Impact Assessment of a New Programming Component on HIV and AIDS

This 71-page study was commissioned by the Takalani Sesame Project, comprising the South African Broadcasting Corporation (SABC) Ltd, the Department of Education (South Africa), and the Sesame Workshop (supported by USAID and Sanlam).

An independent multi-disciplinary research team from Health and Development Africa, Social Surveys, and Aka Associates sought to assess the process and impact of South Africa's Talk to Me, a nationwide initiative that includes a one-hour television special, a radio campaign, and printed materials. This campaign, which emerged from the educational children’s TV series Takalani Sesame, is designed to "encourage caregivers and young children to communicate constructively about HIV and AIDS," and to provide skills to support this dialogue and to reduce the stigma often faced by those infected with and affected by HIV and AIDS.

Researchers studied the following specific Talk to Me elements:

1. A one-hour TV documentary that addressed caregivers of children. The study examined two of the four mini-documentaries from this TV special. The first was in isi-Zulu (the home language in the study area) and explored themes of constructive communication, particularly among generations within families. The second was in English, and depicted a white mother grappling with the difficulties of speaking to her children of various ages about her and their father's HIV-positive status.
2. An illustrated story book intervention that has been developed for use by educators in the classroom with young children to encourage dialogue about HIV and AIDS. Entitled "Who Cares for Me?", the book features characters from Takalani Sesame, including Kami, a Muppet with HIV. In this story, the characters speak openly about alternative kinds of family arrangements, and the deaths of adults close to them due to AID

The Talk to Me intervention was tested between September and December 2004 using a controlled trial comprising an experimental group exposed to the intervention, and a control group that was not exposed. This methodology was designed to ensure that "the intervention was fully under the control of the researchers and thus...was able to report with a high degree of confidence on the level of change that is due to the intervention and not change that may have happened despite the intervention, or because of some other interventions."

Excerpts from the Executive Summary follow:

The evaluation aimed to provide answers to some key questions:

• Was the programming effective in achieving its aim of increasing dialogue between caregivers and young children about HIV?
• How were the materials received and understood by caregivers and young children?

The study was conducted in Escourt, Kwa-Zulu Natal, a province of South Africa which has high levels of HIV infection and high visibility of AIDS illness and death. Both urban and rural areas were included. Altogether 349 young children and their caregivers completed interviews at two points in time (before and after the intervention), so that the changes attributable to Talk to Me could be measured. There were 1400 interviews conducted altogether, as well as two gender-based focus groups with male and female caregivers.

Before the intervention, caregivers indicated that they lacked the skills, knowledge and confidence to talk to young children about HIV. Young children, on the other hand, reported that they heard a great deal about HIV in the household. This suggests that the information that young children hear about HIV is 'overheard' rather than direct age-appropriate communication from their caregivers.

Talk to Me influenced child-caregiver communication in the household

This study found that Talk to Me was positively linked with increased communication about HIV between caregivers and children. At follow-up, over one half (54%) of the control group caregivers and 75% of the intervention group caregivers reported having spoken to any child in their household about HIV in the previous two weeks. Multivariate logistic regression - which adjusted for communication prior to intervention and other factors that may have confounded the effects of the intervention - found that caregivers who were exposed to the media were around 2 and a-half times more likely to have communicated with their children than those who were not exposed. (The corresponding odds ratio was 2.45, with a 95% confidence interval of 1.14 and 5.32.)

The intervention showed strongest effects on caregivers' communication with children aged 7-9 years. Encouraging caregivers’ communication with children younger than 7 years remains a challenge to caregivers, media developers and researchers.

Both quantitative and qualitative analyses indicated that Talk to Me materials were highly relevant to the target audience.

Just over one half of respondents who viewed the video gave positive responses (for example, respondents said that the video 'taught us many things' or 'we should not shout at children'). Over two-thirds of all caregiver respondents said that the media reminded them about their own lives and over 80% said that it equipped them to do something new with their child.

The research highlighted the important role that Grandmothers have in communication with children about HIV, and probably other topics as well

In this study, grandmothers were more likely than biological mothers to report communicating about HIV and other topics with children who live with them. Importantly however, grandmothers tended to have less education, live in rural areas, and hold incorrect beliefs about HIV; fewer of them had exposure to media such as Takalani Sesame on television. This underscores the importance of equipping caregivers in general, and grandmothers in particular, with accurate information about the disease.

The findings highlighted the particular importance of reaching boys with messages promoting stigma reduction, such as those that introduce alternate family compositions.

Promoting more flexible attitudes to alternate family structures was an important focus of the child-targeted materials. While the study did not find an effect of the intervention on children’s attitudes toward alternative family arrangements, the findings suggest the importance of targeting boys with such messages: In this study, girls were around 3 times more likely than boys to hold flexible attitudes about alternate family structures.

While behaviour and attitudes towards HIV-related communication with the 7-9 year old child was positively affected by the intervention, behaviour and attitudes towards HIV-related communication with children aged 3-6 years was not impacted.

Over 90% of caregivers believed it was important to talk openly about HIV in the family. However most did not believe it was necessary to talk to a young child about HIV. The intervention showed a positive effect on attitudes towards communication with 7-9 year old children, but not with 3-6 year old children.

Around two-thirds of caregivers in this sample agreed or strongly agreed that it is not necessary to talk to a young child about HIV. The intervention did not shift attitudes on this measure.

Qualitative data from the focus groups indicated that caregivers lacked the confidence to talk to young children about HIV. Quantitative analysis showed that even after the intervention, caregivers remained unconvinced that they should talk to the 3-6 year old child about various topics related to HIV, such as how it is spread, illness death and dying and how children could protect themselves from HIV.

Looking to the Future: Key Messages for Programme and Media Developer

• Many young children in South Africa are aware of HIV and AIDS and are emotionally and materially affected by illness and death in their families and communities. The objectives of Talk to Me are highly relevant in South Africa and merit high level commitment and ongoing focus and energy.
• The Talk to Me materials have been effective in increasing caregiver-child dialogue, particularly between caregivers and their children ages 7 to 9. Developing messages and materials that caregivers feel are appropriate for 3- to 6-year-old children remains a challenge. The materials tested did not show significant effects on HIV-related communication or attitudes towards communicating with the 3- to 6-year-old child.
• Finding creative ways to build knowledge and skills in rural areas and particularly amongst grandmothers is critical. Caregivers in such circumstances play critical roles in communication but are likely to have less access to mainstream media and other information resources.
• Bear in mind that there can be high levels of incorrect beliefs about HIV amongst caregivers. We can't assume that caregivers have accurate information themselves about HIV. Caregivers cite their own 'ignorance' as an obstacle to speaking to their children.
• Messages should avoid general encouragement of caregivers to talk to children, without providing concrete guidance and skills to do so. Appropriateness of various media channels to assist in building such skills should be considered.
• Many caregivers are already afraid for their children's well-being and media developers will need to ensure that messages do not perpetrate further fear and anxiety that is then transferred onto children.
• Another approach to consider may be how Talk to Me can help caregivers to feel empowered to provide a safer world for their children.
• Continue to ensure that messages are understood and received well by boys as well as girls and by male caregivers as well as females.
• Specific issues related to supporting HIV positive caregivers who wish to disclose their status to their young children may need particular attention; there do not appear to be evidence-based guidelines available on the consequences and most appropriate context for this kind of communication with young children, particularly for the 3-6 year old child. A particular focus on synthesising existing research in this area and further targeted research may be warranted if further media is to be developed in this area.