Download HIV Formative Research - Communications Support for Health

Safe Love Formative Research
Desk Review to Inform
Campaign Development
Studies Reviewed
• Zambia Demographic Health Survey, 2007
• National HIV Prevention Convention Report, 2009
• Multiple and Concurrent Sexual Partnerships in Zambia: A
Target Audience Research Report, 2008
• HIV/AIDS TRaC Study Examining Consistency in Condom Use
Among Population Aged 15-49 in Zambia, 2009
• HIV Prevention Response and Modes of Transmission Analysis,
2009
• Zambia Sexual Behaviour Survey, 2009
2
Zambia Demographic and
Health Survey, 2007
HIV prevalence by sex and age
26.0
24.9
24.1
Percentage HIV positive
22.4
19.9
18.3
18.5
17.1
Men
11.8
5.7
12.1
11.5
Women
5.1
3.6
15-19
Source: Zambia DHS, 2007
20-24
25-29
30-34
35-39
40-44
45-49
4
HIV prevalence by sex and urban-rural residence
(age 15-49)
15.9
Urban
23.1
Men
Women
9.4
Rural
11.0
0
5
10
15
20
25
Percentage HIV positive
Source: Zambia DHS, 2007
5
HIV prevalence by sex and marital status
(age 15-49)
63.1
Percentage HIV positive
52.5
33.1
Men
28.8
16.1
Women
14.7
9.1
4.5
Never married
Source: Zambia DHS, 2007
Married/living together
Divorced or separated
Widowed
6
HIV prevalence among young people by sex and
age
Percentage HIV positive
15.2
9.6
10.0
7.9
Men
Women
4.4
3.5
3.8
2.4
15-17
Source: Zambia DHS, 2007
18-19
20-22
23-24
7
HIV prevalence among young people by sex and
number of sexual partners in past 12 months
Percentage HIV positive
30.0
Men
10.3
10.2
Women
8.9
4.1
3.2
0
1
2
Number of sexual partners
Source: Zambia DHS, 2007
8
National HIV Prevention
Convention Report, 2009
Key drivers of the epidemic
Driver 1: Multiple and concurrent sexual partners (MCP)
• Bulk of new infections are from casual and multiple concurrent
sexual relationships
• MCP is most prevalent among long term couples, young people
(especially young women), mobile populations, and men who
have sex with men (MSM)
Driver 2: Low rates of condom use
• Condom use remains low, particularly among young people,
mobile populations, MSM, and discordant couples
Source: National HIV Prevention Convention Report, 2009
10
Key drivers of the epidemic (continued)
Driver 3: Low rates of male circumcision (MC)
• MC offers at least 60% protection against HIV transmission
• MC is not widely practiced in Zambia except among some ethnic
religious groups
Driver 4: Mobility and migrant labour
• Mobility and migration of workers destabilises long-term
partnerships and so facilitate MCP including with sex workers
Source: National HIV Prevention Convention Report, 2009
11
Key drivers of the epidemic (continued)
Driver 5: Vulnerability and marginalized groups
• Sub population groups such as sex workers, MSM, prisoners,
migrants, and people with disabilities are the most vulnerable
Driver 6: Mother-to-Child Transmission (MTCT)
• HIV infection in children under 14 years of age constitute about
10% of all HIV infections in Zambia. Most of these are a result
of MTCT
Driver 7: Alcohol and drug use
• Decision-making is impaired under the influence of alcohol and
drugs
Source: National HIV Prevention Convention Report, 2009
12
Multiple and Concurrent
Sexual Partnerships in
Zambia: A Target Audience
Research Report, 2008
Study Overview
• Research objective
– Gain insight into the audience’s views, feelings, beliefs, attitudes,
behaviours, and experiences around multiple concurrent sexual
relationships and male circumcision in the context of HIV
prevention
• Methodology
– 16 focus group discussions and 12 in-depth interviews
– Two urban areas: Lusaka and Livingstone
– Two rural areas: Chirundu and Solwezi
• Primary target audience
– Adults between 16 and 55 years of age
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
14
Socioeconomic factors that contribute to MCP
• Poverty
– Exchange of sex for money or other types of support
– More common among women
– Sometimes encouraged by husband and parents, particularly
mothers
• Wealth
– Used to attract sexual partners
– Seen as a strong enticement to establish a relationship
– More common among men
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
15
Socioeconomic factors (continued)
• Abuse of authority/office
– Exchange of sex for “favours”
– Business professionals, hospitality industry workers, doctors,
teachers, taxi drivers, and musicians reported as likely to be
involved in MCP
• Desire for material possessions
– Women, in particular, have sex with many partners to acquire
material goods
• Mobility
– Being away from home provides opportunities for planned and
spontaneous relationships
– Married women are less mobile so have less opportunity
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
16
Relationship factors that contribute to MCP
• Relationship dissatisfaction
– Lack of communication, sexual dissatisfaction, squabbles,
mistreatment, and unfaithfulness are reasons for engaging in MCP
