Lesotho (2006): HIV/AIDS TRaC Study among the General Population (15-35 years) First Round. The PSI Dashboard

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1 SOCIAL MARKETING RESEARCH SERIES Lesotho (2006): HIV/AIDS TRaC Study among the General Population (15-35 years) First Round The PSI Dashboard Maseru, Lesotho October 2006 PSI s Core Values Bottom Line Health Impact * Private Sector Speed and Efficiency * Decentralization, Innovation, and Entrepreneurship * Long-term Commitment to the People We Serve

2 Research & Metrics Population Services International 1120 Nineteenth Street NW, Suite 600 Washington, D.C Lesotho (2006): HIV/AIDS TRaC Study among the General Population (15-35 years) First Round PSI Research & Metrics 2006 Population Services International, 2006 Contact Information: Lipolelo Mokhesi Research, Monitoring and Evaluation Manager PSI/ Lesotho 138 Moshoeshoe Rd, Industrial area Maseru Lesotho Daniella Fanarof Country Representative PSI/ Lesotho 138 Moshoeshoe road, Industrial area Maseru Lesotho

3 Table of Contents Summary... 1 Acknowledgements... 1 Background & Research Objectives... 1 Description of Intervention... 1 Methodology... 1 Main Findings... 1 Monitoring Table... 4 Monitoring Analysis... 6 Segmentation Table... 9 Segmentation Analysis Segmentation Table Segmentation Analysis Programmatic Recommendations Annex 1: Sample Characteristics Annex 2: Methodology Annex 3 : Reliability Analysis Annex 4 : Performance Framework for Social Marketing Annex 5: References... 23

4 Summary Acknowledgements: PSI/Lesotho would like to thank the Royal Dutch for making this study a possible success through their financial support. PSI/Lesotho also extends gratitude to the fieldworkers for undertaking data collection and The National University of Lesotho under ISAS institute for entering the data. This would be incomplete without extending our gratefulness to the RESulTS team for their technical assistance and unfailing support in carrying out this study. Finally we thank the respondents for their time and cooperation in answering the questionnaire, we are really grateful to all of you. Background & Research Objectives In 2006 Population Services International (PSI) Lesotho conducted a household survey designed to investigate consistent condom use and Voluntary Counseling and Testing (for HIV) services uptake for a national sample of 1600 men and women aged between years in Lesotho. Description of Intervention: PSI Lesotho undertakes social marketing of condom brands such as Trust Regular, Trust Studded and Lovers Plus. The organization also offers VCT services. The condom social marketing program includes implementation of interpersonal communication that promotes the benefits of condom use and VCT and advertises the availability of condoms and VCT services with the goal of increasing condom use and VCT utilization in Lesotho. Methodology: The 2006 HIV TRaC survey collected information from randomly selected men and women aged between years in all the 10 districts of Lesotho. A multi stage stratified cluster sampling was used which provided a nationally representative sample of 1600 respondents. Data collection was supervised by PSI staff and external enumerators were used. Results of the study are presented in standard PSI dashboard form. Main Findings: Monitoring Condom Use Majority of respondents (77%) were sexually active. Regarding secondary abstinence, 13% abstained from sex in the last 12 months Close to two thirds, (64%) had ever used a condom 1

5 Consistence condom use was defined as those who claim always using condoms with a particular partner type. The consistent condom use indicator varied significantly with the type of partner. Among those who have a regular partner, 45% used condoms consistently while 62% of those who reported having a non- regular partner always used a condom with their partners. Regarding multiple partners 45% of respondents had had more than one sexual partner in last 12 months. Behavioral Determinants A comparison of respondents who reported always using a condom with regular partner/ non-regular (users) and those who did not use condoms (non- users) shows significant differences in the following determinants: availability, knowledge, self efficacy partner, beliefs, attitudes, locus of control, residence, age, marital status and education. Significantly more users than non- users knew where to obtain condoms. The implication is that condom use will increase if availability of condoms is increased. Users displayed a higher level of self- efficacy than non-users. Self efficacy here related to the perceived ability to negotiate condom use with a partner. Users had significantly better attitude towards condoms than non- users. Users claimed a significantly higher locus of control than the non-users Users were more likely to be married people from urban areas, aged years and have secondary or higher education. Monitoring VCT Only 21% of the respondents had tested for HIV. Approximately 14% of those who had tested had received services at New Start Behaviour Determinants Significantly users had a favorable impression of the New Start than the non- users Users were more knowledgeable about VCT services than the non- users Significantly, users had a high level of self- efficacy and outcome expectation of VCT services than the non-users. The socio-demographic factors indicate that users were more likely to be married females, from urban areas aged between years. 2

