El Tablero de Instrumentos de PSI

Transcription

1 SERIE DE INVESTIGACIÓN DE MERCADEO SOCIAL HIV/AIDS RISK BEHAVIOR TRaC STUDY AMONG PEOPLE LIVING IN BATEYES IN DOMINICAN REPUBLIC. SECOND ROUND El Tablero de Instrumentos de PSI SANTO DOMINGO, REPÚBLICA DOMINICANA, JULIO 2008.

2 Research Division Population Services International 1120 Nineteenth Street NW, Suite 600 Washington, D.C HIV/AIDS RISK BEHAVIOR TRaC STUDY AMONG PEOPLE LIVING IN BATEYES IN DOMINICAN REPUBLIC. SECOND ROUND PSI Research Division Year 2008 Population Services International, 2005 Contact Information: Nombre, Julia Hasbún Dirección Calle 6 No. 4 A1 Ensanche Paraíso Santo Domingo, Distrito Nacional República Dominicana hasbunj@yahoo.com Charles Szymanski PSI/DR Executive Director Calle Desiderio Arias No. 75 Bella Vista, Santo Domingo, D.N Republica Dominicana Ext 229 cszymanski@psidr.org.do

3 INDEX Pages Resume 4 Monitoring table 1.,...7 Monitoring analysis 1..8 Monitoring table Monitoring analysis Segmentation table Segmentation analysis Segmentation table Segmentation analysis Evaluation table. 23 Evaluation analysis Impact table. 28 Programmatic recommendations..30 Appendices. 32 Methodology.. 32 Reliability analysis

4 Acknowledgments: The TRaC study in bateyes in the Dominican Republic was conducted thanks to support provided by the German Development Bank (KfW). Field study was performed by FLACSO, in both 2006 and in this second round in For the analysis of results, we had the decisive participation of Benjamín Nieto Andrade, regional researcher of PSI, and Hongmei Yang as a consultant for the statistical analysis. Special thanks to our partner NGOs through their respective directors for their work and support throughout the development of the project. Special acknowledgement goes to COPRESIDA for their cooperation and openness in enriching the joint collaboration of HIV/STI prevention in the country, in addition to validating our materials, and to DIGECITSS for supporting our prevention work and validating our materials. Likewise, we recognize and appreciate the good work performed by the organizations, agencies and NGO networks working in HIV/AIDS and STI prevention. Background and Research Objectives: The first round of the TRaC survey with men and women living in bateyes in the Dominican Republic was conducted in 2006 and served as a base line for the HIV/AIDS Prevention Project. This survey has the following objectives: (1) to monitor behavioral trends and other key determinants of Opportunity, Ability and Motivation (OAM) among people living in bateyes in the Dominican Republic since 2006, (2) to identify the factors characterizing people having more than two sexual partners, and (3) to evaluate the PSI program s impact on behavior and determinants of OAM. Description of intervention: Population Services International (PSI) is a not-for profit organization (NGO) specialized in social marketing of products and services for HIV/AIDS prevention, family planning and maternal-child health. PSI/DR has operated in the Dominican Republic since PSI/DR implemented a two-year program targeted to people living in bateyes at the national level, funded by the German Development Bank (KfW) in collaboration with PANCAP and through a subcontract with Options Consulting. The purpose of the program is to increase healthy behaviors among people living in bateyes through education and a social marketing (SM) strategy of wide coverage for increased access to and availability of male condoms. As part of this intervention, PSI s own TRaC Studies were conducted to measure the impact of programs and are also used to generate tangible evidence for strategic decision making. This TRaC study was designed based on PSI s research tool Dashboard, a series of standardized tables to segment, evaluate and monitor behavior, attitudes and beliefs among the 4

5 target population and also to measure the impact of PSI interventions. The program advanced by PSI/DR hopes to receive additional financial support from the German Development Bank (KfW) for the next years of implementation. Methodology: The sampling was drawn by using a multi-stage cluster design for selecting participants in the studies. A total of 1500 informants were chosen in 2006 and a total of 1487 in The survey included questions related to demographic characteristics, sexual behavior, condom use, OAM determinants and exposure to PSI interventions. Variance analysis was used to monitor trends between 2006 and 2008 and to identify the impact (evaluation) of PSI interventions in key indicators of behavior and OAM determinants. Logistic regression was used to identify major determinants of dependents variables, controlling for socio-demographic characteristics and for the batey of residence as the design variable. Main Findings: The proportion of people living in bateyes reporting other regular partner decreased from 34% in 2006 to 26% in Having casual partners also decreased from 20% to 15.7%. Having more than two sexual partners was reduced from 23% to 13%. And the proportion of concurrency (having an additional partner to the regular or cohabitational partner) was 12.7% which is a low percentage. Behaviors as condom use with casual and commercial partners increased in year 2008 (81% to 94% and 82% to 97%, respectively). The report of having condoms at home and certain aspects in social support increased too. Although there were some determinants that showed negative changes for year 2008, such as being concerned or ashamed of buying condoms near home, and aspects concerning concurrency with responses that favored that kind of behavior for men, but not for women. Findings showed association between number of partners and determinants such as gender (male), marital status (not married), not being religious, worries about being infected with STI/HIV/AIDS, having condoms at home or knowing a person who has died of AIDS. Having a concurrent partner is associated with being men, not religious, having condoms at home, and exposure to PSI advertisements. Programmatic Recommendations: Most of the non-safe sexual behaviors showed to be reduced in Although, there are several aspects that may be improved in future interventions. Condom use with casual partners increased in 2008, but there was no evidence that the changes were associated to PSI s interventions. The Project has to focus educational resources to target and achieve condom use with casual partners. 5

