Title: Communication inequality, urbanity versus rurality and HIV/AIDS cognitive and affective outcomes: an exploratory study
Authors: Bekalu, Mesfin Awoke
Issue Date: 5-Sep-2014
Abstract: Considering the disproportionate prevalence and impact of HIV/AIDS in low income populations, there is an increasing interest in the social ecology of the pandemic (e.g., poverty, illiteracy, cultural norms, etc.) and the differential vulnerability that such factors are likely to bring about. It has been argued that going beyond the more reductionist view of causation at the individual-level, prevention interventions should aim to address macro-level socioecological factors. Along the same line, studies on health communication have begun to suggest that communication processes may need to be viewed from a macro-social perspective by moving beyond individual-level psychological considerations. There is a growing body of evidence showing that media and message effects reside at the intersection of various levels rather than at any one single-level field of influence. In line with this body of international literature and theorizing, in this study, the hypothesis that urban versus rural residence, as a macro-level socioecological factor, could be importantly associated with variations in HIV/AIDS communication and concomitant cognitive and affective outcomes was tested. Specifically, the study compared urban and rural groups on three major domains, and hence pursued three major objectives:1. Compared urban and rural groups in terms of HIV/AIDS-related communication and cognitive outcomes. Specifically, the two groups were compared in terms of concern about and information needs on HIV/AIDS, HIV/AIDS-related media use and HIV/AIDS-related knowledge. 2. Compared urban and rural residents in terms of HIV/AIDS-related affective outcomes. In particular, the two groups were compared in terms of attitudes and beliefs pertaining to HIV prevention and transmission such as HIV testing and AIDS stigma.3. Examined the potential and actual impacts of HIV/AIDS prevention messages on urban and rural population samples.These objectives were pursued with data gathered from northwest Ethiopia in three methodological approaches: a survey involving 995 (497 urban and 498 rural) aged 15-34 (urban: M = 25.5, SD = 6.0; rural: M = 25.4, SD = 6.3) respondents, a field experiment involving 394 (urban = 199, rural = 195) participants, and a content analysis of twenty-three AIDS songs widely used to aid prevention efforts in Ethiopia.The major conclusions of the study along with their practical and theoretical implications are presented as follows: Conclusion 1: Urban and rural people differ in concern about and information needs on HIV/AIDS as well as HIV/AIDS-related mass media use. This finding illuminates a fundamental issue in HIV/AIDS behavior change communication in the region. Whereas HIV/AIDS is a generalized epidemic in this region, this finding suggests urban-rural differences in motivation for obtaining and utilization of prevention information. This finding might well be interpreted within the region’s wider epidemiological and socioecological contexts. Epidemiologically, in sub-Saharan Africa, where household surveys have been conducted, HIV prevalence has generally been higher in urban than in rural areas (UNAIDS, 2009). For instance, in Ethiopia, urban residents were eight times more likely to be HIV-infected than rural people (UNAIDS, 2009). It could therefore be argued that due to this early urban-rural imbalance in HIV prevalence, the rural people may have thought that HIV/AIDS is not their problem but that of urbanites. This perception is also likely to have been nurtured by the early depiction of the epidemic as limited to certain groups of people such as commercial sex workers, homosexuals and intravenous drug users. Specifically, in sub-Saharan Africa where heterosexual intercourse is the main route of HIV transmission (Morison, 2001), commercial sex and associated establishments such as brothels are more of urban rather than rural characteristics. Hence, from a socioecological perspective, the mere absence of such risk factors as commercial sex and the associated establishments and practices in rural areas may have led the rural populace to believe that they are not at risk of the infection and thereby become less concerned about it. Moreover, it was found that the rural populace is generally at an earlier stage of awareness about the pandemic compared to their urban counterparts. This was gathered through a measure that required urban and rural groups to indicate the specific types of HIV/AIDS-related information that they would be interested in obtaining. The rural people, particularly those with low educational levels, were found to be interested in obtaining information on the ABCs of HIV/AIDS – definition, symptoms, causes/risk factors and prevention methods of HIV. On the other hand, urbanites did not seem to be interested in obtaining the ABCs of the infection and instead were found to be more interested in information on HIV/AIDS-related care and support – where and how to obtain diagnostic services, antiretroviral