NYANGANA Representative Household & Network Analysis Baseline Data in Partnership with Academy for Educational Development Save the Children International HIV/AIDS Alliance Tulane University and University of North Carolina Chapel Hill Johns Hopkins Bloomberg School of Public Health Center for Communication Programs Funded by the President’s Plan for Emergency AIDS Relief

Emergency Plan goals and corresponding summary indicators Estimated from program data and program impact models Total number of clients served by ART and PMTCT+ Total number of clients receiving HIV care and support and total number of OVC receiving care and support Treat 2 million with ART Prevent 7 million new infections Care and support for 10 million PLWHA and AIDS orphans

USG/Namibian Emergency Plan goals and corresponding summary indicators Estimated from program data and program impact models Total number of clients served by ART and PMTCT+ Total number of clients receiving HIV Care and support and total number of OVC receiving care and support Treat 23,000 with ART Prevent 72,000 new infections Care and support for 118,000 PLWHA and AIDS orphans

Data Collection Sept/Oct 2003 Oshikuku Oniipa (Onandjokwe) Rehoboth May/June 2004 Andara Nyangana Rundu Aug-Oct 2004 Katutura Keetmanshoop Oshakati Walvis Bay Windhoek (supplemental, household only) Walvis Bay Keetmanshoop Katutura Rehoboth Windhoek Onandjokwe Oshikuku Oshakati Andara Nyangana Rundu

OVERALL RESEARCH PLAN  HOUSEHOLD SURVEY – Goal was to assess individual level indicators of change like knowledge, perceptions, behaviors  Complete Random Sample of Households in 10 km catchment area around HIV/AIDS focus hospital  exceptions Katutura, Windhoek – standard EAs used  Oshakati, 5km catchment because of overlap  Sample N= 3100, n=300 per site (9 sites, n=200 at two supplemental sites)  NETWORK SURVEY – Goal was to assess community level indicators of change like social norms, information equity, leadership linkages  Complete Census of the households adjacent to the HIV/AIDS focus hospital PLUS health care workers in the focus hospital  Sample N=3763, n=400 per site (10 sites)

SURVEY METHODS continued  Sample size determination – effect sizes extracted, power calculated, conventional standard  =.80,  =.05  Persons 15 years and older eligible for participation in study  At selected households, Inventory of all eligible participants, Participant selected by random draw  Call-backs on evenings/weekends (up to three times).  Non-responses replaced by next eligible household.  One person per household interviewed (privately).

NYANGANA Results reported from two data sets: (Data collected May/June 2004)  HOUSEHOLD SURVEY – Complete Random Sample of Households in 10 km catchment area around Sacred Heart Hospital in Nyangana  Sample n = 300  NETWORK SURVEY – Complete Census of the households adjacent to Sacred Heart Hospital in Nyangana PLUS health care workers in the hospital  Sample n= 400

Household Survey Findings: Awareness, Knowledge, Risk Perceptions

Awareness about AIDS and Sexually Transmitted Diseases (% choosing response, multiple answers allowed, spontaneous responses only)

How Can One Avoid Getting HIV? (% choosing response, spontaneous multiple answers allowed)

Can a mother do anything to reduce the risk of transmission of HIV (the AIDS virus) to her child? (% choosing response)

KNOWLEDGE: % OF PEOPLE CHOOSING “TRUE” IN RESPONSE TO ITEM

How Good is your Understanding of HIV/AIDS? (% choosing response)

What are your Chances of Getting HIV in the future? (% choosing response)

What is the Chance you already have HIV or AIDS? (% choosing response)

The ABCs and HIV Testing

16.7% Say They’ve Been Tested for HIV Of those not tested, Willingness to be tested for HIV (% choosing response)

I would like to get counseling about HIV/AIDS issues. (% choosing response)

