Social and Behavior Change Communication to Address Family Planning Uptake in an Integrated Program in Zambia. December 2011

Transcription

1 Social and Behavior Change Communication to Address Family Planning Uptake in an Integrated Program in Zambia December 2011

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3 Social and Behavior Change Communication to Address Family Planning Uptake in an Integrated Program in Zambia December 2011 By Christina Wegs (CARE/Atlanta); Bamikale Feyisetan (C-Change/Washington); Jane Alaii (C-Change/Kenya); Philimon Cheeba (CARE/Zambia); and Florence Mbewe (CARE/Zambia) This report was produced by CARE, a partner of C-Change, a USAID-funded project implemented by FHI 360. This publication is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Agreement No. GPO-A The contents are the responsibility of C-Change and do not necessarily reflect the views of USAID or the United States Government.

4 Recommended citation: Wegs C., B. Feyisetan, J. Alaii, P. Cheeba, and F. Mbewe Social and Behavior Change Communication to Address Family Planning Uptake in an Integrated Program in Zambia. Washington, DC: C-Change/FHI 360. C-Change is a USAID funded project implemented by FHI 360 and its partners: CARE; Internews; Ohio University; IDEO; Center for Media Studies, India; New Concept, India; Soul City, South Africa; Social Surveys, South Africa; and Straight Talk, Uganda. C-Change/FHI Connecticut Ave. NW, Ste. 800 Washington, DC 20009, USA Tel: Fax: Website:

5 TABLE OF CONTENTS Acronyms and Abbreviations... iv Executive Summary... 1 Chapter 1. Introduction... 6 Chapter 2. The Research Study Chapter 3. Demographic Characteristics of Respondents Chapter 4. Decision-Making about Sex and Childbearing Chapter 5. Knowledge and Use of Family Planning Chapter 6. Service Statistics Chapter 7. Exposure to Information on FP and HIV Chapter 8. Gender Relations Chapter 9. Summary and Conclusions References iii

6 Acronyms and Abbreviations AIDS ART CARE CHW CYP DHS FGD FP GEM HIV ITAP IUD LAM MCH NHC OCP PI PLHIV PMTCT RA RHC SAA SBCC SFH SRH TB TFR VCT Acquired Immunodeficiency Syndrome Antiretroviral therapy Cooperative for Assistance and Relief Everywhere Community health worker Couple years of protection Demographic and Health Survey Focus group discussion Family planning Gender Equitable Men (Scale) Human Immunodeficiency Virus Integrated Tuberculosis and AIDS Program Intrauterine device Lactational amenorrhea method Maternal and child health Neighborhood health committee Oral contraceptive pill Principal investigator People living with HIV and AIDS Prevention of mother-to-child transmission of HIV Research assistant Rural health center Social Action and Analysis Social and behavior change communication Society for Family Health Sexual and reproductive health Tuberculosis Total fertility rate Voluntary HIV counseling and testing iv

7 Executive Summary Introduction Between November 2009 and June 2011, CARE Zambia worked as a partner on the USAID funded Communication for Change (C-Change) Project on an action research study that explored the effects of two complementary sets of interventions. First, in order to improve access to family planning at a large rural health center, the team established a family planning screening and referral system. Second, the project team also implemented a series of social and behavior change (SBCC) communication strategies at the community level to increase demand for FP and reduce barriers to FP use. Overall, the goal of the dual activities was to increase FP use and address the underlying social norms that influence uptake, particularly among HIV positive individuals. The project was implemented in the Mwase Zonal Rural Health Center (Mwase RHC) catchment area in Lundazi District, Eastern Province, Zambia. Under the family planning referral system, clinic workers in three units of the Mwase RHC - the outpatient department (OPD), antiretroviral therapy (ART) clinic, and the laboratory - were trained to ask clients about their interest in family planning. Interested patients were then referred to the family planning section and provided with a referral slip. Screening and referral services were provided to both HIV-infected and non-infected clients. The first phase of SBCC activities included participatory dialogues facilitated by volunteers from neighborhood health committees (NHC), who were trained using the CARE Social Analysis and Action (SAA) approach. Using tools and participatory learning activities from SAA, these volunteers facilitated recurring community dialogues within neighborhood health committee meetings in order to initiate critical reflection about gender roles, power relations between men and women, sexuality, HIV, family planning, and other social/cultural factors and barriers that influence family planning, including community perceptions about ideal family size. A total of 57 community SAA dialogues were facilitated by these volunteers between February and December During the second phase of SBCC activities, this cadre of facilitators integrated a field-tested SBCC tool into their community dialogues. The tool - originally developed by FHI 360 (then AED) and CARE in the Democratic Republic of Congo - was tested in and adapted to the Zambian context, using contextually appropriate images and messages (including information to address myths and concerns about family planning revealed through qualitative research in Mwase- Lundazi). The tool consisted of a set of picture cards that follow the journey of a young couple making family planning decisions together, and highlight the experience of an older couple who has achieved their desired family size and are using a long-acting contraceptive method. The picture cards include simple discussion points for facilitators to help guide discussions about the benefits of birth spacing and provided accurate information about modern family planning methods. During this second phase, dialogues were complemented by community theatre performances about topics related to FP. SBCC facilitators were also trained to conduct one-on- 1

