Health Communication In Southern Africa: Using Social Network Information to Design Effective Health Campaigns to Address HIV in Namibia

Abstract
When programmers only use representative responses from target audiences, they may design an intervention that does not fit a community’s channel of communication. This study illustrates how to use social network analysis and community haracteristics to identify if communitywide health campaigns or mass media programmes best serve communities for communication interventions addressing HIV in Namibia. Interviews were conducted with Namibians from different households (N = 3763) in ten different communities over a year (October, 2003 to June, 2004). Based on community characteristics and social network analysis, group-based interventions rerecommended for seven of the ten communities, with varying suggestions for inclusion of critical groups and/or leaders within each area, and radio programmes to reach isolated groups. Additional suggestions for health interventions in each community are proposed from their community’s characteristics.

Introduction
When health campaign designers only use the average scores from a random sample of their target audience, they may design an intervention that does not fit the community’s channels of communication. When misfits occur, diffusion of information, norms, or behaviours may not occur or may generate unintended community activities, such as ostracism and stigmatisation. Information about the community’s social system – its groups and their interconnections – could allow designers to adjust their interventions to these social influences. Community-level variables differ significantly from individual-level variables. They focus on group and social processes of leadership, equity, and social norms instead of individuallevel behaviours, attitudes, and perceptions. This chapter shows community networks created through people’s participation in social groups, and presents a decision-making model for interventions based on the community’s network and characteristics.

These data come from Namibia. Namibia sits on the northwestern border of South Africa, and South Africa ruled it from 1946 until 1988. Although differences between the countries exist (e.g., population size: 2 million in Namibia versus 44 million in South Africa), their similar HIV prevalence rates for adults (19.6% for Namibia, 18.8% for South Africa, UNAIDS, 2006) make this exploration in Namibia a useful opportunity to further health communication development in Namibia and South Africa. The next section details more about networks and health campaigns followed by details about HIV in Namibia.

Social networks and health communication
Imagine that Sarah, who lives in a rural community in Africa, attends a church meeting where she listens to a dramatic production about HIV transmission, treatment, and care for those living with HIV (e.g., DramAidE, Mbuyazi, 2004). As she talks with other audience members after the show, they may share information about HIV, reinforce or change existing social norms about HIV, and disclose their intentions to help (or not) those living with HIV. After leaving the drama, Sarah may also talk to those who did not attend the drama about its content as well as how other audience members reacted to it.

Through this process, information and social norms diffuse within the community. A map of communication patterns – a social network – of this community ahead of time, might have revealed this church and Sarah as having powerful, central positions within the network. Their central positions could provide them with great potential to diffuse HIV information, norms, and innovations in this community. One way to think about networks is as a system of water pipes. The pipes are channels for communication – the communication is the water flowing through them. As more pipes exist within a community, communication may flow more quickly and easily through the community. People tapping into the water system at strategic places, such as where many pipes come together, may have better opportunities to access communication flowing in the system, stop communication from flowing further, or to put their own messages into the system.

Social networks, then, can be thought of as people tied to each other through one or more specific types of interdependency (e.g., familial, emotional, or economic). A social network is a map of the relationships between actors (e.g., people, groups, leaders, objects, or events); social network analysis investigates these relationships (Wasserman & Faust, 1994). Read more

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Health communication in southern Africa: The Portrayal of HIV/AIDS in Lesotho Print Media: Fragmented Narratives and Untold Stories

Part II: Social Representations and Entertainment Education

Abstract
In late 2005, the Government of Lesotho launched the world’s first  comprehensive plan to offer its entire adult population voluntary HIV testing and counselling. Using manifest and latent content analysis this study explores how articles in the two largest weekly newspapers in Lesotho portrayed HIV/AIDS and the campaign during seven month. While HIV/AIDS is frequently covered and recognised as a public health threat, the 227 articles rarely discuss the underlying causes, and do thereby not offer the reader information on the key driving forces behind collective and individual vulnerability to the virus. Moreover, the portrayal of HIV/AIDS as an insurmountable and overwhelming phenomenon could be counterproductive to efforts to get an entire population to test for HIV.

