Research Article
Learners’ knowledge and and perceptions
of voluntary Counselling and Testing for
HIV and AIDS in the Free State Province
Y Botma
School of Nursing, University of the Free State
ZD Motiki
School of Nursing, University of the Free State
MC Viljoen
School of Nursing, University of the Free State
Abstract: Curationis 30(2): 48-57
The study investigated the perceptions o f the youth regarding Voluntary Counselling and Testing (VCT) and sexual aspects related to HIV and AIDS. The study was grounded in qualitative m ethodology, using 4 focus group interviews for data collection - triangulating the results w ith field notes and literature. The participants o f the four focus groups proved to be w ell inform ed on the topic and had clear perceptions concerning several aspects. They were very positive regarding the advantages o f VCT for the prevention and management o f HIV and AIDS. The participants recognised the need for the youth to be better inform ed about VCT and HIV and AIDS. They were m uch concerned by the lack o f parental involvement in sexual education as well as the perm issiveness o f the youth w ho partook in alcohol and drug abuse as w ell as prostitution. Participants o f the study stated that this problem was exacerbated by poverty and poor socio econom ic conditions.
Opsomming
Die doel van die studie was om die persepsies van die jeu g betreffende Vrywillige Berading en Toetsing (VBT) vir M IV en VIGS asook verw ante seksuale aspekte te ondersoek. Die navorsing w as kw alitatief van aard. M et gebruik van 4 fokusgroep onderhoude is data versam el w at getrianguleer is m et veldnotas en literatuur. Die deelnem ers aan die fokusgroep besprekings, was goed ingelig oor die onderwerp en het sterk opinies gehad rakende verskeie aspekte. Hulle was baie positief oor die rol van VBT in die voorkom ing en hantering van MIV en VIGS. Die deelnemers het die belangrikheid daarvan beklem toon dat die jeug beter ingelig m oet wees oor VBT en M IV en VIGS. Hulle was baie bekom m erd oor die gebrek aan ouerlike bertokkenheid by seksuele opvoeding asook die perm issiw iteit van die jeug w at dwelms en alkohol m isbruik en betrokke is by prostitusie. Die deelnem ers aan die projek het gevoel dat hierdie problem e vererger w ord deur armoede en algem ene sw ak sosio-ekonom iese toestande.
E -m ail: Viljoenmc.m d@ mail.uovs.ac.za
48
Correspondence address:
M. C. Viljoen School o f N ursing
U niversity o f the Free State PO B ox 339
Bloem fontein 9301 South A frica
Introduction
During the last tw o decades, the Human Im m unodeficiency Virus (HIV) and the disease caused by it known as A cquired Immune Deficiency Syndrome (AIDS) has e n te r e d o u r a w a r e n e s s as an incom prehensible calam ity. HIV and AIDS has taken a terrible hum an toll, c la im in g m illio n s o f liv e s , le a v in g thousands o f orphans, inflicting pain and g rie f, c a u s in g fear, u n c e rta in ty and th re a te n in g eco n o m ic d ev astatio n in S o u th A fric a (S ta d le r, M o rris o n & McGregor, 2000:4).
A ccording to Van D yk (2002:19) the problem s caused by HIV and AIDS can be system ised into two broad categories, nam ely p rev en tio n and m anagem ent. Firstly the health sector and scientific c o m m u n ity h a s to fin d w a y s o f preventing the spread o f the virus. And secondly, it has to solve the problem s that are posed by m anaging the people w ho are already infected and who are ill or dying because o f it.
Prevention o f HIV and AIDS is a priority for all health sectors in South A frica. A ccording to the National D epartm ent o f Health Strategic Plan for South A frica 2002-2005 priority area num ber one is v ested in the p rev en tio n o f H IV and A ID S , e sp e c ia lly am ongst the youth (National Department o f Health, 2000:15). A c c o rd in g ly , n u m e ro u s e f fo rts are currently underw ay to reduce the rate o f sexually transm itted infections including H IV in S outh A frica. T h ese effo rts in c lu d e e d u c a tio n p ro g ra m m e s fo r encouraging safer sexual lifestyles, the su p p ly in g o f co n d o m s by the pu b lic sector and the giving o f anti-retroviral (ARV) drugs where necessary. However, ju d g in g by the increased rate o f HIV- in fe c tio n s th ese e ffo rts fall sh o rt o f a c h ie v in g th e ir a im o f c u rb in g the pandem ic and saving lives. Seemingly these efforts have in a w ay successfully in c re a se d k n o w led g e and a w aren ess a b o u t H IV a n d A ID S a m o n g th e population in general w ith little or no change in behaviour (Letsie, 2000:2). M uch research is being done worldwide to d e te r m in e w h ic h in te r v e n tio n program m es are successful in changing sexual lifestyles am ong the youth. This fact w as illustrated w hen in 2001 The Cochrane Library analysed as m any as 60 research articles concerning different intervention program m es for changing se x u a l life s ty le s (S h e p a rd , W eston,
Peersman & Napuli, 2001).
