Impact of Multimedia Campaign on Sexual Responsibility Among Zimbabwean Youth, Study notes of Communication

Download Impact of Multimedia Campaign on Sexual Responsibility Among Zimbabwean Youth and more Study notes Communication in PDF only on Docsity! 11 risky sexual behavior.9 S t e reotyped sexu- al norms and peer pre s s u re encourage young males to prove their manhood and enhance their social status by having sex. At the same time, young women are so- cialized to be submissive and not to dis- cuss sex, which leaves them unable to refuse sex or insist on condom use. Women’s economic dependence on men also leads young females to exchange sex for the opportunity of marriage or for gifts, sometimes with older “sugar dad- dies,” who may be HIV-infected.1 0 Other societal influences have exacer- bated this situation. Traditionally, aunts, uncles and other extended family mem- bers provided sexuality-related informa- tion to young people, but as urbanization i n c reases the distance between family members, parents are taking greater responsibility in this area, and many feel uncomfortable in this unaccustomed ro l e .11 Health care providers have not fil l e d the void because they share the overall so- cietal bias against adolescent sexuality, they lack the skills needed to communi- cate with young people about sensitive topics and they are barred by law fro m p roviding re p roductive health services to individuals younger than 16. Accord i n g Young Mi Kim is senior re s e a rch and evaluation advi- sor, Johns Hopkins University Center for Communica- tion Programs (JHU/CCP), Baltimore, MD, USA; Adri- enne Kols is consultant to JHU/CCP; Ronika Nyakauru is program manager and re s e a rc h e r, Evaluation and Re- s e a rch Unit, Zimbabwe National Family Planning Coun- cil (ZNFPC), Harare, Zimbabwe; Caroline Marangwan- da is assistant dire c t o r, Evaluation and Research Unit, ZNFPC; and Peter Chibatamoto is consultant to ZNFPC. The authors express their appreciation to Godfrey Ti n a r- wo, Fatima Bopoto-Mburiro, Brian Makunike, Hazel Dube, Alford Phiri, Ronald Mukombachoto, the late Flo- rence Chikara, and the province managers and infor- mation, education and communication officers in the study provinces. They also acknowledge Mike Aure t , Peter Roberts, Jane Brown, Jim Williams, Gary Lewis, Karusa Kiragu, Susan Krenn and Bruce Morén. Special thanks go to Roxana Rogers. Both the intervention and the evaluation were made possible by funding from the U.S. Agency for International Development under co- operative agreement CCP-A-00-96-90001-00. Promoting Sexual Responsibility Among Young People in Zimbabwe By Young Mi Kim, Adrienne Kols, Ronika Nyakauru, Caroline Marangwanda and Peter Chibatamoto In Zimbabwe, where 38% of the popu- lation is aged 10–24,1 the average age at first intercourse is 18 for both men and women,2 but many begin sexual ex- perimentation far earlier.3 U n p rotected sex puts young people at risk of unwanted p regnancies, which may contribute to their dropping out of school, marrying e a r l y, abandoning babies and obtaining abortions.4 Sexually active young people also face the risk of contracting HIV and other sexually transmitted infections (STIs). Zimbabwe has one of the highest AIDS prevalence rates in the world;5 H I V infection rates there are highest before age 25, and among teenagers, women are es- pecially vulnerable.6 Most young people in Zimbabwe are aware of HIV, AIDS and the risk of preg- nancy but still engage in unprotected sex.7 According to the 1994 Demographic and Health Survey (DHS), 98% of women aged 15–19 had heard of AIDS, but only o n e - t h i rd of those who were unmarried and sexually active were using modern contraceptives, and only 19% were using c o n d o m s .8 In Zimbabwe, as in other coun- tries around the world, gender roles and social norms—along with a host of eco- nomic and legal factors—contribute to to one study, 72% of service providers believe that contraceptives should not be o ff e red to people aged 16 or younger.1 2 F u r t h e r m o re, even after age 16, most teenagers except for married women with c h i l d ren are denied contraceptives.1 3 A s a result, young people in Zimbabwe gen- erally have inadequate information about re p roductive health issues, lack the skills to negotiate with their partners about de- laying sex and have limited access to re- productive health services.1 4 To address these problems, the Zim- babwe National Family Planning Coun- cil (ZNFPC) launched