It is not a game : the influence of sports in raising HIV/AIDS awareness and empowerment among adolescents in Maputo, Mozambique

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Photo by Chico Carneiro

It is not a game:

The influence of Sports in raising HIV/AIDS awareness and

empowerment among adolescents in Maputo, Mozambique

Nicole Fulco de Almeida Abreu (11656506) MSc in International Development Studies

Graduate School of Social Sciences University of Amsterdam

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Graduate School of Social Sciences

Master of International Development Studies

2017-2018

Name: Nicole Fulco de Almeida Abreu

Student number: 11656506

Email:

nicole.fulco@gmail.com

Date of submission: 15-06-2018

Word Count: 24.855

Supervisor: Jacobijn Olthoff

Second Reader: Esther Miedema

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Abstract

Since 1980s, when the virus was first identified, HIV/AIDS have been seen as a difficult challenge within the field of international development and health policies, resulting in much academic research and receiving the full of attention of civil society. Several studies have focus to find alternative approaches to manage the HIV/AIDS epidemic in the African continent. However, Sports are still portrayed as vague, short-term and entertainment activities rather than processes composed of cultural, political and social aspects which enhance life skills and well-being, and can potentially bring disease awareness and empowerment.

The purpose of this research is to shed light on the capacities of Sports as alternatives to HIV/AIDS management policies by analyzing the influence of Sports-based programs in raising adolescents HIV/AIDS awareness and empowerment in Maputo, Mozambique. Through comprehensive semi-structured interviews with coaches, representatives from Sports-based organizations, health professionals, journalists, Sports experts and adolescents’ participants in the programs, this research aims to promote an understanding of the above mentioned discussion based on ethnographic fieldwork in Maputo.

Results suggest that although Sports-based programs have positive impacts on social change and in raising adolescents HIV/AIDS awareness and empowerment, they fail on developing long-term strategies to ensure the sustainable change of adolescents` behavior towards the disease. Furthermore, the findings indicate that are essential to develop bottom-up Sports-based programs which take into account concerns such as poverty and food insecurity as well as local characteristics as gender norms, culture, religion, politics, economy, education etc..

Keywords: Sport for Development; HIV/AIDS awareness; HIV/AIDS empowerment; social change

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Acknowledgement

This thesis would not have been possible without the guidance and the help of several individuals and my gratitude for their support goes beyond these lines. First and foremost, I would like to thank Dr. Jacobijn Olthoff, my supervisor. This thesis was a process of self-knowledge and her support and feedback during fieldwork and in thesis writing process made me grow as researcher and person. Secondly, I thank Dr. Esther Miedema for agreeing to be the second reader; I feel honored to have a person with her knowledge and background to evaluate my thesis.

I cannot thank all those in Mozambique enough for helping this research to come true. My gratitude to all respondents but in particular to Sténor Lucas Tomo and the staff from Right to Play and Favela United whose love for Sports has inspired me forever. Also, a special thanks to my family in Maputo who warmly welcomed me and made this experience unforgettable.

I would also like to thank my friends in Brazil and all over the world but particularly Carolina Schiller and Marcos Nunes who have been my support and source of laughs throughout the years. Special thanks go to my best friend for life, Bruna (Mozão) Torres, for always pushing me to think from another perspective, for her care and constant support despite the physical distance between us. I am grateful for having all of you in my life.

Last, but by no means least, my sincere thanks also go to all my family for their unconditional support and love during this master, no matter the distance. In particular, there are no words in any language to thank my parents, Fernando and Elizabeth, enough for always helping me to chase my dreams and believing in me even when I didn`t believe in myself. Without their unlimited support this Master and thesis would never have happened. This thesis is for you.

Finally, I want to thank everyone who was somehow part of these thesis and Master processes.

Thank you. Kanimambo. Obrigada. Nicole Abreu

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List of acronyms

AIDS Acquire Immune Deficiency Syndrome

ARV Antiretroviral (drugs)

FRELIMO Frente de Libertação de Moçambique

GoM Government of Mozambique

HIV Human Immunodeficiency Virus

ISA International Sports Alliance

MDG Millennium Development Goals

NGO Non-Governmental Organization

PBL Play-based Learning

RENAMO Resistência Nacional Moçambicana

ROOD Rede de Organizações do Desporto para o

Desenvolvimento

SDGs Sustainable Development Goals

SDP Sport for Development and Peace

SRHR Sexual and Reproductive Health and Rights

UN United Nations

UNAIDS Joint United Nations Programme on HIV & AIDS

UNESCO United Nations Educational, Scientific and Cultural

Organization

UNICEF The United Nations Children`s Fund

UNOSDP United Nations Office on Sport for Development

and Peace

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List of Figures

Figure 1: People living with HIV by region Figure 2: People newly infected with HIV

Figure 3: Dimension and relevant aspects of HIV/AIDS vulnerability Figure 4: Conceptual Scheme

Figure 5: Mozambique geopolitical map

Figure 6: Poster attached to entrance hall of secondary school in Namaacha Figure 7: Public bench in Maputo

Figure 8: Administrative Organization of Sport in Mozambique Figure 9: RODD Sport and Life Skills activities

Figure 10: RCA methodology

Figure 11: Degree of behavior change

Figure 12: Map locating Namaacha and Ilha de Inhaca

Figure 13: Photo illustrative of the Polana Caniço neighborhood Figure 14:Favela United playing field

Figure 15: Live Safe Play Safe Manual

Figure 16: Free available in the border with South Africa

Figure 17: Conceptual framework within the different influences on gender norms. Figure 18: Elements to achieve HIV/AIDS Awareness

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Chapter 1. Introduction

After a long period of literature review and theoretical discussions about development challenges, January 23th_{arrived to finally put in practice this knowledge during the} fieldwork in Mozambique. However, this day had already begun years ago for me. In fact, have grown up in a country where Sports are passion but at the same time suffers from poor investments and recognition had made me questioned why, together with more “orthodox engines” like trade and industry (Levermore, 2008), Sports are not perceived as a potential engine for development initiatives. Therefore, I decided to conduct my research on how Sports can raise adolescents HIV/AIDS awareness and empowerment. Indeed, as will be argued through the thesis, Sports are filled with social, gender and structural, to name but a few, that results in the positive and sustainable social change to develop feasible and effective policies towards decreasing HIV/AIDS epidemic. Finally, this study is a reflection of findings, experiences and discussions within Sports-based programs in order to better understand the roles of Sports towards HIV/AIDS awareness and empowerment.

