Mtwara Rural District was selected as the site for developing a model for Community Based PMTCT in a rural setting. As was the case with Temeke District in Dar es Salaam the approach used was that of consulting with a wide range of stakeholders in different communities in the district as well as with health personnel serving in the health facilities found in these communities and with members of the CHMT. The objectives of these consultations were:
· To gauge the level of awareness and perception of the seriousness of the HIV/AIDS epidemic among community members.
· To gauge the extent to which the health services are prepared for providing PMTCT services.
· To identify the structures within the communities and the district as a whole which can facilitate the organisation of community based PMTCT.
Coverage
The team visited 16 wards in Mtwara Rural District. Observations and discussions in the community focused on leadership, risk environments, strategies for community participation in HIV/AIDS prevention, including the possible educational role for HIV/AIDS prevention played by theatre and ngoma groups found in community. Observation and discussions in the health facilities focused on deployment of health personnel, their training on HIV/AIDS, equipment and supplies and utilization of health services.
Observation at different levels about HIV/AIDS and its control
Community and district level structures
The district health authorities recognize that HIV/AIDS epidemic is a problem but not a serious one. According to the information provided by the Council Health Management Team (CHMT), the HIV prevalence among blood donors in Mtwara Rural District is 2.4%. It was found that women **were disproportionately more affected (23%) than men (2%). However they stressed that there was under reporting because;
· Traditional healers treat many patients and no reports are received,
· No screening is done to individuals for diagnostic purposes,
· Many deaths occur at home, and no records are taken;
· The reporting system using NACP clinical notification forms is not followed by clinicians.
Heterosexual transmission is believed to account for most of the HIV infection in the district. In the annual STDS/HIV/AIDS report there was no mention about Mother-to-Child Transmission. Some of the district officials knew about PMTCT and they wanted to have it promoted in the district. There are very limited HIV/AIDS interventions by District authorities. Banners and posters and HIV/AIDS appear to be limited to the town. There are very few NGOs addressing the problem of HIV/AIDS. The team managed to get in touch with one active NGO, namely CONCERN, which has started an HIV/AIDS program. Consequently the main sources of information for community members are the radio, few newspapers and some leaflets.
Community level
The team had the opportunity to meet with community leaders at village and ward levels. These meetings discussed about the problems which the communities faced and about the situation of HIV/AIDS. In all villages and wards the HIV/AIDS problem did not feature prominently. Nearly all villages reported at least two deaths which were associated HIV/AIDS, but these tended to have been cases which originated elsewhere. The team was informed that extramarital sexual relations were common in the community. There were high numbers of premarital pregnancies among the in school and out of school youths. The availability of condoms was limited. In most of the villages condoms were only found at the health facilities. The ward and village leaders reported that they had been participating in the campaign against HIV/AIDS by implementing directives from higher authorities. The leaders went as far as prohibiting night traditional dances which are thought to provide the opportunity for youths to meet and initiate sexual relationships.
Highlights of observations made and lessons learned
a) There is high prevalence of poverty in the district. For example many people had only one meal per day and some even failed to send their children who were selected to go for secondary education.
b) Polygamy and extramarital affairs are common. For women the driving force to engage in extramarital affairs is poverty.
c) Marriages are not stable as evidenced by high divorce rates.
d) Youths start engaging in sexual activities at an early stage resulting in high numbers of school pregnancies, dropouts and early marriages.
e) Haphazard control measures have been put in place e.g. banning night traditional dances (ngomas). This measure does not appear to have had any impact on high-risk sexual behaviours in the communities. The epidemic is not perceived as real problem, and most of those who are considered to have died of HIV/AIDS came back home when they were ill.
f) Community leaders, including influential people, are willing to participate fully in initiating and implementing community based PMTCT.
g) Married men who had contracted STI, when called upon by the service providers were willing to bring their spouses for treatment.
h) Parents were said to be unable to control their children, especially the adolescents.
i) Health facilities are sparsely distributed in the district. During the rain season access to dispensaries becomes difficult.
j) Fierce wild animals and distance were reported to limit access of most villagers to the health facilities.
k) Drugs at health facilities were said to be available only during the first two to three weeks of the month.
