Research Article
Learners’ knowledge and and perceptions of voluntary Counselling and Testing for HIV and AIDS in the Free State Province Y Botma School of Nursing, University of the Free State ZD Motiki School of Nursing, University of the Free State MC Viljoen School of Nursing, University of the Free State
Abstract: Curationis 30(2): 48-57 The study investigated the perceptions o f the youth regarding Voluntary Counselling and Testing (VCT) and sexual aspects related to HIV and AIDS. The study was grounded in qualitative methodology, using 4 focus group interviews for data collection triangulating the results with field notes and literature. The participants o f the four focus groups proved to be well inform ed on the topic and had clear perceptions concerning several aspects. They were very positive regarding the advantages o f VCT for the prevention and management o f HIV and AIDS. The participants recognised the need for the youth to be better informed about VCT and HIV and AIDS. They were much concerned by the lack o f parental involvement in sexual education as well as the perm issiveness o f the youth w ho partook in alcohol and drug abuse as w ell as prostitution. Participants o f the study stated that this problem was exacerbated by poverty and poor socio economic conditions.
Opsomming
Correspondence address: M. C. Viljoen School o f Nursing U niversity o f the Free State PO Box 339 Bloem fontein 9301 South Africa
Die doel van die studie was om die persepsies van die jeug betreffende Vrywillige Berading en Toetsing (VBT) vir MIV en VIGS asook verwante seksuale aspekte te ondersoek. Die navorsing was kw alitatief van aard. Met gebruik van 4 fokusgroep onderhoude is data versamel w at getrianguleer is met veldnotas en literatuur. Die deelnemers aan die fokusgroep besprekings, was goed ingelig oor die onderwerp en het sterk opinies gehad rakende verskeie aspekte. Hulle was baie positief oor die rol van VBT in die voorkoming en hantering van MIV en VIGS. Die deelnemers het die belangrikheid daarvan beklem toon dat die jeug beter ingelig moet wees oor VBT en M IV en VIGS. Hulle was baie bekom m erd oor die gebrek aan ouerlike bertokkenheid by seksuele opvoeding asook die permissiwiteit van die jeug wat dwelms en alkohol misbruik en betrokke is by prostitusie. Die deelnemers aan die projek het gevoel dat hierdie probleme vererger word deur armoede en algemene swak sosio-ekonomiese toestande.
E -m ail:
[email protected] 48
Curationis June 2007
Introduction During the last tw o decades, the Human Im m unodeficiency Virus (HIV) and the disease caused by it known as Acquired Immune Deficiency Syndrome (AIDS) has e n te re d o u r a w a re n e s s as an incom prehensible calam ity. HIV and AIDS has taken a terrible hum an toll, c la im in g m illio n s o f liv e s, le a v in g thousands o f orphans, inflicting pain and g rie f, ca u sin g fear, u n c e rta in ty and th reaten in g econom ic d ev astatio n in S o u th A fric a (S ta d le r, M o rriso n & McGregor, 2000:4). A ccording to Van D yk (2002:19) the problem s caused by HIV and AIDS can be system ised into two broad categories, nam ely p revention and m anagem ent. Firstly the health sector and scientific c o m m u n ity h as to fin d w a y s o f preventing the spread o f the virus. And secondly, it has to solve the problems that are posed by managing the people who are already infected and who are ill or dying because o f it. Prevention o f HIV and AIDS is a priority for all health sectors in South Africa. A ccording to the National Departm ent o f Health Strategic Plan for South Africa 2002-2005 priority area num ber one is vested in the p revention o f H IV and A ID S, esp ecially am ongst the youth (National Department o f Health, 2000:15). A c c o rd in g ly , n u m e ro u s e ffo rts are currently underw ay to reduce the rate o f sexually transm itted infections including H IV in South A frica. T hese efforts in c lu d e e d u c a tio n p ro g ra m m e s fo r encouraging safer sexual lifestyles, the supplyin g o f condom s by the public sector and the giving o f anti-retroviral (ARV) drugs where necessary. However, judging by the increased rate o f HIVin fectio n s th ese effo rts fall sh o rt o f a c h ie v in g th e ir aim o f c u rb in g the pandem ic and saving lives. Seemingly these efforts have in a way successfully in creased k n o w led g e and aw areness a b o u t H IV an d A ID S a m o n g th e population in general w ith little or no change in behaviour (Letsie, 2000:2). Much research is being done worldwide to d e te rm in e w h ic h in te r v e n tio n program m es are successful in changing sexual lifestyles among the youth. This fact was illustrated when in 2001 The Cochrane Library analysed as m any as 60 research articles concerning different intervention program m es for changing sex u al life s ty le s (S h e p a rd , W eston,
