This report covers the FHI AIDS Control and Prevention (AIDSCAP) Project (1991-1997). Volume 1 covers regional program overviews, technical strategies, and program support strategies.
Table of Contents
Volume 1
Introduction
Regional Program Overviews
-Africa
-Asia
-Latin America & the Caribbean
Technical Strategies
-Behavior Change Communication (See Below)
-Condom Distribution
-STI Services
-Policy
-Behavioral Research
Program Support Strategies
-Program Evaluation
-Program Management
-Women's Initiative
-Information Dissemination
Appendixes
Volume 2
Technical Strategies
Behavior Change Communication
Strategy Overview
Over the course of the AIDSCAP Project, behavior change communication (BCC) for HIV/AIDS prevention continued to evolve into a specialized field, drawing on and using experiences from family planning, social marketing, anthropology, psychology, education, and communication. Because prevention of an often fatal sexually transmitted infection (STI) is significantly different from other health promotion goals, AIDSCAP/FHI BCC programs sought to refine traditional communication approaches to address usually private and sensitive matters such as sex, trust, and death. This meant that BCC specialists had to broaden their focus from just disease prevention to include the social, political, and environmental factors that influence risk behavior. The technical strategy guides this process.
The goal of the BCC component of the AIDSCAP/FHI strategy was to make effective use of behavioral and communication theory and research to develop communication activities that would influence individual behaviors and the social context in which they occurred. The objective was to reduce the number of high-risk exposures for STI/HIV infection through (1) increased condom demand and use; (2) increased STI-related treatment-seeking and preventive behaviors; (3) decreased numbers of sexual partners; and (4) increased norms and policies that support HIV/AIDS prevention activities.
To achieve this objective, BCC interventions were based on a theoretical approach that took into account the complex connections between individual acts and the social settings in which those acts occurred. This approach focused on
- developing interventions and messages acknowledging both the individual and the sexual partner(s).
- targeting social structures that provide the context, which influences an individual's knowledge, attitudes, and behaviors.
To maintain this focus, BCC planners were encouraged to investigate both the individual and the community when formulating a behavior change intervention. The community investigation included analysis of the demographic, economic, political, cultural, epidemiological, and developmental environments. The individual investigation explored the following issues as they affected the target audience:
- How do members of the target audience currently understand and practice HIV/AIDS preventive behaviors?
- What do they see as the benefits to practicing safer sexual behaviors?
- What information will motivate them to change their sexual behaviors or continue safer sex?
- What is their perception of the risk of becoming infected with STI/HIV?
- What are their perceptions of peer and social norms governing sexual behavior and HIV/AIDS prevention?
- Where are they in the process of behavior change?
AIDSCAP/FHI stressed that both the target audience and communities must be involved in developing behavior change interventions to ensure that their values, concerns, and needs are reflected in the program.
The BCC technical strategy also called for the use of multiple communication channels. Information about reach, cost, feasibility, appropriateness to the message, and effectiveness in changing behaviors determined which communication channels (i.e., interpersonal communication, institutional networks, mass media, and "small media") were selected.
As experience accumulated and as individuals became more knowledgeable and aware of their personal risk, the emphasis of the BCC technical strategy shifted to emphasize more interventions for couples, communities, and policymakers. Initially (and appropriately), many implementing agencies had aimed interventions at individuals (e.g., peer education programs). Later, when awareness raising activities had been successful, implementing agencies expanded their reach and developed dyadic-level activities (e.g., couple counseling and dialogue technique) and also activities seeking to modify social norms at the community and institutional level (e.g., condom social marketing, advocacy and consensus building, and private sector leveraging).
Accomplishments and Results
The BCC strategy was applied in more than 500 subprojects -- both long-term and shorter rapid-response-funded activities. Implementing agencies had to commit to a strategy that was considerably more complex than traditional health education. In many cases, this required a new way of thinking about the design and implementation of projects. As a result, training in the principles and skills of BCC was often required and requested. Technical assistance was provided by the professional communication officers based in each AIDSCAP/FHI regional office or by BCC officers and consultants in the country office. Occasionally, BCC staff from headquarters participated in technical assistance activities.
Technical assistance was also provided in the form of small, practical "how-to" handbooks, which were developed and disseminated throughout the project to help the practitioners upgrade their BCC skills. Titles of the handbooks illustrate some of the skills that are required of a successful BCC practitioner in the era of HIV: How to Create an Effective Communication Project; Behavior Change Through Mass Communication; How to Conduct Effective Pretests; Assessment and Monitoring of BCC Interventions; How to Create an Effective Peer Education Project; HIV/AIDS Care and Support Projects; and How to Create a Partnership with the Media. During the project, 180,000 peer educators, health workers, religious and community leaders, and outreach workers were trained to provide STI/HIV/AIDS prevention information; approximately 18 million individuals were educated about STI/HIV/AIDS.
A database of the educational materials (small media) produced during the project contains more than 1,125 items, ranging from posters and leaflets to video productions and scripts for radio soap operas. The database had several purposes: (1) to keep track of all BCC deliverables; (2) to document information on how the materials were being used (e.g., Who is the target group? What message is being communicated? Was it pretested?); (3) to monitor the quality of the materials; and (4) to provide sample materials and ideas to AIDSCAP programs and to outside agencies who requested them.
Because peer education is a component of so many STI/HIV/AIDS prevention projects throughout the world, AIDSCAP/FHI encouraged implementing agencies and health officials to take a critical look at peer education projects. In an effort to better understand how, when, and where these projects can be most usefully used, AIDSCAP/FHI studied 21 peer education projects in 10 countries. The knowledge gained from the findings was the basis for a BCC handbook, which is now available to planners as a guide for planning and developing peer education projects and for selecting, training, and supervising peer educators.
AIDSCAP/FHI-sponsored training and support resulted in a network of committed volunteers and professionals with the necessary skills and with the appropriate educational and motivational materials for effective behavior change interventions. This large group of STI/HIV/AIDS prevention care workers achieved impressive results. In Cameroon, for example, the percentage of male students targeted by the program who reported having more than one partner fell from 53 percent in 1993 to 36 percent in 1996. Similarly, in Jamaica, the proportion of young people who reported having nonregular partners fell from 37 percent in 1994 to 19 percent in 1996. In Bangkok, the proportion of male blue collar workers who reported having more than one noncommercial partner dropped from 15 to 11 percent in 3 years.
Another primary AIDSCAP/FHI objective was to increase condom demand and use, and again, BCC practitioners achieved positive results. In Haiti, the percentage of men who used a condom rose from 16 percent in 1990 to 40 percent in 1995. In Jamaica, the percentage of women who said they had used a condom with their last nonregular partner rose from 37 percent in 1992 to 73 percent in 1996. In Cameroon, 88 percent of commercial sex workers (CSWs) reported using a condom in 1996, compared with only 28 percent in 1988. In Thailand, brothel-based CSWs reported 97 percent condom use with every client in 1996, compared with only 87 percent in 1993.
Lessons Learned and Recommendations
Beyond Awareness
- In addition to encouraging individual behavior change, BCC can and must help create environmental conditions that facilitate personal risk reduction.
In Jamaica, a communication strategy developed with a local public relations firm targeted religious institutions, the media, and private businesses to encourage (1) changed attitudes toward STI/HIV/AIDS education in the workplace, (2) public discussion of sexual issues on radio and television, and (3) increased compassion toward people living with HIV/AIDS. Each target required a different strategy and a different message.
These efforts created a more supportive environment in which individual Jamaicans received encouragement from many sectors to practice safer sex. Media gatekeepers became more receptive to covering HIV/AIDS issues, airing 63 radio and television programs, and publishing 121 newspaper and magazine articles on the subject in 2 years. Business owners and managers agreed to work with the Jamaican Ministry of Health (MOH) to establish workplace prevention programs. Some supported the programs with cash or in-kind contributions. The influential Jamaica Council of Churches endorsed a series of workshops that gave religious leaders a better understanding of STI/HIV/AIDS and helped them counsel their congregations about the disease.
"When we started working, talking openly about sexuality on the radio was simply not done. It is not our culture. But we have watched that break down. People now talk about it on the radio." (Jamaica)
- Risk-reduction efforts need to address the behavior of both partners in a relationship, but particularly the partner who has the most control.
BCC efforts should focus on (1) motivating men to hear and heed the concerns of their female partners, and (2) encouraging partners to improve and use sexual negotiation skills.
AIDSCAP/FHI responded to this need by using a number of methods for encouraging partner negotiation. In the Dominican Republic, provocative theater (a type of street theater performed in bars or on the street that, unknown to the public, is rehearsed drama) is used to model situations in which women express themselves confidently and men learn to listen to their points of view about sexually related problems, such as STI symptoms or condom use. Three of AIDSCAP/FHI's eight "Emma Says" comic books provide models and scripts for sexual negotiation. Numerous videos and soap operas from Kenya, Zambia, Haiti, Brazil, Thailand, and Nepal illustrate men and women working through emotionally difficult discussions. AIDSCAP/FHI used these models to give women and men opportunities to rehearse and develop their own sexual negotiation skills.
"A technique we've found useful and that encourages discussion between men and women is to get them into a group together. Then you bring them together and they speak through you as a chair. You know, they are asking you, the chair, a question that is really meant for the other sex. They're sort of shy for the first 5 or 10 minutes. Then it begins to get heated. Someone asks a question that provokes and eventually they just ignore the chair and are talking and arguing with each other. We've found this facilitation very useful." (Zimbabwe)
- If peer educators are trained only to provide STI/HIV/AIDS awareness information, they may not be effective in influencing later stages of behavior change.
In a study of 21 peer education projects in Africa, Asia, and Latin America, AIDSCAP/FHI project managers found it necessary to revisit the needs of the peer community periodically. If target audiences were already knowledgeable about STI/HIV infection, then peer educators needed advanced training on behavior change and maintenance.
To encourage behavior change, peer educators need to know when to enlarge the basic message, when to listen, when to empathize, and how to bring STI/HIV/AIDS into conversations about other issues. If peer educators do not have these skills, their work may be useful only in the early phases of the behavior change process when they can promote awareness and impart knowledge.
Private Sector Collaboration
- Well-planned BCC can leverage private sector commitment and financial involvement.
In the Dominican Republic, an AIDSCAP/FHI campaign targeting adolescents attracted more than U.S.$9 million worth of free airtime from local and international media. AIDSCAP/FHI leveraged this media support by investing $53,000 in developing high-quality TV and radio spots and related print materials.
- In some settings, collaboration with local communication professionals may be more cost effective than training HIV/AIDS program personnel to perform specialized communication skills.
Working with public relations firms, advertising agencies, and media consultants can be expensive unless they donate their services, but is often worth the cost. Many local firms and consultants have the contacts, understanding of culture and trends, and professional expertise needed to develop effective BCC campaigns.
AIDSCAP/FHI's experience with such collaboration has been rewarding. For example, a Dominican advertising agency worked with AIDSCAP/FHI staff to design an award-winning mass media campaign for youth. A Jamaican public relations firm helped AIDSCAP/FHI and the Jamaican MOH design and implement a BCC strategy that created a supportive environment for individual behavior change. In Kenya, AIDSCAP/FHI worked with a Nairobi communications consulting firm to place a regular weekly column on HIV/AIDS in a national newspaper. Written by a well-known Kenyan journalist, the "AIDS Watch" column reached an estimated 700,000 people every week and generated thousands of letters from readers.
- There is a natural partnership between BCC projects and condom social marketing projects.
CSM projects often create excellent educational and promotional items, as well as mass media promoting brand recognition and condom use. These projects allow BCC interventions to concentrate on interpersonal communication. In addition, the ability of CSM projects to publicize their product helps desensitize the condom issue and in turn, lays the groundwork for more specific behavior change messages.
In Nepal, for example, the CSM program developed radio and TV spots and a film shown in cinema halls and from mobile film vans. The film showings were closely coordinated with intensive outreach efforts throughout the country. These mass media efforts made it easier for outreach workers to discuss HIV/AIDS with target audience members. In Ethiopia, Tanzania, and Haiti, condom advertising on radio and television were an integral part of national risk-reduction campaigns.
