Mass Media and HIV Prevention
I. Definition of the Prevention Area
Mass media interventions aim to prevent HIV by increasing knowledge, improving risk perception, changing sexual behaviors, and questioning potentially harmful social norms. Campaigns may utilize radio, television, and other outlets and ideally operate as part of multi-level efforts, in which mutually reinforcing messages are offered through interpersonal, community, and national channels. Mass media interventions are a critical part of an effective prevention approach.
II. Epidemiological Justification for the Prevention Area
Mass media interventions offer a cost-efficient way to reach large numbers of people, including people who may be difficult to reach through interpersonal approaches, such as migrants and people living in remote areas. These interventions have the potential to influence social norms, engendering productive dialogue at the population level.
III. Core Programmatic Components
Mass media programs should be implemented through multiple channels with mutually reinforcing messages. Radio and television, the most commonly used mass media, have been used creatively to target various populations through formats such as dramas, serials, and diaries. "Edutainment," a combination of education and entertainment, can be used to model and demonstrate behavioral patterns that affect people's risk of HIV, such as partner communication.
Studies also show that promoting branded products and programs as well as specific service delivery points are more likely to achieve the intended outcome as opposed to generic messages. Small media (posters, pamphlets, and flyers) that are typically distributed locally may enjoy a long shelf life. However, mass media is most effective when it is reinforced with community interventions.
The development of a communications campaign must be strategic and aligned to the achievement of specific and measurable outcomes. Critical elements to a campaign's success include understanding the target audience, including the most efficacious media to reach them; pre-testing messages; modifying the campaign, if needed, based on post-test results; and measuring the cost-effectiveness of the media used. Principles for HIV and AIDS communication campaigns include realistic goals; behavior substitution rather than elimination; environmental support for behavioral change; cost-effectiveness; program accessibility to the target audience; and attention to legal and socio-cultural obstacles to change.
IV. Current Status of Implementation Experience
Although a growing body of evidence supports the effectiveness of mass media interventions on many of these outcomes, systematic reviews suggest that the size of the effect can be small to moderate. The effects of mass media may be short term, and reinforcement of messages is needed to sustain behavior change. A dose-response effect to mass media messages has been demonstrated: higher exposure to mass media resulted in increased positive behavioral change. Moreover, individuals need to be exposed to a variety of prevention messages, because risk factors for HIV change over an individual's lifetime.
Updated: March 2011
Mass media campaigns have traditionally targeted individual behaviors and evaluated campaign effectiveness by assessing whether people changed their behavior. Data suggest that while mass media can indeed influence behavior change, changes are usually modest. As evidence accumulates about the need for using structural approaches to modify risk behaviors, communication campaigns too must target more than just individual behaviors. The authors discuss the need for adopting an ecological approach to public health communication campaigns--that is, one that considers not only the individual, but the context within which the individual lives. Between this new approach and rapid changes in technology that have redefined what mass media is and how it reaches people, public health communication efforts must adjust accordingly. The authors recommend that in addition to targeting individuals, behavior change messages must target social networks and communities that influence the individuals whose behavior the campaigns want to change.
Mass media campaigns can increase the use of HIV testing and counseling (HTC) services, and mass media messages explicitly addressing HIV have greater impact. In Kenya, a professionally designed mass media campaign was developed to increase public demand for HTC. The campaign included radio, television, posters, flyers, outdoor advertising, and a recognizable logo that was used on all materials and on signboards at registered HTC sites. Campaign implementation was divided into four phases: phases one and four more overtly mentioned the possibility of testing HIV-positive, whereas phases two and three used a more understated "lifestyle'' approach (for example, the phase two message was to "get in control of your life" by knowing your HIV status). Phase one increased attendance by 28.5 percent and phase four by 42.5 percent. There was also a significant increase in HTC uptake among young people under age 25, particularly in urban areas. Phases two and three did not have a significant effect on HTC uptake. The authors note that the timing of phases one and two overlapped, making it difficult to differentiate a negative effect of phase two from a lack of sustained response to phase one.
Role models--both fictional and real-life--can facilitate behavior change. The Makgabaneng radio drama in Botswana was developed to help listeners protect themselves from HIV and support people with HIV through modeling and reinforcement. It included two major storylines about HIV during pregnancy which informed listeners about preventing mother to child transmission (PMTCT). About 250 episodes of Makgabaneng had been broadcast prior to surveying 500 pregnant and postpartum women. Exposure to this drama was high among these women, with 79% of respondents reporting ever listening to the program, and 53% reporting listening at least once a week. Although many women could recall a character in a PMTCT storyline, this recollection was not significantly associated with seeking HIV testing during pregnancy. Women who identified with characters in the drama, however, were more likely to be tested for HIV while pregnant. The authors conclude that such serial dramas can contribute to HIV prevention, treatment, and care when concurrent with widespread access to such services.
