Download Impact of Multimedia Campaign on Sexual Responsibility Among Zimbabwean Youth and more Study notes Communication in PDF only on Docsity!
11
risky sexual behavior.^9 Stereotyped sexu- al norms and peer pressure encourage young males to prove their manhood and enhance their social status by having sex. At the same time, young women are so- cialized to be submissive and not to dis- cuss sex, which leaves them unable to refuse sex or insist on condom use. Women’s economic dependence on men also leads young females to exchange sex for the opportunity of marriage or for gifts, sometimes with older “sugar dad- dies,” who may be HIV-infected.^10 Other societal influences have exacer- bated this situation. Traditionally, aunts, uncles and other extended family mem- bers provided sexuality-related informa- tion to young people, but as urbanization increases the distance between family members, parents are taking greater responsibility in this area, and many feel uncomfortable in this unaccustomed role.^11 Health care providers have not filled the void because they share the overall so- cietal bias against adolescent sexuality, they lack the skills needed to communi- cate with young people about sensitive topics and they are barred by law from providing reproductive health services to individuals younger than 16. According
Young Mi Kim is senior research and evaluation advi- sor, Johns Hopkins University Center for Communica- tion Programs (JHU/CCP), Baltimore, MD, USA; Adri- enne Kols is consultant to JHU/CCP; Ronika Nyakauru is program manager and researcher, Evaluation and Re- search Unit, Zimbabwe National Family Planning Coun- cil (ZNFPC), Harare, Zimbabwe; Caroline Marangwan- da is assistant director, Evaluation and Research Unit, ZNFPC; and Peter Chibatamoto is consultant to ZNFPC. The authors express their appreciation to Godfrey Tinar- wo, Fatima Bopoto-Mburiro, Brian Makunike, Hazel Dube, Alford Phiri, Ronald Mukombachoto, the late Flo- rence Chikara, and the province managers and infor- mation, education and communication officers in the study provinces. They also acknowledge Mike Auret, Peter Roberts, Jane Brown, Jim Williams, Gary Lewis, Karusa Kiragu, Susan Krenn and Bruce Morén. Special thanks go to Roxana Rogers. Both the intervention and the evaluation were made possible by funding from the U.S. Agency for International Development under co- operative agreement CCP-A-00-96-90001-00.
Promoting Sexual Responsibility
Among Young People in Zimbabwe
By Young Mi Kim, Adrienne Kols, Ronika Nyakauru, Caroline Marangwanda and Peter Chibatamoto
I
n Zimbabwe, where 38% of the popu- lation is aged 10–24,^1 the average age at first intercourse is 18 for both men and women,^2 but many begin sexual ex- perimentation far earlier.^3 Unprotected sex puts young people at risk of unwanted pregnancies, which may contribute to their dropping out of school, marrying early, abandoning babies and obtaining abortions.^4 Sexually active young people also face the risk of contracting HIV and other sexually transmitted infections (STIs). Zimbabwe has one of the highest AIDS prevalence rates in the world;^5 HIV infection rates there are highest before age 25, and among teenagers, women are es- pecially vulnerable.^6 Most young people in Zimbabwe are aware of HIV, AIDS and the risk of preg- nancy but still engage in unprotected sex.^7 According to the 1994 Demographic and Health Survey (DHS), 98% of women aged 15–19 had heard of AIDS, but only one-third of those who were unmarried and sexually active were using modern contraceptives, and only 19% were using condoms.^8 In Zimbabwe, as in other coun- tries around the world, gender roles and social norms—along with a host of eco- nomic and legal factors—contribute to
to one study, 72% of service providers believe that contraceptives should not be offered to people aged 16 or younger.^12 Furthermore, even after age 16, most teenagers except for married women with children are denied contraceptives.^13 As a result, young people in Zimbabwe gen- erally have inadequate information about reproductive health issues, lack the skills to negotiate with their partners about de- laying sex and have limited access to re- productive health services.^14 To address these problems, the Zim- babwe National Family Planning Coun- cil (ZNFPC) launched the Promotion of Youth Responsibility Project, with tech- nical assistance from the Johns Hopkins University Population Communication Services. The project aimed to encourage young people to adopt behaviors that re- duce the risk of pregnancy and STIs, in- cluding HIV. It encouraged abstinence for young people with no sexual experience, but promoted condom use and a reduc- tion in the number of sexual partners for those already sexually active. In this article, we present an assessment of the project’s success at reaching its tar- get audience and promoting responsible sexual behavior among young people.
Project Description
Theoretical Framework At the heart of the project was a six-month multimedia campaign directed at young people in five pilot sites: one urban area
Volume 27, Number 1, March 2001
Context: A 1997–1998 multimedia campaign promoted sexual responsibility among young peo- ple in Zimbabwe, while strengthening their access to reproductive health services by training providers.
Methods: Baseline and follow-up surveys, each involving approximately 1,400 women and men aged 10–24, were conducted in five campaign and two comparison sites. Logistic regression analyses were conducted to assess exposure to the campaign and its impact on young people’s reproductive health knowledge and discussion, safer sexual behaviors and use of services.
