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E. E. Enwereji
Ph. D.
College of Medicine
Abia State University
Uturu, Abia State, Nigeria
Email: hersng@yahoo.com
Phone: 2348036045884
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ABSTRACT
Background and objective:
Partner notification is encouraged
for safer sex practices to minimize
HIV infection, but PLWHA reports violence
after disclosure. Most surveys focusing
on violence and HIV/AIDS concentrate
on identifying women with violence
but do not encourage the participation
of such women in planning feasible
interventions to reduce violence.
Study aimed to use participatory
reservation approach (PRA) to assist
PLWHA to plan interventions to reduce
domestic violence against them.
Methods:PRA was used to enable
PLWHA plan intervention to reduce
domestic violence. Data was collected
through 12 focus group discussions
and interview guides with a sample
of 96 PLWHA in a network of PLWHA.
Data was analyzed quantitatively and
qualitatively using simple percentages.
Results: Domestic violence
was experienced by both sexes. Domestic
violence was perceived from different
experiences including mutual exclusion
or restriction from participating
in social functions after disclosure.
Out of 45(46.9%) PLWHA that disclosed
their status, 36(40%) experienced
violence. Interventions suggested
for reducing violence included theater
plays in public places, providing
job opportunities and others.
Conclusions: Results showed
PRA as an efficient and cost effective
method of planning strategies to reduce
violence among PLWHA. Training programmes
on risks of violence on HIV infection
is needed for both sexes.
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Key Words: domestic
violence, partner notification, participation,
strategies, Nigeria
People
living positively with HIV/AIDS (PLWHA)
especially women are likely to face risks
of being beaten, chastised and other violence.
In Nigeria, the Demographic Health Survey
(2003) states that only 24% of married teenage
women ever discussed their HIV status with
their husbands. HIV Counselors encourage
partner notification to promote safer sex
practices and reduce further infection [1].
But most times, PLWHA report domestic violence
after disclosure [2,3,4].
Most health surveys targeted
at PLWHA including [5] have primarily focused
on effects of violence on HIV/AIDS with
little or no effort to include PLWHA when
planning interventions for them. Nigerian
demographic health surveys are therefore
designed to determine the prevalence of
violence among PLWHA so as to enable policy
plannersto plan effectively. Policy planners
and programme operators of these surveys
are of the view that knowing more about
demographics of PLWHA would enable them
to plan adequately for interventions to
improve their life. These kinds of survey
could be problematic in that they aim to
isolate social determinants of violence
and cut-off levels without involving inputs
from PLWHA who experience violence. Moreover,
most of these surveys have been house-to-house.
They could be expensive, time consuming,
and may result in poor services and/or sustainability.
These kinds of surveys have been reported
as counterproductive especially when services
are not followed up [6].
Study involved PLWHA
in initiating feasible interventions to
reduce domestic violence against them using
participatory reservation approach (PRA).
PRA framework as used in the study provoked
PLWHA participation. PRA is an important
approach derived from agricultural surveys
that have potentials for more effective
sustainability [6]. PRA involves using affected
people as active analysts of their own situation
and to set priorities on how to change their
situations.
PRA has a defined methodology
and systematic learning process that stresses
changes in behaviour and attitude of individuals
through group inquiry and interaction. It
is an important tool for planning, and evaluating
health programmes as well as for identifying
support in service delivery and gaining
access to potential influences to community
change [7,8]. This framework was used because
it recognized views of PLWHA and empowered
them to have a sense of ownership to suggested
intervention processes. It also enabled
the author to gather information from PLWHA
with participatory method procedures.
In Nigeria, social perceptions
of domestic violence are viewed in context
of cultural practices and beliefs in communities.
Some communities see domestic violence as
an incurable disease [9] while others see
it as social problem influenced by religion,
socio-economic status, and educational background
[10]. These cultural beliefs and perceptions
affect how PLWHA are treated as well as
socially accepted in society. Negative attitudes
of society toward HIV infection influence
acceptance of PLWHA [11] and this gives
rise to stigmatization of PLWHA [12,13].
Therefore determining
how PLWHA with different cultural backgrounds
perceive domestic violence could be a good
indicator in assessing effectiveness of
PRA in planning interventions to minimize
violence.
- To use PRA to assist
PLWHA identify strategies to minimize
domestic violence against them.
- To note conditions
that encourage PLWHA disclosure of their
HIV status.
- To identify
factors that influence domestic violence
against PLWHA
Study used qualitative
research method. This method helped to access
PLWHA perceptions of domestic violence thereby
facilitates their participation. Focus group
discussions were used to explore views of
each PLWHA on relevant interventions. Methodology
in using the PRA framework is to initiate
interventions that would transform society's
negative attitudes and behaviour against
PLWHA so as to attract changes that PLWHA
in the situation would regard as improvement.
The researcher is of the view that interventions
suggested by PLWHA using PRA would create
more impact than others. The role of author
in this study was to assist PLWHA to achieve
the desired change using the interventions
they suggested.
