Factors Affecting Health Communication Campaigns

A comparison of HIV Aids and Polio Campaigns in Aligargh, Uttar Pradesh

Introduction:

Last two decades of the century has seen a renewed interest in the field of health communication, disease prevention and health promotion. This was because it was realized that continued investments in clinical health research brings diminishing returns if it is not accompanied with strategic information, education and communication(IEC) efforts. (Pencheon, Guest, Melzer, & Gray, 2004)

Public and government health departments are rich with tacit knowledge regarding health communication practices and the problems encountered with the population in their geographical area. However this information is rarely collected and written down due to lack of resources.

Effective communication can spread knowledge, value and social norms. This can be instrumental in affecting behaviour and improving the over-all health status of the population.

India faces a dual challenge in tackling the problem of HIV Aids and Polio. First is the overall high population and poor living conditions of people living in small towns and villages, and second is the complex socio- cultural factors which lead to poor awareness and stigma attached to these diseases.

It is important to understand these factors which affect the impact of health communication campaigns in a particular geo-graphical sub system if a comprehensive micro understanding of this field has to be generated. Moreover there always exists a gap between the people who design health communication campaigns and the campaign implementers. An assessment and feed-back from the grass root level implementers needs to be taken if this gap has to be effectively filled.

This research hopes to uncover these insights which will be useful not only to the academics but also to the practitioners.

Literature review

Health Communication:

Health communication involves the use of communication strategies by experts in public health domain to influence the health behaviour of people.

It is a link between health care practices and communication which has a significant impact on influencing individual and community behaviour towards health and thereby a huge potential to significantly improve their life. (Neil Mckee, 2004)

HIV AIDS:

The human immunodeficiency virus (HIV) is a retrovirus that infects cells of the immune system, destroying or impairing their function. As the infection progresses, the immune system becomes weaker, and the person becomes more susceptible to infections. The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS). It can take 10-15 years for an HIV-infected person to develop AIDS; antiretroviral drugs can slow down the process even further.

HIV is transmitted through unprotected sexual intercourse (anal or vaginal), transfusion of contaminated blood, sharing of contaminated needles, and between a mother and her infant during pregnancy, childbirth and breastfeeding.

Global Case load: HIV – Aids

In countries most heavily affected, HIV has reduced life expectancy by more than 20 years, slowed economic growth, and deepened household poverty. In sub-Saharan Africa alone, the epidemic has orphaned nearly 12 million children aged less than 18 years. The natural age distribution in many national populations in sub-Saharan Africa has been dramatically skewed by HIV, with potentially perilous consequences for the transfer of knowledge and values from one generation to the next. In Asia, where infection rates are much lower than in Africa, HIV causes a greater loss of productivity than any other disease, and is likely to push an additional 6 million households into poverty by

2015 unless national responses are strengthened (Commission on AIDS in Asia, 2008). According to the United Nations Development Programme (UNDP), HIV has inflicted the “single greatest reversal in human development” in modern history (UNDP, 2005).

Fig 1.1 – A global view of HIV Infection (UNAIDS, 2008)

The current statistics on HIV/AIDS as published by UNAIDS (2008) are:

Estimate

People living with HIV/AIDS

33.0 million

Adults living with HIV/AIDS

30.8 million

Women living with HIV/AIDS

15.5 million

Children living with HIV/AIDS

2.0 million

People newly infected with HIV in 2007

2.7 million

Children newly infected with HIV in 2007

0.37 million

AIDS deaths in 2007

2.0 million

Child AIDS deaths in 2007

0.27 million

Fig. 1.2 -Current Statistics on HIV Aids

Global Health Communication initiatives for HIV Aids:

Education Entertainment Approach: The Soul City, South Africa (Goldstein, Japhet, & E.Scheepers, 2004)

South Africa even though a developed country had a wretched health care system, mainly due to long years of apartheid practices. In late 1990’s Dr Garth Japhet, a young doctor observed this at Alex clinic.

He observed that the health communication efforts in South Africa where very “slogan based “and not sustainable. Bursts of activity like “National Aids day” were not enough. There was no formative research before planning these campaigns. More over the campaigns followed a “Top Down” approach, and lacked synergies between medical community, government and media.

