Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries

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1 HEALTH EDUCATION RESEARCH Vol.21 no Theory & Practice Pages Avance Access publication 17 July 2006 Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-relate behaviors in eveloping countries Jane T. Bertran 1 *, Kevin O Reilly 2, Julie Denison 3, Rebecca Anhang 4 an Michael Sweat 3 Abstract This review systematically examine the effectiveness of 24 mass meia interventions on changing human immunoeficiency virus (HIV)- relate knowlege, attitues an behaviors. The intervention stuies were publishe from 1990 through 2004, reporte ata from eveloping countries an compare outcomes using (i) pre- an post-intervention ata, (ii) treatment versus control (comparison) groups or (iii) postintervention ata across levels of exposure. The most frequently reporte outcomes were conom use (17 stuies) an knowlege of moes of HIV transmission (15), followe by reuction in high-risk sexual behavior (eight), perceive risk of contracting HIV/acquire immunoeficiency synrome (AIDS) (six), interpersonal communication about AIDS or conom use (six), selfefficacy to negotiate conom use (four) an abstaining from sexual relations (three). The results yiele mixe results, an where statistically significant, the effect size was small to moerate (in some cases as low as 1-2% point increase). On two of the seven outcomes, at least 1 Johns Hopkins University, Bloomberg School of Public Health, Center for Communication Programs, Baltimore, MD 21202, USA, 2 Department of HIV/AIDS, The Worl Health Organization, Geneva, Switzerlan, 3 Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21202, USA an 4 PhD Program in Health Policy, Harvar University, Cambrige, MA 02138, USA *Corresponence to: J. T. Bertran. jbertran@jhuccp.org half of the stuies i show a positive impact of the mass meia: knowlege of HIV transmission an reuction in high-risk sexual behavior. Further rigorous evaluation on comprehensive programs is require to provie a more efinitive answer to the question of meia effects on HIV/ AIDS-relate behavior in eveloping countries. Introuction The mass meia have playe a visible role in the human immunoeficiency virus (HIV)/acquire immunoeficiency synrome (AIDS) epiemic in eveloping countries since its onset in the early 1980s [1, 2]. Although many enie or minimize the importance of HIV/AIDS in the early ays of the epiemic, almost all countries in the eveloping worl use some form of mass communication to aress the issue [2, 3]. Early on, these efforts focuse on raising awareness of the existence of HIV/AIDS, the moes of transmission an the means of prevention. These efforts met with consierable success in raising awareness: in most countries, >90% of the population know the basic facts about HIV/AIDS [4]. The secon generation of communication programs in the late 1980s an throughout the 1990s tene to focus more specifically on behavioral change relate to abstinence, limiting one s number of sexual partners, an using conoms. In recent years, communication programs have expane to aress the full continuum from prevention to treatment to care an support [5]. Most of the mass meia campaigns to ate have focuse on members of the general Ó 2006 The Author(s). oi: /her/cyl036 This is an Open Access article istribute uner the terms of the Creative Commons Attribution Non-Commercial License ( licenses/by-nc/2.0/uk/) which permits unrestricte non-commercial use, istribution, an reprouction in any meium, provie the original work is properly cite.

2 J. T. Bertran et al. public, or more narrowly on youth, but not on other high-risk populations. The purpose of this paper is to review an synthesize the ata from eveloping countries on the effectiveness of mass meia interventions in changing HIV-relate knowlege, attitues an behaviors. Mass meia interventions are any programs or other planne efforts that isseminate messages to prouce awareness or behavior change among an intene population through channels that reach a broa auience. These channels inclue raio, television (TV), vieo, print an the Internet, an can take ifferent forms such as raio variety shows, songs, spots, soap operas, music vieos, films, pamphlets, billboars, posters an interactive Web sites. In the analysis, we have istinguishe between broacast interventions, which inclue raio an/or TV, thus having the potential to reach a national auience, an small meia with more local reach (e.g. posters, pamphlets, auio programming, ramas an puppet shows). The latter ten to be face-to-face, interactive an community-base, with greater involvement of local stakeholers. Some reaers may seek the answer to a relate question: why are some campaigns more effective than others? That is, what elements istinguish goo campaigns from less effective ones? Unfortunately, this question goes beyon the scope of this paper, for reasons iscusse in the final section. Conceptual framework for the effects of mass meia Figure 1 illustrates how communication programs are expecte to change HIV-risk behaviors. Social, cultural, political, legal an economic factors often serve as obstacles to behavior change, though context can also facilitate change in certain circumstances. Within this context, the mass meia are expecte to affect a series of psychosocial factors, incluing knowlege, attitues an selfefficacy. Changes in these factors are hypothesize to influence specific behaviors or practices, the most common of which are abstinence, reuction in number of sexual partners an conom use. In countries in which the primary moe of HIV transmission is through sexual relations, the practice of these behaviors reuces the prevalence of HIV, the health outcome. Program evaluation etermines the egree to which the campaign reaches its objectives; it helps planners an scholars unerstan how or why a particular campaign worke an it provies information relevant for planning future activities [5]. Methoology Inclusion an exclusion criteria After establishing the written efinition an theoretical framework for mass meia, the synthesis team evelope inclusion an exclusion criteria for stuy citations. To be eligible, papers ha to present a mass meia intervention as efine above; employ an evaluation esign that compare outcomes using (i) pre- an post-intervention ata, (ii) treatment versus control (comparison) groups or (iii) post-intervention ata across levels of exposure; be publishe in a peer-reviewe journal from 1990 through 2004; an present ata from a eveloping country, efine as a country bearing the Worl Bank esignation of low-income, lowermile income or upper-mile income economy [6]. Evaluation stuies of conom social marketing campaigns were exclue, as these articles were reviewe in a separate analysis. Search an acquisition Traine staff use these criteria to search for eligible citations. A broa search was first initiate on computer-base search engines incluing the National Library of Meicine s Gateway system, PsycINFO, Sociological Abstracts, EMBASE an the Cumulative Inex to Nursing & Allie Health Literature. We also searche the reference sections of papers that were selecte for inclusion in the review. These new citations were acquire, screene, an if accepte, subjecte to aitional reference searches. The process was iterate until no new papers were ientifie. To supplement the computer atabase searches, we han searche the 568

