At the beginning of the new millennium, HIV/AIDS was emerging as a major health threat to Papua New Guinea (PNG), which was found to have the largest HIV epidemic in the Pacific. The cumulative number of HIV cases reported in 1999 reached 2,342 infections, including 772 AIDS cases and 158 deaths due to AIDS. High levels of other sexually transmissible infections (STIs) were also reported in sex workers in PNG, with more than one million new cases of STIs occurring annually. If left unchecked, HIV had the potential to expand rapidly across PNG also spreading the epidemic across the island bridge to the Australian mainland, and other Pacific island nations.
In response, in September 1995, the Government of Papua New Guinea (GoPNG) with the support of the Australian AID Agency (AusAID) commenced a Sexual Health and HIV/AIDS Prevention and Care Project. The project components included the provision of support for the strengthening of community-based HIV/AIDS prevention and care programmes, a targeted peer intervention programme among high-risk behaviour groups, and support for sexual health promotion activities. In June 1997, the Mid Term Review recommended that the project be expanded; the PNG National HIV/AIDS Support Project (NHASP) commenced in October 2000. One of the components of NHASP was a communication programme to raise awareness of HIV/AIDS. The national HIV/AIDS behaviour change and social marketing campaigns for NHASP were seen as an important component of the overall strategy, designed to raise awareness of HIV/AIDS, build risk perceptions, and increase knowledge and motivation by intended populations to engage in risk reduction activities. The thought was that a social marketing strategy incorporating behaviour change communication had the potential to address cultural, social, and other risk factors leading to the rapid rise in HIV cases presenting in hospitals and clinics in PNG. (For more on the campaign, see Related Summaries, below.)
Monitoring and Evaluation (M&E) methods included both qualitative and quantitative approaches, with qualitative approaches used initially for needs assessments and pre-testing of messages during each phase of the strategy development. Additionally, following each campaign phase, nationwide, cross-sectional, quantitative surveys were conducted to measure campaign key performance indicators (KPIs). The first wave of field research was conducted in Sept 2001 (prior to the phase 1 (Ph1) communication campaign implementation), to identify baseline KAP and to compare findings from the post-campaign intervention surveys to follow. Subsequent waves of tracking were conducted following each campaign intervention in December 2001 (Phase 1 (Ph1) campaign), December 2002 (Ph 2 campaign), February 2004 (Ph 3 campaign), and December 2004 (Ph4 campaign), with the end-of-term evaluation (Ph5) conducted in September 2005.
A regionally representative model was used, with Papuan (Port Moresby), Mamose (Lae), Highlands (Goroka) and Islands (Kokopo) regions sampled equally (n=500 respondents in each region). This sample frame allowed robust sample sizes in all locations while also allowing for simple post-weighting proportionately to their populations (20%, 28%, 37%, and 15% respectively).
It was intended that any modification to the questionnaire between the baseline and subsequent waves would be evolutionary to allow valid comparisons to be drawn. Similarly, the agreed sampling system was designed to be adhered to for baseline and subsequent monitoring surveys. Successive waves of tracking monitored campaign effectiveness in terms of the KPIs.
The questionnaire used for all the surveys contained 40 questions, preceded by 5 screener questions. The questionnaire and all show-cards were translated into Pidgin and back-translated to ensure equivalence of items and scales. The instrument was printed in dual language (English and Tok Pisin) and administered in whichever language the respondent preferred. The questionnaire and show-cards were pretested on a pilot sample of 20 respondents in Port Moresby before final modifications, printing, and use in the field. Full-colour prompt-cards were prepared from original messages (using graphic imagery but eliminating text or branding prompts) to measure prompted the recall of the AIDS campaign messages.
Chi-square analyses and independent measures t-tests were used to examine relationships between predictor and outcome variables, related to campaign phases.
A science-based approach to media delivery was embarked upon to provide over 1,200 TV spot placements across all national channels during an intensive 4-6 week programming period for each phase of the strategy and to support community-based activities. During the early phases of the strategy, where the requirement was for a rapid escalation of HIV/AIDS awareness to stem the tide of infection, more than 350,000 publications, as well as 1,800 audio-visuals, and numerous other resources were distributed to provinces around PNG to support community advocacy, prevention, and care activities. Additionally, as the condom social marketing (CSM) component of the strategy evolved in phases 3-5 of the strategy, almost 12 million condoms were produced and disseminated around the country. A "high-risk settings strategy" of the CSM programme focused on more targeted interventions in community settings, including the promotion and dissemination of "Karamap" branded subsidised condoms in bars, nightclubs, and pharmacy locations around the country. CSM complemented the free generic condom distribution also conducted to low-income, high-risk groups.
The most commonly reported sources of HIV/AIDS messages in the Ph4 survey were: radio 94%, TV 83%, and press 78% (all higher than previous waves). The figures were slightly lower in Ph4 for all these media but by margins of 3% or under. In Ph4, radio returned 91%, TV 81%, and press 75%. Sources of messages from community settings were slightly down (68% in Ph5 against 72% in Ph4), with outdoor media also marginally lower (36% in Ph4, 38% in Ph3). Advocacy through talk shows/commentaries (57%) and news articles (45%), on the other hand, was more prominent in Ph4, and word of mouth was as consistent as ever (95%).
