Studies at Ilembula Lutheran Hospital, Tanzania: HIV Awareness ...
Studies at Ilembula Lutheran Hospital, Tanzania: HIV Awareness ...
Studies at Ilembula Lutheran Hospital, Tanzania: HIV Awareness ...
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<strong>Studies</strong> <strong>at</strong> <strong>Ilembula</strong> <strong>Lutheran</strong> <strong>Hospital</strong>, <strong>Tanzania</strong>:<br />
<strong>HIV</strong> <strong>Awareness</strong> among Students and Health Care<br />
Workers in Rural <strong>Tanzania</strong><br />
Cecilia Anderson, e-mail: popstar_77@hotmail.com<br />
Malin Kim, e-mail: kh00hama@medstud.gu.se<br />
The Sahlgrenska Academy <strong>at</strong> Gothenburg University, Sweden. 2003<br />
Supervisors:<br />
Rune Anderson, MD, PhD, Research and Development Centre, Skaraborg <strong>Hospital</strong>, Skövde,<br />
Sweden.<br />
Willis L.Temihango, Doctor in Charge, <strong>Ilembula</strong> <strong>Lutheran</strong> <strong>Hospital</strong>, <strong>Ilembula</strong>, <strong>Tanzania</strong>
List of abbrevi<strong>at</strong>ions and foreign expressions<br />
AIDS Acquired Immune Deficiency Syndrome<br />
Clinical Officer A person with medical training who assists the doctor<br />
ELCT Evangelical <strong>Lutheran</strong> Church in <strong>Tanzania</strong><br />
<strong>HIV</strong> Human Immune Deficiency Virus<br />
ILH <strong>Ilembula</strong> <strong>Lutheran</strong> <strong>Hospital</strong><br />
INWTS <strong>Ilembula</strong> Nurses and Midwives Training School<br />
Mganga A traditional doctor, witch doctor<br />
STD Sexually Transmitted Disease<br />
STI Sexually Transmitted Infection<br />
Veo A governmental secretary<br />
Waganga Plural of mganga, traditional doctors<br />
2
Index<br />
ABSTRACT........................................................................................................................................................... 5<br />
BACKGROUND:.................................................................................................................................................... 5<br />
A BRIEF INTRODUCTION TO TANZANIA................................................................................................... 5<br />
FACTS ABOUT THE COUNTRY............................................................................................................................... 5<br />
THE <strong>HIV</strong> PANDEMIC......................................................................................................................................... 6<br />
PRESENT SITUATION............................................................................................................................................ 6<br />
THE VIRUS .......................................................................................................................................................... 7<br />
THERAPY............................................................................................................................................................. 7<br />
<strong>HIV</strong>/AIDS AND POVERTY................................................................................................................................... 7<br />
<strong>HIV</strong> IN THE REPUBLIC OF TANZANIA .................................................................................................................. 7<br />
<strong>HIV</strong>/AIDS AT ILEMBULA VILLAGE/HOSPITAL..................................................................................................... 8<br />
HOME BASED CARE ............................................................................................................................................ 9<br />
THE VILLAGE OF ILEMBULA........................................................................................................................ 9<br />
LIFESTYLE AND TRADITIONS ............................................................................................................................... 9<br />
SICKNESS AND HEALTH AS SEEN BY THE PEOPLE OF ILEMBULA......................................................................... 11<br />
ILEMBULA LUTHERAN HOSPITAL............................................................................................................ 11<br />
GENERAL INFORMATION ................................................................................................................................... 11<br />
SUMMARY OF HOSPITAL SERVICES 2002 ........................................................................................................... 12<br />
ILEMBULA NURSES AND MIDWIVES TRAINING SCHOOL................................................................. 12<br />
METHODS .......................................................................................................................................................... 13<br />
RESULTS OF THE QUESTIONNAIRES ....................................................................................................... 14<br />
SOCIO-ECONOMIC SITUATION............................................................................................................................ 14<br />
Age: ............................................................................................................................................................. 14<br />
Profession.................................................................................................................................................... 14<br />
Gender......................................................................................................................................................... 14<br />
Family.......................................................................................................................................................... 14<br />
Religion ....................................................................................................................................................... 14<br />
Economical situ<strong>at</strong>ion ................................................................................................................................... 14<br />
KNOWLEDGE OF <strong>HIV</strong> ........................................................................................................................................ 15<br />
First source of inform<strong>at</strong>ion.......................................................................................................................... 15<br />
Ways of transmission................................................................................................................................... 15<br />
Difference between <strong>HIV</strong> and AIDS.............................................................................................................. 17<br />
Ways to cure <strong>HIV</strong>......................................................................................................................................... 17<br />
Risk groups.................................................................................................................................................. 18<br />
Estim<strong>at</strong>ed prevalence of <strong>HIV</strong> in <strong>Ilembula</strong>.................................................................................................... 18<br />
Spread of <strong>HIV</strong>.............................................................................................................................................. 18<br />
PROFESSIONAL SITUATION ................................................................................................................................19<br />
Inform<strong>at</strong>ion <strong>at</strong> work..................................................................................................................................... 19<br />
<strong>Hospital</strong> routines and risk <strong>at</strong> work .............................................................................................................. 19<br />
Inform<strong>at</strong>ion to the p<strong>at</strong>ients .......................................................................................................................... 21<br />
PRIVATE LIFE .................................................................................................................................................... 21<br />
<strong>HIV</strong> among friends and rel<strong>at</strong>ives................................................................................................................. 21<br />
Informing friends and rel<strong>at</strong>ives ................................................................................................................... 21<br />
Protecting oneself........................................................................................................................................ 23<br />
Sexual partners............................................................................................................................................ 24<br />
Children....................................................................................................................................................... 25<br />
RESULTS INTERVIEWS ................................................................................................................................. 25<br />
<strong>HIV</strong> IN GENERAL............................................................................................................................................... 25<br />
3
Wh<strong>at</strong> do you think are the reasons why <strong>HIV</strong> is still spreading so rapidly?................................................. 25<br />
Do people usually want to know if they are <strong>HIV</strong> positive or not? How about you?.................................... 26<br />
Wh<strong>at</strong> do you think can be done to prevent the spread of <strong>HIV</strong>? Wh<strong>at</strong> about the future?.............................. 26<br />
Why is <strong>HIV</strong> stigm<strong>at</strong>ized? ............................................................................................................................. 27<br />
FAMILY AND FRIENDS ....................................................................................................................................... 27<br />
Is it difficult for a person to tell rel<strong>at</strong>ives and partners th<strong>at</strong> s(he) is infected with <strong>HIV</strong>? ............................ 27<br />
Do the families usually take care of rel<strong>at</strong>ives suffering from AIDS?........................................................... 27<br />
<strong>HIV</strong> AT WORK................................................................................................................................................... 28<br />
Do you sometimes feel <strong>at</strong> risk of getting <strong>HIV</strong> <strong>at</strong> work? How do you protect yourself? ............................... 28<br />
When employees <strong>at</strong> the hospital accidentally prick themselves with a dirty needle, wh<strong>at</strong> do they usually do?<br />
..................................................................................................................................................................... 28<br />
Do <strong>HIV</strong> infected persons usually take precautions not to transmit the disease to others?.......................... 28<br />
At wh<strong>at</strong> age do people usually start having sexual intercourse?................................................................. 29<br />
Do people in general have sexual intercourse before marriage/ outside marriage? .................................. 29<br />
Wh<strong>at</strong> do people think about condoms? Do people know how to use them? ................................................ 29<br />
CULTURE AND RELIGION ................................................................................................................................... 30<br />
Do people believe in traditional healers? Do they think th<strong>at</strong> the healers can cure <strong>HIV</strong>? ........................... 30<br />
When it comes to <strong>HIV</strong>, are there any differences between: ......................................................................... 31<br />
DISCUSSION ...................................................................................................................................................... 32<br />
VALIDITY OF THE RESULTS................................................................................................................................32<br />
KNOWLEDGE AND SPREAD OF <strong>HIV</strong> ................................................................................................................... 33<br />
BEHAVIOUR, TRADITIONS AND BELIEFS. ........................................................................................................... 34<br />
CONCLUSIONS ................................................................................................................................................. 36<br />
ACKNOWLEDGEMENTS................................................................................................................................36<br />
APPENDIX.......................................................................................................................................................... 37<br />
QUESTIONS ASKED DURING THE INTERVIEWS.................................................................................................... 37<br />
QUESTIONNAIRE................................................................................................................................................ 38<br />
INTERWIEV WITH WILLIS TEMIHANGO, DOCTOR IN CHARGE AT ILEMBULA LUTHERAN HOSPITAL ................... 40<br />
INTERVIEW WITH ALIFA LUPENDE, PRINCIPAL OF INMTS................................................................................ 41<br />
INTERVIEW WITH ONE OF THE EVANGELISTS OF THE LUTHERAN CHURCH OF ILEMBULA .................................. 42<br />
INTERVIEW WITH THE CHAIRMAN OF ILEMBULA ............................................................................................... 42<br />
INTERVIEW WITH A TRADITIONAL DOCTOR (MGANGA)...................................................................................... 43<br />
REFERENCES.................................................................................................................................................... 44<br />
4
Abstract<br />
Background:<br />
An increasing number of people throughout the world are affected by the <strong>HIV</strong>-pandemic. A<br />
key group in controlling the spread of the virus is the healthcare-workers, since they have<br />
both medical knowledge and insight to the general believes and behaviour of the p<strong>at</strong>ients.<br />
Purpose:<br />
The aim of study is to describe and analyse <strong>HIV</strong> awareness and risk behaviour among health<br />
care workers and student nurses in the <strong>Tanzania</strong>n village of <strong>Ilembula</strong>. We also want to receive<br />
inform<strong>at</strong>ion about their general picture of the <strong>HIV</strong> situ<strong>at</strong>ion in the area. Our wish is th<strong>at</strong> this<br />
survey will provide inform<strong>at</strong>ion helping to design future intervention programs.<br />
Methods:<br />
A total number of 164 questionnaires were handed out to the health care workers <strong>at</strong> <strong>Ilembula</strong><br />
<strong>Lutheran</strong> <strong>Hospital</strong> and the students <strong>at</strong> <strong>Ilembula</strong> Nurses and Midwives Training School.<br />
Interviews were conducted with 41 health care workers and students. The answers collected<br />
from the questionnaires influenced our choice of topics discussed during these interviews. In<br />
addition to this, we collected inform<strong>at</strong>ion from other individuals with influence in the<br />
<strong>Ilembula</strong> community.<br />
Results:<br />
Both health care workers and students have good knowledge of <strong>HIV</strong>.<br />
Concerning other issues, the results of the questionnaires and interviews often pointed in<br />
different directions. The informants generally believed their own behaviour to be different<br />
from others.<br />
Conclusions:<br />
There are numerous complic<strong>at</strong>ed factors contributing to the spread of the disease, of which the<br />
most important is ignorance. Educ<strong>at</strong>ion alone is not enough to stop the epidemic or change<br />
people’s behaviour.<br />
A brief introduction to <strong>Tanzania</strong><br />
Facts about the country<br />
