Mercy Nhamo

Catherine Campbell

Simon Gregson

Community Mobilisation Special Issue -Obstacles to local-level

Keywords: AIDS competent communities, health-enabling contexts, Empowerment, HIV-prevention, Zimbabwe

effectively to AIDS was limited in a context dominated by adult males. People spoke of HIV/AIDS in a passive and fatalistic way, expecting outsiders to solve the problem. This tendency was exacerbated given the community's previous experiences of HIV/AIDS-related NGOs, which had often regarded local people as unpaid volunteer labour rather than building their capacity to make significant decisions and play leadership roles in health programmes.

Despite obstacles, however, there were many potential community strengths and resources. There were high levels of HIV/AIDS-related knowledge. Public denial of HIV/AIDS masked huge reservoirs of support and kindness to AIDSaffected family and friends. There were many strong community organisations and clubs, potentially forming the springboard for more empowered community responses to HIV/AIDS. HIV/AIDS programmers should pay greater attention to community readiness for interventions, especially around (i) identifying and anticipating pre-existing obstacles to programme success; and (ii) mobilising the social assets that exist, even in contexts of poverty and gender inequality.

Introduction

We seek to contribute to on-going debates about how pre-existing local community contexts may enable or hinder the success of HIV/AIDS management programmes. Using the concept of the 'AIDS competent community', we present a study of local community responses to HIV/AIDS in Kumahuswa, a rural Zimbabwean community which was one of several sites of an HIV-prevention programme. This was run by a partnership between two local NGOs and the ministry of health, using state-of-the art community and clinic based activities. After three years of combined community-based peer education, free condom distribution and improved clinic-based STI treatment and counselling services, there were no reductions in HIV-incidence or healthrelated risk behaviours in the target populations of six intervention communities, of which Kumahuswa was one, compared to six matched control communities (Gregson et al., 2007) Most health and social development programme evaluations focus on technical reasons for programme success or failure, especially the design and implementation of programmes e.g. the cultural relevance of programme messages, the efficiency and effectiveness of programme management, the extent to which communities are adequately consulted in programme design and so on. However, Pawson and Tilley (1997) argue that programme success depends as much on the wider community contexts into which programmes are inserted, as on the technical details of the programmes themselves. This insight is summarised in their formula 'programme + context = outcome'. Against this background, we make no comment on the HIVprevention programme in Kumahuswa itself, rather seeking to raise questions about how the wider pre-existing social context might have framed the conditions in which the intervention was implemented. Campbell et al. (2007;2008), characterise an HIV/AIDS competent community as a context in which local people work together to contribute to the challenges of promoting behaviour change, stigma reduction, the support of AIDS patients and carers, and the appropriate accessing and optimal use of existing sources of health and welfare support.

They characterise such a community by six features. The first is access to HIV/AIDS-related information. Secondly, the existence of social spaces for critical dialogue where people feel confident, willing and able to freely engage in debate about obstacles to health-enhancing behaviour change, as the first step towards developing collective action plans to tackle these (Freire, 1970(Freire, , 1973;;Vaughan, 2010). At this stage of the epidemic, even in remote rural areas, people often have the information they need about HIV/AIDS. However it is frequently presented in ways they cannot translate into action plans in their own lives. What people are often lacking is not information but safe and trusting social spaces where they can collectively negotiate ways of making unfamiliar health-related information relevant to their own specific lives (Campbell, 2003;Epstein, 2007).

The third feature of AIDS competence is that community members have a sense of ownership of the HIV/AIDS problem and a sense of responsibility for contributing to its management. In conditions of denial and stigma, people may simply fail to acknowledge the existence of the problem. However, even when people do acknowledge it, they may respond passively, waiting for government or NGOs to solve it rather than acknowledging the role they too have to play (Barnett & Whiteside, 2006). Fourthly, community members should feel confident in their ability to contribute to tackling the problem.

Fifthly, they should be able to identify ways they can make such a contribution, either individually or in groups. Even small-seeming contributions may have powerful effects on creating a supportive community contextprayers for the sick, greeting a person living with HIV/AIDS politely in the street, assisting an affected family with housework and so on.

The sixth property of an AIDS competent community -particularly importantis the existence of bridges or partnerships between local communities and outside support agencies -be they in the public sector (e.g. health services), the private sector (e.g. employers) or civil society (e.g. national AIDS activist groups). Marginalised groupings seldom have the skills or resources to tackle devastating social problems without substantial support from outside agencies with economic and/or political influence (Gillies, 1998).

We examine the extent to which these six features of AIDS competence were present in Kumahuswa in the interests of generating debate about preexisting 'community readiness' for interventions.

Research methods

Study site

Kumahuswa is a small rural town, with much movement in and out of the area. Unemployment is high, promoting high levels of sex work amongst women battling to survive economically. The difficult economic climate contributes to low morale amongst both adults and youth, and high levels of alcohol use/abuse. Kumahuswa has high levels of HIV/AIDS, and, as stated above, was the site of an HIV-prevention intervention which made no impact on the behaviour or sexual health of local residents compared to a matched control community.

Case study methodology

Our case study involved interviews with 44 individuals, 11 focus groups involving 55 people, and fieldworker diaries. We interviewed a range of people living or working in Kumahuswa, focusing on those groupings whose views and actions might impact on the lives, health and sexuality of local people: teachers, AIDS volunteers, traditional leaders, local community organisations (e.g. women's and youth groups), NGOs, school pupils, out of school youth, peer educators, traditional healers, clinic nurses, parents, people living with HIV/AIDS, church ministers and local government officials. Interviews were conducted by the first author, an experienced Shona-speaking social scientist familiar with local conditions and customs. She was introduced to informants through a 'village guide', a local resident who had a long association with the Kumahuswa HIV-prevention programme. Very few of those approached An open-ended topic guide elicited information we believed about social dynamics which may have impacted on peoples' receptiveness to the intervention's goals: including informants' experiences of local community life; their views of the causes of HIV/AIDS; its impact on the community; the role of different groups in HIV/AIDS management; and the potential of peer education, grassroots participation and multi-stakeholder partnerships as HIVprevention strategies.

Informants signed a consent form, and were promised confidentiality and anonymity. Interviews were audio-taped, translated into English and subjected to thematic content analysis (Flick, 1992) by the first two authors, working closely and engaging in extensive discussion of the material. The six dimensions of AIDS competence served as the core categories of our coding frame. These constitute the section headings in the presentation of our findings below.

Findings and discussion: AIDS competence in Kumahuswa

Knowledge

Kumahuswa residents had sound basic knowledge about HIV/AIDS, including that HIV/AIDS is predominantly sexually transmitted, that it kills, that it can be avoided by ABC strategies (abstain, be faithful or condomise). However a various factors may have limited people in turning knowledge into action. The most obvious of these was poverty, which often appeared to undermine the psychological empowerment most likely to predispose people to exercise agency in changing well-established behavioural norms. People repeatedly referred to the negative impacts of poverty on mental health and confidence: People have no confidence anymore, when they are told there is work some won't even go, some don't believe it. Others have got used to a life without work. (Soccer club chair,man,31) Also potentially intervening between knowledge and action were the intertwined emotional, social and gender dynamics framing sexual experience and behaviour. Contrary to much HIV/AIDS prevention literature, which often presents women as willing to use condoms, but unable to insist in the face of male reluctance and power (Dunkle et al., 2004;Harrison, Xaba, & Kunene, 2001), our interviews highlighted a strong female resistance to condom use.

