Conceptual framework and practical implications
Peter Franzkowiak & Eberhard Wenzel
Published in Health Promotion International, 1994, Vol. 9, No 2, 119-135
As the AIDS epidemic continues to expand and as there is no substantial hope for curative treatment, prevention keeps the only tool to cope with the threat of HIV transmission and AIDS. This article presents a conceptual framework and detailed guidelines for the planning, implementation and evaluation of AIDS health promotion for youth. The framework focuses on basic principles of health promotion and refers to the living conditions and lifestyles of youth being of relevance for the development of gender roles and sexual behavior. Community organization plays a crucial role for AIDS health promotion for youth. Only comprehensive approaches taking account of social and cultural conditions present an adequate arena for successful AIDS health promotion.
AIDS, health promotion, youth, lifestyles, sexual behavior, community organization
The global epidemic of HIV infection remains dynamic and is continuing to expand (Mann et al. 1992, Smallman-Raynor et al. 1992). At the beginning of the 1980's only about 100.000 persons worldwide were infected with HIV. Since then, more than 13 million men, women and children have become infected. This cumulative total included more than 1 million persons who were infected with HIV during the first 6 months of 1992 alone. Nearly two thirds of these live in Sub-Saharan Africa, 20% in the Americas, and about 15% in Europe, Asia and Oceania. In 1992, the World Health Organization estimated the actual cumulative global total of AIDS cases at over one million people.
AIDS constitutes a worldwide problem of major proportions, affecting developed and developing countries. Until the end of this decade, about three times more HIV infections will occur than had occurred during the 1980s. The vast majority of new HIV infections would be preventable by globally and nationally coordinated efforts. When the AIDS epidemic was first recognized, a high prevalence of HIV infection was found among specific groups: homosexual and bisexual men, users of injectable drugs, and hemophiliacs. Nowadays, it is no longer appropriate to focus on high risk groups, as the epidemic has contaminated all kinds of population groups. Prevention programmes have to concentrate on high-risk behaviors instead, that is on behaviors that expose people to infection.
Although AIDS has been a major issue of public debate nearly everywhere it is still rather difficult to talk about AIDS and HIV transmission without evoking emotional concern. However, a majority of people worldwide - especially adolescents and youth - do not perceive themselves as being threatened by HIV transmission but feel others are, due to different sexual preferences or certain risk-taking. Blaming the victim is a strategy which individuals and groups frequently choose so that they need not consider their own lifestyles.
Three modes of transmission of HIV infection have been documented so far:
Sexual transmission seems to remain the major mode of HIV infection, and in this context heterosexual transmission is increasing rapidly - especially with regard to developing countries.
At least half of those infected with HIV worldwide are under the age of 25. As many of them are likely to have acquired their HIV infection before the age of 18, AIDS is also a major concern affecting youth in every country. Adolescence, the developmental period between 10 to 19 years, and youth as the stage between 15 to 24 years are periods of profound physiological, psychological, and social change. They are also periods of time particularly related to behavioral experimentation in many aspects of everyday life, including sexuality and drug abuse.
Sexual intercourse between adolescents may bring about a potential risk of HIV infection. In many countries, a large number of adolescents do not protect themselves and their partners in case of intercourse. Sexually active young men and women often change partners before they establish a family or long-term relationships. Experimentation with illegal drugs may expose other young people to hazardous intravenous drug abuse.
In many countries, schools are a common focus of educational activities. A large number of young people throughout the world attend school or are in contact with those who do. There is a general trend towards more health education in school, including sexual and reproductive health, family planning and HIV/AIDS prevention. However, in many countries, sexual issues - if taught at all - are delivered in a highly constrained and only in a biological manner. Very often, even family-life educators will also exclude sensitive topics of adolescent sexuality.
For young people who have left school or never had the opportunity to visit one, the situation is frequently bleak. They have only limited access to counselling, diagnostic and treatment services of reproductive health - or, as in many countries, this is even prohibited by law, particularly with regard to youth . Thus, there is a growing need for HIV/AIDS education and outreach programmes that support adolescents and youth outside the school system.
The prevention of HIV transmission has become one of the most important elements in the work of WHO and many other organizations. As no medical cure will be available for AIDS in the near future and as no vaccine is available to prevent HIV transmission, a psychosocial approach to prevention, i.e., AIDS health promotion, seems to be of utmost importance.
Lifestyles conducive to health in the context of health promotion
The World Health Organization (1990a) has published A Call for Action. Promoting Health in Developing Countries, in which three principal strategies for health promotion are outlined:
Those being concerned with public health have always been strong advocates of policies aiming at the improvement of health conditions. Advocacy for health is first of all advocacy for education in every aspect and aiming at every person regardless of age, gender, social status or religious belief. Thus, health promotion programmes are designed to collaborate closely with the formal and informal educational system.
Secondly, advocacy for health is health-related political action aiming at local, regional, and national politicians and political organizations. It is social lobbying for the health needs of the people.
Thirdly, advocacy for health is the struggle for adequate resource allocation within existing local, regional, and national budgets regarding health needs of the communities. In some cases, it will be the development of health promotion budgets, in others it will be the shifting of resources from one budget to the other. We have to be prepared that health promotion - usually a rather weak player in the money game - has to strengthen its capacities if it will succeed.
