It’s Not As Easy As ABC: Abstain, Be Faithful, Use Condoms in Africa – Antoine Longuet
It’s Not As Easy As ABC: Abstain, Be Faithful, Use Condoms in
AIDS is known to be one of the worst pandemics since its discovery in 1981 (1), particularly in Africa, where the spread of its infection has amounted to 24 million in 2007, with over the 33.8 million infected individuals around the globe (2). A number of organizations have launched intervention initiatives to stop its spread, one of them being the ABC program launched worldwide in the 1990’s by governments of affected countries such as Botswana, Uganda, Mozambique and by the UN which has created the UNAIDS department to deal with this crisis (3). The name of the ABC program is an acronym for the messages it wishes to promote: Abstain, Be faithful, and use Condoms. Recently, the United States Bush Administration launched the President’s Emergency Plan for AIDS Relief (PEPFAR), which endorses the ABC program and increased US funds for AIDS relief (4). The ABC initiative has come under considerable criticism since the early 2000’s by scholars for its ineffectiveness in understanding the complex cultural and sociological factors that lie between the program’s objective and its actual intervention. The ABC intervention has also been criticized for its lack of marketing research to promote itself, incapacitating the effectiveness of its message.
ABC And Local Cultural Factors:
ABC has primarily been promoted in Africa in the 1990’s, where it was believed to have a great success in
Misconceptions of the ABC program are based on assumptions about the different ways through which the disease is spread. This intervention focuses primarily on heterosexual transmission via conventional intercourse. However, the program ignores the many other ways through which the disease spreads. Surprisingly very little research has been done on homosexual transmission in Africa, while it is an important debate topic within the
Local cultural practices involving sexual relations and defining socially acceptable sexual activities have often hindered the efforts of the ABC program. Just as “Ethnographic research […] often reveals how deeply sexual intercourse is enmeshed in meaning and social experience”. It is only recently that “researchers are […] turning their attention to little-known sexual practices”, as Erik Eckholm noted (6), which “might also raise transmission odds” (6). Such practices include female circumcision, which is often forcefully done upon women in
Another cultural issue, to which the ABC program is confronted, is myths about the HIV virus as a whole. Alma Gottlieb documented “rumors connecting AIDS to vampires” (6). Such myths distort the definition of HIV transmission that needs to be assessed on a local basis where the myth is present. Other less obscure myths involve misunderstandings of the inner-functioning of AIDS and its transmission. Older seropositive men often believe that sexual intercourse with virgins or minors, which are considered “AIDS-free” would “wash-out” HIV from the body (5). This particularly poses a problem to the ABC program in terms of abstinence and condom use as many of the older seropositive men either rape their victims, or provide food, clothes and education to women and girls of poor backgrounds in exchange for sexual favors. The men who demand sexual favors in exchange for economic support are often termed as “sugar-daddies” (5). In such as case, not only do these young women not abstain, but also due to the “body-cleansing” myth that is involved, condom use is inexistent. This is particularly threatening for virgins where the rupture of the hymen, at any age, is involved with vaginal-bleeding, and causes automatic HIV transmission if the sexual intercourse involves a seropositive mate while not using a condom (6). It has also been noted that within a couple in which both partners are seropositive, men tend to die before females do. Locals have addressed this by assuming that women are more resistant to the virus because they eliminate the infected blood through the menstrual cycle, another reason why virgins are considered to be “virus-cleaners”. The true explanation to this is earlier male extra-marital affairs than for females (6), which poses a serious challenge to the ABC program.
The main cultural problem that ABC faces in
ABC And Local Social Factors:
The ABC program is proven to be inefficient when facing cultural problem due to the fact that it gives narrow alternatives to prevent the transmission of AIDS, which are culturally unfeasible. Furthermore, this intervention is inflexible because of its inadaptability to local cultural-conditions. The ABC intervention also faces many social challenges on a variety of levels going from the simple one-on-one sexual interaction to post-colonial stereotypes that apply to the African population as whole.
First of all, heterosexual relations within a couple are often stricken with sexual violence and marital rape in
Cases of marital rape and violence clearly show that there is a gender inequality within certain regions of
The Church has also played a controversial role with regards to the ABC program in Africa as it has actively promotes the A and the B of the program (Abstinence and Being faithful) but discredited the use of Condoms, suggesting that it interfered with the natural order of things and that it is an immoral object (8). The Church has actively been opposing the use of the condoms through church sermons, as well as in catholic schools for decades due to its belief that it promotes “immorality and sexual promiscuity” (8). Furthermore, the Islamic community in
Post-colonial stereotypes that remain within the African territories are another obstacle that the ABC initiative has come challenged. Most of these revolve around ideas that women are passive, and that “people of color are undependable, uneducated or nonliterate, [and] cannot understand complex messages (6). These stereotypes underline post-colonial racism, which is still prevalent in African countries and work against the ABC initiative as it dilutes and distorts the effect of the messages that are directed towards the African population. On one hand, a similar narrative can be seen within AIDS media coverage, which often leads to conspiracy theories about interventions performed by post-colonialist countries. Eurocentric media is often “biased, [with a] doomsday mode of reporting typical of Western AIDS coverage, [and afflicts] African people [who] appear as the passive recipients of internal and external help, while Africans at large are charged with failing to address the epidemic, even failing to be aware of it” (6). On the other hand, the African press reports constantly new efforts made to fight the epidemic. This discrepancy in media coverage only accentuates stereotyping, and thus not only creates a reticence from the part of the aid recipients who perceive the ABC message as aggressive and imperialist, imposing upon their way of life. This underlines the C of the program, which is one of the western solutions to stop the spread of HIV/AIDS and other STDs.
