Knowledge of Teachers on Cultural Practices that Influence HIV/AIDS Transmission in Kavango West, Namibia

Background: In the world there are still ethnic groups that promotes cultural practices that may predispose people to HIV/AIDS transmission and hence increase HIV prevalence rate. Namibia is one of the countries that are badly affected by HIV/AIDS in the world, with Kavango West the worst-affected region in Namibia with the prevalence rate of 12.1%. This is the region where ethnic group known as Ukwangari is located. In Namibia, there are policies, guidelines, and programmes in place to manage the HIV/AIDS epidemic, however, the cultural practices regarding the transmission of HIV/AIDS are not well discussed, hence excluded when addressing prevention of HIV. Aim: Is to explore depth knowledge of basic education school teachers on cultural practices that influence HIV/AIDS transmission in Ukwangari culture in Nankudu district, Kavango West region, Namibia. Methods: Qualitative, explorative contextual study was conducted to in which non-probability purposive sampling method was employed. Participants, who knew Ukwangari culture, were purposively selected and focus group discussion was conducted until data were saturated. Data were analysed using Tesch’s open coding system, where themes and sub themes that emerged from the discussion were identified. Results: The findings indicate that basic education school teachers had fair knowledge about HIV/AIDS, while a few teachers had misinformation on culture and transmission of HIV/AIDS. Conclusion: There is a need to sensitise and educate basic education school teachers in Ukwangari community about their cultural practices that influence HIV/AIDS transmission. This will be possible by collaborating with various ministries and stakeholders.