Many women spoke of their unwillingness to use condoms due to their need for a sense of intimacy and trust with their partners, and because condoms reduced the pleasure of sex.

The third factor potentially intervening between technical AIDS-related knowledge and behaviour change was competing knowledge about HIV/AIDS, especially the view HIV/AIDS sufferers had been 'bewitched' by jealous others. This led many to conclude that HIV/AIDS was unavoidable by individual precautions. Technical knowledge often contradicted strongly held local myths, e.g. "If a man has a healthy five year old son, this means he is not HIV positive."

Low levels of literacy may also have undermined the effectiveness of HIV/AIDS messages. The concept of 'using information' to influence one's behaviour seemed very foreign to many people. The concept of 'having and applying knowledge' was not familiar to many with little or no formal education. The idea of separating the message from the medium was often also unfamiliar. People often said that peer education messages could not be believed, since most of the peer educators had died: The ladies (sex workers) that were conducting peer education were the first to die. That is when we realised that peer education was not effective, because they were the first to die. (Women's secretary for political party, 42).

In such a conservative community, the concept of behaviour change itself was often greeted with suspicion. People often expressed strong and negative views about change of any sort. Thus for example, many informants spoke disapprovingly of young people who adopted western lifestyles and 'forgot their own culture'. Such young people were varyingly referred to as 'a shock', 'an irritation' or 'a nuisance'. Others spoke disapprovingly of the way in which their behaviour served to dilute a valued African identity:

People from nowadays are wearing trousers, and these were never meant for women. As Africans let us dress as Africans, rather than copying western culture. (Methodist pastor,man,32) Many people appeared to have a strong gut-level resistance to change. Our case study gave the impression of a conservative semi-rural setting where innovation was often resisted:

Married people don't use condoms because they are not used to them.

(Home based club, elderly women, focus group) I have never used condoms because I was not brought up knowing about them. (Garden co-operative, mixed focus group)

Social spaces for dialogue about HIV/AIDS

We have referred to the importance of social spaces where people can discuss HIV/AIDS information, debating doubts they might have about its relevance or accuracy, and collectively negotiating ways it might be put into action in their own lives. Our study suggested that many (though certainly not all) community members had few opportunities to engage in frank discussion of HIV/AIDS with liked and trusted peers. Stigma and denial were high, as was the local tendency to refer to people with AIDS in veiled terms such as 'a person who is dying' or 'someone who suffers from the disease of nowadays'. However, in our research setting, when given space to talk about HIV/AIDS to a sympathetic listener, interview participants took this opportunity and expressed great appreciation for it at the end of the interview. Despite the fact that the interviewer explicitly gave no information about HIV/AIDS at all during the interviews, many informants later thanked her for the opportunity to participate in the interview, saying they had learned a lot from participating.

From the researchers' perspective, rather than transmitting factual knowledge to interview participants, the interview setting had provided people with social spaces to talk about their doubts, uncertainties and experiences of HIV/AIDS in their own lives -a rare opportunity.

Thus, for example, a sex worker said she had "gained a lot of knowledge" from the interview, and that this had given her the confidence to think of going for voluntary counselling and testing (VCT) for HIV/AIDS. An Apostolic Minister began the interview by dissociating himself from HIV/AIDS, saying "it's not necessary for somebody like me to talk about HIV/AIDS". However after the interview he said the experience had helped him realise it was important to discuss HIV/AIDS, and he asked the interviewer if she had any books on the topic to lend him. The soccer club co-ordinator (a young man) said:

In this interview I have learned a lot about AIDS that I was not aware of. I have also realised how many myths there are in the community, for example, how wrong we are to think we can't catch HIV, just because we stay in a rural area.

. Once again, this information had not been volunteered during the interview.

Rather he had used the interview as a 'social space' to start processing the various pieces of knowledge he had gained from various sources in his daily life, but never been able to apply to his own life through a lack of opportunity to process and discuss information in a safe and sympathetic context.

People repeatedly spoke of stigma as a key obstacle to effective HIV/AIDS management. Yet there was an interesting contradiction here. At the personal level most people appeared to have been kind and supportive to individuals with HIV/AIDS. Family members offered care, neighbours visited with kindness and support. Church members prayed for the sick. Most people contributed to funeral expenses, a long-standing local custom. However at the public level people went to great pains to publicise their disapproval of people living with AIDS: I don't want to lie to you, friends abandon their peers who get HIV. We had a friend who was dying, he used to be promiscuous, we used to laugh at him saying he was now 'going to the man with the long beard'.

(Apostolic church leader, male, 63) Behind her back my mother's friends laugh at her, saying they knew she'd come to this. (Carer of mother living with HIV/AIDS) People with HIV are immoral and they are heathens, these people have been promiscuous, therefore it is only right and proper that the health clinics treat them badly. (Church elder, male, 55) Acts of kindness were often committed in secret, behind the socially desirable mask of public anti-AIDS talk, or under the guise of helping 'the sick' rather than naming AIDS as the issue. Interviews suggested there was no context in which individual acts of caring or assistance could add up to a more powerful collective response, given their highly secretive and individual nature.

Many people may have lacked opportunities for the type of 'critical dialogue' that Freire (1970Freire ( , 1973) ) says is so important for positive individual and social change. People should be forced to listen to HIV/AIDS education. Because it is to their advantage. (Soccer Club leader,male,31).

Chiefs and nurses must give people instructions, education must come from people we look up to, who should stipulate strict regulations. (Female caregiver to PLWHA,19).

Peoples' references to AIDS education were often couched in the genre of instruction, with the targets of information being conceptualised as passive listeners rather than active interactants.

Appreciation of local strengths and resources

The likelihood of people contributing to HIV/AIDS management depends strongly on them believing they have strengths and resources to equip them to do so (Campbell, Foulis, Maimane, & Sibiya, 2005). Our case study suggested that the greatest AIDS resource in the community was women's unpaid -and largely unrecognised -work in giving emotional and practical support to PLWHA. Yet women repeatedly said that they were not respected, consulted or represented in local community affairs:

Men are regarded as the leaders. Us women's ideas are disregarded, even when they are brilliant. (Home based care leader,woman,52) When women did exercise leadership it tended to be in gender-specific spheres of activity, such as women's church groups and in the women's section of the leading political party.

Men were generally not spoken of as a great community resource:

Men just loiter around the place, they don't do a thing that is beneficial. The WAAC focused on providing food parcels and school fees for AIDS orphans. People repeatedly stressed the importance of this assistance.

However, given the scale of the problem, there would always be a need for further resources. In relation to our interest in AIDS competence, this qualified as welfare work rather than social development ('providing fish rather than fishing rods').

