ADOLESCENT BEHAVIOURAL CHANGE VIS-A-VIS HIV/AIDS IN MALAWI

Nordic Journal of African Studies 17(4): 288–299 (2008)
Behavioural Change vis-à-vis Hiv/Aids
Knowledge Mismatch among Adolescents: The
Case of Some Selected Schools in Zomba
MARISEN MWALE
Mzuzu University, Malawi
ABSTRACT
Most researchers on adolescent reproductive health and related susceptibility to contracting
HIV/AIDS have highlighted the ironical mismatch preponderant between adolescent
knowledge of HIV/AIDS transmission dynamics and behavioural change exemplified in part
by abstinence but also condom use. The paradox is compounded by the fact that survey data
seems to depict heightened knowledge of the dynamics per se. Empirical data has previously
posited variables as peer pressure and other psychosocial factors as the crisis at adolescence
as explaining the anomaly. Results in the current study however unveil the culture of silence;
the disdain towards AIDS messages and retrogressive cultural practices as alternative
explanation. The results were obtained through survey data from adolescent students in
selected schools in Zomba, a district in southern Malawi, and are discussed within the larger
context of the applicability of cognitive dissonance theory to the AIDS pandemic.
Keywords: behavioural change, cognitive dissonance, culture of silence, HIV/AIDS, riskreduction,
susceptibility.
1. INTRODUCTION
Empirical findings on adolescent sexuality vis-à-vis the HIV/AIDS pandemic
have highlighted a gap often prevalent between adolescents’ attitudes, beliefs,
knowledge or intentions pertaining sexuality and their actual sexual behaviour(
Caldwell, 2001; Szekeres, 2000; Aggleton and Rivers, 2001; Gulure, 2003).
There is however a dearth in explaining underlying variables relative to this gap
in previous studies. This paucity of information is compounded by the fact that
adolescents’ sexual lives are often not easy to modify. To investigate the
mismatch between adolescents’ knowledge of HIV/AIDS transmission
dynamics and behavioural change in Zomba [Southern Malawi], the current
study applied the theory of cognitive dissonance. The theory proposes that there
is often an inconsistency between people’s attitudes, beliefs or intentions and
their actual behaviour. The study acknowledges the fact that a myriad of
behavioural interventions have been designed to promote safer sexual
behaviours among adolescents yet relatively few have proven effective. One
such intervention is Behavioural change communication [BCC]. Relative to the
study, the paradox emanating from BCC is however that, while adolescents’
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289
awareness of HIV transmission dynamics is generally high [a factor that can be
attributed to intensive BCC campaigns] behavioural change relative to the
HIV/AIDS pandemic in the study area has been limited. The crux of the problem
has been to unveil factors and variables to explain this gap or anomaly.
There is enough empirical evidence supporting the contention that there
tends to be sufficient knowledge of AIDS in most communities, and the limited
success of intervention programmes in controlling the pandemic cannot be
ascribed to limited knowledge (Caldwell, 2001; Szekeres, 2000; Aggleton and
Rivers, 2001). As already highlighted the sole objective of the study was to
assess the reasons as to why there is a pronounced mismatch between
knowledge of HIV/AIDS transmission dynamics and subsequent change in
behaviour. The assumption being that of an anticipated correlation between
knowledge of dynamics and change in behaviour with perceived vulnerability to
a disease such as HIV/AIDS being a major casual factor for compliance with a
health regimen (Becker and Rosenstock, 1974). It is ironical that knowledge is
not really being translated into substantial behavioural change relative to
HIV/AIDS in Malawi in general and Zomba in particular.
At first it was thought possible to explain lack of behavioural change relative
to the AIDS pandemic in terms of inadequate information and seek to overcome
the problem through better and more intensive informational and educational
programmes. Overtime, this explanation has become ever less tenable. Kirby
(1994) notes that AIDS prevention entails behavioural change, which is difficult
to achieve when the social environment is not conducive. Cochran and Mays
(2004) and Osborn (1986) also emphasize the central place of behavioural
change to AIDS prevention.
