![](media/image1.png){width="1.5in" height="1.363888888888889in"}

Carol Underwood

Holo Hachonda

Elizabeth Serlemitsos

Uttara Bharath

November 2001

Acknowledgements

The Zambia Integrated Health Programme (ZIHP) and the Youth Advisory
Group (YAG) for the HEART Campaign, with the invaluable support of the
Central Board of Health, conducted the survey research upon which this
study is based.

We would like to thank the many individuals and organisations that
provided support to this study. The Design Team developed the HEART
Campaign, the impact of which is the focus of this report. Design Team
members, past and present, include Clement Bwalya, (Youth Activists
Organisation (YAO)), Jabulani Chiwaula (Society for Family Health
(SFH)), Susan Gilbert (Consultant), Holo Hachonda, (ZIHPCOMM
(Communication and Community Partnerships)), Lute Kazembe (ZIHPCOMM),
Brad Lucas (SFH), Regina Lungu (ZIHPCOMM), Victor Mawere (Africa
Directions), Crispin Melele (Central Board of Health (CBoH)), Matthews
Miti (Network of Zambian People Living with HIV/AIDS (NZP+)), Chris
Mukkuli, (Consultant),Chilufya Mwaba (SFH), Mary Phiri (Youth Media),
Elizabeth Serlemitsos (ZIHPCOMM), Maimbolwa Shula (ZIHPCOMM), Karen
Sichinga (Christian Medical Association of Zambia (CMAZ)), , Cecilia
Wright (NZP+) and Paul Zietz (USAID), Robert Zulu (Africa Alive!)

The baseline questionnaire was designed by Boniface Sikateyo (CBoH),
Catherine Mukwakwa (ZIHPSERVE), Cosmas Musumali (ZIHPSYS), Elizabeth
Serlemitsos (ZIHPCOMM), Ellie Burleigh (ARCH), Juan Shoemaker (JHU/CCP),
Mubiana Macwan\'gi (ARCH), Thabo Mubonda (CBoH) and Uttara Bharath
(ZIHPCOMM). The baseline survey instrument was revised and updated for
use in the impact survey by Chris Mukkuli, Elizabeth Serlemitsos, Holo
Hachonda, Maria Banda-Nkolola, MiAngel Cody and Uttara Bharath from ZIHP
together with staff at Johns Hopkins Center for Communication Programs
(JHU/CCP) headquarters.

Augustin Kapungwe (Professor at the University of Zambia), Chibwe Lwamba
(Central Statistics Office (CSO)), and Carol Underwood (JHU/CCP),
conducted the training sessions for the enumerators and supervisors.

We extend our special thanks to the District Health Management Teams in
Kitwe, Ndola, Kabwe, Chibombo, Kalomo, Livingstone, Mwense, Samfya,
Kasama, Chipata, Lundazi and Chama without whose assistance we would not
have been able to field the survey.

Chibwe Lwamba (Demographer/Statistician, CSO) and Stanley Kamocha
(Senior Statistician, CSO) supervised data entry and cleaning. Wilson
Chizebuka (CSO) provided programming support and supervised data entry,
which was carried out by Aswel Phiri, Belinda Mainza, Joseph
Mukandawire, and Shambulo Kabongo.

In the ZIHP office, Elizabeth Halubili and Hope Sibanda oversaw
financial administration and logistics. Computer backstopping was
provided by Adam Ng\'uni and Nick Venter Shamilimo.

Young people, who are actively involved in programmes for young people,
were trained to serve as supervisors and enumerators. The supervisors
were Angela Mulenga, Arthur Mazimba, Chipego Changulu, Rikki Mumba,
Robert Mtonga, and Wilbroad Mutale. The enumerators were: Aaron M.
Tembo, Beck Banda, Brenda Nyirenda, Chisenga Lupenga, Drosin
Mwanamuchende, Edford Mutumwa, Elvis Lobe, Fred Mwila, Gertrude Moola,
Jocelyn Zyongwe, Kasonde Zimba, Layson Mwanamuchende, Malunga Syacumpi,
Mapenzi M. Milimo, Martha Ng\'uni, Matanga Mallory Muchangwe, Matauka
Muliokela, Mofya Cheela, Moses Chitimwango, Moses Sikanyika, Mukwati
Akufuna, Mumba Shapi, Munyongo Munkanta, Mwamba Besa, Mwangala Manyando,
Nancy Zyongwe, Nchimunya P. Nkwengele, Robert Zulu, Soka Chirwa, Tenix
Machona, Thabo Kwawna, and Victor Mawere.

We wish to acknowledge the contributions of all the aforementioned
organisations and individuals and the generous support of the US Agency
for International Development (USAID) Mission to Zambia, with particular
appreciation extended to Robert Clay, Director, Office of Population,
Health and Nutrition, and Karen Shelley, Technical Advisor on HIV/AIDS.

Elizabeth Serlemitsos, Uttara Bharath, Holo Hochando, and Maria
Banda-Nkolola of ZIHPCOMM and JHU/CCP staff members Susan Krenn, Chief,
Africa Division, and Peter Roberts, Senior Program Officer, reviewed the
manuscript and contributed significantly to the report.

Finally, we would like to thank all the young people who participated in
the study for their co-operation in the survey, as well as all those who
provided any assistance or contributed in any way towards the completion
of this study.

The analysis, interpretation and recommendations are based on the
authors' interpretation of the survey findings. Yoonjoung Choi assisted
with data analysis under the direction of Carol Underwood, Senior
Research Officer, JHU/CCP, the lead author of this report.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Dr. Ben U. Chirwa

