This document summarizes an article that reviewed 41 empirical studies evaluating international HIV/AIDS prevention campaigns from 17 countries that used mass media. The review examined six key components of campaign design: target audience, communication channels, message content, campaign theme, exposure levels, and outcome measures assessed. Most studies described the target audience and message content, while fewer reported on campaign themes or measured exposure levels. The review concluded campaigns would benefit from better reporting, more systematic evaluation, greater use of theory, and increased focus on community-wide interventions.

1. Journal of Health Communication, Volume 5 (Supplement), pp. 29È45, 2000
Copyright Ó 2000 Taylor & Francis
1081-0730/00 $12.00 1 .00
HIV /AIDS Communication Campaigns : Progress and
Prospects
SONJA L. MYHRE
JUNE A. FLORA
Stanford Center for Research in Disease Prevention
Palo Alto, California, USA
T he mass media have been the primary method for disseminating human immuno -
deÐciency virus (HIV )/acquired immune deÐciency syndrome ( AIDS) prevention
messages worldwide. In this article, we update previous reviews by systematically
examining published articles (n 5 41 ) of empirical evaluations of international
HIV / AIDS prevention campaigns. Of the 41 studies identiÐed, 17 countries are
represented. In this review , we examine six components related to media campaign
design and evaluation : target audience , communication channel(s ), message content,
campaign theme, exposure, and outcomes . Of the studies included in this sample,
each one described the target audience ; 93 % reported on channel selection ; 75 %
described message content ; 63 % mentioned a campaign theme ; and 62% docu -
mented campaign exposure. W e investigate also the extent to which HIV / AIDS
prevention e†orts have moved beyond media campaigns to comprehensive
communitywide programs . W e conclude that HIV / AIDS prevention e†orts would
beneÐt from : ( 1) better reporting of media campaign components and outcomes , (2 )
more systematic evaluation, (3 ) greater integration of theory , and (4) increased
attention to communitywide intervention strategies.
Introduction
To date, virtually every country in the world has been a†ected by HIV / AIDS
according to the Joint United Nations Programme on HIV / AIDS (UNAIDS, 1997).
In response, most countries have established a national AIDS program and have
conducted some sort of mass media HIV / AIDS campaign (World Health Organiz-
ation [WHO], 1994). According to WHO data on 126 countries, 93% broadcast
HIV/ AIDS messages on television, 85% conduct radio broadcasts, and 67% of
countries promote condom use through the media (WHO, 1994). Moreover, an
international survey of governmental national AIDS programs found that 86 coun-
tries worldwide reported collecting information on the numbers of people provided
with targeted HIV /AIDS prevention messages (Mann & Tarantola, 1996). Although
the precise impact of mass media on reducing AIDS risk behaviors is continually
debated, knowledge about AIDS is obtained most often from mass media (i.e., tele-
vision, radio, newspapers, magazines, pamphlets, and posters) rather than from
interpersonal sources (i.e., friends, health workers, or the workplace) (Ross &
Carson, 1988).
This article examines empirical studies of HIV /AIDS campaigns that have been
conducted, evaluated, and disseminated in publicly available health, medical, and
communication journals. The purpose of this article is to review and update previous
Address correspondence to : June A. Flora, Ph.D., Stanford Center for Research in Disease
Prevention, Stanford School of Medicine, 1000 Welch Road, Palo Alto, CA 94304, USA.
E-mail : sonja.myhre@ netzero.net
29