the Promotion of Youth Responsibility Project, with tech- nical assistance from the Johns Hopkins University Population Communication Services. The project aimed to encourage young people to adopt behaviors that re- duce the risk of pregnancy and STIs, in- cluding HIV. It encouraged abstinence for young people with no sexual experience, but promoted condom use and a re d u c- tion in the number of sexual partners for those already sexually active. In this article, we present an assessment of the project’s success at reaching its tar- get audience and promoting responsible sexual behavior among young people. Project Description Theoretical Framework At the heart of the project was a six-month multimedia campaign directed at young people in five pilot sites: one urban are a Volume 27, Number 1, March 2001 C o n t ex t : A 1997–1998 multimedia campaign promoted sexual responsibility among young peo- ple in Zimbabwe, while strengthening their access to reproductive health services by tra i n i n g providers. M e t h o d s : Baseline and fo l l ow-up survey s, each involving approximately 1,400 women and men aged 10–24, were conducted in five campaign and two comparison sites. Logistic regr e s s i o n analyses were conducted to assess exposure to the campaign and its impact on young people’s reproductive health knowledge and discussion, safer sexual behaviors and use of services. R e s u l t s : The campaign reached 97% of the youth audience. Awareness of contra c e p t i ve meth- ods increased in campaign areas, but general reproductive health knowledge changed little. As a result of the campaign, 80% of respondents had discussions about reproductive health—with f riends (72%), siblings (49%), parents (44%), teachers (34%) or partners (28%). In response to the campaign, young people in campaign areas were 2.5 times as likely as those in compari- son sites to report saying no to sex, 4.7 times as likely to visit a health center and 14.0 times as likely to visit a youth center. Contraceptive use at last sex rose significantly in campaign areas (from 56% to 67%). Launch eve n t s, leaflets and dramas were the most influential campaign com- p o n e n t s. The more components respondents were exposed to, the more likely they were to take action in response. C o n cl u s i o n s : A multimedia approach increases the reach and impact of reproductive health in- t e rventions directed to young people. Building community support for behavior change also is es- sential, to ensure that young people find approval for their actions and have access to serv i c e s. International Family Planning Perspectives, 2001, 27(1):11–19 The main themes of the youth campaign, which was launched during August and September 1997, were self- respect and self-control. These were e x p ressed in three slogans, which were repeated in all materials and activities, in both English and native languages: “Have self-control,” “Value your body” and “Respect yourself.” All campaign materials and activities were designed to re i n f o rce a single set of messages, em- phasizing the consequences of unpro- tected sex; negotiation skills; discussion with friends, family and providers; and safer sexual behaviors. Young people helped design appealing materials and re l- evant messages, and local management committees helped plan and execute ac- tivities at each site. ZNFPC wanted to reach an audience of 1 0 – 2 4 - y e a r-olds of both sexes and, secon- d a r i l y, the adults who control young peo- ple’s access to reproductive health infor- mation and services. The age range selected for the young people was chosen for two reasons: Studies suggest that sex- ual responsibility interventions have the g reatest impact on young people before they initiate sexual activity, perhaps even before they reach puberty.19 On the other hand, by encouraging adolescents who are a l ready or are on the verge of becoming sexually active to take preventive mea- s u res (e.g., use condoms and reduce their number of partners), safer sex interven- tions can make an immediate impact on older teenagers. Program Components The campaign employed a mix of com- munication channels, since diff e re n t media can reach diff e rent audiences. Also, by repeating and re i n f o rcing messages, a strategy combining media and activities i n c reases the likelihood that people will recall and act on campaign messages.2 0 Some of the campaign’s components em- ployed mass media, which reach large au- diences at a low cost per