PROMOTING HIV PREVENTION BEHAVIORS IN MALAWI THROUGH THE BRIDGE PROJECT: TRENDS IN EXPOSURE AND OUTCOMES FROM 2003 TO 2009

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2 PROMOTING HIV PREVENTION BEHAVIORS IN MALAWI THROUGH THE BRIDGE PROJECT: TRENDS IN EXPOSURE AND OUTCOMES FROM 2003 TO 2009 Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 i

3 Acknowledgements The BRIDGE project was made possible by funding from the United States Agency for International Development. We are grateful for the generous financial and technical support provided by USAID for this work. This report was written and edited by Rajiv N. Rimal, Rupali Limaye, Jane Brown, and Glory Mkandawire. Significant portions of this report were also written by Marc Boulay, Lisa Aslan, Rachana Sikka, Abigail Dzimadzi Suka, Pius Nakoma, and Joel Suzi. CCP would like to thank Triza Kakhobwe and Josephine Mkandawire for their valuable input in the form of comments and fruitful contributions to this report. We are immensely grateful to the administrative and finance staff at the BRIDGE project office, without whom this report would not have been possible. Data collection was done by Salephera Consulting, J&F Consult, and the Kaneka team. In this regard, we are grateful to the teams led by Hestern Banda, John Kadzandira, and Benjamin Kaneka. Finally, we would like to acknowledge and most sincerely thank the many people and organizations who have contributed to the success of the BRIDGE project over the years with their creativity, insight, and hard work. They include: BRIDGE District Coordinators: Edda Mwamadi, Mary Kumwenda, Linly Sakhama, John Masi, Mumderanji Zipangani, Lawrence Chulu, and Memory Kaleso Kirsten Böse. Lisa Folda, Joan Yonkler, Peter Labouchere, Lisa Basalla, Beth Deutsch, Peter Roberts, Brenda Yamba, Jeanne Russell, Leslie Holst, George Alufandika, Wellington Nkhoma, Victor Kachika Jere, Levison Phiri, Patrick Phoso, and Kent Mpepho BRIDGE Collaborating partners: Malawi Ministry of Health and National AIDS Commission BRIDGE local and international partners: MANASO (Malawi Network of AIDS Service Organizations), PAC (Public Affairs Committee), PSI (Population Services International, National Youth Council of Malawi (NYCOM), TopAd (Top Advertising Inc.), Galaxy Media, Business Eye and Creative Communications, Nanzikambe Art Theatre, MAGGA (Malawi Girl Guides Association), NAPHAM (National Association of People Living with HIV & AIDS in Malawi), MANET+ (Malawi Network of People Living with HIV & AIDS), Zodiac Radio, Power 101, Radio Maria, Transworld Radio, Capital FM, Joy Radio, MBC (Malawi Broadcasting Corporation), and Radio Islam Please Note: The contents in this report are the responsibility of CCP and do not necessarily reflect the views of USAID or the United States Government. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 ii

4 List of Acronyms ARV CCP CBO FBO GLC GOM JHU MAGGA MANASO MANET+ MBC MSH NAC NAPHAM NASFAM NGO NYCOM PAC PLWA/PLHA PSI SC TA USAID YAM Anti-retroviral therapy Center for Communication Programs Community-based organization Faith-based organization Girls Leadership Congress Government of Malawi Johns Hopkins University Malawi Girl Guides Association Malawi Network of AIDS Service Organizations Malawi Network of People Living with HIV & AIDS Malawi Broadcasting Corporation Management Sciences for Health National AIDS Commission National Association of People Living with HIV & AIDS in Malawi National Small Holder Farmers Association of Malawi Non-governmental organization National Youth Council of Malawi Public Affairs Committee Person living with HIV & AIDS Population Services International Save the Children Traditional authority United States Agency for International Development Youth Alert Mix Suggested citation: Limaye, R,,Rimal, R. N., Brown, J., Mkandawire, G., Böse, K., Kakhobwe, T., Boulay, M., Aslan, L., Sikka, R., Suka, A. D., Nakoma, P., & Suzi, J. (2009). Promoting HIV prevention behaviors in Malawi through the BRIDGE project: Trends in exposure and outcomes from 2003 to Johns Hopkins Bloomberg School of Public Health Center for Communication Programs: Baltimore, MD, USA. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 iii

5 Table of Contents Acknowledgements... ii List of Acronyms... iii Table of Contents... iv List of Figures... vi List of Tables... vii Structure of the Report... viii Structure of the Report... viii Executive Summary... A Evaluation Components... A Summary of Methods and Findings... A Methods... A Results... B Conclusion... C PART A: Contextual and Theoretical Background... 1 Contextual and Theoretical Background... 2 Malawi Background... 2 Theoretical Background... 2 Self-Efficacy (Nditha!) as the Primary Focus... 3 Part B: BRIDGE Program Activities and Evaluation Components... 4 BRIDGE Program Activities and Evaluation Components... 5 The Tisankhenji Radio Program... 5 The Hope Kit... 6 The Radio Diaries... 6 Nditha! Sports... 7 Part C: End-of-Project Household Survey Evaluation... 8 End-of-Project Household Survey Evaluation... 9 Research Background... 9 Sampling... 9 Procedures Sample Characteristics Assessing Overall Exposure Exposure to BRIDGE Programs Exposure to District-Level Non-BRIDGE Programs Exposure to National-Level Non-BRIDGE Programs Exposure to Non-BRIDGE Programs through Cued Recall Assigning Exposure Scores Exposure across Population Groups Effects on Key Outcomes Knowledge about HIV & AIDS Community Vibrancy Stigma toward People Living with HIV & AIDS Perceptions of Risk to HIV & AIDS Self-Efficacy Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 iv

6 Behavioral Intentions HIV Testing Sexual Behaviors & Condom Use Part D: Household Survey Trends from Baseline to End-of-Project Household Survey Trend s from Baseline to End-of-Project Overall Study Design Variables of Interest Knowledge about HIV & AIDS Self-efficacy for HIV Prevention Behaviors Stigma Risk Perception Behavioral Intentions HIV Testing Part E: Findings and Conclusions from the Household Surveys Findings & Conclusions from the Household Surveys Findings & Conclusions from the Household Surveys Psychosocial Outcomes Behavioral Outcomes Part F: Quantitative and Qualitative Evaluation of the Tisankhenji Radio Program Quantitative and Qualitative Evaluation of the Tisankhenji Radio Program Quantitative Assessment Study Groups and Sample Sizes Background Characteristics of Respondents Exposure to Tisankhenji Effects on Educational Aspiration Effects on Perceptions of Control in Attaining Educational Goals Effects on Intentions to Attain Educational Goals Effects on Communication Efficacy Effects on Communication Behaviors Conclusions Qualitative Assessment Study Methods Procedures Discussion Format and Content Data Analysis Procedures Results Discussion Limitations Conclusion Part G: Diffusion of the Hope Kit: A Social Network Analysis Diffusion of the Hope Kit: A Social Network Analysis Introduction to Social Networks Study Methods Measures Used in the Study Results Exposure to the Hope Kit Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 v

7 Effects of Participation Network Effects Multivariate Analyses Discussion Limitations Part H: Other Assessments: Agogo Training, Nditha! Sports, and Girls Leadership Congress Other Assessments: Agogo Training, Nditha! Sports, and Girls Leadership Congress Agogo Training Assessment Findings Conclusion Nditha! Sports Assessment Findings Girls Leadership Congress Assessment Findings Part I: Recommendations for Future Programming Recommendations for Future Programming Recommendations from the Household Surveys Recommendations from the Tisankhenji Radio Program (TRP) Recommendations from the Quantitative Assessments Recommendations from the Qualitative Assessments Recommendations from the Social Network Analysis Recommendations from Other Assessments Agogo Training Nditha! Sports Girls Leadership Congress Conclusion References Reports Published by the BRIDGE Project List of Figures Figure 1. Exposure to BRIDGE Program Activities across the Eight Districts Figure 2. Knowledge about HIV & AIDS across the Eight Districts Figure 3. Components of Community Vibrancy in BRIDGE High and Low Activity Areas Figure 4. Percent Respondents Who Perceived Their Risk to be "Somewhat" or "Very Likely" Figure 5. Self-efficacy across the Four Groups Figure 6. Behavioral Intentions across the Four Groups Figure 7. HIV Testing Across the Eight Districts Figure 8. Percent with More than One Sexual Partner in 12 Months and Consistent Condom Use Figure 9. Trend in Knowledge about HIV & AIDS Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 vi

8 Figure 10. Trends in HIV Prevention Efficacy Figure 11. Indicators of stigma: Percent Respondents Agreeing about Stigmatizing Statements Figure 12. Percent Believing They Can Get HIV in 6 months or Year Figure 13. Behavioral Intentions. Percent Expressing Intention to Carry Out the Behavior. 41 Figure 14. Percent Tested for HIV Figure 15. Exposure to the Tisankhenji Program in Treatment and Control Schools Figure 16. Students Seeking (left panel) and Believing they will Achieve (right) Tertiary Level Education Figure 17. Effect of the TRP on Educational Attainment Intentions Figure 18. Overlapping Spheres of Efficacy Figure 19. Mechanism of the TRP s Influence Figure 20. Social Network Measuring Discussion of Personal Issues Figure 21. Social Network Measuring Discussion of the Hope Kit List of Tables Table 1. Key Characteristics of Districts Included in the Household Survey Table 2. Key Demographics of Sample Table 3. Exposure to BRIDGE Program Activities by Demographics Table 4. Exposure to National Organizations across all Districts Table 5. List of Producers of Communication Materials Shown to Respondents Table 6. Correlations across the Three Measures of Exposure Table 7. Percent Exposure to BRIDGE and Other Programs Table 8. Individual Items Comprising the Knowledge Scale, with Percent Correct Responses Table 9. Predictors of Knowledge about HIV & AIDS from Regression Equations Table 10. Differences in Community Vibrancy in Low- and High-BRIDGE Activity Areas Table 11. Effects of Exposure on the three Components of Community Vibrancy from Regression Equations Table 12. Effects of Exposure on the four Components of Stigma from Regression Equations Table 13. Predictors of Self-Efficacy through Multiple Regression Equations Table 14. Predictors of Behavioral Intentions through Multiple Regression Equations Table 15. Predictors of HIV Testing through Multiple Regression Equations Table 16. Predictors of Multiple Sexual Partners and Consistent Condom Use Table 17. Timing of Overall Research Activities and Sample Size during each Period Table 18. Demographic Characteristics of Participants a Table 19. Breakdown of Focu Group Discussions (FGD) and Individual Interviews by District Table 20. Percent Exposure to the Hope Kit Activities, by Gender Table 21. Participation in the Hope Kit Activities by Respondent Characteristics Table 22. Knowledge and Attitudes, by Level of Exposure to the Hope Kit Table 23. Coefficients from Linear Regression Models Predicting Knowledge and Attitudes Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 vii

9 Structure of the Report Part A Contextual and theoretical background Part B BRIDGE program activities and evaluation components Part C Household Survey Evaluation at End-of-Project Part D Household Survey Trends from Baseline to End-of-Project Part E Findings and Conclusions from the Household Surveys Part F Quantitative and Qualitative Evaluation of the Tisankhenji Radio Program Part G Diffusion of the Hope Kit: A Social Network Analysis Part H Other Assessments: Agogo Training, Nditha! Sports, and Girls Leadership Congress Part I Recommendations for Future Programming Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 viii

10 Executive Summary One of the highlights of the BRIDGE project was its reliance on research findings to inform all aspects of the intervention. From the initial conceptualization of the program, which was informed by findings from the baseline qualitative assessments and household surveys, to the final outcome, and the process assessments conducted throughout the program, evaluation of BRIDGE activities has been a central component of the intervention. Evaluation Components This research report presents findings from the outcome evaluations pertaining to the following intervention components: Household Survey Evaluation at End-of-Project: Assessments of the relationship between exposure to the BRIDGE interventions and key outcomes at the end of the project Household Survey Trends from Baseline to End-of-Project: Assessments of fluctuations in behaviors and behavioral outcomes from baseline to end-of-project The Tisankhenji Radio Program: Quantitative and qualitative assessments undertaken to evaluate how the program affected youth and how this influence occurred Social Network Analysis of Dissemination of the Hope Kit: Maps the interpersonal communication patterns in a community to determine how Hope Kit dissemination occurred and what effects ensued Agogo Training: Qualitative assessment to determine the effects of training traditional counselors of young people on HIV & AIDS issues Nditha! Sports: Interviews with participants in an innovate outreach program using games and play to teach about HIV & AIDS to determine if sports is an appropriate vehicle for learning about health Girls Congresses: Qualitative assessment to determine whether and how skills building and information can help build girls resilience to avoid HIV This report is being published simultaneously with its sister report that describes the program entitled Malawi BRIDGE End-of-Project Report Summary of Methods and Findings With funding from USAID, the Malawi BRIDGE project was initiated in 2003 to address the growing problem of accelerating HIV infection rates in the country. The BRIDGE project was the first of its kind mass media- and community-based intervention in Malawi specifically charged with preventing HIV infection through a theoretically informed behavior change program. It operated in eight districts: Balaka, Chikwawa, Kasungu, Mangochi, Mulanje, Mzimba, Ntcheu, and Salima. Methods The primary research and evaluation design comprised a series of household-level cross-sectional surveys, conducted through random sampling procedures at baseline (2003), the first midterm (2006), the second midterm (2007), and end-of-project (2008). The baseline and end-of-project surveys were conducted in all eight BRIDGE districts. The two midterm surveys were designed to Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 A

11 be representative of all eight districts, but were conducted in four districts: Kasungu, Mulanje, Mzimba, and Salima. In addition to the household surveys, other assessments were conducted to evaluate the effectiveness of specific interventions. These included the quantitative and qualitative assessments of the Tisankhenji Radio Program, the social network analysis of diffusion of the Hope Kit, evaluation of the Agogo Training, assessment of Nditha! Sports, and assessment of the Girls Leadership Congress. Results Household Surveys. Overall, the household surveys revealed significant improvements in key outcomes over the life of the campaign. Important gains were observed in psychosocial predictors of behaviors, behavioral intentions, and some behaviors themselves. When compared to baseline values, at the end of the project, we observed gains in knowledge about HIV & AIDS, improvements in self-efficacy to engage in self-protective behaviors, reductions in stigma toward people living with HIV or AIDS, increases in uptake of HIV testing, and gains in behavioral intentions (both directly through exposure and indirectly through the enhancement of self-efficacy). At the end of the project, significant associations were observed between exposure to the BRIDGE project s activities and high-risk sexual behaviors diminished likelihood of engaging in multiple sexual relationships and increased likelihood of using condoms consistently. These associations were observed even after controlling for demographic indicators and exposure to non-bridge activities at both the district and national levels. At the end of the project, we also observed significant differences in community vibrancy (level of activity, community organizing, and unity), as reported by community residents, between areas where the BRIDGE project had an active presence and ones in which the BRIDGE project was not present. Tisankhenji Radio Program. Evaluation of the Tisankhenji Radio Program revealed that students in the treatment, compared to control, schools were significantly more likely to have: greater career aspirations; higher self-efficacy to engage in meaningful discussions with their teachers and parents about topics relating to their future careers; and more discussions about their career plans with their friends, teachers, and parents. Positive outcomes were observed for both boys and girls in the treatment schools, even though the program specifically targeted girls. Qualitative studies done with girl participants revealed that they were cognizant of the barriers they would encounter in their pursuit of career goals, but had higher self-efficacy to overcome these barriers, indicating that their efficacy beliefs were based on a careful appraisal of existing hurdles. Diffusion of the Hope Kit. The social network analysis comprised a study of a community in Njolomole in Ntcheu district to understand how information about the Hope Kit was disseminated within the community and to determine whether the diffusion of information resulted in positive outcomes. Results indicated that participation in Hope Kit activities was associated with higher community efficacy, more favorable gender norms, and self-efficacy to use condoms. The analysis also found; however, that non-participants who interacted with Hope Kit participants did not gain much knowledge despite their social ties. Gains obtained by participating in the Hope Kit appears not to have been disseminated to non-participants. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 B

12 Agogo Training. Assessments of the Agogo (grandmothers) training showed that grandmothers could be used as effective conduits of influence to impart information about HIV prevention behaviors and sexuality to young girls. The trained Agogo counseled not only girls in their own family but also others in the larger community, and both the Agogo themselves as well as the girls they counseled evaluated the program very highly. The Agogo also focused on removing cultural practices that put young girls at greater risk to HIV & AIDS. Nditha! Sports. Participants in Nditha! Sports reported having undergone positive changes in their attitudes, beliefs, and behaviors with regard to sexuality. They also demonstrated keen interest in continuing their education. After the program, participating youth were found to be more knowledgeable about issues pertaining to HIV & AIDS, especially with regard to preventing HIV infection, than when the project was first introduced. Girls Leadership Congress. Participating girls reported having acquired critical thinking skills as a results of the program. This, in turn, helped them solve problems on their own, thereby increasing self-efficacy to deal with the challenges of facing negative gender norms. Girls also reported that their social network had been greatly expanded after their participation in the program. Conclusion These assessments revealed that significant strides have been made during the six years that the BRIDGE project operated in Malawi. Important improvements were observed in behavioral predictors, behaviorial intentions, and some of the behaviors themselves that protect Malawians from HIV & AIDS. Improvements have also been seen in stigmatizing attitudes toward people living with HIV or AIDS. The next phase of the BRIDGE project thus needs to ensure that these improvements are sustained and that significant strides are made in changing the larger societal, structural, and normative factors that continue to put Malawians at risk. Several recommendations are made in this report to achieve these larger goals. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June 2009 C

13 PART A: Contextual and Theoretical Background Promoting HIV Prevention Behaviors in Malawi through the BRIDGE project June

14 Contextual and Theoretical Background Malawi Background Sub-Saharan Africa represents only 10 percent of the world s population, but it is home to 60 percent of all people living with HIV & AIDS (UNAIDS/WHO, 2008). Malawi is a country in this region that has been hit particularly hard by the epidemic. Approximately 68,000 deaths were attributable to this pandemic in 2007 (UNAIDS, WHO, 2008) and AIDS prevalence is currently estimated at 11.9 percent among adults, which has changed little since 2004 (Chipeta et al., 2005). Among the age group, prevalence is estimated at 14.2% (Government of Malawi, 2005). Prevalence of HIV infection in the southern region of the country is 17.6 percent. As of 2005, life expectancy for women was 42 years and for men 41 years (UNAIDS/UNICEF/WHO, 2006). The number of orphans who have lost either parent to AIDS rose almost three-fold in the previous six years: from 201,000 in 2001 to 560,000 in 2007 (UNAIDS/UNICEF/WHO, 2008). Approximately 840,000 adults are currently living with HIV, with 100,000 new infections annually. Eighty-eight percent of new infections in Malawi are through heterosexual transmission (Government of Malawi, 2004) and hence the promotion of safer sexual practices continues to remain one of the most effective long-term strategies in reducing HIV& AIDS in the region. Longterm strategies are also needed to promote and maintain the adoption of safer behaviors that protect Malawians from HIV infection. This entails bringing about changes not only at the individual level, but also at the socio-cultural level through the promotion of open dialog and supportive norms. Recently, behavior-change interventions have become integral to the national strategy to combat AIDS in Malawi. A number of efforts are currently underway to address the growing problem, including provision of antiretroviral treatments and the promotion of HIV testing and counseling. While these efforts are critical to contain the mortality, morbidity and human resource costs (McCoy, McPake, & Mwapasa, 2008) associated with AIDS and other sexually-transmitted diseases (Mwapasa et al., 2006), programs are also needed to promote the prevention of new infections through appropriate changes in behaviors. It is only recently that comprehensive and behavior theory-based programs to prevent AIDS transmission have been undertaken in Malawi, one of which is the program described in this paper the BRIDGE project, begun in 2003 by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, in partnership with Save the Children (US) and funded by the United States Agency for International Development. Theoretical Background In the health behavior literature, the role of risk perception in behavioral modification is considered to be important, but empirical findings are inconsistent (Weinstein & Nicolich, 1993), with some studies showing a positive relationship (Weinstein et al., 1990), others showing a negative relationship (Weinstein et al., 1986), and still others showing no relationship (Svenson et al., 1985). In Africa, HIV prevention efforts have focused on perceptions of risk as one of the central motivators of behavior change (Kaler, 2004; Watkins & Smith, 2005). Reflecting the broader literature in other health domains, findings on the role of HIV-related risk perception and behavior change have also been mixed; some studies show a positive association between risk perception and HIV prevention behaviors (Lindan et al., 1991), whereas others do not (Moyo et al., 2004). Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

