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The Potential of Sport as anImplementation Tool for the Development of Health Education Outreach in South Africa

Tyler Spencer
University of Virginia

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Introduction to the Framework and Topic

According to most Western indicators of economic, social, and cultural achievement, the vast majority of African countries remain firmly rooted at the base of the world order of states (Sachs, 2005). The continent is home to 32 of the 38 states worldwide that are classified as heavily indebted countries by the IMF-World Bank, and 50% of Africans live on less than $1 per day (Cobb, 2005). Recent social science research suggests a direct link between poverty and HIV/AIDS. At the end of 2004, 39.4 million adults and children were living with HIV/AIDS worldwide, but more than 60% of all HIV positive cases were in Africa South of the Sahara, where 17 million persons have died from AIDS and 23.4-28.4 million persons are living with HIV (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2004). The virus is spreading through the African population at alarming rates. HIV prevalence among pregnant women, for instance, has risen to between 15% and 30% in some provinces of South Africa alone (World Health Organization [WHO], 2004; Murray and Lopez, 1996).

In the global sports arena, Africa has begun to make its presence felt. At the February 2007 Health, Sciences, and Sport Conference at Ohio University, several leaders of non-governmental organizations (NGOs) across the continent explored the role that sport has the potential to play in improving both of the aforementioned groups of statistics (HIV/AIDS prevalence and poverty, in turn) .(1) Attempted linkages between sport, development, and health have not been made easily, as many people criticize attempts to put sport, a symbol often associated with leisure and luxury, as a top priority in countries whose people struggle often just to survive to see a new day. Undoubtedly, there will be challenges posed to these projects, as changing people’s health behaviors and addressing cultural beliefs have always been tough obstacles in prevention. The fact that sport-for-development groups must overcome these challenges is only further complicated by the inherent difficulty of attempting change through the seemingly abstract vehicle of sport.

This paper will explore the political and cultural backdrop to the state of HIV/AIDS in Africa and the potential for sport as a tool for development. I will begin with an introduction to HIV/AIDS and an overview of the status of the disease in Africa. I will then explore sport and behavior change models of prevention, and finally I will outline the need for evidence-based practice in this field. South Africa is chosen as a specific case due to high prevalence of both the disease and the popularity of soccer within the country.

HIV/AIDS, Disease Information

HIV (Human Immunodeficiency Virus) is a virus that causes AIDS (Acquired Immunodeficiency Syndrome), a health condition in which a person is affected by a series of diseases because of poor immunity. HIV by itself is not an illness and does not instantly lead to AIDS. In fact, a person infected with HIV can lead a healthy life for several years before developing AIDS, and some infected persons never develop full-blown AIDS. The virus is spread by sexual contact with an infected person, by sharing needles and/or syringes (primarily for drug injection) with someone who is infected, or, less commonly (and now very rarely in countries where blood is screened for HIV antibodies), through transfusions of infected blood or blood clotting factors. Babies born to HIV-infected women may also become infected before or during birth, or through breast-feeding after birth. However, the most common way that HIV is spread in Africa South of the Sahara is through unprotected sex. (2) There is no known vaccine against HIV, and there is no known cure for those infected.

The Wide-Reaching Impact of HIV/AIDS in Africa South of the Sahara

As stated in the introduction, Africa is the continent most affected by AIDS, and nowhere are the circumstances as dire as in Africa South of the Sahara (Figure 1). More than 15% of South Africans—about 5 million people—carry the virus, and experts say the disease is spreading faster there than anywhere else on earth (Carnell, 2000).

Adult HIV/AIDS rates in Africa UNAIDS 2004

Figure 1: Adult HIV/AIDS rates in Africa (UNAIDS, 2004)

Young people continue to bear the brunt of the global HIV/AIDS epidemic in Africa. Africa South of the Sahara, in fact, is home to the majority (62%) of young people worldwide living with HIV/AIDS (Figure 2). A recent, nationally representative household survey of youth in South Africa found that prevalence was as high as 10.2% among 15 to 24 year-old cohort (RHRU, 2004).

