Communication, HIV Prevention and Faith-Health Intersection: An Exploration of
Perspectives among Christian Leaders in Rwanda
A thesis presented to
the faculty of
the Center for International Studies of Ohio University
In partial fulfillment
of the requirements for the degree of
Master of Arts
Jean Claude Kwitonda
August 2010
© 2010 Jean Claude Kwitonda. All Rights Reserved.
2
This thesis titled
Communication, HIV Prevention and Faith-Health Intersection: An Exploration of
Perspectives among Christian Leaders in Rwanda
by
JEAN CLAUDE KWITONDA
has been approved for
the Centre of International Studies by
Rafael A. Obregon
Associate Professor of Media Arts and Studies
______
Rafael A. Obregon
Director, Communication and Development Studies
______
Daniel Weiner
Director, Center for International Studies 3
ABSTRACT
KWITONDA, JEAN CLAUDE, M.A., August 2010, Communication and Development Studies
Communication, HIV Prevention and Faith-Health Intersection: An Exploration of
Perspectives among Christian Leaders in Rwanda (119 pp.)
Director of Thesis: Rafael A. Obregon
This research explores the opinions of religious leaders in Rwanda projected in their interpretation of a salient narrative and HIV prevention methods. The study established that the intersection of faith and health is something that is still of a highly contested terrain. The study also reveals that ABC has been communicated using behavioral messaging at the detriment of the foremost experiential, stage-matched approach of communication. Yet, religious leaders’ opinions reflect fluctuating feelings about their roles in health and faith. The plight of religious leaders finds expression in their vacillating stances that are constantly evaluated, constructed and reconstructed. In order to validate and illustrate these findings, I locate data analysis in the theory of narrative persuasion, Problematic Integration theory and some vital problematics of narrative theorizing. The study concludes and recommends that narrative mode is a viable alternative communication avenue for effectively reaching religious leaders in Rwanda and (perhaps) beyond.
Approved: ______
Rafael A. Obregon
Associate Professor of Media Arts and Studies 4
ACKNOWLEDGEMENTS
I would like to mention some of the many people who, in one way or another, helped me accomplish this research and to whom I am grateful. Because of lack of space and confidentiality reasons, I will single out a few here, but each and every one of them deserves my everlasting gratitude.
My thanks go to my supervisor Dr. Obregon Rafael who, on top of his busy schedules as the Director of Communication and Development program and professor in the school of Media Arts and Studies, accepted to be the chair of this thesis. His timely feedback has been very valuable to this thesis in many ways.
I am equally thankful to Dr. Howard Steve and Dr. Sallar Anthony for accepting my request to have them as committee members. I am especially grateful for their feedback.
I am also grateful to all the religious leaders who gave me their time and probably used their financial resources in order to participate and contribute to this study.
I cannot forget MPAGAZEHE Aloys, a friend, pastor and former classmate for his generosity in coordinating the focus group at his church. Father KARAMUKA Eric also played a generous role by calling participants, traveling and participating in the focus group.
I cannot forget Professor Babrow Austin of the Scripps School of
Communication, Ohio University, for introducing me to and modeling the pleasures of 5 health communication scholarship. His classroom instructions and advice contributed to the state of this thesis.
I am thankful to Benegusenga Aline for taking some field notes during the discussions, doing (open) coding of the data and introducing me to some participants. Her presence was welcome and encouraging.
I would like to thank Kigali Institute of Education for lending me their recording equipment.
6
DEDICATION
To Aline, the best idea I have ever had. 7
TABLE OF CONTENTS
Abstract ...... 3
Acknowledgements ...... 4
Dedication ...... 6
List of Tables ...... 10
List of Figures ...... 11
List of Acronyms and Abbreviations ...... 12
Chapter One: Introduction ...... 13
Aims ...... 16
Chapter Two: Review of Literature & Research Questions ...... 23
Hermeneutics and Religious Culture ...... 23
Hermeneutics, Religious Culture and Social Change ...... 26
The Synergetic Potential between Religion and Health ...... 29
Perceived Risks and Barriers to Communication ...... 31
Behavioral Change Communication in Rwanda ...... 34
How ABC Has Been Communicated to the Public ...... 34
The Socio-Cultural Interactions Between ABC and Spirituality in Rwanda ...... 35
Case Study from Population Services International (PSI) in Rwanda ...... 36
Chapter Three: Methodology ...... 41
Negotiating Access and the Experience of Doing Research in Rwanda ...... 42
The Focus Group Discussion Process ...... 43
The Coding Procedure ...... 46 8
Reliability Measures ...... 48
Validity Measures ...... 49
Ethical Considerations ...... 51
Chapter Four: Results ...... 53
Participants ...... 53
The Roman Catholic Church ...... 53
The Seventh Day Adventists Church ...... 53
Association des Eglises Pantecostales du Rwanda ...... 54
The Pentecostal Churches of Rwanda: ADEPR ...... 54
The Anglican Church ...... 54
Findings ...... 54
Reponses and Lessons Learned From the First Research Question (How do Religious
Leaders in Rwanda Respond to a Dialogue ...... 59
that is Grounded in the Practice of Ordinary Hermeneutics?) ...... 59
Responses and Lessons Learnt From the Second Research Question ...... 62
(What is the Perceived Role of Religion in Public ...... 62
Health Among Religious Leaders in Rwanda?) ...... 62
Responses and Lessons Learned from the Third Research Question ...... 68
(How do Religious Leaders in Rwanda Integrate New Information?) ...... 68
Responses and Lessons Learned From the Fourth Research Question: How Has ABC
...... 76
Been Communicated By and to Religious Leaders in Rwanda? ...... 76 9
Chapter Five: Discussion ...... 86
Motivational Interviewing and the Narrative Mode ...... 86
The Interpretive Process and Routes of Persuasion ...... 88
Communication and Problematic Integration of Varying Responsibilities ...... 92
Implications Emerging from Narrative Sense-Making ...... 96
Chapter Six: Conclusion and Recommendations ...... 101
References ...... 106
10
LIST OF TABLES
Table1: Summary of thematic foci and sub-themes ...... 58 11
LIST OF FIGURES
Figure 1: The Goal and the Four Interlinked Research Objectives ...... 18
Figure 2: A Social Support Campaign in Rwanda ...... 78
Figure 3: The Right to Use Condoms in Rwanda ...... 79 12
LIST OF ACRONYMS AND ABBREVIATIONS
ABC: Abstinence, Being faithful and Condom use
AIDS: Acquired Immunodeficiency Syndrome
CHAMP: Community HIV/AIDS Mobilization Program
HIV: Human Immunodeficiency Virus
PI: Problematic Integration
PSI: Population Services International
USAID: United States Agency for International Development
ELM: Elaboration Likelihood Model
ADEPR: Association Des Eglise Pentecotales du Rwanda 13
CHAPTER ONE: INTRODUCTION
The HIV virus was first identified as a biomedical condition. However, the
prevention of HIV quickly became a social issue that aroused controversy, stigmatization and moral dynamics. Rather than being an individual problem (Airhihenbuwa &
Obregon, 2000), HIV proved to be a group, social and most importantly, a public health predicament. The response to the HIV & AIDS pandemic has been enormous, ranging from care and education among others. Such efforts have emanated from those with greater influences on communities namely public health agencies and other institutions of socialization such as schools and religious denominations. Whilst positive and proactive, these efforts have, at the same time, colluded and collided in their approaches and ethics.
Consequently, this has led to contradictions, the incessant spread of the virus and, sometimes, mutually exclusive spheres of health education.
However, public health practitioners and religious leaders ought to have a
synergetic relationship (Kenneth, Shauna, Purvi, Gene, Nalini, Wachholtz, Sirrine,
Vasconcelles, Murray-Swank,& Locher; Miller, 1990; Babrow & Mattson (in press);
Somlai & Heckman, 2000). But this is not always the case especially when it comes to the HIV prevention methods of ABC (Abstinence, Being Faithful and Condom use). In many parts of the world and in Africa in particular, faith-based groups accept and promote Abstinence and Being Faithful methods but abhor consistent and correct condom
use. 14
This opinion shift on the part of religious leaders has been a real puzzle for health
communicators who advocate an integrated use of all possible methods of prevention that include consistent and correct condom use. How and why the opinions of religious leaders shift has largely been a question of belief, something that is almost understood as ever off-limits, a question whose explorations and answers are better off not attempted or
searched. The result has been none other than an unresolved antagonism between secular and spiritual outlooks especially when it comes to HIV prevention methods. Not surprisingly, consequences have manifested in many different ways.
For example, the demand for condoms has been less than satisfactory and as a consequence, the HIV virus has continued to spread (McKee, Bertrand & Becker-Benton,
2004). Part of the reasons cited include the condom aversion that most religious groups
have continued to uphold and propagate (McKee et al., 2004).
Inevitably, this status quo begs fundamental questions: what happens when a wife
is faithful to an unfaithful husband? Is it morally permissible to condemn and ignore
those who are not yet so religious; the imperfect members of the society who run the risk of becoming infected? And what happens in cases of sero-discordance and sero- concordance? And what happens when, inopportunely, some of our masks of abstinence and faithfulness end up being indistinguishable from our faces? For example, empirical evidence indicates that de-emphasizing condom use is an over-simplification of very complex sets of social power relationships that overshadow sexuality (Hillier, 2006).
And, finally, what will happen under such struggle between teaching and unteaching?
The answer to such questions quickly turns into heated debates that are well documented 15
in the literature of the relationship between health and spirituality (Gordon, 1984; Carlin,
Roach & Gorawaca-Bhat, 2005).
In their reflection on the relationship between health and religion for example,
Carlin, et al. (2005) opine that spirituality exerts a strong influence on the community by
providing a paradigm of interpreting health. Also, Gordon (1984) observes that “religion
can be a source of stress for people who have guilt or who have what they feel are
unresolved spiritual issues [and that] the resulting mental and spiritual struggles can
create pain, anxiety and fear” (p. 57).
From a rather strict medical point of view, Carlin et al. (2005) further remark that
“religious influences are beneficial when they enable patients to cope with suffering and
harmful when they generate psychological conflicts or when they lead patients to decline
medical recommendations” (p.58).
This is where the real conflict sets in; when the spiritual and secular needs
stumble down opposite paths. Nevertheless, Melkolte and Steeves (2001) observe that
religion has largely been misunderstood as points of resistance and obstacles to
development. These opposed perspectives (the secular and spiritual) are valid and
justified, –each in its own right– but efforts to amend their differences have been
diffident and slow. Key to this study is the proposition made by Melkote and Steeves
(2001) especially when they forebode the possibility for these opposed social forces to work together chiefly through what they dub the practice of hermeneutics:
The practice of hermeneutics, that is, the interpretation of sacred texts, within
historically specific contexts and by subjective individuals show that no religion 16
can be reduced to a stereotype. Within every major religion, there are branches
with intellectual and spiritual leaders making strong and spiritual arguments for
development as a process of liberation from injustice, discrimination and
prejudice whenever they occur, including within religious organizations. These
arguments – and accompanying faith – frequently catalyze activism and provide
important openings for individual and community empowerment, openings that
have led to social change (p. 275).
Aims
Inspired by this conciliatory observation (captured in the practice of
hermeneutics) as advocated by Melkolte and Steeves (2001), this study attempted to find
ways in which this common ground can be searched and initiated between religion and
the comprehensive approach of HIV prevention through communication. The discussion
of hermeneutics, as proposed by Melkolte and Steeves (2001) was at the heart of the methods of enquiry as a way of exploring avenues for arguments that are not only grounded in faith but also in secular notions such as comprehensive methods of HIV
prevention. Understandably, the quest for common understanding over the methods calls
for an investigation and search for possibilities of a conducive environment for such a
dialogue that can eventuate in persuasion and positive social change.
Such an exploration is therefore imperative because the intersection between
communication, HIV prevention and faith-health is necessary if we are to have a leveled
field of public health communication and avoid mindsets that guide and beguile. More
challenging in this endeavor is the impetuous to achieve a comprehensive approach of 17
HIV prevention that include ABC. Expectedly, the role and potential of persuasive communication becomes a compelling avenue that can propel change and more understanding between religious and public health leaders. Singal, Papa and Papa (2006) find such a task of social change neither easy nor comfortable but it is a worthwhile endeavor in the long run.
Such dialectical tensions continue to shape the reactions and opinions of religious leaders on the three prevention methods. Condom use is regarded as being outside their beliefs. In other words, any communication that accepts and encourages condom use is regarded and received as deviant information and consequently not necessarily viable.
The potential of communicating and communication research can be among other things identifying the processes that hinder effective persuasion (Wood, 2009). The study hopes to do so by capitalizing on guidelines developed by Rosaline and Kitzinger (1999) on how group dynamics (found in institutions such as religious denominations) engage in the social construction of intriguing issues. The goal of the study was to identify how religious leaders respond to ABC communication in order to explore possibilities for improvements. More precisely, the study explored 4 interlinked research objectives:
18
Figure 1: The goal and the four interlinked research objectives
Through a discussion that is sensitive to issues of religiosity and faith, this study explored perspectives of religious leaders in Rwanda in order to identify communication avenues that can facilitate and occasion a synergetic intersection between communication, ABC methods and religious beliefs in Rwanda.
19
The Rwandan Context
John Mbiti (1992) wrote that “Africans are notoriously religious” (p. 40).
Rwandans are no exception. With the opening of the first Catholic mission in Rwanda in
February 1900, Rwandans were converted from indigenous religion and soon became the
proponents of the religious ideas brought by European missionaries. Adelkundle (2007)
writes that by 1926, “Rwandese who learned how to read and write translated the bible,
prayer books, hymn books and the catechism into Kinyarwanda for the spiritual
nourishment of the congregants” (p. 51).
In addition, Adekunle opines that “through biblical education, the missionaries
taught Rwandans how to read, write and commit the bible into memory” (p 48). This is
evidence of a long standing loyalty that Rwandans hold in relation to religious denominations and their teachings. The genocide and disappointment of war that happened in Rwanda also prompted people to turn massively to the church for comfort and spiritual strength so as cope with the repercussions of an overwhelming past. The main denominations such the Roman Catholic Church and The Seventh Day Adventists have maintained a sizable proportion of the Christian community.
This has many implications in the case of HIV prevention in particular and public health in general. PSI Rwanda, (2006) observes that “98% of Rwandans claim an official religious affiliation and a significant percentage of the population might be influenced by their religious leaders and institutions in their social life in general and particularly for their intimate sexual behavior”. Most primary and secondary schools are run by religious denominations mainly the Catholic Church. And it is in schools that the most sexually 20
active and vulnerable populations are found. Furthermore, 50% of health facilities are
faith-based and cannot therefore promote condoms as a method of HIV prevention (PSI
Rwanda, 2006).