A v e ry im p o r ta n t s tr a te g y in th e p re v en tio n o f H IV is the p ro c e ss o f Voluntary Counselling and Testing (VCT) w hereby an individual is tested for HIV in a confidential setting. D uring the process o f V C T the individual firstly receives counselling to prepare him /her for a positive result. A person is tested and is counselled again w hen the result o f the test is given to him/her. In the case o f a negative result the counseller will confirm his knowledge for remaining safe from HIV infection. In the case o f a p o sitiv e d ia g n o sis the in d iv id u a l is offered ongoing em otional support, is referred for further m edical evaluation and ARV treatm ent and is counselled on how to live a healthy lifestyle so as to protect his im m une system. The person is encouraged to take all precautions not to s p re a d th e v ir u s to o th e rs by practicing sexual risk reduction and by m aking h is /h e r statu s kn o w n to sex partners and m edical personnel where necessary.
The p ro cess o f V C T is im p o rtan t in curbing the spread o f HIV and AIDS. The reasoning is that if an individual tests negative, he will take precautions not to get infected through sexual activities by adopting safe sex practices. Conversely, if an individual tests positive, he will adopt safe sex practices, insuring that he does not infect o ther people, thereby stopping the spread o f the virus. The m anagem ent o f the health o f people who are infected w ith HIV is the second problem that the health community faces. VCT m ay address this problem in the following m anner: Individuals who test positive for HIV receive m edical and e m o tio n a l a s s is ta n c e a n d c a n be counselled to cope w ith the diagnosis. T hey are in fo rm ed ab o u t ad o p tin g a h ealthy life sty le , th u s p ro tectin g the immune system as m uch as possible and delaying the progression o f the disease. The client w ith a positive diagnosis as well as his family members may therefore receive tim ely em otional support and ed u c a tio n a b o u t the d ise a se . “ E arly detection ties in w ith a prolonged life and improved quality o f life for those living with HIV/AIDS” (Soloman, Van Rooyen, Griesel, Grey, Stein & N ott, 2004: 48). Medical assistance includes ARV therapy fo r th o s e w h o s e in f e c tio n has progressed to a certain level o f severity. ARV therapy has been offered by the
public sector in South Africa since 2004. However when this study was completed, in 2003, the public sector did not provide anti-retroviral drug therapy.
F in d in g s from a stu d y by L o v eL ife (2 0 0 1 :2 7 ) in K e n y a fo u n d th a t com m unities placed a higher value on VCT than they did on a hypothetical AIDS vaccine, chronic care services or ARV therapy. Program m es that include VCT have been successful in countries such as Uganda and Kenya.
However, as m uch as researchers m ay v a lu e V C T , th e r e e x is t a lm o s t in s u rm o u n ta b le d if f ic u ltie s in th e acceptance o f V C T by com m unities. People desist from going for VCT because o f the fear o f stigmatisation, rejection and ostracism by the com m unity, fam ily, friends and loved ones once a positive diagnosis has been made. Evian (2003:22) as w ell as G ra n t, S tro d e and S m art (2002:134) stated that stigm atisation o f H IV and A ID S o fte n c a u s e s so cial r e je c tio n , an d a lie n a tio n an d can c o m p ro m ise e m p lo y m e n t, h o u sin g , schooling and childcare responsibilities. “A large num ber o f studies carried out over the last 5-10 years suggest varying degrees o f negativity in the perception o f people with HIV and AIDS” (Hodgson,
1997:283).
O vercom ing the stigm a associated with H IV is th e b ig g e s t c h a lle n g e to its prevention and care. Countries where VCT is well established, such as Uganda, have less stigm atising attitudes to HIV and AIDS (UNAIDS, 2001:46).
Another great barrier to VCT is the fear o f a positive diagnosis. R eactions o f clients to a positive diagnosis include a variety o f emotions such as shock, denial, d is b e lie f , d e s p a ir, n u m b n e s s an d helplessness. O ther em otional reactions are guilt, anxiety and depression as well as obsessional thoughts, w hich include frequently thinking about suicide (Evian, 2003:42). Suicidal tendencies are common w ith people who are tested HIV positive because the em otions that are linked with a positive diagnosis are hopelessness and negative expectations o f the future (Van Dyk, 2002:278).
It is im portant to note at this point that m any o f the problem s o f stigm atisation and fear are based in ignorance about the transm ission, diagnosis, prevention, associated sym ptom s and diseases as 49
well as m anagem ent o f HIV and AIDS. Stadler et al., (2000:4) reiterated this when they nam ed the barriers to achieving HIV p rev en tio n as b ein g fear, d en ial and ignorance. Adding to this they said that the prevention o f the infection o f HIV has been plagued by silence resulting from the stig m a a sso c ia te d w ith the disease.
It was against this background that the re s e a rc h to p ic a n d d e s ig n w as conceptualised.
It w as n e c e s s a ry to d e te r m in e the ex istin g p ercep tio n s ab o u t VCT. In choosing an age group it w as decided to concentrate on the youth because they are so much at risk o f contracting HIV and AIDS (LoveLife, 2001:2). VCT is a relatively new phenom enon and until 2003 when this study w as conducted, no studies concerning it had been done in the Free State.