3 Effectiveness of mass communication programs on HIV/AIDS Fig. 1. Conceptual framework for the effect of communication programs. journals AIDS, AIDS an Behavior, AIDS Care, AIDS Eucation an Prevention an Journal of Health Communication for eligible citations. In aition, we contacte experts in the fiel to review our list of papers, an we solicite any missing references that they recommene. Aitionally, we carefully reviewe the references from previous review papers an meta-analyses for possible citations. Staff ownloae the results from all searches into a atabase system. The Project Principal Investigator (PI) an the Project Coorinator separately reviewe the poole atabase generate by the search staff, an categorize the citations as (i) primary citations qualifying for inclusion in the synthesis; (ii) backgroun citations not qualifying for inclusion but proviing valuable information on mass meia interventions; (iii) citations to be acquire for further inquiry or (iv) not relevant. The separate screene files from the PI an the Coorinator were then merge for comparison; citations with iscorant screening were iscusse to establish consensus (see Fig. 2). Coing Coing was conucte on all primary an backgroun citations. Two inepenent coers extracte etaile information from each primary article using a structure coing form. Extracte ata were transferre to an SPSS statistical atabase (SPSSä, Chicago, IL) for ientification of intercoer iscrepancies. Intercoer resolution was performe by a thir person to correct for ata entry error an to resolve ifferent interpretations of the presentation of results. The stuy rigor of each primary citation was also systematically assesse to etermine whether the stuies coul provie an unbiase quantitative assessment of intervention effectiveness. We assesse the rigor of each primary stuy using an eight-point scale evelope for the project. The scale was aitive, with one point aware for each item. The items were: prospective cohort, control or comparison group, pre-/post-intervention outcome ata, ranom assignment to treatment groups, ranom selection of subjects for intervention an assessments, attrition, comparison group matching, 569

4 J. T. Bertran et al. Potentially relevant abstracts ientifie uring initial computer base search (N=500) Articles retrieve for more etaile evaluation (N=128) Articles meeting eligibility for inclusion in the systematic review (N=24) Abstracts exclue uring screening process for not meeting search criteria (N=372) Articles ientifie as backgroun material (N=77) Articles exclue for not meeting inclusion criteria or backgroun criteria (N=27) Fig. 2. Selection of articles for systematic review. comparison group matching outcome measures an minimum requirements for inclusion in contextual coing (see Table I). Many stuies use several research approaches of iffering rigor; the scoring in Table I reflects the level of rigor with which ata were collecte an analyze for the outcomes reporte here, not necessarily for the overall stuy. Outcomes In an effort to synthesize the results from stuies with iverse outcomes, we selecte a subset of seven variables, three psychosocial factors an four behaviors, for purposes of this review. The seven outcomes are (i) knowlege of HIV transmission; (ii) perceive personal risk of contracting HIV/ AIDS; (iii) self-efficacy to negotiate conom use or protect oneself; (iv) iscussion with others about HIV/AIDS or conom use; (v) abstinence from sexual relations; (vi) reuction in high-risk sexual behavior an (vii) conom use. Within each of the outcome areas outline above, multiple measures were reporte by the stuies uner review. To assess results, we combine ifferent operational efinitions of each outcome an classifie results accoringly (e.g. conom use inclue conom use at last sex, conom use at last sex with a casual partner, conom use with a sex worker, ever use a conom). Results The intensive search of the publishe literature reveale 24 articles that systematically evaluate the effects of mass communication programs on HIV/AIDS-relate knowlege, attitues an behaviors in eveloping countries, an that met the criteria for inclusion (see Table II). Of these 24, five use TV (with supporting meia or alone), seven employe raio (with supporting meia or alone) an the remaining 12 use small meia (with or without interpersonal communication, such as a group meeting or counseling). The majority of the evaluations of mass meia programs publishe from 1990 to 1999 focuse on small meia (10 of 13 stuies). The majority of the evaluations from 2000 onwars (8 of 11) examine programs that use raio or TV, with or without other supporting meia. Thus, we observe an evolution in the types of programs evaluate towar communication programs esigne to reach larger auiences using raio an/or TV. This research represents experiences from aroun the globe, with the largest concentration of stuies from Africa (n = 12), followe by Asia (n = 7) an Latin America an the Caribbean (n = 5). Of the 24, three were publishe uring , nine uring an 12 uring For all but three of the stuies, rigor scores range from 2 to 5 out of a possible 8 points; two stuies score a 1 out of 8, while another feature a highly 570

5 Table I. Quality assessment scores Stuy Cohort Control or comparison group, or outcomes by level of exposure Pre-/postintervention ata Ranom assignment of participants to the intervention Ranom selection of participants for assessment Follow-up rate of >80% Comparison groups equivalent on socio-emographics Comparison groups equivalent at baseline on outcome measure Final quality score (out of 8) 571 TV plus other meia [30] No No Yes No NR NA NR NA 1 [20] No Yes No No Yes NA NA NA 2 [14] Yes Yes Yes No Yes NA No (crosssectional NA 4 groups iffere on age) Before/after analysis [25] No Yes Yes No No NA No NA 2 Post-only exposure analysis [25] No Yes No No No NA No NA 1 TV alone [26] No Yes No No Yes NA NA NA 2 Raio plus other meia [19] No Yes No No Yes NA No NR 2 [10] Yes Yes Yes Yes Yes Yes Yes No 7 Raio alone [18] No Yes No No No NA No NA 1 [15] No Yes Yes No Yes NA NR NR 3 [24] No Yes Yes No Yes NA No NR 3 [27] No No Yes No Yes NA NA NA 2 [12] No Yes Yes No Yes NA No NR 3 Small meia with interpersonal communication [17] No Yes Yes No Yes NA Yes NA 4 [11] Yes No Yes No No No NA NA 2 [9] Yes No Yes Yes Yes Yes NA NA 5 [16] No Yes Yes Yes Yes NA No NR 4 [23] Yes Yes No Yes Yes NA NR NR 4 [22] No No Yes No Yes NA NR NA 2 [21] Yes No Yes NR NR Yes NA NA 3 [33] Yes Yes Yes No NR No No NR 3 Small meia alone [13] No Yes Yes Yes Yes NA NR NR 4 [34] Yes No Yes No No NR NA NA 2 [8] No No Yes No Yes NA NA NA 2 [7] Yes Yes Yes No Yes NR No NA 4 Quality assessment scores were calculate for those outcomes reporte in this synthesis. Other outcomes not reporte in this synthesis may have been subject to higher or lower levels of rigor. Effectiveness of mass communication programs on HIV/AIDS

