HIV and AIDS awareness programs in remote areas of PNG: an evaluation of VSO PNG Tokaut AIDS impact in the second year of activity.

Levy, Catherine

Abstract

VSO Tokaut AIDS started early 2005, first recruiting and training, then touring two local theatre troupes, Kunai Paia Tieta in Raikos (Madang Province), and Bismarck Range Tieta in lower Jimi Valley (Western Highlands Province). The troupes have been operational since August 2005, using scripted theatre as well as Forum and Image Theatre and peer group discussions to create a community-based dialogue on the need for behavior change in the context of HIV&AIDS. In an effort to evaluate the impact of this work, research was conducted in both districts in June 2006. This research follows on the baseline research carried out by VSO Tokaut AIDS in March 2005, before the start of the awareness interventions. This article presents the results of the research.

Key acronyms: AIDS Acquired Immunodeficiency Syndrome; HIV Human Immunodeficiency Virus; PLWHA People Living with HIV&AIDS; PNG Papua New Guinea; STI Sexually Transmitted Infection; TB Tuberculosis; VSO Voluntary Service Overseas

Introduction

The VSO Tokaut AIDS Awareness Community Theatre (ACT) program is focused in the two remote, rural districts of Raikos (Madang Province) and lower Jimi Valley (Western Highlands Province). The ACT program utilizes a layered, multi-sectoral approach to promote positive behaviour change in order to reduce risk and improve the lives of community members, especially women and youth and people living with HIV&AIDS.

Community-based theatre troupes have received extensive, on-going training on the techniques of scripted theatre (drama), Forum Theatre and Image Theatre as well as facilitation and peer education techniques. These troupes are then supported to implement awareness work in the districts.

Target communities are first visited with the scripted theatre, which presents basic education on HIV transmission and the nature of the virus. The theatre presentation is followed by in-depth discussion in peer groups, where the community divide themselves according to age, gender and marital status. Formal discussions are followed by informal opportunities, as the troupe generally remains in the community for two days.

The second time the community is visited, they are introduced to Image and Forum Theatre, where the players reflect behaviours common to the community and associated with HIV transmission. The audiences are taught to raise their hands and interrupt the action when negative behaviours are portrayed. Women are encouraged to speak out and share their perspective. Forum creates an opportunity for the community to speak openly about social problems and begin to formulate solutions for these problems. Again, the theatre is followed by in-depth peer group discussions to further imbed knowledge and understanding and to open a dialogue on behaviours that threaten the health and well-being of the community.

Methodology

In each of the two districts, a total of 48 in-depth interviews were carried out, disaggregated in sub-samples per sex (50% males, 50% females), age (50 % aged 15 to 24 years old, 50 % 26 to 35 years old) and location (50 % living on the 'central' area, 50% in the 'remote' area). Added to this, a number of specialized community agents have been interviewed in each location according to availability. These agents consisted of community and church leaders, hospital and aid post staff, teaching staff, women's groups and district administration. Following the introduction of HIV&AIDS material in the primary school curriculum, male and female students of upper grades (6,7, and 8) were interviewed during focus groups. Main results

Elements of community context

The Raikos district encompasses a large geographic area with varied terrain, coast, mountains, valleys, and islands. The cultural multiplicity becomes apparent when one examines on the map the parallel 'linguistic stripes' perpendicular to the coast. Every village along the coast features a different language and therefore a different culture. This brings to light the language-related challenges likely to be faced by the theater troupe. Added to this mosaic is the 'beach vs mountain' dichotomy, within one single language group.

The research has identified at least three key information centers within the Raikos in Saidor, Malalamai and Teptep. It appears that communities turn towards these centers for schooling, health services and also cultural influence. In the context of the Tokaut AIDS program, this means that information delivered to the villages will be supported by influence from the hospital, the school or the district administration this particular village turns to. On the level of mission influence the area is shared by the Catholic and the Lutheran churches. By contrast, the Lower Jimi presents a simpler picture, with one language, one geo-cultural area, and one main religion (Anglican).

On the level of social structure, in both areas, the social unit appears to be the clan. The clan leader will therefore be the community leader. In some areas, he may also combine these functions with that of church leader.

General knowledge

The large majority of respondents express no clear distinction between HIV and AIDS, but more significantly, they appear to express little interest in the distinction. Both HIV and AIDS are referred to as binatang (Tokpisin for small insect or small live thing); the disease is referred to as sik nogut or sikaids. Spontaneously it is said tha tit is a new disease, that there is no cure, and that it is spreading through the world and through PNG.

