University of Stellenbosch








HIV/AIDS ALIENATION:
BETWEEN PREJUDICE AND ACCEPTANCE


Chapter 6
The Nkhotakota Case Study and Subsequent Project Development











JANET L. BROWN

Dissertation presented for the Degree of Doctor of Theology
At the University of Stellenbosch







Promoter:  Professor H. JURGENS HENDRIKS

April 2004

Chapter 6 The Nkhotakota Case Study And Subsequent Project Development	184
6	INTRODUCTION	184
6.2	INITIAL STEPS - THE NKHOTAKOTA HOME BASED CARE PROJECT	184
6.2.1	Case Study:  Home Based Care at Chididi Baptist Church	189
6.2.2	Initial Steps - Formulation of ideas	192
6.3	OVERVIEW OF VISION FOR HBC	193
6.3.1	Funding Alternatives	193
6.3.2	Village Permission	194
6.3.3	Needs assessment (including Quantitative Approach Survey)	194
6.3.4	Development of working Grounded Theory	200
6.3.5	Defining criteria for recipients of care	201
6.3.6	Who will be involved in HBC (staffing)	202
6.3.7	Training for HBC volunteers	203
6.3.8	Home Based Care Curriculum Development	204
6.3.9	Selection of Volunteers	206
6.3.10	Tentative time frame / scheduling	209
6.3.11	Ownership of Home Based Care program - Issues in Development	211
6.4	TRAINING COMPLETED - MOVING FORWARD	213
6.5	ASSESSMENT	213
6.5.1	Assessment:  Need for Goals Clarification	213
6.5.2	Assessment:  Paperwork Challenges	214
6.5.3	Assessment: Hunger crisis	215
6.6	SECOND TRAINING CLASS USING DIFFERENT MODEL	216
6.7	DAY TO DAY PROCEDURES	217
6.8	ABC STUDENT VOLUNTEERS	218
6.9	ADDITIONAL TRAINING CLASSES	220
6.10	KANING'A CCAP METHODOLOGY	220
6.11	SEVEN MONTH ASSESSMENT AT CHIMBALAME	221
6.12	ONE YEAR REVIEW AND EVALUATION	221
6.13	TRUSTWORTHINESS OF QUALITATIVE RESEARCH	225
6.14	OVERALL SUMMARY OF METHODOLOGY	226

Chapter 6
The Nkhotakota Case Study
And Subsequent Project Development


6	INTRODUCTION
Although divided by chapters for reference and organizational purposes, the methodological procedures involved in the actual 'doing' of the study have been interwoven into all aspects of this project.  In the first chapter, the general problem of the church's negative response to the HIV/AIDS pandemic and the consequential alienation, estrangement and prejudice that became associated with it was identified, using various sampling techniques including interviews and surveys.  Before any of the data collection and processing could begin, it was essential to first discover the minutiae surrounding the problem.  To better understand all of the nuances involved, it was imperative that the broader picture be assessed.  Within this framework, the historical perspectives of the church were evaluated and integrated into the development of the total image as the problem was examined.  From this data, more information was compiled regarding specific traditions and cultural gradations specific to the African paradigm.  With the picture of the African perspective thus identified, focus was then addressed to the more specific issues within the communities that were actually involved in this study.  Just as there are no simple answers to the HIV/AIDS problem, even the questions themselves can be multifaceted and complex.  This brought the study to the next logical step, that of determining the theological implications relating to the problem under study which were discussed in the previous chapters.
This chapter will reconsider the entire project, outlining the methodology and rationale taken in order to ascertain precisely the data to be collected for systematic evaluation and interpretation.  Once gathered, the resulting data will be analysed and interpreted in the final chapter. 

6.2	INITIAL STEPS - THE NKHOTAKOTA HOME BASED CARE PROJECT
Before beginning the project, several fact-finding missions were carried out.  In an effort to determine what types of projects were already in process in the local area, as well as assessing the needs of the community, multiple interviews with various organizations and NGOs (Non-Governmental Organizations) were carried out utilizing a guided 'snowball' or chain reference sampling technique (De Vos 1998:254).   When the proposed ideas of this researcher were presented, and the 'snowball effect' had begun, theoretical sampling was then employed to direct its course. 
One of the main reasons for these initial interviews, other than for the obvious information gathering aspects, was to attempt the avoidance of the 'reinvention of the wheel' by first ascertaining what work was being done in relation to the proposed field of study.  Since qualitative research is not 'linear', meaning that one step automatically leads to the next, many of these preliminary fact finding interviews did not offer valuable information in themselves, but often instead lead this researcher to other sources of information that did prove useful to this study.  
One such interview that proved significant was with Stella Kasirye, the World Relief country representative for Malawi, and her associate Amos Chigwenembe.  They outlined the program they had begun in Nkhotakota, Malawi with HIV/AIDS affected people working from within the church.  From this initial interview it seemed apparent there was more that could be learned from the program in Nkhotakota.  Therefore in order to gain a holistic understanding of the interconnected networks within the HIV/AIDS subculture in the Nkhotakota district, the research began with systematic enquiry to access and review records, and other written data from the World Relief Organization.   In conjunction with this analysis, open-ended interviewing, unstructured interviews with a schedule (De Vos 1998:300) processes were utilized with already identified informants within this organization who have intimate knowledge and understanding of the people and groups involved in the Nkhotakota project.  This allowed for the extraction of sufficient information to provide a basis for data collection and interview / relationship building at the case study site.
One of the fundamental attributes of this program was the approach of using the church as the foundation of the work, instead of building it upon the NGO.  By keeping the focus on the church and the work coming through the church, the potential for a continuing, viable program that the people involved could take ownership of emerged.  Research has shown (Dudley 1996:115) that churches who worked to develop ministries that were consistent with aspects of their own history, vision and mission, instead of seeking new programs which were very different and foreign to their already accepted procedures tended to have less radical and more predictable and satisfying outcomes. 
The steps followed by World Relief in the establishment of their program were as follows:
* A needs assessment survey was done in August 1999 to determine the needs of the community.  From this assessment, it was concluded that an outreach program designed specifically for those suffering from HIV/AIDS was needed. 
o Already in place was the cultural practice of opening of one's home to visiting members from the church, therefore proving access to those sick in the community by 'opening doors' that might not be otherwise available.
Selection of Churches:
* Once the felt-needs were established, they began to share with the churches the vision of what they called 'Resource Mobilization', issuing an open invitation to all community churches that might be interested in participating in the program.
* Twenty-six Churches responded to this initial appeal, but upon the realization that 'gifts' such as bicycles and blankets were not being distributed; the number of actual churches participating dropped to four.
Selection of Volunteers:
* The churches were asked to identify volunteers demonstrating a heart as well as availability to reach out to the sick and needy in their communities.
* They wanted to get a variety of different volunteers, from various socio-economic backgrounds.
* Volunteers had to be church members so that a church based foundation could be developed (as opposed to a community based program)
* The pastor from each participating church was asked to do two things:
1. To recruit ten volunteers (to be known as 'ministry team members') to do the actual visitation work
2. To identify five potential patients based upon the following criteria:
o Chronically ill, recent hospitalisation, on TB treatment, Outward appearance looks like HIV/AIDS (wasting, lethargy, etc.)
From these initial steps, the rudimentary formation of the Nkhotakota HBC developed.  After watching the development of the program and the change in the attitudes of the people, in December of 1999, one additional church came forward requesting the program in their church.  By December of 2000, there were a total of eight churches involved, and by December 2002, twenty-one additional churches were expressing interest in developing the program in their churches.  Due to an inability to properly supervise and undergird additional works, it was suggested that these churches partner with churches that were already participating in the program (Appendix A).
Because of the work previously done by World Relief, entry points into the Nkhotakota HIV/AIDS community were available with already established gatekeepers.  Although generalized permission had been previously granted, understanding the importance of developing and maintaining trust-based relationships to ensure cooperation and accurate information gathering, this researcher made certain that proper permission protocols were continually followed. 
Several meetings with the Nkhotakota group followed, both by this researcher with the accompaniment of the HBC ABC student volunteers, and later with established gatekeepers.  Following the initial entry into the group, a guided use of 'snowball' or chain reference sampling was again utilized, leading to theoretical sampling which was acknowledged to be an important way to gain access to all those individuals who will be able to contribute to the research.  Data collection began as suggested by De Vos, with ethnography and participant observation as a strategy to gain an understanding of the life worlds of the subjects.  Then, in order to gain a better understanding of the meaning that they have attached to their worlds, it was appropriate to switch to a phenomenological or ethnomethodological strategy and thus conduct in-depth interviewing with the various levels of subjects, (i.e. this included the actual patients suffering with HIV/AIDS with their families, the individual volunteers and support group facilitators, and church leaders).  Several patients were considered for the purposes of providing a case study (Appendix F) in order to provide an illustration of the needs of individuals and groups (De Vos 2001:80).  By continually collecting, recording and analysing data, a grounded theory began to emerge, which directed the course of further sources and opportunities for information exchange.
It was important to maintain the focus of the heart of the project directed towards the local church community in order to keep the mission of the project in focus.  This allows the faith community to have a more realistic ownership of the mission, which is supported by Dudley's article demonstrating the propensity for church members to be consistently more concerned with helping people in their own communities deal with the tangible problems they face, as opposed to involvement in the resolution of seemingly elusive problems of society (Dudley 1996:115). 
For the purposes of this research, one church, the Chididi Baptist Church, was selected as representative from those participating in the Nkhotakota study.  This church was chosen, not because it had better results or more respondents; but rather because it was the most typical representation of the whole of the group.  The following case study demonstrated the growth and development of the HBC program within the Chididi Baptist Church:  


