Communicating Strategies of Communication of Adolescent SRHP in Mozambique: Cultural Challenges

Communicating Strategies of Communication of Adolescent SRHP in Mozambique: Cultural Challenges Lurdes da Balbina Vidigal Rodrigues da Silva PhD student - Ghent University, Belgium Lecturer - Eduardo Mondlane University, Mozambique Supervisor: Professor Dr. Koen Stroeken - Ghent University, Belgium

Communication of Adolescent SRH Programmes in Mozambique: Cultural Challenges Structure • Background • Research questions • Objectives • Contribution • Methodology • Results and discussions • Conclusion • Acknowledgements • References

Background Mozambique’s challenges related to adolescent SRH: • Premature marriages – 11th position in the world; • Early pregnancies – 41% of girls were pregnant; • HIV/AIDS/STI’s – 10 % of youth are HIV positive; • Unsafe abortion – double the risk when compared to an older women.

Backgound • MH, ME, MYS created, in 1999, PGB to address Youths problems • Studies point out that PGB and other ASRHP in Mozambique have not reduced ASRH issues. Ex: increasing youth HIV rates. • ASRHP challenges may be related to social norms. • Questioning whether the PGB communication strategies take into account the country’s complex cultural diversities and realities.

Backgound • There is need to examine the CS of PGB in order to identify cultural challenges. • It has increased the recognition of the role of culture in enhancing the effective delivery of communication programmes. • Most studies did not focus on the CS implemented in the ASRHP. • This study attempts to address this gap.

Theoretical Framework - McGuire’s Communication/Persuasion Model using its four input factors

Objectives • To examine PGB CS by analysing the communication process used by peer educators when delivering health messages; • To identify cultural challenges peer educators and adolescents confront when delivering and receiving health messages; • To explore strategies used by peer educators to deal with the identified cultural challenges; • To learn the implications of cultural challenges affecting the PGB.

Research Questions • What communication strategies do peer educators use to deliver adolescent SRH messages in the PGB? • What cultural challenges do peer educators and adolescents identify when delivering and receiving health messages? • What strategies do peer educators use to deal with the identified cultural challenges? • What are the implications of the cultural challenges for the PGB?

Contribution • ↑ in the awareness and a better understanding about ASRH CS. • A definition of the best institutional responses aimed at effective implementation of CS of ASRHP in Mozambique.

Methodology Qualitative Multiple Case Study Data collection from 92 individuals (dealing with PGB) in Nampula and Maputo Provinces (The most affected with ASRH issues) Nampula – 20.6% of girls, under the age of 15 are prematurely married (UNICEF, 2015). Also, about 18% of Mozambican adolescents and youth are from Nampula province (Cau & Arnaldo, 2014). Maputo - It also has the second highest prevalence of HIV/AIDS among people age 15-49 in the southern region of the country.

Methodology - Non-participant observations (n=10); • In-depth interviews (n=10); • Focus group discussions of PGB activities in schools (n=7); • Document analysis (n=4). • Data analysed thematically (content analysis) using Nvivo Pro 11. • Ethical: Research authorisation by the National committee of Ethics – Ref: 45/CNBS/2016 and the Committee of Bioethics of he Faculty of Medicine & MCH - ref: CIBS FM&HCM/016/2016. • Written informed consent was obtained from all participants. Anonymity and confidentiality were safeguarded.

Results & discussion: Communication Strategies of PGB • Source of Messages “The Peer educators are responsible for transmitting sexual and reproductive health messages to adolescents in the programme” (Project Officer Margarida, Maputo, 2016). • Receiver: Although the majority of adolescents in the PGB consider peer educators role models, the minority of adolescents admit that sometimes they consider peer educators to be unknowledgeable and lacking in respect for people and their community by openly discussing sexuality: “I’ve always refused to go to PGB. I used to say that the PGB peer educators and their messages are offensive, they insult. I looked at the PGB messages as insulting” (Adolescent Alice, Nampula city, 2016).

Results and discussion: Communication Strategies of The PGB • Viewing peer educators as having lack of respect for people and their community may result from the cultural notion that in such communities, sexuality is mostly to be discussed and taught by adults and not by adolescents: “People disrespect us and do not believe on what we say in the programme because in our culture sexuality is a kind of taboo and is spoken by adults and elders and not by young people who are considered to be young to have such knowledge” (Peer educator Telma, Maputo city, 2017).

Results and discussions: Communication strategies of the PGB • Moreover, female peer educators suffer sexual harassment from male beneficiaries of PGB: “When you talk about sexuality people look at you as if you were a sexual machine. When you finish your session, about 90% men will make you an indecent proposal. They say that you have taught well. Now I want to use condom with you so you will tell me if I am using it well or not” (Peer educator Isabel, Nampula city, 2016) “Men do not want to learn using condoms with the replicas of the penis. They want to try condoms with us female peer educators” (Peer educator Ruth, Maputo city, 2017).