Behavioural change is very important when it is realized that AIDS even
though a physical or biological disease depends for its transmission and spread
mainly on the volitional behaviour of people. Obstacles to behavioural change
were identified in the current study as the adherence to the present sexual
culture; the refusal of leaders to recognize and come to terms with the situation;
the sanguine acceptance and stoicism towards death; the silence about the
epidemic and the reasons for this; and the limited number of relationships in
which condoms are acceptable. As stipulated by Cochran and Replan (1989), in
Gross (2001) perception of being at risk, especially among youth is a factor in
change of attitude towards the virus.
In William’s (2002) perspective, what has been neglected amidst the current
AIDS epidemic are health practitioners who are being sent into various African
countries to actualize behavioural change amid their own and client’s
homophobia, distrust, suspicion and misconception with little or no preparation
in family life and sex education. These people lack understanding and
appreciation of the sensitive and cultural impact of the Africans. Regan et al.
(2001), asserts that dissemination of information about behavioural change, the
traditional forte of health education, will be ineffective if barriers,
misunderstanding, and fear exist between health professionals and clients. They
maintain that,
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290
“Even if well-informed specialists successfully transfer information, (to
the individual, at risk) a positive behavioral change may not result
because other variables, also motivate behaviour.”
Generally, heterosexual intercourse is the primary mode of HIV/AIDS
transmission in Africa where it accounts for 70-80% of all cases (Hayward,
1990). The sexually active members of the population usually undertake
heterosexual relations. In this case, youth are more involved in heterosexual
relations than other members of the population. Hence, this group becomes the
ideal target of any AIDS prevention programmes and one setting where this
target group of youth can be located is in secondary schools. In view of the
active sex lives of adolescents, AIDS prevention programmes may go a long
way in reducing the spread of the virus if they are informed by knowledge of
AIDS related perceptions of such a target group, with behavioural change being
the final goal of the programmes.
In any case however, behavioral change is a slow process. Before launching
an AIDS educational program, a situational analysis to determine possible areas
of circumstances that might put people at risk and also to discover and
understand the reasons behind people’s actions or motives must be conducted.
Primary strategies for encouraging behavioral change may include as first step
analyzing the life-style and traditions to determine the risk behaviours that might
enhance the spread of the AIDS virus. The second step should be an explanation
of the facts of HIV/AIDS, that is; what it is, how it is spread, how it may be
controlled, the most vulnerable groups, and so on. This is necessary to clear up
some of the misconceptions that may have arisen over the years.
2. COGNITIVE DISSONANCE VIS-À-VIS RISKREDUCTION/
AVERSION IN HIV/AIDS
The paradox imbuing the mismatch between risk-reduction and subsequent
behavioural change, has been grappled with from several dimensions but one
stance that the study tried to delve into is the controversial theoretical
application of Cognitive dissonance theory (Festinger, 1957; Gross, 2001).
According to the theory, whenever persons simultaneously hold two cognitions
or perceptions that are psychologically inconsistent, they experience dissonance.
Dissonance is a negative drive or state of ‘psychological discomfort or tension’,
which motivates people to reduce it by achieving consonance. Attitude change is
a major way of reducing dissonance. Under certain circumstances, we may reevaluate
our attitudes so as to make them more consistent (less ‘dissonant’) with
our present or past behaviour. Cognitions are the traits a person knows about
himself, and about his surroundings. Any two cognitions can be consonant (A
implies B), dissonant (A implies not B), or irrelevant to each other.
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291
The cognition, ‘I am promiscuous or I engage in multiple sexual affairs’ is
psychologically inconsistent with the cognition that ‘promiscuity or engaging in
multiple sexual affairs may result in contracting HIV/AIDS’ (assuming that
persons don’t wish to contract HIV/AIDS anyway). Perhaps the most efficient
and healthiest way to reduce dissonance would be to stop indulging in
promiscuity or sexual risky-behaviours but people, adolescents inclusive, will
work on other cognitions for example, they might:
• First, belittle the evidence about HIV/AIDS (e.g., the human data is only
correlational).