For all respondents, the feeling is that the disease is near, is inside the community. This strong expression of fear evokes a likeness with traditional fears, in analogy with sik bilong ples (a disease associated with traditional black magic, in opposition with sik bilong hausik, that is treated in white man's hospital.

The respondents that appear to have most accurately integrated information about the disease are young people and students, and villages who have had more than two visits by the Tokaut AIDS troupes. Their acute interest is expressed in the memorization of the drama and peer group discussions. Compared to the previous year's research, there are fewer but still existing rumors that transmission could occur through animals.

All respondents express a feeling of inevitability: there is a perception that the disease is progressing and will reach the community; the urgency is in minimizing the damages.

Transmission

General awareness of modes of transmission and of prevention has considerably increased. One of the most salient features of the research is that ALL respondents accurately identify at least one of three modes of transmission (sexual) and a large majority of them are able to add transmission through blood contact. Transmission from mother to child is present in the mind, but not always as clearly. Knowledge of the main modes of prevention of HIV&AIDS have been integrated as abstinence, faithfulness within a relationship, care with fresh blood, and the use of condom--even by the opponents to condom use. A consequence of this increased awareness is less rumours and untrue stories, and less irrational fear of the disease. For diagnosis, emphasis is put on the need of a blood test to establish infection with certainty, with less emphasis than last year on external signs and symptoms of the disease.

Respondents outside the district stations, particularly women, express a lack of confidence in their own knowledge, feeling unsure they know enough and asking for confirmation. Illustrative of this attitude is their answers to risks associated with non-sexual practices: when asked, the majority of respondents refer to their awareness that there are only three modes of transmission, and their rational answer is that there are no risks associated with sharing utensils, a bathroom, a towel ... Beyond this rational knowledge however, and especially in remoter areas, respondents express doubts, further uncertainty and additional need for reassurance: is there really no risk of contamination through saliva, urine, excreta, insects, etc?

Sources of information and impact of Tokaut AIDS information

The Tokaut AIDS' interventions of theatre performance and peer group discussions are (not surprisingly) on top of the respondents' mind as their source of information about the disease, and are unanimously appreciated for their lively techniques, the accuracy and reliability of the information and their perseverance in making repeat visits to remote communities. Perception is that the information is structured in two levels: theatre to attract an audience and retain attention, then the peer group discussions for in-depth, personalized information. Community theatre acts as a social revealer in reflecting negative behaviours in the community, and by providing an opening to information from the outside world. The interactive character of the forum theatre technique provokes open discussion and strong audience involvement.

A particularly illustrative example is the one of the drama 'Kopi man i go spak' presented in Jimi. A Jimi man travels to town to sell his coffee beans. The man 'loses his way' while in town, and spends significant cash on beer and women. Prior to the theatre presentation, most women in Jimi had no idea that men were making so much money from coffee crops... and spending it all before coming back home. The presentation provoked lengthy, open community discussions, with women accusing men of deceit... and men either ashamed or denying the reality of the script. This example shows how the drama addresses social issues, particularly gender inequality. This has resulted in a new assertiveness among women, as opposed to the previous helplessness (identified in the 2005 research).

Local theatre troupe members are focus personalities in the awareness work, and are viewed as role models 'for better and for worse'. As teachers and learners, they provide an opening to the outside world and the perceived quality of the Tokaut AIDS training makes them reliable and trustworthy sources of information. On a negative level, their behaviours are scrutinized and criticized, especially if the troupe display behaviours associated with 'town'. Examples given are the use coarse language outside of theatre presentation, together with playing cards and gambling and (rumoured) loose sexual behaviour.

The presence and style of Tokaut AIDS interventions encourage communities to 'tok aut na tok stret' (speak openly and clearly), which is unanimously recognized by all respondents as a REMEDY to the spread of the disease beyond traditional taboos and beyond religious taboos ('Tok stret, em i marasin bilong dispela sik'). Catholic churchgoers, however, subscribe less heartily to this opinion.

Tokaut AIDS has triggered increased communication around HIV&AIDS, with community and church leaders, health and teaching staff supporting the dissemination of the information. Findings show that cross-generation communication appears as developing as parents express a desire to better educate their youth. This desire is however limited by the parents' lack of practice in discussing sexual matters in general. Research revealed that traditional sexual education for women is as good as non-existent, while it was, and in some cases still is an aspect of young men's initiation. Parents focus their concern on the well-being of their growing children, but are concerned that the message is perceived only superficially ('Avinun ol i harim, nait ol bai i lus tingting'--they listen in the afternoon and forget at night).