Figure 2: Young people, ages 15-24, living with HIV/AIDS, by region, end of 2003 (UNAIDS, 2004)
Figure 2: Young people, ages 15-24, living with HIV/AIDS, by region, end of 2003 (UNAIDS, 2004)

While HIV/AIDS clearly affects a large proportion of youth in Africa, its impact is not limited to the 15 to 24 year-old cohort. On its current trajectory, by 2010 the disease will decrease overall life expectancy on the continent to levels found at the beginning of the last century, and the most recent data far surpass the most pessimistic predictions about the effects of the disease in Africa made just 13 years ago (Murray and Lopez, 1996). In 1997, Gregson, et al. created a model that aimed to predict various impacts of HIV/AIDS on life expectancy, based on a range of estimates (Figure 3).

Figure 3: Life expectancy estimates for South Africa as calculated by various models. High, medium, and low impact data are based on respective estimates of hospital costs (Gregson, et al., 1997).

Figure 3: Life expectancy estimates for South Africa as calculated by various models. High, medium, and low impact data are based on respective estimates of hospital costs (Gregson, et al., 1997).

Gregson, et al.’s model predicted that, from 1990 to 2010, life expectancy would decrease by 45% under a high impact scenario, by 31% under a medium impact scenario, and by 22% in a low impact scenario. Census data supported this information, estimating that life expectancy would decrease from 67.9 years to 47.8 by the year 2010 (U.S. Census, 1998).

When large proportions of the population are affected by the disease, the extent of its impact extends from the sector of medicine into that of the economy. New reports are beginning to describe this fuller picture of the African HIV/AIDS tragedy. As stated in the introduction, a positive feedback loop seems to exist between increasing HIV infection, AIDS cases, and an increased burden of poverty in Africa. One study (UNAIDS, 2004) found that HIV-induced declines in gross domestic product (GDP) levels in Africa South of the Sahara were severely undermining poverty reduction efforts in developing countries. According to the report, the pandemic is reducing annual economic growth by up to 2% in the worst affected countries. It also estimated that some countries will see their gross national product (GNP) shrink by up to 40% within 20 years. The study suggested that, on the whole, Africa’s income growth per capita is being reduced by about 0.7% per year as a direct result of HIV/AIDS. Another study concluded that by 2010, per capita income in South Africa, Africa’s most robust economy, will drop by 7-10% while the GDP will be 17% lower than it would have been without AIDS (Lewis and Arndt, 2000). Broomberg et al. (1993) added support to this linkage by estimating the total direct costs due to HIV/AIDS from 1991 through the year 2000, using two different scenarios (Figure 4)

Figure 4: Estimated direct costs of HIV/AIDS to the South African economy, calculated as percentages of the gross national product (GNP), under various models (Broomberg et al., 1993).

Figure 4: Estimated direct costs of HIV/AIDS to the South African economy, calculated as percentages of the gross national product (GNP), under various models (Broomberg et al., 1993).

In the low scenario and using low hospital costs, they predicted the costs to rise from $21.5 million in 1991 to $1.2 billion in 2000, while in the high scenario and using high hospital costs, the predicted rise was from $32 million to $2.9 billion. This translates into an increase from 0.5% of total health expenditure in 1991 to 34% in 2005 for the low scenario, and from 0.8% in 1991 to 75% of total health expenditure in 2005 for the high scenario. Total direct costs of HIV/AIDS reach 3.6% of current GNP by 2005 for the low scenario, and 8% of current GNP by 2005 for the high scenario (Broomberg et. al, 1993).

While the disease has taken a notable direct toll on the economy, there are also enormous indirect costs, including losses in the labor force (e.g., loss of human capital). The indirect costs, based on assumptions about lost earning per worker, indicate that total lost work years may have decreased by between 20 and 35% over the period of 1991-2000 (Broomberg, et al., 1993; Lewis and Arndt, 2001). For this reason and this reason alone, one might logically expect that the government of South Africa would be doing everything within its means to combat the disease.

