Challenges hindering youth from acquiring knowledge about HIV/AIDS in the internally displaced camps: a case study of Dar el Salaam camp in Omdurman-Sudan.

Mohammed, Hassan Abaker

Introduction

People destabilized by armed conflict, including refugees, internally displaced persons, in particular, women and children are at increased risk of exposure to HIV infection (United Nation General Assembly 2001). The above quotation suggests that internally displaced persons in general and women and children in particular are among the most vulnerable groups who are exposed to an increased risk of contracting HIV/AIDS. As a matter of fact, a number of factors may facilitate the prevalence of the disease among the IDPs. On one hand, the vulnerability of the women emerges from the fact that they are at increased risk of sexual violence and abuse during conflicts and wars (Amowitz et al. 2002, p. 329). This is because at the time of conflicts, rape was considered a weapon of war. Moreover, conflicts and wars usually break down the institutions as well as the social networks that provide support and protection to the women (UNESCO and UNHCR 2007). On the other hand, the psychological effect which is caused by the exposure to the mass trauma during wars leads to alcohol and drug abuse, especially among young people. This may influence their attitudes towards risky behaviors such as unsafe sexual practices that lead to sexual transmitted diseases such as AIDS (UNESCO and UNHCR 2007).

In the absence of an effective medical cure or vaccine, knowledge and awareness about HIV/AIDS are considered the most powerful weapons against the disease (Kelly 2009). The question posed here is: From where do vulnerable people in IDPs situation acquire knowledge about HIV/AIDS? To answer this question, this paper aims to identify the main channels from which young people in Dar el Salaam IDPs camp in Omdurman-Sudan acquire knowledge about HIV/AIDS.

The researcher will first highlight the methods which used to collect data in this study, then will explain how samples for this study were identified and selected. Discussion of the ethical issues that were considered will as well take place, followed by illustrating the qualitative research methods which followed in this study. Following that, will be discussed against studies done on similar issues, the researcher will provide some recommendations and conclusions for further studies.

Dar el Salaam IDPs Camp

For more than two decades, Sudan has suffered from prolonged civil wars. The marginalization of the south, southern Blue Nile, Darfur, and western regions from the sustainable development schemes as well as the unwillingness of the successive governments to acknowledge the country's ethnic diversity were among the main reasons behind those civil wars (IDMC 2010). These civil wars forced a number of people to flee their homeland and live in IDPs camps around the main cities in the country. The study area, Dar el Salaam camp in Omdurman represents one of these camps.

The camp was established in November 1991 (The National Center for the IDPs, 2005). The number of the IDPs in the camp is estimated to be at 120 000 people, according to the Sudanese National Center for IDPs (The National Center for IDPs 2005). The populations of the camp are from different ethnic groups, including South Sudan (which now is an independent country), South Kordofan, Southern Blue Nile, and Darfur states. The government divided the camp, according to the residence location of each group in the camp. Each ethnic group is led by a tribal chief who is officially called the 'Sultan'. A tribal chief from Nuba ethnic groups informed me that the Sultan's role is to referee in quarrels that occur between people in his own tribe, keep the discipline, and help his people to get services that offered by the Non government organization (NGOs).

HIV/AIDS situation in the camp

World Health Organization (WHO) stated that, "Internally displaced persons are the most vulnerable groups to health problems including HIV/AIDS" (Mooney 2005, p. 17). In line with this view, the Sudanese National AIDS Program (SNAP) targeted IDPs as one of the high risk groups when conducted a Behavioral and Epidemiological survey in 2004 to assess the magnitude of HIV/AIDS in the country. A total of 470 blood samples were tested and out of those 20 IDPs were found positive (SNAP 2004). The area targeted by the study was among the areas targeted by SNAPS. Moreover, in 2006 Al Wifaq Charity Society, a community based organization working in the camp, conducted a health program for the IDPs living in the camp. A Voluntary Tests were offered to them. The general secretary of Al Wifaq Charity Society affirmed that the test identified 18 HIV positive persons (Al Wifag Charity Report 2006).

The information confirmed that the camp is infected by HIV/AIDS. This poses some questions about the knowledge and awareness young people in particular acquire about the disease in the camp. The study is guided by the following questions:

1- Do people in Dar el Salaam camp know the different health consequences of HIV/AIDS?

2- Does youth know its modes of transmission and prevention? If so, what are the channels that influenced their knowledge acquisition?

3- Are there any positive socio-cultural factors that may facilitate acquisition of knowledge about the disease?

To answer such questions the researcher had to choose appropriate methods to probe deeper with the identified participants to recognize the factors that influence their acquiring and internalizing of knowledge about HIV/AIDS. The next sub-section will discuss the methods applied in this study.

