Introduction

Since the discovery of the HIV virus and its consequent pandemic, its transmission in Africa has been consistently reported to be heterosexual, followed by use of reusable needles and blood products and recently injecting drug use in some countries such as South Africa, Kenya, and Nigeria (UNAIDS 2010a). In the western countries, HIV epidemiology has been mainly centered on Men who have Sex with Men (MSM), heterosexuals, and injection drug users (UNAIDS 2010a). Similar patterns have also been observed in the Caribbean which has a population similar to the population of sub Saharan Africa but with different epidemiology. The Caribbean recognizes MSM population and reports on how HIV has affected it (UNAIDS 2010a).

Even though there have been official denials of homosexuality in most of Africa, homosexual behavior among men have been documented on the continent: common but practiced in secrecy in Sudan (Ahmed and Kheir 1992), among the Kikuyu in Kenya, the Hausa in Nigeria and mine workers from a variety of groups in South Africa (Standing and Kiskeka 1989), among prisoners in Zambia and Nigeria and among the Wolof community in Senegal (Niang et al. 2003). In the Ghanaian context, traditionally there are terminologies for homosexuality. Among the ethnic Akan it was known as “odi trumu” (having anal sex among men) and the Ewes referred to it as “egbi mola” (someone who engages in anal sex) or “nutsu do nutsu gbo” (a man who has sex with a man) but the practice was criminalized under British colonial rule.

There have been suggestions that homosexuality is underreported because of the high stigma associated with it in most African societies (National Research Council 1996) and most officials have denied its existence (Parker et al. 1998). As a result, HIV/AIDS studies and prevention measures have primarily been centered on heterosexuals, and commercial sex workers hence limited studies on MSM in the continent. Foreman (1999) contends that each society has about 5–10% of its population engaging in same sex relations. If this holds true, then even with a conservative estimate of 1%, about 6.8 million of Africa’s population could have same sex tendencies. With stigma, discrimination and criminalization, if this number is not included in specific HIV interventions designed for this sub population, there is bound to be potential problems.

The purpose of this paper is to discuss (1) the long ignored existence of MSM in the African continent despite its denial, (2) homophobia and its possible impact on the epidemiology of HIV infection drawing from the literature on HIV epidemiology worldwide, (3) official harassment and proscription of MSM and associated penalties and their impact on stigma and HIV prevention, (4) how entertainment education (EE) has been successfully used to address social issues, and (5) how EE can be implemented in sub Saharan Africa to reduce stigma against MSM including how to evaluate its the impact.

The Epidemiology of HIV in MSM Worldwide Including Sub Saharan Africa

Since the beginning of the HIV/AIDS epidemic, irrespective of sexual orientation, more than 60 million people have been infected with about 30 million dying from HIV-related illness worldwide (UNAIDS 2010b).

In North America and Western Europe the epidemic is prevalent among MSM and more men are living with HIV than women (UNAIDS 2010c). In 2009, women accounted for about 26% of people living with HIV in North America and 29% in Western and Central Europe. Thus unprotected sex between men is the major mode of transmission in North America, Western and Central Europe (UNAIDS 2010c). According to UNAIDS, data from 23 European countries show that annual number of HIV diagnoses among MSM rose by 86% between 2000 and 2006. The high infectivity rate among MSM for example is manifested in France where MSM represent only 1.6% of the general population, yet they account for more than 50% of new HIV infections among men (UNAIDS 2010c). In the United States of America, new HIV infections resulting from unprotected sex between men increased by more than 50% between 1991–1993 and 2003–2006 (UNAIDS 2010c). Also, there exists a health disparity in HIV infection in US and Canada among ethnic minorities. For example, even though African Americans represented 12% of the population in the United States they accounted for 45% of people newly infected with HIV in 2006. In Canada in the mid-2000s, aboriginal people represented 3.8% of the national population but 13% of people newly infected with HIV annually (UNAIDS 2010c).

In Oceania, Papua New Guinea’s 0.9% prevalence made it the region’s largest HIV epidemic where unprotected intercourse is the main mode of transmission between heterosexual men and women (UNAIDS 2010d). However, the epidemics of Australia, New Zealand and smaller Pacific countries center on unprotected sex in MSM population (UNAIDS 2010d). Injecting drug use, even though small, is a significant factor in HIV transmission and accounts for 22% of HIV infections among Aboriginal and Torres Strait Islander people (UNAIDS 2010d).

Unreliability of data, according to UNAIDS, makes it difficult to track trends with confidence in the Middle East and in North Africa. Iran’s epidemic is centered largely among injecting drug users and it was estimated that 14% of this population was living with HIV in 2007. It is estimated that 6 and 8–9% of MSM live with HIV in Egypt and Sudan, respectively (UNAIDS 2010e).

In Eastern Europe and Central Asia, the Russian Federation and Ukraine together account for nearly 90% of newly reported HIV infections in Eastern Europe and Central Asia. The epidemic is mostly high in Injection Drug Users (IDUs), commercial sex workers and to some extent among MSM (UNAIDS 2010f).

The HIV epidemic has been said to be stable in Central and South America where 1/3 of all HIV-positive people in the region live in Brazil (UNAIDS 2010g). Sex between men is the driving force of the epidemic in the region and most of the HIV epidemics in Central and South America are concentrated in and around networks of MSM (UNAIDS 2010g). For example, among MSM attending public health clinics in Lima, Peru, HIV incidence was 3.5%. According to UNAIDS, in five Central American countries, the annual HIV incidence among MSM was about 5.1% with other surveys showing a prevalence of at least 10% in 12 countries in the region (UNAIDS 2010g).

Similar to other regions where prevalence is very high in some countries and low in others, Cuba’s HIV prevalence is very low at 0.1% compared to Bahamas’ adult prevalence of 3.1% (UNAIDS 2010h). Heterosexual sex work among female sex workers is very high and is thought to be the main mode of transmission, followed by MSM activities and injection drug use. With regard to MSM, 1 in 5 surveyed in Trinidad and Tobago was living with HIV, and 20% reported they regularly had sex with women (UNAIDS 2010h). In Jamaica, an estimated 32% of men who have sex with men are living with HIV (UNAIDS 2010h).

According to UNAIDS, Asia’s HIV epidemics remain largely concentrated among IDUs, MSM and sex workers. About 16% of IDUs are infected and with estimates of 30–50% in Thailand and 32–58% in Viet Nam (UNAIDS 2010i). Among MSM, it has been reported that 29% in Myanmar, 5% in Indonesia, and between 7 and 18% in parts of southern India are infected (UNAIDS 2010i).