Area: 945084 km2<br />
Capital city: Dodoma<br />
Popul<strong>at</strong>ion: 35.2 million<br />
Head of st<strong>at</strong>e: President Benjamin Mkapa<br />
GNP per capita: 264 USD<br />
Currency: <strong>Tanzania</strong>n Shilling<br />
[1]<br />
5
The republic of <strong>Tanzania</strong> is situ<strong>at</strong>ed is East Africa. The name <strong>Tanzania</strong> is a symbolic<br />
construction of Tanganyika (the mainland) and Zanzibar (an island outside the eastern coast).<br />
The costal areas have tropical clim<strong>at</strong>e, while the inland is warm and dry. The bulk of the<br />
country is a highland pl<strong>at</strong>eau, which is rel<strong>at</strong>ively uninhabited. [1]<br />
The popul<strong>at</strong>ion of <strong>Tanzania</strong> was estim<strong>at</strong>ed to be 35.2 million in 2002 [1] and the annual<br />
popul<strong>at</strong>ion growth r<strong>at</strong>e is 2.3%. The average number of births per woman is 5.5 and infant<br />
mortality r<strong>at</strong>e is 105.9 per 1000 live births [2]. Life expectancy has been decreasing in the<br />
past decade, and is now down to 43.1 years for women and 40.3 years for men. [3]<br />
There are more than 120 ethnical groups in <strong>Tanzania</strong>, all differing in culture, customs and<br />
language. The biggest groups are Sukuma and Nyamwezi. About a dozen tribes form half of<br />
the countries popul<strong>at</strong>ion, but no ethnic group domin<strong>at</strong>es. This has resulted in a balance of<br />
power and much lower level of ethnic conflict than elsewhere in Africa. Religion has also<br />
been a unifying factor, with 45% Christianity, 35% Islam and 20% traditional religions. [4]<br />
Official languages are Swahili and English. Literacy r<strong>at</strong>e is 57% for women and 79% for men<br />
[5]. Seven years of primary school is mand<strong>at</strong>ory and free of charge, although the parents have<br />
to pay for school uniforms and books. Most secondary schools are boarding schools with high<br />
tuition fees th<strong>at</strong> are beyond the economical capacity of most <strong>Tanzania</strong>n families. Few people<br />
continue to higher educ<strong>at</strong>ion. [1]<br />
<strong>Tanzania</strong> gained independence in 1961, after being colonized first by the Germans and after<br />
world war one by the British. The decades th<strong>at</strong> followed, <strong>Tanzania</strong> tried to cre<strong>at</strong>e a society<br />
based on radical socialism and self-reliance, which ultim<strong>at</strong>ely failed. Recurrent periods of<br />
draught, military interventions in neighbour countries and sinking world market prices of<br />
coffee have contributed to the economical instability. <strong>Tanzania</strong> is now one of the world’s<br />
poorest countries and heavily dependent on development aid. Most people are peasants and<br />
farming is the core of the economy. Main export goods are minerals, cashew nuts, coffee, tea,<br />
spices and cotton. Unemployment r<strong>at</strong>e is 30-40%. [1] It has been estim<strong>at</strong>ed th<strong>at</strong> about 60% of<br />
the popul<strong>at</strong>ion in <strong>Tanzania</strong> lack access to modern healthcare, either because they live too far<br />
from the nearest dispensary or because they can’t afford to pay for medical services. [6]<br />
The <strong>HIV</strong> pandemic<br />
Present situ<strong>at</strong>ion<br />
The <strong>HIV</strong>/AIDS pandemic poses one of the gre<strong>at</strong>est challenges to global public health. With<br />
over 40 million of infected people in the world [7] <strong>HIV</strong>/AIDS is the leading cause of de<strong>at</strong>h in<br />
Africa and the fourth leading cause of de<strong>at</strong>h worldwide. Sub-Saharan Africa is the world’s<br />
most severely affected region [8] with 25-28.2 million people infected [7].<br />
The <strong>HIV</strong>/AIDS pandemic has interacted with other public health problems, most notably<br />
tuberculosis (TB). It is reported th<strong>at</strong> in countries of sub-Saharan Africa most admissions are<br />
due to <strong>HIV</strong> rel<strong>at</strong>ed conditions including TB. [9]<br />
There is a direct correl<strong>at</strong>ion between countries with high levels of other sexually transmitted<br />
infections (STI) and <strong>HIV</strong> infection. The presence of an STI has been shown to increase the<br />
6
isk of <strong>HIV</strong> infection in any single contact 2-10 times depending on the n<strong>at</strong>ure and severity of<br />
the STI. To some extent, this may explain the significant differences between <strong>HIV</strong> spread in<br />
many wealthier countries, where STI r<strong>at</strong>es tend to be much lower, compared to poorer<br />
countries. [9]<br />
The Virus<br />
<strong>HIV</strong> belongs to the genus Lentivirus of the family Retroviridae and has been divided into two<br />
groups:<br />
• <strong>HIV</strong> Type 1, responsible for the global pandemic.<br />
• <strong>HIV</strong> Type 2, less p<strong>at</strong>hogenic than <strong>HIV</strong>-1 and largely restricted to West Africa, with<br />
limited spread to other countries.<br />
<strong>HIV</strong>-1 is further classified in three groups:<br />
• M, major, is further divided into subtypes or clades. The subtypes are unevenly<br />
distributed around the world with A, C and D being most common in Africa and B<br />
occurring in Europe and America.<br />
• Group O, outliner, is largely restricted to the central African region.<br />
• Group N, non-M non-O, is rare and has been identified with only a few individuals in<br />
Cameroon. [9]<br />
Therapy<br />
To tre<strong>at</strong> AIDS, Highly Active Antiretroviral Therapies (HAART) are used. However, the high<br />
cost of drugs and the infrastructure needed to administer and monitor their use have so far put<br />
these medic<strong>at</strong>ions beyond reach of most <strong>HIV</strong>-infected persons, especially in third world<br />
countries. [10]<br />
<strong>HIV</strong>/AIDS and poverty<br />
The rel<strong>at</strong>ionship between <strong>HIV</strong>/AIDS and economic development is complex. <strong>HIV</strong>/AIDS<br />
neg<strong>at</strong>ively affects economic growth on the one hand. On the other hand, weak economy<br />
makes it difficult for n<strong>at</strong>ions and individuals to mount adequ<strong>at</strong>e and comprehensive responses<br />
to the epidemic. In many ways poverty cre<strong>at</strong>es vulnerability to <strong>HIV</strong> infection, causes rapid<br />
progression of the infection due to malnutrition and limits access to social and healthcare<br />
services.<br />
De<strong>at</strong>h of a young adult often means loss of a f<strong>at</strong>her/mother and family bread earner.<br />
This means th<strong>at</strong> <strong>HIV</strong> causes a growing breakdown of social networks.<br />
Ultim<strong>at</strong>ely the high cost of care and burials is putting a severe strain on the already<br />
overburdened households. [10]<br />
<strong>HIV</strong> in the Republic of <strong>Tanzania</strong><br />
In <strong>Tanzania</strong>, the first AIDS cases were reported from the North-Western part of the country<br />
(Kagera Region) in November 1983. [11]<br />
About 98% of the adult popul<strong>at</strong>ion in <strong>Tanzania</strong> is now aware of <strong>HIV</strong>/AIDS [10]. In spite of<br />
this, <strong>HIV</strong>/AIDS rel<strong>at</strong>ed stigma is one of the key challenges in the prevention and control of<br />
7
the epidemic. Yet, <strong>HIV</strong> continues to spread and approxim<strong>at</strong>ely 15% of the sexually active<br />
popul<strong>at</strong>ion is infected.<br />
Over 70% of those infected are aged between 20-49 years. Since they are the very future of<br />
the n<strong>at</strong>ion this leads to a major development crisis th<strong>at</strong> affects all sectors. Absenteeism from<br />
workplaces and de<strong>at</strong>hs reflect the manifest<strong>at</strong>ion of the epidemic. Other problems are lowering<br />
of life expectancy, increasing the dependency r<strong>at</strong>io, reducing growth in GDP, increasing<br />
poverty, raising infant and child mortality as well as the growing numbers of orphans. It has<br />
serious and direct implic<strong>at</strong>ions on the social services and welfare [8]. Widows and orphans are<br />
often deprived of their inheritance rights by rel<strong>at</strong>ives through the applic<strong>at</strong>ion of outd<strong>at</strong>ed<br />
traditional and customary laws. [10]<br />
<strong>HIV</strong>/AIDS <strong>at</strong> <strong>Ilembula</strong> village/hospital<br />
According to doctor Temihango, 60 % of the beds of the hospital are occupied by <strong>HIV</strong><br />
p<strong>at</strong>ients. In 2002, AIDS was the most common cause of de<strong>at</strong>h in <strong>Ilembula</strong> [12]. Number 2 on<br />
the list was malaria, which can be more severe if the p<strong>at</strong>ient has <strong>HIV</strong>. Number 3 was<br />
pneumonia followed by tuberculosis [12]. These diseases can be secondary to AIDS.<br />
The prevalence of <strong>HIV</strong>/AIDS <strong>at</strong> <strong>Ilembula</strong> is measured in three ways: Clinical AIDS,<br />
voluntary screening and screening of blood donors. In 2002, 69% of those clinically suspected<br />
were infected with <strong>HIV</strong>. 15% of the blood donors and 13 % of those who came for voluntary<br />
testing were found to be <strong>HIV</strong> positive. [12]<br />
The hospital is following the guidelines of the ELCT (Evangelical <strong>Lutheran</strong> Church of<br />
<strong>Tanzania</strong>). The most important projects to prevent <strong>HIV</strong>/AIDS are according to doctor<br />
Temihango:<br />
• To educ<strong>at</strong>e all the nearby parish leaders through workshops. This was done in July<br />
2002.<br />
• To take care of the orphans whose parents died of AIDS or other causes. Although<br />
most orphans are taken care of by rel<strong>at</strong>ives, the hospital orphanage has room for ten<br />
children. At present there are 44 orphans in <strong>Ilembula</strong> village, 32 in Iglehetsa and 9 in<br />
Igula. When they grow older, the hospital provides them with school uniforms, books<br />
and some other necessities.<br />
• To teach the students about <strong>HIV</strong>/AIDS.<br />
40-45 minutes teaching is given to the students <strong>at</strong> primary school grade 5-7. They are<br />
told to use condoms but do not get instructions on how to use them.<br />
• To give pre- and post counselling.<br />
The hospital as well as the church encourage people to test themselves for <strong>HIV</strong>. All<br />
the test takers receive pre- and post counselling. The <strong>HIV</strong> neg<strong>at</strong>ives are given advice<br />
on how to stay neg<strong>at</strong>ive, while the positives are told how to take care of themselves<br />
and protect others. The infected individuals have ongoing counselling throughout life.<br />
Some of the nurses and clinical officers are trained to be counsellors, under the<br />
direction of Mr Mbilinyi, the <strong>HIV</strong> coordin<strong>at</strong>or of the hospital. Since the hospital is<br />
Christian, the counsellors are not supposed to recommend people to use condoms but<br />
to abstain from sex outside marriage.<br />
• To have home based care for AIDS p<strong>at</strong>ients. [13]<br />
8
Home Based Care<br />
Since the prevalence of <strong>HIV</strong> continues to increase, it has become obvious th<strong>at</strong> the hospital<br />
lacks the resources needed to care for all p<strong>at</strong>ients dying of AIDS. This means th<strong>at</strong> there is less<br />
time to focus on p<strong>at</strong>ients suffering from other medical conditions. To prevent this, a home<br />
based program for <strong>HIV</strong> p<strong>at</strong>ients is being developed. When functioning, the home based care<br />
will provide the following advantages:<br />
• The overcrowding of the hospitals will be reduced.<br />
• For a long time, the people of <strong>Ilembula</strong> has tre<strong>at</strong>ed and cared for their sick rel<strong>at</strong>ives in<br />
their family compounds. It is culturally preferred and accepted.<br />
• When a person is admitted to hospital, all close family members will go there to stay<br />
near their sick rel<strong>at</strong>ive. If it’s possible for the infected person to receive tre<strong>at</strong>ment <strong>at</strong><br />
home, the rel<strong>at</strong>ives can continue to perform their regular work.<br />
• Isol<strong>at</strong>ion of the infected person will be avoided. There will also be time and peace to<br />
discuss future problems with the family.<br />
• Because of the many drug resistant micro organisms th<strong>at</strong> are present, hospital<br />
environment can shorten the life of a person with AIDS.<br />
• For the hospital as well as for the family, it’s less expensive to take care of the AIDS<br />
p<strong>at</strong>ient <strong>at</strong> home.<br />
Before the program can be fully implemented there are some issues th<strong>at</strong> need to be dealt with:<br />
• The family of the infected person must be willing to cooper<strong>at</strong>e. Some people might<br />
fear th<strong>at</strong> caring for an AIDS p<strong>at</strong>ient will put them <strong>at</strong> risk of being infected.<br />
• <strong>HIV</strong> is still carrying a stigma and to be visited by healthcare workers could be very<br />
embarrassing.<br />
• Some of the employees of the hospital must be willing to visit p<strong>at</strong>ients <strong>at</strong> their homes,<br />
sometimes in remote villages.<br />
According to the nurse in charge of the home based care, only about 30 p<strong>at</strong>ients are taking<br />
part in the program, but th<strong>at</strong> she is planning to expand it to more villages. When she comes to<br />
a new village, she visits the chairman and asks him to recommend her suitable p<strong>at</strong>ients. She<br />
tries to visit the affected families once a month, not only to check the health of the p<strong>at</strong>ients,<br />
but also to give them advice on health care. She also hands out medicines and booklets with<br />
inform<strong>at</strong>ion about <strong>HIV</strong> and other common medical problems. At this point, no p<strong>at</strong>ient th<strong>at</strong> is<br />
benefiting from this program has <strong>HIV</strong> as his /her working diagnosis. The nurse in charge<br />
knows th<strong>at</strong> <strong>at</strong> least 11 of the 30 p<strong>at</strong>ients are infected, but only the p<strong>at</strong>ients may bring up<br />
<strong>HIV</strong>/AIDS for discussion. If the nurse takes the initi<strong>at</strong>ive to mention <strong>HIV</strong>, the p<strong>at</strong>ient will<br />
probably refuse to se her again. The stigm<strong>at</strong>is<strong>at</strong>ion of the disease makes this way of helping<br />
<strong>HIV</strong>-infected p<strong>at</strong>ients complic<strong>at</strong>ed. It’s not only important to reduce the risk of rumours about<br />
the families th<strong>at</strong> are visited; the p<strong>at</strong>ients themselves mostly don’t want to realize th<strong>at</strong> they are<br />
suffering from <strong>HIV</strong>.<br />
The village of <strong>Ilembula</strong><br />
Lifestyle and traditions<br />
<strong>Ilembula</strong> is loc<strong>at</strong>ed in the Iringa region, Njombe district, in the southern highlands of<br />
9
<strong>Tanzania</strong>. The popul<strong>at</strong>ion in central <strong>Ilembula</strong> is estim<strong>at</strong>ed to be over 5000 [13] and the near<br />
proximity there are about 30,000 people, the females slightly outnumbering the males. [11]<br />
The majority of the people belong to the Bena tribe, although Hehe, Nyakusa, Samgu and<br />
Kinga are also represented. [13]<br />
<strong>Ilembula</strong> is a rural village th<strong>at</strong> lacks many modern facilities. Electricity is only available to a<br />
few and in the dry season, w<strong>at</strong>er supplies may be scarce. The majority of the people have no<br />
regular income. Most of them are subsistence farmers although some sustain themselves by<br />
small scale business. The basic diet of the people in the village consists of "Ugali" (maize<br />
porridge) and beans, usually e<strong>at</strong>en with greens and tom<strong>at</strong>oes. On special occasions, hens,<br />
go<strong>at</strong>s or cows are slaughtered and served with rice or pot<strong>at</strong>oes. [13]<br />
A typical household consists of a husband, a wife and five to six children. Polygamy still<br />
occurs. Marriage is an agreement between two families and the main topic in the negoti<strong>at</strong>ions<br />
is the amount of dowry the fiancée and his family has to pay. Customarily, widows are<br />