Methods

Qualitative methods were applied to answer the question about the channels as well as the positive factors that may facilitate the acquisition of knowledge about HIV/AIDS for young people in Dar el Salaam IDPs camp. The research aimed to study the socio-cultural aspects that influence the respondents acquiring of knowledge about HIV/AIDS. Therefore, qualitative methods such as semi-structured interviews, focus group discussion, and observation were identified appropriate to explore in-depth the different aspects of HIV/AIDS acquisition of knowledge as revealed by the target group in the camp. Such tools of data collection were identified to be helpful to understand the 'world' of young people in Dar el Salaam IDPs camp, referring to their own 'words' (Chambliss and Schutt 2006). The respondents were allowed the opportunity to elaborate on their answers through the open-ended questions and the following-up questions. This helped the researcher to understand how knowledge about the disease is constructed. In the sections the researcher will briefly present these approaches of data collections and discuss their appropriateness to the study.

The study sample

Purposive sampling strategy was applied in choosing the participants for the study. Beside the young people in Dar el Salaam IDPs camp, the study sample included tribal chiefs, and senior staffs from NGOs.

The first participants in the interviews were identified by a senior staff at Al Wifaq Charity Society, where the researcher conducted all the interviews at one of its offices. Then, the researcher with the help of the organization members the researcher informed other interested friends and relatives to come and participate in the study. Thus a snowball sampling was used in this stage of the research whereby one participant brought another interested participant to contribute to the study and so on, the method was recommended by Bryman, 2008. Two major reasons made this technique useful for this study. On one hand, the insecurity situation in the camp, which was made by the so called "Negers Groups" necessitated that the researcher applies such method of sampling. These are outlaw groups engage in illegal and risky behavior such as drug abuse and robbing people in the streets. The researcher was not allowed to move alone in the camp and had to inform in advance a security officer every time the researcher was entering and leaving the camp. In such situation it was difficult for the researcher to contact young people in the camp directly so as to identify the sample of the study.

On the other hand, at the time of the fieldwork there was a great political tension in the camp due to the southern Sudan referendum. The tension was between the supporters of the National Congress Party who call for the unity of Sudan and the followers of the Sudan People Liberation Movement who call for the separation. This great polarization made the people in the camp, consider any organized activity as a political one. In other words, people thought the study can influence or change their decisions. Therefore, the snowball sampling strategy was useful for this study.

Ethical issues

When conducting a social research in general and with vulnerable groups, such as IDPs, in particular, significant moral issues must be considered (Brymen 2008; & Kvale and Brinkmann, 2009). Some of these issues are identified by Flaskerud and Winslow 1998 when they argue that:

Research with vulnerable populations, challenges us to consider once again ethical principles basic to research. The issues of providing informed consent, maintaining confidentiality and privacy, weighing the risks and benefits of a study, paying attention to issues of fairness are all especially important when working with groups who are vulnerable (Flaskerud and Winslow 1998, p. 37).

To elaborate on the above quotation, the researcher must ensure that his/her participants will not suffer from their participation in the study. In other words, researchers, who conduct their research with vulnerable groups, must avoid anything that may hurt or cause any kind of harm or pain to their subjects. To do so, the researcher had to inform in advance their participants about the kind of study, they are carried out and how the information that they will offer may help them to understand different aspects of the topic under investigation so as to provide effective solutions to them. Furthermore, the participants must have been informed that their participation is not compulsory and they have the right to withdraw at any time of the study and the information which they offered will be deleted (Bryman 2008, & Scheyvens and Storey 2003). Accordingly, and in reference to this paper, the researcher had prepared an informed consent, including all the previously discussed points. Before each interview or focus group discussion session, the researcher read the informed consent to the participant and explained to him/her in details its content. Moreover, the researcher informed the participants that they can ask any questions before they decide whether to participate or not. During the interview sessions, the researcher made it clear to the participants that they have the right to preserve any ideas that they do not feel comfortable to talk about and ask to skip to another question. By this technique the researcher, aimed to minimize any discomfort or fear that the participants might have developed. To do so, the researcher relied on the experience he acquired as a teacher to overcome the power imbalance might be created between him and the participants. It was not difficult to for the researcher to direct and control the interview sessions with them. Such power imbalance might have influenced the data, especially with the vulnerable groups who may provide insufficient information because of the discomfort they feel. This is in line with Schevens and Storey 2003 who claimed that "When approached by outsiders marginalized groups will usually show deference" (Schevens and Storey 2003, p. 149).

