Texas HIV/STD Conference 2


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Texas HIV/STD Conference

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Texas HIV/STD Conference 2

  1. 1. Journal of Health Communication, Volume 5 (Supplement), pp. 29È45, 2000 Copyright Ó 2000 Taylor & Francis 1081-0730/00 $12.00 1 .00 HIV /AIDS Communication Campaigns : Progress and Prospects SONJA L. MYHRE JUNE A. FLORA Stanford Center for Research in Disease Prevention Palo Alto, California, USA T he mass media have been the primary method for disseminating human immuno - deÐciency virus (HIV )/acquired immune deÐciency syndrome ( AIDS) prevention messages worldwide. In this article, we update previous reviews by systematically examining published articles (n 5 41 ) of empirical evaluations of international HIV / AIDS prevention campaigns. Of the 41 studies identiÐed, 17 countries are represented. In this review , we examine six components related to media campaign design and evaluation : target audience , communication channel(s ), message content, campaign theme, exposure, and outcomes . Of the studies included in this sample, each one described the target audience ; 93 % reported on channel selection ; 75 % described message content ; 63 % mentioned a campaign theme ; and 62% docu - mented campaign exposure. W e investigate also the extent to which HIV / AIDS prevention e†orts have moved beyond media campaigns to comprehensive communitywide programs . W e conclude that HIV / AIDS prevention e†orts would beneÐt from : ( 1) better reporting of media campaign components and outcomes , (2 ) more systematic evaluation, (3 ) greater integration of theory , and (4) increased attention to communitywide intervention strategies. Introduction To date, virtually every country in the world has been a†ected by HIV / AIDS according to the Joint United Nations Programme on HIV / AIDS (UNAIDS, 1997). In response, most countries have established a national AIDS program and have conducted some sort of mass media HIV / AIDS campaign (World Health Organiz- ation [WHO], 1994). According to WHO data on 126 countries, 93% broadcast HIV/ AIDS messages on television, 85% conduct radio broadcasts, and 67% of countries promote condom use through the media (WHO, 1994). Moreover, an international survey of governmental national AIDS programs found that 86 coun- tries worldwide reported collecting information on the numbers of people provided with targeted HIV /AIDS prevention messages (Mann & Tarantola, 1996). Although the precise impact of mass media on reducing AIDS risk behaviors is continually debated, knowledge about AIDS is obtained most often from mass media (i.e., tele- vision, radio, newspapers, magazines, pamphlets, and posters) rather than from interpersonal sources (i.e., friends, health workers, or the workplace) (Ross & Carson, 1988). This article examines empirical studies of HIV /AIDS campaigns that have been conducted, evaluated, and disseminated in publicly available health, medical, and communication journals. The purpose of this article is to review and update previous Address correspondence to : June A. Flora, Ph.D., Stanford Center for Research in Disease Prevention, Stanford School of Medicine, 1000 Welch Road, Palo Alto, CA 94304, USA. E-mail : sonja.myhre@ netzero.net 29
  2. 2. 30 S . L . Myhre and J . A. Flora published studies of HIV /AIDS media campaigns conducted throughout the world (Flora, Maibach, & Holtgrave, 1995 ; Holtgrave, 1997) and to identify appropriate steps for future HIV prevention campaign e†orts. Unlike previous reviews of HIV / AIDS prevention interventions processes (Baggaley, 1988 ; Choi & Coates, 1994 ; Holtgrave, 1997 ; Holtgrave et al., 1995 ; Stoller & Rutherford, 1989), this analysis focuses on HIV campaigns or interventions that contain a mass media component and concentrate speciÐcally on the communication processes. Evaluation of mass media campaigns necessitates an investigation of individual communication components that constitute the campaign. Focusing on individual parts enables researchers to pinpoint successful and problematic dimensions. This type of information can be used to reÐne campaigns underway and should be used to guide future e†orts. Based on public communication campaign research and in the interest of parsimony, this study focuses on key features related to campaign design (Rice & Atkin, 1989 ; Windahl & Signitzer, 1992). We examine the following fundamental communication components : speciÐcation of a target audience ; channel selection and mix taking into account reach, speciÐcity, and involvement issues ; message content and campaign themes that consider execution and message appeal (Flora, Saphir, Schooler, & Rimal, 1997 ; Schooler, Cha†ee, Flora, & Roser, 1998) ; measures of exposure ; and evaluative outcomes measures. Methods We attempted to locate all planned HIV /AIDS mass media campaign e†orts that provide explicit documentation of quantitative evaluation data on at least one outcome or impact measure. Formative (i.e., preproduction work), process (i.e., implementation studies), and qualitative (i.e., focus groups, ethnographic inquiry) evaluations were excluded as well as articles that focused on media coverage and AIDS publicity. Identifying studies was accomplished mainly through electronic database searches (e.g. Medline, AIDSLINE, PsychInfo) using key words such as ““AIDS,ÏÏ ““HIV,ÏÏ ““mass media,ÏÏ and ““campaign.