Health Promotion: Is It Health Empowerment? Lessons learnt from Cuba

This case study of a sexually transmitted infections (STIs) and HIV/AIDS project in Central Cuba (Provinces of Sancti Spiritus and Santa Clara), implemented between 2002 and 2006 by the Italian non-governmental organisation (NGO) GVC, aims to analyse the project using the theoretical model of empowerment of Keith Tones. It includes a description of the social and political environment, a review of the empowerment model, and an evaluation of the main actions of the project. Health promotion activities were especially focused on men having sex with men (MSM).

Briefly, the environment in the provinces, as stated here, includes stigma and discrimination against MSM who are in the peak percentile of HIV/AIDS infection of men in Latin America. The author found discrimination against MSM in the health service as shown by a report that between the 30% and the 40% of general practitioners and family nurses won’t accept a homosexual as their apartment mate, and 20% consider sexual orientation as part of the health status of the person and would try to “correct” deviant behaviour in his/her patient. Disempowerment is described in the study as enacted through the placement of MSM in a sanatorium system during the special period in Cuba (a time of economic hardship in the 1990's after the collapse of the Soviet Union and during the United States embargo) and through a social and political climate of discrimination in which MSM could be arbitrarily arrested and held before release without charge.

This document seeks to analyse the health promotion programme of GVC through using Tones model for empowerment, represented here as: health promotion = health education x healthy public policies. The author describes health education as input - not only information on unsafe sex, but also empowerment to choose (i.e., behaviour change or self-efficacy) - and policy advocacy as output - in the case of this project, the ability to work towards influencing community-level decisionmaking in the political arena for the benefit of others.

The project is described as strengthening capacity in the local health promotion centres through educational trainings and trainings of trainers and production and dissemination of materials through major media. In practice, the project established a 24-hour help hotline, coupled with pre- and post-test counselling services. Peer education was established for reaching groups who were more difficult to approach, particularly MSM subgroups like transvestites and commercial sex workers (CSW). Volunteers, including students completing university psychology degrees, were given workshops to improve skills and exchange experiences with others and were, as reported here, crucial to removing barriers to behaviour change.

The project ideal was to mobilise volunteers, people living with HIV/AIDS (PLWHA), and MSM "to balance the national directives from Havana with an independent response from the Sancti Spiritus and the Central Provinces..." so that volunteers, PLWHA, and MSM "... could participate in the local arena as decision-makers."

According to the author, a "sea change" in the political environment between Cuba and donor nations resulted in the need to "soften" the mobilisation, resulting in the non-implementation of that part of the project. "The project failed in removing the structural factors of the top-down approach to health relating to the political element." In conclusion, the author states: "Health promotion activities are not implemented in an aseptic vacuum, but they are tamed by the political and social milieu of intervention. This must be taken into consideration when designing and implementing a health promotion project."

This document may be requested from the author as an MS Word document by email (see contact information below).