2011 Namibia: Break the Chain Campaign Namibia 2009 - 2011
Author: UNICEF Namibia and the Government of the Repubic of Namibia
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The Take Control Task Force for the Namibian HIV & AIDS Media Campaign is, at the time of this evaluation, conducting a multi-year programme focusing on multiple and concurrent partnerships (MCP). The programme is linked to the prevention component of the National Strategic Framework for HIV and AIDS 2010-2016 and previous Medium Term Plan III 2004-2009. It seeks to reduce HIV incidence principally by disrupting sexual networks and concurrent sexual relationships, but also by continuing to promote the traditional mainstay of protection through consistent condom use.
The ‘Break the Chain’ (BTC) Campaign is part of the activities of the Take Control Task Force which is led and co-ordinated by the Ministry of Information, Communication and Technology (MICT). A focus on multiple concurrent partnerships (MCP) was initiated in 2008 through a planning and strategy workshop that identified MCP as a key driver of HIV in Namibia. An MCP working group comprising a wide range of partners from government, civil society and development partners was formed to operationalise the campaign. The Take Control MCP working group falls under the auspices of the Technical Advisory Committee on Prevention of the Ministry of Health and Social Services (MOHSS) and reports to the National AIDS Executive Committee (NAEC).
Focal audiences for Phase One of implementation (the first year) were the general population aged 15-49 years, with a specific focus on singles and cohabiting couples aged 15-29. The specific communication goals during this phase were:
To increase awareness of the practice of multiple sexual concurrency, and
To increase knowledge regarding the reasons why the practice of MCP carries individual risks for contracting HIV.
This evaluation covered Phase One. Plans for a follow-up Phase Two campaign will include expansion into peer networks, families and traditional leaders, with communication objectives extending to addressing social norms related to MCP and to increase condom use.
The epidemiological rationale for the campaign was strongly evidence-based and reviews and analysis of literature and research conducted in Namibia identified the following aspects related to MCP:
There was some knowledge of risks of having multiple partners, but little uptake of preventive practices;
There was acknowledgement of contextual factors underpinning MCP including male gender norms, unmet sexual expectations, poor couple communication, poor communication in relationships, transactional sex, younger females having older partners and alcohol use;
Social norms were seen to be generally favouring MCP. People were also tolerant of HIV risk within a relationship, including tolerance of MCP;
MCP was highest among youth and younger adults 15-29, but extended into the 30-49 year age group;
MCP was highest among people who were unmarried, living apart or cohabiting, although MCP was also noted among people who are married.
The BTC Campaign follows a multi-level, multi-channel, multimedia approach including mass media, small media, and community level interpersonal communications (IPC) conducted by a broad range of partners according to their areas of specialization (Table 1).
The specific interventions include community outreach through promotions and events, group discussions, individual discussions and integration with parallel services (eg. peer education, VCT, workplace programs). Public relations and advocacy were also incorporated into the Campaign. Support materials included various interpersonal communication (IPC) materials including an MCP flannelgram (which visually illustrates how sexual networks are formed), an MCP Picture Code flipchart and an interactive video. Small media support included posters, booklets, leaflets and manuals. Activities were largely branded as ‘Break the Chain’, with some also utilizing regional branding such as ‘One Love’. Campaign implementation was conducted with varying intensity throughout Namibia. The programme overall incorporates a range of implicit psychologically-based behavioural theories as well as communication process approaches encapsulated in theories related to diffusion of innovations and social marketing within a context of health promotion.
Communication activities included the following components: Television and radio advertisements addressing MCP with a broad-based reach conducted in phases;
Outdoor advertising addressing MCP in selected cities and towns including billboards and bus stop advertising;
A 35 part radio drama addressing MCP in Otjiherero;
A 30-minute talk show addressing MCP in Otjiherero;
Billboards promoting the radio drama in two towns;
Marketing of ‘One Love’ materials addressing MCP countrywide;
A 40-page booklet addressing MCP distributed countrywide;
10 short films addressing MCP broadcast on television;
An MCP-related animated video;
Public relations activities promoting discussion of MCP;
Events and activations addressing MCP in selected cities and towns;
Interpersonal communication sessions addressing MCP through Community AIDS Forums in selected cities and towns;
Interpersonal communication sessions addressing MCP in schools and with out of school youth, in clinical settings, in workplaces, in households and with community groups;
Briefings of traditional and church leaders addressing MCP in selected communities;
A training workshop for journalists in Windhoek;
A ‘break the chain’ song;
An SMS platform;
A year planner for students.
Specific interactive approaches varied amongst implementing partners. Many of the interactions included multiple themes in addition to MCP – for example, condom use and HIV counseling and testing (HCT) and couples communication. Interactive sessions were conducted regularly, although repetition of activities varied. Some sites included workplaces such as mines, as well as rural and urban communities. The MCP flannelgram and MCP Picture Code flipchart, as well as ‘One Love’ materials were adapted from other Southern African countries, but re-designed to incorporate Namibian images and perspectives.
Training activities were conducted for the technical staff of all PEPFAR-funded partners working in prevention by C-Change. These provided assistance to implementing partners in social and behaviour change communication and the drivers of the epidemic, and in revising their program strategies to focus on specific behavioral objectives. Content included information on MCP as well strengthening program approaches, such as improved message dosage and supervision and behavioral M&E. C-Change also trained all PEPFAR partners, the Ministry of Education and Peace Corps volunteers in the use of the new IPC materials related to MCP, and provided copies of the MCP Picture Code flip chart as well as Integrated Session Guides for field use. Training was also conducted among NawaLife Trust staff as well as MICT regional staff. IntraHealth trained New Start staff and hospital HIV Prevention Officers.
This evaluation was conducted from April to May 2011, to assess potential mid-term effects of the program. Its objectives were to:
1. Determine the reach of campaign.
2. Determine awareness of MCP and its risks.
3. Determine whether MCP-related behaviors have decreased in association with the campaign.
To examine pre- and post-programming effects on MCP-related risk behaviors (i.e., decreases in the number of multiple partnerships), three (3) communities were identified where community studies had previously been conducted in 2007/8, and whose data could be used as a suitable pre-BTC campaign baseline. These were Oshikuku, Oniipa and Rehoboth.
Research methods included conducting site mapping, a survey with 900 randomly-selected respondents aged 16-49, and 21 focus group discussions with people in the same age bracket, and 14 key-informant interviews with males and females who had been exposed to the campaign, people living with HIV, and identified community stakeholders.
Ethical approval was granted for the study by the ethical review board of the Ministry of Health and Social Services (MoHSS) in Namibia.
An extensive literature review, series of discussion workshops and interviews with Take Control Partners were conducted during 2010. These led to the development of the research methodologies for the evaluation. A case study approach was adopted with a view to exploring and demonstrating the outcomes and impacts of the BTC Campaign in a range of settings. Benefits of case study approaches include:
Showing how interventions work in context – particularly outcomes and impacts;
Allowing stories to be told;
Allowing for multiple research methods to be applied;
Providing deeper insights necessary for understanding complex issue of communication;
Informing gaps and limitations of interventions;
Being generalisable to similar communities where similar interventions are implemented;
Being cost effective;
Allowing for comparison over time.
3.1 Evaluation Objectives
The objectives of the evaluation were to:
1. Determine the reach of campaign
2. Determine awareness of MCP and its risks
3. Determine whether MCP-related behaviors have decreased in association with the campaign
The first two objectives were related to assessing the campaign’s achievement of its goals to increase awareness of MCP, knowledge of risk arising from MCP practices, and highlighting MCP reduction as a key strategy for reducing HIV infection risk. The third objective came about because the opportunity presented itself to examine pre- and post-program effects in targeted study areas, each of which had relevant pre-Break the Chain baseline data.
Among the hypotheses of the evaluation were that:
There would be high awareness of the BTC Campaign, itself (ie. most people have heard of or seen elements of the campaign);
The main messages of the campaign would be understood by those who have been reached;
The BTC Campaign had improved understanding of the dynamics of HIV infection and risks to people living in communities in Namibia;
Risk reduction through reducing MCP is understood;
Awareness of the risks of MCP has increased over time (in comparison to baseline data);
MCP-related risk practices have decreased over time (in comparison to baseline data).
3.2 Ethical review
The study included no invasive procedures and participation in the study was voluntary, with written consent being required. Questionnaire administration was conducted privately on a one-on-one basis with an enumerator and training was provided on confidentiality and anonymity. Focus group participants were advised on the confidentiality and anonymity of discussion transcripts. Participants were also referred to local services as needed.
Ethical clearance of the evaluation protocol was sought from the ethical review board of the MOHSS in Namibia and was received on 20 January 2011.
3.3 Study site selection
Three main criteria were employed to determine selection of study sites – the availability of previously-collected data from community-level studies that could serve as a pre-BTC implementation baseline, evidence of implementation of BTC activities at community-level, and general cost-efficiency for conducting the evaluation. Oshikuku, Oniipa and Rehoboth emerged as the selected sites. The sites also offered variations in terms of urban/rural geotype and north/central locale.
Between 2005 and 2008, NawaLife Trust (NLT) conducted a series of community-based studies on HIV-related behavior. The studies followed a systematic sampling method based on housing counts, with the local hospital as a starting point. Because the most recent of these studies (2007/8) and the present evaluation study had very similar methodologies, and used similar behavioral indicators, there was an opportunity to use the same study sites and the previously collected data as a baseline for evaluation of change over time. However, a larger sample (600 per site) was used in 2007/8 which resulted in a higher proportion of rural households on the outskirts of Oshikuku and Oniipa being included in that sample compared to the sample for this evaluation, and the earlier sample also included a more equitable distribution of males and females in comparison to the present evaluation, where a higher proportion of females were finally recruited. The two studies also varied slightly in the sampling of their populations by age: the “baseline studies” in 2007/8 sampled persons 15-49, while the present evaluation sampled participants from 16-49. For ethical reasons, inclusion of 15 year olds would have required parental consent to participate in the survey. This would have had impact upon the projected time spent in the field, requiring that parents be first located and appointments made in order to obtain their consent for each child. Given the time constraints of the study, it was considered more practical, therefore, to sample participants beginning at age 16, who could consent for themselves (affirmed by the ethics committee during review). Since current 16 year olds can reflect back on the period of the past year of the campaign (ie. when they were 15), this difference between the samples in terms of age groups was not expected to pose a problem in relation to the reported perceptions and other responses to the campaign. The overall age distribution was, moreover, similar in both studies, supporting the comparability of the study groups.
Only three indicators were finally compared between the 2007/8 baseline study and the present evaluation in multivariate analyses: unprompted knowledge of HIV prevention, numbers of partners in past year and numbers of partners in the past month.
Site mapping activities preceded interviews in each community. The mapping process included general observation as well as informal visits to various facilities with the intention of determining the extent to which BTC Campaign components were visible – for example posters at clinics, billboards or other evidence of the campaign. Facilities visited included clinics, hospitals, municipal offices, libraries, community centres, schools, community organization offices and shopping centres. Mapping also served to validate the residential patterns and sampling frame for the quantitative study. The findings are summarised below.
