BRIDGE Project Final Evaluation

Produced for review by the United States Agency for International Development (USAID)/Malawi, this report examines a project launched in 2003 to address two conflicting realities: More than 93% of Malawians had the knowledge necessary to prevent HIV infection. Nevertheless, most Malawians did not engage in preventive behaviours. BRIDGE is a response to this gap, and carries the following theme: Belief in a better future (hope); Risk is shared by everyone (personalised risk); I can STOP AIDS (personal responsibility, action, self-efficacy); Discussion about HIV/AIDS (openness, destigmatisation); Gender equity (girls' empowerment and changed men's behaviour); Emphasising positives (action orientation, community assets, positive role modelling).

Specifically, the project works in 8 districts (Mzimba, Kasungu, Ntcheu, Salima, Mangochi, Balaka, Mulanje, and Chikwawa) to build the capacity of behaviour change agents while coordinating and mobilising community and national stakeholders. Outlets like the media, community leaders, and national celebrities are being used to model and reinforce changed behaviour and support national behaviour change intervention (NBCI) movements.

An excerpt from the Executive Summary follows:

"A final evaluation of the BRIDGE Behavior Change Initiative HIV/AIDS Project led by the Johns Hopkins University Center for Communication Programs (JHU/CCP) and Save the Children, U.S. (SC/US) was conducted in Malawi August 4-30, 2008. The objectives were to determine progress in achieving the results outlined in its work plans and then to formulate recommendations and identify lessons learned for use in future activities USAID/Malawi may wish to explore.

The evaluation team consisted of two consultants from the GH Tech Project. After an initial briefing from the USAID officer in charge and BRIDGE project staff, the team conducted field visits to Mangochi, Salima, Mzimba, Kasungu, Ntcheu, Mulanje, Chikwawa, and Balaka districts and Blantyre city August 8-August 20. During the visits the team interviewed youth groups, cultural committees, parent groups, AIDS support groups, District AIDS Coordinating Committees (DACCs), Community AIDS Committees (CACs), Village AIDS Committees (VACs), community-based organizations (CBOs), radio listening groups, collaborating faith-based (FBO) and nongovernmental organizations (NGO), school staff, and others. In addition, numerous interviews were conducted in Blantyre and Lilongwe with representatives from radio stations, media firms, NGOs, cooperating agencies, and government ministries. Follow-up in-depth interviews were also conducted with BRIDGE and USAID staff.

In general the team found that BRIDGE is achieving most of its stated objectives. Finding after completing its baseline survey that the initial intention of targeting high-risk groups was not appropriate, the project changed its strategy to target the general population, with an emphasis on both youth and adults. The four pillars of the BRIDGE strategic framework (based on the structural-environmental (S-E) model for behavior change) are nation, community, capacity building, and coordination. BRIDGE's multilevel approach is appropriate; it facilitates creation of norms and interpersonal support for adhering to protective behaviors. The evaluators found evidence that dissemination of consistent messages to different audiences is creating synergy that is reinforcing intent to adopt behaviors protecting against HIV. This is particularly evident in the radio listening groups, radio support groups, youth clubs, interfaith groups, and district and community committees. There is reliable evidence that the various groups working on HIV/AIDS prevention and control have harmonized their messages and are building capacity for efficient production of communication materials and dissemination of messages.

Among the most successful campaigns are the Radio Diary program (people living with HIV and AIDS [PLWHAs]), Youth Alert, the Tisankhenji Girls radio program, and the three phases of the Nditha campaign. The unifying themes of openness, hope, and self-efficacy (Nditha), male responsibility (Bambo Wachitsanzo), and raising risk awareness are effectively reaching their target audiences. Initial emphasis was given to youth, and in the later campaigns added weight has been given to adults. The quality of the radio broadcasts is high. Radio Diaries and HIV/AIDS content in the Youth Alert and Tisankhenji programs are reaching audience segments that are a critical link to the community, offering messages of hope and empowerment. These are cited by community members and radio station staff as essential in changing behaviors. The facilitator guides for Youth Alert and Tisankhenji clubs are well written. For continued behavior change, technical capacity building will continue to be needed at the radio stations, in leader/teacher training, and in managerial and programmatic areas at the district levels.

According to its midterm surveys, the project seems to be on track to meet the indicators cited in the agreement and measured at baseline related to improvements in knowledge (more than 60%); risk perception (more than 100%); and self-efficacy (20-40%) among youth and adults. In addition, 17 percent of youth and 43 percent of adults feel more confident in talking with partners about condoms. Other indicators show improvements of 10-20 percent in HIV testing in three out of four districts. In addition, a 2006 study by Population Services International (PSI) shows that 58 percent of youth who have high exposure to Youth Alert programs and clubs use condoms. Although initially there were some data quality problems with measurement of the indicators for the President's Emergency Plan for AIDS Relief (PEPFAR), these were corrected. The project uses PEPFAR data to monitor progress and make management decisions about program direction. It also used the mid-term evaluation survey results to confirm that the audience was ready for the Risk Awareness Campaign phase of the project to be introduced.

However, the actual impact of the project on behavior is not being measured. Consistent with its theory-based approach, the project is measuring knowledge, intention, and perceptions, but not whether behaviors have actually changed. Also, because there is no district-wide coverage data, it is difficult to measure the broad public health impact of activities focused on four to seven traditional authorities in each district...

General Recommendations:

• BRIDGE is the lead NGO working on BCI [behaviour change intervention] in Malawi. After it ends, the team recommends that the NAC [National AIDS Commission] and the governments of Malawi and the United States support a similar project to extend HIV BCI and continue promoting efficacy and risk interventions. State-of-the-art, evidence-based best practices in HIV prevention are not yet demonstrated. This presents an opportunity for BRIDGE to demonstrate its successes.
• In order to scale up, there is a need to increase funding and staff and leverage resources for non-HIV/AIDS-related programming, such as education, reproductive health, and Food for Peace.
• BCI media activities directed to both youth and adults should continue. There is a need to continuously reinforce messages and to scale up implementation throughout districts.
• Building capacity in radio stations, media partners, community-based theater, and advertising agencies also should continue.
• It is recommended that Tisankhenji school activity be expanded by linking it to girls' education, radio learning programs, and gender activities. This program is having a noticeable impact on young girls.
• The Radio Diaries program should be continued; it is reaching a wide audience, reducing stigma and discrimination, and encouraging openness. However, the themes could be expanded to cover pregnancy, prevention of mother-to-child transmission (PMTCT), multiple partners, and mothers who talk about HIV.
• Youth Alert clubs, which have been in place for four years, are having an impact. They should continue but be segmented by age. They could also be linked to education programs and adolescent reproductive health, with BRIDGE providing technical assistance.
• A system is needed to monitor the quality of BCI training and tools once these are turned over to collaborating and implementing partners.
• As time goes on, BRIDGE will need to prioritize because it must respond to more and more requests for technical assistance as other demands and workload increase. Depending on the focus of future projects, it may be necessary to clarify the priority of technical assistance compared to other activities.
• BRIDGE staff members are interested in forming a local BCI organization similar to JHU/CCP that will be eligible for NAC funding. Technical assistance from JHU or another agency would help them formulate a vision for such an organization and understand the organizational and administrative requirements.
• Monitoring and evaluation (M&E) capacity needs to be increased, and NAC, the Government of Malawi (GOM), the U.S. government (USG), BRIDGE, and other development partners need a shared vision for M&E that goes beyond collecting and reporting quality data. It is necessary to better define the relation between self-efficacy, risk assessment, intention to change, and whether change occurs (behavioral impact)."