Towards a curriculum innovation: HIV prevention at the Insitute of Distance Education, University of Swaziland

Towards a curriculum innovation: HIV prevention at the Insitute of Distance Education, University of Swaziland

Nokuthula Vilakati, Institute of Distance Education, University of Swaziland

Abstract
This paper proposes an innovation on HIV prevention, in response to the United Nations Millennium Development Goal to combat HIV/AIDS. The curriculum innovation is through a participatory action research design of life skills based education course, involving both health faculty tutors and first year distance education students at the University of Swaziland. The innovation builds onto the strengths of previous HIV prevention interventions and argues that effective life skills based education targets the individual, peers and the wider community, since the same levels are crucial in HIV transmission. The innovation also recommends a rethinking of the content used to teach and learn life skills based education to prevent HIV and recommends that such content is to be co-constructed by the students and tutors through peers and wider community involvement. The content is to be delivered in a participatory way in order for the students to engage in critical action to prevent HIV. Because of the novelty of such an intervention, the innovation recognises that such an approach to the design and implementation of the curriculum initiative is complex and involves careful planning, monitoring and evaluation to yield desired outcomes. In conclusion, the innovation recommends that HIV prevention can be possible even in a country such as Swaziland, with the highest HIV prevalence in the world.

The role of education in Swaziland's development is critical, particularly because Swaziland has few natural resources, hence the reliance on highly skilled human resources in all spheres of development. However the negative impact of HIV and AIDS on education is manifested in declining investment on good quality educational inputs in Swaziland, which in turn cripples Swaziland's development. It appears that the generation that outlives the epidemic will emerge with an inferior skill-base to draw from for Swaziland's development yet education is important at all levels of Swaziland's development, (NERCHA, 2006). Primary and secondary education plays a key role in passing on basic skills such as literacy which are critical for human growth and socio-economic development.

Thereafter, tertiary education is important because it furthers knowledge and allows for the specialization of skills in individuals who then go on to play a central role in society such as doctors, nurses, and teachers. The higher education system, however, is dependent on an effective primary and secondary education system, as its students are drawn from the latter. In the context of HIV/AIDS, education is also particularly important because it can render the transmission of HIV less likely by instilling important life-skills and attitudes that can lower the risk of HIV infection.

The paper is divided into four main sections. It begins with the contextual background to the innovation, starting with a brief discussion of the international context of life skills based education to prevent HIV. The national context of Swaziland is next discussed, to figure out the factors which drive the HIV/AIDS problem. The rationale for the innovation is then drawn from key issues identified from the context, which are used to justify the innovation. The next section reviews literature on life skills based education to investigate relevant key issues on such education. The key issues identified in the literature are synthesised to form a course design framework for the life skills based education curriculum innovation.

HIV/AIDS is a global concern which has a great impact on education. The international development and education agenda has identified HIV/AIDS as a major global constraint on the provision of good quality education, (UNESCO, EFA 2004). The Millennium Development Goal 6 is to combat HIV/AIDS, malaria and other diseases. The targeted date is that by 2015 the spread of HIV/AIDS is to be reversed. Life skills education has since been recommended to prevent the spread of HIV/AIDS. For example, the prioritisation of life skills is stated in article 53 of the United Nations General Assembly Special Sessions on HIV/AIDS (UNGASS) which declares that between 2005 and 2010 90% to 95% of the youth aged 15 to 24, have to develop life skills to prevent HIV infection. It is evident that many countries have missed the 2005 target. `It also remains questionable, whether this particular goal was ever achievable,' (Boler and Aggleton, 2005). Even though the UNGASS target may not be achievable, some interventions have to be made to reduce HIV infections; otherwise the provision of education will be undermined. It is therefore within this international education context that an innovation on the design of a life skills based education course is proposed to help the students prevent HIV.

