A conceptual framework

Engaging Culture for effective responses to HIV/AIDS

Von Clodagh Miskelly

This paper advocates for engaging culture to enable effective responses to HIV/AIDS in particular it addresses, how culture is being engaged in responses to HIV, why it is important to engage with culture, and points to some of the challenges to engaging with culture.

The paper draws on examples from HIV/AIDS: the Creative Challenge, an action-research project led by Creative Exchange to develop an evidence base and an international practice and policy network of organisations and practitioners using cultural approaches in Vietnam, Cambodia, Kenya, South Africa, Jamaica and Trinidad. Creative Exchange closed in June 2009 but all the resources for HIV/AIDS are still online. http://www.creativexchange.org/hivaids

What is culture?

Culture is difficult to define. The Mexico City Declaration on cultural policies, a widely accepted definition, highlights the scope and multi-leveled aspects of culture describing culture as “the whole complex of distinctive spiritual, material, intellectual and emotional features that characterise a social group (…) not only the arts and letters but also modes of life, fundamental rights of the human being, value systems, traditions and beliefs.” (UNESCO 1982)

These features not only characterise social groups but are the resources from which create “webs of significance” within our daily lives. (Geertz, 1993) Culture is dynamic, we make sense of the world and take action based not just on acquired patterns of meaning and practice but also in response to changing social, economic and cultural influences. Culture is closely tied to power relations where, for example, powerful elites draw selectively on cultural traditions to serve current interests. (Vincent, 2008)

The most visible aspect of culture in development is creative, artistic or expressive methods such as drama, music and visual arts which offer a way of building relationships with a local community, of gauging and expressing thoughts and experience of different groups, of building skills and confidence to act, sharing information, combating myths, using established channels of communication, or introducing new forms of expression to enable different reflections and responses.

Different emphasis is placed on participation in this creative practice depending on the context and goal. Some projects use creative processes within a community to address issues of concern to that community while others co-opt local creative practice or introduce methods such as theatre for development as a way of passing their own messages, adapting a message to fit with local references or languages. Some organisations have developed a mix of approaches to suit particular needs or contexts.

FilmAid working in Kakuma and Daodab refugee camps in Kenya, moved away from ex-pat led film projects which had limitations in regard to the cultural understandings of different refugee communities and moved toward empowering camp residents to investigate their own issues through participatory video. They use different approaches according to their strengths and weaknesses in different contexts and meeting certain purposes. The organisation continues to use large scale mobile cinema film screenings where audiences see a mix of entertainment, edutainment and educational films, as well as smaller group screenings which are followed by discussion groups. Community video production is used to produce material about issues that are relevant to the different communities in the camps and aim to involve the community at large. (ww.creativexchange.org/hivaids/briefings)

Magic Threes worked in Vietnam with people living with HIV and AIDS (PLWHA) to produce a leaflet for people newly diagnosed as HIV positive for whom there was very little information and support available. Participants used different art forms to share their own experiences and identify information that would be appropriate for the leaflets. This project worked to marry what are sometimes seen as incompatible or opposing approaches, using participatory creative approaches to explore experience in order to identify and develop materials for an information and education communications leaflet. (www.creativexchange.org/hivaids/magicthrees) The use of creative approaches to draw out participants own experiences ensured that the leaflet contained material that was resonant with other Vietnamese and understood cultural sensitivities about addressing sexual matters.

Culture may also form an important part of the social fabric that sustains development responses, as can be seen in the way that HIV initiatives in Uganda were able to draw on existing patterns of interpersonal communication and dialogue there, and in South Africa, the tradition of anti-apartheid activism and community mobilization underpinned new campaigns for access to anti-retroviral treatment. (Vincent, 2008)

Kenyan cultural practitioners involved in HIV/AIDS: the Creative Challenge emphasised that working with culture is about working with the emotions – “culture gets you in the gut” – and thus engaging culture can enable affective as well as cognitive learning. (Marsh et al, 2008) The emotional character of culture highlights the potential of cultural approaches to manipulate, for example to increase rather than reduce stigma.

Another less commonly acknowledged understanding of culture in development is in the culture of development that shapes the “practices and assumptions of international development institutions.” (Vincent, 2005) “After fifty years of development assistance, it is clear that policies and projects are not implemented in a vacuum. They are formulated by bureaucrats and planners and implemented by people with a particular mindset in a particular culture, and with particular social norms, reinforced by metaphors, stories, proverbs and film.” Narayan,1999)

Why culture?

Culture, as features of a social group, as webs of significance and as creative expression serves as a resource, a means to engage with a community to address different issues related to HIV prevention, treatment and care. Research demonstrates that culture is a factor in the social trends that contribute to infection and HIV/AIDS in turn has an impact on people’s lives. (UNESCO/UNAIDS, 2000) This suggests that an engagement with culture is needed to address HIV/AIDS prevention, treatment and care.

