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4. Understanding vulnerability: Focusing resources and creating strategies for change
   Last updated: 29.06.02
Creating strategies for change
The experiences of Alliance supported NGOs trying to move beyond awareness raising are consistent with the belief that vulnerability to HIV is associated with socio-economic marginalisation. Participatory community assessments have emerged as a key methodology to help NGOs develop concrete programming strategies to address these contextual issues. However, much more still needs to be learned.

In recent years, increasing numbers of academics, evaluators and people directly involved in HIV prevention have pointed out the inadequacy of prevention efforts which work on the basis of individualistic and/or cognitive models which fail to address other influences on behaviour. UNDP’s “HIV and Development Programme” is well known for drawing attention to poverty and under-development as key factors making people vulnerable to HIV infection and inadequate care. The World Bank concurs, but also notes that economic growth may facilitate the spread of HIV. Researchers at the Harvard School of Public Health have emphasised the centrality of human rights abuses. Others point to economic and social disparities and difference more than deprivation per se. The emerging consensus is that programmes must understand and address the context in which people live in order to succeed.

Often, NGOs working with poor and socially marginalised people within communities instinctively understand the wisdom of addressing these “contextual issues” as part of their response to HIV, but many struggle to identify how relatively small programmes can make a difference.

Focusing resources on the most vulnerable
There are continuing controversies in the world of HIV programming regarding the “targeting” of programmes and the risks that some HIV prevention campaigns are counter-productive: increasing discrimination against particular groups like sex workers, and creating a false sense of security amongst people who do not see themselves as at risk. On the other hand, programmes aimed at the “general public” rarely change behaviour, and are unlikely to be cost-effective even in high prevalence countries. For example, the AIDSCAP project demonstrated that even in high-prevalence Kenya and Tanzania, voluntary testing and counselling was much more cost-effective as a prevention intervention when aimed at women and specific groups of men. Given these challenges, an important theme of the “Community Lessons, Global Learning” seminars was how to focus resources effectively while avoiding stigmatisation.

The work of ACD with young Bangladeshi women illustrates some of the complexities of the concept of vulnerability to HIV. A range of factors interact in their lives to produce their vulnerability, including class background, poverty, gender-related norms, and a lack of access to sexual health information and services. These factors combine to severely constrain the choices that they are able to make about protecting themselves from HIV infection. By contrast, the border guards who buy sex from the young women appear to have choices - such as the power to demand the bribe by virtue of their position, and the power to determine the nature of the sexual encounter by virtue of their gender. However, they, too, are shaped by economic, social and cultural pressures which create norms of masculinity. These norms - which are often heightened in uniformed services - celebrate men’s power over women and sanction the satisfaction of male sexual desire when, where and how they choose it. The men, too, may lack accurate information on their sexual health and lack the social support, from their peers and others, to question the role that expectations of masculinity play in exposing them to greater risk of HIV infection.

Thus, NGOs are learning that an understanding of vulnerability helps them to focus their resources and efforts more effectively. Developing an analysis of vulnerability within particular societies also demonstrates the inadequacy of an over-simplified notion of choice which often underpins HIV awareness programmes (i.e. that people can simply choose whether or not to risk infection). Sophal ## of the KHANA programme in Cambodia illustrated this point starkly at the launching of “Community Lessons, Global Learning” at the 4th International Congress on AIDS in Asia and the Pacific: “There’s no point spending all your time giving AIDS education to poor prostitutes when the police - who are their clients and bosses - live in barracks across the road. You have to work with the policemen too”.

But what can we do with the policemen? An understanding of vulnerability helps NGOs decide who to work with, but it does not help NGOs develop programmatic responses to complex relationships between risk and responsibility, personal agency, social background and setting. More often than not, the NGO success stories shared through “Community Lessons, Global Learning” addressed these questions by starting their programme development processes with participatory community assessment methods and techniques adapted from proven success in rural development work.

Case study: Addressing vulnerability among young migrant women, ACD, Bangladesh
At the country seminar in Bangladesh, the Association for Community Development (ACD) shared their experiences in working with young women being trafficked and migrating across the Bangladeshi / India border. Staff members described the nature of the women’s vulnerabilities to HIV infection:

“People here are very, very poor and their economic situation forces them to find ways to survive. For example, there are officials on both sides of the border [who] demand bribes from people crossing the border. However, the young women from the community don’t have any money to pay the bribes, so they sell sex to the men. The women are very poor and have no work, so they have to sell sex to survive. However, because of their community’s social pressures and values, they can’t do it here, so they go to India.”
Md. Towhidul Alam, Community Educator

“The young women have no information about their personal health and hygiene. They know nothing about sex, except for the act of intercourse, so when they sell sex they have full intercourse with the men. If they become pregnant, they receive no support and go to the quack to try to resolve the situation. Social pressures mean that they don’t like to visit the doctor or talk about their problems - so they have to just keep it within themselves. As a result, some of them become suicidal.”
Monirul Islam, Co-ordinator

Participatory community assessments
In all of the countries where linking organisations have been developed, the Alliance has placed increasing emphasis on participatory community assessments as the foundations of appropriate and effective programmes. This strategy - which focuses upon various forms of “action research” to both mobilise community action and identify key information - was piloted by HASAB in Bangladesh in 1995. Since then it has been shared with other countries - where, in each case, the approach and methodologies have been adapted to meet the specific contexts and needs of the linking organisation and partner NGOs.