inherited as wives by the brothers of their deceased husbands, but this tradition seems to be<br />
fading. At present, it is common for unmarried girls to become mothers <strong>at</strong> an early age. This<br />
is considered a shame in the community. [13]<br />
Bena belong to a p<strong>at</strong>rilineal society, which means their descent is followed through males. In<br />
general, all property of the family is considered to belong to the male family members. The<br />
wife is seen primarily as the mother of one’s children. A marriage is not completed until the<br />
first child is born. The man is the head of the household and his duties are to build houses,<br />
plough, take care of c<strong>at</strong>tle and bring cash to the family. The woman takes care of the home<br />
and assists her husband. She also works in the fields, were he responsibilities include planting,<br />
weeding and harvesting. [13]<br />
In the past few years the spread of <strong>HIV</strong> has had vast effects on the family structure. Due to the<br />
increasing numbers of infected, the number of orphans is growing rapidly. The older<br />
gener<strong>at</strong>ion often gets the burden of providing food and raising children when the younger part<br />
of the popul<strong>at</strong>ion has fallen ill or died. [14]<br />
Like other villages in the area, <strong>Ilembula</strong> has a chairman. Decisions concerning financial<br />
issues, security, social development, health, educ<strong>at</strong>ion and buildings are made <strong>at</strong> village<br />
meetings. The smallest administr<strong>at</strong>ive body is a "10-cell" leader, nomin<strong>at</strong>ed by the inhabitants<br />
of 10-20 houses. The 10-cell leaders work in close cooper<strong>at</strong>ion with the village leaders. Their<br />
duty is to supervise people, to <strong>at</strong>tend village activities and to make sure people follow the<br />
local rules issued by the village government. They also serve as a communic<strong>at</strong>ion link<br />
between their cells and village leaders, primary school teachers and health care workers. [13]<br />
The Bena people emphasise the importance of each individual’s good behaviour within the<br />
family and other social rel<strong>at</strong>ionships. Good behaviour involves fulfilling of the moral<br />
expect<strong>at</strong>ions based on cultural values and knowledge of the culturally defined sex- and aged<br />
based rules. This ensures harmonious co-existence, but breaking the behavioural rules and<br />
taboos is punished by Good or ancestral spirits through illness and failures in life. [13]<br />
To explain some of the <strong>at</strong>titudes and thoughts of the <strong>Tanzania</strong>n people, their concept of time<br />
might be a help. The linear concept of indefinite past, present and an infinite future is foreign<br />
to the African way of thinking. Instead the time is two-dimensional with a long past and a<br />
present. The future as an actual time is absent apart from up to a few years hence. [13]<br />
10
In <strong>Ilembula</strong>, religion is an important issue. In the year of 1906, the first missionaries appeared<br />
<strong>at</strong> <strong>Ilembula</strong>. By now, most of the inhabitants in <strong>Ilembula</strong> are <strong>Lutheran</strong> or Roman C<strong>at</strong>holics.<br />
The Christian values and rules do not always agree with the traditions th<strong>at</strong> the tribes have<br />
practiced for hundreds of years. [13]<br />
Sickness and health as seen by the people of <strong>Ilembula</strong><br />
A central value in Bantu cultures, including Bena, is life or "vital force". Vital force exists in<br />
everything and in every being in the universe. The source of vital force is God or the cre<strong>at</strong>or.<br />
The most important chains linking living human beings to God are the ancestors. The goal is<br />
to acquire as much vital force as possible and to assure th<strong>at</strong> it will remain perpetually in ones<br />
descendants. Illness and suffering are considered to arise when ones vital force is decreased.<br />
[6]<br />
The causes of illness are usually <strong>at</strong>tributed to the viol<strong>at</strong>ion of a taboo or an insult of ancestral<br />
spirits. People with special skills can also use magic to curse others. The illness has to be<br />
cured by acts of reconcili<strong>at</strong>ion or the use of medicines. Sometimes people ask the "mganga"<br />
(medicine man, plural waganga) for help. The mganga can help them finding out who caused<br />
the problem and wh<strong>at</strong> measures need to be taken against it. Some of them also use medical<br />
plants and t<strong>at</strong>toos based on traditional knowledge. [14]<br />
In present day <strong>Tanzania</strong>, traditional healers oper<strong>at</strong>e alongside the modern health care system.<br />
Traditional medicine is considered to be the only efficient cure for some illnesses, while<br />
modern health care facilities are used for others. In general it is up to the man to decide where<br />
the sick family members should receive tre<strong>at</strong>ment. [13]<br />
Please. See appendix for a summary of an interview with one of the waganga in <strong>Ilembula</strong>.<br />
<strong>Ilembula</strong> <strong>Lutheran</strong> <strong>Hospital</strong><br />
General inform<strong>at</strong>ion<br />
The need for health care facilities in the <strong>Ilembula</strong> area was recognized when people from the<br />
surroundings turned to a German missionary st<strong>at</strong>ion for help with medical issues. In 1942 a<br />
dispensary was founded and in 1950 it became a hospital.<br />
Today it provides healthcare services within the fields of internal medicine, paedi<strong>at</strong>rics,<br />
surgery, gynaecology, obstetrics, dentistry, ophthalmology and nutrition. It is also a teaching<br />
hospital for nurse and midwife students <strong>at</strong> <strong>Ilembula</strong> School of nursing. In addition, there is an<br />
orphanage with admission capacity of 10 children [12]<br />
The c<strong>at</strong>chment area of the hospital is inhabited by more than 350,000 people. There are 317<br />
beds, but the bed occupancy r<strong>at</strong>e is over 100% in most of the hospital wards. The hospital<br />
employs 7 doctors, 75 nurses and 15 clinical officers. The hospital is grant aided by the<br />
Ministry of Health for 44 employees and 147 beds. [12]<br />
<strong>Ilembula</strong> <strong>Lutheran</strong> <strong>Hospital</strong> is owned and run by the Evangelical <strong>Lutheran</strong> church in <strong>Tanzania</strong><br />
(ELCT) [12]. ELCT covers a large area in the Southern part of the country where it has a<br />
number of Health institutions [15]. The church decides the guidelines and the rules of the<br />
11
hospital, which in the long run means th<strong>at</strong> the hospital employees are expected to follow<br />
Christianity. For example, if an unmarried female employee gets pregnant she is advised to<br />
get married or look for another place to work.<br />
Summary of hospital services 2002<br />
Number of admissions...................10,689<br />
De<strong>at</strong>hs ……………………………....782<br />
Deliveries ………………………….2409<br />
Caesarean Sections…………….. …..547<br />
Major Oper<strong>at</strong>ions ………………....1176<br />
Labor<strong>at</strong>ory Examin<strong>at</strong>ions……. ….47,976<br />
Top ten diseases diagnosed<br />
1. Malaria<br />
2. Eye infections<br />
3. Pneumonia<br />
4. Diarrhoeal diseases<br />
5. AIDS<br />
6. Anaemia<br />
7. Fractures<br />
8. Tuberculosis<br />
9. Cardiovascular diseases<br />
10. Malnutrition<br />
Top ten causes of de<strong>at</strong>h<br />
1. AIDS<br />
2. Malaria<br />
3. Pneumonia<br />
4. Tuberculosis<br />
5. Diarrhoeal diseases<br />
6. Malnutrition<br />
7. Anaemia<br />
8. Cardiovascular disease<br />
9. Burns<br />
10. Hypertension<br />
<strong>Ilembula</strong> Nurses and Midwives Training School<br />
INMTS was founded 1963 in order to enable ambitious girls to obtain higher educ<strong>at</strong>ion. Like<br />
many other colleges in <strong>Tanzania</strong> it is a boarding school. At present, there are approxim<strong>at</strong>ely<br />
100 students and four teachers. The owner of the school is ELCT, but the school doesn’t<br />
require the students to be Christians. However the majority is Christian and <strong>at</strong>tending church<br />
is mand<strong>at</strong>ory in weekdays.<br />
The school fee is 300,000Tsh /year, which includes tuition, meals, lodging, examin<strong>at</strong>ions,<br />
books and medical expenses. The students also have to perform certain duties around the<br />
school, such as taking care of the garden, growing vegetables and cleaning.<br />
12
While studying <strong>at</strong> the school, the students have to follow some specific rules. Some of them<br />
are set by the Ministry of Health while others are decided by ELCT.<br />
The governmental rules, which are quite elabor<strong>at</strong>e include:<br />
• Staying in the school area after 7 pm.<br />
• Lights should be put out by midnight.<br />
• Smoking, alcohol and other drugs are not permitted.<br />
• The students must not use abusive or obscene language.<br />
• Pregnant students have to postpone their educ<strong>at</strong>ion. They can apply to the school again<br />
when the child is one year old.<br />
• Students should not commit adultery.<br />
In addition to this, the church requires the students to be polite, honest and live like<br />
Christians.<br />
The students are not allowed to visit rel<strong>at</strong>ives except during some holidays. The families are<br />
allowed to visit them once a month. These rules also apply to the married students.<br />
If there is an announcement <strong>at</strong> the hospital or the school th<strong>at</strong> something has been stolen, the<br />
students’ belongings will be searched through.<br />
If a student breaks the rules the punishment will be a written warning, suspension or dismissal<br />
depending on the severity of the viol<strong>at</strong>ion.<br />
Since the school has such a good reput<strong>at</strong>ion, the students face no difficulties to find a job after<br />
gradu<strong>at</strong>ing.<br />
This inform<strong>at</strong>ion was received from Alifa Lupende, the principal of the school. For a<br />
summary of the interview, please turn to the appendix section.<br />
Methods<br />
In total 83 questionnaires were distributed to second, third and fourth year students <strong>at</strong> INMTS.<br />
All the questionnaires were returned. In addition to this, 81 questionnaires were handed out to<br />
nurses, midwives, clinical officers and doctors <strong>at</strong> <strong>Ilembula</strong> <strong>Lutheran</strong> hospital. 33 of the<br />
questionnaires were returned.<br />
With the help of the m<strong>at</strong>ron or by ourselves, we met employees of the hospital in different<br />
wards. Those willing to take part in an interview made an appointment and <strong>at</strong> the agreed time<br />
we met either <strong>at</strong> an office <strong>at</strong> the hospital or <strong>at</strong> our guesthouse.<br />
Since our survey is explor<strong>at</strong>ive, the questions were very open. They have been asked in a way<br />
th<strong>at</strong> shouldn’t give a hint about wh<strong>at</strong> answer is appropri<strong>at</strong>e or preferred. The standardis<strong>at</strong>ion<br />
r<strong>at</strong>e is very low, since the person could steer to the subject th<strong>at</strong> (s)he considered the most<br />
important. The interviews had no time limit. Some of them lasted for half an hour and others<br />
continued for up to two hours. Only the verbal measures were evalu<strong>at</strong>ed since it can be hard<br />
to read other cultures’ body language and inton<strong>at</strong>ion.<br />
The questionnaires as well as the interviews were strictly confidential. We did not ask the<br />
participants to st<strong>at</strong>e their names. In the following text the participants will be referred to as<br />
informants.<br />
13
As question number 10 ( Do you see yourself as a member of a special ethnical group?) was<br />
generally misunderstood, we chose not to analyse the answers. The answers to question<br />
number 18 (If you were found to have <strong>HIV</strong> in your blood, how many years do you think you<br />
would live?) were to complex to account for. Question number 38 (Have you had sexual<br />
contacts with prostitutes?) had to be excluded since we realized th<strong>at</strong> the word prostitution has<br />
another connot<strong>at</strong>ion in <strong>Tanzania</strong>.<br />
To see a copy of the questionnaire and a list of the questions asked during the interviews,<br />
please turn to the appendix.<br />
Results of the questionnaires<br />
Socio-economic situ<strong>at</strong>ion<br />
Age:<br />
Students: The mean age of the participants was 23.6 years and the median age was 23 years.<br />
The age span ranged from 20 to 30 years.<br />
Health care workers: The age span ranged from 25 to 52 years, the mean being 31.4 and the<br />
median 27 years. Three persons did not report their age.<br />
Profession<br />
Students: 24 students were in their second year, 17 were in their third year and 29 were fourth<br />
year midwife students. 13 participants did not specify their present level of educ<strong>at</strong>ion.<br />
Health care workers: 23 of the participants were nurses or midwives, 8 were clinical officers<br />
and two were doctors. The doctors were considered to be too few for the aims of this survey<br />
and were subsequently excluded.<br />
Gender<br />
Students: All the students were female.<br />
Health care workers: 25 were female and 6 were male.<br />
Family<br />
Students: 7/83 (8%) of the students were married, 67/83 (81%) were single, 7/83 (8%) had<br />
boyfriends and 2/83 (3%) had girlfriends. 9/83 (11%) had children. The number of people in<br />
their households ranged from 3 to 12, the mean being 6.2 people.<br />
Health care workers: 18/31 (58%) were married, 9/31 (29%) were single and 3/31 (9%) had<br />
boyfriends. There were between one and nine people in their households, the mean being 4.5<br />
and the median 4 people. 16/31 (52%) had children.<br />
Religion<br />
Students: 80/83 (96%) were C<strong>at</strong>holics or Christians of any denomin<strong>at</strong>ion, while 3/83 (4%)<br />
were Moslems. 65/83 (78%) <strong>at</strong>tended religious services several times a week.<br />
Health care workers: 31/31 (100%) were C<strong>at</strong>holics or Christians. 22/31 (71%) <strong>at</strong>tended<br />
religious services several times a week.<br />
Economical situ<strong>at</strong>ion<br />
Students: 10/83 (12%) considered themselves to be poor or very poor, 41/83 (49%) were<br />
average and 25/83 (30%) graded their economy as good or very good. The most common<br />
14
professions of their f<strong>at</strong>hers were farmer (31%), teacher (13%) and businessman (11%). The<br />
mothers were farmers (27%), housewives (22%) and teachers (16%). 3/83 (4%) claimed th<strong>at</strong><br />
their f<strong>at</strong>her was dead, while the same numbers for the mother were 2/83 (3%).<br />
Health care workers: 8/31 (26%) were poor or very poor. 21/31 (71%) graded their economy<br />
as average. One person said his/her economy was good. Their f<strong>at</strong>hers were usually farmers<br />
(32%) or peasants (13%). 7/31 (23%) claimed their f<strong>at</strong>her was dead. Common professions<br />
among the mothers were farmer (36%), housewife (16%) and peasant (13%). 6/31(19%) of<br />
the mothers were dead. 4/31 (13%) had lost both their parents.<br />
Knowledge of <strong>HIV</strong><br />
First source of inform<strong>at</strong>ion<br />
Most of the participants first heard of <strong>HIV</strong> <strong>at</strong> school. Other common sources of inform<strong>at</strong>ion<br />
were parents and media.<br />
19%<br />
First Source of Inform<strong>at</strong>ion on<br />
<strong>HIV</strong> /AIDS Among Students<br />
0%<br />
11% 2%<br />
16%<br />
52%<br />
Friend<br />
School<br />
Church<br />
Parents<br />
Media<br />
No answ er<br />
Figure 1 Figure 2<br />
15<br />
First Source of Inform<strong>at</strong>ion on <strong>HIV</strong><br />
/AIDS Among Health Care<br />
Workers<br />
23%<br />
6%<br />
3%<br />
3%<br />
65%<br />
Friend<br />
School<br />
Church<br />
Parents<br />
Media<br />
No answ er<br />
Ways of transmission<br />
Nearly all participants claimed th<strong>at</strong> <strong>HIV</strong> can be transmitted by sexual intercourse or from<br />
mother to child during pregnancy and delivery. A clear majority also pointed out breast<br />
feeding. Approxim<strong>at</strong>ely half of them believed th<strong>at</strong> the virus can be spread by kisses. Almost<br />
nobody thought <strong>HIV</strong> can be transmitted by shaking hands or mosquito bites.