This research selected the Catholic Church, Association of Pentecostal Churches
of Rwanda, the Seventh Day Adventists Church and the Anglican Church. The rationale
for choosing the above churches was based on their historical stronghold and influence
they have on Rwandese society. Also, because of their involvement in development
issues in the country, some religious groups have formed associations whose influences
can hardly be attributed to a single group. For example, one such associations is the
Association of Pentecostal Churches of Rwanda (ADEPR). ADEPR became the current
Association of Pentecostal Churches of Rwanda (ADEPR) in January 1984 when
churches decided to come together in order to work under one statute and regulation.
In addition, according to Balandier (1970), the Catholic Church seems to have
more influence and it has a historical record as a church that paved the way to “power,
prestige and wealth” (p. 380). What Balandier (1970) is referring to here is the influence
of the Catholic Church since its missionary days which is mostly reflected in both its well
established educational and health institutions. Most past and current leaders of Rwanda
were educated in Catholic schools. Thus, research by the United Nations has identified
49.6 percent of the population as Catholic. Compared to other religions, the proportion of
Catholics in the Rwandese population is larger than any other religious affiliation.
The exact percentages of ADEPR and the Anglican church in Rwanda are still not
determined. But they are both part of the Counsel of Protestants of Rwanda (CPR, also 21
known as the Conseil Protestant du Rwanda), an association of many churches making up
43.9 percent of the Rwandese population. CPR’s mission is “to promote the unity of
action and vision of Christian churches in Rwanda for the evangelistic witness and for the
well-being of the Rwandan population” (World Council of Churches, 2010). ADEPR and
the Anglican Church are part of the list of the associate members of the council.
The Adventist Church also has a percentage of no less importance as it has 11.1%
of the population as its members. Moslems make up just 4.6%. of the Rwandese
population. Less than two percent of the population reported no religious affiliation.
While the percentage of the population identifying with the indigenous religion is almost
non-existent as it has 0.1% of people who claim to practice it. The colonial history of
Rwanda explains the weak percentage of followers of the indigenous religion. The latter was labeled as pagan and was quickly abandoned as the Christian missionaries settled in
Rwanda.
Due to its marginal and unpopular reputation, it was deemed less productive for this study to include indigenous religions. The same reason can also explain the assumption that it would be hard to find people who can identify themselves with the group. In a related development, the approaches used in this research apply more to
Christian religious culture and may not be applicable to the Muslim religious culture.
Muslims have thus been excluded from this study but future research on HIV prevention
methods should focus on them as they constitute an important religious group. 22
National HIV and AIDS prevalence is 3.0%, with urban prevalence of 7.3% and rural prevalence of 2.2%. The population living below the poverty line is 60% (USAID,
2009). These rates are high and may increase if the faith-health rift on prevention is not bridged. It is thus the latter challenge that mainly informed the rationale of the present study. 23
CHAPTER TWO: REVIEW OF LITERATURE & RESEARCH QUESTIONS
The field of health communication and especially HIV prevention has attracted a lot attention and an abundant related literature is available. For the purpose of discursive departure, this study focused on the literature that has bearing on the research questions, methodology and theoretical rationale of the topic under consideration. The investigator followed Silverman’s (2000) advice that the review of literature is mainly completed after data collection. As the discussion unfolded and based on findings, more relevant literature was considered for a full-fledged discussion of the topic in the discussion section.
Hermeneutics and Religious Culture
What is meant by hermeneutics in this study is not an overly technical interpretation of the bible but rather a discussion that is grounded in religious culture.
This approach has also been adopted by Andrew Village (2007) in his publication The
bible and lay people: An empirical approach to ordinary hermeneutics. Village (2007)
was concerned with the question of how the bible is used and understood among
Anglicans in the Church of England in England. Village divided his research in three
categories mainly 1) attitudes towards the bible, (2) beliefs about the bible, (3) and use of
the bible. However, West (2009), who reviewed Village’s work remarks that “it quickly
becomes apparent that these analytical categories are constructed rather narrowly, shaped
as they are, by the existing empirical work in the western world in these areas (which is
minimal) and by the community in which this research is undertaken” (p.1). Following 24 these critical remarks advanced by West (2009), it would be interesting to see how the practice of ordinary hermeneutics would work in a different setting and situation such as
HIV prevention and public health.
Further lack of research focusing on the issues of HIV prevention and Christianity is also reflected in a volume entitled Communicating health risks to the public edited by
Hillier (2006). In this publication, a wide range of how health communication messages get to the public is explored. The second chapter entitled view from the global village dwells on critical issues of HIV prevention and its subsection is titled “HIV and the ABC:
A duel between western Christian morality and African patriarchy” (p. 14). The author is essentially very critical of “the attempt to de-emphasize condom use in favor of abstinence and monogamy” (p.15) because this increases women’s vulnerability in
Africa. This leads to the complexity of culture and how it shapes gender relationships and sexual networks which in turn can challenge and go beyond the ideals of Christian morality.
Culture and communication are interrelated. HIV prevention interventions therefore need to be contextualized as Airhihenbuwa and Obregon (2000) suggest. In an article entitled “A critical assessment of theories/models used in health communication for HIV/AIDS”, Airhihenbuwa and Obregon (2000) explore communication theories and find that most of them focus on the individual for behavioral change rather than the wider social network in which the individual operates. They also question the universalistic outlook reflected in the models and recommend a cultural contextualization of HIV interventions. This publication is however limited to its scope of theoretical exploration. 25
In the study, I responded to the call made especially by Airhihenbuwa and Obregon
(2000) and other researchers, in order to find ways of integrating HIV prevention in the context of religious culture.
Gorsuch (1997) in an edited volume entitled The psychology of religion traces motivational theories of religious culture. The author discusses religious culture and orientations as questions of both intrinsic and extrinsic commitment. At times, Gorsuch
(1997) remarks, these two types are intertwined because one can reinforce or undermine another depending on how people make use of them. As explained by the author,
“intrinsic religious behavior is the one that is internalized and that exists on its own sake” while extrinsic religiousness is adopted to achieve some other goal” (p. 11). These theoretical notions are relevant to this study in the sense that HIV prevention methods are espoused or rejected on the basis of certain religious orientations. Intrinsic motivation in this case would be difficult to change especially if it is fraught with the potential of hindering HIV prevention interventions.
In order to change habits that beset intrinsic motivation, dialogue is recommended by Gorsuch (1997) so that the fear of change (in this case adopting the extrinsic motivation) can be shaded. Initially, Gorsuch (1997) remarks, “there would be some anxiety about not fulfilling the now unknown extrinsic motivation but the individual would find out overtime that the anxiety was unfounded and desensitization would take place” (p. 19 ). This theory therefore predicts that the more people are exposed to other sources of motivation of religious behaviors that are not necessarily intrinsic the more their intrinsically rooted habits decrease. 26
The benefits of HIV prevention (especially the ones associated with condom use methods) are not intrinsically motivated by religious beliefs. Initiating open dialogue about comprehensive methods of HIV prevention, a dialogue that is contextualized in religious culture, (that is hermeneutics), could be a viable process of attempting to foster a smooth blend of extrinsic and intrinsic motivations that are accommodative of all methods of HIV prevention.
Blending in the process of social change suits the context of the quest for an intersection between secular and religious beliefs. For example, Abstinence and Being faithful seem to be antagonistic to Condom use. Miller (2002) and Papa at el. (2006) warn against this restrictive dualism in the social change process. According to Miller
(2002), dualism, unlike dialectics, is characterized by an either/or relationship. In describing dualism, Fairhurst (2001) indicates that no assumption is made about the interdependence, simultaneity, or possible unification of opposing forces” (p. 380). In
relation to this, Papa at el. (2006) opine that “rather than reducing tensions to binary
decisions (either/or) a dialectical perspective urges us to think in terms of both
either/and” (p. 43).
Hermeneutics, Religious Culture and Social Change
As a process of social change, the coexistence of religious culture and HIV prevention (especially through the practice of ordinary hermeneutics) is therefore worth
exploring because it is possible and supported by many scholars of social change
(Ashcraft, 2000, 2001, 2004; Harter, 2004; Conville, 1998). In addition, the intersection
or coexistence of HIV prevention and Faith-health reflects elements of dialectics 27
(Bakhtin, 1981; Baxter & Montgomery, 1996; Conville, 1998; Dindia, 1998; Rawlins,
1992; 1998; Handy, 1994; Van Leer, 1998). It is worthwhile relating these elements to the intersection of comprehensive HIV prevention methods and religion. Contradiction, the first element of dialectics, refers to the antagonistic relationship of oppositional forces. In this study, religious beliefs and comprehensive HIV prevention seem to be poised as oppositional forces because of their strong stands on divergent opinions on how
HIV should be prevented.
The second element is motion which refers to activities movements and changes that occur as people shift between competing poles of actions. In this study, this shift may be occasioned by the move between intrinsic and extrinsic motivations of religious culture as the other perspectives engage in a dialectical dialogue. The third element of dialectics is totality, which Rawlins (1992) describes as “constant interconnection and reciprocal influence of multiple individuals, interpersonal and social factors” (p. 43).
Totality is related to this study in the sense that it underpins the interdependence of opposed dialectics shaping each other in the process. Actions and beliefs of people affect other people in the network of interdependence. Finally the element of praxis mostly refers to the process of communication whereby communicators influence their environment in two-way relationship, that is, they interact with their environment in the process of persuasion.
Religious culture, hermeneutics and persuasive communication can work towards a common end. For example, Weston (2000) in his book A rulebook for arguments advocate the use of arguments by analogy. The author explains: “rather than multiplying 28
examples to support a generalization, argue for one specific case or example to another
example, reasoning that because the two examples are alike in many ways they are also
alike in one further specific way” (p. 19). Weston (2000) also goes on to point out that
the example must be relevant. Communication that is cognizant to religious culture
especially the one that uses the practice ordinary hermeneutics would thus be expected to
have more effectiveness. For example, the analogy in the story of God and the man who
was waiting to see God observes the principle of analogy and relevance while at the same
time reflecting the realities of comprehensive methods of HIV prevention. (This story is described in the methods section).
The practice of ordinary hermeneutics (through the story of the man and God) was indeed a good rhetorical departure especially given that it has a relatively good match with principles of persuasive communication. The story does not only serve as an example, it also follows some other tips recommended by Weston (2009) such as
presenting ideas in natural order, starting from reliable premises and other tips offered by
Heinrichs (2007) such as getting the audience to listen, controlling the mood, speaking your audience’s language and seizing the occasion among others. All these outlined principles of persuasive communication find their respective place in the analogy used as a method of enquiry in this study. In this case, the discussion of bible stories as a springboard for further discussion was assumed to be an incentive for religious leaders.
This dialogue mediated by the practice of ordinary hermeneutics can serve as gateway to mitigate what Melkolte and Steeves (2001) view as the overwhelming secular orientation of western scholars and practitioners who often assume separation between material and 29
spiritual concerns. In effect, religious leaders are often referred to as community
gatekeepers. But Melkote and Steeves (2001) propose a different view through what they
call liberation theology and its emancipatory arguments. They rather envision arguments
that speak to address specific development challenges such as poverty and HIV
prevention, “these arguments are quite consistent in drawing on sacred texts to reject
exploitation and injustice, and promote compassion and tolerance. Proponents often work
together for common goals” (p. 275).
Based on all the observations raised in this section, one can pose the first research
question:
How do religious leaders in Rwanda respond to a dialogue that is grounded in the
practice of ordinary hermeneutics?
The Synergetic Potential between Religion and Health
The necessity of the intersection between HIV and health is vastly acknowledged
in related literature. It would therefore be beneficial if this potential was exploited
through the promotion of comprehensive methods of HIV prevention. For example, Sallis
and Owens (1997) observe that health is a dynamic interface, a relationship between one’s self and other components of the society.
The group dynamic is very critical because the individual is influenced and shaped by the group. Especially within the cultural structure of group cohesion that is the emblem of most African cultures, group dynamics play an important role in individual decision making. When people fall sick, their families, friends and other members of 30
social groups such as church members become concerned and get involved (Shweder,
1991).
Furthermore, spiritual well-being and physical health are highly correlated.
Headey and Wearing (1992) indicate that when an individual is ill his spiritual or, in more general terms, psychological state is also affected. Lack of a healthy body leads to the lack of spiritual well-being (Jung, 1933). This leads to depression and other psychosomatic illnesses. With high levels of stigmatization against HIV positive people and its morbidity toll, the epidemic can be spiritually devastating and hence cause premature death.
But the potential of religion has been prodigiously generous to health outcomes.
This notwithstanding, religion remains a two-sided concept. For example (Pargament,
Smith, Keong, 1997; Park & Cohen, 1993; Pargament, Maton & Hess, 1999) describe different methods in which religion is used: it is used positively and negatively. They remark that positive religious coping may include seeking support from clergy and church members when faced with distressing situations. Negative coping involves being angry with God or feeling punished especially in the case of HIV & AIDS. But these two differing ways in which religion is used also attests to the potential of religion as an ally through which positive paradigms of preventing epidemics can be cultivated.
A number of studies reiterate the close relationship of religion and psychological
states such as coping with illness or other spiritually distressing phenomena (Khalek,
2006; Argyle, 1987; Balswick & Balkwell, 1979). These studies indicate a strong
influence of religion and many health outcomes. However, in Rwanda, when it comes to 31 comprehensive methods of HIV prevention and religious beliefs, religion tends to be regarded as a “mediator of conflict with medical recommendations” (Carlin, Roach &
Gorawaca-Bhat, 2005, p.763). However, as the literature indicates, it is possible to hope that religious leaders and health communicators can integrate (in a synergetic manner) their roles in public health in general and in HIV prevention in particular.
The second research question would therefore be:
What is the perceived role of religion in public health among religious leaders in
Rwanda?
Perceived Risks and Barriers to Communication
In HIV & AIDS in Africa: Beyond epidemiology, Kalipeni, Craddock, Oppong &
Ghosh (2004) remark that there is a tendency for individuals to distance themselves from the heat of the HIV & AIDS contention, regarding it as a disease for the Other. This is probably why Airhihenbuwa (2007) entitled his book chapter on religion and HIV &
AIDS “Spirituality: The site of true otherness” (p. 137). This kind of othering may be partly due to certain inadequate levels of perception of the interconnectedness of religion and HIV prevention as well as the issues of perceived risk among those who may regard
HIV as a problem affecting ‘sinners’ or so to speak, the Other. This outlook also has far reaching effects especially when they become barriers to communication (wogalter,
DeJoy & Laughery, 1999).
