HIV/AIDS IN RURAL BOTSWANA:
POVERTY, GENDER INEQUALITY, MARGINALIZATION AND STIGMA
by
Seiko Watanabe
B.A. Keio University, Japan , 1972
Diploma Occupational Therapy, Fuchu School of Rehabilitation , Japan , 1980

PROJECT SUBMITTED IN PARTIAL FULLFILMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS
in
INTERNATIONAL STUDIES

THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA
July 2005

UNIVER:J TY ._._-"-'Dv;.THL.: ~
RI'I!G? .. COuJ~ffilA
LIBIU...RY

© Seiko Watanabe, 2005

Prince George, B.C.

Abstract

HIV/AIDS in Africa has strong connections to development, poverty and
gender inequality. Botswana continues to face one of the highest HIV/AIDS
prevalence rates in the world. The common approaches to dealing with HIV
prevalence based on medical and behaviour models have not been effective in
curtailing this epidemic. Particularly in rural areas, people avoid facing the reality of
HIV/AIDS due to fear and stigma.
In this project, the linkage between HIV/AIDS and relevant social, economic
and cultural factors is explored in rural areas of northern Botswana, where
marginalized minority groups, particularly the San, live in extreme poverty. Data
were collected through semi-structured interviews and focus group discussions
between March and October 2004. The analysis indicates that poverty, gender
inequality, traditional beliefs related to illness and healing, marginalization, and
stigma interact and create the key barriers to current HIV prevention strategies.
Recommendations based on my seven months of fieldwork suggest that HIV/AIDS
prevention programmes must address poverty eradication , gender equality, cultural
sensitivity, marginalization and stigma reduction at all levels. Economic-social rights
and non-mainstream cultures of marginalized people must be respected and
incorporated into policy decisions so that the communities gain ownership of
prevention strategies against devastating HIV/AIDS problems.

ii

Table of Contents
Abstract

ii

Table of Contents

iii

List of Tables

v

List of Acronyms

vi

Acknowledgment

vii

Chapter One

Introduction

Chapter Two

Analytical Framework of HIV/AIDS Pandemic
Sub-Saharan Africa
2.0 Introduction
2.1 Analytical Framework
2.2 Current Policies and Strategies of the Botswana
Government
2.3 Summary

Chapter Three

Chapter Four

Chapter Five

Bibliography

Methods
3.0 Introduction
3.1 Methodology and Ethics
3.2 Qualitative Methods
3.3 Research Location
3.4 Opportunities and Constraints
3.5 Summary
Results and Discussions
4.0 Introduction
4.1 Knowledge of and Attitudes toward HIV/AIDS
4.2 Factors Perceived as Contributing to
HIV/AIDS
4.3 Discussion
4.4 Conclusion
Conclusions and Recommendations
5.0 Conclusion
5.1 Recommendations
5.2 Direction for Further Research

1

10

13

25

28

30
31
35
42

49
51

52
53
61

74
79
81

86
89
92

iii

Appendix

A-1
A-2
A-3

Map of Botswana
Map of TOCaDI catchment
Map of Okavango Panhandle

99
100
101

Appendix B

Letter of Support from TOCaDI, Member of
the Kuru Family of Organizations

102

Appendix C

Interview Questionnaires

104

iv

List of Tables

Table 1

Number of staff interviewed by ethnicity and gender

37

Table 2

Number of the participants by area and ethnic background

39

v

List of Acronyms
AIDS

Acquired Immune Deficiency Syndrome

ARV

Anti-Retroviral

CBO

Community-based Organization

CDF

Community Development Facilitator

DHT

District Health Team

GOB

Government of Botswana

HIV

Human Immunodeficiency Virus

MLGLH

Ministry of Local Government, Lands and Housing

MoH

Ministry of Health

MTPII

Second Medium Term Plan

NACA

National AIDS Coordinating Agency

NGO

Non-Governmental Organization

PMTCT

Prevention of Mother-to-Child Transmission

RADP

Remote Area Development Program

STD

Sexually Transmitted Disease

TOCaDI

Trust for Okavango Cultural and Development Initiatives

UNA IDS

The Joint United Nations Programme on HIV/AIDS

UNDP

United Nations Development Programme

WHO

World Health Organization

wusc

World University Service of Canada

vi

-

Acknowledgement
I thank TOCaDI and Kuru Family of Organizations for allowing me to conduct
my MA research and for all the support they have given to me, especially, Karine
Rousset and Willemien LeRoux for their informative discussions.

My sincere appreciation goes to TOCaDI staff especially the following
members of the HIV/AIDS Task Force , Gaetlogelwe Mapa, Nxisae Nxae, Dahm
ll!ae, Semango(Susan) Andreas, Splash Moranga, Joyce Tsaae Xwaa, Poneso
Mwamo, Supa Kanyetu , and David Naude, for their understanding, support and
teaching during my fieldwork. I also thank Moranga Tanago, N!oaxom Extension
Team Leader, for his patience and openness. I am grateful to the people of the
villages I visited for sharing their views and engaging in dialogue with me, especially
Ronny Mahindi, from Shaikarawe, for his support for HIV/AIDS work.

Also, I thank Dr. Fiona MacPhail, my academic supervisor, for her support
and guidance, especially during my fieldwork in Botswana. Finally, my special
appreciation goes to George Harding, my partner and a fellow volunteer at the rural
communities in Botswana, for his support throughout my fieldwork and writing of this
project.

vii

Chapter One
Introduction
1.0 The Problem

I entered the small grass-thatched hut where a young woman was lying down
on a straw mat placed on the sand . It was late summer in 2004 in a rural village in
northern Botswana. I was visiting an Acquired Immune-Deficiency Syndrome (AIDS)
patient with a home-based care worker (her formal title is family welfare educator).
She was immobile and had a pressure sore. She was cold because of her
incontinence. I saw no family member looking after her. A volunteer home-based
caregiver would come once or twice a week and buy some food for her, but she has
not been washed for sometime. She needed another blanket and a mattress to lie
on but had no money, however, there was no government funding. Before coming
to this hut, we visited another young woman , a 19 -year-old mother of twins. The
young mother also had AIDS. While their grandmother cuddled the babies, the
young mother sat quietly on the sand. She had nothing to eat because the system
had failed to register her in the destitute program. Her gaze was on me, then it
wandered off in despair. Both women are eligible for the Anti-Retroviral (ARV)
therapy that the Government of Botswana (GOB) provides to people living with
Human Immuno-deficiency Virus (HIV) or AIDS without cost if their CD4 counts are
200 or below. 1 However, these women have not had a chance to travel 400

1

CD4 count is the number of CD4 T-cell per cubicle millimetre of blood. The CD4 count is a test to
determine the stage of HIV infection . The GOB provides free ARV to persons whose CD4 count is
below 200 or with a symptom of AIDS .

1

kilometres to the nearest ARV clinic for a blood test and treatment. With no money
and no transportation , the twins may soon join the statistics of the increasing number
of AIDS orphans. Moreover, the women's illness is hidden from the community.
The AIDS epidemic update by the Joint United Nations Programme on

17·')

HIV/AIDS (UNAIDS) reported , in December 2002, that a total of 42 million people
worldwide were living with HIV/AIDS, with 29.4 million, or 69% in Sub-Saharan
Africa (UNAIDS/WHO , 2002 , p. 2). In the year 2002, 3.5 million people were newly
infected in the same region. Botswana has one of the highest HIV/AIDS prevalence
rates in the world (UNAIDS/WHO, 2002, p. 5; GOB/NACA 2003a, p. 13f The GOB,
with joint funding from the UNAIDS and the Bill and Melinda Gates Foundation, has
developed an extensive network of researchers as well as strategies to curtail the
prevalence. It established voluntary counselling and testing centres in major cities
such as Gaborone, Francistown and Maun, and provides free ARV therapy to people
who meet the criteria. However, it appears to have made little difference in the
nation when it comes to reducing the prevalence rate during the past decade (GOB,
2002; GOB/NACA, 2003a) 3 .
Most people in Botswana still do not know their HIV status, and only a small
percentage of those living with HIV are receiving ARV therapy (GOB/NACA, 2003a,
p. 11 ). Apparently, the policies and strategies have not reached the most vulnerable
population in the remote area of the north Okavango District where I was posted to

2

In the 2002 UNAIDS statistics, Botswana is listed with the highest prevalence rate at 35.4% followed
by Lesotho 31 %, Zimbabwe 33.7% and Swaziland 33.4% (UNAIDS/WHO, 2002, p. 2- 4). National
AIDS Coordinating Agency listed the rate at 37.4% in its 2003 Report (p. 13).
3
The prevalence rates among attendees of the Prevention of Mother-to-Child Transmission and the
Voluntary Testing Program increased among all ages between 2000 and 2002 (GOB/NACA, 2003a) .

2

work as a HIV/AIDS consultant for a local non-governmental organization (NGO) ,
Trust for Okavango Cultural and Development Initiatives (TOCaDI). After I arrived , I
became increasingly aware of the impact of HIV/AIDS in this rural community. The
staff are often sick themselves, or they miss work due to illnesses or funerals of their
family members. The astonishing reality was that most staff and residents in the
communities did not know their HIV status , therefore , many deaths were assumed to
be due to AIDS related illnesses considering their young ages.
Poverty is visible in these rural communities. During my fieldwork, villagers
told me that they had nothing to eat when a 'healthy diet' was recommended to
strengthen their immune system . People are afraid of knowing their status when the
remedy seems so unattainable for them. They do not want to acknowledge
HIV/AIDS, a new disease, when their lives are already threatened by the high
prevalence of tuberculosis and malaria. AIDS is just another deadly illness added to
their difficult lives. Particularly in the area where I worked , there is a concentrated
population of minority groups, and people are already exhausted from poverty and
seem to have very little ability to cope with HIV/AIDS. There is a need to change the
implementation of the strategies to combat the HIV/AIDS pandemic. Understanding
the reasons why the current strategies are not effective will help to develop more
practical and realistic ones that will meet the unique needs of the communities.

1.1 Nature of HIV/AIDS

HIV is a retrovirus and is transmitted through blood , semen , vaginal
secretions, and breast milk. The virus must enter into the blood stream in order to

3

infect the person. The virus penetrates into the immune system , mutates, and
destroys T-cells 4 , weakening the body's immune system . Over a period of time, the
immune system declines further to such a degree that it is no longer able to resist
infections that are, in normal circumstances, often curable (hence called
opportunistic infections) . This stage is called AIDS and the individual's body
becomes overtly weak. The individual further debilitates and will die of these
diseases (UNAIDS/WHO, 2002; Willis, 2002).
HIV infection is unique because the person may remain asymptomatic tor
many years after infection while being capable of infecting others. The long course
of this disease also makes understanding of HIV/AIDS difficult. Since HIV attacks
the immune system, not particular organs, the infection rates and the progress of
illness depend on the existing status of the individual's immune system when the
virus and opportunistic infections are contracted. If the immune system is already
weakened by other infections such as tuberculosis and malaria, poor health
condition or malnutrition, the individual is highly vulnerable to HIV infection and
developing AIDS (Stillwaggon , 2002, p. 5) .

1.2 The Pandemic of HIV/AIDS in Sub-Saharan Africa

Unlike in European and North-American countries, in Africa more women are
infected than men (UNAIDS 1999, as cited in Willis, 2002 , p. 46- 52). In SubSaharan Africa, the majority of HIV transmissions occur through heterosexual
intercourse (Howson, Harrison, Horta & Law, 1996; Cohen & Trussell, 1996; Webb,
4

Usually called T-cell, the T-lympnocyte cell in the body is directly affected by the HIV virus.

4

1997; Susser & Stein, 2000; Jackson, 2002; GOB/MoH, 2002) and mother-to-child
transmission (Jackson, 2002; Stillwaggon, 2002, p. 3). The highest HIV prevalence
is seen among young women between 20 and 34 years while men have the highest
infection rate in the older age group (35 to 49 years) (Howson, et al., 1996;
GOB/NACA, 2003b, p. 36- 39). In Sub-Saharan Africa, other sexually transmitted
diseases (STDs) are prevalent and strongly coupled to HIV infection, thus STDs are
considered a co-factor of HIV transmission (Howson, et al., 1996; Stillwaggon, 2002,
p. 8- 9). Howson et al. (2002) pointed out that women with STDs will not seek out
medical care until the diseases progress to the advanced stages due to stigma,
leaving women highly susceptive to HIV infection (p. 242). When this biological
vulnerability combines with gender inequality in sexual relationships, women are
highly vulnerable to HIV infection.

1.3 HIV/AIDS in Socio-Economic Context
In a sense, the HIV transmission is based on individual's behaviour and is
thus preventable if the human behaviours that cause virus transmission are
eliminated. Using this simplistic logic, behaviour change approaches were
emphasized in the early research and still tend to be the focus of many policies and
strategies (Cohen & Trussell, 1996; Packard & Esptein, 1991; Simbayi, 1999). This
emphasis on individual behaviour change seems to be the underlying principle of
current policies and strategies of the Botswana Government (GOB/MoH, 2002;
GOB, 2002). However, this common behaviour modification approach called ABC
(Abstain , Be faithful and Condomize) fails to take into account the reality of women's

5

lives (Ackermann & de Klerk, 2002). AIDS is stated as a "disease of poverty in the
African context" (Stillwaggon, 2002 , p.18). Poverty predisposes women to be
extremely vulnerable to HIV infection.
Socio-economic and cultural factors shape individuals' behaviour and have an
impact on individuals' decision-making. Increasingly, anthropologists are
recognizing the culture-based approach to HIV/AIDS prevention and care as critical
(Airhihenbuwa & Webster, 2004; Susser & Stein , 2000; Buseh, Glass, & McElmurry,
2002) . Stigma is one of the primary barriers for people seeking voluntary testing and
counselling , however, the factors creating stigma require further study (Schoepf,
2001; Castro & Farmer, 2005). In the Botswana government policies, socioeconomic and cultural factors are listed as the determinants of the HIV/AIDS
pandemic. However, there seem to be large gaps between the policies and
implementation strategies in that the actual strategies do not include required
structural changes to poverty and gender inequalities (Abt Associates South Africa
Inc., 2000; GOB, 2002; GOB/MoH, 2003). Understanding the linkage between local
socio-cultural process and global inequalities of class, gender and ethnicity is
similarly important in gaining a new perspective on the events in local communities
(Webb, 1997: Schoepf, 2001 ). As Webb (1997) proposed, the crucial question is
"how important are the different determinants in the specific context?", rather than
'what are the determinants of the individual behaviours?' (p. 34).

6

1.4 Research Objectives and My Position

My primary interest is in the welfare of the rural population in the remote
areas of northern Botswana, more specifically, the marginalized minority groups who
live there . It appears that this population is left out of Botswana government policy
and strategies on HIV/AIDS. This exclusion is particularly true for the San people ,
who tend to live with other minority groups, such as Herero, Wayeyi and
Hambukushu , in the same villages. Marginalization , gender inequality, poverty,
traditional beliefs and stigma seem to be the key factors that create barriers to
HIV/AIDS prevention . How these factors intertwine and affect people's behaviour
toward HIV/AIDS need to be investigated in the rural context. My research
objectives for this project are:
1) To understand the knowledge of, and attitudes about, HIV/AIDS held commonly
by the local residents; and ,
2) To gain insight into how poverty, gender inequality, traditional views of illness
and healing, marginalization and stigma intertwine and create the key barriers for
HIV/AIDS prevention .
I use these insights to develop recommendations for policy changes by government
and the effective role TOCaDI can play for its staff and communities in HIV
prevention. TOCaDI has an important role as it is the only NGO in the area that
operates with a particular focus on development issues of minority groups.
I chose a qualitative research design in order to gain insight into the life of the
local people, their knowledge and attitudes toward the problem of HIV/AIDS. During
this fieldwork carried out between March and October 2004, I held a position as a

7

volunteer HIV/AIDS project advisor, funded by the World University Service of
Canada (WUSC) , a Canadian development NGO that had a one- year contract with
TOCaDI. Although , the central interest of the organization is income generation,
TOCaDI is aware of the impact of HIV/AIDS on its work and recognizes the need to
address HIV/AIDS issues in its programs. Within its mandate and with limited
financial and human resources , an assessment of whether TOCaDI is providing
adequate attention to this matter is needed. Currently, the management strategy of
TOCaDI is to encourage behavioural change at an individual staff level.
My primary role for TOCaDI was to assist the organization to gain a deeper
understanding of the impact of HIV/AIDS so that it would be able to mainstream
HIV/AIDS into their policy and day-to-day programs. TOCaDI has three main
extension teams that conduct fieldwork in collaboration with community-based
organizations (CBOs) in each area. The HIV/AIDS project was independent of the
extension team structure but covered all the extension areas. My contribution is first
to provide insight into HIV/AIDS and the minority groups in the north Okavango area:
their knowledge level, attitudes and perceptions. There is little research done on
HIV/AIDS impact on minority groups, the San, Hambukushu and Wayeyi in this area.
Second , I provide perspectives on the impact of socio-economic and cultural factors
on HIV/AIDS prevalence and behaviours of residents in the areas.
I lived in the TOCaDI compound in Shakawe, Botswana from November 2003
to November 2004. From this base, I travelled to the villages with community
development facilitators (CDF) of the extension teams to conduct my fieldwork.
These trips included a number of day trips and also four camping trips.

