Challenging Dogma - Spring 2009

Tuesday, May 5, 2009

Soul City is Not the Sole Solution: How Educational Television Fails to Address HIV/AIDS in South Africa- Kathleen Wood

An estimated 5.5 million South Africans are living with HIV, and approximately 500,000 more people are infected each year (1). The prevalence of HIV in South Africa is higher than anywhere else in the world and the rate at which this disease continues to spread points to failures of existing public health interventions to address this epidemic. A prominent public health campaign which is unproductive in its mission to curtail the spread of HIV/AIDS in South Africa is Soul City. This television series is funded by the Department for International Development and attempts to encourage HIV awareness and prevention. Soul City is a drama that depicts characters in situations that deal with HIV/AIDS and follows them through scenarios as they chose healthy behaviors.
With a solid base of viewers, Soul City is a success as a television series; however it fails as a public health intervention. Soul City began in 1994 and has been extremely popular. An evaluation conducted by Soul City found that over 80% of people were familiar with the programming, 53.5% of adults and 61.5% of children had watched the television show (2). However, despite the high level visibility and popularity, Soul City has not been successful in slowing the spread of HIV/AIDS. HIV rates have increased, not decreased, during the time the show has been on the air (1). I believe Soul City’s lack of impact can be traced to three major flaws in the intervention model. First, Soul City does not reach rural communities effectively. This population makes up a large proportion of the country and is most in need of intervention. Rural communities, however, are the least likely to have access to this intervention. Second, the theoretical framework upon which Soul City is based assumes that conveying information is enough to change behavior. This assumption does not account for the many factors which play into the decision to change behavior or address the barriers which so often prevent action. Finally, Soul City has no engagement with the population. For those few individuals who do receive the messages, and make the leap to take action, there is not support to make meaningful changes.
Ineffective in Accessing Rural Communities
The regions most profoundly affected by the HIV/AIDS epidemic are rural South African communities. These areas have a prevalence of HIV which is even higher than the already staggering statistics of HIV prevalence in the county as a whole (3). This is why it is so unfortunate that Soul City as an HIV intervention neglects these areas. Rural South Africans have less access to television. 40% of South Africans do not have television in the home and the majority of these are rural South Africans (4, 5). In a 2007 article on AIDS in South Africa from the Social Psychology Department at the London School of Economics, Campbell et. al. stated that “[rural] residents have little or no access to radio, television or any sources of information about HIV/AIDS or how to avoid it” (6).
Soul City’s inability to educate rural South Africa is not limited to just those who do not have television. Even if the programming does make it to the segment of this population with access to television, the individuals are unlikely to connect with the material. First, the program generally uses English or Zulu in dialogue. While using Zulu is a positive step, we must remember that there are 11 official languages and many more dialects in South Africa (7). While individuals in urban centers often speak English, this becomes less common in rural areas. Therefore, messages and information delivered in English to those who do not know or frequently use the language may be lost or not fully understood (8, 9). Furthermore, even if English is spoken by an individual, the message will be weakened if English is not their preferred language (7). This leads to another point, the material most often focuses on characters in urban settings. Those in rural settings have a much different lifestyle than the characters depicted in the series. The program’s power to relate to rural viewers is lessened if they cannot connect with storylines. Rural settings are often isolated, underdeveloped and lacking infrastructure (6). When Soul City depicts scenes of urban centers and crowded townships individuals who are rarely, if ever, exposed to such settings will find it hard to relate to situations. With estimates that approximately half of the South African population live in rural areas it is unacceptable that they are neglected by this intervention model (6).
Flawed Theoretical Model