Fourthly, advocacy for health is taking legal rights already existing into action. It is surprising that in many countries, neither politicians and governments nor non-governmental organizations and social groups are aware that the improvement of living conditions and lifestyles conducive to health has been made a legal right - if only by becoming a Member of the United Nations. The Declaration of Human Rights, for example, is legally binding for all Member States of the UN. In the Declaration and its connected laws, the protection of minorities, equality between females and males, access to education and health care are considered to be human rights. Many countries have nationally binding laws regarding these topics. Thus, there is a good starting point for health promotion advocacy.
We will now turn to the development of strong alliances and social support systems. Health promotion, by its definition, is related to several other sectors of society. Health may be promoted everywhere because almost each social sector contributes to health conditions. But it is also true that intersectoral collaboration is difficult to implement, since each sector follows its own sectoral objectives and policies. Nevertheless, the development of strong alliances with other social sectors than health is a priority of health promotion programmes.
Social support systems, on the other side, refer to the circumstances in which people live. Neighbours, relatives, friends, colleagues, and the family itself are elements of the support systems. Human beings live in networks of social relations. Health promotion has to address these networks in order to reach the individual and if it reaches the individual it will have access to her/his social support systems. There is a constant interplay between the individual and the networks she/is is part of. It is a formidable task of health promotion to get in touch with these systems, to enable the people to strengthen and change their relations with regard to health promotion issues, and to give support to the individual and her/his social groups in order to attain lifestyles conducive to health. We understand that building strong alliances and social support systems refers to community organization, which is seen as a key method of health promotion (Minkler 1991, Alinsky 1969).
Finally, we turn to the strategy of empowering people with attitudes, knowledge and skills enabling them to develop lifesytles conducive to health. This seems to be the traditional area of health education, covering formal and informal education related to health. As this is true, we feel however, that the scope of the strategy is somewhat wider.
All of us would like to find some simple things people can do to improve their health. Of course, there are some: many issues that have been taught by health educators during the past, sometimes successfully, however rather frequently not successfully at all. As social, cultural, environmental, economic and political conditions have become more complex and complicated in these days, simple things may be an adequate answer no more. We understand that empowerment refers to the capability of the people to share their views on health conditions with their fellow-neighbours and to recognise that they may have some of the difficulties in common. Common problems may lead to communities of people becoming enabled to solve their problems commonly. This is what empowerment means: enabling people to organise themselves as a community taking care of their living conditions and commonly striving for lifestyles conducive to health.
The new and broader health promotion concept takes a comprehensive social and ecological model of health and human development as its basis (Milio 1986, WHO 1986, 1990a). The key-term is lifestyles conducive to health.
The lifestyles concept draws heavily on sociological and anthropological knowledge concerning patterns of human action and interaction and their relation to health (Armstrong 1983, Bateson 1979, Bennett 1976, Berger & Luckmann 1967, Crawford 1984, Freund 1982, Goffman 1971, Hardesty 1977, Honigman 1973, Polhemus 1978, Strunk 1983). A fundamental difference is made between collective and individual lifestyles, which can be defined as follows (Wenzel 1983, 7f):
"The lifestyle of a social group characterises the totality of patterns of meaning and forms of expression which are produced by a group in the course of collective efforts to cope with the demands and contradictions of the social structures and situations common to all members of that group. The lifestyle brings together efforts related to the demands made, i.e. the external (social, political, economic and cultural) conditions and efforts related to the subjective situation and condition. In the lifestyle is expressed under what conditions a social group acts or reacts in a particular way, i.e. the lifestyle tells us in which directions a group tends to develop its behavior in the ongoing process of coping with the conditions in which they live. These tendencies, in the forms of common social values, norms, language forms, interaction rituals etc., provide a reservoir for individuals or subgroups which they can draw on for their personal and social identity; it makes it possible for them to give some sense and meaning to their specific situation.
The lifestyle of an individual characterises the totality of normative behavioral structures which is developed in the course of his or her life in the ongoing interaction with his or her social and natural environment. Subjective motivation and also potential action are expressed through the lifestyles and are used by the individual according to social situations. The individual's lifestyle contains variations, additions to and omissions from the collective lifestyle which are specific to that individual's personality; nevertheless the individual remains linked to his particular social group - i.e. any change in his or her lifestyle is bound by the collectively developed framework - unless, with this change, there is also a change of the social group, or it is the group which wishes to undergo such a change.
This concept of lifestyles creates a close link between the living conditions of an individual, his activities and socially formed strategies for coping with life. Characteristic for this is the linking of individual and collective lifestyles in relation to the particular socio-structural conditions in which the individual lives. Individual behavior is understood as being largely socially determined - with the implication, among others, that to change it, social changes are necessary. Thus the message for health promotion and health education is that integrative strategies for prevention and intervention must be developed - strategies whose chief characteristic is that they link up the various social sectors and are also effective within them."
The basic concept underlying the lifestyles approach is one of socialization of individuals and social groups and social interaction. Health-related behaviors of individuals and collectives are viewed as reflections of certain living conditions and attempts to cope with and/or alter these conditions. Individual behavior in a social situation is considered an outcome at a certain point in time of the life-long socialization process; since social situations change, individual behavior is also always subject to constant change.
Using this approach, it is possible to study various aspects of health promotion and of health care, including epidemiological patterns, methods used in providing clinical care, patient-caregiver interactions, prevention efforts, etc.
With regard to HIV transmission and AIDS, the lifestyles concept provides a frame of reference for:
Target areas for health promotion interventions
In order to specify appropriate approaches to and strategies for health promotion for the prevention and control of HIV and AIDS, one must analyse in detail possible target areas for preventive measures. Although various HIV transmission modes are affected by components of lifestyles, here we will primarily show how the lifestyles approach can be used to guide programmes focusing on the primary route of sexual transmission.
