C-Change Picks - Information about Behaviour and Social Change Communication - HIV Prevention
C-Change Picks #2 - Information about Behaviour and Social Change Communication - HIV Prevention
Sponsored by C-Change
September 17 2008
From The Communication Initiative (The CI) and the United States Agency for International Development (USAID)'s C-Change programme.
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C-Change Picks is an e-magazine supported by C-Change and implemented by The Communication Initiative that focuses on recent case studies, reports, analyses, and resources on communication for behaviour and social change to address health, environment, and civil society. If you have received this newsletter from a friend or colleague and would like to subscribe, please contact cchange@comminit.com
Emerging from the August 2008 International AIDS conference in Mexico City was a distinct emphasis on social analyses and socially-driven responses to HIV and AIDS. Participants discussed the challenges and also the opportunities of social drivers, social complexities, social change, social mobilisation, social movements, social stigma, socio-economics, socio-cultural factors, and social phenomena (from homophobia to gender equity).
Reflecting the importance of these contextual factors in behavioural and social change processes, this issue of C-Change Picks focuses specifically on behaviour change communication (BCC) and social change communication for HIV prevention, highlighting information and reports around issues such as multiple concurrent partners (MCP), most-at-risk populations, gender equity, and male circumcision, among others.
C-Change Picks continues to seek new knowledge and experiences in behaviour change and social change communication - your case studies, strategic thinking, support materials, and any other relevant documentation. Please contact cchange@comminit.com
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A Focus on HIV/AIDS Prevention
1. Gender Transformative BCC HIV Prevention Intervention in South Africa
2. Talking About Condoms in India Increases Sales
3. Concurrent Sexual Partnerships: Challenges for HIV Prevention Communication
4. Learning from Adolescents to Prevent HIV and Unintended Pregnancy
5. Festival of Love: HIV Prevention in the Sex Trades
6. Fijian BCC Programme Leads to Ownership of HIV/AIDS Prevention Responses
7. Reviewing Approaches to HIV Prevention Among Vulnerable Populations
8. The History and Challenge of HIV Prevention
9. Integrating Biomedical Interventions with Behavioural Interventions
10. HIV Prevention for Youth Through Sport
11. South African Entertainment-Education Television Drama Influences Youth
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HIV/AIDS Prevention
1. Gender Transformative BCC HIV Prevention Intervention in South Africa
This 2007 research brief offers both qualitative and quantitative evidence from an evaluation of a Stepping Stones intervention in the Eastern Cape, South Africa. Stepping Stones is an HIV prevention behaviour change communication (BCC) programme that aims to improve sexual health by building stronger, more gender-equitable relationships with better communication between partners.
The findings here provide evidence of success in bringing about changes that reduced sexually transmitted infections in study participants. This study also shows Stepping Stones to be effective in reducing sexual risk-taking and violence perpetration among young, rural African men. According to this evaluation, the proportion of men in villages participating in the Stepping Stones programme who had transactional sex was lower 12 months after participating in the programme (p=0.01) and the proportion who had perpetrated severe intimate partner violence (defined as more than one episode of physical or sexual IPV) was lower at 12 and 24 months (p=0.11 and p=0.05).
The qualitative research showed that Stepping Stones impacted on a range of different areas of participants’ lives. Many of the participants spoke of changes in relationships with their parents and other elders after the workshops, enhanced skills related to talking about sex with older people, and improvements in communication among both men and women with partners. This, according to the study, supports the argument that participants, and particularly men, changed who they were as individuals and how they related to others. The programme brought about changes in attitudes which could critically lessen HIV risk by providing knowledge, generally raising awareness of personal risk, and giving a much greater openness about HIV. In the process it seems to have provided general life skills which made many of them better partners, friends, family members, and citizens.
