Chiure is the District with the highest population in Cabo Delgado Province,
with about 260’000 inhabitants of mainly Macua origin living in 140 villages
and on 4210 km. There are, on average, 26’000 inhabitants per health centre,
one doctor and 51 nurses for the entire district. As in many other African countries,
AIDS is a highly prevalent chronic disease in Mozambique, with an estimated
16% of the population (15-49 years) carrying the virus and 10% infected in the
Northern part of the country. Chiure District HIV testing centres report a prevalence
of 23% (Chiure District Health Data 2008); a minimum of 25’000 persons in the
District are infected with HIV. Furthermore, less than half of the population
has access to health centres and death registration rate is below 25%.
In such conditions, empowerment of the rural population to prevent and/or manage
health issues appears a necessary but long term intervention. Given that – despite
a constant increase – a relatively low HIV prevalence still prevails in the
Northern region, prevention activities are essential to keep this level down.
Community Empowerment for Health
Wiwanana is a Macua word and means “mutual understanding and collaboration”.
The so-called programme stands at the interface between the state health service
providers and the communities, where it acts as mediator, moderator and educator.
Such interface is necessary where wide spread and deeply rooted distrust against
the state health services exists, as it is the case in this working area (“I
did not go to counselling in the VCT for fear that they would give me pills
with AIDS”, home based care volunteer, 2008). Local partners support the programme
as they recognize the existing communication gap and the importance to approximate
the poles. Wiwanana is mainly active in the rural communities, where trained
field workers use participatory approaches to initiate learning processes on
four health topics: Hygiene and Sanitation, Malaria, Mother and Child Health
and HIV/AIDS. At their first community meeting, key community players are identified
to later facilitate the organisation of health groups within their community.
Such groups then perform house to house visits and speak during community assemblies.
During the many community meetings and discussions on safe sex, HIV/AIDS and
family planning held since the start of the programme, the importance of human
sperm remains paramount and unshakable, and its consequences for HIV/AIDS prevention
are worrying.
The human sperm – traditional beliefs
In Macua culture, men and women are equally convinced that human sperm bears
the following qualities and characteristics:
- Energetic value to the woman who receives it during sexual intercourse
- Nutrition for the foetus during pregnancy
- Food to the pregnant woman
- Having polluted colostrum (“first milk”)
- Capable of polluting normal breast milk
Whereas the population sees the first three aspects as beneficial, the presence
of sperm in the colostrum (sometimes also defined as “sperm which exits in the
mother’s breast”) and breast milk is a negative aspect.
The human sperm – consequences
Following these traditional concepts, single women tend to actively seek casual
relationships with men, as they consider sperm as a necessary and nutritious
element. The same is true during pregnancy: Frequent sex with the husband or
with another man (if there is no husband) is considered beneficial. Married
couples may have unprotected sex regularly. However, if the husband is far away,
a pregnant woman may actively seek a sexual relationship with another man, to
guarantee the best conditions for herself, and for the foetus. This is not always
to the pleasure of the family. Sexual escapades often result in conflicts, as
it is believed that each man who had a sexual relationship with a pregnant woman
shares the development and making of the coming child. If a woman had sexual
relationships with more than one man during pregnancy, one speaks of “gravida
juntada” (Portuguese for “joint pregnancy”).
Whereas sperm is generally considered beneficial to the foetus, it also is
commonly accepted that complications during labour indicate extra-marital sex
during pregnancy. In this case, the family will investigate who else has “contributed”
to the “making” of the child to make him pay child allowances. This potential
economic benefit can be torturous to the woman in labour. A pregnant woman with
complications during labour will be left to suffer and refrain from seeking
help until she admits and tells the name of a second man. Only then will she
be sent to the health centre for help. As a consequence, a woman is likely to
admit extra marital sex on the basis of saving her and her baby’s life. This
delay in care-seeking can be of disastrous consequences both for the women and
for the child.
In 2008 a head of a clan reported, “the first-born of my grand child was
delivered by Caesarean section, done in Nampula hospital, and we thought it
was because she did not tell us the names (of the men with whom she had had
sexual relations ). When she was pregnant for the second time, our family insisted
that she must give birth at home in the village, in presence of the traditional
midwife and the family members, not to repeat the same mistake. But then the
Safe motherhood group of Wiwanana and the traditional midwife convinced us that
she should give birth in the hospital, otherwise she would die.”
Once the newborn has arrived, it is deprived from drinking the highly nutritious
colostrum (first milk) of the mother. Colostrum is perceived as dirty breast
milk, already polluted by sperm from sexual encounters during pregnancy (“we
think that the first milk coming from the breast is full of sperm, and therefore
we do not recommend to feed it to the newborn as it is dirty milk”, group
discussion of various leaders and members of the community, May 09). Instead,
the newborn will receive breast milk from another mother until his/her own mother
has started to produce breast milk – a dangerous behaviour in areas of high
HIV prevalence. Whereas colostrum is considered to be spoiled by sperm from
encounters during pregnancy, normal breast milk has the potential to be polluted
by sperm from sexual encounters during the lactation period. For this reason,
breast-feeding mothers are not allowed to have sex at all for about 2 years.
