HIV/AIDS Prevention Campaigns: a Critical Analysis

In the absence of pharmacological, immunological, and medical interventions, the change in behavior and attitude of the public may only be considered a possible way for the prevention and cure for HIV/AIDS. The basic purpose of this study is to analyze the various communication models and steps that play a pivotal role in making successful communication campaigns for shaping public attitudes related to social stigmas and issues about HIV/AIDS. It further sheds light on the importance of combination of interpersonal and mass communication strategies for the development of these campaigns. In addition, this paper describes the significance of various components of effective message. Introduction In the absence of pharmacological, immunological, and medical interventions, the change in behavior and attitude of the public may only be considered a possible way for the prevention and cure for HIV/AIDS (UNAIDS-WHO 1998, para, 10). Although the human immunodeficiency virus (HIV) has been identified as the etiological agent causing AIDS, transmissions of this virus depends largely on human behavior related to sexuality and drug use. Communication plays an important role in this process because it disseminates information that may prevent risk behavior and spread awareness leading to Canadian Journal of Media Studies, Vol. 5(1) 130 the reduction of a social stigma. AIDS prevention programs disseminated through media or community awareness campaigns, are directed towards changing sexual practices and the use of intravenous needles. Most theories and models applied in HIV/AIDS awareness campaign are derived from social psychology, communications family planning and population. Many theories and models of health behavior change, including reasoned action, social learning, cognitive theory, and the hierarchy of effects, are based on individual psychology. In fact the assumption (such as individualism as opposed to collectivism) on which these theories and models are based are foreign to many nonWestern cultures. In majority of non-Western contexts, the family, group, and community play a greater role in decision-making: theories and models based on individualism continue to dominate communications strategies for HIV/AIDS prevention and care in such settings. Therefore, both strategies including use of mass media and interpersonal communication are effective ways of behavior change. The basic purpose of this study is to analyze the various communication models and steps that play a pivotal role in making successful communication campaigns for shaping public attitudes related to social stigmas and issues about HIV/AIDS. It further sheds light on the importance of combination of inter-personal and mass communication strategies for the development of these campaigns. In addition, this paper describes the significance of various components of effective message. Theories and Models Used in HIV/AIDS Prevention 1. The health belief model The health belief model was developed in the 1950s to predict individual response to screening and other preventive health services and their use. The HBM grew out of Canadian Journal of Media Studies, Vol. 5(1) 131 research by social scientists in the U.S. public health services to explain the reluctance of people to participate in disease reduction program. The HBM is based on value expectancy theory (Melkote & Steeves, 2001, p. 132), that assumes that individuals will take preventive actions (risk-reduction behaviors) when they are susceptible to a disease (self-perception of risk) and acknowledge the consequences as severe; they believe that taking preventive actions will be beneficial in reducing the threat of contracting the disease (e.g., condoms are effective against HIV infection, and that its perceived benefits will be sufficient to overcome perceived barriers such as cost or inconvenience of undertaking the actions (Melkote & Steeves 2001, p. 132). Rosenstock (1974) discusses four constructs of Health Belief Model including (1) Perceived Susceptibility (an individual’s assessment of his/her risk of getting the conditions), (2) Perceived Severity (individual’s assessment of the seriousness of the condition, and its potential consequences), (3) Perceived Barriers (an individual’s assessment of the influences that facilitate or discourage adoption of the promoted behavior), and (4) Perceived Benefits (an individual’s assessment of the positive consequences of adopting the behavior). Two constructs were added later including (5) Perceived Efficacy (an individual’s selfassessment of ability to successfully adopt the desired behavior, and (6) Cues to Action (external influences promoting the desired behavior). Majority of health communication campaigns are based on this model and it is equally useful in HIV/AIDS prevention programs (also in Glanz et al, 2002, pp. 51-53). 2. Theory of Reasoned Action The theory of Reasoned Action (Ajzen & Fishbein, 1975) is an extension of HBM. This theory explains individual behavior by examining attitudes, beliefs and Canadian Journal of Media Studies, Vol. 5(1) 132 behavioral intentions as well as observed and expressed acts. It is based on the idea that the most immediate determinant of a person’s behavior is his/her behavioral intention. Ones’ actions can only be influenced by influencing one’s intentions. Intention in turn is a joint function on one’s positive or negative feeling leading to ‘perform or not to perform’ that particular action. This theory highlights intentions by focusing on attitudes towards risk reduction, response to social norms, and behavioral intentions vis-à-vis risky behavior (UNAIDS, 1999). 