ORIGINAL ARTICLE June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. The Fire is Coming: An HIV Prevention Intervention Contextualized to the Maasai People of Tanzania Holly Freitasa and Marcia A Nayakb a RN, MPH Medical Ambassadors International and Reach Tanzania b PhD, RN Medical Ambassadors International Abstract “The Fire is Coming” film is an innovative HIV-prevention intervention contextu- alized to the Maasai people of Tanzania through use of a traditional Maasai story. The intervention was developed and implemented in partnership with Maasai Pastoralists for Education and Development (MAPED). Although there have been numerous Knowledge-Attitude-Practice (KAP) surveys conducted among the Maasai, this is the first control-group comparison study designed to measure the effectiveness of an HIV- prevention intervention contextualized specifically to the Maasai people of Tanzania. We will first discuss the background and context in which the intervention was devel- oped and methods used to develop the intervention. We will then discuss the evalua- tion methods, results, and implications of a retrospective Knowledge, Attitudes, Prac- tices (KAP) two-village comparison survey (n=200) for “The Fire is Coming” HIV-preven- tion intervention among Maasai people. There was a significant effect for HIV-related attitudes, t(16) = 2.77, p <0.05, regarding willingness to care for an HIV infected person, willingness to be tested for HIV, self-efficacy toward HIV-prevention, married women’s ability to use condoms, unmarried girls’ ability to refuse high-risk sexual behaviors, married men’s ability to use condoms, and married men’s ability to limit sex to their spouses. There was a significant effect for HIV-related behavior changes, t(8) = 2.89, p <0.05, with reported family decisions made, esoto (the ritualized sexual initiation of pre-pubescent girls) stopped, sexual behaviors changed, blade-sharing stopped, and other traditional custom changes reported. Although knowledge rates were often higher in the intervention area than in the comparison area, there was no significant difference in HIV-related knowledge, t(12)=1.85, p >0.05. Implications: Belief in one’s ability to do something is often the pivotal point for behavior change. The results of the survey denote a highly effective intervention in changing HIV-related attitudes and be- haviors. It is promising for replication among other Maasai communities and for adap- tation with indigenous people groups in other regions. Background and Context HIV infection rates are rapidly rising in Maasai regions.1,2 Although actual HIV rates are difficult to obtain due to governmental restrictions on census and data collection differentiation by tribal identifi- cation, sexual traditions and social norms place the Maasai people of Tanzania at high risk for sexually transmitted diseases. Maasai norms and traditions in- clude esoto (coerced sexual initiation of pre-pubes- 35 Freitas and Nayak June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. cent girls), encouragement of multiple sexual part- ners among teenage males, polygamy, marriage of young girls to older men, wife sharing, the obligation for wives to show hospitality by engaging in sexual behaviors with traveling male visitors, and male cir- cumcision using a common blade.1,2,3,4 Among the Maasai, the exchange of reproductive fluids is con- sidered essential to both mental and physical health; intentionally high levels of procreation limit the ac- ceptability of condom use for either birth control or prevention of sexually transmitted disease.1,2 Significant barriers to health education mes- sages have resulted in limited HIV-related knowledge, misconceptions regarding HIV, and con- tinuance of high-risk, HIV-related behaviors. Lan- guage, limited education, and distance from health services make up some of the barriers that keep Tan- zania’s national efforts to reduce HIV transmission from reaching the Maasai people. Approximately 20% of Maasai people speak the national language or have any formal education.5 All public health cam- paigns in Tanzania, including HIV education, are conducted in Swahili, leaving non-Swahili speakers uninformed.4,6 Furthermore, all national HIV surveil- lance efforts, including KAP studies, have been con- ducted in Swahili,7 leaving non-Swahili speakers un- counted, their voices unheard, and their plight un- known to both national and international organiza- tions concerned with HIV and AIDS.8,9 Most Maasai people in Tanzania live in rural areas distant from city hubs where HIV prevention, testing, and treat- ment services can be obtained. Poorly conditioned and infrequently traveled roads limit public transpor- tation. Maasai people generally travel by foot or in the open-bed of delivery trucks on weekly transpor- tation routes from the village areas to the city hub and back. Additional barriers limit the effectiveness of standard ABC (abstinence, be faithful, and condom) messages.2,4,10 Many Maasai people believe that they, as a people group, are immune to HIV or that their traditional medicines will cure the disease. The lack of accessibility and acceptability of condoms further complicates the effectiveness of the ABC mes- sage.4,11 Finally, many of the commonly used HIV education methods, which promote individual behav- ioral change are rendered ineffective within the tra- ditional Maasai