FHI - II. Presentation of Findings (part 6)

6. Communicating AIDS Prevention to Others

A. Counseling Children and Adolescents

They are in danger, but they don't listen to you

Many of the issues that arose in discussions of adult risk resurfaced when the women talked about the risk of HIV in the lives of young people, specifically girls and boys in the 14- to 17-year age range. Women across all participant categories were unanimous on two points: AIDS endangers children, and parents have a responsibility to talk with them about sexuality and prevention. A third area of common ground was that whatever one tells them, young people do not listen, that they behave as they wish. Although the focus group guide phrased questions in gender-neutral terms, there was a tendency on the part of women to talk about girls rather than boys, perhaps suggesting the extent to which they viewed AIDS prevention as a women's issue.

As parents, women attributed the high HIV risk young people run to a variety of causes, first of which was the tendency of adolescents to have several girlfriends or boyfriends and therefore multiple sexual partners. Participants complained that parents often do not know if their sons and daughters are sexually active, because the children hide their activity from parents and, if asked, deny sexual contact. A "vivavek" woman in Savanne with six adolescent children commented that young people

P3: ... can ignore their mothers, who are religious. They sleep around with many husbands (sic.) and say they are going to church and school.

Another Savanne woman, also the mother of teenagers, said:

P2: Young women these days are like rubber bands ("se elastik"). You can't be sure they are not involved in something ("pa nan bagay"). You can spoil them, give them diamonds - they become loose ("gen tan pedi") right before your eyes."

This mother's use of the word, "diamonds", may have been metaphorical, but women in Savanne were especially conscious of the pressure that poverty imposes on young women to accept sexual invitations in exchange for gifts. When the moderator asked a Savanne group to elaborate on why they thought young people were at risk, several explained:

P7: They are in danger because they are young ladies. They want beautiful jewelry, beautiful this, beautiful that. It's bad if their mothers are poor, because then they might take the plunge.
P3: The child can come this afternoon wanting beautiful shoes, beautiful panties, and the poor woman can not give them to her. The girl may then go live anyplace.
P2: Sometimes the child wants to continue school but can't because her mother can't help her.

The last speaker did not specify whether or how the girl would find her own school fees, but the implication was that, like clothing and jewelry, money for school can be had for the price of sex. In another Savanne group, the women warned that 15-year-olds contract AIDS from older men who seduce them with gifts of jewelry. Basic subsistence was also a concern. A 24-year-old woman in Savanne with 12 years of school who lives in a "vivavek" ("ménaj") relationship herself explained that some girls are more at risk because

P7: ... they don't have husbands of their own. They might have children, but the children's fathers don't take care of them. They live with other men who give them five or ten gourdes a day. They can easily catch the disease (AIDS).

While poverty and unscrupulous older men were believed to be root causes of adolescent promiscuity, some of the Savanne women made a distinction between "good" girls and girls who "are born to fool around." If a girl does not have promiscuity "in her blood," she will not compromise her behavior for material gain, but if she does, "you go through a lot of misery."

If she wants it, she may do something bad to get it

Women who equated poverty with sexual risk also defined protection in terms of how much a parent can give her daughter, as in the following segment from a dialogue in Savanne:

Mod: What do you think you could do to help (sexually active adolescents) avoid disease?
P3: If you have the means and the child needs shoes, if she needs a dress, if she likes your earrings, you hurry and give them to her. (Otherwise) if she wants something she'll do what's bad to get it.
Mod: Does this mean that if you hurry to give her everything she wants you might be able to help her not catch AIDS?
P3: As long as you can afford it.
P5: I'd rather stay without a dress so that I can give my child what she needs. I tell her, "My child, it isn't easy out there. There is a disease out there called AIDS." I talk to her about ethics. I say, "My child, please darling, ask me for anything you need and I will give it to you. If you are going out, tell your mother where you are going.

