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Based on the three-days of intense workshop discussions on the role of communication for behaviour and social change, including the operationalizing of the UNAIDS communication framework, workshop participants made the following seven recommendations:

Recommendation #1.: Communication for behaviour and social change should address the full HIV/AIDS continuum of prevention, care, and support.

In the past, communication programmes have tended to treat these aspects of HIV/AIDS as separate. Thus, the role of communication for: a) those who are HIV negative is to keep them HIV free (i.e. prevention through safe sex practices, usage of clean needles, and safe blood supply); b) those who are HIV positive is to promote the provision and use of HIV testing, counselling, antiretroviral drug therapy, and others, and c) those who have full-blown AIDS is to promote an environment free of stigma, and the provision and use of care and support services.

In essence, workshop participants felt that communication programming can be immensely more powerful by promoting:

· diagnosis and treatment of STDs;

· condom availability, accessibility, and use;

· HIV counselling and testing;

· care and support for those with HIV/AIDS;

· information, education, and training for those that provide care and support;

· communication between health care providers and those living with HIV/AIDS (for instance, about adhering to drug treatment regimen);

· communication with the public about the strengths and limitations of antiretroviral treatments, status of vaccines, and others.

Recommendation #2: Communication for behaviour and social change is most effective when integrated with a cross-disciplinary approach, drawing upon knowledge of epidemiology, anthropology, sociology, information science, psychology, and community development.

Communication programmes should involve multi-sectoral and multidisciplinary actors, including the government, civil society organisations, and the private sector.

Recommendation #3: Communication for behaviour and social change should promote provision, access, and use of various services and products.

For instance, voluntary counselling testing (VCT) sites can represent a strategic entry point for communicating about prevention, care, and support. They can facilitate adoption of safe sex practices, counselling on ways to prevent mother-to-child transmission, and provide access to care and support groups.

Recommendation #4: Communication for behaviour and social change should be planned and implemented on a sustained, coherent, and long-term basis, to suitably address the HIV/AIDS continuum of prevention, care, and support.

Sustainability is especially warranted given that HIV prevention calls for continuous and sustained action by individuals over a good deal of their adolescent and adult lives.

Programme sustainability has various components: technical, managerial, political, and financial. Sustainability of communication programmes is often a function of the funding cycles of donor and implementing agencies. Also limited funds tend to foster competition between NGOs rather than cooperation.

Communication practitioners should consider setting project priorities based on how conducive the political environment is to create a sustainable programme, rather than solely being driven by epidemiological data. For sustainability, intersectoral coordination within and across government institutions, civil society, and the private sector is key. Sustainability also can be achieved by working through existing institutional structures of the military, prisons, workplaces, brothels, and others.

Recommendation #5: Communication for behaviour and social change should address regional, country, and community specificity.

A cookie-cutter approach to HIV/AIDS communication programming is likely to be culturally insensitive and ineffective. Resources should be managed in ways to build institutional capacity at the local, regional, national, and international levels.

Recommendation #6: Communication for behaviour and social change should incorporate aspects of research, monitoring and evaluation.

Research should begin in the planning phase to gain contextual understanding of what shapes the behaviours of individuals in a target audience, to understand the emotional and seemingly irrational reasons why people find themselves at risk for HIV, to identify cultural and spiritual opinion leaders, the appropriate communication channels, and other critical variables. Monitoring and evaluation should be participatory, involving the local people in assessing their present conditions and establishing future goals. Evaluation should utilize multiple methods and be able to assess changes at multi-levels i.e. at the level of the individual, family, community, and society. Monitoring and evaluation allow for timely feedback, affording possibilities for mid-course correction for programme interventions. Evaluation also makes possible distillation of lessons learned and documentation of best practices to strengthen subsequent interventions.

Recommendation #7: There should be increased advocacy for, and visibility of, communication for behaviour and social change initiatives, including their contributions, among UNAIDS Co-sponsors and other implementing agencies.

Increase in interagency coordination and collaboration in the implementation of HIV/AIDS communication programmes is an important way of increasing support for communication’s role in social change and development initiatives.