top-down and group-level decision making structure.2,4,6 In late 2006, a small Maasai organization, MAPED (Maasai Pastoralists for Education and De- velopment), of the Olbili sub-village in Simanjioro District, Tanzania, became aware of the threat of HIV. Intent on protecting their people, they sought HIV education. In 2007, sixteen of their young Maa- sai warriors attended an intensive HIV training course which met both international and Tanzanian HIV education standards. The young warriors recog- nized the dangers of high-risk Maasai traditions and sexual practices and determined to make changes, not only to protect themselves and their families but also to educate other Maasai about HIV to preserve their tribe. Intervention and Methods The young warriors, together with MAPED, determined that a public health education interven- tion was necessary to inform and educate the Maasai people. In response, an educational program was de- signed to meet three goals: 1) to bring contextualized HIV prevention education to the Maasai, 2) to in- crease the awareness of vulnerability to HIV infec- tion due to traditional and common HIV-related be- haviors, and 3) to facilitate dialog within Maasai communities that would ultimately result in modifi- cation, adaptation, or discontinuation of high-risk, HIV-related behaviors. A participatory process was used to identify the preferred learning medium for HIV prevention education among the Maasai. It was noted that the existing local public-health education was ineffective in Maasai areas for several reasons. First, written health information is inaccessible to a majority of Maasai who are oral learners. Second, health infor- mation given via radio is also inaccessible to a ma- jority of Maasai, because all official public-health an- nouncements in Tanzania are made in Swahili — not 36 Freitas and Nayak June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. the Maasai language. Third, Maasai perceive national public-health announcements in Swahili as non-ap- plicable to themselves because of cultural differ- ences. Through discussions and the review of previ- ous HIV-related KAP studies, the Maasai leaders and HIV education team determined that the preferred learning medium for HIV prevention education was audiovisual and chose to create an educational film using Maasai spokespersons, traditions, and story- telling. A private donor provided a sum of money to Medical Ambassadors International for HIV educa- tion in Africa. This donation, in turn, was directed to- ward the proposed intervention. The next step in the process was to identify tra- ditional Maasai stories that could effectively convey the HIV-prevention message. Maasai stories were collected from every available source. After review of many stories, a widely-known traditional Maasai story was selected which tells about a foolish man who knew that a great fire was coming across the land, posing great risk to his homestead, family, and animals. After many warnings, the man still did noth- ing to protect himself and was overwhelmed by the fire. The story elicits much laughter among the Maa- sai people, and they find re-telling of the man’s obvi- ous foolishness a source of great humor. The story provided a perfectly contextualized analogy to em- phasize the importance of HIV awareness and pre- ventive action among the Maasai. “The Fire Is Coming” video production began in 2008. Maasai elders, political leaders, warriors, and other tribe members were briefed in the basic story-line and then participated to create the un- scripted footage, telling the story in their own words, providing HIV prevention education, advocating for change of high-risk cultural practices, and warning of the dangers of ignoring the issue. Film editing was conducted in cooperation between Media 7, a volun- teer HIV educator from Medical Ambassadors Inter- national, and MAPED. Field-testing was conducted in 2009, and the film was released for facilitated pub- lic viewing in the Maasai community in 2010. The target level of the intervention was the sub-village level, where general decision-making is done and social and behavioral norms are estab- lished. A participatory, adult-learning approach was chosen in conducting the intervention. The approach relied on the intervention’s problem-posing nature and on discussions guided by trained volunteer Maa- sai facilitators from MAPED following public view- ings of “The Fire Is Coming” video to achieve the intervention goals of changing HIV knowledge, atti- tudes, and behaviors in each village. Evaluation In 2011, after one year of active implementa- tion by MAPED in the local Maasai community, an evaluation was scheduled as part of the assessment and quality improvement for the on-going program. The aim of the evaluation was to determine the effec- tiveness of the intervention in bringing contextual- ized HIV prevention education and awareness to the Maasai people and to influence change in both atti- tudes and high-risk behaviors associated with HIV transmission. An additional aim of the evaluation was to determine whether the intervention influenced change in cultural and social norms in the interven- tion area. A baseline study had not been done prior to the beginning of the intervention; therefore, a two- village comparison survey was designed to obtain HIV-related knowledge, attitudes, and behaviors among