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FINAL EVALUATION REPORT • VOLUME 1

2

‘BREAK THE CHAIN’ CAMPAIGN

NAMIBIA • 2009-2011

EVALUATION REPORT • VOLUME 1

UNICEF • 2011

Evaluator

Dr Warren Parker

Statistical Analysis

Cathy Connolly

Fieldwork

Urban Dynamics

Acknowledgements

The inputs of Take Control partners to the framework of this report and comments on emerging

findings and methodological issues is gratefully acknowledged. The inputs of Rushnan Murtaza,

Arjan de Wacht and Mark Shepherd of UNICEF during the finalization of the report. Thanks go

to Dietrich Riemert of UNICEF for assistance in evaluation logistics leading up to fieldwork and

commentary on the report. Photographs courtesy of Bastian Schwarz.

3

FIELD RESEARCH

Quantitative and Qualitative Survey: Project Managers

Ernst Simon, Johann Opperman and Edwin Thornley

Facilitators

Louis Shivute, Gerhardus Beukes and Nestor Shipingana

Fieldworkers

Oniipa: Katrina Kapolo, Filemon Amwaamwa, Leans Amutenya, Naftali Namukomba, Lovisa

Amutenya, Helaria Hafeni, Johannes Kambonde and Aina Akwanyenga.

Oshikuku: David Nangolo, Ziita Nekundi, Kleopas Endjala, Kaupuukali Mumati, Lea Nkandi,

Mariane Shipiki, Selma Shakungu and Elizabeth Kandjimwena.

Rehoboth: Gerhardus Beukes, Bernadine Beukes, Tresia Amwaalwa, Brandon Maartens and

Uakotoka Kahima.

Coding and capturing

Ernst Simon, Johann Opperman, Edwin Thornley and Carmen Swartz

Transcriptions

KHV Translations and M&M Transcription and Translation Services CC

4

ACRONYMS AND ABBREVIATIONS

ABC Abstain, Be Faithful, Condomise

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Therapy

BTC Break the Chain

C-CHANGE Communication for Change

CAA Catholic AIDS Action

CDC Centers for Disease Control

CP Concurrent Partners

GBV Gender-based Violence

HCT HIV Counseling and Testing

HIV Human Immunodeficiency Virus

IEC Information, Education, Communication

IPC Interpersonal Communication

MCP Multiple and concurrent partners

MICT Ministry of Information, Communication and Technology

MOHSS Ministry of Health and Social Services

MSM Men who have sex with men

NAEC National AIDS Executive Committee

NLT NawaLife Trust

PEPFAR President‟s Emergency Plan for AIDS Relief

PHDP Positive Health, Dignity and Prevention

PLHIV Person(s) Living with HIV

PMTCT Prevention of Mother To Child Transmission

STI Sexually Transmitted Infection

TB Tuberculosis

UN United Nations

UNAIDS Joint United Nations Program on HIV/AIDS

UNICEF United Nations Children‟s Fund

UNFPA United Nations Population Program

VAW Violence Against Women

VCT Voluntary Counseling and Testing

WHO World Health Organization

5

CONTENTS

EXECUTIVE SUMMARY .............................................................................................................. 6 1. BACKGROUND TO THE „BREAK THE CHAIN‟ CAMPAIGN ....................................... 11 2. HIV/AIDS AND MCP IN NAMIBIA .................................................................................... 13 3. THEORETICAL FRAMEWORK FOR THE EVALUATION .............................................. 17

3.1 Multiple partners and concurrent partners ........................................................................ 21 4. METHODOLOGY ................................................................................................................. 22

4.1 Research hypotheses ......................................................................................................... 22 4.2 Study site selection ............................................................................................................ 23 4.3 Research methods.............................................................................................................. 23 4.3.1 Principles of data triangulation in this study .................................................................. 24 4.3.2 Site studies in 2007/2008 ............................................................................................... 25 4.4 Site mapping ..................................................................................................................... 25 4.5 Qualitative sampling ......................................................................................................... 26 4.6 Quantitative sampling ....................................................................................................... 27 4.7 Study instruments and administration ............................................................................... 28 4.8 Fieldworker and supervisor training ................................................................................. 29 4.9 Data management and analysis ......................................................................................... 29 4.9.1 Cultural scripts ............................................................................................................... 29 4.10 Ethical review.................................................................................................................. 30 4.11 Limitations of the study .................................................................................................. 30

5. FINDINGS ................................................................................................................................. 31 5.1 Demographic characteristics ............................................................................................. 31 5.2 Community level exposure to HIV/AIDS ......................................................................... 33 5.2 Communication ................................................................................................................. 34 5.3 Reach of the BTC Campaign ............................................................................................ 35 5.3.1 Exposure to multiple BTC Campaign components ........................................................ 38 5.4 Knowledge of ways to prevent HIV.................................................................................. 39 5.6 Qualitative findings on awareness and knowledge of the campaign ................................ 40 5.7 Discussion of reach, awareness and knowledge of the BTC Campaign ........................... 42 5.8 HIV testing ........................................................................................................................ 45 5.8.1 Qualitative findings on HIV testing ............................................................................... 46 5.9 MCP and social norms ...................................................................................................... 47 5.10 Higher exposure to multiple components of the BTC Campaign and change ................ 51 5.11 MCP and reported changes to sexual behaviour ............................................................. 52 5.11.1 Changes in sexual partnerships over time .................................................................... 54 5.12 Qualitative findings on the social context of MCP, sexual relationships and change .... 57 5.13 Discussion on the social context of MCP, sexual relationships and change ................... 62 5.14 Alcohol consumption ...................................................................................................... 65 5.14.1 Qualitative findings on alcohol and MCP .................................................................... 67 5.14.2 Discussion on alcohol and HIV risk ........................................................................... 68 5.14 Gaps and opportunities .................................................................................................. 68

6. CONCLUSIONS ....................................................................................................................... 72 6.1 Quantifiable outcomes and impacts of the BTC Campaign .............................................. 74 6.2 Safer sexual practices through new cultural scripts .......................................................... 75 6.3 Implications ....................................................................................................................... 78

7. REFERENCES .......................................................................................................................... 81

6

EXECUTIVE SUMMARY

The Take Control Task Force for the Namibian HIV & AIDS Media Campaign is 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 to 2016 and previous Medium Term Plan III 2004-2009. It seeks to reduce HIV incidence

through disrupting sexual networks by reducing concurrent relationships and promoting protected

sex among people in concurrent partnerships.

MCP is well established as an underlying driver of HIV in Namibia, with a complex of factors

contributing to high partner turnover and concurrent sexual partnerships. The densely clustered

sexual networks produced by concurrent sexual partnerships accentuate the likelihood of new

HIV infections as a product of high viral load that occurs during early and late stages of infection

with the virus. Disrupting the pathways that occur in sexual networks through reducing sexual

partner turnover and concurrency has potential to markedly reduce new HIV infections.1 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, responses to these assertions, along with a

comprehensive body of research upholds the necessity to intensify and sustain a focus on

disrupting sexual networks.

For the period addressed during this evaluation, 2009-2011, the behavioural objectives were to

reduce the practice of MCP among men and women 15-49 years of age, and to increase

consistent condom use among men and women 15-49 years of age during sexual intercourse,

including during the practice of MCP. Communication goals included increasing awareness of

MCP, knowledge of risk arising from MCP practices, and highlighting MCP reduction as a key

strategy for reducing HIV infection risk.

The BTC Campaign followed a multi-level, multi-channel, multimedia approach including mass

media, public relations and advocacy, and community level interpersonal communications (IPC)

including community outreach through promotions and events, group discussions, individual

discussions and integration with parallel services. A core unifying slogan was „Break the Chain‟

and activities were implemented by a range of HIV prevention partner organisations in Namibia.

Support to effective implementation was provided through training of implementers provided at

the outset and during the campaign.

Methods

An extensive literature review as well as 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 to explore and demonstrate

the outcomes and impacts of the BTC Campaign in a range of settings.

1 See Figure 2.

7

With a view to drawing on opportunities for comparison of selected MCP indicators over time,

three communities where community studies have previously been conducted were selected.

These were Oshikuku, Oniipa and Rehoboth.

Research methods included site mapping, a quantitative survey with 900 respondents aged 16-49,

and focus groups with males and females aged 16-49 who had been exposed to the campaign.

Focus groups were also conducted with people living with HIV and interviews were conducted

with community stakeholders. In total, 21 focus groups and 14 interviews were conducted.

Ethical approval was granted for the study by the ethical review board of the MOHSS in

Namibia.

Findings and conclusions

The overall hypothesis of the study 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. The

findings point consistently in the direction of all of the hypotheses, and triangulation of the data

clearly demonstrate that important changes in risk perceptions and practices in the study

communities have occurred. Emergent interpretations and meanings of MCP in context that are

directly relevant to reshaping norms and values have also been identified.

Specifically, the logo and slogan of the campaign captured the core concept of the campaign – the

relationship between HIV risk and sexual networks – and the multiple communication

components allowed allowed audiences to assess their risks and vulnerabilities in relation to their

particular relationship contexts.

All evaluation survey respondents were reached by at least one component of the campaign,

and that half of all respondents had been reached by 12 or more components.

The BTC Campaign has prompted discussion about multiple and concurrent sexual

partnerships, and exposure to higher numbers of BTC Campaign components elicited

statistically significant higher likelihood of speaking about HIV/AIDS (65% vs 53%).

Around a third of respondents (36%), perceived that people in the community were changing

their behaviour with „breaking the chain‟ or avoiding concurrent partners being mentioned by

nearly half (49%).

Higher exposure to multiple BTC components resulted in a statistically significant higher

likelihood of reporting having changed one‟s sexual behaviour in past year (65% vs 50%),

with statistically significant mention of „breaking the chain‟ and avoiding concurrent partners

(24% vs 9%).

The BTC Campaign has brought about responses that blend cognitive, situational and social

elements to bring about internalized meaning. These in turn have led to actions and commitments

that have been brought about through reflection about oneself in relation to one‟s partnership

8

practices and context. The campaign resonated with the audience on three levels, conceptually,

situationally and in relation to social contexts. This resonance in turn gave rise to internalized

meaning and commitments to action. An additional feature of response was the development of

new language related to conveying the „break the chain‟ concept at social level.

Conceptual resonance

Participants in the qualitative discussions noted that:

• The BTC Campaign brings about new insights into HIV risk

• The slogan is concise and easy to remember

• The Campaign images clearly describe risk and evoke a sense of concern about danger of

MCP

Situational resonance

In relation to their own circumstances, participants in the qualitative discussions note understood

that:

A sexual partner may have other partners „behind your back‟

• It is not enough to try to be safe in a sexual network through condom use – one has to

„break the chain‟

• One needs to stay HIV negative to care for one‟s children and see them grow

• Having many partners is expensive and also „makes one a liar‟

• PLHIV can avoid concurrent partners, even though they are already HIV positive

Social resonance

In relation to their social context, participants in the qualitative discussions observed that:

• One can feel pride and a sense of achievement if one breaks the chain

• It is socially embarrassing to be known to have many partners

• „Players‟ should be pitied, not admired

Internalised meaning

The understanding of the campaign allowed for the meanings of the BTC Campaign to be

internalized. This included personalizing risk as follows:

• I can stop my own concurrency practices

• I can end relationships with concurrent

partners immediately

• I can conserve my dignity and decency by being selective and not having a partner who

may be unfaithful

9

• I can be assertive about the need for my peers to respect that my partner is „out of bounds‟

Actions and commitments

Actions and commitments that could be taken in response to the BTC Campaign concepts varied

according to individual contexts. The following strategies were identified:

• Ending concurrent partnerships and choosing a single „trusted‟ partner, or having no

partner

• Ending a relationship with a partner known to be unfaithful

• Discussing HIV risk with a partner and making a commitment to honesty and faithfulness

• Discussing the BTC Campaign with friends, and sharing strategies for risk reduction

• Avoiding friends and peers who encourage concurrent partnerships

• Avoiding excess alcohol consumption and drinking at alcohol venues. Stopping alcohol

consumption, or drinking alcohol at home

New language (social meaning)

A broad intended outcome of the BTC Campaign was to bring about understanding of the risks of

having multiple and concurrent sexual partners through comprehension of the BTC slogan and

imagery. The phrase – „break the chain‟ thus serves as a means to convey this concept. As a

product of the campaign, the phrase has entered into language practice as a referent for

articulating HIV risk in relation to sexual networks. The merits of the concept as a way of making

meaning in the context of HIV risk have been further strengthened by the emergence of a new

sign to refer to the concept – a hand gesture to represent „breaking the chain‟.

Other strategies: VCT and condom promotion

The campaign has interfaced well with parallel strategies to address HIV prevention, with HIV

testing and condom use being sustained as personal strategies.

Gaps and opportunities

Participants in the qualitative discussions suggested expanding the age range of BTC

implementers, reaching more extensively into rural communities, increasing the range of

languages employed by the campaign, and ensuring that materials are available in sufficient

quantity.

Youth and older participants highlighted the importance of promoting community-level dialogue

at small group level, with such activities including groups that could be formed and led by

community members themselves. Alcohol venues were also identified as contexts of risk.

Youth were keen for the addition of utility items, integration of BTC into school activities such as

debates as well as sporting activities such as soccer matches, and exploration of the potentials of

internet-based social media communication and use of cellphone technology. Having people

appear on television or speak on radio about how they had „broken the chain‟ was also

10

highlighted, as were suggestions for dramatized depictions of the challenges and solutions to

MCP.

PLHIV were accepting of the BTC Campaign and acknowledged the importance of a focus on

sexual networks. The importance of PLHIV ending concurrent relationships was acknowledged

and there was also reference to group accountability. It was also felt that PLHIV could be drawn

into the implementation of the campaign.

11

1. BACKGROUND TO THE ‘BREAK THE CHAIN’ CAMPAIGN

The Take Control Task Force for the Namibian HIV & AIDS Media Campaign is 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 to 2016 and previous Medium Term Plan III 2004-2009. It seeks to reduce HIV incidence

through disrupting sexual networks by reducing concurrent relationships and promoting protected

sex among people in concurrent partnerships.

The „Break the Chain‟ (BTC) Campaign has been 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).

For the period addressed during this evaluation, 2009-2011, the behavioural objectives were:2

To reduce the practice of MCP among men and women 15-49 years of age, and

To increase consistent condom use among men and women 15-49 years of age during sexual

intercourse, including during the practice of MCP.

Focal audiences for Phase One over a 12-month period were the general population aged 15-49

years, with a specific focus on singles and cohabiting couples aged 15-29. Communication goals

included increasing awareness of MCP, knowledge of risk arising from MCP practices, and

highlighting MCP reduction as a key strategy for reducing HIV infection risk. Plans for a follow-

up Phase Two campaign include expansion into peer networks, families and traditional leaders,

with communication objectives extending to addressing social norms related to MCP.

The epidemiological rationale for the campaign were strongly evidence-based and reviews and

analysis of literature and research conducted in Namibia identified the following aspects related

to MCP:3

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;

2

MICT 2009 3

MICT, 2009

12

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) including

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

allows for illustration of sexual networks), 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 (See Appendix 1):

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;

13

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 as do the extent of the

focus on MCP relative to other focal areas. Specific components are detailed in Appendix 1 (See

Volume 2 of this report). 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.

2. HIV/AIDS AND MCP IN NAMIBIA

Antenatal HIV prevalence in Namibia has been studied since the early 1990s with sentinel site

monitoring occurring every two years. The 2010 survey included 34 health districts and overall

prevalence was 18.8% with declines in prevalence being observed since 2002 in the 15-29 year

age group. HIV prevalence has however increased in the older 30-49 year age groups.4 Rural and

urban prevalence is generally similar, although HIV prevalence ranges considerably between

places and regions – for example, from 4.2% in Rehoboth, to 35.6% in Katima Mulilo in 2010.

