Sbongile Maimane

The impact of social environments on the effectiveness of youth HIV prevention: A South African case study

Few would disagree that ‘social context’ shapes the effectiveness of HIV-prevention programmes. However much work remains to be done in developing systematic conceptualisations of HIV/AIDSrelevant aspects of social environments in vulnerable communities. This paper contributes to this challenge through a case study (44 interviews, 11 focus groups with 55 people and fieldworker diaries) of the impact of social context on a participatory peer education programme involving young people in a peri-urban community in South Africa. Three interacting dimensions of context undermine the likelihood of effective HIV-prevention. Symbolic context includes stigma, the pathologisation of youth sexuality (especially that of girls) and negative images of young people. Organisational/network context includes patchy networking amongst NGOs, health, welfare and education representatives and local community leaders and groups. This is exacerbated by different understandings of the causes of HIV/AIDS and how to manage it. These challenges are exacerbated in a material-political context of poverty, unemployment and crime, coupled with the exclusion of young people from local and national decision-making and politics. HIV-prevention initiatives seeking to promote healthsupporting social environments should work closely with social development programmes to promote young peoples’ social and political participation, increase opportunities for their economic empowerment, challenge negative social representations of youth, and fight for greater recognition of their sexuality and their right to protect their sexual health.

'Dying twice': A multi-level model of the roots of AIDS stigma in two South African communities

We highlight the complex interplay of psychological and social factors driving AIDS stigma, drawing on a study of community responses to HIV/AIDS in two communities in KwaZulu-Natal, South Africa. We draw on 120 semi-structured interviews and focus groups, in which open-ended topic guides were used to explore community responses to HIV/AIDS. Drivers of stigma included fear; the availability and relevance of AIDS-related information; the lack of social spaces to engage in dialogue about HIV/AIDS; the link between HIV/AIDS, sexual moralities and the control of women and young people; the lack of adequate HIV/AIDS management services; and the way in which poverty shaped peoples reactions to HIV/AIDS. We discuss the implications of our findings for stigma-reduction programmes.

Youth Participation in the Fight against AIDS in South Africa: From Policy to Practice.

Effective youth participation in social development and civic life can enhance young peoples’ health and well-being. Yet many obstacles stand in the way of such involvement. Drawing on 105 interviews, 52 focus groups and fieldworker diaries, this paper reports on a study of a rural South African project which sought to promote effective youth participation in HIV/AIDS management. The paper highlights three major obstacles which might be tackled more explicitly in future projects: (i) reluctance by community adults to recognise the potential value of youth inputs, and an unwillingness to regard youth as equals in project structures; (ii) lack of support for meaningful youth participation by external health and welfare agencies involved in the project; and (iii) the failure of the project to provide meaningful incentives to encourage youth involvement. The paper highlights five psycho-social preconditions for participation in AIDS projects (knowledge, social spaces for critical thinking, a sense of ownership, confidence and appropriate bridging relationships). We believe this framework provides a useful and generalisable way of conceptualising the preconditions for effective ‘participatory competence’ in youth projects beyond the specialist HIV/AIDS arena.

AIDS stigma, sexual moralities and the policing of women and youth in South Africa

HIV/AIDS stigma is a key driver of the epidemic in sub-Saharan Africa, undermining HIV-prevention and the care and treatment of people with HIV/AIDS (Ogden and Nyblade, 2005). In this dialogue piece, we seek to examine how the vicious stigmatization of people with HIV/AIDS is intertwined with the social construction of sexual moralities serving to perpetuate the social exclusion of women and young people in South Africa. We do this through highlighting our research into community responses to HIV/AIDS in two communities (one peri-urban and one rural) in Kwa-Zulu Natal province. We conclude by discussing the ongoing complexities of our efforts to implement these findings through our involvement in a community-led HIV/AIDS intervention in our rural research community.

Hearing community voices: grassroots perceptions of an intervention to support health volunteers in South Africa

With the scarcity of African health professionals, volunteers are earmarked for an increased role in HIV/AIDS management, with a growing number of projects relying on grassroots community members to provide home nursing care to those with AIDS – as part of the wider task-shifting agenda. Yet little is known about how best to facilitate such involvement. This paper reports on community perceptions of a 3-year project which sought to train and support volunteer health workers in a rural community in South Africa. Given the growing emphasis on involving community voices in project research, we conducted 17 discussions with 34 community members, including those involved and uninvolved in project activities – at the end of this 3-year period. These discussions aimed to elicit local peoples perceptions of the project, its strengths and its weaknesses. Community members perceived the project to have made various forms of positive progress in empowering volunteers to run a more effective home nursing service. However, discussions suggested that it was unlikely that these efforts would be sustainable in the long term, due to lack of support for volunteers both within and outside of the community. We conclude that those seeking to increase the role and capacity of community volunteers in AIDS care need to make substantial efforts to ensure that appropriate support structures are in place. Chief among these are: sustainable stipends for volunteers; commitment from community leaders and volunteer team leaders to democratic ideals of project management; and substantial support from external agencies in the health, welfare and NGO sectors.