Such barriers to communication and varying levels of perception are deeply embedded in the ways in which HIV epidemic has been communicated to the public. For example, and with close reference to religious stands on HIV prevention methods, 32
(McKee et al. 2004) give a warning that attests to the pitfall of HIV communication from
a faith point of view. They say it is not permissible to rely on “sending the message that
condom use is advisable only if abstinence and faithfulness fail, because this message can
be misleading or even dangerous” (p. 97). Here, (McKee et al. 2004) are warning about
issues that underlie monogamy; what is know as ‘serial monogamy’ and other complex social and sexual networks that can facilitate the spread of HIV. Such issues may include economic vulnerability, gender and culture, rape and stigma that goes with it, HIV status disclosure, sero-discordance, sero-concordance, migration just to name a few (Hillier,
2006).
The role of communication is therefore to identify how such factors undermine
the effectiveness of the process of behavioral and social change. For example, the health
belief model described by Becker (1974) states that if individuals perceived themselves to
be susceptible by a health problem, they would most likely change to avoid it. This is one
of the reasons that make the quest for the intersection between religion and
comprehensive HIV prevention even more compelling.
Miller & Dollard (1941) and Bandura (1997) also developed theories that relate to
motivation that applies to HIV prevention. As in the Health Belief Model, the authors
stress the importance of people’s gaining a sense of their personal power to initiate and
implement risk reduction activities especially when they have learnt or perceived that the action will produce desirable benefits. Here, there is need to focus more on the development of more positive influence and outcomes of religion and comprehensive methods of HIV prevention. However, religious beliefs operate in context of group 33
dynamics or what Ajzen (1998) describe as the Theory of Reasoned Action, which explains people’s perceptions and how for example a significant other feels about one’s performance of an action. This also explains how stigma affects HIV prevention efforts.
Stigma and beliefs are related in the sense that the latter legitimizes norms that justify the former. Beliefs also affect the perception and interpretation of social and health behavior
(Wood, 2009). In Interpersonal communication: Everyday encounters, Wood (2009) describes some critical factors that constitute obstacles to effective communication. She dubs those factors as forms of non-listening some of which explain the demarcation of
communication, HIV prevention methods and faith-health contention today.
For example, according to Wood, (2009) pseudo-listening refers to pretending to
listen when in fact there is no listing. In the context of HIV prevention and religion, this may describe a situation where the issue is considered as being outside one’s beliefs and therefore attention and response to it may tend to be tangential.
Another form of non-listening that pertains to the relationship between HIV prevention and religion is monopolizing. This may be a barrier to HIV prevention when advocacy for one method ignores a differing method. Another form is selective listening where communication of certain prevention methods may be welcomed or sidelined.
Wood (2009) describes this as follows: “we listen selectively when we screen out parts of a message that doesn’t interest us or with which we disagree; conversely, we listen selectively when we rivet attention on topics that do interest us or with which we do agree” (p. 196).
Hence, the third research question is: 34
How do religious leaders in Rwanda integrate new information?
Behavioral Change Communication in Rwanda
Some commendable work as far as ABC and social change has been done in
Rwanda. However, literature from academics and practitioners reflect some intriguing
challenges, debates and contradictions that suggest more examination of the issues related
to ABC communication and social change in the country. Hence, suggestions on how
different approaches of integrated ABC communication can still be made.
How ABC Has Been Communicated to the Public
As in many other religious contexts, emphasis has always been put on abstinence
and being faithful (A and B) in Rwanda. This is done, most of the time, at the expense of
condom use. With the pressure from religious groups, condom use is de-emphasized
ostensibly because it promotes promiscuity (Hillier, 2006). The position of religious people is that people should adopt abstinence and being faithful. When these two fail, they suggest, then use condoms. However, this assumes a linear and oversimplified process of sexual behavior and that people are in total control of their rationality and decisions which is not always the case (Hillier, 2006; Diclemente, Crosby & Kegler,
2002).
In other words, considering condom use as third-tier has the danger of vagueness.
What is questionable here is that this approach is concerned with general impressions formed from an implied warning (McKee at el. 2004; Wolgalta, DeJoy & Laughery,
1999). This implies that the impression formed is a general feeling of danger; that something bad is possible but not really likely. In Rwanda, 40% of the people are 35 illiterate and when this is coupled with suboptimal conditions of such diffident ABC communication, it is highly likely that people will discover this impracticability too late in order to resort to a condom that they have always been told not to have.
The Socio-Cultural Interactions Between ABC and Spirituality in Rwanda
Christianity has recorded a lot of positive achievements in socializing African societies.
But its actions are not also without contradictions and unintended effects. In the case of
HIV and ABC, Hillier (2006) remarks that Christianity fails to account for the contradiction that exists between the social reality of ABC and HIV; what he expresses as
“the duel between western Christian morality and African patriarchy” (p. 14). The author goes on to say:
To date, governments, donor agencies and non-governmental organizations have
mounted massive HIV/AIDS awareness campaigns in a bid to stem the increase in
infection rates. The central prevention message has been abstinence, monogamy
(be faithful) and condom use under the rubric of ABC rule. Empirical evidence
suggests that out of the ABC mantra advocated in prevention campaigns, condom
use is the most effective prevention. Attempt to de-emphasize condom use in
favor of abstinence and monogamy will increase women’s vulnerability to HIV
exposure. (p.14 – 15)
Hillier (2006) contends that preaching abstinence and being faithful at the detriment of condom use assumes autonomy and complete freedom from social and economic situations in which people find themselves. Factors such as mass poverty and many other social disruptions that befell Rwanda especially in the last two decades have made 36 adherence to the manta of abstinence and being faithful difficult. Other scholars further seem to be in support of Hillier by arguing that there are people who are neither abstinent nor faithful (Kalipeni, Craddock & Ghosh, 2004). In Rwanda, there are campaigns that seem to be congruent with the latter view. The prominent Non-Governmental
Organization that implements such campaigns is Population Services International,/PSI
Rwanda. A review of one of the campaigns illustrates some of the remarks made above.
Case Study from Population Services International (PSI) in Rwanda
The National centre for Fight Against HIV in Rwanda (CNLS – in French), in partnership with Population Services International (PSI/Rwanda), launched a multi-media campaign in 2007 to encourage leaders (parents, religious, political, communities) to get more involved in empowering young boys and girls to become more responsible for their sexuality.
The concept of the campaign came from a 2005 qualitative study carried out among youth and female sex workers in the Northern Province of Rwanda. Called
“Making the transition: from good girl to good wife, young girls’ and female sex workers’ narratives on social life, sexuality and risk: the implications for communications programs”, this study was carried out in January - March 2005, and highlighted the lack of social support and open communication as key contributors to risky sexual behaviour among youth.
Here is a summary of the key research findings as presented by PSI Rwanda
(2005): 37
Young girls are not empowered to actively choose when to become sexually
active, or to negotiate safer sex. While girls aspire to maintain the standard of
“good girl” by abstaining until marriage, the pressure they face to maintain a
relationship in order to get married is too great. Eventually, they feel they must
have sex to maintain their relationship, and when they do, they lack the
information they need about reproductive health, and the skills they need to
negotiate safer sex. In this way, the girls can’t actively say “no” to sex (in doing
so they risk losing their relationship), and they can’t actively say “yes” to sex (in
doing so, they risk losing their reputation). Girls therefore may become sexually
active before they want to, or are ready to, and when they do, they are not able to
negotiate condom use. In contrast to the girls, young boys aspire to have sex
before marriage, often lacked the personal exposure to condoms that enabled them
to know how to use them correctly, and did not clearly understand what a girl
means when she says “no”. For the boys, “no” often means “yes” in their sexual
negotiations. Their assumption is that young girls say no because they are
supposed to, not because they actually want to. Both boys and girls clearly stated
that they need more information about sex and sexuality, and more support from
their parents, community and religious leaders, in being able to negotiate their
adolescent sexuality.
In terms of gender relations, this can be understood as a form of sexual submissiveness known as “voluntary compliance” (Hess & Ferree, 1987; Stanko, 1985; Burgess, 1985).
But according to Hess and Ferree (1987), this is only a way of rationalizing sexual 38
coercion because of how men and women are socialized to behave. By extension,
therefore, this can rationalize a Kinyarwanda proverb that says that a bull is never
stopped. This compromises all negotiations because of these power relations. In such a
context, it would be very unrealistic to assume that people, especially women, will be in
full control of abstinence and faithfulness. Culturally, there is deep-seated sexual virility
that is expected from men and young men (Airhihenbuwa, 1996; Adekunle, 2007).
While the PSI Rwanda’s description points to how gender relations are played
out, the findings also imply some specific sexual behavior. Youth sexual behavior is partly influenced by the family members and peers with whom they interact (Guzman,
2003). Nevertheless, sexuality is controversial in many cultures. Rwanda is no exception.
Traditionally, sex education responsibility in Rwanda relied on extended family members
such as aunts, uncles and grandparents (PSI Rwanda, 2007). However, that education
does not often take place and research suggests that young Rwandans are sexually active:
at least 1 in 20 girls and three in 20 boys between the ages of 15 and 19 had sex before
they turned 15 (PSI/Rwanda, 2005).
In response to this situation therefore, Population Services International (PSI
Rwanda) launched the multi-media campaign in 2007. The aim of the campaign was to
encourage open discussion between young people and their parents, leaders and
communities about youth relationships, sex and condom use, issues that have been
considered taboo for open discussion between children and adults according to Rwandan
culture (PSI Rwanda, 2007). The campaign challenged the concern that early and open
communication about relationships, sex and condoms may promote promiscuous sex. 39
Parents, religious and political leaders were the primary target audience of this
campaign whereas the youth were the secondary audience. In execution, the campaign
had young people delivering three key messages under one umbrella theme of DON’T
WAIT or WITEGEREZA (In the local language). The three key messages were (1) Talk
to me about sex, (2) Teach me how to use a condom, (3) No means No, which is split to
suit both sexes: for girls, the running campaign message was teach me that no means no
and for boys it was teach me to respect her no.
The tone of the campaign was described as serious, challenging and
uncomfortable. As stated in the design strategy, the campaign was to begin with
billboards and posters, and be extended into radio and television.
There are other epidemiological factors that may support the rationale of the campaign. A 2005 demographic and health survey in Rwanda showed that the use of condoms is still low especially among the female population with 19.7% encouraging condom use by partners compared to 40.9% among the male population (CNLS, 2007).
This might explain the HIV prevalence that compares infection rates in terms of socio- demographic characteristics: women were the most infected with the prevalence rate of
3.6% compared to men with the prevalence rate of 2.3%. In the same way, the level of knowledge of HIV was still low among the general population. The study found that only
53.6% of women and 57.6% of men were aware of the critical issues related to HIV and
AIDS. PSI Rwanda’s initiative to launch a social support campaign was mainly motivated by the need to increase life skills and knowledge about HIV and promote a culture of non-silence as a way out of the cultural impasse: 40
When asked whether parents talk to young children about sex, they often answer
‘it is not our culture’. We must therefore ask ourselves: is it our culture to stand
back and put our children at risk? This is what we do when we leave our children
at their own devices when it comes to sex. (PSI Rwanda, 2007)
In a related development, the information processing theory of persuasion in public communication campaigns argues that “behavioral change produces attitude change, rather than the reverse, so that to change people’s attitudes one should not present new information on the issues but rather should compel the public’s behavioral change, attitudes will then be adjusted to fit the new behavior” (Rice & Atkin, 2003, p.
53). This controversial theoretical point of view may perhaps explain the description of tone in the social support campaign creative brief: serious, challenging and uncomfortable. It is thus clear from the above descriptions that ABC practitioners and religious leaders have been in some sort of challenging dialogue.
This study comes as an additional intervention in this on-going debate. It hopes to do so by examining how ABC has been communicated in relation to the results of the focus group discussions which also happened to be the data collection procedure of the present study. This may also pave ways or at least make some suggestions for new avenues of HIV communication which are clearly needed for improvement and continuity (McKee at el. 2004; Piotrow, Kincaid, Rimon II, & Rinehart, 1997).
The fourth research question would therefore be:
How has ABC been communicated by and to religious leaders in Rwanda?
41
CHAPTER THREE: METHODOLOGY
Issues of religion and beliefs are shared and are thus deeply rooted in group
dynamics. Hence, the design chosen for this study was primarily focus group discussions
and then follow-up, one-to-one interviews. The rationale for choosing these approaches is
advocated by Rosalinder and Kitzinnger (1999) when they opine that “a defining feature
of focus groups research is the use of interaction between research participants to
generate data” (p. 156). Rosalinder and Kitzinnger (1999) further remark that focus group
methods create an opportunity for the researcher and research participants to explore issues usually evaded, isolated or censored” (p. 156).
Since the overall objective of this study was to explore perspectives among religious leaders (on the subject of HIV prevention methods), focus group discussion
methods imposed themselves as the most suitable. Also, follow-up one-to-one interviews
are recommended in order to supplement focus group discussion (Rosalinder and
Kitzinnger, 1999). Other methods (that are rather supplementary) were used in order to
validate the main method of data collection. These included participant observation and
examinations of some visual materials used in different HIV/ABC related prevention
campaigns in Rwanda.
A convenience sample of religious leaders was obtained where they regularly
hold their prayer or other church meetings. Focus groups were composed of 6-9
participants. Three religious groups were able to participate in the discussions. Also,
follow up, in-depth, one-to-one interviews were conducted after the focus group 42
discussions. One group was held in the convent of the seminary of Kabgayi in Gitarama,
in the Southern Province of Rwanda with a group of priest and nuns. Another group was
held in Nyamirambo with the various leaders of the Seventh Day Adventist Church. The
third was also held in Kigali with Association Des Eglises Pantecotales du Rwanda
(ADEPR Church). The fourth could not convene due to unavailability of participants and
the field work timeline. This group was supposed to meet in Ruhengeri, Northern
Province, with leaders of the Anglican Church.
Negotiating Access and the Experience of Doing Research in Rwanda
Although accessing research respondents entails obtaining administrative approval in Rwanda, my experience with the process was quite straightforward. This is partly due to the fact that I am a native of the communities in which the research was conducted. But this also means that the experience can be different for an outsider who may need some more time to establish rapport with respondents and learn about the socio-political culture of researching and getting reliable information from respondents in the country.