Sexuality can be interpreted as a specific form of bodily interaction with another person or oneself which is situated in the context of the participants' lifestyles and living conditions. Any factors impinging on individual and collective lifestyles accordingly also affect the sexual behaviors of individuals and social groups.
Sexual intercourse is embedded in a series of social situations in which persons communicate verbally and/or non-verbally their normative expectations regarding the interaction process. Usually, this communication does not include clear statements about having sexual intercourse but rather culturally- and socially accepted messages which are understood by the persons as expectations that their relationship will develop into a sexual one.
The intimate character of sexual relations makes it very difficult for people to communicate frankly about their sexual expectations and experiences before they know each other for a longer period of time. Individual sexual behavior is not a matter of public debate as far as a specific person is concerned. Although many modes of sexuality are presented publicly in magazines, books, journals, videos, films and other media, individual sexual preferences and experiences are usually not presented openly to another person at the beginning of a (sexual) relationship.
Given the above, it can be useful to distinguish focal points around which HIV/AIDS related efforts can be developed. We will discuss three such points - sexuality and concepts of body, gender roles and risk behavior; it must be noted that others are possible as well (for example, sexuality and age groups or sexuality and the concept of love).
Sexuality and concepts of body
Basically, health promotion aims at the improvement of body development and behavior as well as to enhance living and working conditions at the individual and collective levels. The term body used here is based on anthropological and ecological concepts which assume that the conditions of human beings comprise physiological, psychological, social and cultural dimensions.
In many cultures, people tend to perceive themselves and others as social beings rather than as embodied persons. The body seems to be a rather difficult issue in social communication except in terms of illness, disease and sports. However, as Bryan S. Turner states in his book The body and society: "...human beings are embodied, just as they are enselved" (Turner 1984, 1), and he continues:
"The body is the most proximate and immediate feature of my social self, a necessary feature of my social location and of my personal enselfment and at the same time an aspect of my personal alienation in the natural environment." (Turner 1984, 8).
The body is the bearer of the human being and at the same time the expression of his/her existential, i.e., economic, political, social, cultural and environmental situation. Individual and social biography are represented in the body, as are the social and cultural circumstances in which it developed; moreover, economic and ecological living conditions also find their expression in the human body. Therefore, body awareness, bodily experiences and bodily expressions are not only subject to individual choices of lifestyle over another; they are primarily structured by social communication and interaction, both of which are dependent upon the symbolic structure of the social system, i.e., the value system, normative expectations and symbolic categories such as health, wealth, happiness, satisfaction, power, etc. Relationships between the individual and collective, between personal and social development, between economic and ecological processes are both directly sensed and expressed by the body.
In introducing the concept of the body as a key element in health promotion, we are referring to the materialistic basis of both health and disease. All measures taken in this respect have an impact on body awareness, bodily experiences and bodily expressions. They interfere with bodily communication and the interaction of individuals and collectives.
There is one aspect of the body which has become more and more relevant for health promotion: the presentation of the self as a bearer of a specifically-styled body. Individual and collective strategies for the development of successful images of the self are pursued in a variety of social and cultural settings. As Turner (1984, 111) states: "successful images require successful bodies, which have been trained, disciplined and orchestrated to enhance our personal value". The symbolic power of fashion and the associated trained, styled and altered body are obvious. Practices such as scarification, tattooing and circumcision are clear examples of this. Turner further adds (1984, 112): "We jog, slim and sleep not for their intrinsic enjoyment but to improve our chances at sex, work and longevity." The body is thus used as a tool to enhance individual and social attractiveness. It is not viewed primarily in terms of health but in terms of social, and thus, sexual relations, too. Health may be a prerequisite, but it is certainly not the objective of such body management.
Given the above, it can be seen that health may play a minor role in peoples' body-related thought and actions. The WHO definition of health focuses on physical, mental and social well-being as indicators of health. In many cultures, however, well-being seems to be related to fun, pleasure, relaxation, happiness, productivity, reproduction, etc., but not necessarily to health per se. One implication of this may be utilized regarding HIV/AIDS-related health promotion in the context of (sexual) relationships: Safe sex promotion might focus on the message that the person who takes precautions is a more attractive potential partner.
Sexuality, reproduction and gender roles
Gender roles and gender relationships are always subject to change. This fact is of particular relevance with regard to ways in which people can protect themselves and others against HIV transmission. For example, in considering condom use the differences between contraceptive behavior and protective behavior must be analyzed in order to specify how health promotion can best approach this topic.
Sexual behavior provides a means for satisfying desire and gaining pleasure and subsequent relaxation, either alone or with another person. However, it may also give rise to problems, such as preventing unwanted pregnancy.
As far as contraception is concerned, communication about its behavioral implications takes place - if at all - before people decide to have sexual relations. In particular, contraception is interpreted by men as a female task: women must take care not to get pregnant. Contraceptive methods such as the pill and diaphragm are handled by women. There is one other important implication of contraception: it is frequently interpreted as a medical approach to preventing unwanted pregnancy and not so much as a social and psychological means of freeing sexual intercourse from the threat of unwanted pregnancy. Contraceptive behavior is aimed at avoiding reproduction, not at preventing certain diseases.
With the advent of HIV transmission, the situation has become completely different. First of all, each act of sexual intercourse carries the risk of contracting or transmitting the virus as long as no one can be certain whether he/she already is infected. Therefore, the prevention of transmission is essential in order to protect oneself and the other person from infection. In this respect, the prevention of HIV transmission is a complementary act: I not only protect myself against a certain hazard but also protect another from getting infected in case I have already contracted the virus. The responsibility for this preventive measure thus lies not only with the individual, but also with his/her partner and his/her future partners. HIV prevention consequently has both individual and collective aspects (Bateson & Goldsby 1989, 101 ff.).
