Media and Behaviour Change: An Endline Evaluation of the STOP HIV Campaign in Nigeria (2005 - 2008)

Introduction
The BBC World Service Trust (WST) launched the 3-year STOP HIV campaign in April 2005 in an effort to raise awareness and change behaviour around HIV and AIDS among young Nigerians aged 15-24. Funded by the United Kingdom (UK) Department for International Development (DFID) and carried out in partnership with the Nigerian Society for Family Health (SFH), the campaign included 2 weekly phone-in talk shows ("Flava" and "Ya Take Ne? (YTN)"), radio and television public service announcements (PSAs), a weekly TV drama ("Wetin Dey?"), and film outputs (in partnership with the Nigerian video film industry, HIV- and AIDS-related messages were incorporated into the storylines of dozens of films).

Methodology
Multi-stage, proportional-to-size random probability sampling was used, with specific survey locations selected to be proportionally reflective of the urban and rural composition of 6 target states in Nigeria: Lagos, Abuja, Kano, Cross Rivers, Kaduna, and Enugu. Households were selected using a random walk method with qualifying respondents selected randomly from each chosen household using a Kish grid. The questionnaire was translated into the 3 major Nigerian languages - Hausa, Ibo, and Yoruba - and administered using locally trained interviewers. Male respondents were interviewed by male interviewers and female respondents by female interviewers.

A total of 4 quantitative surveys were conducted throughout the course of the project against which changes in HIV- and AIDS-related knowledge, attitudes, and practices were assessed.

Campaign Awareness and Reach

The awareness and reach of the STOP HIV campaign, although both still high among the intended audience, had fallen since the March 2007 midline survey¹. The researchers hypothesise that this decline is the result of irregularity in the airing of outputs and changes in partner stations' scheduling. The decline in campaign awareness is largely driven by reductions in awareness of the radio and television public service announcements (PSAs).

Despite a fall in overall awareness of the campaign since the midline survey, awareness of the STOP HIV campaign remained high; approximately 8 in 10 respondents were aware of at least one of the STOP HIV outputs. Awareness of the weekly radio discussion programmes increased; more respondents were aware of YTN - and, to a lesser extent, Flava - than at the midline. The move from prime time (8pm) to the late evening slot (10:30pm) affected Wetin Dey's audience share and hence the programme's ability to raise its profile.

Awareness of the campaign is slightly higher in the southern states surveyed (hereafter, defined as Lagos, Enugu, and Cross Rivers) compared with the northern states (hereafter, defined as Kano, Kaduna, and Abuja). Awareness of YTN is high and closely following the high levels of awareness of the radio and TV spots (the latter in the south). The newer campaign outputs - music videos and radio songs - appear to be capturing the intended audiences' attention, especially in the southern states.

Reductions in campaign awareness translated into changes in reach; the overall reach of the campaign decreased from 80% to 69% meaning that close to 7 in 10 respondents had watched or listened to a campaign output. In the northern states, radio spots and YTN attracted the largest audiences, whereas in the southern states, radio spots, radio songs, and music videos drew the largest audiences. Wetin Dey and Flava were found to have universal, albeit lower, appeal across Nigeria. The film "Hafsah" (released less than 2 months before the endline survey) was already registering an audience.

Levels of Project Exposure

Recognising that audience members could be exposed to STOP HIV Campaign outputs at varying levels of intensity, measures of campaign exposure were introduced. These amounts were threefold and classified as: High, Medium/Low, and No Exposure. Allocated membership to the appropriate exposure group was made using a combination of recency and frequency of watching or listening to campaign outputs. Each exposure group was weighted to match the profile of the baseline data in terms of gender, age, education, and location in order to control any confounding influence that these variables, known to influence exposure, may have on any changes in HIV and AIDS related knowledge, attitudes, and practises.

Key Findings

The evaluation examined whether there is a relationship between exposure to the STOP HIV campaign and changes in HIV- and AIDS-related knowledge, attitude, and behavioural change after controlling for gender, age, education, and location.

Measured Changes in Knowledge

Awareness of HIV increased from 91% at baseline to 95% at endline (96% when highly exposed at endline). Significantly² more respondents with high or medium/low exposure to the STOP HIV campaign at the endline reported being aware of the HIV virus (96%) compared with those respondents not exposed (93%) and baseline levels (91%). Significantly more respondents in both exposure groups (high and low/medium - 97%, 98% respectively) at the endline reported being aware of AIDS compared with those respondents not exposed (95%) or respondents at the baseline (96%).