The national context for the innovation is Swaziland, a Southern African country which covers a surface area of about 17,000 square kilometres. Swaziland has been extremely affected by the HIV/AIDS pandemic. Swaziland seems to have unique socio-cultural factors identified to be behind the spread of HIV. In Swaziland there is still relatively strong adherence to cultural beliefs and practices. This is reflected in the system of governance, which places the King and Queen mother as the supreme rulers of the country. The main social drivers for HIV in Swaziland are culture and the low status of women, for example the Swazi society practises polygamy and the royal family is the proponent of such a way of life. Whiteside, et. al, (2003) are quick to argue that polygamy in itself is not a risk factor, however if one partner is unfaithful in a polygamous family, the HIV infection spreads to far more people. Similarly, other Swazi cultural norms have been found to contribute to HIV transmission, such as the forced marriage of young girls and the customary practice of a widow being inherited by the younger brother of the dead husband, (Beckman and Rai, 2005). Such cultural practices can fuel the spread of HIV alongside other factors.

In addition, some Swazi cultural expectations and gender relations have been found to contribute to HIV transmission, particularly those that increase women's vulnerability, (ibid). For example, culturally women cannot negotiate safer sex and this increases both men and women's risk of contracting HIV. Yet some men practise the culturally accepted bunganwa, which is to have multiple concurrent sexual partners, while some women have secret affairs with men. In contrast, Macheke and Campbell (1998) attribute HIV prevalence to the deterioration of traditional sexual norms and behaviour patterns. Therefore, even though the deterioration of cultural norms can also be used to explain the spread of HIV in Swaziland, this makes the role of culture in explaining the spread of HIV in Swaziland very complex. However, this innovation recognises that some of these cultural practices affect some groups of Swazis more than others. For example, it is uncommon for a university student to be forced into a marriage or be inherited by a husband's younger brother, yet they are equally infected by HIV/AIDS.

Economic factors too, such as poverty have also contributed to the spread of HIV in Swaziland. For example, women tend to be more affected by poverty, which makes them more vulnerable to transactional sex which exposes both men and women to HIV infection. According to the Swaziland National Skills Survey (2003), there is a gender imbalance in skilled public and private sector employment in favour of men. For example in the private sector there are 61.4 % males compared to 38.6% females, while in the unskilled informal sector, there are 56.4% females to 43.6 % males. In addition, a high unemployment rate at 40%, falling incomes and drought have made many Swazis, particularly women, poor and vulnerable to HIV infection, (NERCHA, 2006).

There are massive implications of both socio-cultural and economic factors on gender and HIV/AIDS. Like in other African countries, Swaziland HIV infection is higher among women and varies by age. According to Casey and Thorn (1999), 28% females in Swaziland, in the 15 to 24 age group were infected by HIV against 11% males in the same age category. Then women aged 25 to 29 are the worst affected by HIV, at 56.3%, followed by women who are 20 to 24 years old at 46.3%, (Swaziland Ministry of Health, 2005). Poverty and the disempowered position of women in Swaziland have been identified as the main factors behind the spread of HIV among women, (Beckman and Rai, 2005; Whiteside, et.al. 2003; Casey and Thorn, 1999). It appears that there is a strong link between gender relations and HIV/AIDS in Swaziland. It is also evident that young women seem to have older sexual partners, and this needs to be addressed by the life skills based education.

Two main issues emerge out of the analysis of the Swaziland context. It appears that more women are infected by HIV. The implication for a life skills based education intervention to prevent HIV is that it has to be gender aware and to be positioned within Swaziland's gender context so that the intervention is more socially relevant and can be more effective. In an attempt to analyse the cause of the gendered HIV/AIDS problem, culture seems to emerge as the main underlying factor. It appears that there may be a need to investigate how some Swazi gender norms, values and beliefs interact to contribute to the spread of HIV/AIDS as this context indicates that something unique about Swaziland is behind the spread of HIV/AIDS. The challenge is to establish the cultural and other socio-economic factors which reinforce negative values, attitudes and beliefs that inhibit life skills based education to prevent HIV. Therefore, in this innovation, culture is used in a broad sense to incorporate both traditional and modern aspects of the Swazi culture.

Change and innovation are of particular importance in relation to an epidemic such as HIV because epidemics are, by definition, extraordinary events. They arise because existing understandings of health and illness, and existing public health systems and institutions, are inappropriate for addressing the particular form the epidemic takes, and for stemming the particular mechanisms by which it spreads.

Campbell above aptly points out that dealing with the HIV epidemic presupposes a change in strategies. Such change builds onto previous interventions and approaches to deal with HIV/AIDS. This innovation aims to provide a change in existing understandings on life skills education for HIV prevention.