1.1. Problem Statement

HIV/AIDS are contemporary, complex, and multilevel and two of the most thoroughly global diseases discussed within International Development (Colvin, 2011). Empirical evidence of 36.7 million people living with HIV/AIDS (UNAIDS,2016) is an indicative of the massive scale on which the epidemic run. Furthermore, the major causes go beyond the poor investments in the health system. Cultural, religious and economic aspects play a role in the hidden obstacles that prevents an efficient, holistic and sustainable long term reduction in HIV/AIDS cases. Apart from the common sense, teaching a young person about sex education actually delays initiation in the sexual life and increases the use of contraception- thus preventing from pregnancy, STIs and HIV (Kirby et al., 2006). In an era when traditional approaches and concepts of development are being increasingly questioned due to the deficit of local context and culture concern and the critiques on the business driven policies of aid; Sports arises as a low-cost, popular and universal trend to function as agents of social change for youth and

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by-10 products of development (Levermore, 2008). Although the theory of Sport for Development and Peace (SDP) is growing in importance, the concept of development and notion of Sports have subjective outcomes and is driven by heartfelt narratives that create barriers to recognize its role as a powerful international development tools (Hartmann & Kwauk, 2011).

1.2. Research Aim and Relevance

Sub-Saharan Africa is the worst HIV affected area in the world and contains more than a half of the global burden of HIV (UNAIDS, 2016). The goal of the Joint United Nations Programme on HIV & AIDS (UNAIDS) is to reach the 90-90-90 target. This means that by 2020, 90% of all people living with HIV should know their HIV status, 90% of all people with diagnosed HIV infection should receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy shall have viral suppression (UNAIDS, 2014). By 2030 the global community has commitments to end AIDS epidemic; ending the AIDS epidemic is more than a historic obligation, it also represents the opportunity to build a healthier and more equitable world in order to inspire development efforts, multisectoral partnerships and solidarity (UNAIDS, 2014 & UNAIDS, 2016). Additionally, more International Organizations have set agreements to ends AIDS epidemic as a public health threat by 2030-following the ambitious target of the 2030 Agenda for Sustainable Development (WHO, 2016). This people-centred and human rights-based set of targets and strategy aim to develop the health sector response to HIV and achieve universal health coverage which is one of the key targets of the Sustainable Development Goals (SDGs) (2016, p. 7). Figure 1 illustrates the asymmetry of people living with HIV by region.

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11 Figure 1: People living with HIV by region (WHO, 2016)

The HIV international policy framed by the UNAIDS goals is the Fast-Track approach which desires to increase and front-load investments in order to scale-up and establish the momentum to overcome HIV worldwide challenges (UNAIDS, 2016). The target of US$ 26 billion in investments for AIDS response by 2020 is one of the financial goals to decrease by less than half million AIDS-related deaths (UNAIDS, 2016b).

Worldwide there are 36.7 million people living with HIV (WHO, 2016). Globally, HIV/AIDS have emerged as a threat to security from individual to national levels, as well as the disease challenges social cohesion, political instability, unemployment rates, public spending and productivity (Concern Worldwide, 2003). Mozambique had 1.8 million people living with HIV in 2016 and more than a half of them know their status (UNAIDS, 2016). The country has the 8th highest HIV prevalence in adults worldwide (UNAIDS, 2016) and its capital, Maputo City, has the third highest HIV/AIDS prevalence in Mozambique, only behind Gaza and Maputo Province (Conselho Nacional de Combate ao HIV/SIDA, 2016). From the total scope of infected people, 88% of them (around 1.6 million people) are more than 15 years old and policymakers have made this group age the target in most of the health policies and sensibilisation (2016, p.1). Figure 2 below presents the number of people newly infected with HIV in the past decades and the future targets to be achieved by the international community.

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12 Figure 2: Number of people newly infected with HIV (WHO,2016)

By using youth in the central stage of HIV/AIDS prevention the international community wishes to decrease the HIV transmission after non-protective sex and mother-to-child transmission while reinforcing the preventive steps that need to be followed. However, despite the international effort and policies to reduce or eliminate HIV epidemic, the challenges are many and spaces for alternative approaches capable to efficiently impact bigger groups are necessary.

Sports are wider than the playing fields (Adcroft & Teckman, 2009); they are also a geopolitical, social, development and peace building tools which gathers youth in a playful and safe environment. Sports are grounded in the principles of dignity and equality, and they can reach youth whose prior concern is not necessarily how to prevent themselves from HIV/AIDS (Bosmans, 2006). Sports can foster social change, act as common language, promote intercultural dialogue and contribute for a positive development to adolescents and their communities through HIV/AIDS prevention. Also, enhance personal capacities as collaboration and respect, resilience, address gender equality and even non-political ideas of social responsibility and environmental awareness are implemented through sports projects (Coalter, 2006). Active adolescents grow into healthy adults; physical inactivity and poor diet are the major risk factors for diseases (Koss & Alexandrova, 2005). Regular physical activity improves immunity

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13 and blood pressure, increases lung capacity and decrease the chance of depression (Blashill, 2013). However, as it will be seen throughout the research, Sports also face critiques such as lack of evidence to support the claims of success, the Global North dominated discourse which results in top-down and “neo-colonial” approaches and lack of recognition of the local context and needs. (Nicholls et al., 2010)

The relevance of Sports is not only perceived by the academic field. The Dutch of Health, Welfare and Sport defines sports as a way to promote health, social contact and self-development (Ministry of Health, Welfare and Sport, n.d) and the Dutch Ministry of Foreign Affairs is funding many projects in the SDP framework through the worldwide program World Coaches. Former UN Secretary-General, Kofi Annan, calls that sports “improve the lives of individuals, not only individuals, but whole communities” (Maguire, 2006). The United Nations 58/5 Resolution called various stakeholders in order to recognize Sports as means to promote education, health, development and peace and to enhance sports and physical education as part of development programs and policies (Darnell, 2010). In 2004, UNICEF released a report called “Sport, Recreation and Play” addressing that, through Sports, young people have the opportunity to learn talk openly about many aspects from HIV/AIDS epidemic. (UNICEF, 2004). In November 2013, the United Nations reinforced its position in the recognition of the values of SDP and expanded the vision to embrace the ability of Sports to contribute to the global development goals, including the Millennium Development Goals (MDGs) targets (Coalter, 2006).