6 Programmatic Recommendations: Condom use Interventions to increase consistent condom use with regular partners/ non regular partners should focus on uneducated older males from rural populations. The focus should be on improving attitudes towards condoms, the target group should be encouraged to appreciate that condoms are safe and can be fun. The self-efficacy partner among non- users is low and thus program efforts should aim at improving condom negotiation skills of the target group. The program interventions should also address the low locus of control of the target group. VCT To increase the number of people getting tested in VCT centers, the focus should be on people from rural areas particularly males of older age group. Program efforts should aim at increasing knowledge and outcome expectation and self efficacy of the target group 3

7 Monitoring Table Monitoring Table: Indicators of behaviors and exposure for men and women aged years in Lesotho 2006 Risk: men and women aged between years in Lesotho Behavior: Condom use and knowledge of HIV status INDICATORS % N= Description of base Abstinence -Proportion of target group that is abstaining( primary abstinence) - Proportion of target group that did not have sex in last 12 months (secondary abstinence) All respondents Respondents who ever had sex Condom use -Proportion that have ever used a condom Respondents who ever had sex - Proportion using condom consistently with regular partner Respondents who reported having a regular partner - Proportion using condom consistently with non- regular partner 62 - Proportion who used a condom at last sex with non- marital/ noncohabiting partner Respondents who reported having a non- regular partner Respondents who reported having a non-marital/non cohabiting partner Multiple Partners -Proportion who have multiple partners VCT All respondents who had sex in last 12 months -Proportion of target group who tested for HIV All respondents -Proportion of target group who got tested at New Start Respondents who have ever tested OAM for Condom use N= Description of base OPPORTUNITY Availability Respondents who ever had sex Availability PSI condoms Respondents who ever had sex Brand Appeal Respondents who ever had sex Social Norm Respondents who ever had sex ABILITY Knowledge Respondents who ever had sex Social Support Respondents who ever had sex Self-Efficacy condom Respondents who ever had sex Self-efficacy partner Respondents who ever had sex MOTIVATION Attitudes Respondents who ever had sex Belief Respondents who ever had sex Locus of Control Respondents who ever had sex Outcome Expectation Respondents who ever had sex 4

8 Monitoring Table OAM for VCT N= Description of base OPPORTUNITY Brand appeal All respondents Social norm All respondents ABILITY Self-efficacy All respondents Social support All respondents MOTIVATION Belief All respondents Attitude/threat All respondents Outcome expectation All respondents Knowledge All respondents EXPOSURE % N= Description of base -Proportion that listens to Radio All respondents - Proportion that watch TV All respondents -Proportion that reads newspaper All respondents -Proportion that heard about New Start on Radio Respondents who listen to the radio -Proportion that heard about New Start from: -billboard All respondents -news paper All respondents -directional signs All respondents -PSI vehicle All respondents -promotional material All respondents -leaflet/brochure All respondents -other All respondents - proportion that have heard/ seen Trust/ Lovers Plus condoms All respondents - Proportion that have heard or seen Trust/ Lovers Plus -PSI vehicle Respondents who have seen/ heard about Trust/ Lovers Plus -Stickers Respondents who have seen/ heard about Trust/ Lovers Plus -Calendars Respondents who have seen/ heard about Trust/ Lovers Plus - PSI promotion Respondents who have seen/ heard about Trust/ Lovers Plus -Radio Respondents who have seen/ heard about Trust/ Lovers Plus -Supermarket Respondents who have seen/ heard about Trust/ Lovers Plus - friend Respondents who have seen/ heard about Trust/ Lovers Plus MARKET SHARE % N= Description of base - Commercial Sector Respondents who used a condom during the last 12 months - Social Marketing Respondents who used a condom in last 12 months - Public Sector Respondents who used a condom in last 12 months The table above presents data on sexual behaviour and VCT and their behaviour determinants among the general population men and women years. 5