Generally people were positive about the benefits of groups. For example, interviewees repeatedly said 'soccer keeps young people out of trouble', and that soccer club members were less likely to be HIV positive than nonmembers. People talked about the help and comfort they derived from the church, the way it instilled empowering moral discipline in women, and the way in which church members visited the sick. People also spoke about the burial society as a beneficial support group, paying for members' funerals and also giving them loans whilst they were alive. The bee-keeping club was also seen as very effective -with members having been trained by an NGO, and now using these skills to generate income through selling honey. Moser (1998) reminds us that even resource-poor communities have 'portfolio's of non-material assets'. In Kumahuswa, a number of positive community As mentioned, our informants often emphasised information and instruction as the solution to HIV/AIDS. Many viewed AIDS as the responsibility of outside agencies, with little sense that local people might also have a contribution to make to HIV/AIDS management. This representation of AIDS management as centred around instructions and outsiders is directly contradictory to best practice. Our interviews suggested that earlier well-intentioned HIV-prevention and AIDS-care efforts (prior to our HIV-prevention programme of interest) may sometimes have had less than optimal success in promoting local ownership and leadership of prevention and care programmes. Informants referred to previous interventions that seemed to have focused more on enrolling community members to deliver unpaid services to programmes, than building their capacity to make a significant contribution to programme design, leadership or management.

We illustrate this point with a discussion of a long-standing local home-based care club (not linked to our intervention of interest), chaired by Mrs K, an energetic middle-aged woman with a deep calling to serve her community. At the time of our interviews, Mrs K and her club peers were still working hard in delivering home nursing assistance -but she no longer had any contact with the NGO. In the course of a long interview it became clear that although group members worked with dedication and commitment, they knew nothing about the context of the work, the nature of the NGO, or the origin of the blankets, and had certainly never been consulted about any aspect of it:

They no longer bring the blankets and the food parcels. I am not sure why................ I am not sure who initiated this group………….. Our club members don't network with anyone else besides each other………….

We have run out of gloves and need a refresher course. ………….. I am not sure of the future plans of this group because I am not part of the management. (Home-based club chair, woman, 52)

There is a growing critique of programmes which interpret 'community participation' as the use of local community members to deliver unpaid welfare services according to an externally imposed agenda, without involving participants in wider decisions about project design and management (or at the very least making sure that they are well-informed about such matters) (Campbell, 2003). In so doing, they may miss vital opportunities to build grassroots capacity in project design, management and decision-making, which could constitute vital capacity if/when the NGO withdrew from the community.

Conclusion

We have reported on the wider context into which an HIV-prevention programme was inserted in a rural Zimbabwean community. We have not sought to make any comment on the intervention itself. Rather we have sought to cast our net more widely to examine broader social dynamics, in the interests of advancing debate about ways in which pre-existing local dynamics may serve to facilitate or hinder programme efforts in particular settings. The key aim of HIV-prevention programmes is to bring about sexual behaviour change: increased condom use, delayed sexual debut, fewer sexual partners and so on. However, social psychologists have repeatedly pointed out that the likelihood of behaviour change is influenced not only by the information transmitted by health promotion programmes and the techniques that they use, but also by pre-existing levels of perceived selfefficacy -confidence in one's ability to change one's behaviour -amongst members of programme's target groupings (Bandura, 1995). This insight is echoed in the concept of 'empowerment' which forms the cornerstone of community psychology (Nelson & Prilleltensky, 2005;Wallerstein, 1992) and social development (Parpart, Rai, & Staudt, 2002).

We have used the concept of AIDS competence as a framework for However, in many respects our snapshot of Kumahuswa social relations was not an overwhelmingly bleak one. There were many potential strengths and resources in the community: people did have high levels of HIV/AIDS related knowledge, despite the existence of potential obstacles to actioning this.

Beneath high levels of public denial of HIV/AIDS, there were huge reservoirs of support and kindness towards AIDS-affected friends and family members, albeit often offered clandestinely in conditions of stigma. The community included many well networked community groups, with many local clubs and organisations that might have formed the springboard for a more empowered and positive attitude to HIV/AIDS.

In preparing to implement programmes, there is an urgent need for HIV/AIDS programmers to develop understandings of the way in which the pre-existing social dynamics of their target communities might facilitate or hinder their efforts. Much remains to be learned about how potential obstacles can be identified and anticipated by interventions, and we believe the concept of 'the AIDS competent community' provides a useful conceptual tool for guiding such investigations. Much also remains to be learned about identifying and mobilising the social assets that exist, even in conditions of great poverty and gender inequality. To date the efforts of many programmes have focused on technical details of programme design, implementation/ management and evaluation. There is an urgent need to cast the spotlight more broadly to look at wider dimensions of pre-existing AIDS competence in target communities, in the interests of planning how best to optimise 'community readiness' to derive optimal benefit from interventions in highly marginalised settings. Drawing on 44 individual interviews and 11 focus groups, we use concept of the 'AIDS competent community' to explore community responses to HIV/AIDS. We found that whilst people had high levels of HIV/AIDS related knowledge, there were several ways in which gender, poverty and low levels of literacy may have undermined its perceived relevance to their lives. Lack of opportunities for dialogue in the wider social milieu beyond the immediate context of the intervention potentially limited opportunities for translating factual knowledge into action plans, or sharing hidden individual experiences of HIV/AIDS-affected family members or friends in contexts of stigma and denial. The initiative and energy of women and young people, potentially a vital resource for an effective community response to AIDS were often hindered in a context dominated by adult males. In this context, people often spoke of HIV/AIDS in a passive and fatalistic way, waiting for outsiders (NGOs, government) to come and solve the problem. This tendency had been exacerbated by the community's previous experiences of HIV/AIDS-related NGOs prior to the inception of the project. These had sometimes tended to treat local people as sources of unpaid volunteer labour rather than building their capacity to make significant decisions and play leadership roles in externally imposed health programmes. Despite these obstacles, however, there were many potential strengths and resources in Kumahuswa: people did have high levels of HIV/AIDS related knowledge; public denial of HIV/AIDS masked huge reservoirs of support and kindness to AIDS-affected family and Campbell et al. (2007;2008), characterise an HIV/AIDS competent community as a context in which local people are able to work together to make whatever contributions they can to the challenges of promoting behaviour change, stigma reduction, the support of AIDS patients and carers, and the appropriate accessing and optimal use of existing sources of health and welfare support.

They characterise such a community by six features. The first is access to HIV/AIDS-related information. The second of these is the existence of social spaces for critical dialogue in which people feel confident, willing and able to freely engage in debate about obstacles to health-enhancing behaviour change, as the first step towards developing collective action plans to tackle these (Freire, 1970(Freire, , 1973;;Vaughan, 2010). At this stage of the epidemic, even in remote rural areas, people often have the information they need about HIV/AIDS. However it is frequently presented to them in such a way that they cannot translate it into action plans in their own lives. We argue that what people are often lacking is not so much information as safe and trusting social spaces in which they can collectively negotiate ways in which they can make unfamiliar health-related information relevant to their own specific lives and contexts (Campbell, 2003;Epstein, 2007).