• Second, they may associate with other people indulging in promiscuity or
sexual risk-behaviours (e.g., if so and so does it, then it can’t be very
dangerous or detrimental).
• Third, they may date younger girls with the assumption that these are not
yet infected.
• Last, they may convince themselves that promiscuity or sexual riskbehaviours
exemplified by multiple sexual relationships are highly
pleasurable activities (e.g., after all it’s worthy the consequences)
These analogies illustrate how dissonance theory regards human beings not as
rational but as rationalizing creatures, attempting to appear rational, both to
others and to themselves yet with occasionally devastating consequences (Gross,
2001). Suffice to say there is some wealthy of evidence that unless individuals
feel vulnerable to a threat they are unlikely to form the intention to act on the
recommendations in any message tailored at abating the threat per se.
3. THE RESEARCH SETTING
The study was conducted in Zomba a municipality town in southern Malawi.
Most of the student respondents who participated in the study come from the
same Zomba district with the majority of the populace being Yao in ethnicity.
Like any other ethnic grouping the Yao have their own cultural practices among
which are jando and msondo initiation ceremonies. These ceremonies are
basically rites of passage geared at preparing adolescent boys and girls for adult
roles and responsibilities as well as a smooth transition into adulthood. As was
expected most of the respondents had undergone the ceremonial rites which as
portrayed by empirical research conducted by several authorities including
National AIDS Commission (NAC) (2004) instil traditional knowledge that
sometime breeds cognitive inconsistency within the adolescents and as well
contradict with AIDS messages and information that the youth may have, thus
encouraging them to indulge in promiscuity and sexual risk –taking behaviours.
Needless to say research has also shown that some of the knowledge gained in
these rites of passage and some proclivities like male circumcision may help
negate to some extent the transmission of HIV (Anaffi 1999; Bongaarts and
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Reining 1989). Bearing in mind that a researcher needs to carry out an
investigation with respect and concern for the dignity and welfare of
respondents, consent and permission were sought from the respondents in the
questionnaires administered to report the findings.
4. MATERIALS AND METHODS
The study applied both the quantitative and qualitative paradigms in a
triangulative approach in order to come up with tangible data that would explore
as many dimensions as there were in the topic of concern yet without preempting
and militating against future research possibilities in the area of
adolescent sexuality in Malawi. The respondents who participated in the study
were secondary school adolescents, drawn from three schools considered the
accessible population respectively. The research sites chosen basically on
grounds of proximity to the researcher as well as to carter for the gender
disparity and selected purposively were;
• Mulunguzi co-educational Secondary School
• Zomba Catholic’s boys Secondary School
• St Mary’s girls Secondary School
Of the three secondary schools, all are conventional secondary schools with
Zomba Catholic being a national secondary school for boys within the town
periphery enrolling a cross section of students from several districts. Mulunguzi
secondary school is more urban oriented with most students being enrolled from
primary schools within Zomba and a few from the surrounding rural primary
schools. St Mary’s girls is a secondary school within the urban milieu enrolling
students from several districts, like Zomba Catholic. The gender aspect was
considered as a criterion for sampling with two of the schools being single sex
schools (Zomba Catholic enrolling boys and St Mary’s enrolling girls) with
Mulunguzi being a co-educational school.
The students’ sample consisted of 180 students with 60 coming from each
school and systematic randomly selected from 3 and 4 forms. Thirty students
were girls and the other thirty boys at Mulunguzi secondary school. This was
done so as to have an overall equal number of boys and girls in the study.
Systematic random sampling not only reduced bias and other extraneous
variables that were apt to affect the research process but also made the findings
representative of the targeted population of adolescents in Zomba.