9 Monitoring Analysis Monitoring Analysis: condom use Close to one fourth (23%) of respondents (aged 15-35) reported never having sex while 13% did not have sex in last 12 months (secondary abstinence). Approximately 64% had ever used a condom and 45% had consistently used it in last 12 months with regular partner, while 62% has used it always with their non- regular partner. About 45% had more than one sexual partner in the last 12 months. Behaviour determinants Availability: The mean score for availability was relatively high with 4.17 on a scale of 1-5. However only a small percentage (23%) agreed that they can get a condom within a 10 minute walk. Social Norm: The overall mean score for social norm was fair with a score of Additionally about 52% of respondents stated they discuss condom use with both partners and friends. Knowledge: General knowledge of HIV/AIDS issues was high with a score of Most respondents knew that there is no cure for AIDS and about 74% were aware that HIV can be transmitted through sexual intercourse with an infected person. Self- efficacy for negotiating condom use with partner: The perception of respondents on ability to negotiate condom use was fair with a mean score of Only 33% agreed that they can say no to sex with a partner if they don t have a condom even if they want to have a relationship. Social Support: Overall, perceived social support was fair with a mean score of 3.44 on a scale of 1-5. Only 35% said they can give friends a condom if they think he/she might have sex on a date. Locus of control: Respondents perceived locus of control is high with a score of 3.97 meaning respondents largely believe it is within their control whether they get HIV or not. Almost two thirds (62%) believed they can protect themselves from getting HIV by practicing safe sex. 6

10 Monitoring Analysis Outcome Expectation: Perception of the effectiveness of condoms to prevent STI and HIV is fair with a mean score of About 55% of respondents believe condoms are reliable and a further 56% agree that using a condom consistently will reduce the chances of contracting HIV. Market Share Commercial - 6% Social marketing - 46% Public sector - 45% 7

11 Monitoring Analysis Monitoring analysis - VCT Only 21% of the respondents had ever been tested while among those who had tested 14% had tested at New Start centre or through New Start mobile clinic. Among respondents who had tested 79% said they had tested out of their choice. Behaviour determinants Brand appeal: Brand appeal for New Start scored 3.14 on a scale of 1-5 One third stated that they liked the New Start logo. Social Norms: Overall perceived social norms of respondents scored low with a mean score of Respondents largely seemed to believe that they will face discrimination if they test positive. Knowledge: General knowledge about VCT had a mean score of 3.27 indicating that awareness of VCT services is not as high. Further, only 28% stated knowing the benefits of undergoing VCT. Self- Efficacy: The mean score for VCT self- efficacy was About 59% believe that if they went to a testing center they would go through with the test. Belief: Overall beliefs towards VCT were positive as indicated by a high mean score of Respondents seemed to believe that VCT is something they can benefit from. Close to 90% disagree that VCT is only for people who are sick. Attitudes: Generally respondents have a positive attitude towards VCT. The mean score for VCT attitudes is The respondents displayed an understanding that counseling and testing is for everybody and the majority disagreed with statements such as pregnant woman should consider terminating the pregnancy if she tests positive. 8

12 Segmentation Table Segmentation Table: Determinants of consistent condom use among men and women 15-35, Lesotho 2006 Risk: Sexually active men and women aged Behavior: Consistent condom use with regular partner in last 12 months OPPORTUNITY INDICATORS Users N=_293 45% Non-Users N=_361 55% Availability * Availability PSI condoms.... NS Brand Appeal... NS Social Norm.... NS ABILITY OR % or % or Knowledge ** Social- support.... NS Self-efficacy condom NS Self-efficacy partner *** MOTIVATION OR Belief * Attitude *** Locus of control.... NS Outcome expectation.... NS OR OR Sig. POPULATION CHARACTERISTICS Residence Sex percentage percentage A large percentage 80% of condom users is likely to be from the urban areas than rural areas ***.... NS Age Majority of condom user, about 61% fall under the younger group (15-24) as compared to 39% of older group (25-35) who are users..468 ** Marital status Majority of respondents, 82%, who are users are non- married as compared to 18% *** of the married respondents who are users. Education Majority of condom users, 82%, are likely to have some education ** Occupation.... NS Socio Economic Status.... NS NS: Not significant, *: p<.05, **: p<.01, ***: p< Self- efficacy- partner is the perceived ability to negotiate the use of condom with a partner 2 Self- efficacy- condom is the perceived ability to use a condom) 9

