The introduction of home-based care in rural communities in the 1980s contributed immensely toward the upliftment of the personal and environmental health of communities. Women’s groups provided health promotion skills and health education to communities and made a difference in health-related behaviour change.
The purpose of the study was to explore and describe the home-based carers’ perception regarding health promotion concerning sexual health communication in Vhembe district, in the context of HIV, amongst communities still rooted in their culture.
A qualitative, explorative and descriptive design was used in order to understand home-based carers’ perceptions regarding health promotion on sexual health communication amongst rural communities which may adversely impact on health promotion practices. The population were home-based organisations in Vhembe. The sample was purposive and randomly selected and data were gathered through semi-structured face-to-face interviews and focus groups which determined data saturation. Open coding was used for analysis of data.
The results indicated that sexual communication was absent in most relationships and was not seen as necessary amongst married couples. Socioeconomic conditions, power inequity and emotional dependence had a negative impact on decision making and sexual communication.
This study, therefore, recommends that educational and outreach efforts should focus on motivating change by improving the knowledge base of home-based carers. Since they are health promoters, they should be able to change the perceptions of the communities toward sexually-transmitted infections and HIV by promoting sexual health communication.
The impact of HIV can be seen through an increase in the number of people living with HIV and AIDS (PLWHA), which has put pressure on hospital staff who are already struggling to cope with their workload. This gave rise to home-based care centres with home-based caregivers (HBCGs) to care for the PLWHA. In developing countries, home-based care (HBC) programmes were first initiated and implemented by churches and other faith-based organisations. In South Africa, HBC programmes were largely non-existent, however care groups started in the late 1980s with the introduction of care groups in the rural villages of Limpopo. Care groups, started as a way of mobilising healthcare practices to promote health, aspects of child care, nutrition, health promotion activities of having toilets, pit toilets and vegetable gardens in their homes and/or households, were some of the health promotion aspects that community nurses worked with in this group of people.
In recent years, HBC centres have become more structured and in most countries they remain in the forefront of service delivery. Some of their activities include delivery of treatment, care and support to PLWHA (Joint United Nations Programme on HIV/AIDS
Internationally, the term ‘community health worker’ (CHW) and HBCG are used similarly, as their definitions are exhaustive depending on the area/region or context in which they are used; CHWs are called rural health motivators in Swaziland, rural health workers in other countries and female community health promoters or female multipurpose health workers in Nepal. CHWs are selected within communities and undergo some form of basic health information and skills training so that they provide support in the different areas such as tuberculosis and HIV or nutrition. A variety of community health aides are selected, trained and working in their home communities (World Health Organization
Today, CHWs are widely used as lay counsellors. Lehmann & Sanders (
there is a proliferation of community, church and NGO-initiated activities, particularly in countries with high HIV prevalence, which make use of lay personnel for a wide range of prevention, support and care activities. (p. 13)
Vhembe district is not exceptional – most of the lay counsellors started as CHWs. The problem is accounting for and taking responsibility for the training of these CHWs and empowering them; there is no stipulated and regulated training and, depending on the areas where they are providing services, this makes their services inconsistent. The majority of these are women and their roles and activities are enormously diverse, depending on the programme that they were trained for. For this reason, there are specific institutions that train HCWs through South African Qualifications Authority-accredited programmes which have unit standards that should be achieved. It is from this background that the perception of HBCGs was explored in order to determine their role in providing a wide range of different tasks that are preventive, promote in combating the spread of HIV and promote healthy sexual relations.
Contributing factors to the spread of HIV include poverty, social instability and high levels of sexually-transmitted infections (STIs), to name but a few (AIDS Foundation of South Africa
Many men and women still fail to protect themselves against STIs, including HIV, because they find it difficult, if not impossible, to discuss subjects related to sexuality with their partners. That being said, the desire to maintain a relationship often outweighs health concerns. On the whole, women avoid discussions about safer sex or will talk about AIDS only in a general sense that is not related to their particular sexual relationship (Ramathuba
Women are always vulnerable and often only get to know about their seropositive status when they become pregnant. Based on antenatal clinic surveillance, South Africa’s HIV epidemic shows no evidence of decline. There were 5.5 million adults living with HIV in 2005 – 5.3 million were adults over the age of 15 years, of whom 3.1 million were women (Friedman, Mthembu & Bam
HBC programmes in South Africa are developed inadequately compared with those of other countries around the world, because they are community-based but not community-oriented (Akintola
To explore and describe HBCGs’ perceptions of health promotion with regard to sexual health communication.
