either direct l earning or socially mediated experiences (Strauss and Quinn 1997). On one level, schemata and models offer guidance in doing mundane tasks, such as eating at a restaurant. In such an encounter any number of schemata may be called upon to navigate such familiar, yet always novel, experi ences. On other levels, models and schemata are thought to generate goals and give rise to motiva tion. This cognitivist view attempts to reject renderings of culture that stress either symbolic rule-based processing or that see individuals as totally free from cultural constraints in their ac tions. Instead, the cognitivist view of schemata sees peoples actions as mediated through categorical relations that give orientation to experience (Dressler 2000). Strauss and Quinn (1997) note that cultural models and schemata are important to how we give meaning to individual experience. They say meanings differ from the types of stable cognitive structures investigated in cultural m odels because meanings are momentary states and dependent on context (1997:54). Yet the producti on of meaning is always highly dependent on the cultural models used in in terpreting the experiences. As Dressler and Bindon (2000) point out, to be considered cultural, a model or schema must be shared among members of a society. The extent to which a model or schema must be shared in order to be considered cultural is not defined and is left more or less to the researcher. Methodologically, the development of cultural models or schemata is an interpretive practice, with models developed from the analysis of na rrative and interview data (Agar and Hobbs 1985). Cultural models have been explored through di scourse on a range of topics, including marriage (Quinn 1996), gender relationships (Holland 1987), Micronesian na vigational systems (Gladwin 1970), and models for home heating thermostats (Kempton 1987). Gauging the extent to which cultural models a nd schemata are shared is not central to the investigation of these concepts. How they come to be shared, however, is an important process that constellates an ontological concern rega rding how cultural models are formed. Quinn suggests, One reason knowledge is shared is because it offers a solution to tasks commonly confronted by the members of a given society (1996:392). Cultural schemata and models are shared task solutionssocially mediated answer s to commonly confronted or recurring tasks, problems, or contradictions. Langua ge is probably the preeminent form of socially mediated task solution. Cultural schema and models, as task solutions, must be viewed as adaptive human processes that help groups negotiate social d ilemmas or contradictions. As Quinn suggests, . people are as much active resolvers of conflict as they are passive sites for the play of

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31 contradictions, and felicitous solutions to such inner conflicts become cultural ones (1996:392). Along similar lines, Mathews states in her inv estigation of the development of shared understandings in breast cancer support groups: It woul d seem that groups play a crucial role in promoting the integration of divergent and ofte n conflicting sources of knowledge by striving to find points of agreement and by structuring th em into new models of the domain (2000:409). In work on AIDS, Farmer (1994) has docume nted the process of consensus building with regard to AIDS in a rural Haitian community, tracing the disease from widespread representations to a more prototypical and widely shared model. Mathews (2000), in working with breast cancer survivor groups, documents the de velopment of a shared model fo r breast cancer that incorporates varying elements of both biological and moral explanatory systems. In contrast to the implied shared nature of cultural schemata, there is a formal model of cultural consensus that entails systematic methods for estimating the degree to which a cultural domain is shared among a group by obtaining and evaluating responses to structured questions. Theoretically, culture is assumed to be a socially shared and transmitted information pool from which people derive understanding of things and how things are done in the world (Garro 2000). However, it is important to recognize that the type of knowledge assessed in formal consensus is the type acquired mostly through passive learning, in contrast to knowledge that results from active construction, such as knowledge of how to do complex arithmetic (Boster 1987:155). The development of consensus stems from a desire to better evaluate the information obtained from informants. The identification of a sh ared domain is useful in determining whether it is reasonable to aggregate response data to cr eate a single representation of beliefs, as is often necessary in other cognitive methods such as the multidimensional scaling of systematic response data (Borgatti 1996). Further, when working w ith a small number of informants, agreement cannot be easily inferred from systematic data, so identification of a shared domain provides an inferential tool for evaluating both group and individual responses. It is helpful to think of consensus as chec king for a condition, defined as one of three formal assumptions held within its model: 1) Is there common truth or a correct answer for each question being asked? If not, then one must consider the remaining two tenets: 1) If there is local independence, each informants answers are given in dependent of the other informants; 2) if there is homogeneity of the items being asked, questions equally refer to the same domain (Romney, Weller, and Batchelder 1986). With these assumpti ons in mind, if consensus is found, it is concluded that all of those c onditions have been upheld, which means a single cultural factor directed responses. Otherwise, the researcher must consider whether there was error in the data

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32 collection or type of data, or whether the group of respondents reflects a disparate set of idiosyncratic beliefs. Mathematically speaking, consensus analysis is based on a factor analysis of the matrix of response matches between informants af ter correcting for guessing (Garro 2000). The ANTHROPAC software program provides a rou tine for analyzing consensus among subjects responses. ANTHROPAC analyzes the responses giving 1) a ratio of the factors that account for variation in the reporting, and 2) a competence level for each informant. It is customarily held that if the first factor is three times the second f actor, with the first factor considered to be the influence of a single set of beliefs, then ther e is consensus (Borgatti 1996). Limitations of consensus modeling include the requirement for sy stematic data and an inability to handle incomplete data sets (Weller 1998). Formal consensus theory has been applied to research on blood pressure difference in communities (Dressler 1996), HIV/AIDS-related beliefs (Trotter et al. 1999), and accounts of diabetes causation (Garro 2000). Recent research by Dressler and others (1996, 2000; Dressler and Bindon 2000) focuses on cultural consensus and its connection to behavior, creating methods for estimating the congruence between the two. In adopting a cognitive perspective, this r esearch considers current views of society, which indicate a shift from cohesive models to mo re contradictory and contested ones. As recent cultural theory has stressed, community memberseven in small-scale rural societiesoften occupy varying social positions within the so ciety and are cross-cut by divergent social experiences (Clifford 1988; Abu-Lughod 1991). There is thus a potential for significant intracultural variation in terms of the views a nd actions of community members. Such findings would perhaps appear to confound investigations into shared culture; however, while variation in cultural knowledge is certainly sometimes the resu lt of idiosyncratic differences, this variation often is systematically distributed among the members of a group and is itself worthy of further investigation (Garro 1986). The idea that differences in cultural knowledge are patterned has been precisely the viewpoint investigated through formal cultural modeling. With variation viewed as measurable difference between informants, the measure of cultural competence as outlined in the formal use of consensus theory offers the opportunity to explore and explain such differences. This interest in variation would suggest examination of th e distribution of or access to cultural knowledge across contextual positions (Dressler and Bindon 2000). Conversely, cultural schemata and models research has more to do with how pe ople use cultural knowledge in different cultural

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33 contexts, possibly pulling from different models or using the same models to different ends (Garro 2000). Although this approach to studying culture sees culture as patterned, patterns do not imply structure. As DAndrade says, If culture is seen as socially inherited solutions to lifes problems (how to form families, obtain food and shelter, raise children, fight enemies, cure disease, control disputes, etc.), then the forces that make for systems or structure are the constraints and interdependencies found within these problem-domains. The cultural solutions to lifes problems do form systems of various sorts; systems of social relationships, systems of economic exchange, systems of government, etc., but these systems (each made up of a complex of cultural models, roles, activities) are as various as the problems are (1995:249). Similarly, cultural models are thought to relate to behavi or in powerful and complex ways but without predicting behavior (Strauss and Quinn 1997:6). Th e motivational aspect of cultural models has recently been considered as a research interest (DAndrade and Strauss 1992), but implicit in such undertakings is the understanding that models are simply resources used in structuring behavior and offer all sorts of ambiguity in application. Criticism of investigations into the cognitive si de of culture is that they offer simplified examinations of limited domains of cultural phenomena. Another concern in terms of viewing culture from the point of view of the informants is the likelihood of variation among informants. Again, this suggests investigation of intracultu ral variation. Beyond the socially mediated synthesis of conflicting cultural ideas suggested he re, Strauss (Strauss and Quinn 1997) posits the potential for the compartmentalization of conflicting cultural ideals within individuals. Criticism also has been leveled at methodologies used in cognitive research. The heart of this objection is captured in this statement by Robertson and Beasley: While there have been a plethora of methods for accessing culture contained in the mind, questions remain about whether results, in fact, reflect how individuals organize a nd perceive society, or whether they are merely manufactured by investigators, having no foun dation in their subjects reality (2001). Also problematic is the fact that the majority of th e research in cognitive anthropology is conducted in the researchers own culture, using the research ers own language. DA ndrade (1995:172), noting the advantages of already knowing the language and having familiarity with the culture, comments that research may take longer when conducted outside of ones reference group.

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34 Chapter ThreeResearch Setting This chapter locates the research setting and discusses salient features about it relative to HIV/AIDS. The first section of the chapter describes the modern geopolitical entity of Malawi and the specific research setting of Embangweni. The second section looks at the current AIDS situation in the nation of Malawi with reference to the overall situation in sub-Saharan Africa. Contemporary Malawi The Republic of Malawi located in southeastern Africa, is a long, narrow, landlocked nation stretching about 525 miles from north to south and ranging from 50 to 100 miles in width (Decalo 1995:xi). It is bordered by Tanzania to the north, Mozambique to the east and south, and Zambia to the west. Lake Malawi, running along the eastern border, forms a significant portion of the countrys territorial boundary and is the th ird-largest body of water in Africa. The nation covers 45,747 square miles a nd is home to approximately te n million people (CIA World Factbook 2000). See Table 3-1. Table 3-1. Malawi Social Statistics Total Population 9,838,486 Urban Population 16.4% Annual Population Growth Rate 1.9% Per Capita GNP (US$) 166 UNDP Human Development Ranking 163 out of 174 Human Poverty Index 41.9 UNDP Development Report and Popula tion Census 1998 (UNAIDS 2001b). Malawi, formerly called Nyasaland under British colonial rule, received formal independence on July 6 1964, and the nations most recent constitution was ratified in May of 1995 (CIA World Factbook 2000). After years of a single-party dictatorship, Malawi returned in 1994 to a multiparty democracy. The current president serves as both the Chief of State and the head of the ruling political party, the United Democratic Front (UDF). In 1975, Lilongwe was made the capital city of Malawi in order to cr eate a more central seat of government. However, the city of Blantyre, located in the southern portio n of the nation, remains the countrys industrial and education center (Decalo 1995).

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35 Despite a high population density, the third-largest in Africa, Malawi remains one of the least urbanized nations in the region, with nine out of ten people living in rural areas (Decalo 1995:xiii). Geographically, the population of Mala wi is split into three regions: the more urbanized south, which holds about half the population and the largest portion of wealth; the central plateau region, which is the agriculture center and home to 40 percent of the population; and the northern region, which is less populated and the poorest region of the three (Decalo 1995). Farming is the mainstay of the Malawian economy, with almost 70 percent of the agriculture output coming from small landholders. Land distribution in Malawi is unequal, with more than 40 percent of small landholders cultiva ting less than 0.5 hectares (World Bank Group 2000). Unlike other nations in the region, mineral resources and mining do not play a significant role in Malawis economy. Despite the high ag riculture output, Malawi remains one of the poorest nations in the region and world. The citi zens of the country suffer from malnutrition, high rates of infant mortality, and general poverty. Four teen percent of the nations GNP is attributed to foreign aid (World Bank Group 2000). The people of Malawi are mainly of Bantu ethnic origin. Successive waves of conquering and migrating people have added to the country s extensive ethnic mix of Chewa, Nyanja, Lomwe, Yao, Tumbuka, Sena, Tonga, Ngoni, and Ngonde people (Needham 1992). While the official language of Malawi is English, the most common language is Chewa, spoken by twothirds of Malawians. Based on 1999 estimates, 58 percent of the population ages 15 and over can read and write. As a result of unequal access to e ducation, however, the rate of literacy is unevenly distributed. with 72.8 percent of th e reading population being males (CIA World Factbook 2000). There are two main sources of health care in Malawi: the government health system and the evangelical mission medical systems. Since th e visits of Dr. David Livingstone, Malawi has been a locus of particular missionary zeal, and mi ssion hospitals provide about one-third of the nations health care (King 1992). The national hea lth system, which in 1991 was estimated to serve 80% of the population, comprises local prim ary care clinics, twenty-five district hospitals, and three urban referral centers (Malawi Ministry of Health 2000). Recent innovations in the national health system include the establishment of clinics for children younger than five and the development of a National AIDS Control Programme. Despite regular staffing and expenditure increases in the national system, resources have not kept up with the demand of a growing population. Consequently, shortages of st aff and beds are common (King 1992).

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36 Malawi is near the bottom of most major indicators of national health. In under-five child mortality, which UNICEF holds to be the single mo st important indicator of a nations health status, Malawi is ranked seventh-highest in the world, with a rate of 213 deaths per 1,000 live births (UNICEF 2000). The maternal mortality ratio is also a startling 620 deaths per 100,000 live births, and fertility has remained at a high 6.7 births per mother (UNICEF 2000). Research Community Embangweni, the site of this research, is s ituated in the southern part of the Mzimba district in northern Malawi (see Figure 3-1). The major ethnic groups of the north are Tumbuka, Ngoni, and Ngonde. Tumbuka is the pr edominant language of the north. The town of Embangweni serves as a centra l hub for several small communities in the area, principally due to its mission hospital, school s, and trade market. Established in 1902, the hospital has 133 beds, administers three community health clinics, and is involved in a community shallow well program. Its primary care health services include mobile clinics, family planning services, malaria cont rol programs, a nutrition reha bilitation unit, tuberculosis surveillance and treatment, and a revolving drug fund. The hospital, sponsored jointly by the Christian Health Alliance Ministry (CHAM) in Lilongwe and Central Church of Africa, Presbyterian Synod of Livingstonia, in Mzuzu, receives major funding support from Presbyterian Churches in the United States and Ireland. The ho spital serves a population of about 50,000 people. Embangweni first received grid electrical power in 2001. The actual community of Embangweni is made up of a group of seven villages, all located around the Central Church of Africa Mission Station, that dates back to the end of the nineteenth century, when Scottish missionary Donald Fraser founded the Loudon Mission. In 2002, as part of the work for Tikoleraneko Community AIDS Resource Centre, a census was conducted of the villages forming the Embangweni community and of the communities making up the hospitals primary catch ment area. (See Appendix A.) In the seven villages, mission station, and trade center maki ng up Embangweni, the tota l population is 5,161 (see Table 3-2). The hospitals primary catchment area consists of seventeen communities, each with their own constituent villages, and the popu lation of this area totals about 41,000.

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37Figure 3 Map of Malawi -1. CIA Work FactbookMalawi, 2003

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38Table 3-. Population of the Embangweni Community Total UnderOnes Total UnderFives Women 15-49 2 Village Total Population Chaphonya 205 7 25 80 Chibulu 303 12 42 120 536 14 57 235 148 6 34 75 11 100 356 10 68 148 74 638 36 100 259 24 301 26 141 204 Trade Centre 440 17 64 230 Zazini Foster Jere Kajiunde 326 14 36 Kaseka 204 Malizweni 275 44 Mlefu Simon Jere 196 7 Sinda 27 Station 753 82 Takumanapo 761 168 11 29 32 Totals 5,161 195 749 2,006 In 2001, WHO and UNICEF jointly began sponsorship of a three-year comprehensive program to reduce the rate of mother-to-child transmission of HIV. Partnering with Embangwen Mission Hospital, the community-based program was the first of its i kind in the country. In conjunc AIDS tion with its implementation, Tikoleraneko Community AIDS Resource Centre was expanded in order to support a growing networ k of village communities and committees in prevention work and to eventually provide AIDS testing and educational programming. Table 3-3 provides further social statistics on the Embangweni area. Embangweni During the Period of Research Embangweni is located four hours north of th e capital city of Lilongwe. Traveling means three hours traveling on the M1, the nation s main north-t there o-south road, and another hour travelin g west on a dirt road toward Zambia. The town is located on top of a hill amid a rolling savanna. To its east is the Rukuru River, which runs south to north. Except in the short green growing season, Embangweni mostly looks like the re d clay of dormant fields and the sporadic outgrowth of scrubby trees indigenous to the area.

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39 Table 3-3. Embangweni Social Statistics 1998 Population Density 50100 persons per square km Mean Age 211.9 years Mean Household Size >5 Percentage of Population Whose Level of Consumption is Below 60%.3 % the Poverty Line (41 US cents a day) Percent of Children in Population with One Parent 7.51%8.5% Religion More than 90% Christian Percentage of Population Living in Traditional Housing (Mud Brick) 50%% Percentage of Population without Toilet Facilities 22.7%% MalawiAn Atlas of Social Statistics 2002 (Benson et al. 2002) One enters Embangweni via the trade center, a stretch of one-story brick and plaster stores displaying hand-painted signs, each selling the same assortment of canned and dry goods. Scattered along the row of shops are small open-ai r stalls where people sell smaller items, such sugar and eggs, or offer services, such as shoe and bicycle repair. At one end of this stretch is the fenced-in yard of the official trade center, a roofed structure where people can pay a small fee to sell their produce, mostly tomatoes, onions, and b eans. On the fringe of the trade center are the bottle shops, playing loud music and inviting patrons in for a beer. Embangwenis main intersection, midway thro ugh the trade center strip, offers a turn north on a deeply rutted road lined by two rows of trees planted twenty or more years ago. Located along this stretch of abou as t a hundred yard s are a few intermittent shops and stores before the road o ion ission hospital, its gate a place of perpetual activity as families come to ble the points gives way to a large open green, in th e center of which is the mission church, built in 1902. The church, with its brick tower and peaked four-story metal roof, is massive compared t the other structures in the community. Its br ick visage looks out of place in bush Malawi, reflecting the heritage of the Scottish missionaries who built it. On one side of the green are small hand-ma de brick cottages, homes of mission stat employees. On the other side is the original building of the mission school, now occupied by first through eighth grades of Embangweni Full Primary. Immediately to the north of the church is the walled compound containing the m visit and care for the ill. Traveling ar ound the green, one can head north again on an extension of the main road to the former hom e of Donald Fraser, the missionary founder of the mission station. This two-story house, the only one for fifty miles, is now home to the Malawian Head of Station. Local tradition has it that the original village was laid out to resem

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40 of a cro s that make up the commun n ich every available piece of soil. Those with means w ie art, lso ist to lder men will the clothes are second-hand, donated and shipped from Western nations and sold in bundles at city markets. Th e contents of these clothing bundles are rebundled and resold in nly ss, with the market on the south, the hospital and school on the west and east, the church in the center, and its manse at the norththe components of community required for mission service. Surrounding this center of Embangweni are th e seven different village ity of Embangweni. In these villages, the majority of homes are of mud and thatch, grouped into extended family units. There are no cen tral features that designate a village, aside from a big tree or an open space used by the community for gatherings. The other communal spots in a village are the nearest borehole or shallow well where women, carrying large pots o their heads, travel to collect wa ter. Villages can seem to flow into one another, especially with their unending network of footpaths. Most people are subsistence farmers, relyi ng on the planting of maize and a few root crops to be both their food source and income fo r the year. In planting season, the fields are tilled and seeded using a jamba, a wooden hoe that has remained the tool of choice in this region for more than one hundred years. People try to maximize the productivity of their family plots, wh are generally two or three acres in size, by plan ting on ill use commercial fertilizers to increase thei r yield. Others will have to settle for the stunted crops that result from years of repeated plantings on soil that is never allowed to l fallow. Poor crop yields in 2002 and 2003 contributed to a famine situation in the region. In p the famine has been the result of poor growing conditions, but subsidies for fertilizer were a discontinued during that period. In the mornings, members of a family will head to the fields to tend to the planting, young children will go to school, and those with wa ge-labor jobs will go to their employment. Women dress in chtinjes, two-meter-sized pieces of cloth that can be wrapped around the wa make a skirt or be used as a sling to carry a baby. Men will wear pants and shirts; o wear a coat and tie. All of trade centers such as Embangwenis. Women and girls do not wear pants, and o boys are supposed to wear shorts. The household is a busy place, as the women look after the many domestic chores related to planting and tending crops, processing and pr eparing food, and tending to children. Men will help with the crops, but most prefer to find wa ge jobs. Those who can find the capital will engage in trade, buying and selling ho usehold items such as salt, sugar, eggs, and Cokes. The days begin early; as afternoon comes around, the activity level seems to slow down, as people relax before the darkness that comes early this close to the Equator. Some will go to the

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41 trade ce s s, as ea. The big ders private omes aying nter to shop or visit the bottle shops. O ccasionally there will be a football match, an always-popular event, at one of the two secondary schools in the community. At night, the town becomes mostly quiet and dark. The stars are quite vivid, lacking interference from electric light, and they provide light for walking on footpaths. Most household cannot afford grid power. The trade center, howev er, is not without its interesting nightspot bars use the newly secured electricity or gene rated power to pump out music throughout the night. On some evenings, especially during full moons, drums beat in the distance, signaling a Vimbosa, a healing ceremony conducted by a traditional healer. Sundays are the big weekend day, the day when most people attend their local prayer house. In the north, the majority of people belong to one of the various Christian sects in the ar gest church in Embangweni is the Centra l Church of African Presbyterian. The church day is rarely limited to one service, as there are additional Womens Guild and Church El meetings that require th e attendance of adults. Occasionally there will be a wedding or othe r celebration on Saturdays. These events draw big crowds of guests and curious onlookers. Many marriages in the community are arranged, and only a few can afford to have an actual church ceremony. The newest form of entertainment is satellite television. With the recent arrival of electricity, one bar and a few households have invested in a service that provides South African programming. A bus visits Embangweni once a week, except in the rainy season when the road bec too muddy. Most people will opt to hop a ride on one of the rickety pickups used to ferry p customers to the M1. Almost no one can afford a car of his or her own. Most rely on heavy Chinese bicycles for personal travel or an ox cart to move larger or heavier items. AIDS in Malawi Malawi, like other countries in southern A frica, is severely affected by the AIDS epidemic. The first confirmed case of AIDS in Ma lawi was reported in 1985, and as of Jun over 53,000 official AIDS cases had been reporte d. However, reported cases may make up onl one-fifth of actual cases (NACP 2000). New surveys coordinated by UNAIDS and WHO (UNAIDS Country Fact Sheet Malawi 2002) in the first quarter of 2002 estimate that there are 850,000 people in Malawi who are infected with the HIV virus, 65 e 1999, y ,000 of whom are children younger than ). 16. This suggests a rate of adult (15-49) infection of 15 percent. In 2001, there were an estimated 80,000 deaths from AIDS in Malawi (UNAIDS Country Fact Sheet Malawi 2002 A slowing rate of infection over the last four years suggests that the HIV transmission rate has stabilized. Nonetheless, one in six peopl e are becoming infected with HIV in the country

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42 (Nation isease ctancy of Malawians has decreased fro m 45 years in 1995 to 39 years in 1998 due to HIV/AI n 1992, th nal her in the southern region o an be closest dees. f t (UNAIDS 1998b). A potential asset to the region, however, is the strong influence of traditiona l authority in the north and the continued maintenance al HIV/AIDS/SRH Behavior Change In tervention (BCI) Literature Review 2001). On average, 267 people become infected with HIV and 139 people die from AIDS-related d each day. AIDS is the leading cause of death in adults (15-49), requiring 30 percent of the nations health care budget for care and treatment of those with HIV/AIDS (NACP 2000). The life expe DS ( Prevention of Mother-to-Child Transmission of HIV, an Integrated Training Manual 2000). Sexual intercourse accounts for 88 percent of all HIV infections, followed by mother-tochild transmission (8%) and blood-related transmission (4%) ( The Nation 2002). Other estimates suggest that the AIDS rate in Malawi are rising among young people ages 15-24, making up 46 percent of all new infections, and that 60 percent of these new infections among young people will occur in wome n (Malawis National Response to HIV/AIDS for 2000-2004 2000). Sexual activity contributes significantly to such high rates of infection. I e median age for first sexual encounter among girls was 13.8 years and 15 years for boys. Young girls are four to six times more likely to beco me infected than boys the same age (Natio HIV/AIDS/SRH Behavior Change Interv ention (BCI) Literature Review 2001). AIDS has affected all areas of Malawi. Prev alence, however, is hig f the nation, with its more urbanized and denser population. Rates are highest in the nations two major cities, Lilongwe and Blantyre. With only limited epidemiological data available for Embangweni, the site of this resear ch, rates of infection for this community c inferred from those of other health care facilities in the northern region included in the national sentinel survey on HIV seroprevalen ce (Sentinel Surveillance Report 2001). In Mzuzu, the urban area to Embangweni, the rate of infection is 18.6 percent among ante natal clinic atten In Mzimba, another site in the north that offers a better comparison with Embangweni in terms o rural setting, the rate is 10.5 percent. While th e AIDS rate has been lower in the north, the outmigration of workers for employment and the overall poverty of this region make i susceptible to the increased spread of AIDS of traditional family and village structures. High rates of infection combined with a high fertility rate contribute to increasing cases of mother-to-child transmission of HIV. In 2000, a limited number of programs offering antiretroviral therapy to prevent mother-to-child transmission were started in the country. AIDS has also created an estimated 470,000 orphans (UNAIDS Country Fact Sheet Malawi 2002). In respect to AIDS knowledge, most resear ch has documented levels of knowledge at over 90 percent among tested populations (Na tional HIV/AIDS/SRH Behavior Change

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43 ll on remains poor (McAuliffe 1994). strategies have been advocated in the Malawian setting: Abstinence Being Faithful to a Partner and Condoms known as the ABCs of prevention. No social data are available on the use and effectiveness of the fi rst two methods in Malawi. Condoms, however, have received some attention in social resear ch. A study by Wynerdale et al. (Coombes 2001) found that only 2 percent of Malawians use condoms with regular partners. Dislike of the condom during the sexual encounter, lack of trust in their effectiveness, and denouncement of their use by major barriers to their eff ective use in AIDS prevention in this country. The majority of Malawians are unaware of their HIV serostatus because of limited access to Volu luence HIV-related behaviors, both among HIV-positive individuals and those who test negative (UNAIDS 2001b). ated loss of life expect ed in the next decade, the social a cted IDS. Intervention (BCI) Literature Review 2001). While methods of transmission are generally we understood, peoples understanding of the relative risk of transmissi For prevention, three religious leaders are ntary Counseling and Testing (VCT) services. Where VCT services are available, the testing process has been proven to beneficially inf In addition to the overwhelming HIV-rel nd cultural impact of HIV/AIDS on this largely rural and underdeveloped country also must be considered. The burden of caring for those with AIDS is carried by women, who traditionally provide care at home ill and dying fami ly members. Issues of care for those infe are further complicated by stigmatization a nd non-acceptance of people living with AIDS (National HIV/AIDS/SRH Behavior Change Intervention (BCI) Literature Review 2001). Pervasive levels of poor nutrition also contribute to the accelerated demi se of those with A For now, at the community level, there is an i ndication that family and village support for those with AIDS and their families has staved off disruption in food supply (Mtika 2001). Factors Contributing to AIDS in Malawi To better understand factors contributing to AI DS in Malawi, one must be aware of the complex of political, economic, and social patte rns and traditional and cultural practices that contribute to its spread. Millard (1994), in inves tigating rates of child mortality in developing countries, provides a useful framework for understanding such interactions Millards model of causality posits a Proximate Tier which includes factors that contribute to the immediate biological causes of disease; an Intermediate Tier, which comprises the social, cultural practices and local material patterns that influence the household production of health; and an Ultimate Tier, which includes macro-level historical, politi cal, and economic factors that alter health. Figure 3-2 provides a graphical representation of Millards model.

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Figure 3-2. Millards Model These different tiers of causality are addressed here as they relate to factors of HIV/AIDtransmission in sub-Saharan Africa and Malawi. Proximate Causes of HIV/AIDS in Malawi S s and Causality on the proximate tier results from the direct interaction of biological factor individuals characteristics in creating HIV/AID S risk In Africa, heterosexual intercourse and vertical of ub-t from those found in developed Western nations. Recent research, however, indicates that the cision is practiced, a factor commonly associated with a decrease in STIs (Moses et al. 1994). Another the use of traditional vaginal drying agents to permit of transmission are the principal modes of infection. This contrasts with the patternspread in the West, which is mostly isolated among high-risk groups, such as homosexuals and intravenous drug users. In attempting to understand the explosive spread of HIV/AIDS in sSaharan Africa, initial concern focused on the presence of certain AIDS subtypes that are differen A and D subtypes, those most commonly found in sub-Saharan Africa, do not have increased infectivity. Rather, elevated viral loads and the presence of sexually transmitted infections (STIs) are believed to contribute to increased transmission (Greer 2001). Due to the regions general inability to purchase and distribute protease inhibitors, little has been done in reducing viral loads as a means of reducing transmission. Research in Malawi indicates that the virulence of HIV in male semen increases by up to eight times in the presenceof urethritis (World Bank Policy Research 1997). Efforts to detect and reduce STI prevalence in men and women are among strategies used in abating the spread of HIV. Research done in sub-Saharan Africa also indicates that HIV seroprevalence is lower in areas where male circum practice hypothesized to facilitate transmission is dry sex. In a study conducted in Malawi, 13% of antenatal clinic attendees reported using vaginal agents to carry out dry sex (Dallabetta 1995). HIV is also transmitted from mother to child during pregnancy. In Malawi, the ratetransfer in seropositive mothers was just more than 10 percent (Motti et al. 1999). Coutsoudis et 44

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45 e in n some communities in the sub-Saharan setting (Mann e ngs ir influenc s. er immunosuppressant conditions such as malnutrition, tuberculosis, malaria, or trypano al. (1999) suggest that around 15 percent of babies born to HIV-infected mothers will becom infected through prolonged breast feeding. At odds with these findings are the documented nutritional and immunological benefits of breast feeding. Most international medical organizations involved in AIDS research and prevention support the assertion that heterosexual intercourse is the main mode of transmission of HIV sub-Saharan Africa. However, a minority of r esearchers has challenged this model suggesting iatrogenic transmission may better explain th e magnitude of the problem in the region (Gisselquist et al. 2002). Infection through shar ed and improperly sterili zed needles has been suspected as a means of virus transmission i t al. 1986; Packard and Epstein 1991). Certain religious rituals that involve the sharing of razor blades or other cutting instruments have been identified as another possibl e avenue of infection in other African setti (Romero-Daza 1994; Gausset 2001). In sub-Sahara n Africa, there is limited evidence that intravenous drug use has contributed to the high rates of AIDS infection (Barnett and Whiteside 2002). In treating those with AIDS, there is some concern over the role of co-factors and the e on the natural life and spread of the virus (Feldman 1994; Packard and Epstein 1991; Caldwell et al. 1989). In the West, the average latency of HIV is about ten years; in Africa, that period is about six years (Webb 1997). Much of this difference is attributed to background levels of pathogens in the environment, with Africans be ing exposed to pathogens at much higher rate A number of studies have indicated a positive correlation between HIV seropositivity and the presence of oth somiasis, Packard and Epstein say (1991:7 77). This association can be reversed causally, with the implication that such conditions ma y also increase susceptibility to HIV/AIDS. Causality on the Intermediate Tier On the intermediate tier are those practices or patterns of living that put people in contact with HIV Polygamy and multiple partnering are regional practices that can contribute to the risk of AIDS. Caldwell et al. (1989), in studying patterns of sexuality in Africa, have used the ethnographic record from sub-Saharan Africa to li nk current sexual practices to traditional female roles in a polygamous society, which are often embedded in economic strategies. They cite Goodys (1969) hy pothesis that land for farming has been less limited a commodity in Africa than in Europe and Asia. Instead, the labor re quired for farming production is more scarce than the necessary land, which creates the need to cap ture as much labor as possible through family

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46 is central n le xtremely reluctant to use them nly 10 oms s such as NAIDS 2001b). Likewise, th e continents M1 Highway travels north to south th a put cted Malawian women, suggesting that the dynamics of sexual control are mor s s ens economic opportunities are highly re stricted because they are unable to own land obligation. Also, the importance placed on fer tility often provides motivation for marriage, resulting in more sexual activity and even contact with HIV. Kesby notes that Fertility to heterosexual identity of all people and the soci oeconomic pressure to marry and have childre is such that even those who know they are HIV pos itive feel obliged to engage in unprotected sex in order to secure pr egnancy (2000:1724). When people do have sex, they usually do not use condoms. Regular use of the ma condom is very low, even in conditions of casual sex, and most men are e with their wives (Kesby 2000:1724). In a study of condom usage among sexually active adults in five African countries (Togo, Burundi, Kenya, Lesotho, and Tanzania), o percent of respondents had ever used condoms (Cleland and Ferry 1995). While condom usage data for Malawi are scarce, research on barriers to AIDS prevention indicate distrust of cond efficacy and a general dislike for use among Malawian men and women (McAuliffe 1993). Much of the epidemiological research in Africa has concentrated on at-risk group as bargirls, prostitutes, truckers, and soldiers (Standing 1992). Highe r rates of infection are found among these populations. In Malawi, HIV/AIDS seroprevalence among sex workers is as high 70% in urban areas (U rough Malawi and is be lieved to be one of the main routes by which AIDS has spread (Webb 1997). While reciprocity in the form of material s upport is common in sexual relations, there is growing critique of research that focuses more narrowly on risk groups, such as prostitutes, suggesting that this approach fails to recogni ze the broader and more common activities that people at risk (Standing 1992; Kielmann 1997; Cr addock 2000). Schoepf asserts that most sexual practices must be read in a wider frame of . . pr ocreation, personal identit y, socially constru gender roles, household economics, trade, patron-clie nt relationship, to interpersonal and public power (1991, 73). In addition, research indicates that higher socioeconomic status can be an indicator of increased risk in e complicated and extend beyond simple classifications of risk (Dallabetta et al. 1993). Surveillance data on HIV/AIDS in this regi on show an increasing rate of infection in women. Craddock (2000) suggests that women have a higher rate of infection because women in Africa often occupy different, and arguably larger, spaces of vulnerability to disease. Women have been traditionally locked out of wage-labor opportunities in urban areas, and customary law in nations like Botswana and Malawi have led to continued patern alistic treatment and disenfranchisement of women (MacDonald 19 96; Craddock 2000). Undoubtedly, in setting where wom

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47 or have t are ucture was promote 1994). de . to 1996) discovered in work in Botswana, the traditionally subordinate roles of women eing too e t to erpart who at least colludes in the manifestation of risk and at worst capitalizes on it. This makes targeting and involvin g men in community preventive efforts crucial if womens efforts to protect themselves ar e to have any chance of success (Ankrah 1991; independent access to other productive resources, or where they are prevented from entering a variety of occupations, adult women, like adolescent girls, may experience grea difficulty in separating sex from economic survival, Gage says (1998). Bride payment and levirate, customary practices in many parts of southern Africa, also thought to contribute to a continued lack of power among women and the potential transmission of AIDS (McDonald 1996; LatreGato Lawson 1999). In Malawi, during the longterm rule of Hastings Banda, a national culture based on traditional village str d, which emphasized strict patriarchal relations between men and women (Forster Craddock suggests that this disempowerment of women in Malawi, combined with outsi economic pressures, places households in precarious positions, leading to the production of bodies that will inevitably be more vulnerable to economic deprivation, political neglect and disease (2000:157). Sub-Saharan women have traditionally had less power to negotiate in matters related sex. As MacDonald ( have made it difficult for them to refuse or control sexual relationships, especially with regard to the use of condoms in intercourse. Discussion of sex between partners is a difficult prospect when women are expected to know less about sex, and open discussion can lead to accusations of infidelity (Gupta and Weiss 1993). Ankomah (1998) found that women risk b considered loose or cheap if they request the use of a condom during sex. Consequently, several researchers (Schoepf 1992; Latre-Gato ; Lawson 1999; Craddock 2000; Blanc 2001) have advocated for prevention efforts that work to empower women and to create more positive female social and sexual identities. These insights into gender-differential HIV risk suggest that research on AIDS has often failed to focus on the male side of the equa tion. For men in relationships, social convention has allowed multiple partnering, requiring only material support but not fidelity (Caldwell et al. 1989; MacDonald 1996; Kesby 2000). A recent tren d that has troubling implications for th spread of AIDS is men turning to relationships with younger, school-aged girls in an attemp protect themselves against AIDS. By choosing younger women in order to reduce their risk, men greatly increase the risk of infection of women in younger age groups (Browne and Barrett 2001:25). It is reasonable to conclude that for every woman who finds herself at risk for AIDS, there is a male count

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48 /AIDS risk among South African mine workers, Campbe l ar of ostracism have created an atmosphere of silence e sy ing, or perform on sexuality that focuses exclusively on so cial networking tends to present a view of African Ankomah 1998). Based on her study of HIV ll (1997, 2000) suggests that the continue d construction and mainte nance of a traditiona African male identity can contribute to pa rticipation in risky sexual behaviors. Misconceptions about HIV and AIDS exist within communities, and a variety of ethnomedical explanations for HIV and AIDS may be offered. Studies of AIDS-related knowledge in the region offer mixed results (Schoepf 1991; Ulin 1992; Romero-Daza 1994; Kesby 2000). Research has identified cases wher e knowledge of HIV/AIDS may be relatively extensive, yet high-risk sexual behaviors continue (Campbell 1997). In Malawi, men tend to have more specific knowledge than women regardi ng how AIDS can be transmitted (Mvulu and Kakhongwa 1997). Hindering prevention efforts is a lack of social recognition of AIDS in communities. Its long latency and synergistic relati onship with other infectious disease, combined with a lack of diagnostic ability, has helped to mask its presence in communities. Cultural norms requiring discretion in matters of sex and promoting fe around the disease (Caldwell et al. 1992). Some in sub-Saharan Africa have expressed th belief that AIDS is nothing more than a product of European and American contempt or jealou for African sexuality (Schoepf 1991). Silence, whethe r out of fear of blame, misunderstand stigmatization, only works to facilitate the spread of the disease. While specific cultural practices may suggest certain pathways for infection, these practices are not themselves necessar ily causes of infection. As Gausset (2001) reminds us in his criticism of the portrayal of culture as a barrier to AIDS prevention, it is the failure to these cultural practices in a safe mannernot th e practices themselvesthat leads to the possibility of infection. To many of the peopl e of sub-Saharan Africa, it is the adoption of Western cultural practices and modes of urbaniza tion that are seen as the ultimate causes of the spread of HIV/AIDS among women (Ulin 1992) and in communities (Gausset 2001). Likewise, research s as highly sexualized, while overlooking other areas of causality in HIV/AIDS (Packard and Epstein 1991). Production of Health on the Ultimate Tier On the ultimate tier are the historical patterns of livin g that are shaped by political and economic forces resulting in risk to populations a nd contributing to discontinuities in health and welfare In understanding general patterns of health in sub-Saharan Africa, one must start with the influence of colonization. The arrival of Westerne rs in Africa was followed by the introduction of

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49 s nt h disrupti d and in 996). There due in part to burdensome colonial ual relations (Schoepf 1991). areas t the aphical population shift facilitates the transmission of AIDS to rural households and communities because spouses, most often men, sometimes return home, exposing partners to HIV and STIs (Ankrah 1991). Wars and the resultant refugee resettlement are also associated with the further spread of the disease into new populations (Webb 1997). Malawi has absorbed refugees in communities along its southern borders for the past twenty years, as people have fled the violence in Mozambiques civil war. Schoepf (1991, 1992) suggests that HIV/AIDS must be viewed as a disease of development, with poverty and pow er acting as equal shapers of biology in facilitating its spread. new diseases and increased spread of disease. In partic ular, the spread of t uberculosis and syphili in African populations can be seen as colonial pr ecursors to the spread of HIV/AIDS in curre populations (Packard and Epstein 1991; Schoepf 1991 ). Colonial policies are also associated wit ons in traditional household patterns and the increase of labor migration (Packar Epstein 1991; Campbell and Williams 1999). South African mining employment remains a particularly strong influence in the region, resulti ng in transnational labor migration. Migration turn leads to separation of families and sexua l partners (Campbell 1997; McDonald 1 is coordinated policy among countries to address the relationship among migration, mining, and HIV/AIDS (Campbell and Williams 1999). The influence of colonial policy is also f ound within Malawi. The less arable northern region has historically been underdeveloped, a situation originally taxes that were levied to fund a wa ge-labor force for colonial economic interests operating in central and southern Malawi (Decalo 1995). As a nation, Malawi was less developed during its colonial period than other African nations, which resulted in Malawians becoming a pool of cheap labor for colonial enterprises in more mineral-rich neighboring countries (Craddock 2000). Colonial administration in Malawi also placed restrictions on small landholders, prohibiting the production of coffee and maize in order to protect colonial plantation interests in Kenya. Colonial efforts to reduce plural marriages through taxation are thought to have led to a decrease in the number of married men, with a concomitant increase in the pool of individuals likely to migrate for laborand thus likely to be involved in transient sex Geographic analysis of HIV cases in this regi on shows that the spread of HIV/AIDS has coincided with patterns of urbanization. There are higher incidences of infection in urban and along modern trade routes (Caldwell et al. 1989; Cleland and Ferry 1995; Webb 1997). A heart of this pattern is the search for employment and economic opportunity. This search leads men and women to urban areas, where there are opportunities for increased informal relations away from traditional social practices. This geogr

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50 Sub-Saharan Africa is one the poorest regions in th e orld. It is estimated that in 2000, Africa held 40 percent of the worlds poor (Hope 1999). Wit an annual per capita GNP of approximately $170, Malawi is the fifth-poorest coun ld (Cohen 2000). As Turshen (1998) points out, in nners such as The orld Bank, fails to adequately address AIDS in developing nations. The World Bank may even through illiberal economic policies. of i, l ). In Malawi, anecdotal evidence s uggests that HIV/AIDS has taken a significant toll on h multiple aspects of the liv ed experience and how . . living bodies are incorpo w h try in the wor ternational reaction to AIDS, particularly by economic pla W have worsened the problem Nevertheless, while Africa holds 10 percent of the worlds population and two-thirds the worlds HIV infections, it receives only about 2.8 percent of the global expenditure on AIDS (Waldo and Coates 2000). In treating AIDS cases, de veloped countries are better able to handle the high costs of patient care. Sub-Saharan Africa currently has the lowest ratio of hospital beds per capita in the world; as many as 30 percent of hospital beds in nati ons like Uganda, Malaw and Zaire are now going to people with HIV/AIDS (Hope 1999:82). Likewise, essential medica and research resources have been pulled from other areas of health care to deal with HIV/AIDS (Ankrah 1991 ealth care workers, educators, and members of the civil service. In discussing AIDS in Africa, Ulin suggests, We have evidence that poverty, lack of better resources, and the desire for upward mob ility lead many women to exchange sexual favors for economic survival, or at least for what they perceive to be windows of opportunity (1992:70). In light of such realties, it is unwi se to view AIDS simply as a medical condition. Rather, AIDS affects rated into social relations (Kippax and Crawford 1993:257), whether viewed in terms of social, cultural, political, or economic domains.

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51 Chapter FourResearch Framework and Objectives arch Structure of the Rese Because this research has both applied and th eoretical interests, a two-part research The first part, both a crea tive and a multidisciplinary exercise, involved the develop earch d conducting a pr ocess evaluation of the participatory research activitiein activities. The a sub-field of an s among informa Whilea he activities as th The researchs activities tes between the interest e (knowledge for immediate action in a specific context) and t experience). rch as members o process of dis inated in the mind of an individual, the topi ften shared in and through the lives of others. In addressing the very public to with the community in a tanding of the research must include t Figure 4-1 r vergences of these dialectics (applied and theoretical, researcher andm movement, as the re that is thought to po this process, the rese to improve future appl model was developed ment and implementation of a community AIDS intervention using participatory res methods. The second part concerne s beg implemented so as to understand th e role that group con sensus plays in such process evaluation was highly structured, using formal methods developed in thropology to conduct preand post-comparisons of levels of consensu nts. reserch goals are presented as separate tasks, there is a symbiotic aspect of t eir respective goals and objectives are actualized in a single body of work represent a concomitant pro cess of expanding knowledge, one that oscilla s of applied knowledg heoretical knowledge (knowledge that suggest a broader understanding of human Such activities, when done in and with communities, expand our basic model for resea f the communities function not as p assive subjects but as part of an informed covery. While the seeds of research may be germ cs of research are more o pic of AIDS, this research attempts to seek knowledge and share its findings way that serves the community Therefore, any unders he knowledge sought and created by all parties involved. epresents the con comunity) as expressed in the current research. Inherent to this model is searcher starts the process a nd engages community participants in research tentially em power its participants to take further action in the community. In archer has the potential to use insights ga ined through the research ications.