I have outlined how a major segment of the population does not receive Soul City programming or cannot relate to it. Now I will explain how even for those who do hear and understand the messages, this awareness does not translate into improvement of personal health behavior. Soul City as a public health intervention follows the Theory of Reasoned Action. The Theory of Reasoned Action relies on the premise that people are rational and that our attitudes about a particular issue combined with our view of the behavior others in our social context will determine behavior (10). The theory faults in a presumption that a person’s attitudes and intention are directly linked to behavior. The theory does not explain why people with full understanding of health risks and appropriate behaviors do not practice those behaviors. This issue is continuously seen in HIV/AIDS risk behaviors (9, 11). Additionally, this theory makes the assumption that people carefully assess their feelings about a behavior before taking action. This process does not take into account the fact that people sometimes act in an irrational manner, without thinking first, or that they may act while in an altered state. In the case of limiting risky sexual behavior associated with HIV infection, factors such as alcohol use and heightened sexual arousal could likely reduce the amount of rational consideration an individual makes about their behavior. Situations such as these limit the individual’s ability to think coherently and could lead an individual to behave in a way that is not in line with their rational attitudes and knowledge about the behavior (12). I highlight this as another factor contributing to HIV/AIDS risk behaviors that it wholly unaddressed by mass media interventions such as Soul City.
Lack of Engagement and Support
The criticisms explored above point to the need for a more customized approach to HIV/AIDS intervention. This leads me to my final argument against Soul City as an effective intervention. Soul City lacks engagement with communities to support adoption of better health behaviors relating to HIV/AIDS. A number of studies have suggested although mass media campaigns such as Soul City can be effective in raising awareness of interventions, they may fail to change actual behavior unless followed with individualized contact and discussion (13, 14, 15). Furthermore, mass media as a form of health intervention risks conveying information which may be misinterpreted. This argument is particularly true in the case of South Africa where the multitude of languages, dialects, and culture make complex messages ripe for misinterpretation (14). Individuals watching the show to can incorrectly infer conclusions from the limited information Soul City can convey over the course of a single episode. Moreover, dues to the fact that these messages are conveyed via television, there is no opportunity for clarification. Even Soul City itself recognizes this as an issue. Data from a Soul City evaluation states that “knowledge of how the HIV virus is transmitted remained limited and many misconceptions continued.”(2) Without individuals in the community to hear and clarify information, there is a risk that other misconceptions are being spread through the conversations sparked by Soul City programming.
An intervention which is more targeted will be needed in order to make real change possible. An intensely stigmatized environment surrounds all aspects of HIV/AIDS in South Africa. In order for individuals to overcome the immense barriers to behavior change, they will need more support than what can be offered from a television program alone. Episodes in the series deal with confronting partners and spouses about using protection, getting tested, and obtaining treatment. The culture that exists presently will make taking these steps extremely difficult and they may even be dangerous. This is particularly true for women who risk abuse for bringing up issues around sexual behavior with their partner and who are often alienated if HIV status is discovered (16). Soul City has no way of guiding, supporting, or protecting individuals who chose to take action. Furthermore, even those who do want to make a change will not have information on resources available to them at the local level. It is clear that individual components such as information, self-efficacy, and expectations about outcomes affect behavior choices, but in order for a person to change their actions, social supports must be in place as well (11). Soul City does not provide this support.
The three major flaws outlined in this critique compound one another and progressively limit Soul City’s impact on the HIV/AIDS epidemic in South Africa. When examining this intervention, we immediately become aware that a large segment of the South African population are eliminated as potential beneficiaries of this intervention—those without television. Now, from the reduced population we have left, another portion will be unable to interpret complex messages about HIV/AIDS due to language barriers. A larger portion still will feel unconnected with the characters and environment portrayed. Surely there will be some individuals who do not fall into those categories and who will see and understand the show. However, major deficiencies in the model remain. The removed nature of mass communication as an intervention does not spur people to take action. This is particularly true in environments, such as South Africa where stigma is deeply engrained into the culture. Thus, even the limited number of individuals who do receive the Soul City messages and decide they want to take action, will not find themselves in an environment where there is social support to do so.
Soul City puts itself forward as a health promotion and behavioral change project, however, this campaign does not address the issues that would allow this change to be possible. The inability of Soul City to reach the population most in need, the ineffectiveness of the model upon which it is based and its lack of practical support, combine to form a failed attempt at health promotion. As witnessed by the continued spread of the disease, this intervention is unsuccessful. Soul City has proven to be little more than an entertaining soap opera, popular because it deals with edgy story lines, but unable to effect real change on the health of South Africa.