ÏÏ One limitation of this search tech- nique is that HIV / AIDS mass media campaigns are sometimes discussed in general articles that do not mention mass media or campaign in the title or abstract. There- fore, in addition to electronic database searches, bibliographies of relevant articles and review articles were carefully reviewed (Choi & Coates, 1994 ; Fisher & Fisher, 1992 ; Flora, Maibach, & Holtgrave, 1995). This study di†ers from previous reviews in that abstracts (i.e., conference proceedings), books, book chapters, unpublished reports, and government docu- ments are excluded. Although abstracts have assumed a prominent role in the Ðeld (i.e., AIDSLINE contains more than 30 abstracts from the 1998 AIDS conference proceedings that describe HIV media campaigns in 25 di†erent countries), their brevity severely limits the amount of information that can be analyzed. An author of one review conceded that because of the numbers of studies in abstract form, ““It is virtually impossible to summarize the components of the campaignsÏÏ (Holtgrave, 1997, p. 184). The following six communication components were examined for each article (see Table 1) : target audience, channel selection, message content, campaign theme (i.e., name or slogan), exposure, and outcome measure(s) used to assess the cam- paign. From an evaluative perspective, these six elements provide important clues for understanding campaign success or failure. These features were selected for analysis because they represent a distillation of the essential elements of a campaign and were more consistently reported in the literature.
  3. 3. TABLE 1 Empirical Studies of HIV Prevention Mass Media Campaigns Study author, Target Channel Message Campaign theme Outcome : Country Date of publication audience selection/ mix content (name/ slogan) Exposure KABP 1 or other Argentina Burgos, 1996 General NS Yes AIDS Kills 25% A, B AIDS, DonÏt Let Yourself Fall in a Trap. Australia Bray & Chapman, 1991 General TV, radio, Yes National Campaign 3È93% K, A, B, & anxiety print, buses & against AIDS billboards Ross et al., 1990 General TV, print, & Yes The Grim Reaper 93.5% A, beliefs posters Rigby et al., 1989 General TV Yes The Grim Reaper 93.5% K, A, & personal & social concern Canada Wagman, 1993 19È30- Billboards, Yes Condomania 10È93% K, A year-old bus shelters, & heterosexuals car cards France Rudelic-Fernandez General Fictional short Yes 3000 Scenarios contre un 69% A & discussion, & et al., 1998 Ðlms Virus. sociability e†ects Bajos et al., 1996 General Fictional short Yes 3000 Scenarios contre un 69% A, B, awareness, & Ðlms Virus. discussion France Moatti et al., 1992 General TV, radio, Yes 1987 : No One is Immune 53.2% K, A, B, P, & perceived leaÑets, AIDS. overall risk cinema spots, 1998 : Condoms Protect posters, press, You from Everything Even (18.6È91.9% home video- from Being Laughed At. for di†erent text network 1989 : Condoms Protect media) You from Everything but Love ; Everyone Can Be A†ected by AIDS ; Condoms Wish You a Happy Holiday. 31
  4. 4. 32 TABLE 1 Continued Study author, Target Channel Message Campaign theme Outcome : Country Date of publication audience selection/mix content (name/ slogan) Exposure KABP 1 or other Greenland Moi et al., 1993 General NS Yes Stop AIDS NS K, B, P Haiti Pape & Johnson, General TV, radio, NS NS NS K, A, B 1993 billboards, & interpersonal contact Italy Aboulkhair et al., Youth : NS NS NS B (condom use) 1995 13È20 year olds Bortolotti et al., IVDUs 3 Booklets, NS NS NS B, HIV seroconversion, 1992 posters, & & HIV seroprevalence conferences Bortolotti et al., IVDUs Brochure, NS NS NS B (needle sharing), 1998 lectures, local HIV seroprevalence, & TV, & print hepatitis B incidence The de Vroome et al., Young Radio, print, Yes Excuses Campaign 8È88% A, intention, & Netherlands 1991 adults : Ðlm, posters, condom use 18È25 & brochures year olds de Vroome et al., High-risk Posters, print Yes 4/ 87, 10/ 87 : NS NS K, A, P, condom sales, 1990 groups cinema spots, 5/ 88 : Safe Sex on Holiday & STD incidence free condoms 5/ 89 : Excuses Campaign 10 / 89 : NS Nicaragua Pauw et al., 1996 General Small media : NS NS NS K, A print (leaÑets, stickers, etc.), video, & home visits