The study explored and described perceptions of HBCGs regarding health promotion as it relates to sexual health communication (Creswell
Five HBCGs were men, 25 were women and only three were single whilst the rest were married. Data were collected through face-to-face individual interviews with five participants who were not part of the two focus group discussions. Permission was sought from HBC centres and the participants agreed to participate in the study upon full explanation of the purpose of the research and that interviews would be audio-recorded. The central question that directed the research study during the sessions was: ‘Can you please explain your perception regarding health promotion on communication relating to sexual health amongst the clients you engage with on daily basis’. The question was further paraphrased in Tshivenda so that the informants could understand and participate effectively in their own language. Interview techniques such as paraphrasing to enhance meaning and probing to persuade the participant to give more information were used (De Vos
Trustworthiness followed Lincoln and Guba’s four aspects of measuring trustworthiness, namely, credibility, transferability, dependability and confirmability (Lincoln & Guba
The following ethical measures were considered throughout the process of the research in order to protect the rights of the participants (Creswell
According to De Vos
The study explored HBCGs’ perceptions of health promotion on sexual health and data from interviews and focus group discussions were arranged into a theme and subthemes. The theme was conceptualised from the narratives; and open coding of analysis led to the formulation of subthemes, as illustrated in
Research findings.
Themes | Subthemes |
---|---|
Factors affecting sexual communication. | Male chauvinism. |
Misinformation about male circumcision. | |
Women in any form of marital union. | |
Socioeconomic status. | |
Experiences of guilt feeling and blame. |
Communication taking place amongst partners often contributes negatively to sexual health as men usually boast about sex, feeling that having many sexual partners makes them popular and important in the eyes of their peers. One participant indicated:
‘You know, sexually-transmitted infections won’t be easily controlled as men think that it is an honour to be having more than one women; and these make every man to conform to this ill behaviour.’ (P3, female, 28 years)
Rivers and Aggleton (
‘The problem is if you tell your partner that you don’t need sex or feel like having sex, he insist [
Furthermore, another male participant said:
‘These women can surprise you, they just say they don’t need to have sex but their actions doesn’t say that, when you start brushing their thighs and fondling them, why don’t they remove your hands to show that they don’t really need it.’ (P1, male, 27 years)
Vasconceles, Garcia and Mendonca (1997), as cited by Rivers and Aggleton (
Communication regarding healthy sexual practice is often not occurring – the participants are HIV home-based carers, but because of cultural norms within the VhaVenda, it is difficult to change the social norm. A male participant said:
‘Condoms are rarely used and opening communication about condom use among partners is a risky subject, which suggests that the other partner may be cheating; and if it’s the women who browse the subject, the man thinks the woman is trying to be smart [
Mulaudzi (
Another perception of risk behaviour is the traditional practice of male circumcision as it influences sexual behaviour. Men who have been circumcised think that they are less prone to infection or transmission of disease, often boasting about it. One participant said:
While talking with other men, encouraging them to use condoms, they laugh and tell you that they have been circumcised (
Men resist the use of condoms, thinking that once one is circumcised, there is no risk of being infected. Furthermore, the participant indicated that:
‘[
One female participant also indicated fear of initiating condom use with her partner since it is seen as a sign of mistrust in a relationship. She said:
‘If I ask my husband to use a condom, he will scold me and ask me whether I still trust him or not.’ (P10, female, 24 years)
These statements reflect a lack of sexual knowledge with regard to the fact that even primary partners are at risk of contracting STIs – condom use is associated with a partner’s confession of infidelity, rather than being seen as a method of prevention. Health promotion should be intensified so that men can see the value of condom use; and HBCGs, as health promoters, should assist in the campaigns to reinforce condom use amongst the communities they serve and to change the behaviours and attitudes of the community members. According to the South African survey report by the Human Sciences Research Council, released in April 2014 (Khan
Marital status influences the perception of the risk of HIV infection and sexual behaviour – there is often a perception that married women are unlikely to have STIs as compared to unmarried women. However, Lear (
‘I observed my husband undressing and was messy around the penile area with pieces of toilet papers adherent around the pubic area, but it was so difficult for me to confront the issue, you just beat about the bush and generalise the subject to say people will die; it’s dangerous outside as HIV/AIDS is all over.’ (P8, female, 30 years)
Relationships should be constructed around trust, but most men live under the pretence that they are faithful to their partners whilst exposing them to STIs. Lear (
[
Zulu and Chepngeno (
‘There are times where you suspect that your partner might be seeing someone.’ (P9, female, 25 years)
Double standards of sexual morality place women at risk because society assumes that male sexuality is biologically uncontrollable and hence inevitable, despite the fact that in some ethnographic studies in Nigeria, where:
society confers on women some right to refuse sex to an infected husband, this right does not extend to refusal on the ground of philandering. This has a great implication for the transmission of HIV/AIDS. (Ogunjuyigbe & Adeyemi
