Multiculturalism and AIDS: different communities mean different educational messages required
Olga Lechky
CMAJ 1997;156:1446-8
[ en bref ]
Olga Lechky is a freelance writer living in North York, Ont.
© 1997 Olga Lechky
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In brief
Having a multitude of different ethnic communities forces Canada's AIDS educators to use many different methods to deliver their messages. These range from an AIDS bingo game that has been used to educate natives in northern Manitoba to attempts to take AIDS education to the streets of Toronto. With AIDS education, reports Olga Lechky, one message definitely does not fit all.
En bref
Les éducateurs canadiens qui travaillent en sensibilisation au sida rencontrent des gens de toutes les cultures. Il leur faut donc, pour faire passer le message, emprunter diverses méthodes, qui vont des jeux de «bingo» sur le sida à l'intention des Autochtones du nord du Manitoba jusqu'aux tentatives pour rejoindre les personnes de la rue à Toronto. En matière de sensibilisation au sida, affirme Olga Lechky, impossible de présenter partout le même message.
It was only after he died on the streets of Winnipeg that physicians realized that an aboriginal man had been living with AIDS. In Toronto, an HIV-positive man who was too ashamed to tell family and friends about his illness returned to his native Vietnam to die a lonely death with a minimum of substandard medical care. In Halifax, family and friends mourned the death of a young black Canadian who they believed had died of leukemia. The real cause of death was AIDS. In Toronto, an immigrant from the Caribbean ended her friendship with a woman infected with HIV because she feared being shunned by the community if she associated with "a bad person."
AIDS educators says sad stories like these are too common in Canada, where members of some cultural groups may feel excluded from mainstream HIV/AIDS education, treatment and support services. In response, many ethnic communities are now establishing their own culturally specific AIDS-education programs.
The biggest barrier facing them is the misconception that AIDS is a disease of gay white men -- an unfortunate legacy from the disease's early years. "South Asian people generally think that AIDS can't happen to them," says Sukhi Chahal, education and outreach coordinator with the Alliance for South Asian AIDS Prevention in Toronto. "They reason [that] they're not white, not gay and don't use drugs, and therefore are not at risk. There's still a lot of stigmatization and stereotyping around who gets infected. The sad reality is that India will soon have one the world's highest rates of HIV infection, and because people travel back and forth between Canada and India quite frequently, Indian-Canadians are at risk even if they still live a very traditional lifestyle."
"Traditional lifestyle" means living according to the religious laws that govern some cultures. It also means that sex is rarely discussed, even between parents and children, and sex outside marriage -- and homosexuality -- are considered sinful. Talking about HIV and AIDS goes well beyond the norms of accepted decency.
"These beliefs and attitudes make our job very hard," says Chahal. "You can't talk about HIV without talking about sex, certain body parts, certain activities and certain truths that many people would prefer [not to hear].
"[In India] it's quite possible that a man could be having sex with another man, paying for sex with a prostitute or having an extramarital affair with another woman. This would be kept very secret. If it ever got out, he would be an outcast in the community. So appearances aside, [even] people living a so-called traditional lifestyle are at risk."
Many in the Chinese and Southeast Asian communities still believe AIDS is a gay disease, says Aries Cheung, youth outreach coordinator for Toronto-based Asian Community AIDS Services (ACAS). "Even some very educated people are surprised [to] find that women can get infected with HIV. There's still a lot of ignorance about the disease and a lot of resistance to learning about it."
ACAS targets Chinese immigrants from Hong Kong and mainland China, as well as the Vietnamese and Filipino communities. There is a strong taboo within these communities against talking about sex, sexuality and death, but Cheung believes Vietnamese immigrants are most difficult to reach because they have a strong sense of tradition, morals and family values. Many resist even basic sex education, let alone AIDS education. "It's perceived as an intrusion into people's privacy."
There is also denial that homosexuality exists within these communities, adds Cheung. The Chinese are perhaps more tolerant, since homosexuality has never been condemned by law or teaching in either the Confucian or Taoist traditions. However, it is considered impolite to discuss the subject within the family or community.