The relevance of Sports as tools for development is grounded on the theory of Sport for Development and Peace (SDP). In the timeline of development, Sports have a role in improving social and economic standards for capacity-building and investment. Additionally, they facilitate the participation of private business in development strategies and function as tools to democratize social relations (Darnell, 2010). Thus, in a context marked by the vision that traditional measures to development have not been able to achieve the desired results, Sports are perceived as “pure” and non-political vehicles capable of contributing strongly to development(Levermore, 2008).

During the fieldwork it became clear that in order to have an in-depth qualitative research it would be necessary to overtake the traditional and outdate approaches which understand each modality of Sports as a “physical activity, which, through casual

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14 participation, aim at expressing or improving physical fitness and mental well-being, forming social relationships or obtaining results in competition at all levels” (Rowe et al. 2004 citing Council of Europe, 1993). This research aims to take a step beyond and investigate how and if sports practice can function as sustainable alternatives to increase awareness of health policy and empowerment through life skills, education and cooperation, using as dependent variables HIV/AIDS awareness and empowerment. In order to achieve this, the theory of Sport as Development and Peace (SDP) will be used to embed the different approaches that Sports can be related to. Additionally, how sports practices can respond to HIV/AIDS vulnerabilities and enhance development processes in Maputo City neighborhoods. Aiming to investigate the problem from a holistic perspective, this research discusses the influence and participation of stakeholders, civil society, government and how they act in different frameworks. For example, when analyzing HIV/AIDS awareness it would not be a feasible data to do the analysis without taking into account the role of gender, religion, culture and socio-economic factors in Sports activities because they interact differently in each reality. The hope is that the research adds empirical and theoretical evidence to alternative approaches to development, particularly in HIV/AIDS health prevention. The research differs from an impact study because is a step further in contributing to the theoretical knowledge developed so far. Furthermore, adds on particularities that build on the local context in order to promote a more complex and reliable debate on theory of SDP as an agent of social change and tool for development.

This thesis has academic relevance because, even though there have been studies considering the roles of sports in health, public policies, social impact and development; the links with sustainable and long term social changes are still limited. It aims to promote a discussion on the importance of sports as long-term transformational mechanisms and analyzes the link between the underlying factors and empirical sustainable evidences. This research differs from a restricted study by the analysis of multilevel topic to further replicate considering international context, power relations and multi-approaches. In order to avoid overly simplistic analyses, multidimensional approaches are essential to fully understanding the topic. When analyzing HIV/AIDS phenomenon we cannot detach from the local reality and its complex process. HIV/AIDS spread in Mozambique has particular aspects as gender norms and

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15 performativity, identity, sexual and reproductive rights, cultural traditions, mysticism, economic disparities and social identities.

1.3. Points of Departure

This study aims to be an addition to the existing literature by providing an analysis on the influence of Sports, especially the potential of Sports practices as positive agent of social change and development in Health Education and HIV/AIDS awareness (Coalter, 2006; Coakley, 2011). In doing so, takes a step further away from more conventional approaches of Health Education such as the ones exclusively emphasizing the didactic transmission of information, the use of fear as an educational technique and the appeal to the individual`s sense of responsibility for their own health (Baudier, 1986; Nutbeam, 2000). This approach is applied in order to hopefully contribute with a more holistic research that takes into consideration other social and structural elements in the SDP that influence HIV/AIDS spread and the Sports programs as well. Both case studies used in the research demonstrate that particular attention needs to be drawn to the external and traditional impacts on the different actors in order to provide a network to better comprehend the topic.

Next section presents the main research question and the sub-questions to help answer it. The study focus on addressing particularly HIV/AIDS awareness and HIV/AIDS empowerment because they demonstrate two dimensions of the disease and are mutually dependent; awareness is the amount and quality of information acquired and empowerment is achieved combining the external knowledge and internal change. As result, both lead to behavior change towards HIV/AIDS which is the long-term goal to decrease the epidemic spread.

1.4. Research Question

The main research question is: “How do NGOs programs that use sports as tools to HIV/AIDS education affect the targeted adolescents in terms of HIV/AIDS awareness and empowerment in Maputo, Mozambique?”

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16 1) What is the vision of the NGO`s in relation to Sport for Development and Peace

(SDP)?

2) What are the goals and strategies of the NGO programs towards Health Education and HIV/AIDS?

3) Who are the main actors involved in the programs?

4) What are the consequences of Sports-based programs on adolescents HIV/AIDS awareness and empowerment according to NGO staff and to the adolescents themselves?

5) What is the role of the coaches towards the adolescents HIV/AIDS awareness and empowerment?

6) How can gender norms be related to notions of empowerment and HIV/AIDS awareness?

1.5. Thesis Outline

This thesis is divided into eight chapters, with the objective to provide a holistic and in-depth narrative of the roles of Sports to raise adolescents` HIV/AIDS awareness and empowerment among Sports-based programs in Maputo. Chapter 1 has introduced the motivation, relevance, key points of the departure and introduces the main research question and sub-questions which will be debated through this thesis. Chapter 2 examines the underlying concepts guiding this research and how they interact between each other and with the research question. It reviews and details the theoretical framework which includes the theory of Sport for Development and Peace (SDP), HIV/AIDS vulnerabilities, awareness, empowerment as well as the conceptual scheme, which illustrate the connections between the key concepts. Chapter 3 presents the methodology used for acquiring the data, the unit of analysis and the methods of sampling it, the epistemological stance and the processes for analyzing data. In addition, it delves into the aspects to ensure research quality and presents an overview of ethical considerations and limitations within this study. Chapter 4 contains the presentation of the research context and location; also mentions the HIV/AIDS scenario with a brief overview on data about adolescence, health system and HIV/AIDS. Furthermore, it details the Sports circumstances in Mozambique, the govern structure and policies and local initiatives which aim to foster Sports as tools for development. Chapter 5, Chapter

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17 6 and Chapter 7 contains the data analysis with the critical discussions about the findings from the field.