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52 Figure 4-1. Model for Research Research Objectives In meeting both the applied and theoretical interests of this research, the following objectives were established for it: A. Program Implementation Objectives : To develop and pilot the use of a Drama Dialogue Planning and Production model as a tool for building community capacity for dealing with HIV/AIDS in rural Malawian communities. Specific objectives are: A1. Learn significant local knowledge for effective program development. A2. Conduct research on HIV/AIDS while enhancing the participating communitys ability to conduct research through the use of participatory research techniques. A3. Develop an understanding of the current application of participatory research so as to refine and benefit future applications. B. Process Evaluation Objectives : To develop an understanding of the underlying cultural processes that drive the intervention in terms of creating shared knowledge or values related to HIV/AIDS social causality. Specific objectives are:

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53 B1. Develop an understanding of poten tial variations among the research communities that could influence program activities. B2. Identify the cultural domain of locally relevant social risks for HIV/AIDS in the gard to community AIDS knowledge. The following hypotheses are offered regarding the effect of the intervention process on consensus among participants: ne : The intervention process will increase consensus among concerning intervention-specific issues. ze the interacti on and construction of shared community intervention process. community. B3. Assess levels of consensus on locally relevant social risks for HIV/AIDS before and after participation in th e community intervention, and compare these levels to determine whether the intervention process has an effect on the consensus of the participants with re Hypothesis O the participants in terms of community AIDS knowledge concerning intervention-specific issues. Hypothesis Two : The intervention process will not affect consensus among the participants in terms of community AIDS knowledge B4. Document and analy models as evidenced in the

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54 wed ssion of the research team, informed consent, and the conf Chapter FiveResearch Design and Methods The general organization of the research activiti es is explained in this chapter, follo by a more in-depth explanation of the different data-collection strategies and instruments used in the conduct of this research. Included is discu identiality process used with research participants. Research Design Organization of Research Tasks In fulfilling the research objectives, the r esearch was conceptualized as two separate research tasks corresponding to the resear chs two sets of research objectives: a Program ask Table 5-1 summarizes the main elements of each reson Task Process Evaluation Task Implementation Task and a Process Evaluation T earch task. Table 5-1. Summaries of Research Tasks Program Implementati Objecti IDS ve: To develop and pilot the use of a Drama Dialogue Planning and Production Model as a tool for building community capacity for dealing with HIV/AIDS in rural Malawian communities. Objective: To develop an understanding of the underlying cultural process that drives the intervention in terms of creating shared values on HIV/A social causality. Methods: Participant Observation/Natural Group Discussions Methods: Semi-Structured Interviews Card Sorts Particip Map atory Group Activities ping Activities Diagramming Activities Role-Playing and Dramas Individual Surveys Direct Observation Participants: Volunteers from four villages Purposely selected members of the community Participants: Volunteers from four villages Randomly selected members of the community

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55 IV/AIDS. h menable to methods was that it allowed the research its and ment. The two research tasks, while treated as inde pendent of one another, were completed in concert. Insights gained from the Program Implementation task served to inform the development of activities for the Process Evaluation task by providing information that helped researchers meet the more general aim to understand the nature of communities experiences with H Likewise, research done as part of the Process Evaluation contributed to the ethnographic understanding of the community, particularly when conducting key informant interviews to learn about the AIDS situation in the community. A diverse set of research methods were employed to meet the research objectives, wit methods ranging from exploratory qualitative data co llection to randomized surveys a quantitative analysis. The advantage of using this variety of er to triangulate the data collected, as understanding of a particular research question could stem from analysis based on multiple and diffe rent data sets, each with its own benef limitations. Overview of the Program Implementation Task In the Program Implementation task, research activities centered around developing and implementing a community program on HIV/AIDS. Th e methods used in this task were drawn from cross-disciplinary knowledge, based on formative research, program development, and participatory research. In preparation for the participatory research activities, a range of traditional ethnographic methods were used to (A1) Learn significant local knowledge for effective program develop This knowledge would familiarize the researcher with the social and cultural setting while r the planning and conduct of the interventions research le doing, be d l setting. The use of rapid assessment was con of es providing the necessary building blocks fo activities. As Nichter (1990) suggests, fo rmative inquiry tells us what are peop saying, and thinking now about a problem, helps to identify important problems that need to solved in a community, and lets us investigate how best to implement promising interventions Traditional ethnographic methods, structured in accordance with principles from the fiel of rapid assessment, were used in understanding the socia sidered an important first step in the r esearch, in part because of the sensitive nature the topic. In conducting research on sexual be havior, ethnographic and qualitative approach provide advantages over more structured methods of data-gathering because they allow for exploring behavior using discreet and sensitive techniques that encourage openness (Schrimshaw et al. 1991).

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56 holistic ssful ogram designers use formativ e research to become cogniza ities, implemented as part of the Program Implementation task, bu Ethnographic methods were also thought necessary to developing an integrated or understanding of AIDS in the community setting, something considered critical to the succe piloting and implementation of the short community intervention. Insights such as those gained through participant observation and similar me thods have been labeled by some as the anthropological difference, whereby pr nt of the multitude of forces in a communitycultural, social, political, and economic that can influence the implementation and success of programs (Wulff and Fiske 1987). The formative aspects of this research attempted to be iterative in inquiry and reductive in scope, moving from broad explorations of research interests to progressively more focused investigations of relevant cultural domains (Beebe 2002). The participatory research activ ilt on the findings of the formative ethnographic research and incorporated known methods for conducting group participatory research in developing settings. In the intervention activities, methods common to Participatory Research and Participatory Rural Appraisal were carried out with groups of community volunteers as part of workshops designed to (A2) Conduct research on HIV/AIDS, while enhancing the pa rticipating communitys ability to conduct research, through the use of participatory research techniques Significantly, these more traditional methods were incorporated into dr ama methods used in Theatre of Development programs, such as role-plays and stop-motion th eatre. Participant observation of the program implementation process also co ntributed to the effort to (A3) Develop an understanding of the current application of participatory research so as to refine and benefit future application. Overview of the Process Evaluation Task As part of this researchs effort to develop a better empirical understanding of participatory activities with regard to co n sensus, the design for conducting the community participatory observational tasks related to the participatory activities of the intervention. on research activities reflected a desire to control and evaluate aspects of program implementation. This was primarily achieved by using a quasi-experimental design to structure the research activities in the Process Evaluation phase. The data collection in the Process Evaluation task was oriented toward survey and systematic data, with some Information was collected from in tervention participants in the four research communities at three points: 1) before starting the intervention activity, 2) during the interventi period, and 3) and two weeks after the intervention was completed.

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57 fore conducting the main pr ocess evaluation activities, a survey was conduct However, be ed prior to the intervention activities in order to (B1) Develop an understanding of potential variations between the research comm unities that could influence program activitie s domain concern 2) Identify the cultural domain of locally relevant social For these mostly demographic surveys, a random sa mpling design was used to ensure the greatest representation of community members. The formal steps of a Cultural Domain Analysis were followed in conducting consensus analysis as part of the Process Evaluation activities. This entails a three-step process, starting with 1) Elicitation, in which members of a community id entify the content of a cultural ing issues key to the intervention. In formant interviews of key members of the community allowed this researcher to (B risks for HIV/AIDS in the community. After elicitation of a cu ltural domain, the next step is to determine the 2) Organization of the cultural domain, or rather its structure, cons isting of different associations or relationships among domain items. This organization is also referr ed to as a cultural model for the domain. It is explicated through methods of systematic data collection, as informants organize domain items. Preand post-intervention evaluation activities were conducted in the form of structured surveys, including ranking activities necessary for conducting a systematic analysis of the cultural domain of AIDS issues in the community. In addition to the systematic data, observational data were collected during the intervention to provide additiona l insight into the inter actions and agreements among research participants. The final step is one of analysis, as multivariate data-reduction techniques are used to 3) Visualize the domain so the researcher can make infere nces. In this case, the formal method of consensus analysis was used to visualize or de termine agreement among participants. Using both preand post-intervention measures, comparison can be made to determine the direction and strength of change. The steps of 2) Organization and 3) Visualiza tion together allowed the researcher to (B3) Assess levels of consensus on locally relevant social risks for HIV/AIDS before and after participation in the community intervention, an d compare these levels to determine whether the intervention process has an effect on the consensus of the participan ts with regard to community AIDS knowledge Observations made of the participatory workshops activities allowed the researcher to (B4) Document and analyze the interaction and co nstruction of shared community models as evidenced in the intervention process This contributed to the overall understanding of how consensus can be achieved through such activities.

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58e our understanding of the process of the intervention, with the preand Research Timelin A staggered design was used in the evaluation of the interventions. However, no baseline data were gathered, nor were follow-up procedures implemented for the express purpose ofcomparison between intervention and non-intervention sites. The staggered design served mostlyto allow the researcher time to refine and prepare the research activities to be used in the next community. The decision not to compare intervention sites against non-intervention sites reflects this researchs interest in improving post-surveys designed to assess changes within the intervention participants. Figure 5-1 illustrates the separate components of the research design and their order of use over the 12-month research period. Figure 5-1. Design of Research

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59 ool ed in as establis at she ical skills and experience to the research ; her contacts as a health surveillance officer proved i search man different lp produce a manual descr ibing the work done in communities (see Appendix for details), and they independently continue d the community programs in other villages after m the research setting. Several individuals from the Youth Group at Tikoleraneko Community AIDS Resource Centre also helped with the larger co All Research Team For the initial key informant interviews, three individuals served as translators during the interviews. All three individuals, through o ccupational training, had received some higher education and exhibited advanced skills in Englis h. Two of these individuals were employed in the area of health promotion and HIV/AIDS prevention, and one was a former primary sch teacher. A fourth individual, a recent graduate from one of the local secondary schools, assist the translation of interview tapes. After the initial key informant interviews a more permanent research team w hed for the remainder of the research period. At the core of this team was a government Community Health Surveillance Officer who expressed interest in learning more about conducting health research. After a trial period of working with this person, it was clear th brought crit nvaluable to working in communities, and the intellect that she brought to research tasks contributed to their successful completion. Her role quickly changed from that of assistant to one of community counterpart in the research process. Two more people provided additional re assistance: a younger woman in the community w ho had served as the translator for the key informant interviews and who exhibited exceptional translation skills, and a bright young who was a recent graduate of secondary school and who demonstrated an uncommon ease when talking to groups. This team of three assisted with the development, translation, and implementation of all surveys and questionnaires. In the program implementation stage, they took on key roles as community facilitators, leading group activities and being individually responsible for aspects of the community programs. Near the end of the research period, they collaborated with this researcher to he B the primary researchers departure fro mmunity su rvey, having been selected for employment based on proficiency in English. Research team members received training in their research tasks. research team members were comp ensated for their time. Payment was based on an hourly rate equivalent to the sum paid by the local ho spital for similar community outreach work.

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60 Confidentiality ard h arch, an informed consent statement was read aloud to interview participants, and they were asked if th ey would consent to an interview. To maintain interview codes replaced names on all interview materials. ram of the activities. All worksh ment at an introductory program meeting and included obtaining permission for vi In explaining the conduct of the dvised comfortable telling others in their co y als collected from individuals as part of th eir participation in the workshops. To match surveys between research participants as part of evaluation activities, info rmation on sex, age, and month o Informed Consent and A protocol for this research was submitted to and approved by the Internal Review Bo at the University of South Florida. Due to expected low levels of literacy among research subjects, a wavier of the requirement for writte n informed consent in the research process was petitioned for and approved. In addition to USFs IRB process, the research protocol was submitted to the National Research Council of Malawi, with endorsement from the National AIDS Control Programme. All research activities we re conducted in conjunction with, and wit the approval of, Tikoleraneko Community AIDS Resource Center in Embangweni. In the formative stage of the rese confidentiality in the interview process, With the community prog s, confidentiality was not possible due to the public nature op participants were read an informed consent state asked to sign an informed consent statement, which deotaping of gr oup activities of many workshop, participants were a to shar e only information they would generally feel mmunity. Again, names were not recorded on any surve materi f birth was included on all surveys. From these three pieces of information, matches could be obtained. After matching was completed, the demographic information was disassociated with the survey responses and numeric codes were used to keep the preand postsurveys together. Program Implementation For ease of discussion, the activities encompa ssed in the Program Implementation have been divided into two areas corresponding to research activities to gather formative information for program development (Formativ e Research) and research activities conducted part of community intervention research (Community Participatory Research). task as

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61 Formati nual he ormative research. ve Research In organizing the formative aspects of the Program Implementation task, the manual HIV/AIDS RAPID Assessment Procedures: Rapi d Anthropological Approaches for Studying AIDS Related Beliefs, Attitudes, and Behaviors (Scrimshaw et al. 1991) served as a guide for research activities and provided information useful for modifying methods traditionally used by anthropologists for research on AIDS in commun ities. Among the methods detailed in the ma are participant and direct observation, semi-stru ctured and unstructured interviews, the use of personal diaries, and the collection of data through secondary sources. Table 5-2 outlines t methods used in the f Table 5-2. Formative Research Methods Method Task 1) Participant Observation/Natural Group Discussions Observation and engagement on the part of the researcher to le and understand norms, attitudes, and behaviors in the community in relation to the emergent epidemic of HIV/AIDS and development of insight into peoples understanding of HIV/AIDS and its related social problems and how people choose to communicate about the topic. arn 2) Seconda ry Data Collection Collection of epidemiological and social data related to the research community and HIV/AIDS, in part to better understand how AIDS is presented in government and public discourse Participant Observation/Natural Group Discussions Participant observation, despite being on w p; and e nt h e as a more general e of the cornerstones of the discipline of anthropology, remains a loosely defined method. Bernard (1995) defines participant observation as . establishing a rapport in a ne community; learning to act so that people go about their business as usual when you show u removing yourself every day from cultural immersion so that you can intellectualize what youv learned, put it into perspective, and write about it convincingly (137). Perhaps more significa than trying to define the process is identifying the types of results that can be achieved throug participant observation research. Pelto and Pelto (1978) suggest that data from participant observation can guide development of other met hods of data collection and serv check on information collected through specialized research methods. Findings from participant observation also contribute to a more holistic or integrated understanding of the research setting, as the researcher enters and inter acts in multiple domains of social life in the research setting.

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62 m the the researcher to move to and from the research site easily, this was not the quire tension of t opportunistic encounter s where a group of people may have joined together the nt and visits from outside health organizations having t h is departure in February, a teacher from the local primary school provide a The participant observation activities were carri ed out over the entire period of the field research, approximately one year. The extensive application of this method stems more fro reality of the research setting than from any co nscious decision to apply it extensively. While some research settings allow case in conducting research in the rural northern region of Malawi. Transportation was limited and irregular, necessitating extended peri ods in the research community. Further, the language, daily activities, and customs of the area proved to be sufficiently different as to re a committed effort to understand them if the researcher was to function effectively in the community setting. Group discussions with members of the community were considered both an ex participant observation and an element of the fo rmative research phase. The term natural is applied here to the group discussions to distinguish them from the more formal discussion formats associated with focus groups. The ke y criterion of natural group discussions is tha members of the discussion are not recruited for explicit purposes of a discussion (Beckerleg et al. 1997). Rather, these are more for another purpose, often unspecified, but are willing to discuss matters relevant to research. In participating in natural group discussions, open-ended questions were presented to the group and were used to encourage a free excha nge of thoughts and ideas. The impromptu timing of these discussions and the casual nature of the conversations precluded recording, though notes were taken during discussions, when appropriate, or immediately following such encounters. Journal entries were used to record observations and personal reflections from the participant observation process. In particular, field notes were used to document significa research activities or community events that re lated to HIV/AIDS. Examples of events that warranted entry are community meetings or presen tations related to the intervention element of this research, funerals for community members, o do with health or HIV/AIDS-related issues. In addition to the field journal, a daily calendar of events was kept to record research events and serve as an official timeline for researc activities. When appropriate, a video camer a was used to record public events. The researcher began taking lessons in the Tu mbuka language soon after arrival. In the first months, December and January, a student on term break from the Teachers College in Domasi provided lessons. After h d lessons. Proficiency remained limited, w ith the researcher learning only a modest range of greetings and pleasantries used in everyday interactions, some common vocabulary, and

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63 Malawi, th ey are not often found living and visiting away from the m ork is a s are responsible for bringing wealth ian aid. Likewise, it is recognized that they possess a much higher standard of living. rudimentary understanding of the structure of sentences. Comprehension of spoken conversations increased with daily exposure, but only to the degree of identifying the topic of others conversations. The ability to cross-communicate ne ver reached a level that allowed engaging in conversations in Tumbuka. Entry into the community was facilitated by having previously visited Embangweni and having corresponded with various i ndividuals from the community prior to arrival. Some of the specific steps taken to help the researcher inte grate into the community were visiting local churches, assisting at the hospital with various projects, and associating as members of institutions within Embangweni. My wife taught at the local primary school and became involved in training teachers in the use of computers, part of a school project. I helped with the administration of Tikoleraneko, the community AI DS resource center, and worked with the local hospital as a member of the AIDS Steering Co mmittee, which worked to coordinate AIDS activities among Embangweni institutions. Beyond our more official capacities, we went to community events, shopped in the market, attended weddings and funerals, and shared meals with people from the community. Another aspect of the research setting that facilitated this researchers entering the community and having the ability to engage in participant observation activities was the uncommonness of people of European descent living in interior areas of Malawi. While people of European descent are not uncommon to popular lake tourist areas or cities. At the time of our arrival, there was only one other expatriate couple in Embangweni, a physicia n and his wife, and this number increased only moderately over the period we lived in Embangweni, mostly as young doctors and teachers fro the United Kingdom cycled through the hospital and secondary school as part of churchsupported mission work. With so few foreign reside nts in the area, we were often treated with curiosity. People would frequently approach us, striking up conversations, asking where we were from and what it was like in our homeland. More problematic to the role as participants in the community, however, was the long history of missionary interventions in this region. While missionaries have laid the groundw for genuinely good relationships between Malawians and people of European descent, there corresponding understanding that Americans and Eu ropean to communities in the form of humanitar While our efforts to live modestly may have helped to minimize some of this reactivity, the historical role of non-Africans in the co mmunity and the obvious inequity in resources

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64 lted in ir t aintain a separate residence in the commun vel of attracted a certain level of interest from community members, many of whom may have seen us as potential opportunities for personal and community advancement. If anything, this resu people often going out of their way to please us or be helpful to us, at times perhaps muting the own expressions, desires, and frustrations with us as members of their community. With the research location being rural, the research experience took on some aspects of the classic field experience associated with anthro pology, where total imme rsion is required and where the most mundane activities, such as greeting people as you walk down the road or shopping in markets for unfamiliar foods, require some form of relearning. In such case, participation in the community, along with observa tion, becomes requisite if one is to learn wha is necessary to get by. Still, this researcher chose to m ity, allowing more selectivity regarding par ticipation in aspects of daily community life. Following the continuum of engagement in partic ipant observation elaborated by Dewalt, Dewalt, and Waylands (1998, 262), this particular use of participant observation could be classified as moderate participation, in which the researcher maintains some control over his or her le integration in the community. Secondary Data Collection The secondary data located by the researche r was of two general ive ta could be found, mostly in the form of reports genera ted to program funding agencie ing l Programme (name later changed to the National AIDS Commis ten to fifteen volunteers in four separate work shop sessions in one community and three villages types: epidemiological data developed by government and other social and administrat institutions, and programmatic data concerning the social response to HIV/ AIDS, produced by the government, nonprofits, and churches. In terms of epidemiological resources, the research capacity of Malawi is limited, and most data concerning HIV/AIDS reflects national or district-level surveillance. At the local level, only limited da s (e.g., UNICEF). Similarly, the progra mmatic data generally reflects national-level initiatives on HIV/AIDS. Most of these materials are provided free to individuals upon produc adequate credentials confirming some research affiliation. Other materials were made available for the price of photocopying. Places where documen ts could be obtained included the Ministry of Health, the National AIDS Contro sion), the Centre for Social Research at Chancellor College, and the AIDS Control Program at the Synod of Livingstonia, Centra l Church of Africa Presbyterian. Appendix C provides a list of the materials collected while in Malawi. Program Implementation Research At the core of the implementation research were small-group works hops conducted with

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65 s ation on AIDS in the gned to share inform ation on AIDS. Presented to the group was the overarching task of putting on a community drama or dramas concerning HIV/AIDS in their community bers w as refining the workshop activities to improve application for future use. In general, these refi ties roup. imary researcher would also lead or assist with workshop activities, with translati ch meeting place for workshop activities. In the community of Kakoma and the villages of Foster Jere and Kabira, a dwelling large enough to acco e weekly mee ting place. In village, due to its close proximity to the Tikko AIDS R op in the Tikoleraneko meeting room. mmunities we ose w were the options to do th s a nd to do y sessions on weekdays. Workshop days usually cons isted of greeting participants around 8:00 a.m., conductin g the workshop sessions, and then concluding around one im e meal. Besides participation in the weekly (these four research sites will be referred to as communities from this point forward). Member participated in a set of activities, some desi gned to generate inform community and others desi Members were to use what they had learned or discovered in the workshop to put on a drama that addressed the unique AIDS issues a ffecting their community. Particular emphasis was placed on identifying social practices contributin g to AIDS risk. As a final activity, mem of the group organized a community presentati on that featured their drama work. At each research site, it took approximately six weeks to complete the four full-day workshop sessions and to plan and implement a community presentation. One aspect of the research in this phase nements concerned incorporating smaller activi within the workshop framework, mostly directed at improving group teamwork. The core design remained intact for all four communities. Appendix B provides a synthesis model for the workshop activities, based on the core design con ceived before entering the field, with the modifications and refinements made to improve the process while in the field. A team of four, including the primary researcher, facilitated the workshops. For most activities, one member of the research team woul d introduce and lead an activity with the g At times, the pr on assistance provided from one of the others. When not leading an activity, the resear assistants were taking notes on the research activities, particularly when the group was presenting information. The community was asked to provide a mmodate fifteen people served as th the fourth olerane esource Centre, it was possible to hold the worksh Co re asked to cho hen they would like to hold workshops and given em in half day on weekends. All of the communities chose their workshop sessions in full-da 4:00 p.m. Most sessions were conducted in two three-hour blocks, with two breaks, for a snack in the morning and one for a noont

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66 articipants were encouraged to work in small groups between official meeting unity identifier. The selection of communities was based to some extent on logistica tivities, two factors w f were further considered as potential research co workshop activities, p s to prepare their dramas for the next workshop session. Selection of Communities The activities in the Program Implementation, with the exception of the more general participant observation activities, were conducted in four separate communities, each community consisting of a village or cluster of small villa ges sharing a common village leadership and a unique comm l realities, with a lack of reliable transportation precluding working in communities located beyond a reasonable walking time of thirty minutes. This limited the number of potential communities or villages to seven. Another consideration in selecting communiti es was levels of current engagement in AIDS prevention activities. To understand levels of engagement in health-related ac ere considered: the number of active h ealth committees in each village, and a ranking o perceived engagement in health-related activities. This information was gained through a short survey completed by two key informants, both members of the Primary Health Care (PHC) Department at Embangweni Mission Hospital. To determine the presence of health committees, the survey on community AIDS resources conducted by Tikoleraneko was consulted (see Appendix A). Based on these sources of information, four villages and one community mmunities and we re placed into a three-tiered categorization of High, Medium and Low engagement communities. Table 5-3 provides this categorization. Table 5-3. Categorization of Communities Engagement Category Community Description High Kakoma Kabira Several active health committees (4-5) and engagemen one or more individual community-initiated activities directed toward HIV/AIDS t in Medium Foster Jere Champhonya Some active health Tikoleraneko Villa committees (2-3), including ge Committees Low Takumanapo Presence of health committees, most not active The following summaries of the communities provide further understanding of the criteria for their categorization and selection.

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67 group, led by a security guard from the hospital f akoma was also considered to have an in frastructure for community activities. Its close tation made it a convenient location for outreach activities, as it was not conside als from se ty ve the ardening, including dambo land, a streamb year round. nt of Kakoma is its two-building pr imary school that sits in the center of its five vill f e of a community AIDS orphan garden. Founded by a retired female civil servant, the orphan garden 1) High Engagement Kakoma was selected first, based on the expressed willingness of its AIDS drama group to participate in the research activities and its previously demonstrated commitment to public health and related AIDS activities. The AIDS drama and members of the community had made it known early in the planning stage that they would be interested in participating in any community activities. The drama group, consisting o both men and women, had formed a year earlier and had put on AIDS dramas at previous village gatherings. K proximity to the mission s red part of the hospitals immediate ser vice area. In the past, it had been the focus of several government and NGO-sponsored developm ent activities. In particular, Kakoma had served as a demonstration community for the district water and sanitation project. A concern in choosing Kakoma, however, was th at it is a community consisting of five villages, instead of a single village. The selection of participants could thus include individu parate villages, with memb ers from each potentially having their own unique concerns and interests that would be best addressed in the context of the village and not in the communi as whole. Nonetheless, after visiting the villag es making up the community of Kakoma, it was determined that differences between villages we re minimal. They shared the same level of affluence and resources, with no discer nible difference in functioning. As a community, Kakoma lacks many of the resources that one finds in the other communities surrounding Embangweni, such as shops and a market area. Its close proximity to Embangweni most likely makes these resources unnecessary or unprofitable. Kakoma is suburban to Embangweni, with its skilled and wage laborers working and trading in Embangweni. Many individuals from the community receive regular pay from the mission station but do not ha professional status, such as a teacher or nurse, that accords them station housing. Instead, they live in Kakoma, where their salary can secure land for g ed and a rich resource for growing crops The focal poi ages. This is the location where commun ity gatherings take place, usually using one o the rooms of the school for small meetings and the football field for larger events. Kabira, like Kakoma, had shown interest in addressing AIDS in the community. In Kabiras case, this interest was sustained primar ily through the development and maintenanc

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68 rden od of this research, the orphan garden commit ating th eni for most res was thought to be an op ni. It is e wide paths between its housing nodes. Fences and years earlier separate many of its houses. The inksona, the highest-ranking sub-chief in the community and highest-ranking member 3) Low Enga brought together women of the v illage who take care of orphan children. They work in the ga to produce extra crops to assist in feeding. Duri ng the peri tee, with a small grant from an outside vis itor, became involved in an income-gener activity (IGA) involving the sale of kerosene. Kabira is bisected by the main road out of Embangweni, with some of the village on bo sides. Compared to other villages in Embangweni, Kabira lacked a focal area that served as its center, such as shops or a prayer house. Its me mbers turn to the trade center in Embangw ources. 2) Medium Engagement Foster Jere, the second community selected, was th e most recent village to form a set of village AIDS committees under Tikoleraneko. It al so had shown interest in becoming involved in AIDS prevention activities. The fact that the v illage AIDS committees were new portunity, as the new members of the committees would not have experienced the period of stagnation that had occurred with the AIDS committees in so many other communities. Foster Jere lies directly south of the mission station and trade center of Embangwe located on top of a hill and is separated from th e rest of Embangweni by a small stream and a pond formed by damming the stream. Foster Jere is the most established village among thos surrounding the mission station, with clear hedges planted twenty or thirty s from the Traditional Authority among the Embangweni village headmen, lives in Foster Jere. The current inksona, Chitete Jere, is a direct descendant of Foster Jere, for whom the village is named. After the death of Inkosa (chief) Mzuka Zuka and for the majority of the period of this research, Chitete Jere was the highest-ranking me mber of the Traditional Authority in the southern Mzimba district. Chief and community meetings occurred under a large tree at one corner of the main intersecti on of paths in this village. gement Takumanapos commitment to AIDS activities was less clear. Villagers had met on occasion to form AIDS committees, but members had never achieved a sustained level in their efforts. Takumanapos inclusion was considered to be important because it was considered to be the most problematic village in the Embangweni community. Takumanapo was the primary

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69 community. It has tradition s who if image of the community. illage d lack family ties that entitle them to land. As a res electing one community with di fferences in social structure and community concern n activities is significant to this kind of research. ommunity members, particularly committees. While the dynamics of membership in such committees is not fully understood and is a subject that warrants its own study, the comm ittees were, in fact, established in the communities through the efforts of Malawians from the co mmunity. It seemed counterproductive to bypass these efforts and potentially alienate a group of people who had at some level volunteered or location for the brewing and sales of beer in th e community and was therefore thought to be where people went to engage in AIDS-risking behaviors. Takumanapo is not the name by which most people refer to the ally been called Sanje Meleke, which means dont be jealous, an insult to wive complain of the time their husbands spend drinki ng there. Takumanapo means we all come together and is a reference to the diverse set of outsiders that have settled there. The name is anything, a public relations maneuver aimed at improving the Takumanapo, located just behind the trade center, is the most densely populated v among those that make up Embangweni. The collec tion of structures and surrounding walls lock together to form a maze of homes, broken by an occasional courtyard area where men gather in small, low-slung cabanas to drink millet beer and corn liquor. Those who reside in Takumanapo are mostly those who have resettled to Embangweni an ult, they live in Takumanapo, where one can rent or build on poor land. With its prevalence of drinking behaviors and the lack of family networks characterizing other communities, Takumanapo presented unique challenges in terms of HIV/AIDS. It was thought that s s could be instructive in terms of how variations in communities affect the intervention process. For this reason, Takumanapo, despite its low engagement in AIDS activities, was selected to be a participating community. Recruitment of Participants The question of who participates in community-drive However, there is a lack of clear directives specifying the best method for selection of community participants. The democratizing aspect of including a variety of c those who may be di senfranchised from formal and informal power structures in the community, must be considered. At the same time, ignoring the existing social structures in a community has its own risks in terms of marginalizing the process and limiting its ability to bring about sustained social change (Paul and Demarest 1984). With these considerations in mind, it was d ecided to work among the already established AIDS structures in the community, mostly thro ugh the Tikoleraneko-established village AIDS

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70 o this ticipants. age AIDS ty, e not as established as in other villages. This allowed the rese t ting was nslated into Tumbuka, and asked to sign the informed consent form if they were willing to par ticipate. They were told they did not have to consented to work on AIDS in their community. Perhaps even more significant was the mandate in this research to help Tikoleraneko Commun ity AIDS Resources Cent re develop programming to use with the network of commun ity committees it had established. The only stipulation given to communities in selecting participants was that the representation of men and women in the group be cl ose to equal. There was no resistance t requirement. This appears to be standard w ith churchand government-directed community activities, and people seemed comfortable complying with it. 3 In Kakoma, the first community in which the workshops took place, most of the participants were members of an independently formed AIDS drama group, whose members also belonged to the communitys Tikoleraneko village AIDS committees. In addition to the drama group members, a few senior members of the commun ity were invited to participate by the drama group in order to increase the number of par In Foster Jere, the next community where wo rkshops were conducted, participation in the workshops was established through a process where by the head of the Tikoleraneko vill committee for Foster Jere invited individuals from the committees various sub-committees to participate. In Takumanapo, a process similar to the one in Foster Jere was used. In this communi however, the village AIDS committees wer archer to provide additional input into the selection process with the suggestion that younger members of the community be recruited, if possible. In the two previous communities, i was felt that the selection process had favored senio r members of the community, and this was an effort to achieve a better balance in community participants. In the final community, Kabira, the selection was again made from members of the Tikoleraneko AIDS committee in a fashion si milar to that used in Foster Jere. In each community, after participants had b een nominated, an introductory mee held to explain to indi viduals what participation would entail. The researcher told them the objective of the workshops, described some of the research activities that would be done, and explained what would be required of them if they chose to participate. At that time, they were also presented an informed consent statement, tra 3 The opposite circumstance arose wh en working to establish a grain bank in the community. Based on studies that have shown that women make better managers of money in development projects, it was proposed that the management of the new grain bank be all-female. After several women were selected

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71 make th he next tal workers, nurses, and teachers), as many of the o take place in the day. Some hospital workers were able to participate by shifting work schedules in order to be free on the days of workshop activities. Nonetheless, ent retirees, representing some of the more educated, experienced, and respected member s of the community. Among these were men and women who had benefited from opportunities afford ed by Malawis period of positive economic and social growth in the 1960s an At the completion of the were provided with t-shirts that the articipation. In addition to t-shir ays of full workshops. In each community, t community and were provided mo materials. A meal would then be served the group at a noo In conducting the worksh incentives for participation. Mem Primary Health program at Embangweni Hospital, k issue with the prac m e of a meal. The practice of providing i ndividual per diems to each participant was more costly than providing an actual meal (a total of MK 3,000 to provide individual per diem for 15 people for a single d eir decision at that time, and could turn in the informed consent at any time over t week. In all four communities, all of the individua ls who attended the introductory meeting, with the exception of one individual who felt he could no t dedicate the time, consented to participate. Recognized in the selection of members from communities was the potential exclusion of individuals with wage-labor j obs (hospi workshop activities were scheduled t the process did favor the inclusion of those in the community without regular employment. However, it did allow the inclusion of rec d 1970s. workshop sessions, partic ipants featured an AIDS ribbon and name of their village as a way to thank them for their ts, a lunchtime meal and snack were provided on the d p wo or three women were hired to cook the meal for the ney to buy need ed family-style to n break. ops, no participants voiced concerns regarding the adequacy of bers of the however, too tice of providing a meal during the workshop. Their procedure s for partic ipants, which was intended for the purchas was to provide individual per die ay versus around MK 1,000 for preparati on of a generous meal). Also, in most communities, there were no shops for purchasing food, negating the intention of nourishing and refreshing participants. Furthermore, the per di em suggested by the Primary Health program members was in excess of the actual cost of a meal in any community, thus suggesting that these participants wanted payment for participation 4 had the potential to undermine aspects of community volunteerism and participation by setting expectations of payment for participation that could not be matched in future community activities. In principle, providing a meal to participants fulfilled the original intention of the funding agency to provide money to from local shallow wells committees to be members of the bank management, they voted to include two men on the committee, feeling it would be necessary for security reasons to have men involved. 4 From the perspective of this researcher, paying a per diem was counterproductive for Tikoleraneko and

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72 the card-ranking task of community AIDS concerns necessa During the introductory meeting, a time fo r research assistants to interview each participant was arranged prior to the start of wo rkshops. One of the th ree research assistants would visit at their homes to collect the pre-inte rvention data, including a brief survey to learn about the participants, as well as to conduct ry for the Process Evaluation Participatory Research Workshops Table 5-4 highlights the participatory r esearch activities used in the workshops. Table 5-4. Community Participatory Research Methods Method Task 1. Community Mapping Community or participatory mapping tasks are used to explore the spatial dimensions of risk and to map community assets in relation HIV/AIDS within communities. to 2. Participatory Diagramming Activities Listing activities generate a domain list of AIDS-related issues in the community and offer the opportunity for workshop participants to consider aspects of severity and priority in domain items. Building from the listing activities, domain items are orga workshop members to indicate causal flow in producing i nized by ndividual IDS risk risk for HIV/AIDS. 3. Role-plays Risk scenarios for HIV/AIDS infections were examined through the interaction of actors adopting specific attitudes and motivations identified as either positive or negative in relation to HIV/A activities. 4. Dramas Dramas were used to incorporate the learning of all previous activities into an engaging format to be shared with others, with emphasis placed on maintaining narrative fidelity to real community experiences. For a more detailed explanation of how t he in tervention activities were structured in the worksho s. in e evolving process, and some activities may have varied between applications in communities. It also should be noted that ps, see Appendix B for a copy of the ma nual, Drama Dialogue Pl anning and Production for Community AIDS Prevention, which details steps involved in the community workshop The manual was developed out of the combined experience of implementing the intervention four research communities and was written with input from the four indivi duals involved in th directing the community interventions. While it provides a good overview of the research activities, it should be noted that development of the workshops was an support community activities. From the hospitals pos ition, perhaps it was believed to be counterproductive

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73 neither n the concept of drama nor the participat ory methods used in the workshop setting were original to research on HIV/AIDS in the African setting. This research, however, represents an attempt to synthesize and build on these concepts a nd methods in order to create a more cohesive intervention for use in the current setting. The following discussion describes the main types of activiti es used in the interventio and the type of data generated through their use in the community participatory process. Community Mapping Community mapping was done as an initial activity with three to four sub rivers, to community participatory work to highlight and incr tory Approaches 2000). While mapping exercises are often done to provide o tion -groups of workshop participants. Groups were given sheets of poster paper and were instructed to draw a map of their community, labeling major geographic landmarks such as hills, and roads. After completing the basic map of the community, the group was further instructed to add symbols in different colors of ink representing community resources that help the community deal with HIV/AIDS or in some manner protect individuals from AIDS. After documenting community AIDS resources, the gr oup was instructed to identify places in the community where people may be more at risk for HIV/AIDS or that may encourage the spread of HIV/AIDS in the community. After groups had adeq uate time to complete and label their maps, all the sub-groups joined together and shar ed their observations of their community. This activity, commonly referred to as village or community mapping, is intended stimulate participants thinking and is done early in ease a workshop groups confidence in their knowledge and ability to develop information on their community. It also provides an introduction to the group workshop format (African Network on Participa more utilitarian information on a community, such as census informatio n, their use in this intervention was primarily intended to highlight community perceptions about AIDS risk and t identify resources or starting points for community prevention activities through the identifica of community resources (de Negri et al. 1998). Participatory Diagramming The activity of participatory diagramming formed the core this researchs community participatory works hops, providing a medium for participants to engage in critical discourse on the social, cultura l, and behavioral risk for HIV in their own community. The ideas generated during these activ ities concerning local risk for HIV/AIDS remained principal referents for future works of hop activities invol ving role-play and drama and were us ed as basis for discussion on community prevention activities. to look at cost-effectiveness because that could lead to cuts in money funded to them from like agencies.

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74 8; Smith and Barrett 2000), this rese n. al n, th ree methods of diagramming were used to develop g to er of bottle caps in association with domain items moves the understanding of severity d the group members were instruct g to he In conducting diagramming activities, while more general modes for the process are common in participatory research (Killough 2001; de Negri et al. 199 arch followed Kesbys (2000) applica tion of the method for HIV/AIDS communicatio Used in addressing HIV/AIDS among Zimbabwean women, Kesby outlines a series of participatory diagramming exercises aimed at facilitating communication on issues of sexu health and HIV/AIDS. From Kesbys desig information on issues of HIV/AIDS in the community. Matrix Diagrams require workshop participants to identify and rank concerns voiced in response to the questions, What are the most serious health risks faced by people in your community? and What factors are putting local people at risk for catching HIV/AIDS? Procedurally, the entire group conducts the pro cess of diagramming, with members respondin basic question statements by recording respon ses, alternatively called domain items, on large index cards. Then, as a prioritizing activity, cards ar e arranged on the floor in order of severity or seriousness in relation to their own community. To add depth to the organizing process, anoth step involves having each member of the group pl ace bottle caps next to the items they believe are the most important. With a set number of bottle caps provided to each participant, the cumulative score from an ordinal level to an interval level. After completing a diagram, a representative of the group was required to explain the groups diagram to the workshops facilitator, and both the group and the facilitators recorde diagram for future reference. Flow Diagrams allow people to explore causality in HIV/AIDS risk through associating and linking group-identified risk factors for HIV/AIDS. Through a listing, social factors were identified that contribute to the spread of HI V/AIDS in the community. The group generated these domain items by responding to one of two questions: Are there ways that people are living that put them at risk for HIV? or What kinds of things are people doing to put themselves at risk for HIV/AIDS? After recording these domain items on index cards, ed to move the cards around on the floor to create associations. Then they used strin create causal linkages between domain items, all of which eventually must link to a central card containing the original question statement. As an additional step, cards with the titles Men, Women, Boys, and Girls were given to the group to be incorporated into the flow diagram to capture some of the gendered aspects of AIDS risk and causality. Again, after completing a diagram, a representative of t

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75 th e diagram for future reference. rom the s divided into two sections under those elements that are impeding the use or adoption of safe beh group was required to explain the groups diagra m to the workshops facilitator, and both the group and the facilitators recorded In constructing the flow diagrams, the groups were not constrained to the set of cards created from the listing of social factors. They were told they could add cards if they needed to As a result, additional cards were added to th e diagrams, as groups identified gaps in their original assessment of social risk factors. Force Field Diagrams were used in prevention planning exercises, which were done towards the end of the workshop (Lewin 1951). These diagrams used the domain items f matrix diagram and asked the group to consider forces in the community that were supporting positive behaviors or encouraging negative beha viors around a particular factor identified as placing people at risk for AIDS (Kesby 2000). A sheet of poster paper wa by drawing a diagonal line from a bottom corner to the opposite top corner. A positive sign was drawn in one section and negative sign was drawn in the other. The domain item consideration was then written along the dia gonal. Group members were asked to list on the positive side items or elements within the comm unity that are supportive of safe or preventive behaviors and on the other side of the line aviors. Role-plays Role-play scenarios were used in the community workshops to further uncover issues relating to the spread of HIV/AIDS in the community and to establish awarenes of some of the different social positions held within the community and their relationship to HIV/AIDS risk. Though role-plays are a less common tool in participatory research program where the focus is often on s s, problem identification and planning, they are an important strategy in health c S nd of skills building in health communication. Role-plays were useful in identifying situations of AIDS risk, particularly in terms of gender and other inequalities within the community that are often not addressed in more traditional medical discourse on individual prevention. Furthermore, by engaging people in conversation on such issues as condom use and widow inheritance, the method was thought to contribute to the development of dialogue on sensitive subjects. In this function, role-plays assisted group ommunication interventions, where the meth od is often tied to concepts of self-efficacy found in many social cognitive theories of behavior change (Glanz, Lewis, and Rimer 1997). In efforts to increase peoples self-efficacy around pe rsonal decision-making related to HIV/AID prevention, role-plays are used as skills-buildin g activities intended to empower individuals in confronting social and cultural pressures to engage in at-risk behaviors. In this research, the use of role-playing ac tivities straddled the traditional goals of problem identification in participatory research a

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76 participants in thinking about dialogue on HIV/AIDS that could be incorporated in dramas on s. The role-play design used duals, when presented with a role and scenario on a card, to engage in conversa tion with one or two others in that role and s rsing. The cards provided b asic information indicating the persons social p the conversa tion (i.e., mother, boyfriend, and husband) and a s Each participant was instructe act in this situation. Following a place to identify the different attitudes of volved, in which observers were pr ompted to give explanations for why people behaved and Relationship Skills produced by Strategies for Hope (Welbo role-plays t (Tumbu er HIV/AIDS in their communitie in this research required indivi cenario without rehea osition, relationship to others in ingle desire, such as wants to have sex or w ants partner to use a condom. d to converse and act as they thin k most people would dialogue/conversation, a discussion took the people in they way they did or how th ey could have behaved differently. A reference manual titled STEPPING STONES, A Training Package on HIV/AIDS, Gender Issues, Communication urn 1995), provides direction and examples for doing several different types of for use in HIV/AIDS prevention activities. This manual was used in the design and developmen of the role-plays used in the workshops. The research team devised scenarios to be u sed by group members in the role-plays, based on the information generated in the diagra mming activities. Each scenario was crafted to address a social factor listed by the group by suggesting a situation where dialogue or conflict might arise around a given AIDS topic. (See Appendix B for examples of the drama scenarios used in groups.) The role-play scenarios were provided to the participants in either written ka) or oral form. In a workshop setting, four to five role-p lay scenarios were generally necessary in ord to include all members of the workshop groups. For each role-play, an individual was selected from the workshop group and given a character ca rd to review. After about three minutes, all participants in role-play were instructed to star t enacting their character. After approximately five minutes, the conversation was concluded, after which the group as a whole worked to identify elements of the role-play and answer questions about its topic. Table 5-5 gives examples of some of the questions discussed in role-play sessions.

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77 Table 5-5. Role-Play Questions Role Play Scenario Questions Who is each character? What are they doing? Why has this situation developed? What social expectations, traditions, or other factors have influenced this situation? Do you think the actors reached an adequate resolution to the situation? What else could they have done? The conduct of a full set of role-plays in the workshops took approximately one hour. Role-plays were conducted in Tumbuka, and a r esearch assistant recoded notes on the main issues of the role-play conversation. Dramas As noted in the review of literature, drama can act as both a form of entertainment and as an important means of shari ng social and culturally relevant messages. the African se In tting, the role of the drama is perhap s even more significant, as drama is seen as an extensio s ess of 95). vities and advocated for the continued use of openended d eatre, lp ges to problematic features within the drama (Scott-Danter 1999), are example n of the oral tradition and an important idiom in communication. As a participatory method, drama is advocated as a means of eff ecting change around HIV/AIDS in communitie (Morrison 1995; Scott-Danter 1999; Walter 2001; Whyte and Dalrymple 1996). The proc drama is believed to stimulate creative conflict that is thought to potentially lead to both critical reflection and action in terms of community a ttitudes and behaviors (Cornwall and Jewkes 19 In using drama as a participatory element, this research used an open-ended drama structure as part of the drama-building acti ramas in the community presentations. Op en-ended drama or open theater refers to a drama presentation that breaks from a traditiona l linear and defined presentation, allowing for unscripted dialogue to be interjected in the drama process. Imagine Theatre in which particular social situations are posed to the audi ence through actors frozen in a scene, and Forum Th in which a drama is enacted in a particular manner and then replayed so that a facilitator can he the audience can make chan s of open-ended designs that allow the a udience to participate in the drama process. These modalities have the goal of engaging the audiences in thinking about the issues being presented.