capita, raise awareness, disseminate information and have the potential to change behavior.2 1 The remaining components employed in- terpersonal communication, which re a c h- es fewer people but may be effective in motivating people to adopt new prac- t i c e s .2 2 The campaign’s logo, a yellow tri- angle with a blue circular “youth-friend- ly” seal, was featured on all materials. •Posters. A series of eight posters carried messages like “Value your body and a happy future lies ahead” and “You may think you are ready for sex, but are you ready for the consequences?” In campaign ( M u t a re) and four growth points (Maphisa, Nemanwa, Nzvimbo and Tongogara). (Growth points are small towns at the center of rural districts.) The campaign was based on the Steps to Be- havior Change framework, which syn- thesizes theories of communication and behavior change into a practical model to guide re p roductive health communi- cation pro g r a m s .1 5 The framework de- scribes five stages through which people pass as they change their behavior: knowl- edge, approval, intention, practice and a d v o c a c y. Effective communication cam- paigns determine the stage that their audience is at and focus their energies accordingly. Given the situation in Zimbabwe, the youth campaign focused on the model’s two earliest stages, when people learn key information and skills, then discuss campaign messages with others and fin d support for behavior change among their f a m i l y, peers and community.1 6 I n t e r n a- tional experience with pregnancy and HIV p revention programs for adolescents has found that outside approval is critical for two reasons. First, young people’s deci- sions are strongly influenced by friends, family and social norms. Second, their access to re p roductive health information, commodities and services is controlled by adults, including parents, service p roviders and political leaders. There f o re , it is not surprising that programs have found it easier to improve knowledge and attitudes than to prompt behavioral changes. Effective interventions have ad- dressed gender roles, sexual norms, peer p re s s u res and public policies, in addition to teaching basic information and skills.1 7 Youth Campaign Goals The first objective of the youth campaign was to increase re p roductive health knowledge, because young people in Zim- babwe had only a general awareness of H I V, AIDS and family planning. They did not appreciate the personal risks of u n p rotected sex and did not know how to negotiate with partners about sexual decisions.18 Two other objectives were to heighten approval of safer sexual behav- iors and of the use of re p roductive health s e r v i c e s — first, by promoting discussion of sexual matters with family and friends, and second, by encouraging parents, lead- ers and policymakers to support re p ro- ductive health communication and services for young people. The final ob- jective was to encourage young people to adopt safer sexual behaviors and attend service facilities. sites, 10,000 copies of each poster were dis- tributed. Older ZNFPC posters addre s s- ing AIDS, peer pre s s u re, parental com- munication, sexual re s p o n s i b i l i t y, dru g s and alcohol also were on display. •L e a f l e t s . Five leaflets—on abstinence, how to say no to sex, postponing sex, de- laying parenthood and STIs—were pro- duced, and 19,000 copies of each were dis- tributed. In addition, the popular older ZNFPC booklet Facts About Growing Up continued to circulate. •N e w s l e t t e r. Peer educators and schools distributed 100,000 copies of Straight Ta l k, a four-page newsletter on re p ro d u c t i v e health issues of importance to young peo- ple. Each of the three issues included ad- vice columns and articles written by young people. •Radio pro g r a m . Radio is widely available in Zimbabwe: Ninety-four percent of urban and 87% of rural young people sur- veyed by this project had access to a work- ing radio. During the campaign, 26 episodes of Youth for Real, a one-hour radio variety show, were broadcast nationwide. This weekly program, which has contin- ued to air since the campaign ended, com- bines information and advice with enter- tainment such as music and minidramas. Listeners can phone the show to ask ques- tions of a peer counselor and doctor. •Launch events. To mobilize community support for the campaign, local commit- tees spent months planning elaborate launch activities and garnered substantial support from local businesses. Popular