6.2.1	Case Study:  Home Based Care at Chididi Baptist Church
Reverend Akiwa Chimsolo has been the pastor of Chididi Baptist Church, which is located in Mgombe 2 Village for the past 10 years.  It currently has a membership of 233.  In 1998/99, it was one of the churches that expressed an interest in the initial appeal to local churches to begin a HBC program.  Eight volunteers from this church were identified as interested and qualified to begin visiting the sick.  By the time the program had been in existence two years, there were approximately fifty volunteers, and the following year (2001-2002 the present time) this number rose to one hundred volunteers who are visiting the sick in their community.
The church developed a committee specifically for the visitation work with Rev. Chimsolo as the chairman.  Primarily those who are participating on the committee and the youth do visitation.  Comments were made during the interviewing process that the youth are doing a commendable job in their participation and involvement in the HIV ministry.
Attitudes present in the church prior to the beginning of the HBC program1:
* 5-6 years ago people (children, as well as adults) would laugh at people afflicted with HIV/AIDS, commenting that 'it is your own fault', 'you were negligent', etc.  They would not associate with them.
* HIV positive people had many needs.  In addition to basic physical needs, they were found to be lacking basic human needs such as fellowship with God, thinking that God didn't love them.
* Orphans left by the devastation of HIV/AIDS were sometimes ill-treated.
* Approximately 75% of those in the church shared these negative attitudes.
* Patients were afraid to go for testing or declare publicly their HIV status.
* The program initially started with 25 volunteers, but because of peer pressure and discouragement from the majority of the congregation, that number dropped to the initial eight volunteers.
* The following story about the late Abiti Ahamadi was told by Pastor Chimsolo as an illustration of people's attitudes prior to the development of the HBC program:
o Abiti Ahamadi was shunned by her family and forced to run away and live in the bush.  Her uncle softened in his harsh behaviour and began to look for her.  When he found her, he brought her to Chididi Baptist Church, where she received emergency shelter and provision, along with emotional and spiritual care.  Once her condition was stable, those in the church reached out to the family, providing them with loving acceptance, along with accurate information about HIV/AIDS and its effects.  In the end, the family reached out to Abiti Ahamadi in love, and they were able to provide compassionate care for her until her death.
Current attitudes held by the vast majority (approximately 95%) of the congregation:
* People suffering with HIV/AIDS are part of the church family and are embraced with love.
* People are accepting the fact that HIV is real.
* Some of the people most active in the antagonism against the program have now gone for testing.
* Some members of the church are going for testing, and sharing their positive test results with the church.
* Even the local chiefs receive AIDS Awareness Campaigns warmly.

According to Pastor Chimsolo, the dramatic attitude changes noted in the Chididi Baptist Church can be attributed to the following:
* Education and counselling about HIV/AIDS.
* Individuals with positive HIV declaring their status in public.
* At funerals people are now able to declare in public when a patient died of AIDS, contributing to a change in perception towards these patients by the community. 
* Items of relief (by World Relief, first as an example, and then by the volunteers themselves) that can be distributed to those in need which demonstrated love and kindness in a tangible way.
* The people's attitudes changed as they became more open and aware.  
It should be noted that each person interviewed concurred with the same comments that Rev. Chimsolo was an outstanding demonstration of Christ's love as he continually sought out those who were suffering and offered them love and hope as he not only invited them to join the fellowship group, but also provided counselling, physical assistance and transport as well as sharing his own personal resources with them when necessary.  It appears that he is willing to give and do anything for the cause of Christ.  Certainly it must be concluded that his excellent example has greatly contributed to the direction this church has taken in their fight against AIDS.2

From this initial program of visiting the sick and homebound in Nkhotakota, several other secondary programs have been developed.  Examples of these projects include an HIV/AIDS support group, home visitation by the HIV/AIDS members themselves to others in their groups who are suffering, garden planting and feeding projects, youth awareness programs, health education information sharing, etc.
Of these outcomes and perhaps the most significant, at least to those who are currently HIV positive, is the HIV/AIDS support group.   When visiting with these people, it was clearly the support group that they felt benefited them the most; ministering to them in such a way as to give them a constant source for encouragement and hope.  In addition, it gave their lives cause and purpose while providing them with an opportunity to lose their role as 'victim' and once again become a vibrant, contributing member of the group.  The formation of this support group has led to the group seeking creative ideas for I.G.A. (income generating activity) and land has been identified that team members/patients can use for food production as an I.G.A.
Through the mutual and ongoing support from this group, those infected by the virus were able to gain a sense of purpose and identity, thus giving them the courage to be more open and outspoken about their HIV status.  Members of this group have shared publicly in churches, schools and even on the radio about their personal journeys with HIV/AIDS, educating those hearing them and breaking down the walls of stigma and isolation caused by ignorance and fear.  This has helped to remove the shame and disgrace from this disease, giving others the courage to admit their own status, or that of their loved ones.
Another very important offshoot from the program has been the positive effect it has had on the youth.  The youth have become active participants in the visitation of the sick and have also sought creative ways of expression such as the use of drama and song, which prove to be a witness to others as well.  As the youth are exposed to the sick and dying, the horrors they have witnessed have served to provide a strong reality based message for them to avoid behaviours that contribute to such demise.  The church itself has seen a new vibrancy and sense of caring as its members join the efforts of the volunteers; and visiting the sick and needy becomes a church wide activity.
6.2.2	Initial Steps - Formulation of ideas
The Partners in Hope3 core group used the information gleaned from these interviews in consideration for determining the way forward for the HBC development.  This resulted in the formation of the Partners in Hope HBC Planning Committee (HBCPC), which included Dr. Perry Jansen, Mrs. Grace Banda (Appendix B) along with this researcher.  Sensing the growing and exorbitant need, and through the desire of their hearts to find a way of impacting this problem of HIV/AIDS in this part of the world, this group began meeting on a regular basis to determine the direction and vision of the concept of HBC in the local community.  While accumulating information from the various sources previously indicated, a grounded theory began to develop.  Some of the issues raised for discussion were:  
1. Overview of vision for HBC
2. Foundational / needs assessment
3. Village Permission
4. Funding alternatives
5. Defining criteria for recipients of care
6. Who will be involved in HBC (staffing)
7. Training for HBC volunteers
8. Tentative time frame / scheduling