The innovation will target the most vulnerable group among women infected by HIV, female students in the age range from about 18 to 24, alongside male students then move beyond to target their peers and the wider communities. The innovation takes advantage of the Swaziland population in higher education as a target group and will contribute a new conceptualization in the manner through which life skills based curriculum intervention is designed. The main focus of this innovation is to provide a platform for all stakeholders to analyse the conditions which influence the spread of HIV among IDE students in Swaziland, based on the active involvement of that specific target group to identify the level and the gaps of knowledge on HIV/AIDS and the types of behaviour of such a group. Thereafter a relevant life skills based education course to prevent HIV will be designed collaboratively. Further, the innovation will fill in a gap in integrating HIV/AIDS education into the curriculum at higher education level in Swaziland, especially in distance education at UNISWA, where no life skills curriculum initiative has been attempted so far.

There is also compelling evidence that HIV infection affects all women in Swaziland, including those with post secondary school education and those with lower and no education. Contrary to expectations, women with educational attainment beyond secondary school had higher HIV prevalence than women with just a secondary school education, (NERCHA, 2006). To further compound the HIV situation at university level is that the university in Africa is a high risk institution for the transmission of HIV. Common behaviour patterns are sugar daddy practices, sexual experimentation, prostitution on campus, unprotected casual sex, gender violence, multiple partners and similar high risk behaviours, (Katjavivi and Otaala, 2003; Chetty, 2000; Chetty, 2003). However such analysis does not accommodate distance education students, who are different from conventional university students.The need for life skills based education which targets distance education university students and probes high risk behaviour pertaining them therefore cannot be over-emphasised.

The Swaziland HIV/AIDS context is mainly presented through quantitative ante natal care data, which does not give a complete picture. Such quantitative data cannot by itself be used to accurately generalise HIV infections to the whole population. Most young ante natal care clients of the 15-24 year old range mostly represent sexually active women who fell pregnant. The prevalence rate does not represent women of the same category who use contraceptives or

those who are infertile. There is therefore a need for more qualitative studies targeting the most vulnerable groups in Swaziland to validate such quantitative data. This innovation design process is through action research, which will yield both quantitative and qualitative data which can fill in a gap in the analysis of the HIV/AIDS situation in a specific sample of people in Swaziland. There is therefore need for hard data on IDE students to be incorporated into the design of the life skills course, yet presently the data is not available.

Further, in building upon previous interventions towards HIV/AIDS education, this innovation lays emphasis on students' participation in the design of a life skills based education course, alongside tutors and many other stakeholders, (Global Youth Partners, 2005). It is more likely that all the participants particularly the students will be a useful resource who will share their skills with peers and their communities. Therefore, the innovation acknowledges the influence of peers and the wider community on the students as well as the influence of the students on their peers and their communities to prevent the spread of HIV. Campbell, (2003) notes that community mobilization for HIV prevention does not only limit HIV transmission but also addresses how communities negotiate their response to the epidemic. This view therefore guides the innovation presented in this project, and specifically extends the strengths of HIV prevention intervention achieved through peer education. The issues emerging from this rationale converge into key features of the innovative course design framework discussed in the next section.

The spread of HIV/AIDS calls us all to become learners of new strategies to deal with the HIV/AIDS pandemic because it is apparent that previous education and other interventions to prevent HIV have not been very effective.

`HIV/AIDS is forcing a critical re-examination of what education is all about and how it can best be delivered. It has shaken the world to rethink existing content, technology and delivery paradigms and very decisively calls for a new look at education and a new understanding' (Kelly, 2001, p.102).

This innovation proposes an opportunity to learn through a participatory action research design of life skills based education course to prevent HIV and emphasises the positive aspect of HIV and AIDS education. The specific innovation objectives which arise from the aim, target population and management of the innovation are to:

The innovation targets first year distance education students at the IDE. The action research will be facilitated by part time IDE tutors drawn from the Faculties of Health, Education, Sociology and others, in order to make it possible to simultaneously intervene in preventing HIV among distance education students while also carrying out research into the complex HIV/AIDS problem among students.