Semi-structured interviews

Semi-structured interviews, as an approach of data collection, has an important feature which makes it appropriate in reference to this paper. Using this technique, the researcher used to prepare in advance a number of questions to be asked to the subject. These questions tend to stimulate the interviewee to express his/her point of views about the topic under investigation. Because the interest is on these reflections, and because of the flexibility of this tool the researcher has the opportunity to ask a number of 'why' and 'how' questions to follow-up the interviewee's respond. Such follow-up questions may help the interviewee to elaborate on the main question and provide tested knowledge about the phenomenon under investigation (Bryman 2008). In reference to this study, the researcher conducted semi-structured interviews with the young people in Dar el Salaam IDPs camp, senior staffs from NGOs and with the tribal chiefs. All the interviews took place at Al Wifaq Charity Society in the camp except the one with the senior staff from the Sudanese AIDS National Program (SNAP) which was conducted in his office in Khartoum.

Because each group of respondents had to provide a specific kind of knowledge, the researcher prepared different questions to guide the interview sessions. The researcher worded the questions in standard Arabic language which is a second language to most of the respondents. Therefore, after the third interview session with the young people, the researcher realized that some questions were difficult to be understood. Accordingly, the researcher had to reword and simplify some of the questions so as to be clear to the other respondents.

Focus group discussion

In the focus group discussion knowledge about a specific topic or problem is produced through the interactions between the group members. Each one in the group reflects his/her view about the stimulating question or point of discussion and the others comment on the idea. In this study two focus group discussions were conducted. Each group consisted of ten participants one with the males and the other with the females.

Observation

In this approach of data collection the researcher obtains knowledge about the specific topic or problem through his/her observation of the behavior of the targeted groups while they go through their everyday live activities (Chambliss and Schutt 2006). Such activities may be crucial to the study and may not be easy to obtain through other methods of data collection such as face-to-face interviews. In line with this, Bryman 2008 argues that the researcher has the opportunity to immerse him/herself in the social setting of the targeted groups and makes regular observations about it.

In reference to this study, the researcher adopted the role of the complete observer to gather the information from the field. The researcher was publicly known as a "researcher" because the security office informed the people in the camp in advance about the study and had to accompany the researcher in the camp. The researcher took notice about different aspects of the targeted groups' life in the camp.

Results and discussion

The result of the group discussion shows that young people in Dar el Salaam camp acquire knowledge about HIV/AIDS from the social environment around them such as their parents, friends and schools, as well as from some of their cultural practices. Therefore, Brenfenbrenner's ecological models of human development theory are relevant to the analysis and the discussion of these findings.

The core principle of this theory is that the development of the human, including his/her cognitive development, occurs during the mutual interaction between the developing person and the people in his/her environment over a period of time (Bronfenbrenner 1994). Bandura 1997, divided this environment into dichotomy, the physical and the social environment. The physical environment refers to physical factors around the developing person such as the size of the room, the availability of food, the temperature, etc., while the social environment refers to the people around the developing person such as his/her parents, siblings, friends, teachers, religious leaders, etc., (Bandura 1997). Consequently, the developing person acquires and maintains certain patterns of behavior or knowledge through a long reciprocal interaction between him/her and other people in his/her environment. Bronfenbrenner 1994 classified this environment into four main levels, the micro, meso, exso, and macrosystem. However, in this paper and because of the time and space limits, the researcher only looks at the one model of these layers which includes most of the channels of knowledge about the disease, namely, the microsystems.

The microsystems

Bronfenbrenner 1994 stated that at the microsystems level 'the psychological and educational development of the young person is achieved due to the face-to-face long-term between him/her and other persons in his/her closest surrounding such as the parents, siblings, friends, and close relatives' (Bronfenbrenner 1994, p. 39).

Elaborating on this quote the microsystems includes a number of other circles inside it. These circles represent the closest people to the developing person such as his/her parents, siblings, close friends, relatives and classmates at school teachers. In this circle the developing person is in a continuing reciprocal interaction between him/her and other people around him/her.

During this mutual interaction with the young person is influenced by the people around him/her while he/she can also influence them. This reciprocal influence is called bi-directional influence (Paquette and Ryan 2001, p. 8). Through this mutual influence, the young person acquires or may be prohibited to acquire a certain pattern of behavior or knowledge.

In reference to this study, and since messages on HIV/AIDS are considered as educational messages (Kelly 2009), young people in Dar el Salaam IDPs camp referred to a number of resources in their microsystems as their channels of knowledge about HIV/AIDS. Through the everyday interaction between the respondents and other people in their environment such as their parents, siblings, friends, and classmates at schools, young people acquire knowledge and awareness about the disease. These channels of knowledge are divided into three categories: These are: Family, school, and cultural practices. The next part of the paper discusses each category individually in the following sub-sections.

