Fact Sheet: Number 10 (1997)
Developing Rural HIV/STD Prevention Education Programs
Rural communities face unique challenges in implementing HIV/STD prevention education programs. For example, in urban areas pre-existing high risk groups (e.g., homeless, drug addicted, prostitutes) have been specifically targeted for HIV/STD prevention programs.(1) In rural areas, specific identification of high-risk groups mav be difficult.
The Centers for Disease Control and Prevention (CDC) has recommended that community HIV/STD prevention programs be designed to reach less accessible or identifiable populations.(1) In genera, persons living in rural areas are more difficult to reach with HIV/STD prevention education than those living in urban areas. Some HIV/STD education programs seek community wide changes in social norms. This strategy has advantages in rural areas.(2) CDC has recommended the use of social marketing theory as a basis for modifying community norms.
Social Marketing Theory
Social marketing is a method of convincing community members to practice HIV/STD prevention. The target audience must perceive that the benefits of prevention behaviors are greater than the barriers to the behavior. HIV/STD prevention behaviors include abstinence from sexual intercourse, using condoms for intercourse, and using sterile injection equipment.
Social Marketing Components
A combination of product, price, promotion, and place forms the basis for an effective community HIV/STD prevention education program. Use of condoms for HIV/ STD prevention is used to illustrate these components:
- The product (e.g., condom) must be perceived as beneficial by the user. Condoms should be marketed so that perceived barriers to use appear small compared to perceived benefits.
- The price should be reasonable for the audience. Many communities have made condoms available inexpensively or free.
- Promotion refers to the prevention message. The content and delivery of condom use messages should be based on the characteristics of the target audience, such as their attitudes, values, and behaviors.
- Place refers to an accessible location for distribution of the message and/or product (e.g., condom).
Social Marketing Steps
Effective socia marketing programs involve several steps, each of which should be coordinated by a community planning group (CPG).(2,3) The CPG should include members of the target audience. Such persons can act as positive role models for the target audience and can help identify unique attributes of the audience. Additionally, prevention messages based on behavioral theories are more likely to be effective than those based on "knowledge campaigns" or moral appeals. Ideally, status assessment of the intended population involving several behavioral theories should occur before constructing intervention programs.(4)
STEP 1: Conduct research to understand the intended audience.(5)
- Identify the risk behavior determinants of the intended audience For example, how do poverty and isolation contribute to not using condoms! What are the perceived benefits of engaging in the high risk behavior?
- Determine perceived benefits and barriers related to the adoption of the new behavior (e.g., condom use). Learn enough about the audience to understand how to convince them to practice HIV/STD prevention.
- Identify the prevailing norms of the target audience. For example, youth are likely to share behavioral norms which should be addressed in prevention education. Some groups may deny vulnerability to HIV infection and others may accept vulnerability but still not practice preventive behavior. Each group requires a different message.(6)
STEP 2: Create a barrier/benefit ratio that is clearly beneficial to the target audience.
This ratio should be favorable to behaviors which have the potential to eliminate or lower risk of HIV/STD infection. Audience perception of the ratio is influenced by the product, price, promotion, and place components described previously.
- Based on an assessment of the target audience, create messages designed to maximize perceived benefits and minimize perceived barriers to HIV/STD prevention behaviors.
- Develop ways to minimize barriers associated with adopting the behaviors. For example, condoms should be available inexpensively or free at accessible locations.
- Select effective media for the dissemination of the message and employ leaders of the target audience as spokespersons for the prevention program.(7)
STEP 3: Conduct ongoing research of the audience which identifies possible program changes that would be required to maintain program effectiveness.
- The World Health Organization has developed several prevention indicators that can be used as measures of program effectiveness. These indicators include incidence rates of STDs at local clinics, condom saes/availability, and self reported increase in prevention behaviors by audience members.(8)
- Continue research to determine any changing perceptions of the audience. For example, has the barrier/benefit perception of the target audience changed? Like other marketing programs, new approaches may need to be implemented.
Examples of Prevention Programs
Rural areas throughout the world have benefitted from social marketing programs. This approach has also been applied in rural communities throughout the United States.