Since participants directed most of their remarks on adolescent sexuality to the behavior of girls, there were too few comments on male behavior to demonstrate gender differences in norms of sexuality. Perhaps their preoccupation with girls was an indirect reflection of permissiveness toward boys' sexual activity or of their greater protectiveness toward girls. A 23-year-old Delmas woman remarked that since "girls are more fragile," it is especially important for parents to talk to them about sex. Another young Delmas woman observed ruefully that boys claim "they are playboys ("vagabon"), that they are young and should have several girlfriends."

You teach them morals

Largely due to the AIDS epidemic but also because of the risk of pregnancy, all groups said that adults have a duty to warn children of the dangers they face and teach them to protect themselves. There was wide agreement that along with factual information about AIDS, young people need strong encouragement to lead a "moral" life. "We'll teach them values," said a 34-year-old female factory worker with three children in their teens, a reference to the adult ideal for adolescent behavior, which they defined mainly in terms of school attendance and sexual abstinence, or at least a monogamous relationship with one friend. Many participants said they would advise young people to "be careful" or "take precautions" but without specific reference to the means. With gentle probing, moderators often elicited more detail, such as to "talk about how it is out there and advise them to mind their schoolwork and not go to men's bedrooms ("cham gason")." A "vivavek" woman in Savanne with three teenage children said,

P4: If she is in love with a young man, she should hold on to him. If she leaves him to look for another one, she is looking for disease. You have to tell her not to go to dances or stand on the street.

I'd rather give her condoms than bury her

Opinion on condoms was divided, but most participants said they thought sexually active adolescents should be advised to use them. As a Savanne mother said, "I would rather give her condoms than bury her." And a 23-year-old Delmas woman with three young children said, "I have already had one burial; I will tell my child to use condoms." Their tone of resignation reflected the conclusion of many women that once teenagers have experienced sex, they will not stop. The parents' only alternative, therefore, is to give them condoms along with advice to beware the dangers of promiscuous sex.

If you give her condoms, she'll think she has freedom

On the negative side of the issue was a smaller concentration of participants in Savanne who would not advise adolescents to use condoms. None in Delmas opposed giving condoms to young people. Although fewer in number, the antagonists were equally emphatic that condoms were not an appropriate strategy. "Even though they may look mature," said one of these Savanne women, "they are not yet mature enough for sexual freedom." Other women who opposed condoms did so on the grounds that abstinence is more important and that the mother did not "tell me such things." 28-year-old mother of five young children said:

P8: If I don't know whether my child is involved in anything and I tell her to use condoms, I might as well just let her live like a prostitute ("lagel nan jenes").

I would tell her everything about life

Frequent allusions to the importance of modeling proper conduct suggest that participants were highly aware of the positive influence that parents might have on the lives of their children. Although there was little direct reference to negative role modeling, a Savanne woman commented that "in the old days they used to say that what mothers do in front of their children, children will do themselves." "Telling children about life" was a strategy proposed by several women for discouraging frivolous behavior. Speaking from her own experience, a Savanne mother of four in a "plasé" relationship offered the following advice:

P7: I would tell her everything about life, explain to her how I live. I would not live a bad life in front of her so she can follow in my footsteps. I would tell her, "My child, I'm going to sit you down and tell you what's in a man. Once you have a child, he may not take care of you or the child. Once you've had the child, you go through hell to raise him. I am going through misery to raise you. I am telling you these things so you will know there's nothing out there."

Although nearly everyone had an opinion on what parents should tell children about sexuality and AIDS, on the other hand there was strong agreement in all participant categories that children do not listen to adults. The women saw this fact as the single most important barrier to protecting sexually active young people from HIV. Parental advice, they felt, was often treated with disrespect. A segment from a dialogue in

Savanne illustrates their concern:

P3: Nowadays, young people only talk to each other. If you are a mother, your children will curse you for trying to talk to them (about AIDS). They'll say, "You don't know anything, old woman, trying to talk to me this way." They think they are more important than you.
P9: Some say AIDS is only a political thing and doesn't really exist.
P2: You can't talk to these young people.
Mod: Whom do you think they would listen to?
PX: No one can talk to them. At that age the boys already know about AIDS, and even the young girls are saying they won't use a condom, because it has a greasy substance.