It appears that barriers to PMTCT include
a) Many women (70-80%) are delivering at home with the assistance of TBAs and relatives. Nevertheless many mothers come for the vaccination of their children, indicating that the health of the child is highly valued.
b) There is a limited number of staff in the health facilities visited and none had attended any PMTCT training.
c) Almost all villages have community health workers who work with the communities on issues of sanitation and nutrition surveillance including registering births and deaths; however they are not remunerated and if they are, and then payment is erratic.
d) Even though community leaders indicated readiness to participate in the community based PMTCT they need to get some basic training about HIV/AIDS generally.
e) Energetic labour force migrates to urban centres and comes back during the harvest time and it is believed that it is this time when HIV/AIDS infection takes place.
f) The hardship of getting water makes girls become more exposed to risky to sexual encounters
g) Even though youths participate in cultivation and harvesting cashew nuts and rice as cash crops, after the sale most of the money remains with the father. Children and their respective mothers do not get a fair share of the proceeds.
h) Old people cannot advocate upholding moral values good customs and traditions presumably because they themselves are not role models. Also poverty renders parents incapable of advocating moral values as they cannot meet basic needs for their daughters.
i) Fathers react negatively to the problems in the households and blame the mothers.
Structures that might facilitate PMTCT include
a. Informal traditional educators during the initiation (kungwi/somo) and circumcisers. These play an important educational role associated with puberty rites.
b. Traditional health practitioners (traditional healers, and TBAs)
c. Community health workers
d. Influential people like traditional chiefs (wenye mji), religious people.
e. Income generating groups of women and youths, ngoma and theatre groups.
Gender Relations in Mtwara Rural District
Gender relations between mothers, children, fathers, sons and daughters in Mtwara rural district are determined by social cultural norms and values that are changing from original customs and traditions, as well as from religious norms. Most men and women nowadays are easily attracted towards satisfaction of immediate bodily gratification. This fact implies that infections of various STIs between different actors become the order of the day.
Poor incomes in most households, dominance of ownership, control and distribution of benefits by men make it extra difficult for women to meet their health and social requirements. Limited income earning opportunities by women further contribute towards their difficult conditions in managing their overall well-being. Mtwara rural district also experiences under-employment of male labour and poor capital generation among the youth. As concerns leadership’s aspects, the district faces low involvement of women at all levels. Women are under exposed in leadership from the household level all the way to local government forums. For instance, average number of women representatives in village governments rarely exceeds four in most villages. Moreover, the villages have low follow-up of unconstructive behaviour among its residents.
On health related aspects, most women in the district seem to incur excessive proportions of poor nutrition, high incidents of underage sex, under age marriage, and early motherhood. Women in the district’s villages appear to have limited exposure to reproductive healthy services, and high workload. On the other hand, men were said to indulge in high levels of promiscuity.
The youth in the district appear to be faced with many problems. These range from: inadequate sustained guidance from parents and community members as regards their current misbehaviour; dislike to work; excessive attraction to ngoma and entertainment at the cost of social discipline; escapist solutions towards problems and family demands for work; fragmented responsibility towards their families as well as their girl and boy friends; and excessive attraction towards anti-social elements and influences.
Early sexual adventures by most male and female youths were clearly a big and growing problem. Youths, besides having poor income earning options, face limited alternatives for self-development. Female youths were more or less more easily trapped with this attraction of ngomas, drive for entertainment at any cost and adventurous sexual encounters. Remote or estranged family relations were another aspect in the picture. Examples abounded of families where mothers and fathers are at loggerheads over how they should deal with the upbringing of their daughters. Generally, it seems the situation of poor control of the youths has a bigger impact on girls than boys, for example large proportions of girls who complete primary school are normally impregnated within the first year of completing school.
Main Impact of Gender Inequalities to PMTCT
Gender inequalities in Mtwara Rural district, contribute towards making it difficult for men, women, and youth to be effectively involved in addressing means on arresting the spread of HIV/AIDS in their midst. For instance, men’s poor understanding on socio-cultural issues prevents them from seeing how gender oppression stops most women from accessing better health care during pregnancy, delivery and post delivery. Neglect of women’s subordination by some of the men results in most rural women failing to use family planning services and fuels unplanned childbirths. It appears that a large number of youth striving for immediate sexual gratification and are therefore at high risk for STIs and HIV/AIDS infections. Promiscuous sex was stated as being rampant in most villages, and wearing condoms was equated to eating groundnuts with the shells on. Generally, women said men were at the forefront in objecting to the use of condoms. However, even where condoms were available, the level of poverty would make them too expensive for most people.