In terms of instrumentation diverse areas concerning HIV/AIDS were
assessed in the students’ questionnaires. Some of the items were solicited from a
standardized Knowledge, Attitude, and Behaviour (KAB) model referred to in
Maluwa Banda (1999) with others being modified Likert items adopted from the
Protection Motivation Model as utilized by Abraham (1994) in a study
conducted in the United States. The KAB model in HIV/AIDS research is aimed
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293
at soliciting respondents’ awareness of transmission dynamics relative to the
pandemic as well as their affective ideals. Not only that, finding out about
respondents’ perception of risk and the subsequent intention or non-intention to
change behaviour remains within the scope of the model. Protection Motivation
Models on the other hand utilize constructs adopted from Health Belief Models
with the aim of evaluating respondents’ susceptibility to disease regimen.
The questionnaire was divided into four sections with part A seeking to
solicit data on students’ socio-demographic characteristics. Questions
concerning age, gender, religion, number of siblings in the family, parental
existence and form of family were advanced. Questions in part B sought to
gather data on the knowledge and attitude consistency domains of the KAB
model. The items sought to solicit information about modes of HIV
transmission, prevention, as well as attitude vis-à-vis behaviour consistency and
ranged from item 8 through to item 15.
Part C items were designed to gather data on the students’ attitudes towards
HIV/AIDS with most of these items having been adopted from the Protection
Motivation Model as applied by Abraham (1994). The response items sought to
appraise self-efficacy, response efficacy as well as adaptive and maladaptive
cognition relative to the HIV/AIDS pandemic. In all 9 items were advanced in
this section with response items ranging from item 16 through item 24. The last
part with questions ranging from item 38 sought to gather data on students’ risky
sexual behaviours. More of the skein issues unravelled in this section ranged
from aspects of sexual experience across the continuum to condom use, modes
of HIV/AIDS transmission, as well as behavioural change initiatives. The
uniqueness of this section can be deduced in part from its consideration of
structured items but above all else unstructured, open-ended objective items
geared at soliciting more sensitive issues on adolescent sexual risky behaviours.
A focus group discussion was also conducted to compliment and consolidate
the other device in a bid to foster a triangulative approach. Its major strength
was that it helped in soliciting more personalized sentiments in an open and free
atmosphere. Questions discussed ranged from those grappling with the attitudes
that adolescents hold about HIV/AIDS through modes of behavioral change
relative to the HIV/AIDS pandemic. Also considered were factors that
adolescents consider as explaining the mismatch between adolescents’
unequivocal knowledge of HIV/AIDS transmission dynamics and change in
high risk-sexual behaviours, as portrayed by empirical findings.
5. RESULTS AND DISCUSSION
5.1 CULTURE OF SILENCE
Research findings in the current study have aptly revealed stoicism towards
death and the culture of silence as prominent reasons for the mismatch between
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294
risk-reduction or change in behaviour and unprecedented knowledge of the
dynamics of HIV/AIDS transmission as well as prevention with the overall
score on knowledge items being 7 (SD=2.4) or 87.5%. An exponential response
by respondents (65%) that ‘death is inevitable and one can even die from an
accident or any other disease hence no need to fear AIDS’ qualifies the brave
but detrimental attitude towards death and HIV/AIDS. This qualifies the
research assumption that given the dissonance between indulgence in risky
sexual debuts and non-promiscuous proclivities the majority of respondents
choose to rationalize and uphold the former. Apart from justification basing on
the inevitability of death (55%) of the respondents belittled the evidence about
the existence of HIV/AIDS claiming that ‘AIDS is just a Eurocentric endeavour
to discourage sexual intercourse’. This augurs well with findings documented by
research (Caldwell, 1992; Ngugi, 2000; Abraham, 1994; Gulure, 2003;
McAuliffe, 1994), that a combination of adequate knowledge and continual
high-risk behaviour as well as stoicism towards death and AIDS appears
unequivocal.
