HIV/AIDS behavior change communication for adolescents in developing nations

Innovation Study

HIV / AIDS Behavior Change Communication (BCC) for adolescents in developing nations

Statistics (UNFPA, 2003) indicate that 70% of over a million children ranging between 10-19 years live in developing nations. Increase in the need for formal education, computer technology and knowledge of the internet, media exposure to new ideas, different employment opportunities and telecommunication mark the major differences between the modern children and their parents. There is also a remarkable change in the environment in which young people make decisions related to sexual and reproductive health. The initial age that the young people learn about sex during adolescence is also on the rise as many learn more at younger ages (Ali & Cleland, 2005; Gupta & Mahy, 2003), with the concept of childbearing closely disassociated with getting married (Bearinger, Sieving, Ferguson & Sharma, 2007).

Almost every country in the Sub-Saharan Africa suffers from the epidemic of AIDS, with early sexual activity ranking top on the risk factors that has led to the widespread of HIV (Pettifor et al., 2004).

The spread of HIV among adolescents in Sub-Saharan Africa is ranked top compared to any other part of the world (Joint United Nations Program on HIV / AIDS, 2004), with young people accounting for close to two-thirds of the population. Programs that are taught in school have proven to be of great impact on the youth regarding their choice for sexual and reproductive health education because they obtain at least some form of education (United Nations Department of Economic, 2008). Despite this positive development, latest reviews on the interventions of HIV programs taught in school have on the other hand proven to have mixed results on the population (Paul-Ebhohimhem, Poobalan & Van Teijlingen, 2008; Kirby, Laris & Rolleri, 2007).

Adolescents who do not attend school, however, miss out on such interventions. Regulations that are ideologically driven have additionally prevented interventions on sexual and reproductive health lag behind (Cleland & Ali, 2006). The limitation that comes about because of lack of money has made many countries shift their attention to community-based programs on HIV prevention as opposed to sexual and reproductive health. Another major way that sexual and reproductive health can be taught is through the guidance of parents that they give to their children.

This avenue is however a bit inconvenient because the same parents never received any form of knowledge from their own parents or teachers, a situation that has rendered them incapable of passing that same knowledge to their children.

All over the world, different programs have been on the front line to provide possible solutions to the sexual and reproductive health needs of adolescents. This is because it is the adolescents in the present time that will give way to the social, economic, sexual and reproductive health and overall well-being of all nations worldwide in the coming years.

The context of the rapidly evolving world provides need for the correspondence between communications and other interventions meant to improve the sexual and reproductive health of adolescents (Hindin & Fatusi, 2009). In dealing with adolescents in developing countries, donors, partners, collaborators and potential collaborators have managed to develop the use of the HIV / AIDS strategy as documented by the Behavior Change Communication document below.

Behavior Change Communication (BCC)

BCC is an inclusive process with communities that help come up with approaches that develop positive behaviors, increase individual well-being, change of community and societal behaviors and maintain good behaviors. In relation to the AIDS epidemic, BCC is a vital part in providing services like medical, social, psychological and spiritual, and commodities like condoms, needles and syringes. For successful behavior changes, there is a need to understand HIV facts, change attitude, and access required services for prevention, perceive the environment as promoting change and maintaining safe behavior.

The community needs to give an appropriate environment to discuss relationship, sex and sexuality, risks and risk behaviors and cultural practices that promote transmission as opposed to the notion that HIV is only a sexually transmitted infection. The environment should also provide support for reducing stigma, discrimination, and law / policies as well.

Cultural practices and ideologies that promote transmission should also be eradicated because of the epidemic. A wider socioeconomic impact of the epidemic should mobilize the program politically, socially, economically and provide responsible interventions to the program.

Role of behavior change communication

For a broad prevention, care and support of the HIV / AIDS program, BCC is a very necessary aspect that needs to be put into consideration. An effective BCC has many different but equally related roles too:

Make sure that people receive the basic conceptual facts concerning HIV / AIDS that they easily understand in a language they are familiar with to increase knowledge.

With the help of BCC, community and national discussions are made possible. Once the dialogue is stimulated, various facts about HIV / AIDS are discussed, factors (risk behaviors and risk settings) (e.g. The use of drugs) that contribute to the spread are also talked about, environments and cultural practices that create the conditions are put to the table as well. Various ways of prevention, care and support are also made known in the process of the discussion.

Teaching and reinforcing of new skills and behaviors that encourage improvement skills for self-efficiency is also covered by BCC. A sense of confidence when making and acting on decisions is made possible for instance the use of condoms, negotiating after sex and practices of safe injections.