It was decided to do a qualitative research study on secondary school learners in the M angaung M unicipality, M otheo District in the Free State to determine their perceptions o f VCT. The purpose o f the study w as to explore and describe the perceptions o f the youth on VCT. The information gained could be an important guide to policy form ation concerning VCT at regional and national levels in South Africa.
As is the case w ith m ost q u alitativ e research, the results o f the study yielded m ore in fo rm atio n co n c e rn in g issues related to HIV and AIDS than only the youth’s perceptions o f VCT.
moderator. The Free State D epartm ent o f Education w as contacted to find a school w hose b aselin e language was Is iX h o s a . T h e r e f o r e th e ta rg e t population consisted o f all the learners in o n e s e c o n d a ry s c h o o l o f th e Mangaung M unicipality M otheo District comprising 929 learners from Grades eight to twelve.
In an effort to reduce the influence o f “pecking o rd er” o f ju n io r and senior learners on the groups being studied, the two extreme ends were excluded from the study. These were the learners in grades eight and twelve. This strategy made the age distribution sm aller and the groups more hom ogeneous, w hich adds to the trustw orthiness o f the study.
Selection and size of focus
groups
A ccording to Polit, B eck & H ungler (2001:325) a guiding principle in sampling is the data saturation principle, which m eans sampling to the point at w hich no n e w in f o rm a tio n is o b ta in e d a n d redundancy is achieved. Morse (1998:76) states that: “ In q u a lita tiv e re search , adequacy refers to the am ount o f data co llected , ra th er than the n u m b er o f subjects, as in quantitative research ” . A d e q u a c y is th u s a tta in e d w h en sufficient data have been collected in o rd er th at sa tu ratio n m ay o ccu r and v a ria tio n is bo th a c c o u n te d fo r and understood.
A c c o rd in g ly th e p r in c ip le o f d a ta saturation for focus groups interviewed, was applied and because saturation had o c c u rre d a fte r th e fo u rth g ro u p , no further interviews were needed.
explained below. Learners were selected that were:
• Older than 14 years: Children at this age are interested and know ledgeable about sexual m atters since they are adolescents (Colem an, 2001:14)
• Selected from grades nine to eleven:
This was done to reduce the “pecking order” o f ju n io r and senior learners on the other learners
• Able to communicate in English and IsiXhosa:
The researcher w anted participants who could speak Xhosa but who had been educated in English and therefore comfortable with all terminology regarding HIV and AIDS.
• Outspoken and able to take active part in the discussion: This was to ensure a variety o f participants’ perceptions.
Data collection
The study w as c o n d u c te d u sin g the q u a lita tiv e m e th o d o f fo c u s g ro u p d is c u s s io n s , o b s e r v a tio n an d d o c u m e n ta tio n a n d re s u lts o f ea c h method were triangulated with that o f the o ther as well as w ith literatu re. The following steps were im plem ented in the procedure:
Ethical considerations and consent
Perm ission to conduct the study w as o b ta in e d fro m all r e le v a n t p a rtie s beforehand. These included am ongst others the participants, their parents, teachers and school principal. Everyone involved was briefed on exactly how and where the study would take place so that th e y c o u ld g iv e in fo rm e d c o n se n t. C onfidentiality w as ensured and kept throughout the study and raw data were secured and burnt after completion o f the study. All participants took part in the study voluntarily and they were informed th a t th e y m ig h t d is c o n tin u e th e ir p a r tic ip a tio n at a n y p o in t o f th e proceedings.
Focus groups
Focus groups provides the interviewer
Method
A descriptive design using qualitative m ethods o f data collection w as used. Focus group interviews were conducted with secondary school learners to explore and describe the phenom enon o f youth perception o f VCT. These focus group interviews w ere triangulated with field notes and literature thereby enhancing the trustw orthiness, richness and rigor o f the data collected.
proportions was done according to the
Population and sampling
m e th o d p u r p o s iv e sam pling m ethod in that the One o f the secondary schools in the learners were chosen which had certainBabbie (2001:294) suggests that focus groups should consist o f 12 to 15 people. Therefore the researcher selected four groups o f 15 learners that would form the focus g ro u p s. W ith this n u m b e r o f learners in a group, provision could be made for absenteeism or non-attendance. The percentage o f learners in each grade and gender group was calculated so that each focus group w ould consist o f a representatively correct proportion o f grade and gender. Selection from these
M angaung M unicipality M otheo District was purposefully selected, on the basis o f language, to form the population o f the study. The learners o f this school speak IsiX hosa, w hich is the m other tongue o f the researcher as well as the
pre-identified characteristics. The Life S k ills te a c h e r w a s u s e d as th e “g a te k e e p e r” b e cau se she k n ew the children well enough to assist with the selection criteria. These criteria and the rea so n s for im p lem e n tin g th em , are
w ith the opportunity o f observing the population being studied first hand and gaining an in depth m eaning-, and thus valid insight and understanding o f the p h e n o m e n o n b ein g stu d ied (B ab b ie, 2001:294; Greeff, 2002:313).
Gibbs (1997: http://w w w .soc.surrey.ae. uk/sru/SRU 19htm l) stated that the main purpose o f focus group research is to d ra w u p o n p a r t i c i p a n t s ’ a ttitu d e s , f e e lin g s , b e lie f s e x p e r ie n c e s a n d re a ctio n s co n cern in g the topic being discussed.
