Journal of
Media and Communication Studies

  • Abbreviation: J. Media Commun. Stud.
  • Language: English
  • ISSN: 2141-2545
  • DOI: 10.5897/JMCS
  • Start Year: 2009
  • Published Articles: 223

Review

Literature review of sexual reproductive health campaign messages: What are the milestones and potential research topics within the Kenyan context?

Bernice Ndegi Gatere
  • Bernice Ndegi Gatere
  • Department of Communication Studies, School of Human Resource Development, Moi University, Kenya.
  • Google Scholar
Charles Ongondo
  • Charles Ongondo
  • Department of Communication Studies, School of Human Resource Development, Moi University, Kenya.
  • Google Scholar


  •  Received: 15 August 2019
  •  Accepted: 25 September 2019
  •  Published: 31 October 2019

 ABSTRACT

This paper presents a literature review of the sexual reproductive health campaign messages and highlights the milestones in the existing literature. The review begins with definition of health campaign messages and other key concepts. The subject is then situated within the discipline of communication studies particularly within the branch of health communication. A review of relevant theories follows after which previous research on health campaign messages is highlighted. The paper concludes by pointing out the potential areas of further research on the subject of health campaign messages in Kenya. This paper highlights the key concerns cited among the literature to demonstrate the milestones achieved in sexual reproductive health issues and identifies gaps in research to underscore the need, within a uniquely Kenyan context, for subsequent studies.

 

Key words: Communication studies, Health communication, Health campaign messages, Kenyan sexual reproductive health.


 INTRODUCTION

Health campaign messages are the means through which the general public is exposed to health information content and encouraged to change particularly unsafe behaviours. Health campaign messages are employed by health communication experts to motivate audiences to respond in a certain manner, to encourage risk reduction, and to move people towards behaviour change in health-related matters. In this paper, we seek to demonstrate, in practical terms, the terrain of a literature review for an academic endeavor, particularly in research. We reiterate not only the need for scholars to define their concepts clearly as a way of delineating them from other existing meanings, but also to demonstrate for clarity the focus of a particular academic paper or research report.  Next, we situate health campaign issues robustly within the broader field, discipline and subject. This is intended to enable readers to consider the subject of the paper from a particular lens, given that some of the issues raised could be points of discussion from other disciplinary perspectives. Further, we review related theories that underpin the conceptualizations of the issue under investigation. The review on theories arms the researcher with the necessary tools to discuss the findings from a critical approach. Moreover, the literature review entails the review of previous research on the subject, both in breadth and in depth.  This is intended to indicate any research gaps that subsequent studies could fill and to provide a justification for further studies.
 
 
This paper, therefore, situates the topic of Sexual Reproductive Sexual campaigns (SRHC) within the relevant subject and discipline, reviews related theories and previous research on the subject and highlights milestones in the literature on the subject as well as potential research areas in various contexts.
 
SITUATING HEALTH COMMUNICATION WITHIN THE FIELD OF COMMUNICATION STUDIES
 
Communication scholars have defined Health Communication as "the main currency of healthcare in the 21st century" (Krisberg, 2004). Schiavo (2007) describes health communication as giving ready access to relevant, reliable, and culturally appropriate information to the general public, patients, health care providers, public health professionals and others. This enables all concerned to address personal and public health matters far more efficiently than in the past. Positioning that in the wake of the anthrax crisis in 2001, Schiavo (2007) explains that the Centre for Disease Control (CDC), and other federal authorities defined communication as the most important healthcare related science of the twenty first century.
 
Health communication draws upon multiple disciplines including mass communication, social marketing, health education, anthropology and education (Bernhardt, 2004). Keller and Lehmann (2008) observe that health communication theories fall into two distinct categories, those that examine the positive acceptance of the message recommendation (acceptance, adoption, behaviour change) and those that examine the rejection of such messages (defensive, avoidance, denial). They note it is important to ensure that health campaigns are tailored to specific audiences to ensure effectiveness.
 
Overall, the subject of Health Communication, specifically Sexual Reproductive Health Campaigns, is clearly a multi-disciplinary subject that could be studied within the ambit of Communication Studies. Gamble and Gamble (2013) define Communication as the deliberate or accidental transfer of meaning, the process that occurs when someone observes or experiences behaviour and attributes meaning to it. According to Mcquail (1994) and Berger and Chaffee (1987), Communication Studies is a science that seeks to understand the production, processing and effects of symbol and signal systems by developing testable theories, containing lawful generalizations that explain phenomena associated with production, processing and effects.  Accordingly, it can be successfully argued that Health Communication is where good health promotion and good communication practice meet (Public Health Ontario, 2012).
 
Schiavo (2007) acknowledges that convincing people to adopt healthy behaviours, or convincing policy makers and professionals to introduce and change practices in support of better health is not an easy task. Studies conducted  in   Kenya  so  far  including  the  Kenya  Aids Indicator Survey (KAIS, 2014) and the Kenya Aids Epidemic Update (2012) have shown that the prevalence rate of new infections among married couples and people in long-term relationships remain high despite the Wacha Mpango wa Kando (Stop the concurrent sexual relationships) campaign messages initiated by the government and various stakeholders in 2009.
 
In so far as policymakers are concerned, the progress made in the East African country of Uganda with initiatives to combat HIV/AIDS over the years has brought to the fore the reluctant manner in which their Kenyan counterparts accepted the reality of the epidemic perhaps leading to a later response than in Uganda. Today, with concerted effort and policy framework, Kenya is one of the leading countries in Africa in effective communication campaigns to fight HIV/AIDS. One recent campaign already rated as effective is the campaign encouraging men to undergo Voluntary Male Medical circumcision (VMMC). Another has been the provision of access to HIV care and treatment. About 9 out 10 people knowingly infected with HIV are receiving essential HIV-related care services and treatment for their infection (KAIS, 2013). This goes to show positive impact that effective health communication can make.
 