The Cross Cultural Foundation of Uganda has produced a case study about The Rakai Counsellors’ Association (RACA) strategy of reviving positive local cultural aspects to address the spread of HIV amongst young people. The Association supported
“‘Ssengas’ – paternal aunties – and the Kojjas – uncles –, whose traditional role was to instil moral values especially to adolescents and young married. This community-based cultural referral system had also long existed as a resource in breaking the silence that surrounds sexual matters. RACA has supported Ssengas and Kojjas for the past year, helping communities to select candidates for support, providing up-to-date training, introducing them as a resource to their local areas, and providing them with some inputs to give to their clients. The Ssengas or Kojjas are expected to support their communities, in different ways, according to need and capacity, for instance, individual consultations in private homes or visiting schools. Early signs indicate that this pilot programme is yielding results: the demand for Ssengas’ and Kojjas’ services is rising, there are stories of behavioural change and the approach, because it is based on an existing voluntary system, promises a good measure of sustainability. RACA feels this intervention can provide useful lessons for other development practitioners, although there is a need to adapt the approach to locality, language and cultural context. (HIV/AIDS and family resources)

Social Drivers

At policy level there is growing recognition of the need to address the social drivers of HIV/AIDS including human rights, stigma and discrimination, gender inequality and poverty. (DfID, 2007) Culture since it shapes how people live their lives and the social structures within which they live, needs to be recognised as part of the engine of social drivers. Culture contributes to practices, values, and attitudes which create stigma and discrimination, gender and other inequalities. Engaging with culture can help take into account the networks, values and relationships that shape people’s lives whether to enrich or constrain them and the factors that affect or limit choices which people, especially women, may be able to make about prevention.

To address inequalities requires approaches which involve people in developing culturally relevant responses which tackle the specifics of their own experience. Local organisations using cultural approaches are well placed to do this. Some cultural practitioners involved in HIV/AIDS: The Creative Challenge work with socially vulnerable groups to address a range of concerns, and can therefore address HIV within a community context and in conjunction with other issues of social vulnerability. Other organisations weave HIV/AIDS into the wider themes impacting on their communities, and make use of modes of cultural expression which are well suited to such complexity, for example a drama might weave together a story line addressing a number of social agendas: gender relations, violence against women; the rights of children; poverty and HIV/AIDS.

Organisations already tackling violence against women incorporate HIV prevention into their work. Laphumi’langa (Xhosa for Sunrise) is a project developed by Mothertongue in the Western Cape, South Africa which aims to raise awareness of the link between violence against woman and HIV/AIDS, recognising that broader gender inequalities play a role in the spread of HIV/AIDS. The project trained 28 women who undertook activities including participatory drama techniques to access and creatively express personal stories. These stories were then used to construct plays for forum theatre performances which established dialogues with mixed township audiences in a variety of public venues such as shopping malls. The project explicitly worked within Xhosa culture but in ways which challenged the process of gendering men and women within this culture, in particular the cultural practices which establish men as superior.

The value judgements, fears, misconceptions and taboos that contribute to stigma and discrimination are culturally specific and as such require culturally relevant approaches to awareness raising, skills development and dialogue, sensitivity and inclusivity.

Partners in HIV/AIDS: The Creative Challenge address lack of awareness, knowledge and misconceptions through a range of cultural strategies to do so taking into consideration beliefs and practices which may contribute to the acceptance or stigmatisation of people living with HIV/AIDS as well as willingness to engage in responses to HIV/AIDS. For example, Abila Creative Centre in Kisumu, Kenya makes use of young peoples debating conventions to address the cultural values and practices at the heart of this community which are perceived to contribute to stigma and discrimination and to the spread of HIV. Through this work, which involves young people talking to older generations and researching aspects of their culture such as widow inheritance, they also open up dialogue and develop resilience and solidarity in addressing inequalities or considering community based approaches.

Culture and participation

The complexity of culture and the variety of modes of communication and locally adapted methods in use challenge assumptions about the possibility of communicating health messages to large numbers of people in relatively uniform ways. Research shows that HIV and AIDS prevention projects have failed where there is a preoccupation with achieving individual behavior change, using communications models based on externally-derived and imposed messages. (Panos, 2006)

Engaging with culture is closely aligned in participatory development methods, since it entails starting where people are, respecting and recognising their ability to decide and act on what changes are important in their lives. Engaging with culture means dialogue, working with channels of communication that are favoured and valued within a community, working within the ‘cultural logic’ of that community, supporting a community to define its own solutions which may be adopted because they work through rather than ignore or confound their understandings of the world. Rather than implying a particular toolkit of participatory methods, which are increasingly invoked in the mainstream of development, culture perhaps returns us to an earlier focus on people developing their own critical consciousness and being empowered to change what they identify as relevant in their lives, which is at the root of the initial turn to participation in development.


While the above examples show that it is possible to engage culture productively in development practice, there remains a gap between “how culture in development processes has been conceptualised and how it is implemented.” (Rao & Walton, 2004) Although increasingly recognised as an integral and important aspect of development, culture remains largely hidden. (Gould & Marsh, 2004)

A study of use of cultural approaches to development by 5 UK development agencies uncovered over 350 projects in 40 countries with an estimated cost of £30 million although none of these organisations had a means of systematically documenting or monitoring cultural approaches in the work they funded or implemented. The study concluded that there is no clear rationale behind the use of cultural approaches by development agencies and that “the wider role of culture in development is not well understood and there are few systems in place to capture or assess its impact and the possible outcomes, both positive and negative.”