  5. 5. TABLE 1 Continued Study author, Target Channel Message Campaign theme Outcome : Country Date of publication audience selection/mix content (name/ slogan) Exposure KABP 1 or other Norway Traeen, 1992 Youth Rock music, Yes Beat It ! Talk about Sex, 27.5% B (condom use), radio song, about Being in Love, and interpersonal musical, novel about Love. communication, & campaign involvement Kraft and Rise, General Billboards, Yes Condom Campaign 70% Public awareness & 1988 posters, & acceptance postcards St. Vincent Middlestadt et al., Families : Radio Yes NS 71.6% K, A, B, intentions, & & the 1995 youth & subjective norms Grenadines parents Switzerland Hausser & Michaud, General Traveling bus, Yes Stop AIDS NS B (sexual activity & 1994 & youth art exhibits, condom use) festivals, & computer network Lehmann et al., General : Booklet & Yes Stop AIDS 56% K, A, & beliefs 1987 (20È69 mass media years (unspeciÐed) olds) Thailand van Griensven et CSWs 4 LeaÑets, videotapes, NS NS NS K, perceived vulnerability, al., 1998 audiotapes, social support, poster, comic preventive practices, books, peer HIV incidence & leaders prevalence Hanenberg et al., Men TV, radio Yes NS NS B, STD rates, & HIV 1994 prevalence Uganda Schopper et al., General Print & Yes AIDS : Be Informed and 42% K, A, B 1995 community Protect. (print) educators 33
  6. 6. 34 TABLE 1 Continued Study author, Target Channel Message Campaign theme Outcome : Country Date of publication audience selection/ mix content (name/slogan) Exposure KABP 1 or other U.K. Ross & Scott, 1993 General TV, posters, NS 1986 : DonÏt Die of NS HIV antibody testing newspaper, Ignorance. magazines, & 1998 : AIDS. You Know other print the Risks 1988 : AIDS, YouÏre as Safe as You Want To Be. 1990 : Experts Speak Out against AIDS. Wober, 1988 General TV Yes NS NS K, A, B Sherr, 1987 General Newspaper ad Yes NS 40.5% K, A, B, & anxiety Campbell & General Newspaper ad NS NS NS K Waters, 1987 & TV Mills et al., 1986 General Newspaper ad Yes NS 31% K United Walls et al., 1998 Women Print & Yes NS 51% B (condom use & States community interpersonal outreach communication) CDC, 1996 High-risk Print material Yes AIDS Prevention Project (Dallas) 22È65% B (condom & bleach groups (role model Project REACH (Denver) use) stories) & peer Road Dogs (Long Beach) outreach ShiftinÏ Gears Project (Seattle) Rietmeijer et al., IDUs Small media : Yes Project REACH : Risk 30% B (use of bleach & 1996 brochures, Education Aimed at condoms) pamphlets, Community Health Ñyers, news- letters, & peer outreach
  7. 7. TABLE 1 Continued Study author, Target Channel Message Campaign theme Outcome : Country Date of publication audience selection/ mix content (name/ slogan) Exposure KABP 1 or other United Santelli et al., 1995 Women Small media : Yes AIDS Prevention for 63% B (condom use), social States comic books, Pediatric Life Enrichment norms newsletters, pamphlets, & outreach Caron et al., 1992 College TV, radio, & NS America Responds to NS K, A, B students brochure AIDS & Understanding AIDS Woods et al., 1991 General TV, radio, Yes America Responds to 31È73% K, B, & donated dollar newspaper, AIDS & Understanding value of air time billboards, & AIDS posters Gentry & Jorgensen, 1991 General TV & radio Yes America Responds to NS Donated dollar value AIDS of air time Snyder, 1991 General Pamphlet Yes Understanding AIDS 40% K, A, B, perceived risk, & personal communication Crawford et al., Families TV & Yes Families in Touch : 79% ; K, A, & interpersonal 1990 newspaper Understanding AIDS 60% communication Gerbert & Maguire 1989 General Brochure Yes America Responds to 59% A & interpersonal AIDS communication Dommeyer et al., College Posters, NS AIDS Awareness Week NS K, A, & fear 1989 students billboards, pamphlets, plays, & print Zambia Yoder et al., 1996 General Radio drama Yes Nshilakamona : 45% K, B, conversations, ““I Have Not Yet Seen It.ÏÏ & perceived risk 1 Knowledge, attitude, behavior, and practice. 2 Not speciÐed. 3 Intravenous drug user. 4 Commercial sex workers. 5 Exposure by city and community : Dallas : 31% ; Denver : 22% (IDUs) ; Long Beach : 55% (IDUs), 68% (female sex traders), 45% female sex partners of male IDUs ; New York City : 46% (female sex partners of male IDUs) ; Seattle : 22% (nonhomosexually identifying men who have sex with men), 36% (female sex traders), 25% street youth. 35