6 572 Table II. Description of interventions an evaluation stuy esigns Author(s) Description of intervention Description of evaluation Setting an target group Overview Entertainment eucation? Theoretical basis Primary objectives Duration of campaign Nationwie campaign? Reach an frequency Stuy esign Sample characteristics J. T. Bertran et al. TV plus other meia [30] Haiti, general population [20] South Africa, junior seconary school learners The AIDS prevention effort consiste of raio an TV messages, billboars, faceto-face contact an conom promotion Soul City programs inclue: Soul City TVs an raio programs incluing a weekly rama that covers a range of health issues an isseminates basic information about the epiemic an its consequences (an ault program); Soul buyz TV (a chilren s program), newspaper materials in the form of health eucation booklets an a national life skills program for school chilren in Graes NR NR NR NR Yes Reach: NR Serial crosssectional esign Age: NR Sample size: NR Frequency: NR comparing Sex: NR sero-prevalence rates among various rural an urban populations before an after the intervention. Yes Soul City theory of social an behavioral change. The Soul City weekly rama isseminates basic information about the epiemic an its consequences (the primary objectives of the raio an newspaper components were not reporte). NR Yes Reach: more than one-thir of the learners ha been expose to four ifferent Soul City meia sources >10 times, an about two-thirs six an more time. Urban learners were expose more often to Soul City TV an Soul Buyz than rural learners, an Soul City raio was listene to more often by rural learners. Frequency: NR Serial crosssectional esign, however exposure analysis performe with postintervention crosssectional ata only. Sample size: 3150 Age: mean Sex: 44.1% male, 55.9% female

7 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group Overview Entertainment eucation? Theoretical basis Primary objectives Duration of campaign Nationwie campaign? Reach an frequency Stuy esign Sample characteristics 573 [14] South Africa, general populations [25] Bobo-Dioulasso, Banfora an Niangoloko, Burkino Faso; truck rivers an their assistants Intervention components inclue (i) meia programs incluing Soul City raio, TV an life skills program; (ii) community AIDS awareness forums; (iii) peer eucators, incluing conom emonstrations an istribution; (iv) support groups for people living with HIV an (v) social care programs. The Roulez Protégé campaign is a regional mass meia communication strategy evelope aroun a 30-min film rama entitle Roulez Protégé an aime at proviing AIDS prevention messages to truckers an other mobile people in ifferent target countries. The campaign uses billboars poste at major truckstops along intervention routes, raio, TV, large group emonstrations an small group activites. The film has been aire on national television an in conjunction with mobile vieo units throughout West an Central Africa. Yes NR NR NR Yes Reach: NR Frequency: NR Serial crosssectional esign comparing (i) before to after ata an (ii) an exposure analysis using post-intervention ata only. Yes NR To encourage the aoption of responsible sexual behaviors by the targete population NR Yes Reach: at followup, two-thirs of the sample ha been expose to at least two of the Roulez Protégé activities. Frequency: NR Serial crosssectional stuy esign. Differences between baseline an follow-up populations le the authors to conuct both pre- post-analyses an an exposure analysis, using post-intervention ata only, to evaluate the mass meia intervention. Sample size: baseline: 421, follow-up: 416 Age: mean 20.8 Sex: 44.9%, male 55.1% female Sample size: baseline: 764, follow-up: 1032 Age: years Sex: 100% male Effectiveness of mass communication programs on HIV/AIDS

8 574 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group TV alone [26] Abijan, Bouepe an N Douci Cote Ivoire, general population with electricity Raio plus other meia [19] Mutare, Maphisa, Nemanwa, Nzvimbo, Tongogara, Kwekwe an Mubaira, Zimbabwe, youths age years an aults Overview SIDA ans la Cite is a weekly TV soap opera that escribes the life of a family touche by HIV/AIDS. The series features popular music by Alpha Blony an escribes realistic scenarios that people who have multiple sexual partners can ientify with. Six-month multimeia campaign, irecte at young people in five pilot sites. The campaign inclue posters, leaflets, newsletter, raio program, launch events, ramas, peer eucators, a hotline an training FP proviers in clinics to be youth frienly an the esignation of youth frienly clinics. Entertainment eucation? Theoretical basis Primary objectives Yes NR To eucate the public about AIDS. Each episoe is esign to introuce at least one major theme (example, shows that wife of infecte man can remain uninfecte if she uses conoms). Yes Steps to behavior change framework To increase reprouctive health an contraception knowlege. Duration of campaign Nationwie campaign? Reach an frequency Five months Yes Reach: 65% of the stuy sample ha seen at least one episoe of the soap opera. Frequency: once a week for 5 months. Six months Yes Reach: 97% reporte exposure to at least one campaign component; 61% to >3 components. Exposure to iniviual campaign components: posters: 92%, launch events: 87%, leaflets: 70%, ramas: 46%, hotline: 7%. Frequency: raio program: 26 episoes of the 1-hour weekly variety show were broacast, theater troupes: aily performances for 2 months. Stuy esign Cross-sectional stuy esign comparing iniviuals expose to the interventions versus those not expose in terms of sexualrisk behavior an conom use. Non-ranomize pre-/postintervention trial cross-sectional assessment comparing (i) five intervention an two comparison sites an (ii) combining ata from all sites an analyzing outcomes by exposure to intervention components. Iniviual unit of analysis. Ranom selection of participants. Sample characteristics Sample size: 2150 Age: years Sex: 47.4% male, 52.6% female Sample size: baseline: 1426 (I: 973; C:453), follow-up: 1400 (I: 1000; C: 400) Age: I: years: 33.0%; years: 45.3%; years: 21.7% C: years: 19.7%; years: 49.8%; years: 30.5% Sex: ;50% female; 50% male J. T. Bertran et al.

