Hope on the Air

By Jennifer Acker '00

makgabaneng

María Ramos was young, single and poor when she moved from her rural home in the Andes to Lima, Peru's capital and most congested city. She found work as a maid for a wealthy family, but soon she was seduced by a slick city man and became pregnant. When her employers found out, they fired her. Determined to create a better life for herself and her son, María attended literacy classes at night, bought a Singer sewing machine and launched her own dressmaking business. Through smarts and hard work, she rose above the desperate situations that confronted her, and for an hour every week night, from 1969 to 1971, millions of Peruvians turned on their televisions to discover what would happen to María next.

Simplemente María (Simply María) is remembered as the most popular telenovela, television soap opera, ever aired in Latin America, a region where most television systems broadcast a dozen dramas a day. Yet more interesting than the overwhelming volume of viewers was the effect the show had on the audience: "dressmaker" became the most aspired-to occupation among Peruvian maids in the 1970s, and the sales of Singer sewing machines skyrocketed in Spanish-speaking countries where the telenovela was aired. Enrollment in adult literacy classes rose, and the governments of both Peru and Mexico launched Simplemente María-inspired literacy campaigns.

The significant behavioral changes caused by the soap opera, though unintended by its producers, inspired Mexican television and theater writer-producer-director Miguel Sabido. He wanted to put serial dramas to good, educational use. In 1974 Sabido met with prominent social learning theorist Albert Bandura at Stanford University and worked to solidify the intellectual basis of entertainment with the goals of social change. Following the success of Simplemente María, Sabido produced seven different telenovelas, addressing issues like adult literacy, family planning and child homelessness.

The chapter on Miguel Sabido is earmarked in the book on entertainment-education lent to me by Christine Galavotti '78. The producer's work has been an inspiration to her, and his serial drama framework is a key model for the strategy Galavotti has developed and implemented in her own field. Simply put, her goal is to prevent and treat HIV/AIDS. More specifically, she and her colleagues at the Centers for Disease Control in Atlanta—and their partners around the world—aim to effect individual- and community-level behavior change through radio soap operas. The story begins in Africa.

The method Galavotti has chosen to save the continent from the ravages of one of the worst epidemics in human history—or at least reduce the number of people who die of HIV/AIDS in Africa, over two million a year—has long, historical roots. "Entertainment" has been used for centuries to inform communities and cultures, in the form of folk tales, fables, theater, myth and music. Radio, cheap and portable, is the designated medium of this scientist's plan.

galavotti

Christine Galavotti is the chief of the Behavioral Research Unit in the Division of Reproductive Health at the CDC (an organization divided into dozens of complex parts and acronyms). After a couple years of pursuing dead ends with domestic entertainment-education programs, in 1999 she made promising connections with a representative of the World Health Organization's Africa region. Simultaneously, the wheels began to turn back home, and for the first time ever the CDC received Congressional funding for direct international intervention programs. The Global AIDS Program (GAP) was formed and Galavotti became the team leader of the behavior change division. It received $35 million in 2000, which seemed like a lot of money until Galavotti realized it was already halfway through the fiscal year and she had "no program, no staff, no plan, no nothing." And 14 countries to deal with.

Based on the work of Sabido and social learning researchers, Galavotti's team created MARCH, Modeling and Reinforcement to Combat HIV/AIDS. Its underlying argument is that behavior in individuals is most effectively changed when they are given role models who demonstrate the desired actions and who are participants in culturally familiar, emotionally compelling narratives; also, obstacles to behavior change must be acknowledged, and community support systems must be active and ready to reinforce the narrative's messages. So when a soap opera listener considers a pregnant character who is worried that she may be transmitting the HIV virus to her fetus, the listener also becomes aware of local testing and prenatal care centers.

"One of the principles of role modeling," Galavotti explains in her Atlanta office, "is that in order to learn about your own behavior, you have to observe a model similar to you. If I watch an elite runner doing a marathon, that doesn't give me any indication I could do that. But if I saw someone my age, my size, I'd think 'I could do that.'" (It wouldn't be surprising to learn that Galavotti had run marathons in her life; she is youthful, goal-oriented, passionate and energetic.) Galavotti explains that MARCH uses Sabido's three-part character formula for its dramas: the good guys, the bad guys and the transitional characters, the ones "just like me." It's not enough, however, just to demonstrate healthy behavior. Individuals must believe they are capable of the illustrated behavior changes, and so the dramas must bolster audience self-efficacy, belief in one's capacity to change.

