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Farag M. Elkamel

Abstract: This paper reviews two ways of media utilization: to provide regular entertainment programmes and news events; and to relay specific messages for the purpose of influencing attitudes and behaviour. Obstacles to the effective use of the media for attitude and behaviour change are outlined and communication and training activities in order to overcome these obstacles are recommended.

Les médias peuvent-ils contribuer à la prévention du SIDA: nécessité de programmes bien organisés de communication sur la modification des comportements

Resume: cet article examine les deux moyens d'utiliser les médias: présenter des émissions régulières de divertissement et des nouvelles; et transmettre des messages spécifiques dans le but d'influencer les attitudes et les comportements. Les obstacles à l'utilisation efficace des médias pour modifier les attitudes et les comportements sont exposés et des activités de communication et de formation en vue de surmonter ces obstacles sont recommandées.

Introduction

Mass media are generally defined as those channels of communication which are capable of reaching heterogeneous audiences simultaneously with uniform messages. These include radio, television, the press and cinema. Despite the overwhelming evidence of mass media effectiveness in raising awareness, increasing knowledge and changing attitudes and behaviour, doubts still remain among nonspecialists and some media critics. These may be due to a failure to realize that there are two distinctive ways of media utilization, the first being the usual media coverage of news events, regular programmes and entertainment material, and the second is the use of the media in the context of a planned and systematic process for the clear purpose of influencing attitudes and behaviour.

Regular entertainment and media coverage

Mass media regularly cover all sorts of issues, such as health, arts, crime, sports and political events. In countries which have a "free" press, the guiding principle is more or less to sell more newspapers, reach a larger audience, or sell advertising space. The objective in other countries may be to act as government or political propaganda tools. In all cases, however, the media do not even claim to play a role in health education in their regular treatment of health-related issues. The fact that acquired immunodeficiency syndrome (AIDS), for example, has received more "regular" media coverage in some countries than any other health issue in the history of humanity could very well be due to the fact that AIDS is a disease that involves sex and death, thus providing journalists with all the ingredients for sensationalist copy [1]. Not only is this coverage not motivated by the desire to provide health education, but it may often be a negative force in this regard. For example, journalists often report AIDS in a manner which reflects their own prejudices. In fact, the media coverage of AIDS has been described as having been slow, erratic, distorted and bizarre [2]. Journalists have consistently emphasized rare or bizarre ways in which human immunodeficiency virus (HIV) can be spread, rather than concentrating on the common modes of transmission [1].

While it may seem that news organizations are doing a public service by communicating important health information to their audiences, they do so not because of an altruistic desire to better the human condition, but to sell more newspaper space or charge higher rates for commercial time [3]. A leader in the news media puts it even more bluntly, asserting that the media "will not and cannot serve as direct relays for campaigns to reduce smoking, to use safety belts or condoms, or to submit to frequent breast examinations" [4]. He claims that it is unrealistic to expect that the media will "systematically pass on repetitive messages from the medical community or anyone else".

Usual media programming may even run in the opposite direction. For example, it has been reported that Russian television has aired regular shows hosted by psychotherapists who claim to cure the audience's mental and physical illnesses from a distance [5]. Millions of people watched those shows where the audience was instructed to put bottles of water in front of their television screens; the bottles were "energized" by the hosts of the show, and as a result, became a kind of "medicine". Among other examples of such media coverage were the distinctions repeatedly drawn by the media between "innocent victims" of HIV, such as children, and those "other" patients who are perceived as guilty of causing their own affliction [1].

Regular entertainment material also has the potential both to misinform and mislead the public. There is sufficient evidence that soap operas, music videos and movies are among the most popular television material, especially for women viewers and young adults. There is also sufficient evidence as to the impact of this entertainment material on the audience. Striking examples of the possible negative impact are the documented reports that violent fictional television stories trigger imitative deaths and near-fatal accidents [6]. Data provided by the United States National Center for Health Statistics for 1979 show that the incidence of suicides, motor vehicle deaths and accidents rose immediately following soap opera suicide stories. With respect to AIDS, one would be concerned with how sex is presented and if safe practices are emphasized, considering that sex is a major theme in entertainment. An investigation of the content of two soap operas shown in the United States of America (USA) throughout 1980 (All my children and General hospital) revealed that the most common themes presented were deceit, murder and pre- and extra-marital sex [7].