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78 Titled y are nce the action is stopped, a question must be atory diagramming activities. Three to four of the issues considered most important in the diag a for each drama group to develop a preliminary drama, the Stop-M use ers being a t items, the researcher, following principles from Fishers roups talistic This research, in conducting open theater, used a modified form of Image Theater Stop-Motion Theater members of the audience were given a signal or sign (in workshop groups, the signal was an actual sign displaying the word stop, or lekani in Tumbuka) that the free to use at any time to stop the action within the drama. O posed or a comment offered to the performers about the action in the drama. In the workshop process, Stop-Motion Theater was used to further guide the development of the drama to be presented in the community, with workshop participants providing critique of the messages presented in the dramas. In the community presentations, the use of Stop-Motion Theater was facilitated by an orator, who acted as a trickste r or foil, posing questions for the audience and engaging them in conversation on elements of the drama. The process of drama building followed from the identification of HIV/AIDS issues in the particip ramming stage were presented to sub-groups of workshop participants to be turned into drama. First, however, all of the workshop participants were involved in a discussion on how to make dramas engaging while maintaining a narra tive fidelity to peoples experiences in the community. After time had been given otion Theater design was used to provide feedback from the entire group. Workshop participants were primed to consider whet her the preliminary dramas presented accurate information and fairly represented the HIV/AIDS issues in their communities. Following the of Stop-Motion Theater each drama group was instructed to make any changes based on the feedback of their peers. Dramas were refine d through group critique until they were deemed ready for the larger community audience. The production of dramas was the topic of one entire workshop in the community Included in the session was a discussion of the elements of a successful drama. Group memb were able to contribute ideas on ways of creating successful or engaging dramas in response to sked what makes for a good drama. Topics such as good story lines, good staging (costumes, props), the use of humor, and overa ll organization were all discussed as importan elements in good dramas. In addition to the groupgenerated Narrative Theory (Fisher 1984), discussed the benefits of narrative fidelity to peoples actual lived experiences as a means of increasing the persuasiveness of their stories. The g were cautioned to avoid overly tragic scenarios. Th is was an attempt to eschew the more fa plots often found in local dramas, which typically served as moral object lessons. Instead, the

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79 e character s, to suggest some control within their lives. This lesson, however, was one that was not always clear to the groups. A more extended worksho der e a nked high by the groups as concerns for their community, and 2) t All l hours of drama building, the groups were directed to move into the StopMotion or Lekani Theatre activity, in which indi vidual groups perform their nascent drama for the entir e on the nd leading to revisions of which characters were responsible for the introduc eality of a set of circumstances proposed in a ity become more directive than participatory. Prior to their performance in the community, the groups generally practiced several times among themselves and performed a dress rehearsa cher could vi drawhen presenting the dramas in the commun different formats of drama presentation. In planning their dramas for their communities, th model for conducting community activities that could serv activities. In this model, using the key words of Who What When and Where, the groups identified critical elements for putting on a successf ul community presentation. This aspect of the group was pushed to consider the perspective of their characters and the inclusion of more actionable steps or decision points for th p would be needed to explore these points further. In building the dramas, participants who had wo rked together in the role-plays were used again on the dramas, mostly because they had already been grouped to reflect a balance in gen among the participants. As a workshop activity, groups were given time to develop and practic drama. They were encouraged to build on the theme identified in th eir role-play, since 1) the roleplays themes were taken from items ra hey had already had a chance to think about the topic and develop dialogue around it of the groups chose to build on their role-play themes, adding characters and scenes to complete the story. After severa e group until stopped, at any time within th e drama, to be questioned about their plot and character choices. This activity was intended as a means to provided feedback and critiqu evolving dramas. In some cases, the comments from the Leka ni Theatre activity resulted in profou changes in the dramas, tion of HIV in a couple dynamic. Sma ller changes concerned choice of dialogue or improving ways of conveying action that was repre sentative or symbolic of occupation or leisure time. While the groups enjoyed this activity, pa rticularly the ability to manipulate and stop the dramatic action, their comments were often sha llow or lacked focus. It was often up to the research team to then tease out the issues, aski ng why they had chosen the wife to be the character having an affair or challenging the r drama. These were instances when the research activ l so the resear deo-record the mas. Then, ity, the researcher experimented with e groups were introduced to a planning e as planning model for future

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80 ve e g i un ss Evaluation Me workshop was thought to ha usual occurrence in the community be n successful, resultin n presentations starting on time, an Proce tho ds The activ ities of the followed the steps of a culturalm (CDA). T o gather the data necessary for formally measuring agreement among intervention participants before and after n the intervention activities. Provide here is a discussion of the methods used in following the steps in the CDA process, followed by discussion of observational techniques used to furthe the groupin he plete e ey form can be found in Appeion Items process evaluation of the intervention his was done in order t do ain analysis participation i r evaluate group interactions. However, before discussing the use of the C DA to look at levels of agreement, it is necessary to discuss the survey me thods used to examine the individual intervention communities and their comparability in terms of the CDA activities. Community Survey A survey was conducted in four of the villages in the Embangweni community and in g of villages that make up the separate community of Kakoma in order to better understand basic social dimensions of the research communities and their comparability. T communities were selected based on their like lihood of being included in the eventual intervention research. This survey administered in the local communities was designed to examine general demographic patterns as well as HI V/AIDS awareness and knowledge in the community setting. It was conducted orally by research assistants and recorded on paper survey forms. The com survey comprised three question-sets. Table 5-6 lists the general topic of each question-set, th question formats, and the key variables for data collected. An example surv ndix D. Table 5-6. Community Survey Question Formats Survey Topic Question Format Quest 1. Indivi Infor d, esence ied hest s Years ion or Religious Affiliation, hold Head dual Demographic mation 11 Structured Questions Sex, Age, Marital Status, Years Marrie Presence of a Polygamous Marriage, Pr of Regular Sexual Partner Among Unmarr Individuals, Years Spent in School, Hig Level Completed in School, Continuou in Village, Relig Relation to House

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81f ld ission, 2. Household Demographic Information 3 Structured Questions Number of Adults in Household, Number o Children in Household, Primary Househo Economic Strategy 3. HIV/AIDS Knowledge Questions 10 1 2 Structured, Listing, and Open-Ended Questions Knowledge of the Symptoms, Transm Treatment and Course of the AIDS virus, Awareness of Others with the Disease, Self Efficacy in Prevention The primary researcher developed an initial draft survey instrument that then went through a process of translation and refinement by members of the research team and community The three core members of the research team worked together to translate the original instr into Tumbuka. Their translation was then typed into the survey instrument and given to the Director of Tikoleraneko to be back-translated. The research team and Tikoleraneko director then met to make final corrections ba ument sed on the back-t ranslation. Further refinements were also made to survey questions after the first round of inte rviews in order to address any emerging issue. vey researchers, or surveyo t s part n s from the larger Embangweni area. While a larger sample ge Prior to conducting the survey in the communities, the teams of sur rs as they liked to be called, were given training on using the survey instruments. Members of the survey team practiced on each ot her until each was confident in his or her ability to conduct the survey. One goal of developing survey data was to coordinate the surveys with communities tha would be used in the program intervention phase. With this in mind, the selection of communities included in the community survey was driven by the identification of those geographically convenient to Embangweni, a necessity for c oordinating the community program, and those thought to be willing to participate in the program implementation phase. The community of Kakoma, administratively an equal to the community of Embangweni, was larger in size than the other village-level groups surveyed. However, it was included a of the community survey sample because me mbers of the Kakoma community made it know that they would be willing to participate in any HIV/AIDS training activities. In each of the five communities, the target number of individuals to be surveyed was twenty-four (N=24), for a total of 120 survey size would have increased the representative nature of the sample, time and resources limited the amount of surveys that could be conducted in each locality. To select survey participants, a census was conducted (using the resource of the villa headman) in each community, whether a single village or a cluster of villages such as Kakoma, to

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82 dmen, bout of an adult to be surveyed was based on the further goal of strati ain is a basic unit for describing shared knowledge and is defined as any set of words, concepts, or sen tences, all of the same level of contrast, that jointly refer to a single conceptual sphere (R omeny and Weller 1988a, 9). Within any group of uld expect them to share some cultural domains, so that people who a n a fishing community, for instance, will have certain knowledge about f ra community and that may not fishing. In health research, dom are types of illnesses and symptoms p of people, the types of cures identified by a group, or the types of risks associat ize determine both total population a nd numbers of households in the community. Village hea as part of their government administrative duties, are expected to maintain a list or notebook of adults living in their community. Even if a notebook was not kept, most headmen could, by recalling all of the houses in the community, create a count of men, women and children living under their authority. After completing the censu s, the list of households was numbered, and using a random number list, approximately tw enty-five households and ten alternates were selected. At each of these households, an adult (18 or older) would then be approached a participating in the survey. At each household, the selection fying the sample to have equal gender re presentation. At first, the survey team members simply asked to interview the first available adult. A running tally was kept of completed interviews, and if the numbers started to skew toward one gender, survey team members were directed to ask for individuals of a particular sex until the number more closely approximated an equal division of interviewees. Methods Used In Evaluating Consensus Among Intervention Participants Cultural Domain Analysis (CDA) comes from the area of anthropology concerned with the relationship between culture and cognition and is an examination of how knowledge is shared and distributed among groups. A cultural dom people who regularly interact, we wo re all living i ishing, often labeled cultu l knowledge, that may be shared among the members of that necessarily be held by people in other communities not involved in ains often considered recognized by grou ed with a particular illness or disease. Be yond the bounds of these domains, items within a cultural domain are also thought to have internal structures or attributes that serve to organ the items in the domain and are shared. CDA provides steps for systematic identification a nd investigation of a cultural domain and its attributes. In conducting CDA to dete rmine whether the interventions encouraged agreement, three basic steps were followed: 1) Elicitation in which the content of a cultur domain concerning issues key to the intervention is identified by members from a community. 2) al

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83 Organization in which the structure of the domain, consisting of different associations or relationships between domain items, is explicated through methods of systematic data collection, as infor or mants organize domain items. This organization is also referred to as a cultural model f the domain. 3) Visualization is the last step, in which the researcher can make inferences about the organization of the domain through data-reduc tion methods. Consensus testing belongs to th third step of cultural domain analysis, in that, along with other data-reduction techniques su multidimensional scaling and cluster analysis, it helps us visualize or interpret the data concerning the organization of a domainconsensus being concerned with the extent to whic domain items and attributes are shared e ch as h Elicitation. In conducting CDA, the most common approach to eliciting a domai simply ask people what makes the items of a dom ain. T n is to his is usually done using a free-list techniqu h s less ut re e and works best when a domain mirrors categories people are more familiar with, suc as types of animals or colors. The process of a free-list may be more difficult if the domain i concrete conceptually. This was thought to be th e case in addressing the domain of HIV/AIDS in a community, particularly in regard to this rese archs interest in the problems or issues that HIV/AIDS is producing in a community. However, it was thought reasonable to ask people abo the problems AIDS is causing in their community. Ke y informant interviews (see Table 5-7) we used to determine the specific issues related to AIDS that are found in the overall research community of Embangweni. Table 5-7. Key Informant Interviews Method Task Key Informant Interviews Conduct of semi-structure d, open-ended interviewing with members of the community to elicit the cultural domain of social causes of HIV/AIDS in their community The specific interview format used in the ke y informant interviews was in-depth, openended i problems or issues related to AIDS in the community and 4) efforts at AIDS care and prevention. nterviewing. This methodology was consid ered an essential first step in the research process, as the exploratory nature of open-ended qu estions and the latitude afforded by in-depth conversations allowed for greater delineation of major research domains (Schensul et al. 1999). Explored through interview questions were general topics of 1) pe rsonal knowledge and perceptions of the community, 2) the observed experience of AIDS in the community, 3)

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84 the n was o g many of the questions. For instance re the ed to outside iews notes, it was possible to develop a domain ed in en A guide that outlined more specific questions concerning each of these topics was used for interviews. In a first round of key informant intervie ws, the approach taken was person-centered, asking the informant to reflect on his or her pe rsonal experiences with AIDS in the community. At some point, it became apparent that there was a reticence, and perhaps discomfort, among some informants with this approach. Informan ts seemed to avoid answering questions in a manner that would reflect a personal perspective or experience. In response, a modificatio made in both the manner in which informants we re selected and in the interview format. The selection of informants in the original set of interviews was mostly a convenience sample. In those following the modification, the selection sought to achieve diversity in social and occupational roles among informants (Johnson 1990). Identifying informants based on their role in the community allowed the researcher t privilege their position in the community while depersonalizin a teacher may be asked, As someone who works with young people and who is mo aware of them, what do you think are some of the reasons AIDS is spreading among young people in the community? This contrasts with the more direct type of questioning used in early set of interviews where one might have been asked, Are there things in your community that are contributing to the spread of AIDS among young people? This modification seem produce a greater comfort level for interviewees. As stated, the overall sample of individu als interviewed comprises both a convenience group and a group selected based on key social cr iteria. Care was taken to interview key informants only in those villages that make up the larger community of Embangweni. However in seeking someone with specialized skills, such as a traditional healer, it was necessary to travel of those villages designated in the formal Embangweni community. If the interviewee was proficient in English and comfortable using it, the interview was conducted in English. Otherwise, a translator assist ed during the interview pr ocess. All interv were taped and transcribed and, when necessar y, translated by a research assistant into handwritten notes. From the field analysis of these interviews and field list of sixteen HIV/AIDS-related concerns and issues in the community (more in-depth reporting on the analysis of the interviews and fiel ds to determine the domain items is provid Chapter Six, Research Results). Domain items included such statements as, Men and wom look for partners other than their spouse and C ondoms are not being used in preventing AIDS

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85 (see Appendix E for the complete list of domain items). The list was not considered to be exhaustive but rather representative of the more common or general concerns. Organization With a list of domain items generated, the next step in the domain analy is examination for its underlying organization. It is critical, however, to ensure that in doing so, the appropriate type of data will be gathered fo r purposes of consensus analysis. The analysis of consensus requires data that can be coded in a discrete set of responses, with each response representing some explicit judgment (Weller 1998). The requirement that each response represents a unique judgment limits the possibilit y of incorporating non-response data (such failing to an sis as swer) or indefinite response data (s uch I dont know) into the analysis. Methods traditionally used for producing consensus-compa tible data include dichotomous choice (paired matc hing, pile-sorts, ranki ngs, and sentence-frame complet nd Weller 19a). a, such as free-l he ree meth g data on the or domave profound implications for the ty pe of analysis that can be done. Methods like mportance on what is done with the domain items, as informants are free to sort them in any way they lik e and into any number of piles, large or small. Data of s of ain. in producing consensus-ready data. However, in choosing to use a task such as a ranking t also ne reason for forcing people to make decisions about the domain along given attributes is that this generally results in the use of more familiar types of question formats, such as True/False, over more abstract tasks such as pile-sorts. The question-set comparison or True/False), multiple-choice, ion (Romney a 88 Other kinds of dat ists, can also be recoded as binary data to fit t quir ments for consensus In doing a CDA, the ain can h od selected for developin ganization of the pile-sorts, for instance, place little i this type, with so few restrictions on how it is produced, is helpful for identifying previously unconsidered dimensions or attributes of the domain items. Other methods, such as ranking, are at the opposite end of the spectrum in that they require the informant to make some judgment, usually along a single attribute defined by the researcher, such as size or seriousnes the domain items. A difficulty of this approach is that the researcher-defined attribute may not correspond to a cultural dimension affecting how the informant might otherwise view the dom Because the goal in consensus testing is to look for agreement across decisions concerning domain items, the researcher is less constrained in the choice of organizational tasks to be used one is significantly increasing the thr eshold necessary for achieving consensus across a sample of people, in that they not only must agree that items belong to the same domain bu that they belong to that domain in some particular fashion. Despite possibly higher thresholds for reaching consensus, this research sought to have informants make decisions about the domain of AIDS issues in the community along single attributes, using a ranking task. O

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86 sought t vention participant survey was conduct d ndividual o determine consensus in terms of th e relative seriousness assigned to key HIV/AIDS issues identified in the community by requiring informants to rank the list of domain items. To develop the needed rankings, a preand post-inter ed with all workshop participants. After vol unteers had been identified for the workshops and had attended an introductory workshop meeting, members of the research team coordinate times to administer the survey prior to the start of the participatory workshop. This survey used a subset of questions from the survey done in co mmunities, asking questions concerning i demographic information and group consensus. Table 5-8 describes the type and format of questions. Table 5-8. Pre-Program Questions Formats Survey Topic Question Format Question Items 1. Indi ion, n vidual Demographic Information 11 Structured Questions Sex, Age, Marital Status, Educat Length of Tenure in Village, Religio 2. Consensus: AIDS Issues Ranking 16 Item Card Ranking Ranking of Community AIDS Issues In conducting the ranking of relative ser iousness of domain items, a card-sorting technique was used to produce a ranking by each informant on the list of items. The 16 d items were printed on index cards. Informants were asked to compare tw omain o cards at a time using a quick so aking the task more manageable and less taxing on the informant, especially when working with even moderate-s ized lists, such as 16 items (Romney and Weller anking ranking ne questions concerning their experience with worksho This rt technique to determine which card item represented a more serious problem in the community. The quick-sort technique borrows prin ciples from computer science that allow for transitive arguments to be made in the sorti ng process. This usually decreases the number of dyads to be compared, m 1988a). At the conclusion of the workshops and community presentations, the task of r community issues, done to gauge group consensu s, was repeated with all members of the workshops via postsurveys conducted by the pr ojects research assistants. Beyond the task, participants were asked a series of twenty -o pswhat they had learned and what they felt could be improved about the process. survey was administered orally.

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87 Visualization Formal consensus analysis was the process used in visualizing the data from the ranking task conducted in the CDA pr ocess, measuring changes in shared agreement within the group on key community issues regarding AIDS. Consensus Analysis is a non-probabilistic mathematical procedure for measuring the level of agreement among a set of informants. The model of consensus outlined by Romney, Weller and Batchelder (1986) works by correlati ng the agreement between the informants. Using a Minimum Residual Factor Analysis, it indicates whether a single cultural rationale is responsible for the patterning in the response data By convention, if the first factor, presenting a cultural agreement, is three times that of the next, one concludes that there is consensus based on some shared cultural understanding among the group (Borgatti 1996). This method provides a measure for each informants ag reement with the overall model provided by the group. This is a type of competency score for each individual in regard to the cultural model being considered. The ANTHROPAC (Borgatti 1996) computer program was used in conducting the consensus analysis on the ranking data from the preand post-intervention surveys. The data was first entered into an informant-by-response matrix that was correlated to provide an informant-byinformant correlation matrix. Using ANTHROPAC, a Minimum Residual Factor Analysis was conducted on the correlated matrix. ANTHROPAC was used to analyze the responses, giving 1) a ratio of the factors that account for variation in th e reporting, and 2) a competence level for each informant. Another assumption of the model is that all individual factors making up the competency score are positive and relatively large (Curry et al. 2002). While the presence of consensus is a good inferential indicator of change, the change within the individual competency scores gives a better means for comparing this change. Using a paired T-test, the competency scores from the pr eand post-consensus analysis for each of the groups were compared. Direct Observation Coinciding with the use of the participatory methods in the workshop setting, observations were made by the primary researcher concerning the application of the participatory methods and the types of interaction they engendered among the research participants. Observations were recorded in research notes. Significant to conducting the direct observa tions of the dramas was the limitations imposed by the language difference. Not having mastery of the language, it was not possible to comprehend the dramas in their immediate context of performance. Video taping and translation was provided by research assistants. However, this meant that any description of actions and

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88 ialogue in the dramas had been interpreted by another individual and passed on to the researcher. d

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89 iscussions Chapter SixResults of the Implementation Research Reported are the findings from the various data-gathering activities conducted as part of the Program Implementation Research Activities. The results and analysis parallel the organization of research activities described in the previous chapter on methods. Participant Observation and Natural Group D in ng the general milieu of AIDS activities. The natural y curred in two contexts: either through intercepting a group of people, t the Community AIDS Cent re, or as part of community meetings occurring in villag roup of six to eight youths after a Youth Club meeting and engaging them in convers ogical aspects of HIV/ Participant observation was conduc ted for the entire period that the researcher was in the field, from Dec. 10, 2001, to Nov. 27, 2002. In that period, the researcher engaged in aspects of local community life, most significantly through working in community organizations and with community members. Observations were recorded as a set of field notes. Participant observation and natural group discussions formed the backbone of the formative research activities and were essential to the researchers ab ility to work in the community. These techniques also facilitated design and implementation of the community participatory research activities. Participant obser vation was conducted through daily activities the community and was critical to understandi group discussions provided the researcher access to the dialogue generated by informall organized small groups concerning HIV/AIDS and other relevant issues. Such group conversations generally oc usually youth, while a es. The intercepts at Tikoleraneko were a matter of coincidence, with the researcher encountering a g ation. On at least three occasions, conver sations extended for longer than thirty minutes, and a variety of AIDS topics were covered. The youths (ranging in age from 16 to 25) were candid in their discussions, providing informati on on topics not usually discussed in public settings, such as sexual norms and behaviors with in their peer group. By virtue of their engagement in Tikoleraneko, these individuals were more aware of AIDS and its place in the community. Nonetheless, conversations revealed limited understanding of the biol AIDS. Also encountered in these conve rsations were strong gendered attitudes about sexual roles and entitlements, particularly among men. These conversations occurred among

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90 o the group engaged in free-flowing conversations, asking and responding to question ience ch n their community. In the community-oriented discussions, the topics addressed were de ans. ing from AIDS in women or more of their parents have died or become unable to care for them. While rarely se mixed-gender groups, with girls exhibiting levels of engagement not seen in more general community conversations. The other setting where natural group discussions occurred was in conjunction with community presentations. On four separate occasi ons, as part of visits to communities, the opportunity arose for extended conversations on HIV/AIDS with presentation attendees. In tw instances, these discussions occurred as offshoots of an original presentation, one conducted by Tikoleraneko on HIV/AIDS and the other conducted as part of the hospitals MTCT program. On both occasions s about AIDS in their community. On the two other occasions, presenters and ke y members of the community or aud met in a nearby house for tea after a community presentation on AIDS. These sessions were mu like a debriefing, allowing people to comment about and reflect on the presentation and other topics of interest i veloping a better understandi ng of HIV, particularly with regard to MTCT; what, if any, formal steps the community should be taking in prevention and care for the ill; and what resource could be made available to contend with the difficulties posed by a growing number of orph Groups avoided conversations that included the more contentious issues, such as methods for prevention of HIV/AIDS (e.g., condom use). From the two methods used in conducting fo rmative research, the researcher formed a picture of the AIDS situations and identified some of the needs and challenges result the community. Homes and Villages In the domain of households, factors consider ed are the daily experiences of men, and youth in the community and how their experien ces are being shaped by events related to the spread of HIV. In visiting households in the community, one first notices that many are raising multiple children that do not belong to the primary household couple. These are generally children of relatives, taken in after one publicly stated, many of these missing parents are assumed to have died from AIDS. No attempt was made to determine the percentage of households raising children that are not their own, but it is probable that one-third, if not more, are raising additional children. This situation is quite common in households in the community where a member was engaged in regular wage or professional employment. The employment most likely made the

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91 ned. roots in the tradition nt cleaning and caring for younger children in exchang e very wi d to family size is already quite high, fa pted DS; people for work. Most, however, will head south, if not to Zambia or South Africa, then to households the better candidate within an extended family to absorb additional family members. Most adopted children came from immediate rela tives, such as siblings. In keeping with the lineage system of the Ngoni, ones fathers brothe r has particular responsibility for the orpha For the most part, families are willing to accept child ren of relatives into their houses, in spite of the burden it will place on existing household resources. This acceptance has its al Ngoni household, where adult family me mbers of the same age-set as the male pare are also considered fathers and mothers to a child and hold some obligation toward the parenting of that child. In some cases, households are willing to take in non-related village children, many of whom are orphans, to work as domestic help, e for food and sometimes school fees. Th is appears to happen most often among those householders with regular wage or professional em ployment who are better able to afford the extra individual. There was no evidence of abandoned children in this rural area. In fact, people seem to b lling to take in children, despite the great burden this can impose. There always seeme be a member of the extended family in the village or in a neighboring village to take in an orphaned child. Increasingly common, though, are grandparents raising one or more of their childrens children. In some cases, adults will take in children who have no one else to provide for them. For instance, a widowed schoolteacher in the community adopted one of her students whose father was dead and whose mother proved too unstable to support the child. With increasing household size in a region wh ere average milies may struggle to meet the needs of children in terms of food, school fees, and supervision. Despite an apparent willingness to take in orphans, there may not be parity in meeting the orphans needs, particularly with regard to food. Members of the community expressed concern for the status of some orphans and suggested that feeding in the family often follows a hierarchy, with the male head fed fi rst, followed by the wife and any elder adults. Following the adults, biologically related children would be fed, and then finally any ado children. It is suggested that orphan girls are more often overlooked in the allocation of food resources. Along with the growing number of orphans, there appears to be a rising number of singleparent households, most headed by women. This ma y be a result of the loss of a parent to AI however, it is also common for men to leave the village for extended periods of time to look for work, moving to urban areas to take wage-labor jobs. Mzuzu, the regional urban center, draws

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92 Lilongw No matter the reason, when a single-family situation is created, the remaining parent assumes syndrome requires almost f aring in those with AIDS. ne depende ubled Hasting e and Blantyre, the two most industrialized areas in Malawi. In talking to people about those in the community who had perished from AIDS, a striking number of the stories would start by recounting that a husband or partner had been away, working, before coming back to the village and becoming ill with AIDS. Tacitly ackno wledged was the likelihood that while away, that person had another partner outside of marriage or had visited a prostitute. greater parenting and farming responsibiliti es. Gogos (grandmothers) often fill the void of a missing parent, assisting with the farming or assuming household tasks and the supervision of smaller children. Children in their early teens, particularly girls, may be asked to take over household responsibilities in lieu of school. Some households will have family members who have AIDS and who live elsewhere in the same village. Most families in this situation, however, do not admit to others that AIDS is the illness affecting their family member. Yet it is common for others to reach conclusions about those in the community who have AIDS, based on lo ss of weight and loss of color in their hair. Within families, resources will have to be allocated to caring for the sick individual. Providing palliative care for an HIV/AIDS patient in the terminal phases of the ull-time attention from an adult. Hosp itals, while providing medical treatment, do not provide basic services to patients. This necessitates a family member, called a guardian, staying with the patient in order to provide basic care a nd prepare meals. In talking with an individual caring for ill members in his community, he voiced a concern about the impact of famine, fe that poor nutrition would worsen the illness In general, whether raising additional children or just trying to get by, people suggest that the standard of living is dropping, going down, in Malawi Often-cited causes for this decli are repeated episodes of famine, lack of development as a result of AIDS (a theme echoed in a national campaign by the government concerning HIV/AIDS), and the corruption in local and national government. One teacher, in talking ab out the standard of living in the community, expressed dismay at his own situation. Back in the 1970s, he owned a car, but now he is nt on the government for lorry transporta tion (which was two weeks late in picking him up at the time we talked). Over the year of this fieldwork, the value of the dollar almost do against the kwacha, the Malawian currency. Contra ry to the perceived advantages of a democratic government, many older people state that things were better under the long-standing rule of Banda, the once dictator for life in Mala wi, and his ruling party, the Malawi Congress Party, which left power in 1993. As people often said of that era, at least the buses ran on time.

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93 oing by selling common household items, s rted ys a o a like property, become a part of the husb ssessions, Such me tati ng the claim on her as implied by the labola. If she joins he from y wed as a burden, with limited prospects for remarriage unless she can find another man willing dren, by ent of marriage, there is a traditional practice that suggests that one of the brothers of the husband must sleep with the bride. This encounter is described as part of cleansing process for Single women with husbands who have died or who are gone for employment are left in the village with little means for earning hard curre ncy to be used in purchasing household items. Some, given enough capital, will try to keep a flow of cash g uch as salt, sugar, and beans. For most it is difficult to find cash. Some women repo having to turn to male patrons for support or to r esort to sex work in order to meet their famil needs. One of the more problematic situations in a household occurs when a women loses her spouse to AIDS. Following Ngoni practices common in the region, the husbands family pays labola or bride price at the time of marriage. The amount of the labola varies by a familys wealth, with a high labola consisting of either sever al cattle or a cash payment equal to up t couple of hundred U.S. dollars. In paying the labola, the women, ands household. If a husband dies, the wife, along with the other household po is still considered part of his family. In some ca ses, this results in the husbands family forcibly claiming all of the deceased husbands househol d possessions, including any stored grain. forcible claiming of possessions seems to happen more often when a husband lives away from the extended family. This results in the wi dow having sharply depleted resources. In that case, the widow must decide whether to join her husbands family or face sha in returning to her own. If she joins her husbands family, she may be asked to marry one of her deceased husbands brothers as a way of res r husbands family as a widow, she will have no one in the family to look after her interests and may receive fewer resources. If she chooses not join the husbands family she risks economic disenfranchisement her husbands family and is barred by law from remarrying until a divorce is granted, which usually requires repayment of the labola by the wife s family. In returning to her family, she ma be vie to pay off her labola, which would be unlikely in a second marriage. If there are chil she may also face custody issues, as her husband s family can lay claim to the children. The practice of widow inheritance is not just a practice of people living in bush villages; it occurs among more educated members of the community, as well. In Embangweni, the community of this research, a schoolteacher who had lost her husband to AIDS was threatened her husbands family for the return of the labola once they learned that she was dating a new man. The other half of the widow inheritance equation is that if the husband has died, beyond the requirem

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94 the brid s ated risks for spreading the virus. ider. Polygamy is a practice among more traditional Ngoni people, particularly among indi viduals in families linked to the traditional authority mpoun d. However, among younger and more affluent husbands, wi eem to experience a temporary reprieve when it comes to family responsibiliti one convers or played by couples. In particular, it was suggeste e. However, there also is an ownership dimension, to assert the rights of the husband family to the wifes fertility. With a widow who has potentially been expo sed to HIV/AIDS, this practice carries its associ Larger sexual networks are a risk to c ons structure. Men who were adherents to traditional Ngoni ways and could afford it would take two or possibly three wives. In older polyg amous families, the wives tended to live in close proximity, sharing the same village co ves may be kept in separate villages or towns. While polygamy within a stable sexual network does not confer greater risk for HIV/AIDS, if one or more members of the network has outside partners, the entire network may be at risk. Adolescents s es. In this period, they enjoy more fre edom and less supervision. With this freedom however, comes increased opportunity for in itiating sexual activity. While there is public condemnation of premarital sex, it appears to be common, with a subtle permissiveness evident in the lack of enforcement of these sexual mores. A double standard also exists in the treatment of adolescent sexuality, as attitudes towards boys suggest that early sexual activity is part of a natural curiosity, while repercussions for girls ca ught in a liaison can be quite serious, leading to expulsion from church, school, or family. The young people I talked to had casual attitudes towards sex. There was nothing mysterious about it. Most felt that if they wanted to have sex, it was an option. In ation, I asked about sexual activity in re lation to dating or courtship. To the group of young people gathered at Tikoleraneko, the idea of building a relationship as a precursor to sex was seen as funny. I was told if you want to have sex with someone, you would just ask him her. Dating is less the norm in relationships; instead, short-term or one-time encounters among young people are common. It was acknowle dged that a boy would most likely provide something small in return for the act, such as a bag of chips from the market. In a rather candid conversation with a set of boys and girls, they discussed the gamesmanship d that girls did not want to be seen as too eager to engage in sex and were to be coy about the matter. The boys responded to this by suggesting that boys needed to be bold and sometimes take control in these situations ; when girls said no, it was really just part of the game.

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95 dom AIDS e ask the recognizes it or not, AIDS is its No. 1 business. Professionals in the hospit e of o the dying. No antiretrovirals were avail get discordant test results might suggest about partners, and they feared abandonment if they were What was not candidly or casually discus sed by youth was the relationship between sexual activity and infection. For the most part, they seemed to view AIDS as if it were a ran visitor to many homes. Institutions and Their Response to HIV/ The domain of institutions looks at the various political and social organizations in and around Embangweni and how each has responded to the presence of HIV/AIDS infections in th community. At the center of the AIDS situation in th e community is Embangweni Mission Hospital. In its quasi-governmental role, it remains the onl y resource for modern medicine for close to 40,000 people. It has also been the only consiste nt resource for treatment and services related to HIV/AIDS. To suggest that the hospital simply provides ser vices to those with AIDS is to m true reality of the situation. Whether the hospita l al suggest that AIDS is dominating the patient caseloads. At one point, blood tests conducted on adult patients willing to be screened for HIV/AIDS indicated that 73 percent of patients were HIV-positive. One physicia n, after rounding, reported that all but thre the patients at that time on the male and female wards (which usually house ten to twenty patients each) were positive for HIV, and that three others were of unknown status since they had not been tested. These numbers are supported by estimates done by the World Bank, which suggest that 60 percent of hospital admissions in Malawi are AIDS-related (World Bank 2002). Though besieged by those seeking help, the hospital is only able to treat the opportunistic infections that result from AIDS infection or offe r palliative care t able for treating AIDS cases during this researchers tenure. However, through a program with UNICEF, the hospital is now supplying nevirapine, a low-cost antiretroviral used to prevent mother-to-child transmission (MTCT) of AIDS, to pregnant women who have tested positive for HIV. The MTCT program, unique for a ru ral hospital in southern Africa, was in its early stages at the time of my exiting the research site. The program was struggling to maintain trained personnel to counsel patient s and administer the medications. A lack of trained testing counselors has kept the program from moving out into the community, creating further challenges to getting women tested. When visiting hospital clinics for prenatal services, women seldom came with thei r partners and were generally reluctant to tested without first consulting with their partne rs. Women also had a strong fear of what sero-

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96 might mandate the use of cesarean delivery, something women feared, particularly because n r 000, supplied a Nonethe age of ent er IDS program in South seling and PLAM). With only a couple of found to be HIV-positive. Other barriers to success included the belief that inclusion in the program after three C-sections, sterilization is routinely performed, re ndering women barre and most likely abandoned. Despite heavy AIDS caseloads, the hospital remains fairly silent about AIDS. While breast-feeding and bed net posters cover the walls there are no public displays on AIDS. Most interesting is the extent to which the hospital has sometimes gone to shield patients from thei diagnosis. Prior to 1999, the norm was to not info rm the patient about testing and to not reveal test results or even record them on permanent reco rds. With the availability of rapid tests in 2 by international health groups, the requi rement for consent and counseling has led to more open process. However, the hospital still uses a code system to hide the individuals status on hospital records. In part, this can be seen as an effort to maintain patient confidentiality (though everyone in the hospital knew the codes); however, it also suggests an ongoing reluctance to admit to the reality of HIV/AIDS. In providing care, the hospital, with support from international health groups, has switched to single-use disposable needles to limit the possibility of iatrogenic transmission. less, universal precautions are not always used when treating patients. A short gloves means that sometimes bloody gloves will be washed and reused. Needles are carelessly disposed of and can sometimes be found lying on the ground outside the incinerator pit. Further, staff members fail to see the value in protecting eyes when providing care to wounds or when at risk for splashes, as in the delivery room. As part of a sensitization program, the hospital did begin offering training on HIV/AIDS to its sta ff in 2000, focusing especially on the need for universal precautions to be taken when rendering care. Delivery of information concerning the Pr evention of Mother-to-Child Transmission (PMTCT) program is the hospitals main activit y in terms of AIDS prevention. Because of perceived workload resulting from PMTCT work, th e hospitals Primary Health Care departm employed two full-time staffers devoted to AI DS prevention work. The AIDS program work was formerly a medical assistant who had led some of the first AIDS activities in the community. The other worker, an HIV-positive individual, had received training from the UNA Africa on running support groups. UNAI DS initially sent her to Embangweni on a volunteer basis, and she later was hired by the ho spital. She assisted in testing and coun was the leader of a small AIDS support group. The support group was a local affiliate of the National Association of People Living with AIDS in Malawi (NA

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97 regular ners of ts quasi-governmen tal role (the government pays salaries for the nurses a g. has) in the commun ain uid o tors, ught to be more animistic an d are rarely condoned in the community. attendees, the group met infrequently at the hospital or at Tikoleraneko AIDS Resource Centre. Most of the workers time was spent administering the PMTCT program. Program activities included providing counseling servi ces through trained community volunteers and conducting periodic community awareness trainings in villages, which entailed preparing trai and doing trainings. Counselors tended to repeat the usual litany on preventing transmission HIV by staying faithful inside a marriage or simply abstaining from sex outside of one. Past activities of the program included working with traditional healers to identify and treat TB and training traditional birth attendants on post-deliv ery HIV/AIDS precautions and treatments. The hospital officially only provides condoms to couples attending family planning counseling, though some staff members are willing to distribute them to patients on an individual basis. The hospital, despite i nd medical assistants), is under the mora l directives of its sponsoring church, Central Church African Presbyterian (C.C.A.P.). While AIDS prevention activities were officially supported, the church, fearing a rise in promiscuity with condom use, did not support condoms. Consequently, the subject of condoms was avoided by those responsible for AIDS programmin Some families seek help for illness from traditional healers (sing ities. The reality of this ongoing practice is evident when seeing the telltale signs of a singhas scarification ritual, even on new babies. The singha scars the body with a razor in cert locations to relieve symptoms or cure illness. Of the three healers interv iewed in the community, only one was convinced he could heal AIDS, producing for me a soda bottle full of green liq that he claimed would cure AIDS. The other two healers recognized the fatal nature of AIDS, but each suggested he could help allevi ate the suffering caused by AIDS. While the hospital and major churches profess not to approve of the use of traditional healers, they do acknowledge that a traditional h ealer, with his considerable influence, can provide important access to and information for villagers who otherwise might lack access t Western treatment possibilities. Some healers ha ve incorporated Christian symbols in their rituals, which garners them some measure of in stitutional tolerance, as opposed to witch doc who are tho In January of 2002, with a new medical officer in charge at the hospital, the hospital formed an AIDS Steering Committee to help coordinate AIDS-related activities in the community. Members from the various institutions of the mission station and Tikoleraneko met once a month to coordinate AIDS prevention in the community.

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98 USAID. d at were allowed to present a program on cholera, a disease that the community was not grapplin l ional s t among students, as evidenced by blood d Most of the other institutions involved in the steering committee, however, had little or no involvement in AIDS prevention activities. Robert Laws Secondary School, the C.C.A.P.supported secondary school, had an AIDS TOTO (t otal) club that gave students the chance to perform plays and songs about AIDS. Other than that club, none of the schools had official programs on AIDS. Both of the secondary schools in the community were visited once by a traveling road show on AIDS as part of Yout h Alert, an abstinence-based AIDS prevention program administered by Population Services International (PSI) and funded in part by However, when PSI returned to the community to do a more general presentation on AIDS using music and video, they were told they could not conduct the presentation using the football fiel the primary school on the mission station because the show mentioned the use of condoms. Instead they g with at the time. The national educational curriculum for Mala wi includes lessons on AIDS in officia textbooks. Unfortunately, few students can afford textbooks, and AIDS is not covered on nat exams, relegating it to one of the many subject s often skipped over in classes. Teachers are not trained to discuss AIDS with their classes, and conversations with teachers and administrator indicate that the subject is too controversial for most teachers to broach. School attendance is dropping in the community. Much of this is attributed to modest increases in school fees and the inability of famili es to pay the new costs. The extent to which AIDS is affecting students is unclear. AIDS is certainly presen onations from secondary students tested by the hospital. A C.C.A.P. Synod medical official reported that a significant number of such donations tested positive for HIV. Since most of the secondary schools are boarding schools, most students who become infected drop out before severe illness sets in. At the primary school that serves the majority of children from the seven villages making up Embangweni, at least one child, a 12-year-old, died of AIDS in the course of the research year. More significant is the loss of teachers to AIDS, with the same primary school losing two teachers to AIDS in that same period. All of the schools in the community are understaffed, and replacement t eachers are often undertrained for their new positions. Churches in the community, for the most part have been reluctant to discuss or address AIDS issues among their congregations. In th e more established denominations, such as C.C.A.P., Catholic, and Anglican, policy on social matters tends to emanate from the central head of each institution. Often, heads will espouse an o fficial AIDS program that is to reflect the position and policy of the church. On the local level, with no resources provided for developing

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99 ing C.C.A.P synod worker reported that the ers and had no position on the use of condoms, other than the dictum that the subject mbers of the Trad itional Authority (TA) made up the other significa us subin which to record the adults living in their co s a ed t lead to infections. On one occasion, one chief challenged the mention of condoms, suggesting programs around policy, little is done. Instead, local clergy interpret the objectives for central programs, which are often narrow in scope, as the only acceptable areas for dialogue on AIDS. Moreover, local church leaders tend to take a wait and see approach on AIDS, not wanting to risk taking a stand and possibly being censured by the central church if they are regarded as violating the churchs stance. In one telling situation, a visit central church offices had developed and disseminated a set of AIDS-related pray sermon topics to each of the churches in the region as part of World AIDS Month. In Embangweni, none of the four weeks of prepared prayers or sermons was used as planned. There were reports that in the past in the local C.C. A.P church, some sermons had been very direct about AIDS, though foreign health care workers st ationed at the hospital usually delivered these messages. Perhaps emblematic of the churches stan ce on AIDS was their policy towards condom use. Because C.C.A.P. runs hospitals, it was forced to address the question of condom use. Officially, the church was not appropriate for discussion in the confines of the church. Unofficially, however, condoms were thought to contribute to prom iscuity and unfaithfulness among congregation members, and their use was not supported. As previously mentioned, the hospital, under C.C.A.P. authority, was limited in its ability to use condoms as a tool in prevention, with the only approved use being distribution under the auspices of family planning. This policy denied the reality that most married couples were unlikely to maintain condom use. Besides the church, me nt power base in the community. At the le vel of chief, there were two members of the TA ruling over the catchment area of Embangweni hos pital. The chiefs receive a stipend from the government, mostly for presiding over local courts Below each of these chiefs were vario chiefs and headmen, indunas, who provide leadership for geographic areas usually amounting to a village. In the past, each headman had been given a book mmunity for census and taxation purposes. Today, being given a book by the chief i sign of official authority. The TAs, as a group, were resource-poor, but they had significant influence over people in their territories. On AIDS, there was no cohesive policy among the TAs. For the most part, they remain disengaged from the issue, with the exception of pe rfunctory invitations to participate in activities occurring in their villages or communities. TA l eaders sometimes would weigh in on AIDS at a public forum, offering encouragement for AIDS prevention or condemning the behaviors tha

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100 bangweni area had on previous occasions publicly spoken to peopl g to fs in the last five years, most likely as a result of ival, nd and eed activity involving the purchase and resale of clothing bundles med as no f the strictures of the church, which might li S that they were an inappropriate subject at public gatherings, particularly when young people were around. The chief for the immediate Em e on AIDSissuing a recommendation not to enter your brothers house, alludin the practice of taking a widowa directive consid ered quite progressive among chiefs, especially since he was rumored to be suffering from AIDS himself. AIDS within the ranks of chiefs and sub-chiefs was considered to be a problem. Reportedly, there had been significant turnover in chie AIDS. In the north, most were polygam ist and enjoyed significant influence. Of the two chiefs serving over the Embangweni hospital catchment area, one had died prior to my arr and the position remained open for the entire year of fieldwork. The other died during the period of my fieldworkof AIDS-related illness. While th e position is hereditary within a family, the process of choosing the succeeding family member can be contentious. Th is rapid turnover of TAs may be undermining the overall authority of the position, as positions remain unfilled a leadership dwindles. The community did support various independent AIDS efforts. Two villages, Kabiri Babola, had formed their own orphan support groups For the Kabiri group, land was supplied by the village headmen so families with orphans coul d plant additional crops. In addition, this group in showing their garden to various visitors to the mission station, was able to raise funds for s and fertilizer and start an income-generating Another community, Kakoma, had its ow n drama group that prepared and perfor dramas on AIDS prevention. Of the independent organizations, Tikoleraneko Community AIDS Resource Centre w perhaps the most significant. Tikoleraneko is described as independent because it received funds from within Malawi and was not affiliate d with a church. It was intended to be an independent organization that woul d serve all people, free o mit its ability to provide certain AIDS services. As stated in the introduction to the r esearch problem, Tikoleraneko was formed in Embangweni in 2000, largely through support from Ma lawian and expatriate staff at the local mission hospital. This organization was named Tikoleraneko (hand-in-hand) Community AID Resource Centre, reviving a name given to a s hort-lived community AIDS organization that a British NGO had supported a few years earlier. Initia l funding for the organization, amounting to a couple of thousand U.S. dollars, was obtained from a community church in the United States. Using this money, the community board running the organization hired a director, a former

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101 school h eni to S es, mas and songs on HIV/AIDS and had formal rules for member raining s was followed by a train-the-trainer session, to provide s. Then clients were provided a code number, allowing them to return to addition ity the e names of onduct trainings in the provisi on of home-based care for AIDS patients. eadmistress from the community, and leased a building in the center of Embangw serve as a community resource center. Following a model suggested by the government for organizing community AIDS groups, the new director ambitiously set out to develop a set of AIDS committees in neighboring villages. These committees were intended to be the backbone of the organization, with the AID resource center providing training to a network of village committees on topics such as prevention, home-based care, and orphan assistance. The organization had initial success in developing a network of community committe completing the remarkable task of setting up AIDS committees in over 90 villages in the Embangweni area and hiring two additional staff members. However, little had been done after establishing the committees. At the time of my arri val, a Youth Club was the most active aspect of the organization. A group of young people, unde r the leadership of an ambitious young man, had formed a club that performed dra ship. The youth club progressed in their dramas and songs to point that they were traveling to neighboring villages and performing. The leadership of the youth club was also helping young people in two other communities start similar clubs. Building on the initial success of the Youth Club, a grant was later obtaine d from UNICEF to conduct peer-education t for members of the Embangweni group. Thi skills in propagating youth clubs. In the year of my participation, Tikole raneko also became involved in a condom distribution program and an orphan food progr am. After being supplied with condoms by the National Ministry of Health, Tikoleraneko counseled individuals about safe-sex practices and provided condom al receive condoms. The counseling was im plemented mainly to reassure the commun that condoms were not being indiscriminately handed out. In the orphan food program, supplies of Lakuna Pala, a mix of maize and protection meal, were supplied to Tikole raneko on two occasions as donations from U.S. churches. Each shipment of roughly 2 metric tons was supplied in 50 kg bags that were then distributed in 2 and 5 kg amounts to families caring for orphans. In preparing for the distribution, Tikoleraneko, working with village headmen, conducted registration of orphans in all of the villages in Embangweni area. One challenge to this process was the belief of some that writing th deceased would be a bad omen. At the time of my departure, Africare had promised money to Tikoleraneko to c

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102 al to provide training to community committees. UNICEF granted permission to conduct testing outside of the hospital, using trained counselors from Tikoleraneko. Neve rtheless, the hospitals program continued to undermine attem n. the lead on certain tasks in the community. When the PMTCT program was originally conceive en promised the fund han their monthly teer arrived at Tikoleraneko shortly after my own arrival. When her six One activity that Tikoleraneko hoped to engage in was testing for HIV. With the development of the PMTCT program at the hospita l, UNICEF supplied rapid testing kits to the hospital in sufficient quantities to allow for t esting in communities. Further, Tikoleraneko recruited the AIDS counselors used by the hosp it On repeated occasions pts to broaden the outreach, despite an abundance of test kits facing expiration. The relationship between the hospital and Tikoleraneko was not one of cooperatio There seemed to be petty disagreements between th e staff of the two organizations, the heart of which seemed to be a dispute over who should take d, the two organizations were to partner on the project, with Tikoleraneko providing the community outreach component and the hospital providing required health services. However, all funding for the project went through the hospital. It appears that rather than seeing the funds move outside their organization, the hospital opted to retain them and conduct the huge community outreach work. This was a blow to Tikoleraneko, which had be s from that program to develop pr ogramming in the communities, utilizing the community committees it had established. It is not clear why this change occurred. Ho wever, it should be noted that there are often opportunities for personal gain when cooperating with an international NGO. Hospital staff working on the PMTCT program could be repeatedly sent to the capital city for a few days of training and in the process receive an allowance from the NGO equal to or greater t salary. In 2002, Tikoleraneko also was the recipien t of two Crisis Corps Volunteers, former members of the U.S. Peace Corps who volunteered for a six-month assignment to assist in building AIDS infrastructures in communities. Both volunteers were young women who had served in the Peace Corps in Africa. The first volun months were finished her replacement arrived within three weeks and was still working at Tikoleraneko at the time of my departure. The first volunteer focused on management and financial skills with the center director. The second volunteer, having experience in income-generating plans, work ed with members of the Youth Club and Tikoleraneko staff to develop revenue streams th at would allow Tikoleraneko to become more self-supporting.