3. Social Cognitive Theory This theory is based on the assumption that individual behavior is the result of interaction among cognition, behavior, environment and psychology. Bandura (1994) pointed out that in order to achieve “self-directed change, people need to be given not only reason to alter risky habit but also behavioral means, resources and social supports to do so. It will require certain skills in self-motivation and self-guidance. (Bandura 1994 & Piotrow et al. 1997, p. 22). Bandura’s theory is based on following two elements: a. Self-efficacy b. Social modeling Self-efficacy refers to a person’s belief in his/ her personal ability to affect a change, which determines what course of action that person will choose, how long it will be sustained in the face of resistance, and his/her resiliency to bounce back following the setbacks. Social Modeling is based on the principle that people learn vicariously by observing the actions of others. Moreover, people are likely to judge their own capabilities, in part, by comparing themselves with those who are in the similar situation Canadian Journal of Media Studies, Vol. 5(1) 133 as them. People look up to the models similar to them solving problems successfully which help them develop a stronger belief in their own abilities. The virtue of selfefficiency may be effective only if the actors are confident of their ability to act. Social modeling has been used extensively in television campaigns in order to provide knowledge about HIV/AIDS, as well as strategies to cope with successful situations in sexual encounters. In a nutshell, the dual variables: self-efficiency and modeling have been used widely in campaigns on HIV/AIDS because of their holistic approach that provides knowledge, skill, and confidence to undertake preventive measures against AIDS (Melkote & Steeves, 2001, p. 133). 4. Theories of Emotional Response These theories propose that emotional response precedes and conditions cognitive and attitudinal effects. This implies that highly emotional messages in entertainment would be more likely to influence behavior than messages in low emotional contents (Piotrow et al. 1997, p. 22). 5. Cultivation theory of Mass Media Gerbner proposed this theory in 1973. It specifies that repeated intense exposure and deviant definitions of ‘reality’ in the mass media lead to a perception of that ‘reality’ as normal. The result is a social legitimization of the ‘reality’ depicted in the mass media, which can influence behavior (cited in Piotrow et al. 1997, p. 22). 6. Diffusion of Innovations theory Ryan and Gross propose this theory in 1943, which traces the process by which a new idea or practice is communicated through certain channels over time among members of a social system. This theory also explains the factors that influence people’s Canadian Journal of Media Studies, Vol. 5(1) 134 thoughts, actions and the process of adopting a new technology or idea (Piotrow et al., 1997, p. 22). Rogers (1962) proposes a detailed model of diffusion of innovation and argues that it occurs in four stages: invention, diffusion (or communication) through the social system, time and consequences. The information flows through networks. The nature of networks and the roles opinion leaders play in them determine the likelihood that the innovation will be adopted. Innovation diffusion research has attempted to explain the variables that influence how and why users adopt a new information medium, such as the internet. Opinion leaders exert influence on audience behavior via their personal contact, but additional intermediaries called change agents and gatekeepers are also included in the process of diffusion. Five adopter categories are: (1) innovators, (2) early adopters, (3) early majority, (4) late majority, and (5) laggards. This theory is also significant in health communication especially in HIV/AIDS prevention because it highlights the process of adoption of news ideas despite inconvenience, for instance, the use of condom for prevention of sexually transmitted diseases. 7. Hierarchy of Effects This model focuses on individual behavior change in a linear fashion, which begins with exposure to information and assumes that knowledge, attitudes, trial, and adoption of the desired behavior will necessarily follow (USAIDS, 1999). Baran & Davis (2003) summarizes the model and maintains that It is important to differentiate a large number of persuasion effect-some that are easily induced and other that take more time and effort. This model permits development of a step-by-step persuasion strategy in which the effort begins with easy induced effects, such as awareness, and monitors these effects using survey research. Feedback from that research is used to decide when to transmit messages design to produce more difficult effect such as decision making or activation. Thus, the effort begins by creating audience awareness, then cultivates images or induces interest and information seeking, reinforces learning of information or images, aids people in Canadian Journal of Media Studies, Vol. 5(1) 135 making the “right” decisions, and then activates these people. At each step, the effectiveness of the campaign to that point is monitored, and the messages are changed when the proper results aren’t obtained. (p. 305) To sum up, this model provides a basic framework for public health campaigns by focusing on step-by step persuasion strategies for creating awareness for behavior change. 