What are the best ways to engage the target population in the clinic setting?
While printed materials such as posters and leaflets are often used in a healthcare facility, a second—and extremely important—communications channel is direct counseling and education from healthcare providers to patients. A healthcare provider’s interaction with an individual is a critically important time to ensure that all available HIV prevention options are raised. Multiple studies have highlighted the importance of positive, bias-free provider-client interactions. 1 For example, studies in Malawi and Uganda show that young people are up to twice as likely to choose a service provider they perceive to be friendly than to choose one they perceive not to be. 2
Providers can also help clients assess their own risk. The LINKAGES project has developed an innovative risk-assessment training tool for improving provider attitudes and techniques during the risk assessment process. This approach supports clients to identify and acknowledge risk factors present in their lives and has been successful with key populations across the globe. Because provider attitude plays such a key role in client engagement with discussions of risk, providers must be properly trained to engage clients of all types in sensitive, nonjudgmental conversations about risk.
For example, in one study based on interviews with clinical trial staff, respondents said providers should avoid using the label “high-risk” with clients, and instead ask nonjudgmental questions to help people self-identify their own level of risk. Healthcare providers must also be prepared to explain PrEP—how it works, how to use it correctly, and possible side effects and how to mitigate them. Finally, providers should be trained on using materials as tools for social mobilization and as support mechanisms for clients. 3
In the clinic setting, the waiting room is also a valuable venue for engaging target populations. OPTIONS carried out a study to gather lessons learned from researchers involved with ARV-based HIV prevention trials (oral PrEP, microbicide gel, or dapivirine ring as study products). In this study, researchers described a successful strategy during the recruitment phase of clinical trials, in which outreach staff, sitting in clinic waiting rooms, offered short health talks to educate patients about PrEP. These talks were timed strategically—for example, during times when women tended to congregate in the waiting room ahead of well-baby visits. 3
After receiving such semi-public presentations, it is important that potential PrEP users have the opportunity (and privacy) to ask personal questions. After giving the short health talks in waiting rooms, PrEP outreach staff emphasized the importance of lingering to answer patient questions. Some clinics provide a private room specifically for conversations like these. This strategy gives patients time to understand PrEP before seeing the doctor, and lowers the burden on the healthcare providers. Having informational materials available for patients to take home after the conversations can be an important way to increase understanding and uptake. 3
The clinic setting also offers opportunities for innovative and even entertaining communication methods. Within the research setting, some clinics have successfully screened informational videos on TV sets in waiting rooms, or even invited comedians to entertain people with material that includes prevention messages. Through the OPTIONS study, research teams reported engaging with participants through regular social events such as tea parties and pop quizzes, leading to improved health knowledge and awareness of HIV-related topics. Some social activities allowed participants to bring friends, family members, and partners to the clinic. This improved relationships between clinic staff and study participants, as well as increased study retention. 4 Creative strategies like these may be effective in reaching audiences who are already likely to visit a healthcare clinic, and they might be considered for programmatic rollout. 3
What are the best ways to engage the target population within a community setting?
Community-level outreach and engagement may be one of the most critical settings in which to make an impact. Interventions, information, and support can be taken to places where populations at highest risk for HIV are already spending their time. In this way, community-level outreach meets people “where they are” instead of requiring people to seek out health care and information. Generating community-level activity also creates impact by exposing family members, local leaders, and others in the community to HIV prevention messaging, thereby creating awareness of new prevention methods and eventually normalizing their use. 3
Printed materials are one useful channel for communication within the community. Available in areas frequented by target audiences, materials can include posters and leaflets but may be more engaging in innovative formats (that are still cost-effective) such as stickers, bookmarks, or playing cards. Additionally, advertising on billboards—including both static and mobile ones—can be effective for some populations, as can advertisements at bus stops and on taxis.
Interpersonal communications—such as peer outreach, support groups, seminars, informational/educational talks, social gatherings, and community meetings—are also an important channel at the community level. Community campaigns may include entertainment-focused outreach, such as mobile or pop-up theater events, as these lively and interactive shows can increase engagement. 3
The SASA! Program
The SASA! Program in Uganda has successfully amplified communication events and media channels by engaging “community change agents” to create changes in behaviors and attitudes at the individual and community levels. 5 Learn more about the program here.
