Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

Failures Of The ABC Campaign In Africa: The Need To Reframe The Issue Of HIV/AIDS By Addressing Underlying Social Conditions – Lindsay Litwin

The AIDS epidemic has devastated the African population and consequently more developed nations are funding AIDS prevention programs in Africa. The most commonly implemented intervention is the ABC campaign, which promotes abstinence from sex, being faithful to one’s partner, and condom use. This theory is based on a limited perspective of Africans and their culture, and thus ignores many important factors that shape sexual behavior in these societies. The ABC campaign places too much emphasis on the individual, perpetuates cultural stigmas regarding AIDS and does not consider the social construct of gender in African nations. Overall, the ABC prevention strategy focuses on changing individual behavior in order to effectively slow the spread of HIV/AIDS; however it fails to address underlying social norms, which are the true root of the AIDS epidemic in Africa.
The Health Belief Model: A Faulty Foundation for the ABC Campaign
Most public health interventions are formatted based on the Health-Belief Model, a tool, which constrains the thinking of public health professionals. The Health-Belief Model maps out factors that influence an individual’s health behavior choices. In contemplating one’s behavior, according to the Health-Belief Model, an individual will consider the severity of a disease and their personal perceived likelihood of developing the health outcome (1). The individual then measures these perceived risks against the barriers that one foresees in changing one’s behavior (1). From this contemplative stage the individual develops an intention to act regarding a health behavior and then successfully carries out the action. The Health-Belief Model is inherently flawed because it only considers rational decision-making at an individual level and does not consider community factors and social norms, which dictate the decisions and behaviors of individuals. Since the ABC campaign is based on the reasoning of the Health-Belief Model, it is also inherently flawed and insufficient for preventing AIDS in Africa. In a continent with a rich history and long-standing cultural practices, these community factors influence an individual at all steps of behavior planning.
One limitation of the Health-Belief Model is the fact that this model assumes that an individual will change his/her behavior if he/she believes they are susceptible to the negative health outcome (1). Embedded in the ABC campaign is the assumption that Africans will feel a danger of contracting AIDS and that the fear of death will promote preventative behavior changes. Africans understand the fatal consequences of contracting AIDS, as the majority of them have seen the damaging effects that the disease has had on their family and friends. However, even high perceived susceptibility and risk of death among Africans do not motivate the majority of the population to embrace ABC behavior changes. This is because death and illness are not viewed the same way in African cultures as in western cultures. Due to religious and cultural beliefs, Africans discount the fatality associated with AIDS (2). Many people believe that disease is caused by the supernatural and is a punishment for an individual’s past inequities (2). Thus, contracting AIDS is predetermined and inescapable, so an individual does not have any control over disease outcome. Therefore, many Africans believe that adopting ABC behavioral changes will not decrease their risk of contracting AIDS.
Furthermore, AIDS is so rampant that many Africans either believe that they already have the disease or will contract it despite changing their sexual behaviors. In either case, an individual does not believe that the ABC campaign will help them. Before a behavior change can occur, the masses must want to change and there must be the motivation to do so. The ABC campaign is based on the idea that internal reasoning of an individual will result in rational behavioral choices, however this is not always true (1). The ABC campaign fails to address this lack of motivation in the African population. One program that could motivate the African community to adopt less risky sexual behaviors is the implementation of widespread AIDS screening practices. Research shows that if an individual is aware that he/she is HIV negative, he/she is more likely to adhere to the standards of the ABC campaign and adopt safer sexual practices (3). This widespread screening framework must be in place prior to the implementation of ABC campaign in order for the campaign to succeed.
A Fundamental Problem: The ABC Campaign Ignores Cultural Norms
According to western theory, the ABC campaign promotes logical and acceptable sexual practices; however these assumptions are not adjusted to consider African culture and gender roles. In any program, “if assumptions have not been questioned and alternative sources of knowledge sought, then the knowledge can be faulted” (2). The ABC campaign is not comprehensive enough to effectively change the face of the AIDS epidemic in Africa. The ABC strategy is based on promoting three succinct behaviors: abstinence from sex, being faithful to one’s sexual partner, and using condoms consistently (4). The focus of this intervention is to promote behavioral change; however it does not consider why the African population does not adhere to the ABC standards. Unfortunately, the ABC campaign fails to address the fundamental reason why sexual behavior change is not possible in the 25-35 year old age group, which accounts for the largest burden of the disease. At this stage in life, African people are focused on bearing children, especially giving birth to at least one son (4). Therefore, at this time it is not feasible to apply either the A (abstinence) or the C (condoms) of the ABC campaign. The only part of the campaign that applies is B, be faithful, which is the least feasible portion of the overall campaign. This fundamental barrier cannot be changed, but the scope of the ABC campaign can be changed to include social norms.
Another central shortcoming of the ABC campaign is that it focuses on the individual and does not place that individual within a society. As people live collectively in a community, it is inaccurate to believe that any one person is an island unto himself. Epidemiologists rarely consider social factors in assessing heath outcomes; however for successful public health interventions to be implemented, public health professionals must consider such factors. Applying ideas from the social sciences as well as studying an individual in the context of his/her environment will positively enhance prevention projects like the ABC campaign (5). Social norms are often risk factors for health outcomes and barriers to behavioral change. Many scholars agree that “the worst policy would be one that minimizes the problem [of AIDS] by treating it as a private matter, that is, as an individual’s concern and responsibility rather than a crisis that must be addressed by the society as a whole,” which the ABC campaign fails to do (3). The ABC campaign will not be accepted by Africans unless the campaign is reframed to address cultural stigmas and social norms in sexual behavior.
