Listening to The Voices of Women in KwaZulu-Natal

This 44-page Power Point presentation shares the experience of using community dialogues in Kwa Zulu Natal (KZN), South Africa to gather information to inform a women’s and child health advocacy, communication, and social mobilisation (ACSM) strategy and operational plan. The dialogues used participatory approaches to discuss issues such as low rates of contraceptive use amongst women and girls, high rates of HIV infection, late bookings for antenatal care by pregnant women, low levels of exclusive breast-feeding, and sexual and gender-based violence. The dialogues were developed by DramAidE and Johns Hopkins Health and Education in South Africa (JHHESA) at the request of the KZN Office of the Premier, the Department of Health, Department of Social Development, and the United Nations Population Fund, with support from the United states Agency for International Development (USAID).

The community dialogues were conducted to inform the strategy and operational plan to be used as part of a campaign to mobilise communities, and the structure was designed to encourage community participation and involvement. During a plenary session, forum theatre was used to demonstrate a scenario highlighting key issues for the audience to discuss and attempt to solve. This was followed by small group discussions, segregated by age and gender, which used body mapping, image theatre, community mapping, and storytelling to explore issues they felt important to highlight.

The discussions highlighted the following key issues:

Low rates of contraceptive usage
The dialogues pointed to the following key barriers to use: negative attitudes and the lack of confidentiality by health care workers, negative perceptions related to fidelity, and the effects of contraceptives on a woman's body. In addition, "in some instances the use of contraceptives by women may result in physical violence and an ending of the relationship by their sexual partners." There are also low levels of knowledge of emergency contraceptives and post-exposure prophylaxis (PEP) in communities, and in particular low levels of knowledge of contraceptives and family planning among men, who are often excluded from decision making processes around contraceptive usage.

Termination of Pregnancy
There were reports of self-induced terminations of pregnancies by pregnant teenagers. The lack of support from male partners, parents, and the community towards a pregnancy are key drivers of self-induced terminations. The lack of confidentiality experienced with health care workers is the main reason why young women revert to illegal abortions.

High Rates of HIV
Across all community dialogues, multiple sexual partners and older men, "Sugar Daddies", engaging in transactional sex with younger women for material goods were identified as being prevalent. Multiple sexual partners and casual and unprotected sex are also linked to alcohol and drug abuse consumption. Among all partners, "condom usage is symbolic of casual sexual relationships and the lack of trust or love. Where female partners insist on the use of condoms this is often rejected by their male partners who accuse them of cheating or that they do not love them." In the case of transactional relationships, the power relationships and economic dependency often results in the male partner dictating the terms and conditions (including condom use) of sex.

Access to condoms
According to dialogue participants access to condoms continues to be a problem as condoms are primarily being available through health facilities. Availability of female condoms is particularly low.

HIV Counselling and Testing (HCT)
There are low rates of HCT amongst men with men using the status of women to indicate their own status. There are widespread reports of men who abandon their partners when their HIV status is disclosed, and this fear of being abandoned prevents women from disclosing. Men are reluctant to undergo HCT because of lack of male friendly services, health care worker attitudes, concerns relating to privacy and confidentiality, and fear of knowing what their health problem may be. Men reported that they do not have adequate knowledge of men’s health services and prefer to be attended to by male health care providers. Participants recommended that couples counselling and testing be promoted.

Care and Support for Pregnant Women
Dialogue participants stated that men are sometimes reluctant to take responsibility when their partner becomes pregnant, a situation worsened by having multiple partners competing for time and support. There are still low levels of awareness amongst women of the need to visit antenatal clinic services early on in their pregnancies. Many consult first with traditional health care providers. Physical distances, staffing shortages in clinics, attitude of health care workers, opening and closing times, long queues and lengthy waiting times are barriers to women accessing health care services.

Post Natal Care and Support
It was found that there are "mixed levels of knowledge around the benefits of exclusive breastfeeding within communities for the prevention of HIV. In some instances women know that breastfeeding has protective benefits for babies born to mothers living with HIV. For other women there is no knowledge of the benefits which is reinforced through health care workers." In other cases, women living with HIV refrain from exclusive breast-feeding as this can be taken as an indicator of HIV status and result in discrimination. Exclusive breastfeeding is also a big challenge for working mothers, and young women in particular are concerned about the impact breastfeeding has on their bodies.

Violence Against Women
There are strong links between gender-based violence and the factors that place women at risk of HIV infection and unwanted pregnancies. "Men are still the primary decision makers as to when and how sex will take place, the use of condoms and contraceptives. Attempts to introduce contraceptive usage within the relationship may result in domestic violence." Some reports indicate that men are socialised to use violence as a corrective measure and a symbol of 'love'.