Soul City was an extensive multi media campaign started in South Africa, due to the efforts of Dr Garth Japhet.

The whole campaign was a collection of mass media campaigns which were connected and implemented year on year. There was a 13 part prime time- television series called “Soul city”, which was accompanied by a 60 episode radio show. Even though content of both these shows was not similar yet they both highlighted same health issues. Later on printed IEC material was also developed and distributed based on the characters of Soul City. These booklets were also reviewed by 11 top newspapers of the country. Through 1994 to 1999 five series of Soul city were broadcasted. These were consisted rated as top three most watched drama series in South Africa.

The Radio program also got very high listenership ratings. Formative research and high creative input went into designing the IEC material which was targeted uniquely to adults and young population.

The key to success of Soul City multimedia program was use of media conversion, from print to radio to television. This encouraged inter-personal discussions about health issues.

Learning:

Locally developed content which has quality entertainment works well

For a multimedia educational model to succeed it should return value to all the stake holders

Media advocacy leads to policy and social change

A continual and integrated multimedia strategy is necessary if the effect of communication has to be sustained.

Against Stigma: ACT UP, United States of America (Documents archive/Act Up explained)

Stigma is a problem which plagues every country and becomes a very important factor in HIV + people seeking help and coming out in public .The Aids Coalition to unleash power , is one such organisation which attempts to remove this stigma through bold and creative action. They boldly use their slogan Silence = Death which urges people to speak up about HIV and Aids.

They seek to normalize talks about condoms and Aids by radical action like sticking posters on telephone booths which say “this telephone has been touched by a person with Aids”

Public demonstrations at churches, baseball fields, Wall Street etc are held to imply that Aids is everybody’s business. Once during a Sunday sermon session in New York the ACT UP activists did staged a mass die in outside to highlight the bishop’s silence on Aids.

ACT UP activists use linguistic symbols to make strong statements like -“No, Glove No Love” and “Aids is no ball game”. These were used as places like Shea baseball stadium.

Learning:

ACT UP founder Larry Kramer studied the fight against stigma by Mahatma Gandhi and Dr Martin Luther King and suitably adapted it for modern day audience

Use of creative and clutter breaking ideas helps discussion and normalization of sensitive issues like stigma

Use of public demonstration, Sit ins and Die ins helps create buzz and social change.

Health communication efforts for HIV Aids in India:

The National Aids Control Program (UNAIDS, 2008):

Every State in India has an Aids prevention and Control Society which under supervision from NACO carries out local initiatives.

The second Stage of National Aids control program (NACP) ended on March 2006.This focussed on various platforms to promote youth education about safe sex, safe blood donation and HIV testing. Various platforms like Street plays, concerts, national aids day, TV and radio spots, and celebrity endorsements were utilised.

Use of teachers and peer group influencers was done to disseminate knowledge about HIV aids

The third stage of NACP will have a strong focus on condom promotion. The installation of over 11,000 condom vending machines in colleges, road-side restaurants, stations, gas stations and hospitals has been done. With support from the United States Agency for International Development (USAID), the government has also initiated a campaign called ‘Condom Bindas Bol!’, which involves advertising, public events and celebrity endorsements. It aims to break the taboo that currently surrounds condom use in India, and to persuade people that they should not be embarrassed to buy them. (Shhhh…not anymore!)

Various multi-media campaigns have been implemented in India to create awareness about HIV.

These include special communication programs to target special audience like sex workers, truck drivers, and street children. Radio programs are broadcasted on a regular basis to disseminate information. Field publicity units, Drama and song division has been set up to target rural India. Aids hotlines with around 1097 toll free numbers have been set up in major cities of India.

A very successful program has been the University Talk Aids (UTA program), which covered 4,044 institutions in India and reached out to 3.5 million students. The program was implemented by National Service Scheme with assistance from WHO and NACO.Independent evaluation suggested that the program was highly successful in creating a healthy attitude about sex among young children

­Communication regarding Condom promotion:

Social marketing of Condoms combined with free distribution has been used to promote usage among general public as well as high risk groups. Department of Family welfare has been instrumental in distribution and supply of condoms.