Oshikuku is a relatively small, proclaimed village with a population of approximately 10,000 people, located in the Omusati Region in northern Namibia. The unadjusted antenatal HIV prevalence was 22.5% in 2010 (21.7% in 2008). Among the population surveyed in 2008, 12% lived in brick houses, 6% in shacks, and 82% in houses made of traditional materials. The predominant language is Oshiwambo, which was spoken by 98% of respondents. Some 16% had completed secondary school only, while a further 7% also had a post-secondary school education. Predominant religious groups were Catholic (56%), Protestant (36%) and ‘other Christian’ (6%). Just under a third of respondents were employed (29%), while 19% were students and 38% were unemployed. Although formal housing projects have been implemented there is also a large number of informal houses and commercial development. In terms of educational institutions, the town has one secondary school, a junior secondary school and a primary school. The village is characterised by a large Roman Catholic Hospital and Mission with ancillary services such as the Catholic AIDS Action (CAA). The Hospital also accommodates an Anti-Retroviral Therapy Unit (ART) and a Prevention of Mother to Child Transmission (PMTCT) unit. In terms of implementing partners for the BTC Campaign, institutions that were visited were NLT, New Start, CAA and ART/PMTCT centres which are located at the Roman Catholic Hospital. With the exception of one school and the AIDS prevention office, very few BTC Campaign materials were found on display.
Oniipa is a proclaimed Village Council area of approximately 30,000 people located near Ondangwa in northern Namibia. The unadjusted antenatal HIV prevalence in Oniipa was 24.0% in 2010 (21.9% in 2008). Among the population surveyed in 2008, 38% lived in brick houses, 11% in shacks, and 51% in houses made of traditional materials. The predominant language is Oshiwambo, which was spoken by 96% of respondents. Some 15% of respondents had completed secondary school only, whilst a further 4% also had a post-secondary school education. Predominant religious groups included Protestant (62%), and Catholic (27%) and ‘other Christian’ (7%). One fifth (26%) of respondents were employed, whilst 22% were students and 42% were unemployed. Housing is located densely along a main highway and is then more dispersed with activity centered around a central retail area and the Onandjokwe Hospital. BTC Campaign related groups visited included New Start, the Evangelical Lutheran Church in Namibia (ELCIN) AIDS Action and the Namibian Red Cross Society. BTC Campaign materials were noted to be in limited supply when requested by the hospital, although posters were displayed at the hospital. Similar constraints to accessing BTC materials were experienced by the Namibian Red Cross Society, with most materials being in English or with an urban orientation that also limited implementation. BTC Campaign materials were, however, being used by the group. ELCIN AIDS Action had their own materials and did not use BTC Campaign materials. At New Start, BTC leaflets were noted to be useful and posters were on display. BTC Campaign materials were not on display at the local post office or constituency office, but were used at a local junior secondary school. BTC Campaign materials were not on display at businesses or retail outlets nor at alcohol venues. Other churches in the area did not appear to have been engaged by the programme.
Rehoboth is located in Central Namibia, south of Windhoek, and has a population of approximately 35,000 people. The unadjusted antenatal HIV prevalence was 4.2% in 2010 (6.3% in 2008). Amongst the population surveyed in 2008, 80% lived in brick houses, 18% in shacks, and 2% in houses made of traditional materials. The predominant language is Afrikaans, which was spoken by 61% of respondents. Some 27% of respondents had completed secondary school only, while a further 4% also had a post-secondary school education. Predominant religious groups included Protestant (41%), Catholic (31%) and ‘other Christian’ (20%). Over a third of respondents were employed (33%), whilst 18% were students and 43% are unemployed. Housing in Rehoboth includes formal housing with some informal settlement. BTC implementing partners in the area included NLC, New Start, CAA and a HAART/PMTCT facility at the hospital. There were very few BTC materials in any of the facilities visited. BTC partner organisations were also reducing their level of operation in the area as a product of funding cuts – for example, most New Start staff had been retrenched and the NLC office was being closed down permanently. Flannelgrams were available at CAA.
3.4 Study instruments and administration
All study instruments were pre-tested during training of fieldworkers and minor adaptations were made. Instruments were translated into English, Afrikaans and Oshiwambo.
Written consent was required from all participants in the evaluation study, in both the quantitative (survey) qualitative (focus group) arms. Consenting processes included introducing the purpose of the study, advising that participation was voluntary and that information provided would be kept confidential.
Survey responses were recorded on paper questionnaires. Qualitative data were captured on audio recordings by portable digital recorders. Participants and respondents were free to contribute information in their preferred language. A token payment was provided in compensation for time taken.
The field work for the evaluation study was conducted during March and April 2011.
3.5 Fieldworker and supervisor training
Training for fieldworkers and supervisors took place at a central venue in Ondangwa in Northern Namibia. The training was led by senior staff of Urban Dynamics with assistance from the evaluator.
Training included an overview of the objectives of the study, ethical aspects, sampling and participant selection procedures, qualitative and quantitative approaches, and logistics. Various practice exercises were also conducted.
3.6 Research methods
A combination of qualitative and quantitative research methods were employed in each study community including:
Site mapping and observation which included observing presence of BTC materials and informal discussions and consultations;
Focus groups with males and females aged 16-19; 20-30 and 31-49 who had some exposure to the BTC Campaign.
Focus groups with males and females 25-35 who had been directly involved in BTC activities and also PLHIV who had some exposure to the BTC Campaign.
Interviews with stakeholders including leaders, health workers, members of organisations working in the area;
A quantitative survey conducted with 300 randomly-selected respondents aged 16-49 in each site.
3.6.1 Quantitative sampling
The survey sought to ensure that it provided a representative of portrayal of the residents of each study site. Detailed population data for each community was not available, although it was recognised that population sizes varied, with Oniipa being least populous, and Rehoboth being most populous. Sampling proportional to population size (PPS) would, however, have required more complex survey logistics; a fixed sample size of 300 interviews in each community was adopted instead. Aerial photographs and cadastral maps of the towns were used to conduct housing counts. A sample frame was prepared and a random starting point was selected in each site. A systematic sampling method was used to select households in each site, and differences in the numbers of households in the sampling frame were addressed by increasing or decreasing the sampling interval (every nth household was selected, based on total number of households divided by the desired number of interviews). In the case of Rehoboth, every 19th household was selected while every 2nd and every 3rd household were selected in Oniipa and Oshikuku, respectively.
Once contact was established with a selected household, permission was sought from the head of the household or the person in charge to randomly select one resident of the household. A roster was drawn up of household members by age and sex and a predetermined selection guide was used to select respondents. If the selected person refused, the entire household was dropped from the sample and replaced – first by the house on the left, then the house on the right. When it was not possible to establish contact with a household (i.e., residents away from home, etc.) with the first try, interviewers were required to make three further contact attempts before the household could be replaced. Doing so was intended to reduce selection bias in the sample, and ensure that it did not include only those persons most likely to be at home throughout the day (home makers, physically-disabled, elderly, etc.) or systematically exclude many other persons who might have been at work, at school, or elsewhere at the time of the field staff’s visit. . In cases where none of the household members was aged between 16 and 49, whole households were replaced.
In Oshikuku and Oniipa, the research team had no household refusals. In Rehoboth, five households refused to participate and were substituted. Reasons for refusals included fear of being scouted for a future burglary, not having time, not being interested and the topic being too sensitive. The potential for selection bias due to non-response was, therefore, very low, overall.
3.6.2 Qualitative sampling
Site mapping identified key stakeholders in each community as well as health services, health-related non-governmental organisations (NGO), and community-based organisations (CBOs) working in the area. These organisations supplied key informants for interview, and included community leaders, faith-based leaders, senior health-care workers, traditional healers, and community health workers. In total, 14 key informant interviews were conducted (Table 2).
Site mapping also informed strategies for recruiting male and female community members for participation in focus group discussions (FGDs) in each site. These participants were sampled in various ways, but unlike participants in the survey, FGD participants had to demonstrate some awareness of the campaign to ensure that they would be able to contribute to meaningful discussion about it. For most of these participants, “awareness” included having heard of, having seen one or more campaign components, or having participated in community-level activities. A focus group of people living with HIV (PLHIV) was also recruited at each site, as was one focus group in each community consisting of participants who had worked with or volunteered with BTC campaign partners. In Oshikuku, younger participants were selected randomly through a local secondary school, while older age groups were selected systematically in the streets during site visits. A local AIDS prevention officer assisted in selecting participants involved in BTC as well as PLHIV. In Oniipa, younger participants were selected randomly from a local secondary school, while older age groups, individuals involved in BTC and PLHIV were selected non-randomly with the assistance of a local AIDS co-ordinator at the main hospital. In Rehoboth, local AIDS organisations assisted with recruitment, although some delays and logistical problems occurred as a product of some of the organisation having to close down its offices. In total, 21 FGDs were conducted with 149 participants (Table 3).
4.0 Data Analysis
Data analysis was conducted from May to June, 2011. Quantitative data were entered into a data capture program and checked for accuracy. The dataset was checked by the senior statistician and translated into a final dataset following data cleaning procedures. Data were analysed using STATA statistical software. In comparative analyses, the evaluation set its level of statistical significance at 0.05 (indicating that differences observed between the values of any two evaluation findings would be considered particularly noteworthy if there were less than a 5% probability that such differences might simply have been due to chance), and values of <0.001 (a probability of less than one in 1000 that differences were due to chance) were, therefore, considered highly significant. In some instances, ‘p’ values of 0.06 to 0.1 are reported where they are of interest, although these are interpreted more liberally by the evaluation as having “borderline” statistical significance.
All qualitative data was transcribed from recordings. Data that was not in English or Afrikaans was translated into English, where applicable. Transcriptions were coded into themes using HyperResearch. Initial analysis addressed the extent to which the qualitative findings addressed the hypothesized questions. This was followed by deeper analysis to identify underlying patterns and ‘logics’.
The cross-sectional study design of the evaluation precluded making direct causal inferences about the campaign’s effects upon population behavior change. Triangulation methods were therefore used to investigate whether there were evidence of (self-reported) behavioral impacts associated with the campaign. The principle of research validation through data triangulation allows for multiple sources of information to be examined simultaneously, to understand whether findings from one data source are reinforced (corroborated) or contradicted by another. It therefore allows validation through convergence of findings generated by different methods of enquiry.
The present study employs ‘methodological’ triangulation, exploring the convergence of quantitatively and qualitatively-derived data researching the same outcomes. Both data formats are also ‘triangulated’ internally by comparing and contrasting findings between various groups of respondents/participants. Previous survey data collected in 2007/8 in the same sites was used to support meaningful comparisons of population-level behavior changes over time.
The qualitative data analysis consisted also of triangulation of data from three principal sources: FGDs with recipients of messages, FGDs with partners who promoted the campaign, and key informant interviews with important stakeholders. Age group and sex variation was also introduced into the analysis through segmentation of FGD participants.
All data were analyzed in relation to the key hypotheses of the evaluation, and were then considered in relation to each other with respect to the principles of triangulation – ie. do the various data support or contradict each other?
5.0 Limitations of the study
The evaluation study was tailored to available funding, and its scope was accordingly limited to the examination of a small subset of Namibian communities. Monitoring implementation of the BTC Campaign was not within the scope of this evaluation and specific information on the delivery of campaign components is not reported here; nor is an evaluation of the potential effects of individual components of the BTC Campaign on behavioral outcomes reported.
While household studies are well established for studying social and behavioural phenomena related to health, some recognised limitations of this study include under-representation of mobile populations, persons in institutions, and employed persons (especially men) who were often not in the household during working hours when interviews were conducted and despite efforts to increase the likelihood of their inclusion in the sample.
To allow for comparison to previous community studies, choice was limited to communities where relevant comparative data had recently been gathered. It was principally on this basis that Oshikuku, Oniipa and Rehoboth were selected. Although the selected sites were not representative of all Namibian communities, they were similar to many other communities in Namibia.
Findings and Conclusions:
The primary hypotheses of the evaluation were that (1) the BTC Campaign would show evidence of having both reached and increased knowledge among the target population of MCP and its risks, and (2) that a measurable reduction in (self-reported) MCP-related risk behaviours would be brought about. The evaluation findings support these hypotheses, indicating that the campaign is having the desired effect. Triangulation of the data clearly demonstrates that important changes in risk perception and practices in the study communities have already begun to occur in association with the campaign.