The participatory nature of the work carried out during the community assessment phase helps many NGOs to better understand community vulnerability. Participatory assessments strengthen relationships between NGOs and communities, by requiring NGOs to listen to and ask questions of communities rather than making assumptions. This is especially important in HIV prevention work, where, in the Alliance’s experience, the assumption is often made that the ‘problem’ is a lack of AIDS information. The process of assessment has helped to open the eyes of NGOs to the complexity of problems they must consider when planning their projects. By actively involving the community in the assessment, a participatory process can also engender a community commitment to and ownership of the problems identified and responses planned. In this way, the assessment process helps to mobilise community concern about and action on HIV prevention.

Participatory community assessments also engage NGOs with their communities in ways which challenge traditional ideas about expertise. Such assessments emphasise local people’s ability to analyse and articulate their own lived experiences, the problems that they face and the solutions that they seek. Rather than extracting information, participatory assessments draw on the expertise of the community in a process of discussion and analysis. In this regard, the community focus of the assessment is significant, too. By emphasising exploration of community-wide issues and needs, the assessment process orients NGOs towards appreciation of the community structures, norms and values which differentially shape people’s vulnerability. Importantly, as the Alliance’s partners have used and improved the process of participatory community assessment, the scope of assessment has broadened beyond a narrow focus on needs to consider community aspirations and existing resources. In this way, the assessment process has developed a richer picture of the contexts within which people live and a better analysis of HIV, and its prevention, in relation to these contexts.

As shared at the country seminars, the Alliance continues to adapt and refine a number of assessment methods which promote the participation of communities. Many are drawn from the work of other NGOs and institutions involved in community development work, and are often grouped under the rubrics Participatory Rural Appraisal (PRA) and Participatory Learning Action (PLA). Their emphases on drawing and diagramming as a stimulus to and focus of analysis, and on acknowledging and sharing community expertise, have greatly enhanced community participation. Significantly, too, PRA methods provide structured and accessible ways in which to assess the contexts of HIV transmission with a specific community. These include locational risks and resources, trends over time, temporal patterns, causal relationships, differentiations by age, gender and wealth and priorities of problems and responses.

Participatory community assessments, and the understanding of how to respond to vulnerability that they help to develop, are an important step towards more effective HIV programming. In 1997, the Alliance supported many NGOs to carry out these assessments, and in both Bangladesh and Cambodia, all projects initiated by partner NGOs were based on such assessments. The benefits of careful participatory work at the assessment stage are evident in projects which are better designed to address factors of vulnerability. As shared at the Bangladesh country seminar, in the case of ACD in Bangladesh, Md. Towhidul Alam comments: “The needs assessment showed that there are no entertainment facilities - so we have started to initiate games here...for community members and students at the local college. Before they had nothing to do and would often watch blue films on TV. Now, there’s something else for them to do some of the time - which builds our relationship with them.” In the Philippines, IWAG Dabaw’s assessment with the gay community in Davao City identified a range of issues, beyond the need for HIV/AIDS information and condoms, which related to their vulnerability. These included discrimination, self-esteem, acceptance in the family, sexuality and gay rights. As a result, a Center for Gay Men’s Concerns was planned and designed in consultation with the gay community to offer a meeting place and counselling service.

Comments
“At first we wondered why we should do an assessment, but the more we learned, the more we realised it was crucial. The findings were astonishing. They revealed things which were completely new to us even though we’ve been working in our community for twenty years.”
Ahmed Ilias, Al-Falah, a partner NGO of HASAB, Bangladesh, working with Bihari refugees

“The programme in Morocco has learned from the [HASAB] experiences in Bangladesh - in terms of focusing on the needs of communities. We first ask people about their general concerns, and then begin to talk about more personal factors that influence their vulnerability.”
Issam Moussaoui of PASA/SIDA, Morocco

“NGOs in the Philippines are used to thinking that we are already sufficiently participatory, but after learning about - and using - PRA together with our partners, we have realised how much the work can further be strengthened with these tools.”
Jun Cristobal, PHANSuP Programme Manager, Philippines.

Creating strategies for change
At almost every country seminar over the first year of the “Community Lessons, Global Learning” initiative, NGO participants shared how they had successfully used techniques and approaches from community development work to strengthen their responses to AIDS. Such work encourages an analysis of structures as well as behaviours, and of communities as well as individuals. In turn, this analysis suggests that responses to the epidemic must address not only community problems, but also problems ‘of community’ - including the norms and values that shape relations between people which, in turn, create exposure and vulnerability to HIV.