Cross-gender communication, between men and women and between husband and wife is still weak. Respondents express little or no 'cross-gender' awareness, probably in line with the traditional gender separation. Interviews show that some couples talk together, and they are ususally those who get along well and experience no major communication problems.

The issue of the language used illustrates the challenges--and opportunities met by the theatre troupes in their respective areas. In Jimi, the use of the one local language, Mareng, ensures that the message is clear, and is accessible to the whole community. Moreover, it awakes in the audience a feeling of propriety, allowing them to 'own the program'.

By contrast, the necessity to use Tok Pisin in multi-lingual Raikos, and the choice of vocabulary appear as one of the major challenges in that area. The overwhelming majority of respondents in the Raikos express clear disapproval of the choice of words--and the frequency of their use--to describe sexual body parts and behaviour. The offensive aspect of this part of the program appears to jeopardize its impact and needs to be addressed (1). By addressing issues of sexual behaviours, the program breaks a triple taboo: the traditional one, then the missionary one, where in both cases, sexual matters were not brought out in the open. By using what is considered 'swear words', the troupe then stumbles on a third obstacle.

Perception of impact of Tokaut AIDS

Most respondents admit observing SOME change, 'senis liklik', whether on a personal or community level, on a generation level or on a gender level. The general feeling is that a better awareness of transmission and prevention allows for a less indiscriminate fear of the disease. Fear is still very much present, but appears to be more specific, to be dealt with more practically and rationally that in 2005.

Respondents identify risk behaviour (multiple partners, unprotected sex), risk circumstances (social gatherings, coffee or cacao season that involve cash movements) and risk groups (young people, promiscuous people or their partners, women attracted by the possibility of some 'cash' earnings). The inhabitants of more remote villages are perceived at risk, because of their lack of awareness, while the station inhabitants are perceived at risk because of the temptations that are offered to them: the availability of cash, beer and transient persons. Despite the clarity of the risk involved, respondents also express the perception that information has not been fully integrated yet, therefore slowing the change in behaviour.

For the large majority of respondents, condoms are top of the mind as a mode of prevention against HIV and AIDS, together with faithfulness within the relationship. There is a greater acceptance of condoms than observed in 2005. Condoms are almost perceived as normal by the most progressive respondents. However, a very strong duality is expressed, best summarized in the quotation: 'Condom I orait, tasol I no orait tumas' (Condom is good, but it not really good).

On a positive side: condom is perceived as a reliable solution for a new problem, a modern solution, that is being 'de-Satanized' as arguments against it are slowly crumbling. For a number of respondents, especially the older ones, condom is a 'lesser evil' solution, where it is perceived better to let people use condoms, and THEN try and change their behaviour, as not using condoms may result in no opportunity to change behaviour.

On a negative side, condom is still strongly associated with 'sinful behaviour' (sex before and outside marriage, contraception), especially for the Catholic and to a lesser extent, the Lutheran churchgoers. Condoms are also perceived as new, and their use has not been fully integrated. Respondents' reserve is such that they often do not mention condoms spontaneously, even if they display a good knowledge of them once asked. Finally, their access is difficult in remote areas, and even in Saidor station, where they are not offered anonymously.

Women's capacity for sexual negotiation is now a topic easier to discuss than in 2005. Women are less shy to talk about sexual matters and to acknowledge the place of sex in married life. As in 2005, respondents refer to circumstances allowing or calling for traditional sexual negotiation, such as menstruation, pregnancy, breastfeeding, a new garden preparation, or tribal fights. The Tokaut AIDS information has led to an increased awareness of risk behaviour. There is a perception of improved sexual negotiation ability for women outside marriage. Especially young women express that they are able to demand a condom, or to refuse to have sex. Some women indicate that they have given up multiple partners, and/or choose to marry. Some married women demand a condom from their lover in extra-marital circumstances.

There is not much talk about women's RIGHTS, rather an awareness of a HUMAN right to survive, to not be infected. Within this scope, and despite their increased awareness, as in 2005, most wives find it difficult or impossible to negotiate sex with their husbands. Married women's progress in sexual negotiation with their husbands is still directly dependent on the husband's goodwill and open-mindedness.

