2006/ED/EFA/MRT/PI/64

Background paper* prepared for the Education for All Global Monitoring Report 2006

Literacy for Life

Addressing gender relations in HIV prevention through literacy

Carolyn Medel-Anonuevo
2005

This paper was commissioned by the Education for All Global Monitoring Report as background information to assist in drafting the 2006 report. It has not been edited by the team. The views and opinions expressed in this paper are those of the author(s) and should not be attributed to the EFA Global Monitoring Report or to UNESCO. The papers can be cited with the following reference: Paper commissioned for the EFA Global Monitoring Report 2006, Literacy for Life. For further information, please contact efareport@unesco.org * Commissioned through the UNESCO Institute for Education (UIE)

Addressing Gender Relations in HIV Prevention through Literacy Carolyn Medel-Anonuevo

Recognizing that poverty, underdevelopment and illiteracy are among the principal contributing reasons to the spread of HIV/AIDS ( Para 11, United Nations General Assembly (UNGASS) Declaration of Commitment on HIV/AIDS 2001) The discourse on the relationship between literacy and HIV is dominated by the belief that illiteracy is one of the causes of HIV/AIDS. In this hypothesis, it is argued that together with poverty, peoples inability to read and write, makes them vulnerable to getting the virus.It is assumed that since these people are not able to read and write, they have no access to information regarding HIV transmission and therefore renders them at risk. Furthermore, the gender disparity in literacy rates means that women illiterates belong to the high risk groups. Comparing the literacy rate of the ten countries with double digit HIV prevalence rates (Table 1)seems to disprove this hypothesis as seven of these countries have estimated literacy rates of at least 79%. In contrast, if one looks at the countries with the lowest literacy rates and compares them with their HIV prevalence rate (Table 2) , it could be concluded that lower literacy rates is translated to lower HIV prevalence rates. Moreover, if one adds the Gender Parity Literacy Index, it could even be argued that equal access to literacy means a higher probability of getting the HIV/AIDS. This data set is not enough to debunk the hypothesis that illiteracy is a key factor in the the spread of HIV/AIDS as another set has been cited to show that in 72 capital cities, higher infection rates were higher when the literacy gap between the women and men were larger (Global Campaign for Education, 2004). Indeed the relationship between literacy and HIV/AIDS is more complex. For example, Vandemoortele and Delamonica (2000) explain that the stage of the pandemic, is an important controlling variable for the relationship between literacy and HIV/AIDS. In the early stages of the pandemic, there was a direct and positive relationship between the level of education and prevalence rate while more recent studies are not able to establish a relationship and a few show negative correlation.As sexual intercourse is the main propagation channel of the virus, they argue that in the beginning of the pandemic, those affected were those who had more opportunities and this would include the better-off, the more mobile and educated. After this initial stage, the disease follows the pattern of the inverse relationship between education. At this stage, what is crucial is access to information and knowledge on the transmission of the virus. Whereas educated people were quicker to change their behavior once information on risk behavior has been transmitted, it has been argued that among the less educated, including the illiterates, behavioral change is less likely to happen. Vandemoortele and Delamonica (2000) point out that in the Demographic and Health Surveys conducted in the early nineties, almost half of the illiterate women included in