8 one meetings with interested FP clients. A total of 144 Community FP dialogues (using these SBCC using picture codes) were facilitated by community volunteers between late January and early June Outcomes of interest from this study included: FP acceptance, FP uptake, and changes in underlying social norms that influence FP behaviors. Outcomes were measured using a single time-series research design. SBCC interventions were introduced one at a time, with results measured after each intervention was implemented. Baseline (November 2009), midline (June/July 2010), and endline (June 2011) assessments, including both qualitative interviews and community-based surveys, were used to assess the acceptability and use of FP methods and measure changes in individual behaviors, attitudes, and beliefs about FP, sexuality, and gender norms. Monthly FP service data from the Mwase Lundazi RHC were used to analyze the quantity of FP methods distributed and couple years of protection (CYP) provided. This report summarizes the final evaluation findings of the effectiveness of the SBCC approaches in increasing FP uptake. Methods and Analysis Study participants included HIV positive and HIV negative men and women ages They were selected from a sampling frame built from Mwase Lundazi RHC client registers for antiretroviral treatment (ART) and voluntary counseling and testing (VCT) services. The endline evaluation included a survey of 196 respondents: 102 male and 94 female. Interviews were conducted in Chewa, the local language, by appropriately trained local interviewers. In addition to data on FP commodity distribution obtained from the Mwase Lundazi RHC, the study s monitoring and evaluation officer abstracted data from the clinic s records on distribution by community health workers (CHWs). Qualitative information was obtained through 10 focus group discussions (FGDs) with 43 women and 42 men in which participants were separated by sex and into two reproductive age groups: ages and Research assistants trained in qualitative data collection techniques conducted the FGDs in Chewa. All data collection tools and informed consent transcripts were created both in English and Chewa text for quality assurance. Data analyses focused on: a) determining current levels of key indicators social norms around FP, approval of FP, and knowledge and use of contraceptive methods; and b) associations between participants demographic characteristics and outcome indicators. Particular attention was paid to changes in relevant indicators from baseline to endline, and to inter-survey differences in baseline and endline samples. Highlights of Findings Fertility Intentions and Ideal Family Size At endline, a smaller proportion of female respondents were unsure of their fertility desires than at baseline, and more women reported that they wanted no more children. Respondents 2

9 continued to report perceptions that community ideals relating to family size were higher than their personal ideals. If community perceptions of norms influence childbearing more than personal preferences, these norms could inhibit use of FP services to limit family size. Qualitative data indicated that women more than men are sensitive to perceptions of community pressures and expectations about childbearing. However, inter-survey analyses indicated that perceived norms of ideal family size have shifted downward, for male as well as female respondents. Whereas 67% of female respondents at baseline believed that the community s ideal family size included six or more children, 47.7% of the endline female sample cited this figure. Among male respondents, these proportions decreased from 66.2% to 54.6% from baseline to endline. Inter-survey differences on this indicator were not significant for male samples, but were significant for female respondents both overall (p=.017) and for HIV-negative female respondents (p=.032). Knowledge and Use of Family Planning Over the life of the project, female use of modern methods of FP increased. By endline, over half of women in the survey sample were using a modern family planning method, increasing from 43% at baseline to 54% at endline. Current use of contraceptives fell slightly among all men (52.1% at baseline vs. 44.7% at endline). However, current use of contraceptives did increase among HIV-positive men, from 63% at baseline to 70.4% at endline. It is notable that, at endine, more than twice as many HIVpositive men were currently using contraception, than were HIV-negative men (70.4% vs. 34.3%), a difference that probably reflects higher condom use among HIV-positive respondents. Condoms, injectables, and oral contraceptive pills continue to be the dominant FP methods used, while long-term and permanent methods were reported rarely, if at all. At endline, women reported greater knowledge of FP sources and methods than at baseline. Among respondents using contraceptives, the proportion of the male sample that obtained FP methods from the Mwase Lundazi RHC increased from baseline to endline, and a larger proportion of the endline female sample reported a CHW as a method provider. Approval of Family Planning Approval for FP was high among all groups and not significantly different based on sex or HIV status. Inter-survey comparisons indicated that female approval for FP increased significantly during the study period for female respondents overall (p=.021) and for HIV positive female respondents (p=.038). Male approval for FP was fairly constant across the three surveys. Larger proportions of women in the endline sample reported that their husbands or partners approved of FP, compared to baseline female respondents (p=.016). The significance of this increase held for HIV positive female respondents (p=.094) and for HIV negative female respondents (p=.049). 3

10 Approval of FP use by recently married couples, however, remained low, a finding that complements qualitative data on the strength of community norms related to fertility. These include the belief that couples who do not want children are not normal, that the primary purpose of marriage is to bear children, and that children should be born not long after a young couple gets married. Although communities continue to expect couples to bear children early in a marriage and believe that children give a marriage meaning, some shifting in attitudes may be occurring that allows some space for birth delay. For example, the proportion of male respondents who believed that it was up to a young couple to decide how long they should wait to have a child increased from 22.5% at baseline to 35.3% at endline. The increase was particularly significant among HIV positive respondents, doubling between the baseline and endline from 24.2% to 50.0%. Changes were statistically significant for the male population overall (p=.051) and for HIV positive male respondents (p=.010). Compared to baseline, higher proportions of both male and female endline respondents rejected the idea that a woman who uses FP will be unfaithful, possibly suggesting a change in the prevailing perception that contraceptives promote promiscuity. However, young, unmarried women s use of FP seems to be contentious with some participants associating this use with promiscuity and/or prostitution, whereas others see it as acceptable if the goal is to be able to avoid pregnancy and continue pursuing an education. Gender Attitudes and Norms Endline data from both survey and focus groups suggested a shift in some attitudes and beliefs related to gender. Women reported more equitable attitudes and beliefs about gender at endline than at baseline, as measured using a scale adapted from the Gender Equitable Men (GEM) 1 scale. However, this change was not statistically significant (p =.072). Strongly held norms around shared decision-making in couples were confirmed through FGDs, where both men and women of different ages indicated they engaged in joint decision-making around family planning and childbirth. Importantly, however, qualitative data supported by survey data on gender relations also suggested that men had final decision-making authority in the household, including making final decisions about family planning. In addition, qualitative data suggest that couples decisions about family planning are highly influenced by community norms and that women are especially sensitive to family and community expectations about fertility. Interestingly, at endline significantly more women indicated that it is woman s responsibility to avoid getting pregnant. At baseline, 22.5% of women disagreed with the statement that it is a woman s responsibility to avoid getting pregnant, whereas only 7.4% disagreed at endline. 1 Pulerwitz, J, and G Barker Measuring attitudes toward gender norms among young men in Brazil: Development and psychometric evaluation of the GEM Scale. Men and Masculinities 10:

11 This may reflect a greater sense of control over fertility among women, instead of genderinequitable views of responsibility for fertility. Challenges Facing FP Provision Limited and irregular contraceptive supplies presented challenges to clinic and communitybased FP distribution. Long-term and permanent FP methods such as IUDs and sterilization were not consistently available or easily accessible in the study area. 5

12 Chapter 1. Introduction Background Healthy timing and spacing of births is important to the health and wellbeing of all women and infants, regardless of their HIV status (Kerber et al 2007). Mounting evidence also indicates the critical importance of improving access to family planning (FP) for people living with HIV (PLHIV) and those at risk for HIV. For HIV positive women who do not wish to become pregnant or have more children, access to FP services prevents unwanted pregnancies and the chance they will transmit the virus to their children. In sub-saharan Africa, it has been estimated that 160,000 HIV positive births could be averted each year if all women who wished to avoid pregnancy had access to FP services (Reynolds et al 2008). Several studies have found a high, unmet need for sexual and reproductive health (SRH) services among PLHIV, including FP services (Adair 2007). Despite this great need, FP is often not integrated or is very poorly linked to HIV services (Wilcher and Cates 2009). There is also a dearth of well-evaluated models for effectively providing SRH services to PLHIV and people at risk of HIV infection (Brickley et al 2011). Limited availability and access to FP information and services at health clinics and at the community level can be significant barriers. Myths and misconceptions about FP can also serve as important barriers to the uptake of services. At both community and clinic levels, access to FP services is also often limited by stigma and discrimination against PLHIV. Many providers in health care settings also have discriminating attitudes about the rights of PLHIV to manage their own fertility (Bharat and Mahendra 2007). Gender-related bias also comes into play. When FP services are geared solely toward women, this leaves men without easy options for accessing FP services and information (Ringheim and Feldman-Jacobs 2009). Social and cultural barriers also limit the acceptability and uptake of FP services. Community norms about gender roles and inequitable power dynamics may limit women s ability to make autonomous decisions about their fertility. Community norms around ideal family size may also affect the ability of couples to delay and space births and limit the number of children they have. Taboos about premarital sex may further limit the ability of young, unmarried men and women to access FP services. Although PLHIV may want no more children, they may feel pressured to reproduce, particularly if they have not disclosed their HIV status to family members. Between November 2009 and June 2011, the Communication for Change (C-Change) Project partnered with CARE Zambia on action research activities to explore how social and behavior change communication (SBCC) interventions could help increase access to FP services. The intervention study design was informed by lessons emerging from FP and HIV programs, including FP/HIV integration programs. 6

13 HIV and FP in Eastern Province and CARE Zambia s Response Zambia s national HIV prevalence is 14.3% and 10.3% in rural areas, which is the estimated prevalence in Eastern Province. HIV prevalence is higher among women than men: 16.1% of Zambian women are HIV positive, compared to 12.3% of Zambian men. Unmet need for contraception is also high 26.5% nationally and 24.2% in Eastern Province (Central Statistical Office 2009). In Eastern Province, CARE Zambia provides financial, logistical, and technical assistance to strengthen government health structures at provincial, district, and community levels to deliver effective, high-quality health services. This includes efforts to improve capacity for optimal communication and referrals from community-level volunteers to the primary health system, as well as training for community auxiliary health workers; traditional birth attendants; local leaders; and volunteers in HIV and TB prevention, care, and support. As a complement to strengthened health services and delivery, CARE works with community groups and the general population to raise awareness of HIV and TB issues, and to promote health services. Integrated Tuberculosis and AIDS Program (ITAP) in Lundazi District From 2005 to mid-2009, CARE implemented the PEPFAR funded Integrated Tuberculosis and AIDS Program (ITAP) through the U.S. Centers for Disease Control and Prevention in Eastern Province. ITAP s focus areas and objectives included: 1. Providing a minimum package of prevention of mother-to-child transmission (PMTCT) services or access to PMTCT services for 13,000 women in 30 health facilities in three remote districts, including Lundazi. 2. Providing HIV counseling and testing (VCT) services for 15,000 prospective clients in 47 health centers in six districts, including Lundazi. 3. Facilitating access to basic health care and support and improved TB and HIV services for 5,000 prospective TB and/or HIV and AIDS clients in 117 health centers in four districts, including Lundazi. In 2008, C-Change worked with CARE Zambia to integrate FP into ITAP through SBCC activities. ITAP had already facilitated the formation of buddy groups to increase adherence to TB treatment and antiretroviral therapy (ART) regimens and reduce levels of stigma and discrimination. These activities provided a unique opportunity to reach PLHIV and their partners with FP information and served as an entry point for introducing a community communication strategy on FP. In September 2010, after ITAP entered a second phase of program implementation and scaled down, it no longer operated in Lundazi district. However, this did not affect the SBCC activities and the evaluation of their impact, since the basic structure was in place: the Mwase Lundazi RHC and the network of informal community groups and facilitators. CARE Zambia continued to provide support through its Lundazi office. 7