In this context, there is no other decision to be taken than to use condoms when sexual intercourse takes place. Condom use is exclusively a male task, i.e., women cannot protect themselves against HIV infection except by asking men to use condoms or by choosing non-penetrative forms of sexual contact. In contrast to unwanted pregnancy or sexually-transmitted diseases, HIV infection cannot be treated medically, i.e., if a person has contracted the virus, he/she often may have to cope with the subsequent disease. The threat of HIV transmission thus has consequences for female/male relations and the balance of power between the sexes. Since the transmission of HIV infection can only be reduced via condom use, women cannot protect themselves against it without the collaboration of men. They must depend on them for protective behavior. As far as contraception is concerned, women have the possibility to control their reproductive system themselves in one way or another. Regarding HIV transmission, their bodies are placed somewhat outside their control. This shift in the balance of power has effects on female self-esteem and, probably, on women's behavioral intentions regarding sexuality and sexual behaviors.
While the modes of HIV transmission seem to be rather clear and the need for preventive measures cannot be neglected, many people seem to have difficulties in adjusting their behaviors accordingly.
Condom use may be considered in some cultures as a behavior which does not permit direct bodily interaction; the artificial product condom is viewed as being contrary to the nature of sexuality. Condoms may be considered socially as representing a concrete request for sexual intercourse, i.e., those who have condoms available are suspected of wanting to have sexual intercourse. The condom becomes a symbol of sexual desire; it makes the private desire public. Karen Luker (1978) found a similar interpretation among women concerning the use of diaphragms. Finally, condom use may be considered as an interference in the behavioral process of sexuality, a disturbance of the intimacy of the sexual process and an interruption in the process of satisfying lust and gaining pleasure.
For all these reasons, the content of HIV/AIDS-related health promotion should again be considered very carefully. Campaigns could focus on changing social norms so that condom use comes to be viewed as a common, normal and desirable behavior. The fact that precautionary measures can remove a cause for worry (that is HIV transmission), thus enhancing feelings of trust and intimacy, could be an advantageous message.
Individuals and groups develop behavioral patterns and strategies which help them to cope with the requirements and contradictions inherent in their ecological and economic living conditions. These not only involve health-promotive behaviors; people also practice health-hazardous behaviors for different reasons. Within the framework of the lifestyles approach, the concept of risk behavior has been used to reflect upon those living conditions and social situations in which people might carry out certain behaviors for a specific period of time which can be considered by others as health-hazardous; however, the individuals involved may not feel the hazards are important as long as the positive effects of the behaviors are qualified as superior, both individually and collectively. This is certainly true with regard to specific sexual behaviors in relation to HIV transmission and AIDS. It is, therefore, important to study the concept of risk behavior and its implications for health promotion. Three important aspects need to be discussed further.
1. The function of risk behaviors is to help individuals and groups manage the difficulties and problems of everyday life. It would be a misconception to view risk behaviors per se as deviant behaviors. They are well-accepted by the social groups who carry them out irrespective of what other social groups think of them. Several risk behaviors are socially more or less accepted such as drinking alcohol, smoking cigarettes, sun-bathing, taking pills, having sex with multiple partners, driving fast, etc., while others are viewed as unacceptable by society-at-large, such as train-surfing (a practice in Latin American and European countries where youths ride atop highspeed trains standing upright). Some are presented in the context of sports such as freestyle mountain climbing (in the USA, the slogan is: if life gets boring, risk it), deep-sea diving, high-speed skiing, high-speed motorboat driving, bull-fighting etc.; they communicate the message that those who carry out these sports are somewhat like heroes (at least for one day).
2. The outcomes of risk behaviors are mainly relaxation, pleasure, fun, i.e., wellbeing for a short period of time. Risk behaviors involve only a short-term time perspective. They are always oriented towards a specific social situation and are characterized by a desire to achieve well-being as quickly as possible. In most cases, therefore, risk behaviors are related to leisure because in this temporal context people have more individual and collective opportunities to decide upon what they want to do. This particular social sector has been developed in the European and North American region according to commercial and industrialized patterns. Numerous facilities offer services which meet peoples' desire to achieve relaxation, pleasure and fun. From a sociological point of view, one can argue that there is an industry offering facilities for risk behaviors - and it meets peoples' needs to get away from everyday life for a certain amount of time. This short-term time aspect of risk behaviors is an important factor with regard to health promotion. Health-related behaviors rather frequently are time-consuming and also bear some amount of uncertainty regarding their results, while risk behaviors relate to alternatives offering immediate well-being regardless of their potentially health-hazardous effects. For example, after a day full of stress, an individual may decide to unwind by practicing meditation, taking a nap or doing relaxation exercises, all of which can be beneficial health-wise. However, the alternative of visiting a bar to have a drink is often more attractive, though it might be damaging to health depending on how much the person drinks. Life in the fast lane (Franzkowiak 1987), or living in computime (Rifkin 1989) does not seem to allow for long-term considerations concerning well-being. Risk behaviors thus tend to become an integral part of every lifestyle. The question is whether or not we will be able to reduce the potentially health-hazardous effects of these behaviors.
