Mrs Brown (the chairperson) a single woman in her mid-forties, expressed her gratitude to the rest of the members for accessing first-hand information which would contribute to the survival of their grandchildren. She urged members to be attentive and bear in mind that the Ministry of
169 Health had shown devotion and creativity in implementing new programmes. Mrs Brown congratulated members for punctuality so that none of them would miss information. However, she ended her speech by indicating that her main worry was how males might get involved in the programme because they act as if they own Basotho culture and males were over-protective of it.
Therefore males might not like any recommendations that were introduced by females which compromised cultural beliefs and behaviours.
Mrs Grey: There is a saying that if one is not informed, one becomes reluctant to say yes or no to whatever myth that she comes across. One becomes ‘monna tonki’ like donkey man story and cannot make up her own mind or her own decision because one is never sure of the right or wrong. However, I suggest that we begin today’s programme on time since our educators are here, as you know they are always on time. Time keeping is one of the silent strengths that our educators are giving to us because they are never late for our meetings. So we also need to copy that punctuality aspect. Let’s go on with PMTCT right now to save our day. Lastly ladies I cannot hide my worry about the kind of males we have. They act as if culture is their baby, they are very over-protective of it, yet females too honour culture. It is just that as females we become flexible to let go some of our values to earn good health.
Letuka, Matashane and Morolong (1997) confirm these concerns in their studies where they indicated that African men believed they were the custodians of African culture and regarded women as inferior and believed that women should obey men and their decisions. Letuka et al.
(1997) argue that men preferred to be consulted for minor and major decisions in order to reinforce recognition of their status as heads of families. However, Letuka et al. (1997) point out that men did not involve women’s contribution in any of the decisions made in various aspects of life that sometimes included deciding the number of children a woman should bear without the concerned woman’s involvement. In the face of such cultural traditions this support group was taking the initiative to be sufficiently informed so they would be in a better position to argue their case in their families.
The chairperson reminded the group of the significance of sharing experiences relating to the topic.
Schlechty (1994) indicates that maximum participation in a learning environment is important to maximise absorption of information. Schlechty points out that adult learners need diverse
170 learning strategies to increase their engagement with the content. The chairperson agreed with the nurse that the new programme (MBP which was intended to strengthen PMTCT) would be more effective if they were all abreast with the current programme: Prevention of Mother To Child Transmission of HIV (PMTCT) and Mother Baby Pack (MBP). She emphasised its importance for them to learn the information and what tactics had been working for them to incorporate males in PMTCT and MBP so the nurse would add to what they had previously achieved as a result of being involved in the previous programmes.
Chairperson (Mrs Brown): Our topic is on PMTCT and MBP. We are starting with the importance of PMTCT as it was agreed previously when we were inviting the nurse. We are all aware that our schedule is tight because we need to share PMTCT information and find out whether the specialist will identify the gaps from our conversation and our reports. We might not take too long because these two topics are similar and fall under one umbrella. However, I am aware that during our previous meeting, the nurse already laid the ground for us to continue. Maybe it is also important to report to her that unlike all other topics for which we used to have hunters, with these two topics we have agreed that we call the professional to help us – unless there is one of us who has experiences which we can learn from. Who can be willing to share her stories? You know very well that your stories have made us who we are because they have been our books since this
‘school’ (support group) does not have books for us to read but we see ourselves being clever and wiser every day. Madam Nurse, you can continue to assist us with what you have prepared for the group.
Mrs Black, a widowed woman in her early forties, responded to the chairperson’s request of sharing their experiences for the rest of the group members to learn from them. She blamed herself for not sharing prevention messages, as a result her son never got tested and Mrs Black suspected he was the one who infected his wife during pregnancy and the new-born child also got infected because the mother thought she was HIV negative from the two results she got during pregnancy. Mrs Black responded to Mrs Brown’s worry about culture by telling the group that as females, they had a mandate to bear children and save lives; if culture had to be compromised in the process so be it.
Mrs Black: My experience has been one of its kind. My daughter in law was HIV negative for the first two phases when she got tested. It was during her first three months of pregnancy and when she was thirty-six weeks pregnant. I suspect she was not using protection because we found out when she had taken a baby for the six week check-up that she was infected. I also suspect that she mix fed her baby because she said she
171 introduced the baby to bottle feeding. That was where the child too got infected because the child’s first and second DNA test came out HIV positive. I was really hurt and abandoned them (daughter–in-law, my son and the child) for three months. Being the only male in my house, it was not easy to confront him [my son] with health issues as you all know Basotho males feel insulted if encouraged to attend health services, especially HIV testing. I was also reluctant to emphasise the significance of exclusive bottle feeding when the mother could not produce enough milk for the baby because my son would accuse me of weaning the child early so the mother could have love affairs. I was hurt and blamed my son for infecting two people (his wife and the child). However, I learned later that I too was to blame because I never warned them from the first time I learned about PMTCT. I kept the information to myself for fear of compromising culture.
Thank you for being attentive fellow members.