Knowledge of sexual intercourse as a mode of transmission is extremely high among the intended audience (between 94% and 96% across exposure groups). Awareness of blood transfusion (57%) and mother-to-unborn-child (17%) as modes of HIV transmission is higher among those respondents who were highly exposed to the STOP HIV campaign.

Significantly more respondents who have seen or listened to campaign outputs were aware of methods of prevention (high exposure 89%; low/medium 89%) than those who have not been exposed (86%). Those respondents in the highly exposed group had significantly higher awareness of condom use as a means to reduce their risk of getting the HIV virus (53%) compared to the low exposure group (48%) and baseline (49%). The number of respondents mentioning "not having sex" or "being faithful" has fallen since the baseline. However, at the endline, knowledge of abstinence (60%) and faithfulness (22%) was highest among those with high exposure to the STOP HIV campaign.

Awareness of local HIV testing centres has significantly increased; there has been a 29% increase in awareness of local testing options: Significantly more respondents in the midline and endline survey mentioned that it is possible in the area where they live to get an HIV test (52% and 53% respectively) when compared to respondents at the baseline (41%). The relatively high awareness of HIV testing centres is more pronounced among those who were highly exposed to BBC WST outputs, showing an 18% increase compared to the baseline.

Sexually transmitted infection (STI) awareness increased significantly between the baseline (77%) and midline (86%), but it remained relatively stable between midline and endline (85%). STI awareness is significantly more pronounced among groups who were exposed to the STOP HIV campaign compared with those who were not exposed at midline and the baseline group - nearly 9 in 10 respondents who had been highly exposed to the campaign were aware of STIs at the endline, compared to 77% of respondents being aware of STIs at the baseline.

Looking at the average number of female STI symptoms mentioned by the respondents, the group that was highly exposed to the campaign mentioned a significantly higher number of symptoms (1.51) compared with those whose campaign exposure was low/medium (1.41) or nonexistent (1.27). Looking at the average number of male STI symptoms mentioned by the respondents, the group exposed to the campaign (at high and low/medium levels) mentioned significantly more symptoms (1.55) compared with those who were not exposed to the campaign (1.38).

Measured Changes in Attitudes

The desire to be tested for HIV increased significantly from 40% at the baseline to 47% at the midline and 49% at the endline. When asked, "Do you want to be tested for the HIV virus", 54% of those highly exposed to the STOP HIV campaign said "yes", as compared to 49% of those with medium/low exposure, 46% of those unexposed, and 40% at baseline.

More people at endline than at baseline were likely to accept a person living with HIV/AIDS (PLWHA) who is still healthy enough to continue his or her normal activities - as either a co-worker, classmate, teacher, or community leader. There was also a positive relationship between exposure to the campaign and acceptance of PLWHA continuing their work in professions such as nursing or hospitality. In other words, as exposure increased, acceptance of PLWHA increased.

Stigma towards a spouse who is living with the HIV virus has also significantly reduced from baseline (56%) to (48%) among those classified as highly exposed (48%). Although there is a significant increase in the number of people claiming that they would care for a family member who is HIV-positive, there is also significant increase in the number of people who would want the HIV status of an infected family member to remain a secret and would not want that family member to come to their home. This trend, initially observed in a midline case study remained present.

Measured Changes in Practices

Significantly more respondents had gone for an HIV test at the endline (17%) compared with the beginning of the campaign (11%). 1 in 10 respondents claimed that they had been tested at baseline. In comparison, 1 in 5 highly exposed respondents at the endline made that claim.

Concluding Comment

Where the STOP HIV campaign has been less successful is when indicators are already very high (e.g. knowledge of sex as a mode of transmission) or where they relate to the public disclosure of an HIV-positive family member's status. Also, there have not been consistently significant shifts in each of the ABC (Abstinence, Be faithful, and use Condoms) indicators. Pockets of misconceptions around modes of HIV transmission also remain.

In conclusion, the endline study shows that mass media communication, through the STOP HIV campaign in Nigeria, has the potential to contribute to gains in knowledge and shifts in attitudes as well as actual behaviour change among the intended audience.

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