Mother to child during pregnancy/delivery<br />
Figure 3<br />
Students: Believed ways of transmission<br />
E<strong>at</strong>ing from the same pl<strong>at</strong>e<br />
Shaking hands<br />
Caring for an <strong>HIV</strong> infected<br />
Kissing<br />
Sexual intercourse<br />
Intra venous drug abuse<br />
Breast feeding<br />
By mosquitos<br />
0% 20% 40% 60% 80% 100%<br />
Health Care Workers: Believed ways of transmission<br />
Mother to child during pregnancy/delivery<br />
Figure 4<br />
E<strong>at</strong>ing from the same pl<strong>at</strong>e<br />
Shaking hands<br />
Caring for an <strong>HIV</strong> infected<br />
Kissing<br />
Sexual intercourse<br />
Intra venous drug abuse<br />
Breast feeding<br />
By mosquitos<br />
0% 20% 40% 60% 80% 100%<br />
16<br />
yes<br />
no<br />
don't know<br />
no answer<br />
yes<br />
no<br />
don't know<br />
no answer
Difference between <strong>HIV</strong> and AIDS<br />
A majority of the students and the healthcare workers knows th<strong>at</strong> there is a difference between<br />
<strong>HIV</strong> and AIDS. Most of them are able to explain th<strong>at</strong> AIDS is a manifest disease and <strong>HIV</strong> is<br />
the virus th<strong>at</strong> causes the disease.<br />
68<br />
66<br />
64<br />
62<br />
60<br />
58<br />
56<br />
54<br />
Students: Differences between <strong>HIV</strong> and AIDS<br />
yes (80%) correct explain<strong>at</strong>ion (71%)<br />
Figure 5. Number of students who claimed th<strong>at</strong> there is a difference between <strong>HIV</strong> and AIDS and how many of<br />
them who could explain the differences.<br />
27<br />
26<br />
25<br />
24<br />
23<br />
22<br />
21<br />
20<br />
Health Care Workers: Difference between <strong>HIV</strong> and<br />
AIDS<br />
yes (84%) correct explanaition (71%)<br />
Figure 6. Number of health care workers who claimed th<strong>at</strong> there is a difference between <strong>HIV</strong> and AIDS and how<br />
many of them who could explain the differences.<br />
Ways to cure <strong>HIV</strong><br />
Students: 77/83 (93%) said th<strong>at</strong> there is no medicine to cure <strong>HIV</strong>, while 6/83 (7%) claimed<br />
they did not know.<br />
Health care workers: 30/31 (97%) claimed th<strong>at</strong> curing <strong>HIV</strong> is impossible and one person said<br />
she did not know.<br />
17
Risk groups<br />
Students: 66/83 (68%) thought th<strong>at</strong> some groups of people were more likely to be infected<br />
than others. Groups often mentioned were young people, drivers, bar maids, teachers and<br />
healthcare workers.<br />
Health care workers: 17/31 (55%) believed th<strong>at</strong> some groups were particularly likely to be<br />
infected and 15/31 (49%) pointed out the young gener<strong>at</strong>ion as a risk group. Other groups were<br />
students, soldiers, prostitutes, barmaids, drivers, medical workers and married people.<br />
Estim<strong>at</strong>ed prevalence of <strong>HIV</strong> in <strong>Ilembula</strong>.<br />
Both students and health care workers estim<strong>at</strong>ed the r<strong>at</strong>e of infection to be approxim<strong>at</strong>ely 25%<br />
18<br />
16<br />
14<br />
12<br />
10<br />
8<br />
6<br />
4<br />
2<br />
0<br />
Figure 7<br />
9<br />
8<br />
7<br />
6<br />
5<br />
4<br />
3<br />
2<br />
1<br />
0<br />
Figure 8<br />
Students: Wh<strong>at</strong> is the r<strong>at</strong>e of <strong>HIV</strong> infection in <strong>Ilembula</strong>?<br />
1/100 5/100 10/100 15/100 20/100 25/100 30/100 >35/100 no answer<br />
Health Care Workers: Wh<strong>at</strong> is the r<strong>at</strong>e of <strong>HIV</strong> infection in <strong>Ilembula</strong>?<br />
1/100 5/100 10/100 15/100 20/100 25/100 30/100 >35/100 no answer<br />
Spread of <strong>HIV</strong><br />
The factors contributing to the spread of <strong>HIV</strong> were believed to be:<br />
Students:<br />
1. Sexual activity (25%)<br />
2. Poverty (22%)<br />
3. Lack of educ<strong>at</strong>ion (12%)<br />
4. Unwillingness to use condoms / Ignorance(11%)<br />
5. Prostitution/ alcohol/ infidelity/<br />
lack of medicines/ desire/<br />
sexual intercourse before marriage/<br />
blood transfusions (1-8%)<br />
18
Health care workers:<br />
1. Sexual activity, unsafe sex and infidelity (48%).<br />
2. Poverty (22%)<br />
3. Ignorance (20%)<br />
4. Prostitution, drinking /difficulties in changing one’s habits/ tradition of marrying widows<br />
(3-14%)<br />
Professional situ<strong>at</strong>ion<br />
Inform<strong>at</strong>ion <strong>at</strong> work<br />
Students: 79/83 (95%) thought they had received sufficient inform<strong>at</strong>ion about <strong>HIV</strong> <strong>at</strong> school<br />
and <strong>at</strong> work.<br />
Health care workers: 25/31 (81%) claimed th<strong>at</strong> they were well informed about <strong>HIV</strong>.<br />
<strong>Hospital</strong> routines and risk <strong>at</strong> work<br />
Students: 67/80(82%) believed th<strong>at</strong> the hospital routines were good enough to prevent the<br />
spread of <strong>HIV</strong>. 9/83 (11%) were not s<strong>at</strong>isfied with the routines <strong>at</strong> the hospital and pointed out<br />
problems such as lack of gloves, old equipment and lack of time to inform the p<strong>at</strong>ients.<br />
45/83 (54%) were worried th<strong>at</strong> they might get infected with <strong>HIV</strong> <strong>at</strong> work. Situ<strong>at</strong>ions th<strong>at</strong> were<br />
considered particularly risky included blood sampling, injections, dressing open wounds,<br />
washing bloodstained laundry, working <strong>at</strong> the oper<strong>at</strong>ion the<strong>at</strong>re and <strong>at</strong>tending deliveries.<br />
Some said th<strong>at</strong> sometimes the hospital runs out of gloves, which forces the staff to work with<br />
bare hands. Others expressed concern about the fact th<strong>at</strong> the gloves are washed and used over<br />
and over again. One of the participants said she felt <strong>at</strong> risk of getting infected <strong>at</strong> work because<br />
male co-workers sometimes want to have sex with female employees.<br />
Picture 1 Washed gloves<br />
63/83 (76%) tried to protect themselves by using gloves. Other ways of avoiding <strong>HIV</strong><br />
infection were covering open wounds, washing hands and using disinfectant.<br />
19
Health care workers: 19/31 (61%) believed the hospital routines were good enough to prevent<br />
the spread of the virus. 8/31 (26%) were uns<strong>at</strong>isfied with the routines, the reasons for this<br />
being lack of gloves, lack of other protective articles, lack of strong disinfectant and shortage<br />
of staff. 18/31 (58%) were afraid of getting infected <strong>at</strong> work and 20/31 (65%) said th<strong>at</strong> there<br />
are specific situ<strong>at</strong>ions where they feel <strong>at</strong> risk of being infected. These situ<strong>at</strong>ions included<br />
oper<strong>at</strong>ions, dressing of wounds, deliveries and blood sampling. One person said she felt <strong>at</strong><br />
risk whenever she was exposed to an infected person. 22/31 (71%) said they tried to protect<br />
themselves by wearing gloves. Other ways of avoiding infection were washing hands with<br />
disinfectant, covering wounds and using sterile equipment.<br />
Are the routines for preventing the<br />
spread of <strong>HIV</strong>/AIDS <strong>at</strong> your hospital<br />
sufficient?<br />
Figure 9<br />
Have you recieved sufficient<br />
inform<strong>at</strong>ion about how to protect<br />
yourself <strong>at</strong> work?<br />
Are you worried th<strong>at</strong> you will get<br />
infected <strong>at</strong> work?<br />
Are the routines for preventing the<br />
spread of <strong>HIV</strong>/AIDS <strong>at</strong> your<br />
hospital sufficient?<br />
Figure 10<br />
Have you recieved sufficient<br />
inform<strong>at</strong>ion about how to protect<br />
youirself <strong>at</strong> work?<br />
Are you worried th<strong>at</strong> you will get<br />
infected <strong>at</strong> work?<br />
Students<br />
0 20 40 60 80 100<br />
0% 20% 40% 60% 80% 100%<br />
Health Care Workers<br />
0% 20% 40% 60% 80% 100<br />
%<br />
20<br />
no<br />
don't know<br />
no answer<br />
yes<br />
yes<br />
no<br />
don't know<br />
no answer
Inform<strong>at</strong>ion to the p<strong>at</strong>ients<br />
Students: 71/83 (81%) of the students tried to inform p<strong>at</strong>ients about <strong>HIV</strong> and 51/83 (61%)<br />
believed th<strong>at</strong> the inform<strong>at</strong>ion could have an impact on the p<strong>at</strong>ient’s way of living. 9/83 (11%)<br />
thought it was not always possible for the p<strong>at</strong>ients to follow their advice, the reasons for this<br />
being financial problems, negligence and the tradition of having several wives or partners.<br />
Health care workers: 25/31 (81%) of the participants informed their p<strong>at</strong>ients about <strong>HIV</strong> and<br />
22/31 (71%) believed th<strong>at</strong> inform<strong>at</strong>ion could affect people’s behaviour. 3/31 (10%) thought<br />
th<strong>at</strong> following their advice was sometimes difficult for the p<strong>at</strong>ients, since they had no money<br />
to buy condoms or simply because they didn’t want to protect themselves. One participant<br />
said it was impossible for her p<strong>at</strong>ients to follow her advice, because their husbands were<br />
negligent about the issue.<br />
Priv<strong>at</strong>e life<br />
<strong>HIV</strong> among friends and rel<strong>at</strong>ives<br />
Most of the participants had rel<strong>at</strong>ives or friends who they knew to be infected with <strong>HIV</strong>.<br />
100%<br />
80%<br />
60%<br />
40%<br />
20%<br />
0%<br />
Rel<strong>at</strong>ives and /or friends with <strong>HIV</strong><br />
65%<br />
21<br />
68%<br />
yes yes<br />
Students Health Care Workers<br />
Figure 11 Numbers of students and health care workers who have <strong>HIV</strong> positive rel<strong>at</strong>ives and friends.<br />
Informing friends and rel<strong>at</strong>ives<br />
A majority of the informants claimed th<strong>at</strong> they could discuss <strong>HIV</strong> with rel<strong>at</strong>ives and friends as<br />
well as co-workers and p<strong>at</strong>ients. If they were found to be <strong>HIV</strong> positive, they would usually<br />
inform close family members.
Other rel<strong>at</strong>ives<br />
Figure 12<br />
Mother<br />
F<strong>at</strong>her<br />
Partner<br />
Friends<br />
Coworkers<br />
Other rel<strong>at</strong>ives<br />
Figure 13<br />
Mother<br />
F<strong>at</strong>her<br />
Partner<br />
Friends<br />
Coworkers<br />
Other rel<strong>at</strong>ives<br />
Figure 14<br />
Partner<br />
Parents<br />
Friends<br />
Coworkers<br />
P<strong>at</strong>ients<br />
Others<br />
Students: With whom can you talk about <strong>HIV</strong>?<br />
0% 20% 40% 60% 80% 100%<br />
Health Care Workers: With whom can you talk about <strong>HIV</strong>?<br />
0% 20% 40% 60% 80% 100%<br />
Students: If you were found to have <strong>HIV</strong>, who would you inform?<br />
0% 20% 40% 60% 80% 100%<br />
22<br />
yes<br />
no<br />
don´t know<br />
no answer<br />
yes<br />
no<br />
don't know<br />
no answer<br />
yes<br />
no<br />
don't know<br />
no answer
Other rel<strong>at</strong>ives<br />
Figure 15<br />
Health Care Workers: If you were found to have <strong>HIV</strong>, who would you<br />
inform?<br />
Partner<br />
Parents<br />
Friends<br />
Coworkerrs<br />
P<strong>at</strong>ients<br />
Others<br />
0% 20% 40% 60% 80% 100%<br />
23<br />
yes<br />
no<br />
don't know<br />
no answer<br />
Protecting oneself<br />
Students: Common ways of protecting oneself from <strong>HIV</strong> were:<br />
1. Not having sexual intercourse (35%)<br />
2. Abstain from sex until marriage/ be faithful (28%)<br />
3. Avoid wet kissing/ not sharing toothbrushes/ taking blood tests before starting a sexual<br />
rel<strong>at</strong>ionship/ praying to God (1-8%)<br />
76/83 (92%) claimed th<strong>at</strong> they would ask their partner to take a blood test before starting a<br />
sexual rel<strong>at</strong>ionship. If a partner wanted to have unprotected sex, 36/83 (43%) would refuse to<br />
have sex with him or her, while 33/83 (40%) would try to convince their partner to use a<br />
condom anyway. Only one person said it did not m<strong>at</strong>ter to her.<br />
Health care workers: Common ways of protecting oneself from <strong>HIV</strong> were:<br />
1. Having just one partner (16%)<br />
2. Avoiding sex before marriage/ using condoms (10%)<br />
3. Abstaining from sexual intercourse/ avoiding blood transfusions and practicing careful<br />
personal hygiene (3-6%)<br />
22/31 (71%) said they usually ask a partner to take a blood test before starting a sexual<br />
rel<strong>at</strong>ionship. One person said she asks her partner to use condom instead. 10/31 (32%) would<br />
refuse if a partner wanted to have unprotected sex and another 10/31 (32%) would try to<br />
convince their partner to use a condom anyway. 4/31 (13%),of whom two were married,<br />
claimed it didn’t m<strong>at</strong>ter to them.<br />
The question concerning who usually decides if to use a condom or not, was often<br />
misunderstood. Instead of choosing a, b or c (the man, the woman or both) most participants<br />
ticked a box under each option. This makes it impossible to draw any specific conclusions.<br />
Some of the written comments we received in response to the question were:
• The man is the decision maker. The woman is always commanded by the man.<br />
• The man does not care about or fear <strong>HIV</strong>.<br />
• The man, because he does not feel happy during sexual intercourse.<br />
• The man, because the man is able to choose whether he wants a child or not<br />
• The man, because the man can tear it.<br />
• The man, because the woman has no power during sexual intercourse.<br />
• The man, because if the woman decides to use a condom and the man does not agree,<br />
he can force her.<br />
• The man can not decide, because a woman can feel bad if she will be forced.<br />
• The woman, because the man doesn’t care.<br />
• The woman, because she has fear to get <strong>HIV</strong>.<br />
• The woman, because she is afraid of pregnancy and venereal diseases. .<br />
• Because the woman may fear to get an infection from the man she decides to use a<br />
condom or not.<br />
• Both, because they are able to choose whether to get a child or not or to avoid cross<br />
infection from one person to another.<br />
• We must all agree to use condoms in order to prevent the friction to avoid <strong>HIV</strong>.<br />
• For myself I don’t like condoms because they are not good for protection.<br />
• Not the woman because she is afraid when say to use condom the man will refuse to<br />
do sexual intercourse.<br />
Sexual partners<br />
Students: Most of the students claimed they had no sexual experience. A smaller number had<br />
had one or two sexual partners. 29/83 (35%) st<strong>at</strong>ed th<strong>at</strong> their partners are usually men, (2/82<br />
(2%) preferred women and 10/82 (12%) had sexual rel<strong>at</strong>ionships with both men and women.<br />
42/83 (51%) left the question unanswered. 9/83 (11%) said th<strong>at</strong> it is sometimes difficult to<br />
say no when someone asks for sex.<br />
Health care workers: 7/31 (23%) said th<strong>at</strong> they had never had a sexual rel<strong>at</strong>ionship with<br />
anybody, while 48% claimed th<strong>at</strong> they had had one sexual partner. One person said th<strong>at</strong> she<br />
did not remember how many sexual partners she had had and another person claimed th<strong>at</strong> she<br />
had had 350 sexual partners. 7/31 (23%) did not answer the question. Three participants<br />
claimed th<strong>at</strong> they had never had a sexual rel<strong>at</strong>ionship with anyone, even though they had<br />
children. 2/31 (6%) said th<strong>at</strong> it is sometimes difficult to say no when someone asks for sex.<br />
Only one person gave a reason for this: It is shameful for a man to reject a woman’s wish.<br />
24
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Figure 16<br />
16<br />
14<br />
12<br />
10<br />
8<br />
6<br />
4<br />
2<br />
0<br />
Figure 17<br />
Students: Number of sexual partners<br />
none (54%) one (29%) two (7%) no answer (10%)<br />
Health Care Workers: Number of sexual partners<br />
none (23%) one (48%) 350 (3%) Don´t remember (3%) No answer (23%)<br />
Children<br />
Students: 78/83 (95%) would not want to have children if they were found to be <strong>HIV</strong> positive.<br />
Health care workers: None of the participants would want to have children if they were <strong>HIV</strong><br />
positive, but four persons left the question unanswered.<br />
Results interviews<br />
<strong>HIV</strong> in general<br />
Wh<strong>at</strong> do you think are the reasons why <strong>HIV</strong> is still spreading so rapidly?<br />
The factors considered to contribute to the spread of the virus were (in order of priority):<br />
1. Ignorance<br />
2. Alcohol<br />
3. Poverty<br />
4. Prostitution<br />
5. Negligence/unwillingness to change one’s habits<br />