musicians attracted large crowds to the launches, which featured different activ- ities at each site, including speeches, dra- matic performances, drum majorettes, soc- cer games, donkey parades and a parachute drop. Adults who influence youths—including chiefs, counselors, c h u rch leaders, parents, siblings, teachers and service providers—attended the launches, and novelty items bearing cam- paign messages were distributed. •D r a m a s . During the first two months of the campaign, two community theater t roupes performed daily at schools, churc h- es and town centers, presenting interactive dramas on re p roductive health issues. Peer educators accompanied the troupes and fa- cilitated a discussion with members of the audience after each performance. •Peer educators. Peer educators aged 18–24 w e re re c ruited from the community and trained to speak with groups of young people at schools, churches and town cen- ters and with individuals at home. Four educators were assigned to each gro w t h point and six to Mutare. 12 International Family Planning Perspectives Promoting Sexual Responsibility Among Young People in Zimbabwe 15Volume 27, Number 1, March 2001 n i ficantly from baseline to follow-up, when back- g round variables are con- t rolled for: Teenagers in these areas were 2–4 times as likely to know of most methods after the campaign as they had been before, and about eight times as likely to know of the female con- dom (Table 2). In com- parison areas, knowledge levels rose signific a n t l y for fewer methods, and the magnitude of the changes was smaller. The dramatic increases in a w a reness of the female condom in both cam- paign and comparison sites were due to a sepa- rate initiative to pro m o t e this method. Young people’s level of general reproductive health knowledge re- mained low after the campaign, especially on items re g a rding the safe- ty and efficacy of family planning methods. In campaign sites, corre c t knowledge increased significantly for only one of six questions asked: whether fam- ily planning methods can cause deformi- ties. In comparison sites, c o r rect knowledge in- c reased for whether a healthy-looking person can have HIV, but de- clined for whether fam- ily planning methods could cause infertility. A p p roval and Attitudes The campaign succeeded in generating discussion on a wide variety of top- ics, including sexual is- sues, HIV and AIDS, and physical growth and ma- t u r i t y. Analyses contro l- ling for background vari- ables reveal that in the period during and im- mediately after the cam- paign, respondents in campaign sites were sig- n i ficantly more likely than those in comparison sites to have a discussion with anyone about STIs tionwide, 41% of young people living in urban areas had heard the pro g r a m — a substantial proportion, considering that the show had been on the air for just six months at the time of the survey. Five per- cent of listeners reported having called the show to discuss problems with boyfriends, gangs, drugs, STIs and other issues. In the campaign sites, 67% of young peo- ple recognized the campaign’s logo. By comparison, 98% recognized the Coca-Cola, Dairy Board and Bata Shoe logos, all of which have been in use for more than a decade. Ninety-four percent of re s p o n d e n t s in campaign sites recognized the Shona and Ndebele slogans, compared with 52% in comparison sites. High rates of recall in comparison sites probably re flect that the slogans were phrases in common usage and a p p e a red nationwide on clinic calendars. Gains in Knowledge The campaign did not produce new mate- rials on contraceptive methods because such pamphlets and posters already exist- ed. However, it provided an enabling en- v i ronment for young people to learn about contraceptives. In campaign sites, re s p o n- dents’ knowledge of every contraceptive method except the implant increased sig- and AIDS (78% vs. 67%), whether to have sex (77% vs. 69%), menstruation (56% vs. 47%), body changes associated with pu- berty (50% vs. 41%), the pre s s u re to have sex (48% vs. 42%), sexual urges (43% vs. 34%), wet dreams (43% vs. 34%) and where to buy contraceptives (40% vs. 34%). When asked if they had taken action as a result of the campaign, young people w e re most likely to report having discussed re p roductive health issues with others ( Table 3). Eighty percent of respondents in campaign areas said they had talked with someone—mostly friends (72%), but also siblings (49%), parents (44%), teachers (34%) and partners (28%). When back- g round characteristics are accounted for, these youths were more likely than their peers in comparison areas to report such discussions (odds ratios, 3.5–5.7). While re l- atively few young people had spoken to their partners, many were not married or dating at the time of the campaign and thus did not have a partner to talk to. The campaign had less success in shift- ing young people’s thinking about gen- der roles. Respondents were asked whether the male, the female or both part- ners should be responsible for making sex- ual decisions. About four-fifths of young people in both campaign and comparison sites believed that the male should decide whether to have sex (not shown). Opin- ions did not differ by respondents’ age or g e n d e r, and no significant change oc- curred between baseline and follow-up. Ta ble 2. Pe rc e n t age of respondents in baseline and fo l l ow - u p s u rv eys who knew of specific family planning methods, perc e n t- age who correctly answered questions about reproductive health and odds ratios from multiple regression analysis indicating the likelihood of knowledge or a correct response, by study site Type of knowledge Campaign Comparison Base- Follow- Odds Base- Follow- Odds line up ratio line up ratio Know method Condoms 84.3 96.7 4.3*** 94.9 96.5 1.9 Pills 69.9 89.1 2.9*** 83.0 87.5 1.9*** Injectable 36.5 57.1 2.3*** 46.2 49.8 1.5* Female sterilization 32.5 50.0 1.9*** 42.9 40.5 1.1 IUD 30.0 47.0 2.1*** 41.2 41.3 1.2 Male sterilization 29.0 42.3 1.7*** 35.4 31.0 0.9 Female condom 25.4 68.2 8.2*** 29.4 60.0 5.3*** Implant 15.2 19.3 1.2 10.6 21.1 2.5*** Correctly answer Can a woman can get pregnant the first time she has sex? 62.5 70.1 1.2 67.8 68.5 1.1 Can family planning methods cause deformities? 48.1 54.3 1.2* 55.4 54.8 1.0 Can family planning cause infertility? 37.8 42.3 1.2 47.9 38.5 0.7* Can a healthy-looking person have HIV? 78.1 84.0 1.2 79.7 87.5 1.9*** Can you get HIV the first time you have sex? 70.2 73.8 1.0 68.9 64.8 0.8 Do condoms have small holes that allow HIV to pass through? 46.9 48.2 1.0 46.8 51.8 1.2 *p<.05. ***p<.001. N o t e s : K n owledge of methods includes spontaneous and prompted know l- e d g e. Regression analysis controlled for respondents’ age, sex, education, sexual ex p e ri e n c e, marital status and urban-rural residence. Ta ble 3. Pe rc e n t age of respondents who reported taking action as a result of exposure to the youth campaign, by study site, and o dds ratios from multiple regression analysis indicating the like- lihood of taking action Action Campaign Comparison Odds ratio ALL RESPONDENTS (N=970) (N=294) Had discussion 79.8 20.2 5.6*** With friends 72.0 32.7 5.7*** With siblings 48.9 20.1 3.8*** With parents 44.0 15.3 4.3*** With teachers 34.2 14.0 3.5*** With partner 27.8 12.6 3.8*** Adopted safer sexual behavior 63.9 37.8 2.9*** Said no to sex 52.7 31.6 2.5*** Continued abstinence 31.5 22.3 1.2*** Avoided “sugar daddy” 11.0 9.1 1.1*** Sought services 33.5 9.5 7.6*** At health center 28.2 9.5 4.7*** At youth center 10.8 1.7 14.0*** RESPONDENTS WITH SEXUAL EXPERIENCE (N=334) (N=99) Took any action 41.3 10.1 8.8*** Stopped having sex 12.6 5.1 2.1 Stuck to one partner 20.4 2.0 26.1*** Started to use condoms 10.5 2.0 5.7* Asked partner to use condom 1.5 1.0 1.5 *p<.05. ***p<.001. N o t e : R e gression analysis controlled for respondents’ age, sex, educa- tion, sexual experience, marital status and urban-rural residence. The surveys also measured the cam- paign’s effects on the likelihood that young people would seek services and use a modern family planning method. As a result of the campaign, young people in campaign sites were more likely to visit a health center (odds ratio, 4.7) and to visit a youth center (14.0) than were re s p o n- dents in comparison sites (Table 3). No- t a b l y, the campaign encouraged gro u p s that are historically less likely to seek ser- vices to visit a health center: males, single people and those who lack sexual experi- ence (not shown). Among those exposed to the campaign, almost equal pro p o r t i o n s of young men and women (29% vs. 28%) and of sexually inexperienced and expe- rienced youths (27% v. 31%) visited a health center. The gap between single and married people also was smaller than ex- pected (27% vs. 41%). In contrast, single people, sexually experienced youths and urban residents were more likely than their married, sexually inexperienced and rural peers to visit a