the survey were ignorant on basic facts regarding HIV/AIDS. Moreover, it has been also been argued that lack of education, especially among girls and women could also help facilitate the spread of the virus due to reduced levels of health and nutrition among them (Global Campaign for Education, 2004) Yet inspite of the growing evidence that literacy is an important factor in preventing HIV/AIDS after the initial stage of the epidemic, most of the preventive education efforts are still focused on schools and mass media. While literacy within schools and among the youth is an important area for HIV prevention, the issue of what happens to out-of-school youth and among illiterate adults remains largely unexplored. A. National HIV/AIDS National Plans and Literacy Initiatives Among the countries who have submitted monitoring reports on the progress on UNGASS Commitments, only Lesotho, Cambodia and Macedonia, specify the implications for lower literacy rates on HIV prevention. Most of the reporting countries have cited their literacy rates but have remained at the information level without drawing conclusions on what it means for HIV prevention. In contrast, the Lesotho National Plan raises the question of how to reach the illiterates considering that most of the HIV prevention materials are written. It also draws attention to the work of the Ministry of Justice who provides information on HIV/AIDS to prisoners (who are mostly illiterate) through training that takes place in the form of interpersonal communication. In Cambodia, the government is trying to ensure that HIV/AIDS awareness and training is appropriate to the varying levels of literacy of the population. Projects implemented by the Ministry of Education, Youth and Sports focus on training of trainers including sports instructors and literacy teachers. Meanwhile in Macedonia, it was pointed out that tailored information on HIV/AIDS should be developed for the Romas as well as other mobile populations, who had limited literacy. Meantime for Ghana and Cape Verde, they mention literacy as an important component of their strategy in addressing HIV/AIDS. In the Ghana HIV/AIDS strategic framework (2001-2005) among the priority strategies in addressing HIV/AIDS is intensifying poverty reduction programmes where promoting functional literacy programs for women and other vulnerable groups is a key action point. For Cape Verde, it describes the development of a national strategy for communication that takes into account the combination of mass and interpersonal communication which considers the different target groups- the illiterates being one of them. That only a handful of countries mention literacy even as the UNGASS Declaration is explicit about the role of literacy vis--vis HIV/AIDS is not surprising. For even as the Declaration acknowledges the critical role of education and information and that the preamble stipulates that all countries must continue to emphasize widespread and effective prevention, including awareness raising though education, nutrition, information and health care services, there are no action points related to literacy. The Declaration lacks emphasis on the need for governments to develop and implement sexuality education and information programs through literacy programmes. So even as the Declaration mandates the provision of information, it fails to specify through which channels. By doing so, most countries consider schools and mass media as the major

modes of information transmission even if thousands of their vulnerable population remains unreachable through these. Moreover, the potential of gender sensitive literacy programmes remains untapped. Very few United Nations agencies have problematized literacy levels vis--vis HIV prevention. In a field study on the UN peace keeping mission in Sierra Leone, it was pointed out that since the rank and file soldiers are mostly young with varying levels of literacy, materials have to be developed according to their varying levels of literacy (Bazergan,2002). One of the areas of intervention of the International Fund for Agricultural Development (IFAD) is poverty alleviation and livelihood security programmes adapted to the conditions created by HIV/AIDS which includes functional adult literacy programmes (UNAIDS, 2003a) . In Asia, UNESCO together with some partners has launched a radio program that is primarily aimed at girls and women with low levels of literacy.

Radio Programming: An Effective Tool in Preventive Education In the Asian Mekong Region, a host of complex and interrelated factors affecting the living conditions of different ethnic groups, make them particularly vulnerable to HIV/AIDS. Poverty, lack of access to education, lack of culturally appropriate information in their own languages, cultural and social breakdown within some communities , forced relocation, non-traditional drug use and involvement in the sex trade, all contribute as risk factors . Many of these groups do not use the national language and speak a vast number of distinct languages, usually unwritten, and therefore are not literate in transliteration scripts. It is in this context that UNESCO, the Asian Development Bank (ADB) and Southeast Asia Ministers of Education Organization (SEAMEO) launched a radio drama series project for HIV/AIDS, trafficking and drug prevention education in three countries, China, Lao PDR and Thailand. In preparation for this project, UNESCO conducted research to identify the most effective and low-cost tool of information for ethnic minority people .The radio came out to be the most cost effective way of reaching a wide range of ethnic audiences, within the broadcasting country , as well as cross border, and using their own languages. The main objective of the project is to use drama and music to equip girls and young women, the most vulnerable to sex trafficking and HIV/AIDS with information on HIV prevention, in their local languages. Focused group discussions were conducted to establish themes as well as story lines for the soap operas.Using real life experiences, the script is written by native writers rather than simply translated, which ensures that the programs are culturally and linguistically appropriate to the audience.. Building capacity of the native speakers of the language is an important feature of the project as it has tapped the members of the ethnic groups themselves to be the multimedia producers, scriptwriters, musicians, actresses and actors and technicians Moreover