Lupton (1994) locates and critiques some of the foundational issues that underlie health communication. Arguing that communication in the health context has been traditionally conceptualized as a top-down approach, Lupton demonstrates that communication flows from the centers of authority to peripheral locations. This has posed major challenges for leading health communication professionals to engage in more participatory approaches. In the next section we review some literature on health communication campaigns. The criteria for reviewing literature on these health campaigns are to draw out information that future campaigns could employ.


 HEALTH COMMUNICATION CAMPAIGNS

Both communications and public health practitioners have developed interventions to promote healthy attitudes and actions and to suppress those that place life and health in jeopardy (Freimuth et al., 2000). Communication campaigns are “communication efforts to improve the lives of individuals and the fabric of our society” (Paisley and Rice, 1981), commonly used to reach and inform the ‘mass’ audience about important social issues. Communication campaigns are called public as they exclude no one from their messages (Stappers, 1983) and as they address the audience as citizens, as an ‘active public’ who have to choose to be persuaded to take action on a (social) problem (Roser and Thompson, 1995). Paisley and Rice (1981) argues that reform is a unifying principle of all public communication campaigns whether the structure of society itself is affected (promotion of collective benefits) or only the lifestyles of individuals  (promotion of individual benefits) (Paisley and Rice, 1981).
 
One of the characteristics public communication campaigns is that they are targeted at the general audience but focused to a specific audience segment believed to be at a greater risk for adversity or illness. Most health communicators agree that there is a common set of variables considered in the development of a mass media health communication campaign and a common set of outcomes that one can reasonably expect as a result of a communication experience (Freimuth et al., 2000). These variables can be categorized into four broad areas: 1) psychosocial attributes of the receiver, 2) the source or spokesperson, 3) settings, channels, activities, and materials used to disseminate the message, and 4) the message itself, including content, tone, type of appeal, audio characteristics, and visual attributes. (Maibach and Parrot, 1995)
 
Health communication is anchored in several related theories, in view of its multidisciplinary nature. It is important that scholars indicate the theories that underpin their arguments, especially while interpreting findings of any study. In this regard, the next subsection, reviews key theories that anchor health communication campaigns targeting sexual reproductive health messages.
 
REVIEW OF THEORIES RELEVANT TO SEXUAL REPRODUCTIVE HEALTH MESSAGES
 
The criteria for reviewing these theories are to highlight the grounding of campaign messages in relevant theories.  McCombs (2004) postulates that there are theories applicable to all aspects of public communication campaign strategies, processes, and implementation. The theories also identify the parameters that campaign designers should always strive to meet from a Communications perspective.  Subsequently, a review of these theories follows.
 
Integrative theory of behaviour change
 
This theory is linked to public campaign messages by the argument developed by Cappella et al., 2001). They contend that Integrative Theory of Behaviour Change is multifaceted model as it integrates Social Cognitive Theory (SCT), Theory of Reasoned Action (TRA) and Health Belief Model (HBM) in explaining how external variables, individual differences, and underlying beliefs contribute to differential influence pathways for outcome behaviours, intentions, attitudes, norms, and self-efficacy. Designers should always put into consideration these external variables in developing campaign messages.
 
Social Cognitive Theory (SCT)
 
Also   known   as   social   learning   theory,   the    Social Cognitive theory (Bandura, 1977, 1986, 1997) postulates that health behaviour change is the result of three reciprocal factors: behaviour, personal factors, and outside events. Any change in any of the three factors is expected to determine changes in the remaining ones (National Cancer Institute and National Institute of Health, 2002). Behaviour is therefore viewed as influenced by a combination of personal and outside factors and events.
 
One of SCT’s key premises is its emphasis on the outside environment, which becomes a source of observational learning. SCT reasons that the environment is a place where individuals can observe an action, understand its consequences, and as a result of personal and interpersonal influences, become motivated to repeat and adopt it (Bandura, 1997; National Cancer Institute and National Institute of Heath, 2002; Health Communication Partnership, 2005). According to Health Communication Partnership (2005), SCT’s contributes to health communication by enabling researchers to understand the mechanisms and factors that influence retention, reproduction and motivation on a given behaviour. The components of Social Cognitive Theory are outlined on Table 1.
 
Another component of this multifaceted model of integrative theory of behaviour change is the Theory of Reasoned Action.
 
Theory of Reasoned Action (TRA)
 
This theory (Ajzen and Fishbein, 1980) suggests that behavioural performance is primarily determined by the strength of the person’s intention to perform a specific behaviour. For behaviours that are within a person’s control, behavioural intentions predict actual behaviour. Intentions are determined by two factors – attitude toward the behaviour and beliefs regarding other people’s support of the behaviour (National Cancer Institute and National Institutes of Health, 2002).
 
Generally, attitudes can be defined as positive or negative emotions or feelings towards a behaviour, a concept, or an idea (Schiavo, 2007). This attitude is coupled with a person’s subjective norms about the behaviour. Subjective norms are defined as the opinion or judgement, positive or negative that loved ones, friends, family, colleagues, professional organizations, or other key influences may have about potential behaviour (Schiavo, 2007). Consequently, in TRA attitude towards a specific behavior is a function of the person’s beliefs about the consequences of such behavior. There is a  desire to comply with significant others in a person’s life.  In terms of campaign messages, TRA is particularly useful in analysing and identifying reasons for action and messages that can change people’s attitudes (Schiavo, 2007).
 