8. Social Marketing The concept of social marketing was introduced in 1971 and was defined as “the design, implementation and control of programs calculated to influence the acceptability of social ideas and involving considerations of product, planning, pricing, communication, distribution, and marketing research (Melkote & Steeves, 2001, p. 137). Baran & Davis (2003) highlights the following features of social marketing theory including (1) inducing audience awareness regarding campaign topics, (2) Targeting messages at specific audience, (3) reinforcing messages, (4) cultivating images and impressions of people, product or services, (5) stimulating interests, (6) inducing desired decision making or positioning, (7) activating audience segments (pp. 303-305). Therefore, social marketing is an approach to promoting the acceptability of social ideas through mass media. Social marketing’s well-known four “Ps” (product, place, pricing and promotion) have been applied to HIV/AIDS prevention in condom promotion (USAIDS, 1999). Furthermore, commercial advertising and packaging of condoms, appropriate price and convenient locations (tuck shops, bars & hotels) for sale distribution have resulted in dramatic increase in condoms sales in countries such as Ivory Coast, India, Malaysia and Pakistan. Canadian Journal of Media Studies, Vol. 5(1) 136 9. Entertainment –Education for Behavior Change It is a well known saying that “education is the vaccine against AIDS” (Singh, 2006, para, 6). Singh further maintains that the message about AIDS awareness must have informative educative and entertaining appeal. To corroborate her point of view she has cites Richard Gere as saying that the public announcements are not successful as they lack entertainment element. The education of HIV/AIDS must be done in a holistic manner without isolating or compromising educative or entertaining aspect. To spread the message of AIDS one must sell the message as selling of a product (Singh, 2006, para, 17). Similarly, Hollywood movies like Longtime companion (Wlodkowski, Stanely, & Rene, 1990), Philadelphia (Gary, Utt, Bozman, & Cox, Demme, Zea, 1993), A Mother’s Prayer (Young & Elikann, 1995), Breaking the Surface: The Greg Louganis Story (Bacino, Epstein, Green & Stern, 1996) and Gia (Brubaker, James & Cristofer, 1998) were an attempt in educating people regarding issues related HIV/AIDS through entertainment. In the 1970s, the idea of using television as an instructional/development medium appealed to both administrators and development experts because of its immense potential in propagating useful ideas and practices. Moreover, the mass communication theory the Minimal Effects Hypothesis was also losing its appeal in 1970s. According to this theory mass media were not particularly changing opinions and attitudes of audience. While the research in the area of agenda -setting showed that the mass media were very effective in increasing the cognition levels of audiences of salient events and thus serving as important agents of surveillance (Shaw & McCombs, 1974 & Baran & Davis, 2003, pp. 311-314). Similarly, Uses and Gratifications theory focuses on an active audience Canadian Journal of Media Studies, Vol. 5(1) 137 member as opposed to the passive stereotype depicted in the minimal effect theories. In uses and gratification model, audience member actively select media products to satisfy a range of needs: new information, entertainment, news, relaxation and more. This research shows that audiences were actively selecting radio and television programs to gratify their perceived needs. Furthermore, between 1965-1995 the number of radio and television sets in developing countries grew more than tenfold from 82 million to 997 millions (Piotrow et al. 1997, p. 22, Baran & Davis, 2003, pp. 261-263). This development has increased the importance of entertainment-education through mass media in development perspective. 10. AIDS Risk Reduction and Management The AIDS risk reduction and management model is proposed by Catania 1990. This model combines elements from health belief model and social cognitive theory to describe the process through which individuals change their behavior and it also explains why individuals fail to change their behavior regarding AIDS prevention. The ARRM identifies three stages in behavior change and management. Stage one is labeling high-risk behavior as problematic, which incorporates the notion of susceptibility from health belief model. This involves knowing which sexual activities are associated with HIV transmission, believing that one is personally susceptible to contracting HIV, and believing that AIDS is undesirable. Stage two is making a commitment to changing high-risk behavior. This notion came from cognitive learning theory. Stage three is seeking and enacting solutions that are taking steps to actually adopt the new behavior than adhering to the pervious one. This enactment is influenced Canadian Journal of Media Studies, Vol. 5(1) 138 by social norm and problem solving options, and it may include seeking help (Melkote & Steeves, 2001. p. 134). These stages provide useful diagnostic tool to determine at which stage a target group is situated, and, therefore, the most appropriate intervention. For instance gay men in U.S. as a group are highly aware of the risk of unprotected sex as compared` to Hispanic/Latino women as a group which does not recognize the risk. Therefore, this model identifies target audience that needs information as well as points out that behavior change may not be achieved in a one-shot campaign. To sum up, these theories and models are extensively used in health communication campaigns. While the effectiveness of these theories and models is sometimes questioned in the light of the growth of the HIV/AIDS epidemic in Africa, Asia and Latin America; their value as important theories and models remains unchanged. For instance, “Diffusion of Innovation” continues to be a leading theory widely used in programs for social change. Its use by opinion leaders for information dissemination and behavior change is critical in most development communication programs. Similarly, the interaction between the individual and environment in social cognitive theory is critical, even though behavior modeling and self-efficiency seem to be the common focus of this theory. Almost all health related behavioral change communication theories focus on individual as well as collective behavior change and