Health Communication In Southern Africa: Engaging With Social And Cultural Diversity ~ Introduction

• by: Luuk Lagerwerf, VU University Amsterdam, Henk Boer, University of Twente & Herman Wasserman, Stellenbosch University

Introduction
A focus on Southern Africa as an area where more and better HIV/AIDS communication is needed cannot be better underlined than by recent figures on adults living with HIV (15-49 years): In Sub-Saharan Africa the figure stands at 11%, whereas the global percentage is 3.25% (UNAIDS, 2008). The rise in these figures over recent years can partly be accounted for by the introduction of antiretroviral therapy, which means that statistically people living with HIV have a higher life expectancy.

Still, 67% of the global HIV prevalence in 2007 was accounted for by Sub-Saharan Africa, as was 72% of the global AIDS deaths (UNAIDS, 2008). The HIV/AIDS epidemic in Southern Africa affects women more than men (60% of people living with HIV were female in Southern Africa in 2007; UNAIDS, 2008), especially regarding HIV prevalence among youth. It is within this context that this book wants to consider the role that health communication may play in combating the HIV/AIDS epidemic.

Positive outcomes of health communication
How can health communication benefit the fight against HIV/AIDS? This positive influence may apply at different levels. Communication is an important part of prevention campaigns like in the case of the ABC (Abstinence, Be faithful, use Condoms) motto, which could contribute to a decline in HIV infections. Since the HIV/AIDS epidemic in Southern Africa typically affects women more adversely than men, gender relations form an important contextual dimension of health communication. Prevention messages have to be reinforced by the empowerment of women, enabling them to change their vulnerable position in sexual relations and negotiations.

Prevention and treatment go hand in hand and both aspects should be addressed in health communication. Voluntary Counselling and Testing (VCT) is a desirable outcome for several reasons. If people are infected they can get treatment and guidance. The spreading of infections may be controlled by more knowledgeable and responsible behaviour by HIV-infected people. Being more open about VCT might also change the perceptions of people living with HIV. Health communication can take the form of campaigns for better drug regimens and adequate state support. People living with HIV/AIDS (PLWA) need to take antiretroviral medicine to avoid AIDS, and their Antiretroviral Therapy (ART) compliance might be improved by good instruction and motivation. New media technologies have created opportunities to develop support networks for social movements and non-governmental organisations working to ensure better access to anti-retroviral medicines for PLWA.

The best-known example of such a network in Southern Africa is the one built around the group Treatment Action Campaign (Berger, 2006; Wasserman, 2005). The portrayal of PLWA may be changed in a more positive direction. Mass media and government policies need to be analyzed critically to detect and change negative or undesirable social representations of HIV/AIDS, or of individuals or groups associated with the disease. Health communication may serve to counter stereotyping, vilification or marginalisation of PLWA in sections of society who are seen as undeserving of state support, e.g. prisoners, migrants, asylum seekers, or sex workers (Berger, 2006). Read more

Health Communication In Southern Africa: Condom Use in Tanzania and Zambia: A Study on the Predictive Power of the Theory of Planned Behaviour on Condom Use Intention

• by: Merel Groenenboom, University of Amsterdam - Julia van Weert, University of Amsterdam & Bas van den Putte, University of Amsterdam

Abstract
The aim of this study is to examine determinants of condom use intention of Tanzanian and Zambian high-school students. Additionally, we aim to investigate whether determinants differ among different target (sub)groups. Data were gathered in a sample of high school students from Arusha area, Tanzania (n = 286), and Kabwe area, Zambia (n = 272). The TPB determinants attitude towards condom use and subjective norm explain, respectively, 15.5% and 16.5% of the variance in condom use intention in Tanzania and Zambia, while self-efficacy is not significantly related to this intention in both countries. In most target (sub)groups from Tanzania and Zambia, the same TPB determinants predict condom use intention. Besides the TPB determinants, other variables are significantly related to condom use intention, such as sexual experience and gender. These results vary over the (sub)groups.

The findings of this study prove the utility and global applicability of the TPB on condom use intention in Tanzania and Zambia. Because most subgroups in both countries show the same TPB determinants of condom use intention, cost-effective overall HIV/AIDS prevention programmes can be developed that can easily be adapted for different subgroups in different countries.

Introduction
AIDS (Acquired Immuno-Deficiency Syndrome), caused by HIV (Human Immunodeficiency Virus), is one of the most threatening diseases worldwide (UNAIDS, 2007). Sub-Saharan Africa, the area of Africa south of the Sahara desert, is the most affected region in the world, with AIDS being the leading cause of death in this area. Because relatively little is done on HIV/AIDS prevention and treatment, it is expected that the number of infected people and deaths will rise (UNAIDS, 2007).

HIV infection is often a consequence of a specific behaviour, one of which is unsafe sex (Fishbein, 2000). While condom availability has risen in Sub-Saharan Africa, there are many factors that keep people from using them (AVERT, 2007). Therefore, most HIV/AIDS prevention programmes aim at increasing the use of condoms in order to decrease the risk of infection and restrict the AIDS-epidemic (Bennett & Bozionelos, 2000).

Theoretically, scientific knowledge can contribute to the effectiveness of HIV/AIDS prevention programmes. While some studies found that behaviour change interventions that were explicitly based on theory were not more effective than prevention programmes without a theoretical basis (see Hardeman et al., 2002, for a review), other research showed a higher effectiveness of prevention programmes based on scientific literature (Fishbein, 2000; Gredig, Nideroest & Parpan-Blaser, 2006; Jemmott et al., 2007; Munoz-Silva, Sanchez-Garciá, Nunes & Martins, 2007). A commonly used behavioural model in scientific studies is Ajzen’s Theory of Planned Behaviour (TPB) (Ajzen, 1991). According to the TPB, behaviour is best predicted by asking people whether they have the intention to show this specific behaviour. In turn, behavioural intention is determined by attitude, subjective norm, and self-efficacy. The current study on condom use intention in Tanzania and Zambia used the TPB as a theoretical foundation. Until now, a couple of studies on condom use intention applying the TPB have been conducted in Sub-Saharan Africa. Most of these were carried out in South Africa (Boer & Mashamba, 2007; Bryan, Kagee & Broaddus, 2006; Giles, Liddell & Bydawell, 2005; Jemmott et al., 2007). No studies using the TPB were conducted in Zambia yet, and only one study is available on Tanzania (Lugoe & Rise, 1999). The current study was carried out in Zambia and Tanzania to examine whether the results of studies conducted in South Africa are also valid for other countries in Sub-Saharan Africa. The aim of the study is to examine determinants of condom use intention of Tanzanian and Zambian high-school students. Furthermore, the following subgroups will be compared to identify TPB determinants of intended condom use among specific target groups: males and females, students with and without a steady boy/girlfriend, and students with and without sexual experience. Subgroup analyzes to investigate whether the relation of attitude towards condom use, subjective norm, and selfefficacy to intention varies among specific target groups have hardly been reported in African studies. The research questions are:

* What are the differences between Tanzanian and Zambian high-school students in condom use intention, attitude towards condom use, subjective norm, and self-efficacy?
* What are the determinants of condom use intention of Tanzanian and Zambian high-school students?
* What are the determinants of condom use intention of males and females, students with and without a steady boy/girlfriend, and students with and without sexual experience? Read more

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

• by: Rachel A. Smith, Pennsylvania State University

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

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

• by: Cecilia Strand, Uppsala University

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

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

• by: John-Eudes Lengwe Kunda, University of KwaZulu-Natal & Keyan G. Tomaselli, University of KwaZulu-Natal

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

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

• by: Viola C. Milton, University of Pretoria

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