In Sub-Saharan Africa the epidemic continues to wreck havoc and the region bears a disproportionate share of the global HIV burden. The epidemic has been devastating in sub Saharan Africa where an estimated 22.5 million people were living with HIV in 2009 (UNAIDS 2010j). The proportion represents 68% of the global HIV burden. About 34% of all people living with HIV resided in the 10 countries of southern Africa in 2009 (Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe). Most of the people were infected through unprotected heterosexual intercourse and onward transmission of HIV from mothers to infants (UNAIDS 2010j). Of late injection drug use as well as sex between men have been reported as risk groups with high levels of HIV infection (UNAIDS 2010j). Injection drug use is the main mode of HIV transmission in Mauritius and an important factor in the HIV epidemics of several countries in the region, including Kenya, Zanzibar and Tanzania. In Cape Town, South Africa, and Mombasa, Kenya, more than 40% of the adult population of MSM is living with HIV (UNAIDS 2010j).

From the foregoing, it becomes apparent that HIV affects more MSM than the general population. However, this information is provided in continents where MSM is legal or MSM sexual orientation is recognized. In sub Saharan Africa, almost three decades into the pandemic, little is known about how HIV might have disproportionately affected Africa’s MSM. This is because public health authorities have long believed that almost all cases of AIDS in African adults are attributable to heterosexual transmission but recently, published anthropological reports document the long and diverse history of homosexuality in Africa (Niang et al. 2003). It showed that MSM exist in all parts of Africa and suggested that they could be a population that is significantly vulnerable to HIV/AIDS and sexually transmitted infections (Wade et al. 2005). In spite of this, there is limited data, if any on the impact of the epidemic on MSM as a sub population in sub Saharan Africa. Homophobia has been suggested by some researchers as one of the key forces driving the epidemic in Africa, because stigma and discrimination may be making MSM a hard-to-reach group for prevention and early treatment services. Interventions in this sub population have been neglected because of the criminalization of MSM and discrimination towards them (Niang et al. 2003).

In many parts of the world HIV prevalence among MSM is more than 20 times higher than in the general population (UNAIDS 2009a). This could be due to vulnerability and lack of sexual health because of the legal, cultural and religious environment the MSM found themselves in (UNAIDS 2009a). A UNAIDS report of 2005 estimated that HIV seroprevalence rates for MSM in Africa were higher than in the regions of Latin America, Asia, Eastern and Central Europe who have programs targeted at MSM with resources from their national coffers as well as donors (Johnson 2007). The International AIDS Alliance reported that HIV prevalence in the Middle East and North Africa is under 0.2% for the general population but much higher among homosexuals (Wakabi 2007). It’s been reported that MSM in sub-Saharan Africa are nearly four times more likely to be infected with HIV than the general population (Baral et al. 2007). According to Smith et al. (2009) there is high level of HIV infection among MSM in sub Saharan Africa. In addition, up to 20% of new HIV infections in Senegal and 15% each in Kenya and Rwanda were associated with unprotected sex between men (Lowndes et al. 2008; Gelmon et al. 2009; Asiimwe et al. 2009). Wakabi (2007) earlier reported that a research conducted by the Population Council in Kenya’s city of Mombasa, among 425 male sex workers showed that of the 58% who reported using a condom during anal sex only 36% reported consistent condom use. Thus these male sex workers are increasing their risk of acquiring HIV or if already sero-positive they are exposing their clients to the risk of being infected with HIV. According to Griensven (2007), about 21.5% of the 4,442 MSM in Dakar and 9.3% among 713 MSM in Sudan were HIV positive. HIV prevention services reach only one tenth to one-third of people who engage in male homosexual activity and less than 1 in 20 MSM get HIV care and services they need (UNAIDS 2009a).

Legalized MSM Activities

In a document entitled “State-sponsored homophobia, A world survey of laws prohibiting same sex activity between consenting adults” authored by Ottosson (2010) of the International Lesbian and Gay Association, there are details country by country of prohibition of legalization or prohibition of same sex activity throughout the world. Worldwide there are 8 countries that have no official discrimination towards MSM, which includes marriage and adoption (Argentina, Belgium, Iceland, Netherlands, Norway, Sweden, South Africa, and Spain). Apart from marriage and adoption, MSM activity is legal in many countries, however. It is legal in all countries in North America (Bermuda 1994, Canada 1969, Mexico 1872 and United States 2003) and Australasia (New Zealand 1986, Australia 1994) and all of Europe (Ottosson 2010).

In Central America MSM is legal in countries as diverse as Costa Rica (1971), El Salvador, Guatemala, Honduras (1899), Nicaragua (2008), Panama, Bahamas (1991), Anguilla (2000), Cuba (1979), Aruba, Puerto Rico (2003), Haiti (1986), Martinique and Guadeloupe since 1791 and US Virgin Islands (1984). Even though some countries banned MSM activity, same sex female relationships are legal in countries such as Grenada, Jamaica, Saint Kitts and Nevis, Saint Lucia, and Belize (Ottosson 2010).

All the 25 countries in South America allow same sex relationships except Guyana, which only allows female-female. Same sex relationships have been legal since 1791 in French Guiana through Peru (1836), Paraguay (1880) and Chile’s (1999) (Ottosson 2010).

In western and Central Asia, it is mostly illegal except in Kazakhstan, Kyrgyzstan, Tajikistan (since 1998), Israel, Jordan, Iraq and the Palestinian territory of the West Bank. In South Asia, legalization is found in India, Nepal, China (1997), Taiwan, Hong Kong, Japan, Mongolia, Macau and South Korea. MSM activity is legal in 6 countries in Southeast Asia: Cambodia; East Timor; Indonesia (except for Muslims living in Aceh Province); Laos; Philippines; Thailand and Vietnam (Ottosson 2010).

Proscription of Homosexuality

Same sex relations are criminalized in 79 countries and six apply the death penalty (UNAIDS 2010k). Of the 79 countries that proscribe male same-sex acts, there are 36 in Africa, 11 in Latin America and the Caribbean, 8 in Oceania, and 23 in Asia. Table 1 denotes worldwide, countries that have laws against same sex acts between males. Even though most countries have laws against male homosexuality they do not criminalize same sex acts between women (Ottosson 2010).

Table 1 Worldwide penalties against same sex relationships between males
Full size table

Worldwide 46% of countries that criminalize sex between men are in Africa. Still, only 6 countries (Gabon, Sao Tome and Principe, Mauritius, Central Africa Republic, Cape Verde, and Guinea Bissau) from the continent signed the December 2008 UN Assembly declaration to decriminalize homosexuality. Some of these criminalization dates back to colonial times. For example, in the Portuguese colonial countries (Mozambique, Sao Tome, and Angola) the law was passed in 1886 against same sex acts and amended in 1954 with a penalty of being sent to labor camps (Ottosson 2010).

According to Ehlers et al. (2001) Botswana Penal Code 1964 Chapter 08:01, Section 164 as amended by Penal Code 1998; Section 21 stipulates that engagement in same sex act is punishable by a term not to exceed 7 years. Also, under the Senegalese Criminal Code, (UNAIDS 2007) homosexual acts are punishable by 5 years imprisonment and a fine of 100,000–1,500,000 CFA francs (between 150 and 2,300 Euros). Under Ghanaian law, male homosexual activity is officially illegal. The Ghanaian Criminal Code of 1960, Act 29, Chapter 6, Sexual Offences, Article 105 as amended in 2003 states: “Whoever is guilty of unnatural carnal knowledge—(a) of any person without his consent, is guilty of first degree felony; (b) of any person with his consent, or of any animal, is guilty of a misdemeanor” with a penalty of 5 years imprisonment and not more than 25 years.

