Vida de Rua in Belo Horizonte: Educating Street Youth through Entertainment

• Goals and Objectives
• Formative Research Findings
• Project Implementation
• Project Evaluation
• Conclusions

Reaching street youth who battle daily for mere survival with an HIV/AIDS prevention campaign was the focus of this multi-layered IEC intervention campaign. For the youth this disease was an abstract idea in that it was mysterious and without immediate implications. It was more related to the future, something which these youth did not have. They did not have the pleasure of planning ahead or looking forward; their future extended to where their next meal would come from and where they would sleep for the night. To reach them with appealing preventative messages was the challenge that awaited a team from Johns Hopkins School of Hygiene and Public Health and the Federal University of Minas Gerias.

Goals and Objectives

This intervention campaign targeted the street youth of Belo Horizonte, Brazil, a diverse population including youth living and working in the streets as well as those residing in shelters. The secondary audience was the outreach workers who worked with the street youth. They were in need of standardized information about STDs, AIDS, and teen sexuality, and also in need of training on how to counsel street youth about these subjects.

The overall campaign objectives were as follows:

1. Sensitize institutional directors to the youths' risk of HIV infection and gain their support for the intervention
2. Sensitize and inform educators about sexuality & AIDS
3. Train educators to properly use the support materials
4. Sensitize community leaders and parents to their child's risk of HIV infection and gain their support for the intervention
5. Train gang leaders and other kids as multipliers
6. Educate youth on sexuality
7. Emphasize correct knowledge and correct misinformation about AIDS and HIV infection
8. Develop AIDS prevention skills among the youth
9. Sensitize and elicit support from the media and commercial sponsors.

Formative Research Findings

The project team carried out 394 medical exams of youth in institutional settings revealing few cases of HIV infection, but revealing high rates of other STDs and self reported high-risk behaviors. There were also 379 psychosocial interviews conducted with the street youth, confirming that the youth were sexually active at a very young age and that they participated in high-risk practices. It soon became apparent that living in the street environment put both the working and the homeless youth at risk. It was revealed that there was correct information on the transmission routes of HIV, but also there were also many myths and the knowledge did not translate into preventative measures.

The qualitative methodology included 14 focus group discussions with 53 youth and 27 adults, in-depth interviews with 21 youth and 5 adults, and 93 days of field observations of the youth in their natural setting. The majority of the youth who participated in the focus groups reported unsafe sexual activities with multiple partners. Motivations for these activities ranged from seeking money, food, clothing, shelter, companionship, and pleasure, to protection and violence. For the boys, they referred to their sexual activity in a positive or neutral tone, while the girls were much more negative about their sexual experiences.

The use of I.V. drugs was more common in some neighborhoods than others. Although youth would sometimes travel to other neighborhoods to get I.V. drugs, inhalants were much more common. Although these drugs are not injectable, they do have an affect on the youth's risk of infection as they were used to "raise courage" before sexual encounters. This may affect their ability or desire to use condoms and to avoid unprotected anal sex.

One of the main barriers to condom use was the expense. When the respondents did have money, they first used it to cover the costs of food, transportation, and fun. Some of the problems they had with condoms were size, breakage, and diminished pleasure. Attitudes however, reflected that they were not opposed to the use of condoms in the future. In analyzing their attitudes on other methods (withdrawal or abstinence) and exchanging needles, it became apparent that these practices would not change rapidly, and that for the most part the youth were resistant to changing. The best approach would then be to inform and show the benefits of condoms and clean needles (cleansing with bleach).

Due to the youth's daily struggle for survival in the streets of Belo Horizonte, they saw death as an enemy to fight daily, not something that they could prevent, and planning for the future was an activity that was seen as a luxury. Because of this, it was decided that linking AIDS to death would be an ineffective tactic for this population. It was revealed however, that they perceived their health as essential. Without their health they would not be strong enough to carry out their daily survival activities, and from this discovery came the unifying campaign concept. The intervention reinforced existing values and practices by emphasizing that street smart youth can stay strong without AIDS.

Due to the nature of the street youth's lifestyle and their apprehension of those in positions of authority, there was a need to have a real understanding of the lives of the youth demonstrated in the communication materials. Having materials that correctly depicted the lifestyles of the youth would lend credibility and validity to the intervention campaign for the target audience. They would feel that the campaign was reflecting them and their needs, and that the educators were working for them.

Project Implementation

The communication strategy chosen for this intervention was one that incorporated an enter-educate approach, as youth needed information to be presented in a way that would interest them. The research indicated that the youth enjoyed comics, videos, popular magazines, and occasionally the cinema. Television was not a popular medium due to their lack of access.