The third feature of AIDS competence is that community members have a sense of ownership of the HIV/AIDS problem and a sense of responsibility for contributing to its management. In conditions of denial and stigma, people may simply fail to acknowledge the existence of the problem. However, even when people do acknowledge this they might respond passively, waiting for government or NGOs to come and solve it rather than acknowledging the role that they have to play (Barnett & Whiteside, 2006). The fourth and related characteristic is that community members feel confident in their ability to contribute to tackling the problem. The fifth characteristic relates to the ability of community members to identify ways in which they can make such a contribution, either as individuals or within groups they belong to. Even smallseeming contributions may have powerful effects on creating a supportive community context -prayers for the sick, greeting a person living with The sixth property of an AIDS competent community -and one that is particularly important -is the existence of bridges or partnerships between local communities and outside support agencies -be they in the public sector (e.g. health services), the private sector (e.g. employers) or civil society (e.g. national AIDS activist groups, AIDS-relevant NGOs). Marginalised groupings seldom have the skills or resources to tackle devastating social problems without substantial support from outside agencies with economic and/or political influence (Gillies, 1998).

Research methods

Study site

Kumahuswa is a small town in a deep rural area in Zimbabwe. There is a lot of movement in and out of the area. Unemployment is high, and linked to high levels of sex work amongst women who have few opportunities for making a living. The difficult economic climate contributes to low morale amongst both adults and youth, and high levels of alcohol use/abuse. Kumahuswa has high levels of HIV/AIDS, and, as stated above, was the site of an HIV-prevention intervention which made no impact on the behaviour or sexual health of local residents compared to a matched control community.

Below we present an in-depth case study of Kumahuswa in which we sought to examine the local context in which this programme was inserted. As already stated, our research goal was not to evaluate the Kumahuswa intervention but rather to focus on the context in which this work had been conducted, in the light of our interest in developing better understandings of how social context might impact on HIV-prevention efforts. An open-ended topic guide elicited information we believed might be relevant to understanding the context of HIV prevention, including informants' views of: local community life; the causes of HIV/AIDS; its impact on the community; the role of different groups in HIV/AIDS management; and the potential of peer education, grassroots participation and multi-stakeholder partnerships as strategies for HIV prevention. Informants signed a consent form, and interviews were conducted under conditions of confidentiality and anonymity. Interviews were audiotaped, translated into English and subjected to thematic content analysis (Flick, 1992) by the first two authors, working closely together, and engaging in extensive discussion of the material. The six dimensions of AIDS competence served as the core categories of our coding frame. These constitute the section headings in the presentation of our findings and are further elaborated below.

Case study methodology

Findings and discussion: AIDS competence in Kumahuswa Knowledge

Our interviews suggested that Kumahuswa residents had sound basic knowledge about HIV/AIDS, echoing earlier survey findings (Gregson et al., 2007). There appeared to be general understanding that: HIV/AIDS is predominantly sexually transmitted, that it kills, that it can be avoided by ABC strategies (abstain, be faithful or condomise). However a number of factors potentially undermined the likelihood that people would act on the basis of this information.

What were possible reasons for the gaps between knowledge and action?

The most obvious of these was poverty, which our interviews suggested might often undermine the sense of psychological empowerment most likely to predispose people to exercise agency in changing well-established behavioural norms. People repeatedly referred to the negative impacts of poverty on peoples' mental health and confidence:

My neighbour beats her child whenever they run out of food. She always displaces her emotions on to the child by beating her. (Woman living with HIV/AIDS, 22)

Formatted: Highlight Formatted: Highlight

Formatted: Highlight

Formatted: Highlight Deleted: Our interview data were subjected to thematic content analysis (Flick, 1992) The second factor potentially intervening between knowledge and action related to the complex set of intertwined emotional, social and gender dynamics framing sexual experience and behaviour. Contrary to much HIV/AIDS prevention literature, which often presents women as willing to use condoms, but unable to insist in the face of male reluctance and power (Dunkle et al., 2004;Harrison, Xaba, & Kunene, 2001), our interviews pointed to a strong female resistance to condom use. Many women in our study spoke of their unwillingness to use condoms due to their need for a sense of intimacy and trust with their partners, and also because they felt that condoms reduced the pleasure of sex.

third factor potentially intervening between technical AIDS-related knowledge and the likelihood of behaviour change was competing knowledge about HIV/AIDS, especially the view HIV/AIDS sufferers had been 'bewitched' by jealous others. This belief led many to conclude that HIV/AIDS was unavoidable by individual precautions. AIDS-related knowledge also often stood in contradiction to strongly held local myths, e.g. "If a man has a healthy five year old son, this means he is not HIV positive." Such competing beliefs contributed to the likelihood that knowledge would not contribute to behaviour change.

Our interviews also suggested that low levels of literacy may have played a key role in undermining the effectiveness of HIV/AIDS messages. This was a community in which the concept of 'using information' to influence one's behaviour seemed very foreign to many people. The concept of 'having and applying knowledge' was not a familiar one to many who had little or no formal education. Also unfamiliar for many people was the idea of separating the message from the medium. People often said that peer education messages could not be believed, since most of the peer educators had died: The ladies (sex workers) that were conducting peer education, they were the first people to die in the community. That is when we realised that peer education was not effective, because they were the first to die. (Women's secretary for political party, 42).

Several informants said that the failure of HIV-prevention information to help the very people who had sought to impart it, was proof of the lack of value of the information.

In such a conservative community, the concept of behaviour change itself was often greeted with suspicion. People often expressed strong and negative views about change of any sort. Thus for example, many informants spoke disapprovingly of young people who adopted western lifestyles and 'forgot their own culture'. Such young people were varyingly referred to as 'a shock', 'an irritation' or 'a nuisance'. Others spoke disapprovingly of the way in which their behaviour served to dilute a valued African identity:

People from nowadays are wearing trousers, and these were never meant for women. As Africans let us dress as Africans, rather than Above we have referred to the importance of social spaces in which people can discuss HIV/AIDS information, debating any doubts they might have about its relevance or accuracy, and collectively negotiating ways in which it might or might not be put into action in their own lives. Our case study suggested that many (though certainly not all) community members had limited opportunities in which they could engage in frank discussion about HIV/AIDS with liked and trusted peers. Levels of stigma and denial were high, as was the local tendency to refer to people with AIDS in veiled terms such as 'a person is dying' or 'someone who suffers from the disease of nowadays'.

However, in our research setting, when given space to talk about HIV/AIDS to a sympathetic listener, interview participants took this opportunity and expressed great appreciation for this at the end of the interview. Despite the fact that the interviewer (the 1 st author) explicitly gave no information about HIV/AIDS at all during the interviews, many informants thanked her for the opportunity to participate in the interview, saying they had 'gained a lot of knowledge' from it. From the researchers' perspective, rather than transmitting factual knowledge to interview participants, the interview setting had provided our informants with social spaces to talk about their doubts, uncertainties and experiences of HIV/AIDS in their own lives -a rare opportunity.

Thus, for example, a sex worker said she had "gained a lot of knowledge" from the interview, and that this had given her the confidence to think of going for voluntary counselling and testing (VCT) for HIV/AIDS. An Apostolic Minister began the interview by dissociating himself from HIV/AIDS, saying "its not necessary for somebody like me to talk about HIV/AIDS". However at the end of the interview he said the experience had helped him realise it was important to discuss HIV/AIDS, and he asked the interviewer if she had any books on the topic to lend him. The soccer club co-ordinator (a young man) said:

In this interview I have learned a lot about AIDS that I was not aware of. I have also realised how many myths there are in the community, for example, how wrong we are to think we can't catch HIV, just because we stay in a rural area.

. Once again, this information had not been volunteered during the interview.