Family as a channel of knowledge about HIV/AIDS

According to the microsystems the home, which includes the closest people to the developing person such as his/her parents, play a crucial role in his/her cognitive skills and development. Knowledge about HIV/AIDS can be considered as a cognitive development of the young person. From his/her family member the young person develops an understanding of different aspects of the disease which can be turned later into behavioral attitudes. However, a few numbers of the participants in both face-to-face interviews and focus group discussion indicate to their parents and siblings as their source of knowledge about HIV/AIDS. Even those who mentioned their family as their channel of knowledge about the disease informed me that their parents did not explain them in details about the disease. A male participant informed: 'I first learnt about HIV/AIDS from my family. My mother talked to me about the disease several times. She always warns me to avoid sleeping (having sex) with any girl in this camp because they are all infected with HIV'. Other similar testimonies were provided by the participants who referred to their family as a source of knowledge.

These quotations do not include any educational messages about the disease. In other words, parents in this way are not teaching their children about the different aspects of the disease such as its modes of transmission or prevention. They actually increase their children's fears about HIV/AIDS and create a negative image of people who live with the disease. The Swiss Tropical Institute 2003 affirms that: 'Messages that scare people are often rejected or cause greater stigmatizations of the infected and often causing them to hide their being HIV positive' (The Swiss Tropical Institute 2003, p. 7). Accordingly, one can argue that concentrating on the negative side is a way of imparting knowledge about the disease may increase the sense of stigma and discrimination among the targeted persons. Accordingly, awareness-raising programs that target parents in particular should explain to them how to, positively pass or teach their children this knowledge. This kind of positive learning can be found more in the formal education system such as schools.

Schools as channels of knowledge about HIV/AIDS

In the absence of an effective vaccine or cure to prevent the virus, education, particularly formal education that leads to the behavioral change can be considered effective in controlling HIV/AIDS (Kelly 2009; Shaeffer 1999). In line with this, a number of participants who are still students in schools indicated that the school is the primary channel of knowledge about the disease. A female respondent from the focus group discussion put it as follows: "I first knew about AIDS from Al Andalus Organization (A community based organization that works in the camp). They came to our area and put some posters on the walls and spoke to the people about the disease. But I knew more about it in my school when a midwife came to our school and explained to us in more details how the disease transmits from one person to another as well as how can we protect ourselves from acquiring HIV."

A male participant also referred to his school as a channel of knowledge about HIV/AIDS when he said: "I heard about this disease from my friend but not in details. When I went to school, some people came to our school (NGOs) and told us about this disease. They showed us pictures of infected people and how the virus transmits from one person to another and how we can prevent ourselves from it."

The above quotations illustrate that the use of different pedagogical approaches which were adopted by the NGOs such as midwives visits, lectures, seminars and projector shows, may contribute positively in imparting and constructing knowledge and awareness about HIV/AIDS.

However, the role of schools as channel of knowledge about the HIV/AIDS is limited due to some factors. Firstly, most of the participants who mentioned schools as their source of knowledge about the disease referred to the NGOs' lectures and seminars that conducted in their schools. When the researcher probed deeper with the participants about the number of those seminars and lectures which were conducted by the NGOs, the researcher realized that most of them attended only one or two of these sessions. Those lectures took a length of a lesson which is 40 minutes. For educational perspective and according to researcher's experience as a teacher who teaches in both secondary and basic levels, these few lectures in this short time may not be sufficient to cover such important issue like HIV/AIDS.

Secondly, those lectures and seminars were conducted using standard Arabic language as a medium of instruction while most of the targeted groups in the study area belong to different ethnic groups such as Nuba, Nueer, and Dinka who mainly speak African dialects. In other words, the educational messages about the disease adopted cultural references (Arabic culture) differed from the targeted groups' (African cultures). By analyzing some of the materials used in those lectures the researcher found out that the language, of presentation in the camp and other aspects, mainly represents the Arab culture while the targeted groups' cultures are ignored. It is believed that such differences may limit the capacity of appropriate knowledge acquisition and internalizing knowledge about HIV/AIDS. Badri 1997 suggested 'the mismatched transplantation of any preventive model from one culture to another, even if it is successful in the original culture, can be as dangerous as the mismatched transplant of human organs' (Badri 1997, p. 211). Then, the materials of imparting and constructing knowledge about the disease may fail to achieve its goals if the targeted groups cannot effectively understand what it is about. In contrary to this, using the targeted groups' cultural reference may enhance their ability to grasp and internalize knowledge and awareness about the disease. A number of NGOs in the camp working in the field of HIV/AIDS realized this fact and adopted some of the targeted groups' cultural practices to impart knowledge about the disease. The next sub-section will shed a light on these cultural norms.