14 Overview of FP Services at the Mwase Lundazi RHC The Mwase Lundazi RHC provides a range of FP services, including counseling on modern methods and distribution. The clinic supplies contraceptives to community health workers (CHWs): trained volunteers who provide FP counseling and methods in their own communities. CHWs are authorized to distribute only two FP methods condoms (male and female) and oral contraceptive pills (OCPs) but they mostly provide male condoms. At Mwase Lundazi RHC, female condoms were stocked only intermittently and in limited quantities; when available, stocks were quickly depleted. The CHWs have been trained to refer clients to the RHC who expressed interest in any other methods, such as injectable contraceptives. The Mwase Lundazi RHC provided a limited number of contraceptives on a regular basis: OCPs (three major types Microlut, Microgyn, and Oralcon F), male and female condoms, injectables (mainly Depo Provera), and implants (Jadelle). For male and female sterilization, clients were referred to the Lundazi District Hospital, where trained personnel provide these permanent FP methods. The head maternal and child health (MCH) nurse at the Mwase Lundazi RHC was trained to perform IUD insertions, though IUD supplies were not available at the center. In theory, staff should refer clients interested in this method to the Lundazi District Hospital, although available information indicates that this did not happen because IUD supplies were not available at the hospital either. In July and August 2010, Society for Family Health (SFH), a national NGO, arranged for skilled personnel to perform IUD insertions for interested clients at the Mwase Lundazi RHC. At the time, SFH staff indicated that these IUD camps would be a regular occurrence. However, as of June 2011, SFH had not returned, and no other locally available options for IUD insertion were available. Study Population The study population included HIV positive and HIV negative men and women of reproductive age (18 50 years) in the catchment area of the Mwase Lundazi RHC. HIV positive and HIV negative survey participants were selected from a sampling frame built from ART and VCT registers at the clinic. Components of the SBCC Program Two sets of SBCC interventions were implemented sequentially. 1. Establishment and Ongoing Strengthening of an FP Referral System Interventions focused on integrating FP services into the Mwase Lundazi RHC s outpatient department, ART clinic, and laboratory services. Mwase Lundazi RHC staff was trained to ask all clients about their interest in FP and provide referrals to the FP section accordingly. 8

15 All clients referred to FP services whether from CHWs or from other sections of the clinic received a referral slip to present to the nurse in charge of MCH, who provided them with counseling on the various FP methods available. Implementation of this referral system at the Mwase Lundazi RHC was originally planned for November 2009, concurrent with the initiation of SBCC activities. However, due to implementation challenges, it was initiated in February 2010, continuing through the end of the activity in June Despite engagement with Mwase Lundazi RHC management and reorientation of clinic staff, high staff turnover posed challenges to effective and consistent implementation. 2. Community-Based, Horizontal Communications Strategies A cadre of community-based facilitators was trained to conduct participatory community dialogues about FP, sexuality, and gender. Training and tools were adapted from CARE s Social Analysis and Action (SAA) methodology, and participatory tools were used to initiate dialogue and reflection. The facilitated dialogues were used to identify and address barriers to FP uptake and use of FP services. SBCC facilitators were also trained to conduct one-on-one meetings with individuals who showed interest in FP. Program Implementation and Challenges In November 2009, CHWs from 11 neighborhood health committees (NHCs) received training on the use of SAA strategies and community dialogues to explore social norms around gender, FP, and HIV, and the barriers to FP uptake. SAA dialogues began in December 2009, but were not organized continuously throughout the implementation period. In addition to conducting community-based meetings, CHWs conducted one-on-one consultations on request or when a couple disagreed on FP use. These volunteers did not record information on these one-on-one visits, so no data are available on the intensity of this component. Due to a perceived lack of community support, SAA facilitators suspended dialogues in February 2010, resuming them in March 2010 after follow-up training. While between nine and 15 community dialogues per month were targeted, activity reports indicate that 14 dialogues were conducted from April to May of Further, due to miscommunication among staff, SAA activities were again suspended in June 2010 in preparation for the midline research study. They resumed in August To reinvigorate the community dialogue process in September 2010, CARE Zambia recruited a dedicated officer to support SAA and conduct refresher trainings for facilitators. An additional six facilitators were recruited and trained to strengthen SAA implementation, bringing the total number to 22. As a result, 43 community dialogues were held between September 2010 and January In January 2011, three additional facilitators were recruited, and all 25 were trained to deliver the next SBCC intervention. They used A Family Planning Dialogue Guide for Community Facilitators, a set of SBCC tools adapted from a field-tested set of C-Change materials 9

16 developed in the Democratic Republic of Congo. The materials comprise picture codes with simple notes that assist facilitators during community dialogues. The information highlights the benefits of birth spacing and the use of modern FP methods, countering common myths and misconceptions and offering accurate information about a range of methods. Through a consultative process involving CARE Zambia, FHI 360, and CARE USA, the tool was adapted for the Zambian context, and a local artist was hired to produce new images for the picture codes. Key messages were informed by findings from the baseline and midline assessments, including commonly held misconceptions and fears about FP. The materials were then field tested in three villages in the catchment area, and community leaders, females ages 18 29, males ages 30 50, and the elderly provided feedback on the clarity, appropriateness, and relevance of the messages and picture codes. Once the guide and codes were finalized, hard copies of the guide and large prints of the picture codes were distributed to each volunteer. In the second phase, community educational dramas that complemented the dialogues were also initiated. Often, performances preceded community discussions that used the SBCC tool. The dramas helped bring together groups for discussions and highlighted real-life examples of issues that were discussed in the dialogues. A total of 144 SBCC dialogues using the SBCC tool were conducted between February 2011 and June Six were conducted during PMTCT sessions by a facilitator who was also a clinic health worker. A total of 34 community skits were presented in March and April Facilitators faced several challenges. They found it difficult to conduct groups with a mix of genders, and young married people particularly women were reticent to discuss sex and FP in the presence of in-laws or community elders. Elderly community members were also often reluctant to participate in dialogues, since their generation was unfamiliar with FP and considered it no longer relevant in their lives. Though the dialogues targeted young couples and traditional or community leaders, it was often difficult to recruit young participants. Generally, women were more likely to participate in dialogues than men. To circumvent these issues, facilitators attempted to conduct several dialogues simultaneously segregated by age and gender in the same community. However, communities resisted this segregation, and facilitators found managing the arrangements logistically challenging. Another important challenge was the limited, inconsistent supply of FP methods. Though field reports suggested that the three interventions were successful in generating an increased demand for FP specifically OCPs and condoms the supply at the Mwase Lundazi RHC was often insufficient to meet this demand. Because CHWs were supplied by the clinic, shortages at the clinic also meant shortages in the community. This inability to supply potential new users with methods frustrated facilitators who were successful in generating FP demand. These issues are discussed further in Chapter 6. 10