6.3	OVERVIEW OF VISION FOR HBC
Initial attempts were begun towards the development of HBC, in the form of chaplainry (non-medical) visits, using ABC students as the visiting chaplains in conjunction with those churches that would express an openness and willingness to participate in the HBC program.  This would also be part of an outreach activity designed to meet the students' scholastic practical application requirement for ABC.  In these initial meetings, the vision was expanded to eventually include an eventual medical component.  With the proper funding, it was hoped that a full department of medical home care would be developed in conjunction with the ABC Community Clinic (ABCCC).  This will include the use of registered nurses and other medical staff who will work to meet the physical and spiritual needs of those suffering with illnesses that confine them to their homes.   
6.3.1	Funding Alternatives
Dr. Jansen submitted a proposal for funding, which would underwrite the total program cost, including medical personnel and vehicles (Appendix I).
In addition to this, a proposal was submitted to Second Presbyterian Church (Memphis, Tennessee, USA) Special Project Committee for funding for a special medications fund to provide basic medications such as analgesics and antibiotics for $1000.00 (USD).  It is anticipated that this will be enough to provide medicines for 1-2 years worth of HBC visits.
As the plan began to formulate and the vision began to emerge, it became clear that a grass roots level of church involvement was essential.  As ideas and options were explored, home care began to emerge as a promising entry point into this group of marginalized people.  Once awareness of the situation and possible solutions came under discussion, it became apparent that it was essential for this to be a program designed with a commitment to empower the local church as opposed to one that would be a source of gifts and supplies to be given to the churches.  With this as a priority, it was therefore determined that a program must be developed in order to avoid donor dependency, enabling it to be fully 'owned' by the local church, with only training and facilitation provided by an outside source.
6.3.2	Village Permission
In order for the project to proceed in a harmonious way, it was deemed necessary to obtain the permission and blessing of the Mtsiliza Village chief.   Due to lessons learned from past dealings with this chief, and in consideration of his opportunistic nature, it seemed good to assemble a small Malawian delegation to meet with him.  Prior to this meeting, a meeting of those delegates (Mrs. Grace Banda, Richard Chigwenembe ABCCC Chaplain/Lab Director, Rev. David Phiri, pastor of Chimbalame Assembly of God - which had previously indicated interest in their church participating in the program, and his associate and church treasurer, Thomas Mambo) took place to ascertain the best approach for the meeting with the chief.  From this meeting it was determined that the best approach would be to avoid any obvious connection with the ABCCC in an attempt to minimize the concept that this program was connected with resources which could be manipulated by the chief for his financial gain.  Throughout the formation of the program, and including these beginning meetings, it was emphasized that this was to be a 'grass roots' type of program which would empower the local church to mobilize itself in reaching out to the sick and dying in the community, not a Western backed program from which funds and material items could be extracted.
6.3.3	Needs assessment (including Quantitative Approach Survey)
In order to undertake a preliminary investigation of the target group prior to the more structured study, a randomised cross-sectional quantitative survey was developed (Appendix G), targeting the villages adjacent to the ABC campus collectively known as the Lingadzi4 area, to assess their perception of the attitudes of those in their community who are suffering with HIV/AIDS and their families as they view the Church.  The single-system design (De Vos1998:140) was used to specify the problem as well as establish a baseline for measurement of change as the researchers worked to ascertain the prevailing attitudes of those in the village as they perceive the attitudes of the Church towards those in the community suffering with HIV/AIDS.  This was done to assist in determining the needs of the community as well as for formulating the baseline of information for use as a comparison for studies and surveys in the future.  This information would also establish the baseline criteria necessary to determine the effectiveness of the program once it has had an opportunity to impact the target population.
The quantitative portion of this study was limited to the Lingadzi area and therefore did not including the Kaning'a area for the following reasons:
* Due to the poverty of Lingadzi (all of the people are restricted to pedestrian travel), the villages within this containment area were condensed into a more controlled locale that could be canvassed on foot.
* Kaning'a' level of affluence (the people are able to drive and travel greater distances) allowed for the distribution of their containment area to be much broader and less concentrated, which would have caused considerable difficulty in accurately assessing those influenced by this project.
* Although both groups were involved in this study, the major focus of this project involved the first class of HBC volunteers, with the second class (the Kaning'a group) being used primarily as a balance and model for comparison.  
Further research with quantitative studies of this group would be advisable but were not within the scope of this research.
Prior to beginning the survey, a working hypothesis had been developed to formulate the problem based upon discussions with clergy and individuals in the target area.  Based upon the information gleaned from the Nkhotakota project, it was extrapolated that similar problems would be also prevalent in the target community.  Elders of the community had previously come to the ABCCC voicing a need for Home Based Care, saying there was nothing of that nature in the area, and people were desperate for this type of service.
This assessment survey was done utilizing ABC students, interviewing those people who live in these villages.  These surveyors were selected based on several factors.  
* They were knowledgeable of the geographical areas in the targeted village and could make educated determinations regarding which areas would most typify the village as a whole, along with consideration of which areas were more isolated and therefore less likely to reflect an accurate picture of the villagers.  
* In addition to knowing the area, the surveyors were all Chichewa speakers (as their primary language) who had intimate knowledge of the Chewa culture and would be able to ask their questions with such sensitivity as to avoid offending the people who were being asked to participate in the study.  
* The surveyors also had to demonstrate a personal interest in the HIV/AIDS crisis and have an interest in the results of the study.  It was believed by this researcher that those with a heart for this type of work would be more likely to take the steps outlined to ensure an accurate and reliable survey.
The first step in developing this survey was to identify the research population as the Mtsiliza village and those small villages adjacent to it (known as the Lingadzi area), which would contain the people in the geographical area that would be involved, either as patients or volunteers in the HBC program.  Because of the large population of this area, it was determined that in order to get a representative cross section of individuals, the research assistants would canvas every fourth to fifth home.  People who were clustered in groups were to be avoided as an opportunity to gather information from many people at the same time, due to the fact that these groups would probably be less reliable in their accurate portrayal of individual feelings and attitudes.  Considering the strong influences of peer pressure that might be exerted by the individuals in the group, the reliability of truthful response might be diminished causing respondents to give answers that they thought might be more acceptable to the group, than actually reflecting their personal thoughts and ideas. 
In addition to an in-service meeting explaining the nature and purpose of the survey, a detailed instruction sheet was made for each surveyor with additional guidelines to ensure as unbiased outcome as possible (Appendix E).  Because of the anticipated high illiteracy rate of the subject communities, this informative meeting was designed to take the place of the covering letter explaining the survey, which De Vos described as an 'integral part of any questionnaire (201:157)'.   Once this researcher was satisfied that each field worker had an accurate grasp of the vision and mission of this project, they were then released in eight teams of two in order to accomplish this task.
It was decided that the survey must be completed prior to the time when the Partners in Hope HBC Volunteers would be trained and beginning to make visits in the community, the surveyors were accordingly instructed in the time frame requirements for the completion of the survey.   No attempt was made for mailing the surveys or relating to the individuals in the community in any other way.  This was because for the purposes of this survey, the target group is made up of people on the lower echelon of society, with a high rate of illiteracy, therefore causing an oral communication style in their native language of Chichewa to be the best alternative for an accurate attempt of communication.  The number of respondents finally included in the needs assessment survey totalled 4245 individuals.  Of these individuals who participated in the survey, the following breakdowns were noted.

Age Level of Respondents:
15-20
21-30
31-40
41-50
51+
97
117
107
61
36

Educational Level of Respondents:
Primary School
Secondary School
College
Trade School
Other
222
100
15 (questionable)
54
25

Religious Beliefs:
Christian
Muslim
African Traditional
None
Other
330
66
9
21
25

Of those who considered themselves Christian:
CCAP
Assembly of God
Roman Catholic
New Apostolic
Anglican
63
5
104
1
26

Zambezi Evangelical
Abraham Church
Baptist
Church of Christ
7 Day Adventist
7
2
5
16
38

African Chipangano
Lutheran
Other
21
1
28

Those that believe HIV/AIDS has affected their immediate family:
Yes
No
Uncertain
178
151
92

Efforts were made to reduce the tendency of individuals to answer according to what they considered to be the expected norm by encouraging the respondents that there were no 'right' answers, that all answers were valid providing they were an accurate reflection of the beliefs held by the individual.  In addition, as noted above, surveyors were instructed to avoid groups because those in a group may be motivated to answer the questions according to their perception as to what the group might deem most acceptable.  Children were also to be excluded because they may not fully understand the questions, which would contribute to too large of a section of variables.  It was hoped that the target group for obtaining responses to the questions being posed to them by the surveyors would reflect those who are most likely to contract the disease.
Survey questions were designed with the basic principles outlined by De Vos (1998:157):
* Sentences must be brief and clear, and the vocabulary and style of the questions must be understandable to the respondents.
* Questions and response alternatives must be clear and not reflect the bias of the researcher.
* Every question must contain only one thought.
* Every question must be relevant to the purpose of the questionnaire.
* Abstract questions not applicable to the milieu of the respondents must rather be avoided.   Researchers must also not take it for granted that respondents will have knowledge about a subject.
* The sequence in which the questions are presented must be aimed at general, non-threatening questions first and more sensitive, personal questions later.
The pilot testing of the questionnaire was done with ABC students who are sensitive to the cultural understanding and mindset of the test population, and would become the fieldworkers performing the survey.  Since they would be posing the questions that were given to them in English, in Chichewa, they were given the flexibility to word the questions in what they considered to be the most easily understandable, culturally sensitive way.
A variety of response systems or question types were used in the actual questionnaire.  There were some dichotomous questions, but this format was kept to a minimum in order to get more depth of insight from the responses obtained than can be done from simple 'yes and no' questions.  There were some questions designed as basic multiple choice questions, but most were within the nominal scaling framework, primarily utilizing the numerical scaling method (De Vos 2001:169) with a modified use of the Thurstone technique (De Vos 1998:171).  Modified in the sense that instead of using a scale of 11 with number six (middle) being neutral, this method was simplified to using a scale of 5, with number three (middle) being the neutral response.  Therefore, the questions were designed with number one being the least favourable, number three being neutral, and number five being the most favourable answer.  Numbers two and four were not defined, but available for those respondents who didn't feel their answer clearly fit into the category on either side.   These modifications were deliberate as it was felt that having eleven choices would leave the respondent confused and diminish the reliability of the questionnaire results.
The actual questions used for the survey (a sample questionnaire) follows:
Question #1: How do you think people in the Church feel about those suffering from HIV/AIDS? (total respondents 321)**
1
2
3
4
5
Christians don't get HIV/AIDS.  Those that do are receiving the punishment they deserve for the sins they have committed.

There aren't any people in the church with HIV/AIDS.  It isn't a problem that they have to deal with.

They want to reach out to them with the love of Christ and do all they can to relieve their suffering.

Question #2: How do you think people in the AIDS community feel about the Church? (total respondents 424)**
1
2
3
4
5
People with HIV/AIDS are not welcome in the Church because they are sinners.

People with HIV/AIDS can come to the church, but people keep their distances from them.

People with HIV/AIDS feel love and acceptance when they are in the Church or around Christian people.

Question #3: Do you think attitudes between the church and the HIV/AIDS community have changed in the last few years? (total respondents 342)**
1
2
3
4
5
There is no difference in attitudes in these groups.

People are more open and aware, but continue to act in the same way

The church is seen as more loving and accepting of the HIV/AIDS community now.

Question #4: Has anyone in the family suffered from HIV/AIDS? (total respondents 421)**
1
2
3
Yes
No
Uncertain

Question #5: Level of Education (total respondents 416)**
1
2
3
4
5
Primary
Secondary
College
Trade
Other

Question #6: Religious Beliefs (total respondents 427)**
1
2
3
4
5
Christian*
Muslim
African Traditional
None
Other
For a breakdown of the various Christian denominations, please refer to Appendix G.