8

1.5 Conclusion
My research objectives are explained in conjunction with the background
issues relevant to the HIV/AIDS problems in rural Botswana. This research project
is divided into five chapters. Chapter Two provides an historical and analytical
framework tor understanding current issues in researching HIV/AIDS in SubSaharan Africa. Chapter Three presents research methods used in the study period.
Ethical issues related to conducting fieldwork in a developing country are also
discussed in this chapter, and a description of the research location is given.
Chapter Four presents research findings and discusses the issues identified as
important based on my research , particularly economic, social and cultural factors
contributing to barriers to HIV/AIDS prevention. Chapter Five provides a summary
and recommendations tor the future.

9

Chapter Two
Analytical Framework of HIV/AIDS Pandemic in Sub-Saharan Africa

2.0 Introduction
AIDS has brought the complexity of the structural problems of our society to
the surface. The medical challenges of HIV/AIDS including its fast mutating nature
require continuous epidemiological , pathological and pharmacological research.
However, the HIV/AIDS pandemic is no longer a mere medical issue but clearly a
development issue. It is best regarded as a "disease of development and
underdevelopment" (Symonds & Schoepf, 1999, p. 190).
Since first discovered in 1982, AIDS has made its greatest impact in the
developing countries, where inadequate health and social infrastructures are further
weakened by prolonged economic crisis. The 1997 Human Development Report
(UNDP, 1997) stated , "of the 23 million people with HIV/AIDS, 94% are in the
developing world , with most in Sub-Saharan Africa" (p. 67). Eight years ago, the
United Nations Development Programme (UNDP , 1997) reported that "the incidence
of HIV infection in poorer countries (750 per 100,000 people) is more than ten times
than in industrial countries , and the spread is faster" (p. 67).
In the earlier stage of the pandemic, much attention was given to medical
factors of HIV/AIDS and human behaviour that caused the virus transmission ,
particularly sexual behaviour, and thus a behaviour modification approach was
emphasized (Cohen & Trussell , 1996). However, economic status , cultural beliefs
and societal norms shape behaviours and decisions that an individual makes around

10

HIV/AIDS. Economic and social conditions , such as poverty and malnutrition,
together with poor infrastructure increase the vulnerability of people to HIV infection
and its consequences (Piot & Pinstrup-Anderson , 2002 , p. 3 - 4; Stillwaggon, 2002,
p. 1 - 2). Poor nations lose people in their prime resulting in a decline in the nation's
productivity.
In the early stage of research on HIV/AIDS in Sub-Saharan Africa, the
primary focus was given to African sexuality and promiscuity in an approach
described as "infused with racial stereotypes" (Packard & Epstein , 1991 , p. 349).
Packard and Epstein (1991) blamed this narrow-minded view on the common
cultural assumptions of the "peculiarities of African behaviours" on the part of
western researchers , that have shaped the direction of the initial AIDS research (p.
346) .
The HIV/AIDS pandemic in Africa has its roots in social and cultural dynamics
that are highly complex. Sub-Saharan Africa is geographically, demographically,
socially and culturally heterogeneous. Therefore, the epidemic of HIV/AIDS and the
extent and the spread of HIV infection are diverse while some overall characteristics
and trends can be seen (Cohen & Trussell, 1996). AIDS-related stigma is a major
barrier to voluntary testing and counselling, and prevents people from facing the
reality of HIV/AIDS prevalence in Sub-Saharan Africa (Aggleton & Parker, 2002, p.
6; Castro & Farmer, 2005 , p. 53). There is an urgent need to understand the
dynamics of stigma. The ways in which cultures are overlooked and misrepresented
with stereotypes based on racist assumptions of "African Sexuality" have contributed
to stigmatization (Aggleton & Parker, 2002, p. 9; Treichler, 1991 , p. 381 - 385) .

11

Poverty has a strong association with gender inequality. While prevalence
rates are increasing among poor nations in the Third World , the epidemic trends
have also changed in developed countries. For example, HIV prevalence is higher
among African-American and Latin-American women who are disproportionately
poor in the United States (Simmons, Farmer and Schoepf, 1997, p. 62; UNDP, 1997,
p. 67). Here, the dynamics of relationships between poverty, gender,
marginalization and HIV prevalence are evident.
The AIDS epidemic is rooted in the vulnerability of people. It has exposed
prevailing gender inequality and also other structured inequalities based on race and
class (Castro & Farmer, 2005, p. 56) . The failure to see how socio-economic and
cultural factors are intertwined with HIV/AIDS results in the failure to understand the
implications of those structural inequalities in local events. Without addressing the
socio-economic and cultural structures, the behaviour modification based approach
has little effect in actually changing people's behaviour.
The AIDS strategies of the Botswana government reflect the same problem.
The current policy and strategies heavily focus on individuals' behaviour change and
are not designed to implement infrastructure that will empower women and the poor.
What does this gap mean to local residents in the north Okavango in curtailing the
HIV/AIDS pandemic?
In this chapter, first, I provide the analytical framework for understanding the
HIV/AIDS prevalence in Sub-Saharan Africa that has guided my research. I also
summarize the Botswana Government's current policy and strategies on HIV/AIDS.

12

2.1 Analytical Framework

The analytical framework I use in this research is the interrelationships among
HIV/AIDS , poverty, gender inequality, culture, marginalization and stigma. AIDS is a
disease that has profound social effects with its impacts differing from one society to
another. AIDS is regarded as a disaster that requires full consideration of the
vulnerability of the population at risk (Barnett & Blaikie , 1992, p. 8). The socioeconomic impacts that predispose vulnerable people to HIV/AIDS include famine ,
migration and sexual exploitation of women as result of social unset and warfare,
among others (Howson et al. , 1996, p. 26) . In the rural area of Botswana where I
studied , people are free from warfare and famine. However, poverty and gender
inequality appear to have severe, chronic effects on people's life. In addition ,
traditional beliefs of illness and healing emerge as a strong influence on people's
life. The population in the area consists of marginalized minorities who are exposed
to stigma.

2.1.1 Poverty and HIV/AIDS

a. Definition of Poverty
Poverty itself is multi-dimensional and means more than income poverty. It is
a matter of the quality of people's lives and is defined by many variables. The human
poverty index (HPI) used by UNDP measures different features of deprivations in the
quality of life (UNDP, 1997, p. 18). While the human development index (HOI)
measures achievement including income perspectives, the HPI measures
deprivations in three critical dimensions of human development: survival, knowledge

13

and the decent standard of living (UNDP, 1997, p. 17- 21 ). Sub-Saharan Africa
suffers from chronic poverty. Of the world's population living in absolute poverty,
defined as income of 1 US dollar a day or less, 30% live in Sub-Saharan Africa
(UNDP, 2004, p. 130). The 2004 Human Development Report (HDR) listed all SubSaharan African countries, except Mauritius and Cape Verde, with an HPI index of
more than 30% (UNDP, 2004, p. 247) (higher rates indicate higher deprivation).
According to the HPI index, the quality of life for the people of Botswana declined
since 1996: HPI for Botswana was 22.9% in 1996 (UNDP, 1997, p. 21) increasing to
43.5% in 2004 (UNDP, 2004, p. 247).
Saitoti (2002) listed certain characteristics that all developing countries
usually exhibit, which either cause poverty or are themselves a manifestation of
absolute poverty. The characteristics include extremely low or negative rates of
growth in GDP and per capita income; highly skewed income distribution in which
very few rich people control a large share of income while the rest control a
negligible share; inability of many people to meet basic necessities of life such as
food, clothing, shelter and access to education, health care and clean water, which
translate into high mortality rates; and high levels of unemployment or
underemployment (Saitoti, 2000, p. 69). These indicators are important in
discussing poverty. The problem of poverty is intricately intertwined with the
problem of HIV/AIDS in Africa, therefore, the two problems must be dealt with
simultaneously (Saitoti, 2002; Schwab, 2001; De Waal, 2003; Symonds & Schoepf,
1999). Saitoti (2002) argued, "we cannot win the war against poverty unless we win
the war against AIDS. On the other hand, we are unlikely to make much headway in

14

our war against HIV/AIDS unless we put in place credible policies to fight poverty"(p.
67). Poverty makes people vulnerable to HIV infection and, in turn, HIV/AIDS
aggravates poverty when people are already poor.

b. Impact of HIV/AIDS on Poverty in Sub-Saharan Africa
A common assumption is that an HIV prevalence rate of 10% implies a
reduction in economic growth of 0.4% (De Waal, 2003, p. 7); when HIV prevalence
reaches 15%, a country can expect an annual drop in GOP of more than 1% (Piot &
Pinstrup-Anderson, 2002, p. 6). De Waal (2003) presents a much more complex
picture of the economic implications of HIV/AIDS including a reduction in the overall
population and demographic changes that result in a decline in the labour force.
The pandemic of AIDS is contributing to the shortening of life expectancies in
all Sub-Saharan African countries (UNDP, 2004). According to the 2004 Human
Development Report (UNDP, 2004) , due to the HIV/AIDS pandemic, the life
expectancy at birth declined from 56 years in 1970 -75, to 41.4 years in 2002 in
Botswana (p. 170). It is expected to decline below 39 years by 2010 (UNDP, 1998,
p. 35). The child mortality rate doubled between 1990 and 2000 (UNDP, 2004, p.
132). Despite comparatively well-developed infrastructure including safe water, a
public heath care system, and a democratic government with one of the highest
GOP per capita in Africa, Botswana fell to 1281h place in HOI rank (UNDP, 2004, p.
141 ). Also, Botswana has one of the highest Gini coefficients in the world (0.63),
which indicates a significantly high level of income inequality (UNDP, 2004, p. 190).
In Botswana, an estimated 47% of the population live in income poverty (below $2 a

15

day) (UNDP, 2004, p. 148) and are particularly hard hit by HIV/AIDS (Abt Associates
South Africa Inc. , 2000, p. 38) . In rural Botswana, more than 55% of people live in
poverty (GOB/MoH , 2002 , p. 15).
The direct and indirect costs of AIDS-related expenses are exacerbating the
conditions in which poor people live. AIDS-impoverished families can no longer pay
school fees or uniforms for their children. When their parents die, many girls drop
out school to look after their young siblings (Jackson , 2002, p. 257- 263) .
Communities also lose teachers and other professional workers to AIDS (GOB,
2002 , p.12 -14) .

c. Poverty as Contributor to HIV/AIDS Prevalence
Poverty predisposes people to HIV infection. The majority of poor people are
concentrated in rural areas in Africa (Saitoti , 2002, p. 74- 76) , where infrastructure is
limited and employment opportunities are scarce. People migrate from rural villages
to urban areas seeking employment. The high mobility of Africans has not only
contributed to the spread of HIV/AIDS but also affected social disintegration and
breakdown of the traditional family structure (Klein , Easton, & Parker, 2000, p. 23).
Kaya (1999) pointed out that where labour migration, reinforced by poverty results in
long absences from the origin areas, sex and alcohol become the only source of
pleasure in the daily struggles of life (p. 39) . This makes migrant workers vulnerable
to HIV/AIDS and other sexually transmitted diseases (STDs) (Kaya, 1999). In
Botswana, people are highly mobile resulting in frequent and long-established workrelated separation of spouses or partners (Lesediti , 1999, p. 50- 51).

16

The impact of HIV/AIDS on poverty shows the two-way relationship between
poverty and illness (UNDP, 1997, p. 67) . Poverty increases the risk of malaria,
tuberculosis , and STDs: these illnesses are strongly tied to HIV infection in Africa
(Jackson , 2002 , p. 151; Howson et al. , 1996, p. 246). Poverty makes it difficult for
people to access to medical testing and treatment. In a study conducted in
Botswana, poverty was listed as the primary barrier to seeking treatment, either
because of the cost of medication or the cost of transportation, especially for people
living in rural areas (Weiser et al. , 2003 , p. 283). The spread of AIDS has been
exacerbated by low nutritional level and poor health conditions (Bujra & Baylies,
2000, p. 26) . Stillwaggon (2002) also argued the strong connection between poverty
and malnutrition and HIV/AIDS, while Piot and Pinstrup-Anderson (2002) pointed out
the overlap of the maps of HIV prevalence and malnutrition. 'When you ask people
living with AIDS in rural communities in the developing world what their highest
priority is, very often their answer is food" (Piot & Pinstrup-Anderson , 2002, p. 2).
Poverty also relates to poor educational attainment, which leads to lack of accurate
information on HIV/AIDS (Mwale & Burnard , 1992, p.12; Kaya, 1999, p. 38). The
unemployment rate is high at 70.7% among young people 15 -24 years in Botswana
(MoH , 2003, p. 10) .

d. Poverty and Gender
Poverty has strong ties to gender inequality. Women are disproportionately
poor and often disempowered and burdened by productive work, childbirth , and care
of family members without having adequate access to land and better employment

17

opportunities (UNDP , 1997, p. 3). Poverty affects women differently from men . This
will be further discussed in the next section.

2.1.2 Gender Inequality and HIV/AIDS
a. Vulnerability of Women
HIV prevalence is higher among women than among men in all Sub-Saharan
Africa: among HIV-infected people , an average of 51 -56% are women , 40- 45%
are men , and 2- 6% are children (data extracted from UNAIDS 1999, cited in Willis,
2002, p. 46- 52). Several factors make women more vulnerable to HIV infection.
Farmer, Connors , Fox and Furin (1997) argued that the relationship between
poverty, gender inequality, and biological vulnerability is the major risk factor
contributing to the HIV/AIDS prevalence. Baylies (2000) noted the need to
understand how gender relations create vulnerability in women and how the
epidemic has impact on women in specific ways. Women's bodies are more
susceptible to infection during sexual activity, however, when the physiological
vulnerability is reinforced by the social vulnerability of women, their susceptibility to
infection increases greatly (Howson et al. , 1996, p. 247; Baylies , 2000; Ackermann &
de Klerk, 2002). Klein et al. (2002) argued that poverty, a high level of migration due
to employment, and gender inequalities are the key forces that affect HIV
prevalence , and when they intertwine, lead to an epidemic.