• Reach: All (100%) randomly-sampled community participants had been reached by at least one (1) component of the campaign; the great majority (81%) had been reached by 10 or more.
• Awareness: The BTC Campaign prompted discussion about multiple and concurrent sexual partnerships. Exposure to higher numbers of BTC Campaign components (10 or more) elicited a statistically significantly higher likelihood among community members of speaking about HIV/AIDS with others (65% vs. 53%).
• Awareness: More than a third of randomly-selected respondents (36%), reported their (unprompted) perception that people in the community were specifically changing their behaviour by ‘breaking the chain’ or avoiding concurrent partners (49%).
• Impact: Those randomly-selected community residents who reported exposure to 10 or more BTC components were also statistically significantly more likely to report having changed their sexual behaviour in the past year (65% vs. 50%) compared to those who had lower exposure. Those with more varied exposure also made statistically significantly more frequent (unprompted) mention of ‘breaking the chain’ and avoiding concurrent partners (24% vs. 9%) as their specific behavior change.
• Impact: Compared to the pre-BTC implementation baselines, there was a statistically-significant decline from 2007/8 to 2011 in the reported prevalence of multiple partnering within the year (28% vs. 10%) and within the month (11% vs. 3%) prior to each survey. These declines cannot be directly attributed to the campaign, but triangulation of these findings with other study findings does suggest that potential campaign influence upon the observed changes cannot be ruled out.
• Impact: The BTC Campaign has generated responses among the target population that blend cognitive, situational and social elements to create new, internalized meanings and understandings of MCP and its risks. These new “cultural scripts” appear, in turn, to have led to risk-reducing actions and commitments by individuals and those in their social networks which have the potential to reshape norms and values.
This evaluation was conducted three months after a moderately intensive mass media campaign ‘blast’ in December 2010 and January 2011, and almost one year after the most intensive period of the campaign (early to mid 2010) had ended. It is important to note that the extent and intensity of the community-level activities varied at each site in accordance with the capacity of the implementers. This may account for some of the variability seen in findings at the different sites one year after the greatest push of the campaign had ended. Although receipt of individual components of the campaign was explored by the evaluation, emphasis was placed on understanding the reception, interpretation and engagement of the population with the campaign as a whole. Changes in sexual relationship behaviours that occurred as a product of the campaign were identified by the study as were gaps and associated opportunities for programme improvement.
The figures and tables presented, hereafter, describe the findings of the quantitative survey, along with thematic qualitative findings which support their contextual interpretation.
6.1 Demographic characteristics
Figure 4 and Table 4 describe the demographic characteristics of the survey respondents. The majority of participants were female. This was likely a product of the primary sampling guideline being to reach particular age groups at each household and the lower likelihood of males being in residence. This pattern was similar across all three sites.
The majority of respondents were Christian, with most being Protestant in Oshikuku and Rehoboth, while the majority in Oniipa were Catholic.
Around half of respondents were unemployed in all three communities, while around one in eight (13%) was a student and one in nine (11%) was informally employed. Respondents were overall poor, with nearly two thirds (64%) having no income or a gross monthly income of N$500 or less. However, the evaluation captured only the individual’s income, and data do not reflect household income or other support by partners or family members.
Access to household amenities was defined as having electricity, piped water within the homestead or an indoor flush toilet. Low, medium and high amenity levels were defined in terms of having either one, two or all three amenities. Around a third of households in Oshikuku had low amenities, followed by around one in five households in Oniipa. Very few households in Rehoboth had low amenities.
Less than half of respondents in all communities were married or cohabiting, and more than one of four (28%) was not in a relationship at all. Half of respondents had no children. Table 5 provides greater detail on relationship status by age group. Nearly all respondents younger than 25 were unmarried, with only 5% being married and 14% cohabiting. Marital levels increased slightly for the 25-34 year age group to 22%, arriving at half (52%) for respondents aged 35 and older. Around two fifths (43%) of respondents younger than 25 were not in a relationship, while this was much lower for older respondents – 19% among those aged 25-34, and 21% for those aged 35-49.
6.2 Community Access to Communication Media
Access to mass media communication resources is relatively high in Namibia and this has allowed the BTC Campaign to achieve high levels of reach and awareness. The most widely available mass medium available was radio, with 88% of respondents having a working radio in the household and 77% listening to radio two or more days a week (Table 6). This was followed by television at 62%, with 59% of respondents watching television two or more days a week. Television access was unevenly distributed with only around half of respondents in Oshikuku (51%) and Oniipa (48%) having access. Newspaper and magazine readership varied between sites. Internet use was overall low, at 13%, but the vast majority of respondents had cellphone access (81%). This was lowest in Oniipa (54%) and highest in Rehoboth (95%).
6.3 Community Access to HIV/AIDS Information
Respondents were asked about exposure to HIV/AIDS information in the past 12 months. When analysed by age group, three marked differences were found (1) young people aged 16-24 were more likely to report having received information from a teacher (46%), in comparison to respondents aged 25-34 (16%) and 35-49 (10%). In contrast, (2) older respondents were more likely to report receiving information in the workplace – 30% for respondents aged 25-34, 37% for respondents aged 35-49, and 7% for younger respondents aged 16-24. Older respondents were (3) also more likely to have received information from a pharmacy – 24% for respondents aged 25-34, 26% for respondents aged 35-49, and 18% for younger respondents aged 16-24.
Most respondents (71%) discussed HIV/AIDS with their friends, followed by information from health service providers (69%) or family members (62%). Around half received information from AIDS organisations, while a third received information from faith-based organisations. School learners and teachers were a source of information for around a quarter of respondents, as were pharmacies. Around one in ten received information from a telephone helpline, with this being highest in Oniipa (17%) and lowest in Rehoboth (1%). Information on HIV/AIDS from traditional healers was reported by around one in twenty, with this being highest in Oshikuku (12%).
More than half of respondents in Oshikuku (59%) and Oniipa (69%) had attended an HIV/AIDS play or educational event, while this applied to only 11% in Rehoboth (Table 7). Similarly, half or more in Oshikuku (50%) and Oniipa (60%) had attended a community meeting about HIV/AIDS, while this applied to only 15% in Rehoboth. A lower proportion had attended a training workshop on HIV/AIDS – 38% in Oshikuku, 28% in Oniipa and 8% in Rehoboth.
Respondents were asked about interpersonal exposure to HIV/AIDS in the past 12 months (Table 8). More than half of respondents (55%) had attended a funeral of someone who had died of AIDS; half had also experienced HIV disclosure by a person that they knew. This was most reported in Oniipa (62%) and least in Rehoboth (35%). Around half in Oshikuku (46%) and Oniipa (48%) had cared for a person who was sick with AIDS, but a relatively lower proportion, 21%, had done so in Rehoboth. A similar pattern emerged for respondents who had helped care for a child whose parents had died of AIDS. These site differences may be related to the much lower estimated (antenatal) HIV prevalence in Rehoboth.
It is clear that most participants discuss HIV and AIDS in their day-to-day lives, and communication about the disease occurs with peers, family members, with health care workers, pharmacy staff and others, such as, staff of institutions such as schools. The impact of the epidemic is also personally felt, with many respondents reporting that they know people who have died, or know people who are living with HIV.
6.4 Reach of the BTC Campaign
The BTC Campaign included 25 unique media-based and interpersonal activity-based components. Reach of the BTC Campaign was determined by asking a series of questions of survey participants that demonstrated their awareness of the components, allowing for visual prompting, where necessary (Figure 5). Visual prompts took the form of colour printouts representing particular components of the campaign. These were shown to respondents who could not recall or describe a particular campaign element. All respondents had seen or heard at least one component of the BTC Campaign. Specific findings regarding reach are presented by campaign component and by study site in Tables 9 and 10. Data were also analysed for respondents in three age categories – 16-24, 25-34, and 35-49. There were no marked differences in reach of campaign components in the three age groups, and the findings have therefore not been included in the tables below.
Knowledge of the BTC Campaign was overall high, with the vast majority of respondents (84%) having heard or seen the phrase ‘Break the Chain’. Most had also seen the logo (62%), with a further quarter (25%), recognizing the logo after being shown an example. There was also high awareness (with prompting) of supplementary slogans such as “who are you connected to” (79%) and “say no to sexual networks.” Three quarters of respondents had heard the slogan on the radio (74%), followed by posters and newspapers (69%) and then television (35%). Reach of parallel ‘brands’ falling within the regional ‘One Love’ campaign, was also high, although there was lower recognition of the ‘One Love’ logo.
Although recall of the phrase ‘Break the Chain’ was similar in all three sites (81%-86%), unprompted recall of the logo was lower in Rehoboth (51%). Unprompted recall for televised campaign elements was, however, highest in Rehoboth (61%) and was related to higher community access to television there. While Rehoboth had high mass media reach, respondents were less likely to have been engaged through interpersonal communication (IPC) activities. In comparison to mass media, the reach of IPC activities, which include discussions among, and messages delivered to, small groups of people in communities, is inevitably lower, and findings of lower reach of individual components do not necessarily indicate less effective distribution of the components. Engaging with IPC components of the campaign such as the Picture Codes and Flannelgram was least likely in Rehoboth, but in general, fairly similar in the other two sites. Reach is also context dependent – for example, shebeen patrons represented a sub-audience for the ‘Naked Truth’ shebeen booklet, whereas Galz and Goals Funbook was directed towards young girls participating in a particular programme, and ‘Meet Joe’ was dependent on banking halls as access points.
Most respondents had not seen the shebeen booklet ‘Naked Truth’ (13%), though among respondents who said they drank alcohol [n=396], 39% said they had seen the booklet. Overall awareness of the ‘Fly guy/Fly Girl’ posters was also somewhat low, with more than half of respondents (40%), not having seen these.
Around half of respondents (45%), reported having heard the ‘Break the Chain’ song, with the highest proportion being in Oshikuku (54%). Around half (52%) had heard the Desert Soul radio programme Tjitjikutuare kepembe kotjii, although only a third of respondents in Rehoboth (33%), had done so.
There was very low awareness of the ‘Meet Joe’ animated video (7%), and also the ‘Galz and Goals’ funbook (14%). The former was however mainly disseminated through video in banking halls, while the latter was primarily youth focused.
The majority of respondents had seen the Desert Soul magazine on MCP, with this being most likely in Oshikuku (82%) and least likely in Rehoboth (53%). Most could also recall the ‘One Love’ logo (61%), although recall was much lower in Rehoboth at 41%. There was overall low awareness of an SMS Helpline (20%), although reach was limited as a product of the number mainly being disseminated through the Namibian College of Open Learning (NAMCOL) database.
A number of campaign components were delivered at community level. These included a flannelgram that illustrated how MCP and sexual networks were related, Picture Codes that facilitated discussion of MCP, an interactive video entitled ‘The 3 ½ Lives of Phillip Wetu’, and various events and activities. Not all activities were conducted in all communities. The evaluation could not control for the possibility that respondents may also have been exposed to campaign components when visiting communities beyond the three study sites.
The Picture Codes were more likely to have been seen than the flannelgram or Philip Wetu video (45% vs 39% and 5%, respectively). The Picture Codes were seen by the majority of respondents in Oshikuku (58%) and Oniipa (64%), but only by a small proportion in Rehoboth (13%). The flannelgram was recognised by 63% of respondents in Oniipa, but was less likely to be noted in Oshikuku (42%) and Rehoboth (12%). More than half of respondents in Oshikuku (69%) and Oniipa (58%) had participated in, or had seen, a BTC event, although this only applied to a minority in Rehoboth (10%). Participation in other IPC activities was also overall low.