In South Africa, the African National Congress (ANC) government ensured that the post apartheid constitution explicitly prohibited discrimination against sexual orientation and the ANC government consequently repealed the anti gay laws which were passed during apartheid. South Africa became the first country in the world to protect the rights of homosexuals in its constitution (Croucher 2002; Massoud 2003). Even though MSM activity and gay marriage is legal in South Africa, homosexuality has been condemned on cultural and religious grounds. In the early days in South Africa, similar to other African countries, there were concerted efforts to characterize homosexuality as alien or nonexistent, and among blacks, the discourse characterized homosexuality as a Western colonial import, foreign in all respects to indigenous culture in black and Afrikaner societies (Croucher 2002; Gevisser 1995). A similar discussion existed among Afrikaners who considered homosexuality as foreign too, and inconsistent with true Afrikaner identity, and that wealthy Jewish and English men were rather corrupting Afrikaner boys (Croucher 2002; Gevisser 1995).

Apart from legal sanctions or codified laws there have been official harassments of MSM in sub Saharan Africa. In Cameroon, Zimbabwe, Uganda and Nigeria, actions have been taken against same sex couples. In Cameroon, 11 men were jailed on sodomy charges (Anonymous 2006) and Zimbabwe’s President Robert Mugabe said homosexuals were “worse than dogs and pigs” and should have no rights at all (Wetherell 1995 as cited in Croucher 2002). In Uganda, the President justified discrimination against gays and lesbians by the fact that their actions are “against the order of nature” (Anonymous 2006). In Nigeria, the army fired 10 soldiers for engaging in sexual acts with other men (Anonymous 2006). Namibia’s first President Sam Nujoma described MSM as “foreign influence with corrupt ideology” bent on exploiting Namibia’s democracy (Shigwedha 1997 as cited in Croucher 2002). In 2006 the Chairman for Commission for Human Rights and Administrative Justice in Ghana ruled out any possibility of his outfit advocating for gay rights on the grounds that homosexuality was frowned upon in Ghana (Chronicle 2003a).

A news item report of February 12, 2010 in the New York Times gave an account of Kenyan police officers breaking up a gay wedding and arresting many wedding guests. The police reported that they had to intervene else the irate mob would stone the wedding couple to death (Gentleman 2010). A spokesman for the Kenyan police, Eric Kiraithe, when he was asked to explain the deep seated feelings regarding homosexuality, according to the New York Times, said “It’s culture, just culture. It’s what you are taught when you are young and what you hear in church. Homosexuality is unnatural. It’s wrong.” The spokesman further explained that there was a shroud of secrecy surrounding the wedding between the two men but some local residents in the beach town along Kenya’s coast, Kikambala, the venue, found out. It quickly resulted into the formation of a mob with some outraged bystanders even shouting that the people at the wedding should be burned (Gentleman 2010).

In addition, a report authored by Cary Alan Johnson (2007), an Africa specialist at the International Gay and Lesbian Human Rights Commission (IGLHC), chronicles the rise of violent crimes against gays and lesbians in Africa. A report issued by IGLHC entitled “Off the Map” reports that there is denial of the existence of MSM in the continent as well as widespread arrest, extortion, violence, threats and instances of forcible anal examination of MSM suspected people. Other actions mentioned which might be inimical to MSM include exclusion of HIV programming for same-sex practicing persons, denial of access to HIV information, education and communication to same-sex practicing people, the unwillingness of African research review panels to approve research on homosexuality, and the same sex practice individuals being hesitant to expose themselves to researchers who may be judgmental of them. The IGLHC cited many instances of arrest and detention of MSM in Eastern and Southern African countries. Further details can be found on the IGLHC web site and the report “Off the Map” (Johnson 2007).

Religion and Homophobia

Rees (2009), wondered whether religion makes people homophobic, or whether religion attracts people who are conservative and/or authoritarian—people who also tend to be homophobic? He argued that religion acts to strengthen group cohesion, and it also comes with a lot of moral rules. Either of these could explain the link of religion to homophobia, he stated (Rees 2009). A 2007 Baylor university study of 1,500 adults in USA concluded that religious people were more likely to be homophobic (Rowatt et al. 2009). Religion was found to be one of the strongest predictors of attitudes towards homosexuals. Further, it also turned out that more religious people were more likely to be authoritarian, conservative, poorer, and protestant and all these factors also predicted homophobia (Rees 2009). Women were also more likely to be religious, but less likely than men to be homophobic. An authoritarian conservative is even more likely to be homophobic if they were also religious. Women were more likely to be homophobic if they were religious compared to other women who were not religious. Among all the possible factors the authors explored (religiosity, conservatism, gender, right-wing authoritarianism, education, age, SES, and race) two were prominent as predictors of homophobia than the rest: conservatism and religiosity (Rowatt et al. 2009).

Whitley (2009) in a meta analysis of 61 studies reported an association between fundamentalism, Christian orthodoxy, and homophobia. However, extrinsic orientation (the extent to which people use religion as a means to achieve nonreligious goals) and quest orientation (operationalized as people who score highly on the view of religion as a search for answers to questions about the meaning of life) had no effect on homophobia. Thus the rabble-rousing, church-going aspects of religion are the ones chiefly responsible for homophobia which are counterbalanced to some degree by the less vociferous and introspective components of religion (Rees 2009).

Similar observations have been reported in the media in some sub Saharan countries about religion and homophobia. When in 2003 the United States American Episcopal Diocese consecrated to office an openly gay Bishop, Gene Robinson, in New Hampshire, the Joint Anglican Diocesan Council of Ghana issued a press release saying it was vehemently opposed to any form of unnatural, carnal behavior, including homosexuality, lesbianism and same sex marriage (Chronicle 2003b). In the communiqué signed by The Most Rev. Justice O. Akrofi, the Bishop of Accra who is also the Archbishop-elect of the Province of West Africa, prayed and called on the Holy Spirit to guide the Anglican Communion to come out with a solution to what it termed “these unacceptable acts and behavior” (Chronicle 2003b).

Similar sentiments were echoed by the Head of the Anglican Church in Nigeria, Archbishop Peter Akinola who said “Anglican Orthodox members of this church are poised to do the mission of the church; and those who say that gay is their concern, woe unto them.” Another quote years later attributed to Archbishop Peter Akinola of the Church of Nigeria stated: “It (homosexuality) cannot be supported by the scripture. It is against reason” (Anonymous 2006).