Buckley (2013) argues that in these situations a woman is made to feel like an outsider in her own family. Culturally, men enjoy occupying the high-ranking position of the family, a position which had to be occupied by the sons during temporary or permanent absence of the father.
Buckley points out that the male cultural practice signifies the protection of patriarchal lineage.
The nurse did not wait for the chairperson to invite her to comment, she seemed to be touched by Mrs Black’s story. However, she started her address with a positive note. The nurse wanted the support group to realise the significance of their meetings and encouraged them to document their lessons for the future generation. This was an indication that the nurse appreciated the good work and a huge contribution these members were making for Basotho education. To the issue of compromising culture and confronting males about new health practices, which directs parents (mostly women) to bypass cultural practices, the nurse explained the importance of following the policy and the guidelines in situations such as this.
Nurse: I am very grateful to be called to your meeting because I have learned that your meetings are beneficial and I hope that you could be documenting what you are doing as I could see that these meetings will one day be educative to your children and many other generations to come when you are no longer alive. On the issue of compromising cultural practices, I want to make the group aware that you are protected by the National PMTCT Policy and the National PMTCT Guideline which acts like a law that protects everyone who compromises culture to protect life.
The nurse’s observations are supported by Jackson (2002) who indicates that many times, health innovations emanating from scientific research, get executed under strong observation of policy
172 but the guidelines cause tensions between cultural dimensions and policy. Jackson further suggests that foreign motives for putting pressure on locals to attach laws to policy often results in imposing the implementation of foreign ideas without the consent of locals. Hussain (2011), too, argues that the pressure enforced on service implementers to bridge the gap between domestic and international practices through the use of policy and strict laws or guidelines usually causes conflict between programme implementers and clients. Hussain further indicates that normally the conflict is due to the slow pace of accepting change at the grassroots, regardless of its significance to the community. In this respect, the nurse was faced with the same dilemma:
that the PMTCT programme ignored the fact that the programme compromised community cultural values. While programme innovators feel protected by the guidelines, they take little cognisance of the need to engage with cultural differences.
The government of Lesotho (GOL) (2006) indicates that it is acceptable for a small nation like Basotho to compromise their culture to protect life. GOL further indicates that the significant role of the process of formulating national guidelines and policy was to invite the community leaders in their different cadres, to encourage them to acknowledge the need for compromising culture to save life. In this aspect, community leaders play a mentoring role in their communities because people look up to them. Their involvement in policy and guidelines formulation reduces tensions between policy and culture. The nurse continued.
Nurse: I hope you all understand what these abbreviations mean in Sesotho. MBP in full is (she held up a paper already written ‘Mother Baby Pack’ and explained it briefly in Sesotho, (ke mekotlana kapa mabokose a tsetseng lipilisi tsa mme le ngoana ho sa tsotellehe boemo ba bona ba HIV). It is a bag or box holding pills for mother and the baby regardless of their HIV status. It is just a component of Prevention of Mother to Child Transmission intervention. (Then she explained PMTCT in Sesotho.) You have all heard that PMTCT is an umbrella initiative under which we get MBP and many other programmes that could assist in the reduction of new infections mostly in our new generations. Lesotho has piloted MBP and shown it to be working very well. Many African countries have come to copy our successes and challenges so they could go to their respective countries to start. Therefore, PMTCT and MBP are inseparable.
Previously you invited me to explain exclusive breast feeding, the strategy that ensures the safety of new born from infection, mostly babies, from HIV infected mothers. I am trying to say we can prevent HIV from being transmitted to a child by employing several strategies like exclusive breast feeding and exclusive infant formula feeding and never give our children breast milk if we have started giving other fluids such as nepe (a type of
173 porridge) which I know is a custom for many people in Botha-Bothe. They start their first food taste with nepe before they could taste their parent’s breast milk. (Looking around) do you understand what PMTCT is?
It has already been indicated that this group usually was less inclined to follow the meeting protocols that were exhibited by the fathers-to-fathers support group. Lady Bird (as she was nicknamed) a married woman of her late thirties, was less inclined to follow the meeting protocols that were exhibited by the fathers to fathers support group. She just shouted to the nurse and asked if she could touch MBP to see the contents in each box. Lady Bird then showed her concern that she was doubtful about the strengths of pills. Her concern was that if the pills were powerful, children would still be given nepe to avoid deformed babies (the myth was that this was what happened if the baby was not given this type of porridge).
Lady Bird: I just needed to see the MBP contents even though it might be difficult for me to pronounce all these pills one finds in each pack. At least I am in a position to know which pack holds medication for HIV positive mother and which one holds the ones for HIV negative individual. On the issue of convincing males to deny newborns this special porridge (nepe) I still believe there is a need for this to be announced in a wider manner over different media before we explain to our close family members. Most programmes are publicised by the government to a wider community before we could be bound to sell that initiative.