It was also of interest to examine whether there might be differences in reach by sites and demography in terms of the overall volume or quantity of campaign components that had reached respondents (Tables 12 and 13). While it was not possible to measure the frequency (intensity) of participant exposure to specific components (such as knowing how many times they had heard a slogan on the radio or television), it was possible to measure how many components they received (a proxy for intensity), with the logic that exposure to larger numbers of components suggested intensity in terms of exposure to both a greater variety and to multiple channels of communication. A subset of components was defined as mass media (such as an advertisement on radio or television), while community-level components (IPC) were defined as flannelgram, picture codes small media, such as posters, and booklets and leaflets. Participants could also have been exposed to BTC Campaign concepts in other ways than were measured in this evaluation – for example through discussion with others in the community – or through other discourses about MCP, for example in the news media.
The majority of respondents (74%) were exposed to six or more mass media components, and this was similar between all three sites. Overall community level exposure through IPC was also high, with two thirds of respondents (66%) having been exposed to two or more components. This was however markedly different in Rehoboth where only 37% reported this higher level of exposure. When all components were taken together, the majority of respondents (81%) had been exposed to 10 or more mass media or community level components. This was similar in Oshikuku and Oniipa – 86% and 83% respectively, but lower in Rehoboth at 73% as a product of lower exposure to community-level components.
Exposure to various components by sex and age was overall similar. Three quarters of males (75%) and around three quarters of females (74%) were exposed to six or more mass media components while exposure by age group was overall similar. These similarities were found for community level components, and for combined mass media and community level components.
6.5 Awareness of MCP: Knowledge of HIV Prevention Methods
Respondents were asked to list all the ways that a person could prevent infection with HIV. The same question had been asked in 2007/8, and comparisons are, therefore, given for the six categories most likely to be mentioned (Figure 7 and Table 14). Multiple responses were possible and choices were not prompted.
Condoms remain the category of highest mention (88%) and this has increased from 79% in 2007/8. Abstinence was ranked next highest at 59% and this has decreased from 76% in 2007/8. A higher proportion of respondents identified “having only one sex partner” as top of mind prevention strategy in 2011 than at the baseline (i.e., 57% vs. 49%, respectively). Reporting of non-penetrative sex as a strategy also increased (31% vs. 13%) while the consideration of remaining faithful to one’s sex partner was similar across time frames (37% vs. 34%).
“Breaking the chain” (a response without precedence before the BTC campaign) or not having concurrent partners was specifically mentioned by 30% of respondents in 2011; 40% of respondents in Oniipa and 38% of respondents in Oshikuku spontaneously mentioned ‘breaking the chain’ or not having concurrent partners, though response was much lower in Rehoboth, at 12%. The reasons for these variations are unclear. Nonetheless, these findings suggest appreciable campaign penetration linked to concepts of HIV prevention in the population, overall, and provide evidence of the emergence of a “new” top-of-mind prevention response, since the launching of the campaign.
6.5.1 Awareness of MCP: HIV Testing Behavior as Indicator of Vulnerability
Respondents were asked if they had ever tested for HIV and the timing of their most recent test. The majority of respondents (77%) had had an HIV test at some previous point in time, and levels of reported testing were roughly similar in all three communities. Testing history was reported more frequently among females and the majority of respondents had recently had an HIV test.
Seventy-seven percent (77%) of participants responded to a survey question about their one main reason for having an HIV test. Their responses were unprompted. Two main reasons emerged – most respondents (60%) simply wanted to know their status, while females typically tested because they were pregnant (23%). A very small minority of respondents said they had tested principally because they were concerned about their partner’s HIV status or sexual behaviour, or because they had had multiple partners, themselves.
HIV testing was not explored directly in the qualitative portion of the study. However, there does appear to be evidence that deciding to test for HIV, or have one’s partner test for HIV has been prompted by the campaign. For example, wanting a partner to have an HIV test on the basis of suspected infidelity: “Once I became suspicious of my girlfriend and I asked her to go for a HIV test” (Male, 20-30, Oniipa). Similarly, if one wanted to establish a relationship that avoided risk, the repertoire of prevention strategies included using condoms, or both having an HIV test and also committing to not having other partners: “If you have a partner and you want to have a sexual relationship with him or her without getting HIV you must use a condom or go for a test both of you, so that you can prevent the spread of HIV. This thing of break the chain is you mustn’t have many sexual partners, you must have one partner at a time” (Female, 20-30, Oniipa). As a community health worker noted – the message being delivered through the campaign was “you must have a tested partner to trust the partner that you are with” (BTC implementer, Oshikuku).
A female PLHIV participant in Oshikuku described how a friend removed herself from a sexual network and also tested for HIV, describing her friend as saying: “I had concurrent partners, but when I went and think about it, I saw that I was in dangerous network. So, I cut myself from the network and I went to the hospital, got tested, and was negative and now I really broke the chain”.
Knowing one’s status was also linked to self-awareness in relation to ‘breaking the chain’, with personal responsibility if one found one was HIV positive being related to save the nation – or as was expressed by one participant, conversely, as having the potential to ‘kill the nation’: “After you have been tested and find out that you are HIV positive, you can still stop the spread by coming out in your community and try to warn the people. In this way you can also get your treatment. You can also tell the people the truth how you got the virus and that if they behave in a certain way and they don’t break the chain, they can kill the nation” (Participant, 31-49, Oshikuku).
For one young male participant, there was little distinct value in repeat testing, apart from being the mechanism where one would transition from being HIV negative to being HIV positive: “All you do by testing is to know when its hit you, but it is not going to make any difference. It will hit you. If you are testing and testing, one day you are going to walk in there and you will be positive” (Male, 16-19, Rehoboth).
6.5.2 Awareness: MCP and social norms
Respondents were asked about their perceptions of MCP-related behaviours and attitudes at the community level. Around half of all respondents (47%) agreed that it was common for unmarried women in the community to have many boyfriends at the same time, although there were marked differences between communities, with this perception being lowest in Oshikuku (28%) and highest in Rehoboth (72%). Perceptions of unmarried men having many girlfriends followed a similar pattern with 53% of respondents agreeing, and with very high perceived levels in Rehoboth (83%).
Perceptions of concurrency were not markedly lower for people who were married in comparison to those who were unmarried. More respondents (47%) perceived that it was common for married men to have other sexual partners than married women (30%). The majority of respondents (70%) perceived that young women had older partners for money or other commodities, with perceptions being higher for Oshikuku (78%) and Rehoboth (86%).
Peer modeling and peer pressure to have other partners influences individual behaviour. Despite perceptions that MCP-related behaviours were common, there was also a perception that people who engaged in MCP-related behaviours were not accepted. On average between sites, 38% of respondents agreed that their friends engaged in concurrency, although only 15% agreed that their friends encouraged them to do the same. Along similar lines, perceiving that one’s friends admired people with many sexual partners was only agreed to by 17% of respondents, while 65% agreed that their friends encouraged others to have fewer partners and 45% agreed that their friends encouraged others to avoid concurrent partners.
A large proportion of respondents (77%) perceived disapproval of MCP by community elders , as well as disapproval by friends (64%). Higher proportions perceived such disapproval in Oshikuku – 91% and 86% respectively.
Using condoms was not seen as a justification for having many partners, with only 18% agreeing; moreover, nearly all respondents (94%) agreed that having many partners leads to violence.
6.6 Impacts of the campaign
Respondents were asked whether they had spoken to friends or family about HIV/AIDS in the past month, and if yes, they were asked to report (without prompting) what topics related to sexual behaviour were discussed (Figure 8 and Table 18). Around two thirds (63%) reported speaking to others, with the main topics being HIV testing and condom use. However, around a quarter (27%), reported discussing multiple partners, and a similar proportion 24% reported talking about the BTC Campaign or concurrent partners. Among respondents who had heard of the BTC Campaign, around a quarter (24%) had spoken to others about the campaign in the past month. This was lowest in Rehoboth at 13%.
Respondents were asked whether they believed people in the community in general were changing their sexual behavior (Table 19). Around a third (36%) agreed that changes were taking place. The lowest level of perceived change was reported in Rehoboth, at 17%. For the communities as a whole, breaking the chain or avoiding concurrent partners was mentioned by around half of respondents (49%) as a community-level change followed by condom use and having fewer partners, each at 43%.
Respondents who had ever had sex were asked whether they thought their most recent sexual partners had other partners while they were together (Table 20). Although only 13% responded in the affirmative, there was a high degree of ambiguity in response, with 46% indicating that they did not know or were unsure.
6.6.1 Impact: MCP and reported changes to sexual behaviour
Respondents who had ever had sex were asked if they had made changes to their sexual behaviour recently (Table 21). Two thirds (66%) said that they had done so, although this was lowest in Rehoboth (53%). Respondents who said that they had made changes were asked to mention what changes they had made.
The main change made was increasing condom use, which was reported by around half of respondents (51%). The next most common change was reported as ‘breaking the chain’ or avoiding concurrent partners, which was reported by around one in five respondents (22%). This latter change was similar among males and females (22% vs. 23%), but the community comparison showed lowest levels for Rehoboth at 14%. Males were also more likely to report having fewer partners (26%) in comparison to females (12%).
Of the respondents who said they had not made changes in the past year (34%), only a small proportion indicated that they planned to make changes in the coming year (Table 22). The main planned changes were using condoms more often (12%) and knowing their HIV status or that of their partners (11%).
Respondents were asked about the frequency with which they had used a condom with their most recent sex partner (Table 23). About half (51%) reported using a condom every time or almost every time. Such frequencies of condom use were lowest among respondents who were married (17%), in comparison to 64% for respondents who were cohabiting, and 69% for those who were in a relationship.
6.6.2 Impact: Effects of increased exposure to the BTC Campaign
All respondents in this evaluation had been exposed to at least one component of the BTC Campaign. As stated previously, exposure is represented in this study as the acknowledgement of having heard, seen, or having been told about a given component of the BTC ‘message’ through a given channel – for example, a radio advertisement or a poster, or engaging in a community-level event or activity. In this sense, it represents the variety of messages received, rather than the frequency with which a given message was received. The analysis that follows illustrates differences between groups of persons based upon their exposure to a greater, versus a lesser variety of components.
A “low exposure” group was defined as having received 1-9 components, and a “high exposure” group as having received 10 or more. A number of significant outcomes relating to the BTC Campaign and the issue of sexual partner concurrency were observed between the two groups (Figure 9, and Table 24). Around two thirds of respondents had spoken to a friend about HIV/AIDS, and this was more likely among respondents who were exposed to the higher number of BTC components (65% vs. 53%, p=0.003). Such discussions were also more likely to refer specifically to BTC or concurrency (25% vs. 16%, p=0.06).
Changes to sexual behaviour over the past year were more likely to be reported by respondents with exposure to higher numbers of components (65% vs. 50%, p<0.001), as was breaking the chain or avoiding concurrent partners (24% vs. 9%, p=0.02). Higher exposure to multiple components was statistically significantly associated with intention to change sexual behaviour (p=0.02), but had no relationship with future intentions to break the chain or to avoid multiple partnering within a year or month (proxies for concurrency). Exposure to a larger number of BTC components was also not significantly associated with the number of partners reported in the past year or past month.
6.6.3 Changes in sexual partnerships over time
A multivariate logistical regression analysis was conducted to compare data from the surveys conducted in 2007/8 and the current survey to explore multiple partnership reduction (the evaluation’s proxy measure for MCP) over time.
The analysis demonstrates that there have been significant changes since the baseline assessment, with a marked reduction in the proportion of people reporting 2 or more partners in the past year or past month (Figure 10). It is important to note that the comparisons that follow do not by themselves provide evidence of a causal relationship between the BTC Campaign and the observed effects. However, the findings provide useful information for inclusion in the triangulation analysis of the effects of the BTC Campaign in the context of the three study communities.