youth center. Use of modern contraceptives incre a s e d significantly in campaign sites between surveys: Among respondents who had had sex within the previous six months, the proportion who reportedly used a modern method during their last sexual encounter (not shown) rose from 56% at baseline to 67% at follow-up (odds ratio f rom multivariate analysis=1.7, p<.05). Use of modern methods did not change significantly in comparison areas. By far the campaign’s biggest effect was to convince sexually experienced young people to stick to one partner (Table 3): Sexually experienced respondents in cam- paign sites were much more likely than those in comparison sites to report taking this action as a result of the campaign Behavior Change In theory, increased knowledge and heightened approval lead people to recognize that new behaviors can meet a personal need, to decide to take action and, eventually, to adopt new practices. The follow-up survey asked young peo- ple who were exposed to the campaign— regardless of whether they lived in cam- paign or comparison sites—if they had practiced certain safer sexual behaviors as a result. Saying no to sex was a major cam- paign message, but the phrase covers a wide range of possible behaviors and may best be interpreted as a sign of intention rather than actions taken. The odds that respondents reported that they had said no to sex in campaign sites were 2.5 times as great as the odds that youths in com- parison sites said so. Young people at campaign sites also were somewhat more likely than youths in comparison sites to say that they were continuing to abstain f rom sex as a result of the campaign, which may indicate positive intentions. A c c o rding to the multiple re g re s s i o n analysis, young women were more likely than young men to report having said no to sex. In part, this re flects that young women are frequently pre s s u red by boyfriends and older men to have sex (not shown). However, it also may suggest a positive change in women’s attitudes about g e n d e r- a p p ropriate behavior: As a re s u l t of the campaign, some young women may have come to believe that they had the right and responsibility to refuse unwanted sex. (odds ratio, 26.1). They also were substantially more likely to start using condoms (5.7). Effect of Different Components To determine which campaign compo- nents were most effective, we assessed the impact of each independently. These analyses include all respondents in both campaign and comparison areas who were exposed to at least one component. Bivariate analyses found that nearly all campaign activities and materials had a s i g n i ficant impact on a broad range of re- spondents’ self-reported actions. How- e v e r, these analyses do not take into ac- count that most respondents were exposed to multiple campaign activities and materials. There f o re, we conducted a multivariate analysis that controlled for respondents’ exposure to all other cam- paign components (Table 4). Although posters had the gre a t e s t reach, they had relatively little impact on respondents: Only discussion with friends and with teachers and intention to con- tinue abstaining from sex were positive- ly affected by posters, and the odds ratios w e re small. Launch events proved to have the strongest impact. Exposure to these events substantially increased the odds of youths’ discussing re p roductive health is- sues with others and of seeking services; it also significantly increased their likeli- hood of adopting safer sexual behaviors. ( We cannot explain its dispro p o r t i o n a t e impact on avoiding sugar daddies.) L e a flets also proved surprisingly eff e c t i v e : Although the odds ratios were smaller than those for launch events, exposure to l e a flets significantly increased the likeli- hood of every outcome except the inten- tion to continue abstaining from sex. Dra- mas, which reached fewer than half of respondents, promoted discussion and health center visits.