A Poor Response from South Africa

Other factors compounding the impact of the epidemic on the African continent over the past decade include the failure of many leaders to acknowledge the problem and take decisive (and not divisive) action to stop its spread. The vital importance of such leadership is demonstrated by cases where authorities have responded to the

South Africa’s President Thabo Mbeki at the International AIDS Conference in Durban (Carnell, 2000).

South Africa’s President Thabo Mbeki at the International AIDS Conference in Durban (Carnell, 2000).

challenge - for example in Uganda, Thailand, and Brazil - and significantly reduced the infection rates. Yet, in some of the worst affected areas, such as in South Africa, Zimbabwe, and Kenya, Presidents Mbeki, Mugabe, and Moi have been hesitant to even accept the link between the HIV virus and AIDS, let alone to promote preventive measures against it.

In his September 20, 2000 address to the South African Parliament, South Africa’s President Thabo Mbeki publicly questioned how a virus could cause a syndrome and concluded that it cannot. A year later, Health Minister Manto Tshabalala-Msimang told a news conference that she had never denied a link, but refused to state that HIV caused AIDS. (3) Internationally, scientists say that the link between the virus and AIDS is well-established by robust research, but only one South African minister from the ruling African National Congress (ANC) party, Membathisi Mdladlana, has strayed from the government line by stating publicly that HIV causes AIDS.

Many activists believe that this denial, coupled with weak political leadership, has severely hampered the response to HIV in South Africa. The effects of a failure by macro-level politics are apparent both in terms of treatment and prevention. While 983,000 South Africans need ARV drugs to prevent progression of the illness and death, only 117,000 are receiving medication (UNAIDS, 2004). As an example of failure on the preventative end, President Mbeki’s government has been very slow to begin providing nevirapine and other drugs to help prevent mother-to-child transmission (MTCT) of the virus. In 2005, only around 14.6% of pregnant women with HIV received preventative treatment, according to UNAIDS (though the government’s own estimate is much higher). While this rate is typical for an African country, it is surprisingly low given South Africa’s relative wealth and resources.

Scores of academics have come to the conclusion that this sub-standard response to the HIV/AIDS pandemic stems from a looming sense of denial not only over the relationship of HIV, the virus, to AIDS, the syndrome, but also denial that the disease is even a real problem in the country. (4) Public health experts say that denying the link between the virus and the illness may dilute the message to HIV-positive people that they should take precautions to avoid spreading the virus through sexual intercourse (Carnell, 2000).

Resorting to Treatment and Prevention

Because there is no vaccine against HIV and no cure for HIV/AIDS, and because treatment (typically done through antiretroviral drugs [ARVs]) programs has traditionally been especially difficult in impoverished states,(5) prevention has become paramount in stopping the spread of the disease. The discourse about priorities in treatment and prevention, however, is still taking shape. Because most new infections in Africa occur during unprotected heterosexual sex, the main goal in HIV prevention is to persuade people to change their sexual behavior- to delay first sex, to decrease casual relationships, and to increase condom use. This is always a difficult task, and in Africa it is made harder by poverty, lack of resources, weak infrastructure, and strong cultural taboos associated with talk about sex. To make matters even more complex, only about one in ten Africans has been tested for HIV and knows whether or not they are infected; misconceptions about transmission routes are widespread; and access to condoms is very low (World Bank, 1997).

Several mainstream theories exist among scholars dealing with health promotion and disease prevention.