2. Talking About Condoms in India Increases Sales
Implemented under the Program for Advancement of Commercial Technology - Child and Reproductive Health (PACT-CRH) by ICICI Bank with technical assistance and oversight from the United States Agency for International Development (USAID)-funded Private Sector Partnerships-One (PSP-One) project, this public awareness behaviour change communication campaign was launched in India in September 2006 as part of an effort to expand the condom market in Northern India, which had been declining in previous years, and to decrease the embarrassment associated with purchasing condoms. Through the slogan "Condom bindaas bol" ("Condom, just say it") and a series of humourous television advertisements, the campaign encouraged people to talk openly about condoms and to use the word freely at the point of purchase. The campaign sought to reach both consumers and vendors through a mix of traditional and non-traditional media vehicles, public relations initiatives, and activities meant to address the stigma surrounding condom use by reducing the embarrassment associated with buying condoms.
During the project implementation period (2003 - 2006), the sales volume of commercial condom brands increased 6.4% (the compounded growth rate), and the value of commercial condom brands sold through retail outlets increased by 10.3% (also the compounded annual growth rate). In addition, organisers cite evidence indicating that the campaign was also successful in improving attitudes: consistent use of condoms with non-spousal partners among sexually active men increased from 75% to 80%; current condom use with spouses among married men increased from 38% to 60%; and there was a 16% increase among those reporting the belief that condoms are not only for commercial sex.
3. Concurrent Sexual Partnerships: Challenges for HIV Prevention Communication
This report, from the Centre for AIDS Development, Research and Evaluation (CADRE), looks at the issue of concurrent sexual relationships amongst heterosexual respondents between the ages of 20 and 30, exploring implications for HIV/AIDS communication and offering recommendations and key message concepts for HIV/AIDS communication. It draws on data collected from two studies conducted in South Africa in 2006: 1) a national HIV/AIDS communication survey which looked mainly at the impact of HIV/AIDS communication; and 2) a qualitative study comprising interviews and focus groups which looked at the nature of sexual relationships and sought to identify implications for HIV/AIDS communication.
Based on an analysis of the data, the report offers key recommendations for prevention and communication.
i) There is a need for urgent and intensified focus on the risks of high sexual partner turnover, casual sex, and sexual partner concurrency.
ii) Interventions should avoid dualities of meaning embedded in the concept of 'faithfulness' in favour of more direct and pragmatic guidelines.
iii) Within the context of high HIV prevalence in conjunction with exposure to concentrated sexual networks, it is necessary to focus on reducing concurrency. As well, condom promotion should focus on promotion of correct and consistent condom use.
This report also includes a number of key concepts/messages related to condoms and voluntary counselling and testing (VCT) for complementary HIV prevention communication.
4. Learning from Adolescents to Prevent HIV and Unintended Pregnancy
This research report proposes that new programmes and policies designed to prevent HIV in Africa should focus on providing earlier and more comprehensive sexual health information and reinforcing national health care systems to better serve youth. Published by the Guttmacher Institute and institutional partners in Burkina Faso, Ghana, Kenya, Malawi, and Uganda, the report compiles policy and programme recommendations based on findings from national surveys of approximately 20,000 African adolescents, as well as focus group discussions, and in-depth interviews with hundreds of young people, parents, teachers, and health care providers.
The research found that many adolescents are sexually active and need help to prevent negative consequences stemming from such activity. Adolescent females in sub-Saharan Africa tend to have sex at an earlier age than their male counterparts, and, thus, are at particular risk for HIV, unwanted pregnancy, and other adverse outcomes. The research also suggests that many adolescents do not use contraceptives, have experienced unwanted sex, have multiple or much older partners, and lack adequate knowledge about avoiding sexually transmitted infections (STIs) and pregnancy.
The research points to mass media as a major source for sexual and reproductive health information. In focus group discussions in the four countries, adolescents cited numerous reasons why radio, in particular, is one of their preferred sources of information. For example, they noted that radio is a reliable source (Uganda), it reaches a wide audience (Ghana), it gets information to young people quickly (Malawi), listeners do not need to go somewhere for the information (Burkina Faso), and parents can listen and teach their children what they learn (Malawi). However, adolescents also noted the limitations of mass media, including both the fact that one cannot easily ask questions and, in the four focus countries, as many as one in four adolescents have no access to the mass media. Similarly, the research suggests that new technologies are promising, but still reach relatively few adolescents.