3. Risk behaviors are perceived as individual and/or collective attempts to gain control over certain situations in terms of well-being. The functionality underlying risk behaviors does not necessarily follow rational criteria. The term control is used in a subjective way, i.e., as far as the individual perceives a situation as being under his/her control, a certain risk behavior is considered an appropriate way to contribute to well-being. For example, taking a pill may help one to fall asleep in a situation of constant stress; drinking several glasses of beer may help one get away from the strains of the workplace. By pursuing these risk behaviors, the individual pretends to control the past and future: the past because the behavior enables him/her to escape from a situation so that it no longer serves as a stressor; the future because the behavior contributes to future well-being, i.e., the individual will once again attain a position in which he/she can face reality and to try to cope with it the next day. The problem with risk behaviors lies in the fact that this kind of control is only of subjective relevance; it does not affect the causes of the stress perceived nor does it contribute to an individual and/or collective study of possibilities of overcoming the difficulties involved in certain situations and experiences. The main objective is just to achieve well-being irrespective of the past and future circumstances of one's life.
A further aspect of gaining control can be described as a paradox: while people have little individual control over their living conditions and the development of lifestyles conducive to health, people are asked and forced to exercise individual control over their sexual behavior.
While the distribution of control is generally not individual-oriented, the demand for control with regard to sexual behavior is particularly related to the individual. The difficulty of the situation in question lies in the fact that the individual is not wanted and/or permitted to take control over various other aspects of his/her life; he/she has only a few possibilities to exercise strategies and methods of controlling his/her living conditions and lifestyles. Regarding HIV transmission, on the other hand, he/she is requested to take decisions, behave responsibly and control the situation perfectly. It is questionable whether this request can be complied with effectively as long as the distribution of control in general remains unbalanced.
Here the implication for health promotion efforts resides in promoting activities which contribute to the empowerment of persons, emphasizing the advantages of a long-term perspective and influencing social norms regarding acceptable risk behavior.
AIDS health promotion for youth
AIDS health promotion can be defined as the application of concept, areas of action and methodological principles of health promotion to the prevention of HIV/AIDS among the population and/or selected target audiences of a country, community or area (Aggleton et al. 1990).
AIDS health promotion for youth aims at helping adolescents and youth (that is, young males and females between the ages of 10 to 24) to gain and increase control over the determinants of their health, influencing their lifestyles conducive to health, and prevent HIV infection and the spread of HIV/AIDS among their peers and in their community (Nutbeam & Blakey 1989, Erben 1991, Franzkowiak 1990). AIDS health promotion for youth uses information, personal and mass communication, social support, community resources and policy changes to implement HIV/AIDS prevention in the community and with its target audiences. Although young people should be primarily addressed, it may often be necessary to include community leaders, parents, and concerned adults as target audiences in their own right. These adults will need assistance and training in educating young people about the transmission of HIV/AIDS and all protective skills needed to avoid HIV infection and its spread.
Programme developers must aim at comprehensive participation and cooperation of young people and their parents or other educational guardians, try to secure the support of local services, and attempt to involve all important political and religious organizations and their leaders.
Programmes provide target audiences of adolescents and youth and the whole community with accurate and comprehensive knowledge about HIV/AIDS, effective behavioral skills protecting from sexually or parenterally transmitted HIV infection, and social support for those already infected with HIV or having contracted AIDS. Programme development and implementation respect the community context and are based on cultural beliefs and norms.
Goals and objectives
Many programmes for young people are directed towards knowledge improvement only. These programmes fail to address attitudes, and behavioral and social skills that young people also need to acquire reducing the risk of infection. Programmes should be designed as to:
The following list presents five overall goals for AIDS health promoters working with adolescents and youth:
(1) Give accurate information on HIV/AIDS:
(2) Develop skills for safer sex:
(3) Eliminate discrimination and promote solidarity:
(4) Develop protective behaviors against drug abuse:
(5) Improve community resources and social support;
In terms of programme objectives, adolescents and youth involved in the programme should achieve the following levels of knowledge, attitudes and values, behavioral skills and social support:
In AIDS health promotion for youth, primary audiences are those young people who will receive immediate and direct education, skills training and social support. Secondary audiences consist of people who influence the primary target audiences or the community as a whole. Among them may be adolescent peers, but mostly key adults from the community. Those community groups are defined as secondary audiences whose support and involvement is desirable for programme implementation. It is mandatory to also target local people who have been opposing AIDS health promotion efforts or are likely to produce obstacles to the programme in order to win their support or, at least, neutralize their negative influence.
Primary target audiences
Young people are a diverse and mixed population. In a community or area, programme developers are likely to find a wide variety of ethnic, cultural, social class, and religious backgrounds. There will also be important age and gender divisions or differences in education and health knowledge. Experience of adolescents in isolated rural communities is normally different from those in the heart of cities or from those on the streets in metropolitan areas. Every young person's need for accurate information and for positive responses to their needs, however, is just the same everywhere.
The selection of primary target audiences is to be based on sound epidemiological evidence, comprehensive knowledge about common physiological, psycho-social and cultural steps in the sexual and personal development of adolescents, and on results of an initial community assessment. Given this, highest priority should be given to those young people who practice high-risk behaviors such as:
High priority should then be given to adolescents and youth:
In addition to these high priority youth, AIDS health promotion should be addressed to
When and how adolescents start sexual intercourse or experiment with drug abuse will vary between cultures, countries and communities, also depending on religious and legal norms and values. Even within one culture, health promoters are likely to find differences in onset of risky practices and the practices themselves. Young people in metropolitan regions very often start earlier with sexual behaviors or drug abuse than boys and girls in rural areas. One should also prepare for large differences between male and female youth or different ethnic and social class sub-groups regarding experience related to sexual behavior and drug abuse.