Researchers used 31 in-depth interviews with regular listeners of the Makgabaneng radio drama in Botswana (see Radio Role Models for the Prevention of Mother-To-Child Transmission of HIV and HIV Testing among Pregnant Women in Botswana) to understand why people identified with the positive, negative, and transitional role models in the series. This radio drama included characters dealing with pregnancy and HIV testing. Many listeners aspired to be like the positive role model, who was uniformly admired. The negative role model was not looked upon favorably, and no one aspired to act as she did. Most respondents wanted to discuss the transitional character, with some seeing her in a negative light and others aspiring to be like her. The audience showed evidence of differential modeling: that is, being able to compare and contrast the behaviors among the three characters and seeing the consequences of each characters' actions. The authors conclude that including more than one transitional character in a series can be beneficial, particularly one who is portrayed as adopting positive behavior behaviors at a later time, after discarding previous risky behaviors.
This study used the nationally representative 2001-2002 Zambia Demographic and Health Survey to assess the effect of mass media campaigns on condom use. Statistical methods were used to ensure against the possibility that the same factors that influence media exposure also influence condom use, or that condom users may seek out the health communication programs in question. Men were more likely to recall media messages than women, with fully 75% of men reporting exposure to condom messages. Although there was no correlation between exposure to these campaigns and other sexual risk behaviors, men and women with such exposure were more likely to have ever used condoms. For women, the difference was small but statistically significant; however, men exposed to messages were 50% more likely to have ever used condoms. Generally, the more exposure to the campaign, the greater the likelihood of these positive health behaviors--for example, men with the most exposure to messages were twice as likely to have ever used condoms than those with the least exposure. While the study cannot identify what specific content or messages affect condom use or the pathways of exposure, it nevertheless shows an overall positive effect of media exposure to condom use.
This systematic review evaluated mass media interventions addressing HIV-related behaviors among young people from 1990 to 2004 to analyze whether evidence exists for their effectiveness. Fifteen studies from Africa, Latin America, Asia, and one multi-country study met the authors' inclusion criteria. Study quality varied, and different definitions of variables made it impossible to pool and analyze the data. When radio was combined with other media, or when radio was combined with both television and other media, youth showed improvements in knowledge, skills, awareness, use of health services, use of condoms, and interpersonal communication. These media also had a positive impact on changing social norms. However, not every campaign was successful in influencing every variable. The authors provide recommendations for policy makers, program managers, and researchers about funding, developing, and evaluating mass media programs.
This review examines the effectiveness of 24 mass media interventions on changing HIV-related knowledge, attitudes, and behaviors in developing countries from 1990 through 2004. Media interventions included radio, television, small media, and interpersonal communication, sometimes alone, sometimes mixed. Because the outcome indicators of these studies were so diverse, the researchers evaluated seven key variables, including self-efficacy for condom use, abstinence, perceived risk of HIV, condom use, and discussing HIV or condom use with others. Half of the studies demonstrated a positive impact on knowledge of HIV transmission and reduction in high-risk sexual behavior. For the other five variables, however, the studies showed mixed results or no effect. The authors discuss the difficulties inherent in evaluating mass media campaigns. Their efforts were limited by studies that did not represent the state of the art in mass media communication and were not well designed and evaluated. The authors conclude that "communication campaigns are at the heart of the HIV/AIDS response, yet much work remains…in building the evidence base for their effectiveness."
Using data from household surveys conducted in 2002 and 2004, the authors assessed the impact of the program VISION media campaign on the: 1) discussion of HIV and AIDS with a partner; 2) awareness that consistent condom use reduces HIV risk; and 3) condom use at last intercourse. Although exposure to the campaign was high, its impact on outcome variables was small. Yet, respondents with high program exposure were almost one and a half times more likely than those with no exposure to have discussed HIV and AIDS with a partner, and more than twice as likely as those with low exposure to know condom use could reduce the risk of HIV infection. Program exposure had no significant impact on condom use. While overall differences in the outcome variables were small, effects for some subgroups suggest the potential of media activities.
This article used data from nearly 1,700 surveyed sexually active adults in North India to understand the effect of mediating factors on behavior changes and changes in condom use, extrapolating the findings to estimate costs of increasing condom use. The researchers evaluated the television components of a comprehensive HIV prevention communication campaign, including a TV drama, a youth-focused reality show, and TV spots. Mediating variables included gender attitudes, HIV/AIDS knowledge, perceived risk of HIV, and interpersonal communication skills. Better recall of the TV components was positively associated with positive mediating variables and higher levels of any condom use (though levels were low overall, at 10% among those with good recall and 4% among those with poorer recall). Furthermore, significant associations were found between the mediating variables and frequency and level of condom use. The TV program with the greatest increases in condom use cost $2.49 per additional person using condoms. Costs of mediating factors ranged from $1.23 per person for increases in HIV knowledge to $4.54 per person for reduced perceived risk of HIV.
This study of over 2,000 sexually experienced men and women ages 15-39 throughout Kenya assessed the impact of mass media exposure on predictors of behavior change. Branded messages about Trust condoms were compared to generic messages about HIV and condoms as a means of preventing HIV transmission. Trust messages were developed to destigmatize condoms by presenting condom use as a positive lifestyle choice. Respondents exposed to the branded messages were significantly more likely to report positive health behavior beliefs and behavior change predictors than those exposed to generic messages. Predictors included the belief that one could convince their spouse to use condoms; that condoms are effective for HIV prevention; and that HIV prevention is the reason for one's condom use. Furthermore, there was a positive correlation between exposure and predictors of behavior change. The author concludes that "constructing the image of healthy lifestyle choices can exert a significant influence on risk awareness, self-efficacy and other behavioural predictors" through mass media. While the author used statistical techniques to control bias and confounding, the potential for reverse causality exists in this study.