Some of the women suggested that adolescents could be advocates and counselors for each other, but most participants cited health personnel, especially doctors and nurses, as the most appropriate people, along with parents, to give advice on AIDS. With probing from the moderator, there was usually someone in the group who added that any well-informed person might provide such a service - if the young people will only listen. A 36-year-old Delmas woman whose oldest child was 12 years old said that "(sex) education should not be done in one place. It should be done in school, at home, everywhere." This mother also said she would "rather talk with children than advise them to use condoms."

B. Networking and Communication among Women

When I go for family planning I'll ask

On the topic of communication among women, there was a common denominator of opinion across participant categories and within groups. It was apparent that in both Delmas and Savanne, women not only knew where they could get information about AIDS, but were talking among themselves about what this disease is and how to avoid it. In all categories except women factory workers, health professionals were the most commonly cited source of information, along with health facilities and family planning clinics. Delmas women who were, or had been, employed in factories were somewhat more oriented to non-formal sources such as friends and neighbors, but all participant categories recognized knowledgeable lay informants. Other sources were radio and television, but as one Savanne woman complained, "the radio tells you a little but not everything." Their greater emphasis on face-to-face communication may be more important to the women than radio or television.

When two women meet, they talk

Women talk about AIDS a lot, they said, particularly among close friends and family and when they are engaged in familiar activities. The following dialogue from a Savanne group illustrates their preoccupation with the disease:

Mod: When do women most often talk with each other about AIDS?
P8: When they have something important to tell. When they have time on their way to work.
P1: When they go to fetch water.
P7: When they are talking about important things, or with my neighbor, while combing my hair we may talk about AIDS.
P5: On our way to fetch water, or when we go to the market, we talk about it. We say that we don't know when the man is going to give it to us. We say to each other that we should protect ourselves in order not to get it.
P3: When a person in the neighborhood is sick, we talk to each other about it, we say that no one knows what's wrong with this person and that he might have AIDS. Then the conversation becomes interesting and everyone talks about the person.

Many factory closings in the months prior to the focus groups had left men and women with more time to talk and reflect on the meaning of AIDS and on the circumstances in their lives that put them at risk. "With nothing to do and no jobs," said a Savanne woman, "we gossip a lot." A Delmas woman commented that women who are friends talk "when they do not get along with their husbands, and in the conversation they end up talking about AIDS."

Women often referred to knowing or seeing people with AIDS as an increasingly common event and one that impressed on friends and neighbors the seriousness of the disease. They spoke of the pain they feel when someone with AIDS dies, but like the Savanne women above, their remarks carried a sense of alarm, revealing a need to share with others the meaning of an event with upsetting implications. Addressing a similar question, a Delmas woman said,

P2: They talk. They may talk about how some person has AIDS. There are many people who have already died. How about that person who came to visit the other day? He died of AIDS. He contracted it and that's why he died. You can talk to people about that.

A few participants proposed people with AIDS as good sources of information, and a Savanne woman suggested that those who will not listen to advice about prevention should be taken to a hospital to see for themselves what can happen.

If I am the woman's friend, I can tell her

As they aired their views, participants consistently cast themselves in the role of counselor and friend to other women, constructing situations in which they would attempt to rescue a friend from danger. Frequently the situation involved the hypothetical friend's husband or partner, who had been visiting other women without the knowledge of his wife. In other situations, the rescuer warned her friend not to have so many partners herself, but to protect her life and her children by settling down with one man or getting a job so that she would not be dependent on men. The latter argument is illustrated in the following excerpt from a 40-year-old former street vendor in Savanne:

P1: I would tell my friend to stop having an irregular sex life and find some work to do. There is all kinds of work out there - working as a maid in a private home, working as a street vendor, anything she can do to put an end to that kind of life.

A group of women in Savanne talked about what helping other women meant to them:

P7: If I know the woman's husband is fooling around, I'll tell her so that she can take precautions. I'll tell her to talk to her husband and to use condoms if they are having sex.
P8: I may talk to her if she's doing something wrong, too. If her husband has other women or she has other men, I would tell her that's how she can get AIDS.
P4: I can help other women in many ways. I can talk to them and tell them that everybody's talking about a new disease called AIDS.
P10: If I am the woman's friend, I can tell her that she's doing the wrong thing, that her husband is straight and that she will give him AIDS if she fools around. If it's the man who is fooling around, I will tell the woman to be careful.