Table 25 shows changes in proportions of the population with reported numbers of partners (no more than one or 2 or more) in the past year from 2007/8 to 2011. These changes are examined by site, sex, age, employment status and other demographic characteristics. Overall, the likelihood of having two or more partners in the past year was 70% lower for all respondents (OR: 0.28), and this reduction was highly statistically significant (p< .001).
When analysed by site, partner reduction was most likely to have occurred in Oshikuku, followed by Oniipa, and then Rehoboth. The reduction in odds of having two or more partners in Rehoboth was however only around 50% (OR: 0.53), in comparison to nearly 90% in Oshikuku (OR: 0.11) and this was a significant difference
Partner reduction was as likely to occur among males (OR: 0.30) in comparison to females (OR: 0.31), and respondents 35 and older were most likely to have changed (OR: 0.18). Religion was not statistically significantly associated with the likelihood of multiple partnership change.
Respondents who were unemployed were least likely to have reduced their partners (OR: 0.40), whereas those who were employed were most likely to have done so (OR: 0.18). Partner reduction was also more likely to have occurred among people who were married (OR: 0.21) or cohabiting (OR: 0.18), while higher levels of education were also associated with a reduced likelihood of having multiple partners.
Table 26 shows changes in the number of partners in the past month. The overall likelihood of having two or more partners in the past month was 75% lower for all respondents.
When analysed by site, partner reduction was most likely to have occurred in Oshikuku, followed by Rehoboth and then in Oniipa. The reduction in odds of having two or more partners in Oniipa was not as strong as in the other two sites.
Recent partner reduction (within the past month) was slightly more likely to have been reported by males in comparison with females, and respondents 35 and older were most likely to have reported such change., In this instance, religion also appeared to be strongly associated with the likelihood of recent multiple partnership reduction. Students were least likely to have reduced their partners in the past month, whereas employed respondents were most likely to have done so. Partner reduction was also more likely to have occurred among married or cohabiting persons. No changes in multiple partnership behaviors occurred among respondents who said they were in a non-cohabiting relationship.
Participants in focus groups were asked to talk about how the campaign may have engaged them with regard to their partnerships, and analysis of the interview data examined processes of internalization of messages, as well as the emerging actions or changes that participants reported had been made as a product of the campaign.
Youth and the BTC Campaign
Youth- specific perspectives were explored, and are presented here.
Choosing to avoid multiple partners included rationales such as not wanting to risk having to abandon one’s studies or miss out on employment opportunities. One male participant saw marriage as a preferable goal: “I have decided that I will not be part of multiple sexual networks in the future and that I will only stick to one sexual partner. So the campaign has changed the way I think about my future and it has taught me to wait for the person who I will marry” (Male, 16-19, Oniipa). Another participant felt that abstaining was a viable option to avoid risk from a partner, but such an option was also a product of accepting that it was not ideal to have sex when young: “I decided to give up, just to abstain, because that one partner cannot also be trustworthy, and this thing of our teachers saying that it is not the right time for us to have sex, so I really gave up” (Male, 16-19, Oshikuku).
A female participant highlighted concerns about risks of passing on the disease to others: “I would say in my future, I won’t have many sexual relationships. I’ll be sticking to one person whether I have contracted disease or not. I don’t want to pass the disease to other persons. I will stick to one partner and not have many partners” (Female, 16-19, Oniipa). Disinterest in being part of a sexual network was related to having a sense of pride in oneself that was worth preserving: “It makes me think: ‘let me conserve my dignity, decency, and my relationships for somebody who deserves it’,” (Female, 16-19, Oniipa). Other participants also noted that having many partners led to ‘losing one’s value’ and being the subject of gossip.
Sexually active male participants indicated that the BTC Campaign had elicited a sense of risk and danger and, as a consequence, they were changing their behaviours by reducing their concurrent sexual partnerships –“Like about myself. I was having more than three girls and when I heard about the Break the Chain Campaign I suddenly realized that I was in danger that I should stick to one girl only. So, I decided to leave the other two and stick to one,” (Male, 16-19, Rehoboth). Others spoke about shifting perspectives on having many sexual partners, and avoiding shallow attractions in favour of deeper monogamous relationships. For example, a male participant explained that previously, he would ask girls out because he ‘wanted to be with them’, whereas now, deeper emotional attraction was necessary: “Now, when I ask a girl out it will be because I love her. If I do not love her, I will not ask her to go out with me” (Male, 16-19, Oniipa). The concept of trust was highlighted, and was noted to involve discussion with one’s partner and a commitment to being faithful, with the BTC Campaign being seen as enabling such discussion. As a male participant explained: “I discussed the information with my girlfriend. My girlfriend told me that she trusts me and that she hopes I am being faithful to her and that she will be faithful to me. We decided to stay faithful to each other and see whether our relationship could make it being faithful to each other” (Male, 16-19, Oniipa).
There were also detailed discussions about the concept of being a ‘player’ with attitudinal shifts being noted. For example, in a discussion in Rehoboth, male participants indicated that their previous admiration of ‘players’ had shifted to pity as a product of the key messages of the BTC Campaign: Participant: “So, I personally admired players”. Facilitator: “You admired the players?” Participant: Yes, but [now] I know that they are putting themselves at risk I personally don’t admire them, I pity them… If you are a player you must also know that you are going to be infected soon” (Male, 16-19, Rehoboth).
Female youth were noted to be changing their attitudes to relationship proposals made by young males: “Those girls will tell you: ‘No, I am already in a relationship’. So the girls are changing their behaviour”, (Male, 16-19, Oniipa).
Overall engagement with the BTC Campaign
While the above section has highlighted perspectives of youth, the following subsections detail general engagements with the BTC Campaign and include perspectives of adult participants. Related further perspectives of youth participants have been included where applicable.
While the quantitative findings indicate that the BTC Campaign and concurrency is being discussed with friends and family, the qualitative findings reveal the tensions produced in relation to shifting norms around MCP. Participants in general, particularly males, noted that some of their friends and peers continued to justify having many partners, and encouraged them to do the same: “Sometimes friends can influence you to have many sexual partners. Friends will ask you: ‘How many sexual partners do you have?’ If you say you have only one partner, they will say: ‘I have five sexual partners. You are weak, you must have more sexual partners!’” (Male, 20-30, Oniipa). In such contexts it was necessary to evaluate one’s friendships in relation to peer pressure and HIV risk. One strategy reported by participants was to avoid risk-promoting friends: “If you find yourself with such friends, then you need to avoid them” (Male, 20-30, Oshikuku). Some participants indicated that when they discussed reducing risk behaviors withtheir peers, their views were not necessarily accepted. One male participant reported that when he tried to persuade a friend to stop having concurrent partners, the friend broke off the friendship. Another male participant in Rehoboth recounted an argument he had with a friend at a drinking venue over his risk behaviors, which resulted in disagreement to the extent that the friendship was impacted – “he told me he would not drink with me again” (Male, 20-30, Rehoboth). An emerging discourse, however, concerned the conceptualization of people who had many partners as no longer being trend setters, but rather, being people with a ‘problem’ related to HIV risk: “They have a word for it that you are not in fashion. Just similar to that break the chain picture. You go back and look at your chain, and see there is a problem in your chain…” (Male, 20-30, Rehoboth).
The disadvantages of having multiple partners were also acknowledged. It was noted that if one was a ‘player’, one was always broke because having multiple partners required money – “You don’t have cash all the time because you have got three different girlfriends, that means you have to raise three different incomes. They are going to kick you if you don’t have any money” (Male, 16-19, Rehoboth), with one participant commenting wryly: “the chain is breaking you. The chain will break your pocket” (Male, 20-30, Oshikuku). Having many partners also meant that one had to ‘become a liar’.
Highlighting the exclusivity of sexual partnerships was another way of addressing perceived risks in one’s peer environment – for example, emphasizing that one’s partner was ‘off-limits’: “The guys must also know that she is your girl. You don’t mess with my girl I don’t mess with yours. If you respect your friends, you respect your friend’s girlfriend” (Male, 20-30, Rehoboth). Another male participant said he told his girlfriend to rebuff approaches from other males by refusing to provide her cellphone number when propositioned. This risk was highlighted by other participants, who noted that making contact was very easy through cellphones or social networking programmes such as Facebook: “It is so much easier to stay in contact with your girlfriends. Technology allows us to stay in contact with more people, making it [easier] to have sexual relations with more people” (Male, 20-30, Oniipa).
Shifts were noted in the broader community, where it appears that disapproval of people who are perceived to have multiple partners is being pointedly articulated: As one BTC implementer noted: “Like when you are walking past the poster. Another person will point at you and the poster and advise you to break the chain… So people are publically identifying other people who they think connect to the message of the poster and telling them to do what the poster is saying”. There were limits to the extent of the impacts of exposure to the BTC Campaign however, with some community members being described as not wanting the message to “get through within their heart”.
Although contextual challenges such as poverty were recognised as underpinning sexual networks, it was also seen as possible for individuals to decide not to be part of one by being faithful: “What the networks bring into the community can be stopped already by you not partaking in one. [Unemployment, crime] cannot be stopped. You have to stop yourself from entering into the network …” (Male, 20-30, Rehoboth).
Heightened sense of vulnerability
The BTC Campaign has increased perceptions of personal vulnerability to HIV among many participants. This included invoking self-reflection about one’s relation to sexual networks that was reinforced visually by depictions of the ‘chain’. As one participant remarked: “No, I cannot go after the lady after I have seen the picture of break the chain” (Male, 31-49, Oshikuku), while a young female said she felt embarrassed when she had to acknowledge that she was part of a sexual network: “If, for example, you are having a lot of partners and see the poster. I will be embarrassed because I will be thinking: ‘that’s me being reflected there’. This is good embarrassment, because you take it into consideration and try to break the chain” (Female, Oniipa, 16-19). Another participant observed: “You say, ‘Oh I’m somewhere here between these people’,” (Male, 20-30, Rehoboth).
The need to address one’s risk to HIV was seen as an urgent imperative, as one participant said, having multiple partners “sal net vir my graf toe sleep / will just take me to my grave”(Female, 20-30, Rehoboth). Participants also illustrated a consciousness about the longer-term impacts of HIV infection – notably responsibilities for caring for and enjoying one’s children: “We must break these chains… After the campaign came out, it made me afraid of sexual relationships and I am now much more careful. I must also still raise my children” (Female, 20-30, Rehoboth). This was similarly voiced by a male participant who said: “I am a guy who one day wants to sit on my farm and watch my children grow old, stuff like that. So no, I am not in the chain” (Male, 20-30, Rehoboth).
For some, however, situational factors limited one’s capacity to ‘break the chain’ – for example, the need to feed one’s children: “If someone comes with money and you don’t work and you don’t have food then you don’t want to lose that money – so you must lie down to get money to buy food for the children. So where will the chain be broken?” (Female, 20-30, Rehoboth). Similarly, ending a relationship with a sugar daddy was not a simple matter: “If you have a sugar daddy and he gives you everything, he is loaded, every end of the month you get new fashion clothes and stuff. So you just don’t want to break the chain because of that”.
Breaking the chain
A number of participants reported direct changes to their sexual relationships as a product of engaging with components of the BTC Campaign, either by addressing their own concurrency practices, or ending relationships with partners who were known to have other partners. As a female participant in Rehoboth illustrated: “It forced me to think differently. I should not go on as before… It immediately gave me a click in my head that said, ‘it’s up to you’. I left my partner because I knew that he had more partners and I am not looking for this chain business” (Female, 20-30, Rehoboth). Another participant observed that repetition of the message created a reminder of new rules for relationships, with her understanding of risk being reinforced and leading to change: “It is like you being told to obey the road signs. After being told you realise that the same message is being brought up on TV, which is like a warning. This is how it changed my behaviour to stick to only one partner” (Oshikuku, 31-49).