 
In their summary of these models, (Aggleton and O’Reilly  1994)  identify  individual  factors   such   as  risk  perception, outcome expectations (the belief a person holds about the good or bad results that will happen as a result of adopting a new behavior), perceived social and community norms (a person’s perception that a behavior is expected by the community or by influential people), and self-efficacy (a person’s perception of their ability to undertake a certain behaviour). Salmon and Atkin (2003) provides an in-depth summary on the process of designing campaign messages. They contend that message designing involves the strategic selection of substantive material and the creative production of stylistic features. In developing the combination of message components, the campaign designer seeks to emphasize one or more of five influential message qualities. First, credibility is primarily conveyed by the trustworthiness and competence of the source and the provision of convincing evidence. Second, the style and ideas should be presented in an engaging manner via selection of interesting or arousing substantive content combined with attractive and entertaining stylistic execution. The third dimension emphasizes selection of material and stylistic devices that are personally involving and relevant, so receivers regard the behavioral recommendation as applicable to their situations and needs. The fourth element is understandability, with simple, explicit, and detailed presentation of content that is comprehensive and comprehensible to receivers. For persuasive messages, the fifth factor involves motivational incentives (Salmon and Atkin, 2003).
 
The third component of the integrative theory of behaviour change is the Health Belief Model (HBM)
 
Health Belief Model (HBM)
 
Health believe model (HBM) posits that for people to adopt recommended physical activity behaviours, their perceived threat of disease (and its severity) and benefits of action must outweigh their perceived barriers to action (NCINIH, 2002). The HBM (Becker et al., 1977; Janz and Becker, 1984) was originally intended to explain why people did  not  participate  in  programs  that  could  help them diagnose or prevent diseases. The major assumption of this model is that in order to engage in healthy behaviours, intended audiences need to be aware of their risk for severe or life-threatening diseases and perceive that the benefits of behaviour change outweigh potential barriers or other negative aspects of the recommended actions (Schiavo, 2007). The HBM is one of the first theories developed to explain the process of change in relation to healthy behaviour. It is summarised in Table 2.
 
 
Another theory closely related to the integrative theory of behaviour change and also to audience response to campaign messages is the Diffusion of Innovations Theory, highlighted next.
 
Diffusion of innovations theory
 
According to this theory, the audience should easily accept the campaign messages. The audience should be able to try listening and accepting the messages and recommending them to others.  Rogers (2003) contends that this theory introduces the ideas of relative advantage and trialability of recommended behaviors, and the individual adoption decision process, as well as opinion leadership that shapes diffusion through interpersonal channels and social networks via multistep flows.
 
In their summary of above theories, (Aggleton and O’Reilly, 1994) point out individual factors such as risk perception, outcome expectations (the belief a person holds about the good or bad outcomes that will result from adopting a new behaviour), perceived social and community norms (a person’s perception that a behaviour is expected by the community or by influential people), and self-efficacy (a person’s perception of their own ability to undertake a certain behavior).

 


 THE ROLE OF THEORY IN DESIGNING HEALTH CAMPAIGN MESSAGES

Several theories  of  message   design   are   outlined  by  Maibach and Parrot, (1995) in their book, Designing Health Messages. They devote this work to three major and broad issues; Theory-Driven Approaches to Health Message Design, Audience Centred Strategies for Health Message Design and Combining theory and Practice.
 
Theory plays numerous roles in helping scholars and practitioners understand the communication process. One of the basic roles of theory in behaviour science involves description; theories describe the complex world in which we live in and in doing so render them comprehensive (Maibach and Parrot, 1995). They go on to describe other roles of behaviour theory as the prediction of outcomes; ‘if X occurs, then Y is more (or less) likely to occur’. They state another role of theory as explanation. Theories that are able to answer the question "why" create greater understanding. They become necessary for the attainment of yet another goal of theory - the ability to prescribe effective interventions.
 
Many mediated health messages fall short of attaining the goal of positively affecting people’s behavior's in relation to health. This, according to Levy and Windahl (1984) has to do in part with the way people process the information which they have been exposed to. A number of theories address the differences between active and passive cognitive functioning and why individuals actively or passively process information.  Louis and Sutton's model of "Switching Cognitive gears" (1991) explains that individuals are motivated to become actively cognitively engaged: When presentation of content is unusual, unfamiliar, or novel; when presentation of content represents a discrepancy between expectations and reality; and when an external or internal request causes an individual to initiate an increased level of conscious attention.
 
The question then would be how we move people from passive to active mode in as far as responding to HIV/AIDS prevention messaging is concerned.  According to the "Switching Cognitive Gears”: Invoking Active Thought model, individuals rely on automatic processing of health information, depending on past knowledge or experience  with  similar  messaging  to  assign  meaning and interpretation to present message (Chanowitz and Langer, 1981). Researchers and designers should thus always address the question of how previous information or experience with messaging influenced and continue to influence the meaning and interpretation the target audience assigns to the messages.
 
REVIEW OF RELEVANT PREVIOUS RESEARCH IN HEALTH COMMUNICATION
 
A review of previous research is critical to any scholarly endeavor. This exercise is useful in indicating milestones that have been achieved in investigating a subject, while also indicating the gaps that could provide rationale for future research on the subject. Therefore, in this section, we review relevant previous research, divided into four sub-sections, on the subject of Sexual Reproductive Health Campaigns globally and in Kenya.
 
McAlister (1981) argues that communications that aim at influencing complex and persistent behaviours of the audience must perform three functions: inform audiences about these behaviours and their consequences persuade audiences to cease or avoid those behaviours and finally, train audiences in skills necessary to translate intention into action. The media, McAlister continues, offer economy and uniformity in mass distribution that make them highly attractive options for communicators wishing to influence widespread behaviour change.
 