2. 30 S . L . Myhre and J . A. Flora
published studies of HIV /AIDS media campaigns conducted throughout the world
(Flora, Maibach, & Holtgrave, 1995 ; Holtgrave, 1997) and to identify appropriate
steps for future HIV prevention campaign e†orts. Unlike previous reviews of HIV /
AIDS prevention interventions processes (Baggaley, 1988 ; Choi & Coates, 1994 ;
Holtgrave, 1997 ; Holtgrave et al., 1995 ; Stoller & Rutherford, 1989), this analysis
focuses on HIV campaigns or interventions that contain a mass media component
and concentrate speciÐcally on the communication processes.
Evaluation of mass media campaigns necessitates an investigation of individual
communication components that constitute the campaign. Focusing on individual
parts enables researchers to pinpoint successful and problematic dimensions. This
type of information can be used to reÐne campaigns underway and should be used
to guide future e†orts. Based on public communication campaign research and in
the interest of parsimony, this study focuses on key features related to campaign
design (Rice & Atkin, 1989 ; Windahl & Signitzer, 1992). We examine the following
fundamental communication components : speciÐcation of a target audience ;
channel selection and mix taking into account reach, speciÐcity, and involvement
issues ; message content and campaign themes that consider execution and message
appeal (Flora, Saphir, Schooler, & Rimal, 1997 ; Schooler, Cha†ee, Flora, & Roser,
1998) ; measures of exposure ; and evaluative outcomes measures.
Methods
We attempted to locate all planned HIV /AIDS mass media campaign e†orts that
provide explicit documentation of quantitative evaluation data on at least one
outcome or impact measure. Formative (i.e., preproduction work), process (i.e.,
implementation studies), and qualitative (i.e., focus groups, ethnographic inquiry)
evaluations were excluded as well as articles that focused on media coverage and
AIDS publicity. Identifying studies was accomplished mainly through electronic
database searches (e.g. Medline, AIDSLINE, PsychInfo) using key words such as
““AIDS,ÏÏ ““HIV,ÏÏ ““mass media,ÏÏ and ““campaign.ÏÏ One limitation of this search tech-
nique is that HIV / AIDS mass media campaigns are sometimes discussed in general
articles that do not mention mass media or campaign in the title or abstract. There-
fore, in addition to electronic database searches, bibliographies of relevant articles
and review articles were carefully reviewed (Choi & Coates, 1994 ; Fisher & Fisher,
1992 ; Flora, Maibach, & Holtgrave, 1995).
This study di†ers from previous reviews in that abstracts (i.e., conference
proceedings), books, book chapters, unpublished reports, and government docu-
ments are excluded. Although abstracts have assumed a prominent role in the Ðeld
(i.e., AIDSLINE contains more than 30 abstracts from the 1998 AIDS conference
proceedings that describe HIV media campaigns in 25 di†erent countries), their
brevity severely limits the amount of information that can be analyzed. An author of
one review conceded that because of the numbers of studies in abstract form, ““It is
virtually impossible to summarize the components of the campaignsÏÏ (Holtgrave,
1997, p. 184).
The following six communication components were examined for each article
(see Table 1) : target audience, channel selection, message content, campaign theme
(i.e., name or slogan), exposure, and outcome measure(s) used to assess the cam-
paign. From an evaluative perspective, these six elements provide important clues
for understanding campaign success or failure. These features were selected for
analysis because they represent a distillation of the essential elements of a campaign
and were more consistently reported in the literature.

3. TABLE 1 Empirical Studies of HIV Prevention Mass Media Campaigns
Study author, Target Channel Message Campaign theme Outcome :
Country Date of publication audience selection/ mix content (name/ slogan) Exposure KABP 1 or other
Argentina Burgos, 1996 General NS Yes AIDS Kills 25% A, B
AIDS, DonÏt Let Yourself
Fall in a Trap.
Australia Bray & Chapman, 1991 General TV, radio, Yes National Campaign 3È93% K, A, B, & anxiety
print, buses & against AIDS
billboards
Ross et al., 1990 General TV, print, & Yes The Grim Reaper 93.5% A, beliefs
posters
Rigby et al., 1989 General TV Yes The Grim Reaper 93.5% K, A, & personal &
social concern
Canada Wagman, 1993 19È30- Billboards, Yes Condomania 10È93% K, A
year-old bus shelters, &
heterosexuals car cards
France Rudelic-Fernandez General Fictional short Yes 3000 Scenarios contre un 69% A & discussion, &
et al., 1998 Ðlms Virus. sociability e†ects
Bajos et al., 1996 General Fictional short Yes 3000 Scenarios contre un 69% A, B, awareness, &
Ðlms Virus. discussion
France Moatti et al., 1992 General TV, radio, Yes 1987 : No One is Immune 53.2% K, A, B, P, & perceived
leaÑets, AIDS. overall risk
cinema spots, 1998 : Condoms Protect
posters, press, You from Everything Even (18.6È91.9%
home video- from Being Laughed At. for di†erent
text network 1989 : Condoms Protect media)
You from Everything but
Love ; Everyone Can Be
A†ected by AIDS ;
Condoms Wish You a
Happy Holiday.
31