The actual research for this study was done at a secondary school, chosen for its baseline language o f Isixhosa. Before each focus group discussion took place, c a re w a s ta k e n to c re a te a re la x e d atm osphere am ong the participants and to provide them w ith the opportunity to b u ild r a p p o r t w ith th e m o d e r a to r , researcher and study leader. According to N eum an (1997:355) a field researcher needs social skills and personal charm to build rapport. Prior to interviews in focus groups, participants m et informally for thirty m inutes w ith the m oderator, the researcher and the study leader. Snacks and coffee w ere provided. Purposeful sm all ta lk a v o id s d is c u s s io n o f the research topic and instead concentrates on com m on hum an experiences such as the w eather or sports (K rueger & Casey, 2000:103).
T h e fo c u s g ro u p d is c u s s io n s w e re conducted at the school in a quiet setting with learners placed in a circle to promote good com m unication am ong them. The m oderator was part o f the circle while the researcher and study leader w ere seated outside the circle so as not to be part o f the group. T hey acted as participant observers. The tape recorder w as placed in the m iddle o f the group in full view. It was tried to create a relaxed, natural and non-threatening atm osphere by building rapport and by using a skilled moderator. T h e m o d e r a to r w a s a q u a lif ie d p sy c h ia tric nurse w ith e x p erie n ce in c o n d u c tin g focus group d iscu ssio n s. She w as fluent in English and IsiXhosa, w hich are the tw o languages, used in the region and in w hich participants could ex p ress th e m selv es. T he m o d era to r p o s e d th e fo llo w in g o p e n -e n d e d question to the group:
“ What is y o u r perception o f Voluntary C ounselling a n d Testing f o r H IV and A ID S ? ”
T h e d a ta c o lle c tio n w a s d o n e as m eticulously as possible.
The m oderator requested that everyone should not speak at once but encouraged spontaneity. It w as stressed that the tape recordings could not be linked to any names. To ensure this the participants were given numbers by which they would be known.
The sp o n tan eity and openness o f the learner’s discussions indicated that good rapport had been established w ith the moderator. A lthough some participants were not actively involved by speaking all the tim e they leant forw ard w hich in body language indicated their interest in the ongoing discussions.
Field notes
W hile the focus group discussions were in p r o g r e s s , th e r e s e a r c h e r to o k descriptive, observational, theoretical an d p e r s o n a l n o te s . T h e s e n o te s described the unstructured observations made during the discussions as w ell as the interpretation o f these observations. T h e o b s e r v a tio n s in c lu d e d s e a tin g arrangem ents o f participants, the order in w h ich p e o p le sp o k e to aid v o ice reco g n itio n , n o n -v erb al b eh a v io u r o f participants, them es that were striking as w e ll as p e r s o n a l th o u g h ts , id e a s , hunches and im pressions.
The importance o f field notes is that they aid the researcher in focussing on group d y n am ics w h ic h is im p o rta n t in the analyses o f data since the strength o f focus groups lie in the process o f sharing and com paring am ong the participants (Polit & Hungler, 1999:369).
Trustworthiness
Trustworthiness is described by Polit and H u n g le r ( 1 9 9 9 :4 3 0 ) as c r e d ib ility , dependability and confirm ability. The credibility o f the study was high due to the skill and professionalism o f the study leader and supervisor o f the project as well as triangulation o f the focus group interview data, field notes and literature. Credibility is also described by Polit and Hungler (1999:430) as “truth value” , and therefore the prolonged engagem ent o f the re se a rc h e r w ith the p a rtic ip a n ts during the focus group interviews as well as the fact th a t she w as o f the sam e la n g u a g e an d c u ltu ra l g ro u p as the participants, is regarded as adding to the tr u s tw o r th in e s s o f th e stu d y . Dependability o f the analyses o f the data w as in c re a se d by u sin g a c o -co d er.
Confirmability was added to because the r e s e a r c h e r d ir e c tly o b s e rv e d an d interacted w ith the participants in their natural setting during the data collecting phase.
Data analyses
A q u alitativ e data an aly sis is a tim e c o n s u m in g a n d in te n s iv e a c tiv ity clustering together the related narrative inform ation into a coherent structure. The researcher has to fam iliarise herself w ith the data by rereading o f transcripts. Working together w ith a co-coder, points o f interest are underlined, m eaning is attach ed to elem en ts in the data and notes are made along the margin. Data were analysed from field notes as well and were coded and categorized. Coding refers to the process o f transform ing raw data into standardised form and entails th e id e n tify in g o f re c u rrin g w o rd s, them es and co n cep ts w ithin the data (Polit etal, 2001:697).
The data w ere g ro u p ed acco rd in g to th e m e s a n d c a te g o r is e d an d s u b categorised. The m ain categories were formed by the categories o f the KAPB m odel nam ely, K now ledge, A ttitudes, Practices and Beliefs. (See table 1). This model was derived from the Health Belief M o d e l a n d w as d e v e lo p e d to h e lp determine whether an individual is likely to participate in disease prevention and health prom otion activities (Kozier, Erb, B e rg m a n & S n y d e r, 2 0 0 4 : 178). A ccording to M om a and Lush (2003: h ttp ://w w w .g e n d e rlin k s .o rg .z a /d o c s / 2003/hiv-training-manual/liv-ch4.pdf) the K A PB m o d el c a n lead to a g a in in k n o w le d g e , a c h an g e in b e lie fs and attitu d es and e v e n tu a lly a change in practices and behaviours.