Those who have been Tested for HIV were more likely to: Believe that Witchcraft causes HIV/AIDS Have a relative with HIV or AIDS Believe they were able to use a condom to prevent HIV infection but doubted that condoms worked in preventing infection Believe they were able to be faithful to one partner to prevent HIV infection Had greater knowledge about HIV/AIDS Be females, older, more educated, married, & of higher economic status

Of Those NOT yet Tested for HIV, those WILLING to be tested were more likely to: Have talked with others about HIV/AIDS issues Have a relative with HIV/AIDS Believe that their family was against premarital sex Believe that condoms work in preventing HIV infection Be married Not have children

Have you purposely avoided sex in the past year? (% choosing response)

Of those who purposely avoided sex in the past year, for how long do you plan to continue to avoid sex? (% spontaneously mentioning response)

Those who Purposely Avoided Sex in the Past Year, were more likely to: Be more strongly influenced by religious beliefs Not drink alcohol (regular alcohol drinkers less likely to have avoided sex in the past year) Have stronger beliefs that Abstinence prevents HIV infection & have more Positive Attitudes toward Abstinence Believe that getting HIV/AIDS is the worst thing that could happen to them Believe that stigma toward HIV infection in the community was high Be single, of lower economic status, & lived away from home more than 1 month in the past year

Among year-olds, Those who HAVE Had Sex vs. Have NOT Had Sex

Among year-olds, Those who have NEVER had Sex were more likely to: Believe Witchcraft causes HIV Not drink Alcohol (regular alcohol drinkers were more likely to have had sex) NOT believe that avoiding sex is harmful to one’s health Believe their family was against premarital sex Be younger, a student or employed, & of higher economic status

Percentage of Persons who had 2 or More Sex Partners in Past Year by peer group

Those with 2 or More Sex Partners in Past Year (high risk) were more likely to: Believe that Witchcraft causes HIV/AIDS Be Regular Alcohol Drinkers Believe they were at greater risk for HIV infection Believe they were NOT able to be faithful to one partner Have NEVER been tested for HIV Believe their partner has sex with other persons Be single and of higher economic status

The last time you had sex, did you use a condom? (% choosing response)

Those who used a Condom at Last Sex were more likely to: Believe that Witchcraft causes HIV/AIDS Not drink alcohol (regular alcohol drinkers less likely to use condoms) Perceive themselves at greater risk for HIV infection Never have been tested for HIV Believe their partner has sex with other persons Be single and have a higher economic status

MAJOR UNDERLYING CAUSES – LEADING TO RISKY / UNDESIRABLE BEHAVIORS SUMMARY Stronger beliefs in Witchcraft consistently led to more risky behaviors Regular Alcohol Drinkers consistently more likely to engage in risky behaviors Beliefs about whether or not someone can Do Something to Effectively Avert Infection affects behaviors Perceived Susceptibility to infection seemed to accurately reflect situation; i.e., were at higher risk because were engaging in more risky behaviors; deterrent only for condom use.

MAJOR UNDERLYING CAUSES – LEADING TO RISKY / UNDESIRABLE BEHAVIORS SUMMARY continued Family norm only norm to impact behavior; not religion norm. Stigma only affected abstinence in that greater stigma=more abstinence. Relative with HIV or AIDS significantly increases chance of one having been tested or one’s being willing to be tested. Those with more sex partners and who use condoms also more likely to think their partners have other partners.

Community Beliefs & Responses

Perceptions about prevalence of HIV/AIDS in community. “According to you, would you say that in your community or neighbourhood?” (% choosing response)

Do you think the AIDS problem can be solved in Namibia? (% choosing response)

Negative Association between community Risk Perceptions and Community Participation r = -.24, p <.0001 –The stronger the perception that a lot of people have HIV or AIDS in the community, the less likely respondents believed the community had worked in the past year to solve HIV/AIDS problems. r = -.15, p <.01 –The stronger the perception that a lot of people have HIV or AIDS in the community, the less likely respondents said they themselves worked on HIV/AIDS issues in the community.