Moral and religious beliefs also hamper AIDS education among immigrants from Caribbean countries. "There's a [strong] belief about AIDS being like a biblical plague, like a retribution for having done something very bad," says Andrea Gilpin, an outreach worker with the Caribbean Women Against AIDS project in Toronto. "So people don't want to associate themselves with this. Many people believe that if they're good people they will never get AIDS, so it doesn't concern them."
Toronto's Department of Public Health funds Caribbean Women Against AIDS. Because women are reluctant to attend information sessions, Gilpin visits grocery stores, laundromats and hairdressing salons, where she gets to know the women and talks to them about other concerns. AIDS education is woven into the conversations.
Information about HIV that is produced by mainstream service organizations can actually create resistance in ethnically diverse communities. "[They find] a lot of this material very alienating," says Gilpin. "I can think of several examples where the person or people being depicted are obviously gay white men. Some pamphlets have such graphic drawings or pictures of penises or homosexual sex that people find it not only alienating but offensive."
Some communities get around these limitations by developing their own resources. The Alliance for South Asian AIDS Prevention developed a series of pamphlets in 5 languages, with no pictures or artwork. Chahal says the challenge is to choose the right tone and words so that the material is not offensively explicit. But neither can the resources be so medical, polite or indirect that the message is meaningless. Written in simple, easy-to-understand language, the alliance's information about HIV and AIDS is confined to basic facts: what HIV is, who is at risk, how it is transmitted and how to prevent it. Separate pamphlets deal with HIV testing.
Posters have also proved successful. "We don't show any physical contact because this would be embarrassing for a lot of people," says Chahal. "One of our most effective posters shows a variety of South Asian faces -- young, old, both sexes -- with the underlying message that HIV concerns everyone. It doesn't give away details about anyone's personal life or sexual orientation. When I first saw it, it moved me. It said to me: 'These are my people.' "
In contrast, pictorial material works well in aboriginal communities, where art is one of the traditional methods used to represent life and culture. As well, the Manitoba Aboriginal AIDS Task Force has learned that it can teach natives about AIDS through story-telling and ceremonies.
One example is the use of the medicine wheel as a teaching tool. One wheel, developed by an aboriginal man with AIDS, uses pictures to represent the various stages of HIV infection and AIDS and the disease's physical, psychological, emotional and spiritual elements. In a similar vein, the task force has developed a series of 7 posters depicting the progression of HIV from initial infection to full-blown AIDS.
"AIDS can be included in all aspects of health promotion, such as addictions counselling, diabetes care and family violence programs," says Albert McLeod, education coordinator with the task force. "AIDS prevention education can be part of any health promotion, because we're all sexual beings. The idea behind health promotion is to empower people to make healthy decisions in their lives. One of these decisions can be to have safe sex. AIDS education doesn't have to be scary and alienating."
Nor does it always have to be serious and dour. One highly effective way to get the AIDS message across was developed in Northern Manitoba, where an AIDS bingo game provides a way to reach people who would normally not attend a workshop. In the game, messages about safe sex are read out between the calling of numbers. "People have fun, but they also get a good education in a nonthreatening way," McLeod explains.
Youth in ethnically diverse communities are generally more open to AIDS education than their parents. "With young people more explicit language and images are generally acceptable," says Aries Cheung of Asian Community AIDS Services. "Young people are exposed to many influences in school and are used to seeing sexy images in the media. Being explicit also works well as a way to grab their attention."
ACAS has developed a poster showing young Asian people in a variety of intimate poses -- it includes a homosexual scene and a heterosexual inter-racial scene. It has been well received by Chinese, Vietnamese and Filipino youth but the reception was less positive among older members of these communities.
So how should AIDS be explained within different cultural communities? "The main difference in our approach from the mainstream is that AIDS doesn't just affect the individual, but also the family and the entire community," says McLeod. "Our young people get AIDS education in school, but they need the support of the entire community in order to use that education. We can teach about the use of condoms as a means of protection, but if this is not valued within the community by the family, the elders and the leaders, then this education stands a good chance of being ineffective."
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