Introduction
Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) epidemic on a global level continues to be a challenge for more than three decades since the first case of HIV and AIDS was identified, The United Nations programme on HIV/AIDS (UNAIDS) report on HIV informs that approximately 35.3 million people are HIV-infected worldwide, however, deaths from AIDS are falling due to different measures put in place such as Anti Retral Viral (ARV) Medicine, awareness campaign and reproductive health education (UNAIDS 2015). The increase of risk of HIV infections has been associated with bad culture and traditional practices that are still being practiced among ethnic groups in different parts of the world and hence predispose people to HIV/AIDS transmission (WHO, 2009). Some cultural factors in Africa have proven to be significant in increasing the risks of HIV-infection are cross-generational relationships in which a young women take older men as sexual partners, female genital mutilation in which a person, sometimes unskilled or a health worker, cuts off parts or whole organs of the female genitalia using a knife or a razor blade that is unsterile. The practice often involves repeated use of the same equipment that could be harbouring bacteria and HIV, exposing many children at the same time within a community to HIV infection (Loosli, 2004). However, a study conducted in Nigeria on women with different marital statuses found the highest prevalence of female genital mutilation among widows (95.0%) and married women (92.0%), while the lowest prevalence was among never-married women (65.0%). When instruments used to circumcise women are reused without sterilising them, there is a high possibility of HIV transmission (Oyefara, 2013;Saracoglu & Ozturk, 2014). , practices resulting in exposure of blood, inability of youth to freely discuss sex, widow inheritance, sexual cleansing rituals after the death of men in the family, polygamy and through male sex behavioural dominance. Widow cleansing and inheritance in Uganda have been well documented as factors contributing to HIV transmission (Bajunirwe et al., 2019). A study conducted in Malawi reports that a widow becomes unclean after burial ceremonies of the late husband according to cultural belief. Furthermore, the widows are sexually cleansed through a ritual that requires them to have coitus with another man, normally one of the brothers-in-law to let the spirit of the deceased rest in peace among the dead (Saguti, 2016). This ritual is done to enable the women to marry again. In support of the previous author, a study conducted in Zambia reported that during widow cleansing, a widow is obliged to have coitus with another man, normally a brother-in-law to let the spirit of the deceased rest in peace among the dead. Another study conducted in Malawi reports that women are compelled to have sex with a man called a sex cleaner, who does not use a condom, making the widows susceptible to HIV infection if one of the sex cleaners is HIV positive. The same study reports a tradition practised in Zimbabwe, known as kugara nhaka in the Shona language, where a widow is obliged by her husband's family to choose a family member as her husband. The new husband and the inherited widow do not use a condom during sexual intercourse. If the woman's first husband died of HIV, then the new husband is exposed, or if the new husband is HIV infected, he can also infect the widow. Similarly, a study conducted in Nigeria reports that traditional healers in Nigeria claim to cure HIV and free women from their deceased husband's ghost by sleeping with them without a condom (Loosli, 2004;Adesina, 2015;Saguti, 2016). There is a belief that rape, especially of virgin can cure HIV infection, sex cleaning ritual, polygamy, and some tribe in Nigeria practice polyandry (Audet et al., 2012), wife inheritance, wife exchanging, cross generational sex, incestuous, transactional sex, all these are important risk factors of HIV infection in many areas (Adesina, 2015;Saracoglu & Ozturk, 2014;WHO, 2009). In some cultures, traditional healers contribute the spread of HIV infections due to association with witchcraft as indicated in several studies conducted in some areas in Democratic Republic of Congo, Papua New Guinea, and Tanzania. People go to traditional healers for witchcraft consultation and some of the directions to their clients will predispose them to HIV transmission (UNHCR, 2009). Studies conducted in Uganda and KwaZulu-Natal, South Africa, reported that the traditional healers make cuts on their patients to treat illnesses. For instance, when a patient complains of a headache, the traditional healers make incisions with blades on their foreheads and rub in some local herbs. When performing these procedures, the traditional healers use the same unsterilised instruments like sharp knives or bicycle spokes between patients (Bajunirwe et al., 2019). Furthermore, the study found that 24.0% of traditional healers reused blades for scarification on more than one patient, while 29.0% did not use gloves during scarification and rubbing of traditional herbs into the incisions (Peltzel & Mngqundaniso, 2008). Although traditional healers play a significant role in the treatment of different illnesses, they need to adhere to health protocols to prevent the spread of HIV. Infertility is one of the health problems traditional healers treat (Jaradat & Zaid, 2019). According to a study conducted in Uganda, after marriage, the in-laws start demanding grandchildren. Women are blamed for infertility in a marriage and the pressure put on them to conceive, forces them to seek treatment from the traditional healers. The traditional healers take advantage of these women by having sexual intercourse with them without a condom as part of the remedy for infertility treatment (Bajunirwe et al., 2019). In support of the previous author, a study conducted in Malawi reveals that most men do not wish to admit that they are infertile. Although women are often blamed for infertility in relationships, scientific studies reveal that semen problems could cause infertility. Infertility makes couples involve themselves in multiple sexual affairs without a condom to prove to each other they are not infertile (Parrott, 2014), thus exposing themselves to HIV infection.
In Namibia, there is still some ethnic groups such as Ukwangari in Kavango west region which practices bad cultures that predispose them to HIV/AIDS (Ministry of Health and Social Services (MOHSS), 2017). This is the worst-HIV/AIDS affected region in Namibia with prevalence rate of 12.1%. To reduce HIV/AIDS transmission especially in the most affected areas like Kavango west, the Ministry of Education, Arts and Culture (MoEAC) with collaboration of MOHSS in Namibia came up with different strategies such male circumcision, adolescent management, and different programmes all these are incorporated in the basic education school's curriculum to empower learners and teachers on the prevention of HIV infections (Chinsembu, 2010). However, the cultural practices in Kavango east have been one of stumbling block to achieve MoEAC initiatives regarding the prevention of transmission of HIV/AIDS, hence increase of HIV prevalence and mortality rate (MOHSS, 2017). Therefore, there is a need to explore knowledge of teachers who teach basic education in Kavango west region on Ukwangari cultural practices that influence HIV/AIDS transmission. Exploration of the knowledge of these teachers with assistance from different stakeholders will help to combat the spread of HIV/AIDS in Kavango west region, specifically to Ukwangari ethnic group.

Study Design
A qualitative, explorative descriptive and contextual research design was used to explore the depth knowledge of basic education school teachers regarding cultural practices that may influence HIV/AIDS transmission in Ukwangari culture in Nankudu district, Kavango West region, Namibia.