17 Communications on FP by Other Programs Activities similar to those conducted by CARE and C-Change were also carried out by other organizations at the same time. Africare, for example, employed volunteers to conduct community-based meetings on safe motherhood, and many of them also worked for C-Change as facilitators. Within the catchment area, national NGOs, including SIDAS and Thandizani, also used community meetings to promote HIV awareness and services. The Mwase Lundazi RHC also occasionally conducts its own community-based outreach and has used community meetings to promote male involvement in PMTCT. Given these community-based activities in the same catchment area, it is not feasible to determine how much exposure to information on FP and HIV could be attributed strictly to C- Change activities (see Table 21). 11

18 Chapter 2. The Research Study CARE and FHI 360 conducted the C-Change action research study, which was approved by ERES Converge in Zambia and FHI 360 s Institutional Review Board committee in Washington, DC. The main objective was to determine the effects of community-informed and community-based communication strategies and a health services intervention to increase referrals within a large rural health center on FP uptake. Secondarily, the goal was to identify social norms that influence FP acceptance and uptake, particularly among PLHIV. For the purposes of this report, social norms are focused on gender and defined as the community s expectations about how men and women should behave, and describe the ways in which men and women are expected to behave because they are men or women. The study used a single time-series research design, with interventions introduced one at a time between November 2009 and June Service data were analyzed for each intervention period to determine any changes in contraceptive uptake, measured by the quantity of contraceptives distributed by type and couple years of protection (CYP). In addition to the service records, information on FP use and gender norms was obtained through baseline, midline, and endline community-based surveys and focus group discussions (FGDs). Data were collected using a standardized, interviewer-administered, precoded questionnaire and a qualitative interview guide. The survey population included HIV positive and HIV negative men and women ages The protocol outlined sample targets of 120 male and 120 female individuals at each survey round baseline, midline, and endline. A household-based selection of respondents was found to be inadequate for this study for two reasons. First, because no blood specimens were collected (no biomarkers), it was not feasible to determine the HIV status of respondents through a household survey. Second, even if blood specimens were collected, the householdbased sample selection approach might not yield adequate numbers of either group to enable meaningful analysis. As a result, the ART and VCT registers of the Mwase Lundazi RHC were used as the sampling frames for HIV positive and HIV negative participants, respectively. For the HIV positive subsample, separate lists of male and female patients within the age range were generated from the ART register, followed by a random selection of about 50 HIV positive males and 50 HIV positive females. For the HIV negative subsample, separate lists of male and female clients ages with nonreactive HIV test results were generated from the VCT register, followed by random selection of about 70 HIV negative males and females for the baseline survey and 50 of each for the midline survey. For the baseline and midline surveys, sample selection followed the research protocol. This report outlines results from the endline survey conducted in June 2011, 18 months after implementation began. The primary objective of the endline survey was to document the effects of the C-Change activities, particularly with respect to reaching the target population with interventions and promoting changes in FP uptake and norms around contraceptive use. 12

19 Because of limited numbers of ART and VCT clients at the time of the endline survey, sample selection for the endline deviated slightly from the protocol, as described below. Sampling As with the baseline and midline surveys, potential survey participants for the endline survey were selected from Mwase Lundazi RHC records. For the HIV positive subsample, a thorough review of the records of all patients currently receiving HIV care and treatment yielded 53 HIV positive female and 50 HIV positive male clients who met the study s age and residence criteria. All of these potential participants were selected for the survey. The final sample of completed interviews comprised 35 female and 32 male respondents who were HIV positive, instead of the planned number of 50 for each gender. Incorrect or unidentifiable names and addresses of potential respondents complicated the task of meeting the target numbers, along with the fact that many RHC clients had moved outside the catchment area. The study protocol outlined that HIV negative participants should be drawn from VCT records for the two months preceding the survey to limit the number of respondents who might have contracted the virus since their last test. However, because VCT records for the two months preceding the endline study did not yield sufficient numbers of potential participants, the sampling time frame was extended to six months preceding the survey. This revision yielded 82 female and 83 male clients who were HIV negative and met the age and residence criteria. As with the HIV positive subsample, no randomization was performed for sample selection, and the complete list of potential participants was selected for the survey. In view of the preference for most-recently tested individuals, replacements for HIV negative respondents were purposively selected moving backward from the most recent month April Ultimately, data from interviews with 59 female and 70 male HIV negative respondents were included in the endline sample. Selected participants were assigned unique participant ID codes. To protect the confidentiality of their HIV status, only the research management team the principal investigator (PI), monitoring and evaluation (M&E) officer, and SAA officer knew the relationship between a participant s unique ID code and his or her status. Replacements were drawn initially from the original sample frames. Because replacement needs exceeded the number of individuals available in the original frame, additional names were added from those who registered between the time the initial sample selection was made and June 2011, the date of data collection. Interviewer Training and Deployment of the Field Team Thirteen potential research assistants (RAs) were identified, including three RAs who had participated in the baseline and midline surveys. One dropped out at the beginning of the training period, leaving 12 RA candidates. The nine new RAs completed FHI 360 s online 13