As in many other professional societies where research with human subjects is taken seriously, the subject matter in question may also make the experience and process of obtaining permission to do research in Rwanda straightforward or bureaucratic; depending on the topic of interest. Like in many other sub-Saharan African countries,
HIV prevention is a topic of particular interest in Rwanda which is why people were quite open and cooperative in allowing me to conduct the research. 43
Even then, I had to depend on friends who, on my behalf made telephone calls to
introduce me to their friends and their friends further called and summoned their friends
for the focus group discussions. It was a typical snowball process that may, sometimes be daunting or costly for an outsider. In one case, I was required to write a letter to the legal representative of ADEPR (Association des Eglises Pantecostales du Rwanda/The
Pentecostal Churches of Rwanda), in order to obtain permission to do the focus groups with ADEPR staff/leaders. This group was comprised of different individuals who are involved in church and HIV activities at different levels of the church and local government administration. ADEPR has a leadership hierarchy that corresponds to that of local government administrative hierarchy which meant a lot for the experience of this research. As I continued to get to know other religious denominations, I further realized that the hierarchical administration is common to all of them. This means that the administration, communication process, beliefs and other instructions are highly centralized and follow a top-down pattern of interaction between the leadership and the lower levels of faith-based organizations in Rwanda.
The Focus Group Discussion Process
In The psychology of religion, Spilka and McIntosh (1999) observe that religious people take pleasure in operating in the environment of the sacred word. Also, Rosalinder and Kitzinnger (1999) recommend that it is necessary to make people feel comfortable.
To ensure such ethical considerations, this study sought to ensure the psychological well being of participants by following a deferential procedure of inquiry, what Krueger
(1999) describes as the art and mechanics of asking good questions. 44
This procedure followed Krueger’s (1999) five steps namely: (a) Opening which
ensures that participants get acquainted and feel connected (b) introductory which begins
the discussion of the topic (c) transition which moves seamlessly into key questions (d)
key questions which involve obtaining insights on areas of central concern in the story (e)
ending which helps the investigator identify where to place emphasis and bring closure to
the discussion.
In this study, opening involved an introduction of participants and investigator.
Most importantly, the investigator introduced himself, provided a description of the study
and clarified any foreseeable ethical issues.
The introductory step was the most critical. This step used a story that resembles
very well known bible stories (Rosalinder & Kitzinnger, 1999) which served as an appealing mediator between participants and research questions. In this process, a story whose plot and moral lesson resemble the bible story in Matthew 25: 31-46 was used.
This story was developed by Airhihenbuwa (2007) in his book Healing our differences:
The crisis of global health and the politics of identity:
There is a popular story about a devout Christian whose town was flooded but
refused to evacuate because he was waiting for God to come to him and rescue
him. The first rescuers who came to rescue the man were unsuccessful as he
refused to leave his house while insisting on waiting for God. As flood waters
rose to the man’s chest, a second group came by boat, but the man refused to
budge; because he had been a good Christian and had obeyed all of the laws of
God, he was convinced that God would come directly to rescue him. As the water 45
continued to rise, covering his house, he climbed onto his rooftop, at which point
the third group of rescuers came by a helicopter, but the man was steadfast in his
conviction of seeing God directly. Of course the man drowned and went to
Heaven. At Heaven’s gate, he was furious at God for not coming to rescue him.
God chided the man asking him what else he expected since he had sent him three
groups of rescue workers first on foot, then by boat and finally by helicopter. (p.
146)
The transition step involved asking participants if they know any similar story from the bible. There could be many analogous cases but the following story from
Matthew 25: 31-46 was one the most expected:
‘Come, you that are blessed by my Father, inherit the kingdom prepared for you
from the foundation of the world; for I was hungry and you gave me food, I was
thirsty and you gave me something to drink, I was a stranger and you welcomed
me, I was naked and you gave me clothing, I was sick and you took care of me, I
was in prison and you visited me.' Then the righteous will answer him, 'Lord,
when was it that we saw you hungry and gave you food, or thirsty and gave you
something to drink? And when was it that we saw you a stranger and welcomed
you, or naked and gave you clothing? And when was it that we saw you sick or in
prison and visited you?' And the king will answer them, 'Truly I tell you, just as
you did it to one of the least of these who are members of my family, you did it to
me’ 46
Asking participants to link this story to bible stories was critical because it made
participants feel closer to more familiar stories and experiences. In addition, the
investigator used probing questions asking participants the moral lesson behind the two
stories.
The key stage involved getting insights on areas of concern: the investigator also
asked participants to compare images and symbols in the story of the man and God with
HIV prevention methods (ABC), a procedure that worked well in eliciting the paradoxes
of HIV prevention among religious leaders. During follow up questions, the investigator
asked participants to describe how the symbols are similar or different from the three
methods. Sometimes, during the follow up interviews, the investigator asked participants
to imagine the scenario where the rescue workers were public health agents who advocate
all methods of HIV prevention that include condom use. Participants were able to give their opinions which are described in more details in the subsequent sections.
The Coding Procedure
Recorded interviews were translated and transcribed from Kinyarwanda into
English by the investigator. The investigator also included comments (in brackets) to indicate participants’ reactions and non-verbal cues that were also considered in the analysis.
The investigator shared transcriptions of the focus group discussions with a second coder who also participated by using Insert Comment Menu of Microsoft Word to do open coding. The principal investigator shared the research questions with the second coder in order to sensitize her to the focal points to pay attention to in the data. This 47
process consisted of open coding which was done by identifying comments that are
related to attitude towards the three HIV prevention methods, manners and reaction to the
story of the man and God, the communication and communicative phrases and
comments, role of religious leaders in HIV prevention, contradictions/paradoxes and
agreement and disagreement with HIV prevention methods. This process followed the
recommendation made by Lindlof and Taylor (2002) who posit that identifying instances
of descriptive language help “anchor conceptual categories” (p.220). According to
Lindlof and Taylor (2002) they can also provide quotations for the analysis, as was the case during data analysis and reporting of findings.
After open coding, the principal investigator reread the data and codes and determined the general implications of participants’ reactions and comments. Situational contradictions became overridingly apparent, constraints and attitudinal metaphors were used consistently by participants. These were used in axial coding or what Lindlof and
Taylor (2002) call “the process of integration” or the process “of reshaping the categories and producing deeper meanings for them” (p. 220). On this, Lindlof and Taylor (2002) add that “the process of integrating categories is done with what is called axial coding – using codes that make connections between categories or a theme that spans may categories.” (p. 220). These resulted in the four thematic foci which capture the plight and feelings of religious leaders as they emerged from their reactions and comments to the story of the man and God. The thematic foci are presented and discussed in the subsequent sections.
48
Reliability Measures
A number of efforts can be stated with respect to reliability or consistency of
observations. First, although probing questions were sometimes situational, the steps and
process during the focus group discussions (described above) were consistent across all
group discussions. Second, the investigator used a reliability measure that (Yin, 1994;
Cohen, Manion & Morrison, 2003; Coles, 1989; LeCompte & Preissle, 1993) recommend because they capitalize on drawing from the participants’ own culture. This ensures that the meaning held by the phenomenon under inquiry is interpreted and understood more or less similarly. The story of the man and God proved to be archetypal enough to elicit the same reactions among different groups of Christians (Alastuurtari, 1995). This is also evidence of efforts to establish conditions for transferability (because the story managed to capture a typical procedure across different religious groups).
Third, the investigator provided enough details and illustrative quotes so that the analytical process can be verified (or even be replicated if need be). But the idea of replication is rather difficult and some scholars such as Merrian (1988) are reserved about its attainment. Therefore, this study can only claim reliability based on techniques used to ensure reliable conclusions and logical claims.
Germane to transferability is triangulation of methods of data collection. In
addition to the focus group discussions, the investigator used in depth interviews to
clarify and verify consistency (or the lack of it) of some previously made remarks.
Furthermore, the investigator used observation methods as experienced from campaign
strategies or visual materials used to communicate HIV prevention methods in Rwanda. 49
Therefore one may argue that the pieces of evidence used to reach the conclusions in this
study were drawn from different sources: from field observations, published and
unpublished sources.
Validity Measures
Efforts to achieve validity were made in order to ensure that the discussion of the
findings in this study reflect the reality of the feelings and experiences of religious
leaders or, to borrow Silverman’s (2000) words, one must ensure that the analysis
“warrant for accurate data inferences” (p. 176). Some of measures taken to attain validity overlap with the ones presented to account for reliability in the above section. Hence, checks were made to ensure that claims were derived logically through the comparison of data sources, triangulation or review of comparable or relevant literature reviewed after data collection and data coding.
Validity measures were observed through what Silverman (2000) calls analytical paths in qualitative research. Such measures included triangulation and constant comparative methods. In these regards, the findings section was e-mailed to respondents who requested a copy in English. Two of them responded and suggested one instance that they felt was not an accurate assessment of their opinions. One group of participants did not receive the findings section for validation due to English/linguistic barriers. This effort is one of the components of validity measures that Silverman (2000) calls respondent validation.
Validity measures were also underpinned by constant checks performed from data to research questions and vice versa. This effort is based on the belief that the research 50 process and the derived data are focused and hence trying to measure the same thing across all groups; from data collection to data analysis. In addition to this, checks were made to assess the appropriateness of categories, codes and theoretical notions they seem to summon. This measure mainly capitalized on triangulation that sought to view the data not only through the lens of the investigator’s analytical premises but also through theoretical validation and opinions advanced by others.
Self Reflexive Notes
Soon after my birth, I was baptized in the Catholic Church. I attended both my primary and secondary studies in Catholic schools. At university, I studied English with education and this background shaped my sensitivity to social forces and how education and educational institutions like churches shape people’s behaviors.
When I graduated with a bachelor’s degree in Arts with Education, I worked as a copywriter for an international NGO called Population Services International (PSI) which does social marketing for health. I worked directly with program managers but most importantly, I worked with the department of research to develop campaign messages. In fact, some of the research findings done in Rwanda referred to in the study were collected while working in PSI/Rwanda.
One day, I was sent by my supervisor at PSI to attend a meeting of religious leaders who had met to discuss their role in HIV prevention. I was able to see that they were happy to discuss HIV prevention in that meeting and were eager throughout the three days of the workshop. However, they seemed to have their own resolutions about certain issues; about what they believed was right, and what they felt was wrong with the 51
HIV prevention efforts. I also realized that while such workshops facilitate the sharing of new ideas, they also allow them to consolidate and rationalize their stances. But perhaps the most important thing in this regard was the fact that they came to the meeting. To me, this act was evidence of their commitment to HIV prevention.
My graduate studies at the Ohio University, in the program of Communication and Development Program, also increased my awareness of religious institutions and their roles in communication and social change. As I reflected back about my past
experiences at PSI Rwanda and the three days I spent working and talking with religious
leaders in the above-mentioned workshop, I began to believe that a bridge between faith
and health could be envisioned.
I therefore undertook this study with these experiences. I acknowledge that
conscious and unconscious thoughts stemming from my professional and educational
experiences might have played a role in my understanding and assessment of the data
collected for this study.
Ethical Considerations
This research was approved by the Institutional Review Board of Ohio University
and local authorities in Rwanda prior to field work. In addition, the investigator was
cognizant of the minimal risk that may beset the discussion of comprehensive methods of
HIV prevention with religious people throughout. For example, in order to mitigate
foreseeable ethical issues, the investigator used a strategy of inquiry that is advocated by
Rosalinder and Kitzinnger, (1999). They describe the role of the researcher in focus
groups on sensitive topics as “setting the tone and managing the flow of the discussion” 52
(p. 102). Most importantly, they suggest that the “Discussion of sensitive topics should be preceded by warm-up activities and setting of ground rules; that the discussion should start with a less sensitive topic and then move to more sensitive areas” (p. 110).
Fortunately, this procedure was observed in the design and implementation of the research process namely through the use of “the art and mechanics of asking good questions” developed by Krueger (1999) and described in sufficient details in this study. 53
CHAPTER FOUR: RESULTS
Participants
Three groups out of the four groups that were expected to participate managed to
convene for the focus group discussions. The three groups were made up of nine
participants (nuns and priests) from the Roman Catholic Church, six leaders of the
Seventh Adventists Church and six leaders of Association des Eglises Pantecostales du
Rwanda/The Pentecostal Churches of Rwanda: ADEPR.
The Roman Catholic Church
This group was comprised of eight participants. Three of them were nuns and five were priests. One of the nuns is a nurse in one the local dispensaries. The other two teach and have community outreach activities which also involve teaching parents about the benefits of early education and family values. Priests are involved in development
projects that have to do with the management of health centers that are under the
leadership of the parish. They also interact with community members to discuss
development issues such as family planning and the benefits of birth spacing. The
discussion convened at the premises of the Kagbayi Seminary in the Southern province.
The Seventh Day Adventists Church
The group was made up of two pastors and four church leaders. At the beginning
of the discussion there was one woman among the church leaders. Unfortunately, this
woman had to leave shortly after the beginning of the discussion to attend to an
emergency. I met this group at their church premises in the capital city, Kigali, after their
Tuesday prayers. I also attended the prayers in which they read the bible, discuss the 54
messages and talk about other issues. From the bible’s message, the pastor discussed
health issues. On that day, he discussed at length the benefits of sleep, diet and exercise
on the physical and spiritual life of humans.
Association des Eglises Pantecostales du Rwanda
The Pentecostal Churches of Rwanda: ADEPR
This group was made up of six participants. This group convened at ADEPR
headquarters in Gikondo, Kigali. There were three women and three men. One man and
one woman did not stay long for the discussion because they were called to attend to an
urgent work related task. ADEPR has a very well organized community outreach system
and is the most involved church in health issues in the country. The group that
participated in this study does HIV and church activities as full time jobs. These
programs are sponsored by USAID and other non Governmental Organizations such as
CHAMP (Community HIV/AIDS Mobilization Program). One of the participants is in charge of monitoring and evaluation of those activities that are jointly conducted by
ADEPR and USAID. The other two women and one man do health education and peer education trainings around the country.
The Anglican Church
The group was scheduled to meet in the Northern Province but the meeting failed on several occasions.
Findings
The findings of the focus groups can discursively be illustrated by a quote from a
Yakama Indian woman who once remarked: ‘‘I tell a story, and if it applies and you are 55 ready to hear the message, you will be able to take it with you and make it your own’’
(Strickland, Squeoch, & Chrisman, 1999). This quotation is often used to demonstrate the power of narratives and stories in communicating ideas more deeply and illustratively. As data from the focus groups demonstrates, the narrative mode that was used to mediate the discussions allowed participants to distance themselves from the heat of contentious issues surrounding HIV prevention methods among religious people. Also, potential practical shortfalls of the story of the man used in this study are discussed.
The findings of the study are presented as responses to the research questions.
This presentation follows the process and steps of the interpretation of the story used to facilitate the discussion with the focus groups. First, the story was introduced by reading it aloud to participants who were also following by reading silently from individual handouts. The story was translated into the local language (Kinyarwanda). Most participants enthusiastically participated in making interpretations and assessments of what the man did or what he ought to do.
However, it proved to be hard for the investigator, to introduce, in a direct manner, the comparison of the story with HIV prevention methods. Instead, the investigator began the comparison by probing the groups to interpret the images of the story such as the floods and the messengers. The investigator then probed for the comparison of the symbols and images in the story with the HIV prevention methods.