6.3.4	Development of working Grounded Theory
A substantive grounded theory began to emerge as the above data was analysed and evaluated (see chapter 7 for conclusions, De Vos 1998:266).  From this point, information surfacing had application in the congregational, as well as the individual setting, which led to the formation of a praxis theory as well as a sustainable strategy on how to implement it.  
6.3.5	Defining criteria for recipients of care
When the churches and students selected were prepared and ready to begin, the churches were asked to identify those within their midst who are sick.  There was no attempt at determining if these are truly 'AIDS'6 patients.  This is due to the strong denial system (3.2) that is present, as with many other African cultures, in the Chewa culture.  If it were to become known in the initial phases of the ministry that this was an outreach to AIDS sufferers, there would be no one who would allow a visit that would effectively identify them as an AIDS patient.  
No attempt was made to limit patients to those who attend, or are members of, or are in good standing with, the churches cooperating in the program.  It was recognized that most of the patients, especially in the initial phases of the program, would be comprised by members of those participating churches, and it was hoped that as word spread about the services offered; those outside the church's direct sphere of influence would then seek HBC assistance for themselves and their loved ones as they began to recognize this as a beneficial service that could help them.
There was no selection criterion regarding patient's financial considerations, their family's funds or ability to pay for services.  All services provided by the HBC volunteers were entirely free of charge.  The only criteria was that a referral (from physician, or church or other) and the recognized need of the patient for services.  No attempt was be made to visit anyone who is not receptive to being visited.
The focus of this study was the goal of changing the attitudes of both the churches participating in the study and the local HIV/AIDS community.  By observing the local congregations action plan, the churches in the surrounding community will see the example of Christ's love in action, witnessing the impact it is making in their own community.  If these churches follow the pattern demonstrated in the Nkhotakota area, they will want to become participants in the program so that they too can begin reaching out to HIV/AIDS victims and their families in a loving and compassionate way, and therefore acting out Christ's commandment to 'love one another.'
We love because he first loved us.  If anyone says, 'I love God', yet hates his brother, he is a liar.  For anyone who does not love his brother, whom he has seen, cannot love God, whom he has not seen.  And he has given us this command: Whoever loves God must also love his brother.  Dear children, let us not love with words or tongue but with actions and in truth.
If one of you says to him, 'Go, I wish you well; keep warm and well fed', but does nothing about his physical needs, what good is it?  In the same way, faith by itself, if it is not accompanied by action, is dead.  But someone will say, 'You have faith; I have deeds.'  Show me your faith without deeds, and I will show you my faith by what I do.  1 John 4:19-21, 3:18; James 2:16-18 (NIV)
6.3.6	Who will be involved in HBC (staffing)
During the initial phase of the HBC, the staffing consisted of ABC students as they participated in the HBC program as part of their outreach requirement for ABC.  Amos Chigwenembe from World Relief came to ABC to help the students understand the basic components of HBC, using various teaching methods such as PowerPoint presentations, small group question and answer, and informal lectures.  Once he had shared the initial vision for the program, the students who were familiar with the churches currently working in the targeted village area were asked to consider which churches would be most likely to want to participate in the program.  Three churches were identified and the students proceeded to make contact with them in an effort to enlist them in the project.  Due to various difficulties, such as the heavy bureaucratic nature7 of some of the churches8 (CCAP in particular), only one church was initially identified as willing to participate in the HBC program, the Chimbalame Assembly of God.  Once the target church was identified, the students began as 'chaplains' to immediately seek volunteers from the cooperating church to become the primary HBC visitors.  
It was important from the start to delineate and establish the roles of the ABC students.  They were never to be seen as the primary visiting force, but only in a supplementary role of the HBC program from within the church.  Although this aspect was recognized in the initial stages of development, its significance was not fully appreciated until the visitation actually began.  Because of the ABC class and semester schedule, it was deemed important that the students take a secondary role to the church's volunteers in order to maintain continuity of care for the patients during holidays and breaks from classes for the students.  
Another significant development became apparent when the students began making visits.  As the students teamed up with the volunteers, the volunteers had a natural tendency to take a secondary position, with the assumption that since the ABC students were Bible college students, they were more educated, and therefore in some considerable ways superior to the village volunteers.  Noting this tendency from the start, appropriate measures were taken to avoid this mindset in both the students and the village volunteers.
6.3.7	Training for HBC volunteers
The criterion for selecting volunteers was to search for those demonstrating a 'heart' for the sick and homebound from within the church membership.  It was envisioned that as more churches enter the program, each church would have their own members who would become HBC volunteers for their own respective congregations.  ABC students were to be seen as resources for assisting and encouraging the churches as they develop their own program.  
It was determined that all those who volunteer and demonstrate a willingness to participate in the program, along with possessing an ability to learn, were to be included in the training as HBC volunteers.  Some discussion was held amongst the committee members regarding qualifications and selection of capable volunteers.  It was decided that at least initially, all those who are interested in participating would be invited to come and be part of the training program.  During the actual training sessions the individuals would be evaluated and their commitment and performance abilities assessed.  Based upon local experience along with the results of the Nkhotakota project, it was assumed that a fair number of those who expressed an initial interest would drop out as the program developed and they realized there would be no financial reward for their time and energy spent; that it was only for those truly committed to this Christian benevolent work. 
ABC students were taken to Nkhotakota to visit with the HBC volunteers in the model World Relief program.  In addition to in-depth personal interviews with the volunteers themselves, the ABC students, along with this researcher were able to directly observe through participant observation the ethnography of the groups in an effort to gain an understanding of the life worlds of the support group members during their scheduled meetings.  During these times they were able to interact with the already established control group in Nkhotakota, along with actual HIV/AIDS patients who were currently participating in the HBC program.  They also met with the leadership of the participating churches utilizing open-ended interviewing, and unstructured interview with a schedule (De Vos 1998:300) techniques with the purpose of relationship building, as well as gaining intimate knowledge and understanding of the people in order to gain a better understanding of the HBC program in Nkhotakota.  
Prior to this fact-finding interviewing session, the ABC students were given generalized overviews of the vision along with the anticipated hopeful responses of the local churches by the World Relief leaders who were participants in initialising and maintaining the Nkhotakota program.  It was initially anticipated that several levels of training would be offered.  The first level training course will consist of (tentatively) a four-week plan.  At the end of the four weeks, it was expected that the participants would be able to demonstrate commitment and competency in the areas of instruction.
6.3.8	Home Based Care Curriculum Development
Work then commenced on the development of the proper curriculum.  A team of three:  this researcher, Mrs. Grace Banda, and Mrs. Hillary Edwards, a registered nurse practitioner from England9 who specializes on palliative care, set out to develop a plan for teaching that would effectively equip the volunteers in the basics of physical and spiritual assessment, teaching them how to deliver care and compassion to the sick.  Dr. Perry Jansen, the medical director of ABCCC and Partners in Hope was available for medical consultation as well.  A comprehensive overview of the four critical areas identified was developed, with full translation into Chichewa with the anticipation that most villagers who would want to participate in the program would not have an adequate understanding of the English language for instruction. After much discussion and needs evaluation development, basic needs identified for instruction became apparent.  Home Care workers will be equipped to function as agents of the ABCCC Home Care Program in the following ways:
1. Each HBC volunteer will be required to attend the HIV/AIDS awareness class (provided by the ABCCC) giving evidence of a thorough understanding of the basic components of the HIV/AIDS virus as well as how the human body reacts and responds to it.  Within the framework of this class, participants will become knowledgeable in the prevention, transmission, and various manifestations of the disease, as well as the treatment modalities, available worldwide, as well as in Malawi in particular.
2. Each HBC volunteer will be taught the basic principles of aseptic technique to assist in the reduction of transmission of germs and disease.  Basic medical assistant skills will be taught in order to fully equip the Home Care workers to give basic physical care in a safe and compassionate manner.
3. Each HBC volunteer will be instructed on basic counselling and listening skills in order to assist and equip them in dealing with patients in a caring and emotionally sensitive way.
4. Each HBC volunteer will be taught various ways of sharing their faith so that they will be fully equipped in order to, as stated in 1 Pet 3:15, 
But in your hearts set apart Christ as Lord.  Always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have (NIV). 

