The Funding that has Fueled an Ineffective Intervention-Isadora Nogueira

Intervention: The President’s Emergency Plan For AIDS Relief (PEPFAR) and the Official AB Policy in Uganda

Although a public health intervention’s purpose is for societal improvement, it may be ineffective end harmful if not implemented adequately. In 2004, the Bush administration approved its plan for AIDS relief in Africa- the Presidents Emergency Plan for AIDS Relief (PEPFAR). PEPFAR provides a total of fifteen billion dollars within a five-year period to fourteen African and Caribbean countries. The White House will give $6 billion this year for global AIDS. However one of the requirements for the country receiving the funding is that one third of the overall prevention budget and two thirds of the behavioral prevention budget be spent on abstinence/being faithful (AB) programming. Not only does it dictate that thirty-three percent of the funding go to abstinence-until marriage programs, it limits condom-distribution to “high risk” groups and does not allow the funding to be spent on sex workers (1). In Uganda, with the PEPFAR funding, the government established an official “AB” policy in 2004, undermining the previous ABC policy which included promoting condom (C) usage. Before the AB policy, HIV activists in Uganda had spent the last two decades trying to normalize condom usage. PEPFAR’s guidelines for funding, which has fueled the official AB policy is ineffective and may do the opposite of its intended purpose: to decrease the spread of HIV. The past couple of years HIV in Uganda has actually increased (2). PEPFAR is ineffective because it places too much emphasis on internal characteristics of the individual. Furthermore, it does not universally address all the groups in the community while increasing the stigma on those who become infected. Lastly, it does not take into account the cultural behaviors prevalent in the community.

The AB plan heavily emphasizes internal characteristics, failing to take into account external factors.
Abstinence and Be Faithful policies emphasizes self-control and will-power of the individual. Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (3). Using the SCT, the AB method fails to consider the variety of other factors that affect behavior, and only emphasizes the internal characteristics such as behavioral capability, expectations, and self-control. However, solely addressing these characteristics is not enough. Even if the individual has the intention to avoid sexual intercourse, it may not necessarily translate into action, for we are influenced by much more than our own characteristics but by those around us. Furthermore, even excluding the environmental and social influence, sticking to the AB policy is difficult nonetheless. According to past research and interventions, abstinence is tough and even people who swear by it have a hard time sticking with it (4). Ninety-five percent of the American population has premarital sex (5). In the study Promising the future: virginity pledges and first intercourse, teens who pledged not to have premarital sex were followed over the period of six years. Sixty percent of these teens had broken their vow, which supports the notion that intention does not translate into behavior. Furthermore these teens who pledged to refrain from sexual intercourse until marriage were more likely to engage in oral and anal intercourse and less likely to use condoms compared to non-pledging teens (6). In the United States, the abstinence approach has been ineffective in twelve different states(2).

Not only has the abstinence approach been ineffective in other countries, it also goes against empirical evidence on what has been effective in Uganda. In the last decade, HIV incidence in Uganda has decreased due to comprehensive preventative efforts. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. This first AIDS prevention campaign was called the ABC approach - encouraging sexual Abstinence until marriage; advising the sexually active individuals to Be faithful to one partner; and advising Condom use (7). The ABC approach was effective because it took into account the possibility of the individual being affected by others around him, considering the overall social and physical environment, where it is common to have sexual intercourse before marriage. The individual may be influenced by modeling, the behavior of others and by positive or negative reinforcements from that behavior. Since the adolescent or adult are not completely resistant to societal influence, a public health intervention must include a preventative method that takes these factors into account. Hence encouraging condom usage and increasing their availability are key for HIV prevention. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996. Within the last decade the C for condom in ABC has been removed. Uganda did not implement abstinence education on a large scale until the United States began promoting these programs internationally around 2001. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (8). Health policies in Uganda should be dictated by what has been effective in the past, which should address more than just individual characteristics, but external factors and the interactive process between the social/environmental cues and the individual.