This method was meant to allow participants to make comparisons and draw parallels that reflect their interpretation and beliefs. In cases where direct comparison was still deemed contentious, the investigator used indirect, third-party probing strategies so that 56
any undesirable similarity between participants and the protagonists in the story could not
inhibit the research process. In general, the third-party probing strategy worked well. For
example, after the first focus group, the third-party probing strategy became easier. The
investigator used expressions such as ‘my previous respondents said that (the investigator
would mention an opinion) is that how you see it? How is it different? Overall, the results indicate that the story allowed religious leaders to engage in the process of self-imagining and most importantly the process of self-persuasion, self-discovery and self-creation
(more on this in sections to come).
The discussion was assumed to be about a discussion of the comprehensive methods of HIV prevention but it drifted into and was dominated by condom use as the bone of contention. This signaled that condom use, rather than other prevention methods was going to be the crux of the study and its goal of searching for a more comprehensive prevention strategy.
In general, participants seemed to be highly motivated while reflecting on the story of the man from a religious perspective. However, when they were required to link the story to HIV prevention methods of ABC, a process of re-interpretation of the story and its moral lessons occurred, marking a subjective shift of opinions. Although this opinion shift was pervasive and maintained, it was hard to defend and some agreed that a parallelism between the story of the man and HIV prevention was possible. In one of the one-to-one interviews, a religious leader described the possibility in the following words:
In the context of the story, someone may interpret it the way he wants why not
interpret it as, let’s put methods in place so that people can save themselves but 57
people didn’t use the method in the fight against HIV & AIDS. God gave out
these methods of abstinence and faithless but people did not use them and they
instead resorted to other things and so they perished.
However, it should be pointed out that although all religious leaders found it hard to contradict themselves, they maintained prohibition of condom use among unmarried people and consistently advocated for abstinence and being faithful. A detailed account of the findings and description as well as typical quotes to illustrate these data points follows. 58
Table 1: Summary of thematic foci and sub-themes
Thematic foci 1: Narrativity as an avenue for elaboration and distance Sub themes: • Perceived salience in the story • The man as a familiar figure • Expressed distance from the man • Expressed identification with God and Christianity
Thematic foci 2: Narrative as flash back and flash forward construction and re-
construction of new selves.
Sub themes: • Narrative as self-discovery and self-evaluation • Narrative as self-persuasion • The malleability of narrative interpretation • The shifting of irreconcilable identifications/roles
Thematic foci 3: Fluctuating feelings about health, faith and responsibility
Sub themes: • Acute awareness of the realities of HIV • Expected active involvement in HIV prevention • Paradoxes and contradictions of differing roles • Expressed preference for faith over health
Thematic foci 4: Behavioral messaging and use of metaphor as epitomes of ABC (mis)
communication.
Sub themes: • Observed call-to-action/behavioral messages • Expressed ambiguity and miscommunication • Condom as illicit/licit • Condom as poison • Condom as a drug 59
Reponses and Lessons Learned From the First Research Question (How do Religious
Leaders in Rwanda Respond to a Dialogue
that is Grounded in the Practice of Ordinary Hermeneutics?)
The consistent theme that can capture the way in which they responded to the story is coded as narrativity as an avenue for elaboration and distance. For most participants, the story of the man was familiar and close to bible stories which facilitated the process of elaboration. Elaboration in this sense refers to the ability to engage with the story and perceive it as relevant. For example, one religious leader observed:
So if you want to relate this with our story, there are times we want to wait for
God to come to us directly… another case I see in the Old Testament is again
about Abraham and Lot when angels went to the town where Lot lived and they
had gone to save them. But people in the town despised what Lot was saying
…first he shouted loudly and said that he had learnt that the town was going to be
destroyed. They did not want to listen to him the angels came to his rescue…. and
his in-laws and those who were close to him…but they did not listen to him.
The above quote stands for many other similar parallels made by participants. It shows that even if the story was not drawn from the bible, participants were able to easily find an equivalent from the bible because of its salience to the religious culture. As another religious person remarked, “the bible is full of similar stories”. In general, participants were able to elaborate and get more involved with interpretation because of perceived similarity to their culture (bible narratives). 60
The theme of distance refers to the distance from the subject matter which is
comprehensive HIV prevention methods. Before the discussion, participants were
informed about what the study was about, that is, comprehensive HIV prevention methods. This is usually a sensitive issue (as we shall see later). But the sensitive subject
matter was suspended as it was preceded by a general discussion of what happens in the
story. However, the story acted as distraction from the main issues. Participants were thus
inclined to suspend their counter-arguments that the story may bring into their
consciousness. Some were even critical of the man’s stance. This is what one female
leader remarked in her response to the man’s behavior:
This man wanted to be famous! That is why I was saying that faith goes with
humility… having the discerning spirit…and ask yourself, is this it? So this is
obviously…
This participant was obviously skeptical of the man’s consistency with his stance. This
was so despite the fact that the story can be related to real life. But this likelihood of reality was not immediately perceived as plausible because participants even went further to re-evaluate the basis of such tenuous faith. Most participants agreed with this by saying that “we cannot see God directly”. One male participant reacted using words that echo the same questions about such magical mentality which should not be taken for granted:
God can intervene in many different ways including miracles but he can also
show that he believes in ordinary interventions through people in their beliefs in
their righteousness that is why in the bible we have education, beliefs, change. 61
And so God’s intervention is not a thing…it is not so instrumental and that God’s
interventions should always be taken as magical.
The idea of distance and re-evaluation of unsubstantiated faith is further reflected in the ways in which participants reacted to the story relating it to some other religious beliefs that are dubiously regarded by mainstream Christianity. One male participant related the man’s faith to the traditional religion whose beliefs and practices are considered as counterintuitive by Christianity:
The interpretation I can make out of this is that sometimes we tend to imagine
God as the primary cause of our problems and we take God as something magical
that cannot act in real and ordinary life just like the way those people used to use
sacrifices or the way Rwandese would take Impingi (juju/magical agent) and
believe that the thing will protect them.
In relation to this, all participants of one group agreed that the man was doing what he was doing not because of his devotion to his faith and God but because of his egotism. It was in fact a generally agreed upon conclusion that he got himself in trouble because of his bravado that bullied him into being consistent in his inconsistency. These lines echo the sentiments of one group that agreed: “the man simply wanted to be famous”.
At this stage of the discussion then identification with God and not with the man is evident. The story also established a sense of humor among respondents hence eliciting more elaboration and reflection on what happens in the story. Also, at this stage, participants were operating from the world of fiction and not reality. It was so until the 62 reality and plight of their roles in public health began to be incongruent with the final implications of the story.
Responses and Lessons Learnt From the Second Research Question
(What is the Perceived Role of Religion in Public
Health Among Religious Leaders in Rwanda?)
All religious leaders who participated in the focus groups discussions are in one way or another involved in community health or education programs or both. Some work in health centers or other related programs as their full time jobs. This role allows them to confront HIV issues at the socio-economic, religious, political and biomedical domains of the pandemic. As they elaborated on the story, participants began to reflect on its implications. Gradually, they became aware of implied paradoxes presented through the story of the man and of the various dilemmas they face as they try to navigate the many oscillating roles that HIV care and prevention demand from them. The thematic foci that emerged from accounts of their predicaments were thus coded: fluctuating feelings about health, faith and responsibility.
For example, one female religious leader pointed out these challenges (of assuming many roles) in the following words:
Before going to work in the hospital maternity where I always experience these
things (hesitations… and inaudible sounds), …I also lived as a person…that
means I was also born and lived in town; being a religious person does not mean
that you are abnormal; someone who does not care about how people live or who
never experiences problems. 63
The respondent’s role as a nurse in the hospital ward makes her reflect on the many and conflicting roles of a religious leader. Many other respondents have similar positions that put them in direct involvement with health and HIV-related issues. Also, their roles as trusted educators make them perceive their roles in society as compellingly involving.
The following quote is a typical example:
Well, if you look at the Rwandan society based on priesthood, the priest is very
well respected by the Rwandese society. They respect him because they think
they are people who do good things, who share the word of God. One proof for
that is that every Sunday, despite some testimonies that oppose our image as
priests, you find that people still come to church to get the word of God; that is
evidence of the confidence that people have in priest and the church. The other
proof is that 60% of schools are faith based (they are managed by our church) and
35% or more of health centers are ours.
These many roles and expectations further forced religious leaders to offer manifold responses. This attests to the vacillating positions assumed by religious leaders. For example, in one heated group discussion, the discrepancy of faith and health as sets with fuzzy and shifting boundaries became apparent:
E: I am not sure if this will relate to what we have been saying… but going back
to the story…this man resisted and refused to leave the town…because he wanted
to see God directly. This is like these days we have these mushrooming religions.
There have been stories about some people in these mushrooming religions who
fall sick and refuse to seek treatment. They refuse to take modern drugs or even 64
traditional medicine and they say that God will heal them. All what they do is to
pray…they shut themselves in rooms…there are even those who pray for a dead
body…in order to prove the power of God…and they say: we do not believe in
that…all these medicines are impure and problematic in themselves…God will
heal us…there are things like those…well I do not know how their faith is really
but when you look at things logically…you see that that kind of belief is
naïve…whatever it is, if you are sick with malaria or when you lose a leg in an
accident you cannot say that God will come…and heal the wound naturally…
E: (Joking skeptically) you go to hospital…!!!(general laughter)
J: (concerned) No, Let me explain…But then in the sense of God we cannot deny
that God works miracles, which would even surprise people….there are healing
acts that can be performed in the manner that is miraculous in other words
someone may get better without medicine, without any tablet…let’s say people
may pray…but we believe that God is powerful in the sense that he can work a
miracle of healing a disease for example but in that way of not getting treatment
there are things on which you can advise people without discouraging them from
praying but also without discouraging them from going to hospital. That means,
God created us without our help but he will not save us if we do not help in the
physical and spiritual sense, because there are things that we see outside but do
not see inside…but someone who prays so that he can get better that should not 65
stop him/her from going to see a doctor…that is what I wanted to say about these
religions and people who refuse medical attention.
One respondent expressed a rather nuanced positions but which still seems to support the
above position. He said:
The son of Sirach [in the bible] puts it clearly… he says when you fall sick pray
but also go to hospital do not get stuck in bed and say that you are praying
(general laughter)
This quote illustrates the interplay of health, faith and social responsibility as experienced by religious leaders. Diverging opinions were expressed. This makes it difficult to locate such shifting stands especially when divergence between expectations, desires, responsibilities, and religious values are perceived as discrepant or socially undesirable.
Many other leaders manifested these mutating viewpoints in other group discussions.
Hence, changing one’s mind also occurred:
What I want to add…when I asked that question…on the youth who are not saved
like us…. I just wanted to test the group to see if we really have the same
position. But even me I am of the same position that if God said don’t commit
adultery but you nevertheless go ahead and do it you surely drown in the floods.
These contradictions result from many commitments that participants made either as part of the process of interpretation of the story or as part of real roles that religious leaders often assume. The story used in the focus group discussions provided a forum for them to reflect on the desirable side of being an educator (and a shaper of various behaviors).
However, there is also the other, less desirable aspect of their role that takes them in 66
uncertain and paradoxical territories. As one pastor expressed “you cannot hold the bible
in one hand and a condom in the other”. Yet, this stance was later contradicted. A
member from the same church as the pastor (just quoted in this paragraph) reported in a
one-to-one follow-up interview that they do have ways of transferring responsibilities
that would otherwise be impossible for a pastor to fulfill. He talked about the existence of
subordinate groups that teach comprehensive methods of HIV prevention:
I: [do you have such groups] in your church?
M: In our church, we do have those groups. And the way we work we tell people
to remain behind after church so that we can raise awareness on HIV. When
people remain behind that is after the sermon and all church matters are over,
those people gather and we give those messages. And those messages do not end
there. It is also spread in the wider community and people get to know it. Even
those who are not Adventists. We even get an audience that is not Adventist and
they listen.
I: Do you also teach the condom among other methods?
M: What do you expect? If they are in charge of health information, why should
they forget the condom? They cannot forget it. Yes we do have such groups.
Many religious leaders agreed that their role in HIV prevention and care is the sensitization and education of the community. Specifically, in relation to HIV prevention methods, all of them easily agreed with Abstinence and Being Faithful but disagreed with condom use. In a follow up, one-to-one interview, one leader reiterated this position 67 using one important descriptive word that seems to capture the sentiments of many other leaders of the different groups that participated in this study.
Last time, I said that the condom is illicit. I say that it is allowed in context. For
example, in the case of discordant couples or when it is recommended by a
doctor. We believe that the doctor has the last word on health. So for us we talk as
doctors of the spirit and not doctors of the body.
This kind of acknowledgement of one’s role in public health behavior and education and dissociation with the same role was consistent. “A good life for God”, another leader observed, “is not whether the person is healthy in body, it is about whether the person respects God”. Many agreed with this. They said that God does not want people to be healthy without respecting him. They said that using a condom is like “looking for ways to keep healthy and free of HIV while continuing to keep committing adultery”. They said that would be a way of showing God that we want to be bogged down in sin:
Ok we will tell you how we understand that…for the condom, I will not disagree
with what my colleague has just said, I will reiterate what he said. We do not have
a laboratory that makes drugs and when someone is sick, he goes to hospital and
seek medical assistance. What you cannot teach and what the bible does not
approve of is that you cannot encourage people and say, if you fail then use the
condom. In that case, the message that we have in our church will be
counterproductive. In other words, we are telling people that it is impossible to be
a Christian. 68
These contradictions attest to the plight of religious leaders as they try to navigate their
many roles in public health and religious beliefs. The story of the man presented him in
ways that become gradually less congruent with religious beliefs and, ultimately,
reconciling the two become real dissonance. On the one hand, they are required to project
an image of integrity and on the other, the same image is obliged to face up to further,
discomforting conflicts resulting in fluctuating feelings about their responsibility as far as
health and faith are concerned.
The plight of religious leaders is best felt in their attempt to endorse condom use
in the case of sero-discordant and sero-concordant couples. In these cases, all the
religious leaders agreed that the condom can be regarded as licit or as a drug to borrow
their words. This opinion is, however, likely to present further discrepancies among
religious leaders in their efforts to avoid dissonance: use of condom among sero-
discordance or sero-concordance is neither curative nor preventive as their discourse seems to claim. Thus, a new paradox becomes obvious. This paradox is mostly reflected in the way they responded to the forth research question.
Responses and Lessons Learned from the Third Research Question
(How do Religious Leaders in Rwanda Integrate New Information?)