9 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group Overview Entertainment eucation? Theoretical basis Primary objectives Duration of campaign Nationwie campaign? Reach an frequency Stuy esign Sample characteristics 575 [10] Kunshan county, Jiangsu province in eastern China, young aults (18 30 years) Raio alone [18] St Vincent an the Grenaines, parent of teens, teens an other aults The intervention consiste of written materials, vieos, raio program, workshops, small group iscussions, home visits, personal counseling an free supply of conoms. Intervention emphasize sexual abstinence prior to marriage an the use of conoms for sexually active people, regarless of marital status. A raio campaign. The campaign targete primarily parents of teenage chilren an the central message was When you can t protect them anymore... conoms can. NR NR To promote ABCs (i.e. abstinence, monogamy, conom use or two areas within ABCs) NR Although not explicitly state, research questions refer to constructs from the theory of reasone action/theory of planne behavior. To encourage parents to talk to teens about safer sex an conom use. Twelve months No Reach: NR Pre-/postranomize Sample size: Frequency: baseline: 748 (NR reaing materials: self-stuy, raio program: once a week for 30 min. controlle trial comparing two intervention villages an two control villages sample from two townships that by stuy arm), follow-up: 710 (I: 366; C: 344) Age: mean age: I: 24 years; C: 25 years Sex: I: 51% female; were matche on socio-economic an emographic characteristics. Attempte to recruit all young aults in each of the four ranomly selecte villages. 49% male; C: 52% female, 48% male Two months Yes Reach: NR Frequency: NR Cross-sectional survey comparing participants who were expose to the intervention (intervention arm) to those who were not expose (comparison arm). Iniviual unit of analysis. Nation wie quota sample. Data weighte by age an gener. Sample size: weighte sample 297 (I: 213; C: 84) Age: I (15 19 years: 39.6%; years: 25.4%; years: 26.2%; years: 8.8%), C (15 19 years: 38.1%; years: 25%; years: 20.2%; years: 16.7% Sex: I (50.7% female, 49.3% male), C (57.2% female, 42.8% male) Effectiveness of mass communication programs on HIV/AIDS

10 576 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group [24] St Lucia, general Population [15] Tanzania, General public Overview The entertainment eucation raio soap opera Apwe Plezi aresse 37 eucational issues incluing knowlege, attitues an behaviors relate to family planning, HIV prevention, gener equity, relationship fielity an omestic violence. The raio soap opera ha positive, negative an transitional role moels whose fates provie vicarious learning experiences for listeners to emonstrate the consequences of alternative behaviors. Entertainment eucation raio soap opera emphasizing four key HIV/AIDS prevention themes: (i) STD treatment, (ii) conom use; (iii) AIDS is incurable an transmitte through sexual contact an (iv) an that various rumors about AIDS are false. Entertainment eucation? Yes Yes Theoretical basis Banura s social cognitive theory which posits that iniviuals learn new behaviors by observing an imitating the behaviors of others who serve as role moels. Base on the work of Miguel Sabio, which raws heavily on Banura s social cognitive theory. Primary objectives To promote the use of family planning, the prevention of HIV an other sexually transmitte iseases (STDs), gener equity an other social evelopment goals. To stimulate interpersonal communication about AIDS by showing role moeling of characters iscussing HIV/AIDS. Duration of campaign Phase 1: February 1996 to May 1997, Interim: June July 1997; Phase 2: July 1997 to September 1998; Phase 3: until 2000 Seventy-nine months Nationwie campaign? Reach an frequency Yes Reach: 12% of ault population of St Lucia were regular listeners Frequency: Phase 1: min episoes were broacast Tuesay through Friay, with repeat episoes shown on Monay. Phase 2: min episoes aire three times a week. Phase 3: Street Theater: 21 performances in 1998 Yes Reach: 1994: 47% reporte exposure 1997: 58% Frequency: twice per week for 30 min Stuy esign Pre-/postintervention trial serial crosssectional assessment comparing (i) before to after ata with the two follow-up surveys combine for analysis an (ii) outcomes by listening status (non-listener, casual listener an regular listener). Iniviual unit of analysis. Probability selection of stuy participants. Non-ranomize pre-/postintervention trial serial cross-sectional assessment comparing (i) I versus C; (ii) I versus C, controlling for eight inepenent variables an raio ownership an (iii) a multiple linear regression (MLR) analysis to regress war-level change in the epenent variables against warlevel listenership an 20 control variables. Iniviual an war unit of analyses. Ranom selection of participants. Sample characteristics Sample size: Baseline 753; combine followup 1238 (first follow-up 741, secon follow-up 497); non-listener: 799; casual listener: 288; regular listener: 51 Age: mean age: 29.3 years Sex: 52% female; 48% male Sample size: 1993 baseline: I 1793, C 859; follow-up 1 (1994): I 1924, C 861; follow-up 2 (1995): I 1940, C 861 Age: NR Sex: NR J. T. Bertran et al.