Presentation of the
findings
The findings indicated that the learners who participated in this study had well defined perceptions regarding VCT. As this was a qualitative study, findings o f perceptions regarding related issues o f HIV and AIDS were disclosed and were reported according to the KAPB model.
Knowledge
A ll four focus group participants knew about HIV and AIDS and that it had a high m ortality rate am ongst the youth. They were know ledgeable about the role o f VCT in prevention o f HIV and AIDS 51
Table 1: Frequencies of responses from four focus group interviews
Main category Sub-category Themes Four Focus group interviews
1. 2. 3. 4.
Knowledge VCT & prevention M ust test
Know your status
X X X X
X X -
-Barriers against VCT Fear Rejection Suicide
X X -
-X X X X
X X X X
M odes o f transm ission Infected blood X X X X
Sources o f information Media
Youth groups at school
X X X X
X X X X
A ttitudes M edia Explicit sex scenes X - -
-Parental guidance No guidance
Parents are ignorant
X - X
X X X
School guidance Sex education in the curriculum X X X X
D isclosure To sex partner
By doctors to families
By traditional healers to families
X X X X
X X X X
X X X X
Developm ent o f self concept Em powerm ent to say no to sex Em pow erm ent to use condoms
X X X X
X X X X
Practices Peer counselling Easier to speak to a peer
Youth program s run be youth
X X X X
X X X X
Pre and post-test counselling Ethical and legal right Support is made possible Keeping safe is encouraged
X X X X
X X X X
X X X X
Sexual risk reduction A bstinence Condoms M asturbation Thigh sex Virginity testing X X X X X X X X X X X X - - - X - -
-Beliefs Value clarification Partner loyalty
A bstinence
Alcohol, drugs and morality Poverty and prostitution
X X X X
X X X X
X X X X
X X X X
Support for PLA Encourage VCT
Support groups for PLA
X X X X
X X X X
Religion and culture M orals and religion
A fric a n c u ltu r e a n d se x u a l guidance
X X X X
X X X X
M isconceptions and Myths Paying for VCT Condom s have holes Virgin Cleansing
X - - -
X -
as well as the barriers against VCT. They knew about other m odes o f transm ission apart from the sexual, and where to obtain inform ation regarding the disease.
Voluntary counselling and testing and
prevention of HIV and AIDS
A ll p a r tic ip a n ts k n e w a b o u t th e im p o rta n c e o f V C T. T he fo llo w in g q u o ta tio n s b e a r te s tim o n y to th e ir convictions and are presented verbatim:
“People m ust go f o r the test. A ID S m ust be p re ven ted in anyway. Prevention is better than cure. ”
“You are not negative until y o u have tested; the only way to stop the spread is yo u m ust test. ”
“You m ust know where you stand. ” Studies dem onstrating that sexual risk behaviours are reduced significantly with V CT com e from a num ber o f developing countries (UNAIDS, 2001:46). The recent m ulti-centre V CT efficacy trial w as the first ra n d o m is e d tria l o f V C T from developing countries. It dem onstrated that VCT resulted in greater behaviour change than health education alone. The study also indicated that sero-positive p e o p le w ere m o re lik e ly th a n s e ro n e g a tiv e p e o p le to show s ig n ific a n t b e h a v io u r c h a n g e s in d e v e lo p e d c o u n trie s as o p p o se d to d e v e lo p in g countries w here this behavioural change was less significant (UNAIDS, 2001:46).
Barriers against VCT
T h e fo c u s g ro u p s c o n firm e d th e existence o f barriers against VCT. All four focus groups agreed that people do not go for V CT because o f the fear o f being te s te d p o s itiv e a n d th e n b e in g stigm atised by others. A dded to this, there w as the fear o f dying and thoughts o f suicide. Stadler, M orrison and Me Gregor (2000:4) states that HIV and AIDS a re la rg e ly a s s o c ia te d w ith s tre s s , prolonged suffering and death and Van Dyk (2002:278) m aintains that HIV and AIDS are associated w ith an increased likelihood o f suicide. These were some o f the com m ents;
Modes of transmission
Participants were well infonned about the m ode o f spreading o f the disease other than through sexual contact. In view o f the fact that HIV can be contracted via other m eans than sexual contact, the four focus groups stated the im portance o f VCT even for people who are not sexually active, as in d icated by the follow ing verbatim statement:
“W hen y o u touch the b lo o d o f H I V positive person yo u can g et A ID S i f yo u
have a sore. ”
Sources if Information
Sources o f sexual information were mainly the m edia and youth group activities presented by schools. The m edia in the form o f TV, radio, new spapers, posters, pam phlets as w ell as books and movies, is a rich source o f inform ation on HIV and A ID S (N eethling and Schoem an,
1999:72).
