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Key Findings from the Participatory Community Assessments
The following provides a synthesis of the key findings from the participatory community assessments in Bangladesh, Cambodia and Sri Lanka:
Key finding: HIV prevention is often not a primary concern for poor and marginalised communities.
Most of the assessments were conducted with poor communities, often lacking basic health and education services. Many communities in these assessments live with the threat of violence and conflict, as a result of continuing insurgencies in Sri Lanka and Cambodia. Living conditions are often deplorable. In Bangladesh, for example, many of the NGOs reported communities suffering inadequate shelter, over-crowding, very poor water and sanitation facilities and a range of related health problems. Incomes are low, opportunities for advancement few, and unemployment and job-related mobility and migration are frequent. These daily realities faced by communities unsurprisingly obscure their perception of the HIV epidemic as an urgent and important problem to be addressed in their lives. Furthermore, in the countries where the assessments were carried out, HIV is either of low prevalence (in Bangladesh and Sri Lanka) or still very new as a large-scale challenge (as in Cambodia).
Key finding: Vulnerability to HIV infection is linked to these realities of social, economic and political marginalisation.
In the assessments, poverty was often cited as a cause of the epidemic’s spread. In the case of men, poverty forces job-seeking migration to higher prevalence areas (in towns or across borders). Among women, poverty often results in involvement in sex work.
The assessments frequently found that lack of resources to meet people’s basic health and welfare needs resulted in high levels of sexual health-related morbidity and mortality. Low literacy and low levels of education deprive people of access to sexual health information. Overcrowding can heighten vulnerability in a number of ways. IVH, working in the Rathmalana Industrial Zone in Sri Lanka, reports that: “Owing to lack of space, facilities for an unrestricted sex life are rare even for the married. This leads to lack of sexual satisfaction and related problems among the married.” The frequency of married men’s visits to brothels was blamed on these marital problems. In Bangladesh, CDF working with slum dwellers in Dhaka found that overcrowding affected teenage sexuality: “Several married couples live under the same roof. During the night some of these teenagers have to come outside their room while their parents are engaged in sexual relationship and make friendship with others. This in some time turned into sexual relationships.”
Findings of assessment of drug dependent community, Bangladesh
“SHEASS is a local NGO working with a highly marginalised community of injecting drug users in Rajshahi, an urban area on the Bangladesh / India border. It used a participatory community assessment to re-focus its work - which had previously focused on a detoxification centre - and to develop a participatory HIV/AIDS prevention strategy based upon harm reduction.
The findings of the assessment included:
- The drug users are marginalised. “Neighbours, relatives, near ones....nobody believes and relies on us: we are hated by everybody. We can earn money, but who will give us jobs? We have the skills but they don’t trust us’;
- The children of drug users are marginalised. Others say to them ”You are the son / daughter of addicts.” Some dependants have different opinions. They say “Will education make them different? The son of a rickshaw puller will be a rickshaw puller - heh! like father like son”;
- Wives of drug users feel helpless;
- Drug users sell blood and sex for drug money;
- Drug users have no education about health;
- They feel ashamed even in their families;
- Drug users share their needles;
- Drug users are obsessed with addiction;
- They suffer social rejection. Local leaders and community people said to SHEASS: ”What the hell are you people doing here? Don’t you have anything to do? Do you know you are spending your time in wastage? They are addicts: they are shameless; they can do any crime; they are thieves. They are spoiling the society and you people are talking with them”;
- Women drug users are left out. ”If other people know that I use drugs then what will happen to me? Being a woman will it be possible to continue my family life? Society will push me in the street. And how can we talk to a man? Can we trust you men?’; and
- They don’t like to use condoms.”
Reference: Extract from a case study presented by Kabita Mahbooba, HASAB, at the Alliance Linking Organisations’ Meeting in September 1997.
More key findings
Key finding: One link between marginalisation and vulnerability to HIV infection is low self-esteem and a lack of a sense of being able to control decisions and actions.
The Voluntary Association for Rural Development (VARD), working with rickshaw pullers in Sylhet, Bangladesh reports: “Most of them have no future dream. Struggle for existence is the basis of their lifestyle. Most of them have a fatalistic attitude about life, thinking that they have no control over their lives.” One result of this is a lack of sense of responsibility: “Some of the rickshaw pullers have got the opportunity to conduct multiple sex practice as they have no particular responsibility to the society and family.” This, in turn, makes them and their partners vulnerable to HIV.
This lack of perceived, or real, control over their lives creates a fatalistic attitude toward HIV infection, and also detracts from a sense of personal and collective capacity to respond to the epidemic. This was evident to some during the assessment process. IVH in Sri Lanka notes that; “The community was more keen on listening to lectures than participating in the methodology-related activities.” The dangers of this passivity reinforce the importance of participatory approaches to assessment, which can help communities to know that they can make a difference.