Chapter 5 provides a critical analysis about two NGOs which held Sports-based programs, their guidelines on Sexual Health Education, policies and impact on the community and amongst the adolescents who participates in the Sports-based programs. Chapter 6 discusses structural aspects which create barriers to HIV/AIDS policies and analyze how stigma and cultural aspects are part from the same “engine”. In addition, the sixth chapter addresses the perceptions on the roles of Sports, evaluates the impact of the coaches to raise adolescents HIV/AIDS awareness and empowerment and critically discuss the influence of gender norms and masculinity on HIV/AIDS vulnerabilities. Chapter 7 analyzes and debates the findings concerning the core relationships regarding HIV/AIDS awareness and empowerment. Finally, Chapter 8 addresses the answer to the main research question alongside with a discussion on the findings. Finally, summary of recommendations for Sports-based organizations and suggest further research are presented.

Chapter 2. Theoretical Framework

2.1. Introduction

This theoretical framework chapter is divided into four sections which aim to highlight the concepts of Sport for Development and Peace (SDP), HIV/AIDS vulnerabilities, Awareness and Empowerment, the importance of each key concept and the links between them. Section 2.2 will explore the theory of Sport for Development and Peace (SDP). It delves again into the discussion of SDP and the elements that arise as results and that could be applied in HIV/AIDS context in Mozambique. For example, the debates on Sports as means to or end to development, awareness and empowerment. Section 2.3 will deep into the literature on HIV/AIDS vulnerabilities and the particularities that impact on HIV/AIDS awareness and empowerment. Moreover, the multidimensional approach of what is vulnerability regarding the singular context of the study are discussed. Section 2.4 introduces the concept of awareness and the multiple

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18 degrees that can related to HIV/AIDS. Section 2.5 explores the concept of empowerment and the applicability to HIV/AIDS and Sports. Finally, the last section presents the conceptual scheme in which all the theoretical and conceptual discussions are connected.

2.2. Sport for Development and Peace (SDP)

Based on books, policy documents and scientific authors, this section will analyze the context on which the theory of Sport for Development and Peace (SDP) has emerged. Furthermore, the aspects that will be presented and discussed are the link between sport to development, the related critics and how the resulted social change is connected to HIV/AIDS education aspects.

Sport can be defined as “a human activity capable of achieving a result requiring physical exertion and/or physical skill, which, by its nature and organization, is competitive and is generally accepted as being a sport” (Australian Sport Commission, 2003). In fact, defining the term “Sports” results in a wide range of understandings. Sports definitions have been used in the fields of physical education, medicine, philosophy, history, education, development and gender, to name but a few. Although the evidence of the benefits of sports and physical education has been observed for decades; the connection with development goals, peace and social improvements remains largely unaddressed by policy makers (Beutler, 2008).

The United Nations Office on Sport for Development and Peace (UNOSDP) was created in 2001 by the former UN Secretary-General, Kofi Annan and became popular to define programs that use sports to promote positive social change and try to mobilize sports for a broad and sustainable social development (Coakley, 2011; Kidd, 2008). It is the channel on the UN system to view sports as tools for development, cooperation, gender equality, HIV/AIDS prevention and peace building. UNOSDP supports governments, civil society and stakeholders in adopting Sport for Development and Peace (SDP) policies and in enhancing the Sustainable Development Goals in the Post-2015 Development Agenda (UNOSDP, Post-2015). SDP is not only restricted to the UN field; former Olympic athletes and organizations engaged with humanitarian aid were

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19 also responsible for using sports practices and physical activities to switch “sports development” to “sports for development” (Kidd, 2008).

In 2003, with the support from UN, developing countries and engaged athletes, the major report “Sport for Development and Peace: Towards Achieving the Millennium Development Goals” was released (2008, p.375). The report recommended six approaches in order to create guidelines for SDP projects and their goals: (1) Sports should be better integrated into the development goals. (2) Sports should be incorporated as useful tools for development and peace. (3) Sport-based initiatives should be included in countries programs of the UN, (4) programs supporting sport for development and peace need greater attention and resources from the governments and the UN system. (5) Communications-based activities using sports should focus on well-targeted advocacy and social mobilization and, finally, (6) the most effective way to implement programs is through partnerships (United Nations, 2003).

Looking above the SDP literature it is highlighted that there are two different but often related assumptions on the role of Sports: one that considers Sport as tools to development by setting people together to facilitate the diffusion of knowledge, empowerment, life skills etc. The second view recognizes Sports roles as the end on itself. For example, it would encourage awareness and empowerment through the ability to bring social change, teach values and help the youth to maintain a healthy life. SDP is based on the concept that sports are not an end, but effective tools to help improve the lives of children, families and communities (Sport and Development, 2009). Sports are social constructions and have multidimensional approaches built on movements and activities which understand Sports as a means to achieve an objective instead of the fundamental end. The combination with educational elements is therefore essential to ensure the applicability of Sports policies. International organizations such as United Nations sees Sport as a by-product of development, not as an engine of a vehicle for Development towards achieving their goals like the MDGs and later the Sustainable Development Goals (SDGs) (Hartmann & Kwauk, 2011; Levermore, 2008).

According to Levermore (2008), sports- here understood in its broadest sense to include physical education as well as competition- have long been used by states in an attempt to foster development in a wide range of areas such as peace, education, poverty alleviation, HIV/AIDS awareness and mitigation, and gender empowerment, to name

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20 but a few. This corresponds with Beutler (2008), who describes that the multidimensional capacity to be a mechanism of positive social change emphasizes Sports as an interrelation of elements which aims to create a positive social impact. Additionally, Burnett (2009), UNOSDP (2015), Kidd (2008) and Bourdieu (1983) reflect that Sports are cost-effective tools to development, social inclusion and peace and Sport-based programs, in order to succeed, should respect individualized and cultural meanings from particular social contexts. Coalter (2006) addresses that “Sport-in-development” programs have a wide variety of aims and objectives. Therefore, they are divided into two broad approaches: a) “sports plus” in which the major aim is to develop sustainable objectives, values and practices. It addresses social issues like empowerment, gender equity, citizenship, health promotion as HIV/AIDS education and life skills; b) “plus sports” which differ from sport plus by placing more emphasis on sports as a means to an end. Non-sporting outcomes (e.g. behavior change) are more important than longer-term sustainable development of sport.