it is also expected that the project will strengthen community based groups in the villages as they provide complementary and follow-up peer education support to the radio programs.Finally, follow-up audience research is carried out to improve the succeeding radio programs. (From HIV/AIDS in the GMS:Bulletin for Preventive Education in the Greater Mekong Region, Issue 1, 2004, UNESCO and ADB) Among NGOs, using literacy and language levels of the population as a starting point for HIV prevention work is gaining ground. The Summer Institute of Linguistics in Botswana, for example, prepared attractive posters and booklets on HIV prevention in the San language (SIL, 2005). PLAN and the local Ministry of Health in Burkina Fasso decided to train village communicators who were trained in appropriate information, education and communication techniques depending on the levels of literacy in the community (UNAIDS, 1998). B. Efforts to connect HIV/AIDS Prevention and Literacy For many, given the overwhelming presence of the HIV pandemic, the interaction between literacy stakeholders (government and NGOs) and activists in the HIV/AIDS field in their communities have given birth to programs that are acknowledging the relationship of literacy and HIV prevention, and as such, needs to be taken into consideration in their respective programs. Through the years, three types of programs have evolved: 1) existing literacy programs which have incorporated HIV/AIDS messages; 2) HIV prevention programs which have incorporated literacy components; and 3) comprehensive programs that include more than just literacy HIV prevention components and are targeted to empower special groups. The most common type of programs are literacy programs which had to adjust their content and methodology to incorporate messages on HIV/AIDS transmission as well to develop approaches that take into account the sensitivity of the messages. As literacy stakeholders found themselves in communities being decimated by the virus, a key response was to change their content and methods so as to respond to such a crisis. It is clear that literacy initiatives could help in providing an enabling environment where discussion on the transmission of the virus as well as issues on stigmatization, testing and care could also be discussed. In Namibia, the Okatumbatumba Hawkers Association established in 1989 was primarily aimed at supporting street sellers in their work. For this, literacy and English courses were organized side by side with training for effective negotiation with business establishments. In 1994, 16 women hawkers were trained on HIV prevention work as the members had raised concerns about the pandemic. The aim of the program was to increase HIV/AIDS awareness among the community of Windhoek and neighboring regions. An interactive, visual story-telling technique was the primary learning tool used, which enabled people with varying levels of literacy to participate in the programme (UNAIDS, 2000c).

The Afoulki Association for Women in Morocco have set up a literacy program for women and children, as well as a program against child labour. As they implemented their programs, the members of Afoulki realized that it was important to work with men as their sexual behavior poses risk. For World Education, their literacy training in Mali and Guinea for the parents' associations has included several lessons on HIV/AID (prevention, care, how it affects a school/community). While the main focus of literacy training is improving quality and equity in schools, since HIV/AIDS is becoming an issue on school functioning (teachers contracting the disease, children withdrawing from school to care for a sick family member) these topics were included in the lessons. There are 5 lessons on HIV/AID included in the literacy training. In addition, World Education initiated a health - literacy project that targeted out-of-school youth (called PDY) and where HIV/AIDS awareness was one of the health topics. Finally there is a girls' and women's literacy pilot that uses a revised curriculum from the PDY project and has several lessons on HIV/AIDS. The NGO, PACT in Nepal has launched a project which builds on a successful womens literacy and microcredit project and where 1,000 women are learning about the role of HIV/AIDS in overall reproductive health and how it could be transmitted through commercial sex, marriage and other means. How to negotiate safe sex with their partners is also included in their lessons. The Young Womens Catholic Association (YWCA) of Uganda has also incorporated HIV/AIDS messages in their traditional literacy and agriculture programs, ensuring that social and economic factors which contribute to the infection are also addressed. The Ministry of Womens and Veterans Affairs (MWVA)of Cambodia, together with the Minister of Health have initiated a pilot project in the Takeo province where 20 women participated in a training course on HIV/AIDS. Aside from the members of the MWVA AIDS working group, women working on credit and literacy programs were also involved to discuss and dialogue on how HIV/AIDS messages could be included in their respective programs. CARE started its literacy programme since 2001 in Koh Kong province. Koh Kong has the highest HIV/AIDS prevalence in Cambodia. The number of young people in Koh Kong who have no had opportunity to gain a basic education is increasing and young people aged between 15 to 25b make up a growing percentage of society in Koh Kong. The MOEYS literacy assessment also showed the positive correlation between literacy levels and knowledge of HIV/AIDS. CARE is targeting adolescents aged 15-25, with a special specific on girls, form marginalized groups, including the Khmer Cham minority and Commercial sex workers. The impact goal is increased application of literacy and life skills (HIV/AIDS focused) to community development by out-of-school marginalized adolescents. The project goals is to promote quality and relevant non-formal education and leadership opportunities