Another Savanne woman volunteered the following illustration to explain how one friend might help another:

P4: When two women meet, they talk about the disease. I will say, "My dear, the AIDS disease is out there. I have this friend I have been sleeping with ("sevi avel"), but I don't know if he has been sleeping with other women. I will break away from this relationship." I don't know if the other woman will do the same, but this disease calls for caution. There is no cure.

We feel sad, because we are women, too

Most participants related easily to this discussion, constructing vivid images of women like themselves attempting to communicate to others an imminent danger and a need for change. It was very clear, however, that from their perspective, talking about AIDS in the everyday world had problems and liabilities. Women talking to other women about AIDS is upsetting, they said, because it raises anxiety and forces them to deal with such uncomfortable issues as the sexual behavior of a trusted partner or the possibility that their own behavior may be threatening their lives. When participants discussed how women feel when they talk about AIDS, they identified a broadly significant barrier to AIDS prevention, namely the emotional impact of confrontation with the reality of the disease, including their powerlessness to change that reality without dramatically altering other aspects of their lives. Whether the participants felt competent to deal with these issues outside the protected environment of a focus group was hard to judge. Nevertheless, they were almost unanimous in their agreement that talking about AIDS makes women very uncomfortable.

The moderator's question, "How do women feel when they are talking about AIDS?" elicited strong responses. A 27-year-old Delmas woman with three children and no stable partner said:

P4: When a woman talks to me about AIDS I feel so frightened that I think I should live by myself and never have a man. But now life does not come that way; you have to have a partner.

The following segment from another Delmas group illustrates again the twin specters of fear and doubt that such discussion raised:

P2: We don't feel good when we're talking about AIDS. If you get it, you could die.
P6: We are scared because the woman might have no other friend, but her husband could have another woman, so she lives with doubt.
P8: Once you have a problem and you start thinking about it, you never feel comfortable.

Barriers to communication also arose from the perception of others' response to women who try to initiate a conversation about AIDS. A group of Savanne women shared the following example:

P1: A woman might talk to another about AIDS if she knows this woman is a good person, but if she is a bad person, I would not discuss it with her.
Mod: Why would you talk to her if she is "good" and not if she is "bad?"
P1: The good person would listen, she would think it's for her own good, but the bad one would think I want to discuss AIDS because I don't have any financial problems.
P3: What she said is true. Some people even curse you if you talk to them about AIDS.
P4: If the woman is fooling around and she is my friend, I will tell her to stop so she won't get AIDS. But there are some who will curse you. They will say you don't understand, because you don't have their financial problems, and if you did you would never refuse the little money that a man offered you.

A former factory worker in Delmas said that "you just can't give advice to some women; they get upset and tell their husbands." A Savanne woman reflected similar experience when she said that you can tell another woman about preventing AIDS, but "she may get angry and say you are telling her she is going to catch it." Others reported different reactions: some people don't believe what they are hearing until it's too late; some believe that women who talk about AIDS do so only because they have it; and only loose women or prostitutes talk about such things. There is another kind of woman, one participant said, who will suspect that a friend's warning about her husband's risky behavior is a strategy to take the man for herself. At the end of one of these exchanges, a woman in Savanne added her opinion of the real reason, "... they keep talking about it because they're scared."

Even if the person gets angry, I tell her anyway

Despite the negative reactions they anticipated from some, women in the focus groups seemed willing, and even eager, to talk with others about AIDS, although with some reservations, as the following segment suggests:

P5: I don't feel uncomfortable when I'm talking about it. If the person gets angry, I have to tell her anyway. I understand. I wouldn't feel uncomfortable, either, if she's family or friend, but if I don't know the person I wouldn't talk to her about AIDS.