It was determined that this could be accomplished by providing four structured training sessions one each week for four weeks, with one of the above topics covered at each session.  With this framework in mind, classes were scheduled; the selected churches notified and work began to develop the actual training materials (Appendix D).  Once word began to spread in the area that training opportunities existed for HBC development within the church, many requests began to surface from churches in the surrounding areas.  It was obvious that this could soon develop into something far too big to be managed adequately, and therefore it was decided that only these three churches who had already been identified would be allowed to participate for the first year, and only after evaluating their responses and the impact of this program, would the decision be made as whether to expand and further develop the HBC program.
6.3.9	Selection of Volunteers
ABC students participating in the program were selected by their own admitted interest in desire for working in the HBC setting.  In addition to their college coursework (which includes spiritual instruction and ministry), they will be given additional training in counselling and interpersonal relationship skills.  This actually proved to be more of a challenge than anticipated as some of the students had no previous experience with long-term care/relationships and had a tendency to 'pounce' on the patients with the Gospel message, so special 'sensitivity' training was developed and utilized to aid these students in understanding the special needs of the chronically ill and dying patient.
Following the recommendations of the Partners in Hope HBCPC, and in consideration regarding the local churches in the area that might be open to developing a HBC program in their congregation, three churches stood out as realistic possibilities.  
1. The Chimbalame Assembly of God was considered because of its past relationship with ABC10.  They have proved themselves to be open to participating in various outreach programs with the students at ABC as they seek to develop ministry skills in the local churches.  The pastor of this church, Rev. David Phiri is energetic and forward thinking.  This church is growing and innovative in its ideas for moving ahead in the future.  After a personal interview with Rev. Phiri and his associate and interpreter, Tom Mambo, they were able to see the potential for such a program.  Rev. Phiri confirmed the suspicions of this interviewer by saying that in general the church has a very poor attitude towards those suffering from HIV/AIDS in their community.  He estimated that approximately 75% of church members in his church and the surrounding local area shared such negative views.
2. The Kaning'a CCAP (Church of Central Africa Presbyterian), Nkhoma Synod, was considered because it is physically the closest CCAP congregation to ABC.  This researcher was interested in working with the CCAP because this is the largest protestant denomination in Malawi11.  Overtures were made through students of ABC who are already members of this church, as well as attempts by Amos Chigwenembe, an ABC graduate currently working as one of the national leaders of World Relief Malawi, who is also a member of the CCAP and familiar with the leadership of this particular congregation.  Due to the heavily bureaucratic nature of the CCAP, it has been found by ABC's past experience to be extremely difficult to work with, since new ideas for ministry have a tendency to get bogged down in the local committee level and never have the opportunity to develop.  With this history in mind, this researcher attempted a more creative way of approaching this congregation.  After discussions with Rev. Dr. Hennie van Deventer, the principle of Nifcott (Nkhoma Institute for Continuous Theological Training), it was suggested that this researcher meet with the AIDS task force that was already in place within the Nkhoma Synod to work with HIV/AIDS patients and problems in the central area of Malawi.  This task force was attempting to meet the problem with HIV/AIDS in Malawi with a multi-faceted approach, addressing the issues of gender, families, orphans, poverty, etc.  Their vision was large but their actual capabilities were found to be quite limited due to resources that kept their influence restricted to the local Nkhoma Hospital area.  After meeting with the task force and sharing ideas and concerns it was obvious that they were interested in this project but because of their limited resources, they were unable to have any work of significance outside of the immediate Nkhoma area.  They were therefore pleased to be allowed the opportunity to participate and work in cooperation with a work of this nature in Lilongwe.  Following the full endorsement of the National AIDS Taskforce by the Nkhoma Synod, this researcher then approached Rev. Khombe, the pastor responsible for the ministry at the Kaning'a CCAP.  It was obvious from his response that he had been duly informed of the work we were attempting to do and was anxious to have his congregation involved.  He expressed enthusiastic interest in the prospect of bringing HBC to his congregation (about 2.8 thousand members).  Rev. Khombe stated they are ready to begin as some are visiting the sick already, but they need some organization and this training should be just what is needed.  Listening intently to the concept of HBC development from within his congregation, both he and his wife eagerly said they would like to be involved, and would be members of the first training class.  
3. The third church, which initially seemed to hold possibilities for participation was the Glorious Temple Assembly of God.  Following an intense classroom discussion on HIV/AIDS in Malawi, addressing the role of the church as well as the individual in the fight against AIDS12, one student (Joseph Wowa, freshman student at ABC) shared the events he observed in his church the following Sunday.  He shared in amazement, that his pastor, Rev. Edward J. Chitsonga, had preached a message about HIV/AIDS from the pulpit that very Sunday, covering much of the information he had received from our classroom discussion.  While meeting with Rev. Chitsonga, who has experience as a trained Clinical Officer, and also chairs the commission on HIV/AIDS at the national level of the Assembly of God denomination in Malawi, the opportunity was presented to him for his church to participate in HBC training.  Although personally interested, it was his wife who seemed to more fully grasp the significance of this project.
The pastors from each of these faith communities were in full agreement that the general attitudes within their churches, along with others in this local community reflected and supported the negative attitudes identified at the beginning of this dissertation.
6.3.10	Tentative time frame / scheduling
The saying 'timing is everything' is applicable to the study and work of the church with HIV/AIDS in today's world.  Just a few short years ago the church as a whole, was acting as the proverbial ostrich with its head stuck in the ground.  By pretending that if it didn't see and often refusing to acknowledge the problem (2.2), it would not have to address or deal with it.  Due to world circumstances the church, of Africa in particular, is being forced to realize that this is a problem that must be attended to, but the looming question remains as to how this is to be done (2.3).  Many individuals and groups within the body of the church were beginning to realize that something must be done, but an overwhelming sense of helplessness often prevailed as they saw the magnitude of the problem and had no idea as to how to begin.  It was into this sea of mixed confusion and despair that this researcher found many of the churches.  This is particularly significant when considered in conjunction with the African ubuntu philosophy (as discussed in point 4.3).  Although the associated negative connotations of AIDS kept the African church at a distance from those suffering from the disease, the cultural sense of ubuntu caused them a sense of discomfort and frustration.  Because of this, when presented with an opportunity to train their members, equipping them to actually 'do' something from within the church to deal with these issues, the churches excitedly listened with attention on how they might participate in order to make a difference in their local congregation and community.
An unforeseen turn of events evolved as Rev. David Phiri, the pastor of the church initially selected as the study church, the Chimbalame Assembly of God, took it upon himself to solicit interest from other churches in the local village area to join with him in this project.  With his encouragement, fifty-two individuals from ten churches, representing ten different denominations, from a conglomeration of several villages immediately surrounding the Lingadzi area stepped forward to have some of their members participate in the training programs.13  
There was some preliminary concern that mixing the members of the village churches with those from the Kaning'a CCAP, who come from a higher socio-economic status might prove difficult, but in actuality this did not prove to be a problem.  Because of scheduling and other difficulties, neither the Kaning'a CCAP nor the Glorious Temple Assembly of God elected to participate in this first training class.  This left only the village churches to participate and resolved the potential difficulty.  
In an attempt to convey the message that this was a serious class, it was emphasized that classes would begin at exactly 9:00 o'clock A.M., and each member would be expected to be there at the beginning of each class.  In order to keep the class motivated and under-gird the idea that this was an important event, it was decided that attendance at all four sessions would be required in order to complete the course.  In additional to their comprehensive HBC training manual, each person completing the course was given a certificate of completion, a 'Partners in Hope' tee shirt and tote bag, a Chichewa Bible, a folder with necessary paperwork and an official picture name badge indicating they had completed the course and were recognized as an official HBC worker by their church and the ABCCC Partners in Hope HBC program.
 Because of the emphasis on the importance of the program as well as the motivation and desire of the individuals to participate in the program, all fifty-two of those who had indicated an interest were lined up and ready to start a full hour before class was due to begin.  At the end of the four-week session, all fifty-two participants had met the requirements, and were therefore qualified to receive certification of completion and begin changing their community.  The unexpected total commitment and enthusiasm of this group exceeded the expectations of all those participating in the facilitation of these training sessions.  At least a significant amount of this commitment can be attributed to the fact that Rev. Phiri, and those interested in this program held an all night prayer meeting the night prior to the first meeting, seeking God's will, vision and intervention in this project. 
6.3.11	Ownership of Home Based Care program - Issues in Development
Although the structure and content of the training program was pre-determined, it was deemed important to instil a sense of 'ownership' of the program into the volunteers.  With this concept in mind, an allotment of time at the end of each class was set-aside for practical matters such as determining the means of management and structure for the group.  
The group quickly voted to continue using the name, 'Partners in Hope' for the HBC volunteer program.  At the outset, the proposal was that each church would have its own HBC program, but what this group decided was to continue as a perpetual group, functioning in such a manner so as to include all of the churches in the efforts of the group.  When it came to determining the management system, the individuals in the group became quite interested in determining a rather formal system of government.  For facilitation purposes, during the discussion several possible alternatives were suggested by the HBCPC, leaving ample openings for additional ideas to be brought forward for consideration as well.  With the goal of determining their organizational structure before them, they then decided that a committee should be selected which would represent the entire class.  This committee would then be able to make decisions regarding questions and policies as they were needed.  Since there were ten churches, or denominations involved in the training session, it was suggested that an equal representation from each group be selected for the committee.  After some discussion, they opted to continue the discussion throughout the week, and when they returned for the next training session, they would have worked out the details of how to establish the committee.
The following week they came with their ideas formatted.  Ever mindful of a sense of fairness, they decided that equal representation would not be the most effective way of selection for the committee because of the fact that several of the churches represented only had one member, and others had as many as eighteen.  They were mindful of both hazards:  having smaller churches with too much power and having the larger church overrun all decisions.  Therefore, they suggested that a vote would be held with nominations from the entire body.  From this election, eight members from the entire group were elected as the committee.  From the governing committee, they then proceeded to take nominations and subsequently vote on offices such as president, secretary, etc.  Rev. David Phiri, the pastor of the Chimbalame Assembly of God was elected as the chairman or president of the committee (despite concerns voiced by the trainers as to whether he would have the time to commit to such a project with consideration to his many other duties as pastor); Ruth Kasingi of the Church of Christ was elected vice president and Moses Malengo from the End Time Pentecostals Church was elected as recording secretary of the newly formed, 'Partners in Hope Home Based Care' Program.
Once this committee was selected, in an effort to stimulate interest and cohesiveness, several special meetings and a dinner were arranged.   This produced the desired effect of providing unity in spirit within the committee as well as giving them a sense of approachability to freely meet with the HBCPC.
By the end of the four-week session, the volunteers expressed satisfaction with the course materials and curriculum, commenting that they felt quite well equipped to begin visiting the sick in a meaningful way.  A graduation ceremony took place during the last session when certificates of completion, name badges, etc. (6.3.7) were distributed.  The committee decided that it would report back to the HBCPC after a four-week period.
Suggestions were offered and discussion ensued as to how the committee could maintain the emotional balance and motivation of the volunteers.  This is a significant consideration when one realizes the emotionally draining tendency that comes from caring for the types of patients that will be cared for by the volunteers.  Since the volunteers will be receiving no monetary reward, it is especially important they are given a strong sense of accomplishment and motivation from within their own ranks.  The committee divided the total number of volunteers so that each committee member would oversee 5-6 volunteers.  It was also decided by the committee that they would meet on a regular basis (every 1-2 weeks) for emotional support and sharing times.