18

b. Poverty and Gender Inequality
Poverty and gender inequalities are structured in Sub-Saharan African
societies. Poverty forces women to turn to risky sexual activity for survival ,
increasing the chances of virus transmission . When women have to rely on men for
basic needs, poverty and sexual exploitation force many women into circumstances
where sex becomes a survival strategy (Simmons et al., 1997). Women in poor
communities are especially vulnerable because in most Southern African cultures,
they have little power to refuse sex, and if they insist on using condoms, they may
face physical or economic retaliation (UNDP, 1997, p. 67). Research conducted in
rural areas of Zambia, Uganda and South Africa reveals the common situation
women in Sub-Saharan Africa face. In Zambia, women lack power in sexual
decision-making including lack of control of their husbands' lives outside their
marriage where extra-marital sexual relationships are common (Mwale & Burnard,
1992). The cases in Uganda show that extreme economic deprivation, lack of social
status, and a patriarchal system that encourages polygamous relationships has
predisposed women to high infection rates. Furthermore, poverty lures young
women and girls into prostitution placing them at high risk of infection (Nyakabwa,
1997).
Ackermann and de Klerk (2002) pointed out that sex is a survival strategy (p.
168). Many young women exchange sex for money to buy basics such as food ,
soap , clothes and sometimes to pay for their education in South Africa. Poverty
makes a wide age discrepancy in sexual relationships acceptable , often resulting in

19

exploitation of girls and early pregnancy with many young girls dropping out of
school in Botswana (Lesetedi , 1999, p. 51).

c. Gender Inequality and Cultural Values
Traditional cultural values are strong determinants for decision-making. In
Sub-Saharan Africa, traditional cultural values reinforce gender inequality and
predispose women to vulnerability. Traditional cultural values dispose women to
HIV/AIDS in Africa by structuring social , economic and political inequalities of
women in the society and not allowing women to have a voice in decision-making
(Buseh et al. , 2002 ; Uwakwe, 1997). The multiple roles women play in a society as
wives, mothers and health care providers are framed by cultural norms, which are
central to the society and therefore difficult to change. Lesetedi (1999) argued that
HIV/AIDS prevention programs often fail to recognize the difficulties facing women in
light of traditional obligations and the modern context (p . 53). For example, the
increasing responsibilities and burden to care for the sick fall on women when
women continue to be regarded as socially inferior and are disadvantaged. Culture
is dynamic with changes due to inner and outer forces such as economic demands,
encounters with other cultures , and the pandemic of HIV/AIDS. Traditional culture
values have affected the ways HIV/AIDS spreads. Conversely, the HIV/AIDS
pandemic affects traditional cultural values. Cultural plurality exists when traditional
beliefs and practices face the forces of new cultures and attempts to preserve power
relationships (Baylies et al. , 2000 , p. 96).

20

In many African countries, multiple sexual partnerships and extra-marital
sexual activities for men are widely accepted , especially in rural areas where cultural
and economic pressures remain strong (Sikwibele et al. , 2000; Buseh et al. , 2002 ;
Ackermann & de Klerk, 2002; Susser & Stein , 2000). However, traditional cultural
reasoning behind polygamous sexual relationships may have changed. Ackermann
and de Klerk (2002) argued that urbanization and modernization changed the
organization of sexual partnerships resulting in an increase in mistresses and love
affairs (p. 168). In Botswana, despite rapid economic improvement, persistent
income inequality between men and women sustains women's submissive position
in society (Lesetedi , 1999, p. 51) .
In Sub-Saharan Africa, reproduction carries highly significant weight in
cultural patterns regarding sexuality and needs to be considered when developing
prevention programs (Buseh et al. , 2002). In addition to the submissive position of
women in society, there is a strong belief in fertility. It is almost imperative to have
children, therefore, the cultural attitude toward fertility minimizes condom use
(Susser & Stein , 2002; Lesetedi , 1999, p. 53). Baylies (2002) pointed out the
particular vulnerability of young married women whose desire for children makes
protection problematic as men tend to have more partners before or in the early
years of marriage (p. 11 ).
Breast-feeding and home births are also the norms due to tradition and
poverty. Women transmit the virus to their children and also can be infected by
providing care for infected persons without knowing (Howson et al. , 1996, p. 251).
Most global AIDS prevention programs such as partner reduction , condom

21

promotion and STD treatment are inadequate to protect most of the women in the
world, who are poor and lack the power to negotiate within their sexual relationships
(Klein et al., 2002).
There are ambivalent and conflicted feelings towards sexuality (Blair et al. ,
1997). In traditional African culture, sexuality and sexual behaviour are forbidden
subjects in many societies (Howson et al., 1996, p. 249; Okafor, 1997, p. 114),
therefore, access to accurate information is extremely limited, especially for women
in rural areas (Buseh et al., 2002). Despite the taboo about sexuality, multiple
sexual partnerships are the norm in many societies. Mistrust between spouses and
partners is common in sexual relationships leading to blaming of others, as well as
doubts and misconceptions regarding condoms resulting in their rejection (Blair et
al., 1997, p. 51; Klein et al., 2002).

2.1.3 Traditional Views of Health and HIV/AIDS
Traditional beliefs in illness and healing have a strong influence on people's
understanding of HIV/AIDS and health-seeking behaviour. Although Botswana has
a well-established public health care system compared to other Sub-Saharan African
nations, many people continue to believe that traditional diseases need to be cured
by traditional doctors (Abt Associates South Africa Inc., 2000). The traditional
diseases in Botswana include Depathi, similar to Chira in Kenya (Blair et al., 1997, p.
54) (Depathi is further explained in Chapter Four). Others believe that AIDS is
caused by spirits or supernatural forces (Kalichman & Simbayi, 2004, p. 578).
Kalichman and Simbayi (2004) reported that beliefs in witchcraft as a cause of AIDS

22

and STDs are likely prevalent in rural areas of South Africa and Zambia (p. 576 578) . These beliefs potentially reduce the effectiveness of the HIV/AIDS campaign .
Mbilinyi & Kaihula (2000) argued that beliefs in traditional disease no longer seem to
have an impact on sexual behaviour patterns (p. 85- 86). However, it is used as a
convenient explanation of death in that it does not carry stigma compared to
admitting a family member died of AIDS. The question of whether AIDS is a new or
old disease often arises (Baylies et al. , 2000, p. 103) . Missionaries and Christian
churches also have a strong impact on views on HIV/AIDS and its prevention with
their strong religious principles and doctrine relating to moral sexual and cultural
behaviour that alter traditional authority systems (Mbilinyi & Kaihula, 2000). The
South African government acknowledges the roles of traditional healers in health
and organises them by establishing associations and train them on HIV/AIDS and
other STDs (Green & Zokwe, 1996). However, such a movement is not strong or
well-organized in Botswana (Abt Associates South Africa, Inc. , 2002). Because
traditional healing continues to have complex impact on people , in order to
understand the ways that people perceive HIV/AIDS, it is crucial to understand the
traditional concepts of healing and incorporate "indigenous knowledge systems" into
prevention strategies (Tangwa, 2002 , p. 228).

2.1.4 Marginalization and Stigma
Stigma is one of the most prominent barriers to the prevention of spread of
HIV/AIDS. An ARV adherence study conducted in Botswana reports that 69% of
patients kept their HIV status secret from their families and 94% from their

23

community, fearing they might lose their jobs (Weiser et al. , 2003, p. 285) . Stigma
prevents people from facing the reality of HIV/AIDS. "When discussing behaviour
change, respondents almost always talked about other people's behaviour and not
their own , thus indirectly implying that they themselves were not at risk" (Blair et al.,
1997, p. 51).
Aggelton and Parker (2002) defined stigmatization as a process of
devaluation linked to power and domination throughout the society. HIV/AIDSrelated stigma plays into, and reinforces social inequalities that are based on
gender, race , class and ethnicity (p. 8- 9). Communities of ethnic minorities are
also marginalized and hit hard by the devastating illness (Aggleton & Parker, 2002).
Marginalization has a strong connection with stigmatization as it leads to blaming:
"people with HIV/AIDS from racial and ethnic minorities are often seen not as
individuals living in the context of marginalization and inequality, but as the causes
of their own misfortune" (Aggleton & Parker, 2002 , p. 9) . Aggleton and Parker
(2002) pointed out that the racial assumptions of many early AIDS-related
discourses were clear in statements of "African sexuality" (p. 9). Castro and Farmer
(2005) also argued that "stigma and discrimination are part of complex systems of
beliefs about illness and disease that are often grounded in social inequalities" (p.
54).
Gender inequality, poverty and some cultural beliefs intertwine and create
stigma for people who are infected with HIV and are the most vulnerable. The
consequences of stigmatization are severe. Women , especially, are typically
blamed and endure the most serious consequences that may include violence,

24

divorce, and social ostracism (Howson et al. , 1996). The complications of STDs ,
especially impaired fertility, are even more devastating. HIV infected women are at
risk of abandonment by the very men who infected them (Howson et al., 1996).
Stigma rests in the core of society and disempowers people who are most
vulnerable. Without understanding the dynamics of stigma and addressing factors
behind the stigmatization , HIV/AIDS prevention campaigns have limited effect.

2. 2 Current Policies and Strategies of the Government of Botswana

Health care in Botswana has improved markedly over recent decades with
good access to health services relative to other Sub-Saharan countries in general
(Abt Associates South Africa Inc. , 2000). The Botswana Government initially
attempted to address the HIV/AIDS epidemic as largely a health issue by developing
the Short and Medium Term Plans in 1987 and 1993, in the early stages of the
pandemic (GOB , 2002) . When it recognized the rapidly worsening situation of the
pandemic, the Government formulated the National Policy on AIDS and developed
the Second Medium Term Plan (MTPII) for 1997-2002 to set out a framework and
strategies to integrate multi-sectoral responses (GOB , 2002) 5 . The National AIDS
Policy was under review at the time of my research . The National Strategic
Framework 2003- 2009 was developed based on the assessment of the MTPII with
a goal to prevent new HIV infection by year 2016. The National AIDS Coordinating
Agency (NACA) is commissioned to co-ordinate national responses to HIV/AIDS
5

Confirmed AIDS deaths rose from 2.43% to 9% of total deaths in the 15 - 45 years age group
between 1992 and 1997 (Abt Associates South Africa Inc. 2000) .

25

prevalence at the policy level. The Government also funds and works with AIDS
organizations in civil society such as Botswana Network for AIDS Service
Organizations (BONASO) , Botswana Network for People Living With HIV/AIDS
(BONEPWA) , and Botswana Network for Ethics and Law on HIV/AIDS (BONELA) .
The GOB has two pillars in its public health system, the Ministry of Health
(MoH) and the Ministry of Local Government, Lands and Housing (MLGLH) . The
Ministry of Health sets up overall health policies and strategies, and has direct
authority over hospital services, while providing guidance and supervision to the
districts, city and town councils and private services to ensure that they comply with
its standards. The Primary Health Care, AIDS/STD Unit, Health Education &
Communication Unit and Epidemiology & Disease Control Unit are important parts of
the MoH structure addressing HIV/AIDS prevalence .
The MLGLH has jurisdiction over basic health services such as primary health
care clinics, health posts and other community services within the health district. The
Ministry is also responsible for social welfare services that deal with destitute and
orphans programs. The district, city and town councils determine the organizational
structure of the District Health Teams (DHT) , plan , provide and evaluate the basic
health services under the MoH policies (Abt Associates South Africa Inc., 2000).
Botswana has 24 health districts and each district has a District Multi-Sectoral AIDS
Coordinating Committee (DMSAC). This system aims to co-ordinate all efforts of
various governmental departments, private sectors, NGOs, community-based
organizations (CBO) , the district council , the district health team , members of
parliament, traditional authority (Kgotla- chieftain system) , and groups of people

26

living with HIV/AIDS. DMSAC provides the DHT with consultation on HIV/AIDS and
receives guidance. The multi-sectoral approach policies came from the recognition
that "the results have tended to be narrow, health-focused responses, with
Government as whole abdicating its responsibilities by placing AIDS within the ambit
of the public health sector" (GOB/NACA, April 2002, p. 5) .
Donors and international agencies have played a major role in developing the
government health sector response to HIV/AIDS in Botswana. Donor funding has
funded a substantial portion of developmental activities including research and
evaluation . Donor funds accounted for about 60% of funding for the AIDS/STD Unit
in 1998/99 (Abt Associates South Africa Inc. , 2002 , p. 56) . The major funders for
AIDS activities include the European Union, World Bank, UNAIDS, UNDP, World
Health Organization (WHO) , Swedish International Development Agency (SIDA),
Norwegian Agency for Development Corporation (NORAD) , Bill and Melinda Gates
Foundation , Botswana - Harvard Partnership, and Netherlands Development
Organization (SNV). Currently Botswana has put enormous energy and resources
into research including preparation for vaccines, epidemiology of TB and HIV, and
preparation of microbiocide trials in the country with the Botswana - Harvard
Partnership.
The health sector has several focus areas including voluntary counselling and
testing , home-based care, education and anti-retroviral drug therapy (ARV), all
provided to citizens of Botswana free of charge. Voluntary counselling and testing
for HIV is integrated into hospitals with free-standing testing and counselling centres
being established in various parts of the country with support of development

27

partners. These services have taken a long time to reach the rural areas of north
Okavango. Botswana also puts resources into the prevention of HIV transmission
from a mother to a child through the Prevention of Mother-to-Child Transmission
(PMTCT) program that promotes free AZT and Navirapine to all HIV positive
pregnant women . When a child is born to an HIV positive mother, the child is given
free infant formula and preventative drugs when it is appropriate. There is also a
national Home Based Care Program for terminally ill patients including AIDS
patients. Also, Health and HIV/AIDS Education Program is incorporated into the
school curriculum at all levels including the primary school level. Attention has also
been given to the reproductive health of youth- adolescents (GOB/MoH , 2002) .

2.3. Summary
The analytical framework of HIV/AIDS prevalence and prevention has been
discussed . These five factors of the framework are inter-related. Poverty makes
people vulnerable to infection and accentuates gender inequality which predisposes
women to infection. Traditional cultural values also reinforce women's inequality.
Traditional concepts of illnesses and healing often work as deterrents to attainment
of accurate knowledge and understanding of HIV/AIDS. Stigmatization
disempowers people and creates barriers in facing the reality of HIV/AIDS.
Marginalized people, the poor, women and ethnic minorities are vulnerable to
stigmatization and discrimination.
A summary of the current Botswana health system , policy and strategies on
HIV/AIDS was presented . The linkage between the analytical framework and local

28

events in the rural communities of northern Botswana will be discussed in Chapter
Four.

29

Chapter Three
Methods
3.0 Introduction
For this study, qualitative methods of data collection were used. Qualitative
research design is defined as "one in which the researcher plans to observe ,
discover, describe, compare and analyse the characteristics attributes, themes, and
underlying dimensions of a particular unit" (Seaman , 1987, as quoted in Mwale, &
Burnard , 1992, p. 20). Creswell (1998) defined qualitative research as an inquiry
process of understanding that explores a social or human problem emphasizing a
complex, holistic picture built on the study in a natural setting (p.15). I chose a
qualitative research approach because I sought insight into the complex interrelationships between the socio-economic and cultural factors and HIV/AIDS
prevalence in the particular rural communities . My research question , what are the
key barriers for people in rural communities to address the reality of HIV/AIDS
prevalence , involves the following two aspects: 1) to understand the knowledge of,
and attitudes about, HIV/AIDS held commonly by the local residents; and 2) to gain
insight into how poverty, gender inequality, traditional views of illness and healing,
marginalization and stigma intertwine and create the key barriers for HIV/AIDS
prevention . The communities are unique because minority groups including a large
number of San live there. As an HIV/AIDS advisor, my goal was to ensure the
research conducted was useful to the communities and TOCaDI.

30

My qualitative data collection methods included semi-structured interviews,
focus group discussions, and observations during community visits conducted over
the period between March and October 2004 . The information gathered through the
study period was amalgamated into an end-of-contract report for TOCaDI. The
characteristics of the study area are described in the end of this chapter to provide a
picture of these communities.