Study Area
There are seven basic education schools in rural and urban areas in Nankudu district -three primary schools, two combined schools and two secondary schools (Hamutenya, M, personal communication, May 10, 2019).

Study Population
The target population was the basic education school teachers in Nankudu district. There are 120 primary and secondary school teachers in Nankudu district -25 teachers in primary schools, 45 teachers in the two combined schools and 50 teachers in two secondary schools. Non-probability purposive sampling method was used to select teachers as participants who have knowledge on cultural practices that may influence HIV/AIDS transmission in Ukwangari culture in the rural and urban areas in Nankudu district, Kavango West region, Namibia.

Data Collection
Semi structured interview guide and audio tape were used to collect data during focus group discussion. There were three focus group discussions that were conducted to collect data from participants. The three focus group discussions were from two the primary school and one focus group discussion from the secondary school. These groups were assigned letters namely: group A: participant 1-5; group B: participant 1-5 and group C: participant 1-5.

Sample Size
The sample size was determined by data saturation in the qualitative study. Two schools were selected, one primary and one secondary, in Nankudu district using the non-probability sampling method. Fifteen participants were selected from both primary and secondary schools. There were 10 participants from the primary school and five participants from the secondary school. Data were collected from three groups, namely, two groups from the primary school and one from the secondary school, with each group consisting of five participants until data were saturated.

Statistical Analysis
Data were analysed using Tesch's open coding method. A code is a descriptive construct the researcher designs to capture the primary content of the data. The researcher listened to the audio recordings and transcribed the verbatim reports. The data were compared with the notes and non-verbal responses were considered. All data collected with the audio tape and notes were colour coded concepts with the same meaning and categorised into key themes and sub-themes.

Characteristics of the Study Population
The results of the study were discussed in view of relevant literature. The Table 1, indicates characteristics of participants from basic school education in Nankudu district, Kavango West region, Namibia. The results of the focus group discussions are presented in Table 2. Participants expressed that the following factors could be influencing HIV/AIDS transmission among the Ukwangari people through: -Cleansing rituals, and traditional and cultural practices.
-Insertion of leaves and roots powder into the vagina.