Director, Health Services Planning

Central Board of Health

Zambia

**Table of Contents**

**Acknowledgements** i

**Table of Contents** iii

**List of Figures** iv

**List of Charts** iv

**List of Tables** iv

**Executive Summary** v

**Introduction** 1

**Intervention** 3

**Evaluation Approach** 4

**Methodology** 5

The Baseline Survey: Methodology 5

Impact Survey 5

Theoretical Framework 7

**Findings** 9

Background Characteristics of Survey Respondents 9

**Evaluation of the Campaign** 10

Awareness/Knowledge of the Campaign 10

Media Habits 11

Comprehension of Messages 12

Self-report of Actions Taken as a Result of Viewing the Campaign 13

Attitudes towards Abstinence and Campaign Exposure 14

Correlation between Campaign Exposure and Knowledge, Attitudes

and Self-efficacy Regarding Condom Use 16

Campaign Exposure and HIV/AIDS Knowledge, Attitudes and Risk

Perceptions 17

Discussions Regarding Safer Sex 18

Risk of HIV/AIDS 19

Voluntary Counselling and Testing 19

Social Norms Regarding Sexual Behaviour 20

Campaign Viewership and Behaviour Change 21

**Conclusions and Recommendations** 23

**List of Figures**

Figure 1 TV viewership and viewership of specific health communication

spots by residence 10

Figure 2 Reasons for abstinence among young men 14

Figure 3 Reasons for abstinence among young women 14

Figure 4 Mean number of people with whom respondents discussed

abstinence 15

Figure 5 HIV/AIDS Knowledge: Ways to prevent HIV transmission 17

Figure 6 HIV/AIDS knowledge among women: \"Risk decreases after

you know someone for a while 17

Figure 7 Percent of impact survey respondents who have heard of VCT 19

Figure 8 Social norms & sexual experience among men: How many of

your male friends have had sex? 20

Figure 9 Social norms & sexual experience among women: How many

of your female friends have had sex? 20

**List of Charts**

Chart 10 Odds of primary or secondary abstinence by viewership 21

Chart 11 Odds of condom use by viewership 22

Chart 12 Odds of condom use during last sex by viewership 22

Chart 13 Cumulative effect of ideational factors on condom use among

male adolescents 24

Chart 14 Cumulative effect of ideational factors on condom use among

female adolescents 25

Chart 15 Odds of condom use by ideation and exposure 25

**List of Tables**

Table 1 Percent distribution of respondents by demographic

characteristics 9

Table 2 Percent distribution of respondents by background

characteristics 11

Table 3 Media access and media habits 12

Table 4 Self-reported actions taken as a result of viewing the HEART

campaign 13

Table 5 Self-efficacy score regarding condom use by background

characteristics 16

Table 6 Perceived risk of contracting HIV by background characteristics
18

**[Executive Summary]{.smallcaps}**

The Helping Each other Act Responsibly Together (HEART) Campaign,
designed specifically for youth and by youth, informs young people about
HIV/AIDS, discusses ways to protect oneself from HIV/AIDS and promotes
abstinence and condom use. The Campaign was designed to provide a social
context in which prevailing social norms are discussed, questioned and
reassessed. By creating an atmosphere conducive to changes in social
norms as well as in individual sexual behaviour the campaign was
intended to contribute to the nation-wide effort to enhance the
likelihood that young people would reduce their risk of HIV infection
through either abstinence or consistent condom use and, thereby, reduce
the incidence of HIV/AIDS and other sexually transmitted infections
(STIs). Young people ages 13-19 were the intended audience for the
campaign. The purpose of this report is to evaluate the impact of phase
one of the campaign on young people in Zambia.

To evaluate the campaign, a quasi-experimental, separate sample pre and
post-test design was used.[^1] The pre-test survey was conducted from
July to November 1999 and the post-test was fielded in August 2000.

The campaign goals were largely met. Among the salient findings were the
following:

-   Television is an effective way to reach young people. The HEART
    Campaign reached over fifty percent of the intended audience. 71
    percent of urban and 37 percent of rural youth saw one or more of
    the health communication spots. Young women---both urban and
    rural---were as likely as were young men to have seen some or all of
    the spots.

-   Comprehension of the messages was good. Between 60 and 90 percent of
    viewers spontaneously identified the correct message with any given
    advert.

-   Approximately 74 percent of male viewers and 68 percent of female
    viewers said that the health communication spots prompted them to
    talk with others about the spot, decide to abstain from sex until
    more mature, or use a condom.

-   On average, male as well as female viewers discussed abstinence or
    safer sex with a significantly wider range of people than did their
    counterparts.

-   Among women who are sexually experienced, 82 percent of campaign
    viewers contrasted with 69 percent of baseline and 64 percent of
    impact survey nonviewers reported they feel confident that they have
    "the ability to say no to unwanted sex."

-   Among both men and women, the perceived efficacy to use condoms was
    positively and significantly correlated with viewership.

-   Overall, viewers were more knowledgeable about HIV/AIDS than were
    nonviewers. Nearly 86 percent of viewers of *Mutale & Ing'utu*
    compared with 72 percent of nonviewers recognised that a person who
    looks healthy can still be HIV+.

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-   Using logistic regression and holding the independent variables age,
    educational attainment, urban/rural residence, and sex constant,
    data show that viewers are 1.68 times more likely to report primary
    or secondary abstinence then were non-viewers.

-   There was a dose effect: the more health communication spots
    recalled, the greater the likelihood that the respondent is
    abstinent.

-   Logistic regression analysis found that viewers were 1.91 times more
    likely to have ever used a condom and 1.63 times more likely to
    report condom use during last sex when contrasted with nonviewers
    (holding sex, age, residence and education constant). Older,
    better-educated respondents were more likely than others were to use
    condoms. Interestingly, women were more likely to report condom use
    than were men when background characteristics were held constant.

While impressive, the findings indicate that, in designing the next
phase of the Campaign, the Design Team should consider the following
recommendations:

-   Continue to support and encourage abstinence or a "return to
    abstinence" as a viable alternative;

-   Convey the idea that abstinence is a social norm among young people;

-   Portray the use of consistent condom use as a social norm;

-   Address HIV/AIDS misconceptions directly and in multiple adverts;

-   Continue to encourage young people to discuss safer sex and/or
    abstinence with their partners, close friends and family members;

-   Continue to encourage consistent condom use;

-   Design a health communication spot to help convince all sexually
    active young people that, while they are at risk, they can practice
    safer sex. While some element of "fear" may be needed to convey this
    message in a compelling manner, research shows that it will only be
    effective if accompanied by information regarding specific ways to
    protect oneself from the risk. In short, even as it heightens the
    viewer's awareness that he or she is at risk, it should seek to
    enhance his or her self-efficacy by suggestion options.

The HEART Campaign is one among a range of programs designed to enable
young people to protect their reproductive health. Community
mobilisation efforts, faith-based projects, school curricula and several
media programs have addressed many of the issues central to the HEART
Campaign. While the independent correlation between exposure to the
HEART Campaign and positive reproductive health choices has been
demonstrated, positive secular changes also occurred over the same time
frame that could not be attributed to the campaign, which one could
argue reflects the synergistic effect of multiple campaigns and
interventions. The data show that, while important progress has been
made, there is still much to be done. The HEART Campaign should continue
to expand the depth and breadth of its reach. Future research should be
designed to capture the synergistic effects of reproductive health
programs for young people by asking respondents about their involvement
in community-based programs and exposure to the whole gamut of
HIV-related mediated messages.

INTRODUCTION

**Background**

Youth constitute an important segment of the Zambian population.
Approximately 15 percent of all Zambians are between the ages of 13 and
19, inclusive. Fully 25 percent of women of reproductive age are 19
years of age or younger. The reproductive health knowledge and practices
of Zambia's youth will influence demographic and health trends for
decades to come. Moreover, the social norms embraced by Zambian youth
today may well presage society-wide acceptance in the years ahead,
particularly given the dire and ever-present consequences of Zambia's
full-blown HIV/AIDS epidemic.

The following data describe the context of HIV/AIDS and sexual behaviour
among youth in Zambia:

-   Approximately one in six urban youth aged 15 to 19 is HIV positive
    (Zambian Sentinel Surveillance, 1999)

-   By the age of 15, 37 percent of boys and 27 percent of girls have
    had sex (Zambia Sexual Behaviour Survey, 1998)

-   Among 15-19 year olds, 62 percent of the boys and 59 percent of the
    girls say they had had sex (Zambia Sexual Behaviour Survey, 1998)

-   Of those who have had sex, 84 percent DID NOT use a condom the last
    time they had sex (Zambia Sexual Behaviour Survey, 1998)

-   By the age of 19, only 16 percent of Zambian youth report that they
    have never had sex. (Zambia Sexual Behaviour Survey, 1998)

-   64 percent of girls and 70 percent of boys think they are at no risk
    of contracting HIV (Zambia Demographic and Health Survey, 1996)

-   Among sexually active, never-married youth, 24 percent of boys and
    13 percent of girls reported that they had more than one partner in
    the past year (Zambia Sexual Behaviour Survey, 1998)

In light of this situation, the Government of the Republic of Zambia
(GRZ) asked USAID and its implementing partner, the Zambia Integrated
Health Programme (ZIHP), to work with the Central Board of Health, the
AIDS Council and Secretariat, NGOs and young people themselves, to
implement a mass media campaign to address youth and HIV/AIDS. The
primary objectives of the media campaign are to bring about behaviour
change or influence behaviour formation that will prevent further
transmission of HIV.

