Tulane University School of Public Health and Tropical Medicine
This report describes the findings from an external evaluation of the Namibia component of the Southern African Regional Social and Behavior Change Communication Program. The programme, which has been implemented in 8 countries in Southern Africa with funding from the United Kingdom Department for International Development (DfID), aims to reduce HIV infection by increasing health awareness and by facilitating social and behavioural change through the use of both mass media and community-based activities. In Namibia, the programme is implemented by Desert Soul/Soul City (in this case, OneLove (see Related Summaries, below) and the Southern African HIV and AIDS Dissemination Service (SAfAIDS - see Related Summaries, below).
- Desert Soul has focused on the production and distribution of mass communication materials based on OneLove branding. Desert Soul's efforts have focused on improving communication within relationships and reducing multiple concurrent partnerships. A series of 10 short films, "Love Stories in a Time of HIV and AIDS", focuses on creating awareness around multiple concurrent partners. An earlier film series, "Untold Stories", consists of 9 films that focus on creating awareness around the severity of the HIV epidemic in southern Africa. Intended for mobile populations along the major transport corridors, the Meet Joe campaign consists of a pamphlet series that focuses on the dangers of multiple concurrent partnerships and encourages individuals to make healthy sexual decisions. A radio and TV public service announcement (PSA) series titled Champion for an HIV-free Generation features conversations with African leaders to promote HIV awareness. The Champions series is based on the premise that strong visionary leadership is an important element for achieving change, particularly at the policy level.
- The SAfAIDS approach to behaviour change communication centres on "cultural dialogue" to engage community members and leaders to identify practices that contribute to increased gender-based violence (GBV) and transmission of HIV, as well as ways to eliminate these cultural practices from the community. Volunteers use pamphlets, toolkits, and training packs as informational tools in face-to-face meetings with community members. Another programme, Changing the River's Flow, is designed to scale up health service delivery by using the inter-linkages between HIV, GBV, and culture to create programmes that are designed for women, girls, boys, and men affected by HIV. A key component is the use of home-based care to address these inter-linkages.
The main objective of the evaluation is to assess the net effect of exposure to various components of the programme on key indicators of HIV knowledge, attitudes, and behaviours (after controlling for other factors). Using a post-only cross-sectional research design, the evaluation is based on a nationally representative survey of male and females aged 15-49. Data collection, which involved 4,326 interviews, took place from December 2011 through March 2012. The data collection instrument covers the 7 areas targeted by the programme: multiple/concurrent sexual partnerships, other HIV risk factors, condom use, HIV testing, HIV treatment, HIV stigma, and GBV.
- Nearly 1 in 5 persons had been exposed to the Desert Soul and the OneLove campaign. The highest exposure was with print materials (40%), followed by radio (25%) and television (21%). Effect of OneLove programme exposure on health-related outcomes:
- "The effects on self-reported multiple and concurrent partnerships are inconsistent across exposure measures. While exposure to one booklet has a significant negative effect on multiple partners in the past year (particularly among women), exposure to television presents a positive effect on this outcome. Exposure to radio and television have significant and positive effects on the perception that leaders discourage multiple partnerships. A dose-response relationship for exposure to OneLove on this variable is also observed, with an increasing proportion of respondents agreeing with this statement (33% among unexposed, 36% among exposed to one media channel, and 44% among exposed to two or more channels). Exposed participants are less likely to have received gifts or money in exchange for sex with their next to last and third-last partner (but not with their last partner)...."
- "Exposure to the OneLove program had a significant effect on several indicators of condom use. For example, radio exposure has a significant effect on condom use at last sex with a regular partner for the total population, men, and women. Exposure to two or more media channels is significant on condom use at last sex among people sexually active in the last year. Both analytical methods (PSM and multivariate regression) suggest that exposure to all forms of media channels had an effect on agreement that condom use in marriage is becoming more widely accepted within the community. These effects are greatest with exposure to radio and to two or more media channels."