With BCC, individuals and communities are made bold so as to demand for information about HIV / AIDS and other related services of the same.

Once BCC is done, the risk of stigma and discrimination is made possible. Communication about HIV prevention and reduction of AIDS should seek to address the problem of stigma and discrimination and also try to influence how the society responds to them as well.

Attitude change is also a factor that is covered under the BCC. How one perceives the risk of HIV infection, how they believe and access their rights and responsibility, how they adopt the use of safe practices, broadening their mindsets about the infected and affected population and carrying out the provision of services without judgmental attitude can all be changed by BCC.

BCC is also capable of promoting services for STIs, orphans and vulnerable children (OVCs), voluntary counseling and testing (VCT), support groups for people living with AIDS, intravenous drug users (IDUs) and prevention of mother to child transfer (MTCT).

Framework for BCC Design as a Process of Changing Behavior

Behavior change theories serve as the basis of the development of BCC dating from the past years. Its foundation holds a lot of worth to use in coming up with a well elaborated communication strategies and programs, e.g. The Diffusion of Innovations model by Everett Rogers. The process of behavior change involves many steps for individuals, community, or institution that goes through it.

Such steps include moving ahead, backwards or even skipping others at times. There are certain instances when the individual, community and the institution may go back to their old behaviors as much as they have taken into use the new behaviors.

Different avenues have proven effective at different stages for achieving different goals, with that same reason is vital to understand where majority lie in the change process when designing a BCC strategy. Communication is vital to ensure the right information is received by a target population for positive attitude response.

The policies of the wider social environment on the contrary become more important when an individual or community is driven towards trying out new behaviors. The availability of the activities, services or products for promotion is a must-have when the target population is ready for change.

The main goal of the program is to reduce the prevalence of HIV among adolescents in developing countries.

Behavior change goals include the increase of condom use, delay first-time sexual performance, reduce the number of partners, and increase STI behavior when in need of care.

Among the goals of BCC include increasing the demand for services and information about HIV, promote the manner in which communities accept youth sexuality and value reproductive health, change attitude about condom use and gain the interest of policy makers to invest in youth-friendly VCT services.

The above mentioned BCC goals relate to particular issues that have been identified during the process of assessing the situation, knowledge, attitudes and skills that require change in order to achieve behavior change and goals related to the program.

Target population

The world record of the total number of people under 18 years stands at 2 billion; a number that makes up half the population in developing countries and below a quarter of the developed ones. They suffer from basic survival to discrimination and being exploited as major challenges. In as much as children worldwide have similar traits, optimism, open mindedness and curiosity being their strength, which is the one thing that they beat adults with.

Children in different countries dare to challenge social and health problems for instance, poverty, ethnicity substance abuse, political instability and sexually transmitted diseases; a challenge that has not prevented them from enjoying their freedom (Gigli, 2006).

With the changing technology by the day, the younger generation is increasingly getting absorbed into this new culture. With information shared globally through the social networks at the press of a button, these young adults have all the information at their fingertips. The innovation of the mobile phone made things even much easier. Being young and curious about the changes in their bodies, the teenagers will seek any information regarding their sexuality. Most of the times the information available on the internet is a total contradiction of the traditional values and practices; as a matter of fact, this leads to conflict of interest between the older generation and the younger generation. From schooling, employment and sexual and reproductive choices, the decision making would experience a lot of defiance. Through their adolescent stage, boys and girls are usually at a very critical stage whereby the environment they are exposed to determines a lot about their behavior. It could either affect them positively or negatively.

Ensuring that the environment the adolescents are exposed to is accommodating will be a better way of influencing their character than feeding them a lot of knowledge. The other way would be to establish protective measures such as making school mandatory for the adolescents and making sure that they are safe. In order not to feel like caged birds, the school system should incorporate their aspirations and needs and work towards meeting them. (World Health Organization, 2011).

BCC adoption of Diffusion of Innovations model

Rodgers defined diffusion as "the process through which an innovation is relayed through certain channels over a given time between members of a social system." From this definition we get to realize that main element of diffusion of innovations are the social system, communication channels, time and innovation.