The Helping Each other Act Responsibly Together (HEART) Campaign,
designed by youth specifically for youth, informs young people about
HIV/AIDS, discusses ways to protect oneself from HIV/AIDS and promotes
abstinence and condom use. The overall campaign goal is to provide a
social context in which prevailing social norms are discussed,
questioned and reassessed. By creating an atmosphere conducive to
changes in social norms as well as in individual sexual behaviour the
campaign will contribute to the nation-wide effort to reduce the
incidence of HIV/AIDS and other STIs. The purpose of this report is to
evaluate the impact of that campaign on young people in Zambia. To that
end, findings from pre-test and post-test surveys are compared and
contrasted herein.

**INTERVENTION**

To develop the campaign, a Design Team of communication and adolescent
reproductive health specialists, including seven young people, was
created.[^2] The Design Team is responsible for strategic planning,
campaign development and implementation. The young people on the Design
Team, who were drawn from a variety of backgrounds---including print,
radio, peer education, video and drama, are the key decision-makers for
critical aspects of the campaign. One of these youth is HIV+, which has
been critical to ensure the voice of the HIV+ youth in the design and
implementation of the campaign.

To achieve broader youth involvement a Youth Advisory Group (YAG)
constituted by 35 young people from 11 youth organisations was formed.
The YAG serves as an advisory body to the Design Team. The YAG developed
the communication objectives and messages for each of the four audiences
namely; abstinent males, abstinent females, inconsistent male
condom-users and inconsistent female condom-users, all in the age range
of 15 to 19 years. Finally, message concepts (commercial scripts) were
tested for appeal and comprehension through focus group discussions and
in-depth interviews; post-broadcast spot surveys were conducted to test
reach and recall. This fieldwork has involved over 1200 young people
(ages13-19) in rural and urban settings as well as in and out of school.

The Design Team assessed available data and segmented the audience as
follows:

-   girls, 15-19, who have never had sex;

-   girls, 15-19, who are sexually active and sometimes use condoms;

-   boys, 15-19, who have never had sex;

-   boys, 15-19, who are sexually active and sometimes use condoms.

As a result of the above audience segmentation and message development,
five television health communication spots were developed for Phase One.
The spots include:

-   **Ice Garden Braii**, with the message to boys that condom use is
    cool and non-use is risky;

-   **Choices I Make**, with abstinent boys reminding their peers of why
    they choose to be abstinent;

-   **"When He Says . . ."**, with a series of lines from boys to which
    girls can reply, "no to sex" and maintain their "virgin power/virgin
    pride";

-   **When it Matters**, with a message that condoms are not just for
    casual partners, but for consistent use with regular partners; and,

-   **Mutale and Ing'utu**, with the message that you can't tell who is
    HIV+ by looking.

Radio spots and songs were also developed by adapting the same messages
and concepts. Radio spots were adapted to the rural context and
translated into seven local languages. Other materials such as posters,
stickers, exercise books, messages on buses and music videos were also
developed to complement the mass media materials.

The findings reported in this study are restricted to the Phase One of
the HEART Campaign. After the follow-up study was fielded, Phase Two
commenced. This phase has four new spots:

-   **Ice Mechanic**, with a message encouraging consistent condom use
    by boys;

-   **Christine**, with the message encouraging consistent condom use by
    girls;

-   **Basketball**, with the message that you can\'t tell who is HIV+ by
    looking; and

-   **Mary**, which advocates abstinence for girls.

Phase Three, which is scheduled to commence in Autumn 2001, will be
informed by the findings reported in this study.

**EVALUATION APPROACH**

As the primary implementing partner, ZIHP devised an evaluation approach
that allowed the partners to use existing surveys to gather the
additional required information. By mutual agreement between the Central
Board of Health (CBoH) and USAID, ZIHP is being implemented principally
in 12 "demonstration districts" although certain interventions,
including mass media programs, are accessible throughout the country.
The two surveys that serve as the basis for this report were restricted
to the twelve demonstration districts. It is worth noting that Lusaka,
which accounts for 10-20 percent of the population and is the largest
urban area, is not included in this set of surveys. Adjustments have
been made to account for this anomaly.

For the purposes of survey implementation, the districts were grouped
into 4 clusters, as follows:

-   Copperbelt (Ndola and Kitwe)

-   Central and Southern (Kabwe, Chibombo, Kalomo and Livingstone)

-   Eastern (Chipata, Lundazi and Chama)

-   Luapula and Northern (Kasama, Samfya and Mwense).

### 

### METHODOLOGY

###### The Baseline Survey: Methodology

To evaluate the campaign, a quasi-experimental, separate sample pre and
post-test design was used (Cook and Campbell, 1979). The pre-test survey
was conducted from July to November 1999 to establish some key
indicators at the level of the demonstration districts, to provide ZIHP
and its major stakeholders, i.e., GRZ and USAID, with benchmark
indicators for performance evaluation. The survey was designed to
collect data on indicators related to households, health facilities
(private and public) and district health management teams.

*The sample*. The total sampling frame for the household-based component
was the aggregate of all households in the 4 clusters, which was a total
population of 2,683,982 living in 430,670 households. Within a range of
87 to 95 percent confidence limits, the minimum number of respondent
households required was 2,167. For each cluster and district, a sample
size proportionate to the total available households was selected. The
entry points were the health centres' catchment areas. Two health
centres were selected per district. (Urban health centres were
identified as centres located in or near the district centre, while
rural health centres were located outside the district centres.)
Respondents were selected so that half were urban dwellers and half were
rural residents in each catchment area of the selected heath facilities.

One to two communities were randomly selected from each of the
identified health centres. Depending on the habitant patterns, every
3^rd^ to 5^th^ household was selected for interviews. Within the
selected households, all persons meeting the selection criteria (women
between 15-45 years old, men between 15-65 years and youth between
13-19) were interviewed. The youth sample size totalled 901 (368 men and
533 women).

*The questionnaire*. ZIHP staff developed a structured questionnaire
constituted primarily of closed-ended questions. A youth module was part
of the larger survey and it is the data from the youth module that is
analysed in this report. The questionnaire (see attached) was designed
to collect information about the reproductive health knowledge,
attitudes and behaviours of young people ages 13-19, inclusive. The key
variables measured included: demographic characteristics, media habits,
sexual relations, attitudes towards and perceived social support for
abstinence and condom use as well as knowledge and attitudes regarding
HIV and STIs. The questionnaire was developed in English and
administered in English, Bemba, Nyanja, Tonga and Lozi as required.

**Impact Survey**

*The sample*. The sample was drawn with the understanding that it would
be representative of the twelve demonstration areas that constitute
ZIHP. The sampling frame comprised all young people ages 13-19,
inclusive, living in households located within the 12 demonstration
districts. Given that the total population of this cohort in the 12
demonstration districts was estimated at approximately 402,600 and the
expected frequency of the variable of primary concern---sexually active
youth---was estimated at 40 percent among this cohort, it was estimated
that a sample size of 1,000 (500 men and 500 women) would provide a
confidence level of over 95 percent. Indeed, this sample size allows
separate estimates for young men and young women as reflected in the
data analysis that follows. To allow for non-response the sample size
was inflated by ten percent, giving a total sample size of 1100. The
final sample comprised 533 young men and 656 young women.

The sample design was constrained by two factors: (1) the baseline
sample design and (2) the lack of comprehensive maps for ZIHP's 12
demonstration districts. For purposes of comparability between the
baseline and follow-up surveys, it was necessary to replicate the
baseline sample design with only minor modifications. Four teams of
eight interviewers and one or two supervisors were sent to each of four
regions: Eastern, Central Southern, Copperbelt, and Northern/Luapula.
Each region encompasses two to four of the ZIHP-CBoH demonstration
districts. At the district level, the teams met with the District Health
Director, who gave them a comprehensive list of all urban and all rural
health centres in their district. In each district, one or two urban
health centres and one or two rural health centres (depending on the
population base) were randomly selected. Respondents were drawn from the
catchment areas of the designated health centres.