Rather he had used the interview as a 'social space' to start processing the various pieces of knowledge he had gained from various sources in his daily life, but never been able to apply to his own life through a lack of opportunity to process and discuss information in a safe and sympathetic context.

People repeatedly spoke of stigma as a key obstacle to effective HIV/AIDS management. Yet there was an interesting contradiction here. At the personal level most people appeared to have been kind and supportive to individuals with HIV/AIDS. Family members offered care, neighbours visited with kindness and support. Church members prayed for the sick. Most people contributed to funeral expenses, a long-standing local custom. However at the public level people went to great pains to publicise their disapproval of people living with AIDS:

I don't want to lie to you, friends abandon their peers who get HIV. We had a friend who was dying, he used to be promiscuous, we used to laugh at him saying he was now 'going to the man with the long beard'.

(Apostolic church leader, male, 63)

Behind her back my mother's friends laugh at her, saying they knew It seemed that many people may have lacked opportunities for the type of 'critical dialogue' that Freire (1970Freire ( , 1973) ) says is so important for positive individual and social change.

People should be forced to listen to HIV/AIDS education. Because it is to their advantage. (Soccer Club leader,male,31).

Chiefs and nurses must give people instructions, education must come from people we look up to, who should stipulate strict regulations.

(Female caregiver to PLWHA,19).

Peoples' references to AIDS education were often couched in the genre of instruction, with the targets of information being conceptualised as passive listeners rather than active interactants.

Appreciation of local strengths and resources

The likelihood of people contributing to HIV/AIDS management efforts depends strongly on people believing that they have strengths and resources that would equip them to do this (Campbell, Foulis, Maimane, & Sibiya, 2005).

Our case study suggested that the greatest AIDS resource in the community was women's unpaid -and largely unrecognised -work in giving emotional and practical support to PLWHA. Yet women repeatedly said that they were not respected, consulted or represented in local community affairs:

Men are regarded as the leaders. Us women's ideas are disregarded, even when they are brilliant. (Home based care leader, woman, 52)

The areas in which women did exercise leadership tended to be overwhelmingly in gender-specific spheres of activity, such as women's church groups and in the women's section of the leading political party. Men were not generally seen as a great community resource:

Men just loiter around the place, they don't do a thing that is beneficial.

They just come home without even carrying a parcel. They are the stresses in our lives. (Leader of women's savings club)

Young people also tended to be discounted as any kind of positive community resource, with people often describing them in terms such as 'lazy' and 'incompetent'. In turn, young people said that adult domination totally stifled any attempts they made to show initiative:

We can't do anything because we don't have the resources and we always have to appoint older people to lead us because we are regarded as minors. This has demoralised a lot of young people.

(Political youth group, focus group)

We approached our councillor to help us raise some funds for a soccer ball. He said he would look into it, but nothing happened. We couldn't go back and ask again, because that would have seemed disrespectful. (Soccer club leader, man, 31))

Ownership of the problem of HIV/AIDS

To what extent do people in Kumahuswa believe they have a role to play in addressing HIV/AIDS? And to what extent do they have any sense of possible action they might take as individuals, in groups, or through building links with outsiders? Our interviews suggested that there many of our informants had little sense of ownership of the problem. There was repeated reference to the need for outside organisations to come to the community and take control: There were many local organisations and clubs in Kumahuswa. These included a soccer club, a savings club, a traditional dance group, a garden cooperative, a political youth club, an Apostolic women's group, a beekeeping society and a burial society. There was also a government sponsored Ward AIDS Action Committee (WAAC) and a home-based care club.

Come
The WAAC focused on providing food parcels and school fees for AIDS orphans. People repeatedly stressed the importance of this assistance.

However, given the scale of the problem, there would always be a need for further resources. In relation to our interest in AIDS competence, this qualified as welfare work rather than social development ('providing fish rather than fishing rods').

On the whole people were very positive about groups, and about the benefits of group membership. Thus, for example, interviewees repeatedly said that 'soccer keeps young people out of trouble', and told us that soccer club members were less likely to be HIV positive than non-members. People talked about the help and comfort they derived from the church, the way it instilled empowering moral discipline in women, and the way in which church members visited the sick. People also spoke about the burial society as a beneficial support group, both in terms of paying for members' funerals and also giving them loans whilst they were alive. The bee-keeping club was also seen as very effective -with members having been trained by an NGO now generating an income through selling honey. Moser (1998) reminds us that even resource-poor communities have 'portfolio's of non-material assets'. In Kumahuswa, a number of positive community networks served as key social resources providing various forms of emotional, practical and material support to members. However factors such as stigma and lack of AIDS-related agency may have stood in the way of these networks serving as AIDS-specific resources.

Bridging social capital

This As we have seen, our case study informants often placed a large emphasis on information and instruction as the solution to HIV/AIDS. Many had a tendency to view AIDS as the responsibility of outside agencies, and appeared to have little sense that local people might also have a contribution to make to HIV/AIDS management. This representation of AIDS management programmes -centred around instructions and outsiders -is directly contradictory to best practice. Our interviews suggested that earlier wellintentioned HIV-prevention and AIDS-care efforts may sometimes have had less than optimal success in promoting local ownership and leadership of prevention and care programmes. Informants' references to 'community involvement' in programmes prior to the establishment of the Kumahuswa intervention suggested that these might sometimes have focused more on enrolling community members to deliver unpaid services to programmes, than building their capacity to make a significant contribution to programme design, leadership or management.

We illustrate this point with a discussion of a long-standing local home-based care club (not linked to our intervention of interest), chaired by Mrs K, an energetic middle-aged woman with a deep calling to serve her community.

She said she had been nominated by a local councillor to liase with an internationally funded NGO. The NGO trained Mrs K and six other women (all volunteers) in home nursing skills and had initially provided food parcels and blankets for them to distribute to AIDS-affected families. They met fortnightly to timetable their work and to provide one another with encouragement to continue this gruelling work. This was the only formal local grassroots grouping providing support for people living with AIDS.

At the time of our interviews, she and her club peers were still working hard in delivering home nursing assistance -however she no longer had any contact with the NGO. In the course of a long interview it became clear that although group members worked with dedication and commitment, they knew nothing about the context of the work, the nature of the NGO, or the origin of the blankets, and had certainly never been consulted about any aspect of it: There is a growing critique of programmes which interpret 'community participation' as the use of local community members to deliver unpaid welfare services according to an externally imposed agenda, without involving participants in wider decisions about project design and management (or at the very least making sure that they are well-informed about such matters) (Campbell, 2003). In so doing, such organisations may miss a vital opportunity to build grassroots capacity in areas such as project design, management and decision-making, which could constitute vital sources of local AIDS competence once the NGO withdrew from the community.

Conclusion

In this paper we have reported on the wider social context into which an HIVprevention programme was inserted in a rural Zimbabwean community. We have not sought to make any comment on the intervention itself. Rather we have sought to cast our net more widely to examine the broader social dynamics of the Kumahuswa community, in the interest of generating hypotheses and advancing debate about ways in which pre-existing local dynamics may serve to facilitate or hinder programme efforts in particular social settings. The key aim of HIV-prevention programmes is to bring about sexual behaviour change: increased condom use, delayed sexual debut, fewer sexual partners and so on. However, social psychologists have repeatedly pointed out that the likelihood of behaviour change is influenced not only by the information transmitted by health promotion programmes and the techniques that they use, but also by pre-existing levels of perceived selfefficacy -confidence in one's ability to change one's behaviour -amongst members of programme's target groupings (Bandura, 1995). This insight is echoed in the concept of 'empowerment' which forms the cornerstone of community psychology (Nelson & Prilleltensky, 2005;Wallerstein, 1992) and social development (Parpart, Rai, & Staudt, 2002).

