ABSTRACT
Since the first case of HIV and AIDS in Nigeria, and the epidemics continually evolved with, Nigeria having a pathetic situation of fluctuating prevalence rate. In the bid to forestall this undulating situation of HIV and AIDS prevalence rate, NACA published the National HIV and AIDS BCC Strategy. Despite the availability of the document, Nigeria still experienced fluctuated HIV prevalence rate. In 2008, NACA launched the revised HIV and AIDS NPP for Nigeria, to provide the States with minimum package of prevention activities. Drawing from the NPP, the National HIV and AIDS BCC Strategy, 2009-2014 was published with the major goal to reduce the rate of spread of HIV infection in Nigeria by 25% by year 2014. The study, therefore evaluated the implementation of this document in the prevention of HIV and AIDS in Nigeria.
The study adopted the qualitative design with a study population of thirteen HIV and AIDS implementing organisations registered with NACA in 2008. Sample size of three HIV and AIDS implementing organisations located were selected using the simple random sampling technique and the purposive sampling to select two study areas; Ogun and Oyo States of the South-west Nigeria. Face-to-face interviews were conducted on Key Informants from the three HIV and AIDS implementing organisations, selected staff and AIDS professionals to solicit information for appropriate evaluation. The face and content validity were adopted to ensure that each item on the measuring instrument had logical connection to research objectives and questions. Reliability test was carried out by administering the research instrument to two respondents who had knowledge of the document under investigation. The research instrument of unstructured interview guide was self-administered to the key Informants. Interview responses from the key Informants were transcribed and content analysed based on identified themes in the objectives and research questions of the study.
Result showed that the communication strategy employed by NACA in the implementation of the document under review met the set goal of ensuring media message harmonisation, consistency and effective. The fluctuation of HIV and AIDS prevalence rate within the period of 2011 to 2015 was addressed; stemming the rate of fluctuation from 4.1% in 2010 to 3.1% by 2015.This identified 3.1% HIV prevalence rate in Nigeria is commensurate to the set goal of NACA, as the agency met and surpassed the goal of reducing the rate of the spread of HIV infection in Nigeria by 7.6% reduction. The operational plan of the document under review provided the implementation modalities with players represented at all levels of society. The M&E process as integrated in the NNRIMS and the Operational Plan, 2007-2010 were adopted as the M&E framework.
The study concluded that the implementation of the document under investigation in the prevention of HIV and AIDS in Nigeria was justifiably successful, and the prevalence rate of HIV infection was stemmed. The study recommended that the NACA continues the dissemination of HIV and AIDS information to the Nigeria citizenry to maintain this achievement.
Keywords: Behaviour Change, Development Communication, Evaluation, Communication Strategy, Prevention.
Word Count: 490
TABLE OF CONTENTS
Content Page
Title Page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract v
Table of Contents vi
List of Tables ix
List of Figures x
Abbreviations xi
CHAPTER ONE: INTRODUCTION
- Background to the Study 1
- Statement of the Problem 4
- Objective of the Study 5
- Research Questions 6
- Significance of the Study 6
- Scope of the Study 7
- Operational Definition of Terms 7
CHAPTER TWO: REVIEW OF LITERATURE
2.0 Introduction 9
2.1 Conceptual Model 9
2.1.1 Conceptual Model of Planned Behaviour and National Behaviour
ChangeCommunication Strategy, 2009-2014 9
- Theoretical Framework 10
- The Attitude Change Theory 11
- The Behaviour Change Model 13
- Theory of Planned Behaviour 15
- Review of Relevant Literature 17
Content Page
- Communication: Developmental Approach 17
- Development Communication 20
- Development Communication versus Communicationfor Development 23
- Health Communication: Review of Perspectives 25
- Categories of Health Communication 27
- Health Communication Achievements and Contributions 28
- HIV and AIDS in Nigeria: Historical Review andSituation Analysis 30
- Behaviour Change Communication (BCC) of HIV andAIDS in Nigeria 32
CHAPTER THREE: METHODOLOGY
3.0 Introduction 35
3.1 Research Design 35
3.2 Population 36
3.3 Sample size and sampling Technique 36
3.4 Instrument 37
3.5 Validity of Research Instrument 38
3.6 Reliability of Research Instrument 38
3.7 Administration of Research Instrument/Data Gathering Procedure 38
3.8Method Data Analysis 39
CHAPTER FOUR: DATA ANALYSIS, RESULTS
AND DISCUSSION OF FINDINGS
4.0 Introduction 40