Engaging with the campaign content included acknowledging that temptation might be recurrent, but that it was inappropriate to perpetuate sexual networks: “I have a boyfriend and each time I want to cheat on him, I realise that this is a chain and it is a wrong thing to do and I won't cheat anymore” (Female, Oshikuku, 31-49). Male respondents were similarly aware that the risks of their own concurrency practices were untenable, and changes had to be made: “Sometimes I would have two girlfriends in the village and I might have three or four girlfriends at school and also locally I will have more than two. Once I came across that break the chain information, I came to realise that I should change the way I am having so many girlfriends… I decided to stop the way I was having sex” (Male, 20-30, Oniipa). It was also acknowledged that it was not always easy to change such practices because MCP was ‘addictive’: “Just like when you smoke, it is difficult to quit smoking” (Male, 20-30, Oshikuku).
Reducing one’s partners included differentiating between casual partners and choosing to stick with a preferred partner who could be trusted: “Its like you are a girl and you are staying with five boys. That poster is encouraging you to choose one partner. The trustable one” (Female, 20-30, Oshikuku). Honesty was seen as a key value to incorporate into relationships – as one participant observed: “We should not talk around the truth. Honesty is the best. Honesty will break the chain”(Participant, 31-49, Rehoboth).
Talking to a sexual partner about concurrency and HIV testing provided a means to address HIV risk in a relationship. This did not, however, necessarily preserve the relationship – as a female participant in Rehoboth illustrated: “Yes, I had a partner and after I spoke to him, he left me. That’s what I say, when you ask the men, let’s go to New Start, they start to fight or they ask: ‘But why are you unsure about your status?’” (Female, 20-30, Rehoboth). A participant working with the campaign suggested that it was a good idea to provide counseling support when relationship partners were in conflict and couldn’t resolve matters.
Participants spoke about consciously ‘cutting themselves off’ from sexual networks, and this was seen as being the literal meaning of ‘breaking the chain’. The sense of urgency to remove oneself from risk was positioned as markedly different to previous campaigns. As one BTC Campaign worker noted: “[Previously] it was like, ‘Oh what must I do now. Can I just give the person a chance’. There is nothing like that now. You decide immediately the moment your brain registers ‘Break the Chain’. Then you cut” (BTC implementer, Rehoboth).
Risk perceptions were sometimes one-sided – with female participants noting that their male partners were less open to change. As one BTC implementer noted: “In most cases when a woman understands about the information regarding the break the chain campaign and her man does not understand or does not want to understand, then the woman will then decide to break the chain herself and will leave the man. So she will break up with the man and she will change her own behaviour” (BTC implementer, Oniipa).
6.6.4 Discussion on the social context of MCP, sexual relationships and change
The quantitative data illustrate a broad perception that having multiple and concurrent sexual partners is common in the study communities. The extent of concurrency was perceived to be fairly similar among unmarried men and women as well as among married men; perceptions were that it was somewhat lower among married women. There was widespread agreement that young women often had older partners for money, necessities, or luxuries, and friends were also fairly widely perceived to have concurrent partners. Such perceptions were higher in Rehoboth than in the other two communities.
Notwithstanding the perception that having multiple partners was common, there was, at the same time, the contrary perception that such practices were not endorsed by the majority of one’s peers or community members. This suggests that a foundation exists within the study areas that is antagonistic to MCP and that communities are perceived to include pro- and anti- MCP orientations among community members. While such perceptions cannot be directly attributed to the BTC Campaign, the quantitative finding that a third of participants perceive that changes in sexual behaviour are occurring at community level, and that many of these describe the changes in terms of ‘breaking the chain’ and avoiding concurrent partners, suggests that the campaign is taking hold.Such perceptions were also higher in Oshikuku and Oniipa, where there was higher exposure to multiple BTC Campaign components.
There is evidence in the quantitative findings that the campaign has had some bearing on establishing new attitudes, with around a quarter of those in the quantitative study who spoke to friends and family about HIV/AIDS in the past month specifically discussing the BTC Campaign or concurrency. In addition, the qualitative data illustrate that the risks of MCP are being highlighted amongst peers, that having many partners is ‘unfashionable’ and that it is not productive to continue friendships with those who promoted MCP, and such statements are linked to engaging with the BTC Campaign.
The analysis of exposure to higher numbers of BTC components has demonstrated a significant relationship to relevant indicators of change, including dialogue about HIV/AIDS, dialogue about the BTC Campaign, and changing sexual behaviour, including ‘breaking the chain’ or avoiding concurrent partners.
Of direct bearing to behavioural changes linked to campaign are the responses to the question ‘Have you made changes to your sexual behaviour in the past year?’ with two thirds of respondents agreeing that they had (Table 19), and with ‘breaking the chain’ and avoiding concurrent partners being mentioned by one out of five respondents who reported making a behavioral change. This finding indicates that campaign-related change is taking place.
The qualitative findings support the direction of reported change in the quantitative data. Coherent narratives are provided about how the key messages of the campaign have been internalized and acted upon. Many of the narratives reflect the emergence of new ‘cultural scripts,’ – that is, new ways of thinking, expressing ideas about, and responding to HIV risk in common social situations are developing. The qualitative narratives align with the overall hypotheses that the BTC Campaign has produced new knowledge relevant for HIV prevention with individual outcomes including internalization of risk and reduction in MCP-related risk behaviours.
Youth who were not yet sexually active spoke of integrating an understanding that sexual networks posed untenable risks for future relationships, and this provided support to ongoing abstinence as well as reframing the understanding that long-term committed relationships were necessary. This sense of self was framed to include ‘preserving one’s dignity’. They were also able to explain how their sense of vulnerability to HIV had been internalized, and that knowledge was translated into practice by ending concurrent partnerships, acknowledging the need to only pursue relationships where there were genuine feelings for the other person, and engaging with one’s partner in a discussion about faithfulness. Trust was also acknowledged as an important value to hold in a relationship.
Alongside these practical changes, there is evidence that there are changes in norms within the subgroup of young people who were previously in agreement with MCP practices. The notion that having many partners increases one’s social standing was shown to be moving towards the opposite direction. ‘Players’ are no longer admired, they are pitied, and young women are deflecting approaches from males by saying that they are already in a relationship. The qualitative narratives also showed that although some friends continued to promote having many partners as an appropriate format for sexual relationships, there was evidence of capacity to interrogate and resist entreaties to do the same. Strategies included voicing counter-discourses and removing oneself from the peer environment, with some critiques leading to individuals being rejected by acquaintances. Disadvantages of having concurrent partners (other than the risk of HIV infection) were also highlighted by participants.such as having to ‘be a liar.’ Additionally, having many partners is described as being ‘unfashionable’ and there is an emerging self-consciousness and embarrassment among those with concurrent partners who know they are at risk. Self-confidence is evidenced in narratives that describe friends warning each other not to make advances the other’s partner, and advising one’s girlfriend not to hand over her cellphone number to other men to avoid possible further entreaties for a sexual relationship.
A number of participants described seeing themselves ‘in the chain’ as depicted by the BTC Campaign, and this allowed them to accept their vulnerability to HIV risk. This sense of vulnerability also engaged with perceptions of their future, with action needing to be taken to avoid an early death, or to miss out on seeing their children grow up.
With regard to taking action, the qualitative narratives illustrate rapid and purposeful transitions within sexual partnerships. Respondents acknowledged that they ended relationships because they understood the risks to HIV for themselves, and for their partners. Instead, trust and honesty were emerging as relationship values that were necessary to ‘break the chain’.
While some participants noted that making changes to MCP behaviours was difficult because of exigencies such as needing food, or having to overcome the addictive ‘pleasures’ of having many partners, participants in all groups described strategies and processes of reducing MCP. There were a number of narratives that described rapidly terminating concurrent partnerships, with changes being clearly rationalized towards risk reduction. These narratives did not reflect consideration of the feelings or emotional impacts on those with whom a relationship was ended, which suggests that ties to concurrent partners are intrinsically weak. This is in keeping with research findings that have found that people with concurrent partners distinguish between a main partner that is loved, and other partners who are not loved. Strategies applied with a main partner include discussing risk and going for HIV testing, which illustrate an understanding that sexual partners have an obligation to protect each other from HIV infection.
The comparison of the current evaluation data with the 2007/8 baseline provides a further useful data point for change in the study communities. The analysis shows that changes have occurred in relation to reductions in having 2+ partners in the past year and past month. While these changes are not directly attributable to the BTC Campaign, it remains that significant changes have been measured, and possible campaign impacts cannot be excluded. Change over time has been less marked in Rehoboth than the two smaller communities, although change occurred similarly between males and females. Change was also most likely among people 35 years and older in comparison to younger age groups. People who were employed formally or informally were also more likely to reduce their risks, while being married or cohabiting also produced a higher degree of risk reduction over time.
6.7 Other Findings
6.7.1 Alcohol consumption
Alcohol consumption is known to be associated with having multiple partners – for example, a study in Botswana found that men and women who drank heavily were three times more likely to have had unprotected sex with a non-monogamous partner in the past month than those who did not drink heavily. An ethnographic study on alcohol use in Namibia illustrated the links between alcohol consumption in drinking establishments and casual sexual encounters, while a study in Tanzania found that condom failure was five times more likely in recent sexual encounters among women who had been drinking prior to sex, in comparison to those who had not. Women who drank were also more likely to report recently having sex with a new partner, having casual or transactional sex, or having sex at a location that was unfamiliar or less within their control. A reciprocal expectation for sex was noted among men who bought women drinks at drinking establishments.
In the present study, being seen to be drunk in public was perceived to be high among both women and men at 63% and 83% respectively. This was perceived to be more common for men in all communities, although perceptions for both sexes in Rehoboth were similar – 85% for women and 94% for men.
Respondents were asked about their frequency of alcohol consumption and whether they had been drunk in the past month. Nearly half (44%) said that they drank alcohol, with alcohol consumption being twice as likely among males (64%) as females (32%). Only a minority of respondents drank daily (6%), with the majority drinking once per week or less (63%). However, in spite of the relatively low frequency of drinking, half of all those who drank alcohol reported that they had been drunk in the past month.
When the reported number of partners in the past month was analysed against alcohol consumption, it was found that respondents who drank alcohol were three times more likely to report having two or more partners in the past month, than those who did not.
The proportions of respondents involved in multiple partnerships in the previous year and in the previous month showed statistically significant declines from baseline (2007/8) to evaluation (2011) across the different indicators of drinking behavior (Table 29). However, those persons who reported having been drunk in the previous month were still less likely to have reduced their number of partnerships in the past year (OR: 0.42) or past month (OR: 0.36) than were non-drinkers (OR: 0.23 and OR: 0.27, respectively).
In focus group discussions, alcohol and sexual exchange were seen as interconnected, with many participants mentioning alcohol as the main factor contributing to sexual risk. People who were under the influence of alcohol were noted to adopt an ‘I don’t care’ attitude that contributed to recklessness and risk.
There was a normative understanding that when a man bought a woman alcohol, it was reasonable to expect sex in return. As a consequence, MCP behaviours were perpetuated: “At the shebeen a man buys a ‘cherrie’ a beer then we drink together and he later says to her ‘You got a lot from me, what do I get from you? I must get something out of this’” (Female, 20-30, Rehoboth). Women were aware of such expectations, and did not necessarily resist them: “When they see a man with a lot of money and he buys a lot and he pays with a N$ 100 bill every time and does not ask for change, they would decide to stay with this man for the night” (Female, 20-30, Rehoboth). As another female participant noted, ‘at the end you have to pay back.’
