Chapter 2
Behavior Change Communication: Getting the Message Across

Three boats are afloat in the rising tide. Each bears a different name: Abstinence, Fidelity, Condom. People adrift in the deluge are being urged to board the boat of their choice and save themselves from drowning in the dangerous seas of HIV infection.

In Tanzania, this extended metaphor has become one of the most popular and effective ways to get the message across that individuals have options in how they protect themselves from HIV/AIDS — but that they must act before the waters of the epidemic close over their heads. It was created by a Catholic priest in a rural Tanzanian parish who was concerned that his congregants were caught between religious dictates and condom social marketing, and fearful that the friction might paralyze them rather than prompt them to assess their own risks and avoid infection.

Since its first appearance, the "Fleet of Hope" has been used to reach every sector of the population with the message of HIV/AIDS prevention. It has become the theme for a video, a popular calendar, a radio program, posters, a behavior change communication (BCC) handbook and other materials and has been adapted for similar use in Rwanda, Ethiopia and Haiti. This simple, inclusive concept has also bridged what had been a widening gap between Tanzania's religious leadership — many of whom do not approve of condoms — and standard prevention programming, which strongly promotes condom use.

"The 'Fleet of Hope' has worked miracles," said Anne Kamande, TAP BCC specialist. "It has allowed community leaders who disagree strongly with each other to find a way to unite in promoting prevention."

Expressing Community Needs

The success of the "Fleet of Hope" is a solid confirmation of one of the most important observations TAP staff have made about BCC: that messages and materials that are culturally sensitive expressions of real community needs and conflicts are the most effective ways to influence people. TAP thus supports local involvement in BCC activities and materials production by tapping the energies and creativity of the clusters, which have long been involved in their communities at the grassroots level.

A powerful example is the drama groups that all nine clusters train and support. Each group devises plays to meet the information needs of specific local audiences — secondary school students, high-risk populations that frequent bars and nightclubs, unemployed youth, agricultural workers — and arranges to present them in appropriate and convenient settings, or at such well-attended public events as World AIDS Day and International Women's Day. Local issues often take the spotlight. In Dodoma, for example, where polygamy is widespread, the cluster's highly acclaimed theater group created a drama about the risks of the practice. One of the Arusha cluster's NGOs, DOHOCE, produced prevention dramas in the Maasai language dealing with high-risk practices that prevail among youth in that tribal group.

"These groups present real situations to their audiences," said Kamande. "Drama is so powerful because people are able to participate emotionally by relating their everyday lives to what they see played out in front of them."

To support these efforts, TAP holds training-of-trainers workshops that focus on drama and other folk media. The project also sent a drama consultant from Dar es Salaam to work with cluster drama groups on polishing their communication, scriptwriting and acting skills to more effectively get their messages across.

Clusters are also deeply involved in TAP's production of such BCC materials as posters, brochures and other written and visual materials. Cluster members participate in BCC training-of-trainers activities led by TAP staff and are asked for their input in creating appropriate and relevant messages that will have meaning for the people in their regions. These sessions simultaneously shape TAP's BCC campaign to better reach its audience as they raise the BCC skill level of cluster members.

Training for Prevention

An even more widespread community-based BCC effort involves peer educators, who engage audiences of their peers — fellow workers, young people, commercial sex workers and much more — in education and discussion about the epidemic and how to reduce personal risk of HIV and other STIs. Because they themselves belong to the groups to which they speak, peer educators are able to tailor the contents of their educational sessions and direct discussions to the issues that are most relevant to their audiences. All clusters are deeply involved in training peer educators and in deploying them throughout the community. For example, the Kilimanjaro cluster, which aggressively recruits peer educators to reach a wide variety of audiences within the region, has trained nearly 400 peer educators, who have provided more than 133,000 people with prevention education.

The peer education model works especially well for young people, who are less likely to feel inhibited about expressing their concerns and asking potentially embarrassing questions when the peer educator leading the discussion is about the same age they are. The Tanga cluster's diverse team of peer educators includes 20 out-of-school youth and 20 youth from church groups. The Kilimanjaro cluster devotes a great deal of resources to both school-based and non-school-based peer education activities using peer educators selected from school and community groups.

Several clusters have also embarked on recruiting and training traditional healers (THs) and traditional birth attendants (TBAs) in HIV/AIDS and STI education skills. In many parts of the country, these traditional practitioners are widely consulted by the local population and can have an enormous impact on the health of their communities. The training has two goals: first, to encourage safer clinical practices — such as use of gloves during deliveries or when blood is present — to protect both practitioner and client, and second, to make it possible for practitioners to offer sound advice on HIV/STIs to their patients. The Dodoma cluster provides special educational sessions to THs and TBAs in the region, and the Arusha cluster conducts workshops in the Maasai language for traditional practitioners from that tribal community.