Adolescents and youth being at greatest risk of infection may be identified through available epidemiological data related to the prevalence of high-risk sexual and drug-abusing behaviors in the region or community. If such data is not available, one can refer to information gathered from health and social workers or other community members about the vulnerability of these young people to HIV transmission because of high-risk behavior patterns that they usually perform (but which have not yet been identified by epidemiological surveillance - as in the case of street kids or drug abusers being also sex workers, etc.).
Secondary target audiences
In selecting these audiences, highest priority is given to peers and adults influencing the sexual behavior of the young population or make actual decisions about issues of sexuality (or drug abuse) in the community. An initial assessment provides programme developers with sufficient information to identify decision-makers and opinion-leaders being relevant to the community and its young people.
On this background, secondary audiences may include:
In many parts of the world, it may be assumed that some of the targeted adolescents and youth or some of those who participate in a programme may already be infected with HIV. Many young people may suspect that they are infected - where antibody testing is available and be taken some may be sure. Young people who are infected with HIV face a lot of problems about partnership, sexuality, work and social relations. The existence of these young people must in no case be denied; neither must health promoters be only concerned about them with regard to preventing them from transmitting HIV to others. Their well-being is important and should play an integral part in programme development and implementation.
Information, training and social support for those adolescents and youth living with AIDS, HIV-infection, or receiving the results of HIV-antibody testing cannot be put back in AIDS health promotion. These youth need to be helped understanding their medical, emotional and social situation. They also need education to avoid risky behaviors, and to help them coping with possible physical or social handicaps and discrimination.
HIV-infected adolescents and youth need support in their life settings, and in making life choices. They do not only have to deal with eventual illness but also cope with years of life during which they feel physically well. The same safe sex practices that protect uninfected youth will protect HIV-infected young people from further exposure to HIV or other STDs that may place stress on their immune systems.
The development process of AIDS health promotion for youth programmes should consist of ten steps:
1. Collecting necessary information through an initial assessment in the community (assessing the youth situation in general, the HIV/AIDS situation among and for youth in particular, and the availability of preventive community resources);
2. Setting up programme goals and objectives;
3. Deciding upon main contents and messages of the programme;
4. Selecting one or more target audience(s) of the programme;
5. Securing community acceptance, networking for community involvement and ensuring young people's participation in all stages of the programme (preparing against sources of resistance or potential opponents to the programme, promoting public discussion about HIV/AIDS and young people, seeking local allies and political support, establishing advisory boards or local "taskforces");
6. Looking for effective ways to reach the target audiences (that is, identifying effective channels of communication) and developing practical prevention strategies;
7. Pretesting or piloting of interventions;
8. Planning for monitoring, evaluation and reassessment of the programme;
9. Establishing a programme timetable (schedule) and budget;
10. Implementing the programme in the community.
Adolescents and youth at greatest risks of infection - as a result of behaviors they may practice, and the known or presumed prevalence of HIV in the region they live in - should receive immediate attention when developing a programme. In some countries, HIV/AIDS prevention programmes for young people put special emphasis on the development of self-esteem, communication and decision-making skills, and put an emphasis on peer education aiming at behavioral immunization against risk-taking habits. Reflecting the needs of homeless adolescents and street kids, unconditional survival support is often included, like housing, nutrition, medical care, and education.
Effective behavior change will take a lot of time. Programme planners should plan for a repetition and extension of programme activities over a number of contacts, which can last for months or even years. Information sessions and behavioral trainings for the target audiences have to be presented repeatedly and in different social contexts over a longer period of time. Through this, it is to be ensured that preventive messages and related behavioral changes can be picked up at the time members of the audiences are ready for it and also in settings where they feel secure and comfortable enough to get involved.
Information sessions, skills training and rehearsal, and support activities can and should be simple, frank and direct. It is neither necessary nor appropriate to concentrate efforts only on teaching biomedical information about HIV/AIDS. Instead, the focus should be upon (a) simple, concise information and practical training of how to avoid an infection of oneself and others, and (b) the implementation of social support and community resources.
In preparing for programme development, AIDS health promotion professionals should consider practical recommendations:
It may often be important, even necessary, to seek and develop culture-specific methods and strategies to challenge apparent cultural barriers to effective communication about HIV/AIDS, adolescent sexuality, and injecting drug abuse. The help and collaboration of community leaders, youth leaders or community and youth workers from the non-medical professions should be welcomed by programme developers.
Communication channels and intervention approaches
It is necessary to create and present understandable messages concerning HIV/AIDS prevention for sexually active and/or drug abusing young people in order to influence their knowledge, values and behaviors. However, as the history of health education against communicable diseases and decades of only slightly effective drug abuse prevention have shown, this is not enough. It is the choice of a right medium that bears an equal significance for preventive success as does the right message (Hornik & Romer 1990). Therefore, all messages should be delivered in a way that:
In AIDS health promotion, a key term is channels of communication. To be or become effective, channels of communication must be:
There are two main channels to deliver preventive messages:
Here, messages are delivered to individuals or small groups of people through face-to-face interaction and communication. Intervention methods may include classroom teaching, group instruction, behavioral training workshops, individual or group counselling, group discussions (focus groups) and community outreach.
Rather than mass communication strategies, strategies of personal communication have proven to be effective with high-risk behavior audiences. A good example is the work of outreach educators. Outreach workers walk the streets and places where drug abusers, street kids and other hard-to-reach youth live. They distribute condoms and convey explicit messages and skills which otherwise could hardly be communicated as they would not be permitted in public or on mass communication channels.