3.1 Methodology and Ethics
Conducting field research in the Third World raises certain ethical issues
related to power relationships between a researcher and people studied creating a
dilemma, especially when the studied are poor and marginalized people. The
diverse effects of gender, class, race and ethnicity need to be considered in defining
the research agenda, the research process, and dealing of research outcomes
(Wolf, 1996, p. 2 - 3) . I had two major concerns conducting cross-cultural research:
first of which was the accuracy and credibility of data collected. My second concern
was the possibility of exploiting the local staff and villagers with my position during
and after conducting my research . The first issue was about whether I could gain a
sufficient level of trust and would be given access to information that is intimate and
sensitive to them . Secondly, and more importantly, I needed to minimize damage or
harm that I might cause by conducting my research in the communities.
I entered the field as a researcher and as a female, foreign worker hired by a
local NGO, who is privileged with education , materials and opportunities. Upon
arrival , I was given a prefabricated house that had tap water, hot shower, electricity

31

and a propane cooking stove, while most villagers had no electricity and had to haul
water from a standpipe. Although I had to manage with much less, compared to
what I had in Canada, it was obvious that I had a lot more than the average villager
and local staff to make my life easier. What I did not have was the great network
and support system that the local staff and villagers had among themselves
especially in the time of need and during such occasions as funerals and illness.
The better that I understood the magnitude of the poverty that the villagers faced,
the clearer I realized the division that existed between them and myself. And, the
undeniable fact was that, as an outsider, I would be able to leave when my contract
finished.
Being an outsider also raised other issues. The Botswana Government has
many foreigners working in the HIV/AIDS field and people are used to have
foreigners 'helping' them. Before leaving Canada, I was told by a woman from
Botswana of the perception held by Botswana people that they need foreigners to
help them because foreigners are better than them. During my fieldwork, I received
an impression that this perception was also common among the villagers and
TOCaDI staff. This issue raised a concern that I also might be taking away
ownership of the subject from the local people and making them dependent. If this
were true, my presence would be harmful rather than helpful in the end. I made an
effort to curtail this problem by developing leadership within the communities and the
local staff of TOCaDI by sharing my knowledge and skills, while emphasizing
reciprocal and mutual learning, and confidence building.

32

I was aware that being a female researcher in the patriarchal society would
have some impact wh ile conducting my research. I furthe r did not assume that
being a woman would warrant universal solidarity or trust from women as other
strong factors such as race and class might affect our relationships. Breaking the
norms by insisting on my own western cultural value of women's equality or simply
confronting the exploitation the women face may have backfired (Berik, 1996, p. 65 68). I was often seen with my male partner, who was also a volunteer in the area,
when conducting my fieldwork. Although I did not intentionally use this status, I felt I
was respected because I was seen as a middle-aged married woman. Also, I
realized that being an outsider and being explicit about my role allowed me some
flexibility and I was allowed to openly talk about sex and sexuality.
During my fieldwork, I had a dual role, namely one as a project advisor hired
by TOCaDI and another as a researcher. Although the residents in the area,
particularly the San, have been research subjects for various topics, I felt my MA
research would help develop an HIV/AIDS program. Therefore I shared my
research objectives with TOCaDI staff and management and used my research
results to institute HIV/AIDS initiatives to meet the specific needs of the local
communities. Thus, I felt that there was little conflict between my roles as an advisor
and a researcher.
I was aware that there was an obvious hierarchy and division between local
staff and managers who were mainly non-local, and white. Because of my skin
colour, the local staff regarded me as a manager at the beginning. However, as we
worked together the division between local staff and myself somewhat weakened

33

although it never entirely diminished. I believe that local staff and I established a
collaborative working relationship and trust.
I believe that a researcher has the foremost responsibility to approach
subjects with political awareness and conscientiousness (Wolf, 1996). I avoided
pretence and did not try to immerse in their culture but tried to learn and understand
their culture and life with respect. I avoided making assumptions and tried to
develop and maintain reciprocity by listening. I used a "speaker-centred approach"
(Wolf, 1996, p. 25 - 26) in my focus group discussions by respecting the direction the
speakers were taking whenever it was appropriate. I tried not to assume that my
cultural values were superior to theirs because I was more educated and materially
privileged. My whole experience brought me to the fundamental questions of what
are the core values in life, what is culture, what does development mean, and who
am I? I feel most privileged that I was given this opportunity to touch the lives of
people in very rural and remote communities and learn about their lives.
My research proposal was discussed with the senior management team of
TOCaDI and the Kuru Family of Organizations (an umbrella organization of TOCaDI)
and received full support (Appendix B). Most of the residents in the areas of study
are illiterate and are unfamiliar with the western concept of signing consent. I feared
that asking them to sign a consent form might trigger adverse reactions and result in
reservations in sharing honest thoughts. With a recommendation from a senior
manager, I obtained permission from the Working Group for Indigenous Minorities in
Southern Africa (WIMSA) to conduct my graduate research. WIMSA is an advocacy

34

organization that protects cultural and intellectual rights of the San. A few of the
local staff of TOCaDI are members of the board.
I was introduced to the area extension teams and the communities as a
HIV/AIDS advisor/consultant. I continually consulted with the staff, especially
community development facilitators with whom I closely worked , on the issues of
cultural sensitivity.

3.2 Qualitative Methods

3.2.1 Literature Review
Research conducted by ACORD (2003) 6 on HIV/AIDS in a similar area in

2002 and an action research conducted on HIV/AIDS and :f:khomani San in South
Africa by the San Institute of Southern Africa (SASI) (2003) provided useful
information in designing my research. Particular information on the traditional views
of illness, death and healing , and gender was also obtained from literature. I was
given full access to data collected by an oral history project in past years (Khwe Oral
History/ Testimony Programme, 2003( These data were particularly useful in
learning traditional values and ways of life in the San culture. I became aware that
the beliefs in traditional healing are still strong among the San people.
6

ACORD is a British NGO that focused on HIV/AIDS research and education in some areas of the
Okavango District between 2001 and 2003. It ended its operation in December 2003 due to funding
cuts.
7

The oral history project started in 1998 by Kuru Family of Organizations and WIMSA led by
Willemien Le Roux. Over the next four years, 18 trained interviewers took interviews of 300 San
people. The interview results were compiled as a book "Voices of the San" by Willemien Le Roux &
Alison White, and published in November 2004.

35

3.2.2 Qualitative Data Collection
a. Staff Interviews
Interviews with TOCaDI staff were conducted on two separate occasions.
conducted preliminary staff interviews at the early stage of the research with the
primary focus on their knowledge levels, attitudes toward the disease and
perceptions of the problems with respect to HIV/AIDS prevalence. The staff
interviewed are mainly community development facilitators (CDF) from the three
extension teams of TOCaDI. The CDFs, all from the local communities, are assigned
to implement the TOCaDI program through CBOs, mostly community trusts, in their
areas. I interviewed the same staff members later again to further understand their
perception of economic and cultural-social issues related to HIV/AIDS after I had
worked with them on HIV/AIDS and had developed a stronger rapport. All the CDFs
speak English, therefore, the interviews were conducted in English without
translation . Staff interviews took place in the TOCaDI compound in a secluded
setting, often in my office or under trees, depending on their preferences. I
explained the purpose of the interviews and assured them that information would be
kept anonymous. The staff member signed his or her consent. The total number of
the staff interviewed was 15, all of whom were interviewed twice. The age range was
between 23 and 39 years old with most in their twenties. See Table 1 for details on
interviewed staff by ethnicity and gender.

36

Table 1. Number of staff interviewed by ethnicity and gender:
Area
Ethnicity
Male
Female
Total

N!oaxom/Shakawe
Khwe&
Hambukushu

6

Jakotsha
Hambukushu &
Wayeyi

2

8

3

1

4

Do be
Ju/'hoansi &
Hambukushu
1
2

Total

3

10
5
15

b. Interviews of Villagers
Five villagers were interviewed. The interviewees were three young women,
a male youth leader, and a male community leader. I also interviewed a traditional
healer from the Khwe community on his view of HIV/AIDS. English was used for
interviews except for the traditional healer, for whom staff translated between
Khwedam and English. Interviews of villagers were held in their own villages.
Village interviewees did not mind being interviewed in public. We were often
surrounded by other villagers, who might not understand English. The traditional
healer was willing to share his view on HIV/AIDS while surrounded by his family
members.
In all interviews, except for the one with the traditional healer, an open-end
questionnaire was used to elicit the interviewee's views as much as possible. The
questionnaire was constructed with questions that specifically tie an individual's
knowledge, perceptions and attitudes related to HIV/AIDS to socio-economic and his
or her cultural backgrounds (Appendix C). The interview with the traditional healer
focused on his beliefs on HIV/AIDS.

37

c. Focus Group Discussions
Focus group discussion is one of the common data collection methods for
HIV/AIDS research in Africa (Uwakwe, 1997; Buseh et al., 2002; ACORD, 2003).
found focus group discussion useful because it provided deeper insight into the
issues while opening a window into the common perceptions of the group.
Participants usually appeared comfortable to express their opinions once discussion
started. At the same time, I was aware that there were occasions when strong
opinions overpowered the minor voices among the participants. For example,
women often did not speak at meetings in the presence of men. Many youth did not
speak freely at the meeting when elders were present. I made an effort to encourage
all participants to speak by highlighting the uniqueness and importance of the topic.
All together, 34 focus group discussions were held in 20 villages and
settlements between March and October 2004. See Table 2 for details of the
participants by area, ethnic/ language background and gender.
There are eight different languages spoken in the catchment area of TOCaDI.
Most villagers who participated in the focus group spoke Setswana, with a small
number of the younger generation speaking English. However, some, especially
older people, only spoke their mother tongue, therefore, translation was necessary.
CDFs from the area translated between the local language or Setswana and
English. The staff who translated interviews were proficient in translating between
their mother tongue and English. The San language involves four different tongueclicking sounds. Although there are several ways to express the pronunciation of
the click sounds in writing , I use the symbols commonly used by authors and

38

researchers in the area: I dental click; +alveolar-palatal click; ! palatal click; and//
lateral click (Le Roux & White, 2004, p. ix)

Table 2. Number of the participants by area and ethnic background:
Area

Villages

N!oaxom

Shaikarawe
Kaputura
Gudigwa
Tobere
Mogotlho
Ngarange

Tsodilo
Hills

Jakotsha

Tsodilo Hills
Basarwa
village
Tsodilo Hills
Hambukushu
village
Etsha 6
Etsha 13
lkoga
Etsha 1

Do be

Total

Jao
Do be
Lobala
!ubi
Mahito
G!ohce
Bate
Magopa

Language/ethnic
background
Solely Khwe
Solely Khwe
Mostly Khwe
Khwe and
Hambukushu
Hambukushu
And Khwe
Khwe and
Hambukushu
Ju/'hoansi

Hambukushu
Hambukushu and
Wayeyi
Hambukushu and
Wayeyi
Hambukushu
Hambukushu and
Wayeyi
Wayeyi
Ju/'hoansiand
Herero
Ju/'hoansi
Ju/'hoansi
Ju/'hoansi
Ju/'hoansi
Ju/'hoansi
Ju/'hoansi/Herero

Number of participants
Total
Female Male

340

172

168

42

20

22

221

128

93

125

74

51

728

394

334

39

Focus group discussions took place in various settings that included trust
board meetings, village meetings, two sessions of week -long workshops, and
village meetings with and without a mini-workshop. I took every opportunity to be
present at village meetings and to raise health and HIV/AIDS issues with the
residents. Following the policy of the TOCaDI , effort was made to work through
existing structures such as the Village Development Committee and the Boards of
the Trusts. In some areas, a chief, or headman, called a kgotla (a traditional village
meeting) to discuss HIV/AIDS issues when staff approached the village committee to
arrange a meeting. Some meetings were attended mostly by men (e.g. trust board
meeting), while others were attended mostly by women (a craft workshop, and
payouts of thatching grass income). Age and gender specific discussion sessions
were arranged during the HIV/AIDS workshops in an effort to obtain independent
views of youth and women .
Focus groups took place in natural settings and the participation was usually
spontaneous and the participants were not compensated. The two week-long
workshops were organized to develop HIV/AIDS leadership in the communities. The
participants were selected to those workshops and meals and transportation were
provided.
The data were collected in the most cost-efficient and culturally sensitive
manner. Although TOCaDI has a strong focus on San people, its work
encompasses all minority groups in the area, therefore, my research did not exclude
other minority groups. In consultation with CDFs, I decided not to divide the
communities where more than one minority groups live together by calling only one

40

ethnic group for a meeting. Most communities have long been occupied by two or
more minority groups and they have had to work out how to live together peacefully
and collaboratively in small villages.

3.2.3 Recording Data
I took notes on the interviews and group discussions in English. The
informants are identified only by gender, age group and ethnic background. The
notes will be securely stored for future reference . I did not use an audio tape
recorder for two reasons. First, I thought it might affect the interviewee's attitudes
toward the interview considering the sensitivity of HIV/AIDS issues. Second , I
realized that local staff were not readily available for transcribing the recorded data.
During a group discussion , I took time to allow the staff to translate for me and asked
questions until I understood the answers well.

3.2.4 Qualitative Data Analysis
Behavioural research based on the model referred to as KABP (knowledge,
attitudes , beliefs and practices) survey was developed by the World Health
Organization (WHO) and was central to HIV/AIDS research in 1990s (Simbayi, 1999;
Cohen & Trussell , 1996). However, it soon became evident that the information was
insufficient to produce risk-reducing behavioural change (Klein et al. , 2002; Schoepf,
2001 ). Klein et al. (2002) argued that developing methodologies to evaluate
structural and environmental interventions and documenting the effects of largescale structural and environmental factors (e.g. poverty) on the highly localised

41

events (e.g . unprotected sex) are major challenges for HIV/AIDS research .
Research conducted in Zambia (Mwale & Burnard , 1992) and northern Botswana
(ACORD, 2003) using the KABP model demonstrated difficulties linking the
information collected through the survey to strategies that pragmatically address
larger structural issues.
I adapted this classic research design and methods to frame my
questionnaires but analysed my data by adding a further focus on the perceptions of
culture and socio-economic issues. I divided the findings into two major categories:
1) knowledge and attitudes; and 2) perceived problems such as poverty, and cultural
issues including traditional beliefs and gender, marginalization and stigma. I also
compared the results from different ethnic minority groups to see if there are any
significant differences in the knowledge level, attitudes and perceptions of socioeconomic and cultural factors related to HIV/AIDS that may be contributing to
barriers to behavioural changes.

3.3 Research Location
The physical environment of north Okavango District is described in order to
provide a 'picture' of the study area. This is followed by a brief description of the
history and composition of people in the area. The area is significant due to its ethnic
8

diversity including a large population of San , also commonly called Bushmen in the

8

The San have been called by many names : in Botswana, they are called Basarwa. They are also
commonly called "Bushmen". I use Khwe and Ju/'hoansi when referring to the particular group of
San , except for when I am addressing the San as a whole.

42

western world . Since TOCaDI mainly focuses on the San, attention is directed to
that group. Finally, health seNices available to area residents are summarised.

3.3.1 Geography of the Okavango District

Botswana is a land-locked country situated in the centre of Southern Africa. It
shares borders with Namibia, Zimbabwe, Zambia and South Africa (Appendix A- 1).
Dry riverbeds run through the Kalahari Desert, which covers 75% of Botswana and
forms a sand-filled basin characterised by scrub-covered savannah. The entire
Okavango District lies within the Kalahari Basin, a semi-arid expanse of wind-blown
sand deposits and long sandy valleys that seNe as sporadic water channels. The
Okavango River flows from Angola through Namibia into northwest Botswana
forming the Okavango Delta, 16,000 square kilometres of permanent and seasonal
swamps (Greenway & Swaney, 2001, p. 18; Butchart, 2000 , p. 8).
The area where I conducted my research falls within the Okavango District,
the very north-western corner of Botswana bordered by Namibia and the edge of the
Okavango Delta (Appendix A- 1). This area can be further divided into three areas
in which TOCaDI field extension teams work through community-based
organizations (Appendix A- 2, 3). The first area is called N!oaxom and covers the
north, that is, Shakawe and the north-east side of the Okavango River. The area is
also called the Okavango Panhandle. Here, the Okavango River is a permanent
channel that meanders through papyrus-filled swamps between compacted sand
and peat. The villages in which I conducted my research are Shaikarawe, Kaputura,
Tobere, Ngarange, Mogothlo and Gudigwa. Only Shaikarawe and Kaputura are

43

solely occupied by the San group called Khwe. The second area is between
Shakawe and Etsha 1. It is called Jskotsha after the community trust through which
TOCaDI works. My research was conducted in lkoga, Etsha 13, Etsha 6, Etsha 1,
and Jao. The area is mostly occupied by Hambukushu and Wayeyi people.
The last one, Dobe, is dryland consisting of a deep sandy basin just east of
the Namibian border. Away from the Okavango Delta, it is one of the most arid
areas not subject to permanent or seasonal flooding. A few small villages and many
tiny settlements are scattered in this infertile land. I conducted my research in Dobe,
!ubi, Lobala, Mahito G!ohce, Magopa and Bate. Most of the settlements I visited
were occupied by Ju/'hoansi, a San group, while some are occupied by Herero and
Ju/'hoansi. A unique community of two villages occupied by Hambukushu and
Ju/'hoansi is situated near historic Tsodilo Hills.
After the rainfall between November and March, the floodwaters move slowly
through the network of channels to central Botswana flooding villages along the way.
However, humidity is low during the rest of the year and drought appears to be a
cyclical phenomenon (Butchart, 2000, p. 9).