* Along with more limited exposure, the remaining components had far less impact. These components may have had a stro n g e r e ffect on sexually experienced young peo- ple than on respondents as a whole, but small sample sizes make it impossible to an- alyze this subgroup separately. Sixty-one percent of respondents exposed to the campaign, in both cam- paign and comparison sites, saw or heard at least three campaign components. As the number of campaign materials and ac- tivities to which young people were exposed increased, their likelihood of dis- cussing re p roductive health issues, of adopting safer sexual behavior (except avoiding sugar daddies) and of seeking 16 International Family Planning Perspectives Promoting Sexual Responsibility Among Young People in Zimbabwe Table 4. Odds ratios from multivariate analyses indicating the likelihood of taking action as a result of exposure to individual campaign components, by component, campaign and com- parison sites combined (N=1,263) Action Posters Launch Leaflets Dramas News- Radio Peer Hot events letter program educator line Had discussion With friends 1.6** 2.7*** 1.9*** 1.7*** 1.5* 1.2 0.8 1.7 With siblings 1.4 2.3*** 1.5** 1.6*** 1.3 1.6** 1.0 1.6 With parents 1.4 2.4*** 1.7*** 1.4* 1.1 1.2 1.0 1.5 With teachers 1.6* 1.5* 1.6** 1.2 1.5* 1.4 1.0 1.6 With partner 1.2 2.0*** 1.6** 1.5** 1.4 1.1 1.1 1.9* Adopted safer sexual behavior Said no to sex 1.2 1.8*** 1.6*** 1.3 1.0 1.3 0.7 1.5 Continued abstinence 1.8** 1.4* 1.2 0.9 1.5 1.1 0.9 1.0 Avoided “sugar daddy” 2.7 35.9*** 0.3*** 0.4** 2.5** 1.4 0.4 1.7 Sought services At health center 1.6 2.1*** 1.6** 1.8*** 1.0 0.6* 1.0 2.5*** At youth center 2.1 2.5*** 1.9* 1.2 2.0** 1.9** 1.5 1.2 *p<.05. **p<.01. ***p<.001. N o t e s : R e gression analysis controlled for respondents’ age, sex, education, sexual ex p e ri e n c e, marital sta- tus and urban-rural residence. One respondent was dropped from analysis because of missing data. *The results also show that respondents who attended a drama or received a leaflet had a reduced likelihood of avoiding sugar daddies. These findings are difficult to explain, but we suspect that they result partly from small Ns—i.e., few teenagers both were exposed to these pro- gram components and were accosted by sugar daddies. 17Volume 27, Number 1, March 2001 audiences among adults, including parents and p ro v i d e r s . High levels of cam- paign exposure and mes- sage recall were due to the appeal of the cam- paign components. This appeal, in turn, re s u l t e d f rom young people’s participation in every as- pect of designing and im- plementing campaign materials and activities. The entertainment-edu- cation strategy dre w l a rge audiences to launch events, but was not as successful (in terms of ei- ther exposure or impact) for the radio pro g r a m . Language problems may explain the discrepancy: Rural youths pre- fer radio broadcasts in Shona and Ndebele rather than in English. Greater use of local languages in all components of the cam- paign might have increased its re a c h . (ZNFPC continued to air the radio show after the campaign ended, adding bro a d- casts in local languages and on other radio stations to reach rural youths.) Heightening Impact C o m p a red with other multimedia cam- paigns promoting safer sexual behaviors among young people,3 0 the campaign had little impact on re p roductive health knowledge and beliefs but generated high levels of interpersonal communication. A c o u n t e rcampaign run concurrently by a p rolife organization may have contributed to young people’s misconceptions about condoms, HIV and AIDS. The campaign’s failure to emphasize basic facts about re- p roductive health may also explain its lim- ited impact on knowledge in this area. Ye t the campaign did prompt young people to discuss a range of reproductive health issues with friends and family, and early discussions about re p roductive health is- sues may prompt more responsible deci- sions later in life.3 1 Indeed, a full assess- ment of the campaign’s impact would follow up young people for years rather than months. Given the campaign’s brief duration and the preponderance of sexually inexperi- enced young people in its audience, it had a strong influence on behavior. While it is impossible to directly compare the impact of diff e rent adolescent health campaigns because various outcome measures are used, the proportions of respondents who services increased (Table 5). The intensity of campaign exposure also had a positive i n fluence on their knowledge of family planning methods, but it was not re l a t e d to re p roductive health knowledge or be- liefs about which partner should make the decision to have sex (not shown). Discussion Maximizing Campaign Exposure Like several other multimedia campaigns p romoting re p roductive health among adolescents,29 the Zimbabwe youth cam- paign reached more than 90% of its cho- sen audience, in most cases with multiple materials and activities. It succeeded in reaching young people of diff