Key finding: Women’s vulnerability is clearly linked to gender inequalities.
Several groups of married women taking part in the Cambodian assessments directly equated their vulnerability to HIV infection with the behaviour of their husbands. They had no sense of any independent ability to protect themselves, but relied solely on their husbands for their protection. Unmarried women often felt their main protection lay in ensuring that their future husband was uninfected, by conducting an HIV antibody test before marriage. Once again, there was little sense that they could negotiate their own sexual safety, whether before or during marriage, especially given the value placed on unmarried women’s sexual innocence and reticence in Khmer culture.
The vulnerability of young women was highlighted in Sri Lanka also. The Sevalanka Foundation reports that: “In this village love affairs occur among minors in age. Formerly there were marriages among such minors. Now such marriages are not common. Sometimes the girls are left to face the situation of pregnancy without any support. On such occasions there is resort to abortions secretly...There are occasions when this leads to the death of the women.”
Identifying how gender roles impact on sexual health
GENDER ROLE AND RESPONSIBILITY
Men should be the main decision-makers in the family
IMPACT ON SEXUAL HEALTH
Men – not couples or women – make decisions about when to have sex and whether condoms or contraception are used, while women often bear the sexual health risks of those decisions (unwanted pregnancy and STDs)
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GENDER ROLE & RESPONSIBILITY
Women should be the main caretakers in the family
IMPACT ON SEXUAL HEALTH
Women are unable to take care of their own health needs because they are too busy taking care of everyone else.
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GENDER ROLE & RESPONSIBILITY
“Real men” have a lot of sexual experience. Good women are virgins and after marriage remain faithful to one man.
IMPACT ON SEXUAL HEALTH
Many women with only one partner assume they are not at risk of infection, but their partner may have other sexual partners, women who sex outside of marriage are stigmatized and unable to access sexual health services.
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GENDER ROLE & RESPONSIBILITY
Men control the economic resources in the family and community
IMPACT ON SEXUAL HEALTH
Women have few options to leave situations where they are not able to protect their sexual health.
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GENDER ROLE AND RESPONSIBILITY
“Real men” should be strong and not express fear or worry.
IMPACT ON SEXUAL HEALTH
Men and boys are not able to express the pressures they feel regarding sex, fears of STDs, talking about their feelings and protecting themselves and their partners from unwanted pregnancy and STDs.
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Adapted from “Facing the challenges of HIV/AIDS/STDS: a gender-based response” KIT, SAFAIDS and WHO, 1995. Alliance Lanka training programme, October 1996.
More Key Findings
Key finding: Male violence against women continues women’s sense of disempowerment and makes them vulnerable.
Violence against women was often reported, for example during UJON’s assessment of rickshaw pullers and CDC’s work with dock workers in Bangladesh: “Besides the traditional forms of violence, some women identified the long stay of their spouses outside home and failure to satisfy their sexual need as [the cause of] violence against women”.
In Sri Lanka, violence against women was often associated with the large military presence in areas affected by the Tamil insurgency. Sex workers in Cambodia reported that violence by clients, and the threat of violence, meant that they were often unable to use condoms for their own protection.
“Most of the rickshaw pullers' wives have no role in decision-making in any personal or family matters. Some rickshaw pullers beat their wives. In the time of having sex, the women have no role. Even if they have physical problem and unwillingness to have sex, they are forced to do it which hampers their sexual health...In a few cases, the husband’s sexual diseases are transmitted to the wife.”
Reference: Participatory Community Assessment report of the Voluntary Association for Rural Development (VARD), Bangladesh.
Key finding: Expectations and experiences of sexual autonomy and sexual pleasure contribute to men and women’s vulnerability.
Women interviewed by the Sevalanka Foundation in Sri Lanka: “Stated that they were not asked about their ideas before beginning intercourse...[I]t was emphatically stated that they had no notion of sexual satisfaction.” By contrast, most men interviewed in all the assessments had clear ideas about their sexual satisfaction and expectations of getting such satisfaction.
The most frequently cited reasons given by men for not using condoms and for having multiple partners were about sexual pleasure. In the Cambodian assessments, men were frank in stating their unwillingness or inability to deny themselves their sexual desire. But the assessments also provided interesting insights into male anxiety and perceptions of female sexuality.