Content analysis of a random sample of one week of network television soap operas shown during the summer of 1987 in the USA showed that the ratio of unmarried to married sexual behaviour in soap operas was 23.7 to 1. Even more important, there was no reference—verbal, implied or physical—to pregnancy prevention or sexually-transmitted diseases, including HIV/AIDS [8]. In addition, a study of the 1986 USA prime time television season documented that soap operas contained: touching behaviour (24.5 times per hour); suggestions and insinuation (16.5 times per hour); sexual intercourse (implied 25 times per hour); and socially taboo sexual behaviours, such as sadomasochism and masturbation (implied 6.2 times per hour). In contrast, education was only touched upon 1.6 times per hour [9]. This has led communication researchers and analysts to conclude that Hollywood does not yet acknowledge safe sex [10], as condoms are non-existent in the movies or soap operas despite all of this sex. It has been argued that it would be very difficult for Hollywood to promote condoms, because Hollywood tends to cater to our fantasies and condoms, no matter how life-saving, will never figure in our fantasies. This is indeed a challenge, because it was not until Hollywood had the hero fasten his seat belt that it became more socially acceptable. Even when AIDS is a theme in television material, it is often not addressed in the most responsible way, because television is a business, and "customers" must not be offended. For example, it was found that, of the AIDS cases portrayed on television, 37% were caused by blood transfusion, while the actual figure does not exceed 3% [11].

All of this leads to the conclusion that unplanned, regular media and entertainment material will never, on its own, provide health education which would in any significant way influence HIV/AIDS-related behaviour. Yet media and entertainment are more like nuclear power: they are neither good nor bad in themselves; it all depends on how they are used and for what purposes. The following section, therefore, reviews a different side of mass media and entertainment: professionally planned efforts to harness the powers of the mass media and entertainment for the well-being of audiences.

Planned media and entertainment material

Communication experts and planners have realized the need for, and importance of, professional media planning. Manufacturers of commercial products, in realization of this fact, have devoted a sufficient amount of their budget to the use of communication services, marketing and advertising professionals to plan campaigns to influence the buying behaviour of potential customers. Efforts to curb the HIV/AIDS epidemic cannot rely on news media to do it on their own [2]. Communication experts have called for the mass education of the general public, and argued that this large-scale education has the potential for not only correcting misinformation, but also for creating and maintaining a more favourable environment for AIDS prevention [12]. In addition, it is generally accepted among communication specialists that public education can change and maintain social norms and render the new attitudes more acceptable, more openly expressed and more likely to be acted upon. It is also believed that mass media publicity about AIDS influences people to take actions they might otherwise not [2]. An expert group concluded at their meeting at the World Health Organization (1993) [13] that mass media campaigns "have promoted widespread AIDS awareness, safer sex and condom use". In fact, an analysis of 10 major social marketing programmes concludes that mass media advertising has contributed more to increased condom sales than any other factor, including price, cultural attitudes towards family planning and the level of national socioeconomic development [14].

Evaluation studies show that there have been positive changes in condom use following AIDS prevention campaigns in the Netherlands, Switzerland, the United Kingdom and the USA. For example, the Swiss campaign resulted in an over 50% increase in the use of condoms, with over 70% among those between 17-20 years of age [12]. This has led to the conclusion that large-scale education appears to have the capability of increasing the social acceptance of condoms and their use among persons more at risk. Radio spots used as part of a campaign to increase condom use among Kenyan commercial sex workers have led to a significant increase in condom use [15]. Following mass media publicity, which included specific telephone numbers, calls to AIDS hotlines in the USA almost doubled from May 1990 (16 691) to July 1991 (32 482) [2]. In Mexico City, calls increased more than ten-fold, and in Israel, attendance at a major AIDS testing site increased 431% after the first major television programme on AIDS [2].

Planned entertainment material has achieved impressive results as well. In the Philippines, a popular music video, intended to encourage young people to postpone sex and avoid unwanted pregnancy, resulted in enhancing young people's communication with their parents. It also motivated over 150 000 Filipino youths to call a sexual responsibility hotline, as promoted in the television video featuring musical stars, and 25% of young people sought contraception information as a result of the song [16]. As many as 240 000 women in Turkey are estimated to have adopted modern family planning methods as a result of television dramas and humourous spots [17]. In Mexico, which has been a pioneer in the deliberate use of soap operas for educational purposes, soap operas were the primary cause of a 63% increase in attendance at adult literacy centres in one year, and a rise of 560 000 in those adopting family planning methods [18]. A Ugandan film, It's not easy, was so effective that those who had seen it were more than twice as likely to have used condoms in the two months prior to the interview, as were those who had not seen it [2].

