Evaluation: Is This Justice? Multi-Media Campaign to Reduce Stigma Against Women Living with HIV/AIDS

This document details formative, baseline, and endline research conducted to assess the effectiveness of a multimedia campaign designed to bring attention to the stigma and violence faced by women living with HIV/AIDS (WLHA) in India. Conducted from February to April 2007, "Is This Justice?" was created by the international human rights organisation Breakthrough to demonstrate how an HIV-positive status, compounded by a husband's death, often leads to a loss of rights and consequent eviction of women from marital and natal homes. Focusing on the states of Uttar Pradesh, Karnataka and Maharashtra, the campaign included television, print, radio, and internet and mobile messaging. Media partners included 27 national and regional television channels, 13 regional radio channels, 6 mainline newspapers, and 42 outdoor hoardings (billboards). It is estimated that "Is This Justice?" reached over 34 million people through television, 29 million through print, and 18 million through radio.

To help design the campaign, Breakthrough commissioned an independent research and evaluation agency, Prastut Consulting, to help identify the forms in which WLHA experience discrimination and stigma at the individual, family, and community levels. As part of this formative research process, which took place from April 2006 to June 2006, community interviews were undertaken across the socio-economic classes (SECs) in Aurangabad in Maharashtra, Udupi in Karnataka, and Kanpur in Uttar Pradesh. Researchers carried out interviews with 30 WLHA, 28 family members, 6 men living with HIV/AIDS (MLHA), and 9 women from the general population. In addition, meetings were held with workers and staff at HIV-positive networks. The salient results of this formative research are summarised on pages 11 and 12 of the report. At the end of the formative research phase, a set of indicators of shame, blame, and enacted stigma were enumerated at the community, family, and WLHA levels; see Annexure I of the report.

Prastut Consulting also carried out baseline research (pre-campaign: September 2006 to November 2006) to: assess the interplay between gender, HIV status, and women's rights; ascertain the magnitude of their vulnerability; and identify stigma indicators. Structured questionnaires and focus group discussions (FGDs) were held with the general community and people living with HIV/AIDS (PLHA). Salient results of the baseline research - in terms of awareness and perception of HIV/AIDS, and behaviour patterns that substantiate increased vulnerability of WLHA - are outlined on pages 14 through 16 of the report.

The post-campaign research, conducted March 2007 to May 2007 in the same locations as the baseline, sought to ascertain the exposure to the intervention, message recall, effectiveness of the different media used, likeability of the communication, and the impact on the critical indicators. The endline research, which featured quantitative as well as qualitative facets, included 1,125 people across Kanpur, Udupi, and Aurangabad. To begin, evaluators asked respondents in all 3 locations about any communication on HIV/AIDS that they had seen or heard in the last 6 months, and the last month prior to the survey. If they could recall the main elements of the communication of the "Is This Justice?" campaign, it was considered an "unaided recall". In case they did not mention any elements of the campaign, they were exposed to stimuli using show cards of the print ads and hoardings, and if they could remember seeing the campaign after the exposure, it was considered an "aided recall". Based on this examination, the study draws these conclusions about comparative media effectiveness:

• Hoardings were the most effective.
• TV and print were equally effective.
• Radio was the least effective.
• The "Please forgive me" message had the highest recall.
• Doordarshan television and All India Radio had more than other channels.
• Respondents watched/heard the campaign more than twice in all 4 media.
  