- A social marketing program in Brazil distributed 26 million low cost condoms in 1996, a 44% increase since 1995.(9)
- A social marketing program in Ghana was successful in providing prevention education to a less accessible rural male population.(10)
- Communities in Pennsylvania have implemented HIV prevention programs for gay men in rural areas. Barriers to reaching this population include unstructured gay communities and homophobic social norms.(10)
- An Iowa COG has sponsored the production of three HIV prevention educational videos for rural youth. Videos were developed for (a) secondary school females, (b) middle school youth, and (c) high-risk youth i.e., those in juvenile detention, young men who have sex with men, and substance abusers.(11)
- In Missouri, regional CPGs involved members from community-based organizations, civic groups, and other representatives of rural communities. These groups helped narrow the gap between HIV/STD prevention needs and local politics. Primarily a rural state, the Missouri State Department of Health sponsored a Holistic Harm Reduction Program, which is designed to meet the living needs of recipients. (V. Leighty, persona communication, November 13, 1997)
- Delmarva Rural Ministries (DRM) is a private nonprofit organization that promotes HIV prevention to migrant farm workers and the rural poor in a tristate area of Delaware, Maryland, and Virginia. Programs included distribution of informational pamphlets, free condoms, and HIV information posters to persons in migrant camps.(12)
The combination of (a) social marketing, (b) behavior change theory, (c) community planning groups, and (d) target audience participation creates a promising approach to the development of effective HIV/STD prevention education programs for rural areas. CDC has titled these components, the Prevention Marketing Initiative (PMI). (2) Strategies for implementing PMI are available from CDC through the National AIDS Clearinghouse (call 1-800-458-5231 and ask for Applying Prevention Marketing).
Sources of Information
- Morbidity and Mortality Weekly Review. (1996). Community-level prevention of human immunodeficiency virus infection among high risk populations: The AIDS community demonstration projects. MMWR, 45, (RR-6).
- Ogden, L., Shepherd, M., & Smith W.A. (1996). The prevention marketing initiative: Applying prevention marketing. Atlanta, GA: Centers for Disease Control and Prevention.
- Aggleton, P. (1997). Behavior change communication strategies. AIDS Education and Prevention, 9, 111-123.
- Rural Center for the Study and Promotion of HIV/STD Prevention. (1995). Behavior Change Models for Reducing HIV/STD Risk. (Fact Sheet #3). Bloomington, IN:RCSPHP.
- Ramah, M., & Cassidy, C.M. (1992). Social marketing and the prevention of AIDS. Academy for Educational Development.
- Sumartojo, E., Carey, J.W., Doll, L.S., & Gayle, H. (1997). Targeted and general population interventions for HIV prevention: towards a comprehensive approach. AIDS, 11, 1201-1209.
- Kelly, J.A. et al. (1997). Randomized, controlled, community-level HIV-prevention intervention for sexual-risk bejavior among homosexual men in U.S. cities. Lancet, 350, 1500.
- Mertens, T.E., & Carael, M. (1997) Evaluation of HIV/STD prevention, care and support: an update on WHO's approaches. AIDS Education and Prevention, 9, 133-145.
- Anonymous, (1996). Condom social marketing boosts entire condom market in Brazil. AIDS Captions, 3, 36-38.
- Friedman, M.S. (1997). Strategies for HIV prevention planning among gay men in rural communities. Paper presented at the annual meeting of the American Public Health Association, New York City, NY.
- Centers for Disease Control and Prevention. (1997). Innovative or promising practices in HIV prevention, HIV prevention community planning, and application development. National Center for HIV, STD, and TB Prevention. Division of HIV/AIDS Prevention - Intervention Research and Support.
- Zimmerman, M.A., Israel, B.A., Colman, S.S., & Prevots, D.R. (1995). Delmarva rural ministries, AIDS prevention for farm workers. In M.H. Becker, B.A. Israel, & N.K. Janz (Eds.) AIDS prevention in the community (141-145). Washington, DC: American Public Health Association.