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Vol. 50, No. 1
IN THE COMMONWEALTH
VOLUME 50, No. 1 MARCH 2004
(Copyright reserved and reproduction without permission strictly forbidden)
HIV/AIDS Education in the Commonwealth Caribbean
HIV/AIDS The Urgency of the task Ahead from the Perspective of Trinidad
and Tobago 1
The Honourable Patrick Manning
Education a KeyPartner in Multisectoral Response to HIV/AIDS 5
Sir George Alleyne
University of Technology, Jamaica's Graffiti Wall: Increasing awareness of
HIV/ /AIDS through participatory message design 15
Knowledge Attitudes and Sexual Practices of Medical Students towards
L. Cox, G. Reid, R. Arscott, J. Thomas
Young Children, a neglected group in the HIV Epidemic: Perspectives from
Hope Ramsay, Sian Williams, Janet Brown, Sanjana Bhardwaj
Uniting Three Initiatives on Behalf of Caribbean Youth and Educators: Health
and Family Life Education and the Health Promoting School in the Context of
PANCAP's Strategic Framework for HIV/AIDS 54
Cheryl Vince Whitman
"When You Have AIDS People Laugh at You". A Process Drama Approach to
Stigma with Pupils in Zambia 83
Brian Heap and Tony Simpson
Commercial Publishing's Response to the HIV/AIDS Epidemic: A Report on a
UNESCO/CAPNET Workshop L.nivarmty ul Florida 99
Graham van der Vyver
Notes on Contributors
ABSTRACTS (in English, French and Spanish)
Information for Contributors
Photography by E. Nadine Isaacs
We thank UTECH for allowing Caribbean Quarterly to use these photos.
Photos UTECH, Jamaica.
Cover Design by Pierre Lamaire
Translations by Latin American and Caribbean Centre, (LACC), UWI, Mona
Colour separations by Scanners, Jamaica
Printed in Jamaica by BCNS Printers Ltd.
UNIVERSITY OF THE WEST INDIES
Professor, the Hon. R.M. Nettleford, O.M. Vice Chancellor, Editor
Professor H. Beckles, Pro Vice Chancellor, Principal, Cave Hill Campus, UWI
Professor K. Hall, Pro Vice Chancellor and Principal, Mona Campus, UWI
Dr. B. Tewarie, Pro Vice Chancellor and Principal, St. Augustine Campus, UWI
Sir Roy Augier, Professor Emeritus, Dept. of History, Mona
Professor Neville McMorris, Dept. of Physics, Mona
Dr. V. Salter, C.S.I., Office of Vice Chancellor, Mona (Managing Editor)
All correspondence and contributions should be addressed to: The Editor, Carib-
bean Quarterly, Cultural Studies Initiative, Office of Vice Chancellor,University
of the West Indies, PO Box 130, Mona, Kingston 7, Jamaica
Tel. No. 876-970-3261, Tel Fax 876-977-6105
Email: firstname.lastname@example.org, or email@example.com
We invite readers to submit manuscripts or recommend subjects which they would
like to see discussed in Caribbean Quarterly. Articles and book reviews of
relevance to the Caribbean will be gratefully received. Authors should refer to the
guidelines on this web page. Articles submitted are not returned. Contributors
are asked not to send international postal coupons for this purpose.
Exchanges: Exchanges are conducted by the Gifts and Exchanges Section, Li-
brary, University of the West Indies, Mona, Kingston 7, Jamaica
Back Issues and Microfilm : Information for back volumes supplied on request.
Caribbean Quarterly is available on microfilm from Xerox University Microfilms
and in book form from Kraus-Thompson Reprint Ltd.
Abstract and Index : 1949-2001 Author Keyword and Subject Index available as
a hard copy.
The journal is abstracted by AES and indexed by HAPI
Year One of a new Partnership:UNESCO and UWI building
the role of the Caribbean's education sector to respond to
Michael Morrissey, Senor Education Consultant to the UNESCO Office for the
Caribbean and Honorary Consultant to the Vice Chancellor on Education &
On January 17, 2003, H616ne-Marie Gosselin, Director of the UNESCO
Office of the Caribbean, and Professor the Hon. Rex Nettleford, Vice Chancellor
of the University of the West Indies, signed a Memorandum of Understanding for
UNESCO and UWI to cooperate in the field of HIV/AIDS and Education,
particularly in the areas of research, advocacy, training and publications. The
MOU is one of the first of its kind for UNESCO globally.
UNESCO was given specific responsibility by the United Nations
General Assembly in 2001 to support Member States including those in the
Caribbean in the fight against the spread and impact of HIV/AIDS through its
areas of competence: education, culture, communication and science. Regional
organizations in the Caribbean, including UWI, equally have a role to play in
fighting the epidemic. The new partnership between UNESCO and UWI was
established to accelerate the response of one sector Education that has not been
sufficiently active. While UNESCO is also working on several other fronts in this
field, it views its cooperation with UWI as a particularly important strategy. This
report, summarising accomplishment of the first year of cooperation, is
appropriately carried in this special issue of Caribbean Quarterly, one of the
instances of UNESCO-UWI collaboration.
Enhancing UWI's capacity through international exchange.
UNESCO enabled Michael Kelly, Professor of Education of the University of
Zambia, to continue his work with UWI professors in development of a strategic
framework for the response of the Caribbean's education sector to the HIV/AIDS
epidemic, marrying two decades of experience of sub-Saharan Africa and the
realities of this region. UNESCO also facilitated publication of the book that
resulted: Education & HIV/AIDS in the Caribbean by Michael Kelly and Brendan
Bain (reviewed by Alfred Sangster on page XX of this journal). UNESCO
facilitated the presence of presidents of universities of Haiti and Guyana to interact
with senior UWI administrators on HIV/AIDS at the UWI/UNESCO/UNICA-
sponsored conference of October 2003 and also created an opportunity for
dialogue between international HIV/AIDS Education specialist, Inon Schenker, of
the Hebrew University of Jerusalem and UWI.
Supporting UWI research. Two lines of preliminary research were
initiated at the Mona Campus of UWI with UNESCO support, presumably among
the first instances of research that assess the impact of the HIV/AIDS epidemic on
education in the Caribbean. The Caribbean Child Development Centre, in
collaboration with the UWI HIV/AIDS Response Programme, HARP (in turn
supported by the European Union), undertook a case study in the parish of St.
James, Jamaica, of the epidemic's effect on early childhood education. The result
is reported in this issue of CQ. The second research, still ongoing, is led by
Professor Wilma Bailey (Faculty of Pure and Applied Sciences) and Dr Affette
McCaw-Binns (Faculty of Medicine) and assesses the impact of the epidemic on
demand and supply for primary and secondary education in Jamaica.
Creating advocacy tools. Underlying UNESCO's support for
collaboration on a book between Professors Michael Kelly and Brendan Bain
referred to above, was a perceived need for development of a credible advocacy
tool for dialogue with Caribbean Ministers and Ministries of Education. The book
was launched jointly by the Prime Minister of Trinidad & Tobago, the Director of
the UNESCO Office for the Caribbean, and UWI's Vice Chancellor on October
28, 2003. Prime Minister Manning's address is included in this issue of CQ. The
Vice Chancellor provided the foreword for this book. A Caribbean edition of this
book will be published by Ian Randle Publishers by mid 2004 and is expected to
be a cornerstone of advocacy and teaching, within and beyond UWI, in the years
Cooperation between UWI, UNESCO and UNICA in mounting of
the First Caribbean International Conference on HIV/AIDS and Education,
October 29-31 2003, the inspiration for this issue of CQ. The Vice Chancellor
refers to this Conference in his introduction to this special issue. As mentioned,
this issue of CQ is also a result of UNESCO-UWI collaboration, and UNESCO
plans to obtain part of the print run for distribution in the Caribbean and wider
afield. This issue of CQ will be included in the UNESCO exhibit of resource
material in the forthcoming 15th International AIDS Conference, to be held in July
2004 in Bangkok, and will bring UWI research including that of its medical
students to the attention of the wider world of HIV/AIDS education.
A continuing agenda. Partnership between UWI and UNESCO has
developed on several other fronts and begun even before the MOU was signed.
The Vice Chancellor dispatched a senior representative, Professor Ronnie Young,
to join with UNESCO in Havana in November 2002 in making a case to the
region's Ministers of Education to step up their sector's response to HIV/AIDS.
This resulted in Ministers signing the Havana Commitment, a pledge to enhance
the response of each country's Ministry of Education. UWI was also specially
represented at UNESCO's annual meeting on Education & HIV/AIDS with its UN
Caribbean partners (July 2003). Furthermore, UNESCO is collaborating with
education faculty members on each of UWI's three campuses in development of
initiatives related to HIV/AIDS, from planning, curriculum and comparative
research perspectives. Among others, Carol Keller of the St Augustine Campus,
Vilethia Davis-Morrison of Mona and Anthony Griffiths of Cave Hill are active in
initiatives related to HIV/AIDS and the education sector. It is anticipated that such
initiatives will gain momentum in 2004 and open other avenues of collaboration
between UNESCO and UWI.
Caribbean Quarterly, Vol.50, No. 1, a Special Issue on Education and
HIV/AIDS comes at a time when the Caribbean, second only to Africa in the
spread of HIV/AIDS needs to engage in a pre-emptive strike against ignorance,
denial, stigma and discrimination which are themselves most effective agents
contributing to the spread of AIDS.
The UWI Chancellor, Sir George Alleyne, himself expressed his wish to
see the region emancipate itself 'from the mental slavery that results in homopho-
bia and discrimination against persons who are perceived as having a lifestyle of
which we do not approve.' There is enough to justify this appeal against the stigma
that the AIDS pandemic engenders throughout the region. This can be seen in the
ingrained religion supported by Old Testament texts, in the budding tradition of
Jamaican dance-hall culture among pop musicians calling for death to those
deemed to have sinful sexual orientations, and in the entrenched patriarchy syn-
drome evident everywhere, albeit in a strongly matriarchal Caribbean society.
The fact that the disease is no longer gender-specific is of particular
importance in the Caribbean where the recorded highest rate of infection is not
among men who have sex with men (MSM) but among women of child-bearing
age. This is in itself a threat to the growth and development of an entire society
doomed to witness large numbers of its new generation who have become infected
through the natural processes of child-bearing and breast-feeding. In 2002, at an
International Conference it was stated that "AIDS has a woman's face," for it goes
without saying that gender inequalities including sexual violence sustain and
nurture the virus. Already the myth that sexual intercourse with a virgin will cure
sexually transmitted diseases (STDs), has led to the spread of infection amongst
young girls and the devastating effects of rape have been extended to include
HIV/ AIDS. In Jamaica HIV infection amongst girls is higher than among boys for
the age group 9 to 13 years. This cannot be accounted for by transfer from the
Education is integral to the fight against AIDS. There is a need to provide
support and care to affected educators and learners, and to recognize that creative
measures are needed to reduce the impact of the epidemic on our education
sectors. Procrastination has already stolen too much of the time that is so vital to
planning and action. We must therefore now forge ahead with a constructive,
creative and realistic approach to HIV/AIDS education, starting with the very
young, if we are to eradicate this modem day plague that is already threatening to
decimate our best and brightest the flower of the region's youth population.
Health and education demand serious investment in the human resource
since each has to do with the human being's trajectory of life from cradle to grave,
from infancy to old age. Freedom from disease is closely related to freedom from
ignorance and both lead to freedom from hunger. All three conditions disease,
ignorance and hunger are the hallmarks of poverty, the alleviation and eradica-
tion of which have become 'big questions' on the global development agenda.
The development process only makes sense when human beings, in terms
of their hopes and aspirations, or of ideas about self and perceptions of the world
which they wish to tenant with dignity, are placed at the centre of the process.
Good health, as a key index of the quality of life and as a positive measure of
social capital, then takes on new life and meaning.
But education must not only be for the young. There is a need for greater
continuing public education in health and healthcare.
The medical history of humanity is the story of the struggles of science
with the workings of nature. The HIV/AIDS pandemic is to this generation of
Caribbean people what tuberculosis was to a former one. It threatens not only the
immune system but also, in development terms, the region's productivity and
economic potential. The lifeline tourist industry, which in some places has been
accused of being the chief conduit of the dreaded disease, readily comes to mind.
There is a need for a programme of health science in our primary schools,
to teach the basic tenets of personal hygiene, to alert the student population at a
very early age to the increasing incidence of HIV infection, especially at a time
when there is much pregnancy amongst school girls, and to affirm the presence of
malnutrition and the threatened resurgence of diseases such as tuberculosis that
were once held in check.
The threat of annihilation is a shockingly awesome thing to contemplate
let alone to witness. The very thought indeed deserves much more of the attention,
untied financial assistance from the 'first world', and far more structured public
education across the entire world than it now receives. Caribbean Quarterly is
pleased to be able to contribute in this pursuit.
Education -a Key Partner in a Multisectoral Response to
SIR GEORGE ALLEYNE
First let me congratulate UNESCO, UNICA and UWI for taking the
initiative to host this Conference, and let me say how much I have enjoyed the
enthusiastic advocacy for this field by Ms. Helene-Marie Gosselin of UNESCO.
Her quarterly reports on Education and HIV/AIDS are a joy to read, both for
substance and method of presentation. I also wish to congratulate Professor
Kochhar and PVC Hamilton of the University of the West Indies for their work in
organizing the conference which as I understand it is to "marshal and galvanize
action by and within the education sector, particularly tertiary education against
HIV/AIDS to complement and support efforts already being made in other sectors
of Government and within civil society". It is impressive to see so many
institutions and disciplines taking part.
I take it that our main focus will be to discuss the role of the formal
education sector in consort with other sectors in addressing the problem of
HIV/AIDS. I make a distinction here between the education that is carried out in
other sectors to address the problem and the activities that are discharged within
the education sector itself, because as you all know well, other sectors can also
claim a role in educating the public about HIV/AIDS. Do not think me overly
precise to the point of minutiae when I characterize the education sector as a part
of the economy as are other sectors, and as containing various systems and
resources that are uniquely focused on education. I will try to examine what the
institutions, particularly the tertiary ones in the education sector bring to the table
that will be a critical complement to the offerings of other sectors and their
institutions. I will attempt to separate tertiary education per se from the
responsibilities of the tertiary institutions of the education sector. Formal
education is only one of the responsibilities of the institutions in the sector.
As a matter of history, the Caribbean response has from early been
multisectoral and although the health sector defended the thesis that the main
reason for the concern about the epidemic was that it causes ill health and death,
there was ready acceptance that the response went beyond the kinds of expertise
that was traditionally found in the health systems of our countries. Indeed the
initial signatories to the Pan Caribbean Partnership for the fight against HIV/AIDS
were two Prime Ministers, Peter Piot of UNAIDS and myself. UNAIDS
represented the multisectoriality of the UN system's approach to the problem of
HIV/AIDS. I like to think that even at that early stage it was clear that the health
sector, the education sector and many others had to work in a partnership with
other sectors and the representation at the highest political level showed that there
was a multisectoral perspective.
The education sector brings to this partnership a unique set of resources
human, informational, organizational, physical and financial. In addition to the
institutions of the sector that are the main focus of this conference, it brings
pedagogical and research skills that are unique. The question is how will the
application of those skills and resources advance the fight against HIV/AIDS.
I have read some of the extensive literature on education and HIV/AIDS
and have been impressed with the attention given to the impact of the epidemic on
the human and financial resources of the sector. I have been also taken with the
predominant emphasis on the schools as a critical part of the sector and the focus
on the young. The Inter-Agency Task Team on Education that was formed by
UNAIDS, in elaborating an overall strategy, prioritized certain actions that the
sector should consider with a focus on reducing individual risk as well as
vulnerability that derived from the societal context. These were;
* Efforts to ensure that teachers are well prepared and supported in their work
on HIV/AIDS through pre-service and in-service education and training;
* Preparation and distribution of scientifically accurate, good quality teach-
ing and learning materials on HIV/AIDS, communication and life skills;
* Promotion of life skills and peer education with children and young people,
and among teachers themselves;
* Elimination of stigma and discrimination, with a view to respecting human
rights, and encouraging greater openness concerning the epidemic;
* Support for school health programs that combine school health policies, a
safe and secure school environment for both teachers and learners, skills-
based health education and school health services that explicitly address
* Promotion of policies and practices that favour gender equity, school atten-
dance and effective learning.
These are general recommendations, and I take it as a given that the
tertiary institutions in the education sector will see it as their responsibility to train
teachers and to produce materials for their use. For example, the use of the
pedagogical approaches that may be peculiar to HIV/AIDS will clearly be a
matter for attention. I see also education not being confined to the traditional
physical spaces and the traditional groups. The education sector must seek to reach
the traditionally unreachables and untouchables who need the information and
knowledge as much as or more than others. There is a constant cry for the
involvement of civil society in the fight against the disease. My experience has
been that the civil society organizations also need education about the possible
roles they can play as much as the young students who are the usual target of the
educational offerings at the various levels of the education sector.
But I wish to enter more into the research capability that almost by
definition must lie within the tertiary institutions of the sector. As I have reflected
on the Caribbean situation and my own role as the UN Special envoy I would
focus on three issues that should be of prime importance for the tertiary
institutions of the education sector. The answers or at least better exploration of
these areas would make a tremendous contribution to the fight against the disease.
The three areas are;
* the increased and increasing prevalence rate among young girls;
* the pervasive stigma and discrimination;
* the mechanisms for increasing coverage both with respect to voluntary test-
ing and counseling and the wider use of antiretroviral therapy.
For many years the phenomenon of teen-age pregnancy has been studied
here and various theories advanced as to its high prevalence. I have heard an
eminent professor aver that our perception of who is a teen-ager and the
inappropriateness of pregnancy at an early age stem from a perception that is not
in keeping with our ancestral origins. I know of the benefit of keeping girls in
school in delaying pregnancy. Hitherto this was looked upon as an unfortunate
consequence of early sexual exposure, but now we know that this early sexual
exposure is leading to increased rates of infection and the health sector is being
awakened to the fact that the phenomenon of early sexual exposure is an egregious
manifestation of the unequal gender power relationships that exist in our society.
It will be for the tertiary institutions to undertake better research at unraveling the
nature of these relationships with a view to proposing some societal solutions as I
do not believe that the present situation is immutable. Teenage pregnancies are
harmful, but early HIV infection is lethal.
I have become increasingly concerned about the many faces of stigma
and discrimination in the Caribbean and am anxious to see the tertiary institutions
engaged in the research that attempts to explain its origins. I accept that the disease
is now a heterosexual disease, but it is not only the stigma that attends the
perception of different life-styles, but the discrimination against persons with
HIV/AIDS that concerns me. The fear of such discrimination drives the epidemic
underground. Are our laws and legislative practices in keeping with the
declarations of adhering to basic human rights principles that all our countries
affirm? Discrimination does not exist only in relation to another different group
and the groups against which there is discrimination are society-specific. These are
areas of enquiry that are within the province of the tertiary education institutions,
and they owe it to the societies and to the other sectors of the society to explore
All HIV/AIDS programmes accept that prevention is key, but attention
must also be given to therapy with the drugs that are becoming available. In the
early days after treatment became available, the drugs were prohibitively
expensive, but it was not only the cost of drugs that seemed to be a block to
developing countries undertaking universal treatment. The view was taken that the
basic infrastructure to ensure delivery and compliance with the complicated
regimes was not present. Brazil has shown that this is not so. But I would ask if
whether in anticipation of the more ready availability of therapy there has been the
research to determine the various non-traditional methods of giving and
monitoring therapy here in the Caribbean. There is yet another issue related to
treatment. Given the nature of the epidemic, is voluntary testing and counseling a
cost-effective modality here as it has been shown to be elsewhere? This is an
important question for research, the answer to which is absolutely vital for the
control of the epidemic.
Finally, let me deal very briefly with the more traditional view of the
input of tertiary education. It is a legitimate call on these institutions to be
responsive to the main social concerns of the region. The concern with the overall
health situation of the region led to the medical faculty being the first to start in our
University and we can see the growth of the various faculties and disciplines
taking shape in response to the problems of the region and the need to find
Caribbean solutions. The situation with HIV/AIDS has reached the stage when
there must be educational offerings that accommodate that concern. Thus I see
specific teaching in terms of content and skills about the many facets of the disease
being incorporated into not only the health sciences, but into other faculties as
well. I do not like the expression "mainstreaming" but I do hope that the
educational content of more of our programmes will include material on
I hope the tertiary institutions will be galvanized to address some of the
issues raised here and I plead for research into the areas I have mentioned above. I
also hope that my University (UWI) will play a leading role in stimulating
education about HIV/AIDS an education that the World Bank has dubbed the
"social vaccine" against the disease.