6 The increased feeling of being concerned of buying condoms near home, feeling ashamed for buying condoms and the reduced knowledge of where to buy condoms in 2008, are aspects to be taken in consideration in the educational approaches, especially with women. Also the perception of threats decreased in A qualitative study is quite useful to identify reasons and motivations. Other indicators that showed negative results for 2008, are those related to macho standards. Certain attitudes increased, meaning that women and men are not equals. This indicates that gender equity interventions have to be included in any intervention with target population. The promotional resources that showed higher exposure were the Panté posters. This suggests a direction when creating and producing promotional material. 6

7 Monitoring table Trends in Behavior and OAM Determinants in bateyes residents. Risk: Bateyes residents Behavior: Condom use in last sexual relation with different partners. BEHAVIOR/USE INDICATORS 2006 N= N=1487 % % ^. Used condom last time with casual partner. Q % 93.6% *** -Had sex with commercial partner. Q % 7.4% * ^. Used condom last time with commercial partner. Q % 96.6% ** OPPORTUNITY Condom availability Mean Mean ^Has condoms at home. Q *** -Worries people might see him/her buying condoms. Q *** -Knows where to buy condoms. Q ** Social norms -At the community is well saw using and having condoms. Q *** -At the community people thinks that real men use condoms. Q *** -.At the community people think that condoms are just for using *** with casual partners. Q324 -Real men need more than one partner. Q *** ^At the community is normal that everyone, men and women, have more than one partner. Q *** Ability Auto-efficacy -Feels comfortable taking about condom use to sexual partner *** Q411 -Feels that have the capacity of deciding condom use in his/her ** sexual relations. Q412 -Knows how to put on and take off condoms. R *** -Feels ashamed buying condoms near home. Q *** -Keeps condom in a safe place to avoid damage. Q *** Social Support.-Has someone to talk when having questions about condom use. Q423 Sig *** -There is a place at community where to get information about *** sexual health. Q425 -Learned what knows about sex with friends. Q *** Beliefs -Condoms are too small. Q *** MOTIVATION Threats -AIDS is a serious problem en his/her community. Q *** - The higher the number of partners, the higher the risk of becoming *** infected. Q542 OTHER INDICATORS % % -Has received free condoms in last six months. Q % 69.3% *** ^ Thinks condoms are sold at a fair prize. Q % 90.1% * * p<0.05, ** p<0.01, *** p<0.001, NS=Not significant. ^ Donor s indicator Control variables: Gender, Age, Marital Status, Education, Religion, and Income. Design variable: Batey Note: Values presented as mean, indicate that the variable was measured in a score range of 1 to 4, Lickert s style, where 1= strongly disagree, 2= disagree, 3=agree and 4= strongly agree. When values are presented as percentages, mean proportions of means measured through dummy variables (0 and 1).

8 Monitoring analysis 1 Monitoring Analysis table 1: Comparison between the Two Rounds with Commercial Sex Workers The above table shows the results of variance analyses (ANOVA) conducted to compare the two rounds of the study. This test serves to identify changes in time and if these changes were significant statistically. The table shows percentages and adjusted means, controlling for sociodemographic factors, as well as for the design variable used: batey of residence. Only those indicators measured (coincident) in both surveys are analyzed here. Values expressed as mean show the variables measured with a Lickert-style score range of 1 to 4 that correspond to options of response such as strongly disagree, disagree, agree, strongly agree. BEHAVIOR/USE: Condom use in last sexual episode with regular partner or wife/husband was not compared between years 2006 and 2008 because the indicator was measured in different ways in the two rounds. In 2006 the term regular partner was used in a different way as wife and husband, more as lovers or sweethearts. In 2008 the same term was used as wife or husband. Significant differences were observed between the two rounds in condom use with casual partner in last sexual relation. In 2006 was observed a percentage of 81%, increasing in 2008 to a 94% (p<0.001). This means that condom use with casual partner was higher in 2008 than in In 2006, among people living in bateyes there is a higher reported behavior of having sex with a commercial partner compared with 2008 (9.8% vs. 7.4%, p<0.05), indicating that having commercial partners decreased in Lastly, year 2008 reported higher percentage of condom use in last sexual relation with commercial partner. (96.6% vs.81.6%, p<0.01). As it was observed before, having sex with commercial partners decreased in Now is also observed that people having sex with commercial partners increased condom use in last sexual episode in year This last year showed safer behaviors with commercial partners. 8

