A norms-based approach for HIV prevention in a high HIV-prevalence country: Experience from the Malawi bridge II project

Effective risk communication incorporates not only individual-level risk perceptions but also societal-level normative beliefs. This model informed the BRIDGE 2 intervention for HIV/AIDS prevention in Malawi. Two behaviors of concern to the project were HIV testing and condom use. We evaluated the extent to which exposure to the campaign resulted in improvements in descriptive norms (people's beliefs about the prevalence of a behavior) and injunctive norms (pressures to comply) and asked whether those improvements resulted in behavior change. Household-level data come from two sources: a longitudinal (N=678), and a two-wave cross-sectional (N=1,812 and 1,338 at baseline and midterm, respectively) data, stratified by low-, medium-, and high-intervention communities over two years in 11 districts. Changes in HIV testing descriptive norms, t=3.93, p<.001 (but not injunctive), and changes in condom use injunctive norms, t = 4.11, p < .001 (but not descriptive), improved significantly at midterm from baseline. In the cross-sectional data, both descriptive (t=4.72, p<.001) and injunctive (t=2.88, p<.01) testing norms improved, but condom use injunctive norms declined (t= 3.41, p<.001). Longitudinally, change in descriptive norms, exposure to the campaign, and interpersonal communication were associated with change in HIV testing. Change in injunctive norms, exposure to the campaign, and interpersonal communication were associated with change in condom use. Patterns were similar for cross-sectional data. Social norms play an integral role in promoting and sustaining HIV prevention behaviors and health interventions need to understand how characteristics of particular behaviors make them more or less susceptible to normative influences.