13 Segmentation Analysis Segmentation Analysis: Determinants of consistent condom use for sexually active men and women aged years, Lesotho In the segmentation table, the group at risk was sexually active men and women who have a regular partner. A logistic regression analysis was conducted with the dependent variable measuring whether the respondent reported using a condom always in the past 12 months. scores and adjusted proportions for determinants that were found to be statistically significant are shown in the table, with non-significant factors indicated with dashes. The mean scores and percentages were adjusted for other significant factors in the final logistic regression model. Twelve scales measuring the OAM constructs which were found to be reliable (Cronbach s alpha>0.68), were used for the segmentation analysis: availability of condoms, availability of PSI condoms, brand appeal, social norms, knowledge, social support, self-efficacy for negotiating condom use with partner, self efficacy for using condoms, belief, locus of control, attitudes and outcome expectation. The reliability analysis can be found in Annex 3. The analysis showed that availability, self-efficacy-partner, locus of control and attitudes were important determinants of consistent condom use. All these determinants had OR (Odds ratio) greater than 1 suggesting that if program efforts help to increase the mean score of these determinants, there is likely to be a significant increase in the behaviour. Two other determinants (Knowledge and Beliefs) were found to be significantly associated but had an OR lesser than 1. This signified that non users were already scoring higher than users on these determinants but that was not leading to desired behaviour. In other words, emphasizing program efforts on these determinants (Knowledge and Beliefs) is unlikely to increase consistent condom use. Among determinants with OR greater than 1, Self efficacy to negotiate condom use with partners was the most important one (OR = 6.0). Users scored 4.27 on the self-efficacy- partner scale on average compared to 3.00 for non-users. This means that non- users were less likely to agree with such statements as I can say no to sex with a partner if we don t have a condom even if I want the relationship and I can say no to sex if my partner insists we do not use a condom even if we have not used one in the past. This finding indicates that behavior change communication campaigns should promote discussion between partners regarding condom use and make it normative. 10

14 Segmentation Analysis On availability, the users of condoms score on average 3.34 (on a scale of 5) compared with 3.16 for non-users. This indicates that health interventions that distribute and promote the use of condoms can have a dramatic impact on consistent use. One other significant determinant was attitudes. On average the users of condoms consistently scored 3.77 on the attitude scale compared to 3.23 for non- users. This is also an indication that interventions should aim to improve the non- user s attitudes towards condoms. The non- users should be encouraged to appreciate that condoms are safe. The other determinant locus of control, the users scored 3.46 compared to 3.17 for non-users. This implies that efforts should be taken to address the locus of control of non- users. The socio-demographic factors that were found to significantly differentiate users and non-users were as follows: residence - users more likely to be from urban areas than rural, age - users were likely to be of a younger age group (15-24 years), marital status - married (but having another regular partner) were more likely to be users than non- married (but with regular partner) and lastly education - the educated were more likely to be users than the non- educated. These findings indicate that a prime target could be older non- married people from the rural areas with little or no education. 11

15 Segmentation Table Segmentation Table: Determinants of VCT use by men and women aged 15-35, Lesotho 2006 Risk: Men and women aged Behavior: Tested for HIV OPPORTUNITY INDICATORS Users N=_334 21% Non-Users N=_ % Brand Appeal *** Social Norm.... NS ABILITY OR Knowledge *** Social- support *** Self-efficacy *** MOTIVATION OR % or % or OR OR Sig. *, ** or *** Belief... NS Attitude/ threat... NS Outcome expectation *** POPULATION CHARACTERISTICS Residence Majority of respondents, 63%, who have ever tested reside in the urban areas ** Sex A large percentage, 62%, of respondents who are users of VCT services are females *** Age The older age group (25-35) have more people about 55% who have ever tested *** Marital status Married people are most likely to be VCT users than non- married people *** Education.... NS Occupation.... NS Socio Economic Status.... NS NS: not significant, *: p<.05, **: p<.01, ***: p<.001 OR 12