11 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group Overview Entertainment eucation? Theoretical basis Primary objectives Duration of campaign Nationwie campaign? Reach an frequency Stuy esign Sample characteristics 577 [27] Bucaramanga, Colombia, general population [12] Northern, Zambia Bemba speaking Zambians A raio campaign emphasize conoms use to prevent AIDS (two 10-s spots shown 10 times aily Monay Friay). The first spot opens an closes with the slogan: Prepare men o not ie of AIDS an PROFAMILIA recommens the Majestic conoms for safe sexual relations. The secon spot avises If you are having sexual relations in the next 24 hours, think about AIDS, an think about a safe conom. Tahiti, a safe conom. A weekly raio rama performe in Bemba over a 9-month time perio (August 1991 to June 1992). Each episoe laste 30 min an portraye two families in Lusaka an their friens as they respone to the problems of rearing teenage chilren, maintaining frienships, making ens meet, having sexual relations an learning about AIDS. NR NR To create awareness of the role of conoms in preventing AIDS. Yes Moeling, social learning hierarchy of effects To create awareness regaring the risks of getting AIDS an the importance of preventing transmission of the virus. Three months No Reach: 70% reporte hearing a raio spot about AIDS an the conom in the last 3 months Frequency: two 10-s avertisements were broacast an average of 10 times a ay, Monay through Friay. Nine months Yes Reach: NR Frequency: min rama episoes were broacast weekly Pre-/postintervention serial cross-sectional assessment comparing responses before an after the intervention. Iniviual unit of analysis. Ranom selection of househol. All eligible persons in these househols were interviewe. Pre-/postintervention trial comparing (i) the sample before an after the intervention an (ii) changes over time among participants most likely an least likely to have listene to the raio intervention. (The intervention arm is the high access group versus the comparison arm which is the low access group.) Sample size: baseline: 944; follow-up: 1440 Age: NR Sex: ;60% female; 40% male Sample size: baseline: 1613 (949 low access group, 664 high access group); follow-up: 1682 (997 low access group, 685 high access group) Age: mean age baseline: 25.9 years; mean age followup: 26.9 years Sex: ;50% female; 50% male Effectiveness of mass communication programs on HIV/AIDS

12 578 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group Overview Small meia with interpersonal communication Entertainment eucation? Theoretical basis Primary objectives Duration of campaign Nationwie campaign? Reach an frequency Stuy esign Sample characteristics J. T. Bertran et al. [17] Khon Kaen province of Northeastern Thailan (rural), general population [11] Wattala an Wauwa, Sri Lanka, general population living on the west coast. A five-part (5-ay) motivational auio-rama was broacast over village louspeakers. Ten posters with each ay s major issues acte as aily avertisements. The rama topics inclue marrie men engaging commercial sex workers, risk reuction an ialogues among women, spouses an men. Meetings were also hel with village leaers, volunteers were traine as facilitators an village iscussions on AIDS were hel. Three ramas, performe by volunteers an actors emphasize awareness about HIV/AIDS transmission an prevention. Flyers with prevention an transmission information were istribute uring the rama performances. Yes Moeling, social learning principles of community evelopment To reuce risk of HIV transmission (in a context in which men engage in extramarital sexual activity, specifically with commercial sex workers). To make HIV/AIDS real to the villagers. Yes NR To create awareness regaring the transmission an prevention of HIV/AIDS. Five ays No Reach: NR Frequency: NR Twenty-four months No Reach: NR Frequency: the rama was performe 58 times, with attenance of 4500 people at the formative research site, 500 at evaluation Site 1 an 900 at evaluation Site 2 Non-ranomize intervention trial comparing pre-/ post-ata from six villages in the intervention arm an postintervention only ata from six villages in a control arm. Iniviual unit of analysis Pre-/post-cohort intervention trial. Iniviual unit of analysis. Nonranom selection of stuy sample. Sample size: baseline: 390; post: 689 (I: 339 C: 350) Age: mean age: early 30s Sex: 56% female; 44% male Sample size: baseline: 154; follow-up: 97 Age: mean age: 29.8 years Sex: 18% female; 76% male; 6% non-response

13 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group Overview Entertainment eucation? Theoretical basis Primary objectives Duration of campaign Nationwie campaign? Reach an frequency Stuy esign Sample characteristics 579 [9] Libreville an Lambarene, Gabon High school stuents [16] Managua, Nicaragua Urban Nicaraguans age years High school stuents receive a 15-min classroom presentation on AIDS from a octor with time for questions afterwar. They were then given a comic book containing 36 oneto three-page stories to take home an rea on their own. Health eucation campaign emphasize HIV transmission an conom use. Campaign components consiste of house visits, leaflets on HIV an AIDS, stickers, posters, calenars, t-shirts an conom istribution. Yes NR To emystify the conom in a funny an unusual way in orer to inuce behavior change an limit the number of new HIV infections NR NR To create awareness of sexual transmission of HIV an the ways to prevent infection; emphasis on sexual transmission an protection using conoms. Comic book istribute once. Follow-up assessment conucte ays after istribution. No Reach: out of 964 stuents given the comic book at baseline, 728 ha rea it at follow-up Frequency: of the 728 stuents who reporte reaing the comic book, 43.7% rea it coverto-cover once, 29.5% rea it coverto-cover multiple times, 17.2% rea it almost completely an 9.6% rea it partially. The average amount of time spent reaing was 90 min, with a moe an meian of 30 min an a range of 1 min to 4 ays. NR No Reach: 44% aware of the visit of the health eucation team Frequency: NR Pre-/post-cohort intervention trial using a 10% ranom sample of eligible classes in 11 non-ranomly selecte schools. Iniviual unit of analysis. Ranomize pre-/ post-controlle trial with serial crosssectional assessment. Compares two intervention an two control communities matche on socioeconomic status. Iniviual unit of analysis. Intervention assigne by a coin toss. Ranom selection of participants from househols. Sample size: baseline: 974; post: 771 Age: mean age: 19 years Sex: 45.3% female; 54.7% male Sample size: baseline: 2160 (I:1294, C: 866); follow-up: 2277 (I: 1396, C:875) Age: mean age: 28 years Sex: ;54% women; 46% men Effectiveness of mass communication programs on HIV/AIDS