The strategy for addressing the youth audience thus had three objectives:

1. educate them about sexuality;



2. reinforce correct knowledge about HIV transmission and correct misinformation; and



3. develop HIV prevention skills.

To best accomplish these goals it was decided that interactive communication materials would be designed to provide a basis for group discussions, role playing, theater and art activities. These types of activities gave the participants a way to consolidate knowledge, discuss problems and doubts, and have a forum to ask questions on the topics of sexuality, teen-age pregnancy, STDs, and HIV/AIDS related topics. Materials produced included a video movie depicting street life and the problems youth face daily, a comic book mirroring the same story, and an educators manual illustrating how to use the video and comic books.

The video was shot in a new popular style using puppets as actors, real voices and real background scenes of the city. The background was in black and white while the puppets were in color. The video was an accurate portrayal of survival on the streets, with graphic language and startling scenes. The script for the video was informed by the formative research. The characters are a gang of street children that are sexually active among themselves and also with same sex adult partners. They are also involved in I.V. drug use with neighborhood kids. Their responses to the different situations portray a variety of outcomes and provide the youth a chance to identify with one or more of the characters, and to reflect on their behavior, and the behavior of the other characters.

The comic book was produced by the youth and their educators, and followed the video closely. It provided a means of disseminating messages to those youth who were not exposed to the video. The comic books were passed from youth to youth, from those attending meeting to their friends on the street. This helped maximize the number of youth reached. All materials were thoroughly pre-tested to ensure that they were appealing to the intended audience. Through focus groups and individual interviews, 108 youth participated in the pretesting, and communication materials were subsequently revised.

An integrating component of the strategy was to provide a set of standardized materials for outreach educators to correctly educate the street youth on sexuality, drug use, STDs, HIV/AIDS. This was achieved through a set of intensive workshops and the creation of a trainers manual leading the educators step by step through video and comic book usage. The educators manual was also pretested with 17 educators who rated its overall quality, coverage, accessibility, and usefulness. To increase the sustainability of the project, certain educators were selected as intervention implementors. This core group of educators was crucial in getting the messages and materials out, by: 1) establishing contact and trust with the youth; 2) maintaining dialogue with kids and receiving their feedback regularly; and 3) bringing the educators on-board early on so they could act as multipliers to implement the project in each of their institutions.

Another key component of the project was the implementation of a city-wide coalition of youth service agencies from the public, private and religious sectors, the first of its kind in Brazil. The coalition was formed by outreach workers from the various agencies that participated in the project, who could mobilize staff from their respective agencies to participate.

Project Evaluation

The evaluation process for this project was on-going, with monthly meetings between outreach educators and the project team. These meetings gave the outreach educators a chance to share experiences and further their knowledge on HIV related topics. Both the project team and the educators were responsible for tracking the sessions and completing reports on individual attendance, topics of discussion, materials distributed and the main themes discussed. In the first three months of the intervention, over 600 youth participated in 55 sessions conducted in different institutions and street settings.

Pre and post cross-sectional surveys were conducted on a random sample of 400 youth on the street. The pre-intervention survey was conducted in January 1992, and the follow-up survey was conducted in October 1992. The surveys revealed significant changes both in increased levels of correct HIV transmission knowledge as well as in decreased levels of misconceptions. For example, respondents believing that a person can look strong and still have AIDS decreased by 14 percent, while those who believed that condoms can protect against AIDS increased by 18 percent. These percentages were markedly higher when the responses were compared between those who had seen the video and those who had not.

Conclusions

This innovative strategy proved that "enter-educate" approaches can work, especially when the target audience sees its own images reflected in the materials. The strategy used not only provided educational messages, but also deeply touched the youths. They could relate to the scenes depicted in the video and in the comics. They saw their lives being re-enacted in a movie, and were able to identify with the problem of HIV transmission and prevention because it was presented in the context of their lives. Thanks to this approach, they were willing to listen and discuss their problems and apprehensions surrounding HIV/AIDS.

Thorough formative research made a difference in developing the campaign and its messages. The message that was used stressed preventing HIV in order to remain healthy and strong, and in this way being able to survive on the streets. The methods promoted were ones that were acceptable to the youth-- condoms, clean needles, and reduction of partners. No complete change of lifestyle was necessary, just modifications.

This project advanced AIDS prevention in three ways:

1. Sound communication theories of behavior change and message development were utilized to maximize the impact of the project activities

2. Project activities were designed with the kids in response to their needs and daily realities. The outreach educators - often role models for the kids- were brought on board early on and provided an ongoing link to the youth

3. A methodological evaluation was implemented to better understand the affect of the AIDS prevention messages on youth.