Results: The campaign reached 97% of the youth audience. Awareness of contraceptive meth- ods increased in campaign areas, but general reproductive health knowledge changed little. As a result of the campaign, 80% of respondents had discussions about reproductive health—with friends (72%), siblings (49%), parents (44%), teachers (34%) or partners (28%). In response to the campaign, young people in campaign areas were 2.5 times as likely as those in compari- son sites to report saying no to sex, 4.7 times as likely to visit a health center and 14.0 times as likely to visit a youth center. Contraceptive use at last sex rose significantly in campaign areas (from 56% to 67%). Launch events, leaflets and dramas were the most influential campaign com- ponents. The more components respondents were exposed to, the more likely they were to take action in response.
Conclusions: A multimedia approach increases the reach and impact of reproductive health in- terventions directed to young people. Building community support for behavior change also is es- sential, to ensure that young people find approval for their actions and have access to services. International Family Planning Perspectives, 2001, 27(1):11–
The main themes of the youth campaign, which was launched during August and September 1997, were self- respect and self-control. These were expressed in three slogans, which were repeated in all materials and activities, in both English and native languages: “Have self-control,” “Value your body” and “Respect yourself.” All campaign materials and activities were designed to reinforce a single set of messages, em- phasizing the consequences of unpro- tected sex; negotiation skills; discussion with friends, family and providers; and safer sexual behaviors. Young people helped design appealing materials and rel- evant messages, and local management committees helped plan and execute ac- tivities at each site. ZNFPC wanted to reach an audience of 10–24-year-olds of both sexes and, secon- darily, the adults who control young peo- ple’s access to reproductive health infor- mation and services. The age range selected for the young people was chosen for two reasons: Studies suggest that sex- ual responsibility interventions have the greatest impact on young people before they initiate sexual activity, perhaps even before they reach puberty.^19 On the other hand, by encouraging adolescents who are already or are on the verge of becoming sexually active to take preventive mea- sures (e.g., use condoms and reduce their number of partners), safer sex interven- tions can make an immediate impact on older teenagers.
Program Components The campaign employed a mix of com- munication channels, since different media can reach different audiences. Also, by repeating and reinforcing messages, a strategy combining media and activities increases the likelihood that people will recall and act on campaign messages.^20 Some of the campaign’s components em- ployed mass media, which reach large au- diences at a low cost per capita, raise awareness, disseminate information and have the potential to change behavior.^21 The remaining components employed in- terpersonal communication, which reach- es fewer people but may be effective in motivating people to adopt new prac- tices.^22 The campaign’s logo, a yellow tri- angle with a blue circular “youth-friend- ly” seal, was featured on all materials.
- Posters. A series of eight posters carried messages like “Value your body and a happy future lies ahead” and “You may think you are ready for sex, but are you ready for the consequences?” In campaign
(Mutare) and four growth points (Maphisa, Nemanwa, Nzvimbo and Tongogara). (Growth points are small towns at the center of rural districts.) The campaign was based on the Steps to Be- havior Change framework, which syn- thesizes theories of communication and behavior change into a practical model to guide reproductive health communi- cation programs.^15 The framework de- scribes five stages through which people pass as they change their behavior: knowl- edge, approval, intention, practice and advocacy. Effective communication cam- paigns determine the stage that their audience is at and focus their energies accordingly. Given the situation in Zimbabwe, the youth campaign focused on the model’s two earliest stages, when people learn key information and skills, then discuss campaign messages with others and find support for behavior change among their family, peers and community.^16 Interna- tional experience with pregnancy and HIV prevention programs for adolescents has found that outside approval is critical for two reasons. First, young people’s deci- sions are strongly influenced by friends, family and social norms. Second, their access to reproductive health information, commodities and services is controlled by adults, including parents, service providers and political leaders. Therefore, it is not surprising that programs have found it easier to improve knowledge and attitudes than to prompt behavioral changes. Effective interventions have ad- dressed gender roles, sexual norms, peer pressures and public policies, in addition to teaching basic information and skills.^17
Youth Campaign Goals The first objective of the youth campaign was to increase reproductive health knowledge, because young people in Zim- babwe had only a general awareness of HIV, AIDS and family planning. They did not appreciate the personal risks of unprotected sex and did not know how to negotiate with partners about sexual decisions.^18 Two other objectives were to heighten approval of safer sexual behav- iors and of the use of reproductive health services—first, by promoting discussion of sexual matters with family and friends, and second, by encouraging parents, lead- ers and policymakers to support repro- ductive health communication and services for young people. The final ob- jective was to encourage young people to adopt safer sexual behaviors and attend service facilities.
sites, 10,000 copies of each poster were dis- tributed. Older ZNFPC posters address- ing AIDS, peer pressure, parental com- munication, sexual responsibility, drugs and alcohol also were on display.
