FHI - Reaching Youth

Table of Contents

IV. Reaching Youth (See Below)

VI. Promoting Sustainable Prevention Efforts

IV. Reaching Youth

It could be an ad for clothing, shampoo, musical recordings or almost any other product that appeals to adolescents. In quick succession, four attractive young couples -- sometimes the same person but with a different partner -- are each shown embracing on a couch in a dimly lit living room. In the background a singer croons the opening lyrics of a well-known romantic ballad, "Solamente Una Vez": "Just one time I loved in my life, just one time and never again."

But the mood turns starkly somber as the last of the young women looks up with a grim expression and stares directly at the camera. The word "SIDA" (AIDS) in bold red letters covers her face, and a narrator takes the sweet love song and turns its meaning on its head. "AIDS. Just one time, and never again," he warns. "Protect yourself. Don't change partners. Use condoms. Because just one time is enough, and never again."

This forceful TV ad is one of four that AIDSCAP's Dominican Republic program produced for a campaign targeting adolescents and their parents. Created by a leading Dominican advertising agency, the spots used high-quality production techniques and attractive young actors to convey well-researched public health messages.

Other equally polished materials developed for the campaign -- including radio announcements, brochures, posters and roadside billboards -- presented the same hard-hitting themes, designed to pierce young people's sense of invulnerability.

As attention-grabbing and persuasive as the mass media pieces may have been, they were just part of a comprehensive, well-coordinated national campaign, explained Oscar Vigan�, a communication officer in the AIDSCAP Latin America and Caribbean Regional Office. "The mass media is a tool," said Vigan�, who helped the AIDSCAP staff in the Dominican Republic create the campaign. "If you use it within an integrated plan, you can have an impact."

The communication campaign was, in turn, one of a series of AIDSCAP efforts targeting youth, one of the primary audiences identified in the strategic and implementation plan the program developed in 1993. The Acuario Project, for example, reached thousands of young people in four lower-income Santo Domingo neighborhoods through one-on-one peer communication, small group discussions and other community events. Other youth-focused activities grew out of Acuario, including research to learn why young women were slower than young men to adopt risk-reducing behaviors and a new mass media campaign aimed at remedying that situation. (See Supporting Women at Risk.)

Youth at Risk

As AIDSCAP was getting under way, research data on the epidemic showed the increasing urgency of targeting young people with HIV/AIDS prevention messages. The average age for first sexual intercourse among Dominican youth was 14. By early 1993, some 56 percent of the cumulative AIDS cases reported in the country had been among persons aged 15 to 34. Heterosexual sex was the mode of transmission in some 73 percent of the AIDS cases. Prevalence rates had risen sharply among such "core groups" as sex workers and men who have sex with men -- frequently an advance indicator of a spread of the epidemic to other groups, including sexually active men and pregnant women.

Behavioral studies also showed that many young individuals knew how to safeguard themselves from HIV and other sexually transmitted infections, but they hadn't moved beyond that awareness stage and taken steps to better protect themselves. AIDSCAP officials believed that changing that conduct would be easier with younger people than with adults because youth are still in the process of forming their sexual attitudes and behavior.

The resulting Acuario Project combined the skills and experience of two Dominican NGOs, the Coordinadora de Animaci�n Socio-Cultural (CASCO) and the Instituto Dominicano de Desarrollo Integral (IDDI), to target youth aged 13 to 24 in poor communities of Santo Domingo. The collaboration integrated HIV/AIDS activities into a larger primary prevention system that helped communities address many different health threats. This structure included families, neighbors, sports clubs, churches and other local organizations involved in HIV/AIDS prevention outreach to youth. Young people were also contacted by a corps of volunteer health messengers and through mini-workshops that covered adolescent health, modification of unsafe sex practices, gender stereotypes and self-esteem.

Reinforcing the prevention messages were written materials, including such pamphlets as "AIDS, You Can Avoid It Too," "Take Care of Yourself" and "Speak to Your Children about AIDS." The project also developed user guides for youth leaders and cloth flip charts that could be rolled up and thrown over the shoulder. All the materials went through an extensive process of technical revision and pretesting among target audiences.

Over the five-year life of the project, Acuario reached more than 180,000 persons -- including young people, their parents and their neighbors. The two allied NGOs distributed almost 115,000 brochures, pamphlets, fliers and other informational pieces. Nearly 4,700 persons received training through workshops and other educational activities.

Research studies at the end of the Acuario Project showed impressive shifts in the knowledge, attitudes and behavior of the young people in the targeted neighborhoods. All of the 1996 survey respondents could identify at least two high-risk sexual practices, and almost 19 out of 20 of the young people knew where to purchase condoms. Just over 85 percent of the target population knew where to access appropriate services to treat STIs.