Beaudoin (2002) argues that in any campaign, it is important to address themes and issues that attract the targeted audience. Emotional appeals, and especially appeals to fear are widely used in health promotion campaigns. Fear appeals are described as: “a persuasive communication attempting to arouse fear in order to promote precautionary motivation and self-protection action (for example stop being unfaithful). Fear arousal is an unpleasant emotional state triggered by the perception of threatening stimuli” (Ruiter et al., 2001). This argument is predicted on the fact that if one is made aware of the negative  repercussions  of  their  actions,  then  they  will tend to avoid such actions. If people lack awareness of how their lifestyle habits negatively affect their health, then they have little reason to put themselves through the misery of changing the bad habits they enjoy.
 
Walsh-Childers and Brown (2009) examined sexuality displayed on television programs and found that characters engage in casual sex but never discuss Sexually Transmitted Diseases (STDs). Many forms of media echo this theme. Television programs hardly display negative consequences of sexuality. Cope-Farrar and Kunkel (2008) conducted a content analysis that showed only 14% of discussions about sex on TV mentioned the risk and responsibilities, and only 3% mentioned risk combined with sexual behaviour (Harris et al., 2009). Few broadcast programs discuss sexual risk and even fewer show sexual behavior as actually having consequences. Television audiences, therefore, may not believe exposure to STDs is a possible consequence of unprotected sex.
 
Kutto (2017) addressed the communication complexities in the management of critical health conditions and specifically cervical cancer in Kenya. Underscoring communication complexities as those obstacles that hinder rural women from participating fully in the control of cervical cancer, Kutto (2017) cited lack of awareness as one of the key reasons that lead to the presentation of illness at advanced stages. Disclosure and secrecy at a personal level were some of the other communication complexities noted.


 REVIEW OF RELEVANT PREVIOUS RESEARCH ON HEALTH CAMPAIGN MESSAGES

Haslam et al. (2009) explained that consumers of health campaigns sometimes believe they are not the target for the message and thus react against the health-related messages. They discovered that African Americans and American Indians who were exposed to messages about dieting saw them as emanating from White middle-class sources. Thus, they came to see health-related behavior as non-normative for their group (as if to say “health is not a thing we do”) and expressed less desire and intention to pursue healthy lifestyles. Their study postulates that when people do not identify with messages, they disassociate themselves from the issue and believe they are not at risk because the characters portrayed are not part of their group.
 
A similar study, by Keller and Brown (2002), noted that observers of STD campaigns may not identify with portrayals of people with STDs and therefore disassociate from the message. They indicated that audiences might resist public service announcements as selling a particular behavior because of their infrequency and simplistic messages. This research suggests that characters in ad campaigns are often too simplistic or unrealistic, so people do not identify with them and thus do not see themselves as at-risk of acquiring  an  STD.  By  reducing people to an overly simplistic image of negative characteristics, advertisements can be ineffective.
 
In their article, Designing Effective Health Messages, Keller and Lehmann (2008) investigate the use of Message tactics, which include fear, framing, referencing, and argument strength among others. They argue that people respond to messages based on their reaction to such factors as fear of negative repercussions and how well they perceive the message to be addressing their situation. 
 
Mulwo (2008) analysed students’ response to Abstain-Be faithful – Use condoms (ABC) and Voluntary Counselling and Testing (VCT) messages at three universities in Kwazulu-Natal province of South Africa. The study premised its focus on structures and processes of meaning production within already existing social groups in regard to HIV/AIDS. It analysed how the produced meanings affected the interpretation and impact of HIV prevention texts. In particular, it focused on discovering how participants made sense of cultural meanings offered by HIV prevention messages such as ABC and VCT. The findings supported the conclusion that the categories of students’ responses to HIV prevention messages were often predicated upon their relationships and participation in various social groups.  Further, it suggested that decisions to adopt/not adopt these prevention options were often based on how meanings attached to these options were articulated within the social significance of sex and sexual practices.
 
Were (2015) addressed the societal construction of multiple concurrent partnerships and its implications on the efficacy of HIV communication campaigns in Homa Bay County in Kenya. These findings support the conclusion that HIV communication campaigns, which address individual behaviours to the exclusion of the contextual factors, are bound to be ineffective. For campaign messages to be effective, the study recommends messages be designed and disseminated within the larger cultural context of the targeted audience.


 PREVIOUS RESEARCH ON EFFECTIVENESS OF CAMPAIGN MESSAGES

Previous research demonstrates that some campaigns have been rated as successful while others have failed. Mabachi (2008) argues that although evidence suggests that mass media campaigns do work, particularly when the principles of effective campaign design are followed (Noar, 2006), donors and practitioners are still frustrated at evaluators’ inability to answer the question: “what makes some campaigns more effective than others?” (Bertrand et al., 2006).  The report, “It’s Tough to Stop Sex, Study of U.S. AIDS Effort Shows.” reports that researchers find no benefit from a decade long attempt to curb the spread of HIV in Africa by promoting abstinence and monogamy (Tozzi, 2016).
 
A picture of a billboard on the outskirts of Kampala, Uganda  urges  people  to  be  faithful  to their partners to stop the spread of HIV; the report gives the grim verdict that the campaign has failed. “Abstinence promotion” policies, funded by the United States (U.S) for more than a decade as part of an effort to slow the spread of HIV in Sub-Saharan Africa are largely ineffective (Tozzi, 2016). The study makes reference to the fact that the U.S has spent more than $ 1.4 billion since 2004 telling young people in Africa to abstain from sex before marriage and then to commit to a single partner. The study published in the Journal of Health Affairs by researchers at the Stanford School of medicine found that the funding did not influence the number of sex partners people had, the age at which they started having sex, or teen pregnancy rates.  Though the initiative under President’s Emergency Plan for AIDS Relief (PEPFAR) has recorded success in in the delivery of life-saving HIV medicines to millions of people in poor countries at a cost of $ 50 billion since 2004, it has not delivered lower rates of infection among married people.
 