Strengthening Community Responses to AIDS: Possibilities and Challenges

Many AIDS programmes in sub-Saharan Africa have had disappointing results (Gregson et al., 2007), with HIV rates continuing to rise, stigma remaining stubbornly resistant to change, and access and adherence to treatment and support remaining inconsistent. Other interventions have worked well in carefully controlled research conditions, but these have been difficult to scale up in less highly monitored ‘real-world’ settings (Binswanger, 2000; Chopra and Ford, 2005; Greig et al., 2008). One key reason for the less-than-optimal outcome of many programmes is that they fail to resonate with the worldviews and perceived needs and interests of their target groupings, or to take adequate account of the complex social relations into which programmes are inserted (Gruber and Caffrey, 2005; Pfeiffer, 2003). Too many programmes are imposed on communities in ‘top-down’ ways by outside experts. In such settings, target communities are seen as passive recipients of prevention, care and treatment services rather than active participants working in partnership with health professionals to improve their health (Campbell, 2003).

Frustrated potential, false promise or complicated possibilities? Empowerment and participation amongst female health volunteers in South Africa.

We present a longitudinal case study of lay womens participation in a project seeking to facilitate home-based care of people dying of AIDS in a rural community in South Africa, drawing on four sets of interviews conducted with volunteers over a five-year period. We link participation in the project to three dimensions of womens agency: their knowledge and skills, their confidence; and their personal experiences of efficacy. We show that whilst the experience of participation enhanced each of these dimensions of volunteers’ agency at various stages of the project, the empowerment that did take place appeared to be limited to womens project-related roles, rather than generalising to other areas of their lives beyond the project. The project had limited impact on womens ability to negotiate condom use with husbands, to assert themselves in relation to male project leaders and to become more involved in wider community decision-making and leadership. We discuss three possible interpretations of our findings: (i) that greater empowerment might have occurred had the project run for a longer time period; (ii) that whilst such projects play a vital role in providing services, the more general ‘empowerment via participation’ agenda is a false promise in highly marginalised communities; or (iii) that whilst generalised positive impacts of such projects on volunteers are hard to track, such projects do open up glimpses of increased agency for many women. These might have positive but unpredictable results in ways that defy formulation in linear conceptualisations of social transformation and development, understood in terms of clearly observable and measurable inputs and outputs.

Mismatches between youth aspirations and participatory HIV/AIDS programmes in South Africa.

Although youth participation is a pillar of international HIV/AIDS policy, it is notoriously difficult to facilitate. We explore this challenge through a case study of a community-led HIV/AIDS management project in a South African rural area, in which anticipated youth participation failed to materialise. We take a social psychological view, examining ways in which opportunities offered by the project failed to resonate with the social identities and aspirations of local young people. Interviews and focus group discussions were conducted with 37 young people prior to the programmes establishment and with 21 young people four years later. In response to questions about what they wanted to achieve in life, the young people emphasized: career success through migrating to urban areas to seek education and paid work, non-tokenistic involvement in community affairs, and ‘having fun.’ We look at how the project unintentionally evolved in ways that undermined these goals. Its strong local focus was inappropriately tailored to young people whose views of the future focused on getting away to urban areas as quickly as possible. The volunteer nature of the work held little appeal for ambitious young people who instead saw paid work as their way out of poverty and were reluctant to take unpaid time out from schoolwork. The project failed to develop new and democratic ways of operating—quickly becoming mired in traditional, adult-dominated social relations, in which young people with initiative and independent views were sometimes belittled by adults as being ‘smart’ or ‘clever.’ Finally, the projects focus on sexual abstinence held little interest for young people who took an enthusiastic interest in sex. The article concludes with a discussion of the complexities of implementing youth-friendly projects in communities steeped in top-down adult-dominated social interactions, and recommends ways in which similar projects might seek to involve youths more effectively.