6. Lack of educ<strong>at</strong>ion<br />
7. Infidelity/ the tradition of having many partners<br />
8. Dislike of condoms<br />
25
9. Local traditions, such as polygamy or the custom of inheriting the wife of a deceased<br />
brother.<br />
Almost everybody pointed out ignorance, alcohol and prostitution as parts of the problem.<br />
Excessive drinking is common in the area, particularly among the men. Local brew, such as<br />
alcohol made of bamboo, is cheap and available everywhere. Since the most common way of<br />
supporting oneself is farming and the work load varies with the season, sometimes the men<br />
g<strong>at</strong>her <strong>at</strong> the bars to get some diversion. Women working <strong>at</strong> the bars are poor and often open<br />
to suggestions about having sex for money. Young women, particularly those without<br />
educ<strong>at</strong>ion, turn to prostitution because they see no other way to support themselves. Others<br />
sell sexual services in order to be able to afford some luxury, such as nice clothes or<br />
expensive hairdos.<br />
Some men work far away from their families, which gives them opportunities to socialize<br />
with women without anyone knowing. If the man spends much time away from home, women<br />
are sometimes willing to pay for sexual favours.<br />
We were told th<strong>at</strong> a lot of people just do not care about themselves and their health. They<br />
think they have enough worries already and th<strong>at</strong> AIDS does not deserve more <strong>at</strong>tention than<br />
for example malaria and tuberculosis. The risk of getting infected with <strong>HIV</strong> is a part of life<br />
and it is not worth the trouble trying to avoid it. This <strong>at</strong>titude decreases the use of condoms.<br />
Some informants claimed th<strong>at</strong> lack of educ<strong>at</strong>ion leads to misconceptions about <strong>HIV</strong>. For<br />
example, it can be difficult to understand th<strong>at</strong> a person who looks healthy can be carrying the<br />
virus.<br />
Do people usually want to know if they are <strong>HIV</strong> positive or not? How about you?<br />
Opinions differ on this m<strong>at</strong>ter. Some of the informants said they wanted to know their <strong>HIV</strong><br />
st<strong>at</strong>us, while others preferred not knowing. Of those asked, about 50% had tested themselves<br />
for <strong>HIV</strong>.<br />
The informants said th<strong>at</strong> the main reason for not wanting to test oneself is th<strong>at</strong> people want to<br />
live in peace, without worrying about a future they cannot change. Since there is very little<br />
help to get, they see no point in knowing if they are carrying the virus or not. The risk of<br />
transmitting the disease to others is of less importance. There is a widespread belief th<strong>at</strong> if you<br />
find out th<strong>at</strong> you are <strong>HIV</strong> positive, you will die earlier because of mental distress. People also<br />
fear th<strong>at</strong> rumours will arise if they have to visit the hospital frequently. In spite of this, more<br />
and more people come to the hospital for voluntary testing. The reasons could be th<strong>at</strong> the<br />
hospital is now providing the tests for free and th<strong>at</strong> some of the churches in the area refuse to<br />
marry couples unless they show a certific<strong>at</strong>e saying th<strong>at</strong> they are <strong>HIV</strong> neg<strong>at</strong>ive. There is an<br />
ongoing political discussion in <strong>Tanzania</strong> about we<strong>at</strong>her testing before marriage should be<br />
made mand<strong>at</strong>ory by law.<br />
Most of the informants believed th<strong>at</strong> more people would come for testing if antiviral therapy<br />
was available.<br />
Wh<strong>at</strong> do you think can be done to prevent the spread of <strong>HIV</strong>? Wh<strong>at</strong> about the future?<br />
Preventive measures suggested by the informants included (in order of priority):<br />
1. Pre-and post counselling<br />
26
2. Repe<strong>at</strong>ed educ<strong>at</strong>ion<br />
3. Making people afraid of getting the disease<br />
4. Convincing people to change their behaviour<br />
5. Encouraging infected individuals be open about their medical condition<br />
6. Taking measures to increase the standard of living<br />
Counselling is believed to gener<strong>at</strong>e several positive effects. It will make people more likely to<br />
take an <strong>HIV</strong> test, tell others if they are infected and be willing to protect others.<br />
Many believed th<strong>at</strong> <strong>HIV</strong> could be stopped by further educ<strong>at</strong>ion on the issue. Some said th<strong>at</strong> to<br />
stop the disease, people must be persuaded to use condoms or abstain from sex before<br />
marriage. Few had any ideas about how this could be done, but some believed fear is the best<br />
prevention. Others said th<strong>at</strong> <strong>Tanzania</strong> has a lot to learn from Uganda, where the fight against<br />
<strong>HIV</strong> has been more successful. For example, when a person has died of AIDS, this should be<br />
announced <strong>at</strong> the funeral and <strong>HIV</strong> positive individuals should be encouraged to step forward<br />
and tell others about their disease. There was also a small group of informants who thought<br />
th<strong>at</strong> the legal system has to strike down harder on those who are spreading the disease. One<br />
informant said th<strong>at</strong> people should be recommended to masturb<strong>at</strong>e instead of having multiple<br />
partners.<br />
Questions about the future gener<strong>at</strong>ed gloomy and pessimistic answers. Few thought it would<br />
be possible to control the spread of the disease. Some even said th<strong>at</strong> AIDS will continue to<br />
kill, eventually leading to the end of mankind.<br />
Why is <strong>HIV</strong> stigm<strong>at</strong>ized?<br />
<strong>HIV</strong> is often associ<strong>at</strong>ed with irresponsibility and promiscuity. The main reason for this is not<br />
the disease itself, but the way it is transmitted. If the infected lives in an area where<br />
Christianity or Islam is domin<strong>at</strong>ing, it also indic<strong>at</strong>es th<strong>at</strong> the person is a sinner, since none of<br />
the religions approve of adultery and sex before marriage. There is also a belief th<strong>at</strong> <strong>HIV</strong> is a<br />
punishment from God.<br />
There are still some people who lack proper knowledge about <strong>HIV</strong>, which means th<strong>at</strong> they<br />
don’t know how to deal with the problem. This can cre<strong>at</strong>e unnecessary fears of <strong>HIV</strong> and the<br />
infected persons.<br />
Family and friends<br />
Is it difficult for a person to tell rel<strong>at</strong>ives and partners th<strong>at</strong> (s)he is infected with <strong>HIV</strong>?<br />
A majority claimed th<strong>at</strong> it’s difficult to disclose one’s <strong>HIV</strong> st<strong>at</strong>us for family and friends. The<br />
stigma is one of the main reasons for this. People also fear being accused of transmitting the<br />
disease to their partner. Some of the informants told us th<strong>at</strong> those who inform their partners<br />
are putting themselves <strong>at</strong> risk of being be<strong>at</strong>en or even killed. The fear of retali<strong>at</strong>ions make<br />
many individuals keep their disease as a secret.<br />
There is also a fear th<strong>at</strong> family and friends will turn their backs <strong>at</strong> the infected.<br />
Do the families usually take care of rel<strong>at</strong>ives suffering from AIDS?<br />
Most of the informants claimed th<strong>at</strong> the families usually take good care of a sick rel<strong>at</strong>ive. The<br />
hospital provides educ<strong>at</strong>ion on how to care for infected individuals. The recommend<strong>at</strong>ions<br />
include serving nutritious food, using gloves when necessary and giving psychological<br />
support to the affected. Having received this inform<strong>at</strong>ion the rel<strong>at</strong>ives are usually less<br />
27
eluctant to help the sick person. Even so, some family members are afraid and refuse to have<br />
close contact with the infected when the symptoms of AIDS become evident.<br />
A small group of the informants said th<strong>at</strong> <strong>HIV</strong> p<strong>at</strong>ients often are abandoned by their families.<br />
Some of the nurses had noticed th<strong>at</strong> when rel<strong>at</strong>ives find out th<strong>at</strong> the p<strong>at</strong>ient is suffering from<br />
<strong>HIV</strong>, they sometimes stop visiting him or her. Others deny the sick person further health care,<br />
saying it is unnecessary to spend money on someone who is going to die anyway.<br />
<strong>HIV</strong> <strong>at</strong> work<br />
Do you sometimes feel <strong>at</strong> risk of getting <strong>HIV</strong> <strong>at</strong> work? How do you protect yourself?<br />
A majority of the informants were afraid of getting infected <strong>at</strong> work. Some wards were<br />
considered to be more dangerous than others. When the hospital runs out of gloves the few<br />
th<strong>at</strong> are left are distributed to the more risky ones. One of the nurses said th<strong>at</strong> when there are<br />
no gloves available she refuses to work. Another informant claimed th<strong>at</strong> he is “scared to<br />
de<strong>at</strong>h” and asks God for protection every day. Others felt th<strong>at</strong> as long as their skin is intact,<br />
there is no reason to worry.<br />
Only one person brought up the problem th<strong>at</strong> even p<strong>at</strong>ients <strong>at</strong> the hospital may get infected<br />
with the virus if the health care workers are not careful.<br />
When employees <strong>at</strong> the hospital accidentally prick themselves with a dirty needle, wh<strong>at</strong><br />
do they usually do?<br />
Almost all of the informants would squeeze out some blood and wash the wound with<br />
antiseptic. Some would test themselves for <strong>HIV</strong>, others would not. Most of them preferred to<br />
test the p<strong>at</strong>ient instead. The reasons for not wanting to test oneself were th<strong>at</strong> the risk of getting<br />
infected is so small and the fear of being <strong>HIV</strong> positive. Since there is no insurance to cover<br />
this kind of accidents, nothing good will come out of a positive test.<br />
One of the informants said th<strong>at</strong> testing herself would be useless, since she would still not<br />
know if she got the virus from the p<strong>at</strong>ient or her husband.<br />
One of the students explained th<strong>at</strong> for a student, taking an <strong>HIV</strong> test <strong>at</strong> the hospital is difficult,<br />
since this will raise doubts about her morals.<br />
Do <strong>HIV</strong> infected persons usually take precautions not to transmit the disease to others?<br />
A clear majority of the informants st<strong>at</strong>ed th<strong>at</strong> <strong>HIV</strong> positive individuals usually try to infect as<br />
many others as possible. When people find out th<strong>at</strong> they are infected, the reaction is often a<br />
feeling of injustice and hunger for revenge. Many of them fear to die alone and want to share<br />
their destiny with others. There is a certain expression for this: Tufe wengi, meaning<br />
approxim<strong>at</strong>ely “let us die together in a large number”. One of the students stressed th<strong>at</strong> this<br />
behaviour is particularly common among uneduc<strong>at</strong>ed people. Those who are educ<strong>at</strong>ed know<br />
th<strong>at</strong> there are many other sexually transmitted diseases and are therefore less inclined to<br />
practice unsafe sex. One of the doctors and a couple of the health care employees told us th<strong>at</strong><br />
28
the best way of stopping people from spreading the disease is to instruct them to avoid other<br />
venereal diseases. Telling people to practice safe sex in order to protect others is useless.<br />
Generally spoken, those who were working with counselling of <strong>HIV</strong> p<strong>at</strong>ients had a more<br />
positive <strong>at</strong>titude towards them. They did not think it was common to deliber<strong>at</strong>ely spread the<br />
virus. Even among others, counselling was seen as a way of preventing this behaviour. If the<br />
p<strong>at</strong>ients know th<strong>at</strong> they will have regular check-ups <strong>at</strong> the hospital, they are more likely to<br />
follow the recommend<strong>at</strong>ions.<br />
Sexual behaviour<br />
At wh<strong>at</strong> age do people usually start having sexual intercourse?<br />
The answers to this question ranged from 12 to 20 years. Some believed th<strong>at</strong> it is getting<br />
more and more common to start having sex <strong>at</strong> an early age. One reason for this could be th<strong>at</strong><br />
the <strong>HIV</strong> pandemic has forced teachers to put sexual educ<strong>at</strong>ion on the schedule already in<br />
primary school, which makes children curious about sex. It happens th<strong>at</strong> girls as young as 10<br />
or 12 years turn up <strong>at</strong> the hospital because of pregnancy. One of the nurses explained th<strong>at</strong><br />
instead of protecting themselves by using condoms, some men prefer looking for sexual<br />
partners among very young girls without sexual experience.<br />
The informants said th<strong>at</strong> the youngsters are aware of <strong>HIV</strong> when they start their first sexual<br />
rel<strong>at</strong>ionship, but doubt th<strong>at</strong> they take the disease seriously.<br />
Do people in general have sexual intercourse before marriage/ outside marriage?<br />
All informants except one said th<strong>at</strong> people do not abstain from sex until marriage. On the<br />
contrary, young people usually want to try out several sexual partners before they choose a<br />
future spouse. Most informants also st<strong>at</strong>ed th<strong>at</strong> extramarital affairs are common. Some said<br />
th<strong>at</strong> the low st<strong>at</strong>us of women is making this problem worse.<br />
There are some local customs th<strong>at</strong> enhance and justify infidelity. For example, it is a tradition<br />
among women in the area to abstain from sexual intercourse while breast feeding. There is a<br />
belief th<strong>at</strong> the semen from the man can contamin<strong>at</strong>e the breast milk, giving the child<br />
diarrhoea. Usually women continue to breast feed until it is time to have a second child.<br />
During this period it is more or less accepted for a man to have a mistress. The hospital<br />
recommends abstinence for forty days after delivery, but even th<strong>at</strong> period can be too long for<br />
some men. However, the female informants emphasized th<strong>at</strong> for a woman with higher<br />
educ<strong>at</strong>ion, it is easier to demand fidelity from her husband.<br />
Infidelity occurs among women as well, even though it is less accepted. Sometimes, the man<br />
is working far away from the family, which paves the way for extramarital rel<strong>at</strong>ionships for<br />
both spouses.<br />
Wh<strong>at</strong> do people think about condoms? Do people know how to use them?<br />
Generally spoken, condoms do not seem to be very popular. The reasons for this include:<br />
• Condoms diminish the sens<strong>at</strong>ions.<br />
• There is always a risk th<strong>at</strong> they will break.<br />
29
• There are rumours saying th<strong>at</strong> condoms manufactured in Europe have holes in them,<br />
because the Europeans want <strong>HIV</strong> to spread in Africa.<br />
• Other rumours claim th<strong>at</strong> the manufacturers deliber<strong>at</strong>ely add <strong>HIV</strong> to the m<strong>at</strong>erial the<br />
condoms are made of.<br />
• Some people believe th<strong>at</strong> condoms have pores. In Africa, where the clim<strong>at</strong>e is warm<br />
and humid, these pores will grow big enough to allow passage of a virus.<br />
• Some women fear th<strong>at</strong> condoms will destroy the cervix or cause genital cancer.<br />
Even some of the hospital employees believed these rumours to be true, pointing <strong>at</strong> the fact<br />
th<strong>at</strong> AIDS was non-existent before people started using condoms.<br />
Most of the informants agreed th<strong>at</strong> condoms are readily available, even in small villages.<br />
They are handed out for free <strong>at</strong> the hospital and sold <strong>at</strong> small shops and kiosks in the<br />
surroundings. Unfortun<strong>at</strong>ely, some people think it is embarrassing to ask for condoms. A<br />
woman buying condoms can be reputed to be a prostitute and a man might be suspected of<br />
adultery. One of the informants said th<strong>at</strong> because they are too embarrassed to buy them, some<br />
men borrow condoms from each other and use them several times. A large number of people<br />
