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Rationale for Development of the Communication Framework
Identification and use of “Domains”
Implication of the Communication Framework on HIV/AIDS Interventions
Review of HIV/AIDS Communication Related Literature
AIDS is the leading cause of death for people aged between 15–29 years in the world. Worldwide 40 million people are living with HIV and AIDS and 95% of them live in Developing Countries. In 2001, there was an estimated 5 million people newly infected with HIV, and 3 million who people died due to AIDS (WHO, 2001).
Ethiopia is among the most heavily affected countries in the world by the HIV/AIDS epidemic. With an estimated 3 million adults infected with HIV by end of 1999, Ethiopia has the third highest population of HIV-infected persons in the world accounting for about 9% of the world’s HIV/AIDS cases.
HIV infections were first found in Ethiopia in 1984. HIV/AIDS prevalence remained low in the 1980s but sharply accelerated through the 1990s, rising from an estimated 3.2% in the 15–49 age group in 1993 to 10.63% by the end of 1999, with similar increases in various population subgroups, making Ethiopia the sixteenth in HIV prevalence.
An estimated 120,000 children were infected in 1999 and nearly two-thirds of all antenatal attendees at several clinics were in the 15–24 age group. An estimated 1.2 million children were AIDS orphans in 1999 (UNAIDS 2000). No reliable data are available on mother-to-child-transmission in Ethiopia and a large trial is being carried out (Kebede et al. 2000) by Johns Hopkins University.
The urban/rural and gender differentials in HIV infection and high prevalence in female sex workers, soldiers and truck drivers demonstrate the rapid spread of the epidemic among both high-risk groups. They also indicate that the epidemic is spreading into rural populations, which do come in contact with the urban HIV transmission sites (Shabbir and Larson 1995).
In 1988, a sero epidemiological study of 6,234 female commercial sex workers in 24 communities throughout Ethiopia revealed infection rates between 1.3% and 38.1% in different towns. The mean infection rate was 18.3%, which increased to 29.2% during a follow-up survey in 1989. Rates above 20% were found in communities on major truck routes between Addis Ababa and the Red Sea port of Assab and from Addis Ababa to Bahir Dar and Mekele towns in the north (Mehret et al., 1990a). In Addis Ababa rates among sex workers were 24.7% in 1988, 54.3% at STD clinics in 1990 and 73.4% in 1998 (Mehret et al. 1990c; Aklilu et al. 1999).
It is projected that by the year 2014, the number of person living with HIV infection will be around 4.7 million. It is also expected to have around 260,000 new AIDS cases each year. The mortality due to AIDS is expected to rise dramatically. Various adverse demographic, health care, economic and social impacts are envisaged (MOH 1998).
All published studies on sexual behavior in Ethiopia have been carried out in urban areas. Two large-scale nation-wide surveys on condom use showed an increase from 3.6% in 1978/88 to 47.5% in 1993, and similar changes were reported for college students in Gonder and high school students in Addis Ababa. The proportion of students reporting sex with non-regular partners allegedly decreased during that period about four-fold (Kebede et al. 2000). A study among out-of-school youths aged 15–24 in Awassa town, only 27.6% of them said to using condoms in spite of more than 90% knowing about HIV/AIDS (Taffa 1998), a discrepancy which was reported by a number of other studies in different towns (Kebede et al. 2000). In a district town in south central Ethiopia, visiting rural farmers had significantly lower knowledge of condoms and extramarital sex activities than students, soldiers and merchants. Nevertheless, the large number of farmers visiting local towns for social and business purposes in Ethiopia may make them the major carrier of HIV into rural areas (Shabbir and Larson 1995). In the same study demobilized soldiers were reported to be experiencing high-risk behaviors.
Promiscuity of males in the general population is another major factor in the high HIV prevalence reported from urban populations. High STD prevalence in women still married to their first husband in Addis Ababa was associated with extramarital sexual activities of males (Duncan et al. 1994). A study of the sexual behaviors of farmers, merchants, soldiers and students residing in rural areas found that they had frequent sexual contact with female sex workers while they visited towns (Shabbir and Larson 1995).
Stigma, denial and fear of disclosure due to discrimination among HIV/AIDS affected persons remain a serious problem in many parts of Ethiopia. In Benishangul, the stigma attached to the diagnosis of HIV/AIDS was found to be so strong that health workers were afraid to pronounce the diagnosis of AIDS (UNAIDS 1997). In another study, although knowledge about AIDS was found to be high in a Addis Ababa neighborhood, 90% of the respondents regarded hospitals to be the best place to care for AIDS patients. These results indicate the need for more public education to create more favorable attitudes towards the provision of home-care for persons with AIDS (Berhane and Zakus 1995) and social acceptance of infected persons.