4. 32
TABLE 1 Continued
Study author, Target Channel Message Campaign theme Outcome :
Country Date of publication audience selection/mix content (name/ slogan) Exposure KABP 1 or other
Greenland Moi et al., 1993 General NS Yes Stop AIDS NS K, B, P
Haiti Pape & Johnson, General TV, radio, NS NS NS K, A, B
1993 billboards, &
interpersonal
contact
Italy Aboulkhair et al., Youth : NS NS NS B (condom use)
1995 13È20
year olds
Bortolotti et al., IVDUs 3 Booklets, NS NS NS B, HIV seroconversion,
1992 posters, & & HIV seroprevalence
conferences
Bortolotti et al., IVDUs Brochure, NS NS NS B (needle sharing),
1998 lectures, local HIV seroprevalence, &
TV, & print hepatitis B incidence
The de Vroome et al., Young Radio, print, Yes Excuses Campaign 8È88% A, intention, &
Netherlands 1991 adults : Ðlm, posters, condom use
18È25 & brochures
year olds
de Vroome et al., High-risk Posters, print Yes 4/ 87, 10/ 87 : NS NS K, A, P, condom sales,
1990 groups cinema spots, 5/ 88 : Safe Sex on Holiday & STD incidence
free condoms 5/ 89 : Excuses Campaign
10 / 89 : NS
Nicaragua Pauw et al., 1996 General Small media : NS NS NS K, A
print (leaÑets,
stickers, etc.),
video, & home
visits

5. TABLE 1 Continued
Study author, Target Channel Message Campaign theme Outcome :
Country Date of publication audience selection/mix content (name/ slogan) Exposure KABP 1 or other
Norway Traeen, 1992 Youth Rock music, Yes Beat It ! Talk about Sex, 27.5% B (condom use),
radio song, about Being in Love, and interpersonal
musical, novel about Love. communication, &
campaign involvement
Kraft and Rise, General Billboards, Yes Condom Campaign 70% Public awareness &
1988 posters, & acceptance
postcards
St. Vincent Middlestadt et al., Families : Radio Yes NS 71.6% K, A, B, intentions, &
& the 1995 youth & subjective norms
Grenadines parents
Switzerland Hausser & Michaud, General Traveling bus, Yes Stop AIDS NS B (sexual activity &
1994 & youth art exhibits, condom use)
festivals, &
computer
network
Lehmann et al., General : Booklet & Yes Stop AIDS 56% K, A, & beliefs
1987 (20È69 mass media
years (unspeciÐed)
olds)
Thailand van Griensven et CSWs 4 LeaÑets, videotapes, NS NS NS K, perceived vulnerability,
al., 1998 audiotapes, social support,
poster, comic preventive practices,
books, peer HIV incidence &
leaders prevalence
Hanenberg et al., Men TV, radio Yes NS NS B, STD rates, & HIV
1994 prevalence
Uganda Schopper et al., General Print & Yes AIDS : Be Informed and 42% K, A, B
1995 community Protect. (print)
educators
33

6. 34
TABLE 1 Continued
Study author, Target Channel Message Campaign theme Outcome :
Country Date of publication audience selection/ mix content (name/slogan) Exposure KABP 1 or other
U.K. Ross & Scott, 1993 General TV, posters, NS 1986 : DonÏt Die of NS HIV antibody testing
newspaper, Ignorance.
magazines, & 1998 : AIDS. You Know
other print the Risks
1988 : AIDS, YouÏre as
Safe as You Want To Be.
1990 : Experts Speak Out
against AIDS.
Wober, 1988 General TV Yes NS NS K, A, B
Sherr, 1987 General Newspaper ad Yes NS 40.5% K, A, B, & anxiety
Campbell & General Newspaper ad NS NS NS K
Waters, 1987 & TV
Mills et al., 1986 General Newspaper ad Yes NS 31% K
United Walls et al., 1998 Women Print & Yes NS 51% B (condom use &
States community interpersonal
outreach communication)
CDC, 1996 High-risk Print material Yes AIDS Prevention Project (Dallas) 22È65% B (condom & bleach
groups (role model Project REACH (Denver) use)
stories) & peer Road Dogs (Long Beach)
outreach ShiftinÏ
Gears Project (Seattle)
Rietmeijer et al., IDUs Small media : Yes Project REACH : Risk 30% B (use of bleach &
1996 brochures, Education Aimed at condoms)
pamphlets, Community Health
Ñyers, news-
letters, & peer
outreach

7. TABLE 1 Continued
Study author, Target Channel Message Campaign theme Outcome :
Country Date of publication audience selection/ mix content (name/ slogan) Exposure KABP 1 or other
United Santelli et al., 1995 Women Small media : Yes AIDS Prevention for 63% B (condom use), social
States comic books, Pediatric Life Enrichment norms
newsletters,
pamphlets, &
outreach
Caron et al., 1992 College TV, radio, & NS America Responds to NS K, A, B
students brochure AIDS & Understanding
AIDS
Woods et al., 1991 General TV, radio, Yes America Responds to 31È73% K, B, & donated dollar
newspaper, AIDS & Understanding value of air time
billboards, & AIDS
posters
Gentry & Jorgensen, 1991 General TV & radio Yes America Responds to NS Donated dollar value
AIDS of air time
Snyder, 1991 General Pamphlet Yes Understanding AIDS 40% K, A, B, perceived
risk, & personal
communication
Crawford et al., Families TV & Yes Families in Touch : 79% ; K, A, & interpersonal
1990 newspaper Understanding AIDS 60% communication
Gerbert & Maguire 1989 General Brochure Yes America Responds to 59% A & interpersonal
AIDS communication
Dommeyer et al., College Posters, NS AIDS Awareness Week NS K, A, & fear
1989 students billboards,
pamphlets,
plays, & print
Zambia Yoder et al., 1996 General Radio drama Yes Nshilakamona : 45% K, B, conversations,
““I Have Not Yet Seen It.ÏÏ & perceived risk
1
Knowledge, attitude, behavior, and practice.
2 Not speciÐed.
3
Intravenous drug user.
4
Commercial sex workers.
5
Exposure by city and community : Dallas : 31% ; Denver : 22% (IDUs) ; Long Beach : 55% (IDUs), 68% (female sex traders), 45% female sex partners of male IDUs ; New York City : 46% (female sex
partners of male IDUs) ; Seattle : 22% (nonhomosexually identifying men who have sex with men), 36% (female sex traders), 25% street youth.
35

8. 36 S . L . Myhre and J . A. Flora
Several campaign components, such as theoretical framework and campaign
““dose,ÏÏ were not included in the analysis because of infrequent and inconsistent
documentation in the articles contained in this review. A theoretical framework was
speciÐed in less than a Ðfth of the articles. Psychologically based theories according
particular attention to self-perception of risk and the inÑuence of social norms (e.g.,
theory of reasoned action, health belief model, Marin model, and social cognitive
theory) were the most commonly mentioned theories and models.
For our purposes, target audience refers to the intended recipients of the cam-
paign message(s). Channel selection and mix pertains to the selected communication
modality or modalities used to convey the campaign message(s). Message content
concerns the type of information that is being conveyed to the target audience.
Additional information such as presentation style, execution features, and message
appeal also provide valuable insight about a campaign (Baggaley, 1988). The cam-
paign name or slogan is included as a proxy measure of the fundamental theme of a
campaign. Campaign exposure relates to a measured response regarding hearing or
seeing the campaign messages. Finally, outcome measures refer to the types of issues
that are measured and used to quantify and evaluate campaign e†ects. Because of
the small sample size (n 5 41), we did not attempt to conduct signiÐcance tests in
analyses of the data.
Results
Our search yielded 41 published journal articles from 17 countries. (See Table 1 for
a complete list of the sample studies.) Although we did not limit the nature of the
mass media campaigns, the majority of articles discussed national HIV / AIDS cam-
paigns. Strong representation of national campaigns in this sample likely reÑects the
substantial cost associated with mass media endeavors. A few campaigns (e.g.,
America Responds to AIDS (ARTA), AustraliaÏs ““Grim ReaperÏÏ) are represented
numerous times because several evaluations were conducted in various locations by
di†erent researchers on the same campaign. A pretest/ posttest was the most
common research design mentioned with fewer studies relying on posttest only.
Very few studies (n 5 7) utilized a quasi-experimental design incorporating a
control/ comparison group.
Articles in this sample reveal which countries have the necessary resources (i.e.,
researchers) and interest in disseminating HIV campaign results. Of note, more than
one-third (41%) of the articles describe campaigns in lesser-developed countriesÈ
many of which have been a†ected severely by the AIDS pandemic (e.g., Haiti, Thai-
land, Uganda, and Zambia). No articles describe activity in the Middle East and few
present data on campaigns in Asia (except Thailand), Latin American (except
Argentina), and Africa (except Uganda and Zambia). Although HIV / AIDS preven-
tion e†orts may exist in these regions, we were unable to locate published articles
from these areas that met our inclusion criteria. Finally, the studies in this sample
include reports on early mass media responses to HIV / AIDS (i.e., 1986) as well as
recent campaign e†orts.
Analysis of Communication Components
Target Audience
Every article in the sample articulated the intended target audience of the HIV /
AIDS campaign. Although the general public was identiÐed most frequently as the