Traditional Rituals
Ritual is an act or a series of acts that are performed or observed in a society on occasions, events, festivals, and ceremonies (Adesina, 2015). A study conducted in Nigeria reveals that traditional rituals are done habitually, and they are passed on from one generation to another. The challenges associated with HIV/AIDS have proven to be difficult tackle because cultures differ one from another. Bajunirwe et al. (2019) reveal that many factors influence HIV/AIDS transmission in sub-Saharan Africa, such as stigma surrounding the illness, and traditional and cultural practices.
The sub-themes discussed under traditional rituals are cleansing rituals, female genital mutilation, insertion of leaves and roots powder in the vagina and religious norms. "Herbalists uses sharps such as blades to cut people during consultation on an HIV positive persons and HIV will be spread to another person like that." "Chest pain and legs pain just to mention few that people go for treatment" "Haemorrhoids also the traditional healer cut people with haemorrhoids during the treatment at the anal area." "If a person is having a life-threatening disease, they believe herbalists are the one to help them rather than going to the hospitals for treatment." "It can be excessive nose bleeding, a wound that does not heal, epilepsy and many more." "It is not only diseases but even infertile woman and will be given some medicine that she will insert in the vagina, and she will be instructed to engage in sexual intercourse with another man besides her partner to impregnate her without knowledge of the other man HIV status." "They cut with blades. The problem is that they do not sometimes have blades so they can reuse the same blade between people but sometimes people take their blades with." A study in Zimbabwe reported that self-appointed witch hunters accuse widows of enchanting people with AIDS. This accusation may lead to community violence and emotional abuse of widows (UNHCR, 2009). A study conducted in Uganda reports that a few people in western Uganda denied that one can contract HIV through sexual contact, but rather by witchcraft. Furthermore, people in the community believe they feel safe and protected spiritually when the widow is dealt with by the traditional healers. The procedure that traditional healers use involves injecting an unidentified substance into the widows over 45 sessions. During a witch-hunting ceremony, the witch hunter uses the same razor blade to cut many people. The procedure they use, which involves making incisions with unsterilised objects, could predispose people to HIV infection. Through this procedure, people can acquire or transmit HIV (Behrend, 2007). A study conducted in the Zambezi region, Namibia, shows that some people view HIV as an illness caused by witchcraft (Thomas, 2007). Some people believe people from that region bewitch each other using HIV/AIDS due to jealousy of one acquiring assets or ability to invest in livelihood security (Shirungu, 2010;Thomas, 2007).
Traditional health practitioners, registered with the Health Professions Council of South Africa, treat illnesses by tattooing. Among the supernatural or psychological problems for which patients consult traditional health practitioners are reverse of bad luck, magic poisoning by stepping over something, being poisoned by food purposely, ancestral problem, spirit illnesses, mental problems (Peltzel & Mngqundaniso, 2008). In addition, traditional health practitioners in South Africa treat generalised pain (headaches, sharp pains), acute conditions (stomach problems, sores/shingles), HIV and STIs) and chronic conditions (arthritis, high blood pressure, heart problems, diabetes mellitus and cancers) (Peltzel & Mngqundaniso, 2008).
In support of the previous author, a study conducted in the Kavango regions, Namibia, revealed that some traditional healers view HIV as a modern disease and believe it is caused by misfortune, witchcraft, ancestral anger, pollution through breaking a taboo. A study conducted in Zambezia Province, Mozambique, reported that some traditional healers acknowledged they could treat HIV/AIDS. Some of the traditional healers (43.0%) treat HIV when patients present with a chronic "spirit illness" with identical symptoms. In addition, they believe they cure the origin of the illness, not just the symptoms. Most traditional healers never received training on HIV, and only two traditional healers (0.15%-0.29%) indicated that they received training on HIV/AIDS. Most of the traditional healers' practices (99.0%) involve herbs that are often ingested or injected by mixing directly with blood after cutting with a razor blade. However, in the Kavango regions, Namibia, traditional healers focus on healing illness and do not deal with HIV/AIDS (Shirungu, 2010). These practices are fascinating but could increase the risk of HIV transmission (Audet et al., 2012).
Snakebites are the primary health issue affecting most remote and rural tropical regions and have a high mortality rate if treatment is delayed. Studies conducted in Asian and African countries established that when a snakebite occurs, people visit faith healers (traditional healers) for initial treatment, who indulge in chanting, incision with a sharp object to allow the venom to flow out with the blood to suck venom from the bite site with their mouth and apply cow dung or snakestones and rub chewed herbs into the incision. This treatment by traditional healers could delay medical treatment and result in HIV acquisition and increased mortality (Ralph et al., 2019;Fry, 2018;Omara et al., 2020). In Africa, people sometimes view snakebites as witchcraft and bad luck, mostly when the most venomous snakes bite them (Omara et al., 2020). Although traditional snakebite practices are common worldwide, many snakebites (569)  "The traditional healer cut both parents at the private parts for a small piece and the baby will get better." "It is true, it is very common practice because there is no way a child will get better if both parents are not cut on their private parts." "Because apparently they possessed their child that is why they need to be cut. If not, the baby will die." Mswela (2009) defines female genital mutilation as the excision of part of the female genital organ. According to UNHCR (2016), an estimated 135 million women have undergone female genital mutilation throughout the world.
The former author reports that in Somalia 98% of women (5 million), Gambia (70.0-80.0%), and Egypt both Muslims and non-Muslim women had undergone female genital mutilation, as various ethnic groups and religions perform this practice. Female genital mutilation is practised worldwide in 27 countries and is more common in Indonesia, Ethiopia, Egypt, Yemen, Iraq, Indonesia, Israel, Omani, the United Arab Emirates, Mexico, and Colombia. A study conducted in Egypt found widespread female genital mutilation where nine in 10 women aged 18-64 have been circumcised, with rural women significantly more likely to be circumcised. In support of the previous authors, a study conducted in some African countries reveals various reasons for performing female genital mutilation, such as to prepare girls for adulthood, reduce women's sexual urge, and tighten their vaginas for men's sexual pleasure. In these countries, female genital mutilation is done on children (Saracoglu & Ozturk, 2014).
Although female genital mutilation is common in Africa, there is no literature on female genital mutilation in Namibia. However, studies reflect that female genital mutilation could contribute to HIV/AIDS transmission.