4

MOHSS, 2010

14

Figure 1: Namibia Rural/Urban antenatal HIV prevalence, 20105

A study on HIV prevention in Namibia found that important behavioural drivers of the epidemic

included MCP, inconsistent condom use, intergenerational sex, transactional sex and in a context

of low levels of male circumcision.6

The report found that multiple partners were contributing to

rapid spread of HIV, noting that the disparity between reported MCP by women versus men – for

example, 16% of men and 3% of women reported two or more partners in the past year in the

Demographic and Health Survey (DHS) of 2006 – suggesting that MCP among males markedly

increases female vulnerability to HIV. The report noted that HIV was distributed unevenly

throughout the country and that there were regional variations in underlying risk factors for HIV

prevention. In Caprivi, for example, HIV was more likely to be linked to the higher levels of

commercial sex work reported in the region, whereas in Hardap, later debut and lower levels of

MCP appeared to be keeping HIV prevalence lower. MCP was noted to be more common in

Karas, Omusati, Oshana, Ohangwena and Oshikoto, whereas condom use, sexual debut and other

factors were slightly more prominent in the remaining regions.7 It was observed that DHS data

showed that marriage has declined over time in Namibia, with only 35% of men and 45% of

women married or living in a cohabiting union by the age of 30. An estimated 44% of new

infections were expected to occur among youth, and it was recommended that emphasis should

be given to young women. Risk of infection among women was seen overall to flow primarily

from high-risk partners and it was noted that migrant communities needed to be taken into

account.8

A qualitative research study conducted by Desert Soul identified widespread practice of MCP,

but noted that participants recognized that HIV was a consequence of having multiple partners.9

Men in urban and rural communities agreed that having many partners was a „normal‟ part of

being a man. Women recognized that it was problematic for women to have other partners if their

5

MOHSS, 2010 6

See De la Torre et al., 2009 for detailed findings 7

Ibid 8

Ibid 9

Shipena & Khuruses, 2007a

15

male partner was unfaithful. Nonetheless, both males and females had multiple partners. The

report further noted that cultural practices involving MCP in some Namibian groups had been

long established – for example „tjiramure‟ or having sex with one‟s cousins among Herero, while

other groups practice polygamy. Patriarchy, poverty, migration, peer pressure and alcohol abuse

were all noted as co-factors underpinning MCP. While there was some acquiescence towards

MCP practices, jealousy and violence towards ones partner and/or their partners, was seen as an

outcome of MCP. Breaking off the relationship was also noted to be an outcome. Partner

communication was recognized as an issue that contributed to MCP, and that partner

communication was further impeded in situations where partners were separated by work and

travel. Women noted that they were reserved about talking about sex and sexual issues and needs,

and violence by a partner was feared. Keeping in contact with partners who were in other towns

was seen as important for maintaining a partnership, and cellphones and SMS were readily

available.

Another Desert Soul report on HIV prevention noted that there was good recognition of the

importance of condom use, but that condom use was inconsistent, with inconsistent use being

rationalized in various ways – for example, condoms do not feel good, or one does not need to

use a condom with an attractive woman.10

A study commissioned by the United Nations Children‟s Fund (UNICEF) to evaluate the peer

education and life skills programme (My Future is My Choice) found participants were more

likely to adopt protective sexual attitudes and practices and to be aware of the risks of alcohol

consumption.11

An earlier UNICEF study on the knowledge, attitudes and practices of young

people found that sexual debut occurred relatively early, with the mean age of debut being 15

years with first encounters with older men being common.12

A qualitative study commissioned by UNICEF that explored risks related to HIV among young

females found that risks of MCP were understood, but that multiple partnerships were often

underpinned by economically beneficial arrangements (eg. sugar daddies, transactional sex).

Most girls who were in relationships also reported being uncertain about whether their boyfriends

had other partners, while some girls were aware that this was the case. Such concerns did not

uniformly result in consistent condom use.13

A series of community studies conducted by NawaLife Trust found high levels of multiple

partners (2+ partners in past year), ranging from around one fifth to one third of respondents in

recent studies.14

Significant increases were noted to have occurred in this practice over time – for

example from 11% to 27% in Oshikuku and 10% to 30% in Rehoboth between baseline and

follow-up two years later. Having two or more partners in the past month also increased

significantly in these two sites. The studies also showed poor top-of-mind awareness of multiple

10

Shipena & Khuruses, 2007b 11

HSRC, 2008 12

UNICEF, 2006 13

Survey Warehouse, 2010 14

Parker & Connolly, 2008

16

partnerships as a risk factor for HIV – for example, more than 80% of respondents in Oshikuku

and Oniipa mentioned „always use a condom‟ as a way to prevent HIV, whereas only 28% and

37% in the two communities respectively mentioned „be faithful to your sex partner‟ and only

19% and 27% respectively mentioned limit or reduce your number of sex partners.

A formative study of males and females aged 14-55 commissioned by UNICEF and UNAIDS on

the interlinked themes of MCP, inter-generational sex and transactional sex in Namibia found

that participants were not strongly of the opinion that messages about being faithful „would work‟

in Namibia, and there was also ambivalence about messages discouraging MCP, inter-general sex

and transactional sex in HIV-related campaigns.15

A comprehensive study of HIV in relation to gender illustrated that social norms – in particular in

relation to gender power relations – were shifting as a product of changes in political, economic

and social structures with contemporary changes being underpinned by globalization and

modernization.16

This included important changes in relation to family and kinship structures.17

A qualitative study on alcohol and risk behaviour found that alcohol for sex was a „well known

reciprocal relationship in Namibia‟ with sexual networks clearly associated with alcohol

consumption.18

Recommendations an emphasis on programmes addressing MCP.

A report on treatment literacy that included respondents who were people living with HIV/AIDS

(PLHIV), it was found that around one in 20 (5%) had multiple partners with recommendations

being made to focus on promoting condom use with partners of PLHIV.19

A study on gender-based violence (GBV) commissioned by the Ministry of Gender Equality and

Child Welfare in Namibia found that respect was lacking in non-marital relationships with

considerable physical and psychological abuse occurring, while extra-marital relationships

among men were noted to be accepted by wives and kept secret by girlfriends.20

Late marriage is a feature of most southern African societies, and is considered to be an important

sociological factor contributing HIV incidence. The long period of sexual activity following

debut and preceding marriage or long-term cohabitation increases risk of HIV acquisition.21

In

Namibia, the median age at first marriage for people aged 20-49 is 34 years.22

The long period

prior to marriage contributes to turnover of multiple partners and includes multiple and casual

sexual partnerships and exposure sexual networks produced by concurrent sexual partnerships.23

Although most young women in Namibia are unmarried, many women have children – for

example, 58% of women aged 20-24 are mothers, yet only 5.2% of women in this age group are

married while 16.2% are cohabiting.24

Early fertility is potentially related to unrealistic desire to

15

Siapac, 2008 16

LaFont, 2007 17

See LaFont 2007, Chapter 8, pp130-147. 18

LeBeau & Yoder, 2009 19

van Zyl, 2009 20

Siapac, 2009 21

Bongaarts, 2007 22

MOHSS & Macro International Inc., 2008 23

Bongaarts, 2006 24

MOHSS & Macro International, 2008

17

secure a relationship in a context where partners fail to acknowledge or support children, and

where financial burdens fall to young women and their families.25

Pre-marital fertility among

youth has been linked to a loss of parental authority, while pregnancy may be seen by some as a

means to secure a long-term relationship that leads to marriage, albeit that this strategy is often

unsuccessful.26

A qualitative study in Namibia found that motivation to get married was influenced by a range of

negative perceptions including loss of independence and agency, the need for financial stability

prior to marriage, the need to complete education prior to marriage, perceptions that people who

were married had other partners and perceptions that divorce was common.27

In a study of a mining community in Namibia it was found that factors leading to alcohol use also

led to high risk sexual behaviours including concurrency. 28

It was noted that the fact that there

were fewer women in the town contributed to a predominant pattern of women having multiple

partners, and that alcohol allowed one to forget about risk. An observational and interview study

of bars in Namibia found that many participants reported having a partner who lived far away and

this led to having one or more partners locally.29

Mobility was related to employment. While

condoms were noted to be important for HIV prevention, and condom use was prioritized, some

participants did not use condoms with their main partners. A key concern of the study was the

presence of young girls at alcohol venues with underage drinking occurring alongside

expectations for sex.

3. THEORETICAL FRAMEWORK FOR THE EVALUATION

This section summarises the findings of a detailed literature review conducted at the outset of this

study.30

The BTC Campaign is an evolving communication activity that builds on previous HIV

prevention campaigns in Namibia. As noted above, activities and processes of the campaign

incorporate implicit psychological theories of behaviour change and communication processes

relating to health promotion. In relation to evaluation therefore, it is hypothesised that the

campaign will contribute to linear-causal changes in attitudes and behaviours related to MCP and

that the campaign may stimulate related prevention processes downstream from the initial

intensified campaign. In this instance, the intensified period of the campaign occurred largely

during late 2009 and early to mid-2010, while the evaluation was conducted during early 2011.

The campaign has included mass media, social media, small media and community-level and

small group interactions. Although these components have not been evenly or intensively

25

Harrison et al., 2008 26

Zwang & Garenne, 2008; Harrison et al., 2008; Harrison & O’Sullivan, 2010 27

RFS, 2005 28

Lightfoot et al., 2009 29

LeBeau & Yoder, 2009 30

Parker, 2010

18

implemented in all communities in Namibia, the campaign is expected to have achieved a broad

reach across Namibia.

It is accepted that many contextual factors influence individual vulnerability to HIV among

people who are HIV negative – notably the pre-existing prevalence levels of HIV in a given

community. Higher prevalence of HIV in the communities and contexts within which a person

has sexual relationships contributes to a higher likelihood of exposure to HIV. Exposure may be

relatively direct – for example, via multiple sexual partnerships, but also indirect, via exposure to

sexual networks through a partner who concurrently has other partners.

Historically, in southern Africa, most campaigns have focused on individual choices related to

sexual behaviour – particularly on concepts of safer sex related to use of barrier methods such as

condoms, avoiding sex through abstinence, or being faithful to a sexual partner. Choice-based

individual actions also form the basis for practices such as treatment seeking for STIs, seeking an

HIV test, or male circumcision. Some more recent campaigns have included a focus on couples –

for example, Take Control campaign in Namibia included emphasis on relationship dynamics,

partner negotiation and family communication.

The focus on concurrent sexual partnerships has widened the domain of HIV prevention by

highlighting the risks of having overlapping sexual partnerships oneself, but more particularly,

the risks that flow from a partner who has other partners, even if one is oneself monogamous.

This focus opens up understanding that it is necessary to focus on the social domains of sexual

relationship practices (ie. beyond individual behaviour), and increases understanding that HIV

transmission is directly linked to sexual networks.

The emphasis on concurrency as a key contemporary driver of HIV in southern Africa has been

well recognised, and has been highlighted in numerous policy and strategy meetings in the

southern Africa region – notably the Southern African Development Community (SADC) think-

tank meeting held in Maseru in 2006.31

Although well-evidenced through a range of data including epidemiological and modeling data,

the notion that concurrency plays a key role in HIV epidemics in Africa has been subject to

critique.32

Such critiques are not uncommon in the emerging field of HIV epidemiology, given

that the complex pathways of HIV transmission are difficult to measure (for example, incident

infections are difficult to detect at the time of transmission). While HIV prevalence surveys

provide insight into general patterns of the disease as well as sexual behaviour, these two

components are not easily related given that current and reported sexual behaviours may be

different from those occurring at the time of infection. Furthermore, of interest in studies on

concurrency is exposure to sexual networks, yet this is not readily measurable in surveys since

individuals in sexual partnerships are unlinked. Specifically, cross-sectional surveys gain insight

into the sexual behaviours of individual respondents. However, individuals respondents do not

31

SADC, 2006 32

Sawers & Stillwaggon, 2010.

19

necessarily know, nor cannot be expected to accurately report on other sexual partnerships of

their partners. Consequently, apparently low risk respondents (eg. who say they have only one

partner), may be exposed to sexual networks through a partner who has other partners. The extent

of exposure to sexual networks is thus not readily measured or described using cross-sectional

survey methods.

Sawers and Stillwaggon, who are US-based economists, put forward two main arguments –

firstly, they suggest that concurrency patterns found in Africa are no different from those in many

other countries and that therefore concurrency cannot be the basis for high prevalence, and two,

that mathematical models that have been used to demonstrate the impacts of concurrency are

flawed. Their article also includes a micro-analysis of the use of evidence in a subset of journal

articles on MCP, arguing that they are unrigorous and biased. Qualitative studies are also

dismissed as not being valid as sources of evidence for MCP.

The authors conclude by refuting that sexual behaviour patterns are the primary factor

underpinning the severity of the epidemic in sub-Saharan Africa, asserting instead that other viral

and parasitic infections and diseases such as malaria impact on individual immunity to produce

high susceptibility. The role of unsterilized syringes and other „unsafe‟ medical procedures are

also highlighted, and a call is made to „end the obsession over sexual behaviour‟ such as

investigations into concurrency. Instead, they see a need to conduct a „comprehensive effort to

determine what is driving African HIV epidemics‟.33

While not disputing the potential role of

concurrency, two other researchers, Lurie and Rosenthal, suggest the evidence for concurrency is

insufficient.34

The critiques have been dismissed by a number of authors on various grounds – with obvious

rejections of the call to displace sexual behaviour as central to HIV epidemiology. In focusing on

the nuances of modeling in relation to concurrency, Sawers and Stillwaggon refute the

fundamental relevance of sexual networks for HIV transmission. In doing so, they ignore decades

of research and experience that illustrate that HIV is transmitted along pathways that exist in

sexual networks that allow HIV to move from HIV positive to HIV negative individuals.

Furthermore, they ignore the understanding that networks are more likely to be dense and

interlinked in contexts where there is concurrency. Elevated viral load, whether from acute

infection, chronic or late stage infection, have all been shown to contribute to increasing

transmission. 35

Additionally, young women are also more biologically susceptible, so additional

factors such as age mixing are important.36

Malaria and other diseases mentioned by Sawers and Stillwaggon as underpinning HIV infection

patterns are uncommon in the places where HIV has the highest prevalence, and such assertions

are therefore without basis.37

Equally, the suggestion that unsafe injections and medical

33

Sawers & Stillwaggon, 2010 34

Lurie & Rosenthal, 2010 35

Goodreau et al., 2010 36

Pettifor et al., 2007 37

PlusNews, 18 October 2010; Epstein & Morris, 2011

20

procedures contributed to high numbers of HIV transmissions have been dismissed as unsound.38

Goodreau notes that the authors failed to review or incorporate a number of relevant

developments and expansion of understanding in concurrency modelling „including a decade of

intervening methodological development, [that] confirms and extends the basic hypothesis‟ of the

role of concurrency.39

Other key issues related to HIV exposure in sexual networks include the

higher infection rates of women over men in a context where risk practices are on average, lower

than those of men. Women who have small numbers of partners, or no concurrent partners,

remain at high risk of HIV infection because they are linked to a sexual network through

concurrency practices of their partners. 40

The inclusion of concurrency emphasis in southern Africa has been established through regional

policy consensus that included an extensive review of data as well as expert analysis.41

Researchers and modelers point to the necessity of modeled understandings to address the

limitations of cross-sectional studies and other data that are insufficient to capture the complexity

of concurrency.42

Mapping variations in modes of transmission and sexual networks to known

epidemiological data allows for simulation of partnership patterns. A recent simulation of

Zimbabwean data found that 20-25% of infections stemmed from acute stage infections, with

remaining 30-50% attributed to chronic stage and 30-45% to AIDS stage, leading to the

conclusion that reducing concurrency could potentially end the HIV epidemic.43

Figure 2: Network connectivity and the average number of concurrent sexual partners44

Sexual networks increase the pathways along which HIV is transmitted and it follows that the

greater number of pathways increase the opportunities of transmission. The simulation model of

network components in Figure 2 illustrates that the mean number of concurrent partners in a

network affects the density of the network, with small changes downwards influencing the extent

38

See Brewer et al., 2003; Boily et al., 2009; Epstein & Morris, 2011 39

See Goodreau, 2011 40

See Epstein & Morris, 2011 41

SADC, 2006 42

See Epstein & Morris, 2011; Eaton et al. 2010 43

Goodreau et al., 2010 44

Morris et al, 2008

21

and density of a network. It follows that even relatively small reductions in the prevalence of

concurrency can have marked impacts on HIV incidence and that measurable downward changes

in sexual partnerships have potential to markedly influence HIV incidence patterns and trends.