Here, a general audience is addressed that is and may well stay individually unknown to communicators. Common approaches include the use of printmedia (such as newspapers, magazines, comic strips, and information sheets) or billboards and posters, broadcasting of radio and television spots, public showing of films and videotapes, public awareness campaigns (e.g., for condom promotion), staged community events (AIDS action days or weeks, street theater and drama, music festivals and use of folk media), and public appearances of teen idols and respected youth spokespersons.
Mass communication may be appropriate for reaching and influencing larger youth audiences. They can be addressed on the streets and in market-places, at worksites, at music festivals or folk media events, in discotheques, or as an audience to popular youth radio and television broadcasts. AIDS health promotion professionals may reach out to larger groups of organized youth like, for instance, males in the military system or adolescents and youth in local and national youth organizations.
One will usually achieve greater exposure of preventive messages through mass communication. However, it is not always the better choice. Mass communication channels may not be appropriate if a programme aims at young people who:
Personal or mass communication?
In many cases, a combination of mass and personal communication strategies is recommended. One may start in a step-by-step fashion. At first, broadcasting, posters, billboards and community events are used to inform the target audience about HIV/AIDS threats and prevention. After having enhanced young people's awareness, health promoters may switch to personal channels such as outreach, street and youth work, or counselling. By follow-up personal communication the effectiveness of mass communication on the behavior of the young people can and will be increased. Condom promotion campaigns for smaller, high-risk behavior target audiences have been carried out successfully in many countries by using this step-by-step approach.
Personal communication is often more expensive, shows a limited capacity to reach larger audiences, and may require a significant amount of programme time to do so. It can be more cost-effective, however, in changing attitudes and intentions of young people, especially of those who are hard-to-reach. Mass communication strategies will reach larger audiences, but may not be sensitive, credible, or explicit enough for groups of young people who engage in high-risk behaviors. The mass-plus-personal strategy is appropriate for many cases, but it should not be considered a simple blueprint for all programmes and target audiences.
The following list gathers a whole range of intervention approaches that may be regarded as effective in AIDS health promotion for youth:
Personal communication approaches
Mass communication approaches
Improving community resources and establishing supportive environments
Reorienting available health services
If HIV/AIDS-related services or treatment facilities are available in a community, they may be used as important channels to reach out to the target audiences - thus, also reorienting their service profile. Clinics, ambulatories, mobile health services and their personnel are widely considered credible and effective for obtaining health information and treatment. Young people attending such services are likely to be responsive to information and education offers.
Clinics, hospitals, and their staff can also reach out to high risk behavior groups through the provision of HIV antibody testing. Testing must, with no exception, be voluntary, non-compulsory and confidential. Otherwise the audience will not trust the credibility of this offer and of the whole programme and will never accept it. It is mandatory to combine testing with post-test assistance and counselling. HIV/AIDS information and preventive behavior advice must be given to all young people who participate, regardless of their tested antibody status.
Programme developers must prepare for the special situation of young clients with positive test results. As they are carrying an HIV infection with the prospect of contracting AIDS sooner or later, they should be offered (or referred to) intensive medical and psychological counselling. These adolescents and youth need long-term assistance and support; on the other hand, they must be informed in order to prevent them from spreading the infection to others.
Particularly when working with hard-to-reach groups, AIDS health promoters may often find it necessary to integrate HIV education and training into a comprehensive assistance program. Audiences like urban homeless children and adolescents, mobile urban and rural youth, or male and female adolescents engaging in prostitution for money, food or comfort have needs and concerns that go far beyond accurate and explicit HIV/AIDS education. To improve chances of gettting close to these young people, it may often be necessary to react to their basic needs first. These will normally include shelter, nutrition and clothing, medical care and emergency treatment, education, job and social skills training.
Networking for supportive environments
Preparing for possible resistance and resilience to AIDS health promotion for youth is of extreme importance. Keys to reducing community resistance are involvement and positive communication. To safeguard against obstacles, community leaders, such as political and religious leaders or legal representatives, should be involved into programme development and programme review from the start. It is also essential to include youth leaders or target youth into these consultations to help community leaders recognising the needs that the programme has to address (and, if need be, to help them understand why some explicit messages or educational methods may be employed).
The following list suggests concrete ways how to overcome resistance to an AIDS health promotion for youth programme. They were developed and field-tested in the context of condom promotion.
On the local level, networking is an essential instrument for gaining active allies and securing community involvement. Its aim is to establish a coherent network of relevant people, groups and organizations ensuring that all programme activities are coordinated and integrated. Networking depends on strong coordination which should remain in the hands of programme planners and developers. Networking is an effective tool for disseminating information and methodology, spreading responsibility, creating commitment, and gathering expertise and resources.
When building up a network of programme supporters, the following groups and people may be approached and asked for their collaboration:
There are many advantages regarding the involvement of community members, such as parents, teachers and doctors, in the programme. This involvement gives more credibility to all programme activities. It will increase the likelihood that AIDS health promotion becomes widely accepted and also encourage the selection of programme workers being acceptable to the community.
Monitoring and evaluation
Through monitoring, information is collected and analyzed about proper programme implementation. This involves regular checking to see whether programme activities are being carried out as planned and to control for probable problems, sources of resistance, or lacks in human and other resources.