4.1Discussion of Findings 41
CHAPTER FIVE: SUMMARY, CONCLUSION AND
RECOMMENDATIONS
5.0 Introduction 56
5.1 Summary 56
5.2 Conclusion 58
5.3 Recommendations 59
Content Page
5.3.1 National Agency for the Control of AIDS (NACA) 59
5.3.2 Government: Federal Ministry of Labour and Productivity 59
5.3.3 Private Health Sector 60
5.4 Limitation of the Study 60
5.5 Suggestion for Further Studies 61
References 62
Appendices 70
LIST OF TABLES
Table Page
- UNAIDS HIV and AIDS Estimates (2015) 46
- HIV Prevalence in Nigeria 2008 to 2015 49
LIST OF FIGURES
Figure Page
- Conceptual Model of Planned Behaviour and National
Behaviour Change Communication Strategy, 2009-2014 9
- Monitoring and Evaluation Conceptual Model for BCC Strategy 54
ABBREVIATIONS
AIDS – Acquired Immune Deficiency Syndrome
ANC – Ante-Natal Clinics
ARFH – Association for Reproductiveand Family Health
ART – Anti-Retroviral Therapy
ARV – Anti-Retroviral
BCC – Behaviour Change Communication
CiSHAN – Civil Society for HIV and AIDS in Nigeria
CRH – Centre for the Right to Health
CSO – Civil Society Organization
FCSW – Female Commercial Sex Workers
FHI – Family Health International
FMOH – Federal Ministry of Health
FSW – Female Sex Workers
HEAP – HIV/AIDS Emergency Action Plan
HIV – Human Immunodeficiency Virus
IBBSS – Integrated Biological and Behavioural Surveillance Survey
ICAP – International Centre for AIDS Care and Treatment Programme
IDUs – Injecting Drug Users
LACA – Local Action Committee on AIDS
LGA – Local Government Area
NBS – National Bureau of Statistics
M&E – Monitoring and Evaluation
MSM – Men who have Sex with Men
NACA – National Agency for the Control of AIDS
NARHS – National HIV/AIDS Reproductive Health Survey
NGO – Non-Governmental Organisation
NNRIMS – Nigeria National Response Information Management System
NOP – NNRIMS Operational Plan
NPP – National Prevention Plan
OI – Opportunistic Infections
OVC – Orphans and Vulnerable Children
PATHS – Partnerships for Transforming Health Systems
PLWHA – People Living with HIV and AIDS
PMTCT – Prevention of Mother-to-Child Transmission
PWDs – People with Disabilities
SACA – State Agency for the Control of AIDS
SFH – Society for Family Health
STIs – Sexually Transmitted Infections
TB – Tuberculosis
UNAIDS – Joint United Nations Programme on HIV and AIDS
USAID – United States Agency for International Development
CHAPTER ONE
INTRODUCTION
- Background to the Study
Development communication as a purposive communication driven by the need for positive change and improvement of life, situation or something constitutes the focus of health communication. With the emergence of development communication in the 1950s (Imoh, 2007, p. 20), and the recognition to development in the early 1960s (Moemeka, 1994 p. 23); many wonder if this discourse amongst scholars has impacted on health communication particularly HIV and AIDS in Nigeria. The human immunodeficiency virus and acquired immune deficiency syndrome (HIV and AIDS) is one of the greatest natural challenges that have become a bane and concern for humans in recent times (Ilo & Adeyemi, 2010, p. 1). The impact of the development communication discourse amongst scholars on the health communication of HIV and AIDS prevention in Nigeria calls for evaluation. Globally, HIV and AIDS epidemic has remained a major public health, social, economic and developmental challenge (Nigerian Health Review, 2006 & UNAIDS Global Report, 2010). The technical report of the 2010 national HIV Sero-prevalence Sentinel Survey reveals that:
The HIV and AIDS pandemic has continued to constitute serious health and socio economic challenges for more than two decades. In underdeveloped and developing countries, it has reversed many of the health and developmental gains over the past three decades as reflected by indices such as life expectancy at birth and infant mortality rate among others. (Federal Ministry of Health, 2010, p. 2)
According to Kanki and Adeyi (2006, p. 4), the first case of HIV and AIDS in Nigeria was reported in 1986, and the HIV and AIDS epidemics have continued to evolve in Nigeria since this period (Federal Ministry Health, 2010, p. 2). In 1991, the Federal Ministry of Health (FMOH) conducted the first sentinel sero-prevalence survey in Nigeria. In this survey, and in subsequent surveys conducted in 1993, 1999, and 2001; pregnant women attending antenatal clinics (ANCs), patients with sexually transmitted infections (STIs), patients with tuberculosis (TB), and female commercial sex workers (FCSWs) provided the population for HIV sero-prevalence estimates (Oruonye, 2011, p. 104).This first sentinel surveillance survey showed the national HIV and AIDS prevalence rate to stand at 1.8% in 1991 (FMOH, 2010, p. 2); and the prevalence rate steadily increased from 1.8% in 1991, to 3.8% in 1993, 4.5% in 1995, 5.4% in 1999, and 5.8% in 2001.