20 research ethics training curriculum; three returning RAs had already undergone this training. All 12 candidates also completed a four-day training conducted by CARE USA s technical advisor and M&E officer, and the SAA officer from CARE Zambia. This training detailed the study background, objectives, and design; survey data collection tools; data security and confidentiality; and informed consent procedures. It was divided into qualitative and quantitative sections and included extensive role-play and practice and in-depth discussions, including on the rights of potential participants. Four of the trained RAs two male and two female who completed field tests and demonstrated competence in qualitative data collection were assigned to FGDs. The remaining eight RAs completed two pretest surveys with one male and one female in a neighboring community to demonstrate competence in quantitative data collection and were assigned to the quantitative data collection team. After the field pretest, the study team and trainees refined the survey tools, with special attention to translation accuracy and skip patterns. All 12 trainees were deployed to the field. One served as a field supervisor to coordinate daily operations and assist the M&E officer in checking data quality. The SAA officer was responsible for coordinating FGDs and supervising transcription of FGD data. The PI provided technical support during data collection and validated data through random interviews of participants. Before data collection started, meetings were held with key community representatives CHWs, community volunteers, and clinic staff. These served to introduce the data collectors to the communities, preempt misconceptions about the intentions and outcomes of the research, and secure accommodation for the RAs. Starting in April 2011, the SAA officer used the dialogues to inform communities about the upcoming research. Data Collection and Constraints Data collection was divided into two parts: quantitative, using a standardized survey questionnaire; and qualitative, using an FGD guide. Two teams collected data concurrently. Both data collection instruments contained questions in English and translations in Chewa, the predominant local language. Due to a shortage of female interviewers, about one-third of the interviews with female respondents were conducted by male interviewers. Quantitative Data Survey data were collected over a 20-day period, beginning on May 2, Interviews were conducted in Chewa, except for a small number in English by respondent request. Potential respondent lists were grouped by NHC, an administrative area comprising a cluster of villages. The RA supervisor, M&E officer, and SAA facilitator collaboratively proposed strategies to cover and canvas these areas. RAs were provided with bicycles and driven to central 14

21 locations within the 12 NHCs. The team worked weekends as well as early mornings and evenings so respondents working away from home could be included. The survey team faced a variety of challenges in recruiting study participants. Many respondents could not be located. VCT clients have less incentive than ART clients to provide accurate addresses, and may want to maintain secrecy to avoid stigma. Other potential respondents had died, moved, or were found to be ineligible because of the age criteria. The harvest season had been viewed as an ideal time to collect data because most people would be at home. However, RAs found that many respondents used the end of the season to travel to other towns and visit relatives. RAs also reported that they frequently encountered potential respondents who were drunk, thus judged to be incapable of providing a complete and accurate interview. Whenever possible, follow-up appointments were scheduled. The result of this combination of challenges was that the original sample frame had to be supplemented and the ultimate sample size reduced. Qualitative Data Ten FGDs were conducted over 12 days in four NHCs, selected on the basis of their size and proximity to the Mwase Lundazi RHC. To ensure a cross-section of participants, two NHCs were selected because they were large and close to the health center; two were selected further away. The first two FGDs were treated as a pretest of the qualitative guide and were not taperecorded. Of the remaining eight FGDs, two each were conducted with men and women in two age groups: and Participants for the FGDs were selected with the help of SAA and SBCC volunteers. On the day before an FGD was scheduled, a volunteer visited the community and met with the village head to explain the research and identify potential participants. Facilitators identified potential participants based solely on the age criteria (18 29 or 30 49). For those interested in participating, facilitators explained the basics of the study, the logistics, and purpose of the discussion. On the day of the scheduled FGD, the research team (two male RAs, two female RAs, and the SAA officer) arrived in the village to further explain the study and screen interested participants. In addition to the age criteria, community members were identified as eligible to participate in the FGD only if they had not taken part in a CARE-sponsored community dialogue in the preceding two weeks. Efforts were also made to exclude community members who held positions of authority to prevent them from determining the course of the discussions. Once a group of eligible participants had been identified, the research team led them through the informed consent process. In cases where the research team found a group of interested participants already assembled, the informed-consent script was read to the whole group and questions were elicited. Then consent forms were signed and consent granted individually. In other cases, the informed-consent process was conducted on an individual basis. 15

22 Data Management, Entry, and Analysis Quantitative Data Data quality was checked on a daily basis, with the RA supervisor conducting initial reviews of all completed surveys. Secondary review was completed by either CARE s M&E officer or the C- Change PI. Reviewers checked for internal consistency and completeness. Providing onsite supervision and feedback not only contributed to data quality assurance, but also to overall RA competence. Whenever possible, RAs conducted follow-up visits to respondents to collect missing data. Surveys that had passed the double-review process were transferred to the Lundazi CARE office, where they were securely stored until data entry. Survey data were entered into an Epi Info database using screens with consistency and range checks, then cleaned. Data were analyzed using SPSS, focusing on current levels of key indicators social norm indicators, approval of FP, and knowledge and use of contraception as well as associations between outcome indicators and participants demographic characteristics. Particular attention was paid to changes since the baseline study and to inter-survey differences in baseline and endline samples. Monthly service statistics from Mwase Lundazi RHC were entered into an Excel database, and CYP was estimated using the USAID formula. 2 The calculation took into account that some methods, like condoms and OCPs, may be used incorrectly and then discarded, or that IUDs and implants may be removed before their lifespan is realized. After conversion, CYPs for each method were summed to obtain a total CYP figure for that population. Qualitative Data Data from all 10 FGDs were included in the analyses, since review of the two test interviews indicated they contained useful data. Eight FGDs that were audiotaped were translated from Chewa into English by the facilitators during verbatim transcriptions into Microsoft Word documents. Complete field notes of the remaining two FGDs that were not audiotaped were similarly translated and transcribed into Microsoft Word. The team reviewed initial transcripts for content and interviewing and transcription quality. Reviewed transcripts were shared with other study investigators, who also provided feedback. The team read the FGD transcripts and developed a preliminary code book. All 10 FGD transcripts were uploaded into NVivo for coding, which was subject to revision as themes emerged from the data. A CARE USA consultant performed the data coding, in consultation with the SAA officer. The two worked collaboratively to identify predominant themes and associations and prepare display matrices. 2 More information on USAID s formula for couple years of protection can be found at 16