Although the growing number of studies and relevant theoretical debates regarding the role of Sports as effective tools for development and diseases awareness, such as HIV/AIDS; there are discussions on the gaps of SDP theory, its real motivations and a call for more evidence on the effectiveness and impact of sport for development programs (Nicholls et. al, 2010). Nicholls et al. (2010, p. 257), Kidd (2008) and Eekeren et al. (2003) engage in the discussion on the potential (re)production of post-colonial discourse within currently SDP programs guidelines; in the past, Sports were often portrayed as a tool to reproduce colonialism. Nowadays SDP programs can reproduce post-colonial relationship, dominance and power relations through the maintenance of the paternalistic relationship among donors and policy makers (i.e. typically Northern) and recipients (i.e. typically Southern). This corresponds with Coalter (2010) and Giulianotti (2011) who present that the dualist and potentially neo-colonialist nature of SDP approaches is argued towards the “benevolent” characteristic from Northern/Western countries that deliver aid, goods and expertise to the “marginalized” Southern countries which host the SDP programs.

The scenario would then result in top-down intervention programs designed from stakeholders, NGOs, governments and SDP policy makers that have little local accountability and are disconnected from the recipient`s realities (Spaaij, 2009 ; Coalter, 2010 ; Nicholls et al., 2010). These institutions might not be familiar with local

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21 particularities and try to export their mainstream perception on what it means to be developed. Adding on that, Darnell (2007) presents that Sport-based organizations operate within two discursive frameworks: the first places sports and play as universal and integrative social practices; the second critiques the use of international development as “burden” and benevolent deliverance of aid, goods and expertise from the northern to southern countries.

Moreover, the role of SPD programs as educative purpose is challenged regarding the consensus that Sports automatically teach young people life skills and pro-social behaviors. Hartmann & Kwauk (2011) argue that Sports are not the end on itself and Sport-based programs should focus on developing values in order to change behavior instead of the linear approach that Sports would directly lead to development and social impacts. Based on the Freirean theory of education, oppression and domination, Spaaij & Jeanes (2013) argue that SDP programs fail on the lack or limitation of solid pedagogical strategies. Finally, according to Hartmann & Kwauk (2011), the debate on the meaning of “development” questions that the standards used to consider an initiative as “development” on Sports might be driving by neoliberal approaches.

2.3. HIV/AIDS Vulnerabilities

In order to discuss the roles of Sports in HIV/AIDS awareness and adolescents’ empowerment, the following section focuses on the vulnerabilities that impact the achievement on them. Based on scientific literature, how vulnerability is manifested and what are the social consequences translated to the field of HIV/AIDS will be debated. However, defining vulnerabilities is not an easy task within social science research. Cultural sensitiveness and contextualization are important dynamic aspects that explain what “vulnerable” imply in one context might be of less relevance in a different framework. Therefore, the next section aims to give a broad and general definition of which elements of HIV/AIDS vulnerability can be related to Mozambique context. An important distinction that needs to be initially highlighted is the easily confused difference between addressing HIV and AIDS. Based on Leonard (2017), HIV stands for “Human Immunodeficiency Virus” (HIV) and is a virus that attacks the immune system rendering it deficient and can lead to infection. AIDS is an acronym for

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22 “Acquired Immunodeficiency Syndrome” and is a condition or a syndrome that has been developed when HIV virus has caused serious damage to the immune system plus having very low count of CD4 cells and/or an opportunistic infection. The symptoms of HIV vary depending on the stage of infection; in the first few weeks after initial infection individuals may be asymptomatic or an influenza-like illness including fever, headache or sore throat (World Health Organization, 2018). The risks of transmission in the early stage of infection –the so called “window period”- are high because the HIV positive might not know their condition due to the absence of symptoms (2018,p.1). Skinner et al. (2006) argue that the complexity in defining HIV vulnerabilities is caused by the multiple contexts and aspects that lead to vulnerability. For example, severe chronic illness, poverty, lack of access to services, sexual violence, cultural norms, gender inequality, socio-economic status etc. Additionally, according to Underwood et al. (2011), generalizing the definition of HIV/AIDS vulnerabilities to different settings is problematic because cultural and local context particularities have distinct relevance to each reality and must be met with multi-level responses.

Based on the previous literature, HIV/AIDS have historical, contemporary and structural elements that increase its complexity. Although AIDS is a global epidemic that affects men, women and children at no matter age, the vulnerability reflects unequal social, economic and gender realities (Underwood et al, 2011). Gupta (2000) clarifies: gender is not a synonym for sex; gender is a culture-specific construct which often reinforce the difference between women and men regarding inequality on power relations, roles and decision-making authority.

Adding on the debate on gender inequality, Higgins et al. (2010) discuss that the vulnerability paradigm argues that women are more vulnerable to HIV due to biological differences, reduced sexual autonomy, and men`s sexual power and privilege. This agrees with Ostrach and Singer (2012) and Cruz e Silva et al.(2007) which declared that despite anatomical elements, HIV/AIDS vulnerabilities on women are a complex set of interrelated biopolitical, sociocultural and political-economic factors which resulted in the process entitled as “AIDS feminization”. In this context, structural and social elements reinforce the stigmatization and increasing women vulnerabilities towards HIV/AIDS and unbalanced gender power relations. Gender norms, patriarchal society,

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23 educational model and cultural traditions also reinforce women secondary position regarding agency, power inequality, sexuality and reproduction (2007, p.15).

Hence, it is not possible to discuss HIV/AIDS vulnerabilities without mentioning HIV/AIDS stigma. Carrasco et al. (2017) analyze stigma as social construction which has been studied as a multi-dimensional process that is constantly changing and reproducing social inequalities. The stigma also impacts the access and HIV/AIDS treatment on health care system; HIV positive people fear to be recognized by family or relatives during doctor`s appointments, while lack of confidence on health workers challenges the HIV/AIDS prevention and treatment.

Women`s HIV/AIDS vulnerability concerns economic disempowerment and men`s dependence are caused by gender-based violence, inequality, historical roots and is reinforced by stigma which discourages them to argue with their partners regarding unprotected sex, contraceptive methods, HIV/AIDS treatment and polygamy (Higgins et al., 2010). According to Jewkes et al. (2010), girls are taught to give priority to their partner’s wishes and needs, due to the pressures from patriarchal-based societies. These girls are often afraid to be associated with promiscuity and regarded as HIV positive if they ask for condoms and other prevention method. Due to the hegemony of masculinity, women are expected to remain faithful to their husbands, whereas the infidelity of a man is accepted and tolerated. Even though a woman has become HIV positive due to horizontal infection from her husband, she is often sent away or marginalized by her husband or family (Duffy, 2005).