Peersman & Napuli, 2001). A v e ry im p o rta n t s tra te g y in th e p rev en tio n o f H IV is the pro cess o f Voluntary Counselling and Testing (VCT) w hereby an individual is tested for HIV in a confidential setting. D uring the process o f V CT the individual firstly receives counselling to prepare him /her for a positive result. A person is tested and is counselled again when the result o f the test is given to him/her. In the case o f a negative result the counseller will confirm his knowledge for remaining safe from HIV infection. In the case o f a p o sitiv e d ia g n o sis the in d iv id u al is offered ongoing em otional support, is referred for further m edical evaluation and ARV treatm ent and is counselled on how to live a healthy lifestyle so as to protect his immune system. The person is encouraged to take all precautions not to s p re a d th e v iru s to o th e rs by practicing sexual risk reduction and by m aking h is/h e r status know n to sex partners and m edical personnel where necessary. The p ro cess o f V C T is im portant in curbing the spread o f HIV and AIDS. The reasoning is that if an individual tests negative, he will take precautions not to get infected through sexual activities by adopting safe sex practices. Conversely, if an individual tests positive, he will adopt safe sex practices, insuring that he does not infect other people, thereby stopping the spread o f the virus. The m anagem ent o f the health o f people who are infected with HIV is the second problem that the health community faces. VCT m ay address this problem in the following manner: Individuals who test positive for HIV receive m edical and e m o tio n a l a s s is ta n c e a n d can be counselled to cope with the diagnosis. T hey are inform ed about adopting a healthy lifesty le, thus p rotecting the immune system as m uch as possible and delaying the progression o f the disease. The client w ith a positive diagnosis as well as his family members may therefore receive tim ely em otional support and ed u catio n a b o u t the d isease. “ E arly detection ties in with a prolonged life and improved quality o f life for those living with HIV/AIDS” (Soloman, Van Rooyen, Griesel, Grey, Stein & N ott, 2004: 48). Medical assistance includes ARV therapy fo r th o s e w h o se in fe c tio n has progressed to a certain level o f severity. ARV therapy has been offered by the 49 Curationis June 2007
public sector in South Africa since 2004. However when this study was completed, in 2003, the public sector did not provide anti-retroviral drug therapy. F indings from a stu d y by L oveL ife (2 0 0 1 :2 7 ) in K e n y a fo u n d th a t communities placed a higher value on VCT than they did on a hypothetical AIDS vaccine, chronic care services or ARV therapy. Program m es that include VCT have been successful in countries such as Uganda and Kenya. However, as m uch as researchers may v a lu e V C T, th e re e x is t a lm o st in su rm o u n ta b le d if f ic u ltie s in the acceptance o f V C T by com m unities. People desist from going for VCT because o f the fear o f stigmatisation, rejection and ostracism by the com m unity, fam ily, friends and loved ones once a positive diagnosis has been made. Evian (2003:22) as w ell as G ran t, S trode and Sm art (2002:134) stated that stigmatisation o f H IV and A ID S o fte n ca u se s social r e je c tio n , and a lie n a tio n and can c o m p ro m ise e m p lo y m e n t, h o u sin g , schooling and childcare responsibilities. “A large num ber o f studies carried out over the last 5-10 years suggest varying degrees o f negativity in the perception o f people with HIV and AIDS” (Hodgson, 1997:283). Overcoming the stigm a associated with H IV is the b ig g e st ch allen g e to its prevention and care. Countries where VCT is well established, such as Uganda, have less stigm atising attitudes to HIV and AIDS (UNAIDS, 2001:46). Another great barrier to VCT is the fear o f a positive diagnosis. Reactions o f clients to a positive diagnosis include a variety o f emotions such as shock, denial, d is b e lie f, d e s p a ir, n u m b n e ss and helplessness. O ther em otional reactions are guilt, anxiety and depression as well as obsessional thoughts, which include frequently thinking about suicide (Evian, 2003:42). Suicidal tendencies are common with people who are tested HIV positive because the emotions that are linked with a positive diagnosis are hopelessness and negative expectations o f the future (Van Dyk, 2002:278). It is important to note at this point that m any o f the problem s o f stigmatisation and fear are based in ignorance about the transmission, diagnosis, prevention, associated sym ptom s and diseases as
well as m anagem ent o f HIV and AIDS. Stadler et al., (2000:4) reiterated this when they named the barriers to achieving HIV preven tio n as being fear, d enial and ignorance. Adding to this they said that the prevention o f the infection o f HIV has been plagued by silence resulting from the stigm a asso c ia te d w ith the disease. It was against this background that the re s e a rc h to p ic a n d d e s ig n w as conceptualised. It w as n e c e s s a ry to d e te rm in e the existin g percep tio n s ab o u t VCT. In choosing an age group it was decided to concentrate on the youth because they are so much at risk o f contracting HIV and AIDS (LoveLife, 2001:2). VCT is a relatively new phenom enon and until 2003 when this study was conducted, no studies concerning it had been done in the Free State. It was decided to do a qualitative research study on secondary school learners in the M angaung M unicipality, M otheo District in the Free State to determine their perceptions o f VCT. The purpose o f the study was to explore and describe the perceptions o f the youth on VCT. The information gained could be an important guide to policy form ation concerning VCT at regional and national levels in South Africa. As is the case w ith m ost q ualitative research, the results o f the study yielded m ore info rm atio n co n cern in g issues related to HIV and AIDS than only the youth’s perceptions o f VCT.
