HIV/AIDS Behavior Change Communication for Adolescents

Introduction

Statistics (UNFPA, 2003) indicate that 70% of the more than one billion children between the ages of 10 and 19 live in developing nations. The major differences between today's children and their parents include increased access to formal education, computer technology, the internet, media exposure to new ideas, varied employment opportunities, and expanding telecommunications. There has also been a remarkable change in the environment in which young people make decisions related to sexual and reproductive health. The age at which young people first learn about sex is declining, with many learning more at younger ages (Ali & Cleland, 2005; Gupta & Mahy, 2003), while the concept of childbearing has become increasingly dissociated from marriage (Bearinger, Sieving, Ferguson & Sharma, 2007).

Almost every country in Sub-Saharan Africa suffers from the AIDS epidemic, with early sexual activity ranking as one of the leading risk factors driving the widespread transmission of HIV (Pettifor et al., 2004). The spread of HIV among adolescents in Sub-Saharan Africa is higher than in any other region of the world (Joint United Nations Programme on HIV/AIDS, 2004), with young people accounting for close to two-thirds of the affected population. School-based programs have proven to have significant positive impact on youth sexual and reproductive health decision-making, because they reach at least some portion of the adolescent population (United Nations Department of Economic, 2008). Despite this positive development, recent reviews of school-based HIV interventions have shown mixed results (Paul-Ebhohimhem, Poobalan & Van Teijlingen, 2008; Kirby, Laris & Rolleri, 2007).

Adolescents who do not attend school, however, miss out on such interventions entirely. Ideologically driven regulations have further hampered progress in sexual and reproductive health interventions (Cleland & Ali, 2006). Financial limitations have caused many countries to shift their focus toward community-based HIV prevention programs rather than broader sexual and reproductive health education. Parental guidance represents another avenue for sexual and reproductive health education, yet many parents never received such knowledge themselves, leaving them ill-equipped to pass it on to their children.

Programs around the world have therefore been at the forefront of providing solutions to the sexual and reproductive health needs of adolescents. It is today's adolescents who will determine the social, economic, and health well-being of all nations in the years ahead. The rapidly evolving global context makes it essential that communications and other interventions align to improve adolescent sexual and reproductive health (Hindin & Fatusi, 2009). In addressing adolescents in developing countries, donors, partners, and collaborators have developed the HIV/AIDS Behavior Change Communication (BCC) strategy described in this paper.

Behavior Change Communication (BCC) Overview

Behavior Change Communication (BCC) is an inclusive, community-based process aimed at developing positive behaviors, increasing individual well-being, shifting community and societal behaviors, and sustaining healthy practices. In relation to the AIDS epidemic, BCC is a vital complement to services such as medical, social, psychological, and spiritual support, as well as commodities like condoms, needles, and syringes. For successful behavior change, individuals need access to accurate HIV information, attitude transformation, required prevention services, and an environment that supports and sustains safe behavior.

Communities need to create appropriate environments to discuss relationships, sex and sexuality, risk behaviors, and cultural practices that facilitate transmission — moving beyond the limited notion that HIV is exclusively a sexually transmitted infection. Such environments must also support the reduction of stigma and discrimination, and advocate for enabling laws and policies.

Cultural practices and ideologies that facilitate transmission must be addressed because of the scale of the epidemic. Mobilizing political, social, and economic actors to respond responsibly is a necessary part of any comprehensive BCC program.

Roles of Behavior Change Communication

BCC plays several distinct but interconnected roles in the broader effort to prevent HIV/AIDS and support those affected:

Increasing knowledge: BCC ensures that people receive fundamental, accurate facts about HIV/AIDS in a language they understand.

Stimulating dialogue: BCC facilitates community and national discussions about HIV/AIDS facts, contributing risk behaviors and settings (such as drug use), environmental and cultural conditions that create risk, and available methods of prevention, care, and support.

Building skills: BCC teaches and reinforces new behaviors and skills that build self-efficacy — including confident decision-making about condom use, negotiating safer sex, and practicing safe injection.