The silence posited owes something as portrayed in the focus group
discussion in the current study to fear of being shunned and isolated, and
something to those religious figures who preach that the epidemic is a
punishment for sexual sin. This is also consistent with Caldwell (1994) who
argues that stigmatization does not warrant an absolute appraisal of the misfit
per se. He substantiated that the silence in relation to the HIV/AIDS pandemic
among Africans owes a great deal to suspicions that AIDS is more than an
ordinary disease, that it has supernatural elements or that it is caused or
manipulated by witchcraft. Consequently, individuals including adolescents in
many African cultures seem not to demand more from government because of a
sense of guilt, a feeling that they may have brought the calamity upon
themselves, compounded in many by a feeling that the deaths were inevitable.
This is also consistent with findings by Ngugi et al (2000) in studies
conducted in Ghana and other West African Countries, that beliefs intact or
vestigial in African Cultures that death causation is multiple and does not rest on
a single mechanism (e.g., viral infection would have no effect unless witchcraft
or other machinations were determined it would take hold), that the timing of
death is predetermined, and that the most certain way of becoming sick was to
worry about the possibility of death and change one’s way of life, especially an
extroverted pattern of sexual activity; affecting ways in which Africans in
general respond towards the pandemic.
This stubbornness towards death is thus a fundamental factor in explaining
the continuing high level of new HIV-infection not only among adolescents but
the entire populace (Caldwell, 1992; Mays and Cochran, 2004; Williams et al
2002). It is argued that this stoic attitude is not a characteristic that would induce
the early curtailment of epidemics. Reducing the risk of death has never been the
sole aim of mankind. Risk-taking in sport and for thrills or just the determination
to live a fairly carefree life have always been alternatives and have weighted the
scales a little more towards death.
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Studies also document that it is possible that those exposed longest to the
world’s religions are more focused on the significance of death. In the current
study for instance a sentiment highlighted in the focus group discussion that
‘after all if I were to die I would go to heaven’ seems to tally with this aspect of
religiosity. Awusabo-Asare (1997) argues in the same scenario that in Ghana
older beliefs in predestination are now being reinforced by the rise of Christian
fundamentalism. Indeed, it is possible to argue that African belief in an afterlife
may justify risk-taking, no wonder why the exponential percentile towards the
wishful thinking item response (God will protect me from contracting
HIV/AIDS) was also evident in the current study.
5.2 CULTURAL PRACTICES
Possibly yet another reason for the mismatch between knowledge of HIV/AIDS
transmission and prevention dynamics and subsequent risk reduction as revealed
by the current study are cultural practices. Respondents (95%) posited that there
appeared to be a grave inconsistency between their own beliefs and values and
cultural expectations. Following the focus group discussion, an inquiry into
adolescent risk-behaviours exacerbating susceptibility to contracting HIV/AIDS
and reasons why girls and boys indulge in premarital sexual encounters,
revealed that of the prominent factors at stake was the perpetrating of
counterproductive cultural practices among societies in the study site. Most of
the respondents emanate from the Yao ethnicity which is predominant in the
study area. Among the cultural practices of the Yao are the jando and msondo
initiation ceremonies. The practices per se as highlighted at all research sites
also encompass rituals of ‘fisi’, ‘kusasa fumbi’ ‘kulowa kufa’ and ‘chokolo’.
These are practices which encourage and promote sexual debuts between the
patrons of the cultural rites. After being initiated at either jando or msondo
which are rituals for boys and girls who have respectively become of age
(adolescents), the initiates are strictly encouraged to go out and cleanse
themselves. This cleansing ceremony requires them to indulge in unprotected
sexual intercourse with an experienced person of the opposite sex. It is quite
evident that the experienced person who is known as ‘fisi’ in female cleansing
may as well be HIV positive bearing in mind that he takes cleansing as an
obligation each and every initiation season. It is also quite unequivocal that both
male and female initiates are at risk of contracting HIV/AIDS since they may
not know the sero-status of the persons they have intercourse with. Above all
else the respondents substantiated that to avoid cleansing connotes heralding
unforeseen repercussions which all initiates are threatened with and fear
confronting.