treatment, and prevention of mother to child transmission. Thus, urbanites seem to have a kind of progressive information needs – apparently transitioning from the mere need for basic HIV transmission and prevention information to one of care and support – reflecting their better familiarity with the pandemic, whereas the rural group’s preference for the ABCs suggests how insensitive they have thus far been to the infection and/or how unfamiliar they are with it today despite its rapid expansion to their territories. Conclusion 2: Urban and rural people differ in HIV/AIDS-related cognitive and affective outcomes. First, compared to the rural populace, urbanites were found to be more knowledgeable on the symptoms, ways of transmission, prevention of transmission, risk factors and other HIV/AIDS-related issues. The noted knowledge gap could be associated with differences in motivation for and utilization of HIV/AIDS mass media information between the two groups. It was discerned that exposure to HIV/AIDS-related media content has differential effects on HIV/AIDS-related knowledge in urban and rural contexts. Media exposure was more likely to widen the knowledge gap between urban and rural groups whereas such an exposure was more likely to narrow the gap between individuals with high and low educational levels. This suggests that the widening urban-rural gap as a function of exposure to HIV/AIDS-related media content may not be explained in terms of possible urban-rural differences in information processing capacity, but instead it may have well been caused by differentials in motivation for and utilization of mass media prevention information. According to the knowledge gap hypothesis (Tichenor, Donohue and Olien, 1970, 1980; Viswanath & Finnegan, 1996), within any total social system, some subsystems may have patterns of behavior and values that are conducive to change, and hence these predisposed subsystems tend to adopt and act upon information at a faster rate than more stagnant subsystems. In view of this, the rural community might be considered a subsystem that is more resistant and/or less predisposed to adopt and act upon HIV/AIDS information from the mass media. Moreover, in line with media dependency theory (Ball-Rokeach & DeFleur, 1976) which posits that people’s dependence on the media is a function of their social environment’s degree of stability, we may argue that the urban-rural disparities in HIV prevalence and AIDS-related death rates may have led to urban-rural differences in risk perceptions and response patterns which in turn could lead to differences in motivation for and utilization of mass media prevention information. Overall, our findings suggest that in addition to longstanding urban-rural differences in access to mass media sources (ECSA, 2005), risk perceptions and/or concern about and information needs on the infection are important factors for the noted AIDS knowledge gaps between the two groups. Second, it was noted that urban and rural people differ in harboring stigmatic attitudes towards people with HIV. AIDS stigma was found to be higher among the rural people than among their urban counterparts. As discussed in chapter 4, the effects of urban versus rural residence on AIDS stigma can be mediated by exposure to HIV/AIDS media content and AIDS knowledge. Our analysis indicated that exposure to HIV/AIDS media content, positively associated with urban residence, affects AIDS stigma by changing people’s knowledge of the infection. This finding aligns with and further strengthens our conclusions regarding rural people’s low disposition to and utilization of HIV/AIDS-related prevention information. We have also found that the two groups differ in intention to utilize HIV testing and counselling services, a useful biomedical prevention strategy widely recommended in high HIV prevalence contexts (WHO, 2007). Consistent with preceding findings, the influence of media exposure on intention to be tested was found to be different in urban and rural contexts. Only among urbanites did intention to be tested increase as exposure to HIV/AIDS-related media content increased; media exposure did not seem to have any effect on rural people. Additionally, the psychosocial variables that are associated with intention to be tested for HIV were found to be different among urban and rural people. Whereas intention to be tested was found to be mainly influenced by normative beliefs among urbanites, it appeared to be attitudinally driven among the rural participants, suggesting the need to tailor mass media HIV testing promotion messages for the two groups.Conclusion 3: Differently designed prevention messages are required for urban and rural groups. Given their differences in HIV/AIDS-related communication, cognitive and affective outcomes, it is conceivable that urban and rural groups could require differently designed prevention messages. Indeed, in this study, we have gone a further step to obtain some empirical evidence for this. First, a theory-based content analysis of AIDS songs that have been widely used to aid prevention efforts in Ethiopia showed that the songs contain significantly more