Sample size was selected proportionate to the population of each of the
12 districts. In all catchment areas, four 'start' points were randomly
selected. Probability of selection is not known precisely since
comprehensive maps with household listings for the catchment areas were
not available. Therefore, probability weights could not be developed.
Statistical analysis demonstrated that the baseline and impact samples
were not statistically equivalent with respect to residence. Therefore,
weights were developed and the data adjusted accordingly to render the
two samples comparable with respect to socio-demographic
characteristics. (See Findings below for further explanation.)

*The questionnaire*. The post-test questionnaire (see attached) was
modelled after the structured questionnaire used in the baseline survey.
Sections about peer pressure, access to health facilities, and
viewership of the HEART Campaign were added. The post-test questionnaire
was field tested among 50 young men and 50 young women; adjustments to
the survey instrument were made accordingly. The survey was fielded over
a 3-week period in August 2000.

*Data analysis*. Data were field edited, cleaned and entered using SPPS
6.0. Bivariate and multivariate analyses were conducted. All
correlations were tested for significance. To examine responses on
attitudinal statements, a Likert-type summative scale was used. Five
categories were used, Strongly disagree, Disagree, Uncertain, Agree and
Strongly agree. Scores (0-4) were assigned to each of the responses to
reflect the strength and direction of the attitude expressed in a
particular statement, with 4 indicative of a strongly positive attitude
and 0 reflective of a strongly negative attitude towards the particular
statement. As significant relationships were found among many of the
statements, principal components factor analysis, using Kaiser\'s
varimax rotation, was conducted. When a group of statements was found to
be both statistically and logically related, they were considered a
"factor." By averaging the responses to a given series of related
statements, factor scores were developed. To evaluate the internal
consistency of the newly created factors, Chronbach's alpha coefficient
was computed. Typically, social scientists consider an alpha coefficient
of 0.63 or greater to constitute a strong measure of internal
reliability. For the most part, the alpha values were over 0.8.

#### Theoretical Framework

The guiding assumption of most communication theories is that
communication affects behavioural change through a process. Stage
theories of communication and behavioural change maintain that this
process occurs in a sequence of steps or stages over time. These
theories identify the major factors that influence people\'s knowledge,
attitudes, intentions and, ultimately, practices.[^3] The central
argument of stage theories is that behavioural change or adoption of an
innovation---for example, consistent condom use---begins by learning
about that behaviour (knowledge), and is followed by the development of
positive attitudes or social norms supportive of the innovation
(approval), the decision to adopt the behaviour (intention), actual
behavioural change (practice), and culminates in personal endorsement
and support (advocacy) for the innovation. Whether stated or not, use of
the terms "step" and "stage," implies that each stage is a prerequisite
for, and leads to, the subsequent step. Yet, not all individuals
\"advance\" through all the stages. Moreover, some individuals \"skip\"
a stage or move back and forth among the different stages. In other
words, behavioural change is not necessarily a linear process. While
most theorists who embrace stage theories of behavioural change now
recognise this, the reader must always be reminded that the model is not
linear even though it appears so.

Over the past two decades considerable research has been conducted to
test stage theories of behavioural change and, in the process, variables
such as perceived risk, social norms, self-efficacy, and collective
efficacy. Discussions about a given innovation have been subsumed under
the "attitudinal/approval" stage. Gradually, it became clear that a
constellation of factors is correlated with behavioural change. Cleland
and Wilson use the term "ideation" when referring to the collection of
psychosocial variables associated with behavioural change.[^4] Their
central contention is that a common language and geographical proximity
allow "changing perceptions, ideas, and aspirations" to be shared---that
is, communicated---with members of one's community. While communication
often serves to reinforce shared beliefs, values and social norms,
communication channels can also broadcast reconstructed beliefs, values,
and social norms that have been altered by the introduction of new ways
of thinking. Moreover, research has demonstrated that communication
interventions can themselves introduce and promote those new ways of
thinking. It is with this understanding that the HEART Campaign was
launched in Zambia.

The HEART Campaign was designed to influence sexual practices of young
people, with a focus on abstinence and condom use. In this study, we
seek to identify what factors are correlated with risk reduction
practices. The two primary hypotheses that will be tested follow:

> *(1) Viewership of the HEART Campaign will be associated with higher
> levels of knowledge about, positive attitudes towards, and perceived
> social support for risk reduction practices.*
>
> \(2\) Viewership of the HEART Campaign will affect the likelihood that
> young people will adopt risk reduction practices---particularly
> abstinence or condom use---by influencing the factors that are related
> to behavioural change.

In other words, it is anticipated that those young people who are more
knowledgeable, report higher levels of self-efficacy, and perceive
higher levels of social support for risk reduction practices are more
likely than their less knowledgeable, less confident counterparts to
engage in risk reduction practices.

Among the factors related to behavioural change is the importance of
perceived social support for risk reduction practices. When an attitude
or behaviour is considered a social norm, community members are likely
to think others will support or approve of a given attitude or
behaviour. Social norms emerge from collective beliefs about attitudes
and behaviours that are prevalent, acceptable, or even expected in a
particular social context. That is, social norms are neither constant
nor universal but change over time. The campaign is intended to
influence community or social norms even as it affects individuals'
attitudes and behaviours. Several of the health communication spots were
designed to address this issue directly by encouraging positive peer
pressure for responsible sexual behaviour as discussed above.

The extent to which the campaign has been successful can, in part, be
evaluated on the basis of the following specific goals and objectives
for viewers of the campaign:

-   Significant increases in positive attitudes about abstinence and
    condom use;

-   Significant increases in willingness to discuss these practices;

-   Increased acceptability of "waiting to become sexually active";

-   Enhanced self-efficacy with respect to "the ability to say no";

-   Enhanced self-efficacy with respect to condom use;

-   Increased likelihood of condom use; and

-   Delay in sexual debut or higher levels of abstinence among viewers
    when contrasted with those who did not recall the campaign.

### FINDINGS

**Comparisons of the Baseline and Follow-up Findings**

***Background characteristics of survey respondents***

As noted, this report is based on two data sets. Statistical tests show
that, while the two samples are equivalent with respect to age
distribution and educational attainment, the post-test had significantly
more rural male respondents but fewer rural female respondents than was
true of the pre-test. Since residence is often correlated with
ideational factors and related behaviours, it was necessary to adjust
the samples so that the urban-rural distributions in the two samples
would be comparable. Therefore, both samples were adjusted to reflect
the urban-rural distribution found in the 1996 DHS by creating weights.
All data presented or discussed in this report are adjusted so are
representative of the youth populations in the 12 districts in which
ZIHP is active.

Table 1 shows that the distribution by sample cluster differs
significantly between the two surveys. This was intentional as the
post-test sample was selected proportionate to size, which was not the
case with the baseline. Comparisons between respondents of the two
surveys will be shown when it is necessary to distinguish between
secular changes and changes correlated with exposure to the campaign.

**Evaluation of the Campaign**

![](media/image2.wmf)To assess the actual impact of the *HEART Campaign*
as opposed to changes that may have happened over time even in the
absence of this particular set of interventions, we will also examine
differences between impact respondents who saw all or some of the
television health communication spots and those who saw none. We refer
to these two groups as "viewers" and "non-viewers."

**Awareness/Knowledge of the Campaign**

Just over half of the impact respondents reported that they had seen all
or some of the television adverts (Figure 1). Viewership of all health
communication spots was significantly higher in urban than rural areas,
which was anticipated given that 56 percent of urban but only 18 percent
of rural respondents reported household ownership of a television set.
Nearly 43 percent of urban and about 14 percent of rural youth recalled
all five adverts. While significantly more male than female respondents
recalled *Ice* and *When It Matters*, young men and women were equally
likely to recall the other health communication spots (data not shown).
Still, *on average young men as well as young women recalled two
adverts*.

