Local communities helping to change behaviour

Realising that 20 years of awareness campaigns had failed, Cameroon's HIV/AIDS officials have asked local communities to come up with messages that will resonate among their members. Professor Jacques-Philippe Tsala Tsala, a clinical psychologist and family therapist in the capital, Yaoundé, is one of three experts asked in 2004 by the National Committee for the Fight against AIDS (CNLS) to help establish this innovative project in a country comprising at least 250 ethnic groups, each with its own language. "It was time to get away from messages that were conceived in the initial stages of the fight," Tsala told PlusNews. "Those messages were so general they didn't address anyone, and the campaigns had no impact." Cameroon, like other African countries, initially tried to stop the spread of the virus by alerting its population to the dangers of HIV/AIDS: rejection, illness and death. "Messages like 'AIDS can't be treated' or 'You're going to die' obviously missed their mark or reinforced inadvertently suicidal behaviour," Tsala pointed out. The numbers speak for themselves. After holding steady at one percent between 1985 and 1990, the infection rate had jumped to over five percent by 1995, especially among young people and women. Females made up three out of five cases and a third of HIV-positive people were between the ages of 15 and 34. Among sex-workers in big cities like Douala and Yaoundé, the infection rate surged from six percent in 1987 to nearly 45 percent in 2000, the year the CNLS launched its first campaign to change behaviour patterns. Starting in 2000, health authorities changed tactics in the fight against HIV by putting the emphasis on community participation. The goal was to keep the infection rate below 10 percent, which was hovering around seven percent in 2003, according to the UN. In 2001, provincial, local and community committees were created to raise awareness and promote prevention. "The problem wasn't telling people that AIDS existed, but letting them know what to do about it," Tsala commented. A year later this strategy led to the creation of a "local answers" grassroots approach by the CNLS that relied on youth and women's groups, school health clubs, professional associations (drivers, sex-workers, etc.) and members of religious groups or businesses to come up with community-based ways of fighting the spread of AIDS. The CNLS, which provides financial support for implementing these plans, requires that people living with HIV/AIDS be included in the groups' activities to ensure the quality of the information disseminated. "It was necessary to include the targets of the messages in the process if we wanted effective communication," said Tsala. This strategy also required groups to think more carefully about the words they used. SEXUALITY AND TRADITIONS LIKE OIL AND WATER Workshops have been organised in each of the country's 10 provinces to set out a communication strategy for changing behaviour (CCC), to run from 2003 to 2007, the impact of which will be studied at the end of the period. For Tsala the increase in the number of people being tested in urban areas shows that the message is getting out. "Before now, testing - even when it was free and voluntary - was not popular because it forced people to face up to a lot of responsibility," he noted. "It's still seen as opening up to others when, in fact, it means opening up to oneself." This attitude can be explained partly by the intense prejudice faced daily by people living with the virus, who are perceived as having questionable morals and sexual behaviour. Discussing sexuality openly is difficult in Cameroon because it is still very much taboo, especially in rural areas. As a result, some community leaders have made it nearly impossible to bring men, women and children together in one place. "We sometimes have to separate the groups even if that means a less effective form of community expression," Tsala told PlusNews. "The novelty of sexuality discussions can lead to a number of unexpected reactions, like women covering their faces, averting their eyes, and stifling laughter." At the same time there has been resistance to the egalitarian tone of some of the awareness campaigns, which are at times perceived as a threat to traditional authority. Tsala said members of the community-level committees were often ridiculed ("the AIDSers") when they met with local people and traditional authorities. "This prejudice, which can sometimes be pretty extreme, can't be explained away by ignorance of the virus or how it is transmitted," he wrote in the November 2004 issue of the journal of the Social Aspects of HIV/AIDS Research Alliance. "It displays the complexity of the relationship between the self and an illness that one can carry without even knowing it." AIDS activists in Cameroon are therefore careful not to ruffle feathers among populations that are very attached to customs like the marriage of a widow to her brother-in-law, traditional autopsy, female genital mutilation or scarification. "We avoid, for example, harping on male-female equality because doing so could make prevention efforts more difficult," Tsala commented, citing the example of polygamy, a traditional form of marriage, within which "fidelity is still possible". "The relationship between the sexes is one of the pillars of traditional social fabric and it can't be changed without altering the entire society," he said. "And yet, the attitudes of certain husbands towards sexuality place their wives in physical danger - that is an issue that needs to be addressed." Recent studies have also shown that 64 percent of girls between the ages of 15 and 19 are married or living with their partners. Talking about condoms becomes a real challenge. "The different education campaigns recommend that women have condoms in case their partners doesn't take precautions," Tsala explained. "But that advice can lead to misunderstandings: a woman's decision to carry condoms can cause distrust between partners." Also, people in certain provinces view condoms as a kind of protective charm - merely having one in one's pocket is thought to be enough to fend off sexually transmitted diseases. According to Tsala, the latest awareness campaigns have had to address this kind of fetishism. "Social perception of this illness, of life and death, belief systems, local cultures, sexual behaviour, the status of women, religions, relations between individuals and the state - all of these are 'partners' with which we have to negotiate if we want to be successful," Tsala remarked. He wondered how best to incorporate difficult concepts like the cultural significance of life and death in traditional societies into prevention messages. "Do the people we're targeting really want to live? They can have self-destructive impulses that we don't understand," he explained. "The value one places on life is subjective and people could easily say to me: 'Did I say that life was so good to me that I want to protect it?'" West African glossary of slang terms for condoms