Has your community ever worked together to try to solve problems related to HIV/AIDS in the past year? (% choosing response)

Who does one turn to for support & advice if discovered s/he has HIV+ or AIDS? (% choosing response, multiple answers allowed)

What services are available to People Living with AIDS? (% spontaneously mentioning service)

Tolerance of those with HIV/AIDS. (% choosing “definitely yes” in response to item)

Orphans and Vulnerable Children

If parents or a caretaker DIES from AIDS, who will take care of the children? (% choosing category)

Who SHOULD be responsible for caring for children whose parents DIE from AIDS? (% choosing category)

What are residents doing to help children whose parents have DIED from AIDS? (% spontaneously mentioning category)

What, if any, special services are available for children whose parents/caretakers have DIED of AIDS? (% spontaneously mentioning category)

Beliefs about Health Care Workers

Health care workers are rude to clients in the community. (% choosing response)

Sometimes health care workers tell others my private health information (% choosing response)

I trust doctors more than nurses. (% choosing response)

Network Analysis Results

The Variety and Size of Social Groups in NYANGANA (n=400 respondents) Number of Groups mentioned: 57 Average number of respondents per group: 11 Most often listed group: Roman Catholic Church Groups in Nyangana (93%) believe decisions that affect the community should be made by leaders, not by consensus of group members themselves.

The network of groups as they connect through shared members in Nyangana,, = groups Size of square represents size of group – the larger the square the more members in the group. = individual group members

The Leaders Connecting Groups in NYANGANA,, = groups Size of square represents size of group – the larger the square the more members in the group. = individual group leaders

Shared group members working to address HIV/AIDS for their groups in Nyangana,, =groups Size of square represents size of group – the larger the square the more members in the group. = individual group members

Groups’ knowledge about MTCT in the leadership network in NYANGANA = highest knowledge on MTCT prevention (can recall three methods) = moderate knowledge on MTCT prevention (can recall two methods) = low knowledge on MTCT prevention (can recall only one method) Size of shape represents # of persons in group; large figures = large groups; small figures = small groups.

Groups’ knowledge about ABCs in the leadership network in Nyangana. = highest knowledge on ABC prevention (can recall three methods) = moderate knowledge on ABC prevention (can recall two methods) = low knowledge on ABC prevention (can recall only one method) Size of shape represents # of persons in group; large figures = large groups; small figures = small groups.

Group members’ interest in being tested for HIV and their reported number of sexual partners in NYANGANA = groups where a majority of members have had zero or one sexual partner in the past year and say they would like to be tested or already have been tested = groups where a majority of members have had zero or one sexual partner in the past year and say they would not like to be tested or are unsure = groups where a majority of members have had two or more sexual partners in the past year and say they would like to be tested or already have been tested = groups where a majority of members have had two or more sexual partners in the past year and say they would not like to be tested or are unsure Size of square represents size of group – the larger the circle or triangle, the more members in the group.

The social network of health care workers and their knowledge of MTCT in Nyangana (n=32) = Health worker could name all three methods of MTCT prevention. = Health worker could name two methods of MTCT prevention. = Health worker could name one method of MTCT prevention. = Name of Primary Group to which Health Worker Belong

Network SUMMARY In Nyangana, respondents claim membership in a modest number of social groups (about 57), and there is not much consensus on who leads their groups. Two large groups are centrally located (Roman Catholic Church and Catholic AIDS Action). MTCT and ABC knowledge is very low in the community. MTCT knowledge is very low among health care workers. Group members are more connected than group leaders.

Household Summary Knowledge is weak here with significant proportions of the population believing in myths. Many either don’t know or are unaware that HIV can be passed from mother to child. High Demand for HIV Counseling and Testing. Abstinence and Condom seen as prevention strategies; limiting partners or partner faithfulness less prevalent. High proportions of young persons (ages 15-19) sexually active.

Contact for Additional Information Salen Engelbrecht Health Communication Partnership Based at Johns Hopkins University Center for Communication Programs PO Box 5588 Windhoek, Namibia Tel: