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Programs

Making Prevention Work
Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997

1. Behavior Change Communication: From Individual to Societal Change

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This publication documents the experience of the world's largest international HIV/AIDS prevention project, which was implemented by FHI and its partners in 45 countries. It describes lessons learned during AIDSCAP, with examples and project profiles, in 10 technical and programmatic areas: behavior change communication, improving prevention and treatment of sexually transmitted diseases, prevention marketing, policy development, behavioral research, evaluation, gender and HIV/AIDS, management, AIDS care and support, and cross-border interventions.

Table of Contents

Making Prevention Work

1. Behavior Change Communication: From Individual to Societal Change (See Below)

2. Improving STD Prevention and Treatment

3. Prevention Marketing: Condoms and Beyond

4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change

5. Behavioral Research: Using Results to Design Behavior Change Interventions

6. Evaluating HIV/AIDS Prevention Programs: Developing New Tools for Meaningful Measurement

7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

9. Prevention and Care: Mutually Reinforcing Approaches

10. Crossing Borders: Reaching Mobile Populations at Risk

Partners and Acronyms

1. Behavior Change Communication: From Individual to Societal Change

Behavior change communication (BCC) for HIV/AIDS prevention has evolved into a specialized field that draws on experiences from family planning, social marketing, anthropology, psychology, education and communication. Because prevention of a deadly sexually transmitted disease is significantly different from other health promotion goals, HIV/AIDS programs have been challenged to refine traditional communication approaches to address usually private and sensitive matters such as sex, trust and death.

BCC specialists working in HIV/AIDS have also begun to broaden their approach to address the social, political and environmental factors that influence risk behavior. Experience with HIV/AIDS has made it clear that an individual can rarely sustain a change in behavior without a supportive environment.

But certain time-tested elements of health communication remain the foundation of BCC for HIV/AIDS prevention. These include identifying and segmenting target audiences, using multiple communication channels and involving target audiences in developing materials and messages. Other principles are being subtly changed to meet the needs of populations unaccustomed to sharing concerns about sexuality and of societies whose customs and structures inadvertently encourage risky behavior.

Toward Behavior Change

AIDSCAP's behavior change communication strategy used behavioral and communication theory and research to provide a systematic framework for efforts to influence individual behaviors and the social contexts in which they occur. The project applied this strategy in more than 580 projects and activities in over 40 countries. Almost 19 million people received potentially lifesaving messages about HIV/AIDS prevention through drama, music, radio, television, video, printed materials and interpersonal communication.

AIDSCAP's BCC approach was considerably more complex than traditional health education. In many cases, it required a new way of thinking about the design and implementation of communication projects. Training and technical assistance from AIDSCAP communication officers and consultants equipped more than 180,000 outreach workers, health providers, peer educators, counselors and community leaders with the skills needed to influence and support behavior change.

Technical assistance also came in the form of a series of practical "how-to" handbooks on various steps in the communication process. Project managers and BCC officers reported that AIDSCAP's series of six BCC handbooks were useful as teaching aides, reference materials, sources of new ideas, and check lists.1 Managers of AIDSCAP-supported organizations in Ethiopia used the handbook on peer education to design all their peer education projects. The Kenyan government distributed photocopies of AIDSCAP's handbook on developing an effective HIV/AIDS communication project to 200 Ministry of Health communication officers, who were instructed to use it as their guide. In Nepal, outreach supervisors carried copies of "Assessment and Monitoring of BCC Interventions" with them so that they could use its monitoring checklists during supervisory visits. And in Laos, chapters of two of the handbooks were translated and used in workshops to develop HIV/AIDS prevention messages for projects at three different sites. "The three working teams found that the two books provided them the clearest framework for communication and BCC intervention," an AIDSCAP BCC officer reported.

Because education by members of the target audience is an integral part of many HIV/AIDS prevention programs throughout the world, AIDSCAP encouraged its implementing partners to take a critical look at peer education projects. An AIDSCAP study of 21 such projects in ten countries examined where, when and how peer education can be used most effectively.2 The knowledge gained from this study was used to develop the BCC handbook on peer education, which has been used by many AIDSCAP programs and other HIV/AIDS projects to design peer education projects and improve peer educator training curricula.