Table 2 contrasts the background characteristics of viewers and
nonviewers of the HEART Campaign. (Nonviewers include those who reported
that they never watch television as well as those who did not recall any
of the spots.[^5]^)^ Approximately 50 percent of female and 53 percent
of male respondents reported that they saw at least one of the TV
adverts. *Exposure to the campaign was not significantly different
between men and women.*

That is, young women were as likely to have seen the campaign as were
young men. This is an important finding as nationally representative
surveys in Zambia typically find that men have better access to
television than women do. Indeed, a survey conducted in 1996 found that
38 percent of men age 15-49 but only 29 percent of women age 15-49
reported that they watch television at least once a week.[^6] Since the
sample for the results reported in this report was younger than is
typical of nationally representative samples, this suggests that, as the
current cohort of young people ages, the differences in media access
between men and women will no longer be an issue in the design and
development of communication campaigns.

The age distribution of viewers is similar to that of nonviewers. Among
both male and female respondents, viewers are on average better
educated, of higher socio-economic status and more likely to live in
urban areas than are nonviewers. Indeed, though some 55 percent of all
respondents reside in rural areas, only 38 percent of viewers are from
rural Zambia.

**Media Habits**

Since media habits are closely linked to the likelihood of campaign
exposure, it is useful to examine young people's media access (see Table
3). Again, *the data are not presented separately for male and female
respondents because there were no significant differences between young
men and young women with respect to media habits*. As anticipated,
television ownership clearly facilitated access to the HEART Campaign.
Viewers of the campaign were more likely to live in households that
owned a radio as well as a television set. Fully 80 percent of
respondents who report television ownership in their household recall at
least one of the TV health communication spots. Interestingly, about 36
percent of female and male respondents who live in households that do
not own a television set saw the campaign (data not shown). This
suggests that young women are as likely as are young men to watch
television in a setting other than their own home.

**Comprehension of Messages**

All respondents who recalled a particular health communication spot were
then asked (1) what the main message(s) was (were) and (2) what action
if any they took as a result of having seen the spot.

The health communication spot *Ice* portrays a young man who contracts
an STI as a result of his cavalier refusal to use a condom. About 48
percent of male viewers and 39 percent of female viewers identified the
tag line, "Use a condom every time you have sex," with the spot. This
difference was only marginally significant (p\< .06). Recall of this
message was not different by urban/rural residence. Approximately 28
percent of viewers thought the health communication spot informed the
audience that "you can't tell by looking" whether one is HIV+ or not.
This message was the focus of another advert, though the association
with *Ice* is not illogical as the implied message was that any sexually
active person could have an STI.

The health communication spot *Choices* highlights the prerogative of
young men to choose abstinence until they are ready to make another
choice and gives them reasons they might choose abstinence. Eighteen
percent equated the spot with the message "abstinence is cool," 18
percent thought the message conveyed the idea that "abstinence is best,"
and 13 percent said the advert encouraged them to "wait until marriage
for sex." There were no significant differences between men and women or
by residence.

*Mutale and Ing'utu* discusses the ambitions of two young women and
reveals that the plumper of the two friends is HIV+. Of those who saw
the health communication spot, nearly 63 of male and 49 percent of
female viewers thought it served to inform the audience that "a person
who is HIV+ may look just as healthy as someone who is not." Some 33
percent of males and 20 percent of females said the message exhorts
viewers to "avoid judging a person's HIV status by their appearance."
About nine percent of young men as well as young women thought the
take-away message was to avoid sex or use a condom during sex.
(Percentages add to more than 100 since multiple responses were
allowed.)

*"When he says . . ."* cautions young women to be wary of men's efforts
to seduce them before they are ready for sex. It endorses virginity and
implies that young women should wait until marriage for their sexual
debut. Some 47 percent of male and 36 percent of female viewers said the
main message was "to say no to sex before marriage." There were no
significant differences by residence. Approximately 15 percent of
respondents mentioned that the spot upheld virginity as "cool" or as a
source of "pride."

*When it matters* depicts a number of scenes, concluding with a playful
young couple. As they become seriously involved the spot ends with the
tag line: "When there is love...Use it." At which point, the socially
marketed MAXIMUM brand is shown. Nearly 50 percent of those who saw this
health communication spot mentioned the tag line. It is also worth
noting that this was the first ad aired in Zambia to include brand
advertising for condoms.

**Self-report of Actions Taken as a Result of Viewing the Campaign**

Viewers were asked what actions, if any, they took as a result of seeing
each spot that they recalled. Fully 74 percent of male viewers and 68
percent of female viewers reported that they took at least one action as
a result of having seen the Campaign (data not shown). Young men
reported an average of 1.9 actions taken and young women took 1.5
actions on average. The action most commonly reported by respondents was
that they talked with others---friends, partners, spouses, or
parents---about the spots. The decision to abstain was also frequently
reported by viewers as a direct result of campaign exposure. As can be
seen in Table 4, differences between young men and women were not
significantly different with respect to either of these actions.

Age, educational attainment and urban residence were all positively
associated with the decision to remain or return to abstinence as well
as with the likelihood of talking about the health communication spots
to others. Young men as well as older and better-educated respondents
were significantly more likely than were their counterparts to report
that they decided to use condoms as a result of the Campaign. In short,
the resolve to take positive actions is associated with relative
power---including access to information---and prestige.

Viewers were asked what action, if any, they took as a result of viewing
the various spots. The fact that respondents were more likely to say
they chose "to abstain" than to report that they decided to use a condom
as a result of viewership, needs to be further explored. The frequency
of this response, however, should be highlighted given that a small, but
influential faction of Zambian society turned to the media to voice in
public their objections to some of the health communication messages.
This group argued that the televised health communication spots promoted
condom use at the expense of abstinence. ZIHPCOMM responded to these
allegations with a public information campaign, which was received
favourably by young people and their parents. This data provides
evidence that the audience tended to find those messages consistent with
abstinence.

**Attitudes towards Abstinence and Campaign Exposure**

Only young people who reported that they had never had sex were asked
questions regarding their attitudes about abstinence. As seen in Figure
2, young men in the impact survey were significantly more likely than
were their counterparts in the baseline survey to express fear of HIV as
the major reason for their abstinence. While this secular trend is
important and suggests that factors in addition to the HEART Campaign
are affecting the 13-19 year-old cohort, Figure 2 shows that those
exposed to the campaign were more likely than both baseline and
non-exposed impact respondents to cite fear of HIV as their major reason
for abstinence. Nonviewers were significantly more likely than either
baseline or impact viewers to report that the main reason for abstinence
was that they had neither a partner nor the opportunity for sex (i.e.,
"no opportunity" as shown in Figures 2 and 3). In short, nonviewers were
less likely than were viewers to explain their abstinence within the
context of fearing HIV.

While young women in the impact survey were more concerned about HIV and
unplanned pregnancies than was true of women in the baseline survey,
there was no correlation between exposure to the campaign and increased
concern about these issues (see Figure 3). Nonetheless, it is heartening
to see that the secular trend is towards more awareness of the risks
associated with unprotected sex. This suggests that the message is
reaching young women, if not exclusively through the HEART campaign.

The data show that about 70 percent of abstinent respondents feel
comfortable discussing abstinence with others (data not shown).
Differences between the pre/post-test were not significant nor did
demographic characteristics affect responses. When young people were
asked whether they discussed abstinence with a range of people, viewers
reported more such discussions than did non-viewers and women discussed
abstinence with a wider range of people, on average, than did men (see
Figure 4).