The HIV/AIDS epidemic in Lesotho
Lesotho is a small least-developed country completely encircled by South Africa with a population of 1.8 million. Among the adult population one in four is infected with HIV, making Lesotho one of the hardest hit nations in the world (Ministry of Health and Social Welfare, MoHSW, 2004; United Nations joint programme on HIV/AIDS, UNAIDS, 2006a; Word Health Organisation, WHO, 2005).

Immediate causes contributing to the dramatic increase in infection rates over the past two decades include unsafe heterosexual intercourse and mother to child transmission (World Bank, 2000). Underlying structural causes include widespread poverty and social dislocation because of migratory labor practices and gender inequality (World Bank, 2000; WHO, 2005) A recent positive result is that almost 94 percent of the population is reported to have ‘correct’ knowledge of HIV/AIDS. However, parts of the population still harbor a number of misconceptions about the HIV virus and only 24 percent of the women and 19 percent of the men are said to have comprehensive knowledge of both HIV transmission and prevention methods. Moreover, only 12 percent of men and 9 percent of women have gone for voluntary counselling and testing and know their HIV status (MoHSW, 2004). Today the epidemic in Lesotho has a mature pattern, similar to many countries in southern Africa, where the apparent stability in prevalence masks high rates of new HIV infections and even higher rates of AIDS-related deaths. In Lesotho, life expectancy has plummeted from 60 years in 1990-1995 to the most recent estimate of 42,6 years (United Nations Development Programme, UNDP, 2007) and 97,000 children are living as orphans due to parents dying of AIDS (United Nations Childrens Fund, UNICEF, 2006). High levels of morbidity and mortality increase demands on an already overstretched healthcare system and tend to impose a ‘shock’ to the household economy as it is often the economically active individual that falls ill and dies (World Bank, 2000a).

In 2003 the Government of Lesotho openly acknowledged the dire situation when the Prime Minister Pakalitha Mosisili warned: “we have to act NOW if we are to avert the potential annihilation of our nation” (emphasis in original document, Government of Lesotho/United Nations, 2003, p. xxiv) and in December 2005 the Know Your Status (KYS) Campaign was launched. The Know Your Status Campaign is the first attempt by any country in the world to provide universal HIV testing. The rationale behind the campaign is that voluntary counselling and testing is considered a key entry point into the components and activities of a comprehensive societal response. A comprehensive approach is generally expected to cover: prevention, treatment, care and support for those infected and affected by the virus, and impact mitigation (Barnett & Whiteside, 2006; Hewer, Motaung, Mathope & Meyer, 2005; McKee, Becker- Benton & Bertrand, 2004; UNAIDS, 2000, 2006a, 2006b; Weiser et al., 2006). The objectives of voluntary counselling and testing are to:
(i) detect infection early,
(ii) assist infected individuals to remain as healthy as possible,for as long as possible, by having access to available care and treatment services,
(iii) educate infected individuals to avoid infecting others
(iv) help individuals not infected to remain so through the maintenance of safe behaviour,
(v) assist individuals in life planning issues, and
(vi) assist individuals and couples in decisions about having more children, decreasing the chances of infecting infants (McKee et al., 2004:194). Read more

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Health Communication In Southern Africa: Social Representations Of HIV/AIDS In South Africa And Zambia: Lessons For Health Communication

Abstract
For people infected and affected by HIV/AIDS various linguistic representations have arisen, which create discourses as coping mechanisms and as systems of significations in order to make sense of HIV/AIDS. The AIDS epidemic has invited scientific efforts to revisit language and its role in the construction, positioning and repositioning of identities within cultural systems. This chapter highlights the relationships between language, culture and human experience. In studying the linguistic constructions of meaning vis-à-vis HIV/AIDS, this chapter heightens our understanding of the role of language and meanings in the creation of stigma. The chapter shows that language use with regard to HIV/AIDS is not neutral but has an ideological function. It plays on existing ideological conceptions as well as brings novel discourses into the sphere of interpersonal interaction. The acknowledgement of the power of language is critical for health communication, especially in multi-lingual ethnic groupings, who share similar linguistic forms. People engage with HIV/AIDS in their daily experiences by using familiar symbols, images, words and proverbs. It is argued in this chapter that this discourse of representation hinders the progress of public health interventions, especially with regard to HIV prevention and treatment with antiretroviral drugs. Public health communication and health promotion cannot merely rely on ‘normative’ linguistic labels to persuade, inform or negotiate health ideals, using the taken-for-granted myths/assumptions about the nature of HIV/AIDS and its effects. Listening to, and adapting the audience’s appropriation of language, especially in contemporary times of HIV/AIDS, is important for audience-tailored messaging in order to achieve effective and meaningful negotiation with individuals and communities, so that collective efficacy is strengthened.