15 The risk perception attitude (RPA) framework (Rimal & Real, 2003) posits that efficacy beliefs moderate the effect of risk perceptions on self-protective motivation and behavior. According to the RPA framework, perceptions about the risk to a disease are usually not sufficient to motivate people to take preventive action. Rather, when high risk perceptions are coupled with strong efficacy beliefs, people are motivated and able to engage in self-protective behaviors. As articulated in a number of theories of health behavior change, including the extended parallel process model (Witte, 1992), the RPA framework conceptualizes perceived risk as a motivator of change. This motivation, however, needs to be facilitated by a belief that something can be done to avert the threat; individuals need to feel efficacious in their ability to change if they are to change at all (Bandura, 1986). Central propositions of the RPA framework have been supported by findings from the Malawi BRIDGE project, using both the baseline data (Rimal et al., 2009) and the midterm evaluation data (Rimal et al., in press). These findings point to the central role of self-efficacy in promoting health behavior change. Self-efficacy, people s confidence in their ability to bring about change in their daily lives, is key in initiating change, maintaining a course of action despite challenges along the way, and adapting behaviors in the face of successes and failures. Self-Efficacy (Nditha!) as the Primary Focus Apart from constituting one of the most reliable predictors of behavior change, self-efficacy also affects choices people make: those with higher levels of efficacy take on challenging tasks to further enhance their abilities, whereas those with lower levels of efficacy take on tasks that they know they can achieve without expending much effort (Bandura, 1986). Similarly, higher levels of efficacy also affect the construal processes of individuals and how they interpret successes and failures. Those with higher levels of efficacy tend to construe failures as consequences of inadequate effort, whereas those with lower levels of efficacy construe similar (negative) outcomes as further evidence of their inability to bring about change. Given the central role of self-efficacy in promoting behavior change, the BRIDGE project incorporated this concept as a central intervention strategy early in the conceptualization and implementation of the program. Indeed, findings from the formative evaluation conducted at baseline showed clearly that efficacy beliefs among Malawians were very weak (Rimal et al., 2004). Many citizens felt overwhelmed by a number of factors, including the lack of control in their lives, the extent to which poverty intruded into their ability to make healthy decisions, and their inability to engage in open discussion about sex and sexuality. Strengthening people s perceptions of control and efficacy was thus critical. The BRIDGE project promoted the realization of proximal goals as a central objective, focusing on small do-able steps that contextualized the distal objective (remaining healthy and protecting oneself from HIV infection) in terms of a series of smaller steps. The mass media campaign, which was the central platform for all BRIDGE interventions, adopted Nditha! ( I can in Chichewa) as its primary slogan and campaign tag line in Enhancing selfefficacy also became the primary objective of the many smaller interventions that were implemented throughout the life of the project. It is for this reason that this research report focuses primarily on the evaluation of self-efficacy as the outcome of interest. We also present behavioral outcomes observed at the end of the project and the impact that efficacy enhancement had on these outcomes. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

16 Part B: BRIDGE Program Activities and Evaluation Components Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

17 BRIDGE Program Activities and Evaluation Components The BRIDGE project used both mass media and interpersonal channels to promote its primary messages for the prevention of HIV infection through behavior change. A comprehensive description of the various program components is included in the companion report, Malawi BRIDGE End-of-Project Report In this report, we briefly describe only the programs that were targeted for all eight BRIDGE districts and those that were deemed to be broad enough in scope that their effects would be discernible through a household level survey or through targeted evaluations. Programs and activities included in this report are the Nditha! campaign, Tisankhenji Radio Program, the Hope Kit, the Radio Diaries, Nditha! Sports, Agogo Training 1, and Girls Leadership Congress. The Nditha! campaign was a multi-media effort that combined nationwide radio and targeted billboards, posters, and community outreach to underscore the message that Malawians can prevent the spread of HIV & AIDS. The goal of the first phase of the campaign was to reinforce feelings of confidence and self-efficacy among Malawians in their ability to prevent HIV & AIDS. (Nditha! means I can do it! in Chichewa.) For the second phase, research conducted by BRIDGE showed that men perceive their HIV risk to be lower, are more likely to have multiple partners, typically have more control in relationships, and are highly susceptible to social norms that place them at a higher risk of exposure to HIV. As a result, the second phase of the Nditha! campaign focused specifically on men, building their efficacy to protect themselves, their partners, and families. For the third phase, findings from the mid-term survey (2006) indicated that self-efficacy among Malawians had risen sufficiently, thus it was possible to begin addressing risk perception issues. The third phase of Nditha! therefore concentrated on increasing risk perception and targeted pregnant women, men and young women with specific messages to help them assess their risk factors, more accurately perceive their personal risk to HIV exposure, and develop action plans to minimize the risks. The Tisankhenji Radio Program The Tisankhenji The Choice is Mine Radio Program (TRP) targeted pre-adolescent girls (especially those between 10 and 14) with the aim of instilling self-confidence and self-esteem, as well as promoting resilience as they make critical decisions about their health and future. The program promoted and reinforced the Nditha! campaign messages, bringing into focus the small doable actions that young girls can take to prevent HIV. Each program ran for 30 minutes and consisted of two 15-minute drama and discussion segments. The drama storyline centered around a character named Alinafe, a young but spirited girl determined to overcome life s challenges and achieve her future aspirations. The discussion segment called Tikhoza ( We Can ) featured prerecorded interactive discussions and real life stories shared by young girls. 1 The Agogo intervention was implemented in only one district, but given its innovative approach and potential for impact, it was also assessed. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

18 Three Tisankhenji seasons of 13 episodes each were broadcast on two prominent national radio stations. The messages presented in the program were complemented and reinforced through interactive activities of more than 40 school-based Tisankhenji Listeners Clubs that BRDIGE established across its eight project districts. The Listeners Clubs provided an environment for girls to listen and share their reflections on the issues dealt with in that week s episode. The Listener s Clubs proved so popular that boys subsequently started attending as well. In addition, parents also began listening to the program and used the weekly episodes as a starting point for communicating with their children about their health and future. The Hope Kit The Hope Kit 2 is a package of interactive and participatory tools to guide individuals and community groups to develop personal and appropriate HIV prevention strategies. The Hope Kit assisted CBOs to conduct local outreach and mobilization by providing a package of ready to use discussions, activities and demonstrations that model prevention behaviors, challenge myths and assumptions about HIV transmission, and provide an opportunity for frank discussion to address stigma and discrimination. The Hope Kit promoted open discussion about sexual behavior and issues related to HIV & AIDS, utilizing an interactive and fun approach that actively engages people. Activities included The Bridges, which helps people concretely understand how the A,B and C options can be applied to their own lives; the Future Island, which enables people to set goals and ensure HIV does not prevent them from reaching these goals; and the Positive Living Cards, which allows people to confront stigma. These and other activities provided participants with skills enabling them to make informed, positive health choices to protect themselves from HIV infection. Supplementary updates were produced for the Hope Kit to match the Nditha! campaign themes, In Phase II, BRIDGE built upon the Hope Kit and produced the Bambo Wachitsanzo Hope Kit Update, encouraging men to participate in HIV prevention. In the final phase, BRIDGE developed the Have a Healthy Baby PMTCT Hope Kit Update Supplement, highlighting actions women and couples can take to prevent passing HIV on to their unborn child. The Radio Diaries The Radio Diaries concept is an innovative and practical way of addressing the issues of marginalization that many people living with HIV & AIDS face. Radio Diaries helped people deal with the low perception of the severity of HIV & AIDS and overcome some of the stigma that prevents them from getting an HIV test, or discussing HIV prevention with their partners. The Radio Diaries featured a variety of voices of men and women, from different socioeconomic strata, religions and age groups. The Diarists were people who knew their status and were willing and able to talk about their situations honestly, openly, and with clarity and genuine emotion. Each week, they focused on one issue or key event in their lives. Over time, the diarists covered different topics 2 Modeled after The Fleet of Hope, which was originally developed in Tanzania in 1992 by Father Bernard Joinet, a clinical psychologist at the Dar es Salaam University Medical School. Peter Labouchere and Bernard Joinet, in collaboration with CCP, adapted this curriculum for Malawi, called Journey of Hope. Produced with technical assistance from the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP) with funding from the United States Agency for International Development (USAID). Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

19 of everyday life: relationships with partners, family, friends and the community at large; medical issues and perceptions of response from health care providers (prejudice, support, etc); work and leisure activities; diminished capacity; emotional stress; and coming to terms with the realities of a terminal condition. The Radio Dairies were broadcast on eight stations throughout the country, either on its own or as part of an existing HIV & AIDS related program. Each station featured one male and female diarist. The diversity of radio stations, including government, commercial, and religious, enabled the program to reach a broad cross section of the population. Nditha! Sports In 2006, BRIDGE piloted Nditha! Sports in the Mzimba district. Based on the overwhelming positive results, BRIDGE scaled up the activity to the remaining seven districts. Nditha! Sports integrated HIV prevention themes into constructive recreational activities, including sports and traditional games for youth. The Nditha! Sports package encouraged positive mentoring of young adults by the community, built youth leadership skills through encouraging decision making, and empowered and validated youth involvement in community activities. In addition, it encouraged young adults to set goals and place value on their lives, building their sense of self-esteem and self-worth. Nditha! Sports was implemented at school and community settings through active collaboration with local government departments, NGOs, FBOs, school authorities, and youth clubs. Beyond the training aspect, BRIDGE also provided sports materials and activity guides for the Nditha! Sports program. Girls Congress BRIDGE developed the idea of youth and girls congresses with the goal of building youth skills in HIV prevention and implementing behavior change activities, in addition to sharing best practices to strengthen self-efficacy and leadership skills among Malawian youth. Held at the national level, the first Youth Congress in 2004 brought together Malawians aged throughout Malawi. Following the success of the National Youth Congress, BRIDGE and partners implemented a series of Regional Girls Congresses in all three regions of Malawi followed by Congresses in all eight districts. The Girls Congresses were designed to specifically address the unique social, cultural, and biological challenges faced by Malawian young women and girls that render them particularly vulnerable to HIV. Agogo Agogos (Grandmothers) Workshops equipped older women with HIV & AIDS knowledge and behavior change skills to enable them to effectively discuss HIV & AIDS issues with their children, grandchildren and young family members. Agogos are traditional counselors and youth mentors; BRIDGE found that many of their teachings were putting young girls at increased risk of HIV infection and so trained them to continue carrying out their important role by passing on advice that would instead help, instead of hinder, young people avoid HIV. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

20 Part C: End-of-Project Household Survey Evaluation Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

21 End-of-Project Household Survey Evaluation Research Background In January, 2004, the BRIDGE project conducted assessments in the eight BRIDGE districts (Balaka, Chikwawa, Kasungu, Mangochi, Mulanje, Mzimba, Ntcheu, and Salima) in order to obtain baseline measures on key indicators of behaviors as well as behavioral predictors. In 2006, a midterm evaluation was conducted through a household-level survey in four districts (Kasungu, Mulanje, Mzimba, and Salima), using identical procedures as were used at baseline. In 2007, another midterm survey was conducted in the same four districts, following the same procedures as the first midterm survey. Data collection for this end-of-project survey was initiated in October, Most of the data were collected by December, 2008, with a smaller subsample collected in January, All eight BRIDGE districts were covered at the end-of-project survey. Sampling This end-of-project household survey design followed the same pattern adopted at baseline, conducting the evaluation in all eight BRIDGE districts. Sampling procedures were kept as similar as possible, with one significant change: Whereas at baseline we randomly selected households within each district, at end-of-project, we first identified different parts of each district according to the level of BRIDGE activity that had occurred, and categorized them as either high-exposure areas or low-exposure areas. Within each district, the level of BRIDGE activity thus constituted the primary stratification variable. Within each exposure area, households were randomly selected in proportion to the size of the area. Thus, the sampling procedure involved the following steps: Within each of the eight BRIDGE districts, we first identified traditional authorities (TAs) 3 where BRIDGE activities had occurred. Within each TA where BRIDGE activities had occurred, we further identified villages in which the activities were concentrated. These villages were designated high-exposure areas. Across high-exposure villages, we randomly selected households in proportion to the population size of villages. Within each district, we then selected villages as distal from the high-exposure areas as possible, with the same urban/rural characteristic, and designated them as low-exposure areas. Across low-exposure villages, we randomly selected households in proportion to the population size of villages. From each selected household, we chose one respondent for inclusion in the study. Respondents within households were chosen through a stratified random selection process, with age and gender constituting the stratification variables. We sought to gather data from equal numbers of males and females and one-third of the sample was to constitute youth (15 to 24) and two-thirds adults (25 and older). 3 In Malawi, TAs constitute clusters of villages and each district has multiple TAs. Thus, administratively, the various levels relevant to our research activities are: Country District TA Village Household Respondent Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

22 Procedures Training. Data were collected by interviewers from J&F Consult, a consultancy firm based in Blantyre. All research staff members, including interviewers, supervisors, and team leaders (total = 32), underwent a week-long training held in mid-october, 2008 at the Gymkhana Club in Zomba. The training focused on survey methods, interview techniques, and human subjects issues. This venue was also used to pilot test the survey instrument. Translation. Because many of the questions (approximately 90%) used in the survey had been previously used (at baseline, first midterm, and second midterm), extensive pretesting was not required. However, the new questions used in this survey were translated into Chichewa and Chitumbuka from the original English version by staff from J&F Consult. The translated questions were back-translated and compared with the original English version. Discrepancies were resolved through discussion. Pilot Testing. The translated survey instrument was pilot tested in the Msamala TA in Balaka District, a distance of km from the training venue. Each research assistant, including the supervisors, conducted two interviews for a total of 64 interviews. Feedback obtained from the pilot survey was used to make modifications in the survey instrument, focusing mostly on clarity, length, and ease of administration. This process resulted in deleting some questions, adding others, and clarifying the directions. The survey instrument was finalized at the end of the training session. Data Collection. Data collection was done by teams of four interviewers and one supervisor per team. All interviews were conducted in the local language (either Chichewa in 7 districts or Chitumbuka in Mzimba). Each day supervisors checked the accuracy of each questionnaire and held one-on-one discussions with interviewers who had problems, and then convened meetings every evenings with all interviewers to share common experiences and questionnaire administration problems. Data Entry. Data entry was done on a rolling basis, as the questionnaires were being completed and transported to the J&F Consult office. Double entry was done with all the data and discrepancies were resolved by consulting the raw data. Sample Characteristics The eight BRIDGE districts represented in this survey, together with key statistics pertaining to each district, are shown in Table 1. As shown in Table 1, all districts were equally represented in the survey, each one contributing approximately one-eighth of total respondents. Approximately half the respondents in each district were women and one-third were youth. Kusungu had the most number of TAs (11) and Chikwawa the least (2). The average age of respondents within each district ranged from 28.7 years (Mangochi and Mzimba) to 31.9 years (Ntcheu). Across the sample, the average age of respondents was 30 years (SD = 11.1). Table 2 shows the description of the sample along key demographic indicators. There were significant differences between males and females in the sample. There were relatively more older men in the sample than there were older women. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

23 Table 1. Key Characteristics of Districts Included in the Household Survey District Sample size Traditional Authorities (TAs) in Survey % Female % Youth (15-24 years) Age: Mean (standard deviation, SD) Balaka (14.1) Chikwawa (10.0) Kasungu (9.6) Mangochi (9.4) Mulanje (9.6) Mzimba (9.1) Ntcheu (12.8) Salima (12.2) Total 3, (11.1) Men were also better educated than women: approximately 16% of the sample were men with at least a secondary-level education, whereas the corresponding figure among women was 11%. The number of women in the sample without any formal education was twice as large as men without any formal education. The sample comprised relatively more single men than single women. There were twice as many male heads of household in this sample than there were women heads of household. In terms of religion, differences between men and women were not significant: Approximately 77% of the sample were Christian and 23% were Muslim, equally distributed between men and women. Assessing Overall Exposure Exposure was assessed in four ways exposure to BRIDGE programs, exposure to district-level non-bridge organizations programs, exposure to national organizations programs, and cued recall of non-bridge programs. Exposure to BRIDGE Programs Exposure to the BRIDGE project s messages was assessed by asking respondents a number of questions about whether they remembered hearing about, reading, seeing, or coming across particular BRIDGE activities and messages in various locations. Specifically, exposure was assessed in terms of the following nine items: 1. Recognition of the campaign slogan 2. Seeing campaign messages on posters 3. Interpersonal discussion about the campaign 4. Seeing or hearing about the Bambo Wachitsanzo certificate 5. Seeing the Hope Kit 6. Hearing about the Youth Alert Mix radio program 7. Hearing the Tisankhenji radio program 8. Hearing the Radio Diaries program, and 9. Participation in any of the Nditha! Sports activities Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

24 For each of the nine items, participants were awarded one point if they were exposed and zero points if they were not exposed. These points were then added to create an overall index (α =.72) of exposure, which ranged from 0 to 9 points. Table 2. Key Demographics of Sample Variable Males Females Chi-Square, p n = 1926 n = 1917 Age 18 years 7.2% 8.6% years years years years years , p <.001 Education None Primary Secondary > Secondary , p <.001 Marital status Single Married Other , p <.001 Head of household , p <.001 Religion Christian Muslim Other , p >.05 Note: Percentages are expressed as a proportion of entire sample Table 3 illustrates the extent to which various groups of people were exposed to BRIDGE programs. Overall, across the 9 channels, the average exposure was 3.98 (SD = 2.12). In other words, it appears that the average person was exposed to approximately 4 out of a total of 9 channels. As might be expected, the exposure in the areas designated as low exposure was lower (M = 3.62 channels, SD = 2.00) than exposure in areas designated as high exposure (M = 4.34, SD = 2.17), and this difference was significant F (1, 3842) = , p <.001. This finding points to two conclusions. First, it appears that, even in areas designated as low exposure, there was a significant amount of exposure to BRIDGE program and activities. This likely reflects both diffusion of the program to areas where BRIDGE was not working directly in the community and the fact that national media (particularly radio) were used to disseminate campaign messages, which increased exposure to the campaign in parts of each district that were not reached by other means. Second, the significant difference in exposure between the low and high-exposure areas indicates that our selection and designation of these two areas were appropriate. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

25 Table 3. Exposure to BRIDGE Program Activities by Demographics Variable Mean SD F-statistic, p District areas Low exposure areas High exposure areas F (1, 3842) = , p <.001 Age 18 years years years years years years F(5, 3837) = 21.78, p <.001 Education None Primary Secondary > Secondary F(3, 3839) = , p <.001 Marital status Single Married Other F (2, 3840) = 43.43, p <.001 Head of household No Yes F (1, 3841) = 1.16, p >.05 Religion Christian Muslim Other F (2, 3802) = 40.85, p <.001 Total Note: Cell entries refer to the number of channels (range = 0 to 9) through which exposure occurred Table 3 also shows that exposure to BRIDGE was highest among the younger respondents and lowest among the older respondents. This may be because a vast majority of programming targeted youth and because the younger generation tends to be more mobile, more educated, and therefore more likely to be exposed to various programming efforts. Among the various age groups, levels of exposure were recorded highest among 19 to 24 year-old youth. Lowest exposure occurred among respondents 55 years and older. There was also a strong correlation between education and exposure. Those with the highest level of education, for example, were exposed to BRIDGE programs at almost twice the rate as those without any formal education. Single people were more likely to be exposed to BRIDGE programs, as compared to married people. This likely reflects the effects of youth seen earlier. Head of household status was not associated with exposure, but religion was. Christian respondents were significantly more likely to be exposed to BRIDGE programs, compared to Muslims. Figure 1 shows exposure to BRIDGE programs across the eight districts. Rates of exposure were significantly different, F (7, 3835) = 41.93, p <.001, with highest level of exposure occurring in Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

26 Kasungu (average of about 5 channels), and lowest level of exposure occurring in Chikwawa (average of 3.39 channels). This likely reflects the differential level of programming that took place in each district. Figure 1. Exposure to BRIDGE Program Activities across the Eight Districts No. of Channels for Exposure Balaka Chikwawa Kasungu Mangochi Mulanje Mzimba Ntcheu Salima District Exposure to District-Level Non-BRIDGE Programs Because the BRIDGE program was not operating in an intervention vacuum, we deemed it necessary to assess individuals exposure to other programs being run in their districts. In order to do so, we first generated a list of organizations known to be working in the area of HIV & AIDS in each district. In order to do so, we consulted our district coordinators, partner organizations, the Ministry of Health, the National AIDS Commission, and colleagues in the field. We then asked respondents in each district whether they had heard about the organization s work or activities. Only the names of organizations working in the particular district was read aloud to the respondents; in other words, the name of an organization known to be working in districts other than where the survey was being held was not read to the respondent. Exposure to National-Level Non-BRIDGE Programs We also asked each participant questions about national organizations known to be operating throughout the country. This included Population Services International, National AIDS Commission, and the Red Cross. Table 4 shows the extent to which people recognized messages emanating from each of the national organizations. Table 4. Exposure to National Organizations across all Districts Organization % Exposure Population Services International 33.5 National AIDS Commission (NAC) 50.3 The Red Cross 58.1 Note: Percent exposure reflects percent of people who recognized the name of the organization. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

27 Exposure to Non-BRIDGE Programs through Cued Recall We showed respondents pictures of posters, booklets, billboards, and other communication materials produced by the national organizations and nongovernmental organizations and asked if they recognized the pictures. Organizations whose communication materials were included in the list, together with the number of pictures produced by each organization are shown in Table 5. Table 5. List of Producers of Communication Materials Shown to Respondents # Pictures Organization 2 Malawi Network of AIDS Service Organizations (MANASO) & National AIDS Commission (NAC) 2 Malawi government, NAC, MANASO 5 Population Services International (PSI) 2 PSI, Faith Communities Programme 3 PSI, Youth Alert, NAC 4 Banja La Mtsogolo (BLM) 1 Salama Chield, Chancellor College; NAC 4 Ministry of Health 1 NAC 3 Society for Women and AIDS in Malawi (SWAM); PACT 3 Malawi Interfaith AIDS Association Note: If the communication material was produced by more than one organization, it is listed separately than if it were produced by only a single organization. Across the 30 pictures shown to respondents, the average number of pictures recognized was 5.80 (SD = 4.99). In other words, approximately 6 out of 30 pictures was recognized by an average respondent. Assigning Exposure Scores Given these various measures of exposure, respondents were assigned exposure scores in four different ways. First, as noted earlier, a score ranging from 0 to 9 was assigned on the basis of the total number of BRIDGE-related activities that the respondent was exposed to. This score was converted to a percentage score. For example, someone who was exposed to five BRIDGE activities received a score of 5/9 = 0.56 = 56%. Second, for district-level organizations not related to BRIDGE, we calculated the average number of organizations that the respondent could recall as a proportion of the total number of organizations in the district whose activities were assessed in this survey. For example, a respondent who recognized three of the five organizations in Balaka district received a score of 3/5 = 0.6 = 60%, and a respondent who recognized thee of the six organizations listed in Mzimba received a score of 0.5 = 50%. Third, respondents were also assigned a percent score for the total number (maximum = 3) of national-level organizations they recognized. For example, recognizing one organization was assigned a score of 1/3 = 0.33 = 33%. Finally, respondents were assigned a score ranging from 0 (no recognition of any picture) to 30 (recognition of all 30 pictures) as a measure of cued recall of exposure. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