14 580 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group [23] Eighteen rural parishes in Masaka istrict, south west Ugana. Community members [22] East Moyo, Ugana (rural), general population, incluing Suanese refugees Overview Information was isseminate through large an small group meetings, village rama shows, village vieo shows an group or one-to-one iscussions with community eucators. Information leaflets were istribute at each of the IEC activities. The social marketing of conoms an voluntary HIV counseling an testing services were implemente in all communities. An information pamphlet entitle AIDS: be informe an protecte was prouce. Community eucators hel information sessions about AIDS prevention an care, incluing several sessions for the general public an particular groups such as military, police an traitional healers. Each session inclue the istribution of locally prouce pamphlets in English an Mai as well as conom emonstration an istribution. Entertainment eucation? Yes Theoretical basis Behavioral change for interventions moel Primary objectives To give knowlege an correct misconceptions about HIV/STI, an promote safer sexual behavior an practices. NR NR To create awareness regaring general information about the AIDS epiemic in Ugana an Moyo istrict; length of the incubation perio; nee for correct use of conoms in casual sexual relationships; STD symptoms an nee for immeiate treatment; tolerance an support for people with AIDS. Duration of campaign Nationwie campaign? Reach an frequency NR No Reach: 81% of iniviuals in the intervention arm, an 9% in the comparison communities reporte attening at least one Information eucation communication (IEC) activity in the past year Frequency: NR Twenty-four months No Reach: attene information session: 59%; receive pamphlet about AIDS: 42% Frequency: NR Stuy esign Ranomize controlle trial presenting postintervention exposure ata combining ata from the intervention an comparison communities on sexual behavior an HIV incience. I the expose participants an C the unexpose participants. Iniviual unit of analysis Pre-/post-intervention trial serial crosssectional assessment comparing (i) before to after ata an (ii) follow-up sub group ata base on exposure to (a) info session an pamphlet, (b) info session only, (c) pamphlet only an () no exposure to any intervention element. Iniviual unit of analysis. Ranom selection of stuy participants. Sample characteristics Sample size: baseline: NR; follow-up 1: I 1677, C 1687; Follow-up 2: I 1567, C 1695 Age: meian at follow-up males: I 33.5, C 34; females: I 33; C 34 Sex: follow-up 1 ;56% female 46% male Sample size: baseline: 1486; follow-up: 1744 Age: age range: years; mean age: NR Sex: 50.7% female; 49.3% male J. T. Bertran et al.

15 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group Overview Entertainment eucation? Theoretical basis Primary objectives Duration of campaign Nationwie campaign? Reach an frequency Stuy esign Sample characteristics [21] Chittoor District, Anhra Praesh, Inia, truck rivers The intervention consiste of films of local rama performances, folk meia, group iscussions an counseling by social workers provie at work an at the truckers resiences. Yes NR To inform truck rivers about HIV/ AIDS, the angers associate with it, use of conoms for safer sex an to bring about behavior change in sexual behavior. One year NR Reach: NR Frequency: films were shown an group iscussions hel once in every 2 months, counseling provie once a month, an the frequency of the folk meia component was not reporte. Before/after intervention esign Sample size: baseline: 300; follow-up: 300 Age: NR Sex: 100% male 581 [33] Sungai Kolok an Betong, Thailan, female commercial sex workers Music an messages share through walkmans/ cassettes given to the sex workers. The STD clinics istribute leaflets, comic books an free conoms an showe vieo tapes. Sex establishments showe vieo tapes, ha traine peer eucators, hel meetings with owners/ managers to support conom use, istribute conoms an were visite bi-weekly by a nurse. Leaflets with two conoms were place in hotel rooms. Posters an stickers isplaye in hotels an sex establishments. NR AIDS risk reuction moel To increase correct knowlege regaring HIV an its prevention. To increase women s perceive vulnerability an social support from peers an managers. NR No Reach: NR Frequency: NR Non-ranomize pre-/post-intervention trial with serial cross-sectional assessment comparing two stuy arms. Specific analyses compare (i) change within arm from preto post-intervention an (ii) ifferences between the two arms using ata from those iniviuals who were interviewe both at baseline an followup (a smaller subsample of the total stuy population) is teste. Sample size: baseline: 751 (I: 408, C: 419); follow-up: 739 (I: 343, C: 320); participants who complete both pre- an post-surveys (I: 159, C: 124) Age: mean age: 25 years (intervention site); 24 years (comparison site) Sex: 100% female Effectiveness of mass communication programs on HIV/AIDS

16 582 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group Small meia alone [13] Khon Kaen Province of Northeastern Thailan (rural), marrie women [34] Cape Town, South Africa, general population Overview Eucational pamphlet istribute to every househol by village health workers an research team members. Pamphlets presente information on HIV transmission, symptoms an consequences primarily with pictures, incluing humanoi cartoon conoms ancing across the back. Live puppet performance. The story is about a main character who is infecte with HIV an passes the virus onto others through his sexual liaisons before eventually ying of AIDS. During the show, the central messages concerning the prevention of HIV infection are explaine Entertainment eucation? Theoretical basis Primary objectives No NR To create awareness of HIV transmission, symptoms, an consequences. Yes NR To create awareness regaring HIV/AIDS transmission an prevention. Duration of campaign Nationwie campaign? Reach an frequency Two months No Reach: NR Frequency: NR Three weeks No Reach: NR Frequency: NR Stuy esign Ranomize controlle pre-/posttrial comparing (i) post-intervention ata from the intervention arm (12 villages that receive pamphlets); (ii) post-intervention ata from a comparison arm (six villages) that i not receive pamphlets an (iii) preintervention ata from a before group (ata poole from six villages that eventually receive pamphlets an complete the followup survey an six villages that i not get pamphlets or participate in the follow-up survey). Iniviual unit of analysis, ranom selection of stuy subjects. Non-cohort sample. Pre-/post-intervention trial comparing (i) before to after ata among attenees an (ii) intervention arm (pre-/post-group) versus a comparison arm (attenees who were surveye only once after the performance) in orer to assess the impact of the pre-intervention survey on the stuy outcomes. Iniviual unit of analysis. Convenience sample of stuy participants. Sample characteristics Sample size: baseline: 330; postintervention: 654 (I an C: NR) Age: age range: years; mean age: 31 years Sex: 100% female Sample size: baseline: NR; follow-up: 208; comparison group (post-intervention only): 96 Age: meian age: 24 years Sex: 52.7% female; 47.3% male J. T. Bertran et al.

17 Table II. Continue Author(s) Description of intervention Description of evaluation Setting an target group Overview Entertainment eucation? Theoretical basis Primary objectives Duration of campaign Nationwie campaign? Reach an frequency Stuy esign Sample characteristics 583 [8] Choma istrict Zambia, rural villages [7] Maras, Tamil Nau, Inia, inner city slums Intervention consiste of theater performances, health talks by clinic staff/ community workers an the istribution of pamphlets/posters. The campaign focuse on the transmission of AIDS an conom use with conoms istribute from health centers. Health workers, schoolteachers an traitional healers also attene AIDS seminars/anti-aids clubs. Three rama performances on the topic of HIV/AIDS performe by a community theater group calle Nalamana ( Are you well in Tamil). Yes NR To increase unerstaning the transmission of AIDS To promote the use of conoms Yes NR To create awareness of HIV/AIDS information. IEC = information eucation communication; RHC = rural health centers. NR No Reach: NR Frequency: theater group gave 55 performances for villagers. Rural health centers (RHC) staff an community health workers gave ;250 talks to villagers. Twenty-four months No Reach: NR Frequency: to 2-hour shows were performe, with an average attenance of 1000 people. Two of the three HIV/AIDS shows were performe four times an one performe twice uring the evaluation perio. Pre-/post-intervention trial cross-sectional assessment. Iniviual unit of analysis. Ranom selection of househols. Pre-/post-intervention trial among attenees at the rama performances with a comparison group surveye postintervention only. Analyses inclue (i) before to after comparisons within the intervention arm an (ii) I (before to after) versus C. Iniviual unit of analysis. Ranom selection of participants. Sample size: baseline: 427; intervention: 494 Age: age range: years; mean age: 31.3 years; meian age: 28 years Sex: 57% female; 43% male Sample size: I: pre-/ post-group 93; C (post-intervention only): 99 Age: age reporte by sub-groups only. Sex: pre-/postgroup: 23.4% female; 76.3% male; comparison group: 44.9% female; 55.1% male Effectiveness of mass communication programs on HIV/AIDS

18 J. T. Bertran et al. rigorous ranomize control esign, an therefore, score a 7 (see Table I). Twenty-one of the 24 citations reporte finings base on pre- an postintervention ata; nine of the 24 citations compare results from treatment versus control or comparison groups an nine analyze post-intervention only ata comparing outcomes by level of exposure. (Some stuies employe more than one of these approaches, an as such the total sums to >24.) Of the seven outcomes examine, far more stuies reporte on conom use (17) an HIV knowlege (15) than on reuction in number of partners (8), interpersonal communication (6), perceive risk (6), self-efficacy (4) or abstinence/ age at sexual ebut (3). A complete summary of the outcome measures an associate intervention effects generate from each citation appears in Table III. The results by outcome were as follows. Knowlege of transmission Fifteen stuies measure knowlege of HIV transmission as an outcome. Roughly half of these reporte positive effects on all or a plurality of knowlege measures, with effect sizes ranging from 2 to 100% improvements in the proportion of responents with better knowlege; of the remaining stuies, roughly half showe positive effects for some measures or population subgroups (e.g. women only). For example, in Inia, Valente an Bharath [7; articles that met the criteria for this review are inicate by * in the references] foun significant ifferences between the intervention group an the control group on the percentage correct on 12 knowlege questions (97 versus 94%). After watching an eucational theater performance, subjects of Trykker et al. [8] significantly increase their rejection of incorrect moes of transmission, such as using seconhan clothes from a person having AIDS (48 68%), rinking from the same cup as a person having AIDS (42 60%) an kissing a person having AIDS (26 37%). Similarly, Milleliri et al. [9] foun significant increases in knowlege of various moes of transmission after high school stuents ha been expose to a comic book program in Gabon. In a stuy which score 7 on the rigor scale, Xiaoming et al. [10] showe large, significant increases in the intervention group regaring knowlege of moes of HIV transmission, incluing sexual intercourse (77 95%), multiple sexual partners (69 93%) an sharing neeles for rug use (67 95%). On the other han, McGill an Joseph [11] i not etect significant ifferences in knowlege after rama performances in Sri Lanka, an Yoer et al. [12] i not fin significant ifferences in knowlege of transmission between those with high access to a raio rama in Zambia an those with low access to it. Perceive risk of contracting HIV/AIDS The six stuies that evaluate perceive HIV risk were evenly istribute over the categories of positive effects, no change or mixe results. Evaluation of a pamphlet campaign in Thailan by Elkins et al. [13] showe no significant changes in perceive personal risk of HIV. Similarly, Peltzer an Promtussananon [14] foun no relationship between risk perception an any of four mass meia components uner stuy in South Africa. Vaughan et al. [15] reporte that, after 2 years of raio soap opera broacasts 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 occurre espite strong contrary secular trens; the control group showe substantial reuctions in perceive risk over the same time perio (72 55%). Yoer et al. [12] also reporte that Zambians expose to a raio rama showe significantly higher belief that they coul get AIDS than Zambians who were not expose (30 versus 21%). Interventions evaluate by Pauw et al. [16] an Elkins et al. [13] showe stronger evience for increase perception of HIV risk among female subjects; in fact, the Thai auio rama evaluate by Elkins et al. [17] showe significant ecreases in perceive risk among men in the intervention group, an unintene consequence of the intervention. Self-efficacy Four stuies evaluate self-efficacy to protect oneself or convince a sex partner to use a conom. 584