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103 the Small Farmers of Malawi, a district Agricultural Marketing center, and a national of those who have die of e funeral service, friends and family would b s body. Proper ber of deaths as tragic, but not necessarily as that touched on AIDS-relate d issues. Newspapers, which are not regularly Other institutions in the community included a branch of the agricultural cooperative National Association of agricultural research station. None of these institutions, in my period of research, engaged in any activities related to HIV/AIDS. Public Presentations The most prevalent public events concerning HIV/AIDS are the funerals d from the disease. When one dies from AIDS, however, the cause is seldom acknowledged. In talking with families of the deceased, a literally incredible number of younger adults were reported to have died of heart failure. Funerals would usually take place the day afte r the death, with the immediate family the deceased hosting extended family for the duration of funeral activities. Grieving would include a period of mourning at the familys hom e. At th e expected to make speeches about the deceased. Close family members would attend to the body, bringing it out at some point for the funeral attendees to view The body would finally be taken to the grave location, where the body would be interred and prayers said. If the deceased was employed, his or her employer is expected to pay for the deceased coffin. If the deceased was not employed, it is up to the family to raise the funds. The family may face a financial setback in paying for the funeral and feeding family members who have come to mourn. Another concern in the cases of those suspect ed to have died of AIDS is the handling the precautions in the preparation of th e body for burial are usually not followed, as required items like rubber gloves are generally not available to people in villages. In Embangweni, it was not uncommon to hear a bout three or four funerals in one week. Business and school activity in the community w ould slow in these periods, as people attended the various funerals. As an outsider, one sought explanation for what seemed like an extraordinary number of deaths. Most people saw the num remarkable. Overall, there were very few overt indicato rs to suggest that communities saw themselves as being in the midst of a health crisis. There we re no signs or posters in the community referring to AIDS in Embangweni. Along the M1, the main north-to-south road in the country, one occasionally might see a billboard or PSI-supported condom ad. Most people got their information on AIDS from the radio in the fo rm of news, public services announcements, and radio serial dram

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104 sold in E m son, usually the dram a group leader. More elaborate introductions were sometim rformances, lasting around twenty minutes, showed roups the audience. ducted its sessions in a more public fashion, using choir and drama performances by the Youth Club to attract people. mbangweni, would occasionally make th eir way to town, reporting the latest AIDS figures for the nation. Occasionally, Tikoleranekos Youth Club or one of the other drama groups in the community would perform dramas. These performan ces would occur in the daytime, as there are no lights to support night performances in the villages traditional meeting space. Such performances would attract many children a nd adolescents, along with a few women free fro their work. Men were usually not around during the day to attend such events. Most drama performances follow a fairly co mmon format, starting with an introduction of the drama by a lone per es made through a conversation between two characters, most often depicted as two shabbily dressed gregarious older men. One of the men would comically reveal the others ignorance of some important aspect of AIDS. This aspect of AIDS would then be explained, though an object lesson, in the drama to be performed. The plots of most dramas were fairly simp le. Usually, a man or women would have sex with one or more partners, become infected with AIDS, experience a period of remorse or denial, and eventually succumb to the disease. Most pe humorous elements and depicted comp lex scenarios around the protagonists liaisons. Costumes for these dramas consisted of clothes used to represent the different occupations of the characters. No sets and very few props are used in performing the dramas. Many drama g repeated popular drama themes, such as a sick patient visiting the local witch doctor. Tikoleraneko and the hospital also condu cted the occasional community awareness session on AIDS. Both groups sessions were fairly similar, owing to their past cooperation in conducting such outreach. In general, individuals from the organizations would go to the community to meet with people, discuss AIDS, and field mostly questions from Tikoleraneko generally con The hospital, on the other hand, would invite community leaders, with the promise of providing snacks and Cokes. These sessions would begin with a prayer and then some kind of awareness activity concerning AIDS. The core of these activities was spee ches on the need for communities to be show compassion for those with AIDS and the virtues of getting tested for the virus. Since condoms were off the table for the most part, little was said in terms of prevention other than the standard recommendation to wait fo r sex until marriage and be faithful to your partner.

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105 wanted to nits could remain intact, given such kn es, men woul d go to drink. Night bar girls could be found around t ke, their wives and spending their time drinking in this village. For five kwachas, one can n as po, which means we all come together, in reference to the assortment of landless and o have moved there to make homes.) Nationa Save the Chi ation for disseminating best practices among aid organizations. The question-and-answer session that would follow dealt mostly with basic questions about the transmission of AIDS. The concept of mother-to-child transmission was particularly confusing to many, as they wondered why all childre n of an HIV-infected mother would not also have the virus. Testing questions led to more problematic and open discussions. People know what would happen if a couple was found to be sero-discordant. While the organizers explanations revolved around the need to have safe sexual practices, there seemed to be an underlying concern regarding whether sero-discordant family u owledge. For women, if tested and found positive, there was fear of being ostracized by their husband or partner. In looking at public life and AIDS, the other public aspect to consider is those settings where people engage in activities that put them at risk for HIV/AIDS. In Embangweni, ringing the trade center where all people went to do shoppi ng, were the various bottle shops. With their front doors screened by high reed fenc hese bars, women informally trading sex for material gifts. For many drinkers, the bottle shops, with their packaged drinks, were too expensive. Instead, they would head to Sanje Mala the part of town where millet beer is brewed. Sanje Malake, which means dont be jealous in Tumbuka, was so named because many men were avoiding get either a scoop of millet beer or a shot of clear cornhusk alcohol. Men would congregate in little open drinking huts, sitting ar ound a large gourd or pot containing the millet beer. Sometimes they would become quite intoxi cated. Women were available for sex in Sanje Malake, given something of value to exchange. (B y day, Sanje Malake is more properly know Takumana economically disenfranchised people wh l Representation At the national level, AIDS makes it onto th e radio and a few billboards. However, the most visible sign of this epidemics impact is reflected in the fleets of white NGO vehicles streaming out of the capital, Lilongwe. Almost every major NGO has offices in Lilongwe, from which their various programs in Malawi are administered. Large NGOs in Malawi include ldren, ActionAid, PLAN International, Catholic Charities, Presbyterian Church USA, CARE International, World Vision, the P eace Corps, UNICEF, and UNAIDS. There does not seem to be any coordination of the activities of these groups, beyond a membership organiz that supports a network

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106 also supports efforts to prevent AIDS. Originally, AIDS prevention efforts h e under the vel, a Malawian nonprof it organization called MACRO was providing testing for HIV/AIDS at various regional tes ting and counseling centers. This organization rapid tests, they provided testing and counselin services atay f fa ere ively into smaller communities around Malawi. Their closest testing facility to Mzuzu, about 120 kiloway. t the ti the couations tiretrovirram waset longwe. Operating in conjunction with a me dical research study, a clinic at one of the nations two tertiary care centers was offering antiretroviral medications to adults at a reduced price. T n be Commu The government ad been under the auspices of the National AIDS Control Programme, an offic Ministry of Health. However, in an effort to make AIDS prevention more multi-sectoral, the National AIDS Control Programme was turned into an independent department of the government and named the National AIDS Co mmission (NAC). NAC, whose responsibilities include monitoring the AIDS situation and coor dinating AIDS prevention and treatment on the national level, has very little in the way of a public presence. At the national le received its funding from international AIDS groups. Using g centers aw rom medica l cilities. They w progress expanding Embangweni was in meters a At abou me I left ntry, the n first an al prog being s up in Li he cost was around 2,500 kwacha a month, an amount more than most Malawian families make in a month. In the period of the fieldwork, there was no single AIDS-related issue dominating public attention. Previously, there had been a widespread debate when the C.C.A.P. made public its pla to check the virginity of girls before allowing their attendance in C.C.A.P.-run secondary schools. This proposition received a groundswe ll of public support, but prov ed too controversial to enacted. nity Intervention Activities Starting in June of 2002, the dissertation r esearch moved into a phase that would inv piloting the proposed participatory research activ ities in communities. Over a six-month period (June-November 2002), community workshops that followed the proposed Drama Dialo Planning and Production Model were conducted in a community (Kakoma) and three villages (Foster Jere, Takumanapo, and Kabira) be olve gue longing to the larger Embangweni community. The workshops involved 61 members in AIDS research and planning activities. Along with taking part in the workshops, these individuals also completed preand post-intervention surveys that included a structured interview task. Summarized below is information on the workshop participants.

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107 Workshop Participants r selected research comm were dance with the recruitan, a gendere was achiev ree of the comiesKakomr Jere, and Kabira. In Takumanapo, this distribu tion became skewed after several men who had been recruited failed to attend the mandatory intr oductory meeting. As a result, in Takumanapo, there weTable 6Participating in the workshops were members from the fou unities. Of the 61 participants, 29 me n and 32 were women. In accor ment pl balanc ed in th munit a, Foste re 12 women and only 2 men participati ng. Table 6-1 provides the mean age of workshop participants by village. 1. Mean Age for Workshop Participants by Villages Kakoma Foster Jere Takuman apo Kabira All Villages N 16 15 14 16 61 Mean 52.937 48.059 29.333 39.923 43.000 Standard Dev. 11.835 14.140 9.131 4.902 15.314 The mean age for the intervention participants, 40, was slightly higher than the mean found among a random sample of individuals in the community, determined as part of the community survey in process evaluation research. However, the mean of the overall group mask some differences in ages among the different intervention groups. Kakoma had the oldest set participants, on average ten years older than the mean for all the groups. In the opposite dire Takumanapo had the youngest group, with a mean age of 29. As stated previously, in the selection of Takumanapos participants, the resear cher was able to suggest the inclusion of younger participants, and the p age s of ction, opulation reflects this modification. among a gth of average. Two of the ten non-married individuals were in relationships e. Among the participants, 83 percent were married, a number slightly higher than community survey sample (See Table 6-2). Of the married group, 14 percent were part of a polygamous marriage. Most participating in the workshops had been married for some len time, on average 18 years. This number would be higher if not for the younger group in Takumanapo lowering the with a partner and were sexually activ

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108 Table 6-2. Marital Stat us of Workshop Participants, by Percentage Married Divorced or Separated Widowed Never Married Total 83.607 6.557 4.918 4.918 100.000 In all of the co mmunities, around 70 percent of participants had attended primary school, the rem C.C.A.P. ting in the op participants was the amount of cash income their family r umana po adjoins the trade center, more of its families are engaged in trading s l gender distribution within the group in Takuma mmunity mapping, diagramming, role-pla is aining individuals having completed some secondary school, with the exception of one individual in Takumanapo who had never attended school. Most participants had lived an average of tw enty years in their pr esent villages. was the most common church membership, accounting for 52 percent of those participa workshops. The next-largest church membership was New Apostolic, at 20 percent. When broken down by community, church affiliations were often clustered by community, except Takumanapo, where church membership was dist ributed between several Christian sects within the community. Takumanapo had two participan ts who listed their religion as Muslim. A question asked of the worksh eceived each month. Again, Takumanapo differs in this respect. While the average income in the other communities was MK 730 a month, in Takumanapo it was reported as MK 1960. It is not clear why such a variation in in come was reported. While an age difference is present between the communities, this is unlikel y to explain the difference in income. One possibility is that since Tak or labor versus farming. This could account for a higher cash flow and higher monthly cash income within families. Overall, the individuals involved in the intervention reflected the more general community in terms of demographic features. Notabl e, however, in the distribution of participant between workshop groups, are differences in m ean age, especially between Kakoma and Takumanapo. Another consideration is the une qua napo. Reporting from Workshop Activities The workshops were designed to use met hods of co ys, and dramas as a framework of participatory research. In using these methods, data generated concerning the communities and their experiences with AIDS.

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109 two communities), there are similar data sets from es ere the Fost er Jere, four maps were created for each community by sub-teams from the overall group. The maps provided a detailed spatial f the village areas. Included in th e maps were twenty to thirty landmarks and thoroug oles. e or eeting to have se of the discussions within groups did Since the basic intervention was used in all four communities (with exception of community mapping, which was done in only the fi rst the these communities, which are presented and compared in this section. The activiti conducted with workshop particip ants were not limited to those described here. Appendix B provides a more complete description of workshop activities. The following, however, w more generative activities, c onducted within workshops. Community Mapping In the communities of Kakoma and Foster Jere, the first research activity conducted was to map and identify areas in the community of particular importance in considering HIV/AIDS In conducting this activity in Kakoma and representation o hfares in the community. Common features included significant collections of homes, roads, schools, churches, and locations for drinki ng water, such as shallow wells and bore h In general, the participants were adept at dr awing maps, including the use of legends for th symbols and colors used on the maps. The identification of resources took the greatest amount of time to complete. From questions asked by participants during the task, it appears that the concept of protective places places that could be used as resources may not have been fully understood by participants. However, civic institutions, such as schools, churches, and traditional meeting places, were labeled as such on maps. Community members were able to identify lo cations where people may be at risk for AIDS. On all maps, people identified locations in the community where individuals were m sex. Several groups referred to these as hiding places and described them as locations where couples would arrange to meet. Most of these locations were described as sheltered areas such as groupings of trees, a maize field off a main path, or a frequently visited borehole. The liaisons were said to occur most often after dark. One community labeled a particular road as a location where rape could occur, suggesting that it is a main thoroughfare from the trade center and that drunken men would travel the road at night on their wa y back from the bottle shops. In two cases, groups looked beyond their immediate community, linking risks to the larger community by suggesting that risk came from people visiting places like the trade center or the drinking establishments in Takumanapo. In none

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110 convers sing nodes within commun ach h ow enough about AIDS and that the community needed to be doing a better jo outlined by Kesby (2000), who used them in understanding HIV/AIDS communication in community settings in rural Zambia. Matrix Diagrams ations focus on the more re gional or national consideration of risks, such as individuals traveling to cities or other countries for employment. Others items incorporated on the maps were locations where there are orphans, places where hunger is occurring, places where thefts had occurred, and places where there is poverty. Most of these items corresponded on the map to either villages or hou ities. Groups appeared to be less critical in placing such items, sometimes placing e of these on every housing node in the community. One of the more detailed maps created incl uded the label, lack of knowledge, whic was placed on one of the schoolhouses in their co mmunity. Their explanation was that people, not just children, did not kn b of teaching about HIV/AIDS. Diagramming Diagramming exercises were one of the main participatory activities conducted within the workshop groups. For the most part, th e research followed the diagramming activities The first diagramming exercise was a Matrix Diagram where workshop participants worked together to identif y and rank concerns raised in response to the question, What factors are putting local people at risk for HIV/AIDS ? In Kakoma, in addition to the preceding question, the question, What are the most serious health risks faced by people in your community? was also asked as a lead-in question. Du e to time constraints, this lead-in question was dropped from the matrix diagramming activity in the other communities. Otherwise, the same diagramming activity was conducted in all four of the intervention communities. Each group first engaged in a free-listing ex ercise, listing their responses to the posed question. Responses were then written on sheets of paper, and the group was asked to rank the responses in terms of seriousness or importance, using the floor as a place for organizing the sheets of paper. As a next step, each member wa s provided a set number of tokens, soda bottle caps in this case, to place next to sheets to in dicate the importance of each item. This step converts the ranking to interval-level data, providi ng more contrast between the items in terms of their seriousness. At times, members would place mo re bottle tops next to certain items so as to indicate that the item had greater importance than that assigned by its original ranking. In these situations, the group was asked to consider the ra nking and whether they would like to reorder the ranking of responses to correct this difference.

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111 In addition to creating the ranking of the res ponse items, the group was asked to evaluate ichotomous attribute, such as whether the it primarily affects men or women, or whether it particularly concerns youth or ad mmunity. As part of the piloting process, ent of attributes to consider varied among communities. pleting the diagramming task, her with no real ies. If there was any difference in per e on this task, it seemed toate with gender. In Kakoma and Foster Jere, it ed that younger members oroup he task, while older members ding feedback onthe ranking ed completion. In response to the question, What are the most serious health risks faced by people in munity ? which was posed only to the in Kakoma, HIV/AIDS was the leading concern (see Table 6-3). While onlysenting 16 percent of the concern as ssed in the assignment of tokens, when combd with Orphans, the next-ranked item, the f which is linked to AIDS, th e total becomes closer to 30 percent. some or all of the items listed based on a partic ular d item was a new or old problem in the community, whether ults of the co the assignm In com the par ticipants worked toget difficult form anc correl age, not appear f the g readily set about t held back, provi ly as near your com group community repre expre ine incidence o

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112 Table 6-3. Kakoma Matrix DiagramQuestion One What are the most serious health risks facing your community? Concern Bottle Tops (Out of Thirty-One) Percentage HIV/AIDS 16% Orphans 13% Hunger 13% Poverty 3% 10% Lack of Education 10% TB 10% Malaria 6% Diarrhea 6% Pneumonia 6% HBP 3% Poor Roads the group was given a set number of tokens for each concern, and they were told to distribute among sets of cards featuring potential attributes of AIDS (see Table 6-4). The significant attributes assigned to AIDS were 1) it is ls you and 2) it causes l suffering. Contrary to HIV/AIDS was assigned little erms of being shamefulerty was a more shameful condition than HI th members of the groupesting, leads people to believe that someonrking hard or is lazy. 4. Kakoma Matr ix DiagramAttributes It Kills You It Pains You u Cant Work Its Shameful It Isolates you When assigning attributes to each concern something that kil pain or persona what was expected importance in t . Pov noted as V/AI DS, wi sugg Poverty e is not wo Table 6Yo HIV/AIDS (10) Orphans (8 ) 0) overty (6) Lack of Education (6) Hunger (1 P

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113 roblems is AIDS bringing to your ommunity? On averag list pr om ir e most part, the communities listilar items and viewed them w the same level of im ree of th y rms were Os Loss of Life from re did not to be anyiation in peance ng data on this task by communiagement. -5 through ow to the second matrix Following the Matrix D s in the ity, worksh ed to list social factors thatpeople in the communityrisk experiences in the formative as aware that people at listing biological ms by wh icS can be td and oftenuse mechanisms with social ted to AI DS transmission to avoid atial y of having people list biological factors when being asked about social concerns, a strategy was followed of asking first for the biolog ical factors, so as to eliminate the biological factors from future consideration. What Problems is AIDS bringing to your comm Concern Percentage All of the communities answered the question, What p c e, workshop groups ed eleven oblems resulting fr AIDS in the community. For th ed sim ith relatively portance. Th e more highl anked ite rphan Hunger and AIDS The seem different rform or resulti levels of ty eng Tables 6 6-12 sh responses diagram question. iagrams on AIDS problem commun op participants were next ask are putting at for HIV/AIDS. From research, the res earcher w are adept echanism h AID ransmitte conf these factors rela In order poten difficult Table 6-5. Kakoma Matrix DiagramQuestion Two unity? Bottle Tops (Out of Fifty) Kills Ma ny People 32% Orphans r ent 32% Hunge 12% Widows 10% Illiteracy 10% Poverty 8% Lack of Developm 8% Theft 6% Unwanted Marriage 6% Drinking 4% Rape 4%

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114Attributes New/Onal/External Table 6-6. Kakoma Matrix Diag ramQuestion Two Growing/Lessening ld Inter Hard/Easy Kills Man y People Growing New Internal Ha rd Orphans Growing New Internal Hard Hunger Growing New Internal Ha rd Widow s Growing New Internal Ha rd Illiteracy Lessenin g Old Internal Ha rd Poverty Growing Old Internal Ha rd Lack of Development Growing New Internal Ha rd Theft Growing New Internal Hard Unwanted Marriage Growing New Internal Hard Drinking Growing New Internal Easy Rape Lessening Old External Hard Table 6-7 Foster Jere Matrix Diagram lems is AIDS bringing to your commun ern Bott (Out of Fift Percentage What Prob ity? Conc le Tops y-One) Orphans 19 % Hunger 16 f Support 10% 10% 10% 8% 8% No Development 8% Widowing 6% Loss of the Young 6% Decrease in population 2% Scarcity of Hospital Resources 0% Opportunistic Illness 0% % Lack o Theft Caring for the Ill Moving Around Hatred

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115Table 6-8. Foster Jere Matr ix DiagramAttributes New/Old Adults/Youth Growing/Lessening Orphans Growing New Adults Hunger Growing Ol Adult pport Growing A Growing Ne A Growing New/ A Growing Ne Y Lessening Ol A d s/Youth Lack of Su Old dult Theft w dults Caring for the Ill Old dults Moving Around w outh Hatred d dults Table 6-9. Takumanapo Matri x Diagram bringing to your comy? Concern Bottle Tops (Out of Sixty) Percentage What Problems is AIDS munit Orphans 18% Poverty 15% 13% Lack of Support 10% No Guardian opment f Hospital Resources Hunger s 10% No Devel 10% Theft 8% Widowing 7% No School Fees 5% Scarcity o 3% Decrease in Population 2%

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116butes New/Old Women/Men ults Table 6-10. Takumanapo Matrix DiagramAttri Youth/Ad Orphans New Women uth Yo Poverty Old Men/Women ults Old Women New Women Youth ns New Women New Women New Men/Women Adults idowing New Women Adults No School Fees Old Women Youth Scarcity Ad Hunger Youth Lack of Support No Guardia Youth No Development Theft Youth W of Hospital Resources New Women Decrease in Population New Men/Women Youth Table 6-11. Kabira Matrix Diagram What Problems is AIDS bringing to your community? Bottle Tops Percentage Concern (Out of Thirty-Eight) Orphans 39% People Dying 29% 13% 11% 5% vernm 3% More Money 0% Scarcity of Hospital Resources 0% Decrease in Population 0% Hunger No Development Poverty Goent Spending

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117ributes dults/Youth Table 6-12. Kabira Matr ix DiagramAtt New/Old A Orphans Old Youth People Dying Old Youth unger Old Adults/Youth o Deve New O Adults/Youth overnm Money Nw lts/Youth H Nlopment Poverty ld Gent Spending More e Adu Thus, workshops participants provided two lis ts, one for biological transmission and one ributing to AIDS. For the biological factors, groups arily affected, using gories. diagrammatic responses to the ques tion of how AIDS is transmitted in the hrough 6-16). Matrix Diagram ople in the Comunity a Both: Sexual Intercourse ections Razor Blades concerning social factors that may be cont were also asked to associate the biological mech anism with the group it prim Men Women or Both as cate Following are community (Tables 6-13 t Table 6-13. Kakoma Biological Factors that are Putting Pe mt Risk for HIV/AIDS Inj Blood Transfusion Men: Contact with Body Fluids Women: MTCT Sharing Bathing Materials Touching Dead Bodies

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118tting People in the Community at Risk for HIV/AIDS Both: Sexual I Injection Razor Bdes Widow I Table 6-14. Foster Jere Matrix Diagram Biological Factors that are Pu ntercourse s la nheritance Men: Piercing Sharing Bathing Materials/ Toothbrushes Women: Blood Transfusion Touching Dead Bodies Injections Sharing Toothbrush Table 6-15. Takumanapo Matrix Diagram Biological Factors that are Putting People in the Community at Risk for HIV/AIDS Both: Sexual Intercourse Razor Blades Men: Piercing Sharing Bathing Materials Women: Blood Transfusion Touching Dead Bodies MTCT Table 6-16. Kabira Matrix Diagram Biological Factors that are Putting People in the Community at Risk for HIV/AIDS Both: Sexual Intercourse Blood Transfusion Razor Blades Injections Men: Piercing Sharing Bathing Materials/ Toothbrushes Women: Touching Dead Bodies

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119 After creating a list of biological risk, the group was then asked to consider social factors the following two que tat people are living that put themOr hat kinds of thin doi elve Risk was explained to participmeth ing someone does that makes it more likely for em to be expo HIV. Table 6-17 provides a comparison of thest of the respon responses listed dix were given standard titles across toups to ease comparison). createdommud from14 item mong the itemonly Drinking of Alcoho Poverty wer communities. Listed in at least three of the communities were Fondness of Money Hunger Lack f Support, Not Being Faithful toour Partner, a ow Inheri descriptions of these causes is also provided in T in the community. They were prompted to think of such factors using one or the other of stions: Are there ways h at risk for HIV? W gs are people ants as so ng to put thems s at risk for HIV/AIDS? th sed to or contrac t li ses for each community (the he gr in the appen The lists by each c nity range eight to s, for a total of 25 items. A s listed, l and e listed as factors in all four o Y nd Wid able 6-17. tance A synthesis of group

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120ocial Factors that are Putting People in the Community at Risk for HIV/AIDS Table 6-17. S Kakoma Foster Jere Takuman apo Kabira Description Beauty/Van (Women) ity ity s an affirmation of desirability or self-worth Beauty/Van (Women) Women or girls who have sex a Children Not Listenin g to Parents g to Parents Children Not Listenin Children staying out and not adhering to traditional family values C ondoms Promoting Sex ondoms Promoting Sex C Condoms encouraging sexual promiscuity C ondoms Not Being Used safe People not using condoms for sex Drinking ch Drinking Drinking Drinking People drinking alcohol, whi leads to other risk behaviors D esire Lust for members of the opposite sex F a m e / Reputation en) exploits (M Men or boys feeling the need to boast of sexual Fond of Money Fond of Money Fond of Money ms or pport Women or girls having partners in order to receive material ite financial su Hunger H unger unger H Increased vulnerability/ Effect of AIDS on family G T oing to raditional Doctor azors) oing to raditional Doctor (Razors) (R G T Sharing of unsterilized razor blades Lack of ge nowing Knowled Not understanding or k about AIDS Lack of Support Support Lack of Support Lack of Single female parents needing resources Loc al Injections s ing unsterilized needles U Moving Around Moving Around (Sexually Being sexually promiscuous and having multiple partners (Sexually Active) Active) (contin ued)

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121 Risk for HIV/AIDS (continued) Kakoma Foster Jere Takuman apo Kabira Description Table 6-17. Social Factors that are Putting People in the Community at Not Being Faithful to Not Being Faithful to Not Being Faithful to Your Having extramarital relations Your Partner Your Partner Partner Not Getting Tested Not Getting Tested Not knowing ones HIV status and continuing to engage is sexual activities Not Having School Fees Girls exchanging sex for money in order to attend school Orphanage Orphanage Bei ng an orphan and lacking resources Poverty Poverty Poverty Poverty Increased vulnerability/ Effect of AIDS on a Family Prostitution Women or girls exchanging sex for money Premarital Sex Boys and girls being sexually promiscuous Sister-Giving The prac tice of providing anothe sister in the place of one who ha perhaps died of AIDS in a marriage r s Too Muc Money (Men) Money making it possible for men to have multiple partners through prostitution or patronage h Raping Forcible sex with a person of unknown sero-status Wanting The des Children ire to have a partner who can produce offspring Widow heritance Widow Inheritance Widow Inheritance The practice of a woman sleeping with the brother of her deceased husband In 11 12 12 14 Flow Diagram Rather than having the workshop groups address this list of social factors for AIDS risk along a single attribute, as had been done with the matrix diagrams, they were asked to complete a flow diagram. Flow diag rams as a methodology allow people to explore causality in HIV/AIDS risk through associating a nd linking the group-identified risk factors for HIV/AIDS. Figures 6-1 through 6-4 exhibit the fl ow diagrams for each of the communities.

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Figure 6-1. Kakoma Flow Diagram of Community AIDS Risk Factors Figure 6-2. Foster Jere Flow Diagram of Community AIDS Risk Factors 122

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123akumanapo Flow Diagram of Community AIDS Risk Factors Figure 6-3. T Figure 6-4. Kabira Flow Diagram of Community AIDS Risk Factors Force Field Diagrams As a final diagramming tool, force-field diagrams were used so the group could explore forces in the community that are supporting positive behaviors encouraging negative behaviors around factors identified as putting people at risk for AIDS. To construct the force field diagrams, a piece of paper was bisected along one of its diagonals. A behavior or activity was then placed along the di agonal, and the group was directed to write on or

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124her r planning in the community of Foster Jere. one side of the line the forces that encourage or support the behavior or activity and on the otside the forces that inhibit or are obstacles to achieving it. In the first two communities, Kakoma and Foster Jere, these diagrams were used to stimulate discussions on planning AIDS prevention in the community, offering a way to think about resources and obstacles to planning community programs. In the final two communities, Takumanapo and Kabira, force field diagrams were used as a complement to role-plays as a way to consider why people may act the way they do in certain social situations. Figure 6-5 is anexample of a force field diagram used fo Figure 6.5 Force Field Diagram on Issues Concerning HIV/AIDS Testing Role-plays Role-plays were conducted with members of all four groups as an introductory drama activity. Since the role-play scenarios were created by the researcher, the content of the various role-plays was not recorded. However, members of the various groups were able to actively

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125 ngage in the role-play process and produce s pontaneous dialogue on the topics presented to them. Further discussion of their utility will be provided in the analysis chapter. Dramas In Kakoma, where the drama group had already performed several dramas, it was felt that somethi t ie e dramas as a video, they were filmed using MiniDV video recording technol eature s, or esentation, approxi o, the ourage community involve e the audience with ques tions on the action in the play. For instance, when a mother bemoans the lack of school fees for her daughter, the trickster interrupts and asks lve her dilemma. After presenting the dramas, a movie w e ng different needed to be done, something to attract a larger, more diverse audience. A past performances in the community, it had been noted that the audience was primarily small children and mothers. Given the availability of video projection equipment, it was decided that there would be a video night in the community, where the drama group would present their drama, pre-recorded on video, and the community would be invited to watch a regular mov after the drama movie. To present th ogy and edited using an Apple iMac computer with iMovie software so it would f titles and theatrical transitions between scenes. In addition, information from the workshop including flow diagrams, was presented in the video with voice-over narration provided by the group, interspersed between the dramas. In the e nd, the Kakoma video featured four dramas and ran for about 45 minutes. To advertise the community presentation and video night, flyers were posted in the community. On the day of the drama, a bullhorn was used to announce the event f several hours prior to dusk, when the perform ance was to begin. At that pr mately one hundred men and wo men of all ages were present. In Foster Jere, the second community to complete the workshops, instead of using vide a live presentation format was used. To present the workshop information as a prelude to dramas, the drama performers used cards to disp lay and spell out items for the audience. In putting on the actual dramas, a theatrical devi ce was incorporated to enc ment in the performance. Much like the Lekani Theatre activity done in the workshops, the drama action was frozen at critical points. A trickster character would then enter the frozen scene and provide commentary and questions on the drama. This trickster, dressed like a scarecrow, would challeng for some suggestions as to what she can do to reso as shown to the community. The drama was advertised using handmade flyers, and nearly one hundred men and women attended the presentation. In Takumanapo and Kabira, the dramas were also performed live and followed by a movie. The use of the trickster role, while thought to be effective when used in Foster Jere, was

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126 sufficient facilitative skills to improvise in front of the audience, skills not present in all groups. Attendance levels in these two communities was similar to those In all of the communities, the audience was receptive to the dramas, and crowds clapped and cheered at the performances. A group of village m unity were invited in advance and were provided a row of seats to view the dramas f the vually w rm a group sitting in f the stage. Women generally egated in groups to the sides of the village headmen. Finally, village men and teenage boys ed to participate in some aspect of the drama or presentation, members of the audience quickly complied. At times, the dramas drew great laughs, the ered in the dramas included Orphan Care Poverty Not Trusting a Partner in a Relationship Not Getting Tested and Not Being Faithful. ey represent of diversity of stories, each told nt settingsns. not repeated for logistical reasons. The trickster role required someone with a high comfort level in public performance and achieved in the first two communities. head en and senior m embers of the comm The children o congr illage us ould fo ront of and girls formed the back of the audience. When ask often in response to seeing respected community members dabble in amateur theatre. Appendix F provides a synopsis of and comments on the dramas produced through participatory workshops. In total, 13 dramas were put together, featuring 61 performers from four workshop communities. Topics or themes cov While some of the dramas share similar titles, th using differe and situatio

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127 rategies are repo taChapter SevenResults of the Process Evaluation Reported here are findings from the data-gathering activities conducted as part of the Process Evaluation task. In reporting the results, where anal ytical strategies were used to guide the reporting or summarization process for qualitativ e or quantitative data sets, these st rted in relation to the data. Data coll ected through quantitative measures are tabulated and, when appropriate, summarized through d escriptive statistics or the multivariate da reduction strategy of consensus analysis. Community Survey The orally administered survey of the five communities considered for program implementation activities yielded 121 com pleted surveys from a randomly sampled set of individu in units, ulty in finding eligible particip ants. In only seven households was it necessary to resam the ested l/ratio demographic variables, there was no significant skewing in the data, indicating the likely presence of normal distributions, another enced by non-responses. Data from the survey was elaborated using d escriptive statistics, and when a ifferences in sub-groups (Gen age) wad usin Squars ndent T test, or one-way analysis of variance. All computs were done Community Survey rticipants In the overall sample, then age of indi interviewed was 40.7 years old (see rom the survey seems high when compared to national estimates that suggest a median age for the nation of 16.4 (CIA, The World FactbookMalawi 2000). However, the samp als from the five villages in the Embangw eni community (twenty-four people surveyed four villages and twenty-five from one village). With there often being extended household there was no diffic ple to achieve the desired number of interviews for each community. Members of research team completed the process without any significant difficulties. In the completed surveys there were 54 missing data points, totaling 2% of the requ data. In the missing data, there was no visible patterning indicating a systematic non-response pattern. Further, for the continuous or interv a sign that the data was not systemati cally influ ppropriate, e, Fisher d der and Vill s analyze g either a ChiExact, Indepe ation using the SPSS statistical package. Information on Pa mea viduals Table 7-1). The mean age f les from this research exclude household individuals below the age of 18. The mean age

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128 Kak s from this research simply highlig hts the fact that a significant portion of Malawis population is under the age of eighteen. Table 7-1. Mean Age for Survey Villages Foster oma Jere Takumanapo Kabira Champhonya All Village N 24 24 24 23 24 119 Mean 48.208 40.000 37.917 42.739 34.792 40.714 Standard Dev. 15.157 16.216 13.806 6.715 1.602 15.251 e distribution of gender among those surveyed was stratified in order to achieve an equal distribution (see Table 7-2). However, skewedness occurred in terms of gender as a result he surveys in one village, resulting in slightly more women being sampTble 7-2. Distribution of Sex in all Village Th of failure to adequately control field samp ling while conducting t led. a s All Villages Frequency Percent Valid Percent Cumul ative P ercent Male 51 42.1 42.1 42.1 Female 70 57.9 57.9 100.0 Total 121 100.0 100.0 From the survey, one finds that a majority of the individuals surveyed are married, close to 80 percent, with only 7 percent of the adults over the age of 18 never having been marrie Table 7-3). Table 7-3. Marital Status for the Complete Sample N Married Divorced Widowe d Never Married Total d (see 121 96 9 7 9 79.339 7.438 5.785 7.438 100.00 0 Ninety percent of the men surveyed were married, whereas only 71 percent of women were married. Women from the total sample were also more likely to be widowed. The data on

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129 atterning foun d for the region in terms of male and female household heads, where 90 percent of male household heads were married and 50 percent of female household heads were married (Malawi-An Atlas of Social Statistics 2002). Of those married from the entire sample, 18. 2 percent were engaged in a polygamous marriage ( Polygamous Marriage ). Of the nineteen individuals within the sample who were not married, 4 percent (five individuals) indicated they had a partner with whom they were regularly sexually active ( Presence of Regular Sexual Partner Among Unmarried Individuals) Ninety-eight percent of the males and 91 percent of the females surveyed had one or more years of education. The high number of educated individuals is attributed to the governments long-standing emphasis on education, providing free primary education for all, as well as social norms in the north that place va lue on educational achievement. Current social statistics from the district suggest wide access to primary education, with between 75 percent and 85 percent of children between the ages of 6 a nd 13 regularly attending primary school (MalawiAn Atlas of Social Statistics 2002). The mean number of years of education in the group was 5.75 years. This differed by gender, with men demonstrating a mean of 6. 54 years, while women demonstrated only an average of 5.26. Years of schooling, however, has a limita tion in terms of estimating educational ment, since it is common in Malawi for i ndividuals to repeat grades as the result of not passing national standardized tests. Therefore, another measure was used with respondents concern Marital Status from Embangweni resembles p attain ing their Highest Level Completed in School. Table 7-4 exhibits the overall frequency data for Highest Level Completed in School. Table 7-4. Highest Level Completed in School Freq uency Percent Valid Percent Cumulati ve Percent No Scho oling 7 5.8 5.8 5.8 Primary School 91 75.2 75.2 81.0 Secondary School 23 19.0 19.0 100.0 Tertiary School 0 0 0 Total 121 100.0 100.0 Again, one finds variation by gender in terms of the highest level of education achieved, with 78 percent of males in the group achieving a primary school education, and only 70 percent

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130 ever, a Fishers Exact test of a 2 X 2 contingency table (Sex by Primary or Greater School Achievem ent) suggests no real difference in attainment betwee in terms nal lher ns are tune district level, where 72 per cent of males and females in the district have finished primary (Malawi-An Atlas of Social Statistics 2002). In terms of years lived in the village ( Continuors in Village ), the mean y t entire neteen. When examined in relation to gender, the mean for mas 23 yrs, and was 1ears. An independent samp-test conduc the data, sorted by gender, found that the differ ence in years was significant (see Table 7-5). nation for this difference is the patr ilocal residence system found in tof Malawi, in which a woman leaves her village upon me and moves to the village of her Table 7. of the females reaching this same level. How n men and women of educatio evel. Furt such proportio similar to hose fo d at th school us Yea ears for he sample was ni ales w ea the mean for females 7 y le T ted on O ne expla he north arriag husband. 5. Difference in Years Li ved in the Community by Gender T-test for Equality of Means t df Sig. (2-tailed) Mean Difference Std. Error Difference Village Years 2.063 119 .041 6.17160 2.99145 Another variable considered among the individuals surveyed was their religion or religiou ip of e among a variety of smaller Protestant, Evangeli cal, and indigenous Chris tian denominations in a me mber of the Muslim faith. While Muslims are not common in the North of Malawi, except near Lake Malawi, the community of Takumanapo, w indsid n ty o ma ttle after having relocated from other areas in the natio ides a breakn of th various religiligioustions r d ample. s affiliation. Slightly over half (n = 62, 53%) of the individuals interviewed were members of the Central Church of African Presb yterian (C.C.A.P.). The dominant membersh this church is not surprising, considering the churchs long-standing position in the community. The next-largest religious affiliation was Catho lic, with 5% (n=18) of individuals from th sample belonging to this church. The remaining members of the complete sample were divided the community. One person in the sample was here this ividual re ed, was know for its di versi f people, ny of whom se d there n. Figure 7-1 prov dow e ons or re organiza epr esente ong the sam

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Figure 7-1. Religions or Religious Affiliations Some clustering by village in terms of religious affiliations is evident in the sample. While C.C.A.P. appears to have significant membership across all five villages, other denominations, such as the Catholic Church, New Apostolic, and Last Church, appear to have stronger bases of membership in particular villages. Since many villages are organized around a few sets of extend families, one might expect that one s family, and thereby village, have an influenc e on church membership. A final piece of information collected about each respondent was his or her relationship to the household head (see Table 7-6). Twenty-seven percent of those surveyed were the heads of their households. Most, however, were living in the house of either their mother or father (63 percent). Of those who were household heads, 87.5 percent of them were males. 131

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132d Table 7-6. Frequency of Heads of Househol Household Head Frequency Percent Valid Percent Cumulative Percent Valid Self 32 26.4 27.6 27.6 Spouse 5 4.1 4.3 31.9 Mother 10 8.3 8.6 40.5 Father 66 54.5 56.9 97.4 Brother/Sister 1 .8 .9 98.3 Father/Mother In-law 2 1.7 1.7 100.0 Total 116 95.9 100.0 Missing System 5 4.1 Total 121 100.0 In terms of the 11 variables collected for each individual Sex, Age, Marital Status, Years Married, Presence of a Polygamous Marriage Presence of Regular Sexual Partner Among Unmarried Individuals, Years Spent in School, Highest Level Completed in School, Continuous Years in Village, Religion or Religious Affiliation and Relation to House hold Head variation in data am of llage across the five villages. These results suggested a significant difference among villages only for the variables Age and Continuous Years in Village. ces, a posthoc Shaffe test was conducted on the data. A significant difference, established at the .05 p-value level, was four Age between s a and Champhonya. A significant diffeas a f e of Kakoma and the villages of Foster Jere, Takumanapo, and C Continuous Years in Village lived by an individual (see Table 7-7). T7. Mean Continuous Years in Village Village Kakoma Foster Jere Ta kumanapo Kabira Champhonya All Villages ong the four villages appears minimal. To better validate this assumption, an analysis variance (ANOVA) was conducted on the interval/ratio data of Age Years Married Years Spent in School and Continuous Years in Vi To better understand these differen nd fo the ampled groups for the villages of Kakom rence w lso ound between the villag hamphonya in terms of able 7N 24 24 24 23 24 121 Mean 30.7917 a 15.1667 12.8750 20.0583 16.8800 19.1355 Standard Dev 22.06705 13.01059 11.17572 16.94117 11.63443 16.4678 3

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133 ddition to the individuallevel data collected in the survey, four questions were concern ues number of adults and children in each household. From this sample, there was found to be an ls. ean Number of Children and Adults in a Household a Kakoma was significantly different (P<.05) from the villages of Foster Jere, Takumanapo, and Champhonya in terms of continuous years in residence, as determined by a one-way analysis of variance. In a ed with household demographic information. Examined on this level were Number of Adults in Household, Number of Children in Household, and Primary Household Economic Strategy. In addition, a cumulative household popula tion was derived from the reported number of adults and children in each household. For this survey, household was defined as the immediate members of a family sharing a structure or discrete group of structures in the same village. Table 7-8 provides the mean val found for the almost equal number of adults and children in each household. A cumulative measure, based on the sum of adults and children in a house, suggests a household mean of 7.3 individuaTable 7-8. M N Minimum Maximum Mean Std. Deviation Adults 115 0 15 3.68 2.643 Children 117 0 16 3.79 3.014 Valid N 112 Sources of social data on Malawi, such MalawiAn Atlas of (2002), support tnumbers for household size, with household sizes larger than five indivis b ionav e hseh sizoraws withe higher rates in the north attributed to its patrilineal society. Smaller household sizes are found in t atrilineal societies. were also asked about the prim souesasnc wit t most cmsource of cash for a household, w 45 pcen d from farming. Engwi,re w a y-rd mket m beans, and other vegetas. ar as true cash cps acoer tobao and paprika peppers were purchased fromal rm s. othe p taining cash income was trad inwit earn t ging inis a vitynly percent of the samplad relar salaried e er civil servants or teacher of primary income sources. as Social Statistic s hese high dual eing the norm for the region. The nat al er ag ou old e f Mal i i 4.37 h t he south of Malawi, among its m Survey participants ary rc of c h i ome hin heir households. Farming was the om on ith er t eriving their cash income In mba en the as ear oun ar for aize, tomatoes, ble As f ro re nc ned, cc sm l fa ers annually at local market An r opular strategy for ob g, h 22 percent of the sam ple ing heir primary cash income by enga th c ti O 5 e h gu mployment as eith s. Figure 7-2 provides a further breakdown

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1347-2. Primary Cash Income Sources Figure HIV/AIDS Experience, Knowledge, and Self-Efficacy Questions Beyond collecting data to ascertain demographic dimensions of the research communith n ons). In addition, an open-ended question was asked concerning the sources people use to get their information about HIV/AIDS. were asked two questions concerning their experience with HIV/AId eone ities, the survey also asked participants sets of questions on personal experience wHIV/AIDS (two questions), basic knowledge of AIDS (seven questions), and self-efficacy ipreventing personal infection (two questi Survey respondents DS. One question concerned whether the respondent had known someone who was infected with or had died from HIV/AIDS. The second question, very similar to the first, askewhether they had a family member or close friend who had become infected with or died from HIV/AIDS. Of the 119 individuals who responded to these questions, 83 percent knew somwho was infected with or had died from AIDS, and 66 percent indicated that they had a family member or close friend who was infected with or had died from AIDS.