Sexual risk taking decreased dramatically among the youth. In 1992, 73 percent reported that they were sexually active, compared with 30 percent in 1996. In this same population, the proportion reporting that they engaged in sex for money or gifts dropped from 27 to 7 percent among young men and from 9 to 6 percent among young women. Among the young men who were sexually active, the percentage who reported using a condom during their most recent sexual intercourse rose from 29 percent in 1993 to 47 percent in 1996. The 1996 figure for women -- 17 percent -- was noticeably lower than for males, but still triple the rate reported in 1993.

The impact that CASCO and IDDI had, however, went far beyond the four communities the Acuario Project served directly, as the groups shared the knowledge and expertise they had developed. In March 1997 the two NGOs hosted a three-day national forum in Santo Domingo with more than 100 young leaders of youth programs. Young people were involved in all stages of planning, implementing and evaluating the event. A number of government agencies, NGOs and universities also participated in reviewing youth risk behaviors and devising a new, integrated approach to adolescent health and STI/HIV/AIDS prevention.

The forum participants developed a "manifesto" on health, education and labor issues related to youth. After the meeting, they formally presented the document to government agencies and other organizations working with young people. They also held a series of regional assemblies with youth groups to share the declaration.

The Acuario Project hosted an April 1997 training workshop on HIV/AIDS prevention methodology for community youth organizations. Leaders from more than 20 community groups participated in the seminar, along with government officials from the national STD and AIDS control program (Programa de Control de Enfermedades de Transmisi�n Sexual y SIDA, or PROCETS) and the Ministry of Health's Adolescent Integral Health Program. The course covered arranging and implementing HIV/AIDS prevention activities, as well as integrating health and sexuality components into the local organizations' existing work. Other workshop sessions addressed teenage pregnancy, STIs and problems brought on by the disintegration of families.

Mass Media Campaign

At the same time it was supporting Acuario and dissemination of the project's lessons learned, AIDSCAP was pursuing other strategies for reaching young people. One of the most important was the mass media campaign to reinforce the interpersonal communications activities of CASCO, IDDI and other youth and HIV/AIDS prevention organizations.

The first steps toward creating a mass media campaign came soon after AIDSCAP was launched in the Dominican Republic in September 1992. One of the program's priorities was to work with government agencies and NGOs to create communication strategies for HIV/AIDS prevention. As part of that effort, AIDSCAP and more than a dozen organizations involved with young people set up a special working group to develop a national plan for preventing HIV transmission among 13- to 19-year-olds. Through a special advisory committee that met regularly, many of those organizations continued to provide suggestions and feedback as AIDSCAP planned and later implemented a youth mass media campaign.

In June 1995 AIDSCAP chose Cumbre, a well-known Dominican advertising agency, to produce mass media materials for the first phase of a three-part effort that would ultimately span nearly two years.

The first TV spot created began airing in September 1995. In this "interactive" ad, young actors looked directly at the camera and posed questions for youthful audiences to consider, including: Are you sexually active? Do you know what STIs are? Do you know AIDS can't be cured?

The TV ad and its companion radio piece concluded with a campaign slogan, "�Sabes que si te da, no llegas?" (Do you know, if you get it, that's it, that's the end?) The first part of that question -- si te da -- is a word play on SIDA, the Spanish acronym for AIDS, that was further emphasized in printed materials through the use of contrasting colors.

With the "interactive" format of the first broadcast ads, the Cumbre agency intended to confront the attitudes and misconceptions revealed in research among Dominican youth. "Young people live in their own world," said Cumbre President Freddy Ginebra. "They don't have fear, they take more risks, they're adventurous and rebellious. They don't think death exists, so we looked for a 'code' to challenge them and to make them think."

The campaign's second ad, which began airing in December 1995, was also intended to raise young Dominicans' awareness of HIV/AIDS and their personal risk. Entitled "Party," it showed a crowd of attractive, well-dressed young people dancing, talking and looking for potential partners. It ended with a warning: "You can't know who to be with and who not. You can't guess who has AIDS."

Posters, bumper stickers, brochures and other printed pieces featured photos of the actors in the TV ads and reinforced the broadcast spots' key messages. These ancillary materials were distributed to government agencies, NGOs working with adolescents, radio stations, record and video stores, and movie theaters.

AIDSCAP persuaded dozens of radio and TV broadcasters and cable-TV system operators to carry those first two ads for free, as well as two more produced the following year. While some media ran the announcements only once a day, other outlets carried them more than 30 times daily. In just the first five weeks of the campaign, broadcasters contributed air time worth over U.S.$350,000; in a year, that total reached more than $2.6 million.

The AIDSCAP campaign received additional free exposure from news media reports. For example, List�n 2000, the Sunday youth magazine of the Dominican Republic's largest-circulation newspaper, carried a cover-story piece on the campaign and included basic information on HIV transmission and prevention.