Empowering demand: BCC emboldens individuals and communities to demand information and services related to HIV/AIDS.

Reducing stigma and discrimination: Effective BCC addresses stigma directly and works to influence how society responds to those living with or affected by HIV/AIDS.

Changing attitudes: BCC can reshape how people perceive their risk of HIV infection, how they understand and exercise their rights and responsibilities, how they adopt safer practices, how they broaden their perspective toward those infected or affected, and how service providers approach their work without judgment.

Promoting related services: BCC actively promotes services for sexually transmitted infections (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 transmission (MTCT).

BCC Goals

The overarching goal of the program is to reduce the prevalence of HIV among adolescents in developing countries. Behavior change goals include increasing condom use, delaying sexual debut, reducing the number of sexual partners, and increasing uptake of STI care. BCC-specific goals include increasing demand for HIV information and services, promoting community acceptance of youth sexuality and reproductive health, changing attitudes toward condom use, and engaging policymakers to invest in youth-friendly VCT services. These BCC goals correspond to specific needs identified through situation assessments and analyses of the knowledge, attitudes, and skills that must change in order to achieve the program's broader objectives.

Framework for BCC Design and the Diffusion of Innovations Model

Behavior change theories form the foundation of BCC program development. One particularly influential framework is the Diffusion of Innovations model developed by Everett Rogers. The process of behavior change involves multiple steps for individuals, communities, and institutions — steps that may move forward, backward, or be skipped entirely. Individuals and communities may revert to old behaviors even after adopting new ones.

Different channels and approaches prove effective at different stages of the change process, making it essential to understand where the majority of the target population sits on the change continuum when designing a BCC strategy. Communication is critical for ensuring that the right information reaches a target population and generates a positive attitudinal response. Supportive social environment policies become more important once individuals or communities move toward trying new behaviors. The availability of the activities, services, or products being promoted is essential once the target population is ready to act.

Rogers' Diffusion of Innovations: Core Elements

Rogers defined diffusion as "the process through which an innovation is relayed through certain channels over a given time between members of a social system." The four core elements of diffusion of innovations are: innovation, communication channels, time, and the social system.

Innovation is described as "an idea, project, or practice that is seen as new by an individual or other unit of adoption" (Rogers, 2003, p. 12). Even if an innovation was discovered years ago, it qualifies as an innovation for those encountering it for the first time. A key barrier to adoption is uncertainty, which can be reduced by clearly communicating both the benefits and the potential drawbacks of the innovation so that individuals can make informed decisions.

Communication Channel refers to "a process through which information is created and shared by participants to reach a common understanding." Mass media channels — including radio, television, and newspapers — can reach large audiences rapidly. Interpersonal communication, by contrast, is a two-way exchange between two or more people. Rogers describes diffusion as "a social process that entails a lot of interpersonal communication relationships" (Rogers, 2003, p. 19), suggesting that interpersonal channels are more effective than mass media when the goal is to change or influence attitudes.

Time is a critical but frequently overlooked dimension in behavioral research. Incorporating a time dimension into adopter categorization, the innovation-diffusion process, and rate-of-adoption analyses strengthens the analytical rigor of any program.

Social System is defined as "a number of units that interrelate to solve a mutual problem in order to achieve a common purpose" (Rogers, 2003, p. 23). Because the social system serves as the stage on which diffusion takes place, its social structure significantly influences how and whether an innovation spreads.

Rogers further categorizes adopters of innovations into five groups: innovators, early adopters, early minority, early majority, and laggards. Non-adopters are sometimes listed as a sixth group (Kaminski, 2011). During the initial stages of diffusion, only a small percentage of people adopt a new idea; as early adopters share it with others, the chain grows until a saturation point is reached.

Peer Networks

Peer networks are essential within the Diffusion of Innovations framework. They constitute the critical mass reached after the influence of early adopters and innovators has taken hold. Innovators and early adopters, acting as opinion leaders and change agents, persuade their peers through networking, peer-to-peer communication, and role modeling. The use of opinion leaders in social media, for example, illustrates how this process operates in contemporary contexts (Kaminski, 2011).