Haitian Women's Role in Sexual Decision-Making: The Gap Between AIDS Knowledge and Behavior Change

III. Conclusions and Recommendations

2. Implications for Planning

A. Incorporating Dialogue in AIDS Prevention Education

The intensity with which men and women entered into discussions of sexuality and HIV risk showed that they both wanted and needed a forum in which they could discuss and debate the impact of the disease on their lives and the implications of behavior change for human relations as much as for AIDS prevention. The similarity between men's and women's perspectives on AIDS risk and behavior change also suggests that many may be ready for discussion in mixed, as well as single-gender, groups. In this research, the focus group format, one which used a storytelling modification to introduce pertinent issues, was a successful stimulus for discussion. As an intervention tool, it is likely to be equally successful in engaging people in discussion of prevention strategies and helping them to resolve interpersonal problems which accompany behavioral change.

Focused discussion, moreover, has the potential to foster participation and "ownership" in the process of change and increases the probability that such change will spread and take root. To that end, modified focus groups may serve as a means to identify and train lay leaders in AIDS prevention, providing not only information, but skills for peer support and conflict resolution. The urgency to slow an epidemic which is growing out of control demands strategies to ensure rapid dissemination of techniques which Haitians at all levels can use to promote fundamental change.

Recommendations

• That HIV/AIDS prevention programs identify and train local leadership to conduct focused group discussion which addresses information needs and the resolution of conflict inherent in change.
• That local discussion leaders receive additional training and support to enable them to disseminate discussion techniques by becoming trainers of others.
• That such training and implementation begin with support to grassroots groups already in existence.

B. Storytelling as an Adaptation of the Focus Group Technique

The story of "Joujou" and "René" proved to be an effective technique in drawing participants quickly into the discussion while leaving them free to express their views, with or without disclosing their own behavior. Whether for research or intervention, such stories should be developed in collaboration with representatives of the target population. In fact, the transcripts of this study are rich with real accounts of personal experience which could become the basis for discussion in future groups. Properly integrated in a discussion format, stories can focus attention on critical issues in prevention which might otherwise go undiscussed and unresolved.

Recommendations

• That AIDS educators collaborate with people in the target population to develop a series of vignettes in the form of stories which reflect familiar issues inherent in AIDS risk-related behavior change.
• That such vignettes be pilot-tested and taped for use by trained local discussion leaders in their families, in their neighborhoods, at their workplaces and in schools, as a non-formal technique for introducing change in sexual behavior and helping people to discuss and overcome the barriers to change.

C. Promoting Economic Independence among Women

Findings of this study draw attention to the critical relationship between a woman's economic status and the perception she has of her power, or lack of power, to initiate preventive behavior. Although this relationship needs to be further explored, many women's comments suggested that women with no earning power have no power to negotiate change in their sexual relationships. The heavy dependence of some women on irresponsible sexual partners creates a chasm across which neither AIDS information nor any motivation these women have to protect themselves has little chance of stopping the disease. HIV/AIDS prevention programs in Haiti must acknowledge economic imbalance as a fundamental cause of a gender inequality which has severe consequences for women and children in the AIDS epidemic.

Recommendation

• That national and international efforts to slow the spread of AIDS in Haiti also give high priority to longer-range goals of basic education and training for women in income-generating skills.

3. Implications for Applied Research

As this research begins to clarify important issues in the gap between knowledge of AIDS and preventive behavior, it raises new questions which have a direct bearing on program development and policy for AIDS prevention in Haiti. Some of these are summarized below.

A. Influence of Supernatural Beliefs on Behavior Change

The focus group transcripts offered only hints of the widespread belief in supernatural causation documented by other studies. Reports of two recent HIV/AIDS KABP studies (6,9) suggest that supernatural beliefs about AIDS are more common than the present study would indicate and raise the question whether this difference signifies participants' reluctance to express views which are contrary to the official biomedical position on HIV transmission. To the extent that it exists, such underreporting has serious implications for policy affecting the development of AIDS prevention messages. Knowledge of sexual modes of transmission will have little effect on the behavior of those who also believe that a spiritual force can target AIDS at specific individuals, while others remain immune. The coexistence in many cultures of traditional and biomedical beliefs about disease is well known to social scientists who have explored traditional taxonomies and have often observed the simultaneous use of multiple healing systems. Evidence of widespread belief in the power of voodoo to inflict AIDS, therefore, does not invalidate the finding that people know and accept biomedical explanations of heterosexual spread. What it points to is the possibility that the two belief systems are sending contradictory messages which people rooted in both traditions must reconcile in the best way they can. How Haitian believers in voodoo resolve the dissonance between supernatural and biomedical theories of HIV causation is a critical problem for research; so too is the effect these beliefs have on their attitudes toward prevention and treatment. Answers to such questions would have implications for AIDS counseling as well as for development of culturally sensitive AIDS prevention programs.