Monitoring is an integral part of implementation; it is incorporated from the start of the programme. Preferably, already existing information and reporting resources in the community are utilised such as the local press and community administration. Monitoring must be carried out at frequent intervals (for instance, once a month or every six weeks). It is recommended to apply simple information-gathering techniques that are not costly and provide a rapid feedback.
Programme monitoring in AIDS health promotion for youth keeps track of the following general indicators:
Common monitoring techniques (that can also be applied for evaluation purposes) include:
Evaluation means to collect and analyze information about programme effectiveness and impact as a whole or with regard to some of its elements and stages. Evaluation is crucial in the process of pretesting materials and piloting interventions, and it also includes a later reassessment of programme achievements. Evaluation provides data about how information, education, training, and social support have influenced the HIV/AIDS related knowledge, attitudes, beliefs, practices and skills of the target audiences. Wherever possible, available epidemiogical indicators, such as changes in STD and/or HIV incidence during the course of an intervention, should be integrated into the process of impact evaluation. Evaluation is not an optional extra: it is and should always be an integral component of the preventive process.
In AIDS health promotion for youth the following indicators are relevant (WHO 1990b):
Reassessment means to take a second look at the impact, outcome, and efficiency of an AIDS health promotion for youth programme. After finishing the programme and its evaluation, it is useful to reflect on results and the experience gathered during its conduct.
Planned reassessment permits a reorientation of programme implementation or future programmes. In most countries, the HIV/AIDS situation is changing rapidly. National AIDS plans and programmes for young people must be flexible enough to respond to new problems as they arise and to pinpoint the shortcomings of previous programmes.
Aggleton, P, Horsley, C, Warwick, I & Wilton, T (1990): AIDS - Working with young people. Horsham, West Sussex (AVERT)
Alinsky SD (1969): Reveille for Radicals. New York (Vintage Books)
Armstrong D (1983): Political Anatomy of the Body. London (Cambridge University Press)
Bateson G (1979): Mind and nature. A necessary unity. New York (Dutton)
Bateson MC & Goldsby R (1989): Thinking AIDS. The Social Response to the Biological Threat. Reading, Mass. (Addison-Wesley)
Bennett JW (1976): The Ecological Transition. Cultural Anthropology and Human Adaptation. New York (Pergamon)
Berger PL & Luckmann T (1967): The Social Construction of Reality. A Treatise in the Sociology of Knowledge. Harmondsworth (Penguin)
Crawford R (1984): A Cultural Account of "Health": Control, Release, and the Social Body. In: McKinlay JB (ed), Issues in the Political Economy of Health Care. New York/London (Tavistock), 60-103
Erben R (1991): Health challenges for the year 2000: Health promotion and AIDS. In: Health Education Quarterly, 18, 1, 29-37
Franzkowiak P (1987): Risk-taking and adolescent development. In: Health Promotion International, 2, 1, 51-61
Franzkowiak P (1990): Adolescent development and its implications for AIDS prevention. In: AIDS Health Promotion Exchange (Newsletter of the Global Programme on AIDS of the World Health Organization, Geneva), 1, 1-2
Franzkowiak P & Wenzel E (1991): Guide on health promotion for the prevention and control of HIV/AIDS among out-of-school youth. Geneva (WHO/GPA), Draft, February 1991
Freund P (1982): The Civilized Body. Social Domination, Control, and Health. Philadelphia (Temple University Press)
Goffman E (1971): Relations in Public. Microstudies of the Public Order. New York (Basic Books)
Hardesty DL (1977): Ecological Anthropology. New York (Wiley)
Honigman JH (ed) (1973): Handbook of Social and Cultural Anthropology. Chicago (Rand McNally)
Hornik R & Romer D (1990): Background paper for WHO Technical Working Group meeting on accessing and communicating with youth, Geneva (WHO/GPA), 29-31 August 1990
Luker K (1978): Taking Chances. Abortion and the Decision not to Contracept. Berkeley (University of California Press)
Mann J, Tarantola D & Netter T (1992) (eds.): AIDS in the world. Cambridge, Mass. (Harvard University Press)
Milio N (1986): Promoting health through public policy. Ottawa (Canadian Public Health Association, second printing)
Minkler M (1991): Improving health through community organization. In: Glanz K, Lewis FM & Rimer BK (eds.), Health behavior and health education. Theory, research and practice. San Francisco (Jossey-Bass), 257-287
Nutbeam D & Blakey V (1990): The concept of health promotion and AIDS prevention. A comprehensive and integrated basis for action in the 1990s. In: Health Promotion International, 5, 3, 233-242
Polhemus T (ed) (1978): Social Aspects of the Human Body. Harmondsworth (Penguin)
Rifkin J (1989): Time wars. New York (Simon & Schuster)
Smallman-Raynor M, Cliff A & Haggett P (1992): London International Atlas of AIDS. Oxford (Blackwell)
Strunk D (1983): Political Dimensions of the Body. London (Cambridge University Press)
Turner BS (1984): The Body and Society. Explorations in Social Theory. Oxford (Basil Blackwell)
Wenzel E (1983): Lifestyles and living conditions and their impact on health. In: Scottish Health Education Group, European Monographs in Health Education Research. Vol. 5. Edinburgh (SHEG), 1-18
World Health Organization (1986): Ottawa Charter for health promotion. Ottawa, 21 November 1986
World Health Organization (1990a): A Call for Action. Health Promotion in Developing Countries. Geneva (WHO)
World Health Organization (1990b): School health education to prevent AIDS and sexually transmitted diseases: A guide to teaching and curriculum development. Geneva (WHO/GPA), Draft, February 1990
Copyright © by Eberhard Wenzel, 1997-2001