The final sociological factor that the ABC program faces is based within the legal systems of African countries such as
ABC and the Health Belief Model:
The issue of culture makes it even more complicated for the ABC program, which promotes itself through a health belief approach, assuming that the population is concerned with its health. The Health Belief Model is an individual based model in which it is assumed that the individual perfectly weighs out the costs and the benefits associated with performing a health related behavior. The outcome of this analysis is an intention, which the model assumes to lead necessarily to the performance, or not, of the behavior depending on the intention. Here, the ABC assumes that the individuals involved in a sexual relation are devoid of social pressures, and that each individual perfectly balances out the health costs and benefits of abstaining, being faithful to their partner, and using condoms. However, as proven in the analysis above, each individual is constantly under immense social and cultural pressures, which ultimately lead to their decision rather than their belief. The health practitioners that have developed the ABC intervention have done so without including socio-cultural factors while basing themselves on the belief that each individual evaluates abstaining, being faithful to their partners and using condoms, according to their health concerns only. Yet cultural and social factors have been proven to drive the decision making process of individuals within these three subjects.
Furthermore, the ABC program focuses primarily on the individual, assuming that his or her decision process occurs without social interaction, in a vacuum. The reality of this is very different, particularly for marginalized and abused women who have no choice with regards to their health decisions. We can therefore say that these decisions are made on a group basis, such is the case for women on whom female circumcision if forced. Finally, the ABC program assumes, just like the HBM model over which it is based, that the intentions of the individual will lead to the action. This is clearly flawed due to the fact that even though men and women have the intention of following the ABC program, they might not due to socio-cultural decisions and inherent impulses. Decisions that involve sexual relations and health are often very delicate due to innate human impulses and socio-cultural factors, particularly in uneducated groups of individuals about the risks of HIV/AID transmission.
Flawed Marketing And Advertising:
In order to be delivered to the population, the ABC program needed to be marketed and tailored to the local crowd of each region within
The failure of the Jeito program illustrates an overall failure of marketing interventions that have been put in place based on the ABC program, which is not designed to local population dynamics. This also illustrates the lack of data that such programs have collected within their regions of intervention, which have lead to misconceptions of the extent to which AIDS have affected the population. These misconceptions therefore “[obscure the] details of degree and specificity” about the perception and extent of the HIV/AIDS crisis (6).
The ABC program, which has started in
Resolving the ABC Program’s Flaws:
As suggested before, and ecological approach to this issue would certainly allow a program such as ABC to effectively tailor its messages and intervention to the local conditions. This, however, requires the program to change its philosophy with regards to the individuals it wishes to target by assuming that group based intervention in which sociological and cultural factors are key to determining individual’s health related behaviors. The ABC program therefore will need to research the local population on multiple levels in order to create an ecological intervention that effectively reaches the target population on several levels. In order for this program to effectively design interventions to local population conditions, the program needs to stretch out into domains out of Public Health, such as law enforcement, which would effectively back-up this program and thereby provide it policy cushion. This approach will thereby not only use Public Health measures to assess the population internally, but it will also use binding policies in order to enforce certain aspects of the intervention.
The Use Of Surveys:
An ecological approach to this issue not only requires the program to assess the target population in terms of a group rather than in terms of individuals, as dictated by the HBM, but also to intervene upon multiple levels, assessing sociological as well as cultural factors that need to be determined beforehand. An effective intervention would require a certain amount of research to be done within each particular region, especially in terms of the cultural factors, which have constantly impeded the progress of this program. In order to effectively research the population and understand the underlying factors, a series of studies through one-to-one surveys need to be done on multiple levels of the population. In hindsight of the problems the ABC program faced in
Local myths are particularly problem for ABC and are representations of the misinterpretations about the origins of HIV/AIDS and its inner functioning. Alma Gottlieb acknowledged “rumors connecting AIDS to vampires” vi, while Schoepf showed that older seropositive men believe that sexual relations with young women, and particularly virgins would allow them to clear their blood of impurities. Such misunderstandings can be assessed explicitly by addressing the victims of such abuse through sexual education at a very young age to inform them about the realities of the transmission of this virus. However, the fact that many of them do not attend schools and live in a close knit-community often prevents them from discussing such taboo subjects. The most practical and direct solution would be public campaigns using billboards upon which the “story” of HIV/AIDS transmission can be personified. Furthermore, public speakers need to be recruited in order to publicly inform the people as a whole, and not only these young girls, about this virus.