Increasingly, mobile and social media are becoming prominent channels, as they allow for broader reach and may be more convenient for audiences (as well as more discreet, which for some may be important). 6 Innovative programs in Nigeria and Mozambique have succeeded at increasing the use of modern family planning methods via SMS-based story campaigns. 7 Programs like these and other mobile and social media channels may be used to identify and connect with individuals, influence preferences and behaviors, and disseminate information. 3
Community Mapping & Targeting Hotspots
Campaigns may conduct “community mapping” to identify the places where high-risk people gather (their “hotspots”), as well as whom their influencers and local leaders are. Community mapping involves speaking with members of the community as well as gatekeepers (individuals who are in contact with the community and have the potential to motivate and support its members). 3
Common hotspots may include bars, clubs, shopping malls, communal taps, markets, hair salons, and social gathering places on the street. These places offer opportunities to reach a different population than may be found in a clinic or a community meeting. They can also engender more open discussions of PrEP, as people there are among others they trust. However, campaigns will need to locally assess whether this is the case within the context of HIV prevention and PrEP for a specific target population. 3
Going door to door to share information about PrEP (potentially in tandem with comprehensive sexual and reproductive health services and information, and with testing services) can be successful in neighborhoods with high HIV prevalences, or where a large portion of the population is at risk. Having services close to home is a preference for many young people in rural settings in particular. 2 Door-to-door communications offer the benefit of private, one-on-one conversations with potential PrEP users, although the time and resources required can be a limitation. Note, it is important to go to every door, as targeting certain houses can create stigma. 3
Community campaigns include events—from small health education sessions to community-wide holidays—to reach large, diverse groups of people and build credibility and awareness for PrEP within the community. These should be paired with other strategies to engage potential PrEP users, as it can be difficult to address individuals’ concerns.
What are the best ways to engage the target population across a district or province?
Similar to community-level efforts but on a slightly larger scale, communications on a sub-national level may involve printed materials, interpersonal and word-of-mouth communications, and social media but can also incorporate broadcast communications—local-level community radio stations, local-language (or “vernacular”) radio stations, billboards (both static and mobile), or local newspapers or magazines.
As audiences across sub-Saharan Africa increasingly have access to social media and online content, campaigns may also disseminate audio and video (such as podcasts, video clips, or other digital content) through these channels. Videos in particular have been shown to engage key populations such as adolescent girls and young women. Relatable characters in the videos can break down barriers to PrEP use by presenting a positive angle that is destigmatizing and addresses concerns in a friendly way. 8 Social media can be used to share these informative and engaging tools.
Materials and collateral developed for the national level are sometimes repurposed for use at the sub-national level. However, it is critical to ensure that materials and messages resonate with local audiences. Materials should use locally grounded language and image, and locally relevant statistics about HIV incidence and prevalence may also be more compelling.
What are the best ways to engage the target population across a country?
Mass media channels such as radio and TV are the most popular ways to engage at the national level. Newspaper advertising may be somewhat effective, but increasingly limited audiences engage with this medium. It may be more effective to create audio, video, and web-based content. Created for mass dissemination, these materials have an added benefit in that they can be repurposed for distribution at the district or community level. Finally, journalist engagement may be valuable. Journalists will be especially interested in the promotion or launch of important initiatives, interventions, or outreach (and journalist engagement can help prevent or counter the potential spread of negative rumors).
Pilgrim N, Jani N, Mathur S, et al. Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care. PLoS One. 2018;13(4). doi:10.1371/journal.pone.0196280.
Michaels-Igbokwe C, Terris Prestholt F, Lagarde M, Chipeta E, Integra Initiative, Cairns J. Young People’s Preferences for Family Planning Service Providers in Rural Malawi: A Discrete Choice Experiment. PLoS One. 2015;10(12). doi:10.1371/journal.pone.0143287.
According to the qualitative analysis memos from the Reaching High Risk Women for PrEP: Learning from ARV-based HIV prevention trials study, provided by K Stankevitz, MSc., in May 2018.
According to clinical research site reports referenced in: Schwartz K, Ndase P, Torjesen K, et al. Supporting Participant Adherence through Structured Engagement Activities in the MTN-020 (ASPIRE) Trial. Source. Poster presented at: HIV Research for Prevention Conference; October 2014; Cape Town, South Africa.
Starmann E, Heise L, Kyegombe N, et al. Examining diffusion to understand the how of SASA!, a violence against women and HIV prevention intervention in Uganda. BMC Public Health. 2018;18(1). doi:10.1186/s12889-018-5508-4.
Babalola S, Akiode A, Oyenubi O, Loehr C, Mobley A. Evaluation of the Effects of the Smart Client Digital Health Tool. Source. Published August 2017. Accessed December 23, 2018.
Feyisetan B, Benevides R, Jacinto A, Mutombo N. Assessing the Effects of mCenas! SMS Education on Knowledge, Attitudes, and Self-Efficacy Related to Contraception in Mozambique. Source. Published March 2015. Accessed December 23, 2018.
Myers L, Bekker L-G, Aunger R, et al., A behavior-centred design approach to creating demand for oral PrEP among young women in Masiphumelele, South Africa. Poster presented at: AIDS 2018; July 23–27, 2018; Amsterdam, Netherlands.