Entertainment material was the primary vehicle for spreading messages to curb alcohol-related traffic fatalities, a leading cause of death among young adults aged 15-24 years in the USA, through the popularization of the "designated driver" concept. This concept means that someone is "designated" or selected by another person or group to abstain from drinking, for a certain period of time or on a certain occasion, in order to be responsible for driving others home, so that they do not drive themselves after they have been drinking. The main vehicle used by the project, in addition to television spots, was to work with the communications industry to insert drunk driving prevention messages, including references to designated drivers, into scripts of top-rated television programmes such as Cheers, L.A. law and The Cosby show. The approach was based on the conclusion that entertainment not only mirrors social reality, but also helps shape it by depicting what constitutes popular opinion, by influencing people's perception of the roles and behaviours that are appropriate to members of a culture, and by modelling specific behaviour. The strength of this approach is that short messages, embedded within dialogue, are casually presented by characters who serve as role models within a dramatic context, thereby facilitating social learning [19]. Collaboration with the television industry in this project has yielded remarkable results. Among Americans under the age of thirty, 52% have actually been a designated driver. Among all alcohol drinkers, 28% have been driven home by a designated driver, and 43% of frequent drinkers have been driven home by a designated driver.

Does this suggest that all planned mass media and entertainment efforts succeed in achieving their objectives? Not by any means. In the United Kingdom, for example, injecting drug users, the intended target of a campaign using posters and television spots, did not even perceive that the messages were aimed at them [20]. The slogan "zero grazing", which was used in the Ugandan campaign to mean "stay with one partner", was not even understood by the target audience, and another frequently repeated spot, using drum beats to spread a sense of fear, did not appeal to young people who interpreted the drums as an appeal for abstinence [2]. Just as sensational news coverage can set back AIDS prevention efforts, poorly planned mass media efforts can do the same. In Nigeria, for example, frightening and confusing mass media material has resulted in negative attitudes towards people with AIDS and unfounded fears about the risk of infection. The level of fear aroused by the Australian campaign, which used death visuals, was apparently so great that those at highest risk practised denial and did not respond [2].

What is needed, therefore, is not just planned campaigns, as opposed to regular media programming, but well planned campaigns which utilize the full potential of mass media and entertainment. The "technology" and methodology for planning and implementing such campaigns do exist. Research has established that mass media are most likely to change behaviour when the information is targeted at specific audiences, comes from a credible source, and provides a personally relevant and engaging message. Effective use of mass media requires careful planning, audience research, message development, pre-testing, dissemination strategy, evaluation, coordination with existing services, and linking mass media with interpersonal communication [17]. This methodology has been detailed elsewhere [13,21].

Measures for prevention of AIDS through the mass media

The potential for what the mass media can do in the prevention of AIDS is influenced by how, and how well, the media are used. For example, the media may be used to achieve one or more of the following:

general advocacy

endorsement of society's leaders

community endorsement/support

community involvement

specific programme support

religious leaders' participation

general public information and education.

To be effective, the media, in particular, and communication programmes in general, have to achieve specific "hierarchical" objectives. The effectiveness and success of media interventions should be evaluated in terms of the extent to which each one of the following ten objectives or outputs has been accomplished:

exposing audience to the message;

attracting attention to the message;

creating interest in and liking of the message;

audience comprehending the message—becoming aware of what the problem is;

audience being taught those skills related to solving the problem;

audience understanding of the message—understanding why they should behave in the prescribed manner;

yielding—audience changing pre-existing unfavourable beliefs and attitudes;

audience retaining new information;

audience deciding to comply with the message and adopt changes;

audience behaviour changing in accordance with message [21].

Finally, a legitimate question which can be raised at this point is this: if we have the methodology and the evidence, why have not all countries implemented well planned mass media and entertainment campaigns for AIDS prevention?

Obstacles and challenges to media and entertainment campaigns for AIDS prevention

Lack of political commitment

Political commitment to AIDS prevention is the most important first step. Policy-makers have generally been reluctant to air prevention messages on the mass media, which constitutes a major obstacle [2]. Carefully designed materials have not been released because of opposition from politicians, broadcasters, or other gatekeepers afraid of arousing religious or other resistance. An evaluation of 21 public service announcements about AIDS from public health departments in Canada, Denmark, Norway, Sweden, the United Kingdom and the USA, revealed that three of the five spots considered most effective by 56 knowledgeable reviewers had been rejected for general broadcast. The announcements judged least effective, on the other hand, were broadcast much more frequently [2].