Approaching The Population:
In order to successfully reach the population, these speakers need to have knowledge about the cultural practices and beliefs of the region in which they are intervening; which is why they should be either from that region, or go through local cultural or religious authorities. In a sense, the origin of the speakers and the appearance of familiar cultural ties between the speakers and the population would lean on framing theory (11). These speakers and billboard ads, while still pushing for an HBM approach, which informs people about the basic health concerns of HIV/AIDS, need to use at the same time a marketing theory based approach (11). This will permit the messages of that the speakers and the billboards are sending to not only give health related information about HIV/AIDS to the population, but also package this information in a way that would appeal to the people’s desire. In a sense, by combining the HBM with marketing theory, the speakers and the billboards will present the issue of health through the use of condoms, faithfulness, and abstinence as a socially and through time, a culturally positive object. However, if the program has enough funds, it may even combine an HBM based approach with Advertising theory through the use of more advanced, and more expensive media, such as radio and television (12). Advertising theory would virtually play the same role as marketing theory in these adds, while appealing to the population’s social and cultural aspiration. The use of the advertising and marketing theory thereby necessitate the use of surveys in order to adequately pinpoint the social and cultural aspiration of the population, which need to take into account the religious and governmental positions on the HIV/AIDS issue in order to further the effectiveness of the intervention.
The Use of Dialogue:
The use of surveys to develop effective interventions based on the ABC program which use speakers may not adequately allow the population to effectively feel addressed about the issue. One the main issues with the Jeito program, as determined by Pfeiffer, was its lack of dialogue with the target population (8). Dialogue, through group speakers or through one-to-one surveys, would not only bring information to the target population, but also to the designers of the intervention who, through dialogue, may constantly monitor the changes in the population comportment and perception of the ABC messages. The use of dialogue with the local population will also allow researchers to be able to “think outside the box” in a way that they are not constrained to ask questions to their audience that is restricted to certain guidelines. Such freedom of expression would permit researchers to acquire more in depth information about the socio-cultural background information about the population, such as obscure sexual practices to which Treicher referred, such as homosexual practices and sexual relations with monkeys (6). Dialogue with the population has particularly become important with regards to the religious factors, which are intertwined with the cultural ones. Religious factors are often very complex and are perceived and explained quite differently by the religious authority and the population that follows it. Surveys and dialogue would therefore be appropriate to target the religious authority and the population of followers as not only is this a very delicate and complex subject, but it is also ever increasingly volatile to events.
From a socio-economical point of view, dialogues are not as important as surveys due to the fact that the raw data, such as the state of the economy and how it affects the population, are more readily transcribed and analyzed using this type of research method. However, from a sociological point of view, the dialogue with the population is just as important as from a cultural point of view. Sociological factors depend on the SES status of the group as well as the its cultural attributes, making it also very volatile. In order to assess the problem of HIV/AIDS in women, which are known to be the target to sexual abuse, particularly in South Africa, which has been reported to have the highest rape of rape in the world, the most effective way to address them is to operate a constant dialogue with them in female social events in which they would be allowed not only to speak up and be heard, but also be educated about such concerns. By directly targeting women, who are the victims of sexual abuse, they will have the opportunity to be educated, and thereby by able to make educated choices about their husbands, or their partners, whichever applies best. However, interventions upon women need to be carefully tailored as they are the segment of the population that have been the most abused due to their often marginalized position within society. Women’s position within society has often pushed them to be the target of sexual abuse (13). One of the many ways, which could help women, is the use of the female condom. Even though women who are sexually abused are often do so with no condoms, the use of the female condom will help those who are not being abused, thus giving them a larger leverage when the issue of the use of the condom is being put in question.
Assessing ABC From A Legal Point Of View:
The very fact that women are the targets of sexual abuse not only reveals sociological underpinnings which need to be addressed through dialogue, surveys, and marketing programs in order to change the perception of women and of HIV/AIDS, but also reveals the lack of enforcement of already binding laws. Policies in countries such as
The main issue with the ABC program was its lack of analysis of local socio-cultural factors due to the fact that it was an HBM approach, thereby causing its marketing approaches to be flawed. However, an effective research through the use or surveys and dialogue with the different groups of the target population will allow the designers of the ABC program to clearly understand the different social, cultural and economical elements that shape their population’s attitude and perception of health related interventions. Furthermore, dialoguing with different target groups of the population will allow localized interventions rather than a broad and imprecise one. The presentation of the ABC program’s campaign through speakers, adds, billboards, and advertisement appropriately tailored to the local population conditions and target groups would allow the intervention to incorporate the HBM approach into a more appealing message in which the issue of health not only becomes less taboo, but also, for the lack of a better term, “looks good”. Finally, the use of legal and constitutional enforcement of sexual abuse through adequate funding and policy modification would allow authorities to regulate to a larger extent the spread of the virus.
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