Furthermore, in Ghana, in 2006 homophobic comments were made by religious leaders when a news item reported about an alleged international conference of homosexuals scheduled in Ghana. There is no study among the rank and file of the religious laity to gauge their views to determine whether they subscribed to homophobic views as expressed by their leaders. The government of Ghana issued a statement banning the purported conference. The National Association of Charismatic and Christian Churches (NACC) consequently congratulated the Government on banning the conference, saying it reflected the voice of the vast number of people in Ghana (Ghana News Agency 2006a). A statement in Accra signed by the Reverend Steve Mensah, Chairman of NACC, said it viewed homosexuality and lesbianism as a social vice that clearly contravenes Ghana’s Constitution and an affront to the moral and cultural values of Ghanaians (Ghana News Agency 2006a). The statement condemned homosexuality and lesbianism as sexual perversions that should not be tolerated. It went further on to say that NACC sympathized with persons, who had found themselves enslaved by this unnatural sexual desire and quoted the Scripture in Romans Chapter One which states God’s displeasure of same sex marriages and practice (Ghana News Agency 2006a).

In Ghana, it is not only the utterances of the Christian faith leaders that can be described as homophobic. The National Chief Imam in Ghana, Sheikh Osman Nuhu Sharubutu, in a September 6th news report, also congratulated the Ghana government for turning down the application for gays and lesbians to hold an international conference in Ghana (Ghana News Agency 2006b). The statement called on religious bodies in Ghana to support the government on its ban because of morality and the spiritual values of Ghanaians and to forestall calamities and curses. The statement further drew attention to both the Koran and the Bible on their abhorrence of what it called immoral tendencies and called on all Imams and the clergy to fight what it termed an alien practice in Africa (Ghana News Agency 2006b).

Furthermore, the Christian Council of Ghana, which is the umbrella organization of many Christian denominations in Ghana, at a press conference of September 4th 2006, condemned the activities and operations of gays and lesbians in Ghana (Chronicle 2006). Right Reverend Dr. Paul Fynn, Chairman of the council, castigated gays and lesbians and condemned without reservations the formation of “such an association in our beautiful and peaceful country” (Chronicle 2006).

The Global Evangelical Church of Ghana in a communiqué it issued after its Synod in August 2010 appealed to the Ghana government not to succumb to pressure by some individuals and groups to consider homosexuality as human rights. The release further added that homosexuality is inimical to the moral and spiritual health of Ghanaians and was not only an abomination before God but also a threat to the moral and spiritual foundation of the society (Ghana News Agency 2010).

Consequences of Proscription and Non Recognition of MSM

Due to official harassments, arrest, detention, or religious homophobia, most MSM keep their sexual life secret. The secret of being MSM is even kept from their own family (Wade et al. 2005). Lack of recognition of same sex relationship is a paramount issue in the discourse related to HIV propagation among MSM for the following reasons (1) Some of the MSM can be bisexual or sleep with women to hide their MSM identity because of the stigma associated with being an MSM. According to “Horizons” publication, 88% of MSM in Dakar (Senegal) and 69% in Kenya had reported having sexual relations with a woman at least once in their lives (Johnson 2007). In Senegal, four out of five (82%) of the surveyed men who have sex with men said that they also have sex with women (Ndiaye et al. 2009a, b) and in Malawi, 1/3 of MSM were married or cohabiting with a woman (Beyrer et al. 2010). (2) A Ghanaian news item of December 6th 2006 reported that 62% of “Ghanaian gays indulge in heterosexual activities” with their wives and girlfriends (Ghana News Agency 2006c). Also, studies conducted in Botswana, Malawi, and Namibia found that 34% of MSM were married to women, and a total of 54% reported having sex with both men and women in the previous 6 months (Baral et al. 2009). (3) Studies conducted in USA also observe similar patterns. Women were infected by bisexual men (Satcher et al. 2007), and some men who are bisexual and have HIV do not disclose their seropositivity and their sexual orientation to female partners (Montgomery et al. 2003; Kennamer et al. 2000).

According to Johnson (2007), as a group discriminated against, there are no official programs targeting MSM and they are unable to access services unlike their heterosexual counterparts. The lack of response could be attributed to homophobic stigma and denial and non inclusion of MSM in programmatic efforts to give them access to programs and services. The MSM could not advocate for services or insist on equal rights since they are largely unorganized and have not yet developed organizational acumen backed with financial resources. Consequently, the African lesbian, gay, bisexual and transgender communities were dying just like it happened to their counterparts in the 1980s in North American cities like New York, San Francisco and other European cities (Johnson 2007).

It is not only that the official harassments, stigma, and discrimination against MSM impact on their HIV risk acquisition but it also affects their mental health. It’s been shown that institutional discrimination towards lesbian, gay, and bisexual (LGB) population could impact on the mental health of these individuals. Hatzenbuehler et al. (2010) found in a longitudinal study design that policies that deny LGB individuals rights such as marriage may have deleterious effects on mental health of LGB who live in those states. This is because unlike policies that did not extend protection to LGB individuals, deprivation of certain rights and consequent heated public discourse may lead to stress that negatively impacts on their mental health (Hatzenbuehler et al. 2010). This finding confirms an earlier study which found that in the USA, states passing anti gay marriage amendments had LGB individuals with higher psychological distress than their counterparts living in states which did not (Rostosky et al. 2009).

Limited Studies on MSM in Africa

The majority of the studies on MSM in Africa were conducted in South Africa where homosexuality is legalized (Lane et al. 2006, 2008a, b, 2009; Butler and Astbury 2008; Parry et al. 2008; Sandfort et al. 2008) and in other Southern African countries such as Zambia (Zulu et al. 2006) and Botswana (Ehlers et al. 2001; Ravesi et al. 2006). Others include Eastern Africa: Kenya (Skovdal et al. 2006; Geibel et al. 2007; Sanders et al. 2007; Sharma et al. 2008); Malawi (Ntata et al. 2008); Tanzania (Dahoma et al. 2011); and Uganda (Kajubi et al. 2008). However, in Western Africa there is paucity of data and scant research on MSM: Ghana (Sallar 2009; Porter et al. 2006); Nigeria (Allman et al. 2007); and Senegal (Niang et al. 2003; Tapsoba et al. 2006).

Recent Judicial and Legislative Actions Towards MSM

Recently there have been movements in other continents to repeal laws against same sex acts. In July 2009, the Delhi High Court in India annulled a 150-year-old law criminalizing “carnal intercourse against the order of nature,” commonly known as Section 377 of the Indian Penal Code. The court ruled that Section 377 of Indian Penal Code violated Articles 14, 15, 19 and 21 of the Indian Constitution and said consensual sexual acts of adults in private should not be criminalized (UNAIDS 2009b). In the United States different states have also begun to allow MSM to be married or have civil unions. In May 2008 California’s state Supreme Court ruled in favor of gay marriage. The ruling made it possible for 18,000 gay and lesbian couples to get married in the state. However 6 months later California voters approved Proposition 8, which amended the state constitution to ban gay marriage (CNN 2009; Cloete et al. 2008; Kovac 2002). The voter approved ban was upheld by the state’s highest court. The court however allowed the 18,000 marriages performed before the approval of Proposition 8 to remain valid (CNN 2009). In 2009 lawmakers voted in favor of same-sex marriage in New Hampshire and Maine leaving Rhode Island as the only other New England state without legislation in favor of the measure. Earlier, other states in New England like Vermont, Connecticut and Massachusetts, have all passed laws approving same sex-marriages (CNN 2009). Issues of fairness, equal protection under the law, and the contention that a civil union is not equal to civil marriage are some of the reasons proponents adduce to support same sex marriage. Prior to the passage of the New Hampshire law, Iowa was the only other state that allowed same-sex marriages, after the Iowa state Supreme Court ruled unanimously on April 3 that it was illegal to discriminate against same-sex couples by denying them the right to marry thereby ushering the first gay marriages in the state (CNN 2009).