Varga (
Generally disclosure of a seropositive status is stressful and can cause strain and feelings of insecurity and mistrust in an intimate relationship. Desgrées du Loû (
One of the participants stated:
‘One woman found out that she is infected and it is difficult to disclose her status to his partner, she found out when giving birth to her child, but she still continues to breastfeed her child whilst knowing the implications of her actions since her husband will suspect her if she does not breastfeed, moreover she is not working.’ (P15, female, 26 years)
Women lack the ability to negotiate and communicate their needs and aspirations in a sexual relation because of patriarchal and social orientation. This leads to them dying silently as a result of sexually-related illnesses because men have almost total power and control over women in this setting. Women have less negotiating skills and cannot negotiate condom use or tell their husbands to get tested because condom use within marriage has a negative image and is associated with promiscuity. Negotiating condom use can be a sensitive subject. Ramathuba (
‘[
Poverty or economic dependency also places women at risk as women feels helpless and hopeless once they come to terms with the knowledge of their status. Because of the fear of rejection and lack of social support, they resort to keeping quiet for the sake of support and of maintaining relationships. Unfortunately, women often maintain a relationship at the expense of their health concerns, thus making them unable to deal with concerns related to safer sex. Home-based carers should be able to change the perceptions of women in order to free them from the bondages of poverty. Merely offering health education is not enough; they should encourage women to start with self-help projects, so as to be economically sound. When women engage themselves in some form of social support, they become empowered and emancipate themselves and are then able to assist others.
Women faces humiliation and disrespect every time there is a sexual health problem in their relationship and the blame is placed upon them. This stereotype is common amongst the VhaVenda in that when a person has an STI, they say he has ‘
‘What is the use of discussing the illness with your husband knowing that he would not succumb to the truth or accept to be treated?’ (P4, female, 31 years)
Another said:
‘There is no need to talk about it; it’s your sexual health problem with all the blame placed on you, whilst knowing that you have been faithful all along.’ (P17, female, 28 years)
This type of situation is common amongst families in that the women are blamed, even when they are innocent and not partaking in sexual relations – men are the ones with multiple partners and are tolerated, even when they bring the infection back to their partners. Mulaudzi (
The findings of the study revealed that communication about sexuality amongst men and women is not frank and that this can lead to communication difficulties in relationships. Communication barriers occur as a result of certain stereotyped behaviours and this can also hamper health-seeking behaviour. With this in mind, the following recommendations were made:
Health education and awareness campaigns should focus on changing the perceptions and addressing the socio-cultural determinants affecting men and women, specifically with regard to their protection from HIV and other STIs.
Sexuality, reproductive health and rights should be reinforced so as to build a culture of respect and equality in relation to sexual issues and protecting each other from HIV and STIs.
Men should also be included in reproductive health counselling; they should be counselled on the consistent and correct use of condoms and the importance of remaining faithful to their partners.
Partners in any type of sexual relations should be empowered to communicate freely and have control over matters related to their sexuality.
Primary healthcare should derive a health promotion model in collaboration with HBCGs in order to strengthen the delivery of the services.
Providers of healthcare should strengthen the linkages and collaborations with HBCGs as an inclusive part of the multidisciplinary team and provide them with programmes that will empower them in their role as health promoters.
Partners should be empowered to gain skills in negotiating safer sex; and providers should encourage partner communication.
The study was conducted in one district of Limpopo Province with a limited sample of only three HBC groups. Generalisation of the findings is thus not possible.
The study explored home-based carers’ perceptions regarding health promotion about communication relating to sexual health. Communication seemed to be lacking or not taking place at all, which is an implication for STIs and HIV. Home-based workers at grass-roots level within communities are in a better position to intensify health promotion activities and/or programmes, thus easing the workload burden of nurses in the public hospitals because they are not able to intensify health education programmes. Men need to be co-opted into reproductive health programmes so that they can protect their own health. Women should be empowered to be able to negotiate safe sex practices and to be able to communicate their aspirations and expectations in a frank and assertive manner. Empowering HBCGs with the necessary skills and knowledge may assist in reducing the scourge and expel the myths and stereotypes related to sexual health, as well as improving sexual health communication.
The researchers are grateful to the home-based carers in Vhembe district for their contribution and participation.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
D.U.R. (University of Venda) is the author of the article, conducted the research and designed the methodology. N.S.M. (University of Venda) provided conceptual guidance and methodology; and A.T. (University of Venda) sourced most of the literature.