Systematic Review of the Effectiveness of Mass Communication Programs to Change HIV/AIDS-related Behaviors in Developing Countries

"Even though international donor agencies and governments have invested millions of dollars in different types of communication interventions in developing countries, relatively few have been subjected to any type of rigorous evaluation to date..."

This 31-page resource examines the effectiveness of 24 mass media interventions from developing countries in changing HIV-related knowledge, attitudes, and behaviours. It provides data on a question that may shape the nature and direction of the work of HIV/AIDS programme managers, communication researchers, donor agency staff, and others: to what extent do communication programmes impact HIV/AIDS-related behaviours? In short, it examines the strategy of using mass media interventions to effect change in the HIV/AIDS arena. The authors distinguish between "broadcast" interventions, which include radio and/or television, and "small media" with more local reach (e.g., posters, pamphlets, audio programming, dramas, and puppet shows) that tend to be face-to-face, interactive, and community-based, with greater involvement of local stakeholders.

Following a concise presentation of the conceptual framework of this research - that is, how communication programmes are expected to change HIV-risk behaviours - the authors discuss the research methodology. In short, they selected intervention studies that were published from 1990 through 2004, that reported data from developing countries, and that compared outcomes using (i) pre- and post-intervention data, (ii) treatment versus control (comparison) groups or (iii) post-intervention data across levels of exposure. The research reviewed here represents experiences from around the globe, with the largest concentration of studies from Africa (12), followed by Asia (7) and Latin America and the Caribbean (5). The authors then selected a subset of 7 variables for purposes of this review:

1. knowledge of HIV transmission
2. perceived personal risk of contracting HIV/AIDS
3. self-efficacy to negotiate condom use or protect oneself
4. discussion with others about HIV/AIDS or condom use
5. abstinence from sexual relations
6. reduction in high-risk sexual behaviour
7. condom use

The most frequently reported outcomes were condom use (17 studies) and knowledge of modes of HIV transmission (15), followed by reduction in high-risk sexual behaviour (8), perceived risk of contracting HIV/AIDS (6), interpersonal communication about AIDS or condom use (6), self-efficacy to negotiate condom use (4) and abstaining from sexual relations (3). The results yielded mixed results; on most of the outcomes examined across studies, the authors found no statistically significant impact. Where statistically significant, the effect size was small to moderate (in some cases as low as 1-2% point increase). However, on 2 of the 7 outcomes, at least half of the studies did show a positive impact of the mass media:

• knowledge of HIV transmission - example: "After watching an educational theater performance, subjects of Trykker et al...significantly increased their 'rejection' of incorrect modes of transmission, such as 'using secondhand clothes from a person having AIDS' (48-68%), 'drinking from the same cup as a person having AIDS' (42-60%) and 'kissing a person having AIDS' (26-37%)."
• reduction in high-risk sexual behaviour - example: Peltzer et al...found that those exposed to the Soul City campaign in South Africa had significantly fewer non-commercial and commercial sex partners in the past year."

The authors stress that the studies included in this review "do not capture the current state-of-the art for mass media campaigns for HIV/AIDS prevention....The current analysis did not include a single study that evaluated what communication experts would consider a comprehensive behavior change program: one that uses the full gamut of media".

The Discussion section includes various reflections on a question that is beyond the scope of this paper: what makes some campaigns more effective than others? The authors explain some of the methodological challenges prohibiting the honing of techniques for establishing "what works" in the context of efforts to evaluate media-centred HIV/AIDS programmes designed to change social norms or behaviours in developing countries. They conclude that "This review...underscores the need for researchers working in this area to ensure that their work finds its way into the published literature to help us better understand (i) the outcomes on which communication programs have the greatest effect, (ii) the magnitude of these effects, (iii) the elements of a communication program that contribute to its effectiveness and (iv) the cost effectiveness of communication programs in HIV/AIDS prevention. Given the emergence of communication programs with national scope in many developing countries, we need further evaluation of programs that go to scale and refinements in the methodologies for evaluating such programs when randomization of subjects is not an option..."