  8. 8. 36 S . L . Myhre and J . A. Flora Several campaign components, such as theoretical framework and campaign ““dose,ÏÏ were not included in the analysis because of infrequent and inconsistent documentation in the articles contained in this review. A theoretical framework was speciÐed in less than a Ðfth of the articles. Psychologically based theories according particular attention to self-perception of risk and the inÑuence of social norms (e.g., theory of reasoned action, health belief model, Marin model, and social cognitive theory) were the most commonly mentioned theories and models. For our purposes, target audience refers to the intended recipients of the cam- paign message(s). Channel selection and mix pertains to the selected communication modality or modalities used to convey the campaign message(s). Message content concerns the type of information that is being conveyed to the target audience. Additional information such as presentation style, execution features, and message appeal also provide valuable insight about a campaign (Baggaley, 1988). The cam- paign name or slogan is included as a proxy measure of the fundamental theme of a campaign. Campaign exposure relates to a measured response regarding hearing or seeing the campaign messages. Finally, outcome measures refer to the types of issues that are measured and used to quantify and evaluate campaign e†ects. Because of the small sample size (n 5 41), we did not attempt to conduct signiÐcance tests in analyses of the data. Results Our search yielded 41 published journal articles from 17 countries. (See Table 1 for a complete list of the sample studies.) Although we did not limit the nature of the mass media campaigns, the majority of articles discussed national HIV / AIDS cam- paigns. Strong representation of national campaigns in this sample likely reÑects the substantial cost associated with mass media endeavors. A few campaigns (e.g., America Responds to AIDS (ARTA), AustraliaÏs ““Grim ReaperÏÏ) are represented numerous times because several evaluations were conducted in various locations by di†erent researchers on the same campaign. A pretest/ posttest was the most common research design mentioned with fewer studies relying on posttest only. Very few studies (n 5 7) utilized a quasi-experimental design incorporating a control/ comparison group. Articles in this sample reveal which countries have the necessary resources (i.e., researchers) and interest in disseminating HIV campaign results. Of note, more than one-third (41%) of the articles describe campaigns in lesser-developed countriesÈ many of which have been a†ected severely by the AIDS pandemic (e.g., Haiti, Thai- land, Uganda, and Zambia). No articles describe activity in the Middle East and few present data on campaigns in Asia (except Thailand), Latin American (except Argentina), and Africa (except Uganda and Zambia). Although HIV / AIDS preven- tion e†orts may exist in these regions, we were unable to locate published articles from these areas that met our inclusion criteria. Finally, the studies in this sample include reports on early mass media responses to HIV / AIDS (i.e., 1986) as well as recent campaign e†orts. Analysis of Communication Components Target Audience Every article in the sample articulated the intended target audience of the HIV / AIDS campaign. Although the general public was identiÐed most frequently as the
  9. 9. HIV / AIDS Communication Campaigns 37 target audience, more speciÐc audiences included families (Crawford et al., 1990 ; Middlestadt et al., 1995), youth (Aboulkhair et al., 1995 ; de Vroome et al., 1991 ; Hannonen et al., 1994 ; Hausser & Michaud, 1994 ; Traeen, 1992 ; Wagman, 1993), injecting drug users (Bortolotti et al., 1988 ; 1992 ; Rietmeijer et al., 1996), student populations (Brown et al., 1991 ; Caron, Davis, Wynn, & Roberts, 1992 ; Dommeyer, Marquard, Gibson, & Taylor, 1989), and sex workers (van Griensven et al., 1998). Despite that HIV initially posed the greatest threat to gay men, intra- venous drug users, and persons with hemophilia, the majority of early campaigns were directed at a broad, undeÐned audience. This apparent lack of di†erentiation of the audience presumes that receivers are perceived to be similar with respect to AIDS knowledge and risk and are passive in terms of information processing and action (Dervin, 1989). One exception, the Netherlands campaign, stated that early national campaigns were explicitly directed at the homosexual community (de Vroome et al., 1990) but were undertaken by nongovernmental organizations. In contrast, campaigns directed or funded or both by governmental agencies are faced with the struggle of avoiding controversy in the political arena and, thus, are forced to assume a more indirect, ““untargetedÏÏ approach. Yet, as in the case of AustraliaÏs national campaign, fear arousing messages directed at the general population, a low-risk group overall, resulted in widespread anxiety and social discord (Bray & Chapman, 1991). Channel Selection and Mix The majority of studies (n 5 38) described the channels used to deliver HIV / AIDS messages. Of these studies, approximately one-quarter (26%) relied on a single channel of communication. The single media campaigns utilized print (in the form of a national