- Leaflets. Five leaflets—on abstinence, how to say no to sex, postponing sex, de- laying parenthood and STIs—were pro- duced, and 19,000 copies of each were dis- tributed. In addition, the popular older ZNFPC booklet Facts About Growing Up continued to circulate.
- Newsletter. Peer educators and schools distributed 100,000 copies of Straight Talk , a four-page newsletter on reproductive health issues of importance to young peo- ple. Each of the three issues included ad- vice columns and articles written by young people.
- Radio program. Radio is widely available in Zimbabwe: Ninety-four percent of urban and 87% of rural young people sur- veyed by this project had access to a work- ing radio. During the campaign, 26 episodes of Youth for Real , a one-hour radio variety show, were broadcast nationwide. This weekly program, which has contin- ued to air since the campaign ended, com- bines information and advice with enter- tainment such as music and minidramas. Listeners can phone the show to ask ques- tions of a peer counselor and doctor.
- Launch events. To mobilize community support for the campaign, local commit- tees spent months planning elaborate launch activities and garnered substantial support from local businesses. Popular musicians attracted large crowds to the launches, which featured different activ- ities at each site, including speeches, dra- matic performances, drum majorettes, soc- cer games, donkey parades and a parachute drop. Adults who influence youths—including chiefs, counselors, church leaders, parents, siblings, teachers and service providers—attended the launches, and novelty items bearing cam- paign messages were distributed.
- Dramas. During the first two months of the campaign, two community theater troupes performed daily at schools, church- es and town centers, presenting interactive dramas on reproductive health issues. Peer educators accompanied the troupes and fa- cilitated a discussion with members of the audience after each performance.
- Peer educators. Peer educators aged 18– were recruited from the community and trained to speak with groups of young people at schools, churches and town cen- ters and with individuals at home. Four educators were assigned to each growth point and six to Mutare.
12 International Family Planning Perspectives
Promoting Sexual Responsibility Among Young People in Zimbabwe
some components were substantial in compari- son sites (Figure 1). Two frequent problems for experimental research designs in mass media campaigns may explain this finding. First, the posters, radio program and leaflets were avail- able in comparison sites and had some impact on young people there. Sec- ond, if respondents were unable to distinguish be- tween campaign and similar noncampaign ac- tivities, the follow-up survey may have mea- sured exposure to dra- mas and peer educators sponsored by programs other than the youth campaign. The inclusion of noncampaign activi- ties presumably boosted exposure levels by roughly equal amounts in campaign and com- parison areas. Because of the considerable ex- posure levels in some comparison sites, all analyses include the comparison as well as campaign sites. Ninety-seven percent of respondents in cam- paign areas were ex- posed to the campaign. Posters and launch day events reached the largest proportions of young people (92% and 87%, respectively), fol- lowed by the leaflets (70%) and dramas (46%). The hot line reached the smallest share of the tar- get audience (7%). How- ever, the likelihood of re- spondents’ exposure to each component varied according to the youths’ characteristics. Students were ex- posed to significantly more campaign compo- nents than out-of-school youths (on average, 3. vs. 3.0), presumably be- cause much of the cam- paign was school-based.
Some differences emerged between the baseline and follow-up samples and be- tween campaign and comparison sites. At baseline, respondents in campaign sites were younger, less well educated, less like- ly to be married and less likely to be sex- ually experienced than those in compar- ison sites (Table 1). In campaign sites, respondents to the follow-up survey were significantly older, better educated and more likely to be sexually experienced than participants in the baseline survey. The rural-urban composition of the cam- paign and comparison samples also dif- fered: Four of five respondents at cam- paign sites lived in rural areas, compared with half at comparison sites. Given these differences, we performed multivariate lo- gistic regression analyses to control for age, sex, education, sexual experience, marital status and urban-rural residence.