6.4	TRAINING COMPLETED - MOVING FORWARD
At the completion of the four-weeks, the committee met with the HBCPC to share progress and problems.  They had developed a natural format when meeting with HBCPC that began with a detailed explanation of how poverty-stricken the people in the community were and how desperate their physical needs were.  It was shared with the committee that although there were significant problems and difficulties, it was not the purpose of HBC to meet all of their physical needs and that their emotional and spiritual needs were the primary focus of this group at present.  Reminding them of the vision of reaching out with love and compassion to the sick and dying, they were then able to move to the next item of discussion.  

6.5	ASSESSMENT
The four cognitive processes identified by Morse and Field's approach (De Vos 1998:340) towards data analysis were used (comprehending, synthesizing, theorizing, and recontextualizing).   With continuing assessment with the resultant synthesizing, theorizing, and recontextualizing, theories began to be derived as to how to not only implement this program for use in the local control Lingadzi area, but also to be evaluated for adaptation for uses in other local faith communities in Lilongwe and elsewhere.
6.5.1	Assessment:  Need for Goals Clarification
Utilizing Morse and Field's approach with the first step of comprehending brought the central and peripheral referents to the researcher's attention.  Using intraparticipant microanalysis as an interviewing method, it was soon discovered that there was some misunderstanding about the goals of the HBC program.  The committee proudly stated that they were currently caring for over 365 sick in their community.  Knowing that many of these people were working, and should only have a small amount of time to invest in the care and well being of others, this claim was investigated more closely.  By working with what Morse and Field call the 'comparison of transcripts' (De Vos 1998:341) from several respondents, this researcher was able to synthesize the information presented.  Interpreting the relationships between the findings brought the discovery that the volunteers were equating large numbers of patients under their care with the expectation that they were doing a 'good' job.  This provided an ideal teaching opportunity of 'quality' versus 'quantity'.  This concept, of keeping the numbers small and manageable exposed a cultural difference between the volunteers and the HBCPC, which mainly consisted of Western missionaries (3.4).  After taking time to explain to them that the objective was to take really good care of the individual, with the goal of demonstrating the love of Christ to that person in a real and meaningful way, they were able to see and grasp the concept.   In an effort to recontextualize the situation, it was explained to them that following the usual African pattern of trying to give a 'little to everybody' instead of a 'lot to a few', would inevitably lead to providing sub-standard care.  This would not allow them to care for the patient adequately; it would also cause them a sense of frustration, as they would be faced with doing less than what was necessary.  This dissatisfaction would lead to 'burn-out'.  In addition to the damage done to the potential reward for the volunteer of the satisfaction in knowing they were helping their fellow human beings, and thus fulfilling the law of Christ (5.6), they would also be giving a poor demonstration of Christ's love and compassion to those they were seeking to win to Him.  This would have the counter effect of working directly against the goal, as the patient himself (or herself) would become dissatisfied with the care and see the visit as not only not helpful, but possibly destructive.  With these thoughts in mind, the volunteers were able to easily grasp the concept and pared their number of patients down to a more manageable sixty-five.
6.5.2	Assessment:  Paperwork Challenges
A very simple14 form of paperwork was introduced during the training sessions, but this became more of a hindrance than help as time went by.  A problem developed since the volunteers were not used to being responsible for records of this nature.  Although a few attempts were made in an effort to please the HBCPC, it soon became obvious that since there was no actual medical care taking place, it was not necessary to expect them to keep records of their visits and outcomes.  This might have proved useful for this researcher and those in the HBCPC, but ultimately it was not serving any meaningful purpose to the individual volunteers or their respective churches and was therefore abandoned.  Volunteers were encouraged to keep communicating with the committee on a verbal basis, and any additional concerns or problems could be brought to the attention of the HBCPC for further evaluation or intervention.
6.5.3	Assessment: Hunger crisis
Within the first two months another problem surfaced which demanded attention.  Hunger.  Malawians were starving, and had no way to get or purchase food.  This was particularly apparent in the HBC population.  This is due to the fact that this area is an extremely poverty stricken environment15 in the best of times.  Another factor was the fact that often it was the 'bread-winner' of the family who was the patient, the money that could have been used to provide for the family, was now being diverted towards medical care.  In addition to these problems, the nation of Malawi was suffering as a whole due to lack of food stores from what some have considered to be a governmental problem.
With this devastating factor considered, the HBC volunteers were faced with a dilemma.  They were trying to provide care to their neighbours; yet they were in no better position to provide additional food sources to their patients than the patient's families.  When they brought this problem to the Partners in Hope HBCPC, urgent requests were sent to stateside sponsoring churches for benevolent help to meet this crisis.  With the first $1000.00 of the total of $2500.00 USD that was given to help the need, ufa, the maize based flour used in the staple nsima was purchased.  The committee then determined the most effective way of distribution and worked tirelessly to provide food for those who were suffering.  The need was limitless, and the volunteers suffered some verbal abuse and threats as neighbouring villagers accused them of not sharing all that they had.  When word got out that free ufa was available, it became evident that everyone was in need.
In re-evaluating the situation, it was determined by the Partners in Hope HBCPC that in the future, ufa (which was the staple food for all Malawians) would not be distributed, but lukuni phala would be distributed instead.  Lukuni phala is actually more nutritious than ufa because it is vitamin fortified, but it lacks the desirability of ufa in that it is considered more of a 'porridge' than as a real food.  The next $500.00 worth of food provided was in the form of lukuni phala.  Changing food substances revealed the 'actual need' of the people diminished considerably when the offering was perceived as a less desirable product.  People did not want to receive the lukuni phala unless they were truly desperate for food, so changing sources had the effect of helping to determine those in the most genuine need.  In fact, after this distribution of lukuni phala, the committee informed the Partners in Hope HBCPC that they did not need any additional food at present, but would let them know when it would be needed again.

6.6	SECOND TRAINING CLASS USING DIFFERENT MODEL
A second training class of twenty-nine students (with twenty-seven completing the training) was begun following requests from the Kaning'a CCAP.  Although the tribal and cultural backgrounds were very similar to the initial class, there was one significant difference in that this class was made up of all members from one particular church, representing several different 'prayer houses' which comprised a total membership of approximately 2,800 members.  
This class was handled in very much the same way as far as the actual training design and curriculum content were concerned, but because of significant variants in the group dynamics of this group with the initial training class (7.3), there were a few differences in approach to the class from the pedagogic standpoint.  Even though there were several prayerhouses that varied in their economical and educational levels, the overall level of literacy was greater and therefore the teaching was done at a somewhat higher standard.  Even with the consideration that their educational level was higher and therefore their English comprehension was generally better, all teaching was done in English, and translated into Chichewa to serve two purposes:  1.) to reinforce the message given in English as it was then repeated in Chichewa, and 2.) to make certain that those who were not as proficient in English would have full access to all information in the language they were most comfortable with and certain to understand.  The workbook used was the same as with the first class and prepared with both Chichewa and English text.
As with the first training class, independence and autonomy were paramount.  It was considered essential that the group takes ownership of their home visitation program and this principal was stressed from the beginning of the training program and they seemed eager to make their own decisions as they developed their program.
Since this class was made up from one church, it developed a very different type of governing and management system.  No attempts were made to bend this group into the mould developed by the first group since from the onset, the goal has been for each church to develop their own program and take ownership of it.  Structures were all ready in place for visiting the sick that fell under a benevolent department involving other issues as well, such as orphans, etc.  Therefore, there was no need to develop a 'committee' as was done in the first group.  Rev. Khombe, the minister or pastor of Kaning'a CCAP was interested and supportive of the program from the very beginning.  He was personally unable to attend the training sessions, but his wife and others leaders from his church were part of the training classes.  The existing governing structures simply extended themselves to encompass this new aspect of their benevolent care.  Since those who had already been established as the leaders of the existing groups were present in the HBC training class, this was an easy and well-received transition.
Members of this class were all members of the same church, so therefore upon completion of the four week training program the Kaning'a CCAP formally presented them to the church.  They were all called to the front of the church and Rev. Khombe described to the congregation the essence of the HBC ministry.  In his presentation, he was careful to explain that this group would be visiting the sick in their congregation and took care to avoid presenting the concept that this was an AIDS care group.