villagers whose community received the in- tervention and compare them to survey responses from villagers whose community did not receive the intervention. The evaluative nature of an on-going public health education intervention by a Tanzanian registered non-government organization did not re- quire approval by Tanzania’s Institutional Review Board. A Knowledge, Attitudes, Practices (KAP) sur- vey instrument was developed for the evaluation us- ing the following operational definitions as defined by Tanzania Commission for AIDS (TACAIDS). HIV-related knowledge: TACAIDS defines HIV-related knowledge as knowing that: using con- doms and having just one uninfected, faithful partner can reduce the chance of getting HIV; a healthy look- ing person can have HIV; an infected mother can 37 Freitas and Nayak June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. transmit HIV during childbirth and breastfeeding. Additional HIV-related knowledge included reject- ing the two most common myths about HIV trans- mission: “People get HIV from mosquito bites” and “People can be infected with HIV by sharing food with someone sick with AIDS.”7, 12 HIV-related attitudes: We adapted questions from the Tanzania HIV/AIDS Indicator survey to measure three areas of attitude regarding HIV/AIDS. 1) accepting attitudes toward those living with HIV/AIDS, 2) attitudes toward negotiating safer-sex- ual relationships with husband/wife, and 3) attitudes of adults toward educating youth about condoms to prevent HIV.7 Within our definition we also include attitudes toward self-efficacy in reducing HIV risk, vulnerability, or risk in contracting HIV and willing- ness to be tested for HIV infection. HIV-related behaviors: The concept of HIV risk behaviors includes all HIV-related behaviors that allow for HIV transmission. These practices include esoto (the ritualized sexual initiation of unwed girls), multiple and concurrent sexual partners of the same or opposite sex, the sharing of blades or sharp instru- ments that penetrate the skin, and other traditional customs such as sexual hospitality practices.12 The survey included both closed-ended, socio- demographic questions and open-ended questions modified from international and national KAP stud- ies to capture data relevant to Maasai specific HIV- related knowledge, attitudes, and behaviors. Survey questions also assessed HIV-related knowledge (i.e. condom use) that was not directly addressed in “The Fire Is Coming” video intervention, allowing the evaluators to further ascertain the impact of the inter- vention. Presumably, there would be little if any dif- ference between the intervention and comparison vil- lages on these items. In order to protect informants, no questions regarding personal sexual activity or sexual practices were included in the survey. Survey questions were originally written in English, trans- lated to KiMaasai, and back-translated to ensure un- derstandability and conceptual translation accuracy. Pilot testing and revision of surveys was done prior to data collection to ensure inter-rater reliability and enhance consistency among data collectors. Survey data was collected using semi-structured face-to-face individual interviews conducted in the Maasai lan- guage by a trained, bilingual Maasai data collector. Prior to any data collection, MAPED sought and re- ceived permission to conduct the survey from village elders and leaders and sub-village leaders. Data col- lectors received permission from both boma (home cluster) leaders and individuals prior to each inter- view. Each interview took approximately one hour and occurred over a ten-day period from May 2 to 12, 2011. Intervention and comparison village data were collected simultaneously by four Maasai speaking, trained research assistants, none of whom had visited the villages prior to data-collection. Sample A cluster sampling process was used for the evaluation. Two Maasai villages were selected using purposive sampling to control for location, village size, proximity to the city, and available health ser- vices. A distance of approximately 200km between otherwise homogeneous villages controlled for po- tential intervention crossover effect. Within the vil- lages, a convenience sample of 100 respondents each from sub-villages within the intervention and com- parison area, respectively (n=200), were surveyed. (Note: All figures represent the number of respond- ents who directly answered the respective survey questions.) Demographically, there were 54 female and 45 male respondents documented in the interven- tion area compared with 52 females and 46 males in the comparison area. The age range of study respond- ents was 13-70 years-of-age, with an average age of 31 years in intervention area and 37 years in the con- trol area. Adolescents were included in the study based on documented cultural norms of very early sexual debut, especially for girls.1 In the intervention area, 73 respondents (11 comparison) reported at- tendance at an HIV prevention event in their commu- nity. Christian religion was claimed by 98 respond- ents in the intervention area and by 80 respondents in the comparison area. 38 Freitas and Nayak June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. Results HIV-related Knowledge Sixty respondents from the intervention area (34 comparison) were able to correctly identify two routes of HIV transmission, with