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135Table 7-9. HIV/AIDS Knowledge Questions Yes No Not Sure To gauge respondents knowledge of HIV/AI DS, they were asked a battery of five dichotomous questions taken from an HIV/AIDS quick assessment guide for knowledge. Their responses are reported in Table 7-9. Have y ou heard of an illness called AIDS? 97.5% 3.5% 0% Is AIDS a fatal disease? 99% 0% 1% Is there a cure for AIDS? 20% 79% 1% Can the virus that causes AIDS be transmitted from mother to a child? 89% 8% 3% Is there anything a person can do to prevent getting AIDS? 95% 2% 3% The responses demonstrate an overall understanding concerning some of the basic facts about A r urprising, in that other knowledge have a good understanding of basic facts on AIDS. Two cross-tabulations usi uare st atistic were done to determ was any he data in terms of sex of respondent or village of residence. There was no sex. However, in looking at variation by village, there was a s e (Chi-Square, P= .001) with re gard to understanding whether there is a cure for AIDS. In the villages of Foster Jere and Cham phonya, members were alm st evenly split as to not clear what contributes to this difference in knowledge. g IDS. Most respondents had heard of the disease, knew it was fatal, and knew there were ways to prevent it. There was some confusion aroun d the more specific questions about a cure fo AIDS or whether AIDS can be transmitted from mother to child. Clearly, however, a good number do understand these concepts. The results are not s surveys done in the country have also found pe ople to ng the chi-sq ine whether there significant patterning in t significant variation by ignificant differenc o whether or not there is a cure for AIDS. It is Respondent also were asked two open-ende d questions on prevention, one concernin personal ways that AIDS can be prevented a nd another addressing the primary mode of AIDS infection in the community. Table 7-10 charts r esponses for each community for the first of these questions.

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136 Table 7-10. What a Person Can Do to Prevent AIDS Kakoma Foster Jere Takumanapo Kabira Champhonya What a Person Do to Prevent AIDS % % % % % Abstain from Sex 21 88 20 83 14 58 16 67 22 88 Use Condoms 8 33 12 50 13 54 13 54 8 32 Limit Sex to One Partner/Stay Faithful to Your Partner 7 29 5 21 5 21 6 25 9 36 Limit Number of Sexual Partners 4 16 0 0 0 0 1 4 0 0 Avoid Sex with Prostitutes 0 0 4 17 5 21 5 21 4 16 Avoid Sex with Persons Who Have Many Partners 6 25 3 13 1 4 1 4 2 8 Avoid Blood Transfusions 3 13 3 13 0 0 0 0 1 4 Avoid Injections 5 21 5 21 1 4 4 17 2 8 Avoid Kissing 0 0 0 0 1 4 0 0 0 0 Avoid M 0 osquito Bites 1 4 0 0 0 0 0 0 0 Seek Protection from a Traditional Healer 0 0 0 0 1 4 0 0 0 0 Avoid Sharing Razor Blades 12 50 9 38 3 13 8 33 11 44 67 234 61 256 44 183 54 225 59 236 Twelve separate methods were identified, and respondents were allowed to list more than one method for preventing AIDS, resulting in a tota l percentage of more than 100. On average respondents identified three methods of prevention. The most frequently listed personal method was abstaining from sex. Avoiding sharing razo rs or blades and use of condoms were other common methods of prevention listed. Only two individuals listed methods of transmission th are epidemiologically rejected, avoiding kissing and bites from mosquitoes. In terms of the primary mode by which individuals are becoming infected in the community, the most common mode was sexual intercourse, according to 87 percent of the respondents. Prostitution and razors were each mentioned by 3 percent. Two questions were also asked to gauge individua at ls self-efficacy in preventing personal infectio t felt they could not get AIDS. Ninety-four per cent of the respondents felt they knew enough to keep themselves from getting AIDS. n from HIV/AIDS. The survey showed that 73 percent of the respondents thought i possible that they could get AIDS (see Table 7-11). Significantly, 20 percent of the respondents

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137 Table 7-11. Self-Efficacy Questions HIV/AIDS Knowledge Questions Yes No Not Sure Do you think you can get AIDS? 73.5% 20% 77% Do you think you know enough to keep yourself from getting AIDS 94% 4% 2% As a final question, respondents were asked where they got their information on HIV/AIDS. Hospital, radio, Tikoleraneko, and th eir church were the most frequently cited information sources in the community. Key Informant Interviews Sixteen members of the community were in terviewed as pa rt of the key informant process. s research and in conducting the process evaluation of the interven concern is also reflected in the analysis, with transcripts and notes from the lation erviewed consisted of ten men and six women. These individuals ranged in age from 22 to 76. All but one individual was presen tly married or had been previously married. een of the sixteen had lived in the area continuously for the last three years. Total years in residence ranged from years. The majority of those interviewed had lived in the area for most of their lives, a few having left for employment or school to then return for employment or retirement. One individual, the head of the C.C.A.P. church, was from a neighboring district and had only lived in the Embangweni community for a year. Each person interviewed was affiliated with a community organization that was involved in health care or in AIDS prevention or service organizations, or the person held a politically or Topics explored were 1) personal knowledge and perceptions of the community, 2) experience with AIDS in the community, 3) observations of problems or issues related to AIDS and 4) understanding of efforts toward AIDS care and prevention. In order to develop the community intervention aspect of thi tion, particular interest was paid to th e identification of problems and issues related to AIDS in the community. This interviews coded for examples where informants identified community-related AIDS issues. This information was then entered into an informant-by-ite m matrix to facilitate tabu of totals for each item identified across all interviewees. Characteristics of Interviewees The group int All interviewees lived within 5 km of the center of Embangweni. Fift three to 54

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138 ity. Table 7-12 provides a further breakdown of the individu socially significant position in the commun als interviewed by br oad institutional categories. Table 7-12. Community Aff iliations of Key Informants Type of Community Affiliation Number Interviewed AIDS Workers 3 Health Care Workers 4 Local Village Leadership 4 Heads of Communi Churches 2 ty Educational Worker 3 Of those interviewed from AIDS organizati ons, one was a central figure in both the Tikoleraneko A IDS Youth Club and the local chapter of the National Association of People Living w nity S, was a e of dical officer with significant experience working in the local commu ith AIDS in Malawi (NAPLAM). She was also one of a few members of the commu who was open about her positive HIV/AIDS status. 5 Another individual involved in AIDS prevention work was a Voluntary Counseling and Testing (VCT) program volunteer, trained as a VCT counselor as part of the hospitals PMTCT e fforts. He had lost two children to HIV/AID and he strongly supported prevention efforts. The third person was a senior member of a community and the leading figure in an AIDS orphan group, raising funds and planting crops to benefit orphan children in a nearby village. From the more general health sector, a health surveillance officer in the community interviewed. Employed by the government and paid by the district health office to implement prevention activities on a range of health issues in local villages, Health Surveillance Officers worked out of the mission hospital in Embangwen i. Also interviewed from the hospital was low-level member of the hospital staff who par ticipated in several of the hospitals general trainings on HIV/AIDS and was active in the hospital community. Absent from the sample of health care workers was a physician or senior me dical officer from the hospital. However, in th period when formative research was conducted, th e hospital experienced a significant turnover senior staff, leaving no me nity. 5 This individual was in fact one of only two people I met who was publicly open about being HIV positive. The other was a UN-trained AIDS volunteer working at the hospital.

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139 ealer had no local institutional affiliation, though he was a member n ditional rank, was influent from the ers. S. hristian church that a llows traditional practices, such a polygamy, which nglican, and Catholic churches. The final group consisted of educators from local community schools. One was the head of the Communit much of the Health care workers interviewed included a traditional healer and a traditional birth attendant (TBA). The traditional h of the National Association of Herbalis ts. The TBA was a local village woman who had learned her skills through an apprenticeship a nd had not received training in working with HIV/AIDS as part of her work in delivering children. Four men were interviewed who were member s of the traditional village leadership. One held the very senior position of Inkosana or group village headman. A group village headma is one of only a few high-ranking village headmen immediately under the Encosi (chief), the politically recognized and significant traditional hereditary authority for the area. A headman of a smaller local village was also interviewed. This headman, although low in tra ial in the region based on his role as leader of a group of Ngoni warrior dancers often asked to perform at important political and ritu al events. The other two men interviewed were Nduna, or advisors to village headmen, who held more ascribed positions based on respect in the community and seniority. Incidentally, these we re both men who had spent time away community for employment and who had more edu cation and life experience than most villag One of these men had also lost a daughter to HIV/AID To assess the churchs perspective on comm unity AIDS issues, a leader from the C.C.A.P. was interviewed. The C.C.A.P. is the most important social and economic force in the community, by virtue of its long history in the area and its control of key institutions, including schools and the hospital. The C.C.A.P. head, who was also the head of the mission station, rivals the traditional authorities in terms of community infl uence. In contrast to the established C.C.A.P church, also interviewed was the lay minister from the church of Chipangano, a liberal and informally organized C are rejected by the more conservative Presbyterian, A y Secondary Day School, the local government-run secondary school. Another was a head teacher in the Presbyterian-administered primary school. The third individual was a university student from the Embangweni community. The university student was at home for year due to political and budgetary closures at the university, so the student tutored secondary students preparing for their national placement exams. Six of the interviews were conducted in th e local language of Tumbuka. For ten of the interviews, a research assistant helped with th e interview process, taking additional notes and helping with language issues. Thirteen of the inte rviews were taped, and twelve were transcribed with the aid of a research assistant.

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140 and answered all of the questions asked of them. n askepeicy when AIDS first a f c i the lte eghtes (1985(see Table 7-13). Incidentally, thre imentioned 1985 specifically, the year the first official AIDS case was diagnosed in M the iterviewees kew o at least one person who had died from AIDS. Four had l embers, one having lost her husband, one having lost a sister, and two having lost grown childrenT Idfied for Firs t Caof AIDin the Community 4 1985-1989 1990-1994 1995-1999 All individuals talked freely about their communities and HIV/AIDS Whe d s cif all ppeared in the local community hal pla ed ts emergence in nformants a i i 1989) e of these alawi. 6 All of ost close family m n n f able 7-13. Years enti se S 1980-198 1 4 1 2 Overvie ants expressed concern over the impact of AIDS on their communities. Bey ults to contribute to household farming. A sequence of events was outlined i least two village headmen agreed that AIDS was a problem in the area, requiring additional t neith er knew of actual infections occurring in their villages w of the Key Informant Interviews All sixteen of the inform ond concern for loss of life, many were cognizant of potential economic and developmental effects of the AIDS virus on Mala wi and their community. Several felt that the current famine condition in the country, while exacerbated by government mismanagement, had direct links to the loss of ad n families losing an adult to AIDS; after th e loss, particularly when it is the mother that has died, children are sent to live with othe r relatives, placing a burden on other families. Those interviewed appeared to downplay th e effects of AIDS on their communities. At resources in order to prevent further loss, bu Instead, they suggested that it was occurring among the people in the surrounding communities. 6 This date is a highly publicized date for the firs t AIDS case in Malawi. There is some question as to whether the first local case in Embangweni was dia gnosed at that time. However, th individuals at that time who exhibited common AIDS-related illnesses and whose il ere were some lness is now retrospectively attributed to HIV/AIDS.

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141 t, because of the dissohe traditio ructure in ren were seeg freer fro fal oblig and likely en to th parents or the advice of their eld. In two erviewsis sentim grounded in discussion of the physical order of housing, as the traditional impalastem, where children ohe same a together and took meals tutelagrom the e had ed to me nuclear households, w fathers mothers, as the h eads of families, raising their own children. The ila systradualaned sta g around0, thoug neighboring comunity s reported to still be ganized around the traditional structure. It was elieved that in the old system there was a greater awareness of others activities, particularly the children t, other or father they just m heir marriage partners chosen for them. Rather, they hat can be done to help prevent AIDS in their community, few could offer co ews. l suggested that, in fact, condoms might be cont ributing to the AIDS problem, encouraging the be sustainable. Three members vo condo ms could play in r them in certain circumstans sex outside of ones regular partner. ren ne owhen aout condoms, would have wanted his child t if it would have saved his life. The other gentleman, when asked the same question, contin ued to be opposed to the promotion of condoms, Some of the older interviewees suggested th at AIDS existed, in par lution of t nal family st villages. Child n as bein m milia ation ess l to list e di rections of their ers int th ent was sy f t g e-set lived in huts and e f lde rs in the village, yield or ith and mpa em g ly w r tin 195 h one village in a m wa or b s, and that there was adequate superv ision and guidance in rearing of children and adolescents by multiple adults. In the new system, for example, children are likely to skip family meals to be with friends in unsupervised situati ons. As one member of the TA said, In the pas we used to stay together as a group, teaching our children the better way of life, but now each family should teach his children, and now if t hose children have got no grandm ove anyhow. Others suggested that western media and its values were contributing to a situation that makes young people vulnerable to AIDS. Youth are exposed to movies and television (people with satellite dishes can get South African progr amming, which is similar to programming found in the United States and Western Europe) and are adopting new patterns of behavior. In particular, more young people are unwilling to have t want to be able to choose their pa rtner, which entails a courtship process that can lead to increased sexual activity. When asked about w mmunity-specific ideas, and most only sugg ested that more effort could be made to educate people about AIDS. The subject of condoms was brought up in eleven of the intervi Of these people, nine were opposed to condoms as a strategy for preventing HIV/AIDS. Severa initiation of sex among the young by promising a safety that would ultimately not iced recognition of the role ces, such a prevention, seeing a role fo Of those interviewed, two had lost child to AIDS. O f those two, sked ab o use them

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142 g they wee heart of oblem. Oividual challenged the effectiveness of condoms, suggesting there were tiny holes in them that could be seen with a thus rendering less than 100% effective. These items, while varying in scope, do not surprise. From the participant f activ the comm, it is k nown that these are all concepts well covered in community AIDS programs. The role of poverty is aderscored in many of the AIDS s conducted y and propagated, as almost a slogan, in more public awareness campaigns. Orphans are an undeniable remmunities, and prevention efforts n teaching about routes of transmission and the virtues of knowing tements. ed in Informants contendin re at th the pr nly one ind microscope co me as a observation o ities in unity theme un program by NGOs in the countr ality in co have focused on education, ofte your status. Identification of the Doma in of Social Causes In analyzing the interviews, a central concer n was identifying social factors contributing to the current AIDS situations in the community Interview transcripts and notes were reviewed and coded for instances where particular social f actors were suggested in interview sta In all, twenty-five different social factors we re coded. Many of the factors identified by informants shared a relationship; however, each was coded in terms of specific language us describing the factor. The most a single factor was identified was ten times. On average, the individuals identified six factors. The comple te list of factors and their occurrences by interviewee can be found in table Appendix G. Table 7-14 provides the top five social factors mentioned by key informants. Table 7-14. Five Most Frequently Listed Social Factors Contributing to AIDS Problems Related HIV/A to IDS 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 Total Poverty or Lack of Money 10 Insufficient Knowledge or Understanding of AIDS 7 O rphans 7 Sharing Needles or Razor Blades 6 People Not Knowineir HIV S/Not Getting g Th tatus Tested 6

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143 mentioned by the informants were Insuffic Knowlederstanding of AIS and Orphan accounti% of all factors listed. ere appe lustering of ites in terms of the individuals occupational affiliation, with the exception of greater concern for the role ofdles and g people working in h gender does not dem ular clustering in term of concerns. ddition ing the domain items to be used ihe cultur ysis, the responses were themnalyzed. Appendix H provides a detailed discussion of themes identified among social causes of HIV/AIDS bhe responden Measuring Consensus Among Participants The top three factors Poverty or Lack of Money ient dge or Un D s ng for 25 Th ars to be no c m nee razor sharing amon ealth care. Similarly onstrate any partic In a to identify n t al domain anal atically a y t ts. re nd after the intervention, the results of the individu al card-sorting tasks were averaged across each ue. Table 7-15 presents the top three and bottom three aggregate rankings from the preand post-surveys. Table 7-15. Average Ranking Top and Bottom Items by Community Group ter Jere Takumanapo Kab In addressing consensus among the participants both before and after the intervention workshops, multivariate analysis was conducted on the structured data collected in the form of rankings. First to examine are the raw rankings produced by the workshop participants, both befo and after the intervention activities. To obtain an average ranking for each group both before a item and then reordered from 1 to 16, based on th eir average val Kakoma Fos ira Pre Post Pre Post Pre Post Pre Post 1 1 1 1 5 1 1 1 5 16 6 2 9 5 8 16 10 5 10 3 14 10 14 10 3 2 12 6 13 12 3 12 12 11 11 12 4 16 6 6 4 4 4 4 6 4 4 4

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144 gh and low in the rankings. From the rankings, one sees that item 1, Men and women are noto that they know their AIDS status, was consistently ranked in terms of seriousness. Inv ants consly ranked item eople who pracmagic and witct are g AIDS, low in tf seriousness roblem in com rankings is th tend to be md in the middle. In he extremes, st important important issu their communitople eli ngsnions and can make more definite kely to shift these views. Toward the middle, we might expect people to have more difficulty in making distin ctions, and the ranking becomes less clear and less amenable to s in terms of a ement. Table 7orkshop Consensus Measures Post-Workshop Consensus Measures The highlighted boxes indicate items that were consistently ranked hi tested s high by informants ersely, inform istent 4, P tice hcraf spreadin erms o A p paring at they uddle considering t the mo or least e in y, pe are more likely to be clear about their fe or opi distinctions. People are also less li visual interpretation. Consensus analysis, however, provides an anal ytical device for studying such difference by looking at overall patterns of agreement and summarizing their relationship single factor for agre To determine consensus, a multivariate da ta-reduction technique, as described in the chapter on methods, was applied to the preand post-intervention ranking data. Table 7-16 indicates the ratio of eigenvalues for the preand post-rankings in the four workshop groups. 16. Ratio of Eigenvalue in the Preand PostWorkshop Consensus Analysis Pre-W Community Eigenvalue Ratio Mean Competency Direction of Change Eigenvalue Ratio Mean Competency Kakoma 2.089 .382 Decreased 1.746 .322 Foster Jere 1.344 .110 Increased 1.477 .373 Takumanapo 1.719 .267 Increased 5.699 .607 Kabira 1.842 .365 Increased 3.713 .638 In the first two workshop groups, in Kakoma and Foster Jere, consensus was not found in either the preor post-rankings of domain items. In fact, in the first community, Kakoma, there is

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145 n indication that level of agreement actually d ecreased slightly after the workshop. This would uggest that the informants did not view items elicited on AIDS concerns in the community as a oherent domain in terms of organizing th em along some continuum of seriousness. If we look at ranking there was greeme his cessful in increasing agreement among informants by creating some shared model for organizing th e domain items. Takumanapo shows the greatest its post-ranking task. For both the groups, with an ce te rankings for the two communities that achieve that there are man Appendix E fTable 7Takumana Post Items Kabira Post Items a s c the last two community groups, we find that in the posta nt among the informants. This is evident in the ratio of eigenvalue and in the high positive average competency score for the informants, another condition for consensus. T suggests that the workshops were suc level of change, achieving a factor ratio of 5.6 99 in average cultural competency score of ove r 0.6, the consensus analysis is thought to identify the culturally correct r esponse of 95 percent of ranking items with 95 percent confiden (Romney et al. 1986). Tables 7-17 and 7-18 display the aggrega d consensus in the post-intervention ranking task. Cursory examination shows y similarities between the two communiti es regarding how they ranked the items. (See or a list of the full ranking statements.) 17. Takumanapo Rankings Table 7-18. Kabira Rankings po 1 Test 1 Tes t 5 Sugar Daddy 16 STIs 10 Condoms Not Used 10 Condoms Not Used 14 Needs 14 Needs 8 Prostitution 8 Prostitution 9 Adultery 9 Adultery 16 STIs 5 Sugar Daddy 13 Married 7 Parents 2 Travel 13 Married 3 Knowledge 15 Drinking 7 Parents 11 Condoms Encourage 11 Condoms Encourage 12 Talk 12 Talk 3 Knowledge 15 Drinking 2 Travel 6 Tradition 6 Tradition 4 Magic 4 Magic

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146 ement among workshop participants on the ranking of comm There is an indication from the paired T-tests conducted as part of the analysis that a significant change occurred in the shared agre unity concerns after having attended the community participatory workshops in the two communities that achieved consensus (see Table 7-19). Foster Jere, a group that did not reach consensus, also experienced a positive increase in competency that approaches significance. Table 7-19. P-Values on the Paired T-Test of Competency Scores Community P-value Kakoma .633 Foster Jere 0.074 Takumanapo 0.018 Kabira 0.024 Shaded boxes signify groups that achieved consensus. Bolded numbers signify a P < .05. Individual competency scores among participants, particularly for individuals with low or negative scores, appear to show that the major ity of those with low scores were males. This prompted us to run consensus analysis again, this time dividing the communities into two groups men and women, for a total of eight preand postgroups. Table 7-20 displ ays the results of this gendered analysis. Table 7-20. Eigenvalue Ratios for Consensus by Genders in Workshop Groups Female Males Eigenvalue Ratio Community Pre Post Pre Post Kakoma 7.606 1.403 .92 1.852 Foster Jere 2.134 1.166 1.139 1.385 Takumanapo 1.847 4.660 Kabira 1.491 2.760 0 1.94 Shaded boxes sig nify a finding of consensus.

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147 From this run, one finds that two con sensuses were only achieved among the females, with strong consensus occurring among the women of Takumanapo after the intervention and strong consensus existing for the women of Kakoma before the intervention. Direct Observation To understand the constru ction of agreement in the community intervention, information was col g chapter on analysis of research lected throughout the intervention in or der to document and analyze the interaction and construction of agreement in the intervention. Ob servational data was collected in the workshops, as the participants engaged in the research ac tivities and created their community dramas. The implications of this data will be discussed in the followin findings.

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148 Chapter EightDiscussion of the Research Results This chapter discusses the results of the resea rch activities and how they relate to the research objectives as outlined in Chapter Four. The structure of this chapter follows the objectives laid out in Chapter Four. Discussion of Program Implementation Findings In meeting the overall objective of the Program Implementation phase of developing a piloting the Drama Dialogue Planning and Production model, a tool for building community capacity f nd or dealing with HIV/AIDS in rura l Malawian communities, the following specific objectiv to mortality and morbidity. Observations of health es were addressed through this research: A1) Learn significant local knowledge for effective program development. A2) Conduct research on HIV/AIDS, while enha ncing participating communitys ability to conduct research, through the use of participatory research techniques. A3) Develop an understanding of the current a pplication of participatory research so as refine and benefit future application. A1) Learn Significant Local Knowledge for Effective Program Development For effective implementation of the pro posed community intervention, a local understandin g of the community AIDS situation was required. Data about the community was derived from participant observation and natural group discussions. Participant observation contributed to an understanding of the commun ity, while natural group discussions were helpful in developing an understanding of how AIDS is affecting the community. In addition, the latter allowed people to share their thoughts about the AI DS situation and related issues. Overall, these methods were used in a recursive process of disc overy in order to develop an understanding of community patterns with regard to AIDS and re lated social domains (Glazer and Strauss 1967). In examining domains of social life, such as households, villages, institutions, public presentations, and government, notes and observations appear to show a disconnect between the reality of HIV/AIDS and the social response to it. In almost all aspects of community and social life, there is a struggle to remain viable despite the direct and indirect results of AIDS faciliti es reveal overburdened staff and insufficient resources to meet the challenges of AIDS. Schools are losing both their students and their

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149 e course r details that mak gram er the derstanding of the phenom A2) Con teachers to AIDS, while increased costs and d ecreased enrollment jeopardize their mission. From the family to the community, prosperity is on th e decline. Nonetheless, there is dogged denial of AIDS. The topic is seen as too unseemly for public address. Its impact is but the inevitabl of suffering shared among African people. It is from this general picture of the AIDS situation and stigma, as well as fine e AIDS so vivid in the mind of the researcher, that design and development of a pro to address AIDS in communities could progress. It is through such research that the research identified the challenges of AIDS in the community, in terms of both its impact and how it is presently being realized in discourse, and app lied this knowledge to critiquing the prevailing dialogue, so as to challenge and promote engage ment through the intervention activities. A benefit of the use of qualitative formative me thods is that they helped to evaluate relevance of the literature on HIV in communities in sub-Saharan Africa and its applicability to the current research setting, particularly with re gard to attitudes and stigmas associated with HIV/AIDS. One found a discomfiting familiarity between peoples comments and literature by Schoepf (1991), Campbell (1997), Craddock (20 00), and Kesby (2000), as reticence to discuss AIDS along with gendered attitudes confound a clear community un enon. In conversation, there was a causal dismissal of some of the more critical topics in prevention and care on the grounds that there were clear moral and religious directives on these topics that precluded the need for further discussi on. In the larger community sessions, orphans issues became the only topic safe for di scussion when considering AIDS. duct Research on HIV/AIDS, While Enha ncing Participating Co mmunitys Ability to Conduct Research, Through the Use of Participatory Research Techniques. This objective was met through the conduct of the Drama Planning and Production Workshops in the research communities. The worksh ops served to produce community-specific information on HIV/AIDS as evidenced in the products of the research groups. Mapping Community mapping was conducted in only two of the four workshops. While members of the community were able to complete their maps during the first two interventions, the information on the m aps had limited value in terms of drama planning, and the information provided only used by one of the four did not enhance the dramas. As reported in the research results, people seemed to have skills in creating maps. However, from the items located on the maps, the abstract nature of AIDS risk factors may not have translated well to mapping. For instance, l ack of knowledge,

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150 mapping ised e groups, was perhaps the only abstract appli cation of AIDS risk. It might be well-adv to move the mapping activity to a later point in the workshop activities, after members of the workshops have conducted the diagramming activ ities. Had there been more variation in communities or additional issues being addressed, the maps might have provided more help. Further discussion on the use of mapping is provi ded in the next section on increasing knowledg for future applications. Matrix Diagrams A matrix diagram provided a good starting point for generating ideas about AIDS in participants communities. While th e results of diagrams presented little that not previously known about AIDS in communities, the matrix diagrams were helpful in broachin the more general universe of issues to be tackled among the groups. A few idiosync was g ratic items surfaced on each communitys list, such as rape, loss of populati y in l more ge e or AIDS, f s t on of d of HIV/AIDS and other on, and scarcity of hospital resources. N one of these items, however, ranked sufficientl high in a group to suggest anything other than an item uniquely important to an individual with a workshop group. Many of the items listed also a ppeared to be multiple effects of more genera issues. For instance, concepts like Lack of Support, concerning material support for a female single parent, was also likely related to No School Fees Hunger and Poverty all of which often stemmed from the loss of a provider in a family. In looking at the attributes provided for the list of AIDS problems, most, excepting the neral problems of Hunger and Poverty are seen as either new or growing in the community. In looking across the communities, th ere is no clear consensus regarding whether problems are associated with the youth or adult members of communities In one community, th group was asked whether a problem was more a consideration for men or women (see Table 6.10). From the responses, it appears that ma ny of AIDS problems in the community were associated with women. Groups were asked in the diagramming activity to provide a list of biological risks f ollowed by an explanation of each factor and how it pertains to their community. In term of risk factors concerning all members of the community, the three main ones were Sexual Intercourse, Razor Blades, and Injections Across the groups, Sexual Intercourse referred to heterosexual acts of sex involving va ginal penetration. The mention of Razor Blades referred to both the use of razor blades in traditional heali ng practices, where sets of parallel lines are cu the body to relieve sickness, and to certain ritu als around marriage that call for the shaving head and pubic hair on the groom and bride, with the central issue being the use of blades not properly cleaned between uses, promoting the po tential for sprea

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151 bloodbo cut e receives n at it happens e unity, ome part of the discourse on AIDS prevention in the country a or women. In two of the groups, Blood Transfusion was associated with women. The reason g as the goni and Tumbuka male a dornment. Piercing among younger ch the the ith not differ b rne illness. The group did not voice a concer n for unclean razors used by midwives to the umbilical cord, a relevant biological risk. Injections, another concern in transmission, refers to healing practices where on injections for illnesses, often provided by individuals with no formal training in medicine. Whe asking about this practice during the conduct of th e formative research, people indicated th though they were not clear as to when and where. Strangely, it was possible to locate individuals in the community who practiced traditional medicine, but it was not possible to locat individuals practicing injections as part of thei r healing. This is not to say the practice of injections does not occur. A possibility is that th is practice is not very common in the comm though common among other groups found in Malawi Nonetheless, the belief that injections contribute to transmission of AIDS has bec As had been anticipated in this exercise, certain biological mechanisms for AIDS transmission were associated differently between men and women. In particular, the preparation of bodies for burial was a task and risk attributed to women. Other risks associated with women were mother-to-child transmission (MTCT) of HIV. While MTCT risk is not a risk for the mother, the potential for women to transmit HIV to a breast-feeding child was generalized to concern f iven for this association was that women are more likely to receive a transfusion result of anemia occurring during pregnancy. In this case, members saw women as receiving transfusions more often than men. Risks for men included Piercing and Sharing of Bathing Materials/Toothbrushes Piercing involving the stretching of the lower lobe of the ear is common among the older men in the community and is related to traditional N men and women is less common. The shari ng of bathing materials, including use of the same toothbrush, was associated with men more th an women. One possibility is that items su as toothbrushes are considered status or prestige items and are thus somehow associated with male heads of family. Another thought is that the groups were seeking equity in their listings, thus assigning one of the less clear items to the male category. Notable in the organizing of biological risks, beyond those main items shared by both groups, is that men were associated w less obvious risks than women. The performance and information on this diagramming task of biological factors did etween communities, with each commun ity producing very similar lists. One could surmise that these listings correlated directly to some of the AIDS education programs conducted

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152 ile associat in the community by the hospital or Tikoleraneko. A concern with risk factors is the possibility of a group overlooking a biological mechanism of risk, based on a gendered association of that risk However, from the lists produced, there did not a ppear to be a major risk factor that was associated uniquely with men or women. The ri sks associated with blood transfusion, wh ed more with women, does not lend it self to remedy at the community level. Flow Diagrams As a first step in completing flow diagrams, a list of social factors contributing to the spread of AIDS in the co mmunity was created with the workshop grou (Table 6.17). The lists produced by the workshop groups were parallels to the community issues generated through the key informant interviews This parallel suggests a saliency in results, particularly for the ranking task conducted as part of the preand post-interve ps ntion evaluation. e flow diagrams, even more important than the attributes displayed among the item e the t oys, Girls, Youth, Orphans, Widows) groups seemed able to take small gr ds and to the c essential inf of as concernd others women, the task was made easier, which eliminated the need to conside community It is conceivable that these risks are inextricably associated with the particular categorical groups p a flow diagr socially constructed categories recognized by the group. Of importance in flow diagramming is in stances when items are grouped together, forming a cluster of items. Like informants conducting unrestrained pile-sorts (Weller 1988), on expects those groups or clusters to share some relationship. In this case, with introduction of categorical cards ( Men, Women, Boys, Girls, Youth, Orphans, Widows ), clusters might share a relationship with that category. In other cases, where no category card was placed, clusters would be open to interpretation or would be assumed to be more general. In viewing the s is the causal arguments expressed in how they are linked. It is important to examin order of factors in the diagrams as they flow into the center node. It is reasonable to think tha those items directly connected to the center are likely proximate causes of AIDS in the community, with links away from the center indicating a more distal relation. In creating the diagrams, the groups usually st ruggled at first with the process, creating various associations between the cards with no clear sets of linkages. With the introduction of the category cards ( Men, Women, B oups of cards and associate them with cat egory cards and then link them to other car enter node of the diagram. It became evident that the category cards provided ormation. By introducing potential attri butes, such that some items could be thought ning men a r other attributes that might confound the process, such as magnitude of the items in the rovided, particularly as they relate to gender. If such is the case, then the task of creating am may have only been possible by considering each risk in relation to the basic

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153 Kak nuanced dia of their diagram Lack of Sup orphans to A suggested adding HIV/AIDS in the diagram, but were not clea e r pact of iginal omen s The exp is or her d ould ster on their diagram concerned Youth Grouped around Youth were the item e only e, oma, the first community to conduct a flow diagram, produced one of the more grams, creating several layers of linka ge between items. To the right side stemming from Widows and Orphans, are two items ( Hunger and Poverty ) leading to port Suggested is an underlying recognition of the vulnerability of widows and IDS. Members of the group r where it should go or how it should be linked. In discussion of this possible addition, th group was not clear on the reason for its inclusion. It was suggested to the group by the researche that if AIDS was a social factor causing vulnera bilities that lead to further infections in the community, it might belong behind Widows and Orphan, the groups experiencing the im AIDS. The group agreed with this suggestion, thoug h it was not clear if this was their or intention for the card. One of the more interesting orderings in the cards was the linking of Men and W with multiple motivation factors. In this groups diagram, contributing to AIDS are individual motivation factors leading both men and women to be unfaithful in their relationships, such a Fondness of Money, Beauty, and Lust However, linking men and women was Lack of Trust, a card added later by the group. This is an intr iguing factor and was explored through discussion. lanation given was that not trusting your pa rtner, whether in marriage or in another form of sustained partnership, leads to individuals ta king on new partners outside the relationship. For instance, if a wife suspects that her husband is seeing another woman, she could seek out her own outside partner as retribution for his cheating. Another possibility was that h retaliatory unfaithfulness would make the spouse or partner jealous, the effect of which woul bring back the partner. However, one must c onsider the potential ramifications a woman c face in cheating on a male partner, including dissolution of the relationship and serious economic disenfranchisement. Keeping this in mind, the idea of Lack of Trust contributing to couples not being faithful became an item explored further in the role-plays and dramas of the groups. An independent clu s Lack of Knowledge and Energy or Drive and Misinformed In fact, these items ar shared with youth on the diagram. This was an instance where the group felt the need to add additional cards in order to fully expl ain the situation. Added was the card on Energy and Driv a quasi-hormonal explanation of the need for young people to express themselves sexually, leading to sexual experimentation, and Misinformed the janus face to Lack of Knowledge concerning possessing knowledge that is not accurate or truthful, such as the idea that one cannot get AIDS when they are young or that condoms are ineffective.

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154 relation to any one of the categori ys have no d g d ustered s side are Satisfied described as inability s faction in relationship was viewed important. Takumanapos diagram was the si mplest of the four groups, offering only four lines of causality and only a few mediating factors. They did not focus as much on cause, simply linking More isolated factors included Not Using a Condom Drunkenness and Not Getting Tested along with Ignorance another item added by members of the group, explained as someone having correct knowledge about AIDS prevention but choosing not to use the knowledge. It was thought by the group that these ite ms lacked clear es in the community and were therefor e relegated to smalle r independent groups. As a modification to the process in the v illage of Foster Jere, instead of using Youth to address factors associated with young people in the community of both genders, the terms Bo and Girls were used as category cards. As previously noted, the terms Boys and Girls correspond to an understanding of a particular age set w ithin the community and are terms used by its members. Significantly, included in these groups are young adults who are out of school and who t married or do not have a family. The diagram created by Foster Jere, while sharing many of the same groupings an causal relationships expressed in Kakomas diagram, offers a much more polarized picture of AIDS risk in the community, with Men and Boys and Women Girls and Widows only sharin one factor. Around Men and Boys, based on their list of social risk factors for AIDS, one finds more items concerning individual risk behaviors such as Drinking, Raping, and Polygamy (a car that is also used to tie toge ther the two cultural practices of Widow Inheritance and Gift of a Sister). The behaviors Gift of a Sister and Raping were associated with men, despite the behaviors posing less personal risk to the man than to the female involved. This was not explored with the workshop participants, but it is an issue worthy of further investigation. Items cl around Women Girls and Widows form the other half of the diagram. Included on thi both vulnerability issues, such as Poverty and Lack of Support, and individual motivation factors, including Wanting Children and Desire. A single factor that both sides of the diagram share is Not Being to fulfill ones needs in terms of re lationships, as well as dissatisfaction with ones current relationship, suggesting a qualitative dime nsion. This is one of only two links to the central node and was created by the group in the pr ocess of building the diagram. It is interesting that the group placed this one ite m so centrally in their model having an individuals psychological motivator as an intermediate link between risk and behavior The placement of behavior before more individual motivators is c ontrary to most psychosocial models for human behavior. Nonetheless, the desire to feel sati

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155 ry ey were told in the spirit of participation they had free rein to a lationship. e expression of need linked to prostitu exchange of e of the card for prostitution Takumanap Kab Associated with Women exchange. F and Visiting eing Faithful as another factor c diagram. Inc e other groups had been associat Wh helped to br findings fro rams, all of the groups identified particular themes concerning risk for AIDS in the worksho in developin ategories used by the grou 1) en) 2) unity, Women Girls Widows Orphans abilities. desire, whether for material items into groups by gendered concerns. When th e group suggested the need for another catego card beyond Men Women and Youth, th dd any card needed. As a result, the catch-all card labeled For Everyone was included allowing them to lump even more items togeth er without considering their re As with the other group, risk for AIDS for Women and Youth was associated with a lack of resources or support leading to prostitution. In this case, th tionis not a literal link but is representa tive of a range of relationships that entail resources for sex, including indirect or delayed exchanges. The us was thought to be simply an economical use of the available cards. Also found on the o diagram is Not Being Faithful, a consideration For Everyone ira, as with Takumanapo, tended to use more linear strings of items. were particular vulnerabilities, such as Poverty and Hunger which then lead to sexual or Men there is a split, as men are associated with behaviors ( Injections Drinking Traditional Healers ) as one path to risk, and with Not B ontributing to risk. Different from other groups, Girls have their own separate node on the luded among their risks is Widow Inheritance, which for th ed with men. ile the Matrix Diagrams had generate d topics for discussion, the Flow Diagram ing these often-disparate topics into focus. In particular, in carrying forward the m the flow diag the community, themes that would ultimatel y be further explored in the drama aspects of ps. The researcher thought the followi ng considerations were particularly important g the drama work (Note: the italicized categories relate directly to c ps on their diagrams): Behaviors identified as contributing to risk for AIDS in the community may be differentially distributed in the community along lines of gender ( Men and Wom age sets ( Boys and Girls ), and social categories ( Widows and Orphans ). See all flow diagrams. For particular categories of people in comm and Youth, risk for AIDS is seen as linked to their unique economic vulner See all flow diagrams. 3) An individuals risk for AIDS can be viewed as stemming from or sharing individuallevel factors or motivators for behaviors. Factors such as

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156 lated particular Kakomas and Foster Jeres flow diagrams. ent an articula and address required, the interventionhe community. In this research, however, they serve as topics for discussi One community. AIDS in the research act activity engendered dialogue and furt Rol items or satisfaction in ones relationships, are thought to lead to risk-taking re to AIDS. See in 4) Interpersonal interactions can contri bute to risk, as evidenced in the case of Lack of Trust in relationships contributing to indivi duals engaging in risk behaviors. See Kakomas flow diagram. As rudimentary in social theory as many of these relationships may be, they pres tion of a community theory for AIDS risk and are the building blocks for thinking about ing behaviors or actions that are putting people at risk for AIDS in the community. If se articulations of theory can be turned into testable hypotheses in terms of s within t onsin building the groups dramas. could argue that these theories or models of AIDS are not products of the Rather, they are the theories propagated as part of the more general discourse of nation and, in turn, adopted by the community. Whether generated through the ivities or merely applied to their own community, the hered consideration of how risk for HIV/AIDS applies to their community. e-plays and Dramas In looking at the the mes in the role-plays used and the dramas produce represented the promise of the family, often at S ies: informative or instructive The informa t trusting a partner d, one of repeated story-telling significance was the ubiquitous role of a young woman of school age falling victim to AIDS. This featured character tending school, a highly valued pursuit in Malawian society. Nonetheless, she is susceptible to the vulnerabilities of both economic need and youthful exuberance. From the appeal of such dramas, both to the players a nd to the audience, it appears that people are cognizant of the loss that AIDS brings to their communities and the troubling rate at which AID is taking the lives of young women in their society. One cannot help but wonder what role gender plays in such castings, as women are too often the subject ofand, by transference, the cause ofAIDS in such stories. Most of the dramas fall into one of two categor tive label applies to those dramas concentra ting on elucidating aspects of AIDS in the community, featuring complex plots that underscore a condition or reality in the community. Some examples of these include Kakomas dramas on Poverty and Not Trusting One Another and Foster Jeres drama on Not Being Faithful Lessons provided are contemplative, with the audience left to consider the role of some of th e more distal causes of AIDS, such as no or not communicating to loved ones about AIDS. Generally, these dramas avoid providing clear direction to the audience in terms of preventing AIDS, instead asking for

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157 rama form was instructive with the medium serving as a vehicle for passing on mess DS, y such as benefits of using a condom or the wisdom S was t eir d. This ommunity, respected women and men, speak up in front ens up the possibility for further d e future consideration of wider community values. These dramas were thought to have better dialogue between characters, using subtle allusions, such as a wifes scolding remarks when she says, You used the soap as well, referring to the fa milys silent profiting from the extramarital relationships of a daughter-in-law (Kakomas drama on Orphans ). The other d ages about AIDS. Demonstrating the capacity of this medium for relaying substantive information, such dramas as Takumanapos Condoms and Kabiras Poverty offered concise messages on HIV/AIDS and risk prevention. Throug h often-mundane plots with regard to AI dramas provided AIDS information to the communit of being tested before marriage. Information was factual and often repeated for emphasis. In both instructive and informative dramas, increasing peoples knowledge on AID one of the goals of conducting interventions. But of greater interest from the researchers perspective, the more advanced goal was to stim ulate a certain reflexiveness in the communities. This was only marginally achieved. Some of the more informative dramas tackled difficult subjects, like needs, desire, and responsibility and their corresponding role in producing AIDS risk, offering a more provocative look at AIDS in the community. Most, however, continued to simply examine individuals and their motivations or misdeeds, offering only an improved varian on the standard themes of deviancy and shame. The true metric for success of the drama pr oduction and presentation was not within th content or the subtle nuances of story but in its ability to address the previously unaddresse researcher suggests that the drama was able to speak openly and publicly to the topic of HIV/AIDS and its more controversial issues, such as the use of condoms, making its presentations successful To have members of a c of their peers and suggest the efficacy of using a condom, or for that matter, discuss any topic on HIV/AIDS openly, may be the greatest benefit of the dramas. Regardless of whether people agree on how rela tionships can contribute to AIDS or on how condoms were represented within the drama, the inclusion of such themes as the everpresent school girl and mixed-gendered dialogue on use of condoms op iscourse. The drama establishes 1) th e presence or availability of such topics for discourse, which then offers 2) potential to sh ape or reshape views among the members of th community, which leads to 3) more enabling envi ronments, and creates 4) the potential for change in health behaviors related to HIV.

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158 A3) Dev n HIV/AIDS and other health care issues. IDS ired to work t ogether to reach some output. of the community were able to engage in communication om the IDS in the 5) ities linked sets of behaviors, ss sensitive topics in public settings. The resulting dramas The h activities, as a whole, affirmed that the community had a unique e elop an Understanding of the Current Applica tion of Participatory Research so as to Refine and Benefit Future Application. In discussing the application of participator y methods in this research, an evaluative approach is taken, with particular out comes attributed to the methods used. The use of participatory research methods e nhanced participating communitys ability to conduct research o 1) Through mapping and diagramming activities, people learned and applied research and analytical skill to understanding AIDS in their communities. 2) Men and women were able to talk across gender about important issues of HIV/A risk, as evidenced in the ac tivities, such as diagramming and role-plays, where men and women were requ Elders and young members on HIV/AIDS. Again, the mix of participants allowed for different age sets fr community to interact in drama-production activities. 4) People participating in the group were able to address complex issues on A community, as evidenced in the resulting flow diagrams. People showed a willingness to confront complex social issues. The relationships developed in the flow diagrams by all of the commun risks, and groups in a community in a way that suggested complex and causal relationships. 6) People were able to addre were probably the best evidence of this, as groups stood in front of their communities and talked about previously undiscussed topics, such as condoms. 7) People examined cultural practices and their role in AIDS transmission. Diagramming activities successfully elicited cultural practices, such as widow inheritance identified in the flow diagra ms, and opened dialogue on their risk. 8) People were able to develop expert know ledge on AIDS in their communities researc understanding of its problems with AIDS. This work advanced knowledge and understanding of HIV/AIDS through the presentation of community dramas. 1) People successfully conducted community mee tings as evidence of the conduct of th research and the presentation of the community drama.