9 Monitoring analysis 1 OPPORTUNITY It was observed in 2008 in condom availability a significant increase in having condoms at home. In 2006 the mean score was 1.73 while in 2008 was 2.37 (p<0.001). However, two aspects were significantly different between the two round, indicating negative aspects for Year 2006 showed an adherence of 1.88 to the assertion Worries me that people might watch me buying condoms In 2008 this adherence increased to 2.07, p< In 2008 people reported more concern about other people seeing them buying condoms. Other negative aspect was that in 2006 a 3.61 mean score was reported in knowing where to buy condoms, while in 2008 the mean decreased to 3.49, p<0.01. In general, even there is higher frequency in having condoms at home in 2008, the concern of been watched buying condoms increased and the knowledge of where to buy condoms decreased. In social norms, in general, there were differences between the two rounds that indicated an improvement in One of the norms was the assertion At the community people think that condoms are just for using with casual partners. Year 2006 showed a mean of 3.00 and 2008 a mean of 2.82 (p<0.001). The perception of using condoms just with casual partners decreased in Other positive aspect observed in 2008 was a lower adherence to At the community is normal that everyone, men and women, have more than one partner. In 2006 the mean score was higher than 2008 (3.02 vs. 2.20, p<0.001). In 2008 the perception of considering normal that men and women have more than one partner decreased. Also in 2008 decreased the perception of the community thinking that real men use condoms. Year 2006 showed a mean of 3.38 and 2008 a 3.01 (p<0.001). In this indicator the difference observed is positive for Another negative finding for 2008 showed lower adherence to the assertion At the community is well saw using and having condoms. In 2006 the mean was higher than in 2008 (3.55 vs. 3.20, p<0.01). 9

10 Monitoring analysis 1 In 2008 there was an increase in the agreement with real men needed to have more than one partner. The mean in 2006 was 1.49 and in 2008 was 1.75 p< All this implicates an increase of perception of macho-oriented norms in ABILITY In the self-efficacy bubble, almost all indicators compared indicated positive changes accomplished in In this last year, people living in bateyes reported a higher adherence in feeling comfortable taking about condom use with sexual partner (3.20 vs. 3.01, p<0.001). Likewise, in 2008 increased the report of feeling having the capacity of deciding using condom in all sexual relations (3.19 vs. 3.07, p<0.01), which is a positive change for The knowledge of how to put a condom on and taking it off increased significantly in 2008 compared with 2006 (3.12 vs. 2.87, p<0.001). The only indicator that showed negative results for 2008 was the assertion of feeling ashamed buying condoms near home. In 2008 increased to 2.33 from 2.04 in 2006, p< This last result is coherent with other results obtained in 2008 that showed a higher concern or shyness en purchasing condoms in the community. Two indicators pointed a decisively increase in The adherence of having someone to talk when having questions about condom use was higher in 2008 than in 2006 (3.11 vs. 2.67, p<0.001). Also, it was reported a higher agreement in having a place in the community where to get information about sexual education (2.88 vs. 2.40, p<0.001), pointing the presence of organizations that work in the area. In 2008 there is higher adherence in learning what knows about sex from friends (2.21 vs. 1.97, p<0.001). In general, in 2008 increased the social support compared to MOTIVATION In the beliefs bubble just one indicator was significant showing a higher report in 2006 in believing that condoms are too small showed a mean of 2.09 while in 2008 a mean of 1.86 (p<0.001) was obtained, which means an improvement for

11 Monitoring analysis 1 Year 2006 showed higher adherence in the two indicators concerning threats. In 2008, people living in bateyes reported a mean of 3.41 in the agreement that AIDS is a serious problem in the community, while in 2006, the obtained mean was significantly higher (3.64, p<0.001). The other indicator in threats that did not show an improvement for 2008 was the agreement with the assertion The higher the number of partners, the higher the risk of becoming infected showed a mean of 3.90 and 2008, 3.76 (p<0.001). In 2008, the perceptions of certain threats decreased, which may be explained because of an increase in safe sexual behavior as sawn before, but this explanation in not conclusive. OTHER INDICATORS Results in 2008, showed that people living in bateyes reported more than in 2006, to have received free condoms (69.3% vs. 39.6%, p<0.001). In 2008, a decrease was appreciated in the satisfaction with condom price. In 2006, a 93.2% reported that condoms are sold at a fair price reported a 90.1%, (p<0.05). In 2008 there was an increase in condom price of 5 Dominican pesos. 11

12 Monitoring table 2 Monitoring table 2. Exposure and other indicators in 2008 TRaC Study in Dominican Republic. Risk: People living in bateyes. Behavior: Exposure and others INDICATORS 2008 N=1487 BEHAVIOR ^Had other trusted or regular partner ^Had casual partner ^Had one or two sexual partners ^Had more than two sexual partners ^Concurrency ^ No concurrency EXPOSURE f % Frequency watch TV Almost never One or two times per week days per week Everyday Has heard an HIV/AIDS advertising in last year Has heard an advertising on the radio of a woman taking to her partner about condom use Has heard an advertising on the radio of a man taking to his partner about condom use Saw any Panté poster Participated in HIV/AIDS prevention activities in last year (IPC) Participated in AIDS prevention talk Participated in Panté condom talk Participated in theater presentation Participated in training workshop Watched soap- opera Amor de Batey How many times One time Two times Three times Four or more times Type of exposure None Mass media IPC and mass media DALYS Ever concerned of being infected with HIV HIV tested in last year Ever concerned about having a STI In last year had vaginal or urethral discharge USE OF PANTE Has used Panté condoms Panté condoms have good quality Panté condoms are safe Panté condoms has enough lubricant Prefer to use non-logo condoms because they are free ^Has access to condoms within 15 minutes walking OPPORTUNITY Social Norms(Gender) -Men need to have sex more than women