6.7	DAY TO DAY PROCEDURES
After the volunteers had been making their visits for a couple of months, the visitation process began to stabilize.  By the time the ABC students were ready to begin their end of school holiday (June-August), the local village volunteers were able to continue making their visits to those in the community independently.  Regular meetings were scheduled with the committee and other volunteers as individual needs and concerns arose.  As the 'newness' of the program began to wear off, the volunteers began to seek additional training in areas where they felt inadequate.  The HBCPC purposely did not offer suggestions, but took a passive role of leadership so the committee could be empowered.  Responding to the 'felt' needs of the volunteers as they were presented to the HBCPC instead of directing their path worked to establish their sovereignty from the beginning.  From the suggestions of the volunteers, additional training was organized in a seminar format on a monthly basis at no charge to the participants.  Subjects were determined by the need and requests of the volunteers.  A preliminary list of topics was developed (first aide, disease processes, gardening techniques, etc.) and classes began with avid enthusiasm and support by the volunteers.
In this same way (of passive direction), other avenues of outreach were begun as well.  The HBCPC saw to it that Partners in Hope HBC was known in the community and members were asked to participate in various functions in Lilongwe that were designed to bring together the various HBC groups which were developing in the city.
6.8	ABC STUDENT VOLUNTEERS
When the ABC college semester began in September 2002, the HBC program at Chimbalame was well established.  As a requirement for graduation, ABC requires all students to be involved in some type of ongoing weekly ministry.  The students are allowed to choose from various already established ministries, or encouraged to initiate their own if they choose.  HBC was offered as a ministry choice16 and an assortment of seven students volunteered, several of which had been involved in the more unstructured HBC visitation, which was available the previous semester.
Several concerns and challenges were identified regarding the introduction of student volunteers at this point:
* Since the students were only going to be available during the scheduled school year, their ability to consistently visit patients long-term was limited, and therefore it necessitated their 'partnering' with village volunteers who would maintain the relationship with the patients when the students were unavailable to participate in the home visitation.
* The perception of the village volunteers towards the student volunteers:
o In the past, the volunteers tended to regard the students as their superiors (due to their advanced educational status) and allowed them to take the lead in all visits.
o The village volunteers might look at the students with suspicion, thinking their intention was to evaluate them in their effectiveness and competency as HBC volunteers.
o The village volunteers may resist 'sharing' their patients with whom they had worked to develop relationships, with the students.
* The perception of the student volunteers towards the village volunteers:
o The students may not value the education and experience of the village volunteers and try to assume leadership.
o The students may not want to work with the village volunteers and want to develop independent relationships with the patients.
After consultation with the training team, it was determined that the students entering this ministry would require a period of training, but it would not take the shape of the same structured four week course, and therefore a modified training component was developed and implemented.  One purposeful reason for this was to allow the village volunteers the realization that as far as the HBC visitation program was concerned, they had the advantage of having had a more comprehensive training along with more experience.  It was also stressed to the village volunteers that the students were there to give them 'added hands' and to assist them, and it was stressed that it was essential that the program not be built around the students, because they would not always be available.  Even with this focus in mind, the village volunteers elected to reserve Thursday afternoons as their focal visitation time because that was the 'official' ABC time of visitation when the students would be accessible.
It was also determined that the ABC student volunteers would work along side the Chimbalame village volunteers only, and not with the Kaning'a CCAP volunteers.  This determination was made due to the fact that the Chimbalame volunteers were already accustomed to ABC students and also, and mainly for the reason that the Chimbalame volunteers worked within a more contained area that could easily be reached by foot, whereas the Kaning'a CCAP area was much more vast and depended upon vehicular transportation.

6.9	ADDITIONAL TRAINING CLASSES
Although there were numerous requests for training from other churches and areas that had heard about what was being done here, it was determined by the HBCPC that there would be no further training sessions for the remainder of the fiscal year.  This determination was made so that these two groups could be given the proper supervision and direction and their advancement could be studied thoroughly.  It was felt that if too many groups were allowed into the program, it would soon become unmanageable in addition to the added difficulty in assessing their progress and problems.

6.10	KANING'A CCAP METHODOLOGY
Although the planning and implementation of training curriculum was the same for both study groups, the follow-up methodology differed for several significant reasons.   The Kaning'a group already had in place a structural format for managing their volunteers; so stringent oversight was not as necessary for Kaning'a.  
The same goals and focus of the initial group remained in place for this second group as well, those of autonomy and ownership of the program.  Therefore the training team only made overt gestures at interaction at infrequent intervals to avoid the concept that it wanted to take any authority away from the already existing structure and makeup of the group's management systems.  Aside from occasional phone calls for the purposes of gentle assessment and inquiry of needs, to Mr. Lungu, the key contact person for this group, outside intervention was avoided and the group was allowed to mature and develop independently.  Each phone call was cordially received, and the HBCPC was assured that things were 'going well' and no further help was necessary.  This group was invited to attend the additional training sessions requested by the first group, but few members took advantage of these sessions.  In an effort to allow this group to evolve on its own, and therefore to take full 'ownership' of its members and ministry, contact was avoided after the first few months of assurances that all was 'going well'.

6.11	SEVEN MONTH ASSESSMENT AT CHIMBALAME
By the time seven months had passed, significant changes had occurred in the Chimbalame group (7.4.2) and it was obvious that some intervention was needed to get the group back on track and focused to move forward.  Elections were held and new committee officers were elected during a meeting of the group with opportunities for sharing of ideas and concerns.  Once again energized and focused upon their task, the group once again was back on tract, working toward visiting the sick and meeting needs in their community.

6.12	ONE YEAR REVIEW AND EVALUATION
As the time neared for the completion of the first year of HBC formal efforts of evaluation and re-assessment were begun with attention given to Guba's model (De Vos 1998:348), as he discusses the area of applicability, which he defines as the degree to which the findings can be applied to other contexts and settings or with other groups.
In conjunction with this analysis, for both the Kaning'a and the Chimbalame groups, open-ended interviewing, unstructured interviews with a schedule (De Vos 1998:300), were utilized with already identified informants within their respective organizations who have intimate knowledge and understanding of the people and structures involved.  This was done in order to extract sufficient information to provide a basis for data collection and continuing interview / relationship building at the case study sites, along with providing assessment information for continuing grounded theory development from the analysis of the data.  From this information, the program was systematically assessed and a substantive theory developed, with the intention of broadening into the development of a formal theory (De Vos 1998:266), leading to the formation of a praxis theory as well as a sustainable strategy on how to implement it (7.6; 7.7).
Each of the one-year assessments will now be reviewed:
6.12.1 Chimbalame Home Based Care -
This researcher, along with the others involved in the Partners in Hope, HBC initiative met with a representative group from the official 'committee'.   The following observations were noted:
* Instead of the normal hierarchy of the committee being present, those present instead chose to have Tom Phiri (the associate and 'right hand man' for Rev. David Phiri, the original committee chairman) join with their group to serve as their spokesman.
* All participants of this meeting made sure to wear their 'official' name badge identifying them with Partners in Hope HBC.
* They came with a planned agenda and were pleased that this meeting was called, as they had some items they wanted to discuss.
* They voiced the following concerns:
o They were promised new 'tote bags' and were expressing disappointment that they had not been delivered.  (When this researcher asked them where they had gotten such an idea, because it was never intended that they would get new bags, they emphatically stated that it was indeed this very researcher who had made such promises).
o They didn't have enough gloves and presented a long, detailed case as to why they thought it was necessary, (they admitted that they had never asked the HBC nurse, or the supervisor for more gloves).
o They were upset that other agencies were having more food distributed to them, and expressed concern that they were not getting their fair share, with the insinuation that ABCCC Partners in Hope was withholding from them what they had rightfully coming to them. (This was a MAJOR issue).
o Some of their group's official 'T' shirts were becoming worn and needed replacement, so they felt that they should all be given new shirts.
* Unstated, but perceived from their comments was the idea that they were not happy with the new HBC Nurse who was now directly involved in monitoring and assessing their visitation performance.  They were suspicious of her and felt that their integrity was being challenged.
* Although an exact count was difficult, by their own estimation (which did not agree with the report from the nurse) most of the volunteers were continuing to make visits to the sick, with the exception of a few that had moved from the area.
The HBC Training Team evaluated each of these concerns and response was made to each concern (7.4). 
6.12.2	Kaning'a Home Based Care -
Mr. A. K. Lungu, the main contact person for the program from the beginning was very willing to sit down and give this researcher an honest report of the activities of the HBC initiative from the Kaning'a CCAP.
The following observations were noted:
* The HBC volunteers were active for approximately the first six months, and then their visits began to diminish until they were no longer making visits.  This was due to the following reasons:
o The perception arose in the church congregation in general, and within those serving as guardians and caregivers of the patients in particular, that the HBC program was actually an AIDS program and therefore all those they visited were suffering from AIDS.
o Due to the continued stigma perceived from association with this diagnosis, with its resultant alienation, estrangement and prejudice, the caregivers became resistant to the home visits, fearing the stigma would rest on them as well.  Mr. Lungu offered comments such as, 'you don't want to get a wife from that family, they have AIDS', as a sample of their feelings and responses.
o As the caregivers resisted the visits, the volunteers began to feel unwelcome and eventually stopped visiting all together.
o There was no apparent inter-group support system to help the volunteers deal with the pressures and stresses of visiting the sick and dying.
* Other benevolent ministries (orphan, widow, etc.) that had already been established were continuing to thrive.
* One notable exception was Mrs. Khombe, who was a trained volunteer and also the wife of the pastor.  She did not feel that guardians were shunning her and she continued to make visits to the sick (7.5).
* The caregivers seemed willing to let the program die a natural death, but were willing to explore possibilities of how it might be revived as they had not given up the ideals and vision with which they began the program.
Following this meeting, the resultant situation was discussed in detail with other members of the HBC Training Team.  Following this several other fact-finding interviews with purpose were held, mostly by telephone with Mr. Lungu, and then with the elders responsible for the benevolent ministries of the church to further explore the situation and find ways of moving forward with the program in a constructive, meaningful way (7.5).
At the completion of one year of home visits, a second Quantitative Approach Survey was performed.  The same questionnaire was used with the addition of the following two questions:
Question #8: Are you familiar with Partners in Hope HBC which was started one year ago? (total respondents 250)**
1
2
Yes
No

