Modeling and Reinforcement to Combat HIV: The MARCH to Behavior Change

The CDC has initiated the Global AIDS Program, which seeks to implement projects in primary prevention, improve community- and home-based care and treatment, and develop capacity and infrastructure. In the area of primary prevention, the Global AIDS Program has developed a model strategy for changing behavior that integrates entertainment as a vehicle for education ("entertainment-education") with interpersonal reinforcement. This program strategy is called MARCH: Modeling and Reinforcement to Combat HIV.

In Africa, where HIV/AIDS took an estimated 2.2 million lives in 1999, the harsh reality of having an increasingly infected young adult population threatens the whole fabric of society, with teachers, workers and parents dying at an unprecedented rate. In the face of these public health threats, women and men in developing countries have a limited ability to imagine other futures and other choices. They are held hostage by a societal narrative in which the cycle of early marriage, unprotected sexual behavior, multiple unplanned births, HIV infection and early death is seen as unavoidable, and where patterns of personal behavior are thought to be unalterable.

The purpose of MARCH is to intervene in these incapacitating story lines by providing alternative narratives in which individual control over sexual and reproductive behavior is made not only desirable but, more importantly, possible. MARCH combines two key approaches to behavioral change: entertainment-education through broadcast media and interpersonal reinforcement at the community level.

The first component of MARCH is the use of role models in entertainment that educates. Role modeling is accomplished in many ways. In choosing entertainment-education as a major component of their approach, the authors decided to emphasize its narrative, or story-telling, component. In a sense, the MARCH projects can be thought of as a narrative intervention that permits people "to understand the origins, meanings, and significance of [their] difficulties, and to do so in a way that makes change conceivable and attainable." One reason serial drama can educate is because it is closely aligned with the customs and norms of its audience and uses narrative forms with which they are familiar.

Entertainment focuses on emotional as well as cognitive factors that influence behavior, and thus it keeps the attention of the intended audience. MARCH's interpersonal reinforcement component is as important as role modeling. MARCH projects seek to involve credible members of the affected community and mobilize them to endorse and support behavior changes among members of their own peer, family, and social networks. In MARCH, the serial drama is used as a vehicle for integrating a wide range of interpersonal reinforcement activities. During the period of the drama broadcast, interpersonal and community communication networks can encourage and reinforce attention to the drama, endorse and support the goals and behaviors of specific characters, distribute health-related materials, link people to community services, and advocate other community-level changes.

In the MARCH approach, behavioral change is accomplished by going far beyond the traditional method of promoting the benefits of adopting the desired risk reduction behaviors. Affected populations are helped to identify with new role models, acquire new ways of thinking about and reaching goals, and increase their confidence that they can attain and maintain the behaviors they have been persuaded are necessary for avoiding HIV infection.

Although the MARCH approach shares many features with other approaches to using entertainment-education for achieving behavioral change, it is distinct in several important ways. First, the approach focuses as much on enabling men and women to enact and maintain new cognitive and behavioral patterns as on promoting the behaviors themselves. A second distinction of MARCH is that the goal is long-term rather than short-term change. MARCH attempts to do nothing less than change personal, social, and cultural views of sexual and reproductive health behavior, as well as the behaviors themselves, in individual men and women and in their communities.

Finally, MARCH has a theory-refining objective, because there are key theoretic questions that may have important implications for public health practice. One question of great interest, on both theoretic and practical levels, is how identification with role models in the media really works to influence behavior. "By combining the reach of radio or television with the power of narrative, and by providing supporting elements in the environment, we may equip young women and men with the resources necessary to rewrite the script," the authors concluded.

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