messages that promote efficacy beliefs than messages that promote threat perceptions. Given urbanites’ relatively high threat perception, these songs are more likely to be effective in urban contexts. However, due to their low emphasis on threat promotion, these songs are less likely to motivate and thereby generate responses from the rural audiences who have less or no threat perceptions already (Witte, 1992).The need for differently designed prevention messages in the two contexts has also been further evidenced by the findings of our field experiment. Examining the effects of gain- versus loss-framed messages promoting HIV testing, the field experiment has found a gain-frame advantage among urbanites and a loss-frame advantage among the rural sample. According to Rothman & Salovey (1997) risk-based classification of health behaviors, gain-framed messages should be more effective when people are engaged in deciding whether to adopt a behavior that they perceive as relatively safe and free of undesirable outcomes (e.g., preventing the onset of a health problem), whereas loss-framed messages should be more effective when individuals are faced with deciding whether to adopt a behavior that they perceive involves some risks of an undesirable outcome (e.g., detecting a health problem). In view of this, our findings suggest that while urbanites are more likely to construe HIV testing as a prevention behavior, the rural people are more likely to construe it as a detection behavior. This finding can again be interpreted within the epidemiological and socioecological contexts of the two groups. Given their relative unfamiliarity with the pandemic, including its diagnosis and post-testing scenarios, rural people are more likely to construe HIV testing as a mere means of checking the presence or absence of the virus in their blood. In contrast, given theirfamiliarity with the pandemic, including widespread testing and antiretroviral treatment (ART) services, urbanites are more likely to be in a much better position than their rural counterparts to be able to see the preventive function of HIV testing.Implications for interventionAlthough the infection has initially been characterized as an urban epidemic that could well be contained by urban-focused interventions, over the years, it has become more apparent that it is no longer an urban problem. The infection has diffused hierarchically from larger urban cities to smaller towns and rural villages (Kloos, Haile Mariam & Lindtjorn, 2007), and the urban-rural gap has diminished dramatically in a number of sub-Saharan African countires. For example, in Ethiopia, the ratio has dropped from 8:1 in 2008 to 4:1 in 2011 (UNAIDS, 2009; DHS, 2012). We argue that this situation could be conceived of as a possible consequence of rural people’s lack of concern and relevant knowledge about the pandemic. Based on the findings of this study, the following recommendations are forwarded.First, HIV/AIDS prevention interventions in the region need to maximize their scope and alert the rural populace of the danger of the infection. Ongoing preventive practices need to be expanded beyond their initial focus on the so-called “high-risk groups” and their environs – urban areas – and engage in context-sensitive mass-scaled interventions of sensitizing and educating the rural populace. Since mass media, more specifically radio, are cost-effective and have huge potential reach, the rural populace could be motivated to utilize these sources of information through the inclusion of content more relevant and appealing to them. Furthermore, community conversation programs currently underway in most parts of the country (MoH/HAPCO, 2010) might be useful opportunities to instil concern in the rural people so that they would use information sources at their disposal and engage in sustainable self-initiated talks and discussions about the dangers of the pandemic through existing social and religious networks. Indeed, previous research in the same region has found that social oriented communication formats such as discussions and role play are suitable to address the rural populace with HIV prevention messages (Bogale, Boer, & Seydel, 2011).Second, current HIV/AIDS information campaigns in the region should also move beyond alerting and instilling concern in the rural populace and counteract the noted knowledge gaps between the two groups. It should be noted that the country’s rural population, which accounts for approximately 85% of the total population, will be increasingly vulnerable to the pandemic if rural residents continue to lack the knowledge that would enable them to engage in protective behaviors. The findings suggest that current mass media information campaigns that are prepared and broadcast from urban centres may not improve the HIV/AIDS knowledge of the rural populace, and furthermore, such campaigns are likely to put rural residents at a disadvantage relative to their urban counterparts. This would entail 1) reassessing and re-designing current mass media information campaigns in terms of their relevance and appropriateness to the rural audience, and 2) envisaging ways to redress the relative lack of exposure to the mass media among rural residents and the lack of cognitive outcomes associated with it. Community-based participatory programs and interpersonal communication activities utilizing existing social, cultural and religious networks might be useful to complement mass media campaigns. Indeed, according to this study, the urban-rural disparities are not limited to communication and cognitive outcomes but also span HIV/AIDS-related affective outcomes. For example, AIDS stigma is higher among the rural people and as such rural residents will be increasingly at risk if they continue to stigmatize people with the infection and fail to engage in open talks about the dangers of the pandemic. This suggests the need for more tailored interventions for the rural population of the region.Third, the findings suggest that urban and rural audiences may require communication interventions that are different in both content and form. Several findings have indicated the need for content-wise adjustments. The first is the fact that the two groups were found to be interested in obtaining different types of HIV/AIDS-related information. Second, the psychosocial variables (attitudes and beliefs) that underlie behavioral intentions such as intention to be tested for HIV were found to be different between the two groups, suggesting the need for tailoring content based on the specific psychosocial variables that prevail in the specific (urban or rural) context. Third, an assessment of songs that have been widely used to aid prevention efforts in the country were found to have more efficacy than threat messages, suggesting their potential inadequacy to address the rural populace who are relatively less concerned about the pandemic. Moreover, the findings of the field experiment have indicated the relative persuasiveness of gain- and loss-framed messages in the two contexts, suggesting the need for format-based adjustments in current and future communication campaigns.Finally, given their socioecological and epidemiological differences, the two situations may in general provide different sets of opportunities and challenges in HIV prevention. Communication campaigns should therefore be planned and mounted with a thorough understanding of the urban-rural divide. Nevertheless, while the need to take the urban-rural divide into account is readily discernable from the findings of the present study, caution should also be made against any form of categorical delineation of urban and rural contexts as favorable for one form of intervention and not for the other. Indeed, the interpretation of the findings must also take into account social phenomena such as rural-urban migration and rapid urbanization processes in the region as well as the increasing technological advances in transportation and communication, which might well be responsible for narrowing the urban-rural gap over time. As situations can and indeed will always change, communication interventions need to be planned and mounted based on consistent efforts to understand the dynamics of the urban-rural divide across time and space. Theoretical implicationsThe findings of the present study have several implications to research and theory in HIV/AIDS behavior change communication in particular and health communication in general. First, to our knowledge, none of the existing HIV/AIDS behavior change communication theories to date has considered disparities in communication (information needs and media use) and concomitant cognitive outcomes among population sub-groups. There is also a dearth of empirical evidence on the interplay between disparities in communication and cognitive outcomes in the arena of HIV/AIDS prevention. This study has demonstrated the importance of considering HIV/AIDS knowledge gaps vis-à-vis exposure to mass media among population sub-groups and suggests the need to revisit the decades-old international literature on the knowledge gap phenomenon and to make further inquiries in the field of HIV/AIDS prevention. Second, the study has demonstrated the application of several established behavioural theories to investigate disparity issues in the arena of HIV/AIDS prevention. For example, the integrative model (IM) of behavioral prediction (Fishbein & Yzer, 2003) has been used to examine whether the psychosocial variables that mediate the link between exposure to HIV/AIDS media content and intention to be tested for HIV differed between urban and rural groups. Similarly, Witte’s (1992) extended parallel process model (EPPM) has been employed to determine the potential urban-rural differential effects of songs that have been widely used to aid prevention efforts in the country. Moreover, framing theory has been used to empirically test urban and rural audiences’ differential reactions to differently framed HIV/AIDS prevention messages. Indeed, to our knowledge, this is the first study to utilize health message framing in general and HIV testing message framing in particular to investigate urban-rural differential effects. Overall, these theoretical implications of the study can be viewed as a two-way street: theories have been used to