Introduction
The HIV/AIDS pandemic has covered the world in a cloud of despair. The Panos Institute expresses it thus: “so much energy for so little hope” (Scalway, 2002). By the year 2001, 36 million people were living with HIV worldwide (Piot, Bartos, Ghys, Walker & Schwartlander, 2001), while sub-Saharan Africa shared the largest burden of the disease (DFID, 2003; Piot et al., 2001; The Henry J. Kaiser Family Foundation, 2004). By 2004, sub-Saharan Africa was home to 66 (25 million) of people living with HIV/AIDS (The Henry J. Kaiser Family Foundation, 2004). In 1999, this figure was representative of the entire population of Africa, 23.5 million out of an adult population of 268.9 million (Kelly, 2002). Contrary to the optimism of the Kelly-led report, the battle is far from being won (Kelly, 2002). Latest updates from UNAIDS give little hope of abating the epidemic, though stability is being recorded in some areas:

The global epidemic continues to grow and there is concerning evidence that some countries are seeing a resurgence in new HIV infection rates which were previously stable or declining. However, declines in infection rates are also being observed in some countries, as well as positive trends in young people’s sexual behaviours (UNAIDS, 2006). Read more

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Health Communication In Southern Africa ~ Edutainment Television Programmes: Tackling HIV/AIDS On The South African Broadcasting Corporation

Abstract
The last couple of decades have seen an increase in the use of edutainment to intervene in the socio-political problems faced by people in the developing world. Drama, soap operas and even children’s programmes are used to educate citizens about issues ranging from sanitation to safe sex. In South Africa today, edutainment is especially utilised to intervene in the country’s ongoing battle with HIV/AIDS. While many studies laud the success of these programmes, this article argues that the programmes are not without flaws. Though great strides have been made in terms of de-stigmatizing the disease in certain communities by encouraging open discussion and in some cases even nationwide policy changes, the often racialised, gendered and classist portrayal of people infected and affected by HIV/AIDS remains problematic. To some extent, much of these portrayals are a manifestation of the increasing ressure on South Africa’s public service broadcaster (SABC 1 & 2) to commercialise. This article explores the representation of HIV/AIDS on the South African Broadcasting Corporation (the SABC) in the context of the SABC’s increasing dependence upon advertising revenue.

Introduction
This chapter evaluates the role of the SABC in South Africa’s fight against HIV/AIDS through an ideological analysis of television texts and qualitative interviews. It asks what happens to HIV/AIDS when it is mediated through a public service broadcaster in a highly politicised country. In this respect, the chapter explores the extent to which the SABC functions as an empowering public sphere, with regard to HIV/AIDS intervention in South Africa. Can the SABC play an advocacy role in the fight against HIV/AIDS that would be true to its public service mandate without marginalizing certain groups or stigmatizing others? The chapter argues that the SABC’s role in the fight against HIV/AIDS is strained by the difficulty to develop focused messages for specific groups as the country’s history of segregation makes it difficult to distinguish and define risk groups and other addressees in ways that would avoid old apartheid divisions of issues, groups and people. This chapter therefore concentrates on the SABC’s constitution of audiences for development communication and the implications thereof for edutainment. Read more

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Health Communication In Southern Africa ~ Using Pictograms In A Patient Information Leaflet To Communicate Antiretroviral Medicines Information To HIV/AIDS Patients In Rural South Africa

Part 3: Patient Information

Abstract
The objectives were to design a simple, illustrated patient information leaflet for the antiretroviral regimen of stavudine, lamivudine and efavirenz and to evaluate its readability and acceptability in the local Xhosa population. In order to achieve this, a further objective was to design and evaluate illustrations to include in the patient information leaflet which were culturally acceptable and well interpreted. Illustrations or pictograms were designed to illustrate selected instructions appearing in the patient information leaflet and were individually tested in 30 Xhosa participants who had a maximum of 8 years of formal schooling. Results were used to improve the pictograms for inclusion in the patient information leaflet. The patient information leaflet was designed and tested in sixty Xhosa participants with varied levels of education who had stated they could read. Demographic data were collected and they were then asked to read the patient information leaflet, available in both English and isiXhosa, and a series of questions was asked to assess its comprehension and acceptability. The overall average rate o f understanding was 95. Six of the 20 questions were located and understood by all participants, and only two questions resulted in less than an 85 correct response. Physical appearance and quantity of information were highly rated and all participants were enthusiastic about the inclusion of pictograms.