3.1 Multiple partners and concurrent partners

The terminology utilised in addressing sexual behaviours related to sexual networks is somewhat

slippery, given that the concept of multiple partners is different from that of concurrent partners.

The term „multiple partners‟ generally refers to rates of sexual partner turnover and having many

sexual partners over time, with a common conceptual measurement in surveys being „two or

more partners in the past year‟.

A person who has multiple partners may not necessarily have overlapping sexual partnerships,

and if their partners do not have other partners, they are not connected to a sexual network.

However, a person with overlapping partners is connected to a sexual network by virtue of

having two or more partners within a given time frame.

A proxy measure of concurrency in surveys has been respondents reporting two or more partners

in the past month. This measure suggests potential overlap of recent sexual partners, but only

provides information for recent partnerships and not overlap over longer timeframes. An

additional difficulty is the need to understand the frequency of exposure, which is determined by

the number of sex acts that occur between partners in a given timeframe.

The most recent research guidelines on measuring concurrency have emerged from the UNAIDS

Reference Group on Estimates, Modelling and Projection.45

These include measuring the extent

of overlap of sexual relationships in the past year. A commonly utilised proxy measure of

concurrency in surveys has also been expressed as respondents who have two or more partners in

the past month, although partnerships occurring in close proximity do not necessarily overlap.

As noted further above, a key problem in measuring concurrency and understanding sexual

networks through surveys is that while one may obtain an understanding of sexual behaviours of

persons surveyed, the behaviour of survey respondents‟ sexual partners cannot reliably be

measured. As a consequence, a person who is monogamous may unknowingly be connected to a

sexual network as a product of his/her partner having other partners.

While reducing the overall numbers of people involved in overlapping sexual partnerships is a

key concern of campaigns focused on HIV prevention, a number of broader relationship patterns

are also important to address. Having a high turnover of partners is likely to increase HIV risk as

a product of potential exposure to sexual networks, as well as potential exposure to concurrency

if there is an overlap of partners during transition periods between relationships.

45

UNAIDS, 2009b

22

For purposes of this study the acronym – MCP – is used to encompass both multiple and

concurrent partnerships, although where relevant, concurrent sexual partnerships are referred to

exclusively.

4. METHODOLOGY

An extensive literature review, series of discussion workshops and interviews with Take Control

Partners were conducted during 2010.46

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 utilised;

Being cost effective;

Allowing for comparison over time.

Limitations include variations in the extent to which the BTC interventions have been carried out

in each community, and difficulty in ascertaining the extent to which the findings can be

generalized to similar communities in Namibia.

4.1 Research hypotheses

An overall hypothesis is that the „Break the Chain‟ campaign produced new knowledge relevant

for HIV prevention with individual outcomes including internalisation of risk and reduction in

MCP-related risk behaviours. Further hypotheses include:

There is high awareness of the BTC Campaign (ie. most people have heard of or seen

elements of the campaign);

The main messages of the campaign are understood by those who have been reached;

The BTC Campaign has 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 have increased over time in comparison to previous surveys;

46

See Parker, 2010

23

MCP-related risk practices have decreased over time in comparison to previous surveys.

4.2 Study site selection

Three main criteria were employed to determine selection of study sites – the availability of

previous data from community-level studies, implementation of BTC activities at community-

level, and cost-effectiveness. Oshikuku, Oniipa and Rehoboth emerged as the selected sites. The

sites offered variations in terms of urban/rural geotype and north/central locale.

Oshikuku is located in northern Namibia and has a population of approximately 10,000 people.

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.

Oniipa is located in northern Namibia and has a population of approximately 30,000 people. 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.

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.

4.3 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;

24

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 questionnaire-based random survey survey with 300 respondents aged 16-49 in

each site.

4.3.1 Principles of data triangulation in this study

The principle of research validation through data triangulation allows for multiple sources of

information to be considered with a view to understanding whether findings from one data source

are reinforced or inhibited from another. It allows for „cross-checking‟ of findings generated

through varying methods of enquiry.47

The present study employs „methodological‟ triangulation through exploring the interaction

between quantitative and qualitative data. Both data formats are also „triangulated‟ internally by

allowing for exploration of consistencies or contradictions between various categories of

respondent/participant.

In considering the quantitative data, the findings of the 2011 survey are explored for coherence

through a layered approach to questions addressing the reach and outcomes of the BTC

Campaign. For example, respondents are asked about reach, about their understanding of the

content of the campaign, of their perceptions of the social context of MCP, their perceptions of

the behaviour of their peers and the community, and of their own behaviours. Quantitative

findings are also supplemented through comparison with data from the surveys conducted in

2007/8 in the same sites.

The qualitative data employs multiple sources of information based on varying relations to the

BTC Campaign – for example, information from participants who were reached by the campaign

is considered alongside information from a subset of participants who were involved in campaign

delivery as well as stakeholders in each community. Age group and sex variation was also

introduced through segmentation of FGD participants.

All data were considered 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?

47

Denzin, 2006; Risjord et al., 2002

25

4.3.2 Site studies in 2007/2008

Between 2005 and 2008, a series of community-based studies were conducted by NawaLife Trust

(NLT). These included studies in the three study sites of the present survey, which were most

recently conducted in 2007/8.48

The studies followed a similar random sampling method based on

housing counts, but used the local hospital as a starting point. A larger sample of 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. The sample also included a more equitable distribution of

males and females49

in comparison to the present survey, where a higher proportion of females

were recruited.50

Age distribution was similar in both studies.

The data allow for comparison with the present study based on comparison on a subset of

indicators. There are similarities between the sampling approaches, multivariate analysis can be

used to take into account confounding variables. Only three indicators were compared between

the two studies – unprompted knowledge of HIV prevention, numbers of partners in past year and

numbers of partners in the past month.

4.4 Site mapping

Site mapping activities preceded qualitative and quantitative study in each community. The

mapping process included general observation as well as informal visits to various facilities with

a view to determining whether BTC Campaign components were visible to any extent – 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 detailed in Appendices 7-

9 and are summarised below.

Oshikuku is a relatively small proclaimed village located in the Omusati Region. Although

formal housing projects have been implemented there are 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. 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 Nawa Life Trust, New Start,

Catholic AIDS Action 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.

48

See Parker W., & Connolly, C. (2008). Strategic information report. Final HIV/AIDS Community Survey: Oshikuku, Oniipa and Rehoboth: 2008. Windhoek: NawaLife Trust.

49 Approximately 50:50

50 Approximately 60:40

26

Oniipa is a proclaimed Village Council area located near Ondangwa. 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, 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 also limiting 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. Churches in

the area did not appear to have been engaged by the programme.

Housing in Rehoboth includes formal housing with some informal settlement. BTC

implementing partners in the area included NawaLife Trust, New Start, Catholic AIDS Action

(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 NawaLife office was being closed down permanently. Flannelgrams were

available at CAA.

4.5 Qualitative sampling

Site mapping determined key stakeholders in each community and also health services and

health-related non-governmental (NGO) and community-based organisations (CBOs) working in

the area. This allowed for the identification of interview subjects including community leaders,

faith-based leaders, senior health-care worker, traditional healers, and community health workers.

In total, 14 interviews were conducted. Table 1 describes the interview participants in each site.

Table 1: Interview participants by site

Participant Oshikuku Oniipa Rehoboth

Community health worker Female, 36 Male, 35

Female, 38; Male, 27

Female, 30; Female, 38

Religious leader Female, 69 Male, 57 Male, 67

Traditional Healer Female, 65 Male, 45

Community leader Female, 35 Male, 61 Male, 43

Site mapping informed strategies for recruiting male and female community members for

participation in FGDs in each site. In total, there were 149 participants in the 21 FGDs that were

conducted. Participants are described in further detail in Table 2.

27

A guiding principle during recruitment for FGDs in general was that participants should be aware

of the campaign and have been reached by one or more components. This requirement was to

ensure that they would have sufficient experience of the programme to inform discussion. Three

FGDs included participants who worked with or were volunteers in BTC programmes.

In Oshikuku, younger participants were selected randomly through a local secondary school,

while older age groups were selected randomly 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 through a local secondary school, while older age

groups, individuals involved in BTC and PLHIV were selected 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‟s closing down their offices.

Table 2: Focus Group participants by site

Oshikuku Oniipa Rehoboth

16-19, Female 8 Participants – 8 Unmarried, 8 Unemployed

6 Participants – 6 School learners, 4 single, 2 in relationships

8 Participants – 8 Unmarried, 8 Unemployed

16-19, Male 6 Participants – 6 Unmarried, 6 School learners

9 Participants – 9 Unmarried, 9 Unemployed

8 Participants – 8 Unmarried, 8 Unemployed

20-30, Female 6 Participants – 6 Unmarried, 6 Unemployed

7 Participants – 7 Unmarried, 7 Unemployed

9 Participants – 9 Unmarried, 9 Unemployed

20-30, Male 7 Participants – 7 Unmarried, 3 Employed, 4 Unemployed

8 Participants – 8 Unmarried, 8 Unemployed

7 Participants – 1 Married, 6 Unmarried, 1 Employed, 5 Unemployed, 1 Student

31-49, Male and Female 7 Participants, 6 Married, 1 Unmarried, 4 Employed,

3 Unemployed

7 Participants – 3 Female, 4 Male, 5 Married, 2 Unmarried, 6 Employed, 2 Unemployed

8 Participants – 4 Female, 4 Male, 2 Married, 6 Unmarried, 2

Employed, 5 Unemployed, 1 Student

25+, Male and Female involved in BTC

5 Participants – 3 Female, 2 Male, 1 Married, 4 Unmarried, 5 Employed

6 Participants – 6 Female, 6 Unmarried, 6 Unemployed

8 Participants – 4 Female, 4 Male, 7 Married, 1 Unmarried, 4

Employed, 3 Unemployed, 1 Student

25+, Male and Female, PLHIV

4 Participants – 4 Female, 4 Unmarried, 2 Employed, 2

Unemployed

6 Participants –5 Female, 1 Male, 1 Married, 5 Unmarried, 1 Employed, 5 Unemployed

9 Participants –5 Female, 4 Male, 1 Married, 8 Unmarried, 4 Employed, 5 Unemployed

4.6 Quantitative sampling

The degree to which the findings from a household survey such as this one can be generalised to

the population of the site depends partly on the representivity of the sample. Detailed population

size 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 would however have required more complex survey logistics and a

fixed sample size in each community was adopted instead. Variations in overall household

numbers were thus addressed through increasing or decreasing the frequency of household

selection. A random sample was thus realized in each community to achieve a final sample

number of 300.

28

A random systematic sampling method was used to select households in each site. At the outset,

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. An interval (total number

of households divided by the number of interviews) was used to survey every nth household. 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 participant who was normally

resident in the household for participation in the study. 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 substituted – first to the house on the left

then the house on the right.

When it was not possible to establish contact with a household due to nobody being home or any

other reason, interviewers were required to make three further contact attempts before the

household could be substituted. In cases where none of the household members were aged

between 16 and 49, households were substituted.

In Oshikuku and Oniipa, the research team had no household refusals. However, 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.

4.7 Study instruments and administration

All study instruments were pre-tested during training of fieldworkers and minor adaptations were

made. The study instruments are included as Appendices 2-6. Instruments were translated into

English, Afrikaans and Oshiwambo.

Written consent was required from all quantitative survey respondents and all qualitative

participants. Consenting processes included introducing the purpose of the study, noting that

participation was voluntary and that information provided would be kept confidential.

Quantitative survey data was recorded on paper questionnaires. Qualitative data was documented

via recordings on 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 study was conducted during March and April 2011.

29

4.8 Fieldworker and supervisor training

Fieldworkers and supervisor training 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, participant selection

procedures, qualitative and quantitative approaches, and logistics. Various practical exercises

were also conducted.

4.9 Data management and analysis

Quantitative data was 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 was analysed using STATA. In analysis of statistical relationships, statistical

testing includes „p‟ values. A „p‟ value of <=0.05 is considered significant, and values of <0.001

are highly significant. In some instances, „p‟ values of 0.06 to 0.1 are reported where they are of

interest, although these are of 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‟.

4.9.1 Cultural scripts

Qualitative evaluation data derived from this study includes descriptive responses to questions

asked in the question guides. While literal responses can readily be related to research

hypotheses, underlying linguistic patterns and logics are also relevant. In the context of the

evaluation, respondents included reference to the „logics‟ of their response to the BTC Campaign

including perceptions of social norms, reflections on their own response behaviours, and

linguistic dimensions or „cultural scripts‟ that include emerging conventions related to the

campaign. Goddard and Wierzbicka note that cultural scripts “are intended to capture background

norms, templates, guidelines or models for ways of thinking, acting, feeling, and speaking, in a

particular cultural context”.51

In other words, they are related to processes of making meaning in

a social/cultural context.

Such logics and cultural scripts reveal underlying contextual dimensions including relation

between the self and others, individual agency and self-efficacy, relational needs, and perceptions

of social norms. Linguistic codes may also emerge through such processes – for example,

51

Goddard & Wierzbicka, 2004

30

multiple meanings and interpretations of words or concepts (polysemy),52

non-verbal gestures,53

and emergent words or concepts. These may be considered as organically emerging cultural

adaptations prompted by the reception of the BTC Campaign and may reflect critical reception or

acceptance of campaign concepts.54

In previous studies, MCP practices have been noted to incorporate cultural scripts that reveal

dimensions of relationship power and conceptualization of MCP – for example, a „main partner‟

is loved, whereas other partners are not loved; faithfulness is understood as respecting the

importance of not allowing one‟s partner to know of one‟s fidelity.55

Other cultural scripts related

to sexuality and MCP include notions of unrestrainable male sexual need or gifts being a

demonstration of male love, while giving of sex is a demonstration of female love.56

4.10 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 be referred to local services as needed.

Ethical clearance was sought from the ethical review board of the MOHSS in Namibia and was

received on 20 January 2011.

4.11 Limitations of the study

Evaluation of interventions requires cost-appropriate research and funds available limited the

study to a small subset of Namibian communities. The budget available allowed for a sample of

900 quantitative study participants in three communities, in conjunction with 21 FGDs and a

modest number of interviews.

While household studies are well established for studying social and behavioural phenomena

related to health, limitations include under-representation of mobile populations, persons in

institutions and employed persons who are typically not in the household during working hours.

To allow for comparison to previous community studies, choice was limited to communities

where relevant comparative data had recently been gathered. An additional consideration was the

presence of community-level activities in some sites and that there be some variation in relation

to urban-rural geotypes. It was on this basis that Oshikuku, Oniipa and Rehoboth were selected.