Nigeria had a grip of this undulating growth of the HIV and AIDS epidemic, with the national adult infection rate at 5.8% in 2001 but witnessed a decline to 5.0% in 2003 (FMOH, 2001; 2004). Nigeria is Africa’s most populous nation with a population estimated at well over 120 million in 2002. The National Policy on HIV and AIDS of 2003, indicate that more than 3.5 million Nigerians were infected with the virus in 2002. In the same year, HIV and AIDS epidemic killed 1.7 million people, orphaned 1.5 million children, which totalled the 3.5 million Nigerians living with the virus in 2002 (Peterson & Obileye, 2002, p. 3).
Nigeria recorded further decline in the prevalence rate of HIV in 2005, when the number of HIV infected adults ranked Nigeria second, in the sub-Saharan region after South Africa; with a prevalence rate of 4.4% in 2005 (IPPF et al., 2006; National BCC Strategy, 2008). But a reverse was the case in 2007 and 2008 when the HIV and AIDS prevalence rate increased to 4.6%. It was estimated that 3.6% of the Nigeria population between ages 15 to 49 are infected, and living with HIV and AIDS (UNGASS, 2010; Oruonye, 2011, p. 104); with approximately a death toll of 220,000 people resulting from AIDS in 2009 in Nigeria (UNAIDS, 2010). This undulant situation of HIV and AIDS prevalence rate posed significant threat to Nigeria’s development as the highest number of people placed on antiretroviral therapy (ART) in Africa, which imposed huge financial burden on the country (Oruonye, 2011, p. 104).
The first HIV and AIDS sentinel survey in Nigeria, conducted in 1991 had 1.8% prevalence rate reported (NHEIA, 2014). Judging by the subsequent HIV and AIDS sentinel surveys of Nigeria’s HIV sero-prevalence estimated within the two decades as follows; 3.8% (1993), 4.5% (1996), 5.4% (1999), 5.8% (2001), 5.0% (2003), 4.4% (2005), 4.6% (2008), 4.1% (2010), 3.34% (2011) , 3.0 in 2012; and 3.4% in 2013 (NACA 2012; NACA 2011a; NACA 2011b; NACA and UNAIDS 2010; NACA 2010; NACA 2007; NARHS, 2013); the situation poses major concern for researchers and analysts of HIV and AIDS. The surveys within the two decades were characterised by undulating appraisal of national HIV and AIDS prevalence rates.
Nigeria however, still bore the second heaviest burden of HIV in Africa after South Africa, with a total estimate of 3.14 million to 3.4 million Nigerians living with HIV in 2010, and 1.5 million people in Nigeria in need of antiretroviral (ARV) drugs (FMOH, 2010). The Federal Ministry of Health equally observed that by the end of 2011, a total of 217,148 AIDS-related deaths and a cumulative total of 2.1 million AIDS-related deaths were documented since the first AIDS case was identified in Nigeria, leaving an estimate of 2.2 million AIDS-orphans (FMOH, 2011; NACA 2012; NACA 2011a; UNAIDS, 2010). The National Bureau of Statistics (NBS) equally confirmed a total of 168,067 adults and children were living with HIV in 2013 nationally, which was a modest decrease from 322,529 in 2010 (National Bureau of Statistics, 2014, p. 8).