13 Monitoring table 2 INDICATORS 2008 N=1487 -Women need a husband to build a home The main responsibility of women is to take care of family My trusted partner will be overwhelm if I ask to use a condom It s women s responsibility to avoid getting pregned Social Norms (concurrency) -It s normal that men have more than one family Social Norms (condom use) -Women propose men to use condoms with other women ABILITY Self-efficacy f % Keeps condoms in a safe place MOTIVATION Beliefs Condoms are not to be used with women at home Beliefs (concurrency) A man loyal to his wife is a nerd Any woman with more than one partner is a whore Women must have one partner at a time Threats Knows somebody that died of AIDS SOCIAL-DEMOGRAPHIC FACTORS Male Female Married/living with someone Not married Attended to school Not religious Any religion Get drinking water from bottles Tap water From trucks

14 Monitoring analysis 2 Monitoring analysis table 2: one round. In this part, some of the results for the TRaC study are analyzed using frequencies and valid percentages. Strongly disagree, disagree, agree, strongly agree answers were merge in agreement or disagreement (dichotomist variable) to present the descriptive statistics shown in table 2. BEHAVIOR The proportion of people living in bateyes reporting other regular partner decreased from 34% in 2006 to 26% in Having casual partners also decreased from 20% to 15.7%. Having more than two sexual partners was reduced from 23% to 13%. And the proportion of concurrency was 12.7% which is a low percentage. EXPOSURE 47.1% of people living in bateyes in year 2008 reported to have heard radio advertising about a woman talking to her partner about condom use. Also, a 39.9% mentioned to have heard on the radio, an ad about a man talking to his partner about condom use. Those percentages of radio exposure cannot be considered as low nor high. A 50.6% saw a Panté poster, which is a higher exposure compared to the radio one. A 41.8% of sample participated in interpersonal communication (IPC) in the last year, being the must attended activity the AIDS prevention talks (41.7%). Regarding the exposure to soap-opera Amor del batey, just a 27.4% reported of having watched it. That level of exposure is low associated to the expectations that people living in bateyes were supposed to be more interested in watching a series related to them. One possible explanation for that may be the electricity cuts so often in DR, and quite intensive in the bateyes. Although, must of the sample reported to watch TV daily. An 18.4% reported not to have being exposed to any PSI s intervention. Almost 40% mentioned being exposed to at least one mass media advertising, but not to IPC. A 41.7% reported exposure to mass media and IPC. 14

15 Monitoring analysis 2 DALYS Almost a 20% reported concerns about being infected with HIV. Just a 7% responded in the same direction concerning to STI. Also, almost half of the sample reported to be tested for HIV in last year. Some projects working with bateyes offer this service for free. USE OF PANTE CONDOMS A 54% of the sample had used Panté condoms, which is an acceptable proportion but can be much higher. From that percentage of Panté users a 94% evaluated Panté condoms as safe and with good quality. 96% reported that Panté condoms have enough lubricants. Just a 28% responded to prefer non-logo condoms because they re free, meaning that less than one third of Panté users are willing to use free Non-logo condoms. OPPORTUNITY Almost all indicators of social norms (gender-based) showed high percentages indicating very different roles for men and women. 65% of the sample said that men need to have sex more than women. 86% of informants reported that women need a husband to build a home. 91% assigned women s main responsibility as a family keeper. 77% pointed that is women s responsibility to avoid getting pregned. Those results indicate a clear assignment to very traditional female roles and macho standards. One third of the sample agreed that asking their trusted partner to use a condom would overwhelm them. Just an 18% reported that it s normal that men have more than one family, which is a low and positive proportion for the objectives of the Project. ABILITY 78% of the sample agreed in keeping condoms in a safe place. This of course, does not mean that they do. The indicator just measured a mere report. MOTIVATION A 37% of informants responded that condoms are not for use with women at home. A very low proportion (9.7%) assigned loyal men to wives as nerds. Again, in concurrency beliefs related to women, responses reached very high proportions. 67.5% agreed that any woman with more than one partner is a whore and 92% reported that women must have only one partner at a time. 15

16 Monitoring analysis 2 Comparing these results with given answers related to men, one may conclude that gender equity is quite rare among people living in bateyes. 16

17 Segmentation table1 Segmentation Table 1 OHM determinants associated to number of partners during last month among men and women between years old living in Bateyes,. Risk: Men and women who had a partner last month Behavior: Having 1-2 partners last month versus 3 and more partners BEHAVIOR INDICATORS 1-2 partners N= 1255 (87.1%) 3 & more partners N=186 (12.9%) % % OR Sig. -Have you been worried about being infected with HIV? R *** -Have you been worried about being infected with an STI? R * OPPORTUNITY Availability Mean mean ^ Have condoms at home (scale item) Q303n ** MOTIVATION Threat -I know someone who died because of AIDS (scale item) R545NQ * POPULATION CHARACTERISTICS % % -Gender (male=1 versus female=0) Q *** -Marital Status (married/cohabiting=1 versus other=0) Q105D *** -Being religious (any kind=1, versus not at all=0) Q113D ** EXPOSURE % % -In the last 6 months, have your heard a radio ad about a woman and/or a man talking to their partner about condom use? R127&R128 ** *: p<0.05; **: p<0.01; ***: p<0.01; NS: not significant. Hosmer-Lemeshow goodness-of-fit: χ2=17.611, df=8, p=0.024 Omnibus goodness-of-fit: χ2= , df=45, p<0.001 Cox & Snell R2=0.190 ^ Donor Indicator Note: 1. Present adjusted proportions or means, adjusting for all other significant independent variables in the final logistic regression model and for the study design variable (Batey). Scale items or scales are measured: 1=total disagreement, 2=disagreement, 3=agreement, 4=total agreement 17