According to Temah (2009), the socio-economic dependence caused by the lack of empowerment prevents women to have legal and/or financial means to be autonomous. Therefore their unfavorable position might become the basis for prostitution, which in some cases is the only source of income and a high-risk behavior to HIV/AIDS spread. Regarding Passador (2013) within power relations the social institutions produce the subject that they will represent and control through their formal or informal power mechanisms. In this sense, gender and sexuality are discourses and power mechanisms controlled by formal institutions (for example State) and informal institutions (e.g. culture and tradition). As a result, masculinity is socially constructed in order to reproduce gender norms and power relations. The debate on gender norms, masculinity, HIV/AIDS and the roles of Sports will be further analyzed in Chapter 5.

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24 To summarize the multidimensional character of HIV/AIDS vulnerability, figure 3 below indicates the relevant aspects of HIV/AIDS vulnerability according to Ayres et al. (2006):

Figure 3: Dimension and relevant aspects of HIV/AIDS vulnerability (Ayres et al., 2006)

2.4. Awareness

This thesis is about how SDP programs may support awareness and adolescents empowerment in Maputo, Mozambique. In 2.2 section the concept of SDP was explored, now we will make a shift to further on elaborate the concept of awareness and the link with HIV/AIDS, analyzed in the 2.3 section. First of all, the concept of awareness, followed by the discussion on the various aspects and degrees of awareness concerning HIV/AIDS will be presented. Since HIV/AIDS vulnerabilities are elements

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25 that impact on awareness, the following paragraphs draw on the discussion developed from the previous section.

Awareness has a wide range of meanings; in social science, Merikle (1984) presents awareness as the ability to make forced-choice decisions above a chance level of performance and the equity of awareness with self-reports which indicates the observer consciously sees a stimulus. Conversely, awareness through the lens of Paulo Freire is the first aim of education –which here will be understood in a broader sense and including sexual and health education- in order to achieve individual or collective critical consciousness and stimulate change of behavior (Miranda & Barroso, 2007 citing Freire, 2000; Darder, 2014). According to Darder (2014, p.2) critical awareness and social consciousness are historical phenomenon and a human social processes whereby individuals reinforce their particular capacities to be social actors.

In addition, Levermore (2008) discusses that activities of sport-for-development programs combine intercultural understanding with empowerment to raise awareness within the programs participants. Additionally, Sports educate and create a safe and trustworthy environment where participants` feel more comfortable in addressing sensitive topics as HIV/AIDS. Furthermore, based on Kalichman & Simbayi (2003), awareness goes beyond the cognitive discussion and is influenced by social, political, gender, economic and cultural elements. Kalichman & Simbayi (2003) continues affirming that stigma on HIV/AIDS processes (testing, knowledge, prevention and treatment) prevents the individuals from gaining in-depth awareness, thus constraining the change of behavior towards HIV/AIDS (2003, p.442). Moreover, the stigma creates a pattern where people choose to keep their HIV status to themselves.

Burns et al. (2007) studied the underlying factors that have an impact on HIV/AIDS awareness. It is important to look above the literature to highlight a connection between HIV/AIDS vulnerabilities (see section 2.3) and the effect on HIV/AIDS awareness. These authors` approach contributes to the body of literature by perceiving the influence of gender inequality, economic disempowerment, inadequate sexual education, religion and cultural aspects on HIV/AIDS awareness. According to Burns et al.(2007), the particular context should be prioritized to create programs with trustworthy effect. For example, some African cultures are unfamiliar with a sexual health clinic that is

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“open-26 access” and do not feel comfortable with this kind of approach to such a stigmatized topic as HIV/AIDS.

Although frequently used interchangeably in public health policies, it is important to highlight the difference between awareness, knowledge and how both are not related to behavior change in a linear way. Knowledge is defined as “information that is acquired from authoritative external sources and can therefore be regarded as factual in nature” (Trevethan, 2017) and the “facts, information and skills acquired through experience and education” (Oxford Dictionaries, 2018). This distinction is important because awareness is associated with knowledge and defined as “knowing that something exists and consciousness” (Oxford Dictionaries, 2018) and does not necessarily imply behavioral changes. However, the two concepts are placed in different levels of behavior change; awareness contains strong elements of personalization, an individual self-perception and cognition which contrast with the more impersonal and factual nature of information that is associated with the word knowledge (Trevethan, 2017). Within the thesis there is more concern with the impact on raising HIV/AIDS awareness through Sports than with the dimension of knowledge spread.

2.5. Empowerment

The previous theoretical section develops the concept of empowerment and how it is related to Sports and HIV/AIDS. As seen previously, empowerment is one of the outcomes from Sports-based organizations. The following section will present different views on empowerment which will be present also in Chapter 7.

Over the years, different interpretations have been given to characterize empowerment. Depending on the context, perception and author, the notion of empowerment has been framed as theory, reference framework, an action plan, a goal, an ideology, a process, a result or a consequence within a multilevel dimension (Simard et al., 2014). Also, according to Lee and Joh (2010), empowerment has two distinct aspects; respectively one is the cause and the other the effect: one is empowerment as “behavior of a supervisor” and the other is “psychological state of subordinate”.

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27 For the purpose of the study, empowerment will be recognized as a process in Health Education. According to Simard et al. (2014,p.3) through the understanding of empowerment as a process, that is, a set of stages or actions leading to change, it would be possible to highlight the different elements that contribute to the development of a personal feeling and perception of increased power over itself or the social structure. Thus, empowerment consists of both the physiological ability to control one`s environment and body (internal empowerment) and the feeling that one can do so or have the personal and material resources to effectively take such action (external or situational empowerment) (Diener & Diener, 2005). Narayan-Parker (2005) discusses that neither type of empowerment is sufficient; If the environment allows effective action but the person physiological ability indicates that the action will be ineffective, the person is not truly empowered. Similarly, if a person feels psychological empowered but external conditions prevent effective action, the person is not truly empowered. Therefore, in order to fully achieve empowerment, Sports need to impact on the two levels: personal and social.