"It's really important people believe they can do something, in addition to wanting the outcome," Galavotti says.

Once the two theoretical underpinnings—role modeling and community reinforcement—were in place, the MARCH team realized the key features their radio drama needed to include: role models, emotional impact, connection to social and cultural expectations and norms, personalized attention and messages, and recognition of impediments to behavior change.

Galavotti describes the development of MARCH, once the funding became available, as "very chaotic," with trips to Zimbabwe, Malawi, South Africa, Uganda, Ethiopia and Kenya to survey potential program sites. Winning full acceptence of entertainment-education in the medical community was a slower, difficult process. When she first arrived at the CDC 13 years ago, Galavotti ran a role model-based demonstration program, one of the earliest AIDS intervention programs implemented in a community setting. She had received her graduate degree from a pioneering community psychology program at the University of Texas, Austin, and was eager to apply her efforts broadly. The target audience of the intervention was commercial sex workers. Researchers interviewed them and used their stories in widely distributed pamphlets.

"We were interested in the idea of storytelling, and how these stories could be constructed around theoretical principles," says Galavotti. She wanted to demonstrate that change can occur slowly, to show "people coming to recognize they're at risk, and wondering what they're going to do next. Thinking about using a condom, talking to a friend. You know, it's a gradual process, and that's how we all change. These are major, deeply ingrained behavioral attitudes." But the modern medical model has different expectations; people want change to occur fast, Galavotti says. The great advantage of soap operas is their pace. Change can occur over time, weeks and months, as the listeners become more "emotionally involved."

In 1994 Galavotti learned of a radio soap opera addressing family planning in Tanzania. Called Twende na Wakiti ("Let's Go with the Times"), the program ran for five years, from 1993 to 1998, and was the first of its kind to be rigorously evaluated. A natural control group had formed around the city of Dodoma, where the radio drama was not broadcast for the first two years, creating an ideal comparative situation. Clinic data, surveys and self-reports indicated that those in the broadcast area had adopted methods of family planning and HIV prevention. This kind of thorough evaluation was what entertainment-education theorists and practitioners needed to establish their legitimacy.

healthed

In the past few years the genre has received increasing attention as social change-oriented soap operas have blossomed all over the world—in China, India and Brazil, to name a few countries. Some of the media attention has characterized the serial dramas as "masked" education and "good propaganda." Galavotti disagrees. Such easy labels downgrade the vital importance that stories have in people's social and personal lives and the manner in which they are shared. "The process of identifying with characters can be both an emotional and cognitive one," she says. "We recognize ourselves in characters—they are like us, or they face problems similar to ours, or, perhaps most importantly, they show us what we might be." Crucially, the messages promoting behavior change are not didactic or prescriptive. Technically the dramas are "propaganda," according to the rhetorician's definition of "using information strategically"; on the other hand, Galavotti writes, "We are trying to promote certain health and social outcomes, but we are also trying to get people to re-think their lives and generate their own solutions for reaching those 'healthy' goals." Galavotti and the MARCH team want the target audience to be actively involved in their futures and not just adopt the behaviors they are told will be good for them.

To achieve the twin goals of audience engagement and education the drama must be extremely well-thought out. The characters, scenes, relationships and scenarios—components humans use to make sense of narratives—must be rooted in local realities. This means featuring familiar character types and customs and using regional language. This qualitative assessment is the most nuanced and consequential aspect of MARCH research, which also necessarily includes assessments of local media use, health infrastructure, community infrastructure (current activities and organizations), and a scientific literature review. The qualitative assessment uses techniques like interviews and focus groups to understand the attitudes of the affected population, as well as the stories and parts of stories people use to talk about themselves. That information is then used by scriptwriters to craft culturally appropriate dramas, as well as by the CDC and in-country monitoring agencies to evaluate the drama during and after its broadcast.

Joseph Petraglia, previously a professor of both rhetoric and cognitive science at Georgia Institute of Technology, joined the MARCH team in the fall of 2000. His enthusiasm for the project is immediately obvious in the lively pace and careful choice of his words. Petraglia says he was "getting disenchanted with the academy" and was excited by the linguistically based behavior change program Galavotti
was forming.

"I'm interested in the explicit persuasive impact—as well as the implicit persuasive impact—of things like serial dramas, stories. Rhetoric as a discipline is all about how you get people to change their minds, and then how they change their actions on the basis of that," Petraglia says, taking a comfortable seat inside the door of Galavotti's office. Just above his head are shelves of mammoth binders marked Ghana, Zimbabwe, Botswana, Ethiopia. Folk quilts and weavings hang on the wall, along with a detailed, inviting watercolor of mud huts Galavotti bought in Malawi because it captured her image of Africa. The desk is stacked with manila folders. "Joseph is a godsend," Galavotti says.

