Health Education Research Advance Access originally published online on July 17, 2006
Health Education Research 2006 21(4):567-597; doi:10.1093/her/cyl036
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© 2006 The Author(s).
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries
1 Johns Hopkins University, Bloomberg School of Public Health, Center for Communication Programs, Baltimore, MD 21202, USA
2 Department of HIV/AIDS, The World Health Organization, Geneva, Switzerland
3 Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21202, USA
4 PhD Program in Health Policy, Harvard University, Cambridge, MA 02138, USA
*Correspondence to: J. T. Bertrand. E-mail: jbertran{at}jhuccp.org
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Abstract |
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This review systematically examined the effectiveness of 24 mass media interventions on changing human immunodeficiency virus (HIV)-related knowledge, attitudes and behaviors. The intervention studies were published from 1990 through 2004, reported data from developing countries and 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 most frequently reported outcomes were condom use (17 studies) and knowledge of modes of HIV transmission (15), followed by reduction in high-risk sexual behavior (eight), perceived risk of contracting HIV/acquired immunodeficiency syndrome (AIDS) (six), interpersonal communication about AIDS or condom use (six), self-efficacy to negotiate condom use (four) and abstaining from sexual relations (three). The results yielded mixed results, and where statistically significant, the effect size was small to moderate (in some cases as low as 1-2% point increase). On two of the seven outcomes, at least half of the studies did show a positive impact of the mass media: knowledge of HIV transmission and reduction in high-risk sexual behavior. Further rigorous evaluation on comprehensive programs is required to provide a more definitive answer to the question of media effects on HIV/AIDS-related behavior in developing countries.
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Introduction |
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The mass media have played a visible role in the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic in developing countries since its onset in the early 1980s [1, 2]. Although many denied or minimized the importance of HIV/AIDS in the early days of the epidemic, almost all countries in the developing world used some form of mass communication to address the issue [2, 3]. Early on, these efforts focused on raising awareness of the existence of HIV/AIDS, the modes of transmission and the means of prevention. These efforts met with considerable success in raising awareness: in most countries, >90% of the population know the basic facts about HIV/AIDS [4]. The second generation of communication programs in the late 1980s and throughout the 1990s tended to focus more specifically on behavioral change related to abstinence, limiting one's number of sexual partners, and using condoms. In recent years, communication programs have expanded to address the full continuum from prevention to treatment to care and support [5]. Most of the mass media campaigns to date have focused on members of the general public, or more narrowly on youth, but not on other high-risk populations.
The purpose of this paper is to review and synthesize the data from developing countries on the effectiveness of mass media interventions in changing HIV-related knowledge, attitudes and behaviors. Mass media interventions are any programs or other planned efforts that disseminate messages to produce awareness or behavior change among an intended population through channels that reach a broad audience. These channels include radio, television (TV), video, print and the Internet, and can take different forms such as radio variety shows, songs, spots, soap operas, music videos, films, pamphlets, billboards, posters and interactive Web sites. In the analysis, we have distinguished between ‘broadcast’ interventions, which include radio and/or TV, thus having the potential to reach a national audience, and ‘small media’ with more local reach (e.g. posters, pamphlets, audio programming, dramas and puppet shows). The latter tend to be face-to-face, interactive and community-based, with greater involvement of local stakeholders.
Some readers may seek the answer to a related question: why are some campaigns more effective than others? That is, what elements distinguish good campaigns from less effective ones? Unfortunately, this question goes beyond the scope of this paper, for reasons discussed in the final section.
Conceptual framework for the effects of mass media
Figure 1 illustrates how communication programs are expected to change HIV-risk behaviors.
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Social, cultural, political, legal and economic factors often serve as obstacles to behavior change, though context can also facilitate change in certain circumstances. Within this context, the mass media are expected to affect a series of psychosocial factors, including knowledge, attitudes and self-efficacy. Changes in these factors are hypothesized to influence specific behaviors or practices, the most common of which are abstinence, reduction in number of sexual partners and condom use. In countries in which the primary mode of HIV transmission is through sexual relations, the practice of these behaviors reduces the prevalence of HIV, the ‘health outcome’. Program evaluation determines the degree to which the campaign reaches its objectives; it helps planners and scholars understand how or why a particular campaign worked and it provides information relevant for planning future activities [5].