28 Table 6 shows the correlations across the four measures of exposure. Three of the four indicators (without the cued recall) were correlated moderately among themselves. For example, the correlation between exposure to BRIDGE activities and exposure to non-bridge district-level activities was r =.45 (p <.001). This signifies that individuals who were exposed to one type of activity were also more likely to be exposed to another type of activity. Conversely, individuals not exposed to HIV messages from one organization also tended to remain unexposed to messages from other organizations. This is particularly true for the correlation between the two non-bridge activities, where the correlation was stronger, at r =.58 (p <.001). It should also be noted that the measure of cued recall had the lowest correlations with the other measures at r =.22 to r =.24 (p <.001), even thought the correlation was statistically significant, likely reflecting the large sample size. It also had a relatively low marginal score about 6 out of 30 pictures were recalled, on the average. This signifies that using the cued recall measure also taps into measures other than just exposure to the information, including, for example, ability to recall. Table 6. Correlations across the Three Measures of Exposure BRIDGE Non-BRIDGE, activities district-level activities Non-BRIDGE, national-level activities Cued recall of pictures BRIDGE activities (p <.001).47 (p <.001).24 (p <.001) Non-BRIDGE, district-level (p <.001).24 (p <.001) activities Non-BRIDGE national-level (p <.001) activities Cued recall of pictures from national programs 1.0 Exposure across Population Groups Table 7 shows how the four different measures of exposure varied across population groups and districts. Exposure to BRIDGE activities was highest among boys and lowest among women. District-level and national-level exposure to non-bridge activities was highest among boys and men, and lowest among women. A similar pattern was found for cued recall of pictures. Overall, there was a significant gender effect for exposure: on the whole, male respondents tended to be exposed to BRIDGE and non-bridge activities more than female respondents. Exposure patterns shown in Table 8 also reveal the fair amount of variation in exposure across districts. Exposure to BRIDGE activities were highest in Kasungu and Mzimba and lowest in Chikwawa and Mangochi. Exposure to non-bridge district-level activities was highest in Balaka and Salima and lowest in Mangochi and Chikwawa. Exposure to national-level programs (non- BRIDGE) was highest in Mzimba and Kasungu and lowest in Mangochi and Mulanje. Finally, cued recall was highest in Mzimba and lowest in Chikwawa. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

29 Table 7. Percent Exposure to BRIDGE and Other Programs n BRIDGE activities Non-BRIDGE, district-level activities Age-Gender groups Boys (15-24) Girls (15-24) Men (25+) Women (25+) F-tests across the four groups Districts Balaka Chikwawa Kasungu Mangochi Mulanje Mzimba Ntcheu Salima F-tests across the eight districts N = F = 89.1, p < F = 41.9, p < F = 40.5, p < F = 64.2, p <.001 Non-BRIDGE, national-level activities F = 77.6, p < F = 33.2, p <.001 Cued recall of pictures from national programs F = 10.5, p < F = 55.9, p <.001 Overall, it appears that Kasungu and Mzimba were exposed to a great many activities. At the other extreme, Chikwawa and Mangochi were exposed to relatively fewer number of activities. It is worth noting that in both those districts, the turnover of district staff may have had an impact on the intensity of activities, although it is difficult to know if there were other determinants as well. Effects on Key Outcomes The following sections describe associations between exposure to the BRIDGE project and key outcomes of interest. In these sections, all data come from the end-of-project household survey (N = 3,843) conducted in all eight districts. Knowledge about HIV & AIDS Knowledge about HIV & AIDS was measured by asking questions that pertained to myths about HIV, modes of transmission, role of condoms in HIV prevention and transmission, and mother-tochild transmission. Eleven questions 4 were asked in a true/false format, and each correct response was scored as one point; incorrect answers and don t know responses were assigned zero points. An overall percentage score was calculated for each respondent (range = 0 to 100), which reflected the total number of correct answers. 4 The survey also asked a few other questions pertaining to HIV & AIDS that were not asked during the other data waves. For maintaining comparability across surveys, those additional questions are not included in this report. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

30 Correct responses to individual knowledge items are shown in Table 8. As shown in the table, close to 95% of respondents correctly perceived that healthy looking persons could be HIV positive and that HIV transmission can occur through breast milk. The first item shown in Table 8 that HIV & AIDS are the same thing was answered correctly by only 27%, but it is likely that this item suffered from a lack of clarity. Only 42% were able to correctly identify that it is possible to get HIV if one has sex with only one partner. This may reflect participants lack of awareness that merely being faithful to one s partner may not protect them if their partner is unfaithful. Close to 40% of people still believed that mosquitoes can transmit AIDS. Most of the other questions, however, were answered correctly by the majority of respondents. Knowledge about HIV across the eight districts is shown in Figure 2. There was a great deal of variance across the districts F (7, 3835) = 6.60, p <.001. Mulanje had the highest level of knowledge and Salima the lowest. Table 8. Individual Items Comprising the Knowledge Scale, with Percent Correct Responses Knowledge item % Correct response HIV & AIDS are the same thing A person can get AIDS from mosquito bites A person can get AIDS from sharing dishes and food with people infected with the HIV 83.2 virus. It is possible for a healthy looking person to have the virus that causes AIDS If a person abstains from sex entirely he or she can be protected from the AIDS virus You cannot get HIV if you have sex with only one person People can protect themselves from the HIV virus even if they have multiple partners by 84.1 using condoms every time they have sex. The probability of a person getting AIDS depends mostly on the choices he or she makes 88.5 in life. Some traditional healers have the power to cure AIDS A pregnant woman can transmit the AIDS virus to her unborn child A woman can transmit the AIDS virus to her child through her breast milk Total Correct Responses 77.6 Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

31 Figure 2. Knowledge about HIV & AIDS across the Eight Districts Balaka Chikwawa Kasungu Mangochi Mulanje Mzimba Ntcheu Salima Knowledge about HIV & AIDS was also analyzed through a multivariate hierarchical regression equation. In it, we first controlled for the effects of demographic variables and exposure to non- BRIDGE programs, and subsequently tested the association between exposure to the BRIDGE program and knowledge. Results of the regression equation, together with zero-order Pearson correlations between predictors and knowledge, are shown in Table 9. The table shows that, when the influence of other variables was not taken into account, males tended to have higher knowledge than women, younger respondents were more knowledgeable than older respondents, as were unmarried people, compared to married people. These differences disappeared, however, when the influence of education and exposure were taken into account. Table 9. Predictors of Knowledge about HIV & AIDS from Regression Equations Predictors r a β b Demographics Female -.09*** -.02 Age -.10*** -.01 Married -.06*** -.00 Education.29***.23*** Exposure to non-bridge district-level campaigns.11*** -.06** Exposure to non-bridge national campaigns.20***.10*** Cued recall of pictures from national campaigns.06*** -.03 Exposure to the BRIDGE campaign.22***.11*** a Zero-order Pearson correlation between predictor and knowledge about HIV & AIDS. b Standardized beta from regression equation. *p <.05, **p <.01, ***p <.001. N = Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

32 Education was correlated with knowledge fairly strongly. When its effect was included in the model, however, gender, age, and marital status did not affect knowledge anymore. In other words, gender, age, and marital status were themselves related to education, and their effect on knowledge was due largely to this correlation. The effect of exposure to district-level non-bridge programs was associated with knowledge, but not entirely in the predicted direction. The zero-order correlation was positive and significant (r =.11, p <.001), but with the other variables in the model, its association with knowledge was negative (β = -.06, p <.01). This implies that the other variables in the model were themselves correlated with exposure to non-bridge programs. It could also mean that exposure to non- BRIDGE programs at the district level was happening primarily among those whose knowledge levels were relatively low. Exposure to national-level programs (non-bridge) was also associated with knowledge (β =.10, p <.001), but cued recall of national programs was not associated with knowledge in a multivariate model. After controlling for the effects of all predictors, exposure to the BRIDGE campaign was significantly associated with knowledge (β =.11, p <.005). This indicates that, even accounting for the effects of education and exposure to other campaigns (at both the district level and national level), exposure to the BRIDGE campaign was a significant predictor of knowledge. Knowledge about HIV & AIDS Across the eight districts, there were significant variations in knowledge. Respondents education level was a significant predictor of knowledge about HIV & AIDS. After controlling for the effects of education and exposure to non-bridge programs, those who were exposed to BRIDGE programs were likely to have a significantly higher level of knowledge, compared to those who were not exposed to BRIDGE programs. Community Vibrancy Community vibrancy refers to the activities, organizations, and unifying characteristics of a community that make it ready to take on challenging tasks to tackle the major problems faced by residents. We measured community vibrancy along three components: Community activity. Two questions asked respondents how strongly they agreed that there was a lot more activity in the community now than five years ago in HIV prevention. Responses, coded on 5-point scales, were averaged into an index (α =.87). Community organizing. Three questions asked how strongly respondents agreed that youth clubs, women s clubs, and community organizations were more active now than five years ago. Responses, coded on 5-point scales, were averaged into an index (α =.86). Community unity. Two questions asked how strongly respondents agreed that their community was more prepared and unified in the fight against HIV & AIDS now than five years ago. Responses, coded on 5-point scales, were averaged into an index (α =.93). Table 10 shows how community vibrancy differed from areas where BRIDGE was heavily active versus those where BRIDGE was not active. As shown in the table, in high-activity areas, people also perceived that their community was much more active, as compared to areas where BRIDGE was Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

33 not active. Respondents in high BRIDGE-activity areas (compared to low BRIDGE-activity areas) also believed that there was more community organizing and greater community unity. It thus appears that one of the key outcomes of a high level of BRIDGE activity in a given area was the heightened level of community vibrancy in the area people were more likely to believe that the community was more active, more unified, and more organized. Table 10. Differences in Community Vibrancy in Low- and High-BRIDGE Activity Areas Community Vibrancy Components BRIDGE Activity Area a Statistic Low Mean (SD) High Mean (SD) Community activity to fight HIV & AIDS 3.97 (1.51) 4.33 (1.26) t = 7.93, p <.001 Community organizing 3.56 (1.58) 3.97 (1.41) t = 8.62, p <.001 Community unity to fight HIV & AIDS 4.13 (1.44) 4.46 (1.19) t = 7.69, p <.001 Notes: a Community vibrancy was measured on a 1-5 scale, higher numbers representing greater vibrancy. Figure 3 is another depiction of findings shown in Table 10. The three components of community vibrancy community activity, community organizing, and community unity are significantly higher in the high activity areas (locations where BRIDGE was active) than in the low activity areas. Figure 3. Components of Community Vibrancy in BRIDGE High and Low Activity Areas Level of Vibrancy (1=low, 5=high) Activity Organizing Unity Components of Community Vibrancy Low Activity Areas High Activity Areas Table 11 depicts the predictors of community vibrancy, obtained from regression equations. Each of the three dimensions of community vibrancy community activity, community organizing, and community unity was used as the dependent variable. Predictors were demographic indicators, residing in either high- or low-bridge activity areas, and exposure to BRIDGE and non-bridge campaigns. Level of community activity did not differ by respondent gender, age, or education status. Marital status, however, was a significant predictor: married individuals were more likely to report that their community was highly active. Areas in which BRIDGE was active reported significantly higher levels of overall HIV-prevention activity than areas in which BRIDGE was not active. Exposure to non-bridge campaigns both the district level as well as the national level was significantly Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

34 associated with community activity. Cued recall of national-level campaigns was not associated with community activity. However, exposure to BRIDGE programs was a significant predictor of community activity. A similar pattern of findings is shown in Table 11 for the other two components of community vibrancy: community organizing and community unity. Females and older individuals reported higher levels of community organizing, as did residents of areas where BRIDGE was active. Education, however, was negatively associated with the outcome: less educated individuals believed that there was more organizing in the community where they lived. All exposure indicators were significantly associated with community organizing. After controlling for the other predictors, exposure to BRIDGE activities still remained a significant predictor of community organizing. Perception of greater community unity was associated with being older, being married, and residing in areas where BRIDGE was active. Exposure to district-level and national-level activities was also associated with perception of greater community unity. Exposure to national level activities (as measured by cued recall) was not associated with it. Exposure to BRIDGE activities, however, remained a significant predictor in the model, even after controlling for all the other predictors. Table 11. Effects of Exposure on the three Components of Community Vibrancy from Regression Equations Predictors Components of Community Vibrancy Activity Organizing Unity Demographics Female.01.05**.01 Age.03.05**.05* Education * -.01 Married.06** ** Residing in high-bridge activity area.09***.10***.09*** Exposure to non-bridge district-level campaigns.09***.15***.09** Exposure to non-bridge national campaigns.11***.14***.07** Cued recall of pictures from national campaigns.02.05**.03 Exposure to the BRIDGE campaign.12***.10***.11*** Notes: *p <.05, **p <.01, ***p <.001. Cell entries are standardized betas from regression equations. N = Community Vibrancy Each of the three components of community vibrancy perception of greater community activity, community organizing, and community unity was significantly greater in areas where BRIDGE was active. Exposure to BRIDGE activities was a significant and reliable predictor of community vibrancy, even after controlling for the effects of exposure to other activities at the district and national levels. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

35 Stigma toward People Living with HIV & AIDS In the literature, stigma toward people living with HIV & AIDS has been measured in a number of ways. We assessed stigma along four components: Avoidance. This referred to people s beliefs that people living with HIV or AIDS (PLHA) should be avoided, that teachers who have AIDS should be barred from teaching, that PLHA should be separated and not allowed to visit public places. Five items, each measured on five-point scales, were averaged into an index (α =.93). Overall, level of stigma was fairly low: average of 1.28 (SD =.90) on a 5-point scale. Fear of casual contact. People were asked how fearful they were that they would get HIV if they came in contact with the saliva, sweat, or excreta of a PLHA and if they cared for someone living with HIV. Also included was the fear that their children could get infected by playing with a child living with HIV. Responses, measured on 3-point scales, were averaged into an index (α =.88). Overall, fear of casual contact was fairly low: average of 1.58 (SD =.67) on a 3-point scale. Blame. The extent to which people blamed PLHA for acquiring HIV was measured through five questions that asked how much they agreed with the statements that HIV & AIDS was a punishment from God, that women prostitutes are responsible for the spread of HIV, that PLHA are promiscuous, that PLHA have too much power in society, and that PLHA get too much attention in society. Responses, measured on 5-point scales, were averaged into an index (α =.73). The average score, 3.69 (SD = 1.24), indicates higher scores than the other components of stigma. Shame. Three questions asked the extent to which people would be ashamed if they were to get infected, how ashamed they would be if someone in their family got infected, and the extent to which PLHA should be ashamed of themselves. Responses, measured on 5-point scales, were averaged into an index (α =.92). The averages score, 1.96 (SD = 1.54), was fairly low. In order to determine the extent to which exposure to BRIDGE activities was associated with stigma, we ran a series of regression equations that controlled for the effects of demographic variables and then tested the association between exposure and each stigma component. Results are shown in Table 12. Table 12. Effects of Exposure on the four Components of Stigma from Regression Equations Predictors Components of Stigma a Avoidance Fear of Blame Shame casual contact Demographics Female.02.06***.05**.00 Age *** Education -.10*** -.18*** -.15*** -.08*** Married Social proximity to HIV b -.05** -.10** -.15*** -.08*** Residing in high-bridge activity area * Exposure to non-bridge district-level campaigns.04*.06**.09***.03 Exposure to non-bridge national campaigns *** Cued recall of pictures from national campaigns **.01.03* Exposure to the BRIDGE campaign -.14*** -.15*** *** Notes: *p <.05, **p <.01, ***p <.001. Cell entries are standardized betas from regression equations. a Stigma components measured such that higher values represented higher levels of stigma. b Social proximity to HIV: defined as having a close friend, family member, or co-worker who is HIV positive. N = Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

36 Table 12 shows that the avoidance component of stigma was significantly associated with education: well-educated individuals were less likely to hold the belief that PLHA should be avoided. Social proximity to HIV (knowing someone or having a close friend, family member, or coworker who is HIV positive) was also associated with stigma in that those who were in closer social proximity to HIV were less likely to believe that PLHA should be avoided. There was a small but positive association between avoidance and exposure to district level non-bridge activities. The largest correlation, however, was that between exposure to the BRIDGE campaign and stigma: those who were exposed to BRIDGE were significantly less likely to hold the belief that PLHA should be avoided. A similar pattern of findings is shown for the fear of casual contact component of stigma. Greater perceptions of stigma were associated with female respondents and those who were less educated. Social proximity was also significantly associated with fear of casual contact, such that those with greater social proximity had lower stigma. Exposure to district-level non-bridge activities was positively and exposure to national-level non-bridge activities (as seen with both indicators) was negatively associated with fear of casual contact. Controlling for all predictors, exposure to the BRIDGE campaign was negatively associated with fear of casual contact, such that those who were exposed were less likely to be fearful about contacting HIV through casual contact. The tendency to blame PLHA for HIV was positively associated with being female, lower levels of formal education, and weaker social proximity with HIV. Exposure to district-level non-bridge campaigns was positively associated with blame, whereas none of the other measures of exposure including exposure to BRIDGE was associated with the tendency to blame PLHA. The fourth component of stigma pertained to the belief that PLHA should feel ashamed. Tendency to harbor this feeling was greater among younger individuals and among those with lower levels of education. Social proximity to HIV was negatively associated with blame, meaning that those who personally knew people living with HIV were less likely to believe that PLHA should be ashamed. Residing in high-activity BRIDGE areas was negatively associated with shame (i.e., had less stigma) and cued recall of national campaigns was positively associated with the belief that PLHA should be ashamed. It is difficult to tell what exactly accounts for this finding, but it does point to the fact that stigma is a tricky subject matter and we need a better understanding about how best to reduce it and how to promote prevention messages without inadvertently increasing stigmatizing attitudes. Controlling for all predictors, exposure to BRIDGE was associated with less of a belief that PLHA should be ashamed. Stigma toward People Living with HIV & AIDS Overall stigma perceptions were observed to be low in the population for three (avoidance, fear of casual contact, and shame) of the four components. For the component of blame, stigma was somewhat higher. Social proximity to HIV (e.g., knowing someone or having a direct contact with someone living with HIV) and formal education were consistently positive with regard to stigma they were both negatively associated with stigma. Controlling for demographics and exposure to other programs, exposure to BRIDGE was a significant predictor of lower levels of stigma for three of the four components. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

37 Perceptions of Risk to HIV & AIDS Perceptions of personal risk were measured by asking respondents how likely they thought it was for them to become infected with HIV in the next six months, next year, and in their lifetimes. Responses are shown in Figure 4 for boys (15-24 years old), girls (15-24 years old), men (25+ years old), and women (25+ years old). Overall, there were significant differences across the four groups for each of the three measures of risk: six-month risk, χ 2 = 28.0, p <.001; one-year χ 2 = 31.3, p <.001; and three-year χ 2 = 20.9, p <.001. Overall, boys were least likely to believe that they were at risk and women were most likely to believe that they were at risk. Furthermore, while perceived risk for all four groups generally increased over an extended period of time (i.e., risk over the next six months was lower than the risk over one s lifetime), this increase was significantly higher for women than for any of the other three groups. This signifies that women were much more fearful about acquiring HIV infection in the future than the other three groups, likely because they experience less control. Risk perceptions were not associated with any of the exposure measures (data not shown). Thus, while risk perceptions varied across the four groups (boys, girls, men, and women), they were not associated with exposure to any of the campaigns. The BRIDGE project focused on risk perception only toward the end, which may could explain the lack of significant association. Alternatively, it could mean that campaign-induced behavioral changes may lead to the perception that, because one is engaging in healthy behaviors, vulnerability to HIV & AIDS is no longer an important issue. Given that our data were cross-sectional in nature, we are not able to determine whether this latter explanation is empirically supported. Figure 4. Percent Respondents Who Perceived Their Risk to be "Somewhat" or "Very Likely" Somewhat or Very Likely (% Response) Months Next year Lifetime Perceived Risk of Getting HIV/AIDS Boys Girls Men Women Risk Perceptions Women perceived the greatest level of personal vulnerability to HIV & AIDS, but risk perception was not associated with any of the measures of exposure (to BRIDGE or other campaigns. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