HIV/AIDS The Urgency of the task Ahead from the
Perspective of Trinidad and Tobago
THE HONOURABLE PATRICK MANNING
Permit me to begin by thanking the joint sponsors of this Conference,
The University of the West Indies, the Association of Caribbean Universities and
Research Institutes (UNICA), and the United Nations Educational, Scientific and
Cultural Organization (UNESCO) for affording me the opportunity to address
I must tell you that I accepted the invitation most graciously, enthused
straight away as I was by the very theme of the Conference: "HIV/AIDS: The
Power of Education."
Additionally, the proposed launch this evening of a related and critically
important publication entitled "Education and HIV/AIDS in the Caribbean",
which was co-sponsored by the International Institute for Economic Planning and
UNESCO and co-authored by two outstanding scholars in the field, Professors
Michael Kelly and Brendan Bain, further aroused my curiosity and rendered the
present engagement the more alluring.
To my mind, in a manner of speaking if ever there was a Conference of
importance, this one is. HIV/AIDS is the most deleterious and formidable bio-so-
cial challenge facing the Caribbean and wider world at this time. For years it hung
over our region like a dark, polluted and ominous cloud which, like the rest of the
world, we allowed to overshadow us, through neglect and underestimation. With
the threatened escalation of the HIV/AIDS virus all over the world by the second
decade of this century, the cloud has now burst into a torrential downpour and the
only way out of the deadly acid rain is to seek protection and escape. THe only
way is through education.
If ever there was a worthy agenda, this Conference which seeks to discuss
the manner which through education HIV/AIDS can be better understood, and
how education in the Caribbean can be made more relevant and appropriate to the
challenge set us by this destructive and deadly pandemic, then this Conference is
In a similar way, If ever there was a text worthy of the effort of it authors,
the present publication by Professors Bain and Kelly, designed as it is to equip all
in the Caribbean with information and understanding of what HIV/AIDS means
and the diverse ways in which education can contribute to managing the disease,
this is the text.
I wish upfront to commend the organizers of this Conference and also to
commend the two Professors on a book that is not only sorely needed but, from
what I am already beginning to perceive, has been well researched and well
Ladies and Gentlemen, the present Conference effort is all the more to be
appreciated, given that less than a month ago, I addressed the Caribbean/United
States Chiefs of Mission Conference on HIV/AIDS. At that conference, the
United Nations Development programmeme in its report on Human Development
had complained that all the world over, countries and institutions had not been
doing enough to combat the spread of the deadly HIV/AIDS virus.
The reasons that have been advanced to explain the tardy attitude of
states and institutions are multifarious and complex.
However, more and more we are being told of the lack of leadership and
vision at the global, regional and national levels, and of the silence and denial by
individuals and their families, and about the harmful attitudes and behaviours that
negate and discriminate against those whose misfortune it was to find themselves
infected by the dreaded disease.
We are being told also of the failure of the international community and
of national governments to commit financial and other resources towards the fight
against HIV/AIDS, and of the inability of states and institutions to design and
deliver adequate and appropriate response programmes and measures.
We hear of too much focus on quick-fix solutions, stop-gap measures,
and the lack of comprehensive policies to deal with HIV/AIDS, and of the focus
on the problems of individuals rather than on the implications of HIV/AIDS for
social degeneracy, nemesis and vaporization.
You are the experts, but I wager that somewhere at the root of all of these
problems with HIV/AIDS lies a fundamental lack of education. Since the discov-
ery of the disease in 1981, its prevalence has multiplied by leaps and bounds. The
number of HIV-positive people in the world has quadrupled from 10 million in
1990 to 42 million in 2001. Some nine thousand people die from AIDS each day:
about five or six every minute, some 360 every hour; some three million each year.
As you are no doubt aware, in the Caribbean, we are certainly up against
it. Our region ranks second in the world in terms of HIV-infection. At the end of
2001, some 2.4 % of the Caribbean population, or 500,000 people were living with
HIV/AIDS. Currently for many Caribbean countries someone in every household
knows a person who has been infected.
As you can imagine we are in no way proud of our record, and that no
one has a desire to recall the statistics or recount the disturbing tale. Whai is more,
even the figures themselves raise more questions than answers, and some rather
disturbing ones at that. The frightening and alarming statistics on HIV/AIDS in the
region are neither well known nor appreciated by the masses in the region. Nor are
they as accurate or up to date as they should be about HIV/AIDS.
Of course, this is merely a reflection of the situation regarding HIV/AIDS
Education in the Caribbean. HIV/AIDS is spiraling in the Caribbean because
HIV/AIDS Education is lagging, being neither adequate, accurate, up to date or
relevant to the challenge.
The vast majority of people of the most affected group among us, those
between 15 to 44 years, would probably know that HIV/AIDS constitutes a
formidable problem. But it has to be that too many among them are unaware of just
how serious the problem is.
Almost every one should agree, that the HIV/AIDS pandemic is far more
deadly than it seems, although just how deadly it is, the society on account of
behavioral patterns does not quite seem to know.
There exists among us in the region far too much ignorance about what
HIV/AIDS is, how it is spread, what are its symptoms, and how to evaluate the risk
and options relative to personal health and safety.
The knowledge shortfall is as threatening as the disease itself. Even
among HIV/AIDS victims themselves for example, there exists too much igno-
rance about the availability and use of treatment, the existence of support groups,
conditions for maximizing the effect of therapy and so on.
One would find that many are not aware, for example, of the mutational
quality of the HIV/AIDS virus and of its overwhelmingly phenomenal capacity for
resilience. HIV/AIDS victims on anti retro viral drugs are often unaware that when
they are irregular in their application of their medication, they help to develop and
transmit even more resistant strains to the virus.
The list of concerns is long and indicative of the need for a more
comprehensive orientation towards education and research in respect of the
Among policy planners themselves, there continues to be too many grey
areas concerning individual, as well as group, social and psychological behaviour
among infected classes and their families, and those involved in providing welfare
and support, the health care professionals themselves and so on.
Similarly, each day, thinkers and activists in the field are finding out
more about the potentially devastating, long-term effects of HIV/AIDS on society
and economy, sustainable growth and development, future population optimality,
manpower depletion and health care cost. But there remains much to be discerned
about the direction that health administration and international institutions might
take as countries, regions and the world at large struggle to do battle against the
One need not mention that we are still searching for a cure. An
HIV/AIDS vaccine remains one of the most difficult challenges ever for science
and medicine. However while mankind continues to search for a vaccine which
at any rate the experts say is not likely to come before 2010 HIV/AIDS is killing
not only the individual's immune system cells but the global society's immune
system as well at an accelerated pace.
Indeed and HIV/AIDS vaccine remains the most pressing challenge for
science and medicine. Some one once likened the search for an HIV/AIDS vaccine
to playing a Lotto game. In both instances, if one gets lucky, he/she wins. But there
is a phenomenal element of improbability involved, and the question that emerges
is what happens if one does not win?
As it stands, where there is still no cure for HIV/AIDS, ankind has so far
not secured an outright win in this regard. Our best option still lies in education,
for waiting for a vaccine to happen, is like placing all our income on a bet that we
are not sure to win.
It is important for us to recognize, that HIV/AIDS is the most opportun-
istic virus the world has ever seen. It's development and spread has been more than
a function of our ignorance. At the individual, social and institutional level, AIDS
has exploited every intelligence gap or shortcoming in our human and social
systems. In fact, since its discovery 22 years ago, its survival and spread has been
in inverse proportion to our ability and capacity to gather information and use it
against this most deceptive enemy against mankind's peace, stability and progress.
It follows then that in this war against HIV/AIDS, education is the key,
and we need to strengthen the very foundation and reach of education and research
on HIV/AIDS. All our schools, colleges, institutions of learning, religious or
secular, private and public, local or otherwise must become involved.
Everyone must become more involved because everyone is involved.
However in the new dispensation involvement must mean awareness.
It is time to take control over HIV/AIDS, put a stop to its advance, and
roll back it's defences through the acquisition, interpretation and application of far
more knowledge and information about the disease.
It has come down to the fact that all our institutions must facilitate this
most important quest. However, you the University of the West Indies and
related institutions such as UNICA, UWI/HARP, CAREC and a host of other such
institutions represented at this conference have a critical role to play.
It goes without saying, for example, that we need the involvement of
those operating in the field of medical sciences. But there is the need for the
collaboration of those involved in the social and behavioral sciences. And of
course it would be remiss of us to leave out the political sciences.
It is certainly clear that the organizers of this conference understand fully
that in respect of the struggle against the spread of HIV/AIDS we need to mount
an educational coalition through which all the knowledge bases integrate, and feed
from and into each other.
The institutions represented at this Conference, and the diversity of its
speakers and panelists, bring to us all a certain wealth of experience that in the
final analysis ought very well to lift the context of research and education on
HIV/AIDS in the region. One can only hope that all of our deliberations will be
transferable into rational and comprehensive policy.
As can be appreciated, on the matter of HIV/AIDS, we in the Caribbean
can enjoy no future without action, but action must be within the realm of
possibility and practicality. Your experience and expertise will figure tremen-
When all is said and done the situation regarding HIV/AIDS in the
Caribbean is a call to work and this Conference must help us to set the basis and
orientation for the proactivity which naturally ought to follow.
Confronted with the HIV/AIDS situation in the Caribbean and the world
at large, we must harness the potential of the education sector to prevent further
HIV/AIDS infection. There exists but little choice other than for us to mobilize the
widest educational constituency to offer all the knowledge, information, support
and direction needed by this country, the region and a wider world traumatized by
HIV/AIDS, in order to relieve ourselves of this viral yoke HIV/AIDS and do away
with the burden of its unrelenting death sentence on humanity.
In the Caribbean we need to appreciate the global response to the chal-
lenge. There are countries that have introduced programmes that have made a
significant difference to how the problem is addressed in terms of treatment and
containment Uganda, Thailand, Senegal and Zambia, Cambodia to name but a
How do we benefit from these experiences? How do we draw from and
constitute a regional perspective? How do we develop and act adequately and
appropriately in respect of a Caribbean resolve? This is about our collective quest
for sanity on the question of HIV/AIDS.
There is a saying that only further education can instruct education
further as to what next to do. This to my mind is the reason why this UWI/
UNICA/UNESCO Conference is so important.
I take this opportunity to welcome all participants to the Conference. As
host country, Trinidad and Tobago and the Caribbean region wish you well in your
deliberations. Our region and the world is looking towards that new something
that your deliberations may contribute and pass on.
As you proceed it might be encouraging to be aware that this Government
is neither insensitive nor blind to the challenges that face us here regarding HIV
/AIDS. Last year the Trinidad and Tobago Government agree to allocate 500
million dollars to be used over a five-year period for education and research and
the treatment of HIV-infected persons in the country. We continue to source
funding and expertise from international agencies in order to advance our local
struggle against the spread of HIV/AIDS, acquiring only recently from the World
Bank a loan of $20 M to support additional initiatives against HIV /AIDS. In
addition, only recently the Government appointed a high level Co-ordinating
Committee in the Office of the Prime Minister, involving Non Governmental
Organizations and the Public Service to monitor and co-ordinate our efforts in the
fight against HIV/AIDS.
Further to this, the Government is in the process of finalizing our first
ever National HIV/AIDS Strategic Plan which will be launched very shortly
I would say no more on the matter except that in Trinidad and Tobago the
Government is determined to take on the challenge of HIV/AIDS with a clear
vision and policy orientation, and that the contribution that will flow from this
Conference already has the making of a welcome addition.
As you go to your deliberations you must know that history and necessity
have challenged you with a tremendous responsibility. You have literally taken on
a matter that will affect the lives of so many in the Caribbean and in the world.
Go to these deliberations with all the concern for them that you can bring
to this discourse and with more than ordinary awareness of the importance of the
conclusions that may be arrived at, the decisions that may be taken, or the
perspectives that will be formed.
What you will discuss here is far more important than the moment, bound
up as the issues are with the urgent questions surrounding the survival of Carib-
bean peoples and the future of the human race.
Allow yourselves to be guided accordingly.
The UWI HIV/AIDS Response Programme
BRENDAN C BAIN
At the core of this paper is the belief that strong political will to confront
the human immunodeficiency virus (HIV/AIDS) epidemic in an organized way is
the key to progress in mitigating the impact of this disaster. The paper describes
the formation and early development of the University of the West Indies
HIV/AIDS Response Programme (UWI HARP) and identifies the requirements
for its sustainability and success. The leaders of the UWI HIV/AIDS Response
Programme (UWI HARP) describe the university's programme as a partnership
"to promote awareness and appropriate action in response to the HIV/AIDS
epidemic." The UWI HARP leadership warns, "Let us neither over-emphasize
nor under-emphasize HIV/AIDS."
Discussions leading to the formation of UWI HARP began in the year
2000 when the UWI Vice-Chancellor approached three academic leaders and
called for increased UWI involvement in the response to HIV/AIDS. A meeting
of representatives from the three campuses was held in March 2001 to acknow-
ledge and review the involvement of UWI staff in HIV prevention and care
research and community service and to brainstorm the future shape of UWI's
response to the growing epidemic. The consensus of that meeting was that UWI
needed to organize and accelerate its activities in the face of the growing threat
posed by HIV/AIDS. The meeting recognized HIV/AIDS as a multifaceted threat
requiring a multidisciplinary response. Delegates accepted that the university as a
communal institution had a responsibility to join the regional response to the
epidemic and that a range of talented persons within the university had the
potential ability to mount a meaningful response in collaboration with other
contributors in the field.
Following the March meeting, the first UWI HARP Committee was
formed on the Mona Campus under the chairmanship of Professor Brendan Bain
in August 2001. Then, in February 2002, similar committees were started on the
Cave Hill and St Augustine Campuses at the time of Professor Michael Kelly's
first visit to the Caribbean.
Almost coinciding with the Vice-Chancellor's call for a more obvious
response to the HIV/AIDS epidemic from the university community was an
invitation to UWI from the Caribbean Community Secretariat in Guyana to
participate in a project aimed at "Strengthening the Institutional Response to
HIV/AIDS/STI in the Caribbean (SIRHASC)." This project had begun in Decem-
ber 2000 and, in fact, was to provide the first significant external funding to UWI
HARP a grant of approximately Euro $2.7 million over a three-and-a half year
period from the European Union (EU).
The EU grant enabled UWI to join five other regional organizations in
the SIRHASC project. Under the aegis of the project, UWI has employed a project
officer and six lectures and has embarked on a programme of systematic curricu-
lum review and development in areas relevant to HIV/AIDS. In addition, lecturers
from Cave Hill and St Augustine have undertaken ground-breaking studies to
document the current and possible future socio-economic impact of HIV/AIDS in
Barbados, Guyana and Suriname. Also through the project, the Caribbean Insti-
tute of Media and Communication on the Mona Campus has collaborated with the
Caribbean Epidemiology Centre (CAREC) in sensitizing Caribbean media owners
and practitioners to issues pertaining to HIV/AIDS. While building capacity
within the university, UWI HARP is beginning to reach out to other tertiary level
institutions and is helping to strengthen other national and regional organizations,
including the Caribbean Regional Network of persons living with HIV/AIDS.
Mission and Aims
The mission statement of UWI HARP is "To build and harness capacity
within the university in order to contribute maximally to the national, regional
(Caribbean) and international effort to control the HIV/AIDS epidemic and to
mitigate the impact of HIV/AIDS on the university itself and on the wider soci-
The aims of UWI HARP are:
* To accelerate action by UWI in response to the growing HIV/AIDS epi-
demic through research; education and training; and strategic engagement
with the wider society.
* To develop and monitor HIV/AIDS Policies within the university and in the
* To generate/attract/manage resources to sustain the response to HIV/AIDS,
* To serve as a clearing house for HIV/AIDS information, complementing na-
tional, regional and international agencies.
The skeletal structure of UWI HARP is: a coordinating unit reporting to
the Vice-Chancellery; three campus committees, reporting to the respective Cam-
pus Principals and to the coordinating unit; and sub-committees or task forces
working on specific tasks. On each campus, UWI HARP is bolstered by volun-
teers from among the staff and student body. The coordinating unit is building
relationships with non-campus centres via the UWI School of Continuing Studies
and the UWI School of Clinical Medicine in the Bahamas.
UWI HARP is multi-disciplinary by design in recognition of the reality
that HIV/AIDS is a multi-faceted problem that calls for a multi-sectoral response.
Campus committees are therefore comprised of staff, students and trade union
representatives. In addition, delegates from Governments and non-Governmental
organizations attend by invitation. The latter group includes organizations of
persons living with HIV/AIDS.
Our target audience includes students, teachers, administrators, student
service managers (formerly called Wardens), resident advisors (formerly called
sub-wardens), trade union members, clerical and support staff and significant
others in families and in the general community.
Our Task marketing of attitude and behaviour change
The chief task of UWI HARP is that of marketing attitude and behaviour
change at several levels from administrative to grass-roots. The university
community must be persuaded that HIV/AIDS requires an organized (structured)
response and that an appropriate institutional structure must be maintained for as
long as is necessary to accomplish the task. The aim of this sustained social
marketing programme is to ensure that each target group is aware of UWI HARP,
perceives the programme accurately, believes that the programme is valuable,
accepts their own needs in relation to HIV/AIDS and demonstrates appropriate
action in response to the epidemic.
The desired outcome is: appropriate, measurable action by administra-
tors, and the membership of the university community individually and collec-
tively, attributable, at least in part, to UWI HARP. At corporate level, action will
be organizational, but personal and small group responses at grassroots level will
be seen in effective prevention of HIV/AIDS and active moves to improve care
and treatment and reduce stigma and unfair discrimination against members of the
community who are infected or affected by HIV.
The central challenge to UWI HARP is to make our effort well coordi-
nated and sustained. We recognize that we have started not a sprint, but a
long-distance race. Professor Michael Kelly has intimated to me that the authori-
ties in Southern Africa are digging in for a 50-year response to the epidemic in that
part of the world. Shouldn't our response programme in the Caribbean be a long
range one? And shouldn't universities be part of this long range response?
In order to succeed in the long run, however, we need continued strength-
ening of political will within the university, consolidation of organizational struc-
tures and resources to build and sustain our efforts. For our part, within UWI
HARP, we are prepared to consolidate our activities through sound strategic
planning and we intend to establish excellent systems for monitoring and evaluat-
ing our work.
University of Technology, Jamaica's Graffiti Wall: Increasing
awareness of HIV/AIDS through participatory message design
The University of Technology, Jamaica (UTech) is the first national
public university in Jamaica. Accorded university status in 1995 and chartered in
1999, the university is known for concentrating on producing work-ready gradu-
ates in the fields of Pharmacy and the Health Sciences, Technical and Vocational
Education, the Built Environment, Business and Management and Engineering
In face of the reality that the Caribbean is second only to Southern Africa
in the rate of new HIV infections, UTech determined that it has a critical responsi-
bility to develop methods of educating members of its community about
HIV/AIDS and leading in the fight against the disease. The urgency of this fight
is underscored by the fact that UTech's student clientele is predominantly com-
prised of those in the most at-risk age groups for contracting the disease There-
fore, since late 2002, the University has actively joined the fight against
HIV/AIDS from two distinct directions: increasing awareness about the nature of
the disease among members of the UTech community in order to encourage
behaviour that will reduce the infection rate, and insisting on the rights of those
living with HIV/AIDS.
As part of a major education initiative, the University planned an large-
scale outdoor exhibition related to HIV/AIDS in the Caribbean Sculpture Park at
its Papine Campus in October 2003, inviting all institutions public sector, NGO
and private sector engaged in the fight against the disease to mount booths that
displayed what they were doing to combat the disease. The theme of the exhibi-
tion was HIV/AIDS Awareness protection, prevention and caring for people
living with HIV/AIDS (PLWHA).
However, in planning the exhibition, the organising committee was con-
fronted with a significant challenge: the building adjacent to the Caribbean Sculp-
ture Park was under construction, and the entire length of the park was fenced in
zinc to protect visitors to the park from the construction activity. The organising
committee agreed that this zinc fencing would detract from the exhibits; if, indeed,
the park were to be used as the site for the exhibition, something needed to be done
about the zinc fencing. Hence was born the idea of a graffiti competition on the
zinc fencing that would be conducted as a complementary activity to UTech's
HIV/AIDS Awareness Day 2003.
Following is a detailed account of the planning and execution of the
UTech Graffiti Competition and its outcomes.
Anticipated benefits of the Graffiti Competition
The HIV/AIDS Awareness Day (HAAD) Organising Committee agreed
that the advantages of a graffiti competition were that it would generate interest in
HIV/AIDS as an issue of concern to students and staff, create interest in the
planned HIV/AIDS Awareness Day, and engage students and staff directly in
thinking about the themes of the HAAD itself. An added benefit of the graffiti
competition was that the messages generated would be in place as long as the
construction site remained on campus. At the time of planning the competition, it
was estimated that the construction would not be completed until January 2004.