• Revenge
– Some sexual relationships are initiated when one partner wants to
take revenge on a regular partner who is having, or is suspected of
having, an affair
• Withholding of sex
– Men denied sex by their steady partners say this is a motivation for
additional sexual relationships
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
17
Relationship factors (continued)
• Sexual dissatisfaction
– Other partners are desired because they are seen as less sexually
inhibited
• Low rated spouse
– People who perceive their spouses as not of the same “class,” “not
attractive,” or “not clean” may engage in MCP
• Lack of communication
– Significant problem according to participants
– Perception that women should be submissive to men means that
they do not question their male partners, even when there is a
suspicion that he is having an affair or is placing her at risk for
being infected with an STI or HIV
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
18
Relationship factors (continued)
• Desire for long-term relationship
– Women say they want only one steady and lasting sexual
partnership
– MCP allows women to identify most suitable marriage partner
– When men do not show an interest in marriage or monogamy,
women seek additional relationships
– Some women become pregnant in the hopes that it will lead to
marriage
• If the father of the child does not make an offer of marriage, the
woman will have relationships with other men
• If the father of the child denies the pregnancy, both are likely to go on
to new sexual relationships
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
19
Cultural influences
• Alcohol
– Mentioned often by participants as a factor leading to MCP,
particularly among men
– When people drink, they are more like to engage in MCP
• Peer pressure
– People with only one sexual partner are teased
– Adults are influenced by friends to have MCP
• Positive perception of MCP
– Engaging in MCPs can elevates a person’s status in the community
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
20
MCP and HIV/AIDS
• Perception of risk
– Some people engaged in MCP report that they approach their
relationships with fear and caution because of HIV/AIDS, especially
when it is a means of support rather than sexual satisfaction.
– Participants respond that condoms are used in early stages of
relationship, but this gives way to unprotected sex in later stages
when trust has been established.
– Condoms give people the sense that they are protected against
disease and unwanted pregnancy. However, suggesting condom
use with a spouse may cause suspicion of infidelity.
– Fatalistic attitude towards HIV infection.
• Some people are no longer afraid of MCP because of the availability of
ARVs
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
21
Gender considerations
• Women more affected by poverty than men
– Rely on male sexual partners as source of income
– Single women more vulnerable because they become entangled in
cycles of having several sexual partners to ensure they have an
adequate income
– Increase risk of HIV infection
• Financially independent women are perceived as less submissive
– Able to decide when she wants to have sex
• Married women are expected to be subservient
– Cultural expectations discourage assertiveness and independence
and put women at risk for HIV infection
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
22
Gender considerations (continued)
• Women expected to tolerate husbands’ extra-marital sexual
affairs, but women who have affairs themselves are condemned
• While husbands expect their wives to comply with cultural
dictates such as not initiating sex, men consider boring sex lives
at home as a factor for engaging in MCP
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
23
Recommendations
• Strategic communication
– Conduct more research to better segment audiences and target
messages
• Strategic alliances
– Public-private partnerships to foster a holistic approach to MCP
• Sustained interventions
– Behaviour change is a long term, iterative process
– Sustained communication interventions help changing attitudes and
modifying behaviours while challenging long-established attitudes
and practices
Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008
24
HIV/AIDS TRaC Study
Examining Consistency in
Condom Use Among
Population Aged 15-49 in
Zambia, 2009
Prevalence of MCPs among sexually active men
and women age 15-49
Source: HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009
26
Concurrency
The probability of population aged 15-45 to have only one sexual
partner at a time increases with:
• Perceived susceptibility for contracting HIV
– Men and women who perceive that engaging in concurrency
increases the risk of contracting HIV are less likely to report
engaging in concurrency. (p<.001, OR=2.5).