The Dominican press also gave wide coverage to a September 1995 rally AIDSCAP organized to announce the launch of the campaign. Some 1,000 young volunteers from NGOs working in HIV/AIDS prevention marched through the streets of Santo Domingo wearing campaign hats and T-shirts and carrying colorful balloons and banners with campaign slogans. At the launch ceremony, representatives from the government, church and other influential sectors of Dominican society endorsed the campaign.

In the fall of 1995, AIDSCAP began the campaign's second phase, synchronizing the activities of many of the groups working with young people and establishing a referral network for adolescents' questions about HIV/AIDS.

A two-day workshop brought together representatives from government agencies, NGOs and international organizations in February 1996 to discuss what they had learned from their work with young people and suggest models for effective STI and HIV/AIDS education and counseling services. Using that information, AIDSCAP produced a manual and held training sessions for some 100 groups involved in youth and health issues. (See 4.2. Lessons and Recommendations.)

Both the manual and training sessions, said Ceneyda Brito, AIDSCAP's communication coordinator in the Dominican Republic, "dealt with how to work with young people on any problem, not just HIV and AIDS." The materials emphasized the need to view HIV/AIDS prevention within the context of all the challenges adolescents face and the physical and emotional changes they undergo.

Collaborating with other groups on the manual and encouraging them to convey consistent messages to young people had another benefit, according to Brito. "Working to reach a consensus," she said, "gave them a sense of participation and made them feel like 'owners' of the process. All of the groups that came together have continued participating in the campaign."

A Coordinated Approach

AIDSCAP hired a research firm to conduct focus group discussions with adolescents to assess their reactions to the campaign's first phase. The majority of the participants remembered seeing or hearing the ads on television or radio at many different times of the day. When asked about the campaign's messages, the young people cited the need to protect themselves against HIV/AIDS, the need to have fewer sexual partners and the fact that HIV infection could ruin a person's future.

The focus groups also identified misconceptions about HIV/AIDS for the campaign to address, as well as themes for future advertisements. Many of the participants suggested the campaign encourage better communication between adolescents and their parents about HIV/AIDS and sexuality.

As AIDSCAP and the Cumbre agency began working on the materials for the campaign's third phase, they included a step they hadn't anticipated with the first TV spots. The new actors in the third and fourth ads received "sensitization" training to prepare them for the attention they were likely to receive and "to turn them into peer educators," Brito said. The novice actors in the first two ads had become so well known that members of the public and media frequently asked them questions about HIV/AIDS.

The third advertisement, with the "Solamente Una Vez" theme, was launched in September 1996 with another large rally affirming public support for the campaign. While the ad reinforced the campaign's message of risk awareness, it also listed a telephone hot line number that audience members could call for additional information and referrals (see 4.1. HIV/AIDS Hot Line Offers Information, Advice and Comfort). The ad was especially effective at generating calls during the after-school hours when young people usually watch television, according to Brito.

The last of the campaign's TV and radio ads was another interactive spot. But this one was aimed at adults, encouraging them to talk to their adolescent children. Through a series of questions, parents were challenged: Have you noticed your children are taller than you? Have you talked to them about STIs and AIDS? Do you realize that if you don't talk to them, you'll be responsible if they become infected? And if you haven't talked to them, what are you doing?

As with the first phase of the campaign, printed materials reinforced the radio and TV ads. Dominican broadcasters again aired the new announcements thousands of times without charge, according to data compiled by a media monitoring firm. During the last three months of 1996, the value of the contributed air time was about U.S.$1.6 million.

From September 1995 to March 1997, 38,495 TV spots and 454,770 radio spots were broadcast for free, representing over U.S.$9 million in air time.

As successful as AIDSCAP ultimately was in persuading media executives to break with tradition and carry the ads for free, that task was still one of the campaign's greatest challenges, according to Brito. "I tried to convince them it's a responsibility we all have," she said. "With new stations, I also pointed to other broadcasters that were already running the advertisements. In many cases, they ended up broadcasting the advertisements more often than they promised us."

Brito, who has worked on other public health media campaigns in the Dominican Republic, believes one reason the broadcasters responded so favorably was the high quality of the advertisements. The "Solamente Una Vez" spot received a second-place prize in a nationwide competition for Dominican advertisers -- the only noncommercial organization and the only public service message honored among the contest's 18 award winners. The importance of top-level production techniques, Brito said, could be an important lesson for other organizations considering a mass media campaign.

The Dominican campaign has drawn praise from other countries in Latin America. At meetings in Mexico, Venezuela, Colombia and Costa Rica, advertising and public relations colleagues gave Cumbre's Ginebra standing ovations when he showed them the ads and other campaign materials.

The television and radio spots received the top prize at another meeting in Mexico, awarded by communication experts from 20 countries who gathered in the city of Zacatecas in November 1996 for a seminar on adolescent sexual health. Along with the recognition came a grant of U.S.$3,000, to go toward duplicating the Dominican materials and distributing them to organizations elsewhere in Latin America and the Caribbean.

