Lesotho: External Evaluation of the Southern African Regional Social and Behaviour Change Communication Program

This report discusses the Lesotho findings of an external evaluation of the Southern African Regional Social and Behaviour Change Communication Programme, an initiative implemented in 8 countries in Southern Africa from 2007 to 2011 to reduce HIV infection by increasing health awareness and facilitating social and behavioural change through both mass media and community-based activities. This evaluation assesses the impact of exposure to interventions on key indicators of HIV knowledge, attitudes, and behaviours. The report outlines how impact varied among the intervention components and demonstrates that some different forms of media may be best used based on gender or desired outcome.

The Lesotho component of the Southern African Regional Social and Behaviour Change Communication Program was implemented by Phela Health and Development Communications, the Community Media Trust (CMT), and SAfAIDS, with funding from the United Kingdom Department for International Development (DfID). Phela activities focused on the production and distribution of mass communication materials based on OneLove branding. These efforts focused on improving communication within relationships and understanding the risk of and reducing multiple concurrent partnerships as vital tools in the fight against HIV and AIDS. SAfAIDS and CMT activities were focused mainly at a community level. SAfAIDS built the capacity of national HIV trainers, and used community-based volunteers to disseminate key messages and information in face-to-face meetings with community members, supported by pamphlets, toolkits, and training packs. CMT conducted an outreach programme intended to increase treatment literacy, by promoting and supporting community preparedness for antiretroviral treatment using the "Beat It" audiovisual kit.

The evaluation was based on a post-only researcher administered survey questionnaire with 3,972 nationally representative males and females aged 15-49. Although the evaluation was post-intervention only, the 2012 data was compared with a prior survey to assess progress in Lesotho around health awareness and related social and behavioural change. While little change was found in the numbers of multiple concurrent partnerships (MCP), a key focus issue of this programme, the latest survey found an increase in protective behaviours. "Condom use at last sex among those with multiple partners increased by 30 percentage points for males (from 41% to 71%) and by an even larger amount for females (from 19% to 58%), exceeding targets for both sexes." There is also a slight increase in the percentage (70% to 72%) of adults who know that HIV positive people can transmit HIV while on ARVs, though this still does not meet the desired target of 80%. On the other hand, there has been an increase in HIV related stigma.

The evaluation report discusses impact findings for each of the three partners. The following are a selection of the findings:

• Phela/ One Love Campaign
  The OneLove mass media component of the project, led by Phela in Lesotho, had a high level of reach, with 67% of the population being exposed to the radio, print, or television programming. Radio had the greatest reach, with 57% exposed to either the One Love radio drama or phone-in show. According to the evaluation, men and women exposed to the radio shows were more likely to have tested for HIV (76.7% versus 68.1%). The report notes some gender differences in impact, for example, exposure to print materials resulted in women more likely to have tested for HIV, and exposure to the radio programmes resulted in increased condom use among women, without similar effects on men. On the other hand, exposure to the print materials had a significant effect on men's attitudes (though not behaviours) towards multiple partnerships, but not women's, suggesting shifts in social norms among men only.
• SAfAIDS:
  The evaluation found that nearly one in five people were exposed to the SAfAIDS activities and messages, mostly through the community based volunteers. The data demonstrates that SAfAIDS programmes influenced norms and attitudes, especially among community leaders, but did not significantly impact behaviours, such as condom use and HIV testing. In terms of physical or sexual violence, there was no indication that exposure had an impact on experiencing or reporting violence, but those exposed were more likely to perceive that leaders speak out against gender-based violence. Exposed individuals are also more likely to agree that condom use in marriage is acceptable and that women can ask a regular partner to use a condom. There are also some positive influences on communication. "Nearly one third of exposed individuals have discussed HIV with their children as compared with 27% of unexposed respondents."
• Community Media Trust (CMT):
  The evaluation found that exposure to CMT was much more limited than the other two components, with only 7.8% of respondents reporting exposure. "Effects of exposure to the programme on key behavioural outcomes were modest. A significant effect was found around the likelihood of HIV testing in the past year among men – 53.7% versus 40.4%. On average, exposed males had an estimated 1.3 more tests in their lifetime than unexposed males. Among women aged 15-24 years, exposure to CMT activities had a significant effect on the acceptability of condom use with regular partners (76.9% versus 56.7%)."

A key objective of the evaluation was to assess the impact of this specific programme, rather than previous and other initiatives. The evaluation found that people recently exposed to Phela progammes, and not previously or otherwise exposed, were more likely to report using a condom at last sex, more likely to report favourable norms surrounding condom use, more likely to report condom use in marriage as acceptable, and more likely to have been tested for HIV in the last year. However, cumulative exposure shows the strongest impact on attitudes and norms. "Approximately 60% of those cumulatively exposed agree that people in the community are joining together to help PLHIV versus 51.7% of those only recently exposed and 45.8% of those never exposed. Similarly, 77.8% of the cumulatively exposed report that leaders speak out against gender-based violence as compared with 66.8% of those only recently exposed and 60.1% of those never exposed. "

Another key objective of the Southern African Regional Social and Behavior Change Communication Program, and the evaluation, was to assess the added benefits of a combined partner approach, rather than a standalone project. The report notes that this assessment was difficult, due to the fairly low reach of the interpersonal communication (IPC) aspects, but there is little evidence that IPC combined with mass media has greater impact in most behaviour outcomes. "Alternatively, mass media appears to increase the likelihood of discussion of HIV with anyone, regardless of whether there is concurrent IPC exposure. In fact, those exposed to mass media appear to have the greatest likelihood of using a condom at last sex, using a condom at last sex with a regular partner, and of using a condom at last sex among those with multiple partners in the last year. For other indicators, such as having an HIV test in the last year, the source of exposure – IPC alone, mass media alone or mass media plus IPC – does not seem to matter as long as a person is exposed to at least one of them..." Areas where dual exposure is significant include discussion of HIV/AIDS with children and whether respondents agree that a person’s sex life can improve by communicating with their partner.

Click here for the 2 page summary brief.