e rent ages and backgrounds because of the variety of activities and materials deployed. For example, launches proved especially pop- ular in rural areas, where entertainment is limited, while the radio program and hot line had greater reach in urban areas, w h e re young people are more re c e p t i v e to English-language broadcasts and tele- phones are readily available. Although it was harder to connect with 1 0 – 1 4 - y e a r-olds and sexually inexperi- enced youths than with others, the cam- paign did surprisingly well at re a c h i n g these groups, given the bias in Zimbabwe against teaching children that age about sexual issues and their lack of immediate need for re p roductive health advice. Op- erating in the schools increased exposure among the youngest, least sexually active g roup. However, the best way to re a c h o l d e r, out-of-school youths proved to be activities that reach a general audience. Anecdotal evidence suggests that these ac- tivities also reached important secondary reported changing their sexual behavior or seeking re p roductive health services in response to the campaign in Zimbabwe are similar to those from other multimedia c a m p a i g n s .32 H o w e v e r, the campaign did not increase contraceptive use as much as social marketing campaigns that have fo- cused on promoting condoms.3 3 The use of multiple channels of com- munication contributed to the campaign’s impact. The evaluation confirms a clear d o s e - response relationship between ex- p o s u re and impact: The more materials and activities young people were exposed to, the more actions they took in re s p o n s e . Combining mass media and community events may have been particularly eff e c- tive. An evaluation of the Safer Sex Cam- paign for young people in Uganda found that its featured radio program was most i n fluential in districts that added local ac- tivities such as bicycle rallies and drama c o n t e s t s .3 4 Likewise, a comparison of four operations re s e a rch projects in Sub-Saha- ran Africa found that the most eff e c t i v e adolescent sexual health campaigns com- bined mass media with interpersonal com- m u n i c a t i o n .3 5 In the Zimbabwe campaign, as elsewhere, local events ensured that messages were expressed in young peo- ple’s own languages, in familiar contexts and with the endorsement of re s p e c t e d local fig u res. This finding confirms that mass media and interpersonal communi- cation channels may play complementary roles in encouraging behavior change.3 6 Building Social Support One of the campaign’s greatest accom- plishments was building support, in the community and within the health care sys- tem, for re p roductive health interventions d i rected at young people. It achieved this by decentralizing management to local committees that included re p re s e n t a t i v e s from local government, religious, educa- tional, health and business groups; by de- signing activities to reach a secondary au- dience of family, friends and teachers, and to prompt discussion of re p ro d u c t i v e health issues; by training providers to o v e rcome entrenched biases against of- fering re p roductive health information and services to young people; and by in- volving providers in campaign pre p a r a- tions and launches. Among the results of this strategy were unexpectedly high levels of parent-child discussion about sensitive re p ro d u c t i v e health issues and increases in the number of young clients seeking re p ro d u c t i v e health services, including STI tre a t m e n t and family planning care, at youth-friend- Ta ble 5. Pe rc e n t age of respondents who reported taking action as a result of the youth campaign, by number of components seen or heard, and odds ratio from multiple regression analysis indi- cating the effect of intensity of exposure, according to action Action No. of components Odds ratio 1–2 3–4 5–8 (N=440) (N=476) (N=214) Had discussion With friends 48.2 75.8 84.1 1.7*** With siblings 28.4 52.6 60.8 1.5*** With parents 25.9 47.2 51.9 1.4*** With teachers 21.1 34.4 42.3 1.4*** With partner 17.3 29.1 36.5 1.4*** Adopted safer sexual behavior Said no to sex 37.5 55.9 59.1 1.3*** Continued abstinence 22.3 31.1 36.9 1.2*** Avoided “sugar daddy” 9.1 9.9 7.0 1.1 Sought services At health center 17.5 30.3 33.6 1.3*** At youth center 5.0 12.3 17.8 1.6*** ***p<.001. Note: Regression analysis controlled for respondents’ age, sex, education, sexu- al experience, marital status and urban-rural residence.