Tuesday, December 12, 2006

Why Extrapolating Western Approaches Solely into Educational Campaigns has Led to High Rates of HIV/AIDS Transmission in Africa- Jaquiline K. Muthee

Education is one of the preventative strategies that the Public Health programs have used to combat the spread of communicable diseases and illnesses within a society. This has shown to have strong influences in the altering of behavioral choices which people make in regards to health issues. Education provides information which acts as a catalyst in helping people either to abandon their current habits or choose to adapt a new habit based on how well they have perceived the information given. A good example of successful efforts of educational campaigns was in the decline of smoking prevalence in the United States following the release of the “smoking and health report” which informed people of how smoking causes cancer and other upper respiratory diseases (1).
In the era of the HIV/AIDS pandemic, educational campaigns particularly those advocating for condom use, and having less partners, have somewhat been successfully utilized to reduce the spread of HIV related infections globally. However, when we compare the incidence rates in the different regions of the world, we find that the distribution of the infection is unequal (2). Majority of the HIV cases are found in sub-Saharan Africa where 63% of all infected people worldwide are found (3). These structural inequalities in provision of health care services are an evidence of the ineffectiveness of educational campaigns used in Africa. Some studies even suggest that approaches which solely focus on condom usage and abstinence are meager in Africa (4). Most of the educational campaigns integrated in the fight against HIV/AIDS in Africa are centered primarily on behavioral change and have therefore been faulty as they fail to recognize the socio-cultural differences between African and American cultures (5). The structural inequities in the distribution of the HIV/AIDS infections suggest that sometimes people do not choose their own health; rather, other factors such as the environment, influence people’s health behavior, much of which has to do with the society which an individual belongs to.
Societies differ from each other in terms of the social, political and economic factors and as seen in the socio-demographic factors such as income, age, gender and education. Based on this, it would be imperative to make note of pre-existing differences between the western countries such as the United States or United Kingdom and sub-Saharan Africa. This would, therefore, have implications on distribution of diseases and explains the disproportionate levels of HIV infection. The social, political and economic factors of a society interconnected with other factors such as behavioral patterns, technology, medical care, all affect the disease patterns, life expectancies and the general health (6). Given this integrated system that forms the social determinants of health, it is true to say that educational campaigns that ignore these facts are bound to make insignificant progress.
In the context of this epidemic in Africa, it would help to understand the disease patterns, and the multi-causal factors leading to infections. For example, in Africa, there are two groups in particular, found to be at high risk of getting infection: men who have sex with men and the married women. The question, therefore, lies in what makes the two groups more vulnerable than others. One study found that homosexuality was a criminal offense, but however, it was practiced more than it was actually believed especially in boarding schools, prisons, colleges and among truck drivers (7). In spite of the public health education on promoting condom usage, new infections through heterosexual contact continued to increase as most did not use condoms because in the first place, homosexuality is forbidden in their society. Most of the African societies do not tolerate homosexuality as it is regarded as an abnormal behavior, and this therefore has implications on AIDS education because of some local laws which then leads to the group being ignored in the campaigns as a potential target group (8, 9). Additionally, most epidemiological and demographic studies conducted in Africa concentrate more on characteristics of men who have sex with men and do not have quantitative data on the main variables of interest like behavioral trends in regards to the risks related to HIV (9). This limitation of data highly affects intervention studies because they inaccurately make estimations about the population and this is true of educational campaigns. Reports suggest that, because of missing data, most of the campaigns designed by public health tend to use the same methods globally in attempt to convince people to change their behaviors (8, 9). Consequently, after the earlier examination of the social and political environments which we found as adversely affecting and determining the health of populations, it proves the notion that what works for one society would not always work on another one because of the societal differences.