"The groups in Zacatecas," Brito reported, "were impressed with the campaign's coordination of materials and work being done by the various HIV/AIDS prevention agencies."

That careful structuring of numerous communication channels is vital to a successful campaign, as is cooperation among those who work with the target audience, emphasized Brito. "Having all the groups harmonize their approach," she said, "guaranteed their support, as well as the support of others who saw the example of a product produced jointly to solve a problem."

And, said Brito, that close collaboration and use of multiple dissemination paths ensured that Dominican youth received a consistent message from NGOs, the media, their parents and their peers -- much more often than "just one time."

4.1. HIV/AIDS Hot Line Offers Information, Advice and Comfort
AIDSCAP's media campaign for adolescents was intended to break through the sense of invincibility typical of many young people, and it was extremely effective at that, according to those who have answered calls to a telephone hot line that has supported the campaign.

"They call because they're worried about themselves or someone they know or are involved with," said Miguelina Monta�o, a psychologist who has worked with the telephone service. "They don't even want to say the word 'AIDS.' They say it in a soft voice."

Many young people have called after they've engaged in some risky behavior and are looking for information and a sympathetic listener, according to Monta�o. Often they ask about possible HIV/AIDS symptoms. "They say they've had a rash, a fever, or they've vomited or had a headache for a week, and they want to know if they have AIDS," she said. "A lot of people think once you're infected you'll see something right away. Because the symptoms are so broad, it's likely they'll have one of the symptoms."

The HIV/AIDS telephone information service that was advertised in the campaign's TV ads and roadside billboards was a collaborative undertaking of AIDSCAP, the Dominican NGO Instituto de Desarrollo y Salud Integral (INDESUI) and several universities. It built on the NGO's hot line that since 1991 has answered callers' questions on such issues as depression, alcoholism, drug addiction, suicide and the abuse of women and children. INDESUI works in three low-income neighborhoods of Santo Domingo to strengthen local community groups and to raise residents' incomes and improve their physical and mental health.

In 1995, AIDSCAP trained INDESUI staff and contributed computer equipment so the organization could maintain a database of HIV/AIDS information and a listing of HIV/AIDS service providers to whom callers could be referred. The equipment also allows INDESUI to track the number and type of calls the telephone hot line receives. The Pontificia Universidad Cat�lica Madre y Maestra (PUCMM) created the software INDESUI uses and helps maintain the computer hardware.

Volunteers from PUCMM and four other universities -- many of them psychology students -- and health professionals from the community respond to the callers' questions. All the volunteers must take a ten-hour training course before they can work on the hot line.

During the AIDSCAP campaign, the majority of the callers to the INDESUI hot line were young people asking about HIV and AIDS. "With every call, there's almost always an emotional worry," said Monta�o. "When they call about symptoms, it's usually because they've had an experience and they're worried about it. They want an answer to their doubts."

The INDESUI staff members studied the most frequent HIV/AIDS questions raised in the calls and used those data to compile a training manual for the persons answering the hot line. Among the subjects on which the volunteers most often provided information and advice were the origins of AIDS, means of HIV transmission, testing for HIV/AIDS, homosexuality and homophobia, sexual risks, children and AIDS, commercial sex workers and condoms. With their computerized records, the INDESUI staff could also suggest appropriate health care providers close to a caller's location. "Each call is different," said Monta�o. "You have to figure out what they're looking for, and then you can give them an answer."

INDESUI continues to provide counseling and advice to adolescents and other callers 12 hours a day, seven days a week. During the AIDSCAP campaign, the telephone service typically received 20 to 30 calls per day, in part depending on the number of AIDSCAP adolescent campaign advertisements Dominican broadcasters had been carrying. INDESUI staff members also noted a jump in the number of calls when local newspapers carried stories about the AIDSCAP campaign and the hot line service.

4.2. Lessons and Recommendations
Lessons Learned

Youth appreciate direct messages that give them clear guidance on what to do.
Messages directed to such "gatekeepers" as parents and teachers are needed to complement and support the communications that target youth.
In developing successful mass media campaigns, it is essential to involve organizations that work at the interpersonal level and provide services to the target audience.
Having high-quality advertisements builds private media support and encourages the broadcasters to carry the ads more often.

Recommendations

Youth should remain a high priority for HIV/AIDS educational efforts because they represent an opportunity to reach high-risk individuals before they become infected. In addition, modifying behaviors that are strongly influenced by culture and personal value systems may be easier at an earlier age.
HIV/AIDS communication to reduce sexual risk taking among youth should include messages directed to parents, teachers and other influential gatekeepers.

Meeting the Challenge of the HIV/AIDS Epidemic in the Dominican Republic: The AIDSCAP Response, 1992-1997