moderator. The Free State Department o f Education was contacted to find a school w hose baseline language was Is iX h o s a . T h e re fo re th e ta rg e t population consisted o f all the learners in o n e se c o n d a ry sc h o o l o f the Mangaung Municipality Motheo District comprising 929 learners from Grades eight to twelve. In an effort to reduce the influence o f “pecking order” o f ju n io r and senior learners on the groups being studied, the two extreme ends were excluded from the study. These were the learners in grades eight and twelve. This strategy made the age distribution smaller and the groups more homogeneous, which adds to the trustworthiness o f the study.
explained below. Learners were selected that were: •
Children at this age are interested and knowledgeable about sexual matters since they are adolescents (Coleman, 2001:14) •
Method
Babbie (2001:294) suggests that focus groups should consist o f 12 to 15 people. A descriptive design using qualitative Therefore the researcher selected four m ethods o f data collection w as used. groups o f 15 learners that would form the Focus group interviews were conducted focus g roups. W ith this n u m b er o f with secondary school learners to explore learners in a group, provision could be and describe the phenom enon o f youth made for absenteeism or non-attendance. perception o f VCT. These focus group The percentage o f learners in each grade interviews were triangulated with field and gender group was calculated so that notes and literature thereby enhancing each focus group w ould consist o f a the trustw orthiness, richness and rigor representatively correct proportion o f o f the data collected. grade and gender. Selection from these proportions was done according to the m e th o d p u rp o s iv e sampling m ethod in that the One o f the secondary schools in the learners were chosen which had certain pre-identified characteristics. The Life Mangaung M unicipality M otheo District S k ills te a c h e r w as u se d as the was purposefully selected, on the basis “g a te k e e p er” b ecause she knew the o f language, to form the population o f children well enough to assist with the the study. The learners o f this school selection criteria. These criteria and the speak IsiX hosa, w hich is the m other reaso n s for im p lem enting them , are tongue o f the researcher as well as the
Population and sampling
50 Curationis June 2007
Selected from grades nine to eleven: This was done to reduce the “pecking order” o f junior and senior learners on the other learners
•
Selection and size of focus groups A ccording to Polit, Beck & H ungler (2001:325) a guiding principle in sampling is the data saturation principle, which means sampling to the point at which no n ew in fo rm a tio n is o b ta in e d and redundancy is achieved. Morse (1998:76) states that: “ In q u alitativ e research, adequacy refers to the amount o f data co llected, rather than the num ber o f subjects, as in quantitative research” . A d e q u a c y is th u s a tta in e d w hen sufficient data have been collected in order that saturation m ay occur and v ariatio n is both ac co u n ted for and understood. A c c o rd in g ly th e p rin c ip le o f d ata saturation for focus groups interviewed, was applied and because saturation had o ccu rred afte r the fo u rth gro u p , no further interviews were needed.
Older than 14 years:
Able to communicate in English and IsiXhosa: The researcher wanted participants who could speak Xhosa but who had been educated in English and therefore comfortable with all terminology regarding HIV and AIDS.
•
Outspoken and able to take active part in the discussion: This was to ensure a variety o f participants’ perceptions.
Data collection The study w as c o n d u cted u sing the q u a lita tiv e m e th o d o f fo c u s g ro u p d is c u s s io n s , o b s e rv a tio n and d o c u m e n ta tio n an d re su lts o f each method were triangulated with that o f the other as well as w ith literature. The following steps were implemented in the procedure:
Ethical considerations and consent Perm ission to conduct the study was o b ta in e d fro m all re le v a n t p a rtie s beforehand. These included am ongst others the participants, their parents, teachers and school principal. Everyone involved was briefed on exactly how and where the study would take place so that th ey c o u ld g iv e in fo rm e d co n se n t. Confidentiality was ensured and kept throughout the study and raw data were secured and burnt after completion o f the study. All participants took part in the study voluntarily and they were informed th a t th e y m ig h t d is c o n tin u e th e ir p a rtic ip a tio n at an y p o in t o f the proceedings.