38 Self-Efficacy Self-efficacy is the belief that one has the ability to enact specific changes in one s life. We measured self-efficacy along four components (each measured on 5-point scales, with higher values signifying greater levels of efficacy): Efficacy to remain faithful. This was measured by asking people how strongly they agreed or disagreed that they could remain faithful to their partner. Efficacy to remain abstinent. This was measured by asking people how strongly they agreed or disagreed that, if they were not in a committed relationship, they could remain abstinent. Efficacy to use condoms. Four questions were asked about people s confidence in initiating discussion around condom use, talking about condom use with partner, using a condom during every sexual encounter, and negotiating condom use with sexual partner. Responses were averaged into an index (α =.85). Efficacy to talk openly about HIV & AIDS. This was measured through three questions that asked people s confidence to talk openly about HIV & AIDS with parents, residents of the village and younger family members. Responses were averaged into an index (α =.78). Responses to the self-efficacy items provided by boys, girls, men, and women are shown in Figure 5. Across the four groups, there was considerable variation in efficacy: faithfulness, F(3, 3834) = 2.75, p <.05; abstinence, F(3, 3832) = 4.91, p <.01; condom use, F(3, 3834) = 8.70, p <.001; and ability to talk openly about HIV & AIDS, F(3, 3834) = 7.47, p <.001. It should be noted that self-efficacy across all four measures was quite high, nearing a ceiling of 5 on a 5-point scale. Efficacy to remain faithful to one s partner was lowest among girls and highest among men. Efficacy to remain abstinent if not in a relationship, however, was the highest for women with comparable levels among the other three groups. Efficacy to use condoms was highest among boys and lowest among women. Efficacy to talk openly about HIV & AIDS was higher among the male groups (boys and men) as compared to the female groups (girls and women). Table 13 shows the multivariate predictors of the four measures of self-efficacy, tested through regression equations. Older and married individuals had higher efficacy to remain faithful. Residing in a high-bridge activity area did not automatically translate into higher efficacy. Exposure to district-level non-bridge campaigns was negatively associated with efficacy to remain faithful, although the correlation was small (β =.04), reaching significance only because of the large sample size. Exposure to the BRIDGE campaign, however, was significantly associated with self-efficacy to remain faithful. It was, in fact, the strongest predictor in the model. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

39 Figure 5. Self-efficacy across the Four Groups 5 Strength of efficacy (5-point scale) Boys Girls Men Women 4 Faithfulness Abstinence Condom use Talk openly about HIV/AIDS Self-efficacy Domain (5-point scale; 1=low, 5=high) Efficacy to remain abstinent if not in a relationship was higher among females, older, and better educated individuals. Residing in high-activity areas and exposure to non-bridge campaigns were not associated with efficacy to remain abstinent. The cued recall measure was negatively associated with efficacy. Exposure to the BRIDGE campaign was the strongest predictor of efficacy to remain abstinent if not in a relationship. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

40 Table 13. Predictors of Self-Efficacy through Multiple Regression Equations Predictors Domains of Self-efficacy Faithfulness Abstinence Condom use Talk openly about HIV & AIDS Demographics Female ** ** Age.04*.04* -.06**.04 Education * Married.04* *.03 Residing in high-bridge activity area Exposure to non-bridge district-level campaigns -.04* Exposure to non-bridge national campaigns * Cued recall of pictures from national campaigns ** Exposure to the BRIDGE campaign.08***.11***.10***.14*** Notes: *p <.05, **p <.01, ***p <.001. Cell entries are standardized betas from regression equations. N = Efficacy to use condoms was not associated with gender, but it was higher among younger people and among unmarried people. The only other predictor of efficacy to use condoms was exposure to the BRIDGE campaign. The last column in Table 13 shows the predictors of efficacy to talk openly about HIV & AIDS. Males had higher efficacy than females and exposure to non-bridge national campaigns was negatively associated with efficacy. The strongest predictor of efficacy to talk openly about HIV & AIDS was exposure to BRIDGE campaign. Self-efficacy Across the four domains of self-efficacy faithfulness, abstinence, condom use, and open discussion about HIV & AIDS most individuals scored high. After controlling for demographic differences and exposure to non-bridge campaigns, the strongest and consistent predictor of efficacy, across all four domains, was exposure to the BRIDGE campaign. Behavioral Intentions Respondents intentions to enact safer behaviors were assessed along four topics, each one measured on a 5-point scale such that higher numbers reflected stronger intentions. Intention to remain faithful. Respondents were asked how strongly they intended to have sex with only the person with whom they were in a relationship, and not have sex with anyone else. Intention to be abstinent. Unmarried respondents were asked how strongly they intended to remain abstinent when not in a relationship. Intention to use condoms. Three questions asked about respondents intentions to use condoms: to use one during the next sexual encounter, insist that one be worn even if sexual Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

41 partner does not want to, and talk about condom use with partner. Responses were averaged into an index (α =.85). Intention to talk about HIV prevention. Three questions asked about respondents intentions to talk with family members about their risk to HIV, talk with partner about protecting the family from HIV, and talk with family about making plans for protecting the family from HIV. Responses were averaged into an index (α =.73). Behavioral intentions of boys, girls, men, and women across the four topics are shown in Figure 6. Behavioral Intentions across the Four Groups. Across the four groups, there were significant differences in intentions to remain faithful to one s partner, F (3, 3839) = 3.35, p <.05. Boys had the highest intention and women had the lowest intention. Intention to remain abstinent was asked of unmarried respondents only. Across the four groups, the difference in intentions was not significant. Intention to use condoms, however, differed significantly across the four groups, F (3, 3839) = 31.4, p <.001, with higher intentions among the younger generation (boys and girls) in comparison to the older generation. Intention to talk openly about HIV prevention varied significantly across the four groups F(3, 3839) = 3.60, p <.05, with men showing higher intentions, compared to the other groups. It should be noted, however, that intentions were already quite high across the four groups, almost reaching the maximum value of 5. Table 14 shows the results from regression equations that modeled the multivariate predictors of behavioral intentions. The table shows that males, younger individuals, and married individuals had higher intentions to remain faithful. The strongest predictor of intention to remain faithful was efficacy to remain faithful. Exposure to non-bridge national campaign was negatively associated with behavioral intentions, and exposure to BRIDGE was significantly associated with behavioral intentions. Thus, even after controlling for the powerful effect of efficacy to remain faithful, exposure to BRIDGE programs remained a significant predictor in the model. Figure 6. Behavioral Intentions across the Four Groups 5 Behavioural Intention (5-point scale) Faithfulness Abstinence Condom use Talk openly about HIV/AIDS Behavioral Intention Topics (5-point scale; 1=low, 5=high) Boys Girls Men Women Intention to remain abstinent if not in a relationship was a characteristic of younger and married individuals (in comparison to older and unmarried individuals). Self-efficacy to remain abstinent was the strongest predictor of intention to do so. While exposure to other campaigns was not associated with intention to remain abstinent, exposure to BRIDGE programs was a significant predictor. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

42 Intentions to use a condom was characteristic of younger people with lower levels of education. Self-efficacy to use a condom was a strong predictor of intention to use a condom. Exposure to district-level non-bridge programs was positively and national-level campaign was negatively associated with intention to use a condom. Exposure to BRIDGE programs was a significant predictor of intention to use a condom. Table 14. Predictors of Behavioral Intentions through Multiple Regression Equations Predictors Domains of Behavioral Intentions Faithfulness Abstinence Condom use Talk about protection from HIV & AIDS Demographics Female -.05** Age -.11*** -.06* -.13*** -.01 Education *.00 Married.07***.05* *** Residing in high-bridge activity area * Self-efficacy corresponding to the behavioral domain a.17***.33***.54***.22*** Exposure to non-bridge district-level campaigns ** -.03 Exposure to non-bridge national campaigns -.08*** ***.01 Cued recall of pictures from national campaigns Exposure to the BRIDGE campaign.05*.07*.04**.10*** Notes: *p <.05, **p <.01, ***p <.001. Cell entries are standardized betas from regression equations. a Self-efficacy to be faithful, to remain abstinent, to use condoms, and to talk about HIV & AIDS, respectively, for each of the four outcomes. N = Among demographic indicators, only marital status was significantly associated with intention to talk about protection from HIV & AIDS. Married individuals had stronger intentions in comparison to unmarried individuals, and residing in high-activity BRIDGE areas was negatively associated with intention to talk. Self-efficacy was the strongest predictor, followed by exposure to BRIDGE programs. None of the other exposure measures was associated with intention to talk. Behavioral Intentions Across all four measures of behavioral intentions, self-efficacy was the strongest predictor. Exposure to BRIDGE programs was significantly associated with all four measures of intentions, even after controlling for the effects of self-efficacy. Given that exposure to BRIDGE program was also associated with self-efficacy, it appears that exposure to the BRIDGE program had a dual effect on intention both directly and indirectly through self-efficacy. Given that behavioral intention is a key predictor of behavior change (Ajzen & Fishbein, 1980), this finding indicates achievement of behavioral impact. HIV Testing We asked respondents whether they had been tested for HIV, and if so, whether the test was done in the preceding 12 months. As shown in Figure 7, there was considerable variation across the eight districts in testing uptake (χ = 175.6, p <.001). For example, Mzimba had the highest testing uptake Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

43 in the prior 12 months, followed by Salima and Mangochi. The lowest testing uptake in the prior 12 months was in Ntcheu, where the uptake was only36%. In Balaka, Kasungu, Mzimba, and Salima, the proportion of people who had been tested in the prior 12 months was higher than the proportion of people who had not been tested. In Chidwawa and Ntcheu, there were more people who had not been tested, as opposed to those who had. Overall, approximately 47% of the sample had been tested in the last 12 months. Together with another 8% who had been tested prior to the last 12 month, overall testing rate in the sample was 55%. A regression equation assessed the effects of exposure on HIV testing. The dependent variable was constructed as a 3-level scale in which those who had not been tested were assigned a score of 0, those who had been tested but not in the last 12 months were assigned a score of 1, and those who had been tested in the prior 12 months were assigned a score of 2. Hence, this variable constitutes an HIV-testing scale in which higher values represent the positive behavior having been tested in the past 12 months and lower values represent less desirable behaviors -- not having tested in the prior 12 months and not having tested at all. Results of the regression are shown in Table 15. Figure 7. HIV Testing Across the Eight Districts 70 Percent Balaka Chikwawa Kasungu Mangochi Mulanje Mzimba Ntcheu Salima District Not tested Prior testing Last year testing Table 15. Predictors of HIV Testing through Multiple Regression Equations HIV Testing History a Predictors r b β c Demographics Female.11***.17*** Age -.04* -.05* Education.12***.07*** Married.11***.15*** Residing in high-bridge activity area Exposure to non-bridge district-level campaigns.13***.02 Exposure to non-bridge national campaigns.15***.08*** Cued recall of pictures from national campaigns.11***.06*** Exposure to the BRIDGE campaign.17***.14*** Notes: *p <.05, **p <.01, ***p <.001. a Dependent variable is prior testing (higher scores represent testing in the last 12 months). b Zero-order Pearson correlation between testing history and predictor variable. c Standardized betas from regression equations. N = Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

44 The table shows both the zero-order correlation (between predictors and testing history) as well as the standardized betas from regression equations. HIV testing was greater among female respondents, younger respondents, better educated respondents, and married respondents. Residing in the high-activity BRIDGE areas was not associated with testing. Exposure to districtlevel non-bridge campaigns was associated with HIV testing in the zero-order correlation but not in the multivariate model. This signifies that there was overlap in the effect of exposure to districtlevel non-bridge campaigns with other campaigns, in terms of their effects on HIV testing. Exposure to non-bridge national campaigns was associated with HIV testing according to both measures of exposure (uncued and cued recall). It is likely that some of these inconsistencies can be avoided through better harmonization of efforts among the various organizations working to promote HIV testing. Exposure to BRIDGE messages was one of the strongest predictors of HIV testing uptake. HIV Testing Considerable variation existed across the eight districts in HIV testing rates, with Mzimba having the highest and Ntcheu the lowest testing rates. Characteristics of those who had been tested were: younger, more educated, married, and female. Exposure to the BRIDGE campaign was a significant and strong predictor of HIV testing uptake. Overall, approximately 55% of respondents had been tested, 47% in the prior 12 months. Sexual Behaviors & Condom Use Of the 3,843 individuals included in the survey, 3,466 respondents (90.2%) provided data on their sexual activity. Of the respondents who provided data, 89% reported having either no sexual partners or only one sexual partner in the prior 12 months. This left 382 individuals who reported having had more than one sexual partner in the prior 12 months. The distribution of these 382 respondents is shown in Figure 8. The four groups differed significantly in the percent of individuals who reported having more than one sexual partner in the prior 12 months (χ 2 = 277.1, p <.001). In particular boys (29%) were significantly more likely to have more than one partner, followed by men (14%), girls (7%), and women (3%). When asked about condom use, of the 3241 people who answered this question, 2176 (67.1%) reported never using a condom and only 264 (8.1%) reported using a condom every time they had sex. Figure 8 also shows the distribution of those who reported using a condom consistently, every time they had sex. Boys (24%), girls (9%), men (5%), and women (4%) differed significantly in consistent condom use (χ = 190.7, p <.001). For both behaviors, more boys engaged in sex with more than one partner, but also more boys reported using condoms consistently. There was not, however, a one-to-one match between having multiple partners and using condoms consistently for boys. It also appears that men s behaviors were quite risky: a significantly smaller proportion of them reported using condoms consistently than reported having more than 1 sexual partner. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

45 These two sexual behaviors having multiple sexual partners and consistently using condoms were further analyzed through multiple regression equations. Because the overall sample size for these equations was significantly smaller, a smaller number of predictors were used in the regression equations, as shown in Table 16. In particular, predictors that were not significantly associated with the dependent variables were taken out. In the equations that predicted multiple sexual partners, consistent condom use was used as a control variable, and vice versa. Figure 8. Percent with More than One Sexual Partner in 12 Months and Consistent Condom Use (Note: In calculating percentages, sample size for the two measures are different; n = 382 for number of sexual partners and n = 264 for condom use) Percent Boys Girls Men Women % >1 sexual partner % Condom use The table shows that males were significantly more likely to have multiple sexual partners than females, as were younger people, compared to older people. Unmarried individuals were more likely to have multiple partners. There was a positive correlation between condom use and having multiple partners, perhaps reflecting the fact that people engaging in sex with more partners were becoming more cognizant of their vulnerability and therefore using protection. Exposure to districtlevel non-bridge was associated with having fewer sexual partnerships. Exposure to the BRIDGE program was also associated with having fewer sexual partnerships. Hence, after controlling for multiple predictors and controlling for exposure to non-bridge activities at the district level, exposure to BRIDGE activities appears to have had a positive effect on having fewer multiple sexual partners. Also shown in the table are predictors of consistent condom use. Males and younger respondents were marginally more likely to report consistent condom use. Education was positively associated with consistent condom use. Single individuals were significantly more likely to use condoms consistently, as compared to married individuals. Having multiple sexual partnerships was positively associated with condom use: those who had multiple sexual partners were significantly more likely to report using a condom consistently. Exposure to non-bridge activities at the district level was positively associated with consistent condom use. Finally, exposure to BRIDGE activities was positively associated with consistent condom use. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

46 Table 16. Predictors of Multiple Sexual Partners and Consistent Condom Use Predictors a Sexual Behavior Multiple sexual partners b Consistent condom use c Demographics Female -.25*** -.03^ Age -.12*** -.03^ Education --.05** Married -.11*** -.27*** Consistent condom use.09*** -- Multiple sexual partners --.09*** Exposure to non-bridge district-level campaigns -.04*.07** Exposure to the BRIDGE campaign -.04*.05** Notes: *p <.05, **p <.01, ***p <.001. a Only variables that correlated significantly with the dependent variable were used in the analyses. b Higher scores represent having more than 1 sexual partner in the past 12 months. c Higher scores represent consistently using condoms. N = Sexual Behaviors and Condom Use Boys were significantly more likely to report having multiple sexual partners, but consistently using a condom, in comparison to girls, men, and women. Overall, unmarried individuals were more likely to have multiple sexual partners and use condoms consistently, compared to married individuals. Controlling for the effects of demographic predictors and exposure to non-bridge activities, exposure to BRIDGE activities was significantly associated with positive outcomes reduction in multiple partnerships and consistent condom use. Because of the small sample size associated with these behaviors, however, these findings have to be taken with caution. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

47 Part D: Household Survey Trends from Baseline to End-of- Project Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

48 Household Survey Trend s from Baseline to End-of-Project Overall Study Design This section presents overall trends in key variables across the eight districts where the BRIDGE project was implemented. Data were gathered at baseline (2004), first midterm (2006), second midterm (2007), and end of project (2008). For the most part, variables reported in this section were measured identically across the four data waves. Wording of some questions was modified in subsequent waves on the basis of feedback obtained from participants in prior waves; differences are noted where applicable. At baseline and at the end-of-project, all eight BRIDGE districts were surveyed. During the two midterm surveys, only four of the eight districts Kasungu, Mulanje, Mzimba, and Salima were surveyed, as shown in Table 17. The decision to limit the midterm evaluations to these four districts was made on the basis of maximizing the evaluation output with limited resources. The four districts were judged to be fairly representative of all eight districts where BRIDGE activities were taking place. Baseline data were collected before the BRIDGE intervention began. After baseline, all the subsequent data waves included a high-activity area and a low-activity area, which corresponded to the level of BRIDGE involvement in the area, respectively. High-activity areas represented locations in which BRIDGE programs were active; low-activity areas represent locations in which BRIDGE programs were not run. The mass media programs, of course, were available in the low-activity areas as well, but the community outreach and other community-based activities were not undertaken in the low-activity areas. Table 17. Timing of Overall Research Activities and Sample Size during each Period Baseline (2004) Midterm 1 (2006) Midterm 2 (2007) End-of-Project (2008) Balaka n Chikwawa n Kasungu n Mangochi n Mulanje n Mzimba n Ntcheu n Salima n Total N ,843 This study design comprised a series of cross-sectional data waves, with participants selected at random during each wave. Across all the data waves, sampling procedures and survey methods were kept as similar as possible in order to make them comparable with each other. One significant difference in the study design at baseline, as compared to subsequent waves, was that, at subsequent waves, sampling was stratified according to high-activity areas and low-activity areas. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

49 Variables of Interest We report on key variables that the BRIDGE program targeted for change, which also comprised variables that the literature suggests are critical for behavior change to occur. These include knowledge about HIV, risk perception, efficacy beliefs, stigma, behavioral intentions, HIV testing, gender attitudes, and community-level factors. (General note: Because the description of variables, including their measurement, has been provided elsewhere in this report, they are not repeated here. Please see section beginning Page 17 for description of each variable.) Knowledge about HIV & AIDS Figure 9 shows HIV &AIDS knowledge across the four data waves, controlling for respondent age, gender, and education. Differences across the four time points were significant, F(3, 6517) = 27.02, p <.001. After baseline, there was a considerable jump in knowledge, and this higher level was sustained until the end of the project. Figure 9. Trend in Knowledge about HIV & AIDS (Controlling for age, gender, and education) % Knowledge Score Baseline Midterm 1 Midterm 2 End-of-Project Tests of individual contrasts revealed that knowledge at each of the subsequent data waves was significantly greater than that at baseline (p <.001), differences between the first and second midterms was not significant, but the difference between the second midterm and end-of-project was significantly different (p <.05). In other words, the slight drop during the second midterm was made up significantly at end-of-project. Overall, increases in knowledge were observed from baseline to end of project, with knowledge scores increasing from about 72% to 76%. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

50 Self-efficacy for HIV Prevention Behaviors Three self-efficacy questions were asked during each of the four data waves: efficacy to be faithful to one s partner, efficacy to remain abstinent if not in a relationship, and efficacy to use condoms when having sex. Figure 10 shows the trends in self-efficacy for HIV-prevention behaviors from baseline to end-of project for three domains: efficacy to remain faithful to one s partner, efficacy to be abstinent if not in a relationship, and efficacy to use a condom during sex, controlling for the effects of age, gender, and education. Efficacy was measured on a 5-point scale, where higher values represented greater efficacy (minimum = 1, maximum = 5). Figure 10. Trends in HIV Prevention Efficacy (Controlling for age, gender, and education) Efficacy score (5-point scale) Faithfulness Abstinence Condom use Talk to partner Self-Efficacy Domains Reduce partners Baseline Midterm 1 Midterm 2 End-of-Project Efficacy to remain faithful. From baseline onwards, there was a significant increase in self-efficacy to remain faithful to one s partner. The increase in value from baseline to the first midterm was statistically significant (p <.001), as was the drop from the second midterm to end-of-project (p <.001). Despite the drop, the efficacy at end-of-project was significantly higher (p <.01) than that at the first midterm or at baseline. It should also be noted that levels of efficacy to remain faithful to one s partner were almost at the maximum value during the second midterm (4.9 out of 5), which would have made it virtually impossible to rise any further. Efficacy to be abstinent. There was a significant increase in efficacy to be abstinent (if not in a meaningful relationship) from baseline to the first midterm (p <.001) and a significant drop from the first to the second midterm (p <.001), as shown in Figure 10. The increase in efficacy to be abstinent from the second midterm to the end-of-project was significant (p <.001). Furthermore, the level of efficacy at end-of-project was also significantly greater than the level of efficacy at the first midterm (p <.001). In other words, the drop in efficacy during the second midterm appears to have been temporary; the trend increasing efficacy that began at baseline appears to have followed through until end-of-project (despite the dip during the second midterm). Further analysis revealed that the measurement error associated with this variable was greatest at second midterm, as evidenced by the magnitude of the standard error (.04,.03,.06, and.01 for baseline, first midterm, Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