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159 des rmation fforded orphans were modifying s ld be d of refinement. k. With the for sex, most concerns were expressed as matters within households rather t odel While it was suggested to t consideration did n ion ge nerated, with perhaps the exception of the reference to rape and As highlighteprevious objective, th e use of flow diagrams was well suited for moving communities to explore social causality around HIV/AIDS. Flow diagrams, as an People learned leadership skills as they coordinated and executed their drama presentations. 3) People developed and demonstrated presenta tion skills as they used multiple mo of communication (signs, dramas, speeches, prayers, and songs) to share info on HIV/AIDS in the community. It stimulated critical self-awareness and reflection among research participants. People were able to look at social pract ices with an eye toward promoting positive change. Topics such as widow inheritance and the treatment a acknowledged and addressed through speci fic recommendations provided in the dramas. 2) People challenged stereotypical views of HIV/AIDS. By critiquing and dramas based on the feedback of the group in such activities as stop-motion theatre, groups were able to create more accurate representations of the AIDS experience in the community and share these with othe rs. Significantly, gender issues and value were often challenged in the resulting group drams. 3) People experienced working across gender to achieve tasks. This was necessary for completion of the workshop activities. Given these general outcomes of the community workshops, certain techniques shou highlighted either as successes or in nee The mapping exercise was conducted with only the first two of the four intervention communities. While mapping worked as a good introductory exercise by demonstrating the type of hands-on engagement sought in the work shop sessions, the information resulting from the exercise lacked utility. While well suited to iden tify a broad range of environmental risks in a community (African Network on Participatory Approaches 2002), risk-mapping seemed to have less relevance for the more private and hidden be haviors associated with AIDS ris exception of the locations where people meet han within the community. Second, the information obtained from the mapping exercise did not lend itself to use in the planning or presentation aspects of the Drama Planning and Production M he first two groups to use the mapping exercise to locate scenes in their dramas, this ot warrant the more detailed geo-spatial informat other risks emanating from the trade center. d in the

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160 activity e other worksh an be linked, the completed on searchers by a representative from the worksho Parti -diagramming activities and as a group used the this activity seemed to resonate through the tool that will require further consideration for future implementation, were not as productive as the other diagramming methods utilized in the participatory unity programs. The groups, however, referred f ges. village of Kabira proved less productive. s Given the variability in results, the use of force-field diagrams may require further investigation In better understood in Malawian society. required more abstract visualization on beha lf of workshop participants than some of th op activities. However, with explana tion and a little demonstration of how cards c groups were able to complete the task independently. Each workshop community e diagram, which was then explaine d to the re p group. cipants took a particular interest in the flow activity to create something that uniqu ely described the conditions in their community. The group engagement that developed in doing remaining activities and into the drama production. Force-field diagrams, another workshops. In the first two communities, Kakoma and Foster Jere, they were used to stimulate discussions on planning AIDS prevention in the community by offering a way to think about resources for and obstacles to planning comm back to the items listed in their origin al Matrix Diagrams, first stating the AIDS risks they had identified for the community and then resta ting the risks in terms of an action, such that Drinking was a negative and Reducing Drinking was a positive. Missing was any discussion o the social forces in the community, such as village leadership, needed in order to make chan In the final two communities, force-field diag rams were used as a complement to roleplays as a way to consider why people may act as they do in certain social situations. For instance, in discussing a role-play scenario on couples getting tested for HIV, the group was asked to use the force-field diagram method to consider what could encourage people to get tested and what forces might discourage testing. In applying the diagramming method in the cont ext of role-plays, the results were mixed. In Takumanapo, the group was able to produce some useful diagrams in response to the various role-play scenarios posed to the gr oup. A similar application in the Much like the first two communities, the groups reverted to the items from their matrix diagram, expressing them in platitudes and counter-platitudes. The reason for the difference in success between communities in the force-field diagram is not understood. The directions provided to the groups were thought to be similar for each group. into their application and the typ es of questions that can be used successfully addition, the concept of opposing forces possibl y requires a more appropriate metaphor to be

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161 mmunities, Kakoma and Foster Jere, it was noted, however, that the ften able emes for ent to look beyond the obvious to the cause of the cause This refinement of the use of dramas sugg est a potential new use that goes beyond the individu NES d engage th e group, person-to-person, limits the ability of the moder in hindsight, the effort might have benefited from more structured activities critiquing present dramas, such as better use of trickster characters to challenge the assumptions Malawians are familiar with, if not proficient in, the skills required for dramatic and oral presentations. In two of the early co process was resulting in rather stock or stereotypical dialogues, such as the cheating husband trope. In fact, it appeared that group memb ers performing the role-plays were o to take the provided scenarios and alter or meld them with themes or plots from already common AIDS storylines. However, finding that role-plays could be used as a device to bring out the prototypical conversations on AIDS was methodologically adva ntageous. With some improvisation during the workshops, the role-plays became a venue fo r discussion and critique of the common th around AIDS in the community, allowing in some cases for their dismissal as potential themes the groups community dramas. In this revised role, role-plays: 1) Provide the group the opportunity to try a simple drama device dialogue particularly for those who have had little experience with the venue 2) Promote an atmosphere of safety for future development of drama themes 3) Elicit, then allow dismissal of, stock dialogues/themes as ones potentially unimportant to purposeful drama development, suggesting instead the requirem al skills-building goal found in more common tools, such as the STEPPING STO training packages (Welbourn 1995). To consider in future applications is the la nguage of the moderators and the participants. Often workshop activities required providing imme diate feedback to the drama groups to reinforce activities and to push the drama groups to consider different elements of their dramas. Inability to freely communicate with an ator and potentially weakens the interventio n process. Work is needed to train a local moderator with adequate language skills in order to more effectively implement the drama building sessions. From this researchers perspective, the dr amas produced by the workshop groups showed some variation from the more stock themes on AIDS that are common in communities. Nonetheless, there is room for improvement in dr ama production, particularly in defeating some of the common notions about its appropriate use. While the researcher provided a formal lesson on drama production,

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162 of the d ere able to provi s. counterproductive to keeping a group engaged in th e workshop. In this regard, there is a certain rvation or independent rapid assessment techniques d to provide more detail. he potential utility of the essible to members of the se who produced it. This utility, in using it for other express ory workshops, the retention of the workshop r of people reached through the st potential strengths in combining more informative aspects of drama. Drama as a d in Malawi, was greeted with ure program designs. ramas. This is an area for future atte ntion as drama is explored as a tool for AIDS prevention in the village setting. There is a need to consider the congruen ce of the workshop information with other information on AIDS in the community. The products of the research process should be compared with both the literature on AIDS in the African setting and individual observation After making such a comparison, this researcher c oncluded that people in the workshop w de information on AIDS in their commun ity that captured or encapsulated many of the recognized and theorized relationships between communities and AIDS. Whether this is the most efficient means of getting at that information is a difficult question to answer. Certainly one limitation is the l ack of flexibility in exploring emerging issue In the structured workshop format, radica l deviations in activities would likely be benefit to more traditional participant obse where there is freedom to change research focus when necessary an Still, a benefit of participatory research wort h emphasizing is t information gained. The data generated by the workshop group was acc community and had a certain relevancy, simply by virtue of tho however, ultimately depends on the interest th e community has purposes, such as prevention planning. In general, in considering the participat participants, the production for research findings, and the numbe workshops and their community presentations s ugge traditional participatory activities with the creativ e and medium for sharing knowledge in communities, wi dely practice enthusiasm in this research and should be considered in fut Discussion of Process Evaluation Findings The objective of the Process Evaluation was to develo p an understanding of the ying cultural process that drives the interven tion in terms of creating shared knowledge or values regarding HIV/AIDS social causality. Specific objectives include: B1) Develop an understanding of potential variations among the research communities that could influence program activities. B2) Identify the cultural domain of locally re levant social risks for HIV/AIDS in the community. underl

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163 nd after articipation in the community intervention. ls n at mmunities and contributed to an overall understanding of how data collected he ificantly larger area and is, i er a prevent Other measures, such as household incom es, may have contributed to a better understanding of the community in the survey. However, trade-offs had to be made in doing a B3) Determine whether the intervention pro cess has an effect on the consensus of the participants with regard to commun ity AIDS knowledge through comparison of levels of consensus on locally relevant so cial risks for HIV/AIDS before a p B4) Document and analyze the interaction a nd construction of shared community mode as evidenced in the intervention process. The following is discussion of ho w each research objective for the Process Evaluatio phase was met through the research activities. B1) Develop an Understanding of Potential Variations Among the Research Communities th Could Influence Program Activities. The community survey, prior to community interventions, help ed the researcher to better understand the different research co can be compared. Statistical tests performed on the data sh owed few differences among the communities The only statistical differences were in age of community members and in continuous years living in the village. There is no clear explanation for these differences between villages. This may reflect some true population difference, or some bias may have been introduced in the datacollection process. Age and Continuous Years in Village are highly correlated variables. With t age of respondents being significantly higher in Kakoma, this difference may contribute to the difference in Continuous Years in Village As to why age may be different, the only identified difference between Kakoma and the other villages is that it occupies a sign n essence, a group of autonomous villag es. Perhaps by spreading the sampling ov larger population, some bias was introduced in that older people were in some way more likely to be sampled within a household. Another consideration is whether younger people are more likely to move to and live in the villages closer to Embangweni. In looking at AIDS knowledge, none of the variables explored in the survey indicated an unrecognized gap in terms of knowledge in communities. What was learned from the survey is that people have the requisite building blocks for engaging in AIDS prevention activities. They know of the disease AIDS; many have lost friends or family to it; and most think they can it.

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164 quick and dirty survey of the five communities, with information collected only for items that promise collected on personal sexu individuals, and Internal Roard considera tions made asking questions about individuals sexual histories and HIV status inadvisable. With the focus of this research on community-level efforts o at large and in the activities of this might be infected with or at risk for HIV/AIDS. As regrettable as this may be from an ne rcher nsider the ossibility that com yond es. s or con cerns, which participants in the community intervention risk es conducted in d relatively simple recall. Another consideration in conducting the survey was the level of detail of information al histories. Comm unity norms, high percentages of untested eview B f prevention, the researcher avoided focu sing attentionboth in the community researchon efforts to determine which individuals in the community epidemiological standpoint, it was necessary to maintain the researchers status as someo without special or privileged information on AIDS in the community, a necessity if the resea was to conduct the community intervention efforts within a process of mutual discovery. From the data developed on the intervention communities, it is reasonable to co communities to be similar and part of a matched sa mple. This is not to minimize the p munities will have different AIDS concerns and priorities; it simply suggests that be specifics of history and experience, the communiti es share a majority of social variabl B2) Identify the Cultural Domain of Locally Relevant Social Risks for HIV/AIDS in the community. Needed for the Process Evaluation of the community interventions was a list of community-specific AIDS-related issue would in turn rank as part of the con sensus analysis. The data elicited on social factors for AIDS in the community in the key info rmant interviews was suited to this need, and an initial list of thirteen statements was develope d based on the twenty-five responses identified in the key informant interviews. The selection of items to include in the list was not limited to those most often listed by the informants. In fact, to ease the task of ra nking, both highand low -frequency concerns were included in the thirteen statements to be ranked (Statements 1-13). An additional three statements were added to this list (Statements 12, 13, 16) Two of these (Statements 12 and 13) were issu identified through the participant observation pro cess and thought relevant to the activities to be the community intervention. These items concern issues of interpersonal and family communication that community members associated with peoples adoption of AIDS risk behaviors.

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165 t the key in formant interviews or during the participant observa t in the ity. gs were conveyed in each statement. 1. Me and women are not tested so that they know their AIDS status. 2. Men and women go to other towns to work and come back with AIDS. S and avoid risky behavior. 4. People who practice magic and witchcraft are spreading AIDS. 5. Sugar daddies are tempting young girls to have sex for money. 6. Traditional practices, such as the labola (bride payment), are causing the spread of AIDS. 7. Children do not listen to their parents when it comes to relationships and marriage. 8. Men are paying to have sex with women. 9. Both men and women look for partners other than their spouse. 10. Condoms are not being used in preventing AIDS. 11. Condoms are encouraging young people to have sex. 12. Parents do not talk to their children about the dangers of AIDS. 13. Husbands and wives do not talk to each other about HIV. 14. Women and girls are having sex with men to meet their needs. 15. People are going to bottle stores and meeting up with people for sex. 16. People are not being treated for sexually transmitted diseases. Item number 16, the role of STIs in AIDS infections, is a known risk factor for AIDS, bu no one identified it as a concern during tion process. It was included to be used as something of a test variable. Since it was no mentioned by informants, it was thought to lie outside the domain of items known within the community as social factors that cause or cont ribute to AIDS. The item was expected to be ranked low. The inclusion of this factor served as a minor check on the ranking process. Table 8-1 provides a list of the 16 statements developed for the ranking task used Process Evaluation In converting the risk factors to statements, care was taken to provide adequate context within each statement to refer to specific concepts iden tified by the commun The list was translated into Tumbuka and then b ack translated by a person blind to the research task so as to ensure that the appropriate meanin Table 8-1. List of Community AIDS Issues n 3. People do not know enough to prevent AID

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166 s with S Before and After Participation in the Community Interven is of consensus in the workshop groups? With he are not conclusive concerning whether participatory research g he process seen as a way y is ew B3) Determine if the Intervention Process has an Effect on the Consensus of the Participant regard to Community AIDS Know ledge Through Comparison of L evels of Consensus on Locally Relevant Social Risks for HIV/AID tion. So what are the findings from the analys only two of the four communities (Takumanapo and Kabira) demonstrating consensus among t participants, the results of this research activities in communities can lead to increased consensu s on key community issues. Furthermore, there is contradictory evidence regarding the direction in which the workshop activities are driving the consensu s. In the case of the community of Kakoma, this research suggests the possibility of decreasing consensu s among participants as a result of conductin participatory research activities. In developing this research, two suppositions for outcomes were identified, with both supported by reasonable theory. One possibility, perhaps the more accepted one, was that t groups participation in participatory workshops promotes agreement on community concerns and that these types of activities promote a type of agreement for action concerning AIDS in the community. This possibility stems from the assumption that HIV/AIDS is a recent phenomenon in the African setting, one that challenges curre nt group understandings relating to health and sexuality. This is an empty box view of people s cultural knowledge of AIDS, particularly with regard to knowledge of how to socially conceive of and respond to AIDS, with the participatory to fill this void with socially meaningful dialogue. While it seems likely that people working closely to develop and prioritize local knowledge would experience some convergence in te rm of this knowledge, another possibilit that people already share some public representa tion of AIDS, one based on the current public discourse of AIDS in Malawi. The participatory process may then only encourage the reevaluation of this model, with the end result being that the participants develop a diversity of n concerns, particularly in relation to their own st ructural positions in society. Suggested from this possibility is a movement from some shallow, widely shared model to a more individually nuanced model for AIDS, where forms of intracultural variation play a role in resulting agreement.

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167 c tionompetency as established in the consensus analysis of the ranking after the interven ate t sus th oved from the model, consensus remains but is slightly diminished. Likewise, in Kabira, the other group to demonstr ate consensus previously, consensus is no longer achieved with the removal of men. This indicates that the men were part of the process (if not integral to it) of reaching agreement within the groups and suggests that gender may be an important dynamic in how consensus is achieved in other community activities. The opposite was found in Kakoma, where a consensus was found among women in the workshop group before the workshops. After th e workshop, group agreement is significantly diminished and fails to achieve the stated thr eshold for consensus. Arguably, for Kakoma, the In terms of the two hypotheses for this research objective: Hypothesis One : The intervention process will increa se consensus among the participants in terms of community AIDS knowledge on intervention-specifi issues Or Hypothesis Two : The intervention process will not affect consensus among the participants in terms of commun ity AIDS knowledge on interven specific issues there is slightly more evidence suggesting that the first hypoth esis concerning increased consensus among the participants in terms of community AIDS knowledge on intervention specific issues is correct. This is based on the fact that in three of the groups, there were increases in cultural c tion. However, this change was only significant for two of the three groups. For now, the research suggests that increased consensus is a possible outcome from participatory research activities. The fact that consensus was achieved in the last two communities that received the incrementally improved community workshops could indic some form of a learning effect taking place in terms of conducting the group. Given the opportunity to conduct this research on a larger sample of communities where refinements are no made to the intervention during the research pr ocess, that conduct would improve the ability to interpret the results of the research. The findings from conducting the consensus analysis along gender lines are less definitive but offer some provocative hints concer ning the role of gender in the group consen on AIDS items. When divided by gender, consen sus is found among only two of the groups, bo among female participants. In Takumanapos gr oup, which was made up primarily of women, when the men are rem

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168orkshops achieved the opposite effect for their female participants, decreasing their agreement n AIDS concerns in the community. The history and engagement of these communities in prevention activities should be considng male participants, has been the focus of more PHC activities in the past, which, with their re women then men. Kakoma is considered a High Engage been w o ered in light of the gender analysis. Kakoma, which demonstrated high consensus amo fe strong emphasis on child survival, involves mo ment community. Conversely, Takumanapo was considered a Low Engagement community and has received considerably less attention in terms of health promotions, mainly because it has closer proximity to the hospitals services. This suggests that the effects of the workshop in creating consensus, if that is a goal, are significantly greater where there hasless previous work in communities on health. Figure 8-1 provides an overall model of the interaction of consensus, engagement, and gender based on the findings of this research. Figure 8-1. Model of Consensus Interactions Unfortunately, the small sample of men in the Takumanapo group limits the ability to comment on gendered differences in terms of reaching consensus. While there was adequate male representation in the other three groups, consensus started low and improved only marginally, suggesting several possibilities. One is that men have been exposed or engaged much less in the

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169 ill be B4) Document and A h ell, when there are breakthroughs, and when t or failed y so before them. As an example, in the conduct of its role-play observed instances when issues emerged and were discussed, and a solution surfaced, even if it management of health in the family and community and therefore know less and share less knowledge on it. More community involvement ma y be required to get men to reach consensus on community health priorities. With the small number of workshop groups in this research, further research w required to confirm these preliminary findings. nalyze the Interaction and Construction of Shared Community models as Evidenced in the Intervention Process. Other researchers have used observational me thods to document group interactions, wit the purpose of documenting instances where ideas be come reformed within a group dynamic to create a new model shared among the group (Mathews 2000). This researcher used a similar approach to consider how workshop interactions fostered the development of new, shared understandings concerning AIDS in the four research communities. Though not always able to comprehend the dialogue among individuals or between individuals and the group, the researcher was s till able to tease out the subtleties of group processwhen things are going well, when things are not going w here are hindrances. Fu rther, the nuances of spoken language allowed this researcher to get a feeling for when the group coalesced around an idea or activity tonods, shrugs, etc. Research assistants were al so present to fill any void for this researcher during group interaction. Direct observation pr ovided an important window on group activit that within any period of observation one c ould discern the quality of group performance. In Kakoma, both the primary researcher and the assistants agreed that the group put significant energy and commitment into the tasks put s, questions were posed to th e group about AIDS risk in the community. A conversation ensued on how women might ask their husbands to get tested for HIV and what might happen because of asking. One woman in the group voiced a concern that such asking would amount to accusations, causing retaliation, sometimes physically. The other women chimed in, saying this was a concern. The men, wh en confronted with this concern, begrudgingly acknowledged that the women were probably right. The women were able to adopt a level of ownership over the problem, evidenced by the continued inclusion of this topic in drama activities. This was just one of many was not always to everyones liking. Perhaps the one enduring theme that groups worked through in their own dynamic way was the role of condom use in the prevention of HIV/AIDS. Navigating the difficulties of

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170 s, and in the groups. Foster Jere, the second research community, had a m to ed women labeled a road as a location where r on ly, documenting and understanding the c onstruction of knowledge is an important activity s discussing religious beliefs, cultural assumptions a bout what kinds of persons used condom the overarching desire to prevent HIVs spr ead caused interesting dialogue, discussion, and sometimes dispute. Invariably, and to the researchers surprise, groups worked the condom issue with respect for differences and, without fa il, used condoms and the role of prevention as thematic material for sub sequent developed dramas. Among the groups from the various communities, Kakoma members appeared more willing to confront issues that arose ore divisive experience, with a few of the more senior men in the group sometimes dismissing the products of the groups work. Takum anapo, on the other hand, often appeared offer only the minimum level of engagement re quired for activities, letting some of the more contentious items pass without comment. In Kabira, the conversations resembled those in Kakoma, with the group willing to work through i ssues as part of its participation in the research activities. There was only one instance when there a ppeared to be a breakdown on agreement bas on research activities. On the mapping exercise in Kakoma, apes occur. When asked more about this label, it was learned that the women in the group advocated that the label be added to the ma p. When asked if such rapes were a comm occurrence, there was some pullin g back by the women, who said it is something that could happen. This change occurred after more conversation on the matter, which included men from the community. It is not clear if this change re flected a more accurate description of rape in the community or was a response to the dialogue that developed within the group. Final in understanding participatory research. However, this endeavor was obstructed by language barriers and the speed with which inter actions can occur in group activities. A more concerted effort, with complete recording and tran slation, is needed in order to understand thi dimension in depth.

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171 tations, and Suggestions for Future Research Chapter NineConclusions, Limi Culture, Consensus, and Community Change Community-based participatory efforts offer potential benefits when engaging communities in the preventi on of HIV/AIDS. Howeve r, a concern with such programming is that particip f through such activities. This is p g participatory research, or any health planning or policy p atory efforts are being propagated too quickly and implemented uncritically. Arguably, the use of participatory methods has grown faster than the understanding of their utility, particularly in terms of empirically investigating the small-group process that forms the core o most participatory interventions. Less research h as gone into understanding the micro-structural changes promoted through the use of small-group process (Beeker et al. 1998). Too often, users of participatory methods say that one of thei r aims in using such methods is to empower participants, but they lack an understanding of th e actual changes fostered articularly true in developing-worl d settings, where such methods are used without technical and programming resources and serve as stand-alone interventions for communities. 7 The use of consensus theory in evaluating the dynamic cultural process that is envisioned in participatory research is novel and lacks compar able literature from other research settings. Inherent to the goals of implementin rocess where multiple constituents are i nvolved, are efforts to form agreement among community members regarding problems and pr iorities, with the goal of mobilizing those involved around these priorities. While seldom stated as an objective in participatory research, there is ample discussion of agreement as one of the outcomes sought in its conduct (Park 1993; Cornwall and Jewkes 1995; Kesby 2000; de Koning and Martian 1996). Lasker et al. (2001), Naylor et al. (2002), and Van Gilst (1997) have suggested that one of the critical elements of evaluating participatory research activities is wh ether participants can reach a consensus on 7 This author would argue that participatory research conducted in developi ng-world settings should be distingui alth bers of a shed from the type conducted in Western nations through the discipline of public health. In the Western setting, there is more emphasis on the partnering aspects in identifying and meeting the he needs of communities, often matching the scientific reso urce of health professionals with lay mem community. In the village setting of Malawi, and in many developing settings, participatory research can serve as an intervention and a communicative strategy as well as a means for developing basic information in lieu of other resources not generally available. This distinction is not meant as a definitive typology and needs refinement. However, it underscores the variation in the application of participatory research in different settings.

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172 hether f agreement that results from such collabor process a context of application. It is this dimension of creating agreement for action through participatory methods that has been critically investigated in this research. Res ural domain of locally relevant social risks th arch e cultu ral competency of the group with regard to the domain under investig ul engagement or more ge neral engagement in public health activities, have developed a h d project goals and activities. However, no empirical research has been done to address w participatory research methods lead to increased agreement on issues important to their intended focus. As indicated in the literature review, some studies have examined the quality of partnerships, but none have looked at the qua ntity o ation in the research process. This dissertation helps to fill that void. In looking at knowledge production in pa rticipatory research, examples such as Cornwalls (1994, in de Koning) work on c ontraceptive use among women show how the of participatory research is used to mediate unde rstandings of the body in order to effectively promote contraception use. Reinforced in this u se of participatory research is the possibility of constructing local knowledge formed in earch activities were designed and conducted to determine whether participatory activities related to the drama intervention prom oted increased agreement or shared values among community members concerning problems and priorities related to HIV/AIDS in the their communities. In particular, this research addressed the cult at contribute to the spr ead of HIV/AIDS in communities. Preand post-measures of consensus were taken from groups of participatory rese workshop participants on the significance of social risk factors for HIV/AIDS in their communities. The results suggest improvement in consensus, with two out of four showing significant change in th ation. This suggests that the process of conducting participatory research may have potential for creating knowledge for action in communities as activities foster agreement and develop community-specific knowledge. Gender played a strong role in achieving consensus in this research. On one level, this suggests the need for understanding how gendere d communication may promote or inhibit the promotion of agreement within groups. More impor tant, the finding that gender is significant in the research communities hints at the differential access to or sharing of community knowledge. Women, through purposef more defined domain for cons idering AIDS-related issues. A future researc question includes looking at gendered roles in gene ral health promotion activities and levels of consensus. A provocative finding from researching consensus showed women in one community having significantly decreased consensus on the ra nking task as a result of participation in the participatory workshop. To consider is whether such activities function counter to their intende

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173 tanding. Refining this finding through further r d in or d alues and orientat issues of HIV/AIDS. But further, consens to exist around HIV/AIDS in communities and tend to impair or ent. One need only look to the ethnographic record of this and similar African societies to find evidence of how cultural conventions, such as the role of uncles in providing its bers, as a whole, seems to hold great promise for support and compassion as it assumes the burdens of those sick and orphaned by HIV/AIDS. Change remains purpose in circumstances where there is alread y tacit agreement, assuming that one of the purposes of their application is to increase shar ed unders esearch could prove important to deve loping a better understanding of those for whom it is appropriate to employ similar participatory t echniques. While this contradictory result foun one community may confound the reporting of findings, it serves as an indicator that the methodology used was reasonable and detected changes in consensus and that the methodology holds promise for future research. So what does the research suggest in terms of theory? If we are to understand practices or patterns that contribute to HIV/AIDS infections we must consider the ways in which people conceive of or think about such practices, pa rticularly in terms of shared understanding meaning. To those with a cognitive orientation, these shared meanings or patterns of thinking an cognitionshaped conjointly by human experience and group ethos in terms of goals, v ionare labeled as culture. In addr essing AIDS, we must be prepared to address discourse on it, whether in takes place in the form of knowledge, stigma, or blame, all factors currently influencing the course of AIDS in communities. Further, we must link these shared meanings, in the form of discourse, to actions and behaviors within communities. This research employed the concept of consensus in understanding community knowledge and agreement on us is hypothesized here as a discrete element in a process of cultural changesomething achieved in communities through the intervention ac tivities that allows participants to ask, What is the suzgo? What are the issues? as their cultu res version of findi ng truth and developing knowledge. Change is achieved when cultural models or schemata act as potential shared task solutions that are used by groups to negotiate social dilemmas or contradictions. In this research, such schemata are believed paralyze social engagem guidance to male children, the barri ers between parents and children in discussing matters of sexuality, and the denial of a female sexuality in the face of a permissive male sexuality contribute to the obfuscation of practical discourse on HIV/AIDS (Caldwell et al 1989, Schoepf 1991, and Ulin1992). Nonetheless, th ere are cultural strengths that should not be ignored in the effort to prevent the further delete rious effects of HIV/AIDS. The family with individually constrained mem

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174 a questi d to an ethnographic approach whereby one can see how individual actions fit into and ey worked through and negotiated a new, shared discourse on AIDS. s finding that consensu s can be influenced through participatory research activities, future applications of cognitive theory on cultural models or schemata in understandin of recent cultu ral theory holding that members of communities, even in small-scale, rural societies, may occupy varying social positions within the soci y cross-cut by divergent social experiences. From th s of knowled with the This domain of research bears the potential to further impro widespr ored in this r n efforts a on comm If so, which consensus conditions pr the outc such c onclusions, since collecting outcome data for evaluation purposes was beyond the scope of this change we ar and a variety area. Given the intensive work required to ev promotion, if achieve conse community efforts. Now that consensus-achieving methods are in place, their utility needs to be on of identifying and tapping into tho se strengths and aligning them with motivational forces of culture that seek solu tion to a societys most pressing problems. Again, this is a strength afforde are part of a larger social whole. Community interventions such as those conducted in this research act as catalysts for community change. Simply stated, the practice of drama planning and production increased consensus among participants in the community as th Given this research g community-level change may lead to refinement of our understanding of how groups use cultural models. In particular, establis hing a shared cultural understanding of AIDS is relevant to prevention efforts, pa rticularly in light ety and are potentiall is researchers perspective, it is w ithin these potentially contradictory system ge that change must take place and new mode ls of thinking must be negotiated in dealing dilemma of HIV/AIDS in the African se tting. ve community problem-solving a nd engagement in ways allowing us to address ead and cross-cutting social issues. Ultimately, levels of consensus or distributio n of local or community knowledge expl esearch will need to be linked to outcome s, both in the form of discrete AIDS preventio s well as the long-term contributions to the health of a community. Is higher consensus unity health issues beneficial to prom oting health-improving activities in communities? ovide the great est benefits? This researcher did not address ome measures necessary to form dissertation research. Further, the type of e discussing is often slow and system atic, requiring both longitudinal data collection of methods to detect subtle changes in a community. Challenges to measuring outcomes should not discourage us from future work in this aluate community-directed efforts in health consensus were found to play a positive role in changing communities, methods to nsus could serve as an important medi ating or intermediate variable in evaluating

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175 evaluated throu underst in evalu Naylor Future r ensus on related f health and com determi of agree Engagement, Participation, and Dram gh future research. This resea rch also suggests a new empirical tool for anding the participatory process, one that is independent of subjective measures or scales ating participatory collaborations, unlik e methods suggested by Lasker et al. (2001), (2002), and Kelly and Vlaenderen (1995). esearch should include more communities and multiple measures of cons health domains in order to provide a more accurate picture of agreement in terms o munity knowledge. Further, repeated m easures of consensus need to be made to ne how stable such changes in community agreement are. Most important, these measures ment need to be linked to both shortand long-term measures of health in communities. a Much discussion has gone into understanding the various methods used in the atory workshops, including discussion on utility and improvement. There is still a need to nt on the success in meeting the overall rese arch goal of building community capacity HIV/AIDS in ru ral Malawian communities. This assessment of community capacity would be further informed by additional outcom n comm unities have been sustained and particip comme for dealing with e measures evaluating how efforts begun i whether meaningful community to this research prevention activities. In the first workshop com the work. Thi leaving Malawi, Kako would serve as an under-five nursery 2004, it was reported that t its efforts, having built the building from bricks they burned and community their community. In Chim intervention, and taking co and even py ial effects. A recent drama recorded by the group features an ARMY AGAINST AIDS, uniformed m spread of AIDS. In additi change has resulted. For now, there is only anecdotal evidence attesting s success in engaging and increasing communities capacity to engage in AIDS munity, Kakoma, the group focused on several orphan issues in s remains the focu s of the group, as it has continued to meet. At the time of my ma had developed a plan for building a community health shelter that also during the day to help support families with orphans. In he group is continuing with having raised funds to buy materials for a roof. The group and its appear to be on the way to achievi ng their own objectives in dealing with AIDS in ponya, another community that r eceived the drama dialogue and planning a drama group has become a driving force in the community, performing regularly mmunity drama production to new levels, including the use of costuming, props, rotechnic spec ilitia in search of solutions to fight circumstances that promote the on, the village head men has mobilized the community in building a

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176 meetin me copse o name ba cherished property and remain respected symbo of the K erceived importance of th energy t fuzzy b attribute rudimen scientists versed in th e literature on epidemiology, medicine, geography, and social theor As to the use of drama, it worked as an organizing rationale for the workshops and rought the workshops and their findings to the attention of the larger community. Because the research used a familiar communication vehicle indigenous to the region, there were no difficulties recruiting people to participate. Howe ver, the very familiarity of drama sometimes made it difficult to get group members to fully explore drama as a narrative device without any preconceived notions in terms of plots and characters. In Kesbys article on the use of particip atory diagramming to increase communication on AIDS (2000), there is an explicit call for research that not only helps us learn about AIDS in the context of communities, but that engages communiti es in processes of change, even if this is only discussion. This research has attempted to live up to that call, providing a process for research and the dissemination of findings on AIDS in the A frican setting. As more researchers engage in similar activities, it will hopefully be possible to build and expand on the techniques and process to improve such research. Summary g place for health meetings and drama production, a brick structure now under the sa f trees originally provi ding shade to their stage. In all the groups, participants responded enthusiastically to the intervention. Even now, dges and t-shirts provided to participan ts in 2002 are ls of leadership and volunteeris m in the community. In one instance, a member abira drama group was called to the scene of an accident to assist, based on the p e role of AIDS educator in the community. It is hard to quantify the level of hat came out of these small groups, as well as the sense of empowermentthat somewhat yproduct of participationthat members took away. Much of this empowerment is d to the shared knowledge that group members hold. While this knowledge is tary to social y, there is a genuine sense of discovery among those who participated. b Understanding consensus in relation to commun ity-directed action holds promise in terms of providing theory for understanding sma ll-group processes and for serving as a mediating variable in understanding commun ity change. This research has de monstrated that consensus can be used in conjunction with eval uating participatory research activities. However, further research is needed to link levels of consensus with the long-term outcomes or impact of community research activities.

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177 Second, drama combined with participatory r esearch activities can be used to good effect communities, engaging participants and producing knowledge to inform action within ommunities. This research addresses both applied and theoreti cal interests in the field of anthropology done so and in c and contributes to our understanding of AIDS prevention activities in Africa. Significantly, it has through contributing to and empowering others in a world with suzgoproblems issues that, at times, seem without hope or promise. Tribute In writing this dissertation, it has been difficult to share fact without feeling. In tribute to their example t of the senseless death of someone in Embangweni. Let me reassure you ou had the e gnant ne was one of the most ion elped with the administration of the club. s that is why, when it came time to cast rol es calling for a strong personality or a portrayal the roles well, playing them with just the right amount of emotion, not hamming them up could put in front of its audiences. Despite th e fact that local shopping was limited to the the many people who shared their lives with me through dramas and narratives, I will follow by closing with my own story. The Death of Irene Im sure the title of this story has made you think I am about to launch into another accoun that Irene is quite alive and, I presume, well. Irene was one of the Tikoleraneko Yout h Club members. In fact, if y chance to see one of the Tikoleraneko Youth Clubs drama performances (prior to April 2002) you would surely recall her from such memorable performances as Irene th Bitch, Irene the Bar Girl, and Irene th e Inflated Student (she was the pre schoolgirl, for those of you who missed that on e). In addition, Ire active and visible of the young women who took part in Youth Club activities. In addit to her drama activities, she participated in the Tikoleraneko Youth Choir and h Irene had an unusually feisty personality for a young Malawian woman. Perhap of a less-than-virtuous woman, Irene could be counted on to play those parts. She acted like so many of her male counterparts did. Irene was the pretty fa ce that Tikoleraneko secondhand fare in Embangwenis market, she dressed in village chic.

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178 nd then scold me in English for not understanding. I think she did this in part to cover up her Now that you know something about Irene, let me tell you of her recent someone mentioned that Irene had gotten marri ed and would not be participating in the time forward. Their mood was somber, as if we had experienced a recent death. One aize the other hildren. ion in life would only elevate her to membership a meeting, saying it wasnt right for a young married woman to spend time in the and to she could participate in Tiko leraneko activities from now on, because she s said next hurt the most. A gentleman in our group made the comment, th reasons at our s marriage was probably arr anged though her parentssuch marriages are often a very quick affairand that was why I knew so little of it. My guess is that Irene always gave me a hard time for not speaking Tumbuka. Knowing that I would have no clue as to what she was saying, she would ask things first in Tumbuka a own limited English, fearing it might signal her lack of education. departure. As a passing comment at Tikol eranekos second official staff meeting, Youth Club any longer. The first surprise was that she had gotten married. Here was someone I had seen at least a couple of times a week for the last four months, yet I had no idea that she was even being courted, much less considering marriage. The real surprise, however, was how my colleagues referred to her from that person said what a shame it was to lose her dramatic talents. Another confirmed her new state by telling us they had, in fact, alre ady seen her . pounding m day. I, in fact, had a hard time imagining Irene working around the house dressed in a chitinge, the ragged uniform of the laboring women, and wearing the tired look of one who spends her days farming, cooking, and taking care of c Seeing the dour look on peoples faces, I said, Cant she continue to volunteer with Tikoleraneko? Surely her new stat in one of our community committees. I was told that her new husband had already come by once and taken her away from mixed-gender community of Tikoleraneko. Fu rthermore, it was up to her husb decide whether was now responsible for her new household. What wa Not to worry, and said another girl had b een recruited to fill her place in the You Club. Was that all Irene was to us? Labor? Is she not also our friend who for out of her control can no longer be with us ? Is not the attitude that you are expressing about replacing her labor the same one that denies us her vitality and her place table?. Irene

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179 ened the all-too-co mmon submissive role that so many of her the least, she had just been Irene. S till, it appears that the gravity exerted by now that for sure. If e mmunity AIDS group, how are others to negotiate the important to Irene tried for as long as she could to avoid this eventuality. Her bold behavior and bright personality contrav female counterparts displayed in their public interactions. Irene chose instead to express herself in a manner more modern or Western. At tradition, expectation, and need proved too strong even for this young woman. Irene will do all right, shes too feisty not to. But, I cant k in the current social environment the strong est young woman in the community isnt fre to participate in a co issues? How will she deal with a husband who is not always true to her? Not a penny her name? Too many young women are dying. Were they also victims of such gravities?

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194 Appendices

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195 Appendix A: Survey of Community Resources atchment Area Comunity Po Tota Unde One l I. Population of Communities in Emba ngweni Hospital C m No. of Villages Total pulation l rs Tota Under Fives Women 15-49 Chikomeni 9 6 189 31 1076 288 9 Chiwondwe 6 5 71 31 308 200 98 20 498 3657 160 55 548 ni 13 5270 263 36 1212 2979 68 19 685 2212 86 42 504 6 76 184 28 465 3 5 23 148 28 553 6 6 45 89 295 8 76 156 26 695 da 5 14 177 38 684 5 43 195 38 686 10 5 167 48 685 32 91 39 602 115 4164 2,098 4,94 9,462 243 3 Chizimba Dimi 10 9 2 Emazwini 6 Embangwe 9 8 Ephangweni 8 4 Esigodlweni 7 7 Etchiyeni 18 8 Kachenyu Kakoma 16 0 Kalungulu 229 Mbawa 22 2 Mharaun 32 4 St. Francis 25 3 Thoza 317 3 Zulanga 8 25 4 ,0 5

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196 ni Community Village at Total der-Ones Under-Fives Women 15-49 Appendix A: (Continued) II. Population of Villages in the Embangwe Total Popul ion Un Total Champhonya 7 25 80 205 C hibulu 12 536 14 57 5 326 14 36 8 204 6 34 75 11 0 10 8 7 27 74 638 36 1 9 753 24 82 1 po 26 14 04 re 440 17 64 0 168 11 29 32 5,161 195 74 2,6 303 42 120 Foster Jere 23 Kajiunde 14 Kaseka Malizweni 275 44 10 Mlefu 356 68 14 Simon Jere 196 Sinda 00 25 Station 30 Takumana 761 1 2 Trade Cent 23 Zazini 9 00

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Appendix A: (Continued) 197mmittees in that village. The number in the second box is an estimate of how often the committee meets in a four-week period. III. Village Health Committees by Community Village He ommittee d Survival Program raditioBirth tendanBed Net Coittee DrugRevolving Funds Reading Charts in this section: A check in the first box indicates the presence of the co alth C Chil T nal At ts mm C 2 hikomeni 1 1 C 1 1 hiwondwe 1 C 2 1 hizimba 1 D 1 1 1 imi 1 1 E 1 mazwini Ei 2 1 1 mbangwen 1 Ei 1 phangwen 1 1 E 2 sigodlweni 1 E 1 2 tchiyeni 2 K 1 1 achenyu 1 K 2 akoma 1 1 Ku 2 1 alungul M 2 bawa 1 1 M haraunda 2 1 1 S 2 t. Francis 1 1 Thoza 2 1 Zulanga 2 1 1 C 1 hamphonya C 1 hibula F oster Jere 1 Kabira 1 Takumanapo 1 Zazini 2 (continued) Committee Village Health 2

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198 munity (contd.) Area Primary Health Care Committee Traditional Healers ommittee & unityased Development Assistance Appendix A: (Continued) III. Village Health Committees by Com Growth Comm Monitoring C Volunteers B Chikomeni 1 1 Chiwo ndwe 1 1 Chizimba 1 1 1 Dimi 1 1 1 Emazwini 1 Embangweni 1 1 Ephangwe ni 1 1 Esigodlwen i 1 Etchiyeni 1 1 Kachenyu 2 1 Kakoma 1 1 Kalungulu 1 1 Mbawa 1 1 1 Mharau nda 1 1 St. Franci s 1 1 Thoza 1 1 1 Zulanga 1 1

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199 unity Tikoleraneko Committees Appendix A: (Continued) IV. HIV/AIDS Committees by Comm Prevention r-told sio Voluteers oluntary Coun d Te Volunteers Ex Committee Ca Committee ome Ca Comittee of n V an Mothe Chi Transmis n seling sting AIDS ecutive Orphans re H -Based re m Chikomeni Chiwondw e Chizim ba Dimi 1 1 Emazwini 1 1 1 1 1 Embangweni 1 1 Ephangweni Esigodglw eni Etchiyeni 1 1 Kachenya Kakoma Kalungu lu Mbawa Mharaunda St. Francis Thoza Zulanga nya 1 1 Champho Chibula Foster Je re 1 1 1 Kabira 1 1 1 1 Takuma napo Zazini 1 1 1

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200 V. Water, Sanitation, and Deve lopment Committees by Community Shallow Wells Committee Bore Hole Committee Agriculture Development Committee Rural Finance Committee Appendix A: (Continued) Chikomeni 1 Chiwondwe 1 Chizimba 1 Dimi 1 1 Emazwini 1 1 1 1 Embangweni 1 1 1 Ephangweni Esigodlweni 1 Etchiyeni Kachenyu 1 1 Kakoma 1 1 Kalungulu 1 1 Mbawa 1 1 Mharaunda 1 1 St. Francis 1 1 Thoza 1 Zulanga 1 Champhonya 1 1 1 Chibula 1 1 Foster Jere 1 1 Kabira 1 1 Takumanapo 1 Zazini 1

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201 Appendix A: (Continued) mmittees by Community VI. Social Co Traditional Dance Committee Chikomeni Chiwondwe Chizimba Dimi Emazwin i Embangwe ni Ephangweni Esigodlweni Etchiyeni Kachenya Kakoma Kalungulu Mbawa Mharau nda St. Francis 1 Thoza Zulanga Champhonya Chibula Foster Jere 1 Kabira Takum anapo 3 Zazini

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202 Appendix A: (Continued) VII. AIDS Activities by Community Drama Group for Youth Drama Group for Adults Orphan Group Orphan Fund Communit y C Youth A T ounseling Club IDS OTO Club Chikomeni Chiwondwe Chizimba Dimi 2 2 Emazwini 1 1 1 1 Embangweni Ephangweni Esigodlweni 4 Etchiyeni Kachenyu 4 Kakoma 4 Kalungulu 1 Mbawa Mharaunda St. Francis Thoza Zulanga Champhonya Chibula Foster Jere Kabira 1 Takumanapo Zazini Surveys Conducted in June-July, 2002 Conducted by: Caroline Phiri, EHSA Jon Poehlman, M.A.

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203Dialogue Planning and Production for Community AIDS Prevention Appendix B: Drama Drama Dialogue Planning and Production for Community AIDS Prevention Tikoleraneko Community AIDS Resource Centre Box 48, Embangweni, Mzimba District

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204 anual, steps are detailed for con ducting a set of four small-group workshops, with the goal and cultural factors related to the spread of HIV/AIDS in a co DS. The described intervention falls into a growing class of co ements of social life that sometimes place individuals in hods incorporated in this manual are not new and have been used in other settings. This m eed for better village-level participation in prevention activities. Previous program Introduction This manual is intended to assist communities in addressing the social causes of HIV/AIDS. It is designed to utilize participatory research methods in a community actionoriented approach to the prevention of HIV/AIDS It has been written for use in rural Malawian communities, providing tools for community AIDS groups to use in identifying and establishing social objectives for preventing HIV/AIDS. In this m of identifying and addressing social mmunity. In the workshops, participatory community activities are conducted with a cross-section of community members in order to highlight potential social causes of HIV/AIDS. The design of the workshops incorporates drama as an organizing feature and as a means of disseminating the findings from the workshop sessions. Drama, an already popular medium for spreading information about HIV/AIDS, complements oral traditions present in Malawian communities. Theory holds that the use of participator y methods stimulates critical self-awareness and reflection, which can shape future attitudes and behaviors related to HIV/AI mmun ity and contextually directed interventions designed to address HIV/AIDS. In particular, it focuses on mobilizing communities around what have been called causes of the cause, the el positions of risk. Most of the met anua l only attempts to synthesize and build on these methods in order to create a more cohesive interv ention for its current setting. Thanks goes out to the many people who have worked hard to pion eer the field of community participatory work. This manual was developed and piloted in conjunction with Tikoleraneko AIDS Resource Center in the Embangweni community in the Mzimba District of northern Malawi. Formative research identified a n s in the community addressed HIV/AIDS only among targeted or select populations, such as pregnant women and village headmen. With one of the goals of Tikoleraneko being the establishment of village-level structures to support AIDS prevention activities, this program was designed and impl emented to increase community interest and engagement in community-level prevention activities.

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205 search project conducted by a doctoral student in applied anthrop nd Manual Authors: Suzgo Banda Brenda Mahonie C. A. Phiri Jon Poehlman For information, contact: Jon Poehlman Tikoleraneko AIDS Resource Center Embangweni, Mzimba District, Malawi poehlman@helios.acomp.usf.edu This manual is part of a re ology from the University of South Florida in the United States. UNICEF of Malawi a Leesburg Presbyterian Church of the United States have provided funding in support of the development and piloting of the intervention, conducted in cooperation with Tikoleraneko Community AIDS Resource Center and Enviro nmental Health Surveillance Workers from Embangweni Mission Hospital in the Embangweni community.

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206 general rstanding in terms of HIV/AIDS, this program and the social factors that contribute to its sprea ed, le thinking about what can be done shops as its primary activity, working with ten to fifteen m u enerating information and others that are lessons e inf ing y s al and 1. About this Program The following are some questions and answers prepared about this program in order to help you, your community, or your organization d ecide whether this program is right for you. What are the goals of this program? Past survey research on knowledge, attitude and practices (KAPS) in regard to HIV/AIDS in sub-Saharan Africa and Malawi suggests that most people possess a good understanding of HIV/AIDS and its modes of transmission. While no doubt there are both geographic and topical areas where there are gaps in unde considers knowledge of HIV/AIDS as a necessary but not sufficient component in tackling the problems of HIV/AIDS in commun ities. Instead, this programs focus is on understanding what communities know about HIV/AIDS d. If you are looking to provide basic knowledge on HIV/AIDS, this is probably not the program for your community. If your goal, however, is to increase general awareness of the problems related to AIDS in a community and to stimulate thinking on how it can be address this manual may be of use to you. It is d esigned to increase engagement in AIDS issues by examining the elements of social life that some times place individuals in positions of risk whi encouraging communities to work to confront these factors. In short, it is designed for communities struggling to get a grasp on HIV/AIDS and to start people to address it in their communities. What is the design of the intervention? This intervention uses small-group work embers of a commnity. In these work shops, members will participate in a set of activities, some participatory with the objective of g designed to sharormation on AIDS. Pos ited to the group, however, is the overarch task of putting on a community drama or dramas about HIV/AIDS. Members are to use what the have learned or discovered in the workshop to put on a drama for their community that addresse HIV/AIDS. As a final activity, members of the group organize a community presentation that features their drama work. Why drama? The drama, in its common structure, acts as both a form of entertainment and an important means of sharing social and culturally relevant messages. In dealing with matters of sexuality, as is the case with HIV/AIDS, there is often difficulty in discussing person

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207 sometim ition n audiences in thinking about the issues being presented. Who should use this manual? As previously noted, this intervention is designed for communities struggling to get a grasp on HIV/AIDS. Anyone willing to stand-up among their peers and talk about difficult issues can use it effectively. Primarily it is designed for work with village level committees, where two or three individuals, preferably with some prev ious experience in participating in community level trainings, can be identified to be facilitators. Candidates for facilitators may include Village Health Promoters, Health Surveillance Assistance or anyone trained in community work. It may also be useful to solicit support from your commun ity health facility as a resource for any health or medical questions that may come up during the workshops. While ideally the facilitators will come from the community, this is not to say that people from outside the immediate village cannot be used. Again, all that is needed are people willing to talk openly and honestly about HIV/AIDS. What is needed to do the workshops? In designing the activities for the intervention, care was taken so that items required are either generally available or can be made in rural communities. The main requirements are paper and pens, the basic medium used in recording sh ared ideas in groups. Of course, access to other supplies or equipment is an advantage but not at all necessary. Other supplies that may help include: poster paper, cello tape, string, and na metags. A more detailed list of materials is provided later. Participant incentives will depend on what resources, monetary or otherwise, are available to you. Ask other groups in your comm unity what they have done before. However, providing too much in terms of participation incen tives may take away from the participants and communities sense of volunteerism and self-efficacy. One strategy is to provide some food supplies so that community members can pr epare a meal on the days of workshops. es socially taboo subjects. The drama has been found to be both a sensitive and nonintrusive form of communication. In addition, the drama is seen as extension of the oral trad and an important idiom in the African setting. As a participatory method, drama is advocated as a means of affecting change around HIV/AIDS in African communities. The process of drama building is thought to stimulate creative conflict, conflict that is thought to potentially lead to both critical reflection and action i terms of community attitudes and behaviors. In particular, this workshop utilizes an open-ended drama structure as a means of engaging the

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208 The model provided here for the workshops s uggests that four six-hour days will be needed to com m, How long should it take? plete the workshop sessions. In a ddition, the community presentation will take a few hours at a later point. The workshops can be spread out, as you like. Too long of a break between sessions, however, may disturb the continui ty of activities. Ideally, the whole progra including the community presentation of the dramas, should be done in four weeks, with the group meeting once or twice a week in that period.

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209 u think these program goals and program de scription fits your needs, then your first step to implementation is to simply read this manual and familiarize yourself with its activities. The mo familiar you are with the activities describ ed in this manual, the better you will be at facilitating them when the time comes. When possi ble, practice them. When you find a group of people sitting around, ask them to help you with something that you are working on by participating in one of the activities. Furthermor e, identify the others who can be facilitators as early as possible and get them familiar with the manual. Collect your supplies. Make sure that you have all the items that you will need in hand before you start. Having to stop the workshop to get an item that you need interrupts the flow of the workshop and undermines the role of the facilitator. Make contact with professionals that can pr ovide needed expertise or support. Most likely, if you need help it will be from someone in the medical field, like a doctor, clinical officer, or nurse. As a community facilitator, you are not expected to have the answers to every question about HIV/AIDS. But do know to whom you can turn if you need more explanation about a particular medical or scientific question that ar ises. When a question does arise that you or the other facilitators cannot answer, simply be honest with the group and let them know that you cannot answer that question. Let them know that you are curious as well, and that you will try to get the answer for them by the next workshop. Then, use your experts. Most importantly, you need to be confident. Wh ile getting a group of adults to talk about community concerns may be a new role to you, it really is not that hard. Here are a few things that will help you be confident and successful: Be Professional : Being professional includes being prepared ahead of time, being on time, and dressing appropriately for the occasion. Be Courteous : Treating people with respect goes a long way in getting them to cooperate and participate in activities. In th e group activities, you may sometimes come across attitudes or beliefs that seem wrong or conflic t with your own. Remember, however, it is your role as a facilitator to encourage the expression and sharing of ideas and not to quiet those that are disagreeable to you. Likewise, make sure that group members are courteous to each other. Setting ground-rules for respectful communication in the workshop should be discussed when you do your introduction of the program to the group. Foremost, try not to seem like a boss. Being too strong with the group will only serve to suppress th e groups ideas and enthusiasm. Rather, try to always be sincere in listening to what people say and pay attention to what they do. 2. Getting Prepared and Some General Tips for Success If yo re

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210 afraid if things change or run differently than expected. Even e best-planned activities will turnout a little diffe rent from planned. That is the nature of a group. Each group will be different and may need to do things differently based ou set out to o. Also e of the activities are designed to elicit ideas or e community that you are working in. For most activities, there is not one munity will respond to the activity based on their s and concerns. Be Flexible Dont be th w orking with on the make-up of people in the group. Just do your best to accomplish the things y d as the facilitator, you must remember th at som thoughts unique to th single correct way to do the activity. E ach com unique experience

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211 ng Participants mmunities, fihe individuals to participate in the workshop may not be an issue. There is a good chance you will find unity which has formed to address the problems of HIVS. frustrated because they have not known where to start. Getting to gether may be as easy as contacting one of these groups s lace. h ith, do not worry. After all, part in HIV/AIDS issues. s e an importa for a small group who will need to interact and work together, the numb er of participants should not exceed what is reasonable to work with in that format. That means you are probably looking for no more than a total ofp Conversely, if the numbers are too small, the activities will noe you will end up with bee s, there are several st rategies that you can use in finding people to participate. Important, however, is to keep in mind how the selection will serve the community in the lon your concerns is creating a sustained interest in AIDS activities, you might wank re willing to volunteer for the activity. Make an announceme see what kind of response you get. o volunteers can be identified, you may ask institutions, such as churches, develon local traditio nal authorities, like a village headperson, to suggest potetial participants and to approach them about joining the work. c workshop gives you more opportunity to control the make-up of th ge segments or your community, sumen, men, or even more young people, to participate in important community activities. he ind throughout the recruitment process is that you will probabl your village or community. If your goal is to better understand HIV/AIDS in your community, you will be well served by 3. Organizing and Prepari Your next task is to organize the group of workshop participants. In some co ndi ng t /AID a group in your comm Howeve r, such a group may be rela tively inactive and possibly and If t why Fir ant p etting the time and p ere is not an already existing group that you can work w of you are conducting the workshop is to get people engaged t, you should be clear on how ma ny people you are asking to participate. Sinc rt of the activities covered in th e workshops are intended 15 e inter een 10 In r eople for the workshops t b tw sting. So, you probably do not want l ess than 10 people. Ideally 15 participants. cruiting participant g run loo If n pme If one of t to first for those that who a nt or put up signs in your community and t enough t organizations, business or n Re roup. Y as wo ruiting people for the e g ch ou may even use it as an opportunity to encoura T one rule that you should keep in m y learn more and have a better workshop if there is diversity within your participants. Communities are rarely made up of people who thin k or behave alike. Generally there are people of different backgrounds, heritage occupations, and religions in

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212 ma y be easy to go to one church or existing rganization and recruit from it, but will that necessa rily best achieve the goals of the program? having a mix of people from the community. It o Be diverse.

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213 Materials and Requirements ateria For the training,e P oster oe Ream of pla Pens (onefo Large In Bottle Caps If re per Large Index Cards Stapler orkplace: To conduct the workshops, you will need a good meeting place. You many want to have the group help identify this location. It is b est if it can be in the community where you are working, making it easier for people to attend. It is best to avoid locations where local traffic may interrupt or distract the group from its work. Th ere should be adequate workspace so that people can move around and workshop materials can be spread out, if needed. One good wall for hanging paper, while discussions are taking place, is also recommended. 4 M ls: th following is a list of materials that are needed. r Nwspaper print paper (60 X 80 cm) in paper r each participants) k Markers (Three colors, if possible) (50) String Ta pe sources are available, you may want to try to get these items, as well Colored Pa Nametags (These can be made from plain paper and safety pins) T-shirts (For the group to use during their community presentation) W

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214 hing outlines the activities included in each of the workshop sessions: ions/ Set Workshop Calendar 5. Outline of Workshops T e follow oduc Program Introduction Preparat IntrClosing tion:Greeting Da ats tMatrix DiagramWhat Problem Warm-U y One he SLesson: AIDS in the Wo : uzWarm-Up: Le Wh go Greeting and Sign-in Introduce Work PlanNoteboo k, Dramas and Ground Rules ts Shake Hands rld, Africa, Maand Community s are HDS bringing to your community? p: Unraveling HIV/AIDS Listing: Ways HIV/AIDS is transmittedur community? Closing lawi, IV and AI in yo Day Two: Whats the Vyakuyambisnder ka Greeting and Sign-In Warm-up: Statue Acting Lesson: Whos Moving around? A Discussion of AIDS and Ge Cause of the Cause: Social Factors Flow Diagramming Warm-Up: Ntchindi Says Role-Play Dialogue Closing Day Thr Stop-Moti ee: on Theatre Greeting and Sign-In Lesson: Parts of a Drama Drama Building Lekani TheatreMotivation Identification Closing Homework: Refine Dramas Day Four: Planning and Presation n entPlanning and Preparing your Presentation Reviewing Dramas Closing Homework: Plan Your Presentatio Greeting and Sign-in Warm-Up: Coconut Lesson: Who, What, When and Where of Planning While we have recommended the order of activities, every community group will be diffn the eret and may require changes in that order. Remember to be flexible so that you meet both goals of the project and the needs of the participants.

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215 6. Intro Timel ducing the Program to the Participants ine Greeting 00:05 Program Introduction 00:20 Preparations/ Set Workshop Calendar 00:10 Closing 00:05 s for the Program Introduction: Key Point Greet the Group (in many communities this will include a prayer) Give a brief description of the workshop and its goals: This workshop is intended to: help your community group better understand the problems that AIDS is bringing to the community. encourage members of the community to start planning and solving problems relating to HIV/AIDS. share ideas and knowledge with the community at-large, through a community presentation. Explain what participatory means and what it means to the success of the work All members contributing to the work through discussion and participation in activities. All memb ers coming to all the workshopsthe workshops build on previous It is also important to explain what is expected of the participants and what they can expect tation is that peoples participation is truly voluntary, then make group that no allowance will be provided. It is best to handle e See discussions and participating members n eed to have attended the previous workshops to know what has been said and done. Explain the use of drama in the workshop design Drama is entertaining, which makes people interested. Drama is a good way to share information on sensitive subjects. from participating. Each should be prepared to give up the best part of four days for the workshop sessions and a part of another day for the community presentation Let the group know what will be provi ded to them as a part of their participation (whether writing pens ar e theirs to keep, if lunches will be provided as part of the workshop sessions). If your expec it clear to the such issues in the beginning so those questions do not come up at a later tim and disturb your progress. ppendix A for a sample introductory statement. A

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216 Preparations/ Ma Also, knowing names will help the f workshop sessions while losing: Thank ever to working with them at with a praye Set Workshop Calendar ke any preparations for the first workshop: Gather any information you may need about the participants. A sign-in sheet can be useful for gathering needed information. You many want to take this time to cr eate nametags for everyone. This will assist you in facilitating the workshops sessions feel more personal. Go ahead and set a calendar for the first couple o you have the group together. C yone for attending and let the group know that you look forward the first workshop ses sion. (Again, some communities will want to end the meeting r.) T ip: Crea ting a handout for each of the participants, where they can fill in the dates and times of future workp shos, may help with getting your group together and on time on your workshop days. You can als o inclu de other information that may be useful for the group, such as how to contact your or your organization if a probl em arises.

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217 Day One: Whats the Suzgo Workshop Timel 7 ine Greet ing and Sign-in 0:10 Intd a ro nd Ground Rules 0:30 uce Work PlanNotebooks, Dramas Warm -Up: Shaking Hands 0:15 Lesso n: AIDS in the Malawi, Africa, the W 0:40 orld Matri x DiagramWhat problems are HIV and A IDS bringing to your community? 1:00 Break (Lunch or Snack) 0:20 Warm -Up: Unraveling HIV/AIDS 0:15 Listin is transmitted in g: Ways HIV/AIDS your community? 1:00 Closing 0:10 G reeting f essary, ask a e the plan imeline, using a piece of posterPass a sign-in sheet ar d the general overview provide rogram take me strategies for kshops. Distribute notebooks to all participants. Le know that they should use these notebooks to record key points of the workshop lessons and activities. This is a community presentation. Dramas and role-plays are two of the tools the group will use to generate discussion he situations that will be explored through drama. ginning. These will help to insure respectful and orderly work. Emphasis should be placed on respecting the ual The greetings for all workshop sessions can follow this general fo rmat. Welcome your participants and thank themor coming. If nec member of the group to lead a prayer. Outlinof activities fo r the group for the day, as found in the t pap er. ound while doing these preceding activities. Introduce Work PlanNotebooks, Dramas, and Ground Rules Beyon d to the participants in the Introduction of the P time to introduce so learning th at will be used in conducting the wor of the t them good learning aid that can be used later in planning for the about AIDS issues. Assure the group that they need no prior experience in putting on dramas to participate. All that is required is to do ones best to act as real people would act to t Ground Rules for participation should be stated at the be thoughts and ideas of others within the group while letting all members have an eq chance to express themselves. Tip: Setting Out Ground Rules To keep the rules from being too serious an d intimidating, make learning and enacting them fun. 1. Each day the group members should sit next to different people. Have the group adjust their seating as you explain the rule. Coax them to mak e sure that they do not form clusters of males and females. 2. Explain that only one person should speak at a time. Ask if they would like to make use of a signal for when someone would like to speak, such as raising a hand. 3. If it gets too loud or too many people are talking at the same time, create another sign that indicates that the

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218 whole group should quit speaking, such as touching the top of your head. Practice this a few t imes with the group 4. Wh e group, c ongratulate them for their c ontribution. Have a special en people speak or perform in front of th clapnap, or cheer. Example: us the cheer, Wakhoza, Wakhoza, Sure. s 5. rent captain for To keep yourself from having to monitor the groups be havior, have the group nominate a diffe each day to be in charge of the group and acts as its spokesperson. Warm-Up: Objective : T cannot identify them, people with HIV/AIDS are living among us as a part of our families and community. Also, by IV in this activity, this mirrors the percentage of HIV positive people expected in a group of adults of this groups 1. At pe n to s of HI t they are 2. W o not tell the details about the activity. Simply ask the group to sing the song Tipasane Moni and shake hands with one another. You many th g g the hands of pe 3. id up 4. E ea m o Lesso Objective lp communities understand the magnitude of HIV/AIDS S g the group this question: rcentage of people would that mean are HIV/AIDS positive? Inform them: Lets Shake Hands his exercise demonstrates to the group that, even if we selecting two people to act as the unknown carrier s of H size. some point earlier in the session, take two or three members of the group aside (two ople if the group is fifteen or less, three if you have more people participating). Explai them that when this activity takes place, they will be acting as the unknown carrier V. Mark their hands with an X or another sign, and tell them this represents tha the unknown carriers. Tell them not to show their mark to others in the group. hen it is time to do this activity, d want to say that this is simply a fun way to get the group to greet each other. Once again, e group should move around shaking hands with each other as they sing the song. Your oal is to have the people with the marks sh ake hands with some of the members of the roup. Discourage them from forming a formal line where people will shake everyone in the group. Try to keep the handshaking random and limited to just a few ople in the group. After people have stopped moving around, call those with marks on their hands to entify themselves. Ask the ones who shook hands with those with marks to also standand move behind those with the marks. xplain that not knowing who has marks is like not knowing who has AIDS, and that it is sy to come into contact with people with AI DS. Also, explain that the two or three with arks represents the number of adults that we would expect to be HIV positive in a group f this size. n: AIDS in the Malawi, Africa, and World. : In this activity, you will be providing th e group with some facts and trends about HIV/AIDS. The goal is to he issues in their nation, regions, and the worl d. Try not to discourage or scare, but let them know the seriousness of the problem their communities face. tart with Some Facts To start, build on the previous warm-up exercise by askin If two out of fifteen adults have HIV/AIDS in Malawi, what pe

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219 adults, 15-49 years old, in 1999 was 16.4 %. Chances are that the rate is higher now. The AIDS rate may be as high as ople, that ver a million people are most likely infected in Malawi. That in Malawi, on average, 267 people are infected every day and 139 people Ask them what they thin g is done about HIV/AIDS. (You may want to write down their responses). Reassure them: That while it sounds bad, s not infected However, many are a if nothing is done. Let them know that AIDS is a p ss the world? se to orld where number of AIDS case is increasing most rapidly is Asia. you Matrix Da Objective: G H ation of local problems is thought to be a necessary for the development of any future plan of action. The group will be asked to generate a lis t of problems that are found in their community and will be asked to do prio ritizing tasks on the generated lists. 1. Use the following strategy to develop a list of responses to the question, What problems is AIDS bringing to your community? That the estimated AIDS rate among 20% or one out of every five people may be infected That in the entire population of Malawi, 8.8% of its population is estimated to be HIV Positive. With the population believed to be over 10 million pe means o die from AIDS related disease each day. That AIDS is the leading cause of death in adults (15-49), and that 30% of the nations health care budget is spent on HIV/AIDS That the Life Expectancy of Malawians has deceased from 45 years in 1995 to 39 in 1998 due to HIV/AIDS. k will happen in Ma lawi if nothin till around 90% is of the population is t risk of being infected, roblem shared acro Some 36 Million people around the world are infected with HIV/AIDS. The single most affected region of the world is sub-Saharan Africa, with clo 25 million infected people and 13.5 million already dead. The area of the w Living in the part of the world most affected by HIV/AIDS, ask what advice could share with Asia and other parts of the worlds where AIDS is in creasing. gramW ihat problems is AI DS bringing to your community? et community members to think ab out, identify, and prioritize the problems that IV/AIDS has brought to their particular community. The identific Tip: Pair, Share, and Learn This is a simple strategy for generating ideas that can be helpful in encouraging broad participation from your group. Step One: Ask each participants to take out a piece of paper and create as long of list of responses as they can to the question What problems is AIDS bringing to your comm unity? Give the participants at least two minutes to write as many problems or issues as they can. At this time, encourage people to work alone. Step Two: After most of the people have completed their lists, have them turn to the person next to them and compare list items and create a combined list. Step Three: Lastly, take turns with each pair, having them read one item from their list. Ask a member of the group to volunteer to write these items as a list on a sheet of poster paper on the wa ll. Delete duplications and move around the groups until all items have been placed on the sheet.

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220 2. Have the group prioritize their list of responses. To do this, write each response on a card or sheet of paper and spread those responses at random on the floor. To prioritize the s, give each member of the group three bottle-tops. Let all of the participants walk und and place one bottle top on the three cards that they think represent the most ms in their community. unt the bottle tops foh card and rank the cards from most serious If there are ties, letroup members discuss them and decide ost serious t serious on a poster sheet. Have the group osen as the most serious. Have them explain the relationship lem and HIV/AIDS, if necessary. Ask if these are old or new problems, young or old, if the p s are for men or women only, and if these easing or increasing problems. Write their answers behind the items on Saam: item aro serious proble 3. Have the group co to the least serious r eac the g which of the tied items is m 4. Write the three to five items ranked as discuss why these were ch m os between the prob problems for the roble m problems are decr the poster sheet. mple Diagr Bottle Tops C oncern (Out of Fifty) Percentage Hunger Widows 10% literacy 10% Pov Lack of Theft Unw Dring Rape Kills Many People 32% Orphans 32% 12% Il erty 8% Development 8% 6% anted Marriage 6% kin 4% 4% Topics fo on: What problems is HIV/AIDS bringing to Malawi? r Further Discussi AIDS is killing Malawians in their prim e. Development is stopped when up to 25% of the work force is ill or facing impending death. Businesses, s chools, and fa rms do not have enough trai ned people to do the job required. In M alawi, it is estimated that there are already One Million Orphans The education levels in Malawi are dropping. In particul ar, fewer girls will be given the chance to get an educ ation as they take up the slack in social and economic roles in communities Break (Recommended) Warm-Up: Unraveling HIV/AIDS

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221 Objective : Let t importance of working together. 1. Have the members of the group form a circle at about arms length apart. 2. Inst t people acro ow resemble a giant knot. 3. Instruct the group that they now must untangle the knot by working together and without letting go of hands. The outcome s hould be one circle with people hand in is exercise, that HIV/AIDS is a problem that requires unraveling and people working hand in hand. Listing: Ways HIV/AIDS is transmitted in your community? Obj 1. activity by having the group divi de itself into groups of men and women, needs t as possible of ways that AIDS is being transmitted in their community. Give the groups about ten minutes to work on their lists. 2. ster paper into three sections: Men he group have some fun as you conduct this activity that emphasizes the ruct the group to reach across the circle and join hands with two differen ss from them. The circle should n hand (note: some my end up facing out). 4. Explain to the group, while doing th ective: This exercise gives the group a chance to l earn as they share what they know about the modes of transmission of HIV/AIDS. It is a good way to find out where there is common understanding within the group a nd areas where there are misunderstandings or misconceptions about how HIV/AIDS is spread. If this topic is unfamiliar to you, take the time to either read about it or meet with your local medical practitioner to learn more about the modes of transmission. The activity is done with the group divided along gender line, in order to expl ore if there are any differences in their understanding based on gender. Start this explaining that each group needs to work independently. Explain that each group to come up with as long a lis Next, divide a piece of po Women and Both Hang thh ards you. 3. N, eir list. T e on their list. If they b is seet on the wall and have the group turn their attention tow ow go to one of the groups and ask them to read a mode of transmission from th urn to the other group and ask if they have that same mod othdo, write that mode in the both section of the poster paper. If the second group d irst proposed the mode. Repeat this process, taking turns asking each group first. Do this o des 4. ur d that are not correct, try to 5. the re re segregated by gender that would make knowing that eable. 6. Leave the sheet of modes on the wa ll for use in the next activity. oesnot have the same mode, place the mode under the sheet under the group that f until all the modes the groups can identify are listed on the sheet. Your goal here is t list modes that the groups were able to identif y, but also to record if there are mo identified by only men or women. Hopefully an almost exhaustive list has been created. However, if a major mode has been skipped, take time to introduce it to the group and place it separately on yo sheet. Likewise, if there are modes that have been identifie correct this misconception. Lastly, take time to compare the lists gene rated by just the women and men. Ask group why one group versus the other only iden tified certain items. Probe to see if the are certain social activities that a mode more relevant to one group than the other. In some cases, this may not have happened, as both groups may have identified the same items. If this is the case, just congratulate them on all being so equally knowledg

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222 esson: Identify the Main Modes of Transmission bjective: This lesson builds on the previous exercise by establishing the modes of transmission that are most responsible for the spread of HIV. This lesson is to help the group better understand where changes need to take place to prevent HIV/AIDS in their com 1. Start by asking the group what they think is the most common way that HIV/AIDS is being spread in Malawi. Let them know that the most common way that HIV/AIDS is spread is through sexual Intercourse. Ask them if they know what percentage is spread through sexual intercourse. Repeat this questi oning for each of the three major modes of transmission, providing the correct information. Major Modes of ansmission of HIV/AIDS in Malawi L O munity. Tr Sexual Intercourse 88% Mother to-Child 8% Blood-to-Bood 4% l 2. After questioning the modes, ask the group what this means in terms of preventing HIV/AIDS. What mode would they need to address in order to make the greatest impact in stopping HIV/AIDS? Closing The closing for all workshop sessions can follow this general format. Summarize the activities of the day. You may want to get a member of the group to do this. Set Tha the time and date of the next workshop, if not already done. nk the participants for coming If necessary, ask a member of the group to lead a closing prayer.

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223 Day Two: Tiel 8 Whats the Vyakuyambiska Workshop m ine Greeting aS nd ign-in 0:10 Warm-Up:at Diagramm: Lesson: on of A 0:20 0:15 Stue Acting 0:15 ing Causes of the Cause 1:00 Whos moving around? A IDS and gender 0:30 Discussi Break (Lunch or Snack) Warm-Up: Ntchindi says Role-playing Dialogue 1:00 Closing 0:10 Gre Rep Warm-Up Objective: T w p 1. Hav ck to t bringing to the community. the groups that they are to act out a scene using only their bodies and without speaking that depicts one of the problems caused by HIV/AIDS that was listed 3. Le ey are Diagramm Obje 1. U eting and Sign-in eat activities and preparations done on the first day (See page 11). : Silent Acting his warm-up is intended to get people thinking about the lessons from last week hile introducing them to the idea of expressing HIV/AIDS issues through erformance. e the members of the group divide into groups of two or three. Ask them to refer ba heir notes from last week as to some of th e problems that HIV/AIDS is 2. Next, instruct last week. Give the groups a few minutes to work out their scene. t each team take terns acting out their scen e, and let the group guess what problem th depicting. ing: Causes of the Cause ctive : Through listing, identify some of the social factors that are contributing to the spread of HIV/AIDS in their community. The organization of these factors through flow diagramming will increase the groups understanding of factors that may lead to people being put at risk for HIV/AIDS and help in identifying new areas to address in preventing HIV/ AIDS in the community. sing the Pair, Share, and Learn technique introduced in the Matrix Diagramming on the irst day, hav fe the group create responses to the question:

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224 ( than the biological ways that people can get HIV/AIDS.) 2. Having completed the Pair, Share, and Learn Are there ways that people are living that put them at risk for HIV? Or What kinds of things are people doing to put themselves at risk for HIV/AIDS? You may need to explain that what we are looking for is different process, have the group list the entire list of item aper. At the same time, have one of the other facilitators place the list of items on cards or sheets of paper. 3. In add en , Women, Boys, and Girls. It may help to have the gr hold t to pr age. For exam women? 4. Next, place the four category cards on the floor making a square. Give the other cards that list the different ways people are at ri sk for HIV/AIDS to the spokesperson for the d p r categories. fter the cards have been sorted, spread the cards out so that you can see the cards sociated with each category. First, ask if this is an easy or hard task. Why or why not? Look at the different categories and ask why some of the cards are associated with that group, especially if the relationship is not clear. Ask if there are any cards that are particularly hard to categorize. If any of the categories has a lot more or less cards than others, ask the group why. 6. Next, create a card that says, Ways that people are at risk for HIV/AIDS. Take up the cards that have risk factors and again give them to the group. Now, ask them to place them in clusters according to those that are re lated factors. Have them use string or strips of paper to show connections between items. S uggest that all cards need, in some way, to be connected to the center card. Ask it there are cause and effect relationships between some of the items listed or if one item could lead to another. 7. Once the cards have all been linked, hand back the category cards (Men, Women, Girls, and Boys) and ask them how these categories would link into the diagram they have already made. Tell them they are free to move the cards around again if they need to in order to fit in the category cards. 8. After they have finished adding the categor y cards, have the group give you a walking tour of the diagram explaining the relationship betw een cards and clusters of cards. Leave the cards on the floor as a reference in the next activity. s on a piece of poster p ition, have cards made that say M oup define among themselves what is meant by these categories. You can p the card and have the group create a definition for each category. You may wan u ompt the group to consider if there are more to the categories then simply le, are there certain experiences or duti es that make one a man or a p ay. Instruct the group to examine each card and decide which category of people this roblem most concerns. Have them do the sorting until all the cards are in one of the fou 5. A as Questions for the Group:

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225ample Diagram: der bjcts of HIV/AIDS have become S Men Women Lesson: Whos moving around? A Discussion of AIDS and Gen O ective: From the previous activity, some of the gendered aspe clear, as certain risks are associated with certain groups. Now we want to address the gender inequality risks that make up the reality of HIV/AIDS in southern Africa. Using AIDS statistics, encourage the group to discuss some of the gender issues related to HIV/AIDS. Share the Facts First, ask if there is any group/category of people more affected by HIV/AIDS. Most new HIV/AIDS infections are occurring among youth aged 15-24 years. However, the infection rate among girls in this group is four to six times higher. Draw this chart: All New Infections 40% Under 30 60% Over 30 60% Girls 40% Boys 40% Women 60% Men Factors PuttingPeople at Risk For HIV/AIDS Povert y Hun g e r Orphans Wid ows Lack of Trust Beauty and Lust Not Faithful Prostitution Drunkenness I g norance HIV /AIDS Not Getting Tested Youth Lack of Knowledge Ener gy or Drive Misinforme d Lack of Su pp ort Fond of Mon ey Not using a Condom

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226 et them to Break ( arm-Up: Ntchindi Says bjective: Use this game to get the group up and moving around so that they feel active and Rules: Select one volunteer from the group to act as Ntchindi, who will lead this activity. command and does not mention Jump up and down, the group should ignore this command because the name Ntchindi was not given. If one does not follow the rules by either failing to follow Ntchindis name is not given, then they are out. Ntchindi should try to give commands, tricking the Role-Play Dialogue Objective: This activity is intended to use role played scenarios to help further uncover some of the i some of the different social positions held within the community and their relationship to HIV/AIDS risk. This activity is also a fi rst step in getting the group to think about 1. or this activity, think about conversations between people that may be happening in your community that deal with HIV/AIDS, such as a boy and girl consid oms, or brothers talking to their deceased brothers widow about her obligations. Create five or six scenar ach character in the role play by describing who the characters are, what situation they are 2. When time to do this activity, explain to the group that they are going to do some roleplays w e. must act as that person and react as they think a person in that situation would react. For each role-play, select the appropriate number and gender of participants and More females are infected in the 15-29 age group while more men are infected in the above thirty category. Questions for Discussion: What pattern or patterns can be identified from the chart? Why are certain groups (i.e. Girls and Men) at greater risk for getting HIV/AIDS? Why the difference in age between these groups? What can be done to address the high infection rate in these groups? G start thinking about solutions to these issues. Recommended) W O awake. Tell the group that when the leader, Ntchi ndi, says an action in which he or she includes the name Ntchindi, the group should do that action. For example, when the leader says, Ntchindi says clap hands, the group should follow Ntchindis command and clap. However, when the l eader says a the name Ntchindi, the group should not do that action. For example, if the leader says, Ntchindis command when Ntchindis name is given or acting when participants until only one is left. Th e final participant is the winner. ssues that underlie the spread of HIV/AIDS in the community and to recognize some of the elements of a good drama. In getting ready f ering having sex, a married couple ta lking about using cond ios like these for use as role-plays. Using the scenarios, prepare cards for e in, and what their attitude is likely to be. See Appendix B for some examples of role-play scenarios. here members must assume the identity of a particular character in the scen They

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227 ss hen the 3. Let the role-play continue until there is either a resolution to the conversation or when productive. In genera l, however, role-play should not last for hand them their character cards to learn. Th ey should not be given a chance to discu their character or plan their dialogue with the other participants in the role-play. W everyone in the role -play has had a chance to look at their cards, have them start action. the dialogue is no longer more than five minutes. After the role-play is over, have the participants stay in front of the group to discuss their developed scenarios. To help with the discussion, one may want to write the following questions on a sheet of poster paper. Who is each character? What are they doing? Why has this situation developed? What social expectations, traditions, or other factors have influenced this situation? Do you think the actors reached an adequate resolution to the situation? What else could they have done? epeat this process of acting and discussing of each o R f the other developed scenarios. Remember that the processing of what happened is as important as the role-playing. Closing Repeat activities and preparations done on the first day.

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228 ma Building Workshop Timeline 9. Day Three: Dra Greeting and Sign-in 0:10 Warm -Up: Mime a Lie 0:15 Select Drama Topics 0:05 Lesso n: Creating Good Dramas 0:30 Dram B a Story Building 1:00 reak (Lunch or Snack) 0:20 Dram Closin a: Lekani Theatre 2:00 g 0:10 Greetin ys The focus of day three activities is on th e use of drama to present ideas about HIV/AIDS. While participants will be engaged in activities different from the hops p: Mime a Lie ind. 1. Have the group form a circle in the middle of the room. 2. Have one person start this activity by ente ring the circle and miming an action. After miming an action, the person tells the group that he or she is doing any action other than the one he or she is really doing. For exampl e, she might mime riding a bicycle, but when she leaves the circle she says, I am fishing. 3. The person to the right of the person who starte d the activity should then enter the circle and mime the activity that the person who just left the circle lied about doing. When they finish miming, he, likewise, also lies about what activity he was doing and announce some other action in the same manner. 4. The process should continue around the circle. Usually, the group will catch on that one can embarrass their neighbor by announcing an unusually hard or funny activity. You may want to let it go around a couple of times. Select Drama Topics Objective: Select the topics that the group will address in their dramas and divide the group into drama teams. g and Sign-in on previous da Repeat activities and preparations done previous workshops, what was learned in those workshops is critical for creating good dramas. The group needs to use what they have learned so far to inform their dramas, and they may want to refer to their notes from previous works to help guide them in putting together their dramas. Warm-U Objective: This is to get the group moving a nd into an acting frame of m

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229 the id eas generated from last weeks Causes of the Cause Diagramming. This is the activity where the group addressed, Are there ways that people are living that put them at risk for HIV? If possible, place a sheet with the ups diagram or causes on the wall for the group to examine. ave the participants don three or four causes from the list that subrahe number of causes to pick will depend on alle w ill be only three to four people working on a try the ones that are important, but also those ent issues. (It mayelpfu l to look at their flow diagram from last e of the t are directly related on the diagram.) of the torom those selected they would like to work on in a drama. However, you need to make sure that the distribution of group members topics remains fairly even. is lesson is to help the group think about the elements that go into a good drama and hem some tips on how to make th eir dramas interesting, as well as engaging. group what m Ask if they have seen some AIDS dramas before? If so, 2. rama or the direct chain of events. The m problem s own mo What e? Motivation: What is the character d, or a resolution any esolutn: In w flict or problem in a 1. Start this activity by referring to gro 2. As a group, h ecide group s would like to address in d e mas. T the size of your overall group. Id ggest that they y ther single drama. Su iffer to select addressing d be h week, making sure that non ve people choose which o pics 3. Ha pics f between drama Lesson: Elements of a Drama Objective: Th to give t 1. You may want to start this lesson by putting a sheet of paper on the wall and asking the akes a drama good have some of those been better than others and why? See what standards the group can set for themselves in terms of putting on a good drama. Share some of the following definitions and c oncepts with the group. See if they can add to them. Plot or Story: What happens in a d A good story will flow with logical sequence. You might begin by setting the stage, establishing the problem or main point, and in troducing main characters, etc. by asking: Setting : Where does the story take place? Characters : Who are the main characters? These people must be full, believable, and interesting. iddle section of the story contains the action where characters face the /main issue. How they respond to the problem often depends on each character vation ti. Conflict :problem or difficulty does the character fac s drive or reason to do the things they do? y the end of the story, B a decision may have been made, a problem solve proposed. In case, the main issue of the story should be clear to the listeners. Rio hat way do the characters address the con story?

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230 The storyteller should never conclude by te lling the audience exactly what they should have learned from the story. Encourage listeners to think about the story and come to their own conclusions. Questions at the end of the drama help listeners focus on main points and reinforce what they have just learned. Import ant Tips for Your Drama Teams Be Rea e l Remind the group that fantastic or funny dramas, while en tertaining, my cause people not to associate with th prm ons obles in dramas. While prost itutes and truck drivers have been identified as having high rates of HIV/AIDS infecti and are ities. the subject of many dramas, the large majority of pe ople with HIV are just regular people from their commun They s hould continually ask themselves the question, Is this how it really is? Avoid Overly Tr agic Scenarios If they have seen dramas performed before, most likely they have encountered the plot w her HIV status, and heresomeone performs an at-risk behavior, gets exp osed to HIV/AIDS, gets tested to lear n his or eventu identify a single risk behavior for the disease, it tells a story that i s ally dies of the disease. While this may work to all too common and leaves little room for learning Urge the group to really look at why people get into such risk situations in the first place and what options or choices are available. This is not to say that they cannot express the problems and predicaments that are a result of HI V/AIDS. Just make su re they leave room for original thought. Drama Sto Objective: group to help them put 1. Give ea at need to be addressed in their dram bar drama. Instruct them point they should not be putting together their plot yet, just its elem2. Brin open up the list f e here, making sure that problems proposed are realistic and represent those facing the comm 3. Aft and begin working on the sof their drama. Encourage them to put together a plexity of their topic, referring to their list of ntly tell the group to leave their drama open ended, ry Building The following are some steps that can be used with your together the basic plot of their HIV/AIDS Dramas. ch drama group roughly ten minutes to create a list of issues th a. Suggest that this list should include conflicts, problems, and riers that contribute to their topic, along w ith potential solutions or resolutions to this that at this ents. g the groups back together and have them share their list of issues with the group and or discussion with the whole group. The facilitator has an important rol unity. er discussion of all the groups topics, have the different drama groups separate again tory line drama that captures the problems and com issues for guidance. Most importa w here there is no clear or final resolution to the situation. Looking for resolutions to each top ic will be the basis of an activity done in the next workshop session. You upime limit for their drama. In most cases, 10 minutes e. Giving too much me may result munity performance. Give e grous thirty drama. Break (Recommended an may want to give the gros a t should be adequate time to conv ey a reasonabl e drama to an audienc ti in too elaborate of performance for a good com thp minutes or so to work on the story of their d can be incorporated in the drama building time)

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231 ekani Theatre Objective: This activity is a continuation of the prev ious drama building steps. Now, each group n nd mment on the drama offering criticism or suggestions for improvement. 1. Have one of the drama Give members of the audien hey are free to stop the action in the d must then ask a questi that they should stop i wer any questions about the drama they have crafted. 2 nt to create some questions for them to consider as they watch the dramas. In par ticular, viewers should continually question whe thei dem ions. Another device that might be helpful for discussion is to record character motivation. Pu t a sheet of paper up and record the names of each character as they n of each character to lear 3. Repeat this process for a Homework: The homework for tp g their dramas, keeping in i session. Remind drama r, that they should increase the length of their dramas. Closing Repeat activities and preparations from previous workshop days. L eeds to perform their drama, giving th e audience a chance to stop the action a co teams perform their ne w drama in front of the other groups. ce a signs or placard that says Lekani or Stop. T rama by holding up the sign and saying Lekani or Stop. They on or give advice to the group about the drama. Instruct the actors n their current positi on and be prepared to ans To help the group with this activity, you may wa ther the drama being presented realistically portrays the issue at hand as found in r community. Again, the facilitators may need to take the lead on this activity, onstrating some appropria te quest appear. At the end, have the group try to identity the motivatio n why they do what they do. ll the dramas. he eriod after this session until meeting again is to work on refinin mind any ideas or thoughts that surfaced during the Lekan groups that this does not mean, howeve

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232 10. Day Timeline Four: Planning and Presentation Greeti ng and Sign-in 0:10 Warm Who, Planni Break ack) 0:20 ng Dramas 1:00 rk: Plan their Presentation 0:10 Closing 0:10 -Up: 0:15 What, When and Where of Planning 1:00 ng and Preparing your Presentation 1:00 (Lunch or Sn Reviewi Homewo G reeting and Sign-in Repeat activities and preparations done on previous days. Warm-Up: Objective: As with the previous warm-up activities, encourage the group to get physically active prior to workshop activities. A simple warmup to get people going is stre tching. Have the group stand up and make a circle. Lead the group in moving around and stretching. Make it fun by having the group spell words using their body while stretching. Form the word Coconuts using their arms and legs to form the different letters. Use other words, as well. Who, What, When and Where of Planning Objective: In this activity, the different drama groups will refer back to the dramas they created for last weeks workshop session. They will now be looking for ways to resolve the conflict or problems identified for their drama. Use the following as a guideline to help in planning. 1. Place a sheet of paper on wall that has written down the left-hand side the words, Who, What, When, and Where. Explain to the groups that these are basic questions that one must always answer in planning an activity. You must determine: Who: Who does the problem you are trying to address most effect? Who in your community is best able to address this problem? What: What is really the cause of this problem? What kinds of things can be done to address this problem? When: When is this problem mostly occurring? When is the best time to address this problem? Where: Where is this problem taking place? Where is it best to address this problem?

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233 hen and Where the first question is to elicit understanding of the problem, while the second qu estion is meant to help start a plan of action in addressing the problem. ing discussed with the group the questions for planning, divide back into drama subese questions with regard to the issue me back together ps to For each planning word Who What, W 2. Hav groups and have each drama group answer th underlying their drama. Give them sheets of pos ter paper so that they can write out their plans. 3. After ten to fifteen minutes of working on th eir plan, have the groups co and explain their plans. As facilitator, you ma y find that there is a tendency by grou want to address all problems through teaching. While teaching is a well recognized strategy for preventing AIDS, push the group to think of other kinds of actions that could be undertaken, ones that may help remove people from situations of risk. 4. Let all the groups present their plans. Planning Your Community Program Objective: To help the community program be a succ essful forum for discussing AIDS issues, give the group some tips for putting on a professional and engaging program. Reinforce using planning skills, by applying them to the task of putting on the community program. Use these tips for a good presentation: 1. Golden Rule : Treat All of the Audience with Respect. This includes children, who are often your biggest audience. Be Prepared : Have the items you need ready so that the audience does not have to wait. Be Timely: Make a schedule that includes how long things should take and stick to it as best as you can. You will only have peoples attention for about an unity hour. Be Aware of Seating: Work to accommodate everyone and plan out where to seat people. II. Introduce what you are doing. Greet people, tell them who you are, and explain what you have done. Sample: Greetings Prayer Introduction of members of the drama group Spokesperson explains about the program: Why your group got together Your goal of promoting understa nding and informing about AIDS in your comm What you have been dong in the workshops Why you are here tonight

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234 Programs work best if you can engage the audience and keep them thinking. Ask them what problems they think AIDS is bringing to the ith Remember that drama can be much more than entertainment; it can be starting point for important discussions. Community Theatre is more effective if you can include nd ask the audience what they think is happening, or what problem the drama is demonstrating ight that problem be addressed by the people in the play. Example: If a character refuses to get an AIDS test, stop the play and ask the audience why they think he or she is behaving that way. Allow participation from the audience but make sure that it is ordered and respectful. Call on people and try to limit the number of people talking at one time. V. Provide a closing for your presentation. Summarize some of the important findings of the program and thank everyone for coming. Break (Recommended) Reviewing Dramas Objective: Review the changes that your groups may have made or may need to make to their drama since the last session. Give the actors a chance to rehearse their amended drama so they are more comfortable performing it. 1. Give each group time to re-perform their improved dramas from last week. At the end of each, have the other groups try to identify any changes while allowing for more suggestions of ways to improve the dramas. In addition, ask the group how they could incorporate some of the strategies for engagi ng the audience, as talked about earlier in the day, into their drama. Homework: Tell the group that they need to plan th eir community presentation. Suggest that they answer the questions of Who, What, When and Where as they put together their plans. III. Work to engage the audience. Good activities to start with are: community. Compare their ideas to the groups list. Ask them how AIDS in being spr ead in the community. Share w them the information you have gained from the workshop on what are the most common ways AIDS is spread. IV. Try to effectively use drama for change. the audience in the performance. Stop the play at critical points a and how m

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235 Remind them that they need to also let people know about their presentations. Finally, roup to describe how they intend to engage the audience in their dramas, using some of the suggested strategies. ay want to ask if there is another da y that the group and the facilitators can meet for a short while so that groups can present their revised plans. This also gives you a r other issues that need to be addressed. Closing especially encourage the g You m chance to assist or help if there are any ma terials o Repeat activities and preparations from previous workshop days.

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236 ple Introduction to Community hank you for co you h HIV/AIDS. ma m like the one we are proposing, but it is a rogram that, if to be successful, requires your par ticipation in all aspects. It is what is called a ng you for several ours, you will be learning from each other and your own experiences with EDZI in the y. lso, perhaps different from other programs, wher e a small group of people learn and are counted n to then share with the rest of the community wh at they have learned, this program is designed mmunity on what you have learned. Importantly, iding this feedback hopefully in an entertaining way. IV, you t must xual acts or exchangiy fluids, as has probably often been explained to you. While those ings must take place for its transmission, the spr ead of EDZI is also tied to the ways that we This I know you can nderstand because you can witness what EDZI is doing to your villages and community and how li about ng of nerally, if someone tell us a ders s. If I say that most ed 15-24 years, with infection bei s good to ever for work e will work to We tell the story through drama, something I know you are familiar in using in telling a story. However, to tell the best story of AIDS in a village, we must also spend some time researching the elements of the story. Some questi ons to ask include: who are our main characters in our stories of HIV/AIDS, where do our stories take place, and why are people doing the things they are doing? Most importantly, we need to talk also about resolution and how we want the story of EDZI in your community to end. I hope I have given you a brief, but good, description of what we need to do. Appendix A: Sam [Greeting] ming today. What I would like to talk to you about is a program that we would T like to do in r community, with your help, that deals wit You may or y not have experienced a progra p participatory activity. Rather than someone sta nding up and teaching or traini h communit A o to provide immediate information back to the co e will be prov w W hat most of us probably all know is that EDZI comes from a tiny biological entity called H which cannot be seen by the human eyes yet has the power to kill. This understanding of EDZI, I cannot ask o do anything about. I cannot ask your village to find a cure for the disease. What youlearn, however, is that the spread of EDZI is more than simply a product of se ng of bod th live, move around, all the things that we do in our day-to-day lives. u it affects yourves. This is all visible to you. In talking such things, as how we act and move around in our day-to-day lives, Ive found a story is a good way to understa nd such things. Ge that thinki s tory, we untand what is going on better than if simply heard some fact HIV/AIDS infection in Malawi are occurring among youth ag among girlsng four to six times more than that of boys in the same age group, that i now. How, if someone tell you a story about a young man who went to Lilongwe k and came back ill with EDZI a few years la ter, you know exactly what has gone on. help tell the story of EDZI in your community so that we can all better W understand it.