In the bid to forestall this undulating situation of HIV and AIDS prevalence rate in Nigeria, the National Agency for the Control of AIDS (NACA) published the National HIV and AIDS Behaviour Change Communication Strategy of 2004 to 2008 and the second edition of 2009 to 2014. Behaviour change communication (BCC) according to FHI and USAID (2002) refers to the interactive process with communities (as integrated with an overall programme) to develop tailored messages and approaches using a variety of communication channels to develop positive behaviours; promote and sustain individual, community and societal behaviour change; and maintain appropriate behaviours. BCC is a process of delivering information about the behaviour change on the general procedures of how undesirable behaviours are discouraged (Opondo, 2009).
In the context of this work, BCC became an essential part of NACA’s comprehensive programme which included both services (medical, social, psychological and spiritual) and commodities (for example, condoms, needles and syringes). The National HIV and AIDS BehaviourChange Communication Strategy of 2009-2014 was part of the national response to prevent HIV and AIDS in Nigeria. In view of the undulating situation of HIV and AIDS prevalence rates, the agency sort to address with the document; the challenges of HIV and AIDS information, risk reduction, change in behaviours, adoption of key attitudes, skills and access to appropriate products and services. The aim is to educate the public on improving the knowledge, skills and attitudes towards HIV and AIDS.
Since the first global emergence of HIV and AIDS, the role of Behaviour Change has been recognised as critical to the control of the pandemic (Fatusi & Jimoh, 2006, p. 324). The phrase “education is the only vaccine against AIDS” was commonly aired during the early years to control the epidemic (Liskin, Church, Piotrow & Harris, 1989, p. 3). Against this background, considerable efforts and energy of NACA were devoted to implementing communication programmes to educate people about HIV transmission modes and prevention strategies. The underlying assumption of these early activities was that, improving people’s knowledge about the infection and disease would lead to avoidance of risky behaviours (Fatusi & Jimoh, 2006, p. 324).
Nigeria witnessed fluctuations in HIV prevalence rate in the last two decades, but with an overall picture of significant increase within the period. The national response to prevent HIV and AIDS in Nigeria is one of the major tasks of the National Agency for the Control of AIDS (NACA) set up by the government. With considerable success achieved in coordinating prevention programmes and activities over the years, the necessity for possible eradication of the epidemic has become a discourse among scholars. A retrospective review of national HIV and AIDS prevention plans in Nigeria shows changes in the strategic focus and approach to prevention. Single intervention approach did not actualise the expected levels of behavioural change required to avert new HIV infections in the country.
- Statement of the Problem
Before the introduction of the National HIV and AIDS Behaviour Change Communication Strategy of 2004 to 2008 by NACA; Nigeria was at a crossroad with 3.5million Nigerians between ages 15 and 49 years infected with the virus. HIV prevalence had already reached pandemic proportions with adult HIV prevalence rates increasing from 1.8% in 1991 to 4.5% in 1996, and 5.8% in 2001. By 2008 when the National HIV and AIDS BehaviourChange Communication Strategy of 2009-2014 was published, the Nigeria population of over 140 million people faced HIV epidemic that could easily spin out of control. The national HIV prevalence rate cited at 4.4% in the National AIDS and Reproductive Health Survey (NARHS) of 2005, which translated to more than 2.9 million people living with the virus, and made Nigeria the third highest burdened for HIV in the world, further increased to 4.6% in 2008.
However, despite the introduction the National HIV and AIDS BehaviourChange Communication Strategy, Nigeria still experienced a fluctuated HIV prevalence rate. In 2008, the National Agency for the Control of AIDS (NACA) launched the revised HIV and AIDS National Prevention Plan for Nigeria, which sought to provide the Nigeria states with a minimum package of prevention activities. Drawing from the National Prevention Plan, the second publication of the National HIV and AIDS Behaviour Change Communication Strategy of (2009-2014) had the major goal to reduce the rate of spread of HIV infection in Nigeria by 25% by year 2014 (NACA, 2008, p. 9).