Although the selected sites are not representative of all Namibian communities, they are similar

to many other communities in Namibia. The deeply contextualized nature of the research does

52

See, Hall 1989:47 53

See Bowleg et al., 2010 54

See Wilson & Miller, 2003 55

See Parker et al., 2007 56

Leclerc-Madlala, 2009

31

provide detailed insight into key evaluation questions and non-representativeness of the

communities does not impinge on the validity of findings for each community.

It is important to note that the fieldwork for this study took place in March and April 2011 –

several months after the intensive period of the campaign which occurred during early to mid

2010 and a lower intensity mass media „burst‟ in December 2010 and January 2011. Intensity and

extent of community-level activities varied in each site.

5. FINDINGS

The following tables describe the findings of the quantitative survey, with thematic qualitative

findings presented to inform interpretation in various sections.57

The qualitative findings provide insight into processes of engaging with the BTC Campaign at

individual and community level as well as deepening interpretation of the quantitative findings.

As outlined in the methodology, participants in focus groups and interviews had varying linkages

to the campaign. While interview participants included stakeholders who may have had limited

exposure to the campaign, it was necessary for focus group participants to have engaged with the

campaign in some way. For most participants, engagement included having heard of or seeing

campaign components, or having participated in community-level activities. One focus group in

each community also included participants who had worked with or volunteered with campaign

partners. A group of people living with HIV (PLHIV) were also included in each site.

Although individual components of the campaign were explored, the main emphasis was to

understand the reception, interpretation and engagement with the campaign as a whole. Changes

in relationship patterns occurred as a product of the campaign were discussed. Gaps and

opportunities were noted, as were contextual factors limiting the impact of the campaign.

5.1 Demographic characteristics

Table 3 describes the demographic characteristics of the survey respondents. The majority of

participants were female. This was 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%) were students and one in nine (11%) were informally employed.

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

57

The data is self-weighting. For a number of tables, smaller subcategories and ‘other’ responses have been omitted as they are not relevant for analysis. Consequently in some instances the totals of numbers of respondents may appear to be inconsistent.

32

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.

A quarter (25%) of respondents were married, while overall, less than half of respondents in all

communities were either married or cohabiting. Around a quarter (28%) were not in a

relationship. Half of respondents did not have any children.

Respondents were overall poor, with around two thirds (64%) having no income or an income of

N$500 or less. This data does not however reflect household income or support by partners or

family members.

Table 3: Demographic characteristics of respondents

N=900

All Oshikuku Oniipa Rehoboth

n % n % n % n %

All

Sex

900 300 300 300

Male Female

336 564

37% 63%

112 188

37% 63%

119 181

40% 60%

105 195

35% 65%

Age

16-24 25-34 35-49

329 280 291

37% 31% 32%

97 98 105

32% 33% 35%

119 88 93

40% 29% 31%

113 94 93

38% 31% 31%

Religion

Catholic Protestant+ Other

248 640 12

28% 71% 1%

192 104 4

64% 35% 1%

9 285 6

3% 95% 2%

47 251 2

16% 84% 1%

Employment status

Unemployed Student/learner Informal employment Employed

435 113 96 256

48% 13% 11% 28%

123 45 35 97

41% 15% 12% 32%

146 41 46 67

49% 14% 15% 22%

166 27 15 92

55% 9% 5% 31%

Amenities (Electricity, Water, Sanitation)

Low Amenity Medium Amenity High Amenity

174 298 428

19% 33% 48%

102 74 124

34% 25% 41%

65 136 99

22% 45% 33%

7 88 205

2% 29% 68%

Relationship status

Married Cohabiting In Relationship Single/other

228 154 265 253

25% 17% 29% 28%

82 67 77 74

27% 22% 26% 25%

74 44 111 71

25% 15% 37% 24%

72 43 77 108

24% 14% 26% 36%

Number of children

0 1 2 3 or more

446 191 135 128

50% 21% 15% 14%

160 48 47 45

53% 16% 16% 15%

149 59 43 49

50% 20% 14% 16%

137 84 45 34

46% 28% 15% 11%

Income (N$)

Income 0 Income <=500 Income 501-1000 Income 1001-2000 Income >2000

326 248 109 71 146

36% 28% 12% 8% 16%

141 59 25 18 57

47% 20% 8% 6% 19%

109 110 31 19 31

36% 37% 10% 6% 10%

76 79 53 34 58

25% 26% 18% 11% 19%

33

Table 4 shows relationship status by age group. Nearly all respondents younger than 25 were

unmarried, with only 5% being married and 14% cohabiting. Marital levels increase slightly for

the 25-34 year age group to 22%, reaching just over 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 true for around one fifth of older respondents – 19% those aged 25-34 and 21% for those

aged 35-49.

Table 4: Relationship status by age group

Age group Married Cohabiting In relationship Single/other Total

n % n % n % n % n

16-25 17 5% 45 14% 127 39% 140 43% 329

25-34 61 22% 70 25% 96 34% 53 19% 280

35-49 150 52% 39 13% 42 14% 60 21% 291

Total 228 25% 154 17% 265 29% 253 28% 900

5.2 Community level exposure to HIV/AIDS

Respondents were asked about exposure to HIV/AIDS information in the past 12 months. When

analysed by age group, only three marked differences were found – 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, 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

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. 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.

34

Table 5: Exposure to HIV/AIDS information

In the past 12 months from where or from whom have you received information about HIV/AIDS?

N=900

All Oshikuku Oniipa Rehoboth

n % n % n % n %

Friend(s) 635 71% 243 81% 200 67% 192 64%

Clinic, hospital or doctors office 619 69% 203 68% 204 68% 212 71%

Parent / Family member or caregiver 557 62% 223 74% 163 54% 171 57%

AIDS Organisation 498 55% 206 69% 142 47% 150 50%

Faith Based Organisation 300 33% 101 34% 69 23% 130 43%

A child or learner of school-going age 231 26% 54 18% 92 31% 85 28%

At school from teacher 225 25% 82 27% 96 32% 47 16%

Pharmacy 203 23% 78 26% 86 29% 39 13%

Telephone helpline 98 11% 43 14% 51 17% 4 1%

Traditional healer 56 6% 35 12% 13 4% 8 3%

Attended an HIV/AIDS play or educational event 417 46% 177 59% 207 69% 33 11%

Attended a community meeting about HIV/AIDS 376 42% 151 50% 181 60% 44 15%

Attended a training workshop on HIV/AIDS 223 25% 114 38% 84 28% 25 8%

Respondents were asked about interpersonal exposure to HIV/AIDS in the past 12 months. More

than half of respondents (55%) overall had attended a funeral of someone who had died of AIDS,

while half had experienced HIV disclosure by a person that they knew. This was highest in

Oniipa (62%) and lowest in Rehoboth (35%). Around half in Oshikuku (46%) and Oniipa (48%)

had cared for a person who was sick with AIDS, although this applied to only 21% in Rehoboth.

A similar pattern emerged for respondents who had helped care for a child whose parents had

died of AIDS. These trends are likely to be related to the much lower antenatal HIV prevalence in

Rehoboth.

Table 6: Interpersonal exposure to HIV/AIDS

In the past 12 months, which apply to you?

N=900

All Oshikuku Oniipa Rehoboth

n % n % n % n %

Attended a funeral of someone who has died of AIDS 496 55% 182 61% 177 59% 137 45%

Been told by someone you know that they are HIV positive

453 50% 163 54% 185 62% 105 35%

Cared for a person who is sick with AIDS 346 38% 138 46% 145 48% 63 21%

Helped care for a child whose parents have died of AIDS 239 27% 107 36% 96 32% 36 12%

5.2 Communication

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. 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

35

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%).

Table 7: Mass media and communication access

N=900

All Oshikuku Oniipa Rehoboth

n % n % n % n %

Working television in household 558 62% 153 51% 144 48% 261 87%

Working radio in household 789 88% 258 86% 267 89% 264 88%

Listen to radio 2+ days/week 693 77% 235 78% 209 70% 249 83%

Watch TV 2+ days/week 529 59% 142 47% 114 38% 273 91%

Read a magazine 2+ days/week 204 23% 79 26% 42 14% 83 28%

Read a newspaper 2+ days/week 509 57% 185 62% 114 38% 210 70%

Use internet 2+ days/week 118 13% 35 12% 28 9% 55 18%

Own cellphone 730 81% 283 94% 161 54% 286 95%

5.3 Reach of the BTC Campaign

Awareness of the BTC Campaign was determined through asking a series of questions that

included visual prompting in certain instances. Visual prompts took the form of colour printouts

representing particular elements 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 study

site. Data was 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. 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%). Around three quarters of respondents (79%) could recall the „who

are you connected to‟ slogan unprompted or with prompting. Three quarters of respondents had

heard the slogan on the radio (74%), followed by posters and newspapers (69%) and then

television (35%). Unprompted recall for television was highest in Rehoboth (61%) and is related

the higher access to this medium.

Table 8: Awareness of BTC Campaign and slogans

N=900

All Oshikuku Oniipa Rehoboth

n % n % n % n %

Heard of or seen the phrase „Break the Chain‟? (Yes) 759 84% 259 86% 257 86% 243 81%

Seen the Logo for “Break the Chain”? (Yes, unprompted) 562 62% 196 65% 212 71% 154 51%

Seen the Logo for “Break the Chain”? (Yes, prompted) 224 25% 76 25% 43 14% 105 35%

36

Seen the Logo for “Break the Chain”? (No) 114 13% 28 9% 45 15% 41 14%

Seen or heard the slogan “who does he/she connect you to” or “who are you connected to” (Yes, unprompted)

498 55% 109 36% 202 67% 187 62%

Seen or heard the slogan “who does he/she connect you to” or “who are you connected to” (Yes, prompted)

213 24% 119 40% 34 11% 60 20%

Seen or heard the slogan “who does he/she connect you to” or “who are you connected to” (No)

189 21% 72 24% 64 21% 53 18%

Did you see this on Television? (Yes, unprompted) 424 47% 98 33% 143 48% 183 61%

Did you see this on Television? (Yes, prompted) 162 18% 54 18% 32 11% 76 25%

Did you see this on Television? (No) 314 35% 148 49% 125 42% 41 14%

Did you see these slogans on a poster? (Yes) 624 69% 195 65% 203 68% 226 75%

Did you see these slogans in a newspaper? (Yes) 621 69% 204 68% 199 66% 218 73%

Did you hear these slogans on an advert on the radio? (Yes) 669 74% 225 75% 228 76% 216 72%

Seen or heard the slogan “Say no to sexual networks together”? (Yes)

614 68% 187 62% 229 76% 198 66%

Seen or heard the slogan “Make a stand against sexual networks”? (Yes)

553 61% 170 57% 227 76% 156 52%

Seen or heard the slogan “Reduce your risk to sexual networks”? (Yes)

570 63% 187 62% 237 79% 146 49%

Most respondents had not seen the shebeen booklet „Naked Truth‟ (13%). 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%),

agreed on this question.

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 NAMCOL database.

Table 9: Awareness of BTC Campaign components

N=900

All Oshikuku Oniipa Rehoboth

n % n % n % n %

Seen the “Naked Truth” shebeen booklet? (Yes, unprompted)

121 13% 24 8% 83 28% 14 5%

Seen the “Naked Truth” shebeen booklet? (Yes, prompted)

225 25% 114 38% 42 14% 69 23%

Seen the “Naked Truth” shebeen booklet? (No) 554 62% 162 54% 175 58% 217 72%

Seen the “fly guy/fly girl” posters? (Yes, unprompted) 122 14% 30 10% 77 26% 15 5%

Seen the “fly guy/fly girl” posters? (Yes, prompted) 235 26% 104 35% 37 12% 94 31%

37

Seen the “fly guy/fly girl” posters? (No) 543 60% 166 55% 186 62% 191 64%

Heard a “Break the Chain” song? (Yes) 405 45% 161 54% 113 38% 131 44%

Heard the Desert Soul radio programme “Tjitjikutuare kepembe kotjii” (Yes)

472 52% 170 57% 202 67% 100 33%

Seen the animation „Meet Joe‟ (Yes) 66 7% 9 3% 34 11% 23 8%

Seen the “Galz and Goals” funbook? (Yes, unprompted) 62 7% 14 5% 45 15% 3 1%

Seen the “Galz and Goals” funbook? (Yes, prompted) 66 7% 43 14% 10 3% 13 4%

Seen the “Galz and Goals” funbook? (No) 772 86% 243 81% 245 82% 284 95%

Seen the Desert Soul Magazine/booklet on multiple partners? (Yes, unprompted)

378 42% 161 54% 169 56% 48 16%

Seen the Desert Soul Magazine/booklet on multiple partners? (Yes, prompted)

214 24% 86 29% 19 6% 109 36%

Seen the Desert Soul Magazine/booklet on multiple partners? (No)

306 34% 53 18% 111 37% 142 47%

Seen the Logo for “One Love” ? (Yes, unprompted) 278 31% 98 33% 132 44% 48 16%

Seen the Logo for “One Love” ? (Yes, prompted) 272 30% 144 48% 54 18% 74 25%

Seen the Logo for “One Love” ? (No) 350 39% 58 19% 114 38% 178 59%

Heard about an SMS Helpline 20222 (Yes) 180 20% 66 22% 51 17% 63 21%

A number of campaign components were delivered at community level. These included a

flannelgram that allowed for explanation of MCP, Picture Codes that facilitated discussion of

MCP, a video entitled Phillip Wetu, and various events and activities. Not all activities were

conducted in all communities. Respondents may however also have encountered campaign

components when visiting communities where they are not resident.

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 low 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 seen a BTC event, although this only applied to a minority in

Rehoboth (10%). Participation in other activities was also overall low.

Table 10: Awareness of BTC group activity components

N=900

All Oshikuku Oniipa Rehoboth

n % n % n % n %

In the past 12 months have you seen the Picture Codes about multiple partners (Yes, unprompted)

324 36% 158 53% 154 51% 12 4%

In the past 12 months have you seen the Picture Codes about multiple partners (Yes, prompted)

81 9% 16 5% 38 13% 27 9%

In the past 12 months have you seen the Picture Codes about multiple partners (No)

495 55% 126 42% 108 36% 261 87%

In the past 12 months have you seen the flannelgram about multiple partners (Yes, unprompted)

310 34% 120 40% 171 57% 19 6%

In the past 12 months have you seen the flannelgram about multiple partners (Yes, prompted)

41 5% 7 2% 17 6% 17 6%

In the past 12 months have you seen the flannelgram about multiple partners (No)

549 61% 173 58% 112 37% 264 88%

In the past 12 months have you seen the video „Philip Wetu‟ (Yes)

47 5% 21 7% 20 7% 6 2%

In the past 12 months have you seen the video „Philip 853 95% 279 93% 280 93% 294 98%

38

Wetu‟ (No)

Visited a booth or seen an event where they are promoting “Break the Chain”? (Yes, unprompted)

287 32% 130 43% 150 50% 7 2%

Visited a booth or seen an event where they are promoting “Break the Chain”? (Yes, prompted)

120 13% 75 25% 23 8% 22 7%

Visited a booth or seen an event where they are promoting “Break the Chain”? (No)

491 55% 93 31% 127 42% 271 90%

Been part of an activity by LifeLine (Yes) 35 4% 4 1% 15 5% 16 5%

Been part of an activity by Childline (Yes) 39 4% 8 3% 18 6% 13 4%

Been part of an activity run by “New Start” (An event or promotion – not going for testing) (Yes)

90 10% 46 15% 26 9% 18 6%

Been part of an activity by Catholic AIDS Action (Yes) 68 8% 26 9% 22 7% 20 7%

The BTC Campaign included 25 unique components by medium or activity. Over 50% of

respondents had seen 12 or more components and all respondents had been exposed to at least

one component. Only 10% of respondents had been reached by 6 or less components of the

campaign. The extent of component reach is also described further below.