Innovation

Innovation is further broken down and described as "an idea, project or practice that is seen to be new by an individual or other unit of adoption (Rogers, 2003, p. 12)." Sometimes the innovation might have been discovered years ago, but if the individuals have just realized it then for them it qualifies as an innovation. Most innovations are never adopted due to the barrier known as uncertainty. This can be overcome through detailing all the positivity and negativity of the innovation so that a person is well aware of the consequences that may come about once the innovation is adopted

Communication Channel

Communication is the second element and is thus described as "a process through which information is created and shared by participants to enable them to come to a common understanding." Various channels such as mass media and interpersonal communication are useful in passing across the message. For the mass media, the information is passed to a large number of audiences. Types of mass mediums include radio, TV and Newspaper. The interpersonal communication on the other hand is a two way communication of two or more people. Rodgers then goes ahead and describes diffusion as "a social process that entails a lot of interpersonal communication relationships"(Rogers, 2003, p. 19). What this means is that out of the two communication channels, interpersonal stands to be a better choice when seeking to change or influence people's attitudes.

Time

The time factor is one very important aspect when conducting behavioral research, but unfortunately, it is often left out. Inclusion of the time dimension in the adopter categorization, innovation-diffusion process and rate of adoptions will give them more credit.

Social System

Lastly, the social system is defined as "a number of units that co-relate coming together to solve a mutual problem in order to achieve a common purpose" (p.23).Therefore, the fact that the social system is like the stage where diffusion of innovation takes place, its social structure greatly influences the outcome of the diffusion of innovations.

This theory about the diffusion of innovation is a good principle guideline in the world of technological innovation whereby modification of the innovation will be in such a way that it will be able to cater for the needs of all adopters across all levels. The significance of peer communication and networking among peers is also looked into at great lengths during the adoption process. The diffusion of innovation can simply be described as the process that takes place when individuals take on a new concept, philosophy, product etc.

During the initial stages an idea is never readily adopted by the masses. You will find a very small percentage that would adopt the idea and then with time after they enlighten others who are close to them, the chain grows until more people embrace it. The adoption of the idea by new individuals will steadily rise until it reaches a saturation point. Rodgers then goes ahead to break down the categories of innovation adopters into five distinct groups as follows: the innovators, the early adopters, early minority, early majority and lastly the laggards. Then non-adopters are sometimes listed as the sixth group (Kaminski, 2011).

These five categories can also be explained in relation to the influence of technological advancements on the innovative and adoption process. In this context, the aim would be to restructure the innovation in line with the requirement of the five categories (Kaminski, 2011).

Expected outcome

Reduction in resource wastage and improved service delivery and healthcare outcomes are just some of the positives that will come when people get to invest in beneficial initiatives. One of the beneficial initiatives is that of involving the youth to be part of the change in issues that relate to them or their lifestyle. They are the very important ingredient that is lacking for the recipe to be complete.

For the effective achievement of the MDG goals that are associated with maternal and newborn health (MNH), Sexual and Reproductive Health and Rights (SRHR), and family planning (FP) issues, the young people are needed to be on an a very active capacity especially the ones that are capable of reaching out to a large audience. This is the most appropriate way to getting positive results for MDGs 4, 5 and 6 (reducing child mortality, improving maternal health, and combating HIV / AIDS, malaria, and other diseases respectively) and also MDG 3 (promoting gender equality and empowering women) (Olagunju, 2014).

By engaging the youth more often and ensuring that they participate actively in programs such as the SRHR, you stand to reach a wider youth audience. This is very beneficial since the matters at hand affect the young people on a first hand basis. Using of media that is easily accessed by youths across all levels, such as the radio is also another way by which information about SRHR can be passed effectively. A number of youths aged between 14 years and 25 years lack proper and accurate information to lead them in making better choices concerning their sex life. The information will be able to reach the youths effectively when you equip some of their own and give them the information so that they can share it out. It is more like enabling the young people to enable themselves. In the developing world, the population aged below 24 years takes close to 50% of the total population and the number is expected to shoot up in the next two decades. Unfortunately, close to 6,000 youths get infected with HIV every single day due to lack of SRHR knowledge. Women form the largest percentage of those being infected. It is therefore important that the young people have a seat at the table when policies are being formulated so that they can advise accordingly on how to make the services youth-friendly. Out of the 100 million new infections of sexually transmitted diseases recorded every year, the youth accounts for the largest percentage. As a result, proper measures should be set up to educate the young people to avoid these infections since a large youth population has immense benefits to a society. Their contribution from the front line surpasses what they could achieve from the back seat. Getting more for less and being able to save time in the process is what you will achieve when the young people are made to be part of the great change on matters that touch on their lives (Olagunju, 2014).

