Health e Communication

[Chris Morry]

This is a contribution to the 'Pictures in HIV/AIDS Education' discussion forum. The forum is sponsored by Health e Communication and moderated by Dr. Edwin Mapara who has spent 20 years using such pictures in southern Africa and the United Kingdom. For more details see:
http://www.comminit.com/healthecomm/planning.php?showdetails=188

Editors Note: This was sent from Dr. Edwin Mapara and forwarded to the forum.


Concluding Comments

As we draw near to the conclusion of the three weeks discussion on the use of Pictures in HIV/AIDS Education (PAIDucation), I thought that I would highlight some points. I have seen the close to 100 readers/members who have read or accessed the site to read, comment or to think about this ‘new’ approach to raising HIV/AIDS awareness in both the developed and the developing countries. Initially, I had thought that PAIDucation was best for the developing countries, but now believe it is for both developed and developing world.

For the developed countries, the conclusion has been drawn from the workshops that I have had with various audiences in London, that include General Practioners (GP), nurses, university students, teachers, high school students, health promoters and volunteers from voluntary organisers. Many people in the general community or public do not know about sexually transmitted infections, including HIV/AIDS. Many believe that HIV/AIDS only affects the Gay and African communities! You cannot blame them too much for this perception portrayed by the media. If I compare prevalence rates of Brent (UK), where I am based, and Lobatse in Botswana, former station, of HIV prevalence rates of 0.6% and 32% respectively, one can understand the levels of knowledge. Sadly HIV/AIDS thrives in such an environment of lack of knowledge!

I have also observed the 103 comments on the article on the link:

www.comminit.com/healthecomm/planning.php?showdetails=188 - 35k

I have received quite a number of requests for the actual pictures and slides used, “…for a better assessment” of the HIV/AIDS intervention strategy/method. I have responded to these private individual readers.

There have also been colleagues who have sent me several websites/links for other graphic clinical pictures and asked for my comments. I commented on some.

ON THE PICTURES USED IN AIDUCATION

A) Source of slides
I have used the Teaching aids At Low Cost (TALC) slides, from TALC St Albans, since 1992. In comparison with other slides, the TALC slides were at that time and even now simple, comprehensive, ‘user friendly’ and very African. I am biased and so stand to be corrected. I have seen several other slides from various sources that are strictly very clinical and technical, that I cannot picture with to the picturate community members.

The TALC slides at www.talcuk.org that we use for our sessions (Botswana and UK) are:
1. HIV/AIDS Virology and Transmission
2. HIV/AIDS Clinical Manifestations
3. HIV/AIDS Prevention and Counselling (Old set)
4. HIV/AIDS Parent to Child Transmission
5. Sexually Transmitted Infections.

These modules have 24 colour slides/images in each set. Our workshops have, in an ideal set-up spent a day on each of these slides and that is why it is a four – five days course. The course can be done in five days continuously as we (Athlone Hospital) did in Africa or weekly as we are doing it in Brent.

The pictures are used in a layman’s language during discussions, despite them being made for health care workers. The jargon is minimal. The pictures usually ‘talk’ to the participants and are easy to understand.

I strongly agree with the contributor who said, “…To me the challenge is how to access these materials, look at them and adapt appropriately so as not to re-invent the wheel in each of our different intervention areas”. This is further echoed by another reader who said, “…Despite current avalanche of information, the crucial ones are missed in the morass”. I believe that we can make an appropriate picture bank for raising HIV/AIDS awareness in our local communities, that all can access, instead of waiting for health care workers to come around.

B). Advantages of PAIDucation

As stated before, Pictures in HIV/AIDS Education (PAIDucation) have more advantages than disadvantages. The advantages mentioned by a number of you include:
• Provide specific information. No need for imaginations or cartoon diagrams or sketches.
• Language is not a barrier. In UK and Africa the picture ‘means’ the same thing or relays the same message
• Initiate taboo or sensitive topics ‘…challenge untouchable issues’ as said by another member of the discussion group
• Stimulate discussion
• Introduce or generate new ideas and solutions
• Make complicated concepts and technical issues easier to understand
• Allows talks to be tailored to a specific level for the participants, but with the same pictures. I have used the same pictures for primary and high school students, traditional birth attendants, faith ministers, university students, doctors and nurses.
• Facilitating empowerment of people to take action, usually positive action in addressing HIV/AIDS.