If you wish to help a community improve its health, you must learn to think like the people of that community. Before asking a group of people to assume new health habits, it is wise to ascertain the existing habits, how these habits are linked to one another, what functions they perform, and what they mean to those who practice them. (Paul, 1955)

In responding to the priorities presented by Paul (1955), researchers have posed several different theories and models. The health belief model suggests that decision-making about health behaviors is influenced by four basic premises—perceived susceptibility to illness, perceived severity of illness, perceived benefits of prevention behavior, and perceived barriers to that behavior—as well as other variables, such as socio-demographic factors (Rosenstock et al., 1974). The theory of reasoned action (Ajzen and Fishbein, 1972) predicts an individual’s intention to engage in a behavior in a specific time and place. The theory is intended to explain virtually all behaviors over which people have the ability to exert self-control. There are five basic constructs that precede the performance of a behavior. There are behavioral intents, attitudes, beliefs, and evaluation of behavioral outcomes, subjective norms, and normative beliefs. Behavioral intent is seen as the immediate predictor of behavior, and factors that influence behavioral choices are mediated through this variable. In order to maximize the predictive ability of an intention to perform a specific behavior, the measurement of the intent must closely reflect the measurement of the behavior.

The diffusion of health innovations model proposes that communication is essential

Figure 6: An ABC HIV/AIDS prevention campaign ad (Population Action International, 2007).

Figure 6: An ABC HIV/AIDS prevention campaign ad (Population Action International, 2007).

for social change; diffusion is the process by which an innovation is communicated through certain channels over time and among members of a social system (Rogers, 1983). Figure 6 shows just one example of a communication campaign, “ABC,” that has been launched across Africa. Green, Kreuter, Deeds, and Partridge (1980) first proposed the PRECEDE model of health promotion. PRECEDE is an acronym for “predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation.” This model focuses on communities rather than individuals as the primary units of change. The theory of self-efficacy has proved useful in addressing AIDS (Merson et al., 2006). For example, one study in South Africa found that knowledge of risk and its prevention was important, but not sufficient. The authors stressed the need to improve personal autonomy in decision making about sexual behavior and condom use for both men and women through development programs that promote self-efficacy. These approaches all incorporate specific recommendations for evaluating the effectiveness of interventions and providing a highly focused target for the intervention. Explanatory models are seen as dynamic, and can change based on individual experience with health, health information, and with new discoveries about the illness in question.

A number of other theories can be useful in looking at culture and behavior, as health and illness inherently stem from individual experiences and perceptions that are shaped by cultural forces. A 16-country study of community perceptions of health, illness, and primary health care found that in all 42 communities studied, people used both the Western biomedical system and traditional practices, including indigenous practitioners (Scrimshaw, 1974). Also, there were discrepancies between services the governmental agencies said existed in the community and what was really available. Because of positive experiences with alternative healing systems and shortcomings in the Western biomedical system, people relied on both. Scrimshaw showed that health programs that fail to recognize and work with indigenous beliefs and practices also fail to reach their goals. Similarly, research to plan and evaluate health programs must take cultural beliefs and behaviors into account if researchers expect to understand why programs are not working and what can be done to make improvements. Cultural acceptance, knowledge, and sensitivity will be crucial to the implementation and success of sport for HIV prevention programs.

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Tyler Spencer Bio

Tyler Spencer is a graduate of the University of Virginia (2008) with degrees in International Health and Development and Environmental Sciences. His undergraduate studies focused on issues of health promotion and environmental protection in the global South. Under Professors Hanan Sabea, Rebecca Dillingham, Robert Swap, PhD candidate Clare Terni, and several professors from Georgetown’s School of Foreign Service, he wrote this paper as part of his undergraduate thesis. After being involved as a trip founder with the organization Bike and Build and working on several student-athlete outreach programs, he became interested in better understanding the efficacy of sport initiatives in building successful social and political interventions. He spent two summers in South Africa helping to implement an intervention of Grassroot Soccer, an international NGO that supports soccer-based HIV prevention education programs in sub-Saharan Africa and aims to “use the power of soccer to fight AIDS.” His academic focus stems from a personal reflection on the positive social assets provided by his participation in college athletics along with observations of the absence of this type of social infrastructure in communities he had previously visited in South Africa. Combining service work with evaluative research is a passion he hopes to pursue in his future. How can we bring legitimacy to programs that incorporate sport in development projects, especially in countries where increasing leisure opportunities falls far below more pressing needs such as securing basic health? His goal is to continue work in public service but to always question how we can “make it better.”

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