5.3.1 Exposure to multiple BTC Campaign components

The extent of exposure to various components of the BTC Campaign was explored to understand

whether there were variations between sites and demographic characteristics of respondents.

While measuring frequency of exposure was not possible, exposure to a wider range of

components provides an indication of multiple levels of exposure. A subset of components were

defined as mass media – for example, having heard an advert on radio or seen one on television,

while community programmes were defined by exposure to particular products – for example, the

flannelgram or Picture Codes. Small media such as posters were defined as community-level

components as were booklets and leaflets. Although a minority of respondents could not recall

the BTC Campaign slogan, all respondents were reached by at least one BTC Campaign

component. Participants could also have been exposed to BTC Campaign concepts in other ways

– for example through discussion with others in the community – or through other discourses

about MCP, for example in the news media.

Table 11: Exposure to BTC Campaign components by site

All Oshikuku Onandjokwe Rehoboth

n % n % n % n %

Mass Media BTC Components

1-5 Components 231 26% 91 30% 62 21% 78 26%

6-13 Components 669 74% 209 70% 238 79% 222 74%

Community level BTC Components

1 Component 302 34% 37 12% 76 25% 189 63%

2-15 Components 598 66% 263 88% 224 75% 111 37%

Exposure to any BTC Component

n % n % n % n %

1-9 Components 174 19% 42 14% 52 17% 80 27%

10+ Components 726 81% 258 86% 248 83% 220 73%

39

The majority of respondents (74%) were exposed to six or more mass media components, and

this was similar between all three sites. Community level exposure 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.

Table 12: Exposure to BTC Campaign components by sex and age

Male Female 16-24 25-35 36-49

n % n % n % n % n %

Mass Media BTC Components

1-5 Components 84 25% 147 26% 74 22% 84 30% 73 25%

6-13 Components 252 75% 417 74% 255 78% 196 70% 218 75%

Community level BTC Components

1 Component 102 30% 200 35% 109 33% 100 36% 93 32%

2-15 Components 234 70% 364 65% 220 67% 180 64% 198 68%

Exposure to any BTC Component

n % n % n % n % n %

1-9 Components 62 18% 112 20% 54 16% 64 23% 56 19%

10+ Components 274 82% 452 80% 275 84% 216 77% 235 81%

Exposure by 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.

5.4 Knowledge of ways to prevent HIV

Respondents were asked to list all the ways that a person could prevent infection with HIV. The

same question was asked in 2007/8, and comparative levels are shown for the six categories most

likely to be mentioned. Multiple responses were possible and choices were not prompted, but

were coded by enumerators.

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.

Respondents were however more likely to indicate „having only one sex partner‟ in 2011 – 57%

in comparison to 49% in 2007/8. Indicating that one should be faithful to one‟s sex partner was

similar (37% vs 34%), while there has been an increase in mention of non-penetrative sex from

13% to 31%.

40

„Breaking the chain‟ or not having concurrent partners was mentioned by 30% of respondents in

2011. This was not an questionnaire coding category in 2007/8.

Table 13: Unprompted knowledge of ways to prevent HIV – 2007/8, 2011

Can you tell me all the ways you know that HIV can be prevented

N=900/300/300/300

All Oshikuku Oniipa Rehoboth

n % n % n % n %

Always using condoms (2011)

Always using condoms (2007/8)

792

1422

88%

79%

271

499

90%

83%

235

499

78%

83%

286

424

95%

71%

Abstaining from sex (2011)

Abstaining from sex (2007/8)

528

1363

59%

76%

101

485

34%

81%

221

452

74%

75%

206

426

69%

71%

Have only one sex partner (2011)

Having only one sex partner (2007/8)

509

871

57%

49%

183

180

61%

30%

95

375

32%

63%

231

316

77%

53%

Being faithful to your sex partner (2011)

Being faithful to your sex partner (2007/8)

333

605

37%

34%

100

168

33%

28%

104

223

35%

37%

129

214

43%

36%

Non penetrative sex (2011)

Non penetrative sex (2007/8)

275

242

31%

13%

102

80

34%

13%

154

55

51%

9%

19

107

6%

18%

By breaking the chain (2011)/ Not having concurrent partners (2011)

Not included as a coding option in 2007/8

269 30% 114 38% 119 40% 36 12%

5.6 Qualitative findings on awareness and knowledge of 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. Participants

also reflected on the campaign in relation to previous campaigns.

Core message

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)58

while sexual networks were

readily understood as people who were “…sexually connected to many people at the same time”

(Male, 16-19, Oshikuku).59 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).60

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).61

58

Rehoboth FGD males 16 to 19 final.txt 59

Oshikuku FGD with males 16.19.txt 60

Oniipa, FGD females 16-19.txt 61

Oniipa FGD with Males aged between 20-30.txt

41

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).62

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).63

Other participants described the risks emanating from sexual networks as

having been „hidden‟ or „concealed‟.

Slogan

It was felt that the slogan was easily interpreted by people from all walks of life and that it

incorporated „the whole message‟, 64

while also being included in people‟s conversations because

it „sounded nice‟.65 A religious leader in Oniipa observed that the phrase „Break the Chain‟ could

be used as a means to refuse advances, 66

while PLHIV in the same community67

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 and joking 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).68

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).69

62

Rehoboth FGD People involved in BTC final.txt 63

Oniipa FGD with People living with HIV.txt 64

Rehoboth FGD males 16 to 19 final.txt 65

Oniipa FGD with People living with HIV.txt 66

Oniipa Interview with Faith based Leader.txt 67

Oniipa FGD with People living with HIV.txt. Hand gestures were also noted by the Faith-based leader in Oniipa quoted above. 68

Rehoboth FGD male 20 - 30 final.txt 69

Oshikuku FGD 31-49 mixed.txt

42

Some youth participants raised concerns about the sexualized imagery, noting that it was not

good for children to see „naked people on television‟,70

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 pretentd to receive a cellphone call so that he could go to another room.71

Concerns of the effects on children were also raised by older male participants in Oniipa.72

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).73

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).74

Interpersonal components

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 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”.75

5.7 Discussion of reach, awareness and knowledge of the BTC Campaign

Respondents in the quantitative survey comprised an even spread across the 16-49 age group,

with variations being found in terms of employment, religion, amenity access, and income. Most

respondents were poor with variations in access to amenities being related to the extent of

urbanization in each site, with Rehoboth being the most urbanised. Relationship patterns illustrate

the predominance of low overall rates of marriage, with the majority of respondents being in non-

marital relationships.

70

Oniipa FGD with Females aged between 16-19.txt 71

Rehoboth FGD males 16 to 19 final.txt 72

Oniipa FGD with Males aged between 20-30.txt 73

Rehoboth FGD male 20 - 30 final.txt 74

Oniipa FGD with Females aged between 20-30.txt 75

Oniipa FGD with Males and Females aged between 25-35 Involved with BTC.txt

43

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 workers and

commercial facilities such as pharmacies, and with people in organisations and institutions such

as schools. Telephone helplines do not however feature strongly, and in Rehoboth, only 1%

indicated that they had received information in this way. The deeper dimensions of the epidemic

are also clearly felt, with many respondents knowing people who have died, or knowing people

who are living with HIV.

Access to mass media communication resources is high in Namibia and this has allowed the BTC

Campaign to achieve high levels of reach and awareness. Radio has a very high and even reach

across the study communities, whereas frequent television viewing occurs among less than half

of respondents in Oshikuku and Oniipa. Access to other mediums varied between sites.

There has been a high reach achieved by the BTC Campaign. All respondents have seen or heard

at least one component of the campaign, while half have been exposed to 12 or more

components. The vast majority of respondents know of the campaign through having heard the

slogan or having seen the logo, and there is high prompted awareness of supplementary slogans

such as “who are you connected to” and “say no to sexual networks”. Reach of parallel „brands‟

falling within the regional „One Love‟ campaign, was also high, although there was lower

recognition of the „One Love‟ logo.

While Rehoboth has high mass media reach, respondents are less likely to have been engaged

through community-level activities. In comparison to mass media, the reach of subcomponents

delivered at community level is inevitably lower. Reach is also context dependent – for example,

shebeen goers and drinkers represented a sub-audience for the shebeen booklet, whereas Galz and

Goals was directed towards youth, and „Meet Joe‟ was dependent on banking halls as access

points. Engaging with community-level 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.

There was however very low penetration of the Philip Wetu video in all three sites. Reach of

information booths was modest in Oshikuku and Oniipa, and very low in Rehoboth.

To obtain an understanding of any possible changes in „top of mind‟ awareness of ways to

prevent HIV, current responses to an open-ended question were compared to responses in the

previous surveys. Two fifths (40%) of respondents in Oniipa and 38% of respondents in

Oshikuku spontaneously mentioned „breaking the chain‟ or not having concurrent partners, which

illustrates fair campaign penetration linked to concepts of HIV prevention in these two

communities. Response was much lower in Rehoboth at 12%. The reasons for these variations

are unclear, although the variation could be related to the lower intensity of community activities

in Rehoboth.

Notwithstanding variations in reach for some components and study site differences, the BTC

Campaign has clearly reached a wide audience, with good recall of components and an emerging

prioritisation of the risks of concurrency. The qualitative findings deepen understanding of the

44

interpretation of the campaign, with participant narratives illustrating a number of key points

regarding the 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 readily interpreted literally and is

not confusing 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 risks emanating from

exposure to sexual networks. However, once revealed, the principles of risk through being part

of a sexual network are are clear.

3) There is an awareness that risk flows from one‟s own practices, as well as those of one‟s

partners, and that even if one is faithful, one may still be linked to a sexual network.

In considering the slogan and imagery, the „break the chain‟ slogan is well liked and is seen as

something that is acceptable as a new linguistic sign or code that can form part of day-to-day

discussion with peers. An important outcome of the campaign is the emergent cultural script that

allows people to avoid risk by articulating their desire not to be part of a sexual network by

saying „I have broken the chain‟. What is particularly relevant is that a few participants

mentioned that the „break the chain‟ concept has been extended into a non-verbal code, expressed

by a hand gesture, that can be used to fend off unwanted advances. This enhances individual self-

efficacy, by avoiding a verbal discourse or potential confrontation. Wishing to avoid such a

liaison is validated by the widespread dissemination of an explanatory framework related to HIV

risk, and the slogan allows people to indicate their aversion to such risk. It is also relevant that

this can be done „jokingly‟, which is less likely to lead to conflict with the person being rebuffed.

The concise simplicity of the slogan, and its capacity to be immediately interpreted, allows for a

„top of mind‟ awareness that interjects into one‟s consciousness. This is well exemplified by a

male participant‟s description of seeing a „lady walking by and she is good‟ – ie. sexually

attractive – with the slogan immediately coming to mind. The slogan on its own is enough to

dispel the urge to make sexual advances.

The colours and imagery utilised by the campaign have clearly engendered interest and are

overall well liked and seen as attractive. Use of red has also conveyed a sense of alarm and

urgency, and for some participants, even fear, and this has helped to highlight and reinforce a

sense of vulnerability. The appeal of the novelty of the campaign as a product of a „new message‟

that is delivered in an attractive way, reinforces acceptability of the content.

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.

45

The orientation of the campaign towards social level discussion is also an important element of

the campaign, and apart from BTC implementers noting the benefits of this approach, discussion

in support groups by PLHIV and incorporation into debates at school is also encouraging.

5.8 HIV testing

Respondents were asked if they had ever tested for HIV and the timing of their most recent test.

The vast majority of respondents had ever had an HIV test, and levels were similar in all three

communities. Ever testing was higher among females and the majority of respondents had

recently had an HIV test.

Table 14: HIV testing

HIV Testing

N=900

All Oshikuku Oniipa Rehoboth

n % n % n % n %

Ever had an HIV test (All) 695 77% 242 81% 233 78% 220 73%

Ever had an HIV test (Male) 226 67% 83 74% 78 66% 65 62%

Ever had an HIV test (Female) 469 83% 159 85% 155 86% 155 79%

If yes, tested less than a year ago (All) 407 59% 147 61% 132 57% 128 58%

If yes, tested less than a year ago (Male) 123 54% 42 51% 42 54% 39 60%

If yes, tested less than a year ago (Female) 284 61% 105 66% 90 58% 89 57%

Reasons for having an HIV test were explored and 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 because they were concerned about their partner‟s HIV status or sexual

behaviour, or having had multiple partners themselves.

Table 15: Main reason for most recent HIV test

Main reason for most recent HIV test

N=695

All Oshikuku Oniipa Rehoboth

n % n % n % n %

I just wanted to know my status 414 60% 177 73% 139 60% 98 45%

I was/am pregnant (Females, n=469) 110 23% 25 16% 33 21% 52 34%

I was feeling sick or unwell 25 3% 2 0% 14 6% 9 4%

I was encouraged to do so by friends 23 3% 2 1% 14 6% 7 3%

My partner asked me to go for testing 21 3% 10 4% 8 3% 3 1%

I am worried about my partner‟s status / sexual behaviour 21 3% 7 3% 6 3% 8 4%

I applied for an insurance policy or loan 19 3% 2 1% 0 0% 17 8%

I was instructed by a health worker (nurse/doctor) 13 2% 0 0% 2 1% 11 5%

I was encouraged to do so by advertising 12 2% 3 1% 8 3% 1 0%

I wanted to get married 11 2% 6 2% 3 1% 2 1%

I have had multiple partners 10 1% 2 1% 2 1% 6 3%

46

5.8.1 Qualitative findings on HIV testing

HIV testing was not explored directly in the qualitative study. However, 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).76

Similarly, if one wanted

to establish a relationship that avoided risk, the repertoire of prevention strategies included using

condoms, or both having and HIV test – and then 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).77

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).78

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”.79

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).80

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).81

76

Onandjokwe FGD with Males aged between 20-30.txt 77

Onandjokwe FGD with Females aged between 20-30.txt 78

Oshikuku FGD 31-49 Mixed final 79

Oshikuku FGD PLWHIV final.txt 80

Oshikuku FGD 31-49 mixed.txt 81

Rehoboth FGD males 16 to 19 final.txt

47

5.9 MCP and social norms

Respondents were asked about their perceptions of MCP-related behaviours and attitudes at

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. It was perceived to be common to have other partners for around

half married men (47%) and around a third of married women (30%). Young women were also

perceived to often have older partners for money or other commodities (70%), with perceptions

being higher for Oshikuku (78%) and Rehoboth (86%).

Table 16: Perceptions of MCP-related practices at community level (1)

N=900/300/300/300 Agree/Agree

strongly Neutral Disagree/Disagree

strongly

It is common for unmarried women in this community to have many boyfriends at the same time

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

424

47%

85

28%

123

41%

216

72%

140

16%

42

14%

68

23%

30

10%

336

37%

173

58%

109

36%

54

18%

It is common for unmarried men in this community to have many girlfriends at the same time

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

477

53%

105

35%

123

41%

249

83%

124

14%

38

13%

69

23%

17

6%

`298

33%

156

52%

108

36%

34

11%

It is common for married women in this community to have a sexual partner who is not their husband

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

270

30%

32

11%

72

24%

166

55%

161

18%

37

12%

67

22%

57

19%

468

52%

230

77%

161

54%

77

26%

It is common for married men in this community to have a sexual partner who is not their wife

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

419

47%

105

35%

106

35%

208

69%

149

17%

44

15%

66

22%

39

13%

330

37%

149

50%

128

43%

53

18%

48

Young women in this community often have older sexual partners for money, other necessities or luxuries

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

632

70%

233

78%

141

47%

258

86%

119

13%

34

11%

64

21%

21

7%

148

16%

32

11%

95

32%

21

7%

Peer modeling and peer pressure to have other partners influences individual behaviour. Although

perceptions were 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.