Focus groups Focus groups provides the interviewer
w ith the opportunity o f observing the population being studied first hand and gaining an in depth m eaning-, and thus valid insight and understanding o f the phen o m en o n being studied (B abbie, 2001:294; Greeff, 2002:313). Gibbs (1997: http://www.soc.surrey.ae. uk/sru/SRU 19html) stated that the main purpose o f focus group research is to d raw u p o n p a r tic ip a n ts ’ a ttitu d e s , fe e lin g s , b e lie f s e x p e rie n c e s an d reaction s concerning the topic being discussed. The actual research for this study was done at a secondary school, chosen for its baseline language o f Isixhosa. Before each focus group discussion took place, care w as ta k e n to c re a te a re la x e d atm osphere am ong the participants and to provide them with the opportunity to b u ild r a p p o r t w ith th e m o d e ra to r, researcher and study leader. According to N eum an (1997:355) a field researcher needs social skills and personal charm to build rapport. Prior to interviews in focus groups, participants m et informally for thirty m inutes w ith the moderator, the researcher and the study leader. Snacks and coffee w ere provided. Purposeful sm all ta lk a v o id s d is c u ssio n o f the research topic and instead concentrates on com m on hum an experiences such as the w eather or sports (K rueger & Casey, 2000:103). T h e fo c u s g ro u p d is c u s s io n s w ere conducted at the school in a quiet setting with learners placed in a circle to promote good com m unication am ong them. The moderator was part o f the circle while the researcher and study leader w ere seated outside the circle so as not to be part o f the group. They acted as participant observers. The tape recorder was placed in the m iddle o f the group in full view. It was tried to create a relaxed, natural and non-threatening atm osphere by building rapport and by using a skilled moderator. T h e m o d e r a to r w as a q u a lifie d psy ch iatric nurse w ith ex p erien ce in co n d u ctin g focus group discu ssio n s. She was fluent in English and IsiXhosa, which are the tw o languages, used in the region and in which participants could express th em selv es. T he m o d erato r p o s e d th e fo llo w in g o p e n -e n d e d question to the group: “ What is y o u r perception o f Voluntary C ounselling and Testing f o r H IV and A ID S?”
T h e d a ta c o lle c tio n w as d o n e as m eticulously as possible. The m oderator requested that everyone should not speak at once but encouraged spontaneity. It was stressed that the tape recordings could not be linked to any names. To ensure this the participants were given numbers by which they would be known. The spontaneity and openness o f the learner’s discussions indicated that good rapport had been established with the moderator. A lthough some participants were not actively involved by speaking all the time they leant forward which in body language indicated their interest in the ongoing discussions.
Field notes While the focus group discussions were in p ro g re s s , th e re s e a rc h e r to o k descriptive, observational, theoretical an d p e rs o n a l n o te s. T h e se n o te s described the unstructured observations made during the discussions as well as the interpretation o f these observations. T h e o b s e rv a tio n s in c lu d e d s e a tin g arrangem ents o f participants, the order in w h ich p e o p le spoke to aid voice recognition, non-verbal behaviour o f participants, themes that were striking as w e ll as p e rs o n a l th o u g h ts , id e a s, hunches and impressions. The importance o f field notes is that they aid the researcher in focussing on group d y n am ics w h ich is im p o rtan t in the analyses o f data since the strength o f focus groups lie in the process o f sharing and com paring among the participants (Polit & Hungler, 1999:369).
Trustworthiness Trustworthiness is described by Polit and H u n g le r (1 9 9 9 :4 3 0 ) as c re d ib ility , dependability and confirmability. The credibility o f the study was high due to the skill and professionalism o f the study leader and supervisor o f the project as well as triangulation o f the focus group interview data, field notes and literature. Credibility is also described by Polit and Hungler (1999:430) as “truth value”, and therefore the prolonged engagem ent o f the re se a rc h er w ith the p a rtic ip a n ts during the focus group interviews as well as the fact th at she w as o f the sam e lan g u ag e and c u ltu ra l g ro u p as the participants, is regarded as adding to the tr u s tw o r th in e s s of th e stu d y . Dependability o f the analyses o f the data w as in c rea se d by u sin g a co-coder. 51 Curationis June 2007
Confirmability was added to because the r e s e a rc h e r d ir e c tly o b s e rv e d and interacted with the participants in their natural setting during the data collecting phase.
Data analyses A qualitative data analysis is a tim e c o n su m in g an d in te n s iv e a c tiv ity clustering together the related narrative inform ation into a coherent structure. The researcher has to familiarise herself with the data by rereading o f transcripts. Working together with a co-coder, points o f interest are underlined, m eaning is attached to elem ents in the data and notes are made along the margin. Data were analysed from field notes as well and were coded and categorized. Coding refers to the process o f transforming raw data into standardised form and entails the id e n tify in g o f re c u rrin g w o rd s, them es and concepts w ithin the data (Polit etal, 2001:697). The data w ere grouped according to th e m e s an d c a te g o ris e d and s u b categorised. The main categories were formed by the categories o f the KAPB m odel namely, K now ledge, A ttitudes, Practices and Beliefs. (See table 1). This model was derived from the Health Belief M o d el an d w as d e v e lo p e d to help determine whether an individual is likely to participate in disease prevention and health prom otion activities (Kozier, Erb, B e rg m a n & S n y d e r, 2 0 04: 178). A ccording to M om a and Lush (2003: h ttp ://w w w .g e n d e rlin k s.o rg .z a /d o c s/ 2003/hiv-training-manual/liv-ch4.pdf) the K A PB m odel can lead to a g ain in kno w led g e, a ch ange in b elie fs and attitudes and ev en tu ally a change in practices and behaviours.