To illustrate (in a general manner) how religious leaders sidelined or integrated deviant information, this insightful quote from Bruner (2002) can be used:
There is no such a thing as an intuitively obvious and essential self to know, one
that just sits there ready to be portrayed in words. Rather, we constantly construct
and reconstruct ourselves to meet the needs of the situations we encounter, and we 69
do so with the guidance of our memories of the past and our hopes and fears for
the future. (p. 64)
The focus group discussions hinged on narrativity as a way of fostering discussion and
relating the narrative agency to religious culture. As a result, the integration and
refutation of new information and identities that the narrative enacted followed the
development or plot of the narrative and its denouement. For groups that tried to integrate
the new information embodied in the narrative, the story served as a discursive process
for understanding others (such as the man and God in the story) and hence engaging in a process of self-discovery, self-evaluation and self-reevaluation. These processes may also be described as identification with appealing protagonist(s). The thematic foci that arose
from these processes were coded as narrative as flash back and flash forward
construction and re-construction of new selves.
To begin with, it would be practical to elaborate and illustrate the sub-theme of
narrative as process of flash back construction and reconstruction of new self (which is
an illustration of the retrospective process of integration and refutation of new
information and identities as enacted in the story). The understanding of how integration
(using the narrative mode) occurred is likely to facilitate explanations of how its failure is
likely to take place.
Even though there was integration of new identities (and self-discovery) among
respondents, they eventually backtracked as they realized that their identification with
God (and not with the man) in the story was creating a new self that does not resonate
with some of their strongly felt religious beliefs. However, this was made in 70
retrospective; when they started to link what is happening in the story with the realities
and paradoxes that beset comprehensive HIV prevention methods. Based on this
therefore, the sub theme that summarizes this experience was coded as narrative as
process of flash back construction and reconstruction of new self. A typical
exemplification of this is summed up in one female leader’s words who was reacting to
religious beliefs that are adamant to condom use regardless of circumstances. In this case, one can say that she had constructed this new identity although that was not congruent with her religious group’s beliefs:
F1: I think those people who do not appreciate different circumstances of condom
use are like this man. This man… I don’t know, had strong confidence in his faith,
but he also lacked a discerning power to think through the situation. He could not
give up. He lacked the humility that could enable him to understand and discern.
So for me, I believe condoms are part and parcel of HIV prevention.
For the group that assumed the prospective persuasive intent of the story (and therefore saw it as a process of dislocation and upheaval of self), a reaction of avoidance and dismissal occurred. As it happened with one group, this reaction was characterized by sidelining obvious similarities and reluctance to making any identification or commitment that are likely to dislocate them from their beliefs and established identities.
This occurred once with one group. The sub-theme learned from such reactions is thus coded as narrative as flash forward construction and re-construction of new self. In the end, therefore, these reactions were put together to form thematic foci arising out the 71
third research question coded as narrative as flash back and flash forward construction
and re-construction of new selves.
Reactions that strived to re-construct previously made interpretations were quite
frequent. This is reflected in the words of one male participant who perceived previously made parallels as irreconcilable:
V: the reason why it cannot be comparable is that this man has been given a way
of escaping from the floods. He refused because he believed God would come and
rescue him. That is his belief. So in the case of HIV and the tools that can be used
in order to protect oneself …here comes the HIV pandemic and then a person is
required to… (he hesitates) here is where it becomes complicated for us now..
Such hesitations and difficulty in dissociating with God (the preferred protagonist) were always done retrospectively (or after making a flash back on the implications of the story). As mentioned earlier, participants naturally began by identifying with God as the most appealing and sensible protagonist in the story. Almost all respondents experienced
this difficulty because of commitments made previously. In fact a compelling sub-theme
that emerged out of this and was coded as narrative as process of self-persuasion. (Self
persuasion as a component of construction of new self)
Self-persuasion mostly emerged from questions that required respondents to compare the similarities between images and symbols that are used in the story and the methods of HIV prevention. For example, this was said during the second focus group discussion: 72
A: The way I understand it…let us say that the floods are HIV, those
messengers… yes there is the symbol of HIV and the floods are also there…and
the people they want to attack are also there…but there is also prevention which
can be considered as the three people that were sent and they came with tools that
can save…in the cases of prevention, we have people and we have people and
tools that can be used in order to be saved. So what I am saying should be
regarded in that context…(they will probably help me…) (group laughs)
especially because HIV pandemic we know that it has no cure or immunization…
Like many other respondents, this participant had difficulty sustaining this line of thinking and reconciling it with an imminent incongruity with the beliefs of his religious group (notice his appeal from his fellow members and their subsequent laughter).
Nevertheless a phenomenon of identification or self-discovery is evident in most participants’ utterances. The use of we as a marker of identification and perhaps construction of a new self is observable in most participants’ discourse. This is exemplified in this quote:
A: the materials: I can compare them to the rescue people…materials are there.
Let’s say in the context of prevention, let’s say…we know for example there is a
condom. So there is a prevention method because you can use the condom. And
there are other ways… you can avoid sharing tools and blood contact… we have
methods of using gloves. That is in relation to prevention. If I relate this with our
activities, we do that a lot. 73
As mentioned earlier in this section, there was a case where elaboration and distance
failed to facilitate identification as it easily happened with other groups. Participants in
this group chose to focus on the differences only and deliberately avoided similarities.
They did this by capitalizing on the malleable nature of interpretation. They were
selective in the way they chose elements to compare and by focusing on obvious details
instead of the holistic picture that are common and encompassing. They even began by
denying any similarity between the story and the bible:
I: my first question is do you know any other passage from the bible that could be
similar. I did not get this story from the text but I thought it could be similar. The
other people I work with told me so many other cases like those.
A: We don’t think there is such story in the bible. Let’s go on.
I: I think there are…some other people told me many cases of similarities
The investigator then recounted other stories that other groups provided as being similar to the story. Still, participants refused to acknowledge similarity even when they were made aware of the possibility of such similarity. At this point, they opted for re- interpreting the similarity to make it dissimilarity. This is what they said when the investigator recounted the similarity established by other religious leaders:
Man2: Oh that one!?
I: Yes, there are so many others that they told me about 74
Man1: But that is not similar. Because in this case, it is someone who was saying
‘I can only derive something good from God…he thought that only God could
find a solution so it is different.
In such cases where similarity was identified, characters’ names and places were
different. But thematic foci, overall moral and structures of the stories seemed to be the
same. The implication of this position is that participant felt uncertain about where the
story was taking them and engaging with its interpretation was perceived as a potential
ally for dislocation. In other words, it was anticipated that acknowledging similarity between the story presented to them and other bible stories would mean complete identification with rhetorical implications of the story.
These participants were therefore forward looking and were wary of the outcome of making meaningful commitments or identification with events or characters in the story. They avoided this by making interpretations that distanced them from the story as a way of sidelining new information and any identification deemed deviant. They also re- interpreted what was said by other religious leaders:
A: I think we will not agree on that, as you know different religious groups have
different interpretations. So our interpretation does not go in that direction
because the two stories are not similar at all.
This forward-looking construction and re-construction of differing interpretations of
stories was coded as a sub-theme thusly: narrative as a flash forward construction and re-construction of new selves. The malleability of interpretation in this case allowed 75
participants in this group to avoid making any new identification because of perceived
persuasion inherent in identification with events or characters in stories.
Participants were informed that the discussion was about comprehensive
prevention of HIV. Since they could not see the direct link between the story and HIV
prevention methods at the beginning, this missing link was perceived as confounding and
perhaps a signal of an unpredictable, incoherent or even undesirable outcome that can emerge from such interpretive process. Again, this attests to the plight of religious leaders as they try to navigate their ever varying responsibilities. The reaction also seems to be
congruent with Bruner’s (2000) assertion that “we constantly construct and reconstruct
ourselves to meet the needs of the situations we encounter, and we do so with the
guidance of our memories of the past and our hopes and fears for the future” (p. 64)
As seen in previous reactions to the story of the man, participants’ first reaction
was to identify with God. They were also happy and able to analyze what ought to
happen and what the man should have done in order to survive the drought. At the
beginning of the discussion, none of the participants identified with the man and his faith.
This phenomenon was described in the previous section as elaboration and distance since
the story allowed participants to distance themselves from the possibility of
uncomfortable realities of HIV prevention methods. As the discussion progressed
however, and as the symbolic representations of the story were compared to HIV
prevention methods, dissonance set in. This phenomenon was described as fluctuating
feelings about health, faith and responsibility. 76
Such dissonance stems from the realization that beliefs are embedded in stories which are subject to interpretation and flexibility. Respondents grappled with this challenging unpredictability of narrative interpretation as they made the link between the story and HIV prevention. This can best be illustrated by what one respondent said in a follow-up interview:
Investigator: Do you think there could be some similarity or mismatches?
E: An interpretation of any text can be given any orientation if we want to
understand it that way. Without any hesitation and in the context of HIV
prevention, if we want we may understand it that way. For example those who
support the condom may say that yes of course they are talking about you…there
are cases where you preach and after your sermon someone comes and tells you
‘oh you have taught us and you have also told them too our enemies’…so you
find that the person got his on interpretation out of what you said, sometimes it is
not what you really wanted to say…so also in the context of the story, someone
may interpret it the way he wants why not interpret it as, let’s put methods in
place so that people can save themselves but people didn’t use the method in the
fight against HIV & AIDS. God gave out these methods of abstinence and
faithfulness but people did not use them and they instead resorted to other things
and so they perished. So a person may have such interpretation.
Responses and Lessons Learned From the Fourth Research Question: How Has ABC
Been Communicated By and to Religious Leaders in Rwanda? 77
To answer this question, participant observation methods complemented the focus group discussions and was conducted by the investigator during and before field work.
The thematic foci that emerged from this endeavor were coded Behavioral messaging and Metaphor use as epitomes of ABC (mis)communication (epitomes of either goodness or badness). An account of how the investigator arrived on these thematic foci follows.
During the field work, the investigator participated in a campaign that was launched on World Aids Day on December second. The strategy of the campaign was to use local music celebrities in order to deliver condom use messages to different segments of the population especially religious leaders. The campaign used posters and billboard channels to communicate key ideas of the campaign. Different musicians were photographed holding an open condom. The copy of the campaign was two running lines:
“I use condoms” and “it is my right to protect myself”. These two lines were common on all the billboards and posters.
This campaign followed another campaign launched in 2007 reviewed in chapter one. In this section, the visuals of the latter campaign are presented first and the visuals of the former follow: 78
Figure 2: Social Support Campaign in Rwanda
Don’t wait/Witegereza Social Support Campaign of 2007.
79
Figure 3: The right to use condoms campaign in Rwanda.
“It’s my right to protect myself”- Condom use campaign of December 2009
The sub-theme that emerged in the observations of the use of the visuals was coded as behavioral messaging. As a main component of the process of behavioral change, behavioral messaging is usually arrived at after the experiential stage, that is, when people have had time to experiment with new ideas (Glanz, Rimer & Viswanath, 2008).
However, the investigator has often observed that the experiential stage is often skipped opting instead to less time-bound approaches of social change communication. As a 80
consequence, the target audience is expected to move to the behavioral stage through channels reviewed (and presented visually in this section).
Also, as the visuals demonstrate, a preference of channels with shorter space for message elaboration (such as posters and billboards) attests to the confusion of advertising and social marketing. Advertising usually uses call-to-action messaging
(dubbed behavioral messaging in the context of this study) in order to sell products.
However, this is easier when the intention is to sell less controversial products other than the condom. Social marketing on the other hand concerns itself with selling ideas first with ultimate goal of influencing behaviors.
The reasons behind this confusion (between social marketing and advertising) are acknowledged by other researchers. The lack of experiential period that would demonstrate the need for change can be identified in the literature. Harris (1999) puts it succinctly as he says that “often in social marketing, people are not at all opposed to the message and may even support it; they simply do not feel the immediacy of it and thus are not particularly inclined to act on the message” (p.236). Messages that encourage talking about sex are also sometimes placed in the wrong channels. In the case of
Rwanda, they are not only used in hurried manners (advertising style), they are also disseminated using public media. In effect, Airhihenubuwa (2007) remarks, that “what is often misunderstood is the fact that Africans do talk about sex given the proper context and circumstances” (p. 41).
In addition, McDavid and Hawthorn (2006) attribute this practice to the anticipation of evaluations. The Non Government Organizations that are the major actors 81
that implement these campaigns often find it necessary to find channels that can be easily quantifiable during evolutions due to reasons of accountability. In brief, these practices
may also be attributed to the failure to take into cognizance the theory of social change that is often fraught with dialectical tensions (Papa et al. 2006). Dialectical tensions are not resolved at once.
However, as the data demonstrates, religious beliefs are hard to change and participants expressed difficulties with such behavioral messaging. As participants responded to the investigator’s questions, they could not help drifting to the above mentioned campaigns. For example, one female religious leader made the following comment:
These messages that are given on billboards, radios and television, these are
awareness campaigns that are given in a general manner, that are hurried done in
hurry, but they sometimes offend my sensibility (inaudible sounds) but if you live
in the real world living with people… I really understand, it is simple way
of…(inaudible sounds) because if you lead a country full of people that you must
save you must do something in hurried manner and in the possible manner.
The word hurried was used several times by participants in relation to the billboards and posters. Also participants expressed ambiguity inherent in the use of such channels.
Space for elaboration of marketing ideas on billboard is limited. Consequently, participants felt that controversy is not addressed in the process which can cause confusion and miscommunication in the campaigns. Here is a passage of the participants’ exchange on this issue: 82
P: In general sexuality is not sexual intercourse only…but what we have done
now is we have reduced sexuality to sex only. An adolescent girl or a boy if you
tell them Witegereza ...but even all those messages are confused… because what
that means may be …start now (general laughter) because those messages are
polysemic…ambiguous… a tree is straightened when it is still young ….so a child
would say ‘ok let me start now…let me have some practice…so that when time
comes I will perform very well’ (general laughter). Yes, there are children who
would understand it that way…
T: Yes or SINIGURISHA/I am not selling myself… I give it for free…
(Subjective response/comment – that religious leaders heard from the
public).
The Witegereza (or do not wait) campaign was reviewed in the first chapter. The umbrella theme was framed around a Kinyarwanda proverb that can be translated as
“Witegereza a tree is straightened when it is still young”. Witegereza was an umbrella theme that ran across all the communication materials during the campaign. However, as participants of this group remarked, the theme was subjectively elaborated as do not wait; start having sex now, a tree is straightened when it is still young. (Instead of the intended message to community leaders/educators that they should not wait to discuss sex and
HIV prevention with their children.)
Another similar approach was used in another social campaign in 2009. It was a cross-generational sex campaign whose umbrella theme was SINIGURISHA. This means 83
‘I AM NOT SELLING MYSELF’. However, this was also elaborated as I AM NOT
SELLING MYSELF, I give it for free’. (I give it for free is added as if to complete the message).