It was noted that there was limited explicit reference to culture in policy documentation. There was a lack of evaluation of integral cultural projects meant that in the majority of cases, there is no assessment of how projects address policy (where it exists). Assessment of whether a cultural approach to local issues is more or less appropriate than other approaches was lacking as was other assessment of impact, so limited evidence exists of the effectiveness of cultural approaches in addressing development communications, education, behavioural change or social/economic development, in spite of the conviction and observations of project staff that these approaches are important and do make a difference.

Both HIV/AIDS: The Creative Challenge and recent research from the Ugandan Cross Cultural Foundation point to the effectiveness of participatory cultural approaches citing indications of reduced stigma and discrimination, addressing ‘harmful’ practices, improved well being, volunteer testing and disclosure and tackling opportunistic infections. Culture needs to be considered as part of a wider social and technical mix. It is clear from these projects that a variety of methods and approaches are working and needed. (Drawing on Culture 2008)

Out of the Routemapping project Creative Exchange developed a conceptual framework as a means to make sense of projects described as cultural and to describe the different intersections between culture and development. The framework provides four different ways of conceptualizing culture:

• Culture as context: factors specific to local life: beliefs, value systems, history, geography, social hierarchies, gender, faiths, and concepts of time
• Culture as content: languages, practices, objects, traditions, clothing, and heritage
• Culture as method: the medium or cultural forms that projects will use to engage/communicate with communities
• Culture as expression: the intangible, creative elements of culture that connect with our beliefs, values, attitudes, feelings and ways of viewing the world. (Gould & Marsh, 2004)

The framework serves as a way of identifying different aspects of culture in a project or community and as an aid to preparation when developing a project. It is first step but more evidence is needed to develop a systematic approach to understanding and working with culture that might enable more consistent and effective implementation.

The authors of the Routemapping report point to a three fold impact of the failure to address culture in terms of implementation at policy level:

1) Development agencies are not required to demonstrate how they are considering cultural impacts and therefore there is no system of ensuring their work is culturally sensitive
2) No impetus to evaluate the majority of cultural projects to establish how they affect beneficiaries – no system of quality control
3) No incentive to collect data so role of culture remains invisible (Marsh & Gould, 2003)

There was a consistent call from participants in HIV/AIDS: the Creative Challenge for more appropriate and manageable monitoring and evaluation methods to enable them to demonstrate the value of the approaches they adopt as well as to learn from and improve their work. Commonly current reporting and evaluation methods are inconsistent, in some cases they ‘screen out’ cultural features or activities, or are inappropriate, for example, using purely quantitative measures which address the extent but not the quality of outreach and relate to unrealistic expectations in regard to behaviour change. It is certain that where cultural approaches are one aspect of HIV/AIDS responses in a community then attribution is difficult. Nevertheless monitoring and evaluation methods exist and in some cases what is lacking at project level is training and capacity and what is needed at policy level is understanding and support.


In this paper I have for argued for engaging with culture in HIV responses. Culture is dynamic and constitutes a set of resources which may be mobilised as an integral part of any negotiations and power struggles around development. Culture often gives a distinctive twist to development responses, and may play an important part in finding creative and sustainable ways of addressing development challenges.

While the need to engage with culture is increasingly recognised in policy and theory this is not reflected in practice. There is some evidence of the effectiveness of working through culture and of creative cultural approaches in a wide range of local contexts. However, evidence is patchy and there is no systematic approach to ensuring engagement with culture or to evaluating this engagement.

Engaging culture may be a dimension of participatory approaches that genuinely begin with where people are and work with them to address aspects of their life that they identify as important. Such an engagement however, will often be about creating the space for people to reflect on their situation, and find pathways of change which work in context, rather than the promulgation of particular messages or putting in place particular processes of consensus-based decision-making, which may often be quite ‘unrepresentative’ and subtly coercive.

To recognise culture, reiterates the importance of context, and that people need to be part of driving their own change. It is also to recognise that a technical or ‘off-the-shelf’ approach will not work. Finding ways to effectively work with culture, may hold the key to a more responsive development that eschews pre-determined solutions, and recognises the need for distributed creativity and initiative in sustainably addressing development challenges.

* Dr Clodagh Miskelly is a UK based consultant in participatory communications and media and is currently working with Panos London’s Public Health Programme. She worked as for Creative Exchange on HIV/AIDS: The Creative Challenge, an action-research project that aimed to improve the effectiveness of HIV/AIDS strategies through valuing local cultures and employing cultural (http://www.creativexchange.org/hivaids). Contact: Clodagh.Miskelly@panos.org.uk

Acknowledgements: This paper draws heavily on the work of Robin Vincent, Panos London, and Helen Gould & Mary Marsh formerly of Creative Exchange.


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