In addition to societal differences is the issue of gender equity. Many women in Africa undergo unequal rights including sexual inequality which makes them more susceptible to HIV infections (10). These women depend on their men socially and economically, thereby making them very submissive to men in every aspect and would therefore not negotiate condom use with their partners (11). Moreover, because of their desperate need of income and being discriminated against in terms of education, employment, healthcare, property and inheritance, these circumstances force them to engage in sex with men who might be HIV-positive (11,12). Other findings even indicate that HIV prevention activities have not been fully successful in reaching African women and despite their level of education, majority of them do not use condoms (12). The reason for this was because of the negative attitudes carried by men about condom use and studies suggest that educational interventions which target attitudes of the African men should be incorporated into the campaigns (12). These factors show that educational campaigns designed in the same manner to target both the western and African societies would not be fully efficient because of the various differences in gender roles that exist in the two.
Another distinguishing feature of a society is the culture which uniquely differentiates one society from another. A society’s cultural beliefs are always very influential and the consequences can be seen both socially and politically. Most studies have found out that incorporating integrated approaches such as socio-cultural factors into the intervention strategies used in Africa to prevent HIV infections is always more effective.(5). Therefore, educational campaigns targeted towards behavior change in African are often futile because they fail to recognize important cultural believes held by many African societies. There are certain ways that prove how the western and African cultures differ from one another. Many studies show that African societies greatly value traditional medicine and spiritual beliefs and these have had strong influences on people’s lifestyles (13). Modern medicine, which was introduced by Christian missionaries into majority of the African countries, attributes to the missionaries health care system and this works with the African traditional medicine which they value dearly (13). This dual system has been found to work synergistically with family influences and have had significant effects on behavioral health of individuals. However, this was found to be true only under the condition of locality as it was found that when a person changed his environment, he or she would gain a different educational skill, thereby adopting other norms and values, consequently affecting his choices of health (13). Therefore with these findings, it is imperative to note that as traditional practitioners have been found to have strong influences on healthcare systems; it is therefore true to say that, failing to integrate traditional practitioners into educational campaigns is more likely to be ineffective in reaching majority of people in the African societies.
Religion should also not be ignored as many people in Africa believe in spirituality because it instills a sense of morality to individuals. The use of religious leaders in educating the community members helps the campaigns to gain support from people who play the role of convincing the teenagers who are sexually active at a young age. In addition, one study reported a significant increase of condom use among those who were educated by both religious leaders and health professionals (14). This indicates that collaboration of the African culture with the western systems into educational campaigns could yield better results.
Another factor that may lead to failure of educational campaigns is insufficient communication. A Lack of good and efficient communication skills results in misinterpretation of information. As previously discussed, many differences exist between the western society and the African, and this also includes language. According to Brook’s theory of language expectancy ‘strategic linguistic choices can be significant predictors of persuasive successes’ (15). This shows that the educational campaigns used may not be convincing enough possibly because of language barriers. One way that has been found successful in persuasion and independent of extrapolated methods is the use of peer education as a method of behavioral change (16). This means that from the different targeted groups, such as the university students, heterosexual men, commercial sex workers, individuals from each group are used in educating their fellow peers. Peer education attributes itself from several behavioral theories. These being: the social learning theory which maintains that an individual’s behavior may be highly influenced simply by observing other people- their significant others, based on what an individual values, their risk perception and their own interpretation (17). Another is the theory of reasoned action which states that an individual’s intention to choose a certain behavior depends on that individual’s perception of social norms and how other people, who are important to him, also perceive about the behavior (16). Lastly is the diffusion of innovation theory which holds that behavior is determined by certain group dynamics. This is because certain individuals in a population have a way of making behavioral change as they have a way of influencing group norms (16). Essentially, the use of peer education as an integral part of the campaigns, as observed should be utilized, instead of the same old method that has always been incorporated in campaigns, of using health professionals like in the western approaches, but has been futile when used in African societies.
In conclusion, the evidence provided proves that extrapolating western approaches solely into educational campaigns targeting the African population is deficient in reducing rates of HIV infection. Public Health in planning intervention for prevention of disease in different societies, should consider the socio-cultural issues of other societies.

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