mailing), radio, television, and short Ðlms. (In some instances, articles focused on a single medium that was part of a larger, multifaceted cam- paign.) Two successful, single medium campaigns conducted in St. Vincent and the Grenadines (Middlestadt et al., 1995) and Zambia (Yoder, Hornick, and Chirwa, 1996) demonstrate that carefully planned, low-cost broadcast media campaigns can reach many people e†ectively and efficiently with HIV prevention messages. Most campaigns utilized multiple channels. Recognition of the critical relation- ship between the target audience and channel selection (i.e., speciÐcity) was some- times discussed. In a Norwegian youth campaign, for example, the use of a rock concert, video, pop song, and novel appeared well founded given that the target audience was youth. The investigators concluded, however, that inadequate channel research had resulted in poor planning that hindered program exposure and partici- pation. One could also argue that the selected channels were not credible sources of health information for youth. In sum, a channelÏs reach, speciÐcity, and degree of involvement must be considered carefully with respect to the target audience. The use of multiple channels, as opposed to reliance on a single channel, appeared to be partially related to available media budgetsÈsingle and small media campaigns were noted more often in lesser-developed countries restricted by Ðnan- cial and material resources. To maximize limited resources, campaigns in lesser- developed countries tended to use lower-cost media channels such as print, radio, and small media. Moreover, these media were more suited to the targeted groups (e.g., higher radio versus television use /ownership in some countries). In contrast, many industrialized countries designed multimedia campaigns where multiple chan- nels are used simultaneously. The ARTA campaign, for example, included 83 tele- vision public service announcements (PSAs), 68 radio PSAs, 53 print PSAs, 62
  10. 10. 38 S . L . Myhre and J . A. Flora posters, 19 brochures, three point of purchase displays, and two audio cassettes by as early as 1990 (Woods, Davis, and Westover, 1991). Channel supplementation (i.e., broadcast media supported by interpersonal media or print following broadcast media) was evident in eight articles (Haiti, Nicaragua, Thailand, Uganda, and the United States ; see CDC, 1996 ; Rietmeijer et al., 1996 ; Santelli et al., 1995 ; Walls, Lauby, Lavelle, Derby, & Bond, 1998). The most common supplementation strategy consisted of small media supplemented by outreach in the form of peer leaders, volunteers, or community educators. The array of channels used to convey HIV / AIDS preventive messages illustrates the diversity and innovation that has been applied by HIV / AIDS practitioners. Rather than relying solely on mainstream forms of communication, HIV / AIDS campaigns have utilized venues including less traditional forms such as cinema spots, short Ðlms bar coasters, rock concerts, and even baseball cards to convey HIV/ AIDS messages. Faced with the challenge of discussing personal and private issues related to HIV / AIDS risk behaviors, HIV preventive channel selection has proven both creative and unconventional. Message Content Approximately three-fourths of the articles provided descriptions using either visual images or written detail of the HIV / AIDS campaign messages. The extent of the description of message content varied considerably. Some articles provided con- crete and detailed written and visual examples and others clearly articulated the relationship between content and campaign objectives. In articles that did not specify message content, no information was provided regarding the type of HIV / AIDS prevention message delivered. Consequently, it was unclear whether these campaigns attempted to simply inform (i.e., provide factual information on HIV transmission), to convey preventive messages (i.e., describe how to avoid HIV risk behaviors), or whether they aimed to a†ect individual behavior or social norms. The French national campaign provided descriptive information on message content by specifying the intended style and tone (e.g., emotive, whimsical, erotic) of each campaign (Moatti et al., 1992). Thus, inferences regarding the usefulness of each approach could be investigated with respect to timing, duration, and other features of the campaigns. In addition, the French survey questions addressed explicit issues about how message content had inÑuenced individual attitudes, risk awareness, sexual behavior, and HIV testing behavior. Linkages between campaign content and the impact on collective attitudes could, therefore, be explored. Campaign Theme Nearly two-thirds (63%) of the articles provided the name or slogan of the campaign to the reader. The fact that more