Women’s low understanding of unprotected sex makes them frequently and unknowingly infected with STIs. For instance, 61.2% pregnant women who were tested at Mahurunga Rural Health Centre were found to be infected with syphilis. Village readers and parents appear to be resigned to the “siku hizi” phenomenon, and they complain that they have been dispossessed of the ability to control and manage their families and localities by external agents. For instance, it was stated that villagisation contributed to the erosion of male control over the clan, while professional interventions on child and women’s rights have dispossessed male leaders of control over the family.
Another observation made in the district was the high dependence by most communities on solutions from outside. Although appreciated, there seems to be a cry from rural communities for more consultation on solutions that are shared from their conceptual stages and not merely brought down for implementation. For instance it was stated that IEC materials brought for HIV/AIDS campaigns are too sexually explicit and irritating to some circles. It appears that involvement of community based institutions that deal with health and social issues in Mtwara rural communities needs to be scaled up.
Health care system
The type and number of staff varies between facilities of the same type. Variations in number of staff at dispensary level vary from two to five. For instance, at one health facility it was noted that only two Nurse Assistants (NAs) operated at the facility, which was grossly under staffed. Among the 105 staff surveyed in the study, only 7 had undergone formal training on HIV/AIDS. The number and type of staff in some facilities need to be revised to mitigate the anticipated HIV epidemic at district level.
Utilization of health facility
Number of OPD attendance in 2003 ranged from 1,623 in Lipwidi dispensary to 16,087 in Kitere Rural Health Centre. Also there was wide variation of STIs ranging from 4.0 percent in Mpapura Dispensary to 13.6 percent in Mtimbilimbwi Dispensary. High prevalence of STI among health facility users shows that a significant number of the village populations are sexually active, without using condoms. Reports on HIV/AIDS deaths in the district, stated that prevalence of HIV/AIDS related deaths in the respective communities ranged from 2 to 5. The risk of HIV is relatively high, and an epidemic could occur in the immediate future (e.g., the threat is presently within the incubation phase). Number of first ANC visits by female villagers ranged from 85 at Namgogoli Dispensary to 426 in Nanguruwe Rural Health Centre. This signifies that most mothers go for ANC.
The proportion of women delivering in health facilities ranges from a lowly 6.3 percent at Njengwa Dispensary to 57.6 percent at Namgogoli Dispensary, which signifies that most mothers deliver outside formal health facilities. In the three health facilities that tested all mothers for VDRL, the one that had the highest number of positive VDRL cases was Mahurunga Rural Health Centre, where the women tested resulted in more than 61.2% positive cases. Therefore, risk of both heterosexual and mother to child transmission of HIV is high. The study team observed that low proportion facility deliveries were attributed to a number of factors. One, TBAs are highly trusted by community members including pregnant mothers. Two, some of the villages are located far away from health facilities. Three, long distance is further complicated with poor roads and threat from fierce wild animals. Furthermore, it was reported, the pregnant mothers with risk factors who are referred to Ligula Regional Hospital divert to traditional birth attendants. This was mainly due to lack of fare for most pregnant women to Ligula Regional Hospital, their caretakers, as well as lack of upkeep money.
In spite of high percentage of home delivery, most mothers return to the health facilities for the first immunization of their children. In 2003, for example, BCG immunisation doses ranged from 196 to 338. These figures were very close to the number attending antenatal care in the same period. Such turn up suggests that mothers value their children. It is therefore possible to get mothers after delivery at the facilities, for ARVs and follow up services.
It was also observed that there is limited space for doing extra counselling sessions such as VCT services. However, discussions with the providers revealed that there could be group counselling followed by individual counselling together with antenatal counselling.
Community involvement
Scheduled discussions were held with ward leaders, village leadership, influential persons, TBAs, traditional healers, and, village health workers. Most community leaders acknowledged that HIV/AIDS was a problem but not a serious one. They regarded HIV/AIDS as an external and not localized problem, because the majority of deaths, which have occurred, were on people who had resided outside the district and mostly from Dar-es-Salaam. Most of the leaders in Mtwara rural communities said diagnosis of HIV/AIDS were mainly based on signs and symptoms. Lack of VCT services has made the communities to make unrealistic assessment on the size of the problem.