Peer educators in many countries revealed hidden talents through their participation in AIDSCAP programs. Some performed in plays, others sang about HIV/AIDS prevention, and some even showed a flair for creating cartoons to convey prevention messages. In fact, one of AIDSCAP's greatest strengths in BCC was its ability to tap the creativity of local organizations and communities to create memorable and influential BCC messages and materials. One of many examples is the Fleet of Hope, a metaphor first used by a Catholic priest in Tanzania to explain the various prevention options, which inspired actors in Ethiopia and Haiti to create HIV/AIDS dramas. In Kenya and Rwanda, groups were encouraged to write songs about HIV/AIDS in local languages that were taped and distributed to radio stations for broadcast. And the video of "Vibes" by Jamaica's Little People and Teen Players Club, with its vibrant music and its message to "wait until you have the super, safer sexual skills you need before having sex," has become an international favorite among English-speaking adolescents.

AIDSCAP-sponsored folk theater, street theater, videos, radio and television soap operas, and magazine and newspaper stories generated enthusiastic responses and serious discussion about HIV/AIDS. For example, a Kenyan radio soap opera received 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 prompted 65 percent of the calls to a telephone HIV/STD counseling service, "Helpline," over two years.

Evaluations of AIDSCAP programs in 19 countries suggest that BCC activities, working in combination with other behavior change interventions, moved millions of people along the behavior change continuum from knowledge to awareness to action. In Cameroon, for example, the percentage of male students who reported having more than one sex partner dropped from 53 to 36 in three years. In Thailand, 97 percent of brothel-based sex workers reported using condoms with all clients in 1996 -- up from 87 percent in 1993. And in Jamaica, where the majority of the population now reports some kind of behavior change to avoid HIV, the percentage of 12- to 14-year-old boys reporting sexual experience dropped from 59 to 41.

1.1 Award-Winning Mass Media Campaign Reaches Youth

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 popular 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 advertisement is one of four produced for a campaign by the AIDSCAP program in the Dominican Republic targeting adolescents and their parents. Created by the well-known Dominican advertising agency Cumbre, the spots used high-quality production techniques and attractive young actors to convey well-researched public health messages.

The two-year campaign confronted the attitudes and misconceptions revealed in research among Dominican youth. One ad posed a series of questions to help listeners assess their own risk. Another emphasized that "you can't guess who has AIDS" by a person's appearance. The third ad, "Solamente Una Vez," listed a telephone hot line number to call for information and referrals. The final ad encouraged parents to talk to their children about AIDS and other STDs.

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. "Young people don't think death exists," said Cumbre President Freddy Ginebra, "so we looked for a 'code' to challenge them and to make them think."

AIDSCAP persuaded dozens of radio and TV broadcasters and cable-TV system operators to carry the ads for free. From September 1995 to March 1997, broadcasters contributed air time worth more than U.S.$9 million.

AIDSCAP communication officer Ceneyda Brito, who has worked on other public health campaigns in the Dominican Republic, believes one reason the broadcasters were so receptive was the high quality of the advertisements. The spots have also won praise from advertising and public health specialists throughout Latin America.

At a meeting in Mexico, for example, communication experts from 20 countries awarded their top prize to the AIDSCAP ads. And the "Solamente Una Vez" spot was the only public service announcement recognized in a nationwide competition for Dominican advertisers, receiving the second-place prize.

As attention-grabbing and persuasive as the mass media pieces may have been, they were just part of a comprehensive, well-coordinated national campaign launched in collaboration with a working group of more than a dozen Dominican youth service organizations. Print materials reinforcing the broadcast spots' key messages were distributed to government agencies, NGOs working with adolescents, radio stations, record and video stores, and movie theaters. The working group also established a referral network for adolescents' questions about HIV/AIDS and contributed to AIDSCAP's development of a manual for organizations working with youth.

Such careful coordination of numerous communication channels was vital to the success of the campaign. Close collaboration between organizations working with youth and the 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."