3.3.2 Brief History and People of Okavango Delta

a. History
Historically, northern and north-western Botswana has always been cut off
from the eastern parts of the country (Tiou & Campbell, 1997, p.132). Currently, five
significant ethnic groups live in the area: the San, Hambukushu, Wayeyi, Herero and
Tswana. The Tswana speaking people form the majority in Botswana and live in

44

more central locations such as Shakawe and Gumare. They hold most of the
government administrative positions and professional jobs, such as teachers and
nurses.
The San occupied most of Southern Africa for thousands of years, hunting
and gathering (Tiou & Campbell , 1997). The San themselves are not an identifiable,
homogeneous group but a collection of diverse groups of people with different
languages who are identified by the commonality of hunting and gathering life style
(Lee, 2003). The San are often associated with Khoe who lived in Southern Africa
around the same time , however, they are distinguished by life style as the Khoe
possessed livestock9 . In Botswana, the San are officially called Basarwa. The San
people who live in the Dobe area are called Ju!'hoansi , while the San who live in the
north of the Okavango River call themselves Khwe (also divided into Bugakhwe and
//Anikhwe according to different life styles and languages) 10 .
In the eighteenth century, as European white settlers expanded into northern
part of Southern Africa, conflicts between those settlers and San people escalated to
genocidal warfare and by the nineteenth century the San were almost exterminated
in present-day South Africa (Lee, 2003; Morris, 1996; Penn , 1996). However, in
Botswana, they continued to live in the Kalahari Desert with neighbouring Bantuspeaking people.

9

Tlou & Campbell (1997) argue that the San are as same as Khoe claiming both possessed cattle
before Bantu-speakers arrived in the area. The questions of when and how the encounters between
the San and other immigrants occurred have not been answered .
10

Other San groups live in the southern and western parts of Botswana.

45

The Wayeyi were the first Bantu-speaking people to move into the
Ngamiland, which covers the Okavango Delta area, in the eighteenth to nineteenth
centuries. They were agriculturists who also fished and hunted hippopotamuses
(Tiou & Campbell, 1997). The San people lived peacefully with the Wayeyi people
alongside the waterway. Khwe and Wayeyi had similar life styles and they
intermarried (Taylor, 2000). The next group to move into the area, in the beginning
of the nineteenth century, were Tswana (Bantu)-speaking Batawana people.
Although the number was small, they were powerful and formed a central polity,
leading to a rise of inequality among the population in the area (Taylor, 2000, p. 4853; Tlou & Campbell, 1997, p.140 -141). In the mid-nineteenth century, another
Bantu-speaking people, the Hambukushu, immigrated to the Okavango Delta from
Angola fleeing warfare. Some historians argue that the Hamubukushu settled on the
Okavango River by 1600 (Tiou & Campbell, 1997, p. 142). Between 1904 and 1907,
the Ovaherero (Herero) people who were escaping massacre by Germans in what is
now Namibia crossed the desert and sought refuge under the British Protectorate
and settled in the area. The Ovarherero are pastoralists who own large herds of
cattle, sheep and goats.

b. Marginalization of the San
The immigration of Bantu speaking people into the area had major impacts on
the life of the San. Following the immigration of Bantu-speaking people to the area,
the hierarchical relationships between the San people and other ethnic groups were

46

gradually formed: initially on an economic basis , and later these relationships
determined access to the political structure (Taylor, 2000 , p. 48 - 51).
The Bantu-speaking people are identified as herders and farmers. Due to the
aridity of the land and lack of rainfall , boreholes are of central concern . The Bantu
brought in cattle herding and farming into the areas and sought boreholes. Having a
large number of cattle surrounding boreholes has had a significant impact on the
environment and life style of the San people (Lee, 2003, p. 143 -145). San people
started to work for the Herero as seNants and herded their cattle while they
continued their traditional life style of hunting and gathering. In the meantime, the
quantity of wildlife in the area which the San relied on for their suNival was reduced .
The degraded environment meant that gathering and foraging has become difficult
for the San. The GOB Tribal Grazing Land Policy (TGLP) introduced in 1975 as a
land reform policy has made access to land by the San extremely difficult if not
impossible (Smith et al., 2000, p. 89- 90).
Also, Bantu-speaking people brought chiefdoms as a governance system that
was different from the kinship-based system of the San. In 1966, the Botswana's
independence brought a new era and a new situation for San people (Taylor, 2000,
p. 40- 51). The Botswana independent government, achieving a peaceful transfer
of governance from the British colony administration, used the 'non-racial state'
policy to establish the new nationhood , which denied the 'indigenous status' of San
people (Saugestad , 2001, p. 68- 76). The Bantu traditional chiefdom system was
grafted onto the new independent state, and the process has created the situation in

47

which the San have no representation in the governing system (Taylor, 2000, p. 50;
Saugestad, 2001 , chap. 4; Chumbo & Mmaba, 2002 , p. 18) .
The Botswana political system , kgamelo, is based on chieftaincy with the
kgotla as the centre of political power in a ward system that governs the local
communities (Thapelo, 1997). Within the ward system, the San do not have political
representation, placed at the bottom of the Botswana political hierarchy (Taylor,
2000; Chumba & Mmaba, 2002). As result, the San are "almost completely
excluded from attaining formal position of authority and control over land" (Taylor,
2000, p. 51) .
Saugestad (2001) argued that the Botswana government Remote Area
Development Program (RADP) is a system that also has exacerbated the political
marginalization of the San (p. 154 -169). The RADP is meant to achieve social
justice for people in rural and remote areas through a fair distribution of benefits, by
providing support to particular activities such as developing a community vegetable
garden. Although the official target of the program is not specifically San, 70- 80%
of the recipients of the program are San (Saugestad , 2001, p. 127). The program
does not consider the historical indigenous status or the unique economic and
cultural practice of the San. By using the term 'rural area dwellers', the program
failed to address the cultural identity issues with which the San struggle. Saugestad
(2001) argued that the political debates around the time of the independence
understated the actual extent of cultural and social diversity in Botswana and that
the monocultural image of the country does not reflect the multicultural reality.

48

Currently, approximately 49,000 San people live in Botswana out of estimated
88,025 in Southern Africa (Smith et al., 2000, p. 65) with the majority living in remote
areas and in extreme poverty. The majority of the San struggle to maintain their
traditional way of life and culture outside the mainstream polity and culture.
Wherever they are located, they face discrimination, human rights violations and
marginalization (Pakleppa & Kwononokka, 2003; Felton & Becker, 2001; Suzman,
2001).

3.4 Opportunities and Constraints
a. Power Relationships
As described in Section 3.1, power relationships existed between TOCaDI
local staff and myself. However, since I was specifically assigned as a HIV/AIDS
advisor and was not attached to any particular extension team, most of staff did not
regard me as their supervisor. Especially after working side by side on the
HIV/AIDS issues, the staff appeared to be more open and comfortable to freely talk
about their beliefs and opinions related to HIV/AIDS. For the communities studied,
TOCaDI has never had any direct involvement in health issues, although it tried to
establish a working relationship with an AIDS NGO, ACORD in the previous year.
During the village meetings, some residents expressed their frustrations with chronic
poverty and complained about the lack of support from the government and TOCaDI
in the health area as they now realize that HIV prevalence is a serious matter. Once
discussion started on the HIV/AIDS issue, the villagers did not appear constrained in
speaking about their health concerns.

49

The San in the area, especially Ju/'hoansi have been heavily researched by a
number of anthropologists and scholars (Lee, 2003; Smith et al., 2000; Marshall,
2000;Taylor, 2000) . Researchers sometimes romanticised their traditional life style
despite their extreme poverty (Taylor, 2000; Saugestad, 2001 ). I was aware and
cautious that an interviewee tended to tell the interviewer what he/she thought the
interviewer wanted to hear. I tried to be low-key by focusing on my work objectives
on HIV/AIDS issues and avoided stereotyping local people. I built a collaborative
working relationship with staff and villagers from all ethnic backgrounds by listening
and acknowledging their concerns, offering the information and training on HIV/AIDS
they requested , and incorporating their expressed needs into my HIV/AIDS work as
an advisor. This included training of staff, workshops in the villages, assisting in the
formation of youth groups in villages , promoting female leadership within TOCaDI
and villages , and mentoring staff in the HIV/AIDS work.

b. The Accessibility
Accessibility to the villages and settlements was limited for several reasons. I
needed at least one CDF to accompany me as a translator. CDFs were the most
valuable source of information especially regarding cultural sensitivity issues.
However, the CDFs were also engaged in other activities and often unavailable for
me. Long distances and heavy sandy roads separate Shakawe from most of the
villages and settlements. I needed to cancel scheduled meetings at times due to
unavailability of a four-wheel drive vehicle.

50

c. Language Barrier
There was an obvious language barrier since I only speak English. Few
researchers mention this constraint in their research (Mwale & Burnard, 1992, p. 24 25). However, I felt this issue is important because language also represents
culture. Mwale and Burnard (1992) stated that using locally known assistants could
reduce this difficulty (p. 25). I had to rely on staff for translation. To further my
understanding and reduce limitation of translation, I learned the cultural backgrounds
of each group by reading, attending meetings and consulting with the CDFs as much
as I could.

3.5 Summary
The research methods undertaken for this project included semi-structured
interviews and focus group discussions. Both methods were used in the most
culturally sensitive way informed by my awareness of the power relationships
between interviewees and myself. The historical and cultural uniqueness of the
area, that I learned about through my fieldwork as well as literature review, are taken
into account in the process of adapting the research design, fieldwork and analyses
of the results.

51

Chapter Four
Results and Discussion

4.0 Introduction
Results from interviews and focus group discussions varied from village to
village. There are also many commonalties in the perceptions of HIV/AIDS and
behaviour patterns within the same ethnic group indicating that traditional beliefs are
still strong. At the same time, the different responses in the discussions among the
same ethnic group indicated that encounters with other cultural groups have affected
each other in many ways. Botswana mainstream culture appeared to have had a
strong impact on all groups.
The data collected were divided into two major categories for analysis. The
first category is knowledge and attitudes with respect to HIV/AIDS held by local
residents. The second category is the factors that are perceived by local residents
as HIV/AIDS-related problems, namely, poverty, gender inequality, traditional beliefs
of illness, marginalization and stigma. Each individual factor and their interactions
serve as the analytical framework. In this project, I shed light on the commonalties
and differences between women and men, generations, and different ethnic groups
when possible. In discussion, the linkage between the HIV/AIDS and these
particular economic, social and cultural factors is explored.

52

4.1 Knowledge of and Attitudes towards HIV/AIDS

4.1.1 Knowledge of HIV/AIDS

Data were collected on the knowledge level and significant content of the
knowledge held by local residents so as to learn the accuracy and depth of their
understanding of HIV/AIDS. Data on accessibility to the information were also
collected to see if lack of access to information affects the knowledge held by the
villagers.

a. Knowledge Level
At the time of the initial interviews, all staff had a basic knowledge of
transmission , preventive measures, and availability of ARV therapy. However, they
lacked comprehensive understanding and accurate knowledge of particular topics
such as how mother-to-child transmissions occur and the eligibility criteria and
procedures to receive ARV therapy. Most villagers also know that HIV is transmitted
through unprotected sexual intercourse with an infected person , however, very few
people indicate having knowledge of mother-to-child transmission.
Many people in the remote villages misunderstand and confuse HIV/AIDS
with other diseases, especially tuberculosis and other STDs. In San villages in the
Dobe and N!oaxom areas, people are more concerned about tuberculosis , malaria,
and their health situation in general than about HIV/AIDS. Many people report, that
although they saw people get sick and die, they could not tell whether the person
died of AIDS or not because they do not know the symptoms of AIDS. There are

53

many misconceptions among the older Hambukushu and Khwe men about the
infection : contraceptive pills and condoms are blamed for the spread of HIV directly
(condoms are infected) and indirectly (condoms promote sex and promiscuity) . One
Khwe man stated that having sex with a pregnant woman would bring infection.
The older men and women who lack substantial knowledge of HIV/AIDS have
strong beliefs in traditional healing and it is difficult for them to understand the 'new
disease' (HIV/AIDS) . A number of older people are mixing up AIDS with traditional
diseases such as Depathi.
A Khwe man stated :
I don't know where this disease comes from . In our tradition , when
your spouse passed away, we stayed away for some duration of time
and get healing from a traditional doctor. These days, we don't follow
the tradition, therefore , a person will get bad blood and become sick
and die. We should follow our tradition so that we don't get AIDS.
(Tobere)
A Khwe woman stated:
We don't follow the traditional beliefs anymore, but the person who had
AIDS seems to have the same symptoms as the traditional disease.
So I think these diseases are same. (Kaputura)
There is a discrepancy in knowledge levels among minority groups. San
people tend to demonstrate inaccurate knowledge. Khwe and Ju/'hoansi people
also often express frustration with the lack of information. In general, Hambukushu
people seem to have better basic knowledge. One possible reason is that they tend
to live closer to larger villages where regular access to health clinics and a hospital
in Gumare, the regional government headquarters, are available. At the same time ,
it also appears that the San and other minority groups have different attitudes toward

54

gaining knowledge. There is no significant difference in knowledge between men
and women; however, their behaviours are different. Women tend to show a more
pragmatic and realistic understanding of the risk of HIV/AIDS.

b. Access to Information
Most villagers have heard of HIV/AIDS through radio , at health clinics,
schools, kgotla meetings, and from other villagers. In addition, TOCaDI staff
obtained some knowledge at workshops hosted by NGOs, ACORD in particular.
Despite the common remarks "I don't know anything about HIV/AIDS", many
villagers revealed that they had a basic knowledge of HIV transmission and
prevention, especipJiy the younger generation. At the same time, their knowledge is
often fragmentary and superficial. Many villagers demonstrate difficulty
understanding basic biological concepts such as conception. There seem to be
three possible contributing factors to this difficulty: first, the older generation did not
go to school; second, talking about sex is a taboo in their culture, therefore
education on reproductive health by parents does not occur; and third, a popular
African Independent Church active in the area, reportedly, preaches myths about
conception, resulting in confusion among villagers.
There is a large discrepancy in the levels of knowledge and understanding
among groups of people: some demonstrate very little knowledge while others have
a basic understanding and a willingness to learn more. Two characteristic groups
have very little knowledge. The first group consists of the residents of small villages
and settlements in the extremely remote areas of Dobe and N!oaxom. All live in the

55

more remote areas where there is no electricity. Their information sources are
limited access to radio broadcasts in Setswana and local clinics, which are not
always available . The second group consists of elderly men and women who only
speak their mother tongue. The lack of information available in their own language
(most of the information disseminated by the government is in Setswana, if not in
English) appears to be an important factor.