do not know how to use condoms properly or use them only in order to prevent pregnancy.<br />
When a couple has been d<strong>at</strong>ing for a while they think they know each other well enough to<br />
use other contraceptives instead.<br />
Two of the informants told us th<strong>at</strong> condoms are useless, because they had met p<strong>at</strong>ients who<br />
claimed they got pregnant even though they used condoms.<br />
Some of the students <strong>at</strong> the nursing school said th<strong>at</strong> even though the hospital provides<br />
condoms to the villagers, students are not allowed to fetch or possess any. The staff of the<br />
school has a right to search through the personal belongings of the students and if they find a<br />
condom, the student will be banned from classes or even sent home for a month. This is done<br />
in order to help the students focusing on their studies.<br />
Of those taking part in the interviews, some said it is difficult to recommend the p<strong>at</strong>ients to<br />
use condoms without support from the church authorities. The represent<strong>at</strong>ives of the C<strong>at</strong>holic<br />
Church do not approve of condoms, since they believe this would encourage people to engage<br />
in sexual activities outside marriage. Condoms are also said to be sinful, because they prevent<br />
conception. Some felt th<strong>at</strong> by taking this standpoint, the church contributes to the problem.<br />
Culture and religion<br />
Do people believe in traditional healers? Do they think th<strong>at</strong> the healers can cure <strong>HIV</strong>?<br />
This question resulted in a diverse variety of answers. While some thought th<strong>at</strong> these days<br />
only a few believe in witch doctors, others claimed th<strong>at</strong> they are still respected and powerful.<br />
It happens th<strong>at</strong> <strong>HIV</strong> p<strong>at</strong>ients are diagnosed in very l<strong>at</strong>e stages, because they receive tre<strong>at</strong>ment<br />
from a traditional doctor before they turn to the hospital. It is also common th<strong>at</strong> <strong>HIV</strong> p<strong>at</strong>ients<br />
visit traditional doctors after realizing th<strong>at</strong> there is very little the hospital can do for them.<br />
Doctors <strong>at</strong> the hospital truthfully explain th<strong>at</strong> there is no cure, while witch doctors sometimes<br />
claim they have tre<strong>at</strong>ments th<strong>at</strong> will wipe the virus out of the body. Sometimes the <strong>HIV</strong><br />
p<strong>at</strong>ients prefer traditional doctors because they discredit the hospital and give their clients a<br />
less embarrassing diagnosis. For example, the healer can say th<strong>at</strong> they have fallen ill because<br />
somebody cursed them. Devast<strong>at</strong>ing family feuds can arise when a rel<strong>at</strong>ive is accused of<br />
putting a spell on a family member.<br />
30
Some informants said th<strong>at</strong> the witch doctors are thieves th<strong>at</strong> are making a living out of other<br />
people’s misery. Their services and advice can be expensive and it happens th<strong>at</strong> families ruin<br />
their economy, paying for useless drugs. Nevertheless, it happens th<strong>at</strong> people with high<br />
educ<strong>at</strong>ion turn to a witch doctor for help. One of the informants said th<strong>at</strong> her sister had been<br />
diagnosed with <strong>HIV</strong> several years ago, but was still healthy because of a brew she was taught<br />
too cook by a traditional doctor. The informant did not know the recipe of this medicine, but<br />
recalled th<strong>at</strong> one of the ingredients was boiled me<strong>at</strong>. Two other informants confirmed th<strong>at</strong><br />
there are rumours th<strong>at</strong> pork can prolong life of <strong>HIV</strong> infected individuals.<br />
Some informants expressed concern about the fact th<strong>at</strong> the healers are making medical t<strong>at</strong>toos<br />
with dirty instruments. However, some people are aware of this and bring their own<br />
razorblades and knives.<br />
When it comes to <strong>HIV</strong>, are there any differences between:<br />
• educ<strong>at</strong>ed and uneduc<strong>at</strong>ed?<br />
Few informants thought th<strong>at</strong> there were any differences. The incub<strong>at</strong>ion time is long<br />
and many educ<strong>at</strong>ed people got the disease before the inform<strong>at</strong>ion was spread.<br />
Educ<strong>at</strong>ed people usually know more about the disease, but they still do not protect<br />
themselves. Uneduc<strong>at</strong>ed people are sometimes extra careful because they believe th<strong>at</strong><br />
the <strong>HIV</strong> virus is transmitted very easily.<br />
Some informants pointed out th<strong>at</strong> many teachers have died of AIDS in spite of their<br />
educ<strong>at</strong>ion.<br />
• Rich and poor?<br />
In the past, the majority of the <strong>HIV</strong> infected was rich, but the numbers have equalled<br />
out. Wealthy people can afford to spend money on sexual favours while poverty<br />
sometimes forces people into prostitution.<br />
• Christian and non-Christians?<br />
Almost everybody thought there were no differences between these groups. People<br />
simply do not follow the rules of their religion.<br />
• Men and women?<br />
In <strong>Tanzania</strong>, the social st<strong>at</strong>us of women is inferior to men. The wellbeing of the males<br />
is emphasized. When resources are limited, the nutrition and educ<strong>at</strong>ion of the<br />
daughters are neglected. Finding a job without educ<strong>at</strong>ion is almost impossible, which<br />
makes women economically dependent on their husbands. All the family assets belong<br />
to the man, making it possible for him to spend money on prostitutes and mistresses.<br />
Even if a woman knows th<strong>at</strong> her husband is unfaithful, it is extremely difficult for her<br />
to divorce him because her parents might have to pay back the dowry to the family of<br />
the husband. The husbands are well aware of this and many of them take the<br />
opportunity to abuse their power. Sometimes a woman can ask rel<strong>at</strong>ives or church<br />
leaders to help her convincing the husband to be faithful and take care of his family. If<br />
he refuses to listen to them, there is very little she can do to change the situ<strong>at</strong>ion. One<br />
of the informants said th<strong>at</strong> finding a good husband in <strong>Tanzania</strong> is like winning in a<br />
31
lottery and she thanks God every day for giving her a faithful man. When a couple<br />
gets married they usually do not know each other very well and after a few months the<br />
problems may start. While d<strong>at</strong>ing, the woman has a right to turn down her boyfriends<br />
requests for sex, but after marriage she has no right to say no to her husband. Nor does<br />
she have the right to criticize or question him in any way. Because of this, some<br />
women chose not to get married <strong>at</strong> all.<br />
Polygamy occurs, but only the man is allowed to have several spouses. It still happens<br />
th<strong>at</strong> a man inherits the wife of a deceased brother. If a woman fails to give her<br />
husband children he is allowed to take a second wife. This custom is more common<br />
among uneduc<strong>at</strong>ed. Even so, one of the informants told us th<strong>at</strong> her f<strong>at</strong>her, who is a<br />
doctor, is a polygamist.<br />
The local council in <strong>Ilembula</strong> recently dealt with the following case:<br />
A man who had been working in another part of the country for two years returned to<br />
his wife. She asked him to take an <strong>HIV</strong> test before they started any kind of intim<strong>at</strong>e<br />
life again, but he refused. In response to this, the woman kept a knife in her bed,<br />
thre<strong>at</strong>ening to injure her husband if he touched her. Finally, the man agreed to be<br />
tested. He was found to be <strong>HIV</strong> positive and the woman said she would never have<br />
sexual intercourse with him again, unless he used a condom. The issue was brought up<br />
for discussion <strong>at</strong> the local council, which concluded th<strong>at</strong> the woman was right. The<br />
man refused to accept this, insisting th<strong>at</strong> his wife should obey him and fulfil all his<br />
wishes. Eventually the wife divorced him.<br />
The informant who discussed this case with us said th<strong>at</strong> it clearly illustr<strong>at</strong>es how little<br />
respect some men have for women, thinking th<strong>at</strong> they have a right to infect their wives<br />
with a deadly disease.<br />
Discussion<br />
Validity of the results<br />
This study was carried out by means of both questionnaires and interviews. These methods<br />
sometimes provided us with contradicting inform<strong>at</strong>ion.<br />
The credibility of this project depends to some extent on the number of questionnaires and<br />
interviews. In spite of reminders, most of the health care workers didn’t turn their<br />
questionnaires in. It was also very difficult to find participants to the interviews and of those<br />
who made appointments, only a small share turned up. In conflict with the results of the<br />
questionnaires, this could indic<strong>at</strong>e th<strong>at</strong> <strong>HIV</strong> is still a subject th<strong>at</strong> people would r<strong>at</strong>her not talk<br />
about. Common explan<strong>at</strong>ions for failing to come were difficulties with English and<br />
forgetfulness. Another reason was th<strong>at</strong> we conducted some interviews in our guest house and<br />
the students were not allowed to go outside school without a teacher’s permission.<br />
Unfortun<strong>at</strong>ely, we didn’t receive th<strong>at</strong> inform<strong>at</strong>ion until the end of our stay. One reason why<br />
the questionnaires came out misleading could be th<strong>at</strong> the hospital rules are very restrictive<br />
when it comes to the sexual behaviour of staff and students. Some might have been anxious<br />
about this, doubting the anonymity of the survey. Another source of error is the fact th<strong>at</strong> few<br />
health care workers returned the questionnaires. There is a risk th<strong>at</strong> those who know they have<br />
risky habits were particularly reluctant to particip<strong>at</strong>e.<br />
32
Those who came for interviews were very open and willing to discuss the m<strong>at</strong>ter, but we<br />
noticed th<strong>at</strong> in order to gain inform<strong>at</strong>ion, we had to bring up the topics in a general way,<br />
avoiding questions th<strong>at</strong> would point out the informant in person. We got the feeling th<strong>at</strong> some<br />
of the informants thought th<strong>at</strong> the aim of the project was to lecture people and tell them how<br />
they should live. The participant often claimed th<strong>at</strong> his/her behaviour was very moral but th<strong>at</strong><br />
other peoples’ wasn’t. Of course, it is very difficult for us to determine whether the behaviour<br />
of the participants differs from th<strong>at</strong> of people in general, but most of the health care workers<br />
and students believed th<strong>at</strong> there were few differences.<br />
Most of the participants were well-educ<strong>at</strong>ed women with Christian believes. Even though they<br />
had a gre<strong>at</strong> experience in taking care of the people in the village, their background and<br />
different set of values may have made them misinterpret the behaviour and <strong>at</strong>titudes of the<br />
average <strong>Ilembula</strong>n person. We also believe th<strong>at</strong> some important details may have been lost,<br />
not only because the interviews were conducted in English but also because of our different<br />
values and beliefs.<br />
We also lack inform<strong>at</strong>ion about the males’ situ<strong>at</strong>ion from their own perspectives.<br />
Knowledge and spread of <strong>HIV</strong><br />
When comparing the results of our questionnaires to those of a survey conducted on pregnant<br />
women <strong>at</strong> ILH in 2002, the differences are surprisingly small. From a general point of view,<br />
the people of <strong>Ilembula</strong> have good knowledge of <strong>HIV</strong>/AIDS. [16] In spite of this, many of the<br />
informants believe th<strong>at</strong> <strong>HIV</strong> is spreading by kisses. A few of them had commented on the<br />
questionnaires th<strong>at</strong> kisses may give you <strong>HIV</strong> if both partners have a wound in their mouth.<br />
We don’t know the number of informants who thought th<strong>at</strong> kissing “without complic<strong>at</strong>ions”<br />
could transmit the virus.<br />
When it comes to the spread of <strong>HIV</strong>, ignorance and lack of educ<strong>at</strong>ion were believed to add to<br />
the problem. Still, few informants thought there were any differences between educ<strong>at</strong>ed and<br />
uneduc<strong>at</strong>ed people. This means th<strong>at</strong> there is a link missing between knowledge and behaviour.<br />
One of the clinical officers described this phenomenon in a very illustr<strong>at</strong>ive way: People<br />
know, but they don’t have the will to know. As long as the leading classes of the society are<br />
reluctant to alter their lifestyle, it will be very difficult to change the behaviour of the lot. It is<br />
a discomforting fact th<strong>at</strong> many teachers have died of AIDS, since they serve as role models<br />
for large numbers of children.<br />
Next to all of the informants mentioned alcohol <strong>at</strong> some point during the interviews. Drinking<br />
is believed to be highly associ<strong>at</strong>ed with indulgent sexual behaviour. The informants claimed<br />
th<strong>at</strong> intoxic<strong>at</strong>ion makes people forget all restrictions. We do not know if any survey has<br />
shown a rel<strong>at</strong>ion between abuse of alcohol and <strong>HIV</strong> infection, but we believe th<strong>at</strong> this could<br />
be the case.<br />
Another probable reason is poverty. The so called Mandela Study has found a correl<strong>at</strong>ion<br />
between <strong>HIV</strong> and socio-economic st<strong>at</strong>us in South Africa [17]. One reason could be th<strong>at</strong><br />
poverty may lead to prostitution. Far from all of the women th<strong>at</strong> are selling sexual favours are<br />
seen as prostitutes by others, and don’t get paid for sexual intercourse regularly. Sometimes<br />
trading sex for money also occurs within the rel<strong>at</strong>ionship. This quot<strong>at</strong>ion is taken from “Sex<br />
and <strong>HIV</strong> in the city economy of desire in urban <strong>Tanzania</strong>: “ For most <strong>Tanzania</strong>n men the aim<br />
33
of having a girlfriend is to s<strong>at</strong>isfy their sexual desires and for most <strong>Tanzania</strong>n girls having a<br />
boyfriend is to get help for their basic needs. Th<strong>at</strong>’s why most girls prefer men who have<br />
enough money.” [18]<br />
It seems like people choose to apply only certain recommend<strong>at</strong>ions, rejecting others. For most<br />
persons with medical educ<strong>at</strong>ion, some of the rumours about condoms should seem highly<br />
unreasonable. Still, some people choose to believe in them. This is disquieting in many<br />
aspects. The best way of stopping the spread of <strong>HIV</strong> among sexually active individuals is to<br />
recommend the use of condoms. If the hospital employees do not trust condoms, it might be<br />
difficult for them to convey this message to the p<strong>at</strong>ients. We are also concerned th<strong>at</strong> older<br />
nurses and midwives might transfer their neg<strong>at</strong>ive <strong>at</strong>titude towards condoms to students, who<br />
look up to experienced personnel.<br />
People also seem to listen to the church authorities when they say th<strong>at</strong> condoms are sinful, but<br />
they are still reluctant to abstain from sex until marriage. Students learn <strong>at</strong> school th<strong>at</strong><br />
condoms are far from always safe but even if they chose to believe th<strong>at</strong> a condom would<br />
protect them from <strong>HIV</strong>, they are not allowed to buy or keep them. When young individuals<br />
decide to have sexual intercourse it may be best if they don’t do this in secret. If people are<br />
more open about sex, the adults will have a chance to guide the youngsters in how to protect<br />
themselves. Many Christian ideals, such as honesty, generosity and self-sacrifice are<br />
consistent with the traditional culture and therefore easily incorpor<strong>at</strong>ed in the modern<br />
lifestyle. When traditions and Christian values collide, people randomly choose wh<strong>at</strong> suits<br />
them best.<br />
Common words and expressions used when the informants talked about sexual behaviour<br />
were “desire” and “human needs”. Still people are forced to pretend th<strong>at</strong> unmarried hospital<br />