9. HIV / AIDS Communication Campaigns 37
target audience, more speciÐc audiences included families (Crawford et al., 1990 ;
Middlestadt et al., 1995), youth (Aboulkhair et al., 1995 ; de Vroome et al., 1991 ;
Hannonen et al., 1994 ; Hausser & Michaud, 1994 ; Traeen, 1992 ; Wagman,
1993), injecting drug users (Bortolotti et al., 1988 ; 1992 ; Rietmeijer et al., 1996),
student populations (Brown et al., 1991 ; Caron, Davis, Wynn, & Roberts, 1992 ;
Dommeyer, Marquard, Gibson, & Taylor, 1989), and sex workers (van Griensven et
al., 1998). Despite that HIV initially posed the greatest threat to gay men, intra-
venous drug users, and persons with hemophilia, the majority of early campaigns
were directed at a broad, undeÐned audience. This apparent lack of di†erentiation
of the audience presumes that receivers are perceived to be similar with respect to
AIDS knowledge and risk and are passive in terms of information processing and
action (Dervin, 1989). One exception, the Netherlands campaign, stated that early
national campaigns were explicitly directed at the homosexual community (de
Vroome et al., 1990) but were undertaken by nongovernmental organizations. In
contrast, campaigns directed or funded or both by governmental agencies are faced
with the struggle of avoiding controversy in the political arena and, thus, are forced
to assume a more indirect, ““untargetedÏÏ approach. Yet, as in the case of AustraliaÏs
national campaign, fear arousing messages directed at the general population, a
low-risk group overall, resulted in widespread anxiety and social discord (Bray &
Chapman, 1991).
Channel Selection and Mix
The majority of studies (n 5 38) described the channels used to deliver HIV /
AIDS messages. Of these studies, approximately one-quarter (26%) relied on a
single channel of communication. The single media campaigns utilized print (in the
form of a national mailing), radio, television, and short Ðlms. (In some instances,
articles focused on a single medium that was part of a larger, multifaceted cam-
paign.) Two successful, single medium campaigns conducted in St. Vincent and the
Grenadines (Middlestadt et al., 1995) and Zambia (Yoder, Hornick, and Chirwa,
1996) demonstrate that carefully planned, low-cost broadcast media campaigns can
reach many people e†ectively and efficiently with HIV prevention messages.
Most campaigns utilized multiple channels. Recognition of the critical relation-
ship between the target audience and channel selection (i.e., speciÐcity) was some-
times discussed. In a Norwegian youth campaign, for example, the use of a rock
concert, video, pop song, and novel appeared well founded given that the target
audience was youth. The investigators concluded, however, that inadequate channel
research had resulted in poor planning that hindered program exposure and partici-
pation. One could also argue that the selected channels were not credible sources of
health information for youth. In sum, a channelÏs reach, speciÐcity, and degree of
involvement must be considered carefully with respect to the target audience.
The use of multiple channels, as opposed to reliance on a single channel,
appeared to be partially related to available media budgetsÈsingle and small media
campaigns were noted more often in lesser-developed countries restricted by Ðnan-
cial and material resources. To maximize limited resources, campaigns in lesser-
developed countries tended to use lower-cost media channels such as print, radio,
and small media. Moreover, these media were more suited to the targeted groups
(e.g., higher radio versus television use /ownership in some countries). In contrast,
many industrialized countries designed multimedia campaigns where multiple chan-
nels are used simultaneously. The ARTA campaign, for example, included 83 tele-
vision public service announcements (PSAs), 68 radio PSAs, 53 print PSAs, 62