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237 We are going to do this story b your community. his will require your participati on. After we have done the works hops, we will then put together show nity to tell them what we have learned. wilfour workshops and a pres ld like to ticip a unt ing wan ovide th he group o orking. We patio want yo at you can do. If you a that you st rwise, are free oup t tim co nece oup] sin uilding in a set of workshops conducted here in T a to share with the commu We l be doing entation session. Those of you who wou par ate, it is important that you particip te in all parts. We should al allo so be clear that this is a vol ce. We will do our best to pr ary activity, which means there wil l be no train e s upplies you need and to prepare a meal for t n days that we will be w u to know this now so th will not be providing money for your partici deci de if this is something you would like to n. I re interested, I would ask to go. ay here while we plan when to meet. Othe you [Pass out the schedule sheet and have gr read it] [Se e for the first session and provide ntact information] [If ssary, prepare nametags for gr [Clo g]

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238 Appendix B: Sample Role-Plays Role Play One Character: You are a young man engaged to be married. Situ atio er e n: You have visited your minist and he is urging you to get tested for HIV before th wedding. You are asking you girlfriend if she will go get tested with you. Attit ude: You think that your girlfriend as the mi should do what you say, especially since it w nister who suggested the testing. ract u are young women engage Cha er: Yo d to be married. Situ atio ants to get teste n: Your fianc w d for HIV before you get married. Attitude : You think yo ur fian c is accus et tested. ing you of being unfaithful to him and refuses to g Role Pla ract ho w in y Two Cha er: You are a married man w orks in Lilongwe to support your family who lives your home village. Situ atio ng n: Your wife thinks you are seei another women when you go away to work. She is concerned that you will bring ear a condom when back a disease and wants you to w having sex. A ttitude none of your wifes business. You are taking care of her and she should : You think it is not complain. Character: You are a young married women living in your husbands village. Your husband leaves the family from time to time to work in Lilongwe. Situation: You think that your husband might have a girlfriend in Lilongwe. You are worried about getting a disease from this other women. You want your husband to start using a condom. Attitude: You are concerned for him, yourself, and your children. You want him to be safe if he is seeing another woman.

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239ole Play Three haracter: You are a secondary school boy. R C Situation: Your are t rying to convince your girlfriend to have sex with you. Your relationship has not gone that far and other gu ys are teasing you abo ut it. Attitude: Everyone else is doing it. Why shouldnt we? Character: You are a secondary school girl. Situation: Your boyfriend wants you to have sex and you feel sure about it. un Attitude: You want to please him and not lose him, but you al think you are not ready for sex. so Role Play Four Character: You are a recent widow. You husband died last yea e r after being ill for a long-tim Situation: Your husbands brothers have come to talk to you about your duty to their family. You are in need of support. Attitude: You believe that you should do what is expected of you out of respect for your late husband. Character: You are the brother of a recently deceased man. Situation: You have gone with another brother to talk to your s wife. deceased brother Attitude: You believe that she needs to come live with your family now that your brother has died. You are trying to convince her to come live with you. Char ecently deceased man. acter: You are the brother of a r Situation: You have gone with another brother to talk to your deceased brothers wife. At titude re afraid that if your deceas ed brothers wife comes to live our family that she will : You a with y spread illness in your family. You think she should e of herself. take car

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240 Appendix C: Secondary Materials Organization/Publisher Date Title Action, Finding Out the Facts About AIDS re/The Story Workshop Slippery Stones 3. Anne-Lise Quinn (Dissertation) Working on the Protehic: Life in a Presbyterian Community in Malawi 1993 4. Anne-Marie Wangel (Thesis) AIDS in Malawi a Case Study: A Conspiracy of Silence 1995 1. 2. ACTION Action Theat stant Et 5. Central Church of Africa ivingstonia Embangweni Mission Hospital, Annual Report 2000 6. Central Church of Africa Presbyterian Synod of Livingstonia A Proposal to UNICEF Seeking Support and Funding for a Four-Feature Intervention Within the Catchment of Area o spital to Reduce Mother to Ch of HIV 2000 7. CHAM Christian Health Asso Strategic 2000 8. th and Population r for Disease Control 1999 Emba ary Health Care Community: and Nu Survey 1994 10. eni Mission Hospital Primary Health Care Embangweni Primary Health Care Community: Distribution of Contr 1998 11. tion (GTZ) of Democracy In Malawi: SocioAnthropological Conditions 1998 Minist Magazine 2000 13. Jodi Jean McGill (Thesis) Cultural Practices of of Northern Malawi as They Relate to the Sexual Transmission of HIV 1993 14. Michael King Malawi Collection 2000 15. Ministry of Health and Population Manual of the National Tuberculosis Control Programme In Malawi 1987 16. th and Population Malawi Standard Treatment Guidelines 1993 17. th and Population The Malawi Prescribe 93 18. Ministry of Health and Population Guidelines for Health Interventions to Reduce Mother to Child Transmission of HIV 00 19. Ministry of Health and Population To the Year 2020: A in Malawi 9 20. Ministry of Health and Population Malawi National Health Plan 1999-2004 Volume 2 National Health Facil ment Plan 199 21. Ministry of Health and Population Malawi National Hea -2004 199 22. National HIV/AIDS/ Change Intervention (BCI) Liiew 2001 Presbyterian Synod of L 2000 f a Mission Ho ild Transmission Malawi ciation of Plan 2001-2003 Community Health Science Unit of the Ministry of Heal CHSU Newslette 9. ngweni Mission Hospital Primary Health Care Embangweni Prim Immunization Embangw trition acep tive Program Survey German Agency for Technical Coopera The Challenge Health 12. Education Unit ry of Health and Population Moyo the Tumbuka People Ministry of Heal Ministry of Heal rs Companion 19 Workers for Implementing 20 in Malawi Vision for the Health Sector 199 ities Develop lth Plan 1999 9 9 Ministry of Health and Population SRH Behavior terature Rev (continue d)

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241 Appendix C (Continued) Title Date Org anization/Publisher 23. National AIDS Control Program Malawi National HIV 2000-2004 1999 24. nse to HIV/AIDS for 2000-2004: Combatting HIV/AIDS with Renewed Hope and Vigour in the Mew Millennium 2000 25. National AIDS Control Programme A Decade of AIDS Research in Malawi 1989-1999 1999 tinel Surveillance Report 1998 1998 rvillance Report 2001 2001 las of Social Statistics 2002 29. s Village Malawi Child formal Mid-tern Report 1999 30. SAfAIDS Southern Afr Newsletter 2001 31. DS In Malawi, an Annotated Bibliography rategic Plan for the Health Department of the Synod of Liv 2003 33. The Story Workshop Barriers to Hehior Change 34. Titus B. Phiri (Manuscript) Loudoun Mission Station: Its Developments and Achievements 35. e HIV/AID in Malawi, the Situation and the Response 2001 36. UNICEF Malawi Prevention ofother-to-Child Transmission of HIV, an Integ Manual 2000 37. University of Malawi Center for AIDS: The B or Change 1993 38. ter for Social Research Behavioral Component of the Preparatory AIDS Vaccine Eval 1995 39. Women In Development Southern Africa Awareness Beyond Ineq Malawi 1997 40. ntral ivingstonia Child Surviv 1999 /AIDS Strategic Framework National AIDS Control Programme Malawis National Respo 26. National AIDS Control Programme Sen 27 28 National AIDS Control Programme Sentinel Su National Statistical Office MalawiAn Malawi Children e At rens Village In ica AIDS Action STAFH AI 32 Synod of Livingstonia St ingstonia 1999ealth Bav UNAIDS Th S Epidemic M rated Training Social Research University of Malawi Cen arriers to Behavi uation Studies ualities, Women in World Relief Malawi/ Ce Church of Africa Presbyterian, Synod of L al Proj ect Proposal

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242 Appendix D: Program Consensus and Program Consensus Survey In A. dividual Information 1 CIRCLE SEX OF THE RESPONDENT MALE 1 FEMALE 2 2 Mukawa chaka nchi? th and year were you born?) MONTH.. [__|__] OW MONTH 98 YEAR [__|__][__|__] R 98 (In what mon DONT KN DONT KNOW YEA 3 vilinga kufika sono? Muli navilimika r last birthday?) CORRECT 2 IF NECESSARY MPLETED _|__] ( How old were you at you COMPARE AND AGE IN CO YEARS[_ 4 gwa panji kutola? (What is your Widowed 1 2 3 4 Muli kuten marital status?) Married Divorced, Separated Never married 5 If married Mwakhala pathengwa vyaka vilinga? (How long have you been married?) Years ____ ____ 6 If married Male: Muli nabakazi banyake ? Female: Afumu binubali wali wana kazi wa mnyake? Male: (Do you have other wives?) Female : (Does your husband have other wives?) YES 1 NO 2

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243 tin 7 If not married uku gonana nacho Appendix D (Con ued) Kasi muli nachibwezi icho m nyengo nanyengo? ua YES 1 NO 2 (Are you seeing someone whom you are regularly sex active with?) lly 8 ale, Muli kufikakalasi uli? Pulayimale, Sekond Kujumphirapo? ( What is the highest level of school you attended: primary, PRIMARY SECONDARY HIGHER NEVER ATTENDED secondary or higher?) 9 Mukasambira vyaka vilinga pa sukuluiyo ukawa? at that YEARS COMPLETED [__|__] m (How many years of education did you complete level?) 10 hala vyaka vilinga pa mudzi? E Mwak (How long have you been living continuously in NAM OF VILLAGE ) RECORD 00 IF LESS THAN 1 YEAR MONTHS.. [__|__] YEARS [__|__] 11 Mumpingo uli? (What is your religion?) Religion____________________ Denomination________________ 12 Mutu wabanja linu ninjani? PICK ONE Rs Father/Mother-in-Law Other 1 2 3 4 5 6 7 1 3 (Who is the head of your household) R (Self) Rs Spouse Rs Mother Rs Father Rs Brother-in-Law Rs Brother/Sister

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244 Appendix D (Continued) Pamwezi mukusanga ndalama zilinga? ate, in Kwacha, the income of your hous onth?) 13 (Can you estim ehold Kw_____________________ each m B. Please answer the fo llowing Yes/No Questions 1 Kamuli kupulikako za ka chilombo kakwambiska ntenda ya edzi? (Have you heard of an illness called AIDS?) YES 1 NO 2 2 Kasi muli kusambi rapo za HIV/EDZI? ecial education concerning HDS?) IF YES, DECRIBE TRAINING EXPERINCE YES 1 NO 2 Trainings: (Have you had any training or sp IV/AI 3 Kasi edzi yinlera kunyifwa? yatito (Is AIDS a fa YES 1 NO 2 DONT KNOW 8 tal disease?) 4 Kasi kuli kuchira na edzi? (Is there a cu for AIDS?) YES 1 NO 2 DONT KNOW 8 re 5 Ka mukumum li na edzi panji ali kufwa nayo? (Do you know anyone who is infected with HIV or who has died of AIDS?) YES 1 NO 2 DONT KNOW 8 anyako uyo wa 6 Kasi muli nam wezi uyo wali na edzi panji wali kua edzi? (Do you have ve or close friend who is infected withIV or has died of AIDS?) YES 1 NO 2 DONT KNOW 8 bali panji mb fwa n a close relati H 7 Kasi chingac nthu uyo wakuwoneka makora kuti wwe na kachilombo ka edzi? (Is it possible -looking person to have the AIDS viru) YES 1 NO 2 DONT KNOW 8 hitika kwa mu a f or a healthy s? 8 Kasi ka chibungu ka edzi ka nga ya mbukila kufuma kwamama kuluta kwa mwana? YES 1 NO 2 DONT KNOW 8

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245 Appendix D (Continued) (Can the viruthat causes AIDS be transmitted from a mother to a s child?) 9 Kasi mukumanya umo munga jasungila kuti muleke kutora maten (Do you thinku know enough to keep yourself from getting YES 1 NO 2 DONT KNOW 8 da gha edzi? yo AIDS?) 10 Kasi ziliko nthowa izo muntu wa nga kanizgira kutora ezi? (Is there anything a person can do to avoid getting AIDS or the v es AIDS?) YES 1 NO 2 DONT KNOW 8 irus that caus 11 Muntu wachitechi? (What can a person do?) Chilikoso Chinyake? (Anything else?) RECORD ALL MENTIONED. ABSTAIN FROM SEX USE CONDOMS LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER LIMIT NUMBER OF SEXUAL PARTNERS AVOID SEX WITH PROSTITUTES AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS AVOID BLOOD TRANSFUSIONS AVOID INJECTIONS AVOID KISSING AVOID MOSQUITO BITES SEEK PROTECTION FROM TRADITIONAL HEALER AVOID SHARING RAZORS, BLADES OTHER (SPECIFY) OTHER (SPECIFY) DONT KNOW

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246 Appendix D (Continued) 2 Kasi wanthu wanandi wa kutola uli matenda gha edzi? (How do you think most people get AIDS?) ___________________________________ ____________________ 1 13 Muku tora nku uthenga wa edzi? (Where do you get your information about AIDS?) List: 14 Kasi nimasuzgo uli agho ghiza chifukwa chamatenda List: gha EDZI? ( e prob lems that HIV/AIDS is (Anything else?) What are some of th causing in your community?) Chilikoso Chinyake? RECORD ALL MENTIONED. 15 Kasi suzgo tikulu chomene ilo lilipo chifwa cha _ EDZI nichichi? HIV/AIDS is causing in your community?) __________________________________ __________________________________ ____________________________ ____ __________ ____ __________ ______________________________ ________________________________ ___________________________________ ___________________________________ _________________________________ ___________________________________ ___________________________________ ___________________________________ (What do you consider to be the biggest problem that __________ __________ _______ ___________ ___________ _____ ___ 16 Pakati pa wanthu wose nigulu ndini ilo likukoleka chomewe na EDZI? (Is there a category of people that have been more affected by AIDS in your village community?) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ _________________________________

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247 Appendix D (Continued) 17 Kasi mukughanagha kuti ntchiuichi icho chingachitika na matenda gha EDZI muchigawa? (What do you think needs to be done to prevent HIV/AIDS in your community?) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ pakulimbana C. Ranking of Causes (Rank most serious to least serious) 1 __________ 2 __________ 3 __________ 4 __________ 5 __________ 6 __________ 7 __________ 8 __________ 9 __________ 10 __________ 11 __________

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248 Appendix D (Continued) 12 __________ 13 __________ 14 __________ 15 _________ 16 __________

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249 Items Code Appendix E: List of Community Concerns for Ran king 1. Men and women are not tested to learn their HIV sta tus. Test 2. Men and women go to other towns to work and com e back with AIDS. Travel 3. People do not know enough to prevent AIDS and av oid risky behavior. Knowledge 4. People who practice magic and w itchcraft are spread ing AIDS. Magic 5. Sugar daddies are tempting young girls to have sex f or money. Sugar Daddy 6. Traditional practices, such as the la bola (bride paym spread of AIDS. ent), are causing the Tradition 7. Children do not listen to their parents when it comes marriage. to relationships and Parents 8. Men are paying to have sex with women. Prostitution 9. Both men and women look for partners other than their spouse. Adultery 10. Condoms are not being used in preventing AIDS. Condoms Not Used 11. Condoms are encouraging young people to have sex. Condoms Encouraged 12. Parents do not talk to their child ren about the dangers of AIDS. Talk 13. Husbands and wives do not talk to each other about HIV. Married 14. Women and girls are having sex with men to meet t heir needs. Needs 15. People are going to bottle stores and meeting up wi th people for sex. Drinking 16. People are not being treated for sexually transmitte d diseases. STIs

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250 AIDS Dramas Synopsis: Appendix F: Community Comments: Kakoma Dramas Orphan Care : Grandparents lament the loss of the son and daughter-in-law to AIDS, as they are now raising their grandchildren. At dinnertime, the orphaned children fight among themselves for food and complain to their grandparents that they are not getting the benefit of the money their parents left behind. The grandparents tell them that they had to spend the family money in caring for their parents when they were sick. A side dialogue takes place with the orphan children in which one of the hat she could go into town oyfriend and to support s e ured a discussion in which the two grandparents argue on at orphaned girls suggests t and find a man to be her b her. Covered in this drama were the difficulties that AIDS can bring to families. Other topics or lesson highlighted include the need to treat all of the orphan children the same, not favoring boys over girls in distribution of food, and that being an orphan can lead to great er risk for HIV, as evidenced in the female orphans discussion of how she can obtain money and resources from men. Though having a very simple plot, this drama had very strong dialogue on the issues. In particular, th opening dialogue between the grandparents feat over whose responsibility it was to talk to their s about AIDS, each citing cultural reasons why they did not. In addition, there is a veiled implication th the grandparents knew their daughter-in-law was receiving support from an outside partner and perhaps putting their son at risk. Nonetheless, the daughter-in-law was able to bring needed things to the family, so they were willing to look the other way. Poverty : A son explains to his father that he is leaving the village to go to the city for employment and will be taking his wife with him. The father h no objections. Once in the city, the son gets enthralled by the new possibilities offered by the city and takes on a new lover. Later, he becomes sick and unable to work and his wife has to take care of him. Eventually, as they run out of money, they decide they must return to their village. The wife decries the fact that they are leaving the c poor as when they came and nothing has changed for them. Once as ity as back home, the son admits to having ad an affair with a woman, and he says he fears he has AIDS. The sons mother scolds her husband for not talking to his son about the dangers of the city and AIDS. The point of this drama was to demonstrate the ways that poverty puts people at risk for AIDS. In addressing poverty, it is more common to refer to women seeking economic support from men. However, the women in such dramas, are often cast as more opportunistic than needy. In working with this group, they were pushed to consider how risk from poverty might exist for men. They decided to focus on a mans need to find work. h (continued)

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251 Synopsis: Appendix F: (Continued) Comments: Kakoma Dramas Not Trusting One Another : A husband tells his w that he is going to town for beers, and he leaves at home. He goes to town, where he buys local brew and flirts with the women selling the beer. He comes home drunk, enters the house, and sees a pair of shoes that are not his sticking out from under the bed. He accuses the wife of having a lover over and roughs her up a bit. She says she bought the shoes for their son. He gets mad and storms out, saying he will find another woman if she is going to cheat on him. Months later, he comes home not feeling well. The wife calls the husbands brother and his wife to consult on his new illness. They discuss the illness and decide to take the husband to a traditional healer, who provides them with medicine. They all fear that he has gotten ill from AIDS and what it will mean for their family. ife her ed y is ome part of a miscommunication. Another traditional aspect comes from the original drama, a usually very humorous vignette, featuring the wild dancing of the vimbusa ritual. In this version, the groups tamed down this aspect. They also left the ending more ambiguous in this version in terms of whether the illness was truly from AIDS. This group featured some of the more experienc drama performers from the community. The seemed to adapt a pre-existing drama plot when asked to develop a new drama on Not Trusting one Another about the role trust plays in relationships. In its original form, the drama was intended to be more humorous, and the shoes in question did belong to a lover of the wife. However, in the Stop Motion Theatre portion of the drama workshop, th drama group was encouraged to go further into the issue of trust in relationships. Their response was the following drama, where the shoes bec Not Gettin g Tested : The wife in Couple One the e e The drama concerned testing and attempts to model as ate suggests to her husband that they should go to hospital to see if they ar e healthy. He agrees, and they go to see the doctor. They indicate that they would like to get their blood tested. The doctor congratulates them on their good decision. The wif of couple Two suggests, as well, that they go to th hospital for a blood test. The husband responds negatively, taking the suggestion as an accusation of infidelity. The wife from Couple One and the husband from Couple Two meet on the road to town. They engage in a liaison. The woman, however, asks the man to either get tested for HIV or use a condom if they are going to have sex. He refuses, but is willing to give her something if they can have unprotected sex. The husband from Couple Two returns home to his wife, not feeling well. She takes him to the hospital, where he is tested and found to have HIV. He takes some medicine from the doctor. Back at the home of Couple One, the wife, having slept with the husband from Couple Two, returns home feeling sick. The husband suggests that they go get her checked at the hospital. two possibilities for how testing can go between couples. It also hits on the potential problems of having sex with a partner when you do not know their HIV status. More remarkable, however, w the reference to condom use. This drama, while new in form, falls back into the sort of object lesson form of so many of the AIDS dramas. A problematic but unresolved issue was the immedi nature of the HIV in the drama. This seems to be a convention in AIDS drama, shrinking latency of AIDS and suggesting an unrealistic potency to infections. (continued)

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252 Appendix F: (Continued) Synopsis: Comments: Foster Jere Dramas Poverty : A daughter goes to her mother, telling her it is time to pay her school fees again. The mothe suggests that it will be hard to find the money since her father is dead, but that she is brewing some b to sell. The daughter, disappointed, heads for tow Late that day, the wife sets up her beer shop. Her first customer is man who strikes up a conversation and learns that her husb and died, but not from AIDS. She learns he is divorced and has a lot of money from selling cows. To herself, she comment that he should take her as a wife, since he has so much money. The daughter returns and asks how is going with the beer sales. The mother comfor her and says that things will be fine with the fees after she sells this next batch of beer. The man returns to the shop later and gives the mother more money for beer, eventually buying all her beers in bottles. He suggests that she should become his wife. Later, the mother gives the money for school fees to the girl, telling her that a man bought all the beers. r eer n. s it ts In Foster Jere, in using the trickster character as part of the drama, certain sub tleties within the exchange between the man and women were teased out. For one, it was asked whether the mother and rich man should get married, based simply on the word of the mother that her first husband did not die of AIDS. Toward the end, the audience is led to believe the mother is going to prostitute herself to this man. In the end, however, it works out that the man gives her the money by buying the beer. This ending seems a bit trite, but it manifests a more common sentiment that if one acts appropriately, God will provide for them what is needed. Not Being Faithful: A husband and wife are having their morning tea. The man says good-bye and goes to work. At work, he flirts with his secretary. When he gets home, the wife accuses him of having a relationship with his secretary, telling him that people at this work are talking about it. He dismisses it and says that people are just being jealous and malicious. He says to forget it and come to bed. Once in the bedroom, the wife says she will not have sex unless he uses a condom. The husban refuses, saying there is no need, and they do not d have sex. The next day, the man talks to his secretary, saying people are talking about them. She dismisses it, saying it is the ignorant banter of villagers. The man says he will leave his wife if the accusations keep up. The secretary urges him to do that so they can get marri ed. At home again, the husband confronts the wife, who is demanding that they get a blood test because the secretary goes around with lots of men. The husband refuses. This drama, in accordance w ith the directions given to the group, remains unresolved. The group was asked a parting question by the Trickster concerning whether getting a blood test will solve this couples problems. This was done to emphasize that the issues they are having as a couple are complicated and will still exist even after testing. This drama had particularly good dialogue between the characters. (continued)

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253 Appendix F: (Continued) Synopsis: Comments: Not Getting Tested : A woman enters the docto office asking for a blood test. He says that is good, because they are advising pregnant women to get tested. The women tests positive for HIV and returns home with a note for her husband asking him to come in and get tested. The man denies he could have AIDS and has an explanation for why he was out late so many days. He says he is going to the doctor to get things st raightened out. Instead, he heads to his lovers and asks her if she really loves him and would she love him even if he had AIDS. She says yes. He does not tell his lover that his w has tested positive. He returns home and lies to his wife, saying he got tested and it came back positive rs ife y s of er at he will be abandoned if true. The consideration of the fears around testing was good, but this play also tends to slip back in an object lesson mode, emphasizing a tragic circumstance instead of actively engaging in any type of problem-solving or solution-seeking. This drama seemed to lack direction, relying mostl on the audience reacting negatively to the action husband. It suggests perhaps that he cares for neither woman that much because he both refuses to get tested and doesnt tell his lover the truth. The conversation between the husband and lover was one of the best drama performances, as he asks h whether she would still love him if he had AIDS, barely hiding his fears th Takumanapo Dramas Condom: A girl meets up with the boy she is seei They talk, and he asks her to have sex. She refuses, saying she will not have sex again with him unless they use a condom. He asks what good is a condom She explains that it prot ects from diseases and can prevent pregnancy. They part, not having had sex. Back at the girls house, the mother is cleaning the room and comes across a condom among her two daughters belongings. The mother calls in the two daughters to explain ng. the condom. The one daughter tells her that she has them because she is having sex and she wants to prevent disease and pregnancy. The mother says she did not know about condoms, but wants the girls father to come in and hear this. When hearing about the sex, the father is upset with his daughter, but he is pleased she has chosen to use a condom. Later in the day, the girl meets up with her boyfriend again and he proposes sex again. She repeats her requirement to use a condom. He refuses, explaining he does not like condoms. She dumps him. This drama has a very simple plot and relies on repeating its message several times. At least three times, the daughter repeats the line that condoms protect from disease and prevent pregnancy. This drama featured slang or vernacular from the community, such as referring to sex as that game we play. The boy also delivers a classic line, when he argues against the use of a condom by saying a candy is not as good in the wrapper. (continued)

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254 Synopsis: Comments: Appendix F: (Continued) Lacki ng School Fe ef the so eacher anno that he needs llect school fees. ehstudnts,ir home to ask her parents for fees. ately, the family is pood doeso have r school fees. Thaughtershe o to town and dig latrines for money. In town, goes to the bottle ston meets anlder who offershee mner her she will ha wi him Sh The girl returns home, hits. The pt she b ing te fact that -work sheaid she wog cd ot hthings shs boughLater, i. T mer takes her te earn that she is pregnant. She is ch Te la scereturns to th a female teacher is telling the other o work hard t can bs and afford to support their fhmi twtir havingIDomhiked i the -tiherkTheou originally proposed that the girl would get HIV/AIDS. In talking throuthe dra, litor argued thasamft cobhiev in drama by having the girl get pregnant, without having to be ovly tconethelthre seemed to be soe unresolved elements in this amc t wao get hehool fees. The ending also seemed to place the blame uary oheirl, oonsideration the economic situation that drives her need. es: It is th mid dle o cho l term and the t co unc of t es e to l, On e a g returns Unfortun the money fo will g r a e d n n say t s she re a d r th o y fo Sugar Daddy school fees if o ve sex th e agrees and leaves with him bringing several ho praise her for what piece use old ri ngs, igno em aren h s r the s e as d e ha in oul t. n have paid for all t the girl becomes s ck he oth o th doctor and they l forced to leave s school, whe ool. h st ne e re girls that if they co some ntinu e t hey day get jo families. The act t at th e dra a d d no end ith he g l A Mo S was s on T et wo ng w shop or out gr n p Stop eatr gh e ef am uld the e ac faci ta t ec ed er m ragi N ess, e dr a, su h as how he gi rl s t r sc sq el n t g with ut c of Not Getting Te girlfriend in to that they are not c bout each sted: A boy meets up with his wn. e le from e conversation aual lovrs but instead are there ys t suld e ag. ver, they ed go ths d test for HIV. She is a little afraid o hplns it is a simp press bood is taken. At the hospital, the eir nd toem that d she is ositive and th advises w to take care herself. fter leavhe girl asks whh wimearheir ip. The b sae not ey ould talk with thr pants. Thed thgir f reneo tell them wht ave learned. t first, thmoer of the irl i ghter for slnth other me ally, she suggests that e brl shou et married. Tis nt su wh to do. He oves the gibue wantsam. he boys mother ars thats tdarous fo im to marry her. In the end, the marriage is called ff. This drama was built out of role-play that concerned -ants. I s a subject that peop had a lot oquestbout. Nohel,he lting da seemd touate somf eoypehaths wod aveeend to idsuc toen beinhe promous e while the bs e virtuous one. Whe the upodels a potentially poe ehaor of turning to parens for advice, thtcome that was ach reinforced the feaatany womv garng testin pal that if they are foun beosit t thbene This kes somhcentivoutf geinged. he gp did a goodb of discussing testing and vin the boy settle the fears of the girl on the aestg. The teaching aspect was no somescussed withou It was n clear i the use of drama to ov ercome basic fears was meingeyd lrned in anothoext or as a innovatin ofhe g W s arn e th serious a o H sa hey ho get married, and sh we rees He s ays before they get married, ho ne to to e ho pital and get a bloo the blood test, so where just a little f e ex ai le oc l blood a doctor checks th he is negative an reports th p of en her on ho A ing t hospital, the at t is ll n fo t relationsh oy ys h is t sure bu th sh ei re boy an e l get the two sets o pa ts togeth r t a they h A e th g s upset with her dau Eventu eepi th g wi oy an n. ld d gi still g says he l he bo y o re at rl, gue t h also it i a f nge ily T h oo r o sero discord coup ions a le t wa le f net ess t resu ram e perp ul et e o ster vo t s t h as p he w er ap h g t b goo cu a on m th is il oy i co le m sitiv b vi t e ou m re ed r t h ar ly en ha e re di g, rticu d to p ive, hen ey will abando d. ta e of t e in e o tt test T rou jo ha g actu l t in t thing di gr p. ot f so th th ha ea er c nt w n o t roup (continued)

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255 Synopsis: Comments: Appendix F: (Continued) Kabira Dramas Poverty: to have s condom an AIDS test. parents a me op one me suggesting that it is something that e difficult question of what to lls on en n In a poor household, a father talks to his wife, explaining that they need more money and that their daughter must go to work selling bread in the market. The young girl is instructed to go to market, do her business, and come home. At the market, however, the young girl meets a young man selling plates. They flirt at first and eventually fall in love with each other. At some point, they decide The title of the play is poverty; however, this the only plays a minimal role and is more the backdr for a story about trust and relationships. It offers of the simpler story lines, but perhaps one of the more realistic scenarios. It starts by developing the relationship between a girl and boy and actually spends ti evolves. It tackles th ex. The girl at first asks the boy to use a The boy says what is the matter, do you think I having been sleeping with others? After assuring her that he is not, they have sex. Three months later, the girl comes home late and not feeling well. The mother questions the daughter until the daughter admits she is pregnant. After that is revealed, the mother and father realize that they had been naive, that the girl has obviously had a boyfriend since she had come home from the market with commodity items, such as lotion. They grab the daughter and head to the house of the plate vendor to confront his parents. There, they explain to the boys parents what has occurred. The boys father scolds his son for having a partner and not getting do when you care for someone and that person te you it will be okay to not use a condom, a situati where trust plays a role in decisions around sex. After the topic of sex is broached, the drama th becomes more proscriptive, providing lessons o testing and changes that are required if one is HIVpositive. At the end of the meeting, both gree that the boy and girl should go to the hospital to get AIDS testing. At the hospital, the doctor administers the test and tells the girl she is negative and boy is positive. The girls returns to her house. The doctor returns with the boy to his house to explain to the father what the boy will need to do to take care of himself because of AIDS. He will either need to use a condom or abstain from sex. Looking for Money: A girl has passed her exams and is now seeking school fees so she can continue in school. The parents decide to sell some of their This drama has many similarities in plot to the prece on fam goats so school, b ding drama. However, it puts more emphasis ily leadership. The father figure is presented the she can attend school. She starts attending ut must return home to get more school fees. The father urges the daughter to work to earn her school fees. In going to town to work, she moves around and eventua lly becomes sick. Word in the community has it that she has contracted AIDS. Family members come to consult and advise the family that they will have to take care of her and provide her with a good diet. as lacking in his stewardship of the family. In end, it becomes more instructive, as family members show up offering advice to the family for how the daughter should live now that she has been found to have AIDS. Having a well-rounded diet with beef is the major piece of advice. (cont inued)

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256 Appendix F: (Continued) Synopsis: Comments: Not being Faithful: At the home of a married couple, the husband says he is leaving for town to get some beers. The wife claims he spends all of their money on beer and they dont have enough left over for food. After the husband leaves, a male friend shows up at the house, giving a gift to the wife and saying her husband does not appreciate her. The man leaves the woman and goes to the beer store with the intention of getting her husband drunk so he will not come home. The man then returns. The woman contemplates leaving her husband for this man. The man leaves female friend of the wife This drama was interesting in that there were no good or innocent charact ers. The husband was wasting the familys money on beer and not providing for this wife and children. The wife was taking a lover. It is distinct from the other dramas in that it is so morally ambiguous. It also was one of the shorter dramas. It provides one lesson -not relying on a persons appearance to determine if he or she has HIV/AIDS. but soon afterward a comes to the house. She asks who the man was who had been visiting. The wife claims it was a cousin, but her friend distrusts her and says it must have been a lover. The friend warns her about sleeping with men and catching AIDS. The woman says not to worry, the man is fat and could not have AIDS. Sh e also warns her friend that she plans on leavin g her husband because he does not even provide food for her. The husband comes home drunk, breaking up the conversation and demanding food. The wife tells him that their kids had to go to sleep hungry. The husband sees the gift f they begi rom the lover and gets angry with her, and n to fight.

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257 Appendix G: List of Community Concerns Informants Problems Related to HIV/AIDS tal 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 To Poverty or Lac Mone k of y 10 Insuff Know Under AIDS icient ledge or standing of 7 Orpha ns 7 Sharin Razor g Needles or Blades 6 Peopl Their Gettin e Not Knowing HIV Status/Not g Tested 6 Alcoh ol 5 Condo Sex ms Encouraging 5 Lack or Los of Development s of Labor 5 Men/Women B Unfaithful eing 5 Older for Yo Men Looking unger Girls 5 Wom Looki Throu en/Girls/Boys ng for Money gh Relationships 5 Prostitution 4 Widow Inheritance 4 Western Values 4 Traveling to Urban Area for Employment 3 Money and Status 2 Not Using Condoms 2 Premarital Sex 2 Multiple Partners 2 Care for the Ill 1 Deaths 1 Handling Dead Bodies 1 MTCT 1 Sex Taboos During Pregnancy 1 Witchcraft 1 5 8 3 5 8 3 6 8 8 11 5 5 6 4 3 7 95

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258 Appendix H: Themes tified for HIV/AIDS Among Social Causes Iden Sex as Exchange (30 out of 95 statements, 31 %) One of the major themes to come out of the interviews is the role that exchange plays among those having sex in the community. Statements concerning Poverty or Lack of Money Women/Girls/Boys Looking for Money through Relationships Prostitution Money and Status, and Older Men Looking for Younger Girl all suggest that transmission of AIDS may be occurring as the result of individuals exchanging sex for resources. Poverty or Lack of Money was the most widely shared AIDS-related issue among the interviewees. Comments such as, They dont lis ten because of poverty, they dont listen [to AIDS m ral ou s. Not all statements on the role of poverty in AIDS share the same critical appraisal of the circumstances that lead to potentia l HIV/AIDS infections. The word poverty is also used to describe a more widespread lack of resources in the community, in essence suggesting that all Malawians are poor and cannot afford what others in the world have or what they want. In such usage, statements describing poverty as a cau se may refer to a more casual willingness to exchange sex for the promise of material gain that would otherwise be unachievable. As one village headman said, Sex is something negotiable. This is echoed in the statements concerning Women/Girls/Boys Looking for Money through Relationship. Sex among this group is often viewed in terms of material gain. Schoolgirls are seen ops. ange in the community is mostly o ccurring on an informal basis. essages] because they are looking for m oney, as stated by a village headman in the interviews, reflect a common sentiment in peoples understanding of the spread of AIDS. Seve interviewees expressed opinions similar to this one: The uneducated ones are getting AIDS because of poverty. If a man says you, girl or woman, I want to do sex with you, I will give y this Lifebuoy soap, so the lady just accepts because she wants that soap. The implication in this statement is that some women, particularly those who are economically disfranchised, may be compelled at times to engage in informal sexual ex changes in order to obtain needed resource as coveting non-essential items, such as shoe s, clothes, and jewelry, and are thought to be more willing to engage in sex for exchange While exchange most commonly applies to the relationships of young women, boys were also mentioned as occasionall y having liaisons with older women, mostly widows, in exchange for money. Prostitution was also mentioned as a concern in the community, particularly referring to the women who can be found in bottle sh The fact that formal prostitution was less often me ntioned reflects the fact that sex for exch

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259 Appendix H: (Continued) Money and Status mentioned along with statements about Older Men Looking for Younger Girls are also facets of sexual exchange, as they recognize the dynamics of this twosided trade. Men, who have more money or resources, are thought to use sex as a means of demonstrating their power or authority. As one person described such men, These men think that one girl is not enough to them, but they should have maybe five girls. If they have five or three girls then they become satisfied. Likewise, olde r men are said to target younger girls for sex as a way to protect themselves from AIDS by finding partners less likely to have been exposed to HIV. Often these men are called Sugar Daddies, with the man supplying desired items to secure sexual favors. Widow inheritance, as previously described, is included in this category. While it is certainly a customary practice, the new economics of this act, which allow for buying out of ones obligation, underscore the exchange that lies at its heart. Also, the significant economic disenfranchisement that can occur for a woman who refuses to rejoin her husbands family may serve to maintain the practice. Sex as a Moral Concern (17 out of 95 statements, 18%) Several statements by informants concerned the transgression of moral norms with regard to sexual relationships as a reason for HIV/AIDS in the community. Of particular concern were men and women not being faithfu l in their relationships ( Men/Women Being Unfaithful ). Unfaithfulness is a common subject in stories told by informants on causes of AIDS infections in couples, married or otherwise. Sex Taboos during Pregnancy was listed specifically as a reason men might seek out additional partners. In a similar vein, a few suggested that Premarital Sex is contributing to the AIDS problem in the community. As one informant said, Concerning the boys, I can say they went home to experiment for girls, they propose a girl, just to do sexual intercourse with her so to them I have heard them say. Its just an experiment doing sexual intercourse with a girl. So how long will those boys doing experiments with girls. So its one way transmitting HIV/AIDS because they just want to taste. In considering arguments of moral causation, such influences as Condoms Encouraging Sex and Western Values as expressed in music, television, and movies were seen by several of these community members as undermining some of the traditional values in the community, in turn leading to more sexual promiscuity, particular among the young.

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260 Appendix H: (Continued) Lack of Knowledge or Understanding of HIV/AIDS (17 out of 95 statements, 18%) Another theme among the statements by interviewees was that people have Insufficient Knowledge or Understanding of AIDS to adequately protect themselves from infection. Interviewees repeated such statements as, The major problem is that people do not understand about the preventive measures, if they can unde rstand the preventive measures, they cannot contract HIV. Likewise, it was suggested in some of the interviews that people may be Sharing Needles or Razor Blades without regard for sterilization and that individuals may be Handling Dead Bodies without taking protective precautions. As a health worker said, In the community isnt only sexual intercourse. Secondly, its part ly the traditional ways because they use the same razor blades when they do medicine to their pa h attendants, should not be usin g one razor blade, but if they are very old and they are not educated. Condoms not being used was a behavioral/e ducational issue only brought up by two of the interviewed individuals. Surprisingly, despite the hospitals educational efforts regarding Mother-to-Child Transmission of AIDS, only one individual mentioned the risk of transmission through MTCT, suggesting people did not know what could be done to prevent it. When asked about AIDS, almost everyone in the community said more education was needed. When asked further about what they tho ught people needed to learn, most individuals would refer to educating people on the badness of the disease. To many, AIDS education was seen as a panacea for the problems of AIDS transm ission. Nevertheless, AIDS education remains a poorly formed concept for most people. Outcomes from AIDS (14 out of 95 statements, 15%) rents. But also the traditional birt these people are trained that they One of the more interesting, and perhaps problematic, categories to emerge from the key informant interviews in terms of community social factors contributing to AIDS was the listing of some of the effects that AIDS is having on the community, such as Orphans, Lack of Development or Loss of Labor, Care for the Ill, and Deaths Causally, one can imagine that the effects of these outcomes of AIDS do contribute to the current AIDS situation. Each of these issues can lead to a reduction or reallocation of resources, which has the potential effect of making people more vulnerable to many of the ot her factors already identified as contributing to the AIDS situation. Statements such as, Because, lets say if somebody is sick with HIV/AIDS, he or she is not able to work properly as a result he or she is unable to find thing, because when

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261 Appendix H: (Continued) you are in health you can find means or ways of finding things of finding what you want, underscore that the other side of loss is need. Nevertheless, it is unclear whether such st atements are simply a voicing of problems related to AIDS. A matter of concern is whether the question posed to informants was clear on this dimension or whether the way the question was asked elicited issues that are more the result of AIDS than the cause. It is also significant whether these seemingly different concerns are meaningfully arranged together, constituting a singl e cultural domain for the person interviewed. Risk Behaviors (10 out of 95 statements, 11%) Some risk behaviors were identified as possi ble factors contributing to the spread of AIDS in the community. Most significant was Alcohol mentioned by 5 of the 16 informants. Drinking alcohol was thought to encourage unprotected sexual encounters with new partners. Likewise, drinking alcohol placed people in venu es where such behavior is considered more permissible, such as bottle shops. A nother risk behavior identified was Traveling to Urban Areas for Employment. Again, sexual encounters were seen as more frequent in such areas and were thought to lead to encounters with partners who had unknown sexual and medical histories. However, there is clearly an economic dime nsion to this action, as underscored in the following quote: There are some people who go to South Africa to get employment. They leave their wives here, then there they may be get ED ZI, transmit to their wife and again their wives start moving with other men after their husbands have gone again to South Africa. They do so maybe because they want to find money to he lp themselves. In so doing the disease is increasing. Multiple Partnering was also mentioned by two of the informants as a risk behavior for AIDS; however, no particular reference to s ituations that lead to multiple partnering were offered. Knowing Ones HIV Status (6 of 95 statements, 7%) Another category is a concern for People Not Knowing Their HIV Status/Not Getting Tested Blood testing for HIV/AIDS is a recent phenomenon in the community. In some ways, testing was seen as a potential answer to the AIDS problem. Interviewees assigned importance to this practice based on the hospitals recommenda tion, with little thought about the post-testing steps that would need to be taken, particul arly among those who tested positive, to actively prevent further spread of HIV/AIDS. Here, agai n, a certain moral undertone slips into the

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262 Appendix H: (Continued) discourse, as people suggest testing as a strategy that young people use to help them pick safe partners for marriage, disregarding the poten tial or reality of premarital relations. Witchcraft (1 of 95 statements, 1%) Only one informant mentioned witchcraft as a potential cause of HIV/AIDS. The limited dialogue regarding witchcraft was surprising, sin ce the researcher had heard illnesses attributed to jealousy several times during the participant obser vation process. In this parlance, jealousy is linked to witchcraft, in that the jealous person would have sought the aid of a witch to strike at an individual who is thought to have unfairly or unjustly prospered. Despite such comments expressed in more general conversations, the interv iews only elicited one mention of supernatural forces in the production of AIDS. It is not clear if this resulted from a lack of association between AIDS and the illnesses that it ultimately manifests or if there is a reticence to talk about such matters, for fear that such ideas would app ear unseemly to individuals from outside the community.

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About the Author Jon Aaron Poehlman was born in Columbia, Mo., in 1971, and grew up in Leesburg, Va. He received a bachelor’s degree in Anthropology with a minor in Urban Planning from the University of Virginia in 1994. In 1998, he completed his master’s degree in Applied Anthropology at Georgia State University (Thesis: Moral Treatment and Institutional Practices: An Examination of the Self-Reporting of Rights Violations in a Forensic Mental Institution ). While in the Ph.D. program at the University of South Florida, Mr. Poehlman worked for the Florida Prevention Research Center, where he conducted qualitative research. He also taught classes in the Department of Anthropology. In his r esearch, he is interested in the application of cognitive cultural theory to health-related behavior-change activities and community-level prevention interventions.


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Community participation and consensus in HIV/AIDS prevention
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ABSTRACT: After more than twenty years of increasing understanding of the human immunodeficiency virus known as HIV, the virus continues to spread throughout the world, manifesting itself lethally in the form of the Acquired Immune Deficiency Syndrome (AIDS). With no cure or affordable treatment presently available for the majority of the people of sub-Saharan Africa and the African nation of Malawi, work aimed at preventing the spread of the virus continues to be the best strategy for lessening its impact, both at a personal level and across populations. Most people and communities in this part of the world demonstrate some understanding of HIV and its impact, and strategies such as condom use and abstinence education are familiar program interventions. However, less is known about how social and cultural processes influence personal risk taking and decision making related to HIV/AIDS.In this research, participatory research activities involving planning and producing dramas provide a venue for exploration of how rural Malawian communities can investigate and confront HIV/AIDS social causality through analyzing, planning and acting, presenting, and critiquing research. This research studies the role that shared agreement or consensus plays in developing a community's AIDS-related knowledge and in creating community-specific priorities for AIDS prevention activities. This aspect of the research is significant for applications of participatory research in community AIDS work. The research was designed so that information was collected from individuals participating in the interventions both before and after the interventions. This was intended to facilitate a better understanding of how participatory research affected group knowledge.The analytical process of Cultural Domain Analysis was used in conjunction with the non-probabilistic analytical technique of consensus modeling to gauge whether changes in agreement or consensus occurred as a result of participatory activities among intervention groups.
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