Disapproval of MCP by community elders was also perceived to exist at high levels (77%) as

well as disapproval by friends (64%). Higher levels disapproval by elders and friends were

perceived in Oshikuku – 91% and 86% respectively.

Using condoms was not seen as a justifiable means to have many partners, with only 18%

agreeing, while nearly all respondents (94%) agreed that having many partners leads to violence.

Table 17: Perceptions of MCP-related practices at community level (3)

N=900/300/300/300 Agree/Agree

strongly Neutral Disagree/Disagree

strongly

Many of my friends have relationships with more than one sexual partner at the same time

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

339

38%

80

27%

106

35%

153

51%

118

13%

27

9%

66

22%

25

8%

443

49%

193

64%

128

43%

122

41%

My friends encourage me to have many sexual partners (all)

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

138

15%

21

7%

58

19%

59

20%

58

6%

17

6%

28

9%

13

4%

704

78%

262

87%

214

71%

228

76%

My friends admire a person who has many sexual partners (all)

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

150

17%

32

11%

50

17%

68

23%

105

12%

18

6%

38

13%

49

16%

645

72%

250

83%

212

71%

183

61%

49

My friends encourage people to have fewer partners (of respondents who ever had sex)

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

526

65%

229

85%

154

58%

143

53%

126

16%

14

5%

42

16%

70

26%

154

19%

25

9%

71

27%

58

21%

My friends encourage others to avoid having overlapping / concurrent partners (of respondents who ever had sex)

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

362

45%

192

72%

50

19%

120

44%

117

15%

10

4%

36

13%

71

26%

327

41%

66

25%

181

68%

80

30%

Elders in this community disapprove of people having many sexual partners

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

690

77%

270

91%

163

54%

257

86%

58

6%

5

2%

42

14%

11

4%

150

17%

23

8%

95

32%

32

11%

My friends disapprove of people who have many sexual partners

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

574

64%

257

86%

157

52%

160

53%

125

14%

13

4%

49

16%

63

21%

199

22%

28

9%

94

31%

77

26%

It is not a problem to have many sexual partners if a condom is used with every partner (of respondents who ever had sex)

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

142

18%

28

10%

62

23%

52

19%

85

11%

36

13%

38

14%

11

4%

579

72%

204

76%

167

63%

208

77%

Having many partners leads to violence (all)

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

759

94%

259

97%

252

94%

248

92%

14

2%

1

0%

2

1%

11

4%

33

4%

8

3%

13

5%

12

4%

Respondents were asked whether they had spoken to friends or family about HIV/AIDS in the

past month, and if yes, unprompted topics related to sexual behaviour were documented. 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, while 24% talked

about the BTC Campaign or concurrent partners. Among respondents who had heard of the BTC

50

Campaign, around a quarter (24%) had spoken to others about the campaign in the past month.

This was lowest in Rehoboth at 13%.

Table 18: Speaking to others about HIV/AIDS82

In the past month, have you spoken to a friend or family member about HIV/AIDS? n=900

All Male Female Oshikuku Oniipa Rehoboth

n % n % n % n % n % n %

Yes 563 63% 200 60% 363 64% 202 67% 204 68% 157 52%

No 337 37% 136 40% 201 36% 98 33% 96 32% 143 48%

If yes… (n=563)

HIV testing 329 58% 121 61% 208 57% 162 80% 129 63% 38 24%

Condoms 270 48% 108 54% 162 45% 98 49% 117 57% 55 35%

Having many partners 150 27% 49 25% 101 28% 55 27% 43 21% 52 33%

Break the chain campaign / having concurrent partners 135 24% 47 24% 88 24% 56 28% 59 29% 20 13%

Respondents were asked whether they believed people in the community in general were

changing their sexual behaviour. 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 who agreed change was taking place (49%), followed by condom use and having

fewer partners at 43%.

Table 19: Perceptions of sexual behaviour change at community level83

Are people in this community changing their sexual behaviour in comparison to a few years ago? n=900

All Male Female Oshikuku Oniipa Rehoboth

n % n % n % n % n % n %

Yes 320 36% 119 35% 201 36% 146 49% 124 41% 50 17%

No 580 64% 217 65% 363 64% 154 51% 176 59% 250 83%

If yes… (n=320)

People are breaking the chain / avoiding having concurrent partners

156 49% 61 51% 95 47% 104 71% 44 35% 8 16%

They use condoms more often 138 43% 58 49% 80 40% 88 60% 35 28% 15 30%

They have fewer partners 136 43% 59 50% 77 38% 64 44% 65 52% 7 14%

They know their HIV status 83 26% 30 25% 53 26% 57 39% 17 14% 9 18%

More people are abstaining 64 20% 26 22% 38 19% 40 27% 21 17% 3 6%

They are faithful to each other 57 18% 22 18% 35 17% 35 24% 19 15% 3 6%

Respondents who had ever had sex were asked whether they thought their most recent sexual

partners had other partners while they were together. Although only 13% responded in the

affirmative, there was a high degree of ambivalence in response, with 46% indicating that they

did not know or were unsure.

82

Note: Unprompted response categories, multiple responses possible. ‘Other’ category has been omitted from table. 83

Note: Unprompted response categories, multiple responses possible. ‘Other’ category has been omitted from table.

51

Table 20: Perceptions of partner concurrency

Do you think your most recent sexual partner has had other sexual partners while you have been together? N=806

All Male Female Oshikuku Oniipa Rehoboth

n % n % n % n % n % n %

Yes 108 13% 31 10% 77 15% 40 15% 33 12% 35 13%

No 328 41% 139 46% 189 37% 84 31% 66 25% 178 66%

Don‟t know / Unsure 370 46% 131 44% 239 47% 144 54% 168 63% 58 21%

5.10 Higher exposure to multiple components of the BTC Campaign and change

All respondents in this study had been exposed to at least one component of the BTC Campaign.

It was not possible to measure frequency, or intensity of exposure in the context of a 1-hour

interview that included varied lines of enquiry and the complex nature of the multiple

components of the campaign. Component exposure thus represents receiving the BTC „message‟

through a given channel – for example, a radio advertisement or a poster, or engaging in a

community-level event or activity. It is likely that there may be individuals who were reached by

fewer components, but at a higher intensity, and conversely, multiple component reach may not

have included high intensity. Notwithstanding, the analysis illustrates differences between having

been reached by a few components and many components, and the overall finding is that multiple

component reach is significantly associated with a higher degree of change in MCP related

indicators.

The extent of exposure to multiple components was assessed, and a low-component exposure

group and a high component exposure group was utilised for statistical analysis. As per Table 11

further above, 19% of respondents were exposed to 1-9 components, and 81% were exposed to

10 or more components.

A number of significant outcomes in relation to engaging with the BTC Campaign and issue of

sexual partner concurrency were observed between the two groups reached. Around two thirds of

respondents had spoken to a friend about HIV/AIDS, and this was more likely among

respondents who were exposed to a higher number of BTC components (65% vs 53%, p=0.003).

Such discussions were also more likely to refer to BTC or concurrency (25% vs 16%, p=0.06).84

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), and breaking the chain

or avoiding concurrent partners was also more likely as the change that was mentioned (24% vs

9%, p=0.02). Higher exposure to multiple components was significantly associated with intention

to change sexual behaviour (p=0.02), but there was not a significant relationship to planning to

break the chain or avoid concurrent partners. 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.

84

This is of borderline statistical significance.

52

Table 21: Exposure to BTC Campaign components by MCP-related indicators

All 1-9 Components 10 or more components

p value

n % n % n %

Spoken to a friend about HIV/AIDS

Yes 563 63% 92 53% 471 65% p=0.003

No 337 37% 82 47% 255 35%

Of yes, spoke about BTC or concurrency

Yes 135 24% 15 16% 120 25% p=0.06

No 428 76% 77 84% 351 75%

Made changes to sexual behaviour in past year

Yes 556 62% 87 50% 469 65% p<0.001

No 344 38% 87 50% 257 35%

Of yes, broken chain / avoid concurrent partners

Yes 121 22% 8 9% 113 24% p=0.02

No 435 78% 79 91% 356 76%

Plan to make changes to sexual behaviour in coming year

Yes 562 62% 95 55% 467 64% p=0.02

No 338 38% 79 45% 259 36%

Of yes, broken chain / avoid concurrent partners

Yes 159 28% 22 23% 137 29% p=0.2

No 403 72% 73 77% 330 71%

Partners in past year

0 or 1 727 90% 135 90% 592 90% ns

2+ 79 10% 15 10% 64 10%

Partners in past month

0 or 1 729 97% 128 96% 601 97% ns

2+ 22 3% 5 4% 17 3%

5.11 MCP and reported changes to sexual behaviour

Respondents who had ever had sex were asked if they had made changes to the sexual behaviour

recently. 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%).

53

Table 22: Reported sexual behaviours and practices changed in past year85

In the past year, have you made any changes to your sexual behaviour? N=806

All Male Female Oshikuku Oniipa Rehoboth

n % n % n % n % n % n %

Yes 529 66% 214 71% 315 62% 215 80% 171 64% 143 53%

No 277 34% 87 29% 190 38% 53 20% 96 36% 128 47%

If yes… (N=529)

Used condoms more often 269 51% 108 50% 161 51% 140 65% 79 46% 50 35%

I have broken the chain / Avoid having concurrent partners

119 22% 47 22% 72 23% 60 28% 39 23% 20 14%

I abstain from sex 104 20% 31 14% 73 23% 24 11% 34 20% 46 32%

Have fewer partners 94 18% 56 26% 38 12% 25 12% 30 18% 39 27%

Know my HIV status and my partners HIV status

86 16% 36 17% 50 16% 40 19% 13 8% 33 23%

My partner and I are faithful to each other

84 16% 34 16% 50 16% 35 16% 28 16% 21 15%

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. The main changes

were using condoms more often (12%) and knowing their HIV status or that of their partners

(11%).

Table 23: Planned changes in coming year among non-change group86

Do you plan to make any changes to your sexual behaviour in the coming year?

All Male Female Oshikuku Oniipa Rehoboth

n % n % n % n % n % n %

Had not made changes in previous year (n=277)

Used condoms more often 34 12% 13 15% 21 11% 7 13% 9 9% 18 14%

Know my HIV status and my partners HIV status

30 11% 8 9% 22 12% 3 6% 0 0% 27 21%

Break the chain / Avoid having concurrent partners

14 5% 6 7% 8 4% 3 6% 4 4% 7 5%

Have fewer partners 14 5% 8 9% 6 3% 4 8% 2 2% 8 6%

Abstain from sex 14 5% 8 9% 6 3% 4 8% 2 2% 8 6%

Respondents were asked about the frequency with which they had used a condom with their most

recent sex partner. About half (51%) reported using a condom almost every time or every time.

Levels of condom use every time or almost every time 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.87

85

Note: Unprompted response categories, multiple responses possible. ‘Other’ category has been omitted from table. 86

Note: Unprompted response categories, multiple responses possible. ‘Other’ category has been omitted from table. 87

Data not shown in table

54

Table 24: Condom use with most recent sexual partner

With the person you most recently had sex with, how often do you use condoms? N=794

All Male Female Oshikuku Oniipa Rehoboth

n % n % n % n % n % n %

Every time 357 44% 144 48% 213 42% 168 63% 115 43% 74 27%

Almost every time 59 7% 16 5% 43 9% 16 6% 27 10% 16 6%

Sometimes 135 17% 49 16% 86 17% 21 8% 51 19% 63 23%

Never 255 32% 92 31% 163 32% 63 24% 74 28% 118 44%

5.11.1 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 changes in relationship patterns over the

past three years. The analysis demonstrates that there have been significant changes over the past

three years, with a marked reduction in the proportion of people reporting 2 or more partners in

the past year and past month.

The analysis provides a means to determine whether there have been any changes over time in

partner reduction, and whether or not these have been significant. It is important to note that this

comparison is not intended to reveal a causal relationship between the BTC Campaign and the

two time periods. Rather, the analysis provides a further data point for triangulation when taking

stock of the BTC Campaign in the context of the three study communities.

Table 25 shows changes in partners numbers in the past year, with the likelihood of having two

or more partners in the past year being 70% lower for all respondents (OR: 0.28).

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 around 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 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 lower

likelihood of having had multiple partners.

55

Table 25: Changes in numbers of partners in past year by demographic characteristics: 2007/8, 2011

2007/8 2011

Partners 0,1 2+ 0,1 2+ Odds Ratio

n % n % n % n % OR 95% CI p

All 956 72% 375 28% 727 90% 79 10% 0.28 0.21-0.36 <0.001

Site

Oshikuku 362 73% 136 27% 257 96% 11 4% 0.11 0.06 - 0.21 <0.001

Onandjokwe 308 73% 114 27% 250 94% 17 6% 0.18 0.10 - 0.31 <0.001

Rehoboth 286 70% 125 30% 220 81% 51 19% 0.53 0.37 - 0.76 0.001

Sex

Male 394 59% 277 41% 247 82% 54 18% 0.31 0.2 - 0.4 <0.001

Female 562 85% 98 15% 480 95% 25 5% 0.30 0.2 - 0.5 <0.001

Age group

16-24 288 69% 131 31% 213 87% 31 13% 0.32 0.2-0.5 < 0.001

25-34 268 69% 123 31% 243 88% 33 12% 0.30 0.2-0.5 <0.001

35+ 400 77% 121 23% 271 95% 15 5% 0.18 0.1 - 0.3 < 0.001

Religion

Catholic 374 72% 145 28% 202 91% 21 9% 0.27 0.2 - 0.4

Protestant/other 582 72% 230 28% 525 90% 58 10% 0.28 0.2 - 0.4

Employment

Unemployed 563 78% 161 22% 356 90% 41 10% 0.40 0.3 - 0.6 <0.001

Student/learner 103 72% 42 29% 57 90% 6 10% 0.26 0.1 - 0.7 0.004

Informal employment 98 59% 69 41% 83 90% 9 10% 0.15 0.07 - 0.3 <0.001

Employed 192 65% 104 35% 231 91% 23 9% 0.18 0.11 - 0.3 < 0.001

Relationship

Married 287 85% 51 15% 219 96% 8 4% 0.21 0.1 - 0.4 <0.001

Cohabiting 99 64% 56 36% 139 91% 14 9% 0.18 0.09 - 0.34 <0.001

In Relationship 137 69% 61 31% 220 87% 32 13% 0.33 0.2 - 0.5 < 0.001

Single/other 433 68% 207 32% 149 86% 35 20% 0.35 0.2 - 0.5 <0.001

Education

Primary 447 75% 153 26% 186 91% 19 9% 0.30 0.2 - 0.5 < 0.001

Comp grade 10 255 70% 111 30% 244 86% 40 14% 0.38 0.3 - 0.6 <0.001

comp grade 12 203 70% 87 30% 232 93% 17 7% 0.17 0.1 - 0.3 < 0.001

Tertiary 51 68% 24 32% 65 96% 3 4% 0.10 0.03 - 0.3 < 0.001

Table 26 shows changes in partners numbers in the past month. The likelihood of having two or

more partners in the past year being 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.

Partner reduction was slightly more likely to occur among males in comparison to females, and

respondents 35 and older were most likely to have changed. Religion was not associated with the

likelihood of change.