In this paper we have used the concept of AIDS competence as a framework Have sent you redlined versions of our revisions, and detailed them below.

Have also sent a 'clean' copy with all the revisions accepted. I cut 500 words off the clean copy so it will be quite a bit shorter than the redlined one, so just to say the redlined version is just to flag up the revisions, and not to have any status other than that.

Aside from doing the revisions as recommended below, Simon also made quite a few suggestions at this stage. When he read the final version he worried that Mercy and I hadn't been clear enough this was not intended as any kind of evaluation of his programme, so we went through it again seeking to emphasise very strongly that this paper reports on a study of pre-existing community dynamics, and is not intended as any sort of programme evaluation (I had said this in earlier versions, but he wanted it to be said more loudly).

Thanks for support on this, hope that the revisions meet your approval.

Cathy

From: onbehalfof+l.sherr+ucl.ac.uk@manuscriptcentral.com on behalf of l.sherr@ucl.

Referee: 1 Comments to the Author

This is an interesting paper, presenting good data and case study. It has an important focus on thinking about the contextual factors that act as obstacles to the success of HIV prevention efforts, and so I think it would be a very useful addition to the special issue. It is well-written in parts and offers some good discussion. However, I think it requires a lot more developing and strengthening before it is suitable for publishing. Some of the areas where I feel the paper needs to be developed further are: 1. The authors state that the aim of the paper is not to evaluate the prevention programme in Kumahuswa, but rather to examine the contextual issues that may have led to the "disappointing outcome" of the programme. However the paper lacks any helpful background information about the situation in Kumahuswa and the prevention programme. In addition, the authors refer to "matched control communities" -more details would be useful here. How were they matched? Here the authors refer to Gregson et al. Does the study reported on in this paper form part of this Gregson project? Some clarity would be useful here. All this detail is provided in the Gregson et al PLoS Medicine paper, which is Open Access and freely available on the internet. We have put the link in the Reference list.

We don't have the word count to give more details of the research methods and findings here, and feel more detail would detract from the aim of the paper, which is specifically to focus on the context of the intervention, rather than its evaluation methodology etc.

We are keen to move the focus of the paper away from the intervention fairly early on for 3 reasons: firstly the paper is already much too long, and we have had to cut it to accommodate the revisions suggested by the referees; secondly in the paper we repeatedly emphasise that we are interested in the wider contexts in which interventions are implemented. The details of the precise intervention e.g how outcomes were measured etc, don't throw any light on the wider context. Finally and most importantly, in the Zimbabwean context, informants were understandably anxious about discussing e.g. economic and political issues, and we said we would downplay the location of the community in our reports. We have not mentioned the province of Zimbabwe, the location of the town etc in order to downplay the location of the community. 2. The authors mention the importance of 'critical dialogue' as a second characteristic of AIDS competent communities. In the results section, the authors refer to Freire' notion of 'critical dialogue'. It may be useful to have a brief elaboration of this in the introduction.

Have added the following elaboration, as well as two useful references to Freire's primary text on this topic, and Vaughan's more recent and very clear account of the relevance of Freire to community health programme's:

"The second of these is the existence of social spaces for critical dialogue in which people feel confident, willing and able to freely engage in debate about obstacles to health-enhancing behaviour change with liked and trusted peers, as the first step towards developing collective action plans to tackle these (Freire, 1970(Freire, , 1973;;Vaughan, 2010)."

3. The introduction ends with a single question. I find this a little awkward and wonder if it would be better presented in a form of a mini statement of rationale/aim? Have removed the question, and reformulated this as a mini statement as suggested.

4. Under research methods, the discussion of the study site was a little brief, and again more background (see point 1 above) will be helpful.

See discussion above, we have purposely not said too much about the study site in the light of commitments to research informants. 5. In the section on the case study methodology, it may be helpful to have a little bit more detail about the participants (e.g. ages, gender, how they were identified/recruited, etc.). Furthermore, there is no mention of any ethical considerations. I wondered about whether there was any language barrier, for example, and whether there was any need for interpretation/translation?

Have added information about ages, gender, recruiting, language barriers, and ethical issues.

6. I enjoyed the findings and discussion and I though some of the data presented is very good. However, there are some instances where claims are made about findings, which are not supported by data evidence. For example, in findings related to knowledge, the authors mention that gender dynamics and competing knowledge acted as factors intervening between knowledge and action. Can the authors provide quotes from the data that support this? Other parts include the discussion about illiteracy. We don't have short quotes to support these points, these are more general points that emerged e.g. over the course of a whole interview, in the context of our wider immersion in the whole data set -to elaborate on them would require case studies of particular interview or focus group transcripts rather than pithy quotes. However, we feel very confident about these points.

7. In some quotes details are given of who the responded was (role, gender etc.). It would be useful to have this consistent for all quotes provided. Have provided role, gender and age to describe each respondent that was quoted. 8. I found the discussion of findings about spaces for dialogue convincing and interesting. However, I wonder again what the nature of the HIV prevention programme was, and whether there was any peer education -There was indeed peer education, as stated in our account of the Kumahuswa intervention (peer education, condom distribution and STI treatment) was there no opportunity for dialogue during the intervention? Given the short word count we are keen not to devote too many words to the intervention, and to focus on the wider context. Elsewhere we have written about how peer education, ostensibly a programme to facilitate discussion, is run in an unduly didactic way. This was probably also the case here, but we don't have information on this, and this does not relate to the research goals of this particular paper. I recognise, though, the important point that the authors make is that spaces do not exist outside of any programme. 9. In the conclusion, comments are made about the HIV prevention programme that was "inserted" in this rural community, and its "disappointing outcome". Again this points to the importance, for me, of point 1 above -more details about this programme. I appreciate that the paper is not an evaluation of the programme, but it would help the reader to consider the strengths of your analysis of contextual factors. We have added some more information about the programme, as stated above, but reiterate our point that this is a paper about psycho-social dimensions of an AIDS competent community rather than about the intervention. 10. The authors end with highlighting the importance of identifying obstacles and of indentifying and mobilising social assets. It would be useful if the authors could offer some suggestions for how researchers or HIV programme providers can think about addressing any obstacles, and how to go about mobilising social assets. I know the authors do discuss the importance of community ownership in HIV prevention, but some brief suggestions or even thoughts at this conclusion might be good. We are keen not to end up with speculation, our conclusion is that 'much remains to be learned' about these challenges. We could add the usual trite comments about proper community consultation, participation etc, but these points have already been frequently made.