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Methodology |
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Inclusion and exclusion criteria
After establishing the written definition and theoretical framework for mass media, the synthesis team developed inclusion and exclusion criteria for study citations. To be eligible, papers had to present a mass media intervention as defined above; employ an evaluation design 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; be published in a peer-reviewed journal from 1990 through 2004; and present data from a developing country, defined as a country bearing the World Bank designation of low-income, lower-middle income or upper-middle income economy [6]. Evaluation studies of condom social marketing campaigns were excluded, as these articles were reviewed in a separate analysis.
Search and acquisition
Trained staff used these criteria to search for eligible citations. A broad search was first initiated on computer-based search engines including the National Library of Medicine's Gateway system, PsycINFO, Sociological Abstracts, EMBASE and the Cumulative Index to Nursing & Allied Health Literature. We also searched the reference sections of papers that were selected for inclusion in the review. These new citations were acquired, screened, and if accepted, subjected to additional reference searches. The process was iterated until no new papers were identified. To supplement the computer database searches, we hand searched the journals AIDS, AIDS and Behavior, AIDS Care, AIDS Education and Prevention and Journal of Health Communication for eligible citations. In addition, we contacted experts in the field to review our list of papers, and we solicited any missing references that they recommended. Additionally, we carefully reviewed the references from previous review papers and meta-analyses for possible citations. Staff downloaded the results from all searches into a database system.
The Project Principal Investigator (PI) and the Project Coordinator separately reviewed the pooled database generated by the search staff, and categorized the citations as (i) primary citations qualifying for inclusion in the synthesis; (ii) background citations not qualifying for inclusion but providing valuable information on mass media interventions; (iii) citations to be acquired for further inquiry or (iv) not relevant. The separate screened files from the PI and the Coordinator were then merged for comparison; citations with discordant screening were discussed to establish consensus (see Fig. 2).
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Coding
Coding was conducted on all primary and background citations. Two independent coders extracted detailed information from each primary article using a structured coding form. Extracted data were transferred to an SPSS statistical database (SPSSTM, Chicago, IL) for identification of intercoder discrepancies. Intercoder resolution was performed by a third person to correct for data entry error and to resolve different interpretations of the presentation of results.
The study rigor of each primary citation was also systematically assessed to determine whether the studies could provide an unbiased quantitative assessment of intervention effectiveness. We assessed the rigor of each primary study using an eight-point scale developed for the project. The scale was additive, with one point awarded for each item. The items were: prospective cohort, control or comparison group, pre-/post-intervention outcome data, random assignment to treatment groups, random selection of subjects for intervention and assessments, attrition, comparison group matching, comparison group matching outcome measures and minimum requirements for inclusion in contextual coding (see Table I). Many studies used several research approaches of differing rigor; the scoring in Table I reflects the level of rigor with which data were collected and analyzed for the outcomes reported here, not necessarily for the overall study.
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Outcomes
In an effort to synthesize the results from studies with diverse outcomes, we selected a subset of seven variables, three psychosocial factors and four behaviors, for purposes of this review. The seven outcomes are
- (i) knowledge of HIV transmission;
- (ii) perceived personal risk of contracting HIV/AIDS;
- (iii) self-efficacy to negotiate condom use or protect oneself;
- (iv) discussion with others about HIV/AIDS or condom use;
- (v) abstinence from sexual relations;
- (vi) reduction in high-risk sexual behavior and
- (vii) condom use.
- (ii) perceived personal risk of contracting HIV/AIDS;
Within each of the outcome areas outlined above, multiple measures were reported by the studies under review. To assess results, we combined different operational definitions of each outcome and classified results accordingly (e.g. ‘condom use’ included condom use at last sex, condom use at last sex with a casual partner, condom use with a sex worker, ever used a condom).
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Results |
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The intensive search of the published literature revealed 24 articles that systematically evaluated the effects of mass communication programs on HIV/AIDS-related knowledge, attitudes and behaviors in developing countries, and that met the criteria for inclusion (see Table II). Of these 24, five used TV (with supporting media or alone), seven employed radio (with supporting media or alone) and the remaining 12 used ‘small media’ (with or without interpersonal communication, such as a group meeting or counseling). The majority of the evaluations of mass media programs published from 1990 to 1999 focused on small media (10 of 13 studies). The majority of the evaluations from 2000 onwards (8 of 11) examined programs that used radio or TV, with or without other supporting media. Thus, we observe an evolution in the types of programs evaluated toward communication programs designed to reach larger audiences using radio and/or TV.