As at 2008, when the document under investigation was published, the Nigeria population stood at about 151.2 million and HIV and AIDS national prevalence rate was 4.6%; which reveals that 6,955,200 people were infected. By 2014, the Nigeria population had increased to over 167 million people, and the HIV and AIDS national prevalence rate had reduced to 3.2%; which means 5,344,000 people were infected. However, the current national HIV prevalence rate stands at 4.1%, which translates to about 3.4million people living with HIV. Thus, there seem to be a significant increase of HIV prevalence rate in Nigeria.
The need for behaviour change to ensure HIV and AIDS prevention in Nigeria remains a critical challenge and equally a priorityin the continuous fight against the epidemic. The National HIV and AIDS Behaviour Change Communication (BCC) Strategy 2009-2014 published by NACA; provided Nigeria with the platform for an effective and coordinatedBCC response to the epidemic. The goal of the document was to reduce the rate of spread of HIV infection in Nigeria by 25% by year 2014. The implementation procedure includes a five step process of; know your epidemic, know what works in BCC, develop the BCC strategy and key strategic interventions, operationalise the strategy and measure what is achieved.
Thus, this work seeks to evaluate the achievements and effectiveness of the National Behaviour Change Communication (BCC) Strategy (2009-2014), find out the implementation level of the document, and whether or not the agency met the set goal in the prevention of HIV and AIDS in Nigeria. Furthermore, the work seeks to find out the extent at which the programme as documented, had significant impact on the reduction of HIV and AIDS prevalence rate in Nigeria, and finally find out the drawbacks and challenges experienced in the implementation of the programme.
1.3 Objective of the Study
The main objective of this empirical study is to evaluate the achievement and effectiveness of the implementation of the National Behaviour Change Communication (BCC) Strategy between 2009 and 2014, in the prevention of HIV and AIDS in Nigeria. The specific objectives are to:
- determine the extent to which the communication strategy employed in the National HIV and AIDS Behaviour Change Communication (BCC) Strategy, 2009-2014 met the set goal of HIV and AIDS reduction;
- determine the extent to which the National HIV and AIDS Behaviour Change Communication (BCC) Strategy, 2009-2014 addressed the fluctuation of HIV and AIDS prevalence rates within the period;
- find out if the identified decrease in HIV and AIDS prevalence rate in Nigeria is commensurate to the set goal in the National HIV and AIDS Behaviour Change Communication (BCC) Strategy, 2009-2014;
- identify the implementation modalities that ensured the actualisation of National HIV and AIDS Behaviour Change Communication (BCC) Strategy, 2009-2014, and
- identify the monitoring and evaluation (M&E) process for keeping the programme on course.
1.4 Research Questions
- To what extent did the communication strategy employed in the National HIV and AIDS Behaviour Change Communication (BCC) Strategy, 2009-2014 meet the set goal of HIV and AIDS reduction?
- To what extent did the National HIV and AIDS Behaviour Change Communication (BCC) Strategy, 2009-2014 addressed the fluctuation of HIV and AIDS prevalence rate within the period?
- What is the extent to which the identified decrease in HIV and AIDS prevalence rate in Nigeria is commensurate to the set goal in the National HIV and AIDS Behaviour Change Communication (BCC) Strategy of 2009-2014?
- What are the implementation modalities that ensured the actualisation of National HIV and AIDS Behaviour Change Communication (BCC) Strategy of 2009-2014?
- What are the identifiable monitoring and evaluation (M&E) process for keeping the programme on course?
1.5 Significance of the Study
The National Behaviour Change Communication (BCC) Strategy, 2009-2014 provides the framework for HIV and AIDS prevention and its reduction in Nigeria through behaviour change communication. This work seeks to evaluate the implementation of the framework in relation to HIV and AIDS prevention in Nigeria, and justify whether or not the goal was met. The National Behaviour Change Communication (BCC) Strategy (2009-2014) published in 2008 by the National Agency for the Control of AIDS (NACA), was to enable HIV and AIDS implementation stakeholders develop and implement more effective HIV interventions by strengthening the BCC capacity of their programme managers. The document was equally proposed to provide a strategic focus to plan BCC for a harmonised and coordinated response at all levels (NACA, 2008, p. 8).