Campaign Exposure Significantly higher proportions of youths in campaign than in comparison sites were exposed to each campaign compo- nent; nevertheless, exposure levels to
When background characteristics are taken into account, students were twice as like- ly as other young people to have seen a poster, read a pamphlet, watched a youth drama, read the Straight Talk newsletter or talked to a peer educator. Respondents aged 10–14 were exposed to fewer cam- paign components than older respondents (3.0 vs. 3.3) and were significantly less like- ly to have been exposed to posters, cam- paign launches, Straight Talk , the radio pro- gram and peer educators. Sexually experienced youths were exposed to the same number of components (3.3) as sex- ually inexperienced respondents (3.2), but were more likely to have been exposed to the four components with the least reach: the newsletter, radio program, peer edu- cators and hot line. While gender and urban-rural residence also were related to campaign exposure, the direction of the association varied for different materials and activities. Some components reached a greater proportion of women than men (posters, pamphlets and the radio program), while others reached a higher fraction of men (dramas, newsletter and peer educators ). Similar- ly, launch events, youth dramas, Straight Talk and the peer educators had their greatest reach in rural campaign sites, while leaflets, the radio program and the hot line reached a higher proportion of urban than rural youth. The six-city survey provides a fuller pic- ture of listenership to Youth for Real. Na-
14 International Family Planning Perspectives
Promoting Sexual Responsibility Among Young People in Zimbabwe
Table 1. Percentage distribution of respondents to baseline and follow-up surveys, by selected characteristics, according to study site, Zimbabwe, 1997– Characteristic Campaign Comparison Baseline Follow-up Baseline Follow-up (N=973) (N=1,000) (N=453) (N=400) Sex Female 50.1 49.8 50.0 49. Male 49.9 50.2 50.0 50. Age†,‡ 10–14 33.0 21.9 19.7 23. 15–19 45.3 54.3 49.8 54. 20–24 21.7 23.8 30.5 22. Residence Urban 20.4 20.0 50.8 50. Rural 79.6 80.0 49.2 50. Education‡,§ None 0.2 0.0 0.0 0. Primary 39.2 28.3 31.5 28. Secondary 60.5 71.5 68.1 70. University 0.1 0.2 0.4 0. School attendance Student 64.7 58.4 48.6 57. Working/unemployed 35.3 41.6 51.4 42. Marital status† Single 93.1 90.9 81.6 88. Married/other 6.9 9.1 18.4 11. Sexual experience†,‡,†† No 79.2 65.6 70.4 69. Yes 20.8 34.4 29.6 30. Total 100.0 100.0 100.0 100. †Difference between campaign and comparison data at baseline is statistically significant at p<.001.‡Difference between baseline and follow-up data in campaign area is statistically sig- nificant at p<.001. §Difference between campaign and comparison data at baseline is statis- tically significant at p<.05. ††Difference between baseline and follow-up data in comparison area is statistically significant at p<.05.
Figure 1. Percentage of respondents in campaign and compari- son sites who were exposed to each campaign component
Note: For each component, the difference between the campaign and comparison sites is statistically significant at p≤.001 (calculated by multiple regression analysis controlling for respondents’ age, sex, education, sexual experience, marital status and urban-rural residence).
100
90
80
70
60
50
40
30
20
10
0 Posters Launch Leaflets Dramas News- Radio Peer Hot events letter program educators line
Campaign Comparison
%
Volume 27, Number 1, March 2001 15
nificantly from baseline to follow-up, when back- ground variables are con- trolled for: Teenagers in these areas were 2– times as likely to know of most methods after the campaign as they had been before, and about eight times as likely to know of the female con- dom (Table 2). In com- parison areas, knowledge levels rose significantly for fewer methods, and the magnitude of the changes was smaller. The dramatic increases in awareness of the female condom in both cam- paign and comparison sites were due to a sepa- rate initiative to promote this method. Young people’s level of general reproductive health knowledge re- mained low after the campaign, especially on items regarding the safe- ty and efficacy of family planning methods. In campaign sites, correct knowledge increased significantly for only one of six questions asked: whether fam- ily planning methods can cause deformi- ties. In comparison sites, correct knowledge in- creased for whether a healthy-looking person can have HIV, but de- clined for whether fam- ily planning methods could cause infertility.
Approval and Attitudes The campaign succeeded in generating discussion on a wide variety of top- ics, including sexual is- sues, HIV and AIDS, and physical growth and ma- turity. Analyses control- ling for background vari- ables reveal that in the period during and im- mediately after the cam- paign, respondents in campaign sites were sig- n i ficantly more likely than those in comparison sites to have a discussion with anyone about STIs
tionwide, 41% of young people living in urban areas had heard the program—a substantial proportion, considering that the show had been on the air for just six months at the time of the survey. Five per- cent of listeners reported having called the show to discuss problems with boyfriends, gangs, drugs, STIs and other issues. In the campaign sites, 67% of young peo- ple recognized the campaign’s logo. By comparison, 98% recognized the Coca-Cola, Dairy Board and Bata Shoe logos, all of which have been in use for more than a decade. Ninety-four percent of respondents in campaign sites recognized the Shona and Ndebele slogans, compared with 52% in comparison sites. High rates of recall in comparison sites probably reflect that the slogans were phrases in common usage and appeared nationwide on clinic calendars.
Gains in Knowledge The campaign did not produce new mate- rials on contraceptive methods because such pamphlets and posters already exist- ed. However, it provided an enabling en- vironment for young people to learn about contraceptives. In campaign sites, respon- dents’ knowledge of every contraceptive method except the implant increased sig-
and AIDS (78% vs. 67%), whether to have sex (77% vs. 69%), menstruation (56% vs. 47%), body changes associated with pu- berty (50% vs. 41%), the pressure to have sex (48% vs. 42%), sexual urges (43% vs. 34%), wet dreams (43% vs. 34%) and where to buy contraceptives (40% vs. 34%). When asked if they had taken action as a result of the campaign, young people were most likely to report having discussed re p roductive health issues with others (Table 3). Eighty percent of respondents in campaign areas said they had talked with someone—mostly friends (72%), but also siblings (49%), parents (44%), teachers (34%) and partners (28%). When back- ground characteristics are accounted for, these youths were more likely than their peers in comparison areas to report such discussions (odds ratios, 3.5–5.7). While rel- atively few young people had spoken to their partners, many were not married or dating at the time of the campaign and thus did not have a partner to talk to. The campaign had less success in shift- ing young people’s thinking about gen- der roles. Respondents were asked whether the male, the female or both part- ners should be responsible for making sex- ual decisions. About four-fifths of young people in both campaign and comparison sites believed that the male should decide whether to have sex (not shown). Opin- ions did not differ by respondents’ age or gender, and no significant change oc- curred between baseline and follow-up.