Traditional ngomas, illicit videos shows, abject poverty, commercial influences of the crop-buying season, urban-rural migration, shortage of condoms, and excessive demand for development activities, are contexts which facilitate transmission of HIV. One popular traditional dance called, “singenge”, which is played throughout the night, creates most problems. Majority of the community members who attend such dances range from 12 to 18 years of age. Adolescents’ pregnancies in Mtwara Rural district are relatively common, the predisposing factor being linked to “singenge”. Excessive poverty was another factor that facilitates transmission of HIV infection in the Mtwara rural communities. An example of excessive poverty in the visited communities can be seen at Njengwa village, where 9 students have been selected for public secondary school education, but only three (3) managed to get the financial resources to join their schools. Lack of financial resources to send children to school was a common occurrence in all wards.
Attitudes towards HIV testing were also explored. Community perceptions on HIV testing are mixed. Some communities were of the opinion that if one is not sick why s/he should bother to be tested. It has been observed that if testing were joined with provision of ARVS many people would have been willing to be tested. None of the leaders consulted ranked HIV/AIDS, STIs, or promiscuity as a leading problem in their communities. The leading problem in most communities was lack of safe water. Attempts to link the water problem and HIV/AIDS transmission were done. The team has found that any assistance in solving water problems would reduce gender harassment of girls and women, who are entrusted with the task of collecting water about 15 kilometres away (sometimes with help of bicycle owners, who later demand sexual favours). This was underscored by one girl who said in Kiswahili “Bhaa!! hivyo shida yote ya maji halafu mie niwe mpingo?”(Hey!! with all this water scarcity do you expect me to be as stiff as an ebony tree). Literally meaning that she cannot refuse sexual request from a man who is willing to help her get water from such a distance.
Village health workers
In each village, there are two VHW, one male and female. Notwithstanding their sustained role in the community, they were not remunerated or erratically given a small amount of money. Traditional birth attendants (TBA) play a big role in the community midwifery. Most deliveries occur at home under the care of TBAs. The trust the communities have on TBAs far exceeds that of modern providers. Home deliveries by traditional health system providers range from 42.4 percent at Namgogoli to 93.7 % at Njengwa. The traditional health system provider’s are important stakeholders in interventions targeting pregnancy and childbirth.
Theatre and ngoma groups
Edutainment has become a dominant feature of educational approaches for HIV/AIDS prevention. The team sought to gage the potential for its use in Mtwara Rural District for promoting the community based PMTCT. Attention was focused on ngoma groups, which are to be found in all villages, and theatre groups, which are found in some of the villages.
Some members of the study team managed to visit seven community theatre groups. With the exception of one group, Beni Nyerere, the remaining groups were constituted of young people aged between 16 and 25 years old. Kiromba Dance Group, Mahulunga Dance Group and Beni Nyerere Group, all specialized in traditional dances. The remaining theatre groups had a mixture of theatre forms such as choir, poetry reading, poetic drama and drama. Most of the artists owned their groups. The groups seemed to have good working relationship with the village and ward authorities. Groups visited during the study were actually those used in various official campaigns and functions concerning HIV/AIDS and other community education activities.
Groups visited and watched were Mtama One Theatre Group; Kiyanga Cultural Group; Mtiniko Theatre; Ben Nyerere Group; Mahulunga Dancing Group; Kiromba Dance; and, Nanyamba Traditional Cultural Troup. These groups are highly used by all local Authorities in Community Education e.g health interventions, and entertainment for political and Governmental visits.
Generally, the visits showed that there is high commitment among the artists in arranging and performing their productions, despites being unfairly remunerated for their work.
All theatre groups expressed concern on the current situation whereby they are required by village authorities or District Officials to prepare performances for the authorities without any remuneration or fair incentives. This has led to some of the groups dropping out and some of the good artists leaving their groups (which therefore remain with unqualified artists).
Quality of theatre creations is generally low. It is difficult to see how these productions can influence the rural communities change their behaviour, as regards transmission of HIV/AIDS. Technically, all performances relied on “banking”, “indoctrinating”, “telling” or “preaching” methods. These methods normally ignore the need to extract input from the audience. Most of the messages present in current theatre productions do not adequately address the AIDS problem as a locally based community predicament but rather as a distant national or rather global crisis. This reduces the influence that theatre groups has in making people in these areas think seriously on owning the problem.
Examples of HIV/AIDS Productions
Hereunder are a few examples of materials produced by theatre artists from Nanyamba and Kiromba villages.
AIDS message to the People.
We give to you this serious message
It is about that AIDS Scourge
AIDS is a threat for your life my brother.