Study population:
Study was conducted with a total sample
of 96 PLWHA in a network of PLWHA. The sample
consisted of (56 females and 40 males) between
the ages of 22-65 years.
Network of PLWHA was used because of the
difficultly in identifying PLWHA in society.
People are not willing to disclose names
and addresses of PLWHA and PLWHA themselves
are not disposed to disclose their sero-status.
Moreover, the network is made up of PLWHA
whose sero-statuses are already known.
Men were included
in the study because they were thought to
have valuable experiences and understanding
that would enable them to suggest practical
strategies for reaching other men in society.
It was also to note the extent to which
male PLWHA also experience violence.
Ethical considerations:
Permission to conduct the study was obtained
from the President of the network of PLWHA
in the State. His approval enabled the researcher
to collect information from participants.
Instruments used for study did not request
the participants to write their names or
anything to identify them. In addition,
statements of confidentiality were given.
Participants were given briefs on objectives
of the study. Permission to tape-record
the session was made and guaranteed.
Data collection:
Two methods of data collection, focus group
discussion and interview guides were used.
Interview guide was administered for illiterates
and self-administered for literates. In
all, 10 focus group discussions were conducted.
Each focus group had 9-10 PLWHA.
Focus group discussions
were conducted through a trained moderator.
All discussions were conducted in the local
language to enable participants, even illiterates,
to take active part in discussions. All
discussions were tape-recorded. Participants
were encouraged to talk freely among themselves.
PLWHA were invited through their President
to their regular meeting place. Open-ended
and closed-ended questions characterized
the format of the instruments.
Focus group discussions
were recorded, transcribed, and translated.
Transcript notes were read and cross-checked.
Recording equipment used was checked regularly
to determine its reliability. Data were
coded according to themes, and categorized.
Analyses of data were manually done using
qualitative and quantitative methods with
simple percentages. For clarity, all related
information was pooled together and reported.
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Demographic variables
of the sample:
The age distribution of the PLWHA varied.
More than half, 49(51%) of the sample were
between the ages of 29-42 years (see Table
1). Findings on the marital status of
the sample show that a good number of them,
49(51%) are married. (See Table
2).
For level of schooling,
the sample was made up of 8(8.3%) as illiterates,
47(49%) with primary education six and secondary,
while 41(42.7%) have tertiary education. Also,
59(61.5%) live in rural areas and 37(38.5%)
live in urban areas. In all, 15(15.6%) of
PLWHA made up of (11 females and 4 males)
had sero-status discordant families.
Perceptions of domestic
violence:
Domestic violence was perceived by PLWHA
from three viewpoints; as physical, emotional
and social problems. Finding shows that
most PLWHA perceived domestic violence from
the viewpoints of their experiences. However,
during the focus group discussion, PLWHA
from the rural areas could not see rape
and/or extramarital sexual relationships
as serious violence against them unlike
those from the urban areas. In this study,
participants saw domestic violence as a
functional breakdown rather than by related
causes. Table 3 contains
various perceptions of domestic violence.
Identified PLWHA
with domestic violence:
One unique finding in this study is that
both male and female PLWHA experienced domestic
violence. A total of 65(67.7%) PLWHA experienced
violence ranging from chastisement, flogging,
beating, discrimination, use of abusive
words, to attempted murder, but this was
more on those who disclosed their sero-status
than others. The finding shows that the
main challenges PLWHA faced include whether
or not to disclose their HIV status, who
to disclose to, and if they eventually disclose,
what the consequences would be. Out of 96
PLWHA studied, 35(36.5%) of them disclosed
their sero-status to close relations and
friends. Using the report of one PLWHA,
"when my church pastor learned of my
HIV status, he excluded me from church activities
especially holy communion and he told other
church members about my status and since
then, I have never attended church functions."
Another crucial
finding in the study was the confusion of
the PLWHA on whether or not to get married.
The result of the focus group discussion
showed that a good number of the PLWHA,
especially the singles had the zeal of getting
married and raising their own families.
Factors and/or conditions that increased
violence:
PLWHA identified five factors and/or conditions
that encouraged violence. Table
4 contains the details.
Among the factors listed
by PLWHA, negotiation for condom use was
the commonest cause of violence against
them. Using reports of five PLWHA, "once
the issue of using a condom for sex is raised,
there would be suspicion that the person
has been going out with others. And from
that time onwards, there will be no more
peace." One important finding in this
study is that both male and female gave
this report, showing that violence occasioned
by use of condom cuts across all sexes of
PLWHA.
Another factor that influenced
violence was demanding of financial assistance
. Using the reports of three PLWHA, "there
will be peace as long as one does not demand
for money either for food or for drugs."
Regrettably, a good number of the PLWHA
complained of no meaningful means of livelihood
and the few that had jobs reported setbacks
in their respective businesses as a result
of constant episodes of ill health.
Suggestions
on strategies to reduce domestic violence:
There was an overwhelming desire on the
part of PLWHA to suggest things that could
discourage domestic violence. To express
this desire, a good number of the PLWHA
freely made suggestions, and justified the
reasons why each suggested strategy is considered
realistic and important for reducing domestic
violence. This justification is considered
strength to the study. Table
5 contains the summary of the suggested
interventions.