In Burkina Faso, IPC supported ADESCO to conduct a participatory community assessment among travelling women traders and associated men in the Orodara region. It found that low-literacy and poverty were urgent problems which influenced vulnerability to HIV. In response, they developed a strategy focusing on literacy training, micro-credit for women, and discussion groups on sexual health. More generally, IPC emphasised at its country seminar that the most successful partner NGOs : “Respond not only to AIDS-related needs but also to those other priorities, through a series of development activities undertaken alongside prevention activities.”

Baba Goumbala of ANCS, the Alliance linking organisation in Senegal, describes a similar approach with one of their partner NGOs: “For three years we have supported Association des Jeunes du Peryssae pour le Development (AJPED) in Ziguinchor, in the south of Senegal. The group supports women to carry out literacy projects in the local language, and also economic activities - such as drying fruit to sell in the markets. Now, they are mobilising the community on HIV/AIDS - by including this new subject in their existing work. For example, AIDS is used as the subject of reading classes, and discussion groups on sexuality are held while fruit is being processed. Now, the community is keen to be involved and participate in HIV/AIDS work - because their most urgent needs are being met at the same time.”

The extent to which the Alliance can address the relationship between development and HIV is clearly constrained, both by the Alliance’s own capacities and by the entrenched and complex nature of poverty and distributions of power and wealth in the societies in which it works. At the Sri Lanka country seminar, for example, and important discussion concerned how to work with communities which have been dislocated and traumatised by the continuing conflict in the north of the country. An escalating rate of HIV transmission in these communities is one of the effects of this conflict. The technical support provided by Alliance Lanka focuses on the current strengths of these NGOs’ work (such as rebuilding community identity and structure, and meeting basic needs), and identifies the connections between reconstructing shattered communities and reconstructing the psychological and material conditions in which HIV prevention becomes a feasible and desirable goal for people in those communities. Thus, Alliance Lanka encourages NGOs working in these areas to persist with their present strategies, including the provision of basic health and medical services, rather than investing their scarce resources in HIV-specific information campaigns.
A report on Rajarata Participatory Development Foundation, working with communities affected by the Tamil insurgency, notes that the NGO’s focus on income generating activities “addresses both the mental trauma - by creating grounds for hope and positive action - and sexual health - by offering alternative employment to women involved in selling sex.”

Fragile communities in Sri Lanka
Sewalanka, a partner NGO of Alliance Lanka, based in Anuradhapura in northern Sri Lanka, works with communities affected by the Tamil insurgency:

“Morale amongst the communities is low because of the displacement and disruption of culture. Death has been commonplace, people are intolerant and there are high levels of violence...[T]here may be a high level of STDs in the community, there is no easy access to health services.”

Lessons learned and challenges for the future
The need to integrate HIV prevention into development work emerges clearly from the Alliance’s work on participatory community assessments. A particularly effective route for doing this is through links to gender, sexuality and sexual health work, as explored further in the next section. Other clear recommendations to emerge from NGOs participating in “Community Lessons, Global Learning” include:

  • Helping health and development NGOs understand vulnerability to HIV both motivates and focuses responses. Otherwise NGOs are still prone to work with the “general public”.


  • Participatory community assessments can make significant contributions to good programme design, even when NGOs have been working with communities for many years. The community focus of the assessment process has oriented NGOs towards appreciation of the community structures, norms and values which differentially shape people’s vulnerability. Assessments also allow an exploration of the relationship between risk and responsibility, personal agency and social context.


  • The quality of the assessment and its value in project planning is linked to the focus of the assessment - particularly what questions and what issues the NGO chooses to explore. Too much emphasis on general concerns and ‘felt’ needs produces a long list of immediate and intractable problems. It is more useful to address a mixture explicit sexual health problems (such as STDs and teenage pregnancy) and the issues of gender and sexuality implicit within them. It is also essential to balance such an assessment with a clarification of community expectations and NGO capacities.


  • The quality of assessments is also linked to the degree to which NGO staff and volunteers understand key concepts of gender, sexuality and sexual health, and can use this understanding in the context of the assessment. For many NGOs this has implications for training, which must focus both on participatory assessment skills and on building an understanding of key concepts and their application to the assessment process.


  • NGOs are developing innovative responses to contextual issues, but impact is not yet being measured. For example, the Alliance’s HIV prevention work in Sri Lanka and Cambodia includes a focus on rebuilding community identity and community structure in situations of historical and continuing conflict, and African programmes have used income generation and micro-credit schemes as a development response to the epidemic. The benefits of these initiatives may be more psychologically than materially significant.


  • Working on development issues as a route to HIV prevention will require collaboration with partners, in government and the NGO sector, who are resourced and mandated to carry out such work. For example, when famine struck Burkina Faso last year, IPC and its partners sought to collaborate with development agencies in the distribution of emergency food aid.


Source: Beyond Awareness Raising
This is an extract from Beyond Awareness Raising: Community lessons about improving responses to HIV/AIDS, published by the International HIV/AIDS
Alliance in 1998.

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