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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 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 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. 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.
Beyond Awareness
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.
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
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).
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.
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
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 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
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
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.
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
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