Case: Soul City in South Africa: Where Communication Theory Meets Practice

Soul City is a unique example of communication and social change programming in South Africa. It represents a series of integrated, on-going mass media and interpersonal communication activities. Each year a series of mass media interventions are implemented, including the flagship “Soul City”, a 13-part prime-time television drama series, which runs for three months, and promotes specific health education issues. Next, a 60-episode radio drama series is broadcast daily in eight South African languages. While the story in the radio drama is different, the health issues and topics addressed in it are the same as in the TV series. Once the television and radio series are broadcast, 2.25 million health education booklets, designed around the popularity of the TV series’ characters, are distributed free-of-cost to select target audience groups. Some 12 major newspapers further serialize the booklets. Four sets of “Soul City” series have been broadcast between 1994 and 2000, focusing on issues such as maternal and child health, HIV prevention and control, alcohol abuse, and domestic violence. The Soul City year-long health campaign reaches over 20 million South Africans, including eight million adults. By using a multi-media approach, Soul City helps build a campaign atmosphere which is sustained throughout the year. Each medium reinforces the popularity of the “Soul City” television series, while appealing to a somewhat different target audience: Such a multi-media strategy facilitates the brokering of media partnerships. Soul City recognizes that overt behaviour change is facilitated when audience members talk to one another. So each year, after the television and radio series are broadcast, several campaign activities are implemented to keep people talking. Examples of such initiatives include the “Soul City Search for Stars” (to recruit talent for next year’s television and radio series), the “Soul City Health Care Worker of the Year” (to recognize outstanding outreach workers), and “Soul Citizens” (recognizing outstanding youth who engage in community development activities). The total cost incurred by Soul City for one year of multi-media materials, is about 3.5 million dollars (U.S.). Some 25 percent of it is provided by the South African government, 25 percent by international donor agencies such as the European Union and UNICEF, 25 percent by corporations such as British Petroleum and Old Mutual, and the remaining 25 percent by the broadcast media Interestingly, Soul City is mostly a research and management organization. It coordinates the activities of its various corporate, government, media, and donor partners. Its employees do not directly produce, direct, or publish its health communication materials. They commission them from professionals, and through research, ensure their high quality. Soul City owns the media product that is produced, and they pay the bills. Soul City represents a “site” where communication theory meets practice, to the benefit of health. Source: Singhal and Rogers (1999).

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In addition to the above seven recommendations, workshop participants felt that communication programmes should make a more concerted effort to involve the private sector in HIV/AIDS prevention, care, and support activities. Governments and other civil society organisations have thus far not adequately tapped private sector resources in the war against AIDS, in part because there exists the mistaken assumption that the private sector is only interested in the bottom line, and has little to gain from being involved in HIV/AIDS interventions.

Workshop participants identified a range of private sector entities that could be involved in HIV/AIDS programmes: Corporations, foundations, media organisations, trade associations, private individuals, and others. Private sector involvement may take various forms: Direct monetary contributions, in-kind contributions (for instance, the Bata Shoe Company in Zambia provides shoes to people with HIV); partnering for specific activities; HIV/AIDS workplace policies; and workplace interventions. The private sector might contribute in other creative ways as well: For instance, by training and hiring AIDS orphans, or by partnering in audience research, design of communication materials, media advertising, public relations, and condom social marketing (CSM) projects (UNAIDS, 1998c).

Workshop participants felt that the private sector needs to understand the advantages that can accrue to them by partnering in HIV/AIDS prevention, care, and support activities: For instance, savings in personnel hours lost because of sickness or attending funerals, public relations for the company, and/or enhancement of health within the company. Volkswagen in Brazil and Tata Iron and Steel Company (TISCO) in India have launched exemplary AIDS-workplace programmes (UNAIDS, 2000b). To facilitate private sector involvement, governments should create a single point of contact for private companies in the administration, and provide specific, practical, and mutually-beneficial suggestions for partnerships. Tax advantages may be considered for the implementation of HIV/AIDS prevention programmes in the workplace.

Participants felt that sustaining private sector partnerships is important; hence the private sector should be involved early, beginning with the planning process. There is a special need to create pro-active partnerships in high-risk workplaces, for instance, in the trucking and mining industry. A poignant example is the truck drivers association in Malawi which openly says: “When we hire a new truck driver, we are signing his death warrant”.

In India, UNICEF struck an innovative partnership with the private media channels - both print and cable television -- to address HIV/AIDS issues. UNICEF monitored print media coverage on HIV/AIDS, providing feedback to editors and journalists about the frequency, quantity, and slant of existing HIV/AIDS coverage, and thus pointing out some important gaps. It also prepared press kits and media briefing packages on the vulnerability of children and young women to HIV/AIDS, serving as an advocate to stimulate coverage of these salient issues. UNICEF also partnered with cable television’s Channel V, which broadcasts MTV style-videos and appeals to young audiences. HIV/AIDS messages were inserted in Channel V’s broadcasts and were reinforced through Channel V’s Veejay (video jockey) road shows in major Indian cities and towns. UNICEF arranged for local AIDS NGOs to have programmatic tie-ins with these road shows, thus reaching a large audience of college students with HIV prevention messages.