(literacy and life skills) for marginalized adolescents, especially girls, in partnership with the communities and the MOEYS. The literacy cycle consists of a six-moth literacy programme which is continued with different options of post literacy: health life skills and village life school (with possibility of vocational training such as sewing which depends on learners needs). The core of the project is to build capacity of youths and promote their decision making through the implementation of the literacy /life skills programme. The village support committees (youth committee and village education committee) are established with their clear role and responsibilities in order to support the programme. CARE has worked in partnership with the POE and the DOE. CARE teaching methodologies/ techniques are also being adapted in the MOEYS curriculum. (CARE,2002)

The South African NGO, Operation Upgrade has incorporated AIDS as a topic in its training for literacy tutors for several years. But as the teachers discovered that many of the approaches were ineffective in disseminating information on HIV transmission among poorer communities, Operation Upgrade decided to launch a new project specifically dedicated to HIV/AIDS. Aside from using literacy classes to raise awareness among students, Operation Upgrades Literacy against AIDS project also equips teachers with counseling skills and home care training (CDC News Updates, 2002). It is important to note that the activities of Operation Upgrade (South Africa) and YWCA initiatives in Uganda are part of the PROLITERACY Pan-African Literacy and AIDS Initiative, which also include initiatives in Ethiopia, Malawi, Tanzania and Zimbabwe. Their approach, according to its Vice President Dr. Lynn Curtis, bridges Africas polarizing chastity versus safe sex debate. It promotes open and life saving dialogue and education about a previously taboo subject. It advances literacy and AIDS education in areas where more than half the people lack formal schooling. It mobilizes three diverse sectors- community-based organizations, public schools and churches.It erases divisive stigmas about AIDS, and sets the stage for community action to deal with tough issues such as treatment of people who are infected, orphan care, and underlying issues that include gender discrimination, poverty....(Women in Literacy Fresh News, 2003) The above experiences indicate that the HIV pandemic which affects communities and societies had to be taken into consideration by the literacy stakeholders and therefore resulted in changes in contents and processes in literacy programmes. Meantime there is also the situation where there is first heightened awareness on the need to address HIV/AIDS and followed later by the realization that there is a wide range of literacy levels in the community and those with lower levels are the most vulnerable. In Papua New Guinea, an outreach program started by providing sex workers with STI services, basic information on HIV/AIDS , condom distribution and HIV testing and

counseling. Later a drop-in center was established to provide literacy and vocation training. These combined services resulted in increased demand for condoms as well as demands to address human rights violations (UNAIDS, 2002). AMSED, an NGO in Morocco, established an STD and HIV prevention programme in 1996 involving more than 30 community organizations. In the beginning, its programme was geared towards increasing awareness, providing access to condoms and linking STD prevention and treatment services among female sex workers and MSM. Building on these efforts, it has collaborated with the Moroccan government to incorporate HIV sexual health and gender awareness into the governments literacy programs (Global HIV Prevention Working Group, 2003). The Bandhu Social Welfare Society in Bangladesh, considered MSM (men having sex with men) as their central focus in their programs and services. An ethnographic study, together with a risk and needs assessment was the basis for the development and strengthening of informal and friendship networks. Included in its outreach programs were an interactive approach to promoting condoms, sharing of experiences, referrals to appropriate STD treatment and networking with womens groups. To further enhance acceptability of its members, it offered opportunities to explore other interests such as dance, learning English and other vernacular literacy skills (UNAIDS, 2000c). While many of these two types of programs evolve and eventually incorporate more than just HIV/AIDS messages and literacy skills, there are already existing programs which start with the framework of empowerment and therefore are comprehensive in their approach to literacy. This means that literacy is only one of the many skills needed and that the HIV/AIDS messages are one of the many interrelated themes women and men have to contend with in our world today.

The Sonagachi Project in India was established to create an environment based on the three Rs: 1) respect for sex work and those engaged in it; 2) reliance on those involved in sex work to run the programme; and 3) recognition of their professional and human rights. Since the beginning the sex workers were involved in all aspects of project development and management. With this framework, peer education was a key strategy where the women supported each other. Running their project and organization required that some women were at least literate but later the women wanted a literacy project for themselves. Although one of the supervisors agreed to teach, it became clear that learners like them with special life experiences could learn better if the lessons incorporated their discourses. A more participatory method evolved with the sex workers coming out with their own literacy primer. Moreover, a small newsletter with an attractive format, Namaskar, was produced by the sex workers themselves. These newsletters are sold by the peer educators at fairs and meetings. To meet the increasing demand for literacy, the daughters of the sex workers were recruited to be literacy teachers. This intergenerational learning has given pride to the mothers and daughters and help them gain status in their communities.