Counter-Proposal: Street Counselors-Kathleen Wood
As an alternative to flawed intervention methods delivered through Soul City, I propose Street Counselors. Street Counselors is a peer education and mentorship program which works with adolescent youth towards its mission of breaking through stigma associated with HIV, effectively connecting individuals to resources, and promoting youth ownership of a new era in which HIV is defeated. Program developers select natural leaders from existing youth networks within target communities to serve as counselors. These are informal leaders who are outside of the educational, health, and political institutions; such as coaches of sports teams, musicians and community workers. These young adults have the attention and trust of the youth in their communities and understand the complexity of the HIV crisis in the specific setting. Positive health behaviors are then promoted through culturally relevant programming developed through a collaborative process between counselors, public health professionals and youth participants. In order to provide connection to practical resources, the program will develop strategic partnerships with medical facilities which provide community members with testing and treatment. Street Counselors provides youth, with long-term, psychosocial support that promotes prevention and provides access to testing, treatment, and counseling.
Street Counselors will directly addresses the weaknesses outlined in the critique of Soul City. First, I will demonstrate how Street Counselors is specifically designed to access rural South African communities. Second, will describe the theoretical framework upon which it was based and explain how it is a stronger model than that of Soul City to confront the HIV in this environment. Finally, I will show how this program will engage directly with the community and provide practical support to facilitate health-enhancing behavior change. I believe Street Counselors to be a more comprehensive and effective way to address HIV/AIDS in the South African populations most affected by this epidemic.
Effectively Accesses Rural Communities
Street Counselors will be much more effective in accessing rural communities than Soul City because it does not rely on mass media as a means of delivering its message. The issues that arise due to Soul City’s mass media format are that those who don’t have television can’t access programming and cultural differences prevented others from fully relating to and understanding messages. These issues are addressed in the Street Counselors intervention model.
This program was conceived specifically to reach rural populations who currently receive a disproportionately small amount of HIV/AIDS interventions. Street Counselors interacts directly with rural communities; so lack of personal resources, such as a television will not limit access to the program. Indeed, the communities which have the fewest resources and the least exposure to urban influences will likely be the areas first targeted by Street Counselors. Not only can Street Counselors effectively access rural communities, but due to the fact that is developed with community involvement it can be adapted and scaled to fit many different environments. I believe this to be a major strength of the program.
Within Soul City, there were issues around the programming’s focus on urban environments for episode backdrops and the use of only 2 of the country’s many languages. These factors did not allow rural South Africans or those who did not speak the selected languages to connect with programming and opened room for misinterpretation of messages by non-native speakers. These issues are definitively addressed by Street Counselors because the program employs individuals from the rural community to serve as counselors delivering messages in the resident’s native language. Additionally, if there are misconceptions, then unlike Soul City, counselors are present to speak with and can clarify messages and reinforce vital details.
Drawing on community members to serve as Street Counselors is crucial. Natural youth leaders have formed connections with the people the messages need to reach and know the issues that must be addressed. Catherine Campbell, a social psychologist at the London School of Economics wrote about the key strategies for facilitating the development of HIV interventions in rural South Africa. Identified within Campbell’s key strategies were the following: developing local leadership, emphasizing community strengths, and addressing the specific impact of the disease in different communities (6). It is clear that local individuals, who know the intricacies of life in a rural community, will be unparalleled in their ability to address distinctive needs and overcome barriers to behavioral change. Furthermore, study has found that short-term programs which swoop in and out of poor communities from more developed countries or regions can undermine local capacity to create long-term and effective responses to health problems (17). Street Counselors will draw on local capacity to strengthen the program and eventually turn over workings to the community completely. I think that Campbell summed up this idea well when she stated “building ‘AIDS-competent communities’ does not necessarily involve importing solutions, conceptualized and managed by outside experts, but rather facilitating the most promising local responses” (6). In employing community members on the project and working collaboratively on programming it is hoped that community adoption of Street Counselors will be promoted, in turn creating a long-term community-based intervention which does not rely on external direction.
Appropriate Theoretical Model
Soul City was based on the Theory of Reasoned Action. It is clear that there are aspects of this model which translate poorly into an intervention for HIV/AIDS. The theory wrongly assumes that knowledge leads to action, which is a particularly relevant criticism when attempting to address HIV/AIDS risk behaviors (9, 11). Choi, Yep, and Kumekawa discussed how interventions based on models such as the Theory of Reasoned Action do not fully take into account the social context that people find themselves in and how each situation affects health behavior choices (11). This led me to conclude a more comprehensive approach is required.
The Social Network Theory is a better choice as an intervention model to address HIV/AIDS in South Africa. Engaging key individuals in established social networks will spur change within entire groups of South African youth. Social Network Theory focuses on the power that relationships have in determining an individual’s health behavior. It suggests that major changes in behavior are likely to occur in groups of people simultaneously rather than by individual choices alone (18). When applied to the area of health behavior, the Social Network Theory shows us that networks are a major force in determining whether or not an individual will adopt behaviors that support health. Health habits are often seen to reflect the health patterns of social groups (18, 19). Specifically with regard to sexual behavior, research has proven that peer influence is an important determining factor and critical dialogue about such topics as intimacy and sexuality are most likely to occur in an atmosphere of trust and solidarity (20). I believe that Street Counselors facilitates such an atmosphere through use of peer counselors.
Writing on the Social Network Theory focuses the need to closely examine and map relationships between individuals within a network. Developers of this program will select counselors who are central players within exiting social groups. This will allow counselors to use natural avenues of communication to disseminate information. Employing community members to draw on their existing influence is a powerful strategy in the Social Network Theory. The rapport that counselors already have with participants will create a naturally supportive environment within the program. The concept of community involvement is also supported by Campbell’s research. She emphasizes that community ownership and solidarity among program participants is needed to see genuine change (6). Accessing and influencing social networks spur change within groups which will then lead to change in larger surrounding networks.
Engagement and Support
The removed nature of mass media as a public health intervention left no mechanism for engagement or support through Soul City. While I do not want to argue that mass media campaigns are wholly unproductive, it is clear that when addressing sensitive subjects such as sexual behavior, more personal engagement is needed (14). Street Counselors provides a safe venue for discussion on these sensitive issues. Street Counselors will be formally trained to have the information and tools to provide to youth they work with. They will deliver health messages informally through peer education and display of positive health behaviors, but most importantly, street counselors will use their established roles as leaders to create social spaces within existing youth groups for open discussion of HIV/AIDS. I believe that the protective social network Street Counselors will create is especially important in light of the fact that HIV/AIDS is so intensely stigmatized in some communities of South Africa. The supportive environment will allow groups to question widely held misconceptions. Street Counselors will guide, support, and protect individuals who chose to take action.
Street Counselors will also have partnerships with facilities that can provide testing, treatment, and counseling. Not only will participants have a place to discuss and understand HIV/AIDS, but in express contrast to Soul City, this program has the capability to connect people with the resources needed to take action. This type of connection of multiple stakeholders has proven to be a successful technique in creating environments that support HIV-prevention and treatment efforts (6). Counselors are present to support and assist those who need to access medical facilities. They will encourage testing and adherence to treatment. In an environment that is not currently tolerant of those known to be HIV positive individuals, counselors will be present to provide psychosocial support during acute times of stress. This health behavior intervention will more effectively spur change and facilitate HIV prevention, testing, and treatment in local youth groups.
The power of Street Counselors is that it recognizing the problem of HIV in South Africa goes beyond simply imparting information to the public. Addressing the complexity of this epidemic requires a more comprehensive and holistic approach. A successful intervention must reach isolated populations, spur change by creating supportive groups of informed people, and connect those who wish to change with the resources required to do so. Street Counselors is a peer education program that recruits the most influential leaders, creates spaces for critical thinking, builds solidarity and community ownership of the cause, and adapts to addresses the specific impact of the disease in each community. The goal is for South African youth to become the first generation of change agents to effectively swing the tide in the fight against HIV/AIDS.

