Communication Partners International (Turk); University of Papua New Guinea (Malau); Anglo-Pacific Research (Rose)
"It was likely that behaviour change and integrated condom social marketing approaches flattened the rapidly rising curve of HIV infection and averted a mid-level AIDS epidemic in PNG. As such, strategic, integrated, evidence based communication programs should be scaled up in the Pacific to address emerging pandemic threats, including communicable and non-communicable disease prevention."
This article details the process of developing and implementing the communication strategy and condom social marketing components of a five-year-long, national HIV prevention and care programme in Papua New Guinea (PNG), with a focus on its methods for building ownership and engagement by stakeholders and continuous improvement at each phase of strategy evolution. The purpose of the case study is to examine factors that may contribute to successes in addressing challenges such as HIV/AIDS in the Pacific and other low- and middle-income countries (LMICs) through strategic, long-term, evidence-based approaches to communication programme roll-out and continuous improvement.
As is explained here, at the beginning of the new millennium, HIV/AIDS was emerging as a major health threat to 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.
A four-stage strategic planning cycle was adopted to operationalise national communication campaigns for the five-year term of the strategy (2000-2005). The annual campaign "phases" allowed programmers time to: adequately plan for the communication campaigns; develop and pre-test messages, materials, and activities; implement media plans; disseminate resource materials; and coordinate a raft of synergised advocacy activities. The final stage of the annual planning cycle involved an outcome evaluation of the strategy phase, with findings and lessons learned used to continuously improve the planning and implementation of the next phase of the strategy. This methodological approach facilitated the implementation of four national communication campaigns and five national evaluations.
- The initial "Planning" stage of the strategy involved compiling of a literature review and conducting formative research and a needs assessment with key stakeholders and programme beneficiaries around the country. For example, focus group discussions (FGDs) were conducted in outdoor settings, providing a more relaxed and naturalistic environment to explore knowledge, attitudes and risk behaviours of the various audience segments.
- The second stage, "Development", involved developing the creative strategy, including design and pre-testing of key messages and a range of campaign and socially marketed condom brands. Stream 1 activities were designed to build awareness and risk perceptions of HIV/AIDS, while Stream 2 activities were designed to promote condom use through social marketing approaches. This component provided promotion and distribution of generic free condoms for those unable to pay, as well as branded condoms distributed through retail outlets, including a family planning brand and an edgier black label, ribbed condom brand named "Karamap" (Cover-up). Advertising agency and market research firms were contracted through NHASP to support the creative strategy and independent monitoring and evaluation of the strategy phases. Message designs featured culturally acceptable campaign themes, including being faithful to one's partner, showing how you can and you can't get HIV, an anti-stigma campaign phase incorporating messages from religious leaders and an HIV positive person, and messages focusing on the efficacy of condoms but also emphasising abstinence as a risk prevention option.
- Stage three, "Implementation", involved coordination of a synergised, multi-level platform of communication activities utilising population-level, paid, and earned media approaches, with additional community media resources supporting community activities and interpersonal communication (IPC). In addition to TV, radio, and national print and outdoor advertising, extensive dissemination of community resources such as leaflets, posters, flip-charts, and audiovisuals were implemented to all regions of the country. Key ABC (Abstinence, Being Faithful, Using Condoms) messages were supported by stakeholders in the staunchly Christian settings in which the campaign materials were disseminated. An advocacy component included national launch activities attended by senior government officials, with these and other activities covered prominently through all major media outlets.
- Stage four, "Evaluation", involved the development of a monitoring and evaluation (M&E) framework for the five-year term of the strategy, including standardised key performance indicators (KPIs) linked to annual outcome evaluations, which utilised national cross-sectional, knowledge, attitudes, and practices (KAP) surveys of 2000 respondents across all four regions of the country. Five campaign evaluations were conducted over the course of the strategy (including a baseline survey commenced prior to the campaign's commencement) using the core set of KPIs focusing on KAP determinants. Other KPIs were integrated as the strategy evolved and transitioned into the second stream of condom social marketing activities in years 3-5 of the strategy rollout.
A more detailed outline of the four-stage strategic communication planning cycle activities is provided in the article, and a summary of excerpted impact data from the outcome evaluation stage is available at Related Summaries, below.