Table 2. Percentage of respondents in baseline and follow-up surveys who knew of specific family planning methods, percent- age who correctly answered questions about reproductive health and odds ratios from multiple regression analysis indicating the likelihood of knowledge or a correct response, by study site Type of knowledge Campaign Comparison Base- Follow- Odds Base- Follow- Odds line up ratio line up ratio Know method Condoms 84.3 96.7 4.3*** 94.9 96.5 1. Pills 69.9 89.1 2.9*** 83.0 87.5 1.9*** Injectable 36.5 57.1 2.3*** 46.2 49.8 1.5* Female sterilization 32.5 50.0 1.9*** 42.9 40.5 1. IUD 30.0 47.0 2.1*** 41.2 41.3 1. Male sterilization 29.0 42.3 1.7*** 35.4 31.0 0. Female condom 25.4 68.2 8.2*** 29.4 60.0 5.3*** Implant 15.2 19.3 1.2 10.6 21.1 2.5*** Correctly answer Can a woman can get pregnant the first time she has sex? 62.5 70.1 1.2 67.8 68.5 1. Can family planning methods cause deformities? 48.1 54.3 1.2* 55.4 54.8 1. Can family planning cause infertility? 37.8 42.3 1.2 47.9 38.5 0.7* Can a healthy-looking person have HIV? 78.1 84.0 1.2 79.7 87.5 1.9*** Can you get HIV the first time you have sex? 70.2 73.8 1.0 68.9 64.8 0. Do condoms have small holes that allow HIV to pass through? 46.9 48.2 1.0 46.8 51.8 1. *p<.05. ***p<.001. Notes: Knowledge of methods includes spontaneous and prompted knowl- edge. Regression analysis controlled for respondents’ age, sex, education, sexual experience, marital status and urban-rural residence.
Table 3. Percentage of respondents who reported taking action as a result of exposure to the youth campaign, by study site, and odds ratios from multiple regression analysis indicating the like- lihood of taking action Action Campaign Comparison Odds ratio ALL RESPONDENTS (N=970) (N=294) Had discussion 79.8 20.2 5.6***** With friends 72.0 32.7 5.7* With siblings 48.9 20.1 3.8*** With parents 44.0 15.3 4.3*** With teachers 34.2 14.0 3.5*** With partner 27.8 12.6 3.8*** Adopted safer sexual behavior 63.9 37.8 2.9***** Said no to sex 52.7 31.6 2.5* Continued abstinence 31.5 22.3 1.2*** Avoided “sugar daddy” 11.0 9.1 1.1*** Sought services 33.5 9.5 7.6***** At health center 28.2 9.5 4.7* At youth center 10.8 1.7 14.0*** RESPONDENTS WITH SEXUAL EXPERIENCE (N=334) (N=99) Took any action 41.3 10.1 8.8***** Stopped having sex 12.6 5.1 2. Stuck to one partner 20.4 2.0 26.1* Started to use condoms 10.5 2.0 5.7* Asked partner to use condom 1.5 1.0 1. *p<.05. ***p<.001. Note: Regression analysis controlled for respondents’ age, sex, educa- tion, sexual experience, marital status and urban-rural residence.
Volume 27, Number 1, March 2001 17
audiences among adults, including parents and providers. High levels of cam- paign exposure and mes- sage recall were due to the appeal of the cam- paign components. This appeal, in turn, resulted f rom young people’s participation in every as- pect of designing and im- plementing campaign materials and activities. The entertainment-edu- cation strategy dre w large audiences to launch events, but was not as successful (in terms of ei- ther exposure or impact) for the radio pro g r a m. Language problems may explain the discrepancy: Rural youths pre- fer radio broadcasts in Shona and Ndebele rather than in English. Greater use of local languages in all components of the cam- paign might have increased its re a c h. (ZNFPC continued to air the radio show after the campaign ended, adding broad- casts in local languages and on other radio stations to reach rural youths.)
Heightening Impact Compared with other multimedia cam- paigns promoting safer sexual behaviors among young people,^30 the campaign had little impact on reproductive health knowledge and beliefs but generated high levels of interpersonal communication. A countercampaign run concurrently by a prolife organization may have contributed to young people’s misconceptions about condoms, HIV and AIDS. The campaign’s failure to emphasize basic facts about re- productive health may also explain its lim- ited impact on knowledge in this area. Yet the campaign did prompt young people to discuss a range of reproductive health issues with friends and family, and early discussions about reproductive health is- sues may prompt more responsible deci- sions later in life.^31 Indeed, a full assess- ment of the campaign’s impact would follow up young people for years rather than months. Given the campaign’s brief duration and the preponderance of sexually inexperi- enced young people in its audience, it had a strong influence on behavior. While it is impossible to directly compare the impact of different adolescent health campaigns because various outcome measures are used, the proportions of respondents who
services increased (Table 5). The intensity of campaign exposure also had a positive influence on their knowledge of family planning methods, but it was not related to reproductive health knowledge or be- liefs about which partner should make the decision to have sex (not shown).