Side issues related to marital sex are for instance the fear of sterility, which will push men to turn to another woman. Reasons given by women to refuse sex can be fear of pregnancy, tiredness after work, suspicion that her husband is seeing other women, and polygamy. Also expressed is the understanding that when a woman's refusal of sex to her husband gives him an ('acceptable') argument to see other women.

Added value from the Tokaut AIDS methodology, particularly forum theatre and peer group discussions, are that women are becoming empowered by techniques that encourage them to ASK questions (traditionally frowned upon). At this level, Tokaut AIDS fulfils the role of a 'tokskul' (school through talk, discussion), which brings deep changes in a society where traditionally there is little invested in women. Women's budding assertiveness is causing stirs in the gender and social relations, but will require support to prove sustainable.

Person living with HIV and AIDS

Not one person living with HIV or AIDS has come forward openly in the last year within the target districts. Therefore, discussion around PLWHA's presence within the community remained at a 'theoretical' level. On a rational level, the increased awareness leads to a more rational approach of the concept of PLWHA and the feelings associated with them. However, the emotional reactions and irrational fears are still strongly expressed, together with suggestions of discriminatory reactions in the event of a community member revealing him/herself as HIV+. Tokaut AIDS organized the visit of Thomas Keleya, and HIV+ activist, to Jimi in November 2005. His visit has been described as 'a wish become reality', to see a PLWHA with one's own eyes. Fear had created expectations of a horrible sight, sores, purulent skin or gaunt cheeks. The appearance of Thomas, who has been HIV+ for 11 years was a surprise to all: 'He looks normal!' The reactions to his visit were mixed: from frank open curiosity ('What does a person with HIV look like?'), to a lessening of the fear (' He looks normal, so he makes people want to behave normal'), to disbelief (' He can't be sick, besides he did not transmit to his wife and child?') Still present and openly expressed was the irrational fear of transmission, expressed through rejection of Thomas. Some people would avoid shaking hands and kept a physical distance.

Respondents stated that those who were able to accept Thomas could do so because he is only a visitor. They stated that Thomas is 'only' an outsider, he is not staying within the community, and is not one of his members. This reasoning was echoed in a number of responses about reactions to the HIV+ person: a non-community member would most likely be (politely but firmly) asked to leave. A community member would be accepted, according to traditional community ties and practices, his behaviour would be strongly regulated and monitored.

HIV and AIDS in education and health

The introduction of HIV&AIDS in the primary school curriculum is perceived by teachers as a necessary, albeit challenging step. Teachers acknowledge the quality of the training, the support given by Tokaut AIDS, the value of community networking and their own motivation in protecting the youth. They recognize that as educators they are going through 'growing pains' while tackling this new topic. Challenges are in the difficulties of teaching a sex-related topic, the identification of the adequate level of language and the necessity to gain the parents' support. Some teachers express their perception of a fine line between informing the students and 'pushing them' towards sex. Teachers also mention having to look for a strategy to overcome the parents' traditional or religious beliefs.

The impact of church influence may be appreciated, as research findings contrast the synergy experienced in Jimi, where the Anglican church and church personalities, voice and enact active support to HIV&AIDS awareness. This unity and enthusiasm is compared with the less unanimous leadership in the Raikos, where there exist opposition to awareness efforts and a lack of outspokenness of the part of the Catholic church.

Health staff in the district express their active support to the awareness program, while noting the difficulty in accurately documenting trends. In both health centers, training has made staff sensitive to the need for keeping records such as incidence of STI's, domestic violence, and to the benefits of counseling and of awareness sessions. Health staff's opinions are respected by the community. Aid posts in the remoter areas could be a valuable asset within the awareness network, but are still facing a shortage in qualified staff and lack of resources and support.

Conclusions

The results of the 2006 evaluation research reveal a huge learning curve characterized at different levels:

* An increased confidence on the respondents' part towards being interviewed, and in answering direct questions. Respondents also reflected increased comfort towards the topic of condoms and sexual behaviours.

* A clear and unequivocal appreciation of Tokaut AIDS, as a program that presents accessible solutions to the HIV&AIDS problem through open communication.

* The program is perceived as helping the communities grow through increased knowledge and confidence. The program strengthens self-reliability by putting the solution in the hands of the community.

* Investigation shows an increased awareness of transmission, prevention and diagnosis, with little interest for difference between HIV and AIDS.

* Impact on attitude: respondents display more balanced reactions, especially towards behaviour change, risk management and the concept of PLWHA. On an emotional level, however, a strong irrational FEAR is still detectable, comparable to fear of sanguma (traditional black magic): like sanguma, HIV is invisible and cannot be cured.