Lehman & Koerner (2003) present the link between sports involvement and sexual/health behavior among women through two mechanisms that reflect cultural and social processes: self-empowerment/efficacy and functional body orientation. Furthermore, via sports experiences they are encouraged to see themselves as competent and in control of their lives, bodies and decisions, including developing life skills and abilities concerning their sexuality-related behaviors and gender inequality (2003,p.444; Simard et al., 2014).

In this context, health education- which is a component of health promotion- entails both personal and community empowerment towards increasing self-efficacy and personal competence with the aim to strengthen local authority and community`s impact in order to create social change (Steenbeek, 2004; Bean et al., 2015).

The following section presents the conceptual scheme emerged from theoretical framework insights. It illustrates how, based on the literature, the links between the concepts are visualized.

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28 Figure 4: Conceptual Scheme- Nicole Abreu

Figure 4 illustrates the conceptual scheme upon which this thesis is constructed and the relationship between the aspects analyzed in the theoretical framework. In the Operalization Table (Appendix 3) is possible to analyze in detail the processes behind the concepts framework. The key element is outlined in green and represents the Sports-based programs targeting adolescents, which in this research will be Right to Play and Favela United. Alongside in orange there are the relevant concepts that influence the Sports-based programs and their link with the main concept, which is also presented in the theoretical framework sections. At the same time that the Sports-based programs influence and promote both HIV/AIDS awareness and HIV/AIDS empowerment, they are also affected by the role and behavior of external actors as the adolescents and coaches.

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29 The arrow between Sports-based NGOs and Sports-based programs targeting adolescents portrays the fundamental link between the existences of NGOs based on the guidelines of SDP to ground the programs with their vision to use Sports to promote positive social change, as explained in the theoretical framework. HIV/AIDS awareness is shown to mutually influence HIV/AIDS empowerment, whilst HIV/AIDS empowerment is subdivided into the two levels identified in the theoretical discussion. The smaller box that surrounds the conceptual scheme portrays the influence of gender social institutions in the Sports framework and their elements that affect the whole relationship inside the scheme. These gender social institutions are the social institutions which regulate and (re)produce the unequal and biased gender power relations; for example, they can be referred as religion, family, education, state, media etc. The bigger box represents the HIV/AIDS social context; it demonstrates the different variables and elements that impact HIV/AIDS debate and how the particularities from the local context and culture can modify the findings and HIV/AIDS vulnerabilities.

Chapter 3. Research Methodology

3.1. Introduction

This chapter aims to explore and discuss the methodology used in this eight-week field research project, how the core concepts were explored and the steps taken to analyze the research questions. In line with the qualitative nature of the study, the factors and underlying categories that led to a wide range of distinctive approaches will be taking into account through a set of key characteristics in order to develop explanations at the level of meaning rather than cause (Ritchie et al., 2003). It aims to provide an in-depth and interpretative understanding of the topic under discussion which will be built on through key categories and theories that respect the complexity and uniqueness of each context (2003, p. 4). The participatory methods will then create a bottom-up approach with focus on local context and perspectives which involves a collaborative and nonhierarchical framework for the research (Pain, 2004; Cornwall & Jewkes, 1995).

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30 In this chapter the methodological approach is discussed through research design, conceptual scheme, epistemological stance, unit of analysis and sampling that will address the methods of data collection and analysis. Fundamental aspects such as research quality, ethical considerations and limitations are addressed followed by a conclusion section of this chapter. In order to illustrate the train of thought for this research the Operalization Table (Appendix 3) presents the pre fieldwork process to ensure the quality and value of data.

3.2. Research Design

This research project emerges from a mixed method perspective organized and designed in the pre-fieldwork period, which will be analyze further in the section 3.7. In order to ensure data reliability and validity, a triangulation research design was used to analyze different measures and perspectives, in an attempt to reduce the predisposition in single methods research through an effort to obtain convergence and validation for the same phenomenon (Bryman, 2012; Johnson & Onwuegbuzie, 2004). During the research process it was shared the preliminary findings with a group of respondents. It aimed to ensure the authenticity and trustworthiness of the data and to help them to reflect on the provisional research outcomes. This group of respondents was selected taking into account participants from each category.

3.2.1. Unit of Analysis

Considering the primary focus of the main research question, the unity of analysis in this research are the NGOs Sports-based programs. In order to offer a multi-dimensional data the information was gathered with respondents currently with some level of interaction with Sports or HIV/AIDS arising from distinct fields. Adolescents, policy makers, NGOs staff, coaches, health workers, education professionals, Sports experts and journalist were the targeted respondents for the study. Finally, the unit of observation is the adolescents who participate on the NGOs Sports-based programs since they are the characters that may have their HIV/AIDS awareness and

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31 empowerment raised through the NGOs programs. The details on the type and amount of interviews will be discussed in the Data Collection section (see section 3.5). 3.2.2. Sampling methods

The selection of appropriate respondents and organizations the research would work with. Right to Play and Favela United were chosen upon their relevance for Sport for Development in Mozambique, from local knowledge and pre-fieldwork research (see Chapter 5). Each organization has different capacities and impacts on SDP in Mozambique; the first is an international and well-structured NGO which works on partnerships with others associations and the second is a local organization which the only major project is to offer football training through community outreach and volunteers coaches.

Informant selection is highly relevant in research as the data is important to contribute to a better understanding of a theoretical framework (Tongco, 2007 citing Bernard, 2002). Therefore, it becomes essential to ensure data quality and feasibility to the respondent’s choice. In order to identify the participants this research used purposive sampling to certify the relevance and purpose to the research. The sampling method utilized was purposive sampling on which the choice of informants is made due to the quality of the information they possesses (Tongco, 2007).

Purposive sampling is a non-probability type of sampling which relevance and knowledge of the topic is chosen over randomness, units are selected to reflect particular features or characteristics which will enable detailed exploration and understanding of the main topic (Ritchie et al., 2003). The respondents were chosen through the reference from both Right to Play and Favela United because the both organizations understand the local context and after explaining the range of research structure, key criteria and aims they were able to point out some relevant participants. These participants also recommended other relevant respondents to the research therefore creating a network of respondents. In order to add depth on the understanding of underlying causes of the problem the respondents were not only from or advised by the two organizations, interviews were conducted with a broader group of people as health workers, journalists and Sports experts.