sexual intercourse and sharing of blades being listed most frequently. In the intervention area, 48 respondents (63 compari- son) correctly stated that HIV infection cannot be identified by a person’s appearance (Figure 1). Two respondents in the intervention area (23 comparison) were unable to identify any HIV trans- mission routes. Knowledge regarding HIV preven- tion practices was as follows: abstinence and/or faith- fulness to marital partners (77 intervention, 60 com- parison), not sharing blades (52 intervention, 30 comparison), and condom use (19 intervention, 23 comparison). In the intervention area, 74 respondents (38 comparison) reported that women are tested for HIV during pregnancy; 34 respondents (21 compari- son) said that HIV transmission from mother to infant can be prevented. Two respondents in the interven- tion area (4 comparison) listed medication as a pos- sible HIV-prevention strategy for mother to child HIV transmission, and 82 respondents (56 compari- son) stated that traditional Maasai medicine does not cure HIV. Knowledge that Maasai are not immune to HIV was high in both intervention (96) and compar- ison village areas (85). A two-tailed t-test was con- ducted to compare HIV-related knowledge between the intervention and comparison area respondents re- garding condom use, faithfulness to partner, HIV- transmission routes, perceived Maasai immunity to HIV, cure by traditional Maasai medicines, and ma- ternal-child transmission. Although on most survey items knowledge rates were higher in the interven- tion area, there was no significant HIV-related knowledge difference between intervention and com- parison village areas, t(12)=1.85, p >0.05. Fig. 1. HIV Related Knowledge (N=100) 39 Freitas and Nayak June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. HIV-related Attitudes In the intervention area (figure 2), 81 respond- ents (71 comparison) stated they would care for an HIV infected person. Willingness to be tested for HIV infection was indicated by 83 intervention area respondents (67 comparison); 84 intervention area respondents (25 comparison) stated that Maasai can do something to reduce the risk of HIV. Conversely, 54 respondents in the comparison area stated the be- lief that Maasai are unable to reduce the risk of HIV. Levels of concern about HIV in the community were “very concerned” (39 intervention; 81 comparison), “concerned” (52 intervention; 8 comparison), and “unconcerned” (8 comparison). Few respondents agreed that women can refuse sex with their husbands (10 intervention, 10 compar- ison); however, 67 respondents in the intervention area (50 comparison) stated that women are able to refuse sex with others and can negotiate use of a con- dom with their husbands (33 intervention; 20 com- parison) and with others (53 intervention; 34 compar- ison). In the intervention area, 69 respondents (48 comparison) reported that married men are able to limit their sexual activity exclusively to their wives. In the intervention area, 70 respondents (38 comparison) stated that unwed girls can refuse to have sex or participate in esoto. In the intervention area, 37 respondents (39 comparison) stated that un- wed girls can buy and use condoms. A two-tailed t- test analysis was conducted to compare the interven- tion and comparison area respondents’ HIV-related attitudes regarding willingness to care for an HIV in- fected person, willingness to be tested for HIV infec- tion, self-efficacy toward HIV-prevention, married women’s ability to use condoms, unmarried girls’ ability to refuse high-risk sexual behaviors, married men’s ability to use condoms, and married men’s ability to limit sex to their spouses. There was a sig- nificant effect for HIV-related attitudes t(10) = 2.89, p <0.05. HIV-related Behaviors Esoto, the ritualized sexual initiation of unwed girls, was reported stopped by 85 respondents (figure 3) in the intervention area (41 comparison). A family decision to decrease the risk of HIV was reported by 59 intervention area respondents (12 comparison). Participants reported they stopped sharing blades (30 intervention; 9 comparison), changed sexual behav- iors (60 intervention; 26 comparison), and changed high-risk traditional customs (87 intervention; 47 comparison). A two-tailed t-test analysis was con- ducted to compare the intervention and comparison area respondents reported behaviors regarding family decisions made, esoto stopped, sexual behaviors changed, blade-sharing stopped, and other traditional custom changes. There was a significant effect for HIV-related behavior changes, t(8) = 2.89, p< 0.05. 