Presentation of the findings The findings indicated that the learners who participated in this study had well defined perceptions regarding VCT. As this was a qualitative study, findings o f perceptions regarding related issues o f HIV and AIDS were disclosed and were reported according to the KAPB model.
Knowledge All four focus group participants knew about HIV and AIDS and that it had a high m ortality rate am ongst the youth. They were knowledgeable about the role o f VCT in prevention o f HIV and AIDS
Table 1: Frequencies of responses from four focus group interviews Main category
Themes
Sub-category
Four Focus group interviews 1.
Knowledge
M ust test Know your status
X X
Fear Rejection Suicide
X X X
M odes o f transmission
Infected blood
Sources o f information
VCT & prevention
Barriers against VCT
A ttitudes
Practices
Beliefs
2.
3.
X X
X -
X
4.
X -
-
-
X X
X X
X X
X
X
X
X
Media Youth groups at school
X X
X X
X X
X X
M edia
Explicit sex scenes
X
-
-
-
Parental guidance
No guidance Parents are ignorant
X X
-
X
X X
School guidance
Sex education in the curriculum
X
X
X
X
Disclosure
To sex partner By doctors to families By traditional healers to families
X X X
X X X
X X X
X X X
Developm ent o f self concept
Empowerment to say no to sex Empowerment to use condoms
X X
X X
X X
X X
Peer counselling
Easier to speak to a peer Youth programs run be youth
X X
X X
X X
X X
Pre and post-test counselling
Ethical and legal right Support is made possible Keeping safe is encouraged
X X X
X X X
X X X
X X X
Sexual risk reduction
A bstinence Condoms M asturbation Thigh sex Virginity testing
X X X X X
X X X -
X X X -
X X -
Value clarification
Partner loyalty A bstinence Alcohol, drugs and morality Poverty and prostitution
X X X X
X X X X
X X X X
X X X X
Support for PLA
Encourage VCT Support groups for PLA
X X
X X
X X
X X
Religion and culture
M orals and religion A fric a n c u ltu re a n d sex u al guidance
X X
X X
X X
X X
M isconceptions and Myths
Paying for VCT Condoms have holes Virgin Cleansing
X
X
-
-
52
Curationis June 2007
as well as the barriers against VCT. They knew about other modes o f transm ission apart from the sexual, and where to obtain inform ation regarding the disease.
Voluntary counselling and testing and prevention of HIV and AIDS A ll p a r tic ip a n ts k n ew a b o u t th e im p o rta n c e o f V CT. T he fo llo w in g q u o ta tio n s b e a r te s tim o n y to th e ir convictions and are presented verbatim: “People m ust go f o r the test. A ID S must be preven ted in anyway. Prevention is better than cure. ” “You are not negative until yo u have tested; the only way to stop the spread is you m ust test. ” “You m ust know where you stand. ” Studies dem onstrating that sexual risk behaviours are reduced significantly with VCT come from a num ber o f developing countries (UNAIDS, 2001:46). The recent m ulti-centre VCT efficacy trial was the first ra n d o m ise d tria l o f V C T from developing countries. It dem onstrated that VCT resulted in greater behaviour change than health education alone. The study also indicated that sero-positive p eo p le w ere m o re lik ely th an se ro n eg ativ e p eo p le to show sig n ific a n t b e h a v io u r c h a n g e s in d e v e lo p e d c o u n trie s as o p p o sed to d e v e lo p in g countries w here this behavioural change was less significant (UNAIDS, 2001:46).
Barriers against VCT T h e fo c u s g ro u p s c o n firm e d th e existence o f barriers against VCT. All four focus groups agreed that people do not go for VCT because o f the fear o f being te s te d p o s itiv e a n d th e n b e in g stigm atised by others. A dded to this, there was the fear o f dying and thoughts o f suicide. Stadler, M orrison and Me Gregor (2000:4) states that HIV and AIDS are la rg e ly a s s o c ia te d w ith s tre s s , prolonged suffering and death and Van Dyk (2002:278) maintains that HIV and AIDS are associated with an increased likelihood o f suicide. These were some o f the com m ents; “Some parents have a negative attitude they will say she or he is no longer my d a u g h te r o r son i f a p e rs o n is H IV positive. ” “O ther people say i f la m H IV positive, I am going to kill myself. ”
Modes of transmission Participants were well infonned about the mode o f spreading o f the disease other than through sexual contact. In view o f the fact that HIV can be contracted via other m eans than sexual contact, the four focus groups stated the im portance o f VCT even for people who are not sexually active, as indicated by the follow ing verbatim statement: “When y o u touch the b lo o d o f H IV positive person you can get A ID S i f you have a sore. ”
Sources if Information Sources o f sexual information were mainly the m edia and youth group activities presented by schools. The m edia in the form o f TV, radio, newspapers, posters, pam phlets as well as books and movies, is a rich source o f information on HIV and A ID S (N eethling and Schoem an, 1999:72). The four groups recom m ended a variety o f novel ways o f teaching about HIV and AIDS. Dram as, debating team s, RAP music and even youth groups going from h o u se to h o u se w e re so m e o f th e suggestions m ade by the participants. Some participants raised the valid point that there is enough information from the m edia but that it is just ignored by many y o u n g p e o p le , as re v e a le d by th e following statement: “P e o p le do n o t liste n ; I th in k the governm ent should stop advising people abo u t A ID S because it is a w aste o f money we are like monkeys. ”
Attitudes The participants o f the four focus groups had clearly expressed attitudes regarding the ro le o f th e m e d ia in p ro m o tin g prom iscuity, the inadequacy o f school and parental guidance in curbing the disease and the ro le o f d o cto rs and traditional healers in non-disclosure o f patients’ HIV status. They also felt that the development o f a strong self-concept would em power the youth against highrisk sexual behaviour.