The ideational framework anticipates this relationship between
viewership and reported conversations about abstinence since several
health communication spots---perhaps most notably the adverts *Choices*
and *When he says*---upheld abstinence as a responsible option before
marriage.

Three-quarters of young women who have never had sex registered a high
sense of self-efficacy[^7] with respect to their ability to refuse
unwanted sexual advances. This did not change between the baseline and
impact survey. Among women who are sexually experienced, however, 82
percent of campaign viewers contrasted with 68 percent of baseline and
64 percent of impact non-viewers report that they can "say no to sex."
The differences between viewers and both nonviewers and baseline
respondents were significant. There was no significant difference
between nonviewers and baseline respondents, suggesting no secular
change in this variable (data not shown).

**Correlations between Campaign Exposure and Knowledge, Attitudes and
Self-efficacy Regarding Condom Use**

Baseline respondents were not asked whether they had heard of the male
condom or whether they knew where to obtain one. These questions were
posed in the impact survey and viewership of the program was
significantly and positively correlated with a relatively high level of
knowledge about where to purchase male condoms. Overall, 81 percent of
viewers versus 72 percent of nonviewers could name a source where
condoms could be purchased (p \< .05). This was not a specific goal of
the campaign, but we could surmise that once the audience's awareness of
the advantages of condom use was heightened, audience members would be
more likely to seek such information.

Viewers of the campaign held, on average, more positive attitudes
regarding condom users than was true of either baseline respondents or
impact non-viewers. Respondents were asked whether they agreed or
disagreed with the following statements:

1.  Boys who use condoms are cool.

2.  Boys who use condoms are promiscuous.

3.  Girls who use condoms are smart.

4.  Girls who use condoms are loose.

Respondents were given one point for each response that reflected a
positive attitude towards condom users---i.e., agreement with 1 and 3
but disagreement with statements 2 and 4---and were given no points for
attitudes reflecting a negative attitude. While only eight percent of
baseline and 14 percent of impact non-viewers scored four (on the scale
from 0 to 4), 31 percent of female viewers espoused views in keeping
with a highly positive attitude towards condom users (that is, they
scored four of four). Among men, 15 percent of baseline respondents but
39 percent of nonviewers and 41 percent of viewers held this highly
positive stance. The difference between viewers and nonviewers on this
score was not significant, but does reflect a positive secular trend
towards more positive attitudes about condom users (data not shown).

Respondents were asked a series of questions to help ascertain their
"efficacy" with respect to condom use. Among both men and women, the
perceived efficacy to use condoms was positively and significantly
correlated with viewership (see Table 5). As can be seen, by contrasting
baseline and non-viewers, levels of efficacy were constant among those
not exposed to the campaign. Men scored higher on the efficacy scale, on
average, than did women. Education was highly and positively correlated
with self-efficacy to use condoms. Urban residents and young people aged
15 and above registered higher scores than did their younger and rural
counterparts.

######## Campaign Exposure and HIV/AIDS Knowledge, Attitudes and Risk Perceptions 

Respondents in the impact survey were asked to list the number of ways
that one could prevent HIV transmission. Viewers were more likely
significantly than were non-viewers to mention abstinence as a way to
avoid transmission (see Figure 5). Men were significantly more likely
than were women to mention condom use as an alternative. In this
respect, there was no difference between viewers and non-viewers. The
HEART Campaign included the very clear message that "you can't tell \[if
someone is HIV+\] by looking." In both the pre- and post-test,
respondents were asked whether they agreed or disagreed with the
following statements:

1.  You can tell if someone has HIV/AIDS by the way that they look.

2.  You can tell if someone has HIV/AIDS by their reputation.

3.  Your risk of HIV will become less after you have known your partner
    for a few months.

As discussed above, there was neither a difference between baseline and
impact respondents with respect to the first of these statements nor
between impact nonviewers and viewers. At first glance, therefore, it
seems that the campaign had no measurable impact. When we separate out
those who recall the advert *Mutale & Ing'utu*---namely the health
communication spot that addressed this subject directly---viewers were
significantly more likely to answer correctly than were nonviewers (61
and 50 percent, respectively.)

Approximately 50 percent of baseline respondents as well as of viewers
and nonviewers of *Mutale & Ing'utu* responded correctly to the second
statement. The advert, however, did not discuss reputation. As seen in
Figure 6, impact viewers were more likely to disagree with the statement
"Risk decreases after you know someone for awhile" than were either
baseline or impact non-viewers.

Overall, impact respondents were more likely than were baseline
respondents to disagree with the statement, indicating a secular change
in addition to the impact of the campaign. Still, the small percentage
of respondents who disagreed with this statement is troubling.

In the post-test, respondents were asked: "Do you think that a person
who looks healthy could be infected with HIV?" Nearly 86 percent of
viewers of *Mutale & Ing'utu* compared with 72 percent of nonviewers
responded "yes" to this query. Educational attainment was significantly
and positively correlated with the correct answer, but other demographic
variables were not related to responses.

**Discussions Regarding Safer Sex**

Further analysis found a positive correlation between viewership and
willingness to discuss issues raised by the campaign---i.e., viewers
discussed safer sex with more people, on average, than was true of
nonviewers (data not shown). Since several of the health communication
spots placed condom use very visibly on the public agenda and gave young
people words and phrases to use when broaching this very sensitive
subject, ideational theory would lead us to expect this increase in
discussions around this topic. Differences between male and female
viewers were not significant. Sexually active young people and
better-educated young people discussed safer sex with a broader range of
people than did other respondents.

######## Risk of HIV/AIDS

Respondents were asked whether they thought they were at no risk, a
small risk, a moderate level of risk or at high risk of contracting HIV.
Age, educational attainment, socio-economic status (SES) and residence
are all uncorrelated with perceived risk for HIV (Table 6). The most
important factors correlated with the perception of moderate to high
risk for HIV are related to sexual behaviour. As might be expected,
abstinent youth are the most likely to believe they are not at risk of
HIV infection. Those who report they have had sexual relations in the
past year report higher levels of perceived risk than is true of those
who report they are not currently sexually active. Male condom users are
most likely to believe they are at 'great' risk of contracting HIV (12
percent report they are at 'moderate' risk and an additional 20 percent
think they are at 'great' risk). Female ever-users of condoms are also
more likely than are sexually active but non-condom-using respondents to
feel they are at a moderate-to-high risk of contracting HIV. While
knowing someone who is HIV+ is not related to risk perceptions (data not
shown), having a relative who is HIV+ is related to risk perceptions.

Clearly, sexually active young people severely underestimate their risk
of HIV infection. While the issue of HIV risk was addressed in the first
phase of the campaign (you can't tell by looking \[so\] use a condom
every time you have sex), there was no significant correlation between
exposure to the campaign and risk perception. Still, the fact that there
was a significant decrease between the baseline and impact survey in the
percentage of sexually active young people who believe they are at no
risk of contracting HIV is a positive sign.

**Voluntary Counselling and Testing**

While the HEART Campaign did raise the issue of HIV/AIDS and other STIs,
there was no effort to promote Voluntary Counselling and Testing (VCT).
This was appropriate since services sufficient to cover the broader
population are not yet available in Zambia. Yet, the question was posed
in the impact survey for two reasons: (1) to establish a baseline
against which to measure impact of a future campaign that will be aired
once such services are in place and (2) to ascertain the correlation
between viewership of the HEART Campaign and VCT. It could be
hypothesised that exposure to the HEART Campaign would heighten one's
awareness of HIV and, concomitantly, increase one's effort to learn
about and seek VCT. The data seem to demonstrate this relationship. Male
and female viewers alike were significantly more likely to have heard of
VCT, as shown in Figure 7, than were nonviewers. About 26 percent of
female viewers versus 10 percent of nonviewers reported that they had
been tested (data not shown).[^8]

Approximately 84 percent of respondents who are sexually experienced and
have heard of VCT (n=338) expressed their willingness to pay for an HIV
test. The mean price they are willing to pay is Zambian *Kwacha* 5,500.
When asked the main reasons they are willing to pay, 22 percent said it
is necessary to pay for good services; 14 percent espoused the belief
that cost sharing is important; and 25 percent reported the
straightforward informational need to know their HIV status.