23 Chapter 3. Demographic Characteristics of Respondents A total of 85 respondents (43 women and 42 men) participated in 10 FGDs. The median age among women was 28, and 27 among men. Among the women, 91% were married, as were 74% of the men. Two was the median number of living children for both (ranging from zero to 10 among men and zero to seven among women). Six was the median highest grade completed for the women, and the median highest grade completed for men was seven. A total of 196 respondents participated in the endline survey: 102 men and 94 women, or 42% and 48%, respectively, of the total sample. Among male respondents, 31.4% (n=32) were HIV positive, while 37.2% (n=35) of female respondents were HIV positive. Table 1 below shows the age distribution of endline survey respondents by gender and HIV status. The median ages for the male samples (35.5) and female samples (34.3) were similar. Within the endline male sample, age distribution differed by HIV status. The subsample of HIV negative respondents was younger 55% were between ages 18 and 34 compared to the HIV positive subsample, where 87.5% were between ages 35 and 50. Age distribution differences between HIV positive and HIV negative male respondents were statistically significant (p<.001) when ages were grouped into three categories (18 24, 25 34, 35 50). The endline female sample showed no statistically significant differences by status. Table 1: Percent Distribution of Respondents by Background Characteristics and HIV Status Male Female Positive Negative Total Positive Negative Total Age of respondents n=32 n=70 n=102 n=35 n=59 n= / Don t know/no response Median age (n=69) (n=101) Ever attended school n=32 n=70 n=102 n=35 n=59 n= Highest level of education n=31 n=63 n=94 n=34 n=55 n=89 Primary Secondary and higher Ever married n=47 n=54 n=101 n=51 n=46 n= Median age at first marriage n=31 n=65 n=102 n=32 n=53 n=85 17

24 Male Female Positive Negative Total Positive Negative Total Religion n=32 n=70 n=102 n=35 n=59 n=94 Catholic Protestant Muslim/other Ethnicity n=32 n=70 n=102 n=35 n=59 n=94 Chewa Tumbuka Ngoni Other Comparisons between the baseline and endline samples showed no statistically significant differences in ages or age distributions. Figures 1 and 2 below summarize female and male age distributions across the three surveys. Figure 1: Percent Distribution by Age Group of Baseline, Midline, and Endline Female Sample Baseline Midline Endline /50 Age group 18

25 Figure 2: Percent Distribution of Male Respondents by Age Group, Baseline, Midline, and Endline Baseline Midline Endline /50 Age group At endline, 92.2% of men and 94.7% of women reported having ever attended school. Among these groups, male respondents (41.5%) were more likely to have completed secondary school or higher than female respondents (18.0%). Within male and female samples, educational attainment did not differ significantly by HIV status. Inter-survey comparisons revealed that higher proportions of the endline female survey respondents (94.7%) had ever attended school than baseline female survey respondents (83.3%). This difference held for HIV negative respondents when attendance was analyzed by status: 93.2% of endline HIV negative female respondents reported having ever attended school, compared to just 76% of baseline HIV negative female respondents. Differences were statistically significant for the overall female sample (p=.012) and the HIV negative female subsample (p=.011). These important differences between the baseline and endline samples should be considered when interpreting results and comparing outcomes for women at baseline and endline, since education levels are known to be associated with FP uptake and may also influence other key variables, such as knowledge about FP and attitudes toward gender norms. 19

26 Overall, females in the endline survey reported an earlier age at marriage compared to baseline female respondents. Mean age of marriage at endline was 17.6, compared to 19.2 at baseline (p=.053). This difference holds for HIV negative female respondents whose mean age of marriage was 17.4 at endline and 18.6 at baseline (p=.066). The endline female sample also differed significantly by religion from baseline female respondents. At baseline, female respondents identified as only Catholic or Protestant, while a small proportion of the endline female sample (8.5%) identified as Muslim or other. This difference was statistically significant (p=.011), and was also true for endline HIV positive female respondents (p=.099). Both endline male and female respondents reported higher levels of exposure to TV and radio than respondents in the baseline sample (Table 2). These levels were at times significantly higher than baseline. For exposure to TV, statistically significant differences applied to female respondents overall (p<.001); HIV positive female respondents (p<.001); HIV negative female respondents (p=.004); male respondents overall (p=.002); and HIV-negative male respondents (p=.004). Females in the endline sample also indicated higher exposure to radio than baseline female respondents (p=.001), and differences remained significant for HIV positive female respondents (p=.034). These increased levels of exposure may reflect greater availability of communication media over time or the slightly higher socioeconomic status of the endline sample. Irrespective of the source of these differences, greater exposure to media is often associated with greater levels of information and knowledge about FP and greater levels of exposure to different value systems, including attitudes and beliefs about gender. These differences in exposure to media need to be considered when interpreting the baseline and endline results. Table 2: Frequency of Exposure to TV and Radio, by Gender and HIV Status Male Female Positive Negative Total Positive Negative Total Radio N=32 N=70 N=102 N=35 N=59 N=94 Every day At least once a week Less than once a week Not at all TV N=32 N=70 N=102 N=35 N=59 N=94 Every day At least once a week Less than once a week Not at all The distribution of other socio-demographic characteristics marital status (measured as evermarried) and ethnicity did not differ significantly by gender or HIV status in the endline sample and closely mirrored distributions in the baseline sample. 20