From this Table, encouraging
financial independence and organizing theater
programs in markets, churches and other
public places were the popular strategies
suggested. PLWHA stressed that providing
them with job opportunities would increase
their income generating potentials thereby
reduce over dependence on others, thereby
reduce unnecessary use of uncomplimentary
words on them by relations. Further, PLWHA
explained that theater plays would be beneficial
if the programmes concentrate on information
on gender sensitivity, skills for anger
management, and decision-making. According
to them, the essence of the strategy is
to reach individuals of various classes
in the society.
PLWHA's suggestion on
the need to use male peer groups to sensitize
the communities was aimed at encouraging
gender equity as well as creating situations
that would enable females to express their
problems openly. The idea PLWHA gave for
advocating use of influential adults to
organize workshops/seminars in communities
is to enable influential adults to sensitize
individuals on the effects of violence on
HIV infection. These suggestions point towards
practical ways and opportunities PLWHA perceived
would reduce domestic violence.
The study shows that
PRA is useful in identifying PLWHA with
domestic violence. However, there were discrepancies
on what constituted domestic violence. While
PLWHA from urban areas viewed rape and extramarital
sex as domestic violence, PLWHA from rural
areas did not. They saw extramarital sexual
relationships as men's way of life. From
perspectives of social, physical, and emotional
problems, PLWHA viewed domestic violence
in terms of restricted activity and participation
in social functions. This finding agrees
with that of [4,5] that stigmatization and
rejection dominated life experiences of
PLWHA, and that they view their life along
this way. This implies that stigmatization
(restrictiveness) is a major concern of
PLWHA, especially females.
Surprisingly, male PLWHA
who are traditionally major decision makers,
also experienced domestic violence like
females. This finding suggests that social
welfare of these males like that of females
is neglected. However, the fact that both
sexes experienced violence is a significant
finding. This finding underlies challenges
that each sex had .
Two popular strategies
dominated suggestions of PLWHA. These are
providing job opportunities to encourage
financial independence 69(71.8%), and organizing
theatre plays in public places 54(56.3%).
These suggestions reflected challenges PLWHA
encountered in their life experiences.
One unique benefit of
this study is that PRA encouraged consensus
among PLWHA. It ensured cohesiveness and
flow of quality information. Similar findings
were reflected in the study of [14].
The time span for this
study was limited. There was no time allotted
for evaluating and monitoring the outcome
of all interventions suggested. However,
it could be noted that using PRA approach
proved fast and inexpensive way of identifying
practical activities for reducing domestic
violence against PLWHA. The speedy nature
of identifying problems using PRA was also
highlighted in the studies by (1, 6, 14).
It could be argued that using PRA in this
study served as an educational intervention
method. PRA enabled PLWHA to have a better
understanding of interventions that are
capable of minimizing violence as well as
their roles in the sustainability of interventions
suggested.
Study showed that 36.5% of PLWHA disclosed
their HIV status. This figure is higher
than that of 24% found in Nigeria by [5].
This increase in proportion of PLWHA who
disclosed their sero-status is of advantage
to HIV prevention and could be partly due
to the increased number of people who are
recently joining the network of PLWHA where
they attract care and support from each
other.
The commonest factor
that encouraged domestic violence among
PLWHA was negotiation for condom use. Negotiation
for condom use occasioned suspicion for
sexual promiscuity. This finding is disturbing
because of negative reactions that followed
the word 'condom' among \ participants.
Participants complained of experiencing
violence on mere mention of condom use.
This \ attitude might have partly stemmed
from traditional belief that condom use
is synonymous with sexual immorality. This
could be partly why a good number of PLWHA
took risks of having sex without a condom.
The finding that negotiation for condom
use encouraged violence agrees with the
findings of [4].
The fact that PLWHA lacked
financial support shows the extent to which
relations and others provide care and support.
Expecting PLWHA with no meaningful means
of livelihood to support self and other
\ dependents, is arguably domestic violence.
This trend of argument is in line with that
of [3,11],that abandonment falls under the
ambit of domestic violence.
Instigating violence against PLWHA just
because of spells of ill-health would further
expose them to untold hardship. The best
approach to improve health of PLWHA is to
provide them with good nutrition and also
make treatment facilities accessible and
affordable.
From types of domestic
problems PLWHA encountered, and interventions
they suggested, it could be safe to assume
that they were exposed to traumatic situations.
Including theatre plays in public places
among strategies to reduce violence had
some advantages. Theatre plays are broad-based
with some feasible psychological undertone
(debriefing), needed in conflict management.
It may not be an illusion to state that
theatre plays promoted coherence in PLWHA
social interactions.
Findings point to clear
need for counseling and health education
which would emphasize benefits of conflict
management, condom use, and disclosure of
HIV status.
To ensure community involvement
and sustainability of the programme, the
suggested strategies should be integrated
into the primary health care system.
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