The four groups recom m ended a variety o f novel ways o f teaching about HIV and AIDS. D ram as, debating team s, RAP music and even youth groups going from h o u s e to h o u s e w e re so m e o f th e suggestions m ade by the participants. Some participants raised the valid point that there is enough information from the m edia but that it is ju st ignored by m any y o u n g p e o p le , as re v e a le d b y th e following statement:
“P e o p le d o n o t lis te n ; I th in k th e governm ent should stop advising people ab o u t A ID S because it is a w aste o f money we are like monkeys. ”
Attitudes
The participants o f the four focus groups had clearly expressed attitudes regarding the ro le o f th e m e d ia in p ro m o tin g prom iscuity, the inadequacy o f school and parental guidance in curbing the d ise a se an d th e ro le o f d o c to rs and traditional healers in non-disclosure o f patients’ HIV status. They also felt that the developm ent o f a strong self-concept would em pow er the youth against high- risk sexual behaviour.
“Som e paren ts have a negative attitude they w ill say she or he is no longer my d a u g h te r o r so n i f a p e r s o n is H IV positive. ”
“O ther p eople say i f la m H IV positive, I am g o ing to kill myself. ”
The media
Several p a rtic ip a n ts w ere o u tsp o k en against the incidence o f sex in the movies:
“I think the m edia m ust replace sex in th e m o v ie s w ith an e d u c a tio n a l program. ”
Two participants w ere outspoken about the visual sexual stim ulation caused by m o v ie s s h o w in g e x p lic it se x and according to Louw, Weitz and Radebe (1 9 9 6 :7 1 ) m a ss m e d ia c o n fu s e the children about m oral and ethical issues surrounding sexual behaviours.
The need for m ore inform ation by the media w as expressed as well. Literature from the following sources supports this fact (Maker, 2002:25; A lan Guttm acher Institute, 2003: http://w w w .org/press/ 2001/07/turkey0724-ltr.htm)
Parental guidance
All participants agreed that they were not getting enough parental guidance regarding H IV and A ID S. Literature supported this view (Davey, 1991 http:// w w w . p o p u l a t i o n . o r g . z a / r e a c h ). A cc o rd in g to T h e A lan G u ttm a c h e r Institute (2003: http://w w w .org/press/ 2001/07/turkey0724-ltr.htm ) parents are concerned about HIV and AIDS but do not seem to be c o n v in ced th a t open com m unication about sex and sexuality can reduce the risk o f HIV infection.
“O ur p a ren ts do not talk to us about sex. ”
“Parents m ust be taught how to talk to us about sex. "
School guidance
All four groups felt that m ore sexual education and inform ation on HIV and AIDS m ust be given at school and that it sh o u ld fo rm p a rt o f th e L ife S k ills E ducation p rogram . This o p in io n is supported by Van Dyk (2002:155) who agrees that HIV and A ID S education should be integrated into the existing school curriculum.
Two o f the groups said that they had re c e iv e d in f o r m a tio n fro m th e governm ent via health workers who visited the schools to give sex education. They indicated that the clinics provided information as well.
Disclosure
The focus groups were greatly concerned about the problem posed by keeping HIV status confidential since they felt that the spread o f HIV and AIDS would continue while people are protected by law from disclosing their status.
The four focus groups felt that people should disclose their status to their sexual 53
partners.
They were o f the opinion that when a person has died o f AIDS and the doctors and fa m ilie s and tra d itio n a l h ealers obscures this fact by saying that the cause o f death was some other illness; they are exacerbating the problem o f HIV and AIDS.
“D octors w ill not say a person died o f AIDS. They will say the person died o f
TB or cancer. ”
“Witchdoctors orfortune tellers must not lie, they m ust tell the truth about the illness (AIDS) o f the person, because th e y te ll th e p e o p le th a t th e y a re b ew itch ed a n d y e t th e y are d yin g o f AIDS. ”
Development of self-concept
The idea that a strong self-concept would lead to em pow erm ent o f o n e se lf was expressed and discussed by the groups. Kutz (1997:26) stated that empowerment occurs when one becom es able to take action for oneself. It is accom panied by a g ro w in g b e lie f in o n e s e lf and the grow th o f self-confidence.
All four focus groups were in agreem ent with the principle o f living a positive life a n d a v o id in g h ig h - r is k se x u a l b e h a v io u rs . T h is in c lu d e d th e w illin g n e s s to go fo r V CT. T h e y em phasized the need for the youth to change their sexual behaviour, not being influenced by peer pressure, not being coerced into a sexual relationship by a partner and saying “no” to sex with pride. They advocated the developm ent o f self- respect and assertiveness.
“Be able to say no to sex. Say it with pride. ”
“Being cool is not drinking and sm oking and having sex, it is about doing what is right. "
There was concern for the em powennent o f w om en in unequal relationships such as those married to - and living with HIV positive men. There was also concern fo r le a r n e r s in d is e m p o w e re d relationships. The developm ent o f a s tro n g s e lf - c o n c e p t as re la te d to asse rtiv e n e ss for w om en in unequal relationships was advocated.
Practices
The participants had certain perceptions regarding peer counselling, pre-and post
test counselling and practices regarding sexual risk reduction.