Given the comprehensive range of community-based communication materials disseminated as part of the strategy, questions were asked relating to recall of AIDS messages in community settings. The first was "Do you remember hearing about HIV/AIDS from anyone in your community (and if so, who)?" The vast majority of respondents said they had (many from multiple sources, averaging 2.37 responses per respondent, similar to Ph4), while only 2% said they had not. The major sources of HIV/ AIDS communication were: family and friends (94%), health professionals (69%), non-governmental organisation (NGO) workers/volunteers (20%), church/priest/pastor/elder (13%), theatre/drama groups (13%), community elders/councillors (10%), and teachers/lecturers (10%).
Front-of mind recall of HIV/AIDS, elicited from the question "what is in your opinion the most important health issues facing PNG presently?" found that this was the most prominent health issue recalled at 89% in the Ph5 survey (exactly as it had been following the Ph4 intervention). At baseline, recall of HIV/AIDS was still high 80% but rose to 97% following the Ph1 forthright "wake-up" campaign to launch the strategy. Spontaneous recall of HIV/AIDS showed signs of maturation subsequently, dropping to 82% following the Ph2 and Ph3 campaigns but rising to 89% in the last two waves of tracking.
HIV/AIDS knowledge was assessed through the question: What did you learn from the AIDS messages you have seen or heard?" (multiple responses allowed). Be faithful was again the most prominent mention (67% in Ph4 vs. 73% in Ph3). "Don't have more than one partner" was at 49% (vs. 47% Ph3). "If more than one partner, use a condom" was well up in Ph4 (52% vs. 39% Ph3), as was "Use condoms every time" (46% vs. 36% Ph3). Abstention was consistent at 32% (31% in Ph3). In response to another question on message believability, "Do you feel the AIDS messages you've seen and heard were true?", 94% replied affirmatively in Ph4 (against 97% in Ph3).
An indicator of intention to change sexual behaviour showed consistent improvements across the 5 years of the strategy - from affirmative responses in Ph1 (16%), plateauing in Ph2 (25%), and then achieving a credible and significant increase from the baseline in Ph4 (23%). Given the importance of this indicator, a more specific question was asked: "As a result of the AIDS messages, what do you intend to do about your sexual practices?" Responses identified a drift away from reliance on fidelity (55% Ph4 vs. Ph1 67%) and reassuring drifts towards abstinence (12% Ph4 vs. 9% Ph1), and using condoms (29% Ph4 vs. 20% Ph1).
A critical success indicator for the strategy was to ensure a high uptake of protective behaviours through contraceptive use, with two items exploring this indicator: "Have you yourself ever used a condom?" and "Last time you had sex, was a condom used?" Both indicators identified significant improvements in agreement with ever using a condom from baseline (Ph1 42%) to midline (Ph2 46%) to end of the term of the strategy (Ph4 51%). Similarly, condom use at last sexual contact also identified significant improvements over the term of the strategy (Ph1 24%; Ph2 29%) and finally with a sharper focus back to condom use in the last year of the strategy (Ph4 32%). In the final Ph5 survey, 17% claimed they had been HIV tested, which was similar to the 18% who made this claim following the Ph4 campaign.
A single item question asked about confidence and skills to make protective behavioural changes in Ph4: "Do you feel it is possible for you to make the changes recommended in the AIDS messages?" Almost 90% replied affirmatively (46% strongly agree; 32% agree), 4% negatively, and 5% were unsure, with these figures being almost identical to Ph3 after plateauing at Ph2 (55% strongly agree; 27% agree), which was a significant improvement from a baseline of 79% agreement (45% strongly agree; 34% agree).
The final two stigma-related attitudes items were new for Ph2 (no previous comparative data available): "I think people with HIV/AIDS have probably got it through their own bad behavior and deserve what they get". This scale was included to measure public perceptions of people living with HIV/AIDS (PLWHAs) in terms of stigma and discrimination. The Ph2 findings indicated that 70% of people agreed or strongly agreed with this attitude, with only 10% expressing any degree of disagreement. Following Ph3, which (as a result of findings from Ph2) focused on countering judgmental, stigmatising, and discriminatory attitudes, agreement with these stigmatising attitudes dropped to 58%, with disagreement at 16%. In Ph4, levels of agreement were unchanged at 58%, but some who had previously expressed no opinion either way now expressed disagreement with this proposition (22%). Another stigma item was positively framed: "I think people with HIV/AIDS should be treated with the same respect and care that we would treat anyone else in our community with a serious illness". It identified 62% agreeing with this sentiment and 13% following the Ph2 campaign, with a positive swing to 65% agreeing and 10% disagreeing following the Ph3 campaign. In the final Ph5 campaign, some who had previously expressed no opinion now expressed opinions: stronger overall agreement (69%) while 12% disagreed. Personal risk perceptions were elicited through two questions, one of which was: "How would you rate your own personal risk of contracting AIDS?" The pattern of responses was similar to earlier surveys, but with a tendency towards assessing one's personal risk as lower (as in the perceived threat question above). Those rating themselves very high (7%) or high (8%) decreased, while those rating themselves at low risk (30%) to no risk at all (37%) increased. There was a drop in risk perceptions from very high (dropping from 11% for Ph1 to 7% for Ph4) and high risk (dropping marginally from 9% Ph1 to 8% in Ph4). Whether the results are influenced by a greater understanding of the HIV/AIDS over the course of the strategy or simply by complacency is unclear.
"An Integrated Approach to Strategic Communication and Condom Social Marketing to Address the HIV/AIDS Epidemic in Papua New Guinea" [PDF], by Tahir Turk, Clement Malau, and Andrew Rose, SciFed Journal of AIDS & HIV Research 1:1, July 26 2017.