Introduction
The communication of health-related information in Africa has involved various media including theatre (Mbizvo, 2006), video (Mathews, 2002), television and radio (Health Communication Partnership, 2008) and folk media which includes poems, dance drama, story-telling, rhymes and sayings (Gokah, 2007). However, the most commonly employed method has been the use of print media (Peltzer, 2002). Low literacy rates coupled with inadequate infrastructure and poor technological development in African countries have favoured the use of posters, billboards and pamphlets for health promotion and patient education.

Medicine-taking behaviour is complex, multi-factorial, and depends on a dynamic interaction of several factors, including cognitive, behavioural, social, environmental and physiologic factors (WHO, 2003). A minimum requirement for using medicines safely and effectively is a basic understanding of the medicine instructions and the ability to recall this information. However, the communication of this information to the average patient in southern Africa presents a complex challenge to health professionals as poorly resourced health care systems result in minimal time spent with individual patients and the cultural, educational, socioeconomic and linguistic differences that often exist between health professionals and patients may further challenge successful communication. Limited reading skills, a poor knowledge of the body and its systems and inadequate insight into diseases and their treatment also disadvantage patients seeking to address their health problems. Read more

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Health Communication In Southern Africa ~ Edutainment Radio Programmes: The Importance Of Culturally Relevant Stories

Abstract
The ways in which journalists frame HIV stories can strongly contribute towards news consumers’ perceptions of the epidemic. This paper discusses the news values of HIV radio programmes in Ethiopia, Kenya and South Africa. It argues that the culturally appropriate ‘humanisation’ of HIV stories and the proper use of conflict as adding news value are paramount to the impact of stories. The skillful application of news values can make almost any HIV-related story newsworthy and therefore part of mainstream news. Moreover, it is maintained that HIV advocacy environments contribute to the newsworthiness of HIV stories in the media. The AIDS advocacy milieus of South Africa and Kenya are compared and related to the type of HIV stories that are published and broadcast in the respective countries. Journalism training methods are critically discussed in the context of the above. It is argued, that, in developing countries, where journalists often lack basic journalism skills, it is not sufficient to provide reporters with HIV-related information; HIV information sharing should be combined with general journalism training and mentoring.

Introduction
In December 2007, an excited Bashir Osman – a Somaligna-speaking journalist from Dire Dawa in the east of Ethiopia – broadcast a live call-in show on breastfeeding and HIV to his Somali audience on Dire 106.1 FM. According to the most recent Ethiopian government figures, Dire Dawa has the second highest HIV prevalence rate in the country, and almost doubles the national average. Each year there are almost 1, 000 HIV positive pregnancies with at least 230 children born with the virus. Yet this was the first HIV programme that Bashir had ever produced.

AIDS was so stigmatised in the region that Dire 106.1 FM hardly ever discussed it on air. And Osman had no problem following this route. A week before the
broadcast, the journalist – like most of his listeners – refused to be in the same room as people with HIV because he “didn’t want to risk breathing the same air” (Osman cited in De Masi, 2008) as them. He would never consider sharing a plate, or hosting an HIV positive person in his home, and thought it a deep insult to be tested for the virus.

But then Osman accessed what turned out to be a precious piece of culturally relevant information: he learned that babies of HIV positive women can get infected with the virus through their mothers’ breast milk (personal communication, December 6, 2007). All mothers with babies in his community breastfed their infants … including his very own wife. His own five-month old baby could be at risk, he perceived with shock, because  neither he nor his wife knew their HIV status. The realisation changed Osman’s entire view on AIDS, and HIV was suddenly a virus that had the potential to directly impact his own life and those of everyone else he knew, in ways he had previously vehemently denied (personal communication, December 6, 2007). In short, this piece of information made AIDS newsworthy to Osman, his community and his editors. It became something that was crucial and worthwhile to talk about.  Read more

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