A. Behavior Change Communication
- While Jamaica's BCC campaigns effectively increased knowledge of HIV transmission and prevention in the general population, certain messages were more difficult to convey, and certain target audiences were more difficult to reach.
In Jamaica, more than 95% of the adult population could cite two means of HIV prevention. Nonetheless, 40% of the population believed in an inaccurate means of transmission (such as mosquito bites, public toilets, or social contact). Although 97% of youth (12 to 14 years old) were able to cite two prevention methods, only 50% were aware that individuals with HIV could be asymptomatic. These contradictions indicate that individuals acquire new, preventive, information more easily than they reject myth, rumor, and bias previously acquired.
High levels of knowledge of HIV transmission and prevention in the population do not, by themselves, allow individuals to accurately assess their risk for HIV prevention, or diminish negative attitudes towards, and fear of, individuals with HIV/AIDS. The percentage of the population unable to assess their risk for HIV infection increased over the period of the AIDSCAP project. This trend reflects the ability of BCC campaigns to increase self-examination of risk behaviors but their ultimate limitation to influence appropriate perception of risk. Despite high levels of knowledge, a majority of the population in Jamaica favor compulsory disclosure of HIV status.
Certain target populations which are more geographically, economically, or socially isolated (including youth), require more carefully crafted BCC campaigns with active interaction of target population members, and collaboration with gatekeepers. These contacts improve the projects potential access, legitimacy and visibility. The Targeted Community Intervention (TCI) and Jamaican Red Cross projects used their audiences affinity for drama and the arts as effective communications approaches. Use of local music was especially successful and popular in getting messages out to a wide audience.
- A public relations component benefits a public health campaign, particularly in leveraging support from the private sector for their activities.
By incorporating public relations into its BCC strategy from the beginning, the Jamaica program was able to not only inform and educate the populace about HIV/AIDS but also to persuade and influence policy makers and opinion leaders that the epidemic belonged on the public agenda. Since the role of public relations can be viewed as one of influencing, rather than of informing, its integration into the BCC strategy resulted in greater access to and influence on media, corporate and community contacts.
Prior to program implementation, news coverage about the epidemic was limited and actually served to reinforce the stigma surrounding it. Consequently, Berl Francis and Company Ltd., through its media contacts, met with editors of newspapers and program directors of radio stations to present the findings of a survey that outlined how they reported on HIV/AIDS and the effects of this reporting on the knowledge and attitudes of the public. By humanizing the problem and presenting it as a development issue rather than solely a health issue, the media realized it had a role to play in the prevention and control of HIV/AIDS. Thus, over a course of two years, more than 400 articles appeared in print and over 60 radio and television programs aired that were related to the topic of HIV/AIDS.
The success of large-scale special events, such as World AIDS Day activities, depends not only on good organizational skills but also on support and endorsement from a multitude of sources. The AIDS Run '94 was successful in that it was an island-wide relay with participation of runners from Jamaica's athletic program as well as from school and community groups. Its success can also be described by the donations of promotional T-shirts, beverages for the runners, and ad space in the Jamaica Herald -- all of which were secured through the efforts of the public relations firm. Similarly, cash donations to offset the costs of hosting the Pastors Workshop and presenting prizes for the Comic Competition, Safe Sex Week Quiz, and Drama Competition were requested and received from private sector establishments, such as Burger King, Petroleum Corporation of Jamaica, Universal Stores, and Carib Cement. Over a two-year period, Berl Francis and Company have documented verifiable cash or in-kind contributions totaling more than US$180,000 that benefited program activities and were a result of their public relations efforts.
- BCC messages are best developed by multidisciplinary teams, including professional health educators, media and public relations specialists, evaluators, and psychologists.
A collaborative approach in the development of BCC messages was utilized successfully in Jamaica. A group consisting of project managers and professional health educators, individuals from the Communications Team of the Epi Unit and the public relations and evaluation agencies, and a psychologist met/convened on a frequent basis to review and discuss current and new messages for the specific target audiences. The participation and input from each field/professional resulted in messages which clearly demonstrated an in-depth understanding of the target populations from all aspects -- psychological, sociological, economic and cultural.
The project managers and health educators brought to the discussion the day-to-day realities experienced in the field; the Communications Team contributed with expertise in communicating the health messages, particularly ones which promoted behavior change; the public relations specialist recommended the channels to best reach the audiences and utilized contacts in the media to place the issue of HIV/AIDS on the public's agenda; the psychologist provided a wealth of psychological and sociological information to enable the group to better understand the target populations, in other words "to understand where they were at"; and the evaluation specialist monitored the effects of these messages on the knowledge and attitudes of the target audiences. Thus, this coordinated approach resulted in BCC messages that were appropriate for and relevant to the target audiences, technically sound, and culturally sensitive.