- "Exposure to radio, television and two or more media channels had a significant and positive effect on the mean number of HIV tests among men (the magnitude of the effect for all exposure measures was approximately 0.4 for all channels). Exposure to the any OneLove radio program had a significant effect on ever receiving and HIV test, and on receiving an HIV test in the past 12 months (among men). Program exposure had little effect on knowledge and attitudes toward HIV testing, and some of the effects are in the wrong direction."
- "OneLove exposure had a limited impact on - and in some cases a negative association with - indicators of knowledge of HIV treatment, with the exception of a positive association between exposure to two or more booklets and knowing that ARVs [antiretrovirals] prevent MCT [maternal to child transmission of HIV] during pregnancy (82% versus 73%) and during breastfeeding (79% versus 65%)."
- "Exposure to the mass media components of the OneLove program (particularly men's exposure to TV) showed a significant effect on the belief that community members are joining together to help people with HIV. These effects are inconsistent across gender and media channels (where a negative effect was observed). Exposure to booklets was found to be significantly and positively associated with disagreement that HIV is a punishment for sinning. A dose-response relationship is seen for this variable with disagreement with the statement increasing as exposure increases: 52% among unexposed to 63% and 71% among those exposed to one and two or more booklets, respectively."
- "Exposure to the OneLove campaign had mixed effects on gender-based violence. However, exposure to the campaign is associated with an increase in the reporting of such incidents."
- Nearly 1 in 5 persons had been exposed to the SAfAIDS campaign. Effects on health-related outcomes:
- "For most of the indicators examined, exposure to the SAfAIDS program was much more effective among women than among men."
- "Exposure to any SAfAIDS intervention has inconsistent effects on indicators measuring multiple partnerships. While a negative effect on lifetime number of partners is observed among exposed women, a positive effect on multiple partners in the past year is observed among men. Other indicators relating to attitudes and social norms regarding multiple partners show significant effects with exposure; the perception that people in the community are discussing multiple partnerships and the risk of HIV is higher with exposure to SAfAIDS, as are perceptions that people need to have someone to fill the sexual gap in case they break up with their partner (77% versus 62% among men; 73% versus 59% among women)."
- "SAfAIDS exposure is associated with an increase in the belief that community leaders are discouraging men from having sexual partners much younger than themselves, although this effect is observed only among female respondents. Likewise, among females program exposure is associated with a decreased likelihood of having a partner with a large age gap among women, but among men there is no effect."
- "The results do show that SAfAIDS program exposure is associated with increased levels of condom use at last sex. This effect is observed among men with casual partners and among women with regular partners. However, exposure to the SAfAIDS program does not have a consistent effect on HIV communication, and the effects tend to go in different directions for men and women."
- "No significant effects of exposure to SAfAIDS on uptake of HIV testing are observed in this evaluation. Variables associated with risk perception are higher among those exposed....The effects of the program on measures of knowledge and adherence to treatment are inconsistent. Exposure to the program is however associated with having ever taken ARVs, willingness to care for someone in ART, and having previously cared for someone on ART [antiretroviral treatment]."
- "The SAfAIDS program is not associated with changes in the prevalence of gender-based violence. However, there are indications that exposure to the program is associated with increased reporting of such incidents."
In conclusion: "Overall, the mass communication and community-based interventions of OneLove/Desert Soul and SAfAIDS have demonstrated impacts upon many of the key knowledge, attitude and behavioral outcomes that are the targets of their programmatic efforts. However, these effects of the program are highly dependent on the type of intervention (radio, television or print), and this evaluation noted considerable inconsistencies in measured effects across the range of exposure measures. In several cases, the intensity of exposure (mainly, the number of channels of exposure) is found to have a dose-response relationship with outcome variables, thus substantiating the relationship between exposure and the outcomes."
Research for Development (R4D), DFID website, accessed August 5 2014. Image credit: C-Change