Drawing on more than 25 years of experience in communication for development, behavior change communication programs go beyond information dissemination to give people the skills and support they need to protect themselves and their partners from HIV/AIDS.
A Tanzanian woman talks to a co-worker about AIDS during a tea break. Nepalese truck drivers and commercial sex workers gather at a truck stop to watch a video about a rash young truck driver's assistant who learns about the risks of casual sex in hotels along the highway. NGO representatives meet with government officials in the Dominican Republic to present economic projections of the impact of the epidemic in their country during the next five years.
All of these activities are examples of behavior change communication (BCC) at work.
Of all the HIV/AIDS prevention strategies, BCC is perhaps the one people find most difficult to understand. Isn't it, some ask, just health education -- or IEC (information, education and communication) by a different name? Isn't it really just posters and leaflets?
In fact, BCC is both an art and a science, using the results of epidemiological and 
social science research to guide the design of creative interventions that call on the talents of artists, writers, actors, producers, counselors and other communicators.
Such interventions are an outgrowth of more than 25 years of U.S. Agency for International Development experience with development communication -- also known as health communication, social communication, IEC, or community mobilization. The AIDS Control and Prevention (AIDSCAP) Project uses the term behavior change communication to emphasize the difference between simply providing information and giving people the knowledge, skills, encouragement and support they need for HIV risk reduction and healthy living.
True BCC activities for HIV/AIDS prevention use multiple channels to transmit and reinforce messages that address the needs of well-defined target audiences. They also give people the skills and tools required to prevent HIV and create a supportive social environment that helps people adopt and maintain safer sexual behavior.
But BCC cannot stand alone. It is an integral part of all the strategies that comprise AIDSCAP's comprehensive approach to HIV/AIDS prevention. Behavioral research and evaluation results are used to design BCC interventions that meet the needs of target audiences. BCC is an essential component of the policy process. And efforts to increase condom use, improve sexually transmitted disease (STD) control and change behavior are mutually reinforcing: BCC can persuade people to use condoms or seek STD treatment, and condom sales and STD services make it possible for people to act on BCC messages.
Responding to Real Needs
Behavioral research provides the starting point for risk reduction by helping clarify risk behaviors and their determinants. It is the core of the formative research that is the basis of BCC interventions.
Because individual behavior is influenced by social, economic, political and cultural factors, formative research for BCC planning involves both community and individual investigation. The community investigation, or situation analysis, looks at societal factors such as the demographics of the target population, the economic factors that affect people's purchasing power, and the institutions and other forces that shape society's basic values. The individual investigation (audience research) explores target audience members' perceptions of such issues as HIV risk, the benefits of preventive measures, and the credibility and accessibility of potential sources of prevention messages.
When a BCC intervention is based on this type of information, it responds to the real needs of the target audience. Formative research results make it possible to tailor the message, the communication channel and the strategy to address audience members' needs.
For example, students in Nigeria said they sometimes felt uncomfortable asking their peers questions about HIV, so the Nigerian Youth AIDS Program developed a radio call-in show to complement peer education efforts. Studies showing that Indian film stars were the most influential spokespeople in Madras led to the use of their voices in the voice-response system for an HIV/AIDS hot line. In Tanzania, the AIDSCAP-supported program emphasizes preventing STDs rather than HIV because key informants advised program planners that members of the target audience would be more receptive to such a message. STDs are common and familiar in the areas served by the project, but most people are afraid to admit that they might be at risk of HIV infection.
A comparison of AIDSCAP prevention projects for sex workers and their clients in the two countries that share the island of Hispaniola illustrates how very different approaches can be tailored to meet the needs of similar target audiences. In Haiti, where the sex industry is clandestine and many sex workers operate on the street or from their homes, NGO personnel usually contact sex workers privately and reach clients through workplaces. Printed materials are not widely used because neither clients nor sex workers want to be seen with them and because literacy levels are low. Videos, music tapes and interpersonal approaches have been more successful.
In contrast, the sex industry in the Dominican Republic is more open, and many sex workers work in bars. Both sex workers and their clients are reached through peer education conducted directly in bars and brothels. Printed materials are freely distributed and read. Dramatic presentations in bars and on the streets stimulate open discussion of HIV/STD transmission and prevention.
Supportive Environments
By encouraging changes in cultural attitudes, social norms, and government and institutional policies, BCC campaigns can help create an environment that supports individual HIV risk reduction. Therefore, many BCC interventions are aimed at policy makers, religious leaders and influential community members.