The media Several p a rticip a n ts w ere outspoken against the incidence o f sex in the movies: “I think the media m ust replace sex in th e m o v ie s w ith an e d u c a tio n a l program. ” 53 Curationis June 2007
Two participants were outspoken about the visual sexual stim ulation caused by m o v ie s s h o w in g e x p lic it sex and according to Louw, Weitz and Radebe (1 9 9 6 :7 1 ) m a ss m ed ia c o n fu se the children about moral and ethical issues surrounding sexual behaviours. The need for m ore inform ation by the media was expressed as well. Literature from the following sources supports this fact (Maker, 2002:25; Alan Guttm acher Institute, 2003: http://w w w .org/press/ 2001/07/turkey0724-ltr.htm)
Parental guidance All participants agreed that they were not getting enough parental guidance regarding H IV and AIDS. Literature supported this view (Davey, 1991 http:// w w w . p o p u l a t i o n . o r g . z a / r e a c h ). A cco rd in g to T he A lan G u ttm ac h er Institute (2003: http://w w w .org/press/ 2001/07/turkey0724-ltr.htm) parents are concerned about HIV and AIDS but do not seem to be co n v inced th at open com m unication about sex and sexuality can reduce the risk o f HIV infection. “Our parents do not talk to us about sex. ” “Parents m ust be taught how to talk to us about sex. "
School guidance All four groups felt that m ore sexual education and inform ation on HIV and AIDS must be given at school and that it sh o u ld form p a rt o f the L ife S kills Education program . This opinion is supported by Van Dyk (2002:155) who agrees that HIV and A ID S education should be integrated into the existing school curriculum. Two o f the groups said that they had re c e iv e d in fo rm a tio n fro m the government via health workers who visited the schools to give sex education. They indicated that the clinics provided information as well.
Disclosure The focus groups were greatly concerned about the problem posed by keeping HIV status confidential since they felt that the spread o f HIV and AIDS would continue while people are protected by law from disclosing their status. The four focus groups felt that people should disclose their status to their sexual
partners. They were o f the opinion that when a person has died o f AIDS and the doctors and fam ilies and tra d itio n a l healers obscures this fact by saying that the cause o f death was some other illness; they are exacerbating the problem o f HIV and AIDS. “Doctors will not say a person died o f AIDS. They will say the person died o f TB or cancer. ” “Witchdoctors orfortune tellers must not lie, they m ust tell the truth about the illness (AIDS) o f the person, because th e y te ll th e p e o p le th a t th e y a re bew itch ed a n d y e t th ey are dying o f AIDS. ”
Development of self-concept The idea that a strong self-concept would lead to em pow erm ent o f o n e se lf was expressed and discussed by the groups. Kutz (1997:26) stated that empowerment occurs when one becom es able to take action for oneself. It is accom panied by a gro w in g b e lie f in o n e s e lf and the growth o f self-confidence. All four focus groups were in agreement with the principle o f living a positive life and a v o id in g h ig h - r is k se x u a l b e h a v io u rs . T h is in c lu d e d th e w illin g n e s s to go fo r V CT. T h e y em phasized the need for the youth to change their sexual behaviour, not being influenced by peer pressure, not being coerced into a sexual relationship by a partner and saying “no” to sex with pride. They advocated the development o f selfrespect and assertiveness. “Be able to say no to sex. Say it with pride. ” “Being cool is not drinking and smoking and having sex, it is about doing what is right. " There was concern for the em powennent o f women in unequal relationships such as those married to - and living with HIV positive men. There was also concern fo r le a rn e rs in d is e m p o w e re d relationships. The developm ent o f a s tro n g s e lf-c o n c e p t as re la te d to assertiv en ess for w om en in unequal relationships was advocated.