Also, the penis of the man may “frighten” the child, which will consequently
fall ill. Many men take this period of abstinence during lactation as an excuse
to have sex with other women. Furthermore, it can also have negative consequences
for the baby: A breast feeding woman may not take a sick child to the health
centre for fear of being accused of extra marital sex - since her husband is
supposed to strictly observe the same rule.
In Northern Moçambique, initiation rites are widely held both for young men
and women. During these festivities, mostly elderly “initiation rite counsellors”
tell the young how to behave in sexual matters. The above named concepts are
transmitted and enforced during these rites, which have a very strong sexual
component (e.g. girls dancing naked imitating sex with men using a wood phallus
etc.). Sometimes, at the end of the initiation rites, girls are encouraged to
have sex with many different men, “to try out which fits best” (“from now
on you are grown up; you are ready to sleep with any man”, female rite
counsellor). Due to their length, price, intensity and strong social dynamic,
initiation rites are a key moment in the definition of sexual behaviour for
young people in Cabo Delgado. Messages related to the prevention of AIDS and
other Sexually Transmitted Diseases are normally not given during these rites.
Cultural norms and the compliance with traditional concepts are a means of
social coherence. Today, the same rules increase the spread of HIV, an epidemic
likely to affect 20-30% of the population, and already killing thousands.
Some findings on condoms distribution and use
Wiwanana applies a condom distribution concept which it calls “intelligent
distribution”: Local shop keepers are contracted and supplied with somewhat
stylish and commercially advertised condoms for sale; religious and political
leaders as well as traditional health service providers are supplied with “no-brand”
- condoms for free distribution. Shop keepers are also supplied with balloons
for sale to children, to prevent them from playing with condoms.
Despite the cultural barriers indicated above, the general demand for condoms
appears to be on the rise. In 2008, the programme was not able to meet the demand
due to a complete condom stock rupture at District level during several months.
Complementing national efforts, Wiwanana provides about 1-2 condom per man
per year in the District. The sales of condoms in local community shops are
stagnant and sellers are not interested to sell them anymore due to low demand
(up to 6 condoms sold per month). Women appear to be especially reluctant to
buy condoms at open shops. A woman publicly seeking and receiving condoms may
be accused to be a prostitute by members of the community.
In addition – but probably more for curiosity than eagerness to use it – female
condoms are frequently asked for in community meetings. The Ministry of Health
has now launched the introduction of these on a pilot basis. Wiwanana will support
the District Health Directorate in its efforts and closely monitor the reactions
of the communities.
Traditionally, condom use is out of question for a pregnant woman seeking to
“feed the child and herself”, as the objective of such behaviour is based on
more profound reasons than pure pleasure. The man, on the other hand, may not
use condoms for other reasons (”it needs to be flesh and bone, that is what
I pay for“, man, community reunion, 2009).
During a recent group discussion with young men (n=23) and women (n=12), reasons
for young men to not use condoms were:
• want “flesh-to-flesh” contact
• irrigate the woman
• want value for money
Reasons for young women not to use condoms were:
• suspect HIV/AIDS to be in the condom
• need of vitamins (sperm)
• need to have children
• fear that the condom stays in the womb
These reflections may indicate a certain gender imbalance regarding awareness
and knowledge on the subject. They also confirm the deep roots of cultural concepts
around human sperm, especially its nutritive value to the receiver. Whereas
the concept of “human sperm” is an important influencing factor, sexual decisions
and condom use are affected by other aspects also: “My husband told me to
use condoms such as I could finish my studies, but I refused. I got pregnant,
had the child, my husband left, the child is not registered as it needs the
father to be there”, young woman, focus group discussion 2009. “When
I asked a young woman for sex, she wanted to use a condom, but I refused and
told her I will ejaculate outside. I convinced her as she wanted the money and
I got some sexually transmitted illness from this relationship”, young
man, focus group discussion 2009.
The intervention
Wiwanana has a broad, participatory, community-near approach covering many,
but not all, influential factors, such as promotion, formal and informal information,
education and communication. Most important, the project gained trust among
the population – an essential base for introducing change (“in the beginning
I did not want to participate in Wiwanana meetings; I thought they were spreading
cholera and AIDS”, male farmer, 2008). Methodologies and topics changed
and were added during the last ten years; they were constantly adapted to experiences.
HIV prevention efforts were included in the programme since 2003, with the
following strategic objectives: Consistent use of condoms, reduction of concurrent
relationships, delayed onset of sexual activity, prompt care seeking in case
of illness (STI, HIV), use of sterilized instruments during traditional treatment
(needles, blades), improved referral between traditional healers and formal
healthcare providers, increase of male circumcision, better use of mother-and-child
services (PMTCT).
Main target groups are young people (especially young girls), high risk individuals
such as casual sex workers or truck drivers (which play a paramount role especially
in evolving epidemics), but also “normal” women and men.
To attain the objectives and to increase its impacts, Wiwanana works with relevant
peer leaders, such as initiation rite counsellors, traditional healers, elders,
religious leaders, informal community drug injectors, village health workers
or shebeen (bar)-girls. An enabling and consistent framework is provided by
strong local Government stewardship.
In 2008, Wiwanana has been working with 248 village health groups, organized
222 meetings with traditional healers and initiation rite counsellors; 69 encounters
with young people, 22 at local schools and 83 meetings in bars, discos and other
public high risk places. It has realized 42 radio emissions on AIDS, 24 film
and 15 theatre presentations. A spot to promote Voluntary Counselling and Testing
(VCT) was broadcasted 560 times. About 100’000 believers have been reached through
Christian and Islamic church leaders. Wiwanana also works with 17 female sex
workers, 23 advisors in 10 shebeens (local bars), as well as youth groups in
9 schools.
Strongly committed to HIV prevention, Wiwanana closely works together with
another SolidarMed programme called SMART. SMART supports state HIV services
such as voluntary counselling and testing, antiretroviral treatment, the prevention
of opportunistic infections, the prevention of mother to child transmission,
home based care and STI clinics. With an additional “technical assistance to
the health sector” component at District level, the base for integrated health
system strengthening is also provided.
Discussion
Individual health-related behaviour is influenced by many factors, including
political, socio-cultural, economical, educational, personal and environmental.
Each factor depends on various underlying variables, of which some weigh more
and some weigh less. The collusion of all these variables will, at the end,
result in a certain behaviour of a specific individual at a specific time point.
Understanding these variables, weighing their relevance for specific health
related problems and assessing their interdependency with other variables is
necessary for the design of successful interventions aiming at behaviour change.
With its programme, Wiwanana intends to influence some of the key factors of
health related behaviour.
Having sought to understand the key cultural barriers to HIV prevention, Wiwanana
has subsequently made various efforts to address these obstacles. Its peer education
concept and its strong collaboration with initiation rite counsellors, traditional
healers and village elders are examples for strategies to overcome them.
However, isolated NGO efforts to act on traditional health related concepts
are not sufficient to provoke change. Messages and stimuli must come from multiple
sources, be consistent in content, ongoing in time, adapted to local culture
and embedded in an enabling framework. Changing traditional concepts is a long
term effort (probably over generations) involving various inputs through different
channels and at different levels. Wiwanana’s experience, confirmed by community
members, is that messages are adopted more easily when reaching the individual
from different sources, such as radio, peers, leaders, pamphlets, theatre, traditional
healers, affected relatives, initiation rite counsellors etc.
A female farmer in 2009: “…before, I was a prostitute…I once assisted a
Wiwanana meeting talking about AIDS and its prevention, but I did not believe
it…then, one day I assisted a theatre play about AIDS, and I started wondering
whether it was true or not…finally when I saw a man dying of AIDS here in the
village, then I started thinking and changed my behaviour.”
New behaviour appears to be easier adopted than a complete change of habits
and concepts. For instance, the acceptance of – not harmful – traditional medicines
as a complementary treatment is the basis to motivate people to search help
at health centres in high risk situations.
Working closely with the communities in rural areas, Wiwanana has generated
a rich bouquet of experiences with the local culture and traditional health
beliefs. In this example, the deeply rooted concept of the importance of sperm
for women and foetuses has been identified as an important cause for sexual
high risk behaviour. Taking it into account for the design of its interventions,
Wiwanana is able to contribute to awareness building in young men and women,
who think, debate and act on the AIDS pandemic and prevention measures in the
District. A few years ago it would have been shocking and seriously offending
to publicly talk about sex. This time however, is now over (“some values of
our tradition are braking away for the sake of our health”, female farmer, 28y).
This felt progress is comforting. Yet, whereas behaviour change is possible,
the process may be slow – a mixed acknowledgment given the high human toll and
emergency of the situation. For the moment, constant presence will be necessary
to keep up the momentum and to avoid fall backs into previous structures.
The Wiwanana programme is now in the phase to become a National organisation
with a strong knowledge management component. As such, it hopes to secure a
more permanent position, act long term, disseminate its experience and counsel
other local organisations and institutions on cultural and community empowerment
aspects in health and health promotion.
HIV is a complex disease, resonating far beyond health dimensions. For this
reason, SolidarMed has chosen a comprehensive approach and interventions now
cover all main areas from prevention over treatment to care. One of the most
important variables, however, remains the individual and its beliefs buried
in a network of external inputs.
*M.A. Hobbins is the Country Coordinator of SolidarMed in Chiure, Mozambique;
F. Haupt works as Project Coordinator of Wiwanana, Chiure, Mozambique; J.C.
Samuel is in charge of Strategic Development Wiwanana, Chiure, Mozambique, and
J. Ehmer is the Health Programme Officer of SolidarMed in Lucerne, Switzerland.
Contact: Dr. Michael Hobbins, MSc, PHD; SolidarMed, P.O. Box 357, Pemba, Mozambique;
tel/fax: +258 272 44048, cel: +258 82 34 36 180, Email: m.hobbins@solidarmed.ch
Acknowledgement: We would like to thank all local stakeholders, but especially
the Wiwanana team for all their efforts and contributions in the programme during
the last 10 years. Without them, this article would not exist.
