Mind the Gap: Building a Bridge Between HIV Knowledge and Protective Behaviors in Malawi

In 2003, more than 80% of adults in Malawi could cite how to protect themselves from HIV. But with 90,000 new infections each year and a prevalence rate hovering at 14%, this knowledge was not translating into behavior. Utilizing strong behavior change theory, rigorous evaluation and inventive programming, the BRIDGE Project set out to change that. With a wide range of interventions in the media, in schools, and in the community, the BRIDGE Project inspired action, participation, and hope.

The BRIDGE project began among desperation in Malawi. The southern African nation was battling a climbing HIV prevalence rate and struggling to close the gap between knowledge of HIV and taking action to protect oneself. Initiated in 2003 by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP), in partnership with Save the Children, the six-year project used multi-level interventions, varying media channels and rigorous evaluation to address HIV prevention in eight districts across Malawi.

While studies showed that more than 80% of adult men and women in Malawi knew that partner reduction and condom use were two ways to avoid HIV infection, adoption of these behaviors hadn’t kept pace with knowledge. Many programs tried to address this knowledge-behavior gap, but few had been successful.

The goals of motivating behavior change and ultimately, reducing HIV infection, were common in Malawi. But the BRIDGE Project was unlike any other in the country.

Working with local partners and agencies in Malawi, the BRIDGE Project employed innovative, science-based strategies that made great strides in fighting HIV. People exposed to BRIDGE interventions reported increased confidence in their ability to abstain, be faithful or use a condom. Intention to perform these same behaviors was also increased. Stigma against people living with HIV was significantly reduced and HIV testing rates improved.

Unique Approach

Each of the BRIDGE Project’s interventions was founded in behavior change theory. Relying on empirical findings, the project emphasized raising awareness of risk to HIV infection, while at the same time increasing self-efficacy -- people’s confidence in their ability to bring about change in their lives. One of the project’s central interventions was “Nditha!” (I can do it!). This multi-media effort sought to raise self-efficacy, underscoring the message that all Malawians had the ability to prevent the spread of HIV.

The BRIDGE project also relied on research findings to inform all aspects of the intervention. From the initial conceptualization of the program, which was informed by findings from the baselines assessments and household surveys, to the final outcome and process assessments conducted throughout, evaluation of BRIDGE activities was a central component of the intervention.

Baseline findings showed high levels of knowledge about HIV, but they also revealed Malawians felt they had little control over their lives and did not believe they could do anything to prevent HIV infection. BRIDGE interventions drove to the core of this belief. Nditha! radio spots, posters, promotional materials and community outreach events promoted small do-able actions -- such as openly discussing HIV with family, supporting friends to avoid risky behaviors or encouraging community leaders to speak openly about HIV -- that could have a major impact on the spread of HIV.

Many of the Nditha! materials were included in the BRIDGE project’s Hope Kit, a package of interactive tools and resources to guide individuals and community groups to develop HIV prevention strategies. Hope Kit materials modeled prevention behaviors, challenged myths about HIV and provided opportunities for open, honest discussion. While the Kit was developed for use with any type of audience, supplements to the Hope Kit specifically encouraged men to participate in HIV prevention and focused on strategies for couples to prevent passing HIV on to their unborn child.

BRIDGE’s Radio Diaries program featured the personal narratives of men and women living with HIV. Their powerful stories, broadcast on eight stations throughout the country, engaged the audience and humanized HIV. The innovative approach challenged stigma and aimed to change social norms around acceptance of people living with HIV. Forty radio listening groups were established to engage listeners in dialogue and provide feedback to the intervention. Evaluations revealed that the more programs listened to, the more the audience felt HIV-positive people were “just like them.” A decrease is stigma against people living with HIV was also shown from baseline to the end of the project.

To reach out to youth, a group extremely vulnerable to HIV in Malawi, the BRIDGE Project developed a mix of inventive approaches. The Tisankhenji Radio program and listeners clubs targeted adolescent girls with messages to build self-confidence and self-esteem to help girls deal with critical life decisions. Youth Congresses and Girls Leadership Congresses built leadership skills among youth and identified ways young people could get involved in the fight against HIV. The Nditha! Sports program utilized games, sports and recreation activities to instill knowledge and skills to help youth successfully face challenges and make decisions to prevent HIV.

While Malawi still faces the challenge of HIV, the BRIDGE Project helped promote positive changes in attitudes and behaviors for the prevention of HIV.