Communication Tools
- Despite the initial misgivings of some public health officials, well-planned and well-executed entertainment has proven effective in conveying serious behavior change messages.
Live and taped dramas were used throughout the AIDSCAP Project to show audiences models of behavior change situations as well as possible implications of their behavior. Themes and messages that lend themselves to a dramatic format include sexual negotiation, HIV/AIDS care and support, stigma, and discrimination.
AIDSCAP/FHI-sponsored folk theater, street theater, videos, radio and TV soap operas, and magazine and newspaper stories generated enthusiastic responses from audiences and serious discussions about HIV/AIDS. For example, a Kenyan radio soap opera prompted 27,000 letters from listeners with questions and comments on the topics addressed in the broadcasts. In Jamaica, publication of question and answer columns about safer sex in local newspapers and youth magazines generated 65 percent of the calls received by the telephone STI/HIV counseling service, "Helpline," over 2 years.
Examples of AIDSCAP/FHI's use of entertainment includes provocative theater in the Dominican Republic, the Miujiza Players drama group in Kenya, "The House of Charms" video in Thailand, monthly articles in Claudia magazine in Brazil, soap operas in Zambia and Haiti, a Nepalese video about a truck driver and his assistant, "Fleet of Hope" productions in five countries, and dramas produced by peer educators in Zimbabwe. A Jamaican communication officer noted that "community theater is the most effective tool we have" because it depicts everyday life and encourages discussion.
"Performing plays helps the person to think and see what is applicable to real life. In a play it is easy to tailor a message for a specific target audience, for example students or factory workers. When they see you on stage talking about corruption, diseases, and then eventually to zero down to HIV/AIDS, it's really fascinating for them. After we have done the play and had a chance to ask questions, the audience normally opens up very easily." (Kenya)
- The concept of a behavior change continuum is a useful tool for BCC specialists, helping them develop messages and approaches that are appropriate to the stage of change of their target audiences.
The continuum adopted by AIDSCAP/FHI describes people's movement from awareness of a potential risk to motivation to change, trial of a new behavior, and adoption and maintenance of the behavior. An AIDSCAP/FHI study conducted in eight countries used the behavior change continuum to question BCC officers and program managers about the impact of their work. An example of a typical response is the following, from Zimbabwe: "In the beginning we were at awareness they knew there was some problem, but they were not particularly concerned. And now I think we are bouncing back and forth between motivation and trial. We're distributing a lot of condoms -- about 450,000 this year -- so that's some trial."
Recognition that behavior change is a process and that messages must be appropriate to the stage of change requires considerable ingenuity from BCC specialists. In Cameroon, projects working with relatively cohesive and homogeneous groups, such as sex workers and military personnel, found that members of the target population generally moved along the behavior change continuum at similar rates. However, university students in the same country presented a greater challenge. Because they entered the university with different levels of understanding about HIV/AIDS, and because upper class students had more exposure to prevention education, this large target group was segmented according to their positions on the continuum, and messages and approaches were tailored for the various segments.
- Some BCC messages and materials have a universal appeal.
Although BCC messages and materials should always be pretested with members of the intended audience, it may not be necessary to develop new materials for each target group. In fact, some messages transcend culture and nationality. A study of several AIDSCAP/FHI materials used or adapted throughout the world found that these materials appealed to individuals from many different cultures because they addressed universal concerns.
In Tanzania, for example, a brochure on "The Fleet of Hope" was designed to help individuals and communities with diverse religious backgrounds and moral beliefs understand the impact of HIV/AIDS and assess their own risk. It advises readers to board one of three "boats" -- abstinence, monogamy, or condoms -- to save themselves. This metaphor and the options it offers has proved popular and effective in at least eight countries. It has been used in folk media, video, poster, presentations, and other materials. Another example is "Emma," a West African comic book character who has spread STI/HIV/AIDS prevention and care messages in 20 countries. AIDSCAP/FHI encouraged such cross-fertilization of messages and materials by sharing model materials from its computerized BCC database with communication officers in the field.
Capacity Building
- Capacity building in BCC is critical, even for experienced health educators.
The concept and techniques of BCC are not easy to grasp and apply. Because approaches to STI/HIV/AIDS prevention continue to evolve, donors must recognize and address the need for new knowledge and skills.
AIDSCAP/FHI found that one cost-effective way to build capacity is through the use of practical handbooks that guide the reader through the various steps of the BCC process. Project managers and BCC officers report that AIDSCAP/FHI's series of BCC handbooks are useful as teaching aides, reference material, sources of new ideas, and check lists.
For example, managers of AIDSCAP/FHI-supported projects in Ethiopia used one of AIDSCAP/FHI's six handbooks, How to Create an Effective Peer Education Project, as the framework for developing all their peer education projects. In Kenya, the government distributed photocopies of the AIDSCAP/FHI handbook on creating an effective HIV/AIDS communication project to 200 MOH communication officers, who were instructed to use it as their guide. In the Lao People's Democratic Republic, chapters of two of the handbooks were translated and used in workshops to develop STI/HIV/AIDS prevention messages for projects in three different sites. One BCC officer reported that the three working teams found that the two books provided them with the clearest framework for communication and BCC intervention.
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"Emma Says"
All over the world, people listen to what Emma says. The star of AIDSCAP/FHI's "Emma Says" comic book series has dispensed practical, compassionate advice about STI/HIV/AIDS prevention and care to tens of thousands of people in Africa, Asia, Latin America, and the Caribbean.
Originally developed by AIDSCAP/FHI's predecessor, the AIDSTECH Project, as a character in a flip chart for peer education sessions with West African women, Emma has become a trusted source of information about STI/HIV/AIDS in more than 20 countries. Since the creation of the first comic book in 1994, eight different "Emma Says" have been translated into six languages, and 171,000 copies have been distributed. Thousands of people have seen dramatic presentations about Emma performed by local organizations in Tanzania, Ethiopia, Nigeria, and Cameroon. In Rwanda, she became a film star when AIDSCAP/FHI's social marketing partner, Population Services International, received funding from UNICEF to create an "Emma Says" video and a companion photonovella.
As an aunt, a neighbor, and a friend, Emma deals directly with difficult issues facing individuals, families, and communities in the era of HIV/AIDS. In her first three comic books, she talks to women about how to introduce condoms into a relationship and about the importance of getting prompt, effective treatment for STIs. She also addresses HIV/AIDS care and support in the series by helping neighbors accept and care for their HIV-positive son, showing people how they can assist coworkers and friends living with HIV/AIDS, and motivating a community to organize a care and support network. The final books in the series find Emma helping a 16-year-old friend seek treatment for an STI. |
Challenges for the Future
Change in Social Norms
The art of designing and implementing communication programs to change community norms and values is not yet well understood. We know that mass media can play an important role, but questions remain about its relative value compared with other channels of communication, the timing of BCC campaigns, the synergy of different channels and messages, and the appropriate duration of BCC campaigns. Research is needed to explore the best ways to use communication to support or change social norms and to measure such change.
Maintenance of Behavior Change
Maintenance of safer sexual behaviors over time has not received much attention to date. Some behaviors are expected to change as an individual's life changes. For example, condom use may no longer be necessary when an uninfected person enters a monogamous relationship with another person who is HIV-negative. However, other changes -- or relapses to behavior that is less safe -- may invalidate the previous safer behavior and lead to HIV infection. Strategies and messages that motivate people to maintain safer sexual behaviors need to be investigated.
Stages of Change
Several popular models of the process of behavior change illustrate stages that individuals are likely to go through as they respond to information, make decisions, and try new behaviors. At each stage in the process, individuals need different kinds of information, emotional support, and skills. The ability to track a target audience's movement through these stages in a timely manner would allow program planners and communication specialists to target messages more precisely to the needs of the audience. Research is needed to clarify societal, rather than individual, indicators of change.
Challenges of Reaching Mobile Populations
Research is needed to identify ways to communicate with individuals who are socially marginalized, including migrant workers, refugees, and those who are homeless and may be living on the street. Highly mobile populations pose special challenges for BCC campaigns because they are particularly difficult to continue to reach with consistent messages.