Therefore, the Organising Committee agreed that the benefits of the initiative were
Preparation for the competition
Ownership of the zinc fencing
The Organising Committee first arranged with the contractor, through
UTech's Physical Development and Operations Department, that the graffiti en-
tries could be painted on the zinc fencing, and that the zinc fencing could be
retained by the University at the end of the construction period. These two
agreements were critical to the success of the initiative: entrants needed to know
that they were creating messages for the community that would last beyond the
HAAD. Furthermore, since the initiative addressed so many members of the
UTech community, it was important that the products of the initiative would
remain with the University. The University signed an agreement with the architect
and contractor that allowed UTech to keep the zinc at the conclusion of the
Support for the development of the Graffiti Wall
The HIV/AIDS Organising Committee first applied to the HIV/AIDS
Demand Driven Sub Project (HADDS) of the HIV/AIDS Prevention and Control
Project, a World Bank initiative in the Ministry of Health for funding to support
the Graffiti Competition and other activities related to the HAAD. The Ministry
agreed that it could support the production of messages that would last longer than
the HAAD itself; therefore, the Graffiti Wall seemed an ideal initiative for
HADDS support. The grant from the Ministry covered the cost of paint, brushes
and thinner for the teams to produce their entries.
The Organising Committee also obtained support from two paint compa-
nies: Berger Paints (Jamaica) Ltd. sponsored five of the entries, and Sherwin
Williams (W.I.) Ltd., sponsored four of the entries in the competition. This
private sector support reduced reliance on the Ministry of Health for support of the
A private donor provided the tarpaulins for the entrants' use. The tarpau-
lins were crucial, because of the inclement weather that dogged the competition.
Each team had at least one tarpaulin under which to work and with which to
protect its entry prior to the judging on October 21, 2003. Much of the documen-
tation of the progress in developing the graffiti entries shows the teams working
under tarpaulins protecting them from rain and sun alike.
The Expression of Interest
To promote the competition, the Organising Committee circulated an
advertisement on the University's intranet and through the Heads of School and
Department, as well as through Faculty and Departmental representatives on the
Organising Committee. Paper advertisements promoting the competition were
also mounted on notice boards in each Faculty and in the UTech Administration
Approximately one month before the graffiti competition was scheduled
to begin, both students and staff in all Faculties, Departments and Divisions in the
University were invited to submit an Expression of Interest to participate in the
event. The expectation was that various units in the University would form a
team to enter the competition, nominate a Team Leader, and complete an Expres-
sion of Interest form. These forms were to be submitted to the Organising Com-
mittee three weeks before the beginning of the competition itself.
The Expression of Interest outlined the rules for designing competition en-
* Each entry was to convey a positive message related to prevention of HIV,
avoiding the disease, or caring for persons living with HIV/AIDS (PLWHA)
* Each entry was to appeal to the 17-35 age group
* The section of the fence allocated to each team would be drawn on the Mon-
day preceding the competition, so that the team had time to plan its entry in
advance of the actual competition
* Entries were to be mounted in assigned sections of the zinc fencing over a
five-day period 2. No team was to work on any section of the fence other
than what was allocated to it. The teams could work at any time of the day
or night, but they could not begin before midnight October 16, 2003 and
they had to finish their work by 6:00 p.m. on October 20, 2003.
* Each team would agree to assign the copyright for its entry to the Univer-
sity. In exchange for the assignment of that copyright, the entry would be
eligible to win one of three cash prizes in the competition.
* Each team would be given five quarts of oil paint in different colours, five
tins of spray paint in a variety of colours, a range of paint brushes, a quart of
thinner and the use of a tarpaulin to protect its entry during development. If
the team needed supplies beyond what were distributed, it was up to the
team members to obtain what they needed at their own expense.
The prize money was also promoted in the advertisements as an incen-
tive to enter the competition.
Identifying the judges for the competition
The Organising Committee worked through the UTech Centre for the
Arts to identify appropriate and credible judges for the competition who were
external to the University community. A recognized artist who employs graffiti
without the context of her three-dimensional art, a graphic artist and an art
educator agreed to be the judges of the entries.
In addition, on the day of the HAAD, as an incentive to attend the
exhibition, visitors to the event could vote for their favourite entry during the first
two hours of the exhibition. These participant votes were to be tabulated and used
as 20% of the final score in determining the winning entries.
The entrants in the competition
It was necessary to set a maximum on the number of entries in order to
calculate the amount of paint and number of brushes needed for the competition.
The Organising Committee, in examining the amount of space available on the
zinc surrounding the construction site determined that a maximum of 20 entries
would be accepted for the competition. These spaces did not interfere with the
construction activity in any way,4 although some were more challenging to paint
Of the accepted Expressions of Interest, 19 were from student groups
both in UTech and the University of the West Indies 5 and one was from the
President's Office at UTech. While the response from administrative divisions in
the University was somewhat disappointing, certainly the response of the students
was very encouraging. All five UTech Faculties mounted teams to enter the
competition; seven of the eight Schools in the University entered at least one team,
as did the Students' Union and two of the University clubs. The Caribbean School
of Architecture entered seven teams.
The enthusiasm for entering the competition grew over time. Indeed, the
closing date for entering the competition had to be extended, because on the
original closing date there were only seven Expressions of Interest submitted.
However, on the last day of the extension to the submissions, the Organising
Committee had to turn away applicant teams, as there was not enough paint or
space available to accommodate everyone who wanted to enter.
In reviewing this phenomenon, the Organising Committee determined
that communication about the entry regulations for Graffiti Competition played a
key role in the original apparent lack of interest. Apparently, despite its best
efforts, the Committee did not get information into the right hands initially to
spread word about the competition.
Identifying the prize money for the competition
Originally, the Organising Committee expected that the Ministry of
Health/World Bank HIV/AIDS Demand Driven Sub-Project (HADDS), to which
it had applied for support for the Graffiti Wall initiative, to provide the prize
money for the competition. However, two weeks before the competition began,
the Organising Committee received word that the HADDS would not support the
prize awards that it was willing only to award "educational items" as prizes, and
only up to a value of one quarter the sums that had been advertised as prizes.
While this news created a last-minute challenge to the success of the
initiative, given that the prizes had already been announced, the University deter-
mined that it could not rescind the original announcement nor could it attract
other sponsorship for the prizes so close to the actual competition.
In the end, the University loaned the HIV/AIDS Steering Committee the
prize money against the intended income-generating uses intended for the entries
in subsequent years. The first income earned from uses of the graffiti entries (in
posters, mouse pads, T-shirts, calendars, executive diaries) will be used to repay
the funds borrowed from the University for the prizes.
UNESCO involvement in the Graffiti Wall
Many of UNESCO's current educational initiatives are related to
HIV/AIDS education. When UNESCO learned of the plans for the Graffiti Wall,
it was very interested in documenting the initiative, believing that the idea has
great potential for replication in other countries. Therefore, UNESCO has
awarded UTech a grant to document the process of developing the Graffiti Wall in
a multimedia production, which it will distribute on CD.
Results of the Graffiti Competition
Creation of an outdoor art gallery of HIV/AIDS messages
To say that the results of the competition have been beyond expectation
is an understatement. The first and most obvious outcome is a 20-piece art exhibit
speaking to the themes of prevention, abstention and caring for PLWHA that
surrounds the construction site and runs the length of the Caribbean Sculpture
While initially entrants were concerned that other teams might "steal"
their ideas, it quickly became evident that each team had carefully research and
planned its own entry, and while some of the messages were similar, the format
and execution of the message in each case was unique.
The response of the students to the quality of the entries both those
participating in the competition and those who visited the graffiti wall afterwards
- was astonishment and pride. "I didn't know we had so much artistic talent at
UTech," one visitor to the entries was overheard to say. In the days following the
completion of the entries, many students made a point of visiting the Sculpture
Park to see the results, and then returned with their friends to show them the
Many students and staff from across the campus have expressed concern
about the possibility that the exhibition will be dismantled upon the completion of
the construction. What the University is yet to decide is where the original zinc
entries will be placed when the construction is finished and the zinc fence is
removed from the site.
Exhibition of learner-centred education in action
An unexpected by-product of the Graffiti Competition was the visible
demonstration it provided of learner-centred education in action. The primary
purpose of the Graffiti Competition besides providing an attractive and relevant
backdrop for the HAAD was to engage the students and staff in actively thinking
about the HIV/AIDS pandemic and what it means to them. The Graffiti Wall was
intended as a vehicle for experiential learning about HIV/AIDS.
Observing the teams in action collaborating in designing and executing
their messages on the zinc fence revealed that each team had carefully researched
the subject of HIV/AIDS, thoroughly discussed amongst the team members what
they were going to do, devised a "message" that met the criteria detailed in the
Expression of Interest form, and then worked together to execute that message in
a creative and novel way. Seeing the team members working together, through a
holiday weekend, in the rain, into the night and in the heat of the afternoon sun
demonstrated the power of learner-centred education better than any written
documentation can possibly express.
The President of the University, seeing more than 30 young people at
work on different section of the Graffiti Wall on the first evening of the competi-
[It's] an exciting experience! They've done their research,
they've planned what they're going to do, and now, look at
them! They're all busy working together to put their vision into
their messages on the wall... It's experiential learning in ac-
The result was a cadre of more than 130 students and staff who had
learned far more about the HIV/AIDS pandemic and its effects than could have
possibly been communicated in a public lecture where the content was determined
by the presenter and the audience passively received the message.
1. Zinc fence in the Sculpture Park before the Graffiti Competition
2. The first prize entry from the School of Computing and Information
Technology in development
3. Entrants from the Caribbean School of Architecture incorporated a light
pole into their design
4. Members of the team that won second prize adding finishing touches to
5. Visitors to the graffiti entries on the day of the judging
6. Security guards took a keen interest in the developing graffiti messages
'- .j. -F
Impact of the Graffiti Wall
Certainly, the intended outcomes of the Graffiti Competition were met
and exceeded. The primary intent of mounting the graffiti wall was to provide an
appropriate backdrop for the HIV/AIDS Awareness Day (HAAD) exhibition on
October 22, 2003 in lieu of the zinc fence of the construction site edging the
Caribbean Sculpture Park: it certainly accomplished that objective, providing a
thought-provoking and colourful series of HIV/AIDS-related messages that
prompted visitors to the HAAD to stop and discuss the entries with their friends.
The second objective was to engage staff and students who participated in design-
ing the entries in thoughtful consideration of HIV/AIDS and its potential impact
on the UTech community: the messages mounted by the entering teams demon-
strate the extent of their thought, deliberation and learning in relation to
HIV/AIDS and PLWHA. The third intent was to mount an event that would have
a lasting impact on the UTech community and its thinking about HIV/AIDS: the
fact that students and staff alike are asking where the University is going to keep
the graffiti entries, and their suggestions about how the messages they contain can
be shared with a wider audience, indicates the depth of ownership the community
has developed toward the graffiti entries and their messages. That the University
community is no longer talking about images (i.e. posters) of the graffiti being
kept, but the zinc originals themselves, indicates the value the community is
placing on the work that was done and the products themselves.
An unanticipated group affected by the mounting of the graffiti wall has
been the workers on the construction site the people on the other side of the zinc
fence. During the first days when the tarpaulins were being slung over the fence
and people were spending a great deal of time looking at and working on the zinc
fence, the workers became curious, and even puzzled, about what was happening.
As they looked down from their vantage point two stories up on the construction
site and saw people staring at the zinc fence, they decided something of interest
was occurring in the Sculpture Park. Finally, they began to come out of the
construction site during their lunch breaks to see what it was that people were
looking at. And they began to talk about the messages on the wall with others
visiting the graffiti entries in the park. Therefore, in reaching the construction
workers as well as the staff and students in the UTech community, the impact of
the messages has been even greater than was anticipated.
Perhaps the most eloquent statements of the value of the initiative have
come from the participants in the Graffiti Competition themselves, however. As
part of the multi media production being prepared for UNESCO, team leaders
have been interviewed about their participation in the Graffiti Competition and
what they have gained from the experience. Following are some of the comments
collected from the team leaders in interviews about their learning:
I learned a lot about HIV/AIDS that I didn't know before... the
fact that the Caribbean has so many AIDS victims is something
I didn't take seriously before...this [competition] made me
think about the dangers of AIDS in a much more personal
...I think I want to help [people affected by HIV/AIDS] now -
to get personally involved. Thinking about how to make a
difference and then [how to] communicate it to other people
has made me want to do something... lasting and personal.
You know, we don't think about HIV/AIDS it belongs far
away in Africa or certainly someplace other than here on
campus. But this competition brought it here to us.
...[The competition] very quickly stopped being about the prize
money. It didn't matter whether I won or not... after I did my
research, I just wanted to communicate what I had learned that
affected me so deeply... and I wanted to help other people make
their statements, too. It was an experience in working together,
in saying something to others and sharing an important mes-
The Graffiti Competition has been a particularly useful learning vehicle
for the UTech community. It created a cadre of more than 130 people who spent
time and energy learning about HIV/AIDS and developing messages to share their
learning with others. It proved to be an innovative way of using zinc fencing to
communicate educational messages to which others have paid thoughtful atten-
tion, and it promoted the messages of abstention, prevention and caring for people
living with HIV/AIDS in a new and compelling way on the university campus.
What UTech has done is certainly replicable in other settings: in Jamaica, zinc
fencing abounds as housing, around construction sites and as protection for
communities. Using that zinc fencing as a medium for communicating educa-
tional messages related to HIV/AIDS can spread the messages necessary to under-
pin behaviour change among critically important audiences in an inexpensive and
1. The age groups 17-24 and 25-35 are considered the most at risk. The majority of UTech's students
fall into these two age groups.
2 Some sections of the fence were easier to use than others: at least three sections of the fence had a
tree or a lamp post around which the team had to work. Therefore, the Committee thought that
the fairest way to allocate the sections of the fence was to have the team leaders draw their allo-
3 The five-day period included National Heroes' Day, a three-day holiday weekend in Jamaica.
4 Because the Organising Committee expected the teams to be comprised of eight to ten members, it
determined that the prize money had to be sufficient to interest members of groups that size.
Therefore, first prize was set at $100,000, second prize at $75,000 and third prize at $50,000.
5 The University of the West Indies HIV/AIDS Response Programme (UWI HARP) accepted the in-
vitation to participate in the competition.
6 United Nations Educational, Scientific and Cultural Organisation
7 Dr. Rae Davis, informal interview, October 16, 2003.
Knowledge Attitudes and Sexual Practices of Medical Students
L.COX, G.REID, R. ARSCOTT, J. THOMAS
The centrality of behaviour change in combating HIV has been recog-
nized since the beginning of the epidemic. One of the most widespread approaches
to behaviour change used in the battle against HIV/AIDS has been information,
education and communication (IEC) campaigns focused on raising awareness
about the virus and the syndrome, avoiding behaviours associated with increased
risk, and providing behavioral strategies for the caregivers of people with AIDS
Sexual transmission is clearly the dominant mode of transmission ac-
counting for 75% of all cases of HIV transmission. Heterosexual transmission is
globally the most common mode of HIV spread.
The University of the West Indies Medical Students Association
(UWIMSA) and the International Federation of Medical Student Associations
(IFMSA) Standing Committee on Reproductive Health including AIDS (SCORA)
acknowledges that young people are central to the fight against HIV/AIDS.
Research data that seeks to reveal and educate medical students and the wider
community about risk factors to contracting HIV/AIDS is important to the work of
UWIMSA. We aim to understand the behaviours that drive the increasing rate of
HIV/AIDS amongst our young people.
SCORA has always been of the belief that we need to move from
information to action, to come up with effective interventions to achieve desired
outcomes by changing behaviour and by increasing individuals' sense of control
over their own behaviours.
For information to make sense and be useful to members of the IFMSA,
it must be easily integrated into our social expectations, norms, and values as well
as our political and economic culture. It must be applicable to our everyday lives,
and presented in a narrative form. SCORA has promoted safe sex campaigns and
condom exhibitions throughout the world through IFMSA national member or-
We believe that we can be our own role models and hence act as role
models to young people. Throughout the world behaviour change is necessary at
all levels and this research paper seeks to highlight the positives and the negatives
about knowledge, attitudes and sexual practices of medical students towards
1. To determine knowledge of HIV/AIDS amongst medical students
attending the International Federation of Medical Students
Associa tions (IFMSA) 52nd annual march meeting in Parnu Estonia
with regards to:
a. Modes of Transmission
b. Methods of prevention
c. Causative agent of the disease
2. To determine the behaviour of students with regard to sexual practices
3. To determine the attitudes of Medical students toward people with
4. To make a comparison with the UWI study on: Knowledge and
Attitudes of UWI Students Towards HIV/AIDS
This study was done in Pamu Estonia amongst medical students from 32
countries at the 52nd International conference of the International Federation of
Medical Student Associations (IFMSA) on March 2nd to 8th, 2003.
The research took the form of self administered questionnaires by stu-
dents from 32 countries at the conference. The sample was an incidental one given
out to members of the different National member organizations (NMO).
This research was previously done at the University of the West Indies
(UWI) in February 200 and the data was compared to the UWI study.
The Gender distribution
The ratio was almost 1:1 Male to female as compared with the 1:2 ratio
for the UWI study.
80.2% of the respondents were in the age range 21-24 years compared to 31.4% in
the UWI study. 53.4% of the respondents in the UWI study were less than 21
years, a younger population. The age range was 18-31 years.
86.2% of the respondents were single, 1.7% married, 0.9% divorced and
10.3% were otherwise (most indicated that they were in love)
99.1% of the respondents know that HIV/AIDS is cause by a virus. The
respondents know that HIV is transmitted by sexual intercourse (100%), blood
transfusion (98.3%), IV drug use (97.4%), and HIV positive mother to foetus
(94.8%) and organ transplantation (87.1%). Approximately one third did not
know that HIV can be transmitted by oral sex (31%) and breast feeding (37.1%).
Almost all the respondents knew that HIV is not transmitted by kissing, toilet
seats, sharing cups, swimming pools or mosquito bites. These results were similar
to the UWI study except that half of the respondents in the UWI study did not
know that HIV can be transmitted by oral sex (50.2%) and organ transplantation
(51.0%). Table 1 below summarizes the data.
Table 1. Participants response to knowledge on transmission of HIV/AIDS
Variable Correct Incorrect Not sure
Kissing 92.2% 6.0% 1.7%
Sharing Cups 97.4% 2.6%
Sexual Intercourse 100%
Mosquito Bites 88.8% 5.0% 6.9%
Blood Transfusion 98.3% 0.9% 0.9%
IV Drug Use 97.4% 1.7% 0.9%
Toilet seats 99.1% 0.9%
Oral Sex 69.0% 19.8 11.2
HIV+ve Mother to fetus 94.8% 2.6% 2.6%
Sharing swimming pool 99.1% 0.9%
Breast feeding 62.9% 21.6% 14.7%
Organ transplant 87.1% 1.7% 11.2%
Knowledge on the prevention of HIV was good as 100% of the respon-
dents knew that HIV can be prevented by correct consistent condom use and
abstinence (84.5%). There were no myths surrounding the prevention as most
persons knew that contraceptives after sex, prayer, withdrawal before ejaculation,
antibiotics and having sex in water could not prevent the transmission of HIV. The
comparison was similar in the UWI study. The Table 2. below lists the results.
Table 2. Participants response to Prevention of HIV/AIDS
Variable Correct Incorrect Not Sure
condom Use 100%
Oral Contraceptives 94.8% 4.3% 0.9%
Prayer 98.3% 1.7%
Withdrawal 91.4% 7.8% 0.9%
after unprotected Sex 98.3% 0.0% 0.9%
Abstinence 84.5% 12.9% 0.9%
Having Sex in water 98.3% 0.9% 0.9%
Consulting a Faith Healer/
Voodooist. 99.1% 0.9%
Most of the respondents knew that there is presently no known cure for
HIV/AIDS. However 19% answered yes to an antiretroviral as a cure for
HIV/AIDS. Table 3 below list the results.
Table 3. Participants response to cure of HIV/AIDS
Variable Correct Incorrect Not Sure
Sex with a Virgin 100%
Antiretroviral Drugs 80.3% 19.0% 0.9%
Herbal Medicines 99.1% 0.9%
No Cure Available 82.8% 16.4% 0.9
Most (73.3%) of the Respondents knew that persons with HIV/AIDS can
look normal and that there may be no clinically distinguishing feature of the
disease. The students knew as well that the clinical features can include skin rash,
hair loss and persistent cold.
83.3% of the Respondents has been or is currently sexually active. Of this
only 37.1% always use a condom during sexual intercourse as shown in Table 4.
Table 4. Percentage of sexually active students that always use a condom.
Sexually Active Always use a condom
The majority of sexually active persons were in the age range over 30
(100%), 25-30 (88.2%), 21-24 (84.9%) and under 21 (50%).
The respondents differ in their thoughts of HIV/AIDS during an intimate
encounter. 33.6% always, 52.6% sometimes and 7.8% never thought of
HIV/AIDS during an intimate encounter. All the Respondents in the age group
over 30 never thought of HIV/AIDS during an intimate encounter. See Table 5.