Lessons Learned

Beyond Awareness

  • In addition to encouraging individual behavior change, BCC can help create environmental conditions that facilitate personal risk reduction.

In Jamaica, a focused strategy developed with a local public relations firm targeted religious institutions, the media and private businesses to encourage changed attitudes toward HIV/AIDS education in the workplace, public discussion of sexual issues on radio and television, and increased compassion toward people living with HIV/AIDS.3 Each of the targets required a different strategy and a different message.

All these efforts created a more supportive environment in which individual Jamaicans received encouragement to practice safer sexual behaviors from many sectors. 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 over two years. Business owners and managers agreed to work with the Ministry of Health to establish workplace prevention programs, and some supported the programs with cash or in-kind contributions. And the influential Jamaica Council of Churches endorsed a series of workshops that gave religious leaders a better understanding of HIV/AIDS and helped them counsel their congregations about the disease.

  • If peer educators are only trained to provide STD/HIV awareness information, they are unlikely to be effective in later stages of behavior change.

In a study of 21 peer education projects in Africa, Asia and Latin America, AIDSCAP project managers reported that they found it necessary to revisit the needs of target audiences and their expectations for peer educators.2 When target audiences were already knowledgeable about STD/HIV infection, peer educators needed training to acquire the skills and attitudes necessary to move on to 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 information on HIV/AIDS and STDs into conversations about other issues. If peer educators do not have these skills, they 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 support.

For example, an AIDSCAP campaign targeting adolescents in the Dominican Republic received more than U.S.$9 million worth of free air time from the local and international media. AIDSCAP leveraged this media support by investing $53,000 in development of high-quality television and radio spots and related print materials (Box 1.1).

  • Collaboration with local communication professionals may be more cost effective than training HIV/AIDS program personnel in specialized communication skills in some settings.

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's experience with such collaboration was rewarding. For example, a Dominican advertising agency worked with AIDSCAP staff in the Dominican Republic to design an award-winning mass media campaign for youth (Box 1.1). A Jamaican public relations firm helped AIDSCAP and the Ministry of Health design and implement a BCC strategy that created a supportive environment for individual behavior change.3 And in Kenya, AIDSCAP worked with a Nairobi communications consulting firm to place a weekly column on HIV/AIDS in a popular 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.

Condom social marketing (CSM) projects often produce excellent educational and promotional items, as well as mass media promoting brand recognition and condom use. The ability of CSM projects to place their product in the public eye helps desensitize the issue of condoms, which lays the groundwork for more focused behavior change messages.

In Nepal, for example, the CSM program developed radio and television spots and a film shown in cinema halls and from mobile film vans, which were closely coordinated with intensive outreach efforts throughout the country. By opening the topic for discussion, these mass media efforts made it easier for outreach workers to discuss HIV/AIDS with target audience members (Box 1.2). In many countries, including Ethiopia, Tanzania and Haiti, condom advertising on radio and television were an integral part of national risk reduction campaigns.

Communication Tools

  • Because sexual issues are more sensitive for many people than other kinds of public health topics, drama and other entertaining forms of behavior modeling can be a particularly effective way of helping target audiences move beyond awareness to behavior change.

Live and taped dramas were used throughout the AIDSCAP Project to show models of behavior change situations and to give audience members a comfortable opportunity to consider the implications of their behavior. Communication officers and project managers reported that a dramatic format is a good way to introduce and illustrate serious issues such as sexual negotiation, HIV/AIDS care and support, and stigma and discrimination.

Jamaica's Targeted Community Intervention, for example, enlisted the help of one of the island's most famous comedians to broach the subject of HIV/AIDS with residents of inner-city communities. Project manager Audrey Wilson Campbell noted that the use of comedy was very effective because "it was non-threatening, but we were getting to the root of the issue." In the Dominican Republic, "provocative theater" (a type of street theater performed in bars or on the street, which an unsuspecting public does not know is a rehearsed drama) is used to simulate situations in which women express themselves confidently and men learn to listen to their point of view on a sexually related problem.

AIDSCAP used these models to give women and men opportunities to rehearse and develop their own sexual negotiation skills. A Jamaican communication officer noted that because it depicts the everyday life of people and "makes room" for discussion, "community theater is the most effective tool we have."3

  • 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 stages of change of their target audiences.

The continuum adopted by AIDSCAP 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 study conducted in eight countries used the behavior change continuum concept to question BCC officers and program managers about the perceived impact of their work. Typical of many responses is this, 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."4

Recognition that 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 somewhat cohesive and homogeneous groups such as sex workers and military personnel found that members of their target population generally moved along the change continuum at a similar rate. However, university students in the same country presented a greater challenge. Because they entered the university with different levels of understanding about HIV and because upper class students had more exposure to prevention education, the large target group of "university students" was segmented according to their positions on the change continuum, and messages and approaches were tailored for these various segments.5

  • Some BCC messages and materials have 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, AIDSCAP has found that some messages transcend culture and nationality. A study of several AIDSCAP materials that have been used or adapted throughout the world found that they appealed to people from many different cultures because they addressed universal concerns.6

In Tanzania, for example, a brochure about "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 proved popular and effective in at least eight countries in Africa, Asia, Latin America and the Caribbean. It has been used in folk media, religious sermons, videos, posters, presentations, and other media and materials. Another example is "Emma," a West African character who has spread HIV/AIDS prevention and care messages in 20 countries (Box 1.3). AIDSCAP encouraged such "cross-fertilization" of messages and materials by developing a computerized database of more than 700 BCC materials produced by the project and sharing model materials with its communication officers in all regions.

Capacity Building

  • Capacity building in behavior change communication is critical, even for experienced health educators.

BCC concepts and techniques of behavior change communication are not easy to grasp and apply. And because approaches to HIV/AIDS prevention continue to evolve, the initial design and implementation capacity of project managers and field workers may be weak. AIDSCAP found 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. However, training is necessary to enable some groups to use the handbooks.

1.2 AIDSCAP in Nepal: Comprehensive Behavior Change Communication

One of the first things a truck driver espies as he enters the bustling town of Hetauda is a ten-foot-high billboard featuring Dhaaley Dai, the condom cartoon character that serves as the logo for AIDSCAP's program in Nepal. Most travelers along the road from Kathmandu to the Indian border are familiar with Dhaaley's message: "Wear condoms. Drive away AIDS."

When he stops at a friend's stand to buy a soft drink, the truck driver can buy a packet of the Dhaal condoms prominently displayed on the shelves, and he may hear a Dhaal jingle on the radio. In the early evening, he might join a few hundred people gathered around a video van to watch Hindi music videos and the HIV/AIDS prevention film, "Guruji Ra Antare."

If the truck driver spends the night in one of Hetauda's many hotels for travelers, he is likely to meet a friendly outreach worker or peer educator who will help him assess his risk of contracting HIV/AIDS or other STDs. And if he expresses concern about possible STD symptoms, the outreach worker will give him a referral card for a local center that provides diagnosis and treatment. Should he decide to go to a pharmacy instead of the STD center, the driver will probably find that the person behind the counter was trained by AIDSCAP to dispense the appropriate drugs for different STD syndromes.

This comprehensive approach to prevention education -- one of the hallmarks of true behavior change communication -- was typical of the AIDSCAP program in Nepal. Designed to reach truck drivers and their assistants and sex partners along the main transport routes in Nepal's Terai region, the program used a variety of communication channels and carefully coordinated them to ensure that the target audiences received consistent messages.

One example of this coordination was the creation of the program's mascot. Seeking to design a communication campaign that was memorable and not "too preachy," the Stimulus Advertising Agency contracted by AIDSCAP decided to build on the name recognition achieved by previous condom social marketing efforts for family planning in Nepal. Working with Nepal Contraceptive Retail Sales (CRS), the Nepali company responsible for the social marketing component of AIDSCAP's program, Stimulus named its condom character "Dhaaley," an affectionate version of the CRS condom brand name Dhaal (shield), and "Dai," meaning big brother.

This lovable cartoon character appeared on program materials, billboards, signs, advertisements, and condom packages and displays throughout the Terai region and starred in radio public service announcements. A large inflatable Dhaaley Dai even presided at dozens of public events.

The popularity of Dhaaley Dai was matched only by that of Guruji and Antare, the title characters in AIDSCAP's film about the adventures of a truck driver and his hapless assistant. Like the condom character, the film uses humor to convey a serious message: Condoms are strong, durable, and the only way to protect yourself from HIV/AIDS and other STDs if you cannot remain faithful to one partner. Video van showings of the film, along with popular music videos, drew hundreds of people to enjoy the free entertainment, and thousands more read the companion Guruji and Antare comic book.

After the film had introduced the program's messages in a village or town, outreach workers would follow to reinforce those messages with street dramas about HIV/AIDS and through informal conversations. The outreach workers of AIDSCAP's NGO partner, General Welfare Pratisthan (GWP), and the peer educators they trained reported that the mass media communication -- particularly the radio spots -- enhanced their credibility with target audiences and made it easier for them to talk about controversial topics such as sexuality and STDs.

But one-on-one outreach was the core of the communication program, allowing members of the target audience to ask questions and seek advice from a trusted source. Dedicated outreach workers and the peer educators they had trained reached some 50,000 people during the four-year project.

The key to effective BCC is to ensure that people can act on program messages. In Nepal, where outreach workers and mass media messages urged target audiences to use condoms and seek prompt STD treatment, AIDSCAP coordinated its BCC efforts with the services necessary for these HIV prevention measures. The condom social marketing project provided convenient access to condoms at hundreds of outlets along the highway, and STD training workshops for health providers, family planning staff and pharmacists created a reliable referral network for effective STD treatment.

The results of a 1996 evaluation suggest that this comprehensive approach was successful. Survey responses revealed that target audiences had received and understood the project's messages, and both sex workers and their clients reported increased condom use. In fact, the percentage of sex workers who said that their most recent client had worn a condom increased from 35 percent in 1994 to 61 percent in 1996, while reported condom use actually fell from 48 to 41 percent among sex workers in areas that had not benefited from AIDSCAP interventions. More than half of the clients interviewed in the project area reported consistent condom use with sex workers during the past year.

Another sign of the project's success was the communities' response to the outreach workers. At first, people seemed insulted when outreach workers approached them to talk about STDs. But they persevered, befriending anyone they met in bars, hotels, restaurants and at border check points. Now the outreach workers are considered part of the community, and men and women seek them out with questions about HIV/AIDS and other STDs.

Women who trade in sex -- once an elusive audience in a region where the sex industry is clandestine and brothels are rare -- came to trust the outreach workers. "Now they bring their friends to us," said GWP Director Mahesh Bhattrai. "So sometimes nowadays we are not doing outreach on the highway. Actually the clients are doing outreach to us."

Recommendations

  • BCC programs for HIV prevention should address environmental conditions as well as individual behavior. Carefully planned, well-executed BCC strategies can help change social attitudes and norms, cultural practices, government and industry policies, and other environmental factors that influence individual behavior.
  • As the epidemic evolves, HIV/AIDS program managers should ensure that peer educators have the knowledge and skills required to address the changing needs of their peers. Managers should conduct needs analyses to identify topics to add to their training curricula, such as care, counseling and family planning.
  • HIV/AIDS programs should consider hiring professional advertising, public relations and communication professionals to develop BCC campaigns and materials. In some settings, contracting with professionals may be more cost effective than providing specialized communication training to project staff whose talents and skills may lie in other areas.
  • BCC and condom social marketing projects should coordinate their communication efforts to ensure that their shared target audiences receive reinforcing messages.
  • HIV/AIDS programs should use a stages-of-change continuum to understand the needs of their target audiences and to develop BCC messages, materials and approaches that are relevant to audience members at different stages in the behavior change process.
  • Before creating new materials, HIV/AIDS programs should consider whether existing materials from other programs and even from other countries might fit their needs. These materials should always be pretested with representatives of the target audience before production to determine whether they are appropriate and to identify any revisions that may be necessary.