The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.
Even if the individual is able to stick to the AB program, it does not guarantee that he or she will not be infected by the HIV virus. Abstinence does not protect faithful couples if one is already infected, married couples who have sexual intercourse outside of the marriage, rape victims, injecting drug used, sex workers and people who are already infected. And since in the AB policy, the person is expected to wait until marriage to have sexual intercourse, it assumes that everyone has the intention and capability of getting married, which is discriminatory and excludes certain groups of people. Homosexuals are not by law permitted to get married, so how does abstinence until marriage apply to the gay population? The abstinence policy also discriminates against sex workers, in which the person makes their living off of sexual intercourse. Those who support their families by this profession will most likely not follow the abstinence policy (2). The AB approach has also contributed to increase in stigma on those infected with HIV. The Behavior Change Communications (BCC) theory is an approach developed primarily in the global health context integrates several behavioral change theories ranging from Diffusions of Innovations to Social marketing theory. The BCC has been widely used in designing HIV interventions. One of the major goals of a BCC program are to reduce stigma and discrimination, an important characteristic of what makes a public health intervention effective (3). The AB policy does the opposite, and actually increases stigma and discrimination related to AIDS. Solely promoting messages that advocate abstinence and partner reduction stigmatizes and demoralizes those who do become infected. The message that for the person to prevent infection, he or she must resist temptations and maintain fortitude puts an overwhelming pressure on the individual and demoralizes him if he does become infected. And in countries where 90% of the population does not know their HIV status, how does one identify and avoid sexual interaction with those who are infected and those who are not (2)? Furthermore, for those who know of their HIV positive status, is he expected to not have any sexual interactions with anyone for the rest of their lives? Abstinence would promote that no one should have sexual encounters with the HIV positive person, an extremely demoralizing stigmatization to carry throughout life if the person is the one who is infected. The overemphasis on abstinence and faithful relationships increases stigma and discrimination on those who become HIV positive, precludes certain groups of people, and is not completely effective in certain cases.

Also, the program does not target all populations equally which furthers
contributes to the stigma. In terms of testing for HIV, instead of having widespread testing, the program heavily promotes couples getting married to be tested rather than encouraging universal testing. Also, the Ugandan government does not address the gay, lesbian, and transgendered community in any kind of AIDS prevention service, and therefore discriminates against specific groups. It also does not provide AIDS prevention service or education to sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, however the government does not acknowledges this fact. Furthermore, the United States only provides funding for countries that sign a contract saying the money for HIV prevention will not be spent on sex workers, therefore supporting this kind of exclusion and contributing the spread of the HIV virus. To reiterate, in the AB policy, condoms are only do be given to “high-risk” groups. However two extremely high risk groups are the gay community and sex workers, yet they are treated as if they did not exist. Currently in Uganda, the newly diagnosed HIV cases are being seen with greater intensity in married women, which is not an expected high risk group. Therefore if condoms are to be given out, they must be made available to everyone and not just certain groups that are considered “high risk”. The funding for the AB plan does not address all populations equally, for it literally excludes certain groups from being included in the funding. And since the AB plan is not applicable to everyone, it is discriminatory intervention.