It is hypothesized that it failed because of the policy of restricting funding and requiring that at least a third of the funds go to (PEPFAR). Though the restriction was lifted in 2008 when President Obama came to power, the U.S has continued to devote tens of millions of dollars a year to such programmes. Another reason might be that the policy clashed with the reality of HIV epidemic on the ground in Africa. The Institute of Medicine (2013) noted the “inherent mismatch between abstinence/be faithful approach and programs for individuals engaged in sex work,” who are an important target for prevention efforts. The Health Affairs report (2016) adds that abstinence and faithfulness promotion may be funded “at the opportunity cost of other, potentially more effective, prevention services,” such as promoting condoms or treatment to prevent HIV-positive mothers from passing the virus on to newborns. This underscores the importance of prioritizing the most critical interventions based on the established needs. This may in some cases mean reviewing established donor policy.
 
Poor communication campaigns have also been blamed for the continuing rise in the rate of new infections among the married people in key populations despite the HIV prevention communication campaigns. In the absence of a cure, it is indubitable that communication holds a vast but unexploited potential to halt the spread of the HIV pandemic (Kippax, 2006). As noted earlier, decades of implementing communication campaigns have not yielded any significant improvements. Several communication campaigns have been developed to promote sexual behaviour change in Sub-Saharan Africa.
 
Some of the earliest HIV prevention lessons were borrowed from the U.S. one of the first countries to successfully contain its HIV epidemic. However, many of these responses were targeted towards homogenous groups with similarities of culture, risk and context of sexual practices. For example, in the U.S, the epidemic was   largely    concentrated   among   African    American homosexual men (Merson et al., 2008). This notwithstanding, the same approaches were used for heterogeneous groups in Africa where HIV is transmitted predominantly heterosexually and in varying contexts and risk profiles among the many target groups (Parker, 2004). The result has been that such models have proven inadequate for the communication needs of Africa countries (Airhihenbuwa and Obregon, 2000).
 
In the article, “Know your epidemic, know your response”, Wilson and Halperin (2008) decry the global response as framing HIV as one unilateral epidemic with homogenous characteristics, leading to standardized prevention strategies. This is contrary to emerging findings revealing a multiplicity of diverse evidence epidemics rather than a single epidemic. Wilson and Halperin (2008) posit that there are three types of epidemics; generalized, concentrated and mixed. This points to the fact that standardized interventions are bound to fail since they will not match the characteristic of each type of epidemic. Given the three types of epidemics, it is important for message designers to understand each type of epidemic in order to develop messages targeted at the specific transmission characteristics.
 
The 2008 Kenya Analysis of HIV Prevention Response and Modes of HIV Transmission Study showed that Kenya has a geographically heterogeneous mixed HIV epidemic. This means that HIV transmission largely occurs among the general population and also within defined vulnerable groups (Gelmon et al., 2009). The study also revealed that the key drivers of the Kenyan epidemic include the societal acceptance of multiple concurrent partnerships, low condom use and lack of male circumcision.
 
Based on their findings (Wilson and Halperin, 2008) recommend that prevention campaigns should focus on addressing the social norms surrounding the societal acceptance of multiple concurrent partnerships, while advocating for increased condom use and male circumcision.
 
This position is advised by documented evidence that reduction in multiple sexual partnerships is one key factor that will result in reduced transmission in generalized epidemics. Parker (2004) in the article “Rethinking Conceptual Approaches to Behaviour Change: The Importance of context”, argues that for many years, behaviour change communication campaigns for HIV prevention have predominantly been anchored on cognitive theories and frameworks derived from social psychology and communication
 
PREVIOUS RESEARCH ON HEALTH CAMPAIGN MESSAGES IN KENYA
 
In Kenya, communication campaigns to mitigate against HIV/AIDS borrowed heavily from the family planning campaigns  that were gaining credence to stall the rapidly escalating population explosion (Were, 2015). Following the success in using information education and communication (IEC) in family planning communication, the same was replicated in the HIV arena (Piotrow et al., 2003). Subsequently, the first major HIV/AIDS campaign was launched on a platform of IEC.
 
This was then supplemented by mass media, social mobilization and interpersonal communication approaches. There was also the publication of “Aids Watch” column in the press with information about HIV/AIDS (Mungai, 2001). The government went a step further and launched a condom campaign to promote condom use and reduce risky sexual practices (Aidscap, 1997; Hershey, 2009).
 
The communication methods used were mainly conventional and focused on information transmission and knowledge acquisition (Waisbord, 2000). During this time, the causes and effects of HIV became widely known with the unfortunate effect of highly stigmatising the epidemic. With limited knowledge and understanding of the epidemic’s transmission, there was a lot of fear yet, many bore witness to the adverse effect of the epidemic (Kalipeni and Mbugua, 2005). Even communication campaigns at that time regarded HIV as a death sentence. The epidemic was branded as a “Killer disease” and most of the posters and other communication featured images of emancipated and wasted persons dying from the epidemic (UNAIDS, 2010; Singhal, 2003; Merson et al., 2008).
 
The messages used fear appeal as a preventive measure. Unfortunately, the effects were short-lived (Wakefield et al., 2010) and the expected ripples among the masses that would translate to positive behaviour change were not experienced. Contrary to the expectations, the epidemic continued to escalate at unprecedented rate (Kalipeni and Mbugua, 2005).
 