1. UNAIDS. (2007). AIDS epidemic update: Sub-Saharan Africa. UNAIDS World Health Organization.

2. Soul City. (2005). Evaluation of Soul City season 6. Institute for Health and Development Communication. Houghton, South Africa.

3. Shisana, O., et al. (2005). Nelson Mandela/HSRC study of HIV/AIDS: South African national HIV prevalence, HIV incidence, behaviour and communications survey. Cape Town: HSRC Press.

4. Bhorat, H., Van der Westhuizen, C., & Goga, S. (2008). Welfare shifts in the post-apartheid South Africa: A comprehensive measurement of changes. DPRU Working Paper No. 07-128.

5. Statistics South Africa. (2007). General Household Survey.

6. Campbell, C., Nair, Y., Maimane, S., & Sibiya Z. (2007). Supporting people with AIDS and their carers in rural South Africa: Possibilities and challenges. Health and Place. 14 (3): 507-518.

7. Govender, R.D. (2005). The barriers and challenges to Health Promotion in Africa. South African Family Practice, 47 (10): 39-42.

8. Pillay, K. (1999). Access to Health Care: Language as a Barrier. Socioeconomic Rights. 2005: 1, 2.

9. Alali, A., & Jinadu B. (2002). Health communication in Africa: Contexts, constraints and lessons. New York: University Press of America, Inc.

10. Salazar, M.K. (1991). Comparison of four behavioral theories. AAOHN Journal, 39:128-135.

11. Choi, K., Yep, G.A., & Kumekawa, E. (1998). HIV prevention among Asian and Pacific Islander men who have sex with men: A critical review of theoretical models and directions for future research. AIDS Education and Prevention. 10(Supplement A):19-30.

12. Airely, D. (2008). Predictably irrational: The hidden forces that shape our decisions. New York, NY: HarperCollins Publishers.

13. Dagron, A. G. (2001). Making waves: Soul City. Communication Initiative. Johannesburg, South Africa.

14. Black, M.E., Yamada, J. and Mann, V. (2002). A systematic literature review of the effectiveness of community-based strategies to increase cervical cancer screening. Canadian Journal of Public Health, 93, 386–393.

15. Prochaska, J., Norcross, J., & DiClemente, C.C. (1994). Changing for good. William Morrow, New York.

16. Dunkle, K., et al. (2004). Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. The Lancet, 363 (9419): 1415-21.

17. Pfeiffer, J. (2003). International NGOs and primary health care in Mocambique: The need for a new model of collaboration. Social Science and Medicine, 56: 725-738.

18. Edberg, M. (2007). Essentials of health behavior: Social and behavioral theory in public health. Sudbury, MA: Jones and Bartlett Publishers.

19. Christakis, N.A., Fowler, J.H. (2008). The collective dynamics of smoking in a large social network. New England Journal of Medicine, 358:2249-2258.

20. Campbell, C., & MacPhail, C. (2002). Peer education, gender and the development of critical consciousness: Participatory HIV prevention by South African youth. Social Science and Medicine. 55 (2), 331-345.

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