Practices The participants had certain perceptions regarding peer counselling, pre-and post
test counselling and practices regarding sexual risk reduction.
“I think we m ust abstain from sex before marriage "
Counselling
“Sex is notfor children, it is not a gam e ”
Participants from all four focus groups strongly supported peer counselling. S u g g e stio n s w ere m ad e th a t you n g people should work at clinics because it is easier to speak to a peer than to an adult about sensitive issues.
Safer sex The four focus groups were aware o f high risk sexual practices and agreed that sex without a condom is a num ber one high risk factor for contracting HIV and AIDS.
P e e r c o u n s e llin g is s u p p o rte d by literature, w hich states that behaviour change is most likely to occur when peers ed ucate, em pow er and support each other. That means that youth programs sh o u ld be run by you n g p eo p le. A su c c e ssfu l p e e r e d u c a tio n p ro g ram transfers the control o f knowledge from the hands o f experts to the lay members o f the community, thereby making the educational process more accessible and less intimidating (Cox, 1999:4; Stanhope & Lancaster, 1988:78).
The perceptions and opinions o f the participants regarding safer sex were the following: •
The use o f condoms. The majority o f the four groups were in favour o f using male and/or female condoms for preventing transmission o f HIV and AIDS.
•
Masturbation. There were mixed reactions to the practice o f masturbation. Two groups were in favour o f masturbation as a form o f preventing the spread o f HIV and AIDS. Some participants were however opposed to it without giving valid reasons. Van Schaik (2002:243) says that attitudes towards masturbation are usually based on cultural and religious beliefs.
•
Thigh sex. Only one group mentioned thigh sex as an option for curbing the spread o f HIV and AIDS.
•
Virginity testing. Only one male participant encouraged this method o f practicing safer sex but the other participants did not entertain the idea. Research as done by Leclerc-M adlala (2003:7) says that virginity testing may lead to harassment or banishment o f girls by communities.
Pre and post-test counselling All participants agreed that counselling should be done before and after an HIV test. The client should be prepared fully to face the outcome o f the results. They knew that voluntary confidential pre- and post-test counselling is the ethical and legal rig h t o f each perso n . It is o f invaluable im portance to prepare the person for the outcome o f the test. After a positive finding it is functional in supporting the sero-positive person both e m o tio n a lly an d p h y s ic a lly an d encouraging him /her to preventing the spread o f the disease. The post-test counselling o f a person who has tested n eg a tiv e fu n ctio n s to in flu en c e the person to stay negative by implementing safer sex practices.
Sexual risk reduction Reducing the rate o f HIV infection among teenagers w ould lead to a substantial slowing o f the epidemic over the next five to ten years. Conversely, failure to curtail the rate o f infection in this age group could sustain an epidemic o f catastrophic proportions for future decades (Stadler, et al., 2000:1). The focus groups had strong convictions regarding the need to stop the spread o f H IV and AIDS through the advocacy o f abstinence and/ or safer sexual practices.
Values clarification
Abstinence All groups w ere o f the opinion that abstinence was the most practical way o f protecting oneself from HIV-infection.
T he focus g ro u p s w ere stro n g ly in favour o f virtues such as loyalty and trust am ong partners as well as abstinence from sex until marriage, and were opposed to married men who are unfaithful to their
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Beliefs The participants o f all four groups stated their beliefs in upholding moral values as advocated by different religions and cultures and supporting people living with HIV and AIDS. Some misconceptions and myths were voiced.
spouses. H o w ev er acco rd in g to the Population Registration Bureau (2004: http://www.populatioin.org.za) there is a high level o f sex u al a c tiv ity am ong learners. Nationally, two thirds o f thirteen year-olds in South Africa are estim ated to have already experienced their first sexual encounters. The fo u r fo c u s g ro u p s a g re e d th a t alcohol and d ru g ab u se has a g reat impact on the youth, exposing them to high-risk sexual behaviours. Three groups stated that prostitution was a prominent factor in the spread o f HIV and AIDS. W ith regard to prostitution th ey a lle g e d th a t p o v e rty w as an instigatin g facto r. E v ian (2 0 0 3 :1 3 ) confirm s th is o p in io n in saying that poverty, unem ploym ent and poor socio economic conditions are the factors that exacerbate p ro stitu tio n and th u s the spread o f HIV and AIDS.
Support P articip an ts ag re e d th a t su p p o rt for people living with HIV and AIDS (PLA) would lower the prevalence rate o f the disease. The reasoning behind this belief is that people w ould go for V CT and disclose their status if they did not fear stigmatisation and knew that they could count on the support o f the community. The focus groups w ere m uch in favour o f setting up support groups for people living with HIV and AIDS. "Being H IV positive is no longer a death sentence. ” “We need to help others to p reven t the spread o f HIV. ”
Religion and culture The four focus groups v oiced strong opinions about the need for the youth to change their moral behaviour to be in line with the te a c h in g s o f th eir d ifferen t religions. P a rtic ip a n ts h a d c o n c e rn s th a t in traditional A frican culture parents do not discu ss s e x u a lity is s u e s w ith th e ir children, thus preventing their guidance concerning sexual practices, HIV and AIDS.