Communication planners and others have tried to overcome this hurdle for many years. For example, a workshop intended to increase awareness of the social and economic impact of AIDS persuaded policy-makers in Papua New Guinea to promote and support mass media AIDS educational efforts; and pre-test and impact evaluation reports, as well as audience research results showing the desire of the public to receive clear information, have persuaded policy-makers in Peru and Colombia to do the same [2]. Nongovernmental organizations and other AIDS advocacy groups can bring pressure to bear on government officials to counteract anticipated pressures from other sources. The role of international health and development organizations in promoting, supporting and advocating the use of well planned mass media campaigns can also make a significant difference.

High start-up costs

When given the choice, many policy-makers tend to hesitate in choosing well planned media campaigns because of their initial high start-up costs, despite the fact that mass media may be the cheapest approach to use, on the basis of per capita cost. However, using mass media effectively requires more investment at the beginning than other approaches, which may discourage many countries from effective use of mass media opportunities available to them. Even though the available data on mass media costs are less than would be desired, some good examples are already available. In Turkey, a multi-media campaign cost about US$0.04 to reach one woman of reproductive age and about US$0.67 to gain one user of a modern contraceptive method [22]. It is also reported that in Zimbabwe, a radio soap opera for men cost about US$0.16 for each man reached and US$2.41 for each new contraceptive user. Mass media effort is therefore more cost-effective than other approaches, such as group talks or printed materials [2].

A meeting in WHO on effective approaches to AIDS prevention concluded that "although mass media education is often expensive, it may be cost-effective in terms of costs per person reached"[13]. It also recommended certain measures to reduce mass media costs, such as the provision of free air time on radio and television for AIDS prevention campaigns.

Lack of sufficient technical expertise

An in-depth analysis of the mass communication component of medium-term plans (MTPs) of national AIDS programmes of a sample of seven countries revealed that the plans lacked definitions of appropriate "media-mix" or audience segmentation. They did not seem to be based on good knowledge of media habits and preferences of the various segments of the target audience in different regions of the countries, and among different socioeconomic groups and different age groups, as well as between males and females. These are only a few of the basic components of a good AIDS prevention communication plan which are often neglected, despite their extreme importance. For example, the media-mix selected for a specific campaign should be closely linked to specific audience segments which may require tailored messages, such as women, unmarried youth and people who practise high-risk behaviour or are likely to be in more high-risk situations. Each one of those segments may have different preferences and media habits and thus requires a different approach. Furthermore, when the audience is segmented, it becomes possible both to involve each segment in the design of messages which are intended for it, and engage them in the pre-test of those messages in order to ensure better impact. In addition, AIDS prevention materials have to compete with commercial advertising for air time and audience attention, which requires that AIDS messages be more professionally and creatively packaged. The high quality of the Ugandan AIDS film It's not easy has enabled this film not only to reach 90% of the Ugandan workforce, but to also reach beyond Africa to Asia, Latin America and the USA. The film is considered an unusual case of a developing country's product being used to change attitudes and behaviour in an industrialized country [23].

Conclusion

What emerges from the foregoing discussion is that, with respect to AIDS prevention, although there is a clear opportunity for effective mass education of the general public, unplanned media coverage and entertainment material will not be appropriate or sufficient. Well planned and professionally designed mass media and entertainment material can achieve remarkable results in raising awareness, increasing knowledge, changing attitudes and social norms and changing behaviour, including the use of condoms. Actions that can be taken to overcome the obstacles reviewed above, and to strengthen national capacities to undertake successful media campaigns, should constitute priority activities. In particular, there are three main areas which require special and immediate attention by governments and international donor agencies.

Persuasion and mobilization of decision-makers. Without their active support and involvement, the first necessary steps towards effective use of the media cannot be taken. Their support is needed in acknowledging the following: the importance of AIDS as a national problem; the commitment to using mass media for public education and persuasion; the importance of using the media systematically and by professional media planners and producers; and the need to allocate resources, including the provision of free time and space. Activities needed in this priority area may include public relations campaigns directed at these policy-makers, and utilizing different approaches such as documentaries, booklets, statistics, computer programs, presentations and seminars.

Effective use of available media. Most countries have, in fact, already used mass media for some sort of AIDS communication. However, one often hears the complaint that using the media did not help. As already discussed in this paper, this may very well be due to the way mass media were used. To avoid this problem, training of national programme managers and their communications officers is vital, with the objective of helping them realize the importance of using media through professionally planned campaigns, and providing them with the basic knowledge and skills to recruit, manage and coordinate needed assistance.

Training communicators and journalists. They need to be instructed in the ways to present their material, first to avoid stereotyping and unintended negative effects, and second to enhance and support the main communications programme. They need to be more sensitive to certain factors such as audience segmentation, pre-testing, and evaluation of material impact.

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