B. Partner Exchange

Although this study yielded some insight into attitudes and behavioral expectations of women in "vivavek", "ménage", and other non-binding extra-conjugal relationships, most participants, including women in the "vivavek" groups in Savanne, tended to direct their remarks to concerns of people in married ("maryaj") and common-law ("plasaj") unions. Their responses therefore leave unanswered many questions pertaining to the rules that define extra-conjugal relationships and partner exchange.

Multiple sexual partnerships are common in Haiti, but are little understood in terms of the social and behavioral factors which determine codes of sexual behavior for either men or women. Understanding the ground rules on which partnerships are based is fundamental to understanding behavioral risk in the spread of HIV/AIDS. The findings of this research suggest that male-female relationships in Haiti tend to be loose; that many men maintain the right to have both wives and mistresses, or casual partners outside the home; that women in conjugal relationships are expected to be faithful and to ignore their husbands' extramarital affairs; that men use their sexual freedom to force compliance of their wives or long-term partners; and that economic dependence can prevent a woman in any type of sexual liaison, conjugal or casual, from acting on her right to protect herself from AIDS.

There is need for studies which classify types of sexual relationship on the basis of their length and intensity; contractual exchange and the expectations of each partner; and partners' perceptions of HIV risk and responsibility for prevention. The influence of women's social and economic status on their involvement in multiple partnerships should also be carefully documented, along with evidence of their power, or lack of power to protect themselves from contracting AIDS. Needed is a new taxonomy of sexual unions, one which takes into account the potential impact of the AIDS epidemic and new attitudes toward prevention on patterns of sexual behavior. A clearer understanding of the formation, maintenance, and dissolution of multiple partnerships over time could lead AIDS prevention educators to more effective techniques for promoting behavior change.

C. Economic Barriers to Behavior Change

Unemployment was viewed by female participants in this study as a major constraint on women's ability to influence their partners. This finding leads to the hypothesis that income-generating activity is directly associated with a woman's risk of acquiring HIV as defined by her partner's sexual behavior. Research to test this hypothesis and to measure the costs of vocational training against the benefits of decreasing the risk of HIV could have broad implications for public policy.

D. Change in Sexual Attitudes and Behavior over Time

Findings from this study indicate strong awareness among Haitians that the AIDS epidemic is changing their lives. Needed are studies to describe perceptions of change in the general population, rural as well as urban, and to document temporal relationships between various levels of experience with AIDS, shifts in attitudes toward prevention, and sustained behavioral change. On a policy level, understanding of the natural process of change could offer insight into ways that planned intervention might hasten cultural acceptance of new norms of behavior.

E. Knowledge, Attitudes, Beliefs, and Practices of Adolescents

Focus group participants expressed commitment to protecting young people against HIV but showed little sense of direction as to how they might accomplish this goal. The authors recommend in Section 3.1 of this report that AIDS educators develop specific programs to help parents and teachers counsel children to make healthy choices for responsible sexual behavior. This difficult task requires clear understanding of the perceptions young people have of gender relationships, sexuality and the relation of both to HIV. Research is needed not only on their knowledge and attitudes towards AIDS but on their sexual practices, on psychosocial factors associated with sexual responsibility, and on barriers which may prevent adolescents from protecting themselves and others. Of particular interest would be the degree of congruence between adult perceptions of their children's risk and adolescents' awareness of the dangers of unprotected sex and their willingness to accept prevention. These insights could have significant implications for AIDS prevention programs designed to foster more effective communication between young people and their parents, their teachers, and health providers.

F. Communication Networks and Support Systems among Women

This study has shown clearly the need for women to take a more central role in AIDS prevention in both their personal relationships and in the wider community. Female participants seemed ready to assume responsibility for informing and supporting others, but as yet we have little systematic information on patterns of informal communication and interaction among Haitian women. It is not known, for example, how or to what extent women support each other in domestic crises such as abandonment or physical abuse by a sexual partner. In focus groups, women spoke of warning others of their risk of AIDS, but the data gave few clues as to the effects that such warnings might have or the degree to which the advice of one woman might be disseminated to others in the household or community.

The success of efforts to draw women into AIDS prevention programs may depend on the ability of program planners to use existing networks and familiar patterns of communication to introduce new concepts of sexual behavior and conjugal relations. A grassroots movement such as the Les Cayes Committee for Women against AIDS should be examined carefully for clues to the way that women mobilize their resources in response to the threat of a new disease. In short, more research is needed to identify, describe, and promote culturally appropriate channels for disseminating behavioral change.

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