As is the case with the many other youth-centered HIV programs, the communication program will work in exactly the same way whereby services are relayed through multidisciplinary teams that usually involves outreach workers. For services that may involve case management or integrated clinical settings, the multidisciplinary teams will incorporate individualized care plans through which short- and long-term needs get addressed in depth. In a decentralized system setting, the HIV care services will be separate but related. For both the systems, the youth are actively involved together with their family members and the individuals concerned with the setting up of the care plans.

Use of Diffusion of Innovation (DOI) as a Framework for HIV / AIDS Prevention

Ever since the first diagnosis of HIV / AIDS to the present day, there exists no single theory that acts as a blue print in developing prevention programs. This is where the Diffusion of Innovation (DOI) comes in. The fact that it relates pretty well to the social theories and the model category, it can serve quite well in dealing with the HIV / AIDS calamity. This has been proven to work with a case in point being San Francisco in the United States. The STOP AIDS San Francisco is said to be one of the most effective HIV / AIDS prevention programs to this very day. According to DOI, for the program to work, it needs early adopters who will start a relatively new behavior that would then be adopted by the rest of the population. In the case of the STOP AIDS program, a highly ranked member of the society who happened to be seropositive took the task of being the early adopter. He would give information regarding how the virus is passed from one person to the other and advised the attendees who were mainly fellow gay and bi-sexual men to either stick to a monogamous relationship or use a condom. When concluding, the participants would make a pledge to safe sex and that they would volunteer in organizing and leading futures meetings.

With the help of the media, the small group meetings got a wide coverage and reached many people hence increasing the awareness and spread of knowledge on HIV / AIDS among the gay people. By mid-1980s the rate of new infections had dropped significantly and so did the number of attendants in the STOP AIDS meetings. This meant that the program had successfully reached the critical mass of early adopters of safer sex. As a result, in 1987 the program stopped its local operation. They opened up again in the year 1990 due to the migration of younger gay men into the city. With its success, the STOP AIDS in San Francisco program proved without a shadow of doubt that DOI can be used effectively to deal with HIV / AIDS. Other notable factors that helped DOI include the epidemiological concept that targeted a group that posed a high risk of spreading the disease, the fact that the gay men were educated and had the community's well being at heart and lastly the media coverage. Unlike the developing countries that usually have multiple problems to tackle in one go, the San Francisco case was highly successful because they had only one problem at hand and they put all their energy and will to do away with it before it spread out (Bertrand, 2004).

Various consequences of using DOI

In the developing countries the use of the DOI theory as a reliable means to prevent the spread of HIV / AIDS is still an alien topic. This is owing to the fact that majority of literature on HIV / AIDS in developing nations does not conform to this. There are a number of explanations for this. DOI is mainly a theory based on the society whereby it deals with the social networks, norms and roles to explain certain behaviors. The second explanation follows that DOI purpose and behavior sequencing will play a major role for it to succeed. The San Francisco case turned out to be the success that it was because the message of adopting safe sex was diffused effectively through the highly educated men. It will therefore become very hard for DOI to achieve as much success in other models of society that are not similar to those of the western world. In these countries, sexual behaviors are often considered irrational whereby the best of intentions would stand no chance in the face of sexual arousal and emotions and especially if fear of violence and drugs are involved.

Third is the fact that the structural and environmental factors play a major role in influencing sexual behavior. An example is the case where girls from poor families engage in prostitution so that they can sustain their personal needs and the needs of their families too. Fourth is the culture of the people that could either be a barrier or facilitator in curbing the plague. A case in point is the role of women in that given society whereby an inferior status makes the women to be vulnerable to HIV / AIDS infection. Number five is, innovation-decision process stagnates when another situation crops up. For instance, when anti-retroviral drugs were introduced into the market. This led majority of young gay men to overlook the preventive behaviors and started engaging in risky behaviors.

To summarize everything we acknowledge that HIV / AIDS preventive interventions outline the circumstances under which change in behavior is very important. This is well outlined by Rogers through his DOI basic elements, which would be stated as; an innovation, communicated via certain channels, over a period, to members of a social system. Some of these factors have proven to be very invaluable in many preventive initiatives launched in different countries across the globe. However, the lack of extensive elaboration on DOI in the literature on HIV / AIDS prevention in developing countries could be attributed to the fact that it only recognizes the context but offers no follow up on guidance by which cultural, social and economic obstacle can be solved. With time, use of DOI is likely to make a comeback in the fighting HIV / AIDS as the prevention measures shift slowly from focusing on personal behavior to the significance of social norms in influencing sexual behavior (Bertrand, 2004).