employees and adult students can be made celib<strong>at</strong>es. The informants told th<strong>at</strong> a person usually<br />
starts sexual activities between 12-20 years of age. We think this gives a reason to assume th<strong>at</strong><br />
some of the students and health care workers are breaking the rules.<br />
A clear majority of the participants felt th<strong>at</strong> they had received enough inform<strong>at</strong>ion on how to<br />
protect themselves against <strong>HIV</strong>, but they still felt uneasy because the resources and routines<br />
of the hospital are inadequ<strong>at</strong>e. Circumstances sometimes force them into situ<strong>at</strong>ions where they<br />
are <strong>at</strong> risk of being infected.<br />
Behaviour, traditions and beliefs.<br />
Our impression of the <strong>Ilembula</strong> community is th<strong>at</strong> people usually help each other and share<br />
the burdens. For this reason, it is hard to understand why many individuals don’t feel any<br />
moral responsibility for the health and wellbeing of others. The informants agreed th<strong>at</strong><br />
deliber<strong>at</strong>ely infecting another person is not acceptable. Nevertheless, most of them believed it<br />
is common. Some people seem to have a f<strong>at</strong>alistic view of life, believing th<strong>at</strong> the future is<br />
predestined and impossible to change. Others simply believe th<strong>at</strong> accidents could occur <strong>at</strong><br />
anytime anyway. Hence there is no way of escaping one’s destiny or protecting others from<br />
theirs. This philosophy can also be traced in people’s lack of hope for the future. AIDS is a<br />
disease th<strong>at</strong> can be prevented, but people do not think it is possible to do this. This pessimism<br />
is seen in the overestim<strong>at</strong>ion of the number of infected people in the area. More than fifty<br />
percent believed the r<strong>at</strong>e of infection to be 25% or higher. St<strong>at</strong>istics made <strong>at</strong> the hospital has<br />
shown th<strong>at</strong> the accur<strong>at</strong>e number is about 15-20%.<br />
34
The stigma associ<strong>at</strong>ed with <strong>HIV</strong> makes it impossible to cre<strong>at</strong>e an open <strong>at</strong>mosphere were<br />
infected individuals are fully accepted. A survey on this topic performed in South Africa has<br />
shown th<strong>at</strong> AIDS rel<strong>at</strong>ed stigmas are socially and culturally pervasive. According to this<br />
survey, 26% of the respondents would not be willing to share a meal with a person living with<br />
AIDS and 18% were unwilling to sleep in the same room as someone who has AIDS [19].<br />
Another survey carried out in Dar es Salaam has shown th<strong>at</strong> women often choose not to<br />
disclose their <strong>HIV</strong> st<strong>at</strong>ues because of fear of a violent reaction by male partners [20].<br />
Globally, it is easy to find a connection between high prevalence of <strong>HIV</strong> and low st<strong>at</strong>us of<br />
women. The informants were well aware of this and listed a number of problems rel<strong>at</strong>ed to the<br />
subordin<strong>at</strong>ing of women. We saw a tendency to rebel these traditions among both older and<br />
younger women. For example, some of them said th<strong>at</strong> they refuse to get married because they<br />
don’t want a man in their lives. Others simply submit to the traditions. It is reassuring th<strong>at</strong><br />
even the men identified the inferiority of women as an undesirable part of the culture, since<br />
acknowledging a problem is the first step towards a change. There are numerous customs and<br />
beliefs th<strong>at</strong> need to be evalu<strong>at</strong>ed and abolished and most of them rel<strong>at</strong>e to women directly or<br />
indirectly. The present situ<strong>at</strong>ion, where men can afford to pay for sexual favours and women<br />
cannot afford to say no, should never be accepted. In Mwalimwa in northern <strong>Tanzania</strong>, efforts<br />
to change unproductive traditions have shown encouraging results. The village council have<br />
cracked down on a variety of traditional, social and sexual practices th<strong>at</strong> have made the area a<br />
breeding ground for <strong>HIV</strong>. A survey indic<strong>at</strong>es th<strong>at</strong> 38% of the residents see safer behaviour in<br />
their villages and teachers report a decline in pregnancies among schoolgirls. [21]<br />
There is a general resistance to testing oneself for <strong>HIV</strong>. Our impression is th<strong>at</strong> the main reason<br />
for this is the fear th<strong>at</strong> worry and depression will cause an early de<strong>at</strong>h. In present day<br />
<strong>Tanzania</strong>, a positive blood test is the same as a de<strong>at</strong>h sentence. Therefore, most people who<br />
know they are living a risky life prefer not knowing. This is extremely unfortun<strong>at</strong>e, because it<br />
means th<strong>at</strong> a large number of individuals are unknowing of the fact th<strong>at</strong> they are spreading the<br />
virus. Antiviral therapy could increase the interest for voluntary testing. If combined with<br />
proper and efficient counselling, this could be a way of limiting the spread. It is believed th<strong>at</strong><br />
counselling would make people responsible and willing to protect others from the disease.<br />
This opinion is supported by a survey conducted in Kenya, <strong>Tanzania</strong> and Trinidad. [22]<br />
The problem is th<strong>at</strong> only the people th<strong>at</strong> are thinking about taking an <strong>HIV</strong> test are counselled.<br />
These individuals have in one way already made a decision. We believe it’s necessary to<br />
make efforts to reach out to the people th<strong>at</strong> are far from convinced.<br />
When compiling the results of the questionnaires, we noticed th<strong>at</strong> economy and profession of<br />
the parents did not influence the answers. The difference between second and fourth year<br />
students was also small, which could indic<strong>at</strong>e th<strong>at</strong> the students already have good knowledge<br />
of <strong>HIV</strong> when they start studying <strong>at</strong> the nursing school. This hints th<strong>at</strong> the primary and<br />
secondary schools have been successful in conveying the inform<strong>at</strong>ion. A majority of the<br />
informants received their first inform<strong>at</strong>ion about <strong>HIV</strong> from school. Since the school seems to<br />
reach out to a lot of people, perhaps it could be a tool in changing the <strong>at</strong>titudes towards <strong>HIV</strong><br />
and protection from <strong>HIV</strong>.<br />
The traditional healers are sometimes worsening the situ<strong>at</strong>ion. One of the main problems is<br />
th<strong>at</strong> some of them make people believe th<strong>at</strong> <strong>HIV</strong> can be cured. If people believe them, they<br />
are probably less interested in protecting themselves.<br />
35
Uganda was often described as a possible role model for <strong>Tanzania</strong>. According to a survey<br />
performed by the US Agency for Intern<strong>at</strong>ional Development, the reasons for the successive<br />
reduction of <strong>HIV</strong> in Uganda include making it a p<strong>at</strong>riotic duty to inform others about one’s<br />
<strong>HIV</strong> st<strong>at</strong>us, using well known faces and celebrities to reduce the stigma empowering of<br />
women by giving them more political voice, and making religious leaders active in the<br />
response to the epidemic. [23] We see no reason why this should not be implemented in<br />
<strong>Tanzania</strong>.<br />
Many of the reasons numbered up are connected with each other. Lack of educ<strong>at</strong>ion leads to<br />
difficulties in getting a job, leading to poverty, leading to prostitution… Addressing one of<br />
the problems could have many possible side effects.<br />
Conclusions<br />
• The healthcare workers <strong>at</strong> ILH and the students of INMTS have good knowledge of<br />
<strong>HIV</strong>/AIDS.<br />
• There are misconceptions about condoms, even among people with medical educ<strong>at</strong>ion.<br />
• Educ<strong>at</strong>ion and knowledge of the disease do not guarantee abolition of risk behaviour.<br />
• People are still reluctant to test themselves for <strong>HIV</strong>.<br />
• Local customs, abuse of alcohol and the inferiority of women facilit<strong>at</strong>e the spread of<br />
the virus.<br />
• Poverty is making the fight against <strong>HIV</strong> more complic<strong>at</strong>ed. Jobs to uneduc<strong>at</strong>ed people<br />
or scholarships would probably make a difference.<br />
• The hospital needs more resources to protect the staff from infection. Gre<strong>at</strong>er access to<br />
gloves would make the situ<strong>at</strong>ion considerably better.<br />
• Church traditions and hospital rules are sometimes counterproductive.<br />
• Measures needed to improve the situ<strong>at</strong>ion include strengthening of the laws<br />
concerning <strong>HIV</strong>, empowering of women, reduction of the stigma, actions against<br />
poverty and changing neg<strong>at</strong>ive aspects of the culture.<br />
Acknowledgements<br />
We wish to thank Professor Rune Andersson for making this study possible and for his<br />
invaluable assistance with the revision of the m<strong>at</strong>erial. We also thank his secretaries<br />
Lisbeth Jinnestål-Fernow and Anna-Lena Loft-Eriksson for helping us with the layout of<br />
the questionnaire.<br />
We also express our sincere gr<strong>at</strong>itude to Dr Willis Temihango and Principal Alifa<br />
Lupende, who were willing to share their experience and knowledge with us.<br />
We would also like to thank the m<strong>at</strong>ron, who helped us carrying out the collection of<br />
inform<strong>at</strong>ion and the treasurer, who very kindly lent us his personal computer. Special<br />
thanks go to Aida, the nurse in charge of the home based care, who introduced us to her<br />
work.<br />
We also want to thank Dr Leena Pasanen for her pleasant aerobics classes and Ulla Kagali<br />
for the lovely tea breaks <strong>at</strong> her veranda. We gr<strong>at</strong>efully acknowledge Rehema Mgimba for<br />
her helpful guidance, transl<strong>at</strong>ions and general assistance.<br />
36
In addition to this, we thank all the hospital employees, students, the village chairman, the<br />
evangelist and the traditional healer, who particip<strong>at</strong>ed in the study.<br />
Appendix<br />
Questions asked during the interviews<br />
<strong>HIV</strong> in general<br />
• Wh<strong>at</strong> do you think are the reasons why <strong>HIV</strong> is still spreading so rapidly?<br />
• Do people usually want to know if they are <strong>HIV</strong> positive or not? How about you?<br />
• Wh<strong>at</strong> do you think can be done to prevent the spread of <strong>HIV</strong>? Wh<strong>at</strong> about the future?<br />
• Why is <strong>HIV</strong> stigm<strong>at</strong>ized?<br />
Family and friends<br />
• Is it difficult for a person to tell rel<strong>at</strong>ives and partners th<strong>at</strong> (s)he is infected with <strong>HIV</strong>?<br />
• Do the families usually take care of rel<strong>at</strong>ives suffering from AIDS?<br />
<strong>HIV</strong> <strong>at</strong> work<br />
• Do you sometimes feel <strong>at</strong> risk of getting <strong>HIV</strong> <strong>at</strong> work? How do you protect yourself?<br />
• When employees <strong>at</strong> the hospital accidentally prick themselves with a dirty needle,<br />
wh<strong>at</strong> do they usually do?<br />
• Do <strong>HIV</strong> infected persons usually take precautions not to transmit the disease to others?<br />
Sexual behaviour<br />
• At wh<strong>at</strong> age do people usually start having sexual intercourse?<br />
• Do people in general have sexual intercourse before marriage/ outside marriage?<br />
• Wh<strong>at</strong> do people think about condoms? Do people know how to use them?<br />
Culture and religion<br />
• Do people believe in traditional healers? Do they think th<strong>at</strong> the healers can cure <strong>HIV</strong>?<br />
• When it comes to <strong>HIV</strong>, are there any differences between:<br />
Educ<strong>at</strong>ed and uneduc<strong>at</strong>ed?<br />
Rich and poor?<br />
Christian and non-Christians?<br />
Men and women?<br />
37
Questionnaire<br />
Thank You for taking part in this study about <strong>HIV</strong>/AIDS. All inform<strong>at</strong>ion will be tre<strong>at</strong>ed as<br />
strictly confidential. Some of the questions are of a r<strong>at</strong>her personal character. We hope th<strong>at</strong><br />
this won’t make it difficult for you to answer the questions.<br />
General questions:<br />
1. Age<br />
2. Sex<br />
3. Profession (if student, please specify wh<strong>at</strong> you are studying)<br />
4. Profession of your parents?<br />
5. Marital st<strong>at</strong>us (married, single, boyfriend/girlfriend)<br />
6. Do you have children? If yes, how many?<br />
7. How many people are there in your household?<br />
8. Wh<strong>at</strong> is your religion?<br />
9. How often do you <strong>at</strong>tend religious services? Please mark the best option:<br />
Several times a week<br />
Once a week<br />
Once or a couple of times a month<br />
Once or a few times a year<br />
Never<br />
10. Do you see yourself as a member of a special ethnical group? If yes, please specify:<br />
11. If you were to grade your economical situ<strong>at</strong>ion, how would you classify it? Please<br />
mark the best option:<br />
Very poor<br />
Poor<br />
Average<br />
Good<br />
Very good<br />
Questions about <strong>HIV</strong>/AIDS:<br />
12. How did you first hear about <strong>HIV</strong>/AIDS? (e.g. from a friend, in school etc.)<br />
13. In wh<strong>at</strong> ways do you think <strong>HIV</strong>/AIDS is spread from one person to another? Please<br />
mark all the options you think are correct:<br />
E<strong>at</strong>ing or drinking from the same pl<strong>at</strong>es and cups?<br />
Shaking hands/hugging/living in the same house?<br />
Caring for/washing/changing clothes for someone who has AIDS?<br />
Kissing<br />
Having sexual contact<br />
Injecting narcotic drugs<br />
Breast feeding<br />
From mother to child during pregnancy or delivery<br />
By mosquitoes<br />
Other way<br />
14. Is there a medicine th<strong>at</strong> can cure <strong>HIV</strong>/AIDS? If yes, please describe in short terms<br />
wh<strong>at</strong> you know about th<strong>at</strong>:<br />
15. Is there any way to cure <strong>HIV</strong>/AIDS?<br />
38
16. Do you know if any special groups are more often infected with <strong>HIV</strong>/AIDS than<br />
others? If yes, please specify:<br />
17. Wh<strong>at</strong> do you think is the r<strong>at</strong>e of <strong>HIV</strong>/AIDS infection among adults in the area where<br />
you live? (For example 1/10, 1/1000)<br />
18. If you were found to have <strong>HIV</strong> in your blood, how many years do you think you<br />
would live without medicine? With medicine?<br />
19. Wh<strong>at</strong> do you think are the reasons why <strong>HIV</strong>/AIDS has spread so rapidly?<br />
20. Are there any differences between <strong>HIV</strong> and AIDS? If yes, please specify:<br />
Professional situ<strong>at</strong>ion:<br />
21. Do you think th<strong>at</strong> you have received sufficient inform<strong>at</strong>ion about how to protect<br />
yourself and others from <strong>HIV</strong>/AIDS <strong>at</strong> work? If no, why not?<br />
22. Do you think th<strong>at</strong> the routines for preventing the spread of <strong>HIV</strong>/AIDS <strong>at</strong> your hospital<br />
are sufficient? If no, why not?<br />
23. At work, are there any specific situ<strong>at</strong>ions in which you feel th<strong>at</strong> you are <strong>at</strong> risk of<br />
getting infected with <strong>HIV</strong>/AIDS? If yes, please specify:<br />
24. At work, wh<strong>at</strong> do you do to protect yourself from getting infected with <strong>HIV</strong>/AIDS?<br />
25. Are you worried th<strong>at</strong> you will get infected with <strong>HIV</strong>/AIDS <strong>at</strong> work? If yes, why?<br />
26. Do you inform your p<strong>at</strong>ients about <strong>HIV</strong>/AIDS? If yes, in wh<strong>at</strong> way?<br />
27. Do you think the inform<strong>at</strong>ion you give your p<strong>at</strong>ients has an impact on their way of<br />
living? If yes, in wh<strong>at</strong> way? If no, why not?<br />
28. Is it possible for your p<strong>at</strong>ients to follow the advice you give them? Why, why not?<br />
Priv<strong>at</strong>e life:<br />
29. Do you have any friends or rel<strong>at</strong>ives th<strong>at</strong> are infected with <strong>HIV</strong>/AIDS? If yes, how<br />
many?<br />
30. Wh<strong>at</strong> do you do to protect yourself against <strong>HIV</strong>/AIDS?<br />
31. With whom can you talk about <strong>HIV</strong>/AIDS?<br />
Mother<br />