Petraglia is interested in how people view their options. Through asking, "'Why would you respond that way? What could constrain you to make that choice?'" he says, "you'd get some sense of people's awareness and their alertness to their environment, what it permits and constrains." Such an understanding creates space for intervention. Evaluation, from all of the different perspectives involved in MARCH, including rhetoric, behavioral psychology and epidemiology, is "exciting and really challenging," Petraglia says. "You're trying to meet all these very different standards and disciplinary criteria."

"And we're also trying to change the world," Galavotti adds. They laugh, but their idealism remains hanging in the air between them, like a helium balloon.

In a presentation Petraglia gave on the MARCH qualitative assessment in Botswana, he outlined some of the techniques and collected data. Here are examples of archetypes understood by two men: "A good man looks after his children"; "A man will immediately demand sex from a girlfriend unless he is a strong Christian." Women's responses included: "A good woman is not quarrelsome"; and "Women who love their husbands are naturally jealous." Lines of reasoning about health behavior were also made explicit through statements like, "The only acceptable situation for using a condom is when you are trying to prevent pregnancy," from one woman; and from a male interviewee, "If my wife asks me to use a condom she is giving me license to have an affair." Such responses are then used by the scriptwriting team, who tend to be more urban and educated than their audience.

The scriptwriters and behavior-change scientists first generate an English-language plot synopsis. Then the dialogue writers create the conversations. In some countries, like Zimbabwe, several versions of the soap opera will be produced: one in English, directed at urban youth; one in Shona, spoken by about two-thirds of the population; and a third version in Ndbele, spoken by one in five Zimbabweans in a concentrated area in the southwestern corner of the country.

Galavotti explains that youth will be the primary writers in Malawi, as scriptwriting is not a full-time job and kids have more available time. In Ethiopia there will be two separate radio dramas, in the languages of Amharic and Oromifa, that do not even share the same plot because the cultural differences between the two language groups are so significant. As of this past winter, MARCH projects have begun in three countries, Botswana, Zimbabwe and Ethiopia. More nations are being considered for the Global AIDS Program and MARCH projects all the time, and with the many structural and financial variations among the nations, the projects move at vastly different paces.

In August 2001, MARCH and the Botswanan production team launched Makgabenang, to air twice a week for two years. The drama's name means "A Stony Place," but Galavotti writes that the title conveys ideas of "oases and life amid barrenness." Galavotti hopes fervently to nuture life where there has been unimaginable devastation.

Over lunch with several members of the interdisciplinary MARCH team, whom she praises as "terrific, so smart and dedicated," Galavotti describes how the death toll from HIV/AIDS is cracking the foundations of community life all over Africa. Funeral processions, once conducted with great expense and care, have been reduced to two trucks driving down the street—one carries the coffin, the other the mourners. Coffin-making is a growth industry. Joan Kraft, a sociologist who develops the community reinforcement aspect of MARCH, reflects on a visit to a non-governmental organization that provides services to AIDS orphans: "It's depressing to see five-year-olds who you know don't have parents. But it is also exciting to see what services organizations can provide on a shoestring budget," such as one meal a day, school fees for 85 children, vocational training of students to become tailors, and teaching other income-earning skills.

Since they are at the moment wholly immersed in three countries, the travel associated with the MARCH projects is "hectic" and overwhelming. "There are a lot of needs. For every trip there are two more that need to be taken," the team leader says. Galavotti has a husband with a flexible work schedule—for which she expresses gratitude—and two young children, Casey, 10, and Louis, six; so she tries to limit her travel to a couple weeks at a time, as infrequent as possible. Modern communications mean, however, that there is never a break in the e-mail flow. This morning there were 2,500 messages in her in-box that needed attention. Little dings emitted from the computer every couple of minutes, signaling a new e-mail. But the messages are important because continual project monitoring and evaluation are crucial to the success of the radio dramas. The scriptwriters are "under pressure" because the characters need to be aligned with the story lines; prejudices must be avoided; stakeholders (a diverse committee of government workers, people with AIDS, youth, and other community leaders and members who "sign on" to the project) need to feel that their agreed-upon objectives are being followed.