27 Chapter 4. Decision-Making about Sex and Childbearing The surveys collected data on fertility-related behaviors of respondents and on some of the underlying attitudes and perceptions that influenced their decision-making about sex and childbearing. Inter-survey comparisons indicate several important changes among female respondents between baseline and endline. Compared to the baseline sample, female respondents at endline expressed lower future fertility desires and perceived community norms relating to ideal family size to be lower. Again, when interpreting these results, it is important to note that some of these differences may be associated with the endline female sample s slightly higher educational status or their higher exposure to mass media, compared to the baseline sample. Age at First Sexual Experience All respondents who reported ever having sex (100% of the males and 98.9% of the females) were asked to state their age of sexual debut. Table 3 summarizes their responses. Overall, females reported earlier age at debut than male respondents: 53.8% of females said they had sex before age 17, compared to 42.2% of male respondents. HIV positive female respondents reported a slightly later age of sexual debut than their HIV negative counterparts. This reflects data in Zambia s 2007 Demographic and Health Survey (DHS), which shows clearly that HIV prevalence tends to be higher among women (and, to some extent, men) whose first sex experience occurred at age 20 or older. 3 Though early first sex is typically a risk factor for HIV infection, this association is reversed in Zambia. Table 3: Age at First Sex, by Gender and HIV Status Male Female Positive Negative Total Positive Negative Total N=32 N=70 N=102 N=35 N=58 N=93 Below Don t know Median age at first sex N=27 N=61 N=88 N=31 N=51 N= First sex before marriage N=32 N=70 N=102 N=35 N=59 N= According to the 2007 DHS, HIV prevalence was highest 21.0% among women who had first had sex at age 20 or older. The rate was 17.5% for females who had first sex under age 16 and those between 16 and 17, and prevalence was 17.7% for those experiencing first sex at For men, prevalence was highest (16.4%) among those who had first sex between the ages of 18 and 19. The rate was 12.8% and 12.9% for males having first sex under age 16 and those between 16 and 17, respectively, and was 13.9% for those having first sex at age 20 or older. 21

28 Comparisons between reported age at first sex and reported age at marriage for respondents indicated that more than twice as many males as females had premarital sex: 56.9% versus 24.5%. These data did not differ significantly by HIV status. These quantitative data on the incidence of sex before marriage are of note, since they counter commonly expressed community beliefs that unmarried youth do not need information on sex or FP and do not need to access to FP services. Table 4: Median Age at First Sex at Baseline and Endline, by Gender and HIV Status Male Female Positive Negative Total Positive Negative Total Baseline N=23 N=39 N=62 N=30 N=32 N= Endline N=27 N=61 N=88 N=31 N=51 N= A dominant theme in FGDs was that FP is only socially acceptable for married people. A female participant among the age group pointed out a perceived contradiction between the term and its practice by those not yet married: It is not allowed for a young unmarried woman to use family planning. Which family is she planning? Female, age Negative attitudes toward premarital sex were reported by facilitators of community dialogues and confirmed in FGDs. That FP is inappropriate for unmarried youth appears to be a widely held community belief. It surfaced in almost all female FGDs, including all three FGDs for the age group. Notwithstanding, discussions indicated that some young women feel selfefficacious enough to take some discreet actions to access FP and claim their fertility rights. Qualitative data reveal the extent of negative community perceptions of the use of FP by unmarried individuals and the gender biases inherent within these perceptions. Eight of 10 groups said it was unacceptable for young unmarried men or women to use FP; those doing so were considered promiscuous or suspected of being sex workers. Female groups reported greater negative perceptions of young unmarried women using FP than their male counterparts. However, all groups cited exceptions reasons why it might be considered acceptable for unmarried youth to use FP. Some of the reasons articulated for allowing these exceptions were related to gendered norms and different expectations of women and men. For example, some FGD participants indicated that it was acceptable for an unmarried female student to use FP so that she could avoid pregnancy and continue her education: 22

29 The thing is, that girl is okay preventing pregnancy because she wants to further her education, and by so doing she will eventually come to help us in the community. Male, Participants also said it might be acceptable or even desirable for unmarried young men to use FP. They have strong sexual needs that must be met, and they need to protect themselves from HIV and/or problems that result if they cause a pregnancy: He has made a decision to protect himself from diseases so that even if he runs around with a lot of women he will be safe. Male, It is okay for a man to use family planning. In fact it is a good thing for him because men have high sexual feelings. Female, Sexual Activity in the Last 12 Months Men in the endline sample indicated higher levels of sexual activity than female respondents: 91.2% of males and 79.6% of females reported they had had sex in the last 12 months. HIV positive male respondents reported significantly less sexual activity than their HIV negative counterparts. Among them, 78.1% had sex in the previous 12 months, compared to 97.1% of HIV negative male respondents. This difference was statistically significant (p=.004). Fewer HIV positive female respondents reported sexual activity in the previous 12 months than their HIV negative counterparts (74.3% compared to 82.8%), though the difference was not statistically significant. Although lower proportions of HIV positive respondents overall reported having had sex in the year before the survey, approximately three-quarters of all HIV positive respondents reported sexual activity in the previous 12 months. Number of Living Children The greatest proportions of both male and female respondents 46.1% and 50.5%, respectively reported they had three to five living children, and approximately one-fifth 21.6% and 18.3%, respectively had six or more living children. As Figure 3 illustrates, the distribution of the number of living children was similar overall among HIV positive and HIV negative respondents, although there were some notable differences across sub-samples. Compared to HIV positive female respondents, a greater proportion of HIV negative females reported having three to five children (56.9% compared to 40.0%). The converse was true of the endline male sample. Among HIV positive male respondents, 56.3% reported they had three to five children and 3.1% reported zero children. Among HIV negative males, fewer (41.4%) had three to five children and more of them (15.7%) reported no living children. 23

30 Figure 3: Percent Distribution of Number of Children, by Gender and HIV Status Male Positive Male Negative Female Positive Female Negative Number of living children Desire for Last Pregnancy Female respondents who were pregnant at the time of the survey or had at least one living child were asked to characterize their desire for their last pregnancy (Table 5). The majority of respondents, both overall and within HIV positive and HIV negative subsamples, either did not want to be pregnant, wanted to wait, or had not thought about it. These responses point to a clear unmet need for FP. Table 5: Percent Distribution of Women s Desire for Last Pregnancy, by Number of Children and HIV Status Number of children Desire for last pregnancy N=29 N=47 N=17 Wanted to be pregnant Wanted to wait Did not want to be pregnant Did not think about it Positive Negative Total N=36 N=57 N=93 Wanted to be pregnant Wanted to wait Did not want to be pregnant Did not think about it