Another woman in the same discussion indicated that if she had knowledge about AIDS, she would expect to be paid for disseminating it to others if they were not her friends. "I can not talk to (just) anyone," she said, "because they won't all react the same way." This participant was the only one in all the groups who suggested payment.

What happens to one can happen to all

Most women spoke as individuals, but still they seemed to feel a sense of collective responsibility for a problem too great for most individuals to manage. Participants talked about warning other women of the dangers of sexual freedom, about exposing men who "fooled around" with "loose women", and about sharing information and strategies for preventing transmission. Their readiness to talk to others, despite the risk of being misunderstood or rebuffed by some who might resent the intrusion, suggested a sense of urgency. And when women spoke of their "responsibility" to help friends in difficult and risky sexual relationships, they were expressing a latent sense of solidarity that as yet had little form. Most women had no formal group affiliation, because few such groups exist in Haiti. The clearest articulation of an abstract sense of collective responsibility came from a 38-year-old Savanne woman who had no formal education but belonged to a prayer group in her church. She expressed her concern about preventing AIDS in the context of her religious beliefs when she said,

P5: I think that all of us on earth are brothers and sisters, because there is only one God who is the Father of all of us. Each one should tell another ("bri kouri, nouv l gaye"). If you know about the AIDS disease and that it has no treatment, you have to tell others.

The same woman advised the others in her group to talk about prevention before it is too late:

P5: It's not when a woman is sick that you should preach to her, it's starting from when she is healthy, because the disease has no treatment. When you sleep with a man and take money from him, the money can't cure you. It's when we're healthy that we should talk.

The moderators raised the issue of collective support with a question, "How can women help other women to have more strength ("plis jaret") in the way they live with their men?" It was a difficult concept for the women to grasp. The few who responded did so in terms of advising others on well-known modes of HIV prevention, specifically monogamy and condoms, or they referred vaguely to helping another person "maintain a normal life for herself." A group of women in Delmas answered the question in terms of a more general role of marital advisor:

P4: If your husband treats you well in the home, you could talk to your friend and ask her how her husband treats her - we all can have hope.

P6: Our support ("jaret fos") can help a woman in the way she lives with her husband. But all homes do not function the same way. If the man doesn't give her money, you can't advise her on how much she should get, but you can give her support and tell her how to get along with her husband so he will love her and take care of the children, who won't grow up living promiscuously, and so he won't go around living with other women and fathering other children.

If someone explains it to me, I will teach another

Toward the end of each focus group discussion, moderators asked participants if they thought women in general would benefit from talking about AIDS in small groups. Not surprisingly, the answer in most groups was positive. However, the "vivavek" women in Savanne were unenthusiastic, saying, for example, "We don't belong to groups" and "The sister who gives us condoms tells us how to avoid disease," probably referring to a nurse or health assistant from a clinic. In other participant categories, the question elicited discussion of ways in which women might organize AIDS information meetings with neighbors, friends, or coworkers. The following segment from a dialogue in Delmas illustrates their response:

P2: We would benefit from a group like this one by having a gathering at someone's house so we can talk.
P3: We must invite people.
P1: You hear talk about AIDS, but you don't know what AIDS is. You know there is AIDS out there. If a woman is fooling around ("viv ave") with many men, we must tell her to avoid AIDS. I came here and said all that I understand, but I still can not explain how the AIDS disease is. But if someone can explain it to me, I can teach another.

Women frequently spoke as if they believed they were in an AIDS education meeting, even though the moderators began every session with an explanation of their role as listeners, not teachers. Nor is there any indication in the transcripts that moderators were giving information about HIV. Nevertheless, women made comments like, "When I get home, I'm going to share what I've just learned here" (Savanne). Although the purpose of the focus groups was not education, many women probably did learn something about AIDS, but they were learning from each other. Because they were ready and eager for new information, they perceived themselves as learners and accepted the contributions of their peers as information they needed to have. Unfortunately, not all the information they received was accurate, but their confusion drives home the point that women urgently need a forum in which to sort out fact from fiction and discuss with others the impact of AIDS and AIDS prevention messages on their own lives.

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

II. Presentation of Findings