We artists say AIDS is finishing us
Youth, our potential human resource continue to perish
AIDS kills without segregating young people.
Parents are dying lot of children are orphaned.
Children miss their rights of being taken care.
Fight the AIDS, and should not commit adultery
Luxurious life and drunkard ness should all be reduced
Have one partner who is trustful
And all sharp devices should not be shared.
We beg for change for all behaviours contributing to spread of HIV/AIDS,
Overnight dances they should stop
AIDS has neither religion nor tribe
AIDS is Dangerous
My friends, AIDS kills
It kills many people in the world
Young and the grown up
My brothers, lets take caution
Otherwise, we shall perish
AIDS is dangerous
There is no prevention.
Symptoms are diarrhoea and coughing
Use condom for prevention
The above extracts from the two songs, show that the artists have assumed the authority of commanding community members to follow the directives issued by the artists, instead of guiding them through facilitation. Solutions for societal problems should be approached through animation and provoking involvement of community members rather than giving ready-made solutions.
Examples of Plays on HIV/AIDS
The play centres on multiple partnerships that are apparently very common among rural residents in most villages. The play includes elements of unfaithfulness in marriages and beliefs in sorcery and witchcraft. The following is a plot of the play:
a) A husband and wife are talking about family dealings. The wife complains to the husband about his bad behaviour of womanising. She cautions him about risks of contracting HIV/AIDS.
b) The husband goes out and meets a woman called Shakila. He seduces her and she agrees to have sex with him but on condition of using a condom. The man convinces Shakila that he is HIV free therefore; she does not need to worry. Shakila agrees to have sex with him without using a condom but instead demands an additional two thousands shillings for the sex. They leave the stage.
c) The man comes home coughing. His wife asks him to go for HIV testing as she suspects him of being HIV positive. The husband disagrees to the proposal but insists on going to a traditional healer.
d) The traditional healer comes in and starts treating him. Suddenly he becomes seriously ill and dies. The healer runs away.
The above play by Nanyamba artists, which took thirty minutes, portrays lack of logical flow and realism. The performance was more of a comedy, and hence could not be taken serious by the audience. In fact, laughter was the reaction that dominated among the audience. This problem is caused by the fact that the most artists in Mtwara rural district have limited skills in terms of knowledge on how to create professional theatre productions. Very few artists in the rural villages have had exposure to a large variety of theatre productions. In sum, most of the artists were seen to have the hereunder shortfalls:
a) Most of the artists lacked basic knowledge on HIV/AIDS. Among the groups visited, only three groups had artists who had had a chance to attend a three-day workshop on HIV/AIDS. The remaining artists use information they got from radio or newspapers to create their theatre productions. For example while the performances were discussing about unprotected sex “ngono zembe” few artists could actually define the term when asked. This creates serious questions whether the performances manage to effectively deal with new aspects of the pandemic. Nothing new was being shared in their performances.
b) Traditional dances still remain as the most popular entertainment space for young people in the visited villages. Dances were in the past performed daily from 04.00 p.m. to 01.00 a.m. unfortunately; these dances are linked to increase in the risk of HIV transmission among young people. Dances function very often as meeting place for young people and breeding ground for adventurous sexual relations. In this case, some villages have prohibited them.
c) There were also a few community dance groups formed by elders. These were seen to share the same concern on AIDS pandemic. Beni Nyerere group is one such group. The group is specialises in “Beni” dance. It was seen as an opportunity for enabling old people and youth to meet and exchange ideas through songs on the HIV/AIDs pandemic. The group also sings about other common social ills such as child abuse.
d) There is generally poor or complete absence of role modelling. While theatre performances were meant to influence behaviour change among community members, artists do not necessarily represent that image. For example, some artists have high usage of alcohol; this was the case with those performing the “singenge” dance. In addition, a big number of artists admitted openly that they did not use condoms despite the fact that they strongly advocated its usage in their performances. This makes them appear as hypocrites and thus difficult for their messages to be believed by community the members.
“Study for Preparation of Community Based PMTCT in Mtwara Rural District.” Reported by, Professor Eustace P.Y. Muhondwa (Team Leader), Dr. Innocent A.J. Semali, Dr. Edmund J. Kayombo, Joy M. Bategereza, Mgunga Mwamnyenyelwa, Edward H Mhina and Tumaini Nyamuhanga. June 2004.
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