Male participants observed that women were more likely to be open to sexual liaisons with men who had a car or money: “Ladies like that stuff. It is not difficult to get her. If you have money… it is not difficult to get that girl. It is very easy. More especially if you have a car. Girls will throw themselves on you”(Male, 20-30, Oshikuku). Another observed: “Car and alcohol are the main risks that lead to an increase in multiple partnerships” (Male, 20-30, Oshikuku).
Among some participants, there was an acknowledgement that the risks of alcohol consumption in relation to vulnerability to HIV needed to be addressed. This required conscious strategies such as choosing to drink at home instead of going to alcohol venues: “I used to need to be amongst people when I used alcohol. Now I realise that I can have a few beers at home and does not need put myself in a difficult or dangerous situation… It really had a good impact on me” (Female, 20-30, Rehoboth). A participant who was involved in the campaign described how he stopped drinking as a product of realizing that the risks of having casual partners were unacceptable: “We used to be reckless. We could drink and go somewhere and find beautiful girls and think it was fine. But after this campaign started I decided to stop drinking and it changed my whole lifestyle and how I perceive things and do things now. It really made me realise the seriousness of a sexual network” (Male, BTC implementer, Rehoboth).
6.7.2 Discussion on alcohol and HIV risk
Alcohol consumption and multiple partnerships (the proxy for MCP in this evaluation) were found to be linked; those who drannk had a higher likelihood of having multiple partnerships in the past month than did those who did not drink. This is in keeping with findings in other studies. Although comparison with 2007/8 data has shown overall declines in MCP, respondents who were drunk in the past month were noted to be less likely to have reduced their partners.
The qualitative findings support other research that reports that sexual connections are readily made at alcohol venues, and that for females, being bought drinks requires reciprocity by providing sex. In some instances, males who were perceived to have money were actively pursued by women at alcohol venues.
Of importance are the personal strategies that have emerged to modify alcohol consumption behavior so as to reduce exposure to sexual networks and consequent HIV risk. Such strategies have been prompted by risk awareness generated by the BTC Campaign and include avoiding drinking establishments as well as giving up drinking.
6.7.3 Gaps and opportunities: Feedback from Recipients of Campaign Messages
Participants explored gaps and opportunities for the campaign. A sub-analyses of FGDs among youth, adults, BTC implementers and PLHIV were conducted.
In general, using a wider range of languages and reaching more rural communities was suggested. There were also suggestions related to the need to address shortages of materials and it was also felt that community-level activities were infrequent. A number of participants voiced the idea that more people with HIV should be represented in the campaign.
Participants were asked about their knowledge of the BTC Campaign and how they understood the campaign concepts. This was explored in relation to the core idea of sexual networks, as well as in relation to the slogan and the aesthetic dimensions of the colours and imagery used in the campaign to engage its target audience. Participants also reflected on the campaign in relation to previous campaigns.
The campaign was seen as factual and straightforward – “It is to the point and it brings out the message clearly to the general public” (Male, Rehoboth, 16-19) while sexual networks were readily understood as people who were “…sexually connected to many people at the same time” (Male, 16-19, Oshikuku). This was well understood in all communities as resulting in pathways along which HIV could be transmitted: “…the main message is that when you are connected to so many partners, you are exposed to HIV” (Female, Oniipa, 16-19). Individual risks were also understood as being related to the unknown partnerships of people one had sex with: “…you sleep with one partner today and you sleep with another partner tomorrow. But you do not know where that partner has been” (Male, 20-30, Oniipa).
Community perceptions of the clarity and simplicity of the core campaign messages was affirmed by participants working with the campaign who observed that “when the message came out everyone said ‘oh, this is how it goes’,” (BTC implementers, Rehoboth).
The BTC Campaign was contrasted with campaigns that only focused on safer sex, which were noted to not sufficiently address the importance of disrupting sexual networks: “The other programmes are only focusing on ‘how’ you can be safe within your sexual network … [and] are only encouraging you to always have a condom in your pocket where ever you go” (PLHIV participant, Oniipa). Other participants described the risks emanating from sexual networks as having been previously ‘hidden’ or ‘concealed’.
It was felt that the slogan was easily interpreted by people from all walks of life and that it incorporated ‘the whole message’, while also being included in people’s conversations because it ‘sounded nice’. A religious leader in Oniipa observed that the phrase ‘Break the Chain’ could be used as a means to refuse advances, while PLHIV in the same community felt that it was helping youth because young girls were able to use hand gestures and say ‘No I break the chain’, in a lighthearted, non-threatening, but decisive manner.
A further value of the slogan was its capacity to enter into one’s stream of consciousness to the extent that thoughts of sexual liaisons were immediately checked by the campaign-derived knowledge that entering into sexual partnerships posed a risk for HIV. As one participant in Rehoboth described: “When I see a lady walking by and see she’s good, that moment in my mind it is like break the chain. It is like a memory in my mind. That break the chain slogan it says more than the pictures. Even if you did not see the picture, you immediately know” (Male, Rehoboth, 20-30).
Colour and imagery
The yellow colour that was adopted as a theme for the initial campaign was well liked and seen as attractive by participants in all three communities. The use of red to illustrate HIV and network pathways was also liked as it was seen to represent blood, sickness and danger and for some, this brought about tangible fear for some: “The red colour is not looking nice. It indicates an HIV positive side, which is very scary because it shows people that are infected with the virus” (Participant, Oshikuku, 31-49).
Some youth participants raised concerns about the sexualized imagery, noting that it was not good for children to see ‘naked people on television’, while a young male said that he became embarrassed when the television advertisement was aired during a time that his mother was in the room, leading him to pretend to receive a cellphone call so that he could go to another room. Concerns of the effects on children were also raised by older male participants in Oniipa.
Concerns about sexualized imagery were mainly raised by participants in Oniipa, and it is unclear why these were localized. However, the concerns do seem to relate to an underlying expectation that an HIV prevention campaign should not include overly sexualized content, with considerations being how such representations affect children, or indeed intrude into discourse environments – such as parent-child contexts of television viewing.
The television advertisement had a good overall appeal that included an interest in repeated exposure as a product of the aesthetic dimensions of the advert as well as viewer identification with the message: “The time that advert is running is not long, and you never get bored with the advert. If you hear it playing again you make an effort to come and see it even if you are in the kitchen. It’s a very nice advert with a strong message” (Male, Rehoboth, 20-30). Similarly, in relation to the colour and design of the posters, a female participant noted that she was drawn to examine the text and imagery more closely “When you see the poster with the yellow circles and bubbles and different colours, you will think: ‘Okay why is this poster different from the others’, which makes you more curious to look at it compared to the others” (Female, Oniipa, 20-30).
Although community-level components were not explored in depth, the general view was that interactive items such as DVDs, the flannelgram and Picture Codes all aided understanding and promoted dialogue. PLHIV participants noted that they had engaged with the content of the programme as part of their discussions in support groups, while in Oshikuku and Rehoboth, youth participants talked about how BTC had been a topic that was discussed as part of a formal classroom debating session.
What was particularly valued was the integration of community-level discussions that allowed for interaction. BTC implementers also indicated that the campaign encouraged deeper levels of interaction at community level, observing that previous campaigns “never allowed the communities to share their ideas or thoughts on the message that was brought to them”.
There were interesting contrasts made between the BTC Campaign and previous campaigns – notably highlighting the limitations of a focus on singular strategies such as condom use that did not necessarily critique or disrupt sexual networks. “BTC has a more visible message and it made a big impact. If you see the branches you would just shiver. The other campaigns encouraged one to be part of networks because you could be safe by using condoms. BTC does not talk about condoms, you must just break the chain” (Female, 20-30, Rehoboth).
Condoms were also seen as promoting casual sex – as a faith-based leader in Rehoboth observed: “They see a girl and desire her… as they get to the condom…they buy it and come back. So the condom also becomes a kind of passport to sex”. This viewpoint was affirmed by other participants – for example: “I think that condoms are also promoting HIV/AIDS in a way. It is encouraging people to have sex. That is what is in the mindset of the human brain. So to my understanding, condoms must also be wiped out” (Male, 20-30, Rehoboth), and,“But if you are always using a condom and you have many partners, then you will have more opportunities to have sex with a female”(Male, Oniipa, 20-30).
Gaps and opportunities: Youth
With regard to message content, it was noted that it remained relevant for the campaign to promote abstinence and condoms among youth. ‘Branded’ utility items such as soccer balls, water bottles, bracelets and hairclips were mentioned as ways to reinforce the BTC message.
Youth participants indicated that they were keen to engage with the campaign, and suggested that there be more focus on youth events such as soccer games. Additionally, it was highlighted that churches could provide an avenue for reaching youth. School-related activities could include ‘fun days’, and it was also necessary to engage with parents.
Small group participation was valued, as these allowed for learning to occur – as one participant suggested: “We also need to gather in small numbers so that one can learn easily. Houses also need to be given numbers so that these people of this number should come at this time” (Male, 16-19, Oshikuku). One-on-one conversations with BTC implementers were also suggested, and the need for confidential youth-friendly services was identified. It was also noted that although older people were not respected sources of advice about AIDS ‘because times have changed’, older people could be engaged to help to stimulate and facilitate discussions between youth.
Providing explanations and offering personal experiences and strategies for breaking the chain was suggested as something that could be conveyed through mass media: “They must get a person who was in a sexual network and managed to break up the network. This person must like talk on TV or radio about his personal experience of having many sexual partners and how he managed to break out from the sexual network” (Female, 16-19, Oniipa). Local dramas depicting the challenges and resolutions of MCP were put forward. It was also suggested that there should be depictions of the effects of AIDS on the body on television.
It was noted that youth made use of communication technologies such as cellphones and that interactive messaging could be used to reach young people.
Gaps and opportunities: Adults
There were a number of suggestions for campaign activities that extended processes of working in groups, including community-led ‘support groups’. For example, a male participant put forward the idea of forming groups of men who did not want to be part of sexual networks who could get together and share ideas: “What I was also thinking of is that maybe we can come up with group and say this group is called an A Group and we are not here to have networks and stick to our woman and every Friday or Saturday evening we gather at our place and share ideas” (Male, 20-30, Rehoboth). It was noted that groups could be run along similar lines to alcoholics anonymous meetings. Another potential advantage was that individual accountability to avoiding MCP was enhanced, given that being part of such a group would mean a commitment to setting a good example.
Participants highlighted the importance of engaging with people at alcohol venues: “[The campaign should] be enlarged to the whole community. The number of people campaigning should be increased so that everywhere it would be full of people campaigning, and not only one person. And also, maybe these things should be pasted also in the cuca shops where people go and drink” (Traditional Healer, Oniipa). It was however pointed out that it would be difficult to engage people who were drunk.
Gaps and opportunities: PLHIV
Among PLHIV, the campaign was noted to underscore the importance of ending concurrent partnerships so as not to put others at risk. In Oniipa, it was noted that“…the campaign teaches those who are infected to behave well and also those who are not infected also to behave well. To behave well is to not have unprotected sex and to be faithful to your partner” (PLHIV, Oniipa), while participants in Rehoboth spoke about ‘teasing each other’ as a means to prompt behaviour change – “Like if I see someone that I know that’s today with this man and tomorrow with that man. Then we used to say break the chain” (PLHIV, Rehoboth).
PLHIV reported discussing the BTC Campaign in support groups, and outcomes included ending concurrent relationships. It was also noted that being part of a sexual network posed a risk for reinfection, and that the challenges of living with HIV and alcohol included exposure to MCP at alcohol venues and posed problems in relation to treatment.