This is consistent with Ngugi (2004) that all societies seem to understand the
relationship between early sexual debuts, increased risk of Sexually Transmitted
Diseases (STDs) and reduced fertility yet maintain risky sexual cultural
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296
practices e.g. early age of sexual initiation, multiple partners, polygamy and
extra-marital sexual affairs. Also consistent with the findings, Bauman and
Siegel’s (1987) study of farming and foraging groups in the Ituri ethnic group of
Cameroon ask:
“Why people in the group perish in their promiscuous attitudes and
behaviour even in the face of such a perilous epidemic and by extension,
in their own sense of social and psychological wellbeing,”
Further the belief, logical in a polygynous society, that males are biologically
programmed to need sexual relations with more than one woman; even parallel
relationships must also be construed as perpetrating the misfit per se. That this
belief is widespread, perhaps almost universal across all sub-Saharan African
cultures and is held almost as strongly by women, as men, was reported in
Orubuloye, and Varga (2003). This seems concomitant as well with the findings
of the current study relative to the dilemma why most adolescents prefer having
multiple sexual partners, that:
“Having several sexual partners is seen as a sign of masculinity or
machismo – the boy becomes a champion among his peers.”
This is also consistent with Varga (2003), that indeed, the boys are often most
motivated by the desire to boast to their male peers about the number of their
sexual conquests.
5.3 RESPONSE TO AIDS MESSAGES
Possibly yet another reason for the dichotomy between knowledge of HIV/AIDS
transmission and preventive dynamics and risk-aversion with subsequent
behavioral change as unveiled by the current study is the fact that AIDS
messages are wholly or partly disbelieved. The messages like cultural practices
also appear inconsistent with the attitudes and beliefs of the respondents. In the
focus group discussion it was highlighted for instance by the majority of
adolescent respondents (87%) that the urge for them to abstain is there but
sexual desires seem to outweigh the desire to abstain in the final analysis. There
is also some scepticism about the aptly construed foreign messages often
regarded as wholly wrong or hysterically based on fiction. One respondent in the
focus group discussion actually asserted that ‘AIDS is not real’. Other
respondents claimed that there are already cures while some argued that for
those just infected there will be by the time they will be symptomatic. The most
intriguing argument posited in the focus group discussions was that there is a
tendency by the western media to exaggerate the dangers and implications of
HIV/AIDS. These fear appeals tend to create aversion toward the AIDS
messages and more often than not the target groups respond contrary to these
messages.
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297
6. CONCLUSION
As reflected in the current study, adolescent vulnerability to contracting
HIV/AIDS though explored from compounded risk perception, egocentrism and
other psychosocial factors in various empirical domains has been shown to be
complicated by cultural practices, stoicism towards death and misconstruing of
AIDS messages. These factors have been discussed with reference to how they
foster a mismatch between knowledge of HIV/AIDS and subsequent
behavioural change. It has been noted that perception of being at risk of
contracting HIV/AIDS and knowledge of transmission dynamics has not
necessarily translated into change in behaviour relative to the pandemic.
Behaviour communication programmes therefore need to capture some of these
socio-cultural and psychosocial complexities that may be proximate barriers to
change. Above all else, given such attitudes future HIV/AIDS prevention
programmes for the study area, Malawi and Africa must be innovative,
anticipating the myriad social and historical; ontological as well as
epistemological inconsistencies that may act as barriers to effective intervention
efforts, and must involve the community members and leaders in program
development from the earliest planning stages. Those expatriate informers
geared at steering change in behaviour in a bid to at least mitigate and stem the
incidence of the pandemic must also be extremely conversant with such diverse
barriers as have been portrayed by the current findings. Retrogressive cultural
beliefs perpetrating inconsistencies within and among adolescents should be
revisited.
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About the author: Marisen Mwale is a holder of a Master of Education with
specialty in Psychology from the University of Malawi. He is a lecturer in
Psychology at Mzuzu University in Malawi. His research interests are
adolescent sexuality, reproductive health and HIV/AIDS.