Misconceptions and myths T here w e re a few p a rtic ip a n ts w ho wrongly thought that one had to pay for VCT an d d id n o t k no w th a t it w as available free o f charge in South Africa.
A few p articipants w ho had negative com m ents about the use o f condom s saying that condom s have holes in or can burst. Summerton (2001:60) alleges that people do not like using condoms and prefer having sex “flesh to flesh” .
are aware o f their rights with regard to testing for HIV. It was mentioned several times that pre- and post-test counselling is imperative, empowering the individual to deal with the result in a positive and constructive manner.
Only one boy m entioned that he knew o f “other people” who believe the virgin cleansing myth.
M ost preventative strategies have been b ased on the p re m ise that increased knowledge about HIV and AIDS will lead people to adopt safer sex practices. The fact that the prevalence o f the disease remains high in South Africa seems to su g g e s t th a t th is a p p ro a c h has fundamental shortcom ings (Summerton, 2001:13). People are now encouraged to m ake use o f VCT to find out their HIV status so as to curb the spread o f the disease.
Discussion of field notes The re se a rc h e r d e s c rib e d the tran sactio n s and p ro cesses o b served during the data collection phase. She o b s e rv e d a n d d o c u m e n te d se a tin g arrangements, conversations, non-verbal la n g u a g e a n d ra p p o rt b e tw e e n participants as well between participants and m oderator, research er and study leader. Personal notes and com m ents c o n c e rn in g h e r fe e lin g s d u rin g the interviews were docum ented as well. The re se a rc h e r o b s e rv e d th a t participants w ere open and free in their d is c u s s io n s o f V C T. N o one fe lt intim idated in the group. Rapport with the m oderator was good and there was m utual trust. Some o f the participants were not verbally active in discussions b u t w e re le a n in g fo rw a rd , th e re b y showing interest.
Discussion VCT is a very sensitive topic to discuss especially w ith young people because it h as a m ig h t h av e a c o n n o ta tio n o f encouraging sexual activity. Taking into consideration that it is not accepted in A frican culture to talk about sex with y o u n g p e o p le , th e y o u th th a t w ere in te rv ie w e d w e re o p e n -m in d e d in discussing their views on VCT, sexual practices, HIV and AIDS. In conclusion it can be said that the four focus groups were knowledgeable about H IV a n d A ID S as w e ll as V C T in particular. They were willing to participate in th e d is c u s s io n s , h a d in fo rm e d opinions and expressed their feelings. All groups w ere in favour o f VCT and had insight in to the manner in which VCT can aid the prevention and managem ent o f HIV and AIDS. They w ere adam ant that p eople should be encouraged to come forw ard for VCT and the emphasis should be on “know ing your status” . The study revealed that young people 55 Curationis June 2007
This study also confirm ed that there is a great need for the youth to be informed about HIV and AIDS. The m edia was cited as the best way to inform the youth such as TV, radio, dramas and posters. O th er m odes th a t w ere in d ica ted to provide HIV and AIDS information were w orkshops, m usic, group discussions, debates and going from house to house to provide HIV and AIDS information. T he study cited the lack o f parental guidance as one o f the m ajor obstacles to informing the youth about safer sex p ractices. A frica n cultu re p ro h ib its parents from talking to their children about sex. Parents should be taught skills on how to com m unicate to their children about sex. P a rtic ip a n ts o f th e stu d y fe lt th a t education and life skills training in junior and se c o n d a ry sc h o o ls w h ich w ere direct, specific and concrete w ould be invaluable in informing young people on ways to curb the spreading o f HIV and AIDS. The functioning o f the groups was in line with the observations o f the researcher and the results o f the discussions are on par with literature. This study adheres to the principles o f trustw orthiness in qualitative research. The limitations o f the study lie in the fact th a t the re su lts o f th e focus g roups can n o t be g e n e ra liz ed to the w hole population. How ever generalization in a qu alitativ e study such as this is not s ig n ific a n t b e c a u s e th e stu d y h as intrinsic value o f its own and has heuristic relevance. This value is reflected in that
the re a d e r is ab le to re c o g n is e the phenomenon described in the study, its theoretical significance, its applicability to nursing practice and its influence on future research activities.
Conclusion T he o b je c tiv e o f th e stu d y w as to determine the perceptions o f the youth about VCT. During this process other perceptions o f the youth concerning HIV and AIDS became apparent. They also presented their opinions as to how some problem s related to the prevention and management o f HIV and AIDS can be addressed. The study indicated that the learners w ho w ere interview ed knew a b o u t V C T an d th a t it w as th e ir p e rc e p tio n th a t V C T m ig h t be implemented to prevent the spread o f the disease and help m anage the lives o f those people already influenced by it.
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