Family Health Awareness Campaign

This campaign was focussed on creating awareness about RTI and STI among the general public as well as the field level functionaries. This campaign is organised annually in rural as well as urban slum areas. (Shaukat Mohammed, 2003)

Reaching Special Audiences:

Reaching Men who have Sex with men (MSM): Case Study Naz foundation Trust of India: (Rakesh, 2002)

Background: India with a very high population runs the risks of very high PLHA even if a low prevalence rate of HIV is present. Even though most sources of infection are through hetero-sexual sex yet in certain areas like north -eastern India, IDU becomes a dominant factor for HIV transmission.

Strategy: The Naz foundation was set up in 1994 to address sexual health issues of MSM, women, truck drivers and PLHA.

The key communication objectives were:

Communication about modes of transmission

Prevention and risk reducing strategies

Means of accessing treatment

The intervention strategies utilised were:

Community outreach: Nine outreach sites which were staffed with officers who provided information on safe sexual health practices, condom usage and provided referrals

STI referrals: A non judgemental approach to STI risk patients was followed. STI clinics were set up with a MSM friendly physicians

Social and Group meetings: support groups were formed to help MSM and create a freer environment for information interchange

Counseling:Telephone hot lines and personal counselling was set up to address MSM concerns

Results: The implementation of Naz foundation strategies was evaluated and it showed a number of positive results. An increase from 11 % to 43% for “all time ” condom usage ,the STI clinic visits increased from 24% to 56%, and condom usage by male sex workers increased from 20% to 43 %

Learning:

Naz foundation realized that in order to reach out to special audiences tailored solutions are necessary.

Some risk groups like female partners of MSMs are very difficult to reach and hence intensive efforts are needed in this area.

Reaching out to Injecting Drug Users (IDU): Case Study IDUs in New Delhi India (Dorabjee, 1998)

Background: In some cities of India like New Delhi the HIV prevalence rate among IDU users is as high as 85%.The Indian NGO Sharan has been working for IDU since 1979,and has done some breakthrough work in this area.(AIDS Analysis Asia ,1996).

Strategy: IDU were motivated to join either drug substitution therapy which involved substituting drug injections to oral drug usage or needle exchange program where the registered IDU users vouched to stop exchanging needles during drug usage.

The reason behind the success of this program was that it managed to develop a strong trust among IDU users because it employed recovering drug users as outreach workers. Constant feedback was sought from them and the program was modified accordingly.

The IEC approaches used were counselling, peer education, information on sexual transmission of HIV aids, condom distribution and drug use prevention programs.

Results:

33 % of registered IDU started taking oral drugs instead of Injections

21% stopped sharing needles

Use of advocacy resulted in government accepting the use of harm reduction strategies for IDU users

Learning:

Political support is necessary for the success of any IEC project on sensitive issues. This can be influenced through strong advocacy

Incorporating feedbacks by outreach workers and IDU can significantly increase the impact of the campaign

A range of clinical, social and communication services are required to meet the purpose of HIV prevention among IDU users

Addressing the mobile population: Case Study the Trucker Population of India (Bhoruka, 2001)

There are about 50 million trucker population in India, who spend around ten months away from home. Around 70% of these engage in unprotected extra marital sex (UNAIDS, 2006).HIV infection is high in this segment along with a high STI danger. A major obstacle is that these truck drivers do not use condoms for “road side sex” as it regarded as a re-creational activity.

Strategy: The Bhoruka public welfare trust (BPWT), attempted to reach these truck drivers through free tea parlours set up at 5 main route stops in India. These tea parlours offered a meeting ground for the truck drivers and offered tea, newspaper, TV and other forms of entertainment. However no prostitution or drugs were encouraged. Condoms, clinical counselling and STI medical referrals were offered at a subsidised rate.

The most important aspect was focus on peer education and counselling. As these truck drivers discussed about their life, peer educators gave them counselling and information. Parking lots were used as another reaching stop where peer educator gave out condoms and IEC material.

This program became so successful that various truck drivers themselves became informal peer educators. The tea-shops were also managed by truck drivers or sex workers. Informal truck driver peer educators were later trained and given certificates to become formal peer educators and work in these tea shops.

Small motivational incentives like bags and pens were also offered to these truck drivers as well as informal peer educators.