In the western part of Arusha, traditional Maasai birth attendants in Monduli — who are also revered female village leaders — have been inspired by their workshop training to take on even broader prevention issues in the community. Maasai youth — young men who have undergone circumcision rites and girls as young as 12 or 13 — participate in traditional nighttime dances that often turn into sexual sprees. Rather than offend the rest of the community by acting to ban the practice altogether, these women are now working to educate youth about HIV/AIDS and how to avoid infection, so that the dances can continue but with less high-risk behavior.

"We want to keep the young people healthy, and they will listen to us," said Mama Mbele, a 60-year-old Monduli TBA who participated in a TAP workshop. "But tradition is hard to change, so we look for ways to make change acceptable."

The Tanga cluster's lead NGO — the Tanga AIDS Working Group — received special funding from TAP for a project that not only trains traditional practitioners in HIV/AIDS prevention and caregiving but also builds supportive partnerships between traditional healers and the biomedical community. Armed with a greater understanding of each other's healing practices, these two medical traditions — normally at odds — now work together to improve the health of the region, prevent HIV/STIs and provide effective care to those already infected. The THs and TBAs can recognize potential symptoms of HIV and STI infection and refer patients to local clinics, and clinicians have clinically tested several traditional herbal remedies and found them to be beneficial in treating certain AIDS-related symptoms.

Workplace Initiatives

Because HIV/AIDS strikes hardest at those between 15 and 49 — the sector of the population in its most economically productive years — the epidemic has had a serious impact on the workforce, especially in high-prevalence countries like Tanzania. A 1995 TAP study of Dar es Salaam businesses with more than 100 employees found that 18 percent of those surveyed had lost an average of 23 employees each to AIDS. As these workers sicken and die, the investment that employers made in their training is lost, as is the valuable work experience they've accrued over the years. Time taken from work to go to the doctor, to recover from AIDS-related opportunistic infections or to attend family funerals is costly, as are the employees' medical and funeral expenses and other costs that employers traditionally pay. Individual firms suffer as a result, as does the economy overall. A recent World Bank report predicts that over the next 15 years, the Tanzanian economy could shrink by 14 to 24 percent because of the epidemic's effect on the workforce and the financial pressure it puts on businesses.

Bringing prevention education directly into the workplace has been the mission of several TAP-supported projects in Tanzania. Two of them — conducted by the Organization of Tanzanian Trade Unions (OTTU) and the Tanzania Council for Social Development (TACOSODE) — focus on worksite peer education of workers. (TAP funding has ended for both projects, which now receive support from other donors.) AMREF has directed two other major workplace projects: one in high-risk transmission areas along trucking routes, and a second at workplaces in different regions of the country.

All three organizations recruit workers to receive peer education training so they can engage their fellow workers in small-group discussions, after video presentations and one-on-one in the office, in the lunchroom or on the shop floor. Drama groups are sometimes invited to perform for workplace audiences. Peer educators also sell Salama condoms to their co-workers. Because these organizations cultivate strong relationships with managers who enthusiastically support efforts to curb infection within their companies, peer educators are able to perform their duties during work hours and to attend planning meetings as needed while they receive their regular pay. Together, OTTU, TACOSODE and AMREF developed and field tested a "Model Worksite Intervention Guide" to help TAP's clusters expand prevention programming into worksites on a regional basis.

During its workplace project, which ended in April 1997, AMREF worked with 18 companies to create comprehensive behavior change interventions on-site, including peer education, video showings and condom social marketing. Because of the success of AMREF's efforts to sensitize top management to the threat the epidemic poses to their workforces, each participating company created a company AIDS committee and committed itself to contributing 50 percent of program costs — important factors in the potential sustainability of these workplace efforts.

A Broader Audience

The mass media also provide TAP with important venues for spreading prevention education to a wide audience. While broadcast messages on HIV/AIDS may be less personal and immediate than peer education or drama, consistent use of the airwaves reinforces what viewers and listeners have learned about HIV/AIDS and risk taking and helps build an environment where the message of prevention is pervasive.

But even mass media can be interactive, and TAP media interventions have been especially creative in transforming the public's role from passive listener to engaged participant. For example, TAP collaborates with one of the country's biggest national radio networks, Radio Tanzania, to produce a weekly show that investigates all aspects of the epidemic and how it affects individuals and their families. "AIDS in the Community" has been enormously successful in personalizing HIV/AIDS by inviting HIV-positive people and their families to tell their own stories on the air about the stigmatization, illness, poverty and fear that grip their lives. Interspersed with prevention information and facts about the epidemic's effect on Tanzania, these riveting accounts helped the program win a significant base of listeners around the country, who call and write in with questions and comments and request that specific topics be covered in coming weeks.

"Radio has a big role to play in AIDS prevention," said Edda Sanga, who produces the show for Radio Tanzania. "Because it reaches everywhere, it helps drive a growing national discussion about HIV/AIDS at the same time that it dashes myths and rumors about the epidemic."

The Dodoma and Morogoro clusters also produce well-received community-based radio shows at local affiliates of national networks. These successes — national and regional — have confirmed the value of radio as popular, affordable and widely accessible, and TAP intends to expand its work in the medium.