The gains recorded in using information, education and communication (IEC), were not long lasting. The impact of the posters and mobile campaigns was limited to brief periods of the post campaign spell. This in turn prompted the rise of social marketing approach, which became critical in Kenya’s HIV prevention campaign. It is noted that social marketing grew out of the realization that marketing principles could be applied to promote social change (Waisbord, 2000). Social marketing campaigns in Kenya gained prominence with major campaigns in mass media (radio, television and newspapers), billboards and community outreaches. “Nakufeel” (I feel you) which vigorously promoted condom use among the youth, “Wacha Mpango wa Kando” (stop multiple and concurrent partnerships) and “La sivyo, weka condom mpangoni” (use a condom with your concurrent partner) are some of the most prominent social marketing campaigns.
 
In Kenya, the campaign on Voluntary Male Circumcision has been rated as a success story as has the Nimechill campaign   targeting   teenagers.  On   the   contrary,  the Wacha Mpango wa Kando campaign has been largely ineffective as the rate of new infections among the targeted audiences have remained high. Literature has pointed out that these campaigns have been ineffective as a result of employing cognitive models adapted from the West, which ignored the social and cultural contexts that should be the anchor of any communication campaign in Africa.
 
The Nimechill campaign made the audience aware of what their referent others believe about a recommended behavior and provided the motivation to comply. This campaign effectively depicted characters and slice-of–life situations that were accessible and resonated with their target audiences (Mabachi, 2008). However, social marketing has been criticized for being manipulative, non-participatory, individualistic and expert oriented in nature (Waisbord, 2000).
 
The development of the behavior change communication model has made some strides. Starting in the 1990’s Kenya witnessed strategic communication shifts with the entry of the behaviour change communication approach into the fold (Kalipeni and Mbugua, 2005). Were (2015) notes that though this model signaled some of the pioneering efforts in applying behavioral science theories in the fight against HIV, it was during the same decade that the Country recorded the highest HIV prevalence rates leading to the declaration of the epidemic as a national disaster. Though this declaration increased donor funds, an evaluation of Kenya’s HIV prevention landscape (Gelmon et al., 2009) revealed a lack of common understanding of what behaviour change communication entails.
 
The increase in donor funding saw the entry of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003. Its aim was to support HIV prevention, care and treatment programs in Sub-Saharan Africa. In 2005, PEPFAR issued a policy directive necessitating all beneficiaries of their funding to adopt the ABC campaign model. This restricted the use of PEPFAR funds purely on activities related to promotion of Abstinence, Being faithful/fidelity and Condom use for defined target audiences (PEPFAR, 2005-2015). President’s Bush championed the ABC HIV prevention approach with a significant preference for abstinence only programmes. This approach with the accompanying funding significantly influenced Kenya’s HIV prevention (NACC, 2009). With this in mind, subsequent HIV interventions in Kenya were designed on the ABC model in order to conform to the donor demands.
 
Scholars (Murphy et al., 2006; Merson et al., 2008) have criticized the ABC approach for being ineffective due to its limiting focus on three behaviours (abstinence, fidelity and condoms) as well as its over reliance on linear and rational models of individual behaviour change (Murphy et al., 2006; Merson et al., 2008). The heightened criticism of the limitations of the ABC policy directive  led  PEPFAR  to  revise   its   policy   directives.
 
PEPFAR’s 2010-2015 strategy acknowledges that the HIV epidemic requires a multidimensional and multisectoral approach in order to transition from emergency responses towards sustainability. The policy advocates for the use of epidemiological data to develop prevention responses based on evidence and with proven effectiveness (PEPFAR, 2005-2015).
 
Were (2015) sought to determine whether selected communication campaigns have addressed the factors that contribute to multiple concurrent partnerships in Kenya and found that communication campaigns failed to address the contextual factors that underpin multiple concurrent partnerships. Hence, Were (2015) supported the conclusion that HIV communication campaigns, which address individual behaviours to the exclusion of the contextual factors, are bound to be ineffective.
 
Discussing gender portrayal, Mabachi (2008) notes that men and women were portrayed in positive roles and characterizations, reflecting the planners’ strategy, not necessarily the behaviour and context of the target audience. However, this thematic analysis portrayed gender norms and power positions of men and women in the Kenya society. Mabachi’s (2008) thematic analysis found that the campaigns revealed the presence of cultural beliefs/practices such as gender norms (that promote the inequality of women and the sexuality of men) which are barriers to behavior change and could have decreased the success of the campaigns in terms of the movement from intent to behavior change.
 
An analysis of Health campaign messages therefore falls within the sub topic of Behaviour Change Campaigns, which is situated within the branch of Communication Studies that is increasingly gaining momentum, called Health Communication. In the next section, we look deeper into health communication theories for behaviour change communication


 RATIONALE FOR FUTURE RESEARCH BASED ON LITERATURE REVIEW

The overall goal of any literature review is to synthesize the literature in a meaningful manner and provide a rationale for future research.  With reference to the current subject, this literature review, though brief, gives a practical example of how a study of sexual reproductive health campaign messages could draw its rationale. The review informs future studies in four distinct ways.
 
First, it details the status and development of previous messages, highlighting the needed background information for any study. The review also provides the framework through which researchers review highlights and milestones of the various interventions put in place over the years and the witnessed results.
 
Secondly, by reviewing relevant theories and previous studies, we have identified the gaps that can be explored further in the field of  Health  Communications  and  more specifically, Health Communication Campaigns. The literature review revealed that most of the models used for developing the campaign messages are based on Western models and do not necessarily take into consideration the socio-economic and cultural contexts that drive both the HIV/AIDS epidemic and other sexual practices in Africa and particularly Kenya.
 
Thirdly, the literature review traces and highlights the milestones and results of previous sexual reproductive health campaigns. In the Kenyan context, researchers and campaign designers can learn from the successes and failures of the various campaigns developed since the early 1990’s.
 