This report identifies comprehensive school-based sex education as an effective and efficient way to educate adolescents, improve their knowledge, and reduce sexual risk behaviours. It goes on to make recommendations for improving school-based sex education in Africa and for specific actions to improve adolescents' access to the formal health sector.
5. Festival of Love: HIV Prevention in the Sex Trades
The International Center for Research on Women (ICRW) is conducting a 3-year (Dec 2006-2009), participatory action research (PAR) project that seeks to reduce the risk of HIV among sex workers in Rajahmundry, Andhra Pradesh, India. Working in partnership with CARE India and the Nari SAKSHAM sex workers' collective, ICRW is seeking to understand the factors that encourage individuals to sell sex, and to explore ways to mitigate the impact of HIV risks once they enter the sex trade. The project will generate empirical evidence to be used to inform the development of both programme interventions and policy at the local, national, and international levels, with particular emphasis on reaching United States (US) stakeholders, including members of Congress.
The core strategy involves PAR that is designed to empower women by finding ways to value sex workers' subjective experience related to gender, sexuality, and intimacy (e.g., pleasure, power, pain, shame). Sex workers are at the centre of Prema Panduga (or "Festival of Love"), driving the process and determining next steps. Specifically, Prema Panduga revolves around a series of discussions that were designed to establish a common platform among project staff and sex workers for thinking and acting together. Part of this process of building trust and solidarity involved recognising and addressing social and cultural barriers that might impede communication. According to ICRW, the resulting unguarded conversations between the women and staff that took place enabled the open exchange of ideas for how to refine and deepen harm reduction interventions.
Building on these connections, the participants felt empowered to gather momentum to suggest and implement real-world applications of the concepts they had discussed in the sessions. For instance, based on the fact that, in southern India, many sex workers entertain clients through song and dance before providing sexual services, the women suggested that Prema Panduga provide skills-building on theatre techniques and mime. This led the women to form a cultural troupe called Nari Kala Vedika that works to generate awareness on the risk of HIV among their peers and with the broader community. These performances reflect what ICRW claims is a notable outcome of the discussions held through Prema Panduga: the women situate the issue of HIV risk from their own perspective, choosing to address issues of violence and exploitation, dowry practices which are at the origin of many women's entry into sex work, and lack of access to health and education services, given prevailing stigma and discrimination.
6. Fijian BCC Programme Leads to Ownership of HIV/AIDS Prevention Responses
In June 2006, the Pacific Regional HIV/AIDS Project (PRHP) piloted the Stepping Stones programme in Fijian communities in an effort to improve Fijians' sexual health and to decrease HIV/AIDS in that country through community participation and local-level decision making. This July 2007 evaluation report analyses the effects of the Stepping Stones programme in Fiji as evaluated through both the "Gemscale Model" and the "Most Significant Change (MSC) Technique" (both approaches are described at length in this report), and provides recommendations for the scaling up of the programme into other Pacific Island countries.
Evidence from the stories collected showed that Stepping Stones had facilitated improved HIV-related behaviour change amongst both clients and implementers of Stepping Stones. Of the client stories collected, a number of them reported an improvement in communication with their community, family or sexual partner and spoke of new skills and confidence to speak about HIV and sexual health issues. This in-turn led to clients reporting improved relationships with sexual partners, less community fighting, and better communication and trust between parents and children.
Evidence from this evaluation found that, when well implemented, the Community Self Assessment evaluation, a part of the MSC evaluation approach, can be an effective way of monitoring programme outcomes and capacity development. Its strengths lie in its inclusive approach and its encouragement of communities to become empowered to find their own responses to HIV/AIDS.