Discussion
Maximizing Campaign Exposure Like several other multimedia campaigns promoting reproductive health among adolescents,^29 the Zimbabwe youth cam- paign reached more than 90% of its cho- sen audience, in most cases with multiple materials and activities. It succeeded in reaching young people of different ages and backgrounds because of the variety of activities and materials deployed. For example, launches proved especially pop- ular in rural areas, where entertainment is limited, while the radio program and hot line had greater reach in urban areas, where young people are more receptive to English-language broadcasts and tele- phones are readily available. Although it was harder to connect with 10–14-year-olds and sexually inexperi- enced youths than with others, the cam- paign did surprisingly well at reaching these groups, given the bias in Zimbabwe against teaching children that age about sexual issues and their lack of immediate need for reproductive health advice. Op- erating in the schools increased exposure among the youngest, least sexually active group. However, the best way to reach older, out-of-school youths proved to be activities that reach a general audience. Anecdotal evidence suggests that these ac- tivities also reached important secondary
reported changing their sexual behavior or seeking reproductive health services in response to the campaign in Zimbabwe are similar to those from other multimedia campaigns.^32 However, the campaign did not increase contraceptive use as much as social marketing campaigns that have fo- cused on promoting condoms.^33 The use of multiple channels of com- munication contributed to the campaign’s impact. The evaluation confirms a clear dose-response relationship between ex- posure and impact: The more materials and activities young people were exposed to, the more actions they took in response. Combining mass media and community events may have been particularly effec- tive. An evaluation of the Safer Sex Cam- paign for young people in Uganda found that its featured radio program was most influential in districts that added local ac- tivities such as bicycle rallies and drama contests.^34 Likewise, a comparison of four operations research projects in Sub-Saha- ran Africa found that the most effective adolescent sexual health campaigns com- bined mass media with interpersonal com- munication.^35 In the Zimbabwe campaign, as elsewhere, local events ensured that messages were expressed in young peo- ple’s own languages, in familiar contexts and with the endorsement of respected local figures. This finding confirms that mass media and interpersonal communi- cation channels may play complementary roles in encouraging behavior change.^36
Building Social Support One of the campaign’s greatest accom- plishments was building support, in the community and within the health care sys- tem, for reproductive health interventions directed at young people. It achieved this by decentralizing management to local committees that included representatives from local government, religious, educa- tional, health and business groups; by de- signing activities to reach a secondary au- dience of family, friends and teachers, and to prompt discussion of reproductive health issues; by training providers to overcome entrenched biases against of- fering reproductive health information and services to young people; and by in- volving providers in campaign prepara- tions and launches. Among the results of this strategy were unexpectedly high levels of parent-child discussion about sensitive reproductive health issues and increases in the number of young clients seeking reproductive health services, including STI treatment and family planning care, at youth-friend-
Table 5. Percentage of respondents who reported taking action as a result of the youth campaign, by number of components seen or heard, and odds ratio from multiple regression analysis indi- cating the effect of intensity of exposure, according to action
Action No. of components Odds ratio
1–2 3–4 5– (N=440) (N=476) (N=214)
Had discussion With friends 48.2 75.8 84.1 1.7*** With siblings 28.4 52.6 60.8 1.5*** With parents 25.9 47.2 51.9 1.4*** With teachers 21.1 34.4 42.3 1.4*** With partner 17.3 29.1 36.5 1.4***
Adopted safer sexual behavior Said no to sex 37.5 55.9 59.1 1.3*** Continued abstinence 22.3 31.1 36.9 1.2*** Avoided “sugar daddy” 9.1 9.9 7.0 1.
Sought services At health center 17.5 30.3 33.6 1.3*** At youth center 5.0 12.3 17.8 1.6***
***p<.001. Note: Regression analysis controlled for respondents’ age, sex, education, sexu- al experience, marital status and urban-rural residence.
Situation of Adolescents and Young Adults in Zimbabwe , Calverton, MD, USA: Macro International, 1997.