Fourthly, the literature review and particularly the review of previous research offers a deeper understanding of previous studies and their conclusions. This has helped relate this article to the larger conversations on communication and Sexual Behaviour Change responses.
 
Overall, the literature review reveals that though the HIV/AIDS epidemic and its history and statistics is well documented in the Kenyan context and various studies have been conducted among high risk populations, interventions, especially communication ones, have been erratic and have not borne the desired results partly due to financial sustainability issues leading to early termination of campaigns and inadequate study of the local context and drivers of the phenomenon of concern and other related sexual reproductive practices
 
Nevertheless, the literature review demonstrates that the scholars do not so far concur on effectiveness of designs of Health Campaign messages, especially in the context of HIV/AIDS; hence there is a need to conduct more studies on this issue to enhance the body of empirical literature that could inform the designs of future campaigns.


 CONCLUSION

This article, demonstrated that a well-conceived and constructed literature review is essential and beneficial in the conceptualization of academic research. Such a review begins with situating the subject within the relevant field, discipline and subject of study. For example, it has been demonstrated that Sexual Reproductive health campaigns is a subject within Health Communication which has a home in the discipline of Communication Studies. The second stage is a review of related theories in this case theories like Social Cognitive Theory (SCT), Theory of Reasoned Action (TRA) and Health Belief Model (HBM). The third stage is to review previous research on the subject with minimal attention to the broader aspects (for example review of research on health communication); and more detailed efforts on the more specific subjects (review of previous research on sexual reproductive health campaigns in Kenya). The final  stage  is  to draw a rationale for the further research based on the entire literature review which captures the milestones achieved and indicates the gaps that require further investigation. 


 CONFLICT OF INTERESTS

The authors have not declared any conflict of interests.

 



 REFERENCES

Aggleton P, O'Reilly (1994). Bisexuals and Aids: An International Perspective. Taylor and Francis Inc, Bristol U.S.A

 

Airhihenbuwa C, Obregon R (2000). A Critical Assessment of Theories/Models Used in Health Communication for HIV/AIDS. Journal of Health Communication 5:5-5.
Crossref

 
 

Ajzen I, Fishbein M (1980). Understanding Attitudes and Predicting Social Behaviour. Prentice Hall.

 
 

Bandura A (1977). Self-Efficacy: Towards a Unifying Theory of Behavioral Change. Psychological Review 84.
Crossref

 
 

Bandura A (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Upper Saddle River, N.J, Prentice Hall.

 
 

Bandura A (1997). Self-Efficacy: The Exercise of Control, New York: Freeman.

 
 

Beaudoin CE (2002). Anti-Smoking Ads: Appeals, Themes and Consequences. Journal of Health Communication pp. 123-137.
Crossref

 
 

Becker MH, Maiman LA, Kirscht JP, Haefner DP, Drachman RH (1977). The Health Belief Model and prediction of dietary compliance: a field experiment. Journal of Health and Social behavior pp. 348-366.
Crossref

 
 

Berger CR, Chaffee SH (1987). The Study of Communication as a Science. Handbook of Communication Science, Beverly Hills, CA, and London; Sage Publications pp. 15-19.

 
 

Bernhardt JM (2004). Communication at the Core of Effective Public Health. American Journal of Public Health 94(12):2051-2053.
Crossref

 
 

Bertrand M, Mullainathan S, Shafir E (2006). Behavioral economics and marketing in aid of decision making among the poor. Journal of Public Policy & Marketing 25(1):8-23.
Crossref

 
 

Cappella JN, Fishbein M, Hornik R (2001). Using Theory to Select Messages in anti drug media campaigns. Sage Publications, Inc, Thousand Oaks, California.

 
 

Chanowitz B, Langer EJ (1981). Premature cognitive commitment. Journal of Personality and Social Psychology 41(6):1051-1063.
Crossref

 
 

Cline RW, Johnson SJ, Freeman KE (1992). Talk among sexual partners about AIDS: Interpersonal communication for risk reduction or risk enhancement? Health Communication 4:39-56.
Crossref

 
 

Cope-Farrar KM, Kunkel D (2008). Sexual Messages in Teens' Favorite Prime-Time Television Programs. Sexual Teens, Sexual Media: Investigating Media's Influence on Sexual Activity (2 ed., Mawhah, NJ: Lawrence Erlbaum Associate, Inc. pp. 59-78).

 
 

Freimuth V, Cole G, Kirby S (2000). Issues in Evaluating Mass Media-Based Communication Campaigns. WHO Monologues, Atlanta.

 
 

Gamble T, Gamble M (2013). Communication Works. McGraw-Hill, New York.

 
 

Gelmon L, Kenya P, Oguya F, Cheluget B, Hail G (2009). Kenya HIV Prevention Response and Modes of Transmission Analysis. Nairobi: NACC.

 
 

Harris R, Barlett C (2009). Effects of sex in the media. In: J. Bryant & M.B. Oliver (Eds.). Media Effects: Advances in Theory and Research, 3rd edition. New York: Routledge pp. 304-324.

 
 

Haslam A, Jetten J, Postmes T, Haslam C (2009). Social identity, health, and well-being: An emerging agenda for applied psychology. Applied Psychology: An International Review 58(1):1-24.
Crossref

 
 

Hershey M (2009). Kenya's Delayed Response to HIV/AIDS: A Case Study" Paper Presented at the annual meeting of the Midwest Political Science Association 67th Annual National Conference on 29th April 2009, The Palmer House Hilton, Chicago.