Case: Private Sector Involvement in Brazil’s Fight Against AIDS

In Brazil, in the early 1990s, the National AIDS Programme convinced 10 of the nation’s biggest private companies to contribute $50,000 each to promote HIV prevention. The outcome was a research-based, high quality mass media campaign, which raised awareness about HIV prevention and control. One of the participating companies, an ad agency, made in-kind contributions of $50,000 by designing the media plan and the creative copy. This kind of private sector collaboration has continued in subsequent years. As a bonus, it has fuelled other private sector initiatives with respect to HIV/AIDS, notably the launch of several AIDS- in-the-workplace programmes. Source: Workshop participant.

Evaluating the Role of Communication in HIV/AIDS Programmes

Workshop participants emphasized the need for (1) evaluating the impact of communication programmes on HIV/AIDS prevention, care, and support, and (2) developing new indicators that go beyond the traditional measurement of individual-level behavioural changes to measuring changes at the social-systemic level.

Further, workshop participants felt that:

· A communication programme for behaviour and social change should encourage both internal and external evaluation. In this connection, community members should be actively involved in assessing how the quality of their community life and environment has changed, and communities should be especially encouraged to propose their own indicators of social change.

· Evaluation research should be conducted before, during, and after the launch of communication programmes.

· Skills in conducting various types of evaluation of communication programmes need to, and be strengthened so that the evaluation processes are useful, timely, relevant, practical cost-effective.

· Evaluation should serve the function of evidence-based advocacy. In order words, evaluation should be able to help articulate what role communication programmes play in promoting HIV/AIDS prevention, care, and support.

Workshop participants also pointed to the difficulties in assessing the impact of communication programmes in HIV/AIDS prevention, care, and support. For instance, how does one compute the impact of communication programmes in enhancing the quality of life of those who are afflicted by HIV/AIDS?

Social Change Indicators for HIV/AIDS Interventions

As previously stated, workshop participants strongly expressed the need to develop indicators for measuring social and organizational change in the community, going beyond measurement of individual-level changes. A preliminary list of social change indicators for HIV/AIDS communication interventions may include:

Changes in the degree (in terms of frequency, reach, intensity, and quality) to which:

1. The workplaces in the community have implemented HIV/AIDS programmes.

2. The community has initiated home-based care programmes.

3. The local health services offer HIV/AIDS testing and counselling.

4. The local health services ensure and provide access to safe blood supply.

5. The local brothels and commercial sex houses have initiated a condom adoption and HIV testing policy.

6. The local prisons and military establishments have instituted HIV/AIDS programmes.

7. The local schools have adopted an HIV/AIDS education curriculum.

8. The dropout rate for AIDS orphans at local schools has decreased.

9. Those who are living with HIV/AIDS are part of the “mainstream” in society (employed in regular jobs, working as counselors, etc.).

10. Those who are living with HIV/AIDS are protected by laws (that are designed to uphold their rights).

11. The quality of life of those living with AIDS, and those taking care of them, has been enhanced.

12. The community members openly discuss and debate HIV/AIDS issues in public meetings.

13. New community-based programmes and initiatives have been launched to address HIV/AIDS prevention, care, and support.

14. New coalitions and alliances have emerged among community organizations to address HIV/AIDS issues.

15. The community members have collectively taken decisions or passed resolutions about combating HIV/AIDS.

16. Grassroots leadership has emerged from within the community to tackle HIV/AIDS issues.

17. Religious organizations and spiritual leaders are involved in HIV prevention, care, and support programmes.

18. The community has engaged in acts of mobilization and activism for HIV/AIDS related issues.

19. The community has engaged with the local administration, service delivery organizations, non-governmental organizations, and others on HIV/AIDS issues. 20. The community’s cultural activities (sports, folk media, festivals, celebrations, songs, etc.) engage with HIV/AIDS issues.

21. The most vulnerable groups for HIV/AIDS in a community have been empowered to take more control of their external environment.

22. The media coverage and media advocacy for HIV/AIDS has increased. 23. The overall rates of STDs and HIV infections have decreased.

24. The community has become AIDS-competent in terms of prevention, care, and support.

25. There exists multi-sectoral involvement at the national level for HIV/AIDS prevention, care, and support.