40 Freitas and Nayak June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. Fig.2. HIV-Related Attitudes (N=100) Fig. 3. HIV-Related Behaviors (N=100) 41 Freitas and Nayak June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. Discussion The most significant attitude difference be- tween the intervention and comparison villages was that of collective self-efficacy, or the belief that they as Maasai people are able to reduce the risk of HIV in their community. Self-efficacy has been found by researchers to be one of the key factors involved in behavior change. Those who believe that nothing can be done are likely to do nothing, while those who be- lieve they are able to do something are significantly more likely to take preventive action. Self-efficacy, or collective self-efficacy in this case, when com- bined with risk perception translates into behavior change in ways that knowledge alone does not.13 Maddux14 reported data consistent with our findings, that low self-efficacy has been associated with higher levels of anxiety. The high number of comparison area respondents who reported being “very con- cerned” about HIV is matched with a low number of comparison area respondents who believed that something could be done about HIV. In the compar- ison area, respondents may have had a perceived helplessness regarding HIV and, therefore, reported the highest levels of concern. Conversely, respond- ents in the intervention area demonstrated high levels of self-efficacy regarding their ability to reduce the risk of HIV and positive action taken by their com- munity; thus, they reported being “concerned,” but not “very concerned.” In our attempts to collect and analyze the data, we have applied national standards of comprehensive HIV knowledge, attitudes, and behaviors. However, we must consider the cultural context in which the intervention took place and the very nature of partic- ipatory community based research and development. The hallmark of community-based participa- tory interventions is a process wherein awareness of an issue is raised in the community; the community then discusses the issue and arrives at culturally ap- propriate and, therefore, contextualized solutions to the problem. Among the Maasai communities in this study, a great number of families live in polygynous relationships; early and extramarital sexuality has been sanctioned by the society; and a high birth rate is desirable. Solutions that have come from within the Maasai community focus on the reduction and elimination of extramarital sexual partnerships, elim- ination of blade sharing practices, and mutual en- couragement for HIV testing. In response to the evaluation results, MAPED continues to work toward their goals of HIV preven- tion with a focus on increasing HIV-related knowledge and strengthening the positive outcomes in HIV-related attitudes and behaviors among Maasai communities. It is within the context of these com- munity developed solutions that Maasai can be suc- cessful in changing both attitudes and behaviors that lead to the reduced risk of HIV in the community. Study Limitations Although the results of the program evaluation are indicative of a highly effective intervention, we recognize there are limitations to this evaluation study. Selection of a pre-experimental design does not allow us to unequivocally establish a causal rela- tionship between the independent (HIV intervention) and the dependent (HIV-related knowledge, attitude, and practices) variables.15 After controlling for de- mographics, access to health facilities, distance (to limit cross-contamination), and other variables, we show that there are notable, statistically significant differences between the intervention and comparison Maasai groups. One possible confounding variable may be pre- sent in the selection of communities that were either selected by the program implementers (comparison area) or self-selected (intervention area was in the community where the request originated for an HIV prevention intervention). Either of these two methods of selection may indicate greater interest or aware- ness of HIV among the intervention communities and, thus, potentially a greater willingness to change HIV-related behaviors prior to the intervention. Lastly, the highly sensitive nature of the study questions may have inhibited some of the respond- ents from answering survey questions, thereby limit- ing or skewing the data and analysis. Although some 42 Freitas and Nayak June 2014. Christian Journal for Global Health 2014, 1(1): 34-43. evidence of behavioral changes can be observed, many reported HIV-related sexual and traditional be- havior changes are impossible to validate and, there- fore, may not be a true representation of actual be- haviors. Our findings are limited to the study area, and are not directly generalizable to other Maasai or in- digenous groups, however the results of the survey denote a highly effective contextualized intervention. It is promising for replication among other Maasai communities and for adaptation with indigenous peo- ple groups in other regions. References 1. Coast E. Wasting semen: Context and condom use among the Maasai. Cult Health Sex. 2007;9(4);387- 401. http://dx/doi.org/10.1080/13691050701208474 2. Mbugua T. The Maasai: Preserving culture and pro- tecting girls. Global AIDSLink. 2007 Jan/Feb; 101:12-3. 3. Coast E. Maasai demography [Ph.D. thesis]. Univer- sity of London; 2001. 4. Coast E. (Ereto-NPP). 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Christian Journal for Global Health 2014, 1(1): 34-43. This article was Peer Reviewed. Competing Interests: None declared. Correspondence: Holly Freitas, United Republic of Tanzania. holly.freitas@efca.org Cite this article as: Cite this article as: Freitas H, Nayak, MA. The fire is coming: An HIV-prevention intervention contex- tualized to the Maasai people of Tanzania. Christian Journal for Global Health 2014, 1(1): 34-43. © Author Freitas and Nayak. This is an open-access article distributed under the terms of the Creative Commons At- tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:holly.freitas@efca.org http://creativecommons.org/licenses/by/4.0/