7. Reviewing Approaches to HIV Prevention Among Vulnerable Populations
This publication, a Pathfinder International technical guidance series paper, describes approaches to working with populations especially vulnerable to HIV/AIDS. The document outlines strategies effective in prevention of HIV/AIDS among sex workers (SW), men who have sex with other men (MSM), and injecting drug users (IDU). Programmes described include peer education, comprehensive health services and quality of treatment, provider referral networks, and in-service training and sensitisation.
Pathfinder’s assessments outline three key elements that should be integrated in effective HIV prevention strategies for these groups: 1) identify, develop, and pursue community-determined and -led actions to change individual and social behaviours that reduce risk of HIV infection; 2) guarantee equal access to comprehensive quality health services; and 3) promote respect of fundamental human rights.
As stated here, behaviour change communication (BCC) programmes which focus on the dissemination of large amounts of information related to "healthy" behaviours (usually designed without the participation of vulnerable group members), fail to change attitudes and mold behaviour. Focusing on the "must do's" and "must not do's" seldom has meaning in the priorities and daily struggles of vulnerable communities. Cultural sensitivity within the AIDS epidemic means listening to and respecting the cultural diversity of individuals vulnerable to HIV/AIDS: their life styles, sexuality, values, norms, and rules for daily living. The process of developing communication campaigns and educational materials absolutely must include the participation of the vulnerable groups to be reached, if they are to be relevant and effective.
8. The History and Challenge of HIV Prevention
Published in August 2008 as the first in a series of six articles about HIV prevention in The Lancet, this report assesses strategies that have emerged throughout the history of efforts to respond to the global HIV and AIDS epidemic. The authors' primary claim is that the response has for the most part been delayed, fragmented, inconsistent, and - in general - insufficient.
Tracing the critical events in the global response to HIV/AIDS since the first cases of AIDS were reported by the Centers for Disease Control and Prevention (CDC) in 1981, the authors outline various shortcomings along the way, such as the mistakes of the mid-1990s, when HIV/AIDS slipped down the political agenda and the pandemic greatly expanded. One reason for these failures is an insufficient focus on the role of communication; the authors claim that "[s]uccessful responses have addressed sensitive social factors surrounding HIV prevention, such as sexual behaviour, drug use, and gender equalities, countered stigma and discrimination, and mobilised affected communities; but such responses have been few and far between." They indicate that it was not until the turn of the millennium that a new receptivity to tackling HIV prevention emerged.
The authors conclude by advocating that revitalising the global HIV prevention movement requires that future efforts be grounded in both an awareness of past missteps and in a better understanding of how to combine behavioural, structural, and biomedical approaches - an understanding that is based on scientifically derived evidence as well as the wisdom and ownership of particular communities.
9. Integrating Biomedical Interventions with Behavioural Interventions
Published in August 2008 as the second in a series of six articles about HIV prevention in The Lancet, this review discusses the state of biomedical HIV prevention research. The authors focus on sexual transmission, classifying prevention methods by the specific mechanism of action rather than the mode of delivery. They review physical barrier methods, control of other sexually transmitted infections (STIs), male circumcision, topical antimicrobial (microbicide) preparations, the prophylactic use of antiretroviral drugs (oral and topical), and HIV vaccines. For each of these methods, they describe the available evidence for efficacy or effectiveness, make recommendations for use, and suggest future research needed. They also review levels of evidence for effectiveness for each method.
The authors stress that communication strategies should play a role in moving forward. For example, to avoid risk compensation and to increase adherence, biomedical methods should be inextricably implemented together with behavioural interventions. Likewise, biomedical interventions, such as male circumcision, offer an opportunity for risk reduction counselling. This review suggests that rather than trying to control for the effect of behaviour on biomedical methods, future studies should embrace this integration and use creative designs to examine strategies that offer a variety of prevention methods.