Table 5. The percentages of Respondents be age group who think of
HIV/AIDS at different times.
Age Group <21 21-24 25-30 >30
Always 33.3% 40.9% 11.4
Sometimes 52.3% 88.2%
Never 66.7% 6.8% 100%
65% of those who always think of HIV/AIDS during an intimate encoun-
ter do not use a condom all the time during a sexual intercourse, sometimes (60%)
and never (75%). See Table 6.
Table 6. The percentage of the Respondents Who think of HIV/AIDS in an
intimate encounter at different times and always use a condom.
Yes 34.4% 40.0% 25.0%
No 65.6% 60.0% 75.0%
56% of the Respondents would ask for an HIV/AIDS test from a perma-
nent or steady partner, planning a family (40.45), potential spouse (32.1%), casual
(31.0%), and all individuals (22.4%).
The respondents reported that the following should receive mandatory
HIV/AIDS testing, sexually active people (71.6%), prostitutes (80.2%), pregnant
women (75.9%), Homosexuals (70.7%), and other (23.3%).
37.7% of the respondents admitted to having an HIV/AIDS test done at
The sexually active respondents indicated the sexual practices that they
have participated in. Approximately three quarters admitted to oral sex, one third
anal sex and one third multiple sex partners. 0.6% admitted to group sex and 1%
to needle sharing. Table 8. compares the two groups for sexual risk behaviour.
Table 8 A Comparison Between the Two Groups for Sexual Risk Behav-
iour (as a Percentage)
Oral Sex Anal Sex group sex Multiple needle sharing
Medics 73% 30% 06% 01% 30%
UW1 22.2% 02.6% 03.6% 0.5% 11.3%
Table 9. shows the results for respondents who are sexually active and
the use of condoms with different sexual acts..
Table 9 The percentages of the respondents who are sexually active and the
use of condoms with different sexual acts.
a condom Sexual Practices
Oral Sex Anal Sex Group Sx Multiple Sex Partners Needle
Yes 34.1% 37.10% 42.9% 20.0% 0%
No 65.9% 16.7% 57.1% 80.0% 100%
It is striking to note that 62.9% of the respondents that participated in anal sex and
80% of the respondents who had multiple sex partners did not use a condom.
Most of the respondents (54.3%) said that men and women are at equal
risk of contracting HIV/AIDS. 24.1% thought women, 6.9% men and 8.6% were
unsure of which of the sexes was at greater risk.
The respondents perceive people with HIV/AIDS to be Irresponsible
(43.1%), Promiscuous (12.1%), Homosexuals (15.5%), Just Unlucky (49.1%) and
Drug users (18.1%).
Table 10. ranks the responses for the two groups for their perception of
persons with HIV/AIDS
Table 10. Ranks of Responses for perception of people with HIV/AIDS
Irresponsible 2 2
Promiscuous 5 3
Homosexual 4 4
Just Unlucky 1 1
Drug Users 3 5
Respondents Risk of contracting HIV/AIDS
75% of the respondents thought that their risk of contracting HIV/AIDS
was low, moderate (13%), high risk (6%) and no risk (6%). This is compared to
the UWI study as follows; 55% of the respondents thought that their risk of
contracting HIV/AIDS was low, moderate (14.4%), high risk (22.2%) and no risk
In the study 57.1% of the respondents who thought they were high risk
did not use a condom, moderate risk (84.6%), low risk (60%) and no risk (50%).
See Table 11.
Table 11. Results of cross tabulation of personal perception of risk and con-
Always Use a Condom Personal Perception of Risk
High Risk Moderate Risk Low Risk No Risk
Yes 42.9% 15.4% 40.0% 50.0%
No 57.1% 84.6% 60.0% 50.0%
Co- Workers and AIDS
64.7% thought it important that they be informed if a co-worker becomes
infected with HIV/AIDS.
Of the social facilities asked if the respondents would share with an
HIV/AIDS patient, i.e., kitchen and bathroom, 93.1% said that they would share
both and only 3.4% said they would share none of the above. 94% would interact
socially with an HIV/AIDS person. As to whether they would have protected sex
with and HIV person 41.4% said no, 36.2% not sure and 21.65% said yes they
would have sex with an HIV infected person.
Most (94.8%) of the respondents agree that it is not necessary to live in
separate housing facilities.
Almost two thirds (62.9%) of the respondents thought that there was not
enough information available to the public about HIV/AIDS [64.8% in the UWI
Most (80.2%) of the sample represented young medical students in the
age range 21-24 years. In the UWI study 53.4% were under 21 years of age. Most
were single (86.2%)
There was a high level of knowledge amongst the students about
HIV/AIDS. Most (99.1%) [96.5% UWI study] knew that HIV/AIDS is caused by
a virus. All the respondents (100%) [99% UWI study] knew that HIV/AIDS was
transmitted by sexual intercourse. This is much more than the 90% found in a
previous study by Anglin-Brown. The other modes of transmission reported were
blood transfusion (98.3%), IV drug use (97.4%), and HIV +ve mother to foetus
(94.8% and organ transplantation (87.1%) Approximately one third did not know
that HIV can be transmitted by oral sex (31%) and breast feeding (37.1%). Almost
all the respondents knew that HIV is not transmitted by kissing, toilet seats,
sharing cups, swimming pools or mosquito bites. These results were similar to the
UWI study except that over one half of the respondents in the UWI study did not
know that HIV can be transmitted by oral sex (50.2%) and organ transplantation
(51.0%). This could indicate the higher level of technical knowledge amongst the
The behaviour of the students was not in keeping with the high level of
knowledge reported. Sexual activity was reported in 86.3 % of the students in this
study as compared to 63.6% in the UWI study and 69.2% by Landry in 2000. The
Morbidity and Mortality Weekly Report (MMWR), April, 2001/50(14) 262-5
"Prevalence of Risk behaviour for HIV infection amongst adults USA study 1997"
showed that 83.4% of the respondents were sexually active. The results showed
that sexual activity increased with age as 100% of respondents over 30, 88.2% of
respondents in the 25-30 year group, 84.9% of 21-24 year group and 50% of the
under 21year group were sexually active. This was similar to the UWI study.
Of those who were sexually active only 37.1% did use a condom all the
time during sexual intercourse. This represents a significant 62.9% that practice
unprotected sex some of the time. The USA study reported condom use of
approximately 67.8% at least sometimes.
The respondents reported sexual practices of oral sex (73.3%) [22.2%
UWI study], anal sex (30.2%) [3.6% UWI study], multiple sex partners (30.2%)
[11.3% UWI study], group sex (6.0%0[2.6% UWI study], needle sharing (0.9%)
[0.5% UWI study]. In the USA study 11.0% of the respondents reported having
multiple sex partners and 4.2% had high risk behaviour. The median prevalence of
condom use was 26.6% in those who thought they were at risk of contracting
HIV/AIDS compared to 23.2% who answered no to risk.
The study showed that 34.1% [35.0% in the UWI study] of the students
that practice oral sex use a condom all the time, 37.1% anal sex [0.0% in the UWI
study], 42.9% group sex [50.0% in the UWI study], 20.0% multiple sex partners
[47.4% in the UWI study], and 0.0% needle sharing [47.5% in the UWI study].
The low rate of condom use among the medical students translates to a high level
of risk activity. With such knowledge of HIV/AIDS and the fact that this disease
is a death sentence it is a challenge to understand the reason for the gap that exists
between knowledge and sexual practices. More students were involved in oral,
anal, group and multiple sex partners amongst the medical students than the
students from the UWI study. The fact that most of the respondents (68.3%) in the
medical students study were from Europe seems to highlight differences in cultur-
ally and socially accepted sexual practices between European and Caribbean
Approximately one half (54.3%) of the medical students [68.6% UWI
study] thought that both men and women were at equal risk of contracting
The behaviours of the students were incongruent with the attitudes.
49.1% of the respondents [58.2% UWI study] thought that people who got
HIV/AIDS were just unlucky, 43.1% [48.1% UWI study] thought they were
irresponsible, 12.1%[40.7% UWI study] thought that promiscuity was a major
factor, 15.5% [29.6% UWI study] thought that a large number of HIV victims are
homosexuals and 18.1% [22.8% UWI study] thought they are drug users. It is
uncertain what the thought pattern from these results is but cultural and social
norms may be a factor.
The data above could be used to organize peer empowerment workshops
designed to bridge the gap between knowledge behaviour and attitudes.
A high percentage of the UWI Respondents (90.6% Jamaicans) indicate
a strong association between homosexuality and HIV/AIDS.
75% [55.9% UWI study] thought that their personal risk of contracting
HIV/AIDS was low. More respondents (22.1%) from the UWI study thought their
personal risk of contracting HIV/AIDS was high compared to a significantly lower
(6.0%) amongst the medical students. A little more than one third (37.9%) of the
medical students reported that they had an HIV test done [22.7% UWI study]. A
large number (77.6%) thought that all sexually active people should receive HIV
testing. It is not known why the students would indicate a need to test most
sexually active people.
All medical students were aware that HIV cannot be transmitted through
close social personal contact; most (93.1%) would share bathroom and kitchen
facilities with an HIV infected person while a significant number (21.6%) of the
students indicated that they would have protected sex with an HIV positive person.
The fact that the condom is not 100% safe means that this 21.6% would put
themselves directly at risk
Almost two thirds (62.9%) [64.8% UWI] of the medical students thought
that there was not enough information about HIV/AIDS available to the public.
This calls for more health promotion campaigns and health education amongst
young people in our age group.
Medical students are knowledgeable about the cause, modes of transmis-
sion, prevention and the fact that there is at present no known cure for HIV/AIDS
even though there is some concern about the role of antiretroviral drugs. The
behaviour of the students however is not in keeping with what is known about
HIV/AIDS. The report shows conclusively that our students are putting them-
selves at risk due to their sexual practices.
We will begin to win the battle against HIV/AIDS when we implement
strategies to modify the behaviour of our young people. This information from
young people at the highest level of learning is critical. We need to begin to show
young people how to change, reinforce, support and reward behaviour change.
Our medical curricula need to begin teaching AIDS education, sexuality
and behaviour control. This is the age group that will determine what happens in
the future, as these are the young experimenters with new and currently existing
sexual practices. Our universities must implement awareness programems that
seek to sensitize our students from the first day. The question 'Are you at risk for
contracting HIV/AIDS?' should at all times be in their minds as they seek to
change their risk behaviours.
I. Morbidity and Mortality Weekly Report:" Prevalence of Risk behaviours for HIV infection among
adults-United States, 1997", April 13, 2001/50(14) 262-5.
2. Bogle A, Bullock K, Clarke N, Cox L, Edwards G, Hemmings S, Morgan N, Springer D, Stewart
W, Thompson I 2002:"Knowledge and Attitudes of University of the West Indies Students to-
3. Review of HIV/AIDS behaviour Change Communications strategies and Activities,
4. Robbins S, Cotran R, Kumar V, Collins T (1999). Pathological Basis of Disease (6th Edition). W
B Saunders, Philadelphia
5. Pan American Health Organisation (1998). Diseases and Health impairments. Health in the Ameri-
cas, Volume I.
6. Figueroa P(1996). Myths, Beliefs, Taboos: Current Attitudes towards HIV/AIDS. CAJANUS: Nu-
trition andAIDS, Volume 29, Number 2, 53-61.
7. Anglin -Brown, B (1997): "A Survey of KAP of residential students at the University of the West
Indies concerning AIDS". Unpublished thesis Dept. of Community Health and Psychiatry,
8. Kiragu K (2001). "Youth and HIV/AIDS: Can We Avoid Catastrophe?' Population reports, Series
L, Number 12.
Young Children, a neglected group in the HIV Epidemic:
Perspectives from Jamaica
HOPE RAMSAY, SIAN WILLIAMS, JANET BROWN,
Background to Study
The Human Immunodeficiency Virus (HIV), a disease of the last two
decades, has devastated the world like no other. Its impact is far-reaching,
affecting every region, race, occupation, and cutting across all age groups and
social classes. Since its discovery in the mid-1980s, there has not been a more
serious medical, social and economical challenge for humankind. The variety of
strains, and the way in which these HIV strains transmute within the human body
are still to be fully grasped. As HIV cuts its swath around the world, the Caribbean
region has felt its impact in devastating ways and as a region is now placed second
only to Sub Saharan Africa in prevalence rates.
The UNAIDS report for 2002 states that since its discovery there are over
42 million persons infected with HIV, and over 20 million of those persons have
died. Adults are most severely affected by HIV as is reflected in the 38.6 million
adult cases (almost equally men and women); but there are 3.2 million cases of
infected children under the age of 15. It is estimated that 5 million persons were
newly infected in 2002, of which 800,000 were children under 15 years. Children
are of course also affected in much greater numbers, even when not contracting the
disease, because of their dependence on parents and other adults. Developing
countries are hardest hit; it is estimated that 95% of the 14,000 new cases daily
occur in these countries (UNAIDS, 2003).1
In the Caribbean, 600,000 persons have been estimated to be living with
AIDS (UNAIDS, 2003); HIV/AIDS is currently the leading cause of death in the
15 to 44 age group (UNAIDS, 2002)2. At the end of 1999, the Caribbean Regional
Epidemiological Centre (CAREC) reported that the Caribbean was leading North
and Central America in the number of AIDS cases per 100,000 population
(CAREC, 2000). All these figures have caused alarm and resulted in world
leaders paying close attention to how the pandemic affects their respective coun-
Jamaica reflects the pattern seen in the Caribbean. The first case of AIDS
was diagnosed in 1986 and since then, all efforts to curb the spread have yielded
little result. Of the 6549 cases reported up to 2002, 61.6% have died. In 2000, the
adult prevalence rate stood at 0.7%, moving to 1.2% in 2001 and a drastic 1.6% in
2002 (Ministry of Health, 2002),4 thus more than doubling in 2 years. Although
childhood infection rate has not been estimated, the total population infection rate
has been estimated from the prevalence seen in pregnant women.
As heterosexual transmission continues to rise, many more children in
Jamaica will feel the impact of HIV/AIDS in the years to come. For some that
time may be far removed, while for others the disease may be within them already
destroying their immune system, and eventually leading to their death. Although
most AIDS deaths will be of adults, it is very often the children who feel the
greatest impact. Children are experiencing, and will experience at an increasing
rate, the deaths of their parents, other family members, teachers, and even their
peers. Deaths will affect the provision of education, health and welfare services in
the country. Children will grow up in communities where death is a common
experience, affecting them emotionally, economically and psychologically. Fur-
ther, the epidemic violates many of the fundamental rights of children. A key
global concern is meeting the increasingly difficult circumstances of children,
families and whole communities affected by HIV/AIDS. As world leaders con-
template strategies, little attention has yet been paid to HIV/AIDS prevalence and
impact within the early childhood age group (birth through age 8) in the Carib-
bean. The annual meeting of the International Consultative Group on Early
Childhood Care and Development (May 2003)5 confirmed that worldwide, even
in high prevalence areas, this is also the case.
It is clear that a stronger focus on children must involve the education
sector in offering support and care to those infected and affected as its principal
beneficiaries are young people ranging in age from infancy to adulthood (Kelly,
2002).6 The sector now has to turn its attention to ensuring that the overall goal of
access to meaningful learning for as many years as possible for every child, takes
on special meaning for children infected and affected by HIV/AIDS.
The recent adoption of the National Policy for HIV/AIDS management in
the education sector (Ministry of Education, Youth and Culture, Jamaica, 2001)
is a most welcome step. The new policy promotes non-discrimination, equality,
HIV testing, disclosure and confidentiality, and applies to all educational institu-
tions that enroll students. There is specific reference to the integrated Health and
Family Life Education programme for pre-primary, primary and secondary school
students. However there is no reference to the integrated early childhood service
institutions operating as basic schools, day care centres and home visiting services
for children prior to formal schooling. Although the policy addresses the need for
age appropriate curricula addressing HIV /AIDS education at all levels, it does not
make specific reference to the programmes of care and stimulation in early
The policy provides important guidelines for educational institutions to
develop and implement HIV/AIDS action plans. The challenge is therefore to
ensure the policy's reach to include the early childhood sector with specific
strategies for use in the community based facilities that now serve 91% of the age
cohort between age four and six, and a growing percentage of children from birth
through age three. (PIOJ 2002)8
Rationale for Study:
There is very little attention yet paid to HIV/AIDS prevalence and impact
in relation to the early childhood age group in the Caribbean. Why should this age
group call for special attention? It is scientifically known that the early childhood
period of 0-8 years is the most rapid period of development in human life. This
group of children, when affected by HIV/AIDS, has unique health, educational,
psychological, and protection needs that require priority interventions in order to
fulfill their basic human rights. Some of these needs could be nutritional deficien-
cies, stunting, increased susceptibility to childhood diseases, poor cognitive and
social development and psychosocial stress (World Bank, 2003).
HIV/AIDS leads to requirements for this age group for foster care,
institutional care, and protection from discrimination and abuse. For interventions
to be effective and sustainable, they must be based on the unique situation of a
particular country or community. Situations vary dramatically and reflect socio-
economic, geographic and cultural differences, as well as different rates of
HIV/AIDS prevalence. Ascertaining the current level of knowledge, attitudes and
behaviours in relation to HIV/AIDS among teachers, caregivers and service
providers working with this age group, in and outside school settings, was there-
fore central to this study.
Prevention of HIV/AIDS has been the major priority for most health
ministries until recently. However, it is being increasingly understood that the
response to HIV/AIDS has to be a continuum between prevention and care. Care
and support activities help to normalize the disease and moreover, raise awareness
and encourage prevention activities. Services that address the needs and concerns
of young children therefore need to be fully integrated within the framework of a
national multi-sectored HIV/AIDS programmes. These programmes must be
essential components of the regional and national strategic plans to mitigate the
impact of the HIV/AIDS epidemic.
HIV/AIDS is an increasingly high priority area for the United Nations
Educational Scientific and Cultural Organization (UNESCO). The Caribbean
Child Development Centre (CCDC) is a regional institution that gives particular
attention to the early childhood age group and their families in its research
projects, curriculum development, training and advocacy activities. CCDC and
UNESCO therefore were a logical partnership for a pilot community needs assess-
ment approach in relation to this age group that, depending on relevance of
outcomes, could inform policy and programmes in Jamaica, and, potentially be
replicated or adapted elsewhere in the Caribbean. CCDC enlisted two consultants
from UWI's HIV/AIDS Response Programme (UWIHARP) to provide required
technical assistance and direction to the research design and analysis for this
Overall Project Aims and Specific Objectives:
The overall aim was to determine the current family and community
support needs for children affected by HIV/AIDS in the birth to eight years age
group, both met and unmet, ascertaining community preparedness or willingness
to engage in active responses to the growing presence of HIV/AIDS. A secondary
but related aim was to inform curriculum development in relation to the pandemic
for teacher training colleges, and also for preschools, day care centres and pre-
paratory schools tailored to the needs of this age group and specifically for the
Specifically the project objectives were the following:
* To assess community knowledge of HIV prevalence generally and specifi-
cally in two selected communities.
* To assess persons' attitudes and beliefs about the disease and their level of
awareness of preventive measures, particularly in relation to young children
* To assess the willingness of persons to prepare actively for rising
HIV/AIDS incidence including, numbers of orphans
* To make available lessons learned from this assessment for incorporation in
curriculum materials for teachers college students and for pre-primary cur-
ricula and learning materials
The highest prevalence of HIV/AIDS is seen in the parish of St. James on
Jamaica's North Coast. HIV is now spreading at the alarming rate of 606.9 cases
per 100,000 population (Ministry of Health, 2002)10. The total population in the
parish is 95,940. Montego Bay is the parish capital, and is one of the fastest
growing capitals (Planning Institute of Jamaica, 2000) .
The two communities of Granville and Catherine Hall in the Montego
Bay area were selected for the needs assessment study, as anecdotal reports were
that these are the two communities with the highest and lowest HIV/AIDS preva-
lence rates respectively in the parish.
In addition to the enlistment of the UWIHARP team, the UWI's Univer-
sity Centre of the School of Continuing Studies in Montego Bay, and Sam Sharpe
Teachers College in the same city were brought on board as supporting part-
ners/advisers. The Teachers College Principal was asked to select the eight-per-
son research team from among second year Early Childhood and Guidance student
teachers; this local research team was coordinated by two of the College's teaching
An exploratory cross-sectional qualitative study was designed and imple-
mented by the UWIHARP consultants, assisted by the local research assistants,
using focus group discussions and key informant interviews. A Qualitative design
was chosen to aid understanding of the socio-cultural and political contexts and
their influences on the attitudes and behaviours of persons in these areas, with a
specific focus on children affected by HIV/AIDS in the early childhood age group.
