Reducing the Risk of HIV Transmission among Adolescents in Zambia

Published in the Journal of Adolescent Health, this 13-page paper summarises a study evaluating Phase I of Zambia's Helping Each other Act Responsibly Together (HEART) media campaign. In short, it finds that viewership of HEART television "spots" was "positively and significantly associated with high levels of efficacy to use condoms as well as with ever use of condoms, holding background variables constant."

Designed by and for youth aged 13 to 19 years, HEART was developed by a team made up of communication and adolescent reproductive health specialists, along with 7 young Zambians motivated to encourage their peers to adopt risk-reduction practices (abstinence, a return to abstinence, or consistent condom use) to protect themselves from sexually transmitted infections (STIs) and HIV. The youth-led team created TV spots, which producers of radio spots and songs then adapted to the rural context and translated into local languages. Other materials such as posters, book stickers, exercise books, messages on buses, and music videos complemented the mass media.

HEART was a collaborative effort that involved the Government of the Republic of Zambia (GRZ), USAID, the Zambia Integrated Health Programme (ZIHP), the Central Board of Health, the AIDS Council and Secretariat, the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs. However, as suggested by the make-up of the design team, youth participation was key. To ensure broad-based youth involvement in this process, a Youth Advisory Group (YAG) was established, which initially comprised 35 young people from 11 youth organisations. At least one of the YAG members tested positive for HIV; all were in close contact with people living with HIV or AIDS. "The campaign was intended to create a belief that unprotected sex is not an option. Based on direction from the YAG, professional agencies developed message concepts and scripts that were tested for appeal and comprehension through focus group discussions and in-depth interviews; post-broadcast ad surveys were conducted to test reach and recall."

In addition to youth participation, attention to context was crucial, according to evaluators. As detailed in this report, HEART drew on a "revised stage theory of behavior change" that recognises the fact that behaviour change occurs within particular social contexts and thus is influenced by a host of social factors. In this context, HEART was designed to "provide a social context in which prevailing social norms could be discussed, questioned, and reassessed. By placing communication about abstinence and safer sex on the national agenda, the design team anticipated that the campaign would encourage young people to adopt safer sex..."

This article shares findings from a 1999 baseline survey (July to November 1999), which had a sample of 368 male and 533 female adolescents, and an August 2000 follow-up survey, which comprised 496 male and 660 female adolescents. The latter survey was designed to assess the outcomes of messages televised during phase I of the campaign (aired from November 1999 through May 2000). To assess outcomes related to the HEART campaign as
opposed to changes that may have happened over time even in the absence of this particular set of interventions, evaluators examined differences between follow-up respondents who
saw 1 or more of the televised health communication ads ("viewers") and those who saw none ("nonviewers"). Results of the August 2000 survey informed the development of subsequent phases of the campaign; selected findings include:

• Viewership - 80% of respondents who reported TV ownership in their household recalled at least 1 of the televised health communication ads. About 36% of female and male respondents who lived in households without a TV set saw the campaign. "Young women were as likely as were young men to have seen the TV ads. This finding is important for program planners because it indicates that, unlike their older counterparts, young women have overcome the gender barrier in this respect. Urban youth were almost twice as likely as were rural youth to have seen the televised messages."
• Knowledge - Only 1% of respondents to each of the 2 surveys said it is not possible to take preventive actions against HIV transmission. Follow-up male and female respondents were more likely than their baseline counterparts to list abstinence and condom use as means to avoid HIV. However, misleading beliefs about the way in which a person's HIV status can be ascertained remain widespread despite Phase I campaign messages designed to correct them.
• Discussion & attitudes - More than two-thirds of youth noted that the campaign prompted them to talk with others about the ad, decide to abstain from sex until they were more mature, or to use a condom. Campaign exposure also enhanced self-efficacy: Women who saw the campaign were more likely than were nonviewers to express a high degree of confidence that they could refuse uninvited sexual overtures.
• Practices - Some 74% of male viewers and 68% of female viewers reported that they took at least 1 action as a result of having seen the campaign. This represents about 40% of all male respondents and 32% of all female respondents. The actions most commonly reported by respondents were, in order of magnitude, talking with others, such as friends, partners, spouses, or parents, about the ads; intention to abstain from sex; and intention to use condoms.
  
  

  Controlling for age, sex, educational attainment, and urban or rural residence, logistic regression analyses demonstrated that, compared with nonviewers, campaign viewers were 1.61 times more likely to report primary or secondary abstinence and 2.38 times more likely to have ever used a condom. The odds ratio of condom use during last sex was 2.1 for respondents who recalled at least 3 television spot advertisements compared with other respondents.

Evaluators conclude that the positive correlations between HEART campaign viewership and HIV risk reduction practices demonstrate that mediated messages can influence adolescents. They also highlight several other research limitations/future needs; for instance:

• 40% of respondents said they had not watched any TV over the past year (meaning that the reach of the campaign was comprehensive among those who ever watch TV); however, given the central role of Zambian languages in oral communication, a more precise picture of reach and effect would have been drawn had other components of the HEART campaign been assessed.
• HEART was not the only reproductive health programme for youth in Zambia during the period of this study. Evaluators sought to distinguish this influence by measuring recall of specific campaign ads, but "the effects of the campaign cannot be attributed solely to that single intervention. Future studies should include questions about other media programs that carry complementary messages as well as about those that promote contradictory messages."
• "Other research shows that young people need examples, such as the young protagonists featured in the HEART campaign ads, after which to model their words and actions, and also need the opportunity to practice those skills....the memorable characters in the HEART ads may well have given adolescents the opportunity to model their actions and rehearse skills, either in conversations with friends and family or through parasocial interaction with the HEART personalities. Clearly, to understand more fully how adolescents process these messages, qualitative research is needed."
• The design team purposely avoided the "be faithful" message, because they were concerned that it would be interpreted as "serial monogamy" and give young people an excuse to have unprotected sex. "This issue has not been well researched; we simply do not know how young people would interpret and act on a 'be faithful' message. This finding suggests, minimally, that program planners who work with youth to enhance their repertoire of risk-reduction practices should explore this option further. Furthermore, recent data demonstrate that the greatest risk for HIV transmission is among those who have multiple, concurrent partners."

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