Another typical feature of related (mis)communication or mis(understanding) was expressed in their use of metaphors especially while referring to HIV or condoms.
Participants of different groups consistently used words such poison (to refer to HIV), or poisoning (to refer to adultery), (licit) drug (to refer to condom when used among sero- discordant and sero-discordant married people). Such metaphors are epitomes of ABC
(mis)communication, epitomes that reflect goodness or badness of condom use (or when the condom is considered good and permissible/licit or when it is considered bad/illicit).
The metaphors may also be a reflection of stigma on religious leaders’ part which may be counterproductive given the centrality of their role in public health communication.
Here is a typical comment that reflects the metaphor used to refer to HIV or condom use (by people who are not HIV positive) as poison:
In other words, if you talked about adultery, it would be the same as poisoning.
They say that poison does not always have bad taste. There is also poison that is
sweet. Adultery for me is like poisoning. That means since I cannot find any
opportunity to advise someone to poison in a way that is healthy it is the same
when it comes to HIV. I cannot find an opportunity to advise someone to commit
adultery in an acceptable manner.
The same metaphor was used at a different occasion in a different group discussions: 84
If it is sero-discordance or if both are infected, there must be a way of protecting
each other. In these cases, people infect each other. An example would whereby I
would be having poison in my stomach and I say come and give me some more
quantities of poison…there should be a way of showing that it is a problem if it is
a case of sero-discordance, there is the risk that the person may come to a point of
vulnerability and contract HIV. There is a need to help such people to think twice,
because most of the time abstinence is very difficult, the only means of prevention
is that one or to prevent that the HIV positive people themselves do not re-infect
each other.
All groups agreed on the permissibility of using a condom as a drug, that is, when people are already infected. They can then use it to prevent re-infecting each other or for family planning purposes. The following comment will be used to illustrate the use of the metaphor:
Em: According to the regulations of our society and our Catholic
society…because most of the time HIV is transmitted through sexual intercourse;
I think this is the main track which accounts for 95%, the catholic church teaches
that sexuality is a discourse that is permitted only to married couples… (inaudible
sounds). When it is outside marriage, we advise young people to abstain until they
get married and we tell married couples not to cheat on each other, that is being,
faithful. When it comes to condom, it is illicit, that is the word used and it is used
as medicine and it intervenes in the sense of a medicine and not as an ordinary
tool like a cup that you use to drink water. 85
The use of metaphors is thus a reflection of the attitude of religious leaders as far as HIV
and related issues are concerned. The use of metaphors is also like a reflection of how
HIV and condom use are communicated. As data observed indicate, ABC is
(mis)communicated using channels that often fail to elaborate and address controversies
and counterarguments. In other words, ABC is communicated without first of all
establishing conditions for change, jumping instead to behavioral messaging using
channels that are prone to ambiguity and that appear to be oblivious of religious culture.
The copy used in one of the campaigns “it is my right to protect myself” is both outrightly self-seeking and evidence of such obliviousness. Further, according to Lakoff, and Johnson (1980), the use of metaphor has the inherent potential of “highlighting and hiding” (p.10) (which, in turn, can communicate and mis-communicate).
For example, if we take the metaphor of condom as a licit drug among HIV positive couple, we find an opportunity and a challenge for communicators: it is good news that at least condom use is endorsed by religious leaders in this particular case. If, for example, communicators were to use religious leaders to endorse condom use in this particular instance, it would help in shading the stigma they experience vis-à-vis the condom. The challenge is that the condom is only allowed not as preventive tool but as a drug. Yet again, this undermines prevention efforts (the primary purpose of the tool).
Hence, the thematic foci that emerged from this endeavor was coded Behavioral messaging and Metaphor use as epitomes of ABC (mis)communication.
86
CHAPTER FIVE: DISCUSSION
The goal of this study was to explore opinion shift over comprehensive HIV
prevention methods among religious leaders in Rwanda. In the process, the use of
narrative that is grounded in religious culture was also explored. The implications
emerging from the findings summon alternative avenues in order to improve or adjoin
existing approaches so as to reach religious leaders in Rwanda more effectively through communication. This is likely to reduce the rift between religious people and public health practitioners, a relationship that is referred to as the faith-health intersection.
Specifically, the study investigated the bone of contention in ABC communication which reveals a complex web of challenges. But these challenges also present refreshing opportunities for public health communicators. The challenges and opportunities were uncovered using narrative mode as a proxy for inquiry. Those challenges and opportunities are thus deemed critical (to communicators) based on this view proposed by
Larkey and Hecht (2010):
Health promotion interventions designed for specific cultural groups often
are designed to address cultural values through culturally adapted
messages. Recent trends in health promotion incorporate narrative theory,
locating culture within the narratives of cultural members, and suggesting
the narrative may provide a central, grounded medium for expressing and
shaping health behavior (p. 114).
Motivational Interviewing and the Narrative Mode 87
The implications and usability of the findings of this study seem to lend themselves to some specific models of communication. It is thus critical to highlight those models with the assumption that they can illuminate the findings of this study and, ultimately, inform the designs of strategies for communicating ABC in religious contexts.
For example, the narrative mode used can be comparable to the methods of motivational interviewing. These strategies were developed by Miller and Rollnick (1991, 2002).
Although motivational interviewing strategies were developed to address counseling challenges, their adaptation and transferability to communication issues in religious contexts seems to be quite promising. For example, Miller and Rollnick (2002) in their foundational work Motivational interviewing: Preparing people for change, observed that strategies of motivational interviewing can be used to address ambivalence.
As seen from this study’s data, the general pattern of the plight of religious leaders and their social responsibility is that of fluctuation. This implies that they need strategies that can help them navigate the fluctuating roles, decisions and responsibilities. In effect,
Miller and Rollnick (2002) define Motivational Interviewing as
A client-centered, directive method for enhancing intrinsic motivation to change
by exploring and resolving ambivalence. It includes a combination of
philosophical and clinical aspects that together make up the whole of MI. Three
primary aspects include: the “spirit” of MI, which forms the foundation for all of
the clinical strategies; four general principles to guide the clinical practice; and
five early methods for establishing rapport and eliciting motivational statements.
The strategies are designed to help clients examine their ambivalence about 88
change, with the goal of increasing their desire for change, their recognition of the
importance of change, and their belief in their ability to make the change. As
clients voice these arguments for change, their intention to change increases,
which in turn leads to subsequent behavior change. (p.7.)
Hence, it becomes permissible to envisage that motivational interviewing can be
transferred through the use of narrative mode. Besides, stories and experiences that are
drawn from familiar circumstances and are relevant to particular cultural groups such as
religious people can be used to communicate and negotiate new values that can serve as
catalysts for sustainable and positive change (Botvin, Schinke, Epstein, & Diaz, 1994;
Botvin, Schinke, Epstein, Diaz, & Botvin, 1995).
The Interpretive Process and Routes of Persuasion
O’Shaughnessy (2004) discusses the inherent potential of stories and anecdotes.
Stories do not simply present the sequence of events; they also induce sense-making.
Hence, narratives can be a powerful tactic when used to persuade. O’Shaughnessy (2004) opines: “It is the stories in the bible that people quote and ministers use to illustrate their sermons” (p.31). In this study, a story that is similar to well known bible stories proved to have the potential to persuade. This potential was identified from the data and is captured in thematic foci coded narrativity as elaboration and distance. There is a benefit for avoiding using stories directly taken from the bible: original but commensurate stories give communicators the flexibility for framing and setting the interpretive and persuasive agendas (O’Shaughnessy, 2004). For example, framing the story in such a way that religious leaders identify with God and not the man worked very well in this study. In 89 addition, O’Shaughnessy (2004) provides a theory that illuminates the manners in which the interpretive and persuasive processes facilitate attitude change:
Stories, like good jokes, stick in the memory and set themes for our thinking.
Well chosen examples can be stories in miniature and effective persuaders.
Stories tend to work by transforming into different context what are typically
familiar ideas. The presence of the familiar reassures and lowers defenses (p.31).
In the story used in the present study, familiarity was achieved by relating the story to bible stories. It can be argued that the story helped in staying close to the religious culture while still transforming attitudes and viewpoints.
The main protagonists, God and the man, were also key to the beliefs and culture of participants. Participants naturally identified with God and not with the man. This type of identification is said to be induced by self-persuasion which, according to
O’Shaughnessy (2004), happens when people associate themselves with values, experiences or people who are highly desirable.
There is a rich body of literature that supports the persuasiveness of stories grounded in the culture of the target audience. Stories create situations and characters who sound like real people with cultural resonance or what is know in the narrative theory as engagement or homophily. These are salient narrative characteristics that are credited for being central to persuasive effects of narrative (Singhal & Rogers, 2002;
Slater, Rouner, & Long, 2006; Hoshmand, 2005; Kreuter, Green, Cappella, Slater, Wise,
& Storey, 2007; Papa, Singhal, Law, Pant, Sood, Rogeres, & Shefner-Rogers, 2000; 90
Knobloch-Westerwick, Patzig, Mendie, & Hastall, 2004; Knobloch-Westerwick, &
Keplinger, 2007; Dutta, 2008; Larkey, & Hecht, 2010).
In addition to engagement, there is also the aspect of transportation which explains that the more people are absorbed in the story, the more likely they will identify with the most salient characters (Storey, Boulay, Karki, Heckert, & Karmacharya, 1999;
Wilson & Busselle, 2004). In this study, participants were able to distance themselves from the sensitivities and contradictions of HIV prevention methods. They managed to enjoy the humor of what happens in the story and were happy to engage in the discussion.
This was described as elaboration and distance which may be attributed to the effect of transportation. As discussed in this section, transportation in turn facilitates the lowering of defenses (O’Shaughnessy, 2004).
The ability to elaborate, that is, interpreting and relating the story to the bible or even real life incidences can be likened to the Elaboration Likelihood Model developed by Petty and Cacioppo (1986). Rather than trying to create new attitudes, this model is credited for changing the direction of existing ones (Petty & Cacioppo, 1986; O’Keefe,
1995; O’Shaughnessy, 2004). As the findings describe, religious leaders engaged with the interpretive process by siding with God. The story of the man seemed to have transformed into a different context what are typically familiar ideas. The Elaboration
Likelihood Model is said to work well with attitude change.
According to O’Keefe (1995), “Elaboration Likelihood Model suggests that important variations in the nature of persuasion are a function of the likelihood that receivers will engage in elaboration of (that is, thinking about) information relevant to the 91
persuasive issue” (p. 137). O’Keefe (1995) then proposes two main routes to attitude
change that result from the ELM model: the peripheral and central route of persuasion. In
the latter route, persuasion happens in the form of short term-acceptance of what is highly desirable (such identifying with God) while in the latter, acceptance of persuasive arguments is long-lasting.
Petty and Cacioppo (1986) identify two main factors that affect elaboration motivation or what they call issue-relevant thinking: personal relevance and distraction.
Personal relevance refers to the relevance of the topic to the receiver while distraction refers to the presence of some distracting stimulus that accompanies the persuasive message (O’Keefe (1995). In the context of this study, the identified feature of narratives’ ability to lower defenses can be comparable to distraction. Also, the aspect of transportation can facilitate distraction. Personal relevance can also be ascertained by the fact that participants were able to elaborate on what happens in the story with more familiar and trusted stories from the bible.
However, as it turned out, not all groups were able and willing to make this parallel. One group said the story was not related to any bible story at all. As implied from the data, this particular group might have anticipated or feared uncertainty arising out of probable outcomes of the story’s persuasive intents. Even the groups that identified similarities backtracked, ultimately, after discovering the undesirable implications of identifying with God (and not with man). In this case, their identification is re-evaluated and re-interpreted to avoid adverse identifications. This seems to be 92 congruent with O’Keefe’s (1995) peripheral route of persuasion, that is, the short-term route.
The implication of this peripheral route is three-fold (and is of particular importance to communicators). First, it may be due to the brief, artificial context of the focus group discussion that allowed participants to see, at once and in a short span, the persuasive tactics of the story and were thus able to anticipate and avoid them. In other words, the context in which it was delivered was not natural enough to gather the natural momentum of a narrative. Second, in real life communication, this can be avoided by concealing the express purpose to persuade and by avoiding making direct links between what happens in the narrative and the behaviors that persuasion desires to transform and change. This can be particularly important during the experiential stage on the process of change continuum (Glanz, Rimer, & Viswanath, 2008). Third, it draws our attention to the criticism often directed to the Elaboration Likelihood Model of persuasion because it assumes that change takes place in a linear fashion (O’Keefe, 1995). The data in this case seem to acknowledge the criticism (against the linear assumption).
Communication and Problematic Integration of Varying Responsibilities
The data revealed the plight of religious leaders as they try to navigate their varying roles and responsibilities. This reality was captured as a main theme coded as fluctuating feelings about health, faith and responsibility. Religious leaders find that they cannot avoid their differing roles in spite of the fact that those roles can often be at odds with each other especially when it comes to comprehensive HIV prevention methods. 93
Babrow’s (1995, 1996, 2001, 2007) Problematic Integration theory seems to
explain the plight of religious leaders in Rwanda. According to Babrow (1995, 1996,
2001, 2007), individuals form probabilistic and evaluative orientations to their
experiences when faced with dilemmas. One of the propositions that is more relevant to
the plight of religious leaders in Rwanda is succinctly expressed by Cohen (2009) as she
opines that the implications of the problematic integration theory “are that probabilistic
and evaluative orientations must be integrated, but that integration is often problematic”
(p. 399). Babrow (2007) proposes four situations that explain how problematic integration theory can be used to understand the plight of religious leaders and their role in public health in Rwanda.
The first situation that can be demonstrated through the lens of Problematic
Integration theory is that of divergence. According Babrow (2007), this happens when
“expectations and desires are at odds” (p. 136-137). This seems to be true of religious leaders in Rwanda. On the one hand, they are expected to play a role in sensitizing the community about comprehensive methods of HIV prevention. On the other hand, they want to remain true to their desires enshrined in their religious beliefs that are sometimes at odds with principles of comprehensive HIV prevention methods.
The second situation is uncertainty which according to Babrow (2007) stems from confronting “non-trivial positive and negative evaluations” (p. 136-137). This seems to apply to religious leaders especially when they decided not to make any meaningful engagement with the story because they were uncertain of the outcomes of such 94
engagement. As the findings imply, making such engagement inevitably entails making
commitments that can be difficult to reverse.
The third situation reviewed by Babrow (2007) is ambivalence. According to
Babrow (2007), this happens when an action has known positive and negative consequences. For example, religious leaders in this study observed that “you cannot hold the bible in one and a condom in the other”. Religious leaders know that the condom has positive health benefits. They even recommend it for sero-discordant and sero-concordant married couples. But on the other hand, they recognize that preaching and acknowledging its benefits would be counterintuitive in the context of religious beliefs and practices.
