1. A shift from Traditional School- based HIV Prevention to Community Social Norm Changing Strategy UNICEF Regional Office new approach to inducing new social expectations at community level - Case of Sierra Leone Macoura Oulare, UNICEF WCARO University of Penn, 13 July 2012

2. Overview of HIV interventions uptake in WCAR UA-2011 560,000 Pregnant women HIV+ globally without ARV for PMTCT in 2010 WCAR ESAR

3. Overview of HIV interventions uptake in WCAR SOWC-2011 Weak health system High stigma Limited $ No Task shifting Humanitarian

4. Mama Salone (Sierra Leone) at glance Youthful  2.9m children (of 5.8m people) Youthful  2.9m children (of 5.8m people) – 30% out of primary school – 62% out of secondary school Very traditional society with traditional Chiefs, religious leaders, secrets societies Very traditional society with traditional Chiefs, religious leaders, secrets societies Family oriented, but poor with history of 10 years of civil war Family oriented, but poor with history of 10 years of civil war HIV : high risk factors fueling the epidemics HIV : high risk factors fueling the epidemics

5. Mama Salone at glance

6. What was done before ? What was done before ? School based Life skills education programme – The Sissy Aminata School based Life skills education programme – The Sissy Aminata Policy and Advocacy: PRSP, NSP and Education Sector Plans Policy and Advocacy: PRSP, NSP and Education Sector Plans Capacity building - T eachers Capacity building - T eachers Communication - Radio programmes Communication - Radio programmes Community: club /peers education, sport Community: club /peers education, sport Significant support from UNICEF; CARE Significant support from UNICEF; CARE Pilot in 2 districts in 2003, roll out in > 5400 schools Pilot in 2 districts in 2003, roll out in > 5400 schools

7. Life skills /Sexuality education Age appropriate, culturally relevant approach to teaching about sex and relationship by providing scientifically sound, realistic, non judgmental information. Build skills : i) social skills (communication, negotiation, interpersonal, cooperation and creativity); ii) cognitive skills ( decision making, problem solving and critical thinking); iii) emotional and coping skills (managing stress, internal/self control, coping and resisting peer pressure). Ref; WHO and UNICEF

8. Critical evaluation- The Challenges Critical evaluation- The Challenges Overlooked impact of normative aspects related to sex: Overlooked impact of normative aspects related to sex: – “Sex” labeled “Daddy and Mummy Business”. – Mis-perception of the disease from the religious side – Sex is a Taboo, adult issue No evaluation of social norms No evaluation of social norms – Relied on one knowledge Sex connotation - Teaching sex to children Sex connotation - Teaching sex to children No relevant core groups involved – Children only No relevant core groups involved – Children only No use or creation/strengthening of social networks- No use or creation/strengthening of social networks- Children are not listened to by adults Children are not listened to by adults

9. Social norms A norm is a pattern of behavior (no sex education for children) such that individuals prefer to conform to it on condition that they believe that (a) most people in their relevant network conform to it (empirical expectation), and (b) that most people in their relevant network believe they ought to conform to it (normative expectation). Factual beliefs: Exposure of children to sex education leads to early pregnancy, outside wedlock pregnancy/child Factual beliefs: Exposure of children to sex education leads to early pregnancy, outside wedlock pregnancy/child Normative beliefs: To be assessed Normative beliefs: To be assessed Empirical expectation- Children not exposed to sex education. Empirical expectation- Children not exposed to sex education. Normative Expectation- Parents think that others think children should not be exposed to sex education Normative Expectation- Parents think that others think children should not be exposed to sex education Strong perception- but to be verified Strong perception- but to be verified Sierra Leone  combination beliefs and perceptions Sierra Leone  combination beliefs and perceptions

10. HIV Dilemma- Need for paradigm shift HIV Dilemma- Need for paradigm shift information and education materials available information and education materials available biomedical and the physical components better understood and becoming simpler today- ARV, test kits, equipment, male circumcision etc.. biomedical and the physical components better understood and becoming simpler today- ARV, test kits, equipment, male circumcision etc.. people still do not accept to be tested and treated because of stigma. Thousands of people still go infected each day; people still do not accept to be tested and treated because of stigma. Thousands of people still go infected each day; – Stigma – Misbehavior/Shame – Sex – Taboo, secret, private – Mis-perception HIV  reinforcing existing social norms or perceptions Then, Needs a paradigm shift- more social norms changes!  Apply this approach to all HIV interventions- PMTCT, prevention in adolescents and young people, protection of vulnerable children

11. UNICEF Regional Office new approach to inducing new social expectations at community level The goal is to sustainably improve all HIV programmes performance (adjusted by category) through social norm change by: 1. improving the knowledge base of the community system and norms- country and regional levels : In-depth diagnosis of the social norms and networks at community level- A multi-method, interdisciplinary approach, context specific In-depth diagnosis of the social norms and networks at community level- A multi-method, interdisciplinary approach, context specific Some critical questions such as : Some critical questions such as : – What are the parents’ real perceptions/beliefs/attitudes – What do they value? – What incentive does a parent have to accept discussing sexuality with their children? – What are the relevant networks, central nodes, connectivity – What is appropriate age for sexuality education – Will sex education prevent you sending girls to school? – What is the sexual custom – What is women decision on condom

12. UNICEF Regional Office new approach to inducing new social expectations at community level 2. Community engagement- Identification of community core group and capacity building Identification of community core group and capacity building Confidence creation, community knowledge improvement- media, new technology Confidence creation, community knowledge improvement- media, new technology Community led prioritization- Commitment- symbolic but concrete actions/plan Community led prioritization- Commitment- symbolic but concrete actions/plan Collective Diffusion/dissemination of information and of lessons learnt Collective Diffusion/dissemination of information and of lessons learnt Visibility- certification, celebration Visibility- certification, celebration

13. UNICEF Regional Office new approach to inducing new social expectations at community level 3. Social network strengthening ⁻Recruiting existing trust relationship- IRC, Paramount Chiefs, CTAs ⁻Improving and strengthening the interconnectivity of various social networks ⁻Better targeting of out of school/most at risk children/girls

14. UNICEF Regional Office new approach to inducing new social expectations at community level 4. legislation and policy 4. legislation and policy – The customary laws – The child Right Act – Coordination between HIV, Health, Child Protection and Education for changing norms

15. Future perspectives Even though this paper focuses on the prevention of HIV through sexuality/life skills education, it can be applied to all other HIV interventions. Even though this paper focuses on the prevention of HIV through sexuality/life skills education, it can be applied to all other HIV interventions. For instance PMTCT: For instance PMTCT: – Improving the uptake of HIV testing in pregnant women – Reducing stigma that stops women coming back for their test results, for refilling their life saving drugs – Promoting early antenatal care visit, reducing home delivery by pregnant women

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