Focus group discussions were chosen as the methodology for under-
standing broad community views. It was felt necessary to talk with parents,
teachers, and professionals dealing with this age group to gain information not
only about the prevailing behaviours and practices surrounding HIV/AIDS, but
also provide information about the needs of the children affected by HIV/AIDS in
these specific communities. To be able to get more in-depth perspectives on the
family and community support needs for children affected by HIV/AIDS, it was
also decided to conduct key informant interviews with persons directly involved
with the issue of HIV/AIDS in relation to the early childhood age group.
A total of twelve focus group discussions and eleven key informant
interviews were conducted. The sixty-five (65) focus group participants were
self-selected according to age, sex, profession and location of residence or work
after the project was outlined in their communities. Both Granville and Catherine
Hall each had a total of six focus groups one community included a group of
persons living with the disease. All participants signed an informed consent to
participate in the study. Written parental consent was obtained for adolescents
who participated. Each focus group lasted for approximately an hour and a half. A
note-taker was present for all focus group discussions and key informant inter-
views. Each focus group was tape-recorded and care was taken to maintain
confidentiality of the participants by avoiding any identification by name during
the discussion and in the recording.
The key informant interviews included one each of the following catego-
ries of persons: nurse, businesswoman, day care operator, principal, pharmacist,
contact investigator for HIV/AIDS, regional nutritionist, caregiver of a victim,
politician/councillor for Granville, man in the street and a caregiver of some one
who died from the HIV disease.
A thirteen point questionnaire was used to stimulate discussion in both
the focus groups and the key informant interviews:
1 How do you feel about the HIV/AIDS situation in Jamaica?
2. What are the possible ways you think you can be involved in addressing the
challenge of HIV?
3. Do you know of families in your community facing the HIV epidemic? What
are some of their needs?
4. What are some of the support systems in place in your community for persons
affected by HIV/AIDS?
5. What do you feel are some of the specific issues facing parents/caregivers of
children birth to eight years that are affected/infected with HIV?
6. What should be the society/community's response to a young child affected by
7. Do you feel children infected/affected by HIV/AIDS have a place in our
Society? Suppose you had a neighbour who was HIV positive, suppose there
was a child in your community who was infected with HIV, how would you
8. Who do you think should take responsibility for the child affected /infected by
9. Do you think there is a need for more information and skill based programmes
for parents/caregivers in the current scenario of the HIV epidemic? What kind of
training is needed?
10. What is the role of preschools and daycare centres in the HIV/AIDS
11. Who else apart from parents/caregivers/ early childhood education teachers
should be involved in the developing of an HIV/AIDS programme for 0-8 year
12. How does one really know the HIV status of people and children?
13. Do you feel the need for an HIV/AIDS policy at the preschool or day care
centre and/or at the national level?
The project was completed in six months, from the stage of training the
Teachers College research team to the completion of the project report. The actual
data collection was done in two months, June to July 2003.
Analysis of Findings
The focus group discussion tapes were reviewed and transcripts were
made from the recorded materials for each focus group and key informant inter-
views. These transcripts were consistent with the notes taken during the discus-
sions. Further in-depth analysis was carried out by the consultant team, who
carefully read the transcripts and identified codes that represented broad themes.
The analysis was carried out separately for the two communities. The findings
were summarized by topics, combining responses from both communities.
Summary of Study Findings
1. HIV/AIDS situation in Jamaica
All categories of persons agreed that HIV is a problem in Jamaica. It was
commonly said that 'Many people were infected with the HIV virus and the rates
of infection were high'. Some felt that "HIV positive persons infect others, taking
revenge and thus they need to be put in homes". Many persons saw children as
the "innocent ones" but were afraid to get directly involved in caring for them or
their families. Persons listed their sources of information about HIV as radio,
television, pamphlets, video shows, friends and the internet. Teachers, adoles-
cents and parents were among those who expressed a strong desire to gain more
knowledge about HIV. Some participants were afraid of associating with persons
living with AIDS for fear of contracting the disease, or of the community's
reaction. Only a few persons were aware of the facts of HIV transmission or the
impact of the disease on the society. An alarmingly high number of participants
were still driven by myths surrounding HIV, even when exposed to more accurate
2. Needs of Persons living with AIDS and support systems in Jamaica
Every adult and some of the adolescent participants knew someone who
was suffering or had died from HIV/AIDS. Some of the parents were adamant
about not getting involved with these persons, whilst others extended full support
to those they knew. Participants identified needs of persons living with AIDS
(PLWAs), which included respect, emotional support, medication, family sup-
port, love and affection, financial help, companionship, food, employment and
more education. Of these, love, affection and financial needs were predominant.
There was almost unanimous agreement that there were no support systems in
place for PLWAs in the community. However, it was known that the HIV positive
person went to the health centre, the AIDS hospice and the church for help and
support. The professionals recounted their experiences with the challenges faced
by the PLWAs. They noted that these persons were often not able to afford even
a single meal a day, but also often just wanted to talk to someone and experience
Although participants were aware of the need for support for persons
with HIV disease, there was still a current myth that needs could be ascertained by
appearance: 'They need a lot of things because they keep getting skinnier and
3. Issues relating to children affected by HIV/AIDS with particular reference
to the early childhood period.
Parents were particularly vocal on these issues. They stated that persons
living with HIV/AIDS were treated with scorn, resentment and fear. Further, they
agreed that family caregivers were given similar treatment, too. However, many
admitted that as far as they were concerned, they would be worried if their children
came in contact with a person living with AIDS. Two of them stated 'I would not
allow my child to drink from a container used by a child affected by the disease'
and 'I would not allow my child to play with these children'. Two others,
however, stated that they would treat an infected/affected child as one of their
own, and take care of him or her.
Teachers generally expressed that the children affected by the virus
should still participate in all games at school and that it is important to have
educational programmes on HIV/AIDS as early as basic school so children can
understand the illness better and how they should treat themselves and others.
Participants also indicated their own need for training in universal precautions.
When teachers were asked if they would let their own children associate
with an HIV positive child; there were mixed responses. The majority of the
teachers said they would, but would ensure that their children knew about the risk
and how to handle themselves. One teacher said, 'I would allow my 8 year old to
interact with a positive child but not my 3 year old, as kids need supervision at that
stage'. Another teacher shared that her baby was at day care and came home with
a bite every day. 'What if my child got HIV?' Another stated that, 'We need to
educate the student teachers on how to cope with these children.'
Most of the professional group thought that infected children under 8
years were not really aware of the disease, but just know that they are sick. A
major challenge facing professionals in the early childhood field was identified as
creating safe environments for children to be protected from accidents. There was
concern expressed as well about protecting the child without the virus from
One professional pointed out, 'We have the information but need skills
on how to pass on the information to others'. One participant admitted that she
had never given thought to the issues around early childhood and HIV/AIDS.
Another stated that there was a need for more education for children as well as
professionals on the illness. The adolescents were not very vocal on HIV issues
affecting young children.
The group of persons living with AIDS expressed that one of the greatest
needs of affected children is the need for love. Community support was also
mentioned as a great need. The key informants who have cared for children with
HIV/AIDS expressed that most of these children were brought to the health setting
by their mothers; fathers were rarely seen.
4. Society's response to young children affected by HIV/AIDS
Many participants were hesitant and uncertain in their answers about
society's role in relation to HIV-affected children. Some thought these children
should be placed in a group home. Others said that family members should take
care of them or the church. Only a few expressed that these children should be
accepted and treated like normal children. Participants reiterated that PLWAs
including children are still treated with scorn, ridiculed, teased, criticized and
Some teachers felt that the government should take responsibility for
these children when the parents are not capable, while others felt that members of
the community should embrace the idea that "it takes an entire village to care".
The professionals felt that infected children generally get more sympathy than
parents, but also stated that they knew of persons in the community who would
refuse to send their children to a school where there is a child with HIV/AIDS.
When asked what can be done to deal with this discrimination, one person
answered, 'First of all we cannot get them to use the condom how can we reach
the stage of them keeping an infected child?'
Some within the professional group felt that the community is doing
much more than was done earlier about HIV/AIDS but still more needs to be done.
All professionals felt that there is a place in society for persons who are infected
with the virus, and that parents should primarily be responsible for children
affected by the disease.
Some of the adolescents felt that infected persons have no place in our
society while others felt the opposite. Some of the key informants felt that it was
the parents' responsibility to care for children and only if they are unable to do so
should institutions give special care and attention. Again several called for
"support groups" for these children and their families. One underscored the need
for this by stating 'that child may become the next Prime Minister, one can never
5. Training and other needs identified related to HIV/AIDS
All participants expressed that training for adults and children is needed;
for example, people should be informed about what to do if an infected person gets
a cut. The professional group noted: 'One of the main problems associated with
HIV is fear'. Teachers in day care centres and preschools specifically stated that
they need more training on the disease and how to transfer this knowledge to small
A day care centre worker stated they had never received any formal
training about HIV/AIDS, but just picked up a little information in other work-
shops. She felt the need for specific training focused on practical preventive
measures for day care staff.
Persons living with AIDS suggested that nurses, doctors and teachers
need more training to help them to be better able to take care of the children for
whom they are responsible. One key informant stated that there is a need for skill
based training for persons who are infected: 'Because they would see that they can
still make a contribution to society, as they can help take care of themselves.'
Most of the participants agreed that the school is the best place to start
educating children about their own safety and about preventive measures to be
taken in the face of abuse and possible HIV infection. One person stated 'Educa-
tion is the key'. Participants expressed that children, and especially girls, need to
be taught the dangers and consequences of getting involved sexually, so that they
can better deal with sex when they become adults. Some of the professionals
expressed concern that young girls were going to bed with boys/men 'for materi-
alistic gain such as a phone card'. One parent commented: "I am concerned about
what my daughter will inherit tomorrow and if she will ever find a viable hus-
6. Role of preschools, day care centres in the HIV/AIDS epidemic
Participants generally felt that if teachers are well trained and equipped,
they can then act as resource persons and share the information with others. It was
also felt that children are quick learners, and can be taught through role-plays and
drills what is expected from them in different situations. The professionals
thought that preschool teachers should start educating the children from the early
childhood stage because "when they go home from school they tell their parents
everything that the teacher says and the parents cannot change this because
whatever teacher says is always right". Thus parents can also learn about
The participants were unsure as to how much information should be
given to a small child. A key informant said that "there should be a multi-sectoral
response involving religious leaders, youth, law officers, back door physicians
(herbalists, healers), managers and supervisors, in addition to school and health
7. Programmes and policy related issues
The parents and teachers were most vocal on this topic. They felt that it
was necessary to have a policy for schools and that it was important to involve all
the stakeholders in formulating this policy. However, it is important to note that
some teachers, including principals of early childhood institutions, called for a
policy for children to be tested yearly to determine their HIV status in order to
inform teachers on how to care for HIV positive children. When asked if they,
the teachers, would be willing to do the test themselves so the parents would know
their status, they were reluctant to agree to this as policy.
The teachers proposed that every child should be tested so that if a
child has HIV he can be put into programmes that will improve his life expec-
tancy. Knowing the child's status was believed to be important, as some of the
activities with the class may put the child at risk and may be damaging to a child's
immune system. This feeling about testing was common, including among the
There was general support for a policy at national level for all children to
get an education irrespective of their HIV status. However, instances of children
being turned away from school because they are infected were noted. All partici-
pants agreed that HIV/AIDS should be a part of the school curriculum but were
unsure as to what should be taught to children. Some of the views shared were that
we could tell them about the body parts, or that it was a disease and they could
catch it. However, one participant said honestly, 'I don't have any idea'!
Some participants also felt that labour relations and industrial legislation
need to protect infected and affected persons. The policy, one stated, must include
'Work relations, the continuation of health coverage and an implementation of an
Implications and Recommendations
This pre-intervention community needs assessment was designed to de-
termine the current family and community support needs for children affected by
HIV/AIDS in the birth to eight years age group, and to ascertain community
preparedness or willingness to engage in active responses to the growing presence
of HIV/AIDS. As a consequence the study also aimed to make curriculum devel-
opment recommendations in relation to this age group for use in teacher training
colleges, early childhood facilities and schools.
Throughout the assessment process, from the training to dissemination
stages, the senior researchers were struck by the continuous demand from respon-
dents and research assistants alike for information, clarification, confirmation and
elucidation of facts about HIV/AIDS. The process became a continuous teaching
and learning programme revealing the depth of need for information, and the
ongoing nature of that need for guidance and support at all levels in the commu-
nity. The specific concern of this assessment to recommend supports, responses
and HIV/AIDS prevention education strategies in early childhood therefore of
necessity spans a much wider landscape. However, as emphasized by the joint
operational guidelines of the World Bank, UNAIDS and UNICEF, any interven-
tion for the early childhood group must be a collective and comprehensive effort
to address the increasing vulnerabilities of these children. At the core of this effort
is family-based and community based care for children affected and infected by
HIV/AIDS, addressing specific health and social needs of children.
The concept of integration is key to developing more effective responses
to the needs of families and communities facing the epidemic's threat. The lack of
integration at present in the communities participating in the assessment seemed
evident in the fact that there are organizations in the Montego Bay area directly
addressing HIV/AIDS education, treatment and care, yet few persons within this
study knew of them/mentioned them. There have been national campaigns of
public education on HIV/AIDS, and yet the evidence seen is that new knowledge
cannot of itself dispel myths. There are a number of Ministry of Education
programmes addressing the risks of HIV/AIDS, yet teachers in training are not
routinely equipped to know how to discern or how to treat such risks. The apparent
resistance to change in behaviours that could slow down the spread of HIV/AIDS
and the feeling of hopelessness in the face of inevitable destruction and desolation
are indicators of the lack of integration of messages with experiences within the
minds of individuals. What will it take to get a grip on the epidemic in HIV/AIDS
and arrest its progress?
Lessons learned from the experiences of others tackling this scourge,
particularly in Southern Africa have informed the team's recommendations for
integrated approaches in our region. The task of ensuring that HIV/AIDS preven-
tion education and support reaches children affected and infected must be inte-
grated within current efforts but not assimilated by them; it is a distinct and
specific focus requiring a number of elements, and informing the recommenda-
tions which follow.
Integration, in the Jamaican context, needs to be pursued to drive home
to families and communities the messages for their survival and support:
1. Leadership of Policy, the Media: Government policies need to lead
HIV/AIDS prevention education, and be seen to be providing direction and
hope to the country. A strategy for effective use of the media to influence
behaviours and create an environment of understanding, compassion and ac-
tion in relation to prevention and support is essential to this leadership.
2. Intersectoral collaboration, information systems: The Ministry of Educa-
tion, Youth and Culture's new policy (December 2003) is an important first
step in defining and guiding practices in relation to persons with
HIV/AIDS; but such practices must be consistent across Ministries, across
geographic boundaries, and at all levels of government. Without consis-
tency there will be confusion and stalling in the face of increasing demands
to meet the needs of children affected by HIV/AIDS. Inter-sectoral collabo-
ration must be supported by well maintained information systems, detailing
how many people are affected, where the needs for services are, what the re-
quirements are to make effective high quality interventions.
3. Community services: Rather than a specialized source for HIV/AIDS infor-
mation and treatment (which tends to stigmatise many persons affected by
the disease), such information and services should be widely disseminated
by a range of community-based health and education organizations to all
residents, thus helping to dispel segregationist thinking and practice.
HIV/AIDS precautions, treatment and prevention should be integrated into
general medical practice and not seen as a "specialization", thus further stig-
matizing the disease victims.
4. Community activities and supports: Victims of the disease themselves need
to feel integrated into their own communities via social and recreational ac-
tivities, education and vocational programmes, etc., rather than scorned and
isolated with other perceived victims. This challenge to include persons
with HIV/AIDS must be thrown out to community groups, faith based or-
ganizations, and education programmes to help dispel fears and misconcep-
5. Family supports, trained practitioners: It is critical that families, care giv-
ers, and trained practitioners alike are enabled to manage, and receive sup-
port in doing so. The use of universal precautions as routine health and
safety practice would go far in relieving the levels of anxiety expressed. The
use of universal precautions in early childhood facilities is incorporated into
occupational standards for practitioners and pending regulatory standards
for services. They are not "special" precautions introduced because of
HIV/AIDS, but "universal" to be used with all children, by all practitioners,
to ensure that the health and safety of everyone is managed in a systematic
6. Safe, healthy, developing children: Rather than a single-focus curriculum
based approach, schools and early childhood facilities need to adopt a whole
school/community approach. Young children do not learn in the classroom
alone. They interact in the playground, at break times, at the school gate, go-
ing to and from school through the community, with many ancillary work-
ers as well as teachers, other practitioners and parents. Schools and early
childhood facilities need to be supported to ensure that the critical issues of
prevention of infection, compassion for sufferers, non-discrimination and in-
clusion are dealt with head on by teachers and ancillary workers wherever
children learn: in the classroom, in the playground and in the community.
2. Intervention Recommendation
It is recommended that an intervention be designed based on the findings
of this study to support the piloting of a comprehensive approach to HIV/AIDS
prevention in four early childhood settings in St. James to address the following:
* Extension of PATH assistance to households affected by HIV/AIDS to en-
able access to early learning, health and social supports by young children.
* An assessment of the quality of the settings providing care and education
for the children using the Early Childhood Environment Rating Scale
(1998), an instrument that has been used and validated in seven Caribbean
countries including Jamaica.
* Design a plan for programme improvements based on the assessment find-
ings to include:
training of teachers and care-givers
maintenance of low child/practitioner ratio
provision of a safe environment
participation of children and parents in promotion of health and well
development of appropriate learning environment and tools
participation of SSTC in ongoing in-service support to teachers and
participation of the responsible Early Childhood Education Officer in
the ongoing monitoring of conditions and performance
provision of material assistance to implement the plan in settings to en-
sure not only minimal but good quality conditions and performance in
the areas above
consideration of direct grant aid to centres to reduce fees or waive fees
in the case of children who have been orphaned
development of a community participation plan for support of the set-
ting and participation of community members particularly people living
with HIV/AIDS in the intervention.
Design and implement training modules which:
directly challenge the "hold" of longstanding myths and misconceptions
develop skills in talking with children about HIV/AIDS, what it is and
how it can be prevented; the experience of living with HIV/AIDS and
about keeping each other safe; including one another in play in ways
that are non-discriminatory.
develop counselling skills with children who are affected by HIV/AIDS
through bereavement, displacement, rapid adjustment processes, infec-
tion and their own 'death sentences'.
It was clear that study participants displayed a readiness to discuss more
specific solutions that could involve them, if given sufficient training and informa-
tion to allay fears and ensure self-protection. Involving participants like those in
these two communities in specific problem-solving exercises and interventions
aimed at community education and caring responses would be an important next
step to reducing fears and the sense of helplessness now experienced by many.
NOTES and REFERENCES
1 UNAIDS (2003)AIDS Epidemic Update, available on line at www.unaids.org
2 UNAIDS (2002) Report on the Global HIV/AIDS Epidemic 2000, 2001, 2002 available on line at
3 Caribbean Regional Epidemiology Centre (CAREC) and Centre for Disease Control, USA (CDC)
HIV/AIDS Estimates 2002, CAREC/CDC, Republic of Trinidad and Tobago.
4 Ministry of Health (2002), Jamaica AIDS Report, Second Quarter, Kingston, Jamaica
5 Consultative Group on Early Childhood Care and Development (2002), HIV/AIDS and Early Child-
hood, Coordinators Notebook, No. 26
6 Kelly, MJ. (2002) "Defeating HIV /AIDS through Education", Discussion paper, First Caribbean
Consultation on HIV/ AIDS and Education, July 10th, UNESCO Caribbean Area Office, King-
7 Ministry of Education Youth and Culture (2001) National Policyfor HIV/AIDS Managanent in
Schools. Guidance and Counselling Unit, Ministry of Education, Kingston, Jamaica
8 Planning Institute of Jamaica (2002),The Jamaican Child: A Report of the Social Indicators Moni-
9 World Bank, UNAIDS, UNICEF (2003) Operational Guidelines for supporting early childhood de-
velopment (ECD) in multi sectoral HIV /AIDS programmes in Africa, Washington, D.C. avail-
able at www.worldbank.org/children, www.unaids.org, www.unicef.org
10 Ministry of Health (2002) National HIV/STD Prevention and Control Program Facts and Fig-
ures, Kingston, Jamaica.
II Planning Institute of Jamaica (2000) Economic and Social Survey ofJamaica. Kingston, Jamaica.
12 World Bank (2003),websites: www.allafrica.com, www.soschildrensvillages.com
Uniting Three Initiatives on Behalf of Caribbean Youth and
Educators: Health and Family Life Education and the Health
Promoting School in the Context of PANCAP's Strategic
Framework for HIV/AIDS
CHERYL VINCE WHITMAN
To protect young people and education personnel in the Caribbean Re-
gion from the HIV/AIDS epidemic and to promote their healthy development,
three powerful movements in the education sector must come together: the model
of the Health Promoting School (HPS) (WHO, 1998) or FRESH (Focusing Re-
sources on Effective School Health) (UNESCO, UNICEF, WHO, & World Bank,
2000); the Caribbean tradition of Health and Family Life Education, dating back
to the early eighties (CARICOM & UNICEF, 2001); and the Pan-Caribbean
Partnership's Regional Strategic Framework for HIV/AIDS (2002-2006) (Pan-
Caribbean Partnership, 2002; Kelly & Bain, 2003). The collaboration of these
forces stands to exert the greatest influence, apply the most technical know-how,
and leverage the best possible resources to combat the deadly disease and to offer
Caribbean youth improved opportunities for better health and development.