• Perceived sexual benefits
– Men and women who attach a negative value to the sexual benefits
of engaging in concurrency are less likely to engage in
concurrency. (p<.001, OR=1.8).
Source: HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009
27
Concurrency (continued)
• Perceived negative outcome
– Men and women who have high perceptions about the negative
consequences that result from engaging in concurrency are less
likely to engage in concurrency. (p<.001, OR=1.5).
• Quality of relationship
– Men and women who have high perceptions about the quality of
their primary relationships are less likely to engage in concurrency.
(p<.01, OR=1.37).
• Marital status and sexual experimentation
– Men and women who are married are less likely to engage in
concurrency (p<.05, OR=1.35).
– Sexual experimentation and frustration in primary relationships
increases the likelihood of engaging in concurrency (p<05, OR=1.2).
Source: HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009
28
Recommendations
Communication programs should:
• Convey messages that promote consistent condom use with all
non-marital and non cohabiting partners (NMNCs).
• Focus on improving women and men’s ability to negotiate
condom use consistently (self-efficacy) with all NMNCs.
• Increase awareness on the increased susceptibility to HIV/AIDS
that results from engaging in MCPs.
• Challenge positive benefits and promote negative beliefs of
having MCPs.
Source: HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009
29
HIV Prevention Response
and Modes of Transmission
Analysis, 2009
Extent of MCP
• MCP common among Zambians irrespective of age, marital
status, or geographical location of residence (Kwatu, 2008)
• MCP more common among economically empowered men and
economically disempowered women, and among unmarried
than married people (Health Communication Partnership [HCP],
2008)
• People experiencing sexual problems are more likely to be
engaged in MCP (HCP, 2008)
• Men consistently report much higher frequency of MCP than
women but MCP behaviours and extramarital affairs are
underreported in surveys, especially by women
Source: HIV Prevention Response and Modes of Transmission Analysis, 2009
31
Percentage who had 2+ partners in the past 12
months
25
22.4
21.8
20.4
20
16.2
Percentage
15.2
15
Men
Women
10
5
5.0
1.1
1.2
1.4
0.8
0
15-19
Source: Zambia DHS, 2007
20-24
25-29
30-39
40-49
32
Number of partners in the last 12 months and
HIV prevalence
32
29
HIV prevalence (%)
27
20
20
0 partner
16
2 partners
13
3+ partners
11
Men
Source: Zambia DHS, 2007
1 partner
Women
33
Postpartum abstinence contributes to MCP
• Women‘s sexual abstinence for months after childbirth may be
an important factor leading to men having sexual partners
outside their main relationship
• Six and twelve months after birth, 43% and 20% of Zambian
women still practice postpartum abstinence (DHS, 2007)
Source: HIV Prevention Response and Modes of Transmission Analysis, 2009
34
Predictors of MCP
•
•
•
•
Early sexual debut
Being married
Early marriage
Absence from home (Sandoy et al., 2007)
Source: HIV Prevention Response and Modes of Transmission Analysis, 2009
35
Partner preference
• Preference for having married women or men as girlfriends or
boyfriends because they were thought to have fewer sexual
partners and to be less likely to have an STD
• Men also said that for married men it is safer to have a married
woman as a lover, since she is less likely to tell her friends
(Chiawa, Bond, and Dover, 1997)
Source: HIV Prevention Response and Modes of Transmission Analysis, 2009
36
Recommendation
The practice of MCP in Zambian society is an example of how
individual choices are shaped by social and cultural influences.