10. HIV Prevention for Youth Through Sport
This paper, published by Mercy Corps, looks at the role of Sport for Development in HIV prevention. The document looks specifically at the role of "plus sport" programmes, as opposed to "sport plus" programming. Sport plus programming involves young people in sport to learn new sports skills and/or improve health and social integration. Here the outcomes are sport-related. The plus sport approach discussed in this document, on the other hand, has non-sport, HIV/AIDS-related outcomes as the primary objective. The document draws on the experiences of two plus sport projects run by Mercy Corps – the Yes To Soccer programme in Liberia and the Sports for Peace and Life programme in southern Sudan - to discuss this approach and assess its value and limitations. Based on these projects, the document also offers tools and recommendations intended to contribute to developing a body of knowledge on practices within sport-based youth HIV/AIDS programming.
According to this report, these 2 programmes have demonstrated that a sport-based approach and participatory games-based methodologies are effective in increasing youth HIV/AIDS knowledge and protective attitudes. Yes To Soccer reported a 27% increase in youth knowledge and attitudes from pre- to post-test (from 58%-85%). The programme was placed within an existing youth life skills programme targeting older youth. Sports for Peace and Life, while reaching a larger number of participants, showed a more moderate 12% overall increase in youth knowledge and attitudes (from 69%-81%) across 16 HIV/AIDS related questions.
Based on lessons learned through these two programmes, this report makes a number of specific recommendations for successful behaviour change HIV prevention programmes.
11. South African Entertainment-Education Television Drama Influences Youth
Tsha Tsha is a South African educational-entertainment television drama series about young adults living in a world of HIV/AIDS. The drama series is set in a rural town in the Eastern Cape of South Africa and is produced in the local language, Xhosa, with English subtitles. The series focuses on the lives of several young people, and explores love, sex, and relationships in a world affected by the realities of the pandemic. The series aims to enhance its young adult viewers' capacity to reflect on their own problems, engage in developing solutions, and become active agents in shaping their future. The series comprised 78 episodes broadcast during primetime television between 2003 and 2006.
The Centre for AIDS Development, Research and Evaluation (CADRE), with technical support provided by Health Communication Partnership (HCP) researchers, evaluated audience responses to the first 26 episodes of the television drama Tsha Tsha based on data collected between April 2003 and May 2004. A subsequent evaluation in 2007 provided further information for this impact data.
From the July 2007 evaluation, those who had seen Tsha Tsha were 7.9% more likely to have positive attitudes towards people living with HIV/AIDS. Further, shifts towards positive/empowering values, attitudes, and behaviours were not limited to the context of HIV/AIDS but extended into other areas such as relationships (friendships, parental, sexual), poverty, and social problems such as alcohol and drug abuse, crime, violence, and unemployment.
Among the study's findings was evidence that people who had seen Tsha Tsha were 6.5% more likely to report condom use at last sex, as compared to those who had not seen it; viewers were also 5.5% more likely to help someone who is sick with AIDS.
For additional details on the Tsha Tsha programme, itself, please click here.
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Communication for Change (C-Change), implemented by AED, is USAID's flagship programme to improve the effectiveness and sustainability of communication for behaviour and social change as an integral part of development efforts in health, the environment, and civil society. C-Change works with global, regional, and local partners to use communication to change behaviours and social norms, supported by evidence-based strategies, state-of-the-art training and capacity building, and cutting-edge research. The ultimate goal is the improved health and well-being of people in the developing world. Please see the C-Change website. To contact C-Change, please email cchange@aed.org
The Communication Initiative (The CI) network is an online space for sharing the experiences of, and building bridges between, the people and organisations engaged in or supporting communication as a fundamental strategy for economic and social development and change. It does this through a process of initiating dialogue and debate and giving the network a stronger, more representative and informed voice with which to advance the use and improve the impact of communication for development. This process is supported by web-based resources of summarised information and several electronic publications, as well as online research, review, and discussion platforms providing insight into communication for development experiences. Please see The CI website.
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This publication is made possible by the support of the American people through the United States Agency for International Development (USAID) under the terms of Agreement No. GPO-A-00-07-00004-00. The contents are the responsibility of the Communicative Initiative and the C-Change project, managed by AED, and do not necessarily reflect the views of USAID or the United States Government.
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