Engaging communities in Zimbabwe on substance abuse and HIV

Clement Nhunzvi is a Zimbabwean psychosocial occupational therapy lecturer and mental health researcher, based at the University of Zimbabwe. He is also an awardee of the Developing Excellence, Leadership and Training in Science in Africa (DELTAS Africa) Community and Public Engagement (CPE) seed grant. The DELTAS Africa CPE programme establishes two-way interaction, between scientists and the non-scientific public on science, that is intended to provide opportunities for mutual learning and benefit. DELTAS Africa CPE is implemented through the AESA Platform. AESA (Alliance for Accelerating Excellence in Science in Africa) is a funding, agenda-setting, programme management initiative of the African Academy of Sciences (AAS), the African Union Development Agency (AUDA-NEPAD), founding and funding global partners, and through a resolution of the summit of African Union Heads of Governments. DELTAS Africa CPE is supported by Wellcome and the United Kingdom Foreign, Commonwealth and Development Office (FCDO formerly DFID).

Summary

Substance abuse and HIV are highly prevalent, complex and often misunderstood conditions among youth in Zimbabwe. Clement Nhunzvi and his team used creative arts competitions to engage school children (13-20 years) in Zimbabwe in social inclusion and stigma reduction when confronting substance abuse and HIV in the community.

Background

My PhD study explored social inclusion among young adults afflicted with both substance use disorders and HIV in Zimbabwe. It shows the interplay among substance abuse, HIV, stigma and social exclusion among young adults in the most high-density suburbs in Harare, Zimbabwe.

Stigma, discrimination and social exclusion are major obstacles to health seeking, recovery and meaningful community participation, but they are not well understood. More than 95% of those who participated in a nested cross-sectional survey of social inclusion and associated factors existed outside the formal paid employment sector, citing stigma and other exclusionary norms in their communities. This is much higher than the 75% reported in the general population. In the same context, more than 65% of those living with HIV have reported some form of social stigma which resulted in less meaningful participation and feelings of guilt about their HIV status.

Lack of understanding and myths around HIV and its link to substance abuse largely drive the stigma and social exclusion associated with these conditions. Hence the need to engage the community to raise awareness, by starting critical conversations using local knowledge systems.

We used a creative arts competition to raise awareness, generate insight and start discussion about fighting stigma and promoting social inclusion in HIV and substance abuse, primarily by engaging school children in the community. We tasked learners to produce creative art pieces using poetry, drawings and music to tackle stigma against substance abuse and HIV and to promote social inclusion of those affected.

Description of Study

We invited a variety of stakeholders from Mufakose community to a planning meeting. These included but were not limited to high school pupils, religious organisations, organisations running HIV and substance abuse programmes and people afflicted with HIV and substance abuse, who had been participants in the principal investigator’s doctoral studies. The purpose was to create support, participation and buy-in of the community through stakeholder engagement. We also engaged critical Mufakose community groups, including the Community Social Services Department for the City of Harare. Based on the input of these stakeholders, we designed and published a call for articles and distributed it in churches, schools, shopping centres, and organisations who run HIV- or substance abuse-related programmes. Media outlets helped promote the effort. 

We recruited and trained a team of ten public engagement judges from various health, education, religious and creative arts backgrounds. Some were individuals in recovery and living with HIV. Ninety-two (92) entries were received in the preliminary competitive round. From this group, thirty (30) finalists were selected to advance to the finals. Finalists were designated based on their production of artwork that most effectively portrayed messages of social inclusion and anti-stigma against HIV and substance abuse. The preparations for the grand finale also served as a training ground for mentorship and coaching of the finalists and refinement of the art works. As a result, all the artwork presented in the finals had a clear and refined anti-stigma and pro-social inclusion message for HIV and substance abuse.

The arts competition finals event was attended by more than 300 invited guests, representative of the Mufakose community. The finalists represented three creative art categories: poetry, visual drawings and music. The Member of Parliament for Mufakose constituency was named Guest of Honour, cultivating policy maker engagement. Also invited were national journalists and government media outlets. These constituencies established the foundation for critical conversations on anti-stigma and social inclusion for those afflicted with HIV and substance abuse at the grassroots, policy and legislative levels.  

Since the event, we have maintained visibility through branded CPE material, facilitating focus group discussions and evaluating the impact of the project.

Study outcomes

This project sought to reach young people in the community, primarily of school age, 13-20 years. Some in this cohort were already afflicted with substance abuse and/or HIV. Engagement of key community organisations in the HIV and substance abuse management in young people spaces was also sought, including health and social services, schools, administration, religious organisations, community support groups, local government and policy makers.

School-aged youth was targeted to optimise impact on knowledge, attitude and behaviour change.

Lessons

• I had previously believed that non-expert members of the community were insufficiently knowledgeable to engage meaningfully with scientific research, imagining them limited to the role of passive consumers. I also regarded CPE as peripheral to the research process. But our experience in this work educated us about the potential for the community to be active and empowered contributors to research through well-planned and culturally relevant CPE. Effective CPE must start with generating socially relevant research questions which translate into impactful and sustainable solutions with community ownership and in which all stakeholders are equal partners.
• CPE has transformed my research career: I now consider it to be a primary and integral component of holistic research, research evidence uptake and general evidence-based practice. I also plan to teach the concept to university students.
• The AESA CPE team provided important resources for online training in the Practice and Ethics of Participatory Visual Methods for Community Engagement in Public Health and Health Sciences, in which I now hold a certificate of competence.
• The CPE creative arts competition appeared to have lasting effects on changing community attitude and behaviour. For example, some of the participants and their schools have now established arts clubs to promote social inclusion messaging. Branded t-shirts distributed through the project seem to have maintained an enduring presence: one participant noted that when they wore their t-shirt, people ask them what “social inclusion” means.

Impact

This project used novel engagement strategies which were largely nonconformist, challenging the traditionally hegemonic power imbalance in research which places the researcher as uniquely knowledgeable and community as passive subjects. We drew on strategies that value people as knwoledgeable, thinkers and doers, bringing out their voice and sense of ownership.

The project went an additional step in the use of competitive creative art. Some participants and stakeholders have expressed the hope that the competitions will continue to be held in the future, and potentially be replicated in other communities. One idea is to scale to a national arts competition to seed critical conversations on social inclusion nationally. Videography and recording of the final event allows for additional dissemination of the social inclusion message and potentially sets the stage to scale up.

The Ministry of Health taskforce to fight stigma associated with the COVID-19 pandemic invited me to contribute to their work based on this project.