18 Segmentation analysis 1 Segmentation Analysis 1: OHM determinants associated to number of partners during last month among men and women between years old living in Bateyes, Dominican Republic, In the segmentation table 1, the groups at risk are men and women between years living in the Bateyes, Dominican Republic. A logistic regression analysis was conducted with the dependent variable measuring number of sexual partners last month (0=three and more partners, 1=one or two partners). The table presents the mean scores and adjusted percentages for determinants that were found to be statistically significant. The mean scores and percentages are adjusted for other significant factors in the final logistic regression model and for the study design variable: Batey. The mean scores measure items on a scale from 1 to 4, where 1 is total disagreement and 4 total agreement. Percentages measure dichotomy variables: male versus female, being religious versus not being religious, etc. The analysis shows that having more sexual partners is associated to being male, not married/cohabiting with anyone, not being religious, having worried about being infected with HIV or other STIs, having condoms at home, and having heard radio advertisements about talking to the partners about condom use. Behavior In terms of behavior, having a higher number of sexual partners last month is associated with being worried of HIV and other STIs infection. For example, a greater percentage of informants with 3 or more partners reported worries about being infected with HIV, compared to informants with only 1 or 2 partners: 29.8% versus 17.9% (p<0.001). A similar trend occurred with having worries about being infected with other STIs: 11.5% versus 7.0%, respectively (p<0.05). Opportunity Having condoms at home was also associated with having a higher number of sexual partners last month. This variable was measured in a scale from 1 to 4. Informants with 3 or more partners adhered more to having condoms at home, compared to informants with only 1 or 2 partners: mean score of 2.56 versus 2.36 (p<0.01). Although the table does not measure condom use itself, the variable of having condoms at home suggests that people with more partners is more careful about increasing the opportunity of protection, compared to people with fewer partners. 18

19 Segmentation analysis 1 Motivation Having had more sexual partners last month was associated to knowing a person who had died of AIDS. Informants with 3 or more partners reported a higher adherence to the item I know someone who died because of AIDS : 3.23 versus 3.10 informants with 1 or 2 partners (p<0.05). This suggests that people with many partners might be part of a social network more exposed to the risk of HIV or at least more aware of the HIV status of their members. Population Characteristics Three socio-demographic characteristics were significantly associated to a higher number of sexual partners: being men, not married/cohabiting and not religious. Almost 80% of informants with 3 or more partners were men, versus 46.9% of informants with 1 or 2 partners (p<0.001); only 45.9% of informants with more partners were married, compared to 71.9% of informants with 1 or 2 partners (p<0.001).; and 43.8% respondents with 3 or mores partners were religious, compared to 57.2% (p<0.01). Exposure Informants with more sexual partners have been exposed more to PSI advertisements: while 58.8% of informants with 3 or more partners heard a radio advertisement of a man and/or a woman talking to their partner about condom use, only 46.5% of informants with 1 or 2 partners reported having heard such radio ad (p<0.01). This information may suggest that radio advertisements are reaching people at higher risk of HIV or STIs (at least in terms of number of sexual partners) more, when compared to people with fewer partners. 19

20 Segmentation table 2 Segmentation Table 2 OHM determinants associated to concurrency among men and women between years old living in Bateyes,. Risk: Men and women with a regular/cohabitational partner last month Behavior: Having an additional partner to the regular/cohabitational partner (concurrency) versus just having a regular/cohabitational partner OPPORTUNITY INDICATORS Concurrency N= 128 (12.7%) No concurrency N=881 (87.3%) OR Sig. Availability mean mean ^ Have condoms at home (scale item) Q303n *** ABILITY Self Efficacy (scale) *** MOTIVATION Beliefs Women should only have one partner at a time R534N *** Concurrency Belief (Scale) ** POPULATION CHARACTERISTICS % % Gender (male=1 versus female=0) Q *** Being religious (any kind=1, versus not at all=0) Q113D * EXPOSURE % % In the last 6 months saw an ad about Panté Condoms Q ** *: p<.05; **: p<.01; ***: p<.00; ns: not significant. Hosmer-Lemeshow goodness-of-fit: χ2=13.997, df=8, p=0.082 Omnibus goodness-of-fit: χ2= , df=44, p<0.000 Cox & Snell R2=0.215 ^ Donor Indicator Note: 1. Present adjusted proportions or means, adjusting for all other significant independent variables in the final logistic regression model and for the study design variable (Batey). Self-Efficacy Scale: - You feel comfortable talking about condom use with your sexual partner - You feel with the ability to decide about using condoms in your sexual relations - You can ask your partner to use condoms, even if you have never use them before Concurrency Belief Scale: - A responsible man should not have two families (even if he can support them) - A true man does not have more than one sexual partner - A man that is loyal (faithful)to his partner is not a pariguayo (nerd man) - Women can be supported by only one man 20

21 Segmentation analysis 2 Segmentation Analysis 2: OHM determinants associated to concurrency among men and women between years old living in Bateyes,. In the segmentation table 2, the group at risk is men and women between years old with a regular/cohabitational partner. A logistic regression analysis was conducted with the dependent variable measuring concurrency during last month. Concurrency was defined as having an additional partner to the regular or cohabitational partner (1=concurrency, 0=no concurrency). Like in the previous segmentation analysis, table 2 presents the mean scores and adjusted percentages for determinants that were found to be statistically significant. The mean scores and percentages are adjusted for other significant factors in the final logistic regression model and for the study design variable: Batey. Two scales measuring the OAM constructs (Cronbach s alpha>0.7), were used for the segmentation analysis: Self-Efficacy Scale and Concurrency Belief Scale. Results of the reliability analysis can be found in Annex 4. The mean scores measure individual items and scales on a range from 1 to 4, where 1 is total disagreement and 4 total agreement. Results on concurrency are similar to the analysis on number of sexual partners. Having a concurrent partner is associated with being men, not religious, having condoms at home, and exposure to PSI advertisements. This is not surprising since concurrency and number of sexual partners measure similar things: having multiple partners. Concurrency is nevertheless a better measure of having multiple partners at the same time, one of them being a regular partner; while number of partners may not differentiate between simultaneous partners at the same time and many partners at different times (serial monogamy). Other variables that were significant in the concurrency analysis and not in the number of partner s analysis are higher Self-Efficacy and lower adherence on beliefs about having only one partner. Opportunity Greater availability of condoms is associated to concurrency. Men and women who reported having an additional partner to their regular/cohabitational partner adhere more to having condoms at home, compared to those who just have a regular partner: 2.61 versus 2.17, p< This suggests that people with concurrent partners may be more concerned to protection and to procure having the means for doing so. 21

22 Segmentation analysis 2 Ability Informants with concurrent partners report higher mean scores on Self-Efficacy Scale, which measures the ability to talk about or to decide when to use condoms with their sexual partners, compared to informants with only regular/cohabitational partner: mean 3.33 versus 3.02, respectively (p<0.001). Motivation Men and women with multiple partners at the time, as defined by concurrency, seem less motivated to have only one partner, when compared to those with just a regular/cohabitational partner. Informants with concurrent partners adhere less to the idea that women should only have one partner at a time: mean score of 3.32 versus 3.48 in non concurrent informants (p<0.001). At the same time informants with concurrent partners reported a lower mean score on the Concurrency Belief Scale, compared to informants with only regular partners: 3.30 versus 3.45, p < The Concurrency Scale measures beliefs about having only one partner/family. A lower score is associated to disagreeing that men and women should only have one family. Population Characteristics Being men and/or not religious is associated to having an additional partner to the regular/cohabitational partner: 71.4% of informants with concurrent partners were men versus 36.1% of informants with just a regular partner (p<0.001); only 50.5% of informants with concurrent partners were religious, compared to 63.7% of non concurrent respondents (p<0.05). Exposure A greater percentage of informants with concurrent partners saw an advertisement about Panté condoms in the last six months, compared to informants with only regular/cohabitational partners: 59.5% versus 48.0% (p<0.01). Like in the previous segmentation table, this information suggests that PSI advertisements are reaching people with greater need of protection more than people that report only one partner. 22

23 Evaluation analysis Evaluation table 1 OHM determinants in people living in bateyes by type of exposure. Dominican Republic, Risk: People living in bateyes. Behavior: Mean exposure INDICATORS REF 2006 N=1500 EXPOSURE 2008 None MM N=273 N=594 IPC and MM N=620 Signif. BEHAVIOR/USE % % % % ^. Used condom last time with casual partner. Q a 92.5 abc 97.1 ab 89.9 ac ** ^. Used condom last time with commercial partner. Q a 84.6 a 97.1 ab b * OPPORTUNITY Condom availability Mean Mean Mean Mean ^Has condoms at home. Q a 2.21 b 2.31 b 2.49 c *** -Worries people might see him/her buying condoms. Q a 2.30 b 2.25 b 1.80 ac *** -Knows where to buy condoms. Q a 3.48 b 3.45 b 3.52 b ** Social norms -At the community is well saw using and having condoms. Q a 3.20 b 3.18 b 3.24 b *** -At the community people thinks that real men use condoms. Q a 2.95 b 2.98 b 3.06 b *** -.At the community people think that condoms are just for using with casual partners. Q a 2.89 ab 2.83 b 2.79 b ** -Real men need more than one partner. Q a 1.96 b 1.75 c 1.66 c *** ^At the community is normal that everyone, men and women, have more than one partner. Q a 2.40 b 2.11 c 2.20 d *** Ability Auto-efficacy -Feels comfortable taking about condom use to sexual partner. Q a 3.20 b 3.18 b 3.21 b ** -Feels that have the capacity of deciding condom use in his/her sexual relations. Q a 3.15 ab 3.20 bc 3.21 c * -Knows how to put on and take off condoms. R a 2.97 a 3.10 b 3.20 c *** -Feels ashamed buying condoms near home. Q a 2.56 b 2.40 c 2.16 ac *** -Keeps condom in a safe place to avoid damage. Q a 3.09 b 3.10 b 3.13 b *** Social Support.-Has someone to talk when having questions about condom use. Q a 2.95 b 3.01 b 3.26 c *** -There is a place at community where to get information about sexual health. Q a 2.81 b 2.78 b 3.0 c *** -Learned what knows about sex with friends. Q a 2.89 b 2.32 b 2.09 ab *** Beliefs -Condoms are too small. Q a 1.90 abc 1.97 ab 1.74 c *** MOTIVATION Threats -AIDS is a serious problem en his/her community. Q a 3.41 b 3.35 b 3.46 b *** - The higher the number of partners, the higher the risk of becoming infected. Q a 3.76 b 3.72 b 3.79 b *** OTHER INDICATORS % % % % -Has received free condoms in last six months. Q a 58.8 b 67.2 b 75.4 c *** ^ Thinks condoms are sold at a fair prize. Q a 83.0 b 92.3 a 90.9 a *** * p<0.05, ** p<0.01, *** p<0.001, NS=Not significant. ^ Donor s indicator Control variables: Gender, Age, Marital Status, Education, Religion, and Income. Design variable: Batey 23