 
 

Janz NK, Becker MH (1984). The health belief model: A decade later. Health education quarterly 11(1):1-47.
Crossref

 
 

Kalipeni E, Mbugua N (2005). A Review of Prevention Efforts in the Fight against HIV and AIDS in Africa. Norwegian Journal of Geography 59(1):26-36.
Crossref

 
 

Keller PA, Lehmann RD (2008). Designing Effective Communications: A meta-Analysis. American Marketing Society 27(2).
Crossref

 
 

Keller S, Brown J (2002). Media interventions to promote responsible sexual behavior. The Journal of Sex Research 39(1):67-72.
Crossref

 
 

Kenya Aids Index Survey (KAIS) (2014). Kenya Aids and STI Control Programme (NASCOP). Republic of Kenya.

 
 

Krisberg B (2004). Juvenile Justice: Redeeming our children. Newbury Park, CA: Sage.
Crossref

 
 

Kutto V (2017). Communication Complexities in the Management of critical health conditions: A case of cervical cancer control in Elgeyo Marakwet County, Kenya. Moi University.

 
 

Levy, M. R., & Windahl, S. (1984). Audience activity and gratifications: A conceptual clarification and exploration. Communication Research, 11:51-78.
Crossref

 
 

Lupton D (1994). Towards the Development of Critical Health Communication Praxis. Health Communication. UNSW, Sydney.
Crossref

 
 

Mabachi MN (2008). What makes some campaigns more effective than others? An analysis of three mass media PSI HIV/AIDS campaigns in Kenya. University of Kansas, USA.

 
 

Maibach E, Parrot RL (1995). Designing Health Messages. Sage Publications, California.

 
 

McAlister AL (1981). Social and Environmental Influences on Health Behaviour. Harvard School of Public Health. Health Education Quarterly 8(1).
Crossref

 
 

McCombs ME (2004). Setting the Agenda: The Mass media and Public Agenda. Malden, MA, Blackwell. 

View

 
 

McQuail D (1994). Mass Communication Theory. Sage Publications, London.

 
 

Merson M, O'Malley J, Serwadda D, Apisuk C (2008). The History and Challenge of HIV Prevention. Lancet 372:475-488.
Crossref

 
 

Mulwo AK (2008). An Analysis of Students' Responses to ABC & VCT Messages at Three Universities in KwaZulu-Natal Province, South Africa. University of KwaZulu-Natal, South Africa.

 
 

Mungai J (2001). Aids Watch Weekly Column. Nation Newspapers, Nairobi.

 
 

Murphy EM, Greene ME, Mihailovic A, Olupot-Olupot P (2006). Was the "ABC" Approach (abstinence, being faithful, using condoms) Responsible for Uganda's Decline in HIV? PLoS Med 3(9):e379.
Crossref

 
 

National Cancer Institute and National Institutes of Health (NCINIH) (2002). Making Health Communications Programs Work. Bethsaida, Md. View

 
 

Paisley WJ, Rice RE (1981). Public Communication Campaigns. Sage Publications, London

 
 

Parker W (2004). Rethinking Conceptual Approaches to Behavior Change: The Importance of Context. Center for AIDS Development, Research and Evaluation. Unpublished paper.

 
 

PEPFAR (2010-2015). Strategy Plan. U.S Department of State. Washington DC.

 
 

Piotrow P, Rimon J, Merritt A, Saffitz G (2003). Advancing Health Communication: The PCS Experience in the Field. Baltimore: John Hopkins Bloomberg School of Public Health/Center for Communication Programs.

 
 

Public Health Ontario (2012). Developing Health Communication Campaigns. Agency for Health Protection and Promotion Ontario 3(13).

 
 

Rogers EM (2003). Diffusion of Innovations. Free Press. New York.

 
 

Roser C, Thompson M (1995). Fear Appeals and formation of active Publics. Journal of Communication 45(1):103-122.
Crossref

 
 

Ruiter AR, Kok G, Varplanken B, Brug J (2001). Evoked fear and effects of appeals on attitudes to performing breast self-examination: An Information processing perspective. Health Education Research 16(3).
Crossref

 
 

Salmon C, Atkin CK (2003). Media campaigns for health promotion. In: T. L. Thompson, A. M. Dorsey, K. I. Miller, & R. Parrott, R. (Eds.), Handbook of health communication. Mahwah, NJ: Lawrence Erlbaum pp. 472-494.

 
 

Schiavo R (2007). Health Communication: From theory to practice. Jossey-Bass, San Francisco.

 
 

Singhal A (2003). Focusing on the Forest, Not Just the Tree: Cultural Strategies for Combating AIDS. MICA Communications Review 1(1):21-28.

 
 

Stappers JG (1983). Mass Communication as Public Communication. Journal of Communication 33(3):141-145.
Crossref

 
 

The Kenya Aids Epidemic Update (2012). National Aids Control Council & National Aids and STI's Control Programme, Nairobi. ISBN 978 9966038029

 
 

Tozzi J (2016). Its Tough to Stop Sex, Study of U.S AIDS Effort shows. Health Affairs Journal. Stanford School of Medicine 

View

 
 

Waisbord S (2000). Family Tree of Theories, Methodologies and Strategies in Development Communication: Convergences and Differences. New York: Rockefeller Foundation.

 
 

Wakefield MA, Loken B, Hornik RC (2010). Use of Mass Media Campaigns to Change Health Behaviour. Lancet 376:1261-1271.
Crossref

 
 

Walsh-Childers K, Brown J (2009). Media effects: Advances in theory and research. Routledge.

 
 

Were KD (2015). Societal Construction of Multiple Concurrent Partnerships and its implications on the Efficacy of HIV Communication Campaigns in Homabay County, Kenya. Moi University, Kenya.

 
 

Wilson D, Halperin DT (2008). Know your epidemic, know your response: A Useful Approach, if we get it right. The Lancet 372(9637):423-426.
Crossref

 

 




          */?>