Counselling
Participants from all four focus groups strongly su p p o rted p eer co u n sellin g . S u g g e stio n s w ere m a d e th a t y o u n g people should work at clinics because it is easier to speak to a peer than to an adult about sensitive issues.
P e e r c o u n s e llin g is s u p p o r te d by literature, w hich states that behaviour change is most likely to occur when peers ed u cate, em p o w er and su p p o rt each other. That means that youth program s sh o u ld be run by y o u n g p eo p le. A su c c e s s fu l p e e r e d u c a tio n p ro g ra m transfers the control o f know ledge from the hands o f experts to the lay mem bers o f the community, thereby m aking the educational process m ore accessible and less intimidating (Cox, 1999:4; Stanhope & Lancaster, 1988:78).
Pre and post-test counselling
All participants agreed that counselling should be done before and after an HIV test. The client should be prepared fully to face the outcom e o f the results. They knew that voluntary confidential pre- and post-test counselling is the ethical and legal rig h t o f each p e rso n . It is o f invaluable im portance to prepare the person for the outcome o f the test. After a p o sitiv e finding it is fun ctio n al in supporting the sero-positive person both e m o tio n a lly a n d p h y s ic a lly a n d encouraging him /her to preventing the spread o f the disease. The p o st-test counselling o f a person who has tested n e g a tiv e fu n c tio n s to in flu e n c e the person to stay negative by implem enting safer sex practices.
Sexual risk reduction
Reducing the rate o f HIV infection among teenagers w ould lead to a substantial slowing o f the epidemic over the next five to ten years. Conversely, failure to curtail the rate o f infection in this age group could sustain an epidemic o f catastrophic proportions for future decades (Stadler, et al., 2000:1). The focus groups had strong convictions regarding the need to stop the spread o f H IV and AIDS through the advocacy o f abstinence and/ or safer sexual practices.
Abstinence
All gro u p s w ere o f the o p in io n that abstinence was the most practical way o f protecting oneself from HIV-infection.
“I think we m ust abstain from sex before m arriage "
“Sex is n o tfo r children, it is not a gam e ” Safer sex
The four focus groups were aware o f high risk sexual practices and agreed that sex without a condom is a num ber one high risk factor for contracting HIV and AIDS. The p erceptions an d opinions o f the participants regarding safer sex were the following:
• The use o f condoms. The majority o f the four groups were in favour o f using male and/or female condoms for preventing transm ission o f HIV and AIDS. • M asturbation. There were
mixed reactions to the practice o f m asturbation. Two groups were in favour o f m asturbation as a form o f preventing the spread o f HIV and AIDS. Some participants were however opposed to it w ithout giving valid reasons. Van Schaik (2002:243) says that attitudes towards m asturbation are usually based on cultural and religious beliefs.
• Thigh sex. Only one group m entioned thigh sex as an option for curbing the spread o f HIV and AIDS.
• Virginity testing. Only one male participant encouraged this method o f practicing safer sex but the other participants did not entertain the idea. Research as done by Leclerc-M adlala (2003:7) says that virginity testing may lead to harassm ent or banishm ent o f girls by communities.
Beliefs
The participants o f all four groups stated their beliefs in upholding moral values as advocated by different religions and cultures and supporting people living with HIV and AIDS.
Some misconceptions and myths were voiced.
Values clarification
T he fo cu s g ro u p s w ere stro n g ly in favour o f virtues such as loyalty and trust am ong partners as well as abstinence from sex until marriage, and were opposed to married men who are unfaithful to their
spouses. H o w ev er a c c o rd in g to the Population Registration Bureau (2004: http://www.populatioin.org.za) there is a high level o f se x u al a c tiv ity am o n g learners. Nationally, two thirds o f thirteen year-olds in South A frica are estim ated to have already experienced their first sexual encounters.
The fo u r fo c u s g ro u p s a g re e d th a t alcohol and d ru g ab u se has a g reat impact on the youth, exposing them to high-risk sexual behaviours.
Three groups stated that prostitution was a prominent factor in the spread o f HIV and AIDS. W ith regard to prostitution th e y a lle g e d th a t p o v e r ty w a s an in stig atin g facto r. E v ian (2 0 0 3 :1 3 ) confirm s th is o p in io n in say in g th at poverty, unem ploym ent and poor socio economic conditions are the factors that ex acerbate p ro stitu tio n and th u s the spread o f HIV and AIDS.
Support
P a rtic ip an ts a g re e d th a t su p p o rt for people living with HIV and AIDS (PLA) would low er the prevalence rate o f the disease. The reasoning behind this belief is that people w ould go for V C T and disclose their status if they did not fear stigmatisation and knew that they could count on the support o f the community. The focus groups w ere m uch in favour o f setting up support groups for people living w ith HIV and AIDS.
"Being H IV positive is no longer a death sentence. ”
“We need to help others to p reve n t the spread o f HIV. ”
Religion and culture
The four focus gro u p s v o iced strong opinions about the need for the youth to change their moral behaviour to be in line w ith the te a c h in g s o f th e ir d iffe re n t religions.