While Lady Bird was talking, the nurse and most members were nodding to indicate their support for what Lady Bird was saying. This interjection was an indication of how important it was for community members to have a tangible understanding of medical discourses especially when the information seemed foreign or complex. It was evident that verbal or written communication alone was not enough. It must also be accompanied by visual and practical interaction with the artefacts involved to enhance learning. This practice was confirmed by Kitchenham (2008) who states that adult learners must have a practical element for knowledge reinforcement.
However, the nurse had not yet finished her lesson. She mentioned the importance of the
‘accompaniment’ model which was a component in the programme that would assist in involving males and reduce their anxiety over PMTCT programme.
174 Nurse: PMTCT encourages males to accompany their wives to the clinic. This intervention was intended to involve males in health services so that males would get professional reassurance that would maintain their manhood. Maybe it is also worth mentioning that those males who take the responsibility and bring their children to MCH for health services will be served before anybody else. Ladies, advise your daughters-in- law to adhere to the feeding option she has chosen because it is so expensive and hurting to raise an HIV infected child. It is true they could grow up like a normal child, but they erode the finances in their families while trying to help them cope with opportunistic infections and preventing minor and major illnesses. With PMTCT intervention, every expectant mother gets tested for HIV as a routine test like they do with other blood tests and urine tests to find out other illnesses they have which could be infectious to the unborn baby. An example here could be that of another type of STI which can be dangerous to the unborn baby. When an expectant mother is found to be HIV negative, we try to find out how many months the pregnancy is, so her duration could determine the frequencies she could test before giving birth. If she is found to be HIV infected, then she is given ARVs which she has to take in order to protect the unborn baby as those ARVs will reduce the viral load and thereby reduce chances of infecting that expected child. However, we are just waiting for the new ARVs guidelines to be printed and arrive at our facility which have revised the advice on taking ARVs during pregnancy depending on CD4 cell count. With the new guidelines, if the expectant mother is found to be HIV infected, we are not going to mind the CD4 cell count any more. The expectant mother will be initiated on ARVs and will not stop them after delivery like it happens now when we mind her CD4 cell count. This means that the woman will be served at Mother and Child Health (MCH) corner, until her child is two years old. Then she will be given a transfer to be given her monthly services at Paballong ART centre for further management and monthly check-ups. However, I want to accept the fact that being resistant to change is normal according to researchers. Therefore, it is already expected that both males and females might delay to internalise this wonderful programme and adapt when their children are already HIV infected. I would at this juncture like to put a big full stop on PMTCT but wait for some questions or comments that could help clarify more.
These comments show that the programme itself was endeavouring to recognise the challenge of male cultural attitudes by seeking ways to engage men in the programme as a strategy for ensuring the programme’s success. The Chairperson (Mrs Brown) wanted the group to participate fully on the chosen topics because they were all aware that PMTCT and MBP needed males to change their behaviour and females needed to make decisions for their children based on the parent’s HIV status. Females needed male’s approval for minor and major decisions they had to make yet males were not informed on health related issues because they did not attend health lessons as they thought they were childish and feminine. Berman and Bourne (2015) and Couto et al. (2010) share the same view that males find health services untrustworthy and childish due to
175 the phrase ‘be a man’ which is normally used to mock males seeking to be relieved from suffering. The phrase customarily translates as ‘don’t complain because you are a man’.
Therefore, being sick, regardless of frequency and severity of a man’s suffering was being childish. Couto et al. further indicate that in most cultures, health services are mythically feminine, childish and occupy a lower status. The comments in this support group showed that males needed to keep their high status, therefore females in this particular group had to put their heads together in order to compile facts that would convince males to actively participate in PMTCT prior to introducing the programmes in their different families.
Chairperson: Actually, we had intended to tackle the importance of PMTCT and MBP together with men as heads of families because they are inseparable. I am happy that the nurse has allayed member’s fears and given advice about the cultural implications of the programme. To my knowledge, good members, it is not every family that practices the use of nepe porridge to the new-born. … Do you have questions, ladies, before our nurse leaves us?
Mrs Blue, a woman in her late forties, was a woman separated for more than ten years. Her husband stayed in the same village as hers but was taking care of another family. Although the Nurse had already indicated that she was through, Mrs Blue had a concern which needed to be clarified. She needed to know what happened to the expectant woman who declined all the services. Mrs Blue suggested that the accompaniment model should also target expectant mothers.
Mrs Blue: Madam Nurse, I am wondering if these expectant mothers are expected to agree or refuse to be tested even those that are HIV positive, are they being asked if they can take ARVs or not? I want to believe that if they are denied a chance to consent to such services, it appears as if the programme punishes them for being pregnant. Are those who refused to comply with the programme demands not being denied services as well?
We were previously taught that every individual has to give consent for such services except for rape suspects who are mandatorily being given such services (HTC). On the issue of bringing males on board for approval of compromising cultural practices as a means to enhance zero new infections mostly to children, my suggestion would be to promote the accompaniment model, which targets expectant mothers and their lovers to visit the clinic at least twice before a child is born, this practice can work best. This practice can enable people to familiarise themselves with health practices that can save children’s lives while at the same time help them understand the significance of such programmes.