In view of the above, this research work may serve as reference and guide for government agencies in the health sector to include or further utilise certain communication strategies in their programmes. The outcome of this study may help these agencies in the critical analysis of their communication strategies and implementation. Information provided in this study could equally help government agencies in the allocation of available resources on HIV and AIDS programmes. This study could also serve as resource material for health workers particularly on HIV and AIDS, and the need for constant evaluation of the programmes. This study could provide useful information for these health workers to appropriately implement the programmes and measure their outcomes and impact as agents. This study may equally be useful to social marketers, health communicators, policy makers and other concerned agencies on the communication content and strategy that best meets the needs for HIV and AIDS prevention and risk-reduction in Nigeria. The information provided in this work could be a resource material for these agencies to mirror the situation of HIV and AIDS in Nigeria, and proffer the most appropriate communication content, policies and strategies of programme implementation. By and large, this research effort could provide data to enrich the databank of National Agency for the Control of AIDS (NACA) and State Agency for the Control of AIDS (SACA); and other AIDS related agencies such as World Health Organisation (WHO), AIDS Prevention Initiative Nigeria (APIN), United States Agency for International Development (USAID) et cetera, in planning and implementation of programmes. Finally, the study may be beneficial to researchers in area of health and behaviour change communication in Nigeria.
1.6 Scope of the Study
To determine the success or limitations of the strategies and goal of the National HIV and AIDS Behaviour Change Communication Strategy, 2009-2014 published in 2008 by NACA, both local and international implementing organisations in Oyo and Ogun States, whose mandate is to address the HIV and AIDS crisis between 2009 and 2014 will be critically studied.
1.7 Operational Definition of Terms
Behaviour Change: refers to the expected positive outcome in the disposition and lifestyle of Nigerians in relation to HIV and AIDS as a result of the communication channels used. This also refers to the development, promotion and sustenance of positive behaviours amongst the Nigeria populace. This will be evaluated based on the interview responses and opinions of HIV and AIDS professionals.
Behaviour Change Communication:refers to the inter-related process of developing tailored messages and approaches using a variety of communication channels to encourage the development of positive behaviours of individual and the community. It is also the communication geared towards the encouragement of behaviour change, as well as the maintenance of the appropriate behaviours with individuals and communities. It refers to the process of delivering behavioural change information on the general procedures of how undesirable behaviours are discouraged. This will be analysed based on the general outcome of the major communication employed for behaviour change.
Evaluation: the appraisal of the need, drawbacks, and achievements of the National HIV and AIDS Behaviour Change Communication Strategy of 2009 to 2014 in relation to prevention in Nigeria. This forms a major focus of this study and it will analysed based on the critical review of HIV and AIDS documents.
Development Communication: refers to the communication used for promote development and its purpose to change or improve HIV and AIDS situation in Nigeria. It refers to the messages designed to transform the behaviour of Nigerians for quality and healthy lifestyle, and change in health behaviour to promote the prevention of AIDS in Nigeria.
Prevention: refers to the singular purpose to inhibiting the spread of HIV and AIDS in Nigeria. It refers to the formulation and promotion of communication messages that affect the spread of HIV in Nigeria. This will be evaluated based on the communication messages and prevention modalities made available to Nigerians through the implementing agencies.
Communication Strategies: refers to the communication modalities used in the implementation of the National HIV and AIDS Behaviour Change Communication Strategy, 2009-2014 in the prevention of HIV and AIDS in Nigeria. These communication strategies will be analysed in relations to their achievements.
HIV Prevalence Rate: refers to the percentage of Nigeria population between ages 15-49 who are infected with HIV in Nigeria. The HIV prevalence rate is the indices that will be used to identify the level of HIV and AIDS increase or decrease in Nigeria.
AntiretroviralTherapycoverage: the percentage of Nigerians living with HIV who are receiving government’s technical and health-related responses for prevention of AIDS, care and support to HIV and AIDS treatment. It also includes the policies and guidelines for voluntary counselling and testing for HIV, medications and drugs and the prevention of mother-to-child transmission of AIDS.
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