The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture
The AB plan fails to take into account the overall culture in Uganda, disregarding common behaviors and cognition prevalent in the community. According to cultural anthropologists, there is a strong connection between culture and personality and its expression as behavior. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context. In Uganda, the estimated age girls have their first sexual experience is 16.7 years for girls and 18.8 for boys as of 2001(9). According to the Uganda AIDS Commission, “Ugandan youth begin sexual activity at fairly young ages and with little sexuality information.”13. With a large population of adolescents starting sexual intercourse at a relatively young age and before marriage, the abstinence policy would be hard to push in this sort of community. A public health interventionist who uses the anthropological approach would most likely consider alternatives to address the AIDS epidemic in this community. Furthermore, one fifth of marriages are polygynous, which increases the chances the HIV transmittance if one of the people already have the virus or are unfaithful. Women also marry at a much younger age usually with men who have already been sexually active for several years and who may not have used a condom in the past. In marriages, Forty percent of women experience domestic violence. In the majority of the marriages, the woman is expected to have sex whenever the husband demands it, and the chances of her convincing the husband to use a condom are much lower than with a man who she is not married to(2). The women in the Ugandan community, based on their culture, most likely do not perceive they have power over the man in remaining abstinent and demanding condom usage. The AB plan takes away from the importance of the condom and reinforces the husband’s behavior of failing to use a condom and discourages more women to demand condom. It contributes to stigmatization of condom by denormalizing its usage. In Uganda, the overall belief of the community is that condom does protect against HIV but the AB plan is minimizing the protective power of condom usage (2). Consequently less people are using condoms and more people are infected each day. The Anthropological approach would take into account these overall behaviors and make sure the health intervention fits into the cultural behaviors.

In the Anthropological model, the culture’s cognition of health and disease are important determinants of behavior. The problem with the AB policy is that it is withholding critical information about condom protection without explaining the possible risks associated with abstinence until marriage (10). Therefore the AB policy impacts the cognition in the community, but in a negative way. The AB program was implemented in halls and classrooms of primary and secondary schools across Uganda. Although the Ugandan government had initially said that condom usage would continue to be promoted, it did not maintain this position, for according to them, it conflicts with the abstinence promotion. Out of the funding the United States is giving to Uganda, 3 million is given to a program called te Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), which provides abstinence-until-marriage through assemblies, youth rallies, classroom activities. Inclusion of objective health information with images depicting ejaculation, body changes during puberty, the effectiveness of condoms, and proper cleaning of the foreskin were vetoed from being shown in the educational materials. The materials also includes some false statements about condom usage, minimizing their protective value and emphasizing overall religouss values (2). If the individual makes decisions based on cognition but the cognition turn out to be false, the individuals actions may be of great damage to himself and to those around him. The Ugandan government must promote honest messages and not withhold information in order for people make decisions based on truths rather than faulty information.

Uganda needs to maintain what has been effective in the past based on empirical data and not change solely based on funding requirements set by the United States. The AB program does not address alternatives to abstinence or provide preventative education that includes other contraceptive methods. Improved contraceptive use is responsible for 86 percent of the decline in the U.S. adolescent pregnancy rate between 1995 and 2002 (12). Uganda must reduce HIV by promoting effective behavioral strategies - which includes condom usage. It must make condoms available and affordable throughout the country. It must have HIV testing not only for married but for everyone. Finally, it must not discriminate against the gay community and sex workers, which right now are excluded from their HIV programs. The program must reach individuals of all educational levels, social economic backgrounds, genders. It must take into account cultural factors, statistics on what has been effective in the past in Uganda and in other countries.

The AB policy has shown to be ineffective on many levels. The AB policy places too much emphasis on individual factors, is not completely effective while contributing to stigmatization, and does not address behaviors prevalent in the culture. An effective HIV intervention in Uganda should not ignore empirical data and be based off of religious principles. Public health interventions should be effective and have the purpose to contribute to the well-being of the community.