51 second midterm, and end-of-project, respectively). Thus, a number of factors may have contributed to the apparent low magnitude of efficacy to remain abstinent during the second midterm. Efficacy to use condoms. From baseline to end-of-project, there was a steady increase in respondents efficacy to use condoms (all p s <.001, except the increase from the second midterm to the end-of-project, for which p <.06). Hence, it appears that there was a significant jump in efficacy to use condoms from baseline to the first midterm, after which the rate of increase was slower, but nevertheless statistically significant. Efficacy to talk to partner about condom use. Following the pattern similar to the other efficacy items, respondents efficacy to talk to their partners about condom use also increased significantly from each data wave to a subsequent one (all p s <.001). Efficacy to talk to partner about condom use was the lowest at baseline and highest at end-of-project. Efficacy to reduce number of sexual partners. Figure 10 shows that the increase in efficacy to reduce number of sexual partners was significant from baseline to the first midterm (p <.001) and from the first to the second midterm (p <.001). Efficacy remained at almost maximum levels (close to 5 on a 5-point scale) at the end-of-project. Overall, it appears that there were significant strides made with self-efficacy across the five domains from baseline to end-of-project. Across all the efficacy measures, there were important gains, such that the value of efficacy at the end of the project was significantly greater than that before the BRIDGE activities were undertaken. This likely reflects the Nditha! ( I can ) focus of the BRIDGE activities. Stigma Three stigma topics asked about in each data wave were people s beliefs that PLHA should be isolated, that PLHA should be avoided, and that HIV-positive teachers should not be allowed to teach in schools. Responses are shown in Figure 11.. The belief that PLHA should be avoided also dropped significantly across each data wave, from baseline to the first midterm (p <.001), to the second midterm (p <.05), to end-of-project (p <.001). Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

52 Figure 11. Indicators of stigma: Percent Respondents Agreeing about Stigmatizing Statements (Controlling for age, gender, and education) % Agreeing Isolate PLHA Avoid PLHA Ban HIV+ teachers Stigma Topics Baseline Midterm 1 Midterm 2 End-of-Project The belief that HIV-positive teachers should not be allowed to teach in schools was held by approximately 30% of the respondents at baseline, which dropped to 11% at the first midterm (p <.001), remained unchanged from the second to the third midterm (p <.05), and then dropped again at end-of-project. Across all three topics, there was a significant drop, from baseline to end-of-project, in percent of people who held stigmatizing beliefs toward PLHAs. For example, approximately 26% of respondents at baseline believed that PLHA should be isolated from others, whereas this had dropped down to 7% at the first midterm (p <.001). The slight increase in proportion of people holding this belief increased from the second to the third midterm, but the increase was not statistically significant (p >.05). There was as significant drop from the second midterm to end-ofproject (p <.01). Overall, there were considerable reductions in stigmatizing beliefs from baseline to end-of project for all three stigma topics. This reflects the efforts of programs like the Radio Diaries that focused explicitly on stigma reduction through the broadcasting of real life stories as told by PLHAs. Risk Perception Respondents were asked whether they believed they were likely to get HIV in the next six months and in the next year. Responses are shown in Figure 12. Controlling for the effects of age, gender, and education, the proportion of respondents who believed they could get HIV infection in the next six months increased from 16% at baseline to 40% at the first midterm (p <.001). The increase in 6-month risk from the first to the second midterm was not significant (p >.05), but the increase from the second midterm to end-of-project was significant (p <.05). A similar pattern was observed for the 1-year risk perception measure. There was a significant increase in risk perception from baseline to the first midterm (p <.001), from the first to the second midterm (p <.05), and from the second midterm to end-of-project (p <.001). Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

53 Figure 12. Percent Believing They Can Get HIV in 6 months or Year (Controlling for age, gender, and education) 60 % Agreeing Baseline Midterm 1 Midterm 2 End-of-Project 0 Next 6 months Next year Perceived Risk: Likelihood of Getting HIV Overall, both measures of risk perception indicated that people s perceived vulnerability to HIV infection increased across the life of the BRIDGE campaign. Behavioral Intentions Intentions to enact HIV-prevention behaviors to remain faithful in a relationship, be abstinent if not in a relationship, and use condoms during sex across the four data waves are shown in Figure 13. Controlling for the effects of age, gender, and education, there was a significant upward trend in behavioral intentions from baseline to end-of-project. For intentions to remain faithful, the increase in intentions from baseline to the first midterm was significant (p <.05), the increase from the first to the second midterm was significant (p <.05), after which the intention remained at the high level, without increasing further. Figure 13. Behavioral Intentions. Percent Expressing Intention to Carry Out the Behavior. (Controlling for age, gender, and education) Percent Expressing Intention Faithful Abstinence Condom use Baseline Midterm 1 Midterm 2 End-of-Project Behavioral Intentions Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

54 Intention to remain abstinent increased significantly from baseline to the first midterm (p <.001), remained unchanged at the second midterm, and then dropped during end-of-project (p <.001). The final level of abstinence, however, was significantly higher than that at baseline (p <.001). It should be noted that efficacy to remain abstinent during the second midterm was relatively low, which may explain why, subsequently, the intention to remain abstinent may have dropped. During the two midterms, intention to remain abstinent was already quite high (approximately 95%), and hence the dip may reflect the difficulty of retaining this high level of intention. Intention to use condoms, however, was significantly higher at each subsequent data wave, as compared to the previous one from baseline to the first midterm (p <.05), to the second midterm (p <.05), to end-of-project (p <.001). Overall, intentions to enact healthy sexual behaviors increased significantly from baseline to end-of-project. While intention to remain abstinent was somewhat diminished from the second midterm to end-of-project, it nevertheless remained much higher at end-of-project, as compared to baseline. HIV Testing Figure 14 shows the percent of people who got tested for HIV across the four data waves, controlling for the influence of age, education, and gender. The increase in testing rate was not significant from baseline to the first midterm (p >.05), but it was significantly higher at the second midterm (p <.001) and at end-of-project (p <.001). Figure 14. Percent Tested for HIV (Controlling for age, gender, and education) 60 Percent tested for HIV Baselinie Midterm 1 Midterm 2 End-of-project Overall, HIV testing rates increased significantly from 21% at baseline to 54.2% at end-of-project. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

55 Part E: Findings and Conclusions from the Household Surveys Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

56 Findings & Conclusions from the Household Surveys This report provides abundant evidence that BRIDGE activities were being disseminated extensively in the eight districts where the project operated. Exposure levels were impressively high among survey respondents at the end-of-project survey. On the average, individuals in BRIDGE-areas (where BRIDGE activities were being run) were exposed to approximately four channels (out of a total of nine) through which BRIDGE messages were being communicated. In areas where BRIDGE activities were not being disseminated, the average exposure was 3.6 channels, which represents both word-of-mouth exposure as well as exposure through the mass media. Exposure was particularly high among younger and well-educated individuals, reaching approximately 53% among young boys. Exposure rates were observed highest in Kasungu and lowest in Chikwawa. We also found considerable evidence of exposure to non-bridge activities at both the national level and at the level of individual districts. For example, recognition of two prominent organizations involved in work related to HIV & AIDS, the National AIDS Commission and the Red Cross, was approximately 50% and 58%, respectively. Results of the multivariate analyses presented in this paper took into account exposure to both district-level activities (undertaken by other organizations) as well as exposure to national organizations. Psychosocial Outcomes Knowledge about HIV & AIDS was relatively high (averaging about 78% correct score), but there were some areas in which a more focused intervention on specific knowledge domains is needed. For example, a sizable proportion of the population tended to believe that having sex with only one person would protect them from HIV infection a belief that does not take into account the sexual behavior or the HIV status of the partner. Community vibrancy appears to have been a significant beneficial outcome associated with the BRIDGE project. Residents of communities where BRIDGE was active tended to believe, significantly more than residents of communities where BRIDGE was not active, that their communities were more united, that organizations in their communities were more active, and that there was greater unity in their communities to fight AIDS. Perceived risk to HIV infection showed a great deal of variation across the different population groups. Women in particular perceived their risk to HIV infection to be higher than that perceived by boys, men, or girls (whose perceptions tended to cluster together at lower levels than that of women). It is also clear, however, that risk perception have increased over time. We observed significant increases in risk perception from baseline to end-of-project. People in BRIDGE districts have clearly internalized the notion that their actions can put them at risk to HIV infection, but this process seems to have occurred early in the project. At the end of the project, exposure was not associated with perceived risk. The BRIDGE project also appears to have made considerable strides in reducing stigma toward people living with HIV or AIDS. Significant dips in stigma measured along a number of dimensions such as avoidance, fear of casual contact, blame, and shame were observed, particularly from baseline to the first midterm. The BRIDGE project has pursued this goal from the Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

57 beginning, and the Radio Diaries series comprise one important element in that effort. Indeed, the lower levels of stigma associated with listening to this program has been reported elsewhere (Rimal et al., 2008). Given that the Nditha! branding of the BRIDGE Program was front and center in most activities, it is worthy to note that tremendous gains were made in self-efficacy to enact healthy behaviors. After an initial jump from baseline to the first midterm, efficacy beliefs at the end of the project were extremely high, many reaching close to the maximum value. There were, however, a few dips that occurred along the way (particularly during the second midterm in efficacy to remain abstinent if not in a relationship), but these appear to have been momentary. At the end of the campaign, efficacy levels, across the board were significantly higher than at baseline. Behavioral Outcomes Behavioral intentions to enact healthy behaviors were high at the end of the project, and we observed significant increases from baseline till the end of the project. This included intentions to remain faithful to one s partner, to be abstinent if not in a relationship, and to use condoms. Intention to use condoms were lower among adult men and women, relative to the younger generation, but the intention among younger men was high. This may reflect the youth-oriented efforts undertaken by BRIDGE, or it may also be indicative of the belief held by adult men and women that their sexual behaviors with their longstanding partners do not necessitate the need for condom use. Nevertheless, it appears that understanding the underlying motivations among adult men and women for not using condoms may be a fruitful area for future research and programming. Testing for HIV, a critical behavior in treatment and care, improved significantly from baseline through the two midterms to end-of-project. Rates of improvement were observed in all eight districts. This observation, noted in this report that stigmatizing attitudes toward people living with HIV & AIDS have also been reduced signify a very positive trend. It may well be that these two outcomes feed on each other in a positive way as people s stigma gets reduced, they are more willing to learn about their own HIV status, and vice versa. There is, however, a distinction to be made between ever testing and testing regularly. Many people in our dataset reported prior testing, but not in the past year. People thus need to be informed about the benefits of regular testing. It should also be noted that, despite improvements in testing, a sizable proportion of respondents in our sample had not been tested. The broader literature shows that HIV testing is impacted by a number of structural and psychosocial factors. Individuals living in areas where testing services are inexpensive and readily available (Baiden et al., 2005) and who perceive that test results will be kept confidential (Burchell et al., 2003) are more likely to get tested. Request for testing from partners (Anderson et al., 2000), belief that testing is common among one s peers (Dorr et al., 1999), and perceptions that one s testing status affects other people (Irwin et al., 1996) have all been associated with testing uptake. Future interventions thus need to focus on these factors in order to promote greater testing in Malawi. Among the four population groups (boys, girls, men, and women), boys were most likely to have had more than one sexual partner. This high-risk activity seems to be offset to some extent by the higher rates of condom use among boys. Clearly, information about and the motivation for the need Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

58 to use condoms must continue to be a central part of communication messages targeted to this sexually active group. In our samples we did not observe extensive high-risk sexual behaviors, such as multiple sexual partnerships. At end-of-project, for example, only 382 individuals, out of a total of 3,466 (which is approximately 10% of the sample) reported having had more than one partner. Given this small number, findings from statistical analyses have to be taken with caution. In this remaining small sample, we found that boys and men were disproportionately more likely to have more than one sexual partner in the prior 12 months. Even in this small sample, however, exposure to the BRIDGE project was significantly associated with the tendency not to engage in multiple sexual relationships. It is also interesting to note that the tendency to have multiple partners was not associated with respondents education levels, but the tendency to use condoms consistently was positively associated with education. Thus, while consistent condom use was more prevalent among welleducated individuals, the tendency to have multiple sexual relationships was not a function of the individual s education. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

59 Part F: Quantitative and Qualitative Evaluation of the Tisankhenji Radio Program Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

60 Quantitative and Qualitative Evaluation of the Tisankhenji Radio Program The Tisankhenji Radio Program (TRP) was evaluated in two ways. First, we conducted a quantitative evaluation in order to determine effects of the TRP in the treatment group relative to the control group. Second, working under the assumption that the TRP would have a positive effect, we conducted a qualitative assessment to understand, in an in-depth manner, the nature of the influence. Quantitative Assessment The overall study design was a post-only, treatment-control quasi-experiment in which each treatment school included in the study was matched with a control school within the same district. 5 The treatment schools set aside time for listening to the TRP broadcast and held discussion groups among girls enrolled in the TRP listening clubs. The control schools did neither: time was not set aside for listening to the program and discussion groups were not held. The study was conducted in the Chikwawa, Mzimba, Ntcheu, and Salima, districts. In each study district, a total of six primary schools were sampled, for a total of 24 schools. The intervention and control schools were similar in that they were both full primary schools (had classes 1 to 8), were staffed by qualified teachers employed by the Malawi government, and they both enrolled boys and girls. Study Groups and Sample Sizes A total of 12 treatment and 12 control schools were chosen for this study. Treatment schools were purposely chosen first and a control school was matched on key variables (school size, composition of students, etc.) for each treatment school included in the sample. The number of students from each school who completed the survey ranged from a minimum of 44 to a maximum of 63 students. A total of 696 boys and girls comprised students in the control group. A total of 709 boys and girls comprised students in the treatment group. There were almost equal numbers of boys and girls in treatment and control groups that completed the survey schools. Background Characteristics of Respondents Table 18 presents the background characteristics of students who responded to the survey in both treatment and control schools. There were almost equal numbers of boys and girls who responded to the survey. There was also equal representation from treatment and control schools. There were, however, three important differences between the treatment and control schools. On average, students in the treatment schools were younger than those in the control schools (13 years old versus 14 years old). Students in treatment schools also had a relatively higher socioeconomic status (SES) than students in control schools. For this reason, analyses controlled for the influence of SES on outcomes of interest. The SES score was calculated based on possession of twelve items: cattle, donkey, goats, pigs, poultry, radio, TV set, bicycle, computer, an indoor bathroom, cell phone and a business. An SES score of 0 means that the student s family does not own any of the items. A score of 12, the 5 The quantitative evaluation was compiled by Rachana Sikka, Johns Hopkins University. Data were collected by the consultancy firm of Benjamin Kaneka and George Mandere. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

61 maximum score, means that the student s family owns every single item. On average, girls and boys in treatment schools had SES scores of 5.0 and 5.1, respectively. Girls and boys in control schools had SES scores of 4.8 and 4.6, respectively. On average, students in treatment schools spent fewer days attending religious activities per month (5 days) than students in control schools (5.7 and 6.1 days for girls and boys, respectively). In general, students in both treatment and control schools had an average of two or three older siblings and two younger siblings. About three-quarters of the students in treatment and control schools had fathers who were alive. Over 80 percent of students in both types of schools had mothers who were alive. Table 18. Demographic Characteristics of Participants a Treatment Schools Control Schools p-values from t-test or χ 2 Girls (n = 363) Boys (n = 351) Girls (n = 346) Boys (n = 345) Trmt vs control Boys vs girls Age in years 13.2 (1.72) 13.1 (1.96) 14.3 (1.84) 14.3 (1.8) p <.001 p >.05 Socioeconomic status b 5.1 (2.1) 5.0 (2.1) 4.8 (2.1) 4.6 (2.1) p <.001 p >.05 Number of days attend religious 5.0 (4.3) 5.0 (4.3) 5.7 (5.7) 6.1 (5.9) p <.01 p >.05 activities per month Number of older siblings 2.7 (2.1) 2.7 (2.2) 2.7 (2.1) 2.7 (2.0) p >.05 p >.05 Number of younger siblings 2.1 (1.7) 2.2 (1.7) 2.3 (1.7) 2.3 (1.6) p >.05 p >.05 % Father alive p >.05 p >.05 % Mother alive p >.05 p >.05 a Cell entries are mean and (standard deviation). b Number of items (radio, TV, etc.) owned by the family; range = 0 to 12. Exposure to Tisankhenji We first sought to determine whether students in treatment schools were exposed to the TRP more than students in control schools. Figure 15 shows that more than 50% of girls and boys in treatment schools had ever listened to the Tisankhenji radio program at school, compared to 3.4% of girls and 6.4% of boys in control schools. While there were no significant differences in exposure between boys and girls within treatment or control schools, the differences between treatment and control schools was statistically significant (χ 2 =406.27; p <.001). Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

62 Figure 15. Exposure to the Tisankhenji Program in Treatment and Control Schools 60 Percentage Exposed Girls Boys Treatment Control Another measure of exposure asked students how many times they listened to the TRP in school during a typical month. Almost one-half of boys and girls in treatment schools listened to the radio program at school more than once; only about 4% of girls and 5% of boys in control schools listened to the program more than once at school (t = 23.5, d.f. = 1403, p <.001). Exposure to the Tisankhenji Radio Program (TRP) Exposure to the TRP was significantly higher among students in treatment schools than students in control schools. There were no major differences in exposure to the program between boys and girls in both types of schools. Even though the TRP was broadcast on the radio, thus allowing access to anyone with access to radio, significantly more students (both boys and girls) in the treatment schools reported exposure to the program than students in the control schools. This signifies that the school s participation in the program prompted greater listenership. Effects on Educational Aspiration One of the central objectives of the TRP was to encourage youth to stay in school, despite the many challenges they may face in light of that decision. These challenges may have included financial pressures impinging on the family to bear educational expenses. Two questions on the survey assessed educational aspirations: What is the highest level of education that you would like to achieve? and What is the highest level of education that you think you will be able to achieve? About 96% of girls and 93% of boys in treatment schools reported that they would like to achieve tertiary-level education, compared to 89% of girls and 88% of boys in control schools; these differences were statistically significant (χ 2 = 25.2; p <.001) when we dichotomized the responses into less than tertiary versus tertiary education. Difference between boys and girls within treatment or control condition was not significant. Similarly, about 94% of girls and 88% of boys in treatment schools reported that they would be able to achieve tertiary-level education, compared to 84% of girls and 81% of boys in control schools. The results of the Chi-squared test indicated that the difference between treatment and control schools was significant (χ 2 = 25.2; p <.01). There was no statistical difference between boys Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

63 and girls in both types of schools. Figure 16 shows the percentage of students who said they would seek a tertiary level education (left panel) and those who believed they could achieve tertiary level education (right panel) in their lives. Statistical tests were also conducted through multiple regression equations that controlled for the effects of self-efficacy, gender, socioeconomic status, religiosity, and number of guardians in the home. Results showed that students in the treatment group sought higher level of education (β =.09, p <.01) and believed that they would be able to achieve higher level of education (β =.14, p <.001), compared to students in the control group. Gender differences were not significant in either test. This is a significant finding because the program itself was targeted to young girls. This finding suggests that, in schools were the program was run, there was considerable diffusion of program content from girls to boys. Figure 16. Students Seeking (left panel) and Believing they will Achieve (right) Tertiary Level Education Percentage Seeking Tertiary Level Education Girls Boys Treatment Control Percentage Believing They Will Acquire Teritary Level Education Gi rls Bo ys Treatment Control Educational Aspirations A significantly higher percentage of students in treatment schools reported that they would like to achieve tertiary-level education and they believed they would be able to achieve tertiary-level education, compared to students in control schools. These differences between treatment and control schools remained significant even after controlling for demographic factors, gender and self-efficacy. There were no major differences in educational aspirations between boys and girls in both types of schools. One of the important effects of the TRP was to enhance students aspirations about their own education it appears to have promoted desire to achieve and enhanced efficacy to achieve a higher level of education. Effects on Perceptions of Control in Attaining Educational Goals Five questions assessed students perceptions about how much control they had in attaining their educational goals. Questions asked about their perceptions of control in (a) how much education they were able to achieve, (b) how often they attended school, (c) how often they completed their homework, (d) how well they did in their exams, and (e) how often they studied for their exams. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

64 Responses to each question, recorded in 5-point scales ranging from I have no control to I have total control, were combined into one index by averaging responses across the five items (α =.70). An analysis of covariance model, controlling for socioeconomic status and grade showed a significant difference between the treatment and control schools, F(1,1399) = 9.41, p <.01, and no differences by gender. Students in the treatment group scored significantly higher on perceptions of control to attain their educational objectives (M = 3.80, SE =.02), in comparison to students in the control group (M = 3.90, SE =.02). Thus, consistent with the program goal, it appears that one of the effects of the TRP was to promote greater sense of control among students, in terms of how much education they believed they could achieve. Furthermore, this perception did not differ between boys and girls within the treatment and control schools, suggesting that listening to the program, not the gender that one belonged to, was they key driver of higher perceptions of control. Effects on Intentions to Attain Educational Goals Given the TRP s focus on educational achievement, we also assessed students intentions to attain educational goals. Specifically, we asked students how strongly they agreed or disagreed with the statement I intend to complete my education no matter what. Responses were recorded on a 5- point scale, ranging from strongly disagree (scored as 1) to strongly agree (scored as 5). An analysis of covariance (ANCOVA) model was run with grade, socioeconomic status, and perceptions of control in educational attainment as the covariates; gender and treatment/control status as the independent variables; and intention to attain educational goal as the dependent variable. The ANCOVA model showed no significant main-effects of gender or treatment/control status, but there was a significant gender X treatment/control interaction effect. Findings are shown in Figure 17. Among boys, intentions to attain educational goals in the control schools was slightly higher (M = 4.36, SE =.05) than those in the treatment schools (M = 4.29, SE =.05), but this difference was not statistically significant. Among girls, however, intentions to attain educational goals in the treatment schools (M = 4.41, SE =.05) was significantly higher (p <.05) than in the control schools (M = SE =.05). Furthermore, girls intentions in treatment schools were higher than the intentions of girls in the control schools as well as boys in both the treatment and control schools. This implies that the intervention s primary target audience derived most benefits from exposure to the program and participation in discussion groups. Intentions to Attain Educational Goals Among boys, the TRP intervention did not have a significant impact in changing their intentions to attain their educational goals. Among girls, however, the TRP s effects were to boost their intentions to attain their educational goals. Given that girls were the primary target audience, this shows that the TRP had a significant impact. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

