Evaluating the Impact of a Joint Communication Campaign on Multiple Sexual Partnerships in Mozambique: Interim Report

This 56-page document reports on an evaluation of the impact of a mass media behaviour change communication (BCC) campaign in Mozambique that focused on integrating a strategy to reduce multiple sex partnerships (MSP) and concurrent partnerships (CP) into existing HIV prevention programmes that have already increased condom use and HIV testing. The purpose of this year-long campaign which began in December, 2009, was “to discourage and reduce MSP/CP, emphasising the slogans “Andar fora é maningue arriscado” (to go outside is risky business” and “Amores a mais e demais” (too many loves is too much).”

The four participating organisations were the Foundation for Community Development, the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHU-CCP), Populations Services International, and N`weti, in collaboration with the Mozambique National AIDS Council and with funding from the United States Agency for International Development  (USAID). “The implementing organisations used television, radio, print materials, and billboards as well as community-level activities as channels to disseminate the campaign messages.”

The study also aims to describe the context and mechanisms through which the campaign may have affected MSP (multiple sexual partnerships), condom use, and HIV testing behaviours. Specifically, these mechanisms are ideational (psychosocial) variables through which BCC efforts have an effect on behaviour. Collectively, these results aim to help identify the factors contributing to an effective MSP BCC programme, improve MSP interventions in Mozambique, and inform the development of similar programmes in other settings.

The methodology included household surveys in four provinces with the highest rate of HIV in order to evaluate the impact of the joint communication programme on MSP, condom use, and HIV testing. In addition, the questionnaire also measured ideational variables (context and mechanisms) through which the campaign may have affected MSP, condom use, and HIV testing behaviours. The collective results are focused to uncover factors that contribute to an effective MSP BCC programme in Mozambique and other settings. As such, the questionnaire also measured socio-demographic characteristics in order to determine variables that would confound the effect of the joint communication programme on behavioural outcomes.  The survey used recall of the materials distributed on television, radio and in print to test campaign exposure.

The report summarises the findings:

“The results described in this report provide substantial evidence of a positive effect of the BCC campaign on MSP and other HIV prevention behaviours. The reach of the campaign was high; more than 80% of respondents correctly recalled at least one of the 18 components of the campaign. This proportion represents more than 2.2 million people (men 15-54 and women 15-45) in the four survey areas. Campaign exposure/recall was highly related to the mass media components, especially television advertisements. The slogan 'andar fora e maningue arriscado' also had a high spontaneous completion rate (close to 40% for the overall sample, and 50% for urban areas).

The campaign influenced several ideational variables, the proximate determinants of HIV prevention behaviour. Exposure/recall to the campaign had a negative impact on favourable attitudes towards MSP, a positive impact on knowledge of the risk of MSP, a positive impact on attitudes and self-efficacy for condom use, and a positive impact on discussion with spouse and others about MSP and about HIV testing. The relationship between campaign exposure/recall and positive ideational variables explained a substantial proportion of the campaigns’ observable impact on HIV prevention behaviours, especially MSP.”

The following recommendations are summarised as follows:

• MSP: The campaign and its evaluation “demonstrate the efficacy of using ideational variables such as knowledge, attitude and interpersonal communication (PPC). Communication through the mass media and through community-level interventions should employ strategies to encourage these ideational variables and increase discussions of HIV prevention with others. The more people talk about these issues, the more they will reflect about them, exchange ideas, and change their behaviour.” The results note that men are more likely (65% vs. 35%) to have favourable attitudes towards MSP and to engage in MSP. Alcohol further increases the possibility. “Future campaigns need to help people increase their sense of self-efficacy by modelling this behaviour and by focusing on changing undesirable MSP attitudes among men.”
• Condom use: “The causal relationship found in this evaluation between condom ideation and condom use and the frequency of condom use, suggests that designing messages to increase self-efficacy and positive attitudes about condom use would be an effective way to increase these behaviours.” Young people (15-24) tend to use condoms more often, “suggesting both a generational shift in the practice and the effectiveness of condom promotion and youth programmes in Mozambique. Organisations should continue to promote condom use among youth to ensure consistency in this practice, and increase use at first sex among the next generation of sexually active youth.” Because results suggest that condom use is higher among people who visit bars, drank a lot, or spend a lot of time away from home, messaging needs to address consistent condom use “as a way to prevent HIV infection among regular and non-regular partners (sexual relationships) and consider how to effectively balance the promotion of condom use with one partner messaging.”
• HIV Testing: While HIV testing continues to increase in Mozambique, about one-third of men and women in the study provinces have never been tested. “Future BCC efforts that promote HIV testing should incorporate the ideational variables shown to be effective in this campaign and tailor some of them to men in these specific rural regions.” The study also found that interpersonal communication was very important in the promotion of testing as “normative and socially supported behaviour” and recommends that “campaigns (should) build off these efforts to bring messaging beyond mass media and into the community venues in case where IPC is particularly effective.”
• Partnership and communication channels - According to the report, “it is unlikely that any of the four partner organisations would have independently reach the size of the population that they all reached together, emphasising the importance of collaborative and coordinate efforts in HIV BCC programmes. Future efforts should similarly strive to increase synergy and exposure to the different components of the campaign.” The report notes that while different programmes could focus on different segments of the audience or use different messages, “it would improve the overall impact if the organisations coordinated their efforts with an agreed upon national strategy in which each programme knows where it fits and can contribute effectively.”

Television spots and participation in community and religious meetings were very strongly related to “high recall.” The report recommends increasing community-based activities. The study also found that visiting bars correlated to high recall of television spots due to the airing of the Football World Cup. Hence the report suggests “programmes should consider buying airtime during highly viewed sports events as a potentially effective way to disseminate messages, especially those targeted at men who gather in bars.”

It suggests taking regional differences into account, noting that MSP was seen more favourably in rural areas where condom use was also less prevalent. Recall and exposure in rural areas was lower than in urban areas. Community radio is one way to reach rural populations. “Additionally, programmes should focus on behaviour change pertinent in these areas.”