By definition, culture is engrained in individuals of a community and societal norms perpetuate both positive and negative behaviors. From a young age, all children in Africa are socialized to adopt cultural identities as they mature (4). Many of these beliefs are in conflict with the behaviors promoted in the ABC campaign. Condoms are taboo in many African cultures and religions. They are shunned as products that commercial sex workers and the unfaithful use and are not acceptable for married or ‘exclusive’ couples to use consistently (4). The ABC campaign uses mass media and other advertising outlets to encourage condom use, but these efforts fall short in addressing social barriers. The ABC campaign must be reevaluated in a cultural framework and incorporate religious and political leaders in order to shift social norms and promote the ABC behaviors as an accepted part of an African’s daily life. Furthermore, the ABC campaign does not address the cultural belief that men cannot abstain from sex. Approximately 39% of African males and 29% of African females believe that men cannot control their desires to have sex (4). The message to abstain from sex is reaching the African population, however the tools to overturn these cultural barriers are missing from the ABC campaign. In addition to these social reasons that the ABC campaign fails, there are numerous other cultural barriers that oppose the ABC behavioral change program in African communities.
African Gender Construct: A Barrier to the ABC Campaign
The concept of gender is central in African cultures. Learned gender roles in African societies, as well as some governmental policies perpetuate the masculinity and femininity paradoxes, which shape life in Africa. In its implementation, the ABC campaign fails to address the issue of gender in African communities. In many Sub-Saharan African communities, the core values of manhood are a man’s ability to support his family, sexual competence, and an aggressive nature (4). All of which assure that a male is dominant in his relationships. In contrast, women are expected to be passive, physically weak, sexually reserved, and exhibit marianismo. Marianismo is the idea that women are morally superior to men, and thus must have an aversion to sex and acceptance of male dominance including physical abuse (4). Additionally, unprotected sex is a rite of passage for men who must be sexually experienced before marriage (4). The cultural practices that all men perform increase the spread of AIDS. Furthermore, the subordinate and helpless role of the women further perpetuates male dominancy and risky sexual behaviors. Unfortunately the gender-blind approach of the ABC campaign does not address these gender inequalities. It ignores the fact that women are disempowered and often unable to decide whether or not they will have sex. This makes it impossible for females to adhere to the ABC campaign if males do not.
The ABC campaign places the responsibility to change sexual behavior in the hands of the individual; however gender roles impede the progress of behavior change. In theory, the gender-neutral ABC campaign allows for males and females to make personal choices, however females do not have the control to use any of the ABC prevention behaviors (4). None of the ABC campaign policies relate to the actual life experiences of women in Africa (2). For example, both males and females must follow the ‘be faithful’ portion of the ABC campaign in order for it to be effective. In Rwanda 80% of HIV positive women were monogamous and 25% of these women only had one sexual partner in their entire life (6). These results are consistent throughout Africa and indicate that even if females follow the parameters of the ABC campaign, males continue to follow the social norm of having multiple sexual partners (4). Women can uphold the restrained sexual values, but this female-only approach cannot decrease the AIDS epidemic. In fact the percentage of women infected by AIDS is increasing. Overall, marriage is becoming a risk factor for contracting AIDS, because men are unfaithful and also refuse to use condoms in their own households with their wives (6). The condom use component of the ABC campaign is also in the control of men. Women can negotiate with their partners to use condoms, however the power and decision to perform the action ultimately lies with the males (2). Considering the gender roles in Africa society, it is clear that “the HIV epidemic is driven by men” (4). However, the prominent use of the ABC campaign is gender-neutral and fails to target men. Redefining masculinity and gender roles in African is the most essential prevention strategy for controlling the AIDS epidemic.
Conclusion: A Look Forward
AIDS prevention in Africa is essential to the development of this continent. In order to lower the rates of AIDS transmission in Africa, prevention strategies cannot be constrained to the ABC campaign. Collectively, policymakers must expand prevention programs beyond influencing individual, rational behavior and consider the context in which the individuals live. Involving prominent social figures in the prevention efforts can be a first step in gaining public support and breaking social barriers. The life of individuals in Africa must be studied closely and conceptualized so that policymakers comprehend their experiences and incorporate this information into campaigns in order to address stigmas. Most importantly, gender roles in African society must be considered when forming AIDS prevention programs. These efforts must target males, address destructive social norms, and reframe responsible sexual behavior as a sign of a powerful man. In addition, it is important to provide women with tool like female condoms to increase their power and role in preventing the spread of AIDS. Preventing the spread of AIDS Africa is attainable only if social influences and norms are addressed in the policies.
(1) Salazar MK. Comparison of Four Behavioral Theories. AAOHN Journal 1991; 39:128-135
(2) Reid E. Gender, Knowledge and Responsibility. HIV and Development Programme date; 10.
(3) Daly JL. AIDS in Swaziland: The Battle from Within. African Studies Review 2001; 44: 21-35.
(4) Jordaan S. A Gendered Critique of the ABC Prevention Policy of the South African Government Concerning HIV/AIDS: A Case Study of Northern KwaZulu-Natal.
(5) Herrell RK. HIV/AIDS Research and the Social Sciences. Current Anthropology 1991; 32: 199-203.
(6) Sinding SW. Does ‘CNN’ (Condoms, Needles and Negotiation) Work Better than ‘ABC’ (Abstinence, Being Faithful and Condom Use) In Attacking the AIDS Epidemic?. International Family Planning Perspectives 2005; 31: 38-40.

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