Swaziland: External Evaluation of the Southern African Regional Social and Behaviour Change Communication Program

This report discusses the Swaziland findings of an external evaluation of the Southern African Regional Social and Behaviour Change Communication Programme, an initiative implemented in 8 countries in Southern Africa from 2007 to 2011 to reduce HIV infection by increasing health awareness and facilitating social and behavioural change through both mass media and community-based activities. The evaluation assesses how exposure to specific components of the programme affected HIV knowledge, attitudes, and behaviours. The evaluation found that there are wide differences in associated results among men and women, and among intervention components, which means that different strategies may better address certain outcomes for men or women.

The Swaziland component of the programme was implemented by Lusweti Institute for Health Development Communication and SAfAIDS, with funding from the United Kingdom Department for International Development (DfID). Lusweti activities focused on the production and distribution of mass communication materials based on One Love branding. These efforts focused on improving communication within relationships and understanding the risk of and reducing multiple concurrent partnerships as vital tools in the fight against HIV and AIDS. SAfAIDS activities were focused mainly at a community level. SAfAIDS built the capacity of national HIV trainers, and used community-based volunteers to disseminate key messages and information in face-to-face meetings with community members, supported by pamphlets, toolkits, and training packs.

The evaluation was based on a post-only researcher administered survey questionnaire with 3,972 nationally representative males and females aged 15-49. However, although the evaluation was post-intervention only, the 2012 survey was compared with data from a prior survey to assess progress towards pre-specified DfID targets. The research suggests an increase in multiple concurrent partnerships (MCP), a key focus area of this programme. "Approximately 17% of respondents report having multiple partners in the past year as compared with 13% who reported having multiple partners at baseline," with many more men than women reporting engaging in MCP. On the other hand, "condom use at last sex (among those with multiple partners) increased by 18 percentage points for males (from 56% to 74%) and by an even larger amount for females (from 57% to 81%), exceeding targets for both genders." There has also been a decrease in HIV stigma indicators and an increase in awareness that HIV positive people can transmit HIV while on ARVs.

The evaluation report discusses impact findings for both partners. The following offers a brief overview:

• Lusweti/One Love Campaign
  According to the report, the One Love mass media component of the programme reached 85% of the survey respondents in Swaziland, the largest number through the radio programmes (65.1% of men and 69.8% of women), followed by print (half of all respondents), then television (40.8%). The evaluation data suggests that men and women respond to the campaign materials differently. For example, women exposed to the One Love campaign were less likely to be engaging in multiple concurrent partnerships and more likely to be using condoms, while men exposed to the campaign were only more likely to be using condoms. The report also notes that "nearly all programme exposure indicators registered measurable positive impacts on testing behaviours," and that "exposure to OneLove media significantly influenced stigma and treatment outcomes." In almost all measures the impact of the campaign was increased with multiple exposures. On the other hand, "there were limited effects of exposure to programme media on outcomes related to the exchange of gifts or money for sex, although attitudes towards such exchanges were less favourable among men exposed to the programme."
• SAfAIDS:
  "Overall, 11.9% of respondents report any exposure to SAfAIDS interventions, most commonly via a community volunteer," as well as through SaFAIDS print materials, and their newspaper column. According to the evaluation data, "exposure to the SAfAIDS materials was positively associated with several outcomes related to HIV communication." For example, exposed men were more likely to discuss HIV/AIDS with their children, and people exposed to SAfAIDS activities were more likely to agree that one’s sex life can improve with communication with a partner. The intervention also improved knowledge of men about ARVS and PMTCT, although there was no noticeable effect for females. There was also no measurable associations in reducing MCP, improving condom use, or experiencing gender violence. However, "the likelihood of reporting such violence (to family, friends or authorities) was higher – 85.3% versus 64.1% - among those exposed to SAfAIDS materials."

One of the objectives of evaluation was to distinguish the impact of the current three-year programme of activities from prior programmes and from programmes of other donors. The analysis of the Lusweti-led mass media component, which follows ongoing programming produced by Lusweti, found that "there appears to be a significant cumulative effect of exposure to either radio or television during both time periods on having multiple partners in the past 12 months but no significant effects among those recently exposed." This is also true for television, "84.1% of the cumulatively exposed agree that condom use in marriage is acceptable versus 76.2% of those exposed only during the most recent period and versus 69.9% of the never exposed. " The report also discusses the fact that there was some cumulative effects that were opposite to the desired behaviours. For example, respondents exposed in both time periods "are more likely to suspect that their husband or wife has another sexual partner than those who were never exposed to a television programme. The difference is greater among women; 36.4% exposed during both time periods suspect their husband has another partner as compared with 17.0% of unexposed women."

A key objective of the Southern African Regional Social and Behaviour Change Communication Program and the evaluation was to assess the added benefits of a combined partner approach, rather than a standalone project. As in most countries, this was a challenge due to sample size. Only 23 respondents had been exposed to SAfAIDS interventions only. Thus the analysis model was adjusted and a final total of 403 respondents who had exposure to the combination of SAfAIDS and Lusweti interventions were used for analysis. The report notes that "there is only limited evidence of the effectiveness of the combined approach, particularly for key behavioural outcomes." However, there are some positive associations of the combined approach. For example, "individuals exposed to both Lusweti and SAfAIDS activities are more likely to agree that they can resist the temptation of having sex with someone other than their main partner (97.7% exposed to both, 82.7% exposed to Lusweti only, 80.1% unexposed). They are also more likely to be worried about becoming infected with HIV (82.1% exposed to both, 50.4% exposed to Lusweti only, 41.2% unexposed). " Exposure to both programmes also improved some indicators around living positively with HIV.

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