- Culturally-sensitive public health campaigns have the greatest effect on target populations. Understanding the culture and society in which one is working is vital to a program's success.
Jamaica is an oral culture, and understanding this aspect enabled the program to design and implement elements to fit within this culture. The dance hall disc jockeys, for example, yield tremendous influence on Jamaican society as their lyrics both reflect social attitudes and influence ideas and behaviors. Their influence is island-wide, with the greatest impact in low-income urban areas from which the artists originate, although they also command attention from middle-class Jamaica particularly among teenagers and young adults under the age of 35.
The Sound System Association of Jamaica, the regulatory and representative organization of the disc jockeys, was approached and agreed to have its more influential members videotape public service announcements (PSAs) free of charge for the program. Beenie Man, for instance, recorded two PSAs that were takeoffs from his popular song, "Wickedest Slam", and that encouraged the use of condoms. In addition, the Association distributed condoms during two of its dances as part of the safer sex promotion.
- The economic vulnerability of women has resulted in increased rates of multiple partnerships in the last five years. Prevention efforts must realistically address this population, and offer economic opportunities to this group to increase their economic independence.
The percentage of women reporting non-regular or multiple regular partners is inversely tied to income levels. The economic dependency, and vulnerability, of women in lower socioeconomic levels diminishes their power to negotiate condom use with partners and exposes them to higher risks of HIV infection. Over the five years (1992-1996) of the AIDSCAP project the Jamaican economy significantly worsened resulting in higher rates of multipartnerism among women. While condom use has increased among this population, program managers interested in addressing the cause of this increase must offer more than educational messages, and offer economic alternatives.
- Individual risk prevention strategies adopted by men were closely tied to age cohort. BCC campaigns must recognize these differences and adopt appropriate strategies and messages to each audience.
AIDSCAP's BCC campaigns influenced different age groups differently. Among the youngest group, 12-14 year old boys, a marked delay in sexual debut, and sexual activity, was noted. Among boys 15-19, fewer non-regular partners were reported. Among men older than twenty, fewer multiple regular partnerships were found. By understanding these different adaptations to risk prevention campaigns, program managers can assess what follow-on messages are needed, and how to shape them to their appropriate age cohort.
- Constraints imposed upon BCC campaigns operating in clinic settings can be overcome through small group and individual counseling approaches.
Some clinic-based subprojects initially conducted educational and counseling activities in waiting rooms and other group settings. Due to the sensitive nature of the material, these projects found a much improved dialogue and openness when they began presenting material and giving counseling in a more private setting.
B. STI
- Changing health care provider behavior to improve the counseling and case management of STI patients can be as difficult as changing target population's sexual behavior.
Health care providers often work under large case loads and limited resources, and rely on familiar and practiced clinical techniques. To insure the institutionalization of new means of STI case management requires continuing education, supervision, and an understanding of public health prevention theory, in addition to specific training on case management. Additionally, physicians are more likely to attend training if a system of incentives is established, for example incorporating STI case management training into recertification requirements.
- A comprehensive approach to the improvement of STI case management and STI surveillance must include the training of private sector STI health care providers.
Private sector providers treat approximately 50% of STI patients and commonly do not report surveillance data according to regulations. In order to improve the monitoring of the HIV/AIDS epidemic, and the appropriate treatment of STI patients, private sector providers must be included in STI capacity building efforts.
- STI-related information, education, communication (IEC) campaigns must address the general population's lack of understanding of the term "STI," poor knowledge of STI signs and symptoms, and low rates of treatment and partner referral.
While HIV communication campaigns have substantially raised the level of knowledge related to HIV transmission and prevention in the Jamaican population, knowledge of STI signs and symptoms, transmission, prevention and treatment need to be reinforced. Youth in particular have low rates of consistent condom use, poor knowledge of STI symptoms, and significant obstacles (including social stigma, confidentiality, and cost) to receiving appropriate STI care. A 1996 KABP conducted among youth aged 12-14 found that 63% did not understand the term STI. In a 1996 general population survey nearly half of all men reporting STI symptoms in the past 12 months did not seek appropriate treatment. In a separate study, of 304 GUD patients, 125 (41.1%) self medicated prior to attending clinics. Nonetheless, opportunities abound for more aggressive contact tracing of STI patient partners. Two-thirds of the respondents in a 1996 study of STI clinic attendees claimed that it would be easy to inform their partner about the infection. Overall, 71% said it was either likely or very likely that they could convince their partner to come for treatment.
C. Condoms
- Rates of condom use with non-regular partners in Jamaica are among the highest in the world. However, when measuring condom use frequency (never, rarely, sometimes, or always), we find that both men and women seem to be sharply divided into two groups: those who report always using condoms and those who report rarely or never using condoms. Targeting these persistent nonusers requires more than increasing knowledge or risk perception, but a focus on the structural and economic barriers faced by this group.
The message that non-regular partners represent greater risk for HIV infection seems to have reached the general population in Jamaica. The number of men reporting non-regular partners has decreased from more than one in three men (35%) in 1992 to one in four men (25%) in 1996. However the frequency of condom use among men reporting non-regular partners is unchanged over this period, with approx. 60% of men reporting "every time" condom use. Among women, a similar percentage (64%) reported "every time" use in both 1994 and 1996. Reaching the approx. 10% of the population of men and women who report never using condoms, as well as the 10% who report only occasional use, and the 10% who do not respond to the question, is a continuing challenge to program managers. While this group represents a small percent of the total population (8% of men and 3% of women), they do represent hard core risk behaviors. In profile they are equally represented in the age groups 15-19, 20-29 and 30-39. Compared to their counterparts who protect use condoms every or most times, this group is more likely to be poorly educated (21% versus 77% had secondary education), and unemployed (35% vs. 19%), and are more likely to be involved in transactional sex (35% vs. 19%). However, they do appropriately perceive themselves as more at risk than their counterparts (65% versus 31%). They are also no less knowledgeable about correct preventive practices than their counterparts. With this profile, one wonders whether financial need is supporting this risk behavior.
In addition to the financial and structural barriers to condom use noted among the general population, the use of alcohol and drugs, particularly crack cocaine, among CSWs represent a serious threat to consistent condom use by this population at high-risk. While 22% of all CSWs reported an STI infection in the past year, 64% of CSWs using crack cocaine reported an infection.
- Rates of condom use with non-regular partners do not correlate with rates of condom use with regular partners. Despite the high levels of condom use with non-regular partners achieved in Jamaica, rates with regular partners are much lower.
Despite widespread condom use with non-regular partners, condom use in stable relationships is uncommon. Condom use is often perceived to indicate a lack of trust in one's partner. Moving beyond this perception towards the use of condoms as a way of protecting yourself and your partner is an essential message needed for future interventions.
D. Program Management and Evaluation
- Locating the AIDSCAP Country Office in the MOH/Epi Unit allowed AIDSCAP to clearly define its role as providing technical support to the NHCP and effectively contribute to the sustainability of the NHCP's management of ongoing activities.
By housing the AIDSCAP country office in the Epi Unit, AIDSCAP was able to emphasize the technical support and capacity building of the NHCP. The frequent interaction with program managers and immediate problem solving afforded by the proximity to the NHCP strengthened the sense of ownership of the program by the MOH leading to the sustainability of the program through direct bilateral support. Capacity building is an at times delicate task, however, requiring a cautious balance of responsiveness and directiveness, and requires good listening, negotiation and diplomacy.
- Flexibility and ongoing review of staffing levels and functions should be planned for and built into program management in collaboration with donors and implementing agencies.
Country program and implementing agency staffing needs and personnel profiles should be adequate to provide regular and consistent on-site monitoring and technical assistance as well as to ensure completion of administrative functions. The initial staffing of the Country Office was inadequate initially preventing opportunities for regular field-based monitoring. While the capacity of the Jamaica subprojects was strengthened in the areas of proposal writing and reporting, several mentioned monitoring and evaluation as a weakness of their subprojects. AIDSCAP responded to this need by adding program staff to its country office, though this occurred late in the project.
- The multi-layered system put in place to implement the AIDSCAP program and a lack of clarity on funding levels from USAID resulted in difficulties in maintaining the flow of funds to subprojects.
Several subprojects had to be canceled when funding levels were below the expected budget. A streamlined reporting system and fewer layers within FHI/AIDSCAP should be considered for future programs. Financial levels of obligation need to be confirmed prior to the start of project activities. The extensive delays in securing confirmation for the LAC Bureau greatly impacted program design and implementation.
- By emphasizing the measurement of trends in HIV related knowledge and behavior, rather than the outcomes for specific interventions, AIDSCAP/Jamaica was able to increase the usefulness of the evaluation results, and decrease the resources required of conducting individual, multiple, surveys.
By centralizing evaluation activities under one subagreement AIDSCAP/Jamaica was able to insure high quality and consistent data collection across several projects and target populations. Further, this centralization created one resource with information on trends in knowledge, attitudes and behaviors accessible for collaboration on the development of communication messages, policy initiatives, etc. Depending upon an external organization for evaluation technical support does however create concerns that the development of organizational capacity in evaluation among each intervention project will be diminished. To counter this, biannual meetings were held to plan and discuss data collection, analysis and interpretation of evaluation results for each target population. The most successful development of evaluation capacity however occurred with the Jamaica AIDS Support NGO, who actively participated in all stages of the 1996 KABP study, including the sample design, interviewing, and analysis.