Results:

Every tea centre reaches out to close to 48,000 people annually, provides subsidised treatment to 2,200 patients .Fifty percent of these patients are treated for STIs

Around 200 truck drivers had been trained as peer educators by the year 2000

The condom social marketing component of this program was very successful, with steady increase in condom sales. Till 2000 there were 104,832 sold and 162 active condom distribution set up.

Learning:

A high level of motivation should be maintained amongst the peer learning groups.

It’s important to have support of all the stakeholders for the success of any ICE program.

Poliomyelitis (polio)

Poliomyelitis (polio) is a highly infectious viral disease, which mainly affects young children. The virus is transmitted through contaminated food and water, and multiplies in the intestine, from where it can invade the nervous system. Many infected people have no symptoms, but do excrete the virus in their faeces, hence transmitting infection to others.

Initial symptoms of polio include fever, fatigue, headache, vomiting, stiffness in the neck, and pain in the limbs. In a small proportion of cases, the disease causes paralysis, which is often permanent. Polio can only be prevented by immunization (World Health Organisation)

Global Case load: Polio

Polio cases have decreased by over 99% since 1988, from an estimated 350 000 cases in more than 125 endemic countries then, to 1997 reported cases in 2006. In 2008, only parts of four countries in the world remain endemic for the disease – the smallest geographic area in history.

In 1994, the World Health Organization (WHO) Region of the Americas (36 countries) was certified polio-free, followed by Western Pacific Region (37 countries and areas including China) in 2000 and the WHO European Region (51 countries) in June 2002.

In 2007, more than 400 million children were immunized in 27 countries during 164 supplementary immunization activities (SIAs). Globally, polio surveillance is at historical highs, as represented by the timely detection of cases of acute flaccid paralysis.

Persistent pockets of polio transmission in northern India, northern Nigeria and the border between Afghanistan and Pakistan are key epidemiological challenges.

As long as a single child remains infected with polio, children in all countries are at risk of contracting the disease. The poliovirus can easily be imported into a polio-free country and can spread rapidly among unimmunised populations. Between 2003 and 2005, 25 previously polio-free countries were re-infected due to importations.

The four polio-endemic countries are Afghanistan, India, Nigeria and Pakistan.

Global Health Communication efforts for Pulse Polio:

Strategic communication efforts in Afghanistan (Rafiqi, 2004)

The Pulse polio eradication program of Afghanistan faced stiff challenges due to illiteracy, resistance, inaccessibility and worsening security conditions.

Strategic approach for Polio health communication in Afghanistan focussed on advocacy, social mobilization, communication to support the program and training.

Advocacy was achieved by involving top leaders at every program launch, and getting them involved at all levels by sharing epidemiological data. Social mobilization through involvement of religious leaders, mosque and prayer announcements, and inter-personal communication. Television and Radio was also utilized. Communication to support the program was achieved through district and community based forums which encouraged discussions, dedicated community specific social mobilization workers were employed and training was given to Imams and other religious leaders. Print media was used effectively for brochures, banners and leaflets.

Learning:

It’s a challenge to shift the focus of health communication from campaign type to sustainable communication

Advocacy at highest level is instrumental to success of the campaign

Use of local facilities like mosques, bazaars, mobile loudspeakers etc lead to effective social mobilization

Appropriate mix of print and radio can effectively reach mobile population

Establish strong relationship with religious leaders

Promote health education through health facilities as well as private practitioners

Ensure all factions of community are involved including women

Polio immunization efforts through public health education efforts in West Africa. (African Science Academy Development Initiative (ASADI), 2005)

Nigeria faced a major challenge when polio vaccination was stalled in northern areas due to huge negative controversy in local as well international media regarding the safety of these oral medicines. Moreover allot of trusted religious leaders also spoke out against the vaccine.

To fight this drastic loss of acceptance of Oral Polio Vaccine (OPV), a strong communication plan was developed with the objective that each child should get OPV drops.This was achieved through heightened advocacy through large scale public flag offs of campaigns, direct involvement of the president, working with the private companies including telecom companies, and engagement of religious as well as community networks.

To focus on community education community mobilizers were assigned to high risk area, traditional media like street theatre, town criers, mobile cinema and folk songs were utilized. Mass media like TV spots and radio jingles were also integrated

Effective use of Media for behaviour change was used. This included broadcasting in national languages, special programs for minority groups, projection of human interest stories to create positive dialogue, folk media, community theatre and mobile cinema followed by dialogue.