65 Figure 17. Effect of the TRP on Educational Attainment Intentions Intention to complete educational goal (5-point scale) Control Treatment Girls Boys Effects on Communication Efficacy Communication efficacy was assessed by asking students about the ease with which they could talk about day-to-day events, career aspirations, relationships, and HIV prevention with parents, teachers and other family elders. Students were asked how easy or difficult it was for them to talk with their parents and other elders about various topics, including: (a) day-to-day events, (b) career aspirations, (c) relationships, and (d) HIV prevention. Responses, coded on 5-point scales ranging from 1 (very difficult) to 5 (very easy), were subjected to an analysis of covariance, controlling for grade and socioeconomic status. Day-to-day-Events. Analyses showed that the difference in efficacy to talk about day-to-day-events did not vary by gender males and females were about equally efficacious but there were significant differences between the treatment (M = 3.94, SE =.04) and control (M = 3.79, SE =.04) schools, F(1,1399) = 8.57, p <.01. Both male and female students in the treatment schools had higher efficacy scores, in comparison to male and female students in the control schools. Career Aspirations. Male and female students did not differ in their efficacy to talk about career goals and aspirations, but there were significant differences between treatment and control schools. Those in treatment schools had significantly higher efficacy scores (M = 4.03, SE =.03) compared to those in control schools (M = 3.83, SE =.03), F(1,1399) = 19.02, p <.001, after controlling for the effects of grade and socioeconomic status. Relationships. Analyses showed that the difference in efficacy to talk about relationships did not vary by gender males and females were about equally efficacious but there were significant differences between the treatment (M = 2.77, SE =.05) and control (M = 2.51, SE =.05) schools, F(1,1399) = 12.94, p <.001. Both male and female students in the treatment schools had higher efficacy scores, in comparison to male and female students in the control schools. HIV Prevention. Male and female students did not differ in their efficacy to talk about HIV prevention, but there were significant differences between treatment and control schools. Those in Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

66 treatment schools had significantly higher efficacy scores (M = 4.19, SE =.03) compared to those in control schools (M = 4.00, SE =.03), F(1,1399) = 13.49, p <.001, after controlling for the effects of grade and socioeconomic status. Communication Efficacy The TRP had an impact across all four measures of communication efficacy perceived ability to talk to parents, teachers, and other elders about day-to-day-events, career aspirations, relationships, and HIV prevention. Those in the treatment schools had significantly higher efficacy scores than those in the control schools. Boys and girls did not differ in their efficacy scores. Effects on Communication Behaviors Students were asked whether, in the last year, they had talked about events that happen in their school with their parents or guardians. They were also asked whether they had talked about their career aspirations with their parents, teachers, friends, and others. Discussion about School-related Events. An analysis of covariance model (with grade and socioeconomic status as the covariates) showed that there were significant differences between treatment and control schools in students discussion, F(1, 1399) = 4.66, p <.05. Approximately 91% of those in treatment schools talked about school-related events, whereas the corresponding figure among control school students was 88%. Discussion about Career Aspirations. Four questions asked whether students had talked about their careers with parents, teachers, family elders, and others. Responses were added such that scores ranged from 0 (did not talk with anyone) to 4 (talked with all four parties). An analysis of covariance model (with grade and socioeconomic status as the covariates) showed that, while male and female students did not differ in their communication behaviors, there were significant differences between treatment and control schools. Those in treatment schools talked about career aspirations significantly more often (M = 2.73, SE =.05) than those in control schools (M = 2.73, SE =.05), F(1,1399) = 9.04, p <.01. Boys and girls did not differ in the frequency of their discussion. Discussion Behaviors Students in treatment schools engaged in discussion about school-related events and career aspirations with their parents, teachers, and others significantly more often than students in control schools. Hence, the TRP appears to have enhanced efficacy to discuss and stimulated actual discussion between students and parents, teachers, and others in their communities. Conclusions The Tisankhenji radio program specifically targeted young girls (10-14 years old) to teach them communication skills, build life skills, and promote awareness about HIV. Post-intervention results indicated that the program positively affected educational aspirations, perceived control over education and at least two dimensions of communication skills. Although the program targeted girls, it seems to have exerted positive influences on boys as well. Girls in treatment schools reported the highest absolute percentages and mean scores on almost all outcomes, but these were not significantly different from boys in treatment schools. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

67 A significantly higher proportion of girls and boys in treatment schools reported that they would like and would be able to attain tertiary-level education, compared to girls and boys in control schools. Girls and boys in treatment schools also reported higher perceived control over educationrelated issues and greater ease in talking with parents, teachers and family elders about relationships and HIV prevention. These positive outcomes held true even after controlling for differences in demographic characteristics among students in both treatment and control schools. A similar effect was found for communication-related outcomes. The TRP was able to promote greater openness and willingness to talk about day-to-day events, career aspirations, educational goals and HIV prevention between students and their parents, guardians, and other adults in their communities. Indeed, the administration of the TRP in the designated schools appears to reflect the larger goals of the BRIDGE project to promote an environment of openness and dialog around important social and health issues in the community. Because the radio program runs in school environments, it is not surprising that the program seemed particularly effective in promoting positive educational outcomes. Students in treatment schools reported significantly higher career aspirations, greater perceived control over education, and higher intentions to attain their goals compared to students in control schools. In this context, messages about educational attainment, exams and school expenses may have been emphasized. The intervention format in treatment schools, which consists of students listening to the program in groups moderated by school teachers and matrons, may reinforce educational messages. Having these discussions may also enhance communication skills, indicated by the greater ease reported by students in treatment schools in talking with adults about relationships and HIV prevention. Qualitative Assessment The objective of the qualitative assessment was to understand how the influence of the TRP may have occurred among the primary target audience (girls in the treatment schools). In order to gain an in-depth understanding, it was also deemed important to interview parents of participating girls and teachers who administered the program. This section focuses mostly on findings pertaining to participants themselves, supplemented by findings from the interviews conducted with parents and teachers. 6 Interviews with the participants were conducted through focus group discussions. Interviews with teachers (who facilitated the listening group discussions) and interviews with parents/guardians of girls who participated in the TRP were conducted one-on-one. It is important to note that quantitative data results were not consulted prior to reading the qualitative data so as to prevent any influence of the quantitative results on the qualitative data analysis. While the quantitative results were not consulted to augment this analysis, the analysis was conducted with the underlying assumption that the TRP had an effect on its participants. The purpose of this analysis was to understand the mechanism through which the TRP had an effect on its participants. 6 The qualitative evaluation was compiled by Lisa Aslan, Johns Hopkins University. Data were collected by the consultancy firm of Benjamin Kaneka and George Mandere. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

68 Study Methods Focus group discussions were conducted in the twelve schools that used the TRP intervention for 6 th - 8 th grade girls. A total of twelve focus group discussions were held, using all three schools from each of the four districts. The schools and districts included in the study are shown in Table 19. All schools listed in the table are located in the urban areas in their respective districts. Procedures In the treatment schools, interviewers handed out consent forms to girls participating in the TRP and, within that, students who were members of the Tisankhenji Listening Club (TLC). They were asked to have their parents read and sign the forms. All girls who returned signed parental consent forms were eligible to participate in the focus group discussions (FGDs), which were held in treatment school classrooms. Each FGD lasted approximately 90 minutes and comprised 10 participants. The FGD guide was developed by CCP program and research personnel and revised iteratively by taking into consideration the purpose of the study and the context in which the guide was being used. CCP personnel provided a week-long seminar to the facilitators on human subjects training which included role-play exercises. Discussions were tape recorded, transcribed and the translated into English. The data were used to guide further explorations, identify overall themes within the data, and code answers according to these themes. Table 19. Breakdown of Focu Group Discussions (FGD) and Individual Interviews by District Name of Name of school Girls FGD Teacher Parent District Interview Interview Chikwawa Chikwawa Dyeratu Mitole Ntcheu Salima Mzimba Chitungu Ntcheu Roman Catholic Gumbu Kaphatenga Chimweta Makande Kaphuta Davy Mzimba LEA TOTAL Discussion Format and Content Following a discussion of principles guiding the focus groups, all groups opened with a broad question to be answered in a round robin format, What do you think people your age are concerned with the most? What is their biggest source of concern? This round robin was followed Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

69 by questions about education, its importance, future goals, parental support of future goals, and parental support of education. Participants were then asked to listen to a story about a girl named Maria who has many siblings and whose parents struggle to pay their children s school fees. Maria s mother comments that she does not contribute money to the family and Maria is aware that older men have given her friends clothes and money. Maria is stopped by an older man named Banda who offers her money to go out with him. The facilitator used this scenario to discuss Maria s options, why she would or would not consider Banda s offer, what the participants would do in such a situation, what their friends might do and whether or not they feel better equipped to handle such a situation today versus two years ago. This scenario was followed by an exercise called Yes, but where an action was stated and girls were probed for potential barriers to completing the action. For example a statement like, Make sure you stay in school until you finish high school, would be followed by answers by the girls beginning with Yes, but The next segment of the discussion guide asked questions about HIV & AIDS knowledge and risk perception followed by a segment of questions about the advantages and disadvantages of participating in the TLCs. Data Analysis Procedures A preliminary reading of focus group transcripts was conducted with the goal of identifying main categories. With these overarching categories in mind, answers to each question from all transcripts were compiled and read together. Reading the results by question allowed answers to be coded according to consistent themes. An adequate number of categories were determined to appropriately capture the data. Answers were grouped within these categories and re-read to ensure they corresponded to their category and that no new categories needed to be created. This process resulted in final categories which will be discussed further in the Results and Discussion sections. Interview transcripts with parents and teachers were approached slightly differently as they were not the main focus of this evaluation. As parents were a secondary target audience of this intervention, their interviews were primarily read to understand the impact the TRP had on their relationships with their daughters as well as their impressions of the content of the Tisankhenji programs. The interview results of both parents and teachers were used to augment an understanding of the focus group discussions. Results A first read of the FGD transcripts revealed that perceptions of control and self-efficacy were key constructs underlying the influences brought about by the TRP and discussions held in the listening clubs. Thus, respondents answers were classified under an overarching category of self-efficacy, which was further categorized into personal-level efficacy and group-level efficacy. These levels of efficacy existed in the overarching context of poverty, labeled here as structural constraints. These categories arose somewhat spontaneously during a reading of the coded text in which the concept of having a choice was juxtaposed in three responses to one question. The question was related to the scenario described earlier in which a girl, Maria, was offered money to get into a car with an older man, Banda. The scenario ended with Maria declining the older man s offer and the facilitator asked FGD participants if doing so would be a hard decision for their friends. The following three responses were what led to the final reading of the transcript within the context of Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

70 choice and the extent to which participants felt they had the ability to exert choice against structural constraints. Personal Efficacy: That cannot be difficult because choice is up to everybody. One has to decide what to do next. Group and Personal Efficacy: It cannot be difficult for them if they already had a choice. Structural Constraints: It can be difficult if the person doesn t know what she is doing, if she thinks of the poverty of her parents she ends up accepting the man s [offer] hence after seeing thousands of Kwachas, she doesn t have a say. Following this insight, the FGD transcripts were re-read and coded according to these categories. Responses were analyzed according to participants implicit or explicit expression of choice. Responses that illustrated personal agency were placed in the personal efficacy category, those that expressed an absence of any personal agency were placed in the structural constraints category, and responses that expressed agency on the condition of support from friends, parents, teachers or elders were placed in the group efficacy category. Responses tended to overlap, as respondents expressed varied levels of efficacy within their responses. Figure 18 illustrates the way in which self-efficacy and group efficacy were linked with structural constraints. Figure 18. Overlapping Spheres of Efficacy Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

71 Overall, the data illustrated participants acute awareness of the reality of their day-to-day lives. Participants acknowledged that structural constraints pose obstacles to their future as evidenced by their responses to the question, What do you think can get in the way of you achieving your goal? Responses such as early marriage, forced marriages, poverty, and an inability to pay for school fees demonstrated that the many concerns of these young women are governed by an absence of choice over the trajectory of their lives. Despite these responses, all of which fall within the structural constraints category, other data illustrated that while these concerns are very real for these young women, TRP participants did not let these concerns define the trajectory of their lives. In other words, these constraints were not as salient as their ability to overcome them. When asked a follow-up question, What can you do to make sure that this does not happen? solutions to overcoming these societal level obstacles fell into personal and group efficacy. For example, responses included: By making the right choices. I can tell my parents that I have got a right to education We should not love money, we should wait until we finish school and start working Maybe if there is a lack of school fees I can get assistance so that I can cope with the situation Data gathered from these two questions provide a good context within which to view the results of this analysis. While factors beyond their control influence their lives, the girls in this sample felt comfortable and confident in their ability to mitigate the extent to which structural constraints determined their futures through their own actions and behaviors. These findings are best illustrated by participants reactions to a series of questions about an impoverished girl who is approached by an older man and offered money if she agrees to go out with him. This story encapsulates a realistic event that gets to the core of the daily obstacles that the TRP participants face. Participants were asked to compare how their friends would handle a similar situation to how they, as TRP participants, felt equipped to do so. Many of the participants said that such a proposal would not be difficult to refuse if the girl had a vision of what she wanted to achieve. Their ability to handle such a situation by keeping their vision in mind is illustrated in their responses to the question, Would that [getting into the car with the old man] be a hard decision for you? Why? It would be difficult if you lack resources. If you have a problem, there are organizations that can assist us. No, it cannot be difficult if you know your future plans. It would not be a difficult decision for me because I wish to eat with my own money with my family after reaching my goal, not sugar daddies money. These responses demonstrate a sense of self-efficacy in spite of societal level obstacles like poverty. One powerful response that captures both an awareness of the effects of poverty and the necessity for having goals is illustrated below: Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

72 It can be difficult if the person doesn t know what she is doing, if she thinks of the poverty of her parents she ends up accepting the man s [offer] hence after seeing thousands of Kwachas, she doesn t have a say. When asked if they felt better equipped to handle such a situation now versus two years ago, many respondents attributed feeling better equipped to their participation in TRP: Nowadays programs like Tisankhenji have also helped us to handle this kind of situation I believe we can deal with this problem now than years before because there were no groups to help children and discussion among youth unlike today. This attribution of change as a result of the TRP was supported by the individual interviews conducted with parents of the TRP participants and teachers. Teachers noted an improvement in behavior among girls in school as well as differences in attitudes and behaviors. At first, the girls were not depending on themselves in class, but now they are taking Alinafe s example and they depend on themselves. When we ask them what they want to be in the future they give interesting responses showing they have self-esteem and that they are aiming high as a result of this program. Their aspirations show that they are not underrating themselves by setting their limits low just because they are girls. Girls now know what to do for themselves to get higher with their education and choosing careers of their choice regardless of gender. Parents, too, were encouraged by their children s participation in TRP and cited changes in their children s behavior: These young girls have changed in their behaviors. They have discipline now, they respect their parents, and their performance has changed. The TRP has also influenced how parents and teachers interact with children. One parent noted: We do stay for some time advising the children and encouraging them to work hard at school. And we also give them a chance to express their views so that they can have freedom. Parents also acknowledged a need to approach their children differently. I have changed, what I was doing was bad, I was mistreating my child. I was shouting at her, leaving her without lunch if she came late at home which would have made her fail her exams. But after the introduction of this program I have completely changed. These data indicate that instead of a strictly top-down relationship between parents and adolescents or teachers and students, there is an awareness of the necessity to relate to adolescents. There has increased cooperation and cohesion which has helped to strengthen the Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

73 sense of group efficacy. Parents and teachers expressed increased comfort discussing topics with their children or students that they did not feel comfortable discussing prior to the TRP. FGD participants expressed awareness that in order to accomplish their goals and overcome the barriers posed by poverty, they would need to increase group efficacy. Discussion This qualitative study sought to understand the influence of the TRP on its participants from a variety of perspectives. Results from the study demonstrated awareness among the TRP participants of the obstacles posed by poverty. However, rather than feeling subservient to these structural constraints, participants expressed a marked sense of personal and group efficacy to overcome them. The analysis chose to focus on item 4 of the FGD guide where an older man approached a young woman and offered her money to get in his car. An absence of a sense of personal agency relative to the societal burden of poverty lies at the core of this scenario. In light of these burdens, however, there was a strong sense of how to overcome them as well as confidence in the ability to overcome them. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

74 Figure 19 is a sequential diagram to illustrate the processes through which the TRP had an effect on its participants. A strong sense of self-efficacy, defined as people s judgments of their capabilities to organize and execute courses of action (Bandura, 1986) is at the core of this diagram. This concept is particularly evident in responses to the question of whether or not it would be difficult to refuse a proposal from a sugar daddy. The strength of constraint posed by poverty was mitigated by the potential to minimize constraint by maximizing one s self-efficacy. It is here that the bulk of the TRP s impact was felt. According to Bandura (1986), people initiate and persist in activities that they feel capable of conducting successfully and tend to avoid those that they feel unable to carry out. If poverty is characterized by a lack of self-efficacy, an absence of personal agency and a perception that situations borne out of poverty are inevitable, the TRP participants remained acutely aware of this reality while simultaneously expressing the availability of choices and actions to counteract this inevitability. Where certain trajectories, like accepting the proposal of a sugar daddy, having to leave school to work, and being married early, are the norm for many girls in Malawi, the TRP participants began to question and reject these trajectories as the status quo. Another noteworthy aspect of this analysis is the preference participants expressed for delayed over immediate satisfaction. There was a consistent, if not excessive, use of the words vision, future, and goal throughout the data. A large amount of the consistency of these words is probably attributable to the use of these words throughout the intervention as well as oversimplified note taking coupled with the translation of the notes. Nevertheless, participants recognized the ephemeral nature of money and clothes (although still acknowledging that nice clothes are things they and their peers desired) and expressed the more permanent value to more abstract concepts like education and employment. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

75 Figure 19. Mechanism of the TRP s Influence Mechanism Participants express a strong awareness of the effects of poverty and how it can prevent them and their peers from accomplishing their goals. Participants reject the negative effects of poverty as a foregone conclusion and express the ability to overcome these effects through educational goals and career ambitions. Participants express an ability to exercise personal agency choices such as studying hard, using parents and teachers as resources, and abstaining from sex to prevent cycles of poverty. Empirical Data Question: Why would young girls be tempted to get into such a relationship (with an older man)? -Because of poverty -Some parents force young girls into prostitution so they can provide for the home -Because of pressure from parents to bring money into the household. Question: How did Maria manage to resist Banda s (the older man) offer of money when she was coming from a poor family? -Because of the vision she had of her future -She knew that he will destroy her future and she will not find another -She admired her fellow friends who are working as young nurses so she thought of her future goal of being a doctor Question: What are some of the steps she might need to go through to reach her goal? -She should be able to be strong decisions -She must have self-esteem -She must join clubs like Tisankhenji -She must work extra hard at school -She must be determined with her education -Abstinence An aspect of the TRP that seems to have had a profound, but not necessarily positive, effect on its participants is the abstinence message. Throughout the transcripts, there was an association made between having sexual relationships or even interacting with boys and not being able to achieve goals as a result. When asked about concrete steps to reach their goals, some responses included: We should not be attracted to boys. We should avoid sexual relationships. (There were 7 responses like this one) Avoiding immoral behavior Refusing to indulge in love affairs. These responses encapsulate the negative attitudes towards sex, sexuality and attraction. It appears that an unintended consequence of abstinence-only messages, as presented in the TRP without complementary explanations of healthy and safe expressions of sexuality and attraction, is that participants equated these concepts with only negative outcomes. At a time when many of these girls were only beginning to understand their sexuality and sexual attraction, such messages about sexuality and the negative consequences of sex may shame young women, instead of empowering them. In addition, such messages may push girls who are already sexually active further into a marginalized place and promote engaging in higher risk behaviors as they have already been labeled as bad girls. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

76 Limitations Steps were taken to ensure the credibility of the data, which included running a week-long training for FGD facilitators. However, despite these efforts, there are aspects of the data that could be strengthened. Time constraints did not allow for the FGD guide to be pre-tested on a female population comparable to the population of girls who received the intervention. The transcription of the FGDs was not done verbatim, but instead bulleted answers from respondents were provided. This likely diluted the full meaning and context of the data. In addition, many responses were similar and in some cases word-for-word even across different focus groups. This could be attributed to the group effect that focus groups can have on participants or it is possible that this similarity was a result of the translation of the transcripts. It is important to note here that it is unclear if concerns about forced marriage, rape, prostitution, or leaving school early to work became more prevalent among the TRP participants after the intervention as a result of the storyline of the radio program. This potentially heightened awareness of these issues does not detract from the fact that they are a reality for many Malawian girls, but may account for the abundance of answers that brought up these concerns. In addition, while the analysis drew upon various approaches to qualitative data analysis, a common method across all approaches is that of parallel coding to ensure that themes are reliably identified. This analysis did not use more than one coder for the data analysis. While qualitative data analysis is subjective in nature, this may serve to further bias the results. Conclusion The purpose of this qualitative analysis was to assess the impact of the TRP, a 13-episode radio series designed to build career aspirations and life skills, and to promote self-efficacy and interpersonal communication among Malawian girls ages Given the high prevalence of HIV & AIDS in Malawi and the disproportionate vulnerability of young girls to HIV as a result of gender roles, poverty and a lack of education, the TRP was designed to meet an unmet need of genderspecific HIV & AIDS prevention programming for young girls. Using data from FGDs with the TRP participants and individual interviews with parents and teachers of the TRP participants, this analysis sought to understand the mechanism through which the TRP achieved its impact. The findings revealed that in spite of an acute awareness of pervasive poverty that may lead to stopping one s education, forced marriage or prostitution, labeled in this paper as structural constraints, the TRP participants were not debilitated by these constraints. Instead, they were acutely aware of the constraints and what they needed to do to overcome the barriers to achieve success in their lives. It appears that the girls have developed a rich vocabulary with which to discuss their aspirations, they have thought through strategies to overcome the structural constraints they may encounter, and they have internalized the value of focusing on distal goals through the enactment of many proximal steps. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