19 Effectiveness of mass communication programs on HIV/AIDS Table III. Data showing effects of communication interventions on eight HIV-AIDS-relate outcomes, by outcome Outcomes of interest by stuy Results Knowlege: moes of transmission [13] Knowlege scale (mean 6 95% CI) Those who i NOT communicate about HIV Before ( ), C ( ), I ( ) Those who i communicate about HIV Before ( ), C ( ), I ( ) Mean response to a knowlege scale base on 37 questions on moe of transmission, availability of a cure, moes of prevention, iagnosis an appearance of a person infecte with HIV. Correct responses were given a score of 1 an incorrect responses or responses which might prouce ineffective prevention actions were score ÿ1. Responents scores range from ÿ2 to 14. [17] Mean knowlege score (women) I ( , SIG), C (9.66), [I versus C, SIG] Mean knowlege score (men) I ( , SIG), C (9.08), [I versus C, NS] Mean knowlege score for male an female responents at baseline an follow-up. Scores range from 0 to 14 an were calculate by summing the correct answers to a series of knowlege-base questions, such as: Is it possible to tell from someone s appearance whether they are carrying AIDS? Is there a cure for AIDS? How can AIDS be sprea? [11] Overall knowlege score (% correct) Before to after ( %, NS) Overall knowlege score (mean score) Before to after ( , NS) Overall knowlege score was calculate by summing correct answers to the nine questions shown below. Specific knowlege scale items (% correct): There is a cure for AIDS Before to after ( %, NS) Mosquitoes can cause AIDS Before to after ( %, NS) People with multiple sex partners may be more Before to after ( %, NS) likely to get AIDS You can tell a person has AIDS by looking at them Before to after ( %, NS) If you use a water glass that has been use by a Before to after ( %, NS) person who has AIDS you may get the isease If you use a sharp object that has bloo from Before to after ( %, NS) an AIDS person, you may get the isease If you have AIDS, symptoms will show in Before to after ( %, NS) a few weeks Homosexuals may be more susceptible to Before to after ( %, SIG) getting the isease Except for no sexual relations, conoms are Before to after ( %, NS) the best metho to protect against AIDS [9] HIV transmitte by bloo Before to after ( %, SIG) HIV transmitte sexually Before to after ( %, SIG) HIV transmitte from mother to chil Before to after ( %, SIG) Cite false (incorrect) moe of transmission Before to after ( %, NS) 585

20 J. T. Bertran et al. Table III. Continue Outcomes of interest by stuy Results [16] HIV transmitte by sexual relations Females: I (82 87%, SIG), C (85 87%, NS), [I versus C, NS]; males: I (89 90%, NS), C (82 91%, SIG), [I versus C, NS] HIV transmitte by common use of sharp instruments HIV transmitte by kisses, sweat an saliva HIV transmitte by bloo transfusion HIV transmitte by sharing neeles HIV transmitte uring pregnancy Do not know how HIV is transmitte Females: I (7 12%, SIG), C (7 5%, NS), [I versus C, SIG]; males: I (9 15%, SIG), C (9 7%, NS), [I versus C, SIG] Females: I (7 6%, NS), C (11 8%, NS), [I versus C, NS]; males: I (11 6%, SIG), C (11 8%, NS), [I versus C, NS] Females: I (30 27%, NS), C (23 20%, NS), [I versus C, NS]; males: I (32 36%, NS), C (35 32%, NS), [I versus C, SIG] Females: I (24 31%; SIG), C (19 28%, SIG), [I versus C, NS]; males: I (28 42%, SIG), C (28 35%, SIG), [I versus C, SIG] Females: I (3 2%, NS), C (1 1%, NS), [I versus C, NS]; males: I (1 1%, NS), C (0.3 1%, NS), [I versus C, NS] Females: I (13 8%, SIG), C (10 7%, NS), [I versus C, NS]; males: I (7 4%, NS), C (6 4%, NS), [I versus C, NS] Before to after (7.11 versus 7.33, NS) [14] Mean HIV/AIDS knowlege score (iniviual items below) People can protect themselves from HIV by Before to after ( %, SIG) using conoms correctly every time uring sex? Can a person get HIV from mosquito bites? Before to after ( %, SIG) People protect themselves from HIV by having Before to after (76 85%, SIG) one uninfecte faithful sex partner? People protect themselves from HIV by Before to after ( %, SIG) abstaining from sex? Can a person get HIV by sharing a meal with Before to after ( %, NS) someone who is infecte? Can a person get HIV by getting injections with Before to after ( %, NS) a use neele? Can a healthy-looking person be HIV infecte? Before to after ( %, SIG) Can a pregnant woman infecte with HIV Before to after ( %, NS) transmit the virus to her unborn chil? Can a woman with HIV transmit the virus to Before to after ( %, NS) her newborn chil through breastfeeing? What can a pregnant woman o to reuce Before to after ( %, SIG) the Risk Mother to chil transmission (MTCT) HIV/AIDS knowlege score (epenent variable): Peer eucator exposure to HIV/AIDS message higher score; lower score (b = 0.44) SIG; Soul Buyz (b = 0.49) SIG [20] HIV knowlege as it relates to each of the four Soul City TV (r = 0.08) SIG; raio (r = ÿ0.03) mass meia components using Pearson s correlation NS; Soul buyz (r = 0.02) NS; newspaper materials (r = 0.03) NS [34] Knowlege of moes of transmission Before to after (% NR, SIG) (no. of correct answers) [25] Knowlege of AIDS Before to after ( %, SIG) Knowlege of moes of transmission Before to after ( %, SIG) Knowlege of prevention strategies Before to after ( %, SIG) 586