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This research represents experiences from around the globe, with the largest concentration of studies from Africa (n = 12), followed by Asia (n = 7) and Latin America and the Caribbean (n = 5). Of the 24, three were published during 1990–94, nine during 1995–99 and 12 during 2000–04.
For all but three of the studies, rigor scores range from 2 to 5 out of a possible 8 points; two studies scored a 1 out of 8, while another featured a highly rigorous randomized control design, and therefore, scored a 7 (see Table I). Twenty-one of the 24 citations reported findings based on pre- and post-intervention data; nine of the 24 citations compared results from treatment versus control or comparison groups and nine analyzed post-intervention only data comparing outcomes by level of exposure. (Some studies employed more than one of these approaches, and as such the total sums to >24.)
Of the seven outcomes examined, far more studies reported on condom use (17) and HIV knowledge (15) than on reduction in number of partners (8), interpersonal communication (6), perceived risk (6), self-efficacy (4) or abstinence/age at sexual debut (3). A complete summary of the outcome measures and associated intervention effects generated from each citation appears in Table III. The results by outcome were as follows.
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Knowledge of transmission
Fifteen studies measured knowledge of HIV transmission as an outcome. Roughly half of these reported positive effects on all or a plurality of knowledge measures, with effect sizes ranging from 2 to 100% improvements in the proportion of respondents with better knowledge; of the remaining studies, roughly half showed positive effects for some measures or population subgroups (e.g. women only). For example, in India, Valente and Bharath [7; articles that met the criteria for this review are indicated by * in the references] found significant differences between the intervention group and the control group on the percentage correct on 12 knowledge questions (97 versus 94%). After watching an educational theater performance, subjects of Trykker et al. [8] 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%). Similarly, Milleliri et al. [9] found significant increases in knowledge of various modes of transmission after high school students had been exposed to a comic book program in Gabon. In a study which scored 7 on the rigor scale, Xiaoming et al. [10] showed large, significant increases in the intervention group regarding knowledge of modes of HIV transmission, including sexual intercourse (77–95%), multiple sexual partners (69–93%) and sharing needles for drug use (67–95%).
On the other hand, McGill and Joseph [11] did not detect significant differences in knowledge after drama performances in Sri Lanka, and Yoder et al. [12] did not find significant differences in knowledge of transmission between those with high access to a radio drama in Zambia and those with low access to it.
Perceived risk of contracting HIV/AIDS
The six studies that evaluated perceived HIV risk were evenly distributed over the categories of positive effects, no change or mixed results. Evaluation of a pamphlet campaign in Thailand by Elkins et al. [13] showed no significant changes in perceived personal risk of HIV. Similarly, Peltzer and Promtussananon [14] found no relationship between risk perception and any of four mass media components under study in South Africa. Vaughan et al. [15] reported that, after 2 years of radio soap opera broadcasts in Tanzania, those in the intervention group were significantly more likely to perceive that they were personally at risk than before the intervention (55–61%). This increase occurred despite strong contrary secular trends; the control group showed substantial reductions in perceived risk over the same time period (72–55%). Yoder et al. [12] also reported that Zambians exposed to a radio drama showed significantly higher belief that they could get AIDS than Zambians who were not exposed (30 versus 21%). Interventions evaluated by Pauw et al. [16] and Elkins et al. [13] showed stronger evidence for increased perception of HIV risk among female subjects; in fact, the Thai audio drama evaluated by Elkins et al. [17] showed significant decreases in perceived risk among men in the intervention group, an unintended consequence of the intervention.
Self-efficacy
Four studies evaluated self-efficacy to protect oneself or convince a sex partner to use a condom. The findings were evenly split between positive effects and no effects. In Thailand, Elkins et al. [13] reported no significant changes in self-efficacy to protect oneself if one's husband is suspected to be infected with HIV. In a later study, when Elkins et al. [17] asked Thai villagers, ‘if a married woman thinks she is at risk because of her husband, can she protect herself’, no differences were observed between intervention and control groups. In China, both the intervention and the control group showed increases in confidence to convince sex partners to use condoms, but the increase for the intervention group was significantly larger (83–92% versus 78–84%) [8]. Peltzer and Promtussananon [14] found significant associations between self-efficacy and exposure to newspaper materials, the Soul City campaign's TV programming and Soul Buddyz, a Soul City spin-off campaign targeted at children.