24 Evaluation analysis Evaluation analysis of OAM Determinants by type of exposure in people living in bateyes,. The evaluation table determines whether PSI interventions had any effect on the indicators showing significant changes between 2006 and The variance analysis (ANOVA) is used to compare if there is a significant difference between behavior and OAM determinant indicators among people living in bateyes who participated in the baseline survey in 2006 and those who participated in the follow-up survey in In 2008 the following groups were created: no exposure to intervention (None), exposure to mass media (MM), exposure to interpersonal communication (IPC) and mass media (both interventions), controlling for sociodemographic factors and design variable which was batey of residence. In the Reference column, levels of indicators are taken from the 2006 survey round. The remaining three columns are taken from the 2008 survey round. The none category refers to people living in bateyes who reported that they had not seen any advertisements in the mass media, nor had they participated in IPC activities in the past 12 months. Informants, who reported having seen at least one PSI advertisement in the mass media, but not having participated in IPC activities in the last 12 months, were classified as Mass Media. Lastly, the IPC and MM category includes people living in bateyes who stated that they had participated in some educational interventions on interpersonal communication in the past 12 months, and also had seen any PSI advertisements. In the evaluation table, significant statistical differences between proportions and means are shown with sub-letters. Proportions or means with the same sub-letter (a,b,c) are not significantly different, while those with different sub-letters do have statistically significant differences. A trend is considered attributable to the exposure of PSI interventions if there is a significant difference between any exposure group and the none exposure and reference categories. However, it is important to take into account that the lack of information regarding exposure to interventions from other organizations limits the possibility of solely attributing any change in the level of indicators to PSI. The first analyzed behavior in the evaluation table is condom use in last sexual episode with casual partner. An increase was observed between the reference group (81.1%) and Mass media category (96.8%, p<0.001). Nevertheless, there is no significant differences between none category and mass media, nor in IPC and MM category. Significant differences were observed in the comparison of MM and both interventions. Those who were just exposed to MM showed 24

25 Evaluation analysis a higher percentage of use of condom with casual partner than those who were exposed to both types of interventions (96.8% contra 89.9%, p<0.05). Results cannot be attributable to PSI interventions. Condom use behavior in last time had sex with commercial partner showed significant differences, and in this case, between the baseline or reference category and both types of interventions (82.1% vs %, p<0.01). The reference group was not different to none category or exposed just to MM. Neither were different the groups with none exposure and MM group. The difference observed was between none category vs. both types of interventions (none=84.6% vs % from both types of interventions, p<0.001). The MM group and the both category were not different. In synthesis, those informants exposed to both types of interventions reported higher percentage than the reference group and none exposure group in condom use with commercial partner in last sexual episode. This finding points that the combination of both types of PSI s interventions in part facilitated the increase in condom use with this kind of partner. The indicator of having condoms at home (donant s indicator) showed a clear significant increase between the reference group and the others from It was different to none exposure group (1.73 vs none-, p<0.001); was different with MM (2.31, p<0.001) and was different with both types of interventions (2.49, p<0.001). None exposure group presented lower mean than the both types of interventions group (2.21 vs. 2.49, p<0.05). None exposure group was not different to MM group. The MM group was different to both types of intervention (2.21 vs. 2.49, p<0.05). All of this, indicates a clear influence of the combination of the two types of interventions (IPC and MM) facilitating the reported behavior of having condoms at home. The adherence to the assertion that real men needed to have more than one partner increased in a negative way in People living in bateyes from the reference group are significantly different from de ones in none exposure group (1.49 vs. 1.96, p<0.001), also different to MM group (1.75, p<0.001) and to both types of interventions (1.66, p<0.01). In all comparisons the reference group showed lower adherence to real men needed to have more than one partner. Also, the groups of none exposure and MM were different (1.96 vs. 1.75, p<0.05). Is the same case when comparing none exposure group to both types of interventions group (1.96 vs. 1.66, p<0.01), meaning that those who had none exposure are the ones who reported more than any other group in 2008, that real men need more than one partner. The MM group is not different to both interventions group. Year 2008 reported more than 2006 the acceptance of the assertion. But in 2008, the exposed groups by Project were the ones with lower acceptance. 25