16 Segmentation Analysis Segmentation Analysis: Determinants of VCT services uptake for men and women aged between years in Lesotho In the segmentation table, the group at risk is men and women aged between 15 and 35 years. A logistic regression analysis was conducted with the dependent variable measuring whether the respondent had ever under taken an HIV test. scores and adjusted percentages for determinants that were found to be statistically significant are shown in the table, with nonsignificant factors indicated with dashes. The mean scores and percentages are adjusted for other significant factors in the final logistic regression model. Eight scales measuring the OAM constructs which were found to be reliable (Cronbach s alpha>0.61), were used for the segmentation analysis: availability, knowledge, self- efficacy partner, belief, locus of control and attitude. The VCT analysis showed that brand appeal, knowledge of VCT, self efficacy and outcome expectation were significant determinants that differentiate users of VCT services and non- users. All these determinants had OR (Odds ratio) greater than 1 suggesting that if program efforts help to increase the mean score of these determinants, there is likely to be a significant increase in the behaviour. One other determinant (Social Support) was found to be significantly associated but had an OR lesser than 1. This signified that non users were already scoring higher than users on Social support but that was not leading to desired behaviour. In other words, emphasizing program efforts on Social support is unlikely to increase consistent condom use. On the brand appeal scale, users scored on average 3.29 compared to 3.10 for non- users. This is an indication that the users were more familiar and positive about the New Start Brand. People who knew about New Start were more likely to get tested. Knowledge was another significant factor, the users on average scored 4.14 as compared to non- users with This suggests that the interventions should focus more on educating the non- users about VCT services. On self- efficacy, users scored 3.88 while non- users scored The non- users were more likely to agree to statements such as Even if I went to a testing center, I am not sure I would go through with the test. With self- efficacy, the indication is that behavior change communications campaigns should attempt to effectively address the self- efficacy of non- users. 13

17 Segmentation Analysis The last significant determinant of VCT was outcome expectation. On a scale of 5, users scored 4.19 compared to 4.17 for non- users. This means that interventions should not only address knowledge of VCT but also highlight the benefits of undergoing VCT. The socio-demographic factors that came out as significant were residence- users more likely to be from the urban areas, gender- women more likely to be users than men, age- users were more likely to be from older age group than the younger age group and marital status - users were more likely to be married. This means one important target could be the younger males from rural areas who are not married. 14

18 Programmatic Recommendations Programmatic Recommendations Consistent Condom use Program interventions to increase consistent condom use with regular/ non regular partner should focus on males from rural populations with no education. More efforts should be taken to increase availability of condoms and access to condoms within a 10 minute walk Interventions should also focus on improving self efficacy to enhance the respondent s ability to negotiate safer sex. Program interventions should aim to enhance positive attitudes towards condoms particularly the thinking that condoms interfere with the enjoyment of sex. Locus of control (especially messages relating to the idea that preventing HIV is in control of the individual) should be given priority in order to increase consistent condom use among the target group. VCT For VCT intervention to increase the number of people getting tested, the focus should be on people from rural areas particularly males of older age group. Program efforts should aim at increasing knowledge and outcome expectation of the target group. Program should aim to increase the self-efficacy of non-users. 15

19 Annex Annex 1: Sample Characteristics POPULATION CHARACTERISTICS N= 1600 % District -Maseru -Berea -Buthe- Buthe -Leribe -Mokhotlong -Qacha s Nek -Quthing -Mohale s Hoek -Mafeteng -Thaba- Tseka Marital Status -Not married - Married Age Education -Primary education or less - Secondary and above

20 Annex Annex 2: Methodology The target population of the study was men and women youth aged years in urban and rural parts of Lesotho. Respondents living in these areas were not included if they (1) could not speak or understand the survey language, or (2) were unable to talk or hear, or (3) were visitors in the selected household. A sample of 800 males and 800 eligible women were recruited for this baseline. A multistage stratified sampling was used for this survey. Firstly, using probability proportional to size (PPS) 50 rural Enumeration areas (EA) and 50 urban EAs were selected. Secondly systematic sampling of households in each selected EA was used. In each EA selected, a sketch map showing the boundaries of each EA were drawn by consulting with the local authority, who is the chief in this case. For each EA, five purposive landmarks were identified and one was selected randomly as the reference point for selecting the starting point for the household interviews. A random number (e.g., X ) was picked between 1 and 3 to yield the first household to administer the questionnaire. Beginning at Xth household from the randomly selected reference point, every third household was selected using the Right Hand Rule 3. In each EA 16 interviews were selected. Finally, in the selected household, one eligible respondent was interviewed. Data Collection Procedure: Eligible respondents were interviewed at home by PSI/Lesotho temporary fieldworkers, in October A maximum of two visits (an initial visit plus one call-back for households that were closed at the first visit) were made to each selected house. A face to face interview was conducted by field workers after obtaining informed consent. Survey Instrument: The questionnaire measured the sexual and VCT behavior, vulnerability to HIV/AIDS infection or transmission, perceptions categorized in terms of opportunity, ability and motivation, population characteristics, media habits, exposure to other 3 Right hand rule is a way of controlling interviewer bias in further household selection. It specifies that the interviewer after finishing an interview must move (either select or skip) towards the house falling immediately to the right. 17