Success of this campaign can be determined by the fact that the demand for immunization and OPV drops substantially increased. The OPV controversy was effectively resolved, along with support from key stake holders.

Learning:

Behaviour Change through public education and integrated mass and traditional campaigns can effectively result in more demand and acceptance of polio immunization.

Health communication efforts for Polio: India

Reducing resistance and increasing community dialogue: Meerut, Uttar Pradesh (United Nations Children’s Fund (UNICEF) India, 2007)

Meerut is one of the regions of Uttar -Pradesh which is seen as high risk for the polio endemic. A highly innovative social mobilization campaign was implemented in Meerut, which involved:

Use of distinct influencers; Three teams of 35 Urdu teachers,24 kirana store owners and Haji’s (people who have completed Haj pilgrimage )were involved in these teams.

Close to 25,000 primary schools were approached on republic day, to educate the children, inform them of the dates of immunisation so that better participation is achieved.

Mosques were approached to educate the community. Their participation increase from 61% in January 2007 to 74% in February 2007.

Meetings on a regular basis were conducted with mothers and daughter in laws, to discuss polio and child health issues.

Booklets were published which contained poems written by local influential poets. These boosted the morale of health workers and also worked as strong advocacy measure.

Due to these innovative techniques Meerut recorded the lowest no. of resistant households in Uttar Pradesh in 2007.

Learning:

Polio needs to be incorporated as a part of overall child health program .

Consistent, open and on-going dialogue with all factions of community is necessary.

Use of innovative techniques to create interest: Polio Joker (Kher, 2007)

Brihanmumbai Municipal Corporation (BMC), hired Manchanda Jha to dress up as a joker and attract kids to polio booths .He sings songs about polio, does tricks, engages children and gives information about the importance of polio drops alongside.When dances and sings “Chal chale polio boothpe hum sathiyoon, chalke do boondh jeevan ke le sathiyon” the children are not only humoured but also an important message has been delivered.

He became so successful that he came to be called “Polio Joker” popularly. He has been instrumental in reaching out to care-givers and kids in slum areas. This program was implemented for three years and has very high recall value.

Learning:

New entertaining techniques need to be implemented if communication has to reach children

Communication methods should be tailored to meet the needs of high risk areas.

Rationale of the research

Health status of a country is influenced by a number of factors like food, water, income, sanitation, education and accessibility to health care services. Health communication campaigns and health services don’t exist in a vacuum but are influenced by external socio-economic, cultural and factors.

These factors play an important part on how health information education and communication campaigns are designed, implemented and finally received by the target audience.

These factors also influence policies, resource allocation, technology, training of medical staff and communication strategies used. These in turn shape the health services system of a particular region.

Studies which have documented the health communication efforts have restricted themselves to an analysis at national level. It will be not surprising to find that in a complex nation like India various sub-systems exist, and every sub-system might influence the message in its own way.

HIV AIDS and Polio are two major health concerns faced by Indian population. On-going and consistent efforts are made to educate people regarding these. However again within a geographic sub-system people might react and respond both these campaigns in a differential manner owing to a variety of factors like sensitivity of the issue, complexity of the message and stigma.

Through this study I wish to explore these factors which affect the impact of health communication campaigns of HIV Aids and Polio, in a geographic sub-system.

Research Objectives:

Through the analysis of the literature review and recommendation of my guide the following research objectives have been identified:

To understand the health communication processes and initiatives undertaken for HIV Aids and Polio prevention/care at a sub-system, grass root level.

To identify factors which lead to an differential impact of these health communication campaigns

To suggest improvements ,if possible, to current health communication practices followed in the geographic sub-system

Research Areas:

Health communication campaigns which will be studied extensively are:

Against HIV-Aids:

These will include the communication efforts in the area of prevention (transmission through mother to child, sexual transmission and primary prevention) and against stigma.

Against Pulse Polio:

Campaigns for polio education and routine immunisation will be studied.

This study aims to understand the use of traditional media, electronic and human channel employed at the grass root level. What are the problems faced in implementation, what are the intermediary factors which affect them, and what measures are taken to combat these problems.