I hope that the authors consider some of these thoughts and would be able to strengthen parts of the paper, as I would like to see it included in the special issue. Comments to the Author An excellent and highly important piece of work -highlighting the growing need to explore structural factors that limit the ability of communities to act in health beneficial ways. Detailed, thorough and well argued. Will contribute very well to an emerging and vital field. Some additional points: On page 5 of 14: There are additional references (e.g. Mackegany and Barnard's work) on women being seen not as active agents in wanting to use condoms but wishing instead for the intimacy of 'flesh-to-flesh' contact. Some mention of these refs would perhaps help nuance an argument that at the moment seems as though this particular finding in this study is completely new. On page 8 of 14: Mention of It would also act as a good link to the next section. (Also Freire 1973 in bibliography but not actually mentioned in the text)

Referee: 2

  . The programme had been highly regarded by local residents, who felt motivated to support associated research. An added incentive was the gift of a T-shirt or soap to research participants, much appreciated in conditions of poverty.

  My neighbour beats her child whenever they run out of food. She displaces her emotions on to the child by beating her. (Woman livingwith HIV/AIDS, 22 years old)

  key social resources providing various forms of emotional, practical and material support to members. However factors such as stigma and lack of AIDS-related agency may often have stood in the way of these networks serving as AIDS-specific resources.Bridging social capitalThisfinal component of AIDS competence relates to empowering links with outside organisations capable of helping local people to respond more effectively to HIV/AIDS. The wider context of our research is an interest in how best to facilitate local responses to AIDS, and in understanding how 'interventions by outside professionals' may sometimes unintentionally undermine local coping mechanisms, and reduce the development of effective grassroots AIDS leadership.

  She said she had been nominated by a local councillor to liaise with an internationally funded NGO around home-based care delivery. The NGO and six other women (all volunteers) in home nursing skills and initially provided food parcels and blankets for distribution to AIDS-affected families. They met fortnightly to timetable their work and encourage each other to continue this gruelling work.

  highlighting factors which might have undermined the sense of HIV/AIDS related empowerment in Kumahuswa. People had relatively high levels of HIV/AIDS related knowledge, but gender, poverty and low levels of literacy might have undermined the perceived relevance of this knowledge to their own lives. Lack of opportunities for dialogue in the social milieu beyond the intervention may have meant people had few opportunities for translating factual knowledge into action plans, or for sharing their hidden individual experiences of HIV/AIDS related family members or friends in order to feed these individual experiences into a wider social acknowledgement of the extent of the problem in Kumahuswa. The initiative and energy of women and young people, potentially a vital resource for an effective community response to AIDS were hindered by the dominance of adult males. Many people responded to HIV/AIDS in a passive and fatalistic way, waiting for outsiders to tackle the problem. This passivity may have been exacerbated by earlier experiences of HIV/AIDS-related NGOs, who may have used local people to deliver unpaid community services without building their capacity to lead more effective community responses to AIDS and indeed other future health threats.

  the wider community context of an HIV-prevention programme in Kumahuswa, in rural Zimbabwe. The paper makes no comment on the intervention itself. Rather it examines the wider community dynamics into which the project was inserted, in the interests of raising questions about the extent to which pre-existing social dynamics might have influenced the 'readiness' of the community to derive optimal benefit from the intervention.

  were many strong community organisations and clubs, potentially forming the springboard for a more empowered and positive response to HIV/AIDS. HIV/AIDS programmers should pay greater attention to (i) identifying and anticipating potential obstacles to programme success; and (ii) to mobilising the social assets that exist even in contexts of great poverty and gender inequality.Deleted: which might have formed the to contribute to the on-going debates about how pre-existing local community contexts may serve to enable or hinder the success of HIV/AIDS management programmes. Using the concept of the 'AIDS competent community', we present a study of local community responses to HIV/AIDS in Kumahuswa, a rural Zimbabwean community which was one of several sites of an HIV-prevention programme -run by a partnership between two local non-governmental organisations and the Zimbawean ministry of health, using state-of-the art community and clinic based activities. After three years of combined community-based peer education, free condom distribution and improved clinic-based STI treatment and counselling services, there were no reductions in HIV-incidence or health-related risk behaviours in the target population of six intervention communities, of which Kumahuswa was one, compared to six matched control communities(Gregson et al., 2007) Most health and social development programme evaluations focus on technical reasons for programme success or failure, looking at different aspects of the design and implementation of health and social development programmes. These include factors such as the cultural relevance of programme messages, the efficiency and effectiveness of programme management, the extent to which communities are adequately consulted in programme design and so on. However,Pawson and Tilley (1997) argue that the success of health promotion programmes depends as much on the wider community contexts into which programmes are inserted, as on the technical details of the programmes themselves. This insight is summarised in their formula 'programme + context = outcome'. Against this background, this paper makes no comment on the HIV-prevention programme in Kumahuswa itself, rather seeking to raise questions about ways in which the wider preexisting social context might have framed the conditions in which the intervention was implemented.

  politely in the street, assisting an affected family with housework and so on.

  To what extent were these features of AIDS competence present in Kumahuswa? ¶ ¶ Deleted: ¶ Deleted: The local community is characterised by a high degree of political unity. The case study took the form of interviews with 44 individuals, 11 focus groups involving 55 people, and fieldworker diaries recording observations of the data collection process, conducted whilst the intervention was in progress. The goal of the case study was to generate information about local understandings of HIV/AIDS in Kumahuswa, drawing on interviews and focus groups with a wide range of local residents. It was against this background that we sought to interview a wide range of people living or working in Kumahuswa, drawing from those groupings whose views and actions might impact on the lives, health and sexuality of local people. These included teachers, local health volunteers, traditional leaders, representatives of local community organisations (e.g. women's and youth groups), NGO staff, school pupils, out of school youth, peer educators in and out of school, traditional healers, clinic nurses, parents, people living with HIV/AIDS, church ministers and local government officials. Interviews were conducted by the first author, an experienced Shona-speaking social scientist who had grown up in the adjacent province so was familiar with local conditions and customs. She was introduced to potential informants through a 'village guide', a local resident who had a long association with the Kumahuswa intervention. Very few of those approached refused to participate. The Kumahuswa intervention had been highly regarded by local residents, who were thus motivated to support the evaluation research. An added incentive was the T-shirt or soap which were given to research participants, much appreciated in conditions of great poverty.

  copying western culture.(Methodist pastor, man, 32) Many people appeared to have a strong gut-level resistance to change. Our case study gave the impression of a conservative semi-rural setting where many resisted innovation:Married people don't use condoms because they are not used to them.(Home based club, elderly women, focus group) I have never used condoms because I was not brought up knowing about them. (Garden co-operative, mixed focus group)

  she'd come to this. (Carer of person living with HIV/AIDS)People with HIV are immoral and they are heathens, these people have been promiscuous, therefore it is only right and proper that the health clinics treat them badly. (Church elder, male, 55) Acts of kindness were often committed in secret, either behind the socially desirable mask of public anti-AIDS talk, or under the guise of helping 'the sick' rather than naming AIDS as the issue. There was no context in which caring or assistance could add up to a more powerful collective response, given their highly secretive and individual nature.

  final component of AIDS competence relates to the existence of empowering links with outside organisations capable of assisting local people to respond more effectively to HIV/AIDS. The wider context of our research is an interest in the possibility of facilitating local responses to AIDS, and our belief that the current practice of 'interventions by outside professionals' may potentially undermine local coping mechanisms, and to reduce the development of effective grassroots AIDS leadership.