10. 38 S . L . Myhre and J . A. Flora
posters, 19 brochures, three point of purchase displays, and two audio cassettes by
as early as 1990 (Woods, Davis, and Westover, 1991).
Channel supplementation (i.e., broadcast media supported by interpersonal
media or print following broadcast media) was evident in eight articles (Haiti,
Nicaragua, Thailand, Uganda, and the United States ; see CDC, 1996 ; Rietmeijer et
al., 1996 ; Santelli et al., 1995 ; Walls, Lauby, Lavelle, Derby, & Bond, 1998). The
most common supplementation strategy consisted of small media supplemented by
outreach in the form of peer leaders, volunteers, or community educators.
The array of channels used to convey HIV / AIDS preventive messages illustrates
the diversity and innovation that has been applied by HIV / AIDS practitioners.
Rather than relying solely on mainstream forms of communication, HIV / AIDS
campaigns have utilized venues including less traditional forms such as cinema
spots, short Ðlms bar coasters, rock concerts, and even baseball cards to convey
HIV/ AIDS messages. Faced with the challenge of discussing personal and private
issues related to HIV / AIDS risk behaviors, HIV preventive channel selection has
proven both creative and unconventional.
Message Content
Approximately three-fourths of the articles provided descriptions using either
visual images or written detail of the HIV / AIDS campaign messages. The extent of
the description of message content varied considerably. Some articles provided con-
crete and detailed written and visual examples and others clearly articulated the
relationship between content and campaign objectives. In articles that did not
specify message content, no information was provided regarding the type of HIV /
AIDS prevention message delivered. Consequently, it was unclear whether these
campaigns attempted to simply inform (i.e., provide factual information on HIV
transmission), to convey preventive messages (i.e., describe how to avoid HIV risk
behaviors), or whether they aimed to a†ect individual behavior or social norms.
The French national campaign provided descriptive information on message
content by specifying the intended style and tone (e.g., emotive, whimsical, erotic) of
each campaign (Moatti et al., 1992). Thus, inferences regarding the usefulness of
each approach could be investigated with respect to timing, duration, and other
features of the campaigns. In addition, the French survey questions addressed
explicit issues about how message content had inÑuenced individual attitudes, risk
awareness, sexual behavior, and HIV testing behavior. Linkages between campaign
content and the impact on collective attitudes could, therefore, be explored.
Campaign Theme
Nearly two-thirds (63%) of the articles provided the name or slogan of the
campaign to the reader. The fact that more than one-third (37%) of the articles did
not provide a campaign name may reÑect an author or editorÏs decision to omit this
information or, more likely, suggests that no campaign name existed. Although lack
of a campaign name may seem trivial, a campaignÏs direction and philosophy is
often best articulated by its slogan. The advertising industry, for example, accords a
great deal of importance to the potential impact of slogans and the inÑuence of
branding products. Moreover, given broadcast mediaÏs predilection for encapsulat-
ing information into short sound bites, campaign slogans may be the only take-
home message that many in the target audience receive. In this sample, campaign
names and slogans ranged from fear arousing (ArgentinaÏs AIDS Kills and Aus-

11. HIV / AIDS Communication Campaigns 39
traliaÏs the Grim Reaper) to perfunctory (SwitzerlandÏs STOP AIDS and NorwayÏs
Condom Campaign) and light (CanadaÏs Condomania).
Campaign Exposure
Almost two-thirds (62%) of the articles provided the reader with a measure of
exposure. Assessing what proportion and who among the target audience attended
to the messages is considered one assessment of a campaign and often is an under-
valued indicator of a campaignÏs success (Flora et al., 1997). Obtaining sufficient
exposure is a prerequisite to any outcome e†ect and is essential in post-only and
pretest/ posttest research designs. Even among articles that provided a measure of
exposure, however, many failed to provide details regarding the extent of exposure
(i.e., how many messages) or level of comprehension.
Of the articles that measured campaign exposure, two-thirds (68%) reported
that 50% or more of the target audience were exposed to the campaign. Among
those campaigns that achieved less than 50% exposure, print was the most common
channel mentioned. As channel communication theory would predict, typically tele-
vision campaigns had the highest exposure ratings in this sample of campaigns
(Flora et al., 1997). Multimedia campaigns with data on the reach of individual
communication modalities provide additional evidence that channels vary in their
ability to reach or connect or both with certain target audiences (see de Vroome et
al., 1991 ; Moatti et al., 1992 ; Woods et al., 1991 ; Wagman, 1993).
Outcome Measures
Knowledge and attitudinal outcome measures to assess success were most
common, whereas fewer campaigns sought to measure behavioral change. In many
instances, other outcome indicators were assessed and considered to reÑect the
program success or failure. Although most of the studies reviewed did not describe
with clarity the theoretical framework within which they were conducted, the out-
comes measured indicate an implicit and widespread use of a knowledge, attitude,
behavior, and practices (KABP) model. This apparent reliance on the KABP model
may have resulted in less attention to outcomes that pertain to the maintenance of
healthful behaviors and practices such as perceived norms (e.g., perceived prevalence
of safe behavior), perceived self-efficacy, and social and community outcomes (e.g.,
interpersonal and community advocacy and policy support). These outcomes are
particularly germane to the present challenge of preventing relapse from safer sex
and sustaining long-term risk reduction practices (Stall, Ekstrand, Pollack, McKu-
sick, & Coates, 1990).
A number of recent campaigns, recognizing the limited ability of mass media to
bring about behavioral change, have shifted their focus to intermediary outcomes
theorized to be associated with behavioral change. Increasing public and private
discussion about HIV/ AIDS issues is one such example (see Bajos, Spira, Lert,
Rudelic-Fernandez, & Ducot, 1996 ; Crawford et al., 1990 ; Rudelic-Fernandez,
Bajos, Lert, Ducot, & Spira, 1998 ; Snyder, 1991 ; Walls et al., 1998 ; Yoder et al.,
1996). Personal discussion between sexual partners, parents and children, and
among friends was considered to be an important step toward behavior or attitudi-
nal or both types of change.
Similarly, acknowledging that many campaigns focus only on individual attitu-
dinal and behavior change, the inÑuence of social norms in relation to HIV / AIDS

12. 40 S . L . Myhre and J . A. Flora
preventive behavior has been pursued. Changing the image of safer sex and, more
explicitly, popularizing condom use was a strategy utilized by several campaigns.
Three studies explicitly measured change in social norms as a result of the cam-
paigns (see Middlestadt et al., 1995 ; Santelli et al., 1995 ; Wagman, 1993). A primary
objective of the Canadian campaign, for example, was to popularize condom use by
reducing the embarrassment associated with their use. Similarly, many of the French
messages sought to change the social image of condoms by making them ““more of a
“social routine.ÏÏÏ (Moatti et al., 1992, p. 245).
Campaign E%ectiveness
Because of the highly diverse set of measures and research designs noted in this
sample, cumulating outcome measures into a summary Ðnding would be uninter-
pretable and misleading. Lack of an increase in knowledge at posttest in one study,
for example, may be indicative of an AIDS ““factÏÏ saturated audience, whereas in
others it may reÑect a campaign inadequacy. The broad range of attitudinal and
behavioral measures across studies also prohibits meaningful analysis. In lieu of a
cross-country comparative analysis, we consider a few exemplar studies. In other
words, we discuss studies that provided comprehensive documentation of campaign
components and that illustrate the range of strategies used in campaigns around the
world. We include campaigns with positive Ðndings as well as those with unintended
or unsatisfactory outcomes since recognition of these campaigns is critical to the
advancement of campaign design.
ThailandÏs mass media campaign is an example of a campaign that integrated
HIV prevention messages with the government-sponsored national 100% condom
policy and took into account the commercial sex workerÏs (CSWÏs) unique environ-
ment (van Griensven et al., 1998). Attitudes, behaviors, and relationships were
studied to maximize potential HIV preventive behavior (e.g., CSWsÏ managers were
included in the campaign given their potential inÑuence on CSWs). This campaign
demonstrates the importance and value of working with existing programs, embrac-
ing the cultural context, and understanding the needs of the target audience. Other
examples of campaigns that carefully considered the culture of the target audience
include UgandaÏs Be Informed and Protect and ZambiaÏs Nshilakamona campaign.
These campaigns acknowledged the realities of a village-based campaign by selec-
ting small media and radio and designing messages appropriate to illiterate audi-
ences (Schopper et al., 1995 ; Yoder et al., 1996).
The Australian Grim Reaper campaign, on the other hand, was problematic
based on Ðndings from evaluation data. This campaign achieved very high exposure
but failed to arouse personal and social concern in a productive manner. Instead it
incited strong negativity among the public. What brought on this reaction ? First,
the campaign utilized a macabre and fearful ““grim reaperÏÏ Ðgure to convey HIV /
AIDS messages. Second, by using these arresting spots on broadcast media, the
campaign attained nearly universal campaign exposure in the public sphere. In
terms of awareness, the campaign was highly e†ective but later analysis found little
change in knowledge and high anxiety expressed by the population sample (Bray &
Chapman, 1991). The researchers noted the following :
The data in this paper show the disturbing extent of hysterical and exagger-
ated perceptions of AIDS and potentially social divisive attitudes. Public

