Household Survey to Evaluate The Zambia-led Prevention Initiative: Baseline Report

This 84-page report shares findings of a baseline survey conducted at the beginning of the Zambia-led Prevention Initiative Program (ZPI), to inform monitoring and evaluation as well as programme design. The study was conducted to collect information on key indicators related to HIV knowledge and risk, gender and gender-based violence (GBV), and reproductive health. The ZPI was developed by a consortium led by FHI360, with the Population Council as the evaluation partner. ZPI seeks to reduce HIV transmission in Zambia by building local capacity to increase the delivery and uptake of community-led HIV prevention interventions, while at the same time generating evidence to inform effective approaches.

The baseline survey was conducted in eight districts in four provinces using face-to-face interviews and handheld computers or Personal Digital Assistants (PDA).

The report outlines the following as key findings which "provided critical insights into key areas for interventions in Zambia and highlighted variability in the populations across provinces and between males and females that provide valuable guidance for programming":

HIV prevention and transmission knowledge
The baseline found that comprehensive knowledge related to HIV was low, with only 39% of respondents able to correctly respond to a five-question indicator. Females had a slighter lower comprehensive knowledge than males, and comprehensive knowledge was particularly low in the Eastern province. However, the baseline did not point to "any significant associations between comprehensive HIV knowledge and sexual risk variables (having multiple, non-regular sex partners, or condom use)", meaning that correct HIV knowledge is not likely to be sufficient for practicing HIV preventive behaviours. The programmatic implication is that "behaviour change communication (BCC) must go beyond improving knowledge alone...there is a need to critically assess communication messages and approaches with a view to improving BCC effectiveness as a process of change."

Sexual risk
While rates differed across provinces, the baseline suggests fairly high rates of early sexual debut, having multiple partners, and having non-regular partners. The baseline also found that condom use among persons with multiple sex partners, as measured by use during last sexual act), was also low - 20% among females and 5% among males. The study found that knowing where to get a condom is not sufficient for condom use, but having confidence that he/she could obtain a condom if he/she wanted to was the greatest predictor of condom use. The programmatic implications are that: "there is a need for programmes that reduce sexual risk behaviours for both men and women, with an extra emphasis on male-centered interventions; more and better communication specifically about how and where one can obtain condoms when needed is crucial; and there is a need for critical analysis and utilidation of BCC theory for practice."

Attitudes toward and perceived norms around abstinence and faithfulness
The study found that there is an "apparent disconnect between knowledge and risk behaviour" which is "consistent with apparent contradictions in responses to value statements and perceived social norms around abstinence and faithfulness." As a result, "BCC messages need to be re-evaluated and must be made more persuasive and address psychosocial processes such as the cognitive dissonance using such proven techniques as: motivational interviewing, cognitive-behavioural approaches, harm and risk reduction interventions, etc."

HIV testing
The baseline found that more women than men knew where to get tested and reported having ever been tested and receiving their results (69% versus 53%). This is likely linked to access to ante-natal care (ANC) clinics. While there have been some increases in HIV testing, there is still a need to increase testing rates, particularly among men. The programmatic implications are that "all provinces should consider conducting male-centred information and testing campaigns," and that "HIV testing services should be evaluated to determine whether they are meeting the unique needs of men for HIV testing and sexual health."

Gender equitable attitudes
The study found that 37% of respondents supported gender inequitable norms, though there is wide difference across the provinces. In most provinces males had lower gender equitable attitudes compared to females, yet in Luapula females had substantially lower gender equitable attitudes (60% vs 46%). The report notes that "low gender equitable attitudes seem to be associated with higher risk." Programmatically, ZPI has developed a specific Gender Strategy, and all ZPI interventions have been designed to be gender-sensitive and take into account the impact gender has on becoming infected with HIV as well as on access to treatment, care, and support."

Sexual and physical abuse and rape myths
Female respondents in all provinces reported high rates of ever having experienced sexual abuse, yet the large majority did not seek help. "Underlying the violent behaviours are myths that blame women for rape. Sixty-two percent of all respondents supported one or more of four rape myths such as 'When a woman is raped, she usually did something careless to put her in that situation.'" The report suggests that programmes for survivors of GBV should help women know where else they can turn for help besides family members, while also working to improve family response to abuse. "Providers at health facilities must be sensitized and doctors and nurses need to be trained to provide services for survivors of GBV." As well, there is a need to improve linkages among support services and police, and if possible house all reporting, counselling, and support services in the police stations.

Prevention of Mother to Child Transmission (PMTCT)
The baseline found that a high percentage of both men and women did not know that there were drugs to reduce mother to child transmission of HIV, despite the fact that the majority of women had received antenatal care (ANC) for their last pregnancy (95%), and three-quarters of these women received HIV testing and results. There is a need to "ensure that ANC providers are educating women about ways in which women can prevent HIV transmission to their babies," and possibly to train traditional birth attendants to either test or facilitate referrals.

Alcohol use
Males were "significantly more likely than females to have been drunk in the last four weeks." As well, "being drunk at last sex (either self or partner) was found to be significantly associated with having multiple partners in the past year." The programmatic implication is that there is "a need for prevention programmes to include or intensify alcohol risk reduction counselling as an integral part of HIV counseling and testing. At a minimum, alcohol problem should be assessed of all people accessing HIV counseling and testing, PMTCT, and male circumcision (MC), and appropriate referrals should be made."

Unintended pregnancy and contraceptive use
While findings differed across the provinces, overall half the women surveyed reported that their last birth was unintended, though rates are much higher among young women. The baseline also showed just a quarter of women used any kind of family planning method; among contraceptive users, pills and injectables were the most common methods (85%). The majority (97%) had never heard of emergency contraception. The study suggests "there is an urgent need to understand the dynamics of access to family planning for young, single women" as well as increase awareness of and access to emergency contraceptive.

ANC coverage
While the large majority of women attended one or more ANC visits (over 90%), many (one-third) did not complete the four recommended ANC visits. The challenge was particularly evident in the Eastern province where only half of all women completed the four visits; the Eastern province also had the highest percentage of women who gave birth to a live child who later died. This points to a need for strategies "to improve continuation of antenatal care throughout pregnancy, particularly in Eastern province."

Male circumcision
Except for Western province (47%), reported male circumcision is low (18% overall). Half of those circumcisions occurred at less than 13 years of age, and 60% were performed by traditional circumcisers. Analysis showed that "those who were circumcised had lower comprehensive knowledge of HIV and were significantly more likely to have had multiple partners in the past year. It is important to know whether there is greater sexual risk taking due to a false sense of security in thinking that one is protected from HIV infection due to circumcision." The report also suggests the need for strategies to increase uptake of medical male circumcision tailored for different provinces.

Women’s Economic Empowerment
Luapula provinces had the highest proportion (approximately 60-80%) of participants who indicated that "decisions about earnings, health care, daily purchases, food and clothing, and large investments were made jointly. Interestingly, however, Luapula was also the only province in which a very high proportion of men (51%) indicated that they had no earnings (in money) unlike other provinces where approximately only 13-35% of men had no earnings." Eastern province had the highest proportion of respondents (33-43%) who indicated that the male partner had the final say with regard to earnings and other household decisions. The report suggests that in all provinces, interventions should focus on "improving women’s financial literacy and their ability to make financial management decisions." It is also "worth further exploration into how household decisions are made in Luapula in order to achieve this kind of decision making equity in other provinces."