######## Social Norms Regarding Sexual Behaviour

Beliefs and perceptions are often more important than actual facts in
behaviour change. Noelle-Neumann[^9] argued that the best predictor of
behaviour---whether expressions or actions---is the individual's
perception of what others believe or do. Perceptions about sexual social
norms among peers can have a powerful influence on young people's
decisions regarding sex. Therefore, we asked young people to tell us how
many of their male friends and how many of their female friends are
sexually active. About 60 percent of the abstinent respondents believe
that none or only a few of their friends have had sex, while over 55
percent of currently sexually active respondents believe that most or
all of their friends have had sex (see Figures 8 & 9). This may be a
realistic assessment or it may be pluralistic ignorance---i.e., the
situation in which individuals perceive themselves to be in the majority
when they are not. This study does not allow us to test whether
pluralistic ignorance is a factor, but it does demonstrate that most
respondents believe they are in the majority---at least among their
friends.

Peer pressure is another factor that is associated with sexual choices.
The findings reflect the unhappy fact that 64 percent of currently
sexually active young men and 54 percent of young women feel pressure to
have sex---primarily from friends (data not shown).

**Campaign Viewership and Behaviour Change**

We have examined the relationship between campaign viewership and
knowledge, attitudes, self-efficacy and increased discussions regarding
abstinence, safer sex, HIV and condom use. The ultimate goal of the
campaign, of course, is to influence positive behaviour change. In
short, we hypothesise that viewership will be positively correlated with
abstinence or safer sexual practices, particularly condom use.

First, we examine the relationship between campaign viewership and
primary or secondary abstinence (that is, the "return to abstinence").
As reported above, bivariate analysis revealed a positive relationship
between primary or secondary abstinence and viewership: in short,
nonviewers are significantly more likely to report that they are
currently sexually active than were viewers. Since age, sex of
respondent, educational attainment, and urban versus rural residence are
often correlated with sexual choices and could account for this
relationship, we conducted a multiple logistic regression, which allowed
us to test whether campaign viewership was related to abstinence even
while taking the aforementioned factors into account.

When the independent variables age, educational attainment, urban/rural
residence, sex, and campaign exposure were regressed on the dependent
variable, sexual status, we found that viewers were 1.68 times more
likely to report primary or secondary abstinence then were non-viewers
(see Chart 10). Age was positively associated with sexual activity,
while education was negatively associated. That is, younger respondents
were more likely to be abstinent than were older respondents and, all
other things being equal, better educated respondents were more likely
to practice abstinence than were their less-educated peers. There were
no differences between urban and rural respondents with respect to this
outcome variable when taking into account the other variables. Women are
less likely to be sexually active than are men.

![](media/image11.wmf)

Campaign exposure can also be more finely measured as there were five
spots and respondents were asked about each. Communication research
often finds a 'dose effect': that is, the more messages to which a
viewer is exposed, the greater the impact. Therefore, we regressed the
independent variables age, educational attainment, urban/rural
residence, sex, and campaign exposure (utilising the scaled exposure
variable that ranged from 0 to 5) on the dependent variable, sexual
status. The findings for this regression were particularly interesting
as the number of spots recalled was found to be negatively associated
with current sexual activity---an important finding as this demonstrates
that the more health communication spots recalled, the greater the
likelihood the respondent is abstinent. One might argue that selectivity
bias encourages abstinent youth to recall more adverts, but since only
two of the adverts directly encouraged abstinence, this seems unlikely.
Nonetheless, we tested for selectivity bias and found no statistical
evidence for endogeneity.

![](media/image12.wmf)Next we turn to the question of whether campaign
exposure---holding age, sex, residence, and educational attainment
constant---is positively correlated with condom use. Logistic regression
analysis found that viewers were 1.91 times more likely to report ever
use of a condom when contrasted with nonviewers (Chart 11). As discussed
earlier, the perception that one is at risk of contracting HIV is
associated with condom use in bivariate analysis. When risk
perception[^10] is added into the equation, campaign exposure remains
highly significant (.005) and the odds ratios of ever use among viewers
drops only slightly (viewers 1.87 times more likely to report use than
were nonviewers).

![](media/image13.wmf)

Logistic regression analysis found that viewers were 1.63 times more
likely to report condom use during last sex when contrasted with
nonviewers. As noted in Chart 12, the odds ratios were obtained while
controlling for sex, age, residence and education constant. Respondents
ages 17-19 were more likely to report condom use during last sex than
were their younger counterparts. Women were more likely to report condom
use than were men when holding background characteristics constant.

**Conclusions and Recommendations**

The findings presented above demonstrate that the overall goals of the
campaign were met with only a few qualifications. This section begins
with a brief summary of findings that are correlated with campaign goals
and concludes with recommendations for the next campaign phase.

Among the salient findings were the following:

-   Television is an effective way to reach young people. The HEART
    Campaign reached over fifty percent of the intended audience. 71
    percent of urban and 37 percent of rural youth saw one of more of
    the health communication spots. Young women---both urban and
    rural---were as likely as were young men to have seen some or all of
    the adverts. Still, it is important to use other media in tandem
    with television to reach the 50 percent of youth that did not recall
    the campaign.

-   Comprehension of the messages was good. Between 60 and 90 percent of
    viewers spontaneously identified the correct message with any given
    advert.

-   Approximately 74 percent of male viewers and 68 percent of female
    viewers said that the health communication spots prompted them to
    talk with others about the advert, decide to abstain from sex until
    more mature, or use a condom.

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-   On average, male as well as female viewers discussed abstinence or
    safer sex with a significantly wider range of people than did their
    counterparts.

-   Among women who are sexually experienced, 82 percent of campaign
    viewers contrasted with 69 percent of baseline and 64 percent of
    impact nonviewers reported they feel confident that they have "the
    ability to say no to unwanted sex."

-   Among both men and women, the perceived efficacy to use condoms was
    positively and significantly correlated with viewership.

-   Overall, viewers were more knowledgeable about HIV/AIDS than were
    nonviewers. Nearly 86 percent of viewers of *Mutale & Ing'utu*
    compared with 72 percent of nonviewers recognised that a person who
    looks healthy can be HIV+.

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-   Using logistic regression and holding the independent variables age,
    educational attainment, urban/rural residence, and sex constant,
    data show that viewers are 1.68 times more likely to report primary
    or secondary abstinence then were non-viewers.

-   There was a dose effect: the more health communication spots
    recalled, the greater the likelihood that the respondent is
    abstinent.

-   Logistic regression analysis found that viewers were 1.91 times more
    likely to have ever used a condom and 1.63 times more likely to
    report condom use during last sex when contrasted with nonviewers
    (holding sex, age, residence and education constant). Older,
    better-educated respondents were more likely than others were to use
    condoms. Interestingly, women were more likely to report condom use
    than were men when background characteristics were held constant.

Given these impressive findings, the question remains: How can we
enhance the next phase of the campaign so that the impact will be even
greater than the first phase? Research has shown that variables related
to the desired outcomes\--contraceptive use, abstinence, condom use,
etc.\--can be added together to create a single indicator of ideation.
Since questions regarding attitudes about and social support for
abstinence were asked only of those who categorised themselves as
abstinent, further data analysis will not enable us to ascertain the
factors correlated with abstinence beyond background characteristics.
Still, the data provide evidence of the dose effect, suggesting that it
is important to continue with this theme.