Cultural practices as channels of knowledge about HIV/AIDS

The findings revealed that the socio-cultural practices and beliefs of the young people in Dar el Salaam camp are among the important channels of knowledge about HIV/AIDS. The participants mainly reported that their tribal chiefs and religious leaders' speeches and women's songs to contain educational dozes and a channel through which they get to know about the disease. NGOs working in the field of HIV/AIDS awareness-raising realized the crucial role of these cultural aspects of the people. Therefore, they first targeted those leaders and used them as a means of imparting knowledge about the disease.

Taking the advantages of some special ceremonies such as the start of the autumn season, harvest, wedding, and funerals the tribal chiefs acknowledge people about HIV/AIDS. A tribal chief from Nuba ethnic group elaborated on this as follows: " Yes, with the help of NGOs working in the field of controlling HIV/AIDS, we arranged several health days taking advantage of some ceremonies and festivals (which are attended by a great number of people from the tribe) such as at the beginning of the rainy season or at harvest time (although they do not practice agriculture in Khartoum, they still celebrate these occasions). The day usually includes a projector show, free testing and counseling and I used to address the people directly about this severe killer which threatens our existence."

Women who sing in these ceremonies are led by women called Hakama. Badri and Abdel Sadig 1998 define Hakama as "a woman who composes and sings innovative songs that emphasize and transmit the society's beliefs, norms, and value system". Hakama is influential and respected by both men and women and by tribal chiefs' (Badri and Abdel Sadig 199, p. 16). The trained Hakamas composed songs which address different aspects of HIV/AIDS as well as the modes of prevention. During the interviews it was found that a number of participants who belong to a Nuba ethnic group, especially females, learned some verses of those songs. When asked by the researcher to translate it the content of these songs contained HIV/AIDS modes of transmissions and preventions.

The religious leaders, Muslim in particular, during a Friday sermon (a weekly mass important prayer for Muslim where they receive sermons from an Imam who leads the prayers) spoke to the prayers about the severity of the disease and how people can protect themselves from it. They use different verses from the Holy Qur'an as well as from the Prophet Mohammed's Hadith (prophet says) that forbid illegal sexual practices (sex outside marriage) or drinking alcohol which leads to sexual practices (Badri 1997).

The above mentioned cultural practices can be effective channels of knowledge about the disease for the young people in the camp. This is because these channels use the targeted groups' cultural contexts which may contribute positively to the understanding and internalizing of knowledge. For example, when the tribal chiefs speak to their people about the disease, they use the same language (Nuba dialect) which makes it easier for young people to understand than listen to the same information presented in standard Arabic language. Moreover, messages about HIV/AIDS that are presented in the form of songs may also be easier for the targeted people to understand, and then translate into behavioral change. Religious messages may, as well, be more effective since Muslim are influenced by these massages and believe in them.

Conclusion and recommendations

This paper highlighted the main channels of knowledge from which young people in Dar el Salaam camp built their knowledge and awareness about HIV/AIDS. The field findings revealed a number of sources from which young people in Dar el Salaam camp in Omdurman acquire knowledge about the disease. These are: Parents, friends, schools, songs, tribal chiefs and religious leaders' speeches. The socio-cultural aspects of the respondents such as tribal chiefs, songs, and religious leaders, can be considered as the most influential educational channel for the participants. This is because most of the other channels such as NGOs' lectures use standard Arabic language, which is a second and foreign language of the participants. Thus, it becomes difficult to educate people about HIV/AIDS through these channels, while these channels do not adopt the participants' language and cultural processes. Moreover, people evaluate the educational messages obtained from these channels that inform them using their own understandable language very high. The reason behind that is because these channels respect and evaluate the target group's cultural aspects. Accordingly, the following recommendations are made:

--When targeting multicultural zones, HIV/AIDS program designers and planners should put into their consideration the diversity of the cultures rather than rely only on one cultural reference to address people.

--Awareness raising programs should include and regard highly the targeted groups' cultural background.

--Other qualitative researches on the positive cultural practices that may facilitate and enhance understanding and internalizing of knowledge and awareness about the disease are needed.

Note on contributor

Hassan Abaker Mohammed was a Master Degree graduate enrolled in Norad's Program for Master Studies funded by: The Norwegian Program for Development, Research and Education.

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