Results and discussions: Communication strategies of the PGB • Messages transmitted Preventive messages: protection from HIV and AIDS, STIs, how to use a condom, negotiation skills with a partner, avoidance of early marriage and pregnancy.

Communication strategies of the PGB Channel Interpersonal communication • “The peer educators talk to us in group or individually. They give us speech and some posters and flyers with SRH information” (Adolescent Shelsia, Maputo city, 2017). If the peer educator notes the adolescent has a health problem or needs to receive more health advice, he/she sends him/her to adolescent friendly services (SAAJ):

Communication strategies of the PGB • PGB Health messages include most features of effective communication strategies: accuracy, availability, balance, consistence, reach, and repetition. • Absence of two features: sociocultural and evidential approaches. • Peer educators failed to take into account the sociocultural approach and they rarely used evidence when passing on PGB health messages; Ex: PGB health messages are recounted to boys and girls at the same time, which is a cultural taboo: boys and girls are educated separately.

Communication strategies of the PGB The messages stand in opposition to many traditional practices of the Makhuwa and Changana cultures: “What we learn in the PGB is different from our communities habits” (Peer educator Marta, Rapale, Nampula Province, 2016)

Cultural Challenges The main cultural challenges obstructing the effectiveness of the PGB messages: • Initiation rites (only Nampula) Adherence to initiation rites invariably results in adolescents experiencing sexual relations, marriage and pregnancy at an early age: “The initiation rites are the wedding preparation. They explain about marriage life, how to take care of a man; what happens when having sex with a man. If we are to analyse those that do not send their children to marry later when they leave the ritual are 15%. The rest, are parents who want their children to be married” (Peer educator Cristina, Rapale, Nampula Province, 2016).

Cultural challenges: Taboos surrounding sexuality 2. Taboos surrounding sexuality (Nampula and Maputo) sexuality is not common or accepted in their communities. Sexuality and sexual issues are sensitive topics and are not to be openly discussed: “I found that is not easy to talk about sexuality. When you reach a community and you talk about sexuality, people will look at you as if you were possessed by an evil spirit” (Peer educator Isabel, Nampula city, 2016). CC: sexuality is taught and spoken by adults

Cultural Challenges: Condom use 3. Condom use is still a challenge: • Religion - sin; • community beliefs about its harmful purposes – bring sickness; • the traditional custom of having many children: “The condom use is not good because when you use it you throw away your blood” (Adolescent Thomas, Nampula city, 2016). CC: A birth is considered a gift of life and the wealth of a man is measured by the number of his descendants;

Cultural Challenges: Condom use (iv) initiation rites orientations: • “In the initiation rites I was taught that “no barriers” should exist when having sexual relations” (Adolescent Thomas, Nampula city, 2016). • CC: Natural sex/no barriers (v) the local belief in the unlimited powers of traditional healers: • “Others people say that they will take traditional medicines from the traditional healers that will protect or cure them from HIV and AIDS infections” (Peer educator Rosalind, Moamba, Maputo Province, 2017). • CC: the local belief that traditional healers cure every type of diseases

Cultural Challenges: Consented early marriages 4. forced or consented early marriages by parents “Here in Moambaparents want cows. As soon as a girl is born they choose a wealthy man for her. And once the girl has breasts they force her to marry. The girl has no right to choose her own husband. She only has to accept her faith and destiny (Peer educator Hélder, Moamba, Maputo Province, 2017). “In Nampula province, mostly in rural areas, many parents force their children to marry as soon as they finish the initiation rites” (Peer educator Shaquira, Nampula city, 2016). • Harmful cultural practices • Violation of the children´s rights

Cultural Challenges: Language and health terminolgies 5. Language and health terminologies • Poor Portuguese language skills – 40% of Mozambicans do not speak Portuguese, the official language; • Confusion exists about the meanings of HIV and AIDS as the terms are used interchangeably; • The absence of translated health terminologies into the Makhuwa and Changana languages results in some people refusing to believe what peer educators say.

Peer educators’ strategies to deal with the cultural challenges • There is not available any CS to deal with the CC identified. Peer educators ignore the cultural aspects; • They keep on presenting information as they always have; “We try rescue those who are not there yet, rescue with this information, we encourage even those who arrived there; we tried to explain not to follow the wrong path from the initiation rites. We tell them to respect their parents; to use condom, not to give up going to school, use contraceptive methods” (Peer educator Sandra, Rapale, Nampula Province, 2016).