Anne Sebert, a young CDC fellow who recently received a masters degree in public health, is involved with this process evaluation. She helps ensure, for example, that writers "avoid promoting services not available in particular countries. Botswana has a different landscape—there might be antiretroviral therapy there, but that's not an option in other countries." As Sebert's caution indicates, entertainment-education involves myriad social, economic and other local factors. The MARCH team oversees as many of them as possible, but unintended effects are inherent—Simplemente María producers had no idea their show would increase Singer sales!

One particularly negative risk of the MARCH dramas is the tendency to "blame the victim." With a program that aims to influence the individual, it is clear the benefit is increased self-efficacy; but what about failure? If an individual believes he is responsible for his well-being and has the capacity to effect positive change in his life, how does he respond to negative consequences?

"The emphasis is on individual-level behavior change," Galavotti says. However, the individual is not alone. "Both the narrative side and the community reinforcement side are trying to focus not only on individual behavior but cultural understandings of the social environment and how they influence people." She admits, "It would be easy to fly into story lines that are stereotypical: 'You're a truck driver and if you sleep around you end up with AIDS.' That would contribute to the stigma of people with AIDS." The MARCH team is aware of that risk, she says. They have a list of positive objectives: practicing safe sex, for example, achieved through abstinence, mutual monogamy and using condoms. The anticipated outcomes of these practices are marital harmony and fidelity, and prevention of unintended pregnancy and HIV infection. However, depending on the individual circumstances and the surrounding community structures, discussing the possibility of safe sex with one's partner could create marital disharmony and lead to abuse or even abandonment. Galavotti's team has good evidence to believe that social change-oriented dramas produce positive results; and they will put all of their best practices forward, monitoring closely along the way. "We keep [these risks] very much in the forefront," Galavotti says. "Because stigma is a horrible problem in much of Africa. But so is AIDS."

With all of the effort poured into creating characters, storylines and plots, and the dangers of unintended effects, one could wonder if another kind of entertainment, a documentary about real people like the viewers, for example, might be a more direct way of achieving the same behavior change. Galavotti doesn't think so: "The power of narrative does not lie in its 'realism' but rather in its power to reach beyond what is 'real.'" She asks, would "real-life stories," though powerful, "'change us' in the way that, say, King Lear changes us?" A transcendent quality akin to inspiration seems to be at work in creative narratives. "Don't we believe that there is something in the story, the fiction, the drama, the imagined, that is more powerful than 'real life'? And, more to the point, we want people to imagine and generate new alternatives to the personal and cultural narratives that they are currently trapped in. We give them an imagined community in which to see those new ideas and ways of being played out."

Entertainment-education for social change is a genre Galavotti has long believed in. Her interest in narrative and literature stretch back to her days at Amherst, where she was an English major and shared her poetry with William Pritchard, the college's Henry Clay Folger Professor of English. A self-conscious flush colors her face briefly as she talks about this creative work she no longer has time for. Literary work, however, was never the profession she aimed for, and after working in a group foster home for teenage black boys in Chicago she felt a strong pull toward psychology. "I had taken quite a few psychology classes," she says, "and I knew I wasn't interested in clinical psychology or psychopathology. But I was interested in social action and using psychology to change things."

First a Hampshire College student, Galavotti transferred to Amherst in 1976 after realizing she was too young for the lack of structure at the new, experimental institution. During her Amherst years she was one of few female students. This never bothered her; she was in the first class of women at her previously all-male high school—15 out of 250—Wilbraham & Monson Academy in Wilbraham, Mass. The gender minority was nothing new. "I liked that environment," she says.

Yet in her work Galavotti is sensitive to gender disparities and divergent experiences. She speaks with a touch of awe about a 16-year-old Muslim woman who has taken on the role of health educator in her community. Galavotti watched as the teenager demonstrated how to use a condom in front a group of her peers, nearly all men. The scientist was astonished. "In that setting, to have the courage to do this. . . ." She pauses, her brown eyes opening wide.

Not long after the new year, Galavotti conducted site visits in Malawi, Zimbabwe and Botswana. She was able to hear Makgabenang on the air in Botswana, "to observe a recording session, sit in on a rehearsal, meet with the scriptwriting team." The serial drama production now has its own routine and momentum. "I know it's trite," she adds, "but it really is a dream come true."

The strain of travel and extended days at the office—where Petraglia says he calls first, even on the weekends, to find his team leader—is definitely wearing. "It's getting a little bit more sane," Galavotti says toward the end of the afternoon. A pause, then: "I'm lying."

There seems to be no slowdown in the near future. AIDS continues to ravage families and communities. The serial dramas—a very real hope with fictional roots—have just begun.