Counter Intervention

Solution to: “The AB plan heavily emphasizes internal characteristics, failing to take into account external factors that impact behavior”
To decrease the emphasis on the internal characteristics, an intervention should promote alternatives to preventing HIV that go beyond being faithful or abstinent. To address the flaws of the AB plan, I propose reverting back to the ABC approach in Uganda, where “C” stands for condom usage. An intervention that focuses on promotion of condom usage, if implemented appropriately could address factors that go beyond the individual level. Although both the AB plan and the ABC plan to an extent rely on “internal” characteristics of the individual(e.g willpower), it has been consistently supported that remaining abstinent is significantly more difficult for the individual compared to condom usage (13). Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (14). An effective intervention would apply the SCT at some level. To address environmental factors that affect HIV infection, one would consider societal and social influences on the individual. Although condom usage still relies on the individual’s “internal” characteristic, if it is heavily promoted and widely available, the social and physical environment may be framed to help the individual make the decision to wear condoms. The intervention would educate in schools, health clinics, work-places, and throughout the community by lecturing about condom usage and HIV protection. Along would promoting their usage, condoms must be widely distributed and available. Condom usage must be encouraged by community leaders, whether it is in schools or in health clinics. By having community leaders and health workers, and other well-respected individuals advocate condom usage, the rest of the community may model their behavior. School programs could have individuals with HIV as spokespersons to tell their stories in order for the students to vicariously learn through them. Condom usage must be normalized and through behavior modeling within their social groups, a greater number of individuals will chose to use a condom or demand that the partner uses one. If there are a significant number of positive messages associated with condom usage, seeing the message would make someone who uses condoms positively reinforced to continue using them. Workshops should be incorporated in the health intervention in order to promote self-efficacy. It is important for schools to communicate with parents as well to gain their support in encouraging their children to protect themselves and to be good role-models by promoting safe-sex practices. Using the SCT model, not only would the internal characteristics, but the external characteristics would be addressed. There are endless interventions that could be done applying the SCT, but promoting condom usage, increasing its accessibility, and educating about the importance of condoms would make the physical and social environment more condom-friendly. With this, the external environment is more positively shaped to help the individual make the right decision.

Solution to: “The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.”
The second flaw of the AB approach is that it has shown to not be effective in the past within Uganda and in other countries. The new intervention would be based on facts of what has been effective in the past. The AB policy is not completely effective, for it ignores data that supports the fact that the AB policy generally does not work in preventing the spread of HIV. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (15). A public health interventionist who seeks to carry out an effective intervention must be aware of what has been effective in the past within that specific community and perhaps beyond it. Prior to the recent increase in HIV, there was a steady decline in HIV due to the public health intervention that implemented the ABC (Abstincence, Be-faithful-Condom) approach. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. The program included widespread availability and distribution of condoms, increasing the normalization of its usage and decreasing the spread of the virus. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996 (16). The ABC program has been effective, while the abstinence approach has been ineffective not only in Uganda, but in many several other places including the United States. A public health interventionist would look at past data and evaluate the effectiveness of different programs. Clearly, the ABC approach is what has been effective in Uganda while the AB approach has been ineffective and therefore the ABC approach is clearly what should be implemented.

Furthermore, the AB approach increases stigmatization of those infected with HIV and discriminates against certain groups of people by not providing preventative services. The new program would decrease stigmatization of HIV and would target the entire community, rather than focusing on specific groups. A program that would prevent the increase of stigmatization of HIV would provide alternatives to abstinence and being faithful, for neither protect if the person already has HIV. An effected intervention would consider the fact that abstinence until marriage and being faithful would not prevent the virus from spreading if the person is already an HIV carrier. If it is known that the person has HIV, most likely no one will want to marry or have any kind of sexual relations with the person, feeding on to the stigmatization of HIV. An effective program would focus on how condom usage protects the spread, and therefore the person with HIV would not carry such a heavy stigma. Furthermore, a significant number of people with HIV are unaware they carry the virus, and therefore only through condom usage can it be certain that the virus will not spread. The public health intervention would promote widespread HIV testing rather than promoting only couple that are getting married to be tested. It would promote condom usage to the entire population, rather than to high-risk groups. Unlike the current approach in Uganda, the new public health intervention would not discriminate against certain groups of people (17). An effective intervention should target all segments of the population, despite social class, gender, ethnicity, occupation, and sexual preference. The gay, lesbian, and transgendered community would be included in AIDS prevention service. The new intervention would also provide AIDS prevention service or education for sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, The public health practitioner knows it is unwise to ignore one specific group not only because it us inhumane, but for the well-being of all the other groups as well. HIV will spread between the groups, therefore neglecting to target one group may actually harm all of the others. The program must decrease the stigma of HIV by focusing on condom promotion and it much reach individuals of all educational levels, social economic backgrounds, genders in order to be completely effective.