Talked to others about HIV/AIDS or condom use
The six studies measuring this outcome differed in terms of the person with whom the discussion occurred (e.g. spouse, children, ‘someone’, colleague). Three studies reported on communication with a spouse or partner regarding AIDS, while two studies measured communication with a spouse or partner regarding condoms. Results were split among positive, mixed and no effects, regardless of who the discussions were with and whether they were about AIDS or condoms. For example, the evaluation by Middlestadt et al. [18] of a radio-only campaign in St Vincent and the Grenadines (1995) did not find a difference between those exposed to the campaign and those unexposed on communication about condoms; however, Elkins et al. [17] found substantial, significant differences between those exposed to the Thai audio drama and those who were not (68 versus 48% for women, 65 versus 47% for men). In the same study, significantly more women and men talked with their spouses about AIDS after the campaign than before (43–86% for women, 66–78% for men); however, this difference was not significantly different from the control group. The same finding was reported in Elkins's earlier study in Thailand, suggesting that a secular trend toward increased communication about HIV may have been at play [13].
Abstinence from sexual relations
Only three studies measured this outcome, each using different measures; the results were positive or mixed. Kim et al. [19] reported that those in the intervention group of a multimedia campaign in Zimbabwe were significantly more likely than controls to have continued abstinence (32 versus 22%) and to have ‘said no to sex’ (53 versus 32%). Pauw et al. [16] reported significant increases in both intervention and control groups for changing sexual practices toward abstinence or monogamy due to AIDS, but found no significant differences between them. In South Africa, Peltzer and Promtussananon [14] found significant associations between delay of sexual activity and exposure to newspaper materials, the Soul City campaign's TV programming and Soul Buddyz.
Reduction in high-risk sexual behaviors
The clear majority of eight studies in this category yielded positive effects. The studies measured different aspects of the phenomenon, including number of sexual partners in the past year, percentage of men engaging in casual sex, percent avoiding a sugar daddy and percent avoiding commercial sex workers. Peltzer et al. [20] 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. Ubaidullah [21] reported that after receiving an intervention, only half as many truck drivers reported pre-marital or extra-marital sex. Kim et al. [19] reported a substantial difference between intervention and control groups on the ‘sticking to one partner’ variable (20 versus 2%). The proportion of single women having casual sex decreased significantly from before to after a campaign evaluated by Schopper et al. [22] in Uganda (11–3%); although the proportion of single men having casual sex did not change, the average number of casual partners did significantly decline from 0.29 to 0.19. Small but significant changes were found by Xiaoming et al. [10] and Vaughan et al. [15] with regard to number of partners in the previous year.
Condom use
More studies evaluated effectiveness based on condom use (17 of 24) than any other outcome. Of the 12 evaluations of programs using radio and/or TV (with or without other media), all but one included this outcome. The modal response over the 17 studies was ‘no effect’ followed by ‘positive’ or ‘mixed’. In Uganda, Quigley et al. [23] did not show significant change on the measures ‘ever use condoms’ or ‘use condom with last casual partner’. The radio campaign in St Vincent and the Grenadines [18] also failed to show changes on the variables ‘ever used a condom’ and ‘always used a condom’. The evaluation of the educational radio soap opera in St Lucia also did not report changes in condom use among men in sexual unions [24]. Pauw et al. [16] showed no significant increases in the frequency of condom use due to the house-to-house campaign in Nicaragua, and Schopper et al. [22] reported no significant increases in ever use of condoms after a pamphlet and community education campaign in Uganda. Increases in condom use were not found to be associated with exposure to elements of the Roulez Protégé campaign in Burkina Faso [25] or a variety of HIV-related media in South Africa [14].
However, Kim et al. [19] reported 5-fold higher condom use among sexually experienced campaign participants than among controls (11 versus 2%), and Shapiro et al. [26] found that likelihood of condom use at last sexual encounter was significantly higher among those who had seen more episodes of ‘SIDA dans la Cite’ TV drama. Ever use of condoms and use of condoms in the past year both rose sharply in Colombia after a radio advertising campaign aimed at increasing condom use (25–34% and 8–12%, respectively) [27]. Significant 1–2% differences between intervention and control groups were observed by Xiaoming et al. [10] in China on the variables frequency of condom use and condom use in last sexual intercourse.
In addition to examining these outcomes for the group of 24 studies, we attempted to identify patterns by type of intervention, distinguishing between those that used radio and/or TV (with or without other media) and those employing small media (with or without interpersonal communication). Given the small number of studies (3–8) that reported five of the outcomes, we opted only to examine this question for knowledge (with 15 studies) and condom use (17 studies). In terms of knowledge, the interventions using small media—with interpersonal communication or alone—showed similar effects, both in significance and size, to programs using radio and/or TV. With regard to condom use, evaluations of interventions using small media were less likely to measure this outcome and those that did were less likely to show positive effects. Of six studies that did show a positive outcome for condom use, five used radio and/or TV, alone or with other media.
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Discussion |
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How effective have communication programs been in changing HIV-related behavior? A number of critics have questioned the effectiveness of communication interventions as conducted to date [28, 29].
The current review yielded mixed results on the effectiveness of the mass media to change HIV-related behaviors in developing countries. On most of the outcomes examined across studies, we found no statistically significant impact. Among those that did show significant impacts, the effect sizes—while often statistically significant—were typically small to moderate in size. However, on two of the seven outcomes, at least half of the studies did show a positive impact of the mass media: knowledge of HIV transmission and reduction in high-risk sexual behavior. By contrast, the predominance of evidence for the remaining five outcomes—perceived risk of HIV, self-efficacy, interpersonal communication with partner/spouse, abstinence and condom use—showed mixed results or no effect.
This paper falls short of providing a definitive answer to the question ‘what is the impact of mass media on HIV/AIDS-related behaviors in developing countries’ for two reasons. First, although we identified 24 articles that met the inclusion criteria, many of these studies had weak designs. For example, one study originally established as a randomized trial for other purposes did not use the ‘arms’ of the study in the analysis of communication effects [23]. Another based the conclusion of ‘no effect’ on the increase in HIV prevalence between Time 1 and Time 2, during which time the media carried HIV prevention messages through multiple channels; yet no attempt was made to link exposure to the campaign and HIV status [30]. In another case, the study design called for a baseline and follow-up survey; yet the time elapsed between baseline and follow-up as well as the non-comparability of the two samples on socio-demographic factors resulted in basing the evaluation largely on the post-intervention data [25].
Second, the studies included in this review—representing all published evaluations through 2004 that met the inclusion criteria—do not capture the current state-of-the art for mass media campaigns for HIV/AIDS prevention. The ‘evolution’ in types of programs studied—from those involving small media to those using TV and/or radio—is reflective of the trend among governments, donor agencies and in-country implementing organizations to go to scale. 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—TV, radio, billboards, posters, pamphlets and other media linked with community-level activities (e.g. mobile vans, outreach events) to reach multiple segments of the general public with messages on HIV/AIDS. (In fact, one study did report on what may have been a comprehensive program, but made no linkage between exposure to the campaign and its effects.) This ‘ideal’ exists in a number of developing countries today, yet possibly because such comprehensive programs are still relatively new, no results were available in the published literature as of the end of 2004.
Policy makers, donors and practitioners are often frustrated at evaluators' inability to answer the question: ‘what makes some campaigns more effective than others?’ The experience from commercial advertising and marketing has defined many of the best practices that are now used in promoting social and behavior change. Marketing researchers in developed countries have honed techniques for establishing ‘what works’ by tracking sales using a variety of techniques: scanning bar codes in stores in the target area, tracking number of orders placed by phone or over the Internet for catalogue sales. However, such techniques are not readily applicable to evaluating programs designed to change social norms or behaviors in developing countries, without a means of tracking sales on an hourly or daily basis.