56

Respondents who were students were least likely to have reduced their partners in the past month,

whereas those who were employed were most likely to have done so. Partner reduction was also

more likely to have occurred among people who were married or cohabiting. It did not appear as

if change had occurred among respondents who said they were in a non-cohabiting relationship.

Higher levels of education were also related to a lower likelihood of having had multiple

partners.

Table 26: Changes in numbers of partners in past month by demographic characteristics: 2007, 2011

2008 2011

Partners 0,1 2+ 0,1 2+ Odds Ratio

n % n % n % n n 95% CI n

All 1062 89% 127 11% 729 97% 22 3% 0.25 0.2 - 0.4 < 0.001

Site

Oshikuku 380 88% 53 12% 251 98% 5 2% 0.14 0.06 - 0.4 < 0.001

Onandjokwe 353 93% 28 7% 250 97% 7 3% 0.35 0.2 - 0.8 0.02

Rehoboth 329 88% 46 12% 228 96% 10 4% 0.31 0.2 - 0.6 0.001

Sex

Male 508 83% 105 17% 269 94% 16 6% 0.29 0.2 - 0.5 < 0.001

Female 554 96% 22 4% 460 99% 6 1% 0.33 0.1 - 0.8 0.02

Age group

16-24 358 90% 42 11% 218 96% 9 4% 0.35 0.2 - 0.7 0.006

25-34 334 89% 41 11% 257 96% 10 4% 0.32 0.2 - 0.6 0.002

35+ 370 89% 44 11% 254 99% 3 1% 0.10 0.03 - 0.3 < 0.001

Religion

Catholic 405 88% 57 12% 202 97% 7 3% 0.25 0.1 - 0.5 0.001

Protestant/other 657 90% 70 10% 527 97% 15 3% 0.27 0.2 - 0.5 < 0.001

Employment

Unemployed 533 88% 50 8% 359 98% 9 2% 0.28 0.1 -0.6 < 0.001

Student/learner 125 91% 13 9% 55 95% 3 5% 0.52 0.1 -2.0 0.3

Informal employment 140 88% 20 13% 83 97% 3 3% 0.25 0.07 - 0.9 0.03

Employed 244 85% 44 15% 232 97% 7 3% 0.17 0.07 - 0.4 < 0.001

Relationship

Married 291 95% 16 5% 222 100% 1 0% 0.08 0.01 - 0.6 0.02

Cohabiting 134 88% 19 12% 150 99% 2 1% 0.09 0.02 - 0.4 0.002

In Relationship 183 94% 12 6% 229 93% 16 7% 1.07 0.5 - 2.3 0.9

Single/other 454 85% 80 15% 128 98% 3 2% 0.13 0.04 - 0.4 0.001

Education

Primary 434 88% 58 12% 173 96% 7 4% 0.30 0.1- 0.7 0.004

Comp grade 10 313 91% 31 9% 257 96% 11 4% 0.43 0.2 - 0.9 0.02

comp grade 12 250 89% 30 11% 236 99% 2 1% 0.07 0.02 - 0.3 < 0.001

Tertiary 65 89% 8 11% 63 97% 2 3% 0.26 0.05 - 1.3 0.1

57

5.12 Qualitative findings on the social context of MCP, sexual relationships and change

Participants were asked about how they had engaged with the campaign including processes of

internalization, as well as emerging actions or changes they had perceived or made as a product

of the campaign.

Youth and engaging the BTC Campaign

Although narratives of youth are integrated into the broader analysis of the campaign, youth

specific perspectives were also explored separately, and are presented here.

Choosing to avoid multiple partners included rationale 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).88

Another participant felt that abstaining was a viable course of action to avoid

risk emanating from one‟s partner, but also as 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).89

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).90

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).91

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‟,

88

Oniipa FGD with Males aged between 16-19.txt 89

Oshikuku FGD 16 to 19 Male final.txt 90

Oniipa FGD with Females aged between 16-19.txt 91

Oniipa FGD with Females aged between 16-19.txt

58

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).92 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).93

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.

Peer engagement

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).94

In such contexts it was necessary to evaluate one‟s friendships in relation to peer

pressure and HIV risk, with avoiding risk averse friends being one strategy: “If you find yourself

with such friends, then you need to avoid them” (Male, 20-30, Oshikuku).95

When alternate points

92

Oniipa FGD with Males aged between 16-19.txt 93

Rehoboth FGD males 16 to 19 final.txt 94

Oniipa FGD with Males aged between 20-30.txt 95

Oshikuku FGD 20 to 30 Male updated.txt

59

of view were put forward to peers, they were not necessarily accepted. One male participant

reported that when he tried to persuade a friend to stop having concurrent partners, the response

was to break off the friendship. A participant in Rehoboth recounted an argument he had with a

friend at a drinking venue, 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).96

An

emerging discourse, however, was to see 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).97

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),98

with one participant commenting wryly: “the chain is breaking you. The

chain will break your pocket” (Male, 20-30, Oshikuku).99 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).100

Another male participant said he told his girlfriend to rebuff approaches from other males by

refusing to provide her cellphone number when propositioned.101

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).102

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”.103

There were limits to the extent of the impacts of exposure to the BTC Campaign

96

Rehoboth FGD male 20 - 30 final.txt 97

Rehoboth FGD male 20 - 30 final.txt 98

Rehoboth FGD males 16 to 19 final.txt 99

Oshikuku FGD 20-30 Male.txt 100

Rehoboth FGD male 20 - 30 final.txt 101

Rehoboth FGD male 20 - 30 final.txt 102

Oniipa FGD with Males aged between 20-30.txt 103

Oniipa FGD with Females aged between 16-19.txt

60

however, with some community members being described as not wanting the message to “get

through within their heart”.104

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).105

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),106

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).107

Another participant observed: “You say, „Oh I‟m somewhere here between

these people‟,” (Male, 20-30, Rehoboth).108

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).109

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).110

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).111

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).112

Similarly, ending a relationship with a sugar daddy was not a simple matter: “If you have a sugar

104

Oniipa Interview with a Community Health Volunteer.txt 105

Rehoboth FGD male 20 - 30 final.txt 106

Oshikuku FGD 31-49 mixed.txt 107

Oniipa FGD with Females aged between 16-19.txt 108

Rehoboth FGD male 20 - 30 final.txt 109

Rehoboth FGD female 20 - 30 final.txt 110

Rehoboth FGD female 20 - 30 final.txt 111

Rehoboth FGD male 20 - 30 final.txt 112

Rehoboth FGD female 20 - 30 final.txt

61

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”.113

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).114

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).115

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).116 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).117

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).118

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).119

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).120

113

Rehoboth FGD Female 16 to 19 final.txt 114

Rehoboth FGD female 20 - 30 final.txt 115

Oshikuku FGD 31-49 mixed.txt 116

Oshikuku FGD 31-49 mixed.txt 117

Oniipa FGD with Males aged between 20-30.txt 118

Oshikuku FGD 20 to 30 Male updated.txt 119

Oshikuku FGD 20-30 female.txt 120

Rehoboth FGD mixed 31 to 49 final.txt

62

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).121

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).122

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).123

5.13 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, and married men, although was seen as

somewhat lower among married women. There was widespread agreement that young women

often had older partners for money, or other 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 a similar

weighting given to the perception that such practices were not endorsed by the majority of one‟s

peers or community members. This illustrates 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 can‟t be directly attributed to

the BTC Campaign, the quantitative finding that a third of participants perceive changes in sexual

behaviour at community level that are primarily related to „breaking the chain‟ and avoiding

concurrent partners suggests that the campaign is taking hold. Such perceptions were also higher

121

Rehoboth FGD female 20 - 30 final.txt 122

Rehoboth FGD People involved in BTC final.txt 123

Oniipa FGD with Males and Females aged between 25-35 Involved with BTC.txt

63

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 in the past month 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 for change in relation to exposure, 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. While condoms remain the foremost change, breaking the

chain and avoiding concurrent partners was mentioned by a fifth of respondents, indicating 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 and these reinforce the qualitative findings. In addition, many of

which appear to have emerged as new „cultural scripts‟. These 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 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

64

qualitative narratives also showed that although some friends continued to promote having many

partners as an appropriate format for sexual relationships, there was a 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, although concerns about HIV prevention transcended the concerns about social

acceptance. Disadvantages of having concurrent partners other than HIV infection were also

highlighted to bolster arguments – eg. 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 being warned not to make advances on one‟s

partner with additional strategies such as advising one‟s girlfriend not to hand over her cellphone

number contributes to avoiding possible further entreaties for a sexual relationship.

In acknowledging risk exposure, a number of participants described „seeing themselves in the

chain‟ as was 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 one‟s future, with action

needing to be taken to avoid an early death, or to miss out on seeing one‟s 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.124

Strategies applied with a main

partner include discussing risk and going for HIV testing which illustrate a recentering of

understanding that sexual partners have an obligation to protect each other from HIV infection.

The comparison of current data with 2007/8 survey 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

124

See Parker et al., 2007

65

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.

5.14 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.125

An ethnographic study on alcohol use in Namibia illustrated the links

between alcohol consumption in drinking establishments and casual sexual encounters,126

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.127

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.

Table 27: Perceptions of public drunkenness

N=900/300/300/300 Agree/Agree

strongly Neutral Disagree/Disagree

strongly

It is common to see women in this community drunk in public

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

568

63%

162

54%

152

51%

254

85%

117

13%

53

18%

49

16%

15

5%

214

24%

84

28%

99

33%

31

10%

It is common to see men in this community drunk in public

All

Oshikuku

Oniipa

Rehoboth

n

%

n

%

n

%

n

%

750

83%

256

86%

213

71%

281

94%

70

8%

26

9%

33

11%

11

4%

79

9%

17

6%

54

18%

8

3%

125

Weiser et al., 2006 126

LeBeau & Yoder, 2009. 127

Fisher et al., 2010.

66

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%) than females (32%). Only a minority of

respondents drank daily (6%), with the majority drinking once a 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.

Table 28: Alcohol consumption and being drunk in the past month

N=900 All Male Female Oshikuku Oniipa Rehoboth

n % n % n % n % n % n %

Do you drink alcohol?

Yes 396 44% 214 64% 182 32% 105 35% 152 51% 139 46%

No 504 56% 122 36% 382 68% 195 65% 148 49% 161 54%

If yes… (N=396)

Daily 24 6% 18 8% 6 3% 9 9% 13 9% 2 1%

A few times a week 126 32% 69 32% 57 31% 62 59% 54 36% 10 7%

Once a week 125 32% 69 32% 56 31% 20 19% 53 35% 52 37%

Less than once a week

121 31% 58 27% 63 35% 14 13% 32 21% 75 54%

Have you been drunk in the past month? (N=396)

Yes 197 50% 116 54% 81 45% 30 29% 75 49% 92 66%

No 199 50% 98 46% 101 55% 75 71% 77 51% 47 34%

When data of 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.

When comparative data from 2007/8 was analysed with the present survey data, it was found that

being being drunk in the past year was significantly associated with a lower likelihood of having

reduced one‟s number of partners in the past year (OR: 0.42) in comparison to not having been

drunk (OR: O.27) in the past month or not drinking at all (OR: 0.23). A similar pattern was found

for having had 2+ partners in the past month – OR:0.36 for those who were drunk in the past

month, in comparison to OR:27 for non drinkers and OR.20 for those who were not drunk in the

past month.

Table 29: Changes in numbers of partners in past year by demographic characteristics: 2007/8, 2011

Partners 0,1 2007/8 2+ 0,1 2011 2+ Odds Ratio

n % n % n % n % OR 95% CI p

Alcohol consumption 2+ partners in past year

Non drinker 432 85% 79 15% 413 96% 17 4% 0.23 0.1 – 0.4 < 0.001

Not drunk in last month 257 70% 109 30% 167 90% 19 10% 0.27 0.1 – 0.4 <0.001

Drunk in last month 267 59% 187 41% 147 77% 43 23% 0.42 0.3 – 0.6 < 0.001

67

Alcohol consumption 2+ partners in past month

Non drinker 398 95% 19 5% 385 99% 5 1% 0.27 0.1 - 0.7 0.01

Not drunk in last month 314 92% 26 8% 177 98% 3 2% 0.20 0.06 - 0.7 0.01

Drunk in last month 350 81% 82 19% 167 92% 14 8% 0.36 0.2 - 0.6 0.001

5.14.1 Qualitative findings on alcohol and MCP

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).128

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).129

As another female participant noted, „at the end you have to pay back‟.130

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).131

Another observed: “Car and alcohol are the

main risks that lead to an increase in multiple partnerships” (Male, 20-30, Oshikuku).132

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).133

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

128

Rehoboth FGD female 20 - 30 final.txt 129

Rehoboth FGD female 20 - 30 final.txt 130

Rehoboth FGD Female 16 to 19 final.txt 131

Oshikuku FGD 20 to 30 Male updated.txt 132

Oshikuku FGD 20 to 30 Male updated.txt 133

Rehoboth FGD female 20 - 30 final.txt

68

and how I perceive things and do things now. It really made me realise the seriousness of a

sexual network” (Male, BTC implementer, Rehoboth).134

5.14.2 Discussion on alcohol and HIV risk

Alcohol consumption is widespread in Namibia with two thirds of males (64%) and a third of

females (32%) reporting that they drink. Although most of those who drink do so once a week or

less (63%), drinking to the point that one feels drunk appears to be common, with 50% of

drinkers reporting that they had been drunk in the past month. There is also a widely held

perception that it is common for men and women to be seen drunk in public in the study

communities.

Alcohol consumption and MCP were found to be linked, with a three times higher likelihood of

having two or more partners in the past month than those who did not drink. This is in keeping

with findings in other studies. Although comparison with previous survey data has shown

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 reinforce the understanding that sexual connections are readily made at

alcohol venues, and that for females, being bought drinks requires reciprocity through providing

sex. In some instances, males who were perceived to have money were actively pursued at

alcohol venues.

Of importance are the strategies that have emerged to address alcohol consumption that are

premised on wanting to diminish 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.

5.14 Gaps and opportunities

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.

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

134

Rehoboth FGD People involved in BTC final.txt

69

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).135

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”.136

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),137

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).138

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).139

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).140

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.

135

Rehoboth FGD female 20 - 30 final.txt 136

Rehoboth Interview with faith based leader final.txt 137

Rehoboth FGD male 20 - 30 final.txt 138

Oniipa FGD with Males aged between 20-30.txt 139

Oshikuku FGD 16 to 19 Male final.txt 140

Oniipa FGD with Females aged between 16-19.txt

70

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).141

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).142

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),143

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).144

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,145

and that the challenges of living with HIV and alcohol included exposure to MCP

at alcohol venues and posed problems in relation to treatment.146

141

Rehoboth FGD male 20 - 30 final.txt 142

Oniipa Interview Traditional Healer updated.txt 143

Oniipa FGD People living with HIV.txt 144

Rehoboth FGD People living with HIV.txt 145

Oshikuku FGD PLHIV.txt 146

Rehoboth FGD People living with HIV.txt

71

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.147

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).148

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. 149

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 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).150

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).151

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).152

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.

147

Oniipa FGD People living with HIV.txt 148

Oniipa FGD People living with HIV.txt 149

Oniipa FGD People living with HIV.txt 150

Rehoboth FGD People involved in BTC final.txt 151

Onandjokwe FGD with Males and Females aged between 25-35 Involved with BTC.txt 152

Rehoboth FGD People involved in BTC final.txt

72

In general, the support materials were appreciated… It was felt that Phillip Wetu video should be

in a wider range of languages, and that picture codes could include local imagery. Expansion into

more rural areas was seen as an important next step, and it was noted that apart from additional

materials, vehicles would be needed.