C) Disadvantages of PAIDucation

To be honest, I cannot think of any apart from a bit of gossip and rumour mongering about a possible HIV infection diagnosis. True, “…if used wrongly can reap the wrong results” as stated by another reader. The worst incident that comes to mind is of a drunken old lady who was almost assaulted as she made a ‘diagnosis’ of a neighbour who had shingles/herpes zoster of the face. The old lady in her drunken state told the neighbour, “…You must go and see Dr Mapara. He showed us pictures of your rash and he said it is an outward sign of AIDS. There was even one picture, just like you!” Sadly, this was true and the client was already on our register.

Now the question comes in - are Pictures doing good or harm and to whom?

PAIDUCATION – KNOWLEDGE, ATTITUDE, BEHAVIOUR AND ‘PRACTICALS’

It is said that ‘knowledge is power’. We went one step further and said ‘Self knowledge through pictures is power’. As stated before, the Athlone Hospital AIDS Awareness Programme (AAAP) played a major role in the history of the HIV/AIDS epidemic in Botswana. Athlone had a ‘comprehensive’ package while many organisations were still trying to find their feet. Through Pictures in AIDucation, the team was called many a time as national facilitators. Outstanding national duties that were supposed to be given to the Botswana AIDS STD Unit (ASU) or National AIDS Coordination Agency (NACA) were given to Athlone because of ‘lack of capacity’ by the national bodies “…and your (Athlone) proved track record”, quoting officials from very high positions. Some of the assignments were assigned by:
• Ministry of Health (Health care workers)
• University of Botswana (UB)
• Directorate of Public Service Management (Civil servants)
• Botswana Network of People living with HIV/AIDS (BONEPWA)
• Botswana Christian AIDS Intervention Programme (BOCAIP) – Faith ministers
• Teacher Capacity Building Project (TCBP).

It is no secret that AAAP was in a league of its own, from evaluation reports by local and international bodies. It was a leader! AAAP helped the above bodies to set up community programmes. People ‘pictured’ AIDS through Athlone’s Pictures in AIDucation Programme. The replication of the Athlone ‘…best practice’ Health Resource Centres nation wide is testimony to that effect. Pictures tell their own stories!

All the assignments were addressed with PAIDucation. In some cases the team was invited and reminded to “come with your pictures”. It was not possible for Athlone to share experiences or facilitate without pictures. I admit, I would fail as I would find it very difficult to talk, teach or share experiences without the PAIDucation.

As Vaja, another contributor to the discussion said, “like a prophet, everything you talked about is now happening”. It is very sad that it is happening. It could have possibly been avoided or minimised, had the system had a little bit of faith in its own local initiatives! To be likened to a prophet is promoting me too high! I am a mere mortal and all I did in 1990 was just to make a few predictions, using the HIV/AIDS experience (1983 – 1990) of Zambia. Sadly, all the predictions have come to pass. The only ‘positive’ prediction was of AAAP becoming a national programme in 1996.

I was fortunate to have had the knowledge I had of Uganda’s and Zambia’s AIDS Programmes, in the late 1980s. That was valuable. Recall that by then Zambia was second to Uganda in HIV/AIDS prevention, care and support initiatives. President Museveni (Uganda) and Kaunda (Zambia) laid strong foundations for the HIV/AIDS Programmes in their respective countries. We owe it to them!


HOW ARE PAIDUCATION’ PICTURES USED?

I would not like to put down strict rules or criteria for PAIDucation. The major issue is creating a rapport or a dialogue with the participants and showing them the ‘reality’ of HIV/AIDS. It is about effective communication.

Some tips/hints/pre-requisite:
• Having lived in an area with HIV/AIDS and actively participated in HIV/AIDS prevention, care and support projects or programmes is a very valuable experience or pre-requisite
o I have had the fortune of twenty years clinical medicine and at the same time twenty years of public/community health medicine with twenty years PAIDucation in both. Remember the Athlone Health Resource Centre (AHRC) of 1999. That is the principles it was built on of Preventive and Curative medicine through PAIDucation.