Implications of cultural challenges for the PGB • Adolescents often ignore peer educators’ messages and advice. This, in turn, leads some peer educators to abandon the programme. Others, who continue in the programme, often feel their work with adolescents on SRH issues does not bring about significant behavior change:

Implications of cultural challenges for the PGB “The cultural challenges have implications for the programme as it seems like we are not doing anything; it looks like we are not working. If we have a programme like this we need to reach our objectives. If we look into the rates of adolescents main health problems it is really frustrating because we are not having significant changes: we still have many adolescents who are pregnant and married. It seems like we have done nothing since the programme implementation” (Peer educator Isabel, Nampula city, 2017).

Limitations of the study • As a word of caution to other researchers, this study presents some limitations as itdid not look into what motivates some adolescents to remain in the programme despite the cultural challenges identified. However, future research could fill this gap. • there is further need to study the PGB’s influence for changing adolescents’ attitudes utilising the output factors of the McGuire Communication/Persuasion Model.

Conclusion and recommendations • Communicating PGB messages effectively to adolescents faces challenges: The taboos around sexuality have silenced open communication in this regard. Ideas of sexual abstinence, condom use and campaigns against early marriage stand in opposition to traditional initiation rites orientations. • to reduce the cultural barriers and improvePGB efficiency and efficacy, it is recommended to apply a culturally sensitive approach in the development of partnership and cooperation between the PGB and local communities.

Conclusion and recommencations • bridging of the gap between initiation rites and PGB orientations; using sociocultural approaches and audience segmentation for cultural sensitive messages; • training of initiation rituals masters in relation to PGB messages and equipping communities with relevant SRH messages; translating PGB handbook in the Makhuwa and Changana languages

Conclusion and recommendations • Thank you! • Obrigada! (Thank you in Portuguese) • Khanimambo (Thank you in Changana) • Oxikhuru (Thank you in Makhuwa)

Acknowledgements • Desafio - Development Programme in Reproductive Health; • Eduardo Mondlane University, Mozambique; and • Ghent University and the Flemish Interuniversity Council (VLIR) for supporting this research.

References • Bagnol, B. e Mariano, E. (2009). Cuidados Consigo Mesma, Sexualidade e Erotismo na ProvínciiTete. Rio de Janeiro: Physis Revista de Saúde Coletiva, Vol.19, 2. • Chandra-Mouli. (2015). ProgramaGeração Biz: How did this adolescent health initiative grow from a pilot to a national programme, and what did it achieve? Reproductive Health, 12, 1-12. • Chen, G., Chou, D., Pan, B., & Chang, C. (2008). An analysis of Tzu Chi's public communication campaign on body donation. China Media Research, 4(1), 56-61. • Corcoran, N. (2007). Theories and models in communicating health messages. In Communicating health: strategies for health promotion (pp. 5-31). London: SAGE. • Cruz e Silva, T. et al. (2007). Representações e práticas da sexualidade entre os jovens e a feminização do Sida em Moçambique. Maputo: WLSA Moçambique • Dutta, M. (2007). Communicating about culture and health: Theorizing culture-centered and cultural sensitivity approaches. Communication Theory, 17, 324-328. • Francisco, A. (2014). Situação dos Casamentos Prematuros em Moçambique: Tendências e Impacto. Maputo: Fórum da Sociedade Civil dos Direitos da Criança e Coligação para a Eliminação dos Casamentos Prematuros – CECAP • Governo de Moçambique. (2003). Estratégias de Comunicação sobre o HIV e SIDA. Maputo: Ministério da Educação. • Governo de Moçambique. (2015). Plano Estratégico Nacional de Resposta ao HIV e SIDA 2015-2019. Conselho Nacional de Combate ao HIV/SIDA - CNCS: Maputo.

References • Harrington, N. (2016). Persuasive health message design. 1-32. doi:10.1093/acrefore/9780190228613.013.7 • Kotanyi, S., & Krings-Ney, B. (2009). Introduction of culturally sensitive HIV prevention in the context of female initiation rites: An applied anthropological approach in Mozambique. African Journal of AIDS Research, 8(4), 491-502. • Kreuter, M., & McClure, S. (2004). The role of culture in health communication. Annual Review of Public Health, 25, 439-455. • Loforte, A. (2007). Noções de sexualidade: Respondendo às necessidades dos jovens em matéria de saúde sexual e reprodutiva. Outras Vozes, 19, 1-5. • McGuire, W. (1981). Theoretical foundations of campaigns. In R. Rice, & W. Paisley, Public communication campaigns (pp. 41-70). California: SAGE.

Communicating Strategies of Communication of Adolescent SRHP in Mozambique: Cultural Challenges