* Impact on behaviour: respondents agree on the perception and expression of SOME change, testified by such examples as increased condom use and young (unmarried) women talking about their own assertiveness (they can say no to sex, they can demand condoms). Women demonstrate more confidence in handling condoms (Jimi). Some older respondents overcome traditional taboos to protect the young ones: they try and speak openly about sex, they accept condoms as a 'lesser evil' prevention measure.

* On the topic of PLWHA: the research gathered 'theoretical answers' as no known HIV+ person has come forward. Respondents rely on their awareness of transmission and prevention to feel rationally 'safe'. Emotionally, however, the prevalent fear suggests that if tested by the presence of a PLWHA, probable reactions of rejection and segregation, might result in social fractures in the community.

* Among older respondents, the research has identified a shift in concern from themselves to their children. Older respondents worry about their children's behaviour and ability to manage risk. The research has identified major challenges:

* The size of the territory considered, the spread of population and multiple language groups has meant that many communities have not yet been visited. Tokaut AIDS initiatives and the expectations they awaken through word of mouth work in a 'ripple effect'.

* The memorization of HIV&AIDS awareness is not yet fully integrated. There is a need for repetition, even of basic facts.

* The breakdown in cultural structures creates a perception of a 'void', in which young people are no longer safe within traditional social boundaries. This induces, within the youth a cynicism, a lack of fear and a tendency to not take risk seriously. It weakens women's traditional sexual negotiation ability.

* Traditional leaders are respected, but not necessarily listened to. They are not the trendsetters as are the younger men (and women) who follow white man's behaviour and parameters.

* Cultural/religious barriers can be an impediment to the spread of clear, correct information about HIV&AIDS. The program needs to identify, then educate and thus convince the church leaders of the value of HIV&AIDS education.

* The troupe members are viewed as role models and they are being scrutinized as such 'for better and for worse'.

* Mind your language! The program faces the challenge of addressing language barriers while giving accurate information. In areas where the troupe cannot work in local language, acceptable expressions in Tok Pisin have to be identified or some level of work in local language, lest the impact of the awareness efforts should be jeopardized.

* In order to strengthen the communities' response, the program should add a cross-generation dimension, as parents are struggling to implement already. Cross-generation work could move slowly towards cross-gender communication, through working from inside the family circle.

* Manage the spin-off benefits of HIV&AIDS awareness for sustainable results. Women's increased knowledge and budding assertiveness need to be strengthened and supported from a global community perspective, not from an outsider's perspective.

* All network stakeholders need to be brought 'up to level': differences in the quality of the skills and commitments in teachers, health staff, district administration, police, village health volunteers and workers, peer educators, need to be addressed for optimal cooperation.

The perception emerges from the analysis that the program stands on an enlargement threshold phase. After having met the population's basic expectations, that is, knowledge about transmission and prevention of HIV&AIDS, the challenge appears to be in identifying the most efficient, credible and sustainable paths to follow. For example, the option to further the work on gender issues would demand extreme cultural sensitivity in order to preserve the fine line between intervening /influencing and managing to reach a new balance. Tokaut AIDS acts here clearly as a 'stirrer', disturbing cultural layers and provoking new mixes. Any intervention would require a thorough assessment of the cultural context. For instance, what are the traditional and new roles, what is women's realistic access to change, what is men's access to growth? 'Win win' solutions would need to be identified and promoted to gain the community's full support. Within this context, one should beware of 'intellectual colonialism' or even of colonial-like intransigence. As respondents themselves suggest: Go slowly and consolidate the steps.

(1) The external evaluation was conducted in July 2006. By August, the theatre trainers had met the need for less explicit Tokpisin language usage in the Raikos. The Raikos troupe now uses the terms 'bol bilong man', 'rot bilong karim pikini'and 'bungim boi', rather than the stronger, popular language of 'kok',' kan' and 'koap'.

Catherine Levy has a doctorate in linguistics from the University of Brussels. She conducted her research in the Awar language on the north coast of PNG. Her professional interests include community and grass-roots-based projects especially regarding literacy and cultural conservations. She has been involved in HIV/AIDS-related social research and adult literacy since 2005. Her projects include the creation of HIV/AIDS awareness material in Mareng language (Jimi Valley, WHP), research into optimisation of distribution and use of this material in 25 Mareng-speaker villages. She will be doing further work with Tokaut AIDS, with the next evaluation planned for June 2007. Email: levied@scubamadang.com.pg