4.1.2 Attitudes toward HIV/AIDS

As an outsider, it is often difficult to know actual behaviour patterns of
particular groups, however, one's behaviour reflects the attitudes and beliefs of the
person. The main attitudes I observed during the focus group discussions can be
described as rejection , denial, resistance, fear, and acceptance leading to attempt to
take action.

a. Rejection
Overt rejections came from two small settlements in the Dobe area. In an
isolated small settlement, a CDF and I found several older women with a few young
people gathering under a tree. We were rejected when we offered to have a
discussion about HIV/AIDS. A few older women said one after another:
We don't want to know anything about AIDS. We are hungry, but you
didn't bring food for us. Why are you trying to tell us about AIDS when
we have nothing to eat? (Ju/'hoansi women, Bate)

56

Eventually, after a brief exchange of words, and with the support of a younger
woman, we were able to show an educational video. However, the older women
refused to discuss HIV/AIDS even after the video viewing. The CDF later informed
me that most of the women in the settlement were widows, although, we could not
know whether their husbands died from AIDS or other diseases. She suggested that
the women were afraid that they might also die from the debilitating illness.
Another rejection came from the residents of a remote Ju/'hoansi-Herero
mixed settlement in the Dobe area. The same CDF and I had been trying to visit the
new settlement to disseminate information on HIV/AIDS. When we went back to the
settlement for the second time, as suggested by the villagers, we encountered a
rejection. Older women and a young man sitting around a fire refused to talk
because they were too busy to listen to the information about HIV/AIDS. One
woman said:
Why did you come here without bringing food for us? I don't want to
know about AIDS. We are hungry. (Ju/'hoansi, Magopa)
Perhaps, there was a reason unknown to us behind the rejection. I was with a
Ju/'hoansi CDF from the area who speaks their language and has been working with
the community through TOCaDI. It is important to explore the reasons for the
rejection so that we could provide adequate support to those villagers.

b. Denial
A lack of ownership and internalisation of knowledge is evident among staff
and villagers alike: many informants used a third person term in discussions. For

57

example, "They don't go for testing", and "People should know their status" instead
of using "I' or "we". No one failed to state "ABC" (Abstain, Be faithful and
Condomize) as promoted by the government when answering a question on
preventive measures. However, many staff members admit that those measures are
very difficult to practice because they do not conform to social norms in their culture.
One staff member (Khwe) stated: "Sticking to one partner is very difficult for a
grown-up man like me". Other Khwe staff said: "They (villagers) don't want to know.
They are ignorant".

c. Resistance
Resistance is often expressed as ignorance. In some Hambukushu villages
and Khwe/ Hambukushu mixed villages, participants responded with indifference,
saying that they already knew about AIDS and had no questions to ask. However,
they stated that they did not know their own HIV status because no one had been
tested. Despite much anxiety shown, the men and women stated that they did not
know the symptoms of AIDS while they had seen many people die, young and old,
following debilitating illnesses. Resistance is common among villagers: people resist
accepting this 'new disease' and new information, and resist the preventive
measures particularly the usage of condoms.

Resistance to Condoms

There is strong resistance to condom usage. I find that the condom issue
sensitive because it reflects the complexity of the cultural norms, which includes a

58

conflict between the effort to maintain traditional values and the demands of
modernisation, gender inequality and a generation gap. There are many ambivalent
feelings toward condoms. Strong resistance toward condom use comes from older
participants in Hambukushu and San villages, who demonstrate confusion and
misunderstanding of HIV/AIDS. Condoms require a change in cultural practice by
altering women's position in sexual relationships. Discussion on condoms also
results in breaking the taboo of openly talking about sex, especially across
generations. Condoms are also contraceptives and therefore the usage of them is
contrary to the cultural norm of having many children.
Most churches preach against condom use, saying a condom kills the babies
in the semen, equating usage of a condom with committing murder. This argument
prevails among the villagers who lack a basic knowledge of the biological process of
conception. In Botswana, churches, especially African Independent Churches, have
a strong influence on people, particularly in rural areas. In addition , missionaries
who do not promote the use of condoms continue to have influence in the rural
areas. The villagers are confused by the contradictory messages coming from
churches and missionaries vis-a-vis the government through schools, clinics and
other AIDS workers.
In general, women seem to be more convinced of condom use as a mean of
protection. However, they are often denied the use of condoms due to gender
inequality, especially in Hambukushu society. Some women reported that if a
woman suggests a condom that means she might have been unfaithful to her
husband or she may be accepting her husband's adultery. Many express mutual

59

mistrust between men and women. Unless changes occur in the gender balance,
promotion of condoms will have minimal success.
Mistrust in condoms is used as an excuse for not using a condom: the
lubricant on the condom is said to give a rash to some people, and the condom itself
is infected with HIV, for example. Some people believe that HIV was brought to
Africans by white people to reduce the population growth of Africans. Some people
argue that it is a strategy by the government to control the population. Many older
people argue that condoms are the source of HIV prevalence.
AIDS is transmitted by condoms , because there was no AIDS before
the condoms came around. (Khwe woman , Tobere)
d. Fear
Some people resist accepting the existence of HIV/AIDS and new information
about the disease because of fear. This fear inhibits absorbing accurate information
about HIV/AIDS. As one staff member said , "They don't want to understand it".
What are they afraid of? Staff and villagers state that they are afraid of knowing that
they will die; they do not know what to do and feel hopeless if they are found to be
HIV positive.
If I went for testing and was found to be HIV positive, I will go into the
bush and hang myself. (Khwe male staff, Kaputura)
They are also afraid of the painful and debilitating course of the illness. And , most of
all they are afraid of stigma.
They will laugh at me if they know I am HIV positive. (Khwe female
staff, Ngarange)

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e. Acceptance and Will to Take Action
In some villages, residents demonstrated the courage to accept the reality of
HIV/AIDS prevalence and willingness to take action to prevent further infections. For
such acceptance to occur, it sometimes takes one or two villagers to speak up
positively, emphasizing the importance of caring for people who are affected by
HIV/AIDS. Residents in a Hambukushu village openly talked about HIV after one
courageous woman insisted that they must not be ashamed of being HIV positive.
The village formed an AIDS committee with half of the members being women. The
participants from this village, who later attended a workshop, repeatedly emphasized
the importance of community development around the challenges of HIV/AIDS.

4.2 Factors Perceived as Contributing to HIV/AIDS

Questions were asked as to how staff and villagers perceived problems
related to HIV/AIDS. The concerns demonstrated in relation to the spread of
HIV/AIDS are divided into the following five categories: poverty; gender inequality;
conflicts between traditional beliefs of illness and HIV/AIDS information from modern
medical system; marginalization and stigma. Although not part of the analytical
framework, a sixth factor contributing to HIV/AIDS emerged from focus group
discussions and interviews. This sixth factor is the generation gap, social
disintegration and conflicts in the communities which is brought about by and further
contributes to HIV/AIDS.

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4.2.1

Poverty
Poverty is a major effect on HIV/AIDS prevalence as it is a major concern of

life for the villagers. Away from major centres , people in the Okavango District are
extremely poor. They are not only income poor, but also have limited access to
basic needs. The majority lives in one-room thatched roof huts without electricity.
They have to haul water from a borehole (a drilled well) or government provided
piped water at village standpipes. Sanitation systems are extremely limited. People
use a public outhouse (a few for the entire village if they are available) , or more
likely, 'bush toilet' , referring to anywhere away from village huts.
Very few are employed. Villagers, on a rotational basis, may work on roads,
clearing bush , for example, for minimal pay as part of a government drought relief
program. Staff explained to me that welfare systems are difficult to access due to
lack of knowledge and difficulty meeting the requirements . Villagers living by the
Okavango River survive by fishing , others earn pocket money through short-term
construction work. Most income sources are in the informal sector. Some people
sell local vegetables and crafts such as woven baskets and ostrich eggshell
jewellery for minimal cash. Some work in the fields growing sorghum , millet, and
maize for themselves. There are no cash crops; very few vegetables grow due to the
poor soil and lack of rain in the area. The high unemployment rate (thought to be
well above 90%) combined with a lack of recreational activities , and lack of hope,
appeared to contribute to high alcohol consumption in all ages, and among both
women and men. The San , especially Ju/'hoansi, live in very poor conditions. Their
grass huts often do not have walls. Staff informed me that many have only one meal

62

a day and some only have a meal every two days. I often observed that they share
one bowl eating mealie meal (consist of powered millet) among a family.
Poverty aggravates risky behaviour such as women and girls having sex in
exchange for money and basic needs such as food and clothing. None of the
villagers used the word 'prostitution', however, many residents reported that it has
been happening on an on-going basis especially when a number of people come
from outside (construction , cattle lung disease eradication program 11, drought relief
program , among others).
When the cattle disease happened, so many men came to this area to
kill the cattle . AIDS started after that time. (Khwe man, Ngarange)
The beginning of the drought relief program (along with it, many
workers come to the villages) brought this disease. (Khwe woman ,
Tobere)
The villagers identified the lack of a hygienic environment and poor living conditions.
The villages are dirty; rubbish is everywhere. (men and women from
N!oaxom villages: Ngarange, Tobere and Kaputura)
Although most villages and settlements are provided with clean water piped to
village standpipes, limited access to clean water is a particular concern for the Khwe
villages , because it makes keeping the environment clean and looking after sick
people difficult. Lack of water is particularly critical in the Dobe area.
Poverty has affected the health of villagers due to poor nutrition. Staff
members and villagers point out that food intake and nutrition are limited by poverty,

11

The cattle disease eradication program wiped out cattle in the north of Maun in the middle 1990s.
A high level of mobility in population took place at the time .

63

placing the body's immune system at risk whether the person is affected by HIV or
not.
You say a person with HIV/AIDS needs to eat well. What can I eat if I
have AIDS when there is nothing to eat? (Khwe woman, Shaikarawe)
Why are you talking about AIDS when we are starving? (Ju/'hoansi
woman, Dobe area)
A concern for alcoholism is frequently brought up at the focus group
discussions. All villages except Tsodilo Hills express concerns with high alcohol
consumption because of its correlation with risky sexual behaviour. Some say that
poverty and unemployment promote drinking of cheap traditional beer among the
young and old.
One staff member links poverty to marginalization. He states that the poor are
more vulnerable because they are afraid of discrimination and tend not to seek
health care services they need.

4.2.2. Gender Inequality
a. Gender Inequality as a Societal Norm
The second important factor identified is the role played by traditional norms
with respect to sexual relationships -this include the polygamous custom common
in the Hambukushu culture and women's unequal power in sexual relationships
common in Botswana culture. Female staff express concern about gender inequality
and the harsh lives women face, but they seem to accept it as a norm.

64

As one staff member reports , polygamous relationships and wife inheritance
are still common practice in the Hambukushu community. Hambukushu women
express a strong concern about their safety in sexual relationships that might result
in an HIV infection. The voicelessness of women in their sexual relationships results
in the difficulty when discussing condoms and convincing their husbands to use
them. Women are worried that if they insist on condoms, their husbands will leave
for other women.
If a wife refuses to have sex, a husband can go to the wife's parents to
complain and she will be blamed for causing a marital problem.
(Wayeyi woman , Etsha 6)
Men are the ones who make decisions in the household. In
Hambukushu culture, a woman has to obey her husband. When her
husband dies, she will be the head of the household until her son
grows up, then she will have to obey her son. (Hambukushu man,
lkoga)
If a wife asks her husband his whereabouts during the night, it will frequently result
in spousal violence so women endure voicelessly. A Ju/'hoansi staff member states
that domestic violence involving sexual partners is also common in Ju/'hoansi
society.
Also, in Hambukushu culture , women are expected to bear many children.
During group discussions, the importance of fertility was used to argue against
usage of condoms by both men and women. Many men state that polygamy is
common and accepted in the Hambukushu culture: "Nothing is wrong with having
many wives in our culture" (a Hambukushu man, Etsha 6). At the same time, men

65

blame young girls for "sleeping around and getting pregnant" and "spreading
HIV/AIDS" (Khwe and Hsmbukushu villages).
Staff members and villagers from the Khwe and Ju/'hoansi backgrounds
stated that traditionally marriage was arranged by parents at a particular age and
with one partner. There were initiation ceremonies and coming of age rituals for
both girls and boys where they were taught the traditional way of life by elders.
However, the villagers claim that since they encountered other cultures and
interracial marriages have become common , this traditional norm no longer exists
and girls have sex at a very young age. One staff member states that in these days,
youth have sexual relationships at a very early age and with multiple partners.
Parents have lost authority over their children's sexual behaviors. The taboo against
talking openly about sex, particularly in front of elders inhibits open discussion about
HIV /AIDS.
Hostels for residential schools 12 are especially blamed for creating the early
onset of sexual behaviour and subsequent early pregnancies. School dropout rates
due to pregnancy are very high among San girls. A Khwe woman demonstrates a
serious concern that girls are often sexually exploited at the school hostels (by
students and teachers). Then , the incidents are usually unreported or minimized.
This indicates two issues: a significant level of acceptance of the gender inequality in
society and the weakness of the Khwe parents in seeking justice for their girl
children.

12

In the studied area, due to the remoteness , many ch ildren attend residential school.

66

b. Gender and Poverty
In both Hambukushu and San communities , women are always poorer than
men and often have no means of earning an income. Although villagers say women
and girls are exposed to infection by having sex in exchange for money and food ,
they do not voice a solution to this problem . Early pregnancies result in school
dropouts and make girls and women further unemployable due to lack of education.
There is a repeated cycle of poverty: early onset of sexual relationships and early
pregnancy, unemployment of undereducated women , and poverty as a result.

4.2.3 HIV/AIDS and Traditional Beliefs of Healing and Modern Medicine
Although percentages are unknown, belief in traditional healing is strong
among villagers. Approximately half of the staff interviewed prefer to go only to a
clinic while the other half use both traditional healers and a clinic. The choice is
made according to their symptoms: some diseases are considered non-treatable at
a clinic and have to be treated by a traditional doctor. No staff member reported that
he or she would only go to a traditional doctor. At the same time, most staff
members continue to believe in traditional healing and practices. For example , they
would conform to a traditional healing process with a series of rituals in relation to a
funeral so that they can avoid illness as result of breaking taboos.
Male participants from Hambukushu and Wayeyi villages lament that
traditional values are neglected and this negligence is leading to the HIV prevalence.
Khwe elders also echo similar sentiments and claim that loss of traditional practice is
causing an AIDS epidemic in the community.

67

In our tradition of healing, when a spouse died, the husband or wife
stayed isolated to go through a healing process. These days, people
don't go through this process and meet with other woman/man so he
or she will get contact with bad blood. We should follow this tradition so
that we don't get AIDS. (Khwe man, Kaputura)
We see a person swell first and then shrink, and die. If you take the
person to a traditional doctor, he will get rid of bad blood then it will
help. But if you take him to hospital, the person will die. (Khwe man,
Tobere)
TOCaDI staff explained to me that Depathi is caused by breaking established
taboos such as refraining to have sex with a woman who had a miscarriage before
she completes the cleansing ritual. The symptoms resemble those associated with
full-blown AIDS: headache; pain in the back and legs; weakness; and loss of weight,
for example. The traditional belief is that Depathi has to be treated by a traditional
doctor, and if the patient is taken to a clinic and receives an injection, the person will
die immediately. It appears very difficult for many villagers to understand a disease
to which this traditional concept does not apply. A Khwe traditional doctor whom I
interviewed explained the spread of HIV/AIDS:
When a cold drop from the sky falls and goes into your body, you
get AIDS. (Khwe male traditional doctor, Ngarange)
Traditionally, the San believed in a supernatural world with many gods (Lee,
2003; Marshall, 1999). The San deal with illness and healing by righting wrong
through re-establishing good relationships between the gods and themselves.
Healing dances and medicinal wild plants are central to their healing (Lee, 2003; Le
Roux & White, 2004; Tlou & Campbell, 1997). However, when Bantu-speaking
people came in contact with San, Bantu beliefs presented a major challenge to San

68

people, particularly sorcery and witchcraft. While San believe that illnesses come
from external power of gods, sorcery seeks the source of the misfortune within the
community, therefore, setting kin against kin and neighbour against neighbour (Lee,
2003, p. 138 -139). My observations and information from interviews and group
discussions indicates that most San continue to believe in their traditional concepts
of illness and healing and do not really understand HIV/AIDS. The concepts brought
in by Bantu-speaking people and missionaries have created further confusion in
understanding of HIV/ADS. Some villagers, especially Hambukushu, believe that
illnesses are caused by witchcraft (as a result of a curse by neighbours or family
members).
As they believe most illnesses are caused by witchcraft, breaking of a taboo,
or ancestral gods, the concept of an immune system is completely foreign to them.
Most villagers tend to seek traditional healing when they fall ill or wait for a long time
before seeking medical attention from a clinic. The traditional diseases can create
severe implications, however, there is no stigma attached to them while AIDS is
stigmatized. One reason why people prefer to believe in traditional diseases rather
than trying to understand AIDS is perhaps that traditional diseases will not bring
shame on the person.
At the same time, although strong beliefs in traditional healing are evident
among the villagers during the group discussions, this tradition is being gradually
weakened.
We see people are getting sick like having diarrhoea but we are not getting
any help. We go to traditional doctors, we go to a clinic, we go to everywhere,
but can't get help. (Khwe woman, Kaputura)

69

Those people who go to traditional doctors must know that they are in
denial. Botswana people believe in witchcraft, but those people are the
ones who are making us sick. (Hambukushu woman , Etsha 6)
Traditional doctors may also have difficulty understanding HIV/AIDS. The
traditional doctor I interviewed said that if patients came to see him too late, he
would not be able to cure them.

4.2.4 Marginalization
People living in this area are marginalized. They are marginalized from
the mainstream economy of the country and live in extreme poverty while the rest of
the population enjoys the comparative prosperity of Botswana. They are
marginalized from mainstream information dissemination due to language barriers.
Also, the information given is not culturally sensitive and is often beyond their
comprehension. They are marginalized because they are not part of decision
making in the health care or education systems. Children of school age in N!oaxom
and Dobe areas attend boarding school in larger villages, many from grade one.
Senior secondary education is only available in Maun (400km to south) or Ghanzi
(500km to south- west). Away from home communities, with no cultural
consideration in the curriculum , discrimination and abuse are common for San
children (LeRoux, 1999). School dropouts are a serious problem .
Lack of access to adequate health services is one of the major concerns
expressed by villagers. Villagers feel that they have been marginalized through lack
of access to adequate health services. All staff interviewed stated that poverty in the

70

area resulted in lack of access to adequate health services because there is no
affordable transportation to health facilities. Also, many raised concerns regarding
the current health care services: accessibility, skill levels of nurses and mistrust in
the health care system in general.

a. Lack of Access to Health Care
Villagers note a lack of adequate health services in the remote areas where
they live. According to the Botswana health service policy, small villages and
settlements with a population under 500 receive only monthly mobile clinic visits by a
nurse, which do not materialise whenever a problem arises with a clinic vehicle.
Villagers report that when residents give TB test samples, the test result often
comes back so late that the patient would die before learning the result. Many
villages do not have an adequate home-based-care program that is crucial to patient
care at home. Lack of transportation is also of concern since there is no public
transportation in two of the three TOCaDI catchment areas. The villagers have to
travel many hours on foot on heavy sandy roads to access a nearby clinic. Most
villagers do not have money to hire private transport.
We asked the clinic to transport a patient but they never sent a vehicle.
So, we had to take him on the back of a donkey to the clinic 17
kilometres away. (Ju/'hoansi man, Dobe area)

b. Attitudes of Health Care Providers
Many concerns and complaints relate to the attitudes of the health care
professionals. The San particularly feel that health professionals are negative and

71

discriminatory towards them. Hambukushu who live in the N!oaxom area also
express dissatisfaction with health care professionals' behaviour toward poor
villagers who visit the clinic.

c. Lack of Communication between Clinic Nurses and the Patients
Since the patients are usually accompanied by a translator (family member or
a health clinic staff), lack of communication is more likely due to a cultural issue and
marginalization than to a language issue. San people have a tendency not to
express their symptoms explicitly and assertively to clinic staff, and end up not
receiving the care they need. The communication breakdown results in mistrust in
health service and non-compliant behaviour.
When you go to clinic because you are coughing, a nurse will tell you
to go home and drink hot water. (Khwe woman, Shaikarawe)
We can't explain what is wrong with us; many of us don't tell a nurse
that we have cough for a long time or we have a chest pain. (Khwe
woman, Shaikarawe)
When we go to a clinic for different symptoms, a nurse will gives us the
same pills. (Hambukushu man, Ngarange)
Many villagers complain about the difficulty of going to an HIV testing and
counselling centre; an ARV treatment centre was only available in Maun at the time
of this fieldwork. However, the complaint might be used as an excuse for not going
for an HIV test, as one woman stated:
If you want to be tested, there are many ways to do it. If you really
want to go to the testing centre, you will take a bus and go, you don't
wait until someone pays for your bus fare. (Hambukushu woman,
lkoga)

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4.2.5 Stigma

The leading perceptions among the staff regarding community reactions
toward people affected by HIV/AIDS are divided almost equally between shame and
rejection, and acceptance and caring . Denial and ignorance are listed as the third
common reaction. This result reflects highly ambivalent feelings among the staff:
seven staff members, Khwe and Hambukushu , pointed to shame and rejection as a
common reaction in their villages. Some villagers are afraid to touch an ill person
because they think that they might get the same disease. Whereas , one staff
member states that a tradition to care for the sick still exists in the San community.
The difference in opinions seems to indicate that there is a breakdown of traditional
values after contact with other cultures. At the same time, staff demonstrate
concerns about denial of HIV/AIDS and ignorance of the information by the
villagers. During my stay, no staff members or villager officially informed the
TOCaDI or myself that he or she was HIV positive, while some stated they went to
testing and were negative. Stigma is pervasive in the communities.

4.2.6 Disintegration of the Society- Generation Gap

Along with the diminishing traditional values , almost all villages complained
about a communication breakdown between the young and the older generations as
a serious concern. Hambukushu adults often blame youth for spreading HIV by
being sexually active. In turn, young people blame their parents' generation for
ignoring information and protective measures. Hambukushu participants state that
parents do not talk to their children anymore and youth do not listen to their parents.

73

In Khwe villages, older men and women repeatedly express similar concerns. The
Khwe parents also feel that they no longer have control over their children's
behaviour. The San youth express frustration with their parents for their denial of
HIV/AIDS and neglect of protective measures against the virus.

Due to a taboo of

talking about sex, youths state that they are unable to discuss HIV/AIDS openly.
It is difficult to explain HIV/AIDS to elders because of the certain words
which are not supposed to be used by youth with elders. (Khwe youth ,
Ngarange).
Parents fear that their traditional way of life will be rejected by youth and
tradition would diminish. Dwelling on the fear, older people are not able to accept
the new concept of "HIV/AIDS" while youth are more open to the new information.

4.3 Discussion

Based on my data, the connections among the five themes of the analytical
framework, namely, poverty, gender inequality, traditional beliefs of illness and
healing, marginalization, and stigma, as well as the linkage with HIV/AIDS
prevalence are discussed . Each factor, as well as the connections among them,
influences behaviour, knowledge and attitudes.

4.3.1 Poverty

The extreme poverty combined with their noted marginalization makes it
difficult for people to deal with HIV/AIDS in these rural communities. Major affects of
poverty on HIV/AIDS prevalence in these rural communities include poor health

74

status including malnutrition , vulnerability of women, poor educational attainment,
marginalization , lowered morale, reinforcement of stigma and disintegration of the
society.
The poor living conditions make people susceptible to infections. High
prevalence of tuberculosis , malaria and STDs are reported among the San,
particularly women (Felton & Becker, 2001 , p. 47- 51) . Their immune systems are
weak due to a lack of nutrition and exposure to other diseases. Lack of funds to
travel makes access to HIV testing and ARV treatment very difficult. Also, if found to
be HIV positive, their body may not be able to tolerate ARV therapy. Some people
do not believe that the treatment will make a difference in their life when they have
little hope for their future . Thus, people are discouraged from going for testing even
if they overcome the stigma. This means a delay in starting treatment.
Losing a family member to illness in their prime results in further hardship in
the family. Deaths of parents create more orphans who have very limited support in
poor communities . Poverty is a serious problem that aggravates the problem of
HIV/AIDS in rural northern Botswana communities.

4.3.2 Gender Inequality

Gender inequality is one of the major factors exacerbating HIV/AIDS
prevalence in the rural Botswana. Gender inequality is rooted in the traditional
cultural norms in Botswana society. Combined with the disadvantaged conditions in
which women live, women do not have a decision making power in their sexual

75

relationships as Lesetidi (1999) argued. Poverty only aggravates women's
vulnerability by encouraging risky sexual behaviour.
There is a strong disagreement between men and women regarding
HIV/AIDS prevalence. Men seem to feel a loss of control over the issue and blame
women as a source of HIV infection. Women tend to have more realistic ideas of
HIV/AIDS, perhaps because they are the ones who look after the sick. Women also
blame men , especially because of their multiple sexual relationships. It appears that
some women are caught in the middle between their knowledge and desire to use
condoms and the fact that they are not allowed to do so. The common societal norm
that emphasizes women's fertility is reinforced by the teaching of the churches that
preach use of condoms as murder of babies. It places women who want to use
condom in a hopeless position.
Cultural norms for gender relationships have affected women in different
minority groups differently. Women have many restrictions particularly in
Hambukushu culture. Cultural encounters and intermarriages with other ethnic
groups have affected San women regarding their positions in sexual relationships.
Lee (2003) reported a high status of women relative to men in J/'hoansi in his
research conducted in 1960s, while pointing out that there were major changes after
1970 (p. 192). Fulton and Becker (2001, p. 15 -16) argued that the relative gender
equality appeared to be linked to the extent to which gathering continued to be an
integral part of livelihood of the San groups. Women were the main gatherers and
were proud of their contribution to family sustenance from foraging. Through
encountering neighbouring communities and intermarriage, the San women's status

76

has changed. The literature is not clear as to when and how these encounters
occurred. However, Felton and Becker (2001 , p. 51 -53) warn that there is a
discernible acceleration in the spread of HIV/AIDS among the San, and San women
in particular, combined with an increase in gender-based abuse and alcohol abuse.
Although San women had more autonomy in their traditional life style, in
contemporary San life, "San women throughout southern Africa experience many
forms of violence both inside and outside the San communities" (Felton & Becker,
2001 ' p. 55).

4.3.3 Traditional Beliefs of Healing
For many people in the research area, understanding HIV and AIDS means
confronting their own traditional cultural values especially beliefs in traditional
healing. Traditional beliefs are the values that marginalized people can uphold. It is
the way they can show their autonomy, authority and ownership. However, it makes
understanding the dynamics of HIV/AIDS extremely difficult, especially when they
believe that symptoms of a traditional disease and AIDS are the same. Villagers ,
especially from older generations, refuse to face reality , resist accepting new
information and knowledge, and resist changing behaviour.
Beliefs in traditional healing are extremely important for the residents in these
rural communities because they are the core values of their culture. There are
obvious conflicts between traditional healing and modern health care system, on
which the GOB built their HIV/AIDS policies. In the Botswana National Health
Policy, it is recognized that the traditional health system continues to be an integral

77

part of cultural values and beliefs in Botswana, however, it considers it is so different
from the modern health system that they cannot be fully integrated (Abt Associates
South Africa, Inc. , 2002 , p. 54) . However, if these conflicts are not addressed , there
will continue to be barriers to behavioural change.
The strong beliefs in traditional healing held by older generation create
generation gaps, difficulty in understanding HIV/AIDS and marginalization of the
communities that believe and practice traditional healing.

4.3.4 Marginalization
Marginalization of the rural communities is reflected in the forms of lack of
adequate health care services , poor educational attainment, high unemployment
rates , especially among youths, exclusion from decision making processes
regarding their lives and lack of access information. Remoteness, poverty, nonmainstream cultures with their own languages, strong beliefs in traditional illness and
healing and gender inequality all fortify marginalization.
Marginalization is not only a matter of physical conditions but it also affects
people's mentality. Exclusion from the mainstream of the society creates
resentment and resistance to changes. Most of the villages are struggling to
survive. They have a minimal amount of food, and their cultural identity is at risk, as
is their health. This situation leads them to distrust the government and the system
and despair of the entire situation.

78

4.3.5 Stigma

HIV/AIDS-related stigma plays into, and reinforces , existing social inequalities
(Aggleton & Parker, 2002, p. 9) . Feeling powerless and hopeless as result of stigma
makes people turn away from the reality of HIV/AIDS. Poverty, gender inequality,
and marginalization, exclusion from the mainstream economy and opportunities in
the Botswana society affect the sense of self-worthiness of people and the
communities. HIV/AIDS related stigma reinforces people's vulnerability and reduce
their coping ability. As Aggleton and Parker (2002) argued , empowering
communities through a participatory process that unleashes their own knowledge
and experiences is crucial in reducing stigma (p. 18).

4.4. Conclusion

My data analysis and discussion demonstrate that the connection and
interaction between the five themes of the analytical framework. The five factors are
all important, ranking them is beyond the scope of this research project. However,
when they interact with each other, they exacerbate HIV/AIDS prevalence and
create serious barriers for the marginalized people, especially women in the rural
area.
Reaching beyond my analytical framework themes, I felt that many
communities face disintegration of society, particularly in the form of generation
gaps. The older generations feel that their values are lost in the modern age. They
have difficulty accepting the fact that HIV/AIDS is threatening their future. It appears
that they are confused as to which way they should lead the community. In turn,

79

youth feel frustrated and blamed. The flexible minds of youth understand HIV/AIDS
more easily and many are ready to make changes, however, they feel stymied by
the older generation. Youth in the rural communities are also somewhat confused
because the knowledge they obtained from outside sources such as school and
clinics contradicts the knowledge they gained from the elders. They are not getting
guidance from their own people. The conflicts between generations obstruct
dissemination of accurate and adequate information on HIV/AIDS and development
of supportive communities.
In the Khwe villages in N!oaxon area, youth who accepted the disease took
initiatives to reduce the risk. Village youth live in a highly challenging environment
with poverty, almost no employment opportunities, remoteness , high alcoholism, and
the cultural taboo regarding talking about sex and sexuality with the older
generation. Nevertheless, village youth formed HIV/AIDS youth committees and
sought training to improve the HIV/AIDS situation in their communities. The
incentive to work on HIV/AIDS issues seems to give village youth motivation and
hope to improve village life for themselves and for others.

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Chapter Five
Conclusions and Recommendations

5.0 Conclusions:
HIV/AIDS in villages of north Okavango replicates the large-scale picture that
is taking place on the global level. My research confirms the analytical framework
describing the core factors of HIV/AIDS as poverty, gender inequality, beliefs of
traditional healing, marginalization, and stigma. The problems of HIV/AIDS in the
Okavango District are highly complex and intertwined with social, cultural and
economic challenges in the area. The area is the most marginalized in Botswana
due to its remoteness as well as its highly diverse population and non-mainstream
cultures. Without untangling these issues, the problems imposed by HIV/AIDS will
never be resolved in the area. A summary of the main results follows .
The communities are sensing the creeping impact of the HIV/AIDS pandemic
and feel forced to change. However, without understanding the reality of HIV/AIDS
and internalising the knowledge, people resist change. It is not just individuals'
behaviour but the whole social structure, societal values and norms, and culture that
must change. It is extremely difficult for communities that have very limited
resources and are clinging to their traditional values to survive. If they have to
change, in what ways should they change and what changes are more acceptable to
them? People need to take ownership of the problems and develop the strategies
they can act upon effectively.