F<strong>at</strong>her<br />
Other rel<strong>at</strong>ive/s/<br />
Partner/<br />
Friend/s/<br />
Co-worker/s/<br />
32. If a person wants to have sex with you, is it sometimes difficult to say no? If yes,<br />
when and why?<br />
33. When you meet a new partner, do you usually ask him/her to test for <strong>HIV</strong>/AIDS<br />
before you start a sexual rel<strong>at</strong>ionship? Why/ Why not?<br />
34. How many sexual partners have you had?<br />
35. Are your sexual partners men, women, both?<br />
36. If your partner does not want to use a condom, wh<strong>at</strong> is your response? Please mark the<br />
best option:<br />
It doesn’t m<strong>at</strong>ter to me<br />
I refuse to have sex with him/her<br />
I try to convince him/her th<strong>at</strong> we should use a condom<br />
I break up with him/her<br />
Other altern<strong>at</strong>ive<br />
37. In general, who decides whether if to use a condom or not?<br />
39
The man………………Why?<br />
The woman……………Why?<br />
Both…………………...Why?<br />
38. Have you had sexual contact with prostitutes?<br />
39. If you were found to have <strong>HIV</strong> in your blood, who would you inform?<br />
Partner<br />
Parent/s.<br />
Other rel<strong>at</strong>ive/s/<br />
Friend/s/<br />
Co-worker/s/<br />
P<strong>at</strong>ient/s/<br />
Other<br />
40. If you were found to have <strong>HIV</strong> in your blood, would you still want to have<br />
children/more children?<br />
Interwiev with Willis Temihango, doctor in charge <strong>at</strong> <strong>Ilembula</strong> <strong>Lutheran</strong><br />
<strong>Hospital</strong><br />
Willlis Temihango has been the doctor in charge <strong>at</strong> <strong>Ilembula</strong> Hostipal for 3 years. Since he<br />
started working, he has seen the number of <strong>HIV</strong> infections increase. He believes th<strong>at</strong> the three<br />
most important factors th<strong>at</strong> contribute to the spread are negligence, poverty and local culture.<br />
In particular there are some traditions th<strong>at</strong> are making the comb<strong>at</strong> against <strong>HIV</strong>/AIDS more<br />
difficult. For example all the family assets belong to the husband or the male family members.<br />
The husband is also the head of the family and makes all the decisions. Daughters are set<br />
behind sons and if there is not enough money to educ<strong>at</strong>e all the children, the girls are kept <strong>at</strong><br />
home. Malnutrition is also more common among girls. This makes poverty a huge problem<br />
among women, sometimes forcing them into prostitution.<br />
Polygamy still occurs, but the spouses don’t always stay within the boundaries of the<br />
marriage. There is also a tradition of marrying the husband or wife of a deceased sibling. As<br />
long as the partner of the deceased person looks healthy and f<strong>at</strong> (s)he is generally not believed<br />
to be infected with <strong>HIV</strong>.<br />
Another tradition th<strong>at</strong> makes the situ<strong>at</strong>ion complic<strong>at</strong>ed is the belief in traditional healers.<br />
People often trust them even when they claim th<strong>at</strong> they can cure <strong>HIV</strong>. There is also a<br />
tendency to believe in destiny or the will of God. Since most of the people think th<strong>at</strong> they<br />
cannot influence the future, they just live for today without making plans for tomorrow.<br />
According to the <strong>Tanzania</strong>n culture, love and sex do not always belong together. Sex is just a<br />
release of urge and you don’t have to have warm feelings for your sexual partners. People<br />
often get married for other reasons than love. Popular <strong>at</strong>tributes are beauty and wealth. If the<br />
circumstances change, they feel free to look for partners elsewhere. It is not uncommon to<br />
visit prostitutes, particularly <strong>at</strong> bars. Since men usually prefer unprotected sexual intercourse,<br />
a prostitute who wants to use a condom may earn only a fifth of the price she would get<br />
without one. The majority of their customers are drivers, military people and policemen who<br />
all feel th<strong>at</strong> they are <strong>at</strong> risk of dying soon. For them, a disease th<strong>at</strong> will kill you in<br />
approxim<strong>at</strong>ely 10 years does not seem very thre<strong>at</strong>ening.<br />
Sometimes those who are infected with <strong>HIV</strong> try to infect as many others as possible to avoid<br />
40
dying alone. When counselling p<strong>at</strong>ients Dr Temihango has a trick to prevent them from<br />
spreading the disease. He tells them th<strong>at</strong> in order to stay healthy they have to practise safe sex<br />
or abstinence; otherwise they will c<strong>at</strong>ch other sexually transmitted diseases, which will<br />
weaken their immunity. Simply telling people th<strong>at</strong> they should avoid infecting others is<br />
useless. If the antiviral drugs become available the entire African continent will get<br />
uncontrollable, because people will stop taking any preventive measures <strong>at</strong> all.<br />
Dr Temihango is somewh<strong>at</strong> disappointed th<strong>at</strong> <strong>HIV</strong> has spread so rapidly in spite of all the<br />
efforts th<strong>at</strong> have been made to inform people. Sometimes he feels th<strong>at</strong> it would be better if the<br />
incub<strong>at</strong>ion period of the disease was much shorter, so th<strong>at</strong> people could see a connection<br />
between behaviour and de<strong>at</strong>h in AIDS. But he also emphasises th<strong>at</strong> nobody knows wh<strong>at</strong> the<br />
situ<strong>at</strong>ion would be like if there were no intervention programs <strong>at</strong> all.<br />
To illustr<strong>at</strong>e how hard it could be for certain individuals to protect themselves from <strong>HIV</strong>, Dr<br />
Temihango told the following story:<br />
Once when he held a seminar in a village one of the women in the audience asked him:<br />
-Can you tell me, for how long can a person live with <strong>HIV</strong>?<br />
He answered:<br />
-If you take good care of yourself you can live for up to ten years.<br />
-And for how long can you live without any food?<br />
-You can’t live without food for a very long time.<br />
Then the woman said:<br />
-I have four children and I pay their food, clothes and school fees by myself. The only way I<br />
can do this is by selling local alcohol and my body. So wh<strong>at</strong> should I choose; th<strong>at</strong> we all die<br />
next month or th<strong>at</strong> I die in ten years when my children are grown and can support themselves?<br />
Interview with Alifa Lupende, principal of INMTS<br />
Alifa Lupende has a degree in nursing, but is now in charge of the INMTS. At present, there<br />
are 104 students and four teachers <strong>at</strong> the school. Even the principal herself is teaching.<br />
While studying <strong>at</strong> the school, the students have to follow some specific rules. Some of them<br />
are very strict and Mrs Lupende is well aware th<strong>at</strong> the rules are not always followed. For<br />
example some students make up stories to be able to leave the school area. The students are<br />
allowed to have boyfriends, but they cannot show any signs of affection in public. The<br />
principal is certain th<strong>at</strong> most of them have boyfriends; otherwise they would be very different<br />
from other women in their age. She tries to give them advice in order to help them staying out<br />
of trouble. The students are encouraged to test themselves for <strong>HIV</strong>. Mrs Lupende also tells<br />
them th<strong>at</strong> a good boyfriend will wait for them and th<strong>at</strong> <strong>HIV</strong> is not spread by kissing.<br />
She does not advice the students to use condoms since they are not safe and tells them th<strong>at</strong><br />
some men will purposely make small holes in the condom to infect their partners with <strong>HIV</strong>.<br />
She has noticed th<strong>at</strong> since the use of condoms has increased the number of <strong>HIV</strong> infections has<br />
also been growing. However the students are supposed to teach the p<strong>at</strong>ients th<strong>at</strong> come for<br />
family planning about condoms.<br />
Mrs Lupende claims th<strong>at</strong> <strong>HIV</strong> is an important part of the educ<strong>at</strong>ion and she tries to mention it<br />
as often as possible while teaching. There is also a recommend<strong>at</strong>ion from the ministry of<br />
41
educ<strong>at</strong>ion th<strong>at</strong> the school should show a film on <strong>HIV</strong> <strong>at</strong> least once every three month or<br />
whenever necessary.<br />
Since the school has such a good reput<strong>at</strong>ion, the students will face no difficulties to find a job<br />
after gradu<strong>at</strong>ing.<br />
Interview with one of the evangelists of the <strong>Lutheran</strong> Church of <strong>Ilembula</strong><br />
According to the evangelist, the church is aware of the problems rel<strong>at</strong>ed to <strong>HIV</strong> and tries to<br />
take an active part in the fight against the virus. For example the church has held two<br />
seminars on <strong>HIV</strong> last year. More than 40 people <strong>at</strong>tended the seminars. The key message from<br />
the church authorities is to abstain from sexual intercourse before marriage, to test for <strong>HIV</strong><br />
before marriage and to stay faithful.<br />
Extramarital sex and infidelity are forbidden in the Bible, but the evangelist is aware th<strong>at</strong> this<br />
occurs even among Christians. In spite of this, he cannot as a church authority advice people<br />
to use condoms, since this would encourage them to break the rules of the religion.<br />
The evangelist doesn’t see <strong>HIV</strong> as a punishment from God and infected people are welcome<br />
to take part in the church activities. The church also tries to support them, morally and<br />
spiritually. For example the church gives counselling to infected people and school uniforms<br />
to orphans whose parents died from AIDS.<br />
Interview with the chairman of <strong>Ilembula</strong><br />
The present chairman of <strong>Ilembula</strong> village has been <strong>at</strong> his position since 1995, but was selected<br />
by the people in the year of 2000. In his area there are approxim<strong>at</strong>ely 2500 inhabitants. He<br />
knows most of them personally since its common th<strong>at</strong> the inhabitants of <strong>Ilembula</strong> stay in the<br />
village where they have grown up.<br />
His foremost work is to do justice between the villagers and to make sure th<strong>at</strong> the daily living<br />
is working out as it should. He claims th<strong>at</strong> the most common reasons of fighting are alcohol<br />
and disagreements about the boundaries or the farms. He is co-oper<strong>at</strong>ing with the veo, a<br />
government employee, who functions as a policeman.<br />
When discussing the <strong>HIV</strong>/AIDS issue, the chairman says th<strong>at</strong> he doesn’t know the extent of<br />
the problem is in the village. The villagers themselves would not take the initi<strong>at</strong>ive to discuss<br />
this subject. According to the chairman, the people in the village are aware of <strong>HIV</strong> and its<br />
risks, but he thinks th<strong>at</strong> more needs to be done. He is trying to give inform<strong>at</strong>ion and advice<br />
when <strong>at</strong>tending funerals and other ceremonies. He advises the villagers to be faithful and<br />
abstain from sexual intercourse before marriage or use condoms. He has seen th<strong>at</strong> the shops<br />
are making big business by selling condoms but he asks himself if they are really getting used.<br />
When it comes to <strong>HIV</strong>/AIDS, the Chairman does not feel th<strong>at</strong> he gets any support from the<br />
government. Instead the village gets aid and assistance from others, for example the American<br />
organiz<strong>at</strong>ion IDYDC. In July this year, they educ<strong>at</strong>ed the leaders of the village and other<br />
people with influence with the aim th<strong>at</strong> they could spread the inform<strong>at</strong>ion about <strong>HIV</strong> and<br />
family planning among the villagers of <strong>Ilembula</strong>.<br />
He does not think th<strong>at</strong> the stigm<strong>at</strong>is<strong>at</strong>ion of <strong>HIV</strong>/AIDS is the biggest problem. The key<br />
problem is th<strong>at</strong> people do not believe in the disease. Most of the people who are found to be<br />
<strong>HIV</strong> positive ask a witchdoctor to help them finding out why they got the disease. Sometimes<br />
42
the witchdoctor accuses a person of cursing the <strong>HIV</strong> infected or concludes th<strong>at</strong> the infected<br />
person has <strong>at</strong>tracted the disease by breaking a taboo. In some way these beliefs can help the<br />
infected. If the family thinks th<strong>at</strong> (s)he got the disease because of a curse, it’s not as shameful<br />
and they do not see any risk to get the disease themselves. This means th<strong>at</strong> the infected will<br />
not become isol<strong>at</strong>ed from family and friends. However the chairman himself believes th<strong>at</strong><br />
<strong>HIV</strong> is transmitted to people without any witchcraft involved.<br />
The chairman thinks it would be easier to deal with the problem if the authorities dared to<br />
discuss the issue openly. If a person has died of AIDS it should be possible to announce th<strong>at</strong><br />
<strong>at</strong> the funeral. This would make people less inclined to approach and start sexual rel<strong>at</strong>ionships<br />
with widows and widowers whose spouses died of AIDS. Unfortun<strong>at</strong>ely some of them<br />
purposely transmit the disease to others.<br />
There are some traditions th<strong>at</strong> make the fight against <strong>HIV</strong> more difficult. Polygamy is still<br />
common, but to inherit the wife of a dead brother is no longer an established tradition.<br />
He claims th<strong>at</strong> there is no prostitution in the village, but perhaps the girls th<strong>at</strong> are selling<br />
alcohol are selling their body as well.<br />
Interview with a traditional doctor (mganga)<br />
There are approxim<strong>at</strong>ely 10 waganga working in <strong>Ilembula</strong> village. In the text below, the<br />
mganga will be referred to as Mr M.<br />
Mr M was a businessman until 1974, when he started working as a traditional doctor. He<br />
decided to change his career when his dead grandparents started appearing in his dreams,<br />
telling him recepies of medicines and concoctions to cure all kinds of illnesses. He is now<br />
running a small consulting business in his priv<strong>at</strong>e home in central <strong>Ilembula</strong>. The room where<br />
he sees his p<strong>at</strong>ients is small and dark and the floor is covered with plastic containers and<br />
boxes, where he keeps his medical herbs. In the middle on the room, there is a dried pumpkin<br />
hanging from the ceiling. He uses the pumpkin to gain inform<strong>at</strong>ion about his clients. By<br />
w<strong>at</strong>ching how it moves in the presence of the p<strong>at</strong>ient, he can tell wh<strong>at</strong> kind of disease the<br />
p<strong>at</strong>ient is suffering from and sometimes which medicine he should choose. The medicines he<br />
uses are made from plants and trees. If necessary, he can also perform venesection or make<br />
medical scars and t<strong>at</strong>toos.<br />
Every day, about 10-15 p<strong>at</strong>ients come to benefit from his expertise. The most common<br />
problems are infertility, venereal diseases and inability to find a partner. He can even cure<br />
homosexuality, which he considers to be an illness. He also removes curses and spells. If an<br />
evil spirit has entered a p<strong>at</strong>ient’s body, he has the power to drive it away. Wealthy people pay<br />
for his services, while those without money are tre<strong>at</strong>ed for free.<br />
Mr M claims he can cure all diseases except cancer, anaemia and conditions th<strong>at</strong> require<br />
surgery. He can take away <strong>HIV</strong>, if the p<strong>at</strong>ient seeks his <strong>at</strong>tention before the disease has gone<br />
too far. Those who are suffering from fully developed AIDS are beyond his ability to cure. He<br />
has tre<strong>at</strong>ed so many <strong>HIV</strong> p<strong>at</strong>ients th<strong>at</strong> he does not even know the number. Sometimes it<br />
happens th<strong>at</strong> one of his clients falls ill and dies of AIDS, but this is not because his medicines<br />
are ineffective, but because the p<strong>at</strong>ients has been reinfected after finishing the tre<strong>at</strong>ment. Mr<br />
M stresses th<strong>at</strong> his p<strong>at</strong>ients are allowed to go to the hospital to take <strong>HIV</strong> tests in order to make<br />
sure th<strong>at</strong> his medicines are working.<br />
43
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45