International Public Health Communication (IPHC)

This background document for the United Nations AIDS (UNAIDS) Technical Consultation on Social Change Communication (August 2007) was written to provide a background to issues relating to communication for HIV prevention. It uses the term "social change communication” to include a number of kinds of communication able to address the drivers of the HIV epidemic, including: "communication for social change”, “behavioural change communication” and “participatory communication". The UNAIDS Technical Consultation was called to review how communication could be used to tackle the drivers of the HIV epidemic.

The author begins by pointing to the fact that in the scaling up effort of universal access to treatment, prevention has fallen behind, and there is no consensus on what is needed to deliver prevention. Outcomes for HIV prevention, as stated by the United Nations Declaration of Commitment on HIV/AIDS, are clear and include reducing the proportion of infants infected by HIV and reducing infection rates among young people. Specific communication outputs to achieve these outcomes are fall less clear. In order to facilitate decisions on the "scale and types of efforts necessary to reduce HIV risk behaviour in different epidemic scenarios and to address the drivers which impede prevention efforts by individuals and communities", the author recommends a fresh look at social change communication and how it can contribute to HIV prevention.

The document discusses the multiple drivers of infection. (Statistics include: For every one person put on to HIV treatment in 2006, six people contracted the virus. 4.3 million people were infected with HIV in 2006 over 11 thousand a day.) Because the drivers of infection vary by location and group, scenarios differ, as do infection rates, requiring differing mixes of prevention responses. In concentrated epidemic scenarios, working with vulnerabilities among key groups may be the aim. Where infection rates are hyper-epidemic, the author suggests that "concerted efforts to change widely held social norms, attitudes and beliefs may be more appropriate." With the current focus on universal access, treatment is often measured in output indicators like numbers of people on AIDS treatment. The focus of HIV prevention is on outcome indicators, e.g., changes in number of sexual partners. Output indicators exist in measuring communication interventions, for example, numbers and types of mass-media messages or community dialogues. However, the author states that there is no formulaic answer to what mix of communication programming will achieve a measure of success.

The focus on individual behaviour change includes strategies like social marketing of condoms, awareness-raising through print and broadcast media, and targeted sensitisation campaigns. However, successes can be short-lived unless programmes are part of long-term interventions. Though individuals' behaviour may be influenced, the document states that "understanding the dynamics of HIV transmission cannot be separated from an understanding of the broader context of poverty, inequality and social exclusion which create conditions where unsafe behaviour flourishes."

Recognising the need to tackle the drivers of the epidemic, three specific social drivers are cited as being central: human rights, stigma and discrimination, and gender inequality. Communication thinking on social drivers of HIV infection, as stated here, resonates with the importance of social context in the interpretation and impact of health messages. The author cites Silvio Waisbord and Arvind Singh for their contributions on the nuanced understandings of culturally-based, community-based, dialogic approaches rather than individual behaviour change approaches. Here the author reviews four related bodies of thought emerging on the subject of social change communications:

1. First, from the Communication for Social Change Consortium is the definition of communication for social change as “a process of public and private dialogue through which people themselves define who they are, what they need and how to get what they need in order to improve their own lives. It utilises dialogue that leads to collective problem identification, decision making and community-based implementation of solutions to development issues."
2. Second, as documented by the Panos Institute, is the strategy of moving from "message" to "voice", creating an enabling environment for all kinds of voices to emerge in the environments of policy, civil society, and the media.
3. Third are the decentralised, often uncoordinated, locally driven efforts responding to HIV, partly exemplified through mass participation in internet communication and partly by emerging social movements against AIDS.
4. The fourth is an ecological model of individuals' risk behaviour mediated by social and behavioural change communication, coupled with monitoring and evaluation frameworks, in attempting to unite communication for social change with evidence-based strategic communication.

The following question is posed to the communication field before it begins to tackle the three social drivers: "Is social change communication about communicators changing societies, or societies changing themselves?" Though these drivers cannot be addressed solely by AIDS communication programmes, they can be tackled through social change communication "either as objects of communication, or within a process of communication."

In looking at the first of the drivers, the link between AIDS and human rights has prompted the writing of the International Guidelines on HIV/AIDS and Human Rights, 2006, and has inspired action on a policy level, for example, confrontation of the South African government based on the right to life of people living with HIV, as well as a United Nations Children's Fund (UNICEF) model in which rights holder groups develop a shared vision and negotiate for it through rights-based dialogues. Stigma and discrimination, the second of the social drivers, is presented as barrier to prevention, as well as a source of pain and suffering. Its documentation can now be accessed in UNAIDS "Case Studies on HIV Related Stigma, Discrimination, and Human Rights Violations”. The author notes the existence of frameworks to understand the cycles of stigma and resulting causes and effects related to AIDS. The third driver is gender inequality, an area also documented by human rights literature. The document suggests the reference guide UNAIDS "Operational Guide on Gender and HIV/AIDS: A Rights-Based Approach”.

On the subject of monitoring and evaluation, the document refers to ample amounts available via the internet, journals, and publication of studies, but suggests that peer review and a standardisation of indicators need to be done. It notes 3 evaluation efforts: Soul City's evaluation of their programme, Communication for Social Change Consortium guidelines on participatory monitoring and evaluation, and Johns Hopkins University's model for monitoring and evaluation of social change communication. Because the route of choosing impact indicators and pre-defined tools departs from communication approaches with principles favouring localised indigenous responses, where success is measured by the communities involved, the author speaks for attention to balance.


In conclusion, the document outlines various challenges associated with social change communication in the context of addressing HIV/AIDS. For example, the author describes a potential divide between those who advocate for empowering people to speak out, and those advocating for a range of pre-defined impact indicators - which can create difficulties in relations with some donor communities. The suggestion given for working with this dilemma is to move away from key behaviour indicators towards long-term empowerment processes and social change. Costs associated with the intensity of programming required for social change communication to be effective are needed so that the approaches can be implemented with speed and scale. The document recommends that a "broadly supported framework for social change communication on HIV prevention should be possible, and could be a major contribution towards UNAIDS efforts towards universal access."

Email from Thomas Scalway to The Communication Initiative on August 22 2007.