An evaluation of these campaigns will also be conducted based on how much has the target audience been receptive to them, and responded by either positive action or behaviour change.

Ultimately both these campaigns will be compared and contrasted to arrive at the differentiating factors which impact the outcome of these.

Research Methodology:

Phase One

An extensive secondary research will be done to establish a foundation for the primary research.

The literature review provides certain learning about different methods of strategic health communication. This learning will be taken forward to secondary research where the focus will be kept on the grass root health communication initiatives undertaken in the chosen sub-system.

In addition a case study method will be employed to shape up the key focus areas for the primary research.

Phase two

This phase will consist of primary research will be essentially qualitative and exploratory in nature. The purpose of this type of research methodology is to generate basic knowledge on relevant areas, discover associated factors, and identify information gaps.

Data collection and Analysis:

Secondary research will consist of data collection from online sources, medical and communication journals as well as reports.

Various performance reports and internal documents which are generated at the primary sub-system level will also be looked into gather data.

Expert In-depth interviews will be conducted to gain more understanding on the subject. It is important to note that the interviews will be open -ended and flexible to generate maximum insights.

These interviews will involve extensive probing and will utilize the technique of laddering, An interview guideline will however be prepared for a comprehensive and systematic execution.

Similar technique of in-depth interviews will also be employed to collect information from target audience regarding the appeal of the campaigns.

The reason why in-depth-interviews will be used over other methods of data collection is:

It is flexible

It provides in-depth information about areas to be covered

Since the area of study is very specialised it provides scope for clarification

Some of the issues which needs to be discussed are personal in nature, a face to face and private discussion is necessary

Like other techniques, this tool also suffers from certain limitations. It is prone to bias and

largely depend on the skill of the interviewer. It is an expensive technique, can be time

consuming and responses may be difficult to interpret. The structure of the interview is not

clearly defined unlike a survey and so same questions may not be asked to all the respondents

Area of Study:

The chosen geographical sub-system for the primary research is Aligarh in UP. The reasons behind this are the following:

Northern UP has a relatively high prevalence rate of HIV AIDS

It’s one of the few areas in India which is still Polio Endemic

Familiarity with the local language

Initial contacts are available

Timeframe of the study:

Phase one-: November till mid-December 2009

Phase two/primary research: Mid December to January 2010

Sampling:

Sampling universe consists of all the experts in the area of the study, and the population to which the health communication campaigns are targeted.

The sampling technique would be Purposive Sampling. This is because it is difficult to obtain appointments and approach the working professionals and experts in this field. It will also be more convenient and inexpensive because I am the only one involved in the study and selection. This technique is non random and most appropriate because I need to interview the experts in the field to fulfil the research objective. Here the interviewers will become the key to shaping up the research. These would be the people directly or indirectly connected to the research areas taken up for study.

Further to approach the experts the Snowballing technique will be employed. Snowball sampling uses recommendations to find people with the specific range of skills that has been determined as

being useful, as such, snowball sampling aims to make use of community knowledge about those who have skills or information in particular areas .Therefore this method will help me in identifying interested and knowledgeable professionals required for my study. These participants would then be asked for referrals based on their contacts already established.

Why it is being used over any other technique?

Convenient and easy method

Increases the number of participants in process.

Builds on resources of existing networks

The technique has its own disadvantages too. It is not free from bias because the selected participants may not be representative of the population.

Sample size and Limitations

At least 10 expert (medical and field officers) and 30 beneficiary (of the campaigns currently being implemented) interviews in total will be conducted to obtain their views, opinions and beliefs on the subject under study.

The sampling unit would be individual because the method of research involves in-depth

interviews.

The primary research will be limited to the geographical area of Aligarh, U.P; however the leanings can be extrapolated for cases with similar socio-economic and cultural factors.

Analysis

In depth interview is a data collection technique and provides a basis for future research areas.

Therefore, the data collected through interviews will be organized to arrive at some sort of an

understanding of the field. The data collected will be analysed to develop a comprehensive review of the health communication activities under-taken in Aligarh,U.P.Further on both these campaigns will be developed as cases to be compared and analysed. Finally underlying factors and insights will be generated to fulfil the research objectives.