Even if international agencies were willing to fund such research to identify what makes an effective program, methodological problems exist. First, most evaluation studies focus on a single campaign, making ‘systematic comparisons’ across campaigns impossible. Second, it is difficult to disaggregate the effects of different components of a given campaign. One can stagger the introduction of different components into a campaign and track the point at which change occurs or accelerates; yet change that occurs after introducing a specific component may reflect lagged response to previously disseminated components. Third, experienced practitioners are loath to ‘experiment’ with time-tested techniques (e.g. audience segmentation) for the academic purpose of ‘proving’ that these techniques are effective. Fourth, relatively few campaigns undergo evaluation to determine effectiveness, let alone the factors behind their success. For these reasons, the published literature contains relatively little empirical testing or experimentation to determine what factors or characteristics make for an effective behavior change communication program in developing countries.
Ideally, we would have analyzed the data by sex of the respondent. However, only eight of the 24 studies disaggregated the data by gender. Thus, we did not attempt to incorporate this variable into the current review. Future research on effects would greatly benefit from disaggregation of results by gender.
In keeping with Hornik's findings in his edited volume of studies entitled Public Health Communication, Evidence for Behavior Change [31], this review underscores the need for alternative study designs to randomized trials as the optimal means for evaluating full coverage mass media programs. Only five of the 24 studies in the current review randomly allocated subjects to a treatment group. In four of the five cases, the intervention was limited to small media, making it possible to expose one group to the communication intervention, while withholding it from the other. The only exception was Xiaoming et al. [10] which used a pre-/post-randomized controlled trial comparing two intervention villages and two control villages sampled from two townships that were matched on socio-economic and demographic characteristics. Thus, there were no studies of full coverage media programs with random allocation of subjects to treatment areas, nor were there any studies that involved the randomization of a large number of communities. The fact remains that it is not viable to assign subjects randomly to treatment groups when the intervention consists of full coverage programs aiming to reach the largest possible audience, which is the case with national AIDS prevention programs in most countries.
One frequently used alternative for measuring effects is to compare outcomes by level of exposure, also known as ‘dose response’ analysis. This approach can yield highly biased results if no attempt is made to control for socio-demographic factors or access to media. For example, a strong association between levels of exposure and behavior change may merely reflect the effect of education and urbanization on both variables. To address this bias, researchers often control for socio-economic status and access to media. However, this does not resolve the issue of reverse causality (i.e. that people already doing the behavior may be more attentive to the messages about it). A more statistically advanced approach to measuring communication effects involves the use of propensity score analysis [32, 33]. This methodology relies on post-intervention only (cross-sectional) data with no control or comparison group. In the ideal case, evaluators would continue to collect pre- and post-data to demonstrate the expected change on key outcome indicators, but would use propensity score analysis on the post-intervention data to establish the link between exposure and the desired outcome, controlling for socio-demographic factors and access to media. Testing for endogeneity further strengthens the causal inference drawn from propensity scoring.
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. In addition, few studies address the costs and cost-effectiveness of mass communication programming, leaving funders and policy makers without the data necessary to determine which intervention strategies offer the greatest ‘bang for the buck’ (i.e.—lowest cost per person reached or outcome influenced).
This review addresses an important question for HIV/AIDS program managers, communication researchers, donor agency staff and others: to what extent do communication programs impact HIV/AIDS-related behaviors? It presents a systematic review and analysis of the relatively limited number of studies on this topic, and 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. Such research will be of greatest benefit to program managers if it includes detailed descriptions of the interventions under study, including media channels, main messages, duration, reach, frequency and underlying theoretical principles. Researchers will look for greater methodological rigor and convergence toward a common list of psychosocial outcomes and behaviors, allowing greater comparability across studies. Communication programs continue to be at the heart of the HIV/AIDS response, yet much work remains to be done in building the evidence base for their effectiveness.
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Conflicts of interest |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionMethodologyResultsDiscussionConflicts of interestAcknowledgementsReferences |
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The authors wish to thank Priya Emmart, Jennifer Gonyea, Amy Gregowski, Andrea Ippel, Sarah Kessler, Juliana Kohler, Devaki Nambiar, Anne Palaia and Emma Williams for their coding work, and Caitlin Kennedy and Amy Medley for their coordination of the project. This research was supported by the World Health Organization, Department of HIV/AIDS, The US National Institute of Mental Health, grant number 1R01 MH071204, and The Horizons Program. The Horizons Program is funded by The US Agency for International Development under the terms of HRN-A-00-97-00012-00.
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References |
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Received on December 16, 2004; accepted on April 14, 2006
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