• Knowing the culture of a people is also very important, especially where sexual intercourse, sexuality, relationships, sex education and death is concerned
o I deliberately ventured into the intimate culture of Botswana in the early 1990s as the silence on HIV/AIDS was very loud! As a foreigner who ‘did not know’ about the culture I introduced the pictures to make ‘invisible’ HIV/AIDS visible. Seeing is believing!
o Whereas oral sex might be a ‘normal’ sexual intercourse in Europe, many African cultures find it ‘abnormal’ as stated before by an elderly woman in a PAIDucation workshop, “What are you children doing eating vaginas and penises!?” Talk of dental dams might be a very contentious issue.
• Language should be not be a barrier with PAIDucation
• Medical terms ‘jargon’ to be avoided
o Best done by you using the participants’ words or language. Meaning that the participants must be heard more than you the facilitator
• Remember the rule of PAIDucation, “80% of talking is by participants and 20% (Better still 10%) is by YOU the facilitator/teacher/doctor/nurse/social worker/peer educator/faith minister.
o This is the FOUNDATION for a successful, community owned programme
• Let the pictures ‘talk’ to the audience. The audience will then talk to you. You will then talk back to the participants at the end, from their knowledge or lack of knowledge! As it is said that sometimes “little is more!”
o As the Batswana people say, “Nkosi oja morago (The chief eats at the end!), unlike in the West, where the guest of honour or guests at the high table are served first! As another contributor to the discussion said, that he uses proverbs to get the message across
• Time must not be an issue or hurried. Be generous with time. We have to create time as HIV/AIDS dictates. People at the grassroots may need an extra day or two just to understand that HIV/AIDS is real and we all have a role to play in looking after ourselves and our community.
o I recall the first time in 1992 when I asked for three days workshops on HIV/AIDS. I was told that it was too long! In 2001, Athlone was running five (5) days pictures in AIDucation programmes.

PAIDUCATION AND CONSULTANTS

I believe that HIV/AIDS management is about networking, being honest, transparent and looking at reducing new HIV infections. I have no problems with genuine consultants. My quarrel is with the dubious consultants. I have worked with a few while in Zambia and Botswana. Some were honest and admitted that they were deficient, but nonetheless they were paid their thousands of pounds/dollars.

In 1990, some international consultants branded AAAP and Pictures in AIDucation as “a dream…too ambitious…cannot work…shock tactics”. In 2000, the same programme was now documented, “…one of the best practices in Botswana” and was even worth mentioning at Barcelona 2002. Imagine the possible preventable new infections, the preventable deaths and the preventable potential orphans in those 12 years! What a missed opportunity!

We cannot put all the blame on our leaderships. They were unfortunate in that they listened more to the foreign consultants, than their own ‘hands on’ people. The exceptions have been President Museveni (Uganda), President Kaunda (Zambia) and President Mogae (Botswana).

Conclusion
In every single PAIDucation workshop held to date, close to two hundred, knowledge has been imparted through PAIDucation, experiences have been shared through PAIDucation, stories have been told through PAIDucation, attitudes have been changed through PAIDucation and positive responses/behaviour have been observed through PAIDucation.

I thank The Communication Initiative and Health e Communication for having given me a voice to tell the world, that Pictures in AIDucation is a viable, workable HIV/AIDS intervention strategy. I have lived the Zambian epidemic, the Botswana epidemic and now the UK epidemic through Pictures in AIDucation.

***

If you have received this message because someone has forwarded it to you and you are not registered to the discussion you can register at http://forums.comminit.com/index.php?uber=5

Please note: if you are already registered to The CI forums, please simply sign in using your CI Forums username and password, Edit your Profile and click on the "Using Clinical Pictures in HIV/AIDS Education" Discussion to request participation from the moderators.

To unsubscribe sign in and deselect this discussion in your profile or reply to this e-mail with unsubscribe in the subject line.


Should you want to read more on this or other health communication related issues visit the Health e Communication web site at:
http://www.comminit.com/healthecomm/