In spite of the above legislative and judicial moves in other nations criminalization of same-sex acts remains on the books of countries in sub Saharan Africa. Nevertheless, there have been news reports in the Ghanaian media about increased MSM activity in bars and club houses suggesting that the legislative and judicial sanctions may hardly impact on sexual orientation or behavior. A news item entitled “Adabraka, Tesano, Paloma and Osu-hotspots” reported gay sex selling as a lucrative but illegal activity gaining ground in Ghana and fees are charged based on whether oral sex or anal sex or both is practiced (Gye Nyame Concord 2007). Other newspaper reports headlined the following and talked about: “Sodomy cases rise in prisons” (Ghanaian Observer 2008); “Students dismissed for homosexuality” (Ghana News Agency 2005); “Research showed homosexuality is real in Ghana” (Ghanaian Times 2006); “Stiff Opposition for Gays, Lesbians in Takoradi” (Accra Daily 2006); “Anglican Church Opposed to any Form of Unnatural Carnal Behavior” (Chronicle 2003b); “Sixty-Two percent of Ghanaian Gays indulge in heterosexual activities” (Ghana News Agency 2006c); and “British sodomite to be deported” (Daily Graphic 2007).

It is not likely that the prejudice against MSM would abate soon in the sub continent as shown by the comments of some prominent citizens as well as the reports cited by IGLHC’s Johnson (2007). A study conducted in Ghana (Sallar 2009) among members of parliament on the issue of whether homosexuality should be tolerated elicited an overwhelming response of “no” (98.4%). The reasons given for opposing homosexuality were morality, religion, procreation, alien culture etc. The respondents were of the view that homosexuality is against African culture and religion and “it is a taboo and does not meet any of our time-tested values”. Further, they contended that it is an abomination, unnatural and against their tradition, customs, norms, and values. They added that “homosexuality is morally very very wrong, because it does not conform to natural laws of procreation”. Some respondents questioned whether the MSM in Ghana were really MSM since homosexuality does not look like a natural occurrence in Africa and wondered whether the MSM in Ghana were not motivated by money when they sleep with other men who paid them for their services. Moreover, health concerns were raised that tolerating homosexuality had high odds of increasing HIV prevalence since homosexuality increases the risk of HIV acquisition. Other viewpoints expressed were that homosexuality was immoral and its tolerance would corrupt the young in the society.

Towards Reduction of Stigma

As stated earlier, in some countries there have been movements to decriminalize same sex acts. However in sub Saharan Africa, addressing the legal and policy barriers may be a formidable challenge in the short run as evidenced in the literature. HIV/AIDS related stigmatization remains one of the greatest impediments to the fight against the HIV/AIDS epidemic and is mostly related to negative thoughts surrounding homosexuality especially in Africa (Brooks et al. 2005). Stigmatization which according to the UNAIDS is a social process of devaluation that reinforces negative thoughts about persons living with HIV/AIDS, often results in acts of prejudice towards such persons (Brooks et al. 2005). Stigmatization can create significant barrier to HIV testing, restrict utilization of prevention programs and hinder the adoption of preventive behaviors such as condom use and disclosure of HIV status to sexual partners (Brooks et al. 2005). In addition, it can hinder utilization of health care facilities by HIV positive individuals as well as negatively impact the quality of health care provided to them (Brooks et al. 2005). According to UNAIDS, more than 90% of governments reported that they address stigma and discrimination in their countries’ HIV programmes, but less than ½ costed or budgeted for them (UNAIDS 2010k). From the foregoing, it is apparent that there is need to catalyze awareness among the different stake holders of the public health system in African countries and develop non stigmatization interventions in order to prevent HIV/AIDS related contaminations (Niang et al. 2003).

Such interventions have to be elaborated and implemented with the collaboration of the local governments, donors, local and international NGOs in order to encourage populations to adopt non stigmatization behaviors and to improve HIV prevention interventions in Africa. Such behavior change interventions can be effectively promoted through entertainment education (EE).

EE is “the process of purposely designing and implementing a media message to both entertain and educate, in order to increase audience members’ knowledge about an educational issue, create favorable attitudes, shift social norms, and change overt behavior (Singhal and Rogers 1999). In effect, EE is a communication strategy which brings about behavior and social change. EE has played a key role for social change in empowering people to adopt appropriate behaviors for successful socio-economic, political, educational and developmental goals in developed and in developing countries (Singhal and Rogers 1999). Unlike early communication strategies EE is inspired by several theories which assure the efficacy of EE based projects (Sood et al. 2004).

Theories Behind Entertainment Education

EE is mainly inspired by the Social Cognitive Theory (SCT) (previously Social Learning Theory) which explains how people acquire and maintain behavior (Bandura 1977). EE is also influenced by other theories: Persuasion Theory, Theory of Reasoned Action; Health Belief Theory; and Diffusion of Innovation Theory. For SCT, adopting a behavior will depend on the environment, the person and his/her beliefs. This is because the environment provides the models for a behavior and a person has to have knowledge of a behavior before performing it. In addition, the person will have to possess self-efficacy in performing the behavior. Self efficacy is one’s ability to believe that one is capable of doing a desired action. The SCT argues that individuals learn a behavior from those around them by imitating role models or by learning from vicarious experiences or by assessing the benefits and rewards of the adoption of the behavior (Rimer and Glanz 2005). It states that programs should focus on getting the attention of the audience in order to get them involved, and they should stimulate retention by presenting the models in such a way that the audience remembers them when confronted with a decision to adopt a behavior later.

EE is also influenced by the Persuasion Theory which inspires the characteristics and the sources of the messages that are diffused in EE programs in order to make them interesting, relevant and persuasive (Petty and Cacioppo 1981 as cited in De Fossard 1996). In order to be successful and to lead to persuasion, EE Messages have to be appropriate and effective for a particular audience in relation to the language and vocabulary used and should either induce fear or logic and should be credible and attractive (De Fossard 1996).

In addition, EE is also influenced by the Theory of Reasoned Action which states that a person’s behavior is predicted by his or her intentions which are in turn predicted by attitudes towards the behavior and subjective norms (Fishbein and Ajzen 1975 as cited in Sood et al. 2004). While attitudes refer to the beliefs one has about a behavior and on the positive or negative evaluation of such beliefs, subjective norms refer to the beliefs one thinks other significant people might have regarding the same behavior (Sood et al. 2004). The more positive the evaluation of those beliefs is, the more likely a person is to adopt the suggested behavior (Sood et al. 2004).