than one-third (37%) of the articles did not provide a campaign name may reÑect an author or editorÏs decision to omit this information or, more likely, suggests that no campaign name existed. Although lack of a campaign name may seem trivial, a campaignÏs direction and philosophy is often best articulated by its slogan. The advertising industry, for example, accords a great deal of importance to the potential impact of slogans and the inÑuence of branding products. Moreover, given broadcast mediaÏs predilection for encapsulat- ing information into short sound bites, campaign slogans may be the only take- home message that many in the target audience receive. In this sample, campaign names and slogans ranged from fear arousing (ArgentinaÏs AIDS Kills and Aus-
  11. 11. HIV / AIDS Communication Campaigns 39 traliaÏs the Grim Reaper) to perfunctory (SwitzerlandÏs STOP AIDS and NorwayÏs Condom Campaign) and light (CanadaÏs Condomania). Campaign Exposure Almost two-thirds (62%) of the articles provided the reader with a measure of exposure. Assessing what proportion and who among the target audience attended to the messages is considered one assessment of a campaign and often is an under- valued indicator of a campaignÏs success (Flora et al., 1997). Obtaining sufficient exposure is a prerequisite to any outcome e†ect and is essential in post-only and pretest/ posttest research designs. Even among articles that provided a measure of exposure, however, many failed to provide details regarding the extent of exposure (i.e., how many messages) or level of comprehension. Of the articles that measured campaign exposure, two-thirds (68%) reported that 50% or more of the target audience were exposed to the campaign. Among those campaigns that achieved less than 50% exposure, print was the most common channel mentioned. As channel communication theory would predict, typically tele- vision campaigns had the highest exposure ratings in this sample of campaigns (Flora et al., 1997). Multimedia campaigns with data on the reach of individual communication modalities provide additional evidence that channels vary in their ability to reach or connect or both with certain target audiences (see de Vroome et al., 1991 ; Moatti et al., 1992 ; Woods et al., 1991 ; Wagman, 1993). Outcome Measures Knowledge and attitudinal outcome measures to assess success were most common, whereas fewer campaigns sought to measure behavioral change. In many instances, other outcome indicators were assessed and considered to reÑect the program success or failure. Although most of the studies reviewed did not describe with clarity the theoretical framework within which they were conducted, the out- comes measured indicate an implicit and widespread use of a knowledge, attitude, behavior, and practices (KABP) model. This apparent reliance on the KABP model may have resulted in less attention to outcomes that pertain to the maintenance of healthful behaviors and practices such as perceived norms (e.g., perceived prevalence of safe behavior), perceived self-efficacy, and social and community outcomes (e.g., interpersonal and community advocacy and policy support). These outcomes are particularly germane to the present challenge of preventing relapse from safer sex and sustaining long-term risk reduction practices (Stall, Ekstrand, Pollack, McKu- sick, & Coates, 1990). A number of recent campaigns, recognizing the limited ability of mass media to bring about behavioral change, have shifted their focus to intermediary outcomes theorized to be associated with behavioral change. Increasing public and private discussion about HIV/ AIDS issues is one such example (see Bajos, Spira, Lert, Rudelic-Fernandez, & Ducot, 1996 ; Crawford et al., 1990 ; Rudelic-Fernandez, Bajos, Lert, Ducot, & Spira, 1998 ; Snyder, 1991 ; Walls et al., 1998 ; Yoder et al., 1996). Personal discussion between sexual partners, parents and children, and among friends was considered to be an important step toward behavior or attitudi- nal or both types of change. Similarly, acknowledging that many campaigns focus only on individual attitu- dinal and behavior change, the inÑuence of social norms in relation to HIV / AIDS