A new understanding of life skills based education for HIV prevention has emerged and it is based on the characteristics discussed in this section. The innovation does not predetermine the life skills students need but these will be jointly negotiated with active student participation alongside peers and communities. The teaching of life skills no longer targets only individuals. Structuralists argue that it is not always the case that individuals act upon the skills they have learned because of reasons some of which may be beyond an individual's control, (Boler and Aggleton, 2005; Campbell, 2003). The structuralists' viewpoint is that human action is influenced more by underlying economic, social and cultural structures, (Boler and Aggleton, 2005). Campbell, (2003), Ahlberg, et.al, (2001), Wheelan (1999) cited in Baylies, et.al. (2000) similarly argue that people's desires and actions cannot be explained in isolation of the broader context that informs the choices people make. Such a perspective locates people's sexual behaviour within peers and communities social norms, which define meanings and regulate social interaction.

Through the collaborative life skills based education approach, sexist attitudes and assumptions can be challenged in order to influence Swazi people's beliefs to prevent HIV. Kabeer (1996) cited in Leach (2003) identifies four key institutions which are the state, market, community and family, through which gender inequalities are reproduced. Such gender inequalities are expressed through societal norms, values, traditions and customs, (ibid). However, the literature acknowledges that the discourse of gender and HIV vulnerability is complex mainly because females, like men, are not a homogenous group. Previous interventions tended to treat women as a homogenous group, a view which is challenged by the literature, (Berger, 2005; Aggleton, et. al. 2004; Boler and Aggleton, 2005; Moser, 1989). Leach also (2003) acknowledges that not all female students are passive victims of `sugar daddies' but those who do so choose such relationships to enhance their status within the peer group.

At the same time, the literature identifies similar behaviour patterns in HIV infection among women irrespective of whether or not they are educated. Hence, Baylies, et.al. (2000:17) are cautious about initiatives aimed at `increasing the levels of knowledge and awareness, improving negotiation skills, enhancing assertion and heightening the self esteem of women. In response, this innovation also targets deep seated gender norms manifested in high risk sexual behaviour which makes even some empowered women vulnerable to HIV.

The literature is now sceptical of the discourse of gender and vulnerability to HIV, (Berger, 2005; Berer, 2003; Pettifor, et.al. 2004). Berger, (2005) argues that there are complexities regarding sexual practices which are ignored by the discourse that HIV/AIDS is a result of gendered power relations. He regards such typical gender analysis as reinforcing gender stereotypes and treats women as a homogenous vulnerable group. Berer, (2004:9) concurs with this line of argument that, `women are not always faithful to their sexual partners… and that men and women infect each other.' This perspective will influence the design of the life skills based education approach to prevent HIV that there is need to recognise such complex gender relations.

The literature also discusses an overall discursive shift from negative associations with sex because of the fear of HIV, to sex for pleasure, (Gosine, 2004; Pettifor, et.al 2004). Gosine, (2004) argues that `sex for most people, who engage in it willingly, is a pleasurable activity,' (p.12). This perspective differs from the discourse in life skills based education that characterises sex as a negative activity. Such a shift has implications for life skills based education to prevent HIV, particularly among university students whose age calls for honest, adult approaches to life skills based education to prevent HIV. It seems that a multi-faceted approach to gender and sexuality can make a life skills based education course effective in addressing the core issues then matching strategies in preventing HIV among the IDE students.

This innovation recommends an intervention to HIV/AIDS for a specific target group with special life skills needs. Student involvement is right from the design phase of the life skills based course. Such a participatory design model is more likely to lead to participatory delivery and continuous evaluation of the intervention guided by the action research data. In time, such a life skills based intervention will yield better results in HIV prevention and ensure that highly skilled Swazis live long enough to contribute to Swaziland' s development.

Gosine, A. (October, 2004) `Sex for pleasure, rights to participation and alternatives to AIDS: placing sexual minorities and/or dissidents in development,' Brighton: Institute of Development Studies, Working Paper 228

Ministry of Health and Social Welfare Survey Report, (March, 2005) 9^th Round of National HIV Serosurveillance in women attending antenatal care services at health facilities in Swaziland, Mbabane: Ministry of Health and Social Welfare

Pettifor, A.E., Rees, H.V., Steffenson, A., Hlongwa-Madikizela, L., MacPhail, C., Vermaak, K. & Kleinschmidt, I. (2004) HIV and AIDS among young South Africans: a national survey of 15-24 year old. Johannesburg: Reproductive Health Research Unit, University of Witwatersrand