It was felt that women were accustomed to being members of clubs, but that this was not the case for men. It was suggested that clubs for men could include learning ‘how to behave like gentlemen’ and not have many girlfriends. Clubs could be organized under the auspices of churches and even PLHIV support groups. It was felt that it would be beneficial for PLHIV to be able to tell their life stories to “help other people to realise that HIV is not a joke and it will develop better communication. They will then be able to see what a person infected with HIV looks like” (PLHIV, Oniipa). It was also suggested that people should volunteer to visit those who were sick with AIDS, to get a sense of the gravity of the disease.
Gaps and opportunities: BTC implementers
BTC implementers felt that the campaign had changed many people’s mindsets and had tangibly changed lives. This was achieved through comprehension and acceptance of the key concepts of the campaign. An additional value of the campaign was that it was seen as providing an important new insight into HIV vulnerability that was not previously available: “So, it was like out of the box. There are really people who took it positively and decided to break it off” (BTC implementer, Rehoboth).
Participants noted that involvement in the campaign had impacted their own behaviours because they internalized a sense of vulnerability, but also because they had to set an example: “We were trained by the AIDS coordinator to be good examples in the community. They told us that we should not do the opposite of what we are saying. We should not be seen with one person today and then with another person tomorrow. We should be good examples for the community in breaking the chain of having many sexual partners” (BTC implementer, Oniipa). A number of participants in this group reported that they had concurrent partners at the outset of the campaign, but that these relationships ended as they started their work for BTC. They also spoke about supporting each other to address MCP-related vulnerability, and learning was also shared with immediate family members.
While working in group formats had strongly enhanced engagement with the campaign, promoting and establishing community-run groups was seen as a way of expanding reach and deepening the message – but also enhancing accountability: “You join such a group and if you want to get out from that group to the next person, it will really be difficult because you know you made a commitment of being a public figure but now you want to do things. It will be a self inspiration for you too” (BTC implementer, Rehoboth). It was felt that male participation in the programme was generally poor, but activities that integrated male-oriented events such as soccer, had potential to succeed. Having group meetings was seen as preferable to ‘house to house’ activities, as people were more open to discussing AIDS outside of the household setting.
In summary, the campaign’s orientation towards interpersonal discussion appears in these narratives to have generated discourse about MCP as a social and community issue – rather than as an individual issue. This appears to be an important feature of the campaign, and apart from BTC implementers noting these benefits of the campaign’s approach, the foregoing narratives also give evidence of broader social-level engagement with the campaign’s concepts, such as through discussions in support groups by PLHIV and incorporation of campaign issues into debates at school.
MCP is well established as an underlying driver of HIV in Namibia, and a complex of factors contribute to high partner turnover and concurrent sexual partnerships. Reducing sexual partner turnover and concurrency has potential to markedly reduce new HIV infections. While recent debates led by a minority group of researchers have attempted to decenter the importance of concurrency as a key driver of HIV in Africa, a large body of research in Namibia and elsewhere upholds the importance of this risk behavior, and the value of maintaining a focus on disrupting sexual networks. Such evidence guided the design of the BTC Campaign.
The present evaluation used triangulation of findings from quantitative and qualitative studies to provide a scientifically robust basis for drawing conclusions about the achievement of the primary objectives of the Break the Chain campaign’s first year of implementation, as well as of early indications of the campaigns’ effects upon behavior.
The overall hypothesis of the evaluation was that the BTC Campaign would bring about new knowledge relevant for HIV prevention in Namibia, and that individual outcomes, including internalisation of risk and reduction in MCP-related risk behaviours, would be brought about. Further hypotheses were that there was high awareness of the campaign, that the main messages of the campaign were understood, that the campaign had improved understanding of the dynamics of HIV infection and risk, that risk reduction through reducing sexual partnerships and concurrency was understood, that awareness of MCP had increased over time, and that MCP practices had decreased over time.
The evaluation findings consistently support these hypotheses, and triangulation of the data clearly demonstrates that important changes in risk perception and practices in evaluated communities have occurred. Emergent interpretations and meanings of MCP have also been identified that are directly relevant to reshaping social norms and values.
The BTC campaign followed a multi-level, multi-channel, and multimedia approach that was specifically oriented towards maximising communication reach in Namibia. The approach included a mix of mass media, small media, interpersonal communication, public relations, advocacy and training. The design and technical execution of the campaign followed an approach similar to that of previous campaigns in Namibia, and followed conventional communication approaches common to many national-level campaigns in the southern African region.
A unique feature of the Namibian campaign was the extensiveness of the collaborative partnership undertaken by independent organisations under the leadership of the national Technical Advisory Committee on Prevention and its special Workgroup for “Take Control” and MCP. This partnership structure allowed for broad involvement of prevention implementers in not only execution of the campaign, but in contributing to the development, design and dissemination of its various elements. The principles of the ‘Break the Chain’ concept and its social marketing brand were adhered to by partners. This collaborative approach, based upon a commonly-felt need to address a priority epidemic driver articulated in Namibia’s National Strategic Framework for HIV and AIDS Response, and based upon sound scientific evidence, resulted in a coherent national level campaign with all partners working towards the same goals and objectives.
Reach of the BTC Campaign
The reach of the BTC campaign was clearly strengthened by not only the broad-based collaboration, but the campaign’s multi-level implementation. It is impressive that all randomly-sampled respondents in the evaluation survey from three different geographic sites were reached by at least one component of the campaign, and that the great majority were reached by 10 or more. The campaign’s logo and slogan successfully captured and transmitted its primary concept – the risk of HIV infection through sexual networks – and the multiple communication components allowed for deeper engagement of a variety of audiences.
Variations in reach were found between demographically defined groups within communities, and also between communities. The more urbanized Rehoboth community was found to be different on a range of indicators including campaign reach and behavioural patterns, compared to the other two communities. A number of campaign-related and unique demographic features of each community contribute to such variation. These variations notwithstanding, narratives of participants illustrate common, key points regarding their conceptualization of risk:
1) The content of the campaign clearly highlights the domain of risk – sexual networks – and the means to avoid risk by ‘breaking the chain’. The message is interpreted literally (supported by campaign imagery of people in relationship “chains”) and is clear and meaningful to recipients.
2) The campaign is seen as something new and different, and this novelty is contrasted with previous campaigns that appear to have ‘hidden’ or ‘concealed’ the concept of sexual networks and their inherent risks. However, once revealed, the concept of being part of a sexual network, and the risks of being connected to one, are clear to the target population.
3) There is a new awareness that risk is not simply a function of one’s own sexual practices, and that it involves those of one’s partner; even if one is faithful, one may still be linked to a sexual network through that partner.
The concise simplicity of the slogan, “Break the Chain,” appears to facilitate its ready interpretation and integration into the “top of mind” awareness of message recipients. This is exemplified by a male participant’s description of seeing a “lady walking by and she is good” (i.e., sexually attractive), and having his thoughts of pursuing her interrupted by the campaign slogan. In this way, there is some suggestion that internalization of the slogan, alone, may be sufficient to dispel the urge to make sexual advances.
Figure 11 depicts the basic logic that underlies the outcomes and impacts resulting from the inputs of the communication activities and outputs (reach) of the campaign. Triangulation of the quantitative and qualitative evaluation findings permits the summary interpretation that exposure to higher numbers of BTC Campaign components is not only associated with, but appears to have elicited statistically significant differences in behavior outcomes, such as increasing the likelihood of communication about HIV/AIDS (65% vs. 53%) within social networks (speaking with family or friends); multiple partnerships (27%) and “breaking the chain” (24%). Additionally, among those who felt people in the community were changing their behaviour (36%), the most commonly perceived community-level change was ‘breaking the chain’ or avoiding concurrent partners (49%). Importantly, exposure to a larger number of BTC components was associated with a statistically significantly higher likelihood of self-reported sexual behaviour change in the past year (65% vs 50%), and with statistically significant mention of ‘breaking the chain’ and avoiding concurrent partners (24% vs 9%).
These findings indicate that tangible impacts upon MCP and MCP-related behavior (multiple partnerships) have been brought about by the BTC Campaign, and that high-volume, multi-component campaign reach increases the likelihood of behavioral change in desired directions.
Cultural scripts: Towards a theoretical understanding of the campaign and its effects
Further analysis of the triangulation findings suggests the underlying mechanisms by which the campaign may be producing its reported effects. A challenge in HIV risk communication is making the transition from raising awareness of risk to fostering processes whereby knowledge is internalized and acted upon. Many theories of behaviour change focus on change at the level of the individual – for example, the Health Belief Model, Stages of Change Model, AIDS Risk Reduction Model and Theory of Reasoned Action. Other theories take into account social contexts such as Social Learning and Cognitive theories, while communication processes are addressed through theories such as Diffusion of Innovation and Social Marketing. Although all these theories have some bearing on the outcomes of the BTC campaign, none adequately addresses the relationship between communication content, interpretation and meaning as found in the present study. In particular, the BTC campaign appears to have elicited an interpretive framework that blends cognitive, situational and social elements to bring about internalized meaning in message recipients. Internalised meanings have, in turn, led to reflection about the individual’s relation to his/her partnership practices and social context that have produced specific actions and behavioural commitments. The anthropological concept of ‘cultural scripts’ offers a way to interpret these processes of internalization and their outcomes in a social context of high risk and vulnerability to HIV.
The BTC campaign introduced new concepts that can be understood as ‘resonating’ with (ie. evoking feelings of shared emotion or belief), and as having significance to message recipients in relation to their lived experience in three domains – conceptual (how the key messages of the campaign were understood), situational (how the campaign messages were interpreted in relation to the recipients’ immediate individual risk or vulnerability situation), and social (how these concepts related to the recipients’ relative position in his/her society).
Taken together, these three points of resonance related to three further domains of meaning – 1) internalized meaning, which concerns translating conceptual resonance into concepts relating to individual action, 2) actions and commitments, which concern translating situational resonance into reducing one’s perceived risks, and 3) new language, which represents new vocabulary (especially terms borrowed directly from the campaign, like ‘break the chain’), and new ways of communicating aversion to risk through signs and symbols, all of which follows from social resonance.
These six domains of meaning comprise the inter-related components of a process of cultural “scripting” – ways of thinking, understanding, and acting within a particular context – which, in terms of the effects of the BTC campaign, appears to work to modify not only individual risk, but also the social environment in which MCP-related risk behaviours are found. For instance, the slogan ‘break the chain’ has served not only to promote individual understandings of risk, but it has found sufficient social meaning and utility as to be adopted into every day discourse (new language) to articulate to others an aversion to HIV risk through sexual networks. In particular, the evaluation revealed that campaign concepts have even developed organically among message recipients into a new, non-verbal vernacular -- a hand gesture that represents “breaking the chain,” and that is understood by others in the same social context. In another example, participants describe modifying their own social networks (actions and commitments) – removing themselves from friends, lovers, and others who practice or promote MCP-related behaviors, and creating new interpretations of the social valuation of “players” (social resonance), versus their own new value as persons who have “broken” the chain.
The findings of this evaluation confirm the validity of the theoretical and technical approach to the BTC campaign. There is clear evidence that a foundation has been developed and that this serves as a basis for campaign continuation and expansion in its planned later phases. The BTC campaign has fostered conceptual, situational and social resonance in relation to the core concept of HIV/AIDS risk posed by a sexual network -- either by causing individuals to acknowledge their own position in a network, or by causing them to recognise the plausibility that they may be connected to a network through others. Such resonance elicits strategies for risk reduction that are then acted upon. These forms of personal resonance underpin individual level risk and vulnerability reduction for HIV infection, but also contribute to reshaping a peer and social environment through changes in social networking practices, and by fostering both verbal and non-verbal communication of risk aversion to others. Importantly, the evidence of the development of cultural scripting has contributed to the development of potential new theoretical approaches to communication for HIV prevention, particularly as it relates to the possibilities of promotion of “horizontal,” rather than top-down (“vertical”) communication of risk reduction.
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