investigate the relationships between HIV/AIDS communication and concomitant cognitive and affective outcomes between population sub-groups, and in turn empirical evidence that can inform the theories has been generated from a study context in which limited research has thus far tested the theories’ utility. Last, but most importantly, the study has shown the need to view the effects of HIV/AIDS communication from a macro-social perspective. Indeed, this is the basic thrust that threads all the findings of this PhD dissertation together. In this study, the noted urban-rural differences in motivation for and utilization of HIV prevention information can be characterized as macro-social level communication inequalities (Viswanath, Ramanadhan and Kontos, 2007). Urban-rural communication inequalities and the associated cognitive and affective outcomes suggest that the effects of HIV/AIDS media and messages in sub-Saharan Ethiopia should be seen from a macro-level socioecological perspective that extends beyond the more reductionist individual-level approach upon which most contemporary HIV/AIDS communication interventions seem to be based (Airhihenbuwa & Obregon, 2000; Noar, 2007). Specifically, communication outcomes should be sought at the social environmental level of the two contexts. Social environment, “the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact” (Barnett & Casper, 2001:465), is experienced at various scales ranging from household, neighbourhood and kin networks to town, city and regional networks. Because urban and rural residents are more likely to belong to different such networks, communication campaigners may need to identify the two sets of networks and tailor their interventions accordingly. As detailed in the implications for intervention section, this could entail impacting the nature of information flow through urban and rural networks by providing information resources that are relevant for each group. The observation regarding the need to consider HIV/AIDS communication from a macro-social perspective can well be conceptualized within the structural influence model (SIM) of health communication (Viswanath et al., 2007). According to the SIM (see appendix 5), communication inequality refers to “differences in the generation, manipulation, and distribution of information among social groups; and differences in (a) access and use, (b) attention, (c) retention, and (d) capacity to act on relevant information among individuals” (Viswanath & Emmons, 2006: 242). As elaborated in this model, the motivation for, access to, and use of health information and/or health-related media could at least partially explain the relationship between social determinants and health outcomes. The premise of the SIM is that “audiences attend and react to mediated content based on their structural location in the environment and the social roles they play at any given time” (Viswanath & Emmons, 2006: 244). This model attempts to encapsulate a body of work that views media and message effects from a more structural approach by moving beyond the more reductionist view of effects that has characterized the field of media studies for decades. The model contends that structural antecedents such as SES and geography determine both the information environment and the resources that are available for consumption and suggests that communication may have a role in linking social determinants with health outcomes (Viswanath et al., 2007). In line with the SIM, apart from HIV/AIDS-related epidemiological and socioecological reasons, the noted urban-rural differences in HIV/AIDS-related cognitive and affective outcomes can be seen against structural factors such as differences in health facilities and infrastructure as well as information resources. Indeed, the broader literature on health promotion practices in sub-Saharan Africa suggests that mainstream health information systems in most countries in the region leave many of the health information needs of rural people largely unmet (Nyamwaya, Nordberg & Oduol, 1998).Overall, the findings of this dissertation underscore the importance of considering urban versus rural residence in HIV/AIDS communication campaigns in sub-Saharan Africa. In line with previous observations regarding the role of socioecological factors in health communication and related outcomes (e.g., Southwell et al., 2010), we argue that urban versus rural residence matters, not just as a marker of geographic variation but as an indicator of structural and socio-environmental differences that facilitate or hamper HIV/AIDS-related communication and concomitant cognitive and affective outcomes. These results join a growing body of international literature that highlights the interplay between socioecological factors and health (e.g., Southwell et al., 2010) and accentuates the need to consider the macro-social level effects of health-related media and messages (e.g., Viswanath and Emmons, 2006; Viswanath et al., 2007).
Publication status: published
KU Leuven publication type: TH
Appears in Collections:Leuven School for Mass Communication Research

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