One can also recognize the presence of the Health Belief Theory in EE. The theory states that the perception of threat as well as the perception of benefits related to adopting a recommended behavior in addition to the barriers impeding that behavior motivate behavior change (Sood et al. 2004). If the perceive benefits surpass the perceived barriers individuals are more likely to adopt the recommended behavior (Sood et al. 2004).

The Diffusion of Innovation is another theory which is embedded in the elaboration of EE programs. It is the process by which an innovation is communicated in a way that forces a mental process through which an individual passes from first knowledge of an innovation to forming an attitude toward the innovation, to a decision to adopt or reject, to implementation of the new idea, and to confirmation of this decision (Sood et al. 2004). Diffusion of innovation refers to ideas or products or social practices perceived as new which go through the process of being spread from one society to another. Based on results from research, Singhal and Rogers (1999) concluded that EE affects the public hierarchically. The audience first acquires knowledge of the new idea which evolves. Then they form a positive attitude towards the idea and move to the adoption and use of the idea (Rimer and Glanz 2005).

Entertainment Education as a Tool for Behavior Change

From the foregoing discussions, it can be stated that “EE is a theory-based communication strategy for purposefully embedding educational and social issues in the creation, production, processing and dissemination process of an entertainment program in order to achieve desired individual, community, institutional, and societal changes among the intended media user populations” (Wang and Singhal 2009, p 272).

Combining entertainment with education can be traced back to story telling in countries where rich oral tradition persists (Singhal and Rogers 1999). For instance, two Indian poems Maharishi Valmiki’s “Ramayana” and Ved Vyas’s “Mahabharata” are examples of storytelling combined with moral commentary which were broadcast as television programs in India and earned record ratings (Bhargava 1987; Bhatia 1988 as cited in Singhal and Rogers 1999). Similarly music, drama and dance have been used in many countries for recreational as well as instructional purposes (Murdock 1980; Parmar 1975; Thomas 1993 as cited in Singhal and Rogers 1999).

EE was first used in radio in 1951 through the radio series “The Archers,” broadcast in Britain. The series carried educational messages about agricultural development (Singhal and Rogers 1999). EE in television was first brought to the public’s attention through the remarkable, though non intentional effect that the Peruvian soap opera, “Simplemente Maria” had on its public when it was aired in 1969 (Singhal and Rogers 1999). The soap opera caused women among audiences members to fight in order to be financially independent or to take adult literacy classes in order to acquire knowledge and liberate themselves just like Maria, the main character in the series (Singhal and Rogers 1999). This remarkable success led Miguel Sabido to create an EE methodology which became the dominant strategy in most EE programs throughout the world today (Singhal and Rogers 1999).

Sabido created his first famous soap opera, “Ven Conmigo” in order to help the government of Mexico encourage young men to take adult literacy classes (Singhal and Rogers 1999). To Sabido, entertainment with its ability to reach people all over the world through technology should be used to improve people’s social lives, protect them from sicknesses such as HIV/AIDS or encourage them to emancipate themselves (Singhal and Rogers 1999).

Inspired by the work of some researchers on social theories and/or on EE such as, Rovigatti, Bentley, Jung and Bandura, Miguel Sabido organized a strategy to effectively use entertainment to educate nations. For him, EE as in soap opera for instance, has to attract the audience first, which is the purpose of drama, then convey educational messages through the display of positive and negative characters from whom the audience can identify itself with, imitate or decide not to support a certain behavior (Singhal and Rogers 1999). For Sabido, EE programs have to find a way of helping people retain the moral lessons that they convey. For that reason, they often use epilogues at the end of each soap opera episode where, a famous national actor summarizes the educational issues, relates them to the people’s daily lives and encourages them to participate by making comments via letters for instance (Singhal and Rogers 1999). Sabido established this strategy to ensure that EE programs promote specific pro-social values, go beyond economical purposes, are morally coherent and have a perfect distinction between negative and positive role models (Singhal and Rogers 1999).

In addition, EE programs have to be realistic and to match the culture and natural setting of the targeted audience. Sabido was able to inspire a lot of EE works throughout the world such as: “Hum Log” (we people) soap opera in India, “Twende Na Wakati” (let’s go with the times) in Tanzania and “Tinka Tinka Sukh” (happiness lies in small things), radio soap operas. He also inspired John Hopkins University’s Population Communication Services (JHU/PCS), to re-invent the EE concept in rock music campaigns, promoting sexual responsibilities among teenagers in Latin America, in the Philippines and in Nigeria.

Examples of Successful EE Programs

There are tangible indications that the use of EE has played a key role in empowering people to adopt appropriate behaviors for successful socio-economical, political, educational and other developmental goals not only in developed but also in developing countries. Several EE programs for social change have been implemented in a number of countries across the globe (Singhal and Rogers 1999). Since the 1980s, Sabido’s entertainment education methodology has been among the best strategies adopted in the world by many individuals and organizations (Singhal and Rogers 1999).

Over the past decades, EE, as a communication strategy has grown rapidly in addressing health-related issues. In 1937, the cartoon character “Popeye” was able to influence young children to consume spinach which was beneficial to their health and it also contributed to saving the spinach growing and selling industry (Tufte 2004). Other EE examples dealt with issues such as blood pressure, smoking, vaccine promotion, and family planning and have been used in HIV/AIDS prevention for the past 15 years. Additionally, EE has been applied in environment, rural development, conflict resolution and peace-building. EE is reproducing at a rapid rate and to date, the EE strategy has spread to projects in at least 75 countries including the United States, Europe, Latin America, Africa and Asia (Singhal and Rogers 1999).

The success of EE had manifested itself to the extent that the US Centers for Disease Control has partnered with Hollywood Health and Society which is located at the University of Southern California’s Norman Lear Center to address health using EE (CDC 2009; Blakley 2001). It provides expert consultation, education and resources for writers and producers who develop scripts with health storylines and information (CDC 2009). Recognizing that at least 4 out of 5 people (88%) in US get health-related information from TV, the CDC saw an opportunity to deliver health messages through daytime TV programs, movies and prime time shows (CDC 2009). The partnership involves Hollywood moguls, academicians, and advocacy groups who share information about the country’s pressing health matters. In recognition of EE success, in 2000 the CDC Office of Communication convened an expert panel which consists of 14 mass communication scholars. They were to develop a research agenda for EE. In May 2003, another panel of experts was charged with developing an EE agenda storylines for Hispanics and African Americans. There is a “Tip Sheet for TV Writers and Producers” which provides reliable information from violence against women, suicide, lead poisoning, hospital infection, bioterrorism, youth health issues, through HIV/AIDS and others (CDC 2009). The tip sheet covers risk groups, typical symptoms, prevention messages, case examples, and a list of other resources which are made available to writers. According to CDC (2009) the Hollywood, Health & Society had more than 130 tip sheets in development covering topics such as skin cancer, sudden infant death syndrome, smallpox, antibiotic resistance, and others. The CDC also developed the CDC Sentinel for Health Award for Daytime Drama in October 1999. The award, which recognizes excellent portrayal of health issues in TV soap operas, has coveted winners such as ABC’s One Life to Live for its exemplary portrayal of breast cancer. Other winners were CBS’s The Young and The Restless (2001 for diabetes), CBS’s The Bold and The Beautiful (2002 for HIV) and CBS’s Young and Restless (2003 for alcoholism). According to CDC (2009), the portrayal of diabetes storyline resulted in letters from viewers who indicated that it was really educational and afforded them the opportunity to appreciate the severity of the disease, recognize early signs and get early diagnosis and treatment (CDC 2009). The HIV storyline also significantly increased the calls from the general public to the AIDS hotline throughout the year after the episodes were aired (CDC 2009).