Most young people and teachers in the region enjoy good health, and
there is a high level of school enrolment. A majority of young people report that
they have not had sexual intercourse (65.9%), they do not use alcohol or other
drugs (89.4%), and they get along with their teachers (96.4%). A Portrait of
Adolescent Health in the Caribbean notes, "Of the one-third who are sexually
active, half report that sexual intercourse was forced and half of the boys and about
/4 of the girls say that their age of first intercourse was ten years old. Almost
two-thirds had intercourse before the age of 13. Males were about three times
more likely than females to have five or more sexual partners" (Halcon, Beuhring,
& Blum, 2000, p. 14). With these risk behaviours, practiced by a third of Carib-
bean youth who tend not to use condoms, HIV/AIDS poses a grave threat (World
The region has the second-highest prevalence rate of HIV/AIDS after
sub-Saharan Africa, and the disease is present in the mainstream population. A
World Bank study noted that self-reported heterosexual contact is now acknow-
ledged as the main route of HIV transmission and accounts for approximately
two-thirds of all AIDS cases in Caribbean countries. Of particular concern is the
dramatic and constant increase of HIV/AIDS among Caribbean women, who also
have one of the highest rates of cervical cancer in the world, which is related to
sexually transmitted infections (PAHO, 2003). These patterns cry out for schools
to reach children at early ages, and to provide programs and services for teachers
and other education personnel.
Since the epidemic began, the public health sector has dominated the
response to HIV/AIDS, disseminating important information about how the dis-
ease is transmitted and behavioral change strategies for prevention and access to
care. But these efforts can be strengthened by focusing even more on the human
dimension of relationships and sexuality, as well as strategies to shape people's
positive behaviour and skills early in the life cycle. The education sector, which
plays a central role in the transmission of culture and customs, can and must play
a significant role in protecting the health of young people and in the fight against
HIV/AIDS-especially since research has repeatedly shown that reproductive
health education does not lead to earlier or increased sexual activity among young
people and can in fact reduce sexual risk behaviour (e.g., UNAIDS, 1997a; Kirby,
2001a). The school as a setting needs to return to the invaluable role it played in
the Caribbean immediately after World War II where it was the focal point for
delivering very effective health promotion programmes (Kelly and Bain, 2003).
The formal education system must once again move beyond a primary focus on
academic achievement to embrace a broader mission that will preserve the health
of students and education personnel as well as the survival of the education system
itself-a major force in sustainable development for the Caribbean people.
Health and economic development are highly interdependent; the Nassau
Declaration (2001) stated, "The health of the Caribbean Region is the wealth of the
region." Yet, there is a third critical factor-often overlooked and undervalued-and
that is education, which is vital in the formation of human and social capital and
healthy human development. Dr. Amartya Sen, winner of the 1998 Nobel Prize in
Economics, argues that the development of nations is strongly dependent on their
citizens' freedom to participate in processes that affect their future and their access
to education and health care. These freedoms are essential factors in reducing
poverty and promoting human and economic development (Sen, 1999). Education
has a key role to play in developing the knowledge, skills, confidence, and
political participation of young people and school personnel to protect their health
and to safeguard accomplishments the region has gained.
A growing body of research, which education leaders cannot ignore,
links academic performance and school completion to student and teacher health.
Physical, social, and emotional health has a significant impact on academic per-
formance, school completion, teacher morale, and absenteeism. Global examples
have found that:
S The physical and mental health of the teaching staff affects students di-
rectly through the quality of teaching and the school's psychosocial environ-
ment (WHO, 1997).
* Schooling pays off in terms of higher incomes and a healthier workforce
(World Bank, 1993).
* The report of the Dakar World Education Forum states that education can
be a powerful force-perhaps the most powerful force of all-in combating the
spread of HIV/AIDS (UNESCO, 2000).
This research base shows an inextricable connection between education
and health. For that reason, focusing solely on cognitive performance as a way to
foster school success is entirely inadequate. Further, the Caribbean Region could
find itself facing increased absenteeism of staff and students because of
HIV/AIDS, which will weaken the overall educational system (UNESCO & IIEP,
2003). Recent evidence also shows that more-educated young people are emerging
as less likely to be HIV-infected. Evidence is making it more clear that education
does help individuals protect themselves against HIV infection (Kelly & Bain,
This chapter concentrates on the role of the formal educational system-
the fundamental institutional foundation for HIV/AIDS education to reach stu-
dents and staff on a large scale. The formal system has a key role to play in
planning ways to mitigate the impact of HIV/AIDS on individuals and on educa-
tion processes and systems, and in delivering effective prevention education and
services (World Bank, 2002). We describe three Caribbean movements and how
they can be integrated into the education system to address the full continuum
from stigma and discrimination to prevention, voluntary counselling and testing,
access to anti-retroviral drugs, and support for bereavement (UNESCO & IIEP
2003). Through these efforts, the formal system can be strengthened by linking
with the informal education sector in the community to reach those at risk who are
not in school and to use educational strategies more broadly, including the media
and arts, to touch people's emotions where change begins, to influence policy, and
to galvanize action.
Healthy Child and Adolescent Development: Underlying Factors
The biopsychosocial model of human development describes how bio-
logical (e.g., genetics, pregnancy, birth), psychological (e.g., cognitive develop-
ment, perceptual development), and socio-cultural forces (family, school, media)
interact to shape human behaviour across the lifespan, as depicted in Figure I
(Dacey & Travers, 1991).
Figure I: The Biopsychosocial Model of Development
Robert Havighurst (1972) identified critical development tasks that occur
throughout each individual's lifespan, the successful achievement of which leads
to happiness and success with later tasks, whereas failure can lead to social
disapproval and difficulty with later tasks. He grouped the tasks into three catego-
* Tasks that arise from physical changes, such as learning to walk, talk, and
behave acceptably with the opposite sex, or the hormonal changes brought
on by adolescence or menopause.
* Tasks that arise from intra-personal sources that take the form of personal
values and aspirations, such as learning skills for a new job.
* Tasks that have their source in the socio-cultural pressures of society, such
as mores or taboos about sexual behaviours of men and women, or conform-
ing to certain styles of dress or to a religious doctrine.
Development tasks are specific to a particular life stage. Typical develop-
ment tasks of middle childhood and adolescence, for example, include learning to
get along with age-mates, acquiring values and ethics to guide behaviour, and
achieving a masculine or feminine social role. While a person's genetic and
biological characteristics predispose his or her approach to these tasks, the individ-
ual is constantly influenced by the broader environmental forces in the family,
school, community and society, as shown in Figure II.
Figure II: Spheres of Influence in a Person's Life
Healthy development involves the physical, mental, emotional, spiritual,
and social dimensions of a person's life. School is a major force in a young
person's human development, both directly, through the curriculum, and indi-
rectly, through the values it transmits and the role-modelling and actions of
teachers, who are especially important people in the lives of students. Schools can
strengthen the ways in which they positively affect students' progression through
these development tasks, protecting their health and minimizing risks or threats to
The adoption of a healthy lifestyle is promoted as a way for students to
reach their full potential. Reaching this potential involves the development of
knowledge and skills to make healthy choices as one seeks to master the develop-
mental tasks, as illustrated in Figure III (Education Development Center, 1991;
Gold, 1982). As young people negotiate these tasks, they often experiment with or
engage in multiple, interrelated risk behaviours. For example, alcohol use exacer-
bates the risk for HIV infection and pregnancy as it reduces one's inhibitions and
sense of responsibility. Skill development, such as resolving conflicts, communi-
casting effectively and refusing or resisting sexual activity or substance abuse can
avoid risk and favour safe and healthy outcomes.
Figure III: The Iceberg of Risk-Related Outcomes
At lD Us-
''".. 'i "o -"',:":" ,,."-" "**
- .:" .. />-,. ,, . .. .: :' /:.* ,? '. ,"** ,.,,
:~~ ~ ~ -*z ;;.*'i." ^,?^ ^
: *r, ,lgi .'.
Research has shown that the more risk factors a young person experi-
ences, the more likely it is that he or she will engage in unhealthy practices.
Conversely, the more risks in a child's life that can be reduced, the less vulnerable
that child will be to health and social problems. Schools have an important role to
play in strengthening protective factors and reducing risk factors, such as those
illustrated in Figure IV (Dash, Vince Whitman, Harding, Goddard, & Adler, 2003;
There are protective and risk factors within each domain of individual,
family, school, and society. In the school domain, three major factors in reducing
a child's risk behaviours are (1) the degree to which that child feels a sense of
bonding or connection to school, (2) clear standards, and (3) parental involvement
(McNeely, Nonnemaker, & Blum, 2002). In the school environment,
reducing the risks to students that come from harsh or arbitrary student manage-
ment practices or ineffective administrative leadership can also make a difference.
Many program strategies in schools focus on strengthening these protective fac-
tors by creating greater teacher connection to students and by fostering social
problem-solving, skill-building, or therapeutic interventions.
Figure IV: Selected Protective and Risk Factors
Positive relationships close bonds
Lack of commitment to school
Healthy beliefs and clear standards
Caring and support
Sense of community
Clear standards and rules for
High expectations from school
Recreational activity ies
Easy access to confidential services
Community norms and laws unfavourable
to promiscuity and substance abuse
Friends who engage in risky or
Early and persistent
anti- social behaviour
Harsh and arbitary student
Little emotional and social support
Media portrayal of sex, violence,
and gender inequity
Availability of alcohol and drugs
Related to strengthening protective factors, in 1997, CARICOM (Caribbean
Community Member Countries) heads of government formulated a profile of the
"new Caribbean citizen," whom they wish their education systems to form, as
outlined in Figure V.
In developing this profile, governments acknowledge the central role that
formal education is thought to play in the transmission and reinforcement of
values regarding national and regional development. Clearly, many of these quali-
ties are related to development tasks, healthy development, and protection from
HIV/AIDS (International Bureau of Education, 2002).
Figure V: Profile of the Ideal Caribbean Citizen
The underlying factors that affect child and adolescent development-the
biopsychosocial model, development tasks at stages of the lifecycle, and risk and
protective factors-have informed and influenced frameworks and initiatives for
school health programmes, such as the Health Promoting School and Health and
Family Life Education, which are described in the next section. Coordinating these
initiatives can leverage many resources to achieve the Caribbean Regional Strate-
gic Framework for HIV/AIDS 2002-2006.
Three Powerful Initiatives that Together Can Improve Health and Academic
Health Promoting Schools
A Health Promoting School (HPS) is one that fosters learning with all
measures at its disposal. Figure VI illustrates the concept of the HPS, which
engages health and education officials, teachers, students, parents, and community
leaders in efforts to promote health (WHO, 1998).
The school is also a workplace for teachers and other staff; as such, it
must protect their human rights. Schools should also offer health promotion
activities and health services to teachers and staff.
Essentially, the HPS concept features the combination of an overarching
policy to address health in the school environment via three essential coordinated
components: skills-based health education, health services, and a healthy physical
and psycho-social school environment. Health and Family Life Education in the
The "new Caribbean citizen" must:
* Be imbued with a respect for human life
* Be emotionally secure with a high level of self-confidence and self-esteem
* Regard ethnic, religious, and other diversity as a source of potential strength
* Be aware of the importance of living in harmony with the environment
* Have a strong appreciation for family and kinship values, community cohe-
sion, and moral issues, including responsibility for and accountability to self
* Have an informed respect for cultural heritage
Caribbean offers important resources to address the skills-based (life skills) educa-
tion component as well as linkages with parents and the community.
Figure VI: Health Promoting Schools and Capacities to Support Them
Five core elements
I N Collaboration
As shown in Figure VI, several core capacities are required to implement
the concept at both the national and local levels, including leadership and manage-
ment, a knowledge base of effective public health strategies, collaboration with the
informal sector, policy, and systems to track and monitor progress. Tools and
training materials exist for ministries and local schools to develop these capacities
(Vince Whitman, 2002; WHO, 2000).
The concept of the Health Promoting School was born in Europe out of
work by the European Commission, Council of Europe, and WHO Regional
Office for Europe. It is based on public health theory and builds on the Ottawa
Charter of Health Promotion, which recognized that health is created and lived by
people within the settings of everyday life where they live, learn, work, play, and
love (WHO, 1986). The earliest descriptions of the HPS, then called "Healthy
Schools," were developed during the first major conference of all the European
nations on school health promotion in Scotland in 1986. In 1995, the World Health
Organization headquarters in Geneva launched the concept globally with its
Global School Health Initiative. At the April 2000 Education for All meeting in
Dakar, Senegal, UN agencies, donors, and non-governmental organizations ex-
pressed their unity for these basic concepts by rallying behind FRESH-Focusing
Resources on Effective School Health (Vince Whitman, Aldinger, Levinger, &
Birdthistle, 2001). In 2001, the Caribbean Network of Health Promoting Schools
was created, and held its first meeting in Barbados to facilitate the exchange of
knowledge and experiences regarding the successful implementation of health
promotion and health education activities within and among countries (PAHO,
The value of the concept of the HPS is that it offers a positive approach
for promoting health and preventing disease relevant to the underlying factors of
youth development. Applying the framework to the region's strategic priorities for
HIV/AIDS, in the formal education sector, the HPS concept offers a strategy to
address the continuum of issues ranging from stigma and discrimination to preven-
tion, services, care, bereavement, and linkages with the community and the infor-
mal sector. WHO headquarters and FRESH partners have outlined specific ways
to address HIV/AIDS within the HPS concept and have created numerous training
and resource documents to assist schools with the process. (WHO, 1999; IIEP,
2002; WHO, UNICEF, UNESCO, World Bank, EI, EDC, & PCD, 2003). Later in
this chapter, we review the specifics of how HPS relates to the Caribbean Strategic
Framework for HIV/AIDS and Health and Family Life Education.
Health and Family Life Education
Dating back to the early eighties, Health and Family Life Education has
achieved many impressive accomplishments in the Caribbean Region. HFLE
focuses primarily on the curriculum component of the Health Promoting School.
HFLE is defined as a comprehensive life skills based programme (CARICOM &
UNICEF, 2001). The overall goal is that children and adolescents will be empow-
ered to make life-enhancing choices, which they will carry into adulthood and that
* Enhance the potential of young persons to become productive and contribut-
* Promote an understanding of the principles, which underlie personal and so-
* Foster the development of knowledge, skills and attitudes that make for
healthy social and family life;
* Increase the awareness of children and youth of the fact that the choices
they make in everyday life profoundly influence their health and personal
development into adulthood.
HFLE includes age-appropriate instruction in specific health areas.
HFLE fosters the development of laudable attitudes and values alongside the
knowledge component. The emphasis is on helping children to develop the per-
sonal and social skills they need to become responsible, independent, and contrib-
uting adults. These life-skills include problem-solving, decision-making, critical
and creative thinking, self-awareness, the ability to empathise, cope with emotions
and to refuse and resist pressure to engage in risk behaviours. All such instruction
is designed to promote parental involvement, foster self-concepts and to provide
mechanisms for coping with the stresses of modern living.
The HFLE movement in the region has made substantial progress in
placing the issue on the policy agenda of education leaders, advancing training and
curricula guidelines for teacher education colleges, and offering some teacher
training. Figure VII presents a timeline, highlighting HFLE from 1981 to the
present, also noting a few critical events in the HPS/FRESH and HIV/AIDS
arenas. Over the decades, there have been many key players, such as Dr. Phyllis
MacPherson-Russell from the Fertility Management Unit at the University of the
West Indies, Mona Campus, Jamaica, Ms. Elaine King from UNICEF, Ms Pat
Brandon from PAHO, and Dr. Morella Joseph from CARICOM, who is lending
her leadership to these efforts.
The HFLE initiative now stands on the threshold of an explosion of
activity, with potential to transform the concept much more deeply into mandated
policies that have resources behind them, to develop teachers' skills through more
widespread training and to develop and disseminate region-specific materials
more broadly to local schools.
In April 2003, HFLE received a booster shot from the CARICOM Coun-
cil for Human and Social Development (COHSOD), which endorsed the urgent
need for strengthening HFLE. With invigorated leadership from CARICOM and
continued coordination by UNICEF, major new initiatives are underway.
Most notable and related to achieving the Strategic Objectives for
HIV/AIDS 2002-2006 is the HFLE Regional Curriculum Framework Project.
Working under the guidance of the HFLE Regional Working Group, a team of
Caribbean HFLE experts, in partnership with Education Development Center, Inc.
(EDC) are developing a Regional HFLE Curriculum Framework. This Framework
outlines the standards, pedagogical techniques, learning outcomes, skills, and
knowledge for four themes: Sexuality and HIV/AIDS, Interpersonal Relation-
ships, Fitness and Nutrition, and Managing the Environment. For each theme,
there will also be age-appropriate sample lessons and references to a broad range
of teaching materials. The Framework provides consistent standards for the region
so that curriculum planners, teachers, education officers will all have a tool to use
in reviewing and strengthening their teaching of HFLE for 9-14 year-olds.
At the HFLE Regional Working Group meeting in Jamaica, February
2004, members reviewed and accepted material for the first two themes of Sexual-
ity and Interpersonal Relationships. Figures VIII and IX present these draft stand-
ards for Sexuality and HIV/AIDS (CARICOM/UNICEF, forthcoming), which are
integrally tied to the Region's Strategic Objectives for HIV/AIDS in Figure XI.
Four countries will participate in pilot-testing the Framework in May
2004: Jamaica, Trinidad, St. Lucia and Guyana. The pilot-test will seek to learn
how countries are able to use the Framework to develop or update and strengthen
their HFLE curriculum work. Said Ms. Joycelyn Rampersad of the School of
Education, University of West Indies, St. Augustine, one of the developers, "I see
the HFLE Framework as one of building capacity for the region. My university
students, who are working with us to develop the framework, are not only gaining
expertise in developing skills-based HFLE curriculum and resource materials, but
they are also positioned now to take the process further to train others." An
outcome of the UNESCO meeting, Dialogue on Publishing for AIDS, is a devel-
oping relationship with publishers for broad and ongoing dissemination of these
and related materials (UNESCO Office for the Caribbean, 2003).
In support of implementation of the Framework, CARICOM, UNICEF
and EDC are working with the three-campus UWI system to establish a
HFLE/HIV/AIDS Teacher Resource Centre that will institutionalize the provision
ofpre-service and in-service teacher training and ensure the availability and active
dissemination of up-to-date teaching materials for the various themes. New
courses, certified by UWI, are under development for a summer in-service insti-
tute and HFLE undergraduate course concentration in the education degree pro-
gramme, beginning in 2004.
Talented and committed people in the region have worked tirelessly to
achieve these milestones. But, it is not enough. Given the health threats that lie
ahead, a determined focus across sectors is necessary to develop the infrastructure
and capacity to address health through schools in a much more robust way. Efforts
need to push beyond policy statements, publications, and training primarily at the
tertiary level to make a difference on the ground with teachers and students, who
are most at risk. Increased collaboration to advance implementation can achieve
the shared goals of HFLE and the Strategic Objectives for HIV/AIDS.
Figure VII: Timeline Highlighting Selected HFLE, HPS Accomplishments:
1981 The Pan American Health Organization (PAHO) and the University of the West Indies
(UWI), Cave Hill Campus, Barbados, formed a partnership to strengthen the health curriculum
in the teachers' colleges in the Eastern Caribbean.
1982-84 The PAHO-UWI partnership conducted workshops to develop a prototype HFLE
curriculum for teacher training programs and a plan to introduce the curriculum into teachers'
1986 Health Promoting School concept originates with the European Commission
1985-91 The PAHO-UWI initiative lost significant momentum.
1991 PAHO, in response to CARICOM HFLE Guidelines, convened an interagency group that
included UNESCO, the United Nations Population Fund (UNFPA), the Carnegie Project and
Faculty of Education, UWI and Cave Hill Campus. The group developed "Core Curriculum
Guide for Strengthening Health and Family Life Education in Teacher Training Colleges in
the Eastern Caribbean in 1995." Many Teachers' Colleges used the Guide, devoting 40-60
hours of teaching time to HFLE as an optional course.
1993 -95 The Fertility Management Unit (FMU) of the Department of Obstetrics and Gynecology at
the University of the West Indies at the Mona campus in Jamaica organized a regional meeting
on life skills-based curriculum and training with representatives of Ministries of Education, the
Teachers' Colleges, PAHO, and the Faculty of Education. BY 1995, FMU had trained
approximately 300 people.
1993 The Regional Education Policy, developed through Caribbean Community Member Countries
(CARICOM) and adopted by Ministers of Education, called for the development of life skills.