P a rtic ip a n ts h a d c o n c e r n s th a t in traditional A frican culture parents do not d isc u ss s e x u a lity is s u e s w ith th e ir children, thus preventing their guidance concerning sexual practices, H IV and AIDS.
Misconceptions and myths
T here w e re a few p a rtic ip a n ts w ho wrongly thought that one had to pay for V CT an d d id n o t k n o w th a t it w as available free o f charge in South Africa.
A few p articip an ts w ho had negative com m ents about the use o f condom s saying that condom s have holes in or can burst. Sum m erton (2001:60) alleges that people do not like using condom s and prefer having sex “flesh to flesh” . Only one boy m entioned that he knew o f “other people” w ho believe the virgin cleansing myth.
Discussion of field notes
T h e r e s e a r c h e r d e s c r ib e d th e tra n sa c tio n s and p ro c e sse s o b serv ed during the data collection phase. She o b s e r v e d a n d d o c u m e n te d s e a tin g arrangem ents, conversations, non-verbal la n g u a g e a n d r a p p o r t b e tw e e n participants as well betw een participants an d m o d erato r, rese a rc h er and study leader. Personal notes and com m ents c o n c e rn in g h e r fe e lin g s d u rin g the interview s w ere docum ented as well. T h e r e s e a r c h e r o b s e r v e d th a t participants w ere open and free in their d is c u s s io n s o f V C T . N o o n e fe lt intim idated in the group. R apport w ith the m oderator w as good and there was m utual trust. Som e o f the participants were not verbally active in discussions b u t w e re le a n in g fo rw a rd , th e re b y showing interest.Discussion
V CT is a very sensitive topic to discuss especially w ith young people because it h as a m ig h t h a v e a c o n n o ta tio n o f encouraging sexual activity. Taking into consideration that it is not accepted in A frican culture to talk about sex w ith y o u n g p e o p le , th e y o u th th a t w e re in te r v ie w e d w e re o p e n - m in d e d in discussing their view s on VCT, sexual practices, HIV and AIDS.
In conclusion it can be said that the four focus groups w ere know ledgeable about H IV a n d A ID S as w e ll as V C T in particular. They were willing to participate in th e d is c u s s io n s , h a d in fo rm e d opinions and expressed their feelings. All groups w ere in favour o f VCT and had insight in to the manner in which VCT can aid the prevention and m anagem ent o f HIV and AIDS. They w ere adam ant that p eo p le sh o u ld be en co u rag ed to com e forw ard for V CT and the em phasis should be on “know ing your status” . The study revealed that young people
55
are aware o f their rights w ith regard to testing for HIV. It w as mentioned several tim es that pre- and post-test counselling is imperative, em powering the individual to deal with the result in a positive and constructive manner.
M ost preventative strategies have been b ased on the p re m ise th at in creased knowledge about HIV and AIDS will lead people to adopt safer sex practices. The fact that the prevalence o f the disease rem ains high in South A frica seem s to s u g g e s t th a t th is a p p r o a c h h as fundam ental shortcom ings (Summerton, 2001:13). People are now encouraged to m ake use o f VCT to find out their HIV status so as to curb the spread o f the disease.
This study also confirm ed that there is a great need for the youth to be inform ed about HIV and A IDS. The m edia was cited as the best w ay to inform the youth such as TV, radio, dram as and posters. O th e r m o d es th a t w ere in d ic a te d to provide HIV and AIDS information were w orkshops, m usic, group discussions, debates and going from house to house to provide HIV and A ID S information. T he study c ited the lack o f p aren tal guidance as one o f the m ajor obstacles to inform ing the youth about safer sex p ra c tic e s. A fric a n cu ltu re p ro h ib its parents from talking to their children about sex. P arents should be taught skills on how to com m unicate to their children about sex.
P a r tic ip a n ts o f th e s tu d y f e lt th a t education and life skills training in junior and s e c o n d a ry s c h o o ls w h ic h w ere direct, specific and concrete w ould be invaluable in inform ing young people on ways to curb the spreading o f HIV and AIDS.
The functioning o f the groups was in line w ith the observations o f the researcher and the results o f the discussions are on par w ith literature. This study adheres to the principles o f trustw orthiness in qualitative research.
The limitations o f the study lie in the fact th a t the re s u lts o f th e fo cu s g ro u p s c a n n o t be g e n e ra liz e d to the w h o le population. H ow ever generalization in a q u a lita tiv e stu d y su ch as this is not s ig n if ic a n t b e c a u s e th e s tu d y h a s intrinsic value o f its own and has heuristic relevance. This value is reflected in that
th e re a d e r is a b le to re c o g n is e the phenom enon described in the study, its theoretical significance, its applicability to nursing practice and its influence on future research activities.
Conclusion
T h e o b je c tiv e o f th e s tu d y w as to determ ine the perceptions o f the youth about VCT. During this process other perceptions o f the youth concerning HIV and AIDS became apparent. They also presented their opinions as to how some problem s related to the prevention and managem ent o f HIV and AIDS can be addressed. The study indicated that the learners w ho w ere interview ed knew a b o u t V C T a n d th a t it w a s th e ir p e r c e p tio n th a t V C T m ig h t be implemented to prevent the spread o f the disease and help m anage the lives o f those people already influenced by it.
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