  12. 12. 40 S . L . Myhre and J . A. Flora preventive behavior has been pursued. Changing the image of safer sex and, more explicitly, popularizing condom use was a strategy utilized by several campaigns. Three studies explicitly measured change in social norms as a result of the cam- paigns (see Middlestadt et al., 1995 ; Santelli et al., 1995 ; Wagman, 1993). A primary objective of the Canadian campaign, for example, was to popularize condom use by reducing the embarrassment associated with their use. Similarly, many of the French messages sought to change the social image of condoms by making them ““more of a “social routine.ÏÏÏ (Moatti et al., 1992, p. 245). Campaign E%ectiveness Because of the highly diverse set of measures and research designs noted in this sample, cumulating outcome measures into a summary Ðnding would be uninter- pretable and misleading. Lack of an increase in knowledge at posttest in one study, for example, may be indicative of an AIDS ““factÏÏ saturated audience, whereas in others it may reÑect a campaign inadequacy. The broad range of attitudinal and behavioral measures across studies also prohibits meaningful analysis. In lieu of a cross-country comparative analysis, we consider a few exemplar studies. In other words, we discuss studies that provided comprehensive documentation of campaign components and that illustrate the range of strategies used in campaigns around the world. We include campaigns with positive Ðndings as well as those with unintended or unsatisfactory outcomes since recognition of these campaigns is critical to the advancement of campaign design. ThailandÏs mass media campaign is an example of a campaign that integrated HIV prevention messages with the government-sponsored national 100% condom policy and took into account the commercial sex workerÏs (CSWÏs) unique environ- ment (van Griensven et al., 1998). Attitudes, behaviors, and relationships were studied to maximize potential HIV preventive behavior (e.g., CSWsÏ managers were included in the campaign given their potential inÑuence on CSWs). This campaign demonstrates the importance and value of working with existing programs, embrac- ing the cultural context, and understanding the needs of the target audience. Other examples of campaigns that carefully considered the culture of the target audience include UgandaÏs Be Informed and Protect and ZambiaÏs Nshilakamona campaign. These campaigns acknowledged the realities of a village-based campaign by selec- ting small media and radio and designing messages appropriate to illiterate audi- ences (Schopper et al., 1995 ; Yoder et al., 1996). The Australian Grim Reaper campaign, on the other hand, was problematic based on Ðndings from evaluation data. This campaign achieved very high exposure but failed to arouse personal and social concern in a productive manner. Instead it incited strong negativity among the public. What brought on this reaction ? First, the campaign utilized a macabre and fearful ““grim reaperÏÏ Ðgure to convey HIV / AIDS messages. Second, by using these arresting spots on broadcast media, the campaign attained nearly universal campaign exposure in the public sphere. In terms of awareness, the campaign was highly e†ective but later analysis found little change in knowledge and high anxiety expressed by the population sample (Bray & Chapman, 1991). The researchers noted the following : The data in this paper show the disturbing extent of hysterical and exagger- ated perceptions of AIDS and potentially social divisive attitudes. Public
  13. 13. HIV / AIDS Communication Campaigns 41 health authorities should consider whether public information programs for AIDS control that scare much of the population unnecessarily can be justi- Ðed when they have such stigmatizing and neurosis-producing results. (Bray and Chapman, 1991, p. 113) Thus although the campaign had impressive exposure (93.5%), only 28% of the sample responded that they had been inÑuenced positively by the campaign (Rigby, Brown, Anagnostou, & Ross, 1989). In contrast, for the Norwegian youth culture campaign the issue was not the inappropriate use of strong imagery, but rather an indirect, weak message design combined with the inadequate exposure among the targeted group that resulted in poor recall of the campaign and low participation rates (Traeen, 1992). Finally, the United KingdomÏs newspaper advertisements demonstrate how resources can be squandered by focusing on Ðrst-order outcomes only, i.e., knowledge (Sherr, 1987). Discussion The variety of HIV / AIDS campaign strategies around the world is indicative of the fervency and creativity that abounds in e†orts to stop the AIDS pandemic. Although great progress has been achieved, Ðndings from this review suggest that conceptual and methodological rigor in reporting fundamental communication components can be improved. Most campaigns designate a target audience, but many campaigns have not addressed those at highest risk within a particular society. With regard to channel selection, these studies demonstrate that conven- tional and single medium campaigns have progressed to utilizing nontraditional communication modalities and multiple channels if resources permit. Similarly, message design has beneÐted from an outpouring of creativity despite the challenge associated with communicating private and taboo subjects. More at issue, however, is that message design and campaign themes are, typically, awarded only