Implementation was difficult to track.
1994 The CARICOM Standing Committee of Ministers of Education passed a resolution supporting
the development of a comprehensive approach to life skills-based curriculum, giving rise to the
CARICOM Multi-Agency Health and Family Life Education Project, coordinated by UNICEF
(CARICOM Secretariat, Caribbean Child Development Centre, UWI Schools of Education and the
Advanced Training and Research in Fertility Management Unit (FMU), PAHO/WHO, UNESCO,
UNDCP, UNFPA, UNDP, UNIFEM).
1995 "A Strategy for Strengthening HFLE in CARICOM Member States" described progress,
reporting most programs at the primary level, delivering information rather than skill
development using participatory methods. The report outlined specific objectives for future
activities and HFLE's dependence on larger vision of health promotion in schools.
1995 WHO/HQ launches Global School Health Initiative and Health Promoting School
1995-01 Some countries developed curriculum and trained teachers.
1998 CARICOM formed Caribbean Task Force on HIV/AIDS, which led to the Pan-Caribbean
Partnership on HIV/AIDS which further developed the Regional Strategic Framework.
2000 Education for All, Dakar Senegal, UN, donors and Non-governmental organizations
unite around FRESH, Focusing Resources on Effective School Health
2001 PAHO convenes First Meeting of the Caribbean Network of Health Promoting Schools,
2001-03 Numerous activities take place in training of teacher educators (participatory methods,
alternative assessment and design of country training plans). UNICEF HFLE volunteers
in sample countries advance training and implementation. Three countries have cabinet-
approved HFLE National Policies and six other countries have draft policies awaiting adoption.
2003 UNESCO/UNICA/UWI Conference: HIV/AIDS: The Power of Education, Trinidad launches
"Education and HIV/AIDS in the Caribbean.
2004 CARICOM meeting of HFLE Regional Working Group reviews HFLE Regional Curriculum
Framework and establishes roles at the regional and national levels for committees to deepen
implementation of HFLE.
Figure VIII: Regional Standards Sexuality and Sexual Health
1) Demonstrate an understanding of the concept of human sexuality as an
integral part of the total person which finds expression throughout the
2) Analyze the influence of socio-cultural and economic factors as well as
personal beliefs on the expression of sexuality and sexual choices.
3) Build individual capacity to recognize the basic criteria and conditions
for optimal reproductive health.
4) Develop action competence to reduce vulnerability to priority problems
including HIV/AIDS, cervical cancer and STIs.
5) Develop knowledge and skills to access age-appropriate sources of
health information, products and services related to sexuality,and
Figure IX: Regional Standard 1
Regional Standard 1
Demonstrate an understanding of the concept of human sexuality as an
integral part of the total person which finds expression throughout the life-cycle.
Descriptor: A differentiation needs to be made between the term's sex
and sexuality. Sexuality is presented as including biological sex, gender and
gender identity. One's sexuality also encompasses the many social, emotional and
psychological factors that shape the expression of values, attitudes, social roles,
and beliefs about self and others as being male or female. It is important to have
students develop positive attitudes about self and their evolving sexuality.
Coping Skills (healthy self-management, self-awareness)
Social skills (communication, interpersonal relations, assertiveness, refusal)
Cognitive Skills (critical and creative thinking, decision-making)
Age level 9-10
Explore personal experiences,
attitudes, and feelings about the roles
that boys and girls are expected to
Demonstrate awareness of the
physical, emotional and cognitive
changes that occur during puberty.
Age level 11-12
Develop strategies for coping
with the various changes
associated with puberty.
Assess traditional role
expectation of boys and girls
in our changing society.
Age level 13-14
Assess the capacity to
enter into intimate sexual
Demonstrate use of
strategies For recognizing
sexual feelings and
Assess ways in which
behaviour can be interpreted
as being "sexual".
Figure X: Regional Standard 4
Regional Standard 4
Action competence to reduce vulnerability to priority problems including
HIV/AIDS, cervical cancer and STIs.
Descriptor: Beyond knowledge of HIV/AIDS, cervical cancer and STIs
as a disease, efforts have to be intensified to render students less vulnerable to
contraction and spreading HIV/AIDS, cervical cancer and STIs. Addressing issues
related to the physical and emotional aspects of HIV/AIDS, stigma of living with
HIV/AIDS and discrimination against people living with HIV/AIDS is critical.
Importantly, students are encouraged to practice abstinence and a drug-free life-
Coping Skills (healthy self-management, self monitoring)
Social skills (communication, assertiveness, refusal, negotiation)
Cognitive Skills (critical thinking, creative thinking, problem solving, decision
Core Outcomes Core Outcomes Core Outcomes
Age level: 9-10 Age level 11-12 Age level 13-14
Identify the risk behaviours/
agents that are associated with
contracting HIV, cervical
cancer and STIs.
Make appropriate choices to reduce
risk associated with contracting
HIV, cervical, cancer and STIs.
condom use (if
of HIV, STIs.
Demonstrate skills for assisting Set personal goals to minimize Make appropriate choices
and respond compassionately the risk of contracting to reduce risk associated
to persons affected by HIV. HIV, cervical cancer and with contracting HIV,
STIs. cervical cancer and STIs.
Demonstrate ways of
empathizing Critically examine social norms
and supporting persons and personal beliefs in
and families light of current knowledge
affected by HIV/AIDS. of the transmission and
spread of HIV/AIDS.
Advocate for reducing the
stigma and discrimination
associated with HIV,
cervical cancer and STIs.
Achieving Pan-Caribbean Partnership's (PANCAP) Regional Strategic Frame-
work for HIV/AIDS in the Context of HPS and HFLE
In 2001, CARICOM heads of state established PANCAP to scale up the response
to HIV/AIDS in the region. The PANCAP partnership includes governments,
non-government organizations, private sector, multi/bi-lateral donors and the
United Nations system. PANCAP developed the Regional Strategic Framework
for HIV/AIDS to provide a basis for reducing the spread and impact of HIV/AIDS
in the Caribbean. The framework identifies areas for priority action at the regional
level that are focused on promoting a strengthened, effective and coordinated
regional response and supporting expanded and multi-sectoral HIV programmes at
the national level.
The framework sets forth seven priority areas for HIV/AIDS, see Figure
XI. All seven priorities, not just Priority #3, "Prevention of HIV transmission with
a focus on young people" include actions for the education sector and school
system. These encompass advocacy, policy and legislation (#1), care and support
(#2), workplace populations, such as teachers and other staff (#4), the protection
of women (a large number are women) (#5), capacity building (#6), and resource
These priorities map directly ion the HPS and HFLE frameworks. They
are also consistent with the UNESCO strategy to focus on five tasks:
1. Advocacy at all levels
2. Customizing preventive education to fit culture
3. Designing effective programmes to promote safe behaviour
4. Promoting a new role of education systems toward the infected and affected
5. Building capacity to enable the education sector to cope with the epidemic
The gender approach would permeate all aspects of each of the five tasks
(UNESCO Office for the Caribbean, 2002).
A brief discussion of each component of a comprehensive approach in
the formal education system follows, as illustrated in Figure VI of the Health
Promoting School,: policy, curriculum, services and environment, its relationship
to the priority areas and sample resources to carry out each one.
Policies set out clear national and local standards on health and
HIV/AIDS to guide planning, implementation and evaluation of these efforts, with
indicators to measure progress (Education Development Center, 2003). As stated
by UNAIDS (1997b), in the school school-setting policies cover human rights,
such as (the right to education, to non-discrimination, to confidentiality, to protec-
tion of employment, to protection from exploitation and abuse). Policies also
cover access to schools by students and school workers living with HIV/AIDS,
pre-service and in-service staff training, and community/parent participation. The
school-setting policies also extend to content of curricula and extra curricular
activities, and the link to health services capable of providing prevention services,
diagnosis and treatment of STIs for young people as well as the means of protec-
tion against unwanted pregnancy and HIV/AIDS, including contraceptives and
condoms. Policies are developed at different levels, according to the degree of the
centralization of the school system.
The Ministry of Education, Youth and Culture for Jamaica has developed
and the Cabinet has now endorsed a "National Policy for HIV/AIDS Management
in Schools" that includes a legal framework to protect rights and a policy to
address the many other important issues (Jamaican Ministry of Education, 2003).
The objectives are to:
* Highlight the existence of the HIV/AIDS epidemic in Jamaica and, in par-
ticular, in the education system;
* Provide guidelines for institutions on treatment of students and school per-
sonnel infected with HIV/AIDS;
* Promote the use of universal precautions in all potentially infectious situ-
* Ensure the provision of systematic and consistent information and educa-
tional material on HIV/AIDS to students and personnel throughout the sys-
* Reduce the spread of HIV infection;
* Instil non-discriminatory attitudes towards persons with HIV/AIDS.
Jamaica was one of the pilot-test sites for the University of Natal in South
Africa, which was funded by the UNAIDS Interagency Task Team on AIDS to
create an instrument for ministries of education to use in developing or refining
their HIV/AIDS policies. The University of Natal will be using this tool with
several ministries of education in the Caribbean within a global sample of 100
high-prevalence countries worldwide (IATT, 2003).
Other sample policies include a national policy for Namibia (Govern-
ment of Namibia, n.d.), a local-level policy for the Wyoming Public Schools
(Peterson, 1998), and one in higher education for the University of Natal (Univer-
sity of Natal Aids Committee, 2002).
The International Labor Organization (ILO) has developed excellent
policies for the workplace with extensive training manuals that can be applied to
all education personnel (ILO, 2002). Similarly, the WHO, Education International
(the global teachers' union), and EDC have created training materials for teacher
union leaders to know how to protect themselves, serve as educators in the
community and educate their students about prevention (El & WHO, 2001). In a
January 2004 workshop in Guyana, January 2004, union leaders from 14 Carib-
bean countries were trained in a three-day workshop.
Curriculum: Skills-based Health Education
Priority Area #3 of the PANCAP Strategic Framework, Figure XI fo-
cuses on prevention of HIV/AIDS transmission for young people by ensuring that
there is access to reliable and accurate information, recognition of gender issues
and efforts to improve and support the implementation of HFLE. The new HFLE
Regional Curriculum Framework also sets forth standards for teaching about
sexuality, STIs and HIV/AIDS in the broader context of relationships and the
development of the ideal Caribbean person as outlined in Figures V,VIII, IX, and
X. The Framework addresses substance abuse prevention, and the "Theme on
Relationships" provides added depth on this important aspect.
Education policy makers and planners, using the framework, need to
decide what options they will choose for the educational messages, and at which
age group (WHO, 1999). Those options include:
* Abstinence from sexual intercourse
* Non-penetrative sex
* Condom use
* Monogamy with an uninfected partner
* Abstinence from substance abuse
The HFLE approach to curriculum builds upon the research evidence of
what works in health education. That research has found that:
* Developing skills for making healthy choices in life, in addition to impart-
ing health-related knowledge, attitudes, values, services and support, is
more likely to produce the desired outcomes.
* Skill development is more likely to result in the desired healthy behaviour
when practicing the skill is tied to the content of a specific health behaviour
or health decision;
* The most effective method of skill development is learning by doing-involv-
ing people in active, participatory learning experiences rather than passive
ones (WHO, 2003a; Mangrulkar, Vince Whitman, & Posner, 2001).
Many curriculum and training resources are presently available from UN
agencies globally, but there are few curricula designed specifically for the diver-
sity of cultures, customs and languages of the region. UNESCO with Morton
Publishing Company in Trinidad and Tobago has produced some of the first
HIV/AIDS curricula for the Caribbean, aimed at developing literacy and AIDS
awareness among youth, Understanding HIV/AIDS and Drug Abuse (UNESCO
There are global resources, not customized for the region, available from
the international data base of HIV/AIDS school curricula created by UNESCO's
International Bureau of Education2. WHO and UNICEF have created HIV/AIDS
skills-based planning and training modules (UNICEF, WHO, et al. 2002; WHO,
2003b); and the Inter American Development Bank (IADB) (2004) has developed
with teachers' training institutions in Jamaica and Surinam, a draft "Caribbean
HIV/AIDS Training Package for Teachers." The Teacher Resource Centre will
concentrate on developing ways to put multiple copies of materials in schools
through arrangements with publishers and through electronic methods to expand
The greatest need in the region is to train teachers with accurate informa-
tion and how to teach using active learning strategies, which runs against a
tradition of a more didactic approach. The goal is to put in the hands of teachers
the education resources and tools for effective teaching. Ideally, the proposed
HFLE Teacher Resource Development Centre will be able to serve PANCAP, the
HFLE Regional Working Group and UN agencies, working with individual coun-
tries, to strengthen the mechanisms to address these priorities.
School Environment: Psycho-Social and Physical
The school environment includes the social-emotional climate as well as
the physical climate in terms of the quality of the buildings, availability of basic
sanitation, water, etc. Relatively new research evidence supports the assumption
that schools have an important role to play in creating a climate that not only
produces academic outcomes, but also reduces risk behaviours (Blum & Rinehart,
2001; Karcher, forthcoming; Kirby, 2001b; McNeely & Whitlock, 2003). The less
likely a young person is involved in risk behaviours, the better his or her academic
Findings from the National Longitudinal Study on Adolescent Health in
the U.S., involving 12,118 adolescents in grades 7 through 12, drawn from an
initial national school survey of 90,118 adolescents from 80 high schools plus
their feeder middle schools, found that young people's feelings of connectedness
and belonging to their school was one of the most significant factors against every
health risk behaviour measure except history of pregnancy. Understanding what
promotes school connectedness is a relatively new field of study, but school
climate has historically been found more than other factors in a young person's
life as a most significant factor in affecting risk behaviours. School climate
involves: 1) the opportunity to participate in and influence school classroom
policies and procedures, 2) relationships with caring, mentoring adults, 3) the
perceptions that adults at school did not discriminate based on appearances, and 4)
opportunities for creative involvement and expression (Nonnemaker & Blum,
2002; Whitlock, 2003).
An important investment that Caribbean schools can make in the healthy
development of young people and HIV/AIDS prevention is to develop ways to
improve school climate and the feelings of connectedness that young people have
to the adults there. Educators in the region often comment on the challenges of
shedding the vestiges of colonialism in the educational system -the authoritarian
climate of schools, the power structure, the exclusive emphasis on academics and
didactic way of teaching. Successful prevention for HIV/AIDS may begin with
assessing the school's climate and developing strategies to improve it with such
tools as those developed by WHO, Creating an Environment for Emotional and
Social Well-Being (WHO, 2003).
Other important aspects of school climate for health include gender
equity between administrators and teachers, between teacher to teachers, between
teachers to and students, and between students to student. Noting that in the survey
of Caribbean young people, a large percentage reported that first sexual inter-
course was forced, stresses the importance of the gender imbalance and how it can
affect sexual relationships and the spread of HIV/infection. Schools as a socializ-
ing force can play a major role over time in fostering respect and equity for men
and women and in preventing discrimination against gay and lesbian youth and
The physical environment and provision of safe drinking water and
sanitation facilities are also important. Girls need private facilities once they have
begun menstruation. These facilities can be important in keeping girls in school,
which is an important preventive factor itself in preventing HIV/AIDS and too-
early pregnancy. The school environment will need to have the means to take
precautions for universal infection control in caring for wounds and cleaning up
Services: Counselling and Access to Condoms, Testing and Treatment
The services component, least familiar and developed within the educa-
tion sector, is the component that has terrific potential to make a difference in the
future. While curriculum and school environments address the needs of a broad
range of students, services are often required for those engaged in risk behaviours
or for those who are on the verge of moving in that direction. For those at highest
risk, services can be the last barrier for prevention before infection. For example,
preventive education can be effective to a point, but if young people are sexually
active, they need access to affordable condoms. What availability will schools
provide either through distribution on site or by linking with health clinics or other
The service of counselling has several dimensions. For example, young
people may need counselling to discuss dysfunctional or abusive relationships
with family or friends, new feelings of love and attraction, and confusion about
sexual orientation. The ability to resolve these feelings and inter-personal issues
may be essential to protection for HIV/AIDS. Counselling has an important
function to provide for those who have been tested and found to be HIV-positive.
Finally, counselling to cope with loss and death will increasingly be needed for
teachers losing partners and for students losing family members and friends.
A related service is Voluntary Counselling and Testing (VCT). It is
unlikely that people will practice safe sex using condoms unless they know their
HIV status. For those who are positive, VCT can help them prevent spread to
others and receive treatment that enables them to live healthier lives. For those
who are not infected, the testing provides a teachable and valuable moment for
them to commit to practices to remain that way.
But VCT is often not a high priority and not marketed heavily or easy to
access. VCT requires financial and human resources and it takes time to establish
the infrastructure for its delivery. Very little is known about the HIV prevalence
rates for teachers or education staff. The stigma and fear of discrimination and job
loss are obstacles. And, since most testing takes place in antenatal clinics, it is
difficult to identify or use data for teachers as a group to know and project the
impact on the system.
The component of services and their availability to those in the education
sector is quite undeveloped. There are needs to strengthen the mental health and
counselling capacity in schools. Some of the greatest breakthroughs in the next
decade may be because of the innovative ways in which the education sector and
teachers' unions develop new and stronger partnerships with the health sector-
with clinics, with condom manufacturing companies, with distributors of testing
kits for VCT, and with pharmaceuticals for dedicated distribution of antiretroviral
drugs to affected members of the teaching profession. Innovation and bold steps in
this area could have a significant positive impact on many aspects of the
Summary and Recommendations
The traditional approach to health in schools has focused on curriculum,
which is necessary, but inadequate alone to address the range of risk and protective
factors confronting young people and the threat of HIV/AIDS. Therefore, the
education sector response needs to encompass a more comprehensive approach to
ensure the health, teaching and learning of students and staff. Why?
* Promoting positive behaviours and social norms, which most people in the
Caribbean practice, and which are inherent in the approach ofHFLE and
HPS, can encourage and reinforce others to adopt them. It is important in
the face of the HIV/AIDS epidemic to continue to focus on the positive.
More attention needs to be placed on the many young people and education
staff who are healthy and free of the virus, emphasizing ways to keep them
that way. There is tremendous benefit in promoting the positive social
norms of fidelity, abstinence, or safe sex for those who are active. Health
and Family Life Education and the HPS do not focus only on HIV/AIDS.
They present strategies for the development of the whole person, including
HIV/AIDS, and in this way reinforce the pride and proud heritage of the re-
gion. The two can work together -an overall approach to healthy develop-
ment, taking advantage of the need and opportunity to address HIV/AIDS.
* A coordinated approach provides a more effective wayfor the education
system to plan and implement health programmes. It is a challenge for the
formal educational system to address health. Recent tradition emphasizes
academic achievement and designates health to the health sector. However,
with the need to address health issues in the education system, it is very dif-
ficult for education planners and teachers to build a plan for each separate
health topic. There must be an integrated and simple way to include school
health policy and programmes with the capacity to train personnel in their
implementation. By coordinating HIV/AIDS within the framework of the
HPS and HFLE, there is a set of unified concepts that educators can rally be-
hind and more easily plan implementation. The ability to see how these in-
itiatives fit together can create a critical mass of people, committed with
passion, working toward the same goals.
* HFLE provides a two-decade foundation on which to build. HFLE has estab-
lished its Regional Working Group and is working to strengthen HFLE Na-
tional Committees in countries. There is a long tradition and track record
that is on the verge of creating expanded actions and capacity building.
Results will be strengthened when the education sector coordinates with the
health, mental health and social welfare agencies. In countries and through-
out the region, more and more players want to contribute and have a role in
school health and HIV/AIDS prevention in formal education. Clearly spell-
ing out how the goals of each movement can guide ministries, universities,
teacher education colleges, UN Agencies, Donors and Non-governmental
Organizations in assuming a unified approach will enhance the contribu-
tions of funds, expertise, materials, etc.
How can those who care so much about children, teacher, other education
sector staff and the people of the region and its proud heritage pull together to
prevent so much preventable human loss and suffering? Many of the recom-
mended actions have been described in great detail in "Education and HIV/AIDS
in the Caribbean". Many of the recommendations by Michael Kelly and Brendan
Bain focus on the need for capacity building, and these capacities are the same for
the HPS, outlined in Figure VI depicting the roots beneath the flower of the HPS.
A few suggestions concerning how we might make progress to unite
these three movements follow:
1. At the regional level of CARICOM, fostering close collaboration and a
formal mechanism between PANCAP's HIV/AIDS initiative and
CARICOM's HFLE Regional Working Group, in the context of the
HPS, could produce greater focus for planning, implementation and re-
source allocation to achieve the HIV/AIDS Strategic Objectives. Each
of the seven Priority areas has a different set of lead agencies. Yet, to
provide comprehensive approaches for the education system, there
needs to be a way for the HFLE Regional Group to plan with many of
2. At the country level, the HFLE National Working Groups need mecha-
nisms to work closely with the National HIV/AIDS Committees so that
a comprehensive approach can be applied to the education sector, mov-
ing beyond curriculum alone.