To assess message comprehension, researchers asked the respondents who acknowledged being exposed to the communication (825 out of 1,125 in the sample): "In your opinion, what do these messages convey?" The responses received were marked as TOM (top of mind) or unaided messages. The community comprehended the following messages TOM:

• Throwing an HIV-positive woman out of her house is unjust: 36%
• Violence against women: 33%
• Unequal status of women: 33%
• Women always suffer for the shortcomings of men: 31%
• Rights of women to shelter after their husbands' deaths: 29%
• Family support needed by HIV-positive women: 28%
• Presence of HIV-positive women in general community: 28%
• Number of HIV-positive women in India: 26%
  

Noting that a social messaging communication has a lasting effect only if the situations depicted are realistic, interesting, and impactive, researchers asked questions that revealed the following:

• 41% of the respondents agreed that the campaign directly impacted the mind.
• 21% thought the sarcasm in the campaign was hard-hitting, and perceived the situations as being more real than sarcastic. 55% found the situations to be realistic. What is significant here is that, although the situations depicted in the campaign were exaggerated, the audience considered them real. Only 25% of the respondents agreed that the campaign had exaggerated the situation. Only 8% of the sample felt that the characters shown in the ad were unreal.
• 45% agreed that the campaign was different from the usual campaign on HIV.
• 45% said that the campaign prompted them to think about the problems of HIV-positive women.
  

Figures indicating the effect of the communication, selected from the report, are as follows:

• 55% of the respondents who had been exposed felt that the community will take some action as a result of the ads; 39% mentioned their own desire to do something.
• 53% said they would discuss the messages with someone: friends (82%), followed by spouses (75%) and then siblings.
• After the campaign, the community acknowledged that women are not able to negotiate safer sex (a 4% difference), are subject to domestic violence (an 8% increase), and are treated unjustly after their husbands' deaths (an 8% difference). Specifically, 16% more people acknowledged that this statement is true in society: "A women has no right in her husband's home after his death." Also, 12% more acknowledged the following: "If a woman loses her husband at a young age, she is blamed for his death."
  

The campaign found statistically significant positive changes in two indicators:

• There is a 22% decrease in the number of people who feel it is necessary for a woman to stay with her HIV-positive husband. "In the Indian context this decrease is significant, as it is usually considered the duty of the wife to stand by her husband under all circumstances."
• There is a 10% decrease in the number of people who blame a woman for not satisfying her husband sexually.

Notably, however, the fear of touching a person infected with HIV actually increased by 3%. Shame, blame, and enacted stigma towards PLHA, specifically WLHA, also increased from baseline to endline. For instance, the following attitudes showed an increase from baseline to endline:

• Having an HIV-positive person is shameful for the family (13% increase).
• A woman who has an HIV-positive husband has brought ill luck to the husband’s family (21% increase).
• The wives of HIV-positive husbands are responsible; they infected their husbands (27% increase).
• Having an HIV-positive daughter-in-law is more shameful than having an HIV-positive son (8% increase).
• An HIV-positive woman should die after her husband dies (16% increase).
• HIV-positive persons are not allowed to use common facilities (14% increase).
• HIV-positive persons are teased and ridiculed by the community (6% increase).
• An HIV-positive woman has no right to her husband's or parents' property (14% increase).
• An HIV-positive woman should be sent to an ashram (Hindu hermitage) after her husband’s death (16% increase).
• A woman is not able to refuse sex to her husband even if he is HIV-positive (10% increase).
  

These findings could possibly be attributed to the infection's greater visibility, researchers hypothesise. Also, "No short-term intervention can bring about a change in attitudes and behaviour."

In short, this evaluation found that "Is This Justice?" led to a significant increase in knowledge about the human rights violations faced by WLHA. The campaign was also found to have sensitised the community about the unequal status of women and how it is linked to the violence they experience. Respondents agreed that women usually get blamed for other people's mistakes and have to suffer the consequences in silence because of the fear of violence. This fear of violence is increasingly understood as being connected to women's inability to negotiate safer sex.

Evaluators conclude that, "to reduce stigma and discrimination towards PLHA/WLHA, we need sustained efforts and intervention at all levels - interpersonal, community, institutional and political. Media are effective in reaching large groups of people and starting the process of change." Thus, "Breakthrough will continue building its human rights education efforts to remove barriers to women's full participation in society. We hope Is This Justice? will constitute an important step towards greater care and support for WLHA within the family."