Although conventional wisdom reminds us that information is not enough to help people change behavior, in the policy arena, carefully presented information can be the key to changing the thinking and actions of decision makers. Workplace managers may need to know about the projected financial costs of HIV/AIDS among workers to be convinced to support workplace prevention programs. Politicians may need to hear about the long-term effects of a duty tax on imported condoms before they are willing to devote resources to AIDS prevention. And teachers and parents many need facts about teenage sexuality to help them see the need for HIV/AIDS prevention programs in schools.
Again, it is the combination of art and science that makes for an effective BCC campaign targeted at specific decision makers with particular attitudes and distinctive information needs. Strategic presentation of this information may be as important as the information itself. Skillful communication is an important part of the policy process.
In Kenya, for example, clergy expressed concern about the lack of guidance from church leaders on pastoral counseling about HIV/AIDS. Results of a study sponsored by AIDSCAP and carried out by MAP International revealed that approximately half of church youth were sexually active and perhaps as many as one-third of clergy were not monogamous.
The study results were presented to church leaders at a national conference in Nairobi in February 1996. This information became the impetus for a commitment by the leaders to address the clergy's concerns. A statement of that commitment signed by leaders of six major religions and endorsed by other leaders was issued and printed in local newspapers. Leaders of these churches are now developing HIV/AIDS policies.
Links with Services
BCC is also intertwined with the HIV/AIDS prevention strategies of STD control and increasing condom accessibility and use. Condoms won't be used unless they are introduced and promoted. And they can't be successfully promoted without an understanding of the concerns and barriers that prevent sectors of the population from accepting them.
Audience research in Uganda determined that although sexually active young women wanted their partners to use condoms, they did not dare suggest it because of popular attitudes that associate condoms with commercial sex. To counteract this perception, the national AIDS control program designed BCC materials depicting savvy, popular young women buying and carrying condoms. In Haiti, Population Services International (PSI) produced a video to address women's concerns about negotiating condom use with their partners. The video shows ten different scenarios for sexual negotiation, based on audience research.
Similarly, people are not likely to take advantage of accessible and affordable STD treatment unless they can assess their own risk, understand the consequences, and be assured of professional, confidential treatment. Therefore, BCC targets potential STD patients and the health practitioners serving them.
In Ethiopia, for example, AIDSCAP supported targeted intervention research to learn about community members' understanding of STDs and their treatment. Results indicated that many respondents were reluctant to seek treatment for STDs because they feared rudeness and rejection by health care providers. Consequently, BCC messages targeted both prospective clients ("Seek confidential and professional STD treatment at your local clinic") and health care workers ("Help your STD patients prevent further STDs by giving them time and understanding").
A Coordinated Approach
It is the art of BCC that attracts attention. Performances of "Vibes," a musical revue by the ASHE Caribbean Arts Ensemble in Jamaica, have delighted and informed thousands of young people and their parents. A "Love and Sex Fair," in Bangkok on Valentine's Day drew more than 2,500 people to compete in quizzes testing their knowledge of STDs, watch condom demonstrations, and participate in frank discussions about sex, sexuality and reproductive health. Almost 1 million Haitians followed "Sultana Mon Amor," a television serial drama about a woman whose husband dies of AIDS. And Emma, the vivacious and supportive comic book character created by Family Health International's AIDSTECH Project (the precursor to AIDSCAP), has been used in ten countries. She now "speaks" five languages.
But it is the science behind these interventions -- the painstaking audience research, systematic project design, and coordination with interpersonal communication, condom distribution and STD services -- that makes them work. The "Love and Sex Fair," for example, was a onetime event, but it was designed to reinforce the messages conveyed every day by hundreds of outreach workers and peer educators as part of the Comprehensive Bangkok Program. "Sultana Mon Amor" uses characters and situations familiar to the target audience to address barriers to behavior change identified by AIDSCAP's monitoring efforts.
This coordinated approach is evidenced throughout the AIDSCAP Project. In Jamaica, a project implemented by the Association for the Control of STDs (ACOSTRAD) includes condom social marketing, group educational sessions in STD clinics and outreach education by community members. The Organization of Tanzania Trade Unions (OTTU) works with parastatal and private sector company management in Tanzania to develop HIV/AIDS policies, support peer education programs, and distribute condoms in workplaces. And in Bangsue, Thailand, the World Vision Foundation of Thailand trains and supports peer educators, pharmacists and government health center and STD clinic staff to improve STD services and promote behavior change.
While BCC planning and principles are fundamental to all of these projects, it is the provision of goods, services and skills training that permit people to adopt the behaviors advocated in BCC messages. Helping people move from unsafe to safer behaviors is a complex task that can only be accomplished through concerted efforts to master both the science and the art of behavior change communication.
-- Donna Flanagan
Donna Flanagan, MA, MSW, is AIDSCAP's associate director for behavior change communication.