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32 Although the potentials drawbacks of this method such as narrow social network and difficulties considering social visibility of participants (Faugier, & Sargeant, 1997), purposive sampling requires clear objectivity and theoretical foundation which identifies relevant data and knowledge. The participant’s selection offered a multi-approach data which has taken in account the relationship with the topic and relevant knowledge. In the adolescents selection the two only criteria used was the age range and the participation on the Sports-based programs. Through the theoretical framework it is known that female adolescents have a different experience regarding HIV/AIDS vulnerabilities so the research was attentive to the balance between male and female even though the number of girls participating in these sports are far lower those of boys. However, even after the extensive planning, the topic`s sensitivity remained a huge challenge to the respondents’ willingness to discuss HIV/AIDS issues. From 18 interviewees only 4 of them were women and in the Favela United project there were only one team of female players.

3.3. Epistemological Stance

This research departs primarily from a pragmatic worldview which addresses the importance to think about dualisms and mixing different schools of thought to provide a better understanding and knowledge of the topic (Johnson & Onwuegbuzie, 2004). It is an explanatory and investigate fact-finding endeavor based on the recognition of the importance of local cultural context in order to provide a holistic and complex comprehension from the particular social framework (Udo-Akang, 2012). This aspect is linked with the use of semi-structured interviews that enable the participant to contribute with their own perspective and approach to improve the interview.

Additionally, the research also used a post-positivist approach by agreeing that the findings might be relative. There is not a universal truth and the findings are shaped by our background and the research particular context (Johnson & Onwuegbuzie, 2004).

3.4. Data collection methods

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33 This research project calls mainly for the use of qualitative data. The reason for this is to address the complexity and subjectivity of the topic because most of the data are based on perceptions and experiences. Qualitative methods are based on the perspectives and experiences of the participants and have as characteristics in-depth information, focus on multiple contexts and processes uncovering patterns, and flexible research process (Bhattacherjee, 2012). Nonetheless, in order to develop a better understanding of adolescents’ sexual behavior, the research took a step further on by adding quantitative data. This came from policy documents and other secondary sources and was used to support the subjective and personal data acquired with the qualitative methods. These mixed methods approaches along with triangulation of the data have helped to ensure coherence, feasibility and validity and to analyze different angles in an attempt to reduce the simplistic perspective that may arise from a single methods research (Bryman, 2012).

In order to answer the research questions multiple methods to gather data were used in the two stages of the research. In stage one semi-structured interviews were conducted with health workers, sports experts and the head of office from the Sports organizations in order to gain a general understanding of the HIV/AIDS context in Mozambique and to gain insight of the vision and guidelines from the organizations to subsequently observe if they were applied in the field. These interviews have helped to organize the research in accordance with the local reality and demand. Stage two was characterized by participant observations in the field; more focused semi-structured interviews with University teachers, school director, Sports expert, NGOs staff and coaches, health professionals, a journalist, adolescents who participate in the Sports-based programs and informal interviews. Secondary data was also consulted in order to compare the preliminary findings from the field with the available data.

Semi-structured interviews

Semi-structured interviews allow flexibility. I had a guideline of questions to answer the research question but I could change the directions and approaches that were not working in the field much more easily than structured interviews (Legard, Keegan & Ward, 2003). Due to the flexible characteristics from semi-structured interviews the questions were pre-established but at the same time it was given a room to engage deeper with relevant topics as they emerged during conversations and allowed the

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34 participants to follow a new direction (Bernard, 2012). In order to diversify the data, the standardized set of key questions and topics were discussed with all the interviewees to verify whether the collected data was beyond than a single perception. It was interesting to realize that some interviewees strongly present their personal opinion over the statistics or the major consensus, for example denying the urgency of efficient HIV/AIDS policies. It was not found any possible explanation for this pattern but local contacts compared this procedure when the interviewee does not want to show the poor reality around them. One of the characteristic from semi-structured interviews is the flexibility on the questions posed according to the interviewee area and perception on the subject. Therefore, all the interviews kept similar main topics to standardize the data.

In appendix 1 and 2 there are the Interview Guide and Coding to ensure confidentiality. Through interviews from adolescents to health workers I hoped to achieve a broader understanding of the elements that take part of the process. This method was one of the most important elements on the research because allowed the participants to talk about topics that were not initially in the interview, enriching the quality and range of the analysis.

Participatory Observation

Participant observation method was highly utilized during the fieldwork because it involves an active looking and informal interviewing that enable researches to learn in-depth about the topic, the people and the context under study. It includes more than just observation, also comprehend that the researcher should become part of the community so the conversations, interviews and other data collection would be more natural and open (Kawulich, 2005). During the research, the programs from Favela United and Right to Play were visited around twice a week each with the help from local gatekeepers in order to gain trust from the and engage with informal conversations that provided important data and a clearer picture of the daily basis local context and aspects (see more in 3.7). Additionally, participant observation allowed greater validity for the research because provided aspects from the community framework that only data observation and readings would not had allowed. It was possible to attend a couple of meetings which the Sports-based organizations designed the structure for future

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35 programs and to follow the discussions on how HIV/AIDS prevention and Sexual Education are taken into account in the programs guidelines.

Field notes

Throughout the fieldwork a personal notebook was kept in which personal notes from observations of the community setting, ideas, thoughts and relevant findings were daily written. During and after fieldwork, this notebook was a source of inspiration and ideas that were neglected at the first moment. It was kept all the time because even with an audio recorded interview it was helpful to take some notes at the moment itself.

Secondary data

In order to understand the Health service in Mozambique over the past years, this research analyzed policy documents related to HIV/AIDS and related public policies and the Government of Mozambique (GoM) approach in the Health sector. I found some inconsistencies in the available national statistics therefore creating inconclusive results; however during the research I used the most accurate statistics as possible. The analysis of secondary data in general allowed the comparison between the data and reality thus it also supported the data collected during interviews and other qualitative methods framed as subjective (Harrell & Bradley, 2009).

Informal interview

Informal interviewing gave more freedom and interaction between researcher and respondents (DeWalt & DeWalt, 2002) and was observed that they feel more comfortable during informal conversations than the ones that they knew it was being recorded and taking notes. It is important to be aware that the objective is to collect data for the research so besides the daily conversation I always asked some questions related to Sports and HIV/AIDS. This method collection has allowed me to questioned more than formal interviews methods because the participants were more natural.