Question #9: Do you think the HBC has helped to change attitudes between the Church and the HIV/AIDS community? (total respondents 195)**
1
2
3
4
5
Attitudes are worse now

No change in attitudes

Attitudes are better now
* The denominational codes are as follows:  CCAP - Church of Central Africa Presbyterian; RC - Roman Catholic; AoG - Assemblies of God; EP - End Times Pentecostal; A - Anglican; AA - African Abraham; NA - New African; JW - Jehovah's Witnesses
**The number of total respondents varies from question to question because the surveyors were instructed to allow participants to not answer any questions that they chose not to answer for whatever reason in an attempt to get accurate and honest answers for the ones they did choose to answer.
The goal of such a survey following one year of service was to have an indication as to whether there was any notable resultant attitude change or shifts in the subject communities as a result of the initiation of the HBC Program.  The above-mentioned two additional questions were included as in an effort to reveal precisely that information.  The survey was preformed in the same manner with one notable exception; only one field worker was used.  Other qualifying factors for the surveyor remained the same.  The reduced number of surveyors did produce a somewhat smaller sampling of respondents, as well as a longer surveying period, but it was thought by this researcher that having one person do all of the surveying would eliminate the possible variable of differences of interpretation of data by the field workers as they filled out the survey forms based upon the responses of those in the community being assessed (7.1.2).

6.13	TRUSTWORTHINESS OF QUALITATIVE RESEARCH
In his chapter (22) on Data analysis in qualitative research, De Vos describes Guba's model of trustworthiness of qualitative research (De Vos 1998:348).  This model was designed as a way of providing researches alternative models in order to evaluate the trustworthiness of the data and interpretive results, which are determined by various research areas.  Based upon this model, the variables of this study were posed to several others who share in the line of work with individuals based in the field of HIV/AIDS, HBC, and in the more general area of working with volunteers, and the concept of volunteerism.
Consensus from among these professionals concurs with the basic tenets of this research without variance:
Name of Individual
Area of Expertise
Dr. Perry Jansen
HIV/AIDS, difficulties with volunteerism, HBC
Mrs. Anna Kamanja, R.N.
HIV/AIDS, Volunteerism, Chewa Culture
Mrs. Caroline McLean, R.N.
HIV/AIDS
Mrs. Grace Banda
HIV/AIDS, Volunteerism, Chewa Culture
Mr. Amos Chigwenembe World Relief)17
HIV/AIDS, Volunteerism, HBC, Chewa Culture
NAPLAM18
HIV/AIDS, Volunteerism, Malawi Culture
Lilongwe HBC Stakeholders19
HIV/AIDS, Volunteerism, Malawi Culture

6.14	OVERALL SUMMARY OF METHODOLOGY
 Qualitative research is a like working on a continually evolving project.  Dealing with the variables presented by human vacillations often poses a challenge at best.  As was indicated at the beginning of this research, the process of exploration developed as the needs of the project were evaluated and formatted to make the adjustments necessary to adapt to the continuing variations presented.  Indeed by continually collecting, recording and analysing data, a grounded theory began to emerge, which directed the course of further sources and opportunities for information gathering and exchange.
The speculations and envisioned outcomes which where predicted during the preliminary phases of this project were purposefully readjusted and redirected to accommodate variables and situations which had not been initially anticipated.  Using the methodology outlined in this chapter helped this research to develop in a logical, systematic way, therefore allowing accurate triangulational research, combining quantitative and qualitative methodologies.  By using multiple methods of data collection, an increasing reliability of outcome was anticipated.
It is hoped that this research will meet the goal of fulfilling the following definition recorded by (Grinnell, 1993; Rothman & Thomas, 1994; and Rahman, 1993) in the work by De Vos (1998:20): 
Basic professional research, whether its objective is exploration, description or explanation, is a scientific enquiry into a relevant problem that provides an answer contributing to an increase in the body of generalisable knowledge about the particular profession; applied professional research is geared to the development of knowledge and technology with a view to achieving meaningful intervention which, ideally, should be participatory interventive action, based on participatory action research, in that professional researchers should empower research participants to understand and solve their own situation and problems, become aware of their own potential and regain their own sense of dignity, so as to take collective action for their self-development. 
All that has been recorded to this point serves as a solid foundation to provide an objective, comprehensive appreciation of the problem with its many varying components.  From this base of understanding, the research problem developd as scientific methods were employed to determine the conclusions resulting from the data received by the methodology described in this chapter.  From the data, trends and responses were realized that had not been anticipated; which in turn served to shape and reshape the problem allowing for more refinement and direction as the facts was interpreted and conclusions were drawn.  The praxis theory was continually moulded and re-formatted as the events unfolded.   
During their initial year, from the graduation of the first class to the evaluation done at the completion of their first anniversary; many anticipated as well as many unexpected factors became apparent.  These factors caused the envisioned developmental process to demand a critical re-thinking, with a resultant shift in the project focus and corresponding action. The program under study in this dissertation served as the praxis model as the project continued to evolve.
In the next chapter, the final conclusions developed from the work done on this project will serve to provide a contribution to the increasing body of knowledge regarding the field of HIV/AIDS.  This information is particularly relevant in light of the relationship that has developed between the church and those infected or affected by this deadly virus.  The findings from this study impact the information regarding how AIDS community sees and interprets the role of the church, as well as the response of the church to the AIDS community as it serves as God's witness in this devastating pandemic.  
As the final chapter of this dissertation, chapter seven will provide the elucidation necessary to draw the appropriate conclusions from the data presented in this current chapter on methodology.  These conclusions will provide interpretation to the significance of this project, which will allow the beneficial contributions, as well as the unexpected disappointments to be instrumental in the formation of the new and revised vision necessary in order to continue with the foundation that has been laid by this project.

1 This reflects the attitudes reported by Rev. Chimsolo and supported by others from the congregation as well as workers involved with World Relief
2 For additional case studies of individuals in the Nkhotakota program, please see Appendix (F) 

3 'Partners in Hope' is the name of the department of the ABC Community Clinic whose mission is to reach out to those suffering with HIV/AIDS in Lilongwe.  Dr. Perry Jansen, the ABCCC medical director heads this organization which includes the HBC as well as counseling services and treatment options available to those suffering with HIV/AIDS.
4 The villages included in the Lingadzi area include the following:  Mtsiliza, Chimbalame, Pearson and Mtandira.
5 The difference noted in the numbers of each category can be attributed to the fact that not all respondents answered all questions.
6 Realistically, it is presumed that most of the homebound patients who will be involved, even in the initial steps of this program will indeed be HIV/AIDS sufferers based upon statistics given for both the general population and those who seek medical attention.
7 To qualify this statement, the researcher has questioned approximately 60 students who are members of the CCAP who all have described the governmental structure of the CCAP as being heavily bureaucratic.
8 Mr. Amos Chigwenembe, himself a member of a large, local CCAP church has been unable to introduce HBC into the church due to the heavy bureaucratic system of government that has proved to be a stumbling block to every effort he has tried to make to introduce this program into his church.
9 Mrs. Edwards was working with the V.S.O. in Malawi, for one year during the time of this study with the Lilongwe Central Hospital HBC as their palliative care nurse specialist.
10 The Chimbalame Assembly of God have been allowing ABC students to work with their members in outreach activities to children, and widows; including orphan programs and feeding programs.  They have also hosted the JESUS film from their church as a joint ministry with ABC students.  These programs have proved to be mutually beneficial for both the students as they seek ministry experiences and for the Chimbalame church as they reach out to their membership and community.
11 Apart from the traditional religions, Christianity and Islam have become established in Malawi.  Most Christians belong to one of the four major churches: Presbyterian, Seventh-Day Adventist, and Anglican. Of the four major denominations, the Church of Central Africa Presbyterian (CCAP) is the largest.  Collection and organization of data (c) 2000 by Adherents.com.
12 This discussion took place in the classroom setting where this researcher works as a lecturer at ABC, teaching Christian Ethics and Leadership Development.
13 The 10 churches participating in this initial training class were as follows: Assembly of God (18 participants), CCAP (14), Roman Catholic (9), End Time Pentecostal (7), Anglican (2), African Chipangano (2), Zambezi Evangelical (1), Pentecostal Holiness (1), Baptist (1), Church of Christ (1)
14 In comparison to the reams of paperwork mandated by HBC programs in the United States with which this research is familiar, the paperwork requested seemed very insignificant at the time.
15 It is estimated by a resident of this village area that approximately one half of the population of this village has a 'real', consistent job, another quarter manage to find temporary jobs here and there, and another quarter live by small jobs of piecework and abject poverty.
16 Other ministry choices include hospital, prison, and door-to-door ministries, as well as open air evangelism, various children's ministries, sports evangelism and HIV prevention programs for local secondary schools.
17 Please refer to Appendix 'J' for details of World Relief's contributions to 'volunteers'.
18 When visiting this organization, the coordinator told this researcher that not only are his volunteers paid for their services, the HIV/AIDS patients with whom they counsel are also paid to attend support group meetings and other activities.
19 HBC is a very recent development in Malawi, and the Lilongwe HBC Stakeholders have developed as a result.  Representatives from each of the various HBC institutions come together on scheduled meetings for idea sharing and planning purposes. 



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