26 Evaluation analysis A donant indicator with very positive results for Project showed the decrease of the perception that in their community was normal, that men and women have more than one partner. The reference group presented higher adherence (3.02) to that assertion compared to none exposure group (2.40, p<0.001), compared to MM group (2.11, p<0.001) and to both interventions group (2.20, p<0.001). None exposure group showed higher adherence than MM group (2.40 vs. 2.11, p<0.01) and to both types of interventions group (2.20, p<0.05). The MM group reported lower adherence than both interventions group (2.11 vs. 2.20, p<0.05). In general, the findings indicated that in 2008, the adherence of perceiving as normal that men and women have more than one partner decreased, and the means are lower in those groups exposed to the Project. From those groups, the one that showed lower acceptance to the assertion was MM group. The ability of feeling having the capacity of making decision about using condom in all sexual relations, increased in 2008 compared to The reference group did not presented any significant difference with none exposure group. But there were differences with MM group (3.07 vs. 3.20, p<0.05) and both interventions group (3.21, p<0.05). None exposure group was not different from MM group but different to both types of interventions group (3.15 vs. 3.21, p<0.05). The MM group was not different to both interventions group. All this indicates that the combined interventions of IPC and MM seem to increase the feeling of having the capacity to use condoms in all sexual relations. Regarding to the report on how to put the condom on and taking it off, the reference group from 2006 was not different to none exposure group. There were significant differences between reference group and MM group (2.87 vs. 3.10, p<0.01) and with both interventions group (3.20, p<0.001). At the same time, the both interventions group reported higher adherence than MM group (3.20 vs. 3.10, p<0.05). The results showed that year 2008 had a significant increase in knowing how to put on and taking the condom off and that increase is higher in the group with more intensive exposure by Project. Therefore, a positive influence of Project s interventions was shown in the results of this indicator. Year 2008 presented higher adherence in feeling ashamed when buying condoms near home. The reference group showed lower adherence than none exposure group (2.04 vs. 2.56, p<0.001), than MM group (2.40, p<0.001), but no differences were observed in comparison with both interventions group. None exposure group showed higher adherence to the assertion than MM group ((2.56 vs. 2.40, p<0.05) and also with both interventions group (2.16, p<0.05). Between MM group and both interventions group there were no evidence of significant differences. The people living in bateyes that were exposed to MM reported more than those 26

27 Evaluation analysis from 2006, feelings of being ashamed when buying condoms near home. Although in 2008, those groups exposed to Project (MM and both) showed lower acceptance than none exposure group. In one side, informants from 2008 increased the feeling of shame when buying condoms, but also, the groups with lower adherence to that shame are the ones exposed by project. The social support indicator concerning if has someone to talk when having questions about condom use showed a significant increase in The reference group reported lower adherence to this assertion than none exposure group (2.68 vs. 2.95, p<0.01), than MM group (3.01, p<0.001), and also with both interventions group (3.26, p<0.001). None exposure group is not different from MM group. But none exposure group is significantly different from both interventions group (2.95 vs. 3.26, p<0.001). Both interventions group also reports higher adherence than MM group (3.26 vs. 3.01, p<0.001). Both interventions group was the one that reported the highest adherence of having someone to talk when having questions about condom use, from all groups. PSI s interventions facilitated in part this increase. In the same direction, the indicator regarding having some place in their community where to get sexual education, showed significant differences between the two rounds and between exposed groups. The reference group reported lower adherence than none exposure group (2.40 vs. 2.81, p<0.001), than MM group (2.78, p<0.001) and with both interventions group (3.00, p<0.001). None exposure group was not different from MM group, but to both interventions group (2.81 vs. 3.00, p<0.05). The both interventions group showed higher adherence than MM group (3.00 vs. 2.78, p<0.001). In synthesis, there are evidences that PSI s interventions had a positive influence in increasing the report that there is a place in community where to get sexual education information. Also was increased the report of having received free condoms in last six months. The reference group from 2006 showed significant differences with none exposure group (39.6% vs. 58.8%, p<0.001), with MM group (67.2%, p<0.001) and with both interventions group (75.4%, p<0.001). In other hand, none exposure group was not different from MM group, but to both interventions group (58.8% vs. 75.4%, p<0.001). A higher adherence was observed in both interventions group than in MM group (75.4 vs. 67.2%, p<0.01). It is concluded that interventions from PSI project are associated to higher reports of getting free condoms. 27

28 Impact table Impact table of OAM Determinants INDICATORS MONITORING TABLE EVALUATION TABLE CONCLUSION +, - o not sig. +, - o not sig. +, - o no impact BEHAVIOR/USE ^. Used condom last time with casual partner. Q No impact -Had sex with commercial partner. Q214 + Not significant No impact ^. Used condom last time with commercial partner. Q OPPORTUNITY Condom availability ^Has condoms at home. Q Worries people might see him/her buying condoms Q304 -Knows where to buy condoms. Q Social norms -At the community is well saw using and having condoms. Q321 -At the community people thinks that real men use + - No impact condoms. Q322 -.At the community people think that condoms are just for + - No impact using with casual partners. Q324 -Real men need more than one partner. Q ^At the community is normal that everyone, men and women, have more than one partner. Q327 ABILITY Auto-efficacy -Feels comfortable taking about condom use to sexual + - No impact partner. Q411 -Feels that have the capacity of deciding condom use in his/her sexual relations. Q412 -Knows how to put on and take off condoms. R Feels ashamed buying condoms near home. Q Keeps condom in a safe place to avoid damage. Q417 + Not significant No impact Social Support.-Has someone to talk when having questions about condom use. Q423 -There is a place at community where to get information about sexual health. Q425 -Learned what knows about sex with friends. Q426 + Not significant No impact Beliefs -Condoms are too small. Q