77 Part G: Diffusion of the Hope Kit: A Social Network Analysis Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

78 Diffusion of the Hope Kit: A Social Network Analysis Introduction to Social Networks Social networks describe the web of relationships in which individuals are embedded. Through these relationships, individuals exchange information and resources and provide emotional and physical support to each other. There is growing consensus that the exchange occurring within social networks has important implications for public health programs. 7 This is particularly true for HIV & AIDS programs. The network defined by sexual relationships enables the exchange of HIV and, therefore, a person s location within this network will influence his or her exposure to HIV and risk of infection. Social relationships, including a individuals family and friends, enable the exchange of information about HIV & AIDS and HIV prevention behaviors that contributes to individuals knowledge and attitudes and affects their behavioral decisions. Social networks can also mediate the effects of communication programs. Exposure to a communication program s messages can inform individuals discussions with others in their social network, thereby extending the reach of these messages to those individuals who were not directly exposed to the messages. While this suggests that individuals exposed to a program may affect the rest of their network, it is also possible that the social network may affect individuals exposed to a program. A program can have a greater effect on individuals embedded in supportive social networks than on individuals who are embedded within networks that are opposed to positive health behaviors. This study investigated how existing social networks mediate the effects of the Hope Kit activities on outcomes such as knowledge and attitudes about HIV & AIDS prevention. Community-based programs like the Hope Kit are implemented within a community s existing social networks and these networks can mediate the effect of these programs among both participants and nonparticipants. For instance, the effect of participation in a Hope Kit activity may depend on the level of participation among one s social ties. We may therefore expect a greater effect of the program among individuals socially connected to other participants than among individuals with few friends who also participated in the program. Or, the program s effects may extend to non-participants if participants tell their friends and neighbors what they learned. Study Methods Training of Personnel. All interviewers and the data collection team supervisor underwent a week-long training in Zomba in matters pertaining to the ethical treatment of human subjects, research methods, interview techniques, and network sampling procedures. Questionnaire Development & Testing. Most of the questions used in the study were similar to questions used in prior household surveys conducted by the BRIDGE team at baseline and midterm, and these questions were used again, with minimal modification. New questions used in this study 7 From the write-up and analysis done by Marc Boulay, Ph.D., Johns Hopkins University, with description of research methods provided by J&F Consult. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

79 were field tested as part of the end-of-project survey (described elsewhere in this report). Questions were first translated into Chitumbuka, back-translated into English, compared with the original version, and modifications were made as needed. Procedures. The study was conducted in the Njolomole traditional authority in Ntcheu District. The location was chosen based on previous reports of high levels of participation in Hope Kit activities. While the selection of a high participation village limits the extent that we can generalize from these findings, it was considered necessary to examine the potential effects of the social networks in the community. Within the study village, all households in the community were first mapped and each household was visited to enumerate all eligible respondents. Each respondent was then assigned a unique number, identified by the house number and, within that, the respondent number. Following this listing of all potential respondents, fieldworkers revisited each household to interview all the potential respondents between the ages of 15 and 50 years. A total of 404 individuals consented to be interviewed. In addition to the standard questions, the questionnaire also asked respondents to list the members of their social network. Two networks were measured. First, respondents were asked to identify those individuals who may be influential in their lives, by asking them to list the names of the people who live in the village with whom they discuss personal matters. Second, respondents exposed to the Hope Kit were asked to list the names of the people with whom they had talked about the Hope Kit. This network was measured to assess the potential flow of Hope Kit messages beyond the direct participants. Since there was a high level of correspondence between the individuals listed in the personal discussion network with the individuals listed in the Hope Kit discussion network, this analysis was limited to the personal discussion network measured among both exposed and non-exposed respondents. Once respondents had named the people in their networks, they were asked to identify each person s house in the map of the village. Fieldworkers than consulted the names of the individuals living in that house to identify the survey identifier for each network member listed by the respondent. This enabled us to link a person s network members to the responses that those individuals made during their own interview. By linking the respondents based on social connections, we were able to use network members self-reports to characterize each respondent s social network. The interviews asked respondents a range of questions to measure their participation in Hope Kit activities, their exposure to other components of the BRIDGE project, and their knowledge and attitudes related to HIV & AIDS prevention and people living with HIV or AIDS. From these items, one knowledge index and six attitude scales were created. Measures Used in the Study Knowledge about HIV & AIDS. The knowledge index measured the proportion of 16 items that were answered correctly by each respondent. Knowledge items included questions related to the awareness of routes of HIV transmission, approaches for preventing transmission, and common misconceptions about HIV or AIDS. Respondents were assigned one point for each question they answered correctly (zero otherwise). Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

80 Attitudes toward Condoms. Attitudes towards condoms consisted of six items, including: (a) A woman does not have the right to ask her partner to use a condom, (b) Men believe that only loose women ask their sex partners to use condoms, (c) only loose women ask their partners to use condoms, (d) a man should only use condoms when he is having sex with a prostitute, (d) when a woman asks a man to wear a condom it is because she does not trust him, and (f) condoms are the best protection against HIV and other diseases. Responses, asked on four-point scales, were summed into an index (α =.75). Efficacy to Use Condoms. Perceived efficacy to use condoms consisted of four items, including: (a) If your sexual partner does not talk about condoms, you can bring up the topic with him or her; (b) you can talk about using a condom with the person with whom you re going to have sex; (c) you can use a condom every time you have sex, and (d) you can negotiate condom use with your partner. Responses, asked on five-point scales, were summed into an index (α = 0.96). Community Efficacy. Community efficacy consisted of five items, including: (a) how confident are you that you can set long-term goals for yourself, in terms of what you want to do in life; (b) how confident are you that you can do everything it takes to make your goals and plans come true; (c) how confident are you that you can take small steps every-day to pursue your long-term goal in life; (d) how confident are you that you can get involved in a community group to bring change to this community; and (e) how confident are you that you can convince others in your community to work together to bring about change in your community. Responses, asked on four-point scales, were summed into an index (α =0.92). Gender Norms. Gender norms consisted of three items, including: (a) it is OK if men make all the important decisions that affect the family; (b) women should follow their male partners decisions about whether condoms should be used while having sex; and (c) A man needs other women, even if things with his wife are fine. Responses, measured on five-point scales, were summed into an index (α =0.66). Fear of Infection. Fear of infection consisted of five items, including: (a) how fearful are you about exposure to the saliva of a PLHA; (b) how fearful are you about exposure to the sweat of a PLHA; (c) how fearful are you about exposure to the excreta of a PLHA; (d) how fearful are you that your child could become infected with HIV if they play with a child who has HIV or AIDS; and (e) how fearful are you that you could become infected if you care for a PLHA. Responses, measured on three-point scales, were summed into an index (α =0.83). Shame. Shame associated with HIV infection consisted of three items, including: (a) you would be ashamed if you were infected with HIV; (b) you would be ashamed if someone in your family had HIV & AIDS; and (c) people with HIV should be ashamed of themselves. Responses, measured on five-point scales, were summed into an index (α =0.93). For the condom attitude, condom efficacy, community efficacy, and gender norm scales, higher values reflected more favorable responses. For the two stigma scales measuring fear and shame, higher scores reflected greater fear and shame. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

81 Results Exposure to the Hope Kit Exposure to the Hope Kit is shown in Table 20, segregated by male and female respondents. As expected based on our selection of a high participation village, exposure to the Hope Kit among the survey respondents was high. Overall, 65 percent of males and 46 percent of females reported participating in at least one of the Hope Kit activities. Males were significantly more likely to be exposed to the Hope Kit than the women. Most respondents who were exposed to the Hope Kit reported participating in several of the activities associated with the Hope Kit. Although male participants reported participating in slightly more activities than women (eight versus seven), this difference was not statistically significant. In other words, it appears that, for any given activity, more males than females were exposed, but, overall, males and females were exposed to almost the same number of activities. The Blue Cloth with the Three Boats was the most common activity among both men and women. Half of all males and 38 percent of all females participated in this activity. Other Hope Kit activities frequently mentioned included: Narrow Bridges, Poster Card Discussions, How HIV can and cannot spread, Forum Theater. Wild Fire, Risk Ranking, and the Chewing Gum Challenge were the least frequently mentioned activities. Participants had highly favorable impressions of these activities. Nearly all respondents strongly agreed that they enjoyed playing these games, that they learned a lot about HIV prevention, that these activities helped them to think about HIV & AIDS in a new way, that they have made them confident in their ability to prevent getting infected, and in developing hope for the future. Table 20. Percent Exposure to the Hope Kit Activities, by Gender Individual Activities within the Hope Kit Males n = 166 Females n = 238 Total N = 404 The Blue Cloth with three boats 50.6** Narrow Bridges 54.2*** Poster Card Discussions 45.2** How HIV can and cannot be spread 41.6*** Forum Theater 42.2*** Who is Living with HIV 28.3** Spin and Walk 25.9** What happens in the body of someone living with HIV 23.5** Gender roles 27.1*** Future Islands 25.3*** Reflections from a Sick Bed 28.9*** Forum Theatre for Men s Issues 21.1*** On the Bank, In the River 15.7** Where do I Stand 20.5*** My Supporters 18.1*** Who is a Bambo Wachitsanzo 19.8*** Wild Fire 15.1*** Risk Ranking 14.5*** Chewing Gum Challenge 9.6*** Exposed to at least one Hope Kit activity 65.7*** Average number (among exposed) Note: Differences between males and females tested through Chi-square tests: *p<0.05; **p<0.01; ***p<0.001 Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

82 Table 21. Participation in the Hope Kit Activities by Respondent Characteristics Respondent Characteristics % Who Participated in the N Hope Kit Activities Age years 25+ years 62.1** 48.3 Marital status Currently married or living with someone Currently single Number of years of education Exposure to other HIV prevention programs * *** *** 72.8 Note: Chi-square test: *p<0.05; **p<0.01; ***p<0.001 Exposure to the Hope Kit varied by several background characteristics of respondents, as shown in Table 21. Participants tended to be younger, unmarried individuals with at least seven years of formal education. Participants were also more likely than non-participants to have heard or seen other components of the BRIDGE project. Due to these differences and their possible confounding effects on any relationship between Hope Kit exposure and HIV-related knowledge and attitudes, the remaining analyses controlled for these variables Effects of Participation Table 22 shows the average scores on knowledge and attitude variables for the three levels of exposure (none, low, and high) to the Hope Kit, controlling for age, education, marital status, and exposure to other HIV prevention programs. Participation in a greater number of Hope Kit activities was associated with more favorable perceptions of community efficacy and gender norms. Compared to non-participants, participants in either a small or large number of Hope Kit activities had significantly more favorable scores on the community efficacy scale, with no observed difference between low and high Hope Kit exposure. Individuals exposed to a high number of Hope Kit activities also had significantly more favorable perceptions of gender norms, compared to non-participants and participants in a low number of Hope Kit activities. Exposure to the Hope Kit was not directly associated with knowledge, condom attitudes, condom efficacy, fear of infection, or shame of infection. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

83 Table 22. Knowledge and Attitudes, by Level of Exposure to the Hope Kit Level of exposure to the Hope Kit a None Low High Proportion of 16 knowledge items known Average score on condom attitude scale Average score on condom efficacy scale Average score on community efficacy scale b 18.8 b Average score on gender scale b,c Fear scale d Shame scale d Notes: a Cell entries are average values, controlling for age, marital status, number of years of education, and exposure to other HIV prevention programs. b Wald test; differs from the no exposure group (p<0.05); c Wald test; differs from the low exposure group (p<0.05). d Higher scores reflect greater levels of stigma Network Effects In addition to the direct effect of participation in the Hope Kit, the study also sought to identify additional effects based on the level of participation in the Hope Kit among each respondent s personal network. Figure 20 shows the personal discussion social network measured in the community, and Figure 21 shows the Hope Kit discussion network. In each figure, each square reflects one individual respondent in the village and the lines that connect the squares reflect a close personal relationship between the connected squares. For the sake of simplicity, a relationship between two squares was considered to be present if either person mentioned the other person as a close friend during the interview. The red squares reflect those individuals who reported participating in at least one Hope Kit activity, while the light blue squares reflect non-participants. The squares along the left hand side that are unconnected to any other square are the respondents who did not list any close friend or any person to whom they had discussed the Hope Kit living in the community. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

84 Figure 20. Social Network Measuring Discussion of Personal Issues Figure Notes: 1. Each square = individual respondent 2. Red square = participant and blue square = non-participant in the Hope Kit activity 3. Line connecting squares = social connection between the respondents to discuss personal issues 4. Squares along the left side = non-participating respondents without social connection in the community A number of observations can be made from Figure 20. First, the community was fairly well connected among its individual residents. Second, it appears that Hope Kit participants were likely to be deeply embedded within the social network of the community. They were not located in just one physical space in the diagram, but rather they were found in the midst of connections with other individuals in all parts of the symbolic space shown in the figure. Third, Hope Kit participants had numerous ties with both other participants and other non-participants. Fourth, there was a preponderance of links between non-participants. These observations imply that information about the Hope Kit was being disseminated through social networks defined primarily by engagement in interpersonal discussion about personal matters (not necessarily matters pertaining to the Hope Kit). Furthermore, within the larger social network of the community, there were numerous pockets of smaller social networks; many of these pockets showed the inclusion of Hope Kit participants, but many others did not. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

85 Figure 21. Social Network Measuring Discussion of the Hope Kit Figure Notes: 1. Each square = individual respondent 2. Red square = participant and blue square = non-participant in the Hope Kit activity 3. Line connecting squares = social connection between the respondents who discussed the Hope Kit 4. Squares along the left side = non-participating respondents without social connection in the community Whereas Figure 20 showed the distribution of individuals connected with each other through interpersonal discussion about personal issues, Figure 21 shows the distribution of people who specifically talked about the Hope Kit with others in their community. When compared to Figure 20, the contrast in Figure 21 illustrates the existence of relatively fewer connections between individuals (when connections are contingent upon having talked about the Hope Kit). This is not surprising, given that discussions about the Hope Kit would likely comprise only a smaller subset of all discussions taking place among community residents. In this figure, too, Hope Kit participants were not confined to any one area of the symbolic space; rather, participants had numerous connections with others and they could be found throughout the symbolic space. A small number of Hope Kit participants in the network appear to have played key roles in the community with regard to discussions about the Hope Kit: they themselves had participated in the Hope Kit activities, and they had numerous social ties with others who had not participated (seen in the figure in the form of stars, with red boxes in the middle, connected with many blue boxes). These are the individuals who would play key roles in disseminating innovations within their communities. Multivariate Analyses To measure the effects of Hope Kit participation among one s friends, we created a variable measuring the proportion of one s friends (i.e. the people to whom each respondent is directly connected) that reported in their own interview that they had participated in at least one Hope Kit activity. In other words, for each node in the network, we calculated the proportion of blue squares to whom the individual is directly connected by a line. This variable, ranging from 0 to 1, was then included in separate regression model for each of the seven outcome variables included in Table 22. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

86 This model first included a binary variable measuring the respondent s participation in any Hope Kit activity, the interval-level variable measuring the proportion of the respondent s network members who had participated in any Hope Kit activity, an interaction term assessing whether the effect of participation in one s network differed between participants and non-participants, and control variables measuring age, education, marital status, and exposure to other HIV prevention programs. For all seven models, the personal participation-network participation interaction term was not significant and was dropped from the analysis. Table 23. Coefficients from Linear Regression Models Predicting Knowledge and Attitudes Coefficients from regression models Personal Hope Kit Level of HK participation in participation social network Proportion of 16 knowledge items known Average score on condom attitude scale Average score on condom efficacy scale 1.10^ 1.34 Average score on community efficacy scale 0.70* 0.55 Average score on gender scale 0.85^ 0.40 Fear scale ^ Shame scale * Notes: a Cell entries are unstandardized regression coefficients, controlling for age, marital status, number of years of education, and exposure to other HIV prevention programs. From Wald test, ^p<0.10; *p< Higher scores reflect greater levels of stigma. Table 23 presents the coefficients for the personal participation variable and the network participation variable from each of the seven regression models. These coefficients reflect the change in the outcome variable for each unit change in the predictor variable. Consistent with the previous results, personal participation in a Hope Kit activity was associated with more favorable perceptions of community efficacy and more favorable perceptions of gender norms. Perceived condom self-efficacy was also borderline associated with personal participation in a Hope Kit activity. Knowledge of HIV & AIDS, attitudes towards condoms, fear of HIV infection, and shame associated with HIV infection remained unassociated with personal participation in a Hope Kit activity. The proportion of one s network that participated in a Hope Kit activity was associated with two attitudinal scales, although in the opposite direction from what was expected. A higher proportion of one s friends who participated in a Hope Kit activity was associated with increased fear of HIV infection through casual contact and increased shame associated with HIV infection. The reason underlying this association is not clear, although it is possible that having greater levels of fear and shame was the driver, not the result of, increased discussion among those with those who participated in the Hope Kit activities. The proportion of one s friends who participated in a Hope Kit activity was not associated with knowledge of HIV & AIDS, attitudes towards condoms, perceived self-efficacy for using condoms, perceived community efficacy and gender norms. This suggests that messages from the Hope Kit were not effectively diffusing from participants to non-participants or that there was an added benefit to participants who were surrounded in their social network with other participants. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

87 Discussion This study identified several plausible direct effects of participation in Hope Kit activities. Individuals who participated in the Hope Kit had greater perceptions of community efficacy, more favorable perceptions of gender norms, and somewhat greater confidence in their self-efficacy to use condoms. These effects are in line with the program s objectives, since the value of participatory activities like the Hope Kit are explicitly designed to affect these attitudes. Participation in Hope Kit activities did not appear to have an effect on knowledge of HIV or AIDS, although knowledge in this community was relatively high and additional increases in this knowledge may be difficult to achieve. The finding that participation was not associated with attitudes towards condoms and people living with HIV & AIDS may reflect the fact that these areas were not sufficiently emphasized in the Hope Kit activities. We also found limited effect of social network on these outcomes. The lack of effects among nonparticipants connected to many participants suggests that the program s messages did not appear to diffuse from program participants to non-participants, despite the high levels of interpersonal communication about the Hope Kit illustrated in Figure 21. This suggests that effects on efficacy and norms are more difficult to diffuse and take more time to do so than knowledge and attitudes, neither of which were influenced by direct participation. The apparent reverse network effect on fear and shame likely reflects the possibility that the increased level of interpersonal communication about HIV & AIDS sparked by the Hope Kit may contribute to greater feelings of fear of the disease, particularly among individuals unexposed to the program. Alternatively, the causality of the association between fear and shame and the level of Hope Kit participation may be in the opposite direction. Individuals with greater perceptions of fear and shame may develop linkages to many Hope Kit participants as they seek out information to resolve their concerns. Limitations Several limitations suggest caution when interpreting these results. The study was conducted in a single village that was purposively selected due to its high level of use of the Hope Kit. It is not known how this village differs from other villages, although one would expect motivations to prevent HIV transmission would be higher in a high participation village. It is also not known whether the high levels of participation limited the role that social network may play in causing indirect effects of the program. The study relied on data collected at one point in time following the implementation of the activities. This limits our ability to measure whether attitudes changed over time or whether participants had greater perceived efficacy and gender norms prior to their participation in the activities. It also limits our ability to assess whether the social ties measured in the study were formed prior to or following the Hope Kit activities. The content of the communication occurring within the social networks is not known, limiting our ability to understand the nature of the social influence processes within the network. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

88 Finally, it should be noted that there was a great deal of uncertainty among interviewers who collected data on behalf of the BRIDGE project, given that this type of social network analysis was new to everyone. While the interviewers and supervisors had a great deal of experience conducting surveys at the household level, no one had prior experience collecting social network data. Hence, there was a great deal of learning that took place during data collection. It is possible that this introduced errors of measurement and data collection, despite extensive training that the interviewers first went through. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

89 Part H: Other Assessments: Agogo Training, Nditha! Sports, and Girls Leadership Congress Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