EE programs offer the audience an opportunity for social learning. In fact, they offer an opportunity for the audience to discuss the socially desirable or undesirable role models and this promotes a social learning environment in which participants consider options for change. Together, the people discuss their issues and ways of confronting them. For instance, it has been shown that “Tinka Tinka Suck”, an Indian radio soap opera which focuses on family planning, equal status of women and family harmony, promoted conversations that initiated a process of social learning for some listeners. It resulted in about 50% of the listeners talking to their spouses about family planning. Evidence from the Indian project suggests that effects occur through the social-psychological processes of social modeling, para-social interaction, and efficacy, which take place particularly when individuals discuss the content of an entertainment-education message through peer communication (Singhal and Rogers 1999).

“Soul City” which is an ongoing EE program in South Africa is one of the most impressive ones. This South African EE based program is an efficient soap opera which was able to impact the behavior of South Africans as regards the issue of gender violence. In fact, thanks to “Soul City”, there was an increase in people’s awareness of the negativity and the dangers of practicing violence towards women and an increase of people’s will to denounce violent acts and gender discrimination (Tufte 2004).

In the HIV/AIDS arena there are two classic examples which address the issue of HIV transmission in heterosexual environment and one in MSM. In 1990, the BBC soap opera, “Eastenders” ran a storyline in which an HIV positive major character was infected by his girlfriend who caught HIV from a previous lover. For the next 12 years the soap opera raised awareness of the condition and educated the audience about misperceptions, and the experience of HIV+ individuals. Similarly, in the American drama movie, “Philadelphia” HIV/AIDS, homosexuality and homophobia were discussed. In the drama, a gay lawyer infected with HIV was fired from his conservative law firm because they were concerned about contracting HIV from him. When he sued the company, he was eventually represented by a homophobic lawyer.

Two breast cancer storylines were aired in the United States in 2005 on two primetime television programs: ER and Grey’s Anatomy (Hether et al. 2008). Both stories discussed the risks that confront women who test positive for breast cancer gene mutation (BRCA1) (Hether et al. 2008). It has been shown that as the result of the stories, several audience members increased their knowledge of the fact that the BRCA gene mutation is a risk for ovarian cancer (Hether et al. 2008).

Several other examples of EE programs worldwide in countries as diverse as South Africa, India, Peru, Tanzania, Brazil, Mexico, and Nicaragua are summarized in Table 2.

Table 2 Successful EE programs, country of origin and airing and synopses
Full size table

Thus entertainment used intentionally to educate people about social issues in the domain of public health, gender discrimination, homosexuality, HIV/AIDS, homophobia, and family planning or for development, gives people an opportunity to observe, aspire to new behaviors, imitate and change. All this is done with the help of self-efficacy, individual perceptions, social interaction between audience and entertainment characters, and identification with characters.

From the foregoing, EE could be used to prevent or address stigma and HIV/AIDS contamination among the MSM community in Africa. In addition, community mobilization should be promoted in order to involve members of the community in increasing awareness about the existence of MSM in their community. Unfortunately when it comes to the African continent, EE has not come around to address stigma or homophobia on any significant scale. In recent times the Nigerian film industry (called Nollywood) has been turning out blockbuster movies which have been distributed in many African countries, Anglophone and Francophone. The industry has conveyed themes of Christianity (good) versus voodoo/ritual (evil), where the former more often than not triumphs over the latter. Underlying these good versus evil themes, Nollywood movies deal with topical issues of corruption, violence, unbridled affluence and arrogance of power in the face of abject poverty and eking subsistence living.

With its mass appeal throughout the continent, and originating from Africa’s most populous nation, the movie industry in Nigeria can play a vital role in EE to tackle hitherto taboo subjects like homosexuality on the African continent just like the western entertainment industry has done. Unfortunately, Nollywood’s dealing with the topic has been described as homophobic according to critics and mostly restricted to lesbianism. According to Azuah (2006), one could wonder if it was just coincidental that the characters involved in lesbian relationships in Nollywood movie flicks had tragic endings. They either stabbed themselves to death (“Emotional Crack”), or when being disinherited and disowned by their parents had to explain their sexual orientation which usually was because the strict parents prevented them from seeing boys, they attended a boarding school for only girls, had a sheltered life, or due to an authoritarian father’s control (“Last Wedding”).

Azuah (2006) further added that in the Nollywood movie, “Beautiful Faces” the main lesbian character Vivida on a college campus had unholy alliance with a cult leader (Nick) whom she slept with despite being a lesbian. Vivida used the protection Nick afforded her to terrorize any female sexual partner she wanted. She had her comeuppance when the cult leader became interested in Natasha, the girl Vivida badly wanted. Vivida was further portrayed as a commercial sex worker, a thief, a leader of a notorious occult gang on the university campus and finally was arrested. She and her lesbian friends were punished by the authorities but the male cult leader went unpunished. Nollywood’s attempt to tackle male homosexuality in “End Times” portrayed a Christian fundamentalist preacher who was homosexual and got his powers from the devil, not God. According to Azuah (2006) there was no description about the experiences of life of the gay man but rather his propensity for deceit and his final downfall.

Issues to Consider in Successfully Implementing E–E to Address MSM Stigma in Sub Saharan Africa

The twenty-first century is considered information age and suggests that people everywhere will have increased access to a great variety of sources of information. The development of technology with satellites that bring TV to remote places, proliferation of internet and computers, and the availability of radio, makes it easy to produce more EE programs through sending messages to people and exposing them to ideas, values and conflicts that challenge their social and cultural norms (Coleman et al. 1997). Thus the environment is apt for EE to be used as an instrument to promote awareness and reduce stigma through the creation of radio and/or television soap operas which will present target audiences with messages of MSM and elicit tolerance and compassion. Such EE could focus on presenting the audience with the benefits that it could achieve by recognizing the existence of MSM in the community and could document ways best suited for preventing further HIV/AIDS contamination.

Before implementation, it is suggested that thematic areas that address HIV/AIDS, HIV infectivity, homosexuality and HIV and others be developed and let the episodes revolve around them. Soap operas are better choices because the audiences are usually loyal, follow the characters, generate general conversation among people, as they get involved emotionally, and cliff hangers after every episode makes the audience to crave for more as they have to wait for the next episode. Television and radio soap operas seem to be relevant tools to address homosexuality and its associated stigma reduction in Africa. Radio and television are mostly used in African countries so EE programs diffused through these media impact on a large proportion of people. Several EE strategies which had a positive impact in Africa were usually soap operas broadcast via television and/or radio. Among such programs there are Soul City, Twende Nawakati, (Let us go with the Times) and Things we do for Love as shown in Table 2. The successes of these and others can be drawn upon in program implementation.