Solution to: “The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture”
The new intervention would consider Anthropological factors upheld in the community. The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context (18). Since a large part of the community starts sexual intercourse at a young age, safe sex practices must be advocated to the youth, in school settings. Furthermore, the high prevalence of polygomous relationships and marriages fuel the need to invest in contraceptive education as opposed to abstinence, and further supports the need for widespread distribution of condoms(19). The normalization of condoms must occur in order to decrease stigmatization, which will occur once promotion and access to condom is available. Women must be empowered to demand condom usage through community education and workshops. The protective power of the condom must be advocated in order for the belief that it will prevent HIV infection become more widespread. Although the majority of the population is aware that condoms may protect against HIV, the AB plan is fueling the belief that it can be ineffective. The school programs must send out a clear message about the protective power of the condom, rather than focusing on other alternatives such as abstinence. The programs must teach factual, and comprehensive information regarding HIV and condom usage, without imposing any kinds of religious values. The information must not leave out pictures or figures that would be helpful for the students to understand the HIV virus and its transmittance. The intervention would educate using facts about condom usage taking into account community behaviors and cognition prevalent in the community.

As opposed to the AB policy, the ABC public health intervention would be effective if implemented appropriately. It addresses external factors rather than emphasizing internal characteristics. It decreases the stigma individuals with HIV carry. It is encompassing and target all within the population. It considers prevalent cognition and behaviors entrenched in the Ugandan community. More importantly, it has been proven effective in the past within the same community and therefore must be reimplemented in order to reverse the damages the AB intervention has caused.





References

1) Health Gap Global Access Project. 2009. President’s Emergency Plan for AIDS Relief (PEPFAR). Retrived from http://www.healthgap.org/camp/pepfar.html April 2009

2) Human Right’s Watch.2009 The Less They Know, the Better Abstinence-Only HIV/AIDS Programs in Uganda. Retrieved from http://www.genderhealth.org/pubs/HRWuganda0305.pdf . April 2009.

3) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

4) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.

5) Finer L. Trends in premarital sex in the United States, 1954-2003. Public Health Reports, 2007; 23: 73.
6) Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001; 106:859-912.
7)The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from
http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009

8)Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.

9) Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.

10)Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008

11) Health Gap Global Access Project. 2005. 10 Months and Counting: The Condom Crisis in Uganda. 2005. Retrieved from http://www.healthgap.org/press_releases/05/082905_HGAP_Uganda_call_transcript.html, April 2009.
12) Santelli, Julia.and Laura Lingberg. Explaining Recent Declines in Adolescent Pregnancy in the United States: the Contribution of Abstinence and Improved Contraceptive Use
Am J Public Health. 2007;97(1):150-156



13) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.


14) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

15) Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.

16) Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008

17) The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009

18) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

19)Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.

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.
Conclusion
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.
Conclusion
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.
REFERENCES:

1. UNAIDS. (2007). AIDS epidemic update: Sub-Saharan Africa. UNAIDS World Health Organization. http://data.unaids.org/pub/Report/2008/jc1526_epibriefs_ssafrica_en.pdf

2. Soul City. (2005). Evaluation of Soul City season 6. Institute for Health and Development Communication. Houghton, South Africa. http://www.soulcity.org.za/programmes/the-soul-city-series/soul-city-series-6

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. http://ssrn.com/abstract=1028254

5. Statistics South Africa. (2007). General Household Survey. http://www.statssa.gov.za/PublicationsHTML/P0318July2007/html/P0318July2007.html

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. http://www.comminit.com/en/node/1652

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.