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Saturated in international donors' funds , the GOB strategies are largely based
on western cultural values and concepts. The Botswana Government policy does
not reflect the respect for traditional views of illness and healing widely held by its
residents . Simply imposing western concepts of illness and treatment on villagers
will not bring success in reducing the HIV pandemic.
My research identifies poverty, cultural conflicts that involve gender inequality
and beliefs of traditional illness and healing, and marginalization as the key
contributors to HIV/AIDS in the area. These factors reinforce stigma that is
pervasive, and create barriers to prevention strategies for marginalized minority
groups in the Okavango District.
Poverty is a significant issue in the area. Poverty affects people's health
status not only physically but also mentally. Poor nutrition weakens the immune
system and makes it vulnerable to HIV infection. Poverty is linked to a life style that
is prone to high alcohol consumption and related high-risk behaviours in poor rural
communities. Poverty predisposes women to HIV infection as women struggle to
survive. Poverty often makes people feel powerless; hunger is often felt to be
degrading. Poverty may also stigmatize people and prevents people from facing the
reality of HIV/AIDS and seeking the medical services and care they need.
Gender plays a central role in HIV prevalence in Africa. Women in the
Okavango District are placed in perilous positions in relation to HIV infection and
gender-based violence. Women also infect their babies during and after pregnancy.
Without changing gender dynamics in the local communities , many women will
continue to die of AIDS. Gender has close ties to poverty and is also dictated by

82

traditional cultural values. Gender relationships play a highly sensitive role in the
community and are difficult to change. Nevertheless, empowering women,
especially young girls, economically and socially is pivotal to success in any HIV
prevalence program.
Significant disagreement is found between traditional beliefs and modern
medical systems that disseminate information on HIV/AIDS and promote strategies
for HIV prevention. This disagreement is causing confusion and people also feel
authorities are untrustworthy. Further education is needed. However, the
mainstream system also needs to understand the importance of local cultural values
based on traditional beliefs . I felt that the older generation was seeking assurance
that their most important cultural values would be respected. Culture change is a
dynamic process. However, the ultimate change in societal values will have to come
from within the community. Ignoring traditional culture and forcing them to change
will only result in resistance. In the rural communities in the Okavango District,
cultures are interwoven in the most complex way through intermarriage and cultural
exchanges. Nevertheless, cultural values and languages need to be taken seriously
when disseminating information. HIV/AIDS education needs to be created so people
understand HIV/AIDS through existing knowledge based on their cultural values and
religious beliefs. When the information given is unfamiliar and not understandable,
people will absorb inaccurate and misleading information.
Minorities, particularly the San in the Okavango District, are marginalized to
an unthinkable degree. The cultures, economic status and education of the minority
groups are ignored by the Botswana government policy. The San people in

83

particular are having a difficult battle for survival with minimal resources and minimal
assistance while their autonomy is denied. It is time to re-evaluate real factors that
are contributing to the spread of HIV/AIDS outside of existing medical and behaviour
models. In shifting a view from the medical and behavioural models to development
and cultural aspects, voices of the marginalized minority groups need to be heard
and reflected in policy making so that it reflects their true needs.
Stigmatization of people infected with HIV is common, especially in Africa.
However, particularly in the Okavango District, stigma is reinforced by
marginalization, poverty, gender inequality and traditional societal values. Women
are much more likely to be blamed for the spread of HIV. Stigma creates fear and
denial and results in indifference. Castro and Farmer (2005) reported that
introduction of quality HIV care led to rapid stigma reduction in their study in Haiti.
Their research suggests building a structure that provides care for the people living
with HIV/AIDS is essential in reducing stigma in the Okavango District.
During my fieldwork, I met many young people who are eager to learn and
work on HIV prevention. Sadly, few income sources and employment opportunity
are available to them. Sources available to actualize and support their wishes are
almost non-existent in the communities as well as at TOCaDI. Little research has
been done on the active role that youth can take in the community in HIV/AIDS
prevention and patient care, especially in rural areas. Few resources are allocated
to this type of program.
The Botswana government demonstrates a certain level of commitment and
offers various programmes that are of a high standard compared to other African

84

nations in general. Despite this effort, most of the population does not know its HIV
status (GOB , 2002). There are several shortcomings of the policy and strategies.
In the National HIV/AIDS Assessment for Strategic Framework 2003 -2009,
the Government identified several socio-cultural determinants for the HIV/AIDS
epidemic. Subordination of women that affects decision making in sexual
relationships was highlighted along with the exploitation of young girls, called the
'sugar daddy' problem. The Framework connects the 'sugar daddy' problem to
poverty and discrepancy in wealth distribution in society (GOB/NACA, 2002, p. 12).
Population mobility and limited access to schooling are listed as other socioeconomic factors contributing to HIV/AIDS. Population mobility relates to both the
traditional livelihood that depends on cattle and agriculture , and the modern life of
urbanization and mining. Limited access to schooling in the remote areas makes
children live away from parents where there are inadequate support systems and
supervision. The Botswana HIV/AIDS strategies do not seem to include programs
for poverty reduction such as income generation and employment opportunities in
the local communities, or improvement of primary education systems (GOB/MoH ,
2002).
Stigma is listed as a significant source of fear that induces people to believe
that they would rather not know their HIV status (GOB/NACA, 2002, p. 5). This
denial and fear contribute to a low rate of voluntary testing and reluctance of families
to take care of persons living with HIV/AIDS at home and to seek support for such
care (Abt Associate South Africa Inc. , 2002 , p. 39). However, the national policy and

85

strategies continue to focus on the medical aspect of HIV/AIDS and emphasize the
behavioural change campaign (GOB/MoH , 2002 ; GOB/NACA, 2003a) .
In implementing health care programmes, Botswana faces a chronic scarcity
of trained health care workers, which often leads to fragmentation of services. For
example, home-based care has a fault in its practice: actual home-based caregivers
are volunteers who only receive minimum allowance for transportation costs to the
patient's home. They are given basic training , however, the skills and services are
inconsistent and turnover rates are high.

5.1 Recommendations

Based on my preceding analysis, the following recommendations are made to
Government of Botswana and TOCaDI.
Recommendations to Botswana Government policy change:
1. GOB needs to commit to a multifaceted approach to the HIV/AIDS epidemic,
that is, to incorporate social and economic development work into the HIV/AIDS
programmes. At this moment, the scope of its strategies is narrowly tied to
medically and behaviourally oriented approaches. The government has not done a
comprehensive and holistic socio-economic assessment of the most vulnerable and
marginalized groups of the country. This research should include their economic
status (such as means of income and average household income) , life expectancy,
participation in education , school dropout rate , number of orphans and HIV
prevalence rate among the minority groups as well as other qualities of life.
2. GOB needs to acknowledge the history and existence of the San as

86

indigenous people in Botswana. Efforts to ensure their culture and identity, and
support their existence must be developed as policy.
3. GOB needs to use participatory bottom-up communication in order to
understand the grassroots needs. There is distrust of the government including its
health care system among rural area residents. Resources should be provided to
promote and develop a health care system that respects the uniqueness of each
culture. Village health committees or local health advisory committees need to be
structured to ensure all voices are taken into account. Home-based caregivers
should be treated as trained workers and be paid the salary they deserve. In rural
villages where extreme poverty is the standard of living, volunteerism is unrealistic.
4. Health care professionals should be trained in cultural sensitivity and better
communication skills. In order to reduce stigma, a support system needs to be
established in each community that empowers people with knowledge and hope for
the future.
5. Funds from international donors should be spent Of! actual expenses to look
after the sick; for example, blankets, dressing materials, food, adaptive equipment
such as wheelchairs, pressure relief mattresses and transportation to make home
based-care easier for the family and more feasible for the local government.

Recommendations to TOCaDI:
1. TOCaDI should continue its effort to integrate HIV/AIDS-related issues into its
day-to-day programs. At this moment, there is a clear division between the
managers and local staff that is reflected in the mistrust of managers. Fear and

87

stigma related to HIV/AIDS exist within TOCaDI. Empowering and embracing local
staff as key players in the work against HIV/AIDS will assist in the internalization of
HIV/AIDS and reduction of stigma. TOCaDI managers need to ensure there is an
on-going open dialogue between the local staff and the managers.
2. An AIDS workplace policy has been drafted and needs to be adopted in order
to ensure a safe place for all staff and staff who are HIV positive so that they can
seek assistance when necessary.
3. Work to mainstream HIV/AIDS should be based on teamwork rather than on
one individual. Considering the cultural sensitivity shown by staff and the villagers
related to HIV/AIDS, the local staff will have the most success in working in their
communities. A HIV/AIDS Task Force has been formed to address the issue of
HIV/AIDS within TOCaDI and in the communities, and now it is led by a female staff
member from the local community. TOCaDI should continue to provide as much
support as it can to the Task Force.
4. TOCaDI should provide continuing education and training to staff at all levels
including managers. All education should have a component to address reduction of
HIV/AIDS-related stigma.
5. Income generation projects are crucial in terms of eradicating the extreme
poverty in the villages especially in N!oaxom and Dobe areas. The income
generation program should be expanded so as to benefit the whole village, and
especially more women and youth .
6. TOCaDI should take gender issue seriously and incorporate projects that

88

empower women. For example, recruiting more women at the management level,
and having women direct the education program. Also, educating men and youth in
ways that bring fundamental changes in gender relationships is important.
7. TOCaDI should reinforce the collaborative working relationships with other
organizations including government departments and other NGOs. The Coping
Centre for People Living with HIV/AIDS (COCEPWA) is the one of several
organization that can provide support to staff in overcoming stigma. TOCaDI also
should familiarise themselves with resources available in the community: especially
Shakawe, Gumare and Maun.
8. ToCaDI should build a dialogue/ communication system with communities in
a culturally sensitive manner and with an effort to understand and address the
conflict issues at the grassroots level.

5.2 Direction for Further Research
My research objectives were to understand the complexity of socio- economic
and cultural backgrounds for the HIV/AIDS-related behaviours presented by villagers
and staff in this remote area of Botswana. In the local context, I have made the
linkage between the social , economic and cultural issues and apparent behaviours
targeted by the current GOB policy. By doing so the barriers to the current strategies
are identified. I believe that my research will benefit informants who are local
residents as much as my academic interest. I believe that my research helps
TOCaDI understand the needs of local communities and develop an effective
HIV/AIDS program. The area that my fieldwork covered was vast and diverse. The

89

complexity of HIV/AIDS problems in the area suggests further research needs in the
following areas:
1. The gender issue needs to be considered as urgent and central to
HIV/AIDS research in the area. Particularly, two topics are thought to be useful:
empowerment strategies for women including women-oriented and -directed
income generation programs; secondly, the changes in the roles of the San
women in their communities in relation to gender relationships. This research
may show how San women can be empowered in their communities and take a
leadership role in the fight against HIV/AIDS.
2. I have made every effort to make my research beneficial to local residents
who suffer from HIV/AIDS prevalence in their daily lives. HIV/AIDS research,
especially from development point of view, must have the most benefit to people
who are studied. The research and case studies conducted in the similar settings
such as in rural Zambia helped make my research beneficial. More HIV/AIDS
research needs to be done in rural and remote areas in southern Africa with respect
to their coping strategies and stigma reduction. Strategies for stigma reduction need
to be researched in the light of cultural and socio-economic backgrounds.
3. My research is limited in determining the impact of HIV/AIDS on particular
ethnic groups, especially the San, who are the most marginalized and poorest
people in Botswana. San specific research may be necessary to learn the
significant impact of HIV/AIDS on the group and to protect their cultural and physical
survival. The research should be led or at least involve the San and should be
carried out for their benefit, since the group has been heavily 'researched' as

90

subjects in the past. The participatory action research model such as conducted by
SASI (2003) should be explored and tried in the area.

These recommendations are by no mean inclusive of all potential solutions.
My fieldwork was limited and my research plan needed constant adjustment. Since
the area I studied was vast and culturally complex, my data collected have
limitations. I was an outsider and had limited time. However, despite these
limitations, my working relationships with TOCADI staff from the local communities
and villagers were positive, and invaluable. Their input in my fieldwork was
extremely helpful in making my research meaningful for TOCaDI and the
communities. I do hope my recommendations will stimulate dialogue within
TOCaDI, between TOCADI and local communities, and TOCADI and the
Government of Botswana.

91

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Appendix A - 1: Map of Botswana

Inte rn ati onal boundary
District boundary

*

National capital

e

District capital
Railroad
Road

0

·50

-

100 Kilometers

GHANZI

Source: www. maps-only.com/Botswana-map.html

99

Appendix A- 2: Map of TOCaDI catchment

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100

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Appendix 8 : Letter of Support from ToCaDI , Member of the Kuru Family of
Organizations

102

Dr. Fiona MacPhail
International Studies
University of Northern British Columbia
3333 University Way
Prince George, British Columbia, Canada
January 26, 2004
Dear Dr. MacPhail
RE: SEIKO WATANABE'S RESEARCH PROJECT ON HIV/AIDS
We are writing to inform you of the status of Ms Watanabe with our organization, the purpose of her
research as we understand it and our support of her work.
Seiko arri\led in Shakawe in November of 2003 and she will be here for one year; World University
Services f ii il~ supports her with a living allowance while she is working for TOCaDI. Due to
the severity.of HIVIAIDS in Botswana in general and in this rural area of the country in particular,
she has been engaged to mainstream HIVIAIDS into our development and cultural work with San and
other marginalized people.
We understand the purpose of Seiko's research for her Master's Projecfto i ~ f ll ~ !O
understand the fundamental needs of the communities in which TOCaDI works ,with respect to
IDVI AIDS and to identify effective intervention strategies. Identifying these strategies will enable
her to train TOCaDI staff to effectively help village residents to deal with and'he1p P\event
HIVI AIDS. This organization expects to benefit from this research in tliat it will improve our-efforts
to reduce the impact of this virus.
· ·
··
We understand Seiko will conduct her research in a ;articipator-Y
~ that will·irivolve all staff,
·
including field workers and managers as well as villagers·to' the extent ~ i l
As a NGO that assists community organizations in this depressed area of northwestern Botswana,
TOCaDI fully supports Seiko's planned research; we also support her doing herresearch as an
integral part of her work here. We are happy to have her doing her researchand;we know that her
·
efforts will assist indigenous people here to deal with HIVIAIDS in the \liture . . , ·
Yours sincerely
Willemien le Roux
Culture and Education Advisor
Letloa
Kuru Family of Organisations

F.O.I)ox +72 Shakawe, 5otswana Tel/Fax +267 675 oa+/5

E.-mail: tocadi®into.bw

103

Appendix C: Interview Questionnaires
Interview Questionnaire #1 :
Date:
Initial:
Sex:
Age:
From:
1. Please tell me about what you know about HIV/AIDS.
2. Where did you hear about this disease?
3. Can you tell me how it is transmitted?
4. Who are the people who are most at risk of getting HIV?
5. How can you avoid getting this disease?
6. Can you cure the disease? If so, what cures the disease?
7. Is it shameful to have this disease? What is a reaction of your community when
someone has this disease?
8. Please tell me the problems you see in your community regarding HIV/AIDS.
9. Please tell me what are the causes of or reasons for the problems you have, in
your opinion.
10. Please tell me what needs to happen, or what you want to see happen.
11 . What do you think will help to make difference?
12. Do you encounter problems/ difficulties related to HIV/AIDS when you work in
your community (CDFs)?
13. What are the problems that the women are facing in the rural area where you
live?
14. What can I do to help you to make things better for you or to help you help
people?

104

Interview Questionnaire #2:
Date :
Name (Initial) :
Area:

Age:
Sex:

1. What did you learn about HIV/AIDS during the past four months?
2. Has your behaviour changed? If so, how?
3. Do you know your HIV status?
3a. (If the answer is NO) Why don't you know?
4. Do you think traditional cultural values and way of living have changed in your
community?
4a. Do you think those changes are affecting the spread of HIV/AIDS?
4b . What are those changes affecting the spread of HIV/AIDS?

5. Are there traditional values that have affected the spread of HIV? If so, what
are they?
6. Do you prefer to go to traditional doctor to the clinic?
Why? When do you go to the traditional doctors?
7. How is poverty in your community affecting the spread of HIV/AIDS?
8. How poverty is affecting treatment and well-being of HIV/AIDS patients in
your community?

105

9. Do you think that women are more vulnerable to infection? Why?
Or, are women disadvantaged in protecting themselves? How?

10. What are the most important changes we have to make?

11 . What will help to make those changes?

Thank you for your cooperation.

106