In implementing this EE concept to reduce stigma-related discrimination and its concomitant homophobia, it is important to note that for an EE program to be effective, it has to go beyond the diffusion of information to involving people in order to change the societies. Although it has been shown that educational messages via mass media based entertainment can improve behavior change, it is necessary to remember that it has also been demonstrated that audience participation in the form of listening groups may enhance the impact of these programs (Sood et al. 2004). Thus in planning and implementing these programs, it is imperative to recognize as Sood et al. (2004) explained that it is rare that human behavior change occur only as a result of exposure to prosocial mass media messages. It is therefore likely that radio and television listening and viewing groups provide listeners with a forum to engage in interpersonal communication regarding the health topics they were exposed to (Sood et al. 2004) and in this case MSM issues.

Another critical component in program implementation on MSM issues in sub Saharan Africa will be the importance of involvement of community members in the receiving of the messages. This approach is evidenced by a study in Nepal that suggests that introducing the variable of interpersonal communication cannot only increase knowledge but can also help to change behavior (Lunt 2005). In 2000, radio listening groups in Fulbari, Nepal were first formed and the groups gathered in an open area and listened to a 15 minute radio program. Afterwards they conducted a discussion of the issues raised in the program. One year after the project, survey results showed that men and women in the listening groups were twice as more likely to use contraception than those not in the listening group. Also, they were more likely to share information with their spouse and others. Thus the more involved community members are in the creation and distribution of community messages, the more likely it is that the messages will not only be received well by their audience, but will solve problems that only the community members may be able to perceive. Coupled with participatory listening, the messages can help to influence attitudes and behavior in ways that traditional, large-scale media cannot.

It will be necessary for EE programs addressing homosexuality issues in Africa to facilitate the occurrence of interpersonal communication through the creation of listening and or viewing groups. For instance, audience responses can be solicited by asking listeners or viewers to comment on a particular episode or issue. At the end of each episode, a host can review the educational content of the film and ask for comments or for the answers to quiz questions. Such method has been effectively used in other EE projects such as Hum log in India (Singhal and Rogers 1999). Also, listening groups such as fan clubs could be created and encouraged to undertake discussions over the issues presented in EE programs that were broadcast. This will allow audience members to understand better and encourage them to adopt the desired behavior.

Evaluation of EE Intervention Program

Prior to the introduction of the EE program, baseline data can be obtained through focus groups discussions, in depth interviews, and surveys to measure homophobia and associated stigma in the community. At baseline the survey instrument will elicit demographic information (age, gender, income, residence in terms of rural vs. urban, religious affiliations, highest education level attained, profession, marital status etc.) and HIV knowledge and attitude towards MSM measured on a 5 point Likert scale. The focus group discussions and in depth interviews will inform the evaluation team on information they may not have gathered in the quantitative component of the research at baseline.

Once the EE episodes have started airing, process evaluation will be carried out to determine whether the EE is being implemented as intended. Process measures to be used to monitor and measure progress towards achieving projected results may include how many episodes have been aired, how many summaries and discussions have taken place after airing, or how many small group sessions have taken place. If hot lines or text messaging boards have been set up for people to call in after episodes aired, how many people have called in or sent text messages after episodes aired, and whether the hotlines have been manned during the hours planned. In addition, any barriers that are encountered in the delivery of the EE message will be noted and promptly addressed.

As regards process monitoring, during airing, data will be collected on those who have listened or watched the shows, and determination will be made as to the resources that have been used in delivering the message.

Outcome monitoring may be carried out by individual surveys or as appropriate after EE programs have been aired to measure on a 5 point Likert scale individual’s attitude towards MSM. Indicators from data sources will be used to evaluate the outcome measures such as knowledge of MSM existence, HIV knowledge, attitudes towards MSM etc. derived from the use of a questionnaire. For example, pre-test and post test results will be compared and statistically significant differences will be determined using appropriate statistical test (t tests, chi square tests) to measure changes. Other statistical measures will be multiple logistic regression analysis in order to control for confounding variables that may impact on the outcome measures. This evaluation will answer whether the expected outcomes of using EE to increase tolerance and reduce stigma against MSM have occurred. For example did changes in behavior, utterances that diminish homophobic tendencies and attitudes towards MSM all relating to changes in baseline data occur over time?

With regard to outcome evaluation data will be collected about outcomes such as tolerance of MSM, or stigma before and after the EE intervention for those who listened to the EE-programs as well as with a control group that did not listen or watch the episodes. The question of whether the EE caused the expected outcomes may be answered using the randomized experimental case–control study design. The use of randomization addresses most threat to internal validity since it involves random assignment to experimental and control groups. The people who are watching or listening to the show are in the experimental group and the control group members do not watch or listen. Proliferation of FM stations throughout the continent makes it propitious to have intervention and control groups to deliver the EE message unlike formerly when short wave stations covered a whole country. FM stations and some television stations coverage are not country wide. If television is used to deliver the message individuals inside the broadcast area will be the “cases” and those outside the “controls”. There are two study designs that can be used in this evaluation. The Pretest–Postest Control Group design, coupled with randomization eliminates selection threats and hence allows the evaluation process to rule out alternative explanations of the EE results. Alternatively, the ideal design will be the Solomon Randomized 4 Group Design which combines Pretest–Postest Control group Design and Posttest-Only Control group Design. Even though this design involves large group of participants, it is possible to get the required numbers because the EE program is a community based one and many people are likely to watch. If the broadcast area covers the whole country it is still possible to devise evaluation program using quasi experimental design methods since it has features that rule out many threats to internal validity. In this design, comparison groups can be used which may be similar to the group receiving the EE in terms of demographic variables like age, gender, education, location, and socio economic status.

Conclusion

There is need to promote sexual health in the MSM community in African countries and to create an environment for a user friendly access to health services. Most specifically, interventions should target social and community change rather than just individual behavior change. Such interventions could be guided by communication for social change and most specifically by the use of EE. An EE program offers to the audience examples of behavior that are socially desirable or undesirable through positive and negative role models. Research showed that behavior change occurs as the result of factors which influence individuals in their decision making notably influence from interpersonal communication with opinion leaders and peers (Sood et al. 2004).

In summary, prior studies have supported the relationship between exposure to mass media, interpersonal communication and increases in knowledge and behavior change. EE is a communication strategy which could help create awareness and reduce stigma towards MSM as well as prevent HIV/AIDS contamination. EE programs have a great potential in developing efficient interventions and should be considered by governments and NGOs interested in bettering the situation of MSM living in Africa as well as preserving their health and the health of people around them. However, the intervention messages have to be culturally adjusted in order to allow better impact in the community where they are introduced.