CDC in Bangladesh reports: “According to the participant dock workers, most of them are unable to sexually satisfy their wives, [leading to] disruptions in family life. Women are grieved because of sexual inabilities of their husbands due to STDs and irregular intervals of sexual intercourse due to their husband’s overstay at their workplace.” Some of the women interviewed by CDC were open about their sexual desire and how they coped with their husband’s absences: “The females whose husbands stay more than weeks at a workplace said that they normally opted for masturbation.”
In Cambodia, some married women commented on their own dislike of condoms because they took away sexual pleasure, but wanted their husbands to use them when they visited the brothel. Young women taking part in Cambodia Health Committee’s (CHC) assessment in Svay Rieng province believed that “one-to-one love” was one of their best protections against HIV infection but also felt that this was difficult because of “passion”.
Key finding: Sexuality and sexual safety are influenced by the context in which sexual encounters take place.
Many assessments highlighted the role that drinking, and, in particular, rituals of male group drinking, played in heightening men’s exposure to risk of infection, for example through non-use of condoms with sex workers.) Others noted how difficult it was for wives and husbands to communicate with each other about sexual safety in their hurried sexual encounters in overcrowded living conditions. IVH’s assessment with garment factory workers in Sri Lanka emphasised that: “The situational background to these non-marital relationships is not conducive to use of protective devices.”
Instances of male-to-male sex were reported, especially as experiences of adolescence and all-male occupational environments, but were not sufficiently discussed with reference to questions of sexual safety. Commenting on dock workers in Bangladesh, CDC notes that: “A majority of them were abused in their teens by their elders. Most of them learned about sex from their friends.” While sexual abuse was rarely identified in these explicit terms, many NGOs noted that people’s overcrowded living conditions led to children and young people being exposed to adult’s sexual behaviour, leading them to become sexual themselves at an inappropriately early age. Some pointed out, with disapproval, young people’s (especially boys’) access to pornographic materials and the effects this had on their sexual development.
Adolescent Sexuality in Bangladesh
“The adolescent boys and girls spend their nights on railtracks when their elders are engaged in sexual intercourse...Most of the girls are then abused. Due to space constraint, the married elders have no other alternatives but to engage in sexual intercourse while an adolescent is lying beside them. I know several instances where brothers and sisters eventually were engaged in sexual relations as demonstrative effect of these situations.”
(Reference: Statement by a female teenager from CDF’s assessment of slum dwellers in Dhaka, Bangladesh).
Key finding: Communities continue to lack access to adequate sexual health information and services.
NGOs were struck, especially in Bangladesh and Sri Lanka, by people’s lack of even basic information about reproduction, STDs and HIV/AIDS. Some had never heard of AIDS and had never seen a condom. NGOs in Sri Lanka used body mapping to explore people’s understanding of sexual health and disease and noted the gulf that exists between local peoples’ understandings and those used in conventional HIV education messages.
Awareness of HIV/AIDS was higher in Cambodia, unsurprising given its more advanced epidemic. But it is clear that misinformation persists, for example in relation to people’s fear of touching someone who has HIV. Linked to this lack of adequate information was the dearth of accessible and appropriate sexual health services, including family planning, maternal/child health, STD treatment and HIV testing and counselling. Many people continued to rely on traditional treatments to treat STDs and / or self-medicated with costly treatments obtained from pharmacies.
Key finding: Fear of blood-borne HIV transmission remains high.
Avoiding contact with potentially infected blood, for example through not sharing razors, was frequently mentioned as an HIV protection strategy that people used. Many groups taking part in Cambodian assessments wanted an expansion in HIV testing facilities, in order to render blood transfusions safe.
Less discussed was the risk of HIV transmission posed by sharing of injection equipment, whether for self-administration of medicinal drugs or opiates (and to a lesser extent amphetamines.) Very few NGOs (for example JTS and CDF in Bangladesh) identified needle sharing among people injecting drugs as a significant issue for their HIV prevention programme.
Key finding: People living with HIV/AIDS remain largely invisible.
The assessments in Bangladesh and Sri Lanka rarely, if ever, mentioned people living with HIV/AIDS. Several NGOs in Cambodia recorded people’s own direct experience of the epidemic through knowing or hearing about someone who had died of AIDS. Fearful and negative attitudes towards people living with HIV/AIDS were frequently expressed during the Cambodian assessments. For example, a report by the Cambodian Development and Relief Centre for the Poor, working in Kampot province stated: “In Prek Kres, people know that there are AIDS patients and many of them have died. Most of [the community] think they know about AIDS and they know how to [protect] themselves well - they do not go near or visit the patients because they fear infection. The villagers’ fear becomes discrimination against the patients, which makes their family, parents and relatives hide the illness and beat the patients and send them from one to another, not wanting to accept or look after them. This makes the patients more desperate and more miserable physically and mentally.”