In brief, 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 (not explored in detail in this article). Additionally, following each campaign phase, nationwide, cross-sectional, quantitative surveys were conducted to measure campaign 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 (Ph 4 campaign), with the end-of-term evaluation (hereafter referred to as "Ph5") conducted in September 2005.
Overall findings over the course of the 5-year strategy (see also Related Summaries, below) identified: a significant increase (over 20%) in awareness of HIV/AIDS as the most important health issue in PNG; a significant rise in awareness from all media sources of HIV/AIDS issues; a significant rise in knowledge on partner reduction, abstinence, and condom use as protective responses; a significant rise in knowledge of prevention of mother-to-child transmission of HIV (PMCT) and infection status; a significant rise in negative attitudes towards skin piercing, sharing of sharps, and alcohol- and drug-related risk; a significant rise in attitudes towards condom efficacy; a significant rise in behavioural intentions towards protective behaviours; and a significant rise in condom use (protective behaviours). The Ph4 campaign evaluation also showed significant increases in single partner sex and a reduction in multiple partner sex, despite the focus of campaign activity being toward condom social marketing (CM).
An excerpt from the article follows:
"High recall of campaign with urban and peri-urban groups identify that population level interventions have the ability to rapidly set an agenda for a health issue and change social norms and cultural practices around that issue if consistent multilevel, synergised approaches are adhered to over a period of time...
The results suggest that as a result of the campaigns HIV/AIDS discussion within the communities is widespread and the subject was brought out in the open. The impact of the intensity of campaign messaging in relation to respondent recall is made clearer when examined in relation to the scale of resource distribution in community settings. The findings identify rises and fall in campaign recall with the scale of distribution. This points to the importance of large scale dissemination of messages across multiple communication platforms in the early stages of any emerging pandemic threat....Despite the good recall of community sources of HIV/AIDS information which identified greater discussion on the issue within communities, engaging groups such as faith-based organizations and the teaching profession in AIDS prevention activities remains a challenge, given the low recall of messages from these community gatekeepers in all phases of the strategy.
The campaign findings overall identify the strong influence of messages to audiences as a result of evidence based approaches to message design and pre-testing of messages. The peaking in early campaign phases of message influence (83% strongly influenced) and flattening out in the latter years of the strategy to a still creditable Ph4 campaign result (65% strongly influenced) indicates the high impact of messaging may be best achieved in the launch phases and early years of the strategy with a rapid onset of maturity given the intensive scale of HIV/ AIDS messages at all levels. Given these facts and the stigmatizing health issue in question, there is the need to continue to build momentum with strategy campaigns through more novel, memorable and impactful messages as the strategy matures.
Findings for personal risk perceptions identified respondents who identified themselves at very high or high risk dropped from 20% for the Ph2 campaign to 15% for the Ph5 campaign. However, whether these results are influenced by a greater understanding of HIV/AIDS and improved confidence to deal with the threat, or were simply due to complacency over the course of the strategy is unclear. Findings in regard to condom use protective behaviours identified the potential for cumulative increases in social acceptability and more frequent use of condoms, in line with targeted messages during the term of the strategy, as well as the importance of synchronised dissemination of condoms, with CSM activities, in retail and free distribution points around the country.
Process indicators on the perceptions of the frequency of messages identified potentially high levels of message frequency with around 50% of respondents claiming to have seen the messages "too many times". Rather than being an indicator of a potential diminishing rate of returns for campaign messages..., the findings may also indicate the importance of message saturation when dealing with emerging pandemic threats, given the increased recall of the campaigns in line with message resource dissemination through community channels. Another factor relating to messaging on stigmatizing issues is the potentially higher level of discomfort by audiences to these messages which, while aggravating some audience members, may at the same time, prompt higher levels of recall and calls to action.
Of note are the positive drifts from various campaign themes relating to stigma reduction and condom use, given the need to develop different message themes responding to findings from successive phases of the strategy. The approach testifies to the efficacy of population level interventions to rapidly set campaign agendas across multiple communication platforms and impact on attitudes and behaviors related to priority health issues...
It was likely that the integrated approaches, combining strategic communication with condom social marketing, had an impact in flattening the rapidly rising curve of HIV infection and averted a mid-level AIDS epidemic in PNG, as experienced in African countries exhibiting similar risk behaviors. Strategic approaches provide for greater understandings of target audience needs and want, and the development of pre-tested messages delivered with sufficient reach and frequency to address risk behaviors for priority health issues in the Pacific."