  for highlighting six overlapping factors which might have undermined the sense of HIV/AIDS related empowerment in Kumahuswa. People had relatively high levels of HIV/AIDS related knowledge, but gender, poverty and low levels of literacy might have undermined the perceived relevance of this knowledge to their own lives. Lack of opportunities for dialogue in the social intervention may have meant that people had few opportunities for translating factual knowledge into action plans, or of sharing their hidden individual experiences of HIV/AIDS related family members or friends in the interests of feeding these individual experiences into a wider social acknowledgement of the extent of the problem in Kumahuswa. The initiative and energy of women and young people, potentially a vital resource for an effective community response to AIDS were hindered in a social context dominated by adult males. In such a context, many people responded to HIV/AIDS in a passive and fatalistic way, waiting for outsiders (NGOs, government) to come and solve the problem for them. This tendency may have been exacerbated by the community's earler experiences of particular HIV/AIDS-related NGOs, some of which may have tended to treat local people as sources of unpaid volunteer labour rather than building their capacity to make significant decisions and play leadership roles in externally imposed health and social development programmes.Despite these potential obstacles to local peoples' receptiveness to the Kumahuswa HIV-prevention programme, in many respects our snapshot of Kumahuswa social relations was not an overwhelmingly bleak one. There were many potential strengths and resources in the community: people did have high levels of HIV/AIDS related knowledge, despite the existence of potential obstacles to actioning this. Beneath high levels of public denial of HIV/AIDS, there was evidence of huge reservoirs of support and kindness shown by individuals to AIDS-affected friends and family members, albeit often offered clandestinely, given high levels of HIV/AIDS related stigma amongst some local residents. The community was home to many well networked community organisations, which many local clubs and organisations that might have formed the springboard for a more empowered and positive attitude to HIV/AIDS. There is an urgent need for HIV/AIDS programmers to develop greater understandings of their target communities, along two dimensions. First in relation to potential contextual obstacles to the success of their programmes -much remains to be learned about how such obstacles can be identified and anticipated by interventions. Secondly in relation to identifying and mobilising the social assets that exist in such in conditions of great poverty and gender in equality. To date the efforts of many programmes have focused on the technical details of programme design, implementation/ management and evaluation. There is an urgent need to cast the spotlight more broadly to look at wider dimensions of pre-existing AIDS competence in target communities, in the interests of thinking best how to optimise 'community readiness' to make optimal use of programme efforts in highly marginalised settings.

  ac.uk Sent: Wed 09/06/2010 09:48 To: Campbell,C Subject: AIDS Care -Decision on Manuscript ID AC-2010-03-0163 09-Jun-2010 Manuscript ID AC-2010-03-0163, word count 4647 entitled "Community Mobilisation Special Issue -Contextual determinants of HIV prevention programme outcomes: Obstacles to local-level AIDS competence in rural Zimbabwe" which you submitted to AIDS Care, has been reviewed.

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  It would help the reader to consider the arguments made if they could have a sense of what the programme entailed and what the outcome was. : In this regard I was left with a number of questions: Have addressed these issues as detailed below What was the nature of the prevention programme? Have stated this in the first paragraph: combined community-based peer education, free condom distribution and improved clinic-based STI treatment and counselling services, What was its duration? Have stated in first paragraph: 3 years Who provided the programme? Have stated in first paragraph: 2 local NGOs and Zimb Ministry of Health Was it in the context of a research project (the authors refer to Gregson et al)? It was an intervention, evaluated by Gregson et al. How were the outcomes measured, and what were the outcomes? It will help the reader to have a sense of how there was little change in behaviour and sexual health, other than just the statement of such by the authors. Have stated in first paragraph -no reductions in HIV-incidence or health-related risk behaviours

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  Morten please can you add the final reference to the PLos Medicine paper in the reference list, and also add the link so that readers can access it immediately.

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Ownership of the problem of HIV/AIDS

	Young people also tended to be discounted as a positive community
	resource, often described as 'lazy' and 'incompetent'. In turn, young people
	said adult domination stifled any attempts they made to show initiative:
	We can't do anything because we don't have the resources and we
	always have to appoint older people to lead us because we are
	regarded as minors. This has demoralised a lot of young people.
	(Political youth group, focus group) F We approached our councillor to help us raise some funds for a soccer o r ball. He said he would look into it, but nothing happened. We couldn't
	go back and ask again, because that would have seemed P e disrespectful. (Soccer club leader, man, 31)
	e r
	R To what extent do Kumahuswa residents think they have a role in addressing
	e HIV/AIDS? To what extent do they have ideas for actions they might take as
	individuals, in groups, or through building links with outsiders? Many of our v i informants had little sense of ownership of the problem, with repeated e w reference to the need for outsiders to come and address it:
	O n l
	y
	They just come home without even carrying a parcel. They are the
	stresses in our lives. (Leader of women's savings club)

Come and educate children about their sexual rights, we have too many cases of child abuse. (Garden Cooperative, mixed, focus group)

	I suggest you call a workshop for men to talk to them about what we
	are saying, perhaps if you talk to them, they will realise the importance
	of condom use. (Women's Savings Club, focus group)
	We are stressed. These are the problems we encounter, can you
	please help us? We don't know what to do. (Women's church group,
	focus group)
	F There were many local organisations and clubs in Kumahuswa. These included a soccer club, a savings club, a traditional dance group, a garden co-o r operative, a political youth club, an Apostolic women's group, a beekeeping
	society and a burial society. There was also a government sponsored Ward P AIDS Action Committee (WAAC) dispensing government funding for local e r e AIDS activities, and a home-based care club.
	R
	e
	v i e
	w
	People take it as stigma if you use gloves while you are nursing them, O n l
	please come back and educate them. (Village Health Worker, woman, y
	39)
	You people from AIDS organisations should come here and talk to our
	children. Perhaps if you talk to them they will be scared of AIDS. (Bee-
	keeping Collective, mixed, focus group)

  and educate children about their sexual rights, we have too many cases of child abuse.(Garden Cooperative, mixed, focus group)

	People take it as stigma if you use gloves while you are nursing them,
	please come back and educate them. (Village Health Worker, woman,
	39)
	You people from AIDS organisations should come here and talk to our
	children. Perhaps if you talk to them they will be scared of AIDS. (Bee-
	keeping Collective, mixed, focus group)
	I suggest you call a workshop for men to talk to them about what we	Formatted: Highlight Deleted: generally
	are saying, perhaps if you talk to them, they will realise the importance F of condom use. (Women's Savings Club, focus group) o r We are stressed. These are the problems we encounter, can you
	please help us? We don't know what to do. (Women's church group, P focus group)
	e
	e r
	R
	e
	v i e
	w
	O n l	Formatted: Highlight Formatted: Highlight Deleted: was no
	y

http://mc.manuscriptcentral.com/ac-phm-vcy Health Sciences

Acknowledgements

Grateful thanks to Andy Gibbs for assistance in preparing the manuscript and for conducting background research; to Morten Skovdal for editorial support, and to the Wellcome Trust for providing funding for the study.

Acknowledgements

Grateful thanks to Andy Gibbs for assistance in preparing the manuscript and for conducting background research; to Morten Skovdal for editorial support, and to the Wellcome Trust for providing funding for the study.