90 Other Assessments: Agogo Training, Nditha! Sports, and Girls Leadership Congress This section provides brief descriptions of additional programs and evaluations undertaken by the BRIDGE project. While not quite as large in scope as the other assessments (for example, the household survey), these programs were, nevertheless, key elements in the overall approach adopted by BRIDGE. A fuller description of these programs are provided in the companion report, BRIDGE End-of-Project Report, Agogo Training 8 As part of its communication-based behavior change campaign to reduce high-risk behaviors that lead to HIV & AIDS in Malawi, the BRIDGE project implemented a program where Agogo (grandmothers) were trained in HIV prevention, with the idea that they would, in turn, affect adolescent girls in their communities through discussions and mentorship. The premise for this approach was the existence of cultural norms in Malawi that provide Agogo with a specific role, that of someone whom adolescent girls can readily go to for advice and counseling in matters pertaining to sex and sexuality. Agogo in rural Malawi have been playing this role for many years. Targeting young girls was deemed to be particularly important because of the higher HIV-related risks that girls encounter as a result of social, cultural and economic dynamics that are deeply founded on gender inequities. Assessment The BRIDGE project conducted an assessment of the Agogo Training program, with the aim of identifying the intervention s impact on both the Agogo and the girls whom they counseled. Focus group discussions and in-depth discussions were held with the Agogo and girls at the village level. Discussions were undertaken with two groups of trained Agogo in order to explore how they counseled adolescents and how this compared to the non-trained Agogo. Girls were also interviewed according to whether they received counseling from trained or non-trained Agogo. Findings The assessment found that the Agogo played a critical role in the education of young girls with whom they interacted. They counseled the girls who reached maturity, provided sex education, taught them about their culture and cultural traditions, and acted as a compass for good morals. The most prominent role played by the Agogo was one of a sex educator to girls not only in their own family but to others in their larger community. Trained and non-trained Agogo differed in the type of information that they imparted to adolescent girls. Advocating the girls sexual duties to her future husband took central stage in the counseling provided by non-trained Agogo. They focused a great deal on the girls sexual role. Trained Agogo, on the other hand, tended to adopt a wider information base, as they stressed HIV prevention, 8 Compiled from the write-up provided by Abigail Dzimadzi Suka. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

91 focusing particularly on removing cultural practices that put young girls at greater risk to HIV & AIDS. The issue of protection against HIV & AIDS was observed to have been absent in the conversations of non-trained Agogo. Girls reported that the usual advice that they received from Agogo before their training often focused on stopping schooling in order to get married. Girls cited examples of where previously they were being advised not to go to school when menstruating, thereby loosing a week of schooling each month. However, after the Agogo underwent training, the Agogo advised girls to keep going to school even during menstruation. The counsel from trained Agogo about traditional practices that promote HIV transmission was particularly appreciated. Girls who received their counsel from non-trained Agogo were much more likely to focus on their future sex roles in life, as this was the predominant discussion and counseling they received from their Agogo. Conclusion Training an Agogo in HIV prevention appeared to influence the content of the advice that she provided to young girls. Her advice contained information about behavior change for protection against HIV infection. This motivated girls to aim higher in their lives and be mindful of their behavior. Agogo training also had a positive impact on the self esteem and perceived importance of the Agogo in the community. Girls who were counseled by trained Agogo differed markedly in ease of discussing issues related to HIV & AIDS than girls whose Agogo were not exposed to information about HIV & AIDS. Nditha! Sports 9 Nditha! Sports was one of the key component programs under the BRIDGE project s focus on youth. Nditha! Sports used sports as a means of reaching out to youth to enhance healthy behaviors, build self confidence, and impart skills that enable them to make positive decisions about their lives. This project was first implemented in 2006 in four districts in Malawi (Balaka, Chikwawa, Mangochi, and Mzimba), and was subsequently expanded to the remaining four districts of the BRIDGE project (Kasungu, Salima, Ntcheu and Mulanje). Assessment An assessment was carried out in two districts Mzimba and Mangochi to evaluate the impact of the Nditha! Sports program on youth. Specifically, we sought to determine youth team members reactions to the program, their perceptions about how much they learned about protecting themselves from HIV & AIDS, their overall evaluation of their involvement in the program, and their suggestions for program improvement. The assessment also sought input from parents and it sought to understand what factors would be required for bringing the program to scale. The assessment used in-depth interviews and feedback sessions for data collection. In-depth interviews were conducted with Nditha! Sports committee members, Nditha! Sports zonal coaches; Nditha! Sports club animators, and parents of children participating in Nditha! Sports activities. 9 Compiled from the write-up provided by Pius Nakoma and Joel Suzi. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

92 Feedback sessions were conducted with boys and girls who were members of the Nditha! Sports clubs. Findings Data from the assessments indicated positive changes. Participants in the Nditha! Sports program reported having undergone positive changes in their attitudes, beliefs, and behaviors with regard to sexuality. They also demonstrated keen interest in continuing their education. After the program, participating youth were found to be more knowledgeable about issues pertaining to HIV & AIDS, especially with regard to preventing HIV infection, than when the project was first introduced. Participants also noted that they were better able to talk openly about HIV & AIDS as a result of their participation in the program. One female youth in Mangochi said: Nditha Sports encourages us to talk with people to know more about how we can prevent HIV and perform well class I talk with friends, our coach I ask my mum and dad questions and they answer. The majority of the parents approved of Nditha! Sports, as evidenced by their acceptance of their children s participation in the activities. Furthermore, parents reported noticing positive change among their children, including higher levels of awareness about HIV & AIDS, greater awareness about sexual and reproductive health issues, greater interest in school, and more openness in their children when they talk with them. Parents also reported that their own awareness had changed. One father in Mzimba noted: Since my daughter started talking about Nditha! Sports and informed me about her involvement in school, she seems to have known so many thing that I am not even well knowledgeable about. Actually, I m learning a lot through her. Participating youth generally characterized Nditha! Sports as having been fun and educational. However, they also expressed disappointment in the shortage of support resources such as balls, volleyball nets, boots and uniforms. Girls Leadership Congress 10 The Girls Leadership Congress (GLC) concept is part of a package of behavior change interventions designed to build the efficacy of young girls to adopt lifestyle norms that lead to HIV & AIDS in Malawi. GLCs have taken place at national and district levels. At the district level, the GLC brought together adolescent girls years old, in and out of school, with the objective of building their self-efficacy and leadership skills to enable them to play a leading role in promoting HIV prevention at individual and community levels. Assessment The main purpose of this assessment was to identify outcomes related to girls participation at the congresses. It sought to characterize the extent to which they acquired knowledge and skills for: managing peer pressure; serving as advocates to other girls; and most importantly, adopting protective safer sexual behavior. The main qualitative inquiry method used was community discussions, with the GLC attendees (regardless of which year they participated), some girls who had not attended the GLCs, their patrons, and Tisankhenji Coordinators. Twenty-four sessions were held among the various parties. 10 Compiled from the write-up provided by Abigail Dzimadzi Suka Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

93 This assessment was conducted in four districts: Chikwawa, Mulanje, Mzimba, and Salima. Findings All the girls interviewed indicated that critical thinking and action were key skills they learned from the GLC, which helped them solve problems on their own, thereby increasing their self-efficacy to deal with the challenge of being a girl. Practical techniques to assertively ward off unwanted advances from boys and men was a deeply-appreciated skill for many girls. This skill was particularly important in view of the finding that the biggest challenge cited by girls related to sexual pressure. They perceived that they were being pressured to have sex with boys and men. One 15 year-old girl noted: When boys propose us and we refuse them they warn us that they will beat us and some of us accept their love because of fear to be beaten. Role modeling was another high point of the GLC experiences. Role modeling from health workers has had an impact on the career choices made by the girls. The GLC has indeed made a positive impact beyond the lives of its participants. After the Congress, many girls demonstrably influenced others. They reported imparting information to their friends using informal settings as well as Tisankhenji structures. The girls were aware of their own vulnerability and reported having acquired skills that will allow them manage some of the challenges that they face on their own. Expanding one s network of support was another widespread impact of the GLC. Whereas the girls reported that they relied on friends and parents, specifically mothers, as the people they discussed their concerns with, they reported being able to take their issue to a wider pool of resource persons. These included teachers, community-based organizations, and elders. They also reported increased comfort to discuss a variety of issues and for some to broach the subject of sexuality with parents. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

94 Part I: Recommendations for Future Programming Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

95 Recommendations for Future Programming Recommendations included in this section emerged from the household surveys, the Tisankhenji Radio Program s qualitative and quantitative assessments, the social network analysis, and other assessments (Agogo Training, Nditha! Sports, and the Girls Leadership Congress). Recommendations are provided below. Recommendations from the Household Surveys By and large, we found that the younger generation of Malawians was more exposed to the BRIDGE project s activities and they also appear to have derived greater benefits from the program. Younger individuals also tended to be better educated than their older counterparts. The younger population deriving benefits from the program is definitely positive; after all, a practice of engaging in healthy behaviors solidified at an early age is likely to yield healthy outcomes for a long period. Nevertheless, future programming may need to take active steps to include a greater level of participation by older groups. Older women, in particular, who tend to have the least level of education, can benefit greatly from intervention messages specifically designed for and targeted to them. This raises the possibility that use of sophisticated audience segmentation strategies may be greatly beneficial for future programming. Exposure to BRIDGE programs was positively associated with education, which signifies that better-educated individuals, relative to their less-educated counterparts, derived greater benefits from the program. This suggests that future programming should take special steps to reach those who are not currently being served because of their low literacy levels. Knowledge about transmission and prevention of HIV & AIDS was found to be about 78%, on average. This signifies that there is still a need to dispel rumors and correct misperceptions. A significant proportion of the population believed, for example, that just remaining faithful to one s partner would protect them from HIV & AIDS, without taking into consideration the sexual behavior and HIV status of their partner. Thus, future programming needs to have more nuanced messaging around meanings of faithfulness and multiple concurrent partnerships and evaluations need to continue monitoring progress. Results indicated a great deal of community vibrancy in areas where the BRIDGE project operated. Residents of those communities indicated a great deal of activity, organizing, and internal unity in their efforts to prevent HIV infection. Future interventions need to adopt this positive change into their programming in order to take advantage of the communities ability and willingness to change. Future efforts should also consider novel ways of building capacity of community organizations so that the vibrancy we have observed can be sustained. We observed lower levels of stigma among people who were exposed to the BRIDGE program. This was true for the three out of the four components of stigma (avoidance, fear of casual contact, and shame). The component of stigma that remained unaffected by BRIDGE activities was blame the tendency to blame HIV-positive people for their status. Even though the overall level of stigma was quite low, future programming may wish to focus specifically on strategies to reduce the attribution of blame to PLHA. We also observed slightly higher levels of stigma (in three of the four components) among people who were exposed to district-level non-bridge activities. While the current research activity was not designed to understand the nature of this influence, more research is needed to understand the effects across different programs. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

96 Risk perceptions among women were higher than among boys, girls, or men. Given the finding in the literature that high risk perceptions can be counterproductive if efficacy beliefs are weak, efforts need to be made to ensure that women s efficacy beliefs continue to be strengthened. Future efforts should focus on developing programs that specifically strengthen women s efficacy beliefs. HIV testing rates improved significantly from baseline to end-of-project, but only 47% reported testing in the prior 12 months. There was also considerable variation in testing across the eight districts. Promoting testing thus needs to be an integral strategy of future programming efforts. Boys tended to have multiple partners at greater rates than girls, men, or women, and their rate of condom use was also highest. This suggests that future programming needs to continue to promote condom use among boys, on the one hand, and also promote the adoption of alternative and safer behaviors, particularly reduction of partners, on the other hand. Differential findings with regard to exposure and key outcomes between BRIDGE and non- BRIDGE programs indicates the need to harmonize messages across the various programs working in Malawi. Overall, it appears that great strides have been made in improving the psychosocial predictors of behavior change (including knowledge, risk perception, and efficacy beliefs) behavioral intentions, and some behaviors themselves.. Many of these changes have occurred at the individual level, which comprise a necessary first step for sustained changes in behaviors for reducing HIV infections. The next wave of programming now needs to tackle the issue from both the individual-level and the more macro-level through structural and normative change. Recommendations from the Tisankhenji Radio Program (TRP) The quantitative assessments of the TRP showed that, consistent with the TRP objectives, students in the treatment schools made significant improvements in formulating long-term career aspirations, strengthening self-efficacy to engage in discussion, and actual discussions with parents and teachers regarding their future goals. Similarly, the qualitative assessments found that girls in the treatment schools were able to gain self-confidence despite recognizing significant barriers at the individual and structural levels. Some of the recommendations that emerged from these assessments are listed below. Recommendations from the Quantitative Assessments Most of the treatment schools were in urban areas of districts, while their corresponding control schools were in rural areas. It is thus recommended that the TRP and listeners clubs be expanded to rural areas to increase impact. A strength of the study design was the inclusion of both treatment and control schools. Future research efforts should consider collecting baseline and follow up data as one way to more clearly establish changes in intervention outcomes due to the program itself. Because primary education is not compulsory in Malawi and the school dropout rate for girls is higher than for boys, the TRP should expand radio broadcasting to other districts, as well as other settings where youth (especially female youth) tend to congregate. The latter may include arts (including music and dance) and sports events, as well as certain ceremonies and rituals. The needs of adolescent and pre-adolescent youth in the context of the AIDS pandemic must remain high on the agendas of all relevant stakeholders. These include teachers and school administrators, partners, radio station staff, parents, and youth. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

97 Securing long-term commitment from school districts is needed to maintain Tisankhenji listeners clubs and related activities in schools already running the program. Overall, given the plethora of positive findings reported in this report of the TRP, it appears that the expansion of the program into other venues and expansion of the target group to include boys would make a significant impact in those communities. Recommendations from the Qualitative Assessments Based on our findings that some of the girls equated all sex and sexuality with negativity, future abstinence-based interventions directed at youth may consider presenting messages through a sexpositive lens by acknowledging that sexuality is healthy and normal under the right circumstances. Programming that explores the nuances of healthy versus unhealthy sexual relationships will serve to demystify sexuality and remove the stigma of sex and HIV. Under ideal circumstances, a full exploration of healthy sexual development through sex-positive programming might prevent these unintended consequences. However, in a real-world setting, a more sex-positive approach can be difficult, given the religious and cultural contexts in which these programs are implemented. Nevertheless, a more holistic approach to discussing abstinence messages is an important solution to keep in mind to help prevent the strong negative associations FGD participants expressed between sexuality and sexual attraction. Another, more promising direction for future interventions, is to consider a more systematic approach to increasing the sense of group efficacy. A more systematic approach may be to design an intervention that simultaneously and complementarily targets all relevant stakeholders. In this case, perhaps facilitated discussions with parents and teachers separately on the themes discussed in the TRP may have strengthened one of the goals of the program to promote better interpersonal communication between parents and their children and teachers and students. Having listening clubs for parents and teachers followed by skills building exercises and discussions would serve to facilitate the group efficacy already demonstrated through these data, even without a targeted intervention. Recommendations from the Social Network Analysis The social network analysis found several positive outcomes associated with exposure to the various Hope Kit activities. It also found that people exposed to the Hope Kit activities did not disseminate what they learned to others in their social network. Some of the recommendations that emerged from the social network analysis are listed below. Explicitly motivate participants to serve as conveyors of the messages and themes discussed during the activity to their friends who had not participated. While the analysis showed that a great deal of diffusion of the information about the Hope Kit was taking place in the community spontaneously, an explicit urging from program implementers asking participants to tell others about the program would likely diffuse the information even further. Provide participants with key messages to use when their friends express unfavorable opinions. When participants disseminate information about the Hope Kit to members of their social network, it is likely they will encounter resistance from some. Preparing participants to counter this resistance, by providing rebuttals to counterarguments, for example, will likely be helpful. Formulate content of the Hope Kit to include components that promote diffusion. This network analysis found that, while those exposed to the Hope Kit displayed many positive outcomes, they did not actively promote their own learning among their peers and others in their social network. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

98 Thus, the next generation of the Hope Kit should include games, exercises, and other tools that actively promote the diffusion of knowledge. Make additional efforts to recruit individuals who are centrally located in these social networks and serve as opinion leaders in the community. Key informants are often knowledgeable of the identity of these opinion leaders. Including the participation of key opinion leaders is likely to accelerate the diffusion of information. In addition, the wide variation in the exposure levels to the various Hope Kit activities may suggest that some activities are used more frequently than others. To expand the range of messages to which participants are exposed, implementing partners may need to be reminded to use activities more evenly. Recommendations from Other Assessments The other assessments included in this report included the Agogo Training, Nditha! Sports, and the Girls Leadership Congress. Recommendations emerging from these assessments are summarized below. Agogo Training This assessment made several recommendations concerning capacity building, service delivery and research. It was recommended that a more formalized curriculum for Agogo training be developed so that this model can be replicated in other districts with ease. Along with that will be the need to build capacity of trainers before rolling out more training. There is a need to disseminate the best practices of this model widely. Nditha! Sports Nditha! Sports club activities should be continued in the districts for both in- and out-of-school youth. A greater inclusion of rural areas would be particularly helpful as many such areas are currently not being served. Participants and implementers recommended including refresher sessions to train the trainers and parents sought an orientation session that would better equip them to support their children. Girls Leadership Congress As reported by participants themselves, the girls leadership congress (GLC) appeared to have made a clear difference in the lives of the girls who had the opportunity to participate. It is thus recommended that GLCs continue and that their content be enhanced to take advantage of the unique role-modeling capability that they provide. It should also be noted, however, that gender inequity is one of the key factors that aggravates the disproportionate vulnerability of adolescent girls in Malawi. Therefore, changes happening at the GLC level need to be supported and complimented by national political, legal, and other reform processes that address gender inequality, prohibit gender violence, and hold perpetrators of such violence to account. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

99 Conclusion These assessments revealed that significant strides have been made during the six years that the BRIDGE project operated in Malawi. Important improvements were observed in behavioral predictors, behavioral intentions, and some of the behaviors themselves that protect Malawians from HIV & AIDS. Improvements have also been seen in lower stigmatizing attitudes toward people living with HIV or AIDS. It thus appears that the BRIDGE project has made significant inroads in promoting a climate of hope and openness that is promoting positive changes in knowledge, attitude, and behaviors for the prevention of HIV infection. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

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101 Rimal, R. N., Brown, J., Mkandawire, G., Folda, L., & Creel, A. H. (in press). Audience segmentation as a social marketing tool in health promotion: Use of the risk perception attitude (RPA) framework in HIV prevention in Malawi. American Journal of Public Health. Rimal, R.N., Tapia, M., Böse, K., Brown, J., Joshi, K., & Chipendo, G. Exploring community beliefs, attitudes and behaviors about HIV & AIDS in 8 Malawi BRIDGE districts. Center for Communication Programs, Johns Hopkins University, Baltimore, MD; Svenson, O., Fischhoff, B., MacGregor, D. Perceived driving safety and seatbelt usage. Accident Analysis & Protection, 17, ; Umar, U. S., Adekunle, A. O., & Bakare, R. A. Pattern of condom use among commercial sex workers in Ibadan, Nigeria. African Journal of Medicine & Medical Science, 30, ; UNAIDS/UNICEF/WHO. Epidemiological Fact Sheet on HIV & AIDS. Geneva, Switzerland: UNAIDS/WHO Working Group; UNAIDS/UNICEF/WHO. Malawi Epidemiological Fact Sheet on HIV & AIDS and Sexually Transmitted Infections. Geneva, Switzerland: UNAIDS/WHO Working Group; Watkins, S. C., & Smith, K. P. Perceptions of risk and strategies for prevention: Responses to HIV & AIDS in rural Malawi. Social Science & Medicine, 60, ; Weinstein, N. D., & Nicolich, M. Correct and incorrect interpretations of correlations between risk perceptions and risk behaviors. Health Psychology, 12, ; Weinstein, N. D., Grubb, P. D., & Vautier, J. Increasing automobile seatbelt use: An intervention emphasizing risk susceptibility. Journal of Applied Psychology, 71, ; Weinstein, N. D., Sandman, P. M., & Roberts, N. E. Determinants of self-protective behavior: Home radon testing. Journal of Applied Social Psychology, 20, ; Witte, K. Putting the fear back into fear appeals: The Extended Parallel Process Model. Communication Monographs, 59, ; Reports Published by the BRIDGE Project Aslan, L. (2009). Can a Radio Program Inspire Adolescent Girls and Promote Self-Efficacy? A Qualitative Analysis of the Tisankhenji Radio Program in Malawi. Center for Communication Programs, Johns Hopkins University, MD. Nakoma, P., & Suzi, J. (2009). The Malawi BRIDGE Project: Assessment of Nditha! Sports Project. Center for Communication Programs, Johns Hopkins University, MD. Rimal, R.N., Tapia, M., Böse, K., Brown, J., Joshi, K., & Chipendo, G. (2004). Exploring community beliefs, attitudes and behaviors about HIV/AIDS in 8 Malawi BRIDGE districts. Center for Communication Programs, Johns Hopkins University, MD. Rimal, R. N., Mkandawire, G., Banda, H., & Lokosang, L. (2006). The Malawi BRIDGE Project: A midterm evaluation. Center for Communication Programs, Johns Hopkins University, MD. Rimal, R. N., Mkandawire, G., Folda, L., Böse, K., Brown, J. (2008). The Malawi BRIDGE Project: Second midterm evaluation. Center for Communication Programs, Johns Hopkins University, MD. Sikka, R. (2009). Evaluation of the Tisankhenji Radio Program: Effects on Student Beliefs, Communication, and Aspirations. Center for Communication Programs, Johns Hopkins University, MD. Suka, A. D. (2009). Hope for the Future: Documenting the Impact of the Girls Leadership Congress on Behavior Change amongst Adolescent Girls in Malawi. Center for Communication Programs, Johns Hopkins University, MD Suka, A. D. (2009). Sources of Wisdom : Documenting how Agogo Can Play a Part in Averting AIDS Using an Innovative Approach to Sex Education for Girls in Rural Malawi. The BRIDGE Project: Lilongwe, Malawi. Promoting HIV Prevention Behaviors in Malawi through the BRIDGE Project June

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