3. A top priority must be the training of education personnel and the develop-
ment and dissemination of health promotion and disease prevention ma-
terials relevant to the cultures and customs of counties in the region.
More emphasis must be placed on implantation by thousands of teach-
ers at the local level on the ground strategies specific to HFLE and com-
ponents of the HPS model that tie to the HIV/AIDS priorities.
4. New and bold partnerships can be negotiated between the education sector
health sectors, among others, to support sexuality education and the
continuum of HIV/AIDS components. And, building the capacity of
ministries, teachers' unions through new partnerships with the business
sector to provide affordable condoms, testing and antiretroviral drugs to
education staff and students could save thousands of lives and the
education system itself.
Figure XI: Caribbean Regional Strategic Framework For HIV/AIDS:
2002-2006 Priority Areas and Strategic Objectives
PRIORITY AREA #1: Advocacy, Policy Development and Legislation
* To inform and mobilize policy makers at highest levels with more comprehensive in-
formation on the course, consequences and costs of the epidemic
* To promote the incorporation of human rights and non-discrimination practices in
policy and legislation, in accordance with international guidelines, best practices and
* To mobilize regional opinion leaders on HIV/human rights issues
* To promote awareness at multi-sectoral level on HIV and human Rights issues
* To ensure that national level policies reflect international standards, best prac-
tice/consistency with international guidelines
* To ensure that prevention messages are integrated into as many general advocacy op-
portunities as possible
PRIORITY AREA #2: Care, Treatment, Support for People Living with HIV/AIDS
* To improve access to basic medication (for the prevention and treatment of oppor-
* To improve access to antiretrovirals
* To strengthen and extend counselling services
PRIORITY AREA #3: Prevention of HIV Transmission, with a Focus on Young
* To ensure general access to reliable and accurate information about HIV/AIDS
* To ensure recognition of gender issues within all prevention campaigns
* To improve and support the implementation of Health and Family Life Education
* To Integrate HIV and STI issues into adolescent programmes including reproductive
* To promote the development of HIV/AIDS prevention programmes for young peo-
ple, including condom distribution
* To advocate for the provision of youth-oriented health services and facilities
* To promote and support innovative peer counselling models for youth, parents and
* To ensure the access of out of school youth to HIV/AIDS prevention and
PRIORITY AREA #4: Prevention of HIV Transmission among Especially
Drug and Substance Abusers
* To strengthen understanding of role of substance abuse and drug use in re-
gional epidemiology of HIV/STIs and to use information in appropriate pre-
vention and care strategies
* To identity and address policy issues affecting mobile populations at re-
People in the Workplace
* To mobilize and support key employers at regional and national levels to as-
sess HIV/AIDS in their workplaces and to introduce appropriate prevention
and support programmes for employees
PRIORITY AREA #5: Prevention of Mother to Child Transmission
* To strengthen primary prevention among women
PRIORITY AREA #6: Strengthen National and Regional Capacities for
Analysis, Programme Design, Implementation, Management and Evaluation
* To build analytical and management capacity in key regional institutions
such as UWI
* To expand and improve the quality of information available to programme
managers and policy makers on the course, causes and consequences of the
epidemic at national and regional levels
* To promote information exchange, coordination and formation of strategic
alliance in the region
PRIORTIY AREA #7: Resource Mobilization
* To identify resource needs and gaps
* To ensure access to the Global Fund for HIV/AIDS, TB and Malaria
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"When you have AIDS, people laugh at you":
A Process Drama approach to Stigma with pupils in Zambia
BRIAN HEAP AND ANTHONY SIMPSON
This article describes in detail part of a pilot project conducted in
Zambia by Brian Heap, a process drama practitioner and Staff Tutor in Drama at
the University of the West Indies, Mona, Jamaica and Anthony Simpson a teacher
and anthropologist, working in the U.K. and Zambia, to promote HIV/AIDS
competence. The seeds of the project were sown when Simpson had the opportu-
nity to see Heap using aspects of the Process Drama methodology with trainees at
the School of Advanced Nursing Education at the UWI, Mona in sessions which
addressed issues of how to care for a person living with HIV or AIDS. HIV/AIDS
raises a multiplicity of concerns, not least among them economic and gender
inequalities. Recent UNAIDS campaigns have been designed to "bring men in" in
the recognition that certain constructions of gender are harmful to both women and
men and impact directly upon HIV transmission and upon the care of people living
with HIV and AIDS. Process Drama, when sensitively handled, offers a rich
source of information about participants' perceptions and understandings. Using
cross-gendering in role-play activities, in conjunction with a range of other strate-
gies, Process Drama can provide a safe space for the participants themselves to
interrogate stereotypical constructions of masculinity and femininity and the
sources of stigma against those living with the HIV virus or with AIDS-related
conditions. Participants may explore the constraints upon their lives and test in the
subjunctive mood possible alternative courses of action. For academics and
activists the methodology provides an accessible way of monitoring how
HIV/AIDS campaigns are received and offers important clues as to how they
might be improved. The complexities of the epidemic cannot be successfully
addressed by health professionals alone. An interdisciplinary approach, building
upon a wide spectrum of expertise including social scientists, teachers and drama
practitioners has much to offer. The authors argue that the lessons learnt from
the pilot project have a wide application for HIV/AIDS education in Jamaica and
the West Indies in general.'
In any society HIV/AIDS throws a spotlight upon a plethora of issues,
among them gender, sexuality, human rights, understandings of health and illness,
discrimination and stigma. The problem of stigma was highlighted by teenagers
in schools in the Zambian capital, Lusaka, when the authors talked to them about
their concerns. The students frequently commented, "When you have AIDS,
people laugh at you". They spoke from first-hand experience. With HIV infection
rates estimated countrywide at around 20% of the 15-49 age group, with estimates
of 35% and above for Lusaka itself, and with the growing number of AIDS deaths,
young Zambians spoke with authority. Many of them knew people living with
AIDS-related conditions or indeed had watched their slow decline without access
to anti-retroviral therapy in their own households, in their families and in the
spaces beyond their homes where they conducted their everyday lives. However,
one of the consequences of the enduring stigma around HIV/AIDS, in a context in
which distance is maintained between generations especially between a father
and his children and especially as far as discussions of sex are concerned is that
most Zambian parents do not feel they can discuss the problem of HIV/AIDS.
This does not, of course, mean that young people do not see and know, or, at least,
do not come to learn the circumstances in which they lose their parents and other
family members. Children and young adults often depend upon their age-mates to
sustain them through such traumatic experiences and the haunting possibility that
they too might be HIV positive.
Attention is increasingly being given throughout the world to children
and young men and women in the fight against the transmission of HIV and in
dealing with the multiple consequences of the AIDS epidemic. Regrettably, many
HIV/AIDS campaigns adopt a top-down approach which privileges those "in the
know" and "authorizes" them to speak and to silence other voices. Local teaching
"cultures" often mesh with these didactic approaches. (For a discussion of such
teaching styles in Zambia, see Simpson, 2003). However, it has come to be
recognized that "information delivery" approaches that seek to promote "rational"
decision-making based upon "the facts" are of dubious benefit. Didactic methods
uninformed by the perceptions of young people and unrelated to the contexts of
their lives are unlikely to have much impact.
The HIV/AIDS pandemic like other plagues in history has the danger-
ous capacity to produce scapegoats and stigmatised individuals, creating powerful
metaphors of a society's dis-ease with itself. The early history of AIDS, first
identified as "a gay plague", and thus encouraging homophobia, and then as the
almost exclusive affliction of the sexually "promiscuous", bears witness to such
processes. The temptation to distance oneself from such stigma and indeed from
the care of those infected may run deep. Yet this disease and its consequences will
only be mitigated by a compassionate concern for those infected and affected.
Working towards the eradication of stigma must form an important part of any
When Zambian teenagers talk of AIDS, they rarely make the distinction
between carrying the HIV virus and suffering from AIDS-related illnesses. Goff-
man's (1963) discussion of the culturally relative construction of stigma and his
distinction between being discreditablee" (possessing a hidden stigma and not
disclosing it) and being "discredited" (possessing a visible stigma or having it
disclosed) provide useful insights. Those living with the HIV virus may find
themselves either discreditablee" or "discredited". Those living with AIDS can-
not avoid the risk of being "discredited". Although few medical diagnoses are
obtained or revealed, living with AIDS for so many years has made Zambians
reluctant amateur experts at diagnosis.
Process drama, often called drama in education, 'living through' drama
or 'experiential drama' is one way to approach the problems of stigma and
discrimination. The drama is not created for a watching audience but rather for the
benefit of the participants themselves. They are the ones who, together with the
teacher or facilitator, make meaning for themselves. There is no pre-written
script. Rather those who participate "write" the script for themselves in role-play
which moves the action forward. Process drama is always concerned with people
and their lives and because drama is a social, interactive arts process, it creates
experiences which enable the development of cognitive, emotional, social and
creative understanding and skills. It is drama that can be created by the very
young and the very old and it is based upon the principle that learning takes place
most effectively when it is contextualised. The dramatic context provides an
appropriate lens through which the participants can examine relevant themes.
(See Bowell and Heap ) It is, in Dorothy Heathcote's (1995) phrase,
'education for self-direction'.
Schools and colleges were selected for our pilot project by the Zambian
Ministry of Education. They provided a range of sites countrywide in which to
evaluate how appropriate and useful the methodology was in the Zambian context.
What follows is a reasonably accurate transcription of a split session at Mulcya
Basic School, Lusaka, in 2002. The day school caters for students in grades 1 to
9. The session involved forty Grade Nine pupils (19 girls and 21 boys). Most
pupils were in the 16 18 age range. Besides the facilitator, Brian Heap, and the
ethnographer, Anthony Simpson, others present at various times in the course of
the day were the class teacher, the deputy head, a representative of the British
charity Voluntary Service Overseas and three representatives of the charity Save
the Children (South Africa and Sweden) who were the sponsors of the pilot
project. The authors had made a preliminary visit to the school and met with the
pupils a few days prior to the session, and were particularly impressed by what
appeared to be the caring culture which permeated the school. The Principal
herself, functioned as both teacher and administrator, and clearly gave support to
the work which Heap and Simpson conducted in the school.
After introductions, the facilitator began as follows:
Brian: I'm going to demonstrate some drama with you today. What comes into
your head when you see the word 'drama'?
Boy: a play
Brian: What does acting mean?
Brian: We are going to do a drama for ourselves. I hope you will help me to make
our story. We will need to use our imaginations. We will need to be creative.
(Picks up a broom.) I'm going to use this broom and I want us to imagine that it's
something else. I'll do the first one for you. (Mimes playing a violin.)
Brian: What am I doing?
Chorus: Playing a violin.
(Other pupils now come to the front of the class and mime their ideas while Brian
records them on the board as given below:)
Brian: a violin bow
Boy: a machine-gun
Boy: a martial arts stick
Boy: a toothbrush
Girl: a golf club
Girl: a guitar
Girl: a pool cue
Boy: a microphone
Girl: a hairbrush
Boy: a shoe brush
Girl: a duster
Girl: a walking stick
Boy: a spear
Boy: a cricket bat
Boy: a hoe
Girl: a cobweb broom
Girl: a piece of chalk
Boy: a paddle
Girl: a cooking stick
Boy: a trumpet
[This activity is used both as an ice-breaker and to set the tone for the day's
'work'. It moves participants into 'play' mode and, to some extent, into the
subjunctive ('what if?) mode of interaction. The reader may note some marked
gender differences in the actions that the pupils choose to portray. Three boys
show weapons while three girls show domestic/house implements. Other demon-
strations are not gender-specific in the Zambian context. While choices may not
carry any particular significance, they could, of course, form the basis for a
discussion about gender stereotypical roles. This matter becomes particularly
salient when girls and women are required to carry the biggest burden of care for
those afflicted with AIDS-related conditions in addition to household duties.]
Brian: Good. This is the kind of drama that I want us to do today. I am going to
give you the beginning or the end of a story and I hope you are going to fill in the
story. I want you to use your imagination again.
(Brian puts a man's jacket on the back of a chair at the front of the room.)
[The jacket is an important component for building a way into this drama. It
performs a number offunctions. It inducts a male presence into the room by both
functioning as a sign and representing a role. It protects the participants from
having to deal with the stigma ofHIV/AIDS by allowing them to build the idea of
someone who is HIV positive and to maintain a level of detachment and objectiv-
ity. None of the participants is asked to quickly decide whether they would be
willing to portray such a role. It is also quite possible that a pupil among the
participants may actually be HIV positive.]
Brian points to the chair: I want you to imagine that you can see a 14-year-old boy.
He's sitting right there. He's HIV positive. He's been HIV positive all his life
because he was born HIV positive. Is it possible, do you think, for him to live to
Boy: They do not die if they stay away from sex.
Brian: Do you mean if someone takes care of him?
[The facilitator recognizes that he did not follow this response properly to deter-
mine whether there was clear understanding about the infected person and sexual
activity. It appeared that the respondent could have been having difficulty in
separating the idea of HIV infection from anything other than sexual activity.]
Brian: O.K., now we'll need to give him a name.
Brian: Good. And we will need to give him a Zambian name.
[The fact that the pupils name the characters represented, besides offering an
opportunity for culturally appropriate names to be used, gives them a greater
sense of ownership of the drama and encourages a greater degree of identifica-
tion with those portrayed. This in turn is likely to encourage empathy and
Brian: Good. He's Mark Bwalya. He's 14 now, today. But can we imagine
when he was bor? In drama we can go back in time. Mark has a brother. His
brother was 12 years old when he was bor. His brother was not HIV positive.
But when Mark was born, his mother died shortly after. Would someone be
willing to represent Mark's brother?
(A boy volunteers and comes to the front of the class.)
The facilitator seeks an embodied representation of the older brother in the
drama, while still representing the younger one with the jacket, because there is no
direct stigma attached to this role.
Brian: Thank you. This is going to make things much easier. He'll need a name.
What shall we call him?
(Pupils agree on Thomas Musonda.)
Brian: His mother died soon after his brother was born. His father had already
died from an AIDS-related illness. (Brian wraps a piece of local [citenge] cloth
into a baby and hands the bundle to the boy in role as Thomas. Thomas
spontaneously begins to rock the baby gently.)
[For the purposes of the drama the bundle of cloth simultaneously signs the idea
of infant, and functions as the role of baby Mark. It also shifts the drama back in
time so that the participants function in a 'flashback' mode, to a time fourteen
years earlier. It was observed that whenever a boy took the role of the older
sibling, he immediately and without any apparent self-consciousness or any at-
tempt to 'play up' to the 'audience, engaged in this nurturing activity. This is
particularly striking because generally in Zambia, as in other countries in the
region, boys are neither expected nor encouraged to take up duties that are
strongly marked as feminine tasks. Indeed, boys are often strongly encouraged by
their fathers and male peers to distance themselves from activities that are deemed
to have the potential to emasculate them.]
Brian: What is Thomas thinking about while he is holding this child, his brother?
(Brian explains thought-tracking and invites pupil to come to the front of the class,
put their hand on Thomas' shoulder and speak for Thomas.)
Brian: I will give you an example, "I'm only twelve years old. I don't know how
I am going to manage."
Boy: I don't work. I don't get pay. I don't know what to do.
[Thought-tracking protects the boy playing Thomas into the experience, that is, he
does not have to acLor improvise, but merely represents the role. Pupils doing the
thought-tracking do not feel that they are being put on the spot, but they are
expanding on the facilitator's modelling of the strategy. Girls are automatically
cross-gendered in this activity, since they are speaking in the first person for and
by implication as Thomas. The pupils are thinking out loud Thomas's dilemma
and exploring possible alternatives for action. Each suggested solution could be
pursued and analysed.]
(Brian begins to list these points on the board as below:)
3.who is going to take care of Mark?
4.don't get paid
5. can't afford to feed the baby
(Other pupils follow and speak for Thomas.)
Girl: I need someone to take care of me.
Girl: I can't take this responsibility.
Boy: If I continue to keep this baby, will I go to school?
Girl: I don't have the skills to look after a baby.
Boy: I have nowhere to go.
Brian: Why does he not have anywhere to go?
Boy: If I go somewhere else, who's going to take care of the baby?
Boy: I don't have any other relatives.
Boy: If I go with this child to my relatives, they may be afraid of this HIV positive
baby and they may be afraid that they too may be infected.
Boy: Why can't I take this baby to the hospital?
Girl: I think I will take Mark to the orphanage.
Boy: If I can't take care of myself, then both of us might end up in the street.
[The pupils are able to voice a number of obstacles facing Thomas in his dilemma
and so the facilitator next encourages the thought-tracking to move towards some
kind of resolution or decision.]
Brian: Think now about his decision. What is he going to do? When you come
up now, I'd like you to tell us his decision speaking through him.
Boy: I should just find a solution through work.
Boy: I can go to Victim Support.
Boy: I think I will go to the orphanage.
Girl: It would be better if I go to Global Ministries (a church).
[The facilitator now moves the story on but leaves it open to dispute. He shifts the
strategy to writing-in-role, and in the process articulates the cross-gendering that
will occur in this activity.].
Brian: Good, thank you. I am now going to ask you to imagine one of those
situations. He's going to have to make a very painful decision. He thinks that if
he leaves the baby at the orphanage and not stay himself- he thinks that that is the
best solution. This is the plan. In order for our story to move forward if you
don't agree, you can say so he's going to leave the baby on the doorstep. Think
about it. Whether you are a boy or a girl, imagine you are Thomas and write the
note that you are going to pin to the baby's clothes.
(Brian gives them time to write the note.)
[The writing in role opens up the drama to direct participation by all the pupils,
since no undue pressure was put on them to participate in the earlier thought-
tracking. The facilitator introduces a traditional folk form the lullaby. This is
another moment where pupils may make the action more authentically their own.
While the medium of instruction is English, they often switch back and forth from
English into a local language.]
Brian: If you've finished, I want you to think of a traditional song a song that you
can sing to put the baby to sleep.
(Brian invites Thomas to come out to the front of the class again and invites him
to read what he has written:)
Thomas reads: I'm Thomas Musonda. I am only 12 years old. I have left this
baby because I can't manage to take care of him. I don't have money to buy food
to feed him, and my relatives are refusing to stay with me and the baby because
they are afraid that they might be infected. I can't manage to take the baby to the
hospital. It's too far.
Brian: Thank you. I'd like to hear the lullaby. Can someone suggest a song and
teach the rest of us?
(A girl sings a lullaby in Nyanja a local language commonly used in the Lusaka
Brian: Good. Now I'd like everyone to sing it and then we will listen to someone
reading their note. And then we will sing the lullaby again. We want to hear some
of the things you've been thinking about.
[Reading the notes aloud moves the pupils into drama mode without undue
pressure. Punctuating the reading of the notes with the lullaby establishes a
powerful mood and underscores the painful nature of the decision to make the
Boy: My name is Thomas Musonda. I'm only 12. I am leaving this baby because
I cannot take care of him. When I grow up I can come back and pick up the baby.
Boy: I'm Thomas Musonda. Please I'm sorry for dumping this baby on the
doorstep, but I don't know what to do. My parents are dead. I don't know what to
Boy: Please, please, I am only 12 years old. I cannot manage to keep this baby.
Please take care of him.
Boy: To the orphanage, I'm a boy of 12. My parents are dead. Please help me.
Boy: I have done this because my parents have died. I don't know what to do. I
don't go to school. The baby is HIV positive.
Girl: I'm Thomas Musonda. I am only 12. Both my parents have died. I tried to
live with my relatives but they won't accept. The baby is HIV positive. I thought
of bringing him to you.
[The following phase of the drama was already pre-established. This phase is
also a reminder that the group has been working in flashback]
Brian: Thank you. So Thomas Musonda is going to go off to make his way in the
world. Baby Mark has been left behind, but we know he's going to grow up to be
14. We need to talk to one another to discuss what happens to Mark and to his
(Brian makes ten discussion groups.)
[The discussion groups become in fact groups of 'playwrights' who are filling in
the missing years between Thomas's painful decision to give up his younger
brother, and the present time of the drama when Mark is now fourteen years of
Brian: In your groups, I want you to talk about what happens between then and
now. What happened during those years? I will ask one member of each group to
tell us afterwards what you decided. You are going to fill in some of the blanks in
[Very animated discussions in both Nyanja and English follow. They appear very
engaged and involved in their discussions of what happens after Mark is left at the
Brian: Your ideas will help us to continue the drama this afternoon.
(Brian invites each group to report to the whole class. He records in summary
their suggestions on the blackboard as below.)
Mark grows up in the orphanage. Thomas does not know what has happened. He
does not even know that he has any relatives.
[There is no knowledge of Thomas.]
Thomas sees that his brother grows up alright.
[Thomas looks on from a distance.]
Mark grows up in the orphanage. He has many questions. Thomas and Mark will
[The possibility of a re-union is articulated.]