8. Zimbabwe CSO and Macro International, 1995, op. cit. (see reference 2). 9. Bassett M and Sherman J, Female Sexual Behavior and the Risk of HIV Infection: An Ethnographic Study in Harare, Zim - babwe, Research Report Series, Washington, DC: Interna- tional Center for Research on Women, 1994, No. 3; Rivers K and Aggleton P, Adolescent sexuality, gender, and the HIV epidemic, 1999, <ftp://lists.inet.co.th/pub/sea- aids/gend/gend164.txt>, accessed June 9, 1999; and Mun- odawafa D and Gwede C, 1996, op cit. (see reference 6). 10. Bassett M and Sherman J, 1994, op cit. (see reference 9); and Vos T, Attitudes to sex and sexual behavior in rural Matabeleland, Zimbabwe, AIDS Care , 1994, 6(2):193–203. 11. Bassett M and Sherman J, 1994, op. cit. (see reference 9); Vos T, 1994, op. cit. (see reference 10); Kasule J et al., 1997, op. cit. (see reference 4); and Rivers K and Aggle- ton P, 1999, op. cit. (see reference 9). 12. Kim YM et al., Quality of counseling of young clients in Zimbabwe, East African Medical Journal , 1997, 74(8):514–518. 13. Huber S et al., Zimbabwe Population Sectoral Assess - ment , Arlington, VA, USA: Population Technical Assis- tance Project, 1994. 14. Ibid.; Zimbabwe National Family Planning Council (ZNFPC) and United Nations Population Fund (UNFPA), Prospective Changes in Desired Family Size and Contracep - tive Use: Main Findings and Policy Implications of the Zim - babwe Socio-Cultural Study, Harare, Zimbabwe: ZNFPC, 1995; Bassett M and Sherman J, 1994, op. cit. (see refer- ence 9); and Kim YM et al., 1997, op. cit. (see reference 12). 15. Piotrow PT et al., Health Communication: Lessons from Family Planning and Reproductive Health, Westport, CT, USA: Praeger, 1997. 16. Ibid. 17. Kirby D, A Review of Educational Programs Designed to Reduce Sexual Risk-Taking Behaviors Among School-Aged Youth in the United States, Springfield, VA, USA: Nation- al Technical Information Service, 1995; McCauley AP and Salter C, Meeting the needs of young adults, Population Reports, 1995, Series J, No. 41; and Rivers K and Aggle- ton P, 1999, op. cit. (see reference 9). 18. Bassett M and Sherman J, 1994, op. cit. (see reference 9); ZNFPC and UNFPA, 1995, op. cit. (see reference 14); and Kasule J et al., 1997, op. cit. (see reference 4). 19. Grunseit A, Impact of HIV and Sexual Health Educa - tion on the Sexual Behaviour of Young People: A Review Update , Geneva: UNAIDS, 1997. 20. Jato MN et al., The impact of multimedia family promotion on the contraceptive behavior of women in Tanzania, International Family Planning Perspectives , 1999, 25(2):60–67; and Piotrow PT et al., 1997, op. cit. (see reference 15). 21. McKee N et al., eds., Involving People, Evolving Behavior , Penang, Malaysia: Southbound and UNICEF, 2000; Reger B et al., Using mass media to promote healthy eating: a community-based demonstration project, Preventive Medicine , 1999, 29(5):414–421; Valente TW and Saba WP, Mass media and interpersonal influence in a reproductive health communication campaign in Bolivia, Communication Research, 1998, 25(1):96–124; and Vaugh- an PW and Rogers EM, A staged model of com- munication effects: evidence from an entertainment- education radio soap opera in Tanzania, Journal of Health Communication, 2000, 5(3):203–227. 22. McKee N et al., 2000, op. cit. (see reference 21); and Valente TW and Saba WP, 1998, op. cit. (see reference 21). 23. Zimbabwe CSO and Macro International, 1995, op. cit. (see reference 2) 24. Singhal A and Rogers EM, Entertainment-Education: A Communication Strategy for Social Change, Mahwah, NJ,
ly clinics. Community support for the project also has enabled some key activi- ties to continue, including training for peer educators, youth-friendly clinics and the Mutare hot line. Yet no direct, quantitative evidence for the project’s impact on adults is available. Future evaluations should measure the campaign’s effects on the knowledge, attitudes and behavior of key secondary audiences. As part of the effort to build social sup- port for sexually responsible behavior among young people, the project tried to address gender constraints on sexual be- havior. The campaign called on young fe- males as well as males to take charge of their lives and fostered individual self- esteem. However, it did not directly con- front the problem of unequal gender re- lations and fell into a common trap by ask- ing young women to take actions that contradict accepted female roles, such as refusing sex or insisting on condom use, without first empowering them.^37 Gender attitudes have proven intractable in other adolescent health campaigns. For exam- ple, the Tsa Banana program in Botswana convinced young women of the health benefits of condoms, but the women still believed they would lose their partner’s respect if they initiated condom use.^38 About half of young women reported say- ing no to sex in response to the youth campaign. This is a hopeful sign, but future campaigns need to directly address the gender inequities that underlie risky sexual decisions by young people in Zimbabwe.
References
1. Zimbabwe Central Statistical Office (CSO), 1997 Inter- Censal Demographic Survey Report, Harare, Zimbabwe: CSO, 1998. 2. Zimbabwe CSO and Macro International, Zimbabwe Demographic and Health Survey, 1994 , Calverton, MD, USA: CSO and Macro International, 1995. 3. Boohene E et al., Fertility and contraceptive use among young adults in Harare, Zimbabwe, Studies in Family Plan - ning , 1991, 22(4):264–271; and Campbell B and Mbizvo MT, Sexual behavior and HIV knowledge among adolescent boys in Zimbabwe, Central African Journal of Medicine , 1994, 40(9):245–250. 4. Boohene E et al., 1991, op. cit. (see reference 3); and Kasule J et al., Zimbabwean teenagers’ knowledge of AIDS and other sexually transmitted diseases, East African Medical Journal , 1997, 74(2):76–81. 5. Joint United Nations Programme on HIV/AIDS (UNAIDS), Report on the global HIV/AIDS epidemic, June 2000, <http://www.unaids.org/epidemic_update/ report/index.html#table>, accessed Feb. 7, 2001. 6. Munodawafa D and Gwede C, Patterns of HIV/AIDS in Zimbabwe: implications for health education, AIDS Education and Prevention , 1996, 8(1):1–10. 7. Campbell B and Mbizvo MT, 1994, op. cit. (see refer- ence 3); and Meekers D and Wekwete N, DHS Zimbabwe Further Analysis: The Socioeconomic and Demographic
USA: Lawrence Erlbaum Associates, 1999; and Piotrow PT et al., 1997, op. cit. (see reference 15).
25. McCauley AP and Salter C, 1995, op. cit. (see refer- ence 17). 26. Vaughan PW et al., Entertainment-education and HIV/AIDS prevention: a field experiment in Tanzania, Journal of Health Communication , 2000, 5(Supple- ment):81–100. 27. McCauley AP and Salter C, 1995, op. cit. (see refer- ence 17). 28. Gamurorwa AB, Lettenmaier CL and Lewicky N, HIV/AIDS prevention: the Safer Sex Campaign for the youth in Uganda, in: Family Guidance Association of Ethiopia (FGAE) and International Institute of Rural Re- construction (IIRR), Reproductive Health and Communica - tion at the Grassroots: Experiences from Africa and Asia, Addis Ababa, Ethiopia: FGAE and IIRR, 1998; Israel RC and Nagano R, Promoting Reproductive Health for Young Adults Through Social Marketing and Mass Media: A Review of Trends and Practices, Washington, DC: Pathfinder In- ternational, 1997; and Johns Hopkins University Center for Communication Programs (JHU/CCP), Advocacy and mass media: a winning combination for Kenyan youth, Communication Impact , 1998, No. 2. 29. Ashford L et al., Social Marketing for Adolescent Sexu - al Health: Results of Operations Research Projects in Botswana, Cameroon, Guinea, and South Africa , Washington, DC: Pop- ulation Services International and Population Reference Bureau, 2000; Gamurorwa AB, Lettenmaier CL and Lewicky N, 1998, op. cit. (see reference 28); and Rimon JG II et al., Promoting Sexual Responsibility in the Philippines Through Music: An Enter-Educate Approach, Occasional Paper, Baltimore, MD, USA: JHU/CCP, 1994, No. 3. 30. Ashford L et al., 2000, op. cit. (see reference 29); Is- rael RC and Nagano R, 1997, op. cit. (see reference 28); and Rimon JG II et al., 1994, op. cit. (see reference 29). 31. Grunseit A, 1997, op. cit. (see reference 19) 32. Ashford L et al., 2000, op. cit. (see reference 29); Gamurorwa AB, Lettenmaier CL and Lewicky N, 1998, op. cit. (see reference 28); and Israel RC and Nagano R, 1997, op. cit. (see reference 28); and JHU/CCP, 1998, op. cit. (see reference 28). 33. Ashford L et al., 2000, op. cit. (see reference 29); Gamurorwa AB, Lettenmaier CL and Lewicky N, 1998, op. cit. (see reference 28); and Israel RC and Nagano R, 1997, op. cit. (see reference 28). 34. Gamurorwa AB, Lettenmaier CL and Lewicky N, 1998, op. cit. (see reference 28). 35. Ashford L et al., 2000, op. cit. (see reference 29). 36. McKee N et al., 2000, op. cit. (see reference 21); and Valente TW and Saba WP, 1998, op. cit. (see reference 21). 37. Grunseit A, 1997, op. cit. (see reference 19). 38. Ashford L et al., 2000, op. cit. (see reference 29).
Resumen
C o n t e x t o : Una campaña realizada en 1997–1998 por los medios de comunicación, promovió la responsabilidad sexual entre los jó- venes de Zimbabwe, y al mismo tiempo facili- tó su acceso a los servicios de salud reproducti- va mediante la capacitación de los proveedores. Métodos: Se realizaron encuestas de línea de base y de seguimiento, en las que participaron aproximadamente 1,400 mujeres y hombres de entre 10 y 24 años de edad en cinco lugares donde se realizó la campaña y en dos sitios que se utilizaron para hacer una comparación. Se realizaron análisis de regresión logística para evaluar el alcance de la exposición a la cam-
18 International Family Planning Perspectives
Promoting Sexual Responsibility Among Young People in Zimbabwe
