The Challenge of Changing Behaviour

In February 2009, the Indonesian magazine Tempo reported on the use of Stepping Stones in the province of Papua. We are grateful to Tempo for their permission to reproduce the article, written by Kamellia S. Soenjoto, as below.

Class of Stepping Stones uses creative approach
Photo: HIV Cooperation Program of Indonesia

In the past 10 years, the number of AIDS cases in Indonesia has continued to rise. The Health Department says that most HIV cases are found in Papua, while West Java has the most AIDS cases. A joint report by UNAIDS and WHO in 2003 indicates that Indonesia has one of the fastest-growing HIV/ AIDS epidemics in the world. The National AIDS Commission predicts the number will keep rising until 2020. What is wrong with the prevention efforts?

SECRETARY of the National AIDS Commission (NAC), Nafsiah Mboi, said more resources are needed to cover the huge size of Indonesia. To date, 214 municipalities have reported HIV/AIDS cases. The commission cannot cover them all. The number of cases increases at a faster rate than the resources.

Furthermore, Nafsiah says that the biggest challenge in preventive efforts is in changing people’s behavior, especially among key populations or those whose behavior risks spreading or catching the HIV/AIDS virus.

For example, in condom use. According to the commission’s survey from 2002 to 2007, consistent condom use among those with risky behavior increases only insignificantly every year. It was only 25 percent in 2002, 30 percent in 2004, and The Challenge of Changing Behavior In the past 10 years, the number of AIDS cases in Indonesia has continued to rise. The Health Department says that most HIV cases are found in Papua, while West Java has the most AIDS cases. A joint report by UNAIDS and WHO in 2003 indicates that Indonesia has one of the fastest-growing HIV/ AIDS epidemics in the world. The National AIDS Commission predicts the number will keep rising until 2020. What is wrong with the prevention efforts? 35 percent in 2007. In other words, 65 percent are not using condoms.

In Indonesia, HIV/AIDS spreads mostly through sexual intercourse. Based on data from the Department of Health per 31 December 2008, 48 percent of cases were spread through sexual intercourse, followed by intravenous drug users at 42.3 percent.

Educating those considered to engage in high-risk behavior of spreading through sexual intercourse, such as harbor workers, truck drivers and factory workers are aggressively campaigned. Although they realize the dangers of the virus to themselves, many refuse to use condoms. Various excuses are given, such as interrupting enjoyment and lack of condoms.

Female commercial sex workers can’t do much when their customers refuse to use condoms. They need to survive, so they just say yes. In this case, the government promotes female condoms so that women can protect themselves.

Besides condoms, there’s a high degree of needle sharing among drug users. The commission mentioned that 55 percent of drug users share needles.

The commission’s target is that by 2010, 80 percent of drug users will no longer share needles, and 60 percent of the key population will consistently use condoms.

Innovation Step
With the principal intention being to change high-risk people’s behavior, the commission has designed a program called an innovation program. There are four components in the program.

The first component is intervention to change in behavior in localized areas. The commission will provide education and train a peer-educator. A peer-educator is someone who can persuade friends who are fellow commercial sex workers, to persuade their customers to use condoms. He or she will also invite his or her friends to have their reproductive organs checked routinely.

The second component is involving local stakeholders, namely, commitment from the local regents, pimps, and police to encouraging customers entering localized areas to wear condoms. The third component is condom availability. The fourth component is threemonthly screening and sexual disease treatment. The program will gradually be implemented in 12 provinces this year, including West Papua, South Sulawesi, and Jakarta.

The commission’s deputy secretary, Fonny J Silfanus, said that Suko village in Malang regency is a success story in the implementation of the innovation program. In the village, the spreading of venereal disease has decreased and condom use has increased. This indicates a change in behavior.

Stepping Stones
However, in a place such as Papua, an innovation program alone is not enough. In Papua, the HIV/AIDS virus has spread among the general population, namely those who don’t engage in high-risk behavior, such as housewives and children. A program involving the general population is needed.

Since two years ago, the commission has implemented a program called ‘Stepping Stones’. The program is deemed successful in increasing the awareness of people in Papua and West Papua to protect themselves and improve the quality of living. Stepping Stones is focused on concentrated areas, so that the spread doesn’t expand to other regions.

Stepping Stones is not a new program. It was developed between 1993 and 1995, mainly in Uganda, working with rural communities. The program has been distributed in over 100 countries. In Indonesia, the program has been implemented in Papua only.

Through the program, people are invited to discuss things impacting their sex lives, something that’s often taboo. Stepping Stones also trains communities to make decisions, especially in behavior between men and women.

By talking about them, their perspectives in viewing their lives will become open. Let’s say there are villages where men are decision-makers and women are followers; or where violence against women is considered normal. In the program, women are given a space to communicate. Using this means, people’s horizons become broader. They see their lives from different perspectives. They learn to know the risks of their behavior and how to change them for the better.

In its implementation in Sorong, Merauke, and Wamena last year, 30 public figures, including youths, religious figures, and women were invited. The groups were divided into male and female. They were further divided into those who were married and not married. For 10 days they engaged in intensive discussions on various topics such as gender and agebased roles, money, alcohol, drug use, traditional practices, attitudes to sex, attitudes to death, and their own personalities. On the last day, the groups met to discuss the results of their discussions.

Domi Deda, a program facilitator, revealed that interesting stories were often heard on the last day. Sample cases are when they discuss money. Wives in Papua are considered not to have the right to handle money affairs. However, when the program ended, the husbands planned to manage money together with their wives. Prevention through Education.

An interesting story also happened when they were discussing what they would be leaving behind for the family when they died of the HIV/AIDS virus. A tribal head suddenly realized that Papuans never wrote wills causing conflicts over land when family heads passed away. “Starting now, I will arrange who will inherit my land. I’ll put it in black and white,” said Domi, quoting the tribal head.

Anna Manyakori, another facilitator in this program, says that the program is highly effective in conveying information to the public. Media that uses songs and pictures make it easier for facilitators facing illiterate participants. “It happened when we did the Stepping Stones with seven tribes in Timika,” recalled Anna.

Both Anna and Domi admit that there have been changes in people’s behavior after the program. Based on Domi’s observations, people consider Stepping Stones as an easily understood method of communication, using simple language, especially with the showing of easily understood video during discussions.

Domi says that Stepping Stones is just right to be implemented in Papua as a means for disseminating information and preventing the spread of HIV/AIDS.

However, Nafsiah admits that changing people’s behavior is still a long road. Discussing something considered taboo is a challenge. Changing someone’s perspective to want to have themselves checked is an effort that requires patience. The future of this country is determined today. Support by all parties is a must.

Batu Loncatan is the Indonesian version of the Stepping Stones manual