Thus a campaign to reduce MCP will need to focus not only on
individuals, but also on families, communities and policy. This may
mean challenging entrenched social and cultural norms. These
norms include seeing involvement in MCP as acceptable for men
and regarding women who are sexually proactive as likely to be
having relationships with other men.
Source: HIV Prevention Response and Modes of Transmission Analysis, 2009
37
Zambia Sexual Behaviour
Survey, 2009
Median age at first sex and first marriage among
people age 15-24
Source: Zambia Sexual Behaviour Survey, 2009
39
Percent of respondents who had more than one
ongoing sexual partnership in the past 12
months
Men 15-49
(%)
Women 15-49
(%)
Total
(%)
Urban
7.7
0.4
3.8
Rural
13.3
0.8
6.5
Single, never married
11.2
2.0
7.8
Married/cohabitating
5.2
0.2
2.4
Polygamous marriage
91.9
0.7
31.4
Formerly married
9.8
3.8
5.5
11.3
0.6
5.5
Residence
Marital status
Total
Source: Zambia Sexual Behaviour Survey, 2009
40
Respondents age 15-49 who had more than one
ongoing sexual partnership in the past 12 months
20
18.5
18
16
15.0
14.5
Percentage
14
11.3
12
Men
10
Women
8
6
4
2
2.2
1.8
2.2
0.6
0
2000
2003
Source: Zambia Sexual Behaviour Survey, 2009
2005
2009
41
Percent of respondents age 15-49 who report
condom use with most recent sexual partner
Source: Zambia Sexual Behaviour Survey, 2009
42
Percent of respondents age 15-49 who had multiple
partners in last year, and used a condom at last
sexual intercourse
Source: Zambia Sexual Behaviour Survey, 2009
43
ONE LOVE. KWASILA!
Campaign design
• Target audience
– Men ages 25-35 living in urban areas
• Behavioral objective
– Reduce sexual partners and/or increase consistent condom use,
HIV testing, and disclosure
• Communication objective
– Increase self-risk perception and provoke thought, dialogue, and
action around MCP and mutual rights and responsibilities of
partners
45
Campaign products
• TV/Film
– Animated spots, talk shows,
music video, and DVDs
• Club Risky Business
– TV mini-series
– Audience interacted through text
messages (SMS) and radio
station call-in programmes
46
Campaign products (continued)
• Radio drama series
“Bittersweet”
– 26 episodes aired on ZNBC
Radio 2 and Radio Phoenix
– Translated into Bemba and
aired on Radio 1, Mkushi
community radio, Radio Mano
• Print
– Newspaper features,
supplements, advertisements,
posters, discussion guides,
bumper stickers, and tax discs
for cars
47
Campaign website
http://www.onelovekwasila.org.zm
• Establish an online presence
• Build “One Love. Kwasila!” brand
• Create an online portal for men’s health issues
48
Results (October 2009)
• Created a buzz with target audience
– Within four weeks of airing the TV mini-series, 49% of regular nonLusaka urban television viewers recalled the slogan and 32% had
seen or heard of Club Risky Business
• Sparked audience engagement
– 17,137 SMS competition entries received
– More than 6,000 Facebook fans discuss characters’ actions and
relevance to their lives as well as sex, relationship, and health
topics
– Radio series generated 37 calls and 384 SMS
– 3,466 website visits and 8,960 page views
– 632 YouTube channel views and 10,348 upload views
49
Results (continued)
• 600 branded inter and intra city buses
– Also carried Club Risky Business as onboard entertainment
• 5,000 tax discs
• 5,000 bumper stickers
50
Lessons learned
• Integrated campaigns keep audience engaged in a number of
ways
• Drama works
– People relate to emotions
• Indigenous and high quality products improve message delivery
and also contribute to campaign sustainability
• Engaging audience through radio, competitions, and social
media is recommended
• Momentum needs to be sustained
• Research should involve campaign implementers from the
outset
• Partnerships are important to manage multiple aspects
• Linkages to trusted and credible resources/support services are
key
51