limited discussion thereby hindering dissemination. Moreover, assessing campaign e†ec- tiveness has been seriously hampered by insensitive and unstandardized measures. Limitations This analysis contains only studies that have been published and provide quantita- tive evaluation data. Consequently, this review excludes studies that have not been published to date (e.g., grey literature) and articles that are devoted solely to cam- paign description or qualitative research. Journal articles in languages other than English may not be represented fully, although several databases that were searched contain foreign language journals. Finally, this analysis is constrained by the range of information provided in the articles. Although each study in this review met a minimum set of criteria, there were many conceptual and measurement inconsis- tencies across studies which could not be controlled. Consequently, there was great variation across studies in research design, methodological rigor, and how campaign-related data was presented and deÐned. Studies in the sample appeared in a variety of journals across di†erent multiple disciplines so article content varied according to journal focus and editorial policy.
  14. 14. 42 S . L . Myhre and J . A. Flora Implications HIV/ AIDS prevention has resulted in an impressive outpouring of community- based outreach, innovative media ideas, and communication research, yet there con- tinues to be a dearth of systematically analyzed mass media campaigns. Accurate assessments of HIV / AIDS campaigns are necessary to modify existing campaigns and to build e†ective new campaigns. Because little evaluation data is available publicly, campaigns will continue to have poor estimates of their ability to impact knowledge, attitudes, and behaviors. For us to learn about campaigns we need to continually examine data on communication components and relationships and to establish a more systematic method of evaluating campaigns. This review of HIV /AIDS campaign activity around the world highlights the need for a common set of criteria to evaluate mass media campaigns. Although we acknowledge the scarcity of resources available to many researchers, we recommend that HIV/ AIDS campaign research strive to report a minimum level of information regarding methodology and communication components. The level of reporting and evaluation represents one of the most promising routes for strengthening HIV / AIDS campaign work. This review highlights much of the progress that has been made in HIV / AIDS campaign work. Since communication campaigns alone cannot change community infrastructure, bring about and enforce policies, or increase resources (such as provide condoms or needle exchange programs) and services (such as counseling, testing, or medical care), future work in HIV / AIDS prevention needs to shift toward community e†orts. HIV communication programs should aim to increase the importance of HIV prevention, frame HIV prevention as a community problem, improve the quantity and quality of public and private discourse regarding HIV prevention, and improve the nature and extent of public participation in HIV pre- vention. Some countries have begun to initiate programs that are community based and communitywide (e.g., U.S. Centers for Disease Control & Prevention AIDS com- munity demonstration projects, the NetherlandsÏ safe sex campaigns, and Nicara- guaÏs HIV/ AIDS Health Education Program). To date, seven HIV prevention studies (Ðve of which are CDC-funded AIDS demonstration projects) have been designed as quasi-experimental community studies (i.e., comparison/control groups) with a mass media component (CDC, 1996 ; Pauw et al., 1996 ; Rietmeijer et al., 1996 ; Santelli et al., 1995). A common thread among these studies is their focus on high-risk individuals within the community. Additionally, all of the studies rely on outcomes related to individual behavior change rather than community-level out- comes. Of note, these studies are relatively new, all publishing results since 1995. Conclusion HIV/ AIDS campaigns originated in an atmosphere of public health urgency and fear. For the most part, HIV /AIDS campaigns have only just begun to systemati- cally use communication and behavioral science literature on behavior change, com- munity level theories, and strategic development of campaigns that encompasses message design and channel selection. Relatively recent developments in health communication research, such as emphasizing community involvement, institution- alization, and policy advocacy, have yet to be fully incorporated into HIV / AIDS prevention, treatment, and policy. In addition, persuasive HIV preventive cam- paigns need to collaborate with interventions aimed at changing structural and
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