6. CONCLUSIONS

It is well acknowledged that the densely clustered sexual networks produced by concurrent sexual

partnerships accentuate the likelihood of new HIV infections. Disrupting the HIV transmission

pathways that occur in sexual networks by reducing sexual partner turnover and concurrency has

potential to markedly reduce new HIV infections.153

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, rejoinders to these assertions, along with a comprehensive body of research upholds the

necessity to intensify and sustain a focus on disrupting sexual networks.

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. These factors have been

well documented in previous studies in Namibia and findings from these studies and related

analyses led to the development and design of the BTC Campaign.154

This evaluation study followed a case-study approach in three Namibian communities to

understand reach and response to the BTC Campaign in relation to outcomes and impacts on

MCP. The combination of quantitative and qualitative research components led to an

understanding of the interaction between factors related to addressing and reducing MCP and

contextual factors that underpin MCP. The multiple methods and emerging data have allowed for

triangulation and there is thus a scientifically robust basis for drawing conclusions about the

reach, outcomes and impacts of the campaign.

The overall hypothesis of the study 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 partners and

concurrency was understood, that awareness of MCP had increased over time, and that MCP

practices had decreased over time.

The findings point consistently in the direction of all of the hypotheses, and triangulation of the

data clearly demonstrate that important changes in risk perceptions and practices in the study

communities have occurred. Emergent interpretations and meanings of MCP in context that are

directly relevant to reshaping norms and values have also been identified.

153

See Figure 2. 154

For example, MICT, 2009; De La Torre, et al. 2009; various reports by Parker & Connolly; Shipena & Khuruses, 2007a; SIAPAC, 2008.

73

Campaign orientation

The BTC campaign followed a multi-level, multi-channel, 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 and

advocacy and training. The design and technical execution followed a similar approach to

previous campaigns in Namibia and follows conventional communication approaches common to

many national-level campaigns in the region.

A unique feature of the Namibian campaign was the collaborative partnership between various

organisations under the leadership of the national level Technical Advisory Committee and the

Take Control Working Group on MCP. This allowed for wide involvement by prevention

partners in the interpretation and execution of the campaign, including contributing to the

development, design and dissemination of various sub-elements. The common principles of the

„Break the Chain‟ concept and brand were adhered to between partners. This collaborative

approach, derived from a priority key driver articulated in the National Strategic Framework and

based on sound scientific and technical data, resulted in a coherent national level campaign with

all partners working to the same goals and objectives.

Reach of the BTC Campaign

The reach of the BTC campaign was clearly strengthened by the collaborative approach and

collective multi-layered implementation allowed for widespread reach. It is impressive that all

respondents in the evaluation survey were reached by at least one component of the campaign,

and that half of all respondents had been reached by 12 or more components. The logo and slogan

of the campaign captured the core concept of the campaign – the relationship between HIV risk

and sexual networks – and the multiple communication components allowed for deeper

engagement amongst various audiences reached.

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 in

comparison to the other two communities. Such differences are to be expected, given that there

are differences in mass media access between sites and lower levels of implementation of the

interpersonal communication components in Rehoboth. Other unique demographic features of

each community contribute to such variation.155

155

Differences in the quantitative findings between sites cannot only be explained by differences of reach of the BTC Campaign between sites, given that there are a wide range of underlying current and historical factors that influence the dynamics of sexual behaviours and practices within communities. Such dynamics also influence the heterogeneity of HIV prevalence between communities in Namibia, yet it remains difficult to pinpoint why such HIV prevalence variations exist. It is also difficult to precisely determine apparent contradictory findings when various elements of the HIV epidemic are studied – for example, why apparently higher risk behaviours such as MCP are common in Rehoboth, yet the HIV prevalence in Rehoboth is lower than in communities where risk practices are apparently lower. This challenge points to the need for more comprehensive, multi-method studies of the epidemic.

74

6.1 Quantifiable outcomes and impacts of the BTC Campaign

At an individual level the BTC Campaign has prompted discussion about multiple partnerships,

the BTC slogan and concept, and concurrent partners. Exposure to higher numbers of BTC

Campaign components elicited statistically significant higher likelihood of speaking about

HIV/AIDS (65% vs 53%). Additionally, among those who felt people in the community were

changing their behaviour (36%), the most commonly perceived change at community level was

„breaking the chain‟ or avoiding concurrent partners (49%).

Higher exposure to multiple BTC components resulted in a statistically significant higher

likelihood of reporting having changed one‟s sexual behaviour in past year (65% vs 50%), with

statistically significant mention of „breaking the chain‟ and avoiding concurrent partners (24% vs

9%). These findings show that tangible impacts have been brought about by the BTC Campaign

and that multi-component reach increases the likelihood of change.

Figure 5 depicts the communication activities and reach that underpinned these outcomes and

impacts as illustrated by the quantitative findings.

Figure 5: Outcomes and impacts of the BTC Campaign

75

6.2 Safer sexual practices through new cultural scripts

A challenge in communicating about HIV is the need to transition from raising awareness to

fostering processes whereby knowledge is internalized and acted upon. Many theories of

behaviour change focus primarily 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.156

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.157

Although all these theories have some bearing

on the outcomes of the BTC Campaign, none adequately address the relation between

communication content, interpretation and meaning as found through the present study. In

particular, the BTC Campaign has elicited an interpretive framework that blends cognitive,

situational and social elements to bring about internalized meaning. Internalised meanings have,

in turn, led to actions and commitments that have been brought about through reflection about

oneself in relation to one‟s partnership practices and context. An interpretive framework emerged

that illustrated how the BTC concepts were applied in context and is illustrated in Figure 6.

Figure 6: Communication and cultural scripts in response to the BTC Campaign

156

See Di Clemente & Petersen, 2004 157

Ibid.

76

The anthropological concept of „cultural scripts‟ offers a means to understand how the various

interrelated elements resulted in a process of making meaning in a social context that is enmeshed

with vulnerability to HIV.

The BTC Campaign introduced new concepts that can be understood as „resonating‟ (ie. evoking

feelings of shared emotion or belief) with 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 one‟s immediate individual

situation), and social (how these concepts related to one‟s social standing relative to others, and

also the social standing of others).

Taken together, these three points of resonance related to three further domains of meaning – 1)

internalized meaning, which relates to translating conceptual resonance into concepts of

individual action, 2) actions and commitments, which relate to translating situational resonance

into risk reduction in relation to one‟s understanding of risk factors, and 3) new language (signs,

symbols), which follow from social resonance.

These six domains of meaning comprise the inter-related components of cultural scripts. The

emerging cultural scripts diminish HIV risk in the context of a severe HIV epidemic where MCP

is underpinning driver of new infections.

Conceptual resonance

The qualitative narratives expand understanding of the dimensions of reach in relation to

meaning. Specifically, it was easy for recipients to understand the core concept of the campaign

literally, with the concept of a „chain‟ being readily associated with the concept of a „sexual

network‟. This was aided by the use of imagery and colour in the visual elements of the

campaign, with sexual networks being depicted clearly, and use of red connoting danger and the

passage of HIV along the network. The campaign slogan was also viewed as concise and easy to

remember.

The campaign was seen as providing new insights into personal vulnerability to HIV and the

relative risk of being exposed to sexual networks. Exposure to HIV through sexual networks was

perceived as having been previously concealed, but once revealed, the explanation of

vulnerability was readily accepted as plausible, as well as being important enough to consider in

relation to one‟s own practices. This plausibility enhanced the credibility of the campaign as

illustrated by qualitative study participants who spoke of how the campaign evoked a sense of

concern about the dangers of MCP.

Situational resonance

The BTC Campaign has fostered understanding and reflection of individual risk in relation to

relationship contexts. The campaign raised awareness that a sexual partner might have other

partners without disclosing them, and that condom use is an insufficient strategy for avoiding

77

risk. Perceptions of situational risk were also forward-looking – participants spoke about the

importance of staying HIV negative to care for one‟s children and watching them grow.

Additionally, it was recognised that having concurrent partners compromised one‟s life

circumstances economically (ie. it was expensive to have many sexual partners), while also

compromising personal ethical integrity and trustworthiness, as a product of needing to be „a liar‟

to sustain parallel sexual relationships. The relevance of the campaign was also recognised by

participants who were living with HIV who accepted that being HIV positive and having

concurrent partners was a risk factor for those who were negative.

Social resonance

The BTC Campaign has brought about a number of responses that resonate at a social level. This

includes fostering a sense of pride and achievement if one ended concurrent sexual partnerships

as well as understanding that one‟s self-esteem and social standing is diminished if one has

concurrent partners. Previous social validation accorded to those who are promiscuous „players‟

has shifted to „players‟ being pitied for their failure to prioritise and address HIV risk.

Internalised meaning

Meaning of communication is internalized when it brings about cognitive reflection about oneself

in relation to risk. This includes recognition that it is possible to end concurrent partnerships, and

that termination can occur immediately following as a productive of conceptual resonance. In the

case of the BTC campaign, internalized meanings were expanded to include „conserving one‟s

dignity and decency‟ by avoiding unfaithful partners, and being intolerant of external attempts to

undermine the monogomous integrity of one‟s relationship.

Actions and commitments

This component highlights the range of relationship-related changes that diminish concurrency

and minimize exposure to sexual networks. These include ending concurrent partnerships and

remaining with a single „trusted‟ partner, or choosing not to have a partner. A number of

participants spoke about making this important step in risk reduction rapidly following

internalization of an understanding of risk through exposure to sexual networks using

descriptions such as „cutting‟ or „breaking‟ relationships. This illustrates that, for some, there are

not strong attachments or emotional bonds with such partners, and it is thus relatively easy to

terminate such relationships. Partners who are believed to have other partners, or who refuse to

engage in a relationship dialogue about risk were also abandoned.

Strategies at peer and social level further enhance capacity to manage risk – notably discussing

the risks of concurrency with friends and sharing strategies for risk reduction. Friends and peers

who continue to place value on concurrent sexual partnerships are avoided, sometimes to the

extent of breaking off friendships. Acknowledged risks such as consuming alcohol, particularly at

public venues where casual sexual encounters are easily initiated, are addressed through stopping

alcohol consumption or drinking at home.

78

New language (social meaning)

A broad intended outcome of the BTC Campaign was to bring about understanding of the risks of

having multiple and concurrent sexual partners through comprehension of the BTC slogan and

imagery. The phrase – „break the chain‟ thus serves as a means to convey this concept. As a

product of the campaign, the phrase has entered into language practice as a referent for

articulating HIV risk in relation to sexual networks. The merits of the concept as a way of making

meaning in the context of HIV risk have been further strengthened by the organic emergence of a

new sign to refer to the concept – a hand gesture to represent „breaking the chain‟. The non-

verbal nature of this gesture expands the repertoire of situational responses where the „BTC‟

concept can be applied – for example, by using the non-verbal gesture, it is possible to deflect

discussion or argument with a potential suitor. Use of the phrase „break the chain‟ or the related

hand gesture can also be done in a joking manner, thus reducing the potential for conflict, while

at the same time asserting one‟s right to uphold particular values related to casual sexual

partnerships.

Other strategies: VCT and condom promotion

The campaign has interfaced well with parallel strategies to address HIV prevention, with HIV

testing and condom use being sustained as personal strategies. HIV testing is related to individual

strategies for addressing MCP in a number of ways. Asking one‟s partner to test for HIV is a

means to raise the question of suspected infidelity, while in new relationships, knowing one‟s

status as a couple forms the basis for a discourse that addresses the need to agree not to have

other partners while in the relationship. Such partners are described as one‟s „trusted partner‟.

VCT is also important as the basis for starting afresh, as knowing one‟s status forms the

foundation for decision-making in future relationships – specifically, being conscientious about

avoiding exposure to sexual networks through concurrency.

6.3 Implications

The BTC campaign has fostered conceptual, situational and social resonance in relation to the

core concept of understanding one‟s own position in a sexual network and recognizing the risks

that flow from such positioning. Such resonance elicits strategies for risk reduction that are then

acted upon. These underpin risk and vulnerability reduction for HIV infection at individual level,

but also contribute to reshaping a peer environment through providing a critique of concurrency

as a relationship practice.

Vulnerabilities flowing from sexual networks were appraised critically in relation to previous

emphases on condom use, with an understanding emerging that condom promotion did not

adequately address risks flowing from sexual networks. However, it also appears that the

importance of condoms as a means to prevent HIV have been intensified, as illustrated in the

finding that condoms remain the highest „top of mind‟ referent for HIV prevention. This suggests

that concerns about exposure to sexual networks may contribute to increased awareness of the

importance of consistent condom use.

79

The findings 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 expansion in subsequent phases. An exploration of gaps and opportunities from the

viewpoint of qualitative participants provides insights relevant to the development of

communication strategy, and emerging cultural scripts can be brought into the development of

further communication concepts and products including mass media, small media products and

interpersonal communication elements. The findings have also contributed to potential

developments of new theoretical approaches to communication for HIV prevention.

With regard to implementation, participants have suggested expanding the age range of BTC

implementers, reaching more extensively into rural communities, increasing the range of

languages employed by the campaign, and ensuring that materials are available in sufficient

quantity.

Youth and older participants highlighted the importance of promoting community-level dialogue

at small group level, with such activities including groups that could be formed and led by

community members themselves. Such groups might follow a similar format to support groups

for PLHIV or alcoholics anonymous meetings (although with an HIV prevention focus), and

could be fostered and supported by BTC implementers. Youth also mentioned that elders should

encourage such formations. Alcohol venues were identified as contexts of risk.

Youth were keen for the addition of utility items, integration of BTC into school activities such as

debates as well as sporting activities such as soccer matches, and exploration of the potentials of

internet-based social media communication and use of cellphone technology. Having people

appear on television or speak on radio about how they had „broken the chain‟ was also

highlighted, as were suggestions for dramatized depictions of the challenges and solutions to

MCP.

PLHIV were accepting of the BTC Campaign and acknowledged the importance of a focus on

sexual networks. The importance of PLHIV ending concurrent relationships was acknowledged

and there was also reference to group accountability. It was also felt that PLHIV could be drawn

into the implementation of the campaign.

Ongoing evaluation

The approach to the present evaluation was guided by a range of considerations including the

importance of an approach that enabled triangulation through previous and current quantitative

surveys as well as qualitative study. Comparisons with previous study findings have shown

downward trends in a range of indicators relevant to measuring change related to concurrency,

with these changes being observed to be significant on indicators such as numbers of partners in

past year and past month, while the broad range of indicators utilised in the current survey

provide insight into the dimensions of MCP at individual and social level. The qualitative study

allowed participants to explain how their exposure to the campaign concepts brought about

change at cognitive/psychogical, behavioural and social levels.

80

In subsequent evaluations, funds permitting, the number of study communities could usefully be

expanded to allow for a wider range of audience perspectives and to draw in contextual factors

not represented in the current selection of communities – for example, border towns or towns

with harbours, or areas where HIV prevalence is severe.

Additionally, there are merits to drawing in analysis of changes in HIV prevalence patterns in

later phases of evaluation. Reducing concurrency is hypothesized to bring about rapid changes in

incidence patterns as a product of reducing the density of sexual networks. Such changes

contributed to declines in HIV prevalence among the gay epidemic in the US and in Uganda.

Recent analyses of epidemic declines in Zimbabwe have explored prevalence data in conjunction

with socio-behavioural data and illustrated how these are linked to epidemic declines. Given the

present findings, it is reasonable to expected that such changes would also be observed in

Namibia and that therefore analysis of HIV prevalence data would inform understanding of

impacts of an ongoing campaign to address concurrency.

81

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