13. HIV / AIDS Communication Campaigns 41
health authorities should consider whether public information programs for
AIDS control that scare much of the population unnecessarily can be justi-
Ðed when they have such stigmatizing and neurosis-producing results. (Bray
and Chapman, 1991, p. 113)
Thus although the campaign had impressive exposure (93.5%), only 28% of the
sample responded that they had been inÑuenced positively by the campaign (Rigby,
Brown, Anagnostou, & Ross, 1989). In contrast, for the Norwegian youth culture
campaign the issue was not the inappropriate use of strong imagery, but rather an
indirect, weak message design combined with the inadequate exposure among the
targeted group that resulted in poor recall of the campaign and low participation
rates (Traeen, 1992). Finally, the United KingdomÏs newspaper advertisements
demonstrate how resources can be squandered by focusing on Ðrst-order outcomes
only, i.e., knowledge (Sherr, 1987).
Discussion
The variety of HIV / AIDS campaign strategies around the world is indicative of the
fervency and creativity that abounds in e†orts to stop the AIDS pandemic.
Although great progress has been achieved, Ðndings from this review suggest that
conceptual and methodological rigor in reporting fundamental communication
components can be improved. Most campaigns designate a target audience, but
many campaigns have not addressed those at highest risk within a particular
society. With regard to channel selection, these studies demonstrate that conven-
tional and single medium campaigns have progressed to utilizing nontraditional
communication modalities and multiple channels if resources permit. Similarly,
message design has beneÐted from an outpouring of creativity despite the challenge
associated with communicating private and taboo subjects. More at issue, however,
is that message design and campaign themes are, typically, awarded only limited
discussion thereby hindering dissemination. Moreover, assessing campaign e†ec-
tiveness has been seriously hampered by insensitive and unstandardized measures.
Limitations
This analysis contains only studies that have been published and provide quantita-
tive evaluation data. Consequently, this review excludes studies that have not been
published to date (e.g., grey literature) and articles that are devoted solely to cam-
paign description or qualitative research. Journal articles in languages other than
English may not be represented fully, although several databases that were searched
contain foreign language journals. Finally, this analysis is constrained by the range
of information provided in the articles. Although each study in this review met a
minimum set of criteria, there were many conceptual and measurement inconsis-
tencies across studies which could not be controlled. Consequently, there was great
variation across studies in research design, methodological rigor, and how
campaign-related data was presented and deÐned. Studies in the sample appeared in
a variety of journals across di†erent multiple disciplines so article content varied
according to journal focus and editorial policy.

14. 42 S . L . Myhre and J . A. Flora
Implications
HIV/ AIDS prevention has resulted in an impressive outpouring of community-
based outreach, innovative media ideas, and communication research, yet there con-
tinues to be a dearth of systematically analyzed mass media campaigns. Accurate
assessments of HIV / AIDS campaigns are necessary to modify existing campaigns
and to build e†ective new campaigns. Because little evaluation data is available
publicly, campaigns will continue to have poor estimates of their ability to impact
knowledge, attitudes, and behaviors. For us to learn about campaigns we need to
continually examine data on communication components and relationships and to
establish a more systematic method of evaluating campaigns.
This review of HIV /AIDS campaign activity around the world highlights the
need for a common set of criteria to evaluate mass media campaigns. Although we
acknowledge the scarcity of resources available to many researchers, we recommend
that HIV/ AIDS campaign research strive to report a minimum level of information
regarding methodology and communication components. The level of reporting and
evaluation represents one of the most promising routes for strengthening HIV / AIDS
campaign work.
This review highlights much of the progress that has been made in HIV / AIDS
campaign work. Since communication campaigns alone cannot change community
infrastructure, bring about and enforce policies, or increase resources (such as
provide condoms or needle exchange programs) and services (such as counseling,
testing, or medical care), future work in HIV / AIDS prevention needs to shift toward
community e†orts. HIV communication programs should aim to increase the
importance of HIV prevention, frame HIV prevention as a community problem,
improve the quantity and quality of public and private discourse regarding HIV
prevention, and improve the nature and extent of public participation in HIV pre-
vention.
Some countries have begun to initiate programs that are community based and
communitywide (e.g., U.S. Centers for Disease Control & Prevention AIDS com-
munity demonstration projects, the NetherlandsÏ safe sex campaigns, and Nicara-
guaÏs HIV/ AIDS Health Education Program). To date, seven HIV prevention
studies (Ðve of which are CDC-funded AIDS demonstration projects) have been
designed as quasi-experimental community studies (i.e., comparison/control groups)
with a mass media component (CDC, 1996 ; Pauw et al., 1996 ; Rietmeijer et al.,
1996 ; Santelli et al., 1995). A common thread among these studies is their focus on
high-risk individuals within the community. Additionally, all of the studies rely on
outcomes related to individual behavior change rather than community-level out-
comes. Of note, these studies are relatively new, all publishing results since 1995.
Conclusion
HIV/ AIDS campaigns originated in an atmosphere of public health urgency and
fear. For the most part, HIV /AIDS campaigns have only just begun to systemati-
cally use communication and behavioral science literature on behavior change, com-
munity level theories, and strategic development of campaigns that encompasses
message design and channel selection. Relatively recent developments in health
communication research, such as emphasizing community involvement, institution-
alization, and policy advocacy, have yet to be fully incorporated into HIV / AIDS
prevention, treatment, and policy. In addition, persuasive HIV preventive cam-
paigns need to collaborate with interventions aimed at changing structural and

15. HIV / AIDS Communication Campaigns 43
environmental conditions. Finally, as HIV / AIDS moves into the next century,
research agendas need to embrace fully communitywide perspectives with multiple
audiences and outcomes (from individual behavior change to policy change) and a
strategic mix of communication venues.
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