It was also recognized that the main causes of the sex workers vulnerability had to be addressed simultaneously with their STI/HIV health needs. In addition to literacy, vocational, legal and human rights training and services were carried out to build the sex workers capacity and self esteem. A cooperative provided economic and social assistance to sex workers through savings and loans and social marketing of condoms. Support services for sex workers children were also carried provided. Their new capacities and new identities have made it easier for most of them to negotiate better positions in condom use, dowry and marriage at a later stage. The capacity of Sonagachis women to provide the basis for a regional network has been recognized and such a network was launched in 1998. (UNAIDS, 2000a;UNAIDS, 2002)

C. Conclusion: Lessons in Empowering Literacy Initiatives for HIV/AIDS Prevention The programs cited above have many lessons to those seriously interested in addressing gender relations in HIV/AIDS through literacy. First of all, while information and knowledge on the virus transmission and risk behavior is critical, it is not sufficient for HIV prevention. This knowledge has to be backed up with 1) an understanding of power relations that are in operation in sexual relations and 2) changes in attitudes and behavior that could equip young girls and women with skills to negotiate and transform relations.Whether paid, casual or long term, the kind of power operating in sexual encounters/relationships is a key mediating factor in the spread of the virus. (UNAIDS/WHO, 2004) Young illiterate women who are forced into prostitution and young students who enter into relationships with older men to obtain material things, are all subject to unequal power relationships and would have difficulties in negotiation, among other things, for the use of the condom. Whether literacy equips girls and women with bargaining skills to assert their rights and choices is still debatable. Longwe (1997) for instance argues that schools reproduce traditional gender roles and contribute more to womens subordination.While a number of feminists critique literacy programs as a way of reproducing inequalities, there are increasing number of literacy programs which are working towards the goals of womens empowerment and using them as a vehicle for the transformation of gender roles.It is clear from their experiences that literacy has both enabling and disabling potentials for womens empowerment. There is increasing evidence which shows that risk behavior is reduced by empowering education which is adapted to the linguistic, social and cultural contexts of the populations. A gender sensitive HIV/AIDS strategy must necessarily address the genderbased discrimination and violence that contributes to the spread of the pandemic and in this, literacy has a key role to play in bringing changes in attitudes and behaviors that are reproducing gender inequalities. Literacy programs should help women and men understand how traditional gender roles influence sexual behaviors and increases women and men differential vulnerability and risk behaviors. It needs to provide an environment

where women and men could think of ways of reducing gender inequality,which is one of the fundamental driving forces of the HIV epidemic. Literacy content and process are important to provide updated and relevant information in ways that are appropriate to the learning environment . Literacy could not only provide information on how HIV/AIDS is transmitted but also start a process of questioning that could lead to changes in attitudes and behavior. Action Aids combination of REFLECT and Stepping Stones in Bangladesh has demonstrated the need for sustained experimenting on innovative approaches and is an important example of how participatory methods that create a critical and questioning mind among participants provides a base for unraveling other related problems (Bhattacharjee and Renton, 2003). Training literacy teachers and facilitators in both content areas and methods remain a key challenge. Furthermore in addition to training teachers on dealing with HIV-positive students and knowing how to impart information on HIV/AIDS, there is also a need to develop adequate teaching and learning materials (UNESCO Office in Islamabad, 2004) The programs cited also show that participation of young girls and boys, women and men are key to ensure that programs are empowering them to claim and defend their rights, and to overcome stigma and discrimination. Research on actual conditions of women and men in the community are clearly key in understanding the range of interests of diverse groups in society. A 12-month old World Education project in Africa began as an action research project whose goal was to test a methodology which encouraged the community organizations to lead the education in their communities for the fight against HIV/AIDS and STDs. Finally, the role of government in ensuring that resources (human and financial) for gender-sensitive literacy programs needs to be underscored. The UNGASS declaration calls for measures to empower women and girls and reduce their vulnerability to HIV/AIDS by 2005. Yet in the Report of the Secretary-General on the Progress towards implementation of the Declaration in 2002, it is noted that much remains to be done to engage women as full partners in the fight against HIV/AIDS (UN,2002). It is clear that literacy that is empowering the vulnerable (which at the moment are young girls and women) needs to be encouraged and reinforced by government if it serious in addressing the HIV pandemic.

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