The fourth situation is impossibility (of something that is positively valued). For example, being faithful is a prevention method that is highly valued by religious leaders
(and their congregants). This method is rated by religious leaders in Rwanda as the only one method that can be 100% effective in HIV prevention. However, admitting that cases of sero-discordance and sero-concordance do exist among married couples is a convincing piece of evidence that attests to the impossibility of the ideal (the 100% reliability of the method). Having endorsed the condom in cases of sero-discordance and sero-concordance is another case that attest to the impossibility of maintaining a categorical stance that a condom is poison (as many religious leaders preferred to use the metaphor to refer to the condom).
Also reflected in the data and participants’ shifting opinions is what could match the notions of consistency theory. Participants strived as much as possible to stick to their identification with God, a position that was the most likely and desirable in the first 95
place. The reason why they experienced great difficulty in shifting from this stance could
be understood in terms of consistency theory. Besides, their vacillating stances that kept
going back and forth as they re-evaluated and re-interpreted the story is an indication of
trying to be consistent with some strongly felt values and beliefs.
O’Shaughnessy (2004) reviews three common models that underlie consistency
theory. The balance model posits that people seek equilibrium between their feelings
(affect) and their beliefs (cognitions), since, O’Shaughnessy (2004) asserts, “often something can be felt to be true but believed to be false” (p. 150). O’Shaughnessy (2004) then concludes that “if we are faced up with this conflict, it can be emotionally discomforting” (p. 150). In the context of this study, beliefs win over other values that may be felt to be true but believed to be false. For example, even if identifying with God was felt to be true in the first place, this stance was re-evaluated and found to be false.
The congruent model says that people seek to reconcile their attitudes towards communication sources in order to make them compatible (O’Shaughnessy, 2004;
Festinger, 1957; Higgins, 1987). Close to this component of consistency theory is cognitive dissonance model which, according to O’Shaughnessy, (2004) “results when two inconsistent beliefs are held simultaneously or when there is a conflict between beliefs and actions” (p. 151). Participants demonstrated a similar conflict especially when their opinions kept oscillating. It can even be reasonable to envision that those who were reserved in their interpretation of the story wanted to avoid incongruity and uncertainty.
However, there are communication insights imbued with such integrative predicaments as experienced by religious leaders in Rwanda. For example, Babrow, 96
Kasch, & Ford (1998) ascertain that “communication is thought to be essential to the construction, management and resolution of uncertainty” (p. 1). For example, the differing choices offered to the man in the story and their resolution constructed conflict
(or uncertainty) but it also induced discussion of what ought to be done (managed them).
Cohen’s (2009) review of problematic integration theory affirms this when she says that
“communication is a source which enables individuals to respond to integrative dilemmas” (p. 399). While communication is essential in addressing integrative dilemmas, it is important to add that communication must be culture-centric in order to reach the minds and hearts of religious leaders in Rwanda (Larkey & Hecht, 2010). In other words, it must be sensitive and mindful of religious culture.
Implications Emerging from Narrative Sense-Making
The quest for the intersection between health and faith in Rwanda is not a straight forward endeavor. The data reflect the manifold responses that participants exhibited in relation to how they respond to comprehensive HIV prevention methods. This implies that faith and health co-exist in dialectical relations and their meaning is constantly negotiated, constructed and re-constructed (Baxter & Montgomery, 1996; Papa et al.,
2006). The subsequent new meanings in turn are likely to construct new identities. In the present study, similar dialectical processes were identified under a thematic foci coded as narrative as flash forward and flash back construction and reconstruction of new selves.
In relation to this, Harter, Japp, and Beck, (2005) observe:
Narrating is a central feature of communication between providers and patients, in
the relationships enacted in health organizations, and in the mediated world of 97
health-related persuasion, information, and entertainment. As scholars interested
in narrative as a way of knowing and being within micro and macro-contexts, we
are less concerned with defining what a narrative is and more so with what the
process of narrating does. (p. 10).
By exploring what the process of narrating can do in this study, two concepts developed by Harter, et al. (2005) seemed to play out. The latter scholars have identify “knowing and being” (p. 9) and “continuity and disruption” (p. 14) among other key theories that can be used to understand the implications of what the process of narrating does. How religious leaders made sense and engaged in the interpretation of the story is essential for understanding their plight, place and role in public health. Only then can communication involving religious leaders be effective.
Harter et al. (2005) argue that “understanding the epistemological ontological power of narrative is a vital direction for health communicators researchers to pursue” (p.
8). The problematic of knowing and being then, according to Harter, et al. (2005),
“foregrounds how we narratively construct and understand what we call our lives, creating ourselves in the process and shaping our existence in particular ways.” (p. 8-9).
Hence, (Bruner, 1999, 2001, 2002) observes that narrative concurrently work as medium of self-discovery and self-creation.
Through their interpretation and oscillating identifications with the two main protagonists in the story (God and the man), religious leaders engaged in the process of construction of selves as (Bruner, 1999, 2001, 2002) posits. As observed from data, they did this in both prospective and retrospective manners (through flash forwards and flash 98 backs). One can add that they did this not only in relation to their being in the world (for example their role in public health) but also knowing who they are (their identity as religious leaders). The discrepancies that beset the two (knowing and being) are at the heart of their uncertainties and shifting opinions as they navigate the process of identity construction.
But perhaps more important are the questions related to the process of identity construction raised by Eco, 1994; Ellis and Bochner 2000; Harter et al. (2005). Although they raise the fundamental questions as issues that concern the narrator, one can also extend them to the audience because as Harter, et al. (2005) observe “identity construction depends upon “co-constructed, shared meanings and depends also on dialogically performed modes of discourse” (p.12). Co-construction of meaning thus takes place between the narrator and the audience.
The key questions posed by Eco (1994), Ellis and Bochner (2000) and Harter et al. (2005) for narrators can then be paraphrased thusly: what are the consequences that are likely to be produced by this narrative? What kind of person does it shape me into?
What new possibilities does it introduce for being in this world? How does this story position me? The data from this study show how these questions played out as religious leaders tried to make sense of the story presented to them. A typical example of how this played out is the case of those who were uncertain and unwilling to make parallel between the story of the man and other stories in the bible. It is very possible that questions similar to the ones raised above deterred them from making any meaningful 99
engagement with the story. This then brings the discussion to another concept of narrative
sense-making by Harter et al. (2005): continuity and disruption.
According to Harter et al. (2005), the problematic of continuity and disruption
concerns itself with disorder and the human desire for coherence”. Hence, Harter et al.
(2005) observe, narratives emplot and locate. In other words, narrative sense-making
involves concerns for predictability and familiarity, or, according to Harter et al. (2005),
conventionalizes expectations. The latter notion is what is referred to as emplotting.
When emplotting is ensured, then a narrative fulfils its role of locating, that is, the
continuity of the narrative (plot) continues to flows naturally with no disruptions. This
implies that disruption occurs when the plot and outcomes of the narrative are
unpredictable and uncertain. If, we once again come back to the example of the group
that refused to engage with the interpretation of the story, we can deduce that they feared
dislocation from their beliefs or disruption.
Narratives are simultaneously a source of creating, transforming and managing
continuity and disruption. Continuity is necessary so as to remain located in familiar
territories or, in the context of this study, in the religious cultural space. However, by
creating continuity, transforming it and managing it (through narrative sense-making), we
are engaging a transformative process (or, so to speak, disruption). Hence, we are
molding new, desired selves. As discussed previously, communicating comprehensive
methods of HIV prevention in religious contexts is a dialectical process which, in the
Marxist terms, the existing structure (thesis) is conquered (anti-thesis), leading to a 100
resolution of structural imbalances (synthesis) and so on and so forth (Max, 1977). If this
is true, then the narrative mode seems to suit this role.
The narrative mode is a common pattern in the scholarship of several disciplines
and is recommended as an avenue for advancing health related theory, research and
practice (Harter, et al. 2005). For example, several areas that pertain to health communication acknowledge the potential of narratives in promoting new identities and positive social change: rhetoric (e.g., Fisher, 1984, 1985), medical anthropology (e.g.
Mattingly, 2000, 2001), sociology (Frank, 1995, 1997, 2004; Riessman, 2000, 2004), psychology (e.g., Bruner, 2002; Polkinghorne, 1998), communication (e.g., Bochner,
2002, Carbaugh, 2001; Langellier & Peterson, 2004; Harter, et al., 2005). 101
CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS
This study explored the faith-health intersection and its relationship with the opinions of religious leaders on ABC/HIV prevention methods. The study reveals that despite a number of communication approaches used to bridge the rift between health and faith as far as ABC methods are concerned in Rwanda, the faith-health integration is still something of a highly contested terrain. Yet, health professionals cannot claim that they provide comprehensive services if they are oblivious of spiritual influences and benefits on health. Similarly, religious leaders cannot claim to provide comprehensive spiritual services if they do not attend to vital problematics of health situated in psychosocial and economic contexts. Thus, the results of this study highlight the imperative to bridge the faith-health rift.
A number of efforts to bridge the faith-health rift in Rwanda exist. However, behavioral communication, rather than experiential communication, has been used to promote social support from religious leaders. However, this study found that the faith- health intersection involves relational dialectics that religious leaders find extremely hard to navigate. Nevertheless, this study explored possibilities that can facilitate the contemplation of new faith-health perspectives as far as ABC methods are concerned.
The paramount possibility explored in this study is the narrative mode. The short narrative used helped to establish that the use of narratives can create conducive environments to explore new ideas and information without causing unwarranted feelings of alienation and moral betrayal among religious leaders. It was observed for 102
example, that stories distance people from inhibiting reactions/counterarguments. As
(Ramen, 2001) remarks, “stories help us to become more without becoming different”.
This study also used a narrative that is culture-centric, that is, a story that is similar to bible stories/religious culture. The possibility of becoming more without becoming different was established through the interpretation of the story of the man and God. This potential is captured in the thematic foci coded as narrativity as an avenue for elaboration and distance. Strength and limitations of this possibility were discussed.
The narrative mode also permitted the exploration of the opinions of religious leaders on ABC which can be an entry point for communication efforts. Through the narrative mode and exploration of their opinions, the data divulged the plight of religious leaders as they try to navigate their ever varying roles and responsibilities in public health and society in general. Their opinions kept vacillating; going back and forth. The thematic foci capturing these findings were coded as fluctuating feelings about health, faith and responsibility. However, this study can also posit that this situation should not be regarded as a quagmire for communicators. It can be turned into communication opportunities.
These opportunities were discovered through the analysis of narrative sense- making that was the main method of inquiry in the study. The story and the new perspectives it enacts served as a discursive process for understanding others (such as the man and God in the story) and hence engaging in a process of self-discovery, self- evaluation and self-reevaluation. While these processes create fluctuating feelings and opinions, they are also evidence of an underlying transformative process as religious 103 leaders constructed, evaluated, reconstructed and reevaluated the new identities that the narrative seemed to shape them into. The thematic foci used to capture these findings were coded as narrative as flash back and flash forward construction and re-construction of new selves.
Furthermore, these findings were also illuminated by the theory of Problematic
Integration (PI). As discussed earlier, people who experience problematic integration are plagued by uncertainty. When this happens, the compelling reaction to reduce or cope with uncertainty is to seek information. This means that people who experience problematic integration are attentive and probably susceptible to information which communicators can/should provide. The study discovered that the information provided in social support campaigns in Rwanda is often not culture-centric. ABC has been communicated in ways that are often self-seeking. The shifting opinions of religious leaders indicate that they experience and avoid feelings of dislocation. They feel wary about being dislocated from their strongly felt beliefs. The problematic of narrative as emplotting and locating used to study the shifting opinions substantiates the plight of the roles of religious leaders in Rwanda.
This implies that the faith-heath intersection and comprehensive HIV methods can be cultivated through the use of communication materials and messages that are culture- centric. Based on the results arising from narrative sense-making in this study, the narrative mode emerges as a viable proxy for attaining faith-health intersection.
Strategies for designing culture-centric ABC methods are those that embed cultural knowledge in both the process and content of the communication (Hinyard & Kreuter, 104
2007; Hecht & Miller-Day, 2009; Kincaid, 2002). In this case, narrative genres such as
drama series grounded in religious culture emerge as the most effective channels capable of eliciting attention and positive response from religious leaders. There are a number of
faith-based radio stations that can welcome such programs in Rwanda.
The intersection can also be cultivated by directly involving religious leaders in
the development and production of such culture-centric narratives or public endorsement
of acceptable aspects of ABC. For example, it was established that religious leaders
support condom use in cases of sero-discordance and sero-concordance. Involving them
in such communication programs or having them endorse such cases would help in reducing the cognitive dissonance experienced by religious leaders as they try to manage fluctuating feelings about their roles in health and faith. This strategy may also reduce stigma which manifested in this study through the use of metaphors (by religious leaders).
Furthermore, public health communicators should be cognizant of the dialectical nature of the faith-health intersection as experienced and described in this study by religious leaders in Rwanda. Communicators should make sure that they provide nuanced cues and persuasive situations that help religious leaders as they deal with uncertainties and dialectical tensions engendered by their many and paradoxical roles. As some participants (and the investigator) observed, ABC and other campaigns (that require the support of community leaders) are often designed as single-phase incidences and are usually launched using direct, short and call-to-action messages that resemble advertising 105 approaches. This seems to be similar to what (Glanz, Rimer, & Viswanath, 2002) call behavioral messaging.
However, communication professionals in Rwanda should ensure that behavioral messaging does not overshadow the foremost experiential stage (which involves consciousness-raising, dramatic relief, self-reevaluation, environmental reevaluation, and finally, self-liberation). Again, series of different narrative genres can be very effective in taking religious audiences through these stages. In other words, since narrative series address various issues overtime, as the narrative unfolds, each stage can be incorporated in timely and calculated manners. Narratives can also help in attending to ambiguities and misinterpretations inherent in brief messaging. As Griffin-Blake and DeJoy, (2005) ascertain “it is important to understand why stage-matched interventions tend to be more effective than traditional interventions” (p. 201). More often than not, social marketing operates as a communicative process which is almost contrary to “the magic bullet” or
“hypodermic needle” (p. 171) paradigms (Williams, 2003).
Finally, this study has some limitations. First, it is exploratory in its approaches and nature and therefore more specific research questions arising from this study are encouraged. Second, this study is based on the views of the main three religious groups that participated in the discussions. There are many more religious groups in Rwanda. As it is the case with most qualitative research studies, the findings of this research do not lend themselves to generalization, that is, they can only be considered within the confines of the opinions of the three religious groups that participated.
106
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