This paper broadly reviews behavior change communication strategies implemented over the first 15 years of the HIV epidemic, showing the changes in sophistication and understanding of health communication needs over time. Key principles behind successful communication efforts are taken from health communication, social marketing, and structural intervention theories. The author then provides lessons learned from vulnerable populations, including women, youth, men who have sex with men, and injecting drug users. He closes the paper with a discussion of research and intervention priorities for the future, including communicating with disenfranchised populations and policymakers, addressing stigma and discrimination, and linking HIV prevention activities within existing health programs.
Formative research is key to the development of campaign messages. This article describes a culture-centered approach for developing eight radio and two television advertisements to promote sexual risk reduction in urban African-American adolescents. Two key barriers to sexual risk reduction emerged from the research: 1) social pressure for early initiation of sexual intercourse; and 2) perceptions that condoms reduce sexual pleasure. By focusing on how teens resolve conflicts around sexual risk reduction, the researchers provided the creative team with ideas for modeling realistic arguments for sexual risk reduction in HIV prevention messages. Campaign messages focused on counter arguments that teens can use to overcome these barriers. Pressure to initiate intercourse was addressed by emphasis on respect, and the perception that condoms reduce sexual pleasure was addressed by the counter argument that condoms reduce feelings of stress and worry.
The Soul City Regional Programme is a regional HIV/AIDS communication project in Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia, and Zimbabwe. This document evaluates the impact of 20 media campaigns taking place in these countries between 2002 and 2007. The project achieved and often surpassed regional objectives such as reaching 40% of the population with their campaigns and 15% of those exposed to project materials adopting positive behavior changes. In addition to providing regional data, this evaluation provides succinct summaries of the individual country findings. Among those exposed to the media interventions throughout the region, compelling increases were found in obtaining HIV testing and asking a partner to get tested. Positive effects of the communication campaigns were found on condom use, stigma reduction, and partner reduction, with varying degrees of success taking place in the different countries.
Airing worldwide on MTV, the Staying Alive campaign consisted primarily of 30-second public service announcements about HIV. Researchers used cross-sectional, population-based surveys among 6,000 youth in Kathmandu, Nepal , São Paolo, Brazil, and Dakar, Senegal to assess the campaign's effect on interpersonal communication about HIV/AIDS and beliefs about HIV prevention behavior. Exposure to Staying Alive was associated with youths talking to someone about HIV: with a sex partner in Brazil and Senegal, parents in Brazil, siblings in Senegal, and a teacher or counselor in Nepal. Exposure to the campaign was significantly associated with positive beliefs about HIV prevention behaviors in all three sites. Furthermore, interpersonal communication about HIV was also positively associated with HIV prevention beliefs, regardless of who the discussion was with. Given similar positive findings from three very different settings, the authors conclude that their findings provide evidence that a global mass media campaign can indeed change social norms.
This publication examines the importance of media in the discourse and response to HIV in South Africa, assessing its role as a conduit to air public concerns as well as providing accurate information to challenge stigma and discrimination. It profiles "Soul City," a television and radio soap opera that addresses a range of health issues, the Community Health Media Trust, which uses the media to give a voice to people with HIV through its program, "Beat It," and Talalani Sesame, programming for children. Among many others, key lessons drawn from media implementation include: a mix of media enables projects to maximize impact; mass media projects require a team with many different skills and viewpoints; involving creative people in the development of messages is crucial; enabling the general public to interact with a mass media project or campaign can promote awareness, debate, and personal issue identification; and ensuring involvement of researchers and rigorous research enhances credibility and contributes to developing a quality product.
This website is an online resource where people developing and using communication for social change can come together to share information and experiences. Sections of the site include program experiences, monitoring and evaluation and data, change theories, and many articles, reports, and summaries of programs and program findings. There are also discussion fora, surveys, and classified ads. Readers can narrow their searches to different topics, including HIV/AIDS, Media Development, and Information and Communication Technology for Development. In addition to a global English-language website, readers can find links to a Spanish-language site focusing on Latin America and an English-language site devoted to the African experience and context.
Communication for Change (C-Change)
This website provides an overview of the C-Change project, a communication project that aims to influence change in social norms to improve health behaviors. In addition to providing information about their approach, readers can find program information for 15 countries worldwide. The project's focus areas include strengthening local capacity for communication for social change, family planning, HIV prevention, malaria, and gender equity.
C- Picks E-Magazine
C-Picks is an online magazine that includes resources on social and behavior change communication, including HIV prevention efforts. These selected resources include evaluations, implementation experiences, strategic guidance, and other tools and resources. Readers can browse the archives by date, technical area, country, or region. HIV-related topics include male circumcision, multiple and concurrent partnerships, and integration with family planning/reproductive health services.