21 Annex HIV and VCT information campaigns. Perceptions are measured through single items for which responses were on a Likert-type five point scale anchored with 1 strongly disagree and 5 strongly agree. Analytic Technique: Correlation analysis was used to detect multi-collinearity. The monitoring table is produced based on one data set. s were reported using UNIANOVA in SPSS; separate models were run in which the variable of interest was the outcome and controls were age, education, sex, residence, marital status, occupation and socio-economic status. The segmentation model was based on multiple logistic regression in which explanatory variables were dropped if found not to significantly contribute to explanation of the variance in consistent condom use and VCT uptake. Adjusted means or proportions were presented for explanatory variables which remained in the final logistic regression model, with adjusting for all other explanatory variables in the model. 18

22 Annex Annex 3 : Reliability Analysis Condom Use Composite Variables Year 2006 (N=) Cronbach s Alpha Year (N=) Cronbach s Alpha OPPORTUNITY Availability: ( 1: strongly disagree; 5: strongly agree) - I know a place where I can get condoms - I have easy access to condoms - It is easy to procure a condom within 10 minutes walk - I know a place where I can get condoms even after 9pm - Condoms are available when I need them - Finding condoms at night is very difficult around here. r Availability PSI condoms - The Trust brand is easily available around here - The Lover s Plus brand is easily available around here - I could get LP in my area at nights too. - I could get Trust condoms in my area at nights too. Brand Appeal - Some condoms are better than others - Condoms that you get for free are just as good as the ones you buy in shops - Lover s Plus is better than any other condom brand - Trust is better than any other condom brand - Lover s Plus is a quality brand that I feel comfortable using - Trust is a quality brand that I feel comfortable using Social Norms: - I often discuss the risk for HIV with my friends - I discuss the risk of HIV with my partner - I discuss condom use with my friends - I discuss condoms use with my partner - My friends approve of using condoms regularly 0.79 ABILITY Knowledge: ( 1: strongly disagree; 5: strongly agree) -AIDS can be transmitted from mother to child through breastfeeding - There is no cure for AIDS - Sharing a meal with someone who is HIV positive is risky. r - HIV can be transmitted through sexual intercourse with someone who is infected - a healthy- looking person can be infected with HIV Index Self-Efficacy condom: - I know where to get condoms - I am not ashamed to buy condoms I know how to use condoms if or when I have sex with someone - I am able to carry condoms with me if I want to. Self- efficacy Partner:

23 Annex - I can say no to sex with a partner if we don t have a condom even if I want to have a relationship - I can say no to sex if my partner insists we do not use a condom even if we have not used one in the past - using condoms when having sex tells my partner that I care about both our health - I can talk to every new partner about the importance of using condoms Social Support: - I am very comfortable discussing HIV with my friends - Among my close friends we are comfortable discussing HIV - When I think that one of my friends might have sex on a date, I usually ask them if they have a condom. - If my friend knew that I might have sex on a date he/she would ask me if I were carrying a condom. MOTIVATION Belief: ( 1: strongly disagree; 5: strongly agree) - Only promiscuous people need to use condoms. r - If I asked my partner to use a condom, he/she would think I am hiding something. r -If you trust your partner, you don t need to use a condom. r Attitude: - condoms are pleasant to use - I don t think condoms interfere with the enjoyment of sex - The idea of using condoms doesn t appeal to me. r - Condoms are uncomfortable. r Locus of Control: - I could get HIV even if I do my best to prevent it. r - People like me can t really control whether we get AIDS. r - I can protect myself from getting HIV by practicing safe sex. - Men are in control of whether a condom is used during sex. r Outcome Expectation: - If I use a condom consistently its unlikely that I will get infected with HIV - I think condoms offer excellent protection against the spread of HIV/AIDS - Condoms protect against most kinds of sexually transmitted infections - Condoms seems to be reliable VCT Composite Variables Year 2006 (N=) Cronbach s Alpha Year (N=) Cronbach s Alpha OPPORTUNITY Brand appeal/ New Start: ( 1: strongly disagree; 5: strongly agree) - New Start is a trusted source of information - I like the New Start logo - New Start understands me and my concerns -New Start staff are so friendly Social Norms VCT - If I would test positive for HIV my family would still love me - If I would test positive for HIV, my friends would still want to be my friends - I am worried that I might be treated differently or discriminated against if my test result were to come out positive for the AIDS virus. r

24 Annex - If my friends go to get tested for HIV, then I would be more likely to go and get tested. ABILITY Knowledge - I am familiar with VCT services - Knowing one s status is one way to prevent spread of HIV - I know the benefits of undergoing VCT Self- Efficacy - Even if I went to a testing centre, I am not sure I would go through with the test. r - I think I could convince my partner to go to a VCT centre with me - I think I could convince a friend to go for VCT - I think I could convince a close family member to go for VCT Social- Support - I am comfortable discussing VCT with my partner - I am comfortable discussing VCT with my friends - I am comfortable discussing VCT with my health worker - I am comfortable discussing VCT with my family MOTIVATION Belief - VCT is only for people who are already sick. r - VCT is only for promiscuous people. r - I think that VCT is something that I could benefit from - VCT is important for planning one s future Attitudes: - AIDS is a big problem in my community - HIV/AIDS is an important health concern for me - People like me should be tested and counseled for HIV Outcome Expectation - Testing positive for HIV does not mean a death sentence - I would want to get tested in order to gain access to ARV s or other medical treatment - Getting tested for HIV will give me peace of mind and freedom from worries -I would want to know my status in order to prevent spreading HIV during my (partner s) pregnancy. - Going for VCT will decrease chances of contracting HIV

25 Annex Annex 4 : Performance Framework for Social Marketing HEALTH STATUS QUALITY OF LIFE HALO AND SUBSTITUTION EFFECT USE RISK-REDUCING BEHAVIOR RISK COVERAGE, QUALITY, ACCESS, EQUITY OF ACCESS, EFFICIENCY OPPORTUNITY ABILITY MOTIVATION POPULATION CHARACTERISTICS IMPACT, EQUITY AND COST EFFECTIVENESS EXPOSURE SOCIAL MARKETING INTERVENTION PRODUCT PRICE PLACE PROMOTION This study design is guided by PSI s PERForM framework. PERForM describes the social marketing research process, identifies key concepts important for designing and evaluating social marketing interventions and mirrors the four levels and concepts in the logical framework. The top level consists of the goal of social marketing for any health promotion intervention, namely improved health status and/or for interventions relating to coping with sickness or disability, quality of life. The second level consists of the objectives of social marketing stated as product or service use on the left side and/or other risk-reducing behaviours that do not involve the use of a product or service on the right side. The adoption or maintenance of these behaviours in the presence of a given risk or need for health services is causally antecedent to improving or maintaining health and or quality of life. The third level consists of the determinants of PSI Behaviour Change framework summarised in terms of opportunity, ability and motivation that may differ by population characteristics such as age and sex. The fourth level consists of the characteristics of the social marketing intervention. 22

26 Annex Annex 5: References Capo-Chichi, V. & Chapman, S. (2004). Sampling strategies. In PSI/AIDSMark Social Marketing Research Tool Kit 2004 [CD-ROM]. Washington, DC: Population Services International. Krotki, K.P. (1998). Monitoring Tools for Social Marketing Projects: Guidelines for Survey Sampling. Unpublished report. Ministry of Health and Social Welfare (MOHSW) [Lesotho], Bureau of Statistics (BOS) [Lesotho], and ORC Macro. (2005). Lesotho Demographic and Health Survey Calverton, Maryland: MOH, BOS, and ORC Macro. Patel, D. S. & Chapman, S. (2005). The Dashboard: A Tool for Social Marketing Decision Making (Population Services International Concept Paper). Retrieved July 10, 2007, from 23