Television has been available only since 1994, and, apart from residents of big cities like Dar es Salaam that have local stations, relatively few Tanzanians have TV sets. Filming and purchasing air time for television programs are also quite expensive. For these reasons, TAP has done limited programming for television. Post-test evaluation of several TAP-produced television programs aired early in the project showed that, while the broadcasts were well received, they did not have much lasting impact because — unlike the radio shows — they could not be sustained long enough to build a regular audience.

TAP also moved its media campaign into print. The AIDSWATCH Column, written by TAP's BCC staff, appears in various local newspapers. It examines issues surrounding HIV/AIDS and STIs and relates the experiences of those who are infected and their families. TAP also publishes two quarterly periodicals targeted to specific audiences. Written for adults, Tuzungumze — "Let's Talk" in Swahili — takes a close look at issues such as communication with sexual partners and personal risk assessment. And Straight Talk/ Sema Wazi Wazi, a bilingual quarterly, is designed to reach young people in a frank and engaging way.

While there is as yet no comprehensive evaluation of the program's BCC interventions, one study suggests that TAP's efforts have been effective in influencing sexual behaviors. A 1996 knowledge, attitudes, behavior and practices study conducted by TAP in four of its target regions reveals higher rates of condom use with nonregular partners than among the general population. In the four TAP regions, 38 percent of women reported condom use with their last nonregular partner, as opposed to 17 percent in the general population. For men, the TAP figure was 46 percent, as opposed to 35 percent generally. These higher rates indicate that BCC interventions in regions with TAP programs are influencing more people to protect themselves from HIV/AIDS.

Engaging the Decision-makers

Educating Tanzania's leaders about the epidemic is another important BCC activity that all TAP clusters undertake. Policy makers — from national legislators and cabinet members to regional governors to village mayors — and other community gatekeepers such as clergy, traditional healers, and business and labor leaders who are aware of the dangers of HIV/AIDS can ensure that resources are available for prevention efforts, that legislation favorable to prevention and care initiatives is passed and that the issue of HIV/AIDS becomes a national and regional priority. Leaders can also influence public opinion by lending their voices directly to the cause, speaking out about the epidemic at meetings, at the pulpit or at public events.

To recruit the nation's decision makers, each cluster sponsors periodic "sensitization" workshops to which they invite local and regional leaders. Cluster members who lead the workshops present basic facts about the virus and explain how the epidemic threatens both the region and the nation. The group then discusses how leaders can act as policy advocates and public spokespeople for prevention. Throughout the clusters, hundreds of leaders have participated in these workshops, many of whom now give invaluable support to cluster activities.

Last spring, for example, the Kilimanjaro cluster held a sensitization workshop in Moshi for about 20 regional leaders. The participants included local labor union presidents, ward and village leaders, a minister from the Seventh Day Adventist church and Moshi Mayor Dennis Chuwa. After an animated discussion, several of these leaders became involved in cluster preparations for the upcoming International AIDS Candlelight Memorial celebrations.

"I learned many things I hadn't known about the dangers of AIDS to my constituency," said Mayor Chuwa. "Leaders must take responsibility for helping their communities fight this epidemic."

Of all the clusters, perhaps Iringa has devoted the most effort to educating and developing working relationships with regional leaders. The cluster has systematically invited hundreds of leaders from the regional, district, ward and village levels throughout Iringa to sensitization seminars. To maintain these contacts and encourage ongoing participation, the cluster schedules quarterly meetings to update leaders about HIV/AIDS developments and cluster activities.

Close collaboration between the cluster and the regional power structure has been the outcome. These leaders have made office space available for information and counseling centers, contributed funds to training and special events organized by the cluster, helped find markets for orphan income-generation efforts and loaned vehicles to the cluster so it can carry out its far-flung regional activities. Peer educators and drama group participants who work for ward and village leaders are regularly excused to carry out their prevention duties. And HIV/AIDS is now a permanent agenda item for meetings of village and ward development committees, which have made such decisions as limiting local alcohol consumption hours to cut down on high-risk behaviors.

"We've had a lot of success because these leaders are so involved they now see this as their own project," said Lediana Mafuru, an Iringa cluster activist who leads sensitization workshops. "Developing their leadership in HIV/AIDS means program sustainability."

In a country such as Tanzania, religious leaders are often as influential as political ones. All clusters include religious organizations and attempt to engage the support of the local religious leadership. Inspired by their involvement in various cluster activities, the diverse religious community in Dodoma created its own ecumenical coalition to promote a united front against the epidemic, and — contrary to earlier positions by individual members — came out in support of condom promotion.

On a national level, TAP is also involved in raising awareness about HIV/AIDS among legislators and other prominent leaders. When the national parliament convened for the 1997 session, TAP and the National AIDS Control Program conducted a full-day sensitization workshop for the delegates. The issues discussed included the impact of the epidemic on the national health care system, social welfare and the economy. Throughout the presentations, TAP stressed the important role that these legislators can play in developing policy, backing national and regional prevention and care initiatives, and supporting the human rights of those living with HIV/AIDS.