Further data analysis demonstrated that the following factors were
related to condom use:

-   Knows where to purchase condoms.

-   Knows at least three ways to protect self from HIV/AIDS.

-   Has a positive attitude towards people who use condoms.

-   Has talked with at least three people about safe sex.

-   Has an above-average sense of efficacy regarding ability to use
    condoms even when facing opposition from partner.

-   Perceives self to be at moderate-to-high risk of contracting HIV.

Not all of these variables were included in the foregoing discussion, as
they were not identified as specific communication objectives of the
project. The ideational framework is an important tool to guide impact
evaluation, but it can also be used to point out what factors are
related to the desired behavioural outcome and should, therefore, be
addressed in upcoming programs. For example, data analysis demonstrates
that risk perceptions are highly correlated with condom use, yet this
message was not explicit in the HEART Campaign. Still, it seems
important to identify those factors related to condom use, as it might
be important to include them as part of the focus of future programs.

In addition to finding that each variable listed above is correlated
with condom use, further analysis demonstrated that the factors operate
in a *cumulative* manner---as has been found in other published studies.
In short, the *greater* the number of ideational elements that apply to
someone, the *greater* the likelihood that one will adopt the behaviour
in question. In the two examples that follow, the "***cumulative
likelihood of adoption***" can be determined by examining the
*percentage* of men and women who have ever used a condom by *level* of
ideation.

As shown in Figure 13, condom use increased significantly and
dramatically with each additional ideational factor. Some 47 percent of
sexually active young men who register above the sample mean on five or
more factors have used a condom one or more times contrasted with only
four percent of those who have only one factor. Young women---at 61
percent---are even more likely than are young men to use condoms when
five or six

factors obtain (Figure 14).

These findings suggest that when program interventions address these
factors in a compelling manner results will follow. It should be
emphasised that the variables included in the model above do not
necessarily constitute a comprehensive list of ideational factors
related to condom use. Indeed, as this research continues with different
audience segments, it is anticipated that more factors that will be
found that are related to safer sexual practices and that can be
positively influenced through communication programs.

![](media/image16.wmf)

The odds ratio for condom use by those with low (below the median)
levels of ideation contrasted with those who express high levels of
ideation (at or above the median) are shown in Chart 15. This
demonstrates that those with high levels of ideation are three times as
likely to report condom use as are those who express low levels of
ideation. When campaign viewership is included in the logistic
regression along with age, educational attainment, residence, sex, TV
ownership and ideation, the correlation remains strong: viewers are 2.3
times more likely to report condom use than were non-viewers.

Given the results from the surveys as well as from our exploratory use
of an ideational framework, the following approaches are recommended:

-   Continue to support and encourage abstinence or a "return to
    abstinence" as a viable alternative;

-   Convey the idea that abstinence is a social norm among young people;

-   Portray the use of consistent condom use as a social norm;

-   Address HIV/AIDS misconceptions directly and in multiple adverts;

-   Continue to encourage young people to discuss safer sex and/or
    abstinence with their partners, close friends and family members;

-   Continue to encourage consistent condom use;

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-   Design a health communication spot to help convince all sexually
    active young people that, while they are at risk, they can practice
    safer sex. While some element of "fear" may be needed to convey this
    message in a compelling manner, research shows that it will only be
    effective if accompanied by information regarding specific ways to
    protect oneself from the risk. In short, even as it heightens the
    viewer's awareness that he or she is at risk, it should seek to
    enhance his or her self-efficacy by suggesting options.

The HEART Campaign is part of the national HIV/AIDS programme in Zambia.
It is one among a range of programs designed to enable young people to
protect their reproductive health. Community mobilisation efforts,
faith-based projects, school curricula and several media programs have
addressed many of the issues central to the HEART Campaign. While the
independent correlation between exposure to the HEART Campaign and
positive reproductive health choices has been demonstrated, positive
secular changes also occurred over the same time frame that could not be
attributed to the campaign, which one could argue reflects the
synergistic effect of multiple campaigns and interventions. The data
show that, while important progress has been made, there is still much
to be done. The HEART Campaign should seek to expand the depth and
breadth of its reach. At the same time, complementary programmes with a
consistent set of messages on risk reduction should be encouraged.

[^1]: Cook, T.D. and D.T. Campbell. 1979. *Quasi-Experimentation: Design
    & Analysis Issues for Field Settings*. Chicago, IL: Rand McNally
    College Publishing Company.

[^2]: Phase One Design Team members included Brad Lucas (Society for
    Family Health (SFH)), Chilufya Mwaba (SFH), , Elizabeth Serlemitsos
    (ZIHPCOMM), Holo Hachonda (then Youth Activists Organisation
    Jabulani Chiwaula (SFH), Karen Sichinga (Christian Medical
    Association of Zambia), , Mary Phiri (Youth Media), Paul Zietz
    (USAID, Shula Maimbolwa (ZIHPCOMM), Susan Gilbert (Consultant),
    Uttara Bharath (ZIHPCOMM), and Victor Mawere (then Society of Women
    Against AIDS in Zambia (SWAAZ)).

[^3]: Cf., E. Rogers (*Diffusion of Innovations*. New York: Free Press,
    1962 & 1983) applied diffusion theory to the role of communication
    campaigns in increasing contraceptive use. McGuire (Theory-Oriented
    Research in Natural Settings: The Best of Both Worlds of Social
    Psychology. In M. Sherif and C. W. Sherif (eds.), *Interdisciplinary
    Relationships in the Social Sciences*. Chicago: Aldine, 1969)
    introduced the input/output persuasion theory to model how various
    aspects of the communication process in tandem with audience
    characteristics influence behavior outcomes. The conceptual
    framework known as the Steps to Behavior Change and refined by
    JHU/PCS (Piotrow, P.T., D.L. Kincaid, J.G. Rimon, and W. Rinehart.
    1997. *Health Communication: Lessons from Family Planning and
    Reproductive Health*. Westport, Connecticut: Praeger), is indebted
    to Rogers and McGuire, among others.

[^4]: Cleland, J. and Wilson, C. Demand Theories of Fertility
    Transition: An Iconoclastic View. *Population Studies* 1987,
    41:5-30.

[^5]: Those who reported that they never watch television were not asked
    whether they had seen the television spots.

[^6]: Central Statistical Office (Zambia) and Ministry of Health and
    Macro International Inc., 1997. *Zambia Demographic and Health
    Survey 1996*. Calverton, Maryland: Central Statistical Office and
    Macro International Inc.

[^7]: Self-efficacy with respect to the ability to refuse unwanted
    sexual relations was assessed by asking female respondents (1)
    whether they believe they have the right to refuse unwanted sex; (2)
    whether they know how to refuse unwanted sex; and (3) to describe
    how they would refuse unwanted sex. A scale from 0 to 3 was created
    from responses to these questions. A score of three (i.e., the
    respondent answered yes to the first two questions and was able to
    give a relevant response to the third question) was considered to
    reflect a high degree of self-efficacy with respect to the ability
    to say no to sex.

[^8]: It should be noted that only sexually experienced respondents who
    had heard of VCT were asked whether they had been tested (n=192).

[^9]: Noelle-Neumann, E. 1984. *The spiral of silence: Public
    opinion---our social skin*. Chicago: University of Chicago Press.

[^10]: While perceived risk is correlated with having a relative who is
    HIV+, condom use is not correlated with having a relative who is
    HIV+ when risk is included in the regression. In short, having a
    relative who is HIV+ is indirectly but not directly related to
    condom use. Risk perceptions, as we have seen, are directly related
    to condom use.