Sub-Theme: Insertion of Leaves and Root Powder into the Vagina
Participants reflected on the insertion of leaves and roots powder into the vagina as follows:

"(Smiling) For drying the vagina which causes their vagina to tear because it becomes dry and when engaged in sex it can cause painful sex which a girl can be at risk of contracting HIV if the boy is infected with HIV."
"Some herbs that girls insert in the vagina is used as a family planning method and some use it to have sex sweet." "Because it is sour it kills sperms, and one cannot fall pregnant in that way." The practice of women inserting objects into the vagina is a worldwide phenomenon (Chisembele, Malupande & Jones, 2014). Studies conducted in the Mexico-United States border region, Lusaka, Zambia, and Namibia, report that women insert leaves and roots powder in the vaginal canal to prevent pregnancies and keep their vaginal canal clean. This practice is also used for various reasons, which are influenced by culture for health, during pregnancy, menstruation, family planning, and for sexual pleasure (for dry coitus, which inhibits condom use). This practice could put people at risk of contracting HIV (Chisembele, Malupande, & Jones, 2014;MoHSS, 2016;Turner et al., 2010). In support of the previous studies, a parallel study conducted in sub-Saharan African countries reveals that some women insert leaves and roots powder into the vaginal canal as a traditional norm. Women practice the intravaginal method to clean or facilitate vaginal dryness and tighten the vagina to promote dry sex and enhance sexual pleasure (Chisembele, Malupande, & Jones, 2014;Turner et al., 2010 , 2011). Pope Benedict XVI believed condoms could not solve the problem of sexually transmitted diseases that is why Catholics have a doctrine that requires people to abstain from sex until marriage. Once married, couples should remain faithful to one another. A study conducted in Namibia reports that 85.0% of the respondents (pastors of different religions) disagreed with the use of the condom, saying sexual activities should be within marriage; therefore, there is no need to use condoms even in times of HIV/AIDS. However, 5.0% of the respondents (pastors) had no problem with churches promoting abstention from sex, absolute faithfulness to one sexual partner, and use of condoms during coitus. Furthermore, 10.0% of respondents (pastors) believed that churches should break the silence around HIV/AIDS and human sexuality (Samuel, 2004). In support of the previous authors, a study conducted in Zimbabwe reported that policymakers, educators, and church leaders do not teach about condoms because they fear that young people in the congregation will start engaging in early sexual activities. Therefore, they opt to teach young ones to abstain until marriage. Out of the 60.0% of 700 teens who were interviewed reported that they knew what HIV infection was but did not know how to protect themselves from HIV, which put them at risk of HIV infection (Benagian et al., 2011). A separate study conducted in several African countries reveals that many married women (50-80%) had contracted HIV while married to their first sexual partners (their husbands). Women are vulnerable to acquiring HIV infection irrespective of abstaining from sex before marriage. However, a study conducted in Kenya reported that participants (84.2%) believe that only prayer could cure HIV (Loosli, 2004).

Conclusion/Recommendation.
Most primary and secondary school teachers had a fair knowledge about HIV/AIDS transmission. However, a certain number of teachers had incorrect information or misconceptions of how HIV/AIDS is transmitted. A considerable number of teachers do not want to educate students on the HIV/AIDS and other sex related issues, fear that they will encourage students to practice unsafe sex and hence expose them to HIV infection. Therefore, the Ministry of Health and Social Services needs to collaborate with the Ministry of Education, Arts and Culture; the Ministry of Gender Equality and Child Welfare, church leaders, traditional leaders, and herbalists annually to see how they can mitigate and do away with bad cultural practices that are contributing to HIV/AIDS spread.