1.3 Comic Book Character Has Worldwide Appeal

All over the world, people listen to what Emma says.

The star of AIDSCAP's "Emma Says" comic book series has dispensed practical, compassionate advice about HIV/AIDS prevention and care to hundreds of thousands of people in Africa, Asia, Latin America and the Caribbean.

Originally developed by AIDSTECH (AIDSCAP's precursor) as a character in a flip chart for peer education sessions with West African women, Emma has become a trusted source of information about HIV/AIDS in more than 20 countries. Since the creation of the first comic book in 1994, "Emma Says" has been translated into six languages and distributed to more than 171,000 individuals and organizations.

Thousands more have seen dramatic performances about Emma performed by local organizations in Tanzania, Ethiopia, Nigeria and Cameroon. And in Rwanda, she became a film star when AIDSCAP's condom social marketing partner Population Services International received funding from UNICEF to create an "Emma Says" video and a companion photonovella.

As an aunt, neighbor and friend, Emma deals directly with the 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 STDs. She also addresses HIV/AIDS care and support in the series, 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 comics in the series find Emma helping a teenage niece seek treatment for an STD.

AIDSCAP ensured that each of the books would be relevant to target audiences in different countries by developing plots in conjunction with its local field offices and partners and by pretesting them with audiences in those countries. But in many cases, the pretests found that little or no changes were necessary to adapt the materials. In a 1996 survey of communication professionals who had used the first three comics in 20 countries, 83 percent said that despite Emma's West African origin, women the world over can relate to and benefit from her messages.

The conventional wisdom is that the most effective communication materials are developed locally. But AIDSCAP's experience with "Emma Says" suggests that with careful pretesting, creative, well-designed materials that address universal concerns can influence attitudes and behavior among people from very different cultures.

Future Challenges

Reaching Mobile Populations

Research is needed to identify ways to communicate with those 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 it is particularly difficult to continue reaching them with consistent messages as they move from place to place.

Changing Social Norms

The art of designing and implementing communication programs to bring about changes in community norms and values is not yet well-developed. We know that mass media can play an important role, but questions remain about its relative value compared to other channels of communication, the timing and duration of BCC campaigns, and the synergy of different channels and messages. Research is needed on the best ways to use communication to support or change social norms and to measure such change in different settings and with different audiences.

Maintaining Behavior Change

Maintenance of safer sexual behaviors over time has not received much attention to date. It is expected that some behaviors will 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 into less safe behavior -- may lead to HIV infection. Strategies and messages that motivate people to maintain safer behaviors need to be investigated.

Understanding Stages of Change

There are at least ten popular models of the process of behavior change. Each illustrates stages that people are likely to go through as they respond to information, make decisions and try new behaviors. At each stage in the process, people need different kinds of information, emotional support and skills. An ability to track a target audience's movement through these stages 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.

References

  1. AIDSCAP BCC Handbook Series. AIDSCAP/Family Health International, Arlington, Virginia.Assessment and Monitoring of BCC Interventions (1995)Behavior Change Through Mass Communication (1996)How to Conduct Effective Pretests (1996)How To Create an Effective Peer Education Project (1996)How to Create an Effective Communication Project (1996)HIV/AIDS Care and Support Projects (1997)
  2. Flanagan D, Williams C, Mahler H (1996). Peer Education in Projects Supported by AIDSCAP. AIDSCAP/Family Health International, Arlington, Virginia.
  3. BCC Experiences from the Field in Jamaica (1997). AIDSCAP/Family Health International, Arlington, Virginia
  4. BCC Experiences from the Field in Zimbabwe (1997). AIDSCAP/Family Health International, Arlington, Virginia
  5. BCC Experiences from the Field in Cameroon (1997). AIDSCAP/Family Health International, Arlington, Virginia
  6. Mahler H, Flanagan D, Hassig S (1996). Emma Says and the Fleet of Hope: The appeal of global messages and icons. XI International Conference on HIV/AIDS, abstract Tu.D. 2862. Vancouver, Canada, July 7-12.