A National Task Force was established in 1985, followed in 1987 by the establishment of a National AIDS program under the Ministry of Health. With the change in government in 1991, many government functions were decentralized to regional governments.
Recently, in September 1999, the Ministry of Health issued the National Multisectorial HIV/AIDS Strategic plan for 2000–2004, building on the national HIV/AIDS Policy statement issued in August 1998. Reflecting the increasing recognition of HIV/AIDS as a health, developmental, political, economic, and social problem, the government of Ethiopia has chartered a new National AIDS Council, to be chaired by the President of Ethiopia and involving leaders from multiple sectors.
There is a wide array of donor-supported programs and non-governmental organizations (NGO) active in HIV prevention and care in the country. Activities include NGO capacity development, education and counseling services for high-risk groups, prevention marketing, condom distribution, entertainment-based education, youth education, development of a resource center, etc.
Religious organizations and leaders have become increasingly involved in HIV prevention and care activities. The churches have embraced HIV prevention and have become involved in an array of prevention activities: promotion of sexual responsibility, youth HIV clubs, support for HIV infected persons and their families, and care of HIV orphans.
This document presents the HIV/AIDS Communication Framework developed by UNAIDS/PENN State, which focuses in contextual areas for bringing individual and social changes as oppose to targeting solely the individual for behavior change. In this document, the Communication framework is adopted for the Ethiopian context.
HIV/AIDS Communication programs targeting the individual without tackling the underlying contextual areas/domains has been proven ineffective through recent research. There is noticeable variation in contexts determining behavior. Based on this, it is evident that communication strategies addressing HIV/AIDS prevention, care and support need to be reevaluated.
Most theories used for the models and framework used in HIV/AIDS prevention were drawn from social and psychology and communications. Some models of family planning and population programs that proved successful were also borrowed for HIV/AIDS prevention programs. Yet, it seems that the applicability and adaptability of these borrowed models have not fully or effectively served their purpose in terms of HIV/AIDS prevention programs.
Most of the above mentioned theories and models are based on individual theory, which is basically foreign to non-western societies which tend to view the self as a product of the family and the community. In non-Western contexts the family and the community play a great role in decision-making. The continued use of “individual based intervention methods” is not allowing organizations and institutions to make head way in the combat of HIV/AIDS. The Communication Framework herein described takes into account
the variation among the political, socioeconomic, gender, spiritual and cultural contexts that prevail in the various countries and their impact on efforts to mitigate HIV/AIDS .
It is with the above in mind, that UNAIDS and PENN State have developed the HIV/AIDS Communication framework for individual behavior change by means of focusing on contextual areas such as the policy, the socio-economic, the gender, the culture and the spiritual areas. These contextual areas are referred to as Domains. More in depth conceptual descriptions and definitions will follow in the latter part of this document.
Attempting to influence behavior is not realistic if the underlying social factors that shape the individual behavior remain unchanged. A noticeable number of communications and health promotion programs aim to change behavior alone. When in fact, such, change is unlikely to be sustainable without incurring some minimal social change. Thus, this leads our attention to social and environmental context and their role in behavior change.
As mentioned earlier, the HIV/AIDS communication framework is based on acknowledging the existence of contextual areas influencing behavior. Non-Western societies tend to view the self as product of the family, the community and the environment as oppose to viewing it as a product of the individual as do the Western societies. These contextual areas are called for the purpose of this framework “Contextual Domains”.
Based on prior work and research conducted by UNAIDS / PENN State five inter-related contextual domains have been identified that should be the focus in developing future communication strategies for HIV/AIDS Prevention, Care and Support. These domains are: government policy, socio-economic status, culture, gender relations and spirituality.
These domains are all independent as well as inter-related to each other. HIV/AIDS Communication strategies are formulated around the issues within each Domain. The same issue can surface in one, two or even in all the domains (examples can be found in the Domain table in the Annex). Under this formula, the communication strategy formulation and implementation will vary according to the domain in relation to the issue. (Please refer to Matrix).
Domains are used to ground issues, that belong together, on the same platform and to denominate the main platform or “domain” under which interventions can be initiated or where changes can be expected.
As mentioned earlier, most efforts to date have been focusing on HIV/AIDS Prevention aiming at changing individual behaviors rather than addressing the society or an individual within the environmental and social context in which s/he circulates/operates. Thus, it is a fact that although, noticeable resources have been expended in the efforts of prevention, the prevalence rate of HIV has not decreased proportionally.
Presently, the development of an HIV/AIDS Communication Framework represents the opportunity to address Individual behavior change within the contexts affecting the life of the individual. Hence, recent research and the results of Consultative meeting showed that the use of this communication framework will imply a better coordinated and guided implementation of HIV/AIDS programs within each concerned country.
In Ethiopia, communication materials (including print, audio and otherwise) are not produced in a coordinated manner. There is a great lack of communication among the various organizations disseminating such materials as well as a lack of common standard to follow. Thus, the added-value and benefits of this Communication framework will be to offer means to have Quality of Standards in terms of the communication materials as well as aligning communication organizations and their respective programs to a shared goals. This is necessary for Ethiopia's ability to have effective communication on HIV/AIDS intervention programs as well as other intervention.
Available documents (literature) addressing HIV/AIDS communication were reviewed to find out how they treated priority issues in the framework they followed. The literatures reviewed for this purpose were the National Population Information, Education, Communication (IEC) and advocacy Strategy, Strategic Framework for the National Response to HIV/AIDS in Ethiopia, the National Guideline on the Prevention of Mother to Child Transmission of HIV/AIDS in Ethiopia (PMTCT), the National Guideline for Voluntary Counseling and Testing in Ethiopia, the Rapid Assessment on Knowledge, Attitude and Practices related to Reproductive Health in Ethiopia (I.E.C. and Advocacy), the Ethiopia Family Planning Use and HIV/AIDS Prevention Formative and baseline Study and the Formative Research to Develop Radio Serial Drama for HIV/AIDS Prevention and Reproductive Health Services Utilization.
The National Population IEC & Advocacy Strategy communication framework, which addresses priority population issues including HIV/AIDS, follows logical sequence of steps. These are identification of priority issues, setting of goals and objectives, selection of audiences, messages and communication channels, monitoring and evaluation and identifying implementing institutions for population programs. These steps in the framework have contributed much in the development of this document.
The strategic framework for the national responses to HIV/AIDS and the National Guideline on the PMTCT in Ethiopia give emphasis to mounting IEC/BCC and advocacy as a strategy in achieving the purposes of the prevention of the transmission of HIV/AIDS. To this effect, designing relevant messages for specific target audiences using appropriate multimedia channels are indicated that have relevance for the HIV/AIDS Communication Framework document.
The National Guideline for voluntary HIV Counseling and Testing in Ethiopia stresses the importance of providing appropriate information on HIV/AIDS transmission and methods of prevention.
The Rapid Assessment on Knowledge, Attitude and Practices related to Reproductive Health in Ethiopia (I.E.C. and Advocacy) was conducted in December 2000 in 6 regions of Ethiopia. In this study the most acceptable communication methods and strategies recommended by the communities are utilization of religious institutions, schools, local community organizations, peer education, extensive use of appropriate IEC materials, effective use of mass media as well as the traditional media and role models (such as PLWH/A). Moreover, people are in very much favor of legally banning sexually exciting foreign films, pictures, cartoons, etc. The study recommended five broad sets of recommendations, i.e., on IEC, Channels of Communication, Advocacy, RH services related and on the Roles of The Health Education Center (HEC) of MOH and the National office of Population (NOP) are forwarded.
The Ethiopia Family Planning Use and HIV/AIDS Prevention Formative and Baseline Study conducted by the Johns Hopkins University, Population Communication service, in February 2001, was based in an empirically tested health behavior change model called the Extended Parallel Process Model (EPPM). The components of EPPM are a) severity of threat (b) susceptibility to threat), (c) response efficacy and (d) self-efficacy. There is interaction in the process in a manner to bring out the following:
The research covered urban areas in five major regions of Ethiopia (Tigray, Amhara, Oromia and Southern Nations Nationalities and Peoples Region). Based on the findings some of the recommendations on the prevention of HIV/AIDS are the following:
The “Formative Research to Develop Radio Serial Drama for HIV/AIDS Prevention and Reproductive Health Services Utilization” conducted by Population Media Center (PMC) in November 2001, aims at assisting the development of communication strategy through entertainment education using radio serial dramas.
The objective of the study is to